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Case 10: controlling trachoma in morocco

Case 10
Controlling Trachoma in Morocco
Geographic area: morocco
Health condition: in 992, a national survey found that just over 5 percent of morocco’s population had
the blinding disease trachoma. nearly all the cases were concentrated in five poor, rural provinces in
the southeast of the country where 25,000 people showed a serious decline in vision due to trachoma,
625,000 needed treatment for inflammatory trachoma, and 40,000 urgently needed surgery.
Global importance of the health condition today: trachoma is the second leading cause of blindness in
the world, and the number one cause of preventable blindness. more than 84 million people in 55 coun-
tries have trachoma. Economic development and improved hygiene have eliminated the disease from north
america and Europe. But it plagues millions in hot, dry regions where access to clean water, sanitation,
and health care is limited.
Intervention or program: in 99, morocco formed the national Blindness Control Program to eliminate
trachoma by 2005. Between 997 and 999, the program implemented a new strategy called SaFE
(surgery, antibiotics, face washing, and environmental change), giving morocco the distinction as the first
national-level test of the 4-part strategy. mobile teams have performed simple, inexpensive surgeries in
small towns across the provinces, 4.3 million treatments of the antibiotic azithromycin have been distribut-
ed, health education efforts promoting face washing and hygiene have been conducted, latrines have been
constructed, and safe drinking water supplied.
Cost and cost-effectiveness: the moroccan government has provided the bulk of the financing for the
program, with external support from the United nations Children’s Fund and a public-private partnership
called the international trachoma initiative. through this partnership, the pharmaceutical company Pfizer
has donated over $72 million worth of its antibiotic Zithromax®.
Impact: overall, the prevalence of active disease in children under 0 has been reduced by 99 percent
since 997.
Trachoma is the second leading cause of blind- including the United States (see Box 10–1). With eco-
ness (after cataracts) and the number one cause nomic development and improved hygiene, however, the of preventable blindness in the world. More disease has been eliminated from North America and than 84 million people in 55 countries have trachoma, and some 6 million have been blinded by it.1 Although the disease is now confined to developing But those same changes have not benefited the world’s countries where it threatens an estimated 1 in 10 people, poorest. Today trachoma plagues millions of marginal- just a century ago it was common throughout the world, ized people living in hot, dry regions of Africa, Latin America, the Middle East, and Asia, where access to The first draft of this case was prepared by Gail Vines; significant contributions to the current version were made by Mol y Kinder.
clean water, sanitation, and health care is limited. The Active trachoma alone is not immediately threatening to sight. Repeated trachoma infections over many years, however, cause problems that can eventual y lead to Trachoma in the United
blindness. The upper lid frequently becomes chronical y inflamed, resulting in scarring and a condition called “trichiasis,” or in-turning of the eyelash. If this condition at the end of the 900s, the threat of trachoma is not treated, the eyelash painful y rubs the eye, result- was very real in the United States. the disease ing in corneal scarring, opacity, and blindness. Blind- was rampant in crowded slums in both the United ness from trachoma, whose seeds are first sown in early States and Europe during the industrial revolu- childhood, usual y strikes when a person is between 40 tion, and new York newspapers commonly ran public health notices warning about the disease’s communicable nature. trachoma became a Trachoma is linked closely with poverty—both as a criterion for excluding immigrants from the United symptom of underdevelopment and as a cause. The States, causing more than 36,000 immigrants disease disproportionately affects women, who are in- to be denied entry between 897 and 924. the fected through their close contact with children; women US Public health Service launched an ambitious contract trachoma at a rate two to three times more campaign to control the disease in the “trachoma belt” in the southeastern states. a public edu-cation campaign was initiated, and hospitals to The economic impact of trachoma on endemic areas is treat trachoma were established. in the 960s, profound, as blindness develops during the most eco- after several decades, trachoma was finally elimi- nomical y productive years. An estimated $2.9 billion worth of potential productivity is lost annual y due to heaviest burden of blindness from trachoma affects the populations of sub-Saharan Africa. Modern antibiotics, combined with prevention and other treatment meth- In the mid-1980s, the Edna McConnell Clark Founda- ods that can be deployed in low-income countries, hold tion brought renewed attention to trachoma by funding much promise in the fight against trachoma. Morocco, extensive research on the disease’s epidemiology and the first country to start a large-scale campaign against the viable options for its control. The scientific findings trachoma with a newly developed strategy, is at the contributed to the development of a new, comprehensive threshold of eliminating blinding trachoma.
