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  • br After several decades of community based

    2019-04-15


    After several decades of community-based interventions and surveillance, on Nov 15, 2016, Morocco was recognised by WHO as having eliminated trachoma as a public health problem. A formal ceremony, involving the handover of a letter of recognition from Margaret Chan, WHO\'s Director-General, marked the occasion. Trachoma causes blindness through repeated conjunctival infection with particular strains of , which are transmitted by flies, fingers, and fomites in conditions of extreme poverty. Conjunctival scarring precipitated by these infections ultimately results, in some individuals, in drawing-in of the eyelashes, so that they rub painfully and destructively on the cornea. Risk factors for trachoma include inadequate access to water, inadequate means for disposal of human faeces, and overcrowding. Historical data suggest that, in the first half of the 20th century, most areas of Morocco were affected by trachoma blindness. Beginning in the 1950s, therefore, in cooperation with WHO and UNICEF, Morocco\'s Ministry of Health arranged trachoma-specific training of medical and nursing staff at its National Ophthalmology Center in Rabat-Salé. These health-care workers were then deployed to the field to work with populations considered among Morocco\'s poorest and most disadvantaged. In the 1990s, it emodin was realised that people in the country\'s southeast (in the provinces of Errachidia, Figuig, Ouarzazate, Tata, and Zagora) still had severe disease, with an estimated 35 000–40 000 individuals suffering from trichiasis (the advanced, blinding form of trachoma). The then newly-developed SAFE strategy—comprising surgery for those with trichiasis, antibiotic treatment to clear conjunctival infection, and facial cleanliness and environmental improvement to reduce transmission—was adopted in its entirety. The Government of Morocco quickly understood that implementation of all four components was necessary and sufficient to achieve elimination. Morocco committed itself to eliminate trachoma, and mobilised human and financial resources of its own and from its partners. High-quality eyelid surgery for trichiasis was made permanently available, with 51 939 people operated on nationwide between 1992 and 2015. Mass distribution of the antibiotic azithromycin, donated by Pfizer through the International Trachoma Initiative, was undertaken, with approximately 700 000 doses administered annually between 1999 and 2005; antibiotic coverage was more than 80% in each round in each affected province. This treatment was combined with health education and efforts to improve rural water supply and sanitation. As a result of this work, according to national government data, in each of the five provinces that were endemic for trachoma in 1990, household-level access to potable water increased from less than 20% in 1990 to more than 90% in 2007. A rural electrification programme delivered power to more than 2 million households. Simultaneously, extreme poverty (defined as a per-capita daily income of nflammation—follicular, in 1–9-year-old children fell from 58% in 1997 to less than 5% in 2005 (). Epidemiological endpoints for trachoma elimination were achieved in all endemic provinces by the end of 2005, and a surveillance system was established immediately afterwards. No recrudescence of disease has subsequently been observed. Sustainable changes have been made to the living environments and to the lives of previously-affected populations. The Morocco programme\'s success in eliminating trachoma was made possible through a combination of political engagement at all levels of decision-making and in all phases of the programme; integration of activities into basic health care; a command chain of committees to coordinate activities and facilitate collaboration between sectors at the national, provincial, and community levels, with Ministry of Health leadership; a participatory approach to working with residents of endemic communities; monitoring and evaluation as a fundamental programmatic component; widespread public notification of progress via the media; and robust epidemiological surveillance. The work done in Morocco broke new ground for trachoma in many areas, including innovations in the implementation of SAFE strategy components, creation of systems for post-intervention field surveillance, and first use of WHO\'s newly-drafted standard operating procedures for validation of elimination, helping to refine those procedures for international roll-out. Morocco now looks forward to sharing its experience, in order to assist the remaining 42 endemic countries to eliminate trachoma as a public health problem by 2020.