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Bull. Org. mond. Santi 1968 39, 497-545 Bull. Wid HNth Org. J Studies in the Epidemiology and Control of Seasonal Conjunctivitis and Trachoma in Southern Morocco* J. REINHARDS,1 A. WEBER,' B. NI2ETIt,2 K. KUPKA3 & F. MAXWELL-LYONS' It has been noted in many parts ofthe world that bacterial conjunctivitis is a major cause oftotal or partial loss of vision. In addition, trachoma is aggravated ifthere are associated bacterial infections and these lead to more frequent corneal complications. In the trials described the seasonal variation of bacterial infections was studied in addition to trachoma in 3 pilot sectors in southern Morocco. The frequency of complica- tions and late sequelae from these infections in the whole population of these sectors was also studied. In one of the sectors 3 different methods of limiting the regular seasonal increase in bacterial infections and of curing trachoma were evaluated separately or in combination. These included the effect offly-suppression on the transmission of infection, a possible method ofchemoprophylaxis, and intermittent treatment with chlortetracycline ointment. The effect ofthe latter, when applied to a whole population group by auxiliary personnel, was compared with the long-term effect ofself-treatment, in this and the two other sectors. The total observation period covered 12 years. INTRODUCTION The south of Morocco has only recently come in Only recently have the problems of communicable contact with western civilization; conditions are still eye diseases been considered in health policy plan- largely the same as centuries ago and change is very ning for the south. The expansion of this health slow. policy was made possible by national activities, in- In the last 30-40 years, however, important prog- ternational co-operation and new developments in ress has been made in the fight against some com- chemotherapy and antibiotic therapy. mon epidemic diseases. The great epidemics of The south of Morocco, or more correctly the typhus, smallpox and plague no longer occur and south-eastern region, is mainly desert and is very many other epidemic and endemic diseases have different in character from the rest of the country. It decreased sharply. is separated from the north-west by the Great Atlas * The design of the Goulmima survey and clinical trials in charge, are largely the result of mutual consultations, com- carried out between 1953 and 1956 was a collective project ments and adjustments in which all named authors have in which Dr F. Maxwell-Lyons, then of the WHO Regional taken part. Office for Europe and consultant to the project, was assisted Some of the more recent data from Goulmima and by the late Dr Satya Swaroop, Chief, Health Statistical Skoura are taken from a thesis by K. Kupka, entitled Methodology, World Health Organization, Geneva, Switzer- "A study of Trachoma in Villages of South Morocco" land. All field examinations were made and data recorded presented at the University of Pittsburgh, 1965. by Dr J. Reinhards, then WHO Project Officer. The data were tabulated, systematized and analysed by Dr A. Weber. 1 WHO Regional Office for Europe, Copenhagen, In later surveys (after 1960) the design of the study was Denmark. made by Dr K. Kupka, then WHO Adviser in Health 'Field Officer, WHO Communicable Eye Diseases Pro- Statistics and Epidemiology, assisted by Dr B. Nii:ti4, ject, Rabat, Morocco. WHO Project Ophthalmologist, and Dr J. Reinhards. All field examinations after 1960 were made and recorded by ' Medical Officer, WHO Epidemiology and Health Dr B. NiL-tid. These data were tabulated and analysed Statistics Project, Rabat, Morocco; present address: Division by Dr K. Kupka assisted in computations by Mr Abolfazli, of Health Statistics, World Health Organization, Geneva, WHO Statistician. Switzerland. Parts of the text of the introduction and of various ' Formerly, Division of Communicable Diseases, World chapters, although written by one or other of the authors Health Organization, Geneva, Switzerland. 2244 -497 498 498 ~~~~~~~J.REINHARDS AND OTHERS Mountains (Fig. 1). The climate is harsh, very hot surveys and mass campaigns, to be described here, and dry in summer, but cold and more humid in were started in 1952. Sakon & Accart (1938) winter. claimed an almost constant prevalence of trachoma According to a census in 1960 Morocco had of 100%, in 1938, in Tafilalet; Pag6s (1949) reported II 626 000 inhahitants, or ahout 27 persons per a prevalence between 50% and 100%. Decour kM2. Some 74% of the population iS rural, with (1955) mentions 3% trichiasis in the pre-Sahara. A 52% under 20 years of age and only 4% over 65 survey of the blind carried out in 1953 by Jung years old (Morocco, 1963). The south is much more (1960), with the aid of the civil authorities, showed sparsely populated than the north with no more than that 27 879 out of 7442 110 estimated Moslem in- 6 persons per kM2. The presence of nomads habitants of the country were blind, that is, 3.75 (2 %.