Trachoma: From Neglected Disease to Near Elimination

In the dusty deserts of North Africa, the impoverished villages of the Middle East, and the crowded river valleys of the Indus and Ganges in India and the Yellow River in China, children once faced a quiet and persistent threat that became part of daily life and gradually stole their sight. This disease, known as trachoma, did not arrive suddenly like smallpox or cholera. Instead, it came quietly, often beginning in early childhood with mild itching, irritation, and watery discharge from the eyes. In areas with poor hygiene and limited access to clean water, children experienced repeated infections over several years. Each reinfection blurred their vision and limited their ability to read, recognize faces, and play.

Trachoma is the Greek word (τράχωμα) for “roughness,” referring to the inflamed and uneven inner surface of the eyelids seen in advanced stages of the disease.¹ It is an infectious eye condition caused by the bacterium Chlamydia trachomatis, specifically serotypes A, B, and C. Repeated infections in childhood cause scarring of the eyelid. Over time, the eyelid turns inward, a condition called entropion, which causes the lashes to rub against the cornea, severely impairing vision and increasing the risk of blindness.

But trachoma is not just a disease of the eye. It is a disease of poverty, spreading in places where clean water is scarce, soap is unavailable, and basic sanitation remains out of reach. The disease spreads through direct contact with infected eye secretions, especially from children and via indirect transmission, when contaminated towels, clothing, or hands carry the bacteria from one face to another.² Flies that land on infected faces can also transfer the bacteria. One key vector is Musca sorbens, a species of fly that breeds in human feces and is attracted to facial discharge.³ In areas without toilets, open defecation increases fly populations. In the absence of clean and sufficient water, children’s faces remain unwashed, allowing discharge to accumulate and attract flies. These conditions together facilitate a cycle of transmission within households and communities.

Trachoma is a leading infectious cause of preventable blindness worldwide. Trachoma causes about 1.4 percent of all global blindness, with around 1.9 million people suffering from full or partial vision loss due to chronic, untreated infection. It is highly prevalent in many underdeveloped and rural areas across Africa, Asia, the Middle East, and parts of Central and South America. The majority of cases are concentrated in sub-Saharan Africa. As of April 2025, approximately 103 million people live in trachoma-endemic regions and face the risk of blindness caused by the disease, according to the latest World Health Organization data.

Yet in recent decades, trachoma has declined significantly, thanks to focused and sustained public health efforts. This occurred not through miracle cures or vaccines, but by following a clear framework known as the SAFE strategy: S for Surgery to correct in-turned eyelashes, A for Antibiotics to treat infection, F for Facial cleanliness to prevent spread, and E for Environmental improvement through access to clean water, proper latrines, and better waste disposal to reduce fly breeding and transmission.⁴ In the 1950s, the disease blinded millions of people. Today, dozens of countries are on the path to elimination. This is the story of how a long-standing public health burden was brought under control, not through spectacle, but through consistent effort, coordinated programs, and practical solutions.

Trachoma Through the Ages: Historical Burden and Early Recognition

Trachoma is one of the oldest known diseases in human history. Archaeological evidence of trachoma dates back to the Ice Age, around 8000 BC, with lesions found on Pleistocene human skulls in Australia indicating chronic eye infections likely caused by this disease.⁵ By 1500 BC, the Ebers Papyrus from ancient Egypt recorded medical treatments for trachoma, prescribing remedies such as myrrh, lizard’s blood, and bat’s blood. These findings show that trachoma has affected human health since prehistoric times and was recognized as a medical concern in the world’s earliest civilizations.

Trachoma was also found in ancient Greece. Plato, who lived from approximately 428 to 347 BC, is believed to be the first to describe it as an infectious disease. Galen of Pergamum, in the second century AD, gave one of the earliest clinical descriptions of trachoma.⁶ He described trachoma as beginning with small follicles in the tarsal conjunctiva—the thin membrane lining the inside of the eyelids—causing early inflammation. As the follicles enlarge and inflammation worsens, the upper eyelids become rough. This is followed by thickening of the eyelids. As the disease progresses, the follicles mature, and the inner surface of the eyelid becomes thick, rough, and uneven, developing small, raised bumps that give it a fig-like appearance. Eventually, the follicles rupture and are replaced by scar tissue followed by hardening of the eyelid tissue.

