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The Burden of Epilepsy: using population-based data to define the burden and model a cost-effective intervention for the treatment of epilepsy in rural South Africa
Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
2016 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Rationale Epilepsy is a common, chronic, neurological condition that disproportionately affects individuals living in low- and middle- income countries, including much of sub-Saharan Africa. Epilepsy is treatable, with the majority of individuals who take anti-epileptic drugs experiencing a reduction, or elimination, of seizures. Yet the number of individuals taking and adhering to medication in Africa is low and interventions aimed at improving treatment are lacking.

Aims To define the epidemiology of convulsive epilepsy in rural South Africa in terms of incidence, mortality and disability-adjusted life years; to determine outpatient, out-of-pocket costs resulting from epilepsy treatment; to establish the level of adherence to anti-epileptic drugs amongst people with epilepsy; and, to determine whether the introduction of routine visits to people with epilepsy by community health workers is a cost-effective intervention for improving adherence to anti-epileptic drugs.

Methods Nested within the Agincourt Health and Demographic Surveillance System, this work utilized a cohort of individuals diagnosed with convulsive epilepsy in 2008 to determine health care utilization and out-of-pocket costs due to care sought for epilepsy. Additionally, using blood samples from the cohort, anti-epileptic drug adherence was measured and, following the cohort, mortality rates were determined. Using these collected epidemiological parameters, disability-adjusted life years due to convulsive epilepsy were determined. Finally, combining the epidemiological and cost parameters, a community health worker intervention was modeled to determine its incremental cost-effectiveness ratio.

Key Findings The burden of convulsive epilepsy is lower in rural South Africa than other parts of Africa, likely due to lower levels of known risk factors. Yet the burden, especially in terms of mortality, remains high, as does the treatment gap and health care utilization. Findings from the economic evaluation found the introduction of a community health worker to be highly cost-effective and would likely lower the burden of epilepsy in rural South Africa.

Implications Epilepsy contributes to the burden of disease in rural South Africa, with high levels of mortality and a substantial treatment gap. The introduction of a community-health worker is likely to be one cost-effective, community based intervention that would lower the burden of epilepsy by improving adherence to anti-epileptic drugs. Implementing this intervention, based on these findings, is a justified and important next step.

Place, publisher, year, edition, pages
Umeå: Umeå University , 2016. , 94 p.
Series
Umeå University medical dissertations, ISSN 0346-6612 ; 1814
Keyword [en]
Africa, epilepsy, incidence, mortality, cause of death, disability-adjusted life years, out-of-pocket, costs, health care utilization, treatment cascade, adherence, intervention, economic evaluation, community health worker
National Category
Other Medical Sciences not elsewhere specified Public Health, Global Health, Social Medicine and Epidemiology Neurology
Identifiers
URN: urn:nbn:se:umu:diva-120163ISBN: 978-91-7601-494-3 (print)OAI: oai:DiVA.org:umu-120163DiVA: diva2:926968
Public defence
2016-06-02, Sal 135 Allmänmedicin, Norrlands Universitetssjukhus, Umeå, 09:00 (English)
Opponent
Supervisors
Available from: 2016-05-12 Created: 2016-05-10 Last updated: 2016-05-26Bibliographically approved
List of papers
1. Incidence, Remission and Mortality of Convulsive Epilepsy in Rural Northeast South Africa
Open this publication in new window or tab >>Incidence, Remission and Mortality of Convulsive Epilepsy in Rural Northeast South Africa
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2015 (English)In: PLoS ONE, ISSN 1932-6203, E-ISSN 1932-6203, Vol. 10, no 6, e0129097Article in journal (Refereed) Published
Abstract [en]

Background Epilepsy is one of the most common neurological conditions globally, estimated to constitute 0.75% of the global burden of disease, with the majority of this burden found in low- and middle- income countries (LMICs). Few studies from LMICs, including much of sub-Saharan Africa, have described the incidence, remission or mortality rates due to epilepsy, which are needed to quantify the burden and inform policy. This study investigates the epidemiological parameters of convulsive epilepsy within a context of high HIV prevalence and an emerging burden of cardiovascular disease. Methods A cross-sectional population survey of 82,818 individuals, in the Agincourt Health and Socio-demographic Surveillance Site (HDSS) in rural northeast South Africa was conducted in 2008, from which 296 people were identified with active convulsive epilepsy. A follow-up survey was conducted in 2012. Incidence and mortality rates were estimated, with duration and remission rates calculated using the DISMOD II software package. Results The crude incidence for convulsive epilepsy was 17.4/100,000 per year (95%CI: 13.1-23.0). Remission was 4.6% and 3.9% per year for males and females, respectively. The standardized mortality ratio was 2.6 (95%CI: 1.7-3.5), with 33.3% of deaths directly related to epilepsy. Mortality was higher in men than women (adjusted rate ratio (aRR) 2.6 (95%CI: 1.2-5.4)), and was significantly associated with older ages (50+ years versus those 0-5 years old (RR 4.8 (95%CI: 0.6-36.4)). Conclusions The crude incidence was lower whilst mortality rates were similar to other African studies; however, this study found higher mortality amongst older males. Efforts aimed at further understanding what causes epilepsy in older people and developing interventions to reduce prolonged seizures are likely to reduce the overall burden of ACE in rural South Africa.

