On October 12, 2024, an incident at Trichy Airport involving an aircraft malfunction kept the aircraft circling in the skies for hours. The pilots’ efforts to safely land the plane, preventing potential disaster, captured the public’s imagination. Their actions were tangible, immediate, and visible, making it easy for people to appreciate the significance of their work. This event dominated headlines, occupied significant airtime and social media space, while just days earlier, another important achievement unfolded rather quietly: on October 8, India’s health system achieved a quiet but equally important victory in eliminating trachoma as a public health problem — a success far less visible but just as impactful.

Public health works face the paradox where the nature of their work makes failures highly tangible and visible, leading to headlines, while their successes remain intangible, often going unnoticed despite their significant impact. Acknowledging these achievements is essential, as they reflect the dedication and perseverance of countless individuals working behind the scenes to prevent blindness and improve lives. The achievement marked a significant public health victory and had profound economic implications. Trachoma’s impact, through blindness and visual impairment, results in an estimated economic loss of $2.9 to 5.3 billion annually due to reduced productivity.

Trachoma, a chronic infectious eye disease, affects regions with poor hygiene and sanitation. The disease primarily affects young children and women in areas with limited clean water and sanitation access. Chlamydia trachomatis, the bacterium responsible for trachoma, has serotypes A, B, Ba, and C, which cause eye infections. These infections lead to symptoms such as eye irritation, discharge, swollen eyelids, sensitivity to light, and, in severe cases, blurred vision. If left untreated, repeated infections can cause scarring of the inner eyelid and eventually blindness. Trachoma is transmitted through contact with eye secretions from an infected person’s fingers, contaminated towels or clothes, or flies (Musca sorbens) touching the infected secretions, often exacerbated by poor hygiene and overcrowded living conditions.

Trachoma is one of 20 diseases the World Health Organization (WHO) has classified as neglected tropical diseases (NTDs) and seeks to eliminate by 2030. NTDs disproportionately affect impoverished communities, and controlling them is a key target under the United Nations Sustainable Development Goal 3 (Target 3.3). While many developed nations have long eliminated trachoma, countries like India have struggled due to socio-economic and environmental challenges.

India’s success in significantly reducing trachoma prevalence is largely attributed to the WHO’s SAFE strategy, which has been pivotal in global trachoma elimination efforts. The SAFE acronym stands for surgery to correct trichiasis (misdirected eyelashes), antibiotics to treat and control the infection, facial cleanliness to reduce transmission, and environmental improvements such as access to clean water and sanitation.

WHO’s Criteria

The WHO defines trachoma as eliminated as a health problem when prevalence of trachomatous trichiasis falls below 0.2% in people aged 15 years and above. The prevalence of active trachoma in children aged 1–9 years is less than 5% in endemic countries. It also includes a health system capable of managing new cases. Reaching these thresholds is a significant milestone, but it does not equate to the total eradication of the disease.

In 2005, trachoma accounted for 4% of all blindness cases in India. Remarkably, by 2018, this figure declined to just 0.008% of all blindness. Even with India’s commendable achievement of a 0.7% prevalence, sporadic cases can still exist. The elimination target means that the disease’s burden has been significantly reduced but not eradicated. This distinction is crucial in epidemiology, where reaching elimination is a major milestone. 

India has conducted three major trachoma prevalence surveys, the most recent from 2014 to 2017. Historically, trachoma was highly endemic, especially in northern states like Gujarat, Rajasthan, and Uttar Pradesh. The national surveys conducted in the 20th century demonstrated alarming rates of infection, but successive public health measures have drastically reduced the burden. 

However, this achievement does not mean India is free from trachoma. The term “elimination as a public health problem” signifies that trachoma is no longer a significant threat, but sporadic cases may still exist. This is an important distinction. While India has achieved the elimination of trachoma as a “public health problem,” this does not mean that the disease and transmission have been eliminated. There is often confusion between the two terms: elimination as a public health problem and elimination of disease. The former refers to reducing disease prevalence to such low levels that it no longer poses a significant public health threat. In contrast, the latter implies very negligible to zero transmission of the disease, as seen in India’s polio, measles, and guinea worm infection levels.

Epidemiological Challenges

From an epidemiological standpoint, achieving the elimination threshold is like an associate member country of the ICC being granted test status — it’s a milestone, but maintaining this status requires continuous effort and excellence. Similarly, India has reached an impressive point in the fight against trachoma, but to sustain it, efforts must be ongoing.

Developed countries achieved trachoma elimination much earlier in the 1950s. 

The road to completely eradicating trachoma is long due to lack of vaccines. With no long-lasting protective immunity and the presence of active trachoma cases, the focus must remain on interrupting the transmission cycle of the disease through sustained improvements in sanitation, access to clean water, and continued health education. India’s progress has been remarkable, but it is essential to continue the battle with the same vigour. 

The WHO’s decision not to set an eradication target for trachoma (unlike yaws and guinea worm) reflects the complex epidemiological challenges. Surveillance systems must be vigilant to catch cases early and prevent resurgence. The National Programme for Control of Blindness and Visual Impairment (NPCBVI) needs to regularly conduct surveys, at least once a decade, across all districts to detect any new cases and prevent the resurgence of the disease to maintain India’s status as free from trachoma as a public health threat.

It’s time public health workers receive the acknowledgement they’ve earned for protecting the nation’s health, and we should keep striving to tackle future challenges with the same determination. Eliminating trachoma as a public health problem is a significant achievement for India, and the journey continues. Ongoing surveillance, adherence to the SAFE strategy, and initiatives like Swachh Bharat will be critical in ensuring that trachoma remains a disease of the past. We should keep up the momentum.

The government must be committed to this goal, ensuring that India’s children can grow up in a world free from trachoma. This validation should serve as a reminder that, with continued collective effort, we can also target and eliminate other diseases like kala-azar and tuberculosis. The success against trachoma shows that even in tough conditions, coordinated efforts can bring about change.

((Dr. C. Aravinda is an academic and a public health physician. [email protected])