Are people with disabilities at higher risk of COVID-19-related mortality?: a systematic review and meta-analysis.

OBJECTIVES: To undertake a systematic review and meta-analysis to estimate the relative risk of COVID-19-related mortality among people with disabilities compared to people without disabilities. STUDY DESIGN: Systematic review and meta-analysis. METHODS: We systematically searched four databases from March 1, 2020, to August 15, 2022. We included prospective studies with a baseline assessment of disability and a longitudinal assessment of the COVID-19-related mortality. Two reviewers independently assessed study eligibility, extracted data, and assessed risk of bias. We undertook random-effects meta-analyses to calculate pooled adjusted hazard ratios for COVID-19-related mortality for people with disabilities, also disaggregated by disability type and study setting. RESULTS: We identified 2596 articles throughout the electronic data search, and 56 studies were included in the review. Most (73%) had a moderate risk of bias. The pooled adjusted effect estimate for COVID-19-related mortality in people with disabilities compared to those without was 2.7 (95% confidence interval [CI]: 2.4-3.2). Heterogeneity between the studies was high (τ2 = 0.28, I2 = 97%). Effect estimates were highest for population-based samples (3.3, 95% CI: 2.7-3.9), compared to hospital settings (2.1, 95% CI: 1.7-2.7). Risk was not elevated among people with disabilities in care home settings (1.6, 95% CI: 0.7-3.5). Disaggregation by disability type showed that people with intellectual disabilities were at the highest relative risk of COVID-19 mortality. DISCUSSION: Risk of COVID-19 mortality is elevated among people with disabilities, especially people with intellectual disabilities. Efforts are needed to collect better routine data on disability and to include people with disabilities in the pandemic response for COVID-19.

Disability and participation in breast and bowel cancer screening in England: a large prospective study.

BACKGROUND: There is limited information about participation in organised population-wide screening programmes by people with disabilities. METHODS: Data from the National Health Service routine screening programmes in England were linked to information on disability reported by the Million Women Study cohort participants. RESULTS: Of the 473 185 women offered routine breast or bowel cancer screening, 23% reported some disability. Women with disabilities were less likely than other women to participate in breast cancer screening (RR=0.64, 95% CI: 0.62-0.65) and in bowel cancer screening (RR=0.75, 0.73-0.76). Difficulties with self-care or vision were associated with the greatest reduction in screening participation. CONCLUSION: Participation in routine cancer screening programmes in England is reduced in people with disabilities and participation varies by type of disability.

Initial combination therapy versus step-up therapy in treatment to the target of remission in daily clinical practice in early rheumatoid arthritis patients: results from the DREAM registry.

BACKGROUND: Treat to target (T2T) is widely accepted as the standard of care for patients with rheumatoid arthritis (RA) and has been shown to be more effective than traditional routine care. The objective of this study was to compare the effectiveness of two T2T strategies in patients with early RA: a step-up approach starting with methotrexate (MTX) monotherapy (cohort I) versus an initial disease-modifying antirheumatic drug combination approach (cohort II). METHODS: A total of 128 patients from cohort II were case-control-matched with 128 patients from cohort I on gender, age, and baseline disease activity. Twelve-month follow-up data were available for 121 patients in both cohorts. The primary outcome was the proportion of patients having reached at least one 28-joint Disease Activity Score (DAS28) score <2.6 (remission) during 12 months of follow-up. Secondary outcomes were time until remission was achieved and mean DAS28 scores at 6- and 12-month follow-up. RESULTS: After 12 months of follow-up, remission was reached at least once in 77.3 % of the patients in cohort II versus 71.9 % in cohort I (P = 0.31). Median time until first remission was 17 weeks in cohort II versus 27 weeks in cohort I (P = 0.04). A significant time by strategy interaction was found in mean DAS28 scores. Post hoc analysis revealed a significant difference in mean DAS28 scores between both cohorts at 6 months (P = 0.04), but not at 12 months (P = 0.36). CONCLUSIONS: The initial combination strategy resulted in a comparable remission rate after 1 year but a significantly shorter time until remission. At 6 months, mean DAS28 scores were lower in patients with initial combination treatment than in those with step-up therapy. At 12 months, no significant differences remained in mean DAS28 scores or the proportion of patients in remission.

