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Keywords:

  • Epilepsy;
  • Convulsions;
  • Partial seizures;
  • Electroencephalogram;
  • Status epilepticus;
  • Sub-Saharan Africa

Summary

  1. Top of page
  2. Summary
  3. Methods
  4. Results
  5. Discussion
  6. Acknowledgments
  7. Disclosure
  8. References

Purpose: Epilepsy is common in sub-Saharan Africa but is poorly characterized. Most studies are hospital-based, and may not reflect the situation in rural areas with limited access to medical care. We examined people with active convulsive epilepsy (ACE), to determine if the clinical features could help elucidate the causes.

Methods: We conducted a detailed descriptive analysis of 445 people with ACE identified through a community-based survey of 151,408 people in rural Kenya, including the examination of electroencephalograms.

Results: Approximately half of the 445 people with ACE were children aged 6 to 18 years. Seizures began in childhood in 78% of those diagnosed. An episode of status epilepticus was recalled by 36% cases, with an episode of status epilepticus precipitated by fever in 26%. Overall 169 had an abnormal electroencephalogram, 29% had focal features, and 34% had epileptiform activity. In the 146 individuals who reported generalized tonic–clonic seizures only, 22% had focal features on their electroencephalogram. Overall 71% of patients with ACE had evidence of focal abnormality, documented by partial onset seizures, focal neurologic deficits, or focal abnormalities on the electroencephalogram. Increased seizure frequency was strongly associated with age and cognitive impairment in all ages and nonattendance at school in children (p < 0.01).

Discussion: Children and adolescents bear the brunt of epilepsy in a rural population in Africa. The predominance of focal features and the high proportion of patients with status epilepticus, suggests that much of the epilepsy in this region has identifiable causes, many of which could be prevented.

Epilepsy is common in sub-Saharan Africa (SSA) but is poorly characterized (Belhocine et al., 2004; Preux & Druet-Cabanac, 2005). It is thought that the major causes differ from those in the resource-rich countries; in particular infections of the central nervous system may be more common. Recently, exposure to severe malaria was associated with epilepsy (Carter et al., 2004; Ngoungou et al., 2006). Underlying causes may manifest as focal features, but in SSA these features are often difficult to elicit in the semiology because of the difficulties in language and cultural perception of the symptoms. Many people with epilepsy do not use antiepileptic drugs (AEDs) (Meinardi et al., 2001; Scott et al., 2001; Coleman et al., 2002; Belhocine et al., 2004), thus the considerable treatment gap increases the likelihood of a poor outcome. In addition, the common comorbidities of epilepsy—cognitive, behavioral, and motor impairments—are poorly described in studies from SSA, and these may have a profound influence on social functioning and society’s acceptance of people with epilepsy.

Many studies that characterize epilepsy in SSA are hospital-based (Belhocine et al., 2004; Preux & Druet-Cabanac, 2005), but most people with epilepsy in SSA do not appear to use such facilities (Belhocine et al., 2004), for reasons of availability, cost, or trust in the service (Mbuba et al., 2008). Therefore, the data based on hospital studies may not reflect the situation that many people with epilepsy encounter in SSA, particularly in rural areas. The studies that have been conducted in rural areas either do not describe the features of epilepsy (Birbeck & Kalichi, 2004) or have not been conducted in malarious areas (Tekle-Haimanot et al., 1990). In recent studies of epilepsy in areas of Africa with malaria transmission, most seizures were reported as generalized (Dent et al., 2005; Ndoye et al., 2005; Winkler et al., 2009), but electroencephalography could have identified partial seizures (Kaiser et al., 2000), suggesting focal damage.

This study provides a detailed descriptive analysis of the demographic and clinical characteristics of people with active convulsive epilepsy (ACE) aged 6 years and older, identified during a large community-based survey in a rural malaria endemic area of Kenya (Edwards et al., 2008). In particular, we wanted to determine the prevalence of focal features with the use of electroencephalographic facilities.

Methods

  1. Top of page
  2. Summary
  3. Methods
  4. Results
  5. Discussion
  6. Acknowledgments
  7. Disclosure
  8. References

Study population

This study was conducted in Kilifi District, a rural area on the coast of Kenya. An area of 891 km squared has been mapped and forms part of a demographic surveillance system (DSS) including reenumeration every 4 months. Kilifi is the second poorest district within Kenya; income comes mainly from subsistence farming and there is low adult literacy and poor access to sanitation facilities. Malaria is endemic and pneumonia or bacteremia is also a common cause for admission to Kilifi District Hospital, the primary hospital for the district.

