Meeting the Vision 2020 Goals Hugh R Taylor AC Chairman, Western Pacific Region Shenyang, 7th April 2007

Outline Review of Vision2020 Global data on vision loss Disease control strategies Human Resource Development Health System Development

VISION 2020: The Right to Sight Goal The elimination of avoidable blindness by 2020, in order to give all people in the world, the right to sight

VISION 2020 Partnerships W H O Technical Assistance Capacity Building National Partners - National Vision 2020 Plans Sustainable program delivery

VISION 2020: The Right to Sight Launched in 1999 World Health Assembly Resolution 56.26 2003 calls on all member states to - develop a national plan by 2005 - implement their national plan by 2007 - reduce avoidable blindness by 2010 WHA 59.25 2006 calls for further priority and support to Vision 2020

Causes of Global Blindness 45 million Cataract Refractive Errors Trachoma Vit A Def Oncho Diabetic Retinopathy Glaucoma AMD and other diseases 60% 15% 15% 10%

Global Blindness millions 100 90 75 60 50 50 40 38 30 25 25 1980 1990 1980 1990 2000 2010 2020 1

VISION 2020 Components Effective disease control Cataract Trachoma Onchocerciasis Childhood Blindness Refractive Error and Low Vision Human resource development Infrastructure development

Cataract operations/million population/year First cause of blindness (~50%) backlog: 20 million unoperated cases only 10 million surgeries year major constraints : coverage access quality CSR Cataract operations/million population/year

Cataract Surgery Rates 2000-3999 4000+ no data 0-499 500-999 1000-1999 WHO 2004

Cataract Surgical Rate in India 2001 - 2002 2003 - 2004 WHO 2004

Cataract Surgery Capacity Building Efficiency of programs Surgical Team building and management Sustainability and Cost recovery Outcome Monitoring Visual acuity outcome Surgical coverage rates Cost efficiency

Trachoma- 2004, 84m with active trachoma trachoma is known to be a public health problem trachoma is believed to be a problem, but no data are available known that trachoma is not a problem WHO 2004

Top 20 countries with Active Trachoma

Zithromax Donation Program Pfizer

Onchocerciasis - 80 million to be treated

Mectizan Donation Program Merck

Childhood Blindness Everywhere: congenital cataract / glaucoma hereditary retinal diseases R.O.P R.O.P Measles Vitamin A deficiency R.O.P R.O.P

Refractive Error and Low Vision Huge numbers with uncorrected refractive error under-estimated for a long time particularly in developing countries 1/3 of low vision due to uncorrected refractive errors risk factors: age, social isolation … Low vision care services Either non-existent in most countries or are fragmented and patchy

Myopia affects 2.1 billion worldwide Prevalence of Myopia Europe 26-35% China 88% USA 27% Japan 45% Nepal 3% Mexico 44% HK 80% India 19% We we are seeing very high prevalance rates of myopia in Asia. In Australia it is around 20-30% Australia 20% Chile 20% South Africa 10% Myopia affects 2.1 billion worldwide

Major challenge: How to close the increasing gap Continent Country City Durban - South Africa Shanghai Sao Paulo Sangha - Mali Rural China Sao Paulo

www.v2020.org

Global Blindness 1995 45 million 37 million 2004 Corneal Opacities Trachoma Other Childhood Blindness Other Trachoma Oncho AMD Glaucoma Diabetic Retinopathy Glaucoma Oncho Cataract Cataract 45 million 37 million

World Blindness 2005 Global estimate (best corrected VA) Vision Impairment: 161 million 37 million Blind 124 million Low Vision Refractive Error 153 million (2006) Total estimate 314 million Vision Loss

Visual Impairment Regional Distribution Best corrected Visual Acuity < 6/18 (0.3) WHO 2004

Number of Visually Impaired per Million Population X 2.2 WHO 2004

Global Trends in Blindness Many original factors remain unchanged… Vision 2020 still relevant! Ageing + Population growth + Underdevelopment

Immediate Challenges Unfinished agenda refractive error cataract trachoma onchocerciasis xerophthalmia

Medium/ Long Term Challenges Changing patterns: more linked to life style and more chronic have significant impact on health expenditures Diabetic retinopathy Glaucoma less avoidable or treatable and of increasing relative importance Age-related Macular Degeneration 3rd global cause of blindness 1st cause in many developed countries Retinitis Pigmentosa and other genetic conditions awareness compliance adherence…

Prevalence of obesity (BMI ≥ 30kg/m2) Females > 15

Number of Persons with Diabetes Millions WHO, Wild & Roglic, 2004

Number of People with Glaucoma Quigley. Brit J Ophthalmol 1996

Number of People with Glaucoma in China Number affected Number blinded PACG: 4.5 M POAG: 3.5 M SecG: 1.4 M TOTAL: 9.4 M Foster. Br J Ophthalmol 2001;85:1277-82.

