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Background Survivors of invasive group B Streptococcus (iGBS) disease, notably meningitis, are at increased risk of neurodevelopmental impairment. However, the limited studies to date have a median follow-up to 18 months and have mainly focused on moderate or severe neurodevelopmental impairment, with no previous studies on emotional-behavioral problems among iGBS survivors. Methods In this multicountry, matched cohort study, we included children aged 18 months to 17 years with infant iGBS sepsis and meningitis from health demographic surveillance systems, or hospital records in Argentina, India, Kenya, Mozambique, and South Africa. Children without an iGBS history were matched to iGBS survivors for sex and age. Our primary outcomes were emotional-behavioral problems and psychopathological conditions as measured with the Child Behavior Checklist (CBCL). The CBCL was completed by the child’s primary caregiver. Results Between October 2019 and April 2021, 573 children (mean age, 7.18 years) were assessed, including 156 iGBS survivors and 417 non-iGBS comparison children. On average, we observed more total problems and more anxiety, attention, and conduct problems for school-aged iGBS survivors compared with the non-iGBS group. No differences were found in the proportion of clinically significant psychopathological conditions defined by the Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition). Conclusions Our findings suggested that school-aged iGBS survivors experienced increased mild emotional behavioral problems that may affect children and families. At-risk neonates including iGBS survivors need long-term follow-up with integrated emotional-behavioral assessments and appropriate care. Scale-up will require simplified assessments that are free and culturally adapted.

BackgroundTimely detection and management of comorbid mental disorders in people with epilepsy is essential to improve outcomes. The objective of this study was to measure the performance of primary health care (PHC) workers in identifying comorbid mental disorders in people with epilepsy against a standardised reference diagnosis and a screening instrument in rural Ethiopia.MethodsPeople with active convulsive epilepsy were identified from the community, with confirmatory diagnosis by trained PHC workers. Documented diagnosis of comorbid mental disorders by PHC workers was extracted from clinical records. The standardized reference measure for diagnosing mental disorders was the Operational Criteria for Research (OPCRIT plus) administered by psychiatric nurses. The mental disorder screening scale (Self-Reporting Questionnaire; SRQ-20), was administered by lay data collectors. The sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of PHC worker diagnosis against the reference standard diagnosis was calculated. Logistic regression was used to examine the factors associated with misdiagnosis of comorbid mental disorder by PHC workers.ResultsA total of 237 people with epilepsy were evaluated. The prevalence of mental disorders with standardised reference diagnosis was 13.9% (95% confidence interval (CI) 9.6, 18.2%) and by PHC workers was 6.3% (95%CI 3.2, 9.4%). The prevalence of common mental disorder using SRQ-20 at optimum cut-off point (9 or above) was 41.5% (95% CI 35.2, 47.8%). The sensitivity and specificity of PHC workers diagnosis was 21.1 and 96.1%, respectively, compared to the standardised reference diagnosis. In those diagnosed with comorbid mental disorders by PHC workers, only 6 (40%) had SRQ-20 score of 9 or above. When a combination of both diagnostic methods (SRQ-20 score ≥ 9 and PHC diagnosis of depression) was compared with the standardised reference diagnosis of depression, sensitivity increased to 78.9% (95% (CI) 73.4, 84.4%) with specificity of 59.7% (95% CI 53.2, 66.2%). Only older age was significantly associated with misdiagnosis of comorbid mental disorders by PHC (adjusted odds ratio, 95% CI = 1.06, 1.02 to 1.11).ConclusionRoutine detection of co-morbid mental disorder in people with epilepsy was very low. Combining clinical judgement with use of a screening scale holds promise but needs further evaluation.

Background The COVID-19 pandemic leads to disruptions of health services worldwide. To evaluate the particular impact on neurological services a rapid review was conducted. Methods Studies reporting the provision of neurological services during the pandemic and/or adopted mitigation strategies were included in this review. PubMed and World Health Organization’s (WHO) COVID-19 database were searched. Data extraction followed categories used by WHO COVID-19 pulse surveys and operational guidelines on maintaining essential health services during COVID-19. Findings The search yielded 1101 articles, of which 369 fulfilled eligibility criteria, describing data from 210,419 participants, being adults (81%), children (11.4%) or both (7.3%). Included articles reported data from 105 countries and territories covering all WHO regions and World Bank income levels (low income: 1.9%, lower middle: 24.7%, upper middle: 29.5% and high income; 44.8%). Cross-sectoral services for neurological disorders were most frequently disrupted (62.9%), followed by emergency/acute care (47.1%). The degree of disruption was at least moderate for 75% of studies. Travel restrictions due to lockdowns (81.7%) and regulatory closure of services (65.4%) were the most commonly reported causes of disruption. Authors most frequently described telemedicine (82.1%) and novel dispensing approaches for medicines (51.8%) as mitigation strategies. Evidence for the effectiveness of these measures is largely missing. Interpretation The COVID-19 pandemic affects all aspects of neurological care. Given the worldwide prevalence of neurological disorders and the potential long-term neurological consequences of COVID-19, service disruptions are devastating. Different strategies such as telemedicine might mitigate the negative effects of the pandemic, but their efficacy and acceptability remain to be seen.

Objective Nodding syndrome is a poorly understood epileptic encephalopathy characterized by a unique seizure type—head nodding—and associated with Onchocerca volvulus infection. We hypothesized that altered immune activation in the cerebrospinal fluid (CSF) and plasma of children with nodding syndrome may yield insights into the pathophysiology and progression of this seizure disorder. Method We conducted a case‐control study of 154 children (8 years or older) with long‐standing nodding syndrome and 154 healthy age‐matched community controls in 3 districts of northern Uganda affected by nodding syndrome. Control CSF samples were obtained from Ugandan children in remission from hematological malignancy during routine follow‐up. Markers of immune activation and inflammation (cytokines and chemokines) and complement activation (C5a) were measured in plasma and CSF using ELISA or Multiplex Luminex assays. O volvulus infection was assessed by serology for anti–OV‐16 IgG levels. Results The mean (SD) age of the population was 15.1 (SD: 1.9) years, and the mean duration of nodding syndrome from diagnosis to enrollment was 8.3 (SD: 2.7) years. The majority with nodding syndrome had been exposed to O volvulus (147/154 (95.4%)) compared with community children (86/154 (55.8%)), with an OR of 17.04 (95% CI: 7.33, 45.58), P < .001. C5a was elevated in CSF of children with nodding syndrome compared to controls (P < .0001). The levels of other CSF markers tested were comparable between cases and controls after adjusting for multiple comparisons. Children with nodding syndrome had lower plasma levels of IL‐10, APRIL, CCL5 (RANTES), CCL2, CXCL13, and MMP‐9 compared with community controls (P < .05 for all; multiple comparisons). Plasma CRP was elevated in children with nodding syndrome compared to community children and correlated with disease severity. Significance Nodding syndrome is associated with exposure to O. volvulus. Compared to controls, children with long‐standing symptoms of nodding syndrome show evidence of complement activation in CSF and altered immune activation in plasma.

BackgroundThere is little data on the long-term neurocognitive and educational outcomes among school-aged survivors of neonatal jaundice (NNJ) and hypoxic-ischemic encephalopathy (HIE) in Africa.This study investigates the long-term neurocognitive and educational outcomes and the correlates of these outcomes in school-aged survivors of NNJ or HIE in Kilifi, Kenya.MethodsWe conducted a cross-sectional study on neurocognitive and educational outcomes among school-aged survivors (6–12 years) of NNJ (n = 134) and HIE (n = 107) and compared them to a community comparison group (n = 134). We assessed nonverbal intelligence, planning, working memory, attention, syntax, pragmatics, word-finding, memory, perceptual-motor, mathematical, and reading abilities. We also collected information on medical history, caregivers’ mental health, and family environment.ResultsThe survivors of NNJ had lower mean total scores in word-finding [F (1, 250) = 3.89,p = 0.050] and memory [F (1, 248) = 6.74,p = 0.010] than the comparison group. The survivors of HIE had lower mean scores in pragmatics [F (1, 230) = 6.61,p = 0.011] and higher scores higher scores in non-verbal reasoning [F (1, 225) =4.10,p = 0.044] than the comparison group. Stunted growth was associated with almost all the outcomes in HIE.ConclusionSurvivors of NNJ and HIE present with impairment in the multiple domains, which need to be taken into consideration in the planning of educational and rehabilitative services.

