Status of active trachoma infection among school children who live in villages of open field defecation: a comparative cross-sectional study

Globally, active trachoma is predominant cause of preventable blindness. It is mainly caused by bacterium Chlamydia trachomatis. Trachoma infection is transmitted from infected to healthy person during contact of infected eye discharge though hands, clothing,fomites, and excreta [1]. Musca sorbens, eye-seeking fly, are the vector for active trachoma infection [2]. In Ethiopia, Bacterium Chlamydia trachomatis and Trachomatous trichiasis are concentrated in densely populated regions such as: Amhara, Oromia, and Sidama [3].

After the first infection, active trachoma is manifested sequentially in different clinical stages: First, trachoma manifests as a follicular conjunctivitis, with superficial keratitis and corneal vascularization. Second, it progresses to conjunctival scarring and eyelid distortion with repeated infection gradually. Third, cornea can be damaged. Finally, it can result into chronic inflammation and blindness [4, 5]. Specifically, trachomatous inflammation–follicular (TF) presented as the occurrence of five or more small white follicles (each measure ≥0.5 mm diameters) in the central zone of the upper tarsal conjunctiva. Over time, persistent abrasion of cornea by inward folding of eyelashes could lead to cornea opacification and blindness. Finally, repeated infection can lead to trachomatous trichiasis [6, 7].

Globally; an estimated 84 million people are suffering from active trachoma infection. According to World Health Organization (WHO) estimation, trachoma infection is an endemic disease in 56 Middle East and Africa countries. The problem can be doubled by lack of extensive resources necessary for prevention of trachoma such as: Access to clean water, sanitation facilities and health resources in developing countries [8]. Trachoma endemic communities are usually dry and dusty areas, mired in poverty, and have poor sanitation [9, 10]. Trachoma is expected to be endemic throughout Ethiopia [11]. According to 2005–2006 national survey report, over 9 million children were affected by active trachoma [12]. Specifically, prevalence of active trachoma is expected to be high in the study area [13].

Children are the most vulnerable groups of the population for trachoma infection [14]. Two-fifth of active trachoma infection is occurred among children of age 1–9 years [3]. Active trachoma infection (trachomatous inflammation follicularis and/or trachomatous inflammation intense) reaches peak at the age of pre-school (4–6 years); however, subsequent scarring and blindness can also be occurred among children [7]. Blindness affect not only individuals but also several poverty reduction strategies [15]. Visual impairment can lead to annual productivity loss of $3–$6 billion in the world. Hence, sustainable development goal cannot be achieved in 2030 [16]. In Ethiopia, trachoma is the country’s second most common cause of blindness next to cataract [17]. Approximately two-fifth of blindness is believed to be avoidable in Ethiopia prevention and early treatment [15]. Currently, despite of significant effort made to eliminate trachoma, trachoma is still a major health crisis in Ethiopia [18].

Multiple factors are assumed to be associated with active trachoma infection [13]. Specially, active trachoma infection among children is caused by presence of flies on the face [19], large family size [20], ocular discharge, nasal discharge, low socioeconomic status, living in higher altitude and unsafe water sources [21]. On the contrary, frequent washing of children’s face, clean environment and hygienic disposal of excrement were found to be preventative factors [22]. Several studies indicate that open field defecation is the main risk factor for trachoma infection [19, 23, 24]. On the contrary, other evidence proved that latrine access was not associated with active trachoma or C. trachomatis infection, despite the fact that 60% of individuals do not have access to a latrine. Latrine access does not translate into latrine use [25].

World health organization has targeted trachoma to eliminate trachoma from being as a public health problem by 2020. Therefore, SAFE strategy (surgery for in-turned eyelashes, antibiotics to clear infection, and facial cleanliness and environmental cleanness) was designed and implemented in the last couple of years in the world [25, 26]. The targets for elimination of trachoma in Ethiopia include: Reduce prevalence of Trachomatous inflammation follicular below 5% among children for children aged 1–9 years at the health district level and to minimize trachomatous trichiasis (TT) less than one case per 1000 among the total population at health district level [27]. As a result, policymakers and program designers should know the prevailing problem and factors hindering the elimination of trachoma to design better and logical programs and policy. In this study, we hypothesized that active trachoma should be significantly higher in open field defecation Kebeles than non-open field defecation.

From a total number of 748 study participants, only 701(94%) study participants gave full response in the this study. The socio-demographic characteristic of the study population is shown in Table 1. Regarding the fathers of children in the study, only 14.2% from ODF and 8.5% from non-ODF Kebeles of could read and write. Nearly one third (31.6%) of children lived in the middle wealth quintile household. Three hundred seventy three (53.2%) of parents of the study subjects cared for their children.

Accordingly, one out of two study participants were selected from open field defecation Kebeles and the remaining study subjects were selected from non-open field defecation Kebeles. Based on the districts, more than half (55.9%) of study participants were selected from Boricha district; whereas, the remaining 45.1% were selected from Dale district. More than four-fifth of the study participants had ocular discharge at the time of data collection. Nighty eight (14.4%) of the study participants had nasal discharge at the time of data collection. More than half (54.4%) of the study participants had no finger cleanness during inspection at data collection. Males accounted more than half (51.4%) of study subjects in the current study. Most of the study participants were in the age range of 5–9 years (82.7%), the mean age of 8.8 + 1.67 years. Regarding about cloth hygiene, more than half (53.5%) of the study participants had no cloth cleanness. Only 1 out of 10 (8.3%) study participants had fly on their face, while most (91.7%) of children did not have fly on their face during data collection time. According to Table 2 report, we found that the overall prevalence of active trachoma infection was 17.5% among primary school students in the study area. Specifically, the prevalence of trachoma infection was 67.5% in the ODF villages, while the prevalence of active trachoma infection was 32.5% in non-ODF Kebeles.

