Elsevier

The Lancet Neurology

Volume 13, Issue 10, October 2014, Pages 1029-1044
The Lancet Neurology

Review
Epidemiology, causes, and treatment of epilepsy in sub-Saharan Africa

https://doi.org/10.1016/S1474-4422(14)70114-0Get rights and content

Summary

Epilepsy is a common neurological disease in tropical countries, particularly in sub-Saharan Africa. Previous work on epilepsy in sub-Saharan Africa has shown that many cases are severe, partly a result of some specific causes, that it carries a stigma, and that it is not adequately treated in many cases. Many studies on the epidemiology, aetiology, and management of epilepsy in sub-Saharan Africa have been reported in the past 10 years. The prevalence estimated from door-to-door studies is almost double that in Asia, Europe, and North America. The most commonly implicated risk factors are birth trauma, CNS infections, and traumatic brain injury. About 60% of patients with epilepsy receive no antiepileptic treatment, largely for economic and social reasons. Further epidemiological studies should be a priority to improve understanding of possible risk factors and thereby the prevention of epilepsy in Africa, and action should be taken to improve access to treatment.

Introduction

Epilepsy is a major public health problem: it is common and can have serious physical and psychological consequences, including premature death, traumatic injury, and mental health disorders.1 Epilepsy was defined by the International League Against Epilepsy in 1993 as a condition characterised by recurrent seizures, at least two unprovoked, occurring in a period of more than 24 h.2 The prevalence of epilepsy is higher in less developed than in more developed countries.3, 4

The stigma of epilepsy can be profound because it is widely thought to be contagious and associated with witchcraft or evil spirits.5, 6 In Tanzanian and Kenyan studies,7, 8 disturbed behaviour was significantly more common in children with active epilepsy than in those without the disorder (66 vs 19%; odds ratio [OR] 8·2, 95% CI 4·3–15·6; p<0·001), and children with active epilepsy had more behavioural problems than did those with inactive epilepsy (49% vs 26%; OR 7·86, 95% CI 1·23–50·06; p=0·029).7, 8 The Global Burden of Diseases, Injuries, and Risk Factors Study 2010 found that the burden resulting from epilepsy is very high; only one other disorder (HIV infection) had greater disability weight than uncontrolled, severe epilepsy.9, 10, 11 Comorbidities greatly affect children with epilepsy in terms of quality of life, and life chances are reduced for adults with epilepsy in terms of employment and marriage.12 Left untreated, people with epilepsy face devastating social consequences, including stigma and discrimination, and premature mortality.13

Although effective antiepileptic drugs are available, a substantial treatment gap is evident in developing countries, because human and financial resources for diagnosis and treatment are limited and misconceptions and stigma surround the disorder.4

In 2005, Preux and Druet-Cabanac published a Review3 of studies on the epidemiology and aetiology of epilepsy in sub-Saharan Africa, which highlighted the paucity of studies in Africa. Since then, many studies have been published, particularly a major comparison of clinical features across continents14 and a large multisite epidemiological study (figure 1).15 New insights have been gained into the association between several parasitic diseases (malaria, onchocerciasis, cysticercosis, toxocariasis) and epilepsy,16, 17, 18 and epileptic syndrome (nodding disease) has re-emerged.19 Thus, an update of understanding of the epidemiology, aetiology, and management of epilepsy in sub-Saharan Africa is timely, to provide an overview of the situation now. We have not reviewed publications on stigma, comorbidities, consequences such as burns, or the role of traditional healers in the management of epilepsy in sub-Saharan Africa.

Section snippets

Incidence

Few studies on the incidence of epilepsy in sub-Saharan Africa have been published, but the overall information suggests a high annual incidence of epilepsy in less developed countries of 81·7 per 100 000 (95% CI 28·0–239·5) compared with 45·0 per 100 000 (30·3–66·7) in more developed countries.20 We identified only eight studies estimating the incidence of epilepsy in sub-Saharan Africa, including four done after 2005 (table 1).21, 22, 23, 24, 25, 26, 27, 28 These studies cannot be directly

Prevalence

The prevalence of epilepsy in sub-Saharan Africa15, 23, 24, 25, 27, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61, 62, 63, 64, 65, 66 varied both between and within countries (table 2). The variation could result from the heterogeneity of the methods used, which could result from differences in the definitions of epilepsy used,1, 2 the nature of the epilepsy studied (lifetime or active), the sample population

Sociodemographic characteristics

According to a WHO report,75 the incidence of epilepsy in more developed countries is highest in the age-group 30–50 years. By contrast, in less developed countries, especially in sub-Saharan Africa, more than 90% of people with epilepsy are younger than 20 years (table 2).23, 25, 32, 36, 37, 41, 46, 54, 60 Of these patients, on average, the first seizure occurred before the age of 10 years in 35% and before the age of 20 years in 50% (table 4).

