Public health system integration of avoidable blindness screening and management, India

Abstract

In India, 73 million people have diabetes and 3.5 million infants are born preterm. Without timely screening, there is a risk of visual loss due to diabetic retinopathy and retinopathy of prematurity in these two groups, respectively. Both conditions are emerging causes of visual impairment in India but there is no public health programme for screening or management. Pilot projects were initiated in 2014 to integrate the screening and management of these conditions into existing public health systems, particularly in rural communities and their referral networks. The World Health Organization’s health systems framework was used to develop the projects and strategies were developed with all stakeholders, including the government. Both projects involved hub-and-spoke models of care units around medical schools. For diabetic retinopathy, screening was established at primary health-care facilities and treatment was provided at district hospitals. For retinopathy of prematurity, screening was integrated into sick newborn care units at the district level and treatment facilities were improved at the closest publically funded medical schools. In the first two years, there were substantial improvements in awareness, screening, treatment and partnership between stakeholders, and changes in public health policy. By March 2018, diabetic retinopathy screening was established at 50 facilities in 10 states and treatment had been improved at 10 hospitals, whereas retinopathy of prematurity screening was established at 16 sick newborn care units in district hospital in four states and treatment had been improved at six medical schools. Advocacy within state governments was critical to the success of the initiative.

Diagnostic test accuracy of diabetic retinopathy screening by physician graders using a hand-held non-mydriatic retinal camera at a tertiary level medical clinic

“…DRS also requires appropriate integration into routine care for sustainability [10]. It was shown that public health integration of DRS is a feasible strategy to control avoidable blindness [12]. As such, one feasible model of systematic DRS in LMICs could be screening of PwDM when they attend for routine medical care.…”

ROP examination of premature babies at an eye hospital referred from urban and semi-urban NICUs

“…Screening was integrated into sick new-born care units at the district level and treatment facilities were provided and improved at the closest publicly funded medical schools. In the first two years, there were substantial improvements in awareness, screening, treatment and partnership between stakeholders, and changes in public health policy (Gudlavalleti et al, 2018). Other strategies which are being currently used include training members of the neonatal team to capture retinal images using wide-field imaging which are then read by ROP experts.…”

Examination of preterm babies for ROP referred to an eye department from an urban and semi-urban neonatal intensive care unit: implications for practice.

“…In the first two years, there were substantial improvements in awareness, screening, treatment and partnership between stakeholders, and changes in public health policy. [22] Other strategies which are being currently used include training members of the neonatal team to capture retinal images using wide-field imaging which are then read by ROP experts. A KIDROP like screening model can provide ROP screening in low-resource settings, remote centres, and regions with few ROP specialists.…”