The world’s leading infectious cause of blindness is a disease called trachoma. There are currently 138 million people known to be at risk of the disease in the least developed parts of Africa, the Middle East, and Central and South America.
In endemic countries, trachoma is linked with poverty and low standards of living such as overcrowding and poor environmental conditions. The painful eye disease is caused by a bacterium that spreads by flies and person-to-person contact. Symptoms begin with mild itching and irritation of the eyes and eyelids and can progress to blurred vision and eye pain, with 1.2 million people currently blinded by trachoma.
For more than 20 years, Pfizer Inc. has been working with the International Trachoma Initiative (ITI), a program of The Task Force that works to prevent and treat trachoma, donating a total of 929 million treatments of Zithromax® (azithromycin) so far for early-stage trachoma prevention and treatment. In later stages, surgery is needed to restore vision, but with access to treatment, clean water and sanitation for adequate hygiene (WASH), this disease can be eliminated.
Since its inception in 1998, ITI – initially founded by Pfizer and the Edna McConnell Clark Foundation – has helped reduce the global burden of trachoma by 91 percent, treating a total of more than 250 million people as of 2020. ITI manages the distribution of Zithromax in trachoma endemic countries, working with partners to review country applications for the donated medicine, coordinate the supply chain for transportation, ensure that treatments reach community health facilities, and track cases of the disease.
The World Health Organization (WHO) and partners had set an original target date for eliminating trachoma as a global health problem by 2020; however due to the final mile of disease elimination being the most challenging, the trachoma community revised the target date to 2030. We spoke to Pfizer’s Director of International Product Access Julie Jenson, MPH, ITI Director Paul Emerson, PhD, and Nigeria’s Trachoma Program Manager Nicholas Olobio, MD, about the ITI partnership, successes, and reaching the 2030 goal.
Tell us about Pfizer’s commitment to fighting trachoma. What prompted the company’s engagement and how has that commitment shaped elimination efforts over the years?
Jenson: Pfizer’s social responsibility is to bring our science, leverage our reach, and bring our expertise in health to these global health challenges; especially in cases where we have a unique solution that is desperately needed. In the case of trachoma, we manufacture Zithromax®(azithromycin) which is the antibiotic WHO recommends to prevent and control the spread of trachoma within affected communities. Over 20 years, we continue to be very passionate about having a social impact with this antibiotic and are proud of the commitment to trachoma elimination.
While trachoma is called a neglected tropical disease (NTD), it is not neglected in these communities. It is such a cause of suffering both health-wise and economically so if this antibiotic helps eliminate this suffering, then it is exactly why we want to be a part of this partnership.
What has this partnership meant for trachoma elimination efforts in Nigeria?
Olobio: The partnership with ITI and Pfizer has brought the country to the verge of eliminating trachoma. As of 2019, a total of 20.7 million people are no longer in need of mass community treatment campaigns for trachoma in 89 endemic districts in 16 states in Nigeria. At the inception of the program in Nigeria, 27.6 million people were at risk of going blind from trachoma, but the risk has now been brought down to about 6.9 million, a reduction of 75%. Nigeria is no longer the second most endemic country for trachoma in the world. All this is as a result of the partnership with ITI and Pfizer. Without medicines there would be no program and without the program, there would be no elimination so Nigeria is very grateful to both ITI and Pfizer for their contribution in seeing that we eliminate this disease.
As we see in Nigeria and other countries, trachoma has been significantly reduced in the last two decades. It is now at the stage that public health experts consider the “last mile” of elimination. What has contributed to this success?
Olobio: The global trachoma program is different from other programs because from inception the program set targets on how to eliminate the active and blinding stages of the disease. Secondly, as a program it was one of the first to develop and disseminate holistic preferred practices that use all types of interventions and not just focus on the use of antibiotic interventions.
For the Nigeria program specifically, we have a robust national program led by the government along with the Nigerian people who are very committed to trachoma elimination. It takes the selfless dedication of volunteer community-directed distributors who distribute the Zithromax, as well as the expertise of the National Trachoma Task Force who serves as a technical resource and advises the program, and national trainers who conduct surgical audits and train eye surgeons to reverse the effects of advanced stages of trachoma.
Emerson: To build on Nicholas’s response, we have data-driven solutions, so we know what needs to be done, where it needs to be done, and how it needs to be done. This information provides the clarity necessary for us to leverage Pfizer’s generous donation and all of the resources from major donors like the U.S. government, the UK government, Lions Clubs, Hilton Foundation and others who have been in this from the beginning. With this type of commitment to a common goal, the resources get allocated where they are needed. Another aspect is that this clarity has given ITI the flexibility to tailor program delivery to specific countries, communities, and situations. We’re not constrained to one size fits all because in disease elimination it doesn’t, and that flexibility has enabled ten countries to eliminate trachoma, and 40 others like Nigeria to drastically reduce transmission.
Jenson: I would definitely echo that. While we didn’t achieve the original goal of elimination by 2020, that initial agreed-upon goal has aligned all of these unique partners in the trachoma community so that we cooperate effectively with each other and don’t compete. I see this mirrored also in the World Health Organization’s 2021- 2030 NTD Roadmap because it is laying out these clear goals for NTDs to enable that collaboration.
