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Pakistan Journal of Neurological Sciences (PJNS)

Volume 12 | Issue 3 Article 2

9-2017 Neurological disorder burden in , -:data from the tertiary carecenters of the Ghulam Hussain Government College University, Faisalabad, Pakistan, [email protected]

Asif Shahzad Government College University, Faisalabad, Pakistan

Haseeb Anwar Government College University, Faisalabad, Pakistan

Shahid Mahmood Baig PIEAS, Faisalabad, Pakistan

Asghar Shabbir COMSATS Institute of Information Technology, , Pakistan.

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Follow this and additional works at: https://ecommons.aku.edu/pjns Part of the Neurology Commons

Recommended Citation Hussain, Ghulam; Shahzad, Asif; Anwar, Haseeb; Mahmood Baig, ; Shabbir, Asghar; and De Aaguilar, Jose-luis Gonzalez (2017) "Neurological disorder burden in Faisalabad, Punjab-Pakistan:data from the major tertiary carecenters of the city," Pakistan Journal of Neurological Sciences (PJNS): Vol. 12 : Iss. 3 , Article 2. Available at: https://ecommons.aku.edu/pjns/vol12/iss3/2 Neurological disorder burden in Faisalabad, Punjab-Pakistan:data from the major tertiary carecenters of the city

Authors Ghulam Hussain, Asif Shahzad, Haseeb Anwar, Shahid Mahmood Baig, Asghar Shabbir, and Jose-luis Gonzalez De Aaguilar

This original article is available in Pakistan Journal of Neurological Sciences (PJNS): https://ecommons.aku.edu/pjns/vol12/iss3/2 Corresponding to: Ghulam Hussain, Department of Physiology, Liaquat Block, 1st Floor. New campus, Government College University, Road, 3800 Faisalabad. Contact: +923006654101 Email: [email protected]

The mortality rate and burden of disability caused by NDs is higher than any other major disease worldwide–25. The overall prevalence of NDs is 6.5% and incidence trends have shown an alarming rate of increase over time3. Demographic, geographic, and socioeconomic conditions are major factors that affect the epidemiology oNDs. Previous us research has shown that prevalence and incidence of NDs is positively correlated with the economic condition of a given . The burden of NDs increases as a country expands economically3,6. In lower-income ,the reported prevalence of NDs ranges from 4% to 5%,whileprevalence in countrieswith higher GDP is 10-11%2,3,7. The higher rate of NDs in developed countries may be due to their more robust system of public health services and health- MATERIALS AND METHODS related facilities that screen and provide health services for the average patient. It has been In the present study, study subjects were recruited documented that 6.75% of the American population from the patient population at the outpatient neurology and6% of the Population have been diagnosed with and psychiatry departments of , DHQ NDs. Hospital, Aziz Fatima Trust Hospital, Faisal Hospital, In recent years, the burden of Nds in developing and Al-Noor Hospital in Faisalabad, Punjab-Pakistan. countries has continued to increase; this grow this The inclusion criteria for selecting the hospitals were correlated with increasing epidemiological data, that the facility was well-equipped, possessed prolonged life expectancy, improved health facilities, functional basic and advanced facilities for diagnosis facilitated access to healthcare centers, provision of of complicated NDs, and had a sufficient patient advanced diagnostic technology, and a trend in population for recruitment at the outpatient facility. The urbanization among the population. Although there are selected tertiary care centers are the highest-volume data regarding the incidence and prevalence of ND sin centers in Faisalabad . The health care centers developing countries of , such as , , and were selected from4 different corners of the city in , these data may not be generalizable