Dear Editor

We read with interest the recent editorial entitled "What more is there to learn about trachoma" by Melese et al.[1] Trachoma is responsible for up to 6 million cases of blindness worldwide, yet to a large extent it is a forgotten disease which affects the poorest and most medically underserved people.

The World Health Organisation (WHO) together with the International Agency for Prevention of Blindness jointly launched "VISION 2020 – the right to sight" in 1999 which aims to eliminate avoidable blindness by the year 2020, including blindness from trachoma. WHO has endorsed "SAFE" (Surgery for trichiasis, Antibiotics to reduce the prevalence of chlamydial infection, and Facial cleanliness and Environmental change to reduce the disease transmission) as the strategy implemented by national programmes to achieve the elimination of blinding trachoma. We have recently undertaken a review of the evidence base of the SAFE strategy and judged it to be strong for the surgery and antibiotics components, but weaker for the other components.[2] We therefore concur with the opinion of Melese et al. that more research is required, not only to develop a protocol for the rational use of antibiotics, as they suggest, but also to strengthen the evidence relating to the ‘F’ and ‘E’ components.

The SAFE strategy has been implemented by the national trachoma control programmes of many endemic countries in Africa, Asia and Latin America with varying degrees of success. Melese et al make the observation that the experiences gained from research studies are not directly transferable to real life settings; the need, therefore, is for the publication of the experiences of countries that have successfully dealt with trachoma through implementation of the SAFE strategy to serve as a best practice model for other countries. Morocco is a good example. A decade ago trachoma was a public health problem in five provinces of Morocco, but with the efficient implementation of the SAFE strategy the prevalence of active trachoma and trichiasis have declined dramatically so that Morocco is now close to eliminating trachoma as a public health problem.[3] Real life country examples such as Morocco documented as case studies allow policy makers and programme managers to learn from the mistakes and successes of public health programmes, because, as Melese et al. point out, real life is messier and more complicated than research studies.

References

(1) Melese M, Alemayehu W, Gaynor B, Yi E, Whitcher JP, Lietman TM. What more is there to learn about trachoma? Br J Ophthalmol 2003;87:521- 522.

(2) Kuper H, Solomon AW, Buchan J, Zondervan M, Foster A, Mabey D. A critical review of the SAFE strategy for the prevention of blinding trachoma. Lancet Infect Dis, in press.

(3) Ferriman A. Blinding trachoma almost eliminated from Morocco. BMJ 2001;323;1387.