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In this work, we aim to evaluate the trends and cross-country inequalities of the global trachoma burden from 1990 to 2021 and to project its burden to 2040.
Methods
This study was a systematic analysis of the Global Burden of Diseases Study (GBD) 2021. Estimates for the prevalence and disability-adjusted life-years (DALYs) of trachoma were extracted from the GBD 2021 database. Epidemiological characteristics of trachoma were reported at the global, regional, and national levels. Trend analysis, decomposition analysis, and health inequality analysis were used. The global trachoma burden was further projected to 2040 via Bayesian age–period–cohort analysis.
Results
Globally, 1,414,047 people were estimated to have trachoma in 2021, with an age-standardized prevalence rate of 16.37 per 100,000 population. Between 1990 and 2021, the prevalent cases and DALY numbers of trachoma decreased by 30.2% and 34.4%, respectively. In 2021, Eastern Sub-Saharan Africa was the region, and Ethiopia was the country with the highest number of trachoma cases. Decomposition analysis revealed that the reduction in the global burden was attributed primarily to epidemiological changes. From 1990 to 2021, countries with lower sociodemographic indices (SDIs) disproportionately bore the heaviest burden. While the prevalence and DALY rates are projected to decrease from 2022 to 2040, the prevalent cases and DALY numbers are expected to increase.
Conclusions
Over the past three decades, the global burden of trachoma has decreased significantly, but SDI-related inequalities among countries have persisted. Despite reductions in the prevalence rate, the number of patients with trachoma is projected to increase from 2022 to 2040. Our study provides valuable insights into the elimination of trachoma worldwide.
Trachoma is the leading infectious cause of blindness and remains a public health problem in many countries, despite the global efforts aimed at its elimination.
This study aimed to provide a comprehensive assessment of the global, regional, and national burden, trends, and inequalities of trachoma using the latest data from the Global Burden of Diseases Study 2021.
What was learned from the study?
While substantial progress has been achieved in reducing the trachoma burden since 1990, disparities have persisted between countries, with those having lower sociodemographic indices disproportionately bearing the heaviest burden.
Despite the projected decline in trachoma prevalence by 2040, the number of patients with trachoma is expected to increase.
These findings enhanced our understanding of the global trachoma landscape and may inform targeted interventions to achieve the goal of trachoma elimination.
Introduction
Trachoma is a chronic form of conjunctivitis caused by recurrent infection with specific strains of Chlamydia trachomatis [1, 2]. This disease can cause conjunctival scarring, entropion, trichiasis, and, if left untreated, may eventually progress to corneal opacity and blindness [3]. Currently, trachoma is the most common infectious cause of blindness, accounting for 1.3 million cases of blindness worldwide [4].
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In 1996, the World Health Organization (WHO), in cooperation with several nongovernmental organizations (NGOs), embarked on an ambitious international trachoma control program titled “the WHO Alliance for the Global Elimination of Trachoma by the year 2020 (GET2020)” [5]. This groundbreaking program has, to some extent, succeeded in reducing the burden of trachoma on a global scale [6]. However, trachoma currently remains a public health challenge in many countries and regions, with 125 million people still living in trachoma-endemic areas and facing the risk of trachoma-related blindness [7]. According to the WHO, the annual economic burden attributed to productivity losses by trachoma is approximated US $8 billion [7]. However, as a “neglected tropical disease”, few studies have comprehensively investigated its disease burden, such as its geographical distribution and health inequalities.
To advance the understanding of trachoma epidemiology, this study aimed to provide a comprehensive assessment of the burden, trends, and inequalities of trachoma using the latest data from the Global Burden of Diseases Study (GBD) 2021. This research included: (1) a descriptive analysis of the global, regional, and national trachoma burden from 1990 to 2021; (2) a trend analysis for the dynamic changes in trachoma burden over time; (3) a decomposition analysis dissecting changes in trachoma burden into population aging, population growth, and epidemiological changes; (4) a health inequality analysis quantifying the cross-country inequalities in trachoma burden in relation to the sociodemographic index (SDI); and (5) a prediction for the anticipated global trachoma burden up to 2040.
