09 December 2012

Epilepsy in Developing Countries

Better control of infectious diseases has resulted in an increasing emphasis on the treatment and prevention of chronic non-communicable disease throughout the world.  Certainly seizure disorders rank among the most common and important of these conditions.  Epilepsy accounts for 0.5% of the global burden of disease, and over 7 million disability adjusted life years.  Over 85% of the global burden of epilepsy occurs in the 49% of the population living in low income countries. Unfortunately the very countries where the incidence is highest lack the facilities and the economic means to accurately evaluate and treat this chronic devastating process.  The mortality rate is much higher than in developed nations. The social stigma and the fear related to having this disease are major problems, causing an additional barrier to obtaining proper evaluation and treatment.    The pattern of causes for epilepsy is somewhat different in poorer countries.  Birth injuries with subsequent brain damage are more frequent without adequate care during delivery and in the neonatal period.  The rate of brain injury from accidents is higher and neurosurgical management is often not available.  Untreated epilepsy also increases the risk of subsequent seizures and also brain damage.     A major problem, causing up to 30% of epilepsy in Latin America, is neural cysticercosis.   Larval cysts of the pork tapeworm, Taenia solium, form in the brain, resulting in a focus for chronic seizures.  Treatment of epilepsy at times may be a complex process, but in the majority of cases the seizures can be well controlled using a variety of drugs.  Phenobarbital is widely available, by far the least expensive, but is a controlled drug in some countries.  Phentoin is approximately twice as expensive as phenobarbital, and it is more difficult to establish the optimal dose without blood levels.  Carbamazine and Valproate are two other commonly available drugs, but are many times more expensive, and beyond the economic reach of most in developing countries.  Of great importance is that any treatment for chronic seizures must be maintained on a chronic basis in adequate doses and monitored regularly in order to be effective.  Health personnel, particularly in rural areas, are not trained for this purpose.  Appropriate drugs are often not regularly available or are too expensive.  Fears and superstition about epilepsy cause further barriers to effective management.  Nothing less than a comprehensive education of both health personnel and patients will solve these difficult problems, but the rewards of successfully managing this devastating crippling disease will be well worth the effort.
Ref: Newton, C.R. Epilepsy in Poor Regions of the World.  Lancet 380: 1193-1201, 2012
Submitted by Roger Boe MD>

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