global disparities in the epilepsy treatment gap: a ...the epilepsy treatment gap, defined as the...
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Bull World Health Organ 2010;88:260–266 | doi:10.2471/BLT.09.064147260
Introduction
Epilepsy affects 50 million people worldwide, and 80% of them live in the developing world.1 An individual with epilepsy suffers recurrent seizures unprovoked by acute brain insults or metabolic derangements. Seizures are characterized by a brief period of uncontrolled involuntary shaking. They may be partial, involving only one part of the body, or generalized, involving the entire body, and they may be accompanied by loss of consciousness and of control of bowel or bladder function. Some individuals continue to have frequent seizures despite optimal treatment with anti-epileptic drugs. However, more than 70% of patients who are treated achieve long-term remission or freedom from seizures, usually within 5 years of diagnosis.2
Cost-effective epilepsy treatments are available and an ac-curate diagnosis can be made without technological equipment. Nonetheless, a vast majority of individuals with epilepsy in many resource-poor regions do not receive treatment.3–5 Untreated epilepsy is a critical public health issue, as people with untreated epilepsy face potentially devastating social consequences and poor health outcomes. Due to stigma, many persons with epi-lepsy have lower employment and education levels and lower socioeconomic status. For example, children with epilepsy who have a seizure at school may be dismissed, while adults may be barred from marriage or employment.2,6 In addition, persons with epilepsy have poor health outcomes, including greater psychological distress, more physical injuries such as fractures and burns, and increased mortality.7–12
The epilepsy treatment gap, defined as the proportion of people with epilepsy who require treatment but do not receive it,
has been proposed as a useful parameter to compare access to and quality of care for epilepsy patients across populations.13,14 Prior anecdotal and descriptive estimates suggest a treatment gap of more than 80% in many low-income countries,13,15 yet one recent systematic review and meta-analysis suggests that the treatment gap in developing countries is as low as 56%.16This intriguing discrepancy may be due to the methodological limitations of the prior systematic review, which had an excessively narrow search strategy, included only English-language articles, and used meta-analytic techniques to generate a population estimate of the treatment gap. First, the search strategy focused on “treat-ment gap” and “treatment status”. Many epilepsy prevalence studies report treatment data, but as the term “treatment gap” only recently came into usage in the research literature,13 many studies with treatment gap data may have been missed using this search strategy. Second, many studies, particularly from low-income countries, are published in local rather than international journals. By not including languages other than English, many studies with treatment gap data may have been missed. Finally, the use of meta-analytic techniques to generate a unitary esti-mate of the treatment gap may have biased the estimates for two reasons: first, there was considerable unexplained heterogeneity among treatment gap estimates, and second, included studies were conducted in populations that were not representative of developing countries as a whole.
In this systematic review and analysis of the variation in the epilepsy treatment gap, we have greatly expanded the scope of the systematic review by searching for population-based epilepsy prevalence studies in all languages. We have also described the
Une traduction en français de ce résumé figure à la fin de l’article. Al final del artículo se facilita una traducción al español. الرتجمة العربية لهذه الخالصة يف نهاية النص الكامل لهذه املقالة.
Objective To describe the magnitude and variation of the epilepsy treatment gap worldwide.Methods We conducted a systematic review of the peer-reviewed literature published from 1 January 1987 to 1 September 2007 in all languages using PubMed and EMBASE. The purpose was to identify population-based studies of epilepsy prevalence that reported the epilepsy treatment gap, defined as the proportion of people with epilepsy who require but do not receive treatment. Negative binomial regression models were used to assess trends and associations.Findings The treatment gap was over 75% in low-income countries and over 50% in most lower middle- and upper middle-income countries, while many high-income countries had gaps of less than 10%. However, treatment gaps varied widely both between and within countries. They were significantly higher in rural areas (rate ratio, RR: 2.01; 95% confidence interval, CI: 1.40–2.89) and countries with lower World Bank income classification (RR: 1.55; 95% CI: 1.32–1.82). There was no significant trend in treatment gap over time (RR: 0.92; 95% CI: 0.79–1.07).Conclusion There is dramatic global disparity in the care for epilepsy between high- and low- income countries, and between rural and urban settings. Our understanding of the factors affecting the treatment gap is limited; future investigations should explore other potential explanations of the gap.
Global disparities in the epilepsy treatment gap: a systematic reviewAna-Claire Meyer,a Tarun Dua,b Juliana Ma,c Shekhar Saxenab & Gretchen Birbeckd
a San Francisco General Hospital, University of California, 1001 Potrero Avenue (4M62), Box 0870, San Francisco, CA, 94110, United States of America (USA).b World Health Organization, Geneva, Switzerland.c Vassar College, Poughkeepsie, New York, USA.d Chikankata Health Services Epilepsy Care Team, Mazabuka, Zambia.Correspondence to Ana-Claire Meyer (e-mail: [email protected]).(Submitted: 19 March 2009 – Revised version received: 19 August 2009 – Accepted: 20 August 2009 – Published online: 25 September 2009 )
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magnitude of the treatment gap world-wide and conducted some preliminary assessments of its variation.
MethodsWe conducted a systematic review of the peer-reviewed literature published in all languages from 1 January 1987 to 1 Sep-tember 2007 using PubMed and EM-BASE. Search terms included PubMed MeSH terms and keywords “epilepsy” AND “morbidity,” OR “epilepsy” AND “delivery of health care,” OR “treatment gap” AND “epilepsy”. This generated 14 985 titles. Hand searching of 68 re-views of epilepsy prevalence generated an additional 30 unique titles. All titles were reviewed to identify potential epilepsy prevalence studies, then 499 abstracts and 253 full manuscripts were reviewed to identify population-based epilepsy prevalence studies (Fig. 1). Data were extracted and reviewed independently by two authors.
To be included in the analysis, epi-lepsy prevalence studies had to be based on a population-based sample and ap-ply a standard definition of epilepsy. A population-based sample was defined as a door-to-door or other probability sample of a regional or national population. Stud-ies in which the sample was drawn from a medical care setting were excluded to avoid underestimating the treatment gap. School-based populations in countries where school attendance was low were also excluded. Finally, studies based on methods shown to produce unreliable community-based samples in epilepsy prevalence studies, such as the key infor-mant method, were excluded as well.17,18
The standard definition of epilepsy had to be internally consistent and to
differentiate epilepsy from provoked seizures, febrile seizures and isolated seizures. For lifetime epilepsy, acceptable definitions included a history of more than one unprovoked seizure. For active epilepsy, acceptable definitions included a history of more than one unprovoked seizure and either recent seizures (within the previous 5 years) or current use of anti-epilepsy medication. If the treatment gap or other information was missing from the manuscript, we tried to contact the authors to obtain the information before excluding the study.
