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Cleland CR, Bascaran C, Makupa W, Shilio B, Sandi FA, Philippin H, Marques AP, Egan C, Tufail A, Keane PA, Denniston AK, Macleod D, Burton MJ. Artificial intelligence-supported diabetic retinopathy screening in Tanzania: rationale and design of a randomised controlled trial. BMJ Open 2024; 14:e075055. [PMID: 38272554 PMCID: PMC10824006 DOI: 10.1136/bmjopen-2023-075055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Accepted: 01/12/2024] [Indexed: 01/27/2024] Open
Abstract
INTRODUCTION Globally, diabetic retinopathy (DR) is a major cause of blindness. Sub-Saharan Africa is projected to see the largest proportionate increase in the number of people living with diabetes over the next two decades. Screening for DR is recommended to prevent sight loss; however, in many low and middle-income countries, because of a lack of specialist eye care staff, current screening services for DR are not optimal. The use of artificial intelligence (AI) for DR screening, which automates the grading of retinal photographs and provides a point-of-screening result, offers an innovative potential solution to improve DR screening in Tanzania. METHODS AND ANALYSIS We will test the hypothesis that AI-supported DR screening increases the proportion of persons with true referable DR who attend the central ophthalmology clinic following referral after screening in a single-masked, parallel group, individually randomised controlled trial. Participants (2364) will be randomised (1:1 ratio) to either AI-supported or the standard of care DR screening pathway. Participants allocated to the AI-supported screening pathway will receive their result followed by point-of-screening counselling immediately after retinal image capture. Participants in the standard of care arm will receive their result and counselling by phone once the retinal images have been graded in the usual way (typically after 2-4 weeks). The primary outcome is the proportion of persons with true referable DR attending the central ophthalmology clinic within 8 weeks of screening. Secondary outcomes, by trial arm, include the proportion of persons attending the central ophthalmology clinic out of all those referred, sensitivity and specificity, number of false positive referrals, acceptability and fidelity of AI-supported screening. ETHICS AND DISSEMINATION The London School of Hygiene & Tropical Medicine, Kilimanjaro Christian Medical Centre and Tanzanian National Institute of Medical Research ethics committees have approved the trial. The results will be submitted to peer-reviewed journals for publication. TRIAL REGISTRATION NUMBER ISRCTN18317152.
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Affiliation(s)
- Charles R Cleland
- International Centre for Eye Health, London School of Hygiene & Tropical Medicine, London, UK
- Eye Department, Kilimanjaro Christian Medical Centre, Moshi, Tanzania
| | - Covadonga Bascaran
- International Centre for Eye Health, London School of Hygiene & Tropical Medicine, London, UK
| | - William Makupa
- Eye Department, Kilimanjaro Christian Medical Centre, Moshi, Tanzania
| | - Bernadetha Shilio
- Ministry of Health, Community Development, Gender, Elderly and Children, Dodoma, Tanzania
| | - Frank A Sandi
- Department of Ophthalmology, University of Dodoma School of Medicine and Nursing, Dodoma, Tanzania
| | - Heiko Philippin
- International Centre for Eye Health, London School of Hygiene & Tropical Medicine, London, UK
- Eye Centre, University of Freiburg Faculty of Medicine, Freiburg, Germany
| | - Ana Patricia Marques
- International Centre for Eye Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Catherine Egan
- National Institute for Health and Care Research (NIHR) Biomedical Research Centre (BRC) for Ophthalmology, University College London, Moorfields Hospital London NHS Foundation Trust and Institute of Ophthalmology, London, UK
| | - Adnan Tufail
- National Institute for Health and Care Research (NIHR) Biomedical Research Centre (BRC) for Ophthalmology, University College London, Moorfields Hospital London NHS Foundation Trust and Institute of Ophthalmology, London, UK
| | - Pearse A Keane
- National Institute for Health and Care Research (NIHR) Biomedical Research Centre (BRC) for Ophthalmology, University College London, Moorfields Hospital London NHS Foundation Trust and Institute of Ophthalmology, London, UK
| | - Alastair K Denniston
- National Institute for Health and Care Research (NIHR) Biomedical Research Centre (BRC) for Ophthalmology, University College London, Moorfields Hospital London NHS Foundation Trust and Institute of Ophthalmology, London, UK
- National Institute for Health and Care Research, Birmingham Biomedical Research Centre, Birmingham, UK
| | - David Macleod
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | - Matthew J Burton
- International Centre for Eye Health, London School of Hygiene & Tropical Medicine, London, UK
- National Institute for Health and Care Research (NIHR) Biomedical Research Centre (BRC) for Ophthalmology, University College London, Moorfields Hospital London NHS Foundation Trust and Institute of Ophthalmology, London, UK
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Cleland CR, Rwiza J, Evans JR, Gordon I, MacLeod D, Burton MJ, Bascaran C. Artificial intelligence for diabetic retinopathy in low-income and middle-income countries: a scoping review. BMJ Open Diabetes Res Care 2023; 11:e003424. [PMID: 37532460 PMCID: PMC10401245 DOI: 10.1136/bmjdrc-2023-003424] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Accepted: 07/11/2023] [Indexed: 08/04/2023] Open
Abstract
Diabetic retinopathy (DR) is a leading cause of blindness globally. There is growing evidence to support the use of artificial intelligence (AI) in diabetic eye care, particularly for screening populations at risk of sight loss from DR in low-income and middle-income countries (LMICs) where resources are most stretched. However, implementation into clinical practice remains limited. We conducted a scoping review to identify what AI tools have been used for DR in LMICs and to report their performance and relevant characteristics. 81 articles were included. The reported sensitivities and specificities were generally high providing evidence to support use in clinical practice. However, the majority of studies focused on sensitivity and specificity only and there was limited information on cost, regulatory approvals and whether the use of AI improved health outcomes. Further research that goes beyond reporting sensitivities and specificities is needed prior to wider implementation.
