The World Health Organization (WHO) called for global attention and action against neglected tropical diseases (NTDs) related to poverty in 2010. In Sub-Saharan Africa, approximately 500 million people are threatened by NTDs, most of whom are among the region’s poorest and marginalised. Over the past 10 years, Africa has made significant progress on NTDs, but they remain a severe public health issue. This includes the NTD, trachoma, the world’s leading infectious cause of blindness. This summit will see eye health experts discuss how to integrate the multiple resources required to address NTDs in Africa, and discuss the strategies needed to strengthen the response, particularly in relation to eye health service capacity.
Dr. He Wei, Founder/President of He Vision Group & Deputy Chief of China National Committee for the Prevention of Blindness
Dr. Wang Ningli, Chief, China National Committee for the Prevention of Blindness
Prof. Daniel Etya’ale, former WHO Vision 2020 Coordinator for Africa & former IAPB Executive Director for Africa
Dr. Kgao Legodi, President: African Ophthalmology Council
Dr. He Xingru, Director of Strategic Development and Globalization, He Vision Group
Dr. Tina Chisenga, Assistant Director (Communicable Diseases), Zambia Ministry of Health Public Health Department
Dr. Fikreab Kebede, Senior Technical Advisor: NTD/Trachoma, Ministry of Health, Ethiopia
Dr. Alemayehu Sisay, Country Director, Orbis Ethiopia
Ms. Lucy Nadaf, Country Director, Orbis Zambia
[George] Good afternoon, I’m George Smith, Managing Director of North Asia for Orbis International. On behalf of Orbis, I want to say how honored we are to host the China-Africa Neglected Tropical Disease and Prevention of Blindness Summit. This important summit is part of a series of events we have taken part in to strengthen the partnership between China and Africa, with a goal to help eliminate preventable blindness. I want to thank you and tell you how happy we are to have two of our strongest partners and long-time friends of Orbis as co-hosts for this event. Professor He Wei, founder and chairman of He Vision Group, board member for the International Council of Ophthalmology and Deputy Chief of China National Prevention of Blindness Committee. He has been a central force behind our work across countries and continents and the person who first initiated these China-Africa events. Together, He Vision Group and Orbis have been partnering on projects in China for nearly two decades.
And Professor Wang Ningli, Chief of the China National Prevention of Blindness Committee. Professor Ningli has been one of the strongest advocates for prevention of blindness in China, and also supporting Orbis’s work there. We’re just completing a national level project focusing on building capacity at county-level hospitals for the PBL committee and are now planning a second phase focusing on diabetes and diabetic retinopathy. Professor Wang Ningli will be central to the success of this project and its national impact.
Neglected Tropical Disease Day and this summit gives us a chance to share and celebrate the work that has been done to eliminate trachoma and I look forward to our collective work together. Finally, I would like to thank our Orbis Cybersight team for their technical support in supplying this terrific platform. I would now like to turn the podium over to Professor He Wei. Thank you and good luck.
[Wei] Thank you, George! Dear George Smith, Professor Wang Ningli, and distinguished friends at home and abroad, hello everyone. It’s my great honor to be invited to this China-Africa NTD Day and Prevention of Blindness Summit. On behalf of the China National Training Center for the Prevention and the Treatment of Blindness, and on behalf of the He Eye Specialty Hospital, I would like to extend my facilitations to this forum.
Although China and Africa are far apart from each other, China-Africa friendship is stable and becomes even stronger as time goes by. For many years, He Eye Specialty Hospital. as a training center designated by ICO and the China National Training Center, for the prevention and the treatment of blindness, has actively participated in the International Corporation on Blindness Prevention and provide human resources training to the African nations. We will take this online forum as an opportunity to continue to build the broader academic exchange platform. Seeking new ideas and expand new ways for the future academic research and international cooperation. We’re willing to jointly incorporate with each person, scholars, and friends at home and abroad, to contribute to the development of global eye health. Lastly, I wish the forum outstanding success. I wish all the dear guests, friends good health, wonderful work and a happy life. Thank you.
We expect all the attendees to leave us messages, through the message board at the bottom where we’ll have a question and answer session later at the end. So let’s turn the podium over to Professor Ningli.
[Ningli] Hi, dear George Smith, distinguished guests, and my dear friends at home and abroad. Hello, everyone! This is great pleasure for me to participate in the China-African NTD Day and the Prevention of Blindness Summit. I’d like to take this opportunity to express all our sincere thanks to our hosts, Orbis International, for this learning invitation. On behalf of the China National Committee for the Prevention of Blindness, I would like to extend my warm congratulations on the summit open.
It is in our pursuit and right of the humankind, and the significance of humans’ health as well. As the Chief of China National Committee from the Prevention of Blindness, I have worked in this field for nearly 40 years and witnessed the changes in the spectrum of the blindness eye disease. And the improvement of the technology in diagnosis and the treatment in China. I sincerely hope that China’s successful experience in the prevention and the treatment of blindness can help the innovation, the development in African countries.
This summit gives us the global wisdom online, we hope everyone can have deep and fully communication through that academic thought and collide with more sparks. I would like to work with the expertise and the friends in their home and abroad, to promote the global health business, high quality development, and contribute with wisdom and stress. Finally, I hope this summit complete success. Thank you, all our friends, thank you.
[Wei] Thank you, Ningli. As we all know, over the past 70 years, China has made remarkable achievements in the prevention, treatment of NTD, especially for the elimination of trachoma in 2015. Firstly, we sincerely invite Professor Ningli to share the successful experience in eliminating blinding trachoma in China. Ningli.
[Ningli] So thank you. The organization committee gave me the opportunity to talk about the elimination of the blindness trachoma in China. Actually, here is the experience of sharing with our friends. So, according to the history of the Trachoma Control in China, I would like to read the histories into the three period.
First period is pandemic period. The high prevalence in China. And the second period is the action period. And finally is our conclusion summaries of the elimination of the blinding trachoma as a public health issue. So let’s go to the first part. Let’s go back to the year 1950s. In that year, just after World War II and the civil war in China, China has a very bad conditions because of weaker economy, poor hygiene. And the trachoma, at the time, is the leading cause of the blindness in China. In some area, the rate of the blindness caused by the trachoma is as high as 35%. For every region, it is around 20% of the blindness due to the trachoma.
And let’s see the prevalence in that time. In the northwestern China, the prevalence of the trachoma is so high, almost come to 100%. Even in the central part of China, the trachoma’s prevalence has come to almost 60%. The trachoma in that time is a big, severe challenge for our eye health. And it is the leading cause of the blindness in China in that moment.
The Chinese government put the priority on the trachoma control from the 1950s to 1999. The government first put the trachoma control on the highly priorities, just as one of the 60 major tasks in the National Development Program. And the government make the missions, just like the National Trachoma Control Toilet Reform movement its missions.
And at that time, not just in China, in the whole world, we don’t know what causes trachoma. What is the pathway of the transmission? What kind of medications should be the best? So in China there is two famous scientists and doctors that worked together to try to isolate the etiology of the trachoma. Finally, in 1955, both of them worked together. Separately, first the trachoma virus. Actually it is not a virus, trachoma is chlamydia. And it’s the first time that human beings understand what caused the trachoma. So the WHO gave this first, the discovery of the trachoma chlamydia, the name TE55. And because both of the people’s contributions, and the discovery of the pathogens, classification of the transmission routes, and that pathway of repeat infections, and the identification of the sensitivity drugs, the International Trachoma Gold Medal come to the both of them.
And after this, there are several missions that started in China. And the first, we set up the training teams and the training of our doctors to do the trachoma preventions. And we just took the documents, the guidelines, and the standards from the WHO. And these classification of the trachoma is from the WHO, we translated the English into the Chinese that is widely used in China, information of the trachoma controls.
Now let’s see, after 30 years, in 1987, we did the first national sample survey of the disabled person. We found that blindness caused by the trachoma is down to the third leading cause. And in the last part of our missions, elimination of the blindness trachoma as a public health issue. Actually, that is one of our efforts under the Vision 2020 initiative.
