Mass treatment helps Uganda to eliminate trachoma

PIC: Poor feacal disposal has accelerated the sprread of trachoma in Karamoja. (Credit: Lilian Namusoke Magezi)  

HEALTH

For a long time, Margaret Poot, a resident of Kalodek Village in  Kaabong district, had recurrent eye infections. "It always felt like there was soil in my eyes and I could not see properly," explains Poot.

Poot says a member of the village health team (VHT) diagnosed her condition as trachoma and referred her to a health centre where she was treated and sensitized about trachoma prevention. In 2014, Poot started taking antibiotics every year during mass treatment, which aimed at preventing trachoma. Since then, she has never suffered from trachoma again. Poot says she now endeavors to wash her face and hands every morning and after being to her garden as she was advised by the VHT.

Just like Poot, Maria Sire and Christine Nyarupe, also have a similar story. Sire and Nyarupe, both of whom live in the same manyata (enclosed settlement made up of several households) in Kangigetei in Kaabong parish struggled with recurrent trachoma. However, they say they have been fine since they started taking drugs during the annual mass treatment exercises. They were also sensitized about proper hygiene and sanitation.

At Lomeris Health Centre II in Kaabong West, Hellen Lalam, an enrolled midwife, discloses that since she joined the centre in October 2017, she has only treated one case of trachoma, which she treated in May this year. Records at the health centre also show that there was only one case of trachoma in 2016.

Factfile 

According to the health ministry, trachoma is an infectious eye disease caused by bacteria and it is spread from one person to another through contact with an infected person and by flies, which move the bacteria from one person to another. It is also spread through dirty fingers and contaminated cloth, such as a handkerchief or towel used to clean faces.

Risk factors for transmission include poor hygiene and sanitation (both personal and environmental). For example, not washing one's face and not keeping one's environment clean, like disposing of faeces and other types of waste in an improper manner.

Signs and complications include swelling of the inner part of the eye, itchiness, redness, having a discharge and a sandlike sensation.

Trachoma causes the inner upper eyelid to become inflamed and with repeated infection, the eye lid becomes scarred, which causes it to shorten. Subsequently, this causes the eyelashes to turn inward and rub on the eyeball, which then causes scarring of the cornea (transparent layer on the front of the eye) and can lead to blindness. According to WHO, trachoma is the world's leading cause of preventable blindness.

Trachoma can be prevented through ensuring proper personal and environmental hygiene. Therefore, people are urged to keep their faces clean by washing with soap and water every day and avoid sharing handkerchiefs and towels.

People are also urged to dispose of waste (including faeces) properly, so as to minimize presence of flies, which transmit the disease.

Trachoma is categorised under a group of diseases referred to as neglected tropical diseases (NTDs). The World Health Organization set a target for countries to eliminate NTDs by 2020. 

In May, WHO validated Nepal as the first country to eliminate trachoma as a public health threat.

Mass treatment

Uganda is on the road to eliminating trachoma as a public health problem having moved from 38  districts that were endemic to the condition in 2010 to only two (Moroto and Nakapiripirit). The disease was previously especially endemic in Karamoja and Busoga regions. 

Before the implementation of mass treatment over 900,000 children under 10 years had the disease and 10 million people were at risk of acquiring it. Information from the health ministry also shows that about 47,000 people were blind from it and 250,000 were at risk of becoming blind.

The elimination of trachoma has been achieved through treating everyone in the endemic districts with antibiotics once every year since 2014. The mass drug administration programme is implemented by RTI/ENVISION, a USAID-funded project.

Benjamin Binagwa, the chief of party for RTI/ENVISION, explains that drugs are given to every resident in the endemic districts, save for children below two years for fear of adverse side-effects. Those between two and five years are given syrup, while the rest are given tablets (azithromycin), save for pregnant women and those found with active trachoma infection who are given tetracycline eye ointment.

VHTs instrumental in mass treatment

Binagwa explains that they work with the existing Ministry of Health structures to ensure that all the people in the endemic districts get treated. The drugs are distributed by VHTs who move from house to house for about a week. The distribution takes place in October. Prior to distribution, VHTs have to move from house to house registering residents for proper planning. 

According to Dr. Charity Oneko, the team leader for CUAMM (Doctors with Africa) in Kaabong, as they register residents, the VHTs sensitise them about the treatment and why it is necessary. This has helped to make residents more receptive of the treatment and, thus, increase its uptake, notes Aldo Okwera, a nursing assistant at Lokolia Health Centre III in Kaabong.

Furthermore, Godfrey Kibwota, the senior environmental health officer for Kaabong district, notes that working with VHTs helps to make residents less suspicious of the drugs because the VHTs are part of the communities.


