University of Pennsylvania ScholarlyCommons Botswana-UPenn Scholarly Publications Botswana-UPenn Partnership 10-2011 Survey of Childhood Blindness and Visual Impairment in Botswana Sudha Nallasamy University of Pennsylvania William V. Anninger University of Pennsylvania, [email protected] Graham E. Quinn University of Pennsylvania, [email protected] Brian Kroener University of Pennsylvania Nicola M. Zetola University of Pennsylvania, [email protected] See next page for additional authors Follow this and additional works at: https://repository.upenn.edu/botswana_schol Part of the Diseases Commons, and the Optometry Commons Recommended Citation Nallasamy, Sudha; Anninger, William V.; Quinn, Graham E.; Kroener, Brian; Zetola, Nicola M.; and Nkomazana, Oathokwa, "Survey of Childhood Blindness and Visual Impairment in Botswana" (2011). Botswana-UPenn Scholarly Publications. 29. https://repository.upenn.edu/botswana_schol/29 This paper is posted at ScholarlyCommons. https://repository.upenn.edu/botswana_schol/29 For more information, please contact [email protected]. Survey of Childhood Blindness and Visual Impairment in Botswana Abstract Background/aims In terms of blind-person years, the worldwide burden of childhood blindness is second only to cataracts. In many developing countries, 30–72% of childhood blindness is avoidable. The authors conducted this study to determine the causes of childhood blindness and visual impairment (VI) in Botswana, a middle- income country with limited access to ophthalmic care. Methods This study was conducted over 4 weeks in eight cities and villages in Botswana. Children were recruited through a radio advertisement and local outreach programmes. Those ≤15 years of age with visual acuity <6/18 in either eye were enrolled. The WHO/Prevention of Blindness Eye Examination Record for Children with Blindness and Low Vision was used to record data. Results The authors enrolled 241 children, 79 with unilateral and 162 with bilateral VI. Of unilateral cases, 89% were avoidable: 23% preventable (83% trauma-related) and 66% treatable (40% refractive error and 31% amblyopia). Of bilateral cases, 63% were avoidable: 5% preventable and 58% treatable (33% refractive error and 31% congenital cataracts). Conclusion Refractive error, which is easily correctable with glasses, is the most common cause of bilateral VI, with cataracts a close second. A nationwide intervention is currently being planned to reduce the burden of avoidable childhood VI in Botswana. Keywords blind, blindness, visual impairment, Bostswana, Africa Disciplines Diseases | Medicine and Health Sciences | Optometry Author(s) Sudha Nallasamy, William V. Anninger, Graham E. Quinn, Brian Kroener, Nicola M. Zetola, and Oathokwa Nkomazana This journal article is available at ScholarlyCommons: https://repository.upenn.edu/botswana_schol/29 Survey of childhood blindness and visual impairment in Botswana Sudha Nallasamy1, William V Anninger1, Graham E Quinn1, Brian Kroener2, Nicola M Zetola3, and Oathokwa Nkomazana4 1Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA 2University of Pennsylvania School of Arts and Science, Philadelphia, Pennsylvania, USA 3Division of Infectious Diseases, University of Pennsylvania, Philadelphia, Pennsylvania, USA 4University of Botswana, School of Medicine, Gaborone, Botswana Abstract Background/aims—In terms of blind-person years, the worldwide burden of childhood blindness is second only to cataracts. In many developing countries, 30–72% of childhood blindness is avoidable. The authors conducted this study to determine the causes of childhood blindness and visual impairment (VI) in Botswana, a middle-income country with limited access to ophthalmic care. Methods—This study was conducted over 4 weeks in eight cities and villages in Botswana. Children were recruited through a radio advertisement and local outreach programmes. Those ≤15 years of age with visual acuity <6/18 in either eye were enrolled. The WHO/Prevention of Blindness Eye Examination Record for Children with Blindness and Low Vision was used to record data. Results—The authors enrolled 241 children, 79 with unilateral and 162 with bilateral VI. Of unilateral cases, 89% were avoidable: 23% preventable (83% trauma-related) and 66% treatable (40% refractive error and 31% amblyopia). Of bilateral cases, 63% were avoidable: 5% preventable and 58% treatable (33% refractive error and 31% congenital cataracts). Conclusion—Refractive error, which is easily correctable with glasses, is the most common cause of bilateral VI, with cataracts a close second. A nationwide intervention is currently being planned to reduce the burden of avoidable childhood VI in Botswana. INTRODUCTION By WHO criteria, there are 1.26 million children