WHO

Eliminating trachoma: WHO announces sustained progress with hundreds of millions of people no longer at risk of infection

27 June 2019 | Maputo | Geneva — The number of people at risk of trachoma – the world’s leading infectious cause of blindness – has fallen from 1.5 billion in 2002 to just over 142 million in 2019, a reduction of 91%, the World Health Organization (WHO) has reported.

It was a BIG year for eliminating neglected tropical diseases (NTDs) as a public health problem in three USAID-supported countries.

Ghana (link is external) and Nepal (link is external) said goodbye to trachoma, the leading infectious cause of blindness.

Lymphatic filariasis (elephantiasis) got kicked to the curb by Vietnam.

WHO

Trachoma elimination: Iranians triumph against the world’s leading infectious cause of blindness

25 September 2018 | Tehran | Cairo | Geneva — The World Health Organization (WHO) has validated the elimination of trachoma as a public health problem in the Islamic Republic of Iran. By achieving this milestone, the country becomes the third in WHO’s Eastern Mediterranean Region, after Oman in 2012 and Morocco in 2016, to overcome this centuries-old disease.

“WHO is pleased to have supported the Islamic Republic of Iran through the validation process,” said Dr Ahmed Al-Mandhari, WHO Regional Director for the Eastern Mediterranean. “But this achievement was made possible by the Government and people of Islamic Republic of Iran, who have worked tirelessly over decades to eliminate trachoma as a cause of preventable blindness and unnecessary suffering.”

 

The long fight

Trachoma was a major cause of visual impairment in Islamic Republic of Iran in the early decades of the 20th century.

In 1959, in rural areas of the district of Malayer, two thirds of the population were affected by the disease. A survey in the Dezful district in 1961 showed that 91% of people were affected, including 62% with the active (inflammatory) form. At that time, prevalence in the capital, Tehran, was estimated to be 30–40%.

In 1972, tetracycline ointment was introduced as an essential medication in the Health facilities of Iran, and was provided free of charge to people who needed it for treatment of active trachoma.

Ophthalmologists were trained during their residency programmes to perform surgical management of trichiasis: the advanced, sight-threatening form of trachoma. Health education campaigns designed jointly by the Ministry of Health and Medical Education and the Ministry of Education, including messages about washing hands and faces, were delivered as part of broad-based hygiene improvement initiatives in preschools and primary schools.

In parallel, the Steering Committee for the National Water Programme — a joint committee of the Ministry of Energy and the Environmental Health Centre of the Ministry of Health and Medical Education — allocated US $500 million to improve water supply and sewerage systems in remote areas.

Edging towards success

In 2004, assessments were undertaken in rural areas of four provinces (Bushehr, Kerman, Hormozgan, and Sistan and Baluchestan) in the south of Islamic Republic of Iran, where trachoma was last recognized as a problem. These surveys showed nearly a complete absence of disease. Active trachoma was only seen in Sistan and Baluchestan, where less than 1% of children were affected by the disease.

In 2012–2013, a population-based prevalence study in rural areas of Sistan and Baluchestan re-estimated the prevalence of trachoma at 0.6% of children.

Appropriate plans were put in place to ensure ongoing provision of services to individuals who might develop complications of trachoma later in life. All criteria for validation of elimination of trachoma as a public health problem¹ have been met.

Trachoma disease

Trachoma, a devastating eye disease caused by infection with the bacterium Chlamydia trachomatis, is spread through contact with infective eye or nose discharges, either directly from person to person, or mediated by flies. Active (inflammatory) trachoma occurs as a result of infection, and is common among preschool-aged children. Women are blinded up to four times as often as men, mainly due to their close contact with infected children.

Transmission is associated with poor sanitation and hygiene, which increase eye discharges and encourage the breeding of flies.

GET 2020

In 1996, WHO launched the WHO Alliance for the Global Elimination of Trachoma by the year 2020 (GET2020). With other partners in the Alliance, WHO supports country implementation of the SAFE strategy and strengthening of national capacity through epidemiological assessment, monitoring, surveillance, project evaluation and resource mobilization.