Evaluation of the feasibility and acceptability of the 'Care for Stroke' intervention in India, a smartphone-enabled, carer-supported, educational intervention for management of disability following stroke.

OBJECTIVES: (1) To identify operational issues encountered by study participants in using the 'Care for Stroke' intervention; (2) to evaluate the feasibility and acceptability of the intervention. DESIGN: Mixed-methods research design. SETTING: Participant's home. Participants were selected from a tertiary hospital in Chennai, South India. PARTICIPANTS: Sixty stroke survivors treated and discharged from the hospital, and their caregivers. INTERVENTION: 'Care for Stroke' is a smartphone-enabled, educational intervention for management of physical disabilities following stroke. It is delivered through a web-based, smartphone-enabled application. It includes inputs from stroke rehabilitation experts in a digitised format. METHODS: Evaluation of the intervention was completed in two phases. In the first phase, the preliminary intervention was field-tested with 30 stroke survivors for 2 weeks. In the second phase, the finalised intervention was provided to a further 30 stroke survivors to be used in their homes with support from their carers for 4 weeks. PRIMARY OUTCOMES: (1) operational difficulties in using the intervention; (2) feasibility and acceptability of the intervention in an Indian setting. Disability and dependency were assessed as secondary outcomes. RESULTS: Field-testing identified operational difficulties related to connectivity, video-streaming, picture clarity, quality of videos, and functionality of the application. The intervention was reviewed, revised and finalised before pilot-testing. Findings from the pilot-testing showed that the 'Care for Stroke' intervention was feasible and acceptable. Over 90% (n=27) of the study participants felt that the intervention was relevant, comprehensible and useful. Over 96% (n=29) of the stroke survivors and all the caregivers (100%, n=30) rated the intervention as excellent and very useful. These findings were supported by qualitative interviews. CONCLUSIONS: Evaluation indicated that the 'Care for Stroke' intervention was feasible and acceptable in an Indian context. An assessment of effectiveness is now warranted.

Prevalence and causes of hearing impairment in Africa.

OBJECTIVE: To systematically assess the data on the prevalence and causes of hearing impairment in Africa. METHODS: Systematic review on the prevalence and causes of hearing loss in Africa. We undertook a literature search of seven electronic databases (EMBASE, PubMed, Medline, Global Health, Web of Knowledge, Academic Search Complete and Africa Wide Information) and manually searched bibliographies of included articles. The search was restricted to population-based studies on hearing impairment in Africa. Data were extracted using a standard protocol. RESULTS: We identified 232 articles and included 28 articles in the final analysis. The most common cut-offs used for hearing impairment were 25 and 30 dB HL, but this ranged between 15 and 40 dB HL. For a cut-off of 25 dB, the median was 7.7% for the children- or school-based studies and 17% for population-based studies. For a cut-off of 30 dB HL, the median was 6.6% for the children or school-based studies and 31% for population-based studies. In schools for the deaf, the most common cause of hearing impairment was cryptogenic deafness (50%) followed by infectious causes (43%). In mainstream schools and general population, the most common cause of hearing impairment was middle ear disease (36%), followed by undetermined causes (35%) and cerumen impaction (24%). CONCLUSION: There are very few population-based studies available to estimate the prevalence of hearing impairment in Africa. Those studies that are available use different cut-offs, making comparison difficult. However, the evidence suggests that the prevalence of hearing impairment is high and that much of it is avoidable or treatable.

Sustained beneficial effects of a protocolized treat-to-target strategy in very early rheumatoid arthritis: three-year results of the Dutch Rheumatoid Arthritis Monitoring remission induction cohort.

