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Trachoma elimination in The Gambia: sustaining the success story

Sightsavers, April 2021
A health worker checks childrens' eyes for signs of trachoma.
Community volunteer Ebrima Busia Drammeh examines school children's eyes for signs of trachoma.

The Gambia has become the second country in sub-Saharan Africa to successfully eliminate trachoma, the world’s number one infectious cause of blindness.

In April 2021, the World Health Organization (WHO) confirmed that trachoma is no longer a public health problem for the country.

This major accomplishment should be recognised and celebrated. Sightsavers has been tackling this painful and potentially blinding disease in the country for 35 years, and a key part of our work has been helping strengthen the health system so that it is prepared for this critical moment.

While The Gambia no longer needs intensive mass drug administration campaigns or widespread surgical outreach camps to manage advanced trachoma (known as trichiasis), the health system must now incorporate disease surveillance and management of incident cases into primary health care. It is these strong foundations and continued efforts that will truly consign trachoma to history.

Sightsavers directors Balla Musa Joof and Phil Downs have 40 years of combined experience working on neglected tropical diseases such as trachoma. Here they reflect on what this achievement means for The Gambia, what measures are needed to make sure trachoma is kept at bay there, and how other countries can learn from the experience and stay resilient during the COVID-19 pandemic.

The Gambia's elimination journey

Behind this incredible achievement lie three decades of hard work and collaboration. Meet the people who have been integral to the programme’s success.

Read their stories
A man talking to children outside. He holds an eye chart.
Lamin Camara, a community ophthalmic nurse, shares information about trachoma at Brikama school in The Gambia.

What does trachoma elimination mean for The Gambia?

Elimination of trachoma as a public health problem means that, while the bacterium that causes the disease isn’t eradicated, trachoma can be managed as part of general public health measures and it is no longer overburdening clinics and hospitals.

It ensures that in future, more people won’t have to live in pain. Children will be able to go to school, grow up healthy and go to work, and could even find ways out of poverty that may not have been possible if they were affected by trachoma. For the country, eliminating the disease could contribute to larger-scale economic development.

In 1986, a national survey of blindness and low vision in The Gambia found that 17 per cent of blindness was caused by trachoma, making it the third most common cause of blindness in the country. During that time, The Gambia had limited capacity to tackle trachoma. Eye health services by a trained eye health worker were limited to the Greater Banjul area, meaning people in remote locations were left behind. This changed with the coordination of partners and donors. Health workers’ knowledge and expertise to deliver drug treatments and offer surgical support were expanded to all trachoma-endemic communities, regardless of how difficult they were to access.  

Now, the ministry of health is confident that any remaining trichiasis could be managed in any part of the country, through a referral system that leverages 32 primary eye care centres, eight secondary units and a tertiary centreThe Gambia has worked hard to get to this point and has provided the evidence that trachoma prevalence has fallen below established thresholds and that the health system is strong enough to monitor and respond to any disease cases – and  WHO has now validated this. 

Aluna from Tanzania has her eyes checked for trachoma. They are visibly red and swollen.

What is trachoma?

Trachoma is the world’s leading infectious cause of blindness. Repeated infections cause the eyelashes to turn inwards and rub against the eye, which can lead to sight loss.

More about trachoma

So trachoma has been eliminated in The Gambia.
Does that mean work can stop?

Even though WHO has validated that trachoma is no longer a public health problem in The Gambia, and that large-scale interventions such as mass drug administration are no longer needed, the country still needs to remain on guard to make sure the disease doesn’t come back.

The fact that The Gambia had to manage two outbreaks of trachoma in two successive years at critical times in the elimination effort emphasises how important this is. On these occasions, concerted efforts, especially from the ministry of health surveillance team, controlled the outbreaks and ensured that the momentum needed to eliminate the disease wasn’t lost. So these integrated disease surveillance teams need to remain active to reduce the risk of resurgence.

But surveillance is only one example of the work that needs to continue. Other activities include:

  • Strengthening health information systems to monitor the disease and use the available data to make decisions that will stop the disease re-emerging.
  • Identifying and providing surgery for people with trichiasis who, for whatever reason, weren’t treated before elimination was validated.
  • Maintaining the quality of surgical and treatment services through designated health facilities and hospitals.
  • Continuing to promote eye care services so people are aware of them and encouraged to use them.
  • Continuing behaviour change communications to educate communities on prevention methods such as hand and face washing and maintaining hygienic living environments.
  • Prioritising resources for water and sanitation to improve access to safe water and create environments that are no longer susceptible to spreading trachoma.

“Disease surveillance teams need to remain active to reduce the risk of resurgence.”

Outside of the eye care centre in Banjul, The Gambia.
An eye care centre in Banjul in the west of the country.

How did The Gambia do it – and how can other countries replicate their success?

Elimination is in sight for many other trachoma-endemic countries. Not long ago, in 2018, Ghana became the first sub-Saharan African country to eliminate trachoma as a public health problem. Using experience and learning from Ghana, and now The Gambia, countries are increasingly better equipped with the knowledge they need to tackle trachoma.

Key to work in The Gambia was the WHO-endorsed SAFE strategy, which combines the four elements that spell out the acronym: surgery, antibiotics, face-washing and environmental improvements. But it took much more than that to get to where they are today, and other countries can learn from this. Here are three reasons we believe The Gambia has succeeded.

  1. Robust partnerships. Elimination was possible because organisations worked well together. These included the Gambian government (Ministry of Health, Ministry of Education, Department of Community Development, Department of Water Resources, National Environment Agencies); international organisations (including Sightsavers, the International Trachoma Initiative, which ensured the availability of Pfizer-donated azithromycin, Medical Research Council, The Gambia Unit at London School of Hygiene and Tropical Medicine, WHO, and UNICEF); and last but certainly not least, local partners and communities.
  2. Rigorous training and deployment of trichiasis surgeons. With support from Sightsavers, surgeons were trained, supplied with surgery kits and deployed to detect and manage active cases of trachoma and trichiasis in schools and communities.
  3. Strong community engagement and support. Community members, including village health workers, nyateros (‘friends of the eye’), community volunteers and teachers, actively supported trachoma screening and patient referral. These efforts were complemented by awareness-raising messages about the availability of free surgeries and hygiene prevention behaviours via radio, TV, posters, billboards, traditional communicators and in schools.
A group of women sing songs and dance to raise awareness about trachoma.
Song and dance group Kangenlen Kato helps to raise awareness of trachoma in Mariama Kunda, The Gambia.

What’s next for The Gambia?

We are optimistic about the road ahead for The Gambia. The country’s health system is stronger today than ever, in part because of the trachoma elimination programme. Importantly, it has helped the country in its efforts to reduce the spread of COVID-19 and be resilient in addressing other emerging infectious diseases.

So as the world celebrates The Gambia’s achievement, vigilance and commitment by all who play a part in eliminating trachoma needs to remain high, from the global level down to the community level. It’s not only the job of the government: it’s a long-term collaborative approach that will help us keep neglected tropical diseases like trachoma eliminated forever.

Authors


Sightsavers logoBalla Musa Joof is Sightsavers’ country director for The Gambia and Guinea-Bissau.

Phil Downs is Sightsavers’ technical director for neglected tropical diseases.

 

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