The International Commitment to Eliminate Trachoma

An international commitment allows WHO to give technical advice to member states on how those things should be implemented and to coordinate partners across the global stage.

Together with non‐governmental agency partners, researchers, and funders, WHO established the Alliance for the Global Elimination of Trachoma by 2020 (GET2020) in 1996. The goal for GET 2020 is the elimination of trachoma as a public health problem. Elimination was defined as the achievement of two measurable objectives, which reflect the elimination of the infectious and blinding sequelae of the disease:

• The first objective is the reduction of the prevalence of trachoma follicular infection (TF) to less than 5% among children ages 1–9 in every endemic district.
• The second objective is the reduction to less than two per thousand (<0.2%) in population ages 15 years and older of trachomatous trichiasis cases who are “unknown to the health system”.

WHO has a process for validating a country as having eliminated trachoma, using district-level data. Once a district has achieved the objectives outlined above, then mass drug administration (MDA) is stopped. A period of at least two years must elapse during which there is no mass provision of antibiotics followed by a population‐based survey to ensure that trachoma has not re‐emerged.

Finally, a dossier is prepared that demonstrates, largely through population-based surveys, that there is no evidence of re‐emergence of active trachoma, or unmet need for trichiasis surgery, in any formerly endemic district. An outside review group evaluates the evidence for elimination and recommends either validation of elimination by WHO, or further information/work.

Global Trachoma Elimination

With this in mind, the strategy to eliminate trachoma as a public health problem has specific targets to attain. The plan is built on a framework of:

• Urgency to reduce the suffering of people affected by trachoma.
• Accountable ownership – countries lead their own elimination efforts and solicit coordination from donors and partners.
• Integration of trachoma activities at a local level with those for neglected tropical disease (NTDs), universal eye health, national health service development and/or water and sanitation programmes.
• Efficient, coordinated partnerships to scale up intervention and increase coverage within a country and globally across all affected countries.
• Tailoring of implementation to local data and knowledge.

Global debates about public health interventions to deal with infectious diseases use several key terms: control, elimination and eradication. The agreed definitions are:

• Control is the reduction in disease incidence, prevalence, intensity, morbidity or mortality (or a combination of these) to a locally acceptable level. Activities to maintain the reduction are required, for example, as used for diarrhoeal diseases.
• Elimination of infection (interruption of transmission) implies that disease incidence has been reduced to zero or below the acceptable threshold, in a defined geographical area as a result of deliberate efforts. Continued measures to prevent re-establishment of transmission is required. Examples are measles and poliomyelitis.
• ‘Elimination as a public health problem’ : A term related to both infection and disease, defined by achievement of measurable targets set by WHO in relation to a specific disease. When reached, continued action is required to maintain the targets and/or to advance interruption of transmission.
• Validation – Documentation of elimination as a public health problem
• Eradication is the permanent reduction to zero of the worldwide incidence of infection and further continued action is not required: for example, smallpox.

Which type of target is chosen depends on the effectiveness of available interventions, the availability of resources and the strength of overall commitment from society and government.

To eliminate trachoma as a public health problem, interventions have to contain both biological (disease) and operational (process) dimensions.

The WHO draft road map for neglected tropical diseases 2021-2030 describes the integrated approaches needed to achieve these targets through crosscutting activities that intersect multiple diseases. The aim of the new road map is to facilitate alignment among member states and other stakeholders and to accelerate progress towards the prevention, control, elimination and eradication of the 20 NTDs and disease groups now prioritized by WHO and attaining the Sustainable Development Goals. Trachoma is one of the neglected tropical diseases considered in this roadmap.

The roadmap is built on three pillars that will support global efforts to control, eliminate and eradicate neglected tropical diseases:

Pillar 1. Accelerate programmatic action

Pillar 2. Intensify cross-cutting approaches

Pillar 3. Change operating models and culture to facilitate country ownership

The roadmap for trachoma elimination is summarised in the table below:

By 2020, nine countries were validated as having eliminated trachoma.

In your own setting, who are the key stakeholders involved, or who must be engaged at a district and national level, to eliminate trachoma?