Background

Trachoma can be eliminated as a public health problem with a set of interventions known as the “SAFE strategy”, comprising surgery for TT, antibiotics to clear ocular C. trachomatis infection and facial cleanliness and environmental improvement (particularly improved access to water and sanitation) to reduce C. trachomatis transmission. Surgery should be offered to any individual with TT considered likely to benefit from an operation⁷; the S component of the SAFE strategy is a public health intervention, including active case finding if necessary, which is recommended when the prevalence of TT “unknown to the health system”⁸ is ≥0.2% among people aged ≥15 years. The A, F and E components of SAFE are recommended for evaluation units (EUs; the normal administrative unit for healthcare management: usually populations of 100 000–250 000) in which the prevalence of the active trachoma sign “trachomatous inflammation—follicular” (TF)⁹ is ≥5% in children aged 1–9 years. In those EUs, all residents should usually be offered antibiotic treatment annually, the planned number of rounds depending on the most recent estimate of TF prevalence.¹⁰ The criteria for elimination of trachoma as a public health problem are: (i) a prevalence of TT unknown to the health system of <0.2% among people aged ≥15 years and (ii) a prevalence of TF of <5% among children aged 1–9 years, in each formerly endemic EU, plus (iii) evidence that the health system can continue to identify and manage incident cases of TT.¹¹

Requirements for these interventions are determined by population-based prevalence surveys in EUs suspected of being endemic. After initiation of interventions where needed, surveys are repeated at specified intervals. In particular, it is recommended that impact surveys be undertaken at least 6 months after the last planned annual round of antibiotic mass drug administration (MDA), in order to determine whether treatment should be continued or can safely be stopped.¹²

This report summarizes application of the SAFE strategy against trachoma during 2025. It includes estimates of the global population at risk of trachoma blindness based on EU-by-EU data submitted to WHO by national programmes. Summarizing the epidemiological situation in this way is inherently complex because, for any EU, up to 3 serial estimates of prevalence may be valid at different times during a calendar year. If reported in isolation, TF prevalence estimates from impact surveys done after (but in the same calendar year as) antibiotic treatment might (i) be interpreted as indicating that the previous treatment was unjustified and (ii) result in division-by-zero errors in calculations of antibiotic coverage against need. To avoid these problems, the highest TF prevalence estimated for each EU in a calendar year (regardless of the date in the year on which that estimate was valid) was used to generate a rolling peak prevalence estimate for 1 January–31 December 2025 (Table 1); these figures were used as the denominators for calculating intervention coverage. To provide the most up-to-date snapshot of progress towards global elimination of trachoma as a public health problem, summaries based on EU-level prevalence estimates held in the GET2020¹³ database as of 20 March 2026 are also included (Table 1). The point-prevalence snapshot for 20 March 2026 can be compared with that of 21 April 2025.¹⁴

National status of trachoma

As of 16 July 2026, elimination of trachoma as a public health problem had been validated by WHO¹¹ in 32 countries (Algeria, Australia, Benin, Burundi, Cambodia, China, Egypt, El Salvador, Fiji, Gambia, Ghana, India, Iraq, Islamic Republic of Iran, Lao People’s Democratic Republic, Libya, Malawi, Mali, Mauritania, Mexico, Morocco, Myanmar, Nepal, Oman, Pakistan, Papua New Guinea, Saudi Arabia, Senegal, Togo, Tunisia, Vanuatu and Viet Nam). A further 6 countries (Botswana, Eritrea, Guinea, Guinea-Bissau, Namibia and Sierra Leone) report having achieved the prevalence targets for elimination (Table 1, Map 1). Other countries that are considered not to require interventions are not listed in Table 1, including those that have no recent history of trachoma (such as all the countries in the WHO European Region) and those (such as Congo¹⁵) in which formal investigations have been completed.

Map 1: Status of elimination of Trachoma as a public health problem, 16 July 2026.

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Status of elimination of Trachoma as a public health problem, 16 July 2026

As of 20 March 2026, based on the most recent EU-level prevalence data in the GET2020 database, trachoma was a public health problem in at least part of 29 countries. Two of these (Bolivia (Plurinational State of) and Venezuela (Bolivarian Republic of)) are exploring above-threshold prevalence estimates of TF in children aged 1–9 years through detection of C. trachomatis DNA and anti-C. trachomatis antibodies.¹⁰ Including the 2 countries mentioned above, a total of 12 countries may require interventions, but the necessary investigations in suspected trachoma-endemic areas have not yet been completed. Efforts are being made to undertake those investigations.

