This section describes the current trachoma surveillance arrangements in Western Australia (WA) including screening for active trachoma and trichiasis, the data collection process and integration of trachoma screening with other activities.
3.7.1 Organisation of the active trachoma surveillance programIn WA, active trachoma screening is co-ordinated through four regional population health units (PHUs) and overseen by the Communicable Disease Control Directorate within the Health Department of WA. There are around 123 remote communities in WA (using the definitions of communities adopted for trachoma screening), and these are located in four regions, the Kimberley, Pilbara, Midwest and Goldfields. Figure 3.6 shows the number of screened communities in each region and associated active trachoma prevalence in 2008.
Figure 3.6: Prevalence of active trachoma and communities where trachoma was reported, WA, 2008
Source: Trachoma surveillance report 2008, National Trachoma Surveillance and Reporting Unit, Centre for Eye Research Australiatop of page
3.7.2 Description of the active trachoma screening processIn WA, PHU and local primary health care staff screen for active trachoma68. Screening is undertaken over a two week period throughout WA and it is targeted for the last week of August and first week of September. In 2008, screening was conducted at the end of August in the Goldfields, Kimberley, Midwest and Pilbara regions. The communities screened in WA have been identified by the PHUs as ‘at risk’. Before the establishment of the NTSRU trachoma surveillance was conducted by PHUs in these same regions, so the ‘at risk’ communities currently screened are based on historical data and knowledge. Some PHUs have run trachoma surveillance activities for more than 10 years and have collected and reported data for this entire time. The establishment of the NTSRU meant that the data collected are now standardised and sent to WA Health and then on to the NTSRU.
The time required to undertake the screening process in WA varies between regions. The Kimberley has the largest population of children in ‘at risk’ communities and it generally takes the full two weeks to screen these communities; one week for screening and treatment at schools and a second week for treating families and community members. In the Kimberley the time period from screening to data entry takes about two months. In the Midwest region screening and treatment is conducted over three days covering six communities. Midwest PHU commented that a couple of small communities are missed, however these tend to have better environmental management therefore less trachoma. In the Pilbara usually one day of screening is set aside per community. In the Goldfields region, screening is conducted in 10 communities across the two-week period.
The screening model in WA is based on involving and sometimes training local community health workers in the screening process with the aim of building capacity in local areas to screen and treat active trachoma. The regional PHUs work with the local community health nurses to coordinate the annual active trachoma surveillance activity with the schools. In most regions letters are sent to parents from the schools in order to gain parental consent for the screening of their children. Gaining consent is problematic in WA and schools often spend considerable time following up parents (i.e. door knocking).
The process of screening is similar across all regions. Ideally five to six people would be available to screen one community including at least one nurse and ideally an Aboriginal health worker. On the day of screening, all children attending school are screened. Children identified as having active trachoma are treated immediately. All PHUs commented that it is common for there to be high rates of absenteeism in the schools (approximately 50% of students can be absent). The day of screening can unavoidably coincide with sorry days, deaths in the communities, extreme temperature days, etc., which can increase the absentee rate. This absenteeism presents challenges for both screening and data collection.
3.7.3 Follow-up activities post screeningFollow up activities as a result of screening are ideally carried out by trained staff in the local communities (e.g. local community health nurse, nurse working in local ACCHS, etc.). Given the high rate of absentees in community schools the local community health nurse is asked to follow-up with absentee children, however this task is often difficult due to other competing priorities. Follow up of missed children does not occur in every community due to a lack of trained staff in local communities and a lack of resources. It is also the local community health nurses job to follow-up with antibiotic treatment for the family members of infected children. In all cases where the prevalence in the community is found to be >10% the PHU is also reliant on the local community health nurse to treat the community.top of page
3.7.4 Trichiasis screeningAdults are examined for trichiasis as part of an annual influenza vaccination program in WA. This program generally takes place as a concentrated process between March and April each year. All four PHUs in WA commented that it is becoming rare to identify an adult with trichiasis. Adults identified with having trichiasis are referred to the local ACCHS for an appointment with the visiting ophthalmologist. The comment was made repeatedly that it was common for the patient with trichiasis not to attend their appointment. Those presenting with trichiasis rarely seek surgical treatment as it is not perceived as a high priority and there are inherent barriers to accessing surgery i.e. distance required to travel to hospital. Surgeries that do occur are often not known about at the referring PHU. Some PHUs contact the hospitals to determine if any trichiasis surgery was performed but this process is fraught with its own challenges in getting access to the data.
3.7.5 Data collection processPHUs collect data in partnership with primary health care staff from ACCHSs69. On the day of screening, data are collected on the forms provided by the NTSRU or equivalent. Each PHU is responsible for collating its regions trachoma screening data at the aggregate level using the NTSRU database. The database is then sent to WA Health, where it is reviewed and sent to the NTSRU. PHUs commented that it was common to experience delays in being provided with data by local communities, particularly from the community health nurses undertaking the follow-up, as it was not a high priority for the nurses. If the surveillance activities were conducted by trained local health service staff (and not by the PHU staff), receiving the data was even less timely (due to more pressing priorities). Most PHU representatives complained about using the NTSRU database stating that it took a lot of time to enter the data and they could not get any reports out of the system. They stated that the database required a lot of changing between screens which made it ‘user unfriendly’.
