In Morocco, the elimination of trachoma as a public health problem becomes a reality
Authors: Jaouad Hammou, Houda El Ajaroumi, Hassan Hasbi, Ahmed Nakhlaoui, Abderrahim Hmadna, Abderahmane El Maaroufi
Journal: The Lancet Global Health (2017)

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.1World Health OrganizationMorocco eliminates trachoma—the leading infectious cause of blindness. World Health Organization, Geneva & Marrakech2016http://www.emro.who.int/media/news/morocco-eliminates-trachoma-the-leading-infectious-cause-of-blindness.htmlGoogle Scholar 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 Chlamydia trachomatis, which are transmitted by flies, fingers, and fomites in conditions of extreme poverty.2Mabey DC Solomon AW Foster A Trachoma.Lancet. 2003; 362: 223-229Summary Full Text Full Text PDF PubMed Scopus (183) Google Scholar 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.3Bero B Macleod C Alemayehu W et al.Prevalence of and risk factors for trachoma in Oromia Regional State of Ethiopia: results of 79 population-based prevalence surveys conducted with the global trachoma mapping project.Ophthalmic Epidemiol. 2016; 23: 392-405Crossref PubMed Scopus (41) Google Scholar, 4Elshafie BE Osman KH Macleod C et al.The epidemiology of trachoma in Darfur States and Khartoum State, Sudan: results of 32 population-based prevalence surveys.Ophthalmic Epidemiol. 2016; 23: 381-391Crossref PubMed Scopus (28) Google Scholar, 5Last AR Burr SE Weiss HA et al.Risk factors for active trachoma and ocular Chlamydia trachomatis infection in treatment-naive trachoma-hyperendemic communities of the Bijagos Archipelago, Guinea Bissau.PLoS Negl Trop Dis. 2014; 8: e2900Crossref PubMed Scopus (56) Google Scholar 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.6Reinhards J Weber A Nizetic B Kupka K Maxwell-Lyons F Studies in the epidemiology and control of seasonal conjunctivitis and trachoma in southern Morocco.Bull World Health Organ. 1968; 39: 497-545PubMed Google Scholar In the 1990s, it was realised that people in the country's southeast (in the provinces of Errachidia, Figuig, Ouarzazate, Tata, and Zagora) still had severe disease,7Vines G Kinder M Controlling trachoma in Morocco.in: Levine R What Works Working Group Millions saved: proven successes in global health. Center for Global Development, Washington, DC2007Google Scholar with an estimated 35 000–40 000 individuals suffering from trichiasis (the advanced, blinding form of trachoma). The then newly-developed SAFE strategy8Francis V Turner V Achieving community support for trachoma control (WHO/PBL/93.36). World Health Organization, Geneva1993Google Scholar—comprising surgery for those with trichiasis, antibiotic treatment to clear conjunctival C trachomatis 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 trichiasis9Negrel AD Chami-Khazraji Y Arrache ML Ottmani S Mahjour J [The quality of trichiasis surgery in the kingdom of Morocco].Sante. 2000; 10: 81-92PubMed Google Scholar 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,10Mecaskey JW Knirsch CA Kumaresan JA Cook JA The possibility of eliminating blinding trachoma.Lancet Infect Dis. 2003; 3: 728-734Summary Full Text Full Text PDF PubMed Scopus (43) Google Scholar 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 <US$1 in 1996 prices) almost vanished, falling to 0·6% of the national population by 2007. With dedicated implementation of the SAFE strategy, the prevalence of trachoma in each endemic province progressively declined. In Zagora, the most hyper-endemic at baseline of the five provinces, prevalence of the active (inflammatory) trachoma sign, trachomatous inflammation—follicular, in 1–9-year-old children fell from 58% in 1997 to less than 5% in 2005 (figure). 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 countries11World Health Organization Alliance for the Global Elimination of Trachoma by 2020. Eliminating trachoma: accelerating towards 2020. International Coalition for Trachoma Control, London2016Google Scholar to eliminate trachoma as a public health problem by 2020.12World Health AssemblyGlobal elimination of blinding trachoma. 51st World Health Assembly, Geneva, 16 May 1998, Resolution WHA51.11. World Health Organization, Geneva1998Google Scholar We declare no competing interests.