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IN HER LIFETIME: Female Morbidity and Mortality in Sub-Saharan Africa 5 Nervous System Disorders The evidence available for Sub-Saharan Africa suggests that the burden of nervous system disorders may be heavier in African communities than in comparable communities in other parts of the developing world (Osuntokun, 1970, 1971a; Spillane, 1973). There is also evidence that the burden of certain of these disorders may be heavier in females than in males. Because of their particular significance for females, it is these disorders, presented in Table 5-1, that are the focus of this chapter. They are: toxic and nutritional disorders, headache syndromes, cerebrovascular diseases associated with oral contraceptive use, epilepsies, demyelinating diseases, neurologic complications of collagen diseases, and impaired cognition and dementia. An exception to this picture of gender-distinctive burden is cerebral malaria, potentially a greater problem for females because of their heightened susceptibility during pregnancy. This condition is discussed in-depth in Chapters 4 and 10. LIFE SPAN PERSPECTIVE The female, like the male, is at risk of suffering from specific disorders of the nervous system at certain stages of life, although disease onset for a number of these disorders occurs over a wide spectrum of age. Table 5-2 provides a listing of nervous system disorders, by age category, that affect both African males and females. Because many of the nervous system disorders listed in Table 5-2 are believed to affect males and females equally over the life span, they are not discussed in this chapter. Other illnesses, such as tetanus and cerebral malaria, are reviewed elsewhere in this report (see Chapters 4 and 10, respectively). As noted above, this chapter focuses on the following nervous system disorders for which African females appear to be particularly susceptible or at risk: toxic and nutritional disorders, headache syndromes, cerebrovascular diseases associated with use of oral contraceptives, epilepsies, demyelinating diseases, neurologic complications of collagen diseases, and impaired cognition and dementia. The evidence for these disorders is presented below. TOXIC AND NUTRITIONAL DISORDERS OF THE NERVOUS SYSTEM Nutritional syndromes involving the nervous system are common in Sub-Saharan Africa. Protein-energy malnutrition may afflict 40 percent or more of preschool children at a stage when the maturation of the nervous system is still under way, and malnutrition can result in long-term or permanent damage to cognition and intellect
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IN HER LIFETIME: Female Morbidity and Mortality in Sub-Saharan Africa TABLE 5-1 Nervous System Disorders in Sub-Saharan Africa: Gender-Related Burden Disorder Exclusive to Females Greater for Females than for Males Burden for Females and Males Comparable, but of Particular Significance for Females Cerebrovascular diseases associated with oral contraceptive use X Demyelinating diseases X Epilepsies X Headache syndromes X Impaired cognition and dementia X Neurologic complications of collagen diseases X Toxic and nutritional disorders X NOTE: Significance is defined here as having impact on health that, for any reason—biological, reproductive, sociocultural, or economic —is different in its implications for females than for males. (de Mota et al., 1990; Grantham-McGregor et al., 1991; Lucas et al., 1990; Osuntokun 1972a; Pollitt and Thompson, 1977; Rush, 1984; Smart, 1986; Stocks et al., 1982). Onset of nutritional and toxic diseases of the nervous system, which include the tropical myeloneuropathies (Roman et al., 1987), are known to be precipitated by pregnancy and lactation. Wernicke's encephalopathy, caused by thiamine deficiency, is a known complication of severe morning sickness during pregnancy (hyperemesis gravidarum) and anorexia nervosa. Females also appear highly susceptible to effects of thiaminases in seasonal foods, such as those from the worm anaphe venata, commonly eaten in southwestern Nigeria and postulated as an etiological factor in seasonal epidemic ataxia (Ademolekun, 1993; Osuntokun, 1972b). Folate and iron deficiencies, often associated with pregnancy and lactation, may be important determinants of fetal morbidity and mortality in the Sub-Saharan region. During pregnancy there is a greater requirement for folate because of the increased rate of folate metabolism (McParklin et al., 1993). Folate deficiency is widespread in African women and can contribute to a variety of