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SAFE method to eliminate blinding trachoma by 2020
Mapping and SAFE programs must be underway before 2015 in many countries.
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The World Health Organization has recommended the SAFE strategy to push for the elimination of blinding trachoma by 2020, according to a physician.
“We are very excited that trachoma is on the radar screen, and we have hopes for 2020,” Sheila K. West, PhD, said at the American Ophthalmology Society annual meeting.
Trachoma is a chronic conjunctivitis caused by repeated episodes of infection with Chlamydia trachomatis, according to West.
“We think of trachoma as a disease of communities because we need that milieu where ongoing transmission is constant,” she said.
“Scarring occurs with repeated episodes of infection, and with worsening scarring, you get entropion. When entropion gets severe enough, as those eyelashes are dragged underneath the eyelid, you get these in-turned lashes that scrape across the cornea and lead to blinding complications,” West said.
The World Health Organization has endorsed a multifaceted intervention for global elimination of trachoma called the SAFE strategy, which is an approach that targets the clinical signs, she said. The components include surgery for trichiasis, antibiotics, face washing and environmental change that interrupts transmission.
Surgery
West said that trichiasis surgery can improve vision as well as quality of life and can be acceptably performed by medical assistants and eye nurses.
“This is critical that we have a surgical technique that can be done by people who are in these communities,” she said. “In addition, we have recently shown that postsurgical treatment with a single dose of azithromycin can reduce the recurrence of trichiasis by almost 30%,” she said.
The greatest challenge with surgery is recurrence.
“Sometimes 20% to 80% of patients will develop recurrent trichiasis within 6 months after surgery, suggesting there’s a real problem with the surgery that’s being done,” West said.
Currently, the acceptance of surgery for trachomatous trichiasis is low, well-trained manpower is scarce and supervision is still an issue; therefore, West said a camp approach is likely needed to meet the 2020 goal.
“We estimated the need for surgeries to eliminate the trichiasis backlog by 2020,” West said. “We’ll need 15,000 surgeries a year in Tanzania. Last year they did 1,400, so we are way behind in trying to reach that goal.”
To improve outcomes, good training and certification of trachomatous trichiasis surgeons is needed.
“We need countries to step up and decertify these trachomatous trichiasis surgeons who are not performing well, and we need to institute better systems of surgical audit that make these people accountable for what they do,” she said.
Antibiotics
As the result of a donation program from Pfizer, single doses of azithromycin are offered once a year to everyone in communities or districts where trachoma is present in more than 10% of the population 1 to 9 years old, West said. This treatment is critical in reducing the community pool of infection.
However, in areas where high coverage cannot be attained, these annual treatments could be needed for up to 10 years, according to West. And the greatest need for high coverage of antibiotics — at least 80% —is in children, she said.
West said concerns exist regarding when and how to stop treatment.
“We need to have a better idea of what will happen when mass treatment with antibiotics is stopped in these formerly hyperendemic communities,” West said.
“If hygiene programs and environmental improvement have also been implemented, re-emergence is unlikely,” she said.
“We cannot afford failure,” West said.
Face washing, environmental change
Many cross-sectional surveys have been published associating trachoma with unclean faces, flies, absence of latrines, and lack of clean water and appropriate environmental sanitation, West said. To engage these components, it is necessary to involve new partners beyond health agencies, including, for example, school administrations and sanitation agencies in areas where trachoma is prevalent.
To meet the needs of trachoma elimination by 2020, SAFE trachoma programs need to be established before 2015 in many countries, and the possibility of trachoma re-emergence, as well as causes that hinder the elimination progress, must be understood, according to West.
“With the increasing interest in neglected tropical diseases, there is an increasing number of partners coming on board now with funds, and that has really energized the push toward elimination,” she said – by Christi Fox