[The Institute of Tropical Ophthalmology of Africa]

The Tropical Ophthalmology Institute of Africa (TOIA) is an integral part of the OCCGE. Located in Bamako since 1953, the TOIA is operated jointly by the member states of the OCCGE, the French Cooperation Ministry, and the WHO for which it serves as a center for the prevention of blindness. In addition to providing eye care for the people of western Africa, the TOIA promotes clinical, epidemiologic, and surgical research and carries out health surveys in function of the needs of the member states of the OCCGE. The major purpose of the TOIA is to training doctors and ophthalmologic nurses as well as for cataract operators and eyeglasses technicians. At the center of a network dedicated to the fight against blindness, the range of action of the TOIA now reaches beyond the borders of the eight states in the OCCGE.

[Training at the African Institute of Tropical Ophthalmology in Bamako]

The African Institute of Tropical Ophthalmology (AITO) is an OCCCMED institute, founded in Bamako in 1953. The OCCCMED itself is based at Bobo Dioulasso (Burkina Faso). AITO is a WHO collaborating center for the prevention of blindness. Training is one of the main activities of the institute, along with eye care, research and assessment. The prevalence of blindness in sub-Saharan countries is about 1.2%, with blindness mostly caused by cataracts, trachoma, glaucoma and onchocercosis. The demand for eye care is high but there are currently too few trained personnel to satisfy that demand. Therefore, AITO's role in training eye-care professionals is particularly important. The institute trains ophthalmologists, specialist nurses, eye surgeons (who remove cataracts) and spectacle manufacturers. Training is carried out within the framework of the community and apprenticeship in the workplace. The student must attain specific targets, listed in a "competency passport" issued at the start of training. Clinical and surgical ophthalmology and general eye care are taught. Training costs and grants are mostly paid by the Lions Club International Sight First Program or by the French Overseas Development Ministry. Since 1991, AITO has trained to graduation: 18 ophthalmologists; 24 eye surgeons; 83 specialist nurses; 16 spectacle manufacturers.

[Strategies to control cataracts]

Cataracts, often associated with aging (80%), are a major cause of blindness (more than 50% of cases of blindness in Africa), and for this reason, up to 80% of cases could be predicted or prevented. The socio-economic costs (care and loss of productivity) are increased by morbidity (blindness, impaired vision, congenital, complicated or infected cataracts). The biological determinants of cataracts account for the difficulties in developing and implementing effective preventive action. These epidemiological determinants (prevalence, incidence, increase in life expectancy) account for the size of the public health problem. The surgical removal of cataracts in Africa currently only deals with about 1% of the prevalence rate or 10% of the incidence. Cataracts are, however, easy to cure, resulting in great benefits to public health. The waiting list for cataract operations is very short because of social and cultural barriers which limit the acceptability and accessibility of treatment. Rather than formalizing the dogmatic choices of surgical techniques and structures (fixed, mobile, advanced?), we should promote all phases of treatment from active screening and the selection of cases for surgery to the follow-up of interventions and their impact. We should also increase public awareness, develop a system for the transfer of information that is effective and improve the cost-effectiveness and capacity of the region to provide high quality services on a large scale. We must promote patient satisfaction at all stages of treatment: its quality, its delivery and its low cost.

[Future of ophthalmology nurses and physicians trained at the African Institute of Tropical Ophthalmology]

Six ophthalmologists and 24 specialist ophthalmology nurses from French-speaking African countries graduate from AITO each year. Their training focuses on the skills they will need to participate in the national programs to combat blindness. All the ophthalmologists (10) and specialist ophthalmology nurses (42) from Mali, Niger, Burkina Faso and Senegal, who graduated from AITO within the last ten years were interviewed. Eight of the ten ophthalmologists and all of the specialist nurses are currently working in national programs to combat blindness. The specialist nurses knew more about public eye health issues than about optics. The training given is appropriate for ophthalmology professionals working in these countries. The chief demand of both ophthalmologists and specialist nurses was that they should have continuous training and supervision.

[Activities of the African Institute of Tropical Ophthalmology, 1990-1997]

The African Institute of Tropical Ophthalmology (AITO) was founded in Bamako in 1953. It is part of a regional structure, The Organization for Cooperation and Coordination in the Control of Major Endemic Diseases (OCCCMED). AITO is a WHO collaborating center for the prevention of blindness and has four aims: the provision of eye care, training (ophthalmologists, cataract surgeons, specialist nurses, spectacle manufacturers), research (epidemiology, clinical and surgical) and assessment of public eye care as a function of the needs of the member states of OCCCMED. The European Regional Program for the Prevention of Blindness and an International Sight First Program Center are located at AITO. AITO is at the heart of a network dedicated to fighting blindness, and its activities extend beyond the borders of the OCCCMED.

