TRACHOMA 2020 REPORT OF THE 23RD MEETING OF THE WHO ALLIANCE FOR THE GLOBAL ELIMINATION OF - WHO | World Health Organization
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REPORT OF THE 23RD MEETING
OF THE WHO ALLIANCE FOR
THE GLOBAL ELIMINATION OF
TRACHOMA
BY 2020
30 NOVEMBER–1 DECEMBER 2020
REPORT OF THE 23RD MEETING
OF THE WHO ALLIANCE FOR
THE GLOBAL ELIMINATION OF
TRACHOMA
BY 2020
30 NOVEMBER–1 DECEMBER 2020Report of the 23rd meeting of the WHO Alliance for the Global Elimination of Trachoma by 2020, 30 November–1 December 2020 ISBN 978-92-4-002392-5 (electronic version) ISBN 978-92-4-002393-2 (print version) © World Health Organization 2021 Some rights reserved. This work is available under the Creative Commons Attribution-NonCommercial- ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo). Under the terms of this licence, you may copy, redistribute and adapt the work for non-commercial purposes, provided the work is appropriately cited, as indicated below. In any use of this work, there should be no suggestion that WHO endorses any specific organization, products or services. The use of the WHO logo is not permitted. If you adapt the work, then you must license your work under the same or equivalent Creative Commons licence. If you create a translation of this work, you should add the following disclaimer along with the suggested citation: “This translation was not created by the World Health Organization (WHO). WHO is not responsible for the content or accuracy of this translation. The original English edition shall be the binding and authentic edition”. Any mediation relating to disputes arising under the licence shall be conducted in accordance with the mediation rules of the World Intellectual Property Organization. Suggested citation. Report of the 23rd meeting of the WHO Alliance for the Global Elimination of Trachoma by 2020, 30 November–1 December 2020. Geneva: World Health Organization; 2021. Licence: CC BY-NC-SA 3.0 IGO. Cataloguing-in-Publication (CIP) data. CIP data are available at http://apps.who.int/iris. Sales, rights and licensing. To purchase WHO publications, see http://apps.who.int/bookorders. To submit requests for commercial use and queries on rights and licensing, see https://www.who.int/about/licensing/en. Third-party materials. If you wish to reuse material from this work that is attributed to a third party, such as tables, figures or images, it is your responsibility to determine whether permission is needed for that reuse and to obtain permission from the copyright holder. The risk of claims resulting from infringement of any third-party- owned component in the work rests solely with the user. General disclaimers. The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of WHO concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted and dashed lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by WHO in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by WHO to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall WHO be liable for damages arising from its use.
Contents
Acknowledgements − 5.3 WHO Regional Office for the Americas
− 5.4 WHO Regional Office for South-East Asia
1
− 5.5 WHO Regional Office for the Western
1. Introduction
Pacific
2. The WHO Alliance for the
Global Elimination of Trachoma 3 6. Reports from partners
13
by 2020, 1996–2020
− 6.1 International Coalition for Trachoma Control
− 6.2 International Trachoma Initiative
− 6.3 Tropical Data
3. The road map for neglected
tropical diseases 2021–2030 5 iii
7. Report from the Trachoma
Scientific Informal Workshop 16
4. Report from WHO
8
5. Reports from WHO regional
offices 9
References
18
Annexes
− 5.1 WHO Regional Office for Africa
Annex 1: Agenda
− 5.2 WHO Regional Office for the Eastern
Annex 2: List of participants
MediterraneanAcknowledgements
T he 23rd meeting of the WHO Alliance for the Global Elimination of Trachoma by 2020 was
supported by the Task Force for Global Health and the United States Agency for International
Development.
The Alliance thanks Elisabeth Heseltine for her work as meeting rapporteur, and Karen Ciceri-
Reynolds, Anthony W. Solomon and Patrick Tissot for report editing and design.
iv1. Introduction
O wing to the COVID-19 pandemic, the 23rd meeting of the World Health Organization
(WHO) Alliance for the Global Elimination of Trachoma by 2020 (GET2020) took place
virtually, and in abbreviated form, from 30 November to 1 December 2020.
1
The meeting was opened by Dr Ren Minghui, WHO Assistant Director-General for Universal
Health Coverage/Communicable and Noncommunicable Diseases, who noted that WHO’s
resolve to fight trachoma was as strong as it had ever been, and pledged, at the request of WHO
Member States, that WHO would continue to lead the Alliance until global elimination of
trachoma as a public health problem is achieved. He noted that 2020 was a milestone year for
trachoma, being the original target date for global elimination. Though the trachoma community
was not yet able to celebrate total success, he acknowledged that great progress had been made.
He thanked participants for joining the meeting and for their continuing partnership.
Dr Anthony Solomon, Secretary to the Alliance, nominated a Chair, Dr Fikreab Kebede, and
Rapporteur, Ms Elisabeth Heseltine, who were confirmed by the Alliance by acclamation.
