Improving paediatric epilepsy management at the first level of care: a pilot education intervention for clinical officers in Zambia.

OBJECTIVE: Epilepsy affects approximately 50 million people globally, with approximately 80% living in low/middle-income countries (LMIC), where access to specialist care is limited. In LMIC, primary health workers provide the majority of epilepsy care, despite limited training in this field. Recognising this knowledge gap among these providers is an essential component for closing the epilepsy treatment gap in these regions. SETTING: In Zambia, the vast majority of healthcare is provided by clinical officers (COs), primary health providers with 3 years post-secondary general medical education, who predominantly work in first-level health centres around the country. PARTICIPANTS: With cooperation from the Ministry of Health, a total of 10 COs from 4 surrounding first-level health centres around the capital city of Lusaka participated, with 9 completing the entire course. INTERVENTION: COs were trained in a 3-week structured course on paediatric seizures and epilepsy, based on adapted evidence-based guidelines. RESULTS: Preassessment and postassessment were conducted to assess the intervention. Following the course, there was improved overall knowledge about epilepsy (69% vs 81%, p<0.05), specifically knowledge regarding medication management and recognition of focal seizures (p<0.05), improved seizure history taking and appropriate medication titration (p<0.05). However, knowledge regarding provoked seizures, use of diagnostic studies and general aetiologies of epilepsy remained limited. CONCLUSIONS: This pilot project demonstrated that a focused paediatric epilepsy training programme for COs can improve knowledge and confidence in management, and as such is a promising step for improving the large epilepsy treatment gap in children in Zambia. With feasibility demonstrated, future projects are needed to expand to more rural regions for more diverse and larger sample of primary health provider participants and encompass more case-based training and repetition of key concepts as well as methods to improve and assess long-term knowledge retention.

A retrospective observational study of EEG findings and antiepileptic drug use among children referred for EEG to Zambia's University Teaching Hospital.

OBJECTIVE: Despite the heavy burden of epilepsy in Sub-Saharan Africa, there remains a relative paucity of neurophysiology services and limited published data on electroencephalography (EEG) features among African children. The aim of this study was to describe clinical characteristics, EEG findings, and antiepileptic drug (AED) use among children referred for EEG to the University Teaching Hospital in Zambia. METHODS: EEG referrals and reports from 2013-2015 were reviewed. Within the context of routine care, EEG studies were interpreted by readers with advanced training in child neurology and clinical neurophysiology. Clinical data provided in the referral including seizure semiology and EEG findings were systematically extracted and analyzed. RESULTS: A total of 1,217 EEG reports were reviewed, with 1,187 included in the analysis. Median age was 7 years (interquartile range [IQR] 3-11) and 57% were male. Seventy-three percent of 554 had documented seizure onset before 5 years of age. Among the 23% with seizure etiology documented, 78% were associated with perinatal injuries and central nervous system (CNS) infections. EEG abnormalities were found in 75% of the studies. Clinical semiology per referral identified focal seizures in 29%, but EEG findings increased this proportion to 63% (p = 0.004). Sixty-two percent were taking AEDs, with 85% on monotherapy. The most commonly used AED was carbamazepine (49%).There was no association between the choice of AED and clinical semiology (all p's > 0.05). SIGNIFICANCE: This tertiary care center study identified >60% of referred children to have localization-related epilepsies, with at least 18% of epilepsies being from potentially preventable causes. These findings are consistent with multi-country, population-based data from elsewhere in Africa. Seizure semiology assessed in routine, nonspecialist care does not predict AED choice, and the presence of focality is underestimated in routine care.