[Synthesis of the blindness situation in the countries of the Organization for Cooperation and Coordination in the Control of Major Endemic Diseases]

The major causes of blindness in the OCCCMED states are cataracts, trachoma, glaucoma and oncocercosis. The prevalence of blindness is about 1.2% and there are about 880,000 blind individuals and 2,500,000 people with impaired vision. Cataracts were the cause of blindness in 440,000 people and the cause of visual impairment in 1,320,000 individuals. About 1,500,000 people were found to have oncocercosis, and about 24,000 were blind. The true rate of trachoma is unknown. Thirteen thousand cataracts are surgically removed in the region each year, the CSR (cataract surgery rate) being 210. In the last few years, national programs have been set up to combat blindness and equipment and training have been established. With a ratio of 1 ophthalmologist per 523,000 people, the WHO's objectives are becoming attainable.

Efficacy of massive oral doses of retinyl palmitate and mango (Mangifera indica L.) consumption to correct an existing vitamin A deficiency in Senegalese children

Administration of large oral doses of retinyl palmitate has become the most widely practised vitamin A deficiency prevention strategy in developing countries. We conducted a follow-up study among 220 Senegalese children aged 2-7 years suffering from moderate undernutrition to determine the efficacy of vitamin A treatment on their vitamin A status assessed by biochemical and cytological (impression cytology with transfer) methods. The first examination (T = 0 m[onth]) was carried out during April 1989, before the mango (Mangifera indica L,) harvest. The second examination (T = 2 m) was carried out 2 months after vitamin A treatment during June 1989 when ripe mangoes become widely available. Conjunctival cells of the eyes of the children with or without ocular inflammation were responsive to vitamin A administration (P < 0.01). There was a significant increase (P < 0.001) in mean serum retinol and beta-carotene levels between T = 0 m and T = 2 m. Mean serum retinol-binding protein (RBP) and transthyretin (TTR) levels did not differ significantly (P > 0.05) at T = 0 m and T = 2 m. Despite the intake of vitamin A, 54% of the children who had abnormal cytology at T = 0 m remained abnormal at T = 2 m. This was due to inadequate levels of TTR and RBP, presumably due to the cereal diet eaten by the Senegalese population. children with abnormal eye cytology had lower serum retinol levels than those with normal eyes at T = 0 m, and beta-carotene values did not correlate with eye cytological abnormalities at T = 0 m. Children with normal cytology had higher serum retinol and also beta-carotene levels than those with abnormal cytology after massive oral doses of vitamin A and consumption of mangoes at T = 2 m. Retinyl palmitate may, therefore, only lead to partial cytological improvement due to a lack of retinol-carrier proteins but dietary beta-carotene may also be involved.

Prevalence of malnutrition and vitamin A deficiency in the Diourbel, Fatick, and Kaolack regions of Senegal: a controlled study

Two hundred and six Senegalese preschool children included in an epidemiological study were selected by their results from impression cytology with transfer (ICT) for assessment of their nutritional state by means of biological variables and for assessment of the diagnostic values of the ICT. A problem of protein-calorie malnutrition existed (transthyretin and retinol-binding protein concentrations were low) associated with vitamin A deficiency (retinol concentrations were low). The sensitivity and specificity of the ICT defined with respect to retinol (threshold fixed at 0.35 mumol/L) varied with the classification criteria of ICT and seemed to be fairly insensitive but specific.

Prevalence of malnutrition and vitamin A deficiency in the Diourbel, Fatick, and Kaolack regions of Senegal: epidemiological study

The purpose of our study was to determine the prevalence of protein-calorie malnutrition (PCM), ocular diseases, and vitamin A deficiency in preschool children selected at random in a rural zone of the groundnut belt of Senegal. The prevalence of PCM was 37.1% (95% CI 33.8-40.2%) according to the Waterlow classification, with a majority of stunting, and prevalence of hypovitaminosis A was estimated to be 11.4% (95% CI 9.3-13.5%) by using impression cytology. Furthermore, 19.4% (95% CI 15.8-22.0%) of the children might be defined at risk of deficiency. The prevalence of Bitot's spots was equal to 0.2% (95% CI 0.03-0.9%). A problem of PCM associated with a health-endangering vitamin A deficiency existed.

Prevalence of malnutrition and vitamin A deficiency in the Diourbel, Fatick, and Kaolack regions of Senegal: feasibility of the method of impression cytology with transfer

The evaluation of the prevalence of ophthalmological diseases and vitamin A deficiency in Senegalese preschool-aged children enabled us to confirm the method of impression cytology with transfer (ICT) and to assess the impact of ophthalmological diseases on the cytological appearance of conjunctival cells. A simplification of the ICT method consisted of transferring cells present on a strip of paper to a glass slide by finger pressure. Harris-Schorr staining of the sample papers confirmed the results obtained by the transfer. Inflammatory trachoma influenced the results of the test. This simple method will prove very helpful for detection of vitamin A deficiency in children in underdeveloped areas.