St. John Eye Hospital, Jerusalem (Established 1882) In service of humankind A charitable foundation of THE ORDER OF ST. JOHN

The Epidemiology of Blindness in the Occupied Palestinian Territories Presented by Dr. Nick Sargent St. John Eye Hospital, Jerusalem

St. John Eye Hospital Established in 1882 First ophthalmic hospital in the Middle East

The St. John Facilities East Jerusalem Hospital Gaza Hospital Anabta Clinic Hebron Hospital Mobile outreach clinic

St. John is actively involved in research including projects in the following areas  Ophthalmic Epidemiology (cataract, diabetic retinoapthy, eye injuries)  The genetics of Behcets Disease  Outcome of corneal graft surgery

BLINDNESS IN THE WORLD WIDE CONTEXT

WHO definitions of low vision Visual impairment (Less than 6/18 but greater than 6/60) Severe Visual impairment (Less than 6/60, but greater than 3/30) Blindness Top of the chart at half the distance

Preventing blindness saves money for a nation and for a health care system! Ministers of health, health economists, politicians need to give it the proirity it deserves!

Projected worldwide cost of reduced productivity due to visual impairment caused by eye diseases, (estimated in the 1990s)

According to the 2007 Palestinian Census, the prevalence of visual impairments is the highest disability within the OPT (2.9%) Palestinian Central Bureau of Statistics

Rapid Assessment of Avoidable Blindness (RAAB) survey in the Palestinian Territories

Co-researchers: Far Chiang, Nick Sargent Research Support Committee Hannah Kuper, Robert Lindfield, Ziad Abdeen Field Research Team Members: Tiarnan Keenan, Nasrallah Khalilia, Denise Magauran, Habes Batta, Na’el Seyam, Lina Al Alawi, Rawia Kamal, Khaled Zaiter, Tamer Hreibat, Hussain Al Sous, Abdul Karim Falana, Noha Nijim, Murad Habruman, Warda Samara, Lina Al Kalouti, Hassam El Ghoul, Ahmad Abu Ghannam, Assad Yousef, Ghazi El Baba Assisting organisations and departments  Local municipalities of the Palestinian Authority (West Bank and Gaza)  International Centre for Eye Health (ICEH), London School of Hygiene and Tropical Medicine (LSHTM),  Palestinian Electorial Commission (PEC),  British Consulate-General, Jerusalem,  Palestinian Central Bureau of Statistics (PCBS),  United Nations Relief and Works Agency for Palestinian Refugees in the Near East (UNRWA),  St. John Eye Hospital support staff

Funding… Main funding body Referral of new cases ECHO: procuring assistance of existing outreach service facility

Why we wanted to do the study…. Observations by healthcare workers that there was a big problem with the number of patients presenting with advanced disease and blindness Lack of robust published research Data to help: Funding and proposal writing Planning and delivery Monitoring impact Future research Understanding about barriers to health care Understanding the importance of our own organisation

The RAAB method is a validated population based survey developed by Hans Limburg that has already been used in other countries. The focus is on:  the prevalence and causes of avoidable blindness and visual impairment  aspects related to cataract surgery

 It is rapid survey because it targets people aged 50+ years  It involves only simple examinations

We used 3 teams each consisting of:  Ophthalmologist  Nurse  Driver  Local guide

SAMPLING METHOD

METHODOLOGY  Multistage cluster random sampling  Clusters (groups of people from a selected area) selected through probability proportionate to size  Participants are found through the compact segment method

2 3 1 Maps of the selected cluster showing segments of equal size

One segment is randomly selected

All households are visited in the segment Until 40 people aged >50 years have been included

1)QUESTIONNAIRE 2)EXAMINATION ‘E’ Vision chart Front of the eye examined with a Portable slit-lamp or torch. Back of eye (retina and optic nerve) with an ophthalmoscope

Target population is just under 4 million people 95 Clusters (59 West Bank, 39 Gaza) 3800 Persons needed to be surveyed

Results

AreaSampleExaminedResponse rate West Bank % Gaza % Total OPT % Sample and examined groups

SECURITY: Reselected 3 clusters away from dangerous zones in Gaza

Unadjusted prevalence in ≥50 years age group for OPT MaleFemaleTotal n%n%n%95%CI Blind with available correction (presenting Vision) % % % % Severe visual impairment (<6/60-3/60) % % % % Visual impairment (<6/18-6/60) % % % %

Gaza v West Bank Gaza (95%CI) West Bank (95%CI) Blind with available correction (presenting VA) 4.9% ( %) 2.5% ( %) Severe visual impairment 3.2% ( %) 2.2% ( %) Visual impairment 12.5% ( %) 9.7% ( %) Gaza West Bank

From this information and knowing what proportion of blind people are likely to be blind in the 50 years and above age group, we estimate that the prevalence of blindness for the Palestinian Territories is 0.4%, This equates to 13,000 people.

