International Coalition for Trachoma Control

The category of neglected tropical diseases (NTDs) has earned its name, not only by affecting the world’s most neglected people, but also from a lack of investment into research for mapping, implementation approaches and the development of new diagnostics, medicines, vaccines and vector control tools.

This week the Coalition for Operational Research for NTDs (COR-NTD) and the American Society of Tropical Medicine and Hygiene (ASTMH) will host meetings in Maryland, USA, bringing together a diverse cross-section of researchers, program implementers and partners working towards the shared goal of optimizing NTD control and elimination programs.

The trachoma community has made significant progress towards its target of the global elimination of trachoma as a public health problem by 2020, including a 91% reduction in the number of people at risk since 2002. However, several challenges remain that will require new strategies and innovations to progress global elimination with no one left behind.

Highlighted below are a range of sessions across mapping, safety, human resources and hard to reach populations as well as list of sessions supported by ICTC members and observers at the 2019 COR-NTDs and ASTMH meetings.

Mapping

From 2012-2016, trachoma stakeholders conducted the Global Trachoma Mapping Project (GTMP). The project, funded by the UK Department for International Development and the United States Agency for International Development was the largest infectious disease survey ever conducted, reaching 2.6 million people across 29 countries. This study provided the evidence base to scale up and target interventions where they are needed. 

In July 2016, a service called Tropical Data was launched so that health ministries continued to receive support to generate high-quality prevalence data for trachoma and an increasing number of NTDs. The service uses the same standardised methodology as GTMP and supports health ministries through the entire survey process. This includes providing epidemiological support for the protocol development and sampling, planning and budgeting support, qualified trainers and bespoke training support, support with data collection, storage, cleaning, approvals and analysis.

Join COR-NTDs Breakout Session 3B ‘Supporting countries to generate high-quality NTD prevalence data’ on Tuesday 19 November to learn more about Tropical Data from Chief Scientist, Dr Emma Harding-Esch, who will present ‘A globally standardised methodology for trachoma prevalence survey Data’.

Hard to reach populations

Conflict presents several challenges to achieving NTD targets. Conflict can impede on the ability of programs to provide interventions to communities in need and the impact of interventions provided.  As of 2019, 201 districts across 11 countries are listed in the WHO GET2020 database as having hard to reach populations that impede trachoma elimination efforts, however there is a lack of guidance about how to handle areas in conflict affected areas or provide interventions to hard to reach populations.

In ASTMH Symposium #124: The challenges of implementing NTD assessments in conflict areas and fragile states on Saturday 23 November, participants will share experiences from trachoma and lymphatic filariasis programs in settings affected by conflict.

Several examples exist of NTD programs successfully reaching communities affected by conflict that will support future program planning. In particular, the lessons from mapping trachoma in the Democratic Republic of Congo will inform planning for trachoma impact surveys in 2019. In 2018 and 2019, Ethiopia revised its survey methodologies to account for inaccessibility of conflict affected villages. 

Human resources and quality:

In 2019, the World Health Organization reported that the number of people requiring surgery to treat trachomatous trichiasis, the late blinding stage of trachoma, has reduced by 68% from 7.5 million in 2002 to 2.5 million people today.

Although this is great news, as countries move towards TT elimination thresholds, surgeons will conduct fewer TT surgeries over time as cases become harder to find, which can lead to attrition and poor-quality surgical services. Ensuring that case finding strategies are refined so that all people with TT can be provided treatment and surgeries continue to be conducted at a high standard will be an ongoing and important challenge for national programs.

At ASTMH session #1985 on Sunday 24 November, Dr. Emily Gower will present ‘Photographing operated TT cases during outreach campaigns: results of a pilot at ASTMH’. The presentation will provide information about the effectiveness of using smartphones to collect photograph eyelids post-surgery in order to predict likely surgical outcomes and reduce the incidence of post-operative TT.

During the pilot, photos provided information about the quality of surgery provided, which in turn, informed discussions among surgeons and technical supervisors about how to strengthen surgical skills. The approach complements other quality assurance measures, such as surgical audits, 3-6-month follow-up visits and remote supervision.

Safety

The trachoma community is committed to ensuring that trachoma programs not only provide benefits to populations, but also reduce harm. Although rare, deaths caused by choking have been reported during mass drug administration campaigns for NTDs.

To minimise the risk of treatment, the International Trachoma Initiative has updated its dosing guidelines to support program managers to provide appropriate training and supervision of community drug distributors who provide treatment to communities. New guidelines include:

• Providing powder oral suspension (POS) instead of tablets to children aged 7 or younger and offer tablets only to people who are 120 cm or more in height

• Offer POS to anyone, of any age, who has trouble swallowing tablets

• Directly observe all treatments

• Never force children to take azithromycin, hold their nose to make them swallow, or force their head back to give them the medicine – this increases the risk of choking

• For children who are fussy, irritable, or resist taking azithromycin, reassure the parent or guardian and give them time to calm the child, so the child can receive the treatment

• If the child continues to resist taking azithromycin, do not treat the child during this round of MDA.

Further research is still needed to assess current safety practices within MDA campaigns in order to develop appropriate strategies to prevent harm. To sustain high coverage rates, trachoma stakeholders must ensure community trust, and properly investigate, manage and report adverse events and take decisive action to protect the people programs are designed to benefit. 

Learn more about patient safety from ICTC Chair, Scott McPherson at ASTMH symposium #166: Safety is no accident: Harm reduction and MDA on Sunday 24 of November. 

Going forward

In order to achieve and sustain the global elimination of trachoma as a public health problem, the trachoma community needs to continue to define challenges and build the evidence base to respond. This year’s COR-NTDs and ASTMH programs demonstrate the diversity of challenges experienced by trachoma programs but also provide an important platform to share knowledge promote operational research that provides the evidence base and field learnings for implementation guidelines and preferred practice tools that will be needed to achieve our goals.