Huge progress has been made in the past five years toward eliminating trachoma, one of the world’s oldest diseases. Understanding how we’ve advanced so quickly and ensuring this momentum continues can only be achieved if we assess the factors driving progress.
Trachoma is a neglected tropical disease that is entirely preventable, yet it remains the most common cause of infectious blindness in the world. Triggered by a bacterial infection that is easily transmitted from person to person, found most often in poor, rural communities with limited access to clean water and sanitation, more than 157 million people remain at risk of this excruciating disease.
With a combined investment of £80 million ($104.2 million), the programs have delivered the World Health Organization-approved SAFE strategy on an unprecedented scale — surgery to correct the position of in-turned eyelashes to prevent scarring of the eye, antibiotics to reduce the spread of infection, raising awareness of the need for facial cleanliness to help prevent transmission, and environmental improvements to increase access to safe water sources and sanitation.
Whether countries started with a relatively high or low prevalence of trachoma, all have made significant strides toward elimination, and many have now embedded trachoma services into their health systems, ensuring they are equipped to manage future cases of the disease.
For instance, Malawi recently announced that all endemic districts have achieved elimination thresholds for trachoma, meaning the disease is being effectively controlled. The country has now entered a two-year surveillance period, after which it will be ready to submit evidence to WHO to confirm it has eliminated trachoma as a public health problem.
As the two programs come to a close, our newly released learning paper serves to advance understanding of what works and what doesn’t when it comes to trachoma elimination and to inform future programs. For me, four key insights stand out.
1. Finding people where they are: Systematic, innovative case finding
As countries approach elimination, finding the remaining people to treat for trichiasis — the most severe, blinding form of trachoma — becomes challenging, and it is often the most marginalized who fall through the gaps.
One of the biggest breakthroughs to address this came when all partners adopted a systematic “door-to-door” approach to find people. These searches were carried out by local volunteers, around 68,500 of whom were mobilized through the two programs.
This strategy helped ensure many people with previously undetected trichiasis were reached and given the opportunity to access services, leading to more than 213,500 sight-saving surgeries. This also provided a rich source of data, enabling us to better understand which areas had accessed services and ensure no pockets of the population were left out.
We also utilized existing community networks to find people in need of treatment. For example, we identified and trained women in microfinance groups in the Masai community who had already received surgery to encourage other women to do the same. By doing this, we were able to reach many more women, some of whom had been living with trachoma for years.
2. Standardizing approaches — yet still considering context
The two programs were led by the health ministry in each country and worked with a network of more than 80 organizations. The programs were overseen by the International Coalition of Trachoma Control, and coordinated by Sightsavers, with ICTC members acting as country coordinating and implementing partners.
With so many players involved, developing standardized approaches was key — yet these approaches also had to be flexible enough to suit different environments. From the outset, ICTC clearly set out the trachoma community’s “preferred practices:” manuals outlining what works, based on research and country experience.
Some of these simply advised on the most effective way of doing things; others provided a toolbox of options. This could be as simple as highlighting the need to understand that not all countries have the same district level health structures or emphasizing the effectiveness of translating information about face and hand washing into local languages in certain settings.
3. A tailored approach to providing millions of antibiotic treatments
The programs were hugely successful in providing entire communities with treatment, with around 76 million antibiotic treatments given to around 37.5 million people living in high-risk areas — but we only got there by taking a tailored approach.
Sometimes simple solutions worked, such as recruiting women in Nigeria to act as drug distributors so they could reach Muslim women in Purdah, a practice that secludes women from men or strangers. Other times, as was the case in Chad, local case finders were unable to track and reach nomadic communities, so we used professional mobile teams that could follow communities across borders, giving us the outcome we needed.
This area remains a work in progress. With funding from DFID, the Coalition for Operational Research on NTDs is currently supporting several research projects on equitable access to treatment for neglected tropical diseases worldwide. Future programs will need to use this evidence to ensure that women, people with disabilities, people in remote locations, nomadic communities, and people affected by displacement or insecurity are not left behind.
4. Partnerships and integration
Because the SAFE strategy promotes an inclusive approach to combating trachoma, it has encouraged the global trachoma community to actively forge partnerships with a diverse array of actors.
Collaborations have now been developed with those working on water, sanitation, and hygiene, as well as within education and health, particularly primary eye health care. In many countries, these sectors now place greater importance on their respective roles in eliminating trachoma.
For instance, in Chad, Ethiopia, and Uganda, trachoma prevention has become part of the national school health curriculum and it has also been included in sanitation guidelines. In Tanzania, face washing is now part of sanitation guidelines, and in Malawi, trachoma prevention has been included in the country’s WASH strategy.
A lasting legacy
These are just four insights; there are many others. What is resoundingly clear is that, alongside the millions of people who are no longer at risk of trachoma and the hundreds of thousands of people who have had their sight saved, the legacy of these two programs lies in the mound of evidence they have generated — evidence that, if applied properly, could help to finally eliminate this ancient disease from all parts of the world.
Devex, with financial support from our partner Essilor, is exploring challenges, solutions, and innovations in eye care and vision. Visit the Focus on: Vision page for more.