|Year : 1964 | Volume
| Issue : 2 | Page : 68-73
The national trachoma control programme in India
VV Preobragenski, UC Gupta
National Trachoma Control Programme, India
|Date of Web Publication||14-Feb-2008|
V V Preobragenski
National Trachoma Control Programme
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Preobragenski V V, Gupta U C. The national trachoma control programme in India. Indian J Ophthalmol 1964;12:68-73
Objectives of the paper are to inform the broad groups of Indian Ophthalmologists on the latest developments in mass control of communicable eye diseases in the country and to promote discussions aimed at further improvement of organisation and methods adopted by the present national trachoma control programme.
The programme was started by the Union Ministry of Health on 30th March 1963. It followed an initial phase of trachoma control activities which was undertaken by the Indian Council of Medical Research through the Trachoma Control Pilot Project in 1956-63.
l. Master Plan for the National Programme and Plans of Operations for Various States.
In the light of the experience obtained in the Pilot Project, the Govt. of India decided to develop a national trachoma control programme, with implementation of extensive trachoma control activities, in the States of Punjab, Rajasthan and Uttar Pradesh where the disease represents a major public health problem - (Punjab, 79.1 ; Rajasthan 74.2%; Uttar Pradesh 68.1 %). In addition, trachoma control activities will be continued and extended, as and when practicable, in the States of Gujarat (56%), Madhya Pradesh (41.3%), Bihar (30%) and Jammu & Kashmir (upto 60%, in the plains). Attention will also be given in due course to the pockets of high and moderate (between 20 to 50%) endemicity of trachoma in the States of Assam, Mysore and Maharashtra.
Before starting the preparation of the plan, representatives of Directorate General of Health Services and W.H.O. visited the States of Gujarat, Punjab, Rajasthan and Uttar Pradesh, to investigate the possibility of launching the large scale programme in those states and to ascertain the phasing of the coverage of different districts.
The main characteristic of the new plan was the magnitude of the activities to be undertaken in different States. The following plan has been finalised.
Each State in which the large scale programme is to be undertaken, will appoint an Assistant Director of Health Services (Trachoma) at the Directorate level and two to three Regional Trachoma Officers, depending on the number of districts under treatment and their location in the State. The Assistant Director of Health Services and the Regional Trachoma Officers have to supervise the work of the trachoma control units. The Health Education Officer and the Statistical Assistant at the Directorate level have to assist the Assistant Director of Health Services and the Regional Trachoma Officers in the every day supervision of the work in the field units and in organizing effective health education programme in the fields.
The main working unit will remain as at present, a trachoma control field unit, with one medical officer in charge, six supervisors and 25 field workers as para-technical staff.
It has been planned to divide the programme into three main periods attack period (for two years), consolidation period (for an year and a half) and maintenance period (for 2 years or more). A short but very important term of one to three months preparatory period will precede the attack period, and evaluation of the work will be carried out during consolidation and maintenance periods.
Each trachoma control field unit will be in a position to cover by treatment the population of one community development block, with an average of 75,000 people, in the two years of the attack period.
During consolidation and maintenance periods, the medical officer in charge of the primary health centre of that block will be made responsible to continue trachoma control measures. He will be assisted by one supervisor and five field workers per zone during the consolidation period and by two workers during the maintenance period. This personnel is to be attached to the primary health centres for the work.
The methodology of treatment will be that of blanket treatment of children under ten or fourteen according to the endemicity, along with treatment of their family contacts in rural areas and treatment of children of primary and middle schools in urban and suburban areas adjacent to the blocks under programme.
Blanket treatment of children under ten means the prophylactic treatment of all children of this age group irrespective of clinical signs they show.
The treatment of family contacts means the treatment in households of any one of the other age groups in which clinical signs of eye infection are detected. This treatment will call for the distribution of approximately one tube of ointment for each household in the regions of operation.
This methodology is aimed at protecting children, as the group most affected and responsible for transmission of the infection, and also provides an attempt to attack the source of infection in other age groups.
The treatment programme will be so scheduled as to cover the period of seasonal peaks of associated bacterial conjunctivitis wherever it exists, in order to secure effective control of both trachoma and associated infections.
An intermittent schedule of broad spectrum antibiotic treatment will be employed (local application twice a day on five consecutive days, with this five days cycle repeated six times at monthly intervals in March-April-May and August-September-October).
In urban areas, limited activities only will be necessary, since general and specialized medical care is more readily available and the prevalence of trachoma and associated infections is expected to be comparatively lower and the disease milder than in the rural parts of the country. The treatment in urban areas will be confined to that of school-children upto the eighth standard to cover all school-going children from 6 to 14 years of age.
