Global Health Progress

A. Sam-Abbenyi, M.D. — Director, Programs & Logistics, the International Trachoma Initiative

Trachoma is the world’s leading cause of preventable blindness, affecting 41 million people, mostly women and children, in 56 countries. Ten million people living today have lost some or all of their sight due to trachoma, which is a neglected tropical disease (NTD) and one of the oldest diseases known to man. Trachoma once existed in the United States and Europe, and health inspectors routinely checked for trachoma at Ellis Island in the early 1900s and even turned immigrants away from entry to the U.S. because of the disease.

Today, the developed world has little memory of trachoma—but the disease is a public health threat in the developing world, especially in tropical countries in Africa and Asia where access to health care, clean water and sanitation is limited or lacking.

The SAFE Strategy

In 1998, in response to the World Health Organization’s call to eliminate trachoma by the year 2020 (the “GET 2020” goal), the International Trachoma Initiative (ITI) was founded by Pfizer Inc and the Edna McConnell Clark Foundation. At that time, ITI and its partners in trachoma control, including national governments and nongovernmental organizations, began implementing the WHO-recommended SAFE strategy for the elimination of blinding trachoma in countries where the disease is endemic. SAFE is an acronym for the comprehensive strategy which combines treatment with public health education and environmental improvements:

• Surgery to correct in-turned eyelids – the condition is known as trachomatous trichiasis, which occurs after being infected over and over with trachoma, and which causes blindness as the eyelash scratches the cornea;
• Antibiotics—including Pfizer-donated Zithromax—to treat the reservoir of Chlamydia trachomatis, the bacterium causing trachoma;
• Facial cleanliness to prevent the spread of infection; and
• Environmental improvements to sustain the prevention of trachoma.

Measuring the Impact of SAFE

The good news is that SAFE works: in the past five years the global estimate of people with active trachoma has decreased from 84 million in 2002 to 41 million in 2008 (although part of that reduction is also attributable to an improved methodology to estimate the burden of disease). Morocco became the first country to declare having reached the ultimate intervention goals for SAFE and has now applied for certification of the elimination of blindness due to trachoma. In addition, a number of countries are on-track to eliminate trachoma ahead of the GET 2020 goal, and some—including Ghana, The Gambia, Mauritania and Vietnam—are on track for a 2010 elimination goal.

So how is the impact of the SAFE strategy measured?

Countries with national trachoma control programs measure the reduction in disease burden by taking an assessment at the mid-point of their multi-year (five- or six-year) national trachoma control strategic plans. These assessments, called “Mid-term Reviews,” or MTRs, have three main objectives: (1) to assess at the district level the extent to which strategic plan objectives have been attained (the district is a unit of SAFE strategy intervention—here we think locally, versus nationally); (2) to determine the level of integration and sustainability of the national trachoma control program (NTCP); and (3) to assess constraints and barriers met in the implementation of the plan.

Some MTR results have shown that NTCPs have achieved greater expansion of SAFE strategy implementation than initially planned. In other words, more trachoma-endemic districts benefited from the NTCP. This could be attributed to increased ownership of the NTCP at the district level, whereby district health management teams have considered trachoma among top-ten causes of morbidity, and have thus budgeted for SAFE strategy interventions and increased participation and coordination with stakeholders.

Another factor positively influencing further geographic expansion of the NTCPs can be attributed to integrated programming for the control of other NTDs. For example, a recent expansion of the programs in Niger and Mali, as evidenced by their MTR results, could be attributed to funds from USAID for integration of mass drug administration (MDA) for the control of trachoma and other NTDs, such as lymphatic filariasis.

Reaching the GET 2020 Goal: Concerns?

The success of the SAFE strategy is clear. But it’s also clear that we must keep our eyes trained on what’s needed to reach the GET 2020 goal. One important concern is the lack of funding for surgery to correct trachomatous trichiasis (TT), the blinding complication of trachoma (as mentioned earlier, surgery is the ‘S’ component of SAFE). While over 350,000 sight-saving surgeries have already been carried out in trachoma-endemic countries, the number of TT surgeries being performed has been in constant decline in four of the six countries where an MTR has recently been undertaken.

We cannot afford to allow a backlog of TT surgeries to retard the achievement of elimination of blindness due to trachoma. This important issue needs real attention. Concerted and organized efforts to mobilize funds for TT surgeries will be necessary.

Moreover, there is a lack of quality data on facial cleanliness and environmental improvement that could measure change with respect to baseline. Since the WHO recommends conducting an impact trachoma prevalence survey after three years of annual Zithromax MDA, it would be most appropriate to budget for collecting data on variables measuring the ‘F’ and ‘E’ components of SAFE, as well.

Reaching the goal of elimination of trachoma is not only achievable, it is in sight. Through continued strong partnership and mobilizing adequate resources to the NTCPs for full SAFE strategy implementation, trachoma will one day no longer be a public health threat.

Since joining ITI in August 2003, Dr. Abbenyi has worked in 10 countries to develop and implement national trachoma strategic plans, motivate key partners in implementing the SAFE strategy and monitor program progress.