Conclusions & Recommendations

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.

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 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.

TEC is heartened that Sudan is actively planning to restart MDA in three districts that they deem safe. The national program is asking for a full (95%) allocation instead of the reduced (80%) allocation. TEC noted the following:
- funding is confirmed and the implementing partner is The Carter Center;
- due to migration as a result of active conflict, the population figures will need to be re-estimated prior to the next shipment;
- the security situation must be reassessed right up until the moment of shipment;
- these are persistent districts and, therefore, eligible for a modified MDA treatment strategy; however, TEC also noted that the request for 95% of the drug did not seem to be based on a modified strategy request, but instead, on assumptions that the population is greater than current population estimates suggest;
- while the Khartoum airport has been demolished, other humanitarian shipments are successfully being received at Port Sudan and could be moved by road in convoy to the treatment areas. ITI will need to organize a test shipment since this is a new shipment location.
TEC recommends that:
- a pre-treatment census in the camps be conducted to finalize treatment figures,
- a reduced (80%) allocation be given consistent with other countries, and
- the treatment requests be approved pending confirmation of security (RS).

TEC appreciated the update on the development of the application of model-based geospatial statistics in trachoma programs and looks forward to further validation and information on its application.

TEC expresses their appreciation for the work led by Dr. George Kabona, the MOH of Tanzania, and its partners who quickly put into effect an enhanced monitoring strategy. TEC looks forward to additional updates as data become available.

TEC congratulates the Zambia program for their excellent work during their recent surveys, particularly in the decision to add the collection of complementary indicators in Kaoma, Luampa, and Nkeyema. TEC is grateful for the fast and diligent work in developing a comprehensive and well thought out plan for how to move forward in the three evaluation units categorized as “persistent” districts. TEC recommends:
- In Kaoma, Luampa, and Nkeyema, given the inconsistency between TF1-9 of 9.16% and a seroconversion rate among children 1-5 years of 0.6%, PCR processing of the already collected conjunctival swabs will provide important information to inform program activities. TEC looks forward to receiving the Ct infection results in due course and a further discussion with the program on next steps in these districts. TEC contingently approves the request for these three districts pending review of Ct infection results and confirmation of funding (R2/R1).
- In Shangombo and Sioma where TF1-9 is 12.5%, TEC approves the request for a modified strategy of two treatments 5 months apart (projected for May and October 2024), pending confirmation of funding (R1), followed by a TIS+ including both serology and infection data collection, subject to available funding.
- In Sikongo and Kalabo where TF1-9 is 7.7%, TEC recommends to ITI to hold further discussions with the Ministry of Health and program partners to discuss recent evidence from the trachoma community on areas with TF1-9 5-9% at the endgame, and explain all options available to the program (including timelines and cost implications) for their consideration. These districts are eligible for the modified MDA strategy proposed by the national program, and if the MOH determines this is the best strategy for their situation, TEC will approve the drug (contingent on confirmation of MDA funding). If, instead, the MOH prefers to adopt an enhanced monitoring strategy (e.g., ‘wait and watch’ followed by a TIS+), TEC and ITI stand ready to provide the program with any technical assistance that they may need, if requested.

Given how quickly data are being generated and trachoma program guidance is changing, TEC recommends that ITI discuss with WHO how best to support the convening of a meeting of program managers in countries with persistent/recrudescent districts to disseminate recent findings and help them understand the range of options for how best to move their programs forward.

TEC has been impressed by the incorporation of complementary indicators for trachoma, and encourages continued inclusion when appropriate. TEC also noted considerable interest in other measures of infection beyond serology. In fact, open meeting discussion noted advantages of having a direct measure of infection, which responds more rapidly to intervention, and could act as a “tie-breaker” when results from district-level TF and serology are inconsistent. Several examples of PCR being used constructively in certain settings were presented. PCR would be an obvious candidate for a third complementary indicator.

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.