1. Estrategia para Planeación (RAAB en los Estados). Van C. Lansingh, MD, Ph.D. Octubre 2015 20

2. Recent Publications of the WHO and GBD Estimating the Prevalence of Vision Loss 2 distinct studies estimate the global prevalence and causes of blindness and visual impairment: 1) World Health Organization Prevention of Blindness and Deafness Programme (WHO PBD) 2) An expert group as part of the Global Burden of Diseases, Injuries and Risk Factors Study (GBD). Both update the previous WHO estimates from 1995, 2002, and 2004 Differ in their methodology and results for the estimates of global blindness and visual impairment. Mariotti S. Global Data on Visual Impairments: 2010. World Health Organization 2012. Available at: http://www.who.int/entity/blindness/GLOBALDATAFINALforweb.pdf.http://www.who.int/entity/blindness/GLOBALDATAFINALforweb.pdf Stevens GA et al; Vision Loss Expert Group. Ophthalmology 2013;120(12):2377-2384. Bourne et al;. Ophthalmic Epidemiol 2013;20(1):33-9.

3. Detailed Analysis of Methodologies: Granularity of Results WHO PBDGBD  Age: 0-14, 15-49,  50 years  Gender: grouped  Time: point estimate for 2010, not comparable to previous methodologies for trend comparisons  Geography: 6 WHO regions  Age: by 5 year intervals  Gender: disaggregated  Time: series over 20 years to enable trend analysis for both backward and forward estimates  Geography: 190 countries, 21 GBD subgroups

4. Key Findings of Both Studies WHO PBDGBD Global prevalence of blindness and visual impairment  Total: 285 million  Blind: 39 million  Low Vision: 246 million  Total: 223.4million  Blind: 32.4 million  Moderate and severe visual impairment (MSVI): 191 million  95% uncertainty intervals: 29.4 – 36.5 million blind, 174 - 230 million visually impaired Burden by gender Women represent 60.0% of blindness and 57% of MSVI Burden by age  50 years represent 82% of blindness and 65% of VI  50 years represent 84.6% of blindness and 77.5% of MSVI

5. Key Findings of Both Studies: Principle Causes of Blindness CauseWHO PBDGBD Cataract51%33% Glaucoma8%7% Age related macular degeneration (AMD) 5%7% Childhood blindness and corneal opacities 4%__ Uncorrected refractive errors (URE) 3% URE: 21% Trachoma1% Diabetic retinopathy (DR)1%3% Undetermined21%29% (Other)

6. Key Findings of Both Studies: Principle Causes of Visual Impairment CauseWHO PBDGBD URE43%53% Cataracts33%18% Glaucoma2% AMD1%3% DR1%2% Trachoma1% Corneal Opacities1%__ Undetermined18521% (Other)

7. A Closer Look at the GBD Study Prevalence of Blindness and MSVI in Latin America CountryBlindness Prevalence, ≥ 50 years (%) Blindness Prevalence, All Ages (%) MSVI Prevalence, ≥ 50 years (%) MSVI Prevalence, All Ages (%) Argentina1.20.37.51.9 Bolivia2.30.614.13.7 Brazil3.50.916.74.4 Chile1.20.310.32.7 Colombia2.50.612.93.4 Costa Rica1.40.315.82.2 Cuba1.40.39.12.4 Dominican Republic 1.90.510.62.8

8. A Closer Look at the GBD Study Prevalence of Blindness and MSVI in Latin America CountryBlindness Prevalence, ≥ 50 years (%) Blindness Prevalence, All Ages (%) MSVI Prevalence, ≥ 50 years (%) MSVI Prevalence, All Ages (%) Ecuador1.70.412.73.3 El Salvador2.40.613.53.5 Guatemala3.80.916.24.3 Honduras2.90.714.73.9 Mexico1.80.49.22.4 Nicaragua3.00.715.04.0 Panama1.50.410.12.6 Paraguay1.70.412.33.2 Peru2.20.512.93.4 Uruguay1.10.39.22.4 Venezuela1.80.49.62.5

9. Epidemiological Studies in Latin America Since 1999, there have been 23 RACSS (Rapid Assessments of Cataract Surgical Services) or RAAB (Rapid Assessment of Avoidable Blindness) studies carried out in Latin America These regional or national population-based epidemiological studies provide: the prevalence and percent cause of blindness in a defined area Cataract Surgical Coverage Cataract Surgical Outcomes Local barriers to cataract surgery. The current preferred methodology in the region is the RAAB.

