Ocular disease and ophthalmic services in Malawi

Ocular disease and ophthalmic services in Malawi

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0277-9536/83 $3.00 + 0.00 Pergamon Press Ltd

Sot. SC;. Med. Vol. 17, No. 22. pp. 1773-1780, 1983 Printed in Great Britain

OCULAR

DISEASE

AND OPHTHALMIC

SERVICES

IN MALAWI

MOSES C. CHIRAMBO’ and TEFERA TIZAZU* ‘Chief Medical Oi%x.r, Ministry of Health, P.O. Box 30377, Lilongwe and ‘Malawi Rural Blindness Prevention Project, International Eye Foundation,

Malawi

Abstract-About 17; of the population of Malawi is blind. The major contributors are cataract (40x), trachoma and other infections (IS”/) and measles/Vitamin A deficiency (15%). There are 3 ophthalmologists in government service. However, one serves as the director of medical services, and is therefore frequently burdened with administrative duties. In addition, one missionary ophthalmologist and 25 ophthalmic auxiliaries are available. Two of the ophthalmic auxiliaries are being trained to perform cataract surgery to aid the ophthalmologists in attacking the current backlog of approx. 24,000 blind cataract patients in the country. Trachoma and onchocerciasis are present regionally, although the latter by itself does not appear to be a major cause of vision loss. In children under age five, the major causes of blindness are measles and protein-energy-malnutrition (PEM) and its associated hypovitaminosis A. Previous surveys in Malawi have been either clinic/hospital-based or have been local population-based studies, In order to establish a realistic plan of preventive and therapeutic action, a comprehensive series of country-wide population-based ocular disease prevalence surveys is planned over the next five years. The information will enable the Ministry of Health to more equitably disperse trained ophthalmic personnel and to obtain appropriate supplies and drugs in a rational manner.

OCULAR DISEASE PREVALENCE SURVEYS Introduction

Malawi has a large number of blind persons, posing serious public health, social and economic problems to the country. The blindness rates are between 0.8 and 1.OT: of people in the population with visual acuity poor

enough to make gainful employment impossible. In addition to their lack of individual productivity, the blind remain a constant drain on the resources of the community which must support them. DEMOGRAPHIC DATA was carried out in September/ October 1977 and the final report published in 1980. The total population was 5,547,460 in 1977. This represents a 379; increase over the 1966 census figure The latest

census

of 4,039, 583, equivalent to an annual growth rate of 2.9%. Table 1 gives the summary of total population in the 1901-I 977 census and the intercensal growth rates. The 1956 census figure is not included in the table because the African population was not counted during the 1956 census (the figures for Africans were estimated and the total population was estimated at 2,590,OOO). The main causes of visual impairment and blindness are cataract (40x), trachoma and infections of the eye (15x), measles/Vitamin A deficiency (15x), degenerative/inflammatory diseases of the eye (15%) glaucoma (8x), trauma (4x), onchocerciasis (2%) and others (1%). Over 70% of blindness is either preventable or curable. There are 4 eye specialists and 25 ophthalmic auxiliaries available at present to serve 6 million people in the country.

Table I. Total population:

1901-1977

censuses

DC irrrc population 1901 1911 1921 I926 1931 1945 I966 I977

737. 153’ _ _ 1.263.291 I s73.454 2.049.914 4.039.583 5.547.460

970.430’ I .201,983’ I .293.291 I .603.454 2.183.220 4.305.583 _

1773

_ 2.8 2.2 1.5 4.4 2.2 3.3 2.9

Mos~sC. CHIRAMBO~~~TEFERATIZAZU

1774

Table 2. Summary of population densities

I966

National Northern Central Southern

4.039.583 497.491 I .474.952 2.067.140

1977

94.079 26.874 35.519 31.686

43 19 42 65

5.547.460 648.853 2.143.716 2.754.891

94.276 26.931 35.597 31.753

59 14 60 87

Sorrrw Malawi Population Census 1977. It can be seen that the Southern Rerion ia the most densely populated followed by the Central [email protected] Both rhr 1966 .Ind I977 liyure> show a Gmllar trend.

