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Lutte contre le trachome en Afrique subsaharienne

 | 
Anne-Marie Moulin
, 
Jeanne Orfila
, 
Doulaye Sacko
, 
et al.

Part One. Synopsis and recommendations. English Version

Means of action

Texte intégral

MEDICO-SURGICAL RESOURCES

1Entropion is defined as the introversion of the eyelid, where the front convexity is exaggerated so that it curves inwards and ends up being rolled up inside. Trichiasis can be described as an uncontrolled growth of the eyelashes, which rub the eye. For the WHO, it can be diagnosed as soon as an eyelash rubs the eyeball, or when there are signs of recent depilation of in-turned eyelashes. When one or two in-turned eyelashes rub on the conjunctiva but not on the cornea, we speak of "minor" trichiasis, all other cases are regarded as "major".

2Trichiasis, entropion and corneal opacity are the after-effects of trachoma contracted during childhood. In certain regions, severe scars on the tarsal conjunctiva can appear in childhood, but their prevalence is generally low at this stage of life and increases with age. Reinfections in childhood and superinfection would seem to be responsible for complications in the adult. Opacity, when found in the center of the cornea is directly responsible for trachomatous blindness.

When and how can we operate on trichiasis?

3In Mali, the national survey of 1996-1997 showed a prevalence of trichiasis entropion of 2.5 % among women over 14 years of age. This prevalence goes far beyond the threshold of 1 %, which according to the WHO is a sign of a major public health problem.

4If it is considered that women are twice as often affected as men, approximately 85,000 persons would be waiting for an immediate intervention. The number of surgical operations on trichiasis is currently insufficient to significantly reduce blinding trachoma. Only 2,200 cases were operated in Mali in 2001. There may be insufficient treatment in the country, but this factor is not enough to explain the low number of interventions, since most general nurses or nurses specializing in ophthalmology responsible for these operations, do not operate more than fifty cases a year.

5Many patients refuse to have an operation. Several hypotheses have been advanced: ignorance of possible treatment, low incomes, distance from treatment centers, low number of qualified personnel, poor quality of the treatment, popular conceptions of the disease, and the use of other methods (healers, rural pharmacies, etc). Thus, there are many barriers to surgery for trichiasis. During a study in Tanzania, where surgery was free, only one woman in five agreed to the operation. Others argued that nobody could accompany them, that the journey was too expensive, or that they had children to look after. Thus, fear of pain, lack of money, also lack of information or, on the contrary, the spectacle of recurrence after surgery represent the principal obstacles.

How can we operate?

6Depilation is very frequently practiced by the patient himself or a member of the family. However, eyelashes that grow back or have been broken are even more aggressive for the cornea. The result of depilation is transitory, and can only be a palliative solution aiming at relieving the patient temporarily, while waiting for the right conditions for local surgery.

7The hair follicles of the eyelids can also be destroyed by other means such as cryotherapy, electrolysis or laser. To be effective, these non-surgical methods must be renewed. Moreover, they are not easily available in countries of endemic disease.

8Surgery for trichiasis thus seems the only strategy available for really preventing visual deficiency and blindness due to trachomatous trichiasis. Surgery should be done as soon as trichiasis is detected; in other words as soon as it is seen that at least one eyelash rubs the eye.

9Many techniques are used for operating on trichiasis, which means that none is perfect. The two techniques currently most used are the Trabut method and bi-lamellar rotation of the tarsus.

10In most of the French-speaking African countries south of the Sahara, the Trabut method used for more than fifty years remains the most often practiced. Two studies in Senegal report good results. In Dakar, the monitoring of 200 patients for two years reported 82 % of satisfactory results. Another retrospective study carried out after twelve years on a series of 115 cases in Kolda in Senegal reported 74 % of success.

11The other technique, bi-lamellar rotation of the tarsus, is used in English-speaking countries and in Morocco. The principle is identical to the preceding intervention because it is still a question of incising the tarsus horizontally and turning the furthest part outward in order to turn the eyelashes away from the cornea. This latter technique was recommended by the WHO, following a random study in the Sultanate of Oman, which reported a success rate of around 80 % after one year. Several non-random studies have shown similar results in Tanzania and Morocco. On the other hand, less effective results were reported in another study in Oman with 62 % of recurrence after three years.

How effective and what rate of recurrence?

12Surgery corrects approximately 80 % of trichiasis within one year. Unfortunately, this percentage subsequently falls. Two to five years later, depending on the technique, the frequency of recurrence oscillates between 5 and 50 %, even when the surgery is carried out under optimal conditions. We find no significant difference, whether the surgery is done by licensed ophthalmologists, simple assistants or specialist nurses, as long as the operators are well trained and have sufficient experience. Nevertheless, it would seem that ophthalmologists more often operate on more serious cases.

13Whatever the technique, trichiasis seems to recur more frequently among women. Recurrence is also more frequent in regions with a high prevalence of trachoma and where infectious conjunctivitis is rife. Certain authors have therefore proposed combining trichiasis surgery with azithromycin antibiotic therapy, hoping to minimize the frequency of recurrence. There have been no studies to confirm the usefulness of this practice.

14The effect of surgery on sight has not been quantified perfectly. Surgery can improve sight by decreasing intolerance of light and swelling of the cornea. It does not reduce the lesions and does not always definitively stop the progression of corneal opacity when very advanced.

Who operates?

15There are too few ophthalmologists to deal with all cases of trichiasis. They can delegate this relatively simple and well-codified act to nurses specializing in ophthalmology or to trained nurses or general practitioners ("trichiasis operators"), guided and supervised.

16Several studies have shown that nurses specializing in ophthalmology have better postoperative results than ophthalmologists, who often only deal with the most serious and/or recurrent cases. However, surgical training must be adequate. The operator must be trained by a surgeon ophthalmologist or an experienced nurse specializing in ophthalmology. For example, the duration of training is six months in Tanzania and one month in Mali, where operators must have carried out at least ten Trabut operations before being declared qualified.

17Long-term monitoring of patients makes it possible to assess the quality of surgery and detect recurrence of trichiasis. Refresher courses and certificates for operators could be organized in a regular way to ensure the quality of the work.

When to operate and with what strategy?

18It is obviously important to detect carriers of entropion-trichiasis before the cornea presents central opacity responsible for a decrease in sight, even blindness.

19Experience teaches that the best strategy is the earliest possible screening combined with the possibility of surgery near the home of patients. Persons screened should be operated free of charge or at a cost compatible with their resources.

Conclusions and recommendations

20In regions of endemic disease, screening and treating trichiasis can be part of a "minimum package of action" of the district health services, which assumes that each medical district has at least one nurse specializing in ophthalmology or a trichiasis operator.

21The operators should always have two boxes of instruments.

22Two strategies are then possible, which far from being opposed are rather complementary:

  • operations at the district hospital on patients screened and referred from certain health centers,
  • operations at the health centers or in the villages with a team from the district hospital (in Mali, this approach is called "advanced surgery").

