Fredrick Ibinda

Risk factors associated with the epilepsy treatment gap in Kilifi, Kenya: a cross-sectional study

Summary Background Many people with epilepsy in low-income countries do not receive appropriate biomedical treatment. This epilepsy treatment gap might be caused by patients not seeking biomedical treatment or not adhering to prescribed antiepileptic drugs (AEDs). We measured the prevalence of and investigated risk factors for the epilepsy treatment gap in rural Kenya. Methods All people with active convulsive epilepsy identified during a cross-sectional survey of 232 176 people in Kilifi were approached. The epilepsy treatment gap was defined as the percentage of people with active epilepsy who had not accessed biomedical services or who were not on treatment or were on inadequate treatment. Information about risk factors was obtained through a questionnaire-based interview of sociodemographic characteristics, socioeconomic status, access to health facilities, seizures, stigma, and beliefs and attitudes about epilepsy. The factors associated with people not seeking biomedical treatment and not adhering to AEDs were investigated separately, adjusted for age. Findings 673 people with epilepsy were interviewed, of whom 499 (74%) reported seeking treatment from a health facility. Blood samples were taken from 502 (75%) people, of whom 132 (26%) reported taking AEDs, but 189 (38%) had AEDs detectable in the blood. The sensitivity and specificity of self-reported adherence compared with AEDs detected in blood were 38·1% (95% CI 31·1–45·4) and 80·8% (76·0–85·0). The epilepsy treatment gap was 62·4% (58·1–66·6). In multivariable analysis, failure to seek biomedical treatment was associated with a patient holding traditional animistic religious beliefs (adjusted odds ratio 1·85, 95% CI 1·11–2·71), reporting negative attitudes about biomedical treatment (0·86, 0·78–0·95), living more than 30 km from health facilities (3·89, 1·77–8·51), paying for AEDs (2·99, 1·82–4·92), having learning difficulties (2·30, 1·29–4·11), having had epilepsy for longer than 10 years (4·60, 2·07–10·23), and having focal seizures (2·28, 1·50–3·47). Reduced adherence was associated with negative attitudes about epilepsy (1·10, 1·03–1·18) and taking of AEDs for longer than 5 years (3·78, 1·79–7·98). Interpretation The sensitivity and specificity of self-reported adherence is poor, but on the basis of AED detection in blood almost two-thirds of patients with epilepsy were not on treatment. Education about epilepsy and making AEDs freely available in health facilities near people with epilepsy should be investigated as potential ways to reduce the epilepsy treatment gap. Funding Wellcome Trust.

Evaluation of Kilifi Epilepsy Education Programme: A randomized controlled trial

The epilepsy treatment gap is largest in resource‐poor countries. We evaluated the efficacy of a 1‐day health education program in a rural area of Kenya. The primary outcome was adherence to antiepileptic drugs (AEDs) as measured by drug levels in the blood, and the secondary outcomes were seizure frequency and Kilifi Epilepsy Beliefs and Attitudes Scores (KEBAS).

Incidence, remission and mortality of convulsive epilepsy in rural northeast South Africa

Background Epilepsy is one of the most common neurological conditions globally, estimated to constitute 0.75% of the global burden of disease, with the majority of this burden found in low- and middle- income countries (LMICs). Few studies from LMICs, including much of sub-Saharan Africa, have described the incidence, remission or mortality rates due to epilepsy, which are needed to quantify the burden and inform policy. This study investigates the epidemiological parameters of convulsive epilepsy within a context of high HIV prevalence and an emerging burden of cardiovascular disease. Methods A cross-sectional population survey of 82,818 individuals, in the Agincourt Health and Socio-demographic Surveillance Site (HDSS) in rural northeast South Africa was conducted in 2008, from which 296 people were identified with active convulsive epilepsy. A follow-up survey was conducted in 2012. Incidence and mortality rates were estimated, with duration and remission rates calculated using the DISMOD II software package. Results The crude incidence for convulsive epilepsy was 17.4/100,000 per year (95%CI: 13.1-23.0). Remission was 4.6% and 3.9% per year for males and females, respectively. The standardized mortality ratio was 2.6 (95%CI: 1.7-3.5), with 33.3% of deaths directly related to epilepsy. Mortality was higher in men than women (adjusted rate ratio (aRR) 2.6 (95%CI: 1.2-5.4)), and was significantly associated with older ages (50+ years versus those 0-5 years old (RR 4.8 (95%CI: 0.6-36.4)). Conclusions The crude incidence was lower whilst mortality rates were similar to other African studies; however, this study found higher mortality amongst older males. Efforts aimed at further understanding what causes epilepsy in older people and developing interventions to reduce prolonged seizures are likely to reduce the overall burden of ACE in rural South Africa.

