Epilepsia, 46(1):124–131, 2005

Blackwell Publishing, Inc.

C 2005 International League Against Epilepsy

Prevalence, Incidence, and Etiology of Epilepsies in Rural

Honduras: The Salamá Study

∗ Marco T. Medina, ∗ Reyna M. Durón, †Lisandro Martı́nez, †Juan Ramón Osorio, †Ana L. Estrada,
†Concepción Zúniga, †Dora Cartagena, ‡Julianne S. Collins, and ‡§Kenton R. Holden
∗ Neurology Training Program, Postgraduate Direction, National Autonomous University of Honduras; †Secretary of Health,
Tegucigalpa, Honduras; ‡Greenwood Genetic Center, Greenwood, South Carolina; and §Department of Neurology, Medical
University of South Carolina, Charleston, South Carolina, U.S.A.

Summary: Purpose: Determination of epilepsy etiology in Results: Among 6,473 residents surveyed, 151 persons with
population-based studies is difficult because of the high cost epilepsy (prevalence rate, 23.3/1,000) were identified, 100 of
of diagnostic tests. However, cost-effectiveness may be proven whom had active epilepsy (15.4/1,000) on the prevalence day.
if preventive public-health strategies can be established from the Incidence was determined to be 92.7/100,000. Partial seizures
test results. We report an epilepsy population-based study using with or without secondary generalization were common (92.2%).
clinical and laboratory techniques. Symptomatic epilepsy (62%) was primarily due to neurocysticer-
Methods: A medical team administered an epilepsy sur- cosis (37%), perinatal brain damage (8%), post-traumatic (3%),
vey to 88% of the residents by census in the rural county of and poststroke (2%). Eight percent were idiopathic, and 30%
Salamá, Honduras. Ninety of 100 participants identified with were cryptogenic (unknown cause).
active epilepsy underwent a neurologic examination, video- Conclusions: Symptomatic epilepsies primarily explained the
electroencephalography (video-EEG), brain computed tomogra- high prevalence and incidence of epilepsy in Salamá. Integration
phy (CT) scan, and serum enzyme-linked immunoelectrotrans- of video-EEG and brain CT scan with clinical-epidemiologic
fer blot (EITB) for cysticercosis. Final diagnoses were based evaluation was critical for determination of epilepsy etiology.
on the International League Against Epilepsy classifications Establishment of specific programs for continuation of epi-
for seizures and epilepsy syndromes. Combined epidemiologic, demiologic surveillance, education, intervention, and long-term
clinical, video-EEG, neuroimaging, and serum EITB assays were follow-up will benefit the Salamá region. Key Words:
used for the diagnosis of epilepsy etiologies. Honduras—Epilepsy—Epidemiology—Etiology—Incidence—
Prevalence—Neurocysticercosis.

Epilepsy is a worldwide health problem (1–3). Recent seizures and syndromes (10,11) and recently proposed the
analyses concluded that Latin America, especially Central use of a five-axes approach to include ictal phenomena,
America, has high epilepsy prevalence rates that appear seizure type, syndrome, etiology, and impairment (12).
to be secondary to a high frequency of symptomatic “pre- The cost-effectiveness of obtaining complete seizure-
ventable” epilepsies (4,5). Comparison data are not always evaluation information will be demonstrated by establish-
available because few worldwide epidemiologic studies ment of specific health programs to reduce the frequency
used standardized case-ascertainment criteria (1,3,6–8). of the symptomatic epilepsies in the long term. With these
Primarily because of the high costs and/or multiple lo- recommendations and criteria in mind, we performed a
gistic factors, the vast majority of previous epidemiologic house-to-house survey to establish the prevalence, inci-
studies were two-phased and did not use neuroimaging or dence, and etiology of epilepsies by using clinical evalu-
electroencephalography (EEG) to determine the etiology ations, video-electroencephalography (video-EEG), brain
and syndromic classification of the epilepsies (9). computed tomography (CT) scans, and serum enzyme-
The International League Against Epilepsy (ILAE) has linked immunoelectrotransfer blot (EITB) assays for cys-
published standardized diagnostic criteria for epileptic ticercosis in the rural county of Salamá, Honduras.

METHODS
Accepted July 31, 2004.
Address correspondence and reprint requests to Dr. M.T. Medina at Population
Instituto de Neurociencias, Col. Tepeyac, Calle Yoro, Edificio Mater
Dei, Tegucigalpa, Honduras. E-mail: [email protected] or In 1995, analyses of morbidity in 11 counties in Eastern
[email protected] Honduras identified epilepsy as the tenth leading cause

124
 EPIDEMIOLOGY OF EPILEPSY: SALAMÁ, HONDURAS 125

FIG. 1. Localization of Salamá

County in Olancho, Honduras.