Methods
Overview
This study is a systematic analysis of the GBD 2021 data. Data were obtained via the GBD Results Tool from the Global Health Data Exchange (GHDx) website (https://ghdx.healthdata.org/gbd-2021). The GHDx has provided high-quality disease data on the burden of 371 diseases and injuries in 204 countries and territories worldwide, including trachoma [8]. More details on the protocols and methodology of GBD 2021 are available elsewhere [9].
This study adhered to the Guidelines for Accurate and Transparent Health Estimates Reporting (the GATHER statement) and the tenets of the Declaration of Helsinki [10]. The University of Washington Institutional Review Board Committee approved the GBD 2021 (approval number STUDY00009060). No identifiable data was used in this study.
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Data Collection
In GBD 2021, trachoma epidemiology was documented in 60 countries (territories) worldwide, grouped into 13 GBD regions that are geographically proximate. A list of the 60 countries (territories) can be found in Table S1. Trachoma data from 1990 to 2021 were collected based on sex (female, male, or both), SDI level (high, high-middle, middle, low-middle, or low), and geographical scope (global, regional, or national).
Statistical Analysis
Descriptive Analysis
We used prevalence and disability-adjusted life-years (DALYs) as indicators to quantify the burden of trachoma. Both indicators are reported in two forms: the absolute number and the age-standardized rate (ASR) per 100,000 population, along with the corresponding 95% uncertainty intervals (UIs). The DALY is a summary indicator that combines time lost to premature death and time lived in a less-than-ideal state of health (collectively referred to as "disability"). In this study, DALYs were calculated by summing the years of life lost (YLLs) as well as years lost due to disability (YLDs) attributed to visual impairment caused by trachoma. In short, each DALY related to trachoma is equivalent to 1 year of healthy life lost due to the disease.
Trend Analysis
To evaluate the evolving trends in trachoma burden (i.e., prevalence and DALYs), we employed a joinpoint regression analysis. Joinpoint regression has two pivotal parameters: annual percentage changes (APCs), which illuminate trends in trachoma burden within different joinpoint segments, and average annual percentage changes (AAPCs), which provide a measure of the overall trends from 1990 to 2021.
Decomposition Analysis
To understand the main drivers of the changes in trachoma burden between 1990 and 2021, we performed a decomposition analysis, which divides the overall changes in the burden into three factors: (1) population aging, (2) population growth, and (3) epidemiological changes [11].
Inequality Analysis
To investigate the SDI-related cross-country health inequalities in trachoma burden, we compared the disease burden across five SDI regions and analyzed the relationships between SDI and trachoma prevalence, DALYs, as well as corresponding AAPCs.
The SDI is a composite indicator that integrates income, education, and fertility conditions to assess development status, which is strongly linked to health outcomes [12]. This index spans a scale of 0 to 1, where an SDI value of 1 signifies a theoretical maximum level of development and 0 represents the minimum. In GBD 2021, countries or territories with an SDI above 0.81 are considered to have a high level of development, those with an SDI of 0.71–0.81 are designated as high-middle, 0.62–0.71 as middle, 0.47–0.62 as low-middle, and below 0.47 as low.
Prediction Analysis
To better understand the impact of trachoma on global health in the next two decades, we further conducted a prediction of the global trachoma burden up to 2040. A range of models have been developed for projecting disease burdens. Among these models, the Bayesian age-period-cohort analysis model with integrated nested Laplace approximation was selected as the prediction model due to its superior coverage and precision [13, 14].
Statistical analyses and visualization were accomplished via R software (version 4.3.3) and GraphPad Prism software (version 9.5.1). A two-tailed P value < 0.05 was considered to be statistically significant.
