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3 Epidemiology and Prevention Epidemiologic research assesses epilepsy’s risk factors, burden, comorbidities, and outcomes to identify opportunities for prevention efforts. Although data are incomplete, it is clear that epilepsy is one of the most common brain dis- orders and is likely to increase in prevalence with the aging population. Most cases of epilepsy result from unknown causes, but some cases with known causes—such as neurocysticercosis and other brain infections, traumatic brain injury, and stroke—could be avoided. Epilepsy is linked to numerous physi- cal, neurological, mental health, and cognitive comorbidities, including heart disease, autism spectrum disorders, Alzheimer’s disease, depression, anxiety, and learning and memory problems. People with epilepsy are also more likely than others to have injuries, primarily seizure-related (e.g., fractures, burns, concussion), and to commit suicide. In addition to experiencing prejudice and discrimination, many people with epilepsy internalize feelings of stigma. Overall death rates, including from sudden unexpected death, are higher among people with epilepsy than in the general population. Actions needed to prevent epilepsy and its consequences include interventions to reduce the occurrence of epilepsy’s known risk factors, to eliminate seizures in people with epilepsy and mental health comorbidities, and to decrease felt stigma and epilepsy-related causes of death. E pidemiologic research in epilepsy aims to assess the risk factors for developing the disorder; to evaluate its burden, comorbidities, and outcomes; and to identify opportunities for preventing epilepsy and its consequences. Chapter 2 explores the various methodological and 109
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110 EPILEPSY ACROSS THE SPECTRUM measurement issues associated with epilepsy surveillance and describes sources for data collection. This chapter focuses on the gaps in epilepsy research in terms of what is known and not known related to incidence, prevalence, risk factors, comorbidities, and outcomes. These gaps suggest opportunities for prioritizing future epidemiologic studies in order to guide preventive and early intervention strategies. Improved epilepsy data collec- tion and measurement, as described in Chapter 2, are necessary for better epidemiologic research, along with well-designed and targeted studies to illuminate significant trends and inform health care providers, policy mak- ers, and the public. To improve knowledge regarding preventing epilepsy and its outcomes, the committee’s vision is for well-designed epidemiologic studies that high- light areas ripe for preventive efforts. Some, but by no means all, key focus areas are discussed here, including prevention of epilepsy, its comorbidities, and its consequences, including death. Before discussing these research ar- eas, the continuum of public health prevention is described as background. PUBLIC HEALTH AND PREVENTION In the context of public health, there are traditionally three levels of prevention: primary, secondary, and tertiary. Each aims to intervene at a different point along the continuum of a disease or disorder and involves different types of actions to ameliorate the condition or its impact. “Primary prevention” is the prevention of a disease or disorder before it begins, with the goal of decreasing its incidence in a population. For ex- ample, public health agencies, policy makers, and others work to eliminate environmental hazards (e.g., through sanitary measures such as ensuring clean drinking water), to improve disease resistance (e.g., through immuni- zation), and to decrease high-risk behavior (e.g., tobacco use) and promote healthy behavior (e.g., seatbelt use). In looking forward, future advances in biomedical research hold the promise of greater understanding of epilepto- genesis or possibly a cure; meanwhile, it may be possible to prevent some known causes of epilepsy, such as neurocysticercosis through education and sanitary measures, other brain infections through vaccines, traumatic brain injury (TBI) through seatbelt and helmet use, and stroke through reduction of known risk factors. “Secondary prevention” is the early identification and mitigation of a disease or disorder once it is present in the body but before it is symp- tomatic. For example, public health agencies collaborate with health pro- fessionals to screen a population (e.g., blood glucose or blood pressure screenings) and follow up to manage early symptoms and forestall the development of full-blown disease. Secondary prevention of epilepsy may be possible in the future, if biomarkers of epileptogenesis are identified and early intervention measures are developed.
