|Year : 2019 | Volume
| Issue : 1 | Page : 7-10
Retinopathy of prematurity among syrian refugees: Incidence and severity
Pehmen Yasin Ozcan
Ophthalmology Department, Sanliurfa Education and Research Hospital, Sanliurfa, Turkey
|Date of Web Publication||24-Apr-2019|
Dr. Pehmen Yasin Ozcan
Ophthalmology Department, Sanliurfa Education and Research Hospital, Sanliurfa
Source of Support: None, Conflict of Interest: None
| Abstract|| |
PURPOSE: The aim of this study is to compare the incidence and severity of retinopathy of prematurity (ROP) in premature newborns of Syrian refugees and those of Turkish origin.
METHODS: This retrospective, the single-center study included 1545 premature infants assigned to two groups based on maternal origin. Group 1 comprised 1366 premature infants of Turkish origin, and Group II comprised 179 premature infants born to Syrian refugees. All the premature infants were screened for ROP by the same ophthalmologist who is experienced in the screening and treatment of ROP. All data including gestational age (GA), birth weight (BW), the presence of ROP, and severe ROP collected from 2014 to 2017 were recorded for each group. The outcomes were compared between the two groups.
RESULTS: The mean GA at birth was 30.6 ± 2 weeks and was significantly lower in Group II (P = 0.03). The overall incidence of ROP was similar in both groups. The incidence of severe ROP in Group II was nearly seven times higher than in Group I (1.5% and 10%, respectively). The incidence of severe ROP seen in Group II evaluated according to different ranges of GA and BW was higher than in Group I.
CONCLUSION: The higher incidence of severe ROP in the premature newborns of Syrian refugees could play an important role in identifying ongoing health problems of refugees.
Keywords: Incidence, refugee, retinopathy of prematurity
|How to cite this article:|
Ozcan PY. Retinopathy of prematurity among syrian refugees: Incidence and severity. Middle East Afr J Ophthalmol 2019;26:7-10
|How to cite this URL:|
Ozcan PY. Retinopathy of prematurity among syrian refugees: Incidence and severity. Middle East Afr J Ophthalmol [serial online] 2019 [cited 2019 Sep 21];26:7-10. Available from: http://www.meajo.org/text.asp?2019/26/1/7/256972
| Introduction|| |
Retinopathy of prematurity (ROP) is a sight-threatening and vasoproliferative disease that occurs only in premature infants. ROP is one of the leading causes of preventable blindness in both developed and developing countries. The incidence and severity of ROP are, particularly correlated with low gestational age (GA) at birth, increased survival rate of extremely low birth weight (BW) infants and the lack of an effective screening and treatment program based on the international guidelines.,
Since the outbreak of civil war in Syria, millions of refugees have been admitted by the Republic of Turkey and many of these are living either in accommodation camps or homes in the South-Eastern Anatolian region of the country. The health-care services of Turkey and other countries in the region, particularly Lebanon and Jordan, are struggling with increasing numbers of Syrian refugees, exceeding their capacity. An estimated one in five registered refugees are children under 5 years old, and this group has the highest death rates. Accordingly, sufficient health-care services and high-quality care are essential for children, particularly those below the age of 5 years. To the best of our knowledge, there are no data or information concerning the incidence or severity of ROP among the children of refugees. Syrian refugees living in Turkey have the same rights as Turkish citizens for accessing all types of health services without payment, even at a tertiary level of care. The purpose of this study was to draw attention to the on-going health problems of refugees by determining the incidence of ROP through a screening program and comparing this with data obtained from premature babies of Turkish origin.
| Methods|| |
This single-center retrospective study was carried out in a tertiary referral center for ROP. Data presented in the study was compiled from 1545 preterm infants screened for ROP from 2014 to 2017. The study was carried out in accordance with the Declaration of Helsinki. Written informed consent was obtained from the parents prior to enrollment.
