Journal of Pediatric Ophthalmology and Strabismus

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Analysis of the Prevalence of Trachomas: Selected Environmental and Social Factors

Gerald L Portney, MD

Abstract

In 1968, it was decided to screen every resident of the San Xavier Papago Indian Reservation for the presence of active trachoma. Prior to that time, screening efforts were directed only at the school children. If a child presented with active disease, appropriate doses of triplesulfonamide were sent to his home for all members of the family to take. Whether or not all the medicine was taken as directed was not known.

Because the school-child trachoma rate had become relatively static at about 15 per cent, it was thought that total reservation screening might yield better results. This, in fact, has become the case in that the active trachoma rate for the entire population fell from 12 per cent in October, 1968, to 6 per cent in April, 1969. After both surveys, all active trachoma patients and their families were treated. Results of a home environmental sanitation survey were correlated with the presence or absence of active trachoma. In 1969, only the factors of "area" and "sleeping space per person" were found to be significantly related to trachoma. This correlation was opposite to expectations, i.e., the more space available, the more active trachoma.

In an effort to ascertain more information about the control of trachoma in this population and to follow up the work of the previous \ two years, the following investigation was undertaken.

Method

In February, 1970, one day-long clinic was established at the San Xavier Mission School at which 176 San Xavier residents were seen. During the following week, a door-to-door survey of the remainder of this reservation ? population was conducted. In all, 446 people were examined.

Each household head was asked a series of four questions on the subject of his family's attitude toward trachoma. This part of the survey was conducted in private by the ViceChairman of the San Xavier Papago district. The questions asked were:

1. Has anyone in your family gone blind from trachoma?

2. In recent years, have a lot of people in your family had trachoma?

3. Has everyone taken all the trachoma medicine which they were given?

4. Do you think that the U.S. Public Health Service should stop doing special check-ups for trachoma?

In addition, the results of the home environmental sanitation information were reviewed once more in conjunction with newly gathered data on sanitary conditions in the San Xavier Mission School.

Results and Discussion

The active trachoma rate in the entire San Xavier population in February, 1970, was 7 per cent. Dividing this down further, the rate in the San Xavier Mission School was 20 per cent, whereas in the remaining segment of the population it was only 4 per cent.

Table

In view of the consistently higher trachoma rate in the San Xavier Mission School throughout all three total reservation surveys and the relatively high trachoma rate in that school population during the previous five years, special steps seem warranted. The first involves specific sanitation measures. In terms of the physical plant, the presence of hygienically sound and well-equipped washrooms seems mandatory. In terms of attitude, the students as well as the teachers might be benefited by instruction on how to improve their approach to the prevention of the spread of trachoma. The second step would be the treatment with triplesulfonamides of the entire school population (including all personnel) for a period of three weeks. With these steps taken, the trachoma rate in the Mission School may be markedly reduced.

The absence of the significant correlation of even one individual home sanitation variable with active trachoma further emphasizes the conclusion reached as a result of last…

In 1968, it was decided to screen every resident of the San Xavier Papago Indian Reservation for the presence of active trachoma. Prior to that time, screening efforts were directed only at the school children. If a child presented with active disease, appropriate doses of triplesulfonamide were sent to his home for all members of the family to take. Whether or not all the medicine was taken as directed was not known.

Because the school-child trachoma rate had become relatively static at about 15 per cent, it was thought that total reservation screening might yield better results. This, in fact, has become the case in that the active trachoma rate for the entire population fell from 12 per cent in October, 1968, to 6 per cent in April, 1969. After both surveys, all active trachoma patients and their families were treated. Results of a home environmental sanitation survey were correlated with the presence or absence of active trachoma. In 1969, only the factors of "area" and "sleeping space per person" were found to be significantly related to trachoma. This correlation was opposite to expectations, i.e., the more space available, the more active trachoma.

In an effort to ascertain more information about the control of trachoma in this population and to follow up the work of the previous \ two years, the following investigation was undertaken.

Method

In February, 1970, one day-long clinic was established at the San Xavier Mission School at which 176 San Xavier residents were seen. During the following week, a door-to-door survey of the remainder of this reservation ? population was conducted. In all, 446 people were examined.

Each household head was asked a series of four questions on the subject of his family's attitude toward trachoma. This part of the survey was conducted in private by the ViceChairman of the San Xavier Papago district. The questions asked were:

1. Has anyone in your family gone blind from trachoma?

2. In recent years, have a lot of people in your family had trachoma?

3. Has everyone taken all the trachoma medicine which they were given?

4. Do you think that the U.S. Public Health Service should stop doing special check-ups for trachoma?

In addition, the results of the home environmental sanitation information were reviewed once more in conjunction with newly gathered data on sanitary conditions in the San Xavier Mission School.

Results and Discussion

The active trachoma rate in the entire San Xavier population in February, 1970, was 7 per cent. Dividing this down further, the rate in the San Xavier Mission School was 20 per cent, whereas in the remaining segment of the population it was only 4 per cent.

Table

TABLE ITRACHOMA RATE IN THE SAN XAVIER MISSIONSCHOOL

TABLE I

TRACHOMA RATE IN THE SAN XAVIER MISSIONSCHOOL

Results of screening in this school since 1963 indicate that the active trachoma rate there has always been significant. These statistics are summarized in Table I.

