Richard Le Mesurier

The Global Trachoma Mapping Project: Methodology of a 34-Country Population-Based Study

ABSTRACT Purpose: To complete the baseline trachoma map worldwide by conducting population-based surveys in an estimated 1238 suspected endemic districts of 34 countries. Methods: A series of national and sub-national projects owned, managed and staffed by ministries of health, conduct house-to-house cluster random sample surveys in evaluation units, which generally correspond to “health district” size: populations of 100,000–250,000 people. In each evaluation unit, we invite all residents aged 1 year and older from h households in each of c clusters to be examined for clinical signs of trachoma, where h is the number of households that can be seen by 1 team in 1 day, and the product h × c is calculated to facilitate recruitment of 1019 children aged 1–9 years. In addition to individual-level demographic and clinical data, household-level water, sanitation and hygiene data are entered into the purpose-built LINKS application on Android smartphones, transmitted to the Cloud, and cleaned, analyzed and ministry-of-health-approved via a secure web-based portal. The main outcome measures are the evaluation unit-level prevalence of follicular trachoma in children aged 1–9 years, prevalence of trachomatous trichiasis in adults aged 15 + years, percentage of households using safe methods for disposal of human feces, and percentage of households with proximate access to water for personal hygiene purposes. Results: In the first year of fieldwork, 347 field teams commenced work in 21 projects in 7 countries. Conclusion: With an approach that is innovative in design and scale, we aim to complete baseline mapping of trachoma throughout the world in 2015.

A Global Survey of Low Vision Service Provision

Purpose: To conduct a global survey of low vision services to describe the needs, priorities, and barriers in provision and coverage. Methods: Data were mainly derived from a survey and from some secondary sources. The survey was distributed to Vision 2020 contacts, government, and non-government organizations (NGOs) in 195 countries during 2006–2008. Themes in the survey were: epidemiology of low vision, policies on low vision, provision of services, human resources, barriers to service delivery, equipment availability, and monitoring and evaluation of service outcomes. Contradictory and/or incomplete data were returned for further clarification and verification. The Human Poverty Index was used to compare the findings from developed and developing countries. Results: Service availability was established for 178/195 countries, with 115 having some low vision service. Approximately half the countries in the African and Western Pacific regions have no services. Few countries have >10 low vision health professionals per 10 million of population. In many of the countries NGOs were the main providers and funders. Funding and awareness were frequently cited as barriers to service access. Women, people with disabilities, and rural dwellers were less likely to access services. There were few reports of monitoring and evaluation into the quality and impact of services. Conclusion: This global survey provides the first consolidated baseline of low vision service provision. Where data are available, coverage of services is generally poor. Low vision health professional numbers are low. Services in over half of the world’s countries are funded by NGOs, raising issues of sustainability.

Low Prevalence of Conjunctival Infection with Chlamydia trachomatis in a Treatment-Naïve Trachoma-Endemic Region of the Solomon Islands

Background Trachoma is endemic in several Pacific Island states. Recent surveys across the Solomon Islands indicated that whilst trachomatous inflammation—follicular (TF) was present at levels warranting intervention, the prevalence of trachomatous trichiasis (TT) was low. We set out to determine the relationship between chlamydial infection and trachoma in this population. Methods We conducted a population-based trachoma prevalence survey of 3674 individuals from two Solomon Islands provinces. Participants were examined for clinical signs of trachoma. Conjunctival swabs were collected from all children aged 1–9 years. We tested swabs for Chlamydia trachomatis (Ct) DNA using droplet digital PCR. Chlamydial DNA from positive swabs was enriched and sequenced for use in phylogenetic analysis. Results We observed a moderate prevalence of TF in children aged 1–9 years (n = 296/1135, 26.1%) but low prevalence of trachomatous inflammation—intense (TI) (n = 2/1135, 0.2%) and current Ct infection (n = 13/1002, 1.3%) in children aged 1–9 years, and TT in those aged 15+ years (n = 2/2061, 0.1%). Ten of 13 (76.9%) cases of infection were in persons with TF or TI (p = 0.0005). Sequence analysis of the Ct-positive samples yielded 5/13 (38%) complete (>95% coverage of reference) genome sequences, and 8/13 complete plasmid sequences. Complete sequences all aligned most closely to ocular serovar reference strains. Discussion The low prevalence of TT, TI and Ct infection that we observed are incongruent with the high proportion of children exhibiting signs of TF. TF is present at levels that apparently warrant intervention, but the scarcity of other signs of trachoma indicates the phenotype is mild and may not pose a significant public health threat. Our data suggest that, whilst conjunctival Ct infection appears to be present in the region, it is present at levels that are unlikely to be the dominant driving force for TF in the population. This could be one reason for the low prevalence of TT observed during the study.