Populations that require interventions

On 20 March 2026, the prevalence of TT unknown to the health system was ≥0.2% among people aged ≥15 years in 1649 EUs worldwide. Building on previous work on the number of individuals suffering from TT,¹⁶ the estimated total global burden of TT on 20 March 2026 was 1.2 million cases (26 thousand cases lower than the estimate for 21 April 2025).¹⁴

A total of 101.5 million people lived in the 828 EUs in which the TF prevalence in children aged 1–9 years was ≥5% at some time during 2025. These people potentially qualified for implementation of the A, F and E components of the SAFE strategy for trachoma elimination in that year. Of the 101.5 million, 95% (96.2 million) were in the WHO African Region, including 66% (66.9 million) in Ethiopia (an increase from 62% and 55% of the global total in 2024 and 2023, respectively). No EU in the WHO European or South-East Asia regions is known to require the A, F and E components of SAFE for the purposes of trachoma elimination (Table 1).

Progress in populations requiring interventions

On 20 March 2026, 92.0 million people lived in the 760 EUs in which the TF prevalence was ≥5% (Table 1), a 10% reduction from 102.6 million on 21 April 2025.¹⁴ Since 2015, there has been a progressive decline in the number of EUs worldwide in each above-threshold TF prevalence category, with a particularly notable (78%) fall in the number of EUs with TF prevalence ≥30% (Figure 1).

Figure 1. Number of districts by prevalence of the sign “trachomatous inflammation—follicular” (TF) in children aged 1–9 years, worldwide, 2015–2026.

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Figure 1. Number of districts by prevalence of the sign “trachomatous inflammation—follicular” (TF) in children aged 1–9 years, worldwide, 2015–2026.

Implementation of the SAFE strategy, 2025

In 2025, 98 829 people were managed for TT worldwide, a 13% increase over the 87 349 managed in 2024.¹⁴ About 80% of TT surgery globally in 2025 was performed in Ethiopia (Table 1). Of the 37 countries that reported TT surgery in 2025, 34 reported gender-disaggregated data, covering 99.6% of individuals operated on for TT worldwide; of these, 69% were female.

In 2025, a total of 49.4 million doses of antibiotics were distributed to 47.4 million people for elimination of trachoma (Table 1). The 47.4 million people can be compared with 44.4 million people treated in 2024 and 32.9 million people treated in 2023.¹⁷ Some of these people received antibiotics at the time of TT surgery; some received individual treatment because active trachoma was diagnosed; and some received antibiotics as part of MDA campaigns more than once in the calendar year, as part of work to address persistent and recrudescent active trachoma.¹⁸

The 47.4 million people given antibiotics in 2025 represent 47% of the 101.5 million living in EUs in which MDA was indicated for trachoma elimination in that year (Figure 2), up from 39% in 2024. MDA was undertaken in 401 (48%) of the 828 EUs that qualified during 2025; antibiotics were also distributed for trachoma elimination purposes (using modalities other than MDA) in an additional 57 EUs.

Most of the antibiotic doses administered were azithromycin donated by Pfizer Inc. (New York City (NY), USA) to trachoma-endemic countries through the International Trachoma Initiative. Some 82% of antibiotic treatments in 2025 were given in Ethiopia, the country with the largest population at risk. Of the 21 countries in which antibiotics were used against trachoma in 2025, 19 reported gender-disaggregated data, representing information on 99% of all people treated with antibiotics for trachoma elimination worldwide. Where gender-disaggregated data were provided, 52% of treated individuals were female.

Figure 2. Population coverage with antibiotics for trachoma elimination, by WHO Region and globally, 2014–2025.

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Figure 2. Population coverage with antibiotics for trachoma elimination, by WHO Region and globally, 2014–2025.

Implementation of the S and A components of the SAFE strategy is more uniform and considerably easier to measure and report than that of the F and E components, which are context-specific¹⁹ and generally delivered as part of more comprehensive water, sanitation and hygiene interventions by people working in education, water and sanitation or rural development, in collaboration with health ministries and other government agencies.²⁰ All but one country in which antibiotics were administered for trachoma elimination purposes in 2025 also reported multiple methods of implementation of the F and E components of SAFE.

