refractive error: the african situation daveena brain: icee africa program manager
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Refractive Error: The African Situation
Daveena Brain: ICEE Africa Program Manager
Refractive Error: The African Situation
Daveena Brain: ICEE Africa Program Manager
AFRICAAFRICA
Issues confronting AfricaIssues confronting Africa
• Data • Human Resources• Infrastructure• Access to technology and
spectacles
Difficulties with Current DataDifficulties with Current Data
• Non-uniform definitions across studies
• Non-representative study populations (convenience rather than population-based)
• Dissimilar demographics of study population (age and sex)
• Refraction procedures are different (with/without cycloplegia etc)
Negrel, Ellwein, 2001
Negrel et al. (1995)Blindness in BeninNegrel et al. (1995)Blindness in Benin
• Population based study: 7047 examined
• Prevalence of blindness: 0.6%• 9.6% of blindness is due to
refractive errors
International Centre for Eyecare Education
0.7%
Blindness < 3/60: Low vision (best acuity 6/24 - 3/60):
1.4%
(11% due to RE)AFRICA: The Gambia
Faal et al., 1989
Need for Basic Est. no. of peopleOphthalmic Services in need of treatmentCataract surgery 5,500Eyelid surgery 4,600
Need spectacles (distances) 4,600*Medical eye treatment 83,000
Other surgical or medical treatment 6,500
Need for Basic Est. no. of peopleOphthalmic Services in need of treatmentCataract surgery 5,500Eyelid surgery 4,600
Need spectacles (distances) 4,600*Medical eye treatment 83,000
Other surgical or medical treatment 6,500
*Does not include presbyopes who may need spectacles for close work,or those needing glasses after cataract surgery.
EthiopiaZerihun & Mabey(1997) EthiopiaZerihun & Mabey(1997)
• Population based: 7423 examined• Blindness: 0.85%• Low Vision(<6/18-3/60): 1.7% • 28.8% of low vision due to RE
• Refractive Errors study in Urban schools in Moshi (B. Shilio)
•<6/9 11.8%•<6/12 2.2%•<6/18 1.9%•< 6/18-6/60 1.6%•< 6/60 0.12%
DISEASES
CATARACT
REFRACTIVEERRORS
TRACHOMA
VIT A DEF
ONCHOCERCIASIS
DIABETIC
RETINOPATHY
GLAUCOMA
OTHER
DISEASES
50 -60 % < 5 % 15 - 20 % 10 - 15 %
South AfricaSouth Africa
Blindness =1.0%
Low vision= 1.4%
FACTORS AFFECTING BLINDNESSPREVALENCE IN KwaZulu, SOUTH AFRICA
Cook et al, 1993
6,090 screened268 full exam
10% of blindness due to refractive errors
Only 11.8% of people with RE had spectacles
REFRACTIVE ERROR STUDY IN CHILDREN(AFRICA)
Purpose:• assess the prevalence of vision
disorders in children 5-15 years(5599 enumerated)• address the issue of access of care in several settings
4890 Children ExaminedUrban to semi urban area
Myopia: < 0.50DHyperopia: >2D
4890 Children ExaminedUrban to semi urban area
Myopia: < 0.50DHyperopia: >2D
Myopia vs Hyperopia: RESCAMyopia vs Hyperopia: RESCAMyopia Hyperopia
4 2.6
Myopia vs Hyperopia RESCA
0
0.5
1
1.5
2
2.5
3
3.5
4
4.5
Myopia Hyperopia
Refractive Error
Per
cen
tag
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Series1
Myopia vs Hyperopia RESCA
0
0.5
1
1.5
2
2.5
3
3.5
4
4.5
Myopia Hyperopia
Refractive Error
% Series1
Myopia vs Hyperopia : South Africa
4
2.6
0
0.5
1
1.5
2
2.5
3
3.5
4
4.5
Myopia Hyperopia
Refractive Error
Per
cen
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e
Series1
PROJECTIONS FOR AFRICAPROJECTIONS FOR AFRICA
Country Population Total RE
10% Myopia 4%
Hyperopia 2.6%
Presbyopia 50% of +40 yrs (est 24% of pop +40)
Sub-Saharan Africa
702.6 million 70.2 million 28,104,000
18,267,600 168.62 million
Nigeria 123,338 000 12,334 000 4, 934 000 3,207 000 29,601,000 Ghana 19, 534 000 1, 953 000 781 342 508 000 4,688, 000 Kenya 30, 340 000 3, 034 000 1,214 000 789 000 7,281, 000 Tanzania 35,306 000 3, 531 000 1,412 000 918 000 8,473, 000 South Africa
44,820 000 4,482 000 1,793 000 1,165 000 10,757 000
People needing SpectaclesPeople needing Spectacles
• 10% of population• 70.2 million need correction• 7.2 million have correction• 63 million do not have correction
in Sub Saharan Africa
Projected Situation for TanzaniaProjected Situation for Tanzania
• Population 35,306 000• Estimated refractive error 3.5
million• Children 0-14 45% population,
15.9mill– Est Myopia – 636,000 – Est Hyperopia – 413,400
• Estimated presbyopia 8,4 million
• HUMAN RESOURCES
WHO Provides the Services?WHO Provides the Services?
