Epilepsy: Asia versus Africa

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.

Status of epilepsy in the tropics: An overlooked perspective

Epilepsy is one of the most common serious chronic neurological diseases affecting people of all ages globally. It is characterized by recurrent seizures. About 50 million people worldwide have epilepsy. Indubitably, people with epilepsy (PWE) may be without access to appropriate treatment. Many studies have examined the molecular mechanisms and clinical aspects of epilepsy; nonetheless, the treatment gap exists in some special areas. In the tropics, the specific geographical and ecological conditions and a lack of medical resources result in neglect or delay of diagnosis for PWE. Herein, we summarized the epidemiology of epilepsy in the tropics and discussed the disease burden and existing problems, aiming to offer a medical environment for patients in need and highlight the importance of reducing the epileptic disease burden in tropical countries.

Availability and sufficiency of phenobarbital, an essential medication, in Bhutan: a survey of global and neuropsychiatric relevance

Objective

We aimed to provide a reliable evidence-based conclusion around manufacturing, import, availability and sufficiency of one essential medication, phenobarbital (PB) through our example location (Bhutan). The relevant details about manufacturing, import, annual quantity, dose strength were obtained.

Results

There was no local manufacturing of PB and all other anti-seizure medications. A total of 1068 vials of PB 200 mg/mL inj and 489,350 tablets of PB30 mg (i.e. 14.6 kilos) was estimated to annually become available. Of this, 5.3 k (36.3%) was present at the basic health units (BHUs). The PB was absent at 26 (14.7%) BHUs. There was no availability of PB syrup. Treating supposed target of 50.0% of the 20.0% of the prevalent case-load (N = 4523) require 18.1 kilo of PB annually. To conclude, having or not the local manufacturing may or may not be a limitation. There is a need to overcome challenges of inappropriate dose strength, absent pediatric formulation, indirect cost, and low selling price of PB. The possible therapeutic participation of PB in managing disease conditions (like epilepsy) remains limited despite favorable safety and efficacy profile. Strengthening the availability of essential medications is essential to reduce the treatment gap and public health burden of treatable disease conditions.

Epilepsy in Asia: Disease burden, management barriers, and challenges

This article reviews the burden of epilepsy in Asia, the challenges faced by people with epilepsy, and the management of epilepsy. Comparison is made with other parts of the world. For this narrative review, data were collected using specified search criteria. Articles investigating the epidemiology of epilepsy, diagnosis, comorbidities and associated mortality, stigmatization, and treatment were included. Epilepsy is a global health care issue affecting up to 70 million people worldwide. Nearly 80% of people with epilepsy live in low- and middle-income countries with limited resources. People with epilepsy are prone to physical and psychological comorbidities, including anxiety and depression, which can negatively impact their quality of life. Furthermore, people with epilepsy are at higher risk of premature death than people without epilepsy. Discrimination or stigmatization of people with epilepsy is common in Asia and can affect their education, work, and marriage opportunities. Access to epilepsy treatment varies throughout Asia. Although highly advanced treatment is available in some countries, up to 90% of people with epilepsy are not adequately treated or are not treated with conventional antiepileptic therapy in resource-limited countries. People in remote areas often do not receive any epilepsy care. First-generation antiepileptic drugs (AEDs) are available, but usually only in urban areas, and second-generation AEDs are not available in all countries. Newer AEDs tend to have more favorable safety profiles than first-generation AEDs and provide options to tailor therapy for individual patients, especially those with comorbidities. Active epilepsy surgery centers are present in some countries, although epilepsy surgery is often underutilized given the number of patients who could benefit. Further epidemiologic research is needed to provide accurate epilepsy data across the Asian region. Coordinated action is warranted to improve access to treatment and care.

Knowledge, Attitude, and Practice among Practitioners Regarding Epilepsy in Bhutan: A Rural and a Remote Country

Purpose:

Epilepsy is a major neurological disorder with many countries as scientifically silent and little-to-nothing known on various aspects of epilepsy.

Methods:

Taking background of a first multinational seminar on epilepsy in Bhutan and a short valid questionnaire pertaining to various aspects of epilepsy, before participation.

Results:

Large participation was achieved (76 out of 87 approached, 87.3%; 53.0% males). Based on the responses of 76.0% lecturers and clinician and medical administration, 21.0% nurses, and 3.0% traditional practitioners, important derivations were obtained: positively, (a) event provided at least an opportunity to bring service providers at a common platform toward initiating particular epilepsy goals, (b) none regarded epilepsy as contagious or due to past sins, (c) all responded favorably to that “they found this event useful’ and ‘this event added something meaningful to them personally or professionally,” (d) large participation indicated acceptance, need, and common interest among a number of stakeholders. Negatively, significant knowledge-deficit was noted: for 38.4% electroencephalogram is essential for diagnosis, 48.0% responded with incorrect definition of epilepsy, etc.

Conclusions:

Events, such as this, provides, for scientifically silent countries, basis for not only bringing service providers to a common platform but also to discuss to initiate particular epilepsy goals, to provide additional professional knowledge for strengthening service development, and to determine need and social acceptance around epilepsy. Important knowledge deficit was identified which cannot be fully explained through lack of time or limited training. There might be a need to reappraise the approach to teaching medical professionals about epilepsy.

Epilepsy in Qatar: Causes, treatment, and outcome

OBJECTIVE

Qatar is a small country on the Eastern coast of the Arabian Peninsula. Its population is a unique mixture of native citizens and immigrants. We aimed to describe the features of epilepsy in Qatar as such information is virtually lacking from the current literature.

METHODS

We summarized information retrospectively collected from 468 patients with epilepsy seen through the national health system adult neurology clinic.