In 1999, the WHO conjunctive with the Chinese government there is a Kunming meeting. During the Kunming meeting, the meeting collected the datas from the different parts of China and the meta-analysis of the trachoma epidemiology was analyzed. And from these studies, we found that active trachoma was dramatically controlled. But we still had a quite big number of trachoma trichiasis. From the estimations in that time, we had almost six millions trachoma trichiasis.
Continuously, the Chinese government and the Chinese ophthalmologists worked together to follow the guidelines from the WHO, we used the SAFE strategy for our trachoma control. The year 2003, we rejoined the meeting, WHO’s Global Alliance for Elimination of Blinding Trachoma in Geneva. And from this meeting, we talked and we give the data and we see the results of the survey about trachoma in China. And we get that grant from the WHO, we started to do one of the pilot study in the 14 key provinces.
From the pilot studies ,we find the TF dramatically reduced and also the rate of the trichiasis also reduced dramatically. So we can decide if we do something to the last efforts, maybe we can come to our target. The target of the elimination of the trachoma in China. So here’s the WHO and the Chinese government, the Lion, NGO support us, we start the Sight First, China Action. This project is the third phase we put our focus on the elimination of the blinding trachoma in China. This project should be finished by the year 2016.
Here’s the doctors, the scientists from the WHO, Brinscov, Mary Altes, and the rest of the doctors from WHO. And the people from the Lion NGO and the doctors from different areas of China.
After two years work for the evaluations, screening treatment, finally we got the result. Here the prevalence of the TF is quite lower. It’s just 0.196%. It’s really below the 5%. And to see the rate of the trichiasis overcome to the very lower prevalence, it’s come to the 0.004%. From these result we can come to the conclusion, blinding trachoma is no longer a public health problem in China and in the year 2014. And in the year 2015, at the WHA, the meetings in Geneva, the director Li Bin of the National Health and Family Planning Commission officially announced that in the year 2014, China met the WHO’s requirement of the blinding trachoma elimination. That is the great achievement we got for the trachoma elimination.
This is a certification, official letter from the WHO, that is validation of the elimination of the trachoma as a public health problem in China.
I will end my talk, but for the trachoma elimination in China, it’s not only one person’s contribution. It’s not only one organization’s contributions. It is several generations of people working together and the common guiding.
So finally, what is China’s experience on the trachoma controls? First, the government should put most of the challenge of eye health issue on priority. And we needed help and the guidance from the WHO. And we needed the NGOs support for many perspectives. And we needed our international friends just friends from Japan, Korea, and the friends from the WHO, and the friends from the NGO. And we need our ophthalmologists work together, focus on the challenges. So that is our experience and the achievement of the elimination of the trachoma we did in China.
Thank you, thank you very much, thank you.
[Wei] Thank you very much, Ningli, for your excellent presentation. Next, let’s welcome Professor Daniel Etya’ale, give us a good presentation on moving forward, preliminary lessons from the Vision 2020 initiative for Africa.
Professor Daniel has played a critical role in the eye care delivery in the Africa region. He is a founding partner of Magrabi ICO Cameroon Eye Institute and a former general coordinator of Vision 2020 for all of Africa. Professor Daniel has graduated emeritus and a lifetime member of Executive Committee and Strategic Committee of International Council of Ophthalmology. Daniel, please.
[Daniel] Thank you very much, Wei, for this kind introduction. I thought that as we just ended the official period of Vision 2020, it is not early to start looking back and to learn the lessons. I know that this is still very early days and there is a lot more lessons that are going to be learned over the coming years, but I just wanted us to get started.
I would be talking on four key areas. I would touch on the major achievements during Vision 2020, then I would discuss how we performed against Vision 2020 original objectives, and then I will discuss what I still see in Africa as remaining and ongoing challenges, and then I will end by suggesting some of the things that I believe we must do in priority moving forward.
With respect to the first point, what have been our major achievements in 2020? Again, one can look at it at both the global level but also at regional and country level. And without doubt, at both levels, our greatest achievement has been in the area of advocacy and awareness making. At global level, as you know, within a few years, we actually managed to get past three major WHO World Health Assembly resolutions, which are not always easy to get. But we managed to do that. At regional and country level, we did some extensive work, especially in Africa, because we held at the beginning, major Vision 2020 launches for French speaking and English speaking. And then this was followed by the organization of national and regional planning workshops. And these were extensive, especially in terms of data collection.
Here you have the examples of the sort of things we were able to do as a result of that. Data collected in each country on the availability and distribution of ophthalmic personnel in each country, on the country’s performance in cataract surgery, both at national level. But we were even able to drill down to the provincial and regional level. Because sometimes you may have a good number at the national level, but when you look at region by region, you see the disparity. As you can see here on the right on the example of Tanzania. Where in blue you have what each region had achieved in terms of cataract surgery and in red what still remains to be done.
But we collected even far more information. For example, on training centers and human resources for cataracts in each country. We went further down in collecting data in all our units in Africa, from primary to tertiary. Data on ophthalmologist’s proficiency in surgery, in laser, and so forth. Data on availability of consumables. Now this is very important because sometimes you see that a given center or eye unit is not performing. But when we collected those data, we realized that some of them were not performing well because they did not have, sometimes they would go four to six months without any consumable. And so if you want to address these issues, it’s important that you collect this type of data and of course we also collected data on the functionality of available equipment. And we discovered who many who are listed, but there were very few that were functioning well.
Now moving onto how did we perform against the original objectives of Vision 2020. Here you have, I don’t know how, maybe I can move it. Here you have what we called at the time the Three-Prong Strategy in Vision 2020 implementation, the control of priority blinding diseases, the development of human resources, and I prefer using the term the development of eye care teams. Because it’s not just ophthalmology, it’s the whole time that needs to be available if you want to really get the maximum impact. And then the third strategy was putting in place the right infrastructure. Because if you have staff and you don’t have the right infrastructure, you can’t achieve much.
This is what we had at the end of the official period Vision 2020, years later. And you can see in the areas of disease control, like our colleague from China has shared, who were very successful in the control of trachoma, we have not yet got the certification as China has got for many of the African countries. But we are in a very advanced stage and the same is true also onchocerciasis. Cataract, yes, we have services for cataract in many countries and in most eye hospitals. But when you look overall, all the things that are dimmed in this image, are things for which we have not done very much. And so there’s still quite a lot to do.
Now, moving onto the third aspect which is the remaining and ongoing challenges. Now, again, if you look at this table, I have tried to summarize those challenges. And if you take only cataract is where we managed to do some things. But even there, the infrastructure is still not yet fully available. We still have the problems of skills, equipment, and supplies. And there’s still a need to monitor the quality of surgery everywhere. But outside cataract, all the other top priorities of Vision 2020 in Sub-Saharan Africa, we are still almost at the beginning. And this is a major challenge because if it took us 20 years to do only so much in cataract and we’re still facing usual endurance in glaucoma, diabetes, childhood blindness, and uncorrected refractive errors, we need to rethink our strategy if we want to catch up and probably advance quicker.
Now here is a good example in the area of cataract. The graph on the left is information that I collected myself. Is the cataract surgical rate in 2007. And a graph on the right is data collected by the WHO in 2017. And as you can see, the cataract surgical rate has not changed very much, despite that the fact that yes, some countries have shown some progress. But overall, it is in the area of cataract where infrastructure is available, we have not moved very much.
Now, it becomes more critical if you look at one hand, what the countries are doing and on the other hand, the number of ophthalmologists. When we started Vision 2020, we were saying that all that it will take is if you have a minimum of two ophthalmologists per million population, then maybe you will start achieving things. But now, as you can see, we have a list of many countries and it’s increasing. Of many countries that have more than 2 ophthalmologists per million population. And when you look at what they’re achieving, it’s still not enough. So what can we learn from that? Just training more ophthalmologists is not enough. We have to make sure that they are well distributed in the country and also we have to make sure that they actually perform, that they have been trained to perform, and able to do the things that they need to do.
