Epilepsy and mortality in Africa: a review of the literature

Recovery From Homonymous Hemianopia in Hyperglycemia-Induced Occipital Lobe Electroclinical Seizures Following Glycemic Control

BACKGROUND

Visual changes due to hyperglycemia in diabetes are not uncommon. While blurred vision is a well-established sequela of chronic hyperglycemia, homonymous hemianopia with or without electroclinical seizures is much rarer and can be mistaken for migraine, temporal arteritis, or ischemia of the central nervous system.

METHODS

This article analyzed case studies for 3 patients (67M, 68M, 52F) presenting with complex visual phenomena, from 3 to 42 days duration, including pathogenesis, clinical findings, management, and follow-up.

RESULTS

Examinations demonstrated dense left homonymous hemianopias in 2 patients and a left inferior homonymous quadrantanopia in one, with no other abnormalities. Patients described vivid, nonstereotyped intermittent hallucinations in the affected fields. Blood glucose levels ranged from 13.5 to 35.0 mmol/L (243-630 mg/dL) without ketosis and HbA1c from 14.6% to 16.8%. Computed tomography of the brain showed no acute intracranial pathology. MRI of the brain either detected no abnormalities or demonstrated changes consistent with seizure activity. Electroencephalogram (EEG) demonstrated seizures over the right occipital region in each patient. EEG seizures coincided with patients' hallucinations, while they remained otherwise conscious. Oral hypoglycemic and antiepileptic medications were commenced with rapid and complete reversal of the seizures and visual field deficits, confirmed by repeat Automated 30-2 and MRI.

CONCLUSIONS

Hyperglycemia-induced occipital lobe seizures with visual hallucinations and interictal homonymous visual field defects represent a rare but clinically important diagnosis. This article highlights the importance of prompt recognition and treatment to facilitate recovery.

Epilepsy care and outcome in low- and middle-income countries: A scoping review

Objectives

Epilepsy is a common neurological condition in low- and middle-income countries (LMICs). This study aims to systematically review, analyze, evaluate, and synthesize information on the current state of medical and surgical management and outcomes of epilepsy in LMICs.

Materials and Methods

Systematic searches were conducted on MEDLINE, EMBASE, World Health Organization Global Index Medicus, African Journals Online, WOS, and Scopus, covering the period from the inception of the databases to August 18th, 2021, focusing on studies reporting management and outcomes of epilepsy in LMICs.

Results

A total of 2298 unique studies were identified, of which, 48 were included (38035 cases). The mean age was 20.1 ± 19.26 years with a male predominance in 60.92% of cases. The type of seizure commonly reported in most of the studies was absence seizures (n = 8302, 21.82%); partial focal seizure (n = 3891, 10.23%); and generalized tonic-clonic seizures (n = 3545, 9.32%) which were the next most common types of seizures. Mesiotemporal epilepsy was less frequently reported (n = 87, 0.22%). Electroencephalogram was commonly used (n = 2516, 6.61%), followed by computed tomography scan (n = 1028, 2.70%), magnetic resonance imaging (n = 638, 1.67%), and video telemetry (n = 484, 1.27%) in the care of patients with seizures. Primary epilepsy was recorded in 582 patients (1.53%) whereas secondary epilepsy was present in 333 patients (0.87%). Carbamazepine was the most used anti-epileptic drug (n = 2121, 5.57%). Surgical treatment was required for 465 (1.22%) patients.

Conclusion

In LMICs, epilepsy is underreported. There is still a lack of adequate tools for the diagnosis of primary or secondary epilepsy as well as adequate access to medical management of those reported.

Investigating the Anticonvulsant Properties of Aqueous Ethanolic Extracts of the Leaves, Roots, and Fruits of Jatropha gossypifolia L. (Euphorbiaceae)

Convulsion is a typical symptom associated with epilepsy. Jatropha gossypifolia, a common plant in Ghana, has been used traditionally for the management of epilepsy. This study was carried out to ascertain the scientific basis for the traditional utility of Jatropha gossypifolia for various convulsive disorders and also determine the part of the plant with the most anticonvulsant activity. The anticonvulsant activity of the leaf, root, and fruit extracts in doses of 30–300 mg/kg was assessed using the picrotoxin-induced seizure models in mice. The drugs and chemical preparations used included diazepam, picrotoxin, ethanol (70%), and normal saline. GraphPad Prism 6 was used for all statistical analysis and plotting of graphs. Data were analyzed using one-way ANOVA, followed by Bonferroni's multiple comparison test. The leaf extract significantly and dose-independently reduced the frequency of myoclonic jerks (P=0.0001) and decreased the duration of clonic convulsions (P=0.019). The root extract also significantly and dose-dependently reduced the frequency of myoclonic jerks (P=0.001) but only decreased the frequency of tonic convulsions at 100 mg/kg (P=0.006). It also significantly decreased the duration of tonic convulsions (P=0.0001). The fruit extract only significantly and dose-independently reduced the frequency of myoclonic jerks (P=0.0001). It, however, showed an increase in the duration of both clonic and tonic convulsions. The study shows that the leaves and roots of Jatropha gossypifolia produce anticonvulsant activity which may be through enhancement of GABAergic transmission or activation of GABA receptors which support the traditional use of the plant to treat epileptic fits.

