A Roadmap for Taking Togo off the List of Trachoma-Endemic Countries
March 31st, 2017
A leading infectious cause of blindness worldwide, trachoma is a disease caused by the bacterium Chlamydia trachomatis. Trachoma has not been considered a big problem in Togo because baseline studies in 2006, 2009, and 2011 had shown that the prevalence of trachomatous inflammation—follicular (TF) (an early form of the disease that indicates active trachoma infection) among children 1 – 9 years was below 5% in all the districts.
World Health Organization (WHO) trachoma control guidelines indicate that mass treatments with trachoma medicines are not necessary when the prevalence of trachomatous inflammation—follicular (TF) (an early form of the disease that indicates active trachoma infection) among children 1 – 9 years is below 5% in every district.
The WHO has set a global goal to eliminate trachoma as a public health problem by 2020. However, because the prevalence of trachomatous trichiasis (TT), a more advanced stage of the disease, has exceeded 0.2% (i.e. 2 in 1,000 people) in individuals 15 years of age and older in some areas, Togo has remained on the list of trachoma-endemic countries. To be removed from this list, Togo must act to address the TT situation and to reduce the prevalence of TT to less than 0.2%, the elimination criteria outlined in the WHO guidelines.
With the help of the END in Africa project, health officials have initiated efforts to address the trachoma situation in Togo. A meeting of trachoma experts was held in Lomé, Togo on March 1–2, 2017, to review all available data and determine the way forward for the elimination of trachoma in Togo. Organized by the National Eye Health Program in the Directorate of Health Action of the Ministry of Health (MOH), the meeting gathered experts from the WHO, US Agency for International Development (USAID), Sightsavers, FHI 360, the United States’ Centers for Disease Control and Prevention, and the MOH, to review the 2006, 2009, and 2011 trachoma surveys and other data and to propose a strategy to eliminate trachoma as a public health problem in Togo by 2020.,
Review of the results of the 2006, 2009 and 2011 surveys confirmed that while TF prevalence was below 5% in all districts, TT prevalence was above 0.2% in some districts. An estimated 864 TT cases must be identified and managed through surgery or epilation to reach the criteria of trachoma elimination in Togo.
Sightsavers has been supporting an ongoing project since 2015, with the objective of identifying and managing 500 out of the 864 TT cases. To date, slightly over 200 TT cases have been identified and managed by the National Eye Care Program.
The END in Africa project, through subgrantee Health and Development International (HDI), conducted a nationwide search for TT cases during a mass drug administration (MDA) campaign for NTDs including onchocerciasis, schistosomiasis and soil-transmitted helminthiasis in 2016. The project also trained community-directed drug distributors to identify suspected TT cases, which were referred for confirmation by trained ophthalmic nurses.
Following two days of discussion, a clear-cut roadmap of recommendations emerged on the way forward for trachoma elimination in Togo, along with a renewed commitment among the stakeholders to work together to support the MOH in eliminating trachoma as a public health problem in Togo. Key recommendations were:
- Raw data from the 2011 survey should be entered into a database by the end of March 2017 for thorough analysis, guided by the WHO focal person for trachoma.
- Preparation of the protocol for the upcoming surveys will begin and the protocol will be submitted in April 2017 for ethics approval by the MOH.
- A map of TT distribution in Togo should be developed by the end of March 2017, using data from the ongoing Sightsavers-supported TT case identification, the HDI-supported TT case search, and health facility visits from 2014 to date.
- All above recommendations should be completed by April 26, 2017, so that a decision can be made on where to undertake further population-based surveys for TT.
- Additional surveys should be conducted by August 2017, with the support of NTD partners such as the Tropical Data Coalition, the USAID-supported END in Africa project, and the MOH.
- After the data has been updated with the results of the additional surveys, a trachoma action plan should be prepared to guide the country towards the endgame for trachoma.
 Trachoma medicines consist of tetracycline eye ointment for children below 6 months, Azithromycin/Zithromax syrup for children 6 – 59 months, and Azithromycin/Zithromax tablets for those 5 years and older.
 In addition to data from the 2006, 2009 and 2011 surveys, data on TT interventions carried out by Sightsavers and Health and Development International (HDI), a sub grantee of the END in Africa project in Togo, were also reviewed.
 The required indicators that must be met by any country to confirm elimination of trachoma are TF prevalence below 5% among children 1–9 years and TT prevalence below 0.2% among those 15 years and older.