MOST VISUAL IMPAIRMENT IS AVOIDABLE
Priorities
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Intervention - reach children early in the disease process
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Patient centered - screen children where they are
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Sustainable - maximize the strengths of an existing healthcare systems
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Inclusive - mass screening, evaluation, and care for every child
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Input & Outcome Driven -overcome a global shortage of research and data for causes and rates of pediatric visual impairment
Model
CHILDREN IN MOST THE WORLD DO NOT RECEIVE VISION SCREENING BEFORE THEY ARE SCHOOL AGED. BABIES ARE ONLY REFERRED TO A PEDIATRIC OPHTHALMOLOGIST IF AN ISSUE IS SUSPECTED AT BIRTH.
This model is a framework of early vision screening using an established childhood vaccination protocol that provides vision screenings to infants and children. It relies on instrument-based screening that is quick, requires minimal cooperation of the child, and does not need to be performed by an ophthalmic professional.
In most of the world, the model of primary-care facilities (polyclinics) operate with public funds and are a trusted access point for healthcare. Worldwide, childhood vaccination compliance reaches well above 84% as vaccines are recognized as the most reliable form of disease control. Depending on a country's resources, the protocol for a child's vaccination can range from 3 to 6 injections before the age of 18 months. Primary-care clinics provide free vaccinations to all children. Vaccines are administered in separate visits and balance a child's health while increasing their immune system's resistance to disease, however, children must be well at the time of visits. During this visits and immediately prior to vaccination is a perfect time to administer a vision screening.
Phase I
DEVELOPING A PROTOCOL
Device Selection
Two devices for auto refractors were selected for field testing at Bascom Palmer Eye Institute in a tertiary clinical setting and in a real world setting in the public health clinics of Barbados and Suriname. Factors for consideration were:
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An infrared device that can be used in variable lighting conditions
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Usability for community healthcare workers with no previous vision screening experience
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Ability to record and transfer data into secure cloud based server
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Reliability of detection of ocular conditions
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Ability to charge device via solar power
Ultimately, it was determined that Spot™️ was a better fit for the PPB critteria.
Arclight is the currently the only device in the marketplace that captures an image of red reflex by connecting to a smartphone camera and uploaded to a cloud based server.
Screening Protocol
In May 2019, Dr. Christina Dowell traveled to Suriname and along with Dr. Denise Doelwijt collaborated with local staff to create the screening protocol for community healthcare workers to follow in vaccination clinics. As we begin the implementation of the vision screening protocol, we are ensuring ongoing collaborations with local clinics, organizations, and governmental agencies for feedback to ensure buy-in with in country stakeholders.
SURINAME, TEST OF CONCEPT
Health Provider Structure
In the coastal areas, near the capital of Paramaribo, the Regional Health
Services operates 43 primary health care facilities with public funds.
There are 150 private clinics that are only accessible to patients in the
coastal area. Medical care in the interior districts is provided via medical
mission trips by vans, or boats and planes when the region becomes
inaccessible by vehicle. The interior has 56 primary health clinics and
there are no hospitals in the interior.
Personnel
In collaboration with ophthalmologists at the Suriname Eye Centre,
The Suriname Project solicited volunteer medical students who
were taught to use handheld screening devices to detect signs
of congenital eye diseases.
Details
In July of 2019, Dr. Denise Doelwijt and Dr. Robert Bipat (President,
University of Suriname) and Matthew Javitt trained a team of 6 medical
students to perform vision screenings in vaccination clinics throughout
the capital city of Paramaribo. Over the course of 5 days, the team screened 234 children in 5 different clinics using photo screeners and the Arclight devices. This small cross section of the population provided a referral rate of 12% for refractive error and strabismus. Throughout the vaccination days, nurses and practitioners made vision screening a component of the routine for each child's visit. As a result, the program received an overwhelmingly positive response from caretakers, who were eager to have their children seen.
Symposium
In December 2019, an international team of more than 30 experts in
clinical ophthalmology, early screening, global ophthalmology,
public health, sociology, and health economics gathered at Bascom
Palmer Eye Institute to explore the PPB Model's strengths and
weaknesses. All effort has been made along the way to ensure that
the model addresses ocular disorders in the region, integrates into
local healthcare and referral systems, is responsive to cultural and
community norms.
Phase II
BARBADOS, PROOF OF CONCEPT
During the winter months of 2023 The PPB Team worked with members of Barbados’ Ministry of Health and Wellness (MOH) and the island’s only pediatric ophthalmologist, Mr. David Callender, to lay out plans for roles, responsibilities and logistics and to recruit key opinion leaders within the clinics. Crucial to the success of this project was the support of the MOH’s Chief Medical Officer, The Right Honorable Dr. Kenneth George, the Chief and Deputy Chief Public Health Nurses, Norma Bynoe, and Larone Hyland.
In March, the team hit the ground running. and performed screenings of 120 children in 7 polyclinics over five days where most of the island’s childhood vaccinations are administered. This represented approximately 5% of the infant population on the island. Photoscreeners were used to detect refractive errors and malalignment and to asses the fundus reflex for amblyogenic causes of vision impairment. This small cross-section of the population, provided a referral rate of 7.5% for refractive error.
Timeline
MARCH 2018 - A Concept is Born
MIAMI, Dr. Siban visits for observership in the surgical and clinical management of pediatric glaucoma at Bascom Palmer. Dr. Grajewski forms idea for screening during vaccine visits.
OCT 2018 - Symposium 1.0
MIAMI, Core study designers meet. Collaboration with industry to secure Spot and Arclight devices. LOI to USAID Child Blindness Program. Field work in Suriname over next 6 months
JULY 2019 - Announcement
TRINIDAD, OSWI Congress, Action Plan is laid out to build
partnership with UWI for region wide initiative integration. PAHO/WHO expresses interest in project.
DEC 2019 - Symposium 2.0
MIAMI, Balkan Center assembles 37 int’l experts who share the challenges of global ophthalmology projects. MOU between UMiami and UWI is signed in Jamaica.
JULY 2019 - Proof of Concept
SURINAME, Volunteer medical students trained on use of devices. Along with two project managers, they screen 234 children in 5 days at 5 polyclinics = 2% of newborn population.
NOV 2021- PPVIB
BARBADOS, Landmark study of 3,500 medical charts investigating the causes of Pediatric Visual Impairment in Barbados.
MARCH 2023 - Proof of Concept
BARBADOS, 120 children screened in 5 days at 7 polyclinics. Animated video and consenting adds < 4 minutes to well child visit. = Screening of 5% of newborn population
JULY 2023 - Symposium 3.0
MIAMI, West Indies pediatric visual impairment (VI) is 3x greater than US. Barbados Foreign Service to aid with healthcare policy.