Content uploaded by Yasir Iqbal Malik
Author content
All content in this area was uploaded by Yasir Iqbal Malik on May 30, 2024
Content may be subject to copyright.
27
Prevalence of Trachoma in Gilgit, Pakistan: A Cross-
Sectional Study at Tertiary Care Center (2018-2023)
Qaim Ali Khan1, Muhammad Tahir2, Yasir Iqbal3, Nauroz Fatima1, Qurat ul Ain Ghazanfar4,
Benish Ali4
Abstract:
Objective: To assess the prevalence of trachoma among patients attending a tertiary care
hospital in Gilgit, Pakistan.
Methods: Data for this descriptive cross-sectional study was collected by consecutive
sampling from analyzing the medical records of all the patients presenting to the Gilgit Eye
Care Centre during the spanning from January 2018 to January 2023 (a 5-year period) ensuring
that diagnosis of trachoma was based upon the WHO criteria (FISTO). The data was analyzed
according to gender and age on SPSS and results were compiled.
Results: A total of 24,589 patients were examined during the study period consisting of 61.8%
females and 38.2% males. The estimated prevalence of trachoma was 0.22% (95% confidence
interval: 0.14% - 0.30%). Among them, 54 were diagnosed with active trachoma, with mean
age 23.30, SD 14.32 years with a female to male ratio of approximately 4.26:1 (81% females,
19% males).
Conclusion: This pilot study identified prevalence of trachoma in a hospital setting,
highlighting the need for population-based studies to assess the true disease burden in Gilgit.
Al-Shifa Journal of Ophthalmology 2024; 20(1): 27-32. © Al-Shifa Trust Eye Hospital,
Rawalpindi, Pakistan.
1. Azad Jamu Kashmir Medical College,
Muzaffarabad.
2. Combined Military Hospital, Mardan.
3. Watim Medical College, Rawat
Rawalpindi.
4. Combined Military Hospital,
Muzaffarabad.
Originally Received: 15 February 2024
Revised: 03 April 2024
Accepted: 11 April 2024
Correspondence to:
Yasir Iqbal
Watim Medical College, Rawat
Rawalpindi.
yazeriqbal@gmail.com
Introduction:
Trachoma, a neglected tropical disease
caused by the bacterium Chlamydia
trachomatis, casts a long shadow on global
public health. It remains the leading
infectious cause of blindness worldwide,
disproportionately impacting low-resource
communities.1 An estimated 1.9 million
people globally suffer from vision
impairment or blindness due to trachoma2,
highlighting the devastating consequences
of this chronic eye infection. While most
infected individuals experience no initial
symptoms, repeated infections over
extended periods can lead to a progressive
and debilitating disease.3 Untreated
trachoma progresses through stages,
culminating in trichiasis, a condition where
the eyelashes turn inward and scrape
against the cornea, causing excruciating
pain, corneal scarring, and ultimately,
irreversible blindness.4
ORIGINAL ARTICLE
28
Trachoma remains a significant public
health concern across 42 countries.5
However, stories of success offer hope.
Several nations, including Pakistan, have
made remarkable strides in tackling the
disease. Supported by the World Health
Organization's (WHO) initiative, the
Global Elimination of Blinding Trachoma
by 2020 (GET 2020) program, Pakistan
implemented the SAFE strategy (Surgery,
Antibiotics, Facial cleanliness,
Environmental improvement) with
significant impact.6 This strategy led to a
dramatic decrease in active trachoma cases
and trachomatous trichiasis, particularly in
upper Sindh.7 While the initial GET 2020
target of global elimination by 2020 was
not met, significant progress has been
made. Africa, once the most affected
continent, has witnessed a 90% reduction in
trachoma cases.8 Renewed global efforts,
with a target of elimination by 2030, offer a
glimmer of hope for a trachoma-free future.
Despite these successes, challenges remain.
Population displacement and migration
patterns can reintroduce trachoma into
previously controlled areas.9Furthermore,
achieving complete national elimination
requires sustained commitment and a well-
coordinated national trachoma plan to reach
all at-risk populations.10
Pakistan's progress in tackling trachoma
serves as a testament to the effectiveness of
the SAFE strategy and unwavering
commitment.11 However, achieving
complete national elimination necessitates
continued vigilance. Study6 across various
districts, including D.G. Khan (Punjab),
Chitral (Khyber Pakhtunkhwa), and
Shahdadkot (Sindh), have documented the
presence of trachoma, highlighting the need
for geographically specific data to guide
targeted interventions. Estimates suggest
that roughly 0.81 million people in Pakistan
still suffer from trachoma, underlining the
importance of ongoing efforts to eliminate
this disease.12
This pilot study aimed to obtain a
preliminary assessment of trachoma
prevalence in Gilgit, Pakistan, by
determining the prevalence of trachoma
among patients attending a tertiary care
hospital in Gilgit. This can serve to evaluate
the potential risk in this specific population
and set a path for targeted interventions for
trachoma elimination.