strategy to treat and prevent trachoma. This strategy was called “SAFE,” which stands for surgery, antibiot- ics, facial cleanliness, and environmental change—the four main interventions. The community-based SAFE Trachoma is highly contagious, marked by chronic con- strategy seeks to confront the underlying causes of the junctivitis, or “pink eye.” Children are its first victims. disease as well as the imminent threats of blindness, Active infection is caused when the bacterium Chlamyd- and differs from earlier approaches by emphasizing the ia trachomatis is spread (mainly among young children) need to effect not just medical but also behavioral and through direct contact with eye and nose secretions from affected individuals, contact with contaminated towels and clothing, and through fluid-seeking flies. Disease transmission is rapid and intense in conditions Surgery is needed to halt corneal damage in the later of overcrowding, poor hygiene, and poverty. In endemic stages of trichiasis and prevent the onset of blindness. areas, prevalence rates in children aged 2 to 5 years can Researchers in Oman designed a simple, quick, and inexpensive surgical procedure, which can be applied to treat large numbers of patients at the community level. of the drug in the early 1990s in Africa. Their results Health professionals are trained to make a slit in the established that the drug is a powerful 1-dose cure and a outer part of the eyelid and restitch it in a way that pul s substantial improvement over the tetracycline ointment the edge and lashes away from the eye’s surface. The treatment because it assures a higher adherence rate. simple procedure has a success rate of approximately 80 percent, and in low-income countries like Ghana can With the discovery of azithromycin and the develop- ment of a comprehensive strategy to prevent and treat the disease, the global health community now had Antibiotics
powerful weapons in the fight against trachoma. The Antibiotics are used to treat active trachoma infections mounting evidence demonstrating the feasibility of and can reduce the community pool of infections and eliminating trachoma was first outlined in a 1996 WHO prevent scarring.4 Until the discovery of the one-dose azithromycin, the available antibiotic was a 1 percent topical tetracycline eye ointment applied daily in a 6- to Momentum was boosted further in 1998 when Pfizer 4-week regimen. Because of the time-intensive treat- and the Clark Foundation announced the formation ment and its side effects of stinging sensations and of a public-private partnership called the International blurred vision, however, compliance with the earlier Trachoma Initiative (ITI) aimed at eliminating blinding trachoma worldwide. The initiative was first financed with $3.2 million grants from each of the two main Facial Cleanliness
partners and set out to help governments of endemic Studies have shown that clean faces, especial y among countries start national trachoma programs based on children, can break the cycle of reinfection and prevent the spread of trachoma-causing bacteria. Washing helps remove the discharge from infected eyes, which attracts Pfizer’s pledge to contribute $60 million worth of Zith- disease-spreading flies seeking fluid and salt. Children’s romax® was key to ITI’s strategy and represented a shift faces can be kept clean even with small amounts of wa- in the company’s philanthropy. Zithromax® has a broad ter—one liter can clean as many as 30 faces. consumer market and is the most prescribed branded oral antibiotic in the United States, accounting for more Environmental Change
than $1 billion annual y of the company’s revenues.5 The Improving living conditions and community hygiene company donated large quantities of the drug, despite has reduced the spread of trachoma. Construction of the risk that the donated drugs could be sold on the latrines is an important way to reduce the prevalence of the flies associated with trachoma.4 Health education and the provision of adequate water have also proven With funding, leadership, momentum, and a strategy in effective in reducing the spread of infection. place, the international movement embarked in 1999 on the first national-level test of the SAFE strategy, choos- A major advance for the SAFE strategy occurred in the mid-1990s with the discovery of a much more potent antibiotic, which strengthened the strategy’s “A” compo- Morocco, a North African country of just under 32 mil- nent. Studies showed that a single dose of the antibiotic lion people, has a long history of trachoma control ef- azithromycin was as effective as (or even more effective forts. The country’s fight against the disease began nearly than) the 6-week regimen of the widely used tetracycline a century ago, when the disease ravaged all parts of the antibiotic. Pfizer, the global pharmaceutical giant that country. Dr. Youssef Chami Khazrazi, head of Morocco’s manufactures the prescription version of the drug (Zith- National Blindness Control Program (NBCP), wrote, romax®), and the Clark Foundation began pilot tests “There is not a single Moroccan among two to three generations who does not remember the years where international organizations (ITI, UNICEF, WHO, and the fight of [trachoma] represented one of the major and Helen Keller International), bilateral and multilateral permanent activities of the Ministry of Health.”6 agencies, and local nongovernmental organizations. With scientific evidence, political resolve, and financial Initial y, the disease was regarded as primarily a medical support in place, the