The agenda (Annex 1) and list of participants (Annex 2) for the meeting are found at the end of
this report.2
2. The WHO Alliance
for the Global
Elimination of
Trachoma by 2020,
1996–2020
P rofessor Serge Resnikoff, Organisation
pour la Prévention de la Cécité, reviewing
the work of the Alliance since its inception,
preliminary results quickly showed that it was
at least as effective as tetracycline eye ointment
(8). Directly observed treatment with a
said that much has been achieved since its single oral dose represented an operational
establishment in 1996. Ten countries have advantage over the 6-week course required
been validated as having eliminated trachoma with tetracycline eye ointment. In 1987, when
as a public health problem (1), eight are under the Merck company donated ivermectin for 3
surveillance or awaiting validation and many the treatment of onchocerciasis, a neglected
more are working towards that goal. WHO tropical disease (NTD) that was being
started addressing trachoma very early in its addressed by many of the same organizations
own history, with establishment of a study as were working on trachoma, hopes were
group on trachoma in 1948, which led to raised that a similar donation of azithromycin
adoption of a resolution by the Third World might be made.
Health Assembly in 1950 (2). That resolution The first Global Scientific Meeting on
resulted in joint WHO–UNICEF trachoma Trachoma was held in 1996, and a group–the
control programmes in 23 countries and WHO Alliance–was convened for the global
establishment of a WHO expert committee elimination of trachoma by 2020 (9). They
(3-5). Introduction of the Prevention of endorsed the SAFE strategy within primary
Blindness programme at WHO in 1976, health care, recommended that azithromycin
development of dedicated WHO collaborating be used by programmes and considered
centres and publication of the simplified how it could be made available. The terms of
system for grading trachoma in 1987 (6) were reference of the Alliance were established, and
further major milestones. Development of its priorities were defined. The initiative was
the SAFE strategy (surgery, antibiotics, facial accelerated with the donation of azithromycin
cleanliness and environmental improvement) by Pfizer.
in 1993 (7) was also a significant advance. Much has been achieved since 1996. The
During the same period, several clinical trials number of people who require the A, F and
were undertaken to evaluate the efficacy of E components of SAFE has decreased by
azithromycin in treating active trachoma, and 91% since 2002; the number who receiveantibiotics for trachoma elimination purposes require surgery has decreased from 7.6 million
has increased to 95.2 million annually in 2019; to 2 million, although the numbers who
and the number of people with trichiasis who receive surgery vary considerably from year to
year (10).
43. The road map for
neglected tropical
diseases 2021–2030
D r Mwele Ntuli Malecela, Director, WHO
Department of Control of Neglected
Tropical Diseases, described progress made
to trachoma programmes is ensuring that
100% of the population in endemic areas
have access to at least basic water supply,
since the first NTD road map was published in sanitation and hygiene. A gap assessment for
2012 (11) in the number of treatments delivered NTDs conducted with heat maps showed that
annually and the number of countries that have trachoma programmes have a particular need
eliminated at least one NTD. The new road map for greater advocacy and funding (12). 5
2021–2030 (12) was prepared collaboratively,
with regions, countries, partners, experts, The road map was endorsed by the Seventy-
colleagues, reviewers and the public. It sets third World Health Assembly in November
public health targets for NTDs ranging from 2020 (13), which also adopted a resolution
control through elimination as a public health on integrated, people-centred eye care and
problem to elimination and eradication. The implementation of the recommendations in
road map is a high-level strategy document the World Report on Vision, launched in 2019
that sets the overall direction for combatting (14).
NTDs and can be used for policy and advocacy
and to align efforts. It includes specific,
measurable disease-specific targets and also Panel discussion
cross-cutting targets among related sectors
and health systems, which should reduce costs A panel discussion was held among participants
and increase impact in the context of universal from Cameroon, Colombia, Fiji, Nepal, Sudan
health coverage. The road map encourages and Togo.
three essential shifts: from measuring process to
measuring impact, from vertical programmes On the topic of integrating actions against
to holistic, cross-cutting strategies and from several NTDs, one participant said that some
a situation in which momentum has often areas were more advanced towards elimination
been generated primarily by partners to one and were better financed whereas there
in which country prioritization and domestic was lack of security in others, and the same
funding drive national ownership. One of its personnel are often responsible for activities
cross-cutting targets that is especially relevant against several diseases, with differentcalendars. Training is essential but should interaction, although work against similar
be provided close to the time of a campaign, diseases, such as skin NTDs (15, 16), might be
which is difficult for personnel working on grouped together. Local governments should
several campaigns. In countries with remote have a strong role in integration, with local
populations, such as in the Amazon Basin, it is and domestic resources, coordination and self-
difficult to integrate activities because of lack care. Integration would augment the effects of
of local participation. Parasitic diseases are isolated efforts and encourage development
often addressed in community initiatives, and of mechanisms to share experience,
trachoma could be integrated into primary information and support. Both public and
health care, with an emphasis on WASH. private organizations should be involved, so
Programmes could also cooperate in activities that each knows the role and content of each
such as WASH and SAFE in schools; however, other’s programme, and they should work
competing priorities restrict budgets for in coordination, especially with community
workers and nursing stations, and activities organizations. Operational research should be
should be more practical and adaptable. One conducted to change strategies and improve
limitation to integrating trachoma activities cooperation among programmes and with
with those for other NTDs is that trachoma health ministries.
