GOVT.

COLLEGE OF NURSING
GMC SRINAGAR

Assignment on :TRACHOMA & YAWS

Submitted to: RESPECTED NIGHAT MAM

Submitted on :26/4/2020

Submitted by:TAHREEM HAMID

Class: bsc nsg 2nd year

Roll no.:29

Teachers remarks:
 TRACHOMA
Trachoma is a chronic infectious disease of the
-conjunctiva and cornea, caused by Chlamydia trachomatis,
but other pathogenic microorganisms often contribute to the
disease. Trachoma inflammation may undergo spontaneous
resolution or may progress to conjunctiva! scarring which
can cause inward deviation of eyelashes (trichiasis) or of the
lid margin (entropion). The abrasion of the cornea by
eyelashes frequently result in corneal ulceration, followed by
scarring and visual loss.
From the public health point of view, trachoma is
classified as blinding and non-blinding . A community
with blinding trachoma can be recognized by the presence of
persons with lesions such as entropion, trichiasis and
corneal ulcers. It is the blinding trachoma that requires
urgent control measures. Non-blinding trachoma often
becomes blinding trachoma when other ocular pathogens
interact synergistically and enhance the risk of damage to eye
sight

DIAGNOSIS
In epidemiological studies, more stress is now put on the
upper tarsal conjunctiva as a convenient index of
trachomatous inflammation in the eye as a whole . For
the purpose of diagnosis in the field, cases must have at
least
2 of the following diagnostic criteria .
a. follicles on the upper tarsal conjunctiva
b. limbal follicles or their sequelae, Herbert's pits
c. typical conjunctiva! scarring (trichiasis, entropion)
d. vascular pannus, most marked at the superior

PROBLEM STATEMENT

Trachoma is a major preventable cause of blindness in

developing countries.According to recent estimates,about
2.2 million people currently suffer from visual impairmnt
due to trachoma, of these 1.2 million are irreversibly
blind,
and about 324.85 million are at risk of infection .
The incidence and prevalence of trachoma has shown a
significant decrease in many endemic countries of SEAR
during the past few decades. This decrease has been
mainly due to improved sanitation and housing, and
implementation of control measures. However, trachoma,
particularly in its active form, still remains a public health
concern in some parts of Myanmar,in the western region
of Nepal and in a few rural areas in India.It is estimated to
be responsible for 0.2 per cent of visual impairment and
blindness in India .
Epidemiological determinants
Agent factors
(a) AGENT : The classical endemic trachoma of
developing countries is caused by C. trachomatis of immune
types A, B, or C. The sexually-transmitted C. trachomatis
(serotypes D,E,F,G,H,l,J or K) may also infect, causing an
eye disease difficult to differentiate from endemic trachoma.
Trachomatis, originally believed to be a
virus, is an obligatory intracellular bacteria, now classified as
Chlamydia.
(b) .RESERVOIR : Children with active disease,
chronically infected older children and adults.
(c) SOURCE OF INFECTION
Ocular discharges of infected persons and
Fomites
(d) COMMUNICABILITY: Trachoma is a disease
of low infectivity. It is infective as long as active lesions are
present in the conjunctiva, but not after complete
cicatrization.
Host factors
(a) AGE : In endemic areas, children may show signs of the
disease at the age of only a few months. But typically,
children from the age of two to five years are the most
infected, and this contributes not only to the high rate of
blindness but also to the rate of occurrence among children.
(b) SEX : Prevalence equal in younger age groups. In older
age groups, females have been found to be affected more
than males. The explanation for this may be that women
remain more in contact with children who infect them.
Further, females are more exposed to irritating factors such as
smoke than males.
(c) PRE-DISPOSING FACTORS: Direct
sunlight, dust, smoke and irritants such as kajal or surma may
predispose to infection.
Environmental factors
(a) SEASON · Seasonal epidemics are associated with
vastly increased number of eye-seeking flies. The incidence
of active trachoma is found generally high in India during
April-May and again during July-September. The higher
temperature and rainfall favours the increase in fly
population.
(B). QUALITY OF LIFE: Trachoma is associated
with poor quality of life. The disease thrives in conditions of
poverty, crowding, ignorance, poor personal hygiene,
squalor, illiteracy and poor housing. As living conditions
improve the disease tends to regress.
(c) CUSTOMS : custom of applying kajal or surma to
the eyes is a positive risk factor

