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The Simplified Trachoma Grading System, Amended Anthony W Solomon,A Amir B Kello,B Mathieu Bangert,A Sheila K West,C Hugh R Taylor,D Rabebe Tekeraoie & Allen Fosterf

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The Simplified Trachoma Grading System, Amended Anthony W Solomon,A Amir B Kello,B Mathieu Bangert,A Sheila K West,C Hugh R Taylor,D Rabebe Tekeraoie & Allen Fosterf PolicyPolicy & practice & practice The simplified trachoma grading system, amended Anthony W Solomon,a Amir B Kello,b Mathieu Bangert,a Sheila K West,c Hugh R Taylor,d Rabebe Tekeraoie & Allen Fosterf Abstract A simplified grading system for trachoma was published by the World Health Organization (WHO) in 1987. Intended for use by non-specialist personnel working at community level, the system includes five signs, each of which can be present or absent in any eye: (i) trachomatous trichiasis; (ii) corneal opacity; (iii) trachomatous inflammation—follicular; (iv) trachomatous inflammation—intense; and (v) trachomatous scarring. Though neither perfectly sensitive nor perfectly specific for trachoma, these signs have been essential tools for identifying populations that need interventions to eliminate trachoma as a public health problem. In 2018, at WHO’s 4th global scientific meeting on trachoma, the definition of one of the signs, trachomatous trichiasis, was amended to exclude trichiasis that affects only the lower eyelid. This paper presents the amended system, updates its presentation, offers notes on its use and identifies areas of ongoing debate. Introduction (ii) corneal opacity; (iii) trachomatous inflammation—fol- licular; (iv) trachomatous inflammation—intense; and (v) tra- Trachoma is the most important infectious cause of blindness.1 chomatous scarring.19 Trachomatous inflammation—follicular Repeated conjunctival infection2 with particular strains of and trachomatous inflammation—intense are signs of active Chlamydia trachomatis3–5 results, in some people, in conjunc- (inflammatory) trachoma, usually associated with conjunctival tival scarring, trichiasis and corneal opacity. The disease is C. trachomatis infection.21 The signs of the simplified system strongly linked to poverty.6 In March 2019, 142 million people have been used to complete baseline mapping of trachoma in globally were at risk.7 suspected endemic districts worldwide,22,23 to assess the im- At the population level, trachoma may be hyperendemic, pact of interventions in both research24,25 and programme26,27 severe and blinding; or less severe and non-blinding.8 Models contexts, and to establish criteria for elimination of trachoma suggest that more than 150 episodes of C. trachomatis infec- as a public health problem.28 tion are required to develop trichiasis from trachoma;9 im- During recent programmatic scale-up and transition of mune responses to infection are critical in the pathogenetic countries through the validation process,29 technical questions pathway.10,11 Populations therefore presumably transition from have arisen about the use of some of the simplified system’s having blinding to non-blinding disease through reductions signs. In November 2018, WHO convened the 4th global sci- in intensity of ocular C. trachomatis transmission. These entific meeting on trachoma in part to address those questions. reductions in transmission can occur through general socio- In particular, the meeting considered whether the prevalence economic improvement12,13 or specific implementation of the of trachomatous inflammation—follicular in 1–9-year-olds antibiotics, facial cleanliness and environmental improvement remains the best way for programmes to determine whether components of the SAFE strategy for trachoma elimination;14 ocular C. trachomatis transmission intensity has been suffi- the S of SAFE representing surgery for trichiasis,15 which does ciently reduced to minimize the risk of future trachomatous not alter transmission. However, C. trachomatis transmission blindness. Also considered was whether the definition of intensity16,17 would be extremely difficult to measure directly. trachomatous trichiasis could be improved to better differ- In contrast, conjunctival inflammatory responses to infection11 entiate trachomatous from non-trachomatous trichiasis. As can be observed by examination of the conjunctiva under a consequence, the definition of trachomatous trichiasis was low-power magnification. Because of this, and because the amended to exclude trichiasis affecting only the lower eyelid, vision-impairing effects of trachoma are manifest through on the basis that such cases are unlikely to be due to trachoma macroscopic changes in the eyelid and cornea, assessment of and that labelling them as trachomatous trichiasis constitutes the public health impact of trachoma is carried out through potential misclassification.30 detection of physical signs of disease.18 In the current paper we set out the simplified system In 1987, the