involves the eyes but its complications are
more similar to those of leprosy and lymphatic In Nepal, a national eye organization has
filariasis. Partners might therefore cooperate eliminated trachoma as a public health problem
in small projects, for example trachoma and through integration and mainstreaming.
leprosy. The Government is now preparing for post-
validation surveillance. The action plan
One participant said that mainstreaming with for post-elimination surveillance has been
6 other public health issues risked side-lining integrated into the Government health
humanitarian nongovernmental organizations information management system; in addition,
(NGOs) working on sight, eyes, vision and there is an opportunity for the powerful,
blindness. He said that images of people with autonomous local governments to conduct local
trichiasis can be a stronger advocacy tool than surveillance. Ownership at local level creates
those for other NTDs. the possibility for local resource allocation
for NTD programmes. Opportunities for
In answer to a question on how countries integration across NTDs are being reviewed.
find funding for distributing antibiotics, Dr Nepal has a national NTD road map, and non-
Solomon said most countries are supplied with health sectors and NGOs are integrated into
donated azithromycin (Zithromax®) by Pfizer its work, with domestic resource mobilization;
through the International Trachoma Initiative, the country now plans to restructure its NTD
and the health ministry often partners with steering committee to incorporate actors from
NGOs to get financial support and technical non-health sectors too. Both NGO and some
assistance for training health workers in how Government eye hospitals are available, and
to administer the medicine and for the process the Government plans to integrate eye-care
of actually distributing antibiotics. If a country services in each local government health system
has difficulty in financing distribution to very and in educational establishments with the
remote areas, the health ministry can apply for Department of Education. Successful activities
external funding; partners will do everything require strong government leadership, careful
they can to help. planning and implementation, a passionate
workforce, community participation and
National programmes for different NTDs are careful monitoring.
often under different leadership, with littleIn Togo, long-term integration of work on In response to a question about the effect of the
NTDs was officially recognized 2 years ago, COVID-19 pandemic on trachoma elimination
after elimination of dracunculiasis in 2011, activities, the participant from Fiji said that, as
lymphatic filariasis in 2017 and human African the borders of the country had been closed,
trypanosomiasis in 2020. Integrated field visits the delivery service had been remodelled to
for Buruli ulcer and leprosy are particularly integrate NTDs into primary health care, with
useful for achieving elimination of those a new governance structure. Other countries
diseases. A recurrent problem is abandonment will have to rebuild their resilience and make
by partners once a disease has been eliminated, new plans to work on eliminating trachoma.
which limits support for surveillance, and the
country has had to provide its own financing. Dr Solomon commented that progress is
They have found that useful lessons can be still slow in a small set of districts in which
learnt from other programmes. Another approaches that worked elsewhere to reduce
participant commented that his country had the prevalence of active trachoma appear to
found that schistosomiasis had provided a be less effective. Research is needed for these
good model of experience in conducting districts. It is important to maintain delivery
mass drug administration (MDA), planning, of high-quality surgery and to ensure the high
training and distributing medicines. quality of prevalence surveys. He said that the
goal of eliminating trachoma as a public health
The end in sight: 2020 INSight, published problem by 2020 appeared to be realistic in
in 2011 by the International Coalition for 1996; 2030 was a reasonable new goal, which
Trachoma Control (17) has been a very many countries would achieve before that
useful document in multiple ways, and it was date. Dr Resnikoff said that some donors and
proposed that a similar, up-to-date document governments might find it difficult to maintain
be prepared to meet the fresh challenges of the support for the new goal, and other sources 7
new road map. One participant commented of external funding would have to be found.
that the transitions between programme Others said that countries would be able to
phases described therein are not explicit, use the new delay to recover from COVID-19
and indicators or an explanation should be and make new plans for eliminating trachoma.
provided. One participant said that one focus should be
on improving the empowerment of women
through behaviour change communication.4. Report from WHO
D r Solomon said that the failure to meet the
2020 targets should be acknowledged and
awareness of that failure used as fuel to drive
graders and to prove that they have been
trained well. Follicle size guides on adhesive
discs placed on thumbnails (20) help but do
future work. Since 2002, the global prevalence not fully solve the problem. There is current
of trachomatous trichiasis has been reduced interest in determining whether trained
by 74% and the number of people living in graders could be replaced by photographs of the
8 areas in which active trachoma remains a conjunctiva (21–25) or whether the prevalence
problem reduced by 91% (10). In every effort, of trachomatous inflammation—follicular
the emphasis must be on excellence – for every (TF) could be augmented or replaced by
patient managed for trichiasis, every interaction markers of current or previous infection (26).
in which someone is given antibiotics, at every A third issue is obtaining data from national
health education opportunity, in every effort surveys in order to conduct detailed secondary
to improve access to water or sanitation and in analyses to identify ways to eliminate trachoma
every survey. faster. The process of requesting data from
health ministries of all endemic countries is,
Three issues are of particular concern at global however, disproportionately time-consuming
level as we make plans to achieve elimination for both national coordinators and research
by 2030. First, the continuing COVID-19 teams. He asked participants for suggestions
pandemic is affecting all trachoma elimination on expanding appropriate access to the data.
