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The SAFE Strategy for the Elimination of Trachoma by 2020: Will It Work? Robin Bailey1 & Tom Lietman2

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The SAFE Strategy for the Elimination of Trachoma by 2020: Will It Work? Robin Bailey1 & Tom Lietman2 The SAFE strategy for the elimination of trachoma by 2020: will it work? Robin Bailey1 & Tom Lietman2 WHO has recently launched a programme (GET 2020) for the elimination of trachoma, the leading cause of preventable blindness. GET 2020 has adopted the SAFE strategy, a comprehensive set of control measures (Surgery for entropion/trichiasis; Antibiotics for infectious trachoma; Facial cleanliness to reduce transmission; Environmental improvements such as control of disease-spreading flies and access to clean water). The present article reviews the strengths and weaknesses of each component of the strategy. Although significant hurdles remain to be overcome there is every reason to hope that GET 2020 will be successful. Keywords: Trachoma/surgery/drug therapy/prevention and control; Meibomian glands/surgery; Azithromycin/ therapeutic use; Hygiene; Environmental health (source: MeSH). Mots cle´s: Trachome/chirurgie/chimiothe´rapie/pre´ vention et controˆ le; Glande meibomius/chirurgie; Azithromy- cine/usage the´rapeutique; Hygie`ne; Hygie`ne environnement (source: INSERM). Palabras clave: Tracoma/cirurgı´a/quimioterapia/prevencio´ n y control; Gla´ ndulas meibomianas/cirugı´a; Azitro- micina/uso terape´ utico; Higiene; Salud ambiental (fuente: BIREME). Bulletin of the World Health Organization, 2001, 79: 233–236. Voir page 235 le re´sume´ en franc¸ais. En la pa´ gina 236 figura un resumen en espan˜ ol. Introduction Environmental improvements such as control of disease-spreading flies and access to clean water (6). Trachoma is one of the leading causes of blindness We review the strengths and weaknesses of the worldwide and the leading cause of preventable components of the SAFE strategy below and blindness (1). It is endemic in Africa, the Eastern consider the opportunities and threats presented by Mediterranean Region, Australia and parts of South- its implementation. east Asia (2). Ocular serovars of Chlamydia trachomatis cause recurrent conjunctivitis in children. In older persons the disease progresses through a cascade of Surgery conjunctival scarring, inturned eyelids, trichiasis, and eventually, corneal ulcers and blindness (3). The Surgery is the most direct and efficient way to prevent treatment of children with antibiotics can eliminate blindness from trachoma. Although blindness devel- chlamydia in a high percentage of cases but ops in only a small fraction of persons infected with reinfection is almost inevitable unless there is a chlamydial infection, a significant proportion of those comprehensive programme to prevent transmission with trichiasis become blind. Although a long time from the rest of the community (4). elapses between initial chlamydial infection and WHO, in cooperation with various nongovern- blindness, persons with trichiasis are at immediate risk mental organizations and national health services, of becoming blind (7). Bilamellar tarsal rotation can recently began implementing a programme to eliminate trichiasis over 1–2 years, and a randomized eliminate blinding trachoma — Global Elimination clinical trial showed that this technique was signifi- of Trachoma by 2020 (GET 2020) (5). This cantly more effective than several other methods (8). programme has adopted a strategy (SAFE), consist- While trichiasis is clearly the greatest risk factor ing of the following control measures: Surgery for for corneal ulcers and subsequent blindness, other entropion/trichiasis; Antibiotics for infectious tra- important factors include decreased tear production choma; Facial cleanliness to reduce transmission; and and dry eye, decreased conjunctival goblet cells, and thus decreased mucin, conjunctival and lid margin 1 Medical Research Council Laboratories, Banjul, The Gambia; and keratinization, and poor lid closure. Numerous London School of Hygiene and Tropical Medicine, London, England. procedures have been proposed, including tarsal 2 Francis I. Proctor Foundation, University of California, Box 0944, rotations, tarsal grooves, tarsal advances, cautery and San Francisco, CA 94143-0944, USA (email: [email protected]). cryotherapy, but no single procedure corrects all the Correspondence should be addressed to this author. risk factors for corneal ulcers and subsequent Ref. No. 00-1104 blindness. Some complications, such as dry eye and Bulletin of the World Health Organization, 2001, 79 (3) # World Health Organization 2001 233 Special Theme – Blindness loss of mucin-producing goblet cells, cannot be other control measures; not everyone with infection corrected by surgery. In addition there is a recurrence receives treatment; or migration from untreated areas of trichiasis after