Global Trachoma Mapping Project EMR Alliance Meeting Alliance Meeting 26th April... · Global...

Global Trachoma

Mapping Project

EMR Alliance Meeting 26th April 2014

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Agenda

• Background on the grant

• Progress to date

• How it works (design, methodologies, systems, training etc.)

• Links to drug applications and Trachoma Action Plans

• Process for engagement and getting started

• How do you plan for country based mapping?

Background on the grant

Global Trachoma Mapping Project – the beginning of the end for trachoma

• There is an international commitment to eliminate trachoma by 2020 in line with

the target set by the World Health Assembly. Determining where trachoma is

prevalent by mapping the disease is a critical first stage.

• Historically trachoma mapping has been under-resourced and in the 12 years

before GTMP started, 1,115 districts were mapped with 559 confirmed as

endemic.

• GTMP has set out to map trachoma (as well as other NTD & WaSH data where

possible) in the estimated remaining 1,238 endemic districts, in over 30 countries

by March 2015, in only 2.5 years.

• Mapping must be completed to enable country programmes to undertake

development of action plans, request and distribute donated antibiotics, and

implement the full SAFE strategy over a period of between 3 to 5 years.

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Global Trachoma Mapping Project – an immense international challenge

• In July 2012 the Global Trachoma Mapping Project Consortium (GTMP) was

awarded £10.6M by the Department for International Development (DFID) in the

UK to complete trachoma mapping in the estimated remaining 1,238 districts.

• The founding partners of the GTMP consortium – led by Sightsavers – include

the London School of Hygiene and Tropical Medicine (LSHTM), the International

Trachoma Initiative (ITI) and the International Coalition for Trachoma Control

(ICTC). The wider community includes an array of expert NGOs.

• The first GTMP surveys started in Oromia in Ethiopia on 17th December . The

initial focus of the project was to support mapping in Ethiopia and Nigeria which

together have 50% (over 600 districts) of the suspected endemic districts.

• Since the start of the project, USAID (via RTI/FHI360) has also funded and

supported the trachoma mapping in over 200 districts

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• By developing standard methodologies,

protocols and materials and providing expert

assistance to Ministries of Health, this

collaboration enables the GTMP to meet its

key objective:

• supporting countries to quickly

scale-up their trachoma mapping

plans while maintaining quality in

delivery to support this step towards

global elimination.

• Since the start of the project, the scope has

increased and the estimated number of

districts to be mapped is currently in excess

of 1,800 districts (50% increase)


• All mapping data collected is owned by the national governments and is uploaded to

the Trachoma Atlas - http://http://www.trachomaatlas.org/.


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• The GTMP grant and resources can only be utilised to map districts where

trachoma is suspected to endemic.

• There needs to be evidence of trachoma

• Is there any TT surgery being done?

• If no, are TT cases presenting?

• If no, if any existed in the population, could they present themselves?

• If no, is there any community outreach that could be used to identify

TT patients in the community?

• GTMP cannot support the mapping of districts where there is no evidence of

trachoma or to prove that the districts are trachoma free.



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Trachoma Atlas – Africa & Middle East

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Agenda







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Progress to date

• 1,033 districts have completed mapping

(83% of original target: 1,238)

• 96% of districts have been mapped using

GTMP methodology (987 districts)

• 16 countries have now completed mapping

or are currently conducting mapping

• The total population in all districts mapped is

1.3 million people

• Over 26 million data items have been

processed

• GTMP is currently working with 19 different

implementing organisations

• GTMP has delivered nearly half of all the

trachoma surveys that have ever been

conducted (48%)

Total number of districts mapped for trachoma:

23rd July 2012 to 23rd April 2014 inclusive

763 Districts Mapped with DFID Funding

and GTMP Methods

74%

5 Districts Mapped with DFID Funding

and Other Methods

0%

224 Districts Mapped with Other Funding

and GTMP Methods

22%

41 Districts Mapped with Other Funding

and Other Methods

4%

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Progress to date – GTMP progress as of April 2014

