|Year : 1964 | Volume
| Issue : 2 | Page : 91-97
|Date of Web Publication||14-Feb-2008|
S N Cooper
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Cooper S N. Editorial. Indian J Ophthalmol 1964;12:91-7
The fight is on. For years India has allowed herself to suffer the trachoma scourage, grumbling now and again, but wihout lifting a finger in its fight against this blinding eye disease. There has been an International Organization to fight this scourge but its activities have been confined more to the countries on either side of the Mediteranian, particularly North Africa. Its methods and measures considerably helped in reducing the scourge in the spheres of its activities.
The credit for taking up arms against this invisible host in India, in our opinion must go to the late Dr. Mohanlal of Aligarh, whose enthusiasm about the Institute he helped to found was indirectly responsible for bringing the much needed help from W.H.O. and UNICEF. With the help of these organizations and under the auspices of the Indian Council of Medical Research, the Trachoma Pilot Project was first launched with its headquarters at Aligarh. We make no hesitation to confess that we were luke-warm to this Project which at first apparently seemed to help an Institute in which an individual was interested. But who else was there then to take up the cudgels? We offer our posthumous apology for whatever resistance we may have then unconsciously offered.
The Trachoma Pilot Project has now been in operation since 1955. It has produced some results. Like all scientific data the results are bound to be criticised and the methods challenged by other scientific organizations springing up later and engaged in similar activities. Such criticism, even ruthless in its manner, should be most welcome so that the results can be viewed in a proper perspective. Such criticism should be constructive and not disruptive, for the enemy is a common enemy, invisible, with inexhaustible resources for survival and a method in combat which is not easily understood. Let us therefore not have rivalry between Institutions engaged in similar laudable pursuits, but let each Insitute cultivate its own resources and talent independently so that the approach to the same problem may be from different directions with different minds and different imaginations.
For this trachoma number we have been able to collect material of sufficient variety which includes, the etiological approach, medical and surgical measures and preventive aspects on a mass scale. It contains several reports which had to be drastically edited to accommodate within a modestly sized issue. It may be correct to point out some irrelevancies at this stage.
Taking the method of determining the endemicity, we have the paper of Ursekar (1955) in which he determined the incidence of Trachoma as per cent of attendances in the eye hospital. As against that, there has been a huge project by the T.P.P. to go to the different villages in all the fifteen States of India and prepare an authoritative map of the geographical distributions of this disease. Comparing the two maps on pages 40 and 51, the similarity is very striking. What the T.P.P. has achieved by a laborious village to village and house to house survey extending over three years and at an expense of some lakhs of Rupees, Ursekar has been able to achieve in not more than 3 months, almost sitting in an arm-chair, with rather meager sources at his disposal and all the disadvantages of an inquiry without an official stamp.
This is by no means a criticism of the methodology of the T.P.P., but it has conclusively proved that for future similar assessments which will be required from time o time to check the efficacy of mass measures and preventive vaccinations etc., it will not be necessary to undertake a laborious survey but only check the number of cases in hundred cases of attendance at eye hospitals.
In this connection it is interesting to quote the method employed in Poland for such a statistical survey and communicated to us by Prof. L. Rostkowski, and which has been a subject of a paper by him at the XIX International Ophthalmological Conference at Delhi, 1962. The percentage of trachoma cases among patients with eye diseases, as well as in the conscripts in the army and students in a school may be considered as a degree-sign of the intensity of trachoma. He adds that the percentage of the trachoma-afflicted is more or less 7 times greater than the trachoma degree-sign in the conscripts and school children.
In India, there is one more opportunity to ascertain the degree of trachoma, namely the 'eye-camps'. Hundreds of eye-camps are being organised every year by different organisations, including the government. In return for any financial aid offered, the captain-in-charge while submitting the report, must be made to declare the percentage of trachoma cases per cent of attendances and the number of entropion operations done in the trachomatous population. Thus percentage of trachoma cases in hospitals, camps, and school attendances multiplied by the percentage of entropions done in these cases, to our mind, will give us a degree sign which will be a continuous information about the prevalence and intensity of trachoma from time to time, in different places. This will give us a constant check on the value of different measures for prevention. Such information must be supplied to the T.P.P. and the W.H.O. trachomatologist, who will maintain a 'flag-system' on a map of India.
