Productivity of key informants for identifying blind children: evidence from a pilot study in Malawi.

OBJECTIVES: To determine the productivity of village-based 'key informants' (KIs) in identifying blind children. MATERIALS AND METHODS: Ngabu subdistrict (population 101,000) of Chikwawa district was divided into KI catchment areas. KIs, selected by local village leaders, were trained to register children reported to be blind or with severe visual impairment. These children were clinically assessed at designated centres. RESULTS: In total, 44 KIs were selected and trained to cover 196 villages in Ngabu. They identified and referred 151 children, 37 of whom were blind (presenting vision <3/60 best eye). Overall, village leaders tended to choose female KIs (80%) compared to male KIs (20%); however, male KIs tended to be more productive, identifying 4.22 children each (compared to 3.23 for female KIs). Male KIs were 2.7 times more likely to identify blind children compared to female KIs. Only 25% of all identified blind children of school going age were in school. CONCLUSIONS: KIs may be effective in identifying blind children in the community; however, additional work is needed to determine who will be the most effective KI in a community and whether gender roles will limit interpretation of findings from KIs activities

Comparison of effectiveness of using trained key informants versus health surveillance assistants in identifying blind and visually impaired children in Malawi.

Eye conditions associated with visual impairment and blindness in children, such as congenital cataract, can lead to long lasting visual problems if treatment is delayed. There is need to determine which method can be more effective in identifying blind and visual impaired children. In this study, two methods of identifying blind and visual impaired children (using key informants versus using health surveillance assistants) were compared in a randomised community study conducted in three districts in Southern Malawi. The ministry of Health was advocating for the training of Health Surveillance Assistants (HSAs) in primary eye care, which included case detection and refer of blind and visually impaired children; and the alternative was the training of key informants (KIs). The study was done to compare the effectiveness of the two methods of case identification and to provide guidelines on optimal approaches of identifying blind and severely visually impaired children in Malawi. Twelve clusters (group of villages) were selected, and six were randomly assigned to each group. After training in case identification and referral, Key informants and Heath surveillance assistant identified children from the clusters, within a six-week period, and the number of blind and visual impaired children identified in each group was determined and compared. In total, 159 Key informants and 151 Health Surveillance Assistants were selected and trained, and they identified 550 children with eye problems, among whom, after examination, only 15.1 % were blind or severely visually impaired. Key informants identified one and half times more blind/severally visual impaired children than HSAs (37 vs 22).The prevalence estimates of blindness among children identified by KIs was 3.3 per 10,000 (95% CI 2.7-3.9), while the prevalence estimates of blindness among children identified by HSAs was 1.9 per 10,000 (95% CI 1.3-2.5).The difference was statistically significant (P=0.03), but overall the number of children identified by both groups was lower than was the expected from prevalence estimates of 8.0 per 10,000. False positives between HSAs and KIs were comparable, with 68.8% of children identified by HSAs as blind, confirmed blind on examination, in comparison to 72.5% of children identified by KIs, also confirmed as blind on examination. Cortical blindness seconded by cataract were the commonest causes of blindness. In conclusion, Keys informants were more effective than Health Surveillance assistants in identifying blind and visually impaired children in Malawi, and this study supports and confirms findings from other areas

Presentation of Primary Open Angle Glaucoma (POAG) at Lions Sight First Eye Hospital in Blantyre, Malawi