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Progress to date

Progress in EMR Region

Countries which

are trained and

mapping

Countries in

planning stages

Discussions /

on-going

Mapping on

hold due to

security

concerns

• Sudan (45

districts: $600k)

• Yemen (phase 1,

83 districts :

$150K, phase 2,

128 districts

$280K)

• Egypt (phase 1,

12 districts: $36K

estimated total

districts 60-80)

• Afghanistan (estimated

36 districts: $540K)

• Pakistan (estimated 72

districts: $360K)

• Somalia (estimated 12

districts: $60K)

• Djibouti (estimated 2

districts: $10K)

• Sudan (19 districts

on hold)

• Yemen (1 EU on

hold)

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Progress to date

Status

• Sudan: Training held on the 6th April 2014. Planning completed. Ethics and data

management agreed. Contract formalisation and agreements in final stages.

Mapping to commence in a few weeks time. (20 clusters per EU, 28 EUs,12 teams:

x1 Recorder x1 Grader)

• With thanks to: Dr. Awad, Dr. Balgesa Elkheir Elshafie, Dr Kamal Hashim

• Egypt: Training to be held on the 11th May 2014. Planning completed for phase 1.

Ethics and data management agreed. Contract formalisation and agreements in

final stages. Mapping to commence in a few weeks. (22 clusters per EU, 4

Governorates: 3 districts each (12 EUs),12 teams: x1 Recorder x1 Grader)

• With thanks to: Dr. Khaled, Dr. Gamal, Dr. Islam el Beih, Dr. Ahmed Khairy

• Yemen: Mapping for phase 1 completed (one EU on hold because of security

concerns). Phase 2 budgets in review. Mapping to commence once budgets for

phase 2 are finalised.

• With thanks to: Tawfik Al-Khatib, Ahmed Al-Soofi, Fouad Al-Bahm

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Agenda







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How it works

Approach to mapping:

Collaboration

Programme engages with, and is supported by, the expert trachoma community

(currently working with 19 different organisations)

Standardisation

Standard methodologies and training materials are used, based on WHO protocols

Training

Extensive in-country training workshops – including training of trainers, training and

testing of Supervisors, Graders and Recorders

New technology

Smartphones are used to capture data, all data/results are approved by MoHs

electronically. Web-enabled financial claims and reporting systems support robust

reviews of budgets, claims and reporting.

Implementation

MoH manage and deliver mapping supported by NGOs, NGOs sign agreements and

submit financial claims on a quarterly basis

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How it works – Country Agencies

• It is anticipated that each country will normally have one coordinating NGO and one or several implementing NGOs

• Both the Coordinating and the Implementing NGOs will contract directly with Sightsavers

Implementing NGOs

Requirements Field experience in the relevant country

Responsibilities Has overall program planning, management, and

delivery responsibilities. Delivers the mapping to the agreed quality standards and has access to local

infrastructure, staff and vehicles.

Coordinating NGO

Requirements Existing strong presence, capability and infrastructure in

country (office staff, vehicles) and existing relationship with the National MoH

Responsibilities Builds implementing NGO network and is responsible for

managing relationship with National MoH (including gaining the appropriate ethical and data access

approvals)

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How it works - Training & methodology

• The number of graders/recorders you train

depends on the number of EUs to be

mapped and your timescale for completion.

• One GTMP mapping team will normally be

composed of: 1 grader, 1 recorder and 1

community guide (as well as one driver).

• It normally takes 1 day to map 1 cluster.

• There are generally 20-30 clusters in an EU.

Therefore 1 GTMP mapping team will

normally map 1 EU in a month.

• There is usually a MoH Supervisor who will

supervise and support between 7 and 10

GTMP mapping teams.

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How it works – Utilising new technology: Data

“Ensure that each country’s data sovereignty and security rights are upheld”

• Data are owned by the government

• Data are stored securely and must be accessible

• Access to data is determined by each the national government

• Both the raw data and results are approved and released by the national government

• The MoH will publish the results in a peer-reviewed journal

“DFID grant requirements”

• The national government will grant DFID and the Project Partners a royalty-free and

global licence to use the data for non-commercial use, for the purposes of research

and teaching into, and prevention, treatment and eradication of, trachoma and other

neglected tropical diseases.