Summary Background Infection with Plasmodium falciparum leads to severe malaria and death in approximately 400 000 children each year in sub-Saharan Africa. Blood transfusion might benefit some patients with malaria but could potentially harm others. The aim of this study was to estimate the association between transfusion and death among children admitted to hospital with P falciparum malaria. Methods In this prospective, multicentre observational study, we analysed admissions to six tertiary care hospitals in The Gambia, Malawi, Gabon, Kenya, and Ghana that participated in the Severe Malaria in African Children network. Patients were enrolled if they were younger than 180 months and had a Giemsa-stained thick blood smear that was positive for P falciparum. Blood transfusion (whole blood at a target volume of 20 mL per kg) was administered at the discretion of the responsible physicians who were aware of local and international transfusion guidelines. The primary endpoint was death associated with transfusion, which was estimated using models adjusted for site and disease severity. We also aimed to identify factors associated with the decision to transfuse. The exploratory objective was to estimate optimal haemoglobin transfusion thresholds using generalised additive models. Findings Between Dec 19, 2000, and March 8, 2005, 26 106 patients were enrolled in the study, 25 893 of whom had their transfusion status recorded and were included in the primary analysis. 8513 (32·8%) patients received a blood transfusion. Patients were followed-up until discharge from hospital for a median of 2 days (IQR 1–4). 405 (4·8%) of 8513 patients who received a transfusion died compared with 689 (4·0%) of 17 380 patients who did not receive a transfusion. Transfusion was associated with decreased odds of death in site-adjusted analysis (odds ratio [OR] 0·82 [95% CI 0·71–0·94]) and after adjusting for the increased disease severity of patients who received a transfusion (0·50 [0·42–0·60]). Severe anaemia, elevated lactate concentration, respiratory distress, and parasite density were associated with greater odds of receiving a transfusion. Among all study participants, transfusion was associated with improved survival when the admission haemoglobin concentration was up to 77 g/L (95% CI 65–110). Among those with impaired consciousness (Blantyre Coma Score ≤4), transfusion was associated with improved survival at haemoglobin concentrations up to 105 g/L (95% CI 71–115). Among those with hyperlactataemia (blood lactate ≥5·0 mmol/L), transfusion was not significantly associated with harm at any haemoglobin concentration—ie, the OR of death comparing transfused versus not transfused was less than 1 at all haemoglobin concentrations (lower bound of the 95% CI for the haemoglobin concentration at which the OR of death equals 1: 90 g/L; no upper bound). Interpretation Our findings suggest that whole blood transfusion was associated with improved survival among children hospitalised with P falciparum malaria. Among those with impaired consciousness or hyperlactataemia, transfusion was associated with improved survival at haemoglobin concentrations above the currently recommended transfusion threshold. These findings highlight the need to do randomised controlled trials to test higher transfusion thresholds among African children with severe malaria complicated by these factors. Funding US National Institute of Allergy and Infectious Diseases.

© 2021 The Authors. Journal of the International AIDS Society published by John Wiley & Sons Ltd on behalf of International AIDS SocietyIntroduction: Common mental disorders (CMDs) particularly depression and anxiety, are highly comorbid with HIV also in young people living with HIV (YLWH). In sub-Saharan Africa (SSA) where most YLWH reside, there are limited summary data on CMDs among these youths, yet there are previous systematic reviews summarizing data on CMDs among adults living with HIV. We conducted a systematic literature review on the prevalence and correlates of CMDs among YLWH, aged 10 to 24 years, from SSA. Methods: We searched African Index Medicus, African Journals Online and five other electronic databases (from database inception up to 31 December 2020) for relevant studies published in English. The key search terms applied were as follows: “Depression OR Anxiety”, “Young people”, “HIV infections” and “sub-Saharan Africa”. Results and discussion: Out of 3989 articles, 31 studies were included in the review. The prevalence of CMDs in YLWH widely varied ranging between 16.0% and 40.8% for major depression, 4.4% and 52.6% for depressive symptoms and 2.2% and 25.0% for anxiety symptoms. Anxiety disorder was estimated at 45.6%. Four of the five included studies with a comparison group of HIV-negative young people reported significantly higher prevalence estimates of depressive disorders among YLWH. Several sociodemographic, psychosocial and HIV-related correlates of CMDs were reported but most lacked consensus across studies. Nevertheless, female sex, older age, fewer schooling years, HIV-positive status, bullying, sexual abuse, HIV-related stigma, social support and poor antiretroviral therapy adherence were frequently reported (in ≥2 studies) as significant correlates of depressive symptoms among YLWH. Higher social support was the only frequent significant correlate of anxiety symptoms. Conclusions: The burden of CMDs among YLWH from SSA is substantial and appears to be significantly higher when compared with HIV-negative peers, particularly for depressive disorders. However, more comparative research is needed. Importantly, screening for CMDs at the youth HIV-clinics should be prioritized especially for YLWH at high risk of CMDs, to facilitate early management or referral for treatment. Furthermore, youth-friendly psychological interventions addressing CMDs in YLWH should urgently be piloted in SSA, incorporating contextual components that may directly or indirectly reduce symptoms of CMDs among YLWH, such as social support.

ObjectiveIn this systematic review, we aimed to summarise the empirical evidence on common mental disorders (CMDs), cognitive impairment, frailty and health-related quality of life (HRQoL) among people living with HIV aged ≥50 years (PLWH50 +) residing in sub-Saharan Africa (SSA). Specifically, we document the prevalence and correlates of these outcomes.Design, data sources and eligibility criteriaThe following online databases were systematically searched: PubMed, CINAHL, PsycINFO, Embase and Scopus up to January 2021. English-language publications on depression, anxiety, cognitive function, frailty and quality of life among PLWH50+ residing in SSA were included.Data extraction and synthesisWe extracted information, including study characteristics and main findings. These were tabulated, and a narrative synthesis approach was adopted, given the substantial heterogeneity among included studies.ResultsA total of 50 studies from fifteen SSA countries met the inclusion criteria. About two-thirds of these studies emanated from Ethiopia, Uganda and South Africa. Studies regarding depression predominated (n=26), followed by cognitive impairment (n=13). Overall, PLWH50+ exhibited varying prevalence of depression (6%–59%), cognitive impairments (4%–61%) and frailty (3%–15%). The correlates of CMDs, cognitive impairment, frailty and HRQoL were rarely investigated, but those reported were sociodemographic variables, many of which were inconsistent.ConclusionsThis review documented an increasing number of published studies on HIV and ageing from SSA. However, the current evidence on the mental and well-being outcomes in PLWH50+ is inadequate to characterise the public health dimension of these impairments in SSA, because of heterogeneous findings, few well-designed studies and substantial methodological limitations in many of the available studies. Future work should have sufficiently large samples of PLWH50+, engage appropriate comparison groups, harmonise the measurement of these outcomes using a standardised methodology to generate more robust prevalence estimates and confirm predictors.PROSPERO registration numberCRD42020145791.

Background Health-related quality of life (HRQoL) is an important metric of perceived wellbeing in people living with HIV/AIDS (PLWHA). However, research on HRQoL among PLWHA in sub-Saharan Africa is limited. This study investigates factors associated with HRQoL among PLWHA in Kilifi, coast of Kenya. Methods Between February and April 2018, 450 adults living with HIV and on combined antiretroviral therapy (cART) between 18 to 60 years were sequentially recruited from an HIV-specialized clinic. The Functional Assessment of HIV Infection (FAHI) questionnaire, previously adapted for assessing HRQoL in this setting, was slightly modified and administered to participants alongside other measures of sociodemographic, health and treatment characteristics in a face-to-face interview. Results Linear regression analyses indicated that depressive symptoms, HIV-related stigma, non-disclosure of HIV status, living alone, clinic inaccessibility, and presence of any current opportunistic infection were significantly associated with lower HRQoL scores at both the FAHI overall and sub-scale level. Higher physician empathy, male sex, and higher body mass index were significantly associated with better HRQoL scores at both FAHI overall and sub-scale level. Age and longer duration on cART were significantly associated with better HRQoL only at the sub-scale level. Conclusions Interventions aimed at reducing depressive symptoms and HIV stigma, making HIV-related services more accessible, addressing opportunistic infections, strengthening social support systems, serostatus disclosure and put in place caring, respectful, and compassionate model of care are necessary to improve the HRQoL of PLWHA.

ObjectivesTo provide information on the effect of the coronavirus disease of 2019 (COVID-19) pandemic on people with epilepsy and provide consensus recommendations on how to provide the best possible care for people with epilepsy while avoiding visits to urgent care facilities and hospitalizations during the novel coronavirus pandemic.MethodsThe authors developed consensus statements in 2 sections. The first was “How should we/clinicians modify our clinical care pathway for people with epilepsy during the COVID-19 pandemic?” The second was “What general advice should we give to people with epilepsy during this crisis? The authors individually scored statements on a scale of −10 (strongly disagree) to +10 (strongly agree). Five of 11 recommendations for physicians and 3/5 recommendations for individuals/families were rated by all the authors as 7 or above (strongly agree) on the first round of rating. Subsequently, a teleconference was held where statements for which there was a lack of strong consensus were revised.ResultsAfter revision, all consensus recommendations received a score of 7 or above. The recommendations focus on administration of as much care as possible at home to keep people with epilepsy out of health care facilities, where they are likely to encounter COVID-19 (including strategies for rescue therapy), as well as minimization of risk of seizure exacerbation through adherence, and through ensuring a regular supply of medication. We also provide helpful links to additional helpful information for people with epilepsy and health providers.ConclusionThese recommendations may help health care professionals provide optimal care to people with epilepsy during the coronavirus pandemic.

Background The COVID-19 pandemic outbreak has dramatically disrupted healthcare systems. Two rapid WHO pulse surveys studied disruptions in mental health services, but did not particularly focus on neurology. Here, a global survey was conducted and addresses the impact of the pandemic on neurology services. Methods A cross-sectional study was carried out in which 34 international neurological associations were asked to distribute the survey to national associations. The responses represented the national situation, in November–December 2020, with regard to the main disrupted neurological services, reasons and the mitigation strategies implemented as well as the disruption on training of residents and on neurological research. A comparison with the situation in February–April 2020, first pandemic wave, was also requested. Findings 54 completed surveys came from 43 countries covering all the 6 WHO regions. Overall, neurological services disruption was reported as mild by 26%, moderate by 30%, complete by 13% of associations. The most affected services were cross-sectoral neurological services (57%) and neurorehabilitation (56%). The second wave of the pandemic, however, was associated with the improvement of service provision for diagnostics services (44%) and for neurorehabilitation (41%). Governmental directives were the major cause of services’ disruption (56%). Mitigation strategies were mostly established through telemedicine (48%). Almost half of respondents reported a significant impact on neurological research (48%) and educational activities (60%). Most associations (67%) were not involved in decision making for neurological patients’ issues by their national government. Interpretation The COVID-19 pandemic affects neurological services and raises the universal need for the development of neurological health care at the policy, systems and services levels. A global national plan on mitigation strategies for disruption of neurological services during pandemic situations should be established and neurological scientific and patients associations should get involved in decision making. Supplementary Information The online version contains supplementary material available at 10.1007/s00415-021-10641-3.

