 Okay good afternoon everyone. So I've been asked to give a history of ICH. This is the history as I would like to remember it. It does not mean it's the truth. I'm going to emphasise people rather than activities because we're going to hear a lot about activities later on. So ICH was started in 1981 by Professor Barry Jones. Barry was the Professor of Ophthalmology at Moorfields Eye Hospital and he worked on trachoma and oncosaciasis and towards the later end of his career he realised the importance of epidemiology and public health and it was with that in mind that he started ICH. When he retired in 1986 he handed over to Gordon Jensen. Gordon had worked as an ophthalmologist in Newfoundland, Canada, providing eye services to the Inrit people and Gordon had a particular interest in environment in the eye and also the epidemiology of glaucoma and it was Gordon who brought together that's called reference textbook on the epidemiology of eye disease which is now I think in its third edition. This is a photograph taken from the late 1980s. You can see Gordon and Barry on the front row. Also on the front row is Darwin Minasian. He was the epidemiologist who worked with Barry first on cataract and trachoma and on the back row is a man called Jock Anderson who was an ophthalmologist in Kabul, Afghanistan and then he was very much teaching the clinical side to the students that attended. The lady on the second row was Angela Reedy. She was a social scientist and she began to bring in the aspect of behaviour and eye health. On the back row is Pak Sang Lee. He was Mr Fixit. Basically nothing would have worked without him and he just made everything tick and next to him it is a young me. I came and joined the centre in 1985 having worked in Tanzania. Late in the 1980s, Murray McGavin joined the centre together with Sue who's over here Anita and Anne and they set up the Community Eye Health Journal which started in 1988 and had its 100th anniversary of journals a couple of years back. These are some of the master students from those early days. I'm not going to talk about Hannah, GV and Daksha because they're all going to talk themselves later on but I will mention Baba because I don't think he's here. Baba worked in Nigeria and then Pakistan and he's now the CBM medical director and also the vice president via APB and these just represent a few of the people that came through ICH in those early days. One of the important things that happened I think it was 1982-1994 around that time was we started this capacity building idea. It was not just things in London but outside and Adrienne Burra who worked at the school for many years recently retired. She won two grants one from the Lottery and one from the Nuffield Trust over an eight-year period to establish six community eye health training centres around the world and many of these centres are still going and we still have links and partnerships with them. So in 2002 so that's after about 20 years about halfway through our history ICH moved from the Institute of Ophthalmology to the London School. It wasn't easy and I'm going to describe that process in a little bit of detail because some of the people are important. Yeah first of all the initiator was David maybe I think he's around somewhere. Is that right? Hi David. So David arranged for Claire and I to go for beer and pizza. He was never into kind of flash meals but said look Gordon's going to retire in a few years. You're working on Tacoma. We're working on Tacoma here. It's crazy that two big centres in London are working on Tacoma and are not together so why don't you take the opportunity of Gordon's retirement to move to the school. We spoke to Gordon who kindly agreed and that was quite something to kind of say when I step down I think it's right that you move to the school. The next thing is we had to have funding to do it and these gentlemen you probably don't know this is Christian Garnes from CBM and Dick Porter from Sitesavers and at the beginning they said they would provide five-year funding for the centre at the school and without that promise I don't think the move would have happened. We then had to have the support of the school and Peter Smith was head of faculty, Andy Haines was the head of the school and again it was not easy for them because there was no room at the school to accept new people and you have this whole thing of salaries and finances and so on but they were persuaded. We had to write a five-year business plan on how we were going to make money. I don't know if we ever did make money but we had to write the plan and they did accept us and then last but not least these two ladies Viv who made the move happen if you like because we all had the idea let's move but somebody has to pack the boxes so Viv was in charge of administration and the administrative team that did the move and Clara joined ICH 10 years before and was leading the world work on child blindness and it was very important that Clara agreed to move from the institute to the school as well and she led the academic team that came over. So when we came over which was April 2002 we had the masters, we had the journal, we had six overseas partners, we had some research work on child blindness with Claire, research work on trochoma I'll mention in a minute, we were 10 people, we had some funding and we were scattered in three rooms along Gower Street and literally to kind of cover the department you had to walk almost a mile because we're in different rooms. 20 years on I just want to point out we've had five moves at the school those moves have been done by those two ladies that were pictured here and if nothing is remembered from this talk please school no more moves. So I said we had a trochoma grant when we first came to the school with the help of David Mayby and Joe Cook who was the head of the International Trochoma Initiative we got a very large grant to work on trochoma for a few years and that enabled us to to recruit four people and so from my left to right John Bucken who was a clinical ophthalmologist and who's now course director here and he'll talk later on. Anthony Solomon had done a DTM in H and then a PhD on trochoma and he's now head of trochoma at WHO. Hannah Cooper who'd done a PhD on epidemiology after the trochoma work she subsequently did the cataract impact study for five years and now runs the disability centre here at school and Marcia Zondavan who'd been an ophthalmic nurse in Africa for 15 years and knew both anglophone and francophone Africa which was important for this study and subsequently went on to run the links program that you'll come to so you see that was a critical time because those four people very much became part of the backbone of the ICH going forward and it was all enabled by that first grant. Claire and I were co-directors from ICH from 2002 till we both stepped down at the end of a couple of years ago and Claire worked on childhood blindness, ROP, national surveys in Nigeria and Sri Lanka and more recently work on glaucoma and the world report on vision. I want to mention Joti because Joti's been Claire's right hand for the last 20 odd years and making sure that she caught the plane on time. I emphasised the education side of the work that we did and in 2006 we awarded the Queen's Prize for Education which is a very prestigious prize and this is going to meet the Queen at Buckingham Palace and it was an opportunity for the fab four to get all glammed up they just love a night out. That's Claire, Viv, Adrian and Hannah. The next big thing was the Commonwealth Eye Health Consortium and this was a grant obtained by Matthew in 2015 a five-year grant which extended a bit and which enabled ICH to expand a great deal and it was based around people, knowledge and tools and I think that's a very important concept that and it comes back to I think what Matthew was saying about the vision or the mission of ICH going forward. I digress for one minute because one of the things I remember about Barry Jones who started ICH was him saying we're not primarily about giving people knowledge, we're primarily about changing the way people practice ICA, changing people to think about populations and community and what they're doing. So the Commonwealth Eye Health Consortium here it's 43 countries I think in the end it was more or less all of them wasn't it Matthew that was involved and here's a few photographs of recipients of different aspects of that grant. I just want to mention in particular at the bottom there the three ladies in the middle Cova because Cova again ran the master's program for 10 years I think Cova before moving got before going into links and other things and this was some of the staff on the Commonwealth Eye Health Consortium and again I can't pick out everyone but I want to pick out Nick who's on the second row with the white he's the second row again because he ran the clinical fellowships program and I think that was more than 100 clinical fellowships around the world in the end Nick just an amazing part of the Commonwealth Eye Health Consortium and part of that capacity building and so in 2020 Claire and I stepped down handed over very gratefully I mean we were great for he wasn't to Matthew who had already done the Commonwealth Eye Health Consortium he immediately set about a Lancet Commission on Global Eye Health as well as his own very strong research work on trachoma and corneal disease and I know ICH is in very good hands with him I would like to point out we handed over at the beginning of 2020 he already knew ICH was quite a big undertaking what he didn't know about was COVID and the fact that we've been two years of world at home and working and Zoom calls and that's what Matthew's had to live with over the last two years and it's very nice that we can now all meet face to face again thank you very much great thank you Alan that's lovely to to see all those lovely old photographs and and and being joined by several people in the room John is going to come and talk to us now for a few minutes about the MSc course and joined by Chiki virtually yes that's right almost live from Rwanda so from the last decade so is there a click like just on the so from the last decades we can report various statistics of the number of masters students who've graduated the places they've come from and gone to the majority from lower or low middle income countries the majority being supported by various scholarships with equal gender representation and diverse professional backgrounds as well as diverse geographical backgrounds we can see the number of students from various locations largely proportional to population but just as statistics about blindness don't really convey the individual loss that's suffered by people who lose their sight the statistics of the MSc don't perhaps tell the story very well so I'm taking you back again as as Alan has to 1982 and 1985 and here's some class photos and I want to point out just one student to exemplify part of the legacy of the master's program and you can put your hand up if you think I'm going to point out Hannah Fahl uh I'm not uh obviously um hands up again anyone who's ever heard of or ever seen Samuel Coker in the bottom left hand corner no oh Marcia has Marcia knows everybody um well Samuel Coker is from Lunsar in Sierra Leone he was a nurse trained as a cataract surgeon and he studied here in 1982 so it was nearly 30 years later when I was working in Freetown that I met him and his eye hospital in Lunsar was doing more cataract operations than all the other eye hospitals in the country put together um they ran weekly outreach clinics through their network of established community partners around the all around the country and with local case finders at each place bringing in the cataract blind for them to take back and to operate on and it took my unit nearly four years to get to almost the level of activity that uh Samuel Coker had built up over the the previous uh 30 years with his outreach team and uh that brings me to point that so in in our anniversary here of 40 years it's really also the anniversary of the impact of our alumni um which grows every year it's like compound interest as every new batch of students is added so moving on then to 1995 and again there are our students here we haven't progressed yet to color photos but we have added another 10 years of students by that point to our legacy some of those that you'll have heard of um and some of those that you will not so we're now going to hear from someone who you probably have heard of but who we're always happy to hear from again so um this is live or as I say nearly live from Rwanda Chiku's unable to join us but here she comes. How did I end up on the MSc course? I came on the course as a reward from Sightsevers International they came to evaluate the programs in Kenya and apparently they liked what they saw in the unit where I worked among things being that no matter what time they came to visit I was always on duty so in recognition of that I was offered a partial scholarship by Sightsevers and the other half came from Defeat. I was not so excited about coming on the course at the beginning because I knew people who'd been on the course and I just thought nothing changed after the course but I do say today that it is one of the best things that ever happened to me. I am still and was then a full-time clinician and the additional understanding of how health systems work of how what public health is all those were very new to me and I embraced that and I realized just how much that has impacted the way I perform um there's enough thermologies whether in private practice or in government practice. What impacted me most on the MSc course was the quality of the faculty. You know the names you read about on papers and books and you don't ever imagine that you will come to meet them but to realize that each and every lecturer came to teach us was somebody who was well known out there and that you could engage them and you have discussions with them and sometimes even challenge them. I found that experience so enriching and a reflection of that is you know for my MSc I did a study looking at vitamin A deficiency in prisoners in Kenya and it was a hard study and a lot of people thought it would not be possible to do it but my supervisor Allen Foster said no I tried to do that in Tanzania it was really hard but I think you can do it and I will support you to do it and that's how I ended up in one of the maximum security prisons in Kenya doing a case control study so the quality of the faculty that ICH has I think that's outstanding. There is no doubt in my mind that ICH is one of the most important institutions that exists in ICARE today. Do you have an institution that focuses on ophthalmologists from low and middle income countries with such dedication and to do things to such high standards is unusual it is a well governed institution you know I watched the transition from Gordon Johnson to Allen Foster I watched the move from Moorfields to to the London School I watched when Allen Foster brought Claire Gilbert in and now I have seen as Matthew Barton takes over from that generation it is an institution that is thinking for the future and I have no doubts that it will continue to grow from strength to strength I wish the best to the institution itself and also to all those who will be really lucky to come and become trainees or staff in this institution. Thank you very much. Thank you. So with nearly 80 percent of our students being supported to do the course by scholarships we want to acknowledge those who fund each student. So every funder also has a story and it's with great sadness that we note that the British Council for the Prevention of Blindness that funded so many master students funded Chico's PhD over the decades closed down last year as the funding environment has become increasingly difficult through the pandemic but to those who have been able to continue funding we are very grateful without your funding support we simply would not have the rich and diverse group of senior academics opinion leaders, NGO medical directors, educators and policymakers that we have in the iCare world globally. The outputs of this course is people with a vision and it's a vision that's giving hope to those people who have lost or are in danger of losing their vision. In fact we just have time for me to ask if those who are alumni of the ICH MSC could stand up just briefly just so we can see even just in this room if you are an alumnus there we go good. So we wouldn't want to remove these people from the panoply of the iCare professionals thank you very much. So if the best predictor of past behavior or future behavior sorry past behavior then I hope that we all continue to participate in and to see the growth of this master's program and yeah I look forward to that future and being part of it so thank you. Great thank you very much John thank you very much Chiki for those recordings as well. I'd like to invite Claire Gilbert and Andrew Malick to come and talk to us a little bit about the child eye health research that's being done here. Good afternoon everybody it's a pleasure to be here on our 40th anniversary and I've been around for the last since 1990 so quite a long period of that time