TRA AFGAHAN DRAFT Report1

REPORT 2005
TRACHOMA RAPID
ASSESMENT IN THREE
DISTRICTS OF AFGHANISTAN
Nagarhar, Takhar, Parwan - 2005
Dr. Muhhamd Zahid Jadoon
Collaboration ; Pakistan Institute of Community Opthalmology, CBM Germany, MOPH Afghanistan 1

Contents
1. Background:................................................................................................................................................ 3
Rationale of the study .................................................................................................................................... 6
2. Objectives of the study are: ........................................................................................................................ 8
2.1 Trachoma Rapid Assessment (TRA) ..................................................................................................... 8
2.2 Key Features of TRA ............................................................................................................................... 8
3. Methodology............................................................................................................................................... 8
Selection of endemic areas for TRA ............................................................................................................ 9
The Information Pyramid ............................................................................................................................... 9
3. Results ...................................................................................................................................................... 11
Rapid Assessment Summaries for individual Villages are given below. .................................................... 11
RA Summary sheet for the province of Kandhar ( Distt Kandhar) ........................................................ 13
RA SUMMARY SHEET FOR PROVINCE. Nangahar (District: Dari-Noor) ....................................... 15
RA SUMMARY SHEET FOR PROVINCE. Takhar (District: Taluqan) ............................................... 17
RA SUMMARY SHEET FOR PROVINCE of Parwan (District: Bagram ) ......................................... 18
Prioritisation of Communities on Basis of Active Trachoma and Trachomatous Trichiasis. ..................... 21
Priority Ranking of Villages for Lid Surgery .......................................................................................... 21
Priority Ranking of Villages for Treatment of Active Trachoma and other interventions ...................... 22
High Medium and Low Priority Ranking for Safe Strategy .................................................................... 23
Risk Factors ................................................................................................................................................. 31
Province Nangarahar Distt. Dara-i-noor .................................................................................................. 31
Province Takhar ....................................................................................................................................... 32
Province Heart ......................................................................................................................................... 33
34MAPS....................................................................................................................................................... 36
2
1. Background:
The number of blind people in the world is not accurately known, but has been estimated by the World
Health Organization (WHO) to be approximately 45 million.1 A further 135 million people have low vision
and are at risk of becoming blind. Trachoma is the second leading cause of blindness worldwide. The main
causes of blindness and low vision are cataract, trachoma, glaucoma, onchocerciasis, and xerophthalmia.
What is Trachoma?
Trachoma, a chronic keratoconjunctivitis, is caused by episodes of infection with Chlamydia trachomatis,

an obligate intracellular bacterium. Only serovars A, B, Ba, and C are implicated in trachoma. The disease
tends to cluster in certain communities within a village and certain families within a neighborhood.
Women, especially in rural areas, are affected twice as often as men2.
The evolution of the disease typically presents two stages, that are separated by several years, or often
decades:
 Inflammatory (active) trachoma, diagnosed most often in children. It spreads through contact with
eye discharge from the infected person (on towels, handkerchiefs, fingers, etc.) and through
transmission by eye-seeking flies.3 In many settings, girls tend to have more frequent and severe
active disease than boys.
 Cicatricial (scarring) trachoma, usually found in adults with ultimate development of Trichiasis
which leads to corneal opacities. If untreated, this condition leads to the formation of irreversible
corneal opacities. Blindness results from corneal opacification, which is related to the degree of
entropion or Trichiasis4. This is often found 3-4 times more commonly in women as compared with
men.
Trachoma is almost exclusively a disease of poor families and communities living in developing countries.
It accounts for 15% of blindness worldwide i.e. over 6 million people1. Apart from poverty and illiteracy
other the possible risk factors responsible for spread of trachoma in these communities include use of
open latrines, extent to which the water supply is limited, the distance from the water source, the amount
of water used for washing purposes, and overcrowding5
Role of Vision 2020 in Treatment and Prevention of Trachoma
Environmental risk factors are water shortage, flies, poor hygiene conditions, and crowded households. A
prolonged exposure to infection throughout childhood and young adulthood appears to be necessary to
produce the complications seen in later life. A single episode of acute Chlamydial conjunctivitis is not
considered sight threatening as there is virtually no risk of prolonged inflammation or blinding
complications.
A global initiative to eliminate trachoma as a blinding disease, entitled GET 2020 (Global Elimination of
Trachoma), was launched under WHO’s leadership in 1997. Through this initiative control activities are
instituted through primary health care approaches that follow the evidence-based “SAFE” strategy :
Surgery for Trichiasis, Antibiotics for active disease, Facial hygiene, Environmental improvement (sanitation
and water supply etc) to reduce the transmission of the disease.6,7,8
Surgery: WHO recommends the bilamellar tarsal rotation procedure as the preferred technique; it is easy
to perform and easy to learn9.
3
Antibiotics; A single dose of oral azithromycin (1 g in adults and 20 mg/kg in children)10. Some studies
recommend that in areas where trachoma is moderately prevalent (less than 35% of children with active
infection), it should be treated annually, but in hyper endemic areas (more than 50% of children with
active infection), it should be treated biannually. Such models, however, need to be validated by well-
designed clinical trials11.
Facial Cleanliness: A recent study in Mali found dirtiness of the face to be the most important risk factor
associated with trachoma12. Therefore Good facial hygiene aims to reduce transmission, the risk of
autoinfection in a community, and the risk of attracting flies.6,7
Environmental Factors: This component of the SAFE strategy also aims to reduce transmission of trachoma
by eliminating or reducing its risk factors, some of which are ubiquitous while others are specific to a
region. Improving access to water is a key element. Other measures, such as provision of latrines to reduce
the fly population, have also been found effective in reducing transmission3. As mentioned previously,
there is an important association between water and trachoma—though the association is not a simple
one. The distance to the water source constrains the amount of water used for hygiene practices.
Improving access to water on its own, however, may not be enough. In the case-control study in Gambia,
families with trachoma used less water per person per day for washing children than families without the
disease, regardless of the amount of water available13.
According to the World Health Organization, currently 84 million people, mostly children, have active
disease, and another 7.6 million people have Trichiasis, a stage of trachoma in which the upper eyelid turns
inward and one or more eyelashes rub against the eyeball 14. An estimated 10% of the world's population
lives in endemic areas and is at risk of developing trachoma. Global loss of productivity related to impaired
vision and blindness from trachoma is thought to be as high as $US 5.3 billion annually 15. More than 55
countries have been identified as endemic for trachoma, most of them in Africa and Asia.
Background to the study population
Afghanistan
Location; Southern Asia, north and west of Pakistan, east of Iran
Bordering Countries of Afghanistan: China 76 km, Iran 936 km, Pakistan 2,430 km, Tajikistan 1,206 km,
Turkmenistan 744 km, Uzbekistan 137 km.
Administrative setup 32 provinces (velayat, singular - velayat); Badakhshan, Badghis, Baghlan, Balkh,
Bamian, Farah, Faryab, Ghazni, Ghowr, Helmand, Herat, Jowzjan, Kabol, Kandahar, Kapisa, Konar, Kondoz,
Laghman, Lowgar, Nangarhar, Nimruz, Oruzgan, Paktia, Paktika, Parvan, Samangan, Sar-e Pol, Takhar,
Vardak, Zabol, Nurestan, and Khowst
Popualtion and Health Indicators