Other interventions

Binagwa acknowledges that in fighting trachoma, mass treatment has been complemented by other interventions such as surgery and proper hygiene and sanitation practices such as keeping one's face and environment clean so as to prevent flies that spread trachoma.

Kibwota noted that one of the major factors predisposing residents of Karamoja to trachoma is the practice of open defecation. He said they have been discouraging residents about the practice and encouraging them to build latrines. As a result, latrine coverage in Kaabong has increased from 0.2% in 2010 to 31% as of June 2018. 

Struggle continues 

Binagwa explains that ‘elimination' implies that the prevalence of active trachoma stands at less than 5% of the total population in the district. He adds that they will stop carrying out mass treatment in the districts that have been declared free of trachoma. So in the next round of mass drug administration (to take place in October), drugs will only be distributed in Moroto and Nakapiripirit districts.

However, Binagwa is quick to warn communities against relaxing, saying the condition can reoccur if people do not take the necessary precautions because the factors that predispose them to trachoma are still present. These include open defecation/ low latrine coverage, lack of clean, poor facial and environmental hygiene.


Environmental hygiene 

Oneko noted that there is still need to make homesteads cleaner by separating animals from where people stay because they carry flies that can transmit trachoma.


Open defecation/ low latrine coverage

The toilet coverage in Karamoja region is low, for example Kaabong is at 31% and Moroto is 24.9%. Kibwota noted that open defecation is still a big problem in Karamoja and it is mainly due to cultural beliefs. For example, Oneko explained that unfortunately, people believe that when one uses a latrine, dead people in the soil will be looking at them. On the other hand, pregnant women are discouraged from using latrines for fear that the baby might fall in there; while parents, children and in-laws are told not to share latrines because they believe that it can lead to bad luck if they mixed their faeces. All these beliefs have promoted the practice of open defecation.

Other reasons people give for not constructing latrines is that the soils are loose or rocky or that they lack money, materials and tools to construct permanent latrines. 

In addition, the economic practices among the Karimojong (nomadic pastoralism and gold mining) have made it hard for open defecation to be eliminated. Walter Owiny, the health inspector for Rupa sub-county in Moroto district, explains that as people move from one area to another in search for pasture, water or new areas to mine, they cannot keep on constructing latrines in the new areas.

Owiny also noted that some residents miss treatment during the mass drug administrations because they might have moved.

In addition, local leaders in Moroto, disclose that nomadic pastoralists from Turkana in Kenya keep on spreading trachoma among the people in Moroto where they usually come in search for water and pasture. Lucy Nachuge, a VHT for Acholi Inn Village in Moroto, explained that when mass treatment is being carried out in October, the Turkana are usually in their place, so they do not get treated. They start shifting to the Ugandan side in December where they stay until the end of March. These herders keep on reintroducing trachoma.

Therefore, she urged the Government to liaise with authorities in Kenya so that the normadic pastoralists on the Kenyan side (the Turkana in Moroto and the Pokot in Amudat) are also catered for during mass treatment.


Way forward 

Oneko says there is need to continue sensitizing residents, especially the old people who are stuck in their ways, about the need for proper hygiene and sanitation practices. Kibwota also noted that sometimes posters are put up by the ministry of health with good messages, but the messages do not appeal to the Karimojong because they are usually presented in Iteso or Acholi and the models on them seem foreign. So, he advised the ministry to use some of the dialects in Karimojong and use models that the Karimojong can related with.

Kibwota also urged the Government to employ more environmental health staff at the districts to carry out health education and promotion.

Owiny urged the districts to enact and enforce by-laws to ensure that residents construct and use latrines. He says since a lot of sensitization has been done but people are not responding, there is need to use a law and force to make people do what is required of them.


Government urged

Oneko urged the Government to make water more accessible in Kaabong district and the whole of Karamoja region. She advised for construction of boreholes and valley dams to stop people from sharing water with animals in the streams. She noted that water in the streams is usually contaminated and can lead to water-borne diseases.

Oneko appealed to the Government and partners to continue with surveillance and treatment of the few cases of trachoma that may be there. She explained that when a disease is eliminated, the few people who get it usually end up suffering a lot because they are not planned for. In addition, they are usually misdiagnosed because it becomes hard for a health worker to think about it. She noted that this has already started happening for trachoma, where cases are misdiagnosed as red eyes or conjunctivitis.

In the meantime, she urges the government and partners to celebrate the milestone and make it public. She commends RTI/ENVISION For carrying out mass treatment, noting that as a country, we could not have neared total elimination without the contribution of mass treatment.