Sorry. Another major challenge that we are facing is in the area of glaucoma. And here again, as you can see, we had a series of regional workshops during which we discussed the strategy, the best strategy for glaucoma control in the countries. And we came up with a five-prong strategy. And so that information is there. But unfortunately, to date, there are very, very few countries that have started addressing the challenge of glaucoma in a satisfactory way.
The other major remaining challenge is in the area of uncorrected refractive errors. On the graph on the left hand side, you can see that Africa with South Asia and Southeast Asia, are among the regions where the need is greatest. And yet there again, in the African region, during the workshop we discuss comprehensive strategies on how to address it. Because it has to be a full circle if you want it to be effective. That information is variable unfortunately. Again, it has not been fully implemented. Thankfully, there is a new initiative coming up on the elimination of needless uncorrected refractive errors by 2050. Hopefully that will help.
The last major challenge that I can mention is diabetes. Whether you look at it on the global level or you look at it country by country, this is an emerging emergency. Africa, is the region with the fastest growth in diabetes and its complications. And yet, still there’s very little in terms of infrastructure. When we assess the countries, there were some countries, whole countries, that had only two or three lasers in the whole country. And not enough retinal imaging systems. Things which are essential if you really want to control properly diabetes.
Sorry, the last aspect and huge challenge, is the area in human resource development. What I’m trying to show in this slide is on one hand, on the right is the various key players in human resource development in any country. You have the Minister of Health, you have the Minister of Higher Education, you have professional associations, you have directors of training of institutions, and you have all the major players. But in Vision 2020, somehow we concentrated only two key players were involved. The Minister of Health and the international NGOs, that’s not enough. And especially because when you have international NGOs in many African countries, they concentrated on supporting work at the district level. Not at the institution, training institution level. As a result, we’re still having the same problems with training institutions that are not sufficiently equipped, and the teachers are not sufficiently trained to produce the sort of all around ophthalmologist that we are looking for.
Lastly, and that’s the last part of my presentation, so where do we go from here? Having demonstrated, I hope, that yes, we have achieved quite a lot in Vision 2020, but a lot more still needs to be done. And we have to be creative in doing that. Now first of all before I make my suggestion, we have to keep in mind that the general environment in which we are working in Sub-Saharan Africa, is not likely to change overnight or any time soon. Africa will continue for some time to be a place where with the highest number of poor, it will continue to be a place where most people pay out of their pocket, and a continent where international assistance is highest. As you can see here, compared to other regions.
Which creates some additional problems because with such a high level of dependence on the outside, it means that the ownership of the programs are difficult because sometimes you have to do what those who are giving you the money tell you do. And also sustainability is difficult because it means that if for any reason, those who are helping you today are no longer there, everything may collapse. And it’s even more so because as you can see from this graph, from the UNDP in 2005, this is where they looked at the variability of external aid over time in Sub-Saharan Africa. And as you can see, it’s everything but predictable. And therefore it means that even something that is successful today, if you go back five years later, it may not be successful.
So we need to insist on sustainability or sustainable approaches as we negotiate with those who are helping us. But even more globally, we need to make sure that because we don’t have all the means as activists in blindness prevention, we have to make sure that we are integrated into the health systems of the countries. Because the countries will always be there, the countries are the ones who will eventually eliminate blindness for their own people. And therefore, the sooner we know what they are doing, and we get involved in all those blocks, health system blocks, the better.
This is my last slide. My five top priorities as we move forward. The first one would be to support as much as top priority, the hundreds of young ophthalmologists who are still graduating, even today, with very limited skills in surgery. This is not accessible in a country where many people are still going blind and dying blind because they cannot have surgery.
Priority number two will be to help strengthen training institutions by providing them with safer and better training tools like simulators for eye surgery. I think that this is something that we can afford. And we know the difference that good training, safe training, can do and produce in terms of impact later when the person is out of the training school.
Number three priority is to promote and support the training of subspecialty beginning with the trainers. It is the surest way to produce better, all-around, more skilled ophthalmologists.
Priority number four is to help promote the routine use for WHO Cataract Surgical Outcome Monitoring tools which had been developed for close to 20 years now and which is still heavily used, even by training institutions. It is not enough to do thousands or millions of surgery. We must make sure that every cataract surgery that is done results in sight recovery, not just a person trained.
And lastly, priority number five should be to make sure this time that we don’t forget glaucoma, diabetic retinopathy, and uncorrected refractive errors. So we have plenty, we can rejoice on what we have done, but the challenge ahead of us are still many, and your support is very much welcome. Thank you.
[Wei] Thank you very much, Daniel. Excellent presentation. Dr. Kgao Legodi is involved locally in many positions to improve ophthalmology service in Africa. Dr. Legodi is the president of African Ophthalmology Council and a board member of the Middle East Africa Council of Ophthalmology. Today, he will introduce the insight on strengthening the public eye health system in Africa and the prospects.
[Kgao] I hope you’re all well in these difficult circumstances. I hope COVID-19 is not going to affect our thinking along the line of able to prevent and treat avoidable blindness because of these circumstances we are in. Because it’s causing a lot of hard work in terms of we are losing doctors. We are losing family members. Economy is going down. I hope, probably, at some stage we’ll be able to stabilize the situation and be able to prevent and treat this visual blindness, which is very preventable.
Let’s start with the eye diseases in Africa. Preventable and treatable visual impairments affects estimated about 285 million people worldwide. The low- and middle-income groups being the most affected by about 87%. And we all know that Africa bears most of the burden of visual impairment since visual impairment is proportionately affect the low- and middle-income countries in relation to the high-income region.
The socio-economic factors, poor health system, concomitant human immunodeficiency virus and TB epidemics contributing factors to the burden. It is estimated that 32,700 per million individual in Africa are visually impaired. And this is very sad and disturbing. The different eye disorders contributing to visual impairment include cataract, glaucoma, trachoma, and refractive error. And nearly 80% of impairment are preventable or treatable.
With an aging population and lack of cohesive plans to address the impact of visual impairment on people’s productivity and quality of life, there will likely be an increase in burden in eye diseases in many African countries. Up to 80% of visual impairments are preventable and treatable. And 76% of all Sub-Saharan Africa’s cases in 2015 were due to uncorrected refractive error and cataract. Approximately 26.3 million people in Africa have a form of visual impairment with 20.4 million having low vision and 5.9 million estimated to be blind. Major causes of blindness include, but are not limited to, glaucoma, onchocerciasis, trauma, diabetic retinopathy, and childhood blindness.
As we all know, cataracts are the single largest contributing factor of blindness in Africa. And it is responsible for approximately half of the blindness of Africa. And the good news is something that can be treated, something can be done about it. And when it comes to a trachoma, it is declining in many areas. As Professor Ningli has already mentioned about trachoma, what they are doing on their side, but it remains the second largest cause of blindness in Africa. It’s prevalence is similar for boys and girls. But investigation indicates it is more active in adult women than men.
Glaucoma has a higher rate of chronic open angle glaucoma in Africans of younger age than among white people. In fact, most people impacted by glaucoma are not aware of having it. And that’s the sad part. And when they are aware of it, it’s already late and already half of their eyes are already blind at presentation, which is true.
Coming onto onchocerciasis, which is river blindness, has focal distribution as it is limited to belt stretching from Senegal to Malawi. The other eye disease in Africa that’s affecting our people is diabetic retinopathy, which is prevalent in diabetic Africans. Generally, diabetes treatment in Africa is poor. Thus few diabetics have access to treatment for retinopathy. Looking forward, an improvement on diabetic care will increase life expectancy, and it is likely more blindness from diabetic retinopathy will occur.
Other diseases are leprosy, lagophthalmos, myopia. Natural refractive error is not a significant cause of blindness, however, it is a significant cause of low vision.
