SAFE Succeeds in Cutting Trachoma Burden in Sudan

NEW ORLEANS -- A new strategy appeared effective in reducing the prevalence of trachomatous inflammation-follicular (TF) in Sudan, results of an impact survey indicated.

After implementation of the so-called SAFE program, the researchers assessed the current prevalence of TF in Sudan in the 14 non-Darfur localities that were endemic. Of those localities, nine were under 5% TF and mass drug administration (MDA) had stopped. Three localities were scheduled for impact survey and had 5% to 9% TF, reported Angelia Sanders, MPH, MA, of the Carter Center in Atlanta, at the American Society of Tropical Medicine and Hygiene (ASTMH) meeting.

Two localities still had over 10% TF, of which one had planned impact survey and one was an insecure region with Blue Nile state, Sanders said.

These results, Sanders suggested, were indicative of real progress against chlamydial trachoma with SAFE in Sudan. SAFE is an acronym for programs targeting ocular Surgery, Antibiotics, Face cleanliness, and Environmental improvement (i.e., sanitation) to combat trachoma and its complications.

Sanders reported that the program had resulted in the following:

• 11,471 trachomatous trichiasis (TT) surgeries
• Training of TT surgeons and TT case finders
• Distribution of nearly 8 million doses of azithromycin
• Repeated health education efforts in schools and communities
• Capacity development for national public health officers and state field coordinators

Previous reports on Sudan at baseline showed that 15 localities were not endemic, 56 localities were not endemic for TF but surgeries were needed, 25 localities (of which 11 were Darfur and 14 were non-Darfur) were endemic and needed SAFE, and 14 Darfur localities that still needed baseline mapping.

SAFE Strategy at Work in Al Rahad

Sanders also reported on local effects in one locality in Sudan's southeast, Al Rahad. The region is agriculturally rich and is essentially the breadbasket of Sudan, she explained, but at the same its clay-heavy soils make sanitation, particularly latrine digging and maintenance, a challenge. In the absence of latrines, open defecation is common. Prior to undertaking SAFE, it was the most endemic region for trachoma in Sudan.

Baseline data from 2013 in Al Rahad showed TF in 7.1% of 709 children 1-9 years old. Among 585 adults age 15 and older, TT was seen in 4.8%.

Subdistrict data for children 109 years old showed a TF prevalence of 27.9% in Al Hawata, 34.4% in Al Mafaza, and 26.8% in Wad Al Sha'er. The locality total was 29.4% TF.

Subdistrict data for adults ages 15 years and older showed a prevalence of 1.3% TT in Al Hawata, 1.6% in Al Mafaza, 2.6% in Wad Al Sha'er. The locality total was 1.8% TT.

The S&A portion of SAFE in this area totaled 796 surgeries, with 28 TT case finders trained. There were three rounds of mass drug administration (MDA), with very high coverage during each round, Sanders said.

Three weeks later, the researchers did a MDA coverage survey based on self-reported treatment, with 467 households across 30 different clusters and 1,681 individuals responding.

It showed that 76.0% of people reported having the drug and 82.3% of children ages 1-9 reported having it as well.

From there, the researchers implemented F&E activities in 113 basic schools and 16 secondary schools with the aim that students would pass the information along to their families and community members.

The trachoma curriculum, the trachoma friendship societies on health education, and sanitation efforts were introduced into the communities with the help of the schools, Sanders noted.

After three years of the SAFE intervention, researchers surveyed 25 clusters, with 25 households in each cluster, to examine children ages 1-9 for TF, and all individuals for TT.

Among 860 children examined, the TF rate was 6.3%. Trachomatous inflammation–intense (TI) had a prevalence of 0.2%.

For the 859 older subjects, ages 15 years and older, TT prevalence was 0.68%.

The survey results also showed 72% of children had clean faces and 60% of households were using latrines.

Looking ahead, Al Rahad will continue to train TT surgeons at locality level, to use TT case finders, and to do house to house case searchers. A recent MDA was done in April 2018. The current F&E approach will continue to be implemented, and impact surveys will be done in early 2019.

Sanders also said her group had begun a survey of trachoma infection in children, with 840 conjunctival swabs collected and analysis expected to begin in December.

As for Sudan overall, districts regularly showed less than 5% at impact survey, and it is predicted that by 2020 all non-Darfur will be in surveillance mode. Sanders said aggressive disease reduction should then be focused on Darfur, the western region where the national government still does not have full control after a militia-led rebellion broke out in 2003.

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