National progress towards the elimination of trachomatous inflammation-follicular: analysis of 11 regions in Ethiopia

Abstract

Background

Trachoma is a public health problem worldwide, particularly in Ethiopia, where it contributes to one half of the global burden. Therefore, the aim of this study was to evaluate the progress made toward attaining the TF elimination threshold in Ethiopia.

Methods

This was a retrospective analysis of survey and trachoma elimination monitoring data from 2003 to 2023. In this study, researchers considered implementation units (IUs) that conducted at least one trachoma impact survey and that had received at least one round of mass drug administration were included in the analysis.

Results

In 2023, a total of 85 IUs reported a prevalence among children aged 1–9 years >30%, whereas 284 IUs fell within the 10–29.9% range. Following intervention efforts, 36.1% [95% CI: 32.9 to 39.4%] of the IUs achieved the WHO elimination threshold, defined as a TF prevalence <5% among children aged 1–9 years. In addition, the national mean TF prevalence decreased from 26.0% in 2014/2015 to 10.8% in 2023.

Conclusions

Ethiopia is unlikely to eliminate national trachoma as a public health problem by 2027. This finding underscores the urgent need for context specific interventions to tackle the challenges faced in persistent and recrudescent districts.

Introduction

Globally, trachoma is a public health problem in 42 countries and is caused by repeated infections that may lead to blindness or visual impairment in nearly 2 million individuals.¹ Trachoma is one of the 20 neglected tropical diseases (NTDs) identified for elimination by the WHO as a leading cause of infectious blindness globally.²

In addition, in 1998, the World Health Assembly adopted resolution WHA51.11, which aimed to eliminate trachoma as a public health problem on a global scale by 2020.³ Furthermore, in 2020, the World Health Assembly endorsed a new target, the Sustainable Development Goals, for eliminating NTDs, including trachoma, through road maps from 2021 to 2030.² In line with the WHO road map 2021–2030, the government of Ethiopia endorsed and implemented a 5-y national strategic plan for NTD elimination, including trachoma, as a public health problem by 2030.⁴ While progress is evident, the WHO estimated that approximately 115.7 million people lived in the 1119 implementation units (IUs) in which the active trachoma prevalence in children aged 1–9 y was ≥5% in 2023.⁵

Despite the implementation of the WHO-recommended surgery, antibiotic administration, facial cleanliness and environmental improvement (SAFE) strategy for more than a decade, Ethiopia bears the largest burden of trachoma globally.⁵ Since the inception of the Tropical Data system in 2016, the trachoma community has conducted >3373 trachoma surveys across 50 countries worldwide.⁶ Given the availability of massive amounts of data, several subregional studies have been conducted and reported. Most of those studies have reported significant progress being made over the years.^7–9 Nevertheless, recent evidence has highlighted socioecological and treatment-related barriers contributing to slower progress.¹⁰ In Ethiopia, some district-level surveys have reported trachomatous inflammation-follicular (TF) estimates; for example, a study on trachoma-elimination progress based on 152 surveys conducted in the Amhara region revealed that TF prevalence among children aged 1–9 y was 25.9%.¹¹

Similarly, a study conducted in Oromia to evaluate TF status after the implementation of trachoma-elimination interventions across 139 districts revealed that the prevalence of TF among children aged 1–9 y ranged from 0.15% to 37.5%.¹² In Afars, the TF prevalence was 17.1%.¹³ In addition, evidence from 52 districts of the Southern Nations, Nationalities and People’s Region (SNNPR) and the study from the Sidama region indicated that the TF prevalence ranged from 1.95% to 25.43%.¹⁴

In Ethiopia, 886 IUs were identified as endemic for trachoma in the baseline survey. District-level prevalence estimates revealed that the prevalence of active trachoma cases exceeded the elimination threshold, which was approximately 13% in 2020. However, during the same period, the prevalence of trachomatous triachasis among adults aged ≥15 y significantly declined, dropping from 4% to <1%.⁴

In Ethiopia, although extensive programmatic data on trachoma have been documented over several decades, analysis of trachoma and its reporting remain limited. Strengthening the use of monitoring and documentation is therefore critical for informing strategic decision-making. This study aims to evaluate progress towards active trachoma elimination as a public health problem by region and geographical context, offering a programmatic lens on achievements and gaps. The findings will guide future policy and programming while also highlighting regional and subregional disparities that require tailored interventions.

