Banu, Selina Husna; (2003) Childhood epilepsy in Bangladesh: Clinical profile, predictors of outcome and randomized controlled trial of efficacy and side effect of drug treatment. Doctoral thesis (Ph.D.), University College London (United Kingdom).

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Abstract

Around 80% of the world's patients with epilepsy live in countries with limited resources, and are predominantly young, 90% of whom are not appropriately treated. Bangladesh is probably typical in this respect, with an estimated 6.5/1000 affected in the 2–9 years age group, but detailed information about childhood epilepsy is limited, and services are almost non-existent outside the 2 major cities. A study of childhood epilepsy was carried out in 3 stages. In the 1st, retrospective stage, an epilepsy profile was compiled in children aged 2 months to 15 years and predictors of poor seizure remission identified. Primary care physicians and multidisciplinary health workers were trained on short courses to diagnose and manage epilepsy and additional impairments. An extensive system of patient care, regular follow up and patient recall was set up in collaboration with a community service. The 2nd, prospective, stage was designed to validate the predictors of poor seizure remission using two groups of patients: those with newly diagnosed epilepsy from the community and the second from the child development centre (CDC) who were anticipated to have more neurodevelopmental impairments. In the 3rd stage, 108 patients from the 2nd stage study were enrolled in a randomized controlled trial (RCT) to compare the behavioural side effects of phenobarbitone (PB) and carbamazepine (CBZ). The pilot study of 151 children showed a high rate of neurodevelopmental disabilities (73% had cognitive and 57% had motor problems). Seizure remission was obtained in 45.7%, and predictors of poor seizure remission were multiple seizure types, cognitive impairment, and an abnormal EEG. The poor were under-represented in this study. The socio-economic profile of the newly recruited children in the 2nd stage was more representative of the general population, with around 60% from the poor, both urban and rural. As anticipated, the community group had less associated non-convulsive neurological-disorder(s) than that from CDC (38.8% vs 70.5% for motor and 47% vs 76.3% for cognitive impairment). After 12 months regular treatment, seizure remission was obtained in 77% who did not have additional non-convulsive disorder. In this population, multiple logistic regression analysis showed multiple seizure types (p<0.01), cognitive impairment (p<0.02) and associated motor disorder (p<0.04) predicted poor seizure remission. In the RCT there was no difference in efficacy between PB and CBZ, and no significant difference in behavioural problems between the two treatments. The study suggests that epilepsy outcome can be broadly predicted at first presentation using the 3 factors (associated motor disability, cognitive impairment and multiple seizure types), which could be applied by a community health care physician. A multidisciplinary service in a community health care setting is an appropriate model for managing childhood epilepsy in a developing country such as Bangladesh. The result from the RCT study suggests that and PB does not produce increased behavioural problems compared with CBZ.

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