Browsing by Author "Lewallen, Susan"

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    CMV retinitis screening and treatment in a resource-poor setting: three-year experience from a primary care HIV/AIDS programme in Myanmar
    (BioMed Central Ltd, 2011) Tun, NiNi; London, Nikolas; Kyaw, Moe; Smithuis, Frank; Ford, Nathan; Margolis, Todd; Drew, W Lawrence; Lewallen, Susan; Heiden, David
    BACKGROUND: Cytomegalovirus retinitis is a neglected disease in resource-poor settings, in part because of the perceived complexity of care and because ophthalmologists are rarely accessible. In this paper, we describe a pilot programme of CMV retinitis management by non-ophthalmologists. The programme consists of systematic screening of all high-risk patients (CD4 <100 cells/mm3) by AIDS clinicians using indirect ophthalmoscopy, and treatment of all patients with active retinitis by intravitreal injection of ganciclovir. Prior to this programme, CMV retinitis was not routinely examined for, or treated, in Myanmar. METHODS: This is a retrospective descriptive study. Between November 2006 and July 2009, 17 primary care AIDS clinicians were trained in indirect ophthalmoscopy and diagnosis of CMV retinitis; eight were also trained in intravitreal injection. Evaluation of training by a variety of methods documented high clinical competence. Systematic screening of all high-risk patients (CD4 <100 cells/mm3) was carried out at five separate AIDS clinics throughout Myanmar. RESULTS: A total of 891 new patients (1782 eyes) were screened in the primary area (Yangon); the majority of patients were male (64.3%), median age was 32 years, and median CD4 cell count was 38 cells/mm3. CMV retinitis was diagnosed in 24% (211/891) of these patients. Bilateral disease was present in 36% of patients. Patients with active retinitis were treated with weekly intravitreal injection of ganciclovir, with patients typically receiving five to seven injections per eye. A total of 1296 injections were administered. CONCLUSIONS: A strategy of management of CMV retinitis at the primary care level is feasible in resource-poor settings. With appropriate training and support, CMV retinitis can be diagnosed and treated by AIDS clinicians (non-ophthalmologists), just like other major opportunistic infections.
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    Magnitude and determinants of the ratio between prevalences of low vision and blindness in rapid assessment of avoidable blindness surveys
    (2016) Kaphle, Dinesh; Lewallen, Susan
    Part A of the dissertation includes the protocol of the study, which was approved by Faculty of Health Sciences Human Research Ethics Committee, University of Cape Town. The study was observational analytical, aiming to determine the magnitude and determinants of the ratio between prevalence of low vision and prevalence of blindness using Rapid Assessment of Avoidable Blindness (RAAB) surveys across World Bank regions. The surveys included in the study were available in the RAAB repository and obtained through permission from the primary investigators. A univariate and multivariate analysis were performed using the ratio as an outcome variable and potential explanatory variables as follows: prevalence of Uncorrected Refractive Error (URE), Cataract Surgical Coverage (CSC) at visual acuity 3/60, 6/60 and 6/18 for persons, logarithm of Gross Domestic Product per capita income and health expenditure per capita income. Part B contains the structured literature review. PubMed, Scopus, EBSCOHOST (Africa wide and MEDLINE) and Web of science databases were used to look for literature using the following key words: rapid assessment, blindness, age-related cataract, uncorrected refractive errors, low vision, visual impairment, avoidable OR curable OR preventable OR treatable. The summary of the literature review in addition to the gap in the literature is presented in the section. Part C includes a journal "ready" manuscript. The results showed that the ratio was between 1.35% in Mozambique and 11.03% in India. There was a statistically significant variation of the ratio across the regions: approximately 7.0 in South Asia and approximately 3.0 in Sub-Saharan Africa (X2=28.23, P<0.001). The variables: prevalence of Uncorrected Refractive Errors (URE), Cataract Surgical Coverage at visual acuity 3/60, 6/60 and 6/18 for persons, logarithm of Gross Domestic Product per capita and logarithm of health expenditure per capita were found to be statistically significantly associated with the ratio. However, only prevalence of URE and CSC at 3/60 for persons across the regions were found statistically significant in multivariate analysis.
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    Setting targets for human resources for eye health in sub-Saharan Africa: what evidence should be used?
    (BioMed Central, 2016) Courtright, Paul; Mathenge, Wanjiku; Kello, Amir B; Cook, Colin; Kalua, Khumbo; Lewallen, Susan
    With a global target set at reducing vision loss by 25% by the year 2019, sub-Saharan Africa with an estimated 4.8 million blind persons will require human resources for eye health (HReH) that need to be available, appropriately skilled, supported, and productive. Targets for HReH are useful for planning, monitoring, and resource mobilization, but they need to be updated and informed by evidence of effectiveness and efficiency. Supporting evidence should take into consideration (1) ever-changing disease-specific issues including the epidemiology, the complexity of diagnosis and treatment, and the technology needed for diagnosis and treatment of each condition; (2) the changing demands for vision-related services of an increasingly urbanized population; and (3) interconnected health system issues that affect productivity and quality. The existing targets for HReH and some of the existing strategies such as task shifting of cataract surgery and trichiasis surgery, as well as the scope of eye care interventions for primary eye care workers, will need to be re-evaluated and re-defined against such evidence or supported by new evidence.