Methods and materials

Study settings

Ethiopia is located in the northeastern part of Africa, which is also known as the Horn of Africa. It is bordered by Sudan and South Sudan to the west, Eritrea to the north and Djibouti to the northeast, Somalia to the east and southeast and by Kenya to the south. Ethiopia lies between the Equator and the Tropic of Cancer (lat 30–150°N and long 330–480°E). It is the second most populous country in Africa after Nigeria. The country is administratively divided into 12 regional states and two city administrations. The regional states consist of Afar, Tigray, Amhara, Benishangul-Gumuz, Gambella, Harari, Oromia, Sidama, Somali, Southwest Ethiopia, Central Ethiopia and South Ethiopia. The city administrations are Addis Ababa and Dire Dawa (Figure 1).

Figure 1.

Map of Ethiopia by region and city administration.

Study design and period

Retrospective cohort analysis of regional trachoma data was conducted from 1 December 2023 to 30 January 2024.

Data collection tools and procedure

The Global Trachoma Mapping Project (GTMP) is a well-recognized survey system for trachoma.¹⁵ The Tropical Data system provides a standardized survey monitoring approach that follows WHO-recommended protocols and supports Ministries of Health in conducting surveys. These include baseline mapping, impact surveys and surveillance surveys, which use cluster sampling, field validation and Open data kit (ODK) on smartphones to collect high-quality data. Such data are essential for monitoring the effectiveness of mass drug administration (MDA) programs.^16,17

In this study, we used structured ODK (ODK was developed original by University of Washington/open data kit community, Seattle, Washington, USA) questionnaires to extract data from the Tropical Data system. We included impact and surveillance survey data from trachoma-endemic IUs spanning 2003–2023, with baseline survey data used for comparison. Ethical clearance was not needed, as the study did not involve direct data collection from human subjects; however, data-sharing protocols were strictly followed.

The data sources for this study included the Trachoma Elimination Monitoring Format (TEMF), a standardized framework developed by the WHO to assess whether previously endemic districts or regions have met the criteria for trachoma elimination as a public health problem. Additionally, data were extracted from the Expanded Special Project for Elimination of Neglected Tropical Diseases (ESPEN) portal. The key variables included current TF status, impact and surveillance survey results, MDA rounds, target population, treated population and IUs where MDA was conducted.

Operational definitions

Trachoma elimination is defined as a public health problem when the prevalence of TF remains <5% for at least 2 consecutive years without mass antibiotic treatment in children aged 1–9 y.¹⁸

According to the simplified trachoma-grading system of the WHO, TF is defined as the presence of ≥5 follicles in the upper tarsal conjunctiva.^19–21

Persistent Trachoma: defined as sustained presence of TF prevalence ≥5% among children in the age group of 1–9 years despite continues application of SAFE interventions including several rounds of MDA.^10,22

Recrudescent Trachoma: defined as at least one surveillance survey recording of EUs on TF prevalence ≥5% among children in the age range of 1–9 years which had met the WHO threshold previously.^10,22

Data management and analysis

Our study focused on TF prevalence among children aged 1–9 y at the IU level, comparing baseline data with the most recent regional TF prevalence for IUs that had undergone at least one trachoma impact survey. We also considered the antibiotic administration component (‘A’) of the SAFE strategy, highlighting the number of known-endemic IUs and those that received regular MDA to demonstrate programmatic progress. A spatial temporal map was developed to visualize the distribution of endemic IUs at baseline and their most recent TF status across Ethiopia.

To demonstrate progress, graphs illustrating the number of trachoma survey results above and below the elimination threshold across regions were generated. Data were extracted via Excel and analyzed descriptively for means, frequencies and proportions via SPSS. Additionally, ArcGIS Desktop version 10.8 was used to develop a map of the study area, showing the baseline and current TF status to visualize spatial and temporal trends.