activities, and activities in high-transmission Ending on an optimistic note, he recalled
areas will have to be intensified to catch up. In that, through the RTI ENVISION Project,
such areas, the NTD Modelling Consortium which closed in December 2019, 86 million
has predicted that a 1-year delay in providing people are no longer at risk of trachomatous
antibiotic MDA will result in a more than 2.5- blindness, and, in January 2020, Professor
year delay in eliminating trachoma. Means David Mabey of the London School of Hygiene
must be found to recover the lost ground (18). & Tropical Medicine was presented with the
Second, survey graders are currently trained to 28th Prince Mahidol Award for Public Health,
a high standard in live inter-grader agreement in recognition of his more than 30 years of
exercises (19). As active trachoma disappears, work against trachoma.
however, it becomes more difficult to train5. Reports from WHO
regional offices
5.1 WHO Regional Office other health issues, reach remote populations
in endemic countries and support countries
for Africa that have met the criteria for elimination to
prepare and submit dossiers.
D r Amir B. Kello reminded participants
that the African Region bears 86% of the
global burden of trachoma, with 117 million 9
people at risk and 26 of the 47 countries in
the Region requiring interventions (10). 5.2 WHO Regional
One country (Ghana) has been validated as Office for the Eastern
having eliminated trachoma as a public health Mediterranean
problem, and the claims of two others (Gambia
and Togo) are being evaluated. Progress has
Dr Supriya Warusavithana said that three
been made since the previous meeting, with the
countries in the Eastern Mediterranean Region
population requiring A, F and E reduced by 19
(Morocco, Oman and the Islamic Republic of
million, antibiotic MDA no longer required in
Iran) had been validated as having eliminated
seven countries, and achievement by Ethiopia
trachoma as a public health problem (27),
of 100% MDA coverage for trachoma (10).
10 were thought not to require interventions
COVID-19 has either postponed or delayed
and five to require interventions; no data
trachoma surveys, disrupted planned MDA
were available for three. In the five countries
rounds with resulting expiry of medicines,
that are known to require interventions
postponed surgery for trichiasis and increased
(Afghanistan, Egypt, Pakistan, Sudan and
the cost of interventions by the addition of
Yemen), over 10 million people require A, F
precautionary measures. The priorities now are
and E. Surgery for trachomatous trichiasis
to resume mapping and SAFE interventions,
was provided for 310 people in Pakistan and
reach 100% geographical coverage of MDA,
Sudan in 2019, antibiotics to over 2.3 million
clear the backlog of trachomatous trichiasis
people in four countries, interventions for
to reach the elimination threshold, integrate F
facial cleanliness in all five countries and
and E with interventions for other NTDs andenvironmental improvement in four (10). awaiting operation. Peru has identified a second
COVID-19 has disrupted NTD interventions district in which trachoma may be a public
in community and health centres and health problem, and the Bolivarian Republic
surveillance and reporting by more than 50%, of Venezuela will carry out baseline surveys in
whereas the effect to redirect staff, funds and nine evaluation units, with embedded studies
resources to the COVID-19 response had been on serology for other communicable diseases
smaller. The main challenges for the WHO and proof-of-concept integration of visual
Regional Office are the complex security acuity screening. in collaboration with the
situations in many countries in the Region, PEEK Vision Foundation, PEEK Vision Ltd
COVID-19 restrictions, diversion of resources (28) and Tropical Data (29). A regional road
and shortages of funding and capacity. The map for addressing trachoma, other NTDs and
priorities are to validate elimination in Iraq other vision problems in the populations of the
and Tunisia, initiate SAFE interventions in Amazon Basin has been agreed with countries
Afghanistan, resume MDA in Pakistan once (30) and trachoma elimination has also been
doing so is agreed to be appropriate, and included in an initiative to eliminate more than
continue SAFE strategy implementation in 30 communicable diseases and conditions
Egypt, Sudan and Yemen. Trachoma will be in the Region (https://www.paho.org/en/
mapped in suspected-endemic districts, and destination-elimination). Future priorities
impact surveys will be conducted. Surgery, include the implementation of integrated
surveillance and monitoring for trachoma NTD surveys, promotion of integrated health
will be integrated into other public health services, roll-out of a virtual training course
programmes, such as for the prevention of on WASH and the health sector working
blindness, polio vaccination and malaria; and together to tackle trachoma and other NTDs,
partnerships with other sectors for F and E will and development of innovative strategies to
10 be strengthened with UNICEF and the WHO reach remote populations.
Health Emergencies cluster.