neuropsychiatric syndromes, including peripheral neuropathy, dementia, and depression. The incidence of neural tube defects caused by folic acid deficiency could be as high as 7 per 1,000 deliveries (Airede, 1992), and may well be increasing in areas where maternal malnutrition has increased and folate deficits are significant. It is now well established that periconceptional folate supplementation could prevent first occurrence of neural tube defects (Czeizel and Dudas, 1992; MRC Vitamin Study Research Group, 1991). There is also greater need for folate in subjects with chronic hemolytic disease, such as hemoglobin sickle-cell disease, which afflicts about 1 percent of the West African population, and malaria. Iron-deficiency is particularly common in Sub-Saharan Africa, and more common in females than in males. A major cause of iron-deficiency is hookworm infection, which afflicts millions of black Africans, especially in rural areas. Hookworm anemia is often unrecognized as an underlying cause of high maternal morbidity and mortality, apathy and poor health in children, and easy fatigability and impaired working capacity in adults (Pawlowski et al., 1991). Menorrhagia and pregnancy states predispose to iron-deficiency anemia. Other risk factors for iron-deficiency are the growth spurt of adolescence, with the accompanying burden of providing iron for an increased red cell mass and increased hemoglobin concentration; childhood, especially between the ages of 4 months and 3
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IN HER LIFETIME: Female Morbidity and Mortality in Sub-Saharan Africa TABLE 5-2 Disorders of the Nervous System in the African Female Across Her Life Span Time of Life Disorders Intrauterine Congenital malformations from maternal malnutrition and infections Cretinism from maternal iodine deficiency and goitrogenic diet, including cassava diet Low birthweight from maternal malnutrition may cause poor neurodevelopment, increased occurrence or risk in later life of high blood pressure; and mortality from cardiovascular disease, including stroke (Barker et al., 1989a,b; Edwards et al., 1993; Law et al., 1993, 1991; Seldman et al., 1991; Whincup et al., 1989) Infancy (0–1 year) Congenital malformations Impaired neurodevelopment from malnutrition Febrile convulsions Meningitides, encephalitides (including parainfectious encephalomyelitis), poliomyelitis Cerebral malaria Epilepsies Childhood (1–9 years) Cerebral malaria Meningitides and encephalitides (including parainfectious encephalomyelitis), poliomyelitis Epilepsies Migraine Cerebrovascular disease Lymphomas (especially Burkitt's) of nervous system Adolescence (10–19 years) Migraine Epilepsies Meningitides and encephalitides, cerebral abscess Adulthood (20–45 years) Epilepsies Migraine Meningitides, encephalitides, trypanosomiasis, cerebral malaria Head injuries Nutritional and toxic myeloneuropathies and peripheral nerve disorders Nervous system involvement from choriocarcinoma Polymyositis, myasthenia gravis Demyelinating diseases (often monophasic, as Devic's disease) Neurological complications of snake bites Menopause/late adulthood (46–65 years) Cerebrovascular disease Migraine Nutritional and toxic myeloneuropathies and peripheral nerve disorders Epilepsies Spinal cord and spinal nerve root disorders secondary to osteodegenerative disease of vertebral column Brain and spinal cord neoplasms (primary and secondary) Head injuries Polymyalgia rheumatica, temporal arteritis Elderly (> 65 years) Cerebrovascular disease Spinal cord and spinal nerve root disorders secondary to osteodegenerative disease of the vertebral column (spine) Brain and spinal cord neoplasms Head injuries Parkinson's disease Cognitive impairment/dementia
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IN HER LIFETIME: Female Morbidity and Mortality in Sub-Saharan Africa years, with the rapid rate of growth and increase in red cell mass; and diets consisting primarily of whole grain cereal and legumes with a rich iron content that is not readily absorbable. With the vital role of iron in the fundamental metabolism of the cells (including the neurons), it is not surprising that increasing evidence indicates that impaired psychomotor development and intellectual performance and changes in behavior result from even mild iron-deficiency, particularly in infants between 6 months and 2 years of age (Lozoff, 1988). Such infants showed significant decreases in responsiveness and activity, increased body tension, fearfulness, and tendency to fatigue (Lozoff et al., 1982a,b; Oski et al., 