TRACHOMA IN A RURAL H A I T I A N COMMUNITY ROGER L. NICHOLS,
M.D.
Boston, Massachusetts MOSHE LAHAV, M.D.,
AND DANIEL M. ALBERT,
M.D.
New Haven, Connecticut AND JUDITH A.
WHITTUM
Boston, Massachusetts
Because of variability in the clinical ex pression of trachoma,1-3 a diagnosis based solely on clinical signs may be open to ques tion. We encountered such difficulty between 1969 and 1972 in an eye clinic in Haiti, West Indies. Wide differences of opinion regarding clinical diagnosis of trachoma oc curred among 14 American-trained ophthal mologists who participated in patient care. Based on slit-lamp biomicroscopic examina tion and Giemsa-stained smears, the impres sions ranged from total absence of trachoma to a high prevalence of the disease. With the availability of immunologie and immunofluorescent techniques, the detection of tra choma, even in its mild or atypical forms, has become more accurate.4-5 We undertook this study to establish with the help of nrcrobiologic and correlative immunologie tech niques the presence or absence of the dis ease in the region. SUBJECTS AND METHODS
The living conditions in Central Haiti have
been described.6 Under these conditions per sonal hygiene and public sanitation may pre dispose toward active clinical trachoma. The average income per capita is low and tindernutrition is common, particularly in the nearby mountain regions where keratomalacia is commonly seen. The hospital provides routine clinical and inpatient medical care. A screening clinic is held each morning. Here, all who seek medi cal attention are given an initial evaluation with regard to the nature and severity of their illness and are referred accordingly. In contrast to the other hospital clinics where only patients from the hospital district are seen, eye patients from all over the country are examined in the ophthalmology clinic. These patients present with a variety of prob lems, most commonly with external diseases such as cataracts, glaucoma, uveitis, keratomalacia, and tumors such as squamous cell carcinoma of the conjunctiva and retinoblastoma. The patients were examined by two oph thalmologists (M.L. and D.A.) and one experienced trachoma specialist (R.N.). Pa tients seen in the eye clinic were examined with the slit-lamp biomicroscope. Fluorescein instillation was carried out when corneal involvement was suspected. The grading was based on the MacCallan classification and followed the recommendations of the Fourth W H O Scientific Group on Trachoma Re search.7 Cases of isolated atypical conjunctival or corneal involvement were designated as atypical.
From the Department of Microbiology, Harvard University School of Public Health, Boston, Mas sachusetts (Dr. Nichols and Ms. Whittum), and the Department of Ophthalmology and Visual Sci ence, Yale University School of Medicine, New Haven, Connecticut (Drs. Lahav and Albert). The study was supported in part by a grant from the Arabian American Oil Company ; a grant from the National Eye Institute EY-00812; the Connecticut Lions Eye Research Foundation, Inc. ; and by Na tional Institutes of Health grant EY-00108 and Vision Center grant EY-00785-03. Reprint requests to Roger L. Nichols, M.D., De partment of Microbiology, Harvard School of Pub lic Health, 665 Huntington Ave., Boston, MA 02115.