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    Skills of general health workers in primary eye care in Kenya, Malawi and Tanzania
    (BioMed Central Ltd, 2014) Kalua, Khumbo; Gichangi, Michael; Barassa, Ernest; Eliah, Edson; Lewallen, Susan; Courtright, Paul
    BACKGROUND:Primary eye care (PEC) in sub-Saharan Africa usually means the diagnosis, treatment, and referral of eye conditions at the most basic level of the health system by primary health care workers (PHCWs), who receive minimal training in eye care as part of their curricula. We undertook this study with the aim to evaluate basic PEC knowledge and ophthalmologic skills of PHCWs, as well as the factors associated with these in selected districts in Kenya, Malawi, and Tanzania. METHODS: A standardized (26 items) questionnaire was administered to PHCWs in all primary health care (PHC) facilities of 2 districts in each country. Demographic information was collected and an examination aimed to measure competency in 5 key areas (recognition and management of advanced cataract, conjunctivitis, presbyopia, and severe trauma plus demonstrated ability to measure visual acuity) was administered. RESULTS: Three-hundred-forty-three PHCWs were enrolled (100, 107, and 136 in Tanzania, Kenya, and Malawi, respectively). The competency scores of PHCW varied by area, with 55.7%, 61.2%, 31.2%, and 66.1% scoring at the competency level in advanced cataract, conjunctivitis, presbyopia, and trauma, respectively. Only 8.2% could measure visual acuity. Combining all scores, only 9 (2.6%) demonstrated competence in all areas. CONCLUSION: The current skills of health workers in PEC are low, with a large per cent below the basic competency level. There is an urgent need to reconsider the expectations of PEC and the content of training.
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    Task shifting for cataract surgery in eastern Africa: productivity and attrition of non-physician cataract surgeons in Kenya, Malawi and Tanzania
    (BioMed Central Ltd, 2014) Eliah, Edson; Lewallen, Susan; Kalua, Khumbo; Courtright, Paul; Gichangi, Michael; Bassett, Ken
    BACKGROUND:This project examined the surgical productivity and attrition of non-physician cataract surgeons (NPCSs) in Tanzania, Malawi, and Kenya. METHODS: Baseline (2008-9) data on training, support, and productivity (annual cataract surgery rate) were collected from officially trained NPCSs using mailed questionnaires followed by telephone interviews. Telephone interviews were used to collect follow-up data annually on productivity and semi-annually on attrition. A detailed telephone interview was conducted if a surgeon left his/her post. Data were entered into and analysed using STATA. RESULTS: Among the 135 NPCSs, 129 were enrolled in the study (Kenya 88, Tanzania 38, and Malawi 3) mean age 42 years; average time since completing training 6.6 years. Employment was in District 44%, Regional 24% or mission/ private 32% hospitals. Small incision cataract surgery was practiced by 38% of the NPCSs. The mean cataract surgery rate was 188/year, median 76 (range 0-1700). For 39 (31%) NPCSs their surgical rate was more than 200/year. Approximately 22% in Kenya and 25% in Tanzania had years where the cataract surgical rate was zero. About 11% of the surgeons had no support staff.Factors significantly associated with increased productivity were: 1) located at a regional or private/mission hospital compared to a district hospital (OR = 8.26; 95 % CI 2.89 - 23.81); 2) 3 or more nurses in the eye unit (OR = 8.69; 95% CI 3.27-23.15); 3) 3 or more cataract surgical sets (OR = 3.26; 95% CI 1.48-7.16); 4) a separate eye theatre (OR = 5.41; 95% CI 2.15-13.65); 5) a surgical outreach program (OR = 4.44; 95% CI 1.88-10.52); and 6) providing transport for patients to hospital (OR = 6.39; 95% CI 2.62-15.59). The associations were similar for baseline and follow-up assessments. Attrition during the 3 years occurred in 13 surgeons (10.3%) and was due to retirement or promotion to administration. CONCLUSIONS: High quality training is necessary but not sufficient to result in cataract surgical activity that meets population needs and maintains surgical skill. Needed are supporting institutions and staff, functioning equipment and programs to recruit and transport patients.
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    Task shifting in primary eye care: how sensitive and specific are common signs and symptoms to predict conditions requiring referral to specialist eye personnel?
    (BioMed Central Ltd, 2014) Andriamanjato, Hery; Mathenge, Wanjiku; Kalua, Khumbo; Courtright, Paul; Lewallen, Susan
    BACKGROUND:The inclusion of primary eye care (PEC) in the scope of services provided by general primary health care (PHC) workers is a 'task shifting' strategy to help increase access to eye care in Africa. PEC training, in theory, teaches PHC workers to recognize specific symptoms and signs and to treat or refer according to these. We tested the sensitivity of these symptoms and signs at identifying significant eye pathology. METHODS: Specialized eye care personnel in three African countries evaluated specific symptoms and signs, using a torch alone, in patients who presented to eye clinics. Following this, they conducted a more thorough examination necessary to make a definite diagnosis and manage the patient. The sensitivities and specificities of the symptoms and signs for identifying eyes with conditions requiring referral or threatening sight were calculated. RESULTS: Sensitivities of individual symptoms and signs to detect sight threatening pathology ranged from 6.0% to 55.1%; specificities ranged from 8.6 to 98.9. Using a combination of symptoms or signs increased the sensitivity to 80.8 but specificity was 53.2. CONCLUSIONS: In this study, the sensitivity and specificity of commonly used symptoms and signs were too low to be useful in guiding PHC workers to accurately identify and refer patients with eye complaints. This raises the question of whether this task shifting strategy is likely to contribute to reducing visual loss or to providing an acceptable quality service.