Prevalence of neurological disorders in children less than 10 years of age in RS Pura town of Jammu and Kashmir.

OBJECTIVE: To determine the prevalence of major neurological disorders in children less than 10 years of age.
MATERIALS AND METHODS: The study was conducted in the framework of a population based, single centre, cross-sectional study at Ranbir Singh Pura town, 22 km south-west of Jammu city.
RESULTS: Eight cases of active epilepsy with a crude prevalence rate of 202 (95% confidence interval [CI] 180-220), five cases of Febrile seizures with a crude prevalence of 126 (95% CI 110-140) and eleven cases of cerebral palsy with a crude prevalence rate of 277 (95% CI 245-309) per 100,000 were found. Very few cases of other major neurological disorders were found. The prevalence rate of these disorders is estimated at same level as for other disorders such as - Post-meningitic sequelae, Infantile hemiparesis, Spinal deformity and Tic disorder is at 25 (95% CI 15-34) per 100,000.
INTERPRETATION: On the basis of the data obtained, the present study provides some valuable data on common neurological diseases among children in RS Pura town of Jammu district of Jammu and Kashmir.

Introduction

With a population of over 1 billion, Indian is the second most populous country in the world. According to the 2001 census report, 45% of the Indian population is below 20 years in age. This figure is higher than that of the world standard population where 34.62% are below 20 years of age.[1] The socio-demographic and epidemiological transition in developing countries has changed the morbidity and mortality pattern among communities. This has brought non-communicable diseases to the forefront of the health care delivery system. Within this group, neurological disorders constitute a significant proportion affecting morbidity, mortality, disability and quality of life.[23] However, neurological services are slowly expanding in India and, given the vast population, there is an urgent need for reorganization of the services with optimal utilization of existing specialized manpower. In order to plan services in a socio-culturally appropriate and cost-effective manner, epidemiological data on neurological diseases forms a basic prerequisite. Unfortunately, despite this fact, there is a dearth of epidemiological data on neurological illnesses among children in this country.

The present study was undertaken to determine the prevalence and pattern of major neurological disorders in the urban area of RS health Block of district Jammu, through a community-based approach.

Materials and Methods

This was a population-based, cross-sectional, observational study. Our survey was conducted in R.S.Pura town of RS Pura health block, of district Jammu. Block R.S.Pura is located in the south west of Jammu city adjacent to Indo-Pak border with a total area of 273 sq km and average density of658/sq km. R.S.Pura town of the block is spread over 11 wards and has a population of 17, 245.[4] All the households of the town were surveyed by visiting house to house and covering all the population of the town. During the first phase of the study, the Anganwadi workers (AWW's) were trained in the detection of neurological complaints, and in completing a screening questionnaire written in the local vernacular. The questionnaire used is a modification of World Health Organization (WHO) protocol for measuring the prevalence of neurological disorders in developing countries.[5]

The screening questionnaire consisted of two parts. Part 1 contained socio-demographic details and part 2 was the main screening questionnaire. The main screening questionnaire also consisted of two portions- proforma-a, for all subjects above 7 years; and, proforma-b, for children aged 7 years or below. The process of data collection was similar to the one adopted by one of the contributors in an earlier study in rural Kashmir.[6] After training, the AWWs carried out a house to house screening in the town and census in which no one refused to participate. The evidence was correlated with the help of interview carried out by the epidemiologist on all those suspected as suffering from a neurological disorder. The medical team comprising of Neurologists and epidemiologists interviewed and examined all suspect cases by home visits. The cases were confirmed and categorized as per the operational definitions given below. The clinical history was obtained from the immediate guardian or head of the family, or, if not available, from the next most informative adult person.

Only individuals residing in these 11 wards for a minimum period of one year or more were surveyed to avoid inclusion of migrant population. A total of 3966 children of age less than 10 years (up to 9 years and 364 completed days) were screened for presence of neurological disorders.

