Addressing the challenges of reaching trachoma elimination: leveraging on lessons learnt from programme implementation

Implementation of the Surgery, Antibiotic treatment, Face washing, Environmental improvement (SAFE)¹ strategy recommended by the WHO has enabled 18 countries to attain the elimination of trachoma as a public health problem, and many more countries have made substantial progress on this journey. Implementing the SAFE strategy depends on the availability of data on the prevalence of trachomatous inflammation follicular in children aged 1–9 years and trachomatous trichiasis in people aged ≥15 years. It also requires systematic monitoring of mass drug administration coverage, surgery uptake and a range of behaviour change indicators. Challenges arising during programme implementation need to be promptly identified and addressed through operational research synergistically integrated in the programme cycle.

This special supplement of International Health on trachoma shows how operational research evidence and programmatic data have been effectively used to facilitate the progress towards elimination in a variety of contexts. The issue contains nine original research papers and two commentaries detailing evidence and lessons learnt in these needs to be cited to date.

The paper by Gebreselassie et al.² shows how data from trachoma impact surveys undertaken in the Somali Region of Ethiopia, a country with the highest burden of trachoma, were effectively used to monitor elimination targets and guide and adapt programmatic activities.

With the tremendous progress in eliminating active trachoma, the training and certification of field teams to correctly identify cases of trachomatous inflammation follicular (TF) have become challenging. Although we have become victims of our own success, it is important that the diagnosis of trachoma is as accurate as possible, to avoid wasting resources in treating communities that do not require treatment. Several articles in this supplement address this challenge. Two studies by Aguwa and Nayel^3,4 examine the possibility of using photography as an alternative to grading the clinical signs of trachoma in prevalence surveys. Closely linked to this is the increasing use of alternative indicators such as infection testing and serology for Chlamydia antigens and antibodies to confirm the clinical evidence of infection. The paper by Atekem et al.⁵ from Cote D’ Ivoire describes this scenario, showing that clinical signs of TF do not always agree with the presence of chlamydial infection. It is hoped that more guidelines will emerge on the use of alternative indicators to arrive at programmatic decisions on the treatment of trachoma.

The distribution of antibiotics through mass drug administration (MDA) is aimed at treating active infection and reducing transmission. Country programmes ensure that treatment coverage reaches at least 80%, as recommended by the WHO. However, in some settings, communities targeted by MDA are highly mobile and there is a need for innovative ways to ensure that treatment campaigns are able to reach them, and the coverage is optimal. The paper Baayenda and others⁶ draws on lessons from Uganda, Tanzania and Kenya and helps us understand that administrative boundaries are artificial and, if treatment coverages are to be attained, mobile populations need to be reached with alternative or additional strategies.

The benefits of azithromycin beyond trachoma elimination have long been acknowledged and the evidence on the potential use of trachoma treatment platforms for other public health problems is growing. In this supplement, a paper by Wamyil-Mshelia et al.,⁷ from Nigeria, describes how existing community structures deployed for the elimination of trachoma can be effectively used for child survival interventions and achieve good treatment coverage. Innovations to ensure all populations in need of treatment are reached will continue to evolve and the lessons presented here can help facilitate this broader public health learning.

Children form the nidus for transmission of trachoma infection and if elimination is to be attained and sustained, there is a need to reduce transmission in this population group. Facial cleanliness and environmental improvements are essential aspects of the Surgery, Antibiotic treatment, Face washing, Environmental improvement (SAFE) strategy required for achieving this goal. But attaining and maintaining behaviour change can be very difficult. The paper by Caplan et al. from Ethiopia shows how behaviour change activities turned into games help to sustain the interest of children and become catalysts for communities accepting and sustaining such changes.

With elimination of active trachoma as a public health problem, many countries have stopped MDA. That said, there is still considerable work to be done related to trichiasis in trachoma-endemic communities. Trichiasis surgery requires detailed planning, from the training of surgeons to the delivery of the management required and follow-up. Trichiasis is more common in women and trichiasis programmes need to identify and implement effective strategies targeting female patients. In this supplement, Sullivan et al.⁸ have analysed a global dataset and shown that women were slightly more likely to develop postoperative trichiasis and to have rejected repeated surgery compared with men. For people from remote communities to be able to access surgery, surgery must be provided as close to them as possible. Case finders move from house to house to find people suspected to have trichiasis, encouraging them to attend outreach camps, and assist them in reaching these camps for confirmation and management.

To show the elimination of trichiasis, trachoma programmes need to demonstrate a prevalence of trichiasis unknown to the health system of <0.2% in people aged 15 years and above or provide evidence of documented full geographical coverage (DFGC) showing that all residents in all households of endemic communities have been examined and those with trichiasis offered treatment. The paper by Kamuyu et al.⁹ shows that there are as many districts that will need to demonstrate elimination through DFGC as there are that can demonstrate elimination through surveys. This suggests that DFGC should be undertaken carefully and systematically to ensure that trachoma programmes are confident that all persons with trichiasis have been offered treatment. Further, the multicountry paper by Mwangi et al.¹⁰ presents data from Ethiopia, Kenya, Nigeria and Tanzania and shows that house to house case finding needs to be meticulously planned, executed and properly documented; there must be proper supervision of case finders to ensure that all households are reached and that people who do not show up at outreach sites are followed up at their homes, examined and managed. Only such diligent efforts will ensure that no one is left behind and elimination is attained. As surgeries are performed, there is a need to carefully document these surgeries so that patients are properly followed up. The trachomatous trichiasis (TT) tracker is an electronic data capture tool that has been in use in several countries and the article by Bartlett et al.¹¹ highlights the benefits of the tool and how it enhances analysis and the storage of TT surgery data.

As we approach the last mile of trachoma elimination, lessons learnt from the earlier trachoma programmes will be useful in guiding elimination activities going forward. All aspects of the SAFE strategy will need to be fully implemented and we hope that this special issue provides some useful insights and will guide future implementation.

Acknowledgements

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Funding

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Competing interests

CM, KA, MD, MK, GM and ES are Guest Editors of this supplement but had no role in the review of this manuscript.

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