Burden, causes, and outcomes of people with epilepsy admitted to a rural hospital in Kenya

People with epilepsy (PWE) develop complications and comorbidities often requiring admission to hospital, which adds to the burden on the health system, particularly in low‐income countries. We determined the incidence, disability‐adjusted life years (DALYs), risk factors, and causes of admissions in PWE. We also examined the predictors of prolonged hospital stay and death using data from linked clinical and demographic surveillance system.

Burden of epilepsy in rural Kenya measured in disability-adjusted life years

The burden of epilepsy, in terms of both morbidity and mortality, is likely to vary depending on the etiology (primary [genetic/unknown] vs. secondary [structural/metabolic]) and with the use of antiepileptic drugs (AEDs). We estimated the disability‐adjusted life years (DALYs) and modeled the remission rates of active convulsive epilepsy (ACE) using epidemiologic data collected over the last decade in rural Kilifi, Kenya.

Differing Methods and Definitions Influence DALY estimates: Using Population-Based Data to Calculate the Burden of Convulsive Epilepsy in Rural South Africa

Background The disability adjusted life year (DALY) is a composite measure of disease burden that includes both morbidity and mortality, and is relevant to conditions such as epilepsy that can limit productive functioning. The 2010 Global Burden of Disease (GBD) study introduced a number of new methods and definitions, including a prevalence-based approach and revised disability weights to calculate morbidity and new standard life expectancies to calculate premature mortality. We used these approaches, and local, population-based data, to estimate the burden of convulsive epilepsy in rural South Africa. Methods & Findings Comprehensive prevalence, incidence and mortality data on convulsive epilepsy were collected within the Agincourt sub-district in rural northeastern South Africa between 2008 and 2012. We estimated DALYs using both prevalence- and incidence-based approaches for calculating years of life lived with disability. Additionally, we explored how changing the disease model by varying the disability weights influenced DALY estimates. Using the prevalence-based approach, convulsive epilepsy in Agincourt resulted in 332 DALYs (95% uncertainty interval (UI): 216–455) and 4.1 DALYs per 1,000 individuals (95%UI: 2.7–5.7) annually. Of this, 26% was due to morbidity while 74% was due to premature mortality. DALYs increased by 10% when using the incidence-based method. Varying the disability weight from 0.072 (treated epilepsy, seizure free) to 0.657 (severe epilepsy) caused years lived with disability to increase from 18 (95%UI: 16–19) to 161 (95%UI: 143–170). Conclusions DALY estimates are influenced by both the methods applied and population parameters used in the calculation. Irrespective of method, a significant burden of epilepsy is due to premature mortality in rural South Africa, with a lower burden than rural Kenya. Researchers and national policymakers should carefully interrogate the methods and data used to calculate DALYs as this will influence policy priorities and resource allocation.

Incidence and risk factors for neonatal tetanus in admissions to Kilifi County Hospital, Kenya.

Background Neonatal Tetanus (NT) is a preventable cause of mortality and neurological sequelae that occurs at higher incidence in resource-poor countries, presumably because of low maternal immunisation rates and unhygienic cord care practices. We aimed to determine changes in the incidence of NT, characterize and investigate the associated risk factors and mortality in a prospective cohort study including all admissions over a 15-year period at a County hospital on the Kenyan coast, a region with relatively high historical NT rates within Kenya. Methods We assessed all neonatal admissions to Kilifi County Hospital in Kenya (1999–2013) and identified cases of NT (standard clinical case definition) admitted during this time. Poisson regression was used to examine change in incidence of NT using accurate denominator data from an area of active demographic surveillance. Logistic regression was used to investigate the risk factors for NT and factors associated with mortality in NT amongst neonatal admissions. A subset of sera from mothers (n = 61) and neonates (n = 47) were tested for anti-tetanus antibodies. Results There were 191 NT admissions, of whom 187 (98%) were home deliveries. Incidence of NT declined significantly (Incidence Rate Ratio: 0.85 (95% Confidence interval 0.81–0.89), P<0.001) but the case fatality (62%) did not change over the study period (P = 0.536). Younger infant age at admission (P = 0.001) was the only independent predictor of mortality. Compared to neonatal hospital admittee controls, the proportion of home births was higher among the cases. Sera tested for antitetanus antibodies showed most mothers (50/61, 82%) had undetectable levels of antitetanus antibodies, and most (8/9, 89%) mothers with detectable antibodies had a neonate without protective levels. Conclusions Incidence of NT in Kilifi County has significantly reduced, with reductions following immunisation campaigns. Our results suggest immunisation efforts are effective if sustained and efforts should continue to expand coverage.