Further analysis of the variation in epilepsy treatment gap estimates was lim-ited to studies of active epilepsy, as studies using lifetime epilepsy could overestimate the treatment gap. For example, some individuals captured when considering the lifetime prevalence of epilepsy may be in terminal remission and off treat-ment.19 Including them in the estimates would overestimate the treatment gap because by not being on anti-epileptic drugs, these individuals are receiving the recommended standard of care.
We analysed the variation in the epi-lepsy treatment gap by study area (urban versus rural), country income category and year. We used negative binomial re-gression models to examine associations and trends and used separate models to examine the association between treat-ment gap and study area, country income category and year. Treatment gaps were expressed as the number of untreated persons with active epilepsy, with the number of persons having active epilepsy used as the exposure variable. Studies were classified as rural or not rural based on the site description in the methods section of the manuscripts. Countries were classified as low, lower middle, upper
middle or high-income economies using World Bank criteria.20 Prevalence year was extracted from the manuscripts; if no prevalence year was provided, the year of publication was used instead. World Bank income category and prevalence year, arranged in 5-year intervals, were treated as ordered categorical variables. Stata 10 (StataCorp LP, College Station, TX, United States of America) was used for the analysis. Significance level was set at P ≤ 0.05.
ResultsOur search yielded 157 epilepsy preva-lence studies that met our stated inclu-sion criteria, but 83 (nearly 53%) of them did not collect treatment gap data. Therefore, our final sample con-sisted of 74 studies representing 38 countries (Table 1 and Table 2, available at: http://www.who.int/bulletin/vol-umes/88/4/09-064147/en/index.html). Of note, we reviewed 60 articles in languages other than English (Chinese, English, French, German, Italian, Japa-nese, Portuguese, Russian, Spanish and Turkish) and 10 of them were included in the study. Manuscripts included in our final sample were published in English, French, Spanish and Turkish.
Active epilepsy was used to estimate the treatment gap in 54 populations from 28 countries (Table 1) and lifetime epilepsy was used to estimate the treat-ment gap in 18 populations from 16 countries (10 of which were not among the countries for which the active epilepsy gap was estimated). (Table 2). Studies spanned nearly 30 years, from 1978 to 2006, and originated across the globe, including Africa, Asia, Europe and North and South America. Study populations differed markedly in terms of type of study area (urban versus rural), sample size and degree to which they represented the entire country. Nearly 47% (34/72) of the included studies were drawn from rural populations. Treatment gaps were calculated from samples ranging from 5 to 1175 epilepsy cases. Samples were drawn from many different populations; some were nationally representative, while others represented small ethnic groups, indigenous groups, schoolchildren or military recruits.
Treatment gaps estimated from ac-tive epilepsy prevalence ranged widely between countries. Gaps were 10% or less in China (Province of Taiwan), Norway, Singapore, the United Kingdom of Great
Fig. 1. Flowchart of study selection for systematic review of population-based studies of epilepsy prevalence and treatment gap
14 985 titlesreviewed
68 reviewarticles
499 abstractsreviewed
30 uniquereferences
253manuscripts
reviewed(60 not
in English)
74 studiesmet inclusion
criteria(10 not inEnglish)
- 45 not population based- 83 no treatment data- 18 review or not prevalence study- 22 duplicative or methods papers- 1 no standard definition- 8 incomplete quality- 2 unable to obtain
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Britain and Northern Ireland, the United States of America, and select populations in Argentina, Brazil and France. In sharp contrast, treatment gaps were greater than 95% in China, Ethiopia, the Gambia, the Lao People’s Democratic Republic, Nige-ria, Pakistan, Panama, Togo, Uganda, the United Republic of Tanzania and Zambia (Fig. 2). A wide range of treatment gaps was observed within countries as well. For example, treatment gaps in India ranged from 22% in an urban middle- income population to 90% in a sample of rural villages.18,21
Like treatment gaps estimated from active epilepsy prevalence, the gaps estimated from lifetime prevalence also ranged widely, from 6% in Singapore to 100% in Bolivia (Fig. 3).22,23 In most cases, gaps estimated from lifetime preva-lence were larger than those estimated from active epilepsy prevalence. How-ever, paradoxically, in a few low-income countries such as Pakistan and India, the treatment gap estimated from lifetime prevalence was smaller than some or all of the gap estimates based on active epilepsy prevalence.