23The patients must be registered by each operator and monitored regularly. It is not enough just to operate. It is also particularly necessary to evaluate the quality of the intervention, to follow the patients and measure the sight before and after the operation. Without this, it would be impossible to determine the real impact of the intervention on sight.

How can we evaluate the amount of blindness prevented by trichiasis operations?

24To answer this question, a mathematical model needs to be constructed including answers to the following questions: What is the risk of blindness among persons affected by trichiasis, the risk of recurrence and the influence of the prevalence of trachoma on the spontaneous evolution of trichiasis? It is also necessary to add into the equation the following elements:

  • the death rate among patients affected by trichiasis,
  • the annual incidence of trichiasis (the number of new cases of trichiasis each year), which depends on the prevalence of C. trachomatis in the community,
  • the percentage of acceptance and surgical intervention.

25Some answers are obtained by the longitudinal studies of Gambia and Tanzania. When trichiasis is present, we estimate that approximately one third of women 35 years old and more than 40 % of women over 45 years of age will develop corneal opacity within ten years. Similarly, it has been shown that the evolution of the scars towards trichiasis was slower in areas of low prevalence of active trachoma, as in Gambia, than in areas of high prevalence like Tanzania. We do not know the natural evolution of corneal scars in the absence of reinfection.

ANTIBIOTIC THERAPY

26Antibiotic therapy is the second part of medico-surgical interventions.

27Azithromycin belongs to the family of macrolides. It has revolutionized the treatment of trachoma in recent years because of its effectiveness and its ease of administration orally, once or twice a year. Its molecule includes modifications, which explains its good diffusion in the organism and its penetration of cells where C. trachomatis exists. Today, it tends to replace the old standard treatment, an eye ointment with 1 % tetracycline, whose long-term application is tiresome and badly accepted, particularly by children.

28Because of its ease of administration, azithromycin lends itself particularly well to mass treatment campaigns or targeting groups at risk. With the few years experience we have, we can evaluate the positive and negative effects.

Positive and negative effects of mass antibiotic therapy on other pathologies and on the health of the populations concerned?

29Azithromycin is an antibiotic with a broad spectrum. It is active on serotypes A, B, Ba and C of Chlamydia trachomatis responsible for trachoma; also on the other serotypes of Chlamydia responsible for genital diseases and neonatal conjunctivitis, and on many other bacteria.

Effects of the mass distribution of azithromycin on other pathologies

30The prevalence of pneumococci and haemophilus influenzae in the upper respiratory tracts and conjunctiva decreases during the first months following the campaign. This effect disappears after six months. Diarrhea and respiratory infections decrease among children two weeks later.

31Mass antibiotic therapy in the population can also treat urogenital infections, particularly those due to Chlamydia, and certain skin diseases (impetigo) of bacterial origin.

32Azithromycin also has effects on Plasmodium, agents of malaria. Nevertheless, its use alone is not recommended. However, the study into association (particularly with artemisinine, chloroquine, or quinine) shows encouraging results. However, there is not yet any official recommendation in this direction in the campaign against malaria that would obviously modify the impact of trachoma control programs.

No serious side effects recognized during the mass campaigns

33Experience with certain products in the past has shown the need for caution. Several mass campaigns had to be stopped because of adverse effects in the population. For example, in the fifties, the distribution of sulfon-amides orally to combat trachoma in North Africa and the United States was abandoned because of rare but very serious skin allergic reactions to sul-fonamides.

34Azithromycin has relatively few side effects and it is apparently free from serious adverse effects. The most frequent incidents are not serious: abdominal pains, nauseas, vomiting and diarrhea. However, it should be noted that in mass campaigns it is not easy to detect isolated incidents: for example, in tropical areas it is difficult to accurately list the frequent diarrheal occurrences.

No abnormal formations known among pregnant women nor pathogenic effects in children under one year of age

35To date, there is no proof of abnormal formations due to azithromycin. The Food and Drug Administration has put azithromycin in class B, which allows it to be used by pregnant women as part of a treatment under medical control. Nevertheless, the question is to know if this latter condition really applies in mass treatment. Even if certain programs distribute antibiotics to pregnant women and children over six months of age, the current recommendation of the WHO is still ointment with 1 % tetracycline for treating pregnant women and children under one year of age.

Resistance of Chlamydia or other germs

36The brevity of the treatment (one single administration) does not seem capable of modifying the composition of the bacterial flora of the nose, throat and conjunctiva in a durable and dangerous way.

37In general, the large-scale diffusion of an antibiotic makes one fear the appearance of resistant mutants in the bacterial populations. Currently, only temporary resistance among stocks of streptococci and haemophilus has been published, and none has been shown as caused by C. trachomatis.

38Nevertheless, the use of azithromycin during trachoma control campaigns seems capable of inducing resistance among stocks of S. pneumoniae. Therefore, vigilance is essential, as campaigns will extend over several years. Bacterial stocks capable of becoming resistant must be monitored. The resistance thresholds of the other bacterial populations must be clarified. For the Chlamydia, the reference method consists of typifying resistant genes.

Conclusions and recommendations

39Until now, the distribution of azithromycin in mass campaigns has not been followed by any serious side effect. However, vigilance is essential because the war on trachoma will, in the future and for many years, concern populations often spread over very vast territories where medical services are far from dense.

40The positive effects on other pathologies, especially sexually transmitted diseases, are certain. They should make those responsible for distribution very careful about possible misuse of the product; similarly regarding modifications of sensitivity of sexually transmitted diseases to antibiotics after these campaigns.

National strategies needed to make azithromycin available and ensure the permanence of distribution

41The use of sulfonamides orally, or antibiotics locally, in combating trachoma is not in itself an innovation. In the past, it encountered certain difficulties, particularly allergic reactions, the side effects of sulfonamides and the difficulties of observation. Azithromycin, in a single administration, is perceived by some as a wonder drug, the use of which would smooth out all problems.

42However, its use in mass campaigns raises several problems, particularly that of supplying it and its distribution methods.

Trachoma and the other campaigns against other endemic diseases

43Today in West Africa, the war on trachoma is comparable to the fight against other great and very widespread endemic diseases, and to the serious consequences such as onchocerciasis or schistosomiasis based on a mass distribution of a drug without preliminary diagnosis of the patients treated. It is different from the procedures for diseases like tuberculosis or leprosy, which firstly must be diagnosed before treatment and secondly need the combination of several drugs possibly with serious side effects, hence the need for medical supervision of patients. The situation is very different in the case of trachoma where there is only one medicine without known serious side effects, and easy to administer.

44Mass distribution also supposes the availability of a medicine stripped of side effects and bothersome effects specific to its method of administration. Indeed, for example, during the mass campaigns against schistosomiasis in Egypt, the administration of injectable drugs in the 1960's and 1970's led to a massive contamination of the population by the virus hepatitis C. The anti-schistosomal drug itself was not the cause, but the method of injection did not follow the rules of asepsis.

How can we prevent stock shortages and ensure adequate and regular cover?

45This problem, traditional for all central medical stores in Africa, must be reviewed in line with the specific trachoma data; firstly the donation by Pfizer of 135 million doses of azithromycin, secondly the many supply sources of generic drugs no longer under patent.