Materials and Methods:
This descriptive cross-sectional study
aimed to determine the prevalence of
trachoma in patients presenting to a tertiary
care hospital in Gilgit, Pakistan. Following
ethical approval from the Gilgit Eye Care
Centre's ethical committee, analysis of
medical records from January 2018 to
January 2023 was conducted using
nonprobability consecutive sampling
method. Medical records of all patients
presenting during this period were
reviewed. Patients of all ages were included
if their diagnosis aligned with the WHO
trachoma classification (follicles [F],
inflammation-intense [I], scarring [S],
trichiasis [T], opacity [o]). Exclusion
criteria encompassed corneal opacities,
trichiasis, follicles, or opacities attributable
to other ocular diseases. The data was
entered on SPSS version 21 for analysis.
Descriptive data were presented as
frequencies while numerical data as means
and standard deviations.
Results:
A cross-sectional study examined a total of
24,589 patients consisting of 61.8%
females and 38.2% males. Among them, 54
were diagnosed with active trachoma, with
ages ranging from 3 to 70 years (mean
23.30, SD 14.32 years). The estimated
prevalence of trachoma was 0.22% (95%
confidence interval: 0.14% - 0.30%).
Reflecting the female predominance in the
overall population, trachoma diagnosis
exhibited a female to male ratio of
approximately 4.26:1 (81% females, 19%
males). The data on active trachoma
prevalence by age and sex revealed a
distinct distribution. While the overall
population leaned female, the analysis of
active trachoma cases revealed a surprising
Al-Shifa Journal of Ophthalmology, Vol. 20, No. 1, January – March 2024
29
trend. Contrary to the initial statement
about a female predominance, the data in
the table I shows the highest prevalence
(around 33%) in female children under 10
years old. This rate was nearly double that
observed in males of the same age group
(around 15%). Notably, the prevalence
steadily declined with increasing age, with
patients over 30 years old demonstrating a
significantly lower prevalence (around
7%). In contrast to active trachoma,
trachomatous trichiasis (TT) manifested
primarily in adults, as expected. Table II
highlights the distribution within the 54
active trachoma cases. Interestingly, no
cases of TT were identified in children
under 10 years old. The first appearance
occurs in the 10–15-year age group,
affecting only females (1.85%). This
pattern continues into the 16–30-year age
group, with a low prevalence (3.7%)
equally distributed between sexes. A
dramatic rise in TT prevalence is observed
in those exceeding 30 years old, reaching a
very high value (almost 95%) in the table.
Here, females are significantly more
affected (over 50%) compared to males
(around 7%).
Table 1: Active Trachoma Prevalence by Age and Sex
Age group (years)
Male (%)
Female (%)
Total (%)
1-9
15.75
33.21
48.96
10-15
11.84
19.1
30.94
16-30
3.45
9.48
12.93
>30
1.49
5.69
7.18
Total
32.53
67.47
100
(n=54)
Table 2: Trachomatous Trichiasis Prevalence by Age and Sex
Age Group (years) Male (%) Female (%) Total (%)
1-9 0 0 0
10-15 0 1.85 1.85
16-30
1.85
1.85
3.7
>30 7.4 51.8 94.45
Total
9.25
55.5
100
(n=54)
Discussion:
We estimated a prevalence of active
trachoma of 0.22% among the patients in
our study. While this represents a relatively
low overall burden, a closer look at the data
reveals concerning trends regarding age
and sex distribution. The study identified
the highest prevalence of active trachoma
(around 33%) in females under 10 years
old. This finding is surprising as some
previous research suggests a higher
prevalence in females of reproductive
age.13 Studies conducted in Ethiopia, for
instance, documented a higher burden
among women aged 1-9 years compared to
younger children.14 One possible
explanation for the observed discrepancy in
could be differences in hygiene practices
Iqbal et al. Prevalence of trachoma in Giligit
30
between younger and older girls. Further
research is needed to explore the specific
factors contributing to the high prevalence
in this age group.
The study also found a steady decline in
active trachoma prevalence with increasing
age. This aligns with observations from
other studies15, suggesting a potential link
between repeated exposure and the
development of the more severe stage,
trachomatous trichiasis (TT). The absence
of TT cases in children under 10 further
supports this notion, as TT typically
develops over years of chronic infection.