OBJECTIVE: Treat-to-target (T2T) leads to improved clinical outcomes in early rheumatoid arthritis (RA). The question is whether these results sustain in the long term. Our objective was to investigate the 3-year results of a protocolized T2T strategy in daily clinical practice. METHODS: In the Dutch Rheumatoid Arthritis Monitoring remission induction cohort, patients newly diagnosed with RA were treated according to a T2T strategy aimed at remission (Disease Activity Score in 28 joints [DAS28] <2.6). Patients were treated with methotrexate, followed by the addition of sulfasalazine, and exchange of sulfasalazine with anti-tumor necrosis factor α agents in case of failure. Primary outcomes were disease activity, Health Assessment Questionnaire (HAQ) score, Short Form 36 physical component summary (PCS) and mental component summary (MCS) scores, and the Sharp/van der Heijde score (SHS) after 3 years. Secondary outcomes were sustained DAS28 remission (≥6 months) and remission according to the provisional American College of Rheumatology (ACR)/European League Against Rheumatism (EULAR) definition. RESULTS: After 3 years (n = 342), 61.7% of patients were in DAS28 remission and 25.3% met the provisional ACR/EULAR definition of remission. Sustained remission was experienced by 70.5%, which in the majority was achieved with conventional disease-modifying antirheumatic drugs only. The median scores were 0.4 (interquartile range [IQR] 0.0-1.0) for the HAQ, 45.0 (IQR 38.4-53.2) for the PCS, 53.1 (IQR 43.2-60.8) for the MCS, and 6.0 (IQR 3.0-13.0) for the total SHS. CONCLUSION: In very early RA, T2T leads to high (sustained) remission rates, improved physical function and health-related quality of life, and limited radiographic damage after 3 years in daily clinical practice.

Automated carotid IMT measurement and its validation in low contrast ultrasound database of 885 patient Indian population epidemiological study: results of AtheroEdge™ Software.

AIM: The aim of this paper was to demonstrate the usage of an automated computer-based IMT measurement system called - CALEX 3.0 (a class of patented AtheroEdge™ software) on a low contrast and low resolution image database acquired during an epidemiological study from India. The image contrast was very low with pixel density of 12.7 pixels/mm. Further, to demonstrate the accuracy and reproducibility of the AtheroEdge™ software system we compared it with the manual tracings of a vascular surgeon--considered as a gold standard. METHODS: We automatically measured the IMT value of 885 common carotid arteries in longitudinal B-Mode images. CALEX 3.0 consisted of a stage for the automatic recognition of the carotid artery and an IMT measurement modulus made of a fuzzy K-means classifier. Performance was assessed by measuring the system accuracy and reproducibility against manual tracings by experts. RESULTS: CALEX 3.0 processed all the 885 images of the dataset (100% success). The average automated obtained IMT measurement by CALEX 3.0 was 0.407±0.083 mm compared with 0.429 ± 0.052 mm for the manual tracings, which led to an IMT bias of 0.022±0.081mm. The IMT measurement accuracy (0.022 mm) was comparable to that obtained on high-resolution images and the reproducibility (0.081 mm) was very low and suitable to clinical application. The Figure-of-Merit defined as the percent agreement between the computer-estimated IMT and manually measured IMT for CALEX 3.0 was 94.7%. CONCLUSION: CALEX 3.0 had a 100% success in processing low contrast/low-resolution images. CALEX 3.0 is the first technique, which has led to high accuracy and reproducibility on low-resolution images acquired during an epidemiological study. We propose CALEX 3.0 as a generalized framework for IMT measurement on large datasets.

Predictors of referral uptake in children with disabilities in Bangladesh--exploring barriers as a first step to improving referral provision.

PURPOSE: Making services available to children with disabilities in low- and middle-income countries does not guarantee their use. This study aims to identify factors associated with the uptake of referrals in order to investigate barriers to service use. METHODS: Children with impairments identified in two districts of Bangladesh were invited to attend screening camps where their condition was confirmed; they were provided with referrals for rehabilitation and treatment services. Predictors of referral uptake were identified using logistic regression. RESULTS: Overall referral uptake was 47%, 32% in Sirajganj and 61% in Natore. There was no association between age or gender and referral uptake. Factors predictive of referral uptake were higher income in Sirajganj (OR=2.6 95%CI 1.4-5.0), and the districts combined (OR=1.6 95%CI 1.1-2.1); maternal literacy in Natore (OR=1.6 95%CI 1.0-2.5); and epilepsy in all three models (Sirajganj: OR=2.6 95%CI 1.7-4.0; Natore: OR=13.5 95%CI 6.5-28.3; Combined: OR=4.6 95%CI 3.3-6.5). Physical impairment was associated with increased odds of uptake in Sirajganj and in the combined model (OR=2.7 95%CI 1.8-4.1; OR=3.34 95%CI 2.2-5.2). CONCLUSIONS: Even when some logistical and financial assistance is available, children with impairment from low-income families may require additional support to take up referrals. There may be greater willingness to accept treatment that is locally provided, such as medication for epilepsy or therapy at village level.

