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”,
ReviewEpidemiology, causes, and treatment of epilepsy in sub-Saharan Africa
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
References (162)
- et al.
Epidemiology and aetiology of epilepsy in sub-Saharan Africa
Lancet Neurol
(2005) - et al.
Social–cultural aspects of epilepsy in Kilimanjaro Region, Tanzania: Knowledge and experience among patients and carers
Epilepsy Behav
(2011) Impact of stigma on the quality of life of patients with refractory epilepsy
Seizure
(2013)- et al.
Global and regional mortality from 235 causes of death for 20 age groups in 1990 and 2010: a systematic analysis for the Global Burden of Disease Study 2010
Lancet
(2012) - et al.
Disability-adjusted life years (DALYs) for 291 diseases and injuries in 21 regions, 1990-2010: a systematic analysis for the Global Burden of Disease Study 2010
Lancet
(2012) - et al.
Common values in assessing health outcomes from disease and injury: disability weights measurement study for the Global Burden of Disease Study 2010
Lancet
(2012) - et al.
Co-morbidity of epilepsy in Tanzanian children: a community-based case-control study
Seizure J Br Epilepsy Assoc
(2012) - et al.
Years lived with disability (YLDs) for 1160 sequelae of 289 diseases and injuries 1990-2010: a systematic analysis for the Global Burden of Disease Study 2010
Lancet
(2012) - et al.
Prevalence of active convulsive epilepsy in sub-Saharan Africa and associated risk factors: cross-sectional and case-control studies
Lancet Neurol
(2013) - et al.
Nodding syndrome in northern Uganda: overview and community perspectives
Epilepsy Behav EB
(2013)
High incidence of epilepsy related to onchocerciasis in West Uganda
Epilepsy Res
Prevalence, incidence and risk factors of epilepsy in older children in rural Kenya
Seizure
Prevalence of epilepsy in the 15 years and older in Benin: a door-to-door nationwide survey
Epilepsy Res
L'épilepsie en milieu professionnel urbain au Sud-Bénin
Arch Mal Prof Environ
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
The prevalence of epilepsy in the Zay Society, Ethiopia—an area of high prevalence
Seizure
High prevalence of epilepsy in a village in the Littoral Province of Cameroon
Epilepsy Res
Active convulsive epilepsy in a rural district of Kenya: a study of prevalence and possible risk factors
Lancet Neurol
Prevalence of active epilepsy in rural Tanzania: a large community-based survey in an adult population
Seizure J Br Epilepsy Assoc
Epilepsy in poor regions of the world
Lancet
Mortality from epilepsy in an onchocerciasis-endemic area in West Uganda
Trans R Soc Trop Med Hyg
Electroencephalograms (EEG) in 250 patients with epilepsy in a cysticercosis endemic area in Burundi
Neurophysiol Clin
Clinical and electroencephalographic characteristics of epilepsy in rural Ethiopia: a community-based study
Epilepsy Res
A comprehensive community epilepsy programme: The Nakuru project
Epilepsy Res
The global campaign against epilepsy in Africa
Acta Trop
Epileptic seizures and epilepsy: definitions proposed by the International League Against Epilepsy (ILAE) and the International Bureau for Epilepsy (IBE)
Epilepsia
Guidelines for Epidemiologic Studies on Epilepsy
Epilepsia
Estimation of the burden of active and life-time epilepsy: a meta-analytic approach
Epilepsia
Behavioural comorbidity in Tanzanian children with epilepsy: a community-based case-control study
Dev Med Child Neurol
Acute seizures attributable to falciparum malaria in an endemic area on the Kenyan coast
Brain
Understanding the differences in prevalence of epilepsy in tropical regions
Epilepsia
Case-control studies on the relationship between onchocerciasis and epilepsy: systematic review and meta-analysis
PLoS Negl Trop Dis
Neurocysticercosis in sub-Saharan Africa: a review of prevalence, clinical characteristics, diagnosis, and management
Pathog Glob Health
Toxocariasis and epilepsy: systematic review and meta-analysis
PLoS Negl Trop Dis
Incidence of epilepsy: a systematic review and meta-analysis
Neurology
Incidence of epilepsy in rural central Ethiopia
Epilepsia
Epidemiology of epilepsy in rural Benin: prevalence, incidence, mortality, and follow-up
Epilepsia
Prevalence and incidence of epilepsy in Ulanga, a rural Tanzanian district: a community-based study
Epilepsia
Prevalence, incidence, and clinical characteristics of epilepsy–a community-based door-to-door study in northern Tanzania
Epilepsia
Epidemiology of epilepsy in Burkina Faso
Neurol Trop
Incidence of convulsive epilepsy in a rural area in Kenya
Epilepsia
The prevalence of epilepsy among a rural Kenyan population: its association with premature mortality
Trop Geogr Med
The treatment gap and primary health care for people with epilepsy in rural Gambia
Bull World Health Organ
Prevalence of the epilepsies in Nigerian Africans: a community-based study
Epilepsia
Prevalence of neurological disorders in Udo, a rural community in southern Nigeria
Trop Geogr Med
Prevalence of epilepsy in Rwanda: A national cross-sectional survey
Trop Med Int Health
Epilepsy in rural South African children—prevalence, associated disability and management
South Afr Med J Suid-Afr Tydskr Vir Geneeskd
Prevalence of active epilepsy in a rural area in south Tanzania: a door-to-door survey
Epilepsia
Prévalence de l'épilepsie en milieu rural ivoirien: étude pilote
Pub Méd Afr
Epilepsy in schools in Cotonou (Benin). Epilepsie en Milieu Scolaire a Cotonou (Benin) (English)
Afr J Neurol Sci
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