Page created by Terry Gonzales
                            OF THE WHO ALLIANCE FOR
                            THE GLOBAL ELIMINATION OF

                            BY   2020
                               GENEVA, SWITZERLAND, 20–22 APRIL 2017

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                                OF THE WHO ALLIANCE FOR
                                THE GLOBAL ELIMINATION OF

                                BY   2020
                                   GENEVA, SWITZERLAND, 20–22 APRIL 2017

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         Acknowledgements                                 − Country Perspective: Lao People’s Democratic

                                                          − Country Perspective: Nepal
         Abbreviations and acronyms
                                                          − Country Perspective: Gambia

                                                          −   Dossier Review Group Perspective
         Session 1 – Opening

         − High-level Panel
                                                  1       −
                                                              Donor Perspective
                                                              Report: International Trachoma Initiative
                                                              A, F and E for GET2020
         − World Health Organization Report                   − Selecting and Training Community Drug
         − Tnternational Coalition for Trachoma Control          Distributors
           Report                                             − Going to Scale with A, F and E
         − Regional reports                                   − Interventions for Facial Cleanliness &
                                                                 Environmental Improvement
                                                              − Thresholds for Environmental Improvement
                                                              − Breakout B
         Session 2 – Trachoma Scientific
         Informal Workshop                        12
         − Surgery for GET2020 Panel
           − Reducing the Trichiasis Backlog
                                                          Session 4 – Plans of Action for
                                                          2016 and 2017                              32
           − Getting the Trichiasis Backlog to Zero
           − Transitioning Trichiasis Care into Routine   −   Governments of endemic countries
             Services                                     −   World Health Organization
           − The TT patient tracking app                  −   NGOs and other implementing partners
           − The Morbidity Management and Disability      −   Public and private donors
             Prevention Project                           −   Academic and research institutions
           − Breakout A                                   −   Meeting Close
           − Managing PC-NTD Implementation Data
           − Forecasting Trachoma Elimination

         Session 3 – Panel: Validation of
         Trachoma Elimination

         − Country perspective: Morocco
                                                          Annex 1: Agenda
                                                          Annex 2: List of participants
         − Country Perspective: Mexico

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                     T  The 21st meeting of the WHO Alliance for the Global Elimination of Trachoma by 2020 was
                        supported by the Task Force for Global Health, the United States Agency for International
                     Development, and Uniting to Combat Neglected Tropical Diseases.

                     The Alliance thanks Victor V. Florea for his work as meeting rapporteur, and Karen Ciceri-
                     Reynolds, Anthony W. Solomon and Patrick Tissot for report editing and design


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Abbreviations and

                     DFID		     Department for International Development

                     ESPEN      Expanded Special Project for Elimination of Neglected Tropical Diseases

                     ITI		      International Trachoma Initiative

                     MDA 		     mass drug administration

                     NTD 		     neglected tropical disease

                     SAFE 		    Surgery, Antibiotics, Facial cleanliness, Environmental improvement

                     TEMF 		    Trachoma Elimination Monitoring Form

                     TF 		      trachomatous inflammation–follicular

           vi        USAID      United States Agency for International Development

                     WASH       water, sanitation and hygiene

                     WHO        World Health Organization

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                   T  he 21st meeting of the World Health Organization (WHO) Alliance for the Global
                      Elimination of Trachoma by 2020 (GET2020) took place at the InterContinental Hotel
                   Geneva, Switzerland, from 20–22 April 2017, as part of the 2017 Neglected Tropical Disease
                   (NTD) Summit jointly hosted by the World Health Organization and Uniting to Combat                        vii
                   Neglected Tropical Diseases.

                   Dr Dirk Engels, Director, Department of Control of NTDs, WHO, welcomed participants to
                   Geneva and congratulated the Alliance on the progress being made towards the GET2020 target
                   (1). He noted that the stage was set for going to full scale. This was attributable in part to the
                   work of the Global Trachoma Mapping Project (2), which was a massive effort to understand
                   the epidemiology of trachoma worldwide, and served as a model for efforts to map other NTDs
                   (3). Further evidence of hard work by members of the Alliance could be found in the success
                   of several countries—Oman, Morocco and Mexico by the date of the meeting’s opening—in
                   being validated as having eliminated trachoma as a public health problem. Other countries were
                   making progress, he noted, and more countries were expected to undergo validation in 2017
                   and beyond (1).

                   Dr Anthony Solomon, Medical Officer, Department of Control of NTDs, WHO, nominated
                   Chairs and officers for the meeting, who were then confirmed by the Alliance by acclamation. He
                   thanked the Task Force for Global Health; United States Agency for International Development;
                   and Uniting to Combat NTDs for their contributions to staging the meeting. Dr Solomon
                   reminded participants that the purpose of the meeting was to monitor progress towards the
                   elimination of trachoma at global level, exchange information and experience on implementation
                   of the SAFE strategy (surgery, antibiotics, facial cleanliness and environmental improvement),
                   review partnership opportunities at global, regional and national levels, and discuss obstacles

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and barriers to the achievement of the GET2020 goal. Expected outcomes of the meeting were:
                     global monitoring of progress towards the elimination of trachoma; exchange of information on
                     SAFE implementation at global and regional level; refinement of approaches for optimal impact,
                     where possible; identification of opportunities for increased collaboration with efforts against
                     other NTDs; and a report of the meeting to share progress towards the WHA51.11 target (4)
                     with all endemic countries and partners.

                     The agenda (Annex 1) and list of participants (Annex 2) for the meeting are found at the end of
                     this report.


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                     Dr Ren Minghui, Assistant Director-General,       NTD Summit showed, he felt, the willingness
                     HIV/AIDS, Tuberculosis, Malaria and NTDs,         of the Alliance to collaborate externally, create
                     WHO, opened the meeting                           efficiencies, and share knowledge within the
                                                                       broader NTD community.