Frequency and effectiveness of dose increase of adalimumab, etanercept, and infliximab in daily clinical practice.

OBJECTIVE: To describe the frequency and effectiveness of dose increase of adalimumab, etanercept, and infliximab in the treatment of rheumatoid arthritis (RA) in daily clinical practice. METHODS: All RA patients with a dose increase of tumor necrosis factor (TNF)-blocking therapy between January 1997 and January 2008 were selected from a register including data from RA patients starting a first TNF-blocking agent (the Dutch Rheumatoid Arthritis Monitoring registry). The primary outcome was change in Disease Activity Score in 28 joints (DAS28) at 3 months after dose increase. Secondary outcomes were the change in DAS28 at 6 months after dose increase, the European League Against Rheumatism response rates, and the percentages of patients reaching a DAS28 of ≤3.2 at 3 and at 6 months after dose increase. Furthermore, the effectiveness of dose increase was assessed for the different reasons for dose increase: nonresponse, loss of response, and partial response. RESULTS: During the study period, the dose was increased in 44 (12%) of the 368 adalimumab patients, 32 (8%) of the 420 etanercept patients, and 115 (36%) of the 323 infliximab patients. The change in DAS28 at 3 months and 6 months after dose increase was limited and only significant in etanercept patients at 3 months (-0.51; P = 0.035). Disease activity decreased significantly at 3 months from dose increase in the nonresponders and patients with loss of response (-0.66 and -0.99, respectively; both P = 0.001), but not in the partial responders. CONCLUSION: Although dose increase was applied in all 3 TNF-blocking agents in daily clinical practice, these results suggest that the effectiveness of dose increase is limited.

Outcome of cataract surgery at one year in Kenya, the Philippines and Bangladesh.

AIMS: To assess the change in vision following cataract surgery in Kenya, Bangladesh and the Philippines and to identify causes and predictors of poor outcome. METHODS: Cases were identified through surveys, outreach and clinics. They underwent preoperative visual acuity measurement and ophthalmic examination. Cases were re-examined 8-15 months after cataract surgery. Information on age, gender, poverty and literacy was collected at baseline. RESULTS: 452 eyes of 346 people underwent surgery. 124 (27%) eyes had an adverse outcome. In Kenya and the Philippines, the main cause of adverse outcome was refractive error (37% and 49% respectively of all adverse outcomes) then comorbid ocular disease (26% and 27%). In Bangladesh, this was comorbid disease (58%) then surgical complications (21%). There was no significant association between adverse outcome and gender, age, literacy, poverty or preoperative visual acuity. CONCLUSIONS: Adverse outcomes following cataract surgery were frequent in the three countries. Main causes were refractive error and preoperative comorbidities. Many patients are not attaining the outcomes available with modern surgery. Focus should be on correcting refractive error, through operative techniques or postoperative refraction, and on a system for assessing comorbidities and communicating risk to patients. These are only achievable with a commitment to ongoing surgical audit.

Evaluating guidelines on continuation of anti-tumour necrosis factor treatment after 3 months: clinical effectiveness and costs of observed care and different alternative strategies.

OBJECTIVE: To study the adherence of rheumatologists to the Dutch guidelines for anti-tumour necrosis factor alpha (TNF-alpha) treatment. The secondary objective was to evaluate alternatives to the present guidelines with regard to the percentage of responders and costs. METHODS: The response (>1.2 DAS28 decrease) in patients who started on anti-TNF-alpha treatment for the first time was evaluated at 3 and 6 months after initiation. How many patients continued or discontinued their initial anti-TNF-alpha treatment was evaluated. Possible alternative guidelines were evaluated by means of a decision tree, with regard to the expected percentage of successfully (responders) and unsuccessfully treated patients and expected costs. RESULTS: At 3 months 56% (N = 306) and 44% (N = 233) of all 539 evaluable patients were classified as responders or non-responders, respectively. Despite the guidelines, most (81%) (N = 189) of the non-responders continued treatment. 37% of the non-responders who continued anti-TNF-alpha treatment were eventually classified as responders at 6 months. Decision analytical modelling showed that with equal expected costs all alternative strategies would result in more responders than according to theoretical full adherence with the guidelines. "Continuation in case of partial response" had the best trade-off between successfully treated patients (64%) and unsuccessfully treated patients (17%). CONCLUSION: There was suboptimal adherence to the Dutch guidelines for treatment with anti-TNF-alpha for rheumatoid arthritis patients. This seemed to be justified by the fact that a delayed response up to 6 months was shown. If treatment is continued despite a non-response at 3 months, this is only recommended in patients with at least a partial response (at least 0.6 DAS28 improvement).

