Trachoma: Progress and Promise
  • ISSN: 0002-9637
  • E-ISSN: 1476-1645


Trachoma, the second leading cause of blindness worldwide, differentially affects the poorest communities, which may have the least access to resources. With the establishment of the Global Elimination of Blinding Trachoma by 2020 (GET 2020) goal, the World Health Organization has set an ambitious target for country programs. The currently recommended surgery for trichiasis/entropion, antibiotics for active disease, facial cleanliness, and environmental change to reduce transmission (SAFE) strategy targets all key elements believed to be necessary for a short- and long-term intervention program. This report reviews the need for a multi-faceted strategy, and the evidence supporting the elements of SAFE. Concerns about the implementation are discussed. Additional research is suggested that will enhance the implementation of the SAFE strategy. In the current climate of significant political and social momentum for trachoma control, the SAFE strategy is a safe bet to accomplish the elimination of blinding trachoma.


Article metrics loading...

Loading full text...

Full text loading...



  1. World Health Organization, 1998. Global Elimination of Blinding Trachoma. http://who.int/pbd/trachoma/wha51-e.htm. Geneva World Health Assembly 51.11. 1998.
  2. Bailey R, Lietman T, 2001. The SAFE strategy for the elimination of trachoma by 2020: will it work? Bull World Health Organ 79 : 233–236.
  3. Kuper H, Solomon AW, Buchan J, Zondervan M, Foster A, Mabey D, 2003. A critical review of the SAFE strategy for the prevention of blinding trachoma. Lancet Infect Dis 3 : 372–381.
  4. Bailey R, Duong T, Carpenter R, Whittle H, Mabey D, 1999. The duration of human ocular Chlamydia trachomatis infection is age dependent. Epidemiol Infect 123 : 479–486.
  5. Mabey DC, Robertson JN, Ward ME, 1987. Detection of chlamydial trachomatis by enzyme immunoassay in patients with trachoma. Lancet 2 : 1491–1492.
  6. Mabey DC, Bailey RL, Ward ME, Whittle HC, 1992. A longitudinal study of trachoma in a Gambian village: implications concerning the pathogenesis of chlamydial infection. Epidemiol Infect 108 : 343–351.
  7. Munoz B, Bobo L, Mkocha H, Hseih YH, West SK, 1999. Incidence of trichiasis in a cohort of women with and without scarring. Int Ophthalmol 28 : 1167–1171.
  8. Taylor HR, Rapoza P, West S, Johnson S, Munoz B, Katala S, Mmbaga BB, 1989. The epidemiology of infection in trachoma. Invest Ophthalmol Vis Sci 30 : 1823–1833.
  9. Ward M, Bailey R, Lesley A, Kajbaf M, Robertson J, Mabey D, 1990. Persisting inapparent chlamydial infection in a trachoma endemic community in The Gambia. Scand J Infect Dis Suppl 69 : 137–148.
  10. Bailey RL, Hayes L, Pickett M, Whittle HC, Ward ME, Mabey DC, 1994. Molecular epidemiology of trachoma in a Gambian village. Br J Ophthalmol 78 : 813–817.
  11. West SK, Munoz B, Mkocha H, Hsieh YH, Lynch MC, 2001. Progression of active trachoma to scarring in a cohort of Tanzanian children. Ophthalmic Epidemiol 8 : 137–144.
  12. Courtright P, Sheppard J, Schachter J, Said M, Dawson CR, 1989. Trachoma and blindness in the Nile Delta: current patterns and projections for the future in the rural Egyptian population. Br J Ophthalmol 73 : 536–540.