Management of refractive errors

Uncorrected refractive error accounts for half of the global burden of avoidable vision impairment and nearly a third of the global burden of avoidable blindness.1 2 Globally, 153 million people have visual impairment or are blind due to uncorrected refractive error and the majority live in low income countries.1 Additionally, 410 million people have difficulty with near tasks because they lack reading glasses.2 Interventions to treat refractive error, such as spectacles, are cost-effective and in high income settings are readily accessible, but refractive errors are often not diagnosed or referred and barriers to the use of services exist.1 Under-corrected refractive error can account for as much as 75% of all impairment of vision in high income countries 1 3 4 5 and it may markedly affect quality of life.5 Minor reduction in vision (<6/12 or just below the driving standard) has been associated with an increased risk of death and physical, social, and psychological problems in people older than 50 years (box 1).6 w1-7 The global economic impact of uncorrected refractive error is an estimated 268.8 billion international dollars, based on population and economic data combined with a meta-analysis of prevalence studies.7 We provide an overview of the public health significance of refractive error, its management, and referral strategies for primary care practitioners. #### Box 1 Consequences of minor vision impairment (<6/12) in people older than 50 years ##### Increased social isolation ##### Increased morbidity ##### Increased mortality #### Sources and selection criteria In October 2008 and May 2009 we searched the Cochrane Collaboration database for reviews and clinicaltrials.gov for current trials, returning 420 studies. We also searched Medline and PubMed for articles published between 1 January 2000 and 1 May 2009, using MESH terms and combinations including …

Validation of a quality of life questionnaire in the Pacific Island.

Purpose: To adapt an existing validated quality of life instrument, the Impact of Vision Impairment (IVI) questionnaire for Pacific Island countries. Methods: Following in-depth interviews (n = 24) and a pilot study (n = 67), the original 32-item IVI questionnaire was translated and adapted in Vanuatu. The Melanesian IVI (IVI_M) was administered to participants not previously involved in the pilot study (n = 189). Results: Participants included 117 (62%) with mild, moderate or severe vision impairment, 39 with unilateral loss and 33 with normal vision. Eighty-six percent of the original 32-items were deemed relevant by 90% of participants. Items displaying floor effects were removed (4), 2 were combined and 3 items rephrased to reflect Melanesian-specific activities, resulting in a 23-item IVI_M. Nineteen items were relevant to both the Melanesian and Australian contexts including all 8 items related to the emotional reaction to vision loss. IVI_M demonstrated content and construct validity, reliability and discriminated visually healthy populations from those with vision impairment. Vision impairment of < 6/18 negatively effected quality of life. Conclusion: While the adaptation process demonstrated the need for culturally relevant instruments, it also highlighted the value of adapting existing validated instrument for use in cross-cultural research rather than developing a new instrument from first principles.

Towards standards of outcome quality: a protocol for the surgical treatment of cataract in developing countries

routinely above 1.0 DS – arguably does not fulfil the obligations of surgical aftercare. Consistently poor outcomes are not tolerated in developed countries. Surgeon training, professional bodies, educated consumers, indemnity issues, funding providers, legislative constraints, preferred practice guidelines, and a free and active media probably all contribute to this. In developing countries, however, there is seldom such scrutiny. Some surgeons mistakenly equate this with a tolerance of lesser standards and an attitude that patients are lucky to be receiving any treatment, whatever the outcome. The evidence is that cataract surgical service provider self-regulation frequently does not work in developing countries. Until the health and medical milieux mature in these countries, to the point that there are similar protective mechanisms as occur in developed countries, there is a need to find other means of patient protection. The first of these might be for the local ministry of health to strengthen its capacity to undertake more effective workforce monitoring and control. With this, visiting surgical teams would be less inclined and able to bypass, as frequently occurs now, those responsible for health outcomes in the community. The ministry would also be better able to engage with local surgeons in its employ. The second might be to require surgeons to adopt ‘essential practice requirements’ for the interventions they perform, such as cataract surgery in adults. In the absence of a strong local evidence base, these protocols should be grounded in collective experience. Although they should be amenable to consultative change, adherence to them should be compulsory, avoiding ‘circumstances’ as the justification for any expediency with any outcome. Later, as health care and its delivery advance and resources are more plentiful, the essential requirements may be replaced with evidence-based preferred practice guidelines, which allow practitioner discretion and are more responsive to individual patient need. Third, monitoring of activity and outcomes should be mandatory to ensure that protocols are used and standards are met. 7,8,10 In the case of cataract surgery, this may be done manually or otherwise, and should involve both the practitioner and the health ministry. For the sake of illustration and presentation, these three elements have been combined into a single protocol for cataract surgery in adults (Appendix I). Realizing that local circumstances may require some variation, and that not all of the elements may be enacted immediately, four ministries of health in the Pacific region are currently considering its adoption. The authors commend this approach to ministries of health, surgeons and others interested in finding solutions to the problem of securing quality health outcomes in developing countries.