BackgroundDiagnosing bacterial meningitis is essential to optimise the type and duration of antimicrobial therapy to limit mortality and sequelae. In sub-Saharan Africa, many public hospitals lack laboratory capacity, relying on clinical features to empirically treat or not treat meningitis. We investigated whether clinical features of bacterial meningitis identified prior to the introduction of conjugate vaccines still discriminate meningitis in children aged ≥60 days.MethodsWe conducted a retrospective cohort study to validate seven clinical features identified in 2002 (KCH-2002): bulging fontanel, neck stiffness, cyanosis, seizures outside the febrile convulsion age range, focal seizures, impaired consciousness, or fever without malaria parasitaemia and Integrated Management of Childhood Illness (IMCI) signs: neck stiffness, lethargy, impaired consciousness or seizures, and assessed at admission in discriminating bacterial meningitis after the introduction of conjugate vaccines. Children aged ≥60 days hospitalised between 2012 and 2016 at Kilifi County Hospital were included in this analysis. Meningitis was defined as positive cerebrospinal fluid (CSF) culture, organism observed on CSF microscopy, positive CSF antigen test, leukocytes ≥50/μL, or CSF to blood glucose ratio ResultsAmong 12,837 admissions, 98 (0.8%) had meningitis. The presence ofKCH-2002signs had a sensitivity of 86% (95% CI 77–92) and specificity of 38% (95% CI 37–38). Exclusion of ‘fever without malaria parasitaemia’ reduced sensitivity to 58% (95% CI 48–68) and increased specificity to 80% (95% CI 79–80). IMCI signs had a sensitivity of 80% (95% CI 70–87) and specificity of 62% (95% CI 61–63).ConclusionsA lower prevalence of bacterial meningitis and less typical signs than in 2002 meant the lower performance ofKCH-2002signs. Clinicians and policymakers should be aware of the number of lumbar punctures (LPs) or empirical treatments needed for each case of meningitis. Establishing basic capacity for CSF analysis is essential to exclude bacterial meningitis in children with potential signs.

Background In sub-Saharan Africa, common mental disorders (CMDs) like depression and anxiety are under-investigated amongst young people living with HIV (YLWH). To address the gap, in Kenya we: a) determined the prevalence of CMDs among YLWH compared to their uninfected peers; b) investigated HIV status as an independent predictor of CMDs in young people; c) investigated CMDs risk and protective indicators with more focus on YLWH. Methods Between November 2018 and September 2019, 819 young people aged 18–24 years (407 HIV-infected) were recruited from two Counties on the Kenyan coast. Locally adapted pre-existing mental health measures, Patient Health Questionnaire (9-item) and Generalized Anxiety Disorder scale (7-item), were administered among other questionnaires via audio computer-assisted self-interview. Logistic regression was used to determine the correlates of CMDs. Results Prevalence of CMDs was significantly elevated among YLWH compared to their uninfected peers i.e. 29% vs. 12%; p for depressive symptoms, 19% vs. 8%; p for anxiety symptoms, and 16% vs. 5%; p for comorbid depressive and anxiety symptoms. HIV status independently predicted depressive symptoms and its co-occurrence with anxiety symptoms. Among YLWH, negative life events, higher perceived HIV-related stigma and low adherence to antiretroviral therapy were the risk indicators for elevated CMDs. Among HIV-uninfected youths, death of both parents was a risk indicator for elevated depressive symptoms. Protective indicators against CMDs among youths with and without HIV included higher social support and health-related quality of life. Conclusion At the Kenyan coast, YLWH have significantly higher burden of CMDs compared to their uninfected peers. Being HIV-positive as a youth in this setting is predictive of more depressive symptoms and its comorbidity with anxiety symptoms. YLWH at high risk of CMDs in coastal Kenya can benefit from early detection, referral and treatment if routine screening for CMDs is integrated in their care package. The mental wellbeing of bereaving HIV-unaffected youths could be improved through continued support to help them come to terms with their loss. At the community level, programmes strengthening the social capital or improving the overall quality of life of youths with or without HIV may be beneficial to their mental health.

Background In sub-Saharan Africa, there is paucity of research on substance use patterns among young people living with HIV (YLWH). To address the gap, we sought to: i) determine the prevalence of substance use, specifically alcohol and illicit drug use, among YLWH compared to their HIV-uninfected peers; ii) investigate the independent association between young people’s HIV infection status and substance use; iii) investigate the risk indicators for substance use among these young people. Methods Between November 2018 and September 2019, a cross-sectional study was conducted at the Kenyan coast recruiting 819 young people aged 18–24 years (407 HIV-positive). Alcohol and drug use disorders identification tests (AUDIT and DUDIT) were administered via audio computer-assisted self-interview alongside other measures. Logistic regression was used to determine substance use risk indicators. Results The point prevalence of current substance use was significantly lower among YLWH than HIV-uninfected youths: current alcohol use, 13% vs. 24%, p ; current illicit drug use, 7% vs. 15%, p ; current alcohol and illicit drug use comorbidity, 4 vs. 11%, p . Past-year prevalence estimates for hazardous substance use were generally low among young people in this setting ( with no significant group differences observed. Being HIV-positive independently predicted lower odds of current substance use, but not hazardous substance use. There was overlap of some risk indicators for current substance use between young people with and without HIV including male sex, khat use and an experience of multiple negative life events, but risk indicators unique to either group were also identified. Among YLWH, none of the HIV-related factors was significantly associated with current substance use. Conclusions At the Kenyan coast, substance use is a reality among young people. The frequency of use generally appears to be low among YLWH compared to the HIV-uninfected peers. Substance use prevention initiatives targeting young people, regardless of HIV infection status, are warranted in this setting to avert their potential risk for developing substance use disorders, including dependence. The multifaceted intrapersonal and interpersonal factors that place young people at risk of substance use need to be addressed as part of the substance use awareness and prevention initiatives.

Objective: The International League Against Epilepsy (ILAE) has revised the classification of epilepsies and seizures on several occasions since the original classification published in 1964. It is unclear if these changes have impacted the characterization of epilepsy, including the clinical validity of seizure semiology or epilepsy outcomes in resource-poor areas. We aim to address this important knowledge gap. Methods: We reviewed the clinical seizure semiology and etiological data of 483 persons with epilepsy identified from a population-based survey in rural Kenya. The seizure semiology and etiological data were classified using the 1981 (for seizures) and 1989 (for epilepsy) ILAE criteria and then reclassified according to the ILAE-2017 criteria. Logistic regression models adjusted for potential confounders were used to measure the associations between the seizure semiology and different clinical and electroencephalographic features of epilepsy. Results: Focal (formerly localization-related) and generalized epilepsies were lower in ILAE-2017 (56% and 29%) than that of ILAE-1989 (61% and 34%), P < .001 and P < .001. Combined focal and generalized epilepsy type in ILAE-2017 accounted for 11% of epilepsies. Individual seizure types were statistically similar in both ILAE-1981 and 2017. New classification categories in ILAE-2017 such as unknown seizures and epilepsies were identified, and the proportions were similar to the unclassified category in ILAE-1989, 6% and 5%, respectively. The most common causes of epilepsy were symptomatic (76%) in the ILAE-1989 criteria, with infectious (45%) and structural (36%) causes were highest in the ILAE-2017 criteria. Significance: Our study confirms that the two ILAE classification schemes are broadly consistent, but the introduction of the combined onset seizure category in ILAE-2017 significantly reduces the proportion of mutually exclusive focal and generalized seizures. The comprehensive classification of etiology categories in ILAE-2017 will facilitate appropriate treatment and improve prognosis.

Aim: To investigate geographical change over time in the burden of neurological impairments in school-aged children in a demographic surveillance area. Method: We investigated changes in neurological impairment prevalence in five domains (epilepsy and cognitive, hearing, vision, and motor impairments) using similar two-phase surveys conducted in 2001 (n=10 218) and 2015 (n=11 223) and determined changes in location-level prevalence, geographical clustering, and significant risk factors for children aged 6 to 9 years (mean7y 6mo, SD1y) of whom 50.4% were males. Admission trends for preterm birth, low birthweight (LBW), and encephalopathy were determined using admission data to a local hospital. Results: Overall prevalence for any neurological impairment decreased from 61 per 1000 (95% confidence interval [CI]48.0–74.0) in 2001 to 44.7 per 1000 (95% CI40.9–48.6) in 2015 (p Interpretation: There was a significant decline in the prevalence of neurological impairments and differential changes in the associations of some risk factors with neurological impairments over the study period. Limited geographical variation suggests that similar interventions are appropriate across the defined area.