1983; Walter et al., 1983), and there is some evidence that these abnormalities may persist after correction of iron-deficiency. The deficiency of riboflavin common in African women has been associated with endogenous and neurotic depression, and pyridoxine deficiency has been linked to peripheral neuropathy and affective illness (Carney, 1990). Use of oral contraceptives also contributes to pyridoxine deficiency and may increase existing nutrition-related deficits (Stamp, 1993). In some parts of Africa, endemic cretinism is widespread and is the result of iodine deficiency, further conditioned by a cassava diet. A neurodegenerative syndrome linked to a cassava diet is also endemic in some countries (Monekosso and Wilson, 1966; Osuntokun, 1968, 1981b) and occurs in epidemics, especially at times of drought, as reported from Mozambique, Tanzania, and Zaire (Carton et al., 1986; Cliff et al., 1986; Essers et al., 1992; Howlett et al., 1990, 1992; Mozambique, Ministry of Health, 1984; Rosling, 1986; Rosling et al., 1988; Tylleskar et al., 1992). Evidence that indicates a disproportionate occurrence of these disorders in females is lacking. Poor nutritional status may also enhance the neurotoxicity of the cyanogenic glycosides, found in cassava, manihot, millet, and other dietary items commonly consumed in some parts of Sub-Saharan Africa (Osuntokun, 1968, 1981b); the organophosphates commonly used as pesticides; and some frequently used drugs, including isoniazid, ethambutol, nitrous oxide, chloramphenicol, metronidazole, phenytoin, dapsone, chloroquine, vincristine, and nitrofurantoin (Osuntokun, 1986). Again, there are no data indicating an unusual burden of these disorders in females. HEADACHE SYNDROMES The prevalence of headache syndromes exceeds 50 percent, and the incidence of migraine is 6 percent or higher even in rural communities (Joubert, 1992; Levy, 1983; Lisk, 1987; Longe and Osuntokun, 1988; Osuntokun and Osuntokun, 1972; Osuntokun et al., 1982b,c, 1987b, 1992b). In some parts of Africa, migraine and tension headache are the most common modes of presentation of headache, in the community as well as in the hospital (Osuntokun, 1971b). Migraine Both common and classical migraine are predominantly diseases of women, with female-to-male ratios ranging from 5:2 in hospital case series, to 2:1 in two rural communities, and 6:5 in urban community studies in Nigeria. In one Nigerian study, in a sample of 19,000 people, the female predominance was high in patients under the age of 30 years, but the age-specific incidence rates in males and females over age 30 were comparable (Osuntokun et al., 1992b; see Table 5-3 below). A community-based study among the Zulus in Natal, South Africa, found a prevalence of migraine of 8.8 percent, with a female-to-male ratio of 10:1 (Joubert, 1992). Evidence suggests that migraine, particularly common migraine as defined by the International Headache Society (IHS, 1988), is influenced by hormonal changes associated with menarche, ovulation, and menstruation, which may account for the increased susceptibility of females to migrainous headaches. Contraceptive pills may also precipitate migraine, which may then continue despite stopping the pills. The relationship of migraine to hormonal levels is complex: some individuals experience reduction in migraine during pregnancy; in others, the headaches are worse; and in a third group, the headaches reappear soon after childbirth. Unlike Caucasian patients, who suffer from cluster headaches with a male-to-female ratio of 5:1 or higher, Nigerian females outnumber males among patients with cluster headaches
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IN HER LIFETIME: Female Morbidity and Mortality in Sub-Saharan Africa TABLE 5-3 Migrainous Headaches in Nigerian Africans—Age-Specific Prevalence Ratios Cases per 100 Persons Age Group (years) Male Female 0–9 10–19 20–29 30–39 40–49 50–59 60–69 > 70 Age unknown 10.2 1.8 1.3 3.1 3.8 3.9 5.4 2.9 2.1 10.6 4.0 3.4 3.3 3.8 2.2 4.0 4.7 5.0 Total 5.03 5.64 (Osuntokun, 1971b; Osuntokun et al., 1982a). Nigerian migraine sufferers with hemoglobin AS genotype (usually symptomless, apart from being susceptible to painless hematuria from is chemicrenal papillitis) are significantly liable to suffer from complicated migraine (Osuntokun and Osuntokun, 1972). HBAS has a frequency of 25 percent in West Africans. Among Nigerian migraine sufferers, the relative risk of epilepsy ranged from 2 to 3.2 (Osuntokun, 1971a; Osuntokun et al., 1982b). Among Caucasians, epilepsy is said to be two to six times more common in people