of medical consultation (13). Because of the favorable Study phases

logistic conditions of Salamá County (Fig. 1), this rural Fig. 2 shows the phases of the study.
area was chosen for a population-based study of epilepsy.
Phase I. House-to-house survey and clinical evaluation
The county had a total land surface of 342 km2 . Twenty-
Initially a house-to-house survey was done by some
nine of its 31 communities have fewer than 640 inhabitants
of the authors, including one board-certified neurolo-
each (range, 10–2,422); the county has no major city. A
gist/epileptologist/neurophysiologist, two board-certified
census was previously done by the government in 1994
public health specialists, and two general practition-
(CEFASA or Family Health Census), which reported an
ers. The nonneurologist health care team members were
eligible county population of 7,384.
trained before the survey in the classification of seizures by
For our study, we performed a census simultaneous with
teaching sessions and observing video-EEG recordings.
house-to-house epilepsy-screening, registering the total
Multiple family members often were available in each
population by age and sex. We used the standard age and
sex strata classification used by the Secretary of Health and
the World Health Organization (WHO). We were assisted
by the fact that one of the physicians involved in this study
(Dr. Martı́nez) had lived in this community for 18 years.
Another physician (Dr. Durón) lived in this community
during a portion of the study period.
Primary occupations in Salamá are in agriculture,
forestry, livestock, coffee, and small business. Its 31 com-
munities are accessible by nonpaved roads; the literacy
percentage is 88%; and three governmental health centers
are in the area. Even though 10 different ethnic groups
with their own dialects reside in Honduras, all residents in
Salamá are mestizos and speak Spanish only. According
to the Secretary of Health, the prevalence of poverty as
measured by the index of unsatisfied basic needs for this
community was elevated at 27% (13).
Bioethics
Persons identified with probable or definite active or in-
active epilepsy by the survey were included in the in-depth
epilepsy study. Approval for the epilepsy study protocol
and consent form was given by the Secretary of Health of
Honduras.
Case definitions
The definitions and classifications for epileptic seizures
proposed by the ILAE (10,11) were used, as well as some
additional concepts to make the definitions operative (8). FIG. 2. Methods of the study by phases.

Epilepsia, Vol. 46, No. 1, 2005

126 M. T. MEDINA ET AL.

household and could provide information about the pa- In some cases, these evaluations were performed at home
tient. A few initial general demographic and medical his- when physical and mental disabilities or transportation
tory questions were asked by the investigators to determine issues were a problem. Epilepsy cases were considered
which individual had the most knowledge of the patient, active if any seizures had occurred during the last 5 years,
family, and the patient’s seizures. That person became the and inactive, if greater than 5 years had elapsed.
key informant and was often a relative of the patient and/or
Phase II. Neuroimaging, electroencephalographic, and
a witness to a seizure event. The key informant was then
immunologic studies
asked to describe the clinical history of the patient.
Patients who were identified clinically as having active
We used a similar approach for other epidemiologic
epilepsy were invited to have a video-EEG, brain CT scan,
studies we have conducted in Honduras (14–16). We have
and serum EITB assay for cysticercosis. Local health and
found that in 80% of cases, the mother, grandmother, or
governmental institutions were involved in the organiza-
other female relatives were the best key informants (Med-
tion and transportation of patients 160 km (99.2 miles)
ina, unpublished data).
to the capital city of Tegucigalpa for their studies. Trans-
To identify persons by survey with a history of seizures
portation costs and studies were paid by the project and
in their lifetimes, any seizure-like events were classified
the local government. Every patient had (a) a brain CT
according to the ILAE (8). The screening survey instru-
scan (GE Sytec 2000i) with and without contrast using
ment used had been previously submitted to a pilot test in
5-mm slices; (b) a 30-min video-EEG with photo stimu-
20 Honduran families and was primarily based on four
lation and hyperventilation, following the criteria of the
questions translated into Spanish: (a) Has someone at
10-20 International System, with tracings recorded on an
home lost consciousness or fallen unconscious? (b) Has
eight-channel Grass EEG machine and in video by a split-
someone ever been disconnected from the surroundings
screen system (sleep-induced EEGs were performed in
or without movement and staring? (c) Has someone had
three cases); and (c) serum EITB assays by a parasitologist
involuntary uncontrollable movements or strange sensa-
for cysticercosis by using the specifications of Immunetics
tions in their limbs or any part of the body? and (d) Has
Inc. and the Centers for Disease Control and Prevention.
someone ever had convulsions, seizures, or epilepsy?
These neurocysticercosis (NCC) results were published
This is a modified version of the questionnaire used
separately (23).
in 1996 by Aziz et al. (17) to detect the characteristics of
convulsive and nonconvulsive epileptic seizures. Aziz and Phase III. Final seizure, syndromic, and etiologic classi-
other authors, including Placencia et al. (18), have modi- fication
fied the WHO questionnaire published in 1981 to adapt to All semiologic and neurologic findings were reviewed
local situations and preferences. Some authors used modi- and classified per ILAE criteria (10,11). A combination
fied WHO questionnaires, but, with some exceptions (17– of epidemiologic, clinical, neuroimaging, and laboratory
19), did not publish the modifications (20,21). Acceptable criteria proposed by Sánchez et al. (24) and Del Brutto et
sensitivities and specificities have been reported (>90% al. (25) were used for the diagnosis of NCC. The criteria
and 50%, respectively) (18–21). used for symptomatic epilepsy were those proposed by
We used our modified questionnaire for a National the ILAE (8) and Roger et al. (26).
Prevalence Study in Honduras, which included a popu-
Phase IV. Treatment and follow-up plan
lation of 135,126, and found it effective (22). The survey
After the final diagnosis was made, each patient re-
instrument also included registration of demographic data
ceived information on the diagnosis and a plan for treat-
and the temporal or definite classification of events under
ment and follow-up.
study for epileptic seizures. Inhabitants of Salamá County
were considered residents if they had lived in the county Data quality and analysis
for ≥6 months preceding the prevalence day (April 30, A final review for data validation was performed by
1997). the specialists composing the study team. Brain CT scans
Patients with possible or probable epilepsy who con- were separately interpreted by a study-blinded board-
sented to participate were thoroughly evaluated by a com- certified neuroradiologist. Data entry was done in Mi-
plete history and examination at local health centers in crosoft Excel and verified by two of the researchers. Anal-
Salamá County. A family history including a pedigree was yses were done with the Statistical Package for Social Sci-
completed. After this interview, the relatives or observers ences (SPSS for Windows, version 6.1).
of the event in question were asked to describe the seizures.
Finally, they were asked to identify the patient’s seizure
RESULTS
by watching a 10-min video-EEG that included all the
seizure types according to the ILAE Classification (10). The initial screening survey questionnaire was admin-
These evaluations were initially done by nonneurologists, istered in 1997 to 88% (6,473) of the total eligible pop-
and at a later date, were validated by the epileptologist. ulation of 7,384 persons living in Salamá County. The

