Achieving the Last Mile Against Trachoma: Benin’s Journey to Eliminating Trachoma
Benin's Minister of Health receives trachoma certificate
Dr. Renee Tania Bissouma-Ledjou, WHO-Benin AFRO, presents Dr. Benjamin Hounkpatin, Benin's Minister of Health, with the letter certifying Benin as free of trachoma as a public health problem during the Benin Trachoma Elimination Celebration, June 13 in Benin. (Act | West, FHI 360)

When WHO declared Benin as having eliminated trachoma as a public health problem on May 17, 2023, the country became the fourth country in West Africa and fifth country in WHO’s African Region to do so.  This milestone also signified the last step of a long journey towards the elimination of a neglected tropical disease that began decades ago and, under the leadership of the Ministry of Health, involved multiple stakeholders within the country on the national and local, community levels and with external international partners.  

Evolution of Benin’s trachoma efforts: from a localized effort to a national approach to tackling trachoma 

Benin’s initial efforts in addressing trachoma through surgeries started in 1996, in several health facilities in the northern part of the country. At the time, the country did not have a nationally-run program for trachoma, let alone a coordinated program for neglected tropical diseases.  In 2005 the National Program for the Fight against Blindness program was created and took on temporary responsibility for fighting trachoma until the establishment of the National Program for the Control of Communicable Diseases (Programme National de Lutte contre les Maladies Transmissibles--PNLMT), in 2007.  Over the next six years, the PNLMT continued to engage with endemic communities and deliver trachoma treatments.

In 2013, with support from USAID through its ENVISION project, the PNLMT conducted a document review to identify locations where trachoma still remained a problem within the country.   From this review, it was discovered that trachomatous trichiasis (TT, the form of trachoma that can lead to blindness) cases were mainly from the four northern regions.  The PNLMT subsequently carried out baseline trachoma mapping in 2014-2015 using funding from USAID and Sightsavers.  The results showed that the prevalence of active trachoma warranted mass drug administration with Zithromax in eight health districts and surgical outreach for patients with the blinding form of trachoma was needed in 19 of the health districts.

From Data Mapping to Using a Cross-sector, Comprehensive Collaborative Strategy 

In addition to conducting mass drug administration through the delivery of 1.9 million treatments (through ENVISION), the Benin PNLMT implemented--in collaboration with the Ministry of Nursery and Primary Education and Water and Sanitation Sector Group within Benin’s government--WHO’s SAFE strategy to drive down the prevalence of trachoma. SAFE stands for: 

Surgery – to correct advanced trachoma to prevent further damage to vision or blindness

Antibiotics – to treat infections among entire populations with drugs such as Zithromax and tetracycline eye ointment where active trachoma is more than five percent among children 1 to 9 years of age. 

Facial cleanliness – to prevent spreading infections through washing face and hands with soap, using clean water, and using separate washcloths. 

Environmental improvements to improve access to clean water and basic sanitation, like latrines, to reduce exposure and re-infection, and eliminate the conditions in which flies breed  

By 2019, Benin had reached the elimination threshold for active trachoma and stopped MDA in all endemic districts, and in 2021had shown that trachoma remained below the elimination threshold for over two years in the absence of antibiotic pressure. 

Specific efforts by national and local level governments and community organizations contributed to the successful implementation of the SAFE strategy and demonstrated that Benin had eliminated trachoma as a public health problem. Those efforts included:

●      Logistical and financial support for activity implementation Benin citation textbox

●      Facilitating the official launch of trachoma elimination activities

●      Local authorities’ involvement in the mobilization and detection of patients

●      Recruitment of qualified personnel

●      Involvement of decentralized politico-administrative authorities in organizing trachoma surgery campaigns

●      Technical assistance to the PNLMT for major meetings (assessment workshops, transition workshop and dossier development)

Benin’s Best Practices Realized Along the Road to Elimination

Looking back, the Benin PNLMT Coordinator attributes her country’s success in eliminating trachoma as a public health problem to the following six best practices: 

  1. Use of geographic coverage data for TT cases and not the “TT backlog.” The estimated number of cases by municipality provides an approximate number of TT cases to seek out and manage during surgery campaigns but may be over-or under-estimated. Full geographic coverage is used after surgical activities when the estimated number of cases could not be found and managed. This activity ensures all residents in villages, towns and neighborhoods have been visited and no cases are missed.  
  2. Emphasis of the importance of post-operative follow-up of patients.  Follow up care makes it possible to quickly detect and correct any postoperative complications. The motivation of patients to accept the surgery hinges on the favorable outcomes of surgery among the first operated cases.  Also, the quality of surgery is a factor in the certification of ophthalmologic technicians trained to conduct TT surgery.
  3. Provision of holistic patient care.  During trachoma surgery campaigns, patients benefit from counseling and support for their travel and meals during their stay at the hospital.  During post-operative follow-ups, a listening and orientation service is offered to patients. 
  4. Development of the elimination dossier before all implementation activities have been completed, yielding progressive drafts of the dossier.  Working on different parts of the elimination dossier gradually, as activities unfold, avoids loss of information. 
  5. Desk reviews in non-endemic areas to reaffirm status.  This process reaffirmed that districts that are suspected to not previously had desk reviews were carried out in the 44 districts of the regions of Zou, Mono, Couffo, Ouémé, Plateau, Atlantique and Littoral in Benin.  The reviews captured data such as number of TT cases registered and operated and the water and sanitation situation in the district. These reviews reaffirmed that trachoma was not suspected in all these municipalities. 
  6. Confirmatory mapping to validate successes.  To validate the non-endemic status of these districts and to confirm the document review approach, a baseline trachoma mapping using Tropical Data was carried out in the district of Ouèssè bordering an endemic area (Tchaourou) and in the district of Bantè bordering another endemic country (Togo). The results of these surveys confirmed the desk review findings.    These results allowed the Ministry of Health to be convinced of the reliability of the desk review used for the 51 districts declared non-endemic and to determine whether an area is not suspected of trachoma.  This task reinforced the country's decision to not carry out mapping in other municipalities where trachoma was previously not suspected.

While the Benin PNLMT celebrates their achievement in trachoma, the PNLMT plans to do post-validation surveillance of trachoma and will continue to be dedicated to continuing their efforts to eliminate lymphatic filariasis (LF) and controlling the impact of schistosomiasis within endemic communities.