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111 EPIDEMIOLOGY AND PREVENTION “Tertiary prevention” is the prevention of the progression of a disease or disorder and its outcomes after it has become symptomatic, in order to decrease the degree of resulting disability or impacts on health (i.e., to improve quality of life). For example, health professionals, together with public health agencies, work to minimize or eliminate exposures that make a disease or disorder worse (e.g., air pollution for people with asthma) and to screen for early detection of adverse outcomes (e.g., vision changes for people with diabetes). For chronic diseases and disorders, tertiary preven- tion is sometimes called disease management, although it should not be confused with medical treatment, and it may involve rehabilitation therapy, as after stroke. Some tertiary prevention efforts target the consequences of epilepsy (e.g., early identification of those who do not respond to seizure medications in order to identify options to prevent seizure recurrence), whereas others focus on its comorbidities (e.g., screening and interventions to identify and manage depression in people with epilepsy, described in Chapter 4). Future population health studies on comorbidities, including mental health conditions, and important outcomes (e.g., sudden unexpected death in epilepsy [SUDEP], injuries) may provide opportunities for success- ful interventions to promote optimal quality of life and avoid preventable deaths. INCIDENCE AND PREVALENCE Incidence Studies of the incidence of epilepsy describe the rate of new-onset epilepsy and the characteristics of newly diagnosed epilepsy. The annual incidence of epilepsy in the United States is estimated at approximately 48/100,000 people (Hirtz et al., 2007). This estimate represents the me- dian of a range of incidence estimates across all age groups. The hallmark longitudinal study of the epilepsies in the United States is the Rochester Epidemiology Project (described in Chapter 2), in which the incidence of epilepsy was examined in more than 2 million residents of Rochester, Min- nesota, across 5 decades from 1935 to 1984. The Rochester study found an age-adjusted incidence of 44/100,000 (Hauser et al., 1993). Based on the Rochester project, Hesdorffer and colleagues (2011a) estimated that 1 in 26 people (3.8 percent of people born today) will develop epilepsy over the course of their lifetime. However, this estimate is based on a nonrepresen- tative population from one community in the United States. Furthermore, diagnostic data from this study are out of date, given the advances in imag- ing and other medical technologies (e.g., none of the Rochester participants had available MRI [magnetic resonance imaging] data).
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112 EPILEPSY ACROSS THE SPECTRUM More recent studies have arrived at varying estimates of epilepsy incidence: • A population study in northern Manhattan reported an incidence of 41/100,000 (Benn et al., 2008). • Holden and colleagues (2005) looked at managed care organiza- tions and found an incidence of 47/100,000 for those who were continuously enrolled for 3 years and 71/100,000 for those en- rolled for 5 years. • In a health maintenance organization population, incidence for enrollees under age 65 was 35.5/100,000 (Annegers et al., 1999), although this age group would be expected to have a lower inci- dence than adults 65 years old or older, who have a high incidence of epilepsy (Thurman, 2011). Existing trend information suggests that the incidence of epilepsy may be declining in children and increasing among older adults (Hauser et al., 1993; Kotsopoulos et al., 2002; Sillanpää et al., 2011). However, it is not known whether these trends will continue or if changes in the distribution of risk factors for epilepsy (discussed later) are driving them. Research Gaps Epidemiologic research is needed in large, representative U.S. popula- tions to monitor trends in epilepsy incidence and related mortality and to track outcomes. Studies need to be conducted among the general popula- tion and in subpopulations at higher risk: children, for whom prognosis is a major concern; older adults, who have greater mortality associated with epilepsy; women, to track outcomes, including reproductive outcomes; as well as veterans and diverse racial/ethnic and socioeconomic groups, in order to assess any disparities in incidence, prognosis, and mortality and to determine opportunities for intervention. Within these subpopulations, sufficient numbers are needed to compare incidence by etiology, seizure type, syndrome, and the presence of comorbid conditions. With respect to treatment, these surveillance data could be used to monitor the outcomes of epilepsy care and provide feedback to health care providers (Box et al., 2010; Trevathan, 2011). As examples, specific populations for whom fur- ther research is needed—older adults, veterans, children, and people with epilepsy and associated comorbidities—are described below. Older adults The incidence of epilepsy is highest in children and older adults (Faught et al., 2012; Hauser et al., 1993; Kotsopoulos et al., 2002; Stephen and Brodie, 2000). By 2030, about 20 percent of the U.S. popula-