46In Mali, azithromycin has been on the list of essential drugs since 1998, which is well before the Pfizer "donation".

Possible sources of supplies

47The Pfizer Inc. laboratory acquired the patent on azithromycin and marketed the product under the name Zithromax® in 1987. In 1997, sales of Zithromax® amounted to 821 million dollars. In 1998, this antibiotic occupied the third place in the hit parade of antibiotic prescriptions in the United States.

The Donation

48A "beneficiary" country can obtain azithromycin free of charge from Pfizer through the International Trachoma Initiative (ITI) foundation. Launched in 1999 in two countries, Morocco and Tanzania, this donation was extended to Sudan, Mali and Ghana in 2000, Niger and Nepal in 2002, then Mauritania and Senegal in 2003-2004. In November 2003, Pfizer announced a gift of 135 million doses of azithromycin over the next five years.

49This is a considerable donation. In 2002 in Mali, it was estimated at 400,000 dollars. This donation unquestionably influences the strategic choices of governments in organizing supplies and determining the target to treat. The duration of the donation is not known. Therefore, other possible supply scenarios should be considered.

Purchases outside the donation

50A non-beneficiary country can buy the patent medicine from Pfizer through the normal pharmaceutical supply channels. In pharmacies, the purchase price for a 250 mg capsule of Zithromax® costs, for one patient, between 3.64 and 7.12 dollars, depending on the country.

51Today, azithromycin is no longer under patent in Mali. The patent, issued in 1989 for ten years, expired in 1999 and was not extended. From now, the molecule is available in generic form. The price of these generics, whether manufactured in Spain, Portugal, Bangladesh or India, is much lower than the price of the patent medicine in the trade. Some manufacturers market it at one fifth of the price of the patent medicine available in the pharmacy.

International trade and patent regulations

52In the context of international trade regulations, the question of access to essential drugs for developing countries was the subject of difficult agreements within the World Trade Organization (WTO): agreements on trade-related aspects of intellectual property rights (TRIPS), agreements reviewed at the conference of Doha (Qatar) in 2000.

53On August 30, 2003, the WTO approved a text concerning two arrangements for facilitating access to drugs in developing countries: these are the right to parallel imports and the obligatory license, usable by a country only in the event of real national emergency or for urgent public health reasons.

54The first allows a country to import drugs from another country different from that of the patent holder, and where they are sold cheaper.

55The second allows a country to authorize a pharmaceutical unit at various levels, nationally or sub-regionally, to produce certain drugs, with or without authorization from the patent holder.

56These arrangements, at present seldom applied by poor countries, can be exploited as part of trachoma control.

Purchases through the NGOs

57In Mali, international NGOs intervene in combating trachoma. Among others, there are the International Trachoma Initiative (ITI), Sight Savers International, Helen Keller International (HKI), OPC (Organization for the prevention of blindness), Swiss Red Cross, MSF Luxembourg, Global 2000/Carter Center, Lions Club International, Islamic Relief, World Vision, etc.

58The increasing intervention of NGOs in the field of public health and controlling infectious diseases outside emergencies has introduced a new variable into trachoma control. Firstly, the duration and extent of their work depend partly on decisions within the organizations. Secondly, their interventions need to be integrated into the national programs, to avoid any redundancy or waste.

59Some NGOs, like Médecins sans frontières (MSF) in particular, have moved into a hitherto neglected field, namely access to essential drugs. MSF has thus imported azithromycin into Mali, obtained at a very reasonable price from an Indian manufacturer, and currently distributes it in a district in the Mopti region.

Who should buy azithromycin?

60There are several purchase methods when the product must be bought, each of which has specific advantages and drawbacks. They can be bought nationally by the ministry for pharmacy of the country concerned, regionally by ACAME, or through the NGOs.

61ACAME (association of central medical stores for essential generic drugs), created in 1996, covers practically all the French-speaking African countries to the south of the Sahara for the joint bulk purchasing of essential drugs. It carried out a first experiment in 1998, subsequently not renewed and limited to five drugs, including amoxicillin and chloroquine. NGOs are also an alternative source, with the advantage of multiplying supply sources and avoiding stock shortages, and the drawback of creating confusion by allowing two formulations to circulate for the same disease and many quality controls.

Estimate of needs

62Needs can be estimated either upwardly, from the base of the health pyramid to the central level, which corresponds to the officially advocated decentralized planning, or centrally. At the moment, this latter way is used by the Malian national program for combating blindness, on a census basis and an estimated percentage of the population to be treated. This approach has the advantages of centralization. It is fast and avoids questioning all the levels of the health pyramid. However, it remains approximate, does not take into account the possibility of local stocks, which raises storage problems and favors "leaks". Above all, it does not conform to the law of decentralization.

Distributing the product

63The strategy for distributing azithromycin depends on the targeted level of cover, the prevalence of active trachoma and the local characteristics, especially the density and mobility of the population.

64Two ways of distributing products are theoretically possible, "fixed" and "advanced". The choice between the two is made according to the desired level of cover. Here also, each has its advantages and drawbacks.

Distribution from fixed centers

65This option has the drawback of not reaching all the population. It presupposes good social visibility of the disease, an operational local health system and spontaneous recruitment of beneficiaries. In the case of Mali, this choice is not now relevant, since the level of initial medical training in the country is only 53 %, which does not match the real level of accessibility of the centers, which, similar to the other Sahelian countries, is much lower.

"Advanced" distribution

66The health center mobile team goes to the target populations, prepared in advance by the village leaders, and perhaps even gathered in a particular place. This option has the advantage of concerning the maximum number of people and involving the population more. It requires more logistical and time resources and consequently more expenditure.

67The distribution campaign should take place during the dry season, before the rains, and should be the shortest possible, to avoid misappropriation of the product.

Distribution methods

68Several distribution methods can be considered:

  • indiscriminate distribution to all the members of the community; adults and children (strategy of mass),
  • distribution to all women and children,
  • distribution targeted only to homes where children infected by trachoma live.

69Until 2003, the WHO recommended mass distribution when the prevalence of follicular trachoma was higher than 20 % in children. This threshold was lowered to 10 % at a scientific meeting of the Alliance in August 2003.

70The idea that azithromycin treats sexually transmitted diseases ("one minute" treatment) spread very quickly. This treatment, intended for women, may be monopolized by men. To be sure to reach the reservoir, for reasons more sociocultural than epidemiological, it is perhaps preferable to favor a mass campaign.

71When prevalence drops below this threshold of 10 %, it is possible to use selective distribution just in homes where there is at least one child afflicted with trachoma. This latter strategy requires a clinical examination of all children.

Distribution standards

72Distribution must comply with certain requirements:

  • all patients meeting the selection criteria (sex, age, clinical state, etc.) must be identified and recorded,
  • patients must definitely take the drugs in the prescribed doses and correct dates.

73The drugs are taken and distributed under the supervision of the agent because children may spit out the product, and women may hide it in their hands.

74Considering the special features of the war on trachoma, which depends on the will of the State and for the moment at least does not meet most people's requirements, the distribution of azithromycin should only be completely free for the beneficiaries.

