Impact of Mass Azithromycin Administration on Overcoming Barriers to Trachoma Elimination

Objectives

To assess the effectiveness of azithromycin Mass drug administration (MDA) in reducing trachoma

Introduction

Trachoma is a chronic ocular infection caused by Chlamydia trachomatis and remains concentrated in low-socioeconomic settings (LSES) (Melese et al., 2004). The WHO SAFE strategy underpins global control efforts, with azithromycin playing a key role; however, implementation in resource-limited regions continues to be affected by infrastructure, logistical constraints, and community resistance (Nash et al., 2018; Sanders et al., 2019).

Methodology

A structured review was undertaken using the PICO framework:

• Population: Communities with high trachoma prevalence.
• Intervention: MDA od azithromycin under the SAFE strategy.
• Comparison: Communities receiving standard care or no mass administration.
• Outcome: Reduction in trachoma prevalence

Searches were conducted in PubMed and Scopus for studies published between 2019 and 2025, using combinations of the keywords “trachoma,” “azithromycin,” “mass drug administration,” “SAFE strategy,” and “prevalence.”

Inclusion criteria encompassed peer-reviewed field studies, clinical trials, and implementation analyses reporting post-MDA outcomes. Data were extracted on study setting, MDA rounds, coverage, and post-treatment prevalence, and findings were synthesised narratively.

Results

Across the eight selected studies, repeated azithromycin MDA within the SAFE strategy significantly reduced trachoma burden in LSES settings. In Ethiopia, active trachoma prevalence decreased from approximately 30% to <5% over five years (Nash et al., 2018). A separate study in LSES districts of the ‘Amhara region’ reported a reduction from 20% to <2% among preschool-aged children following multiple MDA cycles (Nash et al., 2020). In the ‘Gambella region’, three MDA rounds enabled several districts to reach post-MDA elimination thresholds (Alemayehu et al., 2024). A similar impact was observed in Sudan, where population-based surveys reported up to a 70% reduction across seven localities (Sanders et al., 2019). Systematic reviews considering ocular chlamydia rather than active signs confirmed consistent prevalence reductions across LSES regions, highlighting the need for repeated rounds and continued surveillance (Xiong et al., 2021; Mahmud et al., 2021).

 

However, multiple barriers to MDA exist including accessibility, limited community acceptance, inadequate Water, Sanitation, and Hygiene (WASH) infrastructure, and socio-economic constraints. Participation in the Goro district was 2–7 times higher among individuals with higher educational attainment (Feyisa et al., 2022). In the Colombian Amazonas region, implementation was impacted by geographic isolation and community mistrust; however, culturally tailored communication improved acceptance (Trujillo-Trujillo et al., 2024). Additional recurring barriers included difficult terrain and access limitations affecting programme reach (Sanders et al., 2019; Trujillo-Trujillo et al., 2024), persistent WASH deficiencies limiting sustained impact (Alemayehu et al., 2024; Xiong et al., 2021), and socio-economic constraints contributing to inconsistent coverage (Feyisa et al., 2022; Sanders et al., 2019).

 

Discussion

The reviewed studies jointly highlight on the remarkable effectiveness of azithromycin in reducing trachoma prevalence when integrated within the WHO SAFE framework. Nonetheless, multiple challenges arise in applying treatment guidelines to reach sustainable trachoma elimination. In Ethiopia, despite high reductions, resistance to participation and inadequate sanitation limited success. In addition, previous infection data was absent prior to the administration of MDA, which limited the measurement effectiveness(Nash, Stewart et al. 2018). In Sudan, socio-economic barriers and poor access to remote areas hindered universal coverage, posing challenges in comparing prevalence across different localities(Sanders, Abdalla et al. 2019). Similarly,(Nash, Chernet et al. 2020) emphasised that repeated interventions were necessary to maintain low infection rates, indicating persistent reintroduction of infection in high-risk communities.  Therefore, effectiveness of azithromycin MDA was linked to the prevalence of trachoma among various districts, as 2020 goals of WHO in eradication were not met (Xiong, Yue et al. 2021).

A consistent theme across all studies is the mutual reliance between medical intervention and socio-environmental reform. Antibiotic administration alone cannot eradicate trachoma without parallel improvements in clean water supply, sanitation, and community engagement (Alemayehu, Mekonen et al. 2024). Moreover, Education level or proper knowledge were linked to 2 to 7 times higher participation in treatment campaigns (Feyisa, Bekele et al. 2022). Thus, transparent communication, through native speakers accepted by community, about drug safety is vital to counter misinformation improving participation (Trujillo-Trujillo, Zamora et al. 2024)

 

 

Conclusion

Azithromycin MDA remains the highest effective intervention for controlling trachoma in endemic settings. Substantial reductions in prevalence have been achieved across Ethiopia Sudan and Colombia, confirming its pivotal role in the WHO SAFE strategy. However, the spread of community resistance, logistical barriers, and inadequate WASH infrastructure continues to threaten sustainability on the long term. Future visions should prioritise overcoming implementation barriers, strengthening WASH and community engagement alongside antibiotic strategies to ensure durable trachoma elimination and prevent the biggest cause of blindness globally.

 

 

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