London School of Hygiene & Tropical Medicine

In 1978 I went to work in The Gambia as a junior doctor at the Medical Research Council (MRC) research unit hospital. With a population of less than one million at the time there was only one government ophthalmologist, Dr Shiona Sowa. I got to know Dr. Sowa well and heard about the work which had brought her to The Gambia - to try out new vaccines for trachoma.

Unknown to me at the time, trachoma is a horrible infection that makes eye lashes turn inwards so they scratch your eyes when you blink, caused by the same Chlamydia trachomatis, a sexually transmitted infection, that I had learned about in medical school.

Trachoma is the leading infectious cause of blindness worldwide, and in 1986 a national eye health survey found that it was responsible for 17% of blindness in The Gambia. This is why the announcement by the World Health Organization (WHO) on the 20^th April 2021 that The Gambia has been validated as having eliminated trachoma as a public health problem is wonderful news for global health, at a time when COVID-19 continues to cause such heartache around the world.

Many congratulations to everyone involved in this wonderful achievement.

However, trachoma persists in more than 40 countries, so can lessons be learnt from The Gambia’s achievement? Well, let’s return to my early days.

At that time the recommended treatment for trachoma was tetracycline 1% ointment, applied to both eyes twice daily for six weeks.  Having tried to put ointment in the eyes of my two-year old daughter without much success, I realised that it must be difficult to do it twice a day for six weeks for all the many children with trachoma.  

In the early 1990s a new antibiotic called azithromycin came on the market, a single dose of which was reported to cure sexually transmitted chlamydial infection.  With my colleague Robin Bailey, and working closely with the local community, we completed a clinical trial in two Gambian villages which showed that a single dose of azithromycin, given by mouth, was as effective as six weeks of supervised tetracycline ointment for the treatment of trachoma.  

With colleagues in The Gambia, Tanzania and Egypt, we went on to show that treating whole villages with a single dose of azithromycin was an effective trachoma control strategy. Fortunately, we were able to persuade the manufacturer, Pfizer, to donate azithromycin to trachoma control programmes for as long as it was needed through the International Trachoma Initiative (ITI).

In 2006 the Gambian National Eye Care Programme (NECP) submitted a plan to the ITI for the elimination of trachoma as a public health problem following the WHO-recommended SAFE strategy:

• Surgery, performed by eye nurses in rural clinics, to correct the in-turned eyelashes
• Mass treatment with azithromycin, given once a year for up to three years, to treat the infection
• Promotion of eye health education, including facial cleanliness, introducing a ‘healthy eyes’ component to the primary school curriculum
• Environmental improvement to reduce transmission of C. trachomatis from eye to eye, focussing on improved water supply and latrine construction using a local design
• Monitoring and evaluation of progress by surveys 

The NECP set-up a national trachoma task force to implement the plan, in partnership with government departments responsible for health and social welfare, community and social development, water resources, and education, with NGOs, principally Sightsavers, and research organisations - -colleagues at the MRC Unit and the London School of Tropical Medicine.  

The Health for Peace Initiative, supported by Sightsavers from 2001, established The Gambia as the lead for Eye Care in the region, and enabled strong cooperation with Senegal as well support for the first ever trachoma survey in Guinea-Bissau. Both countries are now well on track to eliminate trachoma themselves.

The Gambia has achieved this milestone through a successful and productive partnership between government, NGOs, health care workers, community volunteers and research groups based in the country. This sets a wonderful example to other countries in the region.

And the global situation?

Since 1998 more than 900 million doses of azithromycin have been donated to national trachoma control programmes worldwide and The Gambia has become the 11^th country to be validated by WHO as having met the elimination targets. 

The number of people needing surgery for trachoma globally has been reduced from more than eight million to less than two million, and the number of people needing azithromycin mass treatment from 1.5 billion to 137 million.

If progress continues at this rate, we are on target to achieve the global elimination of trachoma as a public health problem by 2030.