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Neuropsychiatric Disease and Treatment
Door-to-door survey of major neurological
disorders (project) in Al Quseir City,
Red Sea Governorate, Egypt
Hamdy NA El Tallawy1
Wafaa MA Farghaly1
Tarek A Rageh1
Ghaydaa A Shehata1
Reda Badry1
Nabil A Metwally2
Esam A El Moselhy2
Mahmoud Hassan2
Mohamed A Sayed3
Ahmed A Waris1
Yaser Hamed2
Islam Shaaban2
Mohamed A Hamed1
Mahmoud Raafat Kandil1
1Department of Neurology, Faculty
of Medicine, Assiut University, Assiut,
Egypt; 2Depar tme nt of N eurology and
Public Health, Faculty of Medicine,
Al-Azhar University (Assiut branch),
Assiut, Egypt; 3Department of
Neurology, Faculty of Medicine, Sohag
University, Sohag, Egypt
Correspondence: Wafaa MA Farghly
Assiut University Hospitals, Neurology
and Psychiatry Department, PO Box
71516, Assiut, Egypt
Tel +20 88 235 0833
Fax +20 88 235 1838
Email wafmaf2002@yahoo.com
Abstract: A door-to-door survey, including every household, was conducted for all inhabitants of
Al Quseir City (33,283), Red Sea Governorate, Egypt by three specialists of neurology as well as
nine senior staff members of neurology and 15 female social workers to assess the epidemiology
of major neurological disorders. Over six phases, from July 1, 2009 to January 31, 2012, screening
of all eligible people in the population was carried out, by which case ascertainment of all major
neurological disorders included in the study was done according to the accepted definitions and diag-
nostic criteria of the World Health Organization. The order of frequency of prevalence of the studied
neurological disorders was dementia (3.83% for those aged . 60 years), migraine (2.8% for those
aged . 8 years), stroke (6.2/1000 for those aged . 20 years), epilepsy (5.5/1000), Parkinson’s disease
(452.1/100,000 for those aged . 40 years), cerebral palsy (3.6/1000 among children , 18 years),
spinal cord disorders (63/100,000) dystonia (39.11/100,000), cerebellar ataxia (30.01/100,000),
trigeminal neuralgia (28/100,000 for those aged . 37 years), chorea (21.03/100,000), athetosis
(15/100,000), and multiple sclerosis (13.74/100,000). The incidence rates of stroke, epilepsy, and
Bell’s palsy were 181/100,000, 48/100,000, and 98.9/100,000 per year, respectively.
Keywords: prevalence, incidence, neurological disorders
Introduction
Over the last 3 decades, population-based studies aiming to determine the true burden
of neurological disorders have increasingly been acknowledged. Nevertheless, in
developing countries, the limited access of neurologists to rural areas and the logistic
and economic limitations to perform neuroepidemiological studies have significantly
complicated their implementation.1
However, a series of epidemiological studies was conducted in upper Egypt in
the last 2 decades. Epidemiologic research has progressed in Egypt, particularly over
the last 6 years, through two major projects to evaluate the incidence and prevalence
of different neurological disorders in Al Kharga district, New Valley and Al Quseir
City, Red Sea Governorate, Upper Egypt.
This project aimed to evaluate the incidence and prevalence of epilepsy and stroke;
the incidence of Bell’s palsy; and the prevalence of dementia, chorea, athetosis,
dystonia, Parkinson’s disease, cerebellar ataxia, multiple sclerosis, migraine, trigeminal
neuralgia, cerebral palsy, and spinal cord disorders.
Methods
Study area
The project was designed to assess major neurological disorders in Al Quseir
City as a representative coastal city lying on the Red Sea. Al Quseir City
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has a long history, dating from the pharaonic era when
it was named Thagho. At the time of the Batlamic and
Romanic eras it was named Leukos Limen and Poptus
Albus, respectively. Its population is representative of native
inhabitants and immigrants from different governorates
who reside there to participate in tourist activities, fishing,
and mining.2
All eligible inhabitants who had been living in Al Quseir
City for at least 6 months at the time of the interview were
included in the survey. The study duration extended from
July 1, 2009 to June 31, 2012 through different stages of
data collection, a preparatory stage, screening, data entry,
statistical manipulation, and tabulation.
