Epilepsia, 51(12):23842391, 2010 doi: 10.1111/j.1528-1167.2010.02740.

FULL-LENGTH ORIGINAL RESEARCH

A longitudinal study of epilepsy in Kolkata, India

*Tapas Kumar Banerjee, yBiman Kanti Ray, yShyamal Kumar Das, zAvijit Hazra, xMalay Kumar Ghosal, {Arijit Chaudhuri, yTrishit Roy, and #Deepak Kumar Raut
*National Neurosciences Centre, Kolkata, India; yDepartment of Neurology, Bangur Institute of Neuroscience, Kolkata, India; zDepartment of Pharmacology, Institute of Postgraduate Medical Education & Research, Kolkata, India; xDepartment of Psychiatry, Institute of Psychiatry, Kolkata, India; {Indian Statistical Institute, Kolkata, India; and #Department of Epidemiology, All India Institute of Hygiene and Public Health, Kolkata, India

SUMMARY
Purpose: This study aimed to determine the prevalence, incidence, and mortality rates of epilepsy in the city of Kolkata, India. This is the rst such longitudinal study in a heterogeneous urban Indian population. Methods: A two-stage door-to-door survey of a stratied random sample was undertaken within the municipal limits of Kolkata. Trained eld workers detected and interviewed the cases using a simple screening questionnaire, and the detailed follow-up was done by neurologists. The survey was conducted annually for ve consecutive years from March 2003 through February 2008. Results: A total of 52,377 (52.74% men) individuals were screened. There were 309 prevalent and 66 incident cases of active epilepsy. The prevalence and average annual incidence rate (AAIR) with 95% condence interval (CI), age-standardized to World Standard

Population, were 572.8 (509.79641.54) per 100,000 and 27.27 (21.0334.80) per 100,000 per year, respectively. The age-specic incidence rates of epilepsy showed bimodal distribution. During the 5-year period, 20 cases of active epilepsy died. The average annual mortality rate (AAMR) was 7.63 (95% CI 4.4511.26) per 100,000 population per year. Compared to the general population of Kolkata, the all-cause standardized mortality ratio (SMR) for persons with epilepsy was 2.58 overall (men 3.67; women 1.77). There was no signicant difference between slum and nonslum dwellers in epidemiologic parameters. Conclusions: The AAIR of epilepsy is comparable to that observed in developed countries, but AAMR is higher. The all-cause SMR for epilepsy relative to the general population is, however, similar to that of developed nations. KEY WORDS: Active epilepsy, Prevalence, Incidence, Mortality, India.

Epilepsy is a common neurologic disorder with significant morbidity and social impact in developing countries. During the past two decades, a spate of epidemiologic surveys on epilepsy has been conducted in different parts of India (Sridharan & Murthy, 1999). These have been crosssectional surveys mainly aimed at determination of prevalence of epilepsy. Epilepsy prevalence in India varies from 425641 per 100,000 population (Sridharan & Murthy, 1999), which is similar to that observed in developed Western countries (Hauser et al., 1996). Reports of two earlier studies from rural India have documented incidence rates, but these did not include during computation those cases that died (Mani et al., 1998; Saha et al., 2008). Two other studies from urban and semiurban areas in western India, which are from small ethnic groupbased populations, have recorded variable standard mortality ratios (SMRs) (Carpio
Accepted August 3, 2010; Early View publication September 30, 2010. Address correspondence to Dr. Shyamal K. Das, Professor and Head, Department of Neurology, Bangur Institute of Neuroscience, Kolkata 700025, India. E-mail: das_sk70@hotmail.com Wiley Periodicals, Inc. 2010 International League Against Epilepsy

et al., 2005). To date, there is no well-designed longitudinal study on epilepsy from urban India. In 1997, the International League Against Epilepsy (ILAE) mentioned the general lack of incidence and mortality data on epilepsy in developing countries and emphasized the need for well-conducted population-based studies to address these issues in those nations (ILAE Commission Report, 1997). Therefore, we aimed to determine the incidence and mortality rates in epilepsy among a heterogeneous urban Indian population through a 5-year prospective study in the metropolis of Kolkata in eastern India. We also sought to compare the epidemiologic indices of epilepsy between slum and nonslum populations, since the former represents the economically weaker section of the urban community in developing countries.

