Anti-Blindness Campaign Cuts Disease Prevalence In Half Among Millions In Poorest Regions Of Tanzania, Morocco

GENEVA and NEW YORK -- In a groundbreaking advance against the world's leading cause of preventable blindness, the New York City-based International Trachoma Initiative announced today 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.

ITI-supported researchers will report these findings at the World Health Organization's (WHO) Alliance for the Global Elimination of Trachoma by 2020 (GET 2020) conference this week. Trachoma is a bacterial infection of the upper eyelid that has caused blindness in six million people worldwide, with another 150 million currently infected.

"These results demonstrate that we are truly revolutionizing the control of this blinding disease," said Joseph Cook, MD, Executive Director of the ITI. "In this new century, no one should go blind due to trachoma."

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 ITI program will embark on a major new expansion to reach 30 million people at risk of trachoma-related blindness worldwide.

"Through the ITI, one of our most advanced medicines is reaching and helping people in the poorest regions of the world," said William C. Steere, Jr., Chairman and CEO of Pfizer Inc. "Pfizer is committed not only to donating Zithromax for trachoma control worldwide, but to the entire public health strategy that will ultimately eliminate this disease forever."

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 ₤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 and its partner organizations will work together to identify candidate countries that offer particular opportunities for success from the WHO GET 2020 list of priority countries. The ITI works with nongovernmental organizations such as Helen Keller International and The Carter Center, in addition to international agencies such as UNICEF and WHO, and governmental agencies.

"The Foundation is supportive of public-private partnerships in global health that can benefit people far into the future," said Gordon Perkin, MD, Director of the Global Health Program at the Bill & Melinda Gates Foundation. "The SAFE strategy being implemented by the ITI will have a long-lasting impact not only on blindness but on the health infrastructure of some of the poorest communities of the world."

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 single-dose, oral treatment for trachoma that is both more effective and easier to use than the previously recommended treatment of tetracycline eye ointment. The four-pronged 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 is the first time that the full SAFE strategy has been implemented on such a large scale, and today's results show that it works," said Michael Bailin, President of The Edna McConnell Clark Foundation. "We are pleased to continue our support of the ITI, a dynamic institution that is both working to defeat this disease and to build the field of trachoma control worldwide."

"This initiative represents a powerful partnership of private and public resources to address a disease of the poorest women and children of the world," said Clare Short, Member of Parliament-U.K. and Secretary of State for International 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—100 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.

"The results in Morocco and Tanzania show that SAFE can really work in a community-based setting," said Jeffrey Mecaskey, Program Director of the ITI. "It is one thing to have antibiotics in the large cities of the developing world and quite another to reach the vast majorities who live in rural areas that are barely touched by modern medicine."

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 southern provinces (Errachidia, Figuig, Ouarzazate, Zagora, and Tata) being targeted for trachoma control border the desert and are also among the poorest and most remote.

"Because SAFE is technologically and operationally simple to implement, trachoma control can be easily integrated with broader health and development efforts like maternal and child health and water and sanitation programs already underway in poor and vulnerable communities," said Youssef Chami-Khazraji, MD, Director of the Division of Communicable Diseases in the Department of Epidemiology and Disease Control of the Ministry of Health, Morocco.

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 Moroccan Ministry of Health/ITI trachoma control program has completed 56 percent of the estimated 15,500 eyelid surgeries needed. The Tanzanian Ministry of Health/ITI trachoma control program has resolved problems related to procurement of equipment and expects to improve substantially on its initial 30 percent coverage rate.

"The ITI ensures that equipment and drugs are not just delivered to a warehouse in the capital city," said Cook. "We are actively solving the problems that sometimes keep needed supplies and medicines from getting to the people in the field who need them most."

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 residing 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 Australia—are 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.

"Trachoma keeps families shackled to a continuous cycle of poverty," said Mecaskey. "The overall vulnerability to the disease and its effects is passed from one generation to another."

ITI trachoma control programs are also underway in Mali and Vietnam, and another is planned to begin early next year in Ghana. The Vietnamese Ministry of Health/ITI 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 programs—including rainwater harvesting spearheaded by International Development Enterprises—and adapt them for new areas.