National Category
Public Health, Global Health, Social Medicine and Epidemiology
Identifiers
urn:nbn:se:umu:diva-106006 (URN)10.1371/journal.pone.0129097 (DOI)000355955300086 ()26053071 (PubMedID)
Available from: 2015-07-07 Created: 2015-07-03 Last updated: 2017-12-04Bibliographically approved
2. Differing Methods and Definitions Influence DALY estimates: Using Population-Based Data to Calculate the Burden of Convulsive Epilepsy in Rural South Africa
Open this publication in new window or tab >>Differing Methods and Definitions Influence DALY estimates: Using Population-Based Data to Calculate the Burden of Convulsive Epilepsy in Rural South Africa
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2015 (English)In: PLoS ONE, ISSN 1932-6203, E-ISSN 1932-6203, Vol. 10, no 12, e0145300Article in journal (Refereed) Published
Abstract [en]

Background

The disability adjusted life year (DALY) is a composite measure of disease burden that includes both morbidity and mortality, and is relevant to conditions such as epilepsy that can limit productive functioning. The 2010 Global Burden of Disease (GBD) study introduced a number of new methods and definitions, including a prevalence-based approach and revised disability weights to calculate morbidity and new standard life expectancies to calculate premature mortality. We used these approaches, and local, population-based data, to estimate the burden of convulsive epilepsy in rural South Africa.

Methods & Findings

Comprehensive prevalence, incidence and mortality data on convulsive epilepsy were collected within the Agincourt sub-district in rural northeastern South Africa between 2008 and 2012. We estimated DALYs using both prevalence- and incidence-based approaches for calculating years of life lived with disability. Additionally, we explored how changing the disease model by varying the disability weights influenced DALY estimates. Using the prevalence- based approach, convulsive epilepsy in Agincourt resulted in 332 DALYs (95% uncertainty interval (UI): 216-455) and 4.1 DALYs per 1,000 individuals (95% UI: 2.7-5.7) annually. Of this, 26% was due to morbidity while 74% was due to premature mortality. DALYs increased by 10% when using the incidence-based method. Varying the disability weight from 0.072 (treated epilepsy, seizure free) to 0.657 (severe epilepsy) caused years lived with disability to increase from 18 (95%UI: 16-19) to 161 (95%UI: 143-170).

Conclusions

DALY estimates are influenced by both the methods applied and population parameters used in the calculation. Irrespective of method, a significant burden of epilepsy is due to premature mortality in rural South Africa, with a lower burden than rural Kenya. Researchers and national policymakers should carefully interrogate the methods and data used to calculate DALYs as this will influence policy priorities and resource allocation.

National Category
Public Health, Global Health, Social Medicine and Epidemiology
Identifiers
urn:nbn:se:umu:diva-114577 (URN)10.1371/journal.pone.0145300 (DOI)000367092600060 ()26697856 (PubMedID)
Available from: 2016-02-11 Created: 2016-01-25 Last updated: 2017-11-30Bibliographically approved
3. Health care utilization and outpatient, out-of-pocket costs for active convulsive epilepsy in rural northeastern South Africa: a cross-sectional survey
Open this publication in new window or tab >>Health care utilization and outpatient, out-of-pocket costs for active convulsive epilepsy in rural northeastern South Africa: a cross-sectional survey
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(English)Article in journal (Other academic) Submitted
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Identifiers
urn:nbn:se:umu:diva-120264 (URN)
Available from: 2016-05-12 Created: 2016-05-12 Last updated: 2016-05-12
4. The convulsive epilepsy treatment cascade and its determinants in rural South Africa
Open this publication in new window or tab >>The convulsive epilepsy treatment cascade and its determinants in rural South Africa
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(English)Article in journal (Refereed) Submitted
National Category
Public Health, Global Health, Social Medicine and Epidemiology Neurology
Identifiers
urn:nbn:se:umu:diva-120155 (URN)
Available from: 2016-05-10 Created: 2016-05-10 Last updated: 2016-05-12
5. A community health workers to improve adherence to anti-epileptic drugs in rural sub-Saharan Africa: Is it cost-effective?
Open this publication in new window or tab >>A community health workers to improve adherence to anti-epileptic drugs in rural sub-Saharan Africa: Is it cost-effective?
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(English)Article in journal (Refereed) Submitted
National Category
Public Health, Global Health, Social Medicine and Epidemiology Health Care Service and Management, Health Policy and Services and Health Economy
Identifiers
urn:nbn:se:umu:diva-120156 (URN)
Available from: 2016-05-10 Created: 2016-05-10 Last updated: 2016-05-12

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