30th anniversary of the WHO Alliance for the Global Elimination of Trachoma

The WHO Alliance for the Global Elimination of Trachoma was established in November 1996 “with the aim of fostering planning, advocacy, research and programme coordination toward the goal of eliminating trachoma as a public health problem by the year 2020”.²¹ 2026 therefore marks its 30th anniversary; though the target date for global elimination has shifted to 2030, the Alliance’s mission statement remains the same. It has formally met 25 times, with the most recent meetings taking place in April 2023 in Istanbul, Türkiye, and in May 2024 in Hammamet, Tunisia. WHO funding restrictions meant that no meeting was convened in 2025.

Discussion

Progress towards global trachoma elimination continues to be strong. Overall, the number of people worldwide who require the A, F and E components of SAFE has fallen from 190.2 million in 2016²² to 92.0 million on 20 March 2026: a 52% fall over ten years. Over the same decade the global burden of TT fell from 2.8 million in 2016¹⁶ to 1.2 million on 20 March 2026: a 58% fall.

Since the most recent progress report on elimination of trachoma in the Weekly Epidemiological Record, published 12 months ago,¹⁴ 7 countries have been validated by WHO as having eliminated trachoma as a public health problem: Fiji (October 2025),²³ Egypt (November 2025),²⁴ Libya (February 2026),²⁵ Algeria (April 2026),²⁶ Australia (May 2026),²⁷ Tunisia (May 2026),²⁸ and El Salvador (July 2026).²⁹ In 2025, Afghanistan undertook antibiotic MDA for the first time.³⁰ The Alliance warmly congratulates each of these countries on their achievements.

As in other global health programmes, equity in intervention delivery is important in trachoma elimination. The fact that 69% of people who received surgery in 2025 were female is encouraging, because, overall, the relative risk of TT for women is 1.8 times that for men,³¹ and women may be more likely than men to refuse intervention.³² The finding that approximately equal numbers of women and men were given antibiotics for trachoma in 2025 is an analogous indication of gender equity in antibiotic delivery, at least at global level.

Even with the excellent prevalence survey support provided by Tropical Data to national trachoma programmes,³³ the data on prevalence and implementation reported here are subject to caveats. First, the estimated number of people requiring A, F and E interventions is based on WHO guidance for those interventions,³⁴ which may not be uniformly applied by health ministries. Second, as prevalence decreases, it is likely that other pathological processes will underlie an increasing proportion of disease resembling both active and cicatricial trachoma. Acceptance is growing of the potential need to refine the way in which we determine the need for antibiotic MDA.¹⁰ Target product profiles for assays to assess exposure to conjunctival C. trachomatis at population level (rather than simply conjunctival inflammation) have now been published.³⁵ In November 2018, in an effort to exclude trichiasis due to conditions other than trachoma, the definition of TT was modified to exclude trichiasis that affects only the lower eyelid, as individuals with lower-eyelid-only trichiasis are considerably more likely to have age-related involutional trichiasis than TT.⁵ Data are not available to adjust previous TT prevalence estimates to the modified definition; more recent surveys, however, include this refinement.³⁶

Third, population estimates are imperfect. Where updated EU-level estimates are not provided by health ministries, a 2% annual inflation term is applied to the corresponding estimate for the previous year; this is likely to be wrong. Fourth, in addition to the countries listed in Table 1 in which investigations are planned to establish whether trachoma is a public health problem, some suspected-endemic, un-surveyed populations remain in countries in which other EUs are already known to require interventions. Fifth, the requirements for water and sanitation in EUs in which active trachoma is not a public health problem have not been considered; other sources³⁷ offer such information.

The trajectory of progress against trachoma remains positive. However, this should not lead us to overlook the considerable challenges we face. These include the phenomena of persistent and recrudescent active trachoma,³⁸ human mobility and displacement,^39,40 the occurrence of post-operative TT,⁴¹ a paucity of evidence for scalable F and E interventions,^10,42,43 and the increasing localization of the remaining populations requiring interventions in areas affected by conflict or insecurity. To meet each of these challenges and others that are sure to arise, ongoing partnerships between academic, donor, governmental and nongovernmental stakeholders are critical for global trachoma elimination. To that end, the next meeting of the WHO Alliance for the Global Elimination of Trachoma is planned for September 2026 in Nairobi, Kenya.