Conclusions & Recommendations

TEC congratulates the Tanzanian NTD program on overcoming challenges due to cessation of USG funding by integrating the trachoma MDA with STH MDA, vitamin A distribution, and malnutrition screening. TEC encourages the continued documentation of preferred practices for sharing with other national programs and partners.

Following a recommendation from TEC 32 that ITI review available data to determine which areas of insecurity might qualify for a modified MDA strategy regardless of meeting the persistent or recrudescent TF criteria, TEC reviewed data from districts that are insecure but do not currently qualify for a modified strategy, including districts where surveys have been delayed due to insecurity. While TEC did not recommend changing its general guidance, it expressed willingness to review case-by-case requests.

TEC noted with concern that the projected azithromycin supply for 2026 did not match current demand, and appreciated Pfizer’s engagement and transparency in describing the existing supply limitations during TEC 34.
After weighing and discussing the pros and cons of several options to balance supply and demand in a way that sustains progress towards elimination of trachoma as a public health problem, TEC recommends:
For districts currently classified as TF1-9 5-9.9% at impact or surveillance and due for MDA in 2026, ITI will request countries to place these districts in ‘wait and watch’ (i.e., not conduct MDA) for 2026, except where complementary indicator data from the most recent survey indicate an ongoing need for treatment.
For districts currently classified as TF1-9 5-9.9% at baseline survey, ITI will request countries consider a ‘wait and watch’ strategy for 2026 if surrounding districts are below the TF1-9 threshold for elimination or there is other evidence suggesting MDA is not warranted. The ‘wait and 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.
For districts in which impact surveys are conducted in 2026 that return a result of TF1-9 5-9.9%, ITI will request countries to place these districts in ‘wait and watch’ for 2026, except where complementary indicator data from that 2026 impact survey indicate an ongoing need for treatment.
For districts conducting surveillance surveys in 2026 that return a result of TF1-9 5-9.9%, azithromycin will be allocated if supply permits, and with discussions around the context of the district (e.g., contiguous areas with TF1-9 ≥ 10%., etc.). Please note priority will be given to districts in 2026 with TF1-9 ≥ 10%.
Where a ‘plus’ survey has been conducted and data for at least one of the complementary indicator results are available to TEC and ITI for review, and there is indication that transmission is ongoing through complementary indicator data, the districts will be eligible for a drug allocation shipment for MDA in 2026, subject to supply availability.
TEC recommends that health ministries consider gathering complementary indicators during their next surveys in these ‘wait and watch’ districts, if possible, based on financial, infrastructure and technical support capacity.As recommended at TEC 32, in districts where at least 2.5 years have elapsed since the last MDA, national programs may wish to consult WHO to determine whether a subsequent impact survey could serve the function of a trachoma surveillance survey, if the resulting TF prevalence is <5%.
TEC encourages ITI to provide clear and transparent guidance to national trachoma programs and implementing partners on the operationalization of these recommendations as soon as possible for program planning purposes.

TEC noted the recent influx of refugees from Darfur (endemic for trachoma) across the border into Chad. TEC recommends to ITI to follow up with the Chad health ministry to understand the situation in refugee camps and have a dialogue about whether they would be interested in requesting azithromycin to treat refugees in camps where populations from Darfur had a TF prevalence warranting MDA.

TEC further noted that given the incredible progress made in Chad in reducing trachoma prevalence to below elimination thresholds in all other areas of the country, it is very unlikely that there is active ocular C. trachomatis infection remaining in the three districts with TF1-9 ≽5%. Therefore, if funding cannot be identified for implementing MDA in 2025/26, a “wait and see” strategy followed by a survey incorporating complementary indicator(s) is a very reasonable approach.

TEC encourages the CAR health ministry to consider conducting surveys that incorporate complementary indicators (“plus” surveys) in Bossangoa and Bouca in 2028 when their next impact survey is due, following completion of their newly-approved modified MDA strategy. TEC recognizes that incorporating complementary indicator(s) adds time and cost to surveys, albeit with a view to save time and costs in the future by avoiding unnecessary MDA and subsequent surveys, and encourages the CAR health ministry to discuss this recommendation with its partners and donors.

TEC noted that activities are sometimes delayed in CAR and further encourages the health ministry to discuss with partners their full funding needs to ensure adequate resources.

TEC encourages the Tanzanian health ministry to consider conducting a TSS+ in Chamwino DC South and Kongwa DC North evaluation units, given their long history of persistent/recrudescent TF. TEC recognizes that incorporating complementary indicator(s) adds time and cost to surveys, albeit with a view to save time and costs in the future by avoiding unnecessary MDA and subsequent surveys, and encourages the Tanzanian health ministry to discuss this recommendation with its partners and donors.

TEC was supportive of the proposal by the Kenya Ministry of Health to conduct “WASH and See” in Kajiado Central and Kajiado South followed by a TIS+ in January 2026 and looks forward to reviewing the results.

In 6 districts (Bore, Kimbibit, Sebeta Hawas, Cheha, Hulbareg, Boloso Bombe), operational research collecting complementary indicators was conducted during TIS (TIS+); the Federal Ministry of Health and Regional Health Bureaus subsequently used that data to decide to put these districts into “wait and see”. TEC encourages the Federal Ministry of Health and Regional Health Bureaus to consider conducting additional surveys incorporating complementary indicator(s) at the end of this period.

TEC further encourages the Federal Ministry of Health and Regional Health Bureaus to consider conducting TIS+ when due in areas where modified MDA strategies were implemented, in persistent or recrudescent woredas, and/or in woredas with TF 5-9%. TEC recognizes that incorporating complementary indicator(s) adds time and cost to surveys, albeit with a view to save time and costs in the future by avoiding unnecessary MDA and subsequent surveys, and encourages the Federal Ministry of Health and Regional Health Bureaus to discuss this recommendation with its partners and donors.

When a survey has been conducted and complementary indicator data are still pending, TEC will maintain the decision of ‘approved contingent on survey data’ (R2) for a district until at least one of the complementary indicator results are available to TEC and ITI for review. This is because complementary indicator results provide vital data to inform programmatic decision making that inform the appropriate use of azithromycin; require funding, time, and human resources to implement; and require the collection of specimens from individuals. Discussions between the national program, ITI, and the TEC liaison will then be held to understand program plans based on the results so that the contingency can be cleared and the final TEC decision can be made.

In the case of extenuating circumstances delaying or preventing the analysis of the samples collected, programs may request an exception for consideration by the TEC.

If health ministries are considering a “wait and see” approach (wherein the program continues S, F & E where needed but does not conduct MDA in a district), TEC suggests that they consider the district’s specific context in making a decision between “wait and see” vs. conducting MDA. Factors they may wish to consider include:
History of survey results
Most recent TF prevalence (the “wait and see” approach is especially appropriate in areas with TF1-9 <10%)
TF prevalence of surrounding districts
Existing availability of complementary indicator data, such as serology
Other relevant factors

Countries should also consider consulting with WHO before undertaking a “wait and see” approach.

TEC also encourages health ministries to conduct a survey incorporating complementary indicator(s) following implementation of a “wait and see” approach.