A global strategy to eliminate blinding trachoma Blinding trachoma, one of the oldest known infectious eye diseases, may be facing its end game A new global strategic plan- 2020 INSight- created by an international coalition of partners, lays out specific actions to take and milestones to meet to eliminate blinding trachoma by the year 2020 A global strategy to eliminate blinding trachoma

We Can Eliminate Trachoma “We Can Eliminate Trachoma” video produced by Fred Hollows Foundation (3 minutes) We Can Eliminate Trachoma

Trachoma is the leading cause of preventable blindness worldwide What is trachoma? Trachoma is the leading cause of preventable blindness worldwide Mainly affects the poorest areas of the world Bacterial infection that leads to chronic eye inflammation Re-infection, scarring and trauma to cornea eventually lead to blindness Typically, children are infected at an early age and develop vision loss and blindness later in life This moving film shows that elimination is possible Trachoma is the leading cause of preventable blindness, and mainly affects the poorest areas of the world It is a bacterial infection that leads to chronic eye inflammation Re-infection, scarring, and trauma to the cornea lead to an advanced stage of the disease, TT (Trachomatis trichiasis), which is a very painful condition in which the eyelashes turn inward and scrape the cornea 4.6 million people live with this advanced stage of trachoma; they face visual impairment or blindness Typically, children are infected at an early age and develop vision loss later in life 2020 INSight trachomacoalition.org

WHO defines blinding trachoma elimination as: What is trachoma? Every 4 minutes, 1 person experiences severe sight loss; every hour, 4 people become blind WHO defines blinding trachoma elimination as: TF prevalence <5% in 1-9 year old children TT prevalence <1 per 1000 in total population Eliminating blinding trachoma is a critical goal in the international health community, since every 4 minutes, 1 person experiences severe sight loss because of trachoma, and every hour, 4 people become blind TECHNICAL AUDIENCE DEFINITION WHO defines trachoma elimination as achieving a TF (Trachomatous Follicular) prevalence of less than 5% in children 1-9 years old, AND a TT (Trachomatous Trichiasis) prevalence of less than 1 per 100 in the total population of a district LAY AUDIENCE DEFINITION WHO defines trachoma elimination as a combination of reducing the active disease in a population and reducing the backlog of Trichiasis, the blinding stage of the disease. 2020 INSight trachomacoalition.org

What is “2020 INSight”? With this understanding of trachoma and its presence in the poorest communities in the developing world, I want to introduce you to “2020 INSight”

Outline of this strategic plan is structured around four questions: What is “2020 INSight”? Outline of this strategic plan is structured around four questions: Where are we? Where do we want to go? How do we get there? What is the cost of eliminating trachoma? Again, 2020 INSight is a global strategic plan with crucial next steps toward eliminating blinding trachoma by the year 2020 The outline of the plan is structured around 4 questions: Where are we  Reviews the current state of trachoma prevalence and elimination efforts Where do we want to go  Provides an overview of the interventions needed to eliminate trachoma How do we get there  Highlights milestones for progress to eliminating blinding trachoma by 2020 What is the cost of eliminating blinding trachoma  Reviews the costs associated with this strategic plan 2020 INSight trachomacoalition.org

Where are we? The first step in eliminating blinding trachoma is to ask ourselves- Where are we in this elimination process?

110 million people need treatment in confirmed endemic areas Where are we? 110 million people need treatment in confirmed endemic areas 210 million more live in areas where trachoma is suspected Trachoma is suspected to be endemic in 59 countries 24% of these countries carry 80% of the burden Using WHO-endorsed SAFE strategy to eliminate trachoma Surgery, Antibiotics, Facial cleanliness, Environmental improvements Progress is significant- 9 countries have achieved their UIG Strong spirit of collaboration among trachoma control programs Right now, 110 million people need treatment for trachoma in confirmed endemic area and 210 million more live in areas where trachoma is suspected to be endemic These populations cover 59 countries where trachoma is suspected to be endemic 14 (24%) of these countries carry 80% of the burden Trachoma control programs use the World Health Organization-endorsed SAFE strategy to work toward eliminating trachoma The main components of this strategy are Surgery, Antibiotics, Facial cleanliness, and Environmental improvements Significant progress has been made using the SAFE strategy- 9 countries have achieved WHO ultimate intervention goals- but urgent intervention is still needed in many countries Finally, there is a strong spirit of collaboration among organizations that belong to the International Coalition for Trachoma Control 2020 INSight trachomacoalition.org

Where are we? SAFE Strategy WHO SAFE strategy consists of 4 components: Surgery- is needed to stop lashes from rubbing against the cornea, which then stops the cycle of trauma and secondary infection that leads to blindness The procedure is simple enough to be performed by trained health care workers Antibiotics- are key to treating infection and decreasing the prevalence and transmission of trachoma in endemic regions MDAs (Mass Drug Administration) get these antibiotics to burdened populations These are made possible by drug donation programs, such Pfizer’s $10 billion donation of Zithromax®, which is managed by the International Trachoma Initiative Facial cleanliness- is the behavioral component of this strategy, which helps reduce the transmission of bacteria with health education about facial hygiene Initiatives within this component work to educate individuals and communities about the transmission cycle of the disease Environmental improvements- reduce exposure and re-infection by increasing people’s access to clean, bacteria-free water For example, constructing new latrines improves basic sanitation 2020 INSight trachomacoalition.org

Where are we? TrachomaCoalition.org The implementation of the SAFE strategy requires collaboration among trachoma control programs and the sharing of resources, such as ICTC’s website, TrachomaCoalition.org The site provides downloadable maps showing where the SAFE strategy is being used around the world For example, these maps show coverage of each component in highly endemic districts of Ethiopia TrachomaCoalition.org also links to coalition member websites and other resources 2020 INSight trachomacoalition.org

