This section describes the purpose and objective of the national trachoma surveillance system, including the planned uses of its data, its level of integration with other systems and the environment in which the system operates to establish a frame of reference for evaluating specific components49.
3.3.1 The objectives of the trachoma surveillance systemIn November 2006, the Centre for Eye Research Australia (CERA) was awarded a three year contract to establish the National Trachoma Surveillance and Reporting Unit (NTSRU). The NTSRU was established to improve the quality and consistency of data collection and reporting of active trachoma in Australia. The principal role and function of the NTSRU is to provide high quality national information on trachoma prevalence and control activities based on data received from jurisdictions in Australia where trachoma remains endemic. The DoHA extended the NTSRU contract until June 30 2010 in order to allow time for a review of the collection and reporting of trachoma surveillance data (this project). CERA have subcontracted the Centre for Molecular, Environmental, Genetic and Analytic Epidemiology (MEGA) to fulfil the last year of their contract with DoHA.
The NTSRU is advised by the National Trachoma Surveillance Reference Group and informed by the Communicable Disease Network Australia (CDNA) Guidelines for the Public Health Management of Trachoma in Australia, 2006,and existing surveillance units in operation throughout Australia. The NTSRU is responsible for50:
- reporting on trachoma prevalence and management based on data received from the NT, SA, and WA;
- monitoring and reporting on antibiotic resistance to azithromycin;
- developing data collection forms that are culturally appropriate using language consistent with the policy in the CDNA Trachoma Guidelines and agreed to by the National Trachoma Surveillance Reference Group; and
- establishing a database that is secure and confidential.
3.3.2 The planned uses of data from the systemData on trachoma are collected by health units and entered into the National Trachoma Database which is managed by the NTSRU. The data collected through the trachoma surveillance system are, in theory, standardised so that data are comparable between regions and states, and so that Australia can contribute meaningful data to global trachoma reports. In practice, the data are collected and entered into the NTSRU database by the health units with variable quality. The collection of the trachoma data is intended to allow for the following calculations of trachoma prevalence (the calculations are undertaken by each regional population health unit)51:
- prevalence of TF, TI, active trachoma and TS in the screened Aboriginal and Torres Strait Islander population in the 1–4, 5–9 and 10–14 years age groups;
- minimal regional prevalence of TF, TI, active trachoma and TS in Aboriginal and Torres Strait Islander peoples in the age groups stated above;
- estimated likely regional prevalence of TF, TI, active trachoma and TS in Aboriginal and Torres Strait Islander peoples in the age groups stated above;
- TT prevalence in the screened Aboriginal and Torres Strait Islander population;
- minimal regional TT prevalence in Aboriginal and Torres Strait Islander peoples in the screened age group; and
- estimated likely regional TT prevalence in Aboriginal and Torres Strait Islander peoples in the screened age group.
- trachoma prevalence in the screened Aboriginal and Torres Strait Islander population is the number of Aboriginal and Torres Strait Islander peoples with trachoma divided by the number of Aboriginal and Torres Strait Islander peoples screened;
- minimal regional Aboriginal and Torres Strait Islander trachoma prevalence is the number of Aboriginal and Torres Strait Islander peoples with trachoma divided by the regional Aboriginal and Torres Strait Islander population in screened age groups (this calculation assumes that all Aboriginal and Torres Strait Islander peoples not screened do not have trachoma); and
- estimated likely regional Aboriginal and Torres Strait Islander trachoma prevalence is the trachoma prevalence in the screened Aboriginal and Torres Strait Islander population multiplied by the number of Aboriginal and Torres Strait Islander peoples in the screening target group, and resulting number then divided by the regional Aboriginal and Torres Strait Islander population in screened age groups (this calculation assumes that trachoma prevalence in the screened Aboriginal and Torres Strait Islander population is a true estimate of trachoma prevalence in Aboriginal and Torres Strait Islander groups targeted for screening, and that all Aboriginal and Torres Strait Islander peoples outside the screening target groups do not have trachoma).
- the proportion of target populations screened for active trachoma/clean face (defined as absence of dirt, dust or crusting on the cheeks and forehead) and trichiasis;
- the proportion of Aboriginal and Torres Strait Islander children with active trachoma who received antibiotic treatment within two weeks of screening;
- the proportion of household contacts aged six months or more who received antibiotic treatment within two weeks of the case being identified;
- if active trachoma prevalence was > 10%, the proportion of Aboriginal and Torres Strait Islander children aged six months to 14 years in the community who received antibiotic treatment within two weeks of screening;
- the surgical waiting time for patients with trichiasis;
- community/patient satisfaction with trachoma control activities; and
- evidence of collaborative partnerships in trachoma control between health, environmental health, education, health promotion and community sectors.
- the prevalence of TF, TI and TS in the Aboriginal and Torres Strait Islander population aged 1–4 years, 5–9 years and 10–14 years; and
- the prevalence of TT in the Aboriginal and Torres Strait Islander population.
