Seizure 23 (2014) 636640

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Prevalence and clinical characteristics of active epilepsy in southern

Han Chinese
Xiaorong Pi a, Luo Zhou b, Lei Cui b, Aizhong Liu c,**, Jie Zhang d, Yan Ma a, Bofu Liu a,
Chaoqun Cai e, Caiyun Zhu a, Tianbin Zhou a, Jia Chen a, Zhen Zhou a, Chunmei Wang c,
Luoqing Li a, Shichuo Li f, Jianzhong Wu f, Bo Xiao b,*
a
Department of Neurology, Yueyang No. 1 Peoples Hospital, Yueyang 414005, Hunan, China
b
Department of Neurology, Xiangya Hospital, Central South University, Changsha 410008, Hunan, China
c
School of Public Health, Central South University, Changsha 410008, Hunan, China
d
Department of Neurology, Hunan Children Hospital, Changsha 410007, Hunan, China
e
Department of Neurology, Yuehua Hospital, Yueyang 414014, Hunan, China
f
Institute of Neurological Surgery, Xicheng District, Beijing 100037, China

A R T I C L E I N F O A B S T R A C T

Article history: Purpose: To investigate the prevalence and clinical characteristics of active epilepsy in southern Han
Received 14 January 2014 Chinese.
Received in revised form 30 April 2014 Method: A door-to-door survey about epilepsy was conducted in communities identied by random
Accepted 4 May 2014
cluster sampling among 20 villages and 3 communities of Yueyang city. A questionnaire for epilepsy
based on the World Health Organization screening questionnaire was used. A nal diagnosis of epilepsy
Keywords: was made by neurology specialists with the support of head magnetic resonance imaging (MRI),
Active epilepsy
computed tomography (CT), and electroencephalography (EEG) if available. The prevalence, clinical
Prevalence
Clinical characteristics
characteristics, and treatment gap were analyzed in patients with active epilepsy within the past year
Treatment gap and the past 5 years.
Results: Active epilepsy was identied in 91 patients within the past year and 117 patients within the
past 5 years. The one-year prevalence was 2.8%, and the ve-year prevalence was 3.7%. The prevalence
for epilepsy active within the last year and the last ve years was signicantly higher in rural areas than
in urban areas (P < 0.05). Secondary generalized tonicclonic seizures (53.8%) were the most common
seizure type in patients whose epilepsy had been active in the last year. 34.1% of patients were diagnosed
with structural or metabolic epilepsy. The most common cause for epilepsy was cerebrovascular disease
(32.3%), followed by traumatic brain injury (29.0%). The treatment gap was 93.4%.
Conclusion: The prevalence of epilepsy active within the last one and ve years was higher in rural areas
than in urban areas of Yueyang city. A large treatment gap exists in this area and a rational intervention
strategy is needed.
2014 British Epilepsy Association. Published by Elsevier Ltd. All rights reserved.

1. Introduction epidimiological features of epilepsy have been widely reported in

Epilepsy has been recognized since the earliest medical
writings and is one of the most commonly diagnosed neurological
conditions. However, the epidemiology of epilepsy is still not
fully understood due to its heterogeneous nature and complex
etiologies.1,2 In addition, regional differences in the etiologies and
* Corresponding author. Tel.: +86 73184327236; fax: +86 73184327236.
** Corresponding author. Tel.: +86 73184805465; fax: +86 73184805454.
E-mail addresses: lazroy@live.cn, aizhongliu@yahoo.com (A. Liu),
xiaobo62_xy@yahoo.com.cn (B. Xiao).
literature.3,4 Numerous studies have identied genetic risk factors
for epilepsy.5 Therefore, studies focusing on isolated geographic
areas with unique genetic and environmental factors may be
important for understanding the etiology and epidemiology of
epilepsy.
Previous studies of epilepsy in China revealed regional
differences in prevalence. For example, Li et al. reported a 4.4%
lifetime prevalence of epilepsy in the urban areas of six cities in
China.6 Wang et al. reported a 7.04% lifetime prevalence of
epilepsy in the rural areas of ve provinces in China. Regional
differences in the prevalence of active epilepsy have also been
reported. For instance, the 5-year prevalence of active epilepsy is

