1. Where there are no Neurologists: Decreasing the Epilepsy Treatment Gap in the Amazon
Patricio S. Espinosa, Aaron L. Berkowitz, Nicole M. Falcone, Denise Dvorquez, Kathleen M. Principe, William Principe, Melissa M. Murphy, Christopher Shanahan, Ann Kao, Dominic B. Fee, Karin R. Swartz, Sydney S. Cash, Blanca R. Vasquez.
Centro Internacional en Neurociencias – CIEN Quito, Ecuador.
C I E N
Introduction
Methods
As much as 80% of the global burden of epilepsy is in the
developing world, where there is a higher prevalence of
CNS infections, less access to prenatal care, and higher
incidence of birth complications.
Moreover, some 90% of patients with epilepsy in
developing countries do not receive appropriate
treatment, due to lack of access to neurological diagnosis
and care.
The city of Tena is located in Napo Province (pop.
90,000) in the rural Amazon region of Ecuador where
the nearest facility with neurological services is located
~200 kilometers away. This distance and a substantial
prevalence of poverty prevent patients from obtaining
proper diagnosis and treatment of neurological
conditions.
In order to assure sustainability, local pediatricians and general practitioners were actively involved in the consultations and trained in the follow-up care of patients with epilepsy who were begun on treatment during the trip, and contact and a telemedicine program for further follow-up were established.
Figure 1. The Team 2009.
Conclusions
                       
Objectives
There is a substantial epilepsy treatment gap in this region: only 1 in 4 patients in the cohort evaluated receive appropriate epilepsy treatment.
Collaborations with local hospitals in the developing world are a way to increase access to neurological care for some of the neediest of patients and decrease the epilepsy treatment gap by establishing a partnership between visiting consulting neurologists and local health care systems.
To develop a sustained collaboration with a hospital in
in the rural Amazon region of Ecuador with aim to reduce
the epilepsy treatment gap.
Methods
Results
Unlike surgical projects in developing countries that generally focus on isolated interventions, neurological care requires sustained collaboration
We established relationship with staff and physicians of the local public Hospital Jose Maria Velasco Ibarra in Tena . In April 2009, a team of 4 neurologists, 1 neurosurgeon, 1 pediatrician, 2 internists, 2 electroencephalography (EEG) technicians, 1 physical therapist and over 20 volunteers (medical students, nurses, and translators both from Ecuador, and the US) saw patients in consultation with the internal medicine and pediatrics staff of the hospital.
Two portable EEG machines were used. Antiepileptic drugs were supplied by the Ministry of Health free of charge.
Members of the team gave educational talks on epilepsy management to local physicians and medical students, as well as workshops on seizure first aid and stigma reduction to the local community, students, and first responders.
In 7 working days, we evaluated a total of 475 patients with neurological complaints from urban and rural areas of the Napo Province. Diagnoses included but were not limited to seizures, migraine, and developmental delay.
Of the patients evaluated 45% were males. 41% of patients were age 0-14 years old, 53% were 15-64, and 6% were over age 65 age. A total of 127 EEGs was performed, 110 of which were abnormal patients were newly diagnosed with epilepsy by history, physical exam, and EEG, and were started on drug therapy. 28 patients with a prior clinical diagnosis of epilepsy were changed to more appropriate medications based on clinical evaluation and EEG results.
The epilepsy educational talks were well received by the community and local health providers.
Acknowledgments
The HydroDot® Disposable EEG Electrode Application System
Cadwell Laboratories, Inc
MVAP Medical Supplies, Inc.
Rotary Club International ( Westford Rotary Club Massachusetts  – Club Rotario San Rafael – Ecuador)
Centro Internacional en Neurociencias – CIEN
Ministerio de Salud Publica del Ecuador
Dirección Provincial de Salud del Tena
Hospital Jose Maria Velasco Ibarra Tena - Ecuador
Fuerza Area Ecuatoriana FAE
Policia Nacional del Ecuador Clinica de Epilepsia Hospital Metropolitano Quito - Ecuador
ILAE: Visiting Professorship in Epileptology Program
Brigham and Women's Hospital - Harvard Medical School