All households (n = 33,285; 7497 families) and both
sexes, with 49.4% males (n = 16,428) and 50.6% females
(n = 16,857), were screened by three neurologists, in addi-
tion to 15 female social workers (for sociodemographic
data collection) via a door-to-door survey. A standardized
questionnaire, the sensitivity and specificity of which are 96%
and 93.2%, respectively,3 was applied by three neurologists
to every member of each family (children and elderly were
questioned through their caregivers). A total population of
31,754 (95.4%) were free from any neurological disorder,
versus 1531 (4.6%) of both sexes (3.9% [n = 647] males
and 5.2% [n = 884] females) had different neurological
disorders.
Full history data and examinations (general, systemic,
and neurological) were carried out by the three neurologists
in collaboration with nine other senior staff members from
neurology departments in Assiut, Al-Azhar, Sohag, and
Qena Universities.
All neurological disorders were finally diagnosed after
evaluation by the three neurologists, each separately, as well
as specific investigatory tools. Diagnoses of different neuro-
logical disorders were based on the accepted definition and
diagnostic criteria given by the World Health Organization.4,5
The definition of incidence rate, prevalence, and lifetime
prevalence in this study are according to those provided by
Abramson.6
Ethics
Ethical approval for the study was obtained from the
Research Ethics Committee of Assiut University and from
the Ministry of Health to carry out this project in Al Quseir
City, Red Sea Governorate. Each participant provided written
informed consent (children, illiterate, and disabled individu-
als consented through the responsible person in the family or
their caregivers).
Statistical analysis
Data management was carried out by two specialists in
data entry and three medical statisticians using SPSS soft-
ware (v 16; IBM Corporation, Armonk, NY, USA), Excel
( Microsoft Corporation, Redmond, WA, USA), and EpiCalc
2000 (Microsoft Corporation).
Results
The incidence rates of epilepsy, stroke, and Bell’s palsy
compared to worldwide rates are illustrated in Table 1. The
prevalence of the neurological disorders studied in Al Quseir
City is illustrated in Tables 2–4. Table 5 shows a record of
the prevalence of different neurological disorders studied in
Al Quseir City and worldwide.
Discussion
The increase in the number of different major projects to
study neurological disorders worldwide during the last 3
decades will help all of us to construct a map of neurologi-
cal disorders throughout the world and clarify the burden of
neurological disorder among different countries.
This study is a new one in the series of large epidemiologi-
cal studies carried out in our country to assess the burden of
neurological disorders at different localities in Egypt. Screening
was carried out through a door-to-door survey, including every
household, by using a standardized questionnaire,7 with subse-
quent clinical evaluation of all suspected cases by neurologists
(three specialists as well as nine senior staff members) in Al
Quseir General Hospital and Assiut University Hospital.
Table 1 Incidence rates of epilepsy, stroke, and Bell’s palsy in Al
Quseir City, Red Sea Governorate, Egypt
Incidence rate
(per 100,000
per year)
Previously reported worldwide
incidence rates (per 100,000
per year)
Epilepsy 48.0
(n = 33,285)
43.14 in Al Kharga District, Egypt7
43.4 in Ferrara, Italy8
63–158 in sub-Saharan Africa10
81.1 in Northern Tanzania11
16 in New York, NY, USA12
47 in England9
29 in The Netherlands13
Stroke 181
($20 years old;
n = 19,848)
250 in Al Kharga District, Egypt10
18.0 in Sohag, Egypt22
240 in France14
Bell’s Palsy 98.9
($9 years old;
n = 27,282)
51.89 in Al Kharga District Egypt
($8 years old)10
13–34 in USA16
52.8 (.15 years old) in Sicily, Italy
(1984–1987)17
20.2 in the UK (1992–1996)18
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Neuropsychiatric Disease and Treatment 2013:9
study was higher than that recorded in New York, NY, USA
(16/100,000)12 and in The Netherlands (29/100,000).13
Although the incidence rate of stroke in Al Quseir City
was lower than that recorded in France14 and other areas of
Egypt (Al Kharga district, New Valley),7 it is similar to that
recorded in Sohag, Upper Egypt.15
The incidence rate of Bell’s palsy in Al Quseir City was
higher than that recorded worldwide.7,16–18
The great variation in the incidence rate of epilepsy,
stroke, and Bell’s palsy in Al Quseir City in comparison to
incidence rates worldwide could be attributed to the different
genetic characteristics of the population in Al Quseir City,
where the population contains a mixture of native inhabit-
ants and immigrants from different adjacent governorates,
and thus a variable (not distinct) genetic predisposition for
various neurological disorders.