76
VOL. 81, NO. 1
77
TRACHOMA
The specimens were collected from the fol lowing four groups of patients (Table 1). Group 1-—Six hundred patients seen in the eye clinic for any reason during April 1972 were examined with a biomicroscope for evidence of trachoma. We re-examined 30 patients who had one or more signs sug gestive of trachoma, including conjunctival follicle or scarring, corneal infiltration or vascularization. Ten patients from 4 to 45 years were selected as having changes con sistent with the findings in "classic" or atypical trachoma. Serum and eye secretions were collected from these ten patients for immunologie antibody determination, and conjunctival scrapings were taken for flu orescent antibody tests and egg inoculations. Group 2—We attempted to examine all the inhabitants in a cluster of houses one mile from the hospital (a habitation) without se lection for clinical ocular complaints. Ninety patients were examined with a focused light and 2X magnifying loupe under field con ditions by three physicians. Specimens were collected from nine patients, ranging in age from 6 months to 57 years, with clinical findings suspicious of trachoma. Group 3—Two hundred children who came to the screening clinic one morning for various medical problems were examined with a loupe by two of us (R.N. and D.A.). Nine suspected cases, with patients ranging from 15 days to 7 years, were selected and samples were obtained. Group 4—A total of 85 children from three nutrition centers were screened using the loupe, and 15 patients between 2 and 7 years of age with clinically suspected trachoma were selected and specimens col lected. Methods for collection and testing have been described for detection of inclusion bodies in conjunctival scrapings by immunofluorescence,8 chlamydial isolation,9 antibody detection in eye secretions,10 serotyping of isolates,11 and antibody specificity in sera and eye secretions.10 The specimens for isolation
were at 4°C during shipment to the labora tory. Strain designation (Table 2) was done according to the method of Gear and asso ciates.12 Serotype designation was in accord with the method of Alexander, Wang, and Grayston.13 Sera and eye secretions positive for the presence of antibodies were tested for trachoma serotype by absorption with serotypes A, B, and C.10 RESULTS
We made a clinical diagnosis of active tra choma (Tr I, II, or I I I ) in 23 of 43 patients, ranging from 1 to 36 years (Cases 1-23), from whom specimens were taken. Six in clusion bodies were found in a 1-year-old child (Case 1). Serum antibodies to chla mydia were present in all 17 patients (Cases 2, 4-6, and 11-23) from whom serum was taken; titers ranged from 1:10 to 1:640. Eleven of the higher titered sera were tested for antibody specificity to three serotypes; all were specific for serotype A. Eye secre tion antibodies to chlamydia, titering 1:10 to 1:1280, were found in 40% of those cases (nine of 23). Serotyping was attempted in eight eye secretion samples and specificity for serotype A was defined in five; two of the remaining three were not typeable. Atypical follicles were described in eight of the 43 patients, 5 to 57 years of age (Cases 24-31) ; none were inclusion positive. Antibodies in the serum were found in eight of eight tested (titers 1:10 to 1:5120). Sero typing, attempted in six cases, was specific for serotype A in two (Cases 25 and 26). Antibodies in eye secretions were found in six of eight cases tested (75%) (titers 1:10 to > 1:640). Serotyping was attempted on only one sample but the specificity was not defined. Conjunctivitis with or without mucopurulent discharge was diagnosed in ten patients, aged 15 days to 43 years (Cases 32-41). In the conjunctival scraping from a 12-year-old patient (Case 40) with mucopurulent con junctivitis, 309 chlamydial inclusion bodies
TABLE 1 CLINICAL AND LABORATORY DATA ON 43 HAITIAN SUBJECTS EXAMINED FOR TRACHOMA*
Case No., Age, yrs.
Source of Patients
No. of Inclusion Bodies/ No. of Cells XI0'
Reciprocal Antibody Titer by Serotypef Serum
Eye Secretions
Trachoma I, II, or III 1, 1 2,1 3, 2 4,2 5,3 6,3 7,4 8,4 9,4 10,5 11,5 12,5 13,5 14,6 15,6 16, 7 17, 7? 18,7 19,8 20, 10 21, 11 22,36 23, Not known
SC SC NC NC NC NC NC NC NC NC NC SC H NC NC NC SC SC H H EC EC EC
24,5 25,6 26, 18 27, 19 28,26 29,35 30,48 31,57
H H H EC EC EC H H
6/3.1ί 0/0.8Î 0/13 0/18.4t 0/4.4 0/19.5$ 0/17.7 0/4.9 0/2.1$ 0/4.3 0/1.5$ 0/6.9$
o§
0/8.3$ 0/2.2$ 0/5.8 0/9.6$ 0/0.86$
ot§ o§
0/14$ 0/1.5$ 0/1.5$ Atypical Follicles
o§ o§ o§
0/44 0/31.9 0/4.6
o§ o§
20 (A)
— 10
—
20 (A) 40 (A)
— — —
10 640 (A) 10 10 80(A) 320 (A) 20 (A) 10 320 (A) 10 320 (A) 320 (A) 320 (A) 20 160 (A) 80(A) 320 (UT) 1,280 (UT) 5,120 (UT) 1,280 (UT) 20
1,280 (UT) 160 (A)
M.D.