Mode of transmission
In communities where trachoma is endemic, eye-to-eye
transmission can be considered as a rule . This may occur
by direct or indirect contact with ocular discharges of
infected persons or fomites, e.g., infected fingers, towels,
kajal or surma. Eye-seeking flies (e.g., Musca spp.,
Hippefatus spp.) play some role in spreading the infection by
mechanical transmission. In countries where only sporadic
cases of trachoma occur, genital localization of C. trachomatis
(urethral, cervical) may lead to venereal transmission It has been
shown that trachoma is a familial disease.When one case is
detected, others will almost certainly befound in the family
group. There is a continuous feedback ofinfection, partly as a
result of grandfathers or sisters andbrothers tending small
children.
 INCUBATION PERIOD
5-12 DAYS
CONTROLOFTRACHOMA
Trachoma control still requires long-term efforts. It
requires proper planning and organization, which should
include the following elements :
1. Assessment of the problem
The primary objective of a programme for the control of
trachoma is the prevention of blindness. Control programmes
should be focussed on communities with a substantial
prevalence of "blinding trachoma" - as indicated by the
presence of:
(a) corneal blindness (b) trachomatous trichiasis
and entropion, and (c) moderate and severe trachomatous
inflammation.
Such communities are likely to be found in
countries with blindness rates that are above 0.5 per cent. The
first task, therefore, is to undertake an epidemiological survey
to identify and delimit communities with blinding trachoma;
assess the magnitude of the problem, local conditions and
other causes of blindness and to obtain information on
existing facilities. The basic principles of these surveys are set
out in the WHO publication : "Methods of Assessment of
Avoidable Blindness" .

2. Chemotherapy
In trachoma control, the main activity is
chemotherapeutic intervention. The objective of chemotherapy
chemotherapy is to reduce severity, lower the incidence and
in the long run decrease the prevalence of trachoma. The
antibiotic of choice is 1 per cent ophthalmic ointment or oily
suspension of tetracyclines. Erythromycin and rifampicin
have also been used in the treatment of trachoma.
Treatment may be given to the entire community this is
known as mass treatment (or blanket treatment). In some
programmes, selective treatment is chosen, in which case,
the whole population at risk is screened, and treatment is
applied only to persons with active trachoma .
(a) Mass treatment
A prevalence of more than 5 per cent severe and
moderate trachoma in children under 10 years is an
indication for mass or blanket treatment. The treatment
consists of the application twice daily of tetracycline 1 per
cent ointment to all children, for 5 consecutive days each
month or once daily for 10 days each month for 6consecutive
months, or for 60 consecutive days
(B) Selective treatment
In communities with a low to medium prevalence,
treatment should be applied to individuals by case finding
rather than by community-wide coverage, the principals of
treatment remaining the same. For the selective treatment to
be effective, the whole population at risk must be screened for
case finding.
3. Surgical correction
Antibiotic ointment is just one component of a trachoma
control programme. Individuals with lid deformities
(trichiasis, entropion) should be actively sought out, so that
necessary surgical procedures can be performed and
followed-up. It has an immediate impact on preventing
blindness.
4. Surveillance
Once control of blinding trachoma has been achieved,
provision must be made to maintain surveillance, which may
be necessary for several years after active inflammatory
trachoma has been controlled. Since trachoma is a familial
disease, the whole family group should be under
surveillance.
5. Health education
In the long run, most of the antibiotic treatment must be
carried out by the affected population itself. To do this, the
population needs to be educated. The mothers of young
children should be the target for health education. Measures of
personal and community hygiene should also be incorporated
in programmes of health education. Thus real primary
prevention could only come through health education for the
total elimination of transmission.
6. Evaluation
Lastly evaluation. Trachoma control programme must be
evaluated at frequent intervals. The effect of intervention
can be judged by the changes in the age-specific rates of
active trachoma and in the prevention of trichiasis and
entropion.
The 28th World Health Assembly in 1975, in a resolution
requested the Director General of WHO "to encourage
Member countries to develop national programmes for the
prevention of blindness especially aimed at the control of
trachoma, xerophthalmia, onchocerciasis and other causes".
With this came the re-orientation of strategies away from
single cause prevention, to the adoption of the concept of
integrated delivery of eye care as part of primary health
care. In this context, many countries have now integrated
their trachoma control programmes into National
Programmes for the Prevention of Blindness, to give
simultaneous introduction of other specific measures for
dealing with all causes of avoidable blindness.
The trachoma control programme in India which was
launched in 1963 has now been integrated with the National
Programme for Control of Blindness The "Health for All by
2000" had set a target of
reducing the prevalence of blindness to 0.3 %.
 YAWS
Yaws is a chronic contagious non-venereal disease caused
by T. pertenue, usually beginning in early childhood. It
resembles syphilis in its clinical course and is characterized
by a primary skin lesion (mother yaw) followed by a
generalized eruption and a late stage of destructive lesions
of the skin and bone. Yaws is also known as pian, bubas or
framboesia.
Geographic distribution and prevalence

