January 2001

Trachoma Program Achieves Major Success in Morocco and Tanzania International Trachoma Initiative (ITI) email: dwitt@trachoma.org URL: www.trachoma.org

In a groundbreaking advance against the world's leading cause of preventable blindness, the New York City-based International Trachoma Initiative (ITI) announced in December 2000 that pilot projects in Morocco and Tanzania have cut the prevalence of trachoma by well over 50 percent among two million people in just over one year. The dramatic drop in disease prevalence is largely due to the program's success on two counts: distribution of Pfizer Inc's antibiotic Zithromax@ on a massive scale in poor and remote villages and an innovative health education strategy emphasizing facial and community hygiene. Based on success in Morocco and Tanzania, the IT! program will embark on a major new expansion to reach 30 million people at risk of trachoma-related blindness worldwide. Pfizer Inc (www.pfizer.com) will contribute approximately 10 million doses of donated Zithromax (valued at US$14.00 per dose) and US$6 million in funding for ITI's operating expenses over three years. The Edna McConnell Clark Foundation (www.emcf.org) will contribute US$6 million in new funding over three years. The Bill & Melinda Gates Foundation (www.gatesfoundation.org) will contribute US$20 million over five years in its largest donation to the field of international blindness prevention to date. The U.K. bilateral agency, the Department for International Development (DFID) (www.dfid.gov.uk) will provide US $1 million over the next year. With this support, the ITI program will target millions more people in the six countries in which it is currently working-Ghana, Mali, Morocco, Tanzania, Vietnam, and, more recently, Sudan-as well as start new programs in additional countries.

The ITI program uses an innovative combination of curative medicine, community-based public health approaches, and social marketing tools. Part of the strategy is use of Zithromax, which offers a singledose, oral treatment for trachoma that is both more effective and easier to use than the previously recommended treatment of tetracycline eye ointment. The fourpronged approach is called SAFE: S for surgery of advanced-stage disease; A for antibiotics using Zithromax; F for face washing or improving facial hygiene; and E for the environmental change needed to improve community-wide sanitation. The strategy is based on 15 years of research supported by the Clark Foundation. "This initiative represents a powerful partnership of private and public resources to address a disease ofthe poorest women and children of the world," said Clare Short, Member of Parliament-U.K., and Secretary of State for Intemational Development. "We are happy to support this effort. It will bring both curative and environmental changes that will eliminate blinding trachoma worldwide. Disease Prevalence Reductions So far, ITI trachoma control programs in Morocco and Tanzania have reached more than two million people overall with the SAFE strategy. In Morocco, the Ministry of Health/ ITI trachoma control program has reached almost 90 percent of its total eligible population-more than 630,000 people and over 1.25 million treatments in all-with the first two rounds of Zithromax treatments. The first treatment resulted in a fall of disease prevalence from 28 percent to 6.5 percent among the 1.5 million people living in the program area and in the complete elimination of severe disease. This reflects a reduction of overall disease prevalence by 75 percent. The program has just conducted a second round of Zithromax treatment.

In Tanzania, the Ministry of Health/ ITI program reached more than 70,000 people with the first Zithromax treatment-1 00 percent of its target population for this phase of the program. The treatment resulted in a fall of disease prevalence by between 50 and 83 percent among the 250,000 people living in the program areas targeted. In the second round of treatment, the program has already reached an additional 210,000 people. Most of the 36 villages across the six districts in which the program in Tanzania has been put into place are among the most remote in central Tanzania, where people live on less than US$1 per day. In Morocco, the five southem provinces (Errachidia, Figuig, Ouarzazate, Zagora, and Tata) being targeted for trachoma control border the desert and are also among the poorest and most remote. Surgery, Face Washing, and Environmental Change Results To fulfill the S for surgery in SAFE, ITI conducts surgeries on advanced trachoma-or trichiasis-cases. The simple, 15-minute surgery rotates the eyelashes away from the eye to stop further abrasion of the cornea and prevent blindness. It can be done in a village setting and can be performed by trained community health workers. After having the surgery, clients retain their vision and are relieved of the pain caused by their eyelashes scratching and damaging their eyes.

The Morocco Ministry of Health/ITI trachoma control program has completed 56 percent of the estimated 15,500 eyelid surgeries needed. The Tanzanian Ministry of Health/IT! trachoma has resolved problems related to procurement of equipment and expects to improve substantially on its initial 30 percent coverage rate. To fulfill the face washing (F) and environmental change (E) components of SAFE, the Moroccan Ministry of Health/ITI program has conducted 30,000 health education sessions, reaching more than one million people. These sessions included health promotion from mobile vans and video training sessions in waiting rooms of clinics. The Tanzanian Ministry of Health/ITI education campaign and pilot school curriculum have already reached hundreds of thousands of children and adults. Additionally, the program has reached some 20 million people with radio health education messages on facial hygiene and environmental improvement. An independent evaluation of the program found that knowledge of how to prevent trachoma has already increased from 26 to 66 percent among residents in the project area. "SAFE works because it addresses the medical, environmental, and behavioral determinants of disease," said Peter Kilima, MD, ITI Representative in Tanzania. "Lasting change in trachoma prevalence can only be achieved if the messages about facial hygiene and improved sanitation get across. This is quite a challenge. It is hard for people in rural villages to understand the connection between a mild eye disease in children and the blindness of their mothers." The Disease Currently, 150 million people have trachoma, and 10 percent of the world's population-540 million people living mainly in Africa, Asia, the Middle East, and in some parts of South America and Australiaare at risk of contracting trachoma. The disease results in US$5 billion in lost productivity per year. Trachoma, caused by the bacterium Chlamydia trachomatis, is easily transmitted from person to person, particularly within families with small children. Repeated infection that commonly begins in childhood drives the progression of the disease cycle. Through the discharge from the eyes of an infected child, trachoma is passed to others by hands, on clothing, or by flies that are attracted to faces and runny noses. Without adequate treatment, the inner eyelid becomes scarred. After repeated infection and scarring, the eyelid will turn inward, causing the eyelashes to rub against and damage the cornea, which leads to blindness. Blindness occurs only after multiple infections, usually when individuals are in their 40s or 50s. Because the disease causes blindness in the most productive years of a person's life, trachoma can ruin the economic well-being of entire families and communities. Women are two to three times more likely than men to be blinded by trachoma. A woman who becomes visually impaired due to the disease can no longer perform life-sustaining activities for her household, such as gathering firewood and cooking. To fill this gap, an older daughter may be pulled from school to assume these responsibilities, forgoing her opportunity to break the cycle of poverty with a formal education. ITI trachoma control programs are also underway in Mali and Vietnam, and another is planned to begin in early 2001 in Ghana. The ITI/ Vietnam Ministry of Health program has treated an estimated 100,000 people with Zithromax. This program will ultimately administer Zithromax to 350,000 people living in 13 districts, reaching a combined population of 1.8 million. Because trachoma is prevalent where water and sanitation systems are in scarce supply, the campaign will significantly expand Vietnam's successful private-sector social development programsincluding rainwater harvesting spearheaded by International Development Enterprises-and adapt them for new areas. The International Trachoma Initiative is a tax-exempt charitable organization. For more information, visit the Web site at http:// www.trachoma.org. Mr. David Witt Program Associate International Trachoma Initiative 441 Lexington Avenue, 16th Floor New York, NY 10017-3910, USA. Phone: +1-212-490-6460 Fax: +1-212-490-6461