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Editor,—In my previous letter on this subject,1 I stressed the importance of starting a trachoma control programme, in addition to the one already planned in Morocco, in one of the countries in which the disease poses a greater problem. However, I did not intend to support widespread implementation of trachoma elimination programmes by non-governmental or other organisations. While the original strategy was too conservative, the latter is unwise for the following reasons.
Azithromycin is effective against small, short lived, fast reproducing parasites that in time will develop resistance to the drug. Widespread, inadequately controlled use of azithromycin in mass treatments may trigger early resistance and the manufacturers may forbid further use of the drug for disease control programmes. Furthermore, such an occurrence could compromise future collaboration between pharmaceutical companies and public health officials.
The objective “elimination of trachoma” is misleading. While countries like Morocco can attempt to achieve such an objective, elimination of trachoma is unfeasible in countries such as Ethiopia or Mali with drugs available today. The objective in such countries should be limited to “elimination of trachoma blindness”. If the goal is not clearly articulated, programmes may fail to develop essential techniques such as mapping of the distribution and severity of the disease, or methods to monitor and evaluate initial results. Convenience will guide mass treatment. As trachoma is a rural disease, most of the people at risk of blindness may be overlooked because difficult or expensive to reach.
Countries affected by trachoma should be divided into two groups:
(1) those that could attempt to climinate the disease; and
(2) those that should attempt to climinate trachoma blindness.
A limited number of well planned and carefully monitored control programmes, using azithromycin, should be conducted in both types of countries to gain experience and develop needed techniques. If these efforts are successful, more ambitious programmes may be designed.