Eliminating Trachoma: Accelerating Towards 2020

WHO Alliance for the Global Elimination of Trachoma by 2020
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Foreword

Trachoma is the world’s leading infectious cause of blindness. It is one of 18 neglected tropical diseases (NTDs) that affect over one billion of the world’s poorest people.1

Trachoma is caused by a contagious bacterial infection of the eye spread from person to person through contact with contaminated hands, clothing2 and eye-seeking flies. It often begins in early childhood, and is worsened by episodes of reinfection. This causes inflammation and scarring of the inner eyelid. The eyelashes touch and scratch the surface of the eyeball and, considering we blink an estimated 19,000 times each day,3 this repeated action leads to horrific pain and irreversible blindness.

Today, 1.9 million people are blind or moderately to severely visually impaired because of trachoma4 and some 200 million people are confirmed to live in endemic areas that need interventions.5 The disease is responsible for an estimated annual productivity loss of up to US$8 billion6 – eliminating it will cost around US$1 billion dollars.7

Whilst impressive progress has been made in recent years, we still have a lot to do, particularly as the elimination of trachoma as a public health problem cannot be achieved in isolation when it is linked to so many other pressing health and development issues, including lack of access to clean water, and improved sanitation and hygiene. Trachoma often co-exists with other NTDs; many of which affect the same communities and demand similar public health approaches.8

As an Alliance of diverse partners with shared commitments to achieving the elimination of trachoma, we need to redouble our efforts, urgently build an even broader coalition of funders and attract technical partners from other sectors if we are to accomplish our 2020 goals.

We know we are on the brink of achieving something significant. Eliminating Trachoma: Accelerating Towards 2020 is our plan of action – outlining what needs to be done to scale up programmes and strengthen health systems to ensure the poorest people, those most affected by NTDs like trachoma, are not left behind. One thing is for certain, a ‘business as usual’ approach is not going to get us to the targeted elimination date.

If you are new to the world of trachoma, we invite you to join this unique and powerful global health community, which is working hard to consign this wretched disease to history. If you are already invested in our work, we thank you for your continued commitment to working alongside us as we target GET2020.

On behalf of the WHO Alliance for the Global Elimination of Trachoma by 2020

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Dr Anthony Solomon, Medical Officer for Trachoma, World Health Organization

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Dr Kesetebirhan Admasu, Minister of Health, Ethiopia

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Dr Astrid Bonfield CBE, Chief Executive, Queen Elizabeth Diamond Jubilee Trust

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Ms Virginia Sarah, Chair, International Coalition for Trachoma Control

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Dr Sheila West, Dana Center for Preventive Ophthalmology, Johns Hopkins University

Executive summary

Many trachoma sufferers are mothers and children who unknowingly pass infection to each other with every hug or touch. Shashetu is a 25-year-old mother of two from Ethiopia. She makes a living weaving baskets and selling them at local markets. As the sole provider for her young family, she knows if she cannot see, she cannot work, and cannot feed her children. Trachoma was threatening to take away her livelihood.

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Executive summary

Trachoma affects people living in remote and rural communities, usually in abject poverty; it is one of the most unfair diseases in the world, blinding the people who have the least to start with and making them poorer.

Globally, 200 million people are still at risk of trachoma,9 children and women being the most affected – with women up to 4 times more likely to need eye surgery than men.10 1.9 million people are blind or visually impaired, and 3.2 million people need surgery to avoid blindness because of trachoma.

Since 201111 we have seen huge progress in efforts to strategically target trachoma elimination: growing partnerships have brought in new people, organisations and resources; comprehensive mapping has given us a fuller picture of the global burden of the disease and allowed us to pinpoint exactly where to target programme interventions; public/private partnerships continue to expand to meet the need with pharmaceutical company Pfizer already donating more than 500 million doses of the antibiotic Zithromax®; research and field practices have improved the way we tackle the disease; and health economists have calculated how much it is going to cost.

However, while progress has been significant, there remains much work to be done and to effectively tackle trachoma where it still exists, we urgently need:

  1. Targeted investments to address the remaining gaps in global progress, some of which must come from domestic budget allocations in endemic countries.
  2. Practical and coordinated engagement from a broader range of technical partners.

To accomplish our goals we are taking a more consolidated approach to tackling NTDs, building a sustainable future, reducing inequality and ultimately ‘leaving no one behind’.

Whilst we are only beginning to accumulate evidence of our burgeoning success, the stage has never been better set to achieve such an ambitious goal. As we accelerate towards our elimination target of 2020, we now have an accurate understanding of where trachoma exists, how to treat it, and at what cost.

The Economic Case

The elimination of trachoma as a public health problem by 2020 is affordable, cost-effective, and pro-poor.

The disease has a devastating impact on livelihoods limiting access to education and preventing men, women, and children from being able to work and lead fulfilled lives. By leveraging the hundreds of millions of dollars in donated antibiotics and water, sanitation and hygiene (WASH) sector investments, quality of life for those living in endemic countries can be significantly improved.

The cost to eliminate trachoma from the world is about US$1 billion12 of which US$200-300 million is already committed – a billion dollars for a disease that causes estimated annual productivity losses of up to US$8 billion.13

Investing in the SAFE strategy (Surgery, Antibiotics, Facial cleanliness, Environmental improvement) and coordinating with NTDs, will prevent the loss of “4 million Healthy Life Years (HLYs) by 2030”.14

For investors, trachoma elimination is a simple and cheap proposition with huge returns on investment. Preserving the sight of an individual with trachomatous trichiasis requires a straightforward operation on the eyelid that costs on average US$86, and can be done in the local health centre; programme activities including antibiotic distribution, education, water and sanitation have positive impact far beyond ‘trachoma-specific’ end goals. Some have called trachoma elimination a ‘best buy’ in development.

