The estimated prevalence of epilepsy in children in Camagüey Province (5.18 per thousand children) is lower than the prevalence in children and adults throughout Latin America (12.4)[3
] and in Brazilian children living in an area of high deprivation (8.7).[4
] It is, however, similar to the only previous study (published 30 years ago) looking at the prevalence of children with epilepsy in Cuba (7.5).[13
A limitation of this study is that the prevalence of epilepsy was estimated by the number of children receiving AEDs. Others have used questionnaires looking at the entire population.[4
] Using the number of patients receiving AEDs has previously been used in countries with good primary health care (Sweden and Denmark).[1
] Cuba has an excellent primary health care system.[11
] All children have a family doctor who routinely sees every child twice a year.[11
] This excellent system of primary health care, alongside integration between primary and secondary health care ensures that children with epilepsy are identified.
The low prevalence of epilepsy in Cuba has previously been noted.[3
] In children, contributory factors include: a comprehensive immunisation schedule; excellent antenatal care that is associated with a low prevalence of low birth weight babies;[14
] a low incidence of infectious diseases such as malaria, tuberculosis, schistosomiasis and cysticercosis.[15
The vast majority of the children (94%) were on a single AED only, which is widely accepted as best clinical practice. Carbamazepine and valproate were the two most frequently prescribed AEDs and they are the medicines recommended as first-line therapy, in both Cuba and the UK.[16
] Many children received magnesium valproate which is not extensively used in Europe. It is, however, widely used in Latin America and has been shown to have bioequivalence and similar efficacy to sodium valproate.[17
] It is considerably cheaper than sodium valproate and may actually have some advantages in that there is less inter-individual variation in plasma concentrations of valproic acid with magnesium valproate.[17
Access to medicines is a significant problem in low and lower-middle income countries. A study of 14 countries in Central Africa identified a significant lack of essential medicines for children in pharmacies and central medical stores with availability in retail or private pharmacies ranging from 38–62%.[10
] A recent study of epilepsy in Africa found that 30% of the patients with epilepsy and 73% of children never received treatment.[20
Access to AEDs in pharmacies in Camagüey is generally good for a lower-middle income country in that on 76% of occasions the AED was available. The USA has imposed an economic blockade on Cuba for the last 50 years, which makes it more difficult to obtain medicines as well as many items involved in the transportation of goods.[21
Three different formulations of valproate and phenobarbitone (sodium valproate syrup, magnesium valproate tablets and phenobarbitone tablets) were not available for between 2 and 5 weeks in the community pharmacies. All three formulations were, however, available at the hospital pharmacy. Hospital pharmacies will dispense AEDs free of charge in an emergency situation, i.e. if the community pharmacy does not have the AED in stock. The hospitals have enough medicines within their storerooms for at least two months. The most significant shortage related to magnesium valproate tablets, which were not available for 5 weeks.
Parents could go to an alternative pharmacy (including the hospital pharmacy) if the AED was unavailable or wait for a maximum of up to 2 days for the pharmacy to arrange transfer of the appropriate formulation from another pharmacy within the province. There is a weekly meeting within the province between the head of pharmacy and the companies involved in the distribution and storage of medicines to try and ensure that children continue to receive treatment.
Despite the successes of ensuring that children receive AED therapy, there are clearly issues that could be improved. Carbamazepine is not available in a liquid formulation. The only medicines available in a liquid formulation are sodium valproate, which is not recommended for children under the age of 3 years because of the risk of hepatotoxicity and the older AEDs (phenytoin, phenobarbitone and primidone) all of which have a higher incidence of side effects. Although health care itself is free within Cuba, parents still have to pay for AEDs for their children with epilepsy. The problems in Cuba in relation to access to AED therapy, however, are minor in comparison to many other lower middle-income countries throughout the world. The stigma of epilepsy is a major problem in many countries.[7
] Universal education plays a major role in combating stigma. As well as combating stigma, health professionals and health systems need to ensure that AEDs are readily available at pharmacies that are accessible and that the AEDs are sold at a price that is affordable to the majority of the population.