We investigated whether face washing prevents active trachoma in endemic communities.
Trachoma is an eye disease caused by bacterial infection. Active infection usually begins in childhood and is characterized by eye discharge, redness and irritation. Poor facial hygiene can lead to the disease spreading from person to person through eye-seeking flies or contaminated fingers. Face washing is promoted as part of the World Health Organization 'SAFE' strategy to eliminate blindness around the world. Face washing is simple and rational, but its effectiveness to reduce transmission of trachoma is uncertain.
We included two randomized controlled trials with a total of 2560 participants set in Australia and Tanzania. One trial compared a combined strategy of face washing plus tetracycline (an antibiotic) ointment with tetracycline ointment alone for up to one year. The second trial compared four intervention groups for three months in children who already had follicular trachoma: a combined strategy of face washing plus tetracycline eye drops, face washing alone, tetracycline eye drops alone, and no treatment. The evidence is current to January 2015.
Both trials reported the number of children with active trachoma as an outcome measure; one trial also reported the number of children with severe trachoma and the percentage of clean faces after one year. One trial reported that face washing was effective in increasing facial cleanliness and in reducing severe trachoma at one year; the second trial did not show that eye washing alone or in combination with tetracycline eye drops reduced follicular trachoma amongst children who had follicular trachoma at time of enrollment.
Quality of evidence
The two included trials were of uncertain risk of bias due to not reporting many aspects of the trial designs.
There is evidence from one trial that face washing combined with topical tetracycline may be effective in reducing severe active trachoma and in increasing the prevalence of clean faces at one year follow-up. Current evidence is inconclusive as to the effectiveness of face washing alone or in combination with topical tetracycline in reducing active or severe trachoma.
Trachoma remains a major cause of avoidable blindness among underprivileged populations in many developing countries. It is estimated that about 146 million people have active trachoma and nearly six million people are blind due to complications associated with repeat infections.
The objective of this review was to assess the effects of face washing promotion for the prevention of active trachoma in endemic communities.
We searched CENTRAL (which contains the Cochrane Eyes and Vision Group Trials Register) (2015, Issue 1), Ovid MEDLINE, Ovid MEDLINE In-Process and Other Non-Indexed Citations, Ovid MEDLINE Daily, Ovid OLDMEDLINE (January 1946 to January 2015), EMBASE (January 1980 to January 2015), PubMed (January 1948 to January 2015), Latin American and Caribbean Health Sciences Literature Database (LILACS) (January 1982 to January 2015), the metaRegister of Controlled Trials (mRCT) (www.controlled-trials.com) (accessed 10 January 2014), ClinicalTrials.gov (www.clinicaltrials.gov) and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en). We did not use any date or language restrictions in the electronic searches for trials. We last searched the electronic databases on 26 January 2015.
To identify further relevant trials we checked the reference lists of the included trials. Also, we used the Science Citation Index to search for references to publications that cited the trials included in the review. We contacted investigators and experts in the field to identify additional trials.
We included randomized controlled trials (RCTs) or quasi-RCTs that compared face washing with no treatment or face washing combined with antibiotics against antibiotics alone. Trial participants were residents of endemic trachoma communities.
Two review authors independently extracted data and assessed trial quality. We contacted trial authors for additional information when needed. Two trials met our inclusion criteria; but we did not conduct meta-analysis due to methodological heterogeneity.
We included two cluster-RCTs, which provided data from 2447 participants. Both trials were conducted in areas endemic to trachoma: Northern Australia and Tanzania. The follow-up period was three months in one trial and 12 months in the other; both trials had about 90% participant follow-up at final visit. Overall the quality of the evidence is uncertain due to the trials not reporting many design methods and the differences in outcomes reported between trials.
Face washing combined with topical tetracycline was compared with topical tetracycline alone in three pairs of villages in one trial. The trial found that face washing combined with topical tetracycline reduced 'severe' active trachoma compared with topical tetracycline alone at 12 months (adjusted odds ratio (OR) 0.62, 95% confidence interval (CI) 0.40 to 0.97); however, the trial did not find any important difference between the intervention and control villages in reducing other types of active trachoma (adjusted OR 0.81, 95% CI 0.42 to 1.59). Intervention villages had a higher prevalence of clean faces than the control villages among children with severe trachoma (adjusted OR 0.35, 95% CI 0.21 to 0.59) and any trachoma (adjusted OR 0.58, 95% CI 0.47 to 0.72) at 12 months follow-up. The second trial compared eye washing to no treatment or to topical tetracycline alone or to a combination of eye washing and tetracycline drops in children with follicular trachoma. At three months, the trial found no evidence of benefit of eye washing alone or in combination with tetracycline eye drops in reducing follicular trachoma amongst children with follicular trachoma (risk ratio (RR) 1.03, 95% CI 0.96 to 1.11; one trial, 1143 participants).