Review

Epidemiology, aetiology, and clinical management of

epilepsy in Asia: a systematic review
Tu Luong Mac, Duc-Si Tran, Fabrice Quet, Peter Odermatt, Pierre-Marie Preux, Chong Tin Tan

Epilepsy is a significant, but often underappreciated, health problem in Asia. Here, we systematically review the Lancet Neurol 2007; 6: 533–43
literature on epidemiology, aetiology, and management of epilepsy in 23 Asian countries. Prevalence estimates are Institute of Neurological
available for only 11 countries from door-to-door surveys and are generally low. Figures for annual incidence in China Epidemiology and Tropical
Neurology, Limoges, France
and India are similar to those in the USA and Europe but lower than those reported from Africa and Latin America.
(T L Mac, F Quet, P-M Preux);
There is a peak in incidence and prevalence in childhood, but a second peak in elderly people, as seen in developed French-Speaking Institute for
countries, has not been documented. The main causes are head injuries, cerebrovascular disease, CNS infections, Tropical Medicine, Vientiane,
and birth trauma. Availability of epilepsy care depends largely on economic factors. Imaging and neurophysiological Laos (D-S Tran); Department of
Public Health and
facilities are available in most countries, but often only in urban centres. Costly drugs, a large treatment gap, limited
Epidemiology, Swiss Tropical
epilepsy surgery, and negative public attitude to epilepsy are other notable features of management in Asia. An Institute, Basel, Switzerland
understanding of the psychosocial, cultural, economic, organisational, and political factors influencing epilepsy (P Odermatt); and Division of
causation, management, and outcome should be of high priority for future investigations. Neurology, University of
Malaya, Kuala Lumpur,
Malaysia (C T Tan)
Introduction Mongolia, Burma, Nepal, Pakistan, the Philippines,
Correspondence to:
Epilepsy is a disorder of the brain that is characterised by South Korea, Singapore, Sri Lanka, Thailand, East Timor, Pierre-Marie Preux, Institut
an enduring predisposition to generate seizures and by and Vietnam. All issues of Neurology Asia and of the d’Epidémiologie Neurologique et
its neurobiological, cognitive, psychological, and social national medical journals of Korea (Journal of Korean de Neurologie Tropicale,
(EA3174), Faculté de Médecine,
consequences.1 WHO estimates that eight people per Medical Science), Singapore (Singapore Medical Journal)
2 rue du Docteur Marcland,
1000 worldwide have this disease.2 The prevalence of and India (Neurology India) were hand-searched with the 87025 Limoges Cedex, France
epilepsy in developing countries is usually higher than in same criteria. Articles were included if they had at least pierre-marie.preux@unilim.fr
developed countries.3–5 an abstract in English or French. We included only
Although substantial economic development and studies reaching the recommendations of the
improvement of health services have occurred, Asia is a International League Against Epilepsy (ILAE) 1993
heterogeneous and resource-constrained continent. Over Commission.8 Background references were identified
half of the 50 million people with epilepsy worldwide are through these searches and through searches of the
estimated to live in Asia. Although much research is authors’ own files.
done in Asia, information about the recognition of the
burden created by the disease is scarce. In 1997, Jallon6 Data collection and analysis
reviewed studies from Asia, mostly done in the 1980s, A total of 1348 articles from 20 countries were found
and showed a prevalence varying from 1·5 per 1000 in using PubMed. No publications were found from Bhutan,
Japan to 10·0 per 1000 in Pakistan. Here, we provide an Brunei, or North Korea. Most articles originated from
update on prevalence, incidence, demographic data, Japan (460 articles), India (343 articles), and China
types of epilepsy, aetiology, treatment, and prognosis in (165 articles). Articles were assessed by the first two
recent years to give a comprehensive view of epilepsy in authors searching in each survey for methods and results
this region. on prevalence, incidence, demography, classification,
causes, treatment, and knowledge, attitudes, and practice.
Methods Data from 119 articles were collected for this Review (see
Search strategy and selection criteria figure for more detail on the selection process).
We searched the PubMed database by using the keyword
“epilepsy”, combined with each of the following: Results
“epidemiology”, “prevalence”, “incidence”, “aetiology”, Prevalence
and “treatment” for each Asian country. Other words The lifetime prevalence of epilepsy varied among
were also used in association with the keywords. These countries from 1·5 to 14·0 per 1000 (table 1).9–30 This wide
were “malaria”, “neurocysticercosis”, “cysticercosis”, variation could partly result from the use of different
“encephalitis”, “classification”, “mortality”, “therapy”, methods and different types of questionnaire. Screening
“antiepileptic”, “AEDs”, “surgery”, “chirurgical”, questionnaires were mainly derived from WHO
“recurrence”, “prognosis”, “stigma”, “stigmatization”, questionnaires, but two studies used Limoges’
“knowledge”, and “awareness”. Asian countries (n=23) questionnaire.19,28 The median lifetime prevalence is
were defined as the countries of the WHO Western estimated at 6 per 1000, which is lower than in developing
Pacific region and WHO Southeast Asian region:7 countries in other areas of the world (15 per 1000 in sub-
Bangladesh, Bhutan, Brunei, Cambodia, China, North Saharan Africa and 18 per 1000 in Latin America).4,5 An
Korea, India, Indonesia, Japan, Laos, Malaysia, Maldives, understanding of these differences could generate

