1. Parkinson’s Disease in Africa Jacques Doumbé MD Department of Neurology Douala Laquintinie Hospital Cameroon

2. Introduction 1 Access to care continue to be limited in most countries. Most people with Parkinson Disease(PD) have likely not been diagnosed and never been treated. In some regions of the world,none of those that have been identified as having PD received care for their condition.

3. Introduction 2 To help increase access to care and to train providers around the world using technology, the Movement Disorder Society(MDS) launched a Telemedicine Task Force in 2012. MDS sponsors pilot projects in care,education,and research that can lay the foundation for reaching the majority of people with PD.

4. Definition 1 PD is a clinical syndrome caused by lesions in basal ganglia,predominantly in the substantia nigra,that produce deficits in motor behavior. The syndrome was first cogently described by James Parkinson in 1817 and named paralysis agitans by Marshall Hall in 1841. Both description and label stress reduction in muscle power unduly,however,omitting rigidity and slowness of movement(akinesia),crucial to the characteristic tetrad known as TRAP:

5. Definition 2 Resting Tremor Cogwheel Rigidity Bradykinesia/ Akinesia Postural reflex impairment. Of this tetrad,only resting tremor is truly suggestive of PD,and early sign that may remain prominent even late in the disorder. The others occur in varying degrees in orther forms of parkinsonism.

6. Classification Parkinsonism is associated with several pathologic processes that damage the extrapyramidal system. Its many causes are divided into : – Primary,or idiopathic(PD) – Secondary parkinsonism(drugs,toxins,vascular disease,trauma,tumor,infectious agents) – Parkinson-plus syndromes – Heredodegenerative diseases.

7. Diagnosis 1 The cardinal signs and symptoms of PD,when present in their entirety, impart the well- known clinical picture of resting tremor,rigidity,akinesia,and impairment of postural reflexes. The diagnostic approach has been categorized as: Clinically possible PD,the presence of any one of the salient features;

8. Diagnosis 2 Clinically probable PD,combination of any two cardinal features; Clinically definite,any combination of three of the four features. When not all the signs are evident,patient must be re-examined at several- month intervals.

9. Epidemiology 1 There is limited data in sub-saharan Africa. Articles published fell into four categories:clinical series(n=18),prevalence studies(n=8),incidence studies(n=1),genetic studies(n=3). The clinical series documented the occurrence of PD in Africa and described its clinical characteristics.

10. Epidemiology 2 The prevalence studies suggested some intracontinental geographic variation in PD prevalence. The published reports on PD in Africa emanated from 14 countries: – Eastern Africa (Kenya,Uganda,Tanzania,Ethiopia); – Western Africa(Nigeria,Senegal,Gana,Togo);

11. Epidemiology 3 Northern Africa (Libya,Tunisia,Algeria); Southern Africa ( Zimbabwe,South Africa); Central Africa ( Cameroon).

12. Epidemiology 3 The majority of prevalence studies used a WHO screening instrument and protocol for neurologic diseases. This WHO instrument was developed to measure the prevalence of common neurologic conditions in developing countries. The prevalence was between 7-20/100 000.

13. Epidemiology 4 The bulk of PD literature from Africa derived from clinical series of patients with neurologic diseases published either by foreign neurologists practicing in Africa or by African Neurologists. The only incidence study of PD in Africa was conducted in Libya. The crude incidence rate of PD was 4,5/100 000 per year;however,no sex or age-specific data were provided.

14. Epidemiology 5 An observational,cross-sectional study was conducted by Cubo et al,2013, to compare the clinical profile of a Cameroonian cohort of PD to the Spanish PD cohort: 74 patients with PD were included and there were no significant differences between the Spanish and Cameroonian cohort in terms of gender,age,PD duration and presence of comorbidities.

15. Epidemiology 6 Cameroonian PD patients were more affected in terms of motor severity,cognitive impairment,psychosis,patient and caregiver quality of live. In terms of treatments: cameroonian patients reported an intermittent use of PD therapies mainly due to economical limitations.

16. Epidemiology 7 PD therapies in Cameroon included levodopa (77%),anticholinergics (21,6%), ergotic dopamine agonists (1,4%). Anticholinergics therapy costs 3.5 euros/monthly Levodopa costs 25 euros monthly.

17. Epidemiology 8 In another recent study by Kuate et al,2013,conducted in a hospital in yaoundé,city capital of Cameroon,out of 4526 admissions between 2005-2011,20,1% were given a neurological diagnosis,and 2.9% were diagnosed with PD.

19. Limitations 1 The median number of neurologists per 100000 population is 0.6 in the low-income countries. In Cameroon, 1 neurologist per 1million population. The median number of neurological nurses per 100 000 population across different income groups of countries also varies. It is 0 for low- income countries, 5,04 for higher middle-income countries,and 0.38 for mild- income countries.

20. Limitations 2 The frequency of neurological disorders in various settings is a rough estimate; data were not collected and calculated using stringent epidemiological research methods as for prevalence studies. PD,like many other chronic diseases receives little recognition in the developing world.

21. Implications 1 Neurologists are essential in order to provide comprehensive neurological care and training. The inequity in the number of neurologists observed across countries in different income groups needs to be specifically dealt with. While training for neurologists is being pursued,specialized neurological nursing training has been neglected even in developed countries.

22. Implications 2 In countries where no formal training facilities exist for neurological nursing,general nurses can be trained to provide specific neurological care. Integration of neurological care for common illnesses into primary health care is essential for extending health services to underserved areas in developing countries.

23. Conclusion PD occurs worldwide but little is known about PD in Africa because: Lack of neurologists and neurological nurses Lower income Lack of solid health information system.