Progress toward Elimination of Trachoma as a Public Health Problem in Seven Localities in the Republic of Sudan: Results from Population-Based Surveys

Trachoma is the leading cause of infectious blindness and is responsible for approximately 1.9 million people being blind or visually impaired.1 Countries such as Sudan have worked hard to reduce the risk of blindness from trachoma through the implementation of the World Health Organization’s (WHO) SAFE (Surgery for those who have the advanced stage of the disease, Antibiotic distribution to treat infection, and Facial cleanliness and Environmental improvement initiatives to decrease transmission) strategy.2 For a country to be considered as having eliminated trachoma as a public health problem, trachomatous inflammation-follicular (TF) must be less than 5% in children aged 1–9 years for a period of at least 2 years and trachomatous trichiasis (TT), the advanced stage of the disease, must be less than either 0.2% in those aged 15 years and older or 0.1% in the total population.3 Between 2006 and 2010, trachoma baseline surveys were conducted across Sudan to determine whether Sudan was endemic for trachoma.4 Trachomatous inflammation-follicular in children aged 1–9 years was above the WHO elimination threshold in 15 localities (the equivalent of a district). The prevalence of TT was above the threshold among adults aged 15 years and older in 48 localities. Further baseline mapping conducted between 2014 and 2015 in Darfur and Khartoum documented TF in children aged 1–9 years above the threshold in 11 localities and TT above the threshold in 30 localities, all in the Darfur region.5 These two sets of baseline surveys demonstrated that of 131 localities surveyed, 26 localities required investment in water, sanitation, and hygiene (WASH) programs and between one to three rounds of mass drug administration (MDA) with azithromycin to reduce infection. Seventy-eight localities required TT surgical interventions. Following these baseline surveys, the Sudan Trachoma Control Program began implementation of the SAFE strategy in endemic localities. Seven of these endemic localities, El Fashaga, El Quraisha, and Baladyat el Gedarif localities in Gedarif state; Sawakin locality, Red Sea state; El Dinder locality, Sinnar state; Gaissan locality, Blue Nile state; and Abu Jebaiha locality, South Kordofan state, implemented SAFE activities; however, the degree to which the activities were implemented and the number of years they were implemented varied between localities. For example, when the program began MDA distributions in the seven localities, there were not clear WHO guidelines regarding how many rounds of MDA should be conducted in districts with TF prevalence between 5.0% and 9.9%; therefore, some localities received more rounds than the others (Table 1). In addition, in Abu Jebaiha locality, South Kordofan state and Gaissan locality, Blue Nile state, only one round of MDA was conducted as internal displacement and security concerns between 2012 and 2015 made it difficult for the national program to consistently access the area. For all MDAs conducted in the seven localities, administrative coverage was reported at greater than 80% of the targeted population. Table 1 Trachomatous inflammation-follicular baseline survey results and rounds of mass drug administration for seven localities in Sudan