Results

TF prevalence status

In Ethiopia, 886 IUs were found to be endemic following trachoma baseline surveys carried out by implementing partners in Amhara, Oromia and the SNNPR before 2013, and by the GTMP in 2014/2015 across seven regions suspected of being endemic, except for Amhara (Table 1). However, as of December 2023, this number decreased from 886 to 566 endemic IUs. Fortunately, after aggressive SAFE implementation, 320 (36.1%; 95% CI: 32.9 to 39.4%) of the IUs achieved the WHO elimination threshold, consisting of a TF prevalence of <5%, both in the trachoma impact survey (TIS) and the trachoma surveillance survey, in children aged 1–9 year who had stopped MDA. However, 197 (22.2%; 95% CI: 19.5 to 25.1%) of the IUs had a TF status of 5–9%, 284 (32.05%; 95% CI: 28.9 to 35.2%) of the IUs had a TF status of 10–29.9% and 85 (9.6%; 95% CI: 7.7 to 11.7%) of the IUs had a TF >30%, which is severe and would require multiple rounds of MDA, enhanced facial cleanliness and environmental improvement interventions.

Table 1.

Current TF1–9 categories in 11 regions of Ethiopia (2023)

Region	No. of ever-endemic IUs (TF1-9 y>5%, n=886)	No. of IUs with TF1-9 y<5% at BL (n=74)	No. of IUs with TF1-9 y<5% after intervention (n=320)	No. of IUs with TF1-9 y 5–9.9% (n=197)	No. of IUs with TF1-9 y 10–29.9% (n=284)	No. of IUs with TF1-9 y>30% (n=85)	Current no. of IUs with TF1-9 y>5% (n=566)	% of districts with TF1-9 y<5%
Afar	22	10	15	6	1	0	7	68.2
Amhara	166	0	58	18	72	18	108	34.9
BG	15	11	13	2	0	0	2	86.7
CER	59	2	12	9	30	8	47	20.3
Gambella	20	0	4	3	13	0	16	20.0
Oromia	292	21	88	81	76	47	204	30.1
SER	83	0	36	20	27	0	47	43.4
Sidama	35	0	11	15	9	0	24	31.4
Somali	60	30	46	6	7	1	14	76.7
SWER	52	0	15	25	11	1	37	28.8
Tigray	82	0	22	12	38	10	60	26.8
Total	886	74	320	197	284	85	566	36.1

BG: Benishangul-Gumuz; BL: baseline; CER: Central Ethiopia Region; IU: implementation unit; SER: Southern Ethiopia Region; SWER: South West Ethiopia Region; TF1–9: Trachomatous inflammation follicular in the age group of 1–9 year.

Figure 2 shows significant progress towards trachoma elimination, as the average prevalence of TF in children aged 1–9 y decreased from 26.0% in 2014/2015 to 10.8% in 2023. Amhara substantially reduced the regional mean TF (1–9 y) prevalence from 33.9 at baseline (BL TF mean) to the recent 13.9 TF mean prevalence, and the Southern Ethiopian region presented a decrease in the mean TF among children aged 1–9 y from 28.3 BL mean to 7.7 in the recent TF mean prevalence, reflecting an overall reduction of 62.5% (95% CI: 40.6 to 81.2%) from the national baseline burden. In addition, in Figure 3, map ‘A’ shows a high burden of TF prevalence at baseline, while map ‘B’ shows a significant reduction in TF1–9 y prevalence in the most recent trachoma surveys, where the majority of the IUs are green (<5%) (Figure 3).

Figure 2.

TF reduction by region at BL (2014/2025) and recently (2023). BG: Benishangul-Gumuz; BL: baseline; CER: Central Ethiopia Region; SER: Southern Ethiopia Region; SWER: South West Ethiopia Region; TF: trachomatous inflammation-follicular.

Figure 3.

Baseline and current survey TF status at the district level. (A) Baseline TF status. (B) Current TF prevalence status. SNNPR: Southern Nations, Nationalities and People’s Region; TF: trachomatous inflammation-follicular.

Community-based MDA

Historically, in Ethiopia, community-based trachoma MDA was initiated by 2003 in three IUs, namely, Enemore Ener, Ebinat and Artuna Furse. During the initial MDA campaign, Zithromax (an antibiotic) was distributed to 291 932 individuals. Surprisingly, the number of IUs where MDA was conducted dramatically increased from these three IUs to 629 IUs by 2016, indicating that 51 339 682 individuals were treated with MDA antibiotics. However, the number of IUs where MDA was conducted decreased from 2020 to 2023. Possible reasons for the decrease in MDA distribution include the coronavirus disease 2019 (COVID-19) pandemic and the shortage of Zithromax supplies at the national level; also, some IUs stopped MDA after achieving the TF1–9 y elimination threshold of <5% (Figure 4).

Figure 4.

Historical MDA at the national level in Ethiopia (2023). MDA: mass drug administration.

