Bridging the childhood epilepsy treatment gap in northern Nigeria (BRIDGE): Rationale and design of pre-clinical trial studies

Abstract

Epilepsy is the most common serious childhood neurological disorder. In the low- and middle-income countries (LMICs) of Africa, children with epilepsy suffer increased morbidity and mortality compared to their counterparts in high-income countries, and the majority do not receive treatment - the childhood epilepsy treatment gap. Reports of the childhood epilepsy treatment gap in Africa are likely underestimates; most surveys do not include several common childhood seizure types, including most types of non-convulsive epilepsy. Efforts to scale up childhood epilepsy care services in the LMICs of Africa must contend with a shortage of physicians and diagnostic technology [e.g., electroencephalograms (EEGs)]. One pragmatic solution is to integrate epilepsy care into primary care by task-shifting to community health extension workers. The aims of this project (BRIDGE) are to: 1) train, develop, and pilot task-shifted epilepsy care teams; 2) develop and pilot innovative childhood epilepsy screening and diagnostic paradigms adapted to the local Hausa language/culture in Kano, northern Nigeria; and, 3) quantify and map the childhood epilepsy treatment gap, using geographic information systems (GIS), to target limited resources to areas of greatest need. Task-shifted teams will diagnose and manage childhood epilepsy using an innovative epilepsy screening tools and diagnostic and management paradigms in environments with limited EEG access. If validated and demonstrated efficacious in clinical trials, this project can be taken to scale across broader areas of west Africa's LMICs that share language and culture. BRIDGE has the potential to enhance access to basic childhood epilepsy care and establish the foundation for childhood epilepsy clinical trials in west Africa.

Keywords: Childhood epilepsy; Epilepsy treatment gap; Hausa; Nigeria; Task shifting.

Fig. 1

BRIDGE timeline.

Fig. 2

Childhood Epilepsy Screening & Seizure Classification Tool^∗. ^∗Modified and expanded from Patel AA et al. Epilepsy & Behavior 2016; 59:57–61, with permission. ^#Question 2 added to screen for absence seizures & focal non-motor seizures ^%Questions 11 and 12 were separated into two questions.

Fig. 3

BRIDGE Task-shifted Childhood epilepsy Protocol.

Fig. 4

Selecting Houses within communities for the childhood epilepsy door-to-door survey. The epilepsy-trained community health extension workers (CHEWs) conducting the community survey in Kano, Nigeria, often without standardized street signs or addresses, will take the following steps, as documented in this map derived from satellite images of Kano (a) Start at a central location (e.g., a mosque as in Fig. 4a). determined by the survey team with local health workers. (b) Spin a pen or pencil in the air and let it to fall on the ground. Investigators will begin walking in the direction indicated by the point of the pen/pencil. (c) The number of houses between the starting point and the boundary of the community will be counted (In Fig. 4a example, there are 11 houses.). (d) A random number (between 1 and 11) will be selected. To select the random number, the numbers will be written on pieces of paper, the pieces of papers will be mixed together, then one will be pulled out of the pile. (In the example, the number 11 was randomly selected.) (3) The random walk will begin at the house that matched the random number (house no. 11 in Fig. 4b). After completing the study in the first selected house, the interviewer will walk to the next closest house. Whenever it seemed that two houses are the same distance away, a coin will be flipped to decide between the two.