Conclusions & Recommendations

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.

TEC acknowledges with gratitude the work being done by Pfizer to increase their manufacturing capacity for the trachoma donation. TEC recommends to ITI to review materials (including supply chain training; Zithromax® Management Guide; Memoranda of Understanding with countries) for necessary updates once Pfizer’s production plans are finalized, including the shift from the brand name of Zithromax® to azithromycin and descriptions of the packaging. TEC further recommends to ITI to send letters to all partners and countries immediately upon finalization of these changes to advise them of the details and to request they update all materials as appropriate.

TEC commends ITI on its work to support countries nearing the end of MDA through their efforts to closely match shipments to expected demand for their anticipated final MDA. Doing so will avoid overstock as MDA finishes.
TEC recommends that ITI:
- investigate reasons for the remaining inventory in Côte d’Ivoire and consider any options to move/use the inventory so it doesn’t go to waste,
- apply lessons learned from Côte d’Ivoire to avoid a large mismatch in the future,
- support countries early in the development of their plans to utilize or destroy (where applicable) in-country Zithromax® as MDA needs decrease or cease altogether,
- update TEC annually on how the process is going, and
- look for opportunities to share lessons learned with other NTD programs.

TEC appreciated the update on the ASPECT trial and requests future updates on any changes to study design, funding, and timeline.
Given the delays in possible funding, TEC recommends to ITI to get a revised list of districts where child MDAs are expected in 2024 to facilitate more accurate forecasting.

TEC appreciated the detailed update from the Bill & Melinda Gates Foundation on the REACH trials. As results are coming in and the Foundation expresses its interest in scaling up child survival programs, TEC noted the currently inadequate global POS production capacity and would appreciate future updates and coordination between ITI, Pfizer, TEC, and BMGF on this issue and its impact on the trachoma program’s POS needs. TEC welcomes the possibility of future engagement for child survival rollout and further requests clarification of its own role. Recognizing ITI’s excellence in supply chain management, evidence gathering, leadership, and convening, TEC further advocates for ITI to be the primary steward of azithromycin procured and/or donated for trachoma and child survival. TEC notes that ITI would need additional resources to take on this additional workload while maintaining its excellent support to national trachoma programs.

TEC is grateful for WHO’s swift work to move the guideline development process forward on the use of serology for trachoma assessments. To better support countries’ capacity to utilize serology in their programs, TEC would like to understand the additive costs associated with collection and processing of specimens for serology.
TEC would like to see a similar process for the development of guidelines on the use of infection data so that trachoma programs can benefit from more comprehensive guidance. To support this, TEC would welcome validating large-scale PCR pooling and data on program costs and evidence of comparability across different tests and platforms.

TEC congratulates the Federal Ministry of Health of Ethiopia, Amhara Regional Health Bureau, Amhara Public Health Institute, and The Carter Center on the important work they’ve been doing for 10+ years on data collection and analyses supporting the evaluation of the trachoma program.