Operational definitions

For the 2009 survey year, a case of neurological disorder was defined as a childborn in between 1st June 1999 to 31st May 2009, whose parent(s) or legal guardian(s) resided inthe surveillance area during the specified period of one year and fulfilling the following criteria:

Active epilepsy was defined as at least one seizure episode in the previous 5 years, regardless of use of antiepileptics during treatment.[7]

Febrile seizure was defined as seizure in children between the age of 6 months and 5 years, accompanied by fever, but without evidence of underlying central nervous system infection.[8]

Cerebral palsy (CP) was defined as a group of nonprogressive, but often changing motor impairment syndromes, secondary to lesions or anomalies of the brain, arising at any time during brain development.[9] For survey purposes; we modified the definition used by Mutch et al.,[9] to include children with postnatally acquired CP.

Tic disorder was defined as abrupt, transient, stereotypical coordinated movement of a body part or parts, or vocalization that is voluntarily suppressible for a short duration.[10]

Results

During the 2 month period, a total of 3966 children (male 2062, female 1904) less than 10 years of age were surveyed in R.S.Pura town of RS Pura health block. They constituted 23% of the total (of all age groups) surveyed population. There were 924 females to 1000 males in the study population [Table 1]. The overall and age-specific prevalence of major neurological disorders has been presented in Table 2. Twenty eight cases of major neurological disorders were found among children giving a prevalence rate of 706 (95% CI 650-750) per 100,000. The prevalence was slightly higher in males with a prevalence rate of 824 (95% CI 770-870) per 100,000 as compared to female children at 577 (95% CI 530-620) per 100,000. The overall prevalence of neurological disorders shows a significant rising trend with increase in age.

Table 1

Demographic profile of children less than 10 years of age of RS Pura town in the study

Table 2

Distribution of children with neurological disorders found in the study

Active epilepsy: Eight cases of epilepsy were found among children giving a prevalence rate of 202 (95% CI 180-220) per 100,000 [Table 3].

Table 3

Type of major neurological disorders seen in the study

Febrile seizures: Five cases of Febrile seizures were found among children giving a prevalence rate of 126 (95% CI 100-140) per 100,000.

Cerebral palsy: Eleven cases of cerebral palsy were ascertained yielding a crude prevalence rate of 277 (95% CI 245-309) per 100,000 in the age group less than 10 years.

Very few cases of other major neurological disorders were found. The prevalence rate of these disorders is estimated at same level for Post-meningitic sequelae, Infantile hemiparesis, Spinal deformity and Tic disorder at 25 (95% CI 15-34) per 100,000.

Discussion

The present study is the only large-scale, adequately designed, representative, population-based epidemiological study on neurological disorders in children from our part of India.

According to an Indian meta-analysis, the prevalence rate of epilepsy is 533 per 100,000 population in India.[11] The prevalence rate in our study was much lower than this. This may be because of difficulty in eliciting proper response on epilepsy in our part of India.

Utilizing adequately trained field investigators for enumeration and screening is a crucial component of neurological studies, since in many developing countries, specialist manpower limitations often hinder researchers from undertaking such studies. The prevalence of febrile seizures in those aged less than 10 years was 126 (95% CI) per 100,000, again much lower than a study conducted in the city of Kolkata.[12] This discrepancy can be partly due to recall bias and partly because of the unwillingness to accept a child as suffering from seizure disorder as in case of epilepsy. Eleven cases of cerebral palsy were ascertained, yielding a crude prevalence rate of 277/100,000 in the age group less than 10 years. The prevalence rates of cerebral palsy among children less than 10 years of age in R. S. town compares favorably with studies from the developed world. The prevalence is almost similar to Kolkata study, and the global figure of 1.2 to 2.5 per 1000 children of early school age, that has been described in standard literature.

The prevalence rate for other major neurological disorders was too small for establishing comparison. This study does have some limitations. On most occasions, we interviewed the head of the family or any other reliable informant in the family. It is possible that if we could examine all children individually and not just the suspects, we could have detected more cases. In spite of the limitations, the screening questionnaires have demonstrated that it is possible to detect a wide spectrum of neurological disorders in a community. Neurological disorders are often obvious with clear symptoms and signs and, in the Indian context - the head of the household is in a better position to report presence or absence of symptoms in comparision to the other members of the family.

Notwithstanding the limitations, the present study provides some valuable data on common neurological diseases among children in RS Pura town of Jammu district of Jammu and Kashmir. The prevalence rates arrived at in this study, do find some justification, if extrapolated for prevalence of neurological disorders in India.