Epilepsy in sub-Sahran Africa : analysis of excess mortality in epilepsy and associated risk factors from cohort studies

Levira, Francis William. Epilepsy in sub-Sahran Africa : analysis of excess mortality in epilepsy and associated risk factors from cohort studies. 2018, Doctoral Thesis, University of Basel, Faculty of Science.

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Official URL: http://edoc.unibas.ch/diss/DissB_13622

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Epilepsy is a disorder of the brain manifested with the recurrent unprovoked seizures. It affects about 71 million people globally. Epileptic seizures may involve a sudden loss of conscious, rapid muscles rigidity and contractions, violent convulsions and falls if a person is standing or sitting. Epilepsy can be controlled by antiepileptic drugs (AEDs) and adherence to treatment has been shown to improve quality of life, reduce seizure frequency, injuries, and death. Epileptic seizures negatively impact the lives of people with epilepsy (PWE) and those around them especially in LMIC. It is estimated that 80% of PWE live in LMICs. Excess mortality in PWE in developed countries is estimated to be up to 2 times higher than general population. There is scant data on excess mortality in PWE in SSA. Scarcity of evidence on the impact of epilepsy has resulted in PWE being marginalized in health services planning and provision despite having high psychological, economic, morbidity and mortality burden relative to the general population.
This thesis provides needed knowledge on uncertainties of epilepsy in SSA in relation to mortality, risk factors, and causes of death in PWE. The knowledge and evidence were generated from five studies using empirical data from community-based studies.
Systematic review
The first thesis objective was aimed at reviewing and summarizing available evidence on excess mortality in PWE compared to general population in LMIC. Systematic review in Chapter 3 identified only 7 studies in LMIC over the period of 25 years. Estimated excess mortality of ranged from 1.3-7.2 times higher in PWE than general population (median=2.6).
Meta-analysis of this systematic review indicated that up to 80% of total variability’s in the estimate of excess mortality (SMR) was only due to differences between studies. These differences may be due to methodological variations between studies or other unknown factors. The estimated excess mortality of 2.6 was median value and not pooled estimate as large variability’s between studies could not allow combined estimate of 7 studies.
In conclusion, until this systematic review was done, there were no sufficient data to provide empirical evidence of excess mortality in PWE in LMIC.
SEEDS study: Excess mortality
At the time the systematic review was completed, new data on mortality of PWE were emerging from SEEDS studies. SEEDS studies had already followed PWE for over 8 years and documented deaths in people with and without epilepsy. Chapter 4 of this thesis was dedicated at pooling and generating new evidence of excess mortality in PWE from SEEDS studies.
The pooled excess mortality was 4.8 times higher in PWE than general population (95% CI: 4.2-5.6). SEEDS estimate is higher than summary findings from systematic review in reported in the literature in Chapter 4. SEEDS studies were conducted to account for methodological limitations encountered in most epilepsy studies related to screening, diagnosis, mortality and causes of death assessment, and population representativeness.
SEEDS study: Risk factors
The studies also identified modifiable risk factors potential for intervention programs and mitigating the negative impact of epilepsy.
Causes of death automation
In addition to summarizing excess mortality in PWE, systematic review in Chapter 3 summarized causes of deaths in PWE from different studies. Summary estimates from different studies in LMIC indicated most PWE died of direct causes which are status epilepticus (SE) and sudden death in epilepsy (SUDEP) and indirect (injuries) causes of epilepsy death. These studies compiled causes of death information from variety of sources including physicians, verbal autopsies and death certificates.
In Chapter 5, this thesis assessed the application of automated tools in ascertaining causes of death in PWE. The assessment indicated that, the use of automated tools is potentials, convenient and affordable alternative to post-mortem and physician death certification. Unlike the use of other sources of cause of death information, automated tool estimated lower number of epilepsy-related deaths (27.5%) compared to around 50% when physician make diagnosis of cause of death. Chapter 5 also provides valuable information and recommendation needed for further development and refinement of these tools especially with regards to coding SUDEP, SE, and injuries.
National estimates
Chapter 6 and 7 provides national and community-based estimates of mortality of epilepsy and other neurological disorders from national (SAVVY) and community-based studies (HDSS). The findings indicate epilepsy the second leading cause of death after cerebrovascular disorders. The estimates of mortality rate in the population ranged from 7-8 and 4-8 deaths per 100,000 populations in SAVVY and HDSS respectively.
HDSS data
HDSS sites have become platform for monitoring demographic indicators in most SSA. Analysis of HDSS data was aimed at ascertaining whether there has been declining trends in epilepsy and other neurological disorders over time. In Chapter 7 of this thesis, results of the analysis indicated epilepsy mortality did not change over the past 15 years.
This thesis generated new insights into the epidemiology of epilepsy in SSA. Limited data of studies of burden of epilepsy mortality in SSA point to either lack of interest in the subject, resources limitations from governments and funding bodies, and lack of knowledge of the negative impact of epilepsy. This study provides vigorous evidence of excess mortality needed for advocacy to health care providers, governments, and funding bodies for increased investment in care, preventions and reduction of the negative impact of epilepsy in SSA. The community and health care providers will benefit from evidence on modifiable risk factors for incidence and excess mortality from SEEDS study.
Advisors:Odermatt, Peter and Winkler, Andrea
Faculties and Departments:09 Associated Institutions > Swiss Tropical and Public Health Institute (Swiss TPH) > Department of Epidemiology and Public Health (EPH) > Eco System Health Sciences > Helminths and Health (Odermatt)
UniBasel Contributors:Odermatt, Peter
Item Type:Thesis
Thesis Subtype:Doctoral Thesis
Thesis no:13622
Thesis status:Complete
Bibsysno:Link to catalogue
Number of Pages:1 Online-Ressource (xv, 193 Seiten)
Identification Number:
Last Modified:04 Jul 2020 04:30
Deposited On:03 Jul 2020 12:41

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