Knowledge and Scale

Trachoma occurs in some of the most remote parts of the world. Without accurate knowledge of where it is, necessary treatment cannot be given. The Global Trachoma Mapping Project (GTMP), the largest ever survey of an infectious disease undertaken, has provided gold standard quality data on disease distribution allowing partners to set targets and direct resources more strategically to the areas of greatest need. More than 600 teams of intensively trained and certified local graders and recorders trekked to the farthest corners of 29 countries over three years to screen 2.6 million people – on average, one person was examined every 40 seconds. By the end of the project, 1,546 districts had been mapped using the same methodologies, processes and systems, generating over 60 million data items.

As a result, health ministries are better equipped than ever to rid their communities of trachoma by 2020, leaving a lasting legacy. Understanding the geographic spread of any disease is fundamental for effective NTD control and a first step to identifying opportunities for integration. Although GTMP has ended, the new WHO-led Tropical Data initiative will continue to be a platform for baseline mapping, impact surveys and surveillance surveys for all NTDs, not just trachoma.

The GTMP data have already been used to plan for surgeries and establish improvements in access to water, sanitation and hygiene. They have also been used to support applications for the Pfizer donated antibiotics – in 2014/2015 319 new districts with a combined population of 43 million people were added to the donation programme. With the huge number of items of data currently being processed, dozens more applications are expected for Pfizer’s donation programme to complement the S, F, E elements of the SAFE strategy. The last decade has seen a massive scale-up of this programme and Pfizer continues to focus its resources on working with partners to achieve elimination by 2020.

Total doses of Zithromax® shipped (yearly) 1999-2016:
2 year increments

Total doses of Zithromax® shipped yearly, 1999-2016

Political will

For the first time, the United Nations Agenda for Sustainable Development specifically incorporates NTDs into the global development framework (SDG3.3) – recognising that the control of NTDs is critical to the push to end a vicious cycle of poverty and disease.

A vicious cycle of poverty and disease

Vicious cycle of poverty and disease

As a disease of inequity, eliminating trachoma will go a long way to tackling at least 9 of the 17 Sustainable Development Goals (SDGs), ensuring no one is left behind:

  • The SDGs apply to all countries and NTDs, including trachoma, are uniquely positioned to ensure targeted treatment interventions reach the most marginalised communities and, in so doing, are excellent tracers of progress to leaving no one behind
  • The SDGs emphasise inclusion of disability and vulnerable populations and have been developed around a universal respect for human rights and dignity15
  • Importantly, the SDG for health (SDG3) articulates a broad vision for a world with equitable and universal access to healthcare and basic social protections (SDG3.8).

For sustainable elimination, trachoma programmes will need to be fully integrated into strengthened national health systems focusing capacity development to the grass-root health workers and communities where it is needed most.

Investment in the health workforce of developing countries, as required by target 3.12, is also critical for the scaling-up of all components of the SAFE strategy. More trained health workers are urgently needed to address the backlog of 3.2 million people in need of trichiasis surgery.16

Recognising the need for urgent and coordinated actions, the trachoma community is committed to supporting the governments of endemic countries to address the necessary programming and partnerships for SAFE, at the scale needed to achieve our common goals and as part of integrated NTD efforts across ministries; and to demonstrating the impact of domestic budget allocations towards these efforts.

Partnerships

The WHO Alliance for the Global Elimination of Trachoma by 2020, benefits from a diverse partnership of highly committed, multi-sector stakeholders, playing to their unique strengths to coordinate with best effect. In addition to this global collaboration, a number of national and regional groups are coming together to tackle such specific issues as training for eye lid surgery, identifying and addressing cross border challenges and the preparation of joint funding applications.

The elimination of trachoma relies on an expansion of the Alliance and on success in forming new and innovative partnerships.

As the GET2020 Alliance, we have the technical skills for S, A; we know that capacity building is not a ‘one size fits all’ approach; we now need to expand the pool of technical talent and encourage new partners to engage with tailored hygiene interventions and investments in water and sanitation infrastructure for F, E. These partners also need to participate in national trachoma task forces, and regional and global meetings.

Scaling up programmes, strengthening health systems and helping the poorest people requires the engagement of traditional and non-traditional partners. Effective coordination between sectors brings many benefits. Importantly, it maximises existing resources for shared goals.

Leadership

Leadership from WHO has significantly increased the visibility of trachoma in recent years. Low and middle-income countries are being encouraged to invest much more in NTD prevention and control, and to collaborate with other organisations and WASH agencies promoting a more cost-effective, comprehensive programme that zeros in on priorities.

It is important that trachoma endemic countries have access to the most relevant and up-to-date guidance on trachoma elimination and technical support as and when needed, in relevant languages. Achieving elimination requires a wide range of skills and diverse experience. Whole-of-government participation is key.

Pulling together education, health and finance ministries, governments can provide domestic funding, leadership and planning for countrywide programmes and post treatment surveillance - framing appropriate local standards, legislation, progress indicators and monitoring systems to implement the SAFE strategy wherever needed. Effective national leadership requires true ownership and participation.

