Under-reporting of road traffic injuries to the police: results from two data sources in urban India.

OBJECTIVE: To report the magnitude of under-reporting of road traffic injury (RTI) to the police from population-based and hospital-based data in the urban population of Hyderabad, India. METHODS: In a cross-sectional population-based survey, 10 459 participants aged 5-49 years (94.3% participation), selected using three-stage systematic cluster sampling, recalled the reporting of non-fatal RTIs to the police in the preceding 12 months and fatal RTIs in the preceding 3 years. In addition, 781 consecutive RTI cases presenting to the emergency department of five hospitals provided information on RTI reporting to the police. RESULTS: In the population-based study, of those who had non-fatal RTIs and sought outpatient or inpatient services, 2.3% (95% 1.1% to 3.5%) and 17.2% (95% CI 3.5% to 30.9%), respectively, reported the RTI to the police. Of the non-fatal consecutive RTI cases presenting to emergency departments, 24.6% (95% CI 21.3% to 27.8%) reported the RTI to the police. In the population-based study, 77.8% (95% CI 65.1% to 90.5%) of the fatal RTIs were reported to the police, and of the consecutive fatal RTI cases presenting to emergency departments, 98.1% (95% CI 95.5% to 100%) were reported to the police. The major reasons cited for not reporting RTIs to the police were "not necessary to report" and "hit and run case". CONCLUSIONS: As road safety policies are based on police data in India, these studies highlight serious limitations in estimating the true magnitude of RTIs from these data, indicating the need for better methods for such estimation.

Incidence and burden of road traffic injuries in urban India.

BACKGROUND: The scale of road traffic injuries (RTIs) in India is uncertain because of limitations in the availability and reliability of incidence data. OBJECTIVE: To report these data for Hyderabad city in southern India. METHODS: In a cross-sectional population-based survey, 10 459 participants aged 5-49 years (94.3% participation), selected using three-stage systematic cluster sampling, were interviewed. Participants recalled RTIs in the preceding 3 months and RTI-related death and disability in the household in the preceding 3 years. RTI was defined as an injury resulting from a road traffic crash irrespective of the severity. RESULTS: The age/sex-adjusted annual incidence of non-fatal RTI requiring a recovery period of < or =7, 8-29, and > or =30 days was 13% (95% CI 12.6% to 13.4%), 5.8% (95% CI 5.5% to 6.0%), and 1.2% (95% CI 1.1% to 1.4%), respectively. The overall adjusted rate for non-fatal RTI was 20.7% (95% CI 20.0% to 21.3%). The relative risk of RTI requiring a recovery period of >7 days was significantly higher in the third per capita monthly income quartile (1.24 (95% CI 1.12 to 1.37); p<0.05). The incidence of non-fatal RTI was highest in pedestrians, motorized two-wheeled vehicle users, and cyclists: 6.4, 6.3, and 5.1/100 persons/year, respectively. Annual RTI mortality and disability rates were 38.2 (95% CI 17.5 to 58.8) and 35.1 (95% CI 12.4 to 57.7) per 100,000 population, respectively. CONCLUSIONS: There is a high burden of RTI in this urban population. With the recent attention focused on RTI by the Government of India, these findings may assist in planning appropriate initiatives to reduce the RTI burden.

Evaluation of the Murex HIV Ag/Ab Combination assay when used with dried blood spots.

This study evaluated the ability of the Murex HIV Ag/Ab Combination assay to detect human immunodeficiency virus (HIV) antibodies in 12 617 dried blood spots (DBSs) on filter paper. The assay had an overall sensitivity of 99.6% and a specificity of 99.9%. In view of its ability to detect p24 antigen and both HIV-1 and HIV-2 antibodies in samples collected in the form of DBSs, the Murex Ag/Ab Combination assay is suitable for use as a standard screening assay for seroprevalence studies, as well as for routine diagnostic use in clinical laboratories.

Patterns of road traffic injuries in a vulnerable population in Hyderabad, India.