Persistence in IUs at the regional level in Ethiopia

According to the TEMF report of 2023, nationally, 207 (36.6%; 95% CI: 32.6 to 40.7%) IUs had persistent trachoma and had not yet achieved the WHO threshold after completing the recommended annual rounds of MDA followed by two successive TISs. Table 2 shows that the Amhara region had a high degree of persistent trachoma (95; 87.9% [95% CI: 80.3 to 93.4%]), followed by the Sidama region (15; [62.5%; 95% CI: 40.6 to 81.2%), the Central Ethiopia Region (23; 48.9% [95% CI: 34.0 to 63.9%]) and the Oromia region (46; 22.5% [95% CI: 17.0 to 28.9%]).

Table 2.

Number of persistent districts at the regional level in Ethiopia, 2023

Persistent IUs
Region	Current no. of endemic IUs	Current no. of IUs with TF1–9 of 5–9.9%	Current no. of IUs with TF1–9 of 10–29.9%	Current no. of IUs with TF1–9 of ≥30%	Total no. of persistent IUs	% persistent (from endemic)
Afar	7	1	0	0	1	14.3
Amhara	108	9	68	18	95	88.0
BG	2	0	0	0	0	0.0
CER	47	2	21	0	23	48.9
Gambella	16	0	1	0	1	6.3
Oromia	204	27	19	0	46	22.5
SER	47	3	14	0	17	36.2
Sidama	24	11	4	0	15	62.5
Somalia	14	2	0	0	2	14.3
SWER	37	0	0	0	0	0.0
Tigray	60	7	0	0	7	11.7
National	566	62	127	18	207	36.6

BG: Benishangul-Gumuz; CER: Central Ethiopia Region; IU: implementation unit; SER: Southern Ethiopia Region; SWER: South West Ethiopia Region; TF1–9: Trachomatous inflammation follicular in the age group of 1–9 year.

Trachoma recrudescence in Ethiopia

Recrudescent IUs are those that initially achieved the WHO elimination threshold of TF<5% during the final TIS, but subsequently had a TF prevalence of ≥5% in follow-up surveillance 2 y later.

Nationally, 85 (15%; 95% CI: 12.2 to 18.2%) IUs experienced recrudescence. Regional disparities were evident: the Southern Ethiopian Region had 27 (57.4%; 95% CI: 42.2 to 71.7%) IUs, which is the highest recrudescence rate; Oromia had 27 (13.2%; 95% CI: 8.9 to 18.7%) IUs and Amhara had 13 (12%; 95% CI: 6.6 to 19.7%) IUs. Among recrudescent IUs, 25 exhibited moderate-to-high TF prevalence (10–29.9%) in children aged 1–9 y at the national level, whereas the Southern Ethiopia Region (13 IUs) and Oromia (6 IUs) were categorized in similar categories. These findings highlight critical gaps in sustaining the trachoma-elimination threshold, particularly in Amhara, Oromia, Southern Ethiopia Region and other regions. Therefore, this study underscores the need for context-based interventions and innovative approaches to address end-game challenges (Table 3).

Table 3.

Number of recrudescent woredas at the regional level in Ethiopia, 2023

Recrudescent districts
Region	Current no. of endemic IUs	Current no. of IUs with TF1–9 of 5–9.9%	Current no. of IUs with TF1–9 of 10–29.9%	Current no. of IUs with TF1–9 of ≥30%	Total no. of recrudescent IUs	% of recrudescent (from endemic)
Afar	7	0	0	0	0	0.0
Amhara	108	9	4	0	13	12.0
BG	2	0	0	0	0	0.0
CER	47	7	0	0	7	14.9
Gambella	16	1	0	0	1	6.3
Oromia	204	21	6	0	27	13.2
SER	47	14	13	0	27	57.4
Sidama	24	1	0	0	1	4.2
Somalia	14	2	2	0	4	28.6
SWER	37	5	0	0	5	13.5
Tigray	60	0	0	0	0	0.0
National	566	60	25	0	85	15.0

BG: Benishangul-Gumuz; CER: Central Ethiopia Region; IU: implementation unit; SER: Southern Ethiopia Region; SWER: South West Ethiopia Region; TF1–9: Trachomatous inflammation follicular in the age group of 1–9 year.