  13. Taylor HR, 1993. Trachoma-the future for a disease of the past. Br J Ophthalmol 77 : 66–67.
  14. Adamu Y, Alemayehu W, 2002. A randomized clinical trial of the success rates of bilamellar tarsal rotation and tarsotomy for upper eyelid trachomatous trichiasis. Ethiop Med J 40 : 107–114.
  15. Reacher MH, Munoz B, Alghassany A, Daar AS, Elbualy M, Taylor HR, 1992. A controlled trial of surgery for trachomatous trichiasis of the upper lid. Arch Ophthalmol 110 : 667–674.
  16. Bog H, Yorston D, Foster A, 1993. Results of community-based eyelid surgery for trichiasis due to trachoma. Br J Ophthalmol 77 : 81–83.
  17. Reacher M, Foster A, Huber J, 2002. Trichiasis Surgery for Trachoma: The Bilamellar Tarsal Rotation Procedure. Geneva: World Health Organization. WHO/PBL/93.29.
  18. Frick KD, Keuffel EL, Bowman RJ, 2001. Epidemiological, demographic, and economic analyses: measurement of the value of trichiasis surgery in The Gambia. Ophthalmic Epidemiol 8 : 191–201.
  19. Oliva MS, Munoz B, Lynch M, Mkocha H, West SK, 1997. Evaluation of barriers to surgical compliance in the treatment of trichiasis. Int Ophthalmol 21 : 235–241.
  20. West S, Lynch M, Munoz B, Katala S, Tobin S, Mmbaga BB, 1994. Predicting surgical compliance in a cohort of women with trichiasis. Int Ophthalmol 18 : 105–109.
  21. Rabiu MM, Abiose A, 2001. Magnitude of trachoma and barriers to uptake of lid surgery in a rural community of northern Nigeria. Ophthalmic Epidemiol 8 : 181–190.
  22. Bowman RJ, Faal H, Jatta B, Myatt M, Foster A, Johnson GJ, Bailey RL, 2002. Longitudinal study of trachomatous trichiasis in The Gambia: barriers to acceptance of surgery. Invest Ophthalmol Vis Sci 43 : 936–940.
  23. Bowman RJ, Soma OS, Alexander N, Milligan P, Rowley J, Faal H, Foster A, Bailey RL, Johnson GJ, 2000. Should trichiasis surgery be offered in the village? A community randomised trial of village vs. health centre-based surgery. Trop Med Int Health 5 : 528–533.
  24. West SK, Munoz B, Turner VM, Mmbaga BBO, Taylor HR, 1991. The epidemiology of trachoma in central Tanzania. Int J Epidemiol 20 : 1088–1092.
  25. Standing H, 1997. Gender and equity in health sector reform programmes: a review. Health Policy Plan 12 : 1–18.
  26. Ezz al Arab G, Tawfik N, El Gendy R, Anwar W, Courtright P, 2001. The burden of trachoma in the rural Nile Delta of Egypt: a survey of Menofiya governorate. Br J Ophthalmol 85 : 1406–1410.
  27. Khandekar R, Mohammed AJ, Courtright P, 2001. Recurrence of trichiasis: a long-term follow-up study in the Sultanate of Oman. Ophthalmic Epidemiol 8 : 155–161.
  28. Negrel AD, Chami-Khazraji Y, Arrache ML, Ottmani S, Mahjour J, 2000. The quality of trichiasis surgery in the kingdom of Morocco. Sante 10 : 81–92.
  29. Frick KD, Melia BM, Buhrmann RR, West SK, 2001. Trichiasis and disability in a trachoma-endemic area of Tanzania. Arch Ophthalmol 119 : 1839–1844.
  30. Schachter J, West SK, Mabey D, Dawson CR, Bobo L, Bailey R, Vitale S, Quinn TC, Sheta A, Sallam S, Mkocha H, Mabey D, Faal H, 1999. Azithromycin in control of trachoma. Lancet 354 : 630–635.
  31. Lynch M, West S, Frick K, Mkocha H, 2003. Azithromycin treatment coverage in Tanzanian children using community volunteers. Ophthalmic Epidemiol 10 : 167–175.
