 Hello and welcome to our Google Hangout for Eliminating Tacoma MOOC and today we're joined by Professor Alan Foster who's seated right here next to me and we're waiting for Dr. Anthony Solomon to join us and from Geneva in WHO and due to some technical problems we've had a small pause in trying to get him onboard and we have Dr. Paul Emerson he is at an airport in Johannesburg and he's going to try and join in from there but to get us started I guess Alan perhaps we could start by you telling us how come you got involved in Tacoma. Thanks thanks and hello to everyone joining in. So when I was a young doctor I always had the interest to go and work in Africa and I had the opportunity to go to Tanzania and I've done some training in ophthalmology, fairly limited training but knew something about ophthalmology and when I went to Tanzania I ended up working in central Tanzania near a town called Dodoma and it was an area with severely endemic Tacoma. So really almost from the first week of being there I was faced with lots of patients coming with interned eyelashes, trichitis and entropion and so that was my first exposure to Tacoma and subsequently I got more and more interested in it over the next 10 years. Excellent. So over the last three weeks while we've been doing this MOOC we've had over 2,600 participants and from over 100 countries and many of you have sent in a range of different questions so to get us started I think I'll just highlight some of the questions that that they've started at us off to while we wait for Sol to join us. So one of the questions that came up was Tacoma is an ocular infection so why are we treating an ocular infection with a systemic antibiotic? Okay so if we kind of go back 15 years or so and look at what the treatment recommended treatment for Tacoma was at that time it was a tetracycline eye ointment and it was twice a day for six weeks and it had been shown in various trials that were conducted in the 1970s that if you gave tetracycline ointment twice a day correctly for six weeks then you did eliminate trachoma, chlamydia trachomatis agent on the eye you treated the trachoma. The difficulty was putting that actually into practice in a public health program because it meant one had to give out tubes of tetracycline to mothers and then show mothers how to treat their children and the tubes of tetracycline often in hot climates as soon as you open them all the ointment would flow out everywhere. It was messy, it was difficult, the children were small so what all that came down to was although theoretically and in a research situation ointment worked in practice compliance was poor and it was difficult to make this ointment work. What then happened I think in the early 1990s it was worked by Robin Bailey maybe in the Gambia and they conducted a trial where they compared tetracycline with one dose of azithromycin given by MERS. Now azithromycin at that time wasn't available as an ointment or as a drop hence they used the systemic formulation and the pediatric formulation to go with it and they basically showed that it was as effective as the ointment even when the ointment was given perfectly and of course in a practical point of view a one-time dose was much easier to get good compliance than six weeks of twice daily ointment so that was really the study that showed a systemic treatment as a public health program would be better than the ointment. I should point out that in the meantime drops are now available of cithromax and they are actually used for small children where you should not give the systemic treatment but in the meantime of course a donation program has become available and that's why the tablet is used. There is one other reason I mean that's that's the kind of practical reason of what happened but the other reason is is that in children who do have chlamydia trichomatous in the eye they usually have chlamydia trichomatous in the nose and the ear and in that sense it's not just an ocular infection it's elsewhere in the body as well. The systemic one has many other beneficial benefits. So something else that has been repeatedly being raised during this period is the use of systemic antibiotics of course raises the concern for antibiotic resistance and this remains a concern so have we seen something on resistance with azithromycin? Right so there's two different parts one has to understand to this first of all is we're using the azithromycin to treat chlamydia trichomatous so the question is does chlamydia trichomatous develop resistance and the answer to that is there is as far as I'm aware anyway no evidence of that and basically the macrolide group of antibiotics which is tetracycline erythromycin and azithromycin is one of those they have been used since the 1950s to treat chlamydia and as far as we know there has been no resistance so I think we're on a fairly safe ground to kind of say chlamydia develop resistance to the macrolides including zeta max however there's another side to this which is used in the treatment of other infections such as streptococcus pneumonia etc and therefore would widespread use of azithromycin in a trichoma program pneumonia and I think in that situation there is some evidence that that doesn't care I don't have all the kind of exact facts but yes other agents can develop resistance to azithrom other bacteria can develop resistance to azithromycin whether whether the public health program against trichoma is encouraging that or not we're not so sure right and we have to remember this is a single dose that we're talking about one time single dose here and in some places where you've only given the single dose you're not even going back to give another dose unless the prevalence is high so I guess this that you know we'll have to watch the evidence as it comes through yeah it's certainly been looked at ever since the donation program started which was around late 1990s so I think if if it was a problem we would have seen it by now and as I say yeah and well we're still still waiting to see if if Dr Solomon can join us but just to keep keep the momentum going um we've got certain questions here on have you ever come across the idea of of using anti-inflammatory treatment such as topical steroid drops particularly in the secretricial phase of managing early trichiosis yeah so this this has been proposed and if you think about the pathogenesis of chlamydia infection and then the immune response in the body and then moving on to fibrous scarring there would be a logic to suppress the inflammatory