delighted to introduce Aisha Malick who's a pediatric ophthalmologist who is coming in to take my place as I fade out and to carry on the work of blindness in children. So we're going to give you a very quick snapshot of how things have changed in childhood blindness research over the period of time that I've been at ICH. So starting in the 1980s Alan had done a lot of work on corneal ulceration in children finding out the different pattern of causes of ulceration and he published a lot on that and also with David Yolston and in 1987 published a landmark trial of vitamin A supplementation of children with measles showing that it reduced mortality and this really was one of the early drivers of increasing vitamin A supplementation and measles immunization and how to treat children with measles and in 1989 WHO hosted the first workshop on blindness in children here in London which I think was chaired by Alan. I'm not sure but Alan played a key part and one of the recommendations from that workshop was more information was needed on the epidemiology of blindness in children. I happened to have just finished my MD degree and so I then came in to fulfill that role and was funded for three years to do that. So the first thing we did was to work with the World Health Organization to develop a classification system for the causes of blindness because that wasn't currently available and while developing and pilot testing and refining that classification I examined thousands of children who were blind in special education in Latin America, Africa and Asia which allowed me to describe the pattern of causes and how they vary depending on levels of socioeconomic development and around that time Mike Eckstein did a clinical trial for different approaches for surgical techniques for congenital cataract and it was while I was in Latin America in 1997 that I saw the first child who was blind from retinopathy of prematurity outside high-income countries. It was thought to be a disease that occurred in the 1950s because babies were given too much oxygen and it no longer occurred so we weren't trained in it but I saw the first child and then I saw more and more children who were blind from this condition and in Latin America at that time around 25% of all blind children were blind from retinopathy of prematurity and in 1999 many of you will be aware of the IAPB WHO initiative called Vision 2020 The Right to Sight and quite a lot of the data that I and colleagues had been collecting fed into that and meant that blindness in children was included in that global initiative which has had a massive impact in terms of NGO support for developing services for children. During the 2000s that really was the decade of ROP and many many workshops were held at national level involving ministries of health, neonatologist, nurses and ophthalmologists for people who are wanting to set up or improve their ROP services and Andrew Zinn and I undertook a trial of training nurses in Rio de Janeiro to see if they could improve the quality of the care that they were providing to try and reduce the blinding stages of retinopathy of prematurity and it was during this time that Dr Mujit who was an alumni did a PhD with me in which he developed the key informant method for finding blind children in the community which essentially entails training people who know the community very well so teachers, religious leaders, people who work for local NGOs and as a result of that he was able to to calculate that there were 40,000 children who were blind in Bangladesh and a third of them were blind from cataract and the results of this study which was supported by CBM and sightsevers were presented to a meeting on blindness in children run by sightsevers who then agreed to support what I thought was a wildly ambitious program in Bangladesh which was to identify well over 30,000 blind children set up 16 eye care services and provide lots and lots of surgery and to my amazement those targets were pretty well met and 25,000 cataract operations were performed on children so this really shows how research can lead to policy and program initiatives through IAPB and WHO and also through developing programs because that program just would not have happened without that evidence. In the 2010 with support from the Queen Elizabeth Diamond Jubilee Trust they also gave a large grant to India which was all managed by GVS Muti through the Public Health Foundation of India for diabetic retinopathy and retinopathy of prematurity and that was a very large body of work basically to develop models of care for how to provide ROP services within government in government neonatal units bringing in the expertise of the private sector for training and also the NGO sector so it was really a sort of tripartite program and that led to services being established in four states I can't remember how many babies now were screened and treated but it was a very large number and lots of those providers have now expanded their provision within those states and have started services in other states as well and working with Priya she undertook two clinical trials of different aspects of spectacle correction and spectacle wear in India and we also undertook a pilot study with another alumni of training staff providing primary care services for children we added in the eye care component and this study really shows that those nurses were eager to learn they saw children with eye conditions they didn't know what to do so given them this knowledge and skill changed their practices they referred more babies and so on and in a moment ish is going to tell us a little bit more about that but the end result is that in Tanzania the Ministry of Health agreed to include an eye model eye module in their program which is called the Integrated Management of Childhood Illness which is a program across the country for all children under the age of five and to date more than 3,000 children staff have been trained to detect and manage eye diseases I just meant to talk about the last bit sorry that's all right so I was just going to say that yeah building on the work from Dr Milkenfury with her MSc work and in the format of research which was also looking around at primary eye care issues for children we wanted to create a model for how we could include eye care into routine child health programs and so we did choose as Claire said the WHO UNICEF joint initiative called the Integrated Management of Newborn and Childhood Illness or IMNTI and we chose this for a number of reasons because it was well established had been since 1995 it's present in over 100 countries globally it works the primary care level and included all the key conditions for children including ears but it does not include the eyes so we worked with the Ministry of Health in Tanzania we developed the eye care module with them we tested it within their routine IMNTI program and found it to be both feasible and acceptable to those primary health care workers and so that was what then led them to include it into their national program and as Claire said after the completion of the program they've gone on to train another 3,000 primary health care workers showing it's a really sustainable and integrated approach so then further there was another another study done by Richard Bowman and Godfrey Ferhini they were comparing different devices for newborn eye screening they found Arcolyte to be the most suitable and then more recently Claire and I were completed a systematic review for WHO as part of their postnatal care guidelines where we recommended that they included newborn eye screening they very kindly accepted and those guidelines have just been published yesterday so that's been you know a really important kind of exciting win for us because now every country when they're thinking about their newborn care guidelines will also have to think about how to include eye screening for babies as well so now we also have as well as that that we've got the eye care included in the IMNTI policy in Tanzania I think Claire did you mention that RAP screening is now included in the WTO survive and thrive initiative so building on this we wanted to do a health policy analysis which we've been conducting currently I've been interviewing key child health policy makers just to try and build on this and to see how we can expand including eye health into child health policies in the future so also during this time we were running a RAP network this was in six countries across Africa and Asia this was built around South-South partnerships some of these countries were starting from scratch with brand new RAP programs others were scaling up already existing programs and what's been good is that even since the completion of the network all of those countries have continued their RAP programs another recent piece of work which Claire and I are involved with which was working with UNICEF to develop a target project profile for RAP imaging devices that's also just been published last month all of this showing just how eye care has been sort of better recognized now within the child health community as well so moving on to what we are hoping to do currently and in the future at the moment we're about to start creating arc light trading videos these will be initially developed to train 800 primary health care workers in Tanzania who will then initially screen 100,000 children over four months but then these will be included into their ongoing program in Tanzania and they'll also be freely available for other countries to use we also plan to do a multi-country evaluation of scaling up including of eye care and the IMNCI program we'd also plan to evaluate models for telemedicine screening for RAP in Africa including looking at the potential impact of AI in that RAP screening as well and we hope we can also include this telemedicine approach in a future expanded RAP network so I'm just going to stop there but I would like to just leave the last word it's just okay I'm going to leave the last word to our partners in Tanzania okay here we go let me just get this to play we needed to open up the modules without putting any difficulties to incorporate this module in the IMCI however after starting implementing it has become easier than what we thought the eye care will be covered in the less of the function the eye health module has been included in the IMCI training program so it will continue to be taught to every training program that is there for NCI in Tanzania thank you very much great wonderful to hear about all that amazing fantastic work going to hand over now to Jackie who's going to give us a bit of a summary of the commission thanks thank you so I wanted to start by saying it is actually a dream come true for me to be here I heard Ellen speak more than 20 years ago now and decided that day that I wanted to join ICH and it did take me quite a while to get here but I wanted to acknowledge and thank Ellen and Claire and Matthew for being amazing leaders and also to say thanks to my colleagues it's really a fantastic team to be a part of my job today is to tell you a little bit about the Lancet Commission on Global Eye Health I imagine many of you have heard about it already but I thoroughly enjoyed working closely with Matthew and with Professor Hannah as in their role as co-chairs of the commission I wanted to start by acknowledging all of our supporters and this support enabled us to assemble a team of 73 academics national program leaders and practitioners from 25 countries and I also wanted to acknowledge more than 75 people who additional people who supported us and contributed to the many original reviews and other analyses which informed the commission in addition to the main report and appendices the commission subsidiary papers case studies and other resources can be accessed through the commission's website and the report and related materials such as a podcast with Matthew and Hannah are also available on the main Lancet Commission website the commission explores eye health from several perspectives the broad importance of eye health the scale of the challenge the economics of vision the research needed and finally looking beyond 2020 and how to deliver high quality eye care for all so today I'm just touching on four pieces of work within the commission that have begun to catalyze action so in the commission we examined the importance of eye health from several perspectives including its impact on quality of life general health and well-being and mortality and our starting point was a systematic scoping review of the looking at the relationship between improving eye health and advancing the sustainable development goals and in this review we found evidence that the provision of eye health services is associated with improvements in workplace and economic productivity household consumption and income and employment and the resulting economic benefits particularly when delivered in resource limited settings contribute to advancing the sdgs on poverty reduction food security and decent work we found evidence that providing spectacles to children improves educational performance supporting quality education we found evidence that gaps in household expenditure between households with and without someone with vision impairment from cataract did not exist one year after the household member underwent cataract surgery sdgs 3 and 11 include targets to reduce road traffic injuries which is a major cause of death in many parts of the world and we identified evidence that cataract surgery leads to reduce driving collision difficulties and fewer collisions globally health care contributes to around 5% of greenhouse gas emissions and eye care as a high volume service is probably a significant contributor to this the commission found only a small number of studies that looked at the environmental impact of eye health services but there are substantial opportunities to reduce this impact and this is an area of research members of our team are pursuing so through multiple direct and indirect connections our overall conclusion was that improving eye health and reducing vision impairment is an important enabler to advancing the sdgs and this and other evidence from the commission was used to advocate for the first ever UN resolution on vision last year over 100 countries supported the resolution which enshrines eye health as part of the sdgs the commission also looked at several aspects of the economics of eye health we updated cost effective analyses for cataract surgery and refractive error services which together account for 90 percent of vision impairment and the good news is that both are highly cost effective interventions we use the latest data to estimate the global economic productivity losses attributable to attributable to vision impairment to be 411 billion us dollars annually and we undertook a systematic review to look at the full extent of economic analysis in vision impairment over the past 20 years this review found a massive gap between the evidence that's been generated in high income compared to all other countries as well as gaps for some conditions and substantial heterogeneity in the methods used so these analyses highlighted the need to develop and apply standardized methodological approaches and to be systematic in terms of how we fill the evidence gaps and ICH has begun to work on this mammoth task continuing with the collaborative approach that we used in the commission the commission also looked back at the 20 years of eye health research to 2020 in terms of where and on what conditions it had been conducted and we also took a forward-looking approach by undertaking a grand challenges prioritization process to determine the critical issues still to be addressed this was a three round panel exercise which prioritized answer the answers to one question which is what are the grand challenges in global eye health where a grand challenge was defined as a specific barrier that if removed would help to solve an important health problem and that its intervention would have a high likelihood of feasibility for scaling up an impact there were more than 300 participants from 118 countries who contributed and voted across the three rounds and I acknowledge those of you here who did contribute to that thank you we generated one global and seven regional lists and the top five global priorities shown here related to refraction services cataract services services for children embedding equity into services and reducing out-of-pocket costs so these provide a clear direction of travel for eye health stakeholders wanting to maximize the impact of their work we're current currently in conversations about how we might take this forward and think there's real promise in working collaboratively to establish global and recent and regional research agenda and a monitoring framework to monitor to track progress and our aim would be for groups to galvanize around particular challenges and undertake a broad range of studies to generate the evidence we need and from an ICH perspective we've been guided by these lists during our recent strategic planning process and a pleas that were well aligned with many of the global priorities identified and a major part of the report is devoted to looking at how we can