who suffer migraines compared with people who do not (Basser,1969; Hannington, 1974). Tension Headache As in Caucasians, there is an excess of females among Africans who suffer from tension headaches as defined by the IHS. In the Zulu study, all 19 patients who suffered from tension headache were females (Joubert, 1992). Among Nigerians, tension headache is twice as frequent as migraine (Osuntokun, 1971a,b), in contrast to subjects in the Zulu study, who experienced migraine with nearly four times the frequency of tension headache (Joubert, 1988; 1992). CEREBROVASCULAR DISEASES AND USE OF ORAL CONTRACEPTIVES Cerebrovascular disease, such as stroke (subarachnoid hemorrhage, cerebral hemorrhage, cerebral infarction, hypertensive encephalopathy), is now as common in most communities in Africa as in the developed countries (Abraham and Abdulkadir, 1981; Bahemuka, 1989; Danesi et al., 1983; Lester, 1982; Matenga et al., 1986; Putterpill et al., 1984). In a community-based study in Nigeria, the age-specific incidence rates of stroke or cerebrovascular accident were comparable to rates in the Caucasian populations in Europe and among the Japanese (Osuntokun et al., 1979). Some analysis has suggested that the age-adjusted mortality rate for stroke in a Nigerian community may surpass that of the United States (Osuntokun, et al., 1987b). In Ethiopia, Ghana, Kenya, Nigeria, Senegal, and Uganda, stroke constitutes between 4 and 10 percent of all causes of death (Osuntokun, 1980). Since the mid-1960s, a vast amount of epidemiologic, clinical, and laboratory evidence in developed countries has linked the current use of combined oral contraceptives with certain types of cardiovascular disease (CVD), especially venous thromboembolism, thrombotic stroke, myocardial infarction, subarachnoid hemorrhage, and hypertension (Irey et al., 1978; Lancet, 1979; Stadel, 1981; Thorgood et al., 1981; Vessey, 1982). Whether these findings from the developed countries can be extrapolated to black African countries is debatable. To date, no valid epidemiologic data link the use of the oral contraceptives by black Africans to increased CVD risk, although it is unlikely that the metabolic changes (Fotherby, 1989) that occur in women using oral contraceptives and
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IN HER LIFETIME: Female Morbidity and Mortality in Sub-Saharan Africa described in the communities of the developed countries would be different from those in African women. It is also true that the smaller-dose oral contraceptives that are now the norm are associated with a lower CVD risk than the formulations common in the 1970s and 1980s. OTHER NEUROLOGICAL DISORDERS Epilepsies The prevalence ratios of epilepsy per 1,000 range from 5 to 42 in Sub-Saharan Africa, compared with 5 to 8 in developed countries (Feksi et al., 1991a,b; Gerritts, 1983; Goudsmit et al., 1983; Jilek and Aall-jilek, 1970; Osuntokun, 1992; Osuntokun et al., 1987a; Tekle-Haimanot, 1990). Data suggest that epilepsy has a higher prevalence in poor, deprived communities in Sub-Saharan Africa than in communities with improved socioeconomic status and adequate access to health care facilities (Osuntokun, 1992; Sorvon and Farmer, 1988). The high prevalence of epilepsy in Sub-Saharan Africa and other developing countries may stem from a high frequency of birth trauma and other forms of head trauma; infective, including parasitic, diseases (such as cysticercosis and cerebral malaria) of the central nervous system; febrile convulsions; and encephalopathies complicating the childhood exanthematas. Immunization against the childhood infections appeared to protect against epilepsy (Ogunniyi et al., 1988). In some cultures it is believed that epilepsy is incurable because it is a manifestation of some divine intervention; hence many African epileptics do not seek modern treatment. Fortunately, drug treatment has proven as effective here as in the developed countries, regardless of whether anticonvulsant therapy was started early or late (Feksi et al., 1991b; Ogunniyi and Osuntokun, 1991). In Africa as elsewhere, about 70 percent of epileptics properly treated in the first year of the occurrence of seizures can go on to be seizure-free. Low compliance with a drug regimen remains a significant problem, however, and appropriate drugs are often unavailable or are too costly to be affordable for the vast majority of patients. Community surveys indicate that many epileptics are not under any form of treatment because of widespread inadequacy of the health care system. In most African