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 15-

60% —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)