For the analysis of the variation in the treatment gap, only studies estimating the gap from individuals with active epilepsy were used. In these studies, rural popula-
tions had treatment gaps nearly twice as high as populations from towns or from suburban, semi-urban or urban locations (rate ratio, RR: 2.01; 95% confidence
Fig. 2. Epilepsy treatment gap (%) and standard errors, by country and World Bank income category
0
Trea
tmen
t gap
(%)
100
Standard error
Rural
Urban or mixed
20
Low income
Ugan
da
Children only80
60
40
Togo
Unite
d Rep
ublic
of Tan
zania
Gambia
Ethiop
ia
Pakis
tan
Lao P
eople
’s Dem
ocrat
ic Re
publi
c
Zambia
Nigeria Ind
iaKe
nya
Mali
Madag
asca
r
Sene
gal
China
Ecua
dor
Hondu
ras
Pana
ma
Low middleincome
South
Afric
aTu
rkey
Brazil
Argen
tina
Upper middleincome
Spain
Unite
d Stat
es of
Ameri
ca
Franc
e
Taiwan
, Chin
a
Norway
Unite
d King
dom of
Great B
ritain
and N
orthe
rn Ire
land
High income
Fig. 3. Epilepsy treatment gap (%) and standard errors calculated from lifetime prevalence estimates
0
Trea
tmen
t gap
(%)
100
Bolivi
a
Standard error
Rural
Urban or mixed
50
Low income
Bang
lades
h
Pakis
tan India
Colombia
Jamaic
a
Sri La
nka
China
Camero
on
Guatem
alaFra
nce
Netherl
ands
Unite
d Stat
es
of Am
erica Ita
lySp
ain
Singa
pore
Lower middle income
Children only
High income
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interval, CI: 1.40–2.89; Z: 3.77; P < 0.001) (Fig. 4). For example, in India the treatment gap ranged from 40 to 90% in rural areas and from 22 to 50% in mixed, suburban and urban populations.18,21,24,25 Similar trends were observed in Brazil, China, Pakistan and Togo. However, there were a few exceptions: in a rural population from Rajasthan, India, the treatment gap was 40% (the third lowest in India),25 while in a rural population of Mali it was 65% (versus 76% in an urban population).26,27
There was a significant trend towards larger epilepsy treatment gaps in countries with lower incomes; for every one-level decrease in World Bank income category, the treatment gap increased by a factor of 1.55 (95% CI: 1.32–1.82; Z: 5.34; P < 0.001) (Fig. 4). However, within high-income countries, larger gaps were found in select populations. In a small sample from Spain, the treatment gap was greater than 50%, while among the Guaymi Indians in Panama the gap was 100%.28,29 Similarly, select populations in low-income countries had surprisingly small gaps; suburban and urban popula-tions in India, Madagascar and Senegal had treatment gaps of less than 30%.21,30–32
Direct comparisons of treatment gaps over time were difficult to carry out because of differences in study methods and populations. In Ethiopia, two studies
in the same population in which the same methods were used showed a gap of 98% in 1986–1988 and a gap of 87% among new cases identified during a repeat survey in 1990.33,34 Overall, treatment gaps de-creased from 1980 to the present, but no significant trend over time was detected (RR: 0.92; 95% CI: 0.79–1.07; Z: −1.08; P = 0.28).
DiscussionThe results of this systematic review of the literature suggest that there are dra-matic global disparities in the care and treatment of epilepsy patients. Treatment gaps for active epilepsy exceeded 75% in most low-income countries and 50% in most lower middle- and upper middle-income countries. In stark contrast, many high-income countries had gaps of less than 10%. However, treatment gaps varied widely, both between and within countries.
Our search methods resulted in more comprehensive estimates of the epilepsy treatment gap than those employed in previous studies. First, our systematic and thorough search strategy and rigor-ous inclusion criteria ensured the quality of included studies. Second, our wider search strategy, which focused on epilepsy prevalence rather than on the treatment gap, captured 26 more studies than did a
recent systematic review,16 even when we applied the same inclusion criteria. Third, our search of the non-English-language literature led to an additional 10 studies.
The subsequent analysis of the varia-tion in the treatment gap showed sig-nificantly higher gaps in rural areas and lower-income countries. These findings are consistent with those for other health indicators, such as the rates of vaccina-tion coverage and of maternal, infant and under-five mortality, which suggest wide disparities in care between rural and urban areas and between high- and low-income countries.35–40 On the other hand, epilepsy treatment gaps have decreased from 1980 to the present, though the trend is not statistically significant.
While intriguing, these preliminary analyses do not fully explain the variation in the treatment gap, which may addition-ally reflect local or regional differences in access to and quality of epilepsy care or in the availability of individual or regional economic resources.13,16 In addition, cul-tural differences in the stigma associated with epilepsy may determine whether an individual seeks care for epilepsy or not.2,6
In our analysis, we found that the treatment gap varied widely both within and between countries and that it was significantly associated with country income classification and a popula-tion’s status as urban or rural. Similarly, prior studies of the gap demonstrated significant heterogeneity in treatment gap estimates.16 The wide variation among estimates as well as the systematic varia-tion as a function of selected covariates suggests that meta-analytic techniques may not be appropriate for obtaining overall population estimates of the epi-lepsy treatment gap. Further study into the influence of macroeconomic and microeconomic factors and of resources for the care of people with epilepsy and other neurologic disorders will be critical to understanding the reasons for this het-erogeneity. Accounting for the systematic variation in the gap is essential to creating summary estimates of the gap. Combining demographic approaches with multiple imputation techniques could generate more representative gap estimates.
Our data set had several limitations. First, our sample was limited because we excluded epilepsy prevalence studies that did not collect treatment information (nearly half of those identified) or that calculated the gap from a potentially biased sample, such as clinic or hospital
Fig. 4. Mean epilepsy treatment gap (%) and standard errors by rural/urban status, World Bank income category and year data collected
0
Trea
tmen
t gap
(%)
100
Standard error
50
Rural
Urban
Low in
come
Lower
middle
incom
e
Uppe
r midd
le inc
ome
High in
come
1980
–84
1985
–89
1990
–94
1995
–99
2000
–04
2004
–08
a
c
b
a RR = 2.01; 95% CI: 1.40–2.89,P < 0.001a b RR = 1.55; 95% CI: 1.32–1.82,P < 0.001b c RR = 0.92; 95% CI: 0.79–1.07,P = 0.28c
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ملخص التباين العاملي يف فجوة معالجة الرصع: مراجعة منهجيةالغرض: وصف املقدار والتباين العاملي يف فجوة معالجة الرصع.