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 Review

hypotheses for studies aimed at identifying ways to

Initial PubMed search prevent this disease: for example, is there a protective
factor in Asia or specific risk factors in Africa or Latin
America?
1348 articles

Incidence
1039 articles excluded:
228 not written in French or English
Incidence rates were available from only two countries,
143 no abstract China and India; of the five estimates, three were based
308 non-epilepsy studies* on retrospective analyses of collections of prevalence data
360 non-epidemiological studies†
(table 2).9,12,17,18,31 The epilepsy incidence rates reported from
China were low—from 28·8 per 100 000 person-years9 to
309 articles that may contain
relevant data 35·0 per 100 000 person-years in the general population.12
The results from India were higher, and reached 60·0 per
Full-text collection via: 100 000 person-years.31 Overall, the results were not
Hinari, Science Direct, Epilepsia, different from those in developed countries where the
The New England Journal of Medicine,
Medscape Infectious Diseases
age-adjusted incidence of epilepsy is 24–53 per 100 000
person-years.32 Some authors report an incidence rate in
190 articles excluded because the full text
developing countries that is as high as 190 per 100 000
was not available or because they did person-years.33,34 Confirmation of low incidence rates in
not contain information relevant to this Asia would be very important, and rigorous population-
systematic review
based prospective studies are needed.
Data collection from 119 references
Demographic indicators
Age
Figure: Study selection for the systematic review The publications included in this Review show one peak
*Articles that were not specifically on epilepsy in Asia, except analytical studies on age for incidence in children19,26 and one peak age for
epilepsy risk factors. †Articles that were not within the framework of this review.
prevalence in young adults.12–13,16,19,35–38 However, one study,
done in Shanghai, showed two prevalence age peaks: one
between 10 and 30 years old and one in people over
Reference Year N Prevalence/1000 Method
60 years old.11 These figures are summarised in
China (five provinces) 9,10 2002 and 55 000 7·0 Door-to-door survey
table 3.11,13,16,19,26,35–38
2003 4·6*
In developed countries, the incidence and prevalence
China (Shanghai) 11 2002 48 628 3·6* Door-to-door survey
of epilepsy both follow a bimodal distribution with a first
China (six cities) 12 1985 63 195 4·4 Door-to-door survey
peak in childhood and another in old age.32,39,40 The most
India (West Godavari) 15 2004 74 086 6·2 Door-to-door survey
probable reason for the missing peak in the older age
India (Kerala state) 16 2000 238 102 4·7† Door-to-door survey
groups in many Asian countries is the relatively young
India 18 1998 64 963 3·9† Door-to-door survey
population compared with that in more developed
India 29 2006 50 617 3·8† Door-to-door survey
regions.
Laos 19 2006 4310 7·7† Door-to-door survey
Turkey 26 1997 11 497 7·0† Door-to-door survey
Sex
Pakistan 21 1994 24 130 10·0† Door-to-door survey
Epilepsy is slightly more common in men than in women
Vietnam 28 2005 6617 10·7† Door-to-door survey but the sex-specific prevalence is not, in general,
Nepal 20 2003 4636 7·3 Community based significantly different (table 4).11,13,18–20,23,26,35,38
Taiwan 24 1997 10 058 2·4 Community based
Taiwan 30 2001 13 663 2·8† Community based Location
Thailand 25 2002 2069 7·2 Community based Two studies (in Pakistan and in India) indicated that the
Singapore 22 1997 20 542 5·0 Men at 18 years old prevalence was higher in rural areas than in urban areas.26,29
Singapore 23 1997 96 047 3·5 Review <9 years Although not significant, a meta-analysis of published and
Hong Kong 13 2003 NA 1·5 Estimation in adult non-published community-based studies in India showed
patients (≥15 years)
a higher prevalence of 5·5 per 1000 (95% CI 4·0–6·9) in
Vietnam 27 2003 NA 14·0 Estimation rural areas than that of 5·1 per 1000 (3·5–6·7) in urban
India 14 2003 NA 5·6 Review areas.35 Indeed, a higher prevalence in rural areas is a
India 17 2002 NA 5·0 Review common tendency in developing countries.6
N=sample size. NA=not available. *Active epilepsy (seizures within the previous year). †Active epilepsy (seizures within
the previous 5 years). Otherwise, details of disease duration were not available. Mortality
Data on mortality rate in Asian people with epilepsy are
Table 1: Prevalence of epilepsy in Asia
scarce, and those that are available indicate high rates in