ObjectivePrimary open angle glaucoma (POAG) is the most common type of glaucoma in Africa. We carried out a study to  determine the clinical presentation pattern of patients with primary open angle glaucoma (POAG) at a tertiary  hospital in Malawi.DesignA cross-sectional studySettingLions Sight First Eye Hospital—a major referral and teaching state eye hospital in Blantyre, MalawiSubjectsStudy participants were newly diagnosed POAG patients at specialist eye clinic during study period.ResultsA total of 60 POAG patients were recruited into the study. The mean age was 58.7 years (SD= 16.6, range 18 - 86). There were more male (44, 73.3%) than female (16, 27.7%) patients. The majority of patients (73%) presented  one year after onset of visual symptoms. Twenty-six patients (43%) had unilateral blindness (visual acuity &lt; 3/60; WHO classification), while nine patients (15%) presented with bilateral blindness. A vertical cup-to-disc ratio (CDR) of 0.8 or worse was seen in 92 eyes (79%). The mean intraocular pressure (IOP) reading was 35.5 mmHg (SD 13.30). Of the thirty-three eyes that successfully underwent visual field analysis, very advanced defects were recorded in 12 eyes (36%).ConclusionThis study demonstrates delayed presentation and male predominance among POAG patients at a tertiary eye hospital in Malawi. Glaucoma intervention programmes should aim at identifying patients with treatable glaucoma with particular attention to women

Blindness in Childhood in Developing Countries: Time for a Reassessment?

Paul Courtright and colleagues argue that the changing patterns of global childhood blindness suggest a need to reassess research, training, and programmatic requirements

A Rapid Assessment of Avoidable Blindness in Southern Zambia

INTRODUCTION: A rapid assessment of avoidable blindness (RAAB) was conducted in Southern Zambia to establish the prevalence and causes of blindness in order to plan effective services and advocate for support for eye care to achieve the goals of VISION 2020: the right to sight. METHODS: Cluster randomisation was used to select villages in the survey area. These were further subdivided into segments. One segment was selected randomly and a survey team moved from house to house examining everyone over the age of 50 years. Each individual received a visual acuity assessment and simple ocular examination. Data was recorded on a standard proforma and entered into an established software programme for analysis. RESULTS: 2.29% of people over the age of 50 were found to be blind (VA <3/60 in the better eye with available correction). The major cause of blindness was cataract (47.2%) with posterior segment disease being the next main cause (18.8%). 113 eyes had received cataract surgery with 30.1% having a poor outcome (VA <6/60) following surgery. Cataract surgical coverage showed that men (72%) received more surgery than women (65%). DISCUSSION: The results from the RAAB survey in Zambia were very similar to the results from a similar survey in Malawi, where the main cause of blindness was cataract but posterior segment disease was also a significant contributor. Blindness in this part of Zambia is mainly avoidable and there is a need for comprehensive eye care services that can address both cataract and posterior segment disease in the population if the aim of VISION 2020 is to be achieved. Services should focus on quality and gender equity of cataract surgery

Combination adherence strategy to support HIV antiretroviral therapy and pre-exposure prophylaxis adherence during pregnancy and breastfeeding: protocol for a pair of pilot randomised trials.

INTRODUCTION To realise the expected gains from prevention of mother-to-child HIV transmission initiatives, adherence to preventative and therapeutic antiretroviral regimens is critical and interventions deployable in busy programmatic settings with a high HIV burden are needed. Based on formative research, we developed an approach that integrates patient-centred counselling and engagement of an adherence supporter for pregnant and breastfeeding women initiating HIV treatment (ie, antiretroviral therapy (ART)) or biomedical HIV prevention (ie, pre-exposure prophylaxis (PrEP)). METHODS Tonse Pamodzi 2 is a pilot study designed to provide acceptability, fidelity and clinical outcomes data on a set of behavioural interventions for adherence support. The study comprises two parallel randomised trials, enrolling HIV-positive pregnant women initiating ART (Trial 1, n=100) and HIV-negative pregnant women with risk of HIV acquisition and willing to initiate PrEP (Trial 2, n=200). Within each trial, participants are randomised 1:1 to either the intervention or control group. The Tonse Pamodzi adherence intervention comprises patient-centred counselling (adapted Integrated Next Step Counseling(iNSC)) and external adherence support tailored to the clinical context (ie, for ART or PrEP). Participants randomly assigned to the control group receive standard counselling based on local HIV guidelines. Participants are followed for 6 months. To assess intervention acceptability, we will employ a mixed method approach to describe participant engagement, satisfaction, and discussion content. We will audit and score recorded counselling sessions to evaluate the implementation fidelity of iNSC sessions. We will also assess clinical outcomes at 3 and 6 months for both Trial 1 (retention in care and viral suppression of HIV) and Trial 2 (retention in care, and plasma and intracellular tenofovir drug concentrations). ETHICS AND DISSEMINATION The study protocol was approved by the Malawi National Health Science Research Committee (19/05/2334) and the University of North Carolina at Chapel Hill Institutional Review Board (19-1060). TRIAL REGISTRATION NUMBER NCT04330989

