Metabolic syndrome and associated factors among psychiatric patients in Jimma University Specialized Hospital,South West Ethiopia

Background

Metabolic syndrome is a multisystem disorder which coined to describe the recognized clustering of metabolic and cardiovascular abnormalities including obesity, hypertension, dyslipidemia, and abnormalities of glucose homeostasis.

Effect of a community intervention with pit latrines in five districts of Amhara,Ethiopia

Objective To evaluate the change in household latrine coverage and investigated predictors of latrine uptake after 3 years of implementation of trachoma control interventions in Dera, Ebinat, Estie, Enebsie Sarmedir and Huleteju Enese districts of Amhara, Ethiopia. Methods Before and after study, baseline surveys were conducted prior to programme implementation and an evaluation after 3 years of interventions. Multi‐stage cluster random sampling was used in both surveys. Results A total of 1096 and 1117 households were sampled and assessed for the presence of household latrines at baseline and evaluation, respectively. The proportion of households with a pit latrine increased by 32.3% overall (95% confidence interval [CI]: 27.9–38.0), ranging from 8.0% (95% CI: 5.1–10.8) in Ebinat to 58.9% (95% CI: 51.9–66.8) in Enebsie Sarmedir. Logistic regression analysis of associations between household latrine ownership and potential factors showed that increasing household size (OR_{per additional person} = 1.2[95% CI: 1.1–1.3]), higher socio‐economic status (tin roof) (OR = 1.8[95% CI: 1.2–2.9]) and participation in health education (OR = 1.6[95% CI: 1.1–2.5]) were independent predictors of latrine ownership. Conclusion Our study documented heterogeneous increase in household latrine coverage after 3 years of latrine promotion; two of five districts had achieved millennium development goal 7.9 and halved the proportion of households without latrine access. We attribute the striking increase in household latrines to increased political commitment of the local government and intensive community mobilisation under the trachoma control programme in Amhara region.     

Human papillomavirus type distribution among women with cervical pathology – a study over 4 years at Jimma Hospital,southwest Ethiopia

Over the period 1998–2001 women attending Jimma hospital (southwest Ethiopia) with cervical dysplasia were screened for human papillomavirus (HPV), identifying a prevalence of 67.1% in this population. High‐risk HPV types 16 (55.7%), 18 (8.2%), 56 (8.2%), 45 (4.1%), 39 (2.5%), 52 (1.6%), 31 (1.6%), 35 (1.6%), 58 (0.8%), 33 (0.8%), 59 (0.8%) caused severe pathology as single/multiple infection. Strategies need to be envisioned for vaccinating children, young women prior to first sexual contact and preventive screening of HPV high‐risk types.     

Prevalence of blindness and visual impairment in the region of Ségou, Mali. A baseline survey for a primary eye care programme

A community‐based cross‐sectional study on the prevalence and causes of blindness and visual impairment was conducted between July and August 1990 in three rural districts in Ségou region, Mali. The study population consisted of 5871 villagers. In the study area, the overall prevalence of bilateral blindness was 1.7% (standardized rate for age 2.0X÷±0.4%), of bilateral visual impairment 1.7% (2.1X÷±0.4%), of unilateral blindness 1.7% (2.2X÷±0.4%) and of unilateral visual impairment 1.0% (1.2±0.3%). No important differences were found between districts.
Cataract was the most common cause of visual loss (54%) and was most prevalent among those over 50 years of age. In 43%, unilateral blindness was associated with trauma. Other major eye diseases accounting for high percentages of visual impairment were trachoma and glaucoma. Xerophthalmia appeared to be a major public health problem among children in the age group 0–5.
It was concluded that blindness is a major public health problem in this region. Some recommendations are given for strengthening integrated primary eye care at the district level in Ségou region.     

