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Case study: Did SAFE make a difference in Morocco?

In this article we look at the data used to measure progress towards elimination of trachoma as a public health problem in the Kingdom of Morocco.

The SAFE implementation programme in Morocco set clear goals known as Ultimate Intervention Goals (UIGs) that needed to be achieved by 2005.

S – The surgery target was set at <1 trachomatous trichiasis (TT) case per 1000 population. Two aspects were evaluated:

  • acceptance of the surgery by the population and the satisfaction of patients who received it
  • measuring the quality of trichiasis surgery.

A – The antibiotic target was set at a minimum 80% coverage with a goal of achieving a prevalence of trachomatous inflammation — follicular (TF) <5% in children aged 1–9 years. Aspects evaluated were: personnel training, and the coverage and acceptance of antibiotics.

F&E – Physical actions to improve individual and collective hygiene were also undertaken, including:

  • Organising cleanliness campaigns, including treatment for flies and demonstrations of hygienic processing of dung and manure
  • Constructing latrines in schools and mosques
  • Drilling wells and constructing water towers to provide water to mosques and schools
  • Facilitating access to water for more than 350 communities
  • Supplying safe, drinkable water for 500 communities.

Impact surveys were carried out every two years between 1997 and 2003. The data from each survey were essential for navigating the programme towards its UIGs. The survey participation rate was over 90% in each of the provinces.

Figure. Impact surveys: Prevalence of TF in children aged 1–9 years, by province, Morocco 1997–2003

The prevalence of TF fell in all the targeted Morocco provinces between 1997 and 2003

Figure. Impact surveys: Prevalence of TT per 1000 total population, by province, Morocco 1997–2003

Recommendations from the 2003 impact survey

The impact surveys showed declining prevalence of both TF and TT in all 5 endemic provinces between 1997–2003. This occurred as the SAFE strategy was being implemented in these provinces.

Although the prevalence of trachomatous inflammation — follicular (TF) in 1–9 year olds did not exceed 2% in four of the provinces, it remained higher than 5% in Zagora province (7.8%).

It was decided that specific actions would be taken regarding TT surgery, targeting the district communities where the burden of TT remained high.

In the Agdez district of Zagora province antibiotic MDA was extended by one more year and a repeat impact survey was carried out .

In September 2005, the national programme conducted the final impact survey in Agdez. This survey showed that the prevalence of TF had decreased from 8.8% in 2004 to 4.6 in 2005, and the prevalence of TT had also decreased from 2.5% in 2004 to 0.7% in 2005.

How was a surveillance system established?

The Kingdom of Morocco set up an epidemiological surveillance system for trachoma in 2006, in collaboration with the World Health Organization (WHO). This system is embedded in the existing structures of the national health care system.

The system used sentinel villages in the 5 endemic provinces to monitor the trends in TF and TT. This enables generation of data for decision-making, with actions to be taken locally.

This was an essential step in enabling the country to apply for validation of elimination of trachoma as a public health problem.

  • The sentinel villages were chosen based on the likelihood that they had trachoma. Recent survey information was used to choose these high-risk villages
  • Children in the sentinel villages were checked twice a year to monitor the at-risk child population.
  • All cases of TF as well as the level of personal hygiene (facial cleanliness in children), availability of water and use of latrines were reported.

The surveillance using these sentinel villages allowed:

  • Systematic notification of any TF or TT case found in health facilities or in the sentinel villages
  • Further examination and tracing of family and friends for each case diagnosed.

Surveillance for trichiasis was based on ‘comprehensive detection of all cases of TT’. Screening was conducted annually in all communities of the 5 target provinces. Health personnel went door-to-door and identified people with TT.

  • TT surgery was scheduled at nearby health centres and a mobile team provided surgery

  • Refusals were recorded and followed up 3 times. If the person refused the intervention after 3 visits, they were regarded as a definitive TT refusal.

Findings from the pre-validation surveillance survey

In 2009, pre-validation surveys were conducted in the most disadvantaged communities in the 5 endemic provinces.

The objective was to demonstrate that trachoma no longer represented a public health problem in the most disadvantaged communities in the target provinces.

Figure. Trachoma surveillance surveys, Morocco 2009: Prevalence of TF found to be < 5% in all areas

<img src="" alt="The surveillance surveys found that the prevalence of TF was

How was completion of the dossier and validation carried out?

Following completion of the pre-validation surveys, discussions were held with the WHO to begin to prepare the application for validation of elimination of trachoma as a public health problem. When the validation dossier template was completed the WHO convened an ad-hoc dossier review group to assess it and produce a recommendation to the WHO.

Key learning points from the validation process

  1. Implementation of all components of SAFE is needed to ensure active disease does not recur after MDA stops. In Morocco, emphasis was placed on implementing improvements in personal hygiene and community sanitation as well as MDA.
  2. Strong support and commitment by the Ministry of Health to carry out impact surveys and implement the surveillance system meant that the Kingdom of Morocco was able to demonstrate that active trachoma prevalence was now below the defined elimination thresholds and that everyone with TT who wished to have surgery had been provided with it
  3. Good design of impact surveys and surveillance systems, with excellent reporting and documentation of results also helped to provide good evidence of elimination as a public health problem.
  4. It takes patience, perseverance and good leadership to continue surveillance when the disease seems to be well on the decline.

SAFE and the impact on poverty

The trachoma programme has had far reaching impact on the targeted communities in Morocco. Improved standards of living and reductions in social inequalities have contributed to significant reduced poverty and vulnerability. Extreme poverty has been almost eradicated.

Figure. Poverty reduction in Morocco 2004–2007

Province Poverty rate 2004 Poverty rate 2007 Poverty reduction (%)
Figuig 27.1 13.8 -49.2
Errachidia 29.5 16.3 -44.7
Tata 24.5 18.2 -25.7
Ouarzazate 22.8 18.0 -20.9
Zagora 33.6 32.4 -3.5
Poverty rate = US$ 1 PPP per day per person or less
© Ministry of Health, Kingdom of Morocco / London School of Hygiene & Tropical Medicine CC BY-NC-SA
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Eliminating Trachoma

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