Pandemics and Burden of Stroke and Epilepsy in Sub-Saharan Africa: Experience from a Longstanding Health Programme

Eighty percent of people with stroke live in low- to middle-income nations, particularly in sub-Saharan Africa (SSA) where stroke has increased by more than 100% in the last decades. More than one-third of all epilepsy-related deaths occur in SSA. HIV infection is a risk factor for neurological disorders, including stroke and epilepsy. The vast majority of the 38 million people living with HIV/AIDS are in SSA, and the burden of neurological disorders in SSA parallels that of HIV/AIDS. Local healthcare systems are weak. Many standalone HIV health centres have become a platform with combined treatment for both HIV and noncommunicable diseases (NCDs), as advised by the United Nations. The COVID-19 pandemic is overwhelming the fragile health systems in SSA, and it is feared it will provoke an upsurge of excess deaths due to the disruption of care for chronic diseases such as HIV, TB, hypertension, diabetes, and cerebrovascular disorders. Disease Relief through Excellent and Advanced Means (DREAM) is a health programme active since 2002 to prevent and treat HIV/AIDS and related disorders in 10 SSA countries. DREAM is scaling up management of NCDs, including neurologic disorders such as stroke and epilepsy. We described challenges and solutions to address disruption and excess deaths from these diseases during the ongoing COVID-19 pandemic.

Antiepileptic Drug Prices, Availability and Affordability in a Resource-Limited Setting

Background:

The availability and affordability of antiepileptic drugs (AEDs) are critical to the success of public health initiatives enabling care for people with epilepsy in the community.

Objective:

To pilot survey the availability and affordability of AEDs in the community.

Methods:

Field workers used standard WHO–Health Action International approaches and collected data on the availability of, and maximum retail prices of originator brands and least price generics of AEDs in 46 randomly selected public (n = 29), private (n = 8), and charitable (n = 9) pharmacy outlets. Median price ratios were computed apropos international reference prices of corresponding medications and affordability gauged with reference to daily wage of lowest paid worker.

Results:

Only 10 outlets (7 – private, 3 – public, and none – charitable) stocked at least one essential AED. Median price ratios varied between 1.1 and 1.5 essentially reflecting the difference between the least price generics and originator brands. Of note, carbamazepine-retard, 200 mg put up the slightest difference in prices of originator and least price generic brands and also was the most affordable AED.

Conclusions:

The availability and affordability of most AEDs were poor and hence, this needs to be studied on a wider scale and thereafter efforts to improve both the availability and affordability are desirable in order to address the huge treatment gap for epilepsy in India.

Epilepsy-associated neurocognitive disorders (EAND) in an onchocerciasis-endemic rural community in Cameroon: A population-based case-control study

BACKGROUND

Epilepsy affects at least 50 million individuals worldwide, especially in sub-Saharan Africa (sSA). Cognitive impairment is common in people with epilepsy (PWE) yet, little is known on the burden of cognitive impairment in people with epilepsy in sSA. This study was thus designed to assess cognitive impairment in PWE or epilepsy-associated neurocognitive disorders (EAND) in a rural population in Cameroon.

METHODS

This was a case-control study including PWE and age/sex-matched healthy controls from July to September 2017 in Bilomo, a village in the Mbam and Kim Division. The Montreal Cognitive Assessment (MoCA), International HIV Dementia Scale (IHDS), Dubois' Five Word testing, Frontal Assessment Battery (FAB), Isaac's Set Test and the Clock drawing test were administered to the study participants to evaluate global and specific cognitive functions.

RESULTS

Eighty participants were included (40 cases and 40 controls) with a mean age of 25.78 years. Using the MoCA, 87.5% of cases had cognitive impairment, against 37.5% of controls (p < 0.001; OR 11.67; CI 3.40-45.09). Using the IHDS, the prevalence of global cognitive impairment was 84.6% among the cases against 40% for the controls (p = <0.001; OR 7.07; CI 2.29-29.19). Specifically, executive function deficits (92.5% of cases vs 40.0% of controls p = <0.001 OR = 18.50 CI; 4.48-105.08) and decreased verbal fluency (100% of cases against 45% of controls p < 0.001) were the most affected cognitive domains. Longer duration of epilepsy and higher seizure frequency were associated with global cognitive impairment. Low level of education was associated with both decreased verbal fluency and executive dysfunction while a longer stay in Bilomo correlated with poor results on the Isaac's Set Test.

CONCLUSION

The prevalence of cognitive impairment appears to be much higher in PWE in the Mbam valley, particularly decreased executive function and verbal fluency, than in people without epilepsy. Longer disease duration, higher seizure frequency, low level of education and length of stay in Bilomo are associated with poorer cognitive performance. More studies are needed to refine evaluation tools to better characterize and manage EAND in sSA.

