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.
Highlights
The Vision Loss Expert Group of the Global Burden of Disease study reported that globally there were 36 million blind people in 2015, of whom 11.7 million (32.5%) lived in South Asia.[1]
Diabetic retinopathy is included in two national, vertical programmes: (i) the National Programme for Prevention and Control of Cardiovascular Diseases, Cancers, Diabetes and Stroke, established in 2010, is responsible for all noncommunicable diseases – programme personnel are responsible for the identification and registration of people with diabetes and for providing monthly medication; and (ii) the National Programme for Control of Blindness assists in the diagnosis and management of diabetic retinopathy
Diabetic retinopathy: (i) annual screening for diabetes implemented at the community level, with people with a high random blood sugar level referred to medically qualified personnel at primary health centres
Summary
The Vision Loss Expert Group of the Global Burden of Disease study reported that globally there were 36 million blind people in 2015, of whom 11.7 million (32.5%) lived in South Asia.[1]. In 2010, an estimated 32 200 infants globally had visual loss from retinopathy of prematurity.[13] In India, the figure that year was 5000 (i.e. 15% of the global estimate) among the 3.52 million preterm births in the country (i.e. 23.6% of 15 million preterm births globally).[9,14,15] Between 10 and 47% of premature babies born under 32 weeks’ gestation who survive neonatal care develop retinopathy of prematurity[16,17] and up to 15% of survivors require treatment for sightthreatening retinopathy.[5,9] Risk factors for the condition are earlier prematurity, inadequate monitoring of supplemental oxygen, respiratory distress syndrome, anaemia and sepsis.[13,18] The risk of blindness can be reduced by minimizing preterm births, better neonatal care from birth and timely screening of infants at risk, with urgent treatment for those who develop sight-threatening retinopathy of prematurity.[19] Screening and treatment of the condition have been reported to be highly cost–effective.[20,21]. Evidence from high-income countries indicates that the risk of visual loss from diabetic retinopathy can be reduced by strategies such as better control of blood glucose and hypertension and regular screening to detect individuals with sight-threatening diabetic retinopathy, followed by confirmatory diagnosis and appropriate management.[26]
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