Follow-up of a low cost latrine promotion programme in one district of Amhara, Ethiopia: characteristics of early adopters and non-adopters

Objectives  To verify reported construction of 22 385 household latrines in 2004, after community mobilization, as part of a trachoma control programme in one district of Amhara, Ethiopia, and to explore characteristics of early latrine adopters and non-adopters.
Methods  We used a two-stage cluster sample survey design to randomly select eight sub-districts and 160 households listed as having built a latrine, and visited them to verify presence and use. Household heads were interviewed to determine latrine cost and knowledge, attitude and practice regarding latrines. Non-latrine adopting neighbours were interviewed for comparison. We estimated district latrine ownership and calculated adjusted odds ratios for factors associated with latrine use.
Results  Latrines were present in 87% (95% CI 77–97) of listed households; 90% (81–99) were in use. Among all district residents we estimated ownership as 50.2% (44–56) and use as 45.2% (36–55). Of latrine owners who had built in 2004, 69% (53/77) had spent nothing on their latrine, those who paid spent an average of US$4.0 [standard deviation (SD) US$3.6]; overall the median cost was US$0 and the mean US$0.80 (SD US$1.7). Household heads adopting latrines were 1.9 times (95% CI 1.3–2.8) more likely to have any education and 1.5 times (95% CI 1.1–2.0) more likely to have a larger family than non-adopting neighbours. Cleanliness (48%, 56/116) and health benefits (42%, 49/116) were the most frequently reported advantages of latrines.
Conclusion  The latrine promotion programme dramatically increased latrine access and use at very low cost. The method of community mobilization used could be an effective way of reaching millennium development sanitation targets.     

Temporal trends in the incidence of HIV infection in antenatal clinic attendees in Addis Ababa, Ethiopia, 1995-2003

BACKGROUND: The HIV incidence data are relevant in depicting the current dynamics and trend of the epidemic. Using a new laboratory method for HIV-1 incidence, we aimed at estimating a 10-year trend in HIV-1 incidence in Addis Ababa, Ethiopia. METHODS: We determined the temporal trends in HIV incidence based on a total of 7744 serum specimens from pregnant women who attended antenatal clinics in Addis Ababa between 1995 and 2003. HIV incidence was determined by IgG-capture HIV-1 BED incidence enzyme immunoassay following a validation using a well-characterized panel of serial serum specimens from subtype C-infected seroconverters. FINDINGS: Of the 1350 HIV+ specimens tested as part of the annual sentinel survey between 1995 and 2003, a total of 1332 (98.7%) were tested by BED HIV-1 incidence assay. The incidence rate of HIV-1 infection declined significantly from 7.7% (95% CI, 3.9-11.5%) in 1995 to 2.0% (95% CI, 0.7-3.3%) in 2003. Although there was a trend, amongst the age group of 15-29 years, in age-specific decline in incidence, it was not statistically significant. No change in HIV incidence rate was observed for the group aged above 30 years. INTERPRETATION: A corresponding decline in the incidence of HIV infection was observed with the decline in the prevalence of HIV infection between 1995 and 2003 in Addis Ababa City. Whether the declines were because of changes in sexual behaviours or other reasons needs to be explored. The BED HIV-1 incidence assay provides a valuable tool in obtaining information on recent HIV-1 infection.     

Economic costs of endemic non-filarial elephantiasis in Wolaita Zone, Ethiopia

BACKGROUND: Endemic non-filarial elephantiasis or podoconiosis is a chronic and debilitating geochemical disease occurring in individuals exposed to red clay soil derived from alkalic volcanic rock. It is a major public health problem in countries in tropical Africa, Central America and North India. OBJECTIVE: To estimate the direct and the average productivity cost attributable to podoconiosis, and to compare the average productivity time of podoconiosis patients with non-patients. METHODS: Matched comparative cross sectional survey involving 702 study subjects (patients and non-patients) supplemented by interviews with key informants in Wolaita Zone, southern Ethiopia. RESULTS: Total direct costs of podoconiosis amounted to the equivalent of US$ 143 per patient per year. The total productivity loss for a patient amounted to 45% of the total working days per year, causing a monetary loss equivalent to US$ 63. In Wolaita zone, the overall cost of podoconiosis exceeds US$ 16 million per year. CONCLUSIONS: Podoconiosis has enormous economic impact in affected areas. Simple preventive measures (such as use of robust footwear) must be promoted by health policy makers.     