Quality of life and visual impairment from cataract in Satkhira district, Bangladesh.

AIMS: To evaluate a vision-related quality of life (QOL) scale (World Health Organization Prevention of Blindness and Deafness Visual Function 20-WHO/PBD VF20) and explore the impact of cataract visual impairment on vision- and health-related QOL in people >or=50 years from Satkhira district, Bangladesh. METHOD: 217 cases visually impaired from cataract and 280 controls with normal vision were interviewed about vision-related QOL (WHO/PBD VF20), generic health-related QOL (EuroQol generic health instrument, EQ-5D) and socio-demographic information. The validity and reliability of the WHO/PBD VF20 were evaluated using standard psychometric tests and criteria. RESULTS: Evidence for validity and reliability of the WHO/PBD VF20 was found. Worsening general functioning, psychosocial and overall eyesight scores were associated with increased visual loss (p for trend<0.001). Cases were more likely to report problems with each EQ-5D descriptive domain and had poorer self-rated health than controls with normal vision (p<0.001). CONCLUSION: Demonstration of the validity and reliability of the WHO/PBD VF20 in this population supports its suitability as a tool for assessing vision-related QOL in low-income settings. The poorer health-related QOL in cases compared with controls suggests an impact of cataract visual impairment on perceived health and well-being, beyond vision-specific experience.

The effectiveness and medication costs of three anti-tumour necrosis factor alpha agents in the treatment of rheumatoid arthritis from prospective clinical practice data.

AIM: to evaluate the effects of adalimumab, etanercept and infliximab on disease activity, functional ability and quality of life and the medication costs in a naturalistic design. METHODS: All patients from the Dutch Rheumatoid Arthritis Monitoring (DREAM) register starting on tumour necrosis factor (TNF)alpha-blocking agents for the first time were monitored and assessed by trained research nurses every 3 months. The primary outcome was the Disease Activity Score (DAS28) course over the 12 months follow-up, analysed by linear mixed models. Secondary outcomes were the Health Assessment Questionnaire (HAQ), EuroQol five dimensions (EQ-5D) and the Short-Form 36 items (SF36) scores, and medication-related total costs. RESULTS: The DAS28 and SF-36 physical component scale decreased in all three medication groups over 12 months, but the decrease was larger for adalimumab and etanercept in comparison to infliximab (p<0.001). The analyses of the HAQ and the EQ-5D scores showed the same (non-significant) trend, namely that at 12 months, the functionality and quality of life was better for adalimumab and etanercept patients. With regard to the medication costs, infliximab treatment resulted in significantly higher costs over the follow-up period than treatments with either adalimumab or etanercept. The comparison between adalimumab and etanercept showed a significant difference in the 12-month DAS28 course (p = 0.031). There were no additional indications for differences in effectiveness or costs between adalimumab and etanercept. CONCLUSION: The evaluation of the effectiveness and costs showed that adalimumab and etanercept are more or less equal and favourable compared to infliximab in the first year of treatment.

Anthropometric characteristics as predictors of coronary heart disease in women.

OBJECTIVES: Obesity and other anthropometric measures are clearly related to risk of coronary heart disease (CHD), although debate remains as to which measures are most important and how the impact of obesity varies over the life course. AIM: We aimed to investigate these issues in a large cohort of Swedish women. The Women's Lifestyle and Health Cohort Study includes 49 259 women, aged 30-50 years at baseline (1991-1992) when an extensive questionnaire was completed. METHODS: Women were given standard instructions for self-measurement of anthropometric characteristics. Women were followed through linkages to national registries until December 2003, during which time 256 cases of incident fatal CHD or nonfatal myocardial infarction occurred. RESULTS: Waist circumference was associated with increased CHD risk after multivariate adjustment for confounders (HR = 1.9; 95% CI:1.1-3.3; highest versus lowest quartile), whereas height, weight and hip circumference were not. Measures of obesity were strongly related to CHD, and after mutual adjustment, waist-hip ratio (HR = 1.9, 95% CI: 1.2-3.2) was more closely related to CHD risk than BMI (HR = 1.5, 95% CI: 1.0-2.4). Risk of CHD was increased in women who remained heavy, those who were heavy at age 18, and those with low birth weight. CONCLUSIONS: In conclusion, there is strong evidence for supporting control of obesity, in particular avoidance of abdominal obesity, as a strategy to prevent CHD.

