A search for trachoma in Timor-Leste: no evidence to justify undertaking population-based prevalence surveys.

PURPOSE: We sought evidence to justify undertaking population-based trachoma surveys in Timor-Leste, believing that in the absence of such evidence, the country could be categorized as not needing interventions to eliminate trachoma. METHODS: We undertook a systematic review of published literature on trachoma in Timor-Leste, with results updated to 28 April 2018. We also undertook a series of clinic- and field-based screening exercises, consisting of: (1) in October 2015, conjunctival examination of all children attending a school in Vila, Atauro Island; (2) from 1 November 2016 to 30 April 2017, examination for trichiasis, by specifically-trained frontline eye workers, of all individuals presenting to the ophthalmic clinics of six referral hospitals and five district eye clinics; and (3) house-to-house case searches in a total of 110 households, drawn from three communities that were reported by investigators from the 2016 Rapid Assessment of Avoidable Blindness (RAAB) to include residents with trachoma. RESULTS: Three RAABs (2005, 2009-2010, 2016) and two relevant published papers were identified. The 2016 RAAB reported one female subject to have been diagnosed with trachomatous corneal opacity. Re-examination of that individual revealed that she had ankyloblepharon, without evidence of trichiasis or entropion. No children on Atauro Island, no clinic attendees, and no individuals examined in the targeted house-to-house searches had any sign of trachoma. CONCLUSION: Trachoma is very unlikely to be a public health problem in Timor-Leste. It would not be appropriate to incur the costs of conducting formal population-based trachoma prevalence surveys here.

Prevalence and causes of blindness, visual impairment, and cataract surgery in Timor-Leste.

PURPOSE: To estimate the prevalence and causes of blindness and visual impairment, cataract surgical coverage (CSC), visual outcome of cataract surgery, and barriers to uptake cataract surgery in Timor-Leste. METHOD: In a nationwide rapid assessment of avoidable blindness (RAAB), the latest population (1,066,409) and household data were used to create a sampling frame which consists of 2,227 population units (study clusters) from all 13 districts, with populations of 450-900 per unit. The sample size of 3,350 was calculated with the assumed prevalence of blindness at 4.5% among people aged ≥50 years with a 20% tolerable error, 95% CI, and a 90% response rate. The team was trained in the survey methodology, and inter-observer variation was measured. Door-to-door visits, led by an ophthalmologist, were made in preselected study clusters, and data were collected in line with the RAAB5 survey protocol. An Android smart phone installed with mRAAB software was used for data collection. RESULT: The age-gender standardized prevalence of blindness, severe visual impairment, and visual impairment were 2.8%, (1.8-3.8), 1.7% (1.7-2.3), and 8.1% (6.6-9.6), respectively. Cataract was the leading cause of blindness (79.4%). Blindness was more prevalent in the older age group and in women. CSC was 41.5% in cataract blind eyes and 48.6% in cataract blind people. Good visual outcome in the cataract-operated eyes was 62% (presenting) and 75.2% (best corrected). Two important barriers to not using available cataract surgical services were accessibility (45.5%) and lack of attendants to accompany (24.8%). CONCLUSION: The prevalence of blindness and visual impairment in Timor-Leste remains high. CSC is unacceptably low; gender inequity in blindness and CSC exists. Lack of access is the prominent barrier to cataract surgery.

An estimation of the prevalence of diabetes mellitus and diabetic retinopathy in adults in Timor-Leste.

BACKGROUND: Once considered an affliction of people in high-income countries, diabetes mellitus is increasingly seen as a global epidemic. However, for many countries very little is known about the prevalence of diabetes and its complications. This study aims to estimate the prevalence of diabetes, and diabetic retinopathy, in adults in Timor-Leste. METHODS: From March 2013 to May 2014, adult patients being assessed for cataract surgery at the Sentru Matan Nasional (National Eye Centre) in Dili, Timor-Leste had a point-of-care HbA1c measurement performed on the DCA Vantage device (Siemens Ltd) under a quality framework. A diagnostic cut-off of 6.5% (48 mmol/mol) HbA1c was used for diagnosis of diabetes. Ocular examination, blood pressure, demographic and general health data were also collected. Diabetic retinopathy assessment was carried out by ophthalmologists. RESULTS: A total of 283 people [mean age 63.6 years (range 20-90 years)] were tested and examined during the study period. Forty-three people (15.2%) were found to have diabetes, with a mean HbA1c of 9.5% (77 mmol/mol). Of these, 27 (62.9%) were newly diagnosed, with a mean HbA1c of 9.7% (83 mmol/mol) and a range of 6.6-14% (49-130 mmol/mol). Nearly half (48.1%) of people newly diagnosed with diabetes had an HbA1c over 10.0% (86 mmol/mol). Of those with known diabetes, only 68.8% were receiving any treatment. Mean HbA1c for treated patients was 9.9% (85 mmol/mol). Diabetic retinopathy was identified in 18.6% of people with diabetes, of whom half had no previous diagnosis of diabetes. CONCLUSIONS: This study estimates the prevalence of diabetes at 15% in adults in Timor-Leste, a substantial proportion of whom have evidence of diabetic retinopathy. This is consistent with regional estimates. With the majority of patients undiagnosed, and management of people known to have diabetes largely inadequate, point-of-care testing is a valuable tool to assist with diabetes case detection and management. Whilst only a preliminary estimate, our data provides important impetus for further investigation of the prevalence and impact of diabetes in Timor-Leste. It provides guidance that further investment is required in expanding testing, as well as in prevention and treatment.