Results
Descriptive Analysis of Trachoma Burden
At the global level, the prevalent cases, ASR of prevalence, DALY numbers, and ASR of DALYs exhibited dramatic downward trends from 1990 to 2021. Specifically, the number of prevalent cases of trachoma decreased by 30.2%, from 2,026,157 in 1990 to 1,414,047 in 2021. Accordingly, the ASR of prevalence decreased by 67.9%, from 51.01 per 100,000 population in 1990 to 16.37 per 100,000 population in 2021. Meanwhile, the DALY number and ASR of DALYs decreased by 34.4% and 70.0%, respectively. In 2021, female patients accounted for 60.6% and 61.5% of the prevalent cases and DALY numbers of trachoma, respectively (Table 1).
Table 1
Global and regional burden of trachoma, 1990 to 2021
Within parentheses were 95% uncertainty intervals for numbers and ASRs, and 95% confidence intervals for AAPCs, respectively. All P values were < 0.001 for AAPCs
At the regional level, Eastern Sub-Saharan Africa was the region with the highest burden of trachoma in 2021, reporting the highest number of prevalent cases, ASR of prevalence, DALY numbers, and ASR of DALYs. In 2021, 49.2% of the global patients with trachoma, amounting to 695,940 out of 1,414,047, lived in this region. The ASR of prevalence in Eastern Sub-Saharan Africa (420.59/100,000) was also 25.7 times the global level (16.37/100,000). In 2021, South Asia ranked second in terms of prevalent cases and DALY numbers, whereas Sub-Saharan Africa ranked second with respect to the ASR of prevalence and DALYs (Table 1).
At the national level, the top three countries with the highest number of trachoma cases in 2021 were Ethiopia (552,129), India (356,503), and Somalia (103,882), whereas the top three countries with the highest ASR of prevalence were Somalia (1703.09/100,000), Ethiopia (1270.23/100,000), and Niger (361.40/100,000). In 2021, Ethiopia (40,209), India (31,432), and Nigeria (7844) had the highest DALY numbers, whereas Somalia (118.95/100,000), Ethiopia (91.61/100,000), and Niger (22.16/100,000) had the highest ASR of DALYs. In 2021, Ethiopia, India, and Somalia accounted for 71.6% (1,012,514 of 1,414,047) of the global patients with trachoma (Fig. 1, Table S1).
Fig. 1
Global map of trachoma burden, 2021. A ASR of prevalence in 2021; B ASR of DALYs in 2021. ASR age-standardized rate, DALY disability-adjusted life-year
Globally, the ASR of prevalence and DALYs of trachoma decreased by an average of − 3.60% (AAPC = − 3.60) and − 3.77% (AAPC = − 3.77) per year from 1990 to 2021, respectively (Table 1). Specifically, the ASR of prevalence and DALYs decreased from 1990 to 2006, with the fastest decline observed between 2006 and 2009 (APC = − 5.12 and − 5.44, respectively), followed by a slowing declining trend from 2009 to 2021 (Fig. 2A, B). Notably, both the ASR of prevalence (AAPCmale = − 3.80, AAPCfemale = − 3.45) and DALYs (AAPCmale = − 4.05, AAPCfemale = − 3.62) declined more rapidly in male patients compared to female patients (Fig. 2 C, D). Regionally, the fastest decreases in the ASR of prevalence and DALYs were observed in East Asia (AAPC = − 7.37) and North Africa and the Middle East (AAPC = − 7.17), respectively (Table 1). Nationally, from 1990 to 2021, the age-standardized burden of trachoma decreased in nearly all countries and territories, with only a few exceptions: Kenya and Mexico experienced an increase in the prevalence rate, and Kenya saw an increase in the DALY rate (Table S1).