Review

qf Literature

Gopsil [l] first reported onchocerciasis in Malawi. Ben Sira and Yassur [2, 31 studied onchocerciasis in Thy010 District, the only known focus. They compared the ocular findings in 500 patients who had positive skin snips at the outer canthus with 500 controls in whom there was no clinical sign of onchocerciasis. They found that 5% (65 eyes) of the onchocercal patients were blind. Common causes of blindness were : cataract (33 eyes); glaucoma (16 eyes); cornea1 opacities (10 eyes); and optic atrophy (5 eyes). During 1955-1956, while making a leprosy survey, Currie [4] found 45 ‘totally blind’ in a population of 26,701 people examined in Lilongwe, Fort Manning (Mchinji), Mulanje and Karonga. The lowest prevalence was in Lilongwe. These findings are quoted by Merin [5]; they show a prevalence of 168 per 10,000 for ‘total blindness’. Clarkson [6], while in charge of the Royal Commonwealth Society for the Blind Mobile Team working in Nsanje area, examined 13,486 persons who presented out of a total estimated population of 24,350. He found 40 ‘totally blind’, i.e. a rate of 297 per 100,000. He also found that 80% of the Nsanje population had had trachoma, but onIy0.7% developed complications. He found complications of measles in 2.12, of those examined and cataracts in a further 1.3%. Merin [7,8] commented on Clarkson’s data that since only a part of the population was examined this might

Table 3. Percentage distributmn in 1977 census by j-year group and sex 1977 Cenau, Ape-Group All age, Under 5 59 IO I4 I5 I9 20 24 25 29 30 34 35 39 40 44 45 49 50 54 55 59 60 64 65

Both hexes 1000 19.5 14.9 10.3 9.7 8.1 7.9 5.5 5.0 3.7 3.9 2.6 2.4 1.9 4.5

Mele 100.0 19.8 15.3 I I.0 9.8 7.3 7.6 5.4 4.9 3.5 3.9 2.5 2.4 1.8 4.6

FClll;lle 100.0 19.2 14.5 9.6 9.7 8.8 8.1 5.6 5.1 3.8 4.0 2.8 2.3 2.0 4.4

age

introduce a serious bias, but that the report supported his own impression of a higher prevalence of blindness in Nsanje area. Assuming the prevalence of inability to count figures at 3 metres was four times as great as total blindness, Merin estimated the prevalence of blindness for Malawi as a whole to be 700 per 100.000 (0.7%). Freund [9] drew attention to the excessive number of persons aged [email protected] years with considerable visual loss due to open angle glaucoma and pointed out that closed angle glaucoma was virtually unknown. Ticho and BenSira [lo] found ocular lesions in 532 (6.3%) of 8325 leprosy patients registered in’ Malawi at the time. The prevalence of blindness (inability to count fingers at 3 metres) due to leprosy among these patients was only 0.3:/,. This low prevalence was attributed to the wide use of sulphones. Chirambo and BenEzra [l 1. 121 examined 270 students in 17 schools for the blind in 1975 and found that 73% were blind before the age of 3. The most commoncauseofblindness was ocular infections (75%) ; sequelae of measles as a single cause of blindness was responsible for 44”% of cases, and bacterial infections were incriminated in 26% of cases. A further study by BenEzra and Chirambo [13] analysed registration of blind children and estimated an annual incidence of 34 blind per 100,000 children under 5 years of age. Among the causes of blindness, direct ocular infection was found in 32% ofcases. Bacterial agents were responsible for 20% of all cases while sequelae of measles were the causes of blindness in 12% of all cases. Budden [14) estimated that the blindness rate in Malawi is 1000 blind per 100.000 using the WHO recommended standard for blindness. With a projected population of 5.9 million in 1979, Malawi therefore had about 60,000 blind persons. Approximately 709; of this blindness was preventable or curable. The common avoidable causes of blindness were cataract (25,000 blind), complications of trachoma (7000 blind) and comeal lesions of childhood onset (5000 blind). Of the estimated 5000 blind due to comeal lesions, the conditions were acquired in childhood as a result of measles and/or malnutrition. The actual incidence of these lesions is no doubt considerably higher than the figure suggests because there is known to be a high mortality among blind malnourished children. The clinical picture closely resembles kerdtomaiacia. It is probable that the underlying cause is Vitamin A deficiency associated with protein-energy malnutrition and that measles is a common precipitating factor. Chirambo and Mbvundula ,[15]. evaluating the

