Thanks to advances in science and technology, the world is now on the cusp of eliminating several debilitating diseases that affect the world’s most disadvantaged populations. Many experts who have dedicated their careers to ending trachoma recently attended an international summit in Geneva (April 19-22, 2017) to discuss the progress to date. There a total of 10 neglected tropical diseases (NTDs) of the 18 identified by the World Health Organization being targeted by these international organizations and partnerships.
Trachoma is a leading infectious cause of blindness currently threatening about 185 million people in 51 developing countries. A smartphone-based data platform called Tropical Data, that was built on the success of the Global Trachoma Mapping Project, has been used towards the elimination of trachoma, as well as for many other treatable diseases. This platform stores data in the Cloud, and provides countries with real-time monitoring of trachoma prevalence that helps with making health policies and decisions.
As a background, for many years a topical preparation of tetracycline was used to treat trachoma. However, the ointment needed to be applied to the eyes twice a day for 6 weeks. In contrast, azithromycin is a single-dose oral systemic antibiotic that results in high tissue to serum concentrations. The concentration of azithromycin in phagocytes insures delivery to infected tissues, and therefore provides high, sustained tissue levels as well as high concentrations in tears, which works as well or better than the topical tetracycline ointment.
We bring to you an exclusive interview with Dr. Paul Emerson, the Director of the International Trachoma Initiative (ITI), and Julie Jenson, director of the global health donation program for Pfizer Corporate Responsibility. Dr. Emerson is a scientist and academic practitioner who is very interested in neglected tropical diseases, as well as monitoring and evaluating the effectiveness of programs. Julie has been with Pfizer for 15 years and has a public health degree, which allows her to combine her manufacturing and supply chain technical background with global health initiatives. She currently leads Pfizer’s targeted international product donations that are directed to areas identified by the Trachoma Mapping Project.
Alice Ferng, Medgadget: How and when did the International Trachoma Initiative (ITI) begin, and what was the motivation behind starting it?
Dr. Paul Emerson, International Trachoma Initiative: The International Trachoma Initiative began back in 1998. There was a series of operational research conducted in a number of countries that demonstrated that Pfizer’s product Zithromax® (azithromycin) in a single oral dose was as effective as 6 weeks of tetracycline. Pfizer was persuaded and readily committed to start up the ITI in collaboration with a non-governmental organization (NGO) in order to facilitate the donation of the drug for the control, and now elimination of trachoma.
Medgadget: Dr. Emerson, what is the role of technology in eliminating disease? How does the use of technologies directly affect the bacterial infection that leads to trachoma?
Dr. Emerson: Pfizer is a fantastic partner with a high standard of quality, requiring rigorous documentation, investigation, and analysis for making the best informed decisions. In the past it could take up to 11 months to get from deploying the survey to conducting it, to completing all of the paperwork forms, to getting them back, and then double-entering them into a database. We wanted to accelerate that process so we shifted to a whole platform based on smartphones whereby the data is collected and immediately uploaded to the cloud. From the cloud it’s analyzed in a central place where the background analysis is performed automatically after it has been checked by a human being. This means that decisions on the donation of drugs, and progress of the disease can be made almost in real-time. In fact, there have been circumstances where the field team has been just finishing their work and just probably getting into their vehicles on the way home when the expert committee of the ITI has approved drugs for donation. It’s really streamlined and accelerated the system while maintaining the highest of standards.
Julie Jenson, Pfizer: To give some background of where we were before the smartphone platform was being used for the mapping project — this project was started back in 1998, as Paul mentioned earlier, and has been continued steadily until now with the goal to eliminate trachoma by 2020. Here we were in 2012, and half of the trachoma endemic communities in the world we didn’t know exactly where geographically half the the affected people with trachoma lived. 20 years ago, all of this mapping would’ve had to be done manually, going to all these communities diagnosing people, and figuring which villages had trachoma and which ones didn’t, and then resorting to paperwork records. It would’ve taken years to compile and aggregate all that information that could be used to make decisions on how to implement this global elimination program. All of the mapping is still done manually, and thousands of healthcare workers will have to go out into the field to find people with trachoma and document. But in this case, that data is directly entered into smartphones and for the most part bypasses all paper records. The huge program that essentially surveyed 2 million people in the world involved records entered directly into the smartphone that was aggregated into the cloud database. The rationale for doing this really didn’t have to do directly with Pfizer–it had to do with the fact that globally, we needed to understand where people with trachoma were living so that we could figure out how to implement programs that would reach those people. That is when the government create a prospectus and would do a prospective survey and pharmaceutical companies would know places to target. This was the largest disease mapping project that has ever been undertaken.