World Health Organization (WHO) pub- including that amendment, and revise the presentation of the lished the simplified trachoma grading system to provide a system to help users better understand and more consistently standardized method for non-specialist personnel to under- apply the definitions. We discuss the continuing programmatic take such assessments.19 The system, which was field-tested in dependence on the prevalence of trachomatous inflamma- three countries,19,20 has five signs: (i) trachomatous trichiasis; tion—follicular as a clinical proxy for current ocular C. tra- a Department of Control of Neglected Tropical Diseases, World Health Organization, Avenue Appia 20, 1211 Geneva 27, Switzerland. b World Health Organization Regional Office for Africa, Brazzaville, Congo. c Wilmer Eye Institute, Johns Hopkins University, Baltimore, United States of America. d Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Australia. e Eye Department, Ministry of Health and Medical Services, South Tarawa, Kiribati. f International Centre for Eye Health, London School of Hygiene & Tropical Medicine, London, England. Correspondence to Anthony W Solomon (email: solomona@ who .int). (Submitted: 1 December 2019 – Revised version received: 6 July 2020 – Accepted: 7 July 2020 – Published online: 3 September 2020 ) 698 Bull World Health Organ 2020;98:698–705 | doi: http://dx.doi.org/10.2471/BLT.19.248708 Policy & practice Anthony W Solomon et al. WHO simplified trachoma grading system chomatis transmission intensity. Finally, Fig. 1. Outline sketch of an everted upper eyelid we outline other topics for continuing research and reflection. Inevitably, this paper draws heavily from the original article.19 Method of examination The examiner should always use clean hands (by, for example, applying alco- hol-based hand sanitizer), binocular loupes (magnification × 2.5) and ad- equate lighting (either sunlight or a torch). Although sunlight provides the best illumination for examining the conjunctiva, it is better to examine for trachomatous trichiasis indoors because of the photophobia that patients with trichiasis experience. An examination station on the edge of a shaded area can be ideal, but survey teams typically move house-to-house. When examining the conjunctiva outdoors, it is important to orient the person being examined so Note: The drawing shows the area of the tarsal conjunctiva (shaded) to be examined for follicles. that light from the sun passes across the examiner’s shoulder onto the person’s should be inspected for empty eyelash present or absent. A sign must be clearly face. When using a torch, care should be follicles or broken eyelash shafts, which seen to be considered present. If the taken not to contaminate it with fingers may indicate recent epilation. examiner is in doubt, a sign should be that have been in contact with the per- The cornea should be inspected for recorded as being absent. The list below son’s skin or eye. An assistant can help opacities. presents the definitions of the signs. to hold and reassure children while they The eyelid is everted and the con- Amendments from the original grading are examined.31 junctiva inspected for follicles, pro- system19 are shown in italics (Fig. 3). To help ensure that abnormal nounced inflammatory thickening, and Trachomatous trichiasis findings are correctly recorded, the scarring. When examining for follicles, right eye should always be examined only those found within the central part At least one eyelash from the upper eyelid first, then the left eye. To assess for of the upper tarsal conjunctiva (Fig. 1) touches the eyeball, or evidence of recent the presence or absence of each of the are considered significant.19 epilation of in-turned eyelashes from the signs of the system, the structures to be upper eyelid. examined in each eye are, in order: the Appearance of the normal Corneal opacity upper eyelid margin and its eyelashes, then the cornea, then the upper tarsal eye Easily visible corneal opacity that is conjunctiva (the conjunctiva lining the so dense that at least part of the pupil The appearance of the normal eye upper eyelid). margin is blurred when viewed through when examined for trachoma is as To examine for trachomatous tri- the opacity. This definition is intended follows (Fig. 2): (i) no eyelashes touch chiasis, with the examinee’s eye open to detect corneal opacities that cause the eyeball and there is no evidence and the eyelid in its resting state, the significant visual impairment. In in- of recent epilation; (ii) the cornea is examiner should adopt a position so that dividuals with corneal opacity, visual smooth, transparent and avascular; his or her eyes are below the horizontal acuity should be measured, if possible. and (iii) the upper tarsal conjunctiva plane through the person’s eye. Light is smooth, thin and transparent. Be- Trachomatous inflammation— should be shone from below then from neath the whole
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