A large community-based screening survey was carried out in 2003 to identify people with ACE. The survey had two screening stages and a third and final diagnostic stage. During stage I, 151,408 individuals were screened by the census team during enumeration, using two questions with a sensitivity of 95% to identify individuals who experienced convulsions (Edwards et al., 2008). In stage II, responses to stage I questions were confirmed and additional questions asked of individuals experiencing convulsions by fieldworkers more experienced with epilepsy screening, in order to improve specificity for the final diagnostic stage. During stage III, a detailed medical history was taken by a clinician in the local language to make a diagnosis and classify epilepsy. All case notes were reviewed by a panel of neurologists (TK, JWS, BGN, and CRN) to confirm diagnoses and seizure classification.

The survey identified 445 individuals aged 6 years and older, who were resident within the study area with ACE. Specificity of stage II screening questions was high (95%) but stigma-related nonresponse led to predictions of missed cases in specific parts of the large study area (Edwards et al., 2008). Detailed results regarding the prevalence, treatment gap, and risk factors from a nested case–control study are reported elsewhere (Edwards et al., 2008).

Definition of active convulsive epilepsy

Two or more unprovoked convulsions, with one occurring within 12 months prior to stage III, based on the most recent International League Against Epilepsy (ILAE) definition of active epilepsy at the time of study design (ILAE, 1997) and criteria for offering AEDs to patients in Kenya (MOH, 1994; Dekker, 1998). Individuals younger than 6 years were excluded in stage II, due to difficulty in differentiating between febrile seizures and epilepsy in younger children (El Sharkawy et al., 2006).

Seizure types were classified according to the ILAE criteria (ILAE, 1981), with status epilepticus defined as a seizure lasting more than 30 min. Cognitive impairment was assessed by the local clinician through assessing the patient’s response to questions (including person, place, and time) and ease of following instructions. Electroencephalography (EEG) was recorded for 30 min from 16 leads using the 10–20 system, with photic stimulation and hyperventilation. All EEG studies were interpreted by an experienced neurophysiologist (SW), who classified them as normal or abnormal, and identified focal features and epileptiform activity.

A blood sample was taken from those who gave consent, to test for levels of phenobarbital. Samples were also tested for phenytoin, but only if use was reported, due to financial limitations. Drug levels were measured with TDxFLx fluorescence polarization immunoassay (Abbott Laboratories, Diagnostics Division, Abbott Park, IL, U.S.A.), which detects concentrations of at least 10 mg/L in phenobarbital and phenytoin. For the purposes of this study, an optimal level of phenobarbital was defined as 10–30 mg/L and for phenytoin, 10–20 mg/L (Perucca, 2004).

Data analysis

Data were double-entered and validated using VISUAL FOXPRO v9.0 (Microsoft Corp., Redmond, WA, U.S.A.) and analyzed using STATA, v9 (Stata Corporation, College Station, TX, U.S.A.). Comparisons of continuous data were by nonparametric Mann-Whitney tests because data were not normally distributed. Categorical data were tabulated and compared using the chi-square test, overall and for trend where appropriate. Seizure frequency was categorized into five groups: seizures occurring daily, weekly, or monthly, and last seizure occurring 2–6 months or 7–12 months prior to diagnosis. To test associations after adjustment for another factor we used likelihood ratio tests (LRTs) for comparing regression models.

Ethical clearance

This study was approved institutional review boards in the United Kingdom (Institute of Child Health and London School of Hygiene and Tropical Medicine) and Kenya (Kenyan National Ethics Review Board and University of Nairobi). The patients or their guardians gave consent for participation in the study.

Results

  1. Top of page
  2. Summary
  3. Methods
  4. Results
  5. Discussion
  6. Acknowledgments
  7. Disclosure
  8. References

Demographic characteristics

Of the 445 people, aged 6 years and older, diagnosed with ACE during the final phase of the screening survey, 225 (50.6%) were male. The overall median age was 18 years [interquartile range (IQR) 12–29 years] and the age distribution did not vary significantly by gender (p = 0.158).