Source: (http://www.unicef.org/infobycountry/afghanistan_statistics.html)
Population Statistics of Afghanistan
Total Population: 27,755,775 people

Population Growth: 3.43 % per year
Population By Gender
Males; 53%
Females: 47%
Population by Age
4
01-14 yrs 42%
15-64 yrs 55.20%
65+ yrs 22.80
Male : Female
0-14; 5,953,291 5,706,542
15-64 7,935,101 7,382,101
65+ 410,278 368,462
Literacy Rate; : 36%

Literacy rate in males : 51%
Literacy rate in females : 21%
Life expectancy at Birth : 46 yrs

Life expectancy at Birth Males : 47.32 yrs
Life expectancy at Birth Females : 45.85 yrs
Water and Sanitation Facilities in Afghanistan

% of total population using improved drinking water sources (2002) 13
% of urban population using improved drinking water sources (2002) 19
% of rural population using improved drinking water sources (2002) 11
% of total population using adequate sanitation facilities (2002) 8
% of urban population using adequate sanitation facilities (2002) 16
% of rural population using adequate sanitation facilities (2002) 5
Recent History of Afghanistan
Afghanistan's recent history is characterized by war and civil strife, with intermittent periods of relative
calm and stability. The Soviet Union invaded in 1979 but was forced to withdraw 10 years later by anti-
Communist mujahidin forces supplied and trained by the US, Saudi Arabia, Pakistan, and others. Fighting
subsequently continued among the various mujahidin factions, giving rise to a state of warlordism that
spawned the Taliban in the early 1990s. The Taliban was able to seize most of the country, aside from
Northern Alliance strongholds primarily in the northeast, until US and allied military action in support of
the opposition following the 11 September 2001 terrorist attacks forced the group's downfall. The four
largest Afghan opposition groups met in Bonn, Germany, in late 2001 and agreed on a plan for the
formulation of a new government structure that resulted in the inauguration of Hamid KARZAI as Chairman
of the Afghan Interim Authority (AIA) on 22 December 2001. In addition to occasionally violent political
jockeying and ongoing military action to root out remaining terrorists and Taliban elements, the country
suffers from enormous poverty, a crumbling infrastructure, and widespread land mines.
5
Overview of the Afghanistan Economy:
Afghanistan is an extremely poor, landlocked country, highly dependent on farming and livestock
raising (sheep and goats). The main source of income in the country is agriculture. The major food crops
produced are: corn, rice, barley, wheat, vegetables, fruits and nuts. During its good years, Afghanistan
produces enough food and food products to provide for the people, as well as to create a surplus for
export. In Afghanistan, industry is also based on agriculture, and pastoral raw materials. The major
industrial crops are: cotton, tobacco, madder, castor beans, and sugar beets. Sheep farming is also
extremely valuable. The major sheep product exports are wool, and highly prized Karakul skins.
Afghanistan is a land that is rich in natural resources. There are numerous mineral and precious stone
deposits, as well as natural gas and yet untapped petroleum stores. Some of these resources have been
exploited, while others have remained relatively unexploited.
During that conflict one-third of the population fled the country, with Pakistan and Iran sheltering a
combined peak of more than 6 million refugees. Gross domestic product has fallen substantially over the
past 20 years because of the loss of labour and capital and the disruption of trade and transport; severe
drought added to the nation's difficulties in 1998-2001.
Many years of war and political instability have left the country in ruins, and dependent on foreign aid. The
majority of the population continues to suffer from insufficient food, clothing, housing, and medical care,
problems exacerbated by military operations and political uncertainties.
Post War Scenario in Afghanistan
The impact of war on health is usually assessed primarily in terms of its most direct and visible effects –
death and injury through conflict. The full effects of war are, however, felt through many other less direct
but potentially equally deadly or more deadly pathways which could lead to disasters in future. These
might include risk factors for certain diseases to which the population is exposed because of the war and
the impact could only be assessed when actually the disease spreads.
Following the US-led coalition war that led to the defeat of the Taliban in November 2001 and the
formulation of the Afghan Interim Authority (AIA) resulting from the December 2001 Bonn Agreement,
International efforts to rebuild Afghanistan were addressed at the Tokyo Donors Conference for Afghan
Reconstruction in January 2002, when $4.5 billion was collected for a trust fund to be administered by the
World Bank. Priority areas for reconstruction include the construction of education, health, and sanitation
facilities, enhancement of administrative capacity, the development of the agricultural sector, and the
rebuilding of road, energy, and telecommunication links.
Rationale of the study
In South East Asia most of the countries are endemic in Trachoma and the situation in Afghanistan may be
worst if not equal and the condition may get worsen in future as the war has left people exposed to the
risk factors responsible for trachoma.
Currently Afghanistan is at a stage of reconstruction for which funds are provided by different
governments and NGDOs. The major focus being Health, education, sanitations, clean water supply etc.
A detailed health survey on infectious diseases will also identify the areas where water health facilities,
water supply and sanitation needs improvement. Such detailed surveys are near to impossible keeping in
view the security situation Afghanistan.
6
WHO has developed some study designs (TRA, RACSS) for quick situation analysis for planning purposes.
This study focuses on Trachoma, a disease which may have risk factors at present and disaster effects in
future.
7
2. Objectives of the study are:
1. To identify Trachoma endemic areas in Afghanistan
2. To rank these areas communities into three groups of high, medium and low priority for
intervention.
When assessing trachoma it is important to assess not only the magnitude of the active disease, but also its
degree of severity and the existing risk factors at community/household levels, at a specific point in time.
In this regards epidemiological surveys offer a very useful way of collecting valuable information that is not
available from routine health information or existing surveillance systems. However, ‘classical’ surveys are
expensive (staff, time and money) and are often difficult to carry out in a timely manner.
Because of the limited resources in terms of Finances and human resources in Afghanistan this situation
analysis was carried out using WHO’s recommended tool “Trachoma Rapid Assessment”.
2.1 Trachoma Rapid Assessment (TRA)
In order to use scarce resources in a cost-effective and appropriate manner, and identify and reach the
communities most in need of intervention, it is necessary to determine where most severe blinding
trachoma is found. Thus, for programme purposes, a rational, rapid and low cost method of identifying
specific areas/communities liable to have a significant problem of blinding trachoma is needed.
RA methodology is one of the operational research issues (along with surveillance, antibiotic distribution
and community-based surgery) which have been agreed upon for further development by the WHO
Alliance for the Global Elimination of Trachoma by the Year 2020 (GET 2020).
2.2 Key Features of TRA
RA is based on community participation.