response from the fibrous scarring with steroids yeah a kind of logic in that sense the issue really is again we're dealing with a public health problem and one would not use steroids topical steroids in any way in a public health campaign in in the case of an individual then of course the danger is in using it in an individual with severe inflammation putting steroids in the eye you're leaving them susceptible to other infections particularly herpes simplex and therefore one would say probably the benefits of reducing the scarring are outweighed by the potential problems that you would get with steroids having said all that I remember a case which I saw myself when I was working in Tanzania which was actually an adult who came with severe bilateral panacea right so a real kind of acute an invasive of the cornea panacea which I believed was due to trachoma and was really threatening his vision in the acute stage and I treated him with topical tetracycline because that's what we had at that time I think I also gave him doxycycline the systemic thing and in a hospital situation I did put some steroids in his eye but that's anecdotal whether it helped or not I don't know and certainly I would say it's not something that is to be recommended I think it's sort of highlights the decision making that has to happen at a clinical level and what policy and guidance you need to prepare for public health and you know the logistics of the two of course the role of the clinician will always remain and like you've shown that sometimes you do need to make that decision it might be right in that scenario but in the public health we cannot give out steroids in a free way so I think that that was a point that was raised by Rosalind Schott in Alice Springs in Australia for this course so it is it seems to be still remaining as a problem to try and get both our experts from these firing light places together and just to keep us going on on the topics that we can still cover we've we've got a few questions here regarding mapping and and the use of trachoma action plans shall we go on to those questions so one of the questions that has been raised after you've finished doing the mapping exercise how soon after that do you need to develop or can you realistically develop the national plan and put that into into place and what is what is the timeline and what are the challenges of the potential to then reach that 2020 target that we want for elimination so I mean this is a very important question and it's not that there's one white answer I mean it can vary from place to place but really the mapping exercise itself should already be part of a national plan because the national plan should be saying we believe that we have a trachoma problem in this country we need a plan to address it and the first question in that plan is which are the endemic districts in the country where we need to focus the safe strategy so in that sense the first action in a national plan is the mapping process and the mapping should be done at district level and now particularly in the last four to five years there's been a huge mapping project around the world which was led by Anthony Solomon and I think most countries the maps are now available there are some worse work still needs to be done but for most countries it's now known these are the endemic districts and and these other districts are clear so once that that mapping is known once you know okay in our country there's 20 districts and 10 of them have got endemic trachoma then as soon as possible one wants to implement the safe strategy and to be honest sometimes the safe strategy has even started before the mapping process because it was just known that this is a very bad area so as soon as possible one then wants to start on the implementing the safe strategy and for that that's what's called the action plan comes in the tap which is to really look at what are we going to do about surgery what are we going to do about mda for azithromycin and what are we doing about f and e in terms of personal hygiene health education water and sanitation and that is done district by district so you may not be able to start everywhere at once you may want to prioritise the worst districts and start in those but certainly the s and the a should be going and closely quickly backed up with the f and e components with a plan of we're going to start in these three districts and from the learnings in those three districts we're then going to expand to the next seven just in terms of the longer term timeframe when it comes to mda if you have districts where the the prevalence of tf trachoma follicular trachoma in children one to nine is more than 30% you will need at least five rounds of mda whereas if it's less than 30% but more than 10 you'll need three rounds so naturally once you've done the mapping you want to start with those districts that have the higher prevalence because they are going to need the more years of the safe strategy right um it's very funny using the google hangout to say something and then not say are there any questions i'm sure there are lots of questions online um so this is an interesting question that's been raised on taps and it's a practical one um where they say taps have to be owned by national programs the challenge in many places is that this is often the stumbling block where certainly there's not enough guidance or leadership in place at that national level to get the process moving or keep it moving um so we in our course we certainly demonstrated how well it worked in kenya and because they have a strong leadership they've been able to manage that process and keep the momentum going um since many of our participants have raised this this so how does one overcome the challenges of leadership when trying to roll out a good tap so first of all leadership is critical and i think many people will say you know if you look at the good programs around the world you can often say you know that national program is good because of that person who's been a leader and developed it and so but there is another side to this which is also it it does relate to structure within the ministry of health so historically trokoma programs were usually part of national prevention of blindness programs so they came under eye care and usually eye care within a ministry of health was led by an ophthalmologist and so there would be the national prevention of blindness coordinator an ophthalmologist hopefully a committee with that person and working with the government and