OBJECTIVE: To describe patterns of road traffic injuries (RTI) in a vulnerable population-pedestrians and users of motorized two-wheeled vehicles (MTVs)-in Hyderabad, India. METHODS: 4019 pedestrians and 4183 MTV drivers provided information on the most recent road traffic crash (RTC) irrespective of the level of injury in the last one year for 17 454 and 17 242 household members, respectively. Crashes in which any household member was involved as a pedestrian or MTV user were analysed. RESULTS: Involvement in an RTC as a pedestrian or MTV user was reported for 1513 (4.4%, 95% CI 4.2 to 4.6%) people in the last one year. In these crashes, the person involved was an MTV user in 1264 (83.5%), aged 21-40 years in 973 (64.3%), and male in 1202 (79.4%). Six (0.4%) people died in RTCs and the cause was collision with a vehicle/person in 1133 (75%) crashes. Among the 1306 people who were injured and survived, 174 (13.3%) were treated as inpatients, 38 (2.9%) could not return fully to routine daily activities, 630 (48.2%) took leave from their regular occupation, and 13 (1%) lost their jobs following injury. Using a three month recall period, the annual incidence per 100 000 population of RTC as a pedestrian or MTV user was 2288 and of non-fatal RTI was 1931, and that of fatal RTI using one year recall period was 17.3 in this population. CONCLUSIONS: These findings on how RTI are caused, their type, and outcomes in pedestrians and MTV users can assist in identifying interventions to improve road safety for this vulnerable population in India, and can also be useful for monitoring the effectiveness of such interventions.

Cost and efficiency of HIV voluntary counselling and testing centres in Andhra Pradesh, India.

BACKGROUND: [corrected] As part of the effort to control HIV/AIDS, the number of HlV voluntarycounselling and testingcentres (VCTCs) is increasing rapidly in the public health system of the Indian state of Andhra Pradesh, which is estimated to have one of the highest rates of HIV infection in India. However, systematic data on the cost and efficiency of providing VCT services in India are not available to help guide efficient use of resources for these services. METHODS: We used standardized methods to obtain detailed cost and output data for the 2002-03 fiscal year from written records and interviews in 17 VCTCs in the public health system in Andhra Pradesh. We calculated the economic cost per client receiving VCT services, and analysed the variation and determinants of total and unit costs across VCTCs. We used multivariate regression techniques to estimate incremental unit costs. We assessed hurdles towards serving an optimal number of clients by VCTCs. RESULTS: In the 2002-03 fiscal year, 32 413 clients received the complete sequence of services at the 17 VCTCs, including post-HIV test counselling. The number of clients served by each VCTC ranged from 334 to 7802 (median 979). The overall HIV-positive rate in post-test counselled clients was 20.5% (range 5.4%-52.6%). The cost per client for the complete VCT sequence varied 6-fold between VCTCs (range Rs 141.5-829.6 [US 2.92-17.14 dollars], median Rs 363.5 [US 7.51 dollars]). The cost per client was significantly lower at VCTCs with more clients (p < 0.001, R2 = 0.83; power function) due to substantial fixed costs. Personnel made up the largest component of cost (53.7%). The cost per client had a significant direct relation with percent personnel cost for VCTCs (p < 0.001, R2 = 0.58; exponential function). A multiple regression model revealed that the incremental cost of providing complete VCT services to each HIV-positive and -negative client was Rs 123.5 (US 2.54 dollars) and Rs 59.2 (US 1.22 dollars), respectively. Fourteen VCTCs (82.4%) reported that they could serve more clients with the available personnel and infrastructure, and that inadequate demand for their services was the main hurdle towards achieving this. CONCLUSION: These data suggest that the efforts of the National AIDS Control Organisation of India and the Andhra Pradesh State AIDS Control Society in increasing VCTCs could yield even higher benefit if the demand for these services was enhanced, as this would increase the number of clients served and reduce the cost per client. Ongoing systematic cost-efficiency analysis is necessary to help guide efficient use of HIV-control resources in India.

Childhood blindness in India: a population based perspective.