Dr. Emerson: Yes, it has included 29 countries, 2.6 million people examined in just under 2 years. We often say that this is the largest disease mapping project that has ever taken place, and no one has contradicted us yet and several people have repeated it, so it must be true! *chuckles*
Medgadget: What was the model for developing the smartphone and cloud technology for the deployment of it? Were there technology gaps when deploying these technologies? I imagine that some countries didn’t initially have the infrastructure for this type of field work. How was the training and execution process streamlined?
Dr. Emerson: These days, smartphones are almost ubiquitous. Even in Sub-saharan Africa, Central Republic of Africa, and Chad, people are already using Android devices. Typically, what we do is train the medical staff in surveying techniques. This involves “flipping lids” to check of active trachoma infection, which is simply and doesn’t hurt the person. We would recruit younger people – undergraduates or people at the local colleges – and have one person do the clinical examination and the other would record the data into the phone.
Depending on the country, as there’s no one-size-fits all with this type of thing, on 3 different continents – many of the phones were purchased locally and then stripped of the useful functional software, so that the incentive to use them for anything but the surveys was refused. An app that we developed was downloaded onto the phone, and has now also been used for many other purposes. While we say “smartphones,” we really mean any Android device. We hook onto a 3G connection if it’s available in the country or we wait for the phone to see a wireless signal to download. The probability that the phones will be dropped, run over by vehicles, or that surveyors will be caught in rain or other bad weather means that there is a risk that the data stored on SD cards will be lost. We actually do not lose any of the data after the phone is connected. Several phones were dropped, broken, immersed in water and so on. But everything was recoverable from the SD card, so the bit of built in redundancy was useful.
Medgadget: Can you tell me more about your smartphone application, whether it is open sourced or not, and how it is modified and distributed?
Dr. Emerson: We developed the app “Tropical Data,” which is flexible and nimble. It has been used to survey other diseases, and we want to make this management service freely available to countries for the monitoring and evaluation of their programs. Unfortunately, we can’t pay for the surveys themselves, but through a funding coalition, we can provide the data service itself, including the training. This is therefore a living and developing system, which is going to support the elimination of disease. The access to the platform is without charge, but through us, so we are paying for the software development and data management. The code cannot be downloaded open source, but the survey can be modified upon request by us. Data can also be downloaded to a host country rather than our data server.
Medgadget: Ridding the world of trachoma by 2020 would be a very significant accomplishment. Do you think this is actually achievable in this timeline?
Julie Jenson: You are catching us at a meeting in Geneva, and that is the entire goal. We are discussing a lot of the NTDs, with the intent of targeting and eliminating 10 of the NTDs. We are very focused on getting as many countries as possible to eliminate trachoma by 2020 since there is so much momentum going with the trachoma initiative. Because of this mapping project, getting the data of where all the people are affected has really helped with the scale-up of donor funding to actually distribute medicine and to do all of the things that need to happen in order for a country to achieve elimination. This also allows for Pfizer to scale-up our drug donation. Everyone is kind of working at scale, and it’s just a matter of continuing to detect and target gaps, and many countries are on track to meet the goal by 2020.
Dr. Emerson: In a perfect world, the blindness of trachoma can be eliminated by 2020. Of course, the problem that we face is that the world is not perfect and by the time we get to 2020, our projections show that we should have cleared 70 to 95% of the known burden from when the scale-up started in 2011. We have made tremendous progress. There will be pockets of disease, and they will be unfortunately where there are the most disadvantaged people – those currently afflicted by war and natural disasters, in addition to man-made disasters. Those populations will be the most vulnerable and will be the focus of attention beyond 2020.
Medgadget: How do you target the areas that most need the help, and do those countries provide proposals?
Julie Jenson: There is a concerted effort in making sure that countries that are the most endemic are being targeted. That there is funding from donors and support.
Dr. Emerson: In order to qualify a drug, countries have to demonstrate that there is trachoma issue that needs to be controlled. This is done through rigorous epidemiological surveys. I think that Julie is underselling Pfizer’s commitment because they are making the drug available and providing access and service to everyone who is at disadvantage with trachoma. Because the most endemic areas will take longest, we encourage the country programs and their partners to focus on the most endemic areas first and to get them on board. These areas may take 5 to 7 years of effort to clear, and the less endemic areas areas are recruited, which can take 1 to 3 years for elimination. It is very important to understand that our target is every man, woman, and child, who is at risk for blindness from trachoma on the planet. Everyone. Our target is to eliminate the disease. To put that into perspective, we are talking about reduction of disease to zero, everywhere, for everyone, forever.
