Marcia Zondervan

A critical review of the SAFE strategy for the prevention of blinding trachoma

Trachoma is an ocular disease caused by repeated infection with Chlamydia trachomatis. It is the leading cause of infectious blindness globally, responsible for 5.9 million cases of blindness. Although trachomatous blindness is untreatable, it is eminently possible to prevent and the World Health Organization promotes the use of the SAFE strategy (surgery to treat end-stage disease, antibiotics to reduce the reservoir of infection, facial cleanliness, and environmental improvement to reduce transmission of C trachomatis) for this purpose. In this review we have assessed the evidence base supporting the elements of the SAFE strategy. We find strong support for the efficacy of the surgery and antibiotics components, although the optimal antibiotic regimens have not yet been established. The evidence for an effect of health education and environmental improvement is weaker, and depends mostly on cross-sectional observational studies.

Participatory evaluations of trachoma control programmes in eight countries

Objectives  Trachoma is a major cause of blindness. The objective of this initiative was to conduct participatory process evaluations of the trachoma control programmes receiving support from the International Trachoma Initiative in eight countries.

Effects of intervention with the SAFE strategy on trachoma across Ethiopia

Background/Aims The impact of the SAFE strategy (surgery, antibiotics, face washing, environmental hygiene), recommended to eliminate blinding trachoma, is not well explored. We determined the operational effectiveness of the whole SAFE intervention package. Methods Analytical cross-sectional trachoma surveys were conducted in four program areas across Ethiopia before and after 3 years of intervention with the SAFE strategy. A total of 8358 children 1–9 years, 4684 people above 14 and 3572 households were assessed in the follow-up evaluations using methodologies recommended by the WHO. Effects were measured by comparing follow-up proportions with baseline estimates of four key indicators. Results Coverage was 36% for trichiasis surgery, 59% for antibiotic and 57% for health-promotion services. Prevalence of trachoma trichiasis (TT) decreased from 4.6% (95% CI: 3.6% to 5.8%) down to 2.9% (CI: 2.1% to 3.9%). Prevalence of trachoma inflammation-follicular (TF) dropped from 36.7% (33.9% to 39.6%) to 18.4% (CI: 15.4% to 21.8%). The proportion of unclean faces and households not using latrines fell from 72.8% (68.9% to 76.4%) and 74.5% (69.9% to 78.7%) down to 47.0% (CI: 43% to 51%) and 51.7% (47.2% to 56.2%), respectively. All the reductions related with antibiotic (TF), face washing (clean face) and environmental (latrine) components were statistically significant except for Surgery (TT). Conclusions Considerable decline in the magnitude of trachoma and its risk factors was observed in areas where the SAFE strategy was implemented. The coverage of services should be maintained or improved in order to eliminate blinding trachoma by the year 2020.

Clinicopathological review of ocular surface squamous neoplasia in Malawi

Background Ocular surface squamous neoplasia (OSSN) is the most common cause of malignancy of the conjunctiva. Variable clinical presentation means that invasive malignant OSSN is often difficult to discriminate from other similarly presenting differential diagnoses which can be managed more conservatively. Aims Identification of clinical factors associated with a histopathological diagnosis of conjunctival squamous cell carcinoma (SCC). Methods Prospective consecutive case series of suspected OSSN cases presenting at two hospitals in Central Malawi over a 1 year period. A pro forma was completed assessing preidentified clinical variables. Suspected lesions underwent excisional biopsy followed by histopathological investigation. Results Fifty-eight patients were recruited. Mean age was 35.8 (range 22–62). 51 cases of histopathologically confirmed OSSN were found. 30 (50%) patients were confirmed HIV seropositive which rose to 86.67% in invasive SCC. Larger size of tumour (p=0.008), male gender (p=0.025) and HIV seropositivity (p=0.010) were associated with invasive SCC pathology. Conclusions A clinicopathological study of OSSN has not previously been performed in Malawi. The association of HIV with SCC corresponds to previous reports from sub-Saharan Africa. A new finding in our study is a relationship between larger tumour size and invasive lesions confirmed by histopathology. When integrated into a clinical decision-making model, tumour area provides a simple clinical measure for ophthalmic practitioners to use in order to differentiate higher risk OSSN from more benign pathology. The higher risk lesions can subsequently be treated with greater surgical care and undergo closer follow-up.