Most studies of epilepsy in more developed

Type of seizure

Only a few study reports describe the distribution of types of seizure. Furthermore, comparison of results from different studies is difficult because of the heterogeneity of classifications used. We have summarised only studies based on the general population (table 6). Screening methods for epilepsy in sub-Saharan Africa, especially in rural areas, cannot generally detect all simple partial seizures or absence seizures. The lack of neurologists and electroencephalographic facilities means

Causes and risk factors

The main risk factors for epilepsy in sub-Saharan Africa are family history of seizures, previous febrile seizures, perinatal trauma, head injury and CNS infections such as neurocysticercosis (table 7). However, there is little evidence from Africa on the association between risk factors and disease. The few case-control or cohort studies we identified are shown in table 8.43, 79, 80, 84, 86, 87, 88, 89, 90, 91

Treatment

The management of epilepsy involves identification of the cause, administration of antiepileptic drugs to control seizures, and the prevention and treatment of the comorbidity. Epilepsy surgery is rarely available in sub-Saharan Africa. Early and appropriate care in more developed countries achieves seizure control in 70–80% of cases.142

The treatment gap is defined as the difference between the number of people with active epilepsy and the number whose seizures are treated appropriately in a

Conclusion

Since the 2005 Review by Preux and Druet-Cabanac,3 several valid epidemiological studies have been carried out in sub-Saharan Africa. However, even now insufficient evidence is available on the incidence and mortality of epilepsy in the region. The use of different methods and variations in sample size and populations studied make the comparison of studies and drawing of robust conclusions very difficult. We have applied random-effects models to take into account this heterogeneity in a

Search strategy and selection criteria

We searched eight electronic databases: PubMed, African Index Medicus, Scopus, Science Direct, African Journal of Neurological Sciences, African Journal Online, the African Virtual Library of Neurology, and the Sudoc Catalog of PhD Theses. The search was done without date limitation, for all 48 countries that make up sub-Saharan Africa, with the keyword “epilepsy”, combined with each of the following: “epidemiology”, “prevalence”, “incidence”, “aetiology”, “cohort”, “case-control”, “seizure”,

References (162)

  • C Kaiser et al.

    High incidence of epilepsy related to onchocerciasis in West Uganda

    Epilepsy Res

    (1998)
  • V Mung'ala-Odera et al.

    Prevalence, incidence and risk factors of epilepsy in older children in rural Kenya

    Seizure

    (2008)
  • L-P Yemadje et al.

    Prevalence of epilepsy in the 15 years and older in Benin: a door-to-door nationwide survey

    Epilepsy Res

    (2012)
  • D Houinato et al.

    L'épilepsie en milieu professionnel urbain au Sud-Bénin

    Arch Mal Prof Environ

    (2007)
  • NF Ndoye et al.

    Prevalence of epilepsy its treatment gap and knowledge, attitude and practice of its population in sub-urban Senegal an ILAE/IBE/WHO study

    Seizure J Br Epilepsy Assoc

    (2005)
  • S Almu et al.

    The prevalence of epilepsy in the Zay Society, Ethiopia—an area of high prevalence

    Seizure

    (2006)
  • F Prischich et al.

    High prevalence of epilepsy in a village in the Littoral Province of Cameroon

    Epilepsy Res

    (2008)
  • T Edwards et al.

    Active convulsive epilepsy in a rural district of Kenya: a study of prevalence and possible risk factors

    Lancet Neurol

    (2008)
  • E Hunter et al.

    Prevalence of active epilepsy in rural Tanzania: a large community-based survey in an adult population

    Seizure J Br Epilepsy Assoc

    (2012)
  • CR Newton et al.

    Epilepsy in poor regions of the world

    Lancet

    (2012)
  • C Kaiser et al.

    Mortality from epilepsy in an onchocerciasis-endemic area in West Uganda

    Trans R Soc Trop Med Hyg

    (2007)
  • M Diagana et al.

