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ARTICLE
Year : 1966  |  Volume : 14  |  Issue : 4  |  Page : 147-164

Epidemiological survey of incidence of trachoma in the district of Nagpur


Mobile Eye Hospital, Medical College Hospital, Nagpur, India

Date of Web Publication17-Jan-2008

Correspondence Address:
S P Shukla
Mobile Eye Hospital, Medical College Hospital, Nagpur
India
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Source of Support: None, Conflict of Interest: None


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How to cite this article:
Shukla S P. Epidemiological survey of incidence of trachoma in the district of Nagpur. Indian J Ophthalmol 1966;14:147-64

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Shukla S P. Epidemiological survey of incidence of trachoma in the district of Nagpur. Indian J Ophthalmol [serial online] 1966 [cited 2020 Feb 20];14:147-64. Available from: http://www.ijo.in/text.asp?1966/14/4/147/38634

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Table 12

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Table 11.

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Table 2.

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Table 1.

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Table 1.

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In spite of the advances in treatment during the past 20 years, trachoma continues to be a major problem in diseases of the eye for the World Health Organization. Since reports are becoming more frequent that the clinical phase of trachoma may be conditioned by climate insanitary environment, associated infections, race, general health and living conditions of the people, it would be well to consider trachoma as a disease that may vary in different parts of the world and even in different regions of the same country. In a large country like India there are bound to be great variations in the epidemiology of the disease. It was with an idea of studying a limited area (Central India) of a vast country, that this study has been undertaken.

Records in the Eye department of Medical College Hospital Nagpur, over a period of eleven years (1952-'62) regarding the incidence of trachoma in relation to other eye diseases and also the total number of cases treated for trachoma as indoor patients, gives the impression of a gradual increase in its incidence [Table - 1].

The above statistical data includes not only patients from Nagpur district but also from districts nearby. In the year 1962 a separate study was made in which only the patients from Nagpur district were accounted and trachoma percentage was calculated. [Table - 2].

Trachoma is a specific communicable kerato-conjunctivitis, usually of chronic evolution, caused by an agent belonging to the Psittacosis-Lymphogranuloma-Trachoma (PLT) group of atypical viruses and clinically characterised by follicles, papillary hyperplasia, pannus and its later stages by cicatrisation. (W.H.O. Tech. Repo. No. 234).

Under field conditions, in the absence of the biomicroscopic and laboratory facilities, the differential diagnosis of pre-cicatricial trachoma from follicular conjunctivitis cannot always be made with certainty but a reasonable degree of accuracy in diagnosis can be obtained if there are present immature follicles involving the upper tarsal conjunctiva or there are soft immature follicles accompanied by infiltrates involving the upper fornix and/ or the semi-lunar fold, associated with infiltrates and extension of limbal vessels into the upper part of cornea.

In the present survey particular attention was paid to differentiate trachoma from chronic follicular conjunctivitis (Axenfeld type) which is apt to have follicles in the upper tarsal conjunctiva and from folliculosis with superimposed bacterial infection which however is less apt to have follicles on the tarsal conjunctiva. These conditions were excluded from the survey wherever it was possible.

Clinical diagnosis was based on the following criteria suggested by WHO.

I. Follicles on the upper tarsal conjunctiva, limbal follicles or their sequelae (Herbert's pits).

2. Epithelial or sub epithelial keratitis most marked on the upper third of the cornea.

3. Pannus most marked superiorly and

4. Scars of characteristic configuration.

The classification of trachoma proposed by the first report of the expert committee on trachoma was applied which recommended the following definitions: -

1. "Tr D" - Trachoma dubium (trachoma suspected).

Clinical signs suggestive of early conjunctival response to invasion by trachoma virus, follicles not visible or not typical of trachoma, corneal changes not visible or not typical of trachoma; H.P. inclusion bodies not demonstrated. This diagnosis is usually made under field conditions.

2. Definite trachoma.

i. "Pr Tr"-Pro-trachoma or Pre-follicular trachoma.

Clinical signs suggestive of earliest phase of conjunctival response to invasion to trachoma virus, follicles not visible, corneal changes not diagnostic, conjunctival scraping positive for TrIc. virus or H.P. inclusions.

ii. "Tr I" Trachoma stage l.