What are the distribution strategies?

75Distribution can be ensured by local health care teams (horizontal strategy), or by teams especially coming for this (vertical strategy). It may be either a question of already trained health workers themselves ensuring this function, or members of the community trained by the health workers (distribution on a community basis). This latter method of distribution can function either on a basis of voluntary help, as for ivermectin, or be paid for.

Distribution on a community basis

76The trachoma control campaign rests on a systematic administration of the treatment to whole populations or to those targeted on non-medical criteria (age, sex, etc.). Distribution may be ensured by non-medical personnel, trained and supervised by health workers. When the prevalence of trachoma decreases and it is decided to choose a strategy only targeting families presenting residual cases of trachoma, it will then be necessary to perform a clinical diagnosis, and change the distribution strategy.

77At the start, when the map of the endemic regions for intervention has been prepared, distribution relies on an organization both centralized and by stages, with a cascade of delegation of responsibilities, including an obligation to send reports up to the next level. This plan assumes the adequate training of personnel at all levels (medical district, health center, and community health workers). This training concerns prescription of drugs, supervision of drug distribution, and the writing of reports. When the distribution is targeted and requires a clinical diagnosis, it will be necessary to train nurses for this.

78Several experiments of this type of distribution have been carried out in West Africa with ivermectin for treating onchocerciasis and albendazole for lymphatic filariasis. Distribution of drugs on a community basis was done through the existing medical system with delegation of responsibility from top to bottom, down to the local community distributors. The persons responsible for the programs did not find it useful to set up circuits outside the existing health system.

79The head nurses train the community health workers so that they can Inform the populations about the disease, identify cases eligible for treatment, distribute drugs according to age and size, make sure that they are ingested, and fill in the report notebooks.

80Recruiting from the community has big advantages. For example, female agents in the village usually know if a woman is pregnant. Their good knowledge of the environment is a favorable asset compared with the second part of the alternative.

Vertical mass distribution

81Mass distribution is often used to make up for the limits of the health services, which only reach some of the population. Vertical distribution programs have the advantage of encouraging the agents, mobilizing extra resources and deploying a visible and immediate aid.

82Thus, we must accurately weigh the advantages and drawbacks of each strategy. The experts' opinion leans rather in favor of distribution on a community basis integrated within the existing health system.

How can we ensure the permanence of the distribution of azithromycin?

83The elimination of blinding trachoma is projected for around 2020. It has to be hoped that before this date, prevalence will have fallen to less than 5 %, meaning the end of transmission, and that the reform of hygiene and sanitation will stabilize the situation after the end of antibiotics.

84How can we ensure the availability of drugs until there is an adequate drop in the prevalence of the infection? Whether there is donation or not, coordination between the State, via the PNLC/T (national program for combating blindness/trachoma), donors, NGOs and other partners in development, is essential for running the program. The document of the second phase of the five-year program of socio-medical development (PRODESS, 2005-2010) is about to be completed and a five-year plan for trachoma control forecasts the number of doses of azithromycin needed until 2009, with annual adjustment of doses distributed depending on the evolution of prevalence.

How much does the program cost?

85What is the cost of the requirements for a country in a sub-region such as Mali, based on annual distribution?

86By using generics, and by making a maximal hypothesis of cover for the whole of Mali, the annual cost for obtaining the product is estimated at three billion CFA. This sum is relatively high, compared with the budget of a developing country. However, it does not seem out of reach.

87Also, the cost of the product needs to be added to that of its distribution, which can be lower if the trachoma control action is included in the current health system.

Conclusions and recommendations

88Whether the product is donated or bought, the supply and distribution strategy depends on the ministry of health in the country. There is a cost, whatever the strategy used, independently of whether the supplies are free of charge or not. It is up to the ministry of each country to plan its needs and manage stocks, even if an international NGO helps it in this undertaking, and itself ensures the continuous availability of antibiotics until there is an adequate drop in the prevalence of trachoma.

89Quality control of the product is also essential when generics are purchased.

What are the consequences of a mass distribution of azithromycin on the health system?

90Whatever its distribution methods, mass campaigns will not fail to have an effect on the functioning of the health service.

The impact of vertical distribution

91The vertical program is one more source of stress in the "daily race", keeping nurses away from their usual work in the health center. Many centers suffer from too many "revitalization" programs, all conceived centrally and reducing the role of nurses to carrying out orders sometimes ill-suited to conditions. Instead of concentrating on the wishes of patients, the nurse is especially concerned about satisfying the needs of specific programs. To do this, the nurse must often submit to rather formal exercises, which do not reflect realities in the field (progress forms, distribution lists, etc.). The nurse risks losing her small amount of availability for responding to the needs of the population, which will not improve frequentation of the fixed premises.

92One wonders whether the revival of routine activities through periodic action is really effective. After a brief bustle announced with a lot of noise, the service sometimes finds itself at an even lower level at the end of the programs and budgets. This short-lived pressure on the health services does not always strengthen them.

93Vertical action has other advantages and drawbacks. For example, resorting to new personnel paid for by the NGOs (the MSF strategy) can cause rivalry between the better-paid personnel and State health workers. Relationships between NGOs and local organizations are not easy, given the big differences in logistical resources and room for maneuver. On the other hand, the advantage is the injection of external resources. Moreover, the MSF takes care to involve at least one member of the health center in the distribution of antibiotics in each village.

The impact of distribution on a community basis

94Experience has shown that a short training is not necessarily enough to make the aims of the operation and its methods clear. The distribution of a drug only seems to be a simple action. It is necessary to check that the drug has been taken without using force on young children, to administer the correct dose, to keep the registers and explain the reasons for the campaign.

Conclusions and recommendations

95Successes, as much in programs run in the sub-region (onchocerciasis, lymphatic filariasis) as in the elimination of trachoma in some countries (Morocco), prove that it is not necessary to set up circuits parallel to the existing health system, risking extra costs for the government, and diverting the interest of health workers, attracted by special fees, towards this program to the detriment of other activities.

96It is however essential for the heads of the health services to have the necessary resources at all levels to ensure the new action (training, supervision, collection and analysis of data, and reports), and consequently for the health system to have a reasonable budget. Thus, one cannot completely avoid the question of a surcharge, even while remaining in the usual system of activity.

97The effectiveness of the strategy rests on the implementation of the national plan for eliminating trachoma through the central organization. When the plan has been adopted, the national coordination of the program undertakes to train instructors in diagnosis, recording and monitoring patients, doses, supervision of taking the drugs, management of medicines, overseeing the activities of the agents working at lower levels, preparation of reports, etc). The number of people to be trained, and the costs of this training, are to be determined by the coordination of the program.

98The inter-sector organizations (medical regions and districts), which coordinate the implementation of the plan to eliminate trachoma, receive all the resources intended for this work at the level of their respective responsibility; then allocate them to the persons in charge of each sector of activity (education, health, etc.).

What is the danger of misappropriation of azithromycin?

  • 1 Acute or chronic respiratory infections, otitis and rhinitis, urinary infections, sexually transmi (...)