  32. Lietman T, Porco T, Dawson C, Blower S, 1999. Global elimination of trachoma: how frequently should we administer mass chemotherapy? Nat Med 5 : 572–576.
  33. Gupta CK, Gupta UC, 1970. Flies and mothers as modes of transmission of trachoma and associated bacterial conjunctivitis. J All India Ophthalmol Soc 18 : 17–22.
  34. Malaty R, Zaki S, Said ME, Vastine DW, Dawson D, Schachter J, 1981. Extraocular infections in children in areas with endemic trachoma. J Infect Dis 143 : 853.
  35. West S, Munoz B, Bobo L, Quinn T, Mkocha H, Lynch M, Mmbaga BB, Viscidi R, 1993. Nonocular chlamydial infection and risk of ocular reinfection after mass treatment in a trachoma hyperendemic area. Invest Ophthalmol Vis Sci 34 : 3194–3198.
  36. West SK, Munoz B, Mkocha H, Ngirwamungu E, Kilima P, 2002. Evaluation of Tanzania National Trachoma Control Program. International Trachoma Initiative.
  37. Bailey RL, Arullendran P, Whittle HC, Mabey DC, 1993. Randomised controlled trial of single-dose azithromycin in treatment of trachoma. Lancet 342 : 453–456.
  38. Frick KD, West SK, 2001. The SAFE strategy for trachoma control: planning a cost-effectiveness analysis of the antibiotic component and beyond. Ophthalmic Epidemiol 8 : 205–214.
  39. Solomon AW, Akudibillah J, Abugri P, Hagan M, Foster A, Bailey RL, Mabey DC, 2001. Pilot study of the use of community volunteers to distribute azithromycin for trachoma control in Ghana. Bull World Health Organ 79 : 8–14.
  40. Basilion E, Kilima P, Turner V, Mecakey J, 2002. Height as a proxy for weight in determining azithromycin treatment for paediatric trachoma. Trans R Soc Trop Med Hyg 96 : 691–694.
  41. Munoz B, Solomon AW, Zingeser J, Barwick R, Burton M, Bailey R, Mabey D, Foster A, West SK, 2003. Antibiotic dosage in trachoma control programs: height as a surrogate for weight in children. Invest Ophthalmol Vis Sci 44 : 1464–1469.
  42. Jones BR, 1980. Changing concepts of trachoma and its control. Trans Ophthalmol Soc U K 100 : 25–29.
  43. Bobo L, Munoz B, Viscidi R, Quinn T, Mkocha H, West SK, 1991. Diagnosis of chlamydial trachomatis eye infection in Tanzania by polymerase chain reaction/enzyme immunoassay. Lancet 338 : 847–850.
  44. Taylor HR, West SK, Mmbaga BB, Katala SJ, Turner V, Lynch M, Munoz B, Rapoza PA, 1989. Hygiene factors and increased risk of trachoma in central Tanzania. Arch Ophthalmol 107 : 1821–1825.
  45. Hsieh YH, Bobo LD, Quinn TO, West SK, 2000. Risk factors for trachoma: 6-year follow-up of children aged 1 and 2 years. Am J Epidemiol 152 : 204–211.
  46. West SK, Congdon N, Katala S, Mele L, 1991. Facial cleanliness and risk of trachoma in families. Arch Ophthalmol 109 : 855–857.
  47. Congdon N, West SK, Vitale S, Katala S, Mmbaga BBO, 1993. Exposure to children and risk of active trachoma in Tanzanian women. Am J Epidemiol 137 : 366–372.
  48. Taylor CE, 1958. Eye infections in a Punjab village. Am J Trop Med Hyg 7 : 42–50.
  49. Taylor HR, Velasco FM, Sommer A, 1985. The ecology of trachoma: an epidemiological study in southern Mexico. Bull World Health Organ 63 : 559–567.
  50. Lynch M, West SK, Munoz B, Kayongoya A, Taylor HR, Mmbaga BB, 1994. Testing a participatory strategy to change hygiene behaviour: face washing in central Tanzania. Trans R Soc Trop Med Hyg 88 : 513–517.
