Papers by Paul Courtright
British Journal of Ophthalmology, Nov 15, 2006
To describe the prevalence and incidence of iris atrophy in patients with multibacillary (MB) lep... more To describe the prevalence and incidence of iris atrophy in patients with multibacillary (MB) leprosy. Methods and patients: Prospective longitudinal cohort study. 301 newly diagnosed patients with MB leprosy were followed up during the 2 years of treatment with multidrug therapy (MDT) and for a further 5 years with biannual ocular examinations. Incidence of iris atrophy was calculated as the number of patients with iris atrophy per person-year (PY) of follow-up among those who did not have iris atrophy at baseline. Stepwise multiple regression confirmed the presence of specific associations of demographic and clinical characteristics (p,0.05) with iris atrophy, detected by univariate analysis. Results: Iris atrophy was present in 6 (2%) patients at enrolment. During MDT, with 445 PYs of follow-up, 9 patients developed iris atrophy (IR 0.02, 95% CI 0.01 to 0.04) that was associated with cataract (HR 15.13, 95% CI 3.71 to 61.79, p,0.001) and corneal opacities (HR 6.83, 95% CI 1.62 to 28.8, p = 0.009). After MDT, with 2005 PYs of follow-up, 60 patients developed iris atrophy (IR 0.03, 95% CI 0.023 to 0.039) that was associated with age (per decade; HR 1.40, 95% CI 1.10 to 1.78, p = 0.006), skin smear positivity (HR 3.50, 95% CI 1.33 to 9.24, p = 0.011), cataract (HR 3.66, 95% CI 1.85 to 7.25, p,0.001), keratic precipitates (HR 2.76, 95% CI 1.02 to 7.47, p = 0.046) and corneal opacity (HR 3.95, 95% CI 1.86 to 8.38, p,0.001). Conclusions: Iris atrophy continues to develop in 3% of patients with MB leprosy every year after they complete a 2-year course of MDT, and is associated with age, increasing loads of mycobacteria, subclinical inflammation, cataract and corneal opacity.
British Journal of Ophthalmology, Apr 13, 2006
To evaluate the incidence of and risk factors for ocular complications in multibacillary (MB) lep... more To evaluate the incidence of and risk factors for ocular complications in multibacillary (MB) leprosy patients following completion of 2 year, fixed duration, multidrug therapy (MDT). Methods: Biannual eye examinations were conducted prospectively on a cohort of MB patients who had completed MDT and followed up for 5 years. The incidence of ocular pathology was calculated as the number of events per person year of event free follow up of patients who did not have the specific finding before completion of MDT. Results: 278 patients had one or more follow up visits after completion of MDT. The incidence of lagophthalmos was 0.24%/patient year (95% CI 0.10% to 0.37%); corneal opacity, 5.35%/patient year (95% CI 4.27% to 6.70%); uveal involvement, 3.78%/patient year (95% CI 2.96% to 4.83%); and cataract that reduced vision to 6/18 or less, 2.4%/patient year (95% CI 1.77% to 3.26%). Overall, 5.65%/patient year (95% CI 4.51% to 7.09%) developed leprosy related ocular disease and 3.86%/patient year (95% CI 3.00% to 4.95%) developed leprosy related, potentially blinding ocular pathology during the period following MDT. Age and other disability also predicted incident eye disease. Conclusions: Every year, approximately 5.6% of patients with MB who have completed MDT can be expected to develop new ocular complications of leprosy, which often (3.9%) are potentially vision threatening. Because many of these complications cannot be detected without slit lamp examination, periodic monitoring, particularly of older patients and those with other disability, is recommended, in order to detect and treat ocular complications satisfactorily.
British Journal of Ophthalmology, May 1, 2004
Background: Globally, blindness is associated with old age and being female. Other sociodemograph... more Background: Globally, blindness is associated with old age and being female. Other sociodemographic and socioeconomic status characteristics associated with blindness have included educational attainment, and occupation. These factors reflect exposure to specific risk factors for blinding eye diseases and utilisation of preventive and curative services by specific sectors of the population. Methods: A population based survey of blindness and trachoma was conducted in Menofiya governorate in Egypt. 3322 adults 50 years of age and over were sampled from throughout the governorate (population 2.7 million). Visual acuity and clinical conditions were recorded and interviews with respondents were conducted. Results: Overall, blindness (,6/60 presenting vision in the better eye) was recorded in 13% of the study population. Besides age and sex, other factors associated with blindness (logistic regression) were marital status and poor sanitation in the household. Conclusion: Socioeconomic status does not appear to be a significant factor associated with blindness in adults in this setting. Instead, sociocultural factors, in particular, characteristics associated with gender sensitive decision making within households, are likely to be more important considerations in understanding blindness in these communities. Successfully combating blindness in the Nile Delta of Egypt will require gender sensitive efforts aimed at timely and effective utilisation of eye care services.