T:~blc 4. V11al alatislics

(government

estimates)

50.8 per 1000 population (nalional) 24.2 per 1000 populalion fnaltonall 26.6 per 1000 OT 2.6”,. 7.7 blrlhs per woman of completed fertihty 296 per 1000 for 25 29 age group in 1971 !I973 20 24 ape group m 1977 142 per 1000 live births (nakmal average) 151 per 1000 live births (rural areas) 74 per 1000 live brrrhs (urban areas) 50.7”,, of all deatha (1972) 40.9 years (national) 44.2 years (national) 42.4 years (national) 40.3 years (rural)

scanty evidence available on the epidemiology of Vitamin A deficiency, concluded that Vitamin A deficiency is a problem in Malawi especially the Lower Shire Valley ecological zone. Vitamin A deficiency is due to multiple factors: interaction of low rainfall with resultant low production and consumption of green leafy vegetables. low fat intake. interaction of infectious eye disease (trachoma) with measles and protein energy malnutrition. Duke [16] confirmed the problem of onchocerciasis in Thyolo. Although the prevalence was high, the intensity of infection was low to moderate. He recommended a plan of action for monitoring the extent and severity of the infection for controlling transmission.

MANPOWER

FOR

THE

EYE HEALTH

CARE

SERVICES

Ophthalmologist There are three government ophthalmologists and one at a mission hospital. One government ophthalmologist is stationed at Queen Elizabeth Central Hospital, Blantyre. and another at Kamuzu Central Hospital, Lilongwe. Each has the task of providing specialist services as well as conducting training courses in eye health care for the auxiliary training school. Large numbers of patients present to the eye clinics for dragnosis and treatment, far exceeding clinic capacity. Little time is available for the ophthalmologists to participate in the didactic and practical training of auxiliaries, adversely affecting the quantity and quality of training in recognition, diagnosis, treatment and/or referral of patients with eye disorders at all levels. Regular. scheduled supervision and refresher training visits to ophthalmic auxiliaries posted to district hospitals is seldom accomplished due to lack of time. Ophthalmic

auxiliaries

Currently there are 25 ophthalmic auxiliaries working throughout the health system. Two are training in intra-ocular surgery’. practicing at Kamuzu Central Hospital and Queen Elizabeth Central Hospital respectively under the supervision of the ophthalmologist. Both Queen Elizabeth Central Hospital and Kamuzu Central Hospital utilize ophthalmic auxiliaries (some at the clinical officer level) to conduct

and 280 per 1000 for

most eye examinations, difficult cases being held for consultation with the ophthalmologist. Fourteen ophthalmic auxiliaries are posted to district hospitals where they provide curative services. In addition, most accompany other teams on visits to peripheral health stations, treating patients and giving practical on-thespot training to health workers stationed there. Two Mobile Eye Units are functioning, one in the Southern Region and the other in the Northern Region. In general, non-ophthalmic medical assistants, clinical officers and Enrolled Nurses/Midwives tend to refer all eye cases to the ophthalmic auxiliaries where possible, rather than to diagnose and treat them [17, 181. This is, in part, due to a lack of practical experience in the eye clinics during their training and a resultant feeling of inadequacy. Enrolled midwives assistants

and

maternal

and

child

health

The activities of the enrolled midwives and maternal and child health assistants currently include some preventive aspects including eye disease prophylaxis at birth, promotion of breast feeding and proper weaning habits, immunization against measles, and early selfreferral for eye disorders. Primary health workers Primary health care training has scant attention paid to vision. This will be changed is developed since eye diseases Malawi.