Materials and Methods

Study design and setting We conducted a community-based, longitudinal, observational study within the municipal limits of Kolkata (erstwhile Calcutta), which is the largest city in eastern

2384

2385 Epilepsy in Kolkata India and one of the six principal cities of the country. The municipal area of the city is home to nearly 4.85 million inhabitants of diverse ethnic, religious, cultural, and linguistic backgrounds. Sampling The method of stratified random sampling was utilized for this study. The municipal area of Kolkata has been demarcated into 5,200 blocks by the National Sample Survey Organization of the Government of India. Comprehensive data for each block, regarding location, boundaries, slum areas, and types of housing are available. Based on this information, the city was divided into six strata (stratum I, slum area; strata IIVI, nonslum areas). From the nonslum component, five strata were chosen to represent different geographic areas: one from the central part and two each from southern and northern parts of the city. From each stratum, a nearly equal number of blocks was selected using random number table. From each block, 50% of the households were surveyed by visiting alternate houses. In this manner, 166 blocks and 52,377 subjects were screened. Survey The survey team comprised four field workers headed by a neurologist. The field work was conducted annually for five consecutive years from March 2003 through February 2008, using the same questionnaire. In the first stage, field workers performed door-to-door survey with the help of a general family screening questionnaire that consisted of two parts: the first part covered demographic details, and the second the screening questions for seizure disorder. The latter section had two components: one applicable for individuals aged 7 years and older and the other for those younger than 7 years of age (Table 1). This screening questionnaire was derived from the World Health Organization research protocol (WHO, 1981, Gourie-Devi et al., 1997). The questions sudden loss of contact with surroundings (applied to those aged 7 years) and blank look and lack of awareness of surroundings (for those aged <7 years) were explained to the respondent. It was asked whether the individual suddenly stopped activities he/she had been engaged in and had a blank or confused look on the face; also whether the subject was unresponsive to commands and performed activities without being aware of the fact. The episode could last from a few seconds to minutes. The purpose of these questions was to capture absence seizures and partial complex seizures. The family questionnaire was applied to the head of the family initially. In case of seizure history of a family member/members, details were taken from the case and also from a reliable eyewitness of the ictal event. In the second stage, the neurologist scrutinized the history in the screen-positive cases, clinically examined these subjects at their residences, and reviewed relevant investigation reports if available. The date of onset of seizure was ascertained as accurately as possible. On the basis of these observations, the neurologist made the diagnosis of epilepsy and of other forms of seizure disorder; the neurologist also identified the false positives. Cases with diagnostic dilemma (1% of total) were personally examined by the senior neurologists (SKD, TKB) in the team. The flow diagram (Fig. 1) illustrates the distribution of the various seizure disorders and the false positives. Ten percent of randomly selected screen-negative individuals were also examined by the neurologist to identify the falsenegative cases. For those individuals with epilepsy who died, the field workers collected information on death based on verbal autopsy (Soleman et al., 2006). Later, the neurologist visited those families and carefully verified the details, including date of onset of epilepsy and date of death.

Table 1. Screening questionnaire to identify potential epilepsy cases

Screening questions for seizures in individuals age 7 years and older Any episode of transient loss of consciousness? Yes Any episode of sudden loss of contact with Yes surroundings? Any episode of involuntary shaking of head, arms, Yes or legs? Screening questions for seizures in individuals below 7 years of age Any episode of transient loss of consciousness? Yes Episode of blank look and lack of awareness of Yes surroundings? Any episode of involuntary shaking of head, arms Yes or legs? No No No

No No No

The person is declared screened positive if the answer is yes to any one of the above queries.

Figure 1. Flow-diagram illustrating identication of cases of active epilepsy along with the false positives (number of subjects given in parenthesis). Epilepsia ILAE
Epilepsia, 51(12):23842391, 2010 doi: 10.1111/j.1528-1167.2010.02740.x