Presence of immature follicles on upper tarsal conjunctiva, early corneal changes and conjunctival scraping positive for H.P. inclusion bodies.

iii. "Tr II"-Trachoma stage II

Presence of well developed mature soft follicles, papillary hyperplasia, pannus and infiltrates extending from upper limbus.

iv. "Tr Ill" -Trachoma stage Ill

Scarring develops usually from necrosis of follicles. some or all the signs of stage II may be present.

v. "Tr IV''--Trachoma stage IV or healed stage.

Follicles and infiltrates of stage III being replaced by scar tissue with its cicatrization. This stage has been divided into sub groups according to visual impairment.

Since visual impairment in trachoma and associated infections mostly result from corneal opacification, its assessment in field work is determined objectively and grouped as follows [Table - 12]

Groups Tr I V (0) and Tr I V (1) may be grouped together as Tr IV (0.1) for all practical purposes.


  Methods and Material Top


This study covered a random survey of incidence of trachoma in Nagpur district, which comprises of five talukas viz., Nagpur, Ramtake, Saoner, Katole and Umrer; with a total population of 1,512,803. Survey in three of the talukas-Saoner, Katol and Ramtek included random collection of persons from Tahsil place itself and a village nearby, while in Umrer only school children and patients attending local dispensaries were examined. In Nagpur an attempt was made to study the incidence of trachoma on community basis, low income group people attending Employees' State Insurance dispensaries and local dispensaries of certain localities.

In all the five places the cases were mostly from the school and help was taken from primary Health Units. Diagnosis of trachoma was based mostly on local examination of the eye with corneal loop (10X). Smear examination was done only in patients who attended the Eye Department of the Medical College Hospital Nagpur, mostly on suspected cases of trachoma and of stage 1 trachoma. Clinical diagnosis was based on the criteria suggested by WHO. and the clinical assessment of cases of trachoma was done by eliciting the data in the following proforma, suggested by WHO. (Tech. Redp. No. 234.).

Name : Age : Sex:

Address: Religion:

Standard of living:

Environmental Factors:

Race:

Climate:

Density of population:

Diet and Nutrition:

Cultural and Social customs:

History:

Educational status:

Stages of trachoma:

Tr 0-Trachoma free.

Tr D-Trachoma Dubium.

Definite trachoma

Pr Tr-Protrachomatous or prefollicular trachoma, using the following symbols to record the clinical observation. F (follicles). P (papilla). C (scar). V (corneal vessels). I (corneal Infiltrations). Kop (corneal opacities) and Comments.
"Tr 1"
"Tr II"
"Tr III"
"Tr IV" (0, 1), (2), (3).

N.B.: Complications and the results of laboratory investigation are added after comments.

Also the relative gravity of trachoma in relation to relative intensity of trachoma was noted. Relative intensity may be defined as the degree of activity of the disease in an individual case at a given time, and the relative gravity of trachoma, as the degree of disabling complications and sequels; or of active lesions, which if untreated. will lead to disabling consequences. According to the definition, intensity may have little or no bearing on the gravity of trachoma, whereas gravity is of value in assessing the prognosis in an individual untreated case and the socio-economic importance of the disease in an untreated community.

World Health Organisation derived a formula, from the common sequence of events of trachoma in absence of treatment to find out group index of gravity of trachoma in a community.

The abbreviations used by W.H.O. in relation to this index which indicates the disabling or potentially disabling lesions of trachoma and/or associated conjunctivitis are

F2 = Follicles involving one-third or more of the conjunctiva of the upper tarsus and adjoining part of the fornix, but falling short of total involvement.

F3 = Follicles involving virtually the whole of upper tarsal conjunctiva and adjoining part of fornix. .

Cicatrization:

C1 = Fine scattered superficial scars.

C2 = Moderate uniformly disturbed scarring with no shortening or distortion of the tarsus.

C3 = Dense and/or irregular scarring with shortening or distortion of tarsus.