Seizure history

The age at onset of seizures was reported by 428 patients with ACE (96.2%). The first seizure occurred before the age of 6 years in 228 patients (51.2%), before the age of 13 years in 296 (66.5%), and before the age of 18 years in 346 (77.8%). There was no significant difference in age at onset by gender (p = 0.176). An episode of status epilepticus (SE) was recalled by 161 people with epilepsy (36.2%), with the episode precipitated by fever by 118 (26.5%). For a further 125 (28.1%), history of reported SE was not available. A history of SE was significantly higher in children (55.9%) than in adults (18.1%) (p < 0.001).

Classification of seizures and EEG results

A single seizure type was determined in 322 people with ACE (72.4%), two seizure types in 113 (25.4%), and three seizure types in 9 (2.0%). Partial evolving into generalized seizures (PSGS) and primary generalized tonic–clonic seizures (GTCS) were the most common seizures experienced (Table 1), with almost half of all cases experiencing each type. Simple partial and complex partial seizures were classified in fewer cases (12.8% and 20.9%, respectively) and nonconvulsive seizures classified in <3%. The proportion of adults and children experiencing each seizure type, as listed in Table 1, did not differ significantly (p > 0.3).

Table 1.   Seizure types in 445 people with ACE
Types of seizureNumber identified from clinical historya n (%)Childrena n (%)Adultsa n (%)
  1. aNumber (%) of all people with ACE; categories not mutually exclusive.

  2. bOther convulsive seizures were defined where there was insufficient information to classify seizures as tonic–clonic, partial evolving into generalized seizures (PSGS), or simple partial.

  3. cNonconvulsive seizures included atonic or tonic seizures.

Simple partial57 (13.0)4 (1.9)7 (3.1)
Complex partial93 (20.9)26 (12.4)15 (6.8)
Partial evolving into generalized seizure189 (42.6)77 (36.8)88 (38.6)
Primary generalized tonic–clonic214 (48.2)90 (43.1)115 (50.4)
Other convulsiveb9 (2)8 (3.8)0 (0)
Nonconvulsivec10 (2.3)3 (1.4)3 (1.3)
Unclassifiable2 (0.5)1 (0.5)0 (0)
Total545209228

Electroencephalography examination was performed in 408 (91.7%). Age was associated with nonconsent for EEG examination (p = 0.017), 55.6% of those not consenting were children aged 6–12 years. Refusal of EEG occurred in more males than females (63.9% vs. 36.1%) but evidence of an association was not strong (p = 0.095). Overall, 169 people had an abnormal EEG study, 117 (28. 7%) of all patients with ACE had focal features on the EEG, and 139 (34.1%) had epileptiform activity where focal features and epileptiform activity are not treated as mutually exclusive events.

More than one seizure type was recorded when this occurred in the patient history. Of the 214 individuals with GTCS, 51 (26.6%) had focal features on their EEG (Table 2). In the 146 individuals who reported GTCS only (without any partial seizures), 36 (22.0%) of these had focal features on their EEG, suggesting that these seizures were PSGS. Abnormal responses to photosensitivity were uncommon.

Table 2.   Seizure types and electroencephalographic findings
Type of seizureNumber identified from clinical historyaElectroencephalography readingsc
Abnormal EEG,n (%)Focal features, n (%)Epileptiform activity,b n (%)Abnormal photosensitivity response, n (%)Not tested, n (%)
  1. aNumber (%) of 445 people with ACE; categories not mutually exclusive.

  2. bIncludes spikes, sharp waves, spike and wave, rhythmic runs.

  3. cNumber (%) of people experiencing each seizure type.

  4. dOther convulsive seizures were defined where there was insufficient information to classify seizures as tonic–clonic, partial evolving into generalized seizures (PSGS), or simple partial; only required for adults, all child seizures were classifiable.

Simple partial57 (12.8)25 (43.9)19 (33.3)21 (36.8)3 (5.3)5 (8.8)
Complex partial93 (20.9)35 (37.6)25 (26.9)32 (34.1)1 (1.1)7 (7.5)
Partial evolving into generalized seizure189 (42.5)77 (40.7)58 (31.2)63 (33.3)3 (1.7)13 (6.9)
Primary generalized tonic–clonic214 (48.1)79 (36.9)51 (23.8)65 (30.4)6 (2.8)22 (10.3)
Other convulsived9 (2.0)1 (11.1)1 (11.1)1 (11.1)01 (11.1)
Nonconvulsive11 (2.5)2 (18.2)2 (18.2)1 (9.1)01 (9.1)
Unclassifiable2 (0.5)00000

On neurologic examination, 55 (12.4%) had focal neurologic signs detected on physical examination, of whom 48 had a motor deficit such as monoparesis or hemiparesis. Overall 315 (70.8%) of patients with ACE had evidence of focal abnormality, documented by partial onset seizures (PSGS or the other partial seizures), focal neurologic deficits, or focal abnormalities on the EEG (Fig. 1). Note that the 315 is inclusive of patients with partial seizures or focal neurologic deficit but for whom EEG data are unavailable.

image

Figure 1.   Venn diagram showing evidence of focal brain damage from seizure type, physical examination, and EEG abnormalities.