http://dx.doi.org/10.1016/j.seizure.2014.05.002
1059-1311/ 2014 British Epilepsy Association. Published by Elsevier Ltd. All rights reserved.
 X. Pi et al. / Seizure 23 (2014) 636640
5.4% in ve provinces of China,7 3.9% in Hong Kong,8 4.4% in a
rural area of Vietnam9 and 2.9% in a rural area of Tanzania.10
Yueyang is a medium-sized city located in southern China and has
the lowest percentage of ethnic minorities in the country. 99.84%
of the population of Yueyang city are Han Chinese and only 0.16%
are ethnic minorities. Thus, people living in this area represent the
typical genetic background of southern Han Chinese.
Patients with active epilepsy are the main group of interest in
current epidemiological studies. Reports on prevalence and clinical
characteristics of active epilepsy, especially on 1-year active
epilepsy are few. Only a handful of studies on the prevalence and
clinical characteristics of active epilepsy in Han Chinese available
in literature are reported in English. In this study, we conducted a
well-controlled epidemiological survey of epilepsy in both the
urban and rural populations of Yueyang city and analyzed the
prevalence and clinical characteristics of cases with 1-year and 5-
year active epilepsy.
2. Materials and methods
2.1. Population
Yueyang city has jurisdiction over three districts and six
counties with a total population of 5.5 million. Random cluster
sampling was performed at 23 survey points and 4 survey units in
20 villages and 3 communities. These villages and communities
were selected because all residents are Han Chinese. The inclusion
criterion was that residents must be currently living in the
surveyed area with household registration and have temporarily
left the area for no more than 1 month.
2.2. Epidemiological survey
This study was approved by the Human Research Committee of
Yueyang City and Xiangya Hospital. The committees check studies
for both scientic content and potential ethical issues. Written
informed consent forms were obtained from all participants or
their guardians. This study was conducted in two stages in
accordance with the Declaration of Helsinki. In the rst stage, well-
trained local healthcare workers conducted a door-to-door
screening of all residents. The questionnaire is a standard
questionnaire for epidemiological studies of epilepsy developed
from the WHO (World Health Organization) screening question-
naire that includes 13 questions.11 When one or more positive
signs of epilepsy were discovered, potential patients were further
validated by interviewing the patients family members and
witnesses. In the second stage, patients were directly interviewed
by experienced neurologists, and a nal diagnosis of epilepsy was
made with the support of available MRI, CT, or EEG data.
Standardized treatments were given to patients who were
diagnosed with epilepsy but did not previously receive standard-
ized treatment. The standardized treatment was dened as
treatment following the internationally accepted norms for the
treatment of epilepsy.12 All difcult-to-diagnose cases were
discussed by experts from the Department of Neurology at
Xiangya Hospital, Central South University.
2.3. Standard of diagnosis
Patients were recruited according to the ILAE recommended
standard epilepsy diagnosis criteria.13 In this study, epileptic
seizures and etiology of seizures were dened according to the
International League Against Epilepsy (ILAE) classication and
Nomenclature Committee Report, 20052009.14 A prevalent case
of active epilepsy is dened as a person with epilepsy who had at
least two epileptic seizures within the past year regardless of
637
antiepileptic drug (AED) treatment.15,16 People who experienced at
least two seizures in the past 5 years were also included in this
study. The seizure frequency is divided into low, moderate, and
high seizure frequency.17 Treatment gap was dened as the
percent of patients with active epilepsy that had not received
optimal, regular AED treatment a week before the survey
began.15,16 Regular AED treatment follows internationally accept-
ed norms for the treatment of epilepsy.12
2.4. Data collection
The patients gender, age, living area (rural or urban), onset age,
frequency, and etiology of epilepsy, family history, and treatment
information were collected. The total prevalence of active epilepsy
was calculated by the number of cases that had 2 or more non-
induced seizures per 1000 investigated individuals. The prevalence
of active epilepsy for each variable or characteristic was the
number of cases with active epilepsy per 1000 individuals with
each variable or characteristic. The patients data was included in
the analysis only when: (1) the patient was Han Chinese with a
clear family history indicating no marriage to ethnic minorities
within the past 5 generations; (2) the patient had lived in southern
China for over 3 generations. The patients with epilepsy that died
were not included in this study because epilepsy is a clinical
syndrome that is not commonly identied as a cause of death.
2.5. Statistical analysis
A database was established with EpiData 3.02 software, and
data were analyzed using SPSS17.0 software. Two-sample x2 test
was used to compare the prevalence of active epilepsy between
different genders and age groups.
3. Results
3.1. General characteristics of the population
A total of 32,059 people (52.9% male, 47.1% female) participated
in the door-to-door surveys. 786 (2.45%) individuals had a history
of seizures, and 143 (4.46%) individuals were clinically diagnosed
with epilepsy. 91 (2.83%) patients were found to have active
epilepsy within the past 1 year. 117 (3.65%) patients were
identied to have active epilepsy within the last 5 years. Among
the 91 patients diagnosed with epilepsy, 60 underwent head MRI/
CT scans (38 patients showed abnormalities), and 49 underwent
electroencephalogram (EEG) examination (33 patients exhibited
abnormal EEG).
3.2. Prevalence of active epilepsy
Table 1 shows the prevalence of active epilepsy within the past
year in different genders, areas, and age groups. The prevalence of
active epilepsy in the past year was 2.8%. The prevalence of active
epilepsy was higher in males (3.12%) than in females (2.52%) but
without signicant difference (P > 0.05). The prevalence of active
epilepsy was signicantly higher in rural areas (3.7%) than in
urban areas (2.0%) (P < 0.05). The prevalence of active epilepsy in
different age groups was statistically signicant (P < 0.05). The
highest prevalence of active epilepsy was found in the 2029 years
old group (6.3%). 30 cases had an onset age before 9 years old
(32.97%), 18 cases had an onset age between 10 and 19 years old
(19.78%), and 17 cases had an onset age between 20 and 29 year old
(18.68%).
Table 2 shows the prevalence of active epilepsy within the past
5 years. The prevalence of active epilepsy in the past 5 years was
3.6%. The prevalence of active epilepsy was higher in males (4.1%)
638 X. Pi et al. / Seizure 23 (2014) 636640

