Bulletin of the World Health Organization

The SAFE strategy for trachoma control: using operational research for policy, and implementation

Paul M Emerson, Matthew J Burton, Anthony W Solomon, Robin Bailey, and David CW Mabey


Trachoma is a neglected disease and also the world’s leading infectious cause of blindness. It causes misery, dependency and is a barrier to development. Trachoma is controlled by a WHO-endorsed integrated strategy of surgery for trichiasis, antibiotic therapy, facial cleanliness and environmental improvement, which is known by the acronym SAFE. The strategy is based on evidence from field trials and is continually being refined by operational research that informs national policy and planning; the strategy has affected both programme delivery and implementation. As a result of the findings of operational research, surgery is now frequently conducted by paramedics in communities rather than by ophthalmologists in hospitals; yearly mass distribution of a single oral dose of azithromycin has replaced the use of topical tetracycline; and the promotion of better hygiene, face-washing and the use of latrines are used to reduce transmission. Those who implement programmes have been equal partners in conducting operational research thus reducing the “know–do” gap and minimizing the lag that often exists between the completion of trials and putting their results into practice. Operational research has become a part of practice. Although there are still many questions without answers, national programme coordinators have a reasonable expectation that trachoma control programmes based on SAFE will work.