Elsevier

The Lancet

Volume 380, Issue 9848, 29 September–5 October 2012, Pages 1193-1201
The Lancet

Series
Epilepsy in poor regions of the world

https://doi.org/10.1016/S0140-6736(12)61381-6Get rights and content

Summary

Epilepsy is a common disorder, particularly in poor areas of the world, and can have a devastating effect on people with the disorder and their families. The burden of epilepsy in low-income countries is more than twice that found in high-income countries, probably because the incidence of risk factors is higher. Many of these risk factors can be prevented with inexpensive interventions, but there are only a few studies that have assessed the effect of reducing risk factors on the burden of epilepsy. The mortality associated with epilepsy in low-income countries is substantially higher than in less impoverished countries and most deaths seem to be related to untreated epilepsy (eg, as a result of falls or status epilepticus), but the risk factors for death have not been adequately examined. Epilepsy is associated with substantial stigma in low-income countries, which acts as a barrier to patients accessing biomedical treatment and becoming integrated within society. Seizures can be controlled by inexpensive antiepileptic drugs, but the supply and quality of these drugs can be erratic in poor areas. The treatment gap for epilepsy is high (>60%) in deprived areas, but this could be reduced with low-cost interventions. The substantial burden of epilepsy in poor regions of the world can be reduced by preventing the risk factors, reducing stigma, improving access to biomedical diagnosis and treatment, and ensuring that there is a continuous supply of good quality antiepileptic drugs.

Introduction

Over 85% of the global burden of epilepsy occurs in the 49% of the population living in low-income and lower-middle-income countries (LLMIC; table).1, 2 Most of these countries are in Africa, where the yearly expenditure on health care is often less than US$50 per person (5·1% of the gross national income; figure 1). However, these mean data often belie the large disparities found within these countries, particularly between the poorer areas (rural or urban settlement) and more affluent urban areas and between the scarcity of health facilities and personnel in the government sector and those in the private medical sector. These disparities contribute to the enormous treatment gap (ie, the proportion of people with epilepsy who have active epilepsy but who are not taking antiepileptic drugs [AEDs] or are inadequately treated): over 60% of people with epilepsy do not access biomedical treatment for epilepsy in LLMIC,3 and if they do, they often do not or are not able to adhere to the prescribed regimens.

Section snippets

The burden of epilepsy

Epilepsy was estimated to account for 0·5% of the global burden of disease, accounting for 7 307 975 disability-adjusted life-years, in 2005.4 These figures did not take into account the limited data from the LLMIC or that the disability weights of epilepsy are not based on measurements in poor areas. Deriving accurate figures on the epidemiology of epilepsy in LLMIC is very difficult since most data have to be derived from cross-sectional surveys, of which there are few and which are expensive

Risk factors

Risk factors for seizure disorders and epilepsy differ between LLMIC and HIC, at least in their frequencies. The most marked difference relates to the age of onset, which in HIC follows a bimodal curve with markedly higher incidence in early childhood and later life (people older than 65 years) than at other ages.17, 18 In LLMIC the incidence is increased in older children and young adults compared with other age groups, probably because of the high incidence of infections and trauma as

Prevention

Since preventable epilepsies arise from well-defined causative agents or situations, most interventions are directed towards the underlying disease or risk factor itself rather than towards preventing the development of epilepsy (ie, epileptogenesis in affected individuals). Improvements in perinatal care should decrease neonatal brain damage. Interventions against some infectious diseases or traumatic brain injury should decrease the incidence of epilepsy.

Stigma

Epilepsy, like many other mental health disorders, is often associated with substantial stigma, particularly in poor areas. Most people with epilepsy in these regions are less likely to be sent to school, find employment, or marry.47, 48, 49 Some of these impediments might be related to the underlying brain disorder, manifesting as cognitive impairment or psychiatric illness. In those studies that have measured stigma, the evidence suggests that most stigma is enacted (ie, discrimination

Treatment gap

Although the International League Against Epilepsy (ILAE) defines active epilepsy as a seizure within the past 5 years, in many LLMIC it is defined as one or two seizures within the past year, since this is the criteria used to start treatment with AEDs and to measure the treatment gap.55 The epilepsy treatment gap has two components: those not accessing or unable to access biomedical facilities for diagnosis and treatment and, if accessing biomedical treatment, those not adhering to the

Services for epilepsy

In LLMIC there are substantial disparities in the care that is available for epilepsy. Most neurologists and psychiatrists work in the urban private sector, where they provide care similar to that found in developed countries, with access to the newer AEDs, sophisticated neuroimaging, and epilepsy surgery programmes. However, in the poorer urban areas, government facilities, and rural areas this level of care is rarely available. To address these disparities, epilepsy needs to be integrated

Initiatives to reduce the burden and treatment gap of epilepsy

The Global Campaign Against Epilepsy was started in 1997 as a result of a collaboration between WHO, ILAE, and the International Bureau for Epilepsy (IBE) to address many of these issues. The first phase aimed to raise awareness, develop regional declarations on epilepsy, and encourage prioritisation of epilepsy services. The second phase was launched in 2001, with demonstration projects set up to support ministries of health in identifying needs and promoting education, training, treatment,

Conclusions

The burden of epilepsy can be reduced in poor parts of the world by alleviating poverty, but perhaps more easily by reducing the preventable causes, namely perinatal insults, parasitic diseases, and head injuries. Community sensitisation, with identification of people with epilepsy in poor areas and education that epilepsy is a controllable disorder, would provide an opportunity for these people to access treatment. Empowering primary health-care workers to diagnose and start treatment might

Search strategy and selection criteria

We searched Medline (1966 to May, 2012), ISI Web of Science (1966 to May, 2012), and Cochrane Reviews (1966 to May, 2012) with the search terms (‘epilepsy” AND “resource poor”) OR (“developing countries”) OR (“low income countries”). Searches were restricted to human studies. We found 646 references.