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 Review

adequately treated and Laos is one of the least developed

Reference Year N Incidence/ Method
100 000 countries in this region. A recent study found a standardised
person-years mortality ratio of 3·9 among 2455 people with epilepsy
China (five 9 2002 55 616 28·8 Door-to-door who participated in an assessment of epilepsy management
provinces) survey at the primary health-care level in rural China.41 Mortality
China 12 1985 63 195 35·0 Door-to-door is also usually high in developing countries in other
survey regions of the world: 28·9 per 1000 person-years in a rural
India 18 1998 64 963 49·3 Door-to-door area of Cameroon42 and 31·6 per 1000 person-years in rural
survey
central Ethiopia.43 Other studies should be done to confirm
India 31 1999 NA 60·0 Estimation
this higher mortality rate in Asia, which might partly
India 17 2002 NA 38·0–49·3 Review
explain the low prevalence rate.
N=sample size. NA=not available. By contrast, mortality in the most developed countries
in Asia is low. A study of childhood epilepsy in a Japanese
Table 2: Incidence of epilepsy in Asia
general population showed a mortality of 45·0 per 1000
people accumulated over a long follow-up period (mean:
developing countries in this region. In one study in Laos, 18·9 years).44 Another study in adult Taiwanese patients
there was a very high case-fatality rate of 90·9 per 1000 showed a mortality of 9 per 1000 person-years.45 Patients
person-years.19 This study was in a mountainous region, in with epilepsy in Taiwan had a nearly 3·5 times higher
which very few people had access to antiepileptic drugs. risk of death than the general population (standardised
These data came from a management project after door-to- mortality ratio 3·47, 95% CI 2·46–4·91).46
door screening. The number of patients followed-up was Other researchers examined the outcome in convulsive
small, but the results might not be too far from the real disorders in a more indirect way: an analysis of 37 125 death
mortality rate, because almost all patients in Laos were not certificates in Sri Lanka since 1967 found death by

Reference Year Age peak (years) Mean age of % children N Method

onset (years) (<18 years)
China (Shanghai) 11 2002 10–30, >60 NA NA 151 Door-to-door survey
India 16 2000 10–19 NA NA 1175 Door-to-door survey
Laos 19 2006 11–20 NA NA 33 Door-to-door survey
Pakistan 26 1997 NA 13·3 74·3 241 Door-to-door survey
Turkey 26 1997 NA 12·9 72·0 81 Door-to-door survey
Hong Kong 13 2003 25–30 19·9 NA 736 Adult patients in hospital
India 37 1999 NA 14·3 NA 972 Hospital-registered patients
India 35 1999 10–19 NA NA 525 Review
Bangladesh 36 2004 16–31 NA NA NA Review
Hong Kong 38 1997 NA 18·8 NA 2952 Review of outpatient records

N=number of patients with epilepsy. NA=not available.

Table 3: Age distribution of patients with epilepsy in Asia

Reference Year Male (%) Female (%) Male prevalence Female prevalence N Method
(‰) (‰)
China (Shanghai) 11 2002 NA NA 3·6 2·5 151 Door-to-door survey
Turkey 26 1997 54·3 45·7 8·7 6·3 81 Door-to-door survey
India 18 1998 NA NA 4·4 3·4 254 Door-to-door survey
Laos 19 2006 60·6 39·4 NA NA 33 Door-to-door survey
Pakistan 26 1997 49·8 50·2 9·2 10·9 241 Door-to-door survey
Nepal 20 2003 NA NA 6·8 7·9 34 Community based
Hong Kong 13 2003 57·1 42·9 NA NA 736 Adult patients in hospital
Hong Kong 38 2001 54·3 45·7 NA NA 2952 Review of outpatient records
Singapore 23 1997 50·1 49·9 3·5 3·5 336 Review <9 years
India 35 1999 NA NA 5·9 5·5 3207 Meta-analysis

N=number of patients with epilepsy. NA=not available.

Table 4: Gender proportions and gender-adjusted prevalence in patients with epilepsy in Asia