                    T    rachoma causes blindness in the world’s
                         poorest people. Those affected by trachoma
                     typically live in the poorest countries; within
                                                                       Thanks to the efforts of the Alliance, Dr Ren
                                                                       noted that trachoma was progressively being              1

                     those countries they live in the poorest          eliminated. In 2011, 325 million people
                     communities; and in those communities,            were living in areas that required the SAFE
                     the people who go blind from trachoma are         strategy (8). As of April 2017, that number had
                     proven to be poorer than their neighbors (5).     dropped to 182 million, a 44% decrease (9).
                     Going blind keeps them poor, and keeps their      Dr Ren felt that this was remarkable progress,
                     children poor, too.                               and would not have been possible without the
                                                                       steadfast leadership of endemic country health
                     Since 1993, WHO has recommended the               ministries, most of which were represented in
                     SAFE strategy to prevent trachoma blindness       the meeting room, and the strong collaboration
                     (6). SAFE is an integrated package of             of civil society, academics and donors.
                     interventions, delivered at community level,      Those donors include the United Kingdom’s
                     that prevents blindness from trachoma at          Department for International Development,
                     multiple stages of its pathogenesis. In 1996,     who had doubled their commitment to NTDs
                     with partners, WHO established the WHO            in an announcement made just prior to the
                     Alliance for GET2020 to help countries use        meeting, the Queen Elizabeth Diamond
                     the SAFE strategy to eliminate trachoma as a      Jubilee Trust, and USAID. The donor group
                     public health problem (7). Dr Ren noted that      also included Pfizer, which by the date of
                     the April 2017 meeting was the 21st Meeting of    the meeting had contributed more than 625
                     the Alliance, and commented that the number       million doses of the antibiotic azithromycin
                     of participants in the room suggested that the    (Zithromax®) to trachoma elimination
                     sense of commitment from its members and          programmes around the world (10).
                     their energy to see trachoma eliminated had
                     never been stronger. The fact that this Meeting   Despite this unprecedented progress, more
                     was being held as part of the multi-disease       work was still required to achieve the shared

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goal of a trachoma-free world. Dr Ren specified    Trachoma elimination is prioritized in the
                     new donors, operational research to refine the     2017–2021 roadmap for WHO’s Eastern
                     way that the SAFE strategy was implemented,        Mediterranean         Region.         Intersectoral
                     and renewed commitment from governments            programmes are being used to improve water
                     and civil society, as particular priorities (11-   supplies and sanitation, and to provide eye care,
                     13). With these ingredients, a world free of       including trichiasis surgery. It is important that
                     blindness from trachoma would be within our        countries meeting their trachoma elimination
                     reach; without them, he felt that we might lose    targets continue to receive support for post-
                     the incredible gains made over recent years.       validation surveillance, and that interventions
                     Dr Ren welcomed participants to Geneva and         are scaled up in countries where trachoma
                     to the meeting, wished them every success          remains a public health problem. Countries
                     in their discussions, and pledged WHO’s            with low burdens of trachoma must be
                     steadfast, ongoing support to ensuring that        prepared to conduct impact and pre-validation
                     no-one is left behind as a result of trachoma.     surveillance surveys.

                                                                        Dr Mark Jacobs, Director, Division of
                     High-level Panel                                   Communicable Diseases, Western Pacific
                                                                        Regional Office, WHO
                     Mr Bruce Gordon, Coordinator, Water,
                     Sanitation and Hygiene, WHO, introduced            Cambodia, China and Lao People’s Democratic
                     the panelists and acted as facilitator for the     Republic all claim to have eliminated
                     subsequent discussion. Apologies for being         trachoma as a public health problem. Fiji,
                     unable to participate in the panel discussion      Kiribati, Solomon Islands and Vanuatu are
                     were received from Professor Yifru Berhan          making progress toward trachoma elimination
                     Mitke, Minister of Health, Ethiopia; and Dr        through implementation of the SAFE strategy.
                     Marcos Espinal, Director, Communicable             Solomon Islands and Vanuatu did their first
                     Diseases and Health Analysis, Regional Office      round of antibiotic mass drug administration
                     for the Americas, WHO.                             (MDA) between 2015 and 2016 (1), and intend
                                                                        to undertake impact surveys in 2017. Kiribati
                     Dr Mahmoud Fikri, Regional Director, Eastern       (15, 16) plans to undertake its first round of
                     Mediterranean Regional Office, WHO                 antibiotic MDA in 2017. Solomon Islands
                                                                        and Vanuatu are known to have populations
                     In 2016, Morocco submitted its dossier for         that are co-endemic for trachoma and yaws
                     validation of elimination of trachoma as a         (17–19), so it is anticipated that the provision
                     public health problem, and achieved formal         of azithromycin will reduce the prevalence of
                     recognition from WHO for having achieved this      both diseases (20); the effect will be closely
                     milestone (14). In the Eastern Mediterranean       measured. Australia and Viet Nam are
                     Region, trachoma was still known to be             implementing targeted MDA in trachoma-
                     a public health problem in Afghanistan,            endemic populations (1). Papua New Guinea
                     Egypt, Pakistan, Somalia, Sudan and Yemen.         implemented baseline surveys for trachoma
                     Trachoma mapping has been completed in             in 2016 (21) and is expected to move forward
                     Yemen; is ongoing in Egypt, Pakistan and           with MDA in endemic districts. Nauru is
                     Sudan; and is planned for Afghanistan and          suspected of having trachoma but has not yet
                     Somalia. The Islamic Republic of Iran claims       started a programme.
                     to have eliminated trachoma as a public health
                     problem, but has not yet submitted a dossier
                     for formal evaluation by WHO.

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It is important that there is good                Dr Matshidiso Moeti, Regional Director, WHO
                     communication between WHO and various             Regional Office for Africa, WHO.
                     partners providing direct support to the
                     countries in the Western Pacific Region. There    The African Region is set to make considerable
                     has been limited support to date for the water,   progress towards the elimination of trachoma
                     sanitation and hygiene (WASH) components          in the next few years. Trachoma elimination
                     of the SAFE strategy. Efforts are being made      is now a part of the remit of the Expanded
                     to encourage multisectoral approaches in a        Special Project for Elimination of Neglected
                     number of countries, in order to strengthen       Tropical Diseases (ESPEN), a five-year
                     WASH delivery (22). It is important that sight    project launched in May 2016 to provide
                     is not lost of what happens after a formerly-     national NTD programmes with technical and
                     endemic country succeeds in eliminating           fundraising support to accelerate the control
                     trachoma as a public health problem. Without      and elimination of the five NTDs whose
                     post-validation surveillance, the disease could   management strategy employs mass drug
                     potentially become re-established, as seen        administration or preventive chemotherapy
                     previously with measles. In addition, trachoma    (25). The NTD mapping portal (http://espen.
                     elimination does not necessarily mean that the was launched as part of ESPEN
                     risk of chronic morbidity has been removed.       to enable improved access and use of mapping
                     Individuals who have received operations for      data, including trachoma data. There has been
                     trichiasis will require follow-up for several     excellent collaboration between the AFRO
                     more years, and efforts need to be made to        mapping initiative and the Global Trachoma
                     detect incident cases, too (23).                  Mapping Project. Regional updates should
                                                                       become available on the ESPEN portal as
                     Dr Ren Minghui                                    approval from countries is obtained to share
                                                                       data. It is important to note that the African          3

