A difficult dilemma

Of the 35 to 40 million people with epilepsy who live in low-income countries, approximately 56% to 85% receive no treatment at all (16; 42; 19; 09). As a consequence, they are at increased risk for excess morbidity and mortality from seizures and the psychosocial consequences of stigma and discrimination. Regrettably, most of these people—many of whom are children—could have their seizures completely controlled and could return to a normal life by taking a single daily dose of a drug that costs less than (£1.50; €2.20) each year (17). Conducting clinical trials in resource-restricted countries is difficult, contributing to wide treatment gaps, which result from lack of resources and trained personnel, and knowledge gaps in these countries (26).

Magnitude of the burden

It is estimated that around 80% of people with epilepsy live in low and middle income countries (43). The incidence rate of epilepsy in low-middle income countries was found to be 61 per 100,000 person-years, with a lifetime prevalence of 7.6 per 1,000 people (10). There were further increased rates in those living in rural areas, up to 15 per 1000, whereas in high income countries (HICs) it was found to be 5 per 1000. In South Africa, incidence rate was found to be as high as 180 to 250 per 100,000, whereas in high income countries was found to be 45 per 100,000 (09). Incidence and prevalence rates of epilepsy in people of low socioeconomic status in high income countries, however, are comparable to those observed in low income countries (15). This could be explained by shared risk factors and limited resources despite country of residence. Additionally, premature mortality is higher in this population, as well as deaths specifically relating to the disease (06). Those deaths directly attributable to epilepsy, based on population studies, were shown to be at 27%, with causes including status epilepticus and SUDEP. Additionally, deaths indirectly related to epilepsy, at 20%, included causes such as drowning, burns, head injury, and falls. Death rates in people with epilepsy in low and middle income countries are estimated to be 2.6 times higher than in the general population in low and middle income countries (18).

Higher incidence rates in LMICs are thought to be attributable to parasitosis (particularly neurocysticercosis, but also falciparum malaria, schistosomiasis, onchocerciasis, toxocariasis, and paragonimiasis), HIV-AIDS, trauma, perinatal morbidity, and consanguinity. The higher incidence is difficult to interpret because of methodological issues, particularly the lack of age adjustment, which is important because epilepsy has a bimodal peak with age. The prevalence of active epilepsy in developing countries has been found to be fairly uniform at 4 to 10 per 1000 in a large number of studies, but higher prevalence has been reported in sub-Saharan Africa and Central and South America; this is possibly due to methodological differences, or increased risk factors as noted above, or both, which are particularly different in rural areas (14; 27). Ascertainment may also be confounded by the ability to group and classify epilepsy in these regions.

Etiological factors

The results of studies on the causes of epilepsy have implications for decision-making about the development of locally relevant strategies for prevention and management, education of primary healthcare workers and community physicians, and further research. Perinatal causes have been reported among the most important etiologies of epilepsy in all income categories except high-income countries (42).

The top 4 most frequently reported etiologies of epilepsy (trauma, central nervous system infections, perinatal risk factors, and cerebrovascular disorders) are often modifiable (36). Where parasitic infections are causative factors, a common issue is that treatment of the infections may not be sufficient to prevent or treat epilepsy. This is due to ongoing neuro-inflammation from the parasitic-induced lesions, leading to seizures and epilepsy. Finding ways to control, eliminate, and eradicate these parasitic diseases via primary prevention would be ideal. It has also been proposed to study the mechanisms for the resultant inflammatory pathways in the brain in order to then develop novel therapies that could interfere with these pathways and reduce seizures (30). Multidisciplinary efforts focusing on risk factors, such as reduction of head trauma incidence through enforcement of traffic regulations, immunization against relevant communicable diseases, and public health measures to reduce exposure to parasites, could substantially decrease the incidence of epilepsy.

Medical services

Epilepsy specialists provide care to people with epilepsy in 88.6% of high-income countries, but they are present in only 55.6% of low-income countries and are available without charge in about 67% of these low-income countries (42). CT scanning is available in 70.5% of low-income countries. MRI is much more useful in the evaluation of epilepsy, but is available in only 29.6% of low-income countries. Similarly, long-term video-EEG monitoring is available in 21.7% of low-income countries, as compared to 77.1% of high-income countries (42). The availability is often limited to high income people in these countries, however, and relatively inaccessible to the poor. Neuropsychological services are less available, with availability in 37% of low-income countries and available free of charge in about one third of these countries.

The median number of professionals per 100,000 population who are members of an organization of epilepsy specialists is 0.17 in southeast Asia and Africa, 0.31 in the Western Pacific, 0.33 in the Eastern Mediterranean, and 0.35 in the Americas, compared with 2.15 in Europe (13). Professional organizations of epilepsy specialists do not exist in 64.6% of low-income countries, compared with 22.9% of high-income countries (23). Also, the median number of professionals per 100,000 population who are members of an organization of epilepsy specialists varies across different income groups of countries, with 0.19 in low-income countries, compared to 1.83 in high-income countries (42).