Much of trachoma elimination can be attributed to the strength of the programmatic infrastructure globally. But when I first started working with the trachoma community, I was also so struck by the human spirit that was driving this effort from partners like the donors to the community health workers and country program managers. The investment in building trusted relationships and the personal passion brought to the table creates this magical interaction between clear goals and data and individual passion and spirit that has led to a very successful global health effort.
Although there has been great progress, there are still roadblocks to reaching the elimination goals in 2030. What are some of the challenges facing elimination efforts in this last mile?
Jenson: The exciting part is that the end is in sight. Now, we have to focus on very specific challenges. From a donor perspective, one major challenge is mobilizing resources to help countries that do achieve elimination sustain it which is a key focus of the WHO’s new NTD Roadmap. Another main challenge is getting to the hard-to-reach communities that remain endemic. These are some of the remotest areas of the world that are often plagued by civil unrest and poor environmental conditions, so it is going to take thinking creatively and even building new partnerships for us to reach these communities. Until we come up with new solutions and reach these communities, we won’t be able to eliminate trachoma.
Emerson: To that end, geopolitical issues, natural disasters, civil war all go together with the proliferation of NTDs. But like all NTD programs, if we have the audacity to have a global elimination effort, we don’t get to choose where we work. From a program perspective, these remaining endemic hotspots that are preventing communities from wiping out trachoma are the hardest places to operate and are going to require new and innovative approaches. It is clear that the usual activities that have been successful are not going to be as successful as we need them to be in the remaining hot spots. The last mile is showing us the limits to what we can achieve with the current tools and guidelines, so as Julie mentioned, we have to be innovative, utilizing our ability to be flexible.
Olobio: An example of what my colleagues are highlighting is the insecurity the Nigeria program faces with activities of insurgents in Borno State [in northeastern Nigeria]. Mass drug administrations (MDAs) where donated Zithromax is distributed broadly to the community have been halted at times because of insecurity and therefore, we are not consistently able to reach the people at the end of the road. We are working hard to strengthen our supply chain so that the medicine gets to the people who need it efficiently.
What are some lessons learned from this partnership?
Emerson: With trachoma, we’ve been building the ship as we sail it, so we’ve been learning and improving as we’ve gone, which requires flexibility. I think flexibility is a transferable skill that can be applied to any disease elimination effort. Use data to measure your successes and failures to see where operations need to be adapted or edited to reach the end goal.
We’ve also learned that you have to think big and not be afraid to go to scale. From the beginning, it is essential to build programs that are scalable and use data to drive decisions. For trachoma we use an integrated strategy that has a surgical component, an antibiotic component, a facial cleanliness or behavioral hygiene component, and an environmental component of quality sanitation and water – commonly known as the SAFE strategy. Building a strategy that integrates various components at the same time like SAFE has strengthened our global effort to go to scale and reach everyone because together this strategy provides a bigger benefit that improves the lives of everyone in a community, not just those living with the disease.
Olobio: Being able to have the data to inform decisions is definitely a key lesson learned; and not only have it but have it collected through a real-time electronic data collection system. In addition to what Paul said, the trachoma program is built and led by the government with the support of partners and not the other way around.
Jenson: As a donor, our goal is to eliminate trachoma but if we can expand beyond that by sharing our lessons learned, it would be the best-case scenario. The SAFE strategy Paul mentioned is an excellent example of that. Like Nicholas said, our data-driven approach with tools like the Global Trachoma Mapping Project which uses mobile phones to systematically collect data in every endemic country is another best practice that we’ve championed and are also eager to help replicate in other elimination efforts. So I hope we can utilize the platforms available to share information and not lose these lessons learned over the years.
On the other hand, I think there are lessons that the trachoma community can still learn from other disease elimination efforts as well. If we’re going to find innovative solutions, cross-disease collaboration will help us think out of the box, and the 2021-2030 NTD Roadmap is setting us on course to do that.
Once trachoma is eliminated as a public health problem and ITI winds down its operations, how will countries ensure that those elimination certificates are sustained?
Olobio: For Nigeria, one of the ways we are working to ensure that elimination is sustainable is by putting structures in place to have a robust transition where for example incident trichiasis cases can be managed by the health system. Secondly, we have been collaborating with WASH agencies to see that trachoma endemic communities are prioritized for WASH interventions.
Jenson: With trachoma, producing the antibiotic was an obvious reason for Pfizer’s commitment but another aspect has been that there is the integrated SAFE approach with multiple interventions that contribute to disease elimination and can help sustain that elimination. Like Nigeria is starting to do, the goal is to help countries develop plans to utilize the facial cleanliness and environmental components to maintain elimination once MDAs wind down. However, we know this is an area that the whole trachoma community needs to work through strategies for how to best support these countries once we do reach our goal.
Emerson: This is the part of the ship we have yet to build. It is mostly uncharted territory for elimination programs in general. After elimination, continued surveillance will be folded into a country’s health system, becoming their responsibility to track any reemergence of the disease so making sure that the countries we work with have strong health systems is essential. Thankfully, NTD control and elimination programs contribute to health system strengthening by fostering research capacity, improving diagnostics, and developing surveillance systems to name a few. There is no doubt that we’ll see some new cases of trachoma at some point after elimination, but as Julie touched on, if we can hold new cases off long enough to allow for greater global development so that the last two components of the SAFE strategy can prevent widespread transmission, then countries will be able to maintain elimination.