RA should be considered as an operational tool, developed to help decision makers to determine and
target the most highly endemic communities for treatment.
RA is a practical way of determining rapidly whether or not blinding trachoma is endemic in a given
community.
RA will allow for ranking of communities (for example into three groups of high, medium and low priority
for intervention). In that sense, RA facilitates the planning of trachoma control activities through the
identification of high-risk zones where large-scale interventions are indicated.
The basic principle is to collect the maximum of relevant information in the minimum of time and at the
lowest cost in order to build an information pyramid . The term ‘information pyramid’ refers to the
description of the trachoma situation in a defined geographical area. This will be a three level pyramid
3. Methodology
1. Selection of field coordinator/ teams
A meeting was held between the following in which Coordinator and Teams for TRA were selected.
1. Dr. Mohammad Babar Qureshi Medical Advisor CBM
8
2. Dr. Ahmed Shah National coordinator for Prevention of
. Blindness Afghanistan.
3.Dr. Mohammad Zahid Jadoon Epidemiologist Pakistan Institute of Comminity Ophthalmology

Pakistan.
4. Dr. Aimal Zaki Community Ophthalmologist Afghanistan
5. Dr. Murtaza Farrahamand Community ophthalmologist Afghanistan
Dr. Murtaza Farrahamand declined to take part in the study and the rest of the participants were given
training on the WHO manaula for TRA.
Dr. Ahmed Shah was selected as Coordinator and as well as team leader for One team. While Ahmed
Shah was the team leader for the second team. Because of lack of financial and human resources only
two teams were finalised.
Each Team were assigned communities for TRA.
3.1 Selection of endemic areas for TRA
The Information Pyramid
 The top level concerns obtaining data on

blinding trachoma and the existence of
cases of Trichiasis in a community.
 The middle level describes the presence and
severity of ‘active’ trachoma in the
community.
 The foundation of the pyramid is built on
information about risk factors and reflects
the socio-ecological factors which may
influence eye health and the severity of
trachoma in that community.
When planners and eye project managers
decide to carry out RA, they should collect
separate sets (‘blocks’) of information, from
different sources, in order to build up this
pyramid. It is therefore crucial for them to
find acceptable ways of gaining that
information.
9
1. First phase of investigationwill be rather
static/passive phase (mainly ‘desk work’) represents
a preliminary assessment and consists of:
 The information about all the endemic areas was gathered and
reviewed with the community ophthalmologists and the
National Corrdinator.
 Communities were selected based on the risk factors (Table 1).
 Out of these some communities were selected for TRA
keeping in view the limited resources available for the survey.
At the end of the first phase the following communities were selected for TRA on priority basis keeping in
view the limited resources.
2. second phase of investigation, the dynamic/active phase (mainly field work) in which visits were
conducted in selected communities.
Province District Village
Herat Gozerah Kort
Kul
Sia-oslian
Qandhar Donal Zakar sharif

