Last summer the World Health Organization confirmed Iraq as the 18th country in the world to eliminate the blinding disease trachoma as a public health problem, just months after Benin and Mali achieved the same goal. Each elimination takes us another step closer to beating this ancient scourge which turns sufferers’ eyelashes inwards causing agony as they scrape against the eye.
Although 1.9m people globally have lost all or part of their sight to trachoma, work to eliminate it is one of the great public health success stories of the 21st century. The number of people at risk has dropped by more than 92% in just one generation (from 1.5 billion in 2002 to 115m people in 2022).
Here are four lessons we’ve learned from trachoma elimination programmes that can be applied to other infectious neglected tropical diseases (NTDs), taken from the recent supplement of International Health Trachoma: Accelerating progress to elimination as a public health problem’ published by the Royal Society of Tropical Medicine and Hygiene.
1. Turning behaviour change into a game
Children are less likely to follow good hygiene practices than adults. They touch their mouths and eyes constantly, helping to spread infections. Meanwhile women are more likely to be exposed to infections through childcare and household responsibilities.
Finding ways to gamify hand and face washing or toilet use for school children has been shown to encourage good hygiene behaviours, when combined with improving access to facilities. We have been trialling this approach as part of the Accelerate programme, a large-scale initiative which is supporting 17 countries to eliminate trachoma, 15 of which hope to achieve this by 2027.
A recent study in Ethiopia, which carries the world’s highest burden of trachoma, saw handwashing after latrine use go up from 10.3% to 59% of schools over nine-months when the availability of handwashing stations with soap and water increased from 13.9% to 78% and teachers were trained to deliver age-appropriate activities encouraging their use. This included story books with activities for the youngest children and, for the oldest, competitive challenges to improve the school environment.
2. We have to cooperate to manage diseases across borders.
Infectious diseases do not respect borders. In East Africa trachoma persists among nomadic communities who move freely between Kenya–Uganda–South Sudan and Kenya–Tanzania and, as a result, may miss out on country specific treatment. Yet if disease is permitted to remain in these pockets, it will potentially re-infect and spread.
To address this, Kenya, Uganda and Tanzania have begun working together to synchronise their trachoma campaigns. This marks a significant departure from previous isolated efforts, which weren’t effective in targeting nomadic populations. The new coordinated, international strategy paves the way for the sustainable elimination of trachoma in these countries.
It is hard to overstate the importance of this collaboration. Other countries targeting disease control and elimination in border areas should watch and learn.
3. Build a culture that uses reliable data
Are you using all the data available to understand what’s happening on the ground? Is that data robust enough to trust? Is it reaching you quickly enough?
In our work on trachoma, we’ve been looking at ways we can improve the speed and quality of data moving within health systems.
The TT Tracker app was developed by Sightsavers and allows surgeons to upload data immediately after each operation for advanced trachoma, feeding directly into the national database (TT stands for trachomatous trichiasis, the advanced stage of trachoma). Having to complete, summarise and consolidate paper surgical records used to be a herculean task and could lead to errors and delays in reporting and loss of records. The app eases the burden of paperwork and supplies the government with fast and accurate data. It helps surgeons to easily identify patients due for follow up, ensuring any post-operative complications are managed. A similar tracker is now being used in several countries to manage hydrocele patients for lymphatic filariasis elimination efforts.
4. Community systems set up for one disease can be used to treat others
Community health workers and volunteers are the cornerstone of trachoma programmes. They are trained to promote, mobilise, monitor and track progress and go door-to-door delivering doses, identifying who might need surgery and making sure that no one is left behind. Without them trachoma elimination would be impossible.
Research in Nigeria shows that these community structures can be successfully repurposed for child survival interventions, with the same teams delivering azithromycin, proven to dramatically reduce infant mortality, to children aged 1 to 11 months.
There are many practical lessons that we can take from years of trachoma programme implementation. If the global community continues to work together, we can go down in history as the generation that not only eliminates trachoma as a public health problem but takes what we’ve learned and uses it to end other diseases.
About the author: Caleb Mpyet is a trachoma specialist, epidemiologist and eye doctor. He is trachoma technical adviser for Sightsavers. Caleb trained as an ophthalmologist at Jos University Teaching Hospital, Nigeria. He is a fellow of the West African College of Surgeons and holds a Master of Science in Public Health for Eye Care from LSHTM, University of London.
Competing interests: None
Handling Editor: Neha Faruqui