Group I comprised 1366 premature infants and Group II comprised 179 premature infants, all of whom were screened for ROP between 2014 and 2017. All preterm infants with BW ≤1500 g or ≤32 weeks GA and preterm infants with BW >1500 g or GA >32 weeks admitted to the neonatal intensive care unit (NICU) due to a requirement for intensive care were enrolled in this study. The initial fundus examination was performed at 4–6 weeks postnatally. An experienced ophthalmologist, particularly for the screening and treatment of ROP, performed all examinations (PYO). The retinal findings implicating the stage of disease, location by zone, the presence or absence of plus disease classified according to the current International Classification of ROP were recorded. When any stage of ROP was detected, the examinations were repeated at weekly or bi-weekly intervals depending on the retinal findings until a completely vascularized peripheral retina was obtained. An eyelid speculum and scleral indentation were used in all examinations. In compliance with the international classification, Type 1 ROP describing for any stage of ROP which requires treatment to prevent blindness was defined as severe ROP. The premature infants were assigned into two groups based on maternal origin. Premature infants with Turkish origin were defined as Group I and premature infants of Syrian refugees were defined as Group II. The data in each group were analyzed according to different ranges of GA as <28 weeks, 28–32 weeks, and >32 weeks and BW as <1250 g, 1250–1500 g, and >1500 g.
All statistical analysis of the study data were performed using SPSS for Windows software (SPSS Inc., Chicago, IL, USA). The data obtained from the groups was expressed as mean ± standard deviation. Conformity of the data to normal distribution was assessed using the Kolmogorov–Smirnov test. Paired Student's t-test was used to analyze the differences between the two groups. Data were analyzed at a 95% confidence interval. A value of P < 0.05 was accepted as statistically significant.
| Results|| |
The overall incidence of ROP was 23.4% in Group I (n = 319) and 21.2% (n = 38) in Group II. The incidence of severe ROP that required treatment was 1.5% (n = 20) in Group I and 10% (n = 18) in Group II.
The mean GA was 31.5 ± 2.7 weeks in Group I and 30.6 ± 2.3 weeks in Group II. The mean GA was significantly lower in Group II (P = 0.2 and P = 0.03, respectively).
The mean BW was 1722 ± 492 g and 1643 ± 473 g, respectively, with no significant difference determined between the two groups. The mean GA was 31 ± 2 weeks, and mean BW was 1480 ± 460 g in premature infants with severe ROP in Group I. The mean GA was 28 ± 2 weeks, and mean BW was 1280 ± 408 g in premature infants with severe ROP in Group II. The difference between the mean GA and BW values in the severe ROP group was higher than the difference in the overall groups (P = 0.32 and P = 0.88, respectively).
The analysis of the incidence of overall ROP and severe ROP in two groups are summarized in [Table 1] and [Table 2].
|Table 1: The incidences of overall and severe retinopathy of prematurity in different ranges of gestational age in two groups|
Click here to view
|Table 2: The incidences of overall and severe retinopathy of prematurity in different ranges of birth weight in two groups|
Click here to view
| Discussion|| |
According to the United Nations High Commission for Refugees data for 2016, the number of Syrian refuges in countries neighboring Syria was approximately 5 million. In Turkey, more than 2.7 million Syrian refugees are living either in accommodation camps settled around the frontier or in homes in urban areas, whereas others are scattered across Turkey. Many refugees are living in overcrowded settlements and unsanitary living conditions, which may lead to serious health problems such as the spread of contagious infectious diseases, including measles, hepatitis, varicella that can cause physical and mental disabilities, diarrhea, respiratory tract disease, chronic malnutrition, and anemia particularly caused by iron and Vitamin B12 deficiency.,
Erenel and et al. reported that pregnant Syrian refugees were significantly younger than Turkish pregnant patients and many had poor antenatal care. Although the pregnant Syrian refugees lack essential nutritional support, antenatal care and are at risk of infectious diseases, preterm birth rates were not found to be different from those of Turkish pregnant patients. There was also found to be no difference in low BW, stillbirth and fetal anomaly rates. This unexpected influx of refugees from the civil war in Syria has increased the population of Turkey, which is considered a middle-income country, and has had many unfavourable effects on health, social and economic issues, such as overloading of the health-care facilities, increasing the unemployment rate and decreasing gross domestic product.