  51. West S, Munoz B, Lynch M, Kayongoya A, Chilangwa Z, Mmbaga BB, Taylor HR, 1995. Impact of face-washing on trachoma in Kongwa, Tanzania. Lancet 345 : 155–158.
  52. Luna EJ, Medina NH, Oliveira MB, de Barros OM, Vranjac A, Melles HH, West S, Taylor HR, 1992. Epidemiology of trachoma in Bebedouro State of Sao Paulo, Brazil: prevalence and risk factors. Int J Epidemiol 21 : 169–177.
  53. Prost A, Negrel AD, 1989. Water, trachoma and conjunctivitis. Bull World Health Organ 67 : 9–18.
  54. Tielsch JM, West KP Jr, Katz J, Keyvan-Larijani E, Tizazu T, Schwab L, Johnson GJ, Chirambo MC, Taylor HR, 1988. The epidemiology of trachoma in southern Malawi. Am J Trop Med Hyg 38 : 393–399.
  55. West S, Lynch M, Turner V, Munoz B, Rapoza P, Mmbaga BB, Taylor HR, 1989. Water availability and trachoma. Bull World Health Organ 67 : 71–75.
  56. Bailey R, Downes B, Downes R, Mabey D, 1991. Trachoma and water use; a case control study in a Gambian village. Trans R Soc Trop Med Hyg 85 : 824–828.
  57. Ballard RC, Fehler HG, Fotheringham P, Sutter EE, Treharne JD, 1983. Trachoma in South Africa. Soc Sci Med 17 : 1755–1765.
  58. Marx R, 1989. Social factors and trachoma: a review of the literature. Soc Sci Med 29 : 23–34.
  59. McCauley AP, Lynch M, Pounds MB, West S, 1990. Changing water-use patterns in a water-poor area: lessons for a trachoma intervention project. Soc Sci Med 31 : 1233–1238.
  60. Brechner RJ, West S, Lynch M, 1992. Trachoma and flies. Individual vs environmental risk factors. Arch Ophthalmol 110 : 687–689.
  61. Weir JM, 1952. An evaluation of health and sanitation in Egyptian villages. J Egypt Public Health Assoc 27 : 55–114.
  62. Wilson RP, 1932. Ophthalmia aegyptiaca. Am J Ophthalmol 15: 397–406.
  63. Dawson CR, Daghfous T, Messadi M, Hoshiwara I, Schachter J, 1976. Severe endemic trachoma in Tunisia. Br J Ophthalmol 60 : 245–252.
  64. Forsey T, Darougar S, 1981. Transmission of chlamydiae by the housefly. Br J Ophthalmol 65 : 147–150.
  65. Emerson PM, Lindsay SW, Walraven GE, Faal H, Bogh C, Lowe K, Bailey RL, 1999. Effect of fly control on trachoma and diarrhoea. Lancet 353 : 1401–1403.
  66. Reinhards J, Weber A, Nizetic B, Kupka K, Maxwell-Lyons F, 1968. Studies in the epidemiology and control of seasonal conjunctivitis and trachoma in southern Morocco. Bull World Health Organ 39 : 497–545.
  67. Emerson PM, Bailey RL, Walraven GE, Lindsay SW, 2001. Human and other faeces as breeding media of the trachoma vector Musca sorbens. Med Vet Entomol 15 : 314–320.
  68. Courtright P, Sheppard J, Lane S, Sadek A, Schachter J, Dawson CR, 1991. Latrine ownership as a protective factor in inflammatory trachoma in Egypt. Br J Ophthalmol 75 : 322–325.
  69. Sutter EE, Ballard RC, 1978. A community approach to trachoma control in the northern Transvaal. S Afr Med J 53 : 622–625.
  70. Sutter EE, Ballard RC, 1983. Community participation in the control of trachoma in Gazankulu. Soc Sci Med 17 : 1813–1817.
  • Received : 30 Jul 2003
  • Accepted : 17 Sep 2003

Most Cited This Month

This is a required field
Please enter a valid email address
Approval was a Success
Invalid data
An Error Occurred
Approval was partially successful, following selected items could not be processed due to error