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Blinding trachoma is an infectious disease that has been challenging mankind for over 10 millennia. 1 The disease process spans the lifetime of individuals, starting as a chronic conjunctivitis caused by the Chlamidia trachomatis in early childhood. Subsequent scarring of the conjunctiva eventually causes in-turning of eye lashes in adulthood. Blindness from trachoma is due to corneal opacities caused by the rubbing of in-turned eyelashes. 2 Trachoma particularly affects isolated communities living in poverty in 55 tropical countries. 3 4 It still remains a leading cause of preventable infectious blindness accounting for 3.6% of global blindness. 5 About 40.6 and 8.2 million people suffer from active trachoma and trichiasis, respectively. 6
At present, the WHO recommends the SAFE strategy (surgery, antibiotic treatment, face washing and environmental change) as the key pathway to achieve Global Elimination of Trachoma by the year 2020. 7 Controlling trachoma was reshaped by the advent of SAFE, which provided a fresh multi-faceted combat strategy. 8 However, the impact of this comprehensive public-health intervention is not well explored.
Systematic reviewers believe that there is some evidence on the four individual components of SAFE or their combination. 9-12 However, literature on effectiveness of the whole SAFE as an intervention package is scarce. Recent comprehensive evaluations by Ngondi et al 13 14 showed that SAFE might be effective in reducing trachoma in Southern Sudan and Northern Ethiopia. The need for huge sample sizes to determine prevalence of trichiasis has so far limited evaluation of the surgical arm of SAFE.
Operational studies and program evaluations have reported encouraging progress on the implementation of SAFE. 15 16 Furthermore, SAFE is a potentially successful and cost-effective strategy. 17-19 However, trachoma can also be eventually eliminated with secular trends as it did in developed countries and even in some parts of Asia and Africa. 20 21 Perhaps, both interventions and socioeconomic development have complementary roles. 6 More evidence is needed to inform decision makers and program managers if SAFE intervention is effective.
Ethiopia has a population of 74 million, and it is one of the most trachoma-affected developing countries in the world. The national prevalence of blindness was 1.6% in 2006, to which trachoma contributed 11%. 22 The prevalence of trichiasis was 3.1%; affecting over a million people....