2386 T. K. Banerjee et al. History of clinical events leading to death was obtained from responsible family members and from reviewing whatever medical records were available. Quality control The field workers were educated up to graduation level, received intensive training on seizure disorders in Bangur Institute of Neuroscience, Kolkata, and had to qualify in written tests. They had to apply the screening questionnaire satisfactorily on known epilepsy cases and healthy controls in neurology outpatient settings under direct supervision of senior neurologists, before being allowed to perform field work. Initially, a pilot survey on seizure disorder was conducted on 3,041 community subjects using the same questionnaire employed in the main survey. In each block, 10% of the randomly selected screen-negative persons were revisited by the neurologist to determine the false-negative cases. The sensitivity and specificity of the screening instrument for epilepsy were found to be 90.9% and 100%, respectively, in the pilot survey. In the main survey, the sensitivity and specificity of the screening instrument were 98% and 99.7%, respectively. The information obtained through verbal autopsy was also validated based upon 61 randomly selected death cases in the community, and the sensitivity and specificity were 97.5% and 57.14%, respectively. Operational definitions Epilepsy: A condition characterized by recurrent (two or more) epileptic seizures, unprovoked by any immediate identified cause. Multiple seizures occurring in a 24-h period are considered a single event (International League Against Epilepsy, 1997). Active epilepsy: Epilepsy is considered to be active, if the affected person has had at least one epileptic seizure in the previous 5 years, regardless of anticonvulsant treatment. However, this excludes single seizure, acute symptomatic seizure, and febrile seizure (International League Against Epilepsy, 1997). Epilepsy in remission or inactive epilepsy: Epilepsy is considered to be inactive, if the person with history of epilepsy has had no epileptic seizure for 5 years, with or without anticonvulsant treatment (International League Against Epilepsy, 1997). SUDEP (probable): the following criteria need to be met (1) history of epilepsy, (2) death sudden and not due to status epilepticus, and (3) death unexpected and unexplained (Leestma et al., 1997). Idiopathic generalized epilepsy (IGE): This included cases with juvenile myoclonic, childhood absence, juvenile absence, or awakening grand mal epilepsy. Epilepsy sufferers with generalized tonicclonic seizures without aura, with electroencephalography (EEG) evidence of 34 Hz generalized spikewaves and with no known cerebral
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pathology were also included in this category (Olafsson et al., 2005). Generalized epilepsynot otherwise specified (GE-NOS): Epilepsy sufferers with generalized tonicclonic seizures without any history of aura, who did not have the abovementioned characteristic seizure semiology of definite IGE (Olafsson et al., 2005; Banerjee & Hauser, 2008). Partial epilepsynot otherwise specified (Partial-NOS): Patients with epilepsy who did not have definite history of partial onset seizure, but whose EEG or imaging showed focal cortical pathology. Partial epilepsy with simple partial seizures: Cases who had episodes consistent with simple partial seizure (Commission of Classification, 1981) with or without secondary generalization. Partial epilepsy with complex partial seizures: Cases who had episodes suggestive of complex partial seizure (Commission of Classification, 1981) with or without secondary generalization. Epidemiologic parameters Prevalence computed in this study is the period prevalence of epilepsy survivors in the first 12-month period of the survey, expressed per 100,000 population. It included the old cases with onset before March 2003 and the new surviving cases between March 2003 and February 2004. Annual incidence rate (AIR) indicates the rate of occurrence of new cases of epilepsy per 100,000 population per year. It included all the new cases between March 2003 and February 2008. The average annual incidence rate (AAIR) was calculated from that of the five consecutive years. Annual mortality rate among those with active epilepsy indicates the number of deaths from epilepsy per 100,000 population per year. From the cases that died between March 2003 and February 2008, the average annual mortality rate (AAMR) was calculated. Standardized mortality ratio (SMR) is the ratio of observed number of deaths in a population with incident epilepsy to that expected based on the age- and sex-specific mortality rates in a reference population (Van Den Eeden et al., 2004). In our study, the general population of Kolkata was the reference population. Statistical analysis To compare the data of prevalence and incidence rates with that of the other nations, direct age standardization was undertaken to World Standard Population (WSP) (Ahmad et al., 2000). The 95% confidence interval (CI) of the prevalence, incidence, and mortality rates of epilepsy and that of the SMR were calculated assuming a Poisson distribution for the observed cases. Weighted prevalence rate is derived from the formula: (N + 10 n)/X, where N = number of cases in primary survey and n = number of false-negative cases detected on resurvey of 10% of negative samples and X represents number of sample population (Das et al., 2007.

