The world through the child's eyes - the journey towards elimination of childhood blindness in Ghana - the Korle-Bu experience

Abstract

In lieu of an abstract, here is a brief excerpt of the content: •5• Chapter 2 The World through the Child’s Eyes – The Journey Towards Elimination of Childhood Blindness in Ghana – The Korle-Bu Experience V. A. Essuman Introduction Childhood Blindness Worldwide UNICEF (United Nations Children’s Fund or originally the United Nations International Children’s Emergency Fund) defines a child as an individual aged less than 16 years. The World Health Organisation (WHO) defines blindness as a corrected visual acuity in the better eye of less than 3/60, and severe visual impairment as a corrected acuity in the better eye of less than 6/60.1 It is estimated that every-minute a child goes blind in the world – an estimated 500,000 new cases per year1 . The prevalence of blindness in children varies according to the socioeconomic development and under-5 mortality rates. In low-income countries with high under-5 mortality rates, the prevalence may be as high as 1.5 per 1000 children, while in high-income countries with low under-5 mortality rates, the prevalence is around 0.3 per 1000 children.2 Most of these children will live in poverty. Three quarters of the world’s blind children live in the developing world and about half of the cases the causes of their blindness are avoidable (i.e. preventable or treatable). More than 50 per cent will die within 1-2 years of going blind. Those children who do survive with blindness, an estimated 1.4 million worldwide, then have an entire life of visual impairment before them.1,3 Taking these ‘blind years’ into account, the scale of blindness in children is second only to cataract as a global cause of blindness – an estimated 70 million blind years.3 •6• Chapter 2 Childhood Blindness in Ghana The elimination of preventable and treatable causes of childhood visual disability is a priority for intervention in Ghana. The prevalence of blindness in children, 0-15 years old, is estimated to be 0.9 per 1,000 children. Most causes of childhood blindness in Ghana are avoidable.4,5,6 History of WHO/Lions Club International/ Government of Ghana Project for the Elimination of Childhood Blindness in Ghana The World Health Organization (WHO) has identified the prevention, treatment and control of blindness and visual impairment in childhood as a priority area of work. Childhood blindness is one of the major causes of avoidable blindness worldwide and thus targeted under the Vision 2020 Initiative for the Elimination of Avoidable Blindness.1 In June 2003, WHO launched the five-year (2003-2007) childhood blindness prevention project. Centres for comprehensive children’s eye care and low-vision care were established in 30 countries, including Ghana. The Korle Bu Teaching Hospital (KBTH) in the Greater Accra Region, was the centre of the Ghana project covering the Greater Accra and Eastern regions of the country (Figure 1) with a population of 5,200,000 [ children < 15 years = 2.2 million]. A model Child Friendly Eye Care Centre (CFECC) was thus established in KBTH to serve this population in particular and the whole country generally. The project was further extended under a Bridge Grant [2008-2011], Ghana being one of 25 countries [out of the initial 30 countries] to benefit from the extension. This model is to be replicated later in the country. The project was supported financially by the Lions Clubs International , through the Sight First Programme of the Lion Clubs International Foundation (LCIF), with the WHO (Prevention of Blindness and Deafness) as the Executing Agency, in partnership with the Ghana Government. •7• The World through the Child’s Eyes Figure 2.1: Project area Goal and Objectives for the Project • Goal • Eliminate avoidable childhood blindness in Ghana • Specific objectives: • to provide Primary Eye Care (PEC) in PHC; • to develop surgical/medical paediatric Eye Care Service (ECS); • to establish/strengthen Low Vision Service (LVS); • to develop & strengthen infrastructure & equipment; • to conduct monitoring and evaluation of project. •8• Chapter 2 A. Performance I. Training i. Paediatric Medical & Surgical Services In 2003/2004, a paediatric ophthalmology team (2 ophthalmologists , 1 nurse and 1 anaesthetist) was trained in India by the International Agency for Prevention of Blindness - (IAPB) In July 2004, a Child Friendly Eye Care Centre (CFECC) was