Tackling diabetic retinopathy globally through the VISION 2020 LINKS Diabetic Retinopathy Network
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VISION 2020
Tackling diabetic retinopathy globally
through the VISION 2020 LINKS Diabetic
Retinopathy Network
BY NICK ASTBURY, PHILIP BURGESS, ALLEN FOSTER, DENISE MABEY, MARCIA ZONDERVAN
I
t is abundantly clear that the burden of for 2017-2019 using the DR Toolkit guide. Caribbean and Pacific countries and their UK
diabetes is rapidly increasing, as there 3. Share learning so that practical partners) worked together to develop and
are now 415 million adults with diabetes improvements can be made in 2017-2019. implement their local and national plans for
in the world, with a projected rise to 642 Each delegate was provided with a practical DR services.
million by 2040 [1]. This equates to 1 in 10 toolkit guide [3] to help develop their The overall programme consisted of
people. Approximately 10% of adults with country’s DR services and was expected to plenary sessions on the epidemiology
diabetes will have sight-threatening diabetic contribute to an action plan specific for their of global diabetes and its control (Dr
retinopathy [2] requiring immediate LINK, including training visits over the next David Cavan and Professor Clare Gilbert)
treatment to prevent blindness. To combat two years. and effective advocacy for DR, based on
this threat, the Diabetic Retinopathy Some 70 invited participants from 17 experience from the work of the Public
Network (DR-NET) was established in 2014 individual institution-to-institution VISION Health Foundation of India (Professor GVS
and has now increased to 17 paired eye 2020 LINKS partnerships (between Africa, Murthy).
institutions, all part of the VISION 2020
LINKS Programme, with funding from the
Queen Elizabeth Diamond Jubilee Trust.
At the inaugural workshop held in
November 2014, each of 15 LINK teams
developed a two-year action plan for their
DR services, specific to their national or
regional situation. In addition, the resolve
was made by the 15 LINKS teams to increase
their treatment outputs by at least one
patient per week. Over the five years of the
project this would equate to the prevention The Botswana team – participants at the DR-NET planning workshop.
of 37,500 years of blindness.
Two years ago we reported on the newly TABLE 1: DR LINKS PARTNERSHIPS INVOLVED WITH THE DR-NET.
formed DR-NET (‘Commonwealth nations International participating Institutions UK LINK
join forces to prevent blindness from
Ministry of Health, Botswana Addenbrooke’s Hospital, Cambridge
diabetes’ – Eye News February/March 2015)
and last year described the situation in 11 Kenyatta National Hospital and University of University Hospital Coventry
Nairobi, Kenya
countries that were all part of the DR-NET
(‘Situation analysis of diabetic retinopathy Blantyre, Malawi Royal Liverpool University Hospital
services in 11 countries’ – Eye News Lilongwe, Malawi PAEP/ Fife, Scotland
December/January 2016). This October, Calabar, Nigeria Royal Wolverhampton NHS Trust
almost halfway through the project, a DR- LUTH, Lagos, Nigeria Royal Bolton Hospital
NET planning and review workshop was
KCMC, Moshi, Tanzania University Hospitals Birmingham
held in Durban, South Africa, alongside the
Muhimbili University, Tanzania St Thomas’ Hospital, London
Queen Elizabeth Diamond Jubilee Trust’s DR
Advocacy Workshop. Mbeya Referral Hospital, Tanzania WHSCT, Altnagelvin, N Ireland
This article describes that meeting, its Makerere University and Mulago Hospital, Uganda Royal Free Hospital, London
aims, achievements and future plans for the Mbarara and Ruharo Hospitals, Uganda University Hospitals Bristol
DR-NET project and summarises the plenary
Kitwe, Zambia Frimley Park Hospital, Surrey
sessions on epidemiology and advocacy.
University Hospital of the West Indies, Jamaica Homerton University Hospital, London
Korle Bu, Accra, Ghana Moorfields Eye Hospital and Homerton
Intended outcomes
The intended outcomes of the DR-NET Pacific Eye Institute, Fiji RANZCO, Sydney, Australia
planning workshop in Durban were that Solomon Islands RANZCO, Sydney, Australia
each partner would: Vanuatu RANZCO, Sydney, Australia
1. Review and build on the progress made in
Gondar, Ethiopia (unable to attend) Leicester Royal Infirmary
2015 and 2016.