countries, epilepsy continues to incur considerable social disadvantage and to cause major disruption in the sufferers' lives. With respect to epilepsy and gender, there is a male preponderance of black African epileptics seen in hospitals, with the exception of two reports from Uganda and South Africa that documented female preponderance in a small series of 83 (38 males and 45 females) and 50 (21 males and 29 females) patients, respectively. Evidence from three Nigerian community-based studies indicating an excess of female over male epileptics, however, support the possibility that the disorder may occur more frequently in females than males in the region (Longe and Osuntokun, 1989; Osuntokun et al., 1982b, 1987b). Demyelinating Diseases In Africans, as in Caucasians, disseminated myelitis with optic neuritis (neuromyelitis optica, Devic's disease) affects both sexes equally (Osuntokun, 1971a; Spillane, 1973). Of the few anecdotal cases of multiple sclerosis reported in Africans, females are in slight excess (Collomb et al., 1970; Kanyerezi et al., 1980; Lisk, 1991; Tekle-Haimanot, 1985). Among Caucasians in most published series, males have been affected more often than females by multiple sclerosis, but the disease often begins earlier and runs a more rapid course in females (Acheson, 1972). Neurologic Complications of Collagen Diseases Collagen diseases appear to be relatively uncommon in black Africans, among whom the prevalence of autoimmune disorders is lower than in Caucasians; polymyositis/dermatomyositis, whether idiopathic or secondary to an underlying neoplasm (which may be occult), is the third most common disease of muscles after pyomyositis and the muscular dystrophies in black Africans. As in Caucasians, females predominate among
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IN HER LIFETIME: Female Morbidity and Mortality in Sub-Saharan Africa African patients with polymyositis/dermatomyositis, with a female-to-male ratio of 2:1 (Osuntokun, 1971a; Spillane, 1973). The neurological manifestations of systemic lupus erythematosus (SLE) are protean. SLE, like neurosarcoidosis, is several times more common in black Americans whose ancestral home is West Africa than in white Americans, but is relatively uncommon in black Africans. SLE is predominantly a disease of females, with female-to-male ratios ranging from 5:1 to 9:1. The female-to-male ratio in polymyalgia rheumatica is 2:1. There is a slight excess of females among patients with polyarteritis nodosa and giant cell arteritis (temporal arteritis); the latter often coexists with polymyalgia rheumatica. Dementia The most common cause of dementia in the elderly, Alzheimer's disease, is an age-related disorder for which age is the prime risk factor. Because females live longer than males in almost every society, there are more females than males overall who suffer from Alzheimer's disease (Jorm, 1990), but analysis of dementia prevalence studies showed no overall gender difference (Jorm et al., 1987). Nevertheless, when studies of specific dementing diseases were analyzed, both prevalence ratio and incidence rates for Alzheimer's disease tended to be higher among females than males, whereas for vascular dementia they tended to be higher for males. The longevity revolution, or greying of the population, that has contributed to increasing rates of age-related dementias in developed countries is also occurring in the developing countries, where 52 percent of the world's population of 400 million individuals older than 65 years now live. It is estimated that this proportion will increase to 75 percent by 2020. Of the worldwide monthly increase of 1 million elderly (65 years or older), 80 percent are in the developing countries, including Africa (WHO, 1984). The elderly already exceed 5 percent or more of the population of some African countries, so it is increasingly important to determine and monitor patterns of epidemiological transition that have particular meaning for the elderly cohorts. Sub-Saharan countries would benefit if ongoing transcultural research (Evans, 1992; Osuntokun et al., 1992a) were to identify some preventable causes of the dementias of the elderly, particularly Alzheimer's disease, before the ''epidemic" raging in the developed world hits Africa. CONCLUSIONS Evidence concerning the contribution of nervous system disorders to the overall burden of disease and disability in females in Sub-Saharan Africa is fragmentary, but disturbing. Data from the few well-conducted neuroepidemiologic studies in the region emphasize the great disability and