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113 EPIDEMIOLOGY AND PREVENTION tion will be age 65 or older, an increase from approximately 13 percent in 2010 (Census Bureau, 2011; IOM, 2008). Due to the aging of the popu- lation and increases in life expectancy, the number of older adults who develop or have epilepsy will increase. Some of the increase will be from known causes, such as stroke, dementia, and TBI, which is often due to falls. Better medical management of stroke has increased survival rates and, thus, the number of survivors at risk for epilepsy; the number of people with aging-related dementia also is increasing; and the incidence of fall- induced TBI is rising in older adults (Annegers et al., 1995; Broderick et al., 1989; Fuster and Bansilal, 2010; Kannus et al., 2007; Ramanathan et al., 2012; Tartaglia et al., 2011; Watson and Mitchell, 2011). Older adults with epilepsy may experience greater disability because of deteriorations in health due to advanced age, comorbid conditions, and greater likelihood of side effects from seizure medications due to altered pharmacokinetics and interactions with other medications (Faught, 1999). The resultant impair- ments can decrease quality of life and increase the need for health services and long-term care (Guralnik et al., 1996). In anticipation of a growing number of older adults with epilepsy, additional research is needed that fo- cuses on concerns specific to this population, including preventing adverse medication interactions and disability and maintaining independent living. Epilepsy takes freedom from those who suffer from it. We cannot allow our citizens who have fought for freedom to lose their own freedom. –Kevin Malone Veterans Returning service members from Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) are a specific population in which research on epilepsy incidence is needed, because TBI, the most com- mon injury of OEF-OIF (U.S. Army Traumatic Brain Injury Task Force, 2007), is associated with up to a 53-percent risk for posttraumatic epi- lepsy, depending on the severity of the injury (Salazar et al., 1985). The number of service members who survive after sustaining a serious injury is higher now than for any previous war (Goldberg, 2010; Lowenstein, 2009). Between 2001 and 2007, an estimated 1.6 million U.S. military personnel were deployed to Afghanistan and Iraq (Tanielian et al., 2008). Among a study population of approximately 868,000 service members, approximately 1,300 were hospitalized with a severe TBI, 1,550 with a moderate TBI, and 133 with a mild TBI (Wojcik et al., 2010). However, most people who sustain a mild TBI are not hospitalized, and many do not go to the emergency department (U.S. Army Traumatic Brain Injury Task Force, 2007), and mild TBIs comprise approximately three-quarters of all TBI cases in OEF-OIF service members (Armed Forces Health Surveillance Center, 2012). A report of the Armed Forces Epidemiological Board (2006) found that the Department of Defense (DOD) did not have a system-wide
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114 EPILEPSY ACROSS THE SPECTRUM approach for identifying, treating, and monitoring TBIs, especially mild cases. Since that report, the DOD has established and is working to imple- ment guidelines for the identification and treatment of mild TBI (U.S. Army Traumatic Brain Injury Task Force, 2007). Similarly, the Department of Veterans Affairs has also dedicated efforts to recognizing and managing mild TBI in OEF-OIF veterans (GAO, 2008). The emphasis on improved surveillance and care of mild TBI in today’s conflicts contrasts with earlier eras, when attention focused on more severe, penetrating TBI (Evans, 1962; Salazar et al., 1985). Studies of returning veterans require validated diagnosis of the severity of TBI and follow-up to monitor a range of potential outcomes, includ- ing the onset of epilepsy. Questions about the validity of the diagnosis of mild TBI have arisen in connection with a study of 2,525 service members answering a questionnaire after 1 year of deployment in Iraq, where symp- toms of mild TBI were reported by 15.2 percent (Hoge et al., 2008). An accompanying New England Journal of Medicine editorial highlighted the difficulty of separating symptoms of mild TBI from posttraumatic stress disorder (PTSD) and other psychological reactions due to the emotional trauma of wartime (Bryant, 2008). Because TBI among returning veterans may be associated with an increased risk for developing epilepsy, work to distinguish mild TBI from PTSD is crucial. PTSD itself is associated with the occurrence of seizure-like events that are not epilepsy (D’Alessio et al., 2006). Recently, Salinsky and colleagues (2011) found that there is a sig- nificant delay in the diagnosis of seizure-like events with a psychological basis in veterans treated with seizure medications, suggesting a presump- tive diagnosis of epilepsy. Among veterans with seizure-like events with a psychological basis, the delay in diagnosis was nearly five times as long as for civilians, and the cumulative treatment with seizure medications was four times higher. Progress in distinguishing between mild TBI and PTSD as well as between epilepsy and seizure-like events with a psychological basis is needed to determine the incidence and prevalence of TBI-related epilepsy among veterans and to provide optimal care. Children The most catastrophic forms of epilepsy occur in children, par- ticularly young children. Previous incidence studies have not assembled a sufficiently large incidence cohort of children with epilepsy to study the prognosis of most individual syndromes. However, it has been possible to study risk factors for poor seizure prognosis in childhood onset epilepsy overall, the risk for status epilepticus (SE), and the risk for early refractory epilepsy1 in different etiologic categories (Arts et al., 2004; Berg et al., 1 As noted in Chapter 1, refractory epilepsy is defined as the failure to control seizures after two seizure medications (whether as monotherapies or in combination) have been appropri- ately chosen and used (Kwan et al., 2010) (see also Chapter 4).