AIM: To estimate the prevalence and causes of blindness in children in the southern Indian state of Andhra Pradesh. METHODS: These data were obtained as part of two population based studies in which 6935 children

The familial contribution to non-syndromic ocular coloboma in south India.

AIMS: To identify the proportion of familial cases of isolated ocular colobomatous malformations in a case series from south India. METHODS: Children with ocular coloboma without systemic features were recruited from multiple sources in Andhra Pradesh, India. Their families were traced, pedigrees drawn, and family members examined. RESULTS: 56 probands, 25 females (44.6%) and 31 males (57.4%) with a colobomatous malformation were identified. In 12 cases (21.4%) another family member was affected. The risk to siblings was 3.8%. The parents were consanguineous in 25 cases (44.6%). CONCLUSIONS: 21.4% of cases of isolated ocular coloboma in this highly consanguineous population of south India were familial, with both autosomal dominant and autosomal recessive mechanisms likely in different families.

Corneal blindness in a southern Indian population: need for health promotion strategies.

AIM: To assess the distribution and causes of corneal blindness in a population in southern India. METHODS: A total of 11 786 people of all ages from 94 clusters representative of the population of the Indian state of Andhra Pradesh were sampled using a stratified, random, cluster, systematic sampling strategy. These participants underwent a detailed interview and eye examination including measurement of visual acuity with logMAR charts, refraction, slit lamp biomicroscopy, applanation tonometry, gonioscopy, and stereoscopic dilated fundus evaluation. An eye was considered to have corneal blindness if the visual acuity was <20/200 due to a corneal disease. RESULTS: Of those sampled, 10 293 (87.3%) people participated in the study. Corneal blindness in at least one eye was present in 86 participants, an age, sex, and urban-rural distribution adjusted prevalence of 0.66% (95% confidence interval 0.49 to 0.86), which included 0.10% prevalence of corneal blindness in both eyes and 0.56% in one eye. The most frequent causes of corneal blindness in at least one eye included keratitis during childhood (36.7%), trauma (28.6%), and keratitis during adulthood (17.7%). Nearly 95% of all corneal blindness was avoidable. Multivariate analysis showed that the prevalence of corneal blindness was significantly higher with decreasing socioeconomic status and with increasing age. Of the 99 eyes with corneal blindness, 51 (51.5%) had visual acuity of inaccurate projection of light or no perception of light. CONCLUSIONS: There is a significant burden of corneal blindness in this population, the majority of which is avoidable. Eye health promotion strategies are warranted to raise awareness about the causes and prevention of corneal blindness.

Moderate visual impairment in India: the Andhra Pradesh Eye Disease Study.

AIM: To assess the prevalence and demographic associations of moderate visual impairment in the population of the southern Indian state of Andhra Pradesh. METHODS: From 94 clusters in one urban and three rural areas of Andhra Pradesh, 11 786 people of all ages were sampled using a stratified, random, cluster, systematic sampling strategy. The eligible people were invited for interview and detailed dilated eye examination by trained professionals. Moderate visual impairment was defined as presenting distance visual acuity less than 6/18 to 6/60 or equivalent visual field loss in the better eye. RESULTS: Of those sampled, 10,293 (87.3%) people participated in the study. In addition to the previously reported 1.84% prevalence of blindness (presenting distance visual acuity less than 6/60 or central visual field less than 20 degrees in the better eye) in this sample, 1237 people had moderate visual impairment, an adjusted prevalence of 8.09% (95% CI 6.89 to 9.30%). The majority of this moderate visual impairment was caused by refractive error (45.8%) and cataract (39.9%). Increasing age, female sex, decreasing socioeconomic status, and rural area of residence had significantly higher odds of being associated with moderate visual impairment. CONCLUSIONS: These data suggest that there is a significant burden of moderate visual impairment in this population in addition to blindness. Extrapolation of these data to the population of India suggests that there were 82 million people with moderate visual impairment in the year 2000, and this number is likely to be 139 million by the year 2020 if the current trend continues. This impending large burden of moderate visual impairment, the majority of which is due to the relatively easily treatable refractive error and cataract, would have to be taken into account while estimating the eye care needs in India, in addition to dealing with blindness. Specific strategies targeting the elderly population, people with low socioeconomic status, those living in the rural areas, and females would have to be implemented in the long term to reduce moderate visual impairment.

