World Sight Day 2023: Advancing universal eye health coverage - contributions from the global trachoma program

11 Oct 2023 
by ICTC Executive Group
Trachoma screening at a health facility, Oromia Regio, Ethiopia. Photo Credit: Brent Stirton/Getty Images for the International Trachoma Initiative

Trachoma, the world’s leading infectious cause of blindness, is one of 20 diseases classified by the World Health Organization (WHO) as a neglected tropical disease (NTD). This classification has been instrumental in mobilizing resources to better understand the epidemiology of trachoma and to scale up the WHO-endorsed SAFE strategy (surgery, antibiotics, facial cleanliness, environmental improvement) for trachoma elimination. Since 2002, this increased investment in trachoma has contributed to a 92% reduction in the number of people at risk and 18 countries validated as having eliminated trachoma as a public health problem.

It is widely recognized that safeguarding the progress made towards trachoma elimination requires programs and health ministries to proactively implement strategies that will strengthen health systems and facilitate the integration of trachoma interventions into routine public services, and where available, national eye health services. This is because the elimination of trachoma as a public health problem does not rid a country of the disease. Rather, it reduces the burden of disease to below a threshold where it is not considered a public health problem. 

These clinical indicators include trachomatous inflammation—follicular (TF), which is an indication of ongoing transmission, and trachomatous trichiasis (TT), which occurs following repeated trachoma infections, causing eyelashes to point inwards and scratch the cornea. If left untreated, this can cause extreme pain and lead to irreversible vision impairment and blindness. Elimination of trachoma as a public health problem is therefore defined as (i) a prevalence of TT unknown to the health system of <0.2% in adults aged ≥15 years and (ii) a prevalence of TF in children aged 1–9 years of <5%, and(iii) evidence that the health system can continue to identify and manage incident cases of TT to prevent its progression to vision impairment or blindness.  

Consequently, as countries are validated for eliminating trachoma as a public health problem, it is essential that systems are in place to ensure that human resources are sufficiently trained and receive supportive supervision, and robust monitoring and surveillance systems are in place to identify cases and ensure there is not a resurgence of the disease.

At a recent meeting of the International Coalition for Trachoma Control (ICTC) in Dar Es Salaam, Tanzania in September 2023, global stakeholders discussed some of the nuances in developing strategies to ensure the sustainability of interventions. It was widely recognized that the infrastructure for achieving health system integration is complex; it requires collaboration and coordination, and is highly context-specific. For instance, in some settings TT services are managed by eye health or medical units within the Ministry of Health, whereas other trachoma interventions such as antibiotic distribution are managed by public health units. Furthermore, within countries, there can be significant variation, particularly countries with decentralized health systems. This means that neighboring districts can have vastly different strategies for managing incident trachoma cases. Some of these districts might have sufficient infrastructure and resources to monitor and manage cases, while other settings utilize passive surveillance strategies, or require user fees to ensure TT services can be sustainably provided. 

Integrating trachoma interventions into the broader eye health system is not only important to sustain progress for trachoma, but can lead to more efficient resource allocation, enhanced expertise sharing, and a more comprehensive approach to the implementation of integrated people centred eye care. 

Discussions like these continue to highlight the importance of having a nuanced understanding of the facilitators and barriers to integrating trachoma interventions into routine health systems, which was the subject of a recent article published in the Community Eye Health Journal. Research from Ethiopia, which accounts for 52% of the global burden of trachoma, identified four key areas as affecting the successful transition of trachoma interventions into the national health system. These included: (i) health system capacity; (2) supply chains; (3) persistent and recrudescent trachoma; and (4) community awareness.

In 2018, ICTC published a series of toolkits across the entire SAFE strategy to support national trachoma programs and implementing partners to transition interventions from disease-specific elimination efforts to routine public services. These toolkits can be used in several ways, including: (i) as a step-by-step planning guide (ii) as a checklist to ensure planning is on the right path (iii) as a reference document on key planning components and (iv) to engage non-trachoma partners in the planning and delivery of transition activities, particularly in collaborations with WASH stakeholders. Going forward, these lessons should be integrated into future preferred practice updates to ensure that transition is not seen as a stand alone activity, but an integral component of all trachoma programs that must be built in at the start of program design. 

Integrating trachoma interventions into the broader eye health system is not only important to sustain progress for trachoma, but can lead to more efficient resource allocation, enhanced expertise sharing, and a more comprehensive approach to the implementation of integrated people centred eye care. This World Sight Day, we must remind ourselves that while trachoma has made significant progress under its classification as a NTD, it remains an eye health issue that requires trained eye health personnel and engaged communities, to prevent vision impairment and blindness that arise from its complications. National trachoma programs must be proactive in coordinating and collaborating with eye health stakeholders and communities to strengthen eye health systems that will advance the achievement of universal eye health coverage, while eliminating trachoma as a public health problem.