Review
A critical review of the SAFE strategy for the prevention of blinding trachoma

https://doi.org/10.1016/S1473-3099(03)00659-5Get rights and content

Summary

Trachoma is an ocular disease caused by repeated infection with Chlamydia trachomatis. It is the leading cause of infectious blindness globally, responsible for 5·9 million cases of blindness. Although trachomatous blindness is untreatable, it is eminently possible to prevent and the World Health Organization promotes the use of the SAFE strategy (surgery to treat end-stage disease, antibiotics to reduce the reservoir of infection, facial cleanliness, and environmental improvement to reduce transmission of C trachomatis) for this purpose. In this review we have assessed the evidence base supporting the elements of the SAFE strategy. We find strong support for the efficacy of the surgery and antibiotics components, although the optimal antibiotic regimens have not yet been established. The evidence for an effect of health education and environmental improvement is weaker, and depends mostly on cross-sectional observational studies.

Section snippets

Clinical features and pathogenesis

Children are the main reservoir of infection with C trachomatis, which is often symptomless. It may present as a mild conjunctivitis with scant muco-purulent discharge, and subconjunctival hyperaemia. Over several weeks,2 lymphoid germinal centres lying subjacent to the conjunctiva of the fornices, the limbus, and the tarsal plate enlarge, forming small white nodules known as follicles. Though follicles are macroscopically visible, clinical examination is best done with binocular magnifying

Trachoma diagnosis and assessment

Several schemes for grading the clinical signs of trachoma have been published.6, 7, 8, 9, 10 The “detailed WHO classification”9 is useful for specialists and for research purposes, but the most commonly used system is the “WHO simplified system”,10 details of which are presented in figure 2. The classification of the conjunctival signs in this system is based exclusively on the changes seen in the upper tarsal conjuctiva. With training and standardisation, good intra-observer and

The SAFE strategy for trachoma control

Blindness from trachoma is very difficult to cure, but eminently possible to prevent. Through the promotion of the full SAFE strategy, the WHO aims to eliminate trachoma as a cause of blindness by the year 2020. Several nongovernmental organisations are key players in this campaign and they work together with UN agencies and national ministries of health towards this goal. Community involvement is an essential component of sustainable trachoma control, and is the key to bringing about necessary

Cost-effectiveness of trachoma control

Although the potential economic effect of trachoma control is great, since trachomatous blindness affects people during their working years, few studies have assessed the cost-effectiveness of trachoma-control interventions.

The cost-effectiveness of trichiasis surgery was estimated in The Gambia, by means of a randomised controlled trial where 120 people with trichiasis were offered surgery either in the village or at the regional health centre.101 The estimated lifetime economic productivity

Conclusion

The priority of trachoma-control programmes must be to treat patients with trichiasis as they are at imminent risk of blindness. The current strategy is to offer surgery to people with trichiasis, and although there has been no trial comparing the effect of trichiasis surgery to no intervention on the development of blindness, there is evidence supporting a role for this surgery in the prevention of blindness. The high rates of refusal of surgery among people with trichiasis, however, may

Search strategy and selection criteria

Data for this review were identified by searches of Medline and by tracing the references of relevant articles. Search terms were “surgery”, “antibiotics”, “tetracycline”, “azithromycin”, “face washing”, “facial cleanliness”, “flies”, “Musca sorbens”, “environment change”, “latrines”, “water”, “cost-effectiveness”, “assessment”, “pathogenesis”, “community interventions”, “trichiasis”, “trachoma”, “trachomatous follicles”, “trachomatous inflammation”, “trachomatous scarring”, “corneal

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