Sudan and Ethiopia have shown huge progress in trachoma elimination by ensuring targeted messages are reaching children and parents via school health curricula and health worker training packages – In Sudan, a comprehensive public health campaign is helping to drive behavioural change in trachoma-affected regions, and 2,000 teachers have been trained to deliver a trachoma health education programme in every primary and secondary school in the country. With women up to four times more likely to need eye surgery than men as a result of trachoma, engaging them as ‘change agents’ in Ethiopia is helping to raise awareness of the benefits of face washing and healthy environments – vital components of an integrated strategy for trachoma control that can also support a myriad of other health benefits in poor and marginalised communities.17

Vision

The potential to eliminate blindness and visual impairment from trachoma is within reach. In November 2012, Oman was validated by WHO as having eliminated trachoma. An additional 6 previously affected countries claim to have eliminated trachoma as a public health problem: China, Gambia, Ghana, Iran, Morocco and Myanmar.18

These and other countries completing pre-validation surveillance, are expected to prepare their dossiers in line with the validation criteria approved by WHO in June 2016.19

With less than four years to reach the elimination target, we need to tackle this preventable disease head on. Recent progress resulting from intensive efforts by partners, has given an accurate understanding of where trachoma exists, how to treat it, and at what cost – and we have the antibiotic donations necessary to do so. There is an urgent need to implement SAFE in all endemic countries to reduce the prevalence of active trachoma and TT below elimination thresholds. As of April 2016, 144 districts in 16 countries (with a collective of more than 16 million people at risk) had active trachoma but had not yet started treatment interventions.

144 districts in 16 countries require urgent interventions

While the challenges are substantial we are better placed than ever before to meet them – with coordinated action to target priorities, we can eliminate trachoma as a public health problem by 2020.

What needs to be done

5-year-old Bigiltuu, from Ethiopia, was the first person to be examined as part of the Global Trachoma Mapping Project in December 2012.

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Understanding the global burden

In 2016, with less than four years until 2020, we stand at a critical point in our collective efforts to eliminate trachoma as a public health problem.

Through a better understanding of the disease burden and direct efforts to tackle it head on, the number of people at risk of trachoma has fallen from 325 million in 2011 to around 200 million at the beginning of 2016.

Our knowledge continues to grow and projections can be progressively revised as more data become available.

Status of endemicity

This map shows the status of endemicity at the country level, as reported in the Global Health Observatory. For more detail and for district-level prevalence maps, visit www.trachomaatlas.org

Map showing current global profile of trachoma

Map showing current global surgical backlog in 6 countries

200.1 million people need antibiotics to clear infection - 3.2 million need surgery - Women up to 4 times more likely to need surgery - Up to US$8 billion lost productivity annually - Estimated US$1 billion to eliminate trachoma - Estimated additional investments US$258 from WASH sectors - Since 1999 500 million plus treatments donated

Increasing efforts to take SAFE to scale

To combat trachoma WHO has endorsed a series of programmatic interventions known as SAFE. These four components form the foundation of the effort to eliminate the disease and must be rolled out together for a trachoma control programme to be successful.

We know that every country’s needs and barriers are unique and not all countries have the necessary health budget to finance trachoma elimination. It is, however, hugely important that national governments own and take the lead to fund, promote, and manage their own elimination plans. For example: generating a national Trachoma Action Plan; tailoring available ‘best practices’ for adoption by the national programme and using training tools/resources derived from field experiences, and the standard equipment list to build capacity and support effective SAFE implementation.

With 144 districts in 16 countries yet to begin implementing community wide distribution of the antibiotics which treat the infection, and 200 million people globally living in areas at risk of trachoma, scale-up of SAFE interventions is critical.

Priorities and barriers to implementing SAFE strategy – Surgery, Antibiotics, Facial cleanliness, Environmental improvements

Each endemic country can benefit from sharing their experience with others. There are some common characteristics shared by countries who are at the final miles of their elimination journey:

  • Coordinated implementation of SAFE in every endemic district
  • Country led elimination programmes, engaging the broader community
  • Coordination within collaborative partnerships
  • Reliable external funding and domestic budget/resourcing commitments
  • Clear and consistent messaging for and by stakeholders.

Transformation in action Ethiopia in the spotlight

spotlight

Map of Africa, showing where Ethiopia is

There are more than 75 million people living in trachoma-endemic areas in Ethiopia, the largest number of any country in the world.20 The backlog of people who urgently need eyelid surgery to prevent blindness stands at over 693,000 – again, the largest number of any country in the world.21

The last few years, however, have seen enormous changes in the way Ethiopia is responding to the trachoma challenge. The country is viewed as an inspirational example of what can be achieved with strong country leadership, coordinated partner support, and application of technical resources in order to eliminate trachoma.

In 2012, Ethiopia launched its first Trachoma Action Plan developed in consultation with the WASH sector, NGOs and local and regional governments. Country leaders were aware that trachoma was prevalent in the Amhara region and large-scale programmes were already underway to tackle the disease; however, as the maps below show, the district-level disease burden in huge parts of the rest of the country was unknown.

Later that same year, the country kicked off the Global Trachoma Mapping Project. This unique and ambitious venture revealed that more than 90 per cent of districts in Ethiopia have trachoma at levels demanding a public health solution.

Increased efforts were necessary to tackle the problem and in 2013, the national Trachoma Action Plan was incorporated into the government’s Neglected Tropical Diseases Master Plan. A Task Force was also created to coordinate efforts to tackle all eight of Ethiopia’s priority NTDs. This plan called for a significant expansion of the SAFE strategy and two members of staff dedicated to trachoma were included in the Task Force.