This year's relatively large amount of trachoma in the school prompted this investigator to undertake informal discussions with the teachers at the Mission School and to investigate the sanitary conditions there. As a result, it was discovered that the children have no towels in their washrooms except for some occasional rags. If they desire a papeT towel, the children must instead return to the classroom and ask for one. This procedure has been reportedly undertaken so that the students will not have the opportunity to scatter the towels on the floor. If, as suspected, trachoma is transfered by liquid vector, the use of either a common towel (possibly the rags) or the childrens' intermingling while their hands and faces are wet on the way back to the classroom might provide a means to transport the trachoma agent among them.

Analysis of the attitudinal survey (Table II) gives the following results:

1. Fourteen per cent of household heads have known of a family member who became blind from trachoma.

2. Fourteen per cent of household heads have had a "lot of trachoma" in their family in recent years.

3. In families where there had been a "lot of trachoma" in recent years, all positive cases took all of the medication which they were given.

4. On the other hand, in families where there had not been a "lot of trachoma" in recent years, only 55 per cent of the people took all of their medication.

5. When a "blind from trachoma" family member was known to the household head, the last percentage rose to 88 per cent.

6. Seventeen per cent of those household heads who had neither known a "blind from trachoma" family member nor had a "lot of trachoma" in their family in recent years thought that the Public Health Service should not continue some sort of mass screening program for trachoma. All others thought that the Public Health Service should continue.

From this survey, it appears, as one might expect, that the people who are most concerned about trachoma are those who have had the most severe exposure to it and its sequelae.

Statistical correlations were performed on 18 home environmental sanitation variables in relation to the presence or absence of active trachoma in various combinations of the three completed total population trachoma surveys (Table III). Contrary to the previous correlations, space available was not found to be in any way significantly related to the incidence of the disease.

Table

TABLE IIRESULT OF ATTITUDINAL SURVEY

TABLE II

RESULT OF ATTITUDINAL SURVEY

This can be explained in part by the observation that the pocket of active trachoma which was found in the adult population 18 months ago has now been reduced from 12 to 4 per cent. Almost always there is a higher percentage of adults in small-sized families. Generally speaking, the smaller the family size, the greater the space available per person (since most homes are of similar size) and the higher the percentage of active trachoma found during the first survey.1 In fact, at that time, 33 per cent of the active trachoma was found in a family size of three or fewer people. During the last survey this figure fell to 17 per cent. This approximately 50 per cent reduction of active trachoma in families with relatively greater space per person is sufficient to abolish the previously found correlation.

An interesting statistic was found in this present survey, however. At the 0.75 per cent confidence limit, poor home toilet maintenance was positively correlated With active trachoma in only that group which had active disease in all three surveys. Besides this objective evidence, this factor may well be a reflection of individual attitude toward personal hygiene. In any event, it is a variable which deserves more careful scrutiny.

Conclusions

Total screening of the San Xavier Papago Reservation seems to have had a sustained lowering effect on the trachoma rate. This is probably in part due to the newly increased level of treatment brought about by this program. On the other hand, better hygiene because of an awakened disease awareness in the people must certainly play a significant role. Whatever the cause, the trachoma rate of 4 per cent in the non-Mission School population is a remarkable improvement.

Table

TABLE IIINUMBER OF PEOPLE WITH ACTIVE TRACHOMA IN VARIOUS SURVEYS

TABLE III

NUMBER OF PEOPLE WITH ACTIVE TRACHOMA IN VARIOUS SURVEYS

In view of the consistently higher trachoma rate in the San Xavier Mission School throughout all three total reservation surveys and the relatively high trachoma rate in that school population during the previous five years, special steps seem warranted. The first involves specific sanitation measures. In terms of the physical plant, the presence of hygienically sound and well-equipped washrooms seems mandatory. In terms of attitude, the students as well as the teachers might be benefited by instruction on how to improve their approach to the prevention of the spread of trachoma. The second step would be the treatment with triplesulfonamides of the entire school population (including all personnel) for a period of three weeks. With these steps taken, the trachoma rate in the Mission School may be markedly reduced.

The absence of the significant correlation of even one individual home sanitation variable with active trachoma further emphasizes the conclusion reached as a result of last year's study, i.e., "[It] is not possible to predict with any degree of confidence that the presence or absence of certain sanitation criteria will alter the individual trachoma rate."1

It is of note that the significance of available space which was found in the previous investigation did not reappear in the present analysis.

The failure of families with "little" trachoma to take all their prescribed trachoma medication is a factor which deserves closer attention. It seems likely that only with increased educational efforts and intensive surveillance could this apparent "trend" be reversed.

If this situation prevails then, as the trachoma rate falls, it could become more difficult to eliminate the remaining small percentage of active disease in families which are poorly motivated to take the prescribed medication.

References

1. Portney, G. L. and Hoshiwara, I.: Analysis of Prevalence of Trachoma and Selected Environmental Factors. Health Program Systems Center, Tucson, Arizona, 1969.

TABLE I

TRACHOMA RATE IN THE SAN XAVIER MISSIONSCHOOL

TABLE II

RESULT OF ATTITUDINAL SURVEY

TABLE III

NUMBER OF PEOPLE WITH ACTIVE TRACHOMA IN VARIOUS SURVEYS

10.3928/0191-3913-19701101-12

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