Trachoma is one of the oldest diseases known to mankind. But can water help eliminate this ancient disease?

For World Water Day, The Fred Hollows Foundation spoke with Dr Wondu Alemayehu, its technical advisor in Ethiopia, to find out.

The Fred Hollows Foundation: What is trachoma and how does it cause blindness?

Dr Wondu AlemayehuTrachoma's one of the oldest infectious diseases known to mankind. It's caused by a micro-organism that spreads through contact with eye discharge from the infected person, on towels, fingers, and so on, and through flies that have had contact with an infected eye.

After years of repeated infection, the inside of the eyelid may be scarred so severely that the eyelid turns inward – a condition known as trichiasis – and the lashes rub on the eyeball, scarring the cornea, the front of the eye. If untreated, this leads to blindness.

FHF: Why is trachoma so prevalent in Ethiopia?

WA: Africa is the most affected continent but trachoma is actually a public health problem in 41 countries worldwide. It is responsible for the blindness or visual impairment of about 1.9 million people globally.
Ethiopia is the most affected country...
- Dr Wondu Alemayehu
Unfortunately, trachoma is endemic in Ethiopia, particularly in Oromia, its largest regional state.

The disease thrives in crowded living conditions where there are shortages of water, inadequate sanitation and where lots of eye-seeking flies are present.

In a recent mapping study, the analysis showed that the independent predictors for children were: younger age, females, greater time to source washing water, open defecation, and lower annual rainfall.
The risk of blinding trachoma is greater in women than in men...
- Dr Wondu Alemayehu
Analysis also identified the predictors for people over the age of 15 and showed  increasing age, female gender, living alone, open defecation, lower altitudes, hottest maximum annual temperatures, and lower mean annual rainfall were associated with the presence of trichiasis, and the risk of blinding trachoma is greater in women than in men.

So, while children are the main people infected, the risk of developing blinding trichiasis increases with age. This affects women and mothers disproportionately we think because of their increased contact with children as primary care givers.

FHF: Trachoma is a 'neglected tropical disease' (NTD). Why is it neglected considering the numbers of people affected?

WA: It's an NTD because it's largely a silent disease in its acute and active stages and its blinding, painful and detrimental end stage disproportionately affects women and mothers living in challenged countries as well as mainly hard to reach areas. There is a huge lack of awareness and gender disparity.

Furthermore, it's wrongly perceived as a ‘non-killer’ disease by decision makers in many of these countries.

The fact that these same countries are faced with other huge competing demands such as tuberculosis, malaria, HIV and so on, is also a formidable challenge, making trachoma a 'neglected tropical disease' despite its enormous detrimental consequences on individuals, their families, communities and countries at large.

FHF: Trachoma is also known as the leading cause of 'infectious preventable blindness'. What does this mean?

WA: Infection spreads from person to person, particularly from child to child, and from child to mother to child.

So, trachoma affects the most vulnerable and disadvantaged in the communities – mothers and children. 
Trachoma affects the most vulnerable and disadvantaged – mothers and children...
- Dr Wondu Alemayehu
In affected communities, infection is often first encountered in infancy or childhood. However, given that the time-tested interventions are implemented at the right time, this disaster can be averted – it can be prevented.

FHF: The Fred Hollows Foundation is a strong proponent of the World Health Organisation’s SAFE Strategy – Surgery, Antibiotics, Facial Cleanliness and Environmental Improvement. Could you explain the F and E components and why these are so important?

WA: The F and E components deal with personal hygiene and environmental improvement which are key in sustainably eliminating blinding trachoma. These components involve a daunting but essential task of the development of water, sanitary facilities and bringing about behavioural change.

Face Washing and Environmental Improvement are fundamental in the achievement of the ultimate goal of The Fred Hollows Foundation, that is the elimination of blinding trachoma as a public health problem.

FHF: Facial cleanliness seems fairly straightforward but what are the current challenges preventing this becoming widespread?

WA: Easier said than done!

Communities living in these resource challenged countries have a lack of awareness, there are high levels of non-literacy particularly amongst mothers; water availability is a huge problem and sanitary facilities are lacking.

These problems amount to a big hurdle in making facial cleanliness widespread.
Water availability is a huge problem and sanitary facilities are lacking...
- Dr Wondu Alemayehu
In addition, scarcity of water and the very nature of the disease, with preschool children being most infected, make it even more difficult.

These children, with minimal symptoms, are totally dependent on care takers for personal hygiene. Un-empowered, busy mothers who shoulder compounded responsibilities and chores, are unable to prioritise this responsibility.

Advocacy for hand washing which is being carried out as a global movement, with new themes annually and being implemented at all levels was non-existent for face washing. The importance of joint messages on face and hand washing is essential.

FHF: What are some examples of environmental improvement?

WA: Examples of environmental improvement are:
•    Sanitary facilities at household level such as improved latrines
•    Availability of liquid and solid waste disposal system
•    Public toilets
•    Accessible water points at household and community levels
•    Open-defecation-free villages  

FHF: How does WASH (water, sanitation and hygiene) link with trachoma?

WA: In Ethiopia and worldwide, the necessity to link WASH efforts with trachoma programs has been broadly acknowledged, but it is only now that the potential for doing so is being tapped in current programs and the policy frameworks that support them.

A joint approach that addresses the causes of trachoma and responds to the basic needs of the affected communities is likely to be more cost effective and sustainable.

The strong link between WASH and trachoma means that elimination will not be possible without collaboration and action on WASH.

The strong link between WASH and trachoma means elimination will not be possible without collaboration and action on WASH. That is why I often use the term 'WASH/Trachoma', because an enhanced joint approach as the best way forward.

The development of public private partnership through social marketing deserves adequate exploration. Integrated promotion of sanitation and better hygiene practices would lead to better living conditions and health improvements. 

FHF: How hard is it for the people in Ethiopia's Oromia region to access clean water and how has this contributed to both the spread of trachoma and the difficulty in eliminating it?

WA: Currently, water access is one of the major challenges severely undermining hygiene practice in affected communities making the elimination effort difficult.

The Oromia region has very high but untapped water resource potential that should be effectively and efficiently utilised to tackle the trachoma problem.

FHF: Are there initiatives underway to provide better access to clean water for the people of Oromia? If so, are they successful and what have been the challenges?

WA: Oromia, its donors, and other stakeholders have been implementing several development programs targeted at improving access to WASH facilities and improved hygiene behaviour.

Furthermore, WASH and NTDs including trachoma have been integrated into the health agenda at the Regional Health Bureau level and NTDs have been included in the Health Extension package at community level.
There is a pressing need for more partners to implement timely scale-up...
- Dr Wondu Alemayehu
However, high staff turnover, coordination, harmonisation and efficient financial management systems have been a challenge.

In addition, there's a lack of standards and guidelines as well as adequate expert support systems. There's a pressing need for more partners to implement timely scale-up in addition to existing initiatives.

FHF: If the people of Oromia had much greater access to clean water today, how rapidly would you see a positive change in the elimination of an NTD like trachoma?

WA: Access to water is a highly critical input, especially to bring about behavioural change in communities, particularly mothers, to promote hygiene among the pre-school population.

That would ensure a positive change. 

FHF: There is the target to eliminate trachoma globally by the year 2020. How significant is the role of clean water in that elimination process?

WA: As mentioned, access to water is a highly critical input. This should go with utilisation, which is closely linked with the level of awareness, understanding of the disease process, and action by the community, decision makers and all other stakeholders.

But rapid scale-up is needed for implementation of the complete SAFE strategy to achieve the ambitious target of elimination.