Study of age-specific prevalence of some neu-
rological disorders in Al Quseir City revealed that
dementia (3.83% of those aged $ 60 years) was the
most frequent, followed by migraine (2.8%), stroke
(6.2/1000), epilepsy (5.5/1000), Parkinson’s disease
(452.1/100,000), and cerebral palsy (3.6/1000). However,
less frequent neurological disorders were spinal cord
injury (63.0/100,000), dystonia (39.1/100,000), cerebellar
ataxia (30.0/100,000), trigeminal neuralgia (28/100,000),
chorea (21.0/100,000), athetosis (15.0/100,000), and
multiple sclerosis (13.7/100,000).
MacDonald et al’s UK study found that stroke was the
most frequent neurological disorder, followed by epilepsy,
then Parkinson’s disease, and, finally, multiple sclerosis.9
On the other hand, in a Mexican rural community in 2011,
Quet et al found that headache was the most frequent neu-
rological disorder, followed by epilepsy, stroke, Parkinson’s
disease, and cerebellar ataxia.19
Table 2 Prevalence per 1000 of cerebral palsy, stroke, and
epilepsy in Al Quseir City, Red Sea Governorate, Egypt
Neurological
disorder
Age of patients n Prevalence
per 1000
Epilepsy All ages 33,285 5.5
Stroke* $20 years 19,848 6.2
Cerebral palsy ,18 years 12,093 3.6
Note: *One case, aged ,20 years, is not shown in the table.
Table 3 Prevalence per 100 of dementia and migraine in Al
Quseir City, Red Sea Governorate, Egypt
Age of patients n Prevalence per 100
Dementia
$50 years
$60 years
$70 years
$80 years
4663
2113
692
158
2.01
3.83
8.12
13.5
Migraine*
$8 years 27,804 2.8
Note: *No recorded cases of migraine in those aged , 8 years.
Table 4 Prevalence of extrapyramidal syndromes, cerebellar
ataxia, trigeminal neuralgia, multiple sclerosis, and spinal cord
injury per 100,000 population
Neurological
disorder
Age of
patients
n Prevalence
per 100,000
Extrapyramidal syndromes
Parkinson’s disease $40 years 8183 452.1
Chorea All ages 33,285 21.03
Dystonia All ages 33,285 39.1
Athetosis All ages 33,285 15.0
Cerebellar ataxia All ages 33,285 30.0
Trigeminal neuralgia $37 years 9142 28.0
Multiple sclerosis $17 years 21,774 13.74
Spinal cord surgery All ages 33,285 63.0
The limitations of this study include:
• The stigma of some neurological disorders (eg, the view
of epilepsy as an “evil” attack and dementia as a normal
aging process) necessitates extraneous effort from the
project team to clarify the nature of these disorders and
their suitability to treat.
• Noncompliance by the patients with the prescribed
treatments due to scarce financial resources and lack of
health care systems suited for long term needs of chronic
neurological disorders.
These limitations required an extra effort on the project
team to encourage participation of most inhabitants
through:
• Detailed explanations of the project goals by the members
of the project team and responsible authorities in the
defined area of the study.
• Recruitment of well-known key persons, as well as female
social workers, among native inhabitants, who accompa-
nied the screening team to facilitate family interviews and
encourage participation.
• A capture–recapture method for those who were not
present at their homes during the first visit, whereby they
were visited again.