Comparing the maps on pages 40 and 51 one other feature strikes us and that is in the case of Mysore. Whereas Ursekar's determination of the distribution pattern shows a gradual wane towards the South, the T.P.P. shows a slight spurt in this region for no accountable reason.
Besides, by comparing his percentage figures with the charting of trachoma per million population, Ursekar points out the discrepancies vividly as being due to unequal transport facilities, (maps I & II p. 51), which snag the T.P.P. has overcome by going directly to the inaccessible places as well.
In the light of this discussion one wonders therefore whether the indirect arm-chair method of determining the endemicity is not superior to that of the direct approach. However, the figures for Mysore need checking in the case of the T.P.P. and for Banaskantha and Mehsana in the case of Ursekar's study.
Having determined such a gross difference in the pattern of distribution of trachoma, the T.P.P. and the W.H.O. teams seem to take this as a matter of fact with no serious attempt at explanation. Indeed some of the conclusions and deductions are not only contradictory to their own findings but appear to lose the high degree of significance involved in such facts gathered so expensively. For instance in one breath it is mentioned that the incidence of trachoma is less in the hills than in the planes of Kashmere and in the next breath it is suggested that considerations of altitude are of little value. In the case of Mysore, which is quoted in support of their conclusion, no attempt is made to study or report any difference in the incidence of trachoma in the hills and in the planes.
To our mind, the uneven disribution of trachoma in India presents a golden opportunity to study the method used by the trachoma virus to maintain a stranglehold in North-West India. We ask, `Why?' On the other hand the T.P.P. contents itself by giving a mere priority to this region for their planned mass treatment with which it is entrusted.
This is exactly why we have been prompted to write the second paper on a Bio-meteorological approach, which even if amounting to nothing or something vague, offers an opportunity of a research on these lines as a new and fascinating approach.
Coming to a study of the different reports on trachoma by the W.H.O. (not presented in this issue) one is gratified to find that spread by contagion is being considered progressively of lesser importance. In a consideration of the problem of spread of trachoma by contagion it is necessary to distinguish between trachoma infections of two types -- (1) imported trachoma and (2) breeding trachoma. India has both.
Unfortunately old concepts die hard. Once established during the Napoleonic wars that trachoma spreads by contagion, most of the problems of trachoma do not go beyond the nose of the contagion theory. In this short-sighted approach the Mohamedan community has undeservedly incurred the displeasure as being a community that imported trachoma into India. Shades of this prejudice can be seen in the first paper, when in a consideration of the history, even though the authors trace its mention in the ancient scriptures of India, they make no hesitation to state that it was imported from Mongolia by the invading hordes. One simple contradiction. Why is it that fifteen years after a mass migration of the trachoma-rich Sindhi and Punjabi population all over the country after 'the Partition', the incidence of trachoma is still 80 per cent in the Punjab and 0.5 per cent in Bengal?
It is also an interesting study of Ursekar that in the comparatively trachoma free cities of Southern and Eastern India, the communities most affected are the Rajasthani Marwadis, who undoubtedly often visit their home state and bring a bit of trachoma on their return for themselves.
It is only when we shed the concept of contagion as being the only cause of spread of trachoma that we hope to make progress.
The T.P.P. does not seem to realise how important a discovery they have trade in disclosing the unequal distribution of trachoma in India. Their field of research must now narrow down to an area 1/6th the part of the country where they can concentrate every thought in determining why this pattern of unusual high incidence persists in the north-west. Surely it is not going to let slip the opportunity to explore such a wonderfully new opening it has made for itself and for the good of India.
We thus feel that trachoma hatching, breeding, seasoning may all be taking place in the north-west, whereas the rest of the country has imported trachoma. The latter is easy to eradicate with hygienic and chemo-therapeutic measures as has been done in countries north of the Mediterranean. It is the other variety, the breeding variety, in the case of Egypt, Iraq, Arabia, Iran and north-west India. It will require measures of greater imagination, very different from mere handing out of tube-packets along with raising educational and hygienic standards.