mortality from disorders of the nervous system that will be experienced by African females during their lifetime, and these, in combination with the other evidence presented in this chapter, suggest that the burden of neuropsychiatric disorders is probably heavier in African communities than in other parts of the world. Table 5-4 presents the times in the life span when the major nervous system disorders discussed in this chapter occur in Sub-Saharan African females. Toxic and nutritional disorders occur more frequently early in life, but are evident throughout the life span; this suggests that they may contribute in an important manner to the overall burden of neurologic disease in the region. Similarly, while the epilepsies appear to predominate in females under the age of 30 years, their chronicity and effect may lead to substantial disability in later life. The headache syndromes occur most commonly in adolescence and adulthood; their sequelae, in contrast, appear to be limited. The onset of cerebrovascular diseases, predominantly stroke, is most common in adulthood. If not fatal, however, the initial disease episode can be expected to result in substantial subsequent disability in many cases. The demyelinating and collagen diseases and dementias are, for the most part, disorders of older adulthood, and their adverse impact on mobility and health status in general can be expected to parallel those of older women in the developed world. RESEARCH NEEDS The nature, extent, and sequelae of nervous system disorders in Sub-Saharan African females (and males)
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IN HER LIFETIME: Female Morbidity and Mortality in Sub-Saharan Africa TABLE 5-4 Ages of Occurrence of Nervous System Disorders and Their Sequelae in Sub-Saharan African Females In Utero Early Childhood (birth through age 4) Infancy/ Childhood (ages 5–14) Adolescence (ages 15–19) Adulthood (ages 20–44) Postmenopause (age 45+) Toxic and nutritional disorders Toxic and nutritional disorders Toxic and nutritional disorders Toxic and nutritional disorders Toxic and nutritional disorders Headache syndromes Headache syndromes Oral contraceptive- related cerebrovascular diseases Oral contraceptive- related cerebrovascular diseases Epilepsies Epilepsies Epilepsies Demyelinating diseases Neurologic complications of collagen diseases Dementias require elucidation. Research attention should be directed toward identification of major risk factors for the more important nervous system disorders in females and development of cost-effective strategies for disease prevention. The prevalence of epilepsies is much higher in Sub-Saharan countries than in developed countries, and there is preliminary evidence that suggests the disorder may be more common in females. There is a need to identify risk factors for epilepsy in Africans and ways to reduce subsequent morbidity and mortality (for example, from falls, household burns, and the like). Evidence suggests that the frequency and mortality from stroke are increasing in Sub-Saharan countries (unlike developed countries, where they are decreasing). Research is needed to identify major risk factors for stroke in women and to determine the feasibility and effectiveness of different preventive intervention measures— for example, control of high blood pressure, the most common risk factor for stroke, and to assure that all available oral contraceptives are of mini-dosage. There is a need to better characterize the extent and severity of nutrition-related toxic syndromes of the nervous system in Sub-Saharan African populations. Nutrition research and intervention activities should be directed, in part, toward reducing the incidence of and morbidity from these disorders. Research is also needed to determine how best to incorporate the management (identification, treatment, and prevention) of the common neurologic diseases of females (and males) into primary health care. Means for training and supervision of nonphysician personnel in this capacity should be developed and assessed. REFERENCES Abraham, G., and J. Abdulkadir. 1981. Cerebrovascular accidents in Ethiopians: a review of 48 cases. E. Afr. Med. J. 58:431–436. Acheson, E. D. 1972. The epidemiology of multiple sclerosis. In Multiple Sclerosis: A Reappraisal. D. McAlpine, C. E. Lumsden and E. D. Acheson, eds. Edinburgh: Churchill-Livingstone. Ademolekun, B. 1993. Anaphe venata entamophagy and seasonal ataxic syndrome in Southwest Nigeria. Lancet 141:629.
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Representative terms from entire chapter: