Community-based prevalence and clinical characteristics of febrile seizures in Tanzania

Long-term clinical course and treatment outcomes of individuals with Nodding Syndrome

Nodding Syndrome is a poorly understood epilepsy disorder in sub-Saharan Africa. The cause(s) of the disease, risk factors and long-term outcomes are unknown or controversial. The objectives of this study were to describe the long-term clinical course and treatment outcomes of individuals suffering from Nodding Syndrome. In addition, we aimed to provide a comprehensive characterization of the epileptological and social features of patients with Nodding Syndrome. From 11/2014 to 4/2015, we conducted a hospital-based, cross-sectional and observational study in Mahenge, Tanzania. Seventy-eight individuals (female:male ratio: 40:38, age at examination: 21.1 ± 6.39 (SD) years) have been enrolled, of whom 38 (49%) had also been examined in 2005 and in 2009. The 10-year clinical course analysis of this revisited subgroup revealed a calculated case fatality of 0.8-2.3%. Progressive physical or cognitive deterioration has not been observed in any of the 78 individuals and more than half of the people studied (38/69; 55%) managed to live and work independently. 14/78 individuals (18%) were seizure-free, (no head nodding, no other seizure types), 13 of whom were taking antiseizure medication. Phenytoin was more effective against head nodding seizures (14/19 (74%)) than monotherapy with other available antiseizure medication (phenobarbitone 12/25 (48%) and carbamazepine 7/22 (32%), p = 0.02, chi-square test). Our ten-year clinical outcome data show that Nodding Syndrome is not a fatal disease, however, the response to treatment is worse than in epilepsy patients in general. Phenytoin may be more effective than carbamazepine and phenobarbitone, but further studies are needed to confirm this observation.

The baseline risk of multiple febrile seizures in the same febrile illness: a meta-analysis

The baseline risk for multiple febrile seizures within the same febrile illness is largely unknown. Estimates range from 5 to 30%. Imprecise estimates can lead to incorrectly powering studies investigating the management of febrile seizures. To estimate the risk of multiple febrile seizures in the same febrile illness, we systematically reviewed and conducted a meta-analysis of studies from January 2000 to December 2021 that contained data for the number of children for both simple and complex febrile seizures in the same febrile illness. We searched MEDLINE, EMBASE, and Web of Science for randomized, quasi-randomized, prospective, and retrospective trials that involved children with febrile seizures. A total of 23,131 febrile illnesses with febrile seizures met the inclusion criteria. The estimated baseline risk of multiple febrile seizures in the same febrile illness was 17% (95% CI, 16-19%). However, the 30 cohorts that included both admitted and non-admitted patients had a lower percentage of multiple FSs within the same illness (14%; 95% CI, 12-15%) than the 30 cohorts that enrolled only admitted patients (20%; 95% CI, 16-25%).

CONCLUSION

Researchers can use estimates in this paper to design future studies. Taking into the account the substantial heterogeneity between countries and studies, clinicians could cautiously use our estimates in their clinical assessment and be better able to set parental expectations about a child's chances of having another febrile seizure during the current illness.

TRIAL REGISTRATION

PROSPERO CRD42020191784. Registered July 18, 2020.

WHAT IS KNOWN

• There is renewed interest in the diagnostic workup and prophylactic treatment of febrile seizures to prevent repeat seizures in the same febrile illness. • There is a lack of accurate estimates of the baseline risk for multiple febrile seizures in the same illness to properly design studies investigating management.

WHAT IS NEW

• This study provides the most robust estimates for the baseline risk for multiple febrile seizures in the same illness.

Febrile seizures in an urban Tanzanian population: lessons learned from a community-based random cluster survey

OBJECTIVE

To analyse the cumulative incidence of febrile seizures, to evaluate the accuracy of our screening questionnaire and to describe clinical characteristics of children with febrile seizure in an urban population in Tanzania.

METHODS

A large random cluster sampled population was screened for a febrile seizure history as part of a larger epilepsy study using a standardised questionnaire in a two-stage door-to-door survey in Tanzania. A subset of screen positive participants was further examined for confirmation of diagnosis and evaluation of clinical characteristics.

RESULTS

Overall, 49 697 people were screened for a febrile seizure history of whom 184 (0.4%) screened positive. Women more commonly screened positive than men (112 [0.4%] vs. 72 [0.3%]). There was no marked difference between age groups or education. The positive predictive value of the screening tool was 37% (95% CI 24-51%) but its accuracy varied with the age of interviewed individuals. Cumulative incidence rates were estimated between 1.1% and 2.0% after adjusting for the inaccuracy of the screening tool. Most febrile seizures occurred before the age of two (65%) and most children had more than one episode (80%). A large proportion of children had complex febrile seizure (65%), often caused by malaria or respiratory infections.