established as a Service Centre and also as a Training Centre in Korle-Bu. In 2005, two extra regional service centres were identified: Ridge hospital in Accra and the Koforidua Central hospital. ii. Primary Eye Care (PEC) Services In 2005, 20 ophthalmic nurses were trained in PEC as trainers for PEC workers. Existing curriculum and training materials for PEC were reviewed and adapted for training. In the same year 1,154 PEC personnel were trained includingcommunity -based health staff, teachers and volunteers. iii. Low Vision (LV) Care Service 2005/2006 In 2005/2006, the following were achieved for low vision care: • A team was trained, made up of one ophthalmologist as trainer in Hong Kong and two optometrists in Pakistan and South Africa. • The low vision team at the CFECC provided training by orienting in LV care 3 ophthalmologists, 4 optometrists, 4 ophthalmic nurses, 4 teachers and 1 low vision client to work in the project area. • Four ophthalmic nurses were fully trained locally in LV care. • LV Centres were established in KBTH and Koforidua Regional Hospital. •9• The World through the Child’s Eyes II. Infrastructure and Equipment at the CFECC • A LV clinic and LV equipment were in place by 2005/2006 at KBTH. • Provision of basic equipment and instruments for paediatric medical and surgical care at the CFECC continued throughout the project period. • A child-friendly play area and a library of books were established at the Outpatient clinic of the CFECC in 2009-2010. This was through the support of parents/guardians, private individuals and corporate bodies (Figure 2.2). Figure 2.2: Children’s play area at the CFECC, KBTH. •10• Chapter 2 III. Service Delivery i. There has been a progressive increase in out-patient attendance at the CFECC (Figure 2.3). 0 100 200 300 400 500 600 700 800 Old New 2004 130 83 244 578 209 397 451 717 223 613 294 766 2005 2006 2007 2008 2009 Years No. of Patients Figure 2.3: Out-patient attendance at the CFECC, KBTH ii. New diseases continue to be seen at the Outpatient Clinic of the CFECC, KBTH, including major causes of avoidable blindness (Table 2.1). Table 2.1 Service Delivery - Yearly Summary of Top Seven New Diseases (CFECC- KORLE BU) Disease 2004 2005 2006 2007 2008 2009 Total Cataract 12 41 101 56 31 48 289 Conjunctivitis 30 108 37 18 8 5 206 Strabismus 14 19 16 39 36 40 164 Glaucoma 6 7 24 33 6 30 106 Refractive error 12 24 8 19 6 0 69 Retinoblastoma 8 15 5 10 9 13 60 Cornea /Ant. Seg. 8 14 2 5 11 6 46 Others 40 16 16 271 116 152 611 Total 130 244 209 451 223 294 1551 •11• The World through the Child’s Eyes iii. Causes of Childhood Blindness at Korle Bu Teaching Hospital Bilateral Causes Unilateral Causes Cataract Retinoblastoma Glaucoma Cataract Cortical visual impairment Injuries- Broomstick Refractive error Others Cornea/Vernalkerato-conjunctivitis Others A C B D D Figure 2.4: Some causes of Childhood Blindness at the CFECC, KBTH A- Bilateral Congenital Cataract – opacity of the lens B- Congenital Glaucoma C - Retinoblastoma – Cancer of the retina D- Ophthalmia neonatorum •12• Chapter 2 Specialised paediatric eye surgeries are now performed (Figure 2.5) with better outcomes. However, only about half the number of children requiring surgeries receive this treatment. The most important reason for this under performance is the inadequate provision of general anaesthesia due to lack of a dedicated anaesthetist for paediatric eye surgical procedures. 0 10 20 30 40 50 60 Others Injuries Enucleation Strabismus Glaucoma Cataract (2009) (2008) (2007) (2006) (2005) (2004) Surgeries Performed 2004 – 2009 Year No. of Surgeries Figure 2.5: Surgeries performed at the CFECC, KBTH. IV. Research and Advocacy The following have either been achieved or are ongoing in this category of performance: • Scientific presentations at both local and international fora; • Public lectures; • Radio & television talks; • Scientific publications in peer-reviewed journals.7,8 • Ongoing research into epidemiological and clinical trials for major causes of childhood blindness in Ghana. • A fund to cater for the treatment of the needy but blind children and also for the acquisition of equipment, instruments and consummables, has been in existence since 2007 through the advocacy of the team at the CFECC. This fund for the control of childhood blindness depends on the generous support of •13• The World through the Child’s Eyes private individuals, parents/ guardians, establishments and corporate bodies. The fund is managed