NBCP was launched. problem, and in the 1970s and 1980s it was tackled by treating schoolchildren in the most-affected provinces with tetracycline eye ointment twice a year. Medical treatment was not yet integrated with improvements in Each of the four elements of the SAFE strategy was sanitation and standard of living among the rural poor. Therefore, while economic development led to the vir- tual disappearance of trachoma from most urban areas in the previous few decades, the disease pervaded many Government officials in the Ministry of Health moved quickly to decentralize surgery so that eyelid correc- tion was readily available in small towns and vil ages. A national survey in 1992 found that approximately 5.4 Before surgical teams arrived in the countryside, vil age percent of the population showed signs of trachoma, leaders and outreach workers were briefed so that they with virtual y all of these cases concentrated in five rural could publicize the procedure and explain its benefits. In provinces in the southeast of the country: Errachidia, partnership with the Hassan II Foundation of Ophthal- Figuig, Ouarzazate, Tata, and Zagora. These five arid mology, the ministry deployed mobile surgical units provinces constitute a quarter of the total area of the staffed by doctors and specialist nurses trained to carry country and have a widely dispersed population of ap- out the vision-saving procedures. Forty-three physicians proximately 1.5 million people. Poverty, scarce water, and 119 nurses have worked in 34 centers throughout agricultural subsistence, and weak infrastructure and the five provinces. Between 1992 and 2005, more than sanitation characterize the region. There, the problems 40,000 people underwent eyelid surgery. At the same of trachoma were great: 25,000 people showed a serious time, education campaigns were launched to motivate decline in vision due to trachoma; some 625,000 needed infected individuals to come forward for treatment. treatment for inflammatory trachoma; and surgery was urgently needed for 40,000 people with trichiasis. Antibiotics
Azithromycin was first field tested in Morocco during
Morocco’s political leaders were committed to eliminat- the mid-1990s, when 10,000 patients were successful y ing trachoma by 2005, and in 1991 formed the National treated. Widespread treatment with the donated drug Blindness Control Program (NBCP). Between 1997 began in the five southeastern provinces in 1999, and and 1999, the SAFE strategy was integrated into the approximately 4.3 million doses have been distributed to program. “We now recognized,” says Dr. Khazrazi, “that date (ITI statistics through December 2005). A success- trachoma at the level of these regions is not strictly a ful strategy was soon developed, built on the recognition medical problem; it is essential y the reflection of a so- that trachoma is a community disease and reinfection cioeconomic problem.” The “real enemies,” he explains, is very likely to occur if only isolated cases are treated. “are the disfavored rural communities, illiteracy, family Different approaches were developed depending on the overcrowding, lack of water, the accumulation of animal prevalence. When more than one fifth of the children wastes, and the proliferation of domestic flies. In sum, under 10 showed signs of active trachoma, everyone in the enemy to combat is not Chlamydia but poverty.”6 the community was treated. Where infection rates were lower—between 10 and 20 percent—treatment focused To address the disease’s wide-ranging causes, the NBCP on affected children and their families; at less than 10 formed a comprehensive partnership including five percent, infections were treated individual y. Treatment government divisions (Ministry of Health, Ministry of campaigns were launched annual y, between the months National Education, Ministry of Employment, Ministry of Equipment, and National Office for Potable Water), Facial Cleanliness
efforts are 350 local vil age associations that have drilled Health education has proven effective in increasing wel s, built latrines, and found safe ways of storing awareness and changing attitudes, thus increasing clean animal dung, so that this valuable natural fertilizer does faces and preventing disease transmission. Campaigns not spread flies through the vil age. The national office is promoting individual and community hygiene have cen- also leading the provision of drinking water: 74 vil ages tered on information, education, and communication in Errachidia and Zagora have been supplied with water, to explain the causes of the disease and the means of and access to potable water is reported to have increased prevention. Outreach workers, health professionals, and from 13 percent of all rural communities in 1992 to 60 teachers have used slide shows, videos, films, commu- percent in 2000 to at least 80 percent in each trachoma nity theater, meetings, photos, notices, pamphlets, and even megaphones to communicate the messages. News- paper articles and radio and television broadcasts have Interventions to reduce poverty and improve literacy also been effective. To educate children, the primary car- among women are now acknowledged to be central riers of the disease, the Ministry of Education designed to the fight against trachoma. In Zagora, for example, a model lesson on trachoma that was incorporated into the work of the Ministry of Employment and Helen the curriculum of primary schools in the five provinces. Keller International has helped 8,500 women learn to read. Helen Keller International has also implemented The education campaigns depend in large part on the economic programs aimed at increasing the incomes of active engagement of the local community. Mosques, lodgings for young women, local associations, and schools have proved to be ideal venues for communicat- The implementation of the SAFE program has had a Environmental Change
