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.
The template aims to facilitate creation of a national level Trachoma Action Plan which will accomplish three objectives Delineate the path to 2020 Use data inputs to generate SAFE +Data-oriented, annual milestones for implementation 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 Drive stakeholder alignment Bring together all interested parties in a collaborative planning process 3
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 TAP guidelines Status 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 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 TT definitions
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 retraining 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 TT Preferred practices manual (Moshi meeting) TT outreach manual Supervision training guidelines TT training of trainers (including Head Start) WHO TT surgery + certification Status Completed Dissemination shortly Dissemination shortly Dissemination shortly 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)
Evidencebased 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 Supervision guidelines With MDA WG Draft completed Zithromax supply chain management Micro-planning guidelines WHO Trachoma programme managers guide Draft completed With MDA WG 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