Abstract
BackgroundSurgery, Antibiotics, Facial cleanliness and Environmental improvement (SAFE) are advocated by the World Health Organization (WHO) for trachoma control. However, few studies have evaluated the complete SAFE strategy, and of these, none have investigated the associations of Antibiotics, Facial cleanliness, and Environmental improvement (A,F,E) interventions and active trachoma. We aimed to investigate associations between active trachoma and A,F,E interventions in communities in Southern Sudan.Methods and FindingsSurveys were undertaken in four districts after 3 years of implementation of the SAFE strategy. Children aged 1–9 years were examined for trachoma and uptake of SAFE assessed through interviews and observations. Using ordinal logistic regression, associations between signs of active trachoma and A,F,E interventions were explored. Trachomatous inflammation-intense (TI) was considered more severe than trachomatous inflammation-follicular (TF). A total of 1,712 children from 25 clusters (villages) were included in the analysis. Overall uptake of A,F,E interventions was: 53.0% of the eligible children had received at least one treatment with azithromycin; 62.4% children had a clean face on examination; 72.5% households reported washing faces of children two or more times a day; 73.1% households had received health education; 44.4% of households had water accessible within 30 minutes; and 6.3% households had pit latrines. Adjusting for age, sex, and district baseline prevalence of active trachoma, factors independently associated with reduced odds of a more severe active trachoma sign were: receiving three treatments with azithromycin (odds ratio [OR] = 0.1; 95% confidence interval [CI] 0.0–0.4); clean face (OR = 0.3; 95% CI 0.2–0.4); washing faces of children three or more times daily (OR = 0.4; 95% CI 0.3–0.7); and presence and use of a pit latrine in the household (OR = 0.4; 95% CI 0.2–0.9).ConclusionAnalysis of associations between the A,F,E components of the SAFE strategy and active trachoma showed independent protective effects against active trachoma of mass systemic azithromycin treatment, facial cleanliness, face washing, and use of pit latrines in the household. This strongly argues for continued use of all the components of the SAFE strategy together.
Highlights
The World Health Organization (WHO) promotes the SAFE strategy for trachoma control (Box 1) which comprises: 1) Surgery, eyelid surgery to correct in-turned eyelashes that stops pain and minimizes risk of corneal damage [1]; 2) Antibiotics, treatment for active trachoma using single-dose oral azithromycin or tetracycline eye ointment [2]; 3) Facial cleanliness, clean faces especially in children through sustained behaviour change [3]; and 4) Environmental improvement, to increase access to water and sanitation [4]
We aimed to find out the relationship between the antibiotics, facial cleanliness, and environmental improvement (A,F,E) and active trachoma signs
Our study revealed that prevalence of active trachoma was less in children who had received treatment with azithromycin, had clean faces, had faces washed more frequently, and used latrines compared to children who had not received these interventions
Summary
The World Health Organization (WHO) promotes the SAFE strategy for trachoma control (Box 1) which comprises: 1) Surgery, eyelid surgery to correct in-turned eyelashes that stops pain and minimizes risk of corneal damage [1]; 2) Antibiotics, treatment for active trachoma using single-dose oral azithromycin or tetracycline eye ointment [2]; 3) Facial cleanliness, clean faces especially in children through sustained behaviour change [3]; and 4) Environmental improvement, to increase access to water and sanitation [4]. There is evidence from randomised controlled trials that the individual A,F,E components of the SAFE strategy have an effect on active trachoma when applied on their own: effect of antibiotics on active trachoma at three months [2]; effect of face-washing on trachomatous inflammation-intense (TI) [3]; and effect of flycontrol on active trachoma at three and six months [5,6]. In these trials, the effects of these components have been tested individually to avoid the use of hybrid interventions that generate findings that are difficult to interpret. We aimed to investigate associations between active trachoma and A,F,E interventions in communities in Southern Sudan
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