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Trachoma and Guinea Worm Disease (GWD) are neglected tropical diseases (NTD) slated for elimination as a public health problem and eradication respectively by the World Health Organization. As these programs wind down, uncovering the last cases becomes an urgent priority. In 2010, Ghana Health Services, along with The Carter Center, Sightsavers, and other partners, conducted integrated case searches for both GWD and the last stage of trachoma disease, trachomatous trichiasis (TT), as well as providing surgical treatment for TT to meet elimination (and eradication targets). House to house case searches for both diseases were conducted and two case management strategies were explored: a centralized referral to services method and a Point of Care (POC) delivery method. 835 suspected TT cases were discovered in the centralized method, of which 554 accepted surgery. 482 suspected TT cases were discovered in the POC method and all TT cases accepted surgery. The cost per TT case examined was lower in the POC searches compared to the centralized searches ($19.97 in the POC searches and $20.85 in the centralized searches). Both strategies resulted in high surgical uptake for TT surgery, with average uptakes of 72.4% and 83.9% for the centralized and POC searches respectively. We present here that house to house case searches offering services at POC are feasible and a potential tool for elimination and eradication programs nearing their end., Author summary Trachoma and Guinea Worm Disease (GWD) are neglected tropical diseases slated for elimination as a public health problem and eradication respectively by the World Health Organization. As these programs wind down, uncovering the last cases becomes an urgent priority in order to confirm that eradiation and elimination targets have been reached. Active case searches are one method of finding these last vestiges of disease. Searches that look for multiple diseases are referred to as integrated searches. We piloted here integrated house-to-house case searches for GWD and Trachoma with two case management strategies; a referral approach to a central location and a point of care approach (POC)–offering services at the household or ‘point of care’ location. POC approaches can be difficult to implement in low resource settings because they require extensive personnel, financial commitment, and logistical support. However, POC approaches remove one of the biggest barriers to treatment, time spent traveling to a health center, and thus can improve treatment acceptance. We found here that integrated active case searches with a POC case management approach can be implemented in a low resource setting; and improve acceptance and uptake of trachoma examination and trichiasis surgery respectively, without costing much more than a referral-based case management approach.

Background: In order to achieve elimination of blinding trachoma, a country needs to demonstrate that the elimination prevalence thresholds have been surpassed and then sustained for a three year period. Ghana achieved the thresholds in 2008, and since 2011 have been implementing their trachoma surveillance strategy, which includes community and school screening for signs of follicular trachoma and trichiasis, in each trachoma-endemic district. In 2015, the country plans to conduct a number of district level population based survey to verify elimination of blinding trachoma. This decision is currently made based on prevalence of clinical evaluation of “trachomatous trichiasis” and “trachomatous inflammation – follicular” (TF), the second of which has been shown to be a problematic indicator in low prevalence settings. Further evidence is required to determine the optimal surveillance strategy and indicators for trachoma. Objectives: This study will determine if Ghana has sustained the elimination prevalence thresholds. Additionally, the study will review the trachoma surveillance strategy employed in Ghana and if it was able to identify any potential resurgence of infection. It will also assess the relationships between the prevalence of the clinical sign TF, compared to prevalence of infection and antibody levels, after completion of what most observers believe to have been a successful programme. This will help to determine whether it may be appropriate to consider one or more alternative indicators for validating elimination of blinding trachoma. Surveillance for other infections (including yaws and other NTDs) will also be integrated into the pre-validation trachoma survey. Methods: The standard World Health Organization (WHO)-recommended population-based prevalence survey will be conducted in areas already scheduled to conduct validation surveys in 2015, but with the addition of eye swabbing to test for infection and finger pricking to collect bloodspots for antibody testing. Villages identified with a TF prevalence ≥5%, either retrospectively, during the on-going surveillance or during the district level survey (index village), will result in focal screening of children in neighbouring villages (and the ‘index’ village), including a clinical assessment and tests for trachoma infection and antibody levels. Surveillance for additional infections will also be included through antibody testing using the same sera collected for trachoma. Finally, document analysis and qualitative methodologies will be employed to review the operationalization of the trachoma surveillance system in Ghana. Impact: Results from this study will provide the Ghana Health Service with evidence, as to whether the country has sustained their elimination targets for trachoma. It will also inform the WHO-led Alliance for the Global Elimination of Trachoma by 2020 (GET2020) on the appropriateness of alternative indicators and surveillance methodologies for verification of blinding trachoma.

Summary The Ghana Health Service plans to eliminate blinding trachoma by 2010 and has implemented the SAFE strategy since 2001. The programme impact was assessed in all endemic districts. A two-stage, cluster random sample of 720 households was selected in each of 18 endemic districts in Upper West and Northern Regions. All eligible residents were examined for trachoma signs. Household environmental risk factors were assessed. In total, 74 225 persons from 12 679 households were examined. Prevalence of trachomatous inflammation-follicular in 1–9 year-old children was 0.84% (95% CI 0.63–1.05, range of point estimates by district 0.14–2.81%) and prevalence of trichiasis in adults aged ≥15 years was 0.31% (95% CI 0.24–0.38, range by district 0.00–1.07%). An estimated 4950 persons have trichiasis, of whom 72.6% are aged ≥60 years and 71.4% are women. Latrines were observed in 11.6% of households and 79.2% of interview respondents reported use of an improved water source. Active trachoma is no longer a public health problem in Ghana after successful implementation of the SAFE strategy. The programme should maintain health education, advocate for improved water and sanitation and focus on providing surgery. Surveillance activities are needed to ensure sustained control.

The northern Ghana Upper East Region [UER], Upper West Region [UWR], and Northern Region (NR) lie within the African trachoma belt. The 3 regions share common features of poverty, dryness, dusty environments, and poor environmental hygiene. Trachoma has been identified previously in the NR and the UWR as a disease of public health importance and a control program is underway.To establish baseline prevalence and risk factor parameters in the Upper East for possible control of trachoma in the region.Population-based cross-sectional survey using multi-staged cluster sampling techniques was used. In all 26,323 participants from 4,374 households in 160 communities were examined with a 2.5x magnifying binocular loupe for trachoma; 7,763 were children aged 1-9 years and 15,191 were aged 15 years and over.Only 3 children were identified with active trachoma (trachoma with follicles, TF = 1; trachoma with intense inflammation, TI = 2) giving regional prevalence of 0.01% (Confidence Limits, CL: 0.0-0.1) for TF and 0.03% (CL: 0.0-0.1) for TI. Trachomatous trichiasis was measured at 0.05% (CL: 0.0-0.1) while children with clean faces was measured at 95.5%. Only 3.6% of the examined households in the region had access to a toilet facility.Trachoma is not a disease of public health importance in the UER of Ghana despite being in a trachoma endemic zone and sharing the necessary risk factors for the disease.