Nepali Times
Seeing tomorrow


An infection so serious it can lead to blindness, and a remedy so simple that all it takes is a habit of washing the face and some pills. Such is the paradox of medical problems in developing countries.

One such infection is trachoma which is endemic in western Nepal, where it afflicts nearly one in every ten people, and it is the leading cause of preventable blindness in the country. But a new prevention and cure campaign launched by a Nepali NGO which will distribute antibiotics donated by the US pharmaceutical company, Pfizer, is expected to eradicate trachoma in the next two decades.

In two weeks, the Nepal Netra Jyoti Sangh (National Society for Comprehensive Eye Care - NNJS) will administer Zithromax pills to patients in Kailali, Kanchanpur, Nawalparasi and Chitwan districts. The antibiotic is the key component of a national strategy to eliminate trachoma. It is part of a strategy called SAFE - Surgery, Antibiotic, Facial Cleanliness and Environmental Improvement. "With SAFE, we hope to eliminate trachoma as a blinding disease by the year 2020," says Bimal Poudyal of NNJS.

Trachoma is a type of chronic conjunctivitis caused by a micro organism which leads to acute inflammation and scarring of the inner lining of the eye. In extreme cases, the eyelashes turn inward, rubbing on the cornea and causing blindness by turning the lens opaque. The key to treatment is Zithromax which can control infection by bacteria in the tissue of the eyelids. But, explains eye specialist NNSJ chairman, Ram Prasad Pokhrel: "It has to be accompanied by a widespread awareness campaign about personal hygiene and a clean environment."

Trachoma, known locally as khasre, is prevalent in 6.9 percent of the population and in the far-western regions of Nepal. The 1981 National Blindness Survey showed that trachoma was endemic in Banke, Bardiya, Kailali, Kanchanpur, Dang, and Surkhet and largely prevalent among the Tharu, Magar, and Thakuri communities. Pockets also exist in hilly and mountain regions like Jajarkot with its poor personal hygiene and lack of community sanitation.

Cataract blindness strikes both the rich and the poor - and most people seek a cure once they lose their sight. But trachoma, a disease of poverty, is common in areas deprived of basic needs in housing, health, water and sanitation, and debilitates families and communities.

Studies show that Tharu communities are three times more likely to contract the disease. Likewise, women who are in close contact with children are more likely to suffer from trachoma blindness because infants and young children are reservoirs of the disease, primarily because they do not wash their faces.

The highly contagious bacteria that spreads trachoma is most active during the hot months, so NNJS and its network of collaborating community groups have their work cut out for them this summer. "We have to get the antibiotics into the field for this cycle if we want to meet national targets," says Diwash S Rijal, NNJS Program Director. That target is part of the National Plan of Action for Eye Care Services in Nepal prepared last September. The Global Initiative for the Prevention of Avoidable Blindness (called \'Vision 2020: The Right to Sight') set the objective of reducing trachoma in Nepal by 30 percent by 2004, 50 percent by 2009, 80 percent by 2014 and complete eradication by 2019.

Effort of NNJS and its collaborating partners have already seen some success. Mobile surgery camps, eye hospital treatment centres and community trachoma control programmes in high-prevalence areas like Banke and Bardiya have brought about a drop in the disease. "With education, awareness and medication, the situation has improved in areas like Bardiya, where prevalence has dropped from 30 to five percent," says Shail Shrestha, the Swiss Red Cross Representative in Kathmandu.

A community-based trachoma control programme run since 1989 by the Nepal Red Cross in collaboration with the Swiss Red Cross and NNJS has mobilised local volunteers to promote awareness about trachoma infections and relatively simple cleanliness and hygiene prevention measures. Makuni Tharu is one of 200 active eye care Red Cross volunteers in Bardiya. She with 15 other volunteers has received a bicycle for referring 50 cases for surgery to the Fateh Bal Eye Hospital in Nepalgunj, and with it she is now able to reach a wider community.

The most recent prevalence study in children under 10 years indicates that 16 percent of the population in Kanchanpur and more than 12 percent of the population in Kailali suffer from the disease. A population-based survey conducted by the Hellen Keller International in May 2001 indicated that 19.9 percent of Chitwan's population suffers from the condition, as well as 16 percent in Nawalparasi. Prevalence is even higher in Surkhet (19.5 percent), Dailekh (27 percent), and Jajarkot (36 percent).

Nepal is one of 16 countries that the World Health Organisation (WHO) has put on its priority list for trachoma elimination. In 1997, the WHO established the Global Elimination of Trachoma (GET 2020) alliance which falls under the umbrella of "Vision 2020 -The Right to Sight". The alliance aims to drastically reduce the global burden of blindness, which currently affects an estimated 146 million people. Trachoma is one of five vision diseases that Vision 2020 has placed a priority on, along with cataracts, onchocerciasis, childhood blindness, refractive errors and low vision.

Nepal is the first country in South Asia to prepare a National Plan of Action which combines the forces of government agencies and institutions working in eye care, and sets up trachoma centres to be established at eye hospitals located in endemic zones. While projects underway so far have had a positive impact, officials acknowledge that greater action is required. "What's extremely urgent is a large scale awareness program aimed at changing behaviour," says Poudyal.

To raise public awareness about trachoma, the BBC World Service Trust, working in partnership with Radio Nepal, NNJS, and the Ministry of Health, launched an innovative media campaign in late March to disseminate information about the disease. Comprised of music and radio spots and posters, the campaign focuses on face and eye washing and a clean environment-two key behaviour changes that can reduce trachoma prevalence. In addition to Nepali language programming, radio spots are also being produced in Tharu.

"Our campaign's aim is to familarise the population with the word trachoma," says Madhu Acharya a radio producer with the BBC Trust. "They must make the link between trachoma and blindness, inform people that it can be prevented by simply washing one's face well and by maintaining a clean environment free of flies."

Trachoma is endemic in 49 countries, primarily in Africa the eastern Mediterranean, Southeast Asia and the western Pacific. It remains the most common preventable cause of blindness in the world with an estimated 5.6 million blind, visually impaired or at immediate risk of blindness from the disease and another 146 million cases of active trachoma in need of treatment.

Five stages of Trachoma

1. Trachomatous Inflammation - Follicular
The presence of five or more follicles in the upper eye lashes. Follicles are round swellings appearing white, grey or yellow. Follicles must be at least 0.5 mm in diameter. At this stage, a treatment of tetracycline cream is sufficient to prevent more serious problems.

2. Trachomatous Inflammation - Intense
Pronounced inflammatory thickening of the base of the lashes that obscures more than half of the vessels. The area appears red, rough and thickened. There are usually numerous follicles. At this stage, doctors recommend giving topical treatment and considering systematic treatment.

3. Trachomatous Scarring
Scars are easily visible as white lines, bands, or sheets in the tarsal conjunctiva. They are glistening and fibrous in appearance. Blood vessels obscured.

4. Trachomatous Trichiarsis
At least one eyelash rubs on the eyeball. Patients should be referred for eyelid surgery.

5. Corneal Opacity
Easily visible corneal opacity over the pupil. Such corneal opacities cause significant visual impairment. Immediate treatment is required.

(11 JAN 2013 - 17 JAN 2013)