All PHUs commented that collecting data on the presence or absence of active trachoma in children is considered a relatively easy process undertaken with confidence by the trained professionals. However the collection of data on environmental conditions and facial cleanliness is considered much more difficult. PHU representatives commented that given the time frame it is often difficult to make a proper assessment of these components, any assessment is affected by respondent bias, and if anything at all is reported, it is often based on a quick assessment. All regions commented that a comprehensive review of environmental conditions is difficult and rarely undertaken. In some cases a proactive school will assist with the environmental analysis. However, most PHUs commented that this data collection work would be better done by a trained environmental officer.
In the majority of regions only aggregate data on screening are kept at the PHUs, although if a local nurse is attending it is up to him/her whether data are entered into the child’s medical record at the local health service. In some cases forms are left with local community health nurses and entered on patient files. The screening process includes identifying the child’s name and their associated family and this information is left with the local health worker for follow up. The Goldfields region is different as the data collection form is duplicated so that one is left with the community health nurse to follow up missing children and enter data in patient files and the other form goes to the PHU for data entry into the NTSRU database. The PHU have never used the patient level data for any purpose other than aggregate reporting.
PHUs commented that due to the high absentee rates, calculating prevalence statistics for communities is difficult as determining the denominator (number of children in the community) is challenging. In WA the enrolment list at the school is used as the denominator, given the highly mobile nature of Aboriginal people this figure is not always correct, but it is believed to be the most appropriate number to use. top of pageThe data collection process in WA is summarised in Figure 3.7.
Figure 3.7: Data collection process in Western Australia
Representatives of WA Health commented that the process for collecting national trachoma surveillance data is not undertaken as it would be in a pure epidemiological/surveillance study however it does provide enough information to prove that trachoma is still endemic in some communities. WA Health does not believe that all remote communities need to be screened to prove that trachoma is not present (e.g. like those on the north west coast and near Esperance) rather funding should be allocated to preventing trachoma in the current endemic populations by providing education programs and addressing the environmental conditions which remain the main cause for trachoma still being present in some communities.
3.7.6 Uses of data and dissemination processOnce the data are entered into the NTSRU database by the population health units, it is reviewed to determine the prevalence rates for each community. If community treatment is required then contact is made with the appropriate person to undertake antibiotic dosing to the required person/s. The data are not used for any other purpose by the PHUs. Although, one PHU stated they compare prevalence rates by community by year to determine if there is any change in the prevalence rates over time. Even though some PHUs keep person level data they have never used the data to determine if a child identified with having trachoma also had it the previous year. Some PHUs provide the communities with individualised reports on the coverage, screening and prevalence rates for trachoma on an ad-hoc basis.
There is some variably between the PHU regions in what the data is used for including:
- in the Goldfields staff are aware that state-wide data are available, but use their own database for tracking prevalence rates, etc.;
- the Kimberley use data reported in the Annual Surveillance Report to identify communities where trachoma prevalence is high; and
- the Midwest generate their own reports and do not use NTSRU database at all.top of page
3.7.7 Costs associated with trachoma screeningThe cost of the trachoma screening program in WA includes staff costs (i.e. wages), training local health workers and PHU staff, travel to the communities and then the actual screening and treatment process. WA Health has estimated that the cost of the active trachoma screening program is approximately $122 per child, however current national trachoma funding only covers around $22 per child. Other estimated costs from specific regions have been stated. In the Midwest the cost of the program is approximated to be $27,000 and in the Kimberley is estimated to be $150,000 per year. This large variation is due to the number of communities screened and the difference in distance travelled between the regions.
3.7.8 The extent of integration with related systemsIn WA active trachoma screening is undertaken as a stand-alone activity by PHUs and/or ACCHS in a two week period in August/September each year. Screening of trichiasis occurs when the influenza vaccination is conducted each year.
3.7.9 ConclusionThe trachoma surveillance program was established in WA over 10 years ago through the PHUs. The establishment of the NTSRU has meant that the data collected are now standardised and sent to WA Health and then on to the NTSRU. Previously data were collected and held only locally. Overall, the approach to the trachoma surveillance program in WA is well coordinated and undertaken in the same two week period across the relevant regions. Over time the regional PHUs have developed relationships with schools and ACCHS in remote areas where trachoma is known to be prevalent. The development of these relationships assists with the coordination of the screening for trachoma as well as the associated follow up treatment. This relationship has also allowed the PHU to facilitate training local health professionals in trachoma screening. top of page
68Tellis 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
69Tellis 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