Sabsi Kartoh
Shir surkh
Nangarhar Dari noor Lamatic

Sutan
Bambat-cot
Takhar Markaz Lataband

Talik
Pitaosai
Goragsai
Parwan Bagram Mahigeer

Ghulam ali
Ali khan
Gokacha
Information Collection in the second Phase
 Trichiasis was assessed through a series of simple questions, followed by the identification by the
community members of persons likely to suffer from ‘in-turned’ eyelids with lashes rubbing against
10
the cornea. An eye examination was carried out in every ‘suspected’ case, in order to confirm the
diagnosis of Trichiasis.
 At least fifty children (1-9 years old) were examined from the households at higher risk to assess
active infection in the community reservoir, using the WHO simplified trachoma grading system.
 Facial cleanliness was recorded for each child examined.
 Other hygiene-related risk factors were assessed at the household or community levels, such as
availability of latrines, availability of water, etc.
3. Results
Rapid Assessment Summaries for individual Villages are given below.
RA SUMMARY SHEET FOR PROVINCE. For the province of Heart (District: Guzara)
Village/Community: Kul Village/Community: Kort
Assessment of trichiasis pattern Assessment of trichiasis pattern
NUMBER OF 30 NUMBER OF 30
PERSONS 3.3 PERSONS 10
EXAMINED (1) EXAMINED (3)
% OF TRICHISIS % OF TRICHISIS
(No of People) (No of People)
Assessment of active trachoma Assessment of active trachoma
Pattern Pattern
PERSONS PERSONS 4
10
EXMANIED EXMANIED
% OF CHILDREN (0) % OF CHILDREN (0)
WITH ACTIVE WITH ACTIVE
TRACHOMA TRACHOMA
(TF)
Assessment of personal hygiene (TF)
NUMBER OF 50 Assessment of personal hygiene
CHILDREN 18 NUMBER OF 50
OBSERVED CHILDREN 10
% OF DIRTY FACES OBSERVED
Assessment of water available % OF DIRTY FACES
HOUSEHOLD Assessment of water available
MORE THAN HALF 0 HOUSEHOLD
HOUR WALK MORE THAN HALF 0
FROM WATER HOUR WALK FROM
SOURCE WATER SOURCE
Assessment of proximity to garbage, Assessment of proximity to garbage,
human wastes or animal pens human wastes or animal pens
HOUSEHOLDS AT 20 HOUSEHOLDS AT 18
RISK RISK
Assessment of absence of latrine Assessment of absence of latrine
HOUSEHOLDS 0 HOUSEHOLDS 0
WITHOUT WITHOUT LATRINE
LATRINE
11
Village/Community: Sia-Oshan
Assessment of trichiasis pattern
NUMBER OF 30
PERSONS 16. 5
EXAMINED (5)
% OF TRICHISIS
(No of People)
Assessment of active trachoma
Pattern
NUMBER OF 50
PERSONS 8
EXMANIED
(4)
% OF CHILDREN
WITH ACTIVE
TRACHOMA
(TF)
Assessment of personal hygiene
NUMBER OF 50
CHILDREN 20
OBSERVED
% OF DIRTY
FACES
Assessment of water available
HOUSEHOLD
MORE THAN 0
HALF HOUR
WALK FROM
WATER SOURCE
Assessment of proximity to garbage,
human wastes or animal pens
HOUSEHOLDS AT 20
RISK
Assessment of absence of latrine
HOUSEHOLDS 0
WITHOUT
LATRINE
12
RA Summary sheet for the province of Kandhar ( Distt Kandhar)
Village/Community: Sabsi-kartoh Village/Community: Shere-Surkh
PERSONS 0 PERSONS 0
Pattern Pattern
PERSONS PERSONS
0 0
EXMANIED EXMANIED
TRACHOMA TRACHOMA
(TF)
% OF DIRTY OBSERVED
FACES % OF DIRTY
Assessment of water available FACES
MORE THAN 0 HOUSEHOLD
HALF HOUR MORE THAN 0
WALK FROM HALF HOUR
WATER SOURCE WALK FROM
Assessment of proximity to WATER SOURCE
garbage, human wastes or animal Assessment of proximity to
pens garbage, human wastes or animal
pens
HOUSEHOLDS AT 25
RISK HOUSEHOLDS AT 15
Assessment of absence of latrine RISK
HOUSEHOLDS 0
WITHOUT HOUSEHOLDS 0
LATRINE WITHOUT
LATRINE
13
Village/Community: Zaker-Sharif
NUMBER OF 30
PERSONS 0
EXAMINED (0)
% OF TRICHISIS
(No of People)
Pattern
NUMBER OF 50
PERSONS 0
EXMANIED
(0)
% OF CHILDREN
WITH ACTIVE
TRACHOMA
(TF)
NUMBER OF 50
CHILDREN 28
OBSERVED
% OF DIRTY
FACES
HOUSEHOLD
MORE THAN 0
HALF HOUR
WALK FROM
WATER SOURCE
HOUSEHOLDS AT 10
RISK
HOUSEHOLDS 0
WITHOUT
LATRINE
14
RA SUMMARY SHEET FOR PROVINCE. Nangahar (District: Dari-Noor)
Village/Community: Lamatic Village/Community: Bambo-Cot
PERSONS 23. 3 PERSONS 0
Pattern Pattern
PERSONS PERSONS
24 8
EXMANIED EXMANIED
TRACHOMA TRACHOMA
(TF)
OBSERVED CHILDREN 0
% OF DIRTY OBSERVED
FACES % OF DIRTY
WALK FROM HALF HOUR
pens
HOUSEHOLDS AT 56
HOUSEHOLDS 100
LATRINE WITHOUT
LATRINE
15
Village/Community: Sutan
NUMBER OF 30
PERSONS 33
EXAMINED (10)
% OF TRICHISIS
(No of People)
Pattern
NUMBER OF 50
PERSONS 18
EXMANIED
(18)
% OF CHILDREN
WITH ACTIVE
TRACHOMA
(TF)
NUMBER OF 50
CHILDREN 70
OBSERVED
% OF DIRTY
FACES
HOUSEHOLD
MORE THAN 0
HALF HOUR
WALK FROM
WATER SOURCE
HOUSEHOLDS AT 70
RISK
HOUSEHOLDS 100
WITHOUT
LATRINE
16
RA SUMMARY SHEET FOR PROVINCE. Takhar (District: Taluqan)
Village/Community: Talik Village/Community: Goroqsai
PERSONS 20 PERSONS 10
Pattern Pattern
PERSONS PERSONS
14 10
EXMANIED EXMANIED
TRACHOMA TRACHOMA
(TF)
% OF DIRTY OBSERVED
FACES % OF DIRTY
WALK FROM HALF HOUR
pens
HOUSEHOLDS AT 100
HOUSEHOLDS 100
LATRINE WITHOUT
LATRINE
17
Village/Community: Pitaosai
Village/Community: Lataband
Pattern Pattern
PERSONS 11 PERSONS
18. 33
EXMANIED EXMANIED
(6) (11)
% OF CHILDREN % OF CHILDREN
TRACHOMA TRACHOMA
(TF) (TF)
Assessment of personal hygiene Assessment of personal hygiene
CHILDREN 71 CHILDREN 68
OBSERVED OBSERVED
% OF DIRTY % OF DIRTY
FACES RA SUMMARY FACES
Assessment of water available SHEET FOR Assessment of water available
HOUSEHOLD PROVINCE of HOUSEHOLD
MORE THAN 100 Parwan (District: MORE THAN 87. 7
HALF HOUR Bagram ) HALF HOUR
WALK FROM WALK FROM
WATER SOURCE WATER SOURCE
Assessment of proximity to garbage, Assessment of proximity to
human wastes or animal pens garbage, human wastes or animal
pens
HOUSEHOLDS AT 100
HOUSEHOLDS 100
LATRINE WITHOUT
LATRINE
18
Village/Community: Gokcha Village/Community: Mohigeer
PERSONS 0 PERSONS 13. 63
Pattern Pattern
NUMBER OF 50 NUMBER OF
PERSONS PERSONS 54
2
EXMANIED EXMANIED
% OF CHILDREN (2) % OF CHILDREN 18. 5
WITH ACTIVE WITH ACTIVE (18. 5)
TRACHOMA TRACHOMA
(TF)
OBSERVED CHILDREN 46. 3
% OF DIRTY OBSERVED
FACES % OF DIRTY
WALK FROM HALF HOUR
pens
HOUSEHOLDS AT 80
HOUSEHOLDS 100
LATRINE WITHOUT
LATRINE
19
Village/Community: Ali Khan Khil Village/Community: Ghulam Ali
Pattern Pattern
PERSONS 9 PERSONS
EXMANIED 8
(9) EXMANIED
% OF CHILDREN (8)
% OF CHILDREN
TRACHOMA TRACHOMA
(TF) (TF)
Assessment of personal hygiene Assessment of personal hygiene
CHILDREN 40 CHILDREN 46
OBSERVED OBSERVED
% OF DIRTY % OF DIRTY
FACES FACES
Assessment of water available Assessment of water available
HOUSEHOLD HOUSEHOLD
MORE THAN 0 MORE THAN 100
HALF HOUR HALF HOUR
WALK FROM WALK FROM
WATER SOURCE WATER SOURCE
Assessment of proximity to garbage, Assessment of proximity to
human wastes or animal pens garbage, human wastes or animal
pens
HOUSEHOLDS AT 85
HOUSEHOLDS 100
LATRINE WITHOUT
LATRINE
20
Prioritisation of Communities on Basis of Active Trachoma and Trachomatous Trichiasis.
Priority Ranking of Villages for Lid Surgery

