Samantha Bobba1,2, Sophie Phelan1, Gill Schierhout1, Hamish McManus1, Rob Menzies3, John Kaldor1

Purpose: Trachoma is the leading infectious cause of preventable blindness worldwide. As the 2020 target for eliminating trachoma approaches, evaluat- ing current evidence for the efficacy of the SAFE strategy (surgery to treat trichiasis, antibiotic ther- apy, facial cleanliness and environmental improve- ment) is timely. Our purpose was to systematically review current evidence for the efficacy of community-level interventions implementing the “A”, “F” and “E” components of the SAFE strategy in reducing trachoma prevalence.
Methods: A systemic literature review was con- ducted (Ovid MEDLINE, PubMed and EMBASE databases searched) and clinical trial registries reviewed (ClinicalTrials.gov, World Health Organi- sation International Clinical Trials Registry Platform and Cochrane Central Register of Controlled Trials). Data was extracted on the safety and efficacy of ran- domised controlled trials of mass drug administra- tion, community-level facial cleanliness and environmental interventions in reducing trachoma. Results: Twenty-two randomised controlled trials evaluating mass drug administration (n = 11), facial cleanliness (n = 3) and environmental improve- ments (n = 8) were included in the qualitative anal- ysis. Mass drug administration and utilisation of insecticide spraying as a fly control measure had the most substantial evidence for reducing active tra- choma and ocular chlamydia infection. It was diffi- cult to establish causality in assessing the efficacy of facial cleanliness initiatives.
Conclusion : To the authors’ knowledge, this is the first and most comprehensive systematic review of all community-level primary prevention compo- nents of the SAFE strategy in reducing trachoma prevalence. Further evaluation of the frequency and duration of mass drug administration and efficacy of facial cleanliness interventions is needed to guide future interventions and optimise global resource allocation.