Fig. 2
Joinpoint analysis of the global burden of trachoma, 1990 to 2021. A Joinpoint analysis of the ASR of prevalence; B Joinpoint analysis of the ASR of DALYs; C Joinpoint analysis of the ASR of prevalence for both sexes; D Joinpoint analysis of the ASR of DALYs for both sexes. AAPC average annual percentage change, APC annual percentage change, ASR age-standardized rate, DALY disability-adjusted life-year. * Time segments in which the changes in trend were statistically significant (P < 0.05)
Overall, the prevalent cases and DALYs of trachoma have decreased significantly globally over the past three decades, with the largest reduction observed in the low-middle SDI quintile (Fig. 3). The contributions of population aging, population growth, and epidemiological changes to the global decrease in prevalent cases were − 81.23%, − 137.13%, and 318.36%, respectively. Similarly, for the global decrease in DALY numbers, these factors contributed − 92.07%, − 158.34%, and 350.41%, respectively (Table S2). In other words, at the global level, population aging and population growth have acted as unfavorable factors in reducing the trachoma burden, while epidemiological changes have been favorable. Epidemiological changes have imposed the greatest positive influence on changes in the trachoma burden, with one exception: population aging was the most significant influencer of change in prevalent cases for the high-SDI quintile.
Fig. 3
Decomposition analysis for changes in trachoma burden by SDI, 1990 to 2021. A Decomposition analysis for change in case number; B Decomposition analysis for change in DALY number. For each component, a positive value signifies a contribution to the increase in trachoma burden, while a negative value signifies a contribution to the decrease in trachoma burden. The magnitude of the components represents the degree of the corresponding contributions. DALY disability-adjusted life-year, SDI sociodemographic index
Longitudinally, from 1990 to 2021, the ASR of prevalence and DALYs decreased significantly in all SDI quintiles. The largest decline was observed in the low SDI quintile, where the ASR of prevalence and DALYs dropped from 541.45/100,000 and 45.51/100,000 in 1990 to 198.30/100,000 and 15.57/100,000 in 2021, respectively. Horizontally, the burden of trachoma, either in terms of prevalence or DALYs, exhibited a negative correlation with the SDI quintile, specifically manifested as a gradual increase in trachoma burden as the SDI quintile decreased from high to low (Fig. 4, Table S3).
Fig. 4
Temporal trends of trachoma burden in regions with different SDI levels, 1990 to 2021. A Trend of the ASR of prevalence; B Trend of the ASR of DALYs. ASR age-standardized rate, DALY disability-adjusted life-year, SDI sociodemographic index
In 2021, at the national level, we found significant negative correlations of country SDI with the ASR of trachoma prevalence and DALYs (Figure S1 A, C). This suggested an overall negative correlation between the trachoma burden and the socioeconomic development level across countries. However, the AAPCs in both ASR of prevalence and DALYs did not exhibit significant correlations with the country SDI, implying that the rate of change in trachoma burden was largely independent of the socioeconomic development level (Figure S1 B, D). This finding aligns with the trend analysis results, which indicated a significant decrease in trachoma burden across almost all countries over the past three decades.
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Prediction Analysis of Trachoma Burden to 2040
Based on the Bayesian age–period–cohort analysis model, it is projected that the ASR of trachoma incidence and DALYs will decrease annually by 2040 at the global level. This trend stands in contrast to the anticipated increase in the number of prevalent cases and DALYs during the same period (Figure S2). The global number of patients with trachoma is expected to increase by 23.6%, from 1,414,047 in 2021 to 1,747,096 in 2040.
Discussion
The current study provided a comprehensive and up-to-date picture of the global, regional, and national trachoma burden from 1990 to 2021 and systematically assessed this burden through trend, decomposition, health inequality, and burden prediction analyses. Despite cross-country variations, the overall global burden exhibited a declining trend from 1990 to 2021. Decomposition analysis revealed epidemiological changes as positive contributors to burden reduction, whereas population aging and growth as factors driving the increase in trachoma burden. Health inequality analysis revealed significant inverse associations between SDI and the ASR of trachoma prevalence/DALYs, with low-SDI countries disproportionately bearing the heaviest burden. Notably, projections indicate that while the ASR of prevalence and DALYs are anticipated to decline from 2022 to 2040, the prevalent cases and DALY numbers will increase, underscoring the upcoming challenge in global trachoma eradication efforts over the next two decades.
