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Skip to 0 minutes and 13 secondsHello, and welcome to week four. This week is titled F&E, for Facial cleanliness and Environmental improvement. Evidence has repeatedly shown that very young children have a high infectious load of chlamydia in endemic regions. Children often remain as a reservoir for infection at a family and community level, even when S&A components of trachoma prevention are implemented. Ocular and nasal discharge on a child's face increases the risk of transmission of the disease through flies, shared fomites, and close contact in crowded homes. Facial cleanliness is therefore critical to reduce the transmission of trachoma, but this can only be achieved through changes in people's behaviour.

Skip to 1 minute and 12 secondsEnvironmental improvement is a very broad category, but it's instrumental in achieving behaviour change that is needed for facial cleanliness. Strengthening access for water and sanitation is an essential building block for improving infrastructure of a society. In trachoma-endemic regions, there are multiple challenges, ranging from dry climate to lack of water and poorly developed infrastructure. Multi-disciplinary actions are therefore required to implement water and sanitation. Every context and community is different in geography, in climate, and even in the ways people behave towards the use of water and sanitation. F&E requires a wide range of stakeholders beyond the health providers. There is no "one size fits all" solution.

Skip to 2 minutes and 15 secondsIn this week, we look closely as to what is meant by water and sanitation hygiene activities. We also learn from an example in Uganda about what is meant by context-specific situation analysis and implementation of F&E. We encourage you to share your perspectives, experiences, and even images as we go along through this week.

Welcome to week 4: Face washing and the environment

The known risk factors for the spread of trachoma all seem to point towards children.

Children with active disease (TF) spread the infection through:

  • Crowding – children often sleep in the same room or share bedding
  • Flies – especially Musca sorbens, the eye seeking fly is attracted to the Ocular and nasal discharge of the faces of children
  • Fomites - materials likely to carry infection such as shared cloths/ towels
  • Fingers - wiping away ocular and nasal discharge

Evidence has pointed to the fact that it is not how often a child cleans their face that is important but the outcome: Does the child have a clean face?

A study in The Gambia demonstrated that an unclean face increase the risk of trachoma by nearly three times. Many other studies have also reported similarly strong association between trachoma and dirty faces.

The presence of flies and ocular or nasal discharge on the face increases the risk of trachoma transmission even further. The table below is from a study of 1960 children in Ethiopia in 2005. The researchers found that children with discharge and flies in their eyes were more than 8 times more likely to have active trachoma compared to children without discharge or flies in their eyes.

Discharge and/or flies seen in child’s eyes Likelyhood that child has active trachoma compared to child with no discharge or flies
No discharge or flies 1
Discharge but no flies 3
Flies but no discharge 3.4
Discharge and flies 8.3

Flies also carry infection from one person to another. This was demonstrated in a simple experiment carried out in 1975 in Iran. A drop of fluorescein liquid was placed in the eye of a child. Fluorescein is a red coloured, slightly soluble compound which is widely used in medicine to trace the movement of bodily fluids. The child then played with other children on a mat in the presence of flies. After about half an hour all the children were examined using a blue light. “Fly spots” of fluorescein were identified in eyes of the children as well on their clothes. This confirmed how effective the flies could be in the transmission of an infection.

Using the evidence from these studies and others, F&E interventions for trachoma elimination aim to achieve clean faces and environmental improvement through reductions in the number of flies, crowding and the sharing of fomites.

The availability of water is an important factor affecting how a community is able to adopt hygiene measures and establish new behaviours to achieve F&E outcomes.

Evidence on the link between availability of latrines and reduced transmission of trachoma is weak but there is no doubt that presence of human and animal faeces or household garbage attracts flies. Any increase in fly density also increases the risk of trachoma transmission.

Achieving F&E is essential to attain sustainable elimination of trachoma. And forging strategic alliances and partnerships in the process are essential for achieving wider developmental goals.

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Eliminating Trachoma

London School of Hygiene & Tropical Medicine

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