Background: Mothers and other primary caregivers play a crucial role in looking after HIV infected, and HIV exposed uninfected adolescents in sub-Saharan Africa. Daily caring may expose these caregivers to adverse states of health. Unfortunately, very few studies have examined their health-related quality of life (HRQoL) despite the additional risk of poor health outcomes. Our study documents the HRQoL profile, and associated factors in primary caregivers of perinatally HIV infected, perinatally HIV exposed but uninfected and HIV unexposed/uninfected adolescents aged 12 – 17 years at the Kenyan Coast. Methods: This was a cross-sectional analysis of 485 primary caregivers: 195 of perinatally HIV infected adolescents, 128 of perinatally HIV exposed but uninfected adolescents and 162 of HIV unexposed/uninfected adolescents. All caregivers completed a self-report measure of HRQoL, depressive symptoms, and parenting stress. They also provided their sociodemographic information and that of the participating adolescents. We used one-way analysis of variance (and its non-parametric version) to assess statistical differences among the groups. Linear regression analyses were used to identify correlates of HRQoL among caregivers. Results: Linear regression analyses indicated that depressive symptoms, increasing age of caregiver, and caring for an HIV exposed adolescent were significantly associated with reduced HRQoL at both the RAND SF-36 overall and sub-scale level. Having a professional job relative to subsistence farming was the only factor associated with improved overall HRQoL. At subscale level, higher socioeconomic status correlated positively with HRQoL (within the limitations due to emotional problems domain) while being a grandparent, and level of education (physical functioning domain), and parenting stress (vitality domain) were negatively associated with HRQoL. Moreover, caring for a male adolescent (vitality domain) and increasing adolescent age (pain domain) was associated with declining HRQoL. Conclusions: Caregivers in this sample, especially those who are ageing, at risk of mental ill-health, and taking care of HIV exposed adolescents, appear to be vulnerable. Inclusive and multi-component interventions tailored to the caregivers' psychosocial and mental needs will potentially enhance their quality of life. Longitudinal studies are also needed to understand the underlying mechanisms and longer-term implications of the correlates of caregivers HRQoL identified in the present study.

Objective: Sexual risk behavior during adolescence is an important public health problem. Self-esteem and hopefulness are potentially important psychological factors that may play a role in the behavioral regulation mechanisms of adolescents. These factors are inadequately explored in sub-Saharan Africa. This study aimed at exploring patterns and associated factors for sexual risk behavior (SRB), self-esteem, and hopefulness among adolescents from a resource-poor setting in Kenya.Method: A cross-sectional study conducted in 2019 among 296 adolescents (12–17 years old) from rural Kilifi (n = 133) and urban informal settings of Nairobi (n = 163) in Kenya. Participants completed the Kilifi Health Risk Behavior Questionnaire, Rosenberg self-esteem questionnaire, and Hope scale administered via computerized tablets. A binary outcome variable based on the experience of adolescents of at least one of the five forms of SRB: transactional sex, sexual violence, intergenerational sex, early sexual debut, and condom non-use was generated. Bi-variate analysis was conducted to summarize various social-demographic and psychosocial factors. A multivariable logistic regression model was fitted to investigate factors associated with the occurrence of SRB, self-esteem, and hopefulness among adolescents.Results: About 13% of the participants had experienced a form of SRB, and among these, 36% reported co-occurrence of multiple forms of SRB. Adolescent SRB was largely characterized by having experienced sexual violence, as well as intergenerational and transactional sex. Higher scores of hopefulness were reported among adolescents who never experienced SRB (P = 0.03) at bivariate analysis level. However, both self-esteem and hopefulness were not significantly associated with the occurrence of SRB in the adjusted logistic regression analysis. Having depressive symptoms (Adj. OR = 3.8, 95% CI: 1.39–10.4), feeling unsafe in the neighborhood (Adj. OR = 3.4, 95% CI: 1.6–7.2), and being in higher compared with lower primary education level (Adj. OR = 0.3, 95% CI: 0.1–0.8) were statistically significantly associated with the occurrence of SRB.Conclusion: Targeted reproductive health interventions, designed with the cognizance of structural and social drivers of adolescent SRB, are needed to concurrently tackle multiple forms of SRB. It is important to integrate mental health promotion within these interventions. More research is needed to understand the mechanisms and implications of self-esteem and hopefulness for adolescent sexual and reproductive health.

Highlights • We surveyed UK healthcare workers (HCWs) involved in the care of people with epilepsy. • During the pandemic, 70% of respondents held most consultations remotely. • HCWs experienced increased mental strain and concern for colleagues/family members. • HCWs reported being less confident in diagnosing epilepsy remotely. • Clinicians were more reluctant to withdraw seizure medications during the pandemic., The COVID-19 pandemic has created an immense pressure on healthcare providers, resulting in a shift to remote consultations and the redeployment of healthcare workers (HCWs). We present survey data from the United Kingdom (UK) HCWs to outline how changes in healthcare provision impact clinicians' wellbeing and ability to provide adequate care. We designed an online survey to gather the experiences of HCWs providing care to people with epilepsy. We received seventy-nine responses from UK-based HCWs, of whom 43% reported an impact on their mental health. Changes to service delivery have resulted in 71% of clinicians performing > 75% of their consultations remotely. Diagnosing and treating epilepsy has changed, with a fifth of respondents being significantly less confident in diagnosing epilepsy. Ultimately, these results show that COVID-19 has had an overall negative impact on HCWs and their ability to provide epilepsy care. These results must be considered when reorganizing health services to ensure optimal outcomes for people with epilepsy.

BackgroundNeurological complications due to chikungunya virus (CHIKV) infection have been described in different parts of the world, with children being disproportionately affected. However, the burden of CHIKV-associated neurological disease in Africa is currently unknown.MethodsWe estimated the incidence of CHIKV infection among children hospitalised with neurological disease in coastal Kenya. We used reverse-transcriptase polymerase chain reaction (RT-PCR) to systematically test for CHIKV in cerebrospinal fluid (CSF) samples from children aged FindingsThere were 18,341 paediatric admissions during the 5-year study period, of which 4,332 (24%) had CSF collected. The most common clinical reasons for CSF collection were impaired consciousness, seizures and coma (47%, 22% and 21% of all collections, respectively). After acute investigations done for immediate clinical care, CSF samples were available for 3,980 admissions, of which 367 (9.2%) were CHIKV RT-PCR positive. The annual incidence of CHIKV-associated neurological disease varied between 13 to 58 episodes per 100,000 person-years among all children InterpretationAlthough not previously recognized, CHIKV-associated neurological disease is common in coastal Kenya and a significant public health burden.

In June 2020, a door-to-door household survey was conducted in Mvolo County, an onchocerciasis-endemic area in South Sudan. A total of 2357 households containing 15,699 individuals agreed to participate in the study. Of these, 5046 (32.1%, 95% CI: 31.4–32.9%) had skin itching and 445 (2.8%, 95% CI: 2.6–3.1%) were blind. An epilepsy screening questionnaire identified 813 (5.1%) persons suspected of having epilepsy. Of them, 804 (98.9%) were seen by a medical doctor, and in 798 (98.1%) the diagnosis of epilepsy was confirmed. The overall epilepsy prevalence was 50.8/1000 (95% CI: 47.6–54.4/1000), while the prevalence of nodding syndrome was 22.4/1000 (95% CI: 20.1–24.9/1000). Younger age, being male, skin itching, blindness, and living in a neighbourhood or village close to the Naam River were risk factors for epilepsy. The annual incidence of epilepsy was 82.8/100,000 (95% CI: 44.1–141.6/100,000). Among children 7–9 years old without epilepsy, 34% were Ov16 seropositive, suggesting high ongoing Onchocerca volvulus transmission, but only 41.9% of them took ivermectin during the last mass distribution. In conclusion, a high prevalence and incidence of epilepsy was observed in Mvolo, South Sudan. Strengthening of the onchocerciasis elimination programme is urgently needed in order to prevent epilepsy in this region.

Climate change is the biggest challenge facing humanity today. The associated global warming and humidification, increases in the severity and frequency of extreme climate events, extension of the ranges of vector‐borne diseases, and the consequent social and economic stresses and disruption will have major negative consequences on many aspects of health care. People whose resilience to change is already impaired may suffer disproportionately from these environmental changes, which are of unprecedented reach and magnitude. There has been little connection made so far between climate change and epilepsy. We briefly review the history of climate change science and the subsequent response of the global scientific community. We consider how climate change effects might in general affect health and disease. We consider some of the underlying complex interactions that, for example, favor the spread of vector‐borne diseases and how climate models operate and may help plan for global and local changes. We then speculate specifically on how these generic ideas may apply specifically to epilepsy. We consider these impacts at levels from molecular to the epidemiological. Data are sparse, and there is undoubtedly a need for more information to enable better estimation of possible effects of climate change on care in epilepsy. We also consider how the professional activities of those involved in epilepsy health care might contribute to global carbon emissions, for example, through flying for conference attendance. Healthcare organizations across the world are already considering, and responding to, many of these issues. We argue for more research in this area, but also for action today. Actions today are likely to generate cobenefits for health care, including care in epilepsy, resulting from efforts to decarbonize, mitigate effects of climate change that has already happened, and plan for adaptation to climate change.