10. Door to door VA measurement VA< 20/60  Eye exam Only one cause of visual impairment/blindness is assigned per eye Clusters are randomly selected based on 50 participants ≥ 50 years old RAAB Methodology

11. RAAB Indicators CSC indicates the percentage of cataract surgeries that are being carried out based on the VA and cataract surgical needs of the population and is an indicator of equity and distribution of cataract surgeries.. The cataract surgical outcome is an indicator of the quality of cataract surgery. Good post-operatory visual outcome: VA >6/18; Poor outcome (with available correction): VA <6/60. At least 90% of patients should have a post-operatory VA better than 6/60 to indicate adequate quality of care. Limburg H, Meester W. Rapid Assessment of Avoidable Blindness. Version 5 for Windows ®. October 2012. www.cehjournal.org/wp-content/uploads/raab/English/Manuals/RAAB%205%20 Manual%20Eng.pdf. Accessed November 22, 2013. World Health Organization Informal consultation on analysis of blindness prevention outcomes. Geneva: World Health Organization, 1998.

12. It may not always be possible to accurately diagnose causes of posterior segment disease Prevalence of blindness in people aged under 50 cannot be estimated Does not measure the prevalence of diseases. It measures the prevalence and causes of visual impairment/blindness. Kuper, et al. Community Eye Health J. 2006 What a RAAB Does Not Do

13. RAAB Indicators in Latin America Based on the results of the RAAB studies in Latin American countries: Prevalence of blindness ranges from 0.9% in Uruguay to 3.5% in Venezuela Cataract is the leading cause of blindness, ranging from 44% of blindness in Paraguay to 74% in Ecuador. CSC ranges from as low as 15% in cataract patients in El Salvador to as high as 77% in Uruguay. The percentage of good surgical outcomes ranges from 56% in El Salvador to 70% in Uruguay. Gallarreta M, email communication, December 2, 2013. Siso F, et al. Rev Oftalmol Venez. 2005;61:112-139. Duerksen R, et al.. Ophthalmic Epidemiol 2013;20(5):301-307. Ministerio de Salud Pública del Ecuador, 2009. Rius A, et al. Catédra UNESCO de Salud Visual y Desarrollo.

14. Epidemiological Studies in Mexico Study Type YearStateStudy Sample Prev. of Blindness CSC RACSS2005Nuevo Leon 3,7801.5%─51% RAAB (with diabetes component) 2010Chiapas2,8642.3%≤3/60 ≤6/60 ≤6/18 69% 63% 42% Limburg H, et al. Rev Panam Salud Pública. 2009;25:449-55. Polack S, et al.. Ophthalmology. 2012;119(5):1033-40.

15. Epidemiological Studies in Mexico First study: RACSS (2005) in the more developed, northern state of Nuevo Leon. Second study: RAAB (2010) in Chiapas in the south, one of the most impoverished and remote states. Prevalence of cataract blindness in Chiapas = 1.5% 50% more than the 1.0% reported in Nuevo Leon. Only 61% of the cataract patients who were operated on in Chiapas had good surgical outcomes (with available correction) 21% had poor outcomes. Limburg H, et al. Rev Panam Salud Pública. 2009;25:449-55. Polack S, et al.. Ophthalmology. 2012;119(5):1033-40.