2387 Epilepsy in Kolkata The chi square test was employed to assess the significance of difference between slum and nonslum populations. p-Value <0.05 was considered statistically significant. prevalence of active epilepsy was 572.80 (509.79641.54) per 100,000; among men 627.46 (538.99725.97) and among women 509.57 (424.77605.37). The age- and gender-specific prevalence and AAIR have been shown in Table 2. Based upon the number of cases detected during rescreening of 10% negative sample, an additional 12 cases were detected, and thus the weighted prevalence per 100,000 persons was calculated to be 819.06 (740.43 903.42). Of 309 cases, 123 cases (39.8%) took antiepileptic drugs regularly, whereas 70 (22.6%) had discontinued drugs on their own. Based upon seizure types, 8.9% of subjects with active epilepsy had findings consistent with idiopathic generalized epilepsy (IGE); 12% were simple partial and 9.2% complex partial epilepsy. There was one case of infantile spasm and two cases of progressive myoclonic epilepsy. Generalized epilepsynot otherwise specified was attributed to 57.4%, and the rest 11.5% partial epilepsy not otherwise specified. Incidentally, EEG and computed tomography (CT) scan records were available for review in 123 (39.8%) and 70 cases (22.6%), respectively, though investigations were not part of the study protocol. Data from the longitudinal surveys held annually between March 2003 and February 2008 There were 66 new cases of epilepsy that occurred during the 5-year longitudinal survey of the sampled population. The overall crude AAIR of epilepsy was 25.20 (95% CI 19.4332.16) per 100,000 persons per year. When age-

Results
A total of 52,377 persons (27,626 men, 24,751 women) living in 11,734 households were screened. However, 1.61% of the selected households could not be interviewed, despite repeated attempts, because of either refusal or nonavailability. Overall literacy rate was 81%. The average family size was 4.46 persons. The sample comprised 74.7% Hindus, 23.6% Muslims, 0.08% Sikhs, 0.56% Christians, and 1.03% individuals of other religious communities; the remaining few refused to disclose their religion. The age and gender distribution of the surveyed population is shown in Table 2. Data from the primary survey held between March 2003 and February 2004 Figure 1 illustrates the distribution of the various seizure disorders and the false-positive cases, derived from the primary door-to-door survey. A total of 309 persons were found to have active epilepsy. The crude prevalence of active epilepsy (with 95% CI) was 589.95 (525.05660.74) per 100,000 population. The prevalence among men was 658.80 (565.91762.23) and among women 517.16 (426.14618.52). When age-standardized to WSP, overall

Table 2. Age- and gender-specic prevalence rate and average annual incidence rate of epilepsy
Age range (years) Population 04 59 1014 1519 2024 2529 3034 3539 4044 4549 5054 5559 6064 6569 7074 7579 8084 85+ Total 95% CI ASR 95% CI 1,690 1,985 2,506 2,717 2,711 2,471 2,231 2,259 1,965 2,042 1,248 1,029 9,20 662 579 302 195 114 27,626 Men PR AAIR Population 1467 1859 2349 2406 2304 2319 2078 2126 1689 1601 1042 853 891 664 538 236 194 135 24751 Women PR AAIR Population 3,157 3,844 4,855 5,123 5,015 4,790 4,309 4,385 3,654 3,643 2,290 1,882 1,811 1,326 1,117 538 389 249 52,377 Overall PR AAIR

236.69 59.17 856.42 0.00 758.18 39.90 1030.55 44.17 959.06 14.75 1133.14 16.19 537.88 0.00 398.41 17.71 712.47 30.53 440.74 19.59 160.26 16.03 583.09 38.87 434.78 65.22 302.11 60.42 345.42 69.08 0.00 0.00 0.00 307.69 0.00 0.00 658.80 28.96 565.91762.23 20.6836.95 627.46 30.54 538.99725.97 21.0642.83

409.00 68.17 645.51 21.52 510.86 8.51 706.57 49.87 520.83 8.68 517.46 0 866.22 9.62 470.37 0 236.83 0 124.92 24.98 575.82 19.19 468.93 0 448.93 67.34 451.81 30.12 185.87 0 423.73 84.75 515.46 103.09 1481.48 296.3 517.16 21.01 426.14618.52 14.1631.01 509.57 24.34 424.22605.37 16.1835.71

316.76 63.35 754.42 10.41 638.52 24.72 878.39 46.85 757.73 11.96 835.07 8.35 696.22 4.64 433.30 9.12 492.61 16.47 301.95 16.47 349.34 17.47 531.35 21.25 441.74 66.26 377.07 45.25 268.58 35.81 185.87 37.17 257.07 205.65 803.21 160.64 589.95 25.20 525.05660.74 19.4332.16 572.80 27.27 509.79641.54 21.0334.80

PR, prevalence (per 100,000 population); AAIR, average annual incidence rate (per 100,000 population per year of study); CI, condence interval; ASR, age standardized (to World Standard Population, WSP) rate.