advance the delivery of high quality eye care for everyone everywhere and building on the WHO world report on vision the commission urged countries to consider eye health to be an essential part of universal health coverage and we argued that UHC is not universal without affordable high quality equitable eye care and I thought I'd finish by sharing one contribution we're currently making in this space building on the work of the commission on effective coverage of cataract services and refractive error services the potential for eye health to provide measures of effective coverage was first demonstrated by ICH and these two indicators are now key indicators for global eye health in response to a request from member states at the world health assembly last year we're now collaborating with WHO and the vision loss expert group to use data from RAB and other surveys to generate baseline estimates of ECSC and ERIC and we understand from our colleagues at WHO that they will then be nominated to join to join the WHO's UHC index as well as the SDGs monitoring framework when this is reviewed in 2025 so these are just a few highlights from the commission and if you haven't had a chance to read it I encourage you to do so and I think we have hard copies at the reception later on so please pick one up thank you great thank you very much Jackie um just to re-emphasize that we we've got about two thousand of the things we would really like you to take one with you if you haven't already got one so um great um on on to something else now uh trachoma is the uh communist cause of infectious cause of blindness in the world and um ICH is part of a wider group based here at the London School of Hygiene and School of Hygiene and Drug Medicine working on trachoma led by David maybe Robin Bailey and uh Martin Holland and myself and uh we've been working together for many years in fact David appointed me to a PhD uh studentship back in I think point two thousand that was my first entry into the school of eye health we work on many aspects of trachoma epidemiology surveys pathophysiology and uh particularly around uh the evidence base for trachoma control and this afternoon I'm joined by Umah Shafiq come on over here um uh he's a current PhD student at leading research program based in Ethiopia um and we're going to share some some uh some things about the current work we're doing and and recent studies that have been completed um as many of you know uh trachoma is being controlled through the implementation of a safe strategy it stands for S for surgery uh to treat trachosis the interning of the eyelid due to the scarring from the infection A is for antibiotics to control that infection and F and E facial cleanliness environmental improvements are really focused on reducing the transmission I'm going to briefly outline some of our more recent work work really over the last decade um looking at uh different approaches to improve the surgical outcomes and non-surgical outcomes for people with trachomatous trachosis and um this has been particularly um focused in Ethiopia in terms of the work through a collaboration with the Umahara Regional Health Bureau the the Carter Center Ethiopia team and ourselves here at the London School and we've conducted four large randomized controlled trials over this last decade I'm going to just briefly mention three of them and this work's being led uh on the ground by um Esmail Habtamu who unfortunately is not with us today he will be here later he's at the expert committee for ITI at the moment and uh Saul Rajak who's not a capacity specialist based in Brighton so the first of these trials compared two different types of sutures silk sutures and absorbal suture called Vycro to see whether there was a difference in the outcomes when you use either of these and what we found was that the the results were equivalent the the the trachosis came back in similar proportions in in in both groups but what we noted was the the absorbable sutures have distinct programmatic advantages because they don't need to be removed people don't need to come back so quickly to have the sutures out and that reduces both the burden for the patient and the burden for the health system and that's now become a programmatic practice in many locations. The second trial looked at people who had mild disease minor trachosis just a few lashes touched on the eye and I asked the questions whether this early stage of the disease could be safely managed with repeated epilation. Epilation is the plucking out of eyelashes and compared to to surgery and what we found was that at two years and again at four years the vision outcomes and the changes in the cornea from scarring due to the trachosis were equivalent in these two groups and people reported them and indeed they voted because they refused surgery in many cases to to opt for epilation in the early stage of the disease and today epilation is becoming increasing a practice a management practice for mild disease and the third trial I'm just going to mention briefly before handing over to Uma is one that formed the core of SML's PhD in which he compared the two most commonly used procedures, the bilimela toss rotation on the right and on the sorry on your left and the posterior lamella toss rotation or tribune procedure on the right and what's here in the team found was that the posterior lamella procedure which was much less frequently performed at stage had about half the trachosis recurrent rate at a year and that difference was sustained for many years to come up to four years and this has led to a shift in in training practice and and the preference towards this procedure in some countries now so I'm not going to hand over to Ima he's going to take over and Matthew spoke about the strategy I will focus on the A and F and E component of the safe strategy currently as you all know there are several regions in the world where the standard safe strategy does not appear to be clearing infection and disease we have identified three critical issues in this the first one is the root of city transmission and their relative contribution to importance to transmission are fully defined the second one is the F and D intervention evidence-based to guide programs is really limited and the third one particularly in countries like Ethiopia with the current treatment schedule the prevalence of teracoma still remains to be high to try to address these issues we are conducting a multi-phase research program designed to develop evidence to strengthen the existing safe strategy we call this stronger safe so when I say multi-phase strategy on phase one focuses on understanding transmission within household and between households we have done extensive household swabbing and testing for the infection to try to map out where this can be found on people closing and surfaces we have also studied the role of flies in the transmission through observational catching flies and testing for infection we have found the infection on flies particularly in household this with people with current eye infection we have done a very extensive work with communities to try to better understand the barriers to limiting teracoma transmission and now we have co-developed an intervention with the community an intervention package together with the community that is acceptable and which makes sense for the community as well basically meaning we are not making these packages sitting in office or from London we were developing them with the community in the community this includes strategies to improve face washing and also reduce fly eye contact at this moment we are now conducting a forearm cluster randomized trial whether the strongest whether the strongest safe intervention package can be impactful in controlling teracoma we have 68 clusters each cluster has 17 17 cluster in each arm there is standard antibiotic standard fne standard antibiotic enhanced fne enhanced antibiotic standard fne and enhanced antibiotic and enhanced fne which we call a stronger safe when we say enhanced antibiotic we mean giving two dose of azithromycin instead of a single dose and we give them two weeks apart and when I say enhanced fne I'll talk about it later we have what we call face of dignity campaign fly trapping and fly repellent clothings and our final outcome is actually CT infection at the end of 36 months the core find for facial hygiene intervention approach is something what we call face of dignity why did we choose dignity if you tell people if you tell our community that early stage of infection will finally get you to blind in us after 30 40 years or 20 years they might find it's difficult to connect it so we have to look for a value that a value in the community that they care they care about and dignity was rated the highest above the other community values like happiness love from spouse and respect from our community so the key messaging is face washing is dignity also embedded within the face of dignity campaign we are providing some equipment training to support face washing which in which complement is the campaign and allows people in the community to use limited water they have access to the maximum to the maximum benefit basically meaning they have some water the point is prioritizing that water to face washing and there is some water so to make sure that they prioritize that is we are trying to connect that to dignity instead of actually the blindness which will eventually come and also to control flies we are distributing fly traps these are the traps and there is a smelling glue inside flies go inside and then they because they see the light they go up and then they stay there because they are not intelligent enough to to see this and these are the materials that we actually provide with physical meaning this program is funded by welcome trust through collaborative award and it is a partnership between the oromia region has the bureau the federal minister of health the fred holos foundation the london school of hygienic tropical mix and the welcome the welcome sandal institute we are very thankful for our partners thank you thank you i suggest you catch rumor at the break either before or after the tea break or at the end and asking about some of the stories of running this study and getting this trial going and keeping it going it has been the most enormous herculean effort and hats off to to email i'm going to invite claire and hannah to the podium and claire you're going to have a conversation with hannah and can i suggest andrew while that's happening that you might want to flip the presentations because the technology is my advice is never do a hybrid meeting if you can avoid it and since then it's been involved in many international initiatives particularly for trochoma control and uh she was a president of the international agency for the prevention of blindness and she's been a consultant to psychsators for many years as well so hannah can you please tell us about the survey that you or the project that you did after you finished our diploma thank you very much claire um i would like to start not to the survey but to start with professor barry jones because the course was community eye health and i thought i'd press appropriately to reflect the importance of the community um the ministry of health of the gambia in 1986 had a very very strong primary healthcare system but eye care was not part of it and there i was as the only ophthalmologist supposed to provide eye care to the community what could i do the only place we could go to at the time was international center for eye health where professor barry jones just gave us all that we needed to go and deliver eye care to a population the very first task we had to do was a survey and the lectures on the survey we had a class exercise and planning a survey and that translated to a national survey with icc providing the technical assistance and without that survey would not have the evidence or the data to plan a national program so that was the importance of attending the icc at the time i think i've written saying that was the first national survey in africa it was the first national survey in africa yes can you just briefly tell us what the results were and more importantly how you went on to use those results in the gambia well the the numbers you know at my age you don't remember so much but i can tell you that the prevalence of blindness at the time was 0.7 we knew that the causes cataracts corneal opacity and trachoma were the leading causes so we knew the prevalence we knew the numbers of people we knew the causes then we could develop a national eye care program based on evidence and that was involving things in the community in hospitals it was throughout the whole yes throughout the country i mean you travel from one end of the country to the other and we talk about national surveys but what you remember are the difficulties of reaching that small village that was picked out in the randomization and having to get there to count and actually make friends with the community and have them to be part of that survey yeah and then it's going to say so you planned the program so that people even in the remotest villages could have access isn't that right that that was the end point it was really about getting eye health to the community thank you so since that first survey in the gambia which had a population of less than a million lessons were learned and then ICH was provided technical support to four national surveys in far larger countries so initially in Bangladesh initiated and supported by site savers and then in Pakistan that survey was the second survey that they had done and it was initiated by the Ministry of Health through their prevention of liners program because they wanted to track change so the the first survey had been done 15 years earlier that had been used to plan a national program and the approach that they had adopted was support from cbm fatollos and other NGOs was to go district by district strengthening eye care delivery training staff making sure it was operating theaters and managers importantly so they wanted to go back to the population to see if that had made any difference so the survey that we helped them to do showed that over a 15-year period the prevalence of blindness had halved over that time period really demonstrating how that approach has helped and the other survey another survey was undertaken in Nigeria which was suggested by Serge Resnikov he was the prevention of blindness coordinator at WHO at the time and was aware that there was real shortage of data on blindness in Africa and so we were commissioned to do that with support from site savers and other NGOs and then the last survey was done in Sri Lanka and those surveys have had a major impact really allowing countries to plan their services like has been undertaken in Nigeria and importantly to identify the subsets of the population who had a higher prevalence of blindness than other subsets of the population so that services could be targeted to those people who had less access and that includes rural communities often women and people living in rural areas and it also provides information for advocacy for more resources and it provides the basis for further research and two of the ophthalmologists who played a key role in the national survey in Nigeria so Fatima who's sitting here who did our master's first and then she took part in the survey and we realized that blindness from glaucoma was the highest of any survey reported so she and another ophthalmologist called Abdul Mohammed Abdul both came back to do PhDs with us on different aspects of glaucoma so finding some surveys can also help to inform policies and Fatima has been playing a key role in that in in Nigeria and data from these services have also contributed to the global burden of diseases which is a huge global initiative to provide estimates of the number of people who have a huge array of conditions and they update the data every 20 years or so as more evidence becomes available so Hannah since the first survey in 1986 I understand there have been two more surveys can you explain why they were done what was found and what was different about the last one well the 1990 it is its survey laid the foundation for the planning and we had two five-year plans after that and conducted another survey in 1996 which showed that the blindness prevalence had dropped by 40% and it provided a global evidence to start the vision 2020 the right to sight which became a global health initiative between countries and the umbrella body for all the injuries so in a way doing the survey provides the evidence pools in the community pools in the government to get action at the community level we have we have had another survey in 2019 which was a much bigger survey even including disabilities and the new thing about it was this time we chose a population cohort to study in depth so in another five years we can follow the same people and see what has happened to them but I think really it captures what this institution is about the research the education and the capacity strengthening all coming together in a process that makes an impact on the community itself and I would like to thank Barry Jones for starting community health community