British Journal of Ophthalmology, 2005
Background: A recently published, population based survey of the Tibet Autonomous Region (TAR) of... more Background: A recently published, population based survey of the Tibet Autonomous Region (TAR) of China reported on low vision, blindness, and blinding conditions. This paper presents detailed findings from that survey regarding cataract, including prevalence, cataract surgical coverage, surgical outcome, and barriers to use of services. Methods: The Tibet Eye Care Assessment (TECA) was a prevalence survey of people from randomly selected households from three of the seven provinces of the TAR (Lhoka, Nakchu, and Lingzhr), representing its three main environmental regions. The survey, conducted in 1999 and 2000, assessed visual acuity, cause of vision loss, and eye care services. Results: Among the 15 900 people enumerated, 12 644 were examined (79.6%). Cataract prevalence was 5.2% and 13.8%, for the total population, and those over age 50, respectively. Cataract surgical coverage (vision ,6/60) for people age 50 and older (85-90% of cataract blind) was 56% overall, 70% for men and 47% for women. The most common barriers to use of cataract surgical services were distance and cost. In the 216 eyes with cataract surgery, 60% were aphakic and 40% were pseudophakic. Pseudophakic surgery left 19% of eyes blind (,6/60) and an additional 20% of eyes with poor vision (6/24-6/60). Aphakic surgery left 24% of eyes blind and an additional 21% of eyes with poor vision. Even though more women remained blind than men, 28% versus 18% respectively, the different was not statistically significant (p = 0.25). Conclusions: Cataract surgical coverage was remarkably high despite the difficulty of providing services to such an isolated and sparse population. Cataract surgical outcome was poor for both aphakic and pseudophakic surgery. Two main priorities are improving cataract surgical quality and cataract surgical coverage, particularly for women.
British Journal of Ophthalmology, Jun 1, 1996
British Journal of Ophthalmology, Sep 1, 2003
Background/aims: In the coming two decades significant increases in the burden of blindness are a... more Background/aims: In the coming two decades significant increases in the burden of blindness are anticipated unless concerted efforts are made to improve eye care in developing countries. Evidence of changing prevalence rates or numbers of blind people are few. The change in blindness prevalence and the number of blind people in an adult population of Malawi was measured over a 16 year period. Methods: In 1999 a population based survey of blindness in adults (age 50+) was conducted in Chikwawa district of Malawi. Visual acuity and cause of vision loss were recorded for each eye independently. Blindness was defined as presenting better eye vision of <6/60. Findings from a 1983 survey of blindness in the same district (using similar methods) were re-analysed to be comparable with the survey conducted in 1999. Results: Among 1630 enumerated adults 89% were examined. The age adjusted prevalence of blindness in the adult population was 5.4% and more common in women than men. In each age group the prevalence of blindness was lower in 1999 than in 1983; the overall reduction in blindness was 31%. During this period the 50+ population in Malawi increased almost twofold. Extrapolating the Chikwawa district data to the Malawi population reveals that the number of blind people has increased by 24%; the increase is primarily because of the large increase in the size of the most elderly group, aged 70 and above. Conclusion: The majority of blind people in Chikwawa (1983 and 1999) are in the age group 70 and over. This group has had the largest proportional increase in population size in this time. Services in this population have improved in the intervening 16 years and yet there was still an increase in the number of blind people. There was little change in excess blindness in women, suggesting that the same barriers that prevented utilisation of services in 1983 probably persist in 1999. Efforts to reach the most elderly and to reach women are needed to lead to a reduction in blind people in settings such as rural Malawi.