Introduction: The growing impact of non-communicable diseases in low- to middle-income countries makes epilepsy a key research priority. We evaluated peer-reviewed published literature on childhood epilepsy specific to Kenya to identify knowledge gaps and inform future priorities. Methodology: A literature search utilizing the terms "epilepsy" OR "seizure" as exploded subject headings AND "Kenya" was conducted. Relevant databases were searched, generating 908 articles. After initial screening to remove duplications, irrelevant articles, and publications older than 15 years, 154 papers remained for full-article review, which identified 35 publications containing relevant information. Data were extracted from these reports on epidemiology, etiology, clinical features, management, and outcomes. Results: The estimated prevalence of lifetime epilepsy in children was 21-41 per 1,000, while the incidence of active convulsive epilepsy was 39-187 cases per 100,000 children per year. The incidence of acute seizures was 312-879 per 100,000 children per year and neonatal seizures 3,950 per 100,000 live births per year. Common risk factors for both epilepsy and acute seizures included adverse perinatal events, meningitis, malaria, febrile seizures, and family history of epilepsy. Electroencephalography abnormalities were documented in 20%-41% and neurocognitive comorbidities in more than half. Mortality in children admitted with acute seizures was 3%-6%, and neurological sequelae were identified in 31% following convulsive status epilepticus. Only 7%-29% children with epilepsy were on antiseizure medication. Conclusion: Active convulsive epilepsy is a common condition among Kenyan children, remains largely untreated, and leads to extremely poor outcomes. The high proportion of epilepsy attributable to preventable causes, in particular neonatal morbidity, contributes significantly to the lifetime burden of the condition. This review reaffirms the ongoing need for better public awareness of epilepsy as a treatable disease and for national-level action that targets both prevention and management.

Background: Neurological impairment (NI) and disability are associated with reduced life expectancy, but the risk and magnitude of premature mortality in children vary considerably across study settings. We conducted a systematic review to estimate the magnitude of premature mortality following childhood-onset NI worldwide and to summarize known risk factors and causes of death.Methods: We searched various databases for published studies from their inception up to 31st October 2020. We included all cohort studies that assessed the overall risk of mortality in individuals with childhood-onset epilepsy, intellectual disability (ID), and deficits in hearing, vision and motor functions. Comparative measures of mortality such as the standardized mortality ratio (SMR), risk factors and causes were synthesized quantitatively under each domain of impairment. This review is registered on the PROSPERO database (registration number CRD42019119239).Results: The search identified 2,159 studies, of which 24 studies were included in the final synthesis. Twenty-two (91.7%) studies originated from high-income countries (HICs). The median SMR was higher for epilepsy compared with ID (7.1 [range 3.1–22.4] vs. 2.9 [range 2.0–11.6]). In epilepsy, mortality was highest among younger age groups, comorbid neurological disorders, generalized seizures (at univariable levels), untreatable epilepsy, soon after diagnosis and among cases with structural/metabolic types, but there were no differences by sex. Most deaths (87.5%) were caused by non-epilepsy-related causes. For ID, mortality was highest in younger age groups and girls had a higher risk compared to the general population. Important risk factors for premature mortality were severe-to-profound severity, congenital disorders e.g., Down Syndrome, comorbid neurological disorders and adverse pregnancy and perinatal events. Respiratory infections and comorbid neurological disorders were the leading causes of death in ID. Mortality is infrequently examined in impairments of vision, hearing and motor functions.Summary: The risk of premature mortality is elevated in individuals with childhood-onset NI, particularly in epilepsy and lower in ID, with a need for more studies for vision, hearing, and motor impairments. Survival in NI could be improved through interventions targeting modifiable risk factors and underlying causes.

Background Evidence from high-income countries demonstrates that co-morbid mental disorders in people with epilepsy adversely affect clinical and social outcomes. However, evidence from low-income countries is lacking. The objective of this study was to measure the association between co-morbid mental disorders and quality of life and functioning in people with epilepsy. Methods A facility-based, community ascertained cross-sectional survey was carried out in selected districts of the Gurage Zone, Southern Ethiopia. Participants were identified in the community and referred to primary health care (PHC) clinics. Those diagnosed by PHC workers were recruited. Co-morbid mental disorders were measured using a standardised, semi-structured clinical interview administered by mental health professionals. The main outcome, quality of life, was measured using the Quality of Life in Epilepsy questionnaire (QOLIE-10p). The secondary outcome, functional disability, was assessed using the 12-item World Health Organization Disability Assessment Schedule (WHODAS-2). Results The prevalence of comorbid mental disorders was 13.9%. Comorbid mental disorders were associated with poorer quality of life (Adjusted (Adj.) β -13.27; 95% CI -23.28 to-3.26) and greater disability (multiplier of WHODAS-2 score 1.62; 95% CI 1.05, 2.50) after adjusting for hypothesised confounding factors. Low or very low relative wealth (Adj. β = -12.57, 95% CI -19.94 to-5.20), higher seizure frequency (Adj.β coef. = -1.92, 95% CI -2.83 to -1.02), and poor to intermediate social support (Adj. β coef. = -9.66, 95% CI -16.51 to -2.81) were associated independently with decreased quality of life. Higher seizure frequency (multiplier of WHODAS-2 score 1.11; 95% CI 1.04, 1.19) was associated independently with functional disability. Conclusion Co-morbid mental disorders were associated with poorer quality of life and impairment, independent of level of seizure control. Integrated and comprehensive psychosocial care is required for better health and social outcomes of people with epilepsy.

Background The possibility that onchocerciasis may cause epilepsy has been suggested for a long time, but thus far, an etiological link has not been universally accepted. The objective of this review is to critically appraise the relationship between Onchocerca volvulus and epilepsy and subsequently apply the Bradford Hill criteria to further evaluate the likelihood of a causal association. Methods PubMed and gray literature published until September 15, 2020, were searched and findings from original research were synthesized. Adherence to the 9 Bradford Hill criteria in the context of onchocerciasis and epilepsy was determined to assess whether the criteria are met to strengthen the evidence base for a causal link between infection with O. volvulus and epilepsy, including the nodding syndrome. Results Onchocerciasis as a risk factor for epilepsy meets the following Bradford Hill criteria for causality: strength of the association, consistency, temporality, and biological gradient. There is weaker evidence supporting causality based on the specificity, plausibility, coherence, and analogy criteria. There is little experimental evidence. Considering the Bradford Hill criteria, available data suggest that under certain conditions (high microfilarial load, timing of infection, and perhaps genetic predisposition), onchocerciasis is likely to cause epilepsy including nodding and Nakalanga syndromes. Conclusion Applying the Bradford Hill criteria suggests consistent epidemiological evidence that O. volvulus infection is a trigger of epilepsy. However, the pathophysiological mechanisms responsible for seizure induction still need to be elucidated., Author summary There is growing epidemiological evidence that an infection with Onchocerca volvulus (the parasite causing onchocerciasis or river blindness) can trigger epilepsy, including nodding and Nakalanga syndromes. We studied the association between onchocerciasis and epilepsy using previously proposed criteria for causality and found strong arguments in favor of a causal relationship. The risk for children to develop epilepsy seems to be determined by the O. volvulus microfilarial load. However, the mechanism by which the O. volvulus parasite is able to trigger seizures remains to be elucidated. This form of epilepsy, called onchocerciasis-associated epilepsy (OAE), is an important public health problem in onchocerciasis-endemic regions with nonexistent or suboptimal onchocerciasis elimination programs. OAE is often characterized by sudden seizure onset in previously healthy children, between 3 to 18 years, without any other obvious cause of epilepsy. On the basis of the findings presented in this paper, it appears that onchocerciasis control may be able to prevent OAE. This further highlights the importance to eliminate onchocerciasis, particularly in areas with a high burden of epilepsy.

Objectives The prevalence of all epilepsies (both convulsive and non-convulsive seizures) in Low- and Middle-Income Countries (LMIC), particularly sub-Saharan Africa is unknown. Under estimation of non-convulsive epilepsies in data from these countries may lead to inadequate and sub-optimal allocation of resources to control and prevent epilepsy. We determined the prevalence of all types of epilepsies and compared the mortality between convulsive seizures and non-convulsive seizures in a resource limited rural area in Kenya. Methods Trained clinicians identified cases of epilepsy in a randomly selected sample of 4,441 residents in the Kilifi Health and Demographic Surveillance System site using a cross-sectional survey design. Seizure types were classified by epileptologists using the current guidelines of the International League Against Epilepsy (ILAE). We estimated prevalence for epilepsy with convulsive seizures and non-convulsive seizures and for epilepsy with non-convulsive seizures only and compared premature mortality between these groups of seizures. Results Of the 4441 people visited, 141 had lifetime epilepsy and 96 active epilepsy, which is a crude prevalence of 31.7/1,000 persons (95% CI: 26.6-36.9) and 21.6/1,000 (95% CI: 17.3-25.9), respectively. Both convulsive and non-convulsive seizures occurred in 7% people with epilepsy (PWE), only convulsive seizures in 52% and only non-convulsive seizures in 35% PWE; there was insufficient information to classify epilepsy in the remainder 6%. The age- and sex-adjusted prevalence of lifetime people was 23.5/1,000 (95% CI: 11.0-36.0), with the adjusted prevalence of epilepsy with non-convulsive seizures only estimated at 8.2/1,000 (95%CI:3.9-12.6). The mortality rate in PWE was 6.3/1,000 (95%CI: 3.4-11.8), compared to 2.8/1,000 (2.3-3.3) in those without epilepsy; hazard ratio (HR) =2.31 (1.22-4.39; p=0.011). The annual mortality rate was 11.2/1,000 (95%CI: 5.3-23.4) in PWE with convulsive and non-convulsive seizures and none died in PWE with non-convulsive seizures alone. Conclusions Our study shows that epilepsy with non-convulsive seizures is common and adds to the prevalence of previously reported estimates of active convulsive epilepsy. Both epilepsy with convulsive seizures and that with non-convulsive seizures should be identified for optimising treatment and for planning resource allocation.