Treatment gap

A consensus definition of the “treatment gap” was adopted by international experts sponsored by the International League Against Epilepsy (ILAE): “The difference between the number of people with active epilepsy and the number whose seizures are being appropriately treated in a given population at a given point in time, expressed as a percentage” (20). The treatment gap has been shown to be 75% in low income countries and 50% in middle income countries (21). It is important to note, additionally, that rural areas are more affected than urban and suburban areas. A study in India showed a treatment gap of 40% to 90% in rural areas versus 22% to 50% in suburban/urban regions (09). Lack of access has been identified as a major barrier to adequate treatment in both high-income and low-income countries. The attributed causes with the highest medians have been related to the health systems: inadequately skilled personnel, lack of available drugs, and excessive cost of treatment. Improved training of the health workers providing first level of contact in case detection, initiation of treatment with antiseizure medications, follow-up, and monitoring for compliance and adverse effects might be the most cost-effective ways to decrease the treatment gaps in the majority of countries. Both cultural and structural factors affect the treatment gap (34), and cultural values affect health-seeking strategies. If people believe epilepsy has non-medical causes, then treatment through Western medicine may not be sought (20). In many developing countries, epilepsy is perceived as a manifestation of supernatural forces (39; 28; 34). In such situations, the family and the patient first consult the traditional healers and follow their recommendations; this treatment may be followed for a long period of time (29; 28; 34). Reports have identified this period as lasting 6 to 14 years (28; 34; 35). This depends on the area of residence (urban or rural), impact of cultural beliefs, and financial means.

Antiseizure medication usage

A consensus definition of the “treatment gap” was adopted by international experts There is wide disparity in the availability of treatment modalities in different parts of the world. The reasons for these inequalities are multifactorial. They may include both “hardware” factors (eg, availability of technologies and a reliable drug supply) and “software” factors (eg, availability of expertise and access to health care), which are often dictated by economic constraints (42). Phenobarbital has the lowest cost among the antiseizure medications and can be reliably supplied to rural areas. Phenytoin, carbamazepine, and sodium valproate can also be accessed in most countries. In low-income countries, inclusion of first-line antiseizure medications in the lists of essential drugs varies (12). Phenobarbital is included in 96%, carbamazepine in 82.6%, phenytoin in 68.2%, and valproic acid in 62.5% of the countries. The median cost in international dollars for the first-line antiseizure medications is variable across World Health Organization regions. The cost of carbamazepine and sodium valproate in Europe and the Western Pacific is almost half that of other regions. The cost of phenobarbital is 2.7 times higher in southeast Asia than in Europe (42). Even so, the use of newer antiseizure medications is increasing even in resource-limited settings, particularly among those in the upper income strata of their societies.

Epilepsy surgery

Services provided by epilepsy specialists vary among countries with regard to provision of surgical therapy. The outcome of epilepsy surgery in LMICs is comparable to that of HICs in terms of quality of life and rates of seizure freedom. It is difficult to know how widely epilepsy surgery is offered in LMICs, but it appears that this has increased in availability in Latin America and Asia. One review found mention of epilepsy surgery in only 22% of LMICs, with the most common procedure being temporal lobectomy (38). Surgery can provide a significant improvement in quality of life for many of the 30% of people with epilepsy who continue to have seizures while taking appropriate medication. However, epilepsy surgery is not available in a majority of low-income countries. Availability of epilepsy surgery requires a knowledgeable team consisting of an epileptologist and neurosurgeon, and technical services, including MRI and video-EEG (08; 32; 02).

Whereas the treatment gap for epilepsy is of considerable concern in the developing world, there is a marked treatment gap with respect to epilepsy surgery even in industrialized countries, where perhaps only 5% of potential surgical candidates are ever referred to an epilepsy surgery center. This is largely attributed to misinformation about the risks and benefits of surgery, particularly with respect to recent advances in diagnostic and surgical approaches that have greatly improved safety and efficacy. Until recently, epilepsy surgery was not available in countries with limited resources, but epilepsy surgery programs are now found widely Brazil, China, India, and Turkey and are being developed in many other countries with limited resources where it is recognized as a more cost-effective treatment for surgically remediable syndromes than continued pharmacotherapy (07; 40). The success of epilepsy surgery depends on the accurate identification of good surgical candidates, and then selecting the best candidates based on the available resources and technologies without jeopardizing safety (08; 32; 02).