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 Review

convulsions in 23·7 per 1000.47 The most common cause,
febrile convulsions, was documented in 396 (44·9%)
deaths. Neonatal and infantile convulsions accounted for
186 (21·1%) deaths. Other causes of death associated with
seizures included chest complications (60; 6·8%), drowning
(28; 3·2%), asphyxia (20; 2·3%), status epilepticus (19;
2·2%), burns (7; 0·8%), and poisoning (2; 0·2%).47 In this
study, deaths due to convulsive disorders showed a decrease
from 37·3 per 1000 people in 1967 to 9·5 per 1000 people in
1987.47 Mortality from status epilepticus in patients in a large
community hospital in Hong Kong from 1996 to 2001 was
16·0%. Predictors of mortality were older age (OR 1·04,
95% CI 1·01–1·07), a delay in starting treatment (3·52,
1·01–12·18), status epilepticus due to cerebrovascular
disease (9·73, 1·58–59·96), and CNS infection (30·27,
3·14–292·19).48 Complications related to steroid treatment
in West syndrome were also an important cause of death as
seen in Hong Kong.49 Specific mortality rates for the main
causes of death must be estimated in Asia to enable better
prevention.
Prognosis
In general, a third to two-thirds of patients will have
recurrent seizures within 5 years of the first unprovoked
seizure.50,51 Similar recurrence rates are seen in Asia. A
study in Thai children showed a cumulative risk of
recurrence of 25% at 14 days, 50% at 4 months, 51% at
6 months, and 66% at 12 months.52 In children treated for
epilepsy, follow-up after withdrawal of antiepileptic drugs
(average duration 43·5 months) showed a cumulative
risk of recurrence of 10% at 12 months and 12% at
36 months.53 The need for two AEDs to control seizures
was a risk factor for recurrence (incidence 0·025 vs 0·002,
p=0·001).53 Another study in India noted seizure
recurrence in 31% of patients (of all ages) during a follow-
up period of 18 months. Longer duration of active
epilepsy (relative risk 2·86, 95% CI 2·35–3·48) and a
higher number of seizures before seizure control (1·50,
1·30–1·73) increased the risk of recurrence. Seizure-free
duration before beginning drug withdrawal (2 years vs
4 years) did not significantly influence this risk.54
Surgery for intractable temporal-lobe epilepsy led to
good results in a study in Indonesia.55 Of 56 patients
who had anterior temporal lobectomy with amygdalo-
hippocampectomy, 46 patients (82·0%) were seizure-free
(Engel I). Six patients (11%) had fewer than two seizures
per year (Engel II), and seizures decreased by more than
75% (Engel III) in four patients (7%). Complications
included extradural empyema in five patients (9%),
depression in two patients (4%), and transient
hemiparesis in one patient (2%). 31 patients were able to
stop taking antiepileptic drugs. The follow-up varied
between 12 and 76 months. This is the only description
found in Asia on epilepsy surgery, an efficient solution
for intractable epilepsy. Few patients in Asia can benefit
from this therapy even if it is available in several countries
(see Surgery section).
Clinical classification
Numerous clinical studies have been published but few
have described the distribution of seizure types in
community-based studies. In addition, comparison of
the results from different studies is difficult because
classifications used are not homogeneous. Here, we
present only the results based on the 1981 ILAE
classification (table 5).13,16,19,22,38,49,56–59
The range of patients with generalised seizures was
50–69%, and 31–50% had partial seizures.16,19,22,56 The
prevalence rates of symptomatic, idiopathic, and
cryptogenic epilepsy were 22–53%, 4–42%, and 13–60%,
respectively.13,19,38,49,56,59 The predominance of generalised
epilepsy and wider range of cryptogenic epilepsy may be

Reference Year Seizure type classification Aetiological classification N Method

GS FS US IE CE SE
India 16 2000 58·8 30·6 NA NA NA NA 1175 Door-to-door survey
Laos 19 2006 63·6 27·3 9·1 27·3 48·5 24·2 33 Door-to-door survey
Hong Kong 13 2003 NA NA NA 38·7 13·6 38·7 736 Adult patients in hospital
Hong Kong 49 2001 NA NA NA 18·0 22·0 53·3 105 Children with West syndrome
Hong Kong 38 2001 NA NA NA 3·9 59·9 35·1 2952 Review of outpatient records
Hong Kong 56 2001 49·5 48·2 2·3 42·4 16·8 40·8 309 Child patients
India 57 2005 42·0 58·0 NA NA NA NA 112 PWE with follow-up >12 months at tertiary care
epilepsy centre and aged >16 years
Malaysia 58 1993 86·0 14·0 NA NA NA NA 593 Adult patients with EEG
Malaysia 58 1993 92·0 8·0 NA NA NA NA 593 Child patients with EEG
Malaysia 59 1999 NA NA NA 78·0* 22·0 165 Newly diagnosed epilepsy
Singapore 22 1997 69·0 31·0 NA NA NA NA 106 All epilepsy
Singapore 22 1997 29·0 64·0 7·0 NA NA NA 14 Refractory seizures

GS=generalised seizures. FS=focal seizures. US=unclassified seizures or multiple seizure types. IE=idiopathic epilepsy. CE=cryptogenic epilepsy. SE=symptomatic epilepsy.
N=number of patients with epilepsy. NA=not available. PWE= people with epilepsy. EEG=electroencephalogram. *This figure applies to IE and CE combined.