ROP is a major cause of blindness in middle-income countries, with infant mortality rates ranging from 9 to 60/1000 live births. Increased rates of teenage pregnancy and premature birth, and NICUs with variable standards of care are risk factors for the development of ROP. All the above-mentioned problems related to refugees, the lack of antenatal care, food supply, unsanitary environment and risk of infectious disease, contribute to the increasing rate of premature births, which is a major risk factor for the development of ROP.
In the present study, the overall incidence of any stage of ROP was 23% and 21%, and the incidence of severe ROP was 1.5% and 10% of the preterm infants of Turkish and Syrian origin, respectively. Bas et al. highlighted that the incidence of any stage of ROP and severe ROP was 30% and 5%, respectively. Holmström et al. reported the incidence of any stage of ROP and severe ROP was 31.9% and 5.7% with an increased incidence of ROP during an 8-year study period in Sweden. In a study conducted in the same region as the current study, Özcan et al. reported the overall incidence of any stage of ROP as30% and severe ROP as 12%. In the current study, the overall incidence of ROP among Syrian refugees was similar, whereas the incidence of severe ROP was nearly seven times higher than that of infants of Turkish-origin.
In respect of the percentage of ROP in preterm infants with GA <28 weeks, 28–32 weeks and >32 weeks, while the overall values were closer between the two groups, the frequency of severe ROP in Group II with GA <28 weeks was much higher than in Group I. Accordingly, the mean GA in Group II was significantly lower than in Group I (P < 0.05). In a study conducted in the same region, the incidence of any stage of ROP and severe ROP were reported as 66% and 35.8% among preterm births with GA <28 weeks. Özcan et al. reported the frequencies of ROP and severe ROP in preterm infants with the same ranges of GA to be nearly higher than those of Syrian refugees. In Turkey, the rates of ROP alter among the regions according to the neonatal care quality, despite the fact that the worst data of the incidence of ROP have been reported in the South-Eastern Anatolian region where many refugees are living and many camps have been established.,, It can, therefore, be concluded that irrespective of origin, infants with GA <28 weeks are more prone to develop both any stage of ROP and severe ROP.
The outcomes of this study demonstrate that the frequencies of severe ROP were higher in newborns weighing >1500 g (g), BW between 1250 g and 1500 g and weighing <1250 g in Group II. Özcan et al. reported that the incidence of severe ROP was higher (18%) in neonates with a BW between 1250 and 1500 g than those of the current study. Bas et al. revealed that the percentages of ROP and severe ROP were 42% and 8.2% in premature infants weighing ≤1500 g and 56% and 18.7% in infants weighing ≤1000, respectively. It was also stressed in that study that the frequencies of ROP and severe ROP were strongly associated with low GA and BW. Inadequate postnatal nutrition for effective postnatal growth which has been clearly linked with an increased risk for severe ROP may lead to higher incidence of severe ROP among premature newborns of Syrian refugees, despite the fact that all prematures with different origin have been receiving similar intensive care unit services. These higher incidences of severe ROP classified according to different ranges of BW and GA indicate that more attention is required to prevent blindness, particularly in premature infants born to Syrian refugees. The lackness of risk factor data is one of the important shortcomings of this study.
Diode laser photocoagulation was selected for the treatment of all the preterm infants in Group II with severe ROP irrespective of zone of the disease due to the possibility of problems in the accommodation camps during the follow-up period. With these timely interventions that were made, no patients progressed to stage 4 or 5 ROP.
| Conclusion|| |
The results of this study demonstrate that premature infants born to Syrian refugees should be considered at a higher risk for developing severe ROP, possibly due to the increasing number of premature infants with lower GA and BW than infants of Turkish origin and might need closer follow-up. The high prevalence of severe ROP can be considered to be associated with the lack of many humanitarian necessities for premature infants of Syrian refugees. Improving the environmental, social, and nutritional conditions may reduce the preterm birth rates and poorly postnatal growth among refugees, which is an important risk factor for the development of ROP and severe ROP. Despite the many on-going problems, attempts and efforts to provide better health care and living conditions are continuing.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Ozcan PY, Çıtırk M, Özçalışkan S. Current Epidemiology, Pathophysiology and risk Factors in retinopathy of prematurity. Ret Vit 2016;24:263-70.
