Epidemiology of Epilepsy in Nigeria: A Community-Based Study From 3 Sites.

BACKGROUND: We determined the prevalence, incidence, and risk factors for epilepsy in Nigeria. METHODS: We conducted a door-to-door survey to identify cases of epilepsy in 3 regions. We estimated age-standardized prevalence adjusted for nonresponse and sensitivity and the 1-year retrospective incidence for active epilepsy. To assess potential risk factors, we conducted a case-control study by collecting sociodemographic and risk factor data. We estimated odds ratios using logistic regression analysis and corresponding population attributable fractions (PAFs). RESULTS: We screened 42,427 persons (age ≥6 years), of whom 254 had confirmed active epilepsy. The pooled prevalence of active epilepsy per 1,000 was 9.8 (95% confidence interval [CI] 8.6-11.1), 17.7 (14.2-20.6) in Gwandu, 4.8 (3.4-6.6) in Afikpo, and 3.3 (2.0-5.1) in Ijebu-Jesa. The pooled incidence per 100,000 was 101.3 (95% CI 57.9-167.6), 201.2 (105.0-358.9) in Gwandu, 27.6 (3.3-128.0) in Afikpo, and 23.9 (3.2-157.0) in Ijebu-Jesa. Children's significant risk factors included febrile seizures, meningitis, poor perinatal care, open defecation, measles, and family history in first-degree relatives. In adults, head injury, poor perinatal care, febrile seizures, family history in second-degree relatives, and consanguinity were significant. Gwandu had more significant risk factors. The PAF for the important factors in children was 74.0% (71.0%-76.0%) and in adults was 79.0% (75.0%-81.0%). CONCLUSION: This work suggests varied epidemiologic numbers, which may be explained by differences in risk factors and population structure in the different regions. These variations should differentially determine and drive prevention and health care responses.

Translation and validation of an epilepsy-screening questionnaire in three Nigerian languages.

OBJECTIVE: We describe the development, translation and validation of epilepsy-screening questionnaires in the three most popular Nigerian languages: Hausa, Igbo and Yoruba. METHODS: A 9-item epilepsy-screening questionnaire was developed by modifying previously validated English language questionnaires. Separate multilingual experts forward- and back-translated them to the three target languages. Translations were discussed with fieldworkers and community members for ethnolinguistic acceptability and comprehension. We used an unmatched affected-case versus unaffected-control design for the pilot study. Cases were people with epilepsy attending the tertiary hospitals where these languages are spoken. The controls were relatives of cases or people attending for other medical conditions. An affirmative response to any of the nine questions amounted to a positive screen for epilepsy. RESULTS: We recruited 153 (75 cases and 78 controls) people for the Hausa version, 106 (45 cases and 61 controls) for Igbo and 153 (66 cases and 87 controls) for the Yoruba. The sensitivity and specificity of the questionnaire were: Hausa (97.3% and 88.5%), Igbo (91.1% and 88.5%) and Yoruba (93.9% and 86.7%). The three versions reliably indicated epilepsy with positive predictive values of 85.9% (Hausa), 85.4% (Igbo) and 87.3% (Yoruba) and reliably excluded epilepsy with negative predictive values of 97.1% (Hausa), 93.1% (Igbo) and 95.1% (Yoruba). Positive likelihood ratios were all greater than one. CONCLUSIONS: Validated epilepsy screening questionnaires are now available for the three languages to be used for community-based epilepsy survey in Nigeria. The translation and validation process are discussed to facilitate usage and development for other languages in sub-Saharan Africa.

Epilepsy surgery in low- and middle-income countries: A scoping review.

BACKGROUND: Epilepsy surgery is an important treatment option for people with drug-resistant epilepsy. Surgical procedures for epilepsy are underutilized worldwide, but it is far worse in low- and middle-income countries (LMIC), and it is less clear as to what extent people with drug-resistant epilepsy receive such treatment at all. Here, we review the existing evidence for the availability and outcome of epilepsy surgery in LMIC and discuss some challenges and priority. METHODS: We used an accepted six-stage methodological framework for scoping reviews as a guide. We searched PubMed, Embase, Global Health Archives, Index Medicus for South East Asia Region (IMSEAR), Index Medicus for Eastern Mediterranean Region (IMEMR), Latin American & Caribbean Health Sciences Literature (LILACS), African Journal Online (AJOL), and African Index Medicus (AIM) to identify the relevant literature. RESULTS: We retrieved 148 articles on epilepsy surgery from 31 countries representing 22% of the 143 LMIC. Epilepsy surgery appears established in some of these centers in Asia and Latin America while some are in their embryonic stage reporting procedures in a small cohort performed mostly by motivated neurosurgeons. The commonest surgical procedure reported was temporal lobectomies. The postoperative seizure-free rates and quality of life (QOL) are comparable with those in the high-income countries (HIC). Some models have shown that epilepsy surgery can be performed within a resource-limited setting through collaboration with international partners and through the use of information and communications technology (ICT). The cost of surgery is a fraction of what is available in HIC. CONCLUSION: This review has demonstrated the availability of epilepsy surgery in a few LMIC. The information available is inadequate to make any reasonable conclusion of its existence as routine practice. Collaborations with international partners can provide an opportunity to bring high-quality academic training and technological transfer directly to surgeons working in these regions and should be encouraged.