Risk factors for active trachoma and Chlamydia trachomatis infection in rural Ethiopia after mass treatment with azithromycin

Objectives To investigate risk factors for ocular Chlamydia trachomatis infection and active trachoma, comparing communities receiving or not receiving an intervention programme of community‐wide azithromycin treatment and health education. Methods In a 3‐year post‐intervention follow‐up survey, 1722 children aged 3–9 years, from randomly selected households in 37 communities, were examined for signs of active trachoma and had samples taken to test for ocular C. trachomatis by polymerase chain reaction. Multivariate random effects logistic regression analyses considered interventions at community level, adjusting for other independent risk factors as appropriate. Results Younger age, ocular discharge and flies on eyes were risk factors for active trachoma in communities with and without antibiotic treatment. After azithromycin treatment, odds of active trachoma were lower in children aged 6–9 years than in children aged 3–5 years (OR 0.48, 95% CI: 0.36–0.66) and higher for children with ocular discharge (OR 4.5, 95% CI: 2.6–7.7) or flies on their eyes (OR 2.5, 95% CI: 1.6–3.7). Odds of C. trachomatis infection were lower in children aged 6–9 years than in younger children (OR 0.47, 95% CI: 0.23–0.96); and in children who received 2 or 3 doses rather than 1 (OR 0.26, 95% CI: 0.08–0.88). Conclusions In communities that received or did not receive the mass antibiotic treatment, the same risk factors for C. trachomatis and active trachoma were identified. Education and environmental improvements need to supplement antibiotic campaigns in order to positively impact on these remaining child level risk factors.     

Changes in prevalence and site of care of diabetes in a health district 1991-2001.

AIMS: Alongside a rising prevalence of known diabetes, patterns of care for diabetes have been changing in the United Kingdom. The aim of this study is to describe the changes in the prevalence of known diabetes and shift in site of care of patients in a single health district over a 10-year period. METHODS: Repeat cross-sectional study over 10 years of patients with diabetes resident in North Tyneside district. RESULTS: The crude prevalence of known diabetes in North Tyneside rose from 1.1 to 3.0% between 1991 and 2001. The proportion of patients receiving their diabetes care wholly in primary care rose significantly from 608/2236 (27%) in 1991 to 3995/5809 (69%) in 2001 (chi(2) = 968, 1 d.f., P < 0.001). The number of patients attending secondary care also rose by 14% over this period of time from 1508 to 1712 patients. CONCLUSIONS: Most of the extra workload of the rising prevalence of diabetes has been met in primary care. However, hospital care has not seen a drop in workload. This has important implications for health care planning, as an increase in resources will be required within both primary and secondary care to meet the needs of the diabetic population.     

Evaluation of the performance of CareStart™ Malaria Pf/Pv Combo rapid diagnostic test for the diagnosis of malaria in Jimma, southwestern Ethiopia

Objective

To evaluate the diagnostic performance of CareStart™ Malaria Pf/Pv Combo test relative to microscopy, for the diagnosis of falciparum and vivax malaria in Ethiopia.

Methods

Two hundred and forty febrile patients visiting the Serbo health center in Jimma zone, southwestern Ethiopia, were involved in this study in 2008. Giemsa-stained thin and thick blood smears were prepared and microscopically examined under a 100× oil immersion microscope objective for Plasmodium species identification and determination of parasitemia respectively. CareStart™ Malaria Pf/Pv Combo test was performed as per the manufacturers’ instruction.

Findings

The validity of CareStart™ Malaria Pf/Pv Combo test for the diagnosis of Plasmodium was very good with a sensitivity of 95.8%, specificity of 100%, positive predictive value of 100% and negative predictive value of 96%. The test performed equally well for the identification of Plasmodium falciparum and P. vivax. The diagnostic performance of this CareStart™ test is comparable to light microscopy of thin and thick blood smears.

Conclusion

Although CareStart™ Malaria Pf/Pv Combo test and blood microscopy have comparable diagnostic performance for Plasmodium detection, the CareStart™ test has the added advantage of being simple to interpret, cost-efficient, and hence it is preferable to use this rapid diagnostic test for malaria diagnosis in areas where microscopy is not accessible and during times of malaria epidemics that are observed approximately every 4-5 years in Ethiopia.     

Defaulters from antiretroviral treatment in Jimma University Specialized Hospital, Southwest Ethiopia

