Stronger-SAFE

The World Health Organisation recommended approach for tackling trachoma is SAFE: Surgery for trichiasis, Antibiotics to treat infection, promotion of Facial cleanliness and Environmental improvements to supress transmission of infection.

Despite the implementation of this strategy in areas around the world, trachoma remains an endemic disease, with 103 million people living in trachoma-endemic areas, and 1.9 million people living with blindness from the condition.

With this in mind, strategies are needed to ensure that trachoma is addressed as comprehensively as possible. Stronger-SAFE launched in 2018, as a multi-year research project with three main aims:

1. Increasing our understanding of how trachoma is transmitted

2. Developing strategies for improved trachoma control

3. Testing these strategies in a trachoma endemic population in a clinical trial

Transmission was assessed by testing people and household objects for C. Trachomatis, observing contact behaviours and the behaviour of flies on people’s faces. People’s eyes, face, hands and clothing as well as flies and household objects were tested to understand in much greater detail than previously attempted where the bacterium could be detected to identify putative transmission routes.

Fly control and WASH (water, sanitation and hygiene) interventions were then co-designed with the local communities and stakeholders.

In the main trial, we randomised 68 clusters (around 45,000 people) to test whether enhanced azithromycin treatment combined with targeted transmission-interrupting strategies (the interventions developed in phase 2) could more effectively eliminate trachoma than current approaches.

The project recently came to a close, finding that:

• The WHO-recommended SAFE strategy remains effective and continues to substantially reduce Ct levels. Standard SAFE methods with a single annual Mass Drug Administration can successfully reduce infection when implemented with good coverage
• Enhanced interventions (Stronger SAFE), including increasing MDA to two doses given two weeks apart, did not provide additional benefit over standard SAFE. There was no significant difference between trial arms in terms of Ct prevalence, load or signs of clinical trachoma. Overall, Ct prevalence was reduced by approximately 80% from baseline
• The trial strengthens evidence on transmission pathways and showed an increase in face washing with soap following interventions that were co-developed with the community 
• Programme priorities should focus on improving coverage, quality, and adherence to SAFE 
• We were able to identify the most frequent extra-ocular sites where C.trachomatis can be detected. These included faces and hands of individuals, particularly younger children (age 2-9), and on flies. This provides a clear map for transmission routes – to inform approaches to interrupt transmission
• Washing faces with soap was more effective at removing ocular discharge, a reservoir of C. Trachomatis
• Scarves treated with permethrin (an insect repellent) were effective at repelling flies from faces

Watch a video on the project here: https://youtu.be/YqeIsBZ7aSc

Find out more about Stronger-SAFE here: https://www.lshtm.ac.uk/research/centres-projects-groups/stronger-safe