CONCLUSIONS

The community-based cumulative incidence of a febrile seizure history in an urban Tanzanian population was similar to rates reported from other rural populations after adjusting for the inaccuracy of our screening tool. Based on the integrated nature of the febrile seizure questionnaire, screening positivity rates may have been too low. This has implications for the design of future studies. The majority of cases had complex febrile seizures often associated with malaria. This has implications for clinical case management.

The assessment of parents' knowledge, attitudes and concerns about febrile seizures in children at tertiary hospitals in Rwanda-a descriptive study

BACKGROUND

Febrile seizures (FSs) are the most common seizure disorder in childhood. No previous research has been performed to assess caregiver attitudes, knowledge and concerns of FSs in Rwanda or East Africa.

OBJECTIVES

This study sought to assess knowledge, attitudes and concerns regarding FS among caregivers of children presenting to tertiary hospitals in Rwanda using a previously validated questionnaire. The secondary objective was to assess the reliability of a translated version of the Huang Febrile Seizures Questionnaire (HFSQ).

METHODS

A multi-centre observational study was conducted at four tertiary teaching hospitals in Rwanda. The admitting doctor determined that children met the definition of FSs. A translated version, of a validated questionnaire, the HFSQ, employing yes/no and five-point Likert questions, was used for this study, after minor adjustments.

RESULTS

Eighty-six caregivers were recruited. Caregivers had low levels of pre-existing knowledge regarding FSs. The most significant caregiver concern was that 'siblings will have FSs too'(mean = 3.62 ± 0.7). Caregivers felt that children with FSs do not need more attention and care and that FSs can be outgrown (mean = 3.4 ± 1.0).

DISCUSSION

The findings support the need for locally relevant educational materials to be shared with caregivers after a FS event. The HFSQ is a good quality tool for assessing parental knowledge and concerns and has the potential to be used in clinical practice as a benchmarking tool for education.

Prevalence, risk factors and behavioural and emotional comorbidity of acute seizures in young Kenyan children: a population-based study

BACKGROUND

Acute symptomatic seizures and febrile seizures are common in children admitted to hospitals in Africa and may be markers of brain dysfunction. They may be associated with behavioural and emotional problems, but there are no published community-based studies in Africa.

METHODS

We screened 7047 children aged 1-6 years (randomly sampled from 50,000 in the community) for seizures (using seven questions) and invited those who screened positive and a proportion of negatives for a clinical assessment. Risk factors were identified using a parental questionnaire. Behavioural and emotional problems were examined using the Child Behaviour Checklist (CBCL) in 3273 children randomly selected from 7047. Generalised linear models with appropriate link functions were used to determine risk factors and associations between behavioural or emotional problems and acute seizures. Sobel-Goodman mediation tests were used to investigate if the association between acute seizures and CBCL scores was mediated by co-diagnosis of epilepsy.

RESULTS

Acute seizures were identified in 429 (6.1%) preschool children: 3.2% (95% confidence interval CI: 2.9-3.5%) for symptomatic seizures, and 2.9% (95% CI: 2.6-3.3%) for febrile seizures. Risk factors for acute seizures included family history of febrile seizures (odds ratio OR = 3.19; 95% CI: 2.03-5.01) and previous hospitalisation (OR = 6.65; 95% CI: 4.60-9.63). Total CBCL problems occurred more frequently in children with acute seizures (27%; 95% CI: 21-34%) than for those without seizures (11%; 95% CI: 11-12%; chi-squared p ≤ 0.001). Acute seizures were associated with total CBCL problems (adjusted risk ratio (aRR) = 1.92; 95% CI: 1.34-2.77), externalising problems (aRR = 1.82; 95% CI: 1.21-2.75) and internalising problems (aRR = 1.57; 95% CI: 1.22-2.02), with the proportion of the comorbidity mediated by a co-diagnosis of epilepsy being small (15.3%; 95% CI: 4.5-34.9%). Risk factors for this comorbidity included family history of febrile seizures (risk ratio (RR) = 3.36; 95% CI: 1.34-8.41), repetitive acute seizures (β = 0.36; 95% CI: 0.15-0.57) and focal acute seizures (RR = 1.80; 95% CI: 1.05-3.08).