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Affiliation(s)
- Charles R Cleland
- International Centre for Eye Health, Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK
- Eye Department, Kilimanjaro Christian Medical Centre, Moshi, United Republic of Tanzania
| | - Justus Rwiza
- Eye Department, Kilimanjaro Christian Medical Centre, Moshi, United Republic of Tanzania
| | - Jennifer R Evans
- International Centre for Eye Health, Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK
| | - Iris Gordon
- International Centre for Eye Health, Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK
| | - David MacLeod
- Tropical Epidemiology Group, Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | - Matthew J Burton
- International Centre for Eye Health, Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK
- National Institute for Health Research Biomedical Research Centre for Ophthalmology, Moorfields Eye Hospital NHS Foundation Trust and UCL Institute of Ophthalmology, London, UK
| | - Covadonga Bascaran
- International Centre for Eye Health, Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK
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Stanifer JW, Cleland CR, Makuka GJ, Egger JR, Maro V, Maro H, Karia F, Patel UD, Burton MJ, Philippin H. Prevalence, Risk Factors, and Complications of Diabetes in the Kilimanjaro Region: A Population-Based Study from Tanzania. PLoS One 2016; 11:e0164428. [PMID: 27711179 PMCID: PMC5053499 DOI: 10.1371/journal.pone.0164428] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2016] [Accepted: 09/25/2016] [Indexed: 01/02/2023] Open
Abstract
BACKGROUND In sub-Saharan Africa, diabetes is a growing burden, yet little is known about its prevalence, risk factors, and complications. To address these gaps and help inform public health efforts aimed at prevention and treatment, we conducted a community-based study assessing diabetes epidemiology. METHODS AND FINDINGS We conducted a stratified, cluster-designed, serial cross-sectional household study from 2014-2015 in the Kilimanjaro Region, Tanzania. We used a three-stage cluster probability sampling method to randomly select individuals. To estimate prevalence, we screened individuals for glucose impairment, including diabetes, using hemoglobin A1C. We also screened for hypertension and obesity, and to assess for potential complications, individuals with diabetes were assessed for retinopathy, neuropathy, and nephropathy. We enrolled 481 adults from 346 urban and rural households. The prevalence of glucose impairment was 21.7% (95% CI 15.2-29.8), which included diabetes (5.7%; 95% CI 3.37-9.47) and glucose impairment with increased risk for diabetes (16.0%; 95% CI 10.2-24.0). Overweight or obesity status had an independent prevalence risk ratio for glucose impairment (2.16; 95% CI 1.39-3.36). Diabetes awareness was low (35.6%), and few individuals with diabetes were receiving biomedical treatment (33.3%). Diabetes-associated complications were common (50.2%; 95% CI 33.7-66.7), including renal (12.0%; 95% CI 4.7-27.3), ophthalmic (49.6%; 95% CI 28.6-70.7), and neurological (28.8%; 95% CI 8.0-65.1) abnormalities. CONCLUSIONS In a northern region of Tanzania, diabetes is an under-recognized health condition, despite the fact that many people either have diabetes or are at increased risk for developing diabetes. Most individuals were undiagnosed or untreated, and the prevalence of diabetes-associated complications was high. Public health efforts in this region will need to focus on reducing modifiable risk factors, which appear to include obesity, as well as early detection that includes increasing awareness. These findings highlight a growing urgency of diabetes prevention in this region as well as the need for treatment, including management of complications.
