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Skip to 0 minutes and 12 secondsBy the end of this presentation, you should be able to explain why antibiotics are used to treat trachoma. Describe the purpose of antibiotic Mass Drug Administration, MDA, for trachoma elimination. And explain the World Health Organization's guidance on the use of antibiotics for trachoma elimination. The World Health Organization, the WHO, recommends two effective antibiotic agents to treat the infection that causes trachoma. Tetracycline eye ointment and oral azithromycin.

Skip to 0 minutes and 48 secondsThese antibiotics are used to reduce the level of chlamydia trachomatis infection in the community. Firstly, by treating infection in individuals with active trachoma. And secondly, mass treatment reduces the transmission of infection from person to person. Fewer infected people equals less reinfection. 1% tetracycline eye ointment is applied twice daily to both eyes for a period of six weeks. Tetracycline ointment is widely available, but application can be difficult and unpleasant. This means compliance for the full course can be poor. Azithromycin is a broad spectrum antibiotic, which acts by blocking chlamydia replication. Azithromycin is provided in a tablet or suspension form. It is effective as a single oral dose of 20 milligrams per kilogram body weight.

Skip to 1 minute and 40 secondsTo a maximum of one gram in adults. Usually, dosage is calculated according to height. Azithromycin is extremely well tolerated and very safe, even for pregnant women. Usually, the only people who are not given azithromycin are those who are known to be allergic to azithromycin or the drug class to which it belongs, macrolides. And children age less than six months old who are instead treated with tetracycline eye ointment.

Skip to 2 minutes and 11 secondsThe strategy for antibiotic treatment requires that four key questions are addressed. Number one, who to treat? Infected people only? Pregnant women? Infants? Everyone? Whole communities? Number two, where to treat? Based on the prevalence of active disease or not? Number three, how to treat? Once or twice a year? Or at the same time as the other community based treatment programs? And finally number four, when to stop? At what prevalence of TF, active trachoma, should antibiotics be discontinued? When a person acquires a chlamydia tracomatis infection in the eye, it is not immediately obvious. After a few days a mild inflammation may become visible.

Skip to 2 minutes and 59 secondsEvidence of active trachoma, graded as TF and or TI will be seen on examination only after several weeks of chronic or repeated infection. Therefore, if we only treat people with active trachoma, many infected people will remain untreated. And there will be an increased risk of reinfection of treated people from those who are untreated. This pattern was observed in early clinical trials of community based azithromycin. As a result, Mass Drug Administration, MDA, was initiated. And has proven to be a much more effective approach. In MDA events, all members of the target population are offered for treatment regardless of whether or not they have active trachoma. As an example, let's look at District X, which has 200,000 people.

Skip to 3 minutes and 50 secondsAbout 70,000 of them are aged one to nine years old. The prevalence of TF is 20%. In other words, one in five or 14,000 children age one to nine years have active trachoma in this district. And no doubt, so do some of the older inhabitants. Treating the whole population, and not just those with active trachoma, or just the children, ensures that no one remains infected. And there is no risk of re-infection from within the treated population. Reinfection would only occur through contact with a neighboring untreated area. However, if we only treat half the population in District X, one in ten or 7,000 children will still have untreated active trachoma.

Skip to 4 minutes and 38 secondsMany of these children will be heavily infected, and will quickly reinfect others in their households, leading to a rapid spread of trachoma infection within District X after the MDA event. In this scenario, the impact of antibiotic treatment in District X would be very limited. The goal of a MDA program is to treat all the residents in any affected district. But this is extremely hard to achieve. Some people will be away on the day of distribution, some will refuse treatment, and some people will be too sick to take the drug. Because of these challenges, trachoma elimination programs aim to achieve a minimum coverage of 80% for MDA events.

Skip to 5 minutes and 20 secondsCoverage is defined as the number of people treated with antibiotics, either azithromycin or tetracycline eye ointment, divided by the total number of residents. This is then multiplied by 100 to give a percentage. 80% coverage means that 80 out of every 100 residents in the district are treated. This high coverage reduces how much infection will return before the next round of treatment.

Skip to 5 minutes and 47 secondsThe decision on when to start or stop antibiotic treatment in a district depends on the prevalence of TF in children, aged one to nine [years], as measured in a recent baseline survey.

Skip to 5 minutes and 59 secondsIf TF is less than 5%, community level antibiotic distribution is not required for trachoma elimination purposes. If TF is less than 10%, but greater than or equal to 5%, plan for one round of MDA, plus interventions for facial cleanliness and environmental improvements, known as F&E. They should be followed by an impact survey [6-12 months] after treatment. If TF is less than 30%, but greater than or equal to 10%, plan for annual MDA for all residents, for three years, plus interventions for F&E, then an impact survey [6-12 months] after the final round of treatment.

Skip to 6 minutes and 41 secondsIf TF is greater than or equal to 30%, plan for annual MDA for all residents, for five years, plus interventions for F&E and an impact survey [6-12 months] after the final round of treatment. The impact survey measures TF prevalence in children aged one to nine years. And the results determine whether or not we need to continue with further rounds of MDA. Antibiotic treatment in a district is stopped when the prevalence of TF is found to have reached the trachoma elimination threshold, 5% or less. Protocol requires a wait for 24 months after the last impact survey, before a district level pure-validation surveillance survey is conducted.

Skip to 7 minutes and 22 secondsIf this survey finds that the prevalence of TF in children aged one to nine years remains below 5%, no more routine interventions or surveys for trachoma elimination are required.

Skip to 7 minutes and 37 secondsIn summary, you should now understand the decision points for starting and stopping antibiotic treatments for trachoma elimination. And why it is important to achieve high coverage of Mass Drug Administration.

Introducing Mass Drug Administration

Pfizer and the International Coalition for Trachoma Control (ICTC), which includes the Carter Center and the International Trachoma Initiative (ITI), are part of the World Health Organization (WHO) Alliance for the Global Elimination of Trachoma by the year 2020 (GET 2020). This international Alliance implements the WHO-recommended SAFE strategy to eliminate trachoma as a public health problem.

President Jimmy Carter said Pfizer’s donation of Zithromax® - the trade name for azithromycin - was “momentous in trachoma control” and that it allowed organisations and programmes to “get the medicine into the villages and demonstrate the world can end blinding trachoma”. He continued: “Millions of people worldwide will be spared the injustice, indignity and pain of their eyelashes scratching and scarring their eyes.” On November 16, 2015, ITI, ICTC and Pfizer announced the 500 millionth dose of donated Zithromax®.

Mass Drug Administration (MDA) of antibiotics is the WHO’s recommended strategy to clear ocular chlamydial infection and reduce its transmission within trachoma-endemic communities. In this presentation we look at the evidence supporting the use of MDA and the guidance on how to implement it.

As you watch, consider why the donation programme from Pfizer is critical to achieving trachoma elimination.

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Eliminating Trachoma

London School of Hygiene & Tropical Medicine

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