Evaluating alternative models to optimise trachoma trichiasis case finding and surgical outreach in areas with low prevalance

• To explore the most appropriate method of finding trachoma trichiasis (TT) cases for the areas with rapidly decreasing TT prevalence
• To consider the positive and negative impacts of adding additional eye care services to the TT outreach

This was a prospective descriptive study which utilised both routine programme data and additional primary data collected from the field. The study was conducted in Ajingi, Kura, and Tudun Wada local government areas of the Kano State.

The study compared the following four methods:

• Method 1: House-to-house case finding by community volunteers for TT only, and management of TT only at the outreach camps.
• Method 2: House-to-house case finding by community volunteers for TT only, followed by management of TT, cataract and other ocular morbidities through treatments at the outreach camps and referrals to nearby hospitals.
• Method 3: House-to-house case finding by trained health workers for TT and visual impairment, and management of different eye conditions through treatment at the camps and referrals to nearby hospitals.
• Method 4: Use of mass media to mobilise communities for eye care outreach camps and management of different eye conditions through treatment at the camps and referrals to nearby hospitals.

Each of the study sites was divided into four clusters to accommodate the four different methods. Clusters were matched across sites based on population and known eye morbidity to ensure comparability.

Results

The number of camp attendees across methods 1-4 was 403; 1,072; 1,419 and 1,901. The yield of TT cases among people presenting at the camp was 32.5%, 16%, 11.9% and 10.25% respectively.

The proportion of females among patients attending the camps varied from 53.4% in method 3 to 70% in method 1.

The proportion of self-referrals varied from 40.1% in method 3 to 55.7% in method 2. There was little difference in the proportion of confirmed TT cases among those referred by the case finders (79%-82%), and little difference in the proportion of TT cases managed at the camp (90.8%- 98.8%).

The proportion of patients diagnosed with cataract among those attending the camps varied from 14% in method 2 to 38.9% in method 4. The proportion of females among those with diagnosed cataract varied from 50.3% in method 2 to 71% in method 1. The proportion of other (non-TT and non-cataract) ocular morbidities identified at the camps varied from 13.4% in method 4 to 39.2% in method 1.

The average project expenditure for finding one TT case were similar in methods 1- 3 ($5.4-$6.3 US dollars). The expenditure per one TT case found using method 4 was 3.5 times higher ($21.5  per TT case found). The average project expenditure per cataract case managed varied from $32.6  in method 4, to $48.8 in method 2. The expenditure for managing other ocular morbidities varied from $4 per case in method 4, to $6.7 in method 3.

Conclusion

This study found that the house-to-house search for TT cases only and the focus of outreach camps on patients with TT had the highest yield of TT cases among patients attending the camp. However, even in this TT-focused approach, two thirds of the camp attendees were non-TT cases; about a quarter of patients had cataract and nearly 40% required treatment for other ocular morbidities.

This study showed that mobilising patients with other eye conditions alongside TT outreach campaign is feasible. However, such camps can increase the number of camp attendees four to five fold; the camps require additional human resources and effective camp management. It will be useful to further evaluate the effect of providing additional eye care services on the TT surgical outcomes and camp staff motivation.

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