worldwide who are blind, 0.42 million of whom live in sub-Saharan Africa.1 While the estimated number of blind children has Correspondence to: Oathokwa Nkomazana, University of Botswana, School of Medicine, P/Bag 00713, Gaborone, Botswana; [email protected]. Competing interests None. Ethics approval This study was conducted with the approval of the Children’s Hospital of Philadelphia Institutional Review Board, Princess Marina Hospital Institutional Review Board and Ministry of Health of Botswana. Provenance and peer review Not commissioned; externally peer reviewed. Nallasamy et al. Page 2 improved or at least stabilised in other parts of the developing world, in sub-Saharan Africa, this number has increased by 31% over the past 10 years.1 Children who are blind have a lifetime of visual impairment (VI) ahead of them, with all the associated emotional, social and economic costs to the child, the family and the society. The worldwide burden of childhood blindness is second only to cataracts after accounting for duration of disability.2 Thus, childhood blindness is a major public health concern. In order to help nations combat childhood blindness and VI, it is important to determine the specific aetiologies by region. This will enable each nation to better understand its specific needs, and better ensure that appropriate resources are efficiently allocated for prevention and treatment. Botswana is a middle-income country in southern Africa with limited access to ophthalmic care. We conducted this study to determine avoidable causes of childhood blindness and VI in Botswana so that a nationwide intervention can be planned. METHODS Population of children in Botswana at risk for blindness or VI In Botswana, the population aged 0–15 years is approximately 720 000.3 Under 5 mortality rates (U5MR) are used to estimate prevalence of childhood blindness. For Botswana, this is 112/1000 children. However, if we estimate that 60% of deaths are due to HIV, as in neighbouring Zambia, the U5MR due to non-HIV causes is 40% of 112 or 45/1000 children. The estimated prevalence of blindness is, therefore, approximately 0.5/1000 children which translates to 360 blind children in Botswana (C Gilbert, personal communication, 2009).1 Children were recruited for this study from the community, schools and eye clinics. Radio announcements were made on Radio Botswana (national radio, with over 90% national coverage) in Setswana (the language spoken by more than 80% of the population, and the primary language of instruction in primary schools), throughout the day 2 weeks prior to the survey and throughout the survey period. Parents, guardians and other care givers were asked to bring children with ‘difficulty seeing’ to be examined on the dates that the study team would be in their area. In addition, the Ministry of Education, through the Special Education Division, mobilised district education officers, schools and district rehabilitation officers to identify children with ‘difficulty seeing’ for examination during the survey. The schools transported the children to examination sites. The Ministry of Health, through the Prevention of Blindness Programme, requested all ophthalmologists and ophthalmic nurses to keep a record of all the children with VI seen at their clinics so they could be recalled for examination by the research team. Botswana has one primary school for the blind in the north (Francistown) and one primary, three junior and one senior secondary schools in the south (Mochudi), which accept blind and severely visually impaired children. All the children in these schools who met the recruitment criteria were enrolled in the study. Screening was also done at a school in the far north of the country (Maun) which accepts children with multiple disabilities. The plan was for children to be recruited from the whole country. This study was approved by the Institutional Review Board of the Children’s Hospital of Philadelphia, the Ministry of Health of Botswana and the Institutional Review Board of Br J Ophthalmol. Author manuscript. Nallasamy et al. Page 3 Princess Marina Hospital in Gaborone, Botswana and conformed to the US Health Insurance Portability and Accountability Act. Study team and eye examinations The study was conducted over a 4-week period in February to March 2009 in eight cities and villages in Botswana (figure 1). The core study team consisted of three ophthalmologists (SN, WVA and ON), one refractionist, one ophthalmic nurse and low vision officer from the Ministry of Education. One day was used to train the core team. Additional personnel were recruited and trained locally at each site. Children ≤15 years of age with visual acuity <6/18 in one or both eyes were enrolled. Parental or guardian informed