Alajbegovic-Halimic J, Zvizdic D, Alimanovic-Halilovic E, Dodik I, Duvnjak S. Risk factors for retinopathy of prematurity in premature born children. Med Arch 2015;69:409-13.
Gilbert C, Fielder A, Gordillo L, Quinn G, Semiglia R, Visintin P, et al.
Characteristics of infants with severe retinopathy of prematurity in countries with low, moderate, and high levels of development: Implications for screening programs. Pediatrics 2005;115:e518-25.
Bucak IH, Almis H, Benli S, Turgut M. An overview of the health status of syrian refugee children in a tertiary hospital in Turkey. Avicenna J Med 2017;7:110-4.
] [Full text]
Fierson WM. Screening examination of premature infants for retinopathy of prematurity. Pediatrics 2013;131:189-95.
Office for the Coordination of Humanitarian Affairs. Humanitarian Bulletin: Syrian Arab Republic. Office for the Coordination of Humanitarian Affairs; 2013. Available from: http://www.unocha.org/node/159056
. [Last accessed on 2016 Apr 20].
Doganay M, Demiraslan H. Refugees of the syrian civil war: Impact on reemerging infections, health services, and biosecurity in Turkey. Health Secur 2016;14:220-5.
Hossain SM, Leidman E, Kingori J, Al Harun A, Bilukha OO. Nutritional situation among syrian refugees hosted in İraq, Jordan, and Lebanon: Cross sectional surveys. Confl Health 2016;10:26.
Simsek Z, Yentur Doni Z, Gül Hilal N, Yildirimkaya G. A community-based survey on Syrian refugees women's health and its predictors in Sanliurfa, Turkey. Women Health 2017;21:1-15.
Erenel H, Aydogan Mathyk B, Sal V, Ayhan I, Karatas S, Koc Bebek A, et al.
Clinical characteristics and pregnancy outcomes of syrian refugees: A case-control study in a tertiary care hospital in İstanbul, Turkey. Arch Gynecol Obstet 2017;295:45-50.
Gilbert C, Rahi J, Eckstein M, O'Sullivan J, Foster A. Retinopathy of prematurity in middle-income countries. Lancet 1997;350:12-4.
Bas AY, Koc E, Dilmen U; ROP Neonatal Study Group. Incidence and severity of retinopathy of prematurity in Turkey. Br J Ophthalmol 2015;99:1311-4.
Holmström G, Tornqvist K, Al-Hawasi A, Nilsson Š, Wallin A, Hellström A, et al.
Increased frequency of retinopathy of prematurity over the last decade and significant regional differences. Acta Ophthalmol 2018;96:142-8.
Özcan PY, Çon R, Celik HT. Incidence, risk factors and treatment outcomes of retinopathy of prematurity in the Southeastern Anatolian region Province of Sanliurfa in Turkey. Turk Klin J Med Sci 2015;35:240-7.
Sahin A, Sahin M, Türkcü FM, Cingü AK, Yüksel H, Cınar Y, et al.
Incidence of retinopathy of prematurity in extremely premature infants. ISRN Pediatr 2014;2014:134347.
Saygılı O, Özcan E, Kimyon S, Mete A, Kenan S, Güngör K, et al
. Retinopathy of prematurity screening in a tertiary hospital in the South-East region of Turkey: Prevalence and relation with multiple pregnancies. Ret Vit 2017;26:105-9.
Küçükevcilioǧlu M, Mutlu FM, Sarıcı SU, Ceylan OM, Altınsoy HI, Kılıç S, et al.
Frequency, risk factors and outcomes of retinopathy of prematurity in a tertiary care hospital in Turkey. Turk J Pediatr 2013;55:467-74.
Mutlu FM, Altinsoy HI, Mumcuoglu T, Kerimoglu H, Kiliç S, Kul M, et al.
Screening for retinopathy of prematurity in a tertiary care newborn unit in Turkey: Frequency, outcomes, and risk factor analysis. J Pediatr Ophthalmol Strabismus 2008;45:291-8.
Liegl R, Hellström A, Smith LE. Retinopathy of prematurity: The need for prevention. Eye Brain 2016;8:91-102.
[Table 1], [Table 2]