Objective To determine the prevalence of and factors associated with defaulting from antiretroviral treatment (ART) in Jimma, Ethiopia. Methods Unmatched case control study: cases were individuals who had missed two or more clinical appointments (i.e. had not been seen for the last 2 months) between January 2005 and February 2007; controls were individuals who had been on ART at least for 1 year and were rated as excellent adherers by the providers. Data were collected from patient records, and by telephone call and home visit to identify the reason for defaulting. Results Of 1270 patients who started ART, 915 (72.0%) were active ART users and 355 (28.0%) had missed two or more clinical appointments. The latter comprised 173 (13.6%) defaulters, 101 (8.0%) who transferred out, 75 (5.9%) who died, and 6 (0.5%) who restarted ART. Reasons for defaulting were unclear in most cases. Reasons given were loss of hope in medication, lack of food, mental illness, holy water, no money for transport, and other illnesses. Tracing was not successful because of incorrect address on the register in 61.6% of the cases. Taking hard drugs (cocaine, cannabis and IV drugs), excessive alcohol consumption, being bedridden, living outside Jimma town and having an HIV negative or unknown HIV status partner were associated with defaulting ART. Conclusion A significant proportion of patients defaulted from ART treatment. ART clinics should ensure that patients’ addresses are correct and complete. Programmatic and counseling efforts to decrease ART defaulting should address illicit drug and excessive alcohol use, decentralise ART services, institute home‐based treatment options for seriously ill and bedridden patients, and address patients concerns.     

Effect of diabetes mellitus on pregnancy and birth outcomes in Wolaita Zone,Southern Ethiopia: A retrospective cohort study

Background and aimsPresence of diabetes mellitus (DM) during pregnancy is important cause of maternal and fetal complications. Studies that address the effect of DM on pregnancy and birth outcome are scarce in Ethiopia. The aim of this study was to determine the effect of DM on maternal and birth outcomes in Wolaita Zone, Southern Ethiopia.MethodsA retrospective cohort study was done to compare maternal and birth outcomes of mothers with DM and non-DM who received maternity service in three hospitals and four health centers in Southern Ethiopia. A total of 136 exposed (with DM) and 272 unexposed (non-DM) mothers were included in the study. Data were extracted from medical records of mothers by experienced and trained data collectors. Means were compared for continuous variables. Logistic regression analysis model was used to check the effect of DM on pregnancy and birth outcome. Risk Ratio was calculated and p value less than 0.05 was considered statistically significant.ResultsPregnancy of diabetic mothers was significantly complicated by pre-eclampsia when compared with non-diabetic mothers, (RR = 1.8: 95% CI; 1.2–2.7). The risk of macrosomia was higher for neonates of diabetic mothers than non-diabetic mothers, (RR = 1.9: 95% CI; 1.3–2.7). From multivariate analysis, mothers with DM were 2.9 times more likely to be delivered by caesarean section than non-diabetic mothers (RR = 2.9: 95%CI; 1.3–6.2) and the risk of pre-term delivery was 2.5 times higher among mothers with DM, (RR = 2.5: 95% CI; 1.1–6.2).ConclusionsDiabetes mellitus among pregnant mothers is associated with increased risk of pre-term delivery, macrosomia and maternal complications of pre-eclampsia and caesarian delivery. Early detection and management of DM should be one of the key activities to improve maternal and child mortality and morbidity.     

Trends in the prevalence and management of atrial fibrillation in general practice in England and Wales, 1994-1998: analysis of data from the general practice research database

OBJECTIVE—To determine the prevalence of atrial fibrillation in England and Wales, and examine trends in its treatment with warfarin and aspirin between 1994 and 1998.
DESIGN—Analysis of data from the general practice research database.
SETTING—England and Wales.
PATIENTS—1.4 million patients registered with 211 general practices.
MAIN OUTCOME MEASURES—Age and sex specific prevalence rates of atrial fibrillation; percentage of patients with atrial fibrillation treated with oral anticoagulants or aspirin.
RESULTS—The prevalence of atrial fibrillation in 1998 was 12.1/1000 in men and 12.7/1000 in women. Prevalence increased from less than 1/1000 in under 35 year olds to over 100/1000 in those aged 85 years and over. There was a 22% increase in the age standardised prevalence of atrial fibrillation in men and a 14% increase in women between 1994 and 1998. The percentage of patients prescribed oral anticoagulants increased from 20% to 34% in men and from 17% to 25% in women. The percentage of men with atrial fibrillation prescribed aspirin increased from 26% to 36%, and the percentage of women increased from 24% to 36%. Applying the age and sex specific prevalence and treatment rates to the population gives an estimate of around 650 000 cases of atrial fibrillation in England and Wales. The greatest number of cases occurs in the 75-84 year old age group.
CONCLUSIONS—The number of patients in the community with identified atrial fibrillation is increasing. There has also been a pronounced increase in the percentage of patients with atrial fibrillation prescribed oral anticoagulants or aspirin.


