This section describes the current trachoma surveillance arrangements in the Northern Territory including screening for active trachoma and trichiasis, the data collection process and integration of trachoma screening with other activities.
3.6.1 Organisation of the active trachoma surveillance programIn the NT, trachoma screening is co-ordinated through the Centre for Disease Control, Department of Health and Families (DHF), NT Government. The NT Trachoma Co-ordinator is based in Alice Springs and has a Territory-wide coordination responsibility. As shown in Figure 3.4 there are around 90 remote communities in the NT (using the definitions of communities adopted for trachoma screening) located in five regions across the NT including Darwin (rural regions), Barkly, Alice Springs (remote regions) and in some communities in the East Arnhem and the Katherine regions. In 2008, active trachoma screening was also undertaken in one town camp in urban Alice Springs.
Figure 3.4: Prevalence of active trachoma and communities where trachoma was reported, NT, 2008
Source: Trachoma surveillance report 2008, National Trachoma Surveillance and Reporting Unit, Centre for Eye Research Australiatop of pageThe main approach for active trachoma screening is for it to be done as part of the Healthy School Aged Kids (HSAK) program. This program is operated through DHF, in co-operation with local primary health care services, which may be either Aboriginal Community Controlled Health Services (ACCHS) or government managed services. HSAK adopts a holistic approach to child and adolescent health, and is an evidence-based population health program for school-age children in remote areas of the NT. The program works within the health promoting school model which is primarily concerned with making sure that the children are healthy so they can learn to the best of their ability thereby improving future employment opportunities. It recognises the need for schools, health services, families and communities to work in partnership. The trachoma coordinator works collaboratively with HSAK program assisting with active trachoma screening and management. HSAK has been implemented over several years and it has only recently achieved full staffing levels.
The other approach for active trachoma screening is for it to be done by the ACCHSs in communities where they have assumed full responsibility for health care delivery (Katherine West and Sunrise Health Services – both include communities around the Katherine region, and some communities in the East Arnhem region). For example, the Katherine West Health Board runs a skin and eyes program which includes active trachoma screening.
In 2007, Child Health Checks were undertaken throughout the NT under the Australian Government Emergency Initiative. The clinical advisory panel decided that active trachoma screening was only to be conducted by members of the intervention teams who had appropriate skills and training65. However, during Phase 2 of the Emergency Initiative in 2008, some children in the NT were examined for active trachoma during the Child Health Check by clinicians with varying experience with trachoma. These data were excluded from national reporting and the 2008 surveillance report66.
3.6.2 The screening process for active trachomaScreening and management of active trachoma in the NT is conducted in line with the National Guidelines for the Public Health Management of Trachoma in Australia produced by CDNA. The Centre for Disease Control developed Guidelines for Management of Trachoma in the NT based on the CDNA guidelines, with minor regional variations. Screening under the HSAK program is conducted by Maternal, Child and Youth Health program (MCYH). Staff are located in Darwin, Nhulunbuy, Tennant Creek and Alice Springs. They provide expert advice and assistance to remote primary health care staff, schools and the community on the co-ordination of annual school screening.
At the beginning of each school year the HSAK team consult with remote schools and health centres to plan screening. Best practice dictates that this process is conducted as early as practical in Term 1 to address conditions that may impede learning. However, this timing is not always possible and HSAK screening is conducted throughout the school year at mutually suitable times, with some communities screened in the last term of the school year.
Prior to the screening team visiting the community, local school or health staff will attempt to get parental consent for each child to participate in screening. Individual parental consent is required for the health check, for immunisation, and for information sharing with the Department of Education (this consent does not include consent for follow-up treatment, which is obtained in a separate process). In practice, consent may not have been obtained for all children prior to the team’s visit and the team may have to obtain consent when they arrive for the screening. In instances where arrangements for screening change, parental consent may need to be obtained again due to expiration of the time frame for the original consent.
The teams travel to local communities and work with local primary health care staff (e.g. clinic staff, remote area nurses, Aboriginal health workers and doctors) to undertake screening. The NT Trachoma Coordinator assists with training of MCYH staff and local staff, and in setting up arrangements for HSAK screening. HSAK team members are often directly involved in undertaking aspects of the screening, particularly where local staff have not been trained in screening for specific health issues such as trachoma.
Some screening of active trachoma occurs outside the HSAK arrangements, at the request of the community. This is solely trachoma screening and occurs in two to three communities each year, usually managed directly by the Trachoma Co-ordinator. Also, Aboriginal Community Controlled Health Centres conduct screening for active trachoma either through the HSAK team or by service providers in their organisation.
Delay in HSAK screening is a barrier to the implementation of the SAFE strategy in remote communities. In particular, antibiotic treatment and face washing health promotion activities are at times not implemented in accordance with national guidelines. The HSAK program does not provide services to urban areas in the NT. Children from town camps in Alice Springs screened as part of the NT Emergency Response in 2008 revealed a prevalence of 40% for active trachoma. This gap in service to urban areas needs to be addressed especially given the high mobility between urban and remote communities. top of page
3.6.3 Follow-up activities post screeningBased on the prevalence rates (revealed through the community reports), the Trachoma Co-ordinator will institute follow-up action for communities where active trachoma prevalence is greater than 10%. In some cases this process includes the Trachoma Coordinator travelling to the community and working with local clinic staff to identify the appropriate strategy (i.e. household or community antibiotic treatment). Follow up sometimes also occurs for lower prevalence communities. In most cases where trachoma is identified the Trachoma Co-ordinator or other qualified staff will have a discussion with the community about a strategy for treatment and whether further assistance is required i.e. if local resources are not available.
