International Coalition for Trachoma Control

Ending the neglect to attain the Sustainable Development Goals: a road map for neglected tropical diseases 2021-2030 targets trachoma for elimination as a public health problem by 2030. Achieving the global target, however, is complicated by political, environmental and social factors that make it hard to reach some of the world’s most marginalised populations, such as refugees. In many cases, refugees are forced to enter trachoma-endemic settings, or leave trachoma-endemic settings and go to areas that have limited capacity to deliver the interventions needed to treat infection. 

This is particularly true in Sudan, which has seen an increase in refugees entering from Tigray, Ethiopia, across its Eastern border, as well as refugees from South Sudan, on its southern border. Recognising the importance of reaching all populations at risk of trachoma, Sudan’s Ministry of Health has been increasing efforts to provide trachoma interventions within refugee camps since 2017.

In March and May 2022, the Sudanese National Trachoma Program, led by the Ministry of Health with support from The Carter Center, conducted mass drug administration (MDA) and health education campaigns in the Tunaidba Camp, in Al Rahad locality and Um Rakuba Camp, in East El Galabat locality, both in the state of Gedarif. Both camps are located in areas known to require interventions for trachoma, and currently host approximately 20,000 refugees in each camp, many of whom left trachoma-endemic settings in Tigray, or settings where trachoma is suspected to be a public health problem.

To deliver the MDA campaign, volunteers were recruited from the refugee population and training was provided, using preferred practices developed by the International Coalition for Trachoma Control. The training included information to effectively sensitise the community to the interventions, provide health education, and distribute the antibiotics safely within the target communities. Twenty teams, consisting of a dispenser and recorder, were then deployed alongside four team leaders, to deliver antibiotics through the each refugee camps. The antibiotics were delivered to houses and through schools, which was deemed the most appropriate setting as it had been involved in other health campaigns that were widely trusted by the community and it was open throughout the day. 

As refugees largely entered Sudan from trachoma-endemic settings, including Tigray and Amhara, Ethiopia, many of the individuals understood what trachoma was and the importance of interventions. In cases where refugees were unaware of trachoma, or hesitant about participating in interventions, they were provided health education in their native language. This was facilitated by translators, who were able to speak Arabic, English and Tigrinya. The National Trachoma Program also organised cars to travel throughout the camp sharing positive health education messages via loudspeakers, promoting participation in the campaigns as well as hygiene messaging around facial cleanliness. 

Implementing MDA campaigns in refugee camps requires careful planning to ensure that interventions are delivered ethically and safely as well as being designed appropriately to the people they benefit. In Sudan, the National Trachoma Program partnered with the Humanitarian Aid Commission (HAC) and the Commission of Refugees (COR) who were the main administrators of the camps, in addition to the Gedaref State Ministry of Health, Gedaref State Health Promotion Department, and the El Rahad, El Mafaza, Galabat East and Basonda Localities Health Affaire. This ensured that the appropriate security protocols were in place for interventions to be delivered, and facilitated collaboration across sectors, including the local school, which was part of the MDA campaign. 

The MDA in the Tunaidba and Um Rakuba Camps was an important step forward to protect some of the country’s most vulnerable inhabitants and over 25,000 people received treatment. However, several challenges impacted the campaign and resulted in fewer people being treated than had been targeted. Cultural factors, such as fasting, prohibited some from participating in the intervention. Others were unavailable for the campaign as a result of travel for employment.   

Sudan’s experiences delivering trachoma interventions to refugee populations provide important lessons of what can be achieved with sufficient planning across sectors and government agencies. This recent MDA campaign in Gedaref state, combined with past MDA and surgical campaigns in eight South Sudanese refugee camps in White Nile state provides further examples of the Ministry of Health’s continued commitment to achieve the elimination of trachoma with no one left behind. These efforts are essential for the country to achieve its targets in eliminating trachoma as a public health problem by 2030 and provide examples to other countries that have special populations, including refugees, that require tailored programming to deliver interventions. 

Authors

• Dr Balgesa Elkhair Elshafie,Federal Ministry of Health, Sudan

• Zeinab Abdalla, The Carter Center, Sudan

• Dr Angelia Sanders, The Carter Center, International Coalition for Trachoma Control