• The summary data is made publically available on the Trachoma Atlas that is managed

by the International Trachoma Initiative (ITI)

• In line with academic best practise, the detailed, anonymised dataset should be made

available for the purpose of research and teaching, at least 12 months after initial

government approval and only after primary publication

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How it works – Utilising new technology: Ownership

“Data are owned by the government”

To avoid a situation in which multiple data storage and processing solutions have

to be quickly created in each country and then, as required by the grant

agreement, uploaded into the Trachoma Atlas; the GTMP has developed an

innovative system to support data processing and storage and protect the rights

of national governments.

• Data are owned by the government

The government is protected by legal agreements with all the project partners

• The MoH will publish the results in a peer-reviewed journal

The government is protected by legal agreements with all the project partners

and the GTMP will support a first MoH author(s) to prepare a manuscript for

publication in a peer-reviewed journal.

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How it works – Utilising new technology: Process

The system has the capability to process and manage large volumes of data

approx. 26 million items in the first 15 months

• Data are stored securely and must be accessible

The data is encrypted and securely uploaded to the database

Data can be stored in-country but will also be stored in a “world-class” data management services

provider, maximising uptime, data-security and accessibility

• Access to data is determined by each the national government

ITI (not NGOs, donors or academic institutions) will support the national governments by providing

stewardship of the data and systems. Access to data will be determined by explicit written agreements

between the national governments and ITI

• Both the raw data and results are approved and released by the national government

There is a fully transparent cleaning process undertaken in communication with field supervisors.

The raw data and the analyses of the data are approved and released by the national government

The MoH can access, run reports, download and transfer the data at any stage

• Capacity building

The MoH data collectors (recorders), MOH Data Managers, MOH Epidemiologist and MOH Permanent

Secretary (or designate) will be supported with training to collect, access, analyse, approve and

download / transfer the data.

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How it works - New technology

Mapping data is available on the Trachoma Atlas as early as two weeks after the survey

Collection by smartphone

Standard surveys (incl WASH)

GPS coordinates

Dynamic/regular uploads

Ownership & access

Data sovereignty and security is key

Data available to be viewed online

Data can be downloaded

Data cleansing & Approval

Data reviewed daily by data manager

& by Chief Scientist

Both data and results are electronically

reviewed and approved by MoH

Reports available for implementation

planning and drug applications

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How it works

Online CLAIMS system facilitates reporting and provides an

easy to use template

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Agenda







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Drug Applications & Trachoma Action Plans

• ITI manage the relationship with the drug company Pfizer Inc.

• Pfizer donate the drug Zithromax to support trachoma elimination in line with the WHOs

SAFE strategy.

• ITI has instituted an annual application process for new country applications as well as

countries applying for additional rounds of Zithromax treatments. This process is

designed to assess a country’s Zithromax need over a five year horizon.

• The application requests information on up-to-date treatment distribution data, in-country

inventory and an update on prevalence data. The data collected in this process allows ITI

to determine the long term Zithromax needs in a particular Country, as well as evaluate

the progress towards the elimination of blinding trachoma.

• Zithromax donations are only approved when given in the context of the full SAFE

strategy.

• Trachoma Action Plans are created once survey data is finalised. (More on this later)

The ITI Trachoma Expert Committee (TEC) endorses the systems of the GTMP

as the gold standard method for applying WHO methodologies to produce

baseline trachoma data.

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Agenda






• How do you plan for country based mapping

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Process for engagement and getting started

Process for engagement

Building relationships and agreement • Identify the key partners who will be involved in the trachoma baseline surveys: MoH, ophthalmic

advisors, national and regional INGOs

• Make contact with GTMP to request technical and planning assistance to establish the evidence

base and proposed scope (districts) of work for the trachoma baseline surveys

• Hold a co-ordinating meeting with all stakeholders to further refine and agree the proposed scope of

work and to propose the mapping methodology, plan of action and high level budget – capture

decisions in the protocol (a word document) (GTMP are able to facilitate or advise the co-ordination

meeting if helpful)