Magnitude and factors associated with nonadherence to antiepileptic drug treatment in Africa: A cross-sectional multisite study

The epilepsy treatment gap is large in low‐ and middle‐income countries, but the reasons behind nonadherence to treatment with antiepileptic drugs (AEDs) across African countries remain unclear. We investigated the extent to which AEDs are not taken and associated factors in people with active convulsive epilepsy (ACE) identified in cross‐sectional studies conducted in five African countries.

Sodium Disturbances in Children Admitted to a Kenyan Hospital: Magnitude, Outcome and Associated Factors.

Background Perturbations of blood sodium are the most frequently encountered electrolyte disorder in sick children, and may influence fluid therapy. We examined the frequency of blood sodium perturbations, and factors and outcomes associated with hyponatremia in children admitted to a rural Kenyan hospital and investigated the risk factors associated with deaths in hyponatremic children. Methods Plasma sodium levels and other laboratory parameters were measured in children admitted to a rural Kenyan hospital. Clinical measurements were collected using standard forms and entered into a computer database. The proportion of children admitted with hyponatremia was determined. Logistic regression models were used to investigate factors associated with hyponatremia, and death in those with hyponatremia. Results Abnormal plasma sodium occurred in 46.6% (95% confidence interval (95%CI) 43.5–49.6%) of 1026 pediatric admissions. Hyponatremia occurred in 44.4% (95%CI 41.4–47.5%) and hypernatremia in 2.1% (95%CI 1.3–3.0%). Malaria (40.8%) was the most common underlying primary diagnosis in hyponatremic children. Malaria, hyperglycemia, wasting, high creatinine levels and preserved consciousness were associated with hyponatremia. Pallor and seizures were associated with increased mortality in hyponatremic children. Conclusions Sodium disturbances are common in pediatric admissions to a County hospital in rural Kenya. Seizures and pallor were predictors of mortality in hyponatremic children.

G269 Neuro-developmental sequelae of severe neonatal infections in rural Kenya

Introduction Serious neonatal infections including pneumonia, sepsis and meningitis account for a third of neonatal deaths around the world. However data on neuro-cognitive impairment after neonatal infection, particularly following clinical diagnosis of possible serious bacterial infection (pSBI) used to guide empiric treatment are lacking. Methodology This prospective study included 102/196 children born in a rural hospital in Kenya who survived neonatal pSBI (excluding those with confirmed meningitis) and 94/196 well neonates born in the same hospital. Children had neurodevelopmental assessments (incl. vision, hearing, motor) at between 18 to 36 months. A culturally appropriate neurodevelopmental assessment tool, Kilifi developmental inventory (KDI) was utilised in this study. Risks and differences in impairment were assessed using multivariable logistic and linear regressions respectively, adjusting for age, birth weight, gestational age, clinical diagnosis of HIE and bacteraemia. Results The children who had neonatal pSBI had a higher risk of developing neurodevelopmental impairment (18/102(17.6%) vs 5/94 (5.3%); Odds Ratio (OR) 1.78, 95%confidence interval (CI) 1.60–1.99) compared to those without pSBI. Speech and language (13/102 (12.7%) vs 3/94 (3.2%); OR 1.41, 95% CI 1.29–1.56) and neuro-motor domains (11/102 (10.8%) vs 4/94 (4.3%); OR 1.38, 95% CI 1.22–1.58) were most commonly affected domains. Psychomotor scores from KDI tool were also significantly higher for those unexposed to pSBI for total scores compared to those exposed. Conclusion Neonatal pSBI (excluding cases of confirmed meningitis) caused significant neurodevelopmental impairment in children after adjusting for confirmed bacteraemia. This has important implications for improving prevention, supporting effective neonatal care and managing the long-term consequences of neonatal infection in resource-poor settings.