RESULTS

Epilepsy was classified as focal in 65.5% of the cases and generalized in 23%. Common causes of epilepsy were as follows: stroke (9%), hippocampal sclerosis (7%), infections (6%), and trauma (6%). Sixty-six percent of patients were receiving a single antiepileptic drug, with levetiracetam being the most frequently prescribed drug (41% of subjects). When the patients were divided by geographical background, remote infections caused the epilepsy in 15% of Asian patients (with neurocysticercosis accounting for 10%) but only in 1% of Qatari and 3% of Middle East/North African subjects (with no reported neurocysticercosis) (p<0.001). Cerebrovascular and neurodegenerative etiologies were the most prominent in Qataris, accounting for 14% (p=0.005) and 4% (p=0.03) of cases, respectively. The choice of antiepileptic drugs varied also according to the regional background, but the seizure freedom rate did not, averaging at 54% on the last clinic visit.

SIGNIFICANCE

To our knowledge, this is the first detailed information about epilepsy in Qatar. The geographical origin of patients adds to the heterogeneity of this disorder. Neurocysticercosis should be in the etiological differential diagnosis of epilepsy in patients coming from Southeast Asian countries, despite the fact that it is not endemic to Qatar. The choice of antiepileptic drugs is influenced by the availability of individual agents in the patients' native countries but had no bearing on the final seizure outcome.

Quality of life in epilepsy in Bhutan

PURPOSE

To assess the quality of life in epilepsy (QOLIE) among adults in the lower middle-income country of Bhutan and assess the potential demographic and clinical associations with better QOLIE.

METHODS

People with clinically diagnosed epilepsy were prospectively enrolled at the Jigme Dorji Wangchuck National Referral Hospital in Thimphu (2014-2015). Regression models were constructed to assess the potential impact of age, sex, residence in the capital city, wealth quintile, educational attainment, seizure in the prior year, seizures with loss of consciousness, self-reported stigma score, and need for multiple antiepileptic drugs.

RESULTS

The mean Bhutanese 48.4/100 ± 17.3 [corrected] score among 172 adults (mean age 31.1 years, 93 female) was 48.9/100±17.7. Younger age, lower educational attainment level, and increased self-perceived stigma were each observed to have an independent, negative association with QOLIE (p<0.05), while a patient's wealth quintile, sex, seizure frequency, seizure type and number of antiepileptic drugs were not. Education appeared to be most strongly associated with QOL at the high school and college levels.

CONCLUSIONS

There are potentially modifiable associations with low QOLIE. Addressing the educational level and self-perceived stigma of PWE may have an especial impact. The low QOLIE in Bhutan may reflect cultural approaches to epilepsy, health services, or other factors including those outside of the health sector.

Effect of Liraglutide on Corneal Kindling Epilepsy Induced Depression and Cognitive Impairment in Mice

GLP-1 play important role in neuroprotection and GLP-1 receptor deficit mice showed decreased seizure threshold and increased cognitive impairment. Therefore, study was premeditated to investigate the effect of liraglutide (GLP-1 analogue) on cornel kindling epilepsy induced co-morbidities in mice. Corneal kindling was induced by electrical stimulation (6 mA, 50 Hz, 3 s); twice daily for 13 days. Liraglutide (75 and 150 µg/kg) and phenytoin (20 mg/kg) were administered in corneal kindled groups. On day 14, elevated plus maze, passive shock avoidance paradigms were performed, and on day 15, retention was taken. On day 16 tail suspension test were performed. On 20th day challenge test was performed with same electrical stimulation and retention was observed on elevated plus maze and passive avoidance paradigm. Animal were sacrificed on 21st day for biochemical (LPO, GSH, and nitrite) and neurochemical (GABA, glutamate, DA, NE, 5-HT and their metabolites) estimation. Electrical stimulation by corneal electrode for 13 days developed generalized clonic seizures, increased cognitive impairment, oxidative stress and neurochemical alteration in mice brain. Co-treatment with liraglutide (75 and 150 μg/kg) significantly prevented the seizure severity, restored behavioural activity, oxidative stress and restored the altered level of neurotransmitters observed in corneal kindled mouse.

A comprehensive review of epilepsy in the Arab world

PURPOSE

We conducted a comprehensive review of the epidemiology of epilepsy in the Arab world.

METHODS

Epidemiological literature about epilepsy from 22 countries of the Arab League was searched in French and English using several keywords (specific and wider) and combinations, individually for each country. The search was conducted on Google first and then on PubMed. The results are presented as counts, proportions, and medians along with 95% confidence intervals (CI). Unpaired t-test with unequal variance and regressions were performed, altogether and individually, for lifetime and active epilepsy prevalence as well as incidence.

RESULTS

Google provided 21 prevalence, four camp and nine incidence estimates while PubMed provided ten such estimates; none of them was identified by Google. No epidemiological data about epilepsy was found from 10/22 countries. Excluding pediatric studies, 13 prevalence estimates from six countries were identified. Including pediatric studies, 21 estimates from nine countries were found. Median lifetime and active epilepsy prevalence were 7.5/1000 (95% CI 2.6-12.3, range 1.9-12.9) and 4.4/1000 (95% CI 2.1-9.3, range 2.1-9.3), respectively, excluding pediatric studies (1984-2014, N=244081). Median incidence was 56.0/100,000 (n=9, N=122484, 95% CI 13.7-147.9, range 10.4-190).

CONCLUSION

The fact that no epidemiological data about epilepsy is available in the public domain for almost one half of all Arab countries offers opportunities for future research. This thorough review of existing literature demonstrates a prevalence of epilepsy three times higher than previously reported for this region. The median incidence is similar to other regions of the world, e.g. North America. Google yielded additional valuable sources not indexed in PubMed and provided pertinent references more quickly.