Epilepsy Cambodia InterVention (ECIR): Résultats et enseignements

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Sclérose en plaques et exposition solaire.

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Organisation et développement de la neurologie dans les pays en voie de développement.

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La neurologie en Asie du Sud-Est : progrès et perspectives

International audienceL’Asie du Sud-Est, composée de 11 pays, dont la plupart sont membres de l’Association des Nations de l’Asie du Sud-Est (ANASE), regroupe 8,58 % de la population mondiale (soit 668 millions de personnes) dans des pays aux revenus faibles et intermédiaires. Les traditions culturelles et les politiques menées y conditionnent le système de soins et les priorités de santé publique, ce qui conduit à une gestion et des pratiques en neurologie différentes de celles observées dans les pays occidentaux. Si le panorama des maladies neurologiques est similaire à celui de l’Occident, certaines caractéristiques concernant la démographie médicale et les équipements de santé conduisent à un bilan très différent. En effet, les accidents vasculaires cérébraux, la démence, l’épilepsie ou bien encore la maladie de Parkinson sont des pathologies significatives dans les bilans de morbidité et de mortalité pour de nombreuses sociétés. Toutefois, les ressources et les services permettant de traiter ces maladies sont inégalitaires, et particulièrement déficitaires dans les pays aux revenus faibles et intermédiaires. Les services modernes de neuro-imagerie (tels que les IRM, les scanners) et les services de neurophysiologie, sont presque toujours disponibles dans les capitales, mais leur accessibilité devient très variable dans les pôles urbains secondaires selon le système de financement national concerné. A contrario, ils sont quasi inaccessibles pour les populations vivant en milieu rural. Seulement 20 % des neurologues dans le monde exercent en Asie, et la plupart d’entre eux travaillent exclusivement en zone urbaine. Cette communication traite ainsi de la démographie médicale et des équipements en neurologie dans le contexte d’Asie du sud-est, afin de montrer la nécessité d’améliorer la qualité des services de soins ainsi que la formation des neurologues dans cette partie du monde

Peut-on réduire le déficit de traitement de l’épilepsie dans les pays en développement ? Étude comparée Cambodge – Laos

International audienceIntroductionAlors que les prévalences en Asie du sud-est (7,7‰ au Laos et 5,8‰ au Cambodge) sont proches de celle observée en France (6‰), l’enjeu de santé publique pour ces pays relève avant tout du déficit thérapeutique qui est supérieur à 95 % au Laos comme au Cambodge. L’objectif principal de notre programme de recherche était de mesurer l’efficience d’une nouvelle approche des soins de santé de proximité en testant deux stratégies : (1) des visites villageoises mensuelles des personnels des centres de santé (nommés DHV) formés au dépistage et au suivi des patients épileptiques au Laos vs (2) une stratégie identique où les missions du DHV étaient assurées par les volontaires de santé résidant dans les villages au Cambodge.MéthodeCes deux études quasi-expérimentales d’une durée de 12 mois (réalisées en 2015–2016 au Laos et en 2016–2017 au Cambodge) ont été conduites dans des districts ruraux grâce à une approche comparée entre une zone d’intervention et une zone contrôle. Notre recherche a ainsi permis des analyses comparatives « avant–après et ici–ailleurs » pour démontrer l’efficacité de l’intervention dans chaque pays, ainsi qu’une comparaison entre les deux stratégies d’intervention.RésultatsAu Laos, après 12 mois d’expérimentation, le déficit de traitement a baissé de 5,5 % dans la zone d’intervention contre 0,5 % dans la zone contrôle (p = 0,0001). Dans la zone d’intervention, 36,1 % des épileptiques ont refusé le traitement, 27,8 % ont préféré être soigné sans passer par le centre de santé primaire (circuit de proximité) ; et parmi ceux qui ont adhéré, le suivi à domicile a permis d’augmenter de 27,6 % le nombre de compliants (p = 0,019). Au Cambodge, après 6 mois d’expérimentation, la stratégie a permis de baisser significativement le déficit de traitement de 31,1 % dans la zone d’intervention, au regard des 7,0 % de baisse dans la zone contrôle (p = 0,0001). Incontestablement, la stratégie est plus efficace lorsque le DHV réside dans le village.ConclusionD’ores et déjà, les points positifs de l’expérimentation au Laos ont permis la rédaction d’une « Advocacy Policy » (promotion et politique) favorablement accueillis par le Ministère de la Santé au Laos, comme cela est également envisagé au Cambodge à la fin de notre intervention en juin 2017

Anti-epileptic drugs: is terminology appropriate? A change might be needed.

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Intervention strategy for the management of epilepsy in South-East Asia

International audiencePurpose:The prevalence of epilepsy is 7.7& in Laos and 5.8 & in Cambodia, the treatment gap exceeds 95% in both countries. Our researchprogram aims to measure the effectiveness of two new community-based health care approaches using two different types of Domestic HealthVisitors (DHV) trained to screen and follow patients with epilepsy (PWE): (1) in Laos DHV chosen from health center staff (2) an identicalstrategy in Cambodia where DHV duty was carried out by health volunteers residing in the villages.Method:Between 2015 and 2017, these two quasi-experimental studies were conducted in rural districts over a 12-months period comparing anintervention area and a control area. Our intervention included an Information, Education and Communication campaign, training of the DHVstaff, a number of surveys on general population about Knowledge, attitudes and practices (KAP) and regular monitoring.Results:In Laos after a 12-month intervention period, the treatment gap was reduced by 5.5% (20 to 43 cases under treatment of the 418expected) in the intervention vs. 0.5% (21 to 25 cases under treatment of the 788 expected) in the control area (p <0.0001). In Cambodia, after a6-month period in area with a treatment gap of 100%, he was reduced by 31.1% (55 cases out of the 177 expected) in the intervention compared toa 7.0% decrease (23 cases out of the 327 expected) in the control area (p <0.0001).Conclusion:The strategy is more successful when the DHV lives in the village where he/she is going to perform his/her duty. Observations on KAP in the general population and among health staff, in addition to the therapeutic pathway of PWE will enlighten our results. The results of the intervention in Laos have resulted in an Advocacy Policy Plan which has been favorably received by the Lao Ministry of Health

Development of an interventional strategy for the management of epilepsy in South-East Asia.