Clinical findings, consanguinity, and pedigrees in children with anophthalmos in southern India.

This study aimed to describe clinical findings, pedigrees, and possible environmental risk factors in children with clinical anophthalmos and remnant microphthalmos in either eye in southern India. Twenty-four children (14 male, 10 female; mean age 10.3 years, age range 1.3 to 18 years,) were recruited from schools for the blind, hospitals, and community-based rehabilitation programmes in Andhra Pradesh, India, over 1 year. Family members were examined, and mothers interviewed. Fifteen children had anophthalmos and nine had remnant microphthalmos in one or both eyes. Twelve children had associated systemic findings, of which six were major and six were minor abnormalities. Information on consanguinity was available in 19 children, 12 of whom had consanguineous parents. Five children had a positive family history. Two mothers had a history of night blindness, and one had a history of pesticide exposure during pregnancy. High rates of consanguinity suggest a genetic recessive aetiology.

Refractive error blindness.

Recent data suggest that a large number of people are blind in different parts of the world due to high refractive error because they are not using appropriate refractive correction. Refractive error as a cause of blindness has been recognized only recently with the increasing use of presenting visual acuity for defining blindness. In addition to blindness due to naturally occurring high refractive error, inadequate refractive correction of aphakia after cataract surgery is also a significant cause of blindness in developing countries. Blindness due to refractive error in any population suggests that eye care services in general in that population are inadequate since treatment of refractive error is perhaps the simplest and most effective form of eye care. Strategies such as vision screening programmes need to be implemented on a large scale to detect individuals suffering from refractive error blindness. Sufficient numbers of personnel to perform reasonable quality refraction need to be trained in developing countries. Also adequate infrastructure has to be developed in underserved areas of the world to facilitate the logistics of providing affordable reasonable-quality spectacles to individuals suffering from refractive error blindness. Long-term success in reducing refractive error blindness worldwide will require attention to these issues within the context of comprehensive approaches to reduce all causes of avoidable blindness.

Blindness in the Indian state of Andhra Pradesh.

PURPOSE: To determine the current prevalence and causes of blindness in the Indian state of Andhra Pradesh to assess if blindness has decreased since the last survey of 1986-1989. METHODS: A population-based epidemiology study, using a stratified, random, cluster, systematic sampling strategy, was conducted in the state of Andhra Pradesh in India. Participants of all ages (n = 10,293), 87.3% of the 11,786 eligible, from 94 clusters in one urban and three rural areas representative of the population of Andhra Pradesh, underwent interview and a detailed dilated ocular evaluation by trained professionals. Blindness was defined as presenting distance visual acuity < 6/60 or central visual field < 20(o) in the better eye. RESULTS: Two hundred seventy-five participants were blind, a prevalence of 1.84% (95% confidence interval, 1.49%-2.19%) when adjusted for the age, sex, and urban-rural distribution of the population in 2000. The causes of this blindness were easily treatable in 60.3% (cataract, 44%; refractive error, 16.3%). Preventable corneal disease, glaucoma, complications of cataract surgery, and amblyopia caused another 19% of the blindness. Blindness was more likely with increasing age and decreasing socioeconomic status, and in female subjects and in rural areas. Among the 76 million population of Andhra Pradesh, 714,400 are estimated to have cataract-related blindness (615,600 cataract, 53,200 cataract surgery-related complications, 45,600 aphakia), and 228,000 refractive error-related blindness (159,600 myopia, 22,800 hyperopia, 45,600 refractive error-related amblyopia). If 95% of the cataract and refractive error blindness in Andhra Pradesh had been treated effectively, 3.4 and 7.4 million blind-person-years, respectively, could have been prevented. If 90% of the blindness due to preventable corneal disease and glaucoma had been prevented, another 2.7 million blind-person-years could have been prevented. CONCLUSIONS: The prevalence of blindness in this Indian state has increased from 1.5% in the late 1980s to 1.84% currently, as against the target of the National Program for Control of Blindness to reduce the prevalence to 0.3% by 2000. The number of people with cataract-related blindness has not reduced even with the eye care policy focus on cataract. Reduction of blindness in India will require strategies that are more effective than those that have been pursued so far.