An intermitten treatment in schools will be employed (local application, twice a day at the first and last school periods, on five consecutive days, with this cycle repeated three times at monthly intervals during two winters, giving 60 applications to each child).
The large-scale trachoma control activities shall be conducted under the close supervision of the State Directorate of Health Services and shall be carried out in constant co-operation with primary health Centres, and gradually integrated into the general public health services of the State.
Treatment by the health personnel shall be followed by self-treatment. In order not only to ensure acceptance by the people but also to make the people health conscious, they must be made to learn the basic principles of healthy living and to stabilize the achievements. This programme shall be very actively supplemented by intensive health education activities.
In addition to the Master Plan of Operations for the national programme, plans of operation for each of the respective States in which the trachoma control programme is planned to continue have been prepared after consultation with State health authorities. The plan of operations outlines the pattern of organization and the methodology as per the Master Plan and gives details of the region of operation in each State.
2. First steps in carrying out the National Programme
The referred Master Plan of Operarations envisaged the trachoma control activities in India from 1st April 1963 till 31st March 1966. W.H.O. has provided technical aid and UNICEF has contributed supplies (vehicles, antibiotics and other equipment as per requirements for attack period).
Today, almost one year after the start of the programme a preliminary assessment of progress of the national trachoma control programme is advisable for the sake of further development.
The first steps taken to carry out the programme appear to have been quite satisfactory.
An Office of National Trachoma Control Programme has been established under the responsibility of the Director General of Health Services at Aligarh.
The office has an ophthalmic section and supporting statistical and health education sections.
The functions of the unit are: (1) to co-ordinate the trachoma control programmes in different states; (2) to standardize methodology for mass campaign purposes; (3) to organize training programmes for various categories of personnel as and when necessary; (4) to organize pilot zones in order to improve the methodology of control programmes; (5) to assess periodically achievements and experience gained in various phases of the national programme.
The Government of Punjab is to appoint an Assistant Director of Health Services (Trachoma) in Chandigarh and has appointed two Regional Trachoma Officers in Ambala and Patiala. Fifteen medical officers were appointed in May 1963. A comprehensive two-week training course was given to them in June 1963. All fifteen units started the treatment programme in July, covering the blocks of Ambala and Patiala Districts in the State. After completing the first three rounds of treatment in the villages, the Medical Officers gave treatment to children in the schools in both urban and suburban areas of the blocks concerned during December 1963-February 1964.
The Government of Rajasthan will appoint an Assistant Director of Health Services (Trachoma) and one Regional Trachoma Officer to supervise the work in Sikar and Jhunjhunu districts. Five medical officers were appointed and trained in August 1963, and eleven more medical officers from December 1963 to January 1964; seven more joined the programme in January-February 1964 and were trained in the blocks selected for them. The field staff was assigned to 25 units. In five of them the treatment of school children in urban areas is going on: 20 new units are in the preparatory period so that the treatment programme may be started in the villages by early March 1964. All 25 units will cover Sikar Jhunjhunu and the north Jaipur Districts.
The Uttar Pradesh Government is considering the establishment of six trachoma control units in Muzaffarnagar, Meerut and Saharanpur Districts bordering Punjab. One voluntary organization unit, sponsored by Sitapur Eye Hospital, is already in position in Pithoragarh District.
The Government of Gujarat is carrying out the programme by means of four Government and one voluntary organization units and have appointed a Senior Trachoma Officer at the Directorate. The programme is progressing quite satisfactorily in the blocks of 5 different districts of the State (Deesa in Banaskantha, Mansa in Mehsana, Babra in Amreli, Naliya in Kutch and Dholka in Ahmedabad Districts).
The States of Bihar, Jammu & Kashmir and Madhya Pradesh have one unit each established between 1960 and 1962. The unit in Bihar covers the second block in Patna District, the unit in Madhya Pradesh covers the Sanchi Block in Raisen district; the unit in J & K is working by turns in Jammu & Srinagar provinces, covering the rural population of the blocks in Jammu in winter and that of Srinagar valley in the summer.
3. Planning of Further Extension of the Programme
India has now a total of 49 trachoma control units working in seven States which have high or moderate endemicity of the disease.