16. Mexico: A Socio-Economic Overview United Nations Statistics Division. Social Indicators. United Nations, 2012. United Nations Development Programme. Human Development Reports. 2013 Report. The World Development Indicators Database. Gross domestic product 2011, PPP. The World Bank. Gini Index. The World Bank Group, 2013. The World Bank. Countries and Economies. The World Bank Group, 2013. Saloman JA, et al. Lancet 2012;380:2144-62. Hausmann R. The Global Gender Gap Report. World Economic Forum. Geneva, Switzerland. 2013. Population (millions), 2012116.2 Human Development Index, 20120.775 Inequality-adjusted Human Development Index, 20120.593 Gross Domestic Product Purchasing Power Parity (International $, millions) 2011 1,904,197 Gini Index, 201047.2 Income LevelUpper middle Population <15 years (%), 201228.3 Population ≥50 years (%), 201017.4 Male Life Expectancy, 201072.5 Female Life Expectancy, 201078.4 Global Gender Gap Index, 20120.67

17. Prevalence (Prev) of Visual Impairment (VI) and Blindness (BL) YearDistrict/Region/Area of DataPrev, VI Prev, BL 2012MEXICO (national)7.0%1.5% Reference: ENSANUT 2012 page 39 /200 Eye Health Indicators in Mexico

18. 1.1 Reference Causes of VI and BL in Mexico Cause% of BL% of VIYearDistrict/Region Cataract67402011, 2006 Montemorelos y Chiapas Diabetic Retinopathy8112011Chiapas Glaucoma5.1 a 7 1.2 (20,000) pacientes 2009Mexicanos en EEUU Refractive Error24 – 34Ninos mexicanos e hispanos Age Related Macular Degeneration 5.1Mexicanos en EEUU Trachoma00.32005Chiapas

19. YearSourceNumber of ophthalmologists 2013Mexican Society of Ophthalmology3000 inscritos y 2000? Eye Health Indicators in Mexico: Number of Eye Health Professionals YearSourceNumber of optometrists 2013www.amfecco.org/article_estadisti cas.php 4000

20. Total Number of Cataract Surgeries Performed in the Country in 2013 180,000 # of Cataract Surgeries by Government 80,000 # of Cataract Surgeries by Private Practice 80,000 # of Cataract Surgeries by Non-Governmental Organizations 20,000 Eye Health Indicators in Mexico: Number of Cataract Surgeries

21. Given the total population of 116.2 million, a government national blindness prevalence rate of 1.5%, and 67% of blindness is caused by cataract (from the RAAB + RACSS), then: A Closer Look at the Cataract Situation in Mexico 116.2 million * 0.015 * 0.67 = 1,167,810 people with cataract blindness in Mexico, or how many cataract surgeries at least should be done each year. Only 180,000 surgeries are being done in Mexico => Cataract Surgical Shortfall = 987,810 (85%)

22. Queretaro State Data, Instituto Nacional de Estadísticas State Population, 2010 Conapo 2015 1.8 million 2 million State Population ≥50 Years, 2010* Conapo 2015 Population ≥50 Years Conapo Population of Santiago de Queretaro 2015 342,000 380,000 863,000 Population Entitled to Health Services, 20101,35 million # of Medical Personnel, 20113,092 # of Medical Units, 2011251 Population Economically Active766,000 (42.6%) *Based on UN World Population Statistics, which estimates that the proportion of the population 50 years and older in Mexico is 0.19.

23. Cataract Situation in Queretaro If you consider the state population is 1.8 million, the official government national prevalence rate is 1.5%, and 67% of blindness in Mexico is caused by cataract (according to the RACSS + RAAB) then: 1.8 million * 0.015 * 0.67 = 18,090 people with cataract blindness in Queretaro If we now consider Santiago de Queretaro with 863,000 with same data we have 9,061 people with cataract blindness

24. Cataract Situation in Queretaro According to IMO estimates, there are approximately 700 cataract surgeries performed each year at the Institute and another 700 surgeries performed in Queretaro by other providers. 1,400 cataract surgeries performed each year in Queretaro At least 18,090 surgeries should be performed each year Cataract surgery shortfall = 16,690 (92%) When considering the annual cataract incidence 20% increase of cataract cases… Total cataract surgeries needed = 21,708 Cataract surgery shortfall= 20,308 (94%) And this is only considering blinding cataract!!