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Affiliation(s)
- John W. Stanifer
- Division of Nephrology, Department of Medicine, Duke University, Durham, North Carolina, United States of America
- Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America
- Duke Clinical Research Institute, Duke University, Durham, North Carolina, United States of America
| | | | | | - Joseph R. Egger
- Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America
| | - Venance Maro
- Kilimanjaro Christian Medical University College, Moshi, Tanzania
| | - Honest Maro
- Eye Department, Kilimanjaro Christian Medical Centre, Moshi, Tanzania
| | - Francis Karia
- Kilimanjaro Christian Medical University College, Moshi, Tanzania
| | - Uptal D. Patel
- Division of Nephrology, Department of Medicine, Duke University, Durham, North Carolina, United States of America
- Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America
- Duke Clinical Research Institute, Duke University, Durham, North Carolina, United States of America
| | - Matthew J. Burton
- International Centre for Eye Health, London School of Hygiene & Tropical Medicine, London, United Kingdom
- Moorfields Eye Hospital, London, United Kingdom
| | - Heiko Philippin
- Eye Department, Kilimanjaro Christian Medical Centre, Moshi, Tanzania
- International Centre for Eye Health, London School of Hygiene & Tropical Medicine, London, United Kingdom
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Mtuya C, Cleland CR, Philippin H, Paulo K, Njau B, Makupa WU, Hall C, Hall A, Courtright P, Mushi D. Reasons for poor follow-up of diabetic retinopathy patients after screening in Tanzania: a cross-sectional study. BMC Ophthalmol 2016; 16:115. [PMID: 27435362 PMCID: PMC4950081 DOI: 10.1186/s12886-016-0288-z] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2015] [Accepted: 07/05/2016] [Indexed: 11/25/2022] Open
Abstract
Background Diabetes is an emerging public health problem in sub-Saharan Africa. Diabetic retinopathy is the commonest microvascular complication of diabetes and is a leading cause of blindness, mainly in adults of working age. Follow-up is crucial to the effective management of diabetic retinopathy, however, follow-up rates are often poor in sub-Saharan Africa. The aim of this study was to assess the proportion of patients not presenting for follow-up and the reasons for poor follow-up of diabetic patients after screening for retinopathy in Kilimanjaro Region of Tanzania. Methods All diabetic patients referred to a tertiary ophthalmology hospital after screening for retinopathy in 2012 were eligible for inclusion in the study. A randomly selected group of patients from the community-based diabetic retinopathy screening register were identified; among this group, follow-up was assessed. Interviews were conducted within this group to inform on the reasons for poor follow-up. Results Among the 203 patients interviewed in the study 50 patients (24.6 %) attended the recommended referral appointment and 153 (75.4 %) did not. Financial reasons were self-reported by 35.3 % of those who did not attend the follow-up appointment as the reason for non-attendance. Multiple logistic regression analysis showed that the patient report of the clarity of the referral process (p = 0.014) and the patient report of whether a healthcare worker told the patient that diabetic retinopathy could be treated (p = 0.005) were independently associated with attendance at a follow-up appointment. Income per month was not associated with attendance at a follow-up appointment on multivariate analysis. Conclusions Financial factors are commonly cited as the reason for non-compliance with follow-up recommendations. However, the reasons for poor compliance are likely to be more complicated. This study highlights the importance of health system factors. Improving the clarity of the referral process and frequent reminders to patients that diabetic retinopathy can be treated are practical strategies that should be incorporated into screening programmes to increase attendance at subsequent follow-up appointments. The results from this study are applicable to other screening programmes as well as those for diabetic retinopathy. Electronic supplementary material The online version of this article (doi:10.1186/s12886-016-0288-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Christina Mtuya
- Kilimanjaro Christian Medical University College, Faculty of Nursing, Moshi, Tanzania
| | - Charles R Cleland
- Eye Department, Kilimanjaro Christian Medical Centre, Moshi, Tanzania.
