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ABSTRACT |
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INTRODUCTION |
"The further you look back, the better you prepare for the future"
Sir Winston Churchill
"Trachoma is both an ancient and a stubborn disease, slow to blind, and obviously hard to "cure" in a public health context. All through human history, in times of peace as in times of war, it has taken a steady toll of human sight. Against this persistent affliction, some of the best minds in public health ophthalmology have during the course of the last half century or so, been forging increasingly effective weapons to control and eliminate blinding trachoma. Not a decade has passed without some improvement in strategy or medication against this leading cause of preventable blindness."*
Recent intervention strategies are promising. But there is no reason for complacency.
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HISTORY OF TRACHOMA CONTROL |
In 1987, a simplified grading system was adopted, enabling basic health workers to identify and manage trachoma cases.3,4 In 1993, the community approach to trachoma control was developed by the WHO and published in collaboration with the Edna McConnell Clark Foundation.5 The 1990s heralded the introduction of the surgery, antibiotics, facial cleanliness, and environmental improvement (SAFE) strategy,6 which was based on proven and cost-effective interventions. Some of the components in the SAFE strategy were the missing links in the evolution of our earlier trachoma control efforts. In the early years of these efforts, the interventions were medical, local and sometimes systemic treatment of the active disease, and surgical treatment of the sight-threatening complications such as trichiasis. This was done generally oblivious of the behavioral and environmental determinants of the disease and its transmission and persistence in clustered communities.
Although some success attended the medical interventions, they could not be sustained. As evidence of this is the persistence of pockets of blinding trachoma in a number of countries where the disease has been endemic to varying degrees and in many of whom control activities have been in place for a number of years.
Conversely, we have recorded the virtual, if not total, disappearance of trachoma as a blinding disease from parts of the world where it was known to be endemic. This has happened without medical interventions but exclusively through improvement in socioeconomic parameters, which have led to the elimination of the multifactorial determinants of this blinding disease. In other instances, there has been at least a reduction in the blinding propensity of the disease.
Thus, it is clear from the past lessons of our control efforts that the secret to sustainable elimination of trachoma as a blinding disease rests not on medical and surgical interventions alone, but more importantly, on addressing the behavioral and environmental aspects in high-risk populations and communities. On these renewed foundations, the Prevention of Blindness program of the WHO established in 1996 a large partnership of Member States, Non-governmental Development Organizations, Research Institutions, Philanthropic Foundations, and Industry: the Alliance for the Global Elimination of Trachoma by 2020 (GET2020).7 The clearly set target was endorsed by the World Health Assembly in 1998 with the resolution 51.11, calling Member States to collaborate in the WHO Alliance GET2020 to finally eliminate blindness for trachoma, implementing the SAFE strategy and using the newly available tools.8
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PUBLIC HEALTH IMPLICATIONS OF TRACHOMA |
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INSUFFICIENT KNOWLEDGE AND NEED FOR RESEARCH |
The WHO Trachoma Rapid Assessment methodology does not provide for such estimation. However, it provides clues to the areas where population-based epidemiologic surveys would need to be carried out. Priority studies should target areas of known previous endemicity, where active trachoma in children may not be a public health problem, but trichiasis resulting from previous trachoma, may present a problem. Parts of mega-countries such as China and India may be examples of such areas.
Disease dynamics and treatment. We do know more about trachoma than we did during our initial efforts at control. However, there are still gaps in our knowledge. We still do not fully understand the epidemiology of trachoma, the relationship between transmission intensity, disease pattern, and severity of the disease, and subsequent blinding complications. We still need to know more about the optimum treatment schedules using the newer macrolides and have more insights on the effect of mass treatment compared with targeted treatment, given the cost of the medication.
Cultural issues. People’s knowledge and perceptions about trachoma, how and when to do deal with it, and where to seek treatment, are important and not always fully understood. We need to know through sociology- and medical anthropology-based studies what happens at the community level, how health-seeking behavior develops, and the outcomes of health education in children and in adults pertaining to blinding trachoma prevention.
Monitoring. Monitoring of the progress in trachoma control/elimination efforts and evaluation of outcomes should be an integral part of these projects. Standardized methodologies, appropriate indicators, and an appropriate framework for monitoring need to be put in place at national and global levels.
Consensus has been reached on the indicators to determine achievement of elimination; the best administrative or geographic level for this assessment remains to be identified (provinces/states/districts), mainly in large countries. Standardized methodologies and protocols for certifying achieved elimination would need to be developed.
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AVAILABLE TOOLS |
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INTERVENTIONS WITHIN AND OUTSIDE THE HEALTH CARE SYSTEM |
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IMPLEMENTATION: AN AREA OF CONCERN |
In many countries, SAFE is been implemented by public-private partnerships: of great concern is the slow speed at which the strategy is implemented in these areas, provinces, and countries. Current implementation rate is unlikely to help meet the set goal. It is needed to identify ways to expand the deployment of the strategy in all countries and in all areas where blinding trachoma is still a public health problem. This problem is strictly related to the lack of awareness of many decision-makers and their lack of support to the elimination activities. Resources available to date, human and financial, are not of adequate proportion for the final elimination of this cause of blindness.
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CHALLENGES AND OPPORTUNITIES |
The need for intersectoral collaborative action to address the issues pertaining to personal and environmental hygiene in endemic communities warrants urgent attention, not only to facilitate control and elimination efforts, but also to sustain such achievements. Working relationships with Ministries of Education would facilitate development of interventions, both health educational as well as treatment in the target school population. The challenge is to get non-medical entities (ministries and organizations) fully involved in trachoma elimination work, and to take advantage of their ongoing activities to add the needed components to make them SAFE compliant. Thus, the provision of water and improved environmental sanitation should not fall behind the implementation of surgical and antibiotic treatment interventions.
To make trachoma elimination interventions sustainable there is the obvious need to integrate them in the development of the national primary eye care system of countries: this integration will not threaten the momentum that exists today for elimination, but rather constitute an advantage. Other major interventions in eye care shall be implemented bearing in mind the set goal for GET2020
The slow speed of implementation, alluded to earlier, even where private-public partnerships are in place, pose a serious challenge. However, such partnerships, which could be wide ranging as exemplified by the WHO Global Alliance, provide an opportunity to energize and accelerate the implementation of the SAFE strategy wherever it is needed in a more synergistic manner.
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SUMMARY |
Received July 30, 2003. Accepted for publication October 7, 2003.
Authors’ address: Silvio Mariotti, Serge Resnikoff, and Ramachandra Pararajasegaram, Prevention of Blindness and Deafness, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland, Telephone: 41-22-791-3491, Fax: 41-22-791-4772, E-mail: mariottis{at}who.int.
* Adapted from a reference to malaria by R. B. Fosdick, President of the Rockefeller Foundation (1946). 
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REFERENCES |
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ABSTRACT
INTRODUCTION