Today's issue of The Lancet focuses on epilepsy, and aims, together with content in The Lancet Neurology and The Lancet Oncology, to highlight the challenges and achievements in the global campaign against this disorder. Epilepsy is a costly and complex public health problem. According to WHO, epilepsy accounted for about 05% of the global burden of disease in 2005, or more than 7 million disability-adjusted life-years. The prevalence and burden of epilepsy is especially high in poor countriesmore than 85% of the global burden of epilepsy occurs in low-income and lower-middle-income countries (LLMIC).
Effective drugs to control seizures and associated comorbidities are available, and are widely used in high-income countries. However, worldwide, up to 30% of people with epilepsy have seizures uncontrolled by available drugs; for many others, adverse effects or contraindications make drug use untenable, leaving non-drug management or surgery. Investigations into the molecular mechanisms that lead to epileptogenic changes have shown promise in preclinical models; this information could lead to more antiepileptogenic drug candidates entering clinical trials.
Although many inexpensive antiepileptic drugs are available, and surgical options exist for patients who are resistant to the drugs, the epilepsy treatment gapie, the proportion of patients not seeking medical treatment or not adhering to prescribed antiepileptic drugsin LLMIC is enormous. Overall, the median epilepsy treatment gap for active epilepsy ranges from 25% to 100% by country, compared with less than 10% in high-income countries. This disparity is partly due to differing risk factors. Risk factors in LLMIC include antenatal and perinatal complications and parasitic diseases, particularly neurocysticercosis, onchocerciasis, malaria, toxocariasis, and toxoplasmosis. These identifiable causes should be preventable or curable.
In some low-income countries, traditional beliefs about the causes of epilepsy, such as bewitchment, spiritual causes, and curses, lead to stigma and contribute to the treatment gap. Many people with epilepsy and their families do not know that the disorder can be controlled with medical treatment, so seek help through traditional medicine practitioners, particularly for seizures involving sensory or psychic phenomena. The social burden for people with epilepsy and their families is greatest in poor countries; since there is more stigma, people with epilepsy are prevented from attending school, and have reduced chances of being employed or married. This problem can be tackled. In The Lancet Neurology, Caroline Mbuba and colleagues describe a cross-sectional survey of 232176 people in Kilifi, Kenya, in 2008. The epilepsy treatment gap was 62%, and the independent risk factors associated with not seeking medical treatment were traditional religious beliefs, negative attitudes about medical treatments, living more than 30 km from health-care facilities, paying for antiepileptic drugs, learning difficulties, duration of epilepsy of more than 10 years, and focal seizures. The treatment gap was lower than the 74% found in 2003, the reduction being attributed to sensitisation of the community and establishment of an epilepsy clinic.
In government facilities, poor urban areas, and rural areas in the developing world, an accepted level of care is rarely available; few facilities generally exist for electroencephalography and neuroimaging in poor regions, and those available are usually in the private sector or lack staff with the appropriate skills. Ministries of health in LLMIC need to address the disparity of expenditure on epilepsy, improve facilities' accessibility, and hence narrow the treatment gap. Epilepsy is associated with substantial mortality and morbidity, yet is usually cost-effective to treat.
Scaling up the availability of antiepileptic drugs is one of the most cost-effective interventions for neuropsychiatric disorders. Ministries of health in LLMIC should ensure a continuous supply of antiepileptic drugs and preferably provide free antiepileptic drugs to patients in the entire country, particularly in poor rural areas. At the global level, epilepsy needs to be brought into the agenda of non-communicable diseasesdespite the substantial burden of ill health caused by epilepsy, the disease was neglected at the 2011 UN high-level meeting in New York on the global burden of non-communicable diseases. Given the prevalence of epilepsy globally, it should be included as a priority on the public health agenda, and access to treatment should be greatly improved in developing countries. It is time for all governments to take epilepsy more seriously.
See EditorialLancet Neurol 2012; 11: 739
See ArticlesLancet Neurol 2012; 11: 688
See ReviewLancet Neurol 2012; 11: 792 and 803
See ReviewLancet Oncol 2012; 13: e375
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