Epilepsy in south sudan significado de anoxia

Author(s): peter. K. Newman FRCP

All images belong to peter newman. Introduction

Faced with the magnitude of health care

Challenges in south sudan, one could argue that

Epilepsy is a minor problem and that resources should not be diverted from more

Pressing needs. Yet epilepsy is a common and often devastating condition which

In south sudan burdens the lives of more than

100,000 sufferers and their families. In most cases it could be effectively and

Cheaply treated if resources and systems were available. This paper aims to:

• estimate the likely patterns of

Epilepsy in south sudan

• give practical advice about

Managing epilepsy

• suggest

Ways to bring epilepsy care to those needing it.


Epilepsy in south sudan is difficult due to

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Lack of local information and documentation. Therefore information on its

Prevalence, patterns, causes, treatment and attitudes must be extrapolated from

Data from nearby countries such as tanzania,

Uganda and kenya. When data

From south sudan eventually becomes available comparisons can be made with

Epilepsy patterns from elsewhere in africa 1. What can we conclude about epilepsy in south

Sudan from published material? Prevalence

The prevalence of epilepsy prevalence in south sudan is not known but studies from nearby

Countries show a much higher prevalence than is reported from western countries

Or other developing areas. In the west the prevalence ranges from 4-8 per

Thousand inhabitants but studies in african populations give rates as high as

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28/1000. For example, in rural tanzania,

A recent door-to-door study gave an age-adjusted prevalence rate of 13.2/1000

With an incidence of 81.1/100,000. Fifty four per cent of these cases had generalised seizures

For which no cause had been identified, and 76% had never received treatment

(1). In rwanda

The prevalence rate was lower at 7/1000 (2) and in ugandan children it was higher

At 20.4/1000 (3).

The high

Prevalence of epilepsy in africa may be due to

Several factors including poor obstetric care with consequent increased

Perinatal brain injury, high levels of head injury in children and adults, CNS

And other infections and, particularly, the aftermath of cerebral malaria. The

Younger age range in african populations compared with other societies may also

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Be a factor in the higher prevalence, as epilepsy is commoner in young people. The treatment gap

Few people with epilepsy in south sudan receive orthodox medical treatment although

When available this successfully controls most cases and leads to remission in

At least 70%. Estimates of the treatment gap (the proportion of people with

Epilepsy who do not receive treatment) in some african countries are 85% and it

Is probably higher in south sudan.

Epilepsy is

Associated with a significant morbidity. For example, a study in a burns unit

In south africa

Showed that 50% of people admitted with burns had epilepsy and that their

Injury occurred during a seizure (4) (figure 1). Mortality is also

Significantly increased in epilepsy, with up to a six-fold increase identified

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In one african review (5), compared with a 2-3 fold increase in those with

Epilepsy in the west.

Figure 1. Burns caused by an epileptic



Employment and status in the community are adversely influenced by uncontrolled

Epilepsy. In a mild case the condition may be hidden within the immediate

Family and so does not adversely affect social standing, but in more overt

Cases there is a major adverse impact. There is a deep-rooted prejudice against

Epilepsy and many still attribute it to witchcraft and curses (6,7). The result

Is that the person with epilepsy seeks treatment from traditional healers (herbal

Medicines, scarifications or other forms of healing) or christian spiritual

Healing (8).Significado de anoxia some traditional healers do recognise the need for orthodox health care in

Refractory epilepsy and collaborative relationships may be fruitful (9). The

Enlightened traditional practitioner may also help the patient and family to

Manage the problems associated with epilepsy.

Central nervous system (CNS) infections

Bacterial meningitis, encephalitis and the

Complications of HIV infection, common problems in south sudan,

Are associated with epilepsy both in the acute period and chronically.


Frequently leads to epilepsy (figure 2) and is found wherever domestic pigs are

Kept close to human homes. In an area of rural tanzania, 50% of cases have been

Linked with taenia solium infestation

Of the brain (10).Significado de anoxia there is no published work on the prevalence of

Neurocysticercosis in south sudan (where

Cattle ownership predominates) but this disease is probably common where pigs

Are kept.

Figure 2.

Brain scans showing neurocysticercosis.

Cerebral malaria (figure

3) is a potent trigger for seizures during the acute illness, and these can be

Differentiated from febrile convulsions. A study from south

Sudan found convulsions in 25.6% of affected children (11).

Epilepsy is often seen later in those who have recovered (12). Studies from kenya

Show that approximately 10% of survivors develop this complication with 5%

Having active epilepsy, often associated with cognitive problems. Seventy per

Cent of children admitted with seizures have malaria which is usually causative

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Rather than coincidental.

Figure 3. Cerebral

Malaria can trigger seizures.