All data collected are used to produce the annual Trachoma Surveillance Report. The report provides a national overview, a regional overview and a community level overview of the key data for trachoma affected areas. top of page
3.3.3 Collection of data on antibiotic resistanceCommunity distribution of azithromycin has an important role to play in trachoma control. Previous studies have suggested an association between the widespread community use of antibiotics and a rise in antibiotic resistance in Streptococcus pneumonia55,56. Accordingly, the NTSRU monitors antibiotic resistance in Indigenous communities through data collection from pathology services to determine whether any communities have developed a resistance to the antibiotic used to treat active trachoma, azithromycin. Three pathology services (Institute of Medical Veterinary Science (IMVS) in SA; Northern Territory Government Pathology Service (NTGPS); and Western Diagnostic Pathology Service (WDPS) in WA) in 2008 provided erythromycin (the broader class of antibiotics to which azithromycin belongs) resistance data for isolates of S.pneumoniae specimens collected from Indigenous people in trachoma endemic regions57.
Specific information on Aboriginality was only reported from the NTGPS; specimens were collected from outpatients or those in the emergency room of the Alice Springs hospital. This information is not routinely collected by the other two pathology services. For this reason IMVS and WDP have provided data for specimens from those regions or health services that predominately serve Aboriginal people (this approach would seem to provide a useful surrogate measure, in the absence of a specific data item on Aboriginality). PathWest pathology services in WA have not been able to provide the NTSRU with antibiotic resistance data due to difficulties in obtaining the necessary clearances58.
According to the National Trachoma Surveillance Reports between 2006 and 2008 no change in antibiotic resistance of S.pneumoniae was detected. The results can be compared to those collected by the nation-wide survey conducted by the Australian Group on Antimicrobial Resistance (AGAR) in 2005. The AGAR performs regular multicentre point-prevalence studies to monitor changes in antimicrobial resistanc59. In 2005, 20 laboratories participated in national surveillance of Streptococcus pneumoniae resistance and 1,776 strains of S.pneumoniae were collected. Table 3.4 presents azithromycin resistance data based on AGAR and NTSRU monitoring, showing that the NTSRU results are comparable to those obtained by the AGAR.
Table 3.4: Comparison of azithromycin resistance to invasive and non-invasive S. Pneumonia isolates
|New South Wales/ ACT|
Source: Source: Tellis 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 AustraliaThe data suggest that the use of azithromycin for trachoma control in the Indigenous communities for which data are available has not resulted in significantly different resistance rates to those in the general population as measured by AGAR.top of page
3.3.4 The environment in which the system operatesThe trachoma control program is guided by the Guidelines for the public health management of trachoma in Australia developed by the Communicable Disease Network of Australia (CDNA)60. The guidelines provide recommendations to ensure consistent trachoma screening, control measures and data collection in Australia covering the following areas:
- responsibility for trachoma control;
- engaging with communities for trachoma control activities;
- educating the health workforce;
- implementing the SAFE strategy;
- program evaluation;
- data collection; and
- the role of nucleic acid detection tests (NADTs) in trachoma screening and diagnosis.
Figure 3.3: A National Framework for the Delivery of Trachoma Control Programs
Source: A National Framework for delivery of trachoma control programs, November 2009 (unpublished)As recommended by the 2006 Guidelines for the Public Health Management of trachoma in Australia trachoma control is the responsibility of state and territory government-run regional population health units or their equivalents. Primary health care services are involved in the detection and treatment of trachoma under the coordination of regional population health units. Primary health care staff, including Aboriginal health workers, community health and remote area nurses are likely to be the best placed to engage with community councils, leaders and key stakeholders regarding trachoma control61. Regional population health units collect trachoma data in accordance with the minimum national trachoma dataset and report these data to a national trachoma database, which is managed at a national level by the NTSRU.
Establishing and maintaining an effective health workforce for trachoma control can be difficult given the location of endemic regions. Challenges to achieving effective trachoma control include high staff turnover in rural and remote health care settings and the disappearance of trachoma from many parts of Australia, including capital cities and regional centres where health professionals are trained62. top of page
49Center for Disease Control (2001). Updated guidelines for evaluating public health surveillance systems: recommendations from the guidelines working group. Available from: http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5013a1.htm
51Department of Health and Ageing (2006). Guidelines for the public health management of trachoma in Australia, Communicable Disease Network Australia
52Department of Health and Ageing (2006). Guidelines for the public health management of trachoma in Australia, Communicable Disease Network Australia
54Department of Health and Ageing (2006). Guidelines for the public health management of trachoma in Australia, Communicable Disease Network Australia
55Arason, V. A., K. G. Kristinsson, J. A. Sigurdsson, G. Stefansdottir, S. Molstad, and S. Gudmundsson (1996). Do antimicrobials increase the carriage rate of penicillin-resistant pneumococci in children? Cross sectional prevalence study. Br. Med. J. 313:387–391
56Pedersen, G., H. C. Schonheyder, F. H. Steffensen, and H. T. Sorensen (1999). Risk of resistance related to antibiotic use before admission in patients with community-acquired bacteraemia. J. Antimicrob. Chemother. 43:119–126.
57Tellis 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.
59http://www.agargroup.org/surveys accessed 1 April 2010
60Department of Health and Ageing (2006). Guidelines for the public health management of trachoma in Australia, Communicable Disease Network Australia
61Department of Health and Ageing (2006). Guidelines for the public health management of trachoma in Australia, Communicable Disease Network Australia