Keeping in mind that these units cover only 49 Community Development Blocks in the period of two years only, we can imagine how far we are from the achievement of our goal in the control of trachoma in the country. The total number of blocks in the above seven States comes up to 2626 blocks (Bihar 575, Gujarat 224, J & K 52, M.P. 416, Punjab 228, Rajasthan 232, U.P. 899). Even if we take the States of Punjab, Rajasthan and Gujarat, where the programme is progressing on a larger scale than in other states, the number of working units (45) against 684 blocks is small. It means that to cover 684 blocks in the states by the existing 45 units we should need rougly 30 years. If we want to cover these States in two years beginning from January 1965 we shall need at least 640 medical officers, about 4,000 Supervisors and 16,000 field workers. The fleet of vehicles will exceed 650, and the number of antibiotic tubes will reach astronomic figures.
Do these calculations decrease our zeal in controlling communicable eye diseases in India? Not at all. We should constantly increase our efforts in combatting trachoma, in seeking new ways and means of increasing the coverage of population by treatment and in introducing new patterns of organization and methodology to speed up the programme.
The over all progress of the country itself helps our purposes. The raising of living and educational standards of the public increases on chances of eliminating the main factors indirectly and directly responsible for spreading communicable eye diseases-poverty, anti-sanitary conditions, un-hygienic habits, superstitions etc. One of our objectives is through health education to help these natural processes of society progress to fight the communicable eye diseases in various communities.
This national programme though rather small and slow, remains the only one which is helping the people to combat the communicable eye diseases in the country. The programme has to be developed at a quicker pace so as to cover the endemic regions with effective control measures in the least possible time. To achieve this we need more trachoma control units with effective organization and methodology of the work.
The everyday evaluation of the progress of the work of trachoma control units gives us some examples which may be considered useful for the purpose of extending and accelerating the trachoma control activities in the country.
The first State to give us such an example was the State of Gujarat. Out of five units of this State one was run by voluntary organisation, one by the medical officer in charge of public health centre and one by District Health Officer of the district as his additional duty. In all three units the work was going satisfactorily for a period from one and a half to three years. The coverage of children by treatment was the same as in the units under specially appointed medical officers.
The Union Minister of Health, Dr. Sushila Nayar many times has expressed her concern about starting more voluntary organization units in the trachoma control campaign.
Besides the one voluntary organized unit already working in Gujarat, two more voluntary organizations are planning to start their activities shortly.
In Uttar Pradesh one unit started the work in July 1963. This unit was run by the Sitapur Eye Hospital. It was planned that Government subsidies to the voluntary organized units would be minimal to start with.
The initiative taken by the Gujarat State Council for the prevention of blindness in Ahmedabad, (it is running trachoma control unit in the Dholka Block) and of the Sitapur Eye Hospital (which started the Trachoma Control Unit in Pithoragarh District) should be very much appreciated. But the achievements of these organizations are yet to be evaluated. If the experiment proves successful the voluntary organizations can be also utilized to cover the pockets of high endemicity in the States with average low prevalence rates of trachoma (Maharashtra, Mysore).
To consolidate the results of attack period, the Government of Gujarat approved and introduced the sale of drugs at a nominal price to the villages in which the six-month treatment programme had been completed. Tubes of l% tetracycline group of antibiotics available in the market for Rs. 2.27 were sold to the villagers through Primary Health Centres for sixty naipaisa only. The average sale of tubes was 50%, but in some villages about 80% of households regularly bought the drug.
The experience in Gujarat showed that success in selling drug depended on the thorough and effective preparation of the region with adequate health education.
The sale of drug at cheap rates in rural areas by the State Governments through authorized agencies is one of the principle features of the national trachoma control programme. This encourages the people to go in for scientific drug when required instead of going to quacks. Government of India has initiated necessary action to make required amendments to the present Drugs Act so that the drug for trachoma control in rural areas may be sold through panchayats, primary school teachers, co-operative depots, village grocers etc. at a nominal price.
In Rajasthan due to the extreme shortage of Medical Officers, some unit officers have been given charge of an additional unit and in some cases have been allowed to look after primary health centres or dispensaries during spare time and when not out on tour.
During the initiation of our programme in various states, the greatest difficulty experienced by the State Health Administrators has been to get suitable and willing medical officers to man field units as per present Plan of Actions. This has made us think actively of the possibility of reducing the number of medical officers and put in more of para-medicals as Sanitary Inspectors or Health Assistants. If this is considered practicable without affecting the efficiency, it will be possible to go ahead with the programme at a quicker pace.
As for urban areas, congested and unhygienic localities of the cities should be surveyed and control measures instituted wherever warranted, by the state trachoma control organizations.
[Figure - 1]