Overall and cause-specific premature mortality in epilepsy: A systematic review.

BACKGROUND: We conducted a systematic review to ascertain the overall mortality and causes of premature mortality in epilepsy. METHODOLOGY: We searched PubMed and Embase to identify relevant articles reporting mortality in epilepsy. An assessment of the methodological quality and overall quality of evidence of the identified studies was done using appropriate checklists. We extracted data from these studies reporting measures of overall and cause-specific mortality in epilepsy. RESULTS: Sixty-three articles from fifty-six cohorts met the eligibility criteria, thirty-three population- or community-based and twenty-three hospital- or institutional-based studies. The majority of studies are from high-income countries (HIC). These studies reported overall excess mortality for people with epilepsy, with wide variability reported for population- or community-based studies and from low- and middle-income countries (LMIC). Twenty-seven articles from twenty-three cohorts reported measures of mortality for cause-specific mortality in epilepsy. People with epilepsy from HIC and LMIC have a higher risk of dying from various causes compared with the general population. Those in LMIC, however, have a particularly high chance of dying from external causes such as drowning and suicide. We observed a decrement over time in measures of overall and cause-specific mortality in cohorts. CONCLUSIONS: Despite the heterogeneity in reports, our findings support the suggestions that people with epilepsy have an increased risk of premature mortality from various causes. Further work is needed to elucidate the mechanisms, to determine biomarkers for predicting those at risk, and to understand the implications of counseling and preventive strategies.

Health service provision for people with epilepsy in sub-Saharan Africa: A situational review.

BACKGROUND: Epilepsy is a public health issue in sub-Saharan Africa (SSA) where many people with the condition receive no treatment. Health-care services for epilepsy in this region have not been comprehensively assessed. We examined key features of epilepsy health services provided in SSA. METHODOLOGY: This was a scoping review conducted using pre-specified protocols. We implemented an electronic search strategy to identify relevant citations using PUBMED, EMBASE, Web of Science, Scopus, Cumulative Index to Nursing and Allied Health Literature (CINAHL), African Index Medicus (AIM), Open Grey, Cochrane database, and Google Scholar. Articles eligible for full-text review were screened and data of interest were reported. RESULT: The search identified 81 eligible articles, forty-nine from East Africa, 19 from West Africa, 8 from South Africa, and 5 from Central Africa. A variety of care services were identified, with reporting of rural epilepsy care in 75% of retrieved articles mainly from East and South African countries. The majority of the rural epilepsy clinics were health worker- or nurse-led, reporting good seizure control in about two-thirds of patients using phenobarbital as the most commonly prescribed antiepileptic drug. Funding for rural epilepsy care came mainly from external donor agencies. CONCLUSION: We attempted to provide a 'snapshot' of epilepsy care services in SSA. The successes achieved in some of the centers are due to the use of existing primary health-care systems and employing non-physician health-care personnel. The true picture of epilepsy care coverage is not apparent due to the lack of data and proper health system structure in most parts of SSA. As more individuals begin to receive care, the long-term funding for epilepsy care in African countries will depend on the commitment of their respective governments.

Prestroke treatment of stroke risk factors: A cross-sectional survey in central Nigeria.

BACKGROUND: Stroke can be prevented with treatments targeted at hypertension, diabetes mellitus, hyperlipidemia and atrial fibrillation, but this is often hampered by under-diagnosis and under-treatment of those risk factors. The magnitude of this problem is not well-studied in sub-Saharan Africa. MATERIALS AND METHODS: We conducted a cross-sectional survey of stroke patients at a tertiary hospital during January 2010 to July 2013 to determine patient awareness of a pre-existing stroke risk factor and prior use of anti-hypertensive, anti-diabetic, antiplatelet and lipid-lowering agents. We also investigated whether gender and school education influenced patient awareness and treatment of a stroke risk factor prior to stroke. RESULTS: Three hundred and sixty nine stroke patients presented during the study period, of which 344 eligible subjects were studied. Mean age at presentation (±SD) was 55.8 ± 13.7 years, and was not different for men and women. Hypertension, hyperlipidemia, diabetes and atrial fibrillation were prevalent among 83.7%, 26.5%, 25.6% and 9.6% patients respectively. Awareness was high for pre-existing diabetes (81.8%) and hypertension (76.7%), but not for hyperlipidemia (26.4%) and atrial fibrillation (15.2%). Men were better educated than women (p = 0.002), and had better awareness for hyperlipidemia (37.3% versus 13.5%; p = 0.009). Men were also more likely to take drug treatments for a stroke risk factor, but the differences were significant. CONCLUSIONS: A high rate of under-diagnosis and under-treatment of hypertension, hyperlipidemia and atrial fibrillation contributes to the stroke burden in sub-Saharan Africa, especially among women. Public health measures including mass media campaigns could help reduce the burden of stroke.