[NEW DELHI] The world moved closer to eliminating trachoma this month after the World Health Organization (WHO) confirmed India and Pakistan as being free of the disease, a leading cause of blindness.

Trachoma is a bacterial infection affecting poor communities where clean water and sanitation are lacking. If left untreated it can cause excruciating pain and eventual loss of sight.

India, the 20^th country to have eliminated trachoma, is the world’s most populated country with 1.45 billion people living there, while Pakistan ranks as the fifth most populous country, with around 250 million inhabitants. They are the 20^th and 19^th countries respectively to be declared free of trachoma.

Munazza Gillani, Pakistan and Middle East director for Sightsavers, a UK-based charity that works to treat and prevent avoidable blindness, says Pakistan’s achievement is down to the “resilience and dedication of countless individuals and organisations who have come together in this fight”.

However, she warned: “We must not become complacent.

“Trachoma can still return unless we sustain efforts to maintain awareness of the disease among communities and health staff.”

Under the WHO’s 2021-2030 road map for neglected tropical diseases, the target date for global elimination of trachoma as a public health problem is 2030. The road map calls for a holistic approach based on universal health coverage rather than a disease-specific strategy to end the disease.

An estimated 1.9 million people have partly or fully lost their sight to trachoma, according to the WHO.

Caused by the bacterium Chlamydia trachomatis, the disease spreads through contact with eye, nose, or throat secretions, typically in areas with limited water and sanitation facilities. Flies that breed on animal dung, human faeces and food scraps also help spread it.

SAFE strategy

The WHO’s elimination strategy – dubbed SAFE, for surgery, antibiotics, facial cleanliness and environmental change – includes safe waste disposal and improved access to clean water and basic sanitation, as well as antibiotics to treat the infection.

Roderico H. Ofrin, the WHO’s representative in India, attributes the country’s success to the implementation of this strategy, including surgeries and drug administration conducted by the Ministry of Health and Family Welfare and the government’s intensive water and sanitation programmes.

“India’s success is an inspiration for other nations striving to eliminate trachoma and improve public health,” said Ofrin.

China, Nepal, Iraq and Iran are among 20 countries that have eliminated the ancient scourge which causes the eyelashes to turn inwards and scrape against the eye, causing intense pain. Repeated infections in childhood, if left untreated, can lead to visual impairment and irreversible blindness.

Trachoma, eliminated in Europe and North America in the 1950s, thanks to improved hygiene conditions, continues to plague communities in poorer countries, where crowding is common and access to clean water and sanitation remain inadequate.

However, the dramatic reduction in trachoma incidence is considered a major public health success story of the 21^st century, with multiple agencies acting together to bring the number of people at risk down from 1.5 billion in 2002 to 103 million people in 2024.

In 2023, according to WHO, 13,746 people received surgical treatment for advanced trachoma – known as trachomatous trichiasis – and 32.9 people were treated with antibiotics.

Community-wide distribution of the antibiotic azithromycin is an important component of the SAFE strategy to limit the spread of the disease.

Azithromycin is donated to trachoma-endemic countries for free mass administration to both infected and non-infected individuals through the International Trachoma Initiative.

India has developed a surveillance plan for sustained elimination, including provision of surgery to correct trichiasis. The plan also covers community awareness and promotion of water, sanitation and hygiene.

According to Gillani, India’s success was driven by concerted efforts by the government and organisations such as Sightsavers, The Fred Hollows Foundation, and the Christian Blind Mission as well efforts of health workers, communities, volunteers, donors, and pharmaceuticals.

However, trachoma remains the world’s leading infectious cause of blindness, affecting people in 39 countries.

Caleb Mpyet, trachoma specialist and technical adviser to Sightsavers, says international cooperation is needed to see an end to the disease. “Infectious diseases do not respect borders,” he says.

Mpyet cites the examples of Kenya, Uganda and Tanzania synchronising their trachoma campaigns. “The new coordinated, international strategy paves the way for the sustainable elimination of trachoma in these countries,” says Mpyet in a blog for the British Medical Journal (BMJ).

Trachoma is extremely common in many of the poor, rural areas of Africa, Central and South America, Asia, Australia and the Middle East. Overall, Africa remains the most affected continent and the one with the most intensive control efforts, according to the WHO.

The other countries that have eliminated trachoma include Benin, Cambodia, Gambia, Laos, Ghana, Malawi, Mali, Mexico, Morocco, Myanmar, Oman, Saudi Arabia, Togo and Vanuatu.

This piece was produced by SciDev.Net’s Asia & Pacific desk.