Guidelines for Elimination of Blinding Trachoma

1. Guidelines for Elimination of Blinding Trachoma Recommendations from World Health Organization Global Scientific and Informal Meetings Sheila West, PhD Dana Center for Preventive Ophthalmology Wilmer Eye Institute Baltimore MD

2. Background 1997: WHO establishes the Global Alliance for the Elimination of Blinding Trachoma by 2020 (GET2020) 1998: World Health Assembly signs resolution endorsing the Alliance and encourages countries to eliminate trachoma (WHA51.11)

3. What is meant by Elimination? Trachoma Signs Follicular Trachoma: TF Intense Trachoma : TI Scarring Trachoma: TS Trachomatous Trichiasis: TT Corneal Opacity: CO Ultimate Intervention Goals Prevalence of TF <5% in 1-9 year olds Prevalence of TT is <0.1% in pop’n

4. Intervention: SAFE “S”: Surgery targets TT-prevention of immediate blindness “AFE” : Antibiotic, Facial cleanliness, environmental change: Targets active trachoma, by reduction of community pool of infection, and efforts to reduce transmission, re-emergence Prevention of blindness in long term

5. How do we operationalize UIGS District 100,00-250,000 people >10% TF 1-9 yo <5% TF 1-9 yo Mapping/Baseline Survey 5-9% TF 1-9 yo AFE for at least 3 years then impact survey No need for AFE F and E for at least 3 years, targeted A

6. Updates to Operationalization District IF: there is some evidence that trachoma is widespread and highly endemic THEN: a survey at super-district (regional) can be conducted BUT: if survey results are TF<10%, then district level data will be needed to plan a programme

7. Updates to Operationalization District 100,00-250,000 people >10% TF 1-9 yo Mapping/Baseline Survey IF: If prevalence is ≥30%, Impact surveys non informative before 5 years of AFE AFE for at least 3 years then impact survey Aim for 100% coverage Do not have interrupted treatment

8. How do we declare reaching UIG? District <5% TF 1-9 yo Impact/Outcome Survey No need for AFE

9. % villages Prevalence of Trachoma

10. How do we declare reaching UIG? District <5% TF 1-9 yo Impact/Outcome Survey 5-9% TF 1-9 yo Survey at SUB district level AFE for at least 3 years then impact survey >10% TF 1-9 yo <5% TF 1-9 yo 5-9% TF 1-9 yo F and E for at least 3 years, targeted A F and E, no A If all <5%, declare UIG

11. Surveys at Sub District Level Sub district: Stratification to make units more homogeneous for trachoma -geographical information on hotspots -absence of infrastructure suggesting higher rates -sum of # of sub-units=district Cannot be smaller than 3 villages Survey precision is 4% +/- 2%

12. Surgery UIG: <1/1,000 TT pop’n 2005 WHO Working Group recommendation for elimination “Satisfactory implementation of a program to reduce the prevalence of trachomatous trichiasis through identification and surgical management through the health system, with a commitment to reach the Ultimate Intervention Goal of less than 1 case of TT (refusals, recurrences, and incident cases) per 1,000 population”

13. Operationalize UIG for Surgery At district level, <1/1,000 total population of TT cases unknown to health system “known”: operated, refusals, recurrent cases, listed but not yet operated “unknown”: in population and not recorded by health system Health system is able to identify and manage incident TT cases Report recurrence rate as part of HIS with a target of recurrence <10% at one year

14. Activities After UIGs are Met Surveillance Documents for Elimination • Surveys to document elimination • Sub district surveys where TF <5% • Demonstrate sustained reduction of TF at least 3 years after A stopped • Evidence that district TT is <1/1,000 pop’n &health system is able to detect, provide treatment and follow up TT cases • Evidence of surveillance activities to detect and respond to resurgent TF and incident TT

15. Timeline for Elimination Surveys reveal Sustained TF<5% Surveys reveal TF<5% A can be stopped A activities stop 1 yr 2 yr 3 yr Implement surveillance activities Verify reports Verify response if new surge found Create reporting network, plan surveillance activities, test in early success areas

16. Objectives of Surveillance System • Monitor the prevalence of TF to detect and respond to potential resurgence • Ensure that routine eye care services are operating incident and recurrent TT cases and monitoring incidence to detect any unknown cases

17. Monitor the prevalence of TF to detect and respond to potential resurgence • Select 2 communities per district per year biased to the least developed and suspected most endemic • Examine all school entrance-aged children where attendance is >90% and there is no gender bias • Examine a minimum of 50 children in the community (5±2 years), but if feasible examine all

18. Monitor the prevalence of TF to detect and respond to potential resurgence • Respond to a finding of >5% TF in any community • -Examine all children aged 1-9 years and treat TF • -If >5% TF in all 1-9 year olds, assess AFE coverage and treat community • -Examine school entrance aged children in all communities in the surrounding sub-district • -If >5% TF in sub-district re-implement AFE for 3 years and assess TF in other sub-districts to determine whether district warrants AFE

19. Ensure that routine eye care services are operating incident and recurrent TT cases and monitoring incidence to detect any increase in blinding disease • Ongoing collection and review of TT surgical output data and recurrence rates • Incorporate TT into National Health Information Management System or similar national surveillance system • In each community assessed for TF, examine adults aged 40 years and above for TT • Classify cases as to known or unknown to health system

20. Conclusions WHO guidelines evolve, in response to new data, concerns Basic rules -SAFE is recommended control strategy -Map at district (special case: region)to document need -Surgery: implement surgical program to meet needs by 2020, with documentation of recurrence, plans -Implement for 3-5 years and do impact survey at district level -If impact survey suggest <10%TF, do impact survey at sub-district level and follow guidelines -Meet UIGs, start surveillance Push for 2020!