Case study: Challenges and approaches to managing trachoma in Morocco

The Kingdom of Morocco had been seriously affected by trachoma for a very long time. Their first statistics indicated that in the regions of Errachidia, Ouarzazate, Tata and Goulmima, the prevalence of trachomatous inflammation—follicular (TF) was between 41 and 63% and trachomatous trichiasis (TT) affected between 2 and 7% of the population. Trachoma was a medical and social problem in these regions and characterised as a family disease leading to poverty and marginalisation.

Based on these alarming figures, many activities were undertaken to tackle the problem of trachoma.

• Between 1953 and 1971 the Kingdom undertook prevention strategies in partnership with WHO and UNICEF. Education on hygiene and methods of self care were delivered to the most disadvantaged and poorest communities. School eye health was introduced along with other health programmes
• 1971: Medication for trachoma self-treatment was made available in local tobacco shops
• 1975: A programme was introduced to give 1% oxytetracycline ointment to all students in schools twice each day for 3 days.
• 1984: Decision taken to expand antibiotic ointment distribution to 13 Saharan provinces.

Morocco undertook a national blindness survey in 1992, primarily to develop a national prevention of blindness programme. The survey clearly identified trachoma as a public health problem:

• 360 000 Moroccans had signs of trachomatous inflammation—follicular (TF)
• 25,000 had severe visual impairment from trachoma
• 35,000 - 40,000 required TT surgery to prevent blindness.

In the 5 most affected provinces:

• Prevalence of TF/TI in this age group was found to be 5.6% in Figuig and 30.5% in Ouarzazate
• Twice as many women were affected by TT and corneal opacities than men
• Trachoma was a significant cause of corneal blindness.

These indicators illustrated the need to make trachoma a priority public health intervention target in the southern region of Morocco. These provinces are characterised as being arid or semi-desert regions with frequent sandstorms, dust storms and water scarcity. There is significant poverty, with the main economic activity being subsistence agriculture.

Because water scarcity is a significant issue, hygiene and personal hygiene in particular are believed to be major factors in the prevention of trachoma.

Sand dunes, Sahara, Kingdom of Morocco. © Rich Holman CC BY-NC

A school-based survey found that despite previous health education, students regarded the use of ophthalmic ointment as a ‘game’, an obligation imposed by the school and the adult world. They did not recognise the link between their behaviour and their long-term eye health. The authorities concluded that in these regions trachoma was not only a medical problem but, fundamentally and chiefly, a socio-economic problem.

The main factors in fighting the ‘true enemies’ in disadvantaged rural communities were identified as:

• Illiteracy
• Family members living in close quarters
• Lack of water
• Accumulation of animal waste
• House fly populations.

These are the recognised risk factors for trachoma!

Trachoma elimination structure, Kingdom of Morocco (Click to expand)

Introduction of SAFE

In 1997, the SAFE strategy was introduced in 5 provinces of Morocco. Local political will and global partnerships were central to organised action taken across multiple levels and agencies.

Surgery

TT surgery was provided after active screening through static and mobile units.

Antibiotics

In 1996, the programme conducted a community test of trachoma treatment. Oral azithromycin was compared with topical 1% chlortetracycline ointment. Mass drug administration using the one-dose treatment with azithromycin was adopted following this study.

Facial cleanliness and environmental improvements

The programme began by providing information, education and communication on hygiene. Advocacy for rural development, improved water and sanitation, electrification, and literacy programmes for women were also established.

From 1994 to 2000

200 health professionals were trained to operate on trachomatous trichiasis (TT) and 200 surgical kits were obtained.

In addition, the Ministry of Health adopted a policy of decentralisation and devolution which enabled the health service to maximise available resources for trachoma elimination in endemic regions. This facilitated the development of a localised approach - called ‘une politique de proximité’ in French - which has proved appropriate for addressing the population’s needs more effectively.

• It brings the health service closer to the community addressing its concerns and operating with greater impact and efficiency.
• It establishes direct communication between the state and its partners on the ground - local communities and civilian partners. This helps to identify the most relevant touch points in community life and lets the programme develop a better balance with regards to methods of public intervention.
• It achieves greater coherence and effective multi-sectoral coordination of local level action.

Figure. TT surgery patients attending outreach/basic health centre or hospital, Morocco 1992 - 2000

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Figure. Distribution of antibiotics for elimination of active trachoma, Morocco 1992–2000

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