خضعت التي للمنشورات منهجية مراجعة الباحثون أجرى الطريقة: ملراجعة الزمالء ونرشت خالل الفرتة من أول كانون الثاين/يناير 1987 حتى النرشيات موقعي يف املستخدمة اللغات بجميع 2007 أيلول/سبتمرب أول ذلك وراء الهدف وكان .EMBASE و PubMed اإلنرتنت عىل الطبية تحديد الدراسات السكانية النتشار الرصع التي أبلغت عن وجود فجوة يف معالجة الرصع، وميكن تعريف الفجوة عىل أنها نسبة املصابني بالرصع الذين يحتاجون إىل العالج ولكن ال يحصلون عليه. استخدمت مناذج توزيع التحوف
ثنايئ الحد لتقييم االتجاهات واالرتباطات. البلدان املنخفضة بلغت فجوة املعالجة أكرث من %75 يف املوجودات: الدخل، وأكرث من %50 يف أغلب البلدان الواقعة يف املرتبة السفىل واملرتبة البلدان املتوسطة الدخل، يف حني بلغت أقل من %10 يف أغلب العليا من
البلدان املرتفعة الدخل، إال أن فجوة املعالجة تباينت عىل نحو واسع سواء بني البلدان بعضها البعض أو يف داخل البلدان نفسها. وكانت الفجوة أعىل بدرجة يعتد بها يف املناطق الريفية )نسبة املعدل rate ratio: 2.01؛ وفاصلة منخفضة البلدان ويف )confidence interval 95%: 1.40 - 2.89 الثقة الثقة وفاصلة 1.55؛ املعدل: )نسبة الدويل البنك تصنيف حسب الدخل العالجية مع الفجوة به يف يعتد اتجاه %95: 1.32 - 1.82(. ومل يكن هنا
مرور الوقت )نسبة املعدل: 0.92؛ فاصلة الثقة 95%: 0.79 - 1.07(.املرتفعة البلدان بني الرصع رعاية يف ملحوظ تباين هناك االستنتاج: الدخل والبلدان املنخفضة الدخل، وبني املناطق الريفية واملناطق الحرضية. ومازال اإلملام بالعوامل التي تؤثر يف الفجوة العالجية محدوداً؛ وينبغي أن
تستكشف االستقصاءات مستقباًل سائر التفسريات املحتملة لهذه الفجوة.
patients. Using lifetime prevalence to calculate the gap could have resulted in an overestimate, so we only included data on lifetime prevalence for descrip-tive purposes.
Furthermore, our ability to generate national treatment gap estimates was lim-ited. Most treatment gap estimates were based on data from selected populations that were not representative of the nation as a whole. A sample not representative of the population was not a criterion for exclusion because it was a limitation of nearly all the studies reviewed. Among the studies we included were several per-formed in a rural or urban area only,34,41 among the elderly or children exclu-sively,27,42,43 in areas with a high prevalence of epilepsy,44 in military22,45 or school populations,46 or in regions populated by only one or a few ethnic groups.7,47 Likewise, several included studies had been conducted in ethnic or social groups that differed from the population of the country as a whole. Examples include the Parsi community in India,21 the Bakairi indians from Brazil,44 the Zay society in Ethiopia48 or the Guaymi indians of Panama.28 Therefore, caution should be exercised in extrapolating treatment gap estimates from such select populations to the country as a whole without proper adjustment.
Although we tried to minimize varia-tion by means of our inclusion criteria,
study methods – case ascertainment, sampling technique, the definitions of active epilepsy and of adequate treatment, etc. – differed widely among studies. The quality and comparability of treatment gap data could be improved by apply-ing standard definitions for adequate treatment and active epilepsy and by using more nationally representative population-based samples to generate active epilepsy prevalence and estimate the treatment gap. Better insight into the causes of this gap would be obtained if epilepsy prevalence studies routinely collected information on other sociode-mographic characteristics, the availability and accessibility of local or regional health services and treatment, and the stigma associated with seeking care.
ConclusionIn summary, our systematic review of the epilepsy treatment gap worldwide shows a dramatic global disparity in the care of epilepsy patients between high- and low-income countries and between rural and urban settings. Epilepsy is a common and potentially serious neurological dis-order that can be diagnosed and treated inexpensively. Historically, epilepsy has received little public health attention despite poor health outcomes and po-tentially devastating social consequences from untreated disease. In recent years,
many countries have undertaken initia-tives to decrease the epilepsy treatment gap, notably the demonstration projects such as the Global Campaign Against Epilepsy, conducted jointly by the In-ternational League against Epilepsy, the International Bureau for Epilepsy and the World Health Organization. Large community based trials in Brazil and China have demonstrated that epilepsy can be treated with inexpensive and ef-fective drugs at the community level by primary health professionals with basic training.5,49 Increased commitment by the global health community is needed to reduce the treatment gap and thereby reduce the potentially devastating social consequences and poor health outcomes resulting from untreated epilepsy. ■
AcknowledgementsWe thank John Boscardin, Associate Professor of Medicine and Biostatistics, for his help with the statistical analysis.
Funding: Ana-Claire Meyer: Veterans Affairs/Robert Wood Johnson Clinical Scholars Program, American Academy of Neurology Practice Research Train-ing Fellowship. Gretchen Birbeck: The Global Burden of Diseases, Injuries, and Risk Factors Study.
Competing interests: None declared.
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Objectif Décrire l’ampleur et les variations de l’insuffisance du traitement de l’épilepsie dans le monde. Méthodes A l’aide de PubMed et d’EMBASE, nous avons réalisé une revue systématique de la littérature examinée par des pairs et publiée entre le 1er janvier 1987 et le 1er septembre 2007 dans toutes les langues. L’objectif était d’identifier des études en population de la prévalence de l’épilepsie indiquant l’insuffisance du traitement de cette maladie, définie comme la proportion des personnes épileptiques ayant besoin d’être traitées, mais ne recevant pas de traitement. Des modèles par régression binomiale négative ont été utilisés pour évaluer les tendances et les associations. Résultats L’insuffisance du traitement de l’épilepsie dépassait 75 % dans les pays à faible revenu et 50 % dans la plupart des pays à revenu moyen inférieur et moyen supérieur, alors que dans de nombreux pays à revenu élevé, cette insuffisance était inférieure à 10 %. Néanmoins,
l’insuffisance du traitement variait fortement d’un pays à l’autre et au sein d’un même pays. Elle était significativement plus importante dans les zones rurales (risque relatif, RR : 2,01 ; intervalle de confiance à 95 %, IC : 1,40-2,89) et dans les pays appartenant à la classe de revenu inférieure de la Banque mondiale (RR : 1,55 ; IC à 95 % : 1,32-1,82). On n’a relevé aucune tendance significative de l’insuffisance du traitement de l’épilepsie au cours du temps (RR : 0,92 ; IC à 95 % : 0,79-1,07). Conclusion Il existe à travers le monde des disparités considérables dans les soins dispensés aux épileptiques, et notamment entre les pays à revenu faible et élevé et entre les environnements ruraux et urbains. Notre compréhension des facteurs influant sur l’insuffisance du traitement est limitée : dans le cadre d’investigations futures, il conviendrait d’étudier d’autres explications possibles de cette insuffisance.
