A cluster-randomized trial comparing home-based primary health care and usual clinic care for epilepsy in a resource-limited country

OBJECTIVE

To ascertain whether home-based care with community and primary healthcare workers' support improves adherence to antiseizure medications, seizure control, and quality of life over routine clinic-based care in community samples of people with epilepsy in a resource-poor country.

METHODS

Participants included consenting individuals with active epilepsy identified in a population survey in impoverished communities. The intervention included antiseizure medication provision, adherence reinforcement and epilepsy self- and stigma management guidance provided by a primary health care-equivalent worker. We compared the intervention group to a routine clinic-based care group in a cluster-randomized trial lasting 24 months. The primary outcome was antiseizure medication adherence, appraised from monthly pill counts. Seizure outcomes were assessed by monthly seizure aggregates and time to first seizure and impact by the Personal Impact of Epilepsy scale.

RESULTS

Enrolment began on September 25, 2017 and was complete by July 24, 2018. Twenty-four clusters, each comprising ten people with epilepsy, were randomized to either home- or clinic-care. Home-care recipients were more likely to have used up their monthly-dispensed epilepsy medicine stock (regression coefficient: 0.585; 95% confidence intervals, 0.289-0.881; P = 0.001) and had fewer seizures (regression coefficient: -2.060; 95%CI, -3.335 to -0.785; P = 0.002). More people from clinic-care (n = 44; 37%) than home-care (n = 23; 19%) exited the trial (P = 0.003). The time to first seizure, adverse effects and the personal impact of epilepsy were similar in the two arms.

SIGNIFICANCE

Home care for epilepsy compared to clinic care in resource-limited communities improves medication adherence and seizure outcomes and reduces the secondary epilepsy treatment gap.

Potential Ecological Impacts of Heavy Metals in Sediments of Industrially Contaminated Perennial Drain of India

Globally, heavy metal contamination of natural waterways and surrounding environments due to anthropogenic activities has become a grave cause of concern. Therefore, the present study was conducted to analyze the ecological risk posed by heavy metals in sediment samples (N = 24) collected from different depths of Budha Nalah drain located in Ludhiana (Punjab, India). The concentration of As, Cd, Cr, Cu, Ni, Pb and Zn were found to be above the maximum permissible limits for metals in soils and sediments, which was attributed to anthropogenic activities (industrialization, urbanization and agriculture). The values observed for Contamination Factor, Enrichment Factor and Pollution Load Index revealed that sediment samples were highly contaminated by As, Cd, Cr and Pb. The ecological Risk Index (range: 212-1566) and Modified Risk Index (range: 2793-12,182) values indicated that high concentrations of metals (especially As, Cd, Cr and Pb) posed severe ecological risks in the areas around the drain.

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.

Clinical characteristics of epilepsy in resource-limited communities in Punjab, Northwest India

OBJECTIVES

To describe clinical characteristics of a community-based epilepsy cohort from resource-limited communities in Punjab, Northwest India.

METHODS

The cohort was gathered following a two-stage screening survey. We cross-sectionally examined and followed up the cohort for one year. A panel of neurologists assigned seizure types, syndromes, and putative etiologies and categorized drug responsiveness.

RESULTS

The cohort of 240 included 161 (67.1%) men, 109 (45.4%) illiterates and 149 (62.1%) unemployed. Current age was >18 years in 155 (64.6%) but age at epilepsy onset was <18 years in 173 (72.1%). Epilepsies due to structural and metabolic causes were diagnosed in 99 (41.3%), but syndromic assignments were not possible in 97 (40.4%). After one year, drug-resistant epilepsy was established in 74 (30.8%). Perinatal events (n = 35; 14.6%) followed by CNS infections (n = 32; 13.3%) and traumatic brain injury (n = 12; 5.0%) were common risk factors. Most of those with CNS infections (n = 19; 63.3%), perinatal antecedents (n = 23; 76.7%), and other acquired risk factors (n = 27; 90.0%) presented with epilepsy due to structural and metabolic causes. Perinatal events were the putative etiology for nearly 40.7% of generalized epilepsies due to structural and metabolic causes and 28.2% of all epilepsies with onset <10 years.

SIGNIFICANCE

Existing classifications schemes should be better suited to field conditions in resource-limited communities in low- and middle-income countries. The finding of drug-resistant epilepsy in nearly at least a third in a community-based sample underscores an unmet need for enhancing services for this segment within healthcare systems. Perinatal events, CNS infections, and head injury account for a third of all epilepsies and hence preventative interventions focusing on these epilepsy risk factors should be stepped up.

Epilepsy knowledge, attitudes, and practices among primary healthcare providers in an Indian district

INTRODUCTION

Scaling up the involvement of primary care providers in epilepsy management in low- and middle-income countries (LMICs) requires an understanding of their epilepsy knowledge, attitudes, and practices (KAP).

AIM

The aim of the study was to document levels of knowledge about, attitudes towards, and practices regarding epilepsy among different ranks of primary healthcare providers in a North-Western Indian district.

METHODS

The survey included government medical officers (MOs), auxiliary nurse midwives (ANMs), and accredited social health activists (ASHAs). They were administered a specially designed KAP questionnaire. Responses were analyzed according to rank.

RESULTS

The survey showed that nearly 10% of ANMs and almost a fifth of ASHAs had never heard about epilepsy. A quarter of MOs and over two-thirds of ANMs and ASHAs had never provided care to someone with epilepsy. There were significant differences in the levels of knowledge between the three groups of workers.

CONCLUSIONS

Closing the huge gaps in KAP by educating primary care and community health workers about epilepsy should be a priority before engaging them in the epilepsy care delivery.

A home-based, primary-care model for epilepsy care in India: Basis and design

OBJECTIVES

A cluster-randomized trial of home-based care using primary-care resources for people with epilepsy has been set up to optimize epilepsy care in resource-limited communities in low- and middle-income countries. The primary aim is to determine whether treatment adherence to antiepileptic drugs is better with home-based care or with routine clinic-based care. The secondary aims are to compare the effects of the two care pathways on seizure control and quality of life.

METHODS

The home-based intervention comprises epilepsy medication provision, adherence reinforcement, and epilepsy self-management and stigma management guidance provided by an auxiliary nurse-midwife equivalent. The experimental group will be compared to a routine clinic-based care group using a cluster-randomized design in which the unit of analysis is a cluster of 10 people with epilepsy residing in an area cared for by a single accredited government grass-roots health care worker. The primary outcome is treatment adherence as measured by monthly tablet counts supplemented by two self-completed questionnaires. The secondary outcomes include monthly seizure frequency, time to first seizure (in days) after enrollment, proportion of patients experiencing seizure freedom for the duration of the study, and quality of life measured by the "Personal Impact of Epilepsy Scale," all assessed by an independent study nurse.

RESULTS

The screening phase and neurologic evaluations and randomizations have been recently completed and follow-up is underway.

SIGNIFICANCE

The results of the trial are likely to have substantial bearing on the development of governmental policies and strategies to provide coverage and care for patients with epilepsy in resource-limited countries.