Epilepsia, Vol. 46, No. 1, 2005

 EPIDEMIOLOGY OF EPILEPSY: SALAMÁ, HONDURAS 127

TABLE 1. Classification of the 272 persons initially an evaluation by the epileptologist were done. These were
suspected of having seizures cases with symptoms suggestive of epilepsy but ultimately
Initial Prevalence 95% diagnosed as hemiplegic migraine (one case), migraine
Cases group (%) rate/1,000 CI with aura (three cases), syncope (one case), and Gilles de
La Tourette syndrome (one case).
All epileptic seizures 248 91.2 38.3 33.5–43.1
All epilepsies 151 55.5 23.3 19.6–27.0 Criteria for epileptic seizures were met by 248 (91.2%)
Activea 100 36.8 15.4 12.4–18.5 persons. Final classification and prevalence rates of all
Inactive 51 18.8 7.9 5.7–10.0 cases with epileptic seizures are shown in Table 1. The
Single seizure 58 21.3 9.0 6.7–11.3
Febrile seizures 39 14.3 6.0 4.1–7.9 most frequent seizure group (55.5%) met criteria for
Simple 33 12.1 5.1 3.4–6.8 active or inactive epilepsy. The second most frequent
Complex 6 2.2 0.9 0.2–1.7 group (21.3%) had isolated seizure events (prevalence
Pseudoseizures 7 2.6 1.1 0.3–1.9
Nonepileptic events 17 6.3 2.6 1.4–3.9 rate, 9.0/1,000). Attributable causes of isolated seizures
were diagnosed as alcohol withdrawal (8.9%), NCC con-
a This category includes the only two patients diagnosed with neonatal
firmed by brain CT scan (6.5%), brain trauma (4.3%),
seizures.
eclampsia (2.1%), and encephalitis (2.1%). However, the
etiology of the isolated seizures was undetermined in 76%
population was very cooperative, and the house-to-house- of cases. The third most frequent category of seizures
survey was done in 11 days. The population was 51% (14.3%) was febrile seizures (prevalence rate, 6.0/1,000)
female; 56% were younger than 20 years. This is repre- and most patients (84.6%) met criteria for simple febrile
sentative of the general demographic characteristics of the seizures (1). Of the entire population surveyed, only two
population in Honduras. Our modified epilepsy question- patients had a history of neonatal seizures (prevalence rate,
naire had a sensitivity of 99.2% and a specificity of 75%. 0.3/1,000), and both now experience active epilepsy.
The total number of houses in the county was 1,328.
All were visited by the survey team, and 187 (14%) were
Epilepsy prevalence
uninhabited. A house was not considered uninhabited un-
The overall prevalence of epilepsy was 23.3/1,000
til the survey team had visited it 3 times and confirmed
[95% confidence interval (CI), 19.6–27.0). The prevalence
(with the assistance of neighbors and health community
of active epilepsy was 15.4/1,000 (95% CI, 12.4–18.5)
volunteers) that the residents were not in the community.
and inactive epilepsy was 7.9/1,000 (95% CI, 5.7–10.0;
In this community, people migrate to major cities or other
Table 1). Overall prevalence rates were 25.2/1,000 in fe-
locations during months that coffee, corn, or beans are
males and 21.3/1,000 in males. The prevalence of active
being harvested.
epilepsy (Table 2) was higher in females (17.1/1,000) than
Classification of population suspected in males (13.7/1,000), but was not statistically significant
of having seizures (χ 21 = 1.24; p = 0.2653). However, a significantly greater
In the survey, initially a total number of 272 persons prevalence was found in women age 20 years or older
had a history of events compatible with epileptic seizures (χ 21 = 6.30; p = 0.0121) as compared with men.
(Table 1). Of these, 24 (8.8%) were secondary to Fifty percent of all epileptic seizures occurred in pa-
nonepileptic events (migraine, syncope, other systemic tients younger than 10 years. In patients with active
causes of loss of consciousness, nonepileptic abnormal epilepsy, 50% were younger than 20 years at examination,
movements, schizophrenia, circulatory problems in the and 18% were younger than 10 years. Fifty-two percent
limbs, and pseudoseizures). A seizure diagnosis was re- of patients with active epilepsy had onset before age 10
jected in six cases after a video-EEG, a brain CT scan, and years, and 77% had onset before age 20 years. In general,

