Skip to 0 minutes and 13 seconds By the end of this presentation you should: - Understand the principles of decision making for trachoma interventions and monitoring of progress - Appreciate the importance of the data flow from the district to the national trachoma task force Virtually all the decisions made during implementation and monitoring of trachoma control activities are based on data. The data come from surveys and programmes and are used to decide on interventions. Trachoma control activities in an endemic district
Skip to 0 minutes and 42 seconds aim to achieve two elimination targets: - First, managing trachomatous trichiasis (TT). How many trichiasis surgeries do we need to do to get rid of the TT backlog? and how long will it take to achieve the elimination target of a prevalence of TT cases unknown to the health system of less than 0.2% in adults aged 15 years and above? And second, reducing active trachoma. How many mass drug administration (MDA) cycles are required? How many doses of antibiotics? And how long will it take to achieve a prevalence of TF less than 5% in children aged 1-9 years? Activities for F&E - facial cleanliness and environmental improvements - vary from place to place, and have locally agreed targets and indicators for monitoring.
Skip to 1 minute and 32 seconds Let’s start with the management of TT. The target number of TT surgeries that each district needs to do is established in the national trachoma action plan. It is important to monitor progress each year against the established annual target. Data can be used to motivate and encourage the team’s progress as well as give feedback and support. Managers should not wait until the end of the year to provide feedback. Each team should be aware of how they are progressing each quarter. Managers can use a range of process indicators
Skip to 2 minutes and 3 seconds to help monitor progress towards achieving targets: - Number of surgeries per outreach, per surgeon - Quality of surgeries provided per surgeon - Acceptance rate for surgeries at outreach campaigns. At the national level, the annual reports per district are discussed. If a district is on track then the team is congratulated. If the district is not on track, the district manager is asked to provide the key reasons and to give the team more support. The national task force should always ensure that district teams are provided with the appropriate resources, training and surgeon accreditation.
Skip to 2 minutes and 40 seconds Management of active trachoma requires data on: - Antibiotic coverage of the population. Ideally everyone in the population is treated, but a minimum coverage of 80% is acceptable - Number of antibiotic doses dispensed. This figure is reported back to ensure further requests to Pfizer - the drug donor - are appropriate. District managers work closely with the MDA teams. They use microplanning to ensure that each MDA will reach 80% or more of the target population. When coverage is less than 80%, it is important to identify and take practical decisions in the field to address the problem. At national level, data are closely followed each year.
Skip to 3 minutes and 21 seconds After the planned A, F and E activities for the required number of years have been completed, an impact survey should be undertaken to determine if TF prevalence has dropped below 5%. If not, then the A, F and E activities are continued. If TF prevalence is found to be less than 5%, MDA is stopped but F&E activities are continued for a 2-year period which will, ideally, continue to see TF fall. After this, a pre-validation surveillance survey should be undertaken to confirm that active trachoma has not re-emerged.
Skip to 3 minutes and 53 seconds The use of data is like regularly measuring progress on a journey: - How much petrol have we used so far? - How far have we gone? - How far do we have to go? - And finally, did we get to the right destination on time as we planned, or not?
Skip to 4 minutes and 8 seconds In trachoma elimination, national coordinators must: - Implement a clear process for collecting and sharing data, either on paper or electronic format - Provide training and guidance for district managers on the data required, and on how to collect and report on those data. - Include feedback mechanisms from the same level at which the data are collected. - Use data to measure progress and to motivate, support and encourage the teams. And, use data to secure resources for the districts.
Skip to 4 minutes and 41 seconds In summary: Data are used to guide planning, implementation and management decisions for the district-level trachoma team. Data must be shared by the district team with the national coordinator for provision of support, resources and guidance. Targets for TT surgeries and antibiotic distribution are agreed in planning meetings for the national Trachoma Action Plan. The national Trachoma Action Plan is a living document. It tracks and adjusts for annual data, identifies gaps and updates progress towards elimination.
Using data to make decisions at the local level
The strategic drivers to eliminate trachoma at the local level are based on data.
Data is used to:
- Know where, and how big, the problem is.
- Develop an appropriate Trachoma Action Plan at a national level.
- Advocate with local stakeholders.
- Ensure resources (both human and infrastructure) and finances are appropriately allocated at district level.
- Track and monitor SAFE implementation against a timeline.
- Assess the outputs and achievement of elimination targets through further surveys.
World Health Organization (WHO) guidance on eliminating TT at the programme level
As trachomatous trichiasis (TT) becomes rarer, obtaining precise estimates of its prevalence becomes progressively more difficult.
The prevalence of TT is measured at the district level, the administrative unit for healthcare management. Districts have a population of between 100 000 - 250 000 people and are referred to as evaluation units (EU). The elimination prevalence threshold for TT is set at < 0.2% in people aged over 15 years in each formerly-endemic EU.
For programmatic surveys specifically designed to measure the prevalence of TT unknown to the health system at the EU level, the current WHO recommendation is that enough households are visited to examine 2 818 individuals aged 15 years and above. This number should provide sufficient data (power) to enable an accurate estimation of the prevalence of trachomatous trichiasis (TT).
As an example, here are some typical figures from a programmatic survey of TT in an evaluation unit (EU):
- Number of people aged 15 years and above = 100,000.
- Prevalence of TT unknown to the health system = 0.5% in people aged 15 years and above.
- Target for elimination: prevalence of TT unknown to the health system < 0.2% in people aged 15 years and above.
- Estimated number of TT cases that need treatment = 100,000 x 0.5% = 500.
- The TT programme must set a target to achieve a prevalence < 0.2% in people aged 15 years and above at the end of a specified time period, e.g., in 3 years.
It is important to remember that the number of prevalent cases is just an estimate to help programmes to plan for service provision and resource allocation. Programmes should aim to cover each entire EU with case finding and TT management as this may identify more, or fewer, people with TT than the estimate has indicated.
National programmes can use one of three methods to assess whether the elimination prevalence target for trachomatous trichiasis has been reached within a country:
- A population-based prevalence survey powered at the level of the evaluation-unit (i.e. a population of 100 000 - 250 000 people), or
- House-to-house case searches, which can be integrated with other public health activities, or
- A combination of data from multiple adjacent evaluation units. Professional statistical advice to identify the best way to achieve this, is being generated: more advice from WHO will follow soon.
As you watch the video, consider how data can be used to motivate a district team to maintain implementation of SAFE and scale up services.
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