Blindness from Glaucoma in China Urban Rural Foster PJ 2005

Unilateral Glaucoma Blindness, Asia Range 11-27% Range 33-75% Proportion of unilateral blindness in population surveys

Traditional Classification of Angle-closure Glaucoma Acute ACG severe symptoms Intermittent ACG remitting symptoms Chronic ACG high IOP, no symptoms Latent ACG angle-closure inducible Therefore Term “glaucoma” used regardless of presence of neuropathy Emphasis is on IOP and presence/absence of symptoms Does not differentiate people with and without visual loss

Distribution of Angle-closure in Mongolia Foster PJ, et al. GJ. Arch Ophthalmol 1996;114:1235-1241

Prevalence of Angle-closure Mongolia Singapore Occludable angles 6.4% (4.3, 8.5) 6.3% (4.9, 7.6) Angle-closure 2.0% (1.3, 3.1) 2.2% (1.4, 3.1) PACG 0.8% (0.4, 1.2) 0.8% (0.4, 1.2) Rates are age- and gender-standardised (95% Confidence intervals) Foster 2005

Numbers of People with Angle-closure in China Foster. Br J Ophthalmol 2001;85:1277

Incidence of Symptomatic Angle-closure NOTE: Only 30-40% of all angle-closure in Asians is symptomatic

Incidence of Acute Angle Closure in Singapore Incidence 12.2/100,000/year Risk factors Female 2.4 : 1 Age > 60 9.1 : 1 Chinese > Malay or Indian 2.8 : 1 S Seah, et al.Arch. Ophthalmol 1997:115;1436.

Incidence of Primary Angle-Closure in Singapore Wong TY, et al. Br J Ophthalmol 2000;84:990

Missed Diagnoses, Australia Time since last reported eye examination (n = 72) < 1 year < 2 years < 5 year Undiagnosed Glaucoma 51.4 31.9 15.3 Unoperated Cataract 43.4 26.3 11.8 Undercorrected Refractive Error 59.4 44.3 25.1 Diabetes Mellitus 34.4 21.6 8.8 Age-related Macular Degeneration 48.0 30.6 Visual Acuity < 612 11.4 15.8 25.3 Blysma et al CEO 2004

Summary Angle Closure Glaucoma is more important than often recognised Especially a problem in East Asia Care must be taken in routine examinations to assess angle closure Prompt treatment is required

Human Resource Development Increase in Training Programmes Improved Quality of Training Access to Education Materials Increased International Collaborations Improved Programme Management

World Health Report 2006 Make the most of existing health workers availability, competence, responsiveness and productivity Supervision firm, fair and supportive Crucial support systems Life-long learning Institutions produce an appropriate mix using regional resources and IT to drive down cost Gearing recruitment for right skills, right place, social compatibility between workers and clients

Key Issues Related to Training Particularly in developing countries: Not enough ophthalmologists and other eye care providers to provide the care needed Mal-distribution: Lack of providers where most needed Not enough training programs Existing training programs not focused on public needs, e.g., for community eye health Lack of infrastructure and professional development for those who are trained

Eye Care Personnel Needed Teams of: Ophthalmologists (surgeons and “eye doctors”) Subspecialists (pediatric, retina, etc.) Primary physicians trained in eye care Mid level eye personnel (MLEP) and nurses Optometrists or refractionists and opticians Managers and community eye health workers

Training Principles Training in ophthalmology Needs are best met focus on needs of communities and populations, not just individuals Needs are best met by eye care teams, trained together to work toghether Comprehensive eye care should be an integral part of the health care system

Training Principles (2) Community-level primary eye care should be integrated into primary health care Eye care training should be integrated with training for the rest of the health care system Those who are trained need infrastructure and continuing professional development

Infrastructure and Appropriate Technology Models of Care at All Levels of Eye Care Affordable Products to all Construction of appropriate Facilities

Infrastructure Model Proposed LVPEI Centre of Excellence 50 million CEC Training Centre 5 million TC Service Centre 500,000 SC You can sit with Azam or Shubhra and make these slides more contrasting. Explain the model! – may take 2 minutes and concentrate on the role of Vision centres Vision Centre 50,000 VC

Global Burden Of Disease Perinatal Condition Lower Respiratory Infection Ischaemic Heart Disease Cerebro-Vascular Disease HIV/AIDS Eye Conditions (include DRN) Diarrhoeal Disease Unipolar Depressive Disorders Malaria Ch Obstructive Pulmonary Dis TB Road Traffic Injuries Percentage Chiang et al Lancet 2006

Economic Impact of Blindness In many parts of the world, blindness leads to individual, family and community poverty Effective interventions are available that can prevent or cure 80% of blindness These interventions can be very inexpensive; Vitamin A capsules US$2/QALY Cataract surgery US$2020/QALY Diabetic retinopathy screening US$15,000/QALY

Annual Productivity Loss Due to Blindness $150 billion saved in productivity loss

Summary Vision 2020 is already highly successful Blindness will continue to increase with ageing of population Even greater effort is required to achieve “the right to sight for all”

VISION 2020: the Right to Sight World Free of Avoidable Blindness

WHA Resolution 59-25 Adopted by World Health Association in May 2006 Calls on countries to: reinforce efforts to define national VISION 2020 plans mobilize domestic funding to support VISION 2020 include prevention of blindness in national development plans and goals integrate prevention of blindness into primary health care

WHA Resolution 59-25 Adopted by World Health Association in May 2006 Calls on countries to: develop and strengthen eye care services and integrate them in the existing health care system, including training and re-training of health workers in visual health Calls on WHO to: provide support to collaboration among countries for the prevention of avoidable blindness and visual impairment in particular in the area of training of all categories of relevant staff

WHA Resolution 59-25 Offers an unprecedented opportunity to: Convince national governments to assign higher priority to prevention of blindness and visual loss, and Advocate for increased support for training of ophthalmologists and other eye care providers to meet public needs

Unmet Public Need for Eye Care Worldwide at least 161 million people are severely visually impaired: 37 million blind 124 million with low vision In addition 153 million have under-corrected refractive error – the total is 314 million Burden of blindness greatest in the least developed regions of the globe. Global vision loss is certain to increase, particularly in developing countries, due to population growth and aging, unless concerted action is taken.