Packages of Care for Epilepsy in Low- and Middle-Income Countries

Epilepsy is one of the most common and widespread neurological disorders. Recent estimates suggest that it accounts for 1% of the global burden of disease [1] and affects over 65 million people [2]. In addition, because the relatives and friends of people with epilepsy (PWE) also bear the burden of this condition, more than 500 million people are indirectly affected by epilepsy [3]. Thus, epilepsy imposes a large economic burden on global health care systems and is a major public health problem in lowand middle-income countries (LMICs) [1]. The World Health Organization (WHO) estimates that 80% of PWE live in LMICs. The incidence and prevalence of epilepsy are thought to be higher in LMICs than in high-income countries (HIC)—the median prevalence in LMICs is 9.5/1,000 compared to 8/1,000 in Europe, although the prevalence varies widely among countries [1,2]. The incidence of epilepsy in LMICs is thought to be up to five times that in HICs, although there are fewer studies on which to base this estimate. Worldwide, mortality among PWE is two to three times higher than in the general population and it is thought to be higher in LMICs than in HICs although data are scarce [4]. The treatment gap, i.e., the difference between the number of people with active epilepsy and the number whose seizures are being appropriately treated, is high in many LMICs [1]. Overall, 56% (range 7%–98%) of PWE in LMICs remain untreated, with 73% remaining untreated in rural regions compared to 46% in urban settings [5]. The International Classification of Disease (ICD) 10 diagnostic criteria for epilepsy are given in Box 1 [6]. The definition of epilepsy has recently been revised by the International League Against Epilepsy (ILAE) [7], but the original classification of seizures (transient occurrences of signs and/or symptoms due to excessive or synchronous discharge of neuronal activity in the brain) as partial (focal), generalized, or unclassified remains useful [8]. Epilepsy has many different etiologies, with head trauma, central nervous system infections, perinatal problems, and cerebrovascular accidents most commonly identified [1], although in most cases a cause is not found. Focal epilepsies represent a greater proportion of epilepsies in LMICs than in HICs and risk factor analysis has identified many causes that are preventable. Although seizures are its most overt manifestations, epilepsy is associated with significant psychological [9] and psychiatric conditions [10], which have social consequences for everyday living [11]. Psychiatric disorders occur in 25%–30% of PWE [10], with depression being the most common, followed by anxiety disorders, psychoses, and personality disorders [12,13]. Psychiatric comorbidity appears to be particularly common in some LMICs [14]. Stigma poses a major burden to PWE and their families, interfering with the opportunities that PWE have for employment and marriage [15]. Finally, women with epilepsy are particularly vulnerable to sexual exploitation, physical abuse, and extreme poverty [16]. In this article, we focus on the management of epilepsy in LMICs. We review the evidence from LMICs on the efficacy of treatments and delivery of interventions. Because that evidence is often limited, we also refer to systematic reviews, meta-analyses, and key trials from HICs where appropriate. On the basis of this review, we propose a package of care—a combination of interventions aimed at improving the recognition and management of conditions to achieve optimal outcomes—for epilepsy.