The highest priority is given to villages with largest number of Trichiasis and suspected Trichiasis cases.
Province District Village No examined No with TT

Nangahar Dari-Noor Sutan 30 10
Nangahar Dari-Noor Lamatic 30 7
Takhar Taluqan Pitaosai 20 7
Herat Gozerah Sia-Oshan 30 5
Takhar Taluqan Talik 20 4
Herat Gozerah Kort 30 3
Parwan Bagram Ghulam Ali 20 3
Parwan Bagram Mohigeer 22 3
Takhar Taluqan Goroqsai 20 2
Parwan Bagram Ali Khan Khil 20 2
Herat Gozerah Kul 30 1
Parwan Bagram Gokcha 20 0
Kandahar Kandahar Sabsi-kartoh 30 0
Nangahar Dari-Noor Bambo-Cot 30 0
Kandahar Kandahar Zaker-Sharif 30 0
Kandahar Kandahar Shere-Surkh 30 0
21
Priority Ranking of Villages for Treatment of Active Trachoma and other interventions
For full implementation of SAFE strategy villages are prioritised according to the level of active trachoma.
Villages with highest percentage of active trachoma are ranked first on the priority list.
Province District Village No of Children % A.Trachoma

examined
Nangahar Dara-i-Noor Lamatic 50 24
Parwan Bagram Mohigeer 54 18.5
Takhar Taluqan Lataband 60 18.33
Nangahar Dara-i-Noor Sutan 50 18
Takhar Taluqan Talik 54 14
Takhar Taluqan Pitaosai 55 11
Takhar Taluqan Goroqsai 50 10
Herat Guzara Kul 50 10
Parwan Bagram Ali Khan Khil 54 9
Nangahar Dara-i-Noor Bambo-Cot 50 8
Parwan Bagram Ghulam Ali 50 8
Herat Guzara Sia-Oshan 50 8
Herat Guzara Kort 50 4
Parwan Bagram Gokcha 50 2
Kandahar Kandahar Zaker-Sharif 50 0
Kandahar Kandahar Shere-Surkh 50 0
Kandahar Kandahar Sabsi-kartoh 50 0
This is continuous list of communities based on priority ranking from 0 to 1. in order to categorically
classify the communities into High , Medium and Low priority for SAFE strategy the data was entered into
the following format and codes were yielded as given in the summary for each village below:
22
High Medium and Low Priority Ranking for Safe Strategy
The data was coded as follows:
Trichiasis Pattern
No Case 0
At least one case but prevalence < 0.5% 1
Prevalence >0.5% but < 1% 2
Prevalence >=1% but <2% 3
Prevalence >=2% 4
Trichiasis Surgery Accessibility
< 30 minutes 0
> 30 minutes but < 2 hrs 1
> 2hours 2
Active Trachoma
Prevalence < 5% 0
Prevalence > 5% but < 20% 1
Prevalence > 60 % 4
PHC Accessibility
< 30 minutes 0
> 30 minutes but < 2 hrs 1
> 2hours 2
CODING FOR RISK FACOTRS