Association of race and ethnicity to incident epilepsy, or epileptogenesis, after subdural hematoma

OBJECTIVE

To determine whether race is associated with the development of epilepsy after subdural hematoma (SDH), we identified adult survivors of SDH in a statewide administrative dataset and followed them up for at least 1 year for revisits associated with epilepsy.

METHODS

We performed a retrospective cohort study using claims data on all discharges from emergency departments (EDs) and hospitals in California. We identified adults (age ≥18 years) admitted from 2005 to 2011 with first-time traumatic and nontraumatic SDH. We used validated diagnosis codes to identify a primary outcome of ED or inpatient revisit for epilepsy. We used multivariable Cox regression for survival analysis to identify demographic and medical risk factors for epilepsy.

RESULTS

We identified 29,342 survivors of SDH (mean age 71.2 [SD 16.4] years, female sex 11,954 [41.1%]). Three thousand two hundred thirty (11.0%) patients had revisits to EDs or hospitals with a diagnosis of epilepsy during the study period. Black patients (n = 1,684 [5.7%]) had significantly increased risk compared to White patients (n = 16,945 [57.7%]; hazard ratio [HR] 1.45, 95% confidence interval [CI] 1.28-1.64, p < 0.001). Status epilepticus during the index SDH admission, although infrequent (n = 94 [0.3%]), was associated with a nearly 4-fold risk of epilepsy (HR 3.75, 95% CI 2.80-5.03, p < 0.001). Alcohol use, drug use, smoking, renal disease, and markers of injury severity (i.e., intubation, surgical intervention, length of stay, disposition other than home) were also associated with epilepsy (all p < 0.05).

CONCLUSIONS

We found an association between Black race and ED and hospital revisits for epilepsy after SDH, establishing the presence of a racial subgroup that is particularly vulnerable to post-SDH epileptogenesis.

Community-based door to door census of suspected people living with epilepsy: empowering community drug distributors to improve the provision of care to rural communities in Cameroon

Background

Epilepsy is a severe neurological disorder with huge psychological, social, and economic consequences, including premature deaths and loss of productivity. Sub-Saharan Africa carries the highest burden of epilepsy. The management of epilepsy in Cameroon remains unsatisfactory due to poor identification of cases and a limited knowledge of the distribution of the disease. The objective of this study was to determine whether community drug distributors (CDDs) - volunteers selected by their communities to distribute ivermectin against onchocerciasis and who have been proven efficient to deliver other health interventions such as insecticide-treated bed nets to prevent malaria, vitamin A tablets, and albendazole to treat soil transmitted helminthiasis - can be used to reliably identify people living with epilepsy to promote better management of cases.

Methods

This study was carried out in three health Districts in Cameroon. An exhaustive house to house census was carried out by trained CDDs under the supervision of local nurses. In each household, all suspected cases of epilepsy were identified. In each health district, five communities were randomly selected for a second census by trained health personnel (research team). The results of the two censuses were compared for verification purposes.

Results

A total of 53,005 people was registered in the 190 communities surveyed with 794 (1.4%) individuals identified as suspected cases of epilepsy (SCE) by the CDDs. In the 15 communities where the SCE census was verified, the average ratio between the number of suspected cases of epilepsy reported in a community by the research team and that reported by the CDDs was 1.1; this ratio was < 0.8 and > 1.2 in 6 communities.

Conclusions

The results of this study suggest that CDDs, who are present in about 200,000 communities in 31 Sub Saharan African countries where onchocerciasis is endemic, can be successfully used to assess epilepsy prevalence, and therefore map epilepsy in many African countries.

Epilepsy Treatment Outcome and Its Predictors among Ambulatory Patients with Epilepsy at Mizan-Tepi University Teaching Hospital, Southwest Ethiopia

Background

Epilepsy is among the most common neurological disorders which is highly treatable with currently available antiepileptic drugs at a reasonable price. In Ethiopia, despite a number of studies revealed high prevalence of epilepsy, little is known on predictors of poorly controlled seizures. Thus, the aim of this study was to assess epilepsy treatment outcome and its predictors among patients with epilepsy on follow-up at the ambulatory care unit of Mizan-Tepi University Teaching Hospital, Southwest Ethiopia.

Methods

A hospital-based cross-sectional study involving patient interview and chart review was conducted from March 10 to April 10, 2018. Drug use patterns and sociodemographic data of the study participants were accustomed to descriptive statistics. Backward logistic regression analysis was done to identify predictors of poor seizure control. Statistical significance was considered at p value <0.05.

Results

From a total of 143 studied patients with epilepsy, 60.8% had uncontrolled seizures. Monotherapy (79%) was commonly used for the treatment of seizures, of which phenobarbital was the most commonly utilized single anticonvulsant drug (62.9%). The majority (72.7%) of the patients had developed one or more antiepileptic-related adverse effects. Medium medication adherence (adjusted odds ratio (AOR) = 5.4; 95% CI = 1.52–19.23; p=0.009), poor medication adherence (AOR = 8.16; 95% CI = 3.04–21.90; p=0.001), head injury before seizure occurrence (AOR = 4.9; 95% CI = 1.25–19.27; p=0.02), and seizure attacks ≥4 episodes/week before AEDs initiation (AOR = 8.52; % CI = 2.41–13.45; p=0.001) were the predictors of uncontrolled seizure.