• Submit the proposal in the form of a protocol to GTMP’s Chief Scientist Dr. Solomon and request a

formal review and agreement of the mapping methodology

Formalising mapping activities and gaining approvals • Once the protocol has been agreed by both the Ministry of Health and GTMP detailed budgets can

be submitted to GTMP for review and agreement

• After which a contract will be established between the Co-ordinating Agency and GTMP to continue

engagement and co-ordination between all stakeholders during the mapping project

• A contract will also be established between each Implementation Agency and GTMP to oversee the

delivery of the baseline mapping (this will document the number of districts and the total budget)

• The Ministry of Health are asked to provide a formal letter which stipulates that GTMP and

associated stakeholder partners are granted ethical agreement to conduct the surveys and data

access approval to upload the prevalence data onto the Trachoma Atlas website.

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Getting started and running the project

Training • The Implementation Agency and the Ministry of Health identify potential trainers, and share the listing

with GTMP

• The Implementation Agency and the Ministry of Health hold the training workshop in collaboration with

GTMP training methods (classroom and field)

• GTMP provide certified grader and recorder trainers, loupes, androids and manuals (as required)

• Implementation agencies will be asked to provide EU names and the name of a Ministry of Health data

manager and Ministry of Health data approver to GTMP to enable data processing

Mapping • Smartphones can be tested during training to ensure they are operational for the mapping

• Also whilst training there is time to refine plans and to ensure all resources, vehicles and equipment

are in place for the mapping

• Conduct trachoma baseline surveys, record and send data on a regular basis

• ITI are available to answer any queries or questions that may occur regarding data capture and review

• Once the Ministry of Health has approved the data it is validated by GTMP and uploaded onto

trachoma atlas

• On conclusion of all baseline mapping activities a meeting can be held to discuss the outputs of the

survey and to update the Trachoma Action Plan

Reporting • A quarterly progress report and expenditure claim is submitted to GTMP within 10 working days of the

quarter end. Funds will be reimbursed within 30 days after submission of the claim

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Check list

• Protocol and methodology ………………

• Ethical agreement and data access agreement letter ……………...

• Time line and plan ………………

• Budgets agreed ………………

• Trainers identified and support materials requested ………………

• What do you need to do next?

Date for completion/

people to contact

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How do you plan for country based mapping?

• After lunch we will be holding a workshop to talk you through the first steps to establish

a plan and proposal for country based mapping

• We will provide:

• A sample protocol

• A planning tool

• A draft ethics and data management agreement letter

• An implementer agreement template

• Budget templates

• Considerations to include:

• Methodology – number of clusters etc

• Cultural and religious sensitivities

• Timeframe

• Stakeholders

• Security

• People to own the process and champion the work

• End date for grant

• Copies of the training manual and surveys on the android telephones are available to

view

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Benefits of using GTMP processes and systems

• Funding and expert resources and systems to support countries to quickly

scale-up trachoma mapping plans while maintaining high quality

• Data is owned by the national government

• Use of, and access to, data is controlled by MoH

• GTMP systems and processes are proven and cost efficient

• GTMP methodologies and systems are endorsed as gold standard by the ITI

Expert Committee and will help ensure that the quality standard of the

mapping is acceptable for drug applications to Pfizer.

• The extensive training and use of new technologies will provide an opportunity

for countries to adapt these new processes to support the mapping and

intervention activities of all NTDs.

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Contacts

Dr Anthony Solomon (Chief Scientist GTMP): Contact if you have questions over project

methodology and protocol. [email protected]

Dr Paul Courtright (GTMP Technical Advisor): Advice on country set up and training support

[email protected]

Eleanor Challenger (Project Administrator, GTMP, LSHTM): Contact for training and general

requirements. Please copy in to all training correspondence. [email protected]

0044 (0) 207 927 2847

Tom Millar (Operations Director, NTDs, Sightsavers): Contact if you have any general

questions regarding the project or getting started. [email protected]

Siobhain McCullagh (GTMP Operations Director at Sightsavers) Overall project management

for the GTMP. [email protected] +44 (0) 1444 446771

Sarah Bovill (Risk and Finance Manager at Sightsavers) Contact for budgeting, finance &

CLAIMS. [email protected] +44 (0) 1444 446665

Cristina Jimenez (NTD co-ordinator at Sightsavers) Contact for travel and visa arrangements.