Worldwide, trachoma accounted for 1,414,047 prevalent cases and 123,190 DALY numbers in 2021. The heaviest burden was observed in Eastern Sub-Saharan Africa, where the ASR of prevalence was 25.7 times the global average. Poor sanitation conditions, inadequate awareness of trachoma, economic constraints, and limited access to medical care were all contributing factors responsible for the widespread transmission of trachoma in this region [15‐17]. In addition, Western Sub-Saharan Africa, North Africa and the Middle East, as well as South Asia, were also noteworthy regions because their ASR of prevalence and DALYs were all significantly higher than the global average. At the national level, Ethiopia stood out in 2021 with the highest number of prevalent cases and DALYs, whereas Somalia reported the highest ASR of prevalence and DALYs. Despite the implementation of the SAFE strategy (surgery, antibiotics, facial cleanliness, and environmental improvements) and mass drug administration (MDA) of azithromycin, which led to a decrease in trachomatous inflammation–follicular in Ethiopia, trachoma continues to pose a significant public health concern in this country [18, 19]. In 2021, the WHO estimated that nearly 460,000 patients in Ethiopia were still in need of surgical intervention for trachomatous trichiasis, the advanced, vision-threatening stage of the disease [20]. Recently published literature indicates that the prevalence of active trachoma among children aged 1–9 years varies between 9.5 and 47.7% across different regions of Ethiopia, with an estimated pooled prevalence of 24% using a random effects model [21‐24]. This underscores the persistent challenge that trachoma presents to Ethiopia's public health system, highlighting the necessity for consistent and focused intervention strategies. Despite advancements in reducing specific manifestations of the disease, the high incidence of active trachoma among young children emphasizes the pressing need for sustained efforts to eradicate this avoidable cause of blindness. Although literature on the trachoma epidemic in Somalia is limited, its geographical proximity and epidemiological similarities with Ethiopia underscore the need for urgent attention to the trachoma problem in this country. Another country of attention is India. In 2021, India accounted for approximately a quarter of the global patients with trachoma, ranking second in the world, partly owing to its enormous population base and a prevalence rate that was twice the global average. This underscores the urgency of intensifying efforts to eliminate trachoma as a public health issue in this populous country [25]. Moreover, despite having a relatively lower trachoma burden compared to the aforementioned countries, Kenya and Mexico were the only two countries where the prevalence rate of trachoma increased amidst the overall global decline in trachoma burden. In a certain region of Kenya, the treatment coverage of mass drug administration for trachoma in 2021 was still below the 80% threshold recommended by the WHO, which may partly account for the increase in the prevalence of trachoma in the country [26]. In short, more health investments are needed to halt and reverse the emerging trend of trachoma in these two countries.
Notably, from 1990 to 2021, female patients have consistently borne a heavier trachoma burden than male patients. Gender roles, rather than biological differences, are recognized as the reason for the female predilection of trachoma [27]. For example, in many societies of developing countries, women predominantly take on the role of caregivers within families, which exposes them more frequently to unsanitary environments, as well as contaminated water sources. As a result, they become more susceptible to trachoma infections [27‐29]. In summary, future initiatives to control trachoma should take into account the disadvantaged position of female patients in this health predicament.
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Decomposition analysis revealed that the reduction in trachoma burden was driven mainly by global epidemiological changes, which masked the burden increase by population growth and aging. Ultimately, this resulted in an overall reduction in the burden. This pattern holds for most SDI quintiles, with the exception of the high-SDI quintile, where the impact of population aging and population growth surpassed that of epidemiological changes. This phenomenon may be attributed to the already low prevalence of trachoma in the high SDI quintile, leaving limited scope for further reduction.