TABLE 2. Age distribution and prevalence (cases per 1,000) of active epilepsy
Age Total Total Total male Total male Prevalence Total female Female Prevalence
groups (yr) population cases Prevalence population cases in males population cases in females

0–9 1,895 18 9.5 944 11 11.7 951 7 7.4

10–19 1,742 32 18.4 848 17 20.0 894 15 16.8
20–29 901 17 18.9 453 7 15.5 448 10 22.3
30–39 691 11 15.9 325 4 12.3 366 7 19.1
40–49 489 12 24.5 233 2 8.6 256 10 39.1
50–59 334 6 18.0 150 1 6.7 184 5 27.2
60–69 230 3 13.0 111 1 9.0 119 2 16.8
70–79 123 1 8.1 52 0 0.0 71 1 14.1
80+ 68 0 0.0 25 0 0.0 43 0 0.0
Total 6,473 100 15.4 3,141 43 13.7 3,332 57 17.1

Epilepsia, Vol. 46, No. 1, 2005

128 M. T. MEDINA ET AL.

prevalence rates higher than 10/1,000 were present in most were found in all age groups. The idiopathic epilepsies
groups, with peaks in males in the age intervals from 10 to found were benign childhood epilepsy with centrotempo-
19 years, and in females, from 40 to 49 years (Table 2). ral spikes (4.4%), childhood epilepsy with occipital parox-
ysms (1.1%), and childhood absence epilepsy (1.1%). One
Epilepsy incidence
patient had myoclonic–astatic epilepsy (1.1%) that met
The incidence of epilepsy in this prospective study was
criteria for idiopathic epilepsy, even though the actual
calculated on a door-to-door basis for the 1996 to 1997 pe-
classification considers this syndrome as symptomatic or
riod. For the determination of incidence in the following
cryptogenic (8,11). One case of progressive myoclonic
years, a capture-recapture method was established through
epilepsy was probably due to Unverricht–Lundborg dis-
a permanent surveillance program by the Secretary of
ease (1.1%).
Health. The denominator used was the survey popula-
The overall contribution of the diagnostic studies per-
tion of 1997. New cases are now being studied with the
formed can be measured by positive or abnormal findings.
same methods including video-EEG and brain CT scan.
With the electroclinical diagnostic approach of the ILAE
Epilepsy incidence by year was 92.7/100,000 (six cases;
(10,11), which used interictal as well as ictal video-EEG
95% CI, 18.5–166.9) in 1996–1997, 61.8 (four cases; 95%
findings, 84% of our active epilepsy cases demonstrated
CI, 1.2–122.4) in 1998, 15.4 (one case; 95% CI, 0.0–45.7)
either specific focal or generalized epileptiform activities
in 1999, 30.9 (two cases; 95% CI, 0.0–73.7) in 2000, 77.2
and/or focal slow activities that correlated with the seizure
(five cases; 95% CI, 9.5–145.0) in 2001, and 61.8 (four
semiology and neuroimaging findings. In five cases, in-
cases; 95% CI, 1.2–122.4) in 2002 to 2003. Differences
terictal findings were very specific [i.e., the presence of
between these rates were not statistically significant.
centrotemporal spikes with normal background in four
Seizure and syndromes classification cases with partial rolandic epilepsy (idiopathic epilepsy)
for active epilepsy and the presence of occipital paroxysms in a case typical of
Of the 90 persons with active epilepsy who consented childhood epilepsy with occipital paroxysms (idiopathic
to diagnostic studies, 92.2% had simple or complex par- partial epilepsy)]. Although most of our significant EEG
tial seizures with or without secondary generalization abnormalities were interictal, in two cases, we recorded
(Fig. 3). Patients most commonly had symptomatic epilep- ictal discharges related to myoclonias and absences.
sies (62%) primarily due to NCC (37%). According to Del Significant findings were present in 60% of brain CT
Brutto’s criteria (25), all patients had definitive criteria for scans and in 30% of blood EITB assays for cysticercosis.
NCC (presence of a major + one minor + one epidemi- Brain calcifications that were probably due to NCC were
ologic criterion), with the majority of patients by history found in three (3.3%) additional cases and were considered
having had or been exposed to tapeworms. Detailed data incidental findings.
on the epilepsy due to NCC will be reported in a sepa-
Past history
rate article. Other causes of symptomatic epilepsies are
Historical data that could be related to the increased
detailed in Table 3.
risk for active epilepsy were family history of epilepsy
Eight percent had idiopathic epilepsies, and 30%
(67%); febrile seizures (8%) and neonatal seizures (2.2%);
had cryptogenic epilepsies (unknown cause). Idiopathic
personal (14%) and household (37%) history of taeniosis;
epilepsies were primarily present in persons younger than
midwife-assisted delivery (79%); delivery abnormalities
20 years. Symptomatic and epilepsies of unknown cause
including forceps use, prolonged or precipitate labor, or
abnormal bleeding before or during delivery (32%); head
trauma (7%); and neuroinfection (2%).
Treatment
Fourteen patients with active epilepsy had never vis-
ited a doctor for treatment; 7.7% had visited their doctor,
but an epilepsy diagnosis had not been made. In retro-
spect, these were cases with simple, complex partial, and
absence seizures. Forty-two (46.7%) patients with active
epilepsy were receiving AED treatment. Although ∼20%
of patients with active and inactive epilepsy in the world
are treated (27), 46.7% of patients with active epilepsy in
Salamá were receiving treatment. This higher percentage
of treated epileptics was primarily due to 1994 census re-
ports identifying the high frequency of epilepsy and a local
FIG. 3. Electroclinical classification of seizure types in 90 par- community physician (Dr. Martinez) becoming an advo-
ticipants with active epilepsy. cate for this group of patients. The percentage of treated