                     The day is approaching when global                Region is the most affected by trachoma, with
                     elimination of trachoma will become a reality.    27 of a total of 42 endemic countries located
                     More countries will reach their trachoma          in Africa (1). The Region also has the most
                     elimination targets (23), and national trachoma   intensive elimination efforts for trachoma.
                     programmes will face new challenges related       In 2016, about 250,000 people in Africa had
                     to surveillance (24). In the post-validation      operations for trichiasis and nearly 83 million
                     phase, there is risk that donors may leave and    people were treated with antibiotics for
                     investments from governments may disappear        trachoma, both of which represent significant
                     as trachoma will no longer be an immediate        increases from the previous year (1). These
                     concern.                                          interventions are hugely beneficial, and relieve
                                                                       people of trachoma-related disability, poverty,
                     Governments must be prepared to facilitate        and chronic morbidity.
                     integration of public health programmes,
                     provide leverage for common public health         Though trachoma mapping is virtually
                     interventions and address challenges relating     complete for countries suspected of being
                     to broader public health issues such as           endemic for trachoma, thanks to the financial
                     the development of universal health care          support of partners, improved mapping data
                     coverage. It will be especially challenging for   are still needed in some countries to target
                     governments to coordinate efforts among the       interventions to the populations that need
                     many players involved.                            them. With additional support from ESPEN,
                                                                       the WHO Regional Office for Africa hopes
                                                                       to help to complete trachoma mapping in

Twenty_first_report_ok.indd 3                                                                                             4/1/2019 9:58:50 AM
currently unmapped areas, such as in South          Ms Emily Wainwright, United States Agency for
                     Sudan, and to introduce SAFE interventions          International Development (USAID)
                     where required. In 2016, there was a large
                     expansion of SAFE roll-out in 16 countries          USAID supports MDA and/or trachoma
                     in Africa (1). These interventions reached          surveys in 19 countries, most of which are
                     40 million people in 277 districts, most of         in Africa. Partly as a result of this support,
                     whom were children. Ethiopia has seen a             in 2016, the number of people receiving
                     tremendous scale-up of interventions, funded        antibiotics for trachoma worldwide rose from
                     in part through an increase in commitment           56 million to 85 million (1). There are several
                     of domestic resources to support application        current challenges that USAID foresees. First,
                     of the SAFE strategy. Ghana and Gambia              as success in some areas becomes documented,
                     have scaled down SAFE implementation and            communication within and beyond existing
                     are awaiting formal validation of elimination       stakeholders is important, in order to maximize
                     of trachoma as a public health problem from         the visibility of the programme at global
                     WHO.                                                level. It is important to show that countries
                                                                         are meeting their elimination goals, as this
                     Mr Iain Jones, Department for International         provides incentives for continued partner
                     Development (DFID), United Kingdom                  support and funding. Second, USAID supports
                                                                         surgical work in three endemic countries.
                     The United Kingdom is committed to funding          There should be greater emphasis on quality as
                     antibiotic MDA and some 400,000 surgeries           an integral component of surgery interventions
                     for trichiasis. DFID will also provide specific     for trichiasis (26). Third, it is important
                     support to the Coalition for Operational            that trachoma interventions take advantage
                     Research on Neglected Tropical Diseases             of structures that are already in place. For
           4         for research and development relevant to            instance, monitoring of interventions for facial
                     trachoma. It is important that partners work        cleanliness and environmental improvement
                     to strengthen healthcare systems in trachoma        can be included within existing WASH
                     endemic countries, in order to sustain public       monitoring and evaluation frameworks, in
                     health interventions and achieve lasting results.   order to increase efficiency.
                     It is equally important to ensure that trichiasis
                     surgeries being delivered are of high quality.      Discussion
                     Moving forward, DFID will evaluate how
                     support for and engagement with trachoma            Mr Gordon pointed out that many issues had
                     elimination programmes should change with           been raised, and invited the audience to engage
                     the cessation of MDA, as countries approach         with the panelists.
                     their elimination goals. Evaluation will also
                     be required to determine how best to use            The first question asked about the strategy for
                     trachoma metrics in models, supported by            scaling down in areas where trachoma is no
                     case studies on health system strengthening,        longer a public health problem, and whether
                     and quality and access to water and sanitation,     any lessons for scaling down could be learned
                     in order to inspire domestic governments and        from campaigns to eliminate or eradicate other
                     other collaborators to continue the fight to        diseases, such as polio and malaria.
                     eliminate trachoma.

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The panel agreed that this question was          3. In July 2016, Tropical Data was
                     important. Mr Jones pointed out that health         launched (27, 28). This collaboration
                     system strengthening and continued disease          supports the full trachoma survey
                     surveillance would be needed post-validation,       process from protocol development to
                     in order to ensure that health systems have         data management and analysis.
                     capacity to sustain the gains made against       4. Also in July 2016, the Alliance published
                     trachoma.      Ms     Wainwright     reminded       Eliminating Trachoma: Accelerating
                     participants that interventions against NTDs        Towards 2020 (12).
                     benefited low-income communities in many
                     ways other than specifically addressing          5. In August 2016, WHO’s Strategic and
                     endemicity of disease. Precipitous scale-down       Technical Advisory Group on NTDS
                     could remove community outreach services to         convened a technical consultation to
                     the most disadvantaged. Dr Moeti said that it       review data generated to date by the
                     was important to continue to engage the people      “Trachoma Alternative Indicators
                     helping with surveillance, data precision and       Study”, consider the implications
                     data quality in the post-elimination phase. Dr      for global policy development on
                     Fikri reiterated that disease monitoring must       validation of trachoma elimination,
                     continue for many years as a component of           and plan further work. No changes were
                     scaling down. Dr Jacobs noted that scaling          made to current guidelines. The Group
                     down occurs in connection with cessation of         requested that national programmes
                     funding. He said that it is important to have       continue to help implement the
                     a planned, measured transition from a single        research agenda (29).
                     disease program to integration within a health   6. Also in August, the 2016 Hilton
                     system capable of sustaining the impact of          Humanitarian Prize was awarded to
                     previous interventions and able to continue         the Task Force for Global Health, the             5

                     disease monitoring. Dr Ren concluded that           parent organization of the International
                     we should review our messaging for these            Trachoma Initiative (ITI).
                     processes, to help ensure smooth transitions.
                                                                      7. In September 2016, more than
                                                                         300 partners came together to
                                                                         commemorate the 10th anniversary
                     World Health Organization                           of the USAID NTD Program, which
                     Report                                              had by that date delivered more than
                                                                         1.6 billion treatments against NTDs in
                     Dr Anthony Solomon, Medical Officer,                31 countries, in the process leveraging
                     Department of Control of NTDs, WHO                  US$11.1 billion worth of in-kind
                                                                         donations from the pharmaceutical
                     Highlights for the global programme over the        industry.
                     twelve months since the previous (April 2016)    8. In October 2016, at its 10th General
                     meeting of the Alliance were presented:             Assembly in Durban, South Africa, the
                                                                         International Agency for the Prevention
                          1. Marked scale-up in interventions            of Blindness awarded its Global
                             against trachoma (1) was noted (see         Partnership Award to the Alliance, in
                             below).                                     recognition of its remarkable work to
                          2. In June 2016, WHO published its             eliminate trachoma.
                             standard operating procedures for        9. October 2016 also saw the launch of a free
                             validating national elimination of          online course on eliminating trachoma,
                             trachoma as a public health problem         developed by the International Centre

