Research in epilepsy: development priorities for developing nations

Epilepsy treatment gap in Sub-Saharan Africa: Meta-analysis of community-based studies

OBJECTIVE

To evaluate the prevalence, highlight the variation and determine the trend over time, of epilepsy treatment gap (ETG) in Sub-Saharan Africa (SSA).

METHODS

We systematically searched PubMed, MEDLINE, Embase, ISI databases, and African Journal Online (AJOL). We determined the pooled prevalence estimate of ETG and the degree of heterogeneity in the region. Further subgroup analysis by sub-region, settlement setting, and cutoff adopted for active epilepsy in the studies was carried out. Meta-regression technique was also used to determine the trend of the ETG magnitude over time.

RESULTS

Twenty-three studies from SSA met the inclusion criteria. We found a high level of discordance among the studies that were included. Collectively, the estimated ETG was 68.5% (95% CI: 59.5%-77.5%). On subgroup analysis, the prevalence of the ETG was 67% (95% CI: 52%, 83%) in the Western, 68% (95% CI: 56%, 80%) in the Eastern, and 63% (95% CI: 53%, 73%) in the Southern Africa sub-regions. On stratified analysis based on 1-year, 5-year, and 2-year cutoffs for definition of active epilepsy, the prevalence figures for the ETG were 71% (95% CI: 56%, 85%), 55% (95% CI: 33%, 77%), and 57% (95% CI: 43%, 71%), respectively. Meta-regression result suggested that the prevalence of the ETG decreases by approximately by 0.006 per year.

CONCLUSION

The study showed a high prevalence of ETG, higher than the average for resource poor countries, and twice in rural compared with urban settlements in SSA.

Investigating epilepsy in Africa: 10 years of data collection using a standardized questionnaire in 2,269 peoples with epilepsy

PURPOSE

The need for comparable epidemiologic data on epilepsy from various locations in tropical areas has led in 1994 to the creation of a questionnaire able to standardize information. The Limoges' questionnaire was created to collect information independently of the objectives of each survey performed, and since it has been employed in various continents under tropics latitude. In Africa between 1994 and 2004, 13 epidemiologic surveys in 12 countries were performed by this means. Authors of these works were solicited to communicate their raw data on people with epilepsy (PWE).

METHODS

Information collected was aggregated in a database upon which operations of data management were processed. Undernutrition status was determined using an anthropologic method, according World Health Organization (WHO) recommendations. Factors associated with undernutrition and absence of treatment by phenobarbitone were searched for by using multivariate logistic regression.

KEY FINDINGS

Information about 2,269 PWE was collected. Mean treatment gap and undernutrition were determined, respectively, to be 30.6% [95% confidence interval (95% CI) 28.7-32.6] and 25.4% (95% CI 22.7-28.2). Factors significantly associated with undernutrition and not being treated with phenobarbitone were determined.

SIGNIFICANCE

Despite the different purposes of each study, we were able to pool information in order to characterize and study particular traits of PWE in Africa. Some items of particular importance should be collected systematically and will be highlighted in a newer version of this questionnaire. Because many surveys were undertaken using this tool in tropical areas, a backward compatibility should be ensured.

Health care delivery model in epilepsy to reduce treatment gap: World Health Organization study from a rural tribal population of India

PURPOSE

To design and develop an effective health care delivery model in epilepsy to reduce the treatment gap in a rural tribal community in India.

METHOD

This study was conducted in tribal dominated Namkum Block (114,068 population) of Ranchi, Ranchi District, Jharkhand state, India and carried out as four-staged program-first stage consisted of separate training programs (to 6 volunteer health workers, traditional practitioners of community including 267 faith healers and qualified practitioners), second stage consisted of awareness campaign programs, third stage consisted of diagnosis, treatment delivery and follow-up in once a month camps with free medication and final stage consisted of continued follow-up after the end of study by local practitioners.

RESULTS

Health volunteers identified 787 probable cases in the community, 453 attended the camps, and 318 were diagnosed and treated for epilepsy in the camp. Treatment gap was 95% on the initial assessment. 213 epileptic patients enrolled in the study completed 12 months treatment and more than 75% were seizure free at the end of the study. Eighty percent of patients' care-givers and their family members were satisfied with the care provided. At the end of study, local medical practitioners continued to do the follow-up of study participants to ensure continuity of care although results of further follow-up are not included in the present study.

CONCLUSION

A four-staged program in epilepsy treatment delivery model was successful. Voluntary health workers from the community can be effectively trained to identify cases and persuade them to seek treatment. The delivery model should include intensive health awareness campaign, training of doctors and other health care providers, free supply of AEDs (Antiepileptic drugs), continuous follow-up for compliance and side-effects of the drug and tactful dealing with indigenous practitioners and faith healers without antagonising them.