by the University of Ghana Medical School. Strengths, Weaknesses, Opportunities and Threats (SWOT) Analysis of the Project The childhood blindness prevention can further point to significant accomplishments and strengths such as the recognition of the centre/ project in Ghana and in neighbouring countries (Togo, Ivory-coast, Liberia and Sierra Leone) resulting in the centre receiving referrals from all over the country and also from these neighbouring countries. In addition, the country now has access to specialised paediatric medical, surgical and low vision services, augmented by the dedicated eye theatre at the CFECC, KBTH. The gains of the project are further highlighted by the incorporation of Child Eye Health into the curricula of residency programmes in ophthalmology (West African College of Surgeons, Ghana College of Physicians and Surgeons) and Ophthalmic Nurses Training School at (KBTH). Thus, cadres of the eye care are being progressively trained for the elimination of childhood blindness throughout the country. The establishment of the National Task Team in 2005, an oversight body for the Elimination of Childhood Blindness especially by CFECC, gave the project further impetus. The task team draws representatives from: Local Lions Club, National School Health Programme, Ministry of Women & Children’s Affairs, Integrated Management of Childhood Illness[IMCI], WHO, Ghana Health Service, Society of Paediatricians, National Eye Care Programme and a Paediatric Ophthalmologist from the CFECC. The team is presently inactive but is expected to resume its role with the start of the Phase 2 of the project later in 2013. Over the years, the CFECC has had its share of weaknesses that threaten to undermine its progress, including the late presentation of children with blinding conditions such as retinoblastoma7 , congenital glaucoma8 and congenital cataracts. Compounding this are the inadequate provision of general anaesthesia coverage resulting in fewer surgeries performed; irregular supplies of surgical instruments and consumables such as intraocular lenses, vitrector probes and •14• Chapter 2 affordable spectacles; poor reporting systems and data management among others. Sustaining the gains of CFECC activities in particular and the project as a whole, will require pragmatic steps. These should include health education of the general public and health professionals on these conditions, early detection and funding for treatment. There are on-going research projects to find out the reasons for the late presentations of some of the major causes of childhood blindness at the CFECC. Another aspect of the CFECC’s quest to eliminate childhood blindness in Ghana is the establishment of the Moorfields Eye Hospital Foundation Surgical Training Centre for West Africa in KBTH which is expected to be completed in the year 2013. This collaboration between Moorfields Eye Hospital (UK) and the West African College of Surgeons will include a paediatric wing with out-patient, play area and in-patient care. There will also be an opportunity for subspecialty/ fellowship training in paediatric ophthalmology and other eyecare workers. As regards funding for treatment, the establishment of the National Health Insurance Scheme by the government and the Fund for the Needy and Blind Children, spearheaded by the CFECC team are helping greatly. However more donors are needed for this cause. There is a dedicated computer for data management. There is the need however, for a dedicated data management clerk. Ultimately, the computerisation of the KBTH hospital medical records system would improve on data management. Low-vision service in the country has also been further enhanced by the care provision and human resource development supported by Sight Savers International (SSI) in two regions for the pilot project in Phase 1. The establishment of integrated schools for visually challenged children in Ghana by the Government with additional support from Force Foundation (Netherlands), through the supply of LV aids (e.g. CCTV, braille and vision assessment tools to universities, integrated second cycle schools and schools for the visually challenged) continue to impact greatly on the elimination of visual impairment in Ghanaian children. •15• The World through the Child’s Eyes The ongoing establishment of a second Paediatric Ophthalmology Centre at Komfo Anokye Teaching Hospital, Kumasi, to cater for the northern sector of the country is an added advantage. The