Please copy in to all travel/visa correspondence.

[email protected] +44 (0) 1444 446715

mailto:[email protected]






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Workshop 1: Trachoma Mapping

• Over the next 3 hours we will help you to develop a protocol which will form the

basis of your Trachoma mapping proposal.

• We will explain the different stages, and ask you to work in your groups to

review:

• Choice of mapping areas

• Mapping methodology

• Timeline for activities

- If you already have completed your protocol please start to work on your

budgets with assistance from Siobhain McCullagh and Tom Millar (GTMP)

Please form groups to work through the

Trachoma mapping proposal activities

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How do you choose the mapping areas?

• Is there any TT surgery being done?

• If no, are TT cases presenting?

• If no, if any existed in the population, could they present themselves?

• If no, is there any community outreach that could be used to identify TT patients in

the community?

• For the actual prioritising of countries local stakeholders (MoH, INGOs) should be

consulted

• An area will only be mapped if there is some evidence that there is trachoma

• The status of countries with regards to trachoma is listed on the WHO webpage under

http://apps.who.int/neglected_diseases/ntddata/trachoma/trachoma.html. However, this can be taken as

a first indication only, as even countries that are not listed to be endemic might have some pocket areas

of trachoma within their country.

http://apps.who.int/neglected_diseases/ntddata/trachoma/trachoma.html

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How do you establish the mapping methodology ?

• One area to be mapped at a given time consists of 150.000 to 250.000 persons, the

“mapping population”. For TF 1019 children aged between none and nine are examined,

while the number of TT patients can be estimated from the TF figure.

• The number of 1-9 year old children expected to be seen in one area are based on the

census data, which then indicates the number of clusters needed to get sufficient data. The

selection of villages to include in a cluster depends very much of the population of a village,

which has to be representative for the total population in the area. However, refugees are to

be treated as a different part of the population. As a general rule at least 20 clusters should

be included in one survey. Due to the GPS technique the number and location of

households included in the survey can easily be monitored. In countries with a very high

percentage of children attending schools (> 95%) it could also be considered to screen

schools, however this in not likely to be the case in most countries.

• In areas where the security situation doesn’t allow the filed team to go from house to house,

any mapping procedure isn’t possible as the welfare of the team has absolute priority.

Moreover, any implementation might then be even more risky.

Statistical figure as stated by Anthony Solomon during the ERM Trachoma Alliance Inaugural

Meeting, 15-16 December 2013, Dubai

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1. Acronyms

2. Introduction

• Background

• Country Profile

• Justification

3. Aim and Objectives

• Aim

• General objective

• Specific objectives

4. Methodology

• Study design

• Target population

• Sample Size

• Sample size

determination

• Sampling plan

• Survey Teams

• Data Management

Collection

• Data Ownership

• Data

collection/Questionn

aire administration

• Examination

methods

• Trachoma surgery

• Materials

5. Work plan

6. Distribution of GTMP Survey

sample size

7. Budget

8. Planning Outline

9. References

10. Annexes

How is a protocol structured?

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Guidelines for breakout work

Activity 1: In your group, please consider and record the information which build the content of your protocol

against the headings provided.

• Considerations to include:

• Methodology – number of clusters etc

• Cultural and religious sensitivities

• Timeframe

• Stakeholders

• Security

• People to own the process and champion the work

• End date for grant

Activity 2: Please also record your timeline to:

• finalise the protocol,

• agree the ethical and data management with the MoH,

• arrange and hold training, and

• conduct the baseline survey mapping

• GTMP team members will rotate through the groups to help

• We will take 20 minutes to wrap up at the end of the working session

• Are there any questions before we begin?

• Note – tea and coffee will be served between 15.30 and 15.45

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• What challenges did you face?

• Do you have any additional questions?

• What dependencies or outstanding activities remain?

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