BackgroundDetection of meningitis is essential to optimise the duration and choice of antimicrobial agents to limit mortality and sequelae. In low and middle-income countries most health facilities lack laboratory capacity and rely on clinical features to empirically treat meningitis.ObjectiveWe conducted a diagnostic validation study to investigate the performance of clinical features (fever, convulsions, irritability, bulging fontanel and temperature ≥39°C) and WHO-recommended signs (drowsiness, lethargy, unconsciousness, convulsions, bulging fontanel, irritability or a high-pitched cry) in discriminating meningitis in young infants.DesignRetrospective cohort study.SettingKilifi County Hospital.PatientsInfants aged Main outcome measureDefinite meningitis defined as positive cerebrospinal fluid (CSF) culture, microscopy or antigen test, or leucocytes ≥0.05 x 10∧9/L.ResultsOf 4809 infants aged ConclusionsDespite a lower prevalence of definite meningitis, the performance of previously identified signs at admission in predicting meningitis was unchanged. Presence of history of fever improves the sensitivity of WHO-recommended signs but loses specificity. Careful evaluation, repeated assessment and capacity for lumbar puncture and CSF microscopy to exclude meningitis in most young infants with potential signs are essential to management in this age group.

Highlights • The COVID-19 and Epilepsy (COV-E) global surveys launched in May 2020. • UK respondents (n=463) report changes in seizure frequency, mental health and sleep. • Discussion of risk, including of SUDEP, was infrequent even before the pandemic. • COVID-19 is having far-reaching consequences on people with epilepsy. • Our study exemplifies the importance of delivering optimal care to mitigate risk., The COVID-19 pandemic has caused global anguish unparalleled in recent times. As cases rise, increased pressure on health services, combined with severe disruption to people’s everyday lives, can adversely affect individuals living with chronic illnesses, including people with epilepsy. Stressors related to disruption to healthcare, finances, mental well-being, relationships, schooling, physical activity, and increased isolation could increase seizures and impair epilepsy self-management. We aim to understand the impact that COVID-19 has had on the health and well-being of people with epilepsy with a focus on exposure to increased risk of seizures, associated comorbidity, and mortality. We designed two online surveys with one addressing people with epilepsy directly and the second for caregivers to report on behalf of a person with epilepsy. The survey is ongoing and has yielded 463 UK-based responses by the end of September 2020. Forty percent of respondents reported health changes during the pandemic (n=185). Respondents cited a change in seizures (19%, n=88), mental health difficulties (34%, n=161) and sleep disruption (26%, n=121) as the main reasons. Thirteen per cent found it difficult to take medication on time. A third had difficulty accessing medical services (n=154), with 8% having had an appointment canceled (n=39). Only a small proportion reported having had discussions about epilepsy related risks, such as safety precautions (16%, n=74); mental health (29%, n=134); sleep (30%, n=140); and Sudden Unexpected Death in Epilepsy (SUDEP; 15%, n=69) in the previous 12 months. These findings suggest that people with epilepsy are currently experiencing health changes, coupled with inadequate access to services. Also, there seems to be a history of poor risk communication in the months preceding the pandemic. As the UK witnesses a second COVID-19 wave, those involved in healthcare delivery must ensure optimal care is provided for people with chronic conditions, such as epilepsy, to ensure that avoidable morbidity and mortality is prevented during the pandemic, and beyond.

Objective Epilepsy is a common, chronic neurological disorder that disproportionately affects individuals living in low‐ and middle‐income countries (LMICs), where the treatment gap remains high and adherence to medication remains low. Community health workers (CHWs) have been shown to be effective at improving adherence to chronic medications, yet no study assessing the costs of CHWs in epilepsy management has been reported. Methods Using a Markov model with age‐ and sex‐varying transition probabilities, we determined whether deploying CHWs to improve epilepsy treatment adherence in rural South Africa would be cost‐effective. Data were derived using published studies from rural South Africa. Official statistics and international disability weights provided cost and health state values, respectively, and health gains were measured using quality adjusted life years (QALYs). Results The intervention was estimated at International Dollars ($) 123 250 per annum per sub‐district community and cost $1494 and $1857 per QALY gained for males and females, respectively. Assuming a costlier intervention and lower effectiveness, cost per QALY was still less than South Africa's Gross Domestic Product per capita of $13 215, the cost‐effectiveness threshold applied. Significance CHWs would be cost‐effective and the intervention dominated even when costs and effects of the intervention were unfavorably varied. Health system re‐engineering currently underway in South Africa identifies CHWs as vital links in primary health care, thereby ensuring sustainability of the intervention. Further research on understanding local health state utility values and cost‐effectiveness thresholds could further inform the current model, and undertaking the proposed intervention would provide better estimates of its efficacy on reducing the epilepsy treatment gap in rural South Africa.

Globally, epilepsy is the most common chronic neurological disorder. The incidence in sub-Saharan Africa is 2-3 times higher than that in high income countries. Infection by Onchocerca volvulus may be an underlying risk factor for the high burden and based upon epidemiological associations, has been proposed to cause a group of disorders—Onchocerca associated epilepsies (OAE) like nodding syndrome (NS). To improve our understanding of the disease spectrum, we described the clinical, electroencephalographic (EEG) and magnetic resonance imaging (MRI) features of children with epilepsy and sero-positive for Onchocerca volvulus (possible OAEs other than nodding syndrome). Twenty-nine children and adolescents with non-nodding syndrome OAE in northern Uganda were enrolled. A diagnosis of OAE was made in patients with epilepsy and seizure onset after age 3 years, no reported exposure to perinatal severe febrile illness or traumatic brain injury, no syndromic epilepsy diagnosis and a positive Ov-16 ELISA test. Detailed clinical evaluation including psychiatric, diagnostic EEG, a diagnostic brain MRI (in 10 patients) and laboratory testing were performed. Twenty participants (69%) were male. The mean age was 15.9 (standard deviation [SD] 1.9) years while the mean age at seizure onset was 9.8 (SD 2.9) years. All reported normal early childhood development. The most common clinical presentation was a tonic-clonic seizure. The median number of seizures was 2 (IQR 1–4) in the previous month. No specific musculoskeletal changes, or cranial nerve palsies were reported, neither were any vision, hearing and speech difficulties observed. The interictal EEG was abnormal in the majority with slow wave background activity in 52% (15/29) while 41% (12/29) had focal epileptiform activity. The brain MRI showed mild to moderate cerebellar atrophy and varying degrees of atrophy of the frontal, parietal and occipital lobes. The clinical spectrum of epilepsies associated with Onchocerca may be broader than previously described. In addition, focal onset tonic-clonic seizures, cortical and cerebellar atrophy may be important brain imaging and clinical features.

This chapter looks at the epidemiology of bacterial and parasitic infections of the central nervous system (CNS). Bacteria and parasites are important infections of the CNS, but the epidemiology has changed significantly over the last few decades with the introduction of vaccines; appearance of organisms resistant to antimicrobial and anti-parasitic drugs; increase in number of immunocompromised people from human immunodeficiency virus (HIV) and oncological conditions; and increased movement of people throughout the world. The CNS infections present with a multitude of symptoms and signs, which often overlap, making case definitions for epidemiological studies difficult. The main syndromes of CNS infections are meningitis, encephalitis, epilepsy, and paralysis. Most bacteria gain access to the CNS via blood, although scalp, ear, and oropharyngeal infections are possible routes of infection. The chapter then discusses acute bacterial meningitis, brain abscesses, ventriculitis, tuberculosis meningitis, malaria, cysticercosis, onchocerciasis, sparganosis, and paragonimiasis.

Background Health risk behaviors during adolescence may cluster into patterns that might be predicted by specific factors, among which HIV may have an important role. Method In a cross-sectional study conducted between 2017 and 2018, clustering of HRB and its associated factors was investigated in rural Kenya among 588 adolescents (36% perinatally HIV infected; 28% perinatally HIV exposed but uninfected; and 36% HIV unexposed/uninfected). Latent class analysis of 22 behaviors followed by multinomial logistic regression were conducted. Four risk behavior classes were identified. Results No significant differences were found in behavioral class membership across the three HIV groups (p = 0.366). The risk of membership to the higher risk behavioral classes relative to class 1 (the substance and drug abstinent low risk takers) increased with older adolescent age (p = 0.047), increased among adolescent who experienced mental distress (p p p = 0.0037) was found to be protective. Conclusion The results highlight a need to include screening and interventions for internalizing mental health problems and deficits in executive functioning, as well as steps to involve family members and communities to address psychosocial risk factors in adolescents in Kenya.

BACKGROUND: Estimates of children and adolescents with disabilities worldwide are needed to inform global intervention under the disability-inclusive provisions of the Sustainable Development Goals. We sought to update the most widely reported estimate of 93 million children METHODS: We analyzed Global Burden of Disease Study 2017 data on the prevalence of childhood epilepsy, intellectual disability, and vision or hearing loss and on years lived with disability (YLD) derived from systematic reviews, health surveys, hospital and claims databases, cohort studies, and disease-specific registries. Point estimates of the prevalence and YLD and the 95% uncertainty intervals (UIs) around the estimates were assessed. RESULTS: Globally, 291.2 million (11.2%) of the 2.6 billion children and adolescents (95% UI: 249.9–335.4 million) were estimated to have 1 of the 4 specified disabilities in 2017. The prevalence of these disabilities increased with age from 6.1% among children aged CONCLUSIONS: The number of children and adolescents with these 4 disabilities is far higher than the 2004 estimate, increases from infancy to adolescence, and accounts for a substantial proportion of all-cause YLD.