EYE HEALTH

CARE

as presently eye disease as the PHC are common

TRAINING

constituted and loss of curriculum throughout

IN MALAWI

Physician No residency programme leading to specialization in ophthalmology is available in Malawi. Increases in numbers of specialists must come from training Malawian physicians abroad or by recruiting expatriates. Lectures and case presentations by ophthalmologists are given to the Medical Association of Malawi, hospital staff conferences, and schools for nurses and auxiliaries. Ophthalmic auxiliaries (OA ‘s) Training leading to a designation as ophthalmic auxiliary is given in a nine-month course located at

1776

MOSES C. CHIRAMBO

Kamuzu Central Hospital in Lilongwe. Minimum entry requirements include at least medical assistants or clinical officer or enrolled nurse training, three to five years’ experience in general medicine, the Malawi Certificate of Education or Junior certificate, and recommendation from the applicant’s superiors. Policy prescribes that medical auxiliaries recruited from health units will be returned to their original post on completion of training; this is not always achieved. The training includes an extensive series of didactic lectures covering anatomy, physiology, pathology, vision and refraction, diagnosis and treatment up to and including extra-ocular surgery. Intra-ocular surgery is not currently being taught to trainees owing to the lack of facilities and equipment at the district hospital level and unavailability of adequate supervision by ophthalmologists [IS]. No courses are given currently outlining the theory and practice of Primary Health Care and the concept of Primary Eye Care as an integral component. Also lacking are lessons in teaching techniques and discussions about motivating communities to participate in their own eye health care. Public health and preventive ophthalmology, as well as the prevention of blindness, while touched upon, need to be expanded. Since 1969, 27 ophthalmic auxiliaries have been trained. Twenty-five ophthalmic auxiliaries are still in practice, 6 at Queen Elizabeth Central Hospital, 8 in Southern, 4 in Central and 4 in Northern Region. Two are attached to the Mobile Eye Units at Ngabu in the Southern Region and at Karonga in the Northern Region. Only two ophthalmic auxiliaries are performing intra-ocular surgery, at Queen Elizabeth Central Hospital and Kamuzu Central Hospital respectively.

and

covered of cases wented

Bacterial conjunctivitis Vernal conjunctivitis Keratitis Trachoma Uveitis Lid repair Refractions Others Opcvolions h.v .WEU Trichiasts Pterygium Conjunctival tnmnnr Chalazion Others (eviscerations and enucleations) Re/irrol of NLW.S ,o Q. E. Cenrrul Hospirul Senile cataract Developmental cataract Traumatic cataract Others (complicated) (sic) Leucoma (graft) (sic) Leucoma (optic iridectomy) (SIL.) Others (tumoura etc.) Nunrhrr.\ ,IJ operutions or Rumphi Disrrkr Cataract extraction Optic itidectomy Glaucoma

TIZAZU

Clinical officers, medical assistants, state registered nurses, enrolled nurses

Each of the above categories of health workers has an ophthalmic section in their studies. The curriculum is well rounded in the basics of diagnosis and treatment of a wide range of eye disorders and diseases. Because of the lack of supervisory and training staff, however, little time is given to practical guided experience in clinic, leaving the students somewhat uncertain of their own capability in eye care. No special emphasis is placed on primary eye care as an integral part of primary health care. The relationship between public health and preventive ophthalmology is not stressed. No courses in teaching methodologies and techniques are given. Prevention of blindness programme components and functions are not outlined for these students. The role of the primary health care workers in providing primary eye care and the role of the health care workers in the health centres, sub-centres and posts who train, support and supervise them should be taught and demonstrated. Other auxiliaries and allied sectors

