National Brain Week 18 to 24 December 2015 -Neurological diseases in India- Need more awareness

National Brain Week 18 to 24 December 2015


Neurological diseases in India- Need more awareness


Dr M A Aleem
Vice President
Tamilnadu and Pondycheery States Association of Neurologists (TAN)


Former Vice Principal and
HOD and Professor of Neurology
KAPV Govt. Medical College and MGM Govt. Hospital
Trichy


Neurologist and Epileptologist
ABC Hospital
Trichy

December 18-24, 2015 as the
National Brain Week, to commemorate the Foundation of the Indian Academy of Neurology (IAN) on December 18, 1991. This year happens to be the Silver Jubilee year of the IAN.

Indian Academy of Neurology (IAN), the professional registered body of neurologists across India was founded on December 18, 1991. The Academy completes 25 years on December 18, 2015. It is only appropriate to celebrate December 18-24 as the “National Brain Week”. To begin with, the IAN had only 250 members comprising of the few trained neurologists that existed in the country. Over 25 years, it has grown by leaps and bounds to 1677 members across the country.

At present, DM/DNB (Neurology), the post-graduate qualification requisite for practicing as a neurologist is available at 89 medical institutes with a total of 205 seats through-out the country, which means approximately 200 qualified practicing neurologist will be added every year. The average number of neurologists per 100, 000 population across different income group countries also varies: In the United States, there are five neurologists per 100, 000 population where as in India this ratio is only 0.01 neurologist per 100, 000 population.

Burden of disease largely underestimated:

The burden of brain disorders and neurological diseases is largely underestimated. “Stroke and traumatic brain injuries are two most important causes of disability around the globe, one to two percent of the global population suffers from some kind of disability related to traumatic brain injury. Worldwide, stroke is the second commonest cause of death after Islamic heart disease and ahead of chronic obstructive pulmonary disease. According to WHO data, neurological diseases alone are responsible for between 4.5 and 11 percent of all burden of disease, depending on whether you look at low- or high-income economies. This is far higher than the number of respiratory ailments, gastrointestinal disorders or malignant tumours.”

Neurological diseases are a major cause of death. According to the WHO, they account for 12 percent of deaths worldwide, a figure that varies according to levels of economic development. Lower-middle-income countries are the hardest hit. They account for nearly 17 percent of deaths attributable to neurological causes because both infectious and non-communicable neurological diseases contribute to mortality. Of all neurological illnesses, stroke and other cerebrovascular disorders are by far the commonest cause of death, accounting for 85 percent of all fatalities.


Neurological diseases in India- Need more awareness

India, with a population of more than one billion, is facing new challenges in the health sector due to a paradigm shift in disease burden. Added to the burden of communicable diseases with emerging and re-emerging infections and nutritional deficiency disorders, there is epidemiological transition with increasing incidence of non-communicable disorders (NCD), some attributable to lifestyle and others to increased life expectancy. Amongst the NCDs, neurological disorders have been recognized to lead to significant mortality, morbidity, disability and socioeconomic loss. Epilepsy, cerebrovascular disorders, migraine, dementia, Parkinson's disease, motor neuron disorder, traumatic injuries, brain damage due to birth trauma, neuromuscular disorders, demyelinating disorders and neurological disorders consequent to nutritional deficiency and exposure to neurotoxic substances contribute to significant burden. Further, widely prevalent infections of the nervous system such as tuberculosis, malaria, cysticercosis and viral infections, particularly Japanese encephalitis and HIV also lead to neurological deficits.

The unique characteristics of neurological disorders such as chronicity, progressive degeneration, limited therapeutic options and lack of specific treatment for many diseases, further contribute to the disease burden and morbidity. The effect of stigma associated with epilepsy, particularly in developing countries, on disease burden cannot be easily estimated since it leads to complexities in diagnosis and management and a large treatment gap. Redeeming features are recent developments including (i) advances in diagnostic modalities of imaging, immunological and molecular tests, (ii) introduction of new therapeutic strategies such as thrombolysis, immunomodulating agents (immunoglobulins, interferon) and (iii) use of new drugs for treatment of epilepsy, Parkinson's disease and neuroinfections which have ushered a sea change in the clinical practice of neurology, enabling early diagnosis and more effective treatment leading to improved outcome of the disease.