Boston, Massachusetts MOSHE LAHAV, M.D.,
AND DANIEL M. ALBERT,
M.D.
New Haven, Connecticut AND JUDITH A.
WHITTUM
Boston, Massachusetts
Because of variability in the clinical ex pression of trachoma,1-3 a diagnosis based solely on clinical signs may be open to ques tion. We encountered such difficulty between 1969 and 1972 in an eye clinic in Haiti, West Indies. Wide differences of opinion regarding clinical diagnosis of trachoma oc curred among 14 American-trained ophthal mologists who participated in patient care. Based on slit-lamp biomicroscopic examina tion and Giemsa-stained smears, the impres sions ranged from total absence of trachoma to a high prevalence of the disease. With the availability of immunologie and immunofluorescent techniques, the detection of tra choma, even in its mild or atypical forms, has become more accurate.4-5 We undertook this study to establish with the help of nrcrobiologic and correlative immunologie tech niques the presence or absence of the dis ease in the region. SUBJECTS AND METHODS
The living conditions in Central Haiti have
been described.6 Under these conditions per sonal hygiene and public sanitation may pre dispose toward active clinical trachoma. The average income per capita is low and tindernutrition is common, particularly in the nearby mountain regions where keratomalacia is commonly seen. The hospital provides routine clinical and inpatient medical care. A screening clinic is held each morning. Here, all who seek medi cal attention are given an initial evaluation with regard to the nature and severity of their illness and are referred accordingly. In contrast to the other hospital clinics where only patients from the hospital district are seen, eye patients from all over the country are examined in the ophthalmology clinic. These patients present with a variety of prob lems, most commonly with external diseases such as cataracts, glaucoma, uveitis, keratomalacia, and tumors such as squamous cell carcinoma of the conjunctiva and retinoblastoma. The patients were examined by two oph thalmologists (M.L. and D.A.) and one experienced trachoma specialist (R.N.). Pa tients seen in the eye clinic were examined with the slit-lamp biomicroscope. Fluorescein instillation was carried out when corneal involvement was suspected. The grading was based on the MacCallan classification and followed the recommendations of the Fourth W H O Scientific Group on Trachoma Re search.7 Cases of isolated atypical conjunctival or corneal involvement were designated as atypical.
From the Department of Microbiology, Harvard University School of Public Health, Boston, Mas sachusetts (Dr. Nichols and Ms. Whittum), and the Department of Ophthalmology and Visual Sci ence, Yale University School of Medicine, New Haven, Connecticut (Drs. Lahav and Albert). The study was supported in part by a grant from the Arabian American Oil Company ; a grant from the National Eye Institute EY-00812; the Connecticut Lions Eye Research Foundation, Inc. ; and by Na tional Institutes of Health grant EY-00108 and Vision Center grant EY-00785-03. Reprint requests to Roger L. Nichols, M.D., De partment of Microbiology, Harvard School of Pub lic Health, 665 Huntington Ave., Boston, MA 02115.