dramatic impact in Morocco and represents the most The National Office for Potable Water has overseen the rapid elimination of blindness due to trachoma in construction of latrines in 32 vil ages. Supporting these a single country in history. Prevalence has fallen 99 percent since 1997, from 28 percent to just less than 2.5 percent in 2005.7 Acute infections have been signifi- cantly reduced in children and in some places, such as Figuig and Ouarzazate, eliminated. In Zagora province, which remains the hardest hit, annual epidemiological Prevalence of active disease
surveys beginning in 1997 revealed a drop in prevalence in five provinces in Morocco,
from 69 percent to 3.3 percent in 2004. In Tata, Ouarza- 1997–2004.
zate, and Figuig provinces, no cases of active infection have been reported since 2003. Overal , the intervention has achieved a 99 percent reduction in the prevalence of active disease in children under 10 since 1997 (see Morocco has reached its “ultimate intervention goals” and has reduced the burden of disease to the trachoma elimination target levels set by the WHO: less than 5 percent prevalence of active disease in children 1 to 9 years of age and less than 0.1 percent trichiasis in adults Note: In Morocco, the prevalence of active disease in children over the age of 15. The next phase is surveil ance of the under 10 has been reduced by 99 percent.
disease to ensure that levels remain below these targets. Source: Ministry of Health, Morocco (2006). Once this is sustained, Morocco will apply for WHO certification of elimination of blinding trachoma.
to the household where all members are examined for infections and, if needed, treated with antibiotics.
The elements of the SAFE strategy that are most expen- sive are improving environmental infrastructure and It can often take years of repeated infections to cause providing the drugs. Although quantitative information scarring of the upper lid and trichiasis, or inversion of about total spending on the initiative is unavailable, to the upper lid that precedes blindness, so surgery cases date the Moroccan government has provided the bulk of will continue to emerge even after active trachoma is in- the funds to improve vil age sanitation—supplemented terrupted in Morocco. Community leaders and organi- with grants worth over $2 million from ITI between zations such as the Red Crescent Society will continue to play an important role in locating and reporting trichia- sis cases to district surgical teams.
The dramatic reduction in trachoma achieved in Mo- rocco over the past few years would probably have been Because of the expected emergence of a limited number impossible without Pfizer’s donation of the antibiotic, of new cases of active trachoma and trichiasis, the need valued at around US$72 million. The company has also for an effective epidemiological surveil ance system provided grants for public education to support other for trachoma is great. All new cases are reported to the district health departments by vil age sentinel sites and health facilities. Periodic reviews are conducted, with The US Fund for UNICEF has supported the imple- the results shared with provincial and central authori- mentation of the face cleanliness and environmental ties. Unless unforeseen epidemics occur, this surveil- change components of the SAFE strategy with a grant lance phase is expected to continue until 2009. of $225,000. Total costs for surgical treatment have been estimated at $15 to $25 per person, with funding from the Moroccan government as well as ITI, worth between US$440,000 and US$730,000. A further grant Dr. Jacob Kumaresan, the president of ITI, has identi- from ITI—$180,000 from 2000 to 2004—supported the fied three factors as the keys to Morocco’s success in the Moroccan Ministry of Health’s evaluation of the impacts elimination of blindness due to trachoma, which can be an inspiration for other trachoma endemic countries.9 First, government buy-in exists at all levels of the na- tional blindness control program. Second, the program developed strong public-private partnerships, including a network of NGOs and local associations; and third, the Morocco’s SAFE program has succeeded in slashing the government has taken an aggressive approach to provi- prevalence rate of active trachoma among children and sion of safe drinking water and improved sanitation for clearing the backlog of surgeries. The effort to eliminate blinding trachoma from Morocco has thus entered its final, and crucial, stage: maintenance and surveil ance Dr. Khazrazi also reported that the solid support of the before being certified by WHO as having eliminated government of Morocco was invaluable. “One of the blinding trachoma. This entails the early identifica- major assets is commitment and political wil . Political tion of active trachoma cases and prompt treatment of will is, first of al , the commitment of the Ministry of those infected in order to prevent spread of the disease. Health.” This support is evidenced by frequent periodic Identification of infected patients can occur during visits of ministry officials to endemic areas to affirm the health visits, such as at maternal and child health clinics; government’s commitment to the disease’s elimination.