Interventions to eliminate trachoma are inexpensive, simple and extremely cost effective, yielding a high rate of net economic return.

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¹WHO has now validated elimination of trachoma as a public health problem in the following countries: Cambodia, Ghana, Islamic Republic of Iran, Lao People’s Democratic Republic, Mexico, Morocco, Nepal and Oman.

NYT

“…..The bacterium, Chlamydia trachomatis, can be transmitted from person to person by, for example, sharing a towel. But in rural areas, it is more commonly transmitted by flies that crawl over children’s faces to eat the discharge from runny eyes and noses, and then flit back to human feces to lay their eggs.

Victims are first infected as toddlers, but permanent eye damage takes decades and usually sets in after age 30. To break that chain, the W.H.O. recommends a four-pronged strategy: surgery for advanced cases; annual antibiotic doses for everyone in hard-hit areas; teaching mothers to wash their children’s faces frequently; and use of pit latrines, which reduce fly populations……”

WHO

13 June 2018 ¦ Brazzaville ¦ Accra ¦ Geneva – The World Health Organization (WHO) today congratulated Ghana for having eliminated trachoma as a public health problem, two decades after the World Health Assembly resolved to tackle the leading infectious cause of blindness. The announcement comes the day after a commitment from Pfizer, the manufacturer of Zithromax (azithromycin) to extend their donation programme for the antibiotic until 2025, if required, to finish the task of global trachoma elimination.

“It’s been 20 years since the global health community committed to eliminating trachoma worldwide” said WHO Director-General, Dr Tedros Adhanom Ghebreyesus. “Although there’s more work to do elsewhere, the validation of elimination in Ghana allows another previously heavily-endemic country to celebrate significant success.”
Ghana is the first country in WHO’s African Region to achieve this milestone.

“This success is a result of a tremendous amount of hard work by thousands of health, education and development workers to improve the lives of individuals with trachoma and their families”, said Mr Kwaku Agyemang-Manu, Ghana’s Minister of Health. “The Government of Ghana is enormously grateful to its staff and to the many partners  that have joined forces with us to eliminate trachoma and the cycle of poverty it triggers.”

The global trachoma community learnt a lot from Ghana’s experience. Innovations pioneered there include the use of height-based dosing for azithromycin; systematic active case-searches for trichiasis involving door-to-door, community-by-community fieldwork; and, intensive counselling of patients found to have trichiasis with an offer of immediate surgery, which produced considerable improvement in surgical uptake.

“Success in Ghana is a result of the strong leadership at all levels, implementation of the full SAFE strategy right from the outset, strong collaboration between Ghana Health Service and its many partners, and integration at lower levels of programme delivery, including community ownership,” said Dr Matshidiso Moeti, WHO Regional Director for Africa. “Hearty congratulations are deserved for this achievement.”

Trachoma: Ghana’s story

Trachoma was identified in the 1950s as the most important cause of blindness in Ghana. By the 1990s, the disease was known to persist as a significant public health problem in the Northern and Upper West Regions. There were about 2.8 million people at risk of trachomatous blindness nationally, with an estimated 13 000 people suffering from trichiasis. In 2000, the Ministry of Health and Ghana Health Service set up a national Trachoma Elimination Programme.

Ghana’s Trachoma Elimination Programme implemented the WHO-recommended elimination strategy, SAFE, which comprises Surgery for trichiasis, Antibiotics to clear infection, Facial cleanliness, and Environmental improvement to reduce transmission.

Trichiasis surgery was provided at no cost, a critical Ghana Health Service decision reflecting the socioeconomic disadvantage of people with trichiasis and the impact of the condition on future earning potential.

Azithromycin, donated by Pfizer through the International Trachoma Initiative, was distributed with support from FHI 360 (using funds from the United States Agency for International Development), The Carter Center, Sightsavers and other organizations.