Unclean Faces
< 50% children with unclean faces 0

> 50 % but < 90% children with unclean faces 1
> 90% children with unclean faces 2
Exposure to Garbage
< 50% of visited house holds is exposed 0

> 50 % but < 90% of visited house holds is exposed 1
> 90% of visited house holds is exposed 2
Absence of an “adequate system” of faeces elimination in the house hold.
< 50% of visited house holds do not have adequate system 0

> 50 % but < 90% of visited house holds do not have adequate system 1
23
> 90% of visited house holds do not have adequate system 2
Based on these codings summary of each village is given below.
24
Province District Province District
Nangahar Dari-Noor Nangahar Dari-Noor
Village Bambo-cot Village Lamatic
Assessment of Trichiasis Pattern Assessment of Trichiasis Pattern

(1) % of Trichiasis 0 (1) % of Trichiasis 4
(2) Accessibility Trichiasis 2 (2) Accessibility Trichiasis 2
Sum(1) + (2) 2 Sum(1) + (2) 6
Assessment of Active Trachoma Assessment of Active Trachoma
Pattern Pattern
(3)% of Children with Active 1 (3)% of Children with Active 2
Trachoma Trachoma
(4) Accessibility PHC 1 (4) Accessibility PHC 2

Sum (3) + (4) 2 Sum (3) + (4) 4
Assessment of community risk factors

(5) Facial uncleanliness 1
(6) Garbage 1
Assessment of community risk factors (7) Latrines 2
(5) Facial uncleanliness 1 Sum (5) + (6) + (7) 4
(6) Garbage 0
Village Profile
(7) Latrines 2
Score Score Active Score
Sum (5) + (6) + (7) 3
Trichiasis Trachoma Risk
Factors
6 4 4
Village Profile
Factors
2 2 3
Province District
Nangahar Dari-Noor
Village Sutan
(6) Garbage 1
Assessment of Trichiasis Pattern (7) Latrines 2
(1) % of Trichiasis 4 Sum (5) + (6) + (7) 4
(2) Accessibility Trichiasis 2
Sum(1) + (2) 6
Village Profile
Assessment of Active Trachoma
Score Score Active Score Risk
Pattern
Trichiasis Trachoma Factors
(3)% of Children with Active 1
6 2 4
Trachoma
(4) Accessibility PHC 1

Sum (3) + (4) 2
25
rovince District Province District
Takhar Markaz Takhar Markaz
Village Goroqsai Village Lataband
Sum(1) + (2) 6 Sum(1) + (2) 6
Assessment of Active Trachoma Assessment of Active Trachoma Pattern
Pattern (3)% of Children with Active 1
(3)% of Children with Active 1 Trachoma
Trachoma
(4) Accessibility PHC 2 Sum (3) + (4) 1
Sum (3) + (4) 3
Assessment of community risk factors Assessment of community risk factors
(5) Facial uncleanliness 1 (5) Facial uncleanliness 1
(6) Garbage 2 (6) Garbage 2
(7) Latrines 2 (7) Latrines 2
Sum (5) + (6) + (7) 5 Sum (5) + (6) + (7) 5
Village Profile Village Profile
Score Score Active Score Score Score Active Score Risk
Trichiasis Trachoma Risk Trichiasis Trachoma Factors
Factors 6 1 5
6 3 5

Takhar Markaz Takhar Markaz
Village Pitaosai Village Talik
Sum(1) + (2) 6 Sum(1) + (2) 6

Trachoma
Sum (3) + (4) 3
26
(5) Facial uncleanliness 1 Assessment of community risk factors
(6) Garbage 2 (5) Facial uncleanliness 1
(7) Latrines 2 (6) Garbage 2
Sum (5) + (6) + (7) 5 (7) Latrines 2
Sum (5) + (6) + (7) 5
Village Profile Village Profile

Score Score Active Score Risk Score Score Active Score Risk
Trichiasis Trachoma Factors Trichiasis Trachoma Factors
6 3 5 6 4 5
Province District Province

District
Pawar Bagram Pawar Bagram

Village Ali Khan Khil Village Ghulam Ali
Sum(1) + (2) 6 Sum(1) + (2) 6
Pattern Assessment of Active Trachoma Pattern
(3)% of Children with Active 1 (3)% of Children with Active 1
Trachoma Trachoma
(4) Accessibility PHC 1 (4) Accessibility PHC 1

Sum (3) + (4) 2 Sum (3) + (4) 2
(5) Facial uncleanliness 0 Assessment of community risk factors
(6) Garbage 1 (5) Facial uncleanliness 0
(7) Latrines 2 (6) Garbage 2
Sum (5) + (6) + (7) 3 (7) Latrines 2
Sum (5) + (6) + (7) 4
Village Profile
Score Score Active Score Village Profile
Trichiasis Trachoma Risk Score Score Active Score Risk
Factors Trichiasis Trachoma Factors
Province 6 2 4
6 2 3 District
Province District
27
Pawar Bagram Pawar Bagram
Village Gulaiha Village Mohigeer
Sum(1) + (2) 2 Sum(1) + (2) 6
Trachoma
Sum (3) + (4) 1
Assessment of community risk factors (6) Garbage 1
(5) Facial uncleanliness 0 (7) Latrines 2
(6) Garbage 1 Sum (5) + (6) + (7) 3
(7) Latrines 2 Village Profile
Sum (5) + (6) + (7) 3 Score Score Active Score Risk
Village Profile 6 1 3
2 1 3
Province District
Province District
Heart Gozerah Heart Gozerah
Village kul Village Kort
Sum(1) + (2) 6 Sum(1) + (2) 6
Assessment of Active Trachoma Pattern
Pattern
Trachoma
Trachoma
Sum (3) + (4) 1
Sum (3) + (4) 2
(6) Garbage 0
(6) Garbage 0
(7) Latrines 0
(7) Latrines 0
Sum (5) + (6) + (7) 0
Sum (5) + (6) + (7) 0
28
Village Profile
Village Profile
Trichiasis Trachoma Risk Score Score Active Score Risk
Factors Trichiasis Trachoma Factors
6 2 0 6 1 0