The dramatic rise in TT prevalence
observed in those exceeding 30 years old
(almost 95%) underscores the long-term
consequences of untreated trachoma. This
finding is consistent with global data
highlighting the disproportionate burden of
TT in adults, particularly females.16
The female predominance in trachoma
diagnosis (around 4.26:1) aligns with
previous research.17 Factors such as close
contact with young children, who may be
asymptomatic carriers, and increased
caregiving responsibilities could contribute
to this disparity.18 However, the reasons
behind the higher prevalence of TT in
females over 30 require further
investigation.
Several factors are believed to contribute to
trachoma infection. Studies suggest that the
presence of facial flies, large family size,
ocular discharge, nasal discharge, and low
socioeconomic status all increase the risk of
trachoma.19 Living in high-altitude regions
with unsafe water sources is also
considered a risk factor. Open defecation is
widely recognized as a major risk factor for
trachoma transmission.19 However, some
studies suggest that simply having access to
a latrine might not be enough. 17 Latrine use
is crucial and research indicates that a
significant portion of the population may
not be using available facilities.
Conversely, several practices can help
prevent trachoma infection i.e. regularly
washing children's faces and clean
environment and hygienic waste disposal.20
This study offers valuable insight into
understanding trachoma in Gilgit. A key
strength is the utilization of a standard
clinical examination and WHO criteria for
diagnosing trachoma. This approach
ensures the accuracy and generalizability of
the findings within the context of
established practices.
This study has several limitations. Firstly,
the cross-sectional hospital-based design
limits the generalizability of the findings to
the entire population of Gilgit. People with
existing eye complaints are more likely to
seek care at a hospital, potentially biasing
the sample towards a higher prevalence
than what exists in the general population.
Additionally, the study did not investigate
the reasons behind the observed higher
prevalence in young females. Furthermore,
seasonal variations in trachoma prevalence
were not considered. Confounding factors
such as access to clean water and sanitation,
along with socioeconomic status, were not
addressed in this study. Obtaining
information on these factors through
surveys and questionnaires could provide
valuable insights into potential risk factors
for trachoma.
Despite these limitations, our study
indicated the tip of the ice burg and
necessitates further investigation for
trachoma prevalence in the region. Larger-
scale, population-based studies with
prospective survey-based clinical
examinations are needed to confirm our
findings and establish the true regional
burden of trachoma. Additionally,
employing advanced diagnostic tools like
PCR tests could provide a more
comprehensive picture of active infections.
Furthermore, exploring alternative
treatment options and the effectiveness of
community-based interventions alongside
antibiotics could offer valuable insights for
optimizing trachoma control strategies in
Gilgit and Pakistan as a whole.
Conclusion:
This pilot study identified prevalence of
trachoma in a hospital setting, highlighting
Al-Shifa Journal of Ophthalmology, Vol. 20, No. 1, January – March 2024
31
the need for population-based studies to
assess the true disease burden in Gilgit.
References:
1. Martin K. Challenges confronting
global public health. Journal of Moral
Theology. 2021 May 19;1(CTEWC
Book Series 1):40-52.
2. Atsbha SG. A review of the prevalence
of trachoma, its control program and
challenges in Ethiopia. International
Journal of Drug Regulatory Affairs.
2023;11(1):54-60.
3. Solomon AW, Burton MJ, Gower EW,
Harding-Esch EM, Oldenburg CE,
Taylor HR, Traoré L. Trachoma
(Primer). Nature Reviews: Disease
Primers. 2022;8(1).
4. Ahmad B, Patel BC. Trachoma. 2023
May 23. StatPearls [Internet]. Treasure
Island (FL): StatPearls Publishing.
2023.
5. Debrah O, Mensah EO, Senyonjo L, de
Souza DK, Hervie TE, Agyemang D,
Bakajika D, Marfo B, Ahorsu F, Wanye
S, Bailey R. Elimination of trachoma as
a public health problem in Ghana:
Providing evidence through a pre-
validation survey. PLoS neglected
tropical diseases. 2017 Dec
12;11(12):e0006099.
6. Khan AA, Florea VV, Hussain A,
Jadoon Z, Boisson S, Willis R, Dejene
M, Bakhtiari A, Mpyet C, Pavluck AL,
Gillani M. Prevalence of Trachoma in
Pakistan: results of 42 population-based
prevalence surveys from the global
trachoma mapping project. Ophthalmic
epidemiology. 2020 Mar 3;27(2):155-
64.
7. Salahuddin T, Nisar MY, Ahmed A,
Naseem I. Trachoma in School Going
Children at District Bahawalpur,
Pakistan: Incidence and Causes.
Review of Education, Administration &
Law. 2018 Dec 31;1(1):33-40.