Conclusions

Based on our findings, more than half of the patients with epilepsy had poorly controlled seizures. Nonadherence to antiepileptic drugs, high frequency of seizure attack before AEDs initiation, and history of a head injury before the occurrence of seizure were predictors of uncontrolled seizure. Patient medication adherence should be increased by the free access of antiepileptic drugs and attention should be given for the patients with a history of head injury and high frequency of seizure attacks before AEDs initiation.

Health-related quality of life and its determinants among ambulatory patients with epilepsy at Ambo General Hospital, Ethiopia: Using WHOQOL-BREF

Background

Health‐related quality of life (HRQOL) is used as a measure of treatment outcomes, in addition to seizure control. Hence, the study was aimed to assess HRQOL and its determinants among adult patients with epilepsy (PWE).

Method

A hospital-based cross-sectional study was conducted from April 20 to June 27/2019, through patient interviews and patient’s chart review (medication and clinical information). Data were analyzed using SPSS version 20. The psychometric property was done using Cronbach’s alpha test value of >0.7 as accepted internal consistency and Kaiser-Meyer-Olkin (KMO) measure of sample size adequacy value of ≥0.5 as acceptable construct validity, for Afaan Oromo version questionnaire. Multivariate linear logistic regression analysis was done to find predictors for the HRQOL score.

Results

Of 121 PWE included in the study, 24.4% had overall poor HRQOL with the overall mean ±SD score of 56.42±10.96. The predictors for low overall HRQOL score were: presence of co-morbidity (B = -5.620, SE = 1.531, p<0.0001, 95% C.I = -8.656 to -2.584), uncontrolled seizure for at least 2 years (B = -4.239, SE = 1.296, p = 0.001, 95% C.I = -6.809 to -1.670), divorced (B = -8.423, SE = 2.241, p<0.0001, 95%C.I = -12.867 to -3.978) relative to married, and no education (B = -8.715, SE = -8.15, SE = 2.604, p = 0.001, 95%C.I = -9.648 to -1.316) relative to who had level of education above tertiary. In addition, uncontrolled seizure (irrespective of time since seizure-free) (B = -10.083, SE = 2.104, p<0.0001, 95%C.I = -14.256 to -5.910), being widowed (B = -9.300, SE = 3.594, p = 0.011, 95%C.I = -16.429–2.170) relative to married and being illiterate/no education (B = -13.004, SE = 3.910, p = 0.001, 95%C.I = -20.760 to -5.248) relative to educational level of tertiary and above were found to be the strongest negative predictors of HRQOL of physical health. Moreover, uncontrolled seizure (irrespective of time since seizure-free) (B = -12.668, SE = 2.019, p<0.0001, 95%C.I = -16.671 to -8.664) and being divorced (B = -10.153, SE = 3.228, p = 0.002, 95%C.I = -16.556 to -3.751) compared to married were strong predictors for low HRQOL score of psychological health. Absence of Poly-pharmacy (B = 9.050, SE = 3.027, P = 0.003, 95%C.I = 3.047 to 15.054), being single (B = -9.551, SE = 2.095, p<0.0001, 95%C.I = -14.419 to -4.683), and divorced (B = -11.022, SE = 3.351, P = 0.001, 95%C.I = -17.668 to -4.376) relative to married were found to be strong predictors for HRQOL score of social health. Moreover, low HRQOL score of environmental health was predicted by rural residence (B = -5.795, SE = 2.101, p = 0.007, 95%C.I = -9.962 to -1.628), co-morbidity (B+ -4.230, SE = 2.125, p = 0.049, 95%C.I = -8.444 to -0.015) & uncontrolled seizure irrespective of time since seizure-free (B = -6.907, SE = 1.945, p = 0.001, 95%C.I = -10.765 to -3.049) and uncontrolled seizure of at least 2 years (B = -4.520, SE = 1.798, p = 0.014, 95%C.I = -8.088 to -0.953).

Conclusions

The majority of the study participants had a good overall HRQOL. In general, a low level of HRQOL score was significantly associated with the marital status of single/widowed/divorced, low level of education, low level of monthly income, co-morbidity, uncontrolled seizure, and poly-pharmacy; irrespective of HRQOL domains. Therefore, it is required to improve HRQOL, by avoiding modifiable factors for PWE to achieve the optimum HRQOL.