Causes of poor outcome after cataract surgery in Satkhira district, Bangladesh.

AIMS: Recent data have raised concerns about visual outcome following cataract surgery. The aim of this study was to assess the frequency and causes of poor and borderline outcome after cataract surgery in a population-based case series in Satkhira district, Bangladesh. METHODS: A population-based case series was conducted within a population-based cluster survey of people aged over 50 years in Satkhira district where 4868 people underwent visual acuity (VA) screening. Eyes operated for cataract with VA<6/18 were examined in detail by an ophthalmologist, including a full history and dilated fundoscopy, to determine the cause of the visual outcome. RESULTS: Cataract surgery was performed on 213 eyes. Outcome was good (VA>6/18) for 128 eyes (60.1%), borderline (VA<6/18 to 6/60) for 35 eyes (16.4%), and poor (VA<6/60) for 50 eyes (23.5%) with available correction. Borderline and poor outcomes were most commonly due to lack of spectacles (25.8%), poor selection (33.8%), or surgical complications (30.6%). Surgical sequelae, namely posterior capsule opacification, was a less common cause of poor or borderline outcome (9.7%). CONCLUSIONS: Quality of surgical outcomes is of concern in Satkhira district. Increased emphasis on selection of subjects for surgery, provision of spectacles, and monitoring of surgery may improve outcomes.

The efficacy of anti-TNF in rheumatoid arthritis, a comparison between randomised controlled trials and clinical practice.

BACKGROUND: Randomised controlled trials (RCTs) evaluating the efficacy of antagonists to tumour necrosis factor alpha (TNFalpha) showed high response percentages in the groups treated with active drugs. OBJECTIVE: To compare the efficacy of anti-TNF treatments for rheumatoid arthritis (RA) patients in RCTs and in daily clinical practice, with an emphasis on the efficacy for patients eligible and not eligible for RCTs of anti-TNF treatments. METHODS: First, randomised placebo-controlled trials written in English for etanercept, infliximab and adalimumab for patients with RA were selected by a systematic review. Second, the DREAM (Dutch Rheumatoid Arthritis Monitoring) register with patients starting for the first time on one of the TNF-blocking agents was used. Patient characteristics, doses of medication and co-medication as well as the ACR20 response percentages were compared between RCTs and DREAM data, stratified for trial eligibility. RESULTS: In 10 of 11 comparisons, the ACR20 response percentages were lower in daily clinical practice than in the RCT active drug group, which was significant in five of 11 comparisons. Only 34-79% of DREAM patients fulfilled the selection criteria for disease activity in the several RCTs examined. DREAM patients eligible for RCTs had higher response percentages than ineligible DREAM patients. ACR20 response percentages of eligible DREAM patients were comparable with the ACR20 response percentages of the RCT active drug group in 10 of 11 comparisons. CONCLUSION: The efficacy of TNF-blocking agents in RCTs exceeded the efficacy of these drugs in clinical practice. However, in clinical practice more patients with lower disease activity were treated with TNF-blocking agents compared with those treated in RCTs. For daily practice patients who were eligible for RCTs, responses were more similar to responses reached in RCTs.

Rapid assessment of avoidable blindness and needs assessment of cataract surgical services in Satkhira District, Bangladesh.