Facial cleanliness was promoted through community events, dramas, the school health education programme, radio messages and radio clubs. Environmental improvement was coordinated by Ghana’s Community Water and Sanitation Agency.

The disease

Trachoma, a devastating eye disease caused by infection with the bacterium Chlamydia trachomatis, is spread through contact with infective eye or nose discharges, either directly from person to person, or mediated by flies. Active (inflammatory) trachoma occurs as a result of infection, and is common among preschool-aged children. Women are blinded up to four times as often as men, mainly due to their close contact with infected children.
Transmission is associated with poor sanitation and hygiene, which increase the availability of eye discharges and encourage the breeding of flies.

GET2020

In 1996, WHO launched the WHO Alliance for the Global Elimination of Trachoma by the year 2020 (GET2020). With other partners in the Alliance, WHO supports country implementation of the SAFE strategy and strengthening of national capacity through epidemiological assessment, monitoring, surveillance, project evaluation and resource mobilization. Elimination of trachoma is inexpensive, simple and extremely cost effective, yielding a high rate of net economic return.

Telegraph

“…….Pfizer has announced it will extend its donations of antibiotics to treat the debilitating eye disease trachoma for five years.

Pfizer initially said its donation of the drug Zithromax would end in 2020, the target for the worldwide elimination of the disease. Now it has said that the drugs will be available until 2025 “to help all endemic countries reach their targets”……”

CDC

Trachoma is an infectious disease of the eye cause by a bacteria called Chlamydia trachomatis. Five hundred forty million people are at risk in 55 countries, and 84 million are already infected. Repeated infections cause the eyelids to turn inward, at which point the eyelashes scrape and permanently scar the cornea. This stage of trachoma infection is called trichiasis and can lead to blindness.

The disease spreads quickly through close personal contact and often is more common in areas where people live close together. Often, whole communities can be affected. For these reasons, trachoma infections are often common in the poorest communities.

Trachoma is particularly common in children who are less than five years of age and in the adults – mainly women – who care for them. In some rural communities, 60 – 90 percent of children are infected.

Trachoma

Trachoma is the world’s leading cause of preventable blindness of infectious origin (1). Caused by the bacterium Chlamydia trachomatis, trachoma is easily spread through direct personal contact, shared towels and cloths, and flies that have come in contact with the eyes or nose of an infected person. If left untreated, repeated trachoma infections can cause severe scarring of the inside of the eyelid and can cause the eyelashes to scratch the cornea (trichiasis). In addition to causing pain, trichiasis permanently damages the cornea and can lead to irreversible blindness. Trachoma, which spreads in areas that lack adequate access to water and sanitation, affects the most marginalized communities in the world (2). Globally, almost 8 million people are visually impaired by trachoma; 500 million are at risk of blindness from the disease throughout 57 endemic countries (1).

The World Health Organization has targeted trachoma for elimination by 2020 through an innovative, multi-faceted public health strategy known as S.A.F.E. (3,4):

• Surgery to correct the advanced, blinding stage of the disease (trichiasis),
• Antibiotics to treat active infection,
• Facial cleanliness and,
• Environmental improvements in the areas of water and sanitation to reduce disease transmission

The comprehensive SAFE strategy combines measures for the treatment of active infection and trichiasis (S&A) with preventive measures to reduce disease transmission (F&E) (5,6). Implementation of the full SAFE strategy in endemic areas increases the effectiveness of trachoma programs. The F and E components of SAFE (7), which reduce disease transmission, are particularly critical to achieving sustainable elimination of trachoma.

The “F” in the SAFE strategy refers to facial cleanliness. Because trachoma is transmitted through close personal contact, it tends to occur in clusters, often infecting entire families and communities. Children, who are more likely to touch their eyes and have unclean faces that attract eye-seeking flies, are especially vulnerable to infection, as are women (8), the traditional caretakers of the home. Therefore, the promotion of good hygiene practices, such as hand washing and the washing of children’s faces at least once a day with water, is a key step in breaking the cycle of trachoma transmission (9).