Bridging the childhood epilepsy treatment gap in northern Nigeria (BRIDGE): Rationale and design of pre-clinical trial studies

Epilepsy is the most common serious childhood neurological disorder. In the low- and middle-income countries (LMICs) of Africa, children with epilepsy suffer increased morbidity and mortality compared to their counterparts in high-income countries, and the majority do not receive treatment - the childhood epilepsy treatment gap. Reports of the childhood epilepsy treatment gap in Africa are likely underestimates; most surveys do not include several common childhood seizure types, including most types of non-convulsive epilepsy. Efforts to scale up childhood epilepsy care services in the LMICs of Africa must contend with a shortage of physicians and diagnostic technology [e.g., electroencephalograms (EEGs)]. One pragmatic solution is to integrate epilepsy care into primary care by task-shifting to community health extension workers. The aims of this project (BRIDGE) are to: 1) train, develop, and pilot task-shifted epilepsy care teams; 2) develop and pilot innovative childhood epilepsy screening and diagnostic paradigms adapted to the local Hausa language/culture in Kano, northern Nigeria; and, 3) quantify and map the childhood epilepsy treatment gap, using geographic information systems (GIS), to target limited resources to areas of greatest need. Task-shifted teams will diagnose and manage childhood epilepsy using an innovative epilepsy screening tools and diagnostic and management paradigms in environments with limited EEG access. If validated and demonstrated efficacious in clinical trials, this project can be taken to scale across broader areas of west Africa's LMICs that share language and culture. BRIDGE has the potential to enhance access to basic childhood epilepsy care and establish the foundation for childhood epilepsy clinical trials in west Africa.

Premature mortality of epilepsy in low- and middle-income countries: A systematic review from the Mortality Task Force of the International League Against Epilepsy

To determine the magnitude of risk factors and causes of premature mortality associated with epilepsy in low- and middle-income countries (LMICs). We conducted a systematic search of the literature reporting mortality and epilepsy in the World Bank-defined LMICs. We assessed the quality of the studies based on representativeness; ascertainment of cases, diagnosis, and mortality; and extracted data on standardized mortality ratios (SMRs) and mortality rates in people with epilepsy. We examined risk factors and causes of death. The annual mortality rate was estimated at 19.8 (range 9.7-45.1) deaths per 1,000 people with epilepsy with a weighted median SMR of 2.6 (range 1.3-7.2) among higher-quality population-based studies. Clinical cohort studies yielded 7.1 (range 1.6-25.1) deaths per 1,000 people. The weighted median SMRs were 5.0 in male and 4.5 in female patients; relatively higher SMRs within studies were measured in children and adolescents, those with symptomatic epilepsies, and those reporting less adherence to treatment. The main causes of death in people with epilepsy living in LMICs include those directly attributable to epilepsy, which yield a mean proportional mortality ratio (PMR) of 27.3% (range 5-75.5%) derived from population-based studies. These direct causes comprise status epilepticus, with reported PMRs ranging from 5 to 56.6%, and sudden unexpected death in epilepsy (SUDEP), with reported PMRs ranging from 1 to 18.9%. Important causes of mortality indirectly related to epilepsy include drowning, head injury, and burns. Epilepsy in LMICs has a significantly greater premature mortality, as in high-income countries, but in LMICs the excess mortality is more likely to be associated with causes attributable to lack of access to medical facilities such as status epilepticus, and preventable causes such as drowning, head injuries, and burns. This excess premature mortality could be substantially reduced with education about the risk of death and improved access to treatments, including AEDs.

Prevalence of alcohol use disorders and associated factors among people with epilepsy attending Amanuel Mental Specialized Hospital, Addis Ababa, Ethiopia

INTRODUCTION

Alcohol use disorders represent one of the leading causes of preventable death, illness, and injury in many societies throughout the world. Heavy alcohol consumption has multiple negative consequences for people with epilepsy such as precipitation of seizure, exacerbation of seizure, poor seizure control, increased side effects of antiepileptic drugs, noncompliance to antiepileptic drugs, alcohol withdrawal seizures, long-term hospital admission, status epilepticus, sudden unexpected death, and premature mortality.

METHODS

An institution-based cross sectional study was conducted from April 15, 2014 to May 15, 2014 with the aim of assessing prevalence of alcohol use disorders and associated factors among people with epilepsy attending Amanuel Mental Specialized Hospital, Addis Ababa, Ethiopia. A total of 413 randomly selected epileptic patients were included in this study. Data were structured using the 10-item Alcohol Use Disorders Identification questionnaire. Data were analyzed using SPSS Version 20. Bivariate and multivariate logistic regression analyses were performed to study the association, and variables with P-value <0.05 were considered as having a statistically significant association at 95% confidence interval.

RESULTS

A total of 423 study participants were selected, of whom 413 completely filled the questionnaire making the response rate 97.6%. The mean age of the respondents was 31.9 years with standard deviation of ±10.97, and 248 (60%) were males. The prevalence of alcohol use disorder was 17.4%. Educational status (grade 9-12) (adjusted odds ratio [AOR] =3.25, [1.21, 8.69]), not living with family members (AOR =1.89, [1.06, 3.39]), availability of house (AOR =2.04, [1.10, 3.78]), taking carbamazepine (AOR =2.38, [1.13, 5.01]), and drinking alcohol to find relief from stress (AOR =4.28, [1.89, 9.67]) were significantly associated with alcohol use disorder among people with epilepsy.

CONCLUSION AND RECOMMENDATION

The findings of this study revealed that the prevalence of alcohol use disorder among people with epilepsy was high. Routine screening of epileptic patients with the Alcohol Use Disorders Identification Test is recommended.

