F&E activities and F&E research are often underfunded and underprioritized in trachoma elimination efforts. This World Water Day, ICTC invites you to join us to develop an actionable agenda to accelerate F&E progress within trachoma elimination programs. Register your interest here. 

Facial cleanliness and environmental improvement (F&E) are pillars of the World Health Organization (WHO)-endorsed SAFE strategy to eliminate trachoma as a public health problem. However, too often, F&E activities, and F&E research, are under-prioritized and underfunded in trachoma programs, despite being essential to reduce transmission and sustain trachoma elimination.

The lack of funding for F&E activities within trachoma programs is, in part, related to a perception that F&E programs are expensive and that there is not sufficient evidence to support investment in any specific WASH interventions to reduce trachoma prevalence. This perception is contrary to evidence from observational studies that show clean faces, use of soap, reduced distance to water, and access to a latrine are associated with reduced prevalence of trachoma and ocular Chlamydia trachomatis infection. A strong evidence base for F&E programs is however difficult to establish because programs vary widely in the strategies they employ, a variety of outcome and process measures are used to assess efficacy, and too few program evaluations are published. 

To achieve the elimination of trachoma as a public health problem by 2030, national trachoma programs would benefit from increased guidance, particularly related to indicators to measure facial cleanliness and environmental improvement, and coverage levels that might need to be achieved to successfully reduce transmission. However, empirical evidence to support this guidance is limited. 

Recent research utilizing modeling techniques and data collected through the Global Trachoma Mapping Project and Tropical Data explored the relationship between face-washing water and latrine use coverages and the prevalence of trachomatous inflammation—follicular among children aged 1–9 years (TF1-9). The model estimated that for evaluation units (EUs) which had not yet met the TF1-9 elimination target, increasing access to nearby face-washing water and latrine use coverages above 30% were generally associated with consistent decreases in TF1-9 prevalence. The model estimated a decrease in TF1-9 prevalence of at least 25% when access to water was at 65% coverage. Further, the estimated decrease in TF1-9 prevalence accelerated starting from 80% coverage of latrine usage, with a decrease in TF1-9 prevalence of at least 25% when latrine usage reached 85% coverage.

This study provides insights into the relationship between trachoma and WASH-related coverages under certain conditions. However, the paper also acknowledges that the same patterns were not observed in areas that had already met trachoma elimination targets – suggesting a need for additional research to explore the WASH-TF1-9 relationship in this context.

Going forward, the trachoma community must do more to bring together its diverse stakeholders, including WASH partners, to identify the major evidence gaps and resources required, including the breadth of cross-sectoral collaboration and coordination, to achieve scale-up of F&E activities. This might include improved understanding of WASH coverage targets, identifying indicators to measure facial cleanliness and environmental improvement, and an improved understanding of the economics and return on investment for F&E activities. 

To facilitate cross-sectoral collaboration, several key resources have been developed, including Ending the neglect to attain the sustainable development goals: A global strategy on water, sanitation and hygiene to combat neglected tropical diseases 2021–2030. The strategy sets out the critical role of WASH for prevention, care and management of NTDs, and the actions needed to ensure that WASH efforts result in improved and sustained health and wellbeing outcomes. Furthermore WASH and health working together: A ‘how-to’ guide for neglected tropical disease programmes, published by the World Health Organization and Neglected Tropical Disease NGO Network in 2019, with a second edition to be launched in 2023, provides step-by-step guidance to NTD program managers and partners on how to engage and work collaboratively with the WASH community to improve delivery of WASH services to underserved populations affected by NTDs, including trachoma.

The International Coalition for Trachoma Control (ICTC) Strategic Plan 2022-2030 commits to bringing stakeholders together to share programmatic experiences and generate evidence to increase investment and support the provision of technical assistance through the development of preferred practices – including F&E. This World Water Day, ICTC is acting on its commitment by convening ICTC members and observers, and other stakeholders with relevant experience, to define a path forward, to identify research gaps, refine advocacy messaging and develop tools that will drive new investment for F&E and advance the global elimination of trachoma by 2030. 

Register your interest here. 

This blog was written by:

• Sarity Dodson, Research Director, The Fred Hollows Foundation, co-Chair, Neglected Tropical Disease NGO Network (NNN) Water, Sanitation, and Hygiene Working Group

• Kristin M. Sullivan, Senior Associate Director of Programs, Children Without Worms (The Task Force for Global Health)

• Angelia Sanders, Chair, International Coalition for Trachoma Control