• 1

    World Health Organization, 1973. Handbook of Resolutions and Decisions of the World Health Assembly and the Executive Board. Volume 1, 1948–1972. Geneva: World Health Organization.

  • 2

    Tang FF, Chang HL, Huang YT, Wang KC, 1957. Isolation of trachoma virus in chick embryo. Chin Med J 75 :429–447.

  • 3

    Thylefors B, Dawson CR, Jones BR, West SK, Taylor HR, 1987. A simple system for the assessment of trachoma and its complications. Bull World Health Organ 65 :97–105.

    • Search Google Scholar
    • Export Citation
  • 4

    Taylor H, West SK, Katala S, Foster A, 1987. Trachoma: evaluation of a new grading scheme in the United Republic of Tanzania. Bull World Health Organ 65 :485–488.

    • Search Google Scholar
    • Export Citation
  • 5

    World Health Organization, 1993. Prise en Charge du Trachome à l’Échelon de Soins de Santé Primaires. Geneva: World Health Organization. WHO/PBL/93.33.

  • 6

    Francis V, Turner V, 1993. L’Appui Communautaire en Faveur de la Lutte Contre le Trachome. Guide d’Action Sanitaire de District. Geneva: World Health Organization. WHO/PBL/93.36.

  • 7

    World Health Organization, 1996. Planning Meeting for the Global Elimination of Trachoma. Geneva: World Health Organization. November 25–28, 1996.

  • 8

    World Health Assembly, 1998. Resolution 51.11. May 16, 1998.

 

 

 

 

TRACHOMA: LOOKING FORWARD TO GLOBAL ELIMINATION OF TRACHOMA BY 2020 (GET 2020)

View More View Less
  • 1 Prevention of Blindness and Deafness, World Health Organization, Geneva, Switzerland

There is fortunately increasing international awareness of the problem of needless blindness from trachoma and enhanced international cooperation. This is exemplified by the World Health Organization Alliance for the Global Elimination of Blinding Trachoma by 2020 (GET 2020), the World Health Assembly resolution 51.11, 1998, and the inclusion of trachoma as a priority under the disease control component of the Global Initiative for the Elimination of Avoidable Blindness, Vision 2020 – the Right to Sight. Evidence-based advances in knowledge and intervention strategies together with the additional financial resources now available offer opportunities for a concerted effort to control and eliminate blinding trachoma, long before the year 2020, in most countries.

INTRODUCTION

“The further you look back, the better you prepare for the future”

Sir Winston Churchill

“Trachoma is both an ancient and a stubborn disease, slow to blind, and obviously hard to “cure” in a public health context. All through human history, in times of peace as in times of war, it has taken a steady toll of human sight. Against this persistent affliction, some of the best minds in public health ophthalmology have during the course of the last half century or so, been forging increasingly effective weapons to control and eliminate blinding trachoma. Not a decade has passed without some improvement in strategy or medication against this leading cause of preventable blindness.”*

Adapted from a reference to malaria by R. B. Fosdick, President of the Rockefeller Foundation (1946).

Recent intervention strategies are promising. But there is no reason for complacency.

HISTORY OF TRACHOMA CONTROL

Trachoma control has a long history and is among the major disease control programs initiated by the World Health Organization (WHO), almost since its inception.1 Besides the virtual disappearance of trachoma as a blinding disease from the industrialized world where it was endemic, considerable achievements have been made in parts of Asia and in many Middle Eastern countries.2 Efforts to control trachoma and related blindness came later in most of the African countries. For a number of reasons the early successful efforts could not be sustained in many parts of the world. The elimination of blinding trachoma, which is a complex disease, associated with poverty and deprivation, in the broadest sense, remains the “unfinished agenda” in public health ophthalmology. Trachoma has the dubious distinction of being the leading cause of preventable blindness.

In 1987, a simplified grading system was adopted, enabling basic health workers to identify and manage trachoma cases.3,4 In 1993, the community approach to trachoma control was developed by the WHO and published in collaboration with the Edna McConnell Clark Foundation.5 The 1990s heralded the introduction of the surgery, antibiotics, facial cleanliness, and environmental improvement (SAFE) strategy,6 which was based on proven and cost-effective interventions. Some of the components in the SAFE strategy were the missing links in the evolution of our earlier trachoma control efforts. In the early years of these efforts, the interventions were medical, local and sometimes systemic treatment of the active disease, and surgical treatment of the sight-threatening complications such as trichiasis. This was done generally oblivious of the behavioral and environmental determinants of the disease and its transmission and persistence in clustered communities.

Although some success attended the medical interventions, they could not be sustained. As evidence of this is the persistence of pockets of blinding trachoma in a number of countries where the disease has been endemic to varying degrees and in many of whom control activities have been in place for a number of years.

Conversely, we have recorded the virtual, if not total, disappearance of trachoma as a blinding disease from parts of the world where it was known to be endemic. This has happened without medical interventions but exclusively through improvement in socioeconomic parameters, which have led to the elimination of the multifactorial determinants of this blinding disease. In other instances, there has been at least a reduction in the blinding propensity of the disease.