is the reason for doing all that we do great thank you very much both for you great good welcome Andrew to talk to us a bit about peak and other things good afternoon everyone I think like many people here there's a chapter in my life that starts with and then I met Alan Foster and so Alan is largely responsible for a lot of things in my life haven't gone in a certain direction but in my first meeting with Alan he said you really should meet Hannah Cooper and Matthew Burton who I did have become incredible mentors and all the work that I'm sharing here is really sitting on the shoulders of giants and I had the opportunity to move to Kenya with my young family 10 years ago now and I was also doing a population survey similar to work Clara and Hannah were talking about building on the expertise that they had here and but it was really difficult we had so many problems and although we were able to do really robust research my mind was always thinking about surely there would be an easier way to do this and many of you are now familiar that we've developed a whole you know a lot of technology and so on but it was really grounded in this idea of how do you find people who are unseen and and ensure they become visible to the system and Rob had been going for you know three decades and we had the the pleasure of collaborating for ICH and pizza developed the latest iteration of that which is now called Rob7 and as many of you know Rob7 populates a huge amount of our global understanding on the prevalence of blindness and last year a new repository was launched and a lot of the data that's underpinning our current global understanding of the the magnitude and prevalence of of our health issues comes from the Rob survey and one one thing that has always kind of struck me over the last last few years apologies that you're seeing a version of my chest let me see if I can so I was going to talk about technology maybe minimize there you go thank you not just a phd mental and so although we've we've addressed you know we've understood that this huge global unmet need for for our health and one of the things that has changed in our you know in the time that ICH has been been around is the proliferation of mobile technology so the current data as of 2021 is 6.4 billion people own a smartphone it's not even just a phone but most of the world today are connected on a smart device and behind could we try and close that gap between this huge unmet need and this huge opportunity that technology might provide and I'm going to give you a very quick whistle stop tour through some of the key uh bits of research we did whilst peak was being incubated here within ICH so the first was a study to see could we develop a smartphone-based vision test that could work accurately in the hands of non-i health workers so could people deliver the test to the same level that i health worker would and we're able to demonstrate through several studies that it was and and through a period of validation and then developing a social enterprise we were able to launch the peak security application which is currently used across 190 countries and we're constantly hearing stories about how people use it in in their practice and it remains a robust test but we also realised quite early on that testing vision alone was never going to solve the problem and so working with a friend and colleague who later became my PhD student Dr Hilary Ronno we set about trying to answer this challenge that he was facing in his community in Kenya where he knew there were thousands of children in his community who were not being reached and in every class he projected that at least three or four children had a vision impairment that was going undetected but he couldn't justify sending the two ophthalmic nurses he had in an already over on clinic out to the schools to identify them so we thought could we train teachers now that we'd develop this application to do that first line of screening identification and we're able to demonstrate that it worked really effectively but we needed to build a back end so that once you found those children they would actually get to the services so in that first version of the of the software we built something that would enable messages to the parents or guardians if they've been identified the hospital would be informed if patients would need to come and we built this into a randomized control trial in which 21 000 children were screened 900 identified with a vision impairment and it was delivered by 25 teachers in just nine days and this is when we had the first inkling that this could be something that might be an opportunity to go beyond research some of the key findings that came from that Lancet Global Health RCT were the ability to identify those in the population with the problem understand those who'd reached the service but also understand the quality of the referrals how many people were being referred and didn't need to and critically who was not actually making it to the service because this we found was a huge gap in the data if you found someone it did not mean that they reached the service and then my colleague Dr Priya Mojharia a leading public health optometrist said I'd like to take this further in India and so as part of her PhD Priya started looking at what would happen if children were identified in schools with refractive error they were triage bi optometrists and then they were given a free pair of spectacles what would happen at three months if you did an unannounced visit since they were still wearing the glasses and the findings of the study were fascinating but what fascinated me was that we could track this process in real time so we started to understand the impact pipeline as it was happening and Priya continues to work closely across ICH and Pika is just going to share a little glimpse to the future of something that's been developed. Thank you so what I've been working on is the school eye health rapid assessment tool and this brings together sort of the experience at ICH about surveys and rapid assessments such as the rub seven but also peaks experience on using technology and powering school eye health programs. So what is CIRA? CIRA is a school eye health rapid assessment tool which will not only find what is the magnitude of the eye health need for children in schools but it will also better understand what is the environment where these programs are being embedded so we know that school eye health programs are very popular and implemented in lots of places and sometimes what the problem is that we don't actually understand what is the actual need in these programs? Is it a refractive error need? Is it a non-vision impairing need and what sort of environment do these programs exist in? Who can do the refractions? Where can they go to get their spectacles? What are the referral pathways etc? So we've developed the first prototype for this and it was recently tested in South Africa and you can see the results of those here. We're too small for you to read out but what this gives us an understanding of is that when we did the first implementation of the program these are the sort of results we found that 70% of children passed the screening and left the survey. 19% of children who were referred either needed a refraction or had another condition which could be dealt with on the spot and so there was very few of those who actually needed to go on to get specialist treatment. Zero is being developed in collaboration with a global advisory group and at first we met like this for a while and now just last month we were able to meet in person where we had the first face-to-face advisory group and we went through the results of the first prototype and agreed on what it is that we need to trial for the second prototype which we'll be doing now in May, again back in South Africa. Thanks Priya. So similar to the work we've been doing in school eye health we've also been working in community eye health and as part of Dr Harry Rono's PhD he also looked at could he connect community health workers using peak at the household level to the primary system and then to the hospital and the key findings from the study were that at the baseline the majority of people coming to the hospital had a condition in orange which is primary eye care needs so 61% of people had a condition that didn't need to be managed in the hospital and only 8% were coming with cataract refraction and glaucoma and when we embedded this system more than three times the number of people accessed care but the hospital saw no more people just different people and this was a really good demonstration of changing the system to bring care closer to people that needed it but better utilization of specialist services of the hospital and the way we do this is through what we call peak solutions so peak solutions is made up broadly of two components we have peak capture which is the software application that sits in health centers or in the hands of healthcare workers that captures the journey of the patient and then peak admin which allows you to see what's going on in that program in real time peak admin also allows you to set up the journey of the patient or patients and based on that health system and how things work in that context so that it can be adapted as the program evolves and learns what that might look like in practice is community health worker or a teacher screening in a home or a school and if they're identified with a vision impairment then automatically refer to one of the predetermined locations based on their condition but critically the program manager can look across the whole data as it's happening to really focus on who's being left behind it's that data that used to be a footnote in terms of did not attend you'll find there's often 80% of people screened and so when you consult see who is it that's not attending the program can actually be designed with equity in mind into how come change the program for their benefit and what we've found now consistently across our programs and you know with special thanks to cbm christine blind mission who've been our anchor NGO partner since we spun out as a social enterprise is this change in the way that programs work in that if you take orange again here's those with a primary eye condition and red as those with a more serious complex condition what was happening is very few people getting any eye care at the primary level and the hospital was full everyone had too many patients but most of the people in the hospital had a condition that didn't need to come to the hospital and then when the system was connected and integrated the composition changed many more people are getting eye care but the people with more serious condition to be managing the hospital and the data that came from the trial work in in kenya plus many other papers program reports advocacy media led to this being adopted into kenya's national health strategy and with cbm and there's been the launch of this new vision impact project which president ruru kenyatta was due to launch yesterday it's now just happening next month where it's really a strategic partnership with the government to embed eye care in in this way across across the country we're really proud to be a partner in that we also if any of you were at the iapb meeting last year we'll have heard so last month president mesisi of boswana himself a former teacher talking about how he's now going to use pink within their ministry of health and ministry of education to screenetry every single school child in the country and and he's now come forward to say he's going to be an ambassador for school eye health globally and so we're really excited by the role technology is playing in terms of raising the understanding but also raising the awareness in terms of this is a global issue and i'm just going to touch on one case study and which has been in pakistan where uh the the the i think it's like no program anywhere else we've been pulled rather than try to push with we're constantly trying to keep up with the work that they're doing and one of the transitions has been this kind of manual vision testing manual data collection into automated vision testing automated data collection and learning in the program and the system there is now connected from end to end from from the schools and household level to primary second and tertiary centers and and what that looks like in practice is that programs are able to learn and improve constantly so in one of the early programs this data showed that the health centers within a certain proximity to the referral site were getting many patients turning up to the line to look at here's the red line so 95 percent of people who were found and referred made it but if you look at all the facilities that are red one in five people referred made it and the key data point here was whether you have to walk or whether you have to take transport and so learning from that program the the program leaders there adapted the program evolved how it works to completely transition us and you can see the locations furthest away no longer were being discriminated in terms of their opportunity to to get care today that program in Pakistan has over 130 connected health facilities they're currently on boarding over 1500 schools and very excitingly last month started training 1500 loading health workers who will go household to household and what we've seen so far in that program is consistent to what we've been seeing in the trials a huge increase in the proportion of people accessing care but a complete change in the composition of those turning up at the hospital so specialists are spending more time doing specialist activity and and if time allows i'm going to give you a little view to the future well started a an exciting welcome trust an NIHR funded collaboration award which is between the center here and partners in Kenya box one and the pool and and we're trying to learn from technology industry where the mantra has always been fail fast to learn faster what is it that they're doing in industry to sell products and sell marketing how can we bring that into the public health arena where we actually have a different mindset of do no harm and therefore have to be very careful and slow and so what we're looking at doing is three things better understanding who is being left behind co-creating with them solutions and then doing randomized uncontrolled trials so what this looks like is getting more data on the groups being left behind so capturing more than we currently have in terms of things like gender and their their socio demographic status so we're starting to get a better understanding of the specific subgroups who are less likely in any given context to make it to care and we're trying different ways of collecting that data in a way that keeps the program streamlined and pulling that data together to to help us understand who are the groups who are most being left behind in any given program and then working with those groups to co-create potential solutions to to that so bringing together focus groups using different ways to connect with them to understand how would they propose that these barriers are overcome and then because we expect many proposed solutions to be created we're looking at doing randomized uncontrolled trials so this is what the tech industry have been doing for years to sell you flights and sell you any anything that you buy online but starting doing things like A-B testing so within for example a school program you might hypothesize that text messages are better than voice messages but rather than having to run a large randomized controlled trial certain people will automatically be given one of the decided interventions and we can start to test that very rapidly in real time to see which of those start to have a meaningful effect and pulling that together gives us this new constant learning of understanding those who are being left behind co-creating solutions with them and then testing them rapidly and we were very fortunate to be together Matthew and I and our and our colleagues in Kenya recently to to build on this work and so as as the programs go deeper and become more equitable they're also scaling into many different countries and and some I think some of the most exciting part of that is I think part of what the DNA of this centre has been around how do we learn and share our experiences and this was pre-pandemic we were able to bring together many partners to discuss and share learnings and and I think my highlight of that meeting was hearing the team in Pakistan speaking to teamings in Barbway about how they overcome an issue that the teams in Barbway were facing and and they were able to apply that into our program and and this these are the I suppose the ultimate reason why we all do the work that we do and for this lady Kyase Halemi who's a farmer in Zimbabwe receiving a pair of glasses for the first time and just you know I think that looks as it all and that's ultimately why we're we're here and I feel really privileged to be a part of International Centre for Health thank you Andrew thank you very much um we've come to our halfway point and we're going to have a short break now ideally we'd start again at about four that's 20 minutes