‘Follow the cattle’: a joint cross-border trachoma MDA perspective

Abstract

Trachoma, a disease caused by Chlamydia trachomatis, is the leading infectious cause of blindness. To fight it, endemic East African countries adopted the World Health Organization’s SAFE Strategy, targeting surgery, antibiotics through mass drug administration (MDA), facial cleanliness and environmental improvement. Trachoma persists among nomadic communities along the Kenya–Uganda and Kenya–Tanzania borders. To address this, Kenya, Tanzania and Uganda launched synchronized MDA campaigns, simultaneously treating populations across borders. Successes included joint planning, community involvement and intergovernmental cooperation, although challenges remained in resourcing MDA cross-border focal points and in addressing coverage and funding. Novel strategies like synchronized joint cross-border MDA with community engagement are vital for sustainable trachoma elimination in these nomadic settings.

Introduction

Trachoma, a neglected tropical disease (NTD) caused by repeated ocular infections with the bacteria Chlamydia trachomatis, stands as the leading infectious cause of blindness.¹ In response, endemic countries have embraced the World Health Organization's (WHO) SAFE Strategy, a recommended approach consisting of surgery for trachomatous trichiasis (TT), antibiotics for treating C. trachomatis infection through mass drug administration (MDA), facial cleanliness and environmental improvement to curb transmission.² MDA is an essential component of the SAFE strategy, aiming to treat entire populations in endemic regions. The WHO outlines the recommended duration of MDA based on the trachomatous infection–follicular (TF) prevalence in children ages 1–9 y. This approach calls for 5 y of MDA, along with facial cleanliness and environmental improvement, in a situation where the TF prevalence is ≥30%, 3 y where TF falls between 10.0% and 29.9% and 1 y where TF is between 5.0% and 9.9%, before re-evaluating TF prevalence.¹ ‘Persistence’ refers to a situation where trachoma prevalence remains above the WHO threshold for elimination even after the recommended rounds of MDA, while ‘recrudescence’ indicates a resurgence of trachoma prevalence above the WHO threshold for elimination, as found in surveillance surveys.²

The elimination of trachoma as a public health problem entails documenting a prevalence of TT <0.2% in adults ≥15 y of age and a prevalence of TF in children 1–9 y of age of<5%, sustained for at least 2 y in the absence of MDA in each previously endemic district. This definition also includes the existence of a system capable of identifying and managing trichiasis cases.¹ Despite significant progress in fighting trachoma in East African countries, challenges persist, evident in the prevalence of the disease among nomadic communities along the Kenya–Uganda border and the Kenya–Tanzania Masai cattle corridors (Figure 1). Due to the need to optimize scarce resources, especially pasture and water, these communities engage in frequent migration, which poses unique obstacles for disease control.³ Fieldwork accounts have highlighted the importance of considering the perspectives of nomadic people to develop effective trachoma elimination strategies. A former animal health worker in Uganda's Kotido District offered valuable insight, humorously noting, ‘Where are the people? Just follow the cattle and try not to get shot.’ This district, situated on the border with Kenya, has historically been trachoma endemic and is also considered one of the country's most insecure areas.

Figure 1.

Map showing Uganda, Kenya and Tanzania TF prevalence among children 1–9 y of age (courtesy of Trachoma Atlas). The map illustrates the regions along the Kenya–Uganda border (Ateker area marked A) and the Kenya–Tanzania border (Masai area marked M) where persistent trachoma remains prevalent.

Trachoma epidemiologic mapping in Uganda identified the disease as endemic in 31 districts⁴; with the recent redistricting efforts, the number of districts previously affected by trachoma increased to 53. Four of the five remaining districts to eliminate trachoma as a public health problem (Moroto, Nakapiripirit, Nabilatuk and Amudat in the Ateker belt) (Figure 1) have persistent or recrudescent TF. The Ateker belt comprises several ethnic groups residing in northwest Kenya, southeast South Sudan, northeast Uganda and southwest Ethiopia.⁵ These groups, including the Jiye, Toposa, Nyangatom, Turkana, Iteso, Karimojong, Jie and Dodoth, share mutually understandable languages, agrarian practices and cultural norms.⁵ The interactions between pastoralists and government officers are often characterized by mistrust, especially as nomadic people residing in border regions may be unaware of national boundaries.