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2388 T. K. Banerjee et al. (56.06%) of the incident cases were taking antiepileptic medication, whereas six (9.1%) were not, having discontinued the drugs on their own. There are 20 cases of active epilepsy that died within the 5 years of the study. Eight of these subjects expired due to cerebrovascular accidents in four, two due to heart attack, one due to cancer and chronic kidney disease in each. Of the remaining 12 cases, three died due to drowning, one due to status epilepticus, two due to road traffic accident, one due to rail track accident, and unexplained fever in another. Among the remaining four cases, the cause of death was undetermined, although no case of probable SUDEP (sudden unexpected death because of epilepsy) was apparent in our study. The AAMR was 7.63 (95% CI 4.6611.75) per 100,000 population per year. The AAMR in men was 10.13 (5.5316.99) and that in women 4.84 (1.7710.53). When age-standardized to WSP, the AAMR was 7.29 (95% CI 4.4511.26). Seventeen of the cases that died were from the 66 incident cases of epilepsy. The age- and gender-specific mortality rates of the general population of Kolkata are available (Sample Registration System Statistical Report 2004), and on the basis of these data SMR were computed. The all-cause SMR of epilepsy cases with 95% CI was 2.58 (1.504.13). The SMR in men was 3.67 (1.836.57) and that in women 1.77 (0.653.85). To assess the impact of socioeconomic factors on active epilepsy, the major parameters were compared between slum and nonslum populations. Despite differences in socioeconomic parameters such as education and income (Das et al., 2007), no statistically significant differences in epilepsy prevalence, incidence, and mortality emerged

Figure 2. The chart shows bimodal distribution of age-specic annual incidence rate (per 100,000 persons) of epilepsy in both male (M) and female (F) individuals. Epilepsia ILAE

standardized to WSP, the AAIR was 27.27 (21.0334.80) per 100,000 population per year (in men 30.54 and in women 24.34). The age- and gender-specific AAIR, shown in Table 2 and Fig. 2 reveals bimodal distribution. The incidence was high during childhood, declined by 20 years of age, remained low throughout the adult years, and again rose steeply after the fifth decade of life. The age and gender distribution of the incident cases of epilepsy based upon seizure types are depicted in Table 3. At the time of survey, 37

Table 3. Age-gender distribution of incident epilepsy (survivor deceased), based on seizure subtypes (gures in parenthesis indicate the number of male cases)
Age group 04 59 1014 1519 2024 2529 3034 3539 4044 4549 5054 5559 6064 6569 7074 7579 8084 85+ Total (%) IGE 2 (1) 0 0 1 (0) 0 0 0 0 0 0 0 0 0 0 0 0 0 0 3 (4.54%) GE-NOS 5 (3) 0 1 (1) 6 (3) 2 (1) 2 (2) 1 (0) 0 2 (2) 2 (1) 0 1 (1) 3 (2) 0 1 (1) 0 3 (3) 0 29 (43.93%) Simple partial 0 0 4 (3) 3 (2) 1 (1) 0 0 1 (1) 1 (1) 0 0 1 (1) 0 0 0 1 (0) 0 0 12 (18.18%) Complex partial 0 0 0 1 (0) 0 0 0 0 0 0 1 (1) 0 0 1 (0) 1 (1) 0 0 0 4 (6.06%) Partial-NOS 1 (1) 1 (0) 1 (1) 1 (1) 0 0 0 0 0 2 (1) 1 (0) 0 3 (1) 2 (2) 1 (1) 0 1 (0) 2 (0) 16 (24.24%) Others 2 (LGS) 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 2 (3.03%)