so if we say about five past four um if you'd like to head up the stairs and then down the main stairs all the way to the basement um and you'll be directed to uh where we where we got some tea and coffee set up um and we'll we will start at five past with the links program and something on retinoblastoma I believe great thank you very much for coming back so punctually I'm moving to our second half now and we're going to start with hearing from uh Marcia and Richard about Vision 2020 links program and the retinoblastoma network so over to you guys right arrow there and just stand and everyone um it's such a pleasure to be able to give you a little bit of information and update on the Vision 2020 links program and the Vision 2020 links program started it's a partnership program which started in 2004 and it was really um developing a formal approach to establishing and maintaining long-term whole team partnerships between institutions in Africa and institutions and i departments in the UK and this program has grown over these years since 2004 and um we are now in in 18 countries and more than 30 partnerships so one of the important things of the success in a partnership is recognizing and identifying what the priority needs are in the overseas or in the partner institution wherever that is um we began in Africa um but the aim was really to enhance the quantity and quality of i health services in the partner institutions um it soon became apparent that the learning was not just in the overseas partner institutions it had actually become apparent that the learning was more than mutual and the gains within the NHS were reported time after time after time so our funding for the program um over these the partnerships over this years has come through um UK government via that we had a lot of funding through there and through the Scottish Government as well as long-term core funders cbm site savers and we've continued to find to look for core funders and this program as i mentioned this program is now in 18 countries and in and we have it has grown organically and it has grown into areas of specialist needs which have been prioritized by these participating links we have established three networks so far which are formalized and that's the diabetic retinopathy network known as the dr net the retinoblastoma network known as the rb net and the more recent the glaucoma net now these networks will be described in more detail by some of our technical leads in further presentation so i won't go into details about this but we will begin with the rb net as one of the introductions to the networks these networks were formed because of a requested need for shared learning shared learning from others who were involved in similar situations and from those partners who had services that were more developed so an opportunity to learn from one another we received funding from the Queen Elizabeth Diamond Jubilee Trust which provided an opportunity to meet together to work on tools and protocols and to develop these and to help develop the capacity building activities across the partners even during this difficult time of the pandemic these networks were able to continue online and um Richard Bowman is going to talk to us about the rb net and our colleague DD and DD Fabian um who isn't here to join us today but Richard and DD are working with us in the rb net Richard thanks very much so it's not often as eye specialist we have a chance to save the lives of our patients but when cancer affects the eye that can happen and retinoblastoma is a cancer that affects children's eyes and we now have this global network that is aimed at helping each other to do just that to save the lives of children in addition to preserving their eyes and vision where possible and this network now involves 24 countries in four continents but it started with these bilateral links programs in East Africa, India and the UK and has built up from there it's based on knowledge sharing and development of partnerships and even in the UK if we're managing a problem like retinoblastoma we need a multi a multitude of different professionals eye surgeons can't save the lives of these children by themselves and uh so when we launched this network in Hyderabad five years ago it was great to see not only representatives from many different countries but also from many of these different professions right from the beginning and the aim right from the beginning was to improve outcomes for children to save lives and so the emphasis was on practice practice we had an issue of the journal devoted to highlighting the problems of retinoblastoma and how to manage it we developed a practical management toolkit or manual even we started right at that initial meeting it's been updated by leading experts from around the world, Ashwin Reddy's help is here today but also by doctors practicing in low and middle income countries who know the constraints there and give a realistic protocol about what can be done there was so much enthusiasm and traction that we thought this also represents a chance to actually find out what's going on in retinoblastoma around the world. Victor said shall I remove the slide that doesn't have anything on it but this is this is what was known about global rb before the rb net happens he says modestly and uh I had to have one graphic in after Andrew's performance so during 2017 we recruited as many of the new cases of retinoblastoma from around the world as possible thanks to herculean effort from from doctors and professionals in all those centres that you can see there and from Diddy Fabian who Marcia mentioned who's based in Tel Aviv but also here at school we collected half over half the world's cases from that year which is an amazing research resource a big cohort of patients and we started analysing it straight away we found that sure enough in low and middle income countries children present later with a bigger lag time and because of that the tumour is more likely to have spread outside the eye by the time they come for treatment and that means they're going to have a much less chance of surviving and in fact we have just collected the three-year outcome data from that cohort and sure enough if you live here you're virtually guaranteed to survive but if you're in a low income country it's 50 50 so there's a big disparity and this is the first time we've really shown those figures that the glaring inequality and the reason for it two real reasons awareness and accessibility that's why they present late and we looked at a couple of particular issues so gender we know that retinoblastoma affects boys and girls equally but there were more boys in our our sample so some girls are left to die without ever seeing medical treatment and looking at the geography of that that seemed to be more of an issue in Asia and India so that gives us a challenge to work on and another issue we found was five percent of this cohort actually had to travel across national boundaries to get treatment they didn't have the the facilities they needed in their own country in some cases across continent so those are just two examples of some of the research that's come out of it but there were biological findings as well with such a big cohort we found that okay children present in Africa with more advanced disease we think that's because there's a big delay in them presenting and they present older but actually even if you allow for that older age they still present with more advanced disease so there may be a biological difference in the way the tumours behaving there maybe there's an infective co-factor or a genetic difference so that gives us a new hypothesis to work on and take research forward so we've probably published ten or so papers from that cohort but we're not losing our original vision of improving outcomes for individual children and this is a relatively recent development the national multidisciplinary team meetings on zoom which happen most months they already involve at least 14 countries from around the world again leading experts in retinoblastoma and doctors trying to manage children in difficult situations not knowing quite what to do having discussions about individual cases and that's that's really taken off well as a website that makes starter then it's got 450 people on it already and just to finish with thinking about those two arms of the network the research and the capacity development improving outcomes for individual children we're thinking about the future and could we take that amazing data repository of 4 000 patients from one year could we create a live data repository we've got partners in Tanzania who are developing programs electronic patient records and something called clever chemo which where basically you enter the patient's clinical details how they're presenting and the program will tell you how to manage them what what chemo to give and what those to give it and there's quite a lot of errors even fatal errors in giving chemo around the world for this thing so if we had a combination of a live data repository where doctors from low income and middle income countries can enter their cases to update in the database but they also get automated advice on how to best manage the patients that that would be a great thing so if anyone wants to fund that project please see me afterwards that's the home team and thank you very much to every one of them for their efforts great Marcia and Richard thank you so much amazing more than half the kids presented in the year globally i'm going to invite cova and gv up now and they're going to tell us a sort of a similar sort of story about a diabetic retinopathy network work okay let's just go on that that's right yeah thank you Matthew and we started this project which i'm going to describe in 2014 i still had some black hair that time in 2019 work time we finished the project everything was great thanks to andrew and if i spend an extra minute jackie and victor will see that i don't have any hair so let me just get into the presentation straight so this was a project funded by the queen Elizabeth diamond jubilee trust and we followed the entire planning cycle in developing this particular project we had a situation analysis conducted in the most populated metropolitan cities of india use those findings to develop a plan went to the stakeholders including the government of india and the national program to look at getting a buy-in for integrating diabetic retinopathy services in the public health system at least as a pilot project initially and this was unanimously decided in this stakeholder engagement that we need to move away from an eye clinic when we're looking at increasing the number of people screened for diabetic retinopathy and get into adaptive physicians or what we have in india the non-communicable disease clinics and that was the paradigm shift which was unanimously decided upon and we looked at bringing about linkages at four different levels getting people to talk to each other the physicians and the ophthalmologists the government and the NGO sector get them to talk to each other about how to implement the blindness and the non-communicable disease program getting them together and finally building a referral network which is robust and functional between the primary and secondary levels of care a range of approaches were used it could be a static facility or a mobile facility reporting on the spot or remote reporting a comprehensive screening for all complications of diabetes or a standalone diabetic retinopathy screen we looked at four major domains in rolling out this project the advocacy to create an enabling environment so that the policies could be implemented the strengthening of the health systems which was the meat of the project trying to look at the government public health system and how we could strengthen that to deliver these services empowering communities and families so that they could tackle diabetic retinopathy and the diabetes in a better manner and within that we also embedded research both operational as well as hospital-based implementation research we looked at 10 pilot districts the yellow are the states where we went in the entire state is not covered one district in each of these states five million populations the entire project was based at the non-communicable disease centers and looking at capacity building and infrastructure support we looked at those people who were registered people with diabetes were registered with the government health system and they were provided the facility of getting their fund is examined and referral to a secondary center wherever required during a two and a half year period of implementation able to sensitize more than 6000 health workers nearly 600 physicians being trained more than 225 i professionals being trained for screening 40 of the mollages trained for treating 10 district hospitals have their infrastructure support and 60 the primary health facilities being provided the infrastructure over a period of that two two and a half years more than 66000 people were screened and six percent were treated as part of the project some of the outputs we had hospital-based studies we had operational research studies 22 publications during their entire project period developed technical guidelines with operational as well as technical guidelines at the national level a website dedicated outputs in relation to IAC material and manuals to improve practice we had facilities like I said both at the primary level where we had where we had the funder screening screening we had vision testing and at the base hospital facilities including OCT laser and treatment for medical treatment facilities were provided last slide scaling up and sustainability what we were interested in is that this should lead to further enhancement of diabetic retinopathy screen services in the public health system what we find is that many international ion users are now supporting the diabetic retinopathy initiative in India we've been able to see that in five states of those 10 the program has been scaled up to other districts and in one state the entire state and equipment skills and skills are available in more than 100 facilities the trajectory would have been even sharper but for covid people are getting back now on making up for the lost time thank you co next to you so another of the areas of work diabetic retinopathy at ICH is very diabetic with this network starting in 2014 as part of the community eye health consortium which was another grant from the Queen Elizabeth Diamond and Diamond Jubilee Trust and it brings together now 36 diabetic retinopathy screening and treatment programs from 17 low and middle income countries mostly in South Saharan Africa but also Pacific Caribbean and India these are all centers that are working to prevent visual impairment through diabetic retinopathy through establishing sometimes from scratch or scaling up the implementation of screening and and treatment programs for dr as Marcia mentioned this network also started underpinned by the links program so after a few years of links partnerships having catrax or glaucoma as priorities it became clear that many of them particularly in Africa started asking for help to establish diabetic retinopathy programs and is bringing those links together that started the network the objectives of the DR network to coordinate and facilitate building national frameworks and also guidelines at national level for DR services also to promote the integration of DR services and treatment services in general health systems diabetic services mainly and also to assist with technology and with infrastructure challenges that the programs were facing and finally to help with clinical skills and knowledge has changed where needed depending on the level that each program was at the original target was very clear it was to treat one more patient per week over the time that the first five years of the program that was greatly exceeded and in from baseline the program increased the number of screened patients by 88 percent and the number of treated by 47 percent across all the internet members just to give an example of what's happening particularly now since the pandemic we have regular workshops every year and in one of the servers that we run with all members the big challenge in the pandemic was that the graders were losing their skills so a lot of people were taught to grade as part of the programs to screen during the first five years and they didn't have enough exposure to patients so as a DR network created a virtual DR grading training and quality assurance which has two components one is in partnership with the University of Gloucester there's a system called the ITADS where the graders can get 20 images every month that they grade and get feedback on and then we have just like the MDTs that they do for RV we have quarterly grading ground rounds where we meet live not face-to-face but online and we have live images that we comment on and they help with quality assurance some of these programs are becoming now part of the former quality assurance of the programs at the government level particularly in the Caribbean and that's really it from the DR net just a quick comment about DR research there's a keen team