Download figure to PowerPoint

Use of antiepileptic drugs (AEDs), seizure frequency, and consequences of ACE

Overall, 257 of people with ACE (57.8%) reported very frequent seizures: 61 (13.7%) daily, 56 (12.6%) weekly, and 140 (31.5%) monthly (Table 3). There was strong evidence of a difference in seizure frequency between adults and children (p = 0.008), with similar proportions of adults and children experiencing daily or weekly seizures, but more children having their last seizure more than a month previously, compared to adults. There was no difference in seizure frequency by sex (p = 0.933). AEDs were detected in 132 patients: phenobarbital in 120 and phenytoin in 27. Seizure frequency was not associated with detection of AED in blood samples in adults (p = 0.417) or in children (p = 0.823).

Table 3.   Seizure frequency, antiepileptic drug use, and possible consequences of active convulsive epilepsy
 Seizure frequency
DailyWeeklyMonthlyLast seizure within 2–6 monthsLast seizure within 7–12 monthsTotal
  1. aChildren; 6–17 years, adults; 18 years and older.

  2. bOne missing value for marital status in adults.

ChildrenaN = 33N = 24N = 51N = 97N = 8213
 AED
  Not detected21 (63.6)12 (50.0)29 (58.6)59 (60.8)3 (37.5)124
  Detected4 (12.1)2 (8.3)5 (9.8)9 (9.3)1 (12.5)21
  Optimal range5 (15.2)7 (29.2)11 (21.6)17 (17.5)0 (0)40
  Not tested3 (9.1)3 (12.5)6 (11.8)12 (12.4)4 (50.0)28
 Cognitive impairment14 (42.4)15 (62.5)18 (35.3)17 (17.5)0 (0)64
 Not attending school25 (75.8)18 (75.0)32 (62.8)41 (42.3)1 (12.5)117
AdultsaN = 28N = 32N = 89N = 75N = 8232
 AED
  Not detected18 (64.3)17 (53.1)58 (65.2)53 (70.7)6 (75.0)152
  Detected6 (21.4)9 (28.1)19 (21.4)12 (16.0)2 (25.0)48
  Optimal range4 (14.3)5 (15.6)7 (7.9)7 (9.3)0 (0)46
  Not tested0 (0)1 (3.1)5 (5.6)3 (4.0)0 (0)9
 Cognitive impairment18 (64.3)11 (34.4)25 (28.1)3 (4.0)0 (0)57
 Unemployed26 (92.9)26 (81.3)66 (74.2)68 (90.7)7 (87.5)250
 Marital statusb
  Not married23 (82.1)19 (59.4)51 (57.3)25 (33.3)2 (25.0)120
  Married3 (10.7)6 (18.8)21 (23.6)38 (50.7)4 (50.0)72
  Separated/divorced1 (3.6)4 (12.5)10 (11.2)5 (6.7)0 (0)20
  Widowed1 (3.6)3 (9.4)7 (7.9)6 (8.0)2 (25.0)19

On a clinical assessment, 122 (27.2%) had evidence of cognitive impairment, with no difference between children and adults. There was no difference by gender in the frequency of cognitive impairment (p = 0.256) or motor deficits (p = 0.135).

Increased seizure frequency was associated with cognitive impairment (chi-square tests for trend p < 0.001) in both adults and children (Table 3). In adults, there was some evidence that increased seizure frequency was associated with being unemployed (p = 0.036); however, cognitive impairment was not associated with unemployment (p = 0.403). Increased seizure frequency was associated with being unmarried, compared to ever having been married (p < 0.001). After taking into account seizure frequency, cognitive impairment was also associated with being unmarried (LRT p = 0.003).

In children, more frequent seizures were associated (p < 0.001) with nonattendance at school. Significantly fewer cognitively impaired children attend school (p < 0.001). In the 185 children whose parents gave consent for blood testing, there was no evidence of an association between AED use and school attendance (p = 0.928).