The incidence rate of epilepsy (48/100,000 per year) in Al
Quseir City is within the international rate7–9 and lower than
that recorded in sub-Saharan Africa10 and Northern Tanzania.11
Meanwhile, the incidence rate of epilepsy (48/100,000) in this
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Neuropsychiatric Disease and Treatment 2013:9
Table 5 Prevalence of different neurological disorders worldwide per 100,000
Study D M S E P CP DY CA TN C A MS SCD
Present study (Al Quseir, Egypt) 3830 2800 620 550 452.1 360 39.1 30 28 21.03 15 13.74 63
El Tallawy et al (Al Kharga, Egypt)74450 – 560 698 213.15 203 30.36 38 – 31.96 1.6 – –
MacDonald et al (UK)10 – – 900 400
Active
200 – – – – – – 200 –
Gourie-Devi et al (Bangalore India)23 – 967 150 883 76 – – – – – – – –
Benamer (Libya)24 – – – 190 60 – – – – – – 5.9 –
Quet et al (rural Mexican community)1– – 290 390 170 – – 30 – – – – –
Kandil et al (Assiut, Egypt)22 – – – – – – 26 – – 62 12 – –
Note: – means disorders not included in the study.
Abbreviations: D, dementia; M, migraine; S, stroke; E, epilepsy; P, Parkinson’s disease; CP, cerebral palsy; DY, dystonia; CA, cerebellar ataxia; TN, trigeminal neuralgia;
C, chorea; A, athetosis; MS, multiple sclerosis; SCD, spinal cord disorders.
In the Al Kharga district, the order of frequency of preva-
lence of the neurological disorders studied was as follows:
dementia, epilepsy, stroke, Parkinson’s disease, cerebral
palsy, cerebellar ataxia, chorea, dystonia, and athetosis.7
These variable results of different epidemiological studies
might be attributed to differences in the methodology and
types of neurological disorders studied; the impact of differ-
ent environmental factors in diverse geographic areas; and
different genetic compositions of the studied populations.
The prevalence of multiple sclerosis (13.7/100,000) and
spinal cord disorders (63/100,000) (18/100,000 traumatic
and 45/100,000 nontraumatic causes) in Al Quseir City are
the first results of a community-based epidemiological study
in Egypt.
While Radhakrishnan et al recorded a lower prevalence of
multiple sclerosis in Libya (5.9/100,000)20 than that recorded
in our study, MacDonald et al recorded a much higher
prevalence (200/100,000) in the UK.9 On the other hand,
an intermediate figure (33.9/100,000) for the prevalence of
multiple sclerosis was recorded by Çelik et al in the metro-
politan area of Edrine City, Turkey.21 This wide variation
in the prevalence of multiple sclerosis worldwide could be
attributed to differences in climate, race, immigration, and
emigration, as well as varied genetic predispositions of the
studied sample frame.
This study clarified important issues regarding the epi-
demiology of the studied neurological disorders, which can
be summarized as follows:
1. The high prevalence of Parkinson’s disease (452.1/100,000)
in comparison with worldwide studies and those in other
localities in Egypt, which could be attributed to environ-
mental pollution by heavy metals (manganese, lead, and
phosphorus) in this area.
2. The higher prevalence of cerebral palsy (3.6/1000)
than in worldwide records and previously recorded
data in Al Kharga District, Egypt could be explained
by a lack of antenatal, perinatal, and postnatal care in
Al-Quseir City.
3. The lower prevalence of chorea in Al-Quseir City
(21.03/100,000) in comparison to the other two studies con-
ducted in our country (Al Kharga district: 31.96/100,000;7
Assiut: 62.00/100,00022) for rheumatic chorea could be
attributed to governmental efforts for the eradication of
rheumatic activities in the last few years.
Epidemiological studies represent a faithful mirror that
reflects the burden of neurological disorders worldwide.
Door-to-door surveys, with direct personal interviews with
both health-seeking and non-health-seeking individuals,
gives a better chance for diagnosing rare neurological
disorders. It remains the gold standard method of epidemio-
logical studies, especially in the absence of existing coded
data due to a lack of medical registry systems and health
insurance coverage.
Conclusion
1. This study had the aim of evaluating the prevalence of
trigeminal neuralgia, multiple sclerosis, and spinal cord
disorders for the first time in Egypt.
2. The study shows a high prevalence of Parkinson’s
disease, cerebral palsy, and stroke in Al Quseir City
compared with other cities worldwide.
3. The study shows a marked decline in the prevalence of
chorea in Egypt, compared to a previous study.22
Disclosure
The authors report no conflicts of interest in this work.
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