Discussion

In this retrospective cohort study, we evaluated national progress towards the elimination of active trachoma among 11 regions in Ethiopia. In Ethiopia, 886 IUs were found to be endemic following trachoma baseline mapping; however, this number decreased from 886 to 566 endemic IUs by December 2023. Surprisingly, after aggressive SAFE implementation, 36.1% (95% CI: 32.9 to 39.4%) of the IUs achieved the WHO elimination threshold, with TF<5% in children aged 1–9 y, and stopped MDA. This finding is comparable with those of existing studies from Nigeria⁹ and Kenya.^23–25 However, progress is slow, despite the multiple annual rounds of antibiotic treatment recommended by the WHO to achieve elimination targets.^7,26 Possible reasons for this could be the heavy TF burden at baseline, the interruption of MDA due to a shortage of Zithromax at the manufacturer, local conflicts, persistent insecurity and COVID-19, which negatively affected the implementation of the trachoma program. In addition, inadequate materialization of the facial cleanliness (‘F’) and environmental improvement (‘E’) components of the SAFE strategy could be a critical barrier to trachoma elimination as a public health problem in the country. Six percent of households (HHs) in Ethiopia use an improved and not shared toilet or latrine facility. While, half of HHs in urban areas (50 percent) use an unimproved toilet facility. Moreover, limited access to clean water persists, undermining efforts to sustainably eliminate trachoma as a public health problem.²⁷

A recent study revealed that a significant number of IUs had high TF prevalence, with 5–9.9% (n=197), 10–29.9% (n=284) and >30% (n=85) of those aged 1–9 y; overall, 63.8% (95% CI: 60.6 to 67.0%) of the IUs had TF levels >5% in the 1–9 y age group. This evidence is consistent with the recent WHO weekly epidemiological record that Ethiopia bears the highest burden of trachoma, accounting for 55% of the global burden.^28,29 An existing study on longitudinal trends in TF prevalence in the Amhara region revealed similar scenarios in terms of baseline and current TF burdens.³⁰ By contrast, a previous trachoma study reported a low incidence of TF.³¹ These findings require the consideration of policymakers and trachoma program managers to design and implement tailored innovative and enhanced interventions, such as context-based trachoma MDA microplanning, as well as GPS in the field during the MDA campaign, which would ensure that azithromycin treatment reaches target groups. Moreover, training for local elders and youth as champions to lead houses in terms of sanitation, hygiene education and facial cleanliness should be provided. In addition, strong implementation of sanitation, water and hygiene (WASH) interventions could accelerate the elimination of trachoma.

Surprisingly, the number of IUs where MDA was conducted dramatically increased from three to 629 by 2016, indicating that 51 339 682 people were treated through MDA. Unfortunately, the number of IUs where MDA was conducted decreased from 2020 to 2023. During this period, the cumulative 4-y performance of trachoma MDAs was only slightly greater than one-half of the planned geographic and treatment coverage. A study from Ethiopia revealed that the mean antibiotic treatment coverage was 90%.³² A study from the Gambella region, Ethiopia, demonstrated that, after the survey, IUs needed additional rounds of MDA.³³ A study conducted in the Solomon Islands revealed a 40% reduction in trachoma infection after azithromycin (MDA) treatment for trachoma elimination.³⁴ Similarly, another study confirmed that the distribution of even one MDA round significantly reduces active trachoma-TF1–9 years.³⁵ In addition, the current evidence on the distribution of community-based MDA has demonstrated that various factors affect children’s participation in subsequent rounds of MDA treatment.³⁶ The possible reasons for low MDA coverage were security challenges, the COVID-19 pandemic and delays in baseline mapping of IUs in almost all of the regions until 2013, with the exception of the Amhara region. Therefore, the ability of MDA to prevent trachoma needs more attention to meet the national NTD elimination target by 2030.