The number of people with access to safe drinking water in Ethiopia has tripled since 1990 and promotion of hygiene and latrine use has been provided nationally through Ethiopia’s 48,000 community based health extension workers.22

However, an estimated 71 million people are still without access to adequate sanitation and more than 42 million people are without safe drinking water.23 Without targeted WASH investments, these people and entire communities are at unnecessary risk of blindness from trachoma.

Trachoma burden in Ethiopia: Prevalence and the need for intervention in 2012 and 2016

Comparison of trachoma burden in Ethiopia 2012, 2016www.trachomaatlas.org

Leading the way

Ethiopia launched its ambitious One WASH national programme in 2013 bringing together ministries and development partners to provide universal access to water and sanitation by 2020. Although this support may not be enough to address each and every community, it presents opportunities for even greater collaboration between sectors to realise shared goals of improved health and prosperity for Ethiopia’s poorest.

Significant financial investment has been made to help eliminate trachoma and to bring SAFE interventions into a broader health and development agenda. In 2014 the Federal Minister of Health announced his ‘Fast Track Initiative’ to clear the then-estimated backlog of more than 792,705 people in need of TT surgery, by the end of 2016.24

The initiative aims to train 1,117 Integrated Eye Care Workers (IECWs) to perform surgery, train 17,000 health extension workers to identify and refer trichiasis cases, and set up 50 mobile surgical teams.25

Since the launch of the pilot, 490 IECWs at static sites and 6 mobile teams have begun undertaking trichiasis surgery.26 Ethiopia is now preparing to implement the initiative nationwide and has committed an additional US$1.7 million of government money for this purpose.27

Not only has the country concentrated efforts towards the elimination of trachoma, creative efforts to link the disease with other priority programmes have seen Ethiopia reach a huge proportion of its at-risk population with antibiotic treatment and measures to reduce the transmission of infection.

Moving forward, the challenge for Ethiopia will be to close the gaps with SAFE coverage particularly in the Somali and the Southern Nations, Nationalities and Peoples’ Regions – and to encourage behaviour change in remote communities through even greater collaboration between sectors.

The country expects to achieve a remarkable 84 percent coverage of endemic districts with surgery and antibiotics in 2016. Due to investments in water and sanitation, and increasing collaboration between the trachoma community and WASH sectors, 70 percent of endemic districts in Ethiopia have existing plans for delivering the full SAFE strategy.

Trachoma – elimination and the SDGs

Children at Kalenyang Primary School in Naremit village, Kenya, wash their hands and faces at a communal water station as part of their education on trachoma prevention

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Trachoma – elimination and the Sustainable Development Goals

In the run up to 2020 we need to raise the bar even more, to highlight the importance of trachoma in the context of other global issues.

Eliminating trachoma by 2020 will go a long way to tackling at least 9 of the 17 Sustainable Development Goals, underpinned by a commitment to end extreme poverty and to leave no one behind.

  1. ‘Where there are NTDs, there is more poverty, hunger, school absenteeism and vulnerability to the environment.’

    Christopher Fitzpatrick, Health Economist, World Health Organization
  2. ‘A people plays out its future by its ability to respond to the hunger and thirst of its brothers and sisters...for this reason, I desire that the fight to eradicate the hunger and thirst of our brothers and sisters, and with our brothers and sisters, will continue to challenge us to seek creative solutions of change and transformation.’

    Pope Francis
  3. ‘Preferred practices and capacity building measures provide the much needed inputs for national trachoma programme managers to ensure quality service provision whose benefits go beyond trachoma control and contribute towards strengthening the overall health system.’

    Amir Bedri, Senior Advisor, Light for the World
  4. ‘Action now has to happen urgently because of the sheer scale of numbers of children impacted…These young people are missing out on schooling and this is becoming a full-blown global crisis that will haunt the world for generations.’

    Gordon Brown, UN Special Envoy for Global Education
  5. ‘To get there, we must have inclusive community-led programmes that offer freedom from trachoma for all, but that also specifically and deliberately target women and girls.’

    Jimmy Carter, former US President
  6. ‘With over 800 children dying each day from diseases linked to the lack of adequate water, sanitation, and hygiene, the cause is urgent.’

    Kevin Rudd, Chair, Sanitation and Water for All
  7. ‘NTDs are diseases of poverty – not only do they mainly affect the poorest within developing societies, but they also keep people in poverty as they impair them from engaging in a productive life.’

    Angela Weaver, Senior Technical Advisor, USAID
  8. ‘…We will see the last of diseases like elephantiasis, river blindness, and blinding trachoma, which disable tens of millions of people in poor countries, thanks to advances in digital maps that show where diseases are most prevalent. We believe that people can work together to make the world a more equitable place. In fact, we’re betting on it.’

    Bill and Melinda Gates
  9. ‘While I am pleased that Pfizer has made this landmark donation of medicine and will continue these donations, I am equally gratified that we are one of many working toward our goal. Together, we are highlighting the power of collaboration among public and private organisations.’

    Ian C Read, CEO, Pfizer

Leaving no one behind – meet the people behind the statistics

‘I thought I was going to go blind one day.’

Azmera

For the past 6 years, 25-year-old Azmera has been in constant pain with trachoma. ‘I thought I was going to go blind one day,’ said Azmera. ‘I will now work and live my life and I can take care of my children better.’ Usually trachoma attacks the upper eyelid, but in Azmera’s case it had affected the lower lid.

‘I had a painful burning and prickling in both my eyes and lots of tears, as if I had something in my eyes all the time.’

Abdul-Rahman

Chief Abdul-Rahman had trichiasis in both eyes. He was gradually becoming blind, a state that would have been irreversible. He was told he could have an operation to end the pain. ‘I had a painful burning and prickling in both my eyes and lots of tears, as if I had something in my eyes all the time. I was really pleased to have found a solution. My eyes are so much better now.’