all forms of surgery to correct it, and takes place. The rate and sources of disease re- there is some indication that this continues to happen emergence are poorly understood but knowledge of even two years after surgery (9). them is vital when decisions are being taken on whom An excellent opportunity exists for improving and how often to treat. the implementation of bilamellar tarsal rotation There is an unparalleled opportunity to obtain surgery throughout those regions where trachoma new knowledge through research within the frame- is endemic. Better access to and acceptance of the work of the donation programme and the implemen- surgery are necessary in many areas (10, 11). There is tation of the SAFE strategy. Studies using quantitative interest in the development of procedures that molecular diagnostic and typing methods could lead to reduce recurrence rates and deal with the more a better understanding of the relationship between complicated entropion/trichiasis cases. Further- infection and clinical signs and to the identification of more, it may be possible to reduce the progression likely sources of infectious shedding in affected of cicatricial trachoma to trichiasis by reducing communities. The public health significance of reinfection with Chlamydia, and perhaps even the extraocular reservoirs of infection and subclinical recurrence rates of trichiasis after surgery can be infections in different groups can be evaluated by reduced also in this way (7). comparing different treatment strategies. Azithromy- In 1995 WHO estimated that there were 10.6 cin apparently suppresses infection for prolonged peri- million people worldwide with trichiasis attributable ods even in the context of re-emergent disease, perhaps to trachoma (12). Such people are at high risk for by enhancing functional immunity to chlamydial bacterial or fungal corneal ulcer. If trichiasis cases are infection (16). This requires further study. left untreated, a significant fraction of them develop The development of serious resistance of corneal scarring and blindness. Even if programmes C. trachomatis to azithromycin or tetracyclines would succeeded in reducing or eliminating chlamydial seriously compromise the antibiotic component of the infections there would still be individuals at risk for SAFE strategy. There are, however, few indications trichiasis and blindness from cicatricial trachoma, that this is likely to occur. Tetracyclines, for example, many in urgent need of surgery. Because of the have remained effective for many years. The emer- recurrence of trichiasis, there is bound to be a gence of resistance to common dangerous pathogens continuing need for reoperation. It is important for such as Streptococcus pneumoniae and Plasmodium falciparum surgical trachoma programmes not to lose momen- needs to be to monitored, although macrolide tum, even if new incident cases of cicatricial trachoma antibiotics are not widely used against these pathogens can be eliminated by reducing chlamydial infection. in areas where trachoma is endemic. The risk of Stevens–Johnson syndrome stopped mass treatments of trachoma with sulfonamides among native Amer- Antibiotics icans in the south-west of the USA (19), but there are no reports of such rare serious side-effects associated The feasibility of this component of the SAFE with azithromycin. Nevertheless, appropriate mon- strategy has been greatly enhanced by the advent of itoring should be in place (18). azithromycin (a macrolide-like antibiotic) for the treatment of active trachoma in one or a few doses, t together with Pfizer’s Zithromax donation pro- Facial cleanliness gramme. Several trials have confirmed that azithro- mycin treatment is at least as good as, if not better There is considerable evidence that persons with than, topical tetracycline for the clinical and micro- clean faces are less likely than others to have active biological cure of active trachoma (13–16). Most of trachoma. Consequently, there is an assumption that these trials have striven to maintain compliance with promoting hygiene may reduce trachoma (20, 21). A topical tetracycline treatment. The relative advantage controlled trial suggested that a vigorous campaign of azithromycin is greatest under practical opera- promoting facial cleanliness may reduce the like- tional conditions (17). Community volunteers can lihood of persons developing intense trachoma (22). administer azithromycin treatments and can effec- Educational activities in the form of skits, school tively use height-based dosing. A million doses of programmes and national radio announcements have azithromycin have been administered without ap- been implemented in a variety of cultural conditions, parent serious side-effects and with favourable and many groups have long included the distribution effects on other common diseases (18). of soap and the availability of fresh water
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