within the framework of the blindness program one should one could embed the trokoma control program and the tap the trokoma action plan however over the last probably five years or so there have been changes and increasingly now trokoma comes within the remit of neglected tropical diseases and very often now within ministries of health there will be a focal person for neglected tropical diseases in that country and within that the mandate will be trokoma and that then is the leadership through which to work and for example if you're an eye care worker an ophthalmologist interested in blindness prevention the country you want to then work with the NTD program to look at how trokoma is integrated within the NTD program of the country so it varies some countries are prevention of blindness and eye care leadership others are NTDs and of course like you say sometimes it falls in between and one just has to try and push as well as possible and to find that advocate within the government who will kind of say yes I'm going to take this on and make sure it happens and then work with that leadership but that's anything that have we got oh we have Dr Solomon who is online excellent thank you Anthony hello can you hear us we are doing sign language right now so we can't hear you no he's certainly saying something but we can't have we got I think we carry on and then we'll try and get solved so as we work on the audio side of it we've got visual but no audio now and so within the TAP programs one of the things that has come up is sadly when trying to set up trichiasis programs and the issues that many people don't seem to be faced with is the lack of resources and without the resources they cannot deliver the services they require so what are these challenges and how can these challenges be addressed in order to get to our elimination targets okay so obviously resources are critical I think one has to say right at the beginning that generally the safe strategy certainly S&A and add F to it as health education that is a very cost effective intervention so one's not looking at huge amounts of money there to do yes and yeah and yes if one thinks of health generally the e-component more than sanitation particularly the hardware that goes that's an expensive intervention but let's just take an F and think about what the resources are that are required and the first critical one is people so are the people trained in chakras are ophthalmic assistance available and can be trained and again that's relatively low cost to be able to do that the A obviously the drug is free of charge it's a donation but it's the distribution program yeah if the distribution program again can be part of other distribution programs like NTDs and that's lower than the cost right because one can do several treatments at the same time and within that I'm going to be doing that at the same time you can do the health promotion which is the F component so just go to that what what may look as you know significant resources in actual practice are not very expensive probably the most important things are the cost of the instrument and the trichiasis and each cost to either take the surgery to the village or to take the MDA to the villages now where is that money going to come from of course ideally from the government it should be a commitment by the government that this is part of the program I'm going I just go back to it it's not a lot of money but one needs to do it if literally the government can't afford to do it or if it's a question of getting some seed money in to get it started then often there has been external donors that have been all this be it NGOs or be it other international donors that have given money USA and the Quiddus with Diamond Jubilee Trust have all given funding for safe implementation hello Dr Solomon hi Dexter hi Alan sorry about the delay no problem I can hear you now and it sounds like you can hear me too which is great yeah that's excellent but I'm I'm going to let Alan start you off on a few questions that we've got lined up for you so it's it's almost like an exam panel that you've got sitting here and so just to let you know that we have most of we have over 2,600 participants from more than a hundred countries that are involved in the MOOC at present and once the recording goes out on YouTube there will be a transcript also provided for those who can't get the audio to download okay great thank you so Sol I'm gonna I've been quizzed for the last half an hour by Daxa I won't ask you the same questions because you made it everybody different answers sure and maybe just to start and to kind of kind of warm things up Sol how did you get involved in trachoma work well it was you Alan as you probably remember you gave us a lecture as baby well David Davis was there as well obviously but you were the first person who I can recall ever hearing anything about trachoma from as part of the ophthalmology day on the diploma in tropical medicine and hygiene course in 1999 I think it's fair to say that changed my life in all sorts of useful ways so what was your what was your first kind of field work with trachoma I was lucky enough to get involved in a project in northern Ghana in which we worked with the Ghana Health Service to take a group of Guinea worm volunteers to see if we can work with them to diagnose and treat trachoma with zithromycin and that was in 99 that was just at the stage that Pfizer was warming up towards starting a donation program they started the program to donate the drug to trachoma elimination programs in that year and several people including yourself were looking for sensible ways to make the distribution possible and the opportunity of having a program that was functioning well in the Guinea worm program and that was functioning so well that it was starting to run out of cases was a really good idea and as you probably remember that was a successful trial that we did in Ghana and has led in part to Ghana's success in eliminating trachoma which they seem to be very close to you now yeah so can you briefly just tell the people who are joining what your job and role is today sure as of the last two years I'm responsible for the global trachoma program at the World Health Organization in Geneva so I'm based here with trying to provide support to trachoma different countries and their partners around the world okay thanks so so we've just been talking a little bit about national programs and trachoma action plans and kind of how some countries do that very well and other