We have made recommendations for enhancements to the surveillance strategy for the three principal components of the system, active trachoma, trichiasis and antibiotic resistance.

5.1.1 Surveillance of active trachoma

The evaluators conclude that trachoma surveillance is essential to monitor and evaluate the impact of the Australian Government’s Improving Eye and Ear Health Services for Indigenous Australians for Better Education and Employment Outcomes measure. The evaluation team believes that, although it is important to obtain reasonably precise measures of prevalence, a system designed to estimate prevalence and facilitate the control of trachoma is most appropriate in the Australian situation. This conclusion implies that the surveillance system should place particular emphasis on regular (but no more than annual) and comprehensive screening of populations at greatest risk; that screening should be closely linked with agreed intervention strategies and that information should be collected on the implementation of those strategies and their effectiveness.

The three jurisdictions that have implemented screening have adopted different strategies, for example, in terms of whether trachoma screening occurs along with other childhood screening and when screening occurs during the year. The evaluation team has concluded that it would not be sensible to attempt to standardise all aspects of the screening arrangements across jurisdictions. However, it is important to maintain good standards in terms of training of staff that perform screening, standardise the data collected, and standardise processes for assessing the adequacy of screening (e.g. coverage rates). It is also important for jurisdictions to comply with the CDNA Guidelines which require annual screening of trachoma endemic communities until prevalence is less than 5% for five consecutive years.top of page

The current system is not likely to produce highly representative estimates of the prevalence of active trachoma in 1-9 year old children (the WHO recommended target group). However, it is concluded that screening of all children within the school age target group (5-9 years) remains appropriate, as the prevalence of trachoma in this age group is generally an accurate indicator of the levels of trachoma in the 1-4 year old age group, and provides an appropriate basis on which action can be decided. Other factors that impact on the representativeness of the estimates of active trachoma prevalence include:
  • where coverage rates for screening are low, the resulting prevalence rates are unlikely to be representative of trachoma prevalence in the community;
  • children not attending school who are not screened are likely to be more exposed to social, housing and environmental conditions that are associated with trachoma;
  • not all of the ‘at risk’ communities with endemic trachoma are screened annually until prevalence is <5% for five consecutive years, as required by the CDNA Guidelines; and
  • the recent National Indigenous Eye Health Survey has shown that there is trachoma in some communities in Queensland and NSW, jurisdictions in which there is no screening.
These problems need to be tackled to ensure that the national trachoma surveillance system can be used to assess the impact of the trachoma surveillance and control component of the Improving Eye and Ear Health Services for Indigenous Australians for Better Education and Employment Outcomes measure announced by the Prime Minister in February 2009. To start the improvement process, the evaluators initially considered that formalising the definition of ‘at risk’ communities, by identifying objective criteria and decision rules to improve the basis for estimating prevalence rates and aid the interpretation of the derived prevalence rates. Consultation with stakeholders revealed that validating and determining such criteria would be problematic. In view of these difficulties, the historical anecdotal determination of ‘at risk’ communities is considered to be appropriate, so long as the screening strategy is enhanced.

As the first step, all communities located in remote and very remote locations within NT, WA and SA should be included in the screening program at least once in a five year cycle using a rapid assessment method. Second, active trachoma screening activities should be extended, at least on a once off basis, to remote and very remote communities in NSW and Queensland also using the rapid assessment method. Third, jurisdictions should consider screening ‘at risk’ communities in other regions (that is communities that are not located in remote and very remote regions) at least on a once off basis every five years using the rapid assessment method. A decision to continue ongoing annual screening should always depend on the prevalence of active trachoma is found within the community. In all circumstances, jurisdictions should be able to exercise the discretion to not screen communities in which there is good local evidence that active trachoma is no longer present. However, the reasons for a decision not to screen a community located in remote and very remote locations at least once in a five year cycle should be conveyed to the NTSRU.

R1: It is recommended that within NT, WA and SA all communities located in remote and very remote locations should be included in the screening program at least once in a five year cycle using the rapid assessment method. A decision to continue ongoing annual screening in these communities should depend on the estimated prevalence of active trachoma found within the community.

R2: It is recommended that active trachoma screening activities should be extended, at least on a once off basis, to remote and very remote communities in NSW and Queensland using the rapid assessment method. A decision to continue ongoing annual screening in these communities should depend on the estimated prevalence of active trachoma found within the community.

R3: It is recommend that jurisdictions consider screening ‘at risk’ communities that are not located in remote and very remote areas) at least on a once off basis every five years using a rapid assessment method. A decision to continue ongoing annual screening in these communities should depend on the estimated prevalence of active trachoma found within the community.

