Review of the evidence base for the 'F' and 'E' components of the SAFE strategy for trachoma control

Community control of trachoma as a blinding disease is based on the SAFE st rategy of Surgery, Antibiotic therapy, Facial cleanliness and Environmental improvement. Surgery and antibiotic therapy currently dominate most progra mmes. Blindness from trachoma results from frequent infections repeated ove r many years, so ultimate success requires the reduction of transmission. T his is only likely to be sustainable through the F and E components of SAFE . Environmental improvement with access to water, enhanced hygiene and bett er sanitation reduces trachoma transmission and the blinding sequelae event ually disappear. Transmission routes and factors that cause this are not kn own and consequently no single specific tool for F and E is in place. Evide nce from intervention studies shows that the promotion of face-washing gave modest gains for intense effort and a pilot study showed that trachoma tra nsmission was reduced in the absence of eye-seeking flies. Other studies ha ve shown that latrines and improved access to water are associated with a l ower prevalence of active trachoma. There is likely to be a long-term benef icial effect of a combination of improved water supplies, provision of latr ines, facial hygiene promotion through established infrastructure and contr ol of eye-seeking flies. Each of these interventions offers additional publ ic health and other benefits in its own right. Further research on the rout es of transmission, the role of hygiene and means of sustainable fly contro l should be a priority.