Thus, it is clear from the past lessons of our control efforts that the secret to sustainable elimination of trachoma as a blinding disease rests not on medical and surgical interventions alone, but more importantly, on addressing the behavioral and environmental aspects in high-risk populations and communities. On these renewed foundations, the Prevention of Blindness program of the WHO established in 1996 a large partnership of Member States, Non-governmental Development Organizations, Research Institutions, Philanthropic Foundations, and Industry: the Alliance for the Global Elimination of Trachoma by 2020 (GET2020).7 The clearly set target was endorsed by the World Health Assembly in 1998 with the resolution 51.11, calling Member States to collaborate in the WHO Alliance GET2020 to finally eliminate blindness for trachoma, implementing the SAFE strategy and using the newly available tools.8

PUBLIC HEALTH IMPLICATIONS OF TRACHOMA

The human and public health burden of trachoma stems not only from the blinding sequelae, but also from the visual impairing consequences, the pain and discomfort, all of which impact on the quality of life. The occurrence of the acute form of the disease in children has far reaching implications for school attendance. The proven sex inequity, with women four times more likely to be visually impaired from trachoma than men, has implications for child nurturing and productivity. In the long term, these contribute in different ways to the perpetuation of the vicious circle of poverty in already indigent and deprived populations.

INSUFFICIENT KNOWLEDGE AND NEED FOR RESEARCH

Epidemiology.

Fifty years after the identification of trachoma as a public health problem, there is as yet insufficient reliable data on the global prevalence of blinding trachoma. While many countries have made remarkable progress in determining the size of the problem and the geographic limits of its burden, many countries have only rough estimates to plan elimination activities. Before the possibility of aspiring for the global elimination of the disease there is an urgent need to map areas of the world through carefully conducted population surveys.

The WHO Trachoma Rapid Assessment methodology does not provide for such estimation. However, it provides clues to the areas where population-based epidemiologic surveys would need to be carried out. Priority studies should target areas of known previous endemicity, where active trachoma in children may not be a public health problem, but trichiasis resulting from previous trachoma, may present a problem. Parts of mega-countries such as China and India may be examples of such areas.

Disease dynamics and treatment.

We do know more about trachoma than we did during our initial efforts at control. However, there are still gaps in our knowledge. We still do not fully understand the epidemiology of trachoma, the relationship between transmission intensity, disease pattern, and severity of the disease, and subsequent blinding complications. We still need to know more about the optimum treatment schedules using the newer macrolides and have more insights on the effect of mass treatment compared with targeted treatment, given the cost of the medication.

Cultural issues.

People’s knowledge and perceptions about trachoma, how and when to do deal with it, and where to seek treatment, are important and not always fully understood. We need to know through sociology- and medical anthropology-based studies what happens at the community level, how health-seeking behavior develops, and the outcomes of health education in children and in adults pertaining to blinding trachoma prevention.

Monitoring.

Monitoring of the progress in trachoma control/elimination efforts and evaluation of outcomes should be an integral part of these projects. Standardized methodologies, appropriate indicators, and an appropriate framework for monitoring need to be put in place at national and global levels.

Consensus has been reached on the indicators to determine achievement of elimination; the best administrative or geographic level for this assessment remains to be identified (provinces/states/districts), mainly in large countries. Standardized methodologies and protocols for certifying achieved elimination would need to be developed.

AVAILABLE TOOLS

The SAFE strategy provides a template for action. Although, as a priority surgery for trichiasis is urgent to prevent imminent and impending vision loss, the need to apply all four components of the strategy, if we are to achieve sustainable control and elimination, must be emphasized. In this regard, those at the end of the track are the communities at greatest risk and the most difficult to reach. The SAFE strategy would need to be combined with active efforts to “reach the unreached.”

INTERVENTIONS WITHIN AND OUTSIDE THE HEALTH CARE SYSTEM

Since the mid 1990s, the SAFE strategy has been introduced. It addresses as a priority the blinding consequences of the disease (by surgery for trichiasis) and the responsible biologic agent (Chlamydia trachomatis) (by antibiotics) on the one hand, and the important behavioral and environmental determinants, through facial cleanliness and environmental improvement, respectively, on the other. The introduction of newer antibiotic agents such as azithromycin has improved community compliance as far as medical treatment is concerned. However, factors such as costs and availability of such new treatments (drug and distribution costs) remain a constraint. The paucity of trained personnel to carry out trichiasis surgery, the most urgent of the blindness prevention interventions, needs to be addressed. The need for intersectoral collaborative action to address the issues pertaining to personal and environmental hygiene in endemic communities warrants urgent attention, not only to facilitate control and elimination efforts, but also to sustain such achievements.

