Progress towards the elimination of trachoma as a public health problem in four counties of Eastern Equatoria State, Republic of South Sudan.

Background: Trachoma is targeted by the World Health Organization (WHO) for elimination as a public health problem by 2030. Trachoma impact surveys using standardised methodology are recommended to monitor progress towards elimination and to determine eligibility for continued surgery, antibiotics, facial cleanliness, and environmental improvement (SAFE) interventions. From 2007 to 2015, four counties of Eastern Equatoria State, South Sudan, received three to five rounds of mass drug administration with antibiotics. A trachoma impact survey in 2015 indicated all four counties had trachomatous-inflammation follicular prevalence among children ages 1-9 years above the WHO elimination threshold (range 17.4%-47.6%). Based on these results, the recommended number of years of SAFE interventions were implemented and the counties were subsequently resurveyed.

Methods: Between 2021 and 2023, trachoma impact surveys were conducted in Budi, Kapoeta East, Kapoeta North, and Kapoeta South counties using a two-stage cluster sample design. Trained and certified graders examined participants for trachoma clinical signs using the WHO simplified grading system to estimate county-level prevalence.

Results: A total of 12,570 individuals from 3286 households in 116 survey clusters were examined for trachoma. Prevalence of trachomatous-inflammation follicular among children ages 1-9 years was 5.6% (95% confidence interval [CI]:3.7%-8.3%) in Kapoeta South, 7.4% (CI:5.1%-10.7%) in Budi, 12.3% (CI:7.8%-18.9%) in Kapoeta East, and 18.1% (CI:13.5%-24.0%) in Kapoeta North. Trachomatous inflammation-intense prevalence among children ages 1-9 years ranged from 0.4% (CI:0.2%-1.0%) in Kapoeta East to 2.1% (CI:1.4%-3.2%) in Kapoeta North, and trachomatous trichiasis in individuals ages ≥15 years ranged from 1.0% (CI:0.5%-2.1%) in Kapoeta North to 1.9% (CI:1.3%-2.8%) in Budi.

Conclusions: As no county reached the WHO elimination thresholds of trachomatous-inflammation follicular <5% or trachomatous trichiasis <0.2%, SAFE interventions should continue. Furthermore, these districts are classified as having persistent trachoma, based on trachomatous-inflammation follicular levels remaining >5% after two impact surveys. Compared to results from 2015, the prevalence of trachomatous-inflammation follicular, trachomatous inflammation-intense, and trachomatous trichiasis in all counties decreased, indicating that the Republic of South Sudan Ministry of Health's Trachoma Control Program is advancing towards its elimination goal.