5.4 WHO Regional Office
5.3 WHO Regional Office for South-East Asia
for the Americas
Dr Mohamed Ahmed Jamsheed said that
Dr Martha Saboyá said that trachoma is a trachoma is known to have recently been a
public health problem in four countries in problem in India, Myanmar and Nepal, but
the Region of the Americas, one of which is elimination of the disease as a public health
planning baseline surveys. A total of 5.2 million problem has been validated in the last two.
people require A, F and E interventions. Since The SAFE strategy has been continued in all
the previous meeting of the Alliance, Brazil has countries, and in 2019, 918 operations for
reassessed nine non-indigenous districts and trichiasis were conducted in India and 424
found a prevalence of < 5% TF in 1–9-year-olds in Nepal (10). Since the previous meeting,
in all nine, and < 0.2% trachomatous trichiasis a national guideline on post-validation
in ≥ 15-year-olds in eight of the nine; surveys surveillance had been issued in Nepal, and a
in five indigenous evaluation units have been series of pre-validation surveillance surveys
postponed because of COVID-19. Colombia is is being planned in India. Nepal is developing
preparing a plan to reinforce SAFE. Guatemala an integrated NTD road map that includes
has completed house-to-house searches for trachoma and is restructuring the national
trichiasis cases, and the first surgery camp technical working group on trachoma into
was held for 40 people; about 100 people are an NTD steering committee that includessectors beyond health, such as environment, might not actually be trachoma. An expert
water, sanitation and education. Trachoma consultation in January 2018 recommended
surveillance will be integrated into the national that the two countries undertake ancillary
health information system to strengthen post- surveys to determine the proportion of
validation surveillance and give access to children aged 10–14 years with trachoma-
NGOs, which provide most eye care services related conjunctival scarring in communities
in Nepal. Myanmar is developing a post- with a prevalence of active trachoma ≥ 30%,
validation surveillance plan. while at the same time continuing to promote
facial cleanliness (31). Fiji and Papua New
Guinea were advised to repeat population-
based baseline surveys and the same ancillary
5.5 WHO Regional Office survey (31). The ancillary surveys in the
Solomon Islands and Vanuatu showed that
for the Western Pacific MDA should not be continued (32), and
Vanuatu has submitted a dossier claiming
Dr Aya Yajima reported that 11 countries in elimination of trachoma as a public health
the Region are endemic for trachoma. Three problem to WHO, which is under review.
have been validated as having eliminated
trachoma as a public health problem, one more Increasing use of serology (33) provides
has submitted a dossier, two are conducting opportunities for integrating post-validation
impact or pre-validation surveillance surveys, surveillance with surveillance for other
and five are implementing the SAFE strategy diseases, such as lymphatic filariasis and
or mapping (10). She said that COVID-19 is vaccine-preventable diseases. In Melanesia,
largely under control in the Region. In Australia, work to eliminate yaws and to control scabies is
implementation of the SAFE strategy and being accelerated, and azithromycin MDA and 11
annual screening and treatment have resulted intensified WASH delivery are planned from
in major gains, although a further reduction in next year. The Regional Office is preparing a new
active trachoma will require improved facial regional action plan to strengthen general eye
cleanliness and better access of communities health programme capacity and infrastructure,
and households to washing facilities; trachoma including trachoma elimination.
activities were halted for the first half of the
year because of the COVID-19 pandemic.
Discussion
Viet Nam has a long history of fighting against
trachoma. After pre-validation surveillance In the discussion that followed the regional
identified hotspots in one province, the SAFE office presentations, clarifications were given
strategy was initiated, and it is hoped that a post- about the trachoma situation in countries in
MDA impact survey will allow Viet Nam to North Africa. Intensified post-elimination
prepare a dossier for validation of elimination. surveillance is being conducted in Morocco.
After trachoma mapping, Solomon Islands Speakers suggested that another means be
and Vanuatu started implementation of the found to validate elimination of trachoma as
SAFE strategy and MDA; however, post- a public health problem in Iraq, Tunisia and
MDA surveys showed limited impacts on the Saudi Arabia; however, Dr Solomon recalled
prevalence of trachoma. While the prevalence the importance of consistent criteria for
of TF in children aged 1–9 years is ≥ 5%, the validating elimination (34). In Algeria, the
prevalence of trachomatous trichiasis in those population in areas most strongly suspected
aged ≥ 15 years is low, and evidence of current of being endemic for trachoma should be
ocular infection with Chlamydia trachomatis is surveyed.
rare. This implies that TF in parts of MelanesiaWith regard to integration of trachoma In answer to a question about the post-
activities with those for other diseases, several validation activities to be included in previously
speakers recognized that general hygiene trachoma-endemic indigenous communities
and sanitation are the basis of programmes in South America, Dr Solomon replied that
against many NTDs. Therefore, trachoma access to personal and environmental hygiene
should not be integrated with other eye health is essential.
programmes. Dr Solomon commented that,
although SAFE is considered an integrated Dr Kello said that preliminary investigations on
strategy, it could perhaps be better thought of endemicity of trachoma had been carried out
as S in relation to management of individuals in Angola, Botswana and Namibia. In Angola,
who already have trichiasis and A, F and E there are recommendations for baseline
for the population-level prevention of future population-based surveys; in Botswana, it is
cases of trichiasis. One participant pointed out recommended to conduct a population-based
that there is an imperfect correlation between survey in Ngamiland district; and in Namibia,
the number of people with trichiasis and the baseline population-based surveys are needed
number of people who need treatment with and are currently being planned.