‘Now I will be able to milk my two cows, fetch firewood and cook for my beautiful granddaughter.’

Cheposera (left)

14-year-old Adiyo (right) wove and sold necklaces for eight months to pay for the transport to take her grandmother to the clinic. ‘My grandmother’s personality had changed, she couldn’t see, I had to do almost everything for her,’ says Adiyo. ‘Before surgery I had to wait for my granddaughter to get home to pluck my eyelashes,’ says Cheposera, a widow, mother of 11, grandmother of 18 and great grandmother of 17.

Awa said her eyes already felt better and she was looking forward to finding a new husband!

Sisters Awa (left) and Arame (right) Ndiaye each underwent fifteen minute operations for trichiasis on the same afternoon. Both sisters are widows and have found it hard to run their houses with limited eyesight and constant pain, but Awa said her eyes already felt better and she was looking forward to finding a new husband!

Blueprint for action

Drs Michael Samal and Maurice Oduor are both Kenyan eye surgeons performing trachoma operations, often under trees and in schools. Oduor says: ‘My vision as an eye surgeon is to do something unique in my country that gives me pride.’

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Blueprint for action

At its meeting in April 2016, recognising the need for urgent and coordinated action to advance the GET2020 goals, members of the WHO Alliance for the Global Elimination of Trachoma by 2020 adopted these commitments by acclamation.

All parties
Because we achieve more together, we collaborate for GET2020 Our commitments
  • Promote trachoma elimination within the context of universal health coverage and as a tracer for poverty alleviation within the Sustainable Development Goals.
  • Enhance national ownership and partnership for elimination efforts.
  • Use the latest data to inform elimination plans, promotional materials and funding proposals; and update all relevant information sources.
  • Use technology where possible to improve efficiency of elimination efforts and reproducibility of data.
  • Share emerging data and experience to inform current practice and realign priorities as needed for elimination.
  • Support validation dossier development where requested.
World Health Organization
We provide technical support for trachoma elimination Our commitments
  • Revise the template dossier in light of the Morocco experience, and finalise standard operating procedures for dossier review and validation of elimination.
  • Support dossier development with countries claiming to have eliminated trachoma.
  • Validate countries as having achieved the elimination of trachoma as a public health problem.
  • Lead the NTD financing dialogue and publish the economic case for trachoma elimination.
  • Engage WHO country offices to influence relevant ministries of trachoma-endemic Member States.
  • Facilitate meetings of the WHO Alliance for GET2020.
  • Help to maintain and update the WHO Alliance for GET2020 Database.
  • Update relevant WHO guidance on trachoma as needed and contribute to the development of implementation tools.
  • Formalise the Network of WHO Collaborating Centres for Trachoma and contribute to operational research as appropriate.
  • Lead the standardisation of impact surveys and surveillance surveys through the WHO-led Tropical Data platform.
  • Contribute to ongoing capacity building efforts.
Governments of endemic countries
We create a sustainable and enabling environment to eliminate trachoma as a public health problem Our commitments
  • Ensure political commitment to elimination extends from national decision-makers to communities in need.
  • Increase domestic funding for these initiatives, as an investment in a strong and functioning public health system.
  • Bring together key decision makers from health, education, WASH and finance ministries; and with donors and implementing partners to better integrate elimination efforts.
  • Apply the WHO global strategy, ‘Water, sanitation and hygiene for accelerating and sustaining progress on neglected tropical diseases’ to maximise the integration of trachoma and WASH interventions.
  • Embed targeted hygiene practices relevant to trachoma elimination in school health curricula and health worker training packages.
  • Work with neighbouring countries to address common trachoma challenges, particularly along shared borders.
Public and private donors
We invest in and attract additional supporters for trachoma elimination Our commitments
  • Reaffirm our commitments across implementation, research and drug donation.
  • Create a Donor Coordination Group that meets virtually every quarter to: review timelines and activities, discuss long-term priorities, and identify opportunities for greater coordination in advocacy and funding, informed by input from other constituencies within the Alliance.
  • Support the Alliance in developing new partnerships and initiatives to further the goals of GET2020.
  • Explore the development of a coordinated, proactive advocacy strategy to help raise visibility of the Alliance, and attract new donors and partners.
  • Recognising the importance of domestic financing, stand ready to support country efforts.
NGOs and other implementing partners
We support endemic country governments to eliminate trachoma Our commitments
  • Help to maintain and update Global SAFE Implementation Cost Estimates.
  • Prioritise strategic resource mobilisation and SAFE implementation for all areas with a TF prevalence in 1-9 year-olds ≥30% that are still not under intervention.
  • Support implementation of high quality TT surgery, through the application of technology to track cases and adoption of protocols for surgical supervision.
  • Work together to focus efforts on underperforming ‘A,F,E’ areas, including through raising awareness of the tools available to support decision making, strengthening MDA planning for improved coverage, and coordinating expansion by maximising drug availability and involving WASH partners.
  • Stand ready to support countries to prepare and submit their dossiers to WHO for validation of elimination.
Academic and research institutions
We prioritise knowledge gaps to address the barriers to eliminating trachoma Our commitments
  • Facilitate the annual Trachoma Scientific Informal Workshop.
  • Develop and maintain a forum for discussing strategic directions for trachoma research.
  • Work with ministries of health in endemic countries and other stakeholders to undertake, publish, package and disseminate research that will help accelerate achievement of and validate the global elimination of trachoma; a particular focus should be to include research components in large-scale elimination programmes, as part of multi-centre investigations that address critical questions about the effectiveness of various interventions.
  • Build scientific capacity in endemic countries in which research is undertaken.