What are the size of problem that we see in Sub-Saharan Africa? One of the greater challenges to achieve wider health goals is the critical shortage of health workers, which is the heart and soul of any health system. Given the low numbers of ophthalmologists and cataract surgeons in Africa, it is paradoxical why professionals are not overwhelmed with cataract surgery. As a consequence, it is objectively believed that patients presented for cataract surgery are a small proportion of the cataract blind in the community.
Factors that prevent people from presenting for cataract surgery, or any other eye surgery, include but are not limited to the following. Number one, the costs. Cost of operation as well as other less obvious costs: transportation costs, loss of employment, or wages, living expenses while in the hospital, and recovery. The second one, accessibility of services. Most Africans live in rural areas whereas care facilities are found in the cities. Third one, knowledge of services. Lack of awareness and understanding prevents many from seeking treatment. Fourth one, trust in outcome. Patients justifiably fear surgery outcome. A few unfavorable outcomes may discourage a community. Cultural and social barriers. Adults with less education, control of time, and/or money, social support will be less likely to present themselves for surgery.
Come into the eye health workers in Africa. There are 4.8 million blind persons and 16.6 million visually impaired. Yet, there’s less than 1% of global ophthalmologists practicing there. Of the 54 recognized countries only 13, 1-3, meet the requirements of one eye health professional to 55,000 people for patients. The shortage of eye health human resources is compounded by the limited capacity of training institutions. As such, the workforce crisis has even greater impact in the Africa region. The lack of sufficient ophthalmologists increases the risk of eye health epidemic in Africa if sufficient eye health workers are not added to the fight against preventable blindness.
Glaucoma in Africa. Of the causes of world blindness, glaucoma is the leading cause after cataract. And it is a devastating and neglected infliction. And we all know that it is irreversible. In Africa, most of the glaucoma in primary chronic open angle glaucoma is the cause. Its prevalence has been conservatively estimated to be 10,000 people for every one million in population. Despite the disease’s high incidence and prevalence, it’s only recently that Africa is recognizing glaucoma as a priority eye disease.
The size of the problems is stupendous if you’re not even aware of it. Glaucoma is responsible for up to 30% of blindness in the world. And research suggests it is affecting Africans at an unparalleled scale, rapidly. Research also suggests that approximately 90% of African patient with glaucoma are unaware they are infected.
Due to the urbanization, trained eye care providers are found in eye centers and the majority of the population lives in rural areas. There is a serious shortage of trained eye care providers in the continent. Even with 24% of the global burden of eye disease being found in Africa, Africa has less than 1% of all ophthalmologists over 200,000 people. Lack of public awareness/education about the disease.
A call to action in Africa. Ladies and gentlemen, glaucoma should be prioritized in the Vision 2020 programs. I know Professor Daniel Etya’ale already said, we are no longer on the Vision 2020. But yes, he said also, we still have to go ahead with our Vision 2020 programs. And we should make sure that we have action in those programs. Educating the population will be essential to raise awareness, providing clinical and surgical training opportunities for African ophthalmologists. And it would be nice and proper to strengthen our relationship between us and China, so that we can be able to manage this call. We need that. Africa needs the world. I’m so happy that among the presenters today are the gurus of Africa, like Profession Daniel Etya’ale, he’s been there for years. Professor He has been there for years, and also supporting Africa as much as we can. I think we still need that. And I thank you all.
[Wei] Thank you, Dr. Legodi, very nice. Thank you. Next, let’s please welcome Dr. He Xingru, to give us his insights on prevention of eye care developments in the age of digital era. Dr. He Xingru received his DrPH, MPH and MBA degrees from Johns Hopkins University, Bloomberg School of Public Health and California Business School, respectively. He’s now the director of Strategic Development and Globalization at the He Vision Group. Also also managing the Center of Vision Intelligence at He University. Dr. He.
[Xingru] Yes, thank you for your kind introduction. Dear respected guests and panelists, I thank you for giving me this opportunity to share some of my insights regarding to the eye care development in the age of digital health.
My name is Xingru, I’m from He University School of Public Health and also the director managing the Center of Vision Intelligence. In a brief 10 minutes, I would like to discuss the four topics. Including how the current health status of Sub-Saharan Africa, the ongoing challenges, most of the panelists already discussed so I will briefly go through them, and what can digital health bring at this moment, and what we, as collective stakeholders, could do to improve the status of vision health. Not only at the continent at where we are located, but also in Africa.
Based on the most updated study conducted by Flaxman, et al, I learned that about five million blind people are expected to exist in 2020 in Sub-Saharan Africa. Which constitutes about 12% of the world blindness, as well as 8.3% of the world’s moderate to severe visual impairment. By looking at this data, stratified by region including different sections of Sub-Saharan Africa, East Asia, high-income North America, and the world, we can see compared to the contribution of eye diseases in all the population who are above 50 years old. Between the year of 1990 and 2015, we could see clearly we’ve made great progress in eliminating and eradicating trachoma. Although there’s still a long way to go in regarding how to control the uncorrected refractive error as well as cataracts. But we could see the trend, it’s going towards quite a good direction.
Then here comes the question that is what are the ongoing eye care challenges that’s facing us, not only in Sub-Saharan Africa? Based on the gathered number of ophthalmologists per million populations, we could see that in China they’re about 21 ophthalmologists per million population there. Japan, about more than 100. And if we look at many of the Sub-Saharan African countries, it is still quite low. The challenges not only comes from the human resources, but also the unbalanced medical resources, the lack of eye care access, low affordability as well as the short of connectivity, from the technology perspective.
Then what can digital health bring at this time of the year? I would like to separate the topics into three components including the primary prevention from the education only from the eye care professionals as well as to the public. The secondary prevention including surveillance, monitoring and screening. And also the tertiary prevention regarding to the on time treatment. Of not only the communicable, but also the non-communicable eye diseases.
For instance, I would like to raise some examples. Some of the digital health solutions in primary prevention including education towards health care professionals, not only using telecommunication technologies. But also using a lot of the smartphone and not even not smartphones, just mobile phone devices using short messages to educate and notify information toward the specialists and towards the public.
In the secondary prevention side, I think in the world there are a lot of fast, great leap that was focused on developing crowdsourcing technologies to support the surveillance system, especially for communicable, contagious eye diseases like trachoma. And also to train artificial intelligence models to screen and predict the trend of not only the outbreak of contagious eye diseases, but also the non-communicable eye diseases such as diabetic retinopathy, as well as a lot of the uncorrected refractive error. However, most of the technologies today are focused on detecting posterior eye diseases. So there’s still a lot of opportunities for all of us to continue to focus and to collaborate and develop the AI tools to look for interior eye diseases such as the trachoma, but also the middle segment, as well as other glaucoma related to algorithms.
And from the crowdsourcing perspective, I would like to suggest, for example, for trachoma control. It’s really difficult to use AI to screen for trachoma, not only because of the device’s availability but also its nature that it’s infectious. Rather than screening for the disease itself, why not come up with a surveillance system that could be collaborated and supported by the crowd using existing mobile health technologies to monitor the existence of the temperature, the development of the outbreak, as well as the development and the population of the flies. For example, that’s acting as the vector that’s causing one of the biggest risk factors of trachoma. Of course, this is for the communicable disease perspective.
And in the tertiary prevention side, we can potentially use a lot of the mobile health technology to support, to deliver the treatment or the eye drops to the target population using the technologies like drones, if possible.
But the problem is, I think a lot of panelists already mentioned the problem is how do we sustain? And yes, we do have the technology. Yes, we do have the human capital, but the problem is how can we scale from there? How can we make the program more sustainable? So rather than making it as a program or project that has clear starting and end point, why not or how can we transfer a project into a daily operation that can ask long and forever? So the key question comes from how can we scale and I think the issue would originate and focus on the next step, that is about implementation science.
What can we do? And here I constantly ask myself who are “we”? Are we the doctors and optometrists only? Or are we the hospitals and vision centers that’s acting as the agencies to do so? Are we the government and public health agencies that’s focusing on providing funds, looking for resources? Are we the pharmaceutical companies that’s providing the treatments, are the we the health insurance payers to provide affordability to the population? Or device companies, or research institutes, or IT tech companies? And I believe we are collective. I think all of what we have discussed should be included in the “we” that I’ve suggested.