Prevalence of and Risk Factors for Trachoma in Southern Nations, Nationalities, and Peoples' Region, Ethiopia: Results of 40 Population-Based Prevalence Surveys Carried Out with the Global Trachoma Mapping Project.

PURPOSE: We sought to estimate the prevalence of trachoma at sufficiently fine resolution to allow elimination interventions to begin, where required, in the Southern Nations, Nationalities, and Peoples' Region (SNNPR) of Ethiopia. METHODS: We carried out cross-sectional population-based surveys in 14 rural zones. A 2-stage cluster randomized sampling technique was used. A total of 40 evaluation units (EUs) covering 110 districts ("woredas") were surveyed from February 2013 to May 2014 as part of the Global Trachoma Mapping Project (GTMP), using the standardized GTMP training package and methodology. RESULTS: A total of 30,187 households were visited in 1047 kebeles (clusters). A total of 131,926 people were enumerated, with 121,397 (92.0%) consenting to examination. Of these, 65,903 (54.3%) were female. In 38 EUs (108 woredas), TF prevalence was above the 10% threshold at which the World Health Organization recommends mass drug administration with azithromycin annually for at least 3 years. The region-level age- and sex-adjusted trichiasis prevalence was 1.5%, with the highest prevalence of 6.1% found in Cheha woreda in Gurage zone. The region-level age-adjusted TF prevalence was 25.9%. The highest TF prevalence found was 48.5% in Amaro and Burji woredas. In children aged 1-9 years, TF was associated with being a younger child, living at an altitude 15°C, and the use of open defecation by household members. CONCLUSION: Active trachoma and trichiasis are significant public health problems in SNNPR, requiring full implementation of the SAFE strategy (surgery, antibiotics, facial cleanliness, and environmental improvement)

Optimizing HIV testing services in sub-Saharan Africa: cost and performance of verification testing with HIV self-tests and tests for triage

INTRODUCTION: Strategies employing a single rapid diagnostic test (RDT) such as HIV self-testing (HIVST) or "test for triage" (T4T) are proposed to increase HIV testing programme impact. Current guidelines recommend serial testing with two or three RDTs for HIV diagnosis, followed by retesting with the same algorithm to verify HIV-positive status before anti-retroviral therapy (ART) initiation. We investigated whether clients presenting to HIV testing services (HTS) following a single reactive RDT must undergo the diagnostic algorithm twice to diagnose and verify HIV-positive status, or whether a diagnosis with the setting-specific algorithm is adequate for ART initiation. METHODS: We calculated (1) expected number of false-positive (FP) misclassifications per 10,000 HIV negative persons tested, (2) positive predictive value (PPV) of the overall HIV testing strategy compared to the WHO recommended PPV ≥99%, and (3) expected cost per FP misclassified person identified by additional verification testing in a typical low-/middle-income setting, compared to the expected lifetime ART cost of $3000. Scenarios considered were as follows: 10$5879, $3770, and$24,259 respectively. Results were sensitive to assumptions about accuracy of self-reported reactive results and whether reactive triage test results influenced biased interpretation of subsequent RDT results by the HTS provider. CONCLUSIONS: Diagnosis with the full algorithm following presentation with a reactive triage test is expected to achieve PPV above the 99% threshold. Continuing verification testing prior to ART initiation remains recommended, but HIV testing strategies involving HIVST and T4T may provide opportunities to maintain quality while increasing efficiency as part of broader restructuring of HIV testing service delivery