Herat Gozerah
Village Sai-Oshan
Kandahar Kandahar
Assessment of Trichiasis Pattern
Village Shio - Surkh
(1) % of Trichiasis 4
Assessment of Trichiasis Pattern
Sum(1) + (2) 6
Assessment of Active Trachoma (1) % of Trichiasis 0
Pattern (2) Accessibility Trichiasis 2
(3)% of Children with Active 1 Sum(1) + (2) 0
Trachoma
Assessment of Active Trachoma Pattern
(4) Accessibility PHC 0 (3)% of Children with Active 0
Sum (3) + (4) 1 Trachoma
(5) Facial uncleanliness 0 (4) Accessibility PHC 1
(6) Garbage 0 Sum (3) + (4) 1
(7) Latrines 0
Sum (5) + (6) + (7) 0 Assessment of community risk factors
Village Profile (5) Facial uncleanliness 0
Score Score Active Score Risk (6) Garbage 0
Trichiasis Trachoma Factors (7) Latrines 0
6 1 0 Sum (5) + (6) + (7) 0
Village Profile
Province District 0 1 0
Kandahar Kandahar Assessment of Active Trachoma
Village Sabsi Kartah Pattern
Assessment of Trichiasis Pattern (3)% of Children with Active 0
(1) % of Trichiasis 0 Trachoma
Sum(1) + (2) 2 (4) Accessibility PHC 1
Sum (3) + (4) 1
(6) Garbage 0
Village Profile
(7) Latrines 0
Sum (5) + (6) + (7) 0
Factors
2 1 0
29
Province District
Kandahar Kandahar Assessment of Active Trachoma
Village Zaker - Sharif Pattern
Assessment of Trichiasis Pattern Trachoma
(1) % of Trichiasis 0
(2) Accessibility Trichiasis 2 (4) Accessibility PHC 1
Sum(1) + (2) 2 Sum (3) + (4) 1

Village Profile
(6) Garbage 0
(7) Latrines 0
2 1 0
Sum (5) + (6) + (7) 0
SUMMARY OF VIIAGE PROFILES
Province District Village Village Profile

Score of Score for Score
Trichaisis Aactive fro
Trachoma Risk
Factors
Herat Gozerah Kort 6 1 0
Kul 6 2 0
Sia-oslian 6 1 0
Kandhar Kandhar Zakar sharif 2 1 0

Sabsi Kartoh 2 1 0
Shir surkh 0 1 0
Nangarhar Dara-i-noor Lamatic 6 4 4

Sutan 6 2 4
Bambat-cot 2 2 3
Takhar Taluqan Lataband 6 1 5

Talik 6 4 5
Pitaosai 6 3 5
Goragsai 6 3 5
Parwan Bagram Mahigeer 6 1 3

Ghulam ali 6 2 4
Ali khan 6 2 3
Gokacha 2 1 3
30
The villages were ranked into high medium and Low priority SAFE Startegy using the following scales based
on the scores of village profiles.
RANKING ON LOW MEDIUM AND HIGH PRIORITY
Trachomatous Trichiasis
Out of the 17 communities 12 communities were on high priority and 3 communities on medium priority
for Lid Surgery.
Active Trachoma
Out of the total 17 communities 2 communities were on High priority and 7 communities each on medium
and low priority for Active Trachoma Intervention.
Risk Factors
For Risk factors 7 communities were on high and 4 on medium priority for environmental intervention.
Province Wise Details
Province Nangarahar Distt. Dara-i-noor

In total 3 communities were surveyed from district Dara-i-noor.
Lid Antibiotic Risk

Surgery Intervention Factors
High 2 1 2
Medium 1 2 1
31
a. Trachomatous Trichiasis
High Medium Low

Priority Priority Prioirty
Lamatic Bombat-cot None
Sutan
b. Active Trachoma
High Medium Low

Lamatic Sutan None
Bombat-cot
c. Risk Factors
High Medium Low

Lamatic Bombat-cot None
Sutan
Province Takhar
In total 4 communities were surveyed from District Taluqan.
Lid Antibiotic Risk

High 4 1 4
Medium 0 3 0
Low 0 0 0
a. Trachomatous Trichiasis ( Lid Surgery)
High Medium Low

Lataband None None
Talik
Pitaosai
Goragsai
32
b. Active Trachoma (Antibiotics)
High Medium Low

Talik Pitaosai Lataband
Goragsai
c. Risk Factors ( F& E Components)
High Medium Low

Lataband None None
Talik
Pitaosai
Goragsai
Province Heart
3 communities were survey from District Guzara.
Lid Antibiotic Risk

High 3 0 0
Medium 0 1 0
Low 0 2 0
High Medium Low

Kort None None
Kul
Sia-Oslian
33
High Medium Low

None Kul Kort
Sia-Oslian
Risk Factors ( F& E Components)
None of the communities were on High, Medium or Low priorities for F & E Components.
Province Prawan
4 communities were surveyed for TRA
Lid Antibiotic Risk

High 3 0 1
Medium 1 2 3
Low 0 2 0
Trachomatous Trichiasis ( Lid Surgery)
High Medium Low

Mahigeer Gokacha None
Ghulam Ali
Ali Khan
Active Trachoma (Antibiotics)
High Medium Low

None Ghulam Ali Mahigeer
Ali Khan Gokacha
34
High Medium Low

Ghulam Ali Ali Khan None
Mahigeer
Gokacha
5. Province Kandahar
3 communities were survey from district Guzara
Lid Antibiotic Risk