Maternal and child health assistants have only a brief introduction to eye care. Little or nothing is taught to the Farm Home Instructress in recognition of eye problems and the need for early treatment and referral. Other workers closely allied to the rural communities likewise receive scant attention. Primary health workers The present Primary Health Care curriculum training course only mentions conjunctivitis in passing and has no section on the recognition of eye disorders

Table 5. Shows the statistics of the Mobile

I. Mileage 2. Nwnber

TEFERA

Eye Untt at Rumphi

1975

I976

I977

5713 5051* 203 1 56 85 143 93 IO 2076 557. 42 14 5 8 II 4 74 39

6551 4597 1270 43 306 169 70 IO 2392 332 35 13 3 7 8 4 120 49 _ 5 19

2340 3155 876 57 47 76 49 24 I706 320 14 4 0 7 2

3359 4868 1376 38 55 424 78 6 2436 458 20 6

4 21 3 6 Hmpt/ol

19741977

1974

55 53

6 40 43 41 2

33 19 4 6 2

44 43

4 5 51 41 8 2 _

Oculx disease and ophthalmic seruces in Malawi and loss of vision. Treatment of simple eye infections is not taught. No mention of prevention of blindness is included. No visual aids are currently available for demonstrating normal and abnormal eyes and examples of eye conditions which should be referred or treated. PREVENTION

ACTIVITIES

177-l

an average of 200 eye operations every year. In 1977 no such visits were made because of shortage of staff. The ophthalmic theatre has adequate equipment to cope with the most common eye operations. In the future, however, the ophthalmic theatre will soon need the replacement of some instruments. Out-patient departmenr. At Queen Elizabeth Central Hospital accurate records exist only for the general OPD and not for the eye-OPD. Figures given below of 45,OOO-50,000 attendances per year at the eye-OPD in 1977 are estimates only. In 198 1 a separate register for the eye-OPD was introduced in order to determine the number of attendances accurately.

During the past 15 years, this field has received a boost through the operation of Mobile Eye Units (MEU), donated by the Royal Commonwealth Society for the Blind. Currently, there are two such MEU’s; one for the Northern Region and the other for the _ Southern Region. The MEU consists of a four-wheel SUPPLIES/DRUGS/EQUIPMENT drive Landrover, an ophthalmic auxiliary and a driver. It is fully equipped and plays a major role in The bulk of drugs and equipment for eye health preventive ophthalmology. The ophthalmic auxiliary facilitiesarepurchased from thecentral Medical Stores travels from village to village to give talks on basic by the Ministry of Health. Mobile Eye Units, and hygiene, explains ocular complications arising from the some surgical equipments and drugs, are supplied by use of traditional herbs, and encourages mothers to the Royal Commonwealth Society for the Blind and the vaccinate their child against the six communicable International Eye Foundation. diseases of children in general and against measles in particular. The rural communities are also urged to NATIONAL HEALTH POLICIES, make use of the available health services. Common eye PLANS AND LEGISLATION infections are treated on the spot and complicated cases are referred to central hospitals. Planning machinery in the health sector CURATIVE

SERVICES

There are three ophthalmic departments: Queen Elizabeth Central Hospital (54 beds), Kamuzu Central Hospital (32 beds) and Nkhoma (20 beds). Besides the three departments, there are 15 static clinics and 2 mobile clinics providing curative services in health. Eye department