The “E” in the SAFE strategy refers to environmental change. Improvements in community and household sanitation, such as the provision of household latrines, help control fly populations and breeding grounds. Increased access to water facilitates good hygiene practices and is vital to achieving sustainable elimination of the disease (10). Separation of animal quarters from human living space, as well as safe handling of food and drinking water, are also important environmental measures that affected communities can take within a trachoma control program.

For more information on trachoma, visit:

• CDC – Trachoma fact sheet
• World Health Organization (WHO) – Trachoma
• WHO Alliance for the Global Elimination of Blinding Trachoma (GET 2020)
• International Trachoma Initiative
• The Carter Center – Trachoma
• Vision 2020

For more information on the SAFE strategy, visit:

• Implementing the SAFE Strategy for Trachoma Control (The Carter Center) [PDF – 798 kb]
• The SAFE Strategy: Preventing Trachoma (WHO) [PDF – 2.78 mb]
• SAFE Manuals and Materials (WHO)
• School Health Programs (Helen Keller International)

1. Resnikoff, S., et al. Global data on visual impairment in the year 2002. Bull World Health Organ, 2004. 82(11): p. 844-51.
2. Wright, H.R., A. Turner, and H.R. Taylor. Trachoma and poverty: unnecessary blindness further disadvantages the poorest people in the poorest countries. Clin Exp Optom, 2007. 90(6): p. 422-8.
3. World Health Organization. Alliance for the Global Elimination of Blinding Trachoma by 2020. Report of the 2nd Global Scientific Meeting on Trachoma, Geneva, 25-27 August 2003. (WHO/PBD/GET.03.1). 2003.
4. Mariotti SP, P.A.. The SAFE strategy. Preventing trachoma: a guide for environmental sanitation and improved hygiene . Geneva: WHO, 2001 (WHO/PBD/GET/00.7/rev.1). 2001. Available at: http://www.who.int/blindness/SAFE_en.pdf [PDF – 2.78 mb].
5. West, S.K.. Blinding trachoma: prevention with the safe strategy. Am J Trop Med Hyg, 2003. 69(5 Suppl): p. 18-23.
6. Wright, H.R., A. Turner, and H.R. Taylor. Trachoma. Lancet, 2008. 371(9628): p. 1945-54.
7. Emerson, P.M., et al. Review of the evidence base for the ‘F’ and ‘E’ components of the SAFE strategy for trachoma control. Trop Med Int Health, 2000. 5(8): p. 515-27.
8. Courtright, P. and S.K. West. Contribution of sex-linked biology and gender roles to disparities with trachoma. Emerg Infect Dis, 2004. 10(11): p. 2012-6.
9. Ngondi, J., et al., Associations between Active Trachoma and Community Intervention with Antibiotics, Facial Cleanliness, and Environmental Improvement (A,F,E). PLoS Negl Trop Dis, 2008. 2(4): p. e229.
10. Emerson, P.M. and J. Ngondi, Mass antibiotic treatment alone does not eliminate ocular chlamydial infection. PLoS Negl Trop Dis, 2009. 3(3): p. e394.

WHO

Nepal: first country in South-East Asia validated for eliminating trachoma

21 May 2018 | Kathmandu | New Delhi | Geneva — The World Health Organization (WHO) has validated Nepal for having eliminated trachoma as a public health problem – a milestone, as the country becomes the first in WHO’s South-East Asia Region to defeat the world’s leading infectious cause of blindness.

Trachoma was the second leading cause of preventable blindness in Nepal in the 1980s.

A letter acknowledging validation was presented yesterday to Nepal’s Minister of State for Health and Population Ms Padma Kumari Aryal by the WHO South-East Asia Regional Director Dr Poonam Khetrapal Singh and the WHO Director-General Dr Tedros Adhanom Ghebreyesus in Geneva, Switzerland where the World Health Assembly is taking place.

In 2002, the Government of Nepal stepped up efforts to eliminate the disease with the establishment of a national trachoma programme. From 2002 to 2005, following the implementation of sustained control activities, the prevalence of active (inflammatory) trachoma fell by 40%.