A review of 'medical' knowledge of epilepsy amongst isiZulu-speaking patients at a regional hospital in KwaZulu-Natal

BACKGROUND

Epilepsy is a common disorder in South Africa and the literature indicates that many patients do not access treatment. The reasons are complex and include a poor knowledge about causes, symptoms, diagnosis and treatment (medical knowledge). This study aimed to assess the medical knowledge of isiZulu-speaking people with epilepsy (PWE) who attend a combination regional and district hospital in the eThekwini district in KwaZulu-Natal Province.

METHOD

This was a prospective, cross-sectional, descriptive study. Data were collected using a validated data collection tool for assessing the medical knowledge of PWE and analysed descriptively.

RESULTS

The questionnaires were completed by 199 PWE, with the general level of schooling being low and half being unemployed. Knowledge around causes, symptoms, diagnosis and treatments was good, but there were significant gaps in knowledge that may affect morbidity and mortality.

DISCUSSION

The findings will serve as a useful guide to develop both preventive and educational interventions to enhance knowledge around the causes and treatment of epilepsy in this population. It is important that such interventions also consider family and healthcare providers.

CONCLUSION

There were considerable gaps in the medical knowledge of isiZulu-speaking PWE's, indicating the need for an educational intervention to improve their understanding of epilepsy. Further research is needed-using a range of tools to ensure that the data is reliable and valid-if the results are to be generalisable to the rest of the province and South Africa.

Incidence, Remission and Mortality of Convulsive Epilepsy in Rural Northeast South Africa

Background

Epilepsy is one of the most common neurological conditions globally, estimated to constitute 0.75% of the global burden of disease, with the majority of this burden found in low- and middle- income countries (LMICs). Few studies from LMICs, including much of sub-Saharan Africa, have described the incidence, remission or mortality rates due to epilepsy, which are needed to quantify the burden and inform policy. This study investigates the epidemiological parameters of convulsive epilepsy within a context of high HIV prevalence and an emerging burden of cardiovascular disease.

Methods

A cross-sectional population survey of 82,818 individuals, in the Agincourt Health and Socio-demographic Surveillance Site (HDSS) in rural northeast South Africa was conducted in 2008, from which 296 people were identified with active convulsive epilepsy. A follow-up survey was conducted in 2012. Incidence and mortality rates were estimated, with duration and remission rates calculated using the DISMOD II software package.

Results

The crude incidence for convulsive epilepsy was 17.4/100,000 per year (95%CI: 13.1-23.0). Remission was 4.6% and 3.9% per year for males and females, respectively. The standardized mortality ratio was 2.6 (95%CI: 1.7-3.5), with 33.3% of deaths directly related to epilepsy. Mortality was higher in men than women (adjusted rate ratio (aRR) 2.6 (95%CI: 1.2-5.4)), and was significantly associated with older ages (50+ years versus those 0-5 years old (RR 4.8 (95%CI: 0.6-36.4)).

Conclusions

The crude incidence was lower whilst mortality rates were similar to other African studies; however, this study found higher mortality amongst older males. Efforts aimed at further understanding what causes epilepsy in older people and developing interventions to reduce prolonged seizures are likely to reduce the overall burden of ACE in rural South Africa.

Excess mortality from mental, neurological and substance use disorders in the Global Burden of Disease Study 2010

AIMS

Mortality-associated burden of disease estimates from the Global Burden of Disease 2010 (GBD 2010) may erroneously lead to the interpretation that premature death in people with mental, neurological and substance use disorders (MNSDs) is inconsequential when evidence shows that people with MNSDs experience a significant reduction in life expectancy. We explore differences between cause-specific and excess mortality of MNSDs estimated by GBD 2010.

METHODS

GBD 2010 cause-specific death estimates were produced using the International Classification of Diseases death-coding system. Excess mortality (all-cause) was estimated using natural history models. Additional mortality attributed to MNSDs as underlying causes but not captured through GBD 2010 methodology is quantified in the comparative risk assessments.

RESULTS

In GBD 2010, MNSDs were estimated to be directly responsible for 840 000 deaths compared with more than 13 million excess deaths using natural history models.

CONCLUSIONS

Numbers of excess deaths and attributable deaths clearly demonstrate the high degree of mortality associated with these disorders. There is substantial evidence pointing to potential causal pathways for this premature mortality with evidence-based interventions available to address this mortality. The life expectancy gap between persons with MNSDs and the general population is high and should be a focus for health systems reform.

The global burden of mental, neurological and substance use disorders: an analysis from the Global Burden of Disease Study 2010

Background

The Global Burden of Disease Study 2010 (GBD 2010), estimated that a substantial proportion of the world’s disease burden came from mental, neurological and substance use disorders. In this paper, we used GBD 2010 data to investigate time, year, region and age specific trends in burden due to mental, neurological and substance use disorders.

Method

For each disorder, prevalence data were assembled from systematic literature reviews. DisMod-MR, a Bayesian meta-regression tool, was used to model prevalence by country, region, age, sex and year. Prevalence data were combined with disability weights derived from survey data to estimate years lived with disability (YLDs). Years lost to premature mortality (YLLs) were estimated by multiplying deaths occurring as a result of a given disorder by the reference standard life expectancy at the age death occurred. Disability-adjusted life years (DALYs) were computed as the sum of YLDs and YLLs.

