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African Journal of Neurological Sciences
Pan African Association of Neurological Sciences
ISSN: 1015-8618
Vol. 16, Num. 2, 1997
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Afri
Afri. J. Neuro. Sci. Vol. 16 No. 2 July
1997
THE FEATURES OF EPILEPSY IN THE MALAGASY. A HOSPITAL
STUDY ON 213 CASES FROM THE NORTH WESTERN PART OF MADAGASCAR
Andriantseheno L.M., Andrianasy T.F.
Code Number:NS97007
Department of Neuropsychiatry, University Hospital,
Mahajanga, Madagascar.
SUMMARY
A retrospective study on 213 files of
epileptic patients issued from a sample of 741 referrals to the
University Hospital of Majunga, Neuropsychiatry Unit, between June
1, 1993 December, 31, 1995 was reported.
Mahajanga, the chief-town of the Province is a
hot and dry region where malaria, shistosomiasis, tuberculosis and
syphilis are endemic. As in the majority of tropical series, the
most involved agegroup was between 10 and 30 years; partial
seizures had a higher rate compared to the generalized forms (52%
vs 46%). The most prominent risk factors were linked to parasitosis
(neurocysticercosis), to defective obstetrical cares (perinatal
injuries) and infatile conditions (febrile convulsions). The lack
of neurodiagnosis facilities (EEG, EMG, brain imaging) restrains
notably the aetiological researches. In Madagascar, the compliance
to a long lasting and expensive treatment set a problem (due to the
indigence of the population, and a bad distribution of
antiepileptic drugs).
RESUME
Une etude retrospective des dossiers de 213
epiletiques tires d'une population de 741 malades admis au niveau
d'un service de Neuropsychiatrie de Mahajanga (du 01.06.93 au
31.12.95) a ete rapportee. Cette ville, chef-lieu de la province du
meme nom a un climat et sec ou le paludisme, la bilharziose, la
tuberculose et la syphilis sont endemiques. Comme dans la plupart
des series tropicales, la tranche d'age la plus atteint est celle
comprise entre 10 et 30 ans; les crises partielles predominent sur
les formes g6neralisees (52% vs 46%). Les facteurs de risque les
plus importants sont d'origine parasitaire (neurocysticercose) ou
lies aux conditions obstetricales (souffrances perinatales) et
pediatriques precaires (convulsions febriles).
Le manque d'equipements de neurodiagnostic (EEG,
EMG, imageries cerebrales) limite considerablement les recherches
etiologiques. A Madagascar se pose aussi le probleme de la
compliance a un traitement prolonge et couteux (indigence de la
population, distribution defectueuse des antiepileptiques).
Key words: epidemiology, epilepsy,
Madagascar.
INTRODUCTION:
In a recent Press release (1), the World
Health Organisation (WHO) launched, jointly with two
non-governmental organisations (the International League Against
Epilepsy, ILAE, and the International Bureau for Epilepsy, IBE), a
worldwide campaign against epilepsy. The ILAE represents doctors
and scientists, whereas the Bureau acts for patients and their
families.
According to this influential institution, the
average prevalence of active epilepsy in the general population
(i.e. continuing seizures or needing for treatment) is around 7 per
1,000 inhabitants (Fact Sheet/WHO no. 165, June 1997).
The burden of epilepsy is considerable: a
study from UK has estimated the cost of active epilepsy per patient
at
£4167 per annum, that of inactive epilepsy at
£1630 per annum (Fact Sheet/WHO no 166, June 1997). If indirect cost was added, the expenditure
would be far larger.
In developing countries, where the
prevalence rate is twice-fold higher (10-15 per 1,000 inhabitants)
than in developed countries [2], epidemiological data are
insufficient or of uneven interest.
Anyhow, three-quarters of the affected people
(up to 30 millions, 90% of whom are in developing
MATERIALS AND METHODS:
The study took place in the only Department
of Neurospsychiatry, expected to serve the whole province of
Mahajanga (1,379,000 inhabitants). In fact, geographical isolation
(seasonal roads), economic restraints, preference for traditional
healers and sometimes pure fatalism, limited the access of the
Department to the only inhabitants of Mahajanga City and its
nearest surroundings. The province has a dry and hot climate, where
malaria, schistosomiasis, tuberculosis and syphilis are endemic.
The study population (3) was young (44% of the people were less
than 15 years-old, only 3.20% were 65 years-old or more), and had a
low instruction level (table 1).
Table 1 -Comparative instruction level of
patients versus that of the general population.
Instruction level of
patients |
Epileptic patients
N=213 |
General population
n=1,379000 |
|
Number of cases |
Percentage% |
Percentage% |
Illiterate & Primary school at
the best |
119 |
56 |
84.90 |
Secondary school &High
School |
94 |
44 |
15.1 |
Ethnical groups distribution is plotted
on table 2. Certain ethnics (Comorois, Sakalava...) have a strong
Islamic influence.