The Government of Nepal, through the Ministry of Water Supply and Sanitation, provided incentives to local communities and districts to build and maintain latrines – measures that were crucial to improving sanitation and reducing disease-carrying flies.

To increase awareness, the national trachoma programme collaborated with the Ministry of Education to include a module on trachoma in the school curriculum.

Approximately 30 000 operations were provided to manage trichiasis, and almost 15 million doses of azithromycin were distributed. Between 2002 and 2014, eye hospitals and dozens of eye centres and clinics with trained staff were established across Nepal.

Azithromycin is donated by the pharmaceutical company Pfizer through the International Trachoma Initiative and was delivered in Nepal by NNJS with support from the United States Agency for International Development-funded ENVISION project, implemented by RTI International.

A series of surveys conducted progressively from 2005 to 2015 showed that active trachoma in children had been brought below the elimination prevalence threshold. Low prevalence was maintained after mass antibiotic treatment was discontinued.

GET 2020

In 1996, WHO launched the WHO Alliance for the Global Elimination of Trachoma by the year 2020 (GET2020). With other partners in the Alliance, WHO supports country implementation of the SAFE strategy (Surgery for trichiasis, Antibiotics to clear infection, Facial cleanliness, and Environmental improvement to limit transmission) and strengthening of national capacity through epidemiological assessment, monitoring, surveillance, project evaluation and resource mobilization.

Elimination of trachoma is inexpensive, simple and highly cost-effective, yielding a high rate of net economic return.

Global progress

In 1998, the World Health Assembly resolved to eliminate trachoma as a public health problem worldwide (WHA 51.11). Since then, significant progress has been made and an increasing number of endemic countries are meeting targets and preparing documentation of national elimination of trachoma as a public health problem.²

In 2014, the WHO South-East Asia Regional Director Dr Poonam Khetrapal Singh identified elimination of neglected tropical diseases as one of the flagship priority programmes. Since then countries in the Region, including Nepal, have been making concerted efforts to eliminate these diseases.

Several criteria are used to assess a country’s claim for having eliminated trachoma as a public health problem. These include:

• less than 5% of children aged 1–9 years have signs of active trachoma (trachomatous inflammation–follicular), which can be treated with antibiotics, in each previously-endemic district;
• less than 0.2% of people aged 15 years and older have trachomatous trichiasis, which requires eyelid surgery, in each previously-endemic district; and
• a health system which can identify and manage new cases of trachomatous trichiasis.

The disease

Trachoma, an eye disease caused by infection with the bacterium Chlamydia trachomatis, is spread through contact with infective eye or nose discharges. Infection is particularly common in young children.

Ocular or nasal discharge can be transmitted directly from person to person, or be mediated by flies which have been in contact with the eyes and noses of infected people. Transmission is associated with poor sanitation and hygiene, which increase the availability of eye discharges and encourage the breeding of flies.

Trachoma puts more than 190 million people at risk of blindness in 41 countries. It is responsible for the blindness or visual impairment of around 1.9 million people worldwide.

STAT

“…Yet one of the most inspiring success stories is perhaps the one most overlooked: the global effort to eliminate neglected tropical diseases, or NTDs.

Much of the recent success stems from a meeting in London on Jan. 30, 2012 ……

NTDs affect nearly 1.5 billion of the poorest and most marginalized people around the world. And while 500,000 people lose their lives to NTDs every year, these diseases are more likely to disable and disfigure than to kill. …….These agonizing conditions keep children from school and adults from work, trapping families and communities in cycles of poverty……

Today, the landscape is dramatically different. In 2015, nearly 1 billion people received NTD treatments — 20 percent more than just two years before. As a result, fewer people are suffering from these diseases than at any point in history. ……Much of this success can be traced to the 2012 meeting in London. There, the World Health Organization, pharmaceutical companies, donors, governments, and non-governmental organizations committed to work together to control and eliminate 10 NTDs. …”