Epilepsia, Vol. 46, No. 1, 2005

 EPIDEMIOLOGY OF EPILEPSY: SALAMÁ, HONDURAS 129

TABLE 3. Etiology of active epilepsy in the patients studied by age groups

Etiology/Age groups 0–9 10–19 20–29 30–39 40–49 50–59 60+ Total %

Cryptogenic 7 8 3 3 2 3 1 27 30.0
Idiopathic 3 4 7 7.8
All symptomatic 7 21 8 6 9 3 2 56 62.2
Neurocysticercosis 4 13 5 3 6 1 1 33 36.6
Perinatal brain damage 5 1 1 7 7.8
Poststroke 1 1 2 2.2
Cortical dysplasia 1 1 2 2.2
Post-traumatic 2 1 3 3.3
Postmeningitis/encephalitis 1 1 2 2.2
Multifactorial 1 1 2 2.2
Othera 1 1 1 2 5 5.6
All etiologies 24 55 18 15 21 9 5 90 100.0
a The “Other” category includes a tumor (probable meningioma), noncysticercotic granuloma, chronic alcoholism sequelae, chronic hydrocephalus,
progressive myoclonic epilepsy (probable Unverricht–Lundborg disease).

persons would be lower if we considered epilepsy patients are reported, most report sensitivities >90% but variable
with both active and inactive epilepsy. Fifty-eight percent specificities as low as 50.8% (18). Our questionnaire had
of those treated were receiving monotherapy with pheny- a sensitivity of 99.2% and a specificity of 75%.
toin (PHT) or phenobarbital (PB). The remainder received The overall epilepsy prevalence rate (23.3/1,000 inhab-
carbamazepine (CBZ) or valproate (VPA) in combination itants) and the prevalence of active epilepsy (15.4/1,000)
with PHT or PB. Seventy-six percent of patients had had in Salamá are high compared with data of developed in-
seizures in the last 12 months, and 47% had had status dustrialized countries but similar to other Latin-American
epilepticus sometime during the course of their epilepsy. data (4,5). In the former, overall prevalence rates range
from 5/1,000 to 8/1,000. Most studies published in Cen-
Interventional and follow-up program
tral and South America show prevalence rates ranging
After the results of the epidemiologic and clinical study
from 7/1,000 to 57/1,000 (4,5) and include: 57/1,000 in a
were known, they were discussed with the Secretary of
Panama rural county, 22/1,000 in Panama City (31,32),
Health to design strategies for community interventions,
8.5 to 52/1,000 in Guatemala (4), and 21.4/1,000 in
epidemiologic surveillance, and follow-up of the cohort.
Medellı́n, Colombia (30). Other studies have reported
A full report of the details of the interventional program
rates of 3/1,000 to 15/1,000 in Africa (33) and 9.9/1,000
will be published separately as results become available.
in Pakistan (17). These studies appear not to be strictly
comparable because of methodologic differences and lo-
DISCUSSION
cal regional characteristics (1,3,7). The Salamá incidence
Epilepsy is highly prevalent in the rural county of rate also was high (92.7/100,000), with rates usually re-
Salamá, Honduras. This is one of the first studies from ported from 30 to 50/100,000 person-years in industrial-
a developing country that shows epilepsy etiologies in a ized countries (1,3,6).
population-based study. We found that the vast majority Most persons in population studies with active epilepsy
of epilepsies were symptomatic, which contrasts with in- have an onset of seizures in the first two decades of life
dustrialized countries, where idiopathic epilepsies are re- (1,3,6). This was true in Salamá County. The prevalence
ported to be more frequent (28,29). NCC was the primary peaks from the second to the fifth decade of life. Con-
cause of symptomatic epilepsy. trary to this finding, it has been reported that in industrial-
Our field study showed that the percentage of per- ized countries like the United States, the prevalence rate is
sons with epileptic seizures identified in the first phase higher in the young, levels off, and then increases again in
of the Salamá study (4.2%) is lower than that in other the older population (older than 65 years) (1,3). Rates in
population-based studies from Karachi, Pakistan (6%; 17) the older population were lower in Salamá. Possibly this
and Medellı́n, Colombia (9.7%; 30). Differences may be is a result of a lower life expectancy and high mortality
due to methodologic aspects, especially the training and associated with lack of access to optimal care, resulting in
experience of the persons involved in the survey, and to inadequate control of seizures and status epilepticus.
financial support. All of our study patients had a full eval- The epidemiology of single isolated seizures varies in
uation regardless of ability to pay. The higher percentage previous studies. We found a prevalence of 8.9/1,000.
of cases considered suggestive of epilepsy in other stud- A similar study from Pakistan reported a prevalence of
ies may reflect lower specificity of the screening. This 2/1,000 (17). Although a cumulative incidence is used,
results in more suspected cases and more excluded cases the risk of having a single seizure is 3.6% in Rochester,
from the final data. When sensitivities and specificities Minnesota (34). The rate of febrile seizures in the total