Table 1 Table 3
Different characteristics of the active epilepsy prevalence in 1 year. Clinical Characteristics of active epilepsy in the past 1 and 5 years.

Population Number Prevalence x2 P 1 year 5 years

(%) Number (%) Number (%)
Gender 1.036 0.309 Gender
Male 16,966 53 3.1 Male 53 (58.2) 70 (59.8)
Female 15,093 38 2.5 Female 38 (41.8) 47 (40.2)
Area 8.257 0.004 Area
Urban 15,964 32 2.0 Urban area 31 (34.1) 37 (31.6)
Rural 16,095 59 3.7 Rural area 60 (65.9) 80 (68.4)
Age at diagnosis 21.771 0.005 Pathogeny type
0 2872 6 2.1 Unknown pathogeny 60 (65.9) 79 (67.5)
10 2932 8 2.7 Heredity 0 (0) 0 (0)
20 2865 18 6.3 Structural or metabolic epilepsy 31 (34.1) 38 (32.5)
30 5390 19 3.5 Seizure types
40 6530 10 1.5 Secondary generalized 49 (53.8) 68 (58.1)
50 5154 8 1.6 tonicclonic
60 4078 15 3.7 Focal seizures with unconsicious and 7 (7.7) 7 (5.9)
70 1753 6 3.4 perception harm
80 485 1 2.1 Focal seizures without unconsicious 3 (3.2) 4 (3.4)
Onset age and perception harm
0 2872 30 3.3 Generalized tonicclonic 0 (0) 1 (0.8)
10 2932 18 2.0 Absence 0 (0) 1 (0.8)
20 2865 17 1.9 Other types 0 (0) 0 (0)
30 5390 7 0.8 Mixed 32 (35.2) 36 (30.8)
40 6530 4 0.4 Seizure frequency
50 5154 7 0.8 Low 13 (14.3) 39 (33.3)
60 4078 6 0.7 Moderate 28 (30.8) 28 (23.9)
70 1753 2 0.2 High 50 (54.9) 50 (42.7)
80 485 0 0 Treatments
Standard treatment 5 (5.5) 7 (6.0)
Non-standard treatment 59 (64.8) 71 (60.7)
than in females (3.1%) but without signicant difference No treatment 27 (29.7) 39 (33.3)
(P > 0.05). The prevalence of active epilepsy was signicantly
higher in rural areas (4.9%) than in urban areas (2.4%) (P < 0.05).
The prevalence of active epilepsy in different age groups showed
no signicant difference (P > 0.05). awareness (7.7%), and focal seizures without impairment of
consciousness and awareness (3.2%). Among the 91 patients with
3.3. Clinical characteristics of active epilepsy active epilepsy, 13, 28, and 50 cases (14.3%, 30.8%, 54.9%) had low,
moderate, and high seizure frequency, respectively. 64.8% of the
Table 3 shows the clinical characteristics of patients with active patients received nonstandard treatments and 29.7% did not
epilepsy in the past 1 year and the past 5 years. 91 patients had receive any treatment. The treatment gap for patients with active
active epilepsy in the past 1 year. Among them, 34.1% of patients epilepsy within the past year was 93.4%. 117 people had active
had a clear cause of structural or metabolic epilepsy with the most epilepsy in the past 5 years with ages ranging from 1 to 87 years old
common cause being cerebrovascular disease (32.3%), followed by (39.0  21.4 years). The treatment gap for patients with active
traumatic brain injury (29.0%), central nervous system infections epilepsy within the past 5 years was 86.3%.
(6.5%), brain tumors (9.6), cerebral hypoplasia (12.9%), neonatal
intracranial hemorrhage (3.2%), and rodenticide poisoning (3.2%). 4. Discussion
Secondary generalized tonicclonic seizures were the most
common type of seizure (53.8%), followed by mixed seizures Despite the fact that epilepsy is one of the most common
(35.2%), focal seizures with impairment of consciousness and neurological diseases and has been studied for many decades, our
understanding of its epidemiology is still decient. This is partly
because the etiology of epilepsy is complex, accurate diagnosis is
Table 2 difcult, and the heterogeneous nature of epilepsy has not been
Different characteristics of active epilepsy prevalence in past 5 years. fully considered. In addition, most reports focus on the lifetime
Population Number Prevalence (%) x2 P prevalence of epilepsy; whereas, there are relatively fewer reports
examining the prevalence of active epilepsy. Thus, an epidemio-
Gender 2.248 0.135
Male 16,966 70 4.1 logical study of active epilepsy can provide more information for
Female 15,093 47 3.1 the prevention and treatment of epilepsy. In this study, we
Area 14.759 0.000 investigated the prevalence of active epilepsy in a geographic area
Urban 15,964 38 2.4
of southern China using a sensitive screening survey and relatively
Rural 16,095 79 4.9
Age group 12.549 0.128
accurate diagnostic approach.
0 2872 13 4.5 Diagnostic accuracy and case ascertainment were thought to be