Yaws is exclusively confined to the belt between the

Tropic of Capricorn and the Tropic of Cancer. Not long ago,
it was a significant public health problem in Africa, South
East Asia and Central America. Recent country reports
reveal marked variations in prevalence and patchiness in
distribution in the former endemic area). In Africa (e.g.,
Benin, Ghana, Ivory Coast) there has been a great
resurgence of yaws.
In asia ,it occurs in Indonesia, Papua New Guinea and the South
Pacific. Persistent low levels of yaws is reported in Sri Lanka
and India.
Problem in India
The disease was reported in India from the tribal
communities living in hilly forests and difficult to reach areas
in 49 districts of 10 states, namely Andhra Pradesh, Assam,
Chhattisgarh, Gujarat, Jharkhand, Madhya Pradesh,
Maharashtra, Orissa, Tamil Nadu and Uttar Pradesh. Yaws
eradication programme was started in 1996-97 in Koraput
district of Orissa and then extended to endemic states as
centrally sponsored health scheme. The number of reported
cases has come down from 3500 during 1996 to zero during
2004. Since then, no new case has been reported .
Certification for disease free status requires an abscence of
disease for at least 5 years. In India, this happened on 19th
Sept. 2011.
Epidemiological determinants
Agent factors
(a) AGENT : Yaws is caused by T. pertenue which closely
resembles T. pal/idum culturally and morphologically. It
measures 20μ in length with 8 to 12 rigid spirals. The agent
occurs in the epidermis of the lesions, lymph glands, spleen
and bone marrow. The organism rapidly dies outside the
tissues
. (b) RESERVOIR OF INFECTION : Man is the only
known reservoir of yaws. He is an infected person. Clinical
lesions may relapse 2 to 3 times or more during the first 5
years of infection, and serve as source for new infections .
Most latent cases are found in clusters centred around an
infectious case. There are frequent relapses in latent cases
within the first 3 to 5 years of infection. The source of
infection is usually the skin lesions and the exudates from
early lesions.
(c) COMMUNICABIUTY : Variable, and may
extend over several years intermittently as moist lesions
break out. Treponema are usually not found in late lesions.
Host factors
(a) AGE : Yaws is primarily a disease of childhood and
adolescence. Over 75 per cent of cases occur before the age
of 15 years, but the disease can occur at any age (9).
(b) SEX : Generally, the prevalence among males is greater
than among females.
(c) IMMUNITY : Man has no natural immunity. A months or years to
develop fully unless suppressed by treatment
Environmental factors
(a) CLIMATE : Yaws is endemic in warm and humid
regions. High humidity for at least 6 months of the year and
an average rainfall of at least 40 inches are considered
favourable for the transmission of yaws.
(b) social factors
: Social factors are even more important than
biological factors in the perpetuation of yaws in the endemic
areas. Yaws is mostly endemic among the tribal people,
whose ways of living favour its transmission. Scanty
clothing, poor personal cleanliness, overcrowding, bad
housing, low standard of living and the absence of soap are
important socio-economic factors in the epidemiology of
yaws. Yaws is a crippling disease; lesions on palms and soles
may disable a person for long periods making him
dependant on others.
Mode of transmission
Yaws is transmitted non-venereally by : (a) DIRECT
CONTACT : That is, by contact with secretions from
infectious lesions. (b) FOMITES : Yaws may also be
transmitted by indirect contact. The organism may remain
alive on fomites or on the earthen floor in hot and humid
conditions long enough to cause infection, and (c) VECTOR:
There is some evidence that small flies and other insects
feeding on the lesion may possibly convey the infection
mechanically for brief periods.
Transplacental, congenital transmission does not occur.
Incubation period
9-90 days (average 21 days).
 Clinical features
(a) EARLY YAWS : The primary lesion or "mother yaw"
appears at the site of inoculation after an incubation period
of 3 to 5 weeks. The lesion is extra-genital and is seen on
exposed parts of the body such as legs, arms, buttocks or
face. The local lymph glands are enlarged and the blood
becomes positive for STS. Within the next 3 to 6 weeks, a
generalized eruption appears consisting of large, yellow,
crusted, granulomatous eruptions often resembling
condylomata lata in secondary syphilis. During the next 5
years skin, mucous membrane, periosteal and bone lesions
may develop, subside and relapse at irregular intervals. The
early lesions are highly infectious.