Table 2 - Comparative distribution of
different ethnical groups (in %), between epileptic patients and
the population of MAHAJANGA City
Ethnical Groups |
Epileptic patients |
Population of Mahajanga City |
|
Number of cases |
Percentage |
Percentage |
Merina |
85 |
40.00 |
36.10 |
Betsi leo |
3 0 |
14.00 |
16.10 |
Antaisaka |
27 |
12.50 |
12.50 |
Tsimihety |
27 |
12.50 |
13.90 |
Sakalava |
15 |
7.00 |
9.60 |
Other groups |
29 |
13.00 |
11.00 |
The study itself consisted in a retrospective
review of patients' files. Neurological patients of 1 year old or
more, who have been attending the Department, between June 1, 1993
and December 31, 1995, were included.
Basic neurodiagnosis facilities (EEG, EMG, brain
imageries) were lacking, so case ascertainment were set up only
with clinical criteria, routine laboratory exams and therapeutic
tests.
We used the International Classification of
seizures, ICES, 1981 version (4) without EEG data, recognised by
some authorities (5).
Term definitions were extracted from the
guidelines of the ILAE (5)]: febrile seizures, single or isolate
seizures were thus excluded.
RESULTS:
The epilepsies (n=213) represented 28.75% of all new
neurological referrals (n=741 ) for the period (table 3).
Table 3 - Aetiological repartition of
neurological referrals (in percentage) during the study
period.
Nature of the disease |
Number |
Rate (%) |
Total |
n=741 |
100.00 |
Epilepsies |
213 |
28.75 |
Chronic headaches |
155 |
20.95 |
Peripheral neuropathies |
102 |
13.75 |
Cerebrolvascular diseases |
83 |
11.30 |
Infections of the CNS |
69 |
9.35 |
Cerebral palsy |
42 |
5.60 |
Degenerative diseases |
26 |
3.50 |
Tumoral syndromes of the CNS |
24 |
3.20 |
Sleep disorders |
6 |
0.80 |
Traumatic brain injuries |
3 |
0.40 |
Myopathies |
3 |
2.00 |
Unclassifiable disorders |
15 |
2.00 |
It was possible to classify 98%
(208/213) of the seizures (table 4).
Table 4 - Comparative patterns of epilepsies
between series from developed countries
Seizure types |
Present series |
Indian series |
Nigerian series |
Caucasianseries |
Number of cases |
Percentage |
(11%) |
(10%) |
(13%) |
Total |
213 |
100.00 |
100.00 |
100.00 |
100.00 |
Unclassifiable seizures |
5 |
2.00 |
19.00 |
3.00 |
24.00 |
Classifiable seizures |
208 |
98.00 |
81.00 |
97.00 |
76.00 |
Generalised seizures |
97 |
46.00 |
20.00 |
23.40 |
38.00 |
Tonic clonic |
89 |
42.00 |
9.80 |
- |
- |
(Grand Mal) Absence |
2 |
1.00 |
3.00 |
1.2 0 |
10. 00 |
(Petit Mal) Myoclonic |
2 |
1.00 |
2.00 |
0.98 |
4.00 |
Others |
- |
- |
- |
- |
- |
Partial seizures |
111 |
52.00 |
80.00 |
76.60 |
62.00 |
Simple |
42 |
20.00 |
58.00 |
25.40 |
10.00 |
Complex |
10 |
4.50 |
7.00 |
34.00 |
40.00 |
Secondarily generalised |
59 |
27.50 |
15.00 |
17.20 |
12.00 |
The mean age of the patients
was 23.96 years with a dispersion varying between 1 year and 73
years. More than 1 patient out of 2 were less than 20 years-old
(table 5).
Table 5- - Age distribution of
epilepticpatients (in percentage)
Age (years) |
Number of cases |
Percentage(%) |
0-9 |
46 |
22 |
10-19 |
64 |
30 |
20-29 |
54 |
25 |
30-39 |
26 |
12 |
40-49 |
15 |
7 |
+50 |
8 |
4 |
Assumed secondary epilepsies supervened
significally later than primary ones Mean age of occurrence
respectively 30.56 years and 17.36 years).
There was male predominance (sex
ratio=127/86=1.48).
Certain ethnical groups (Merina, Betsileo) were
over represented (table 1 ). Forty two per cent (42%) of the
patients (90/213) were students, 36% were unemployed (77/213).
Farmers represented only 6,8% of care-attenders
( 14/213); it confirms the preferential recruitment of urban city
dwellers. Epileptic patients had a significantly higher level of
instruction, compared to the general population (table 1).
Eighty per cent (80%) of cases (170/213) had at
least one crisis per year. Partial seizures accounted for 52% of
cases (111/213); among them, the simple type was prevalent (table
4).
Forty four per cent (44%) of the epilepsies (93/
213) were deemed as primary. Among the 120 remaining cases, 55
were cryptogenic, whereas 65 had an imputable cause among which
neurocysticercosis was the most frequent (table 6).
Sixteen per cent (165%) of the patients (34/213)
had a previous history of febrile convulsion, 13% of them (28/213)
had a minor or specific cerebral dsyfunctions and 5.5% (12/213) had
a mental retardation.
The physician rarely witnessed an attack, so the
clinical disgnosis of epilepsy was essentially anamnestic.
