Trachoma in Malawi: from mapping to action plan

Dr Khumbo Kalua, Trachoma Technical Advisor for the Malawi Ministry of Health, reports on progress towards elimination of trachoma in Malawi, a densely populated country in southern Africa with 16 million inhabitants.

Using the opportunity provided by the Global Trachoma Mapping Project (GTMP) the Malawi Ministry of Health decided to map 25 districts suspected of being trachoma-endemic.

The mapping survey aimed to:

• Determine the prevalence of active trachoma (TF) in 1-9 year old children, and the prevalence of trachomatous trichiasis (TT) in adults aged 15 years and above.

• Guide the implementation of a trachoma program in any evaluation unit (EU) found to have prevalences of TF or TT higher than the elimination threshold set by the WHO.

<img src="https://ugc.futurelearn.com/uploads/assets/ef/55/ef55a967-4ecf-4cca-a538-8a0169589a53.png" alt="The two WHO trachoma elimination targets are: TF < 5% in children aged 1-9 years and TT

Key features of the survey

• Mapping carried out between 2013 and 2015, using the standard GTMP protocols
• Total population in suspected trachoma endemic districts = 9 million
• Number of evaluation units (EUs) = 28. In trachoma mapping, the population is divided into EUs first. It is helpful but not always possible for the EU boundaries to correspond with the boundaries of existing administrative divisions. Several Malawi districts had to be divided into multiple EUs as they were too large (they had populations of >250,000 people)
• Sample size in each EU = 1019 children aged 1-9 years, inflated by 1.2 to account for non-response
• 30 clusters of 30 households in each EU were needed to achieve the required sample size
• In total there were 840 clusters and 25 200 households
• GTMP-certified graders examined approximately 84 000 residents aged one year and over.

Mapping was carried out by 10 survey teams, each consisting of a GTMP-certified grader, a GTMP-certified recorder and a driver. Each team examined one cluster per day. Teams were assisted by a community health worker in each cluster and three senior staff provided supervision.

Survey results

Trachoma was identified as being a public health problem in six districts in Malawi. All six had prevalences of TF and TT above the WHO-defined elimination targets. None of the districts were providing trichiasis surgery services at the time of the survey.

The mapping also provided data on access to water and sanitation in each EU.

Trachoma endemic districts in Malawi identified by the GTMP

Trachoma Action Plan

Based on the evidence provided by the mapping, a taskforce was formed involving all the key trachoma elimination stakeholders in Malawi:

• Ministry of Health
• Blantyre Institute of Community Ophthalmology
• Non-Governmental Organisations (NGOs) – WaterAid and Sightsavers
• Coordinators of Neglected Tropical Disease (NTD) and Water, Sanitation and Hygiene (WASH) programmes
• District clinical officers
• Cataract surgeons
• Pharmacy technicians
• Academics.

In 2014, the taskforce drew up a five year trachoma action plan (TAP) to implement the SAFE strategy to eliminate trachoma in the six endemic districts.

Mass drug administration with azithromycin was started. Mangochi and Machinga districts, which had TF prevalences of 5.0 – 9.9%, were allocated one round of treatment. The remaining four districts were allocated three rounds of annual treatment. Interventions to address facial cleanliness and hygiene improvements (F&E) were begun.

The TAP also planned how to increase productivity of Malawi’s trichiasis surgery services by strengthening infrastructure, human resources and community involvement.

Improvements to infrastructure:

• Procurement of trichiasis surgery instrument sets (three per surgeon) and supplies
• Renovation of eye theatres in district hospitals and purchase of theatre beds.

Increased human resources and community involvement:

• Training and certification of 17 ophthalmic clinical officers as trichiasis surgeons
• Training ophthalmologists as district supervisors
• Training 100 case finders per district to find and refer cases for trichiasis surgery.

Supporting and implementing partners were identified and the Ministry of Health took on the overall co-ordination of the programme. Standardised reporting and monitoring tools were put in place and stronger links developed with district hospitals.

The Queen Elizabeth Diamond Jubilee Trust agreed to finance the entire Malawi budget over the five years 2014 – 2019 through a coalition of partners active in the country.

Path to elimination

An active trachoma elimination programme was implemented in Malawi between 2014 and 2019 with approximately 6000 people with trichiasis operated on.

The last planned mass drug administration took place in 2017. For all districts, except two, a round of impact surveys and subsequent surveillance surveys have demonstrated that the prevalence of both TF and TT is below the World Health Organization (WHO) threshold for elimination. The last two districts have had their impact surveys, with both having TF and TT prevalence below the WHO target thresholds by 2018. These two districts will therefore have their surveillance surveys in the second half of 2020 to ensure that they are on track and being supported appropriately to attain elimination.

In addition, stakeholders are working to jointly implement water, sanitation and hygiene (WASH) interventions in areas identified by the survey. These should have an impact on trachoma and other diseases of public health importance and improve the general quality of life for many people in Malawi.

The trachoma mapping exercise was crucial in helping to spur the Malawi trachoma elimination programme to its current productive state. There is justified optimism Malawi will achieve trachoma elimination before the December 2020 deadline.

The last planned mass drug administration took place in 2017. For all districts, except two, a round of impact surveys and subsequent surveillance surveys have demonstrated that the prevalences of both TF and TT are below the WHO threshold for elimination. The last two districts have had their impact surveys, with both having TF and TT prevalence below the WHO target threshold by 2018. These two districts will therefore have their surveillance surveys in the second half of 2020 to ensure that they are on track, and being supported appropriately, to attain elimination.

In addition, stakeholders continue to implement water, sanitation and hygiene (WASH) interventions in targeted areas. These should have a sustained impact on trachoma and other diseases of public health importance and improve the general quality of life for many people in Malawi.

The Ministry of Health is preparing a draft dossier for submission to WHO for validation of trachoma elimination as soon as the remaining two districts have been cleared.

The initial trachoma mapping exercise was crucial in helping to spur the Malawi trachoma elimination programme to its current productive state.