10 2932 15 5.1 major problems in the epidemiological study of epilepsy.2 This is
20 2865 17 5.9 because a majority of patients with epilepsy do not exhibit
30 5390 20 3.7
permanent physical signs and can only be identied by looking
40 6530 13 2.0
50 5154 17 3.3 through the patients medical history. Therefore, diagnosis
60 4078 13 3.2 depends on the skill and experience of the diagnostician as well
70 1753 8 4.5 as the quality of witness information. Moreover, some patients
80 485 1 2.1
with seizures may never seek medical care for a variety of reasons.
Total 32,059 117 3.6
This study was conducted in two stages. First, well-trained local
 X. Pi et al. / Seizure 23 (2014) 636640
Table 4
Comparison of methods and results of each active epilepsy prevalence survey.
Regions Yueyang, China Five provinces
in China
Screening 13 questions from 13 questions from
questionnaire WHO demonstration WHO demonstration
projects projects
Standard of At least two seizures At least two seizure
diagnosis in the previous 1 and in the previous 1
5 years and 5 years
Survey way Door-to-door Door-to-door
Prevalence (%)
1 year
Urban 2
Rural 3.7 4.6
Total 2.8
5 years
Urban 2.4
Rural 4.9 5.4
Total 3.7
healthcare workers conducted door-to-door screening using a
standard questionnaire for epidemiological study of epilepsy.
Individuals with one or more positive signs of epilepsy were
further conrmed by a thorough interview with the patients
family members or witnesses. Second, potential patients were
directly interviewed by experienced neurologists and examined in
a clinic. Therefore, our study provides relatively accurate
information on the diagnosis of epilepsy in patients. In addition,
the etiologies and risk factors of epilepsy varies with geographic
location.3,4 This suggests that genetic and environmental factors
are important in the etiology of epilepsy. In this study, random
cluster sampling was performed at 23 survey units in Yueyang city,
an area with the lowest percentage of ethnic minority groups in
China, and data from patients with a family history of marriage to
ethnic minority groups were excluded from analysis. Therefore,
the study population represents the typical southern Han Chinese
population.
In this study, 117 cases were diagnosed with active epilepsy
within the past 5 years, of which 91 cases (78%) were diagnosed
with active epilepsy within the past year; therefore, the majority of
seizures occurred in the past year. The prevalence of active
epilepsy was signicantly higher in rural areas than in urban areas.
The prevalence of active epilepsy in the past year and past 5 years
in the rural areas of Yueyang city was lower than the reported
prevalence in a study in rural areas of ve provinces of China
(Table 4).7 These differences may reect the differences in
geographical environment and genetic background between
samples. Our study might best represent the southern Han Chinese
population. In addition, Wang et al. study was conducted in 2002,7
while our study was performed in 2010. During the past decade,
socio-economic development brought great changes in the quality
of medical care and education to patients in rural areas of China.
The increased quality of medical care and education brought a
decrease in the stigma associated with epilepsy and an increase in
physician-patient condentiality. Epilepsy is now starting to be
recognized as a treatable disease and no longer as a case of
supernatural possession in rural areas. This might also be a factor
leading to the reduced prevalence of epilepsy observed in this
study compared to previous studies. Although Hong Kong is also
located in southern China, there are signicant differences in the
healthcare resources for patients with epilepsy between Hong
Kong and Yueyang city. Patients in Hong Kong have access to better
healthcare and better epidemiological report system. In addition,
patients in the Hong Kong study were screened through phone
calls although clinical follow up was used to conrm the results of
639
Hong Kong, China Northern Vietnam Tanzania Kenya22
7 screening Screening Screening Ten questions
questions questionnaire questionnaire questionnaire
was designed developed by adapted from
specically WHO for the Placencia et al.
global campaign