antibiotics (35). He proposed that a document
be prepared specifically on surveillance, both In answer to Dr Solomon’s request for
during and after validation. suggestions on acquiring data from countries
in order to conduct secondary analyses, Dr
At the time of the meeting, COVID-19 had Saboyá said that she would try to schedule
delayed trachoma activities by 6–9 months, a meeting of the managers of trachoma
and the effect of those delays is likely to become programmes in the Region of the Americas to
more apparent in 2021. Another aspect of the determine what they require from WHO and
12 pandemic is the cost of personal protective to discuss how their data would be interpreted.
equipment.6. Reports from
partners
6.1 International Coalition Diamond Jubilee Trust Trachoma Initiative
and the DFID-SAFE Trachoma Programme.
for Trachoma Control These initiatives have been coordinated with
ENVISION/USAID and the ITI/Pfizer drug
M r Scott McPherson recalled that
the Coalition (ICTC, https://www.
trachomacoalition.org/) was conceived in 2004,
donation programmes, allowing the SAFE
strategy to be extended widely throughout
trachoma-endemic countries. Together, those 13
initially to bring together implementing NGOs investments have achieved significant gains
and donor organizations immediately after the against trachoma, generated further evidence
annual meetings of the GET2020 Alliance to on how to best implement programmes and
discuss how to support implementation of attracted additional donors. 2020 INSight
the recommendations of the Alliance. ICTC helped to position investment for trachoma
currently comprises 51 nongovernmental, according to the best data available at that
donor, private sector and academic time and shaped the strategic direction of the
organizations that support the Alliance Coalition.
and implementation of the SAFE strategy.
Members add value by supporting national COVID-19 has stimulated innovation and
programmes comprehensively, sharing annual demonstrated the adaptability of health
work plans to avoid duplication of effort programmes, and the trachoma community
and maximize efficiency, documenting joint should learn from other groups, including the
operational effectiveness, identifying gaps in eye health community, to strengthen its work.
implementation and preparing joint funding Multisectoral engagement among sectors
proposals. In 2011, ICTC published, The end that address WASH, inclusion of people with
in sight: 2020 INSight (17), which describes the disabilities, education and nutrition, with
actions thought then to be needed to achieve hard science and advocacy, are essential. The
global elimination of trachoma as a public narrative will have to be reframed for the “final
health problem by 2020. The document boosted mile”, to move from control to elimination of
trachoma programmes (36), contributed trachoma as a public health problem, extending
to bringing about the Global Trachoma it beyond trachoma to common issues of
Mapping Project (37, 38) and attracted sustainability, continuous surveillance and
two large initiatives: the Queen Elizabeth effective health system strengthening. A newgeneration of leaders in the NTD community by 2030. Azithromycin will be provided in
should be identified, engaged and empowered the quantities required (40), including for
in research, programmes, campaigns, policy countries that will be attempting to complete
and advocacy, with poverty alleviation, cross- all their activities for 2020 and 2021 in 1 year
border issues and insecure states addressed in to catch up the time lost to COVID-19. For
order to leave no one behind. The trachoma countries with high prevalence populations
community must continue to identify gaps and that have been most severely affected by
financial and other requirements for scaling up missed treatment rounds, such as Ethiopia
the global programme, supported by evidence, (41, 42), where more rounds of MDA, perhaps
updating the cost of implementing the SAFE given more frequently than annually (43, 44),
strategy and supporting advocacy to integrate may be necessary, support will be provided.
trachoma into eye health and wider health Future empirical trials should be structured to
systems. In a world where we will have to provide clear evidence of effect, with enhanced
achieve more for less in light of the economic surveillance. He noted that the Trachoma Atlas
repercussions of COVID-19, we must work (https://www.trachomaatlas.org/) has been
together towards common goals such as the improved, with greater functionality and clean
Sustainable Development Goals and universal interfaces. The website will continue to evolve.
health coverage.
ICTC will develop a new resource for
identifying gaps, built on the GET2020 6.3 Tropical Data
Alliance Plan of Action (39), 2020 INSight (17)
and alignment with the NTD road map 2021–
Dr Emma Harding-Esch said that the Tropical
2030 (12). Sustaining elimination efforts will
Data initiative (www.tropicaldata.org) consists
14 require addressing systemic challenges such
of six partners, which support national
as governance, financing, health access and
programmes in conducting standardized,
health inequity. Strengthening health systems
epidemiologically robust prevalence surveys,
for the control and elimination of NTDs
from protocol review to results provision. The
will require a broader, systemic approach,
interests of the countries in which surveys are
including sustainable data collection systems
conducted are protected, as the methods and
to monitor progress.