25. Mexico is only doing approximately 15% of the cataract surgeries it should be doing to meet the national population’s needs. Queretaro is only doing approximately 8% of the cataract surgeries it should be doing to meet the state population’s needs. IMO is doing half (50%) of the cataract surgeries in Queretaro, but you should be doing a lot more!! Key Cataract Lessons Learned

26. Introduction to the Economic Burden of Blindness and Visual Impairment We have just reviewed the blindness and visual impairment data. I would now like to discuss for the remainder of my presentation the economic burden of blindness and visual impairment. The cost of blindness (COB) and cost of moderate and severe visual impairment (COMSVI) have a wide range of socio-economic implications on the individual, when considering unemployment, caretaking requirements, loss of mobility, inability to read due to vision loss, increased dependence on others, and lower quality of life.

27. Introduction to the Economic Burden of Blindness and Visual Impairment There has not yet been one standard method to carry-out cost-analyses of blindness. Studies have considered direct costs of blindness and visual impairment, including treatment and rehabilitation, and indirect costs of blindness, including caretaker’s costs and productivity loss.

28. Introduction to the Economic Burden of Blindness and Visual Impairment We are going to take a closer look at the loss of economic productivity due to blindness and MSVI, which could be avoided if people with preventable and avoidable blindness were treated and able to enter the work force and work at full (or increased) productivity. This simplified methodology estimates the costs of loss of productivity for all causes and moderate and severe visual impairment for the age group ≥ 50 years.

29. Key terms associated with Productivity Loss Gross domestic product (GDP) purchasing power parity (PPP) per capita: The total market value of all recognized final goods and services produced within a country in a given period of time divided by the population on a given date with the total value relative to another currency (such as in terms of USD). GDP is often considered the indicator of standard of living. Gross National Income (GNI) per capita: (All resident producers + product taxes ( - subsidies) + net receipts of primary income from abroad) / mid-year population Minimum Wage (MW): The lowest hourly, daily, or monthly remuneration that must be legally paid to workers Source: Wikipedia

30. Methodology: Assumptions We will assume the loss of current MW and the loss of GNI per capita as a result of unemployment or reduced employment due to visual impairment with all individuals working until 65 years old. Second, about half of the blindness or visual impairment is allotted to the 50-64 years-old group. For COMSVI, an individual MW/GNI per capita loss of 30% is assumed. Bourne R et al. Ophthalmic Epidemiol 2013;20(1):33-9.

31. Methodology: Sources of Data Population Data: Sources: 2011 United Nations (UN) World Population Prospects GNI data: The World Bank MW data: International Labor Organization (ILO) Blindness and MSVI Prevalence Data: The 2010 Global Burden of Disease (GBD) Study. Bourne R et al. Ophthalmic Epidemiol 2013;20(1):33-9.

32. Economic, Demographic, and Prevalence Data from Sample Countries CountryPopulation (millions) Proportion of Population ≥ 50 years GNI per capita 2011 (PPP) MW (USD per year) Prevalence of blindness (%) ≥ 50 years Prevalence of MSVI (%) ≥50 years Japan126.50.49642,15021,6830.31.6 Brazil199.70.21611,5003,8971.810.1 Nigeria158.40.1081,1801,3325.717.6 United States 310.40.35747,14015,0800.32.1 Mexico116.40.19015,1201,6761.89.2 Pakistan173.60.1841,0508945.322.2 Honduras7.80.1313,8403,7172.914.7 Australia22.30.35443,74030,7260.34.4 Malaysia28.40.1727,9003,2641.412.3

33. COB and COMSVI Using MW and GNI, +50 years

34. Key Model Conclusions This simplified method to calculate productivity loss due to visual impairment can be calculated annually using the 2010 GBD data with economic and demographic data updated regularly on the UN, ILO, and World Bank websites. Total economic burden is incomplete, as caregiver, disability, or treatment costs are not included. Although the majority of people with blindness and visual impairment live in developing countries, the highest economic impact is in middle to high income countries, due to their higher minimum wage and GNI.