GET2020 data

Shashetu has now had the trichiasis surgery she so desperately needed and her children have received antibiotics to break the vicious cycle of reinfection.

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GET2020 data

Overview epidemiology

todo

Trachoma confirmed to require
public health level interventions
Trachoma suspected to be a public health problem1,3
Requiring S interventions Requiring A,F,E interventions Requiring S and/or A,F,E interventions2
Country Total districts in country Total population in country Districts Trichiasis backlog (number of persons) Districts Population in those districts Districts Districts Population in those districts
Afghanistan1 398 32,561,285 Status uncertain 83,100 Status uncertain 25 2,559,392
Algeria 1,546 40,633,474 Status uncertain 86,700 Status uncertain Status uncertain
Angola 163 22,817,833 Status uncertain Status uncertain
Australia 26 22,751,014 1,100 5 15,219 5 0 0
Benin 77 10,882,190 19 11,782 8 663,711 19 0 0
Botswana 26 2,056,375 0 0 0 0 0 0 0
Brazil 5,570 195,198,833 58,000 37 2,183,430 37 0 0
Burkina Faso 63 17,914,677 39 35,352 17 4,543,925 43 0 0
Burundi 45 10,803,141 0 0 11 2,293,534 11 0 0
Cambodia2 185 14,335,302 1 4,999 0 0 1 0 0
Cameroon 181 23,393,087 17 12,012 15 2,170,239 21 0 0
Central African Republic1 17 4,803,476 7 11,890 8 2,021,778 8 7 1,530,830
Chad1 62 13,605,628 46 66,459 33 6,777,417 49 2 159,150
China 333 1,342,564,066 0 0 0 0 0 0 0
Colombia 1,102 46,347,916 15 90 30 139,305 30 33 411,049
Congo 86 4,673,929 0 0 0 0 0 0 0
Côte d’Ivoire 82 21,301,139 2 1,908 9 1,890,060 9 0 0
Democratic Republic of the Congo1 515 71,277,131 29 31,277 18 3,011,531 29 16 2,210,617
Djibouti 11 859,303 75 0 0 0 0 0
Egypt 342 84,705,380 4 207,822 4 1,115,530 4 29 10,911,891
Eritrea1 58 6,719,043 27 45,851 22 1,428,291 33 3 89,552
Ethiopia1 825 98,959,759 655 693,037 654 75,679,775 708 22 1,024,367
Fiji 4 898,821 0 0 4 898,821 4 0 0
Gambia 41 1,970,081 0 0 0 0 0 0 0
Ghana2 216 26,984,329 6 2,507 0 0 6 0 0
Guatemala 338 14,651,125 2 988 2 116,582 2 0 0
Guinea 38 12,344,113 19 29,825 18 5,834,024 22 0 0
Guinea-Bissau 11 1,787,793 11 21,255 8 1,266,847 11 0 0
India 683 1,203,547,658 Status uncertain 443,000 Status uncertain 9 15,198,038
Iran (Islamic Republic of) 31 81,824,270 0 0 0 0 0 0 0
Iraq1 120 37,056,169 Status uncertain 43,900 Status uncertain 18 5,468,418
Kenya1 72 46,134,818 21 76,264 21 5,942,339 23 4 743,966
Kiribati 24 115,077 1 69 24 115,077 24 0 0
Lao People’s Democratic Republic 144 6,267,370 0 630 0 0 0 0 0
Libya 22 6,317,080 Status uncertain 33,400 Status uncertain Status uncertain
Malawi 41 17,307,466 12 16,313 17 11,673,207 19 0 0
Mali 56 16,254,687 49 13,852 10 978,391 53 0 0
Mauritania 45 4,080,522 14 2,828 9 224,323 16 0 0
Mexico 2,438 118,617,773 0 0 0 0 0 0 0
Morocco 75 33,955,158 0 0 0 0 0 0 0
Mozambique 148 27,100,272 37 18,913 50 7,374,821 59 0 0
Myanmar 67 47,556,698 65,800 0 0 0 0 0
Namibia 121 2,391,867 Status uncertain 0 0
Nauru 14 7,077 Status uncertain 0 0
Nepal 75 30,367,879 15 49,143 1 245,717 16 0 0
Niger 63 19,269,034 32 116,086 19 6,568,845 32 0 0
Nigeria1 774 183,520,388 216 362,959 105 19,999,010 241 48 7,960,812
Oman 61 3,286,936 600 0 0 0 0 0
Pakistan1 149 177,305,842 13 48,881 9 3,074,598 21 16 4,908,029
Papua New Guinea2,3 87 6,807,403 1 156 5 924,650 5 2 121,647
Peru 195 29,898,819 Status uncertain Status uncertain
Senegal 78 14,965,847 42 71,975 27 4,845,365 50 0 0
Solomon Islands 46 531,836 59 46 531,836 46 0 0
Somalia1 90 11,120,105 Status uncertain 10,300 Status uncertain 12 2,400,000
South Sudan1 79 11,927,328 18 81,093 24 2,433,069 29 35 3,808,049
Sudan1 151 39,800,390 80 71,765 28 5,577,495 84 13 1,649,820
Timor-Leste 62 1,300,843 Status uncertain Status uncertain
Togo 30 7,170,797 2 579 0 0 2 0 0
Uganda 112 40,104,504 34 101,162 21 5,711,138 39 0 0
United Republic of Tanzania 176 52,248,782 64 77,600 19 4,726,008 67 0 0
Vanuatu 64 266,041 0 48 64 266,041 64 0 0
Venezuela (Bolivarian Republic of) 338 23,946,759 Status uncertain Status uncertain
Viet Nam 663 87,308,008 100,000 0 0 0 0 0
Yemen1 333 26,737,317 33 5,821 31 1,939,180 58 38 709,394
Zambia 105 15,522,251 4 5,465 22 2,990,824 24 78 11,365,450
Zimbabwe 61 15,050,336 10 6,765 11 1,911,091 13 6 969,787

