Conclusions & Recommendations

TEC recommends that ITI work with the national program and partners to strategize how to move the program forward by clarifying roles and responsibilities and addressing funding gaps.

A recent TSS in Tahoua Madoua 1 returned a TF1-9 prevalence of 7.03% and the national program is requesting azithromycin to conduct more frequent than annual MDA - two rounds in 2024. TEC noted, however, that children ages 1 to 59 months are already planned to receive azithromycin for child survival twice per year in this region starting in Fall 2024. Further, this area benefits from seasonal malaria chemoprophylaxis with a sulfadoxine antibiotic 4 times per year (monthly during malaria transmission season). While TEC recognizes that the district meets criteria for trachoma MDA, given that this district will already be receiving other antibiotic treatments in the same timeframe, TEC recommends Niger not to conduct trachoma-specific MDA in 2024 and instead conduct a TIS+ at least six months following the second child survival MDA.

TEC was encouraged to learn that some areas of Amhara are now accessible for the resumption of program activities. Through a detailed woreda-level consideration of security status, TEC was able to move treatments for 28 woredas (4,250,387 treatments) from ‘Reserve pending security’ to ‘Approved for MDA’ in 2024. ITI’s supply chain team is working to get 2024 shipments to Ethiopia and will include treatments for these areas, pending the FMOH returning the signed waiver letter along with the remaining elements of the greenlight checklist.

TEC recommends to the Amhara RHB and partners that in addition to the routine collection of ocular swabs for Ct infection in children, ocular swabs should also be collected from a representative sample of adults aged 15 years and above in woredas that have had 7 or more rounds of MDA to determine whether there is detectable ocular chlamydia in adults.

TEC noted that the security situation in Oromia is rapidly changing and it will be important for partners to support the RHB to conduct program activities as areas become accessible. There are 158 woredas pending impact surveys - the results of which could vastly change program plans and funding requirements for this region. TEC recommends that given the recent security improvements in most parts of Oromia region, ITI work with the MoH and Oromia Regional Health Bureau to re-evaluate the security situation in all districts that are currently labeled as having security issues so that drug can be made available where survey data indicate that MDA needs to be continued.

TEC recommends that the Kenya and Tanzania National Programs identify transnational EUs that warrant cross-border interventions and develop a workplan to meet shared goals.

TEC recommends that the Kenya and Uganda National Programs identify transnational EUs that warrant cross-border interventions and develop a workplan to meet shared goals.

Recognizing the program is on hold and ITI is unable to ship treatments, if there is not a signed MOU by the end of August 2024 TEC recommends that ITI consider a high-level delegation visit to the Ministry of Health with implementing partners to pursue execution of the MOU.

A baseline survey in Uror (Jonglei) indicated TF1-9 prevalence of 52.8% (in 2022), warranting up to seven rounds of MDA. By starting treatment in 2024 (round 1), this area will not complete treatments and be ready for TIS until 2030. This situation also applies in Pigi (2023 baseline TF1-9 prevalence of 46.0%) and Pibor/Boma (2023 TIS showing TF1-9 prevalence of 40.2%); starting round one in 2025 would mean they will not complete their fifth round until 2029 in both counties. Recognizing that these areas are not defined as having persistent TF, TEC recommends that the Ministry of Health consider a modified strategy (i.e., MFTA) to accelerate progress and reflect this in their TAP and future drug requests.

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?

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.

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.