Makassar, Indonesia (unable to attend) Dundee University
2. Develop local and national activity plans
eye news | FEBRUARY/MARCH 2017 | VOL 23 NO 5 | www.eyenews.uk.com
VISION 2020
Epidemiology of diabetic and diabetes physicians do not work diabetes, the prevention of which is key to
retinopathy together – to the detriment of their preserving sight, as well as its many other
It is remarkable enough to realise that patients. In India it has been realised complications.
there will be a 50% increase in diabetes that acceptance of the philosophy of
in the next 25 years but more amazing integration has been key to success. Country action plans: progress
still is the fact that at least 50% of those Not only doctors working together since 2014
people with diabetes are undiagnosed and but also NGOs and government, and At the start of the meeting the LINKS
have no idea they have the disease. This blindness programmes working with partners gave presentations on their
calls for strategies of primary prevention, NCD programmes. This is especially progress since the start of the project in
secondary prevention of complications relevant given the current prominence 2014.
and tertiary prevention of sight loss. of NCDs in policy making. For those Overall there has been an increase in
Successful strategies for reducing the who like alliteration this piece of advice numbers screened and treated and more
incidence of diabetes include lifestyle was considered essential for success: health workers and allied professionals
programmes and legislation of foodstuffs Persistence, Perseverance and Patience! have been trained. ‘Task-shifting’ has
so that individuals with diabetes can work enabled eye care personnel to be utilised
towards achieving lower HbA1c levels Effective advocacy – lessons from more efficiently as members of a team.
and reducing their blood pressure. A 1% India The DR-NET web platform has been
reduction in HbA1c can lead to a 37% In India there are 70 million underserved used for sharing resources and housing a
reduction in microvascular complications people with diabetes where services database for monthly statistics [5].
[4]. Prof Clare Gilbert explained that a are often excellent but fragmented. A Issues included lack of suitably qualified
health systems approach is necessary as situational analysis was performed over screener / graders, malfunctioning
health systems function in the context four months involving clinical gurus, equipment and insufficient anti-
of socio-economic, ecological, policy and the Public Health Foundation of India VEGF. However, there were positive
cultural environments. Services for DR and the London School of Hygiene & reports of more partnerships between
are different from the “one-stop” model Tropical Medicine (LSHTM). There was ophthalmologists and diabetologists and
used for cataract and refractive error. democratic and transparent consultation good models of district programmes that
They require services that involve patient with stakeholders followed by a national were being expanded to other districts.
participation in care, proactive case summit, after which the Government Botswana is the only country in the
detection, responsive location and timing convened a National Task Force to tackle programme that currently has achieved a
of services, and continuity of care from the problem. national screening programme.
home to hospital. It is vital that services The Indian experience has shown Several learning points have emerged:
are equitable and do not impoverish that advocacy in addition to good It is important to have data collection and
individuals and families. Progress will communication can lead to changing registries for organisation, planning and
require national policies, district level attitudes and behaviour, but advocacy advocacy. Joint training of eye care and
planning and co-ordination, capacity requires a process – there are goals to be diabetes / NCD health workers has yielded
building, education and awareness of identified, and there must be adequate many benefits and contributed towards
primary care providers, community capacity to deliver what is promised in programme staff having ‘ownership’
engagement and integration of services order to give credibility. Integration is the of their projects. Finally, patient
into Non Communicable Disease (NCD) key – ophthalmology, primary care and empowerment and patient advocacy
programmes. diabetes services and medical and MoH are important in ‘creating demand’ for
personnel. Stages in the process are listed services.
The Indian perspective in Table 2.
Many useful lessons have been learnt Prof Murthy quoted the chronic disease Summary of country progress
from the work of the Public Health ‘rule of halves’ as it is particularly relevant • Jamaica: excellent progress, increased
Foundation of India which has developed for diabetes and diabetic retinopathy and equipment, treatment and awareness.
diabetes programmes in partnership with demonstrates how far we have to go to • Pacific: Fiji well established, Solomon
national government, state governments tackle the burden of diabetic eye disease: Islands moving forwards, Vanuatu
and Non Governmental Organisations • Half are not aware of disease (50%) infrastructure set up.
(NGOs). A Ministry of Health (MoH) • Half are not engaging with services • South and Central Africa: Model
task force was an essential element, (25%) programmes developing well, moving to
with integration of programmes into all • Half are getting treatment (12.5%) national programmes.
levels of government health services. • Half are treated to target (6.25%). • East Africa: Focus on training centres
Expert groups gave technical advice and and building up tertiary centres,
underpinning all the programmes was the Manifesto beginning to expand to other districts.
generation and use of evidence for policy One output of the Trust’s advocacy • West Africa: Model programmes
change and programme development. meeting was an eight-point manifesto need to be implemented nationally –
Although there were regional differences entitled ‘Preserving the sight of people strengthening tertiary centres.
there were common features which with diabetes across the Commonwealth’ At the end of the workshop each LINKS
included 1. National guidelines, 2. Pilot (Table 3). The intended audience is anyone institution had developed a two-year plan,
programmes for control of diabetes, whose actions or policies could affect each being different according to the local
3. Early detection and management of the health of people with diabetes. The needs and priorities. In some situations
diabetic retinopathy, 4. Enhanced capacity manifesto includes the principle that there was a need for equipment, for
health workforce and 5. Empowerment of ophthalmology teams must integrate example, a laser, in order to move forward
patients and families. with other healthcare professionals to with the programme. Other places were
In many countries ophthalmologists deliver an holistic service for people with short of ophthalmologists or screener /
eye news | FEBRUARY/MARCH 2017 | VOL 23 NO 5 | www.eyenews.uk.com
VISION 2020
Delegates for the DR-NET planning and review workshop and the Queen Elizabeth Diamond Jubilee Trust’s DR Advocacy Workshop.