data belong to their health ministries, and
quality is assured and controlled throughout
(19), maximizing the likelihood of reliable
data for programmatic decision-making. Since
6.2 International Trachoma 2016, Tropical Data has supported 2025 surveys
Initiative in 43 countries. These include baseline, impact
and pre-validation surveillance surveys as
Dr Paul Emerson commented that the goals well as trachomatous trichiasis-only surveys;
that were set for 2020 are unchanged. To the combined number of people examined in
achieve the goal by 2030, programmes and evaluation units surveyed with Tropical Data
supporting organizations should be “bigger, support to date totals > 6 million residents.
better and faster” and based on the best science Data on TF prevalence in children aged 1–9
and the best management. Trachoma activities years have resulted in 151 172 521 antibiotic
should be integrated with those of other disease treatments. MDA can now be stopped in 596
programmes only if that helps to achieve the evaluation units and it is not necessary to start
elimination goal. All the necessary elements it in 308. Surveys have also helped countries
are available for eliminating trachoma globally to confirm completion of pre-validationsurveillance in 377 evaluation units. Since the reviewed journals. Its plans include continuing
previous meeting of the Alliance, Tropical Data to provide existing services, participation in
has conducted refresher training of trainers, operational research and providing support
updated its tools and resources and provided for quality-assured, quality-controlled surveys
support for publication of articles in peer- for other NTDs.
157. Report from the
Trachoma Scientific
Informal Workshop
M r Harran Mkocha, Director of the
Kongwa Trachoma Project in the
United Republic of Tanzania, reported
for personal protective equipment have
been assessed, including use of face shields
during trichiasis surgery. One group reported
highlights from the 2020 Trachoma Scientific successful training in trichiasis surgery during
Informal Workshop. One study was reported the pandemic after using the WHO risk
in which the association between severity assessment and mitigation tool.
16 of trachomatous scarring of the conjunctiva
and severity of trichiasis was confirmed. In
a study of weekly practice with the HEAD Discussion
START system, with remote monitoring by
senior ophthalmologists, both trainees and In the discussion that followed the
monitors considered that regular practice presentations, one participant commented that
and feedback were beneficial. A promising the serological tests described indicate whether
procedure for management of post-operative a person has been exposed and not whether
trichiasis is being evaluated in a clinical trial in they are currently infected. Their specificity is
Ethiopia. In countries in which trachoma has about 98% and their precision good, with close
not been empirically mapped because disease agreement among laboratories; the limit of
at the level of a public health problem was detection is being determined.
not suspected, desk reviews can be conducted
for systematic collection of evidence to In reply to a question about the approach to
support claims of elimination or to identify be taken in areas of persistent active trachoma,
areas in which mapping or an intervention is which were seen even before COVID-19, Dr
necessary, while strong donor support is still Emerson said that, although all the necessary
available. Several sources of data should be supplies of medicines are available, ITI cannot
used; however, only enough data should be pay for enhanced surveillance. Dr Solomon
collected to decide whether there is a rationale suggested that recovery from COVID-19
to conduct mapping. The anti-C. trachomatis be linked to the question of how to manage
antibody testing platforms available for sero- trachoma in hyperendemic areas, in a trial
surveillance are bead-based assays, ELISA and conducted with intensive treatment. Such
lateral flow assays. With regard to precautions operational research might demonstrate the
to be taken against COVID-19, various options role of ongoing C. trachomatis transmission indistricts in which the TF prevalence at impact One speaker pointed out that trichiasis is
or surveillance surveys is ≥ 5%. Dr Emerson present in more than 50 districts in Sudan;
said that the response of national programmes however, there is no programme in many
should remain the SAFE strategy, which has of those districts, as trachoma has not been
been proven. Persistence of disease could demonstrated to be a public health problem
indicate that the strategy is not being adhered through population-based surveys. A further
to everywhere, and standardized surveys complication is the arrival of large numbers of
should be conducted. refugees from the Tigray Province in Ethiopia.
In a discussion about whether the name
One participant commented that the “GET2020” should now be changed to
combination of Vision 2020, the Sustainable GET2030, the consensus was to maintain
Development Goals and the NTD road map 2020 because of the connotation of good
2021–2030 would spur activity for reaching visual acuity. Dr Solomon added that legal
the new 2030 goal. considerations might make changing the
name complicated; furthermore, maintaining
A question was raised about whether some 2020 in the name would be a reminder that the
districts or countries have not yet been deadline had been missed and would convey
validated as having eliminated trachoma as a a sense of urgency. Dr Emerson agreed: the
public health problem because they have had name would help to keep up the momentum
difficulty in meeting the trichiasis prevalence and raise ambition. The achievements made
criterion for elimination. Dr Solomon said that up to 2020 should be used as a springboard to
evidence had to be provided that trichiasis is no go further.