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2389 Epilepsy in Kolkata

Table 4. Comparison of demographic, socioeconomic, and epidemiologic indices for active epilepsy between slum versus nonslum residents
Features Population surveyed Sex distribution Men Women Age 60 years Occupation of earning members Manual Nonmanual Education Primary (standard I to X) Higher (standard XI and higher) Income (per family per month) <Rs. 2,500 (US$ 56) Rs. 2,5005,000 (US$ 56111) >Rs. 5,000 (US$ 111) Number of NSSO blocks selected for study Prevalence of epilepsy per 100,000 persons (number of cases) Average annual incidence rate of epilepsy per 100,000 persons per year (number of cases) Average annual mortality rate of epilepsy (number of cases) Slum areas 11,005 (21%) [2,321 families] 5,839 (53.05%) 5,166 (46.94%) 1,223 (11.11%) 2,798 (25.42%) 1,651 (15%) 7,268 (66%) 1,651 (15%) 252 (10.86%) 1,850 (79.70%) 219 (9.44%) 31 of 727 (4.26%) 608.81 (67) 19.99 (11) 5.11 (3) Nonslum areas 41,372 (79%) [9,413 families] 21,787 (52.66%) 19,585 (47.34%) 7,032 (17%) 22,153 (53.5%) 7,032 (17%) 4,207 (10.17%) 22,135 (53.5%) 1,232 (13.08%) 5,729 (60.86%) 2,537 (26.95%) 135 of 4,473 (3.01%) 584.93 (242) 26.59 (55) 8.22 (17) NS <0.001 <0.001 Chi square p-valuea

<0.001

<0.001

NS NS NS NS

NSSO, National Sample Survey Organization, India; NS, not signicant. a Chi square p-value assesses the signicance of difference between slum and nonslum populations.

between these two populations (Table 4). The prevalence, AAIR, and AAMR of epilepsy in slum dwellers, age-standardized to nonslum dwellers, were 619.81 (95% CI 483.45783.44), 18.55 (95% CI 9.2633.18), and 5.11 (95% CI 1.0514.94), respectively. Even after age-adjustment of slum to nonslum population, there was no significant difference between the two in the prevalence, incidence, and mortality rates.

Discussion
The use of standard definitions, stratified random selection from a heterogeneous population, case ascertainment through house-to-house survey, age-standardization to WSP for comparison, and longitudinal study over 5 years are the strengths of our study. To the best of our knowledge there has been no previous longitudinal study on epilepsy in the heterogeneous urban Indian population. The prevalence of epilepsy in the present study is similar to that obtained in earlier Indian studies (Sridharan & Murthy, 1999). Based upon the seizure subtypes, a study in Rochester, Minnesota (Hauser et al., 1996) demonstrated that >50% cases had partial epilepsy with complex partial seizure predominating, whereas generalized epilepsy without aura accounted for about 40%. In Canada, 5256% of the epilepsy in community was reported to be generalized epilepsy without aura (Theodore et al., 2006). In an Icelandic community study, generalized epilepsynot otherwise specified constituted the vast majority (48.7%) of cases;