at Queen Elizabeth

Central Hospital

Ward. The ophthalmic Unit has 54 beds. In 1977 there were 1446 admissions and the average daily bed state was 63.2. As can be seen from Table 6, the commonest eye diseases were cataract, acute ophthalmia, ocular injury and glaucoma. The incidence of retinoblastoma was higher than in previous years. Operating theatre. Since 1969 the Ophthalmic Unit at Queen Elizabeth Central Hospital has had its own operating theatre. This has enabled eye surgeons to operate without having to depend entirely on the facilities of the general theatre which serves the other surgical wards in the hospital. In 1977 there were 1533 operations. As can be seen from Table 7, in 1977 and the previous years, the operations for cataract, glaucoma, repair of comeal perforation, excision of conjunctival tumours and enucleation/evisceration of globe due to either an intra-ocular cancer/anterior staphyloma or severe intra-ocular infection, constituted a large proportion of all operations. Comeal transplantation has been done on a distressingly low number of patients due to the considerable difficulties in obtaining donor material. These operations were all done on in-patients and out-patients at the Eye Department of the Queen Elizabeth Central Hospital in Blantyre. In the past; periodical visits to conduct eye clinics and perform eye operations at selected district hospitals helped to reduce the number of referrals. During such visits, there were

Overall coordination is the responsibility of the Health Planning Unit in the Ministry of Health. This

Table

6. Diagnosis of 1446 patients admitted LO the eye ward I January. 1977-31 December, 1977

cararact Senile Development Traumatic Complicated

517 480 14 10 9

GhUCOlllii

ConJuncliLitis Muco-purulenl Ophthalmia neonatorum Keraritis Non-suppurative Purulenl keratitis Measles,keralomalscia Mooren’r ulcer Panophthalmitis Swabismus Painful blind eye Anterior aaphyloma Uveitis Conjuncrival carcinoma Retinoblaaoma Retmal detachment Trauma Cornea! perforation Hyphema Dislocation of lens Ruptured globe , Penelratmg cornea1 FB Lid lacerauon Cornea1 opacity Trichiws PlOSl, Orbital rumour Pterygtum Cortical blindness Optic atroph! Others

62 70 56 14 II5

.

41 59 6 9 45 7 26 20 44 II 23 6 112 47 I4 8 15 8 20 36 31 I4 33 I2 IO 13 239 1446

1778

MOSES C. CHlRAhiBo Table 7. Operations

performed

and TEFERATIZAZU

at Queen Elizaberh

I974 Catllract operations Senile Developmental Traumatic Cornea1 transplantations Repair of perforated cornea Eviscerationienucleation Glaucoma operations Trabeculectomy Other Exenteractlon Excision of conjunctival turnour Retinal detachment operations Strabismus Lid operattons Laceration Ectropion Trichiasis Ptosis Optic iridectomy Dacryocystorrhinostomy Other major operation Other mmor operation Totals

Central

Ho~p~rai. 1974- 1977

1975

1976 936

638 865 32 39

587 14 37

57 2

I6 65

1616

1675

National health policy The national health policy, developed by the Ministry of Health in 1980, has the following aims: To provide a comprehensive health care delivery system throughout the country. While the basic health service network, consisting of a Primary Health Centre for every 50,000 people, a sub-centre for every 10,000 people and a Health Post for every 2000, will be established, health services at the community level will be provided by Primary Health Workers. To strengthen and expand Maternal and Child Health Services and health education. Replacement and renovation of old and inadequate hospital facilities in rural and urban areas. To strengthen measures for the prevention and control ofcommunicable diseases. These include vector control (e.g. Simulium), provision of basic sanitation facilities and safe water supplies, and the early detection and treatment of disease. To train health personnel at all levels and orient health manpower development towards meeting the needs of the communities in which they work.

LEADING CAUSES OF BLINDNESS IN MALAWI

Cataract

Senile cataract is the commonest overall cause of blindness in Malawi. While cataracts cannot be prevented, the blindness resulting therefrom can be cured by means of cataract extraction and the provision of aphakic glasses. With only three ophthalmologists and two ophthalmic auxiliaries currently performing

II

3 73

86

I

4 9 I23

I6 90 36 29 53 5

19 2s 46 24 -_ II6 223

Unit prepares the proposed plan in cooperation and consultation with the technical and administrative division in the Ministry of Health. The Ministry of Health processes the plan directly with the Develop ment Division oftheOt%ce of the President and Cabinet.