to order to acquire representative data from each region Pakistan, due to differing social, geographical, of the district. Furthermore, a mix of government and religious, cultural, and ethnic aspects unique to those private-sector hospitals were selected to ensure the in countries. Therefore, it is necessary to conduct clusion of an economically divers ecohort that would epidemiological studies in Pakistan to collect and be more representative of the population in . A analyze reliable data for this region of the . structured questionnaire was used to gather basic data The prevalence of Nds in India ranges from about the patients receiving care in the selected 967–4,070/100,000 with a mean of 2,394/100,000 hospital departments. population. Such prevalence indicates that over 30 The data were collected from 2015 to May 2015. million people are living with NDs in this country with Prior authorization was sought from the hospital the second largest population in the world. The administration for collection of data. The prevalence of common disorders, such as stroke, and psychiatrists of participating patients were epilepsy, tremors, Parkinson's disease (PD), and requested to make a detailed diagnosis based on the mental retardation, is not uniform across the different available medical tests for the possible ND. Patients regions of the country . were interviewed and data were recorded on The overall crude prevalence of NDs in questionnaires. Patients undergoing their first clinical was reported to be 131/1,000population .Recent visit were excluded, as their clinical diagnosis may not reports indicate about68.5/10,000 prevalence of NDs have been fully determined. Patients with confirmed in the pediatric population of Saudi Arabia . diagnoses were included in the study, and data were Published data regarding the epidemiology of major collected from the subjects after obtaining consent of NDs in Pakistan is limited, and most available either the patient or his/her care giver. The available information are hospital-based estimations or record of medications and treatment was also -collected data, limited to a few . These collected for further verification as needed. data are likely not nationally representative . In Information about , age, marital status, type of comparison to neighboring countries, it maybe disorder, familial history for the disorders of interest, possible to determine aggregation of the existing, and consanguineous were collected for disparate data sources. The existing information the further analysis of related risk factors. prevalence of NDs in Pakistan based concerning the prevalence of NDs in selected cities of Pakistan INSTITUTIONAL REVIEW BOARD APPROVAL indicate that the burden of NDs is a serious concern. Epidemiological data concerning selected Nds are The Institutional Review Board (IRB) of Government available, but this information is limited to particular College University, Faisalabad-Pakistan carefully locations and, therefore, cannot be generalized to reviewed and granted approval for this study. determine the overall burden of NDs in Pakistan nationally. Most available data are from the city of RESULTS , while prevalence and incidence in the other mega-cities of Pakistan have yet to be investigated. In The overall burden of NDs in was the present study, we focused our evaluation of NDs in assessed in the 3,068 study participants. The rate of Faisalabad, the third largest city of Pakistan. To our each ND reported in this population was as follows: . knowledge, this is the first study concerning the depression 19.6% (n = 602), epilepsy 16.6% (n = 508), prevalence and burden of NDs at the leading tertiary migraine 15.2 % (n = 466),disc prolapse 8.8% (n = care centers of this mega-city. 269), paralysis 8.5% (n = 262), trauma 5.3% (n = 163),

