Trachoma Action Plans (TAPs) - PBUnion Action Plans (TAPs).pdf · Trachoma Action Plan which will...
Transcript of Trachoma Action Plans (TAPs) - PBUnion Action Plans (TAPs).pdf · Trachoma Action Plan which will...
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
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
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
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%
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)
• 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
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