We anticipated high prevalence of active trachoma in open field defecation Kebeles among children of 1–9 years in this study. However, it has demonstrated that active trachoma was found to be high in non-open field defecation Kebeles. The prevalence of active trachoma among school children was 76.5% in ODF Kebeles; the prevalence of active trachoma was 88.5% among school children who live in Non-ODF Kebeles. This proportion was statistically significant (x² = 17.5, p-value < 0.000). These findings indicate that 12% of excess active trachoma was observed among school children in non-ODF Kebeles. This mainly indicates that presence of latrine only does not give guarantee for prevention of active trachoma elimination rather the health behaviour related with hygiene determine the prevalence of active trachoma. From this, we can understand effective utilization of latrine, hand hygiene after utilization of latrine and increase awareness about active trachoma are mandatory apart from transforming ODF Kebeles to non ODF status. The overall prevalence of active trachoma infection was 17.5% (95% CI, 16.1–18.8) among primary school students aged 1–9 years. Specifically, prevalence of trachoma infection was 55.9 and 44.1% in Boricha and Dale district respectively. These findings are reduced almost by half when compared with prevalence of active trachoma in Southern Nation Nationalities Regional State (33.2%). Furthermore, these findings were also lower than age adjusted prevalence of South region (25.9%) [3]. The possible rational for this difference might be due to lack of awareness about personal hygiene and sanitation. Besides, lack of water and hygiene materials in this study might result into higher trachoma infection. Compared to prevalence of active trachoma in 2014, prevalence of active trachoma was higher in 2019 in the study area [31]. This might indicate that despite progress in prevention of active trachoma in the region, little effort was made to prevent active trachoma in the study area in the last couple of years. Ethiopian federal ministry of health, and other stakeholders have identified various type of strategy to control and eradicate active trachoma like: Hygiene and promotion, improved access to clean water, and proper sanitation for disposal of human waste as a priority intervention for trachoma infection and other wash related disease through the health extension program and adoption of community-led total Sanitation [32]. The current study showed that prevalence of active trachoma inflammation follicular (TF) was found to be 55.7%. The current finding is more than the WHO criteria for elimination of trachoma as public health problem i.e. TF < 5% in children aged from 1 to 9 years (WHO) [33]. This might be due to absence of universal supplementation of antibiotics, facial cleanliness and environmental cleanness strategy for trachoma elimination. Previous evidence recommend A, F and E components of the SAFE (Surgery, Antibiotic, Facial cleanliness and Environmental improvement) strategy for trachoma elimination for settings with prevalence of active trachoma infection more than 5% [34]. Primary school children in ODF Kebeles were two and half times more likely prone for active trachoma infection than their counterparts. This finding is in line with previous study conducted in Southern parts of Ethiopia [31, 35]. The possible explanation could be the following: Firstly, active trachoma infection might be due lack of personal hygiene (finger cleanness, facial cleanness and environment hygiene) more than latrine utilization. This indicates that the mere presence of latrine could not guarantee the prevention of active trachoma infection unless appropriate hygiene practices are not performed after latrine utilization [36]. Secondly, community led total sanitation campaigns are practiced by ODF Kebeles more than non-ODF Kebeles. Finally, health education program might be strengthened by community health workers about personal hygiene, environmental sanitation and disease prevention in ODF Kebeles than their counterparts. Similar studies also approved this fact that health education intervention statistically significant reduction in the prevalence of active trachoma [22]. Finally, in these populations children aged 1–9 years are often discouraged from using latrines due to caregiver concerns about their safety when using latrines.

The odd of getting active trachoma infection among primary school children who had flies on their face is higher than their counterparts. This finding is consistent with finding of similar study carried out in East Nigeria [19, 37‐39]. The possible rational might be that school children with flies on their face did not wash their face frequently due to lack of water source. Previous evidence indicate that improving access to safe water sources and better hygiene practices can reduce trachoma morbidity nearly by one third [40]. As previous evidence proved that frequent washing of children, clean environment and hygienic disposal of excretion were valuable preventative factors for active trachoma infection [22].

In this study, females were more affected by active trachoma infection than males. This finding is inconsistent with the previous study done in Guinea [41]. On the contrary, females have low odds of getting trachoma infection in the study conducted in Biogas [42]. The possible explanation might be female children are in close contact with vectors and other exposure variables during home works. In addition, some communities might have sex preference in taking care of children.

The chance of children who had ocular discharge more than their counterparts. This finding is consistent with the previous study. This finding is in line with the previous study [41]. The possible rational might be that children who had ocular discharge were more likely to attract flies on their eye and less likely to wash with clean water and soap. Similar study proved that children who did not wash their face with soap and water were more likely affected by active trachoma infection [43].

Children with nasal discharge were more affected than their counterparts. This finding is similar with the previous study [41]. This might be due to the fact that nasal discharge might create good media for attracting flies on their face causing active trachoma infection. Flies are vectors of chlamydia trichromatic infection [44]. Nasal and ocular discharges might result from the inflammation of active trachoma and cause the face to be classified as unclean [24, 45, 46]. At last, children with clean finger had lower risk of infection than their counterparts [47]. The possible explanation might be due to the fact that children with unclean finger had chlamydia Trachomatous with their finger and subsequent transmission through direct contact at the time of touching of their eyes.

Prevalence of active trachoma is high among school children in open field defecation than school children of non-open field defecation. Furthermore, the prevalence of active trachoma among school children is higher than the national prevalence in both areas. Hence, the government should strength proper environmental sanitation, hand hygiene and proper use of latrine. Campaigns focusing on introducing educational intervention programs in women’s organizations, schools, and communities could help bring behavioural changes among school children, which are the change agents, and lower the burden of trachoma in the study area.