As far as diagnosis of trachoma is concerned, we have the clinical diagnosis, microscopic examination of epithelial scrapings and now serological tests on which to depend and make researches on. The situation here is confusing. Clinical diagnosis needs confirmation by some kind of laboratory tests. Discovery of inclusion bodies in epithelial scrapings is mainly confined to the acute and early stages. The serological (CFT) test is gaining ground gradually, but is not easily practicable because the antigen is not quite specific and not easily available. What is then wrong with a good old-fashioned clinical diagnosis? Does it make a practical difference if a few cases of inclusion conjunctivitis get diagnosed and treated as trachoma in a population teeming with trachoma, especially when it is believed that the respective viruses belong to the same lympho-granuloma group and the serological tests are also identical? The modern tendency to depend more and more on laboratory examinations tends to turn out less alert clinicians and when we have to deal with incidence as high as 80%, such methods prove costly, tedious and sometimes even confusing. If India has yet to practice economy for at least a decade, a sound clinical examination with no other appliance than a magnifying loupe (x 8 or 10) should serve our purpose admirably. The cases that will need a laboratory examination will be only those cases that are without pannus.
VIROLOGY in trachoma is the new trend and thanks to the successful cultivation of the virus in yolk sacs of chick embryos, similar viruses have been isolated in China, West Africa, Arabia and Egypt. In India attempts to cultivate and identify the same by Srivastava cannot be called successful, because the required criteria of successful transmission through three serial passages in the chickembryo yolk sac and the test of human inoculation have not been fulfilled.
The appointment of virologists to the Institutes at Aligarh, Delhi and Chandigarh should bring the day nearer when we can depend on the Indian Trachoma virus for obtaining the heat-resistant antigen from the elementary bodies for the C.F. Test and for preparing inoculable vaccine for prophylaxis and treatment. Till then we have to depend upon imported antigens.
THE HUMAN INOCULATION TEST should not be so dangerous or disagreeable as one may imagine at first thought. The severity of trachomatous infection depends on the boosting factors via. bacterial infections, allergic inflammations, unhygienic environment and low nutritional status. It is for this reason that we have come to distinguish between trachoma of the rich and that of the poor. In the former the ocular lesion produced by the virus alone though betraying inclusion bodies in the epithelial scrapings, is comparatively mild, capable of spontaneous resolution with minimal scarring. Healthy human volunteers should have no hesitation to offer themselves for clinical examination. For clinical research it would be easier, cheaper and more dependable to have human volunteers than baboons and the rhesus family.
CURES. Results of prophylactic, therapeutic and hygienic measures when used against the infection will naturally be judged by the cures they produce. It is necessary therefore to state what is understood by cure. In this connection the paper on the results of antitrachoma vaccination trials by Bietti and associates is worth a patient reading. From the paper on activation test by cortisone and dionin, it can be seen that it is the reactivation or otherwise of a booster to latent infection that it to be taken as a criterion for cure. It is necessary to draw attention to this as in the first surveys of the T.P.P. in Aligarh district (1956) while determining the value of treatment with local applications, no distinction has been made between new infections and reactivation of old infections.
It is also necessary to make a note that in programmes C and D of the T.P.P. at that time quite 25% of spontaneous cures have been recorded. Therefore while evaluating actual cures allowance should be made for spontaneous cures in the population studied.
In continuation it may be remarked that in the programme of determining cures by the T.P.P. the teams have treated a complete village and used a complete untreated village as controls. Would it be correct to keep absolutely untreated villages as controls?
When a treatment staff visits a village, it not only visits a village but it also creates a certain consciousness and interest in every villager in the condition of his own eye. Doubtless, the dresser when he visits a village he must also be instructing the villagers in matters of hygiene and sanitation since he is a dresser, trained specially for a mass campaign in trachoma.
A proper control would be to send a dresser to the control villages, who will act, do and instruct in exactly the same way as may be planned for the treated villages, except that instead of the antibiotic he should be made to use the base of the ointment or the oil in which the antibiotic is suspended. That would be a correct control and it would not be surprising if the difference between cases treated with antibiotics and controls may still further be narrowed since spontaneous cures have been acknowledged.
REMEDIES. The T.P.P. seem to take it for granted that local applications of the Tetracyclin group of drugs is an established form of dealing with the trachomatous lesion. We find that for controls they have either used untreated cases or cases treated with the ointment base without the antibiotic.
It may be noted here that antibiotics have been found unable to affect the virus, isolated and developed in vitro, prior to animal transfer.
