Introduction from Dr Markus Reuber, editor-in-chief of Seizure
Despite a steady reduction of the number of people around the world living in absolute poverty, there are stark and undiminishing differences of wealth between countries and corresponding differences in access to health care. One well-established way of characterising the adequacy of provisions for people with epilepsy is the epilepsy treatment gap (ETG). The ETG is defined as the percentage of people with active epilepsy who are not receiving appropriate treatment in a given population at a particular time. One comprehensive review based on the analysis of 74 studies found considerable variations of the ETG between and within countries. In the majority of High Income Countries (HICs) and Upper Middle Income Countries (UMICs) (such as Taiwan, Norway, Singapore, the UK, USA or) the ETG was estimated at less than 10%. In contrast, the ETG was greater than 95% in many Lower Middle Income countries (LMICs) and LICs (including China, Laos, Pakistan and most sub-Saharan countries). The ETG was more than twice as large in rural as in urban populations (rate ratio (RR): 2.01; 95% CI 1.4, 2.9) (1).
My editor’s choice paper from the current issue of Seizure is about a different and less established kind of gap – the evidence gap. In their systematic review, Sharika Raga and Jo Wilmshurst consider the evidence for treatments, which may be available for infants and young children with Epileptic Spasms (ES) in countries in which first line treatments recommended in international guidelines and reviews are simply not available (2). With an incidence of 0.25 to 0.42 per 1000 live births per year ES are the most common seizure type in the infantile period in high income countries – and likely to be commoner still in LMICs and LICs (3). Rapid and effective treatment of ES (and the hypsarrhythmia in the EEG which ES are associated with) is of great importance because it is associated with better developmental outcomes. Reviews of the available research (largely carried out in HICs) suggest that ACTH should be considered the treatment of choice for ES except when ES are caused by Tuberous Sclerosis (and when Vigabatrin should be used) (4). The problem with this recommendation is that a course of ACTH in a country such as South Africa will cost over 11,000 times as much as a course of oral steroids. However, as the review by Raga and Wilmshurst shows, it is much less certain whether the drugs more likely to be available (prednisolone or prednisone, with its uncertain metabolism in infants) are as effective as ACTH and vigabatrin. The good news is that the cheaper drugs may work for many children. The bad news is that the evidence gap may turn out to be as difficult to close as the treatment gap!
1) Meyer AC, Dua T, Ma J, et al. Global disparities in the epilepsy treatment gap: a systematic review. Bulletin of the World Health Organization 2010;88: 260-266.
2) Raga S, Wilmshurst J. Epileptic spasms: Evidence for oral corticosteroids and implications for Low and Middle Income Countries Seizure 2018, please add details.
3) Cowan LD,Hudson LS.The epidemiology and natural history of infantilec spasms. Journal of Child Neurology. 1991;6(4):355-64.
4) Hancock EC, Osborne JP, Edwards SW. Treatment of infantile spasms. The Cochrane database of systematic reviews. 2013(6):CD001770