Twenty_first_report_ok.indd 5                                                                                         4/1/2019 9:58:50 AM
for Eye Health at the London School of     300

                                Hygiene & Tropical Medicine.               250

                          10. In November 2016, WHO formally               200

                              validated elimination of trachoma as a       150

                              public health problem from Morocco           100

                              (14). Validation was then undertaken          50
                              in Mexico in January 2017 (30).                0
                                                                                     2014              2015             2016
                          11. In April 2017, the United Kingdom
                                                                         Fig. 1 Number of people operated for trichiasis annually,
                              announced a doubling of its support        worldwide, 2014–2016 (thousands)
                              to fight NTDs, including trachoma,
                              over the subsequent five years. The
                              total support package was anticipated
                              to prevent up to 400,000 cases of
                              trachomatous blindness.                       80


                     In 2017, 69 countries were asked by WHO
                     to submit Trachoma Elimination Monitoring          20

                     Forms, and 61 countries did so. Of the eight        0

                     countries that did not, six did not have active             2014           2015            2016

                     trachoma programmes. Forms were still sent Fig. 2 Number of people given antibiotics for trachoma
                     to countries that had already been recognized elimination
                                                                                  purposes annually, worldwide, 2014–2016

                     as having eliminated trachoma, in order to help
                     encourage post-validation surveillance and to
                     maintain visibility for data that continue to 85% of treated districts achieved antibiotic
                     collect.                                         coverage of ≥ 80% in 2016, an increase from
                                                                      72% of districts achieving ≥ 80% coverage
                     Worldwide, 260,759 people with trichiasis in 2015. Recent data (34) support the use of
                     received corrective surgery in 2016, a 41% 80% as the minimum acceptable coverage in
                     increase from the 185,000 people managed azithromycin MDA for trachoma.
                     in 2015 (Figure 1). Available data showed that
                     54% of those receiving corrective surgery for The number of people living with trichiasis
                     trichiasis were female. Women are known to be decreased from approximately 3.2 million in
                     affected by trichiasis up to four times as often 2015 to approximately 2.8 million in 2016.
                     as men (31, 32), so these data suggest that in The number of people living in districts in
                     2016, women were still relatively under-served which the most recent estimated prevalence of
                     by trichiasis surgery programmes (32, 33).       trachomatous inflammation—follicular (TF)
                                                                      was ≥ 5% (and therefore need treatment with
                     The number of people given antibiotics for the A, F and E components of SAFE) decreased
                     trachoma increased from 56.1 million in from 192 million in 2015 to 190 million in 2016
                     2015 to 85.2 million in 2016. In Ethiopia (1); preliminary analyses suggested that by
                     alone, the number of people given antibiotics April 2017, that number had declined further
                     for trachoma increased from 32.6 million in to < 182 million.
                     2015 to 47.2 million in 2016. Global antibiotic
                     coverage (the number of people treated Dr Solomon noted that in the 12 months
                     divided by the number living in districts that following the meeting, WHO anticipated
                     need antibiotic MDA) increased from 30% in receiving completed dossiers claiming
                     2015 to 45% in 2016 (1).                         elimination of trachoma as a public health
                                                                      problem from several more countries. He

Twenty_first_report_ok.indd 6                                                                                                        4/1/2019 9:58:50 AM
expressed a hope that WHO would be able            In response to a question asking about what
                     to validate elimination in these countries and     needed to be done to expand trichiasis surgery
                     continue to focus the efforts of the Alliance      output, Dr Solomon said that there was a
                     on populations where interventions were still      continuing need to focus on surgeon training
                     required. It was also anticipated that regional    and supervision (35), quality of operations
                     elimination plans would be generated for           provided, and follow-up with patients to
                     several regions, detailing the concrete actions    ensure that outcomes are good. He added
                     to be undertaken by various actors to get rid      that a protocol for a trichiasis-only prevalence
                     of trachoma.                                       survey had recently been developed and
                                                                        validated (36).

                     The first question related to the reasoning for International Coalition for
                     sending TEMFs to countries which were not
                     known to be trachoma-endemic. Dr Solomon Trachoma Control Report
                     said that TEMFS are sent to such countries
                     in order to raise awareness and encourage Ms Virginia Sarah, Chair, International
                     engagement with global trachoma elimination Coalition for Trachoma Control, described the
                     efforts.                                         Coalition as a diverse and highly committed
                                                                      group of members and observers who come
                     The second question was a request for an together to amplify support for GET2020.
                     opinion as to why the return rate for 2017 The Coalition’s 2015–2020 strategic objectives
                     TEMFs had been so high. Dr Solomon replied are to: increase commitment to trachoma
                     that the TEMF response rate had been very elimination among donors and decision
                     high since 2014, but agreed that this was the makers; increase investment in trachoma                      7

                     highest yet. He said that the TEMF format had elimination        programmes;        strengthen
                     been progressively revised to reduce the time capacity and human resources needed to
                     required for its completion and to maximize achieve trachoma elimination; coordinate
                     the value of the data collected. Redundant the provision of technical assistance and
                     questions had been removed. In addition, sharing of knowledge by its membership to
                     integration of the data collection process with support high quality outcomes in trachoma
                     the process for requesting donated azithromycin elimination programmes; and ensure that the
                     from ITI and reporting on its use in-country Coalition remained a strong partner within
                     means that endemic countries now receive one the Alliance. The Coalition’s members include
                     combined form about trachoma from WHO non-governmental organizations, research
                     and ITI per year, rather than the five that they and academic institutions, donors and private
                     received in 2013. Dr Solomon also said that sector organizations.
                     the ITI team works closely with WHO and
                     health ministries to ensure that the responsible   The Coalition supported the development
                     individuals within each health ministry are        of the Alliance’s current plan of action,
                     supported to complete the forms. He thanked        Eliminating Trachoma: Accelerating Towards
                     all those involved for their hard work. Dr         2020 (12), which outlines what needs to be
                     Solomon indicated that the high response rate      done to scale up programmes and strengthen
                     will make the dossier development process          health systems to achieve the trachoma
                     easier, as information shared becomes part of      elimination target. The document illustrates
                     the database that can be used to pre-populate      the cost of implementing SAFE, presents a
                     the spreadsheet component of a draft dossier,      strong economic case for investment and
                     which can then be reviewed and finalized by        frames momentum against trachoma within
                     the health ministry.                               the broader sustainable development goal and
                                                                        universal health coverage agendas.

