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TRACHOMA 2020 REPORT OF THE 23RD MEETING OF THE WHO ALLIANCE FOR THE GLOBAL ELIMINATION OF - WHO | World Health Organization
REPORT OF THE 23RD MEETING
OF THE WHO ALLIANCE FOR
THE GLOBAL ELIMINATION OF

TRACHOMA
BY   2020
     30 NOVEMBER–1 DECEMBER 2020
TRACHOMA 2020 REPORT OF THE 23RD MEETING OF THE WHO ALLIANCE FOR THE GLOBAL ELIMINATION OF - WHO | World Health Organization
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 2020

ISBN 978-92-4-002392-5 (electronic version)
ISBN 978-92-4-002393-2 (print version)

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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
  Mediterranean
Acknowledgements

     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.

iv
1. 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 receive
antibiotics 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).

4
3. 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 different
calendars. 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 little
In 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 train
5. 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 and
environmental 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 includes
sectors 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 Melanesia
With 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 new
generation 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-validation
surveillance 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.

                                                                                                    15
7. 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 in
districts 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.                                17
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                                                                                                  21
Annexes

     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                                    Chair
ANNEX 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, Ethiopia
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