Trachoma Action Plans (TAPs)

Lessons learned since 2011

• Need to have 2 days set aside for trichiasis & 3 days for F&E

• Need to have the data in order to plan

• Need 2-3 “writers” during planning

• Facilitation should include 1-2 days afterwards to finalize the plan

• Need to reduce the number of excel sheets

• Now have preferred practices for S & A

• Surveillance included

• Need adequate planning time (about 1-2 months) to get all data compiled, etc.

3

The template aims to facilitate creation of a national level

Trachoma Action Plan which will accomplish three objectives

Drive stakeholder

alignment

– Bring together all interested parties in a

collaborative planning process

Develop message

necessary to drive

advocacy

– Provide metrics for compelling statements

regarding the need for and benefits of elimination

(person blinded; economic loss to disability)

– Clearly articulate the actions and resources

needed to achieve 2020 elimination

– Use data inputs to generate “SAFE”+Data-oriented,

annual milestones for implementation

Delineate the path to

2020

General documents or data needed

for planning Documents

• National trachoma strategic plans

• NTD master plans

• Ministry of Education school health plans

• WASH plans

Data

• List of districts and population

• TF & TT data (baseline data + impact assessment data)

• Latrine and safe water coverage

• Existing plans for mapping, impact assessment, and surveillance

Trichiasis data needed for planning

• TT prevalence (to calculate backlog,

ultimate intervention goal, and annual

intervention objectives)

• Number and placement of trichiasis

surgeons

• Number of people receiving trichiasis

surgery in each district during the last

calendar year

• (ideally….productivity of trichiasis

surgeons)

MDA data needed for planning

• TF prevalence in mapped districts

• MDA undertaken in each district year upon

year (showing number of people receiving

treatment)

• MDA coverage for each district

WASH data needed for planning

• Situation analysis format being finalized by

ICTC F&E Working Group

ICTC TAP planning material

Manual/tool Status

TAP guidelines Dissemination shortly

Evidence-based planning for

elimination of blinding trachoma

(trichiasis) in EMR

Background

Trachomatous Trichiasis (TT) is the major cause of blindness from trachoma in some countries of EMR

Management of TT is a key component of SAFE Strategy

Global goal: to reduce the prevalence of TT to below 1 in 1000 people by the year 2020

Will the global goal

for TT be met?

Great progress and scale up

has already been made in

some countries

But, using current

productivity figures, it will

take 28 years to address

the existing backlog

There is a need to

do more and better

What do we know?

• Surgery output is currently significantly below that

needed to address the TT backlog by 2020

• Growing realization that surgery quality and outcomes

are not always as good as needed

• Research carried out recently years provides evidence for

improvements to:

– Surgical procedure

– Training and supervision

– Service delivery

Evidence for

action was

compiled at a

global scientific

meeting held at

KCCO Moshi in

January 2012

• Surgical

management

• Surgical training

& quality

• Surgical output

& uptake

Surgical Management

TT definitions • TT defined as

– Any lash touching the

globe

– Evidence of epilation

• Indications for surgical

management

– Any central lashes

– Peripheral lashes that

touch the cornea

– Requested by TT

patients

• Patient who refuse

surgery should be offered

other alternatives such as

epilation

Surgical management

• Excellent results have been reported from clinical trials using bilamellar tarsal rotation (BLTR)

• Add special lid clamp/plate to BLTR

• WHO TT surgery manual & training of trainers manual (including Head Start)

• Follow WHO “Final Assessment of Trichiasis Surgeons” guidelines

• Epilation is an option if surgery is not acceptable to patient (need to budget for and provide epilation forceps)

Surgical Outcomes

• Poor outcomes occur

– “Surgical failure” when TT present within 6

months of surgery

– “Recurrence”- if TT present only after 6

months post operative

• Conduct a post-operative follow-up within 6

months of surgery

• Poor outcomes (post-operative TT) have

been 15-60% —most variation surgeon

related

• Re-operations have worse outcomes

For consideration in EMR

• Adopting BLTR/Trabut procedure (where

not currently used)

• Establishing a system for recording and

reporting outcomes of surgery & epilation

• Management of people refusing surgery

Surgical

Training &

Quality

Training needs to be strengthened

• Reported attrition of non-eye care TT surgeons is high: up to 50%

• Dedicated eye workers are more likely to be retained and are doing the most surgery. “Task shifting” to general nurses not most efficient

• Selection of trainees needs clear criteria - including binocular vision & manual dexterity

• Use of various manuals (training of trainers) and materials (Head Start)

• Use of WHO “Final Assessment of TT Surgeons” for certification is strongly encouraged

Strengthening supervision

• Supervisors need training in how to supervise

• TT surgeons need a supervisor who has

experience in TT surgery

• Supervision should be both active and supportive

• Supervisors need training in how to supervise

• Supervision guidelines are under development

and include

– Occasional direct observation of surgery

– Record keeping & audit of outcomes

– Review of efficiency and effectiveness of outreach

For consideration in EMR

• Selection criteria for training and re-

training TT surgeons

• Adoption of standard training and

certification criteria

• Deciding what to do if surgical failures

exceed 20%

Surgical Output & Uptake

Increasing output

• Outreach surgical provision accounts for 65-85% of total TT surgeries performed