Results

In 2010, mental, neurological and substance use disorders accounted for 10.4% of global DALYs, 2.3% of global YLLs and, 28.5% of global YLDs, making them the leading cause of YLDs. Mental disorders accounted for the largest proportion of DALYs (56.7%), followed by neurological disorders (28.6%) and substance use disorders (14.7%). DALYs peaked in early adulthood for mental and substance use disorders but were more consistent across age for neurological disorders. Females accounted for more DALYs in all mental and neurological disorders, except for mental disorders occurring in childhood, schizophrenia, substance use disorders, Parkinson’s disease and epilepsy where males accounted for more DALYs. Overall DALYs were highest in Eastern Europe/Central Asia and lowest in East Asia/the Pacific.

Conclusion

Mental, neurological and substance use disorders contribute to a significant proportion of disease burden. Health systems can respond by implementing established, cost effective interventions, or by supporting the research necessary to develop better prevention and treatment options.

Epidemiology, causes, and treatment of epilepsy in sub-Saharan Africa

SUMMARY

Epilepsy is a common neurological disease in tropical countries, particularly in sub-Saharan Africa. Previous work on epilepsy in sub-Saharan Africa has shown that many cases are severe, partly a result of some specific causes, that it carries a stigma, and that it is not adequately treated in many cases. Many studies on the epidemiology, aetiology, and management of epilepsy in sub-Saharan Africa have been reported in the past 10 years. The prevalence estimated from door-to-door studies is almost double that in Asia, Europe, and North America. The most commonly implicated risk factors are birth trauma, CNS infections, and traumatic brain injury. About 60% of patients with epilepsy receive no antiepileptic treatment, largely for economic and social reasons. Further epidemiological studies should be a priority to improve understanding of possible risk factors and thereby the prevention of epilepsy in Africa, and action should be taken to improve access to treatment.

Epilepsy is ubiquitous, but more devastating in the poorer regions of the world... or is it?

The incidence and prevalence of active epilepsy are greatest in Africa compared to all other continents, even those with equivalent poor settings. This is a reflection of the high levels of structural and metabolic causes and may reflect an increased risk in parts of the continent. The full burden of epilepsy, which includes the social and medical morbidity of the disorder and where people with epilepsy are heavily stigmatized and frequently untreated, cannot be fully assessed even using the disability adjusted life-years, since the assigned disability weights are not specific to these regions. The burden is further exacerbated by social, geographic, and economic barriers to care and the inability of African health systems to manage people with epilepsy effectively because of lack of trained personnel, limited facilities, and poor access to effective or sustained supplies of antiepileptic drugs, or even therapy at all. The situation is compounded by a probable underestimation of the prevalence and incidence of people with epilepsy related to the major stigma associated with the condition in Africa, and the limited training available to most health care workers who are the primary point of assessing most people with epilepsy. Finding innovative ways to address the huge barriers faced by people with epilepsy in Africa needs to be a major goal for the millennium. A PowerPoint slide summarizing this article is available for download in the Supporting Information section here.

The challenges and innovations for therapy in children with epilepsy

Major advances have been made in the diagnosis, evaluation and management of children with epilepsy over the past 15 years. There has been a marked increase in genetic diagnoses of a number of key childhood-onset epilepsy syndromes, such as Dravet syndrome, which has been linked to mutations in the SCN1A gene. The reorganization and reclassification of epilepsies, devised by the International League Against Epilepsy, has stimulated specialists to reassess their diagnostic practices; however, many studies have not addressed the global issues in treating children with epilepsy-specifically, the challenges of diagnosis through to optimal, and appropriate, therapeutic management. Also, Class I evidence-based data that are needed as a foundation for the development of treatment guidelines worldwide are lacking. Epilepsy is common, and the impact of this disease crosses age ranges and should be managed at all levels of care from community to quaternary care. In this Review, existing data and new therapeutic management approaches are discussed with the aim of highlighting the incidence of standard practices that may not be based on clinical evidence.

The challenges of managing children with epilepsy in Africa

Children with epilepsy who reside in the African continent are faced with some of the greatest challenges of receiving adequate care. The burden of disease is exacerbated by the high incidence of acquired causes and the large treatment gap. Skilled teams to identify and care for children with epilepsy are lacking. Many patients are managed through psychiatric services, thus potentially compounding the stigma associated with the condition. Little data exist to assess the true proportion of comorbidities suffered by children with epilepsy, the assumption is that this is high, further aggravated by delayed interventions and adverse responses to some of the more commonly used antiepileptic drugs.