Despite the implementation of the trachoma program for two decades in the country, a significant proportion (36.6%; 95% CI: 32.6 to 40.7%) of the IUs displayed persistent trachoma and had not yet reached the WHO elimination thresholds after completing the recommended annual rounds of MDA. This evidence is comparable with the findings of a study from the Amhara region, which demonstrated that seven IUs were persistently endemic for trachoma, and their TF prevalence ranged from 11.8% (95% CI: 7.6 to 16.0%) to 36.1% (95% CI: 27.4 to 44.3%), while the trachoma infection prevalence was between 2.7% and 34.4%.³⁷ Even with the implementation of the SAFE strategy, TF is >5% in southern Ethiopia, and persistent trachoma is characterized by a population segment with substandard treatment and inadequate sanitation and hygiene practices.¹⁰ Similar challenges in persistent and recrudescent trachoma have been faced in West Africa.³⁸ In addition, at an informal WHO meeting on end-game problems for trachoma elimination, prioritizing high-quality delivery of agreed-upon A, F and E interventions across all geographical and demographic diversities was proposed.³⁹ The ability to achieve the planned elimination targets by 2030 is a pressing challenge. The possible reasons for this could be inadequate implementation of face washing, hygiene and environmental sanitation, as well as suboptimal MDAs hindering achievement of the trachoma-elimination thresholds. Furthermore, despite receiving multiple rounds of MDA treatment for many years, the slow pace of progress towards achieving the WHO elimination targets continues to challenge the national trachoma program. In Ethiopia, a significant number of recrudescent IUs that conducted a TIS after completing the recommended annual rounds of MDA achieved the TF elimination threshold (TF<5%) and then stopped MDA for 2 y, after which surveillance surveys were conducted. The results of the surveillance survey indicated that TF prevalence decreased, but remained >5% among the 1–9 years age groups. Unfortunately, at the national level, 15% (95% CI: 12.2 to 18.2%) of IUs experienced recrudescent trachoma and needed additional rounds of MDA interventions. A study conducted in Ghana demonstrated that a trachoma surveillance survey for recrudescence is necessary both before and after validation, but evidence-based recommendations are essential to address this challenge.⁴⁰ Similarly, the available data have demonstrated that there are causes of persistent and recrudescent TF that require attention, including close monitoring and the restart of MDA. Low household water and sanitation data were identified as factors that are likely to contribute to the ongoing transmission of trachoma in this environment.⁴¹ Moreover, a study conducted on the global progress of trachoma indicated that, 2 y after achieving a TF_1–9 prevalence of <5%, IUs maintained this target; however, 56.3% of IUs in Ethiopia exhibited recrudescence.⁴² Furthermore, evidence from a systematic review has shown that the application of geospatial techniques in trachoma research is important but limited; nevertheless, it has the potential to identify disease hotspots and regions susceptible to recrudescence, thereby guiding local, national and global programming requirements.⁴³ Another systematic review suggested that, if MDA is stopped after the survey, ocular chlamydia infection might be a more accurate indicator of trachoma recrudescence in communities rather than TF in clinical grading.^44,45

Therefore, researchers recommend the use of alternative indicators, such as serology and Polymerase chain reaction (PCR), to improve the confirmation of trachoma infection, particularly in districts with recrudescent and persistent trachoma. Unlike traditional methods that rely on the clinical grading of TF, these methods have recently gained attention as more reliable tools. Current evidence suggests that serological testing, which involves collecting dried blood spot samples from children aged 1–9 y, can detect antibodies against Chlamydia trachomatis and thus indicate past exposure. By contrast, PCR testing requires ocular swabs to detect C. trachomatis, providing evidence of an active infection. In particular, PCR is regarded as more objective and precise than clinical grading.^46–48 The ability of Chlamydia trachomatis to detect current trachoma infection, even the clinical signs of TF, is more apparent. Therefore, it is helpful to detect asymptomatic trachoma infection. In addition, it is an alternative indicator rather than a replacement for a clinical survey.

The Ministry of Health (MOH) in Ethiopia has renewed its dedication to fast-tracking the application of the SAFE strategy and has collaborated closely with implementing partners in the mobilization of funds for scaled-up initiatives towards trachoma elimination as a public health problem. Since 2014/2015, substantial investments and efforts have been made towards increasing the availability of MDA, and treatment for trichiasis, particularly urgency, has focused on enhancing service delivery in an integrated, contextually relevant manner. The WHO reviews have time and again testified to Ethiopia’s unwavering commitment towards trachoma elimination as a public health concern.⁵ Similarly, in West Africa, particularly Cameroon and Niger, governments are exerting efforts to address persistent and recrudescent trachoma in national programs, which remain committed to addressing these issues and assisting countries in eliminating trachoma as a public health problem.³⁸

Implications for practice, policy and research

In this study, we evaluated national progress towards the elimination of active trachoma among 11 regions in Ethiopia. These findings have important implications for practice, policy and research. The detailed implications follow below.

Tailored intervention, such as general MDA with enhanced child MDA, along with strong hygiene practices, environmental improvements, behavioral change communication and community engagement, is needed for persistent and recrudescent districts.