Awareness of eye diseases in an urban population in southern India.

OBJECTIVE: To assess the level of awareness of eye diseases in the urban population of Hyderabad in southern India. METHODS: A total of 2522 subjects of all ages, who were representative of the Hyderabad population, participated in the population-based Andhra Pradesh Eye Disease Study. Of these subjects, 1859 aged > 15 years responded to a structured questionnaire on cataract, glaucoma, night blindness and diabetic retinopathy to trained field investigators. Having heard of the eye disease in question was defined as "awareness" and having some understanding of the eye disease was defined as "knowledge". FINDINGS: Awareness of cataract (69.8%) and night blindness (60.0%) was moderate but that of diabetic retinopathy (27.0%) was low, while that of glaucoma (2.3%) was very poor. Knowledge of all the eye diseases assessed was poor. Subjects aged > or = 30 years were significantly more aware of all eye diseases assessed except night blindness. Multivariate analysis revealed that women were significantly less aware of night blindness (odds ratio (OR) = 0.78; 95% confidence interval (CI) = 0.63-0.97). Education played a significant role in awareness of these eye diseases. Study subjects of upper socioeconomic status were significantly more aware of night blindness (OR = 2.20; 95% CI = 1.29-3.74) and those belonging to upper and middle socioeconomic strata were significantly more aware of diabetic retinopathy (OR = 2.79; 95% CI = 2.19-3.56). Muslims were significantly more aware of cataract (OR = 2.36; 95% CI = 1.84-3.02) and less aware of night blindness (OR = 0.52; 95% CI = 0.42-0.64). The major source of awareness of the eye diseases was a family member/friend/relative suffering from that eye disease. CONCLUSION: These data suggest that there is a need for health education in this Indian population to increase their level of awareness and knowledge of common eye diseases. Such awareness and knowledge could lead to better understanding and acceptance of the importance of routine eye examinations for the early detection and treatment of eye diseases, thereby reducing visual impairment in this population.

Planimetric optic disc parameters in normal eyes: a population-based study in South India.

PURPOSE: To study the optic disc parameters of normal eyes in a population-based south Indian study. METHODS: One hundred and fifty three subjects from a population-based sample of 1060 included in the Andhra Pradesh Eye Disease Survey (APEDS) were enrolled in the optic disc study. The male-female ratio, the refractive error and distribution of other ocular parameters in the disc study subjects and the APEDS were not significantly different. Magnification corrected morphometry of optic disc photographs obtained by Zeiss telocentric fundus camera was carried out in one randomly chosen eye of each of these 143 subjects. RESULTS: The mean optic disc parameters with the 95% confidence intervals for the distribution were: disc area 3.37 mm2 (2.04 - 4.7), vertical disc diameter 2.12 mm (1.67 - 2.57), vertical cup to disc ratio 0.37 (0.19 -0.55) and neuroretinal rim area 2.8 mm2 (1.76 - 3.84). The disc area, the vertical cup to disc ratio and the rim area showed a normal distribution. The cup to disc ratio correlated with the vertical disc diameter but the association was not strong. CONCLUSION: The disc area, the vertical cup to disc ratio and the neuroretinal rim area are normally distributed in the South Indian population. The normal optic disc parameters would form a basis for future comparisons in different forms of glaucoma.

Review of findings of the Andhra Pradesh Eye Disease Study: policy implications for eye-care services.