Long-term survival and outcome in children admitted to kilifi district hospital with convulsive status epilepticus

Objectives. The incidence of convulsive status epilepticus (CSE) is high in Africa but the long-term outcome is unknown. We examined the neurocognitive outcome and survival of children treated for CSE in a Kenyan hospital 3 to 4 years after discharge. Methods. The frequency and nature of neurological deficits among this group of children were determined and compared to a control group. The children were screened with the Ten Questions Questionnaire for neurodevelopmental impairment if alive and those that screened positive were invited for further assessment to determine the pattern and extent of their impairment. A verbal autopsy was performed to determine the cause of death in those that died. Results. In the 119 cases followed-up, 9 (8%) died after discharge, with the majority having seizures during their fatal illness. The 110 survivors (median age 5 years) had significantly more neurological impairments on the screening compared to 282 controls (34/110 (30.9%) versus 11/282 (3.9%), OR = 11.0, 95% CI 5.3–22.8). Fifteen percent of the cases had active epilepsy. Conclusions. This study demonstrates the considerable burden of CSE in African children. Strategies to manage children with CSE that are acceptable to the community need to be explored to improve the longer-term outcome.

Incidence of convulsive epilepsy in a rural area in Kenya

Purpose

There are only a few studies of incidence of epilepsy in low and middle income countries (LMICs). These are often small and conducted in specific age groups or areas where the prevalence of risk factors is high; therefore, these studies are not representative of the wider populations. We determined the incidence of convulsive epilepsy (CE) in a large rural population in Kenya.

Methods

We conducted two cross‐sectional surveys 5 years apart within a health and demographic surveillance system. Initially we identified residents without epilepsy who were then reexamined in the follow‐up survey to determine incidence. We estimated the overall incidence of CE and incidence by age‐group, sex, and by administrative location. Estimates were adjusted for attrition during case identification and for the sensitivity of the screening method.

Key Findings

In a cohort of 151,408 people, 194 developed CE over the 5 years. The minimum crude incidence rate was 37.6/100,000 persons per year (95% confidence interval (CI) 32.7–43.3) and adjusted for loss to follow‐up, and the sensitivity of the survey methodology was 77.0/100,000 persons per year (95% CI 67.7–87.4). Incidence was highest in children 6–12 years (96.1/100,000 persons per year; 95% CI 78.4–117.9), and was lowest in the 29–49 year age group (37.4/100,000 persons per year; 95% CI 25.7–54.7).

Significance

We estimated a high incidence of convulsive epilepsy in this population. Incidence was highest early and late in life, suggesting that preventive interventions should target exposures that occur in these age groups. Incidence of focal epilepsy was more than twice that of generalized epilepsy, suggesting that etiologies that are amenable to intervention were most important in this population. It is likely that incidence is underestimated because of the early mortality of incident cases.

Incidence of epilepsy: a systematic review and meta-analysis

OBJECTIVE

To estimate the pooled incidence of epilepsy from published studies and investigate sources of heterogeneity in the estimates.

METHODS

We searched online databases for incidence studies and used meta-analytic methods to analyze the data.

RESULTS

Thirty-three articles met the entry criteria. The median incidence of epilepsy was 50.4/100,000/year (interquartile range [IQR] 33.6-75.6), while it was 45.0 (IQR 30.3-66.7) for high-income countries and 81.7 (IQR 28.0-239.5) for low- and middle-income countries. Population-based studies had higher incidence estimates than hospital-based studies (p = 0.02) while retrospective study design was associated with lower estimates than prospective studies (p = 0.04).

CONCLUSION

We provide data that could potentially be used to assess the burden and analyze the trends in incidence of epilepsy. Our results support the need for large population-based incidence studies of epilepsy.

Estimation of the burden of active and life-time epilepsy: a meta-analytic approach

PURPOSE

To estimate the burden of lifetime epilepsy (LTE) and active epilepsy (AE) and examine the influence of study characteristics on prevalence estimates.

METHODS

We searched online databases and identified articles using prespecified criteria. Random-effects meta-analyses were used to estimate the median prevalence in developed countries and in urban and rural settings in developing countries. The impact of study characteristics on prevalence estimates was determined using meta-regression models.

RESULTS

The median LTE prevalence for developed countries was 5.8 per 1,000 (5th-95th percentile range 2.7-12.4) compared to 15.4 per 1,000 (4.8-49.6) for rural and 10.3 (2.8-37.7) for urban studies in developing countries. The median prevalence of AE was 4.9 per 1,000 (2.3-10.3) for developed countries and 12.7 per 1,000 (3.5-45.5) and 5.9 (3.4-10.2) in rural and urban studies in developing countries. The estimates of burden for LTE and AE in developed countries were 6.8 million (5th-95th percentile range 3.2-14.7) and 5.7 million (2.7-12.2), respectively. In developing countries these were 45 (14-145) million LTE and 17 (10-133) million AE in rural areas and 17 (5-61) million LTE and 10 (5-17) million AE in urban areas. Studies involving all ages or only adults showed higher estimates than pediatric studies. Higher prevalence estimates were also associated with rural location and small study size.

CONCLUSIONS

This study estimates the global burden of epilepsy and the proportions with AE, which may benefit from treatment. There are systematic differences in reported prevalence estimates, which are only partially explained by study characteristics.

Packages of care for epilepsy in low- and middle-income countries

In the second in a series of six articles on packages of care for mental health disorders in low- and middle-income countries, Caroline Mbuba and Charles Newton discuss treatment for epilepsy.

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.