76
VOL. 81, NO. 1
77
TRACHOMA
The specimens were collected from the fol lowing four groups of patients (Table 1). Group 1-—Six hundred patients seen in the eye clinic for any reason during April 1972 were examined with a biomicroscope for evidence of trachoma. We re-examined 30 patients who had one or more signs sug gestive of trachoma, including conjunctival follicle or scarring, corneal infiltration or vascularization. Ten patients from 4 to 45 years were selected as having changes con sistent with the findings in "classic" or atypical trachoma. Serum and eye secretions were collected from these ten patients for immunologie antibody determination, and conjunctival scrapings were taken for flu orescent antibody tests and egg inoculations. Group 2—We attempted to examine all the inhabitants in a cluster of houses one mile from the hospital (a habitation) without se lection for clinical ocular complaints. Ninety patients were examined with a focused light and 2X magnifying loupe under field con ditions by three physicians. Specimens were collected from nine patients, ranging in age from 6 months to 57 years, with clinical findings suspicious of trachoma. Group 3—Two hundred children who came to the screening clinic one morning for various medical problems were examined with a loupe by two of us (R.N. and D.A.). Nine suspected cases, with patients ranging from 15 days to 7 years, were selected and samples were obtained. Group 4—A total of 85 children from three nutrition centers were screened using the loupe, and 15 patients between 2 and 7 years of age with clinically suspected trachoma were selected and specimens col lected. Methods for collection and testing have been described for detection of inclusion bodies in conjunctival scrapings by immunofluorescence,8 chlamydial isolation,9 antibody detection in eye secretions,10 serotyping of isolates,11 and antibody specificity in sera and eye secretions.10 The specimens for isolation
were at 4°C during shipment to the labora tory. Strain designation (Table 2) was done according to the method of Gear and asso ciates.12 Serotype designation was in accord with the method of Alexander, Wang, and Grayston.13 Sera and eye secretions positive for the presence of antibodies were tested for trachoma serotype by absorption with serotypes A, B, and C.10 RESULTS
We made a clinical diagnosis of active tra choma (Tr I, II, or I I I ) in 23 of 43 patients, ranging from 1 to 36 years (Cases 1-23), from whom specimens were taken. Six in clusion bodies were found in a 1-year-old child (Case 1). Serum antibodies to chla mydia were present in all 17 patients (Cases 2, 4-6, and 11-23) from whom serum was taken; titers ranged from 1:10 to 1:640. Eleven of the higher titered sera were tested for antibody specificity to three serotypes; all were specific for serotype A. Eye secre tion antibodies to chlamydia, titering 1:10 to 1:1280, were found in 40% of those cases (nine of 23). Serotyping was attempted in eight eye secretion samples and specificity for serotype A was defined in five; two of the remaining three were not typeable. Atypical follicles were described in eight of the 43 patients, 5 to 57 years of age (Cases 24-31) ; none were inclusion positive. Antibodies in the serum were found in eight of eight tested (titers 1:10 to 1:5120). Sero typing, attempted in six cases, was specific for serotype A in two (Cases 25 and 26). Antibodies in eye secretions were found in six of eight cases tested (75%) (titers 1:10 to > 1:640). Serotyping was attempted on only one sample but the specificity was not defined. Conjunctivitis with or without mucopurulent discharge was diagnosed in ten patients, aged 15 days to 43 years (Cases 32-41). In the conjunctival scraping from a 12-year-old patient (Case 40) with mucopurulent con junctivitis, 309 chlamydial inclusion bodies
TABLE 1 CLINICAL AND LABORATORY DATA ON 43 HAITIAN SUBJECTS EXAMINED FOR TRACHOMA*
Case No., Age, yrs.
Source of Patients
No. of Inclusion Bodies/ No. of Cells XI0'
Reciprocal Antibody Titer by Serotypef Serum
Eye Secretions
Trachoma I, II, or III 1, 1 2,1 3, 2 4,2 5,3 6,3 7,4 8,4 9,4 10,5 11,5 12,5 13,5 14,6 15,6 16, 7 17, 7? 18,7 19,8 20, 10 21, 11 22,36 23, Not known
SC SC NC NC NC NC NC NC NC NC NC SC H NC NC NC SC SC H H EC EC EC
24,5 25,6 26, 18 27, 19 28,26 29,35 30,48 31,57
H H H EC EC EC H H
6/3.1ί 0/0.8Î 0/13 0/18.4t 0/4.4 0/19.5$ 0/17.7 0/4.9 0/2.1$ 0/4.3 0/1.5$ 0/6.9$
o§
0/8.3$ 0/2.2$ 0/5.8 0/9.6$ 0/0.86$
ot§ o§
0/14$ 0/1.5$ 0/1.5$ Atypical Follicles
o§ o§ o§
0/44 0/31.9 0/4.6
o§ o§
20 (A)
— 10
—
20 (A) 40 (A)
— — —
10 640 (A) 10 10 80(A) 320 (A) 20 (A) 10 320 (A) 10 320 (A) 320 (A) 320 (A) 20 160 (A) 80(A) 320 (UT) 1,280 (UT) 5,120 (UT) 1,280 (UT) 20
1,280 (UT) 160 (A)