The Andhra Pradesh Eye Disease Study (APEDS) was conducted in order to design long-term strategies to reduce blindness in the background of non-availability of recent population-based data on various aspects of blindness. The objectives of APEDS were to determine the prevalence and causes of blindness and visual impairment, prevalence of and risk factors for major eye diseases, barriers to eye-care services, and quality of life among the visually impaired. Multistage sampling was used to select 11,786 subjects of all ages from 24 urban clusters and 70 rural clusters in one urban and three rural areas belonging to different parts of Andhra Pradesh, with the aim of obtaining a study sample representative of the urban-rural and socioeconomic distribution of the population of this state. A total of 10,293 subjects underwent a detailed interview and dilated eye examination by trained professionals. The adjusted prevalence of blindness (presenting visual acuity <6/60 or central visual field <20 degrees in the better eye) was 1.84%, and moderate visual impairment (presenting visual acuity <6/18-6/60 or equivalent visual field loss in the better eye) was 8.1%. Cataract and refractive error were responsible for 60.3% of blindness and 85.7% of moderate visual impairment. Increasing age, decreasing socioeconomic status, female gender, and rural area of residence were associated with higher risk of blindness. Projections from APEDS suggest that there were 18.7 million blind people in 2000 in India, and that this number is likely to increase to 24.1 million and 31.6 million in 2010 and 2020 respectively, if the current trend continues. This review summarizes the findings of APEDS and discusses the implications of these data on the policy and planning of eye-care services.

Estimation of blindness in India from 2000 through 2020: implications for the blindness control policy.

BACKGROUND: To eliminate avoidable blindness in India, appropriate national planning is necessary, which should be based on current and reliable data. A national survey done in 1986-89 reported that 1.5% of the Indian population (12 million people) was blind with a presenting visual acuity of < 6/60 in the better eye. The original goal of the National Programme for Control of Blindness was to reduce this prevalence to 0.3% by 2000. We have recently reported the prevalence of blindness in the population of Andhra Pradesh to be 1.66% with a presenting visual acuity of < 6/60 in the better eye as the sole criterion and 1.84% with a presenting visual acuity of < 6/60 orcentral visual field < 20 degrees in the better eye. We used these population-based data to estimate blindness in India in 2000 and project the possible scenarios of blindness through 2020 with different emphases of the blindness control policy in India. METHODS: Recent population-based data on the age-, sex- and cause-specific blindness rates from the Andhra Pradesh Eye Disease Study for the entire age range were applied to the population distribution of India to estimate the number of blind persons in 2000. The age-, sex- and cause-specific rates of blindness were then applied to the estimated age, sex and urban-rural population distribution of India in 2010 and 2020 to project the number of persons blind (from various causes) and the blind person-years that would be suffered under varying degrees of emphasis in the policy to control blindness due to particular diseases. For these projections, blindness was defined as a presenting distance visual acuity of < 6/60 or central visual field < 200 in the better eye. RESULTS: The number of blind persons in India in 2000 was estimated to be 18.7 million (95% confidence interval [CI]: 15.2-22.3), of which 9.5 million were cataract-related and 3 million refractive error-related. If there is no change in the current trend of blindness, the number of blind persons in India would increase to 24.1 million (95% CI: 19.7-28.4) in 2010, and to 31.6 million (95% Cl: 26.4-36.9) in 2020. If effective strategies are put in place to eliminate 95% of blindness due to cataract by 2020, blindness in 15.6 million persons would be prevented who would otherwise be blind in 2020 if the current trend continues, and 78 million blind person-years would be prevented in these persons. Similarly, if effective strategies are also implemented to eliminate 95% of the refractive error blindness by 2020, another 4.2 million persons would be prevented from being blind in 2020, and 82 million blind person-years would be prevented. In addition, if strategies to prevent 90% of the preventable blindness due to corneal disease and glaucoma are successful by 2020, blindness in an additional 3.6 million persons in 2020 and 29 million blind person-years would be prevented. CONCLUSION: The planning of blindness control in India should take into account recent population-based data for the entire age range, which suggest that the number of blind persons in India is currently over 18 million. This estimate is 50% more than the figure of 12 million from a decade ago that is still quoted widely in the blindness control policy documents. If avoidable blindness is to be substantially reduced in India by 2020, effective strategies against blindness due to cataract and refractive error are needed urgently as both these conditions are relatively easy to treat. Also, strategies against preventable corneal and glaucoma blindness need to be strengthened soon for them to show an impact over the next two decades.