countries struggle and I was giving a little bit the background that historically often trachoma control came under prevention of blindness but more recently it tended to come under neglected tropical diseases could you could you tell us a little bit now from the side of WHO but also working with member states with countries a word trachoma fits in terms of the NTD programs of countries and plans going forward sure I think it's it's entirely up to countries in in how they arrange the administrative responsibility for a trachoma within WHO has moved from prevention of blindness to the neglected tropical disease department but it doesn't have to be that way at national level and whatever works administratively is is that is the thing that should be taken forward I think good so changing kind of topics quite a bit you led the global trachoma mapping project can you update us on where that project is now quickly kind of what has been achieved and what is still left to do we're cutting up in and out a little bit there Alan in terms of mapping what's been achieved and what's still left to do correct that's right yeah so the global trachoma mapping project started with the goal of completing the baseline trachoma map worldwide we we thought we had about 30 countries in which to work and we ended up doing mapping in in 29 we thought we had around 1238 districts I think it was to map and we ended up mapping 1546 districts so for the most part the project which ran over three years fulfilled its mandate and and a little bit more but the in the course of having conversations with health ministries about what needed to be mapped which districts were suspected pandemic we discovered a lot more than we knew about at the beginning and so there are still some districts that need mapping either because they came into the conversation rather later or because they were insecure at the time when we wanted to map them with with the support of health ministries and and so they couldn't be done at that time trachoma is obviously not not an emergency intervention and collecting data about it is even less an emergency so we took the view and this was a view supported by health ministries that putting field teams in danger because insecurity was not something that we wanted to so sol if somebody joining us now wanted to know whether mapping is complete in the country and where the endemic districts are how would they find that information out well the international trachoma initiative hosts a very nice resource called the global trachoma which is available online and that has district by district prevalence category data for for the whole world and usually it also includes an indication of where districts are suspected to be endemic but don't yet have data so that that's I guess the first port of call but you know it's often the case that that health ministries may have reason to suspect trachoma to be a problem in places but they haven't yet necessarily had that categorization put on the atlas so making sure that there's a conversation with with the relevant ministry at national level is also often helpful and that's a process of conversation that we continue okay good so I'm changing topics away from mapping now to MDA and with MDA we've got this thing of five years and three years and one year depending on what the prevalence of EF is and we've had a few questions regarding what's what why do we recommend that is there any evidence forward what's the rational reasons for why we say five years for this prevalence and three for that and one for this can you give us some background to that sure the I guess it's mostly sorry I'm having to move because my battery's running low I wasn't expecting to do this on the mobile the evidence is in the form of of programmatic experience mostly rather than level evidence in a kind of randomized controlled trial format to kind of definitively establish that that five years was needed for a particular prevalence category and three years was needed for another you would need quite a large randomized controlled trial with literally hundreds of of communities and and probably quite a lot of of districts in quite a lot of countries but the experience that's been accumulated over the last 17 years of the donation program from Pfizer suggests that the higher the prevalence of of this inflammatory sign TF in one to nine children the more or the greater the duration of interventions that's needed in order to make a sustained impact in other words to to bring the the prevalence of TF down below the elimination threshold um the the sort of most recent addition to that that suite of guidance the fact that for districts in which the prevalence is between five and nine point nine percent that we should try one round that's a it's a quite recent addition to to to what we suggest to countries and we're only just beginning to see the impact of that and so far it actually seems very positive so sometimes that that pragmatic approach of needing to make a recommendation in the absence of good evidence can still generate something that that seems to work and I think the the Chamber of Expert Committee of ITI uh particularly helpful in that in that regard under your leadership in in coming up with the sensible suggestions that would seem to be born out in greatness okay thanks Sol um what one question that's come in is the the goal is elimination of Tacoma now control of Tacoma is a public health problem by the year 2020 maybe we should just make sure that we've got the wording right there but the question is um well if a country is not achieved that by 2020 what will happen regarding MDA will the donation program still be available will Tacoma control the carrying on yeah I hope so uh it's it's difficult to say and and perhaps it's a it's a more of a political question than a public health question um and and well politics is always fairly intricately intertwined with uh with public health um but I think that so far Pfizer has said that they they're committed to the donation until 2020 now I think that if we if we manage to show substantial progress towards going to Tacoma elimination by the end of 2020 that there will be enthusiasm to continue to the to the public health endpoint so I think it's it's my job and the job of others interested in seeing this thing done to get as far as we can as quickly as we can and to demonstrate that success in order to ensure that the political commitment is sustained beyond the the date of 2020 if that's required and it's certainly likely based