Keywords: atrial fibrillation; prevalence; treatment; primary care     

Visceral leishmaniasis and HIV in Tigray,Ethiopia

OBJECTIVES: To identify characteristics that increased the risk of mortality in Ethiopian visceral leishmaniasis patients in a treatment programme managed by Médecins sans Frontières, in Tigray, Northern Ethiopia. METHODS: Retrospective review of a cohort of 791 patients treated for visceral leishmaniasis. RESULTS: The cohort displayed all the classical signs and symptoms of the disease. The case fatality rate was 18.5% (146) (95% CI: 15.8-21.3%). Logistic regression showed that individuals who experienced at least one episode of vomiting or haemorrhage were more likely to die than those who did not. A subcohort of individuals who tested human immunodeficiency virus (HIV)-positive were more than four times more likely to die than those who tested HIV-negative (OR 4.5, 95% CI: 1.8-11.4). CONCLUSION: This study identifies characteristics associated with death in this population and highlights the devastating effect of co-infection with visceral leishmaniasis and HIV in the African context.     

Macrovascular disease in middle-aged diabetic patients in Addis Ababa,Ethiopia

Summary To define the prevalence of large vessel disease in Ethiopian diabetic patients, the protocol of the World Health Organisation Multinational Study of Vascular disease in Diabetics was used in the Diabetic Clinic of Yekatit 12 Hospital, Addis Ababa: 221 of the possible 261 patients aged 35 to 54 years were examined during 6 months. One hundred seven were diagnosed diabetic 1 to 6 years before study, 74, 7 to 13 years and 40, 14 years or more before the study. Forty-two percent were taking insulin; 18% had retinopathy, 7% heavy albuminuria. Body mass index (BMI) of less than 18 kg/m² was found in 13.6%; 6.4% of men had BMI more than 27 and 50% of women more than 25. Only 30 patients had ever smoked cigarettes. The plasma cholesterol was less than 6.72 mmol/l in 90% of the 221 patients. Vascular disease led to the diagnosis of diabetes in 3 patients. At study, 19.9% were hypertensive but only 5% at the time of diagnosis. Only 1 patient had had ischaemic gangrene, 1 a stroke, 4 intermittent claudication, 4 angina pectoris and 1 a myocardial infarction. Electrocardiograms, centrally Minnesota-coded in London, were interpreted as Coronary Disease Probable in only 6 patients, and Coronary Disease Possible in 25; the other 190 tracings were normal. It is concluded that macrovascular disease is uncommon in middle-aged Ethiopian diabetic patients in Addis Ababa.     

Comparison of screening methods for anaemia in pregnant women in Awassa,Ethiopia

Screening for anaemia in pregnancy is essential for implementing and monitoring effective antenatal programmes. We compared the diagnostic accuracy of invasive and non-invasive screening methods in a cross-sectional survey of 403 pregnant women attending an urban health centre in Awassa, southern Ethiopia. Overall anaemia prevalence [haemoglobin (Hb): <11 g/dl] was 15.1% (95% CI: 12.1-19.9), mild anaemia (Hb: 10-10.9 g/dl) 10.4%, moderate anaemia (Hb: 7-9.9 g/dl) 4.2% and severe anaemia (Hb < 7 g/dl) 0.3%. Sensitivity, specificity and predictive values of conjunctival pallor and the WHO Hb colour scale were calculated for Hb cut-off points <11, <10 and <9 g/dl. All methods in combination with the symptoms and complaints reported by the mothers were entered into a predictive scoring system. None of the methods tested or models predicted anaemia with suitable accuracy in this population. The diagnosis of anaemia based on clinical signs and symptoms remains unreliable despite attempts to develop predictive models.     

Treatment outcome of tuberculosis patients under directly observed treatment in Addis Ababa,Ethiopia