-3 Y.), however, makes it difficult to establish persons per 1000. Slightly higher rates were found in reliable figures. The people inhabit for the most part the south and the figures are thought to be an the mountain valleys where the streams usually en- underestimate of the position. sure an adequate water supply. Except for the In 1952 practically all of the people were infected nomads most people live in villages or ksour; sani- with trachoma in the first months of their life (Rein- tary conditions are bad everywhere. hards, 1954) and every year almost all were affected Very little information was available on trachoma by bacterial conjunctivitis. In Morocco, as in other and seasonal conjunctivitis in Morocco before the countries in North Africa and the Middle East, the FIG. I GOULMIMA, SKOURA AND OUARZAZATE EXPERIMENTAL AREAS a IN MOROCCO Wmamb."..-W 3U. ZY- Mink.. op., - -- -- -- A4TL.4N1~C -OCEAAN i. JimC'~ ~ sq - I~~~~~~~t .000' L4PrLwf .001 .- - I... i- I .. '' .. c . ..; .W '- -'.. ': _j 1- 11 .1 " I .1 - "A '. r 'i. _' 1. 0. - a See Fig. 2 for details of shaded area. SEASONAL CONJUNCTIVITIS AND TRACHOMA IN SOUTHERN MOROCCO 499 seasonal rise and fall in the incidence of bacterial Wilson (1945) provided circumstantial evidence conjunctivitis was closely correlated with seasonal that the trachoma agent may be transmitted in the fluctuations in fly breeding (Wilson, 1931-1937, infective discharge of conjunctivitis and it was con- 1945; Pages, 1951) because of the complete lack of sidered important to check this point in field trials in sanitary measures to dispose of human and animal this country. excreta on which the flies breed (Ponghis, 1957). Studies carried out in 1952-54 established the fact Epidemic conjunctivitis has been attributed chiefly that in south Morocco the prevalence of both tra- to Haemophilus bacilli. Sporadic cases of gonococ- choma and seasonal conjunctivitis was high and that cal infection of the eye occur, usually in autumn, and both assumed a grave form resulting in high inci- sometimes lead to small localized epidemics. It is dence of impaired vision. In the south 18 years ago, suspected that more widespread gonococcal epidem- no solution could be envisaged to this problem. In ics occurred in the past with the coincidence of countries where trachoma and seasonal conjunctivi- certain favourable climatic and other environmental tis are prevalent it is well known that hospital and factors. Thus, in some districts, numerous leucoma- dispensary services have generally failed to reduce ta could be related to a " bad year " when, according the incidence of communicable eye diseases, al- to local accounts, " many eyes were lost ". though they may have done much to reduce individ- In general the magnitude of seasonal epidemics ual suffering and the incidence of blindness. depends on the following factors: Because of the insidious onset of trachoma in early childhood and the relative absence of subjec- (1) the reservoir of bacterial carriers; tive symptoms in the early stages, the children and (2) the abundance of flies during major breeding their parents are unaware of their illness. Usually seasons; only those suffering pain and loss of sight attend (3) the hospitals and dispensaries. Persons suffering from direct influence of climatic conditions on conjunctivitis are very often satisfied with fly breeding and possibly indirectly on the virulence the imme- of the organisms; diate symptomatic relief given by modem treatment, and few of them continue the treatment until cured (4) the lack of personal hygiene of the popula- of the underlying trachoma. It is also well known tion; and that treatment of a few individual cases cannot (5) the presence or absence of rational treatment. change the natural course of an epidemic of conjunc- tivitis in a community. The second and third of these factors usually As early as 1950, experimental work was conduct- affect the course of the epidemic from May to ed in Morocco to find a suitable mass-treatment December, while the first and the fourth exercise a method (Bardon, 1953; Bidart & Racoillet, 1953; permanent influence. Ferrand & Parlange, 1951; Ferrand & Soyer, 1953; Seasonal conjunctivitis was by far the most fre- Gaud, 1949; Gaud & Decour, 1951; Gaud et al., quent cause of total blindness for the country as a 1950; Pages, 1938, 1950a, 1950b). whole. Many ulcers occurred in the second halfofthe Information on the environmental conditions season, less often with Koch-Weeks conjunctivitis favouring seasonal conjunctivitis and trachoma infec- but frequently with gonoblennorrhoea. Perforations tion was available from other countries with similar were relatively frequent, resulting in total or partial problems (Wilson, 1945; Maxwell-Lyons, 1953). It adherent leucomata, secondary glaucoma, staphylo- has long been recognized that in regions like North ma or phthisis bulbi. Moreover the bacterial infec- Africa and the Middle East, where trachoma and tions have further disastrous effects in that they seasonal conjunctivitis co-exist, control measures facilitate the transmission of trachoma, prolong its must be directed against both.

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