Approach

The neglected tropical diseases road map 2021-2030, endorsed by the World Health Assembly in 2020, has set 2030 as the target date for global elimination of trachoma.[1][21]

The public health approach recommended by the World Health Organization (WHO) to prevent and treat trachoma is called the SAFE strategy.[22]​ This acronym stands for:

  • Surgery for trichiasis

  • Antibiotics for active infection

  • Facial cleanliness

  • Environmental improvements

Interventions tailored to the local epidemiology may be of benefit in areas where persistent disease remains.[1][23][24]

Trachoma almost exclusively occurs in resource-poor countries of the world, so treatment programs (e.g., the SAFE strategy) have been developed for this setting. However, physicians in resource-rich countries may encounter people who have been living in, or have emigrated or are visiting from, a trachoma-endemic region, requiring treatment for this condition. The approach to treatment in these two settings differ.

International Coalition for Trachoma Control: about trachoma Opens in new window

Resource-poor endemic area: recommendations for mass antibiotic treatment

When trachoma is suspected, it should lead to a community-wide assessment of the prevalence of trachoma. The decision concerning treatment will depend on the results of this survey. Individual treatment alone is futile; because of the facile transmission of trachoma, an individual will be rapidly reinfected. Therefore, a community-wide intervention is the best approach to treat endemic trachoma within a community.[40]

If the prevalence of active trachoma is greater than 10% in children ages 1 to 9 years, WHO recommends treatment of all members of a community older than ages 6 months with mass antibiotic distribution on an annual basis for a total of 3 years.[36] ​This approach is supported by randomized controlled trials.[41][42]​​​ Infants ages 1 to 6 months are an important reservoir of infection and there is growing opinion that they should be included within any mass treatment program.[43][44]​​ Antibiotic distribution should be undertaken in conjunction with a range of public health measures.[45]​ 

The WHO recommendations for criteria to treat a community are ideal, but the actual approach taken must be decided on a community-by-community basis. If those affected are confined to several large families within a small community, it may be possible to target those large families.

Treatment of children without treating households

One cluster-randomized trial reported that treatment of children ages 1 to 9 three-monthly for 1 year not only dramatically reduced the prevalence of infection in the target group (from 48.4% to 3.6%) but that this also resulted in a reduced prevalence of infection in other untreated adults (from 15.5% to 8.2%).[46]​ One subsequent study concluded that biannual treatment of children (6 months to 12 years) was noninferior to annual treatment of the entire community.[47]​ Children ages <6 months received topical tetracycline ointment.

Various antibiotic regimens exist:

  • A single dose of oral azithromycin

  • Tetracycline eye ointment twice daily for 6 weeks

  • A 2-week course of erythromycin.

Azithromycin is at least as effective as tetracycline eye ointment twice daily for 6 weeks in resolving active trachoma, and the single dose has an obvious compliance benefit, making it first choice for treatment if available.​​​[48]​​ Azithromycin has a favorable adverse-effect profile, and chlamydial resistance has not been documented, making it suitable for mass distribution.[49][50]​​​ An increase in macrolide resistance in Streptococcus pneumoniae has been reported immediately following treatment.[50]​ Resistance appears to dissipate with time, but monitoring for resistance in nontarget organisms is required during mass azithromycin distribution programs.

Observational data suggest that skin and soft tissue infections, acute respiratory illness, diarrheal illness, and rheumatic heart disease may be incidentally treated during mass azithromycin administration, thereby reducing childhood mortality.[51][52]​​​ The mechanism remains unclear.

Optimal distribution strategy

Important unanswered questions remain with respect to the optimal distribution strategy (mass treatment versus targeted treatment), and the timing of treatment.[46][47]​ Given the almost universal recrudescence of infection a year after a single dose of azithromycin, 6-monthly or even 3-monthly treatment may be appropriate. However, 6-monthly treatment does not show a longer term benefit compared with annual treatment.[53]​ Further research is required to elucidate the optimal timing of treatment and the exact group to target.

