Information needed for evidence-based planning for blinding trachoma (trichiasis) in Burkina Faso, Cameroon, & Ethiopia

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 in recent 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

Evidence for action… 1.Surgical Management 2.Surgical Training & Quality 3.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 Patients 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 patient does not accept surgery (need to budget for and provide epilation forceps)

Improve surgical outcomes Poor outcomes (post-operative TT) have been % —most variation surgeon related Poor outcomes defined as: –“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 Re-operations have worse outcomes –Should aim to avoid/but need intervention TT Surgery & Follow up Form (in TT Outreach Manual)

Strengthen Training Selection of TT surgeon (where using general health workers attrition of TT surgeons is generally high) Dedicated eye workers are more likely to be retained and are reported as doing most surgery Selection of trainees needs clear criteria - including binocular vision & manual dexterity Training of trainers manual (“Final Assessment of TT Surgeons” included in yellow manual)

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 Supportive supervision Supervision training as part of ToT

Increasing Output “Campaign” / “Outreach” surgical provision often accounts for 65-85% of total TT surgeries performed “Static” services alone will not be sufficient Training general health workers unlikely to deliver the volume of surgery needed In high prevalence areas use “dedicated teams” Priority to areas with highest UIG (camp approach) TT Outreach Manual

Increasing Uptake (1) Mobilization and sensitization not sufficient to increase uptake Service needs to minimize the cost to the patient and “brought close to the TT patient” TT case finding & referral essential for effective and efficient camps TT Case Finding Training manual

Increasing Uptake (2) All TT patients should have an “intervention” appropriate to their condition Good quality counseling of patients & family members needed While surgery should be offered, not all will accept it, therefore, other management options may be considered TT Counseling manual

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)