PLANNING AND DEVELOPING SERVICES FOR DIABETIC RETINOPATHY IN SUB-SAHARAN AFRICA

BACKGROUND Over the past few decades diabetes has emerged as an important non-communicable disease in Sub-Saharan Africa (SSA). Sight loss from Diabetic Retinopathy (DR) can be prevented with screening and early treatment. The objective of this paper is to outline the required actions and considerations in the planning and development of DR screening services. METHODS A multiple-case study approach was used to analyse five DR screening services in Botswana, Ghana, Tanzania and Zambia. Cases included: two regional screening programmes, two hospital-based screening services and one nationwide screening service. Data was collected using qualitative methodologies including: document analysis, in-depth interviews and observation. The World Health Organization (WHO) Health Systems Framework was adopted as the conceptual framework for analysis. RESULTS Planning for a sustainable and integrated DR screening programme demanded a health systems approach. Collaboration with representatives from a variety of ministerial departments and professional bodies was required. Evolution of DR screening services may occur in a variety of ways including: increasing geographical coverage, integration into the general healthcare system, and stepwise progression from a passive, opportunistic service to one that systematically and proactively seeks to prevent DR. Lessons learned from the implementation of cervical cancer prevention programmes in resource-poor settings may assist the development of DR programmes in similar settings. CONCLUSION To promote good planning of DR screening services and ensure limited resources are used effectively, there is a need to learn from screening programmes in other medical specialities and a need to share experiences between newly-developing DR programmes in resource-poor countries. The WHO Health Systems Framework presents an invaluable tool to ensure a systematic approach to planning DR screening services.

Trachoma: a review

determine the optimum age for cataract surgery, the best surgical techniques and the most effective method of correcting aphakia in children. These studies will need a large enough sample size and long enough follow-up period to be able to determine significant outcomes and long-term complications. A rapid assessment method for childhood blindness needs to be developed to plan timely, effective and targeted interventions to control childhood blindness.

Analysis of an international collaboration for capacity building of human resources for eye care: case study of the college-college VISION 2020 LINK

BackgroundThere is an extreme health workforce shortage in Eastern, Central, and Southern Africa. Shortage of eye care workers impedes effective implementation of prevention of blindness programs. The World Health Organization has identified education, partnership, leadership, financing, and policy as intertwined interventions that are critical to resolving this crisis on the long term.Case presentationThe VISION 2020 LINK between the College of Ophthalmology of Eastern, Central, and Southern Africa and the Royal College of Ophthalmologists in the United Kingdom aims to increase the quantity and quality of eye care training in East, Central, and Southern Africa through a focus on five strategic areas: fellowship examination for ophthalmologists, training the trainers, curriculum development for residents in ophthalmology and ophthalmic clinical officers, continuous professional development (CPD), and mentoring program for young ophthalmologists. This study examined how education and partnership can be linked to improve eye care, through an evaluation of this north-south link based on its own targets and established frameworks to guide north-south links.MethodsAn exploratory qualitative case study design was used. Twenty-nine link representatives were recruited through purposive sampling and snowballing. Face-to-face interviews were conducted using a semi-structured interview schedule that incorporated the components of a successful link from an existing framework. Documents pertaining to the link were also examined. Thematic analysis was used for data analysis.ResultsThe findings revealed that the perception to the contribution of the link to eye care in the region is generally positive. Process indicators showed that the targets in three strategic objectives of the link have been achieved. Framework-based evaluation also showed that the link is successful. Mutual learning and development of friendships were the most commonly identified success factors. Inadequate awareness of the link by college members is a key challenge.ConclusionThe study concludes that the link is active and evolving and has achieved most of its targets. Further developments should be directed to influence health system strengthening in Eastern, Central, and Southern Africa more strategically. The study recommends expansion of the scope of collaboration to involve multiple health system building blocks.

Trachoma visual impairment in a SAFE area in Ethiopia

Summary A cross-sectional survey of visual impairment (VI) was undertaken in the Enemor district in Southern Ethiopian where five years of trachoma control programme has been implemented using the SAFE (Surgery, Antibiotics, Face washing, Environmental hygiene) strategy. The prevalence of VI (presenting visual acuity in the better eye <6/18) in 451 people above 40 years of age was 22% (CI:17.6 to 27.6) and most of it was accounted for by cataract (67%) and trachoma (13%). Whereas cataract remains a prominent cause, contribution of trachoma among leading causes of VI is declining in communities where SAFE strategy has been implemented.

A tool for planning retinoblastoma services in sub‐Saharan Africa

Cancer care remains inadequate in low‐middle income countries (LMICs). Children with cancer have 80% chance of surviving in high‐income countries compared to 20% in LMICs. Retinoblastoma (RB), an aggressive eye cancer of childhood and top childhood cancer in sub‐Saharan Africa (SSA), has a low survival rate, due to a delay in diagnosis and abandonment of treatment. The purpose of this study is to provide a tool for planning human resources required to manage RB in SSA.