IMPLEMENTATION: AN AREA OF CONCERN

The multifactorial etiology of trachoma calls for a multi-disciplinary approach. The basic strategy of primary health care lends itself admirably to application in the field of trachoma control. Regrettably, this is weakly developed in most regions where blinding trachoma is endemic. Although strengthening of primary health care may fall outside specific projects aimed at the elimination of blinding trachoma, the need to support such development may be the key to success. National capacity building in primary health care thus becomes a worthwhile investment.

In many countries, SAFE is been implemented by public-private partnerships: of great concern is the slow speed at which the strategy is implemented in these areas, provinces, and countries. Current implementation rate is unlikely to help meet the set goal. It is needed to identify ways to expand the deployment of the strategy in all countries and in all areas where blinding trachoma is still a public health problem. This problem is strictly related to the lack of awareness of many decision-makers and their lack of support to the elimination activities. Resources available to date, human and financial, are not of adequate proportion for the final elimination of this cause of blindness.

CHALLENGES AND OPPORTUNITIES

The paucity of trained personnel to carry out trichiasis surgery, the most urgent of the blindness prevention interventions, needs to be addressed. Together with availability of surgical care, its quality needs to be watched carefully because only good quality services are likely to generate the uptake of surgical care in endemic communities.

The need for intersectoral collaborative action to address the issues pertaining to personal and environmental hygiene in endemic communities warrants urgent attention, not only to facilitate control and elimination efforts, but also to sustain such achievements. Working relationships with Ministries of Education would facilitate development of interventions, both health educational as well as treatment in the target school population. The challenge is to get non-medical entities (ministries and organizations) fully involved in trachoma elimination work, and to take advantage of their ongoing activities to add the needed components to make them SAFE compliant. Thus, the provision of water and improved environmental sanitation should not fall behind the implementation of surgical and antibiotic treatment interventions.

To make trachoma elimination interventions sustainable there is the obvious need to integrate them in the development of the national primary eye care system of countries: this integration will not threaten the momentum that exists today for elimination, but rather constitute an advantage. Other major interventions in eye care shall be implemented bearing in mind the set goal for GET2020

The slow speed of implementation, alluded to earlier, even where private-public partnerships are in place, pose a serious challenge. However, such partnerships, which could be wide ranging as exemplified by the WHO Global Alliance, provide an opportunity to energize and accelerate the implementation of the SAFE strategy wherever it is needed in a more synergistic manner.

SUMMARY

Fortunately, there is an increasing international awareness of the problem of needless blindness from trachoma and enhanced international cooperation. This is shown by the WHO Alliance for the Global Elimination of Blinding Trachoma by 2020 (GET 2020), the World Health Assembly resolution 51.11, 1998, and the inclusion of trachoma as a priority under the disease control component of the Global Initiative for the Elimination of Avoidable Blindness, Vision 2020 – the Right to Sight. Evidence-based advances in knowledge and intervention strategies, together with the additional financial resources now available, offer opportunities for a concerted effort to control and eliminate blinding trachoma, long before the year 2020, in most countries. The war against blinding trachoma has not been won as yet, but we can and must prevail.

Authors’ address: Silvio Mariotti, Serge Resnikoff, and Ramachandra Pararajasegaram, Prevention of Blindness and Deafness, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland, Telephone: 41-22-791-3491, Fax: 41-22-791-4772, E-mail: mariottis@who.int.

REFERENCES

  • 1

    World Health Organization, 1973. Handbook of Resolutions and Decisions of the World Health Assembly and the Executive Board. Volume 1, 1948–1972. Geneva: World Health Organization.

  • 2

    Tang FF, Chang HL, Huang YT, Wang KC, 1957. Isolation of trachoma virus in chick embryo. Chin Med J 75 :429–447.

  • 3

    Thylefors B, Dawson CR, Jones BR, West SK, Taylor HR, 1987. A simple system for the assessment of trachoma and its complications. Bull World Health Organ 65 :97–105.

    • Search Google Scholar
    • Export Citation
  • 4

    Taylor H, West SK, Katala S, Foster A, 1987. Trachoma: evaluation of a new grading scheme in the United Republic of Tanzania. Bull World Health Organ 65 :485–488.

    • Search Google Scholar
    • Export Citation
  • 5

    World Health Organization, 1993. Prise en Charge du Trachome à l’Échelon de Soins de Santé Primaires. Geneva: World Health Organization. WHO/PBL/93.33.

  • 6

    Francis V, Turner V, 1993. L’Appui Communautaire en Faveur de la Lutte Contre le Trachome. Guide d’Action Sanitaire de District. Geneva: World Health Organization. WHO/PBL/93.36.

  • 7

    World Health Organization, 1996. Planning Meeting for the Global Elimination of Trachoma. Geneva: World Health Organization. November 25–28, 1996.

  • 8

    World Health Assembly, 1998. Resolution 51.11. May 16, 1998.

Footnotes

*

Adapted from a reference to malaria by R. B. Fosdick, President of the Rockefeller Foundation (1946).

Save