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Source: WHO Alliance for GET2020 Database, as at 1 March 2016

  1. Insecure (country followed by district count): Afghanistan (25), Central African Republic (7), Chad (2), Democratic Republic of Congo (16), Eritrea (3), Ethiopia (22), Iraq (18), Kenya (4), Nigeria (48), Pakistan (16), Somalia (12), South Sudan (35), Sudan (13) and Yemen (38).
  2. Further assessment pending (country followed by district count): Cambodia (1), Ghana (6), Papua New Guinea (1).
  3. Awaiting approval (country followed by district count): Papua New Guinea (1).

Terminology

World Health Organization simplified trachoma grading system

WHO simplified trachoma grading system

Source: www.who.int

Baseline mapping

Population-based surveys conducted to determine the presence of trachoma within an identified population, usually a district.

District

The usual administrative unit for health care management, which for purposes of clarification generally contains a population between 100,000 and 250,000 people.

Elimination

Elimination as a public health problem is defined by achievement of measureable global targets set by WHO in relation to a specific disease. In the case of trachoma, those targets are a reduction in the prevalence of trachomatous trichiasis (in-turned eyelashes) unknown to the health system to <1 per 1,000 total population, and a reduction in the prevalence of active trachoma in 1-9 year-olds to <5%, in each formerly endemic district.

Endemicity

The quality of being endemic (that is, the presence of a disease in a particular population).

GET2020 Alliance

The WHO Alliance for the Global Elimination of Trachoma by 2020, website: http://www.who.int/trachoma/partnership

GTMP

‘The Global Trachoma Mapping Project’ a funded project that completed population-based trachoma prevalence surveys in 1,627 districts of 29 countries, from 2012-2015, website: http://www.sightsavers.org/gtmp/

ICTC

The International Coalition for Trachoma Control, a group of non-governmental, academic, donor, and private sector organisations working together to support the GET2020 Alliance, website: http://www.trachomacoalition.org

MDA

Mass Drug Administration

NGO

Non-Governmental Organisation

NTDs

Neglected Tropical Diseases, a diverse group of diseases found in tropical and subtropical conditions in 149 countries worldwide.

Prevalence

The proportion of a population affected by a disease at a given time.

SAFE

The WHO-recommended strategy to eliminate trachoma as a public health problem, incorporating Surgery for trichiasis (in-turned eyelashes), Antibiotics, Facial cleanliness and Environmental improvement.

SDGs

The United Nation’s ‘2030 Agenda for Sustainable Development’ comprises 17 Sustainable Development Goals which focus on commitments to end poverty and guide policy and funding to 2030.

TAP

Trachoma Action Plan, a guided planning tool, with supportive resources, for national planners to achieve elimination of trachoma using the SAFE strategy, website: http://www.trachomacoalition.org/TAP-planning

Trachoma

Trachoma is the world’s leading infectious cause of blindness and one of the neglected tropical diseases that affect over 1 billion of the world’s poorest people, website: http://www.who.int/trachoma

Trachoma Atlas

The Global Atlas of Trachoma is an open-access resource on the geographical distribution of trachoma, website: http://www.trachomaatlas.org/

Validation

The process of documenting elimination as a public health problem.

WASH

Water, Sanitation and Hygiene

WHO

The World Health Organization, website: http://www.who.int/

Zithromax®

A trade name for the antibiotic azithromycin, produced by Pfizer and used to implement the ‘A’ of SAFE.

