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Elimination of trachoma: are we in danger of being blinded by the randomised controlled trial?
  1. H R Wright,
  2. J E Keeffe,
  3. H R Taylor
  1. Centre for Eye Research Australia, University of Melbourne, WHO Collaborating Centre for the Prevention of Blindness, East Melbourne Victoria, Australia
  1. Correspondence to: H R Wright CERA, Locked Bag 8, East Melbourne, Victoria 8002, Australia; h.wright2{at}

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Implementing SAFE (Surgery for trichiasis, Antibiotics for active trachoma, Facial cleanliness and Environmental improvements) strategy and mass antibiotic treatment and prevent blinding trachoma at low cost.

The past decade has seen a major reduction in the burden of infectious blindness, of which trachoma is the leading cause. Repeated infection with the obligate intracellular bacteria Chlamydia trachomatis results in the clinical syndrome of blinding trachoma. Trachoma progresses from inflammation of the upper tarsal conjunctiva to scarring; distortion of the eyelid causes trichiasis and eventual loss of vision secondary to corneal opacity. Accounting for about 7 million cases, or 15% of world blindness a decade ago, 1 trachoma now accounts for approximately 2 million cases or around 4% of the total.2 Trachoma is a disease usually associated with poor personal and community hygiene and poverty, now largely confined to the developing world. The gradual improvement in socioeconomic conditions in these nations has contributed to the decrease in the prevalence of this terrible blinding disease. However, the widespread implementation of the SAFE strategy (Surgery for trichiasis, Antibiotics for active trachoma, Facial cleanliness and Environmental improvements) has been important also.

The SAFE strategy was developed by the World Health Organization (WHO) in the 1990s and the mass distribution of antibiotics, particularly azithromycin, in communities where trachoma is endemic is an important component of this strategy. In 1999, the results of the first randomised controlled trial (RCT) that randomised at community level were published and supported community-wide treatment with oral azithromycin as being superior to community-wide treatment with topical tetracycline.3 Since then, at least four large cohort studies carried out in Tanzania,4,5 Ethiopia6 and The Gambia7 have shown reduced prevalence of chlamydial infection or clinical …

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