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During the year 1798, trachoma became a serious public health concern as Napoleon Bonaparte’s revolutionary army invaded Egypt.⁷ Soldiers from France and Britain developed eye infections, particularly trachoma. Upon their return, they unknowingly carried the infection back to Europe, where it spread rapidly through military camps and civilian populations during the Napoleonic wars. Poor sanitation and overcrowded living conditions further fueled the transmission. Referred to as “Egyptian ophthalmia” or “military ophthalmia,” the disease triggered widespread epidemics globally.

In the 19th century, trachoma was seen as a major threat coming to the US through immigrants from Europe during the third wave of immigration between 1880 and 1930.⁸ The 1891 Immigration Act established compulsory medical inspections at US ports, listing trachoma as a dangerous, contagious condition warranting exclusion from entry to prevent the spread of the disease within the country. During Ellis Island’s peak years (1892-1924), examiners assessed thousands of individuals daily for trachoma, using chalk marks and buttonhooks to identify and screen for symptoms. Those suspected of infection underwent further examination and, if confirmed, were detained, monitored, or deported.

Unveiling the Cause of Trachoma

For many years, scientists around the world struggled to isolate the germ that caused trachoma, which made finding a cure difficult. In the early days, researchers thought a virus or other germ must cause trachoma, but repeated tests failed to confirm this. In China, Feifan Tang, a microbiologist, and his team worked carefully with 227 eye samples from patients. After hundreds of unsuccessful bacterial culture attempts with these tissues between 1932 and 1935, they chose to use chicken eggs to grow the germ in August 1955.⁹ Using this method, they successfully isolated the bacterium C. trachomatis and confirmed it was the true cause of trachoma. Their work allowed scientists worldwide to develop better treatments and start using antibiotics to combat trachoma.

Attempts to control trachoma with antibiotics before the 1990s were mostly disappointing, largely due to severe side effects and poor compliance.¹⁰ Mass administration of oral sulfonamides in the 1930s and 1940s caused serious adverse reactions, including the life-threatening Stevens–Johnson syndrome, leading to abandonment of this approach. In the 1950s and 1960s, countries adopted mass distribution of tetracycline eye ointment, but this intervention failed because the ointment required twice-daily use for six weeks to be effective and was associated with poor compliance among patients, especially children.

In the early 1990s, infectious disease researchers David Mabey and Robin Bailey at the London School of Hygiene and Tropical Medicine faced similar challenges in The Gambia, where compliance with the standard tetracycline regimen remained low. In 1993, they published a landmark trial showing that a single oral dose of azithromycin was as effective as the supervised tetracycline regimen.¹¹ However, reinfection remained common due to untreated individuals in the community. To address this, Mabey and Bailey led a multicenter study with Johns Hopkins University and the University of California, San Francisco, demonstrating that mass treatment with oral azithromycin matched or exceeded the effectiveness of ointment-based approaches at the community level.¹²

Turning Point: The SAFE Strategy and Global Partnerships

Recognizing the need for an integrated approach to eliminate this blinding disease, the World Health Organization (WHO) introduced the SAFE strategy in 1993 as a groundbreaking global framework for its control and prevention.

Three years later, the WHO created a global group to strengthen the fight against trachoma, becoming the WHO Alliance for the Global Elimination of Trachoma (GET) and showing a broad commitment from many sectors. GET is still active today. It is a working group of non-governmental development organizations, foundations, and other interested parties that meet up to encourage careful planning, promote advocacy, support research, and coordinate programs for trachoma control. Their work focused on reaching the GET 2020 goal, which aimed to remove trachoma as a major health problem by 2020.

In 1998, Pfizer partnered with the Edna McConnell Clark Foundation to launch the International Trachoma Initiative (ITI), pledging to donate 10 million doses of antibiotics for five years to fight trachoma. By 2003, Pfizer increased this commitment to 35 million doses for the following five years, significantly expanding treatment access in affected regions. Since its inception, ITI has delivered 1 billion antibiotic doses, benefiting over 300 million people across 40 countries. Thanks to these efforts and the WHO-supported SAFE strategy, trachoma prevalence dropped by 92 percent in 2021, and the number of people at risk decreased from 1.5 billion to 136 million between 2002 and 2021.