Guidance on preferred practices for trachoma MDA is available.[54]

Resource-poor endemic area: public health measures

Evidence to support the efficacy of interventions targeting facial cleanliness and environmental improvements is limited.[55]​ Facial cleanliness, in conjunction with mass antibiotic treatment, may be effective in reducing severe active trachoma.[55]​​ [ Cochrane Clinical Answers logo ] ​​ Washing with soap may remove ocular discharge more effectively than washing with water alone.[56]​ There is no conclusive evidence to support face washing in isolation.[55]​ One cluster-randomized trial reported no reduction in ocular chlamydia prevalence among both intervention and control groups 36 months after the implementation of a facial cleanliness plus environmental improvement program.[29]​ The trial is ongoing.

Access to a clean water supply, adequate latrines and refuse disposal, and attempts to minimize fly density are all potentially important factors for trachoma control.[9][18][19]​​ However, delivered in isolation (e.g., in the absence of an educational campaign, or concurrent antibiotic therapy) these measures are unlikely to be effective.[29][57][58]

WHO, as part of their roadmap tackling neglected tropical diseases by 2030, have recommended that future research focus on identifying critical facial cleanliness and environmental improvement interventions to reduce trachoma transmission.[21]

Resource-poor endemic area: management of trachomatous trichiasis

Adults with trichiasis must be immediately referred for consideration of corrective lid surgery to prevent vision loss.

Trichiasis itself is a cause of significant disability and reduced quality of life.[59][60] However, it is the corneal opacity that develops in 33% of individuals with untreated trichiasis over 1 year that causes blindness.[61]

In a resource-poor setting, surgical intervention can be undertaken by nurses trained in the appropriate procedure (where permitted). Posterior lamellar tarsal rotation is the preferred procedure and is recommended by the WHO.[62][63]​​ 

Surgery for trichiasis is safe to be performed at the village level to minimize the cost to the patient and related logistics for a program. Very high recurrence rates have been reported, but lower rates (≤10%) are achievable with meticulous surgical procedure.[64][65]​​ Adjunctive azithromycin given at the time of surgery may help decrease postoperative recurrence in areas with high levels of infection.[66][67]​ Posterior lamellar tarsal rotation surgery is associated with significantly lower rates of recurrence than bilamellar tarsal rotation surgery.[63]

As surgery only corrects the architecture of the eyelid (but does not alter the pathologic process, which may continue), some degree of recurrence is probably inevitable due to the natural history of trachomatous trichiasis and the ongoing scarring of the tissue. Poor surgical uptake rates may be improved by addressing negative attitudes toward surgical treatment, providing surgical services at existing health clinics, and community-based promotion.[68][69]​​​

Epilation (eyelash removal) may be associated with protection from corneal opacity in the eyes with moderate or severe entropion, but is usually not recommended. Epilation gives no long-term relief and broken lashes are likely to abrade and damage the cornea.[70] It may be a useful treatment for patients suffering from minor trichiasis who decline surgery, are difficult to access, or are awaiting surgery.[71][72]

Resource-rich nonendemic area: acute infection of individual or family member

Trachoma almost exclusively occurs in resource-poor settings. However, physicians in resource-rich countries may encounter people who have been living in, or emigrated or are visiting from, a trachoma-endemic region, requiring treatment for this condition.

In this situation, azithromycin is given to the patient and the family, and they are followed up at 6-monthly intervals. Retreatment can be given if necessary.

Resource-rich nonendemic area: management of trachomatous trichiasis

In a resource-rich setting, surgery should be undertaken by an experienced oculoplastic surgeon. A variety of different techniques are available, and surgery will be tailored to the individual situation to take into account the full clinical picture.

The decision regarding whether or not to give perioperative antibiotics and about which antibiotic to use varies between individual surgeons.

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