British Journal of Ophthalmology, May 1, 2006
To evaluate the incidence of and risk factors for ocular complications in multibacillary (MB) lep... more To evaluate the incidence of and risk factors for ocular complications in multibacillary (MB) leprosy patients during their 2 year, fixed duration, multidrug therapy (MDT). Methods: Periodic eye examinations were conducted prospectively on a cohort of 301 consecutive newly diagnosed MB patients every 6 months during their 2 year course of MDT. Incidence of ocular pathology was calculated as the number of events per person year of event free follow up of patients who did not have the specific finding at baseline. Results: 292 (97%) patients had one or more follow up visits. The incidence of lagophthalmos was 1.2%/patient year (95% CI 0.5% to 2.8%); corneal opacity was 7.4%/patient year (95% CI 5.1% to 10.6%); uveal involvement was 5.1%/patient year (95% CI 3.3% to 7.8%), and cataract that reduced vision to 6/18 or less was seen in 4.3%/patient year (95% CI 2.7% to 6.9%) of patients. Overall, 23 individuals (5.8%/patient year, 95% CI 3.9 to 8.8) developed leprosy related potentially blinding pathology during the 2 years of MDT. Conclusions: Approximately 20% of patients with MB leprosy can be expected to develop ocular complications of leprosy during a 2 year course of MDT, many (11%) of which are potentially vision threatening. Ophthalmological monitoring to detect and treat ocular complications at defined intervals during MDT is indicated.
Journal of Epidemiology and Community Health, Feb 1, 1993
Study objective-The aims were (1) to review inpatient burn records of Attat Hospital (Ethiopia) f... more Study objective-The aims were (1) to review inpatient burn records of Attat Hospital (Ethiopia) for the years 1983-1989, and (2) to determine the prevalance of burns and knowledge of first aid for burns in 16 communities served by Attat Hospital in rural Ethiopia
Carolina Digital Repository (University of North Carolina at Chapel Hill), 2022
Background: Postoperative trachomatous trichiasis (PTT) is a challenge for trichiasis surgery pro... more Background: Postoperative trachomatous trichiasis (PTT) is a challenge for trichiasis surgery programs. Little is known about PTT patients' perceptions regarding outcomes and future disease management. This study aimed to understand the characteristics of PTT patients, how they managed trichiasis and their perceptions of prior surgeries and future surgery uptake. Methods: Patients with PTT were identified during an existing trichiasis screening program in Hadiya Zone, Ethiopia. A vision assessment and evaluation of the eyelids were conducted to determine distance vision, presence and severity of trichiasis and eyelid contour abnormalities. A questionnaire was administered to obtain information regarding patients' perceptions of surgery and PTT management approaches. Descriptive statistics were used to characterize PTT and determine associations between PTT severity and patient perceptions. Results: Among 404 participants, most were female (79.7%) and aged 40-60 y (62.6%). In total, 514 eyelids had PTT, and nearly half had severe PTT (46.9%). Although >50% of participants were currently epilating to manage their PTT, the majority (82.8%) indicated that they wanted repeat surgery. Most participants indicated that pain persisted despite epilation. The majority (75.1%) indicated satisfaction with their prior surgery and 59.6% indicated that they would recommend surgery to others. Conclusions: This study, which included a large proportion of severe PTT cases, indicated that individuals were generally satisfied with prior surgery and would prefer to have surgery again for PTT management.
Malawi Medical Journal, 1992
March 1991 the International Eye Foundation and Adventist Development Be Relief Agency conducted ... more March 1991 the International Eye Foundation and Adventist Development Be Relief Agency conducted a workshop on village health volunteers, bringing together representatives from Malawibased non-governmental organizations, the Ministry of Health, and USAID. The participants discussed recruitment, training, rewards, retention, and roles of village health volunteers. This paper presents background data on village health volunteers in Malawi and elsewhere and reviews the key issues facing health care providers in working with village health volunteers. A copy of the workshop report can be obtained from IEF or ADRA.
Malawi Medical Journal, 1998
In the twelve month period from March 1992 to February 1993. 266 consecutive children with measle... more In the twelve month period from March 1992 to February 1993. 266 consecutive children with measles were admitted to the children's unit at Queen Elizabeth Central Hospital (QECH). Blantyre. During the 12 month period the overall mortality was 10.9%; mortality was highest (22.5%) in children 12-23 months age. One-third of the children admitted were under 9 months of age. not eligible for measles vaccination. Pneumonia complicated illness of 30% of cases and was the greatest clinical predictor of mortality. Among inf.mts under 9 months of age, who were receiving inappropriate food supplementation before 4 months of age the risk of death was 6.4 rimes the risk of death in children who were not receiving food supplementation. Other aspects of measles epidemiology are discussed.
Leprosy Review, 1984
A survey on the ocular complications ofleprosy has been carried out in South Korea by members of ... more A survey on the ocular complications ofleprosy has been carried out in South Korea by members of the American Peace Corps. The results in 2925 patients examined in resettlement villages show the high incidence of ocular damage caused by the disease with over 40% of the sample having some form of eye problem. As many as II % of the patients had visual levels of less than 20/200 in both eyes, and extrapolation of these and other figures emphasizes the magnitude of the problem in the country. The setting up of regional clinics to deal with eye complications of leprosy is recommended.