The majority of trachoma-endemic areas in Tanzania and southern Kenya are predominantly inhabited by the Maasai, a pastoral ethnic group.⁶ Due to their regular cross-border movements, the Ateker and Maasai populations pose challenges for trachoma elimination programs.

We focus on Kenya, Tanzania and Uganda, the three countries currently implementing joint cross-border MDAs. Trachoma surveys in Kenya began in 2004 and concluded in March 2012 for all districts suspected to be endemic for trachoma⁷ and interventions have been under way for almost 20 y. Despite these efforts, the persistence and recrudescence of trachoma can still be observed in the Kenyan districts bordering the Ateker belt in Uganda and the Maasai districts in Tanzania. Presently, only seven districts in Tanzania are above the WHO threshold for elimination of TF, five of which are in the Masai corridor, marked by internal district mobility, shifting and external migration across the border to Kenya.

Table 1.

TF among children 1–9 y of age in the Uganda–Kenya border districts

Uganda district	TF category 2023 (%)	Kenya district	TF category 2023 (%)
Moroto	10–29.9	Turkana West	10–29.9
Nabilatuk	10–29.9	Loima	10–29.9
Nakapirirprirt	5–9.9	Kacheliba	10–29.9
Amudat	5–9.9	Kacheliba	10–29.9

Table 2.

TF among children 1–9 y of age in the Kenya–Tanzania border districts

Kenya district	TF category 2023 (%)	Tanzania district	TF category 2023 (%)
Narok	10–29.9	Ngorongoro	10–29.9
Kajiado West	10–29.9	Longido	10–29.9
Kajiado Central	5–9.9	Longido	10–29.9
Kajiado South	5–9.9	Longido	10–29.9

Interventions

The three East African countries of Kenya, Tanzania and Uganda have embraced an approach known as synchronized MDA to jointly combat trachoma in cross-border nomadic populations. Synchronized MDA involves treating the entire population in endemic areas across borders with antibiotics to control C. trachomatis infections during the same treatment period. The synchronized MDA strategy aims to ensure equitable treatment for nomadic communities in Kenya, Tanzania and Uganda by fostering teamwork and effective communication among health professionals in border regions. Collaborative planning sessions led to successful social mobilization, team selection and joint approval from local leaders, enabling the implementation of MDA and TT surgery in April 2019, reaching an additional 40 000 people in eight nomadic border districts with MDA.

The success of the initiative was sustained through synchronized planning, implementation and supervision during subsequent MDAs in 2019 and 2021. Notably, cultural and kraal (cattle camp) leaders played vital roles in ensuring community involvement. Kenya conducted synchronized MDAs in the Turkana and West Pokot districts along the northwest border with Uganda in October 2021 to address the periodic migration of nomadic populations. This synchronized approach aimed to leave no one behind, regardless of their travel patterns, among the frequently unreached cross-border migrant communities residing in Kenya and Uganda. Regular coordination meetings, data sharing and discussions were held to ensure seamless execution of activities across the respective countries.

The Tanzania–Kenya MDA collaboration in July and December of 2022 specifically targeted the nomadic Masai community traversing the shared border between the two countries. Drawing inspiration from the successful Uganda–Kenya model, the partnership involved joint planning, community mobilization, joint supervision and implementation of the MDA program. This collaborative MDA effectively reached approximately one million residents in transborder Maasai communities in just 5 d. By taking this synergistic approach, the two countries overcame the limitations inherent in their previous, isolated interventions. This enabled a more expansive reach across migratory populations residing in trachoma-endemic border regions. The initiative marks a significant departure from isolated efforts, transitioning to a more coordinated, international strategy. As a result, it paves the way for the sustainable elimination of trachoma. This collaboration resulted in successful treatment in nine districts regarded as persistent or recrudescent after the joint implementation effort between Tanzania and Kenya in 2022. Ensuring inclusivity in cross-border contexts required identifying and facilitating cross-border MDA focal points to lead advocacy, planning, execution and oversight. The synchronized approach exemplifies the strength of cross-border collaboration in combating NTDs and ensuring no one is left behind in the fight against trachoma. The collaboration extended to MDA, social mobilization, supervision and data sharing among Masai communities along their shared border, who continue to pose challenges to trachoma elimination. This comprehensive approach presents an effective framework for future cross-border initiatives in tackling NTDs and achieving global health targets.