Resumen
Disparidades mundiales en la brecha de tratamiento de la epilepsia: revisión sistemáticaObjetivo Describir la magnitud y las diferencias de la brecha de tratamiento de la epilepsia a nivel mundial. Métodos A través de PubMed y EMBASE, se hizo una revisión sistemática de los artículos revisados por homólogos publicados entre el 1 de enero de 1987 y el 1 de septiembre de 2007. La finalidad era encontrar estudios poblacionales sobre la prevalencia de la epilepsia que informaran acerca de la brecha de tratamiento de esa enfermedad, definida como la proporción de personas afectadas que necesitan pero no reciben tratamiento. Las tendencias y relaciones se evaluaron mediante modelos de regresión binomial negativa.Resultados La brecha terapéutica era superior al 75% en los países de ingresos bajos, y superior al 50% en la mayoría de los países de ingresos medios bajos y medios altos, mientras que muchos países de ingresos
altos presentaban brechas inferiores al 10%. Sin embargo, la magnitud de la brecha terapéutica difería ampliamente tanto entre los países como en cada país. Era significativamente mayor en las zonas rurales (razón de tasas, RT: 2,01, intervalo de confianza del 95%: 1,40–2,89) y en los países incluidos en la categoría de ingresos bajos del Banco Mundial (RT: 1,55, IC95%: 1,32–1,82). No se observó ninguna tendencia significativa de la brecha a lo largo del tiempo (RT: 0,92, IC95%: 0,79–1,07).Conclusión En lo referente al tratamiento de la epilepsia, existe una enorme disparidad mundial entre los países de altos y de bajos ingresos, y entre las zonas rurales y las urbanas. Nuestros conocimientos sobre los factores que determinan esa brecha terapéutica son limitados, y en las investigaciones futuras se deberían estudiar otras posibles explicaciones de la misma.
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Tabl
e 1.
Stu
dies
use
d fo
r est
imat
ing
epile
psy
trea
tmen
t gap
bas
ed o
n th
e pr
eval
ence
of a
ctiv
e ep
ileps
y, by
cou
ntry
Coun
try
Loca
tion
Year
No. o
f ca
ses
% tr
eatm
ent
gap
Setti
ng/
popu
latio
nSt
udy
Arge
ntin
aJu
nin
1991
6422
Tow
nKo
chen
S, M
elco
n M
O. P
rogn
osis
of e
pile
psy
in a
com
mun
ity-b
ased
stu
dy: 8
yea
rs o
f fol
low
-up
in a
n Ar
gent
ine
com
mun
ity. A
cta
Neur
ol S
cand
200
5;11
2:37
0-4.
doi
:10.
1111
/j.16
00-0
404.
2005
.005
19.x
PM
ID:1
6281
918
Arge
ntin
aBu
enos
Aire
s19
9184
7Ur
ban,
pr
imar
y
scho
ol
Som
oza
MJ,
For
lenz
a RH
, Bru
ssin
o M
, Lic
ciar
di L
. Epi
dem
iolo
gica
l sur
vey
of e
pile
psy
in th
e pr
imar
y sc
hool
po
pula
tion
in B
ueno
s Ai
res.
Neu
roep
idem
iolo
gy 2
005;
25:6
2-8.
doi
:10.
1159
/000
0862
85 P
MID
:159
4749
2
Braz
ilM
ato
Gros
so s
tate
2000
967
Rura
l, Ba
kairi
in
dian
sBo
rges
MA,
Bar
ros
EP, Z
anet
ta D
M, B
orge
s AP
. Pre
vale
nce
of e
pile
psy
in B
akai
ri in
dian
s fro
m M
ato
Gros
so
Stat
e, B
razil
. Arq
Neu
rops
iqui
atr 2
002;
60:8
0-5
[Por
tugu
ese.
]. PM
ID:1
1965
413
Braz
ilRi
o de
Jan
eiro
2000
50
Urba
n, lo
w-
inco
me
Gom
es M
, Zei
toun
e R,
Kro
pf L
, Van
Bee
ck E
. A h
ouse
-to-
hous
e su
rvey
of e
pile
ptic
sei
zure
s in
an
urba
n co
mm
unity
of R
io d
e Ja
neiro
, Bra
zil. A
rq N
euro
psiq
uiat
r 200
2;60
:708
-11.
PM
ID:1
2364
934
Braz
ilBa
rao
Gera
ldo,
Cam
pina
s; J
agua
re
and
Sant
o An
toni
o, S
ao J
ose
do R
io
Pret
o, s
outh
-eas
tern
Bra
zil
2002
290
38M
ixed
Noro
nha
AL, B
orge
s M
, Mar
ques
L, Z
anet
ta D
, Fer
nand
es P
, De
Boer
H, e
t al.
Prev
alen
ce a
nd p
atte
rn o
f ep
ileps
y tre
atm
ent i
n di
ffere
nt s
ocio
econ
omic
cla
sses
in B
razil
. Epi
leps
ia 2
007;
48:8
80-8
85. d
oi:1
0.11
11/
j.152
8-11
67.2
006.
0097
4.x
PMID
:173
2678
8Ch
ina
5 pr
ovin
ces:
Hei
long
jiang
, Nin
gxia
, He
nan,
Sha
nxi,
Jian
gsu
2003
a25
763
Mixe
dW
ang
WZ,
Wu
JZ, W
ang
DS, D
ai X
Y, Ya
ng B
, Wan
g TP
, et a
l. Th
e pr
eval
ence
and
trea
tmen
t gap
in e
pile
psy
in C
hina
: an
ILAE
/IBE/
WHO
stu
dy. N
euro
logy
200
3;60
:154
4-5.
PM
ID:1
2743
252
Chin
a, P
rovin
ce
of T
aiw
an20
dis
trict
s an
d to
wns
hips
in Il
an
Coun
ty, N
E Ta
iwan
1993
–95
254
Mixe
d,
adul
ts >
40
yr
s ol
d
Su C
L, C
hang
SF,
Chen
ZY,
Lee
CS, C
hen
RC. N
euro
epid
emio
logi
cal s
urve
y in
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, Tai
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(NES
IT):
Prev
alen
ce o
f epi
leps
y. Ac
ta N
euro
l Tai
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1998
;7:7
5-84
.
Chin
aTi
bet A
uton
omou
s Re
gion
2006
3597
Rura
lZh
ao Y,
Zha
ng Q
, Tse
ring
T, Sa
ngw
an, H
u X,
Liu
L, e
t al.
