Symon M. Kariuki

Incidence of epilepsy A systematic review and meta-analysis

Objective: To estimate the pooled incidence of epilepsy from published studies and investigate sources of heterogeneity in the estimates. Methods: We searched online databases for incidence studies and used meta-analytic methods to analyze the data. Results: Thirty-three articles met the entry criteria. The median incidence of epilepsy was 50.4/100,000/year (interquartile range [IQR] 33.6–75.6), while it was 45.0 (IQR 30.3–66.7) for high-income countries and 81.7 (IQR 28.0–239.5) for low- and middle-income countries. Population-based studies had higher incidence estimates than hospital-based studies (p = 0.02) while retrospective study design was associated with lower estimates than prospective studies (p = 0.04). Conclusion: We provide data that could potentially be used to assess the burden and analyze the trends in incidence of epilepsy. Our results support the need for large population-based incidence studies of epilepsy.

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

Falciparum malaria is an important cause of acute symptomatic seizures in children admitted to hospitals in sub-Saharan Africa, and these seizures are associated with neurological disabilities and epilepsy. However, it is difficult to determine the proportion of seizures attributable to malaria in endemic areas since a significant proportion of asymptomatic children have malaria parasitaemia. We studied children aged 0–13 years who had been admitted with a history of seizures to a rural Kenyan hospital between 2002 and 2008. We examined the changes in the incidence of seizures with the reduction of malaria. Logistic regression was used to model malaria-attributable fractions for seizures (the proportion of seizures caused by malaria) to determine if the observed decrease in acute symptomatic seizures was a measure of seizures that are attributable to malaria. The overall incidence of acute symptomatic seizures over the period was 651/100u2009000/year (95% confidence interval 632–670) and it was 400/100u2009000/year (95% confidence interval 385–415) for acute complex symptomatic seizures (convulsive status epilepticus, repetitive or focal) and 163/100u2009000/year (95% confidence interval 154–173) for febrile seizures. From 2002 to 2008, the incidence of all acute symptomatic seizures decreased by 809/100u2009000/year (69.2%) with 93.1% of this decrease in malaria-associated seizures. The decrease in the incidence of acute complex symptomatic seizures during the period was 111/100u2009000/year (57.2%) for convulsive status epilepticus, 440/100u2009000/year (73.7%) for repetitive seizures and 153/100u2009000/year (80.5%) for focal seizures. The adjusted malaria-attributable fractions for seizures with parasitaemia were 92.9% (95% confidence interval 90.4–95.1%) for all acute symptomatic seizures, 92.9% (95% confidence interval 89.4–95.5%) for convulsive status epilepticus, 93.6% (95% confidence interval 90.9–95.9%) for repetitive seizures and 91.8% (95% confidence interval 85.6–95.5%) for focal seizures. The adjusted malaria-attributable fractions for seizures in children above 6 months of age decreased with age. The observed decrease in all acute symptomatic seizures (809/100u2009000/year) was similar to the predicted decline (794/100u2009000/year) estimated by malaria-attributable fractions at the beginning of the study. In endemic areas, falciparum malaria is the most common cause of seizures and the risk for seizures in malaria decreases with age. The reduction in malaria has decreased the burden of seizures that are attributable to malaria and this could lead to reduced neurological disabilities and epilepsy in the area.

Clinical features, proximate causes, and consequences of active convulsive epilepsy in Africa.

Epilepsy is common in sub‐Saharan Africa (SSA), but the clinical features and consequences are poorly characterized. Most studies are hospital‐based, and few studies have compared different ecological sites in SSA. We described active convulsive epilepsy (ACE) identified in cross‐sectional community‐based surveys in SSA, to understand the proximate causes, features, and consequences.

The genetic risk of acute seizures in African children with falciparum malaria

It is unclear why some children with falciparum malaria develop acute seizures and what determines the phenotype of seizures. We sought to determine if polymorphisms of malaria candidate genes are associated with acute seizures.

Value of Plasmodium falciparum histidine-rich protein 2 level and malaria retinopathy in distinguishing cerebral malaria from other acute encephalopathies in Kenyan children.

Background.u2003The diagnosis of cerebral malaria is problematic in malaria-endemic areas because encephalopathy in patients with parasitemia may have another cause. Abnormal retinal findings are thought to increase the specificity of the diagnosis, and the level of histidine-rich protein 2 (HRP2) may reflect the parasite biomass. Methods.u2003We examined the retina and measured plasma HRP2 levels in children with acute nontraumatic encephalopathy in Kenya. Logistic regression, with HRP2 level as an independent variable and World Health Organization–defined cerebral malaria and/or retinopathy as the outcome, was used to calculate malaria-attributable fractions (MAFs) and retinopathy-attributable fractions (RAFs). Results.u2003Of 270 children, 140 (52%) had peripheral parasitemia, 80 (30%) had malaria retinopathy, and 164 (61%) had an HRP2 level of >0 U/mL. During 2006–2011, the incidence of HRP2 positivity among admitted children declined by 49 cases per 100 000 per year (a 78% reduction). An HRP2 level of >0 U/mL had a MAF of 93% for cerebral malaria, with a MAF of 97% observed for HRP2 levels of ≥10 U/mL (the level of the best combined sensitivity and specificity). HRP2 levels of >0 U/mL had a RAF of 77% for features of retinopathy combined, with the highest RAFs for macular whitening (99%), peripheral whitening (98%), and hemorrhages (90%). Conclusion.u2003HRP2 has a high attributable fraction for features of malarial retinopathy, supporting its use in the diagnosis of cerebral malaria. HRP2 thresholds improve the specificity of the definition.

