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National Trachoma Program
Trachoma is a disease of the eye caused by an infection with the bacterium Chlamydia trachomatis. Infection spreads through the personal contact (via hands, clothes or bedding) and by flies that have been in contact with discharge from the eyes or nose of an infected person. With repeated episodes of infection over many years, the eyelashes may be drawn in so that they rub on the surface of the eye, with pain and discomfort and permanent damage to the cornea. This permanent damage will lead to blindness from trachoma which is irreversible. A simplified WHO grading system for trachoma comprises five signs- trachomatous inflammation-follicular (TF), trachomatous inflammation-intense (TI), trachomatous scarring (TS), trachomatous trichiasis (TT) and corneal opacity (CO). (please refer to annex for details on simplified WHO grading system for trachoma).
As of June 2020, trachoma is a public health problem in 44 countries, and is responsible for the blindness or visual impairment of an estimated 1.9 million people. Some of the root causes of trachoma are unhygienic conditions (leading to inadequate facial hygiene) and lack of total sanitation in rural areas which serve as breeding ground for vectors. The World Health Assembly adopted resolution 51.11 in 1998, targeting the global elimination of trachoma as a public health problem. The elimination strategy is summarized by the acronym "SAFE", which means Surgery for advanced disease, Antibiotics to clear C. trachomatis infection, Facial cleanliness and Environmental improvement to reduce transmission.
2. EPIDEMIOLOGY OF TRACHOMA
The national epidemiological survey of blindness in Nepal, conducted in 1981 showed trachoma as the second leading cause of preventable blindness in the country after cataract with active trachoma being endemic in several districts of the hills and plains where prevalence rate was as high as 23%. Starting in 1990, Nepal Netra Jyoti Sangh (NNJS) worked to successfully reduce trachoma prevalence in endemic areas through the implementation of a community-based trachoma control program. While progress was made in disease reduction, there was still a tremendous amount of work to be accomplished. To end this, Ministry of Health and Population (MoHP), NNJS, Department of Water Supply & Sewerage (DWSS) with the support from International Trachoma Initiative (ITI) initiated the National Trachoma Program (NTP) in 2002 to achieve the goal of eliminating trachoma from Nepal. This initiation was further supported by USAID funded Neglected Tropical Diseases (NTD) control program implemented by RTI International and technically supported by WHO. The WHO endorsed SAFE strategy was implemented in all endemic districts with great dedication and collaborative approaches.
Trachoma rapid assessments (TRAs) followed by prevalence surveys were carried out nationwide and from 2002 to 2014, full SAFE strategy were rolled out in 19 districts in which the baseline prevalence of TF in 1–9 year-olds was ≥ 10 % (Kailali, Kanchanpur, Chitwan, Nawalparasi, Banke, Bardiya, Surkhet, Dailekh, Rolpa, Doti, Achham, Bara, Parsa, Sarlahi, Rasuwa, Rukum, Dang, Kapilbastu and Rautahat) and one additional district (Baitadi) where baseline TF prevalence was 4.5%. Impact and pre-validation surveillance surveys conducted between 2014 and 2017 showed the targets for elimination of trachoma as a public health problem had been met in all 20 formerly-endemic districts.
The following technical indicators must be met for validation of elimination of trachoma as a public health problem:
Table 1: Technical indicators considered for attaining elimination of trachoma as a public health problem
Trachomatous inflammation- follicular (TF)
|Prevalence of TF in children aged 1-9 years of < 5 % in each formerly- endemic district|
|Trachomatous trichiasis (TT)||Prevalence of TT “unknown to the health system” in adults aged ≥ 15 years of < 0.2 %|
|TT surgery services||Evidence that the health system is able to identify and manage incident TT, using defined strategies, with evidence of appropriate financial resources to implement those strategies|
Note: TT “unknown to the system” excludes TT in individuals with post-surgical recurrence, TT in individuals who have refused surgery, and TT in individuals who are listed for surgery but have not yet received an operation, but for whom a surgical date has been set.
3. NATIONAL TRACHOMA PROGRAM
Eye health activities in Nepal fall under the Ministry of Health and Population which has also engaged Nepal Netra Jyoti Sangh (NNJS) and other eye care service providers to manage eye health activities in Nepal.
The National Trachoma Program was set up in 2002 jointly implemented by MoHP, NNJS, DWSS, RTI/ENVISION, and ITI. The goal of the NTP was to eliminate trachoma as a public health problem by the year 2017.
The NTP has an independent Project Steering Committee (PSC) which meets quarterly and composed of the following members: NNJS, DWSS, MOHP Policy, Planning and International Cooperation Division (PPICD), Epidemiology and Disease Control Division (EDCD), Department of Health Services (DoHS), the World Health Organization (WHO), and the National Planning Commission (NPC). Invited guests include the Health Secretary MOHP, Director General- DoHS, and Director- Logistics Management Division, DoHS. Policy level decision making, and strategic direction is set by the PSC.
The National Trachoma Program in close collaboration with NNJS, mobilized the district-based eye hospital staff to conduct district-level trachoma rapid assessments (TRA) and baseline, impact, and pre-validation surveillance surveys for trachoma. Survey activities were directly supervised and monitored by NNJS/NTP. Prevalence data from surveys were used to make programmatic decisions on implementation of the SAFE strategy in accordance with WHO guidelines.
The national trachoma program was initially established as a vertical program which later was integrated in 2005 to allow for program expansion to all trachoma endemic districts. NNJS was responsible for the surgical component of the SAFE strategy; MoHP structures were used to conduct Zithromax® mass drug administration (MDA) with support from ITI and RTI/ENVISION; facial cleanliness and environmental improvement activities were carried out by the NNJS/NTP, Ministry of Education (MoE) and the DWSS; and WHO provided technical support.
A dossier on validation of elimination of Trachoma as a public health problem in Nepal was submitted to WHO in early 201¬8. After evaluation of dossier by an ad-hoc Dossier Review Group, in accordance with its standard operating procedures in May 2018, WHO validated Nepal as the first country in its South- East Asia Region to eliminate trachoma as a public health problem.
The MoHP, Nepal is committed to sustain the elimination status of trachoma in Nepal. While Nepal has successfully eliminated trachoma as a public health problem, with any disease elimination status attainment , it is crucial to recognize that the validated status is reversible and ensure that the surveillance is adequate to ensure timely detection of any upsurge.
Now NNJS is planning to start the Post Validation Surveillance of Trachoma with the support of Ministry of Health.