A long queue of tiny patients wriggling on their mother’s lap, some wailing, some sleeping while some feeding. Just born babies of every size and weight bide for their turn to be examined by Dr Anand Vinekar and his core team comprising Praveen Kumar (Project Manager), N Krishnan and Siva Kumar Munniswamy (technicians) at Narayana Netralaya in Bangalore. After a course of dilation, one by one, each baby’s retina is checked for abnormalities or visual impairments. Most of them are premature or low weight babies and in fact, under the risk of turning blind if less than two kilograms.
This is Karnataka’s most ambitious project to screen ‘preventable and avoidable infant blindness’ using technology, passion and complete dedication.
The Karnataka Internet Assisted Diagnosis of Retinopathy of Prematurity (KIDROP) project which has till date screened more than 8500 babies in 18 districts of northern and central parts of the state has attracted worldwide attention and garnered national and international laurels for its simplicity, innovativeness and accessibility. The Harvard Business review has cited KIDROP and its technology as an example of “reverse innovation” for the more developed world to emulate.
Can you imagine, premature babies who are just a few days old, born in rural hospitals have been provided remote diagnosis by experts followed by treatment without the need for these babies to travel to the city. All this is achieved by a team of specially trained non-doctors, obviating the need of specialist in the rural areas.
A passionate and dedicated doctor, the Program Director of KIDROP, Dr Anand Vinekar, whose day begins with a commitment on his lips to ensure that no baby turns blind, says, “New born babies, especially premature, need to be screened for blindness at the right time as it is largely preventable. But only a handful of them are screened in the country today. If this disease of the eye caused by disorganised growth of retinal blood vessels progresses without treatment, it results in varying degrees of visual impairment while in the most severe stages, it causes total blindness.”
After examining eight month old Chandrakala Santosh from Davangere for the second time who was just 1800 grams at birth, the doctor informs the happy mother of the absence of Retinopathy of Prematurity (ROP). “Normally, in 60 per cent of the cases, the disease is not observed but when a baby is born at 32 weeks as Chandrakala, the growth has to be monitored.” The major focus of the project is to prevent blindness from ROP, the leading cause of infant blindness worldwide. In India, two million babies are at risk each year.
Presently, there are less than 20 ROP experts in the country and 22 teams in the country to tackle this blinding issue. A core team comprising of a ROP specialist, a project manager and a technician is all that needs to drive this programme in the rural backward hinterland of Karnataka. In 2008-09, a core team was developed which worked in three hospitals in Bangalore and Mandya. Over a period of five years, the KIDROP programme has grown to become the largest tele-ROP project in the country. The project, which began sedately in just five centres, has today expanded to 81 hospitals in 18 districts. With 3 teams in place in Bangalore, Raichur and Davangere, the screening is done for different geographical zones of the state. However, the entire state will be covered in two more zones of Belgaum and Udupi by 2014.
In 2009, the project turned into a private-public initiative in collaboration with the National Rural Health Mission (GOI) and the Karnataka Government. According to Dr Vinekar, under the MOU signed with the state government, the project will run till next March, providing free training, screening, reading, treatment and payment of salaries in six districts each of Bangalore, Raichur and Davangere divisions. Training for technicians is a complex process and irrespective of their qualifications, they are selected for their dedication and put under training for 90 days. The training is so thorough that the technicians are adept at diagnosing the disease themselves.
In fact, while doing screening, there have been instances when they have been able to save babies suffering from a life threatening condition.
Siva Kumar, Ophthalmic imaging expert says, “Last year, in Mandya district, a baby from Channapatna was brought in for screening and was found to be suffering from hypothermia. The baby was in a critical condition. Fortunately, we rushed to the paediatrician who was able to revive the baby.”
Under KIDROP, many technicians have been trained to screen infants in the peripheral centres using the Ret Cam Shuttle that images the retina.
The technicians will store, read, analyse, grade and upload these images from the rural centre itself using an indigenously developed internet based PACS system. In fact, these images are delivered live to the remote expert on his or her iPhone, PC or iPad while at the same time, the technician will receive live reports delivered through the internet based server.
With 3.5 million premature births in the country whose birth weight is less than two kilograms, 9-10 per cent are at risk of developing ROP within two to three weeks.
Dr Vinekar emphasises, “The first screening should be done before the fourth week of the life of the baby. It is a fast moving disease and by the sixth week, the baby may go blind. Even the stage of the disease should be detected and monitored regularly. Apart from that, the treatment should start as soon as it reaches Stage III, whether it is a one or two kilogram baby. It is a non-invasive procedure where in 99 per cent of cases, the laser treatment is done uneventfully.”
With Karnataka’s Infant Mortality Rate (IMR) decreasing to 35 per thousand compared to the national average of 48, even premature babies are surviving but to monitor them, there are not enough ROP services available. Adding to this, the doctor ruefully says, “The awareness about ROP is dismal as far as medical fraternity and the society is concerned.
The barrier of accepting anything new is very acute in any project. Paediatricians are the people who are supposed to call the ophthalmologist for ROP screening. So, we have regular focused group meetings every month in the targeted districts to educate everybody but our biggest ambassadors are mothers. We need to do more so that no child goes blind.”
But as the KIDROP team states that the government hospitals in both Tumkur and Mandya were very enthusiastic while the paediatric staff are so keen that not a single premature baby was missed for screening. At Mandya Institute of Medical Sciences, 500 babies were screened with absolutely no prodding or pushing. With each day in a week marked for a particular district, every month, 1,400 sessions are carried out.
But the project managers met with a serious problem as many babies were being discharged from hospitals immediately after birth. With the KIDROP team’s first point of contact being only after one or two days after birth, they were missing many a child. Therefore, a new initiative, the REDROP programme, where cost of enrolment is just `5, has been launched to start early enrolment at all KIDROP centres. Under this, when a new born baby is weighed, every mother with a premature baby gets a ‘red card’ to come into the centre for a check up.
KIDROP is now poised for a countrywide expansion, while training and implementation have already begun in some states. The model has been replicated in parts of Maharashtra and Gujarat with the assistance of this team. In March, this year, a team from Rajasthan was trained in Bangalore. The countries that have shown interest in this model and are at various stages of collaboration include Thailand, Indonesia, Russia, Mexico, Dominican Republic, South Africa and Brazil.