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115 EPIDEMIOLOGY AND PREVENTION 2001a,b; Camfield et al., 2002; Sillanpää and Shinnar, 2002, 2010). How- ever, studies have focused on common syndromes, and studies that have elucidated risk factors for poor prognosis within specific syndromes have been rare (Wirrell et al., 1996). Future studies of unselected incident cohorts of children with epilepsy are needed to assemble large enough cohorts with rare syndromes to study factors affecting prognosis. Epilepsy accompanied by comorbidities There is some evidence (see the discussion below on comorbidities) that the prognosis for epilepsy is worse in the presence of comorbidities that predate the diagnosis of epilepsy. Because comorbidities may influence epilepsy prognosis and are known to affect quality of life, studies of the incidence of epilepsy in people with comorbidities at or before the onset of epilepsy will permit greater under- standing of the consequences of the disorder when it is accompanied by comorbidities. For example, case-control studies of people with newly di- agnosed epilepsy could be conducted retrospectively to identify preexisting comorbidities, or prospective cohort studies of individuals with depression or migraine could look at the incidence of epilepsy in these groups. These studies may provide a greater understanding of how the timing of epilepsy onset in relation to its comorbidities affects prognosis. Prevalence Studies of the prevalence of epilepsy provide information on its burden in the population. Prevalence data encompass the number of newly diag- nosed cases of epilepsy as well as cases of epilepsy that persist over time, which includes people with continued seizures and people who are in remis- sion but who take seizure medications. Except for rapidly fatal conditions, prevalence is greater than incidence, because it accounts for the accumula- tion of cases over time. Prevalence thus reflects the incidence, chronicity, and related mortality of epilepsy. Similar to incidence, there is a range of estimates of prevalence of epi- lepsy in the United States: • Hirtz and colleagues (2007) estimate annual prevalence at 7.1/ 1,000 people. • The Rochester Epidemiology Project found that prevalence in- creased from 2.7/1,000 in 1940 to 6.8/1,000 in 1980 (Hauser et al., 1991). • Kelvin and colleagues (2007) found a 5/1,000 prevalence in New York City. • The Centers for Disease Control and Prevention’s (CDC’s) Behav- ioral Risk Factor Surveillance System (BRFSS), which depends on
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116 EPILEPSY ACROSS THE SPECTRUM self-reporting, estimated 8.4/1,000 cases of active epilepsy2 (Kobau et al., 2008). If lifetime prevalence (i.e., ever having epilepsy) is considered, the BRFSS estimate increases to 16.5/1,000 (1.7 per- cent of respondents) (Kobau et al., 2008). Research Gaps More studies have been done on the prevalence of epilepsy than on its incidence because prevalence studies are easier and faster to conduct. Prevalence data are used to inform planning for resources and services to meet the health care and social needs of people with epilepsy. To obtain a complete picture of epilepsy, prevalence studies should be conducted us- ing the same data sources as those in which long-term studies of epilepsy incidence are conducted. Socioeconomic status (SES) and race/ethnicity are discussed below as examples of two areas in which further research on incidence and prevalence is needed. Socioeconomic status Low SES is associated with a higher incidence of epilepsy (Heaney et al., 2002). Hesdorffer and colleagues (2005) studied adults in Iceland and found that people with epilepsy are more likely to have low SES in comparison to age- and gender-matched controls without epilepsy. This association exists in a society with universal health care where everyone has health insurance, and it also persists in adults with epilepsy of unknown etiology, even after adjustment for cumulative alco- hol consumption, which could be a confounding factor. Furthermore, low SES is also associated with an increased prevalence of epilepsy (Morgan et al., 2000; Shamansky and Glaser, 1979). Reasons for this are not well understood because these studies did not distinguish between epilepsy of unknown etiology and epilepsy of known etiology, which is problematic because some known etiologies of epilepsy (e.g., TBI, stroke) may them- selves be associated with low SES (Chang et al., 2002; Cubbin et al., 2000). While associations between SES and the etiology of epilepsy is one possible explanation for the association between SES and prevalence, existing treat- ment gaps may play a role as well, since people of lower SES are less likely to obtain seizure medications or to be under the care of a neurologist than people of higher SES (Begley et al., 2009), making them more likely to experience persistent seizures (Chapter 4). Race/ethnicity A study in the Harlem neighborhood of New York City found epilepsy prevalence to be higher in Hispanics than in non-Hispanics 2 Defined as “a history of epilepsy and currently taking medication or reporting one or more seizures during the past 3 months” (Kobau et al., 2008, p. 1).