The common sequence of events are [Table - 13]

Standard of living: During the survey, investigation, of. the economic standard of the general population was determined on which depends the standard of living. The patients or the relatives On the case of children) were asked their daily wages or the monthly income and the number of dependents on him and-per-capita share was calculated. It was noticed that more than 80 were of low Income group with 50 to 75 Paise per day per capita for their daily food clothing, shelter, and education, which is far below the standard

RACE: The people in Nagpur are a mixture of Dravidians with Aryo and Scytho groups of races with Hinduism as the prevailing religion.

CLIMATE: Nagpur district being situated roughly 400 miles away from the sea coast on either side is not affected by the sea, so the climate is of extreme variations with an annual rain fall of not more than 7,500 to 10,000 mm. Ramtek and Umrer talukas have mountainous ranges with forests, as a result, these two areas have a rainfall greater by about 125 mm. than other areas of Nagpur district. Winds throught are dry and dusty over the land except in monsoon when the south-west maritime winds are moisture laden. The returning winter monsoon from the Himalayan region give about 250-300 mm more rain in this district specially in the hilly tracts in the north.

DENSITY OF POPULATION: According to the 1961 census the total population of Nagpur district was as under: [Table - 14]

The total population of the district is 15,12,803, covering an area of 3,842 square miles with an average density of 394 per square miles. The density of population was noted to be more in urban than in rural areas.

DIET AND NUTRITION: It was noted that the diet in general population is of a mixed type, more persons being vegetarians. Most of the population is undernourished.

CULTURAL AND SOCIAL CUSTOMS : Dravidians are supposed to be highly cultured, but as the race in this district is of a mixed type, the cultural and social customs too have become mixed. About 60% of the population is illiterate, with a poor cultural and social status due to poverty.

HISTORY: During the survey, the history of migration from different areas was elicited, particularly in the case of Mohammedans and Sindhis and any history of past infection was asked for to locate the probable source of trachoma infection from an alien district.

EDUCATIONAL STATUS: The degree of education in the community was observed particularly from the point of importance of prevention of eye diseases, care of eyes, attitude of people towards eye troubles and if any eye applications like kajal or surma were normally practised. It was noted that knowledge about ocular hygiene was practically nil in the majority of the population.


  Observations Top


It is impossible in the case of a disease as widespread as trachoma, to examine each and every individual without the co-operation of the general public in an area having a population of over 150,000. To make the survey possible, it was done separately in each of the five talukas. In Nagpur taluka the cases were selected and classified on a community basis to some extent, wherever such groupings were available for analysis, specially Sindhis, Mohammedans and Christians. For classification of low income groups, persons working in cotton mills of Nagpur and attending Employees' State Insurance dispensaries and trachomatous cases from patients attending the Eye Department of he Medical College Hospital, Nagpur, in the year 19,52 were picked and those belonging to Nagpur district only were selected. Cases from other districts were excluded from the Nagpur list.

In the rest of the four talukas, Ramtek, Umrer, Saoner and Katol no survey on a communal basis was done as there was no such mixing of different communities. The majority of the population in these talukas are Mahar. Kunbi, Kosti, and Teli belonging mostly to agricultural and labour classes.

In the Christian group most of the cases were school children from the Convent High Schools with their teachers and nuns. Also 250 Christian nurses from the Medical College Hospital, Nagpur were included in this group.

The result of the survey have been presented in two parts of tables for each group [Table - 1],[Table - 2],[Table - 3],[Table - 4],[Table - 5],[Table - 6],[Table - 7],[Table - 8],[Table - 9],[Table - 10]. The upper part presenting a summary of clinical findings in all persons examined and a lower part of a summary of disabling and potentially disabling lesions in the trachomatous cases to indicate the gravity of trachoma in the community. A summary of the salient findings in these tables has been retabulated in [Table - 11] for easier comprehension.


  Discussion Top


[Table - 1] gives an impression that the incidence of trachoma is on the increase since 1952. This may be true but there is a possible explanation. Since the launching of the trachoma pilot project in India, ophthalmologists in India have become more trachoma conscious and have been diagnosing cases more frequently and more accurately with the help of modern methods and a trained staff. In previous years trachoma was a much neglected stepchild, which is not the case to-day.

[Table - 11] compares the salient points in the observations tabulated in tables [Table - 2],[Table - 3],[Table - 4],[Table - 5],[Table - 6],[Table - 7],[Table - 8],[Table - 9],[Table - 10]. A glance at it shows that no community is completely immune to trachoma but the incidence shows definite differences between communities and in different districts.