Building on this global momentum, the International Coalition for Trachoma Control (ICTC) began in 2004 as a collaborative group that works to end trachoma by uniting charities, researchers, donors, and companies to support countries in using the WHO’s SAFE approach.¹³ In support of these initiatives, the charitable foundation the Queen Elizabeth Diamond Jubilee Trust supported trachoma elimination efforts. Over a five-year period, the Trust delivered 26.6 million antibiotic eye treatments and carried out 102,400 sight-saving surgeries across seven countries: Kenya, Malawi, Mozambique, Nigeria, Tanzania, Uganda, and Zambia. Around the same time, the UK Department for International Development played a pivotal role in the fight against trachoma by investing £40 million to support elimination efforts in endemic countries such as Ethiopia, Nigeria, Zambia, Chad, and Tanzania through the SAFE strategy.

In 2020, the ICTC published the “2020 INSight” report, providing a comprehensive roadmap for the global elimination of blinding trachoma. The total cost to address the confirmed disease burden is estimated at about $430 million, covering interventions such as surgery, drug distribution, face washing promotion, and environmental improvements. Surgery alone accounts for $182 million, while drug distribution costs approximately $94 million with major contributions from Pfizer’s donation program. Face washing campaigns and environmental improvements, including latrine construction and water sanitation, contribute $28 million and $112 million, respectively. Investment in trachoma elimination is highly cost-effective, translating every $20 spent into one additional person free from vision loss each year. Beyond health benefits, eliminating trachoma can provide a 20–30 percent boost to the gross domestic product of affected African regions by reducing productivity losses. ICTC set out its 2022–2030 plan to push for stronger advocacy, increased funding, and expanded technical support. The plan also stresses that trachoma care should be part of regular national eye health services so that surgery, treatment, and follow-up remain accessible and sustainable within health systems.

Additionally, modern philanthropic organizations including the Bill & Melinda Gates Foundation, Children’s Investment Fund Foundation, ELMA Foundation, and UK aid contributed a combined $105 million fund to accelerate the Trachoma Elimination Program.

Towards a Trachoma-Free Future

In June 2022, Pfizer extended its donation program to 2030, supporting ongoing trachoma elimination efforts in 18 countries. As progress continued, the World Health Assembly’s 2021–2030 Neglected Tropical Diseases road map sets the goal of global elimination of trachoma by 2030. The original target year of 2020 was extended to 2030 to allow for a more comprehensive and integrated approach, ensuring sustained commitment and collaboration to meet this goal. Experts remain hopeful that this target will be met with continued effort. As of November 2025, WHO validated that 27 countries have eliminated trachoma as a public health problem: Benin, Burundi, Cambodia, China, Egypt, Fiji, Gambia, Iran, the Lao People’s Democratic Republic, Ghana, India, Iraq, Malawi, Mali, Mauritania, Mexico, Morocco, Myanmar, Nepal, Oman, Pakistan, Papua New Guinea, Saudi Arabia, Senegal, Togo, Vanuatu, and Vietnam.

The long story of trachoma shows how a disease linked to poverty, poor hygiene, and lack of water can slowly disappear when the world works together. For centuries, trachoma silently stole the sight of millions, especially children. But over the past few decades, through steady efforts and support from many partners, many countries have pushed back this ancient disease.

What made this progress possible was not a sudden cure, but a simple, practical strategy: clean faces, clean water, good sanitation, eye surgery, and effective antibiotics. With the help of global groups, charities, donors, and local communities, 27 countries have now officially ended trachoma as a public health problem. This is a major achievement.

However, the journey is not yet over. Some regions still face challenges, particularly in places where access to clean water, sanitation, and eye care remains limited. To complete the task, we must continue investing in hygiene promotion, community health, and eye care services, making sure every person can benefit. With continued commitment, a world free from this ancient disease is within reach.