Behavioral problems in children with epilepsy in rural Kenya

The aims of this study were to record behavioral problems in children with epilepsy (CWE), compare the prevalence with that reported among healthy children without epilepsy, and investigate the risk factors. A child behavioral questionnaire for parents comprising 15 items was administered to the main caregiver of 108 CWE and 108 controls matched for age in Kilifi, Kenya. CWE had a higher mean score for reported behavioral problems than controls (6.9 vs 4.9, t = 4.7, P < 0.001). CWE with active epilepsy also recorded more behavioral problems than those with inactive epilepsy (8.2 vs 6.2, t = − 2.9, P = 0.005). A significantly greater proportion of CWE (49% vs 26% of controls) were reported to have behavioral problems. Active epilepsy, cognitive impairment, and focal seizures were the most significant independent covariates of behavioral problems. Behavioral problems in African CWE are common and need to be taken into consideration in planning comprehensive clinical services in this region.

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).

Evaluation of psychometric properties and factorial structure of the pre-school child behaviour checklist at the Kenyan Coast

BackgroundBehavioural/emotional problems may be common in preschool children living in resource-poor settings, but assessment of these problems in preschool children from poor areas is challenging owing to lack of appropriate behavioural screening tools. The child behaviour checklist (CBCL) is widely known for its reliability in identifying behavioural/emotional problems in preschool children, but it has not been validated for use in sub-Saharan Africa.MethodsWith permission from developers of CBCL, we translated this tool into Ki-Swahili and adapted the items to make them culturally appropriate and contextually relevant and examined the psychometric properties of the CBCL, particularly reliability, validity and factorial structure in a Kenyan community preschool sample of 301 children. It was also re-administered after 2xa0weeks to 38 randomly selected respondents, for the purpose of evaluating retest reliability. To evaluate inter-informant reliability, the CBCL was administered to 46 respondents (17 alternative caretakers and 29 fathers) alongside the child’s mother. Generalised linear model was used to measure associations with behavioural/emotional scores. We used structural equation modelling to perform a confirmatory factor analysis to examine the seven-syndrome CBCL structure.ResultsDuring the first phase we found that most of the items could be adequately translated and easily understood by the participants. The inter-informant agreement for CBCL scores was excellent between the mothers and other caretakers [Pearson’s correlation coefficient (r)xa0=xa00.89, pxa0<xa00.001] and fathers (rxa0=xa00.81; pxa0<xa00.001). The test–retest reliability was acceptable (rxa0=xa00.76; pxa0<xa00.001). The scale internal consistency coefficients were excellent for total problems [Cronbach’s alpha (α)xa0=xa00.95] and between good and excellent for most CBCL sub-scales (αxa0=xa00.65–0.86). Behavioural/emotional scores were associated with pregnancy complications [adjusted beta coefficient (β)xa0=xa00.44 (95xa0% CI, 0.07–0.81)] and adverse perinatal events [βxa0=xa00.61 (95xa0% CI, 0.09–1.13)] suggesting discriminant validity of the CBCL. Most fit indices for the seven-syndrome CBCL structure were within acceptable range, being <0.09 for root mean squared error of approximation and >0.90 for Tucker–Lewis Index and Comparative Fit Index.ConclusionThe CBCL has good psychometric properties and the seven-syndrome structure fits well with the Kenyan preschool children suggesting it can be used to assess behavioural/emotional problems in this rural area.

Prevalence and factors associated with convulsive status epilepticus in Africans with epilepsy

Objective: We conducted a community survey to estimate the prevalence and describe the features, risk factors, and consequences of convulsive status epilepticus (CSE) among people with active convulsive epilepsy (ACE) identified in a multisite survey in Africa. Methods: We obtained clinical histories of CSE and neurologic examination data among 1,196 people with ACE identified from a population of 379,166 people in 3 sites: Agincourt, South Africa; Iganga-Mayuge, Uganda; and Kilifi, Kenya. We performed serologic assessment for the presence of antibodies to parasitic infections and HIV and determined adherence to antiepileptic drugs. Consequences of CSE were assessed using a questionnaire. Logistic regression was used to identify risk factors. Results: The adjusted prevalence of CSE in ACE among the general population across the 3 sites was 2.3 per 1,000, and differed with site (p < 0.0001). Over half (55%) of CSE occurred in febrile illnesses and focal seizures were present in 61%. Risk factors for CSE in ACE were neurologic impairments, acute encephalopathy, previous hospitalization, and presence of antibody titers to falciparum malaria and HIV; these differed across sites. Burns (15%), lack of education (49%), being single (77%), and unemployment (78%) were common in CSE; these differed across the 3 sites. Nine percent with and 10% without CSE died. Conclusions: CSE is common in people with ACE in Africa; most occurs with febrile illnesses, is untreated, and has focal features suggesting preventable risk factors. Effective prevention and the management of infections and neurologic impairments may reduce the burden of CSE in ACE.

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.