Conclusions & Recommendations

Recognizing both the potential advantages and challenges in ‘integrated’ MDA for both trachoma and child survival, as well as the need for more information, TEC recommends that ITI commission a white paper that analyzes the programmatic impact, cost, safety, supply chain, and operational implications of different options for integrated trachoma/child survival MDA. TEC looks forward to engaging in future conversations about how best to achieve integration.

The TEC congratulates the REACH Network on their impressive progress in supporting national programs using azithromycin MDA to reduce child mortality. TEC is committed to support the emerging partnership between the child survival and trachoma communities. TEC reviewed preliminary information on geographic overlap of areas requiring MDA for trachoma elimination and child survival. The TEC encourages national health ministries to explore opportunities for integrating child survival and trachoma MDAs where possible.

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.

ITI requested feedback from TEC on the level of review/discussion actually needed for straightforward requests to streamline those requests so that more complicated districts/requests get more attention/focus/discussion. Through a brainstorming discussion, TEC and ITI came up with a number of suggestions:
Printed applications could show only the line by line actual requests to reduce the number of rows, categorized by request type rather than geography.
Straightforward requests (mid-cycle) could probably all be considered approved/approved with contingency and then we would only focus on the areas that have a change, are new, or require discussion.
Only print ‘progress to elimination’, ‘azithromycin request’, other summary data tables (e.g., complementary indicator results), applications, and maps. Narratives in totality do not need to be printed.
Consider hiding some columns:
Month of MDA
Treatment history up until the most recent year (keep cumulative rounds)
Treatment coverage up until the most recent year
Surveys after Survey 1 through most recent Survey X (e.g. show Survey 1 data and Survey 6 data only)
Consider hiding some rows:
Any districts with baseline TF1-9 <5%
Project maps on the screen.

Overall, ITI and TEC could do offline approvals wherein TEC liaisons (or small group of TEC liaisons) review and provide TEC decisions prior to the TEC meetings. ITI could then still provide applications to TEC meeting participants for transparency, but with approvals already indicated. ITI could create tables of approvals/TEC decisions for each country.

During pre-TEC conversations with TEC liaisons, ITI would identify the challenges/celebrations/highlights to be discussed at the meeting. ITI would then develop the TEC agenda organized around topics/discussions/input needed. Note that this new arrangement would require earlier engagement and time commitments with TEC members. ITI will mock up some ways we can do this and re-engage with TEC.

ITI has noted some challenges with predicting TEC decisions when results from multiple indicators are discordant, and would like guidance on the process for moving a district from R2 to either A-MDA or DNMC after results from complementary indicators are available. ITI is requesting:
a decision tree for ITI to apply when results come in from complementary indicators; and
guidance on when a district could be put into R2 (e.g., Binji in Nigeria with TF1-9 <5% was put in R2 rather than DNMC, pending complementary indicator data).

Recognizing that thresholds have not yet been established for Ct and serology, TEC has a role in allocating drug in the meantime based on available evidence for the rational use of antibiotic. If/when official guidelines become available, drug allocation decision making can be adjusted. A TEC subcommittee was developed to issue this guidance, including David, Tom, Jeremiah, Kelly, and Emily.

Consider adding a column to all azithromycin applications that allows the Ministry to indicate security that allows for accessibility at a district level.