Table 5: Clinical classification of patients in studies on epilepsy in Asia

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due to differences in the extent of imaging studies and
the lack of standardised classification and terminology in
epilepsy research in Asia. Electroencephalographic data
were often not available, which could also have influenced
the proportions of idiopathic epilepsy reported in several
studies. Population-based studies with electroencephalo-
graphic recording are required to enable accurate clinical
classification of epilepsy in Asia.
Causes
There are very few studies on the causes of epilepsy in
Asian populations, and there are particularly few case–
control studies or cohort studies. From the available
literature, causes seem to be dominated by head injury,
birth trauma, and intracranial infections, such as
neurocysticercosis or meningoencephalitis. Where socio-
economic development is better, head trauma and stroke
are the leading causes of epilepsy. In China in the 1980s,
brain injury, intracranial infection, and cerebrovascular
disease, in that order, were the leading putative causes of
epilepsy.12 Cases reported from China during 1994–2003
allowed the estimation of an average incidence of 8·7% for
epilepsy with cerebrovascular disease and of 8% with post-
traumatic epilepsy.60 In patients in Hong Kong, the
commonest causes were cerebrovascular disease (26·2%),
a history of CNS infection (26·0%), head trauma (11·4%),
perinatal insult (9·7%), congenital brain malformation
(7·4%), hippocampal sclerosis (5·9%), and intracranial
neoplasm (5·6%).61 By contrast, in 300 incident cases of
epilepsy in Nepal 47% were caused by neurocysticercosis,
9% by tumour, 4% by vascular disease, and 2% by head
injury.20 In this section, we elaborate on these causes of
epilepsy in Asia.
Head injury
In Asia, post-traumatic epilepsy is one of the most
common complications of head injury. One study claimed
that post-traumatic epilepsy accounted for 5% of total
epilepsy and 20% of symptomatic epilepsy.60 A history of
major brain trauma (20·9%) was also the leading cause
of epilepsy in surgically treated patients in China.62
CNS infections
In developing countries in other regions of the world,
such as sub-Saharan Africa or Latin America, CNS
infections seem to explain the high prevalence of epilepsy.
The Commission on Tropical Disease of the International
League Against Epilepsy listed several diseases as causes
of epilepsy, including malaria, tuberculosis, schisto-
somiasis, AIDS, and cysticercosis—among these, the
latter seems to be the most common cause of epilepsy.3
In Asia, there is a lack of rigorous analytical studies to
assess the effect of these infections in epilepsy.
An association between neurocysticercosis and epilepsy
was found in numerous studies in Africa5 and Latin
America.63,64 Neurocysticercosis was the cause of epilepsy
in about 50% of patients in some studies,42,65 and seizures
http://neurology.thelancet.com Vol 6 June 2007
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occur in 50–80% of patients with parenchymal
cysticercosis.65 In Asia, many studies report the presence
of cysticercosis (taeniasis).65–76 However, there are few
studies on the relation between neurocysticercosis and
epilepsy in Asia, and their results vary widely.
Neurocysticercosis is probably an important cause of
seizures and epilepsy in regions with a high prevalence
of Taenia solium infection in human beings. In Asia, this
includes India, Nepal, Bali, Papua and Sulawesi in
Indonesia, and parts of Vietnam and China. Cysticercosis
is only rarely detected in the most economically advanced
countries of Asia, such as South Korea,74 but the
prevalence might also be low in poor regions.15,19,71 In a
meta-analysis, seizures were the most common symptom
(56·2%) of cysticercosis in China.69 Another study noted
that between 8·7% and 50·0% of cysticercosis-infected
patients had recent seizures.66 Single CT enhancing
lesions and neurocysticercosis together accounted for
67% of the provoking factors of acute symptomatic
seizures.77 Conversely, in some studies, the cysticercosis
seropositivity was not higher in patients with epilepsy in
regions with either a low prevalence (eg, Laos19) or a high
prevalence (eg, Indonesia73).
Paragonimiasis is endemic in several Asian countries:
China, South Korea, the Philippines, Japan, and
Vietnam.78,79 During migration, the causal lung fluke may
reach the brain and may cause seizures, epilepsy, and
other neurological syndromes.80–82 However, no study has
quantified the importance of Paragonimus infection in
epilepsy.
Malaria is still widely endemic in Asia, with more than
3 million cases per year. India, Burma, Indonesia,
Pakistan, Cambodia, Papua New Guinea, and Bangladesh
each have more than 50 000 cases per year.83 Malaria
causes various symptoms, such as fever and convulsions.
7·7% of patients with childhood malaria (with or without
the presence of cerebral malaria) in a retrospective survey
in Thailand had convulsions.84 In cerebral malaria,
convulsions present in 60% of cases.85 However, we did
not find any analytical study reporting the relation
between malaria and epilepsy in Asia. Nevertheless, the
link between epilepsy and malaria was recently supported
by a case–control study in Gabon and a cohort study in
Mali in Africa.86,87
Japanese encephalitis is one of the most common
encephalitic disorders worldwide. Most of China,
southeast Asia, and the Indian subcontinent are affected.88
65% of patients with Japanese encephalitis have acute
symptomatic seizures and 13% have chronic epilepsy.89
In a study in India, 30 of 65 patients with Japanese
encephalitis had seizures in the first weeks of illness;
19 of them had two or more seizures.90
Genetic factors
Two studies in India found no relation between being a
twin and epilepsy, and twins of people with epilepsy did not
have a high risk of epilepsy.91,92 Case–control studies in
537
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China have found no relation between epilepsy and
susceptibility genes, such as GABABR1,93,94 KHDRBS3
(T-STAR),95 and CACNA1G (calcium channel, voltage
dependent, T-type, alpha 1G subunit).96 However, numerous
studies have confirmed familial history of epilepsy and
parental consanguinity as risk factors. In Kerala, south
India, a family history of epilepsy was three times more
common in patients with epilepsy than in controls (OR
3·2, 95% CI 2·1–4·7)97 and two times higher in another
study in north India (2·1, 1·1–4·3).31 Family history was also
a risk factor for epilepsy in studies in Laos19 and China.98
This level of risk is similar to that in studies from Africa.5
In Asia, consanguineous marriage is common in
certain cultures, in particular among Indian and Muslim
populations. Consanguinity of parents was significantly
more common among patients than among controls
(13·1% vs 6·6%).97 The odds ratio for parental
consanguinity was higher in patients with generalised
epilepsy than for controls (2·6; 95% CI 1·5–4·4).97
Another study of 316 patients with epilepsy of Indian
origin in Malaysia showed that 29·5% of them had a
parental consanguineous marriage, and that there was a
significant association with parental consanguinity in
idiopathic and cryptogenic epilepsies.99 Consanguinity
could be a target for a campaign to prevent epilepsy.
Epilepsy care
Typically, there is great variability in the case management
of epilepsy among different countries. In southeast Asia,
this variability depends on factors such as the economic
status, the quality of the health system and peripheral
services, rural or urban residence, and the cultural
frameworks of societies.33,100
Health-care facilities
According to WHO, the median number of hospital beds
for epilepsy care per 100 000 population is very low in
Asia: 0·05 in southeast Asia and 0·46 in the Western
Pacific—fewer than in Africa (0·55) and far fewer than in
Europe (1·65).101 Similarly, the number of neurologists is
extremely low in most Asian countries. In 2004, in India,
Laos, and Bangladesh, WHO estimated that there was
fewer than one neurologist per million inhabitants. In
Japan, there are between one and 50 neurologists per
million people,101,102 and a proportion of these neurologists
work in the private sector.100 In 2001, a comparative study
of epilepsy reference centres in Europe and Asia showed
that medical specialists in Asia examined more patients
per day in walk-in clinics than did their European
counterparts.103 The development of epilepsy care is
commonly driven by epileptologists—neurologists with a
special interest in epilepsy. If an epileptologist is defined
practically as someone who has had a period of fellowship
after training in general neurology, only Japan, South
Korea, Singapore, and Taiwan have at least one
epileptologist per million people. Paramedical
professionals, such as nurses, occupational therapists,
538
and educators rarely participate in the management of
epilepsy in Asia—another difference from epilepsy care
in Europe.103
Technologies such as electroencephalography, CT, and
MRI used in epilepsy diagnosis are widely available in
Asian countries, but their accessibility varies in the
different geographical regions. In developed economies,
such as Japan, South Korea, Singapore, and Taiwan,
sophisticated facilities are highly accessible to most of the
population, whereas almost no electroencephalography
or imaging facilities are available in other countries, such
as Cambodia, East Timor, Laos, or Mongolia. In addition,
many of these facilities are privately operated and available
only in big cities, with MRI being mainly used for
assessments for epilepsy surgery.100 However, the
development of these facilities is changing rapidly.
Currently, there are 15 ILAE chapters in Asia. They are
located in Bangladesh, China and Hong Kong, India,
Indonesia, Japan, South Korea, Malaysia, Mongolia,
Nepal, Pakistan, the Philippines, Taiwan, Thailand, and
Singapore. These chapters are absent in the less
developed nations.
Antiepileptic drugs
Antiepileptic drugs are the simplest and the safest means
of controlling epilepsy. Various first-generation anti-
epileptic drugs—phenytoin, carbamazepine, valproic
acid, phenobarbital, clonazepam, primidone, and
ethosuximide—are used widely in Asian countries104
(table 6),20,39,61,105–112 and monotherapy is common. The
particular drug used depends on the medical culture and
practices in each country.
Second-generation antiepileptic drugs, such as
lamotrigine, gabapentin, tiagabine, felbamate, vigabatrin,
or topiramate, are used widely in Malaysia, China, and
Singapore and in some of the economically less developed
countries, including the Philippines and Vietnam.7,113
Clobazam, oxcarbazepine, and levetiracetam are available
in large Asian countries, such as India, but are
prohibitively expensive. Access to drugs is probably easier
in Asia than in Africa but this varies widely according to
the context (degree of development, urbanisation, etc).
Although first-generation antiepileptic drugs are
predominant, there are availability and accessibility
problems in several places. In 2003, a study in Long Xuyen,
Vietnam, showed that drugs were available but only for a
short period of time. Moreover, these antiepileptic drugs
were sold in pharmacies that were located in only a small
area in the city centres.114 In most parts of Asia, there are
limited amounts of or no subsidised antiepileptic drugs.
The patients and families have to pay beyond their means
for even the most common first-generation drugs. For
example, the yearly cost of 100 mg daily phenobarbital, one
of the cheapest drugs, is about US$30 in Laos, which is
about the monthly salary of a school teacher; in north
India, this cost is US$11. In consequence, almost all
patients would not be able to have long-term treatment if it
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 Review