2

I

4 6 250 278

6 34 92 27 2b

25

I7 IO 70 2

21 20 42 4

729 33 47 7 58 95 26

3 56 2 12 99

2 47 2 7 93

809

645 541 38 66

23 34 88 59

70 24 114 81

I977

48 3 59 235 1356

cataract surgery. the estimated back-log 24,000 cases will continue to grow. Approaches

20 60 75, ___ 1533

of at least

:

(1) The recruitment

of more eye specialists for curative and preventive eye health care. (2) The training of more ophthalmic auxiliaries to conduct cataract operations under supervision. (3) The extension of-eye health care services to remote areas through mobile units to restore sight by utilizing district hospitals for cataract extractions. Truchoma The Lower Shire Valley, with its large population, is the major source of blindness from the effect of recurrent untreated bouts of trdchoma resulting in entropion, trichiasis and comeal opacitication. There is also trachoma in the Lakeshore areas. While not of the same severity of the Lower Shire Valley, cases of trichiasis and entropion from other areas continue to present for care. This blindness is almost entirely preventable. Comeal transplantation of trachomadamaged corneas has been unrewarding as a curative measure once the damage has occurred. Approaches:

(1) Case-finding and mass chemotherapy especially for children with the active infectious phase. (2) Surveillance of adults in endemic areas to detect those with complications leading to blindness and early referral for corrective surgery on the lids. (3) Community-based environmental and behavioural intervention through health education. (4) Establishment of additional eye clinics and posting of more OAs to the Lower Shire Valley.

Ocular disease and ophthalmic services in

Malawi

I779

Corned blindness due to microbial infktions

Onchocerciasis

In older agegroups, comeal blindnessdue to keratitis and comeal ulceration, much of which follows trauma, assumes a more important role. The role of the use of corrosive ‘traditional’ medicine in the eye in the pathogenesis of comeal blindness should not be overlooked. This category of blindness is amenable to prevention ; curative comeal transplantation is exaltogether time-consuming not pensive, and satisfactory.

Thyolo district, with a population of 322,000, is the only known focus of onchocerciasis in Malawi. According to current data, there is little serious eye disease and the infections are of light to moderate intensity. But it is possible that onchocerciasis is on the increase due to an increase in the S. dumnos~rm populationfollowingdeforestation. The biting nuisance of the fly, and the fear of onchocerciasis among the workers and their families on the extensive and economically important Thy010 Tea Estates, indicate the need for local control measures based on larviciding.

Approaches: (1) Early referral and treatment with locally available drugs by any health personnel. (2) Limitation in the distribution of topical corticosteroids. (3) Education of traditional practitioners to avoid the use of corrosive medicine in the eye. Cornea/ bliminess Deficiencies

due

to

measles

and

nutritional

In children under the age of five, the main cause of blindness appears to be the association between measles and protein-energy malnutrition, though the mechanism is uncertain [7, 11, 13, 151. The Expanded Program of Immunization (EPI) appears to have decreased the incidence of comeal blindness in children due to measles. Once the attack phase of the measles campaign is over, immunization will be limited to children visiting under-five clinics. This may result in a resurgence of measles and accompanying blindness, as only a portion of the population will be served. Approaches :

(I) An extensive

continued vigorous health education program and immunization against measles for under-five clinics. (2) Research to determine the covariant conditions leading to comeal blindness in children with measles keratitis. concomitant viral (herpes simplex virus) and bacterial infections.

Chronic simple glaucoma is an important cause of blindness and is difficult to detect at an early stage. It is painless, insidious and remains unpecognised by the patient until vision is irretrievably lost. .4pprouche.s : (1) Referral of all cases of vision loss for specialty examination. (2) Routine tonometry for over-40s.