International audienceBackgroundThe prevalence of epilepsy is 7.7‰ in Laos and 5.8‰ in Cambodia, and the treatment gap exceeds 90% inboth countries.ObjectiveOur research program aims to measure the effectiveness of two community-based health care approaches usingtwo different types of Domestic Health Visitors (DHV) trained to screen and follow patients with epilepsy (PWE):(1) in Laos, DHV were chosen from health center staff (2) in Cambodia, DHV were health volunteers residing inthe villages.Patients and Methods / Material and MethodsBetween 2015 and 2017, these two quasi-experimental studies were conducted in rural districts over a 12-months period comparing an intervention area and a control area. Our intervention included an Information,Education and Communication campaign, specific training of the DHV staff, and regular monitoring.In Laos, the treatment gap was reduced by 5.5% (20 to 43 cases under treatment of the 418 expected) in theintervention area versus 0.5% (21 to 25 cases under treatment of the 788 expected) in the control area(p<0.0001). In Cambodia, after a 6-month period (ongoing study) in area, it was reduced by 31.1% (0 to 55cases out of the 177 expected) in the intervention compared to a 7.0% decrease (0 to 23 cases out of the 327expected) in the control area (p<0.0001).ConclusionThe strategy is more successful when the DHV lives in the village where he/she is going to perform his/her duty.The results of the intervention in Laos have resulted in an Advocacy Policy Plan which has been favorablyreceived by the Lao Ministry of Health

Availability, affordability, and quality of essential anti‐seizure medication in Cambodia

International audienceObjective: Epilepsy is a major neurological disorder that requires long-term medical treatment. Once epilepsy is diagnosed, people with epilepsy face many difficulties in accessing treatment (treatment gap). Our objective was to assess the situation regarding the availability, price, affordability, and quality of anti-seizure medication (ASM), which are major determinants of access to treatment. Method: A cross-sectional study was performed in provincial/district hospitals and private pharmacies in urban and rural areas in Cambodia. Data on ASM availability and price were obtained through drug suppliers. Affordability was estimated as the number of day wages the lowest-paid government employee must work to purchase a monthly treatment. Samples of ASM were collected, and the quality of ASM was assessed through Medicine Quality Assessment Reporting Guidelines. Results: Out of 138 outlets visited, only 72 outlets (52.2% [95% CI 43.5-60.7]) had at least one ASM available. Phenobarbital 100 mg was the most available (35.5%), followed by carbamazepine 200 mg (21.7%), phenobarbital 50 mg (11.6%), sodium valproate 500 mg (9.4%), and phenytoin 100 mg (9.4%). In provincial/district hospitals, ASM was provided free of charge. In private pharmacies, affordability for phenobarbital 50 mg and 100 mg was the best, with 0.6 and 0.5 days, respectively, compared to phenytoin 100 mg (1.8 days), and other ASM. No counterfeit ASM was found in this study. Phenytoin sample presented the worst quality (33.0%) compared to carbamazepine (27.8%), and other ASM. Significance: A lack of access to affordable and effective ASM due to low availability and poor quality of ASM was identified. Our research highlights the need for future policy efforts to ensure the quality of ASM and improve their availability. This can be achieved by involving the calculation of their annual needs for these drugs and increasing the national production of ASM

Community-based management of epilepsy in Southeast Asia: Two intervention strategies in Lao PDR and Cambodia

International audienceBackgroundEpilepsy affects more than 50 million people worldwide, 80% of whom live in low- and middle-income countries (LMICs). In Southeast Asia, the prevalence is moderate (6‰), and the main public health challenge is reducing the treatment gap, which reaches more than 90% in rural areas.MethodsThis 12-month comparative study (intervention vs. control areas) assessed the community effectiveness of two different strategies for the identification and home follow-up of people with epilepsy by Domestic Health Visitors for epilepsy (DHVes). In Lao PDR, DHVes were health center staff covering several villages via monthly visits; in Cambodia, DHVes were health volunteers living in the villages.FindingsAt baseline, the treatment gap was >95% in Lao PDR and 100% in Cambodia. After 12 months, the treatment gap in Lao PDR decreased by 5·5% (range: 4·0–12·2) in the intervention area and 0·5% (range: 0·4–0·8) in the control area (p<0·0001). In Cambodia, the treatment gap decreased by 34·9% (range: 29·0–44·1) in the intervention area and 8·1% (range: 6·7–10·2) in the control area (p<0·0001). Among the PWEs followed at home by the DHVes, the proportion adhering to drug treatment was 85·2% in Lao PDR and 78·1% in Cambodia. The cost associated with strategy implemented in Cambodia, compared with the control area, was lower than the cost associated with strategy implemented in Lao PDR.”InterpretationThe treatment gap was significantly reduced with both intervention strategies, but the effect was larger in Cambodia. The results of this cost analysis pave the way for scaling-up in rural areas of Lao PDR and Cambodia, and experimental adaptation in other LMICs