P A K I S T A N J O U R N A L O F N E U R O L O G I C A L S C I E N C E S 0 4 V O L . 1 2 ( 3 ) J U L - S E P 2 0 1 7 P 33) = schizophrenia, c p history There and T (n 421), L t The miscellaneous 19), 1.4% mania (n schizophrenia o own 8.6%(n=243),Samundritown4.5%126), A yallpurtown30.7% a a 15) F w = = K t t % of patients 0 5 1 1 2 2 i e i migraine g I e . . 0 5 0 5 n T 2.2% 498), 0 0 D 68), F g rate S . . . . 17.7% u bipolar 0 0 0 e 0 andliyanwala n depression,30.8%

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5 122; 0 103; 262; r d w n 0 a a 2 41; the n n 44.0 e . i a l as 0 e a i 5 56.0 in r = = n n s , , . The study subjects were divided into 4 age groups, Timely and accurate diagnosis of such cases may group I (10-30 years), group II (31-50 years), group III facilitate provision of effective treatment and help (51-70 years), and group IV (70-90 years),in order to prevent the chronicity and post-disease effects on capture the burden of ND sat early or late age onset. patients and their families . Groups I and II, covering the age ranges of 10-50 In developing countries, such as Pakistan, diagnosis of years, manifested a similar rate of ND burden (37.8% complex NDs is challenging due to lack of and 37.5%, n = 1073 and n = 1065, respectively). The infrastructure and expertise, which creates a hurdle in burden was remarkably lower in age groups III and IV determining and providing proper treatment. The (20.7%, n = 587 and 4%, n = 115, respectively). present study is the first hospital based study of NDs Depression was higher in group II as compared to conducted in Faisalabad, the third largest city of other groups. Majority of epileptic patients feel in Pakistan. younger age group as compared to older age group. Depression accounted for as substantial portion Half of the patients with migraine were in group II 207 (19.6%) of the NDs among the study subjects, 11.5% of (45.1%), followed by migraine in group I 39.7% (n = which were in youth with at least 1 parent who also had 182). Disc prolapse was more common in group II depression. This value was close to the global burden 46.9% (n = 122)while group III manifested the highest (20%), and local burden of depression in Karachi (20- value of paralysis 40.2% (n = 103).Trauma was more 23%)– . The higher proportion off depression among abundant in group I 40.6% (n = 63) than in any other the female group(67.1%), as compared to the male group, while brain hemorrhage was mostly noted group (32.9%), was in accordance with previous ingroup III 52.0% (n = 78).Schizophrenia60.2% (n = studies by various authors . The heritability and burden 50) and tumor 42.1% (n = 16) were recorded mostly in of ND among the younger generation (10-30 years of the young population belonging to group I. The age) is reported here for the first time in Pakistan, and subjects of group III manifested highly level of highlights an issue of pressing concern. The Dementia63.5% (n = 33).The proportion of patients substantial proportion of NDs among younger suffering from mania was high in group I 44.0% (n = 11) generations in Faisalabad suggests that national rates and group II 44.0% (n = 11) respectively (Figure 5). of NDs may be higher than previously assumed and affect more of the population, posing a serious health DISCUSSION burden. Epilepsy appeared to be the second most common In developing countries, prevalence and incidence of ND, accounting for 16.6% of cases. One third of cases ND sare underestimated due to lack of data and were found to have a positive family history, and awareness about the burden and impact. Most of NDs, slightly more of the male group (53%) than female such as meningitis, encephalitis, and cerebral malaria, group (47%)experienced epilepsy. There was also a the on set of the condition is acute in nature and higher proportion among patients in the age range of frequently lethal in a short course of time. Mortality due 10-30 years, which is in accordance with previously- to many of these NDs could be prevented by early reported data . diagnosis and providing effective treatment. Other We also found that of the 15.2% of subjects with a NDs are chronic in nature, for example epilepsy, and, in diagnosis of migraine, one third had a positive family addition to the morbidity experienced by the patient, history, and the female group (75.4%) accounted for a this illness carries a socioeconomic burden and larger proportion of cases compared to the male group stigmatization is commonly observed in many cases, (24.6%). The age groups 10-30 and 30-50 years of age which also affects the broader family. experienced the highest proportion of cases.

Age Group 10-30 Age Group 31-50 Age Group 51-70 Age Group 71-90 6 .

80.0 1 7 5 2 . . 3 0 6 0 6 s . t 9 7 2 1 2 . 0 0 .

60.0 . . . . 1 5 n 6 . 2 6 5 7 5 5 4 4 . . 9 . 8 5 4 4 2 4 . e 4 4 . . . 4 4 6 0 0 8 7 9 i 5 . 4 8 . . 7 7 . 8 4 4 1 t 6 0 3 5 . . 3 4 3 . 3 3 3 3 3 3 a 1 1 3 3 0 .

40.0 3 3 6 7 1 . 3 . 3 3 . 6 7 . . 1 3 2 2 0 p 2 1 . 6 . 0 7 7 f 2 2 . 2 0 . 0 2 . 7 6 3 2 . . 5 . 3 o 3 1 1 2 2 6 6 1 1 9 20.0 1 1 . . 1 . 1 7 0 1 8 8 9 9 . . 2 . . % 7 1 8 5 2 . 4 . . . 0 0 5 6 . 4 4 0 . . . 3 2 3 1 1 1 0 0.0 0

umor Mania Overall rauma T T s Disease Dementia Epilepsy Migraine Paralysis Schizophrenia Miscellaneous Disc Proiapse Brain HaemorhageParkinson’ Figure 5. Distribution of NDs by Age Group (N = 2840)