99The broad action spectrum of azithromycin1, its ease of administration, its speed of action arouse fears of misappropriation during use in mass distribution, to treat other diseases, with or without compensatory payment.

100The drug is normally administered under the supervision of the agent responsible for distribution, who keeps a named register of administration on a complete and periodically updated list of all beneficiaries. How can we make sure that all patients are reached and that the drug is indeed used only in the situations for which it was intended?

101Experience gained with other drugs in the war against other endemic diseases is instructive. Indeed, unforeseen therapeutic indications have appeared. For example, Dapsone®, used against leprosy seems to have a "stimulating" effect, perhaps because of its action against the bouts of malaria. This "doping" effect, appreciated by the patients, causes a demand for drugs, even after the leprosy has been cured. Drug trafficking has developed with the complicity of certain nurses. Similarly, the effectiveness of ivermectin, used against onchocerciasis, on several intestinal parasites has resulted in persistence of the demand for the product outside distribution periods, and even after interruption of the treatment.

102Azithromycin can be used in treating bronchopulmonary diseases. However, the most frequent indication will probably be sexually transmitted diseases and urinary disorders, where people feel embarrassed about consultations; this risks generating other trafficking.

103With the pretext of increased demand, health workers with access to drugs, or responsible for determining local needs, can "inflate" needs.

104Health workers can also misappropriate the product; a fairly current practice when the demand for a product is strong and its price is high. This risk will decrease if the price of the product drops and if it is widely available in the form of generics.

105The risk of misappropriation can be avoided, or at least limited, by the use of DOTS (Directly Observed Therapy Short Course). This method is used in tuberculosis to prevent chemoresistance due to the irregular administration of drugs and the selection of bacteria. Community agents responsible for distribution make sure that the product is swallowed in their presence. They avoid entrusting to a third party, doses intended for a patient, who is absent during their visit. Nevertheless, they may undergo pressure from their associates to keep reserves of products.

106This technique assumes a higher level of control and reliability from the supervising nurse. This supervising nurse must give the community agent the doses corresponding to the number of person living in his area of responsibility and listed in his book, and make sure that the names of person having actually taken the product are marked in the community agent's notebook. Unallocated drugs (people absent) should be returned to the nurse after the round, together with the names of those absent. Moreover, regular and systematic recording of drugs given to the health centers (batch numbers, quantities given, dates of withdrawal), recovery of empty boxes from the health centers, constitute supplementary measures designed to ensure traceability of the product.

107Nevertheless, weaknesses in such a system are fairly quickly noted.

Conclusions and recommendations

108The misappropriation of azithromycin during distribution on a community basis is quite possible. However, strict application of the recommended measures (especially supervision and control) would make it possible to lessen the scale and seriousness of it.

How can we evaluate the effectiveness of azithromycin?

109For the individual or community, the effectiveness of an antibiotic such as azithromycin is evaluated as short term (less than one year), or long term (after several years). According to the documentation, one single oral dose of azithromycin is enough in more than 90 % of cases to get rid of genital infections due to Chlamydia (cervicitis and urethritis). This result can probably be extrapolated to ocular Chlamydia. As regards trachoma, even if Chlamydia is no longer found in the conjunctival cells with the most sensitive laboratory methods (PCR), follicles and accompanying inflammation continue to evolve for some time. Conjunctivitis of other origins may also occur, simulate trachoma and complicate the diagnosis.

Short-term effectiveness

110During the clinical trial carried out at the same time in Egypt, Gambia and Tanzania, a spectacular reduction in the infection was observed two to four months after antibiotic therapy. Two years later, prevalence had nowhere gone back to its initial level.

111In other tests in Morocco, Gambia and Nepal, the therapy also appeared very effective in the short term. In no country, did the situation return to its original state within two years.

112To evaluate the short-term effectiveness of azithromycin, a bacteriological examination, carried out with the most recent methods (PCR), would no doubt have been preferable to a simple clinical examination. At the moment, this method is only applicable in certain urban sites.

Long-term effectiveness

113The long-term results are still difficult to specify. Morocco obtained very satisfactory results thanks to treatment repeated annually over three years. In one village, only one case of trachoma was announced after three years of annual treatment of the population. Similarly, in Nepal, three successive treatments were very effective.

114The importance of cover appears to be the determining factor. In Tanzania, where the level of cover was only 65 %, the prevalence of trachoma did not decrease one year after treatment.

Conclusions and recommendations

115When the prevalence of inflammatory trachoma remains high, clinical diagnosis makes it possible to well evaluate trachomatous endemic disease and the effectiveness of the treatment. If prevalence is low, it can be worthwhile, when local conditions allow it, and when an equipped and qualified laboratory can participate, to use PCR to assess the real level of the infection.

WORK ON THE ENVIRONMENT

116Improved private and public hygiene has in the past facilitated the disappearance of trachoma in many countries. Modern epidemiological and experimental research confirms their overall effect.

117Changes in hygiene concern behavior of the people and environmental sanitation. Within this context, schools can play a role favoring the transformation of behavior. Still, this should go hand in hand with improving sanitation systems (water and management of refuse).

Can hygiene education and its application in schools help to improve hygiene in the families and villages?

118There is no historical or sociological general study concerning the influence of schools on hygiene in West African countries. Several occasional studies have highlighted the importance of promoting hygiene in schools and the role that pupils could play in transmitting the message and changing behavior at home. These studies justify the strategies aimed at motivating teachers so that they again become a real force for change in the village.

119In both Burkina and Mali, hygiene is officially recognized as a factor of progress and modernity in the educational world and a priority for everyone, perhaps because of the still high level of infectious diseases. However, the promotion of hygiene is currently covered in a few periodic projects supported by certain bilateral cooperation and the UNICEF.

The historical background and current evolution

120In the nineteenth century, the importance given to Pasteur's discoveries triggered an evolution in society, persuaded to reform its ways of personal washing, spitting, and nose blowing. In France, the instrument of this "revolution" was the republican school, with hygiene education entrusted to the teacher, a highly respected person who put in a lot of effort. The reading of handbooks, with place of honor in primary schools, reveals insistence on good hygiene practices, washing faces and hands as well as clothing, and the declaration of dirtiness as a vice. In the forefront of the rules of hygiene, appeared the correct use of the latrines, management of waste and refuse, sweeping and mopping the rooms. The school, perceived as a potential source of contamination, was historically also the center of the war on trachoma. Notions about trachoma appeared in the program of teacher training colleges and were the subject of questions in exams.

121In several countries like Vietnam and the Maghreb countries, the teacher played a major role in hygiene education. In Tunisia, during the protectorate and especially during the rapid growth in schooling that followed independence, the teacher kept this role of master in hygiene and even of nurse. It is he who was often responsible for applying the tetracycline ointment. The teacher training college organized visits of student teachers to dispensaries, to make them aware of the question of trachoma and to train them in screening it.