on the prevalence data that we have that there will be a number of districts that will require surveys after 2020 and some of those districts are likely to require ongoing interventions after 2020 so this is a a political challenge that will need to to grapple with over the next few years um having said all that you know there's in in my view there's a a real need to continue to to kind of support the get 2020 target in order that we maintain as much positive momentum as we can between now and 2020 so that we can achieve and document the the success between now and then so I don't I don't yet want to back away from from that that target I think the harder we push to to try and achieve it whilst realising that it may not necessarily be 100 possible the better it will be for the program as a whole good thanks um so I think I've got three more questions and then we'll let you get back to your what I'm sure is a very busy day so it's fine and these are kind of fairly if you like general questions but kind of as all and the audience understand and what's going on the first would be as you look for the next four to five years up to 2020 what do you think are the biggest challenges that we face in elimination of trocoma by 2020 okay but I think number one would be issues related to trociasis uh and and two in particular what what do we do about uh postoperative trociasis uh what do we do about low electric ciasis what do we do about um uh you know those those sort of more complicated surgical problems where there's not good access to ophthalmologists or or even better good access to oculoplastic surgeons because even even uh fully trained medical ophthalmologists struggle a little bit with the with the problem of recurrent disease and no one's quite sure as to how to to deal with lower lip disease and that's going to become an increasing problem as we increase as we scale up programs um you know there'll be several several hundred thousand operations done in Ethiopia over the next 12 months if things go to plan and in in the best programs one expects 10 percent recurrence or 10 percent postoperative trociasis so that's 20 000 people who'll potentially need management by specialists who who just don't exist at the present time uh the trociasis case finding is another issue how to how to manage that and that becomes more and more difficult the lower the prevalence of disease becomes so the job becomes harder the closer you get to the endpoint uh for antibiotics I think the one of the principal problems is funds for distribution and I think I came in to the conversation at a point where you were talking about some of the funding that's available and talking about the need for increased domestic financing uh which I absolutely support and then on the fne side evidence for the critical things that work in fne is a is a major challenge for the program uh there's uh there's a clear need for programs to get involved in in good quality operational research to to better establish what needs to be done okay thank you and then perhaps more on the positive side what would you see are the the the encouraging things uh with regard to trocoma and again the future not necessarily the achievements of the past but going forward why should we be positive in our outlook um well I suppose momentum and trajectory and and perhaps that's not what you wanted to hear because that that comes in in part from looking at at where we were 10 years ago where we thought there were 8.2 million people who needed an operation uh for trichiasis and and now we think there are 3.2 million people who need that surgery so the the backlog's been reduced quite a lot uh and the momentum is there and and the the support is there so the kind of global community of of practice around trichoma is really energised at the moment to to go on and get this done so community and partnership I think is is a is a real key uh along with that is a group of very committed donors who are involved in the in the partnership uh who really want to see the work completed uh I think we're we're getting better and better at being evidence based in the program and and work that uh the London school's been involved in recently looking at at the best operation to do for trichiasis is a particularly encouraging thing the ongoing commitment of Pfizer to donate the drug I think is wonderful they would be the the main things that I'd identify there okay and this is my last question there Sol um we as as Daksha mentioned before the been very encouraging that more than 2,600 people have registered for this course and are participating um what would be your message to those people well I'm I'm extremely grateful to them for having taken the time showing the interest to join the course I think it's a tremendous time to be involved in trichoma elimination I think we can do an enormous amount together I think their their participation in the course will will hopefully help that I would just like us all to to work together as hard as possible for as long as possible to see as much progress as we can against trichoma in the in the next few years and if there's anything that I can do to help that then then I'm here thanks Sol if I can just add to that my my as I mentioned right at the beginning of this my first contact or exposure to trichoma was in 1975 in Tanzania and if I think of what I saw a new then and what I see and believe is happening now I mean it's just incredible the amount of progress there has been and you can say well that's 40 years but I can assure you I think one couldn't have dreamed 40 years ago where we are today so I think realistically yes we all get worried about 2020 but I think certainly in the next decade this disease and hopefully before the next decade but in the next few years we are going to see this disease come under control around the world which is a very positive thing so Sol thank you for joining with us thank you for your precious time and thank you for all that you're doing at the World Health Organization to lead this global program and my thanks to Daksha who has put together the trichoma course and started off with this Google Hangout at this time and Sally who's our IT technician sat across the table from me who's been pulling her out trying to get people online for the last hour we hope you've enjoyed it we were sorry for the technical problems that we've had but it's been great and we wish you all well thank you and we have apologies from Dr Emerson who is stuck in an airport somewhere near Johannesburg okay bye now