High 0 0 0
Medium 2 0 0
Low 0 1 0
High Medium Low

None Zakar Sahrif None
Sabsi Kartoh
High Medium Low

None None Sabsi
Kartoh
Shere
Surkh
Zakar
Sahrif
35
None of the communities were on High, Medium or Low priorities for F & E Components
MAPS
36
37
References
1
Thylefors B, Negrel AD, Pararajasegaram R, Dadzie KY (1995) Global data on blindness. Bull World Health Organ 73: 115–
121.
2
Regassa K, Teshome T (2004) Trachoma among adults in Damot Gale District, South Ethiopia. Ophthalmic Epidemiol 11:
9–16
3
Emerson PM, Lindsay SW, Alexander N, Bah M, Dibba SM, et al. (2004) Role of flies and provision of latrines in trachoma
control: Cluster-randomised controlled trial. Lancet 363: 1093–1098.
4
West SK (2004) Trachoma: New assault on an ancient disease. Prog Retin Eye Res 23: 381–401.
5
Prost A, Negrel AD (1989) Water, trachoma and conjunctivitis. Bull World Health Organ 67: 9–18.
6
Bailey R, Lietman T (2001) The SAFE strategy for the elimination of trachoma by 2020: Will it work? Bull World Health
Organ 79: 233–236
7
Kuper H, Solomon AW, Buchan J, Zondervan M, Foster A, et al. (2003) A critical review of the SAFE strategy for the
prevention of blinding trachoma. Lancet Infect Dis 3: 372–38
8
Emerson PM, Cairncross S, Bailey RL, Mabey DC (2000) Review of the evidence base for the ‘F’ and ‘E’ components of the
SAFE strategy for trachoma control. Trop Med Int Health 5: 515–527
9
Reacher M, Foster A, Huber J (1993) Trichiasis surgery for trachoma: The bilamellar tarsal rotation procedure. Geneva:
World Health Organization. Programme for the Prevention of Blindness Available
10
Mabey D, Fraser-Hurt N (2002) Antibiotics for trachoma. Cochrane Database Syst Rev 1. CD001860.
11
Lietman T, Porco T, Dawson C, Blower S (1999) Global elimination of trachoma: How frequently should we administer
mass chemotherapy? Nat Med 5: 572–576
12
Schemann JF, Sacko D, Malvy D, Momo G, Traore L, et al. (2002) Risk factors for trachoma in Mali. Int J Epidemiol 31: 194–
201.
13
Bailey R, Downes B, Downes R, Mabey D (1991) Trachoma and water use; a case control study in a Gambian village. Trans
R Soc Trop Med Hyg 85: 824–828.
14
World Health Organization (2004) Report of the Eighth Meeting of the WHO Alliance for the Global Elimination of
Trachoma. (2004 March 29–31) Geneva: World Health Organization
15
Frick KD, Hanson CL, Jacobson GA (2003) Global burden of trachoma and economics of the disease. Am J Trop Med Hyg
69: 1–10
38

TRA AFGAHAN DRAFT Report1

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TRA AFGAHAN DRAFT Report1

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REPORT 2005

Dr. Muhhamd Zahid Jadoon

Collaboration ; Pakistan Institute of Community Opthalmology, CBM Germany, MOPH Afghanistan 1

Trachoma, a chronic keratoconjunctivitis, is caused by episodes of infection with Chlamydia trachomatis,

Role of Vision 2020 in Treatment and Prevention of Trachoma

Background to the study population

Popualtion and Health Indicators

Population Statistics of Afghanistan

Total Population: 27,755,775 people

Literacy Rate; : 36%

Life expectancy at Birth : 46 yrs

Water and Sanitation Facilities in Afghanistan

Recent History of Afghanistan

Post War Scenario in Afghanistan

Rationale of the study

1. To identify Trachoma endemic areas in Afghanistan

2.1 Trachoma Rapid Assessment (TRA)

2.2 Key Features of TRA

RA is based on community participation.

1. Selection of field coordinator/ teams

1. Dr. Mohammad Babar Qureshi Medical Advisor CBM

3.Dr. Mohammad Zahid Jadoon Epidemiologist Pakistan Institute of Comminity Ophthalmology

4. Dr. Aimal Zaki Community Ophthalmologist Afghanistan

5. Dr. Murtaza Farrahamand Community ophthalmologist Afghanistan

Each Team were assigned communities for TRA.

3.1 Selection of endemic areas for TRA

The Information Pyramid

 The top level concerns obtaining data on

Qandhar Donal Zakar sharif

Nangarhar Dari noor Lamatic

Takhar Markaz Lataband

Parwan Bagram Mahigeer

Information Collection in the second Phase

Priority Ranking of Villages for Lid Surgery

Province District Village No examined No with TT

Province District Village No of Children % A.Trachoma

The data was coded as follows:

Trichiasis Surgery Accessibility

CODING FOR RISK FACOTRS

< 50% children with unclean faces 0

< 50% of visited house holds is exposed 0

< 50% of visited house holds do not have adequate system 0

Based on these codings summary of each village is given below.

Assessment of Trichiasis Pattern Assessment of Trichiasis Pattern

(4) Accessibility PHC 1 (4) Accessibility PHC 2

Assessment of community risk factors

(4) Accessibility PHC 1

Province District Province District

Assessment of Active Trachoma Assessment of Active Trachoma Pattern

Village Profile Village Profile

Province District Province

Pawar Bagram Pawar Bagram

(4) Accessibility PHC 1 (4) Accessibility PHC 1

Province District Province District

Assessment of community risk factors

SUMMARY OF VIIAGE PROFILES

Province District Village Village Profile

Kandhar Kandhar Zakar sharif 2 1 0

Nangarhar Dara-i-noor Lamatic 6 4 4

Takhar Taluqan Lataband 6 1 5

Parwan Bagram Mahigeer 6 1 3

RANKING ON LOW MEDIUM AND HIGH PRIORITY