Conclusions & Recommendations

TEC applauds Afghanistan’s MOH, its partners and ITI for making the test shipment and upcoming MDA possible. TEC would like a presentation on the MDA at an upcoming TEC meeting, with details about ensuring equitable distribution.

TEC reviewed a modified strategy request to treat two districts in Amhara. These districts, Mida Woreno and Wogide, last conducted surveys in 2019, followed by three rounds of MDA, and are now overdue for impact surveys but are currently insecure. While surveys are not currently possible in these two districts, MDA is deemed acceptable. The program is requesting one round of MDA in each district, and plans to collect dried blood spots during MDA. The program will conduct research to assess the feasibility of implementing this approach to guide decision-making. Once the program analyzes serology from these districts, and if it is indicated that transmission is ongoing, the program will request additional rounds of MDA. TEC approved this strategy as a non-precedent setting request.
TEC recommends that the program present on lessons learned from this strategy once the project is completed.

The TEC is impressed by the pilot work undertaken by MOH-Ethiopia and its partners on achieving full population coverage for TT. TEC invites future presentations on progress.

TEC notes with concern that recent global funding interruptions for trachoma activities may significantly delay Ethiopia’s progress toward achieving elimination by 2030. TEC calls upon the global health community to ensure sustained and predictable funding support to help Ethiopia reach the elimination target.

TEC commends the MOH-Ethiopia’s commitment to conducting ‘plus’ surveys and using complementary indicators to guide programmatic decisions. This is a critical step toward accelerating trachoma elimination through cost savings and evidence-based planning. However, recognising the current capacity limitations, TEC recommends:
a) The MOH-Ethiopia and partners develop criteria to prioritise districts for ‘Plus’ surveys using a phased, staggered approach over the next few years.
b) Funders and implementing partners support the establishment of national capacity for serology and PCR testing to sustain and scale this initiative.

TEC commends the Ministry of Health of Ethiopia (MOH-Ethiopia) for its strong commitment to conducting trachoma surveys in districts previously considered insecure. It is encouraging to note that other healthcare activities are also being implemented with minimal disruption. TEC recommends that the MOH-Ethiopia, in collaboration with regional health bureaus and implementing partners, undertake a detailed assessment of the current security situation to categorise districts as follows:
a) Relatively secure districts where surveys can proceed using the standard Tropical Data protocol.
b) Partially insecure districts where surveys may be feasible with protocol modifications, such as paper-based data collection, training of local health workers and supervisors, and use of local transport.
c) Completely insecure districts where surveys are currently not feasible.
TEC urges the FMOH-Ethiopia to prioritise this activity to allow resumption of MDA in districts that have missed treatment for several years.

TEC acknowledges the MOH-Ethiopia’s concerns around drug shipment timing. The TEC recommends that ITI work with the MOH-Ethiopia to increase communication and coordination around shipment planning.

TEC appreciates the strong engagement and leadership of the ministry of health and the ETAG. TEC also appreciates the work done by the ministry and its partners to generate evidence on multiple facets of the SAFE strategy (including the need for Chlamydia trachomatis (Ct) infection monitoring in persistent and recrudescent TF woredas, on Full Population (or Geographic) Case (FGC) finding, and WASH aspects of programming (in F&E).

If health ministries are considering a “wait & watch” approach (wherein the program continues S, F, & E activities where needed but does not conduct MDA in a district for a predetermined period of time), TEC suggests that they consider the district’s specific context in making a decision between “wait & watch” vs. conducting MDA. Factors they may wish to consider include:
History of survey results - Programs may choose a “wait & watch” approach for districts with a history of recrudescent trachoma.
Current TF prevalence <10% - The “wait & watch” approach may be appropriate in areas with TF1-9 5-9%.
TF prevalence and epidemiology of surrounding districts - The “wait & watch” approach may be more appropriate when the surrounding districts are below the TF threshold or there is other evidence suggesting MDA is not warranted. The “wait & watch” approach may be less appropriate in areas that are surrounded by highly endemic districts, especially if there is a high level of movement between the districts, or there is other evidence suggesting MDA is warranted.
Existing availability of complementary indicator data, such as serology and/or Ct infection data – The “wait & watch” approach may be particularly appropriate in areas where TF1-9 ≥ 5% but serology and/or Ct infection data suggest that MDA may not be warranted.
Other relevant factors – these may be taken into consideration in context with the above factors.
F&E infrastructure and indicators – If there has been a strong improvement in F&E infrastructure and/or indicators to support the sustained interruption of trachoma transmission, this may be a supporting factor in a program’s consideration of “wait & watch.”
Other ongoing interventions that may impact trachoma transmission, such as MDA with azithromycin for child survival or yaws eradication.
Programs may opt for a “wait & watch” approach in districts with one or multiple of the above factors being applicable. For example, a program may choose a “wait & watch” approach in a district with recrudescent trachoma with TF1-9 between 5 and 9.9%, and evidence from surrounding districts suggesting that MDA is not warranted.
Programs should also consider consulting with WHO before undertaking a “wait & watch” approach.
TEC also encourages health ministries to conduct a survey incorporating complementary indicator(s) following implementation of a “wait & watch” approach.

TEC tasked the complementary indicator working group with developing a working methodology for reviewing Chlamydia trachomatis (Ct) results in consultation with relevant experts. Once finalized, the methodology will be applied to review available data.