Trachoma

Europeans called it Egyptian ophthalmia because Napoleon's invading armies had first encountered this communicable dis ease in the Nile Valley. Large numbers of British troops, stationed in the Middle East during the early 191'1 Century, also contracted this infection; and many were then rendered unfit for military duty because of the blindness which it caused.

This was not, of course, a newly confronted ailment. It had been well known in antiquity and was fully described in ancient Egyptian papyri. Historically it represented a recurrent medical hazard with each military incursion in the Middle East. The Macedonian troops of Alexander, the Roman legions of Vespasian and the Crusader armies all became afflicted with this painful eye disease.

Because of the inflamed surfaces of the affected eyeballs and the sandpaper-like granularity of the inner eyelids, the Greeks called the disease, trachoma, a word meaning roughened.

Galen [c.l 30-200CE] provided medicine with a detailed description of trachoma and its clinical evolution. It commenced as an acute conjunctival irritation with much redness and itching. Sometimes it resolved spontaneously; but if it persisted [often because of repeated re-infection] the inner eyelid surfaces assumed a characteristically thickened, reddish granularity associated with much pain. The resultant scarring caused the upper eyelids to invert [a condition called trichiasis], thus impelling the misdirected eyelashes to rub repeatedly again the conjunctival surface. Over the years, the irritated eyeball surface became irreversibly scarred, causing blindness.

Trachoma remained a communicable disease of the tropics, particularly the arid lands of the Middle East, until the Crusaders brought it back to the heartland of Europe. The major importation of trachoma from the Middle East to the European continent, however, did not come about until the early decades of the 19'1' Century, particularly with the French and British troops returning from northern Egypt. By the middle decades of the 19'1' Century, there were pockets of trachoma throughout much of Europe.

European physicians documented the following about the disease: It was clearly communicable although the causative organism was not identified until the early 20'1' Century. It was virtually confined to the crowded and impoverished ghettocs of the continent, largely a disease of children, and particularly children with no access to running water for the washing of their faces.

Trachoma came to American shores in the mid-19'1' Century in the infected eyes of immigrant children. By 1880 it constituted a major public health threat to the vision of poorer children on the east coast cities and the Immigration Service then declared that trachoma-along with tuberculosis, epilepsy, syphilis and mental deficiency-represented grounds for denying entry to this nation. Parents in countries of eastern and southern Europe now had an additional source of anxiety: for if their children showed the characteristic redness of their eyes, the entire family might then be returned to the old country. It was not unusual for mothers to blindfold their children at the beginning of the lengthy transatlantic voyage so as to diminish any contact with eye irritants. The number of immigrants actually barred, because of trachoma, was relatively small. During the interval from 1880 to 1920, an estimated 20,000 were rejected, expressly because of trachoma, in an immigrant population numbering m the many millions.

As the standard of living for the newly arrived families improved, as running water became a near-universal urban resource, and as the levels of literacy and personal hygiene were elevated, the endemicity of trachoma diminished; and by the mid-1920s the disease disappeared in the United States, except in an occasional newly-arrived immigrant.

And the remainder of the world? Trachoma continues to be the leading cause of preventable blindness in the world today, particularly in the impoverished sub-Saharan nations, the countries of the Middle East and southern Asia. Prevalence is highest in children between the ages of 2 and 5 years. The World Health Organization (WHO) estimates that there are about 146 million people, worldwide, with active trachoma nd perhaps 14 million permanently blinded by the infection. The heaviest infestations arc found in Mali, Sudan, Morocco, Ghana, Egypt, Ethiopia, Niger, Tanzania, Vietnam and Nepal.

Trachoma is caused by a micro-organism in the Chlamydia family. It is an infectious process which can be abruptly halted by a single dose of a systemic antibiotic called azichromycin. This medication costs less than 40 cents per treatment; and it would appear, simplistically, that a determined and morally motivated global community might easily eliminate the scourge of trachoma in one massive program. But the real world is not that simple. Many, perhaps most, trachoma cases are in small villages. Health care teams may then go from village to village dispensing azithromycin, thus curing the infected children [and infected adults, usually mothers who are in continuous contact with children]. But while one corner of a village is being treated, the children cured last week are concurrently being reinfected. Clearly, a concerted, meticulously and broadly coordinated global program was needed.

In 1 989 such a WHO program was begun [called the International Trachoma Initiative], with the active participation of the Clark, Gates, Rockefeller and Hilton Foundations and other organizations, as well as the Pfizer Company, which committed itself to provide free azithromycin until the year 2020, the target date for the worldwide extinction of trachoma. The initiative includes a program to train local health workers to perform a brief operative procedure to re-orient the inverted eyelashes in advanced cases of trachoma, a coordinated azithromycin delivery program, an intensive educational initiative for children in the rudiments of personal hygiene, and a parallel program to build clean water facilities in the affected villages. By last year over 30,000 cyclic! surgeries had been undertaken and over 2.8 million children treated. In many of the programmed nations, trachoma has already been reduced by almost 50%.

For centuries, perhaps millennia, millions have been blinded by the Chlamydia organism. Blindness from trachoma need not be; and a feasible program is now underway to reduce if not eradicate the disease by the year 2020.

STANLEY M. ARONSON, MD, MPH

Copyright Rhode Island Medical Society Apr 2004
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