IGE was diagnosed in about 10% (Olafsson et al., 2005). The percentage of definite IGE from our prevalence and incidence study is similar to that of the Icelandic study. In our prevalence study generalized epilepsynot otherwise specified occurred in the majority. On the contrary, in the incidence study, partial epilepsy was slightly predominant and this might be related to less recall bias in the latter. The age-standardized AAIR of epilepsy in developed countries varies between 24 and 53 per 100,000 persons per year (Jallon, 2002). Data from Chinese studies show annual incidence rate varying from 28.835.0 per 100,000 persons per year (Li et al., 1985; Wang et al., 2002). A report from Rochester, Minnesota, stated the epilepsy incidence rate at 44 per 100,000 per year (Hauser et al., 1993). In a Texas health maintenance organization study, it was observed that Asian population had 75% lower incidence of epilepsy compared to their caucasian, African-American, and Hispanic counterparts (Annegers et al., 1999); however, the Asian population in that study was small. In our study, the incidence rate of epilepsy is slightly on the lower side compared to data from developed nations. Earlier, population-based studies from Southern and Eastern India in rural settings revealed higher incidence rates than ours at, 49.3 and 42.1 per 100,000 persons per year, respectively (Mani et al., 1998; Saha et al., 2008). The present study is the first to be conducted among urban Indian population. The developing countries of Africa and Latin America have reported much higher incidence of epilepsy in rural setting. One of these studies from Latin America included single and
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2390 T. K. Banerjee et al. symptomatic seizures (Placencia et al., 1992; Rwiza et al., 1992). Bimodal distribution of epilepsy incidence, as revealed in our study, concurs with data from developed countries (Hauser et al., 1993, 1996). This raises the possibility of vascular causes of seizure in late-onset cases in view of rising stroke incidence in developing countries such as India (Das et al., 2007) and this issue needs to be explored further in future studies. This study also represents a comprehensive study on mortality in epilepsy in a large heterogeneous urban Indian population. In most countries, the mortality rate of epilepsy is 12 per 100,000 (Massey & Schoenberg, 1985). Our data showed fivefold higher mortality rates of epilepsy. This may reflect a higher proportion of symptomatic seizures, poor social support systems. and lack of access to appropriate medical care (Bharucha & Shorvon, 1997). Epidemiologic studies in other parts of the world have consistently shown two- to threefold higher mortality among epilepsy patients compared to those among the general population. The increase is largely confined to the initial 10 years after epilepsy diagnosis (Hauser et al., 1980). The higher mortality in epilepsy may be related to underlying structural lesions like cerebrovascular disorders, brain tumors, and granulomas. Accidents, status epilepticus, and sudden unexpected deaths are the direct seizure-related causes of death (Tomson, 2000). Accidental deaths were encountered among our subjects with epilepsy, emphasizing the need for greater awareness among epilepsy patients and their families in these regards. In Western countries, the all-cause SMR for epilepsy relative to the general population varies from 1.53.0 (Cockerell et al., 1994; Olafsson et al., 1998). Our SMR data are similar. Among the Chinese, however, the SMR for epilepsy is higher, varying from 3.53.9 (Chen et al., 2005; Ding et al., 2006). In an Indian study among Parsis, a relatively affluent community, SMR was low possibly reflecting the availability of better health care for the literate and well-off epilepsy patients (Carpio et al., 2005). The lack of any significant difference in the various epidemiologic indices of active epilepsy between slum and nonslum dwellers in this study, despite their socioeconomic differences, suggests that socioeconomic factors may not impose any inherent differences in rates (Bharucha & Shorvon, 1997; Das et al., 2007). However, the small numbers of incident cases and deaths, despite the 5-year longitudinal follow-up, may also mean that data are not sufficiently powered to identify any difference. There were certain limitations to our study. The pilot study showed high sensitivity and specificity of the screening instrument. In this study all the cases were individually assessed by a neurologist in the field, and based on his assessment the epilepsy diagnosis was made clinically. In the absence of supportive investigation, there may be some biasness in case ascertainment. Higher weighted prevalence rate of epilepsy based on 10% re-screening of negative subEpilepsia, 51(12):23842391, 2010 doi: 10.1111/j.1528-1167.2010.02740.x

jects may indicate better cooperation extended by the family responders toward a doctor rather than field workers, since it is a social disease and the family members are concerned about the dissemination of undisclosed information. Therefore, actual estimate for prevalence and incidence cases may be higher, if the screening of all household members could be carried out by doctor instead of the field workers. In a proportion of cases, the seizure type could not be categorized due to lack of detailed eyewitness accounts of the events. This could be the reason behind the low incidence of partial epilepsy complex partial seizures in our study. Lack of EEG and neuroimaging data in a large number of subjects also contributed to incomplete seizure subtype categorization. It is possible that a few patients may have died of SUDEP, but there was no way to verify the cause of these deaths because of the lack of autopsy confirmation. Notwithstanding these limitations, we can conclude that this study provides the incidence and mortality data on epilepsy for the urban population of Kolkata, which being heterogeneous, would reflect the situation in urban India in general. Age-standardized AAIR of epilepsy is similar, whereas AAMR is higher in India compared to that of the developed countries. This emphasizes the need for greater awareness regarding epilepsy and improvement in health care for people with epilepsy in our society.

Acknowledgments
We gratefully acknowledge contributions of members of the Task Force on Neurological Disorders of the Indian Council of Medical Research, New Delhi, the diligent efforts of the field staff and the data entry operators, as well as the cooperation extended by the surveyed people of Kolkata. Financial disclosure: This project has been financed by Indian Council of Medical Research (Department of Medical Research), New Delhi, vide grant no SWG/Neuro/9/2001-NCD-I dated 24.09.2002 and SWG/Neuro/ 20/2005/NCD-I dated 31.01.2006. None of the authors have any financial interests in this study.

Disclosure
We confirm that we have read the journals position on issues involved in ethical publication and affirm that this report is consistent with these guidelines. None of the authors have received any financial remuneration for the project and we have no other conflict of interest.

References
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