– “Static” services (at health centres) only provide 15-35% of total TT surgeries

• Expecting general health workers (trained in TT) to provide the service as part of their general responsibilities is unlikely to lead to success

• Dedicated teams devoted mostly to TT surgery are most likely to get the job done

• Prioritze areas with large numbers of TT cases

• Manual on how to conduct effective / efficient outreach programme is under development

Increasing Uptake

• Mobilization should be driven by local understanding of barriers

• Minimise the cost to the patient; bring as close as possible to the TT patient

• TT patient identification key to good mobilization

• While surgery should be offered, not all will accept it, therefore, other management options is needed (counseling, epilation)

For consideration in EMR

• # of TT surgeries per surgeon per day on

outreach

• Mobilization approaches to adapt and

adopt

• Composition of the TT outreach team

(including roles and responsibilities)

ICTC TT material

Manual/tool Status

TT Preferred practices

manual (Moshi meeting)

Completed

TT outreach manual Dissemination shortly

Supervision training

guidelines

Dissemination shortly

TT training of trainers

(including Head Start)

Dissemination shortly

WHO TT surgery +

certification

Completed

Trichiasis is a “time-limited”

problem…and requires urgent

intervention

• Long term “sustainability” of the TT

service is not the most important

consideration (different from cataract)

Evidence-

based planning

for Zithromax®

MDA for

trachoma

• Learn from various Zithromax® MDA

programmes and in order to develop

Zithromax® MDA “preferred practice”

guidelines

Supported by the International

Trachoma Initiative

The approach…

• Issues/challenges in MDA

– Practices from the field that

address the issues

• Preferred practices NOT

“written in stone”

– As programmes mature,

situations change

– As experience grows, new

ideas emerge

– As technology changes,

new approaches possible

National coordination Preferred practices:

1. Invest resources in national coordination

2. Have a strong NTTF (includes partners)

3. Budget based on practical national and county plans

4. Strong coordination between NTD and eye care

5. For integrated programmes, need drugs in country at the same time

6. Coordination and planning need to be context specific

– Integrated NTD coordination

Integrated MDA programmes

Preferred practices:

1. Integrate activities as

programme mature

2. Build on existing

programmes

3. Do not overwhelm the

health system

4. Build on the lessons from

CDDs (but often context

specific)

5. Must have strong

supervision

Communication & building trust for

MDA

Preferred practices

1. Investment in advocacy essential

2. Have a strong advocacy plan

3. Scale up advocacy plan throughout the country

4. Have strategy to deal with “bad press”

5. Launch (campaign) to get/maintain support

6. Use media & local leaders according to needs

MDA Micro-planning

Preferred practices

• Plan timetables carefully

• Plan drug movement

• Manage cash at local level

• Plan organization of distribution strategy

• Plan for determining coverage (and steps if coverage low)

• Link micro-planning with post MDA review

MDA Micro-planning (cont.)

Preferred practices

• Micro-planning for efficiency and effectiveness

• Micro-planning done annually

• Use standardized tools

• Engage stakeholders in micro-planning

• Make micro-planning transparent

• Link micro-planning to accountability

Training for MDA

Preferred practices:

1. Standardize training

2. Use cascade approach (keep training focused)

3. Set target population (and coverage %) per distributor

4. Re-train each year

5. Adult-education techniques (practice, practice, practice)

Personnel for MDA

Preferred practices:

1. Identify clear roles and responsibilities

2. Incentives for distribution

3. Anticipate attrition

4. Train health staff in supervision

5. Supervision to focus on key tasks

6. Supervision tailored to field practicalities

7. Supervisors accountable for coverage

MDA implementation

Preferred practices:

1. Planning for distribution

system evidence based

(central site distribution vs.

house to house distribution)

2. Selection of distributors an

important part of community

engagement

3. Community mobilization

requires community

engagement as early as

possible

MDA implementation (cont.)

Preferred practices:

1. Establish & maintain census

book

2. Standardized recording &

reporting for scale up

3. Coverage assessed

daily/weekly to identify gaps

4. District coverage measured

as soon as possible to

identify district-wide gaps

For consideration in EMR

• Adaptation and adoption of preferred

practice guidelines

• Capturing lessons learned in EMR MDA

programmes (e.g., Sudan)—improve upon

preferred practices

• How to build capacity for effective and

efficient MDA

ICTC MDA material

Manual/tool Status

MDA Preferred practices manual Completed

Training guide for antibiotic

distribution

With MDA WG

Supervision guidelines Draft completed

Zithromax supply chain

management

Draft completed

Micro-planning guidelines With MDA WG

WHO Trachoma programme

managers guide

To be revised

http://www.trachomacoalition.org

Other aspects to TAP

• Review of WASH situational analysis

• Discussion of monitoring progress

• Timeline for impact assessments

• Surveillance plan

• Establishment/strengthening of NTTF (and

small working groups)

• Next steps

During TAP, working groups to

draft components of the plan

1. Trichiasis programme questions

2. MDA programme questions

3. F&E programme questions and

coordination questions