graders. There were examples of advocacy TABLE 2: STAGES IN THE ADVOCACY PROCESS.
resulting in resources being made
Collect evidence on the problem and available resources: infrastructure and skills
available from ministries of health, LINKS
or the World Diabetes Federation. On the Assess barriers
same topic, delegates talked about trying Identify simple key messages or ‘punch-lines’
to get an ‘ambassador’ in some form but Engage all stakeholders from planning phase
it was not always clear what their role Identify measureable impact
should be – creating awareness of diabetes
Identify strategies and whose support to seek
and healthy eating, or advocating for eye
care services with ministries of health. Seek ambassadors in government and media
Countries where there has been good Integrated approach across professions, sectors, levels of care and across vertical programmes
expansion of DR services demonstrated Plan for sustainability
the importance of engaging with the MoH, Prove with what you have before asking for more
the national eye care programme or with
the NCD programme (or both).
One exciting development has been TABLE 3: 8-POINT MANIFESTO. ‘PRESERVING THE SIGHT OF PEOPLE WITH DIABETES ACROSS
THE COMMONWEALTH’.
cooperation between diabetologists and
1. Universal: action to reduce incidence of DM; Timely access to affordable treatment
the eye team. For the first time we heard
evidence of patients being screened in the 2. Patient-centred care: patients and families supported to improvement of DM
diabetes clinic. It has proved beneficial for 3. Evidence based: research and data collection; Information and learning shared
patients and has enhanced the standing of 4. Quality services: adapted as required for context and learning from implementation
diabetologists who have been able to offer 5. Integrated services
a valuable service in their own clinics. 6. Appropriate human resources: available, affordable, appropriate, safe; appropriate training; safe and quality
The need for better statistics was services. Task shifting and sharing
highlighted as this produces the evidence 7. Accessible: community awareness of services and patient education
that is used for advocacy to acquire more 8. Cost-effective and sustainable: appropriate use of technology; regular review
resources – so there is a need for common
management information systems – at
specialist training opportunities for References
least a common database system into 1. International Diabetes Federation. IDF Diabetes
ophthalmologists (medical retina) and
which all members of the DR-NET can atlas. 7th Edition. 2015. International Diabetes
technicians (equipment maintenance). Federation, Brussels. http://www.idf.org/
input their data.
diabetesatlas/ Last accessed December 2016.
At the conclusion of the meeting it was 2. Yau JW, Rogers SL, Kawasaki R. Global prevalence
agreed to address some of the barriers Conclusion and major risk factors of diabetic retinopathy.
to progress in the areas of equipment The DR-NET has proved an effective Diabetes Care 2012;35(3):556-64.
procurement, data sharing and training. way of utilising VISION 2020 LINKS 3. VISION 2020 LINKS Diabetic Retinopathy Network
Toolkit, 2016 available at: https://www.dropbox.
Good quality low cost equipment can be partnerships to share expertise and com/s/xwl0kh0j1awyr6e/DR-NET%20Toolkit%20
sourced through the International Agency strategies and increase the provision -%202016%20all%20PDF.pdf?dl=0 Last accessed
of diabetic retinopathy services within December 2016.
for the Prevention of Blindness (IAPB) 4. Stratton IM, Adler AI, Neil HA. Association of
‘standard list’. It was resolved to improve the 12 countries. The programme has glycaemia with macrovascular and microvascular
the DR-NET website and create a forum expanded to include Indonesia, Jamaica complications of type 2 diabetes (UKPDS 35):
prospective observational study. Br Med J
for sharing knowledge and resources. The and the Pacific Islands, all places where
2000;321:405-12.
Commonwealth Eye Health Consortium the prevalence of diabetes is high. We look 5. DR-NET https://sites.google.com/site/drnetcomm/
(CEHC) fellowship programme can provide forward to further significant progress home Last accessed December 2016.
over the next two years of the DR-NET.
eye news | FEBRUARY/MARCH 2017 | VOL 23 NO 5 | www.eyenews.uk.com
VISION 2020
Nick Astbury, Denise Mabey,
Clinical Advisor, DR-NET, VISION 2020 LINKS Programme, London
International Centre for Eye Health (ICEH), School of Hygiene & Tropical Medicine.
London School of Hygiene & Tropical Medicine
(LSHTM).
Philip Burgess, Marcia Zondervan,
Clinical Lecturer in Ophthalmology, University Programme Manager, VISION 2020 LINKS
of Liverpool. Programme, ICEH, LSHTM, London, UK.
Prof Allen Foster, Correspondence: Marcia Zondervan, VISION 2020 LINKS Programme Manager,
International Centre for Eye Health, LSHTM, Keppel Street, London, WC1E 7HT.
Co-Director of the International Centre for Eye
Health, London School of Hygiene & Tropical E: marcia.zondervan@lshtm.ac.uk
Medicine. www.iceh.org.uk
eye news | FEBRUARY/MARCH 2017 | VOL 23 NO 5 | www.eyenews.uk.com
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