Public health approaches to addressing trachoma

Introduction: Trachoma is a neglected tropical disease (NTD) caused by infection with Chlamydia trachomatis (C. trachomatis) and is the leading cause of preventable blindness globally. It is a disease rooted in poverty and remains endemic in several low- and middle-income countries, predominantly in the tropics, where determinants of health—including poor hygiene, sanitation, and living conditions—favour disease transmission. This paper aims to critically appraise the public health approaches addressing trachoma, namely implementation of the WHO ‘SAFE’ strategy, with reference to trachoma control in Tanzania.

Methods: Online databases were searched for literature containing relevant keywords. Literature sources included published data, peer-reviewed publications, and relevant grey literature.

Results: The SAFE strategy has been highly effective in reducing the global prevalence of trachoma. However, it has failed to reach its target of global elimination by 2020. Strengths of this approach include the dual focus on preventative and curative aspects of trachoma management and the GET2020 Alliance to aid state implementation. Challenges in trachoma management include the political landscape influencing global health governance and funding, as well as a pressing need for an intersectoral ‘Health in All Policies’ approach to address the social determinants of health perpetuating trachoma transmission.

Conclusions: An integrated, multisectoral approach to trachoma management with NTDs is required to attain increased and sustainable progress across the spectrum of NTDs, reduce the risk of resurgence, and achieve the United Nations Sustainable Development Goals (SDGs). This progress can be achieved only by continuing to address the underlying determinants of health and utilising integrated management programs.

Prevalence of Trachoma in Pakistan: Results of 42 Population-Based Prevalence Surveys from the Global Trachoma Mapping Project

Purpose: Previous phases of trachoma mapping in Pakistan completed baseline surveys in 38 districts. To help guide national trachoma elimination planning, we set out to estimate trachoma prevalence in 43 suspected-endemic evaluation units (EUs) of 15 further districts.

Methods: We planned a population-based trachoma prevalence survey in each EU. Two-stage cluster sampling was employed, using the systems and approaches of the Global Trachoma Mapping Project. In each EU, residents aged ≥1 year living in 30 households in each of 26 villages were invited to be examined by trained, certified trachoma graders. Questionnaires and direct observation were used to evaluate household-level access to water and sanitation.

Results: One EU was not completed due to insecurity. Of the remaining 42, three EUs had trichiasis prevalence estimates in ≥15-year-olds ≥0.2%, and six (different) EUs had prevalence estimates of trachomatous inflammation—follicular (TF) in 1–9-year-olds ≥5%; each EU requires trichiasis and TF prevalence estimates below these thresholds to achieve elimination of trachoma as a public health problem. All six EUs with TF prevalences ≥5% were in Khyber Pakhtunkhwa Province. Household-level access to improved sanitation ranged by EU from 6% to 100%. Household-level access to an improved source of water for face and hand washing ranged by EU from 37% to 100%.

Conclusion: Trachoma was a public health problem in 21% (9/42) of the EUs. Because the current outbreak of extremely drug-resistant typhoid in Pakistan limits domestic use of azithromycin mass drug administration, other interventions against active trachoma should be considered here.

Trachomatous trichiasis and its management in endemic countries

Trichiasis is the sight-threatening consequence of conjunctival scarring in trachoma, the most common infectious cause of blindness worldwide. Trachomatous trichiasis is the result of multiple infections from childhood with Chlamydia trachomatis, which causes recurrent chronic inflammation in the tarsal conjunctiva. This produces conjunctival scarring, entropion, trichiasis, and ultimately blinding corneal opacification. The disease causes painful, usually irreversible sight loss. Over eight million people have trachomatous trichiasis, mostly those living in poor rural communities in 57 endemic countries. The global cost is estimated at US$ 5.3 billion. The WHO recommends surgery as part of the SAFE strategy for controlling the disease.We examine the principles of clinical management, treatment options, and the challenging issues of providing the quantity and quality of surgery that is needed in resource-poor settings.