BackgroundTuberculosis is one of the leading causes of mortality among infectious diseases worldwide. For effective tuberculosis control, it is a pre-requisite to detect the cases as early as possible, and to ensure that the tuberculosis patients complete their treatment and get cured. However, in many resource-constrained settings treatment outcome for tuberculosis has not been satisfactory.ObjectiveThe aim of the study was to assess the treatment outcome of tuberculosis patients and investigate the association of demographic and clinical factors with treatment success of patients enrolled in Directly Observed Treatment Short Course program in government owned health centers over the course of five consecutive years in Addis Ababa, Ethiopia.MethodsA register based historical cohort study covering the period of July 2004 to June 2009 was conducted to determine the treatment outcome of Directly Observed Treatment Short Course in government owned health centers in Addis Ababa. Sex and age of tuberculosis patients, health center at which the patient was treated, year of treatment, type of tuberculosis for which the patient was treated, type of treatment offered to the patient, follow-up status and documented treatment outcome were extracted from the Directly Observed Treatment Short Course clinics of three randomly selected health centers.ResultRecords of 6450 registered tuberculosis patients (n = 3147 males and 3433 females) were included in this document review. Of these patients 18.1% were reported as being cured, 64.6% were documented as treatment completed, 3.7% died during follow-up, 5.1% were reported as defaulters, 0.4% were documented as treatment failure and 8.2% were transferred out to another health institution. Treatment center and year of enrollment were significantly associated with treatment success.ConclusionYear of enrollment and treatment center were significantly associated with treatment success. Although the overall treatment success obtained in this study is in line with the World Health Organization (WHO) target, continuous follow-up of patients with frequent supportive supervision during the course of treatment, and further investigate the cause for the observed difference in treatment success across treatment centers are recommended.     

Audit of public sector primary diabetes care in Cape Town,South Africa: high prevalence of complications,uncontrolled hyperglycaemia,and hypertension

This study was undertaken to investigate the prevalence of diabetes complications and level of glycaemic and blood pressure control in Black African patients at the primary care level in the public sector Cape Town, South Africa. A stratified random sample of 300 patients attending the three largest ambulatory diabetes clinics in community health centres in Black African residential areas of Cape Town (100 patients from each) during the last 6 months of 1992 was selected. Each patient had a clinical examination, interview, and 1 year retrospective record review. Eighty-one per cent of the sampled patients were reviewed, 90 % were non-insulin-dependent (NIDDM) and 10 % were treated with insulin. The mean duration of diabetes was 8 (range 0–28) years. Acceptable glycaemic control was present in 49.4 % (95 % Confidence Intervals 45.6–53.5) of patients while 38.5 % (CI 24.8–52.2) of hypertensive patients had acceptable blood pressure control. The prevalence of any grade of retinopathy was 55.4 % (CI 48.90–62.9), proliferative and preproliferative retinopathy 15.6 % (CI 8.5–22.8), cataracts 7.9 % (CI 4.4–11.4), peripheral neuropathy 27.6 % (CI 15.2–39.4), absent foot pulses 8.2 % (CI 5.2–12.6), amputations 1.4 % (CI 0.4–2.4), persistent proteinuria 5.3 % (CI 2.5–8.1) and an elevated albumin-creatinine ratio 36.7 % (CI 29.0–44.4). The complications were not documented in the clinic records of the preceding year with the exception of 1 patient with absent foot pulses and the 12 patients with proteinuria. The high prevalence of suboptimal glycaemic and blood pressure control as well as complications of diabetes, largely unrecorded in the preceding years’ clinic notes, demonstrates the deficiency of and need for preventative diabetes care at the primary care level. The design, institution, and evaluation of effective intervention programmes are a priority to improve the quality of care provided and the health of diabetic patients. © 1997 John Wiley & Sons, Ltd.     

Participatory evaluations of trachoma control programmes in eight countries

Objectives Trachoma is a major cause of blindness. The objective of this initiative was to conduct participatory process evaluations of the trachoma control programmes receiving support from the International Trachoma Initiative in eight countries. Methods During each 2- to 4-week evaluation we analysed information collected at the central, district and community level through interviews, focus groups, questionnaires, direct observation of trachoma control activities, and existing data. Results Mapping and assessment of disease prevalence had been completed in four of eight countries. Integration of trachoma control activities into national planning and district-level service provision varied. Intersectoral partnerships to implement the SAFE strategy (i.e. surgery, antibiotics, facial cleanliness and environmental change) were well established in a few countries. In all eight countries, the number of surgeries performed annually was insufficient; and quality of surgery was rarely monitored. Mass distribution of antibiotics was carried out well in extremely resource-poor settings and good coverage was achieved, although the strategy for antibiotic distribution varied. Inadequate water and sanitation remained a major problem in all programme areas. Monitoring of programme activities was generally inadequate. The Morocco programme is an example from which lessons and processes can be learnt and adapted to other programme countries. Conclusions Significant achievements have been made in implementing the SAFE strategy. Scaling up of activities to true national coverage should be planned and implemented provided the resources can be made available. Further standardization of how to assess, implement and monitor trachoma control activities will facilitate expansion of the programme.