Reference First or second- Monotherapy or AEDs used Comments

generation AEDs polytherapy
Hong Kong 61 First and second Monotherapy: 57·4% Phenytoin used in 38·7%
India 39 First Polytherapy: 57·8% (entry) Carbamazepine used at entry
and monotherapy: 76·4% and at follow-up
(follow-up)
India (secondary level hospital) 105 NA Polytherapy: 20·8% Phenytoin used in 93·0%
India (university medical 106 First and second Polytherapy: 24·5% and Carbamazepine used in 47·4%
centres) monotherapy 75·5%
Indonesia 107 First and second NA NA Availability of AEDs depending on urban or rural area
Nepal (hospital) 20 First NA NA AEDs used depending on geographical location. Monotherapy:
with carbamazepine used at 92·0% in one hospital
Sri Lanka 108 First Monotherapy: 75·0% Carbamazepine used in 48·0%
Sri Lanka (hospital) 109 First Monotherapy: 70·8% Carbamazepine Second-generation AEDs are available in private clinic
Taiwan 110 First and second Polytherapy: 0·6% and Carbamazepine used in 78·4%
monotherapy: 29·4%
Taiwan 111 First Monotherapy: 61·0% Carbamazepine used in 56·9%
Thailand 112 NA Polytherapy: 58·6% NA

First-generation antiepileptic drugs (AEDs): phenytoin, carbamazepine, valproic acid, phenobarbital, clonazepam, primidone, ethosuximide. Second-generation AEDs: lamotrigine, gabapentin, tiagabine,
felbamate, vigabatrin, topiramate. NA=not available.