Twenty_first_report_ok.indd 7                                                                                              4/1/2019 9:58:50 AM
Published in July 2016, the document was           backlog of trichiasis surgery to undertake. He
                     updated in April 2017 to include 2017 global       said that Benin was implementing antibiotic
                     epidemiological data and other relevant            MDA, but required external support for its
                     statistics, to ensure that it remained a useful    trichiasis surgery programme in order to reach
                     tool for assessing progress and advocating         GET2020 goals.
                     for support towards elimination. The updates
                     were contained in a stand-alone Appendix that      Ms Sarah noted that Dr Batcho had raised
                     could be inserted inside the cover of the parent   two very important issues: cross-border
                     document.                                          transmission and the fact that all components
                                                                        of the SAFE strategy need to be in place for
                     Implementation of the SAFE strategy is             trachoma to be fully addressed. She said that
                     being achieved through collaboration and           ongoing interventions in Nigeria should reduce
                     commitment from governments and their              the burden of trachoma there, and commented
                     partners. Eliminating Trachoma: Accelerating       that eliminating trachoma in one country
                     Towards 2020 includes a blueprint for action       could have indirect benefits for neighboring
                     which recognizes the need for this collaboration   countries. Ms Sarah also emphasized that
                     to continue to strengthen, allowing urgent         some partners of the Alliance may be more
                     coordinated action to advance the GET2020          specialized in one component of trachoma
                     goals.                                             than another, and that creating partnerships
                                                                        and coordinating interventions was critical to
                     The updated document was approved by the           achieving elimination.
                     Alliance by acclamation.

                     With less than four years left until December      Regional reports
           8         2020, Ms Sarah noted the period in which
                     the meeting was being held as a critical point
                                                                        In the absence of a representative from WHO’s
                     in the campaign to eliminate trachoma as a
                                                                        South East Asia Regional Office, Dr Promila
                     public health problem. She commented that
                                                                        Gupta (representing India), Dr Hla Marlar
                     the Alliance was making astounding progress
                                                                        (representing Myanmar), and Mr Sailesh
                     to reach its goals, and needed to ensure that it
                                                                        Kumar Mishra (representing Nepal), delivered
                     engaged new partners to sustain momentum.
                                                                        brief country-level reports.
                     Ms Sarah closed by noting that it would be her
                                                                        India, Myanmar and Nepal each previously
                     last Alliance meeting as Chair of the Coalition,
                                                                        had a public health problem from trachoma.
                     and asked meeting participants to join her in
                                                                        In India, a series of surveys conducted in ten
                     welcoming Dr Serge Resnikoff as the incoming
                                                                        formerly-endemic districts from 2014–2017
                                                                        found the district-level prevalence of TF in
                                                                        1–9-year-olds to 0.1–2.1%, while the age- and
                                                                        gender-adjusted district-level prevalence of
                                                                        trichiasis in ≥ 15-year-olds was 0.1–2.4% (42).
                     Dr Wilfrid Batcho, representing Benin,
                                                                        Trachoma rapid assessments were conducted
                     expressed concern that after local elimination
                                                                        in parallel in 17 other districts; very low
                     is achieved, trachoma might spread back to
                                                                        proportions of children examined had active
                     Benin from Nigeria (37–40), a larger country
                                                                        trachoma, and very low proportions of ≥
                     immediately bordering Benin to the East. He
                                                                        10-year-olds had trichiasis (43). The country
                     noted that Benin had only two evaluation units
                                                                        intended to strengthen its trichiasis surgery
                     (comprising four districts) in which the TF
                                                                        programme in order to reach elimination
                     prevalence in 1–9-year-olds was ≥ 10% (41),
                                                                        targets by 2020. Dr Hla reported that in
                     though the country still had a considerable
                                                                        Myanmar, public health-level interventions

Twenty_first_report_ok.indd 8                                                                                             4/1/2019 9:58:50 AM
had been successful in reducing transmission of    from an integrated approach for eliminating
                     infection. While Myanmar still has individuals     trachoma and other NTDs by combining
                     with trichiasis (44), it no longer required        interventions from the health, water and
                     implementation of the A, F and E components        sanitation, education, and other sectors in a
                     of SAFE to reach the elimination endpoint.         coordinated way.
                     Myanmar hoped to conduct prevalence
                     surveys in 2017–2018, and to submit a dossier
                                                                Many countries nearing elimination targets
                     for validation of elimination of trachoma  have health systems that are not prepared to
                     as a public health problem soon after thosesustain gains made through implementation
                     surveys are complete. Mr Mishra reported   of the SAFE strategy. It is important that those
                     a small backlog of trichiasis in Nepal, which
                                                                countries receive external guidance on how to
                     no longer required implementation of the A,establish and maintain effective surveillance
                     F and E components of the SAFE strategy forsystems in the post-validation phase. The
                     trachoma elimination purposes. A request toWHO Regional Office is planning to work
                     WHO to validate elimination of trachoma as with countries to achieve the health-related
                     a public health problem was expected to occur
                                                                Sustainable Development Goals by 2030. If
                     in 2017 or 2018.                           a country in the region eliminates trachoma
                                                                by 2020, there will be more than a decade in
                     Dr Rabindra Abeyasinghe, Coordinator, which trachoma may resurface. The Alliance
                     Malaria, Other Vectorborne and Parasitic should develop a post-validation strategy for
                     Diseases, Western Pacific Regional Office, countries, which should include methods for
                     WHO.                                       disease surveillance.