The impact of the COVID-19 pandemic

The COVID-19 pandemic brought increased stress and isolation into these already resource-poor countries, with varied implications depending on the country. A Bolivian study showed 73% of patients surveyed reported irregular antiseizure medication intake, due to lack of availability at local health centers, with a resultant increase in seizure frequency (24). A study done in Sri Lanka looking at caregivers of children with epilepsy showed that epilepsy control was not affected by the pandemic, though there were gaps in regular visits and medication refills (37).

In the Philippines, during the Enhanced Community Quarantine, outpatient clinics were closed, and there was a significant decrease in EEGs performed; this was on top of an already large treatment gap due to the high burden of disease, high cost of antiseizure medications leading to limited access, poor access to epileptologists, and the underutilization of epilepsy surgery. This deficit, however, subsequently led to the adoption of telemedicine services and the establishment of an online clinic during the pandemic (22). The use of telemedicine has been of significant benefit during this time to many groups. A study done through a tertiary care teaching hospital in Uttarakhand showed that the use of teleconsultation via voice call, text message, and or video message all helped to address issues with breakthrough seizures, medication side effects, incorrect dosages of medications dosing, and pandemic-related symptoms (25).

Technological bridges

Technology can be used to aid in access to care for persons with epilepsy in low and middle income countries. As noted above, use of telemedicine services has been enhanced during the COVID-19 pandemic. Other technological advances can also help to bridge the gaps. A study done in the Republic of Guinea looked at a smartphone-based EEG technology, which compared a standard 21 lead EEG to a portable 14 lead cap with a Smartphone Branner-2 (SBS-2) that has with capability to transmit data to a web-based platform (41). The first was administered by a U.S. board-certified EEG technologist, and the latter was administered by medical students and neurology residents after less than an hour of training. Both were read by randomly assigned North American board-certified neurologists and neurophysiologists. This study showed a moderate (43%) sensitivity, as well as high (96%) specificity in detecting epileptiform changes in children with epilepsy using the SBS-2 EEG, when compared with standard EEG (41).

Many phone applications have been created to help with the task of bringing access to care to low and middle income countries. One such application, Epilepsy Diagnosis Aid, was developed for use by non-physician health workers to aid in the diagnosis of epilepsy in low income countries. The app was studied in a high income and rural low income country and showed a high sensitivity and specificity for epilepsy (11). Another new application used a validated algorithm to help providers who lack experience in epilepsy management classify seizures and choose appropriate antiseizure medications for their patients with the disease (03). More information can be accessed at the following website: EpiPick.

Conclusion

Although the World Health Organization has made significant progress in defining the magnitude of the problem of epilepsy and identifying the likely etiological factors, our understanding of the epidemiology of epilepsy in developing countries is still incomplete. The problem is particularly compounded in areas where patients with epilepsy do not have access to neurologists, or even to physicians, and where diagnostic methods such as CT or MRI scans and electroencephalography (EEG) are not available. Other difficulties include the complexity of diagnosis in epilepsy.

Stigma, an important contributor to resistance to diagnosis and treatment, can be addressed with creative strategies and education. A pilot study done in Bolivia, using a comic book based educational program, showed improvement in scoring in knowledge, attitudes, and practices regarding epilepsy, with the implications of reduction of stigma against the disease (04). Additionally, education regarding risks of death from epilepsy along with improving access to treatment could decrease premature mortality in this disease (18).

The causes of epilepsy in low-middle income countries differ from those in high-income countries; however, some of the etiological factors in low and middle income countries may be preventable with appropriate public health measures (01; 33). Prenatal factors and intracranial infections are of particular importance in low and middle income countries, as nutrition, improvement in hygiene, and vaccination can have major impacts. Epilepsy and other long-term sequelae of intracranial infections can be minimized by early detection and prompt treatment, and research is ongoing in regards to how these inflammatory pathways function and how to diminish their magnitude.

The treatment gap is substantial in low and middle income countries, but many of the causes could be addressed by effective government, infrastructure improvement, and public health schemes. The financial burden to most people in most low-middle income countries is considerable because patients often must pay directly for their healthcare. This situation differs from high-income countries, nearly all of whom have government or privately-funded insurance mechanisms to provide healthcare for those at low income levels. This financial burden results in further inequity, with underutilization of medical services in low-income countries. This situation could be improved if countries in every region took a collective and cohesive effort toward the management of epilepsy (05). Developing effective national programs will go a long way in reducing the treatment gap in epilepsy in the poor regions of the world.

The start of the COVID-19 pandemic forced many people into quarantine and isolation, disrupted supply chains, and brought increased treatment gaps in the management of epilepsy. Compensatory strategies, such as this, additionally brought on the expansion of telemedicine and the use of technologies to aid in the treatment and diagnosis of epilepsy to provide a path to improve care. This was especially needed in countries with already limited access to specialists pre-pandemic. It is hoped that with the continued expansion of technological resources, this will help to lessen the gap in the treatment of epilepsy in low and middle income countries.