And if we were to mention about the implementation science in regarding to how can we scale the programs that we’re developing today? I think it’s really important to have this mentality, this is where business and clinical medicine comes to join together. To have the mentality of the business model. But rather than business it’s more of a public health model. By not only considering what kind of technology or digital health technology, not only that, but also the products, the treatment, the human capital. What kind of value are we providing to what kind of patients, and potential patients, and what kind of channels are we going to deliver that value and services or treatment to those targeted patients? And what kind of relationship are we to maintain with the target audiences?
Yes, that’s the outer loop of an agency or initiative. But what kind of activities and what kind of resources are needed to conduct these activities to generate, to provide the value, and deliver the value to the potential patients. And who are the key partners? I think Dr. Ningli Wang and Daniel have mentioned closely who should be partners. And I think we’ve had a lot of good examples of how to work along well together. And the key issue, not only that is maintain a very healthy and organic program or operation by gaining enough revenue, and understanding what are the cost structures to make it sustain and make it a long-lasting operation.
I would like to, sorry, it’s a very short and brief idea of suggestion. But I would like to end my presentation with a book that I really like, written by the creator of The Wire, from Kevin Kelly. He mentioned about the inevitable trend that’s coming, that’s facing us from this year and to the next decade. Including cognifying related to how to apply artificial intelligence technologies into our daily lives but also in clinical care. How we, as health care provider, to interact with the patients, but also the patients between patients. The data flowing and how do we become a sustainable eye care organization? How the screening technologies get used to potentially identify potential patients, and for those who we need at which location? And what kind of accessing technologies can we provide to the target audiences? How can we share our knowledge, how to filter the thousands and hundreds of millions of information everyday that we accept from the media? And how do we remix and collaborate by joining our resources together to implement those technologies and services, and how to generate values to our target audiences?
Tracking. And we’ll be able to use our mobile health technologies to track enough daily health information from the potential audiences in order for us to generate precision medicine and clinical services. And to continue to ask questions of ourselves to look for additional answers and by using cognifying artificial intelligence, we could shorten and reduce the gap between the questions that we ask and the answers that we identify.
So thank you so much for your attention and I would like to listen and learn more from all of you and share more ideas from you. Thank you so much.
[Ningli] Thank you, thank you, young man, or young generation, Dr. Xingru. Your talk brings us to the new paradise. I hope we can use AI technique to improve our eye care and give us the opportunity to promoting the eye care in the future.
[Xingru] Thank you, I’m looking forward to the collaboration.
[Ningli] Thank you very much. I’m greatly honored to be a monitor for the next sensation. Now let’s move to the Dr. Tina, public health specialist with 12 years experience. She will give us a presentation to introduce the new progress and achievement of public Health in Zambia. Please, Dr. Tina.
[Tina] Good morning, good afternoon, and good evening, everyone. And warm greetings from Zambia, southern Africa. My previous speakers have been speaking on a global level as well as a regional level. I’m going to speak on a country level.
And this is not specifically on trachoma, which causes blindness, but an overview of the whole neglected tropical diseases in our country in Zambia. The next speaker is going to focus on trachoma and that’s another person from Zambia.
Zambia is a small country in southern Africa, it has approximately 18 million people. And we are also affected by neglected tropical diseases. What we hope to do, as a country, is to have a Zambia free of neglected tropical diseases. And of course, to eliminate NTDs in Zambia by 2030. We have various strategies that we’ve put into place and of course, like other countries, we contact mass drug administrations, using preventive chemotherapy for the neglected tropical diseases that are endemic to Zambia. And we also have enhanced surveillance of neglected tropical diseases in order to improve management so that all cases are promptly treated.
We try to formulate health promotion programs that are aimed at preventing and reducing neglected tropical diseases. Some of our other strategic objectives are to sustain the elimination of leprosy, as Zambia, we have achieved elimination of leprosy. So we have enhanced surveillance of leprosy. This is through implementation of our treatment guidelines as well as strengthening coordination between stakeholders involved in neglected tropical diseases control and elimination.
We try to integrate the neglected tropical diseases control activities into our primary health care services. And this has been through production of data capturing tools as well as including control of neglected tropical diseases in the health care of professionals.
This slide shows you the three neglected tropical diseases, their endemicity in the country, and what drugs we’re currently using from the mass drug administration as a strategy for elimination. This again, shows you the actual endemicity. You will see we are affected by the lymphatic filariasis throughout the country, as well as soil-transmitted helminthiasis, and schistosomiasis.
In terms of lymphatic filariasis, this is endemic in 94 districts of our 117 districts in Zambia. We have conducted four rounds of the five/six MDAs in all the 10 provinces and we hope that we should have attained our elimination. And we’re expecting to do the fifth round this season of 2020-2021 in all the 10 provinces. So after that, we’re going to do a coverage survey and also conduct a pretest to see if we have reached the elimination status. However, Sentinel and Coverage Surveys so far conducted for each of the four rounds have shown a positive trend.
This is some pictures that we still have case identification of lymphatic filariasis in our communities, we contact our mass drug administration activities in the community, using community health workers as our support staff.
In terms of trachoma, trachoma is endemic in 50 districts of 117 districts in Zambia. And we again, as I mentioned, continue to conduct trachoma campaigns and this has helped us in confirming elimination in at least 26 districts. And this implies that five million people have been treated through mass drug administration. We have 18 districts that are due for MDA in 2021, and then we continue to provide trichiasis surgeries in different districts and we’re yet to do that in 12 districts of our national trachoma elimination program.
Endemicity, you will see the red zones as showing that we still have active trachoma, and then the dark green zones are showing that they are trachoma-free. So all in all, we’re trying to say that there is a vision for us to eliminate trachoma in our country and we continue to strive to make sure that we eliminate trachoma before 2030.
This just shows a picture of one of our community health workers conducting the door to door MDA for trachoma. We must say that we commend our community health workers for supporting the Ministry of Health, even during this pandemic. We continue to use our community health workers, of course in the safety of the pandemic.
Schistosomiasis is another disease that is endemic in Zambia in 103 of our 117 districts. The estimation of schistosomiasis has so far been conducted, has been very difficult because of different issues to do with implementation and the geographical coverage by province. However four provinces, comprising of 43 districts, may benefit for schistosomiasis MDAs by the end of 2021. We will conduct impact and coverage surveys throughout our districts where schistosomiasis is said to be endemic.
This slide is showing you some of the trends of therapeutic coverage over the years since we’ve been doing MDAs for the four diseases. You see that as has been alluded to by the previous speakers, we continue to encounter challenges in some of the diseases. But I must say that some of the diseases are actually well in terms of trend for therapeutic coverage, such as trachoma, which is in red. And soil-transmitted helminthiasis which is in green. However lymphatic filariasis has been performing very well and continues to perform well. And unfortunately, for schistosomiasis, as earlier alluded to, we are seeing a decline of therapeutic coverage.
How are we faring with some of our colleagues, or our countries, our neighbors in the region? We are doing quite well in Zambia. If you look at the country coverage index compared to other countries, we are not in green yet, but we are in amber, meaning we’re progressing from 25% to about 75% coverage. In terms of our treatment coverage, as of 2017, we had quite good coverage for lymphatic filariasis at 93%, for blinding trachoma at 61% and for intestinal worms at 58%, and bilharzia at 30%.
In terms of the treatment coverage increases or the trends we have been increasing from 2016 to 2017, you will see that for lymphatic filariasis, we had people needing treatment at 12.2 million. But those that received treatment were 11.37 million. And for blinding trachoma, we had a treatment coverage that increased from 41% in 2016 to 61% in 2017, meaning that we are trying to make sure that we have the people who need that treatment get the treatment. Similar trends have been seen in soil-transmitted helminthiasis as well as in bilharzia.