BackgroundTrichiasis is present when one or more eyelashes touches the eye. Uncorrected, it can c... more BackgroundTrichiasis is present when one or more eyelashes touches the eye. Uncorrected, it can cause blindness. Accurate estimates of numbers affected, and their geographical distribution, help guide resource allocation.MethodsWe obtained district-level trichiasis prevalence estimates for 44 endemic and previously-endemic countries. We used (1) the most recent data for a district, if more than one estimate was available; (2) age- and sex-standardized corrections of historic estimates, where raw data were available; (3) historic estimates adjusted using a mean adjustment factor for districts where raw data were unavailable; and (4) expert assessment of available data for districts for which no prevalence estimates were available.FindingsInternally age- and sex-standardized data represented 1,355 districts and contributed 662 thousand cases (95% confidence interval [CI] 324 thousand-1.1 million) to the global total. age- and sex-standardized district-level prevalence estimates differ...
Ophthalmic Epidemiology, 2018
Purpose: To estimate the prevalence of trachoma in suspected-endemic areas of Chad, and thereby d... more Purpose: To estimate the prevalence of trachoma in suspected-endemic areas of Chad, and thereby determine whether trachoma is a public health problem requiring intervention. Methods: We divided the suspected-endemic population living in secure districts into 46 evaluation units (EUs), and used the standardized methodologies of the Global Trachoma Mapping Project. A two-stage cluster-sampling procedure was adopted. In each EU, the goal was to examine at least 1019 children aged 1-9 years by recruiting 649 households; all consenting residents aged ≥ 1 year living in those households were examined. Each participant was examined for trachomatous inflammation-follicular (TF), trachomatous inflammation-intense (TI), and trichiasis. Results: Two EUs had data that could not be validated, and were excluded from the analysis. GPS data for three other pairs of EUs suggested that EU divisions were inaccurate; data for each pair were combined within the pair. In the 41 resulting EUs, 29,924 households in 967 clusters were visited, and 104,584 people were examined. The age-adjusted EU-level prevalence of TF in 1-9-year-olds ranged from 0.0% to 23.3%, and the age-and gender-adjusted EU-level prevalence of trichiasis in ≥ 15-year-olds ranged from 0.02% to 1.3%. TF was above the WHO elimination threshold in 16 EUs (39%) and trichiasis was above the WHO elimination threshold in 29 EUs (71%). Women had a higher prevalence of trichiasis than did men in 31 EUs (76%). A higher ratio of trichiasis prevalence in women to trichiasis prevalence in men was associated (p = 0.03) with a higher prevalence of trichiasis at EU level. Conclusion: Public health-level interventions against trachoma are needed in Chad. Over 10,000 people need management of their trichiasis; women account for about two-thirds of this total. The association between a higher ratio of trichiasis prevalence in women to that in men with higher overall trichiasis prevalence needs further investigation.
Ophthalmic Epidemiology, 2018
Purpose: In 2015, to determine where interventions are needed to eliminate trachoma as a public h... more Purpose: In 2015, to determine where interventions are needed to eliminate trachoma as a public health problem from Egypt, we initiated population-based prevalence surveys using the Global Trachoma Mapping Project platform in four suspected-endemic marakez (districts; singular: markaz) of the governorates of Elmenia and Bani Suef. Methods: In each markaz, 30 households were selected in each of 25 villages. Certified graders examined a total of 3682 children aged 1-9 years in 2993 households, noting the presence or absence of trachomatous inflammation-follicular (TF) and trachomatous inflammation-intense (TI) in each eye. A total of 5582 adults aged ≥15 years living in the same households were examined for trachomatous trichiasis (TT). Household-level access to water and sanitation was recorded. Results: Three of four marakez had age-adjusted TF prevalence estimates in 1-9-year olds of >10%; the other markaz had a TF prevalence estimate of 5-9.9%. Estimates of the age-and gender-adjusted prevalence of unmanaged TT in adults ranged from 0.7% to 2.3%. Householdlevel access to water and sanitation was high. (We did not, however, measure use of water or sanitation facilities.) Conclusions: Each of the four marakez surveyed has trachoma as a public health problem, with a need for implementation of the SAFE (surgery, antibiotics, facial cleanliness, environmental improvement) strategy. Further mapping is also required to determine the need for interventions in other areas of Egypt.