P A K I S T A N J O U R N A L O F N E U R O L O G I C A L S C I E N C E S 0 6 V O L . 1 2 ( 3 ) J U L - S E P 2 0 1 7 Our results regarding headache and migraine are not facilities in Pakistan may explain the higher rate of Nds in accordance with other studies conducted elsewhere Dementia has increased and is approaching epidemic in Pakistan – . This contradiction of ND burden levels in Pakistan, and requires timely, focused observed in our results is possibly due to demographic resources. Prevalence of dementia is projected to be factors, parameters, and the methodology used in much higher in the future – . Dementia accounted for those studies. Although specific aspects of our findings 1.7% of the NDs among study subjects, similar to differ from previous studies, the trend of NDs in gender previous findings of a1.9 % prevalence of dementia in and age groups of patients appear similar to data .The available prevalence data about reported previously. dementia is limited and prior studies report 8% and 7% The number of patients with PD in Asian countries is of elderly people are suffering from dementia– . expected to reach 6.17 million in a few decades . The Although other disorders,such disc prolapse (8.8%), presence and increasing burden of PD in some cities of paralysis (8.5%), trauma (5.3%), brain hemorrhage Pakistan has also been documented – , but the (5%), mania (0.8%), tumor (1.6%), acute nationwide data on prevalence of PD is limited. In the psychological illness (1.4%), disruptive behavior present study, our finding that 3% of the study disorder (0.6%), bipolar affective disorder (0.7%) and population has a diagnosis of PD has not been other miscellaneous minor diseases (6.2%)account for validated in the literature and is higher than the more than one quarter of the NDs among the study worldwide prevalence of PD of about 1% . A majority of population, other studies with which to compare the cases in this study was found to demonstrate an finding at a national level are unavailable. inherited pattern of transmission, and the female group The presence of major neurological, psychological, experienced a higher proportion of NDs (63%) than the and neurodegenerative disorders in Pakistan, the sixth male group (37%).Of concern, the age group 31-50 largest population in the world, should not be assumed years were noted to account for a high proportion of to be absentnor speculated upon, due to the lack of cases (38.9%) as compared to other age groups, epidemiological data. Due to an improved health although NDs are generally a late onset disorder . infrastructure and facilitated access to health facilities, Schizophrenia affects about 1% of the population and life expectancy in Pakistan is increasing, which leads to an increasing population vulnerable to late onset is among the top 25 leading causes of disability neurodegenerative disorders such as Alzheimer's worldwide. Its prevalence varies by region and ethnic disease (AD), Huntington's disease (HD), Amyotrophic group .Our study has found that 2.7% of the study Lateral Sclerosis (ALS),and PD. These diseases may population has been diagnosed with schizophrenia, be prevalent in elderly people of Pakistan, but out of which almost 25% have a positive family history. available data do not exist to describe the These results cannot be compared with other studies, epidemiology and describe the population burden. due to unavailability of existing epidemiological data Although the presence of multiple sclerosis (MS) and regarding schizophrenia in Pakistan. Regarding PD, in Karachi and , has been documented schizophrenia, the burden did not vary significantly by at the hospital level. gender and most patients belonged to the 10-30-year The present study lays a foundation of data regarding age group. The substantial burden of this ND burden in this region to build a bank of data and psychological disorder affecting youth highlights the the gap in existing information about this morbidity experienced in this age group, as well as the neglected of disease epidemiology. In the health expected life-long, future morbidity. Previous studies policy framework of Pakistan, there is little focus on have reported that birth order, gender difference sand management and treatment of NDs due to lack of data age of on set influence diagnosis and disease regarding the epidemiology of NDs. It is recommended trajectory for schizophrenia in Pakistan population – . to conduct community based epidemiological studies About 2% of cases were found to be congenital in Pakistan. The findings of such studies will pave the anomalies, and distribution was similar between males way for health policies and fund ingallocation for and females. Due to varying results from different research, eradication, and improved treatment of NDs regions of Pakistan, the present results are in in Pakistan. accordance with some studies, 2.9% reported by et. al., 2015 , and contradictory to other results, for ACKNOWLEDGMENTS example Hussain et. al., 2014 , who reported that We are indebted to Prof. Dr. Ahmad , Dr. about 7% of neonates had congenital anomalies. In Azam Aslam, Dr. Naeem Ur , Dr. UK, researchers have noted that babies born to Irfan Ullah, Dr. Khalid Mahmood Yahya, Dr. Faisal of Pakistani origin are more prone to be Ghafoor, Dr. Irum Farooq, Mr. Muhammad Ilyas and affected with congenital anomalies as compared to Dr. Amir Sharif for their cooperation and support babies of mothers from other regions . Various factors regarding data collection. We also extend our thanks to such as malnutrition, consanguineous , Mr. Usama Nadeem and the pioneer batch of illiteracy, and unavailability of adequate health care the Department of Physiology, GCUF for their help.

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Author's contribution: Ghulam Hussain; concept, data collection, data analysis, manuscript , manuscript review Asif Shehzad; data collection, data analysis, manuscript writing, manuscript review Haseeb Anwar; data analysis, manuscript writing, manuscript review Muhammad Umar Sohaildata analysis, manuscript writing, manuscript review Shahid Mahmood Baig; data analysis, manuscript writing, manuscript review Asghar Shabbir; data analysis, manuscript writing, manuscript review Jose-Luis GONZALEZ DE AGUILAR;manuscript writing, manuscript review ; data analysis, manuscript review

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