CONCLUSIONS

Acute seizures are common in preschool children in this area and are associated with behavioural and emotional problems. Both conditions should be assessed and addressed in children.

Prevalence, risk factors, and neurobehavioral comorbidities of epilepsy in Kenyan children

Objective

To investigate the prevalence, risk factors, clinical features, and neurobehavioral comorbidities of epilepsy and acute symptomatic seizures in school‐aged children in Kilifi, Kenya.

Methods

Randomly selected children (N = 11,223) were screened for epilepsy and other neurodevelopmental disorders. Those who screened positive were invited for further clinical, electroencephalographic (EEG), and neuropsychological evaluations. Prevalence was measured by dividing cases by screened population, providing Agresti–Coull confidence intervals (CIs). Prevalence ratios were computed using log binomial regression, and odds ratios (ORs) were computed using logistic regression; both were implemented with generalized linear models. Attention‐deficit hyperactivity disorder (ADHD), autism spectrum disorder (ASD), and other neurodevelopmental impairments were assessed in cases and controls.

Results

Prevalence of lifetime epilepsy was 20.9 per 1,000 (95% CI = 18.4–23.7), and that of active epilepsy was 11.5 per 1,000 (95% CI = 9.7–13.6). Prevalence of acute symptomatic seizures was 68.8 per 1,000 (95% CI = 64.2–73.6). Acute symptomatic seizures preceded a diagnosis of epilepsy in 8% of children. Of 98 children diagnosed with epilepsy, focal seizures were seen in 79%, abnormal EEG was seen in 39%, and 83% were not receiving antiepileptic drugs. Childhood absence epilepsy and Lennox–Gastaut epilepsy were the most easily identifiable epilepsy syndromes. Perinatal complications, previous hospitalization, geophagia, and snoring were risk factors for epilepsy. Family history of seizures, abnormal pregnancy, previous hospitalization, and snoring were risk factors for acute symptomatic seizures. Neurobehavioral comorbidities were present in 54% of subjects with lifetime epilepsy and in 3% of controls, with associations for individual comorbidities being statistically significant: ADHD (OR = 14.55, 95% CI = 7.54–28.06), ASD (OR = 36.83, 95% CI = 7.97–170.14), and cognitive impairments (OR = 14.55, 95% CI = 3.52–60.14).

Significance

The burden of seizure disorders in this area is higher than in locations in high‐income countries, and can be reduced by preventing risk factors. A comprehensive management plan for neurobehavioral comorbidities of epilepsy should be incorporated into standard epilepsy care.

Prevalence, causes, and behavioral and emotional comorbidities of acute symptomatic seizures in Africa: A critical review

Seizures with fever includes both febrile seizures (due to nonneurological febrile infections) and acute symptomatic seizures (due to neurological febrile infections). The cumulative incidence (lifetime prevalence) of febrile seizures in children aged ≤6 years is 2-5% in American and European studies, but there are no community-based data on acute symptomatic seizures in Africa. The incidence of acute symptomatic seizures in sub-Saharan Africa is more than twice that in high-income countries. However, most studies of acute symptomatic seizures from Africa are based on hospital samples or do not conduct surveys in demographic surveillance systems, which underestimates the burden. It is difficult to differentiate between febrile seizures and acute symptomatic seizures in Africa, especially in malaria-endemic areas where malaria parasites can sequester in the brain microvasculature; but this challenge can be addressed by robust identification of underlying causes. The proportion of complex acute symptomatic seizures (i.e., seizures that are focal, repetitive, or prolonged) in Africa are twice that reported in other parts of the world (>60% vs. ∼30%), which is often attributed to falciparum malaria. These complex phenotypes of acute symptomatic seizures can be associated with behavioral and emotional problems in high-income countries, and outcomes may be even worse in Africa. One Kenyan study reported behavioral and emotional problems in approximately 10% of children admitted with acute symptomatic seizures, but it is not clear whether the behavioral and emotional problems were due to the seizures, shared genetic susceptibility, etiology, or underlying neurological damage. The underlying neurological damage in acute symptomatic seizures can lead not only to behavioral and emotional problems but also to neurocognitive impairment and epilepsy. Electroencephalography may have a prognostic role in African children with acute symptomatic seizures. There are significant knowledge gaps regarding acute symptomatic seizures in Africa, which results in lack of reliable estimates for planning interventions. Future epidemiological studies of acute symptomatic seizures should be set up in Africa.