Epilepsia, Vol. 46, No. 1, 2005

130 M. T. MEDINA ET AL.

population from Salamá is low (6.0/1,000) when com- ment with or without the use of alternative medicines
pared with that in Rochester, Minnesota data (1,6), which need to be included in a comprehensive management plan
reports a rate of 5% in the childhood population and 2% (41–43).
in the total population (2). Our low prevalence of neonatal The use of standardized definitions/criteria and al-
seizures probably confirms that most seizures are subtle gorithms/protocols with proven clinical effectiveness is
and difficult to distinguish from normal movements (35). needed for accurate case ascertainment for epilepsy stud-
Epidemiologic studies on epilepsy must consider the ies (44). Neuroimaging studies, video-EEG, and labora-
methodologic gaps and variables influencing the preva- tory studies are critical in determining the etiology of the
lence rates (7). For example, a retrospective review of epilepsies. By using these investigative criteria and tech-
medical records may be an inaccurate method to deter- niques in our Salamá study, the high prevalence and inci-
mine epilepsy prevalence, because patients may never con- dence of epilepsy was found to be explained primarily by
sult a doctor because of the subtle nature of some seizure symptomatic epilepsies. This led to the establishment of
symptoms. The Salamá governmental clinic’s registry of programs in epidemiologic surveillance, education, inter-
persons with epilepsy, when compared with the house-to- vention, and long-term follow-up specifically planned to
house survey, underreported active epilepsy by 64%. Prob- benefit the people of the Salamá region.
lems with access to diagnostic studies and social stigma
Acknowledgment: We thank the patients, their families, and
can delay the diagnosis and also contribute to underreport- all the Salamá communities for their participation in this study.
ing of epilepsy (15,36). For these reasons, the most cur- We also thank Rafael Aguilar-Estrada, Arnold Thompson, Sofı́a
rent sensitive and specific method for detecting epilepsy Dubón, Francis Barahona, Marisabel Rivera, Francisco Ramı́rez,
is community screening by an appropriate questionnaire, and Ana L. Sánchez from the National Autonomous University
complete clinical evaluations, and the use of diagnostic of Honduras for their assistance during this study. Funding for
transportation, brain CT scans, and video-EEGs was provided by
procedures/tests. the World Bank through the project Nutrition and Health under
By combining clinical and diagnostic findings, 98% of the Secretary of Health. The Mayor of Salamá, Rafael Zúniga,
Salamá’s active epilepsy patients had their seizures classi- provided assistance for transportation of patients and did col-
fied. The video-EEG contributed to the diagnosis 84% of laborative work with the Secretary of Health on the establish-
the time. Although the MRI has greater sensitivity (37,38), ment of the interventional program. The Karolinska International
Research Training (KIRT) and Inger Ljungström provided sup-
brain CT neuroimaging studies helped clarify the etiol- port for the immunologic studies. Centro de Neurodiagnóstico
ogy of active epilepsy in 60% of the Salamá cases. Al- provided video-EEG material for patient interviews and edu-
though most studies in developed industrialized countries cation, and technical assistance for EEG studies. The Japanese
report a higher proportion of primary generalized epilep- International Cooperation Agency (JICA), Dr. M. Sone from the
sies (1,6), recent reports from developing countries report Shizuoka Swine and Poultry Research Station (Shizuoka, Japan),
Dr. H. Sakai from the Laboratory of Parasitology, Department of
a higher frequency of partial seizures with or without sec- Disease Control of the Graduate School of Veterinary Medicine,
ondary generalization, which may indicate a high inci- Hokkaido University (Sapporo, Japan), and Dr. Peter Schantz
dence of symptomatic epilepsy (2,5). Our data are con- from the division of Parasitic Disease, National Center for In-
sistent with this and also indicate that many epilepsies fectious Disease, Centers for Disease Control and Prevention
in developing countries are probably preventable. NCC (Atlanta, Georgia, U.S.A.) provided the funding and technical
assistance for the EITB assays. Lenı́n Banegas from the head-
is highly endemic in Latin America, and previous reports quarters of the Secretary of Health in Salamá contributed to the
from hospital-based studies in the region document NCC field study and follow-up program.
as a common cause of epilepsy and epileptic seizures
(39,40). Although not as frequent, perinatal brain damage
appears to be responsible for 8% of the active symptomatic REFERENCES
epilepsy in our study. Although the methods differed, peri- 1. Hauser W, Hesdorffer D. Epilepsy: frequency, causes and con-
natal brain damage has been reported to be the cause of sequences. New York: Demos Medical Publishing, 1990:93–
0.5–14% of the epilepsies in the world, with higher preva- 118.
2. Jallon P. Epilepsy in developing countries. Epilepsia 1997;38:1143–
lences in underdeveloped countries (2,4,5). 51.
Another problem detected by the current study is the 3. Shorvon S. Epidemiology, classification, natural history, and genet-
high percentage of patients with active epilepsy who are ics of epilepsy. Lancet 1990;336:93–6.
4. Gracia F. Epidemiologı́a de las epilepsias en Latinoamerica. In:
not taking their prescribed treatment. Because 76% had Medina MT, Chávez F, Chinchilla Net al., eds. Las epilepsias en
seizures in the last 12 months with a high frequency of centroamérica. Tegucigalpa: Scancolor, 2001:17–22.
status epilepticus, concerns can be raised with regard to 5. Senanayake N, Román G. Epidemiology of epilepsy in developing
countries. Bull WHO 1993;71:247–58.
the access to treatment in this surveyed region. A sim- 6. Annegers JF. The epidemiology of epilepsy. In: Wyllie E, ed. The
ilar situation has been found in other regions of Latin treatment of epilepsy: principles and practices. 2nd ed. Baltimore:
America, Asia, and Africa (27). Cost-effective access to Williams & Wilkins, 1996:165–72.
7. Sander J, Shorvon S. Incidence and prevalence studies in epilepsy
AED treatments, education about medication side effects and their methodological problems: a review. J Neurol Neurosurg
and stigma, as well as self-withdrawal from AED treat- Psychiatry 1987;50:829–39.