Population-based neuroepidemiologic surveys during the last 15 years, using standardized WHO questionnaire with modifications, in different regions of our country have shown the prevalence rate of neurological disorders to vary from 967 to 4070 per 100000 population. The Parsis, a distinct ethnic group, have an unusually high prevalence rate, but they do not represent the general population of the country. In these surveys, infections of the nervous system and traumatic injuries of brain, spinal cord and peripheral nerves have not been included and therefore it would be an underestimate of the total burden of neurological disorders.

All age groups are affected with peaking in the elderly above 60 years of age. In India according to the 2001 census there are 77 million people above the age of 60 years and it is expected that by 2025 there will be a huge increase to 177 million with consequent significant rise in age-related disorders such as cerebrovascular disorders, Parkinson's disease and dementia. Contradicting the perception of the policy-makers and administrators that neurological disorders are seen mostly in the urban population, neuroepidemiologic surveys have demonstrated that the prevalence in the rural population is significantly higher than in the urban population. In a large community-based survey in Bangalore of a population of 102557 comprising an urban population of 51502 and rural population of 51055, the prevalence rates were 2190 and 4070, respectively, with a ratio of 1:1.85. This fact is critical for planning infrastructure and trained manpower for providing equitable neurology care in the country. Prevalence of some common disorders . Based on the prevalence studies, it may be estimated that in India there are 20 to 30 million people with neurological disorders and the common disorders include epilepsy (6 to 8 million), headache (10-12 million), strokes (1 to 2 million). Transient ischemic attacks are not included in surveys and hence the actual burden of cerebrovascular disorders will be higher than these projected figures.

Special mention needs to be made regarding care of people with epilepsy in view of the associated stigma, the myths and misconceptions about the nature of the disorder and the consequent burden to the patients and their family members, factors which are not considered while determining the disability adjusted life years (DALYS). Some of the crucial factors leading to a wide treatment gap of 38 to 80% in the country are stigma associated with epilepsy preventing patients seeking medical advice, lack of awareness that epilepsy is a brain disorder and that it can be treated. It is therefore important to move forward from descriptive neuroepidemiologic studies to interventional strategies for prevention and treatment of neurological disorders.


Neurological disorders such as stroke, epilepsy and migraine are the commonest reason for disability at a global scale.

Stroke

In India, approximately six people suffer from a stroke every minute amounting to 1.5 million people with stroke in a year. One person dies of stroke every three minutes. Anyone with symptoms of stroke should be rushed to a hospital where facilities for thrombolysis with intravenous tissue plasminogen activator (tPA) are available to burst the arterial clot. The latter can be administered only within a 4.5 hours window period after the onset of stroke. In this time period many investigations including a CT scan of the brain needs to be done before thrombolysis. Thrombolysis requires special expertise and neurologists are best equipped to take the decision whether to thrombolyse or not. When given after 4.5 hours, tPA can produce unwanted harmful effects. So then, how does one recognize symptoms of stroke? It is easy to recognize stroke with a FAST test.

Epilepsy

The estimated number of people with epilepsy in India is 5.5 million. Approximately 65% of newly diagnosed people with epilepsy have no obvious cause. However, 80% of these 5.5 million people with epilepsy in India do not receive treatment as epilepsy medications are not available in Dispensaries and Pharmacies. This is perhaps the highest treatment gap for epilepsy in the world apart from few African countries. This treatment gap can be reduced by:

1. Educating people about epilepsy

2. Increasing awareness among public about the different treatments available including medications, surgery and diet.

3. Making epilepsy medications easily available in all pharmacy and dispensaries.

For complicated cases of epilepsy patients should be refereed to comprehensive epilepsy center. At present less than ten centers where treatment with epilepsy surgery is available. To further enhance the care for uncontrolled epilepsy patients, more number of comprehensive epilepsy centers should be set up across the country.

Migraine

Migraine is the most common cause for headache noted in the population. Approximately 6% of men and 18% of women suffer migraine attacks and over 80% of these suffer had some degree of headache-related disability. Women have more frequent and more severe attacks than men. Having three migraine attacks per month is equivalent to three days of work lost

Treatment choice depends on the frequency and severity of attacks, the presence and degree of temporary disability and associated symptoms such as nausea and vomiting. For migraine management greater emphasis is on the avoidance of identifiable trigger factors (Box 2) and non-pharmacological techniques. These include biofeedback, relaxation technique, physical medicine, yoga, pranaayaam and counseling.

These non-pharmacologic treatments must be combined with drug therapy to achieve better clinical improvement for migraine relief.