on DR research at ICH we have from the DR network we're about to publish a compendium of papers from african DR programs which will come out in in I as a supplement soon we also conduct evidence reviews to the root diabetic adenopathy in collaboration with the Fred Hollis Foundation and we're working on on real-world application of AI in independent evaluation of AI in real-world programs with some of the DR net partners in the last few years we've had PhD students there we are Mewangu and alumnus works both on she did a lot of work on DR guidelines which resulted in the national DR guidelines in Kenya and analyze the process for the diabetic guidelines at national level and she also tested the strategies peer supported interventions to to increase the access of people with diabetes to eye examination that was through a clinical trial and currently Charles Cleland is also about to start a clinical trial in Tanzania for the implementation of artificial intelligence to improve patient outcomes and that's it I think. Thank you very much that was fantastic can I invite Fatima and Haike who are going to share with us something of the the glaucoma work that they're leading on here at the moment. Hello everyone it's it's really lovely to be here I think LSHTM ICH is such a wonderful place to work and I'm very grateful for that it's actually such a blessing working with people like Matthew, Claire, Alan it's also that story when I met Alan and very encouraged by Hannah Fow who has been a lovely wonderful mentor so I'm very grateful to be here and it's a great team and when I did my MSc that was 20 years ago so I've been part of this journey for about half the time of what we're celebrating today and Hannah Cooper there was my tutor I came to her saying I want to do surgery because I came from a very clinical background and she was like oh so right now it's like the public health aspect of it has actually helped me in what I do and one of the things that came up at the time was the Nigeria survey which I participated in and we developed data we got we found data that was very telling of the glaucoma that was out there and it was one of the most serious things that we did sitting in our clinics we knew that they came in very severe over 50 percent of the patients with glaucoma that we saw were already blind more than that blind in one eye and it was necessary to go out there and find out what was happening and that was what we found out during the survey and some of the research that we have done has actually shown that glaucoma is a blinding eye disease in Africa and probably not so in other parts of the world and that's also informed a lot of the investigative or treatment research that has been done one is the Kilimanjaro glaucoma intervention study which is done by Haku who will tell us a little bit more about it in a minute and the other one is the bolchi laser feasibility study by Abdul who is doing it in bolchi Nigeria other findings also told us more about glaucoma in Africa some of them were qualitative studies and really sad really difficult to read because one said so let me find my way whatever it will cost me rather than leaving myself in darkness um this looked at experiences of patients with glaucoma and it was really hard to take information from such people and then we also noticed that we actually confirmed that glaucoma was the silent thief of sight because it creeps on the patients without really knowing because they're not able to understand the symptoms at the earlier start so what was the journey like in 2010 we had the first Africa glaucoma summit in Akra Ghana and here it was to strengthen and incorporate glaucoma management training and education in existing programs of the world glaucoma association in 2012 it was a reinforcement at the Kampala resolution on glaucoma and then in 2012 the Queen Elizabeth Diamond Jubilee Trust Fund which was run by the common eye health consortium was almost like an exponential growth because it trained sub specialists in glaucoma who went back home to to to practice to give the adequate optimum practice for glaucoma but there were other things that needed to be done and so we formed the glaucoma clinical and research network I will tell you a little bit about that the issue was we needed to give affordable and effective treatment for glaucoma and we also noticed that we had to monitor individuals for progression and how they treat how they use their treatment the whole aim is to preserve sight and people with glaucoma and we had eight main activities the first one is the best practice toolkit which was developed by Africans we had a group of consortium of different glaucoma experts and ophthalmologists from different parts of Africa who sat down together and formed the two and another one is the training which is the highlight of the links program it's yet to start physically due to COVID but we've had training with the Morfields Eye Hospital with the Lagos University teaching hospital and University of Calaba and a number of places in Africa and there are Tanzania Uganda places we want to train now we also have the glaucoma disk which is the decision intervention support cluster and we've had meetings online for that so far we've had over about 14 countries joining us on that disk and there are other things that like the research the training which is going going to happen with the glaucoma network and the glaucoma network is now the baby of the Vision 2020 links program which is run by Maizia we just heard about the diabetic retinopathy the retinoblastoma and then now it's the glaucoma links program and these are the academically I don't have the fancy photos but Dan Kiage is from Kenya Winnie Nolan is at Morfields Eye Hospital and also here at the London School Heiko is from Germany who will be speaking in a moment and Abdul Mohammed Abdul is from Nigeria he's doing the laser feasibility study at Bauchi just a clinical reminder of how severe we see this is a 23 year old man and his IOP presentation was 40 in one eye and 50 this is skyrocket intraocular pressure and severe cups disc ratios which means he was severely affected and at 23 this was really something that we have to think about and tackle so what's the outlook today how to best provide equitable affordable high quality glaucoma care for the next 10 years is what we're looking at yes we do want to use some of our competencies that we already exist and we need to define what equitable glaucoma care is and we need to check how much of glaucoma service treatment or coverage is available and we have to think globally but with a focus in Africa where the need is most yeah so I'll hand over to Heiko who will tell us a little bit about some treatment working has been doing thank you Fatima so I want to start with Dara Musi he's a patient with glaucoma and he allowed us to tell his story and it actually stands for many many glaucoma patients and key challenges for him was he didn't know where to go he realized he has an eye problem he was a businessman trading fish and he moved already from being a fisherman to being a businessman only in trade he also was a father and of three children and husband and finally he came to us but needed more than a day of travel his mother had glaucoma but nobody helped him to connect the dots that he also was at a higher risk to develop the same disease and what to do at what time so long distance limited awareness and then as Fatima has alluded to already once many patients come to be seen that disease is already very advanced so we cannot turn back the wheel but what we can do at least is try to prevent it from getting worse and what we then the main thing we do is that the reduced pressure and there are three ways in general to reduce pressure eye drops and the challenge with eye drops is they have side effects it's a nuisance to take eye drops and there are also costs to them especially in longer term cost add up and often they are not available or only very few options are available they also have surgery which is a very potent and strong way to reduce eye drop but doing surgery has a long learning curve they are not enough surgeons well trained and also sometimes patients are hesitant to accept surgery or sometimes even clinicians are hesitant to offer it because they know they will not improve vision and it can be a challenge so then there is a difference and this is where the story continues with the link and I had the privilege to be part of the link between in case you see where I work at that time in northern Tanzania and Birmingham here where I actually was this morning and with Professor P. Char long time ago also some changes here and we we thought about this idea of a laser as well and there's one laser in particular called selective laser trapeculoplasty it's a five minute procedure you can do it as an outpatient procedure patients can go home afterwards it's being taught relatively quickly and easily it basically cleans a sponge type structure in the eye which trains the fluid out of the eye we don't exactly know what it does but there's probably something it does but nobody has looked into it formally in an African country yet we had some promising pilot data from different colleagues but nobody looked at it so by that time working at KSMC I worked together with Matthew also we also were next door neighbors so we continued these ideas this was one iteration of them I'm very impressed by this forearm trial actually our funders refused to and forearm so we decided for two we compared the laser as I said with the Timolole itops which is a standard treatment we also had some guidance and oversight from a group of patients led by professor of line on the left side and also I'm very grateful for Stingy Chul's help on the data and safety monitoring board so what were the results of the comparison this couple my aircraft shows with every step eyes which did not have a low enough pressure and they left the trial over time and the gray line stands for the chops and you can see many eyes had to leave the trial earlier than the blue line which is the SLT so that that was a very impressive difference for the laser these are the one-year data we also looked at acceptance of treatment safety quality of life and visual acuity preservation of visual acuity and cost I don't want to into more details if you follow the coup art board you will end up at the publication hopefully so coming back to our patient what does it matter in real life so we treated him also with the laser and at least for three years we were able to keep a small island of vision this light area in the center of these parks but usually most of us will have a completely white visual field so this is one example where we want to move forward so this is I know who is continuing now our work at KCMC which is also part of the link or the network and yeah we just need to deliver it earlier and hopefully better interventions thank you very much great thank you very much Fasma here about all the work that's going on at KCMC can I invite Dacia to join me um Dacia is going to speak about opening up my health which she leads here thank you for this opportunity and it's a real pleasure to see so many old friends here and I'm thrilled to to see that we also have a lot of people online as well really you you would have guessed by now that responding to public health knowledge needs is huge and unlike many other of Thalmik clinical training programs what ICH does is really about how do we find out what's happening in the population level and that really needs a whole different set of knowledge and skill sets that are required and so much of our educational work is towards how do we equip clinicians educators researchers and leadership to think in a public health way um so delivering education isn't as simple as as we'd like it to be it's not as accessible as we'd like it to be we know that there's a cost attached to coming to ICH here in the in the UK and of course we want to maintain the same quality experience right across any location that might be delivering this kind of education so the questions that ICH has been asking for many years and I wouldn't say it was just this last period but over the years I'm going to give a shout out to Sue Stevens there who has tried to set up resource centers to provide access to knowledge. Allen ran many many overseas workshops to get the knowledge out there we also had a lot of preloaded CDs that were distributed at almost every conference that we went to and of course we tried to set up regional training so with with with that as a backdrop we know that we were trying to address this this educational iron triangle what happened in 2014 and subsequently was that we decided to use technology towards addressing some of these needs knowledge needs that are out there and using a core team and I could give a shout out to Astrid Yalena and Rom who are part of the core team that work here in education we started to work internally within ICH and LSHDM so we collaborated with over 40 internal collaborators but more importantly we had collaborations externally from over 80 plus different people around the world and these were subject matter experts, alumni, other educators, facilitators but also platform providers and also ICH alumni more central to everything that's happened. I have to thank the Queen Elizabeth to Jubilee trust and I look at Andrew for that and say they were the catalyst to get our content out there so with that as a backdrop what we've done over the times is that we've changed the practice we've gone to a collaborative model of developing and delivering the content we've put in place a robust pedagogy so that it all brings the different threads together we've worked with platforms and those are platforms outside of our ICH and LSHDM and that's platforms like FutureLearn we've looked at always delivering high quality at a minimum or free cost level and that has been a major priority for us. In the process of the last five years of development we've created more than 600 plus learning resources and these are open access resources under a Creative Commons license that means that you can use them you can download them and reuse them and even adapt them that means you don't have to be reliant on what are the copyright issues that are around learning resources. We have created eight online courses they now are available on demand and they are CPD accredited. Over this period we've had over 36 000 plus participants from 180 countries and what's interesting is that all to 51.5 percent were women who were participating in online learning 46.5 percent of the people who participated were in full-time employment showing us that lifelong learning is an important part of what we do next and we must deliver on that. We've evaluated it and I apologize it looks quite small there for lack of time but we've evaluated how and what have participants done on these courses and it's been from just simply understanding the subject to delivering to a transformational level at a local location and just going back those are that's the list of courses that we've we've already got and active and glaucoma is on its way so we've really tried to use technology to shift that model of dependency that we had that people had to come to a training centre and try to work across networks and beyond that one dependency that we've had. I want to very quickly walk you through what would an open online course be and I'm using the example of course that we've delivered on retinopathy of prematurity it's a four-week course it begins with the participant understanding what is ROP what is prematurity and how big is that problem so what is the epidemiology behind it and then trying to understand how big is that problem at a local level. In the second week we've worked very closely with neonatologists and neonatal nurses to understand what needs to be done to prevent ROP from even developing so what is the quality of care that needs to be put in place what needs to be done within the neonatal intensive care units should ROP develop how do we detect it that's what we look at very closely in week three how do you detect it quickly and manage it correctly how do you involve the parents what do you do to counsel them should the treatment not go as it needs to and the final week is long-term management ROP wants to establish is not going to go away and so the child will need long-term management the parents will need support so what this shows is that our course is very unusual it looks at the whole journey and the whole program that needs to be put in place in order to deliver ROP care and this is how we've tailored our courses so that they're practical and applicable at different levels so we've tried to address the quality access and cost as much as we can so going forward what we want to do is that quality anything that we put online there is an expectation that it will always remain updated so there is the element of sustaining that quality the ROP course which launched only two years ago has already been updated twice the Tacoma one has been updated four times so the quality and the sustainability has to be part of the planning that we do access the demand that we now have is not simply access but it's providing that additional