8. Renneker KK, Abdala M, Addy J, Al-
Khatib T, Amer K, Badiane MD,
Batcho W, Bella L, Bougouma C,
Bucumi V, Chisenga T. Global progress
toward the elimination of active
trachoma: an analysis of 38 countries.
The Lancet Global Health. 2022 Apr
1;10(4):e491-500.
9. Sanders AM, Abdalla Z, Elshafie BE,
Nute AW, Long EF, Aziz N, Weiss P,
Callahan EK, Nash SD. Prevalence of
trachoma within refugee camps serving
South Sudanese refugees in White Nile
State, Sudan: Results from population-
based surveys. PLoS Neglected
Tropical Diseases. 2019 Jun
13;13(6):e0007491.8.
10. Yajima A, Lin Z, Mohamed AJ, Dash
AP, Rijal S. Finishing the task of
eliminating neglected tropical diseases
(NTDs) in WHO South-East Asia
Region: promises kept, challenges, and
the way forward. The Lancet Regional
Health-Southeast Asia. 2023 Nov 1;18.
11. World Health Organization. Report of
the 21st meeting of the WHO alliance
for the global elimination of trachoma
by 2020, Geneva, Switzerland, 20-22
April 2017. World Health
Organization; 2019.
12. Khokhar AR, Iqbal T, Hussain M,
Rehman QU. Seasonal variation in
trachoma prevalence among children,
District Dera Ghazi Khan of Punjab,
Pakistan. JPMA. The Journal of the
Pakistan Medical Association. 2021 Jan
1;71(1 (B)):201-4.
13. Burr SE, Sillah A, Sanou AS, Wadagni
AC, Hart J, Harding-Esch EM, Kanyi S,
Bailey RL. Cross-sectional surveys of
the prevalence of follicular trachoma
and trichiasis in The Gambia: has
elimination been reached?. PLoS
neglected tropical diseases. 2016 Sep
19;10(9):e0004906.
14. Shafi Abdurahman O, Last A, Macleod
D, Habtamu E, Versteeg B, Dumessa G,
Guye M, Nure R, Adugna D, Miecha H,
Greenland K. Trachoma risk factors in
Oromia Region, Ethiopia. PLoS
Neglected Tropical Diseases. 2023 Nov
7;17(11):e0011679.
15. Renneker KK, Abdala M, Addy J, Al-
Khatib T, Amer K, Badiane MD,
Batcho W, Bella L, Bougouma C,
Iqbal et al. Prevalence of trachoma in Giligit
32
Bucumi V, Chisenga T. Global progress
toward the elimination of active
trachoma: an analysis of 38 countries.
The Lancet Global Health. 2022 Apr
1;10(4):e491-500.
16. Szwarcwald CL, Lopes MD, Borges de
Souza Junior PR, Vaz Ferreira Gómez
D, Luna EJ, da Silva de Almeida W,
Damacena GN, Ribeiro Favacho JD,
Germano de Frias P, Butcher R, Boyd
S. Population prevalence of trachoma in
nine rural non-indigenous evaluation
units of Brazil. Ophthalmic
Epidemiology. 2023 Nov 2;30(6):561-
70.
17. Delelegn D, Tolcha A, Beyene H,
Tsegaye B. Status of active trachoma
infection among school children who
live in villages of open field defecation:
a comparative cross-sectional study.
BMC public health. 2021 Dec;21:1-0.
18. Maciel AM, Ramos Jr AN, Gomes VD,
Ferreira AF, Almeida NM, Gómez DV,
Favacho JD, Maciel MM, Delerino AL,
Pires Neto RD. Epidemiology and
control of trachoma in the state of
Ceará, Northeast Brazil, 2007-2021.
Revista da Sociedade Brasileira de
Medicina Tropical. 2023 Jan
23;56:e0207-2022.
19. WoldeKidan E, Daka D, Legesse D,
Laelago T, Betebo B. Prevalence of
active trachoma and associated factors
among children aged 1 to 9 years in
rural communities of Lemo district,
southern Ethiopia: community based
cross sectional study. BMC infectious
diseases. 2019 Dec;19:1-8.
20. Chen X, Munoz B, Wolle MA, Woods
G, Odonkor M, Naufal F, Mkocha H,
West SK. Environmental factors and
hygiene behaviors associated with
facial cleanliness and trachoma in
Kongwa, Tanzania. PLoS neglected
tropical diseases. 2021 Oct
28;15(10):e0009902.
Authors Contribution
Concept and Design: Qaim Ali Khan
Data Collection / Assembly: Muhammad Tahir, Nauroz Fatima
Drafting: Qurat ul Ain Ghazanfar
Statistical expertise: Benish Ali
Critical Revision: Yasir Iqbal
Al-Shifa Journal of Ophthalmology, Vol. 20, No. 1, January – March 2024