• Ophthalmologists• Optometrists• Ophthalmic Nurses• Ophthalmic Assistants
REFRACTIONISTS: SUB-SAHARAN AFRICA
• 2004 2020*
•Population 703m 1400m•Eye Exams Needed (10%) 70.3m 140m
•Refractionistsneeded (1:100 000)70,000 140,000
• Current 7,000 11,000
• Extra needed 63,000 129,000
AFRICA: The Needs by 2020
Need : Need : 129,000 129,000
“refractionists”“refractionists”
Tanzania Tanzania
• Has the largest percentage of Optometrists in the public sector of any country in the world
• The infrastructure present at KCMC means that significant advances and improvements in eyecare for the people of Tanzania can be achieved
SpectaclesSpectacles
SPECTACLESSPECTACLES
• Inaccessible
• Complicated delivery systems
• Expensive
SPECTACLES: NEEDSSPECTACLES: NEEDS
• LOW COST• READY MADES• DECENTRALISED OPTICAL LABS• COLLOBARATIVE BUYING TO
REDUCE COSTS: – ICEE/SIGHTSAVERS MODEL
The ICEE ResponseThe ICEE Response
• Community Optometrist Model: Unique due to number of public sector optometrists
• Refraction Training• Train the Trainer• Low Cost Spectacles• Research: understand the problem and
develop alternative approaches– Situational Analysis
• THANK YOU
Hyperopia with Autorefraction: MulticountryHyperopia with Autorefraction: Multicountry
Hyperopia with Autorefraction
2.6 2.7
0.68
7.4
2.1
0
1
2
3
4
5
6
7
8
SA China Hyd Delhi Nepal
Countries
Perc
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tag
e
Series1
Myopia with Autorefraction: Country ComparisonMyopia with Autorefraction: Country Comparison
Myopia with Autorefraction
4
7.3
21.6
5.67.4
1.2
0
5
10
15
20
25
SA Chile China Hyd Delhi Nepal
Countries
Perc
en
tag
e
Series1
Country Population Total RE
10% Myopia 4%
Hyperopia 2.6%
Presbyopia 50% of +40 yrs (est 24% of pop +40)
Nigeria 123,337,822 12,333,782 4,933,512 3,206,783 14,800,538 Ghana 19,533,560 1,953,356 781,342 507,872 2,344,027 Kenya 30,339,770 3,033,977 1,213,590 788,834 3,640,772 Tanzania 35,306,126 3,530,612 1,412,245 917,959 4,236,735 South Africa 44,819,778 4,481,977 1,792,791 1,165,314 5,378,373 Sub-Saharan Africa
702.6 million 28,104,000 18,267,600
Number of Ophthalmologists and OMAsNumber of Ophthalmologists and OMAs
• Optometrists: – SA: 2100– Nigeria: 1100– Tanzania: 350– Ghana: 75– Kenya: 10– Zimbabwe: 20
• 1589 Ophthalmologists(47/million pop/21 countries x 703 million)
• 3620 OMAs(103/20x703 M)• Extra 250 per year
WEST AFRICAWEST AFRICA
• OPHTHALMOLOGISTS• OPHTHALMIC NURSES/ASSISTANTS• NO OPTOMETRISTS
OPTOMETRISTSOPTOMETRISTS
• Untapped Resources
• Need to bring them into the system
Current ProgramsCurrent Programs
• Nigeria: 600 optometrists and 200 ophthalmologists
• South Africa: 2000, only 30 in the Public sector
• Tanzania: 170 optometrists, 30 Ophthalmologists
• Other countries with programs: Ghana, Sudan
What is Needed?What is Needed?
• Flexible Approach: Mobilise all e• Utilise available resources• Integrate into a longterm strategy• Multiple Approaches• Affordability• Comprehensive Eye Care plan• Sustainability