Background:Neonatal jaundice (NNJ) is common in sub‐Saharan Africa (SSA), and it is associated with sepsis. Despite the high incidence, little has been documented about developmental impairments associated with NNJ in SSA. In particular, it is not clear if sepsis is associated with greater impairment following NNJ. Methods:We followed up 169 participants aged 12 months (57 cases and 112 controls) within the Kilifi Health Demographic Surveillance System. The diagnosis of NNJ was based on clinical laboratory measurement of total serum bilirubin on admission, whereas the developmental outcomes were assessed using the Developmental Milestones Checklist and Kilifi Development Inventory. Results:There were significant differences between the cases and controls in all developmental domains. Cases scored lower in language functioning (mean [M] = 6.5, standard deviation [SD] = 4.3 vs.M= 8.9,SD= 4.6;p< .001); psychomotor functioning (Mdn= 23, interquartile range [IQR] = 17–34 vs.Mdn= 31.0, IQR = 22.0–44.0; Mann–WhitneyU= 4,122,p= .002); and socio‐emotional functioning ([Mdn= 30.0, IQR = 27.0–33.0 vs.Mdn= 34.0, IQR = 30.0–37.0], Mann–WhitneyU= 4,289,p< .001). There was no evidence of association between sepsis and psychomotor (rpb= −.2,p= .214), language (rpb= −.1,p= .510), and socio‐emotional functioning (rpb= .0,p= .916). Significant and medium to large portions of the variance (34–64%) in the developmental outcomes among children who survived NNJ were associated with home birth, low maternal education, and feeding problems during the first days of life. Conclusions:NNJ is associated with developmental impairments in the early childhood years; however, NNJ associated with sepsis does not lead to more severe impairment. Prenatal and postnatal care services are needed to reduce the negative impact of NNJ for children from low resourced settings.

The epidemiology of autism has been recently highlighted with the apparent increase in the prevalence of autism in North America and Europe, and controversy about the association of autism with vaccines. The overall prevalence is about 1%, and the apparent increase is probably due to greater awareness of the diagnosis, more facilities for diagnosis, and changes in the criteria for the diagnosis. Autism is likely to arise from an interaction between genetic susceptibility and environmental factors. Identified risk factors include maternal infection, prematurity, intrauterine growth retardation, and perinatal and postnatal exposure to toxins and infections. There is no evidence that autism is associated with vaccination. Autism is associated with premature mortality and has considerable financial burden on national health and educational systems.

Background Eighty per cent of perinatally HIV infected (PHI) adolescents live in sub-Saharan Africa (sSA), a setting also characterized by huge economic disparities. Caregiving is crucial to the management of chronic illness such as HIV/AIDS, but the economic costs and mental disorders borne by caregivers of PHI adolescents often go unnoticed. In this study, we evaluated economic costs, coping strategies and association between economic cost and mental health functioning of caregivers of perinatally HIV infected adolescents in Kilifi, Kenya. Methods We used a cost of illness descriptive analysis approach to determine the economic burden and Patient Health Questionnaire (PHQ-9) to assess the caregivers’ mental health. Cross-sectional data were collected from 121 primary caregivers of PHI adolescents in Kilifi using a structured cost questionnaire. Economic costs (direct and indirect costs) were measured from primary caregivers’ perspective. We used descriptive statistics in reporting the results of this study. Results Average monthly direct and indirect costs per primary caregiver was Ksh 2784.51 (USD 27.85). Key drivers of direct costs were transportation (66.5%) and medications (13.8%). Total monthly costs represented 28.8% of the reported caregiver monthly earnings. Majority of the caregivers borrowed resources to cope with high economic burden. About 10.7% of primary caregivers reported depressive symptoms. Caregivers with positive depression screen (PHQ-9 score ≥ 10) had high average monthly direct and indirect costs. However, this was not statistically different compared to costs incurred by caregivers who screened negative for depressive symptoms. Conclusion Our study indicates that HIV/AIDS is associated with a significant economic burden for caregivers of adolescents living with HIV. Results underscore the need for developing economic empowerment and social support programmes that reduce the economic burden of caring for perinatally infected adolescent. These efforts may improve the mental health and quality of life of caregivers of adolescents living with HIV.

Background: Perinatally HIV exposed uninfected (PHEU) adolescents are an increasing sub-population, especially in high HIV epidemic settings. HIV exposure may have some lasting implications for adolescents’ development, however, longer term health outcomes such as health risk behavior (HRB) are so far not well understood in this adolescent sub-population. Methods: In this systematic review, we identify the prevalent forms, burden, and underlying risk factors for HRB of PHEU adolescents. We searched in PubMed, PsycINFO and Applied Social Sciences Index & Abstracts for peer reviewed empirical studies published between 1980 and August 2018 on HRB among PHEU adolescents aged 10 – 19 years. Results: Eleven eligible studies, all conducted in North America were identified and they showed that sexual risk behavior such as lifetime unprotected sex increased drastically especially in mid-adolescence. PHEU adolescents’ substance use (especially alcohol and marijuana) was high and increased over time. In a significant minority (10-18%) substance use disorder was screened. Some intra and interpersonal risk factors such as caregiver and PHEU adolescents’ mental health problems, age and HIV status were shared across the two forms of HRB. However, other risk factors like race, gender and experience of traumatic life events were behavior specific. Conclusion: Overall, there is need to conduct similar research in other settings especially those with high HIV burden where the PHEU adolescent sub-population is rising. Future research in this area could benefit from examining more forms of HRB and exploring the clustering of HRB among PHEU adolescents.

Background: Studies in high-income countries have reported that school-aged children who survive neonatal jaundice (NNJ) and hypoxic-ischemic encephalopathy (HIE) develop long-term neurocognitive problems. However, less is known about the patterns of functioning in school-aged survivors of NNJ and HIE in sub-Saharan Africa. This study examined patterns of functioning in school-aged children who survived NNJ and HIE in Kilifi, Kenya. Methods: This is a cross-sectional study that included 107 survivors of NNJ/HIE (64 with NNJ, 43 with HIE), aged 6-12 years, admitted to Kilifi County Hospital on the Kenyan Coast. The Gross Motor Function Classification System (GMFCS), Adapted Communication Profile, Raven’s Coloured Progressive Matrices (RCPM) and an epilepsy screening tool were used to assess gross motor function, communication function, intellectual functioning, and epilepsy, respectively. Results: Most of the survivors of NNJ (95.2%) and HIE (95.3%) had no impairments in gross motor functioning. A small percentage of the children in the NNJ and HIE groups had profound problems in their communication (4.7% and 4.7%); expressive communication function (4.7% and 4.7%); social functions (3.1% and 2.3%); receptive communication (4.7% and 2.3%); and communicative effectiveness (4.7% and 2.3%). Cognitive impairment was reported in 10.9% and 11.9% for NNJ and HIE survivors, respectively. Active epilepsy was detected in 1.6% of survivors of NNJ and 2.3% of survivors of HIE. All children had normal hearing and visual functioning except one participant who presented with mild visual acuity problems. Conclusions: Most school-aged children who survive with NNJ and HIE have normal motor and communication function; however, one in ten are likely to present with lowered intellectual functioning compared to the normative sample.

INTRODUCTION:Epilepsy is a major public health concern in sub-Saharan Africa, particularly in resource-limited rural villages where persons with epilepsy (PWE) are often confronted with a wide treatment gap, frequent stigma and high cost of epilepsy care. We investigated stigma and economic cost related to epilepsy in the states of Maridi and Amadi in South Sudan, two onchocerciasis endemic areas with high epilepsy prevalence. METHODS:Between November 2019 and February 2020, community-based surveys were conducted in eight villages of Maridi and Amadi States. Consenting PWE were identified via a door-to-door approach, and perceived stigma was assessed using the validated Kilifi stigma scale. Additional data about household income, as well as epilepsy-related direct and indirect costs were collected. RESULTS:239 PWE were recruited (95 from Maridi, 144 from Amadi). Stigma scores were higher in Maridi compared to Amadi (mean scores: 13.9 vs 6.5, p CONCLUSION:In rural South Sudan, PWE and their families often experienced stigma from the community. Higher perceived stigma was associated with traditional medicine use, which increased the overall cost of epilepsy management. Demystifying epilepsy and making AED more accessible would improve the quality of life of PWE and their families, and reduce the economic burden of epilepsy.

Background Little data exists about the methodology of contextualizing version two of the Mental Health Gap Action Programme Intervention Guide (mhGAP-IG) in resource-poor settings. This paper describes the contextualisation and pilot testing of the guide in Kilifi, Kenya. Methods Contextualisation was conducted as a collaboration between the KEMRI-Wellcome Trust Research Programme (KWTRP) and Kilifi County Government's Department of Health (KCGH) between 2016 and 2018. It adapted a mixed-method design and involved a situational analysis, stakeholder engagement, local adaptation and pilot testing of the adapted guide. Qualitative data were analysed using content analysis to identify key facilitators and barriers to the implementation process. Pre- and post-training scores of the adapted guide were compared using the Wilcoxon signed-rank test. Results Human resource for mental health in Kilifi is strained with limited infrastructure and outdated legislation. Barriers to implementation included few specialists for referral, unreliable drug supply, difficulty in translating the guide to Kiswahili language, lack of clarity of the roles of KWTRP and KCGH in the implementation process and the unwillingness of the biomedical practitioners to collaborate with traditional health practitioners to enhance referrals to hospital. In the adaptation process, stakeholders recommended the exclusion of child and adolescent mental and behavioural problems, as well as dementia modules from the final version of the guide. Pilot testing of the adapted guide showed a significant improvement in the post-training scores: 66.3% (95% CI 62.4–70.8) v. 76.6% (95% CI 71.6–79.2) (p < 0.001). Conclusion The adapted mhGAP-IG version two can be used across coastal Kenya to train primary healthcare providers. However, successful implementation in Kilifi will require a review of new evidence on the burden of disease, improvements in the mental health system and sustained dialogue among stakeholders.