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117 EPIDEMIOLOGY AND PREVENTION and a higher prevalence of active epilepsy3 in whites than in blacks, although the prevalence of lifetime epilepsy4 was higher in blacks compared to whites (Kelvin et al., 2007). In this community, there were racial/ethnic disparities in care; blacks were more likely to receive care in the emergency department compared to whites and Hispanics. Similarly, Hope and colleagues (2009) found that blacks and Hispanics were more likely than whites to be diag- nosed in an emergency department, and blacks were more likely to receive a suboptimal seizure medication. Differences in care for prevalent epilepsy were also observed in residents of Alabama and surrounding states, where blacks were 60 percent less likely than non-Hispanic whites to undergo epilepsy surgery after receiving electroencephalograph (EEG) monitoring as part of a surgical evaluation, an association that persisted after control- ling for factors such as SES and medical insurance coverage (Burneo et al., 2005). The degree to which differences in epilepsy incidence and prevalence in different racial/ethnic groups reflect differences in socioeconomic status is unknown. Also unknown is the degree to which treatment gaps contribute to the higher epilepsy prevalence in some subgroups. Next Steps for Incidence and Prevalence Studies As described in Chapter 2, none of the recent estimates of incidence and prevalence are based on active and ongoing surveillance of epilepsy in the U.S. population over time. Updated and longitudinal data are needed from large, representative populations throughout the country to generate population-wide estimates of incidence and prevalence and allow subgroup analysis by severity and type of epilepsy, age, gender, race/ethnicity, geogra- phy, and SES. This information is necessary to have a complete understand- ing of the burden of epilepsy in the United States compared to other diseases and conditions, to show trends over time, and to learn whether specific populations carry a disproportionate amount of the epilepsy burden so that actions can be taken to provide needed health care and support services. Future studies of time trends in the incidence and prevalence of epi- lepsy conducted in large, representative cohorts will also be able to assess trends in remission, relapse, and refractory epilepsy. Although previous and ongoing prospective studies have examined these outcomes, the studies are mostly short term, outdated, and too small to enable subgroup analysis. A major contribution of the types of surveillance and population-based stud- ies suggested in this report would be the ability not only to report incidence and prevalence but also to examine the course of epilepsy overall and in 3 In this study, active epilepsy was defined as having ongoing seizures or taking a seizure medication within the previous 5 years. 4 In this study, lifetime epilepsy was defined as having a history of two or more unprovoked seizures.