Medgadget: Can you tell me about your drug Zithromax (azithromycin), the dosing, and its effectiveness?
Dr. Emerson: Having established the therapeutic target dose for trachoma , we give all adults (even ones over 50) a single oral dose of 1 gram of azithromycin. We give children a dose according to an algorithm that takes into account their height per weight that works very well across the countries. The drug is donated in the context of a comprehensive strategy. It is highly effective at clearing individual infection if it’s present. But we also want to reduce transmission by reducing the infectious reservoir through treatment by promoting hand washing, face washing, and environmental sanitation. This is the promotion of access to water, toilets, which reduces the attraction of eye-infecting flies that spread the disease. The trachoma control program differs from many others, in that it is an integrated, comprehensive strategy that aims to provide the curative as well as the preventative solution that will sustain the program in the long term.
Julie Jenson: Fundamentally the disease is related to the lack of access to water, sanitation, and hygiene, and people living in very under-resourced settings. Therefore, the real focus is on the spatial cleanliness and environmental improvement. The antibiotic has a role as part of the strategy.
Medgadget: Do you have other partners that target this since the environmental issues are a whole different type of problem to solve?
Dr. Emerson: Pfizer and ITI are two members of the international coalition for trachoma control, where 60 different organizations work together to implement the strategy for trachoma control over 61 countries at the moment.
Julie Jenson: In total, the efforts include over 100 organizations, not-for-profit organizations, academic institutions, and countries themselves, since that is the way these programs are implemented. While we have NGOs involved to implement the program, it is really a country on the program. ITI is active in 35 countries, and there are trachoma programs in 61 countries. The real implementation is happening at the ministry of health level of the countries, and it is really the local workers, volunteers, staff, and communities that are implementing this program. It is not even directly ITI oftentimes.
Dr. Emerson: Yes, that’s right. The governments are the driving force.
Medgadget: What other neglected tropical diseases can be targeted by this model?
Julie Jenson: We are at the neglected tropical disease summit talking about a lot of these NTDs. 10 of these diseases are targeted by preventative drug therapy. We are celebrating the 5 year anniversary of what is called the “London declaration.” This is where all of these players (governments, NGOs, donors, pharmaceutical companies, academic institutions, etc.) have come together to support the control, elimination, and eradication of at least 2 of these diseases by 2020. There are 18 NTDs under the WHO definition in total, and 10 diseases of them have drug donations.
Medgadget: I understand Pfizer is helping fund this social medicine cause. How do people usually approach you with proposals, and how do you decide which projects to fund? What is Pfizer’s role in the International Trachoma Initiative? Who are other major players in the ITI that have made championing this cause possible?
Julie Jenson: That is the great thing about this partnership – the London Declaration includes all of these players. We are just one of many major peer pharmaceutical companies that are involved in this. We all play very similar roles in different diseases. There are many actors, and we are all very proud that we are all working together amongst our peers to share information, benchmarking, networking groups to best address areas and increase our overall impact on these diseases and goals. This is a great example of public-private partnership and a call to action to address similar goals and targets with everyone playing to their individual strengths.
Dr. Emerson: I think that the level of support is unprecedented. The multi-national efforts of everyone and unprecedented scaled up donations from so many players makes this a golden age of collaboration.
Medgadget: What have been the major difficulties and setbacks in launching a project of this scale?
Julie Jenson: We can take a step back to the mapping project. The trachoma mapping stage played a really pivotal role in allowing the scale-up of the global program.
Dr. Emerson: The main issues that the data collection teams faced were security and environmental related. We chose to survey at random from a list of all of the villages in a prospective district. In some cases, these places would require something like an 8 hour walk from as far as a car could be taken, where the volunteer would conduct the survey at the village and spend the night there then walk back the next day. There were therefore considerable environmental limitations where people would need to scale a mountain, cross rivers, and mire through mud, in some of the most difficult terrain on the planet. The other issue was in security, where people may put themselves in harm’s way, such as during unstable political disputes. There are places such as South Sudan and Mali where it has been just impossible to get out and do the survey work needed because the areas are so insecure.
Medgadget: What are anticipated issues that will arise in the near future with the massive amounts of data being collected? Is there a plan for parsing out that data?
Dr. Emerson: Each set of data collected belongs to the respective government. Each government has been very keen to use the data. The data is collected for the purpose of using it for the programming and there’s not a single case that the data has not been put to use in decision-making or an application for a drug or funding. Per country, there’s often around 1,500 separate surveyed districts. Of the district level data collected, it has not been possible to use all of this data yet and this will require additional resources for the implementation of data in all the areas surveyed.
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