3.6.4 Trichiasis screening and surgeryScreening of adults for trichiasis has only occurred in the context of Integrated Eye Service clinics conducted by optometrists and/or ophthalmologists visiting communities. It is also part of the Healthy Adult Check for Indigenous adults however this clinical component is often incomplete. During 2008, in the NT, 206 adults aged 20 years and over were examined and 26 were found to have trichiasis. Data from these visits are obtained from regional eye health coordinators who are based in ACCHS in each NT region. Data on adults receiving surgery are obtained directly from ophthalmologists. The Trachoma Co-ordinator contacts ophthalmologists directly and, with assistance, analyses the list of patients who have received the procedure.
Notwithstanding the 206 adults examined opportunistically, no comprehensive trichiasis screening was conducted by remote primary health care providers in the NT during 2008. Two surveys of trichiasis prevalence in the NT were conducted by the Centre for Eye Research in 2007 (in association with the Fred Hollows Foundation) and 2008 as part of research projects. These surveys provided limited data suggesting high prevalence of trichiasis, well above the WHO recommended guidelines. Overall, information on trichiasis for individuals with severe scarring in the NT is limited.
3.6.5 Data collection processIn communities where the HSAK program exists, data are collected on the standard HSAK forms. DHF health centres then enter data into the NT electronic health system – PCIS, while the ACCHS use other computer systems. There are often delays in data entry in both instances. Data on the results of screening and treatment can be cross checked with unit record HSAK data entered in PCIS, which can be accessed by the trachoma data manager. However, data entry delays limit this process. In some instances, the Trachoma Co-ordinator and/or the trachoma data manager have had to obtain the original HSAK forms themselves and generate the data consistent with the national requirements.
In Katherine West, Sunrise and East Arnhem communities where screening occurs as a separate process, data consistent with the national forms are requested from the health services. However, there have been issues with gaining data from these services that are consistent with the national reporting requirements. For example, age breakdowns were not provided for some of the communities screened in the Katherine region in 2008, with rates reported relating to children aged 0-15 years .
For communities with endemic trachoma, the national form providing details on treatment action will be completed by the Trachoma Co-ordinator with assistance from local staff. In other communities (where trachoma prevalence is lower), contact is made with local clinic staff to complete details of treatment in accordance with the national form. top of page
Data flows to the trachoma coordinator and/or data manager occur as follows (see Figure 3.5):
- HSAK or local staff complete national forms (the individual data collection form and/or national forms 1 and 2) and fax these to the NT trachoma screening unit (in general, HSAK staff are not involved with the treatment components);
- in communities where ACCHS manage screening, local staff will complete national forms (or local variants of these) and forward these to the NT trachoma screening unit.
- where data consistent with the national forms are not provided, the trachoma coordinator and/or data manager will contact relevant staff directly to obtain information, which may involve the data manager collating data from the HSAK forms directly;
- for communities with endemic trachoma, the NT trachoma coordinator will travel to the community and Form 2 is likely to be completed by the trachoma coordinator;
- data can be subsequently verified through reports generated from the individual level HSAK data entered into PCIS (delays in entering data are often experienced);
- data on trichiasis and associated procedures are obtained from Integrated Eye Services and the Ophthalmologist providing surgery to the Central Australian communities;
- data are entered into the national access database by the NT Trachoma Data Manager and at the end of the year, the database is forwarded to the NTSRU;
- trachoma examinations as part of the Australian Government Emergency Initiative (AGEI) were excluded from national reporting.
*Only DHF health centres use PCIS the ACCHS use other computer systemstop of page
3.6.6 Uses of data and dissemination processThe NT Trachoma Co-ordinator and data manager produce reports to feed back information to local communities. The reports generally include information about the level of participation in screening and trachoma prevalence in the community.
3.6.7 Costs associated with trachoma screeningCosts associated with employment of the Trachoma Co-ordinator (initially 0.75 FTE and now a 1.0 FTE) and (the more recently appointed) Data Manager have been $476,878 across four years (an average of around $120,000 per year). This figure does not include the costs of actual screening undertaken by HSAK teams or other local staff. For communities covered by HSAK, screening active for trachoma is integrated into screening for a broad range of other conditions. The HSAK is a very costly undertaking, but the costs of including active trachoma screening in the broader screening program are marginal. The integrated screening arrangement has some significant cost advantages (e.g. management of consent, co-ordination of travel by staff to communities, minimisation of disruption to schooling).
3.6.8 The extent of integration with related systemsHSAK screens for a range of conditions which are known to be problems for Aboriginal children in the NT. These include immunisation status, worms, active trachoma and clean face status, skin conditions (e.g. sores, scabies, ringworm), dental health, ear health (e.g. otitis media and other ear conditions), tuberculosis, heart, and urine and blood analysis. In the Katherine region, screening is undertaken under a healthy skin and eyes program. Similar arrangements occur for some communities in the East Arnhem regions.
3.6.9 ConclusionTrachoma surveillance in the NT has taken time to establish and is still evolving. The trachoma program staff in the NT believe screening processes are now better than when national screening began due to improved awareness and regular training and education on detection and grading of trachoma. The adequate staffing of trained MCYH staff has also improved management of trachoma across the NT. The Australian Government Emergency Intervention created some issues for screening in the first few years of the program. The number of children being screened in the communities within which screening is regularly undertaken has increased over time. The HSAK program is only now beginning to be fully operational across the NT. top of page
65Tellis B, Fotis K, Dunn R, Keeffe J and Taylor H (2009). Trachoma surveillance report 2008, National Trachoma Surveillance and Reporting Unit, Centre for Eye Research Australia
67Tellis B, Fotis K, Dunn R, Keeffe J and Taylor H (2009). Trachoma surveillance report 2008, National Trachoma Surveillance and Reporting Unit, Centre for Eye Research Australia