Table 6: Use of antiepileptic drugs in Asian countries

is not funded. The average annual cost (direct and indirect)
of outpatient treatment of epilepsy is US$47 per patient. In
general, the cost of phenobarbital in southeast Asia is 2·7
times higher than in Europe,101 and two to six times higher
than in sub-Saharan Africa. The annual cost incurred in
emergency and inpatient management in India is
estimated to be US$810·50 and US$168·30, respectively,
for all the patients attending a secondary hospital.105 In
general, the cost of treatment is much lower than
productivity losses, and it would be cost efficient for
governments or societies to invest in epilepsy treatment.105
Epilepsy control assessment
Treatment with phenobarbital was assessed in 2455
Chinese patients from rural areas in a community-based
intervention trial. In 68% of patients who completed
12 months’ treatment, seizure frequency was decreased
by at least 50%, and a third of patients were seizure-free.
72% of patients who completed 24 months’ treatment
with active epilepsy (defined in this case as two or more
unprovoked seizures on different days in the previous
year) and the number whose seizures are being
appropriately treated in a given population at a given
point in time, expressed as a percentage.33,117 In
developing countries in sub-Saharan Africa and Latin
America, up to 90% of people with epilepsy receive
inadequate treatment or no treatment at all.33,118,119 In
Asian countries, the treatment gap was 29–98%, with
values for most countries between 50% and 80%. The
treatment gap was higher in rural areas than in urban
areas (table 7).9,10,16,17,21,26,35,120–126 In rural areas, lack of
antiepileptic drugs and knowledge of epilepsy contribute
to the treatment gap.
References Year Treatment
gap (%)
China 9,10 2002 (and 2003) 62·6

had at least 50% reduction in seizure frequency and a India 120 2003 50·0–70·0
quarter of patients remained seizure-free. 597 patients India 17 2002 73·0–78·0
discontinued treatment before the end of the study. Many India (semi-urban) 16 2000 38·0
of those withdrew because of a misunderstanding that India (rural) 35 1999 >70·0
they were cured on becoming seizure-free (28%); others India (rural) 121 1999 54·0
withdrew because they perceived the treatment to be India (rural) 122 1997 78·0
ineffective (16%). Only 5% discontinued the treatment India (semi-urban) 123 1997 57·0
because of adverse events.115 Another study in India India (rural) 124 1988 74·5
showed that strict drug compliance and early treatment India (urban) 125 1988 29·0
(with phenobarbital or phenytoin or both) were important Nepal 126 2004 >70·0
predictors of a 2 year terminal remission.116 Pakistan (rural) 21,26 1994 (and 1997) 98·0
Pakistan (urban) 21,26 1994 (and 1997) >72·0
Treatment gap Turkey 26 1997 70·0
The treatment gap was defined by a workshop of the
Table 7: Treatment gap for epilepsy in Asia
ILAE as the difference between the number of people

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 Review

Surgery reported from Taiwan that 50% of their patients used

The ILAE reported the presence of epilepsy surgery
centres in 26 countries worldwide from 1980 to 1990; at
that time, only four Asian countries were on the list:
Japan, China, Taiwan, and Vietnam.127 More recent reports
revealed some others in Hong Kong, India, Iran, North
Korea and South Korea, the Philippines, Singapore,
Thailand, and Turkey.128,129 A cohort study of patients with
medically refractory temporal-lobe epilepsy in India
showed a significantly better outcome of surgery (77·0%
seizure-free, 32·7% off medication) compared with
medical treatment (11·5% seizure-free, 0·8% off
medication). There was no statistically significant
difference in mortality between the two groups.130
Concepts of disease and use of traditional, complementary, and
alternative medicine
There are few dedicated studies on the concepts of
disease and use of traditional, complementary, and
alternative medicine among patients with epilepsy in
Asia, although many clinicians practising in the region
have reported widespread use of traditional medicine
and spiritual medium, particularly in rural areas.20,100,131
Tan and Lim100 reported prevalence of syncretism (ie,
simultaneously holding to concepts from different
schools of thought) in concepts and practice among the
ethnic Chinese patients with chronic epilepsy in Kuala
Lumpur, with some patients attributing the illness to
epilepsy as well as to the traditional concepts of
“weakness” (xu), “hotness” (re), “wind” (feng), and
“supernatural cause” (xie). Rajbhandari20 reported that
69% of the newly diagnosed patients with epilepsy in
Kathmandu worshipped family gods, 66% wore mantra
butti, jantar, and beets (items believed to protect patients
from evil spirits), and 58% made animal sacrifices. Tsai132
Chinese traditional medicine, and 47% sought folk
healing methods including Qian interpretation, fortune
telling, Qigong, geomancy, and shamanism. The use of
these traditional treatment modalities is probably related
to the large treatment gap in large parts of Asia. Some of
the so-called traditional preparations are adulterated with
conventional antiepileptic drugs, which complicates the
management of these patients.133 This situation is
comparable to that in sub-Saharan Africa.5 As long as
traditional beliefs exist, patients with epilepsy are not
likely to be correctly treated.
Knowledge, attitudes, and practice
Numerous studies on knowledge, attitudes, and practice
have been done, particularly in Chinese communities
within and outside China (table 8).16,134–144 Stigma was least
important but evident in some advanced regions, such as
Hong Kong or Singapore.131,137,138 In Hong Kong, 94·1% of
respondents thought that people with epilepsy could be
married, but only 67·8% would allow their child to marry a
person with epilepsy;138 from the reports discussed in this
Review, it seems that people in Hong Kong have the most
open-minded attitudes towards epilepsy. In another study
in China, only 13·0% of the respondents would allow their
child to marry a person with epilepsy.141 Lack of awareness
may be a factor explaining stigma. In almost all studies, a
third to a half of responding people thought that a person
with epilepsy cannot work like other people, and a quarter
thought that epilepsy is a mental illness or a form of
insanity. As in other parts of the world, epilepsy is believed
to be a contagious disease,123,145 and some people avoid
touching patients, especially during seizures, when some
simple forms of help may avoid dangerous situations.
Health education campaigns are necessary to rehabilitate