Most eye injuries occur in the course of agricultural pursuits. These injuries often result in disabling eye lesions from secondary infection, due to delayed treatment. Increasing industrialization is likely to increase the incidence of ocular injuries. .4pprouchf.s

(1) Referral

for treatment of those cases where indicated. (2) Promotion of the use of protective eye devices where ocular hazards exist in various industries.

Approaches :

(1) Determination

of the distribution and severity of onchocerciasis in the Thyolo District by simple surveys and spot surveys in some other areas. (2) Studies of the biology and breeding sites of Simulium damnosum in Thyolo, with a view to developing a larvicidal control programme. (3) Legislation to allow women in Thy010 to wear long trousers for possible protection against S. damnosum. (4) Utilization of a medical entomologist in the community health unit. Leproq’ Leprosy is a major public health problem However, the contribution of leprosy blindness rates is not known.

in Malawi. to overall

Approaches : (I) Determination of ocular leprosy prevalence in endemic areas. (2) Training of ophthalmic auxiliaries in diagnosing ocular leprosy and treating its complications

SURVEYS AND DATA COLLECTIOii

Previous prevalence surveys were conducted by WHO consultants in four districts of Malawi in 1979 [14]. All other ‘surveys’ were estimates by field officers or ophthalmologists at the Central Hospital. In future, broader surveys will be carried out to obtain information on the prevalence of visual impairment and blindness and their causes in all age groups.

SUMMARk’ AND CONCLUSIONS

The main causes of visual impairment and blindness are cataract, trachoma and niicrobial infections of the eye. measles/nutritional deficiency. degenerativejinflammatory diseases of the eye, glaucoma, ocular injury and onchocerciasis. There are four ophthalmologists and 25 ophthalmic auxiliaries who provide eye health care in the 3 central hospitals and 15 (of 24) districts, and 2 Mobile Eye Units providing preventive services in the 2 regions. The training of ophthalmic auxiliaries. begun in 1969, has qualified 27 ophthalmic auxiliaries: the ophthalmologists at central hospitals participate in the training of other health personnel in basic e)e health care.

1780

Moses C. CHIRAMBO and TEFERATIZAZU

During the next five years the following objectives will be achieved : (1) Thecompletion of surveys to obtain information on the prevalence of visual impairment and blindness, and their causes. (2) The formulation of national programmes for the control of blindness. (3) The establishment of permanent facilities for eye health care as an integral part of general health services at peripheral, district and central levels. (4) The development of eye health manpower required for all levels, particularly at the peripheral and district levels. (5) The intensification of educational efforts on eye health care through the mass media and the spread of education. (6) The extension of eye-care services through mobile units to restore sight by conducting eye operations in district hospitals to clear the back-

log of cataract cases. (7) The mobilization of resources to implement the programme through the National Prevention of Blindness Committee, comprised of representatives from the government, the Malawi Council for the Handicapped, community service clubs and international agencies. At the initial stages well-controlled surveys will be carried out with WHO/IEF collaboration and other bilateral assistance to determine the prevalence and causes of blindness and to distinguish which are preventable and which are curable. Subsequently, a national programme for the control of blindness and the treatment of eye diseases will be developed. This will include the expansion and strengthening of the infrastructure for the delivery of eye health care to both urban and rural communities and the utilization of health personnel as ophthalmic auxiliaries. Furthermore, it is necessary to establish and expand the training programme for ophthalmic auxiliaries within the existing Medical Auxiliary Training School in Lilongwe.

REFEREYCES I. Gopsil W. L. Onchocerciasis in Nbasaland. Sot. rrop. .Llrti. H.yg. 32. 551-552. 1939.

Trtrrls. R.

2. Ben Sira I., Ticho U. and Yassur Y. Onchocerciasis in Malawi: prevalence and distribution. Trans. R. Sot. tron

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