AIMS: To estimate the magnitude and causes of blindness in people aged > or =50 years in Satkhira district, Bangladesh, and to assess the availability of cataract surgical services. METHODS: 106 clusters of 50 people aged > or =50 years were selected by probability-proportionate to size sampling. Households were selected by compact segment sampling. Eligible participants had their visual acuity measured. Those with visual acuity <6/18 were examined by an ophthalmologist. A needs assessment of surgical services was conducted by interviewing service providers. RESULTS: 4868 people were examined (response rate 91.9%). The prevalence of bilateral blindness was 2.9% (95% confidence interval (CI) 2.4% to 3.5%), that of severe visual impairment was 1.6% (95% CI 1.2% to 2.0%) and that of visual impairment was 8.4% (95% CI 7.5% to 9.3%). 79% of bilateral blindness was due to cataract. The cataract surgical coverage was moderate; 61% of people with bilateral cataract blindness (visual acuity <3/60) had undergone surgery. 20% of the 213 eyes that had undergone cataract surgery had a best-corrected poor outcome (visual acuity <6/60). The cataract surgical rate (CSR) in Satkhira was 547 cataract surgeries per million people per year. CONCLUSIONS: Although the prevalence of blindness and visual impairment was lower than expected, the CSR is inadequate to meet the existing need, and the quality of surgery needs to be improved.

Prevalence and causes of blindness and visual impairment in Muyuka: a rural health district in South West Province, Cameroon.

AIM: To estimate the prevalence and causes of blindness and visual impairment in the population aged 40 years and over in Muyuka, a rural district in the South West Province of Cameroon. METHODS: A multistage cluster random sampling methodology was used to select 20 clusters of 100 people each. In each cluster households were randomly selected and all eligible people had their visual acuity (VA) measured by an ophthalmic nurse. Those with VA <6/18 were examined by an ophthalmologist. RESULTS: 1787 people were examined (response rate 89.3%). The prevalence of binocular blindness was 1.6% (95% CI: 0.8% to 2.4%), 2.2% (1.% to 3.1%) for binocular severe visual impairment, and 6.4% (5.0% to 7.8%) for binocular visual impairment. Cataract was the main cause of blindness (62.1%), severe visual impairment (65.0%), and visual impairment (40.0%). Refractive error was an important cause of severe visual impairment (15.0%) and visual impairment (22.5%). The cataract surgical coverage for people was 55% at the <3/60 level and 33% at the <6/60 level. 64.3% of eyes operated for cataract had poor visual outcome (presenting VA<6/60). CONCLUSIONS: Strategies should be developed to make cataract services affordable and accessible to the population in the rural areas. There is an urgent need to improve the outcome of cataract surgery. Refractive error services should be provided at the community level.

Distance to water source and altitude in relation to active trachoma in Rombo district, Tanzania.

OBJECTIVES: To investigate the relationship between distance to water source, altitude and active trachoma in children in Rombo district, Tanzania. METHODS: In each of Rombo's 64 villages, 10 balozis (groups of 8-40 households) were selected at random and all resident children aged 1-9 years were examined for clinical signs of active trachoma. The households of these children and village water sources were mapped using differentially corrected global positioning system data to determine each household's altitude and distance to the nearest water supply. RESULTS: We examined 12 415 children and diagnosed 1171 cases of active trachoma (weighted prevalence=9.1%, 95% CI: 8.0, 10.2%). Active trachoma prevalence ranged from 0% to 33.7% across villages. Increasing distance to the nearest water source was significantly associated with rising trachoma prevalence (age-adjusted odds ratio for infection (OR) for highest quartile compared to lowest=3.56, 95% CI 2.47, 5.14, P for trend <0.0001). Altitude was significantly inversely associated with trachoma prevalence (age-adjusted OR for highest quartile compared to lowest=0.55, 95% CI 0.41, 0.75, P for trend <0.0001). These associations remained significant after adjustment in multivariate analysis. CONCLUSIONS: Trachoma is endemic in Rombo district, although the prevalence varies considerably between villages. Spatial mapping is a useful method for analysing risk factors for active trachoma.

Epidemiology for ophthalmologists: an introduction to concepts, study designs, and interpreting findings.

This review provides an overview of the types of information epidemiological research can provide and how these data can be used. The aim is to provide the readers with basic epidemiological skills to allow them to read critically scientific articles and to gain proficiency in communicating about epidemiological research. All examples in the review are drawn from the ophthalmic literature. The first part of the review is relatively conceptual and focuses on epidemiological theory, including case definition, measures of the burden of disease, sampling and the interpretation of results. In the second part different study designs are described--specifically, cross sectional surveys, cohort studies, case-control studies, and randomised controlled trials, and the strengths and limitations of each highlighted.