Overall, 69 people with ACE (15.5%) were recorded as having burn marks, often extensive, with significantly more in female (20.7%) than male patients (12.3%) (p = 0.021) and significantly more in adults (22.3%) than children (10.1%) (p = 0.001).

Other medical history and examination

A family history of unprovoked seizures was reported in approximately one-third of people with ACE and a history of febrile seizures in 14% (Table 4). A dysmorphic facial appearance was found in <3% of people with ACE and in none were features of a neurocutaneous syndrome identified. The parents of children included in the study were asked about perinatal difficulties, among whom 15% of mothers reported problems before delivery or neonatal difficulties during or soon after birth. Serious head injuries requiring admission to the hospital were reported in 8% of patients. There was no difference in the prevalence of head injuries by children and adults (p = 0.346) but weak evidence of a difference by sex in adults, with more male adults experiencing head injuries than women (12.8% vs. 5.7%, p = 0.058).

Table 4.   Possible etiologies in adults and children
 Children N = 213Adults N = 232All N = 445
  1. a43 Missing values in children, 82 in adults.

  2. bTwo missing values for adults.

  3. cTwo missing values for adults, one for children.

  4. dOne missing value for adults.

Neonatal difficulties34 (16.0) 
Past history of status epilepticus (SE)a, n (%)119 (55.9)42 (18.1)161 (36.2)
History of febrile status epilepticus, n (%)91 (42.7)27 (11.6)118 (26.5)
Head injuryb, n (%)14 (6.6)21 (9.1)35 (7.9)
Dysmorphic facial syndrome9 (4.2)3 (1.3)12 (2.7)
Family history of convulsive seizuresc
 None reported138 (64.8)159 (68.5)297 (66.7)
 First-degree relatives57 (26.8)58 (25.0)115 (25.8)
 Extended family9 (4.2)6 (2.6)15 (3.4)
 Both first-degree and extended  relatives8 (3.8)7 (3.0)15 (3.4)
Family history of febrile seizuresd35 (16.4)28 (12.1)63 (14.2)

Discussion

  1. Top of page
  2. Summary
  3. Methods
  4. Results
  5. Discussion
  6. Acknowledgments
  7. Disclosure
  8. References

This study has been performed on data from people with ACE, identified through the largest door-to-door prevalence survey carried out in sub-Saharan Africa to date (Edwards et al., 2008). It demonstrates that the burden of epilepsy in this rural area lies with the adolescents and young adults, despite excluding children <6 years of age. A high proportion had a history of status epilepticus, often occurring in childhood, associated with a febrile illness. The high proportion of focal features in the semiology, physical examination, and EEG suggests that an underlying cause may be identifiable by the use of magnetic resonance imaging (MRI). The high prevalence of status epilepticus and those with focal seizures suggests that many cases of epilepsy may be preventable. In addition, these patients have substantial comorbidity in terms of neurologic deficits and cognitive impairment, with reduced schooling, employment, and marriage. Furthermore, they considerably underutilize AEDs, the use of which may improve their outcome in terms of functioning within society.

Half of the patients were <18 years of age, with onset of seizures before the age of 18 years in two-thirds. More than half of the patients had seizures starting before 6 years of age, but it was difficult to differentiate between febrile seizures, seizures as part of acute infections, and unprovoked seizures in this context. The recall for febrile status epilepticus was much better in children than adults, because the parents provided the information. The finding that more than one-fourth of all patients had an episode of status epilepticus associated with febrile illness, suggests that infections may be an important cause of epilepsy, particularly malaria. In other contexts febrile status epilepticus is associated with a very high rate of subsequent epilepsy (Annegers et al., 1988). We have documented a high incidence of acute symptomatic seizures (Idro et al., 2008) and convulsive status epilepticus (Sadarangani et al., 2008) in this area and found that malaria was the most common cause. Severe falciparum malaria is associated with the subsequent development of epilepsy (Carter et al., 2004; Ngoungou et al., 2006).

The proportion of patients with abnormal interictal EEG findings using a 30-min sample without sleep in this rural population, is higher than that reported from Ethiopia (Tekle-Haimanot et al., 1990), but lower than in an area with a high prevalence of epilepsy and onchocerciasis (Kaiser et al., 2000). The EEG indicated that more than one-fifth of patients with GTCS only, had focal abnormalities. suggesting that these seizures are likely to be partial in origin. This supports data from other parts of Africa (Tekle-Haimanot et al., 1990; Kaiser et al., 2000). The overall high prevalence of focal abnormalities would suggest insults to the brain, and this is supported by the identification of adverse perinatal events (Mung’Ala-Odera et al., 2008; Sadarangani et al., 2008) and head injury as significant risk factors.

