ReviewRole of tele-medicine in retinopathy of prematurity screening in rural outreach centers in India – a report of 20,214 imaging sessions in the KIDROP program
Introduction
Retinopathy of prematurity (ROP) is one of the leading causes of preventable infant blindness worldwide ∗[1], ∗[2]. Since the 1990s the focus of ROP as a public health problem has shifted from the industrialized world to middle-income nations ∗[1], ∗[2]. Countries with improving economies and standard of living have also shown rapid improvement in the survival of their infants. Infant mortality rates in India have fallen in the past two decades resulting in increased numbers of survivors, even in the rural areas. With decreasing mortality, emphasis on “intact survival” is now the new benchmark of neonatal quality of life in government-based child health programs [3], ∗[4]. Despite this, factors such as a high birth rate, declining infant mortality, improved survival of low-birth-weight babies, and lack of uniform neonatal care increase the vulnerability of these babies to unscreened ROP blindness in rural areas ∗[5], [6]. If detected on time, ROP blindness is largely preventable and has thus gained public importance in countries such as India, which have mandated ROP and universal screening [3]. Yet, the operational guidelines and road map remain incomplete and the infrastructure to execute these services remains grossly inadequate.
Countries such as India and China together account for more than half of the total number of premature infants born, with India alone accounting for 3.5 million preterm infants annually [4]. Whereas the incidence of ROP in India varies from 38% to 52% of “at-risk” babies in urban areas [7], [8], [9], [10], [11], [12], [13], rural ROP has recently been reported to be comparable [14], [15], [16]. The incidence of treatable ROP is ∼5–10% and this accounts for >60,000 infants annually who may progress to treatment requiring disease in India alone [17]. With <100 ROP specialists, most of whom practice in the cities, the vast majority of rural preterm infants remain unscreened, or are screened too late when they present with stage 5 disease to tertiary care centers in larger cities [18].
The Karnataka Internet Assisted Diagnosis of Retinopathy of Prematurity program (KIDROP) is a telemedicine project initiated in Bangalore, in the south Indian state of Karnataka, in 2008. It was the first endeavor to address the lack of rural ROP specialists by employing trained and accredited technicians who use portable, wide-field, digital, ocular, imaging cameras, namely the Retcam Shuttle (Clarity MSI, Pleasanton, CA, USA) to capture, analyze and report images of “at-risk” infants in rural outreach centers on a weekly rotation within designated rural zones ∗[5], [19]. Remote city ROP specialists provide diagnostic and treatment services to these demarcated zones. The ongoing program has undergone considerable expansion in the past six years through the support of the state and federal government, to include more centers throughout the state and train other states also (unpublished data). To the best of our knowledge, this is the first multicenter, rural outreach ROP incidence report collated through a telemedicine approach. All centers in this study received ROP screening exclusively through teams of non-physicians using tele-ROP exclusively managed through a public–private partnership (PPP) (Fig. 1).
We hope that our experience of 20,214 infant retinal imaging sessions from 36 rural neonatal intensive care units (NICUs) would help in further expansion of ROP services using tele-ROP in India and other middle-income countries with similar demographics. We also discuss the merits and demerits of a publicly supported private ROP screening program in India.
Section snippets
KIDROP outreach team
The KIDROP method of screening has been described before ∗[5], [19], [20]. Briefly, after initiation in 200 as a stand-alone program by Narayana Nethralaya Postgraduate Institute of Ophthalmology (NNPIO), Bangalore, the program was expanded a public–private partnership under the aegis of the National Rural Health Mission (NRHM), Ministry of Health and Family Welfare, Government of Karnataka in 2009. The data in this manuscript are derived exclusively from these PPP centers. The Institution
Results
The period of data analysis of this ongoing program covers the period of February 14th, 2011 to February 28th, 2015 for NK zone and October 1st, 2012 to February 28th, 2015 for CK zone. This is ∼77.5 cumulative months of program activity. During this period, 2345 visits to 36 rural NICUs in 13 district headquarters were completed. In all, 20,214 infant imaging sessions were completed and analyzed. The zonal demographic details are summarized in Table 1.
During this period, 7106 premature infants
Discussion
The World Health Organization's “Born too soon” report has shifted the focus of care of premature infants from industrialized countries to middle-income nations such as India, which currently leads the order of countries with the highest burden of prematurity [4]. Unfortunately, ROP screening programs have not been able to keep up with improving neonatal care practices and remained grossly inadequate. In India today, there are very few ROP specialists and they only cater to a handful of NICUs
Conflict of interest statement
None declared.
Funding sources
The rural outreach component of KIDROP is supported through a public-private partnership between the The National Rural Health Mission, Government of India and Government of Karnataka with Narayana Nethralaya Postgraduate Institute of Ophthalmology, Bangalore, India.
Acknowledgements
We acknowledge the following for their support in this program: North Karnataka team: Dr Siddesh Kumar, Mr Muralidhar Gayakwad, Mr Ravishankar Kandagal, Mr Sudendra Babu; Central Zone team: Dr Prakash Suranagi, Mr Madhava Prasad Padaki, Mr Someshwara Matad, Mr Manjunatha Kalleshappa; KIDROP's headquarter team: Mr Praveen Sharma, Mr Sivakumar Munusamy, Mr Krishnan Narasimha, Mr Srinivas Gowda.
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