flexibility for learning and personalization for the needs of the learner and of course beyond just the cost of attending our audience are demanding an accreditation for what they've learned value for what they've they put together and we want to work closely with regional partners because this belongs to all of us so this is our future plan what we want to do in the immediate future is to start by taking what we've already created and put together stackable flexible accredited postgraduate programs that will allow a wider audience to get engaged with the learning particularly understanding about what is research how do you get involved in doing research and also using evidence in practice and then building on that towards diseases and hopefully shoot their career pathways allow for it come and finish it off with an MSc degree so this is our vision for the next few years and building this as yet another element of what ICH wants to do so really what we feel very strongly about the pathways for education is that we no longer want to sit with it within one core but it's now become a catalyst for doing things in different ways around the world so thank you for listening great thank you very much Daksha I'm going to invite Stephen Gertue he's going to come to talk to us about some of the work he did for his PhD but also around research capacity strengthening in general thank you Stephen thank you Matthew um I'm going to tell you the story of a trial I did as an illustration of what research capacity development can achieve I will not start again by saying that I once met Arlen because you know what happens to everybody who meets Arlen I'll tell you about a disease you don't often read about in your books you don't hear about it in prevention of blindness meetings because it doesn't cause blindness you may lose vision in one eye what was done that is that it kills these patients in the end and I was very happy to get a grant to do some work in this field because that's a rare opportunity indeed so this is just different levels of disease that we see and unfortunately whenever I opened my books they said that it was a rare disease of elderly men and that's not what I was seeing I've seen it in young people women in their 30s and 40s and when I tried to look up any information about it it was a problem because there was no trial evidence at all today what we were doing I did a Cochrane review and found no trial not one we were treating a very serious disease in the whole world using the evidence from case series and case reports there is also a very high incidence of this disease despite availability of ART it has a lot to do with HIV in fact it really came on the scene in our region of the world once the HIV pandemic hit and remember this is not about the story today is not about this too much it's about the networks that helped to build research capacity and I first got aware of this because of a Ugandan called Athenia Gabba who used to present work about this at our conferences and that really got me interested and people like Keith Waddell who some of you may know and so we sought to do a trial when you got money to do this and this was part of my PhD work and Matthew was my supervisor I'll keep name dropping every once in a while so that you can see how research capacity is built and hopefully also if I name drop a famous person then you'll pay attention so the question was if we used five a few drops after surgical excision which is what we do with most of these tumors would we reduce the recurrence and our objectives was mainly to compare the recurrence rate at one year and then secondly come secondarily to look at the mean time to recurrence how long does it take before the tumor occurs and what were the co-factors of recurrence and as with every trial is good to describe the adverse effects so we worked in four different centers and I'm showing you this again to show you just the power of networks the most northern site that you see there is Kitale Hospital which is where Hilary Rono was working and so he was one of the partners who helped me conduct this study and I was in surprise later on when he came on and did his master's and did his PhD so we ended up enrolling the 47 participants in each arm in the interest of time let's just move on to where the results are so what happened at one year in the five a few group after surgical excision used five a few for a month we only had five out of 47 recurrences it was 11 percent and the placebo group which was using artificial tears instead of the five a few drops we had 17 or 36 percent recurrence which gives a crude drugs ratio of 0.21 and they adjusted ratio after we took care of imbalances in people using air teas and cigarettes smoking but simple result we managed to reduce the relative risk by about 71 percent which was quite an achievement and the other big achievement of this trial actually was that it was a first trial of its kind in the world remember I told you when we did a Cochrane review we found no trials at all that was a couple of Maya survival estimates which showed that is people who are on the five a few arm were doing a lot better than the placebo group the main cofactor of recurrence was people who had a larger tumor were more likely to have a recurrence and we concluded that four weeks treatment with these eye drops was very effective in reducing the recurrence it's actually very safe and well tolerated and it's readily available because we have to reconstitute it ourselves and use it for other things in ophthalmology besides treatment of this tumor and below that was a real patient before and one year after treatment we published that in the Lancet Global Health and you've seen the papers downstairs but again I want you to see the names there some are not famous apart from the last one I suppose but others are people in this school Helen Weiss was were you know supported as a lot of statistics and I have a host of other people there who have worked with me in different things in the different centers and some of them are actually interested in research because of having been involved in this project so those were the many people who supported our work in the different institutions bcpb funded this work and it's hard to see that they're not there anymore but the meat of the story how do you build research capacity if we had done this maybe 10 years ago you might have only had David Meyer the professor in South Africa on that picture out of all those people those who love to count can count two-thirds of those people are alumni of this school and that's an achievement so how do you build capacity because that's the thing we need to do and again I'm hoping that in another year or two we'll see a few more names I see some people in the audience who hopefully will put a picture of them in the West African corner there no pressure building capacity is a long-term exercise it takes a long time my first contact with research was working as a resident doing my elective term at Kikuyu hospital in Kenya with David Yoston who many of you know and the first assignment he gave me was could you enter some data we were doing on the monitoring of cataract surgery and that got published in the British general of ophthalmology and with that slowly I started getting involved in many other things met many more people but the most important statement David told me is ICH is a good place to show your face so I met Allen and dot dot dot but later on in a conference in East Africa while I was looking for a chance actually I was looking for money to do a study on a trial on OSSN I ran into Matthew and we sat together and my life changed I got a chance to do a PhD which was a huge piece of work but I was very happy because we managed to publish we got 10 publications out of that PhD project so it's been a long walk and after that I got a postdoctoral grant with his support and we were able to do so much more the other thing is really mentorship and you know in with a handshake it's not just mentorship it's friendships it's relationships shake hands across barriers different people the small little things you do for them you don't know where they're going to be you know David gave me a little assignment I don't think he knew if or I knew I was going to be doing the kind of things I'm doing now and that I've also realized that when you're doing some of the most profound things in life you don't even know you are you think you're just doing your job so just be friendly cross barriers talk to someone that you normally wouldn't talk to and just a word of encouragement goes a long way that got me going a long way I'll never forget having come here for the first time to a vision 2020 course with Alan Foster and he came from Cambridge early in the morning to meet me in the hotel where I was staying to have breakfast with me and ask me what would I like to do in my life I had only read about Alan in journals and books and that was a life-changing experience another statement which and I'll mention David may be here David may be supervised Matthew's supervisor so I don't know that you know about this David but David once told me you know you're like my great-grandson and you have good genes because I was clearly following a lineage of people who had done very well in research well like most great-grandsons I didn't do trachoma sometimes they go off and do their own thing but to our consolation I was in the neighborhood because they were working on trachoma and I was working on the barber contact table which is not very far from there and lastly which is more looking in the future it's not about individuals I've had a lot put into me but I'd like to build a team and we really need to start building up teams of people hubs of people so that when I'm in Nairobi I can have a research coordinator I can have a project coordinator I can have staff and project managers who'd help me be able to do more than what I've been able to do at the present also building up infrastructure and things like that thank you very much great thank you very very much Stephen um I'd like to invite um at this point uh yeah Simon great to uh come and talk to us about some of the corn infection work we can do thank you in the interest of in the interest of time I decided to have the acknowledge men's slide and my t-shirt just missing Matthew but Matthew thank you so much for bringing me to ICH so I'm presenting this on behalf of myself and my colleague Jeremy who had to leave but what we have been doing basically is looking after patients with corn infections and these are some of the patients that have looked after in Uganda as individuals they may not mean much and that's get through the 80 year old grandmother and Ronald a young father 25 years old get through and and Ronald from part of the 2 million people who got blind from this corn infection and over the last decade our group has been grappling with the question of how we prevent people like this from needless blindness due to this disease our work has been mostly in Uganda in the last few years and this was part of my opportunity to do a PhD at the ICH which had 12 publications Stephen Kishu who had 10 I did promise you that and but what we learned was that uh Fango Charitatis was the most common cause and the risk factors were a traditional medicine which is a common problem where I come from and trauma but also HIV and diabetes were significant contributors to the risk but what was really shocking was that majority of the patients were coming late to the hospital where too little could be done it was too late and they ended up with poor outcomes when we looked at their three months data about half of them had vision impairment a significant proportion had these hideous looking corneous cars and about 10% lost their eyes due to this infection what we really saw on discovering why these patients eventually came late we realized it was actually not their problem it was a problem of the major weaknesses in the health system so if you look at this diagram you can see the top I don't know left or right depending on why you're seated is home is where the action happens when the patients start getting the symptoms about 20% of those come straight to the eye hospital where we have the facilities and the care that they need but majority will come within eight days now eight days for kidney infections that's already late but what was shocking was that the 80% within two days had already interfaced with the health system this was either a primary health facility nearby or a dispensary and that's where everything broke down many ended up in circular movements and some came as late as 42 days to our hospital and this has been the highlight of why we need to strengthen primary eye care and this was captured in the Lancet commission report and this case study has also been taken up by the IAPBA in the IPEC training those who have done that this is the work that has informed that decision why we need to inform and strengthen primary eye care like I said majority of the patients had phyngoceratitis and so we treated them with natomycin which was the first line then the challenge was that not everyone did well with natomycin actually we just the report which we published we had a number of patients who did not do well on the natomycin alone so these are some of the patients I picked up from our series and you can see that these patients presented with conure infection we started them on natomycin but they went ahead to worsen so on review the the infiltrate sizes were increasing some had developed new infiltrates at that point we introduced cohexidine and they went on to do well at three months so what we're observing was really consistent with some of the work which had been done previously which had showed that cohexidine had a role and actually in 2015 the Cochrane review had had showed from the only two trials then that compared cohexidine and natomycin that there was a slight advantage in using cohexidine over natomycin and this is what led to our group starting to to think about a trial of cohexidine versus natomycin and the first trial the first trial was done by my colleague led by my colleague Dr. Jeremy Hoffman in Nepal where we wanted to compare as a non-inferiorated trial a cohexidine versus natomycin and we randomized patients presenting with fangoceratitis these were then randomized either to receive cohexidine 0.2 percent or natomycin 5 percent and we followed them up periodically what we wanted to see was at three months who had the best vision this was conducted in south Nepal at a hospital called Sagmatha Chondri Eye Hospital it's a very busy hospital and they see about over 100 patients with mycobiocaetitis per month and the results of this trial have just been published in ophthalmology what did we find let's do a drum roll we actually found that at three months the patients in the cohexidine arm did worse than natomycin this is not what we had hoped for as the result but putting this in context we found that this was only when you look at the vision outcome but actually the patients in the cohexidine arm actually did well they healed although they just had worse vision now the performance of cohexidine is comparable to how a vorekonosal performs and currently vorekonosal is still the second line agent after natomycin and still really widely used in many places in the US and in Europe but not to forget that natomycin is still largely unavailable in many parts of the world especially in low and middle income countries so this does not really get the role of cohexidine it still has a place especially in places where the natomycin is not largely available and following the lessons from this we're currently doing a trial mild center trial in Tanzania and Uganda and we are comparing natomycin alone versus a combination of natomycin and cohexidine what we have been learning over the last few years just to reiterate that the elephant in the room is still fangus the incidence of cone infections keeps on rising the fangocarotitis is really challenging to treat and so that's why even when we start the treatment we have to have this conversation with our patients on the expectation it is difficult it's going to take long and sometimes the results may not be great in terms of vision so if you have natomycin by all means go for it is still the first line and much superior to the others but where you don't have natomycin or where patients are failing on natomycin cohexidine is your go-to drug it sounds like a drug all right um thank you very much thank you very much Simon and can I invite um Victor and Elby you come and talk to us about the work of the community eye health journal thank you um the journal is probably 34 years old this year we've done 130 issues and it's definitely something completely unique in the world of eye health and eye care delivery and it um dovetails really well with everything else ICH is doing and really is um I was thinking of asking people to raise their hands if you've either written for the journal or reviewed an article otherwise um contributed or you're a member of the editorial committee we have a show of hands fantastic no it's wonderful really wonderful to be part of it um now the journal was started um just to flip forward aside by Mary