In terms of challenges, I would just focus on a couple of them. Coming from the government side, we continue to have inadequate resources as been alluded to by the previous speakers. And of course, we have to find a way in which we can work with different stakeholders and not just the Ministry of Health or government working with international organizations, but really bringing in the communities to be a part of this fight to ensuring that we eliminate neglected tropical diseases.
The uncertainty of weather patterns, we have had some floods in some of the parts of the country, and this has really affected the implementation of our program. And of course, as everybody knows, COVID-19 the pandemic, has really affected the way we conduct business. Of course if our major strategy is mass drug administration, it makes it very difficult because then the interaction with the community is very enhanced and it becomes a risk for the health workers, as well as the community health workers. So this has made it really challenging in conducting and ensuring that we complete all our rounds of mass drug administrations, as well as the coverage surveys that I earlier mentioned.
So with that, I’d like to thank all our partners. And make sure that, in conclusion, we have reached elimination, or almost reaching elimination for lymphatic filariasis and trachoma. There is need to find innovative and sustainable interventions to ensure that the gains achieved in the program are not lost. And of course, continued global efforts are needed to ensure that all neglected tropical diseases are eliminated.
I would like to thank Orbis for giving me this opportunity to come and speak on this platform and of course we will ensure that we continue working together to make sure that we have a Zambia trachoma-free by 2030. I thank you, everyone, and hope to continue listening in.
[Ningli] Thank you, thank you for your presentation and here’s a congratulations that your achievement in your country and there’s good news. You’re almost come to the elimination of the trachoma. Now let’s move to the next speaker. The next speaker will be the presented by Lucy, who is Country Director of Orbis International-Zambia. She has 17 years of the work experience in public health and the development. She will introduce neglected tropical disease work on the trachoma. Welcome, please.
[Lucy] Thank you very much. Good morning, good afternoon, and good evening, everyone. Thank you for this opportunity. So as I was introduced, my name is Lucy Nadaf, I am the Country Director for Orbis in Zambia. And I am going to briefly share what we have done as Orbis Zambia in terms of trachoma activities.
Briefly, that’s just about Zambia. We have a prevalence of blindness at 2% for population of 17.9 million people. That’s the number of estimated blind people, about 340,000 people. The moderate to severe visually impaired is at 202,846. Childhood blindness stands at 0.9% per 1,000 children. And we basically have a problem, challenge with human resources for eye health with one ophthalmologist per one million people.
Our cataract surgical rate stands at 732 per million. And for Orbis Zambia, the focus in terms of our programming is basically childhood blindness, adults cataract, as well as comprehensive eye health. And we also are looking at human resource for eye health that is basically training. We work in three regions in the country. The northern region, called the Copperbelt province where we have a childhood blindness project, we’ve been there for 10 years. In North-Western province where we have trachoma prevention activities, as well as adults cataract programming. And the blue circle which is basically the capital. This is where we are in implementing comprehensive eye health as well as human resource for eye health.
Basically, we as Orbis Zambia, in collaboration with the Ministry of Health, and other eye partners have been responding to the trachoma response, the NTD response, through trachoma prevention activities and working under the SAFE strategy. Having started our work in 2014, and the last activities that we had around trachoma was 2019. We’ve had funding from Standard Chartered Bank, through the Seeing is Believing project, as well as the UK Aid and the Queen Elizabeth Diamond Jubilee Trust to conduct MDA activities and basically in the North-Western province of Zambia, as well as one MDA that we conducted in 2017 in the Copperbelt province of Zambia.
And in terms of our activities, we had reached about 1.2 million people with antibiotics. And part of this is also a combination around information dissemination and awareness. So this has been talked about in terms of educating our communities. Most people don’t even know they have trachoma. And basically not just sticking to trachoma, but also talking to eye health in terms of information and awareness.
This is basically a short history of our work. 2014, we started our first activities around trachoma, working on MDA for one of the regions in North-Western province where the tier of 10.4%. We conducted three MDAs in that region in 2014, 15 and 16, and the tier was reduced to 2.78%. We also conducted one round of MDA in the Copperbelt province where the tier was 14%. And after an impact survey after a year that came down to 2%. So it’s still under surveillance. 2018, we did receive a grant and conducted three MDAs again in North-Western province and in three other districts, and we are awaiting impact survey results in that one as well.
Unfortunately, the first district where we started, where the TF came down to 2.78, now has active trachoma prevalence of 5.8 and the plan is to conduct another MDA in that region. And that is just a summary of our performance. Where we talked about having reached about 1.2 million people and of our performance of about 98% across the two provinces.
This is just our recognition for our work. The Queen Elizabeth Diamond Jubilee Trust and working with other partners within the country. Where we were awarded recognition for our work. Thank you. That was very brief.
[Ningli] Thank you! Thank you very much for your excellent presentation and work in Zambia. Now, let’s move to our next talk. We’re meeting with Dr. Fikreab, to introduce Ethiopia Trachoma Control program. He’s a Senior Technical Advisor for the Trachoma and the Neglected Tropical Diseases in the Ministry of Health Ethiopia. And has over 13 years of experience in public health and the community development programs. Please welcome.
[Fikreab] Thank you Mr. Chair, and good morning, good afternoon, good evening, colleagues and friends. I am Fikreab Kebede the Senior Technical Advisor for Neglected Tropical Disease Ethiopia. I would share with you Ethiopia’s Trachoma Control program, some experiences.
For those of you who might not be familiar with Ethiopia, Ethiopia’s located in Africa in the Eastern border, usually called the Horn of Africa. The population of Ethiopia is estimated close to 120,000 where the population is fairly relatively young with median age of 19.5 years. The life expectancy for men is 63, while it is 67 for women. Four in five Ethiopians are living in rural areas, mostly they are farmers. We have a diversity of ethic groups. There are over 80 ethnic groups overall in Ethiopia with diverse language, different language, cultures and so on.
Ethiopia’s Trachoma Control Program, the NTD vision, is an NTD-free Ethiopia which ultimately contributes to the vision of the department of health of government, to see healthy, and productive, and prosperous Ethiopians. The mission of ending NTD program is to have an integrated NTD strategy which will help to control, eliminate, and eliminate neglected tropical diseases and replication of tropical diseases.
The trachoma goal is in line with the global Vision 2020, elimination of blinding trachoma by 2020. Of course, this is not realized now globally, as well here in Ethiopia, we are revising that target. I’m sure in the next few months we’ll have a national NTD master plan where we will add this trachoma also to the health system. The target is also quite in line with the WHO which is to bring trachoma less than 5% among children one to nine years old and trachoma trichiasis unknown to the health system of less than .2% in adults age 15 and older.
Some major milestones in blinding trachoma elimination program in Ethiopia started in 2001, that followed the adaptation of Vision 2020 by the WHO and also by the government of Ethiopia. In 2001, the National Steering Committee was established and in 2002, Azithromycin was registered to be treatment for trachoma, especially for mass drug administration. In line with that, in 2003, SAFE intervention was started in three districts as a pilot with the support of some non government organization. And that actually paved the way for the first national survey on blindness, low vision and trachoma that was conducted in 2006. And this was also followed by trachoma baseline mapping in Amhara regional state in northern part of Ethiopia, which was 2007 to 2010, which was a part of the Carter Center.
That was followed in 2013 and 2014 with Global Trachoma Mapping Project that was conducted in other 672 districts. So now we know, of course, the intent and magnitude of the problem where we have to strategize to prioritize our action involved.
Following that national surveys, we have started the first massive scale up of trachoma elimination program in the endemic districts. So not only in Amara, but the program was launched all over the country. In 2015, one of the problems that we had which we saw from the mapping exercise was trichiasis was really very, very high. So the honorable minister, Dr. Kesetebirhan, launched Fast Track Trichiasis Initiative to clear TT surgery backlog in all Ethiopia.
By 2020, around 150 districts have stopped MDA which is really, which is a major state for our elimination of blinding trachoma. As I said earlier, the SAFE strategy is the one that we are applying and also that is being implemented in trachoma in the weaker districts.