(b) LATE YAWS : By the end of 5 years, destructive and
often deforming lesions of the skin, bone and periosteum
appear. The lesions of sole and palms are called "crab
yaws". The destructive lesions of soft palate, hard palate,
and nose are called "Gangosa". Swelling by the side of the
nose due to osteo-periostitis of the superior maxillary bone
is called "Goundu".
CONTROL OF YAWS
The control of yaws is based on the following principles :
1. Survey
A clinical survey of all the families in endemic areas is made. The
survey should cover not less than 95 per cent of
the total population. During the survey, persons suffering
from yaws and their contacts are listed.
2. Treatment
Treatment is based on the following observations :
(a) treatment with a single dose of Azithromycin oral or a
single injection of long-acting penicillin will cure infection.
(b) the simultaneous treatment of all clinical cases and their
likely contacts in the community will interrupt transmission
in the community
Benzathine penicillin G is the penicillin of choice. It has
now replaced PAM . The dose of BPG is 1.2 million units
for all cases and contacts, and half that dose (0.6 million
units) for children under 10 years of age. Azithromycin is
given as a single oral dose at 30 mg/kg body weight
(maximum 2 gm).
The WHO has recommended three treatment policies :
(a) TOTAL MASS TREATMENT : In areas where yaws is
hyperendemic (i.e., more than 10 per cent prevalence of
clinically active yaws), a great part of the population is at
risk. The entire population including the cases should be
given penicillin in the doses mentioned above.
(b) JUVENILE MASS TREATMENT : In meso-endemic
communities (5 to 10 per cent prevalence), treatment is
given to all cases and to all children under 15 years of age
and other obvious contacts of infectious cases.
(c) SELECTIVE MASS TREATMENT : In hypo-endemic or
areas of low prevalence (less than 5 per cent) treatment is
confined to cases, their household, and other obvious
contacts of infectious cases.
3. Resurvey and treatment
It is unlikely that a single round of survey and treatment
will cover the entire population. In order to interrupt
transmission, it is necessary to find out and treat the missed
cases and new cases. Resurveys should be undertaken every
6 to 12 months. Several such follow-ups may be needed
before eradication is achieved.
4. Surveillance
With the decline of yaws to very low levels, emphasis has
shifted to "Surveillance and containment" - a technique
which has proved highly successful in the eradication of
smallpox. The surveillance and containment measures
would be concentrated on affected villages, households and
other contacts of known yaws cases. The measures comprise
epidemiological investigation of cases to identify probable
source(s) of infection and contacts of each known case so as ·
to discover previously unknown cases and prevent new
cases; treatment of cases; prophylactic treatment of contacts
with BPG; and, monthly follow-up of households with
confirmed cases for at least 3 to 4 months after treatment of
the last active case to assure interruption of transmission.
5. Environmental Improvement
In a disease like yaws, an attack on social and economic
conditions of life is as important as an attack on the
biological cause. Recrudescence of the disease is apt to
occur unless environmental improvement is promoted, e.g.,
improvement of personal and domestic hygiene, adequate
water supply, liberal use of soap, better housing conditions
and improvement of the quality of life.
6. Renewed eradication efforts
The WHO roadmap for neglected cquired resist (NTDs) have set 2020
target for the eradication of yaws
from the remaining countries.
Since January 2012, when the WHO roadmap for NTDs
were set and an article in the Lancet on the efficacy of a
single-dose azithromycin in the treatment of yaws was
published, WHO has taken steps to move the renewed
eradication efforts by developing a new eradication strategy
based on single dose treatment with azithromycin. These
are:
a. Total community treatment (TCT) - treatment of the
endemic community, irrespective of the number of active
clinical cases;
b. Total targeted treatment (TIT) treatment of all active
clinical cases and their contacts .
7. Evaluation
To determine whether or not yaws has really been
brought under control, serological studies are needed.
Ideally if no yaws antibodies were found among children
born since the yaws mass campaign was completed, it would
mean that the campaign had been totally successful. The
actual sample of the population to be tested may be as low
as 1 or 2 per cent .