Cataract Surgical Outcomes from a Large-scale Micro-surgical Campaign in China

Abstract Purpose: To assess cataract surgical outcomes during the Jiangxi Provincial Government’s “Brightness and Smile Initiative” (BSI) in South East China during May 2009 to July 2010. Method: This cross sectional combined with retrospective study included 1157 cataract surgical patients (1254 eyes) recruited from six counties in Jiangxi during the initiative. Patient information before surgery and at discharge was obtained from hospitals’ case records. Patient follow-up eye examinations were conducted during field visits in the autumn of 2010. Fifteen months after the initiative started, study subjects were examined by provincial ophthalmologists using a Snellen visual chart, portable slit lamp, torch and ophthalmoscope. The World Health Organization (WHO) cataract surgical outcome monitoring tally sheet and the outcome categories good (visual acuity, VA, ≥0.3 (6/18)), borderline (VA <0.3 but ≥0.1 (6/60)) and poor (VA < 0.1) were used for data collection and analysis. Results: A total of 99.7% of operated patients had intraocular lenses implanted. The percentage of eyes with good outcomes (presenting VA) at follow-up was low (49.6%), while the borderline and poor outcome rates were high (34.1% and 16.3%, respectively), in comparison to WHO recommendations. There was a significant outcome difference at follow-up (p < 0.01) between eyes operated by county surgeons trained by an International Non-Government Organization and those operated on by other visiting surgeons. Conclusions: This study documented a low rate of good cataract surgical outcomes from the BSI in Jiangxi. The quality of cataract surgery should be improved further in the province.

Prevalence of signs of trachoma, ocular Chlamydia trachomatis infection and antibodies to Pgp3 in residents of Kiritimati Island, Kiribati.

Objective In some Pacific Island countries, such as Solomon Islands and Fiji, active trachoma is common, but ocular Chlamydia trachomatis (Ct) infection and trachomatous trichiasis (TT) are rare. On Tarawa, the most populous Kiribati island, both the active trachoma sign “trachomatous inflammation—follicular” (TF) and TT are present at prevalences warranting intervention. We sought to estimate prevalences of TF, TT, ocular Ct infection, and anti-Ct antibodies on Kiritimati Island, Kiribati, to assess local relationships between these parameters, and to help determine the need for interventions against trachoma on Kiribati islands other than Tarawa. Methods As part of the Global Trachoma Mapping Project (GTMP), on Kiritimati, we examined 406 children aged 1–9 years for active trachoma. We collected conjunctival swabs (for droplet digital PCR against Ct plasmid targets) from 1–9-year-olds with active trachoma, and a systematic selection of 1–9-year-olds without active trachoma. We collected dried blood spots (for anti-Pgp3 ELISA) from all 1–9-year-old children. We also examined 416 adults aged ≥15 years for TT. Prevalence of TF and TT was adjusted for age (TF) or age and gender (TT) in five-year age bands. Results The age-adjusted prevalence of TF in 1–9-year-olds was 28% (95% confidence interval [CI]: 24–35). The age- and gender-adjusted prevalence of TT in those aged ≥15 years was 0.2% (95% CI: 0.1–0.3%). Twenty-six (13.5%) of 193 swabs from children without active trachoma, and 58 (49.2%) of 118 swabs from children with active trachoma were positive for Ct DNA. Two hundred and ten (53%) of 397 children had anti-Pgp3 antibodies. Both infection (p<0.0001) and seropositivity (p<0.0001) were strongly associated with active trachoma. In 1–9-year-olds, the prevalence of anti-Pgp3 antibodies rose steeply with age. Conclusion Trachoma presents a public health problem on Kiritimati, where the high prevalence of ocular Ct infection and rapid increase in seropositivity with age suggest intense Ct transmission amongst young children. Interventions are required here to prevent future blindness.

Ocular trauma in the Solomon Islands.