Reference Year N Proportion of affirmative answers Population interviewed

Q1 (%) Q2 (%) Q3 (%) Q4 (%) Q5 (%)
Malaysia 134 1999 379 99·0 9·0* 13·0 91·0 57·0 Public
Malaysia 135 2000 839 91·0 24·0 58·0 80·0 52·0 Public
Burma 136 2002 296 82·0 25·0* 86·0 56·0 29·0 Public
Hong Kong 137 2004 233 96·0 10·0* 10·0 89·0 56·0 Public
Hong Kong 138 2002 1128 58·2 10·4 22·5† 88·8 67·8 Public
India 16 2000 1118 98·7 27·3 45·6 89·2 71·3‡ Public
Korea 140 2003 820 93·0 34·0 52·0 49·0 4·0 Public
Taiwan 141 1995 2610 87·0 7·0* 31·0 82·0 28·0 Public
Vietnam 143 2005 523 68·0 25·0 NA NA 14·0 Public
Vietnam 144 2006 1000 54·6 23·8* 57·9 81·3 44·0 Public
Indonesia 139 2002 84 100·0 57·0 43·0 75·0 44·0 School teacher
Thailand 142 1999 284 57·8 18·2 NA 94·7 41·2 School teacher

Q1=have you ever heard about epilepsy? Q2=do you think that epilepsy is a mental illness? Q3=do you think that people with epilepsy would not be employed like others?
Q4=would you allow your child to associate with a child with epilepsy at school or in play? Q5=would you allow your child to marry a person with epilepsy? N=number of
respondents. NA=not available. *Epilepsy is a form of insanity. †Employers would terminate the employment contract after an epileptic seizure in an employee with
unreported epilepsy. ‡Patient with epilepsy can lead a married life.

Table 8: Awareness, attitudes and understanding towards epilepsy in Asia

540 http://neurology.thelancet.com Vol 6 June 2007


patients with epilepsy in the community and to improve
their quality of life.
Conclusion
There have been significant advances in the
understanding of the epidemiology of epilepsy in Asia
over the past 20 years. The median lifetime prevalence
rate is estimated to be six per 1000 people, which is lower
than in other developing regions. However, the number
of affected patients in the region is large and much
remains poorly documented or unknown. There are few
data on incidence and mortality (in particular in elderly
people), the treatment gap, public understanding and
attitudes, patients’ concepts of disease, and help-seeking
behaviour. What distinguishes epilepsy in Asia from
other regions is probably not so much genetics or
biological differences of Asians or environmental factors
that influence the causes of symptomatic epilepsy, but
most likely, the psychosocial, cultural, economic,
organisational, and political factors that influence
epilepsy causation, management, and outcome. These
areas should be the focus of further study, and
governments must give a higher priority to the fight
against epilepsy in Asia. Some of the countries included
in this Review are no longer poor, and could make free
or subsidised antiepileptic drugs available to the general
public, as the cost of even phenobarbital can be a burden
on some of these communities. Nurturing of
epileptologists who can spearhead improvements in
epilepsy care in the community is also important.
Moreover, governments should give high priority to the
development of epilepsy surgery to treat drug-resistant
epilepsy and should identify centres to be equipped with
physical facilities such as video-electroencephalography
and MRI.
Contributors
TLM and DST contributed equally in reviewing all the publications and
analysing data, FQ and PO participated in interpretation, and the work
was coordinated by PMP and CTT. All authors contributed to the writing
of the paper.
Conflicts of interest
We have no conflicts of interest.
Acknowledgments
We thank Sandra Gresiak for her help typing the paper and obtaining
references. We have received an unrestricted grant from Sanofi Aventis.
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