This map on the left side shows the trachoma follicles distribution in 2015, just after the mapping and on the right side, the progress made in trachoma elimination through mass drug administration by 2020. So you can come to the orange and red painted districts, that was very, very large and also some of the yellow ones. That on the right side you can see that the red and orange ones have shrinked, and more green and yellow colors have emerged, that the trachoma, mass drug administration of azithromycin has really affected it. And it’s promising that it’s progressing in the right direction.
Just to show you the progress azithromycin made in mass drug administration, on the left side you can see the trends in azithromycin treatment, the number of districts have increased. So it was like185 districts by 2020, in 2014 that has really jumped to 238 and reached around close to 600 districts by 2019. Of course, by now some of the districts have stopped and that number comes down. And also on the right side you can see the treatment, the doses that are being administered. So it depends with the large volume of population with trachoma and it has really distributed millions of azithromycin tablets in the past years. And you can see that the support of the international community is very appreciated and they were very generous and we appreciate that one.
As I said, around 150 districts have stopped MDA by the end of 2020 and currently we are also gained some assessments. This number might also increase in 2021. To show you the situation of trachoma in graphic wise. There were around 839 districts in the country of which 679 were endemic, 657 were requiring intervention with azithromycin. That number is now 576, but you can see the number of districts 679 but by 2020, it was 726. Meaning that some of the districts which a large size of population have split in two, sometimes in three, so the number of districts of the country for observational purposes, are increased. The number is relatively large as you can see. And on the right, far side, you can see also the population at risk. Close to 90 million of the population, that is almost 90% of the population, is living in trachoma endemic districts. That number is coming down, but the burden is really very, very huge.
Almost now around 50% of the trachoma burden in Sub-Sahara Africa is in Ethiopia. Meaning that it appears there’s a lot to do and it’s collaboration and support from the international community should be more strengthened.
Trachoma trichiasis in Ethiopia again in 2015 and 2020, you can see the red and orange colors of most districts, this was really very huge. But on the right side you can see that the map has trained heavy intensity of trichiasis. So it decreases more, more districts are coming now free from trichiasis meaning that the number has really gone down below 0.1% among adults 15 and older. When we see that one, with the size of the population is really it was very, very huge. So there is by 2015, there is close to 700,000 estimated trichiasis cases to manage in 680 woredas. By 2020, the number of endemic woredas has gone down to 715, our target woredas. 115 districts that are reaching elimination threshold where new cases emerged of course, so by the trichiasis elimination, the Fast Track Initiative, we have done almost 80% of the backlog. But now with new cases and so on, the estimated TT cases from tracking service stands close to 300,000 and we have launched a plan to clear that one in three years time.
With F&E, that’s one of the challenges when you have a large area of endemic districts with various geography, some of them in dry areas, some of them in mountains, gorges and so on. So F&E is really a challenge, but there are some promising efforts. The government has one national problem for WASH: water, and sanitation and hygiene. So the Minister of Education, Minister of Ethiopian Culture, Minister of Water Resource and so on, they are part and parcel of this national effort. The Minister of Health is leading the soft component of the WASH, where the other sectors, especially the Minister of Water Resources, is responsible for the hardware. Of course, one of the primary targets for WASH. We are working very closely with the government in creating access to sanitation and water facilities, but also with good practice in hygiene as well.
There is a national coordination mechanism, now with regards to NTD. That platform actually has made an assessment of the landscape, with WASH NTD, by now we know which districts have high endemicity. With endemicity, we strive for more hygiene and so on. And at the same time we know which districts are not behind with WASH interventions. So with this landscape, now we are retargeting our integrations. Both at the ministry and also with our stakeholders and hopefully that will also help to be picked up.
The key challenges that the Ethiopian Trachoma Control Program faces is one is access to services. High proportion of TT cases are unknown to the health system, above 75%. Even though the trachoma mapping and part of the national surveys tells us there are still cases through central mobiliation and also cases are cast off and thrown away, it’s really very difficult to get the TT cases.
The other reasons are the weak quality assurance, they can’t get the post op follow up, especially at three to six months. Almost 50% of patients who are operated aren’t showing up for a follow up. Meaning that we have a post op trichiasis around 15% at six months, so that’s also one challenge. For quality and especially also for surgical uptick of new cases.
Another problem that we’re also facing is recrudescence, especially in those areas which are stayed for three years under surveillance and after getting the minimum threshold of less than 5% are now almost 50%. Half of the districts are going back after stopped MDA for another round of treatment. So that’s also a challenge, meaning that maybe we have to look for the reasons, but also at the same time we have to see also if any components are sustained and practiced for cleanliness and any environment improvement.
Integration of TT surgery service is a primary another challenge because the African behavior is very, very low, especially in remote areas where people are living far from trichiasis surgery services. So now the government, we are working that every health center is targeting around 25,000 population to have one integrated eye care worker so that the trichiasis surgery service will be more accessible to people living in remote areas far away from big towns.
Another is access to wash facilities. And this one thing, as I said, the wash facility landscape assessment report will help us to monitor and see that F&E screening will address one thing that the government with stakeholders is that trachoma will be used as a proper indicator for Minister of Water Resource and so on. So when they are doing water activities, so they have to see not only access but trachoma is really brought down.
Another problem is sustainability and financing. As we know that most of the funds is coming from outside sources, so this is a challenge. Once we meet the threshold for elimination, and actually for scaling up. So we need that sustainability and now we are working out on the national master plan for NTDs that runs from 2021 to 2025, for the next five years, for sustainability. And domestic financing will be high in the agenda of that master plan.
I thank you again for your attention as well as giving us the opportunity for us to share our experiences. Thank you.
[Ningli] Thank you, thank you very much for your talk, presentation and thank you for your introduction about the WASH target and the missions.
Last but not least, let’s please welcome Dr. Alemayehu to summarize the trachoma elimination in southern Ethiopia. He’s Orbis’ Country Director and the senior ophthalmologist. He’s one of the leading trachoma experts globally and a strong advocate for comprehensive eye care to help to improve the lives around the world. Also he’s a member of the International Corporation for Trachoma Control. And the National Trachoma Task Force. Today, he will share the progress in the elimination of the trachoma in southern Ethiopia with us. Please.
[Alemayehu] Thank you very much for the kind introduction. Good morning, good afternoon, and good evening, everybody around the world. Today I’m going to share with you a very highlight of Orbis’ work in our attempt to eliminate blinding trachoma.
I’d like to thank Dr. Fikreab to give us a general highlight of what has been done over the years in trachoma elimination. Orbis’ trachoma work is focusing in southern nation, national people and people’s region. It’s located in the southern part of the country. It is the third largest region in terms of population and geographical area and we have been implementing trachoma control program in the region for the last 22 years now.
So far we have administered, I will go to present in the WHO recommended SAFE strategy way. So I’ll focus on the A part first. So far we have administered 74.4 million doses of Zithromax across the two decades. Over the years we have been expanding to cover the whole region and as it stands now, we are 100% coverage of the region in terms of SAFE implementation. As you can see, on the map over the years, we have still increasing the MDA coverage of endemic districts. And in 2020, the graph shows a slight decline in terms of MDA coverage and that’s because we are doing a lot of impact surveys. And based on the results of the impact survey, we may be able to continue in some districts and we may declare elimination of TF in some of the districts.
The large bulk of our MDA has been distributed over the last five years as we expand to achieve geographic coverage. In terms of trachoma trichiasis, we have performed 168,773 TT surgeries. Our trainings are based on the WHO recommended midlevel eye care worker training for trachoma trichiasis management. And we have conducted this number through those midlevel eye care workers. All the continuing education, quality assurance, and assessment has been in place.
To do trachoma trichiasis surgery, we have to establish primary eye care units. These are the link between communities and secondary and primary eye care units. And train nurses to provide trichiasis surgery and also train community members in the identification and referral of those cases. In 2020, we have under 60 functional primary eye care unit, providing trichiasis surgery on a regular basis.