                     Trachoma was believed to be, or to have recently   Dr Simona Minchiotti, Medical Officer, Non
                     been, a public health problem in ten countries     Communicable Diseases, Africa Regional Office,          9

                     in the Western Pacific Region. Cambodia (45),      WHO
                     China and Lao People’s Democratic Republic
                     (46) had all already claimed to have eliminated    The African Region bears the largest burden
                     trachoma as a public health problem.               of trachoma globally (1). The prevalence of
                     Implementation of the antibiotic component of      TF was ≥30% at most recent survey in areas
                     the SAFE strategy covers all endemic districts     of Democratic Republic of the Congo (53),
                     in Australia (47, 48), Solomon Islands (15, 19)    Guinea, Kenya (54), South Sudan (55), United
                     and Vanuatu (17). As of April 2017, antibiotic     Republic of Tanzania (56) and Zambia,
                     MDA had not been started in Fiji (15, 49-51),      indicating that implementation of the A, F
                     Kiribati (15, 16), Papua New Guinea (21), or       and E components of the SAFE strategy are
                     Viet Nam (52). Progress towards elimination        needed for at least five years before re-survey.
                     in these countries may be impeded by the           The countries with the highest national-level
                     distribution of the affected populations, which    trichiasis backlogs include Chad, Democratic
                     are scattered, remote and often difficult to       Republic of the Congo, Ethiopia and Nigeria
                     access; political focus on other priorities; and   (1). Gambia (57, 58) and Ghana (59, 60) claim
                     limited donor support for improving access to      to have eliminated trachoma as a public health
                     WASH.                                              problem, and plan to submit dossiers for
                                                                        formal validation of elimination in 2017.
                     Many Pacific Island countries have experience
                     of    undertaking        successful   preventive   Since its launch in May 2016, ESPEN has
                     chemotherapy campaigns for the elimination         supported efforts to improve access to NTD
                     of lymphatic filariasis, which should make local   data and enable data sharing. Increased
                     populations receptive to antibiotic MDA for        collaboration between country governments,
                     trachoma. Countries in the region can benefit      donors and partners has helped to coordinate

Twenty_first_report_ok.indd 9                                                                                              4/1/2019 9:58:50 AM
mapping and SAFE interventions. Many               trachoma mapping. Mapping in Afghanistan
                     countries report a lack of communication           and Somalia is expected to begin in 2017.
                     between programmes for other NTDs and              The Islamic Republic of Iran is expected
                     the trachoma programme. Insufficient               to soon prepare a dossier in line with the
                     coordination between these programmes may          standard operating procedures for validation
                     increase costs and make it more difficult to       published by WHO (23). The WHO Eastern
                     secure funding. Several countries in the region    Mediterranean Regional Office target for 2019
                     are experiencing political instability and poor    is to have at least four additional countries
                     security conditions which impede public            validated for trachoma elimination, possibly
                     health programmes. These limitations must          including Djibouti, Iraq, the Islamic Republic
                     be addressed in order to survey unmapped           of Iran and Saudi Arabia. The target for 2021 is
                     regions, introduce interventions, and integrate    to have at least six more countries validated for
                     surveillance into existing health systems.         trachoma elimination. These targets have been
                                                                        endorsed by the Regional Director.
                                                                        Socio-political conflict and unrest, complex
                     Mr Martin Kabore, representing Burkina             emergencies and insecurity are major
                     Faso, asked what source data were used for         challenges in about one-third of countries in the
                     determining national trichiasis backlogs. Dr       region, influencing priority-setting for health
                     Minchiotti replied that trichiasis backlog         care. SAFE interventions have been mostly
                     estimates were determined from population-         undertaken without external donor support.
                     based prevalence survey data shared with           It has been a challenge to facilitate stronger
                     WHO.                                               networking and developing of partnerships,
                                                                        participatory planning and comprehensive
           10        Dr Ismatullah Chaudhry, Medical Officer,           approaches in programme implementation in
                     Prevention of Blindness, Eastern Mediterranean     order to increase productivity and create better
                     Regional Office, WHO.                              outcomes. It is important to address weak
                                                                        health management information systems and
                     Six countries are believed to be trachoma          compromised surveillance systems in most of
                     endemic in the Eastern Mediterranean Region.       the region’s trachoma-endemic countries.
                     Egypt, Pakistan and Sudan (61, 62) have
                     undertaken at least some baseline trachoma         Dr Martha Saboya, Advisor, Neglected Infectious
                     mapping. In these countries, surgeons trained      Diseases Epidemiology, WHO Regional Office
                     to undertake trichiasis surgery are beginning      for the Americas.
                     to address trichiasis backlogs in districts
                     where the prevalence of trichiasis is ≥ 0.2%,      Mexico has become the first country in the
                     and there is engagement with ITI concerning        Region of the Americas and the third country
                     an azithromycin donation, in order to facilitate   in the world to be officially validated as
                     MDA in districts where the prevalence of TF is     having eliminated trachoma as a public health
                     ≥ 5%. Yemen has recently completed trachoma        problem (30). Mexico has zero new cases of
                     mapping (63) and urgently requires surgery         trichiasis unknown to the health system.
                     and antibiotics interventions, but insecurity
                     has delayed implementation. Afghanistan            However, trachoma remains endemic in at
                     and Somalia still need to undertake mapping.       least 136 districts across Brazil, Colombia and
                     Based on trachoma rapid assessment data from       Guatemala. Overall, 5 million people live in
                     eye outreach camps and hospital registries in      these endemic districts, and a large proportion
                     Afghanistan, 25 districts across 19 provinces      of them live in 128 known-endemic districts
                     are prioritized for mapping. In Somalia, 12        in Brazil.
                     districts from six regions are prioritized for

Twenty_first_report_ok.indd 10                                                                                              4/1/2019 9:58:51 AM
About 285 000 people in Brazil, some of              The Pan-American Health Organization’s
                     whom live in indigenous communities,                 regional trachoma forum takes place
                     received antibiotic treatment in 2016 (1).           biennially, allowing experts from various
                     Facial cleanliness interventions are being           organizations to share recommendations and
                     delivered as part of an integrated campaign          country representatives to share progress on
                     against leprosy, schistosomiasis, soil-              SAFE implementation (64).
                     transmitted helminthiases and trachoma, and
                     environmental improvement is being funded            There are several challenges that still need to
                     through local investments in WASH.                   be addressed in the region. Mapping needs to
                                                                          be conducted in countries with populations at
                     Colombia has expanded mapping in districts           risk of trachoma but which are not currently
                     surrounding its known focus in Vaupés,               proven to require interventions. In 2017, Peru
                     delineating four newly-characterized endemic         will complete a baseline survey for trachoma
                     districts. It is now carrying out active case        that will also include collection of data on soil-
                     finding of trichiasis. Colombia is undertaking       transmitted helminth infections, but may then
                     antibiotic MDA interventions across its six          require additional support to complete further
                     known-endemic districts, with interventions          mapping. Indigenous populations are at greater
                     to promote facial cleanliness being delivered        risk of trachoma than non-indigenous groups,
                     concurrently, both in schools and at village-        but high costs and limited access to these
                     level. Interventions to improve WASH are             populations makes mapping difficult. The
                     being financed by various stakeholders.              plan is to conduct population-based surveys
                     Guatemala will carry out impact surveys from         in several countries in areas covered by the
                     April to May 2017.                                   Amazon rainforest. Standardized training of
                                                                          graders is currently difficult and costly, and
                     Guatemala is in the pre-validation surveillance      endemic countries have trouble affording                  11

                     phase. It had only two trachoma-endemic              it. In Mexico, tools and procedures for post-
                     districts. Village health workers promote            validation surveillance have not yet been
                     facial cleanliness, and water and sanitation         defined. There is therefore a risk of undetected
                     improvements are led by the community.               recurrence in populations following validation,
                                                                          and a system for picking up and notifying
                     In the Americas, it is currently recommended         recurrence needs to be created.
                     that, to ensure high quality, trichiasis surgeries
                     be performed by ophthalmologists or                  The Alliance applauded the success of Mexico,
                     oculoplastic surgeons. In areas suspected to         Morocco and Oman in being validated as
                     be endemic for trichiasis, active case-finding is    having eliminated trachoma.
                     preferred to passive detection.