References (91)

  • R Baskind et al.

    Epilepsy-associated stigma in sub-Saharan Africa: the social landscape of a disease

    Epilepsy Behav

    (2005)
  • K Das et al.

    Evaluation of socio-economic factors causing discontinuation of epilepsy treatment resulting in seizure recurrence: a study in an urban epilepsy clinic in India

    Seizure

    (2007)
  • CK Mbuba et al.

    Risk factors associated with the epilepsy treatment gap in Kilifi, Kenya: a cross-sectional study

    Lancet Neurol

    (2012)
  • S Berhanu et al.

    Primary care treatment of epilepsy in rural Ethiopia: causes of default from follow-up

    Seizure

    (2009)
  • SH Nizamie et al.

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

    Epilepsy Res

    (2009)
  • J Qiu

    Epilepsy surgery: challenges for developing countries

    Lancet Neurol

    (2009)
  • AK Ngugi et al.

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

    Epilepsia

    (2010)

  • Countries and economies

  • AC Meyer et al.

    Global disparities in the epilepsy treatment gap: a systematic review

    Bull World Health Organ

    (2010)

  • Neurological Disorders: Public Health Challenges

    (2006)
  • AK Ngugi et al.

    Incidence of epilepsy: a systematic review and meta-analysis

    Neurology

    (2011)
  • OC Cockerell et al.

    Epilepsy in a population of 6000 re-examined: secular trends in first attendance rates, prevalence, and prognosis

    J Neurol Neurosurg Psychiatry

    (1995)
  • GL Birbeck

    Epilepsy care in developing countries: part I of II

    Epilepsy Curr

    (2010)
  • TA Bruckner et al.

    The mental health workforce gap in low- and middle-income countries: a needs-based approach

    Bull World Health Organ

    (2011)
  • AS Winker et al.

    Aetiologies of altered states of consciousness: a prospective hospital-based study in a series of 464 patients of northern Tanzania

    J Neurol Sci

    (2011)

  • Atlas: epilepsy care in the world

    (2005)
  • L Forsgren et al.

    Mortality of epilepsy in developed countries: a review

    Epilepsia

    (2005)
  • J Mu et al.

    Causes of death among people with convulsive epilepsy in rural west China: a prospective study

    Neurology

    (2011)
  • C Adelow et al.

    Newly diagnosed single unprovoked seizures and epilepsy in Stockholm, Sweden: first report from the Stockholm Incidence Registry of Epilepsy (SIRE)

    Epilepsia

    (2009)
  • DC Hesdorffer et al.

    Estimating risk for developing epilepsy: a population-based study in Rochester, Minnesota

    Neurology

    (2011)
  • SM Montano et al.

    Neurocysticercosis: association between seizures, serology, and brain CT in rural Peru

    Neurology

    (2005)
  • JA Carter et al.

    Increased prevalence of epilepsy associated with severe falciparum malaria in children

    Epilepsia

    (2004)
  • JF Annegers et al.

    The risk of unprovoked seizures after encephalitis and meningitis

    Neurology

    (1988)
  • OH Del Brutto et al.

    Epilepsy and neurocysticercosis in Atahualpa: a door-to-door survey in rural coastal Ecuador

    Epilepsia

    (2005)
  • R Powell et al.

    Acute symptomatic seizures

    Pract Neurol

    (2012)
  • LC Frey

    Epidemiology of posttraumatic epilepsy: a critical review

    Epilepsia

    (2003)
  • J Bruns et al.

    The epidemiology of traumatic brain injury: a review

    Epilepsia

    (2003)
  • D Silberberg et al.

    Neurological disorders

  • MJ De Silva et al.

    Patient outcome after traumatic brain injury in high-, middle- and low-income countries: analysis of data on 8927 patients in 46 countries

    Int J Epidemiol

    (2009)
  • KJ Burton et al.

    Epilepsy in Tanzanian children: association with perinatal events and other risk factors

    Epilepsia

    (2012)
  • JM Wilmshurst et al.

    Withdrawal of older anticonvulsants for management of status epilepticus: implications for resource-poor countries

    Dev Med Child Neurol

    (2005)
  • CR Newton

    Status epilepticus in resource-poor countries

    Epilepsia

    (2009)
  • T Jenssen et al.

    Alzheimer disease and other neurodegenerative diseases

  • LP Yemadje et al.

    Understanding the differences in prevalence of epilepsy in tropical regions

    Epilepsia

    (2011)
  • CC Chen et al.

    Geographic variation in the age- and gender-specific prevalence and incidence of epilepsy: analysis of Taiwanese National Health Insurance-based data

    Epilepsia

    (2012)

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