Conclusions & Recommendations

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.

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.

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.

When ITI has not received an azithromycin request, include the list of ‘missing’ countries in the Director’s Report with information about why there is no request so that meeting participants can either celebrate progress or be aware of challenges that are hampering programs or troubleshoot solutions.

Overlay on the TEC maps any areas that are on hold pending security.

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

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.

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.