support for comprehensive primary eye care in the project area by Sight Savers International and in the two Northern regions (Action Against Childhood Blindness, AACHIB) by Swiss Red Cross, further demonstrates the important role and partnership that non-governmental development organisations provide in the country’s effort to eliminate childhood blindness and improve on the general eye health of Ghanaian children. However, the success of the CFECC is threatened by the erratic supply of equipment and consummables by KBTH. In addition, the inadequate provision of general anaesthesia has been one of the major threats to the success of the project. Going Forward/ Future Plans Phase 2 of the WHO/Lions Club International/ Government of Ghana Project for the Elimination of Childhood Blindness. In January 2011 the SightFirst Advisory Committee (SAC) of the LCIF approved a two-year extension [2012- 2014] of the project for 10 of the best-performing institutions worldwide. The CFECC, thanks to its previous success, was chosen to receive funding in order to upgrade the existing CFECC at the Korle Bu Teaching Hospital, to create a new satellite center at the Ga South Municipal Hospital in Weija, and to support the training of local staff in the areas of primary eye care and paediatric surgery. Training of practising ophthalmologists to augment skills in medical and surgical care in paediatric eye health; fellowship training in paediatric ophthalmology and the establishment of low-vision teams for other regions will continue to engage the centre’s attention. The increasing numbers of children with eye health needs attending the CFECC have brought to the fore the need to establish a Counselling Unit for patients and parents/ carers at the centre to enhance patient and carer education and also free the doctors to dedicate their time and efforts to the medical and surgical care of the children. •16• Chapter 2 Efforts will be made to strengthen the referral systems and collaboration with other stakeholders in the Elimination of Childhood Blindness locally, especially with the new unit at KATH and with all the peripheral eye clinics in the country. Finally, attention will be given to collaboration with external and local institutions in the area of mentorship programmes and in research. Conclusion This pilot project for the elimination of childhood blindness in Ghana has been a good programme in spite of the teething challenges. There is the need for more advocacy and additional sourcing of funding to ensure sustainability of the project. Finally, it will be important to continue with the building of strong teams and fostering multi-sectoral and collaborative linkages both locally and internationally. Appreciation/Acknowledgements Special appreciation to the following: i. LICF-SF / WHO; ii. Govt. of Ghana – GHS, MOH, University of Ghana Medical School; iii. All other partners: Sight Savers International, Swiss Red Cross, Operation Eyesight Universal; iv. Task Team for the Elimination of Childhood Blindness in Ghana. •17• The World through the Child’s Eyes Figure 2.6: Keep our children’s eyes healthy, for they are our future. References 1. Gilbert, C., Foster, A. Childhood blindness in the context of VISION 2020- The Right to Sight. Bulletin of the World Health Organization, 2001, 79: 227–232. 2. Gilbert C.E., Anderton, L., Dandona, L. Foster, A. Prevalence of visual impairment in children: A review of available data. Ophthalmic Epidemiology. 1999, 6:73-82. 3. World Health Organization. Preventing blindness in children -www. who.int/ncd/vision2020_actionplan/.../WHO_PBL_00.77 4. Akafo, S. K. and Hagan, M. Causes of childhood blindness in Southern Ghana–a blind school survey, Ghana Med J, 1990; 24:113-9. 5. Ntim-Amponsah, C.T and Amoaku, W.M.K., Causes of Visual Impairment and Unmet Low Vision Care in a School for the Blind, Int Ophthalmol, 2008; 28:317–23. 6. Gyasi, M.E. Setting the pace for Vision 2020 in Ghana: the case of Bawku Eye Care Program, Community Eye Health, 2006; 19(59):46–7. •18• Chapter 2 7. Essuman, V, Akafo, S., Ntim-Amponsah, C.T., Renner, L., and Edusei L. Presentation of Retinoblastoma at a Paediatric Eye Clinic in Ghana. Ghana Medical Journal. 2010; 44:10-15. 8. Essuman V. A., Braimah I. Z., Ndanu T. A. and Ntim-Amponsah, C. T. Combined trabeculotomy and trabeculectomy: outcome for primary congenital glaucoma in a West African population. Eye.201125: 77–83; doi:10.1038/eye.2010.156; published online 5 November 2010. ...