Following eye trauma in Papua New Guinea, there is frequently a poor visual outcome with 60% having a visual acuity of less than 6/60 in the injured eye. The factors predisposing the Solomon Islanders to poor visual outcome after eye trauma also exist elsewhere in the Pacific. There is often a delay in obtaining ophthalmic care: primary surgical repair for penetrating trauma and the timely application of intensive appropriate topical ocular antibiotics. The reasons for this delay include a lack of community eye health awareness (with patients often presenting when the vision has deteriorated), long distances on foot or by canoe to primary healthcare centres, inconsistent and expensive transport systems and lack of appropriate medication at many primary, district and even provincial clinics. Also there is a common fear of hospitals and faith in traditional health workers (THWs). After eye injuries, most patients admit to self-medicating with substances such as the skin of the betel nut, freshly squeezed plant juice or breast milk. Breast milk, although initially sterile is sticky, attracts flies and provides a media for microbial growth. Others consult THWs, believing their ‘kastom meresin’ is more effective. However, traditional eye medicines have an unknown content, concentration, pH and are non-sterile. Other factors that may predispose the eye to infection are the faecal contamination of the ocean surrounding most coastal villages, compromised personal hygiene due to the shortage of running water and the humid climate promoting fungal infection. Thylefors argued that in the developing world superficial corneal injury, which occurs as a result of agricultural work, often leads to rapidly progressive corneal ulceration and subsequent visual loss and has been overlooked as a worldwide cause of monocular blindness. Corneal opacity secondary to trauma has been termed the ‘silent epidemic’ and corneal opacity is the source of 39–70% of monocular blindness worldwide. Indeed a report by the World Health Organization in 2002 lists corneal opacity as the second major cause of blindness in Tonga. However, Tonga and Vanuatu were the only two countries with available data from the Pacific from 1991 and 1989, respectively. Considering the importance of corneal scarring, there are few studies evaluating the aetiological factors predisposing a population to corneal infection secondary to trauma. Upadhyay et al. reported in Nepal if trivial corneal abrasions were treated within 18 h of injury with 1% chloramphenicol 96% healed without developing an ulcer. However, 28.6% developed a corneal ulcer if the treatment was delayed 25–48 h. Furthermore, as public health programmes have become more effective in reducing the prevalence of the traditional causes of corneal blindness, such as trachoma, keratomalacia and leprosy, ocular trauma has become relatively more important. Moreover, there have been no studies in the Pacific to determine if diabetes has an influence on the incidence of infection, or causes delay in healing after ocular trauma. From previous studies the importance of early intervention in ocular trauma seems to be crucial. Therefore the role of the priOcular trauma in the Solomon Islands

Eye care provision in the developing world: a regional perspective

of the priority areas of health infrastructure identified by VISION 2020. The potential of real-time telemedicine to screen for clinically significant diabetic macular oedema in remote populations was investigated by Peter et al . although they found that the equipment used was not up to the task. 6 However, telemedicine does allow teleconsulting and provision of education through interactive tutorials, bringing expertise to underserved areas in a cost-effective way. The use of digital retinal photography and transmission of the images through the Internet is likely to remain a more sustainable and appropriate method for screening in remote locations. Although access to eye care services remains a problem in some regions in Australia, both Australia and New Zealand have done much to provide eye care delivery in neighbouring countries. 7 Non-governmental organizations from both countries have led the way and both governments have helped fund some of these initiatives, although funding has rarely been a limiting factor: antipodean generosity is second to none. It is, however, anomalous that one of the major initiatives to assist neighbours is administered not by the Royal Australian and New Zealand College of Ophthalmologists (RANZCO) but by the Royal Australian College of Surgeons (RACS). Ophthalmic specialist teams visit Pacific Island countries as part of the successful RACS Pacific Islands Project. Cataract and refraction service delivery is the focus but surgical outcome performance has been rarely monitored or documented: AusAID, the main funding agency, only requires reports on numbers of surgeries performed and patients seen. It was noted in 1994 that a key issue in the provision of aid to developing countries was training of local health-care workers so that aid programmes will eventually make themselves redundant. 8 We need to consider both the quality of service delivery provided to our neighbours and how best to increase their capacity to effectively, and sustainably, manage by themselves. Quality assurance through monitoring outcomes, especially when providing services overseas, is mandatory if the reputation of Australasian Ophthalmology is to remain high. We need to be as accountable to patients seen and operated on overseas as in Australia or New Zealand: presumed merit is no longer sufficient and the responsibility for this should rest with RANZCO, supported by RACS and AusAID. The developing world is where 90% of blindness and vision impairment occurs, caused by cataract, trachoma, childhood blindness, onchocerciasis and refractive error. Most blindness (80%) is avoidable: these conditions can be prevented or cured. The Western Pacific Region, like others, shows an alarming increase in diabetes and the preventable complication of blinding diabetic retinopathy. With a threefold increase in blindness for each decade of life, the blind and vision impaired are elderly. The World Health Organization (WHO) and the International Agency for the Prevention of Blindness (IAPB) launched VISION 2020 The Right to Sight in 1999 after realizing that the consequence of an ageing world population would be an untenable increase in the number of blind and vision impaired. It was projected that by 2020 there could be up to 100 million blind. The world would have insufficient resources to deal with a problem of this magnitude. VISION 2020 addresses this. Avoidable blindness is often considered to be a problem for developing countries. ‘First World’ Australia, however, has within it an aboriginal population with health indicators typical of the most depressed ‘Third World’ scenario. It is the only developed country in the world where trachoma still blinds its citizens. 1 The papers in this issue by Laforest et al . 2