The epilepsy treatment gap in developing countries: a systematic review of the magnitude, causes, and intervention strategies

SUMMARY

In many developing countries, people with epilepsy do not receive appropriate treatment for their condition, a phenomenon called the treatment gap (TG). We carried out a systematic review to investigate the magnitude, causes, and intervention strategies to improve outcomes in developing countries. We systematically searched MEDLINE, EMBASE, and PsycINFO databases, supplemented by a hand search of references in the key papers. The degree of heterogeneity and a pooled TG estimate were determined using metaanalysis techniques. The estimates were further stratified by continent and location of study (urban, rural). Twenty-seven studies met the inclusion criteria: twelve from Africa, nine from Asia and six from Latin America. We observed a high degree of heterogeneity and inconsistency between studies. The overall estimate of the TG was 56/100 [95% confidence interval (CI) 31.1-100.0]. The variation in estimates could possibly be explained by nonuniform TG estimation methods and the diverse study populations, among other factors. The TG was mainly attributed to inadequate skilled manpower, cost of treatment, cultural beliefs, and unavailability of antiepileptic drugs (AEDs). These factors have been addressed using different intervention strategies, such as education and supply of AEDs. Future research should estimate the TG coherently and develop sustainable interventions that will address the causes.

Prevalence, Incidence, and Etiology of Epilepsies in Rural Honduras: The Salama Study

PURPOSE

Determination of epilepsy etiology in population-based studies is difficult because of the high cost of diagnostic tests. However, cost-effectiveness may be proven if preventive public-health strategies can be established from the test results. We report an epilepsy population-based study using clinical and laboratory techniques.

METHODS

A medical team administered an epilepsy survey to 88% of the residents by census in the rural county of Salamá, Honduras. Ninety of 100 participants identified with active epilepsy underwent a neurologic examination, video-electroencephalography (video-EEG), brain computed tomography (CT) scan, and serum enzyme-linked immunoelectrotransfer blot (EITB) for cysticercosis. Final diagnoses were based on the International League Against Epilepsy classifications for seizures and epilepsy syndromes. Combined epidemiologic, clinical, video-EEG, neuroimaging, and serum EITB assays were used for the diagnosis of epilepsy etiologies.

RESULTS

Among 6,473 residents surveyed, 151 persons with epilepsy (prevalence rate, 23.3/1,000) were identified, 100 of whom had active epilepsy (15.4/1,000) on the prevalence day. Incidence was determined to be 92.7/100,000. Partial seizures with or without secondary generalization were common (92.2%). Symptomatic epilepsy (62%) was primarily due to neurocysticercosis (37%), perinatal brain damage (8%), post-traumatic (3%), and poststroke (2%). Eight percent were idiopathic, and 30% were cryptogenic (unknown cause).

CONCLUSIONS

Symptomatic epilepsies primarily explained the high prevalence and incidence of epilepsy in Salamá. Integration of video-EEG and brain CT scan with clinical-epidemiologic evaluation was critical for determination of epilepsy etiology. Establishment of specific programs for continuation of epidemiologic surveillance, education, intervention, and long-term follow-up will benefit the Salamá region.

Outcome of prolonged video-EEG monitoring at a typical referral epilepsy center

PURPOSE

When seizures do not respond to medications, video-EEG monitoring is the best available diagnostic tool and is the principal activity of epilepsy centers. The purpose of this study was to analyze the eventual disposition of patients who undergo video-EEG monitoring at a typical referral epilepsy center.

METHODS

We reviewed the diagnoses and dispositions of all patients (adults and children) who underwent inpatient video-EEG monitoring (> or = 24 h) at our center (University of South Florida-Tampa General Hospital) over a 1-year period (2002).

RESULTS

In total, 251 inpatient video-EEG monitoring sessions were performed. Nonepileptic seizures were diagnosed in 75 (30%); 58 (23%) were found to be surgical candidates; seven were implanted with the vagus nerve stimulator. In 47 (19%) patients, seizures were recorded, and the diagnosis of epilepsy was confirmed and clarified (symptomatic/cryptogenic generalized epilepsy, seven; localization-related epilepsy, 35; idiopathic generalized epilepsy, five).

CONCLUSIONS

The eventual outcome of video-EEG monitoring is diverse. The largest groups, as expected, are psychogenic nonepileptic seizures (30%), and surgery (23%).

Epidemiology, clinical manifestations and diagnosis of zoonotic cestode infections: an update

This paper reviews the literature on zoonotic cestode infections with specific reference to the years 1999-2003. The sources and prevalence of various zoonotic tapeworm infections caused by adult and larval stages of the genera Taenia, Echinococcus, Diphyllobothrium, Hymenolepis and Dipylidium continue to be an important cause of morbidity and mortality, not only in most underdeveloped countries but also in industrialized countries, particularly in rural areas or among immigrant groups from endemic areas. The review gives a detailed report on recent molecular epidemiological studies on the taxonomy and phylogenetic variations in Echinococcus granulosus, immunological tests and imaging techniques used in epidemiological surveys and clinical investigations of important adult and larval tapeworm infections of animals and humans. Larval stages or metacestodes of Taenia solium, Echinococcus spp. and pseudophyllidean tapeworms (Spirometra syn. Diphyllobothrium spp.) may reside in various tissues of their intermediate hosts, including humans. In particular, Cysticercus cellulosae (T. solium) and the larvae of E. granulosus, and E. multilocularis, which are predominantly located in the liver, lungs and central nervous system forming various types of cysts, lead to a complex of systemic diseases such as cysticercosis, cystic echinococcosis and alveolar echinococcosis, respectively. Relatively rare clinical manifestations are seen in the muscles, subcutaneous tissue, spleen, kidneys, bones and body cavities.