Comm Eye Health Vol. 12 No. 32 1999 pp 49 - 51. Published online 01 December 1999.

Trachoma and the SAFE strategy

Joseph A Cook MD MPH FACP

Executive Director, International Trachoma Initiative, 6 East 45th Street, Suite 1600, New York, NY 10017, USA

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Eight years have passed since the Journal of Community Eye Health devoted an Issue to trachoma, the leading cause of preventable blindness. That edition of the Journal of Community Eye Health (Vol.7, Issue 14) noted that it was surprising that the most common cause of blindness after cataract was, in fact, attracting so little attention. Perhaps our recognition that trachoma can disappear with economic development, improved sanitation, and better personal hygiene led to complacence in Ministries of Health in many countries. The partial success of trachoma control through World Health Organization (WHO) programmes mounted in the 1960s, together with economic development in urban areas where trachoma had been a problem, led to neglect of this disease among the poorest segments of the world’s population, especially in rural areas. It is these poor people, generally without basic sanitation, access to water, with little or no experience of economic development, who are most likely to become infected with Chlamydia Trachomatis and are at risk of blindness. Today trachoma is confined to 46 countries, mainly in Africa, the Middle East and Asia. Almost 150 million people are thought to have active infection and 5.6 million are blind or at immediate risk of blindness. Ten million people need simple eyelid surgery to prevent consequent blindness.

Trachoma control: the SAFE strategy

The good news, however, is that there is a rebirth of interest in control measures and an enthusiasm to launch programmes that include tertiary prevention (surgery), secondary prevention (antibiotic treatment of the infection) and primary prevention (facial hygiene and environmental change to improve sanitation) – the SAFE strategy. The acronym SAFE provides both an understandable approach and a rallying cry for those who are interested in eliminating this cause of blindness. SAFE combines the three elements of primary, secondary, and tertiary prevention but in the reverse order:

  • Surgery to prevent blindness in those who have trichiasis/entropion.
  • Antibiotics (tetracycline ointment or azithromycin) to combat active chlamydial infection.
  • Facial hygiene.
  • Environmental change.

The importance of environmental change has never been stronger with the recent evidence by Paul Emerson and his colleagues that fly control can reduce trachoma prevalence.1 Some have suggested that the final E should include not just environmental change but education and economic development. Perhaps SAFE with E3!

WHO manuals and GET 2020

The World Health Organization has led the way in this rebirth, through the publication of the five technical manuals on trachoma control (Assessment, Trachoma Rapid Assessment, Surgery, A guide for Environmental Sanitation and Improved Hygiene and Achieving Community Support) and in the formation of the Global Alliance for the Elimination of Trachoma by the Year 2020 (GET 2020). Adding further support to the Alliance, in May 1998, the 51st World Health Assembly adopted a resolution calling for the elimination of trachoma as a cause of blindness and recommending that Ministries of Health pursue the SAFE strategy to do so (WHA Resolution 51.11). This Alliance is open to all who are concerned with controlling this disease. It has grown from an original meeting of 12-13 interested parties to an attendance of representatives of 29 endemic countries, 9 non-governmental organizations and 10 research institutions concerned with trachoma control in Geneva at the seventh meeting in January 2003. Prior to the 2003 meeting, an informal Trachoma Scientific Workshop was held to promote scientific exchange and to provide focus on applied research to improve control programs.


A new long-acting oral antibiotic, azithromycin, is as effective in a single dose as six weeks of daily tetracycline ointment. This has greatly improved the chances of reducing infection within a community and, when combined with the other elements of the SAFE strategy, could lead to elimination of the disease. Robin Bailey and his colleagues first reported the potential of azithromycin in The Gambia.2 More recently, community trials using a common protocol in Egypt, Tanzania, and The Gambia have verified the effectiveness of this antibiotic in a rigorous comparison with tetracycline ointment.3 In these studies, compliance was assured. In actual public health campaigns, because of the difficulty in using the ointment and its unpopularity, one would expect that a single dose oral drug would be far superior. Encouraged by these results and the WHO recommendation that azithromycin should be tested in community control programmes, Pfizer Inc, the global pharmaceutical company, has embarked on its largest international philanthropy: a donation so far of more than $200 million worth of Zithromax®.

International Trachoma Initiative

In November 1998, Pfizer Inc, together with the Edna McConnell Clark Foundation, established the International Trachoma Initiative, an effort to test the SAFE strategy using Zithromax. Beginning in five countries (Tanzania, Mali, Morocco, Ghana and Vietnam) chosen from the WHO’s 16 priority countries defined by the GET 2020 Alliance, the International Trachoma Initiative (ITI) has added programs in Nepal, Niger, and Ethiopia. The ITI also collaborates with the Carter Center in its program for trachoma control in Sudan. In the areas where ITI-supported programs have begun in the first five countries, there has been a reduction in acute infection in young children of 45 – 50%; at the same time progress has been made against the backlog of patients requiring lid surgery. The International Trachoma Initiative, working with the Global Alliance, hopes to share information on operational research and programme evaluation and monitoring, based on its experience in implementing control in these five countries.

This edition of the Journal of Community Eye Health provides sound background information concerning trachoma control and recent developments in this area. The brief articles in this issue explain and amplify the steps needed to undertake the SAFE strategy. Additional detailed information can be found in the technical manuals available through the Prevention of Blindness Programme of the World Health Organization. In addition, the previous Issue of the Journal of Community Eye Health on this theme (No. 14) continues to be highly relevant, and back issues are available free of charge from the International Resource Centre (see page 54). One should also be aware of the trachoma teaching CD-Rom that has been produced by the Wellcome Trust and is distributed by CAB International. (See page 63 for details on how to obtain these and other teaching and educational materials).

The new antibiotic, azithromycin, is important as it may effect a decrease of transmission in a community, while the longer lasting elements of facial hygiene and environmental control are put in place. More important, however, is the rebirth of interest to assess and then take action to end trachoma as a cause of blindness. If the SAFE strategy can be put into practice where trachoma remains endemic, transmission could be halted well before 2020, the year that the Global Alliance expects to see an end to the need for corrective lid surgery.


1 Emerson PM, Lindsay SW, Walraven GEL, Faal H, Bogh C, Lowe K, Bailey RL. Effect of fly control on trachoma and diarrhoea. Lancet 1999; 353: 1401-3.

2 Bailey RL, Arullendran P, Whittle HC, Mabey DCW. Randomised controlled trial of single-dose azithromycin in treatment of trachoma. Lancet 1993; 342: 453-6.

3 Schachter J, West SK, Mabey DH, Dawson CR, Bobo L, Bailey R, Vitale S, Quinn TC, Sheta A, Sallam S, Mkocha H, Mabey D, Faal H. Azithromycin in control of trachoma. Lancet 1999; 354: 630-5.

Updates: This article was updated in January 2003.