122In West Africa, hygiene education today encounters difficulties, linked to the crisis in public schools. Immediately after independence, the emphasis was on mass education. In Mali, the net rate of schooling in primary education went up from 7 % in 1961 to 41 % in the year 2000. This rapid development, and economic difficulties of all kinds in recent years, brought about a loss of prestige in teaching and of those who represented it in towns and villages. In Mali and Burkina Faso, several reforms have not succeeded in stemming the deterioration in primary education teaching. In Mali, in the 1970s, following political conflict, around two thousand teachers were laid off and replaced by improvised teachers. At the same time, new schools were created without taking into account minimum conditions of hygiene. "Deputy teachers" were recruited with a lower level of training than that of qualified teachers. The impossibility of setting up a mass education of quality generated a lot of frustration. Some families went to the Muslim colleges, which currently accommodate nearly 20 % of children. The recent emergence, especially in rural environments, of schools managed by the community, teaching in French or the national languages, often poorly controlled by education inspectors, is also revealing the crisis in the public system.

123In Mali and Burkina Faso, the living and working conditions of teachers (lack of books and teaching documents) have gradually deteriorated, resulting in lower professional conscientiousness and motivation of teachers. Teachers are poorly paid and no longer have the charisma that enabled them to significantly influence behavior and opinions in the community; or they no longer want to engage in any action beyond the limits of their work.

124The image of the scholar as a different being, bringing hope to the group of a rise in social standing, has also changed a great deal; progressively as the unemployment of graduates reduced these brilliant prospects to nothing. Many families ceased regarding investment in education as a priority.

125Today, most children leave school after six to nine years of education without acquiring the minimum essential knowledge especially as regards hygiene. This is particularly true for girls, who usually occupy the function of older sister and very often find themselves mothers shortly after leaving school.

Hygiene education

126During the colonial and immediate post-colonial period, hygiene education was universal and rigorously applied and guided by the teachers. It was authoritative in style, generally accepted at the time, requiring few visual aids or participative action.

127In recent years, hygiene education has been neglected. Handbooks have disappeared from the basic primary school documentation. Currently, hygiene has a very small place in teacher training.

128A considerable proportion of schools do not have the minimum conditions (no water or latrines) needed to demonstrate hygiene procedures and to get into the minds of pupils the model experienced at school.

129Hygiene education in general and its practice (cleanliness of schoolchildren, classes, latrines, water points and the yard) cannot be developed for trachoma alone. To promote hygiene in regions of trachomatous endemic disease, there has to be harmony between natural science programs (notions of microbes and infectious diseases) and hygiene programs (cleanliness of hands and face in everyday life). However, reference to trachoma control can help to mobilize society in regions of endemic disease because it provides a concrete illustration of the benefits expected from hygiene.

Schoolchildren and the environment

130The evaluation of trachoma control campaigns reveals that the child is often considered by the mother as the source of knowledge about trachoma. If schoolchildren themselves adopt what is taught about hygiene at school, they can pass on this information to the family and talk about it with playmates of the same age group who do not go to school. However, there are difficulties in talking about this subject, which is considered delicate by older relatives or those in authority, for whom respect overrides familiarity.

  • 2 An experiment of this type took place in partnership with "Clowns sans frontières".

131The influence of schoolchildren alone is not enough to change habits. Communication channels, other than the school, such as the "free" community radios, or shows in the villages2 can relay messages about hygiene. It appears easier to answer questions from parents rising from listening to a radio broadcast about hygiene than to approach them directly.

Involvement of the community and partners

132Experience gained in the sixties, and a few current projects in the area, show that it is possible to generalize hygiene education and its practice in the school environment. However, the teacher cannot alone fulfill this mission. He can involve associations, seek the cooperation of the municipal and technical services of health and sanitation, where they exist, or the agent for village development, to support him in communicating the concepts of hygiene and suggesting innovations.

133Industrial soap is not available, neither to poor people in the towns nor to the majority in rural areas. In many villages, potash soap is made with shea butter by women. The teacher can urge associations of mothers of pupils to produce the local soap. Additional finance is possible through the NGOs, twinning with towns in the north, village association networks, nonresident members of the villages concerned and the humanitarian work of tourist organizations.

134Today, international initiatives supported by UNICEF, UNESCO, WHO and the World Bank encourage the resumption of hygiene education and its practice in the school environment. Moreover, Burkina Faso, with the support of its partners, has just prepared a national policy document concerning hygiene.

135The ten-year plan of basic education, in Mali and Burkina Faso, gives more place to hygiene, and improving the environment.

Conclusions and recommendations

136The school can be regarded as an excellent place for communicating the hygiene message and inculcating good hygiene habits in children. Although this only concerns some children, they can in turn help change behavior within the family.

137Schoolteachers should have handbooks bearing in mind local situations. So that practice accompanies theory, each school should have a water point and latrines.

138The intermediary for the school within the community can be local television and radio or local theatre groups, in agreement with the national education system.

Can the availability of water improve protection against trachoma?

139Water must be available for good hygiene practices to spread. The link between the difficulty of access to water and trachoma has been clearly established. The risk of trachoma increases with the distance to the water supply. In Mali, the quantity of water used for washing the child is inversely proportional to the distance from the water supply. The current challenge is to give rural populations access to water in sufficient quantity. Even if the quality of water is less important in combating trachoma, it is reasonable to aim at increasing the quality and quantity of water at the same time in order to reduce the prevalence of all diseases transmitted by water.

140However, even if water is available, its use for hygiene purposes is not automatic.

The existence and proximity of water points

141The increase in the number of water points and supply facilities are a priority in order to satisfy consumers and avoid the long queues seen in certain African towns at the public fountains.

142In Mali, several thousand villages are still several kilometers from a permanent water point, whether traditional (well, river, side channel, rainwater) or modern (modern well, bores equipped with pumps, public fountains, etc). All the village water programs in the coming years will help to improve hygiene and thereby reduce the prevalence of inflammatory trachoma.

Access to water for the greatest number

143Running water supplies to the home are limited to medium and large towns and only reach the middle classes and the well-off. In these towns, the water supplies were first organized by the authorities. In certain towns, privatization of water conveyance in the nineties sometimes reduced water supplies to the poorest townsfolk because of increased prices.

144In the poor rural regions, the private sector is reticent to finance investments considered not very profitable, such as the creation and maintenance of modern water points. When villages are already equipped with such water points, various systems for recovering costs can be set up. They are run by committees, which often encounter management problems, lack of spare parts and recurring social conflicts concerning the rotating use of the water points and allocation of resources among consumers.

Maintenance of the water systems

145In the Malian rural environment, approximately 30 to 40 % of the systems no longer function a short while after installation. However, the experience in Mali, Burkina and Niger shows that when the issues of the utility services are discussed in line with local politics, and communities are involved at the various stages, people are better organized to maintain the system in operating condition. However, they need to be prepared for this task. The cost of repairing pumps varies, and can be very high, even prohibitive. Repairs could be often done by local mechanics at low cost.

146The example of Morocco illustrates the importance of the public administration of water in combating trachoma. In the oases of the south, the national office for drinking water has financed the water supplies of rural communities from its own funds, and supported village associations to equip themselves with sanitation systems.

