update rop situation in la

ROP como causa de ceguera en niños

en América Central y América del Sur

Andrea Zin

Departamento de Neonatologia/Unidade de Pesquisa Clinica

Instituto Fernandes Figueira/FIOCRUZ

Rio de Janeiro, Brasil

Subcomite Ceguera Infantil/IAPB

ROP in Latin America:Where are we and where are we going?

Gilbert C, Rahi J, Eckstein M, O’Sullivan J, Foster A. Retinopathy of prematurity in middle-income countries. The Lancet 1997;350:12-4

ROP in Latin America:Where are we and where are we going?

ROP Workshops in the region

1997: Ecuador (8 countries – situational analysis)

1998:Brazil

1999: Cuba

2000: Peru

2001

Objectives of the Childhood Blindness Subcommittee

• Situational analysis

• Awareness: Paediatricians/Ophthalmologists (National Societies)

• Standard guidelines for the region: appropriate screening criteria

• Expand/implement screening and treatment programmes (funding opportunities: CBM/Lions/Orbis)

Support the improvement of the national programmes• Awareness: courses, workshops• Human resource development• Equipment • Co operational visits

International Colaboration

Latin America: IAPB Situation Analysis - ROP

Chairs: A Zin, M de la Fuente

Country Pop Survive < 1500g Severe ROP Blind

Argentina 39,921,833 2688 403 202

Bolivia 8,989,046 422 42 21

Brazil 188,078,277 12512 1251 626

Chile 16,134,219 1483 74 37

Colombia 43,593,035 3515 352 176

Costa Rica 4,075,261 394 59 30

Cuba 11,382,820 918 92 46

Dominican Republic 9,183,984 852 85 43

Ecuador 13,547,510 1202 120 60

El Salvador 6,822,378 732 73 37

Guatemala 12,293,545 1477 148 74

Honduras 7,326,496 833 83 42

Mexico 107,449,525 8925 892 446

Nicaragua 5,570,129 550 55 28

Panama 3,191,319 283 28 14

Paraguay 6,506,464 761 76 38

Peru 28,302,603 2328 233 116

Uruguay 3,431,932 220 22 11

Venezuela 25,730,435 1940 194 97

Total 541,530,811 42035 4282 2144

What is being done?

National ROP Workshops (supported by IAPB, CBM and PAHO)

• 2001: Mexico

• 2002: Argentina, Brazil

• 2003: Colombia, Brazil

• 2004: Ecuador, Brazil, Cuba

• 2005: Colombia, Brazil, Ecuador, and I Latin American workshop in Peru

• 2006: Argentina, Ecuador, Brazil, Venezuela, Meeting of the LA ROP group during the WCO, February São Paulo, Brazil

• 2007: Ecuador, Dominican Republic, Venezuela, Mexico, Peru, Brazil, Meeting of the LA

ROP Working group in Cancun, Mexico during PAAO, visit to Nicaragua. PAHO

Strategic Plan (Argentina and US)

• 2008: Facilitators workshop in Panama, Colombia, Venezuela, Dominican Republic, Brazil, Mexico, II Latin American workshop in Argentina. Visit to Honduras, Guatemala and Bolivia

• 2009: Bolivia, I Centroamerican workshop in Costa Rica, Paraguay and Brazil

ROP in Latin America

I LA ROP Workshop, Lima, Peru, 2005


Facilitators ROP Workshop, Panama, 2008

II LA ROP Workshop, Mar del Plata, Argentina, 2008

Screening and Treatment Guidelines

The LA ROP screening and treatment

guidelines were written according to

what was presented in the Latin

American Workshop, Lima, Peru


Current Status in Latin America

• Wide variation in implementation of

screening programmes

• Transportation problems

• Screening criteria not established in

several countries

• Availability of laser/cryo

– NGOs

– Government

• Infrastructure/human resources

• Follow-up/low vision services

Courtesy: Dr C Zuluaga

Characteristics of babies with “severe” ROP in middle/low income countries

• Wider range of birth weights

• Wider range of gestational ages

• More premature births per million population in Latin America Peruvian Twins – 34 wks

GA, 1900g & 2400g

Courtesy L Gordillo

Current situation• Levels of neonatal care

• Availability of nurses/neonatologists

• Capacity to monitor oxygen

• Lack of adequate training

Improvement of neonatal care initiativesArgentina, Peru and Brazil


ROP workshops

• 1997-2005: workshops more o’gist centred

– Equipment, training ophthalmologists, NGOs

• 2006-2008: ROP as an indicator of level of neonatal

care (more comprehensive approach)

• Need to standardise ROP workshops, considering local

variations


• Chile: 100% coverage (MoH)• Costa Rica: 100% coverage • Argentina: MoH, SAOI, SAO, SAN• Brazil: national committee (CBO, SBP), national screening criteria• Peru: national policy MoH• Colombia, Cuba, Ecuador: national plan

• ROP programmes funded by CBM in South America:– Argentina: Córdoba, La Plata, San Juan (ROP 21)– Brazil: Recife, Rio de Janeiro, Belém, Fortaleza, São Luis, Salvador– Colombia: Cali– Ecuador: Guayaquil– Paraguay: Asunción– Peru: Lima– Venezuela: Caracas, Maracaibo

• Orbis– Costa Rica– Peru

• ROP programmes WHO/Lions in South America– Argentina: Buenos Aires– Brasil: São Paulo– Colombia– Ecuador: Quito

• PAOF– Argentina: La Plata (low vision)– Bolivia: Tarija (exam and treatment)– Brazil (website)