Where are we? TrachomaAtlas.org Other resources include TrachomaAtlas.org, which is an open-access site with updated maps of the geographical distribution of trachoma These maps are freely accessible to countries, partners, and the public This is an example of a map from the Trachoma Atlas website, showing the prevalence of trachoma on the African continent Maps can be downloaded according to a country, region, or district 2020 INSight trachomacoalition.org

Where do we want to go? The next phase of the 2020INSight plan asks “Where do we want to go?”, and provides an overview of exactly what interventions are needed to eliminate trachoma

Model for surgery scale-up Model for antibiotics scale-up Where do we want to go? Model for surgery scale-up Model for antibiotics scale-up Again, our goal is to eliminate blinding trachoma by 2020, which gives us 9 years To achieve this, we must scale up interventions at each level of WHO’s SAFE strategy 2020 INSight has modeled scale-up scenarios to help us understand how this process will work On the left is a model for scale-up of surgery, showing the impact of increasing the number of surgeries (yellow bars) on the backlog of patients (purple line) We need to address the backlog of about 4.6 million people needing surgery in confirmed districts It is important to note that the capacity for surgery needs to remain beyond 2020 to ensure that future patients (those already on their way to developing TT) will be able to receive treatment On the right is a model for scale-up of antibiotics, showing the impact of increasing MDAs (yellow bars) on the number of people remaining in confirmed endemic areas (purple line) 200 million treatments have already been distributed, but we need 380 million more treatments for confirmed districts alone Scale-up also needs to happen for F & E components of the SAFE strategy, which will mean continuing facial-cleansing initiatives in existing districts and starting them in 500 new districts and collaborating with NTD (Neglected Tropical Disease), WASH (Water/Sanitation/Hygiene), and education sectors to dramatically increase access to clean water and latrines 2020 INSight trachomacoalition.org

How do we get there? How do we get there? This phase of 2020 INSight highlights the milestones for progress to achieve this scale-up and reach our elimination goal

Guiding principles of elimination plan: Urgent need for action How do we get there? Guiding principles of elimination plan: Urgent need for action Aim for fastest possible timeline in each district and focus on high-burden countries Accountable ownership Countries lead their own elimination process Integration of trachoma-focused efforts With other NTDs, Vision 2020, F & E initiatives Efficient, coordinated partnerships Tailored local interventions Guiding principles of 2020INSight elimination plan: 1. Urgency There is an urgent need for action in order to eliminate blinding trachoma in the next 9 years We want to aim for fastest timeline possible in each district, beginning by focusing on high-burden countries 2. Accountable ownership Countries should lead their own elimination process from planning to implementation, and should be responsible for integrating trachoma control into national health services Programs such as ITI can help to solicit & coordinate contributions from donors, but in the end, each country is responsible to their own people 3. Integration Trachoma-focused efforts should be integrated with other initiatives within the broader NTD community and with programs focused on health education and environmental improvements 4. Efficient, coordinated partnerships All partners and stakeholders in the trachoma field should coordinate their activities to maximize impact and avoid doing the same work twice 5. Tailored local interventions Programs should plan according to WHO guidelines, but tailor specific interventions to the each country and the local needs of each district, building on strategies that have been shown to work and using the best available local knowledge 2020 INSight trachomacoalition.org

How do we get there? Milestones to 2020 35% 50% 100% 75% 2020 2011 2014 2012 2013 2015 2016 2017 2018 2019 % of mapped districts with E interventions % of countries having reached certification reached UIGs in all districts with A-started % of surgery backlog addressed % of mapped districts with F interventions % of countries with impact surveys done high burden countries with NTD plans -- other Assessment complete -- other countries surveillance plan with NTD plans -- high burden countries Planning and Funding Interventions Certification 2020INSight also gives up this timeline map of milestones to elimination and provides targets for when each step of the process should be accomplished (This graphic can be viewed in more detail in the 2020INSight book) While this timeline stops in 9 years, part of the 2020INSight strategy is to plan beyond elimination, with long-term intentions to have systems in place that will allow for sustained trachoma monitoring and control after 2020 2020 INSight trachomacoalition.org

What is the cost of elimination? The last phase of the 2020INSight strategic plan addresses what it will cost to eliminate blinding trachoma

What is the cost of elimination? Economic burden of trachoma  $3-6 billion in annual productivity loss Estimated cost of elimination  $430 million for confirmed burden Even conservative estimates suggest that the annual loss of productivity due to trachoma is between $3-6 billion Estimated cost of all interventions to address confirmed disease burden is $430 million If, indeed, 50% of suspected districts are confirmed, this cost will increase to $748 million Most of this money is needed for surgery, environmental improvements, and antibiotic distribution [Elimination costs breakdown –FYI] Surgery (42%) $182 million Environment (26%) $112 million Antibiotics (22%) $94 million Face-washing (7%) $28 million Data gathering (3%) $14 million When we look at these costs, it is also important to ask, What are the savings? Eliminating the disease in Africa alone would boost the continent’s GDP 20-30 percentage points based on conservative annual productivity loss estimates It would also break the cycle of poverty and human suffering that traps many individuals and communities across the globe 2020 INSight trachomacoalition.org

The challenge for the coming years is large, but with the incredible momentum created through our partnerships, together, we can reach our shared goals. Thank You! www.trachoma.org www.trachomaatlas.org www.trachomacoalition.org The challenge of eliminating blinding trachoma by 2020 is considerable, but with the momentum of our partnerships and the strategic guidance that the 2020INSight plan provides, together, we can reach our shared goals. 2020 INSight trachomacoalition.org