Elimination of trachoma

Editor,—The availability of a new long lasting antibiotic, azithromycin, has sparked a new trachoma control initiative. Morocco has been chosen as the first country in the programme for the elimination of trachoma. This country was selected because it offers ideal conditions for success and may provide some insight towards sustainable control. The search for an initial success is sound, as long as it is understood that Morocco is not typical of the poorest countries in which the disease poses a greater problem. However, the Moroccan programme may provide misleading insights toward sustainable control of the disease in less optimal environments. Morocco has strong health infrastructures and the disease is limited to few pockets of moderate intensity that are isolated from other important foci of trachoma by thousands of kilometres of desert, a barrier that has proved formidable throughout history. Therefore, the risk of recrudescence of the disease caused by migration will be minimal. The vast majority of poor countries will have to defend the result achieved by the attack phase of their programme with a maintenance phase of undetermined length.

Elimination of trachoma blindness rather than elimination of trachoma may prove the feasible objective in poor African countries. To achieve this objective the following techniques should be developed:

1

mapping of the disease distribution and severity

2

flexible cut off point for mass treatment

3

definition of a maintenance phase

4

evaluation of the maintenance phase

 Probably, none of these will be needed, and therefore devised, by the Moroccan programme.

If these assumptions are correct, a second effort should start as soon as possible in a poor country. Such programmes should add a note of realism to the enthusiasm that the success of the Moroccan programme may generate. It should also develop the needed techniques for effective, efficient, and sustainable control of trachoma in the countries in which the disease poses the greater problem. Otherwise, when these countries become interested in trachoma control we should ask them to wait until we find out how to do it.