Lessons learned

Challenge 1: identifying and facilitating cross-border MDA focal points

A critical challenge in cross-border trachoma elimination is the need to identify and facilitate country-level health professionals as focal points to lead MDA initiatives effectively. These focal points play a pivotal role in advocating for cross-border collaboration, jointly planning interventions, overseeing their execution and ensuring no community is left behind. To address this challenge, countries should establish clear and robust selection criteria for these focal points and provide them with comprehensive training and adequate resources to carry out their responsibilities proficiently.

Challenge 2: geographical and therapeutic coverage issues

Uncoordinated cross-border MDA efforts have been shown to perpetuate the spread of NTDs, including trachoma, due to geographical and therapeutic coverage issues.⁸ The lack of synchronized intervention can lead to persistence and recrudescence of trachoma in nomadic populations, further exacerbating the problem. To mitigate this challenge, it is vital to conduct regular physical and virtual coordination meetings, fostering seamless communication and collaboration among the involved countries. These meetings can ensure effective tracking, prediction and timely engagement with nomadic communities, thereby enhancing therapeutic coverage and control measures.

Challenge 3: limited attention and partner limitations

Another significant challenge lies in the limited attention given to cross-border MDAs, often accompanied by partner-imposed limitations on fund transfers, hindering efforts to provide essential services to vulnerable populations. Addressing this challenge requires a paradigm shift in the approach of governments and partners, embracing innovative mechanisms for cross-border cooperation in health. Countries should allocate flexible budgets and proactively mobilize resources to overcome the higher costs associated with accessing and maintaining nomadic settlements. By forging strong partnerships and engaging in open dialogue, governments can collaborate more effectively with partners, ensuring adequate funding and resources for successful cross-border initiatives.

Success 1: flexible budgets and increased resource mobilization

A remarkable success in cross-border trachoma elimination can be observed through this concrete example of flexible budgets and increased resource mobilization. Adequate funding and resources were instrumental in surmounting challenges associated with accessing remote nomadic settings, leading to the implementation of highly effective MDA campaigns. This success can serve as a blueprint for other countries, emphasizing the critical role of financial planning and resource mobilization in achieving successful cross-border health programs.

Success 2: intergovernmental cooperation and communication

Another achievement in the fight against trachoma is the success of regular coordination meetings held before, during and after MDA campaigns. This exemplifies the overriding importance of intergovernmental cooperation. By fostering continuous communication and information sharing between governments involved in transnational trachoma control, countries can forge stronger partnerships, effectively address challenges and sustain long-term cooperation beyond the implementation phase. This success underscores the significance of collaborative efforts and open communication to ensure the triumph of cross-border initiatives in eliminating trachoma and promoting public health on a global scale.

Conclusions

Eliminating trachoma in the Ateker and Masai cattle corridors requires tailored approaches that account for the persistence of the disease within nomadic communities. To ensure sustainable progress in trachoma control, comprehensive strategies should incorporate the perspectives and needs of nomadic pastoralists. Inclusive interventions guided by community engagement, cultural sensitivity and mobile healthcare delivery, can effectively implement the SAFE strategy.

Authors’ contributions:

Gilbert Baayenda: As the corresponding author, Baayenda conceived and designed the study, conducted the research, performed data analysis and interpretation, and wrote the manuscript. He also reviewed and addressed comments, providing final approval of the version to be published. He agrees to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. Raphael Opon: Opon provided valuable data essential for the completion of this research. He offered initial insights and reviewed the manuscript, providing constructive comments for its improvement. He has given approval for the final version of the manuscript to be published. Titus Waititu: Waititu contributed to the acquisition of data and gave significant feedback on the manuscript. He reviewed and approved the final manuscript and agrees to be accountable for the aspects of the work related to the data he provided. George Kabona: Kabona supplied critical data and gave substantial comments to enhance the manuscript's quality. He has reviewed and approved the final manuscript for publication, ensuring his accountability for his contributions to the work.

Funding:

None

Competing interests:

None declared.

Ethical approval:

Not required.

Data availability

The dataset supporting the conclusions of this article is available upon reasonable request. Given the sensitive nature of the data, it is not publicly available to ensure the privacy and confidentiality of the participants. However, non-identifiable data can be provided after approval from the corresponding author, Gilbert Baayenda. All relevant data are within the paper. Any additional information required to reanalyze the data reported in this paper is available from the corresponding author upon reasonable request. All links or identifiers necessary for the understanding of the data have been included in the manuscript as per the journal's guidelines.