R4: It is recommended that jurisdictions should be able to exercise some discretion in choosing not to screen communities in which there is good local evidence that active trachoma is no longer present. However, the reasons for a decision not to screen a community located in remote and very remote locations at least once in a five year cycle should be conveyed to the NTSRU.
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To supplement this more comprehensive approach to trachoma screening the documented screening performance benchmarks must be adopted. First, the CDNA Guidelines which require annual screening in trachoma endemic communities until prevalence is less than 5% for five consecutive years should be incorporated into funding and performance agreements between the Commonwealth and the jurisdictions relating to the allocation of additional funds under the new trachoma eradication initiative. Second, the benchmark coverage rate of 80% for ‘at risk’ communities as required by the National Framework for Delivery of Trachoma Control Programs developed by the Commonwealth and jurisdictions should also be adopted as part of any new funding agreement.

R5: It is recommended that the CDNA Guidelines which require annual screening in trachoma endemic communities until prevalence is less than 5% for five consecutive years be incorporated into funding and performance agreements between the Commonwealth and the jurisdictions relating to the allocation of additional funds under the new trachoma eradication initiative.

R6: It is recommended that the target screening coverage rate of 80% (i.e. the number of children aged 5-9 years screened as a proportion of the estimated number of children aged 5-9 years present in the community at the time of screening) stated in the National Framework for Delivery of Trachoma Control Programs should be adopted to ensure that screening coverage is sufficient to provide a reasonable estimate of trachoma prevalence.


Further, it is important to acknowledge that quality estimates of prevalence require both a correct diagnosis of trachoma in screened children and an accurate measurement of number of children in the target group residing in the community at the time of screening (the ‘denominator’). The evaluators believe that the denominator should be estimated locally at the time of screening, based on a discussion between screening staff and local school and/or health clinic staff, using a list of school enrolees or local resident children within the specified age ranges. Local staff or other informants will need to identify children who are not present in the community at the time of screening or additional children in the target age group who are visiting the community. To support this process, jurisdictions, in collaboration with the NTSRU, should develop guidelines to be followed by screening staff in estimating the denominator. Such guidelines will introduce a degree of consistency into the process and provide an opportunity, to emphasise to screening staff, the importance of obtaining a reliable estimate of the target population to the national trachoma surveillance program.

R7: It is recommended that the denominator used in calculating the screening coverage rate should be estimated locally at the time of screening, based on a discussion between screening staff and local school and/or health clinic staff using a list of school enrolees or local resident children within the specified age ranges.

R8: It is recommended that jurisdictions in collaboration with the NTSRU develop guidelines to be followed by screening staff in estimating the number of children in the target age group in the community at the time of screening.


To round out the enhanced active trachoma surveillance strategy, the evaluators believe that there is value in commissioning a national survey using randomised cluster sampling (the ‘gold standard’ method) once in about a five year period. The recent National Indigenous Eye Survey revealed information about the prevalence of trachoma in Australia that was not known from the national trachoma surveillance system. The nature of the rapid assessment process is that it will not yield the same breadth of information as a survey done using a randomised national sample. Given the costs involved the national survey should address both active trachoma and trichiasis surveillance.

R9: It is recommended that the national surveillance system data on the prevalence of active trachoma (and trichiasis) be supplemented through conducting a national eye health survey of Indigenous people about once every five years using a randomised cluster sampling method, similar to that used for the recent National Indigenous Eye Survey.

5.1.2 Surveillance of trichiasis

The evaluators believe that there is value in continuing with the surveillance of trichiasis. The evaluation has shown that the current system is not likely to produce estimates that are highly representative of the prevalence of trichiasis in older Aboriginal people as:
there is no systematic approach to screening (except in WA where screening is linked to the provision of annual vaccinations for Aboriginal adults); and
only a very small proportion of at risk communities are screened.

It is possible that trichiasis could be more widely spread across the country relative to active trachoma as adults who grew up in remote regions could now be residing in metropolitan or rural regions. It would be appropriate for the NT and SA to adopt a similar strategy to WA, in conducting trichiasis screening as part of the annual adult influenza vaccination program or potentially as an aspect of ‘adult health checks.’ Resources will need to be allocated to ensure training of staff undertaking screening, and to establish mechanisms through which these staff provide the results of screening to regional and/or jurisdictional trachoma units.

R10: It is recommended that trichiasis surveillance be enhanced by pursuing integration of screening for trichiasis with the provision of annual influenza vaccinations to Aboriginal adults and/or ‘healthy adult checks’ in at risk communities in the Northern Territory and South Australia.

5.1.3 Surveillance of antibiotic resistance

The evaluators found that the current approach to monitoring antibiotic resistance as part of the national trachoma surveillance system is inadequate. The method used to monitor antibiotic resistance levels in the Aboriginal population in Australia is considered to be appropriate. However the coverage of the pathology service providers that contribute data is thought not to be the most appropriate. The current arrangements result in the Indigenous population of WA not being represented in the data. This weakness occurs largely because the major pathology service provider in WA (PathWest) does not contribute data. The addition of data from PathWest would improve the current situation to the point where there could be confidence that the data are more representative of the actual situation. The evaluators believe that NTSRU should pursue the collection of data from PathWest.

R11: It is recommended that the current approach to monitoring antibiotic resistance be retained. The national trachoma surveillance system should be enhanced by the NTSRU seeking agreement from PathWest to contribute annual data on azithromycin resistance to the system.
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