Twenty_first_report_ok.indd 11                                                                                                 4/1/2019 9:58:51 AM
                                          Trachoma Scientific
                                          Informal Workshop

                    The Trachoma Scientific Informal Workshop           5. There is ongoing work to assess the role
                    had taken place on 18th April 2017, at                 of serology for use in trachoma surveys
                    WHO Headquarters. Dr Solomon presented                 as a tool to understand community
                    highlights of the Workshop for the information         transmission (29). Researchers are
                    of the Alliance.                                       looking to partner with national
                                                                           programmes in ongoing work.
           12            1. While programmes should aim for             6. New cases of conjunctival scarring may
                            100% coverage when undertaking                 continue to appear for at least four years
                            azithromycin MDA, at least 80%                 after the prevalence of TF in 1–9-year-
                            coverage in children has been shown            olds has been reduced to
Questions                                       Surgery for GET2020 Panel
                     One participant asked for clarification on
                     the role of supervisors in the provision of
                                                                     Reducing the Trichiasis Backlog
                     trichiasis surgery. Dr Solomon answered that
                                                                     Dr Dézoumbé Djoré, Coordonnateur du
                     supervisors have a number of important roles,
                                                                     Programme National de Lutte Contre la Cécité,
                     and in the interests of time, suggested that
                     details be sought in the report on the Second
                     Global Scientific Meeting on Trachomatous
                     Trichiasis (68).                                In Chad, trichiasis is a public health problem
                                                                     in 11 districts with a collective 2.5 million
                     Another      participant      asked   whether   inhabitants. In the district of Mongo, impact
                     programmes should continue to use two-          survey results suggest that the prevalence
                     dimensional photographs for training graders    of trichiasis decreased from 6.2% in 2015 to
                     to recognize trichiasis. Dr Solomon responded   1.2% in 2017. There are currently an estimated
                     that training using three-dimensional           63,888 cases of trichiasis nationally that require
                     photographs was still in development, so        corrective surgery. To reduce the prevalence
                     existing training systems should continue to    everywhere to below the elimination
                     be used until further notice.                   threshold, the programme needs to manage an


                                                                                                                                         © Sightsavers

Twenty_first_report_ok.indd 13                                                                                            4/1/2019 9:58:51 AM
estimated 35,106 individuals with trichiasis,     In 2009, surveys were undertaken using a
                     using a combination of fixed and mobile           non-standard integrated mapping approach
                     surgery teams. In 2014, 2281 individuals with     (69). In three districts in which those surveys
                     trichiasis were managed. In 2015, 9569 cases of   suggested an elevated prevalence of trachoma,
                     trichiasis were managed. In 2016, 17,809 cases    cluster-sampled surveys were implemented
                     of trichiasis were managed, representing 51%      in 2011. Very little active trachoma was
                     of the calculated backlog at that time. Guera,    found. District-level prevalence of trichiasis
                     Salamat, Ouaddai regions are thought to still     in women aged ≥15 years was ≥0.2% in two
                     require surgery interventions in order to reach   districts, Binah and Blitta.
                     elimination prevalence targets.
                                                                       Subsequently, two strategies have been used
                     A survey of districts with active surgery         to find and address prevalent trichiasis
                     programmes indicated that 89% of operated         cases. The first approach required healthcare
                     individuals were followed up post-operatively.    workers in rural settings to report detection
                     The incidence of post-operative complications     of any new cases of trichiasis. This passive
                     was 2%. Additional surveys were carried out       surveillance system had low sensitivity, and
                     in other districts to determine the prevalence    may have provided limited information. Using
                     of trichiasis and number of cases requiring       this approach, 17 cases of trichiasis were
                     operation. Results showed 26 new endemic          detected, of which 16 had surgery. The second
                     districts with 9703 new cases of trichiasis to    approach, implemented with support from
                     manage in a population of 5.5 million people.     the Bill & Melinda Gates Foundation, was a
                     Trichiasis endemicity in these districts ranged   form of active surveillance involving door-to-
                     from 0–1.2%.                                      door visits by community health workers or
                                                                       ophthalmic nurses. This approach was more
           14        In order to address the trichiasis backlog in     sensitive, and able to detect cases that existed
                     Chad, graders are being trained to detect         in remote areas. However, it was costly, labor
                     trichiasis, and surgeons are being certified.     intensive and difficult to sustain over time.
                     Trichiasis case-finding is conducted on a door-   This approach detected 203 cases of trichiasis,
                     to-door basis. The Ministry of Health plans to    of which 158 had surgery. Some of the detected
                     continue interventions in the 11 districts that   cases did not consent to the operation. Reasons
                     have completed mapping, and conduct surveys       cited for refusing surgery included being too
                     for trichiasis in the remaining 26 districts.     old, being afraid of the procedure, or being
                                                                       unable to afford the operation. Patients also
                     Getting the Trichiasis Backlog to                 refused surgery if their families were resistant
                                                                       to them doing so.
                                                                       A review meeting was held in Lomé, Togo, from
                     Dr Marcel Awoussi, Togo
                                                                       1–2 March 2017. The meeting recommended
                                                                       that all previous and ongoing data from routine
                     Trichiasis is not a common presentation in        trichiasis surgeries at health facilities, surveys
                     Togo. To help develop a dossier for validation    and screening initiatives be collated to inform
                     of elimination of trachoma as a public health     decisions on where to undertake further
                     problem, prevalence data collection is a very     population-based surveys. Those surveys are
                     important concern. In some areas, people          intended to be completed by the end of 2017,
                     working in the health sector are simply not       with the support of Tropical Data and funding
                     aware of the disease. Data on trichiasis are      from USAID, to allow for subsequent planning
                     not routinely recorded at local health centers.   and action.