At least one At least one seizure At least two At least two
seizure in the in the previous seizures in the seizures in the
previous 5 years 5 years previous 5 years previous 1 year
Telephone Door-to-door Door-to-door Door-to-door
11
3.9
4.4 2.9
their epidemiological survey of epilepsy (Table 4).8 When
compared to studies in other resource-poor countries, the
prevalence of active epilepsy in the past 5 years in the rural areas
of Yueyang (4.9%) was higher than that in rural Tanzania10 (2.9%)
and rural Vietnam (4.4%).9 However, the study in Tanzania was an
adult-based survey of active epilepsy with a 9-month census
survey conducted in 2009 (Table 4).10 The study lasted too long and
is susceptible to the effects of oating population and disease
factors, which may affect the prevalence rate. The study in rural
Vietnam conducted in 2005 was based solely on residents over the
age of 1 year and lasted for 11 months (Table 4).9 Besides the
effects of a different sampling method and the lengthy study
period, the diagnostic criteria were also different. Individuals with
one epileptic seizure were included in Tuan et al. study,9 whereas
only individuals with at least 2 seizures were included in our study.
The prevalence of epilepsy active within the past 5 years in
population-based European studies in all ages varied from 3.3% to
7.8%.2 Therefore, comparing the prevalence of epilepsy between
studies in different countries is not likely to be helpful unless they
used identical research approaches, similar diagnostic criteria, are
located in similar geographic environments, and are clearly
hypothesis driven.
Although previous studies have described the distribution of
seizure types in Asia, few studies are population-based studies.18
In this study, secondary generalized tonicclonic seizure (53.8%)
was the most common type of seizure in patients with active
epilepsy within the past year. There are very few studies that
investigate the causes of epilepsy in Asian populations. Our study
demonstrated that 34.1% of patients had a clear cause of structural
or metabolic epilepsy. The most common cause was cerebrovas-
cular disease (32.3%), followed by traumatic brain injury (29.0%).
Previous reports on the etiologies and risk factors of epilepsy are
highly divergent in regards to age and geographic location.19
However, successful detection of risk factors depends on the extent
of the investigation. Therefore, comparison of the results between
studies is often problematic due to the differences in research
methods and diagnostic accuracy.
The epilepsy treatment gap has been proposed as a useful
parameter to compare quality of care for epilepsy patients across
populations.20 In this study, the treatment gap was dened as the
percent of patients with active epilepsy that did not receive regular
AED treatment a week before the survey began. The duration of
1 week was used in reference to a previous study in Chinese7 to
make comparing the two studies easier. In this study, only 6.6% of
patients with active epilepsy took anti-epileptic drugs one week
640 X. Pi et al. / Seizure 23 (2014) 636640
before the investigation. The treatment gap for patients with active
epilepsy within the past year was 93.4%, which is higher than the
treatment gap identied in a previous report.7 The geographic
environment, lack of neurology specialists, and a general lack of
knowledge about epilepsy medication in this area may be
responsible for the high treatment gap. Indeed, Wang et al. study
in rural areas of ve provinces in China21 demonstrated that the
treatment gap for active epilepsy can be decreased by 12.8% through
the implementation of an epilepsy community control program.
In conclusion, the prevalence of epilepsy active within the
past year and past 5 years is higher in rural areas than in urban
areas of Yueyang city, which represents the prevalence of active
epilepsy in southern Han Chinese. A large treatment gap suggests
the need for a reasonable intervention strategy.
Acknowledgments
This study was supported by National Natural Science
Foundation of China (No: 81071048), and the explore program
of Health Bureau of Hunan, China (B2010-110).
Conict of interest. All authors declared no conict of interest.
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