McAvon as you saw in Alan Slides earlier today back in 1988 um followed by Victoria Francis as the second editor and then myself um but it's much more than just the three of us as editors it takes a big team um it takes everybody who showed their hands and it takes all of the we've got some people here like Lance who's been with the journal started with Victoria rounded by 2004-5 and Lance so hi Lance has been our designer for for that long and Paddy Ricard sitting next to him is the editor of the French edition and we have I don't know if Critis was able to join online but we also have a fantastic South Asia edition very capably led by Critis Shukla and with the supervision and guidance of GV Murthy over in India so we have as I mentioned already two of the editions the French edition just be spoken to Paddy it's about 2006 so so 16 years old so it's it's been going a lot and then then I I even realised actually time's gone so fast and Frankfurt and Africa a search will probably be a test issue if you speak to me afterwards tonight and Frankfurt and Africa is really an area that has a massive need for IK resources and as everywhere else in the world and learn middle income countries but Lucifer and Africa probably the most affected in most need and we did have for a very brief period one issue of a of a Portuguese language journal and but definitely Frankfurt and Africa has a great need for it. We needed a journal really and what Murray realised when he was in Afghanistan is that there's no real access for up-to-date IK information for the people who actually deliver IK eye health not the researchers but the practising of thermologists optometrists and nurses and allied health professionals who work and deliver IK and these days more and more journals are publishing open access but even then a large proportion of the research and of the information is not really applicable to learn middle income countries thanks to ICH and the team here that is rapidly changing as well but the reason for having a journal is to pull together this research and knowledge in a way that's really accessible and easy to pick up and use for very very busy clinicians and just to speak very briefly about the other editions we have in the you can see our South Asia edition off to the side and we are making rapid progress towards the Chinese edition of the journal that will have all this while hopefully launched in the beginning of 2023 and we're also speaking with IEP and working together with Partnersons Latin America about a Spanish edition and just to show that in addition to sort of review articles we commission and we also part of what makes us so unique in the journal is that we reach out to the field and we ask people to contribute case studies in their real lived experience because it's about where their theory you know where the tie hits the road so how is IK actually implemented and what can we learn from each other so I very much see the journal as playing a very facilitative role in helping people across the world to share their experience and best practice in fact you know it's not as I mentioned for the whole I team and readers have been telling us that they learned so much from one another in this way and it inspires them to think beyond the clinic and to reach beyond the clinic so a lot of we've done but a lot of surveys in fact Victoria Francis did our first survey in 2005 and in two of the surveys we've had in one in 2010 and one in 2015 we've had an optometrist in Nigeria send us this quote to say without this journal I am an utter darkness and a lot of our readers say that it's the only source of up-to-date IK information that helps them to feel less alone they're part of a community of practice which is so important and we also have a large portion of our readers who are educated in a recent journal adapt the information which like the open online courses that Dr spoke about everything we produce is open access it's free all of our images can be used for slides and we've even in our strategy meeting this week we've had people talk about students and talking to them and saying that for some of their courses they just handed a copy of the journal you know on a particular topic and exams are set based on on journal topics recently it's not that recent anymore but 2018-2019 we worked on developing the community iHealth Journal smartphone app and this app is very much designed to be useful in a low and middle income country setting and big thank you to Andrew in the peak foundation and also Tyson who funded this development really invested in it and we've got 2,500 active users we'd really like to see it grow so you can find the app on either the app store on Google Play by looking for community iHealth Journal or just CEHJ so please spread the word it allows users to bookmark articles and download things for offline use so when they go out in the field for example they can have all the ROP or child iHealth and articles that they want to have with them. Now the app came out just in time for COVID-19 so as soon as that happened I just huge accolades and thanks to the links program to Marcia and her team because the first thing you did really I think Victor was involved as well is decide to convene a meeting for all the links partnerships about how do we what does COVID-19 mean for iHealth how can we continue to implement iHealth programs in these new and difficult circumstances so convene this fantastic webinar that had I think almost 300 participants and people shared this practice and ideas and guidelines and so on and that gave us the idea to as quickly as possible produce an issue of the journal on COVID-19 and uses to some examples of articles that we that we did so how to make hand sanitizer how to make a very quick mask and so on and that really led to a new way of working for us we decided to publish the articles online soon as they were available and it also meant that we could have so many more people giving input into the journal and into the content so we had eight authors and co-authors for the editorial article for example. Now we have not in addition to the iK team members who read the journal we do have policy makers and people at Ministry of Health level and this quote for me just it just blew us away really now you know these people read the journal and we know that it has an impact but to hear that that issue helps them and plan their iK delivery during the pandemic this was incredibly satisfying so one of the benefits of the new ways of working is that our editorial committee has really expanded where before the pandemic we met in London and that means only people who were really in the UK could join us we now have all of our editorial committee meetings online and many of the people in this room are members of the committee and we're really grateful to have the input so we're also looking working with IPB to develop contacts from western Pacific area and more people from South from South America from Latin America do to join our committee and also looking at mid-level activists now to come and sit on the committee and whether that's on the editorial committee or as readers and the members of the Chinese editorial committee I think they'll be joining us from May onwards and then yeah so that's really good and they're already involved in the in producing the research issue which is coming out later this year. We had our first glaucoma webinar and actually what I needed to mention is Victor who joined us as a medical editor of the journal and because Victor and I worked really closely together with Heiko as well on that glaucoma issue and Victor realised he couldn't live without us so he joined us as the medical editor and glaucoma is also Victor's area of research so we worked on a fantastic issue in glaucoma that looked at you know wide range of topics and these are some of the authors of that issue who came and talked about their articles in the journal and we were really pleased to have 87 people join us and asking lots of questions and that really gave us an idea of how the how the journal is impacting the readers and what else readers need and so for example they there were lots of questions about glaucoma and children so we're looking at potentially having an issue on glaucoma and children and from the survey we did afterwards everybody really just were interested in having webinars about all our issues which was took us by surprise so we'll be looking at doing more of this in future and we also asked readers if they'd be interested in joining us in focus groups to help plan issues and everybody said yes which is really good so a few in terms of funding is always you know a challenge is a very challenging environment so we're looking at really consolidating how we distribute so reducing print copies where we can and that we really know that especially in francophone africa for example print copies are sorely needed and many countries as well and so while at the same time we're actively marketing the online version and the app also consolidating the print issue but our key focus is going to be on partnering with educational institutions globally because it's one thing to train somebody and then they often work but I think part of our responsibility is the continuing professional development and education of iHealth workers at all levels once they get out in the field and work and the journal is a way to keep in touch with people who've been trained and then very quickly just thank you to all our supporters you're amazing and without you we couldn't do any of this work and we're really pleased that all of our supporters that you see on here are also members of our our strategy group which meets twice a year and we get so much support encouragement and advice and feedback on what we do and ways of strengthening both our content and our reach and our sort of capacity and fundraising so we're extremely grateful for this partnership thank you so much great thank you very much Elmina that was terrific to hear about the work of the journal and so we're getting towards the end of our time together and we've just got a few minutes to kind of open the conversation up to the floor as it were and I mean there may be some folk here some alumni and others who might like to say something and we've got a microphone I think you and Victor have got microphones so if you'd like to say anything just pop your hand up in the air and they'll come and find you and I guess probably keep things fairly focused because I'm sure there might be a few people who'd like to say things over to you For those of you who are young, please come in from 5BB, I guess I was going to say congratulations on the anniversary I think we've probably had a history of publishing for as long as the, as I said you've been in the systems, I think actually at the end of the year, there's been much more about that than me but I think it's been fantastic. The way it is, we've had connections through people, it's been so fascinating that we've had some students give me that connection and I think probably most of them have been what we've told you, the likes and the good yourselves to me, it's really been, that's the connection and goals and values that we've shared that generally we've had, because we've been so incredibly influential in putting public health on the other agenda that absolutely underpins our work, that we've got our work and the work we've done, I think we've heard from Patrick, we've heard from Richard, now that the journals are signed in terms of the evidence that's been described in some of the videos that we've tried to implement with respect to people who have died there, they're not so very different and we were so influential in driving through it last year in the year and achieving the other solution. So, it's been a fantastic friendship and I hope you'll continue to thank me. Thank you. Sorry about the stuff but I can't see them. Hello everybody, I'm Catherine Cross and I was a program director for site savers for the past few years and I'd like to say that working with ICH was one of the most rewarding parts of the job. You've seen site savers in several places as being a funder but we were a lot more than that and not only I was on the, well several of us were on the committees for originally the journal and the selfless courses but we've had such wide experience in Africa with so many field staff, new candidates and therefore I think we were able to channel, help channel the right people onto the courses, help to the journal to find correspondence in various parts of the world. So, it was an extremely good experience and it's very nice to be here again. Thank you. Does anyone else want to reminisce on the time? Thank you very much, it's been a fantastic afternoon. I knew I was internationally trained from when we started to the energy finish and I just wanted to build on what Foster said by the start which is really around I feel that ICH and its master's and self-education programs really helped shift people. It's not just about knowledge, it's about empowering people, giving, yes giving them knowledge, giving them network, inspiring them and I was fortunate much to be when I finished and I was incredibly invited back to do some lectures around the work that I've done since I've finished my master's course. I remember I used to say to the students when I was talking with them I felt that the M in master's stands for maturing. It's maturing view clinically beyond the four walls of a school. It's maturing so that you actually take real ownership for a defined catchment population, a holistic multi-disease pathway process which is not something really very many clinicians do in their hospital setting unless they have to be something like a clinical director where they're kind of forced or encouraged to. And the other end for me was really maturing into managing yourself to really public health is a long-term goal. It's not a quick fit. So yesterday we were going to grab a few cataracts and makes the group some better but to actually shift the program forward is a long term so it's not been maturing into being sustainable. Not just the health service that you're working with but also the customer because I think sometimes you can get very carried away and very excited and infused but you can also get very frustrated with the case of change, particularly with the surgeon who's still swishing a knife and getting a result within 20 minutes sort of thing. So that was one of the things that I felt I just wanted to reinforce is that maturing thing with the masters in particular. Thank you. Thank you Andy. I was looking around for some maybe that I see is done so instead I should say something about the partnership relationship between the Dambia IPA program, the Medital Research Council and I see the population of Dambia will be more maturing last year. Great looking around. I don't see anyone else putting their hand up. We're almost at the end of our afternoon together here, the formal part and I'd like to say thank you very, very much to all of you both here in the room and online who've joined us. It's been a real delight to meet together again physically. Thank you very much to my colleagues who've worked really hard and done fantastic presentations and it's been a real really interesting afternoon just listening again to some of the work that you've been doing leading on and just really proud of your achievements and immensely grateful to your hard work and dedication. In a way kind of a week and a half, so sorry two and a half days so it wasn't a week and a half but like a week and a half. I think one of the last questions we asked each other is why am I part of ICH and it was very interesting to hear the responses and Hannah had a lovely long piece about it but I think a very frequent recurring thing was the sense of passion about what we're doing. We are passionate about seeking to address improving eye health worldwide and we really enjoy working together. I think we're immensely blessed to have such wonderful colleagues not just within ICH but globally. It is such a rich environment for relating and you've heard some of the stories from Stephen and Simon who I've worked with particularly closely over the years and there will be many other relationships like that in this room and beyond. And thank you again to the people who support us in many, many ways and we mentioned through the afternoon but we are very very grateful to on-game partnership and as Catherine mentioned it's not just about the financial support, it's much much deeper than that. It's about working with you in programs and seeking to come alongside and in the capacity to strengthen work that you are doing in many cases. I think we're pretty much at the end. I hope very much that those of you who can will join us down to say we've got a reception, some drinks and some nibbles to to spend a bit more time together with and around that space you'll find there are lots of boards with pictures and some publications, various things like the journal and the Lancer Commission you can pick up and take home if you'd like to encourage you to do that. So to find that it's basically up the stairs and down the stairs all the way into this one. Okay thank you very much again for joining us.