| | - Heiko Philippin
- Eye Department, Kilimanjaro Christian Medical Centre, Moshi, Tanzania.,International Centre for Eye Health, Faculty of Infectious & Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK
| | - Kidayi Paulo
- Kilimanjaro Christian Medical University College, Faculty of Nursing, Moshi, Tanzania
| | - Bernard Njau
- Kilimanjaro Christian Medical University College, Faculty of Nursing, Moshi, Tanzania
| | - William U Makupa
- Eye Department, Kilimanjaro Christian Medical Centre, Moshi, Tanzania
| | - Claudette Hall
- Department of Work & Social Psychology, University Maastricht, Faculty of Psychology and Neuroscience, P.O. Box 616, 6200 MD, Maastricht, The Netherlands
| | - Anthony Hall
- Newcastle Eye Hospital Research Foundation, 182 Christo Road, Waratah, NSW, 2289, Australia
| | - Paul Courtright
- Kilimanjaro Centre for Community Ophthalmology, Division of Ophthalmology, University of Cape Town, Cape Town, South Africa
| | - Declare Mushi
- Kilimanjaro Christian Medical University College, Faculty of Nursing, Moshi, Tanzania
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Cleland CR, Burton MJ, Hall C, Hall A, Courtright P, Makupa WU, Philippin H. Diabetic retinopathy in Tanzania: prevalence and risk factors at entry into a regional screening programme. Trop Med Int Health 2016; 21:417-26. [PMID: 26644361 PMCID: PMC4819693 DOI: 10.1111/tmi.12652] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE The number of adults with diabetes in sub-Saharan Africa (SSA) is expected to almost double by 2035. This study investigated the prevalence of diabetic retinopathy (DR) and its risk factors at entry into a community-based screening programme. METHODS All persons with diabetes screened for retinopathy at entry into a screening programme in Kilimanjaro Region, Tanzania between November 2010 and December 2014 were included. Fundus photographs were taken with a Topcon retinal camera following pupil dilation. Data were collected on BP, random blood sugar, duration of diabetes, BMI and visual acuity on entry. RESULTS A total of 3187 persons were screened for DR. The prevalence of any DR was 27.9% (95%CI 26.4-29.5%) with background diabetic retinopathy (BDR), pre-proliferative diabetic retinopathy (PPDR) and proliferative diabetic retinopathy (PDR) having a prevalence of 19.1% (95% CI 17.7-20.4%), 6.0% (95%CI 5.2-6.8%) and 2.9% (95%CI 2.3-3.5%), respectively. Maculopathy was present in 16.1% (95%CI 14.8-17.4%) of participants. Multivariable logistic regression analysis for the presence of any DR found independent associations with duration of diabetes (P < 0.0001), systolic BP (P < 0.0001), random blood sugar (P < 0.0001) and attending a government hospital diabetic clinic (P = 0.0339). CONCLUSIONS This study is the first to present data from a DR screening programme in SSA. The results will provide policymakers with data to aid planning of DR screening and treatment services in the African region. The study highlights the importance of managing comorbidities within DR screening programmes.
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Affiliation(s)
- Charles R Cleland
- Eye Department, Kilimanjaro Christina Medical Centre, Moshi, Tanzania
| | - Matthew J Burton
- International Centre for Eye Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Claudette Hall
- Faculty of Psychology and Neuroscience, University Maastricht, Maastricht, The Netherlands
| | - Anthony Hall
- Newcastle Eye Hospital Research Foundation, Waratah, NSW, Australia
| | - Paul Courtright
- Kilimanjaro Centre for Community Ophthalmology, University of Cape Town, Cape Town, South Africa
| | - William U Makupa
- Eye Department, Kilimanjaro Christina Medical Centre, Moshi, Tanzania
| | - Heiko Philippin
- Eye Department, Kilimanjaro Christina Medical Centre, Moshi, Tanzania.,International Centre for Eye Health, London School of Hygiene & Tropical Medicine, London, UK
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Cleland CR, Burton MJ, Hall C, Hall A, Courtright P, Makupa WU, Philippin H. Diabetic retinopathy screening: experiences from northern Tanzania. Lancet Diabetes Endocrinol 2016; 4:10-2. [PMID: 26656290 DOI: 10.1016/s2213-8587(15)00422-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2015] [Revised: 10/27/2015] [Accepted: 10/28/2015] [Indexed: 10/22/2022]
Affiliation(s)
- Charles R Cleland
- Eye Department, Kilimanjaro Christina Medical Centre, PO Box 3010, Moshi, Tanzania.
| | - Matthew J Burton
- International Centre for Eye Health, Clinical Research Department, London School of Hygiene & Tropical Medicine, London, UK
| | - Claudette Hall
- University Maastricht, Faculty of Psychology and Neuroscience, Department of Work & Social Psychology, Maastricht, Netherlands
| | - Anthony Hall
- Newcastle Eye Hospital Research Foundation, Waratah, NSW, Australia
| | - Paul Courtright
- Kilimanjaro Centre for Community Ophthalmology, Division of Ophthalmology, University of Cape Town, Cape Town, South Africa
| | - William U Makupa
- Eye Department, Kilimanjaro Christina Medical Centre, PO Box 3010, Moshi, Tanzania
| | - Heiko Philippin
- Eye Department, Kilimanjaro Christina Medical Centre, PO Box 3010, Moshi, Tanzania; International Centre for Eye Health, Clinical Research Department, London School of Hygiene & Tropical Medicine, London, UK
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Cleland CR, Tukahebwa EM, Fenwick A, Blair L. Mass drug administration with praziquantel reduces the prevalence of Schistosoma mansoni and improves liver morbidity in untreated preschool children. Trans R Soc Trop Med Hyg 2014; 108:575-81. [DOI: 10.1093/trstmh/tru097] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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