Epilepsia, Vol. 46, No. 1, 2005

 EPIDEMIOLOGY OF EPILEPSY: SALAMÁ, HONDURAS 131

8. Commission on Epidemiology and Prognosis of the International 25. Del Brutto OH, Rajshekhar V, White AC, et al. Proposed diagnostic
League Against Epilepsy. Guidelines for epidemiological studies criteria for neurocysticercosis. Neurology 2001;57:177–83.
on epilepsy. Epilepsia 1993;34:592–6. 26. Roger J, Genton P, Bureau M. La classification internationale des
9. Annegers JF, Rocca WA, Hauser WA. Causes of epilepsy: con- epilepsies et des syndromes épileptiques adopteé au Congrèss de
tributions of the Rochester epidemiology project. Mayo Clin Proc New Delhi (Octobre 1989): commentaries et traduction. Epilepsies
1996;71:570–5. 1990;2:183–97.
10. Commission on Classification and Terminology of the International 27. Kale R. Global campaign against epilepsy: the treatment gap. Epilep-
League Against Epilepsy. Proposal for revised clinical and electro- sia 2002;43:31–3.
graphic classification of epileptic seizures. Epilepsia 1981;22:489– 28. Hauser WA, Kurland LT. Epidemiology of epilepsy in Rochester,
501. Minnesota, 1935 through 1967. Epilepsia 1975;16:1–66.
11. Commission on Classification and Terminology of the International 29. Granieri E, Rosati G, Tola R, et al. A descriptive study of epilepsy in
League Against Epilepsy. Proposal for revised classification of the district of Copparo, Italy, 1964–1978. Epilepsia 1983;24:502–
epilepsies and epileptic syndromes. Epilepsia 1989;30:389–99. 14.
12. Engel J. A proposed diagnostic scheme for people with epileptic 30. Zuloaga L, Soto C, Jaramillo D. Prevalencia de epilepsia en
seizures and with epilepsy: report of the ILAE Task Force on Clas- Medellı́n. Bol Sanit Panama 1988;104:331–44.
sification and Terminology. Epilepsia 2001;42:1–8. 31. Gracia FJ, Bayard V, Triana E, et al. Prevalencia de enfermedades
13. Martı́nez L, Banegas L, Cartagena D. Análisis de situación de salud neurológicas en el Corregimiento Belisario Porras Distrito de San
según condiciones de vida (ASIS/SCV), Municipios del Norte de Miguelito, Panamá, 1986. Rev Med Panama 1988;13:40–5.
Olancho 2002: reporte a la Secretaria de Salud, Julio 2002. 32. Gracia F, de Lao SL, Castillo L, et al. Epidemiology of epilepsy in
14. Medina MT, Durón R, Ramı́rez F, et al. Prevalence of neurologi- Guaymi Indians from Bocas del Toro Province, Republic of Panama.
cal disorders in Tegucigalpa: the Kennedy Study. Rev Med Hond Epilepsia 1990;31:718–23.
2003;71:8–17. 33. Osuntokun BO, Adeuja AOG, Nottidge VA, et al. Prevalence of the
15. Varela F, Nicolás O, Durón R, et al. Aspectos antropológicos y epilepsies in Nigerian Africans: a community-based study. Epilepsia
culturales que inciden en la determinación de la prevalencia de 1987;28:272–9.
las epilepsias en la etnia miskita de Honduras. Rev Med Hond 34. Annegers J, Hauser W, Lee J, et al. Incidence of acute symp-