Onchocerciasis is

Prevalent in parts of south sudan and there

Has been much debate as to whether this is linked with epilepsy. Some have

Found an association (13, 14) whereas others have not (15). More work is

Needed, although the author is

Sceptical in that brain infestation with the microfilariae of

Onchocerciasis is unlikely. The intriguing condition of nodding syndrome

This was noted first in tanzania in the

1960s, has been seen in uganda, and many cases have been detected in south

Sudan (16). The disorder has not yet been satisfactorily classified. Some cases

Having nodding in isolation (possibly a form of tic rather than a seizure

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Disorder) but in others there is a definite association with epileptic

Seizures. There seems to be a high burden of cognitive disorder in affected

Cases (17) and the few MR scans undertaken have shown hippocampal changes or

Gliosis (18). Some eegs show a spike and

Wave pattern.

A comprehensive

Field study was recently published in this journal (19) where 96 cases were

Documented in witto payam, western equatoria

Mainly affecting children and teenagers. Speculation as to possible causes

Noted the high prevalence of onchocerciasis in the area. The authors concluded

That nodding syndrome, a possible seizure disorder of unknown cause, is likely

To be widespread in south sudan and further

Research is urgently needed to explain and define the condition.Significado de anoxia A pilot study

Is underway under the auspices of the centers for disease control, USA. 2. How is epilepsy managed?

The optimal management of epilepsy requires

Attention to the following points:

• the diagnosis must be secure. Remember

That febrile convulsions are usually not indicative of epilepsy. Syncopal

Attacks and hysterical seizures can superficially look similar to genuine

Epilepsy. In northern uganda among the population exposed

To the LRA, people presenting with “seizures” have a 25% frequency of

Psychogenic, non-epileptic seizures triggered by the mental trauma. The long

Period of strife in south sudan may have had a

Similar effect. Thus the diagnosis of epilepsy should be made after a competent

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Healthcare worker with local as well as generic experience in the disease has

Taken a careful history.

At first

Presentation most cases of epilepsy have no obvious cause, and it is not

Feasible to investigate with tests like EEG and MR scans. However, consider the

Possibility of underlying CNS infection in acute onset of seizures particularly

Where there are additional systemic features, fever or neurological signs.

• do not underestimate the

Influence of unorthodox beliefs.

• in much of sub-saharan africa drugs for epilepsy are not obtainable or supplies

Are unreliable. If available they are too expensive for most people. Some

Antiepileptic drugs (aeds) like phenobarbitone and phenytoin are cheap and

Effective, and although may have some adverse effects, it is better to control

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Epilepsy by using them than to have no treatment at all. There are many

Examples of effective and sustained AED treatment programmes using these drugs,

And many success stories of lives transformed after seizures are brought under


It is usual

Practice not to treat febrile convulsions or an isolated seizure with an AED,

But in a case of epileptic seizures which recur, phenobarbitone or phenytoin

Can be started at the appropriate dose. Advise a patient who has passed one or

Two years free of seizures while on treatment to attempt a cautious withdrawal

Of their treatment. Sudden withdrawal is dangerous.

• the management of convulsive

Status epilepticus is particularly challenging. In children and adults, suspect

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And treat an underlying infection, particularly bacterial meningitis or

Cerebral malaria, and always consider the possibility of hypoglycaemia in these

Cases (20). Where facilities are available for specifically treating the

Seizures, buccal midazolam may be as effective as rectal diazepam, and equally

Safe to use (21).

3. How could epilepsy care be made available in south sudan?


Treatment of epilepsy is cheap and has a high impact on individuals and societies.

It needs only systematic organisation and dedicated healthcare workers.

For example, in

The1980s in malawi,

A doctor together with local chiefs and other influential people set up a

Network of epilepsy treatment clinics using phenobarbitone from the “essential”

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Drugs allocation and treated thousands of people (22). This model utilises

Missionary or NGO healthcare already available at community level. Another model,

Widely used in resource poor parts of africa, involves

Training nurses, clinical officers or medical assistants in simple epilepsy

Management and establishing nurse-led outpatient treatment clinics (23). The

Nurse-led system can link with community-based NGO activity to cover more of

The population. In other countries epilepsy treatment and training has been

Linked with already organized leprosy, tuberculosis or HIV programmes.

The five steps needed to start an epilepsy

Programme in south sudan are:

• identify and link the few NGO,

Charity or church groups which are treating epilepsy in their community and

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Local programmes.

• train a small group of nurses

In epilepsy care with the intention of setting up nurse-led epilepsy treatment

Clinics in the larger towns. These trained people cascade their expertise and

Knowledge to others.

• begin basic epidemiological


• ensure a steady supply of

Phenobarbitone to pharmacies in hospitals and community health centres.

• bring together those interested

In epilepsy care and, with patient representation, form a south sudan epilepsy

Association, thus establishing a pressure group and a forum for education about



You would like to help develop epilepsy care in south

Sudan contact the author at [email protected] references

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