Among communities, the Sindhis take the cake in the district of Nagpur (see Graph 1). Not only are the incidence and the gravity index the highest but the incidence is highest in an earlier age group, the school going age (5-24). It may be argued that the Sindhis brought trachoma from Sindh after the Partition. If that were the only reason the incidence should not be so markedly high between the ages of 5-24 years that is after the partition. The cause of this disparity should be sought in the living conditions of the community. Although evacuees, this community has prospered and the income group on an average is by no means low. However, they still live crowded together and chances of contagion from old porters of infection are high, thus keeping the infection alive and vigorous in that community. It is a definite problem in this particular community. A little more attention to the hygiene of the eyes and routine medication should control the scourge easily in this community.

Contrary to the usual belief in India that trachoma is commoner in the Mohammedans of India, it can be seen from [Table - 2],[Table - 3],[Table - 4],[Table - 5],[Table - 6],[Table - 7],[Table - 8],[Table - 9],[Table - 10],[Table - 11] that it is not so. As a matter of fact it is rather low.

The Christians have the lowest incidence and the lowest gravity index. Sheltered in the clean atmosphere of convents and convent schools the low incidence here distinctly indicates the value of clean habits and hygiene. What little trachoma was encountered was in the inmates of an orphanage where the living conditions were not as satisfactory as in convents.

In the labour classes of Nagpur, which is a center for textile mills, the incidence is definitely higher than in the other classes. Graph I indicates that the peak of incidence unlike the incidence in teaching institutions, is in the age group of 25-44 years indicating that the working conditions should be responsible for this feature. Since the majority of people from the labour class are employed in textile mills, particles of cotton-fiber may be playing an important though indirect part in the incidence. In this connection it is interesting to note that the incidence of trachoma in Katol, a cotton growing district is slightly higher than in the wheat and rice growing districts of Ramtek, Saoner and Umrer. It has also been reported by Siniscal (1957) that in cotton growing low lands of South Eastern Missouri and along the Mississippi river valley, trachoma was common among white cotton farmers. The contributing role of cotton fiber in the incidence of trachoma is thus worth investigating.

Comparing the incidence area wise [Table - 11] and Graph 2 visualize for us the relative situations. The difference in incidence (11 to 22 per cent of eye diseases) is not marked but it calls for an explanation.

Hitherto unequal distribution of trachoma in India which is highest in the North-West (80%) and drops gradually towards the South and East (0.5%) has been sought to be explained on geological (Ursekar-1955) and meteorological (Cooper 1964) lines where the Arabian winds blowing in summer over the north-west part of India and the desert areas of Kutch and Thar have been implicated.

Maps 1 and 2 show the geological set up and density of population in the areas surveyed. Nagpur district with its four talukas surveyed is well surrounded by hills of fair dimensions leaving a window in West Katol through which what remains of the incriminated Arabian winds blowing along the valleys of the Satpura mountains and along the Tapti river enter the district. This may account for the higher incidence n Katol in the west (22.2) and lowest in Umrer (11.9) in the South East. The slightly higher incidence of (16.02) in a comparatively less densely populated Rantake may be due to its more Westerly position according to the pattern of distribution of trachoma over India and to the fact that it is a holy place for pilgrimage where there is a periodic influx and mixing of populations, many coming from trachoma infested regions.

The highest figure of incidence for Nagpur (29.2) requires explanation. It should be due to the boosting of the figure in the first place with the singularly high incidence of trachoma in Sindhis, already reported, who have settled in Nagpur only and not in the neighbouring districts. Secondly, the method of study is different in the case of Nagpur taluka because the cases have been picked in Nagpur city partly from hospital attendances in the eye department of a public hospital and attendances in the State Insurance Dispensaries, where labourers come for their eye troubles. This selective sampling must necessarily make the incidence higher than in the case of random sampling, which was practised in the other talukas.

Comparing the incidence of trachoma IV and of trichiasis in [Table - 11] which give an idea of the severity of the disease, one finds that the incidence in Nagpur is less severe than in the case of Katol [Table - 11] and so 29.2% as the figure for total trachoma in Nagpur does not compare proportionately to those for the other talukas.