Prev
alen
ce o
f con
vuls
ive e
pile
psy
and
heal
th-
rela
ted
qual
ity o
f life
of t
he p
opul
atio
n w
ith c
onvu
lsive
epi
leps
y in
rura
l are
as o
f Tib
et A
uton
omou
s Re
gion
in
Chi
na: A
n in
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durin
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dic
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81.
doi:1
0.10
16/j.
yebe
h.20
07.1
0.01
2 PM
ID:1
8180
204
Ecua
dor
Atah
ualp
a20
0318
28Ru
ral
Del B
rutto
OH,
San
tiban
ez R
, Idr
ovo
L, R
odrig
uez
S, D
iaz-
Cald
eron
E, N
avas
C, e
t al.
Epile
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and
neur
ocys
ticer
cosi
s in
Ata
hual
pa: a
doo
r-to
-doo
r sur
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in ru
ral c
oast
al E
cuad
or. E
pile
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200
5;46
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doi:1
0.11
11/j.
0013
-958
0.20
05.3
6504
.x P
MID
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1695
6Ec
uado
rEl
Car
chi a
nd Im
babu
ra re
gion
s,
north
ern
Ecua
dor
1992
a57
579
Rura
lPl
acen
cia
M, S
horv
on S
D, P
ared
es V
, Bim
os C
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der J
W, S
uare
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et a
l. Ep
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ic s
eizu
res
in a
n An
dean
regi
on o
f Ecu
ador
. Inc
iden
ce a
nd p
reva
lenc
e an
d re
gion
al v
aria
tion.
Bra
in 1
992;
115:
771-
82.
doi:1
0.10
93/b
rain
/115
.3.7
71 P
MID
:162
8201
Pl
acen
cia
M, S
ande
r J, R
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M, M
ader
a A,
Cre
spo
F, Ca
scan
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ated
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Neu
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3.32
0 PM
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1581
80Et
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06a
3453
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Year
No. o
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ent
gap
Setti
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popu
latio
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fenn
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ld
deve
lopm
ent s
tudy
. BM
J 19
98;3
16:3
39-4
2. P
MID
:948
7166
Unite
d Re
publ
ic o
f Ta
nzan
ia
Nach
ingw
ea d
istri
ct19
9942
95Ru
ral
Dent
W, H
elbo
k R,
Mat
uja
WB,
Sch
eune
man
n S,
Sch
mut
zhar
d E.
Pre
vale
nce
of a
ctive
epi
leps
y in
a
rura
l are
a in
Sou
th U
nite
d Re
publ
ic o
f Tan
zani
a: a
doo
r-to
-doo
r sur
vey.
Epile
psia
200
5;46
:196
3-9.
do
i:10.
1111
/j.15
28-1
167.
2005
.003
38.x
PM
ID:1
6393
163
Unite
d Re
publ
ic o
f Ta
nzan
ia
Ulan
ga d
istri
ct19
89–1
990
185
100
Rura
lRw
iza H
, Kilo
nzo
G, H
aule
J, M
atuj
a W
, Mte
za I,
Mbe
na P
, et a
l. Pr
eval
ence
and
inci
denc
e of
ep
ileps
y in
Ula
nga,
a ru
ral T
anza
nian
dis
trict
: a c
omm
unity
-bas
ed s
tudy
. Epi
leps
ia 1
992;
33:1
051-
6.
doi:1
0.11
11/j.
1528
-115
7.19
92.tb
0175
8.x
PMID
:146
4263
Rw
iza H
. The
Muh
imbi
li ep
ileps
y pr
ojec
t, a
thre
e pr
onge
d ap
proa
ch. T
rop
Geog
r Med
199
4;46
Sup
pl;2
2-4.
Unite
d St
ates
of
Amer
ica
Was
hing
ton
Heig
hts,
Inw
ood,
New
Yor
k Ci
ty20
04–2
005
427
Urba
nKe
lvin
EA, H
esdo
rffer
DC,
Bag
iella
E, A
ndre
ws
H, P
edle
y TA
, Shi
h TT
, et a
l. Pr
eval
ence
of s
elf-
repo
rted
epile
psy
in a
mul
tirac
ial a
nd m
ultie
thni
c co
mm
unity
in N
ew Y
ork
City.
Epi
leps
y Re
s 20
07;7
7:14
1-50
. do
i:10.
1016
/j.ep
leps
yres
.200
7.09
.012
PM
ID:1
8023
147
Unite
d St
ates
of
Amer
ica
Calif
orni
a20
0332
210
Mixe
dKo
bau
R, Z
ahra
n H,
Gra
nt D
, Thu
rman
DJ,
Pric
e PH
, Zac
k M
M. P
reva
lenc
e of
act
ive e
pile
psy
and
heal
th-
rela
ted
qual
ity o
f life
am
ong
adul
ts w
ith s
elf-
repo
rted
epile
psy
in C
alifo
rnia
: Cal
iforn
ia H
ealth
Inte
rvie
w
Surv
ey, 2
003.
Epi
leps
ia 2
007;
48:1
904-
13. d
oi:1
0.11
11/j.
1528
-116
7.20
07.0
1161
.x P
MID
:175
6559
1Un
ited
Stat
es o
f Am
eric
a
19 s
tate
s20
0591
97
Mixe
dKo
bau
R, Z
ahra
n H,
Thu
rman
DJ,
Zac
k M
M, H
enry
TR,
Sch
acht
er S
C, e
t al.
Epile
psy
surv
eilla
nce
amon
g ad
ults
— 1
9 St
ates
, Beh
avio
ural
Ris
k Fa
ctor
Sur
veilla
nce
Syst
em, 2
005.
MM
WR
Surv
eill
Sum
m
2008
;57:
1-20
. PM
ID:1
8685
554
Zam
bia
Chik
anka
ta c
atch
men
t are
a20
00–2
001
799
97Ru
ral
Birb
eck
GL, K
alic
hi E
M. E
pile
psy
prev
alen
ce in
rura
l Zam
bia:
a d
oor-
to-d
oor s
urve
y. Tr
op M
ed In
t Hea
lth
2004
;9:9
2-5.
doi
:10.
1046
/j.13
65-3
156.