PRINCIPLE CAUSES (main categories): Blind with available correction Severe visual impairment 1Cataract6655%5257% 2Corneal scar (non- trachomatous) 1714%78% 3Diabetic retinopathy108%1314% 4Glaucoma76%33% 5Surgical complications 65%44% 6Other retinal, optic nerve and central nervous disease 43%67% 7Age-related macular degeneration 33%44%

Looking at the causes as a whole 80% of bilateral blindness was found to be avoidable

Comparing our prevalence findings with other studies Difficult to compare in a meaningful way population profiles, different age groups studied, different definitions and levels of visual impairment studied UK Age-related macular degeneratio Glaucoma Cataract Israel Glaucoma Age-related Macular degenerationGlaucoma Diabetic retinopathy OPT Cataract Corneal Opacification Diabetic Retinopathy

Reasons for not having cataract surgery (Blind people) 1Old age: no need32% 2Cannot afford18% 3Contra-indication to surgery 18% 4Fear of operation14% 5Unaware of treatment7% 6 Permit problems/ movement restrictions due to the military occupation 4%

PlaceWest Bank %Gaza%OPT% St. John Facilities (NGO) %5223.3% % Palestinian Authority Hospital % % % Private hospital/clinic7021.9%83.6%7814.4% Other NGOs103.1%20.9%122.2% Outside OPT (Egypt, Jordan, Israel, etc) %4118.4%7313.4% TOTAL320100%223100%543100% Where cataract surgery is being performed NGOs were the single largest providers of cataract surgery in OPT

Post-op VAPT (Gaza and West Bank) West BankGazaWHO Standard n=543n=320n=223 Available correction Good (6/6-6/18) Borderline (6/18-6/60) Poor (<6/60) 296 (54.5%) 126 (23.2%) 121 (22.3%) 184 (57.5%) 70 (21.9%) 66 (20.6%) 112 (50.2%) 56 (25.1%) 55 (24.7%) >80% <15% <5% Best correction Good (6/6-6/18) Borderline (6/18-6/60) Poor (<6/60) 357 (65.7%) 87 (16.0%) 99 (18.2%) 220 (68.8%) 42 (13.1%) 58 (18.1%) 137 (61.4%) 45 (20.2%) 41 (18.4%) >90% <5% Looking at results of cataract surgery…

Post-op VAPT (Gaza and West Bank) West BankGazaWHO Standard n=543n=320n=223 Available correction Good (6/6-6/18) Borderline (6/18-6/60) Poor (<6/60) 296 (54.5%) 126 (23.2%) 121 (22.3%) 184 (57.5%) 70 (21.9%) 66 (20.6%) 112 (50.2%) 56 (25.1%) 55 (24.7%) >80% <15% <5% Best correction Good (6/6-6/18) Borderline (6/18-6/60) Poor (<6/60) 357 (65.7%) 87 (16.0%) 99 (18.2%) 220 (68.8%) 42 (13.1%) 58 (18.1%) 137 (61.4%) 45 (20.2%) 41 (18.4%) >90% <5% Looking at results of cataract surgery… We are below WHO standards 84% of patients were partially or very satisfied 

Selection eyes (%) Surgery eyes (%) Spectacles eyes (%) Sequelae eyes (%) Incomplete data eyes (%) Total Eyes Poor outcome (<6/60) 72 (59.5%) 34 (28.1%) 2 (1.7%)13 (10.7%) 0121 Visually impaired (<6/18- 6/60) 32 (25.4%) 26 (20.6%) 45 (35.7%) 10 (7.9%) 8 (6.3%) 126 Total 104 (42.1%) 60 (24.3%) 47 (19.0%) 23 (9.3%) 8 (3.2%) 247 CAUSES OF POOR SURGICAL OUTCOME with available correction (Total OPT)

Selection eyes (%) Surgery eyes (%) Spectacles eyes (%) Sequelae eyes (%) Incomplete data eyes (%) Total Eyes Poor outcome (<6/60) 72 (59.5%) 34 (28.1%) 2 (1.7%)13 (10.7%) 0121 Visually impaired (<6/18- 6/60) 32 (25.4%) 26 (20.6%) 45 (35.7%) 10 (7.9%) 8 (6.3%) 126 Total 104 (42.1%) 60 (24.3%) 47 (19.0%) 23 (9.3%) 8 (3.2%) 247 CAUSES OF POOR SURGICAL OUTCOME with available correction (Total OPT) Co-morbidity was the major single reason for poor outcome

PlaceMalesFemalesTotal West Bank 85.2%79.8%82.1% Gaza87.3%71.9%78.3% Total OPT 86.1%76.4%80.5% Cataract surgical coverage (CSC) in persons with VA<6/60, by sex and area

Prevalence of self-reported diabetes for population in 50 years and above age group in OPT 26.4% (95% CI %) Prevalence of diagnosed diabetes in England in 1990 in 55 years and above group was 2.2%

WHAT DOES THIS MEAN FOR PLANNING?

 Phase 1 priorities: Cataract, infectious causes of blindness, Childhood blindness and CBR  However, for Palestine, diabetic eye disease is moved up into high priority

Number of people with cataract causing bilateral blindness and severe visual loss in the OPT is 11,000 people To reach the Vision 2020 target of operating on 20% of the prevalence of cataract per year is 2,200 cataract operations on those with severe visual loss or blindness

 SJEH operates on about 250 people who are blind or severely visually impaired per year with the 3,000 cataract operations done. Clearly the answer is not simply to increase the number of operations per year, but to reach the blind people and improve on the number referred to hospitals

The Palestine signed up to the VISION 2020 initiative in 2005  the first VISION 2020 policy making workshop took place in December 2009 in the West Bank. It identified diabetic retinopathy as a high priority.  The writing of the National Vision 2020 Plan has been completed: - still waiting to finalize plans

PLANNING : Need to focus on… Training issues: Getting doctors out and teachers in. Improving on current training inside Gaza Finding ways to overcome the interrupted running of services Gaza Females Clear gender inequity apparent Cultural and financial attitudes How women differ to men in seeking eye treatment

Barriers Education (resistance to treatment) Poverty Cataract services Need to strengthen cataract services (increase number and quality) Improving early detection in the community e.g. better coverage by outreach services

CONCLUSIONS  This is the first robust comprehensive survey to be completed in OPT and is an essential baseline for Vision 2020 programmes.  80% of blindness is avoidable  Cataract was the main cause of blindness (55.0%).  The prevalence of blindness is higher in Gaza and in women.

Thank you for your attention!