2002;70:9–14 tomatic seizures in Rochester, Minnesota 1935–1984. Epilepsia
16. Sánchez AL, Lindback J, Schantz PM, et al. A population based, 1995;36:327–33.
case-control study of Taenia solium taeniasis and cysticercosis. Ann 35. Scher MS. Seizures in special clinical settings: neonatal seizures. In:
Trop Med Parasitol 1999;93:247–58. Wyllie E, ed. The treatment of epilepsy: principles and practices.
17. Aziz H, Ali SM, Frances P, et al. Epilepsy in Pakistan: a population- 2nd ed. Baltimore: Williams & Wilkins, 1996:600–21.
based epidemiologic study. Epilepsia 1994;35:950–8. 36. Sander J, Hart Y, Johnson A, et al. National General Practice Study
18. Placencia M, Sander JWAS, Shorvon SD, et al. Validation of a of Epilepsy: newly diagnosed epileptic seizures in a general popu-
screening questionnaire for the detection of epileptic seizures in lation. Lancet 1990;336:1267–71.
epidemiological studies. Brain 1992;115:783–94. 37. Jack C Jr. Magnetic resonance imaging in epilepsy. Mayo Clin Proc
19. Pradilla G, Vesga VE, Leon-Sarmiento FE, et al. Neuroepidemiolo- 1996;71:695–711.
gia en el oriente colombiano. Rev Neurol 2002;34:1035–43. 38. Connor SE, Jarosz JM. Magnetic resonance imaging of patients with
20. Nicoletti A, Regio A, Bartoloni A, et al. Prevalence of epilepsy in epilepsy. Clin Radiol 2001;56:787–801.
rural Bolivia: A door-to-door survey. Neurology 1999;53:2064–9. 39. Medina MT. Epilepsy due to neurocysticercosis. Neurology
21. Wang WZ, Wu JZ, Wang DS, et al. The prevalence and treatment 1992;42:2055.
gap in epilepsy in China: an ILAE/IBE/WHO study. Neurology 40. Nash TE, Del Brutto OH, Butman JA, et al. Calcific neurocysticer-
2003;60:1544–5. cosis and epileptogenesis. Neurology 2004;62:1934–8.
22. Medina MT, Molina L, Durón R, et al. Prevalence of the epilep- 41. Medina MT, DeGiorgio C. Introduction to neurocysticercosis: a
sies in Honduras: a national population-based study. Epilepsia worldwide epidemic. Neurosurg Focus 2002;12:6.
2003;44:155. 42. Trevathan E, Medina MT, Madrid A. A broad-spectrum anti-
23. Sánchez AL, Durón R, Osorio J, et al. Evaluation of the enzyme- epileptic drug for the developing world. Lancet 1998;351:1210.
linked immunoelectrotransfer blot (EITB) assay in epileptic patients 43. Durón R, Medina MT, Holden KR, et al. Pilot trial on antiepilep-
from a rural community in Honduras. Proc IX Intl Congr Parasitol tic treatment compliance in epileptic patients at Hospital Escuela,
ICOPA 1998;9:185–9. Tegucigalpa, Honduras, CA. Rev Med Hond 2001;69:140–5.
24. Sánchez AL, Ljungström I, Medina MT. Diagnosis of human neu- 44. Krishnamoorthy ES, Satishchandra P, Sander JW. Research in
rocysticercosis in endemic countries: a clinical study in Honduras. epilepsy: development priorities for developing nations. Epilepsia
Parasitol Int 1999;48:81–9. 2003;44:5–8.

Epilepsia, Vol. 46, No. 1, 2005