Ophthalmic Epidemiology, 2018
trachoma in Yemen: results of population-based prevalence surveys of 42 evaluation units in nine ... more trachoma in Yemen: results of population-based prevalence surveys of 42 evaluation units in nine governorates. OPHTHALMIC EPIDEMIOLOGY, 25 (sup1). pp. 62-69.
The British journal of ophthalmology, Jan 15, 2018
Trachoma is the leading infectious cause of blindness. Until recently, reliable data on the globa... more Trachoma is the leading infectious cause of blindness. Until recently, reliable data on the global extent of the disease, detailed plans for elimination, and government, donor and partner engagement were all inadequate. The trachoma community undertook a systematic, three-pronged strategy to map trachoma district by district, develop national-level trachoma elimination plans, and create a framework for governments, donors and partners to convene and coordinate in support of trachoma elimination. RESULT: There has been a frame-shift in internal and external perceptions of the global trachoma programme, from being an effort working towards disease control in focussed geographical areas, to one in the process of achieving worldwide disease elimination. Multiple factors contributed to the successful implementation of mapping, planning, and cross-sectional engagement of governments, partners and donors. Elimination of trachoma is possible if the right combination of factors is in place....
Emerging Infectious Diseases, Nov 1, 2004
Eye, May 1, 2022
The Kilimanjaro Diabetic Programme used the Intervention Mapping framework to develop a theory-an... more The Kilimanjaro Diabetic Programme used the Intervention Mapping framework to develop a theory-and evidence-based diabetic retinopathy screening programme. A Working Committee of health care workers and stakeholders ensured community engagement and empowerment of the target audience. OBJECTIVES: To deliver a culturally appropriate, sustainable, community supported health intervention, promoting eye health behaviour change, to prevent avoidable blindness. METHODS: The six steps of the Intervention Mapping protocol incorporated eight components: (1) a needs assessment of people with diabetes and health care workers (2) a clinical trial of diabetic retinopathy screening modes, (3) comic strips as a motivational strategy for diabetic retinopathy screening uptake, (4) health care worker education (5) an electronic database of people with diabetes (6) a self-carry diary (7) implementation of mobile diabetic retinopathy retinal screening (8) process and outcome programme evaluation. The programme eliminated barriers to diabetic retinopathy screening in Kilimanjaro Christian Medical Centre eye and diabetic clinics, placing a digital retinal screening camera in the diabetic clinic and a fast-track screening system in the eye clinic. Two comic strips and a diary provided information about self-management and record of medications, treatment, blood sugar and blood pressure at clinic visits. An annual rural health care worker education programme met requests for knowledge on treatment and care of diabetes, targeting prevention of diabetic retinopathy. Rural digital retinal screening was implemented. Rural diabetes clinics were initiated. CONCLUSIONS: Intervention Mapping provided a systematic, iterative model to formulate and deliver an urban and rural diabetic retinopathy screening programme.
Eye, May 1, 2022
INTRODUCTION: Intervention Mapping is the protocol used by the Kilimanjaro Diabetic Programme to ... more INTRODUCTION: Intervention Mapping is the protocol used by the Kilimanjaro Diabetic Programme to plan, develop, implement, and evaluate an evidence-based screening programme for diabetic retinopathy. Two comic strips were developed to deliver the message on the need for diabetic retinopathy screening. OBJECTIVES: The first objective was to develop a culturally appropriate and accessible health message to promote diabetic retinopathy screening for the target audience. The second objective was to deliver a motivational message to promote acceptance of diabetic retinopathy screening irrespective of past eye health behaviour. METHODS: A multi-method research design was used. Social cognitive theory provided the theoretical basis for the intervention, involving community participation to promote positive eye health behaviour. RESULTS: For the Draughts Comic Strip, Flesch-Kincaid readability was 75.7% and comprehension was 87.04%, and for the Soap Opera Comic Strip Flesch-Kincaid readability was 75.6% and comprehension was 86.54%. CONCLUSION: The development of the diabetic retinopathy comic strips was a positive health education strategy implemented during a clinical trial comparing methods of screening for diabetic retinopathy at the Kilimanjaro Christian Medical Centre Hospital. The level of comprehension of the comic strips by stakeholders indicated their understanding of the message. Patients enroled in the clinical trial requested the comic strips. No discarded comic strips were found in the clinic during the clinical trial. TRIAL REGISTRATION: Trial registration number: ISRCTN31439939. Details available at .
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Papers by Paul Courtright