Highlights • Most people with active convulsive epilepsy in rural South Africa are diagnosed. • Most individuals diagnosed have some blood level of anti-seizure medication. • Most individuals do not have optimal levels of medication. • The epilepsy treatment gap is high in rural South Africa, especially in children. • Identifying the epilepsy care cascade may better allow for targeting of interventions., Purpose The percentage of people who are diagnosed with epilepsy (diagnostic gap), access, receive and adhere (treatment gap) to anti-seizure medication (ASM) in low- and middle- income countries remains low. We explored the epilepsy care cascade, measured the diagnostic and treatment gaps, and examined socio-demographic factors associated with adherence to ASMs in rural South Africa. Methods Utilizing a population-based cohort of 311 people with active convulsive epilepsy (ACE) residing in rural northeastern South Africa, a questionnaire was administered to examine associations between demographic and socioeconomic factors and the epilepsy treatment gap. Blood was taken to measure levels of ASMs. Results Of the 311 individuals diagnosed, 93 % of individuals reported being previously told they had epilepsy and 94 % reported previously attending a health facility for their epilepsy. ASMs were detected in 138 individuals (76 %) and optimal levels were detected in 67 individuals, resulting in a treatment gap of 63 % (95 % confidence interval [95 %CI]: 56 %–70 %). Self-reported specificity of ASM use was 23 % (95 %CI: 12–39 %) and individuals ≥18 years were significantly more likely to report taking ASM than children and were significantly (p = 0.011) more likely to be adherent. Conclusion Most people with epilepsy in rural South Africa had been previously diagnosed with epilepsy and had accessed care for epilepsy, yet the level of ASM adherence remained low, significantly lower amongst children. Understanding ways of improving knowledge of and adherence to ASM in rural South Africa is necessary, especially amongst children. The epilepsy care cascade can be useful in identifying gaps in care and targeting interventions to reduce these gaps.

Background Most children with epilepsy reside in resource-limited regions such as sub-Saharan Africa, where the majority of studies have been conducted in rural areas with limited investigations. Medical records from children with epilepsy seen at an urban hospital in Kenya were examined to provide a comprehensive description of epilepsy in children from this hospital. Methods A retrospective observational study was conducted which involved reviewing medical records of 426 epilepsy patients (260 males and 166 females) aged 0 - 18 years, seen at Aga Khan University Hospital, Nairobi, Kenya between February 2011 and December 2014. Results The most frequent age at presentation; documented in 29% was in infancy. Generalized seizures due to structural brain abnormalities were the most common form of epilepsy (28%). Lennox-Gastaut Syndrome was the most common electroclinical syndrome (7%). Focal seizures and focal seizures with loss of awareness were identified in 12% of the population. There were no cases of childhood absence epilepsy in this group. Brain atrophy was the most common MRI finding, occurring in a fifth of the population (20%), while cystic encephalomalacia occurred in 13%. Half (50%) of all EEG recordings performed for this cohort were abnormal. Generalized seizures due to structural brain abnormalities and Lennox-Gastaut Syndrome (LGS) were significant predictors of a treatment history of three or more AEDs. At the conclusion of the review period, 16% of the patients had not visited the clinic for more than 12 months and were considered to be lost to follow-up. Conclusion The highest frequency of epilepsy cases was documented in children less than one year of age. Generalized seizures due to structural abnormalities and Lennox-Gastaut syndrome were the most common seizure type and syndrome. Improvement of public awareness of different types of seizures in children may increase identification of children with childhood absence epilepsy.

Background: Zika virus (ZIKV) was first discovered in East Africa in 1947. ZIKV has caused microcephaly in the Americas, but it is not known whether ZIKV is a cause of microcephaly in East Africa. Methods: We used surveillance data from 11,061 live births at Kilifi County Hospital in coastal Kenya between January 2012 and October 2016 to identify microcephaly cases and conducted a nested case-control study to determine risk factors for microcephaly. Gestational age at birth was estimated based on antenatal ultrasound scanning (‘Scanned cohort’) or last menstrual period (‘LMP cohort’, including births ≥37 weeks’ gestation only). Controls were newborns with head circumference Z scores between >-2 and ≤2 SD that were compared to microcephaly cases in relation to ZIKV exposure and other maternal and newborn factors. Results: Of the 11,061 newborns, 214 (1.9%, 95%CI 1.69, 2.21) had microcephaly. Microcephaly prevalence was 1.0% (95%CI 0.64, 1.70, n=1529) and 2.1% (95%CI 1.81, 2.38, n=9532) in the scanned and LMP cohorts, respectively. After excluding babies Conclusions: Microcephaly was prevalent in coastal Kenya, but does not appear to be related to ZIKV exposure; the ZIKV response observed in our study population was largely due to cross-reactive responses to DENV or other related flaviviruses. Further research into potential causes and the clinical consequences of microcephaly in this population is urgently needed.

Background Published research on depression among people living with HIV/AIDS (PLWHA) from Africa is increasing, but data from Kenya remains scarce. This cross-sectional study measured the prevalence and correlates of depressive symptoms among PLWHA in rural Kilifi, on the Kenyan coast. Methods Between February and April 2018, we consecutively recruited and interviewed 450 adults living with HIV and on combination antiretroviral therapy (cART). Depressive symptoms were assessed with the 9-item Patient Health Questionnaire (PHQ-9), with a positive depression screen defined as PHQ-9 score ≥ 10. Measures of psychosocial, health, and treatment characteristics were also administered. Results The overall prevalence of depressive symptoms was 13.8% (95% Confidence Interval (95%CI): 10.9, 17.3). Multivariable logistic regression analysis identified current comorbid chronic illness (adjusted Odds Ratio (aOR) 5.72, 95% CI: 2.28, 14.34; p , cART regimen (aOR 6.93, 95%CI: 2.34, 20.49; p , perceived HIV-related stigma (aOR 1.10, 95%CI: 1.05, 1.14, p and difficulties accessing HIV care and treatment services (aOR 2.37, 95%CI: 1.14, 4.91; p = 0.02) as correlates of depressive symptoms. Conclusion The prevalence of depressive symptoms among adults living with HIV on the Kenyan coast is high. Those at high risk for elevated depressive symptoms (e.g., with comorbid chronic illnesses, on second-line cART, experiencing perceived HIV-stigma or with problems accessing HIV care) may benefit from early identification, treatment or referral, which requires integration of mental health programmes into HIV primary care.

Background: Epilepsy affects 70 million people worldwide, 80% of whom are in low-and-middle income countries (LMICs). Infections of the central nervous system (CNS) contribute considerably to the burden of epilepsy in LMICs, but the nature and presentation of epilepsy following these infections is not fully understood. We examined if epilepsy foutcomes are associated with the exposure to parasitic infections. Methods: This was a case-comparison study nested in a cross-sectional survey of people with active convulsive epilepsy, with cases as those exposed to parasitic infections, and comparison as those unexposed. Associations of exposure to parasites with clinical and electroencephalographic features of epilepsy were done using a modified mixed effects Poisson regression model across five sites in Africa. Multiplicative and additive scale (RERI) interactions were explored to determine the effect of co-infections on epilepsy features. Population attributable fractions (PAF) were calculated to determine the proportion of severe clinical and electroencephalographic features of epilepsy attributable to CNS infections. Results: A total of 997 participants with active convulsive epilepsy from the five African sites were analyzed, 51% of whom were males. Exposure to parasitic infections was associated with more frequent seizures in adult epilepsy (relative risk (RR)=2.58, 95% confidence interval (95%CI):1.71-3.89). In children, exposure to any parasite was associated with convulsive status epilepticus (RR=4.68, (95%CI: 3.79-5.78), intellectual disabilities (RR=2.13, 95%CI: 1.35-3.34) and neurological deficits (RR=1.92, 95%CI: 1.42-2.61). Toxoplasma gondii and Onchocerca volvulus interacted synergistically to increase the risk of status epilepticus (RERI=0.91, 95%CI=0.48-1.35) in the data pooled across the sites. Exposure to parasitic infections contributed to 30% of severe features of epilepsy as shown by PAF. Conclusions: Parasitic infections may determine features and phenotypes of epilepsy through synergistic or antagonistic interactions, which can be different in children and adults. Interventions to control or manage infections may reduce complications and improve prognosis in epilepsy.

The classification of epilepsy is essential for people with epilepsy and their families, healthcare providers, physicians and researchers. The International League Against Epilepsy proposed updated seizure and epilepsy classifications in 2017, while another four-dimensional epilepsy classification was updated in 2019. An Integrated Epilepsy Classification system was proposed in 2020. Existing classifications, however, lack consideration of important pragmatic factors relevant to the day-to-day life of people with epilepsy and stakeholders. Despite promising developments, consideration of comorbidities in brain development, genetic causes, and environmental triggers of epilepsy remains largely user-dependent in existing classifications. Demographics of epilepsy have changed over time, while existing classification schemes exhibit caveats. A pragmatic classification scheme should incorporate these factors to provide a nuanced classification. Validation across disparate contexts will ensure widespread applicability and ease of use. A team-based approach may simplify communication between healthcare personnel, while an individual-centred perspective may empower people with epilepsy. Together, incorporating these elements into a modern but pragmatic classification scheme may ensure optimal care for people with epilepsy by emphasising cohesiveness among its myriad users. Technological advancements such as 7T MRI, next-generation sequencing, and artificial intelligence may affect future classification efforts.