References

  1. World Health Organization. (2016). World Health Organization. [online] Available at: http://www.who.int/neglected_diseases/diseases/en/ [Accessed 22 Mar. 2016].
  2. World Health Organization. (2016). Trachoma. [online] Available at: http://www.who.int/mediacentre/factsheets/fs382/en/ [Accessed 22 Mar. 2016].
  3. The Huffington Post. (2012). Why Do We Blink So Much?. [online] Available at: http://www.huffingtonpost.com/2012/12/30/why-do-we-blink-so-much-mental-rest_n_2377720.html [Accessed 22 Mar. 2016].
  4. Bourne RR, Stevens GA, White RA, et al. Causes of vision loss worldwide, 1990-2010: a systematic analysis. The Lancet Global health 2013; 1(6): e339-49.
  5. WHO Alliance for GET2020 Database.
  6. Frick KD, Hanson CL, Jacobson GA. (2003). Global burden of trachoma and economics of the disease. The American Journal of Tropical Medicine and Hygiene, [online] 69(5 suppl 1), pp.1-10. Available at: http://www.ajtmh.org/content/69/5_suppl_1/1.long [Accessed 24 Jun. 2016].
  7. The International Coalition for Trachoma Control (ICTC), (2016). Global SAFE Implementation Cost Estimates, April 2016.
  8. Tristao, I. and Cali, J. (2014). It Can Be Done: An Integrated Approach for Controlling and Eliminating Neglected Tropical Diseases. Inter-American Development Bank. [online] Available at: https://publications.iadb.org/handle/11319/6644?locale-attribute=en [Accessed 22 Mar. 2016].
  9. WHO Alliance for GET2020 Database.
  10. Cromwell, E., Courtright, P., King, J., Rotondo, L., Ngondi, J. and Emerson, P. (2009). The excess burden of trachomatous trichiasis in women: a systematic review and meta-analysis. Transactions of the Royal Society of Tropical Medicine and Hygiene, 103(10), pp.985-992.
  11. The International Coalition for Trachoma Control (ICTC). (2016). The end in sight: 2020 INSight: The global roadmap to elimination | www.trachomacoalition.org. [online] Available at: http://www.trachomacoalition.org/2020insight [Accessed 22 Mar. 2016].
  12. The International Coalition for Trachoma Control (ICTC), (2016). Global SAFE Implementation Cost Estimates, April 2016.
  13. Frick KD, Hanson CL, Jacobson GA. (2003). Global burden of trachoma and economics of the disease. The American Journal of Tropical Medicine and Hygiene, [online] 69(5 suppl 1), pp.1-10. Available at: http://www.ajtmh.org/content/69/5_suppl_1/1.long [Accessed 24 Jun. 2016].
  14. De Vlas SJ, Stolk WA, le Rutte EA, Hontelez JAC, Bakker R, Blok DJ, et al. Concerted Efforts to Control or Eliminate Neglected Tropical Diseases: How Much Health Will Be Gained? Liang S, editor. PLOS Neglected Tropical Diseases. 2016;10: e0004386.
  15. United Nations, Department of Economic and Social Affairs. (2016). Transforming our world: the 2030 Agenda for Sustainable Development: Sustainable Development Knowledge Platform. [online] Available at: https://sustainabledevelopment.un.org/post2015/transformingourworld [Accessed 24 Jun. 2016].
  16. WHO Alliance for GET2020 Database.
  17. The Fred Hollows Foundation, (2015). Restoring vision to empower women. Australia: The Fred Hollows Foundation.
  18. World Health Organization. (2016). World Health Organization Global Health Observatory. [online] Available at: http://apps.who.int/neglected_diseases/ntddata/trachoma/trachoma.html [Accessed 24 Jun. 2016].
  19. World Health Organization. (2016). Validation of Elimination of Trachoma as a Public Health Problem [online] Available at: http://apps.who.int/iris/bitstream/10665/208901/1/WHO-HTM-NTD-2016.8-eng.pdf?ua=1 [Accessed 24 Jun. 2016].
  20. WHO Alliance for GET2020 Database.
  21. WHO Alliance for GET2020 Database.
  22. World Health Organization (WHO) and UNICEF Joint Monitoring Programme. (2016). Progress on Drinking Water and Sanitation: 2015 Update and MDG Assessment. [online] Available at: http://www.wssinfo.org/fileadmin/user_upload/resources/JMP-Update-report-2015_English.pdf [Accessed 22 Mar. 2016].
  23. WaterAid. (2016). WaterAid - Where we work - Ethiopia. [online] Available at: http://www.wateraid.org/au/where-we-work/page/ethiopia [Accessed 22 Mar. 2016].
  24. Federal Democratic Republic of Ethiopia, Ethiopia Ministry of Health Ethiopia.gov.et. (2016). The Ethiopian Initiative to Clear the TT Backlog: Fast Track to the Elimination of Blinding Trachoma - AWD Update - Ministry of Health. [online] Available at: http://www.moh.gov.et/en_GB/ebola-update/-/asset_publisher/R1dUfCspGqqN/content/the-ethiopian-initiative-to-clear-the-tt-backlog-fast-track-to-the-elimination-of-blinding-trachoma [Accessed 24 Jun. 2016].
  25. Federal Democratic Republic of Ethiopia, Ethiopia Ministry of Health Ethiopia.gov.et. (2016). The Ethiopian Initiative to Clear the TT Backlog: Fast Track to the Elimination of Blinding Trachoma - AWD Update - Ministry of Health. [online] Available at: http://www.moh.gov.et/en_GB/ebola-update/-/asset_publisher/R1dUfCspGqqN/content/the-ethiopian-initiative-to-clear-the-tt-backlog-fast-track-to-the-elimination-of-blinding-trachoma [Accessed 24 Jun. 2016].
  26. Federal Democratic Republic of Ethiopia, Ethiopia Ministry of Health Ethiopia.gov.et. (2016). Mobile - Ethiopian Government Portal. [online] Available at: http://www.ethiopia.gov.et/web/pages/home [Accessed 24 Jun. 2016].
  27. Federal Democratic Republic of Ethiopia, Ethiopia Ministry of Health Ethiopia.gov.et. (2016). Mobile - Ethiopian Government Portal. [online] Available at: http://www.ethiopia.gov.et/web/pages/home [Accessed 24 Jun. 2016].

Photography credits

© Ashley Gilbertson / The Queen Elizabeth Diamond Jubilee Trust. Photos are part of Time to See – an exhibition documenting the impact of avoidable blindness across the Commonwealth, www.timetosee.org.

© Michael Amendolia/The Fred Hollows Foundation

© Sightsavers

© The Fred Hollows Foundation

© CBM

© International Trachoma Initiative

© Orbis

Disclaimer
This document has been developed and published by the International Coalition for Trachoma Control on behalf of the WHO Alliance for the Global Elimination of Trachoma by 2020. It is not an official publication of WHO, and the material it contains does not necessarily represent the decisions, views or stated policy of the World Health Organization.