Conclusions & Recommendations

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.

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 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.

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.

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 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).

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 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 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 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.