About F&E activities, I think we have done 126 communal latrines. Mainly in schools and in public gathering areas. And these are model constructions that our community members could take the lessons and come up with their own version of latrines. Be it communal or private. We also focus on water development, so far we have protected 36 water point protected and create networking to provide water to community members. I think that wash partners are significant in this regard by providing resources, experiences, and other required technical areas.
In terms of researches, I think we conducted more than 100 trachoma related researches and we have published significant part of those research on peer-reviewed journals. We also conduct baseline and impact assessment based on the WHO-recommended at Global Trachoma Mapping Project, and also recently adopted Tropical Data Systems, particularly in terms of conducting trachoma impact surveys. And we also do a lot of operational researches, particularly in trying to improve trichiasis surgery. Because recurrence is a major challenge in terms of achieving the management of trachoma trichiasis.
Having said that, over the years, more than 26 districts have achieved the WHO elimination target, particularly for the active infection. And as we speak, our team is doing a lot of trachoma impact surveys and that result will tell us how successful we are. This is just a high level summary of our trachoma control activity in Ethiopia. But generally we are implementing comprehensive eye care services, ranging from community level to tertiary level eye care facility, providing human first development infrastructure support, and also working research to influence policy in eye care, and bringing NTDs in eye care into the development agenda.
With that I conclude my presentation and thank you so much for the opportunity.
[Ningli] Thank you, thank you very much. Thank you to all the speakers here give marvelous presentation and shared their experiences from the different countries and regions. So our meeting will come to the end. I’ll lead it back to Dr. He, our co-chair, to make the conclusion and the summary. Dr. He, please.
[Wei] Ningli, before closing the session, we have two questions remaining on our question board. One is for Professor Ningli. Ningli, can you answer this question?
[Ningli] What is the questions?
[Wei] “Ningli, thank you for your presentation. As we know, Africa, Ethiopia, have the highest incidence of trachoma in the world. How is China going to help Africa eliminate trachoma as in Africa as it has been done in China? Is it a human resource, development, infrastructure, or any other thing? Thank you.”
[Ningli] Okay, it is a good question. We just think about to summarize the experience, the technique we used in China and we really like to share the experience, the technique with our friends from Ethiopia. Please contact me by email and right now our teams will work up on the summary of the trachoma elimination, the experience, and the technique from the China aspect. So we will send what you like. The experience, the technique, maybe we can have some kind of surgical instruments for the trichiasis surgery. That is my answer.
[Wei] Thank you, Ningli. Here is a comment on the question board from Dr. Raymond in Obachari, “Blinding trachoma is still a public health issue in Nigeria, especially among citizens living in north part of Nigeria.” I want to combine these comments with the following discussion focusing for how to integrate multiple resources to address NTD in Africa and strengthen our health capacity. I hope our panel discussion for five minutes then we have a summary of this meeting, together with Ningli.
[Ningli] So maybe some talk from the African countries to give the answer to him?
[Daniel] This is Daniel here. I can quickly address that problem, can you hear me?
[Daniel] Yes? Okay. I think this has been an ongoing challenge in Africa because when we started Vision 2020, I think it was good to have an initiative that was a separate initiative because that’s the only way that we could quickly get some momentum and bring the visibility to a national level. But what we have also discovered now, that I have activities and blindness prevention activities cannot continue to go in isolation. Because when you look at the country level, the resources are limited for the various interventions.
And at the same time, in many countries, prevention of blindness activities are funded sometimes up to 80% only on the input of NGO, international NGOs, and other international partners. Which is not a sustainable way to look at it. So we all understand now that if we have to sustain our activities, we need to seek how to link with other forces within the countries. And I showed you one of the diagrams where we have many more players at every level. Whether you talk about training, not only the Minister of Health or NGOs support training, there are many others who are involved in training and we have not really worked with them enough so far. And the same is true when it comes to funding. I think the challenge is in all of us to become creative.
[Wei] Thank you, Daniel. Anyone have comments regarding how to integrate multiple resources? Address NTD and other blindness-causing problems in Africa and strengthen the health capacity?
I got a message from Alex Yabio, he comments that, “China is advanced in terms of technology. My question is how can China assist Africa with the technology in eye health?” I give some comments on this, as China do have advanced technology now, especially the cloud-based internet solution for remote early diagnosis by screening. There are a lot of devices available, use less professional, cost-effective, and no limits for distance. That’s especially useful for using in the subserved area with less ophthalmology and optometry. Which can be really good, can be well used in Africa region. I write down my email there and I’ll ask the social responsibility department, the director, Hilin, she will connect you to see what kind of help you need and what we can. We’ll try our best to supply any possible help. Thank you.
[Ningli] Maybe Dr. He Xingru. He has some suggestions for these questions? Xingru?
[Xingru] Yes, thank you Dr. Ningli. Thank you, Alex. I think before we can discuss further, I think it’ll be better to complete your question more in detail. For example, when you say technology, it’s pretty broad. And about how China can assist Africa, I think it’s pretty broad too. So if you could kindly write your question more in detail? For example, what kind of technology? Are you saying existing devices or are you more talking about mobile health technologies, or applications, or more like artificial intelligence algorithms? I think once you list out all your needs, I think it’ll be really helpful for us to understand how exactly we can exchange our more detailed collaboration efforts in the future. Sorry I couldn’t answer your question, it’s pretty broad, so please forgive my straightforwardness. (laughs) But please let me know, if you can reach Wei, you can reach me. So I’m looking forward to talking to you more.
But in any aspect, I think this type of joint collaboration will be very important. But please bear in mind that I think it comes back to the business model that I presented. Will come back all the time, that is how we can jointly help each other would be the key question. So I’m really looking forward to talk to you more if necessary. Thank you.
[Daniel] Xingru, is it possible for me to add, to make a quick comment following what you’ve just said. I think it’s important that we realize there’s a lot that is being said right now in terms of new technologies, artificial intelligence. I think in most places in Africa, what we need in priority is actually to build an infrastructure. And having visited some of the infrastructure in China, I think that that’s an area where you can help us the most. But it will mean, on our part, that we identify those people who are likely to be trained, to be in power, so that they can come back. And then with your help, establishing those. There’s a lot that can be done right now in many parts of Africa, but we can’t do it in a piecemeal manner, you need a system, you need an infrastructure, and you need a vision for short, mid and long-term.
[Xingru] I see, that’s a good point. Thank you, Daniel. And I think there’s also, even though Africa might be the late coming group in regarding to how to establish the infrastructure, it’s actually there’s a certain advantage for Africa and for many African countries. Because you can witness the development of how other countries, what kind of mistakes other countries have made, try to avoid the same mistakes in order to establish an African model alone with a specific, unique model that could be established there. And I’m looking forward to working closely with everyone in the field of eye care to establish an African model of blindness prevention.
[Wei] Yes. Time is passing. The ultimate goal of medical research education is to serve the society and get rid of illness. Today we keep our appointment for the bright future. Our common ideal and belief enable us to grow the space, gather in online forum, share experiences, and seek a common interest for the eye health of African people. I believe that what we share at the meeting today will become the driving force for the innovation and the development of eye health in African countries in the future.
Thanks again, to each person, for your experiences, works and suggestions, for the development of eye health in African countries. We expect to jointly move forward to view the brighter future and make new and greater contributions to the high quality development of global eye health. Thank you. Professor Ningli, please provide your insights on this meeting and close our summit. Ningli.
[Ningli] So again, thank you, everyone, thank you. Every participant and thank you for contributions and we have a very good time to share the experiences. I hope in the near future we can hear the good news from the different countries and the regions. Let’s, hands in hands together, to fighting the blindness in your country and all our country. Thank you.
[Wei] Thank you, Ningli, and all colleagues. As we all know, the city tower called the Window of the World, is located in Shanghai, China. It is a landmark in China. Let’s celebrate the World Neglected Tropical Disease Day and see the lighting of the tower.
January 31, 2021