More than one-half of children and adults had seizures more frequently than once per month, with frequency associated with cognitive impairment on clinical examination. In previous studies, cognitive impairment was found to be associated with behavioral difficulties and poor control of the seizures (Sillanpaa et al., 1998). The cognitive impairment may also explain the lower attendance and lack of progression in school in the children. It may also explain the difficulties in obtaining a job and reduce the prospects of marriage in the adults and possibly predict a higher mortality.

In these patients there was considerable evidence for the detrimental effects of epilepsy, in terms of physical manifestations, that is, burns, impaired schooling, and reduced chances of marriage. The increased frequency of burns in female patients is probably related to their domestic duties of cooking over open fires. The severity of burns suggests a hidden mortality. The severe underutilization of AEDs is likely to contribute to social functioning difficulties.

The causes of epilepsy could not be determined in most patients because documentation of antenatal, perinatal, and postnatal events was missing and because of the lack of facilities for investigation. In a multivariate case–control analysis of this group of patients, family history of febrile convulsions and unprovoked seizures and adverse perinatal events were identified as independent risk factors (Edwards et al., 2008). The associations with adverse perinatal events has emerged in other studies of children in this area (Mung’Ala-Odera et al., 2008) and elsewhere (Banu et al., 2003) and needs further investigation to understand the pathogenetic relationship. In the analysis of individual cases, head injury appeared to precede the onset of epilepsy in 8%. Because nearly three-fourths of the patients had focal features from the semiology of their seizures, on the EEG and/or focal neurologic deficits, this would suggest that many other causes may be found with neuroimaging, particularly MRI.

The epidemiologic study screened only for convulsive seizures in order to identify those at highest risk in terms of mortality and comorbidity, and, therefore, those in greatest need of diagnosis and treatment. Hence, this study underestimated nonconvulsive epilepsies, for example, absences, which were only recognized in addition to convulsive seizures. Undetected cases of all ages, due to stigma related nonresponse in early screening phases of the prevalence survey, may mean that the prevalence of certain characteristics within cases of ACE has been underestimated here. Recall bias is likely, particularly in adults who did not have a guardian available to provide additional information. The classification of seizure types and the determination of the onset of unprovoked seizures may also have been influenced by a lack of additional information. The cultural perceptions of symptoms may have influenced the diagnosis and classification of epilepsy. The clinical assessment of cognition is likely to have underestimated the prevalence of cognitive impairment. Finally we examined children 6 years and older only, since there are difficulties in differentiating febrile seizures from epilepsy.

Despite these limitations, it is clear that epilepsy affects mainly children and young adults in this part of Africa, and that it has a profound impact on their functioning in society, reducing their chances for attending school, obtaining a job, and getting married. There is considerable comorbidity in terms of cognitive impairment and physical manifestations such as burns. The lack of evidence of an association between AED use and seizure frequency further highlights the need for increased awareness of epilepsy as a treatable condition. The high proportion of focal features in these patients suggests that a cause of the epilepsy could be identified with further investigation, particularly neuroimaging. These findings together with the high prevalence of febrile status epilepticus suggest that much epilepsy could be prevented in this area.

Acknowledgments

  1. Top of page
  2. Summary
  3. Methods
  4. Results
  5. Discussion
  6. Acknowledgments
  7. Disclosure
  8. References

We thank the staff of the KEMRI unit at Kilifi, particularly Godfrey Otieno and the epilepsy field team led by Francis Yaah. This article is published with the permission of the Director, KEMRI.

Disclosure

  1. Top of page
  2. Summary
  3. Methods
  4. Results
  5. Discussion
  6. Acknowledgments
  7. Disclosure
  8. References

This work received financial support from KEMRI and Wellcome Trust through grants to Professor C.R.J.C. Newton (No. 070114) as part of the Wellcome Trust Senior Research fellow programme. We confirm that we have read the Journal’s position on issues involved in ethical publication and affirm that this report is consistent with those guidelines.

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  1. Top of page
  2. Summary
  3. Methods
  4. Results
  5. Discussion
  6. Acknowledgments
  7. Disclosure
  8. References
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