through sentinel site activities; and through the report- ing of suspected cases to local partners in trachoma control, such as local NGOs, teachers, health personnel, and the Red Crescent Society. Immediately following The success of the trachoma program in Morocco has the diagnosis of an active trachoma case, a visit is made provided a catalyst for efforts to eliminate the disease worldwide. Robert L. Mallett, senior vice president of 3. Frick K, Hanson C, Jacobson G. Global burden of corporate affairs of Pfizer’s international philanthropy trachoma and economics of the disease. Am J Trop department, explained that Morocco’s program “made Med Hygiene. 2003;69(suppl 5):1–10. history by completing their mass antibiotic and surgi- cal campaigns, signaling the beginning of the end for a 4. West S. Blinding trachoma: prevention with disease that has plagued the country for centuries.” the SAFE strategy. Am J Trop Med Hygiene. In 2000, after data demonstrated that prevalence rates in Morocco had been reduced by more than half in just 5. Barrett D, Austin J, McCarthy S. Cross-Sector Col- one year, the ITI accelerated its international efforts. laboration: Lessons from the International Trachoma Pfizer committed to donating 10 million additional Initiative. Paper presented at: Workshop on Public- doses of Zithromax® and $6 million in operational Private Partnerships in Public Health; Endicott funding, the Clark Foundation contributed another $6 million, the UK Department for International Develop- ment provided approximately $1.8 million, and the Bill 6. Khazraji YC. Revival in the fight of trachoma: ten & Melinda Gates Foundation awarded $20 million over years of fight in the Kingdom of Morocco, 1991– five years—the foundation’s largest donation to date to 2001. 2002 report of the French League Against international blindness. With the additional funding in Trachoma and International Organization Against place, the SAFE strategy was initiated in Tanzania, Mali, Trachoma. Available at: Sudan, Ghana, Vietnam, Ethiopia, Nepal, Niger, Mau- millions/Trachoma_in_Morocco.pdf. Accessed ritania, Senegal, and Kenya. In these countries, repre- senting one quarter of the global burden of trachoma, 221,000 surgeries have been performed and around 36.7 7. Ministry of Health, Morocco. Presentation at the million doses of Zithromax® were distributed (ITI statis- Global Elimination of Blinding Trachoma 2020 meeting, Geneva, Switzerland; April 10, 2006.
In November 2003, recognizing the effectiveness of 8. Donnel y J. Pfizer to donate US$500 million in the SAFE strategy and the need to scale up programs, drugs. Boston Globe. November 12, 2003. Pfizer announced that it would donate up to 135 million doses of Zithromax® over the next five years.8 Pfizer’s 9. Kumaresan J, Mecaskey J. The global elimination contribution represents one of the largest donations of a of blinding trachoma: progress and promise. Am J patented drug in history. According to Pfizer’s Chairman Trop Med Hygiene. 2003;69(suppl 5):S24–S28.
and CEO Hank McKinnel , “By 2020 we hope to have all of (the endemic countries).” Thus, ITI and its many partners have helped ensure that Morocco’s success with SAFE, like the disease that it has nearly eliminated, is 1. Mariotti S. New steps toward eliminating blinding trachoma. N Engl J Med. 2004;351;19:2004–2007. 2. Mecaskey J, Knirsch C, Kumaresan J, Cook J. The possibility of eliminating blinding trachoma. Lancet Infect Dis. 2003;3(11):728–734.



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