Conclusions & Recommendations

In areas where trachoma impact surveys have been delayed for more than 2.5 years since MDA and the new TIS results indicate TF above threshold, TEC would consider a request from national programs for a drug donation for a modified MDA strategy (even if the district did not previously qualify as 'persistent' or 'recrudescent').

The TEC reviewed data on trachoma impact surveys that have been delayed due to conflict and other factors. Such delays can postpone submission of the national dossier and thus the validation of the elimination of trachoma as a public health problem. When the recommended number of MDA rounds has been completed and trachoma impact surveys are delayed by more than 2.5 years, national programs may wish to consult WHO on whether such an impact survey may serve the function of a trachoma surveillance survey if the TF prevalence is <5%.

TEC appreciated the progress in developing innovative ways to assess the need for intervention in areas of conflict, and encouraged ongoing development of methods to assess the need for, and deliver interventions in, areas of conflict. Options for this may include using local teams to conduct surveys, simultaneously collecting complementary indicators, and using paper-based surveys.

TEC reviewed the experience of national trachoma programs in areas that completed trachoma MDA and are awaiting impact or surveillance surveys, while also being targeted for MDA for child survival. Noting the validation requirement for a two-year antibiotic MDA free period before a TSS is in tension with the ethical mandate of MDA for child survival, TEC requested that WHO provide relevant guidance to affected countries.

TEC congratulates the national program of Senegal on reaching the important milestone of completing their dossier for the validation of the elimination of trachoma as a public health problem. The strong political engagement displayed by the Senegal program in the fight against NTDs is well noted. TEC looks forward to hearing that the dossier has been submitted and validated by WHO.

The TEC Research Subcommittee reviewed the protocol for the ATIRA study, which aims to understand whether "the proportion of children who clear infection after mass azithromycin treatment is lower, and the rate of infection re-acquisition after treatment is higher than other settings, maintaining the persistently high trachoma prevalence" in the hyperendemic district of Argoba in the South Wollo Zone of Amhara. This district has historically received 11 rounds of annual MDA, and in their most recent TIS in 2020 the TF1-9 prevalence was 41% and Ct infection was 16%. This project is funded by CIFF and The Carter Center and planned to be conducted from July 2024 through April 2026, in partnership with the Ministry of Health Ethiopia, Amhara Region Health Bureau, Eyu-Ethiopia, and The Carter Center.

The TEC Research Subcommittee approved the full (95%) research allocation for the study woreda (Argoba in Amhara).

Suggestions from meeting participants related to the protocol included:
assessing micronutrient status rather than anthropometric measurements;
collecting ocular swabs from adults aged 15 years and above in one of the follow-up time points to detect the presence of ocular chlamydia;
analyzing RNA in addition to DNA, though the group noted challenges with this approach; and
conducting serovar testing, if additional funding can be identified.

The TEC noted with concern the chronic underfunding in Afar and Somali regions in Ethiopia, in parts of South Sudan and Yemen, and throughout the Central African Republic. To potentially mitigate this chronic underfunding, TEC recommended:
ICTC continue its Gap Analysis to support community fundraising efforts with a particular emphasis on areas of great concern; and
partners consider reprogramming funding from areas that may not be ready for treatment (e.g., due to insecurity putting a program on hold) to areas that could implement quickly given an infusion of funding.

TEC discussed the importance of using innovative strategies to ensure safe program implementation to maintain and accelerate progress in insecure areas. For surveys, suggestions included the training of local people to conduct and supervise surveys so that external participants are not required, and the use of local transport methods with adequate time to visit all clusters. For MDA, suggestions included the ‘hit and run’ strategy whereby the program is able to quickly mobilize treatments as soon as the security situation permits, which requires rapid access to a stock of drug. However, each National Program should determine feasible solutions based on their own contexts. TEC recommends to ITI to make this a focus area for TEC 32, inviting presentations from implementing partners and Ministries of Health to review available evidence and propose mitigation strategies.

TEC recommended that the reduced 80% allocation of treatments will need to remain throughout the remainder of 2024, based on the supply outlook for the next six months. TEC will revisit this decision at the January 2025 TEC meeting to make a decision for the 2025 shipments. ITI will communicate this update to national programs and partners in June/July 2024.

There are currently 29 districts with a prevalence of TF1-9 30-49% (population 3 million) and three districts with TF1-9 ≥50% (population 325,000) in Central African Republic, Ethiopia, Peru, and South Sudan that are not persistent or recrudescent and either have not yet started MDA or are mid-cycle. TEC would consider azithromycin donation requests from Ministries in these countries for modified strategies TF1-9 ≥30% districts if funding and partner support is available.
Subject to there being available azithromycin, you may choose to modify your trachoma program implementation using donated azithromycin by increasing the frequency of MDA (more-frequent-than-annual [MFTA] MDA). The additional treatment rounds can be targeted (for example, to children only) or provided to the whole community. The timing is flexible (e.g., biannual MDA can be conducted on months 0 and 1, months 0 and 4, months 0 and 6, or whatever makes programmatic sense). Likewise, these modified rounds could be conducted in any timing combination that works for the program. The sum of the MFTA MDAs conducted in a year are considered one round. It is important that the implementation plan leaves no one behind, anticipates high coverage MDA, and is paired with strong F&E.
Understanding that intensifying program activities is a significant change, we expect the applications to be an iterative process including countries, implementing partners, WHO, scientific advisors, your TEC liaison, and ITI. Please include your ITI representative in the process as soon as possible. In your discussions, please consider:
- Strategies such as MFTA MDA may be more effective if implemented in a region (a group of districts that are geographically contiguous and with similar epidemiology) than in a single district; please consider whether this strategy is relevant to your country situation.
- If you are planning to conduct more-frequent-than-annual MDA, will you target additional rounds of MDA to children (or another sub-group)? If so, how will you manage community expectations?
- What will you do to monitor program delivery?