2003
.011
49.x
PM
ID:1
4728
612
a Pre
vale
nce
year
not
repo
rted
in m
anus
crip
t, th
eref
ore
publ
icat
ion
year
su
bstit
uted
.
E
Ana-Claire Meyer et al. Global disparities in the epilepsy treatment gapResearch
Bull World Health Organ 2010;88:260–266 | doi:10.2471/BLT.09.064147
Coun
try
Loca
tion
Year
No. o
f ca
ses
% tr
eatm
ent
gap
Setti
ng/
popu
latio
nSt
udy
Ugan
daKa
bend
e pa
rish,
Kab
arol
e di
stric
t19
9461
100
Rura
lKa
iser
C, K
ipp
W, A
saba
G, M
ugis
a C,
Kab
agam
be G
, Rat
ing
D, e
t al.
The
prev
alen
ce o
f epi
leps
y fo
llow
s th
e di
strib
utio
n of
onc
hoce
rcia
sis
in a
wes
t Uga
ndan
focu
s. B
ull W
orld
Hea
lth O
rgan
199
6;74
:361
-7.
PMID
:882
3957
Unite
d Ki
ngdo
m
of G
reat
Br
itain
and
No
rther
n Ire
land
Natio
nal c
hild
sur
vey
1988
124
2Na
tiona
l, ch
ildre
n on
lyKu
rtz Z
, Too
key
P, Ro
ss E
. Epi
leps
y in
you
ng p
eopl
e: 2
3 ye
ar fo
llow
up
of th
e Br
itish
nat
iona
l chi
ld
deve
lopm
ent s
tudy
. BM
J 19
98;3
16:3
39-4
2. P
MID
:948
7166
Unite
d Re
publ
ic o
f Ta
nzan
ia
Nach
ingw
ea d
istri
ct19
9942
95Ru
ral
Dent
W, H
elbo
k R,
Mat
uja
WB,
Sch
eune
man
n S,
Sch
mut
zhar
d E.
Pre
vale
nce
of a
ctive
epi
leps
y in
a
rura
l are
a in
Sou
th U
nite
d Re
publ
ic o
f Tan
zani
a: a
doo
r-to
-doo
r sur
vey.
Epile
psia
200
5;46
:196
3-9.
do
i:10.
1111
/j.15
28-1
167.
2005
.003
38.x
PM
ID:1
6393
163
Unite
d Re
publ
ic o
f Ta
nzan
ia
Ulan
ga d
istri
ct19
89–1
990
185
100
Rura
lRw
iza H
, Kilo
nzo
G, H
aule
J, M
atuj
a W
, Mte
za I,
Mbe
na P
, et a
l. Pr
eval
ence
and
inci
denc
e of
ep
ileps
y in
Ula
nga,
a ru
ral T
anza
nian
dis
trict
: a c
omm
unity
-bas
ed s
tudy
. Epi
leps
ia 1
992;
33:1
051-
6.
doi:1
0.11
11/j.
1528
-115
7.19
92.tb
0175
8.x
PMID
:146
4263
Rw
iza H
. The
Muh
imbi
li ep
ileps
y pr
ojec
t, a
thre
e pr
onge
d ap
proa
ch. T
rop
Geog
r Med
199
4;46
Sup
pl;2
2-4.
Unite
d St
ates
of
Amer
ica
Was
hing
ton
Heig
hts,
Inw
ood,
New
Yor
k Ci
ty20
04–2
005
427
Urba
nKe
lvin
EA, H
esdo
rffer
DC,
Bag
iella
E, A
ndre
ws
H, P
edle
y TA
, Shi
h TT
, et a
l. Pr
eval
ence
of s
elf-
repo
rted
epile
psy
in a
mul
tirac
ial a
nd m
ultie
thni
c co
mm
unity
in N
ew Y
ork
City.
Epi
leps
y Re
s 20
07;7
7:14
1-50
. do
i:10.
1016
/j.ep
leps
yres
.200
7.09
.012
PM
ID:1
8023
147
Unite
d St
ates
of
Amer
ica
Calif
orni
a20
0332
210
Mixe
dKo
bau
R, Z
ahra
n H,
Gra
nt D
, Thu
rman
DJ,
Pric
e PH
, Zac
k M
M. P
reva
lenc
e of
act
ive e
pile
psy
and
heal
th-
rela
ted
qual
ity o
f life
am
ong
adul
ts w
ith s
elf-
repo
rted
epile
psy
in C
alifo
rnia
: Cal
iforn
ia H
ealth
Inte
rvie
w
Surv
ey, 2
003.
Epi
leps
ia 2
007;
48:1
904-
13. d
oi:1
0.11
11/j.
1528
-116
7.20
07.0
1161
.x P
MID
:175
6559
1Un
ited
Stat
es o
f Am
eric
a
19 s
tate
s20
0591
97
Mixe
dKo
bau
R, Z
ahra
n H,
Thu
rman
DJ,
Zac
k M
M, H
enry
TR,
Sch
acht
er S
C, e
t al.
Epile
psy
surv
eilla
nce
amon
g ad
ults
— 1
9 St
ates
, Beh
avio
ural
Ris
k Fa
ctor
Sur
veilla
nce
Syst
em, 2
005.
MM
WR
Surv
eill
Sum
m
2008
;57:
1-20
. PM
ID:1
8685
554
Zam
bia
Chik
anka
ta c
atch
men
t are
a20
00–2
001
799
97Ru
ral
Birb
eck
GL, K
alic
hi E
M. E
pile
psy
prev
alen
ce in
rura
l Zam
bia:
a d
oor-
to-d
oor s
urve
y. Tr
op M
ed In
t Hea
lth
2004
;9:9
2-5.
doi
:10.
1046
/j.13
65-3
156.
2003
.011
49.x
PM
ID:1
4728
612
a Pre
vale
nce
year
not
repo
rted
in m
anus
crip
t, th
eref
ore
publ
icat
ion
year
su
bstit
uted
.
Tabl
e 2.