We observed pronounced inequalities in the trachoma burden that correlated with the SDI. Specifically, the disease burden tended to increase as the SDI decreased, with low-SDI countries disproportionately bearing the greatest proportion of the burden. For a long time, trachoma has been seen as a “disease of poverty”, which stands in line with some previous studies declaring strong associations between trachoma and indicators of poverty [30‐32]. In fact, the relationship between poverty and trachoma is more intricate, potentially involving a bidirectional causality [33]. Poor hygiene conditions, inadequate awareness of trachoma, and limited medical resources that stem from poverty can contribute to a greater risk of trachoma. Conversely, productivity loss in patients with trachoma (with trachoma-induced blindness rendering individuals completely unproductive in extreme cases) and medical expenses associated with trachoma can both exacerbate poverty [33, 34]. To alleviate the cross-country inequalities in trachoma burden, while adhering to the implementation of the SAFE strategy, targeted policies should be adopted for countries with different development levels. Furthermore, international organizations and developed countries should strengthen medical assistance and guidance for low-income countries, helping them break the vicious cycle between trachoma and poverty.
Notably, despite predictions indicating a continued decline in the ASR of prevalence and DALYs for trachoma between 2022 and 2040, the number of prevalent cases and DALYs is projected to increase, highlighting the heavy disease burden in the future fight against trachoma. According to the decomposition analysis, population growth and aging (especially the former) are responsible for the anticipated increases in the prevalent cases and DALY numbers. To address this upcoming challenge, it is important that prevention and control strategies be tailored to the specific needs of different regions and populations. This includes targeting high-risk groups, such as the younger generations and implementing interventions that are culturally appropriate. Additionally, there is a need for continued monitoring and evaluation of trachoma control programs to ensure their effectiveness and make necessary adjustments. By adopting a proactive and targeted approach, we can anticipate progress in eliminating trachoma and reducing health inequalities across regions.
This study has several limitations. First, the burden estimates for some underdeveloped countries with limited resources may be underestimated because of the potential under-registration of trachoma data. Second, although advanced disease models were developed by GBD investigators, variations in the quality of raw data across countries might cause potential bias. Third, since DALYs were calculated on the basis of chronic ocular conditions, i.e., visual impairment, DALYs caused by trachoma without visual impairment could be ignored, leading to an underestimation of the disease burden. In addition, since the data provided by GBD is up to the year 2021, the latest trends in the global burden of trachoma have not been studied. Despite these limitations, this study has offered valuable up-to-date information for international organizations and health policy makers to formulate targeted strategies for the prevention and control of trachoma.
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Conclusions
In summary, the global burden of trachoma decreased significantly from 1990 to 2021, primarily due to epidemiological changes. Moreover, notable across-country inequalities existed in the global landscape of trachoma, with lower-SDI countries disproportionately undertaking the heaviest disease burden. From 2022 to 2040, the prevalence and DALY rates of trachoma are projected to continue the downward trend. However, the number of patients with trachoma and trachoma-related DALYs are predicted to further increase. Collectively, these findings highlight the challenges faced in global trachoma elimination efforts, including the unequal distribution of disease burden among countries and the projected increase in the number of patients. Global health policymakers should develop timely and adaptable strategies to address the already coming and upcoming challenges.
Medical Writing, Editorial, and Other Assistance
We are grateful for the help by Dr. Zongbiao Tan in the methodology of GBD 2021.
Declarations
Conflict of Interest
Yang Meng, Furong Li, Shun Zeng, Chaoqun Liang, and Wei Chi declare that they have no competing interests.
Ethical Approval
This study adhered to the Guidelines for Accurate and Transparent Health Estimates Reporting (the GATHER statement) and the tenets of the Declaration of Helsinki. The University of Washington Institutional Review Board Committee approved the GBD 2021 (approval number STUDY00009060). No identifiable data was used in this study.
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Mehr Begleitkrankheiten, geringere physiologische Reserven: Ältere Patientinnen und Patienten tragen ein erhöhtes Risiko für perioperative Komplikationen. Ob und wie ausgeprägt das für die Thyreoidektomie gilt, war Gegenstand einer Metaanalyse von elf Studien.
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Radiologische Progressionen ohne vorherige PSA-Wert-Erhöhungen sind mit 10% recht häufig. Dafür sprechen zumindest Ergebnisse einer explorativen Reanalyse von Daten aus der australisch-neuseeländischen ENZAMET-Studie.