• Dominican Republic

– 2005: no screening/detection/treatment

– ROP workshops 2007/2008

– 6/8 governmental NICUs with ROP programme

– 0/15 private NICUs

– 40% of governmental NICUs: CPAP, blenders, MV

– < 2500g < 37 wks

– 87/648 severe ROP


Source: ROP WS Mar del Plata, 2008

• El Salvador– Ministerio de Salud Pública y Asistencia Social: 80%– 30 hospitales nacionales; 3 3o nivel

• Hospital Nacional de Maternidad para la atención gineco obstétrica, • Hospital Nacional de Niños Benjamín Bloom para la atención pediátrica• Hospital Nacional Rosales para la atención de medicina y cirugía

– 69,000 NV; 630 < 1500 g; Sobrevida aprox 79%– Guía Clínica para la Prevención de la Retinopatía del Prematuro

El Ministerio de Salud Pública y Asistencia Social ha elaborado una ”Guía Técnica para el seguimiento del recién nacido prematuro menor de 2000 gr. al nacer”


UNIDADES DE CUIDADO INTENSIVO NEONATAL EXISTENTES (UCIN) CON PROGRAMA PARA DETECCION DE PETINOPATIA DEL PREMATURO (ROP)

UCIN de Gobierno

UCIN Privadas UCIN de Universidad

Con Programa ROP

6 0 0 6

Sin Programa ROP

0 3 0 3

Total 6 3 0 9


• Nicaragua

– It is estimated that at least 500 babies would need screening for ROP

every year and that approximately 50 would benefit from treatment

– 5/17 with ROP programme

– BW 1 800 g < 35 wks

– 15% with plus disease

– Lack of equipment

– Lack of neonatologists, nurses

– Cryo



• Mexico

– Resolucion Ministerial

– Guias examen y tratamiento

– Encuesta nacional 2006: 28 unidades

– 60% con tamizaje

– Diferentes criterios de selecion

– 53%: tratamiento

– 16% de los examinados fueron tratados



How do we prevent ROP?

Level of neonatal care • Quality of services provided• Availability of adequately trained human resources

• nurses, neonatologists

• Availability of equipment • Oxygen monitors, ventilators

Detection and treatment• Availability of adequately trained human resources

• ophthalmologists

• Availability of equipment • Indirect ophthalmoscopes, 28 diopters lens, diode laser

Visual (re)habilitation

Strategies• Awareness:

• general public• obstetricians• neonatologists and neonatal nurses• ophthalmologists• parents

• Advocacy:• service providers, government

• Increase coverage of effective programmes:• all units caring for babies at risk should have a screening and

treatment programme• screening criteria should include all babies at risk of ROP

needing treatment

• Improvement of neonatal care

ROP in Latin America2009

ROP: 1 = Yes; 0 = No Population Live Births Policy* National Policy** MoH CommitteePlan

Programme Guideline % Coverage

South America

Argentina 40,914,000 734,000 1 1 1 1 1 1 ?

Bolivia 9,775,000 252,000 0 0 0 0 1 0 ?

Brazil 198,739,000 3,663,000 1 0 0 0 1 1 ?

Colombia 43,677 790,000 1 1 1 0 1 1 ?

Chile 16,602,000 243,000 1 1 1 1 1 1 ?

Ecuador 14,573,000 303,000 1 1 1 1 1 1 ?

Guyana 753,000 14,000 0 0 0 0 0 0 ?

Paraguay 6,996,000 197,000 0 0 0 0 1 0 ?

Peru 29,547,000 573,000 1 0 1 0 1 1 ?

Uruguay 3,494,000 49,000 0 0 0 0 0 0 ?

Venezuela 26,815,000 553,000 0 0 0 0 1 0 ?

Total 348,251,677 7,371,000 6 4 5 3 8 6 ?

*ROP Included in National Health Plan** Written StrategySource http://www.census.gov/ipc/www/idb/informationGateway.php accessed July 14 2009

ROP in Latin AmericaMexico C-America Caribe Population Live births Policy*

National Policy**

MoH Committee Plan Programme Guideline % Coverage

Belize 308,000 8,000 0 0 0 0 0 0 ?

Costa Rica 4,254,000 74,000 0 0 0 0 1 1 ?

Cuba 11,452,000 127,000 1 1 1 0 1 1 ?

Dom Republic 9,650,000 216,000 0 0 0 0 1 1 ?

ELS 7,185,000 182,000 0 0 0 0 1 0 ?

Guatemala 13,277,000 371,000 0 0 0 0 1 0 ?

Haiti 9,036,000 263,000 0 0 0 0 0 0 ?

Honduras 7,834,000 206,000 0 0 0 0 1 0 ?

Jamaica 2,826,000 56,000 0 0 0 0 0 0 ?

Mexico 111,212,000 2,192,000 1 0 1 0 1 1 ?

Nicaragua 5,891,000 137,000 0 0 0 0 1 0 ?

Panama 3,360,000 68,000 0 0 0 0 1 0 ?

Total 186,285,000 3,900,000 2 1 2 0 9 4 ?

*ROP Included in National Health Plan** Written StrategySource http://www.census.gov/ipc/www/idb/informationGateway.php accessed July 14 2009

• ROP National Policies

• MoH committees

• Plans

• Programme

• Guidelines


• Prevention of Blindness: ROP– Multidisciplinary approach/collaboration– Education health care personnel– Adequate equipment– Adequate number of trained health care personnel– Protocols– Indicators / Monitoring– Governmental support /Sustainability

• Coordinated effort:– National Societies / professionals– Governments– PAHO– IAPB - LA– Local NGOs


Thank you

update rop situation in la

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