Inclusion bodies are intra-epithelial and a drop of 1 % silver nitrate is known to cause a coagulation of the superficial epithelium in which the virus is lodged. Crede by instilling one drop of silver nitrate brought down the incidence of ophthalmia neonetorum to almost zero. It is a wonder why this simple measure has not been used as a control opposite the treatment by local applications of antibiotics. The same treatment schedule used for antibiotics when used in the case of 1 drop of 1 % silver nitrate should not cause argyrosis and if found not significantly different in efficacy, should be much cheaper and convenient for mass control projects. May be Crede, who in our estimation ranks as a saint, has also cast his benediction on the trachoma infested population of the world. Only we do not know it; nobody seems to have attempted to explore this possibility.
The treatment schedule with antibiotics may produce one great indirect advantage. At the present moment quite a lot of indigenous remedies are prevalent among villages, remedies which are more responsible for uncurable blindness than the disease itself. A free supply of sulfonamidis can easily displace these "remedies" and prevent much blindness resulting from them.
Coming to "THE NATIONAL TRACHOMA CONTROL IN INDIA" by Preobraganski and Gupta, one can see in it the colossal magnitude of the programme set with difficulties of finance and personnel even though it may be undertaken initially only in the highly endemic areas. Such a programme seems to be an established fact. To us, however, it appears wanting in imagination. Instead of going for the cause they seem to go mostly for the effects. True it is that it has incorporated an educational programme to combat the socio-economic factors. In that much we go all out on our approbation. But to dole out tubes of eye ointments medicated with antibiotics the efficacy of which against the virus is not yet proved, appears to us to be drudgersome and perhaps even wasteful.
Secondly, the fact that the Complement Fixation Tests come positive in most of the cases, shows that trachoma is not a local condition but a viraemia capable of producing allergic humoral and cytological responses. From this it is reasonable to conclude that local applications, however effective, can never be the final answer for the treatment of trachoma. In this connection the use of vaccine appeals most to our imagination and the paper by Bietti and associates shows that this approach is well on the way.
In view of the extreme concentration of the infection in the north-west corner of India, at the moment the programme should be confined only to this area, viz. upper Gujarat, Cutch, Rajasthan, Punjab and West Uttar-Pradesh. The master plan gives no indication of planning a search for the cause of this concentration. Where is the virus to be found and where does it come from? We have suggested a bio-meteorological approach (p. 50). This problem is asking for research with both arms open. We are surprised that the fruits of this unique discovery of trachoma concentration in the north-west, through an expensive country-wide survey is used only to decorate the map of incidence and to settle priority for the prevention programme by a drab methodology.
Again we do not find any provision in it for research on proplylactic inoculation trials which, as explained earlier, is a new trend and is round the corner. We have yet to learn about the immunizing value of the vaccine but if successful the method will be cheaper. more convenient, and will find the Achilles' heel of the virus.
Finally we come to the surgical aspects of trachoma. Trachoma is a scourge far from conquered, and with an inadequate number of ophthalmic surgeons, distressing complications and sequelae will remain for a long time yet. It affords a scope for imaginative and highly skilled surgery and we are in full agreement with Shukla that it is no task for juniors who will content themselves by doing one of the routine operations for entropion and turn away the rest that offer a challenge to their judgement, imagination and skill.
In this, implantation of Stenson's duct into the lower conjunctival fornix and the use of peritoeum in reconstructing the conjunctival cul-de-sac offer a new hope for those whose eyesight is doomed by cicatrization of the worst kind. Such operations need patience, thinking and long-term planning, examples of which are well set out in the paper by Nath and associates.
The report from the Cornea Grafting Unit at Indore is a major advance in surgery of trachoma whereas the use of contact glasses in other reconstructive and plastic surgery of the eye puts trachoma under the most modern concept in all medical sciences that it is impossible to progress without co-ordination from thoughts, knowledge and skill from departments other than ophthalmic.
In this fight, our first task is to keep the enemy subdued. Can he be conquered and if almost eradicated can we keep him under the heels in an area with an endemicity of 80% in a sixth part of the country? Dr. Sushila Nayyer, the central minister for health is tuned up to this thought but the fight is not as easy as she had expressed herself once. It is not merely a matter of organizations and financial helps. We have to fight the invisible enemy with our brains and brawn and in this editorial if some comments are offered which may be harsh but without prejudice, it is because in this forum of free thought the editor too has entered the fight with his weapon. The preparation for the fight is complete.
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