35. Key Conclusions Eye Health Interventions Can Save Billions in Productivity Loss ! This same exercise can be completed to calculate the COB and COMSVI in Queretaro.

36. Calculating the Productivity Loss Due to Blindness and Visual Impairment in Queretaro State Population ≥50 Years, 2010*342,000 Minimum Wage (national, USD, 2011)1,676 GNI per capita (national, USD, 2011)15,210 Prevalence of Blindness (%, GBD Study 2010)1.8 Prevalence of Moderate and Severe Visual Impairment (%, GBD Study 2010) 9.2 * Based on UN World Population Statistics, which estimates that the proportion of the population 50 years and older in Mexico is 0.19.

37. COB and COMSVI (defined as productivity loss) in Queretaro, USD millions, 2011 Minimum Wage MethodGNI Per Capita Method COBCOMSVICOVI*COBCOMSVICOVI* 5.27.913.146.571.4117.9 *COVI = total cost of visual impairment, or the sum of COB and COMSVI Total visual impairment is costing the state of Queretaro between $13.1 million and $117.9 million each year in lost economic productivity!!

38. Key Takeaways to Economics Implications of Blindness and Visual Impairment The Impact of Cataract Surgery on the Economic Burden of Productivity Loss of Blindness and Visual Impairment Aravind Eye Hospital in India conducted a survey on productivity gains following sight-restoring cataract surgery. 85% of male patients and 58% of female patients, who had lost their jobs as a result of their previous cataract blindness, were able to re-enter the work force after their cataract surgery. Javitt J.C. Cataract. Chapter 26 ─ Jamison D.T. et al. Disease control priorities in developing countries. New York. Oxford University Press for the World Bank, 1993.

39. Key Takeaways to Economics Implications of Blindness and Visual Impairment The Impact of Cataract Surgery on the Economic Burden of Productivity Loss of Blindness and Visual Impairment A study based on poverty and VI in Kenya, the Philippines, and Bangladesh, likewise found that 1 year after cataract surgery: patients increased productivity by an average of 1- 2 hours per day patients spent less time inactive and required less assistance from other household members. Per capita expenditure of cataract patients also increased to the levels of people who did not have VI in their communities. The results of these studies show that cataract surgery can alleviate poverty and lead to economic gain in productivity. Polack S, et al. PLoS ONE. 2010;5:e10913. Kuper H, et al. PLoS ONE. 2010;5:e15431.

40. Key Takeaways to Economics Implications of Blindness and Visual Impairment Key Takeaways to the Economic Burden of Blindness and Visual Impairment in Queretaro Productivity loss due to blindness and VI costs Mexico billions each year and costs Queretaro millions each year. The economic gain of eye health intervention (i.e., cataract surgery) in Mexico has yet to be studied. The first RAAB to be carried out in Queretaro by IMO in 2014 could be a great opportunity to survey the local population with cataract blindness on their economic gains following cataract surgery. Cost of blindness studies are important advocacy tools to gain greater eye health investment from the government, NGOs, industry, and other stakeholders.

41. Key Takeaways to Economics Implications of Blindness and Visual Impairment IMO Strategic Planning: An Important Opportunity to Become the Leader in Eye Care in the Region The strategic planning exercise that is currently being undertaken at the IMO presents an excellent opportunity to convert the IMO into a comprehensive eye care and training center of excellence that can serve as a key referral center for Mexico and, through e-learning and long- distance learning initiatives, can become an important regional training center for Mexico and Latin America.

42. Thank you!