longer a public health problem. Geostatistical
approaches are being explored to try to obtain After the usual exchange of courtesies, the
more precise estimates of trichiasis prevalence. meeting was closed. 17References
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21Annexes
ANNEX1: AGENDA
Monday, 30 November 2020 (session 1)
Time (GMT+1) Topic Speakers / Facilitators
14:00–14:10 Opening and welcome Ren Minghui (WHO)
14:10–14:15 Purpose, outcome and outputs of Anthony Solomon (WHO)
meeting
Nomination of officers
Adoption of agenda Chair
14:15–14:45 The WHO Alliance for GET2020: Serge Resnikoff (OPC)
1996–2020
14:45–15:15 The NTD road map 2021–2030 Mwele Malecela (WHO)
22 15:15–16:00 Panel Selected country representatives
16:00–17:00 Discussion All
Tuesday, 1 December 2020 (session 2)
Time (GMT+1) Topic Speakers / Facilitators
14:00–14:10 WHO report Anthony Solomon (WHO)
14:10–15:00 Regional reports Amir Kello (AFRO)
Supriya Warusavithana (EMRO)
Martha Idalí Saboyá-Díaz (PAHO)
Mohamed Jamsheed (SEARO)
Aya Yajima (WPRO)
15:00–15:45 Discussion All
15:45–15:55 International Coalition for Trachoma Scott McPherson (ICTC)
Control report
15:55–16:05 International Trachoma Initiative report Paul Emerson (ITI)
16:05–16:15 Tropical Data report Emma Harding-Esch (LSHTM)
16:15–15:25 Trachoma Scientific Informal Workshop Harran Mkocha (KTP)
report
16:25–16:55 Discussion All
16:55–17:00 Closure ChairANNEX 2. LIST OF PARTICIPANTS
Ange Elvis Aba, FHI 360, Abidjan, Côte d’Ivoire Gilbert Baayenda, Ministry of Health, Kampala,
Aida Abashawl, Berhan Public Health and Eye Uganda
Care Consultancy, Addis Ababa, Ethiopia Robin Bailey, London School of Hygiene &
Agatha Aboe, Sightsavers, Accra, Ghana Tropical Medicine, London, United Kingdom
Aparna Adams, International Coalition for Ana Bakhtiari, ITI/Tropical Data, Atlanta, United
Trachoma Control, London, United Kingdom States of America
Moses Aderogba, RTI International, Abuja, Kira Barbre, The Task Force for Global Health,
Nigeria Decatur, United States of America
Oluwole Afolayan, Federal Ministry of Health, Colin Beckwith, Sightsavers, Atlanta, United
Abuja, Nigeria States of America
Fentahun Akale, Crown Agents, Addis Ababa, Suzannah Bell, Moorfields Eye Hospital, London,
Ethiopia United Kingdom
Kossi Amevor Alaglo, Programme National des Jerome Bernasconi, Organisation pour la
Maladies Tropicales Négligées, Lomé, Togo Prevention de la Cécité, Paris, France
Mutasim Albattah, First Moscow State Medical Jean-Eudes Biao, Organisation pour la
University, Irbid, Jordan Prevention de la Cécité, N’Djamena, Chad
Wondu Alemayehu, The Fred Hollows Seth Blumberg, UCSF, San Francisco, United
Foundation, Arlington, United States of America States of America
Menbere Alemu, ITI, Task Force for Global Sophie Boisson, World Health Organization,
Health, Addis Ababa, Ethiopia Geneva, Switzerland.
Esmael Ali, London School of Hygiene & Tropical Sarah Boyd, ITI/Tropical Data, Decatur, United
Medicine, London, United Kingdom States of America 23
Najeebullah Alizoi, HealthNet TPO, Kabul, Amanda Bradica, The Task Force for Global
Afghanistan Health, Decatur, United States of America
Tawfik Al-Khateeb, Ministry of Health, Sana’a, Clara Burgert, RTI International, Washington,
Yemen United States of America
Angel Alvarez, OPS, Caracas, Bolivarian Republic Simon Bush, Sightsavers, Chippenham, United
of Venezuela Kingdom
Juliana Amanyi-Enegela, CBM International, Robert Butcher, London School of Hygiene &
Cambridge, United Kingdom Tropical Medicine, London, United Kingdom
Khaled Amer, Ministry of Health, Cairo, Egypt Laura Cane, RTI International, Washington,
United States of America
Shyamala Anand, American Leprosy Missions,
Hyderabad, India Ismat Chaudhry, Pakistan Institute of
Ophthalmology, Pakistan
Molly Anderson, The END Fund, Brooklyn,
United States of America Amel Chebbi, Hedi Rais Institute of
Ophthalmology, Tunis, Tunisia
Liuzer Aragie, The Carter Center, Addis Ababa,
Ethiopia Xinyi Chen, Dana Center, Johns Hopkins Wilmer
Eye Institute, Baltimore, United States of America
Miguel Aragon, PAHO, Brasilia, Brazil
Karen Ciceri-Reynolds, World Health
Elham Ashrafi, Translational Ophthalmology
Organization, Geneva Switzerland
Research Center, Farabi Eye Hospital, Tehran,
Iran (Islamic Republic of) Joseph Cook, University of North Carolina,
Chapel Hill, United States of America
Kingsley Asiedu, World Health Organization,
Geneva, Switzerland Paul Courtright, Kilimanjaro Centre for
Community Ophthalmology, San Diego, United
Zahid Awan, CBM, Islamabad, Pakistan
States of America
Nebiyu Ayele, Addis Ababa, EthiopiaYou can also read