In regard to << Grand Mal >> seizure, ten
criteria were used to identify it in rural area surveys in Africa,
Asia, and South America (6).
The basic sign was the loss of consciousness for
1 to 30 mn:, only 15% of our crisis attenders were able to give the
right duration of the seizures.
The second major criteria was the sequence of a
tonic, then a clonic phase of movements: here again, only 25% of
witnesses could describe it accurately. We find it more informative
to make people mimick crisis.
Foaming at the mouth was reported in 80% of
cases, but it was also observed in some hysterical attacks.
Lateral tongue biting (57%), sphincter
disturbances (47%) and fall stigma (40%) are more specific but in
our observations they were not very sensitive.
Phenobarbital (PB) was prescribed in 83.50% of
cases (178 prescriptions out of 213), and was generally well
tolerated (in 85% of patients).
Carbamazepine (7.50% of prescriptions) exposed
to further treatment-gap, because of its high cost and its bad
distribution.
The effect of the treatment was good; 55% of the
patients (118/213) had 50% of their seizures controlled; yet, long
term follow-up was uncertain.
Table 6 - Likely aetiologies of secondary
epilepsies, referred to partial and all types of seizures.
Assumed aetiologies |
Number of cases |
Percentage, referred to partial seizures
(n=111) |
Percentage referred to all types of seizures
(n=213) |
Neurocysticercosis |
27 |
24.32% |
12.67 |
Perinatal brain insults |
20 |
18.00% |
9.38 |
Traumatic brain injuries |
7 |
6.30% |
3.28 |
Miscellaneous encephalopathies |
6 |
5.40% |
2.82 |
Alcoholism |
4 |
3.60% |
1.87 |
Phakomatosis |
1 |
0.90% |
0.46 |
DISCUSSION:
Our hospital-based study is not designed to
assess morbidity rates (incidence, prevalence), because of
selection biases.
Moreover, they are not representative of all the
Malagasy population, which is made of slightly different cultural
and ecosystemic subunits.
In spite of these drawbacks, the first rank
occupied by epilepsies among our neurological referrals, indirectly
emphasizes their importance for the Public Health.
Like in most of the studies from developing
countries (6,7,8), epilepsies involve younger peoples; in
industrialized countries, they display a bimodal distribution
(9).
Our 0-9 years-old class is surely underrated
because of parallel recruitment in Paediatry. As in the majority of
series, there is male predominance. Neither sex, nor ethnic factors
have any influence; the apparent overrepresentation of certain
ethnics (Merina, Betsileo) results of the cumulative effect of
their numerical superiority in the general population and their
preference for medical resources.
The distribution pattern of patients' profession
and their academic level can be explained by socioeconomical
factors: recruitment of underprivileged people (students,
unemployed persons) in public health informations, low hospital
frequentation of country-people for different reasons
aforementioned.
The characteristics of epilepsies are similar to
those described in most tropical seizures, and the underevaluation
of << Petit Mal >>. European data display a far
higher rate for this latter (13).
In the absence of sophisticated investigations,
the careful research of focal neurological symptoms is helpful to
diagnose focal crisis secondarily generalized. (table 3).
The features of partial seizures vary according
to the prevailing risk factor: Nigerian searchers report a higher
rate of complex partial seizures (10), which they associate with a
past history of febrile convulsions; recent findings support this
assumption (14).
Contrariwise, simple partial seizures are
predominant in Indian series (11 ), where head injuries and CNS
infections (including neurocysticercosis) are the main risk
factors. Our pattem is closer to the Indian type, and
neurocysticercosis is the first aetiology disclosed, however the
Islamic influence on behaviours (prohibition of pork consumption)
mitigate the importance of this parasitosis in Mahajanga City:
12.67% of cases (table 6) versus 51% from Ecuador (15), 6% of
pathologic specimen vs 40% in Antananarivo (16), were pork
consumption is larger.
Cautious anamnesis and examination are
fundamental for epilepsy diagnosis in the absence of instrumental
investigations. Population knowledge, local representation, beliefs
and attitudes toward the disease must be taken in account to gather
relevant informations.
Bad compliance remains a thorny problem for the
long term treatment of epilepsy in the Third World. Drug
unavailability and expensiveness, lack of inadequacy of
informations, and illiteracy are the main contributors to this
drawback.
The worse outcome of our cases compared to that
of some comprehensive studies supports these conclusions: 55.40% of
good results versus 78% for Feski's (17).
CONCLUSION:
The global campaign launched by the WHO against epilepsy,
expresses the importance of this disease. This stigmatizing illness
constitute a real Public Health problem for the Third World.
Madagascar, globally shares the same lack of
facilities and the same patterns of the disease as other poor
tropical countries.
The high rate of partial seizures results from
avoidable causes such as, febrile convulsions, perinatal and
infectious brain insults.
Struggle against known risk factors, education
and sensitization of the both the population and the primary
caredeliverers, endowment of essential drugs, are the best options
recommended to face this disease, in developing countries.
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Copyright 1995 Pan African Association of Neurological
Sciences
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