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118 EPILEPSY ACROSS THE SPECTRUM subpopulations. Such data may allow assessment of how risk factors influ- ence the prevalence of epilepsy over time. Specific subgroups of interest include older adults, veterans, children, people with epilepsy accompanied by comorbidities, and diverse racial/ethnic and socioeconomic populations. These data are needed to know where and how to better focus epilepsy prevention and treatment efforts. RISK FACTORS Epilepsy Due to a Known Cause Cases of epilepsy that have a known etiology have a worse overall prognosis, more commonly involve persistent seizures, and have a higher mortality rate than cases in which the cause is unknown (Forsgren et al., 2005b; Hauser et al., 1998). Less than half of all newly diagnosed cases of epilepsy have a known structural or metabolic cause (Adelöw et al., 2009; Forsgren et al., 2005a; Hauser et al., 1993). Among people with newly diagnosed epilepsy, the predominant known causes are stroke, neurode- generative diseases such as dementia and multiple sclerosis, primary brain tumors or the spread of cancer from another site to the brain, and TBI (Annegers and Coan, 2000; Hauser et al., 1993; Herman, 2002; Hesdorffer et al., 1996a; Kelley and Rodriguez, 2009). Other known causes are rarer but confer a strong risk for developing epilepsy: brain infections, such as meningitis, encephalitis, and neurocysticercosis; pre- and perinatal in- jury; intellectual disability; cerebral palsy; and autism spectrum disorders (Annegers et al., 1988; Bergamasco et al., 1984; Carpio et al., 1998; Nelson and Ellenberg, 1987; Rocca et al., 1987; Tuchman and Rapin, 2002; Van der Berg and Yerushalmy, 1969). A recent study by Crump and colleagues (2011) found that preterm birth is associated with an increased risk of epilepsy in adulthood. Identifying causes of epilepsy is the first step in primary prevention. Prevention of posttraumatic epilepsy has been attempted through indirect means and planned interventions. Efforts to prevent epilepsy from devel- oping after TBI have involved randomized clinical trials of drug therapies; regrettably, these have not been successful (Temkin et al., 1990, 1999, 2007). Prevention of epilepsy after TBI is a complex problem, because the types, location, and extent of brain injury vary widely, and the process of epileptogenesis after TBI is not well understood. The heterogeneity of TBI has hindered the development of effective interventions to prevent poor functional outcomes in general. A systematic review of the literature found that only a third of randomized clinical trials of interventions to prevent negative health outcomes after TBI have been successful, underscoring the complexity of this injury (Hernández et al., 2005). Currently, the prevention of TBI itself allows the best opportunity to prevent posttraumatic epilepsy.
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119 EPIDEMIOLOGY AND PREVENTION Significant public health efforts have successfully increased the use of helmets and seatbelts to prevent TBI (Coronado et al., 2011). These measures to reduce the occurrence of TBI have likely led to a decrease in new cases of epilepsy associated with TBI, although this is undocumented. However, motor vehicle accidents are still among the leading causes of TBI (Bruns and Hauser, 2003; Coronado et al., 2011; Labi et al., 2003; Tagliaferri et al., 2006). Furthermore, in some populations, the incidence of TBI appears to be rising. For example, the number of visits to the emer- gency department because of TBI due to sports and recreational activities, in particular bicycling and football, increased from approximately 150,000 to 250,000 between 2001 and 2009 (Gilchrist et al., 2011). Therefore, TBI remains a significant public health problem, where people who participate in sports, especially children and adolescents, and members of the military and older adults (discussed earlier in the chapter) are at particularly high risk (Armed Forces Health Surveillance Center, 2012; Gilchrist et al., 2011; Ramanathan et al., 2012). The prevention of other risk factors for epilepsy could decrease the incidence of epilepsy as well. Prevention efforts for stroke often target its established risk factors, which include hypertension, cigarette smoking, and insufficient physical activity (Sacco et al., 1999). Results from the 2005 BRFSS found disparities in stroke prevalence among categories such as race/ ethnicity, age, and educational level (Neyer et al., 2007), indicating a need for targeted prevention programs. Prevention of brain infections such as meningitis through the use of childhood vaccines has proven to be effective (Robbins et al., 1996; Tsai et al., 2008) and should be continued. Among the known infectious etiologies of epilepsy, primary prevention associated with neurocysticercosis5 may be most likely to succeed. Neu- rocysticercosis is caused by infection of the nervous system by a type of tapeworm, Taenia solium, and is a major cause of epilepsy in many devel- oping countries throughout the world, including Latin America. Like other parasites that are transmitted through the digestive tract, tapeworms are spread to others through the consumption of food contaminated with the feces of an infected carrier, primarily due to poor sanitation, improper food handling practices, and inadequate hand washing. Neurocysticercosis is in- creasingly diagnosed in areas of the United States, especially the Southwest and other areas with large populations who travel to or immigrate from countries where the parasite is endemic (Del Brutto, 2012; Ong et al., 2002; White, 2000). For people who develop epilepsy from neurocysticercosis, 5 Cysticercosis is a parasitic infection with Taenia solium, an adult tapeworm, resulting from ingestion of the eggs of the tapeworm through consuming undercooked food (e.g., vegetables, pork) or water contaminated with the feces of a carrier of T. solium larvae. Cysticercosis that involves the central nervous system is termed neurocysticercosis and is the most common parasitic brain infection (DeGiorgio et al., 2004).
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