147As part of decentralization in Mali, the local districts are invited to play an effective role in this field. The new institutional framework allows the transfer of decision-making and control over expenditure to the local authorities, which set priorities and take responsibility for supplying essential collective services, including water. They can use the local taxes for this, and negotiate a budget with the State.

148The role of the various players in improving access to water remains to be fixed; the local districts in the choice of equipment and its management; the State in the identification of water resources and ensuring fair distribution.

Uses of water in the households

149Even when water is available, social customs can, despite everything, hamper the benefit for children, the reservoir of trachoma. Whatever the quantity of water, custom often restricts the quantity of water reserved for washing children and babies. In several West African societies, when there is a water shortage, only the morning wash of adults remains a priority, especially the face. Failure to perform this practice can bring misfortune on people encountered. On the other hand, children, particularly the very young, are often regarded as innocent and not a danger to others. Moreover, dirtiness is traditionally accepted for babies as a way of protecting the body. In other groups, the baby may be cared for attentively, but the young child who starts to walk receives less attention as regards cleanliness - as if he had to get used to the pathogenic environment where he is to live.

150Even if the utility of washing is recognized, in rural or urban environments without water conveyance, the traditional systems of storage do not provide permanent access to water and fair distribution among all members of the family. There is little water storage capacity at home, even when the source is located in the village or the home district. The child's access to water is often limited and passes via the person responsible for looking after him. Consumers lack low cost domestic storage and distribution systems; such as containers (earthenware jars or buckets as in Togo) fitted with taps. For example, the production cost of a plastic prototype is 14,000 FCFA per unit. The price could be reduced, if the market is large enough. Thus, improving conditions of hygiene and living standards in the countryside does not necessarily engender the retreat of trachoma.

151Fitting faucets in houses does not necessarily change the way in which mothers clean the child's face. There is no provision for discharging waste water, and the water basins used again on several occasions are a reservoir of reinfection for the household. Furthermore, puddles in the domestic quarters can create an environment favorable to the proliferation of mosquitoes (particularly, anopheles, the vector of malaria). There needs to be a wastewater removal system. Absence of this creates voluntary restrictions on water, like that seen in Egypt.

152In the immediate future, habits created by shortages mean that there is hardly any waste. Improving access to water should allow a less parsimonious use of water for washing children. The evolution of customs in this direction can be helped by information-education-communication (IEC) action. In Niger, an educational program around the water points obtained significant results thanks to "health communicators" stationed in the district health center, who succeeded in creating a real climate of cooperation between the health services and villagers. The NGOs and local associations can play a role in the prevention of trachoma, when creating and maintaining water points.

Conclusions and recommendations

153Improving the availability of water in the villages is a fundamental factor for changing the population's hygiene practices. Combating blindness is a powerful argument for developing or renewing water points near dwellings. The upkeep of wells and bores already installed is a major problem that must be tackled by the authorities and the many NGOs working in this field.

154This provision of water is not enough in itself. Water systems must be accompanied by IEC action aimed at improving the cleanliness of children. The work of anthropologists suggests finer and more complex analyses are needed.

155Simple equipment for storing water in the house may also facilitate its use for hygiene purposes.

What can we expect from controlling flies in the prevention of trachoma?

156Several studies suggest the importance of controlling flies in reducing trachoma. The measures advocated rise from the idea that it is preferable to eliminate flies from the home environment. For that, it is necessary to use latrines, have good management of domestic refuse, keep cattle away from dwellings and clean secretions from the face, which attract flies.

  • 3 Musca sorbens prefers laying its eggs on human feces deposited on the ground and not in the latrin (...)
  • 4 The pullulation of Musca domestica is encouraged by the presence of animal excrement.

157Flies, especially Musca sorbens3 and Musca domestica4, are known as passive vectors of trachoma. They can carry Chlamydia trachomatis and deposit it on the eye of a healthy child. Secretions from the nose and eyes also attract flies. Measures encouraging cleanliness of the child will decrease this attraction. Thus, flies on children's faces signal an increased risk of trachoma.

158Many species of flies lay their eggs on excrement. They carry fecal matter and convey pathogenic agents present in animal or human feces. All factors are present so that they transmit germs, especially when they are put on human food. Flies have a real and sometimes major harmful effect.

159Spraying DDT proved to be effective in the past, but many species are now resistant. A pilot study has shown that spraying deltametrine (insecticide derived from a plant, pyrethrum, not very poisonous for the environment) for three months reduces the number of flies by 75 % and the incidence of trachoma at three months by 75 % in villages where applied. The authors also observed a reduction of 25 % of infantile diarrhea (a phenomenon already noted in other research). The collateral effects on other diseases must therefore be taken into account. Nevertheless, in the end, extensive insecticide spraying finally has little effect on the density of flies and does not appear to be possible at present.

160The ecological approach consists of, as far as possible, eliminating the reproduction sites (excrement, refuse). Six or seven days are needed for the eggs of the common house fly Musca domestica to turn into larvae, which migrate into the ground and then hatch. It is therefore important to eliminate refuse and excrement before this time.

161Building functional latrines reduces the density of flies and contact with the eyes. In Gambia, in villages where latrines had been built, the number of fly-eye contacts and the prevalence of trachoma fell by 30 %.

162Setting up a policy of building latrines does not pose real technical or financial problems. The great difficulty is using and maintaining these places; failing which, the sanitary risks and drawbacks prove to be higher than in their absence. This implies taking into account customs and cultural preferences. Many rural people consider that human excrement is dangerous and that the best strategy is to disperse it into nature. The idea of latrines accumulating feces is repugnant to them, as well as the idea of mixing urine (considered without danger) and excrement. In certain cases, showing the benefit of the installations in terms of more privacy can be more effective than justifying it as a means of preventing disease.

163The cleanliness of houses and yards has a well-known effect on the density of flies. The association of the proximity to cattle with trachoma is debatable (protective factor in Mali, aggravating factor in Burkina Faso). In fact, the importance of cattle, a source of wealth, and the difference in customs between nomads and sedentary populations could be confusing factors. In any event, one has to be very careful before blaming man/animal cohabitation, very much anchored in custom. Differently from human excrement, considered dangerous, animal excrement appears to the populations as without danger and even valuable as manure. Nevertheless, it appears desirable for animal waste and refuse to be removed from yards of houses as quickly as possible.

Conclusions and recommendations

164The reduction in the number of flies landing on the eyes is an important element in combating trachoma. Flies, which cannot be controlled by spraying insecticides, could be controlled by environmental sanitation. It is first a question of installing suitable latrines where they do not exist and making sure that they are used. The removal of refuse and animal manure from house yards also eliminates sites where flies breed. Removing the feces of children from the immediate environment by burial or depositing in the latrines is also useful.

What are the main hygiene and sanitation measures for combating trachoma?

165The increase in available drinking water and sanitation are some of the factors contributing to an improvement in the health of the populations.