Twenty_first_report_ok.indd 14                                                                                              4/1/2019 9:58:51 AM
Questions                                         or 67% of the trichiasis backlog, would need
                                                                       to be managed by 2020, in order for this to
                     OA participant asked Dr Djoré for clarification   occur. There are currently 14 trainers and 175
                     on the methodology used to estimate the           ophthalmologists trained to deliver trichiasis
                     prevalence of trichiasis. A question to both      surgeries in the country. The Ministério da
                     speakers asked what was being done to ensure      Saúde is now working to build health system
                     that surgery interventions were effective in      capacity by training more surgeons and health
                     preventing vision loss.                           personnel. The trichiasis surgical service has
                                                                       been integrated into local hospital services,
                     Dr Djoré responded that in 2004, the trachoma     and people with trichiasis are being offered
                     survey performed in Chad was carried out          transport to the nearest hospital offering
                     in a sample of 27 villages in one region (70).    surgery free of charge. Local health centers
                     Surveys were later conducted in three other       are continuing to undertake surveillance for
                     regions. In 2013, the Ministry of Health          additional cases of trichiasis.
                     began surgical activities in all four regions
                     (11 districts) that had completed trachoma        The TT patient tracking app
                     surveys. In 2014, 41 evaluation units were
                     surveyed, and 29 had trichiasis prevalence        Dr Michael Masika, Ministry of Health, Malawi
                     estimates which indicated a need for public-
                     health-level surgery interventions (71). Dr
                                                                       The Trichiasis Patient Tracking Application
                     Djoré added that post-operative follow-up
                                                                       was created in order to address the lack of
                     was undertaken for all patients. Patterns of
                                                                       standardized trichiasis monitoring tools.
                     recurrence and other data were used to inform
                                                                       Before it was launched, different partners
                     refresher training for surgeons.
                                                                       used different tools to monitor output of                15
                                                                       interventions against trichiasis, and many of
                     Dr Awoussi said that ophthalmic nurses from
                                                                       those tools overlapped geographically. Post-
                     Togo received training to undertake trichiasis
                                                                       operative patient follow-up was challenging.
                     surgery in Mali, plus supplementary training
                                                                       It was difficult for surgeons to provide
                     in Ghana to correctly assess trichiasis cases.
                                                                       supervision and support to their patients.
                     Funding was also being used to provide
                                                                       Reporting of trichiasis case identification
                     additional training to surgeons to ensure that
                                                                       and of surgical delivery did not occur in
                     they were able to deliver quality surgeries.
                                                                       timely fashion. These issues created a need
                                                                       to develop a common system for registering
                     Transitioning Trichiasis Care into                patients with trichiasis, tracking them through
                     Routine Services                                  to the operation and through their post-
                                                                       operative follow-up course, and making data
                     Dr Marilia Messangaie, Mozambique                 available at all levels of service delivery. As a
                                                                       solution, WHO held a consultation (72) to
                     In 2014, the Queen Elizabeth Diamond Jubilee      develop a target product profile for a standard
                     Trust launched an initiative to support the       system, which has since been produced and is
                     Ministério da Saúde to reduce the backlog         being piloted in Chikwawa, Malawi. Patient
                     of trichiasis throughout Mozambique. The          registration, surgery and follow-up data are
                     aim was to achieve 100% coverage across           collected on smartphones. The application uses
                     the 50 districts in which the prevalence of       data entry fields modeled on standard forms
                     trichiasis exceeded the elimination prevalence    developed by the International Coalition for
                     threshold. An estimated 11,709 individuals,       Trachoma Control. Patients are tracked using

Twenty_first_report_ok.indd 15                                                                                             4/1/2019 9:58:51 AM
identification numbers. Data are made available   The Morbidity Management and
                     online for supervisors to plan outreach and       Disability Prevention Project
                     oversee each surgeon’s performance. The
                     application can be customized as needed to        Dr Joe Amon, Helen Keller International.
                     be interoperable with other databases or other
                     reporting forms used by national programmes.
                                                                   The Morbidity Management and Disability
                     In Malawi, the government will maintain
                                                                   Prevention Project is a five-year initiative
                     the system and make data freely available to
                                                                   funded by USAID to help support efforts in
                     its partners. This tool will be very useful for
                                                                   Burkina Faso, Cameroon and Ethiopia to
                     trichiasis programmes. It is faster and less
                                                                   eliminate trachoma and lymphatic filariasis
                     prone to error than paper-based monitoring
                                                                   as public health problems. The project works
                     methods. The application can facilitate
                                                                   to increase availability of quality data for
                     planning by producing reports of patient
                                                                   decision-making, increase support for scale-
                     surgery and follow-up status, organized at
                                                                   up in implementation, improve quality,
                     different administrative levels. Downloadable
                                                                   strengthen capacity within health ministries
                     summary statistics make it easier to report
                                                                   and strengthen the evidence base for preferred
                     programme output to donors and partners. The
                                                                   practices in morbidity management and
                     Blantyre Institute for Community Outreach,
                                                                   disability prevention. For trachoma, tools
                     Tropical Data, and WHO were acknowledged
                                                                   and resources developed or augmented by the
                     for their work in developing this tool.
                                                                   project include those on infection control and
                                                                   waste management, supportive supervision,
                                                                   epilation, trichiasis surgeon training and a
                                                                   procurement calculator to determine the cost
                     The first question addressed to Dr Masika
                                                                   of surgeries in order to support programme
           16        was whether the application uses free, open-
                     source software. A follow-up question asked
                     which other programmes can benefit from this
                                                                   To date, the project has made good progress
                     application. A third question asked whether
                                                                   towards reducing trachoma morbidity in
                     the data being uploaded from the app were
                                                                   the three participating countries. More than
                                                                   200 trichiasis surgeons have been trained,
                                                                   300,000 people have been screened, and
                     Dr Masika asked Dr Khumbo Kalua (Blantyre
                                                                   25,000 surgeries have been completed. The
                     Institute for Community Outreach) to help
                                                                   project supports post-operative follow-up
                     respond to these questions. Dr Kalua noted
                                                                   of patients, which is critical both for the
                     that the application was not open-source. The
                                                                   patients themselves and to provide feedback to
                     pilot testing in Malawi had been an excellent
                                                                   surgeons for continuous quality improvement.
                     opportunity to refine the system, and the
                                                                   In Cameroon, the project has supported the
                     aim was now to undertake a second round of
                                                                   Ministre de la Santé publique to measure
                     testing in Ethiopia. The intention is to then
                                                                   the prevalence of trichiasis more precisely,
                     make the system available to any country that
                                                                   and implementation data have been used as
                     would like to use it. The data are stored and
                                                                   a tool for sub-district-level trichiasis service
                     transferred fully encrypted.

Twenty_first_report_ok.indd 16                                                                                        4/1/2019 9:58:51 AM
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