Thus, the incidence in Nagpur district, though highest, has got to be cut down proportionately, in which case it should not be higher than the next highest, which is in the case of Katol, that is 22.2%.

Taking all in all, the incidence over the whole of Nagpur district must lie between 22 and 11%, which is considerably less than in the case of Punjab where the incidence is 80% with a complication percentage of nearly 8.3 (Tulsidas, Nirankari and Chaddha (1961) ).

Coming to the severity of the infection, the comparative severity and disabling index can be visualized from [Table - 11] and Graphs 2 and 2A. The pattern of rise is very similar in all the groups. In this connection we can also look at [Table - 11] which summarizes the figures for these cases that reach trachoma IV stage and those that develop trichiasis through the years. These clearly indicate that cicatrization is a progressive process which continues through the years long after the acute inflammation has ceased. Thus trachoma IV and trichiasis are encountered mostly in the higher age groups and not at all or very little upto the age of 44. Although trachoma is supposed to be a disease of the young which no doubt it is, (see Graphs 1, 2) it does not then stop at that and the effects of the distressing sequelae are experienced mostly after the age of 45.

The severity of the disease generally conforms with the incidence patterns. Thus the severity is also highest in the Sindhi community and lowest in the Christians. Likewise it is highest in Katol in the West and lowest in Umerer in the East, and conforms to the general distribution pattern worked out by the Trachoma Pilot Project India, and by Ursekar (1955). The disability index shows a similar drop from Katol to Umerer.


  Summary Top


Data collected during a trachoma survey of four talukas of Nagpur district along with data for Nagpur collected from the eye department of the city hospital and State Insurance Dispensaries has been classified and tabulated to study the incidence of trachoma in the different communities of Nagpur and the distribution of the disease, its severity and disabling index over an area of 3842 sq. miles of central India with a total population of 1,512,803.

The incidence and severity in the refugee Sindhi community was singularly highest which seemed to boost the incidence figures for Nagpur considerably. Making a further allowance for the selective nature of the survey in Nagpur city, the incidence cannot be higher than the highest for Karol taluka in the West. The incidence can therefore be between 22 and 11 per cent population, over the whole of Nagpur district.

A drop in incidence from the highest in the West, (22% in Katol to 11 % in Umerer in the East) follows the well known pattern of the drop in trachoma incidence from North West to South East in India as worked out by Ursekar (1955) and the trachoma pilot project, India.

The contributing value of the nature of employment, weather conditions and the economic status are incidentally commented.

Acknowledgement

I express my deep gratitude to Dr. Ishwarchandra, Professor of Ophthalmology, Medical College, Nagpur, for his time to time guidance and critical interest shown in carrying out this work, and Dr. P. L. Powar, the Dean of the College for providing laboratory facilities. I also thank Dr. S. N. Cooper for his help in preparing the graphs and [Table - 11].[7]

 
  References Top

1.
Banaji. P. B.: Blind Welfare (1962). 4: 2.  Back to cited text no. 1
    
2.
Cobb, J. C. & Dawson: J.A.M.A. (1961) 175: 405.  Back to cited text no. 2
    
3.
Cooper S. N. (1963), J. All India Ophthal. Soe.  Back to cited text no. 3
    
4.
Siniscal. D. D.: Missouri Trach. Hospital Mo. U.S.A. (1957).  Back to cited text no. 4
    
5.
Tulsidas, Nirankari, M. S. & Chaddha, M. R., All India Ophthal. Soc. (1961), 72: 76.  Back to cited text no. 5
    
6.
Ursekar. T. N.: Jour. All Ind. Ophthal. Soc. (1955). 2: 94.  Back to cited text no. 6
    
7.
W.H.O.. Expert Committee on Trachoma, Tech. Rep. No. 234.  Back to cited text no. 7
    


    Figures

  [Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4]
 
 
    Tables

  [Table - 1], [Table - 2], [Table - 3], [Table - 4], [Table - 5], [Table - 6], [Table - 7], [Table - 8], [Table - 9], [Table - 10], [Table - 11], [Table - 12], [Table - 13], [Table - 14]



 

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