    Electroencephalograms (EEG) in 250 patients with epilepsy in a cysticercosis endemic area in Burundi

    Neurophysiol Clin

    (2005)
  • R Tekle-Haimanot et al.

    Clinical and electroencephalographic characteristics of epilepsy in rural Ethiopia: a community-based study

    Epilepsy Res

    (1990)
  • AT Feksi et al.

    A comprehensive community epilepsy programme: The Nakuru project

    Epilepsy Res

    (1991)
  • AG Diop et al.

    The global campaign against epilepsy in Africa

    Acta Trop

    (2003)
  • RS Fisher et al.

    Epileptic seizures and epilepsy: definitions proposed by the International League Against Epilepsy (ILAE) and the International Bureau for Epilepsy (IBE)

    Epilepsia

    (2005)
  • Guidelines for Epidemiologic Studies on Epilepsy

    Epilepsia

    (1993)
  • AK Ngugi et al.

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

    Epilepsia

    (2010)
  • K Burton et al.

    Behavioural comorbidity in Tanzanian children with epilepsy: a community-based case-control study

    Dev Med Child Neurol

    (2011)
  • SM Kariuki et al.

    Acute seizures attributable to falciparum malaria in an endemic area on the Kenyan coast

    Brain

    (2011)
  • L-P Yemadje et al.

    Understanding the differences in prevalence of epilepsy in tropical regions

    Epilepsia

    (2011)
  • C Kaiser et al.

    Case-control studies on the relationship between onchocerciasis and epilepsy: systematic review and meta-analysis

    PLoS Negl Trop Dis

    (2013)
  • AS Winkler

    Neurocysticercosis in sub-Saharan Africa: a review of prevalence, clinical characteristics, diagnosis, and management

    Pathog Glob Health

    (2012)
  • G Quattrocchi et al.

    Toxocariasis and epilepsy: systematic review and meta-analysis

    PLoS Negl Trop Dis

    (2012)
  • AK Ngugi et al.

    Incidence of epilepsy: a systematic review and meta-analysis

    Neurology

    (2011)
  • R Tekle-Haimanot et al.

    Incidence of epilepsy in rural central Ethiopia

    Epilepsia

    (1997)
  • D Houinato et al.

    Epidemiology of epilepsy in rural Benin: prevalence, incidence, mortality, and follow-up

    Epilepsia

    (2013)
  • HT Rwiza et al.

    Prevalence and incidence of epilepsy in Ulanga, a rural Tanzanian district: a community-based study

    Epilepsia

    (1992)
  • AS Winkler et al.

    Prevalence, incidence, and clinical characteristics of epilepsy–a community-based door-to-door study in northern Tanzania

    Epilepsia

    (2009)
  • M Debouverie et al.

    Epidemiology of epilepsy in Burkina Faso

    Neurol Trop

    (1993)
  • AK Ngugi et al.

    Incidence of convulsive epilepsy in a rural area in Kenya

    Epilepsia

    (2013)
  • RW Snow et al.

    The prevalence of epilepsy among a rural Kenyan population: its association with premature mortality

    Trop Geogr Med

    (1994)
  • R Coleman et al.

    The treatment gap and primary health care for people with epilepsy in rural Gambia

    Bull World Health Organ

    (2002)
  • BO Osuntokun et al.

    Prevalence of the epilepsies in Nigerian Africans: a community-based study

    Epilepsia

    (1987)
  • AC Longe et al.

    Prevalence of neurological disorders in Udo, a rural community in southern Nigeria

    Trop Geogr Med

    (1989)
  • V Simms et al.

    Prevalence of epilepsy in Rwanda: A national cross-sectional survey

    Trop Med Int Health

    (2008)
  • AL Christianson et al.

    Epilepsy in rural South African children—prevalence, associated disability and management

    South Afr Med J Suid-Afr Tydskr Vir Geneeskd

    (2000)
  • W Dent et al.

    Prevalence of active epilepsy in a rural area in south Tanzania: a door-to-door survey

    Epilepsia

    (2005)
  • B Kouassi et al.

    Prévalence de l'épilepsie en milieu rural ivoirien: étude pilote

    Pub Méd Afr

    (1988)
  • G Avode Dossou et al.

    Epilepsy in schools in Cotonou (Benin). Epilepsie en Milieu Scolaire a Cotonou (Benin) (English)

    Afr J Neurol Sci

    (2003)
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