Eliminating trachoma as a public health problem requires long-term, context-specific efforts from high-ranking officials, government delegates and stakeholders.

The current findings revealed 89 recrudescent and 207 persistent IUs despite multiple rounds of MDA treatment; thus, an understanding of the drivers of ongoing transmission is needed. Furthermore, addressing these problems underscores that future research should focus on (i) developing predictive models to identify risk factors; (ii) elucidating the genetic mechanisms of reinfection; and (iii) implementing robust evaluations of MDA effectiveness and delivery strategy performance.

The findings indicate that 85 IUs with TF prevalence rates of >30% and 284 IUs with prevalence between 10% and 29.9% were hotspots. To address this, tailored MDA strategies for both community-wide and enhanced MDA in children should be implemented. These must be coupled with intensified integration of WASH and antibiotic distribution. Finally, eliminating trachoma as a public health problem requires that the MOH, donors and partners practice data-driven approaches to make decisions to prioritize fund and resource allocation.

Strengths and limitations

This study aimed to analyze the progress of national trachoma with large datasets with technical experts. However, this study has a retrospective study design and incomplete F and E data for some regions. In addition, these data did not reveal the factors that affect the progression of trachoma elimination.

Conclusion

At the national level, the elimination of trachoma as a public health problem by 2027 will not be attainable, and Ethiopia has achieved remarkable progress in the elimination of trachoma through community engagement and partnerships.

However, the country now faces the critical ‘last-mile’ challenge: addressing residual cases, preventing recrudescence and tackling persistent transmission of trachoma.

To sustain elimination, Ethiopia must prioritize four key areas: (i) innovative service delivery models tailored to hard-to-reach populations; (ii) investing in the minimum package for WASH (F and E), which consists of important elements of hygiene and sanitation, leadership and Social and Behaviorial change communication (health promotion, community mobilization, advocacy); (iii) considering intensified community engagement to ensure lasting behavioral change; and (iv) continuing investment in intensified child MDA to benefit the country in the elimination of trachoma.

Author contributions

Tsegaye Alemu (Conceptualization [lead], Data curation [lead], Formal Analysis [lead], Funding acquisition [equal], Investigation [lead], Methodology [lead], Project administration [lead], Resources [equal], Software [lead], Supervision [equal], Validation [equal], Visualization [lead], Writing—original draft [lead], Writing—review & editing [lead]), Fikre Seife (Conceptualization [equal], Data curation [equal], Formal Analysis [equal], Funding acquisition [equal], Investigation [equal], Methodology [equal], Project administration [equal], Software [equal], Supervision [equal], Validation [equal], Visualization [equal], Writing—original draft [equal], Writing—review & editing [equal]), Dawit Seyum (Conceptualization [equal], Data curation [equal], Formal Analysis [equal], Investigation [equal], Methodology [equal], Project administration [equal], Software [equal], Supervision [equal], Validation [equal], Visualization [equal], Writing—original draft [equal], Writing—review & editing [equal]), Genet Kefilu (Conceptualization [equal], Data curation [equal], Formal Analysis [equal], Investigation [equal], Methodology [equal], Project administration [equal], Software [equal], Supervision [equal], Validation [equal], Visualization [equal], Writing—original draft [equal], Writing—review & editing [equal]), Fikreab Kebede (Conceptualization [equal], Data curation [equal], Methodology [equal], Writing—original draft [equal], Writing—review & editing [equal]), Hiwot Solomon (Conceptualization [equal], Data curation [equal], Methodology [equal], Writing—original draft [equal]), and Tesfaye Teferi (Conceptualization [equal], Data curation [equal], Methodology [equal], Writing—original draft [equal])

Funding

The authors received no financial support for the research, authorship and/or publication of this article.

Competing interests

The authors declare that there are no potential conflicts of interest with respect to the research, authorship and/or publication of this article.

Ethical approval

The research team received permission from the Ministry of Health, Ethiopia, to access and extract TEMF and Tropical Data. The extracted data were kept confidential, with no participants’ names or identification IDs. Moreover, this study was not conducted with human participants. Moreover, the protocol was submitted to Yanet-Liyana College of Health Sciences for ethical approval. However, the ethical committee waived because of the secondary data used for analysis.

Data availability

The data used for this report are included in the main manuscript. The original data are available from the corresponding author.