Stu
dies
use
d fo
r est
imat
ing
epile
psy
trea
tmen
t gap
bas
ed o
n th
e lif
etim
e pr
eval
ence
of e
pile
psy,
by c
ount
ry
Cou
ntry
Loca
tion
Year
No. o
f ca
ses
% tr
eatm
ent
gap
Setti
ng/
popu
latio
nAu
thor
Bang
lade
shAt
tem
pts
to b
e re
pres
enta
tive
of c
ount
ry;
3 ru
ral,
2 ur
ban
area
s19
92a
6786
Mixe
d,
child
ren
Durk
in M
S, D
avid
son
L, H
asan
K, H
asan
Z, H
ause
r W, K
han
N, e
t al.
Estim
ates
of t
he p
reva
lenc
e of
chi
ldho
od s
eizu
re d
isor
ders
in c
omm
uniti
es w
here
pro
fess
iona
l res
ourc
es a
re s
carc
e:
resu
lts fr
om B
angl
ades
h, J
amai
ca a
nd P
akis
tan.
Pae
diat
r Per
inat
Epi
dem
iol 1
992;
6:16
6-80
. do
i:10.
1111
/j.13
65-3
016.
1992
.tb00
758.
x PM
ID:1
5847
19Bo
livia
Cord
illera
Pro
vince
, San
ta C
ruz
Depa
rtmen
t19
9412
410
0Ru
ral
Nico
letti
A, R
eggi
o A,
Bar
tolo
ni A
, Fai
lla G
, Sofi
a V,
Bar
tale
si F,
et a
l. Pr
eval
ence
of e
pile
psy
in ru
ral B
olivi
a:
a do
or-t
o-do
or s
urve
y. Ne
urol
ogy
1999
;53:
2064
-9. P
MID
:105
9978
2Ca
mer
oon
Bilo
mo,
wes
t ban
k of
Mba
m ri
ver i
n Ce
ntre
Pro
vince
of C
amer
oon
1998
9332
Rura
lNj
amns
hi A
K, S
ini V
, Djie
ntch
eu V
DP, O
ngol
o-Zo
go P
, Map
oure
Y, Y
epnj
io F
N, e
t al.
Risk
fact
ors
asso
ciat
ed
with
epi
leps
y in
a ru
ral a
rea
in C
amer
oon:
A p
relim
inar
y st
udy.
Afric
an J
Neu
rol S
ci 20
07;2
6:18
-26.
Chin
a4
tow
ns, 6
villa
ges
in D
ongn
ing
Coun
ty,
Mun
danj
iang
City
, Hei
long
jiang
Pro
vince
2000
8136
Rura
lM
a GY
, Li Z
Q, L
u S,
Wan
g LH
, Wen
SR,
Li G
Z, e
t al.
Surv
ey o
f etio
logi
cal f
acto
rs o
f epi
leps
y in
Mud
anjia
n ru
ral p
opul
atio
n by
rand
omly
clus
ter s
ampl
ing.
Chi
n J
Clin
Reh
abil
2004
;8:3
178-
9.
Tang
Y, L
i GZ,
Ma
GY, W
ang
DS. E
pide
mio
logi
cal s
urve
y of
epi
leps
y in
Don
gnin
g co
unty,
a ru
ral a
rea
in
Heilo
ngjia
ng P
rovin
ce o
f Chi
na. C
hin
J Cl
in R
ehab
il 20
04;8
:770
-1.
Colo
mbi
aM
edel
lin19
8377
73Ur
ban
Zulo
aga
L, S
oto
C, J
aram
illo D
, Mor
a O,
Bet
ancu
r C, L
ondo
no R
. [Pr
eval
ence
of e
pile
psy
in M
edel
lin,
Colo
mbi
a, 1
983]
. Bol
Ofic
ina
Sani
t Pan
am 1
988;
104:
331-
44. P
MID
:297
1372
Fran
ceHa
ute-
Vien
ne, L
imou
sin
regi
on19
86–8
720
55M
ixed
Mun
oz M
, Bou
tros-
Toni
F, P
reux
PM
, Cha
rtier
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Ndza
nga
E, B
oa F,
et a
l. Pr
eval
ence
of n
euro
logi
cal
diso
rder
s in
Hau
te-V
ienn
e de
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ent (
Lim
ousi
n re
gion
-Fra
nce)
. Neu
roep
idem
iolo
gy 1
995;
14:1
93-8
. do
i:10.
1159
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1097
96 P
MID
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3954
Guat
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aSm
all r
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ge19
96a
1631
Rura
lM
endi
zaba
l JE,
Sal
guer
o LF
. Pre
vale
nce
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pile
psy
in a
rura
l com
mun
ity o
f Gua
tem
ala.
Epi
leps
ia
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373-
6. d
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0.11
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Indi
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C ca
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Har
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th
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Sing
h A,
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r A. E
pile
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ral H
arya
na –
pre
vale
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ania
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sa
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iva (M
essi
na P
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ce);
Terra
sini
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aler
mo
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39Se
mi-u
rban
Rocc
a W
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tieri
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DW, M
eneg
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F, G
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etto
F, M
orga
nte
L, e
t al.
Door
-to-
door
pr
eval
ence
sur
vey
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pile
psy
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ree
Sici
lian
mun
icip
aliti
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euro
epid
emio
logy
200
1;20
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do
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1159
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MID
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8489
9Ja
mai
caM
ay P
en a
nd L
ione
l Tow
n, C
lare
ndon
pa
rish
1992
a32
62Ru
ral,
child
ren
Durk
in M
S, D
avid
son
L, H
asan
K, H
asan
Z, H
ause
r W, K
han
N, e
t al.
Estim
ates
of t
he p
reva
lenc
e of
chi
ldho
od s
eizu
re d
isor
ders
in c
omm
uniti
es w
here
pro
fess
iona
l res
ourc
es a
re s
carc
e:
resu
lts fr
om B
angl
ades
h, J
amai
ca a
nd P
akis
tan.
Pae
diat
r Per
inat
Epi
dem
iol 1
992;
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1111
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016.
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r WA,
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96.tb
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Paki
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arac
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3 ur
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1992
a99
62M
ixed,
ch
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an Z
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ser W
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vale
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rce:
re
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Ban
glad
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Jam
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Ana-Claire Meyer et al.Global disparities in the epilepsy treatment gapResearch
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8596
2a P
reva
lenc
e ye
ar n
ot re
porte
d in
man
uscr
ipt,
ther
efor
e pu
blic
atio
n ye
ar s
ubst
itute
d.