166The lesson of history is revealing here. The pastoral revolution, in the widest sense, made Europe sensitive to insects and refuse. At the end of the nineteenth century, after the mosquito of the anopheles kind was recognized as a transmitter of malaria, insects became the enemy in the mind of doctors, and progressively in the mind of the public. In the countryside, heaps of manure gradually disappeared from in front of houses. Latrines at the bottom of the garden were moved into the house. The pump gave place to the faucet. All these transformations in Europe required more than a generation. In the rest of the world, when they gathered speed, it is generally in a context of intense political upheaval, sometimes at a high human and social cost, like the Chinese revolution.

167Where trachoma is concerned, it is clear that good sanitation effectively helps to reduce the spread of the disease. Indeed, it causes the disappearance of human or animal excrement, and solid or liquid domestic waste, of which the fermentable or putrefiable part attracts flies, vectors of the disease.

The current situation

168In most "water and sanitation" programs in the last thirty years, the effort of all the partners in development (international backers, NGOs, governments, local communities) has been directed to bringing drinking water to the urban and rural populations. The "sanitation" element has been the poor relation in development projects. It is true that the populations demand drinking water as a priority.

169Nevertheless, as regards sanitation, a certain number of advances are real, especially in the towns. Independent sanitation on house plots is widespread. Most of the time, this consists of a latrine and a cesspool for collecting waste water. Models of improved latrines are now well known and their use is supported by the NGOs. Semi-collective sanitation systems are being developed. Many towns have set up a commercial service of mechanical emptying by truck. A system of pre-collection of domestic solid waste, set up by district associations and NGOs, is developing quickly. This makes it possible to periodically evacuate solid waste from the districts, usually twice a week. Investigations have shown that inhabitants are ready to pay, if they get the service (waste disposal and drain sludge). Nevertheless, many problems remain; intermediate depots not evacuated, illegal dumping of drain sludge, lack of tips, etc.

170In the rural world, sanitation has more often been the subject of information and educational campaigns than real improvement or construction programs. These campaigns were generally about personal hygiene and sanitation in the surroundings: sweeping yards, waste disposal, developing water points, etc. Combating blindness (and trachoma) is seldom mentioned during such campaigns (except perhaps in regions where the endemic disease is present).

171Thus, the situation remains satisfactory to varying degrees in rural regions. In many villages, places for defecation are still very often used. Existing latrines are very basic. Domestic animals wander about, including in the village compounds and land. Household refuse remains on the plot or, at best, is evacuated to the nearest place, not necessarily suitable (abandoned plot, nearby valley slope, etc.). This disposal work is often the job of young children, which also explains the proximity of the discharge points because of their limited strength.

172However, the work of anthropologists leads us to moderate this picture according to the village and region, which could explain differences in prevalence.

Long-term measures

173Let us remember that it is a question of changing behavior resulting from ancestral customs, in which the relationship of cleanliness and dirt has been established with reference to order and disorder and thus, finally, to the construction of social ties. These practices have their own logic and are adapted to the local situation.

174Thus, any policy aiming at changing practices must be long term. However, too often, the short duration of projects does not allow for continuity. Moreover, any voluntary modification in behavior implies that the populations understand the reasons for, and the value of, the suggested change. In this respect, the IEC campaigns have shown their limits; their evaluation has demonstrated the memory powers of the villagers more than their real adoption of the concepts.

175The promoters of these campaigns have understood this fact because they now prefer to target two sectors of the public:

  • women who, as mothers or future mothers, can transmit the new practices to their children,
  • schoolchildren ready to learn and absorb new knowledge through the school.

176In both cases, it is a long-term aim and forms part of a program spread over several years rather than an occasional project.

177The current decentralization policy in West Africa may be a chance to see the war against disease receiving increased local resources, especially if this policy results in the delegation of a real autonomy of decision and provides the rural authorities with the resources for implementing their decisions. It remains to convince politicians of the importance of devoting resources to this fight, being aware that politicians are concerned with short-term visible achievements, not public health, where improvements can only be measured in the long term.

178Moreover, even if it is important to mobilize local councilors, decentralization should not release the State from its responsibility regarding the health of the population. It is up to the State to implement a long-term public health policy and stimulate the war on trachoma.

Recommendations

179A certain number of simple measures can be proposed for combating the transmission of trachoma.

Disposal of domestic waste

180The main objective is to remove waste within a time shorter than the hatching cycle of the eggs, which is less than six days. Burying waste remains the most attainable solution for populations without technical or financial resources. It is common for domestic waste to be used as manure in the "kitchen garden" or fields. This practice can be maintained, on condition that the waste is immediately buried in the field or garden.

181Incineration, another simple technique, depends on the kind of waste and the climate.

182A single site for disposal can be considered, with a basic treatment of waste either by periodic covering, or by continuous incineration. Its site must be carefully chosen to avoid polluting the environment, particularly rivers. Ideally, the distance to the dwellings should be greater than the flight distance of flies.

183It is understood that more effective solutions should be used as soon as the authorities have better resources.

Disposal of excrement

184The simplest measure consists of moving the defecation areas beyond the flight distance of flies, but this appears difficult to achieve. Moreover, when the villages are close together, flies prevented from going to one village may go to another...

185Improving the existing latrines is another more realistic solution. The effectiveness of improved latrines (particularly with a ventilated pit), installed in public buildings and schools, is no longer in doubt.

186More than speeches on health and hygiene, it is often the argument of comfort (intimacy, elimination of smells and flies) that triggers the will for change and investment. The organization of rural societies, the appearance of a middle class, the influence of migrants bringing modern ideas are also powerful factors of change.

187The penning of animals in the village is highly recommended. Among other things, it makes it possible to concentrate the animal excrement for use as manure on the fields. Here too, it is advisable to bury this manure as quickly as possible.

Improvement in good hygiene practices

188The hygiene message only has a chance to be integrated in new practices if it is repeated regularly, and with a real dialogue. Periodic assessments should be made to find out the impact. In areas with trachoma, the message should insist on washing the bodies and faces of children, washing hands after defecation or after cleaning a child's dirty buttocks, before meals, cleanliness in the home, clean kitchen utensils and clothing. The child's daily bath also appears more effective than washing the child's face.

189Improved domestic hygiene in order to decrease trachoma will have beneficial side effects, particularly on diarrhea among children, responsible for more than a quarter of deaths in this age group. A health education program centered on washing hands and body cleanliness held in a Gambian village has shown that the incidence of skin diseases, eye infections, and diarrhea decreased by more than half, whereas the incidence of respiratory diseases remained unchanged.

Conclusion

190The domestic environment of poor populations increases the risk of transmission of trachoma. This risk can be reduced if a policy of access to drinking water and environmental sanitation is followed with determination over a long period. The local communities need to be made aware and prepared, but it is up to the State to make access to water and sanitation part of its health policy.

Notes

1 Acute or chronic respiratory infections, otitis and rhinitis, urinary infections, sexually transmitted diseases, opportunistic infections among patients affected by HIV, gastroenteritis, etc.

2 An experiment of this type took place in partnership with "Clowns sans frontières".

3 Musca sorbens prefers laying its eggs on human feces deposited on the ground and not in the latrines; to a lesser extent on the excrement of animals.

4 The pullulation of Musca domestica is encouraged by the presence of animal excrement.

© IRD Éditions, 2006

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