On Christmas Eve 2024, ophthalmologist Hugh Taylor, MD, received a present that wasn’t under the tree wrapped in paper — it was delivered by email. The message brought news that Australia had submitted a dossier to the World Health Organization (WHO) seeking confirmation of the elimination of trachoma.

“It was the best Christmas present I ever had,” Taylor, the Melbourne Laureate Professor Emeritus in the University of Melbourne’s School of Population and Global Health in Parkville, Victoria, told Medscape News Australia.

At the end of April, the WHO officially declared that Australia had become the 30th country to eliminate trachoma as a public health problem. Trachoma, which is caused by the bacterium Chlamydia trachomatis, is the world’s leading infectious cause of preventable blindless. It’s transmitted by direct or indirect transfer of the eye and nose discharges of infected people, particularly young children.

Until Australia reached its goal of elimination, it was the only developed country in the world that still had endemic levels of trachoma. Affected patients were all Aborigines and Torres Strait Islanders.

Government Commitment Crucial

Trachoma largely disappeared from urban populations in Australia more than 100 years ago following improvements in water quality, sanitation, and hygiene. But nationwide mapping in the 1970s found widespread infections in Aboriginal and Torres Strait Islander communities.

The fact that trachoma remained prevalent for decades highlighted underlying inequality, including disparities in access to clean water, housing, and healthcare. These disparities served as a reminder of the legacy of colonization.

Taylor worked on trachoma elimination for 50 years, initially with Fred Hollows on the National Trachoma and Eye Health Program in the 1970s. In 1997, he returned to a remote community he’d visited in 1977 to find the prevalence of active trachoma in children unchanged at 72%. He was aghast at the lack of progress.

For him, the greatest challenge in eliminating the disease was government commitment.

“The challenge was to get the government to commit and implement funding to do the work. It’s not the photo op, but the follow-up and the measuring and monitoring of what is being done,” he said.

‘The Tyranny of Distance’

Melissa Stoneham, PhD, senior research fellow with the Public Health Advocacy Institute at Curtin University in Perth, Australia, led the #endingtrachoma project for the past 9 years. She agreed with Taylor’s assessment.

“The elimination of trachoma has taken so long because we, as Australians, tend to have this perception that everyone is healthy, has access to services, and can go down to the shops and buy soap if they need it. But that’s only true of urban and most regional centres. As soon as you get out to remote and very remote areas, the situation is different,” she told Medscape News Australia.

“There’s the tyranny of distance, the lack of services, poor house maintenance, and there’s the fact that things like towels, soap, and shampoo cost so much more in remote areas. Some remote communities don’t even have a store anymore.”

The tide shifted in 2006, however, when Australia established its National Trachoma Management Program, which implemented the WHO-recommended SAFE strategy: surgery for trichiasis, antibiotics to treat infection, promotion of facial cleanliness, and environmental improvement. Interventions were delivered through coordinated partnerships between federal and state governments, Aboriginal community-controlled health services, and local communities, the latter of which were crucial to the program’s success, said Taylor.

“The community’s close involvement in developing the health promotion materials, the health promotion itself, and compliance with the antibiotic treatment and so on were [key],” he added.

A Targeted Approach

Instead of implementing widespread drug administration, Australia adopted a targeted approach and provided treatment based on local prevalence. Health promotion — which used a goanna [ie, a lizard] called Milpa to disseminate the message, “Clean Faces, Strong Eyes” — and addressing the environmental risk factors that led to disease was also central to reducing transmission.

Stoneham’s work focused on building the capacity of the Aboriginal Environmental Health Workforce to implement trachoma prevention strategies in remote communities in Western Australia, some of which had a trachoma prevalence of 20% among children.

The specific focus was on the F and E of the SAFE strategy: facial cleanliness and environmental improvement.

“We went into people’s homes — with their permission, of course — and the environmental health workers and our team would jointly do an audit of all the things in the house that affected the ability to wash,” she said, explaining that they looked for broken shower heads, taps that weren’t working, and blocked drains — all the things that could prevent kids from washing their faces.

“Being able to fix those issues in the home was important, and from there, we built the program up with the Rotary’s End Trachoma project to make sure families had the ability and the knowledge about how to wash,” she said.

The team handed out hygiene kits that reinforced Milpa’s Six Steps to Stop Germs, which included soap and different colored towels for each family member, for example. The team fixed plumbing issues, installed new light bulbs, hung up towel hooks, and in some communities provided washing machines.

For Australia to retain its elimination status, it is crucial to ensure that kids’ faces are kept clean and that they have access to safe and functional bathrooms and washing facilities, said Taylor and Stoneham.

Moreover, the emphasis on hygiene, they said, continues to contribute to progress in tackling other infections, such as scabies, otitis media, and respiratory infections, which can lead to rheumatic fever and heart and kidney problems.

“The risk factors for trachoma are like those for other infections. That’s why we used the Six Steps to Stop Germs as our key message because it applies to so many diseases and issues that it was always going to carry on after trachoma was eliminated,” Stoneham said.

Taylor and Stoneham reported having no relevant financial relationships.