Pediatric Neurology in Africa

Fellowship program builds skills for health practitioners

Doctors trained in the management of child neurology conditions are lacking in Africa^1,2. Epilepsy is one of the major disease burdens in the continent and training in this area is even more scarce. EEG interpretation in children is very different to that for adults and grave errors can occur in patient management when misinterpretations occur.

The African Paediatric Fellowship Program (APFP) is a project developed by the Department of Paediatrics and Child Health at the Red Cross War Memorial Children's Hospital, under the University of Cape Town in South Africa, to build skills capacity of health practitioners from Africa. The center is the largest dedicated children's hospital in sub-Saharan Africa. Children are managed across primary to quaternary levels of care with the spectrum of diseases prevalent in Africa.

Figure 1. – Some of the 2014 APFP fellows attending the end-of-year discussion group. Dr. Kija, child neurology trainee from Tanzania, is fourth from the left. Represented in the group are doctors training in areas from paediatric urology to paediatric rheumatology from areas in Africa inclusive of Uganda, Zambia, Kenya, Ghana, Zimbabwe and Malawi. The group remains as a cohesive support network and stay in contact after completion and following their return home.

The APFP formed collaborations with tertiary centers across Africa and has assisted their identification of strategic training requirements based on their countries' key health care needs. Structured training occurs at the paediatric units through the University of Cape Town. More than 65 specialists have completed, or are completing in 2015, the training program in diverse paediatric areas, referred from 33 centers in 12 different African countries. There has been a 98 percent retention rate of trainees returning to work in their home country since 2008. The program is evolving with training arms supporting nursing and ancillary services. The trainee becomes the trainer in his or her home center, and a key opinion leader equipped to lobby for changes to health care policy (Figure 1).

The grant provided by the WFN to support neurology training in 2013 has enabled the focused training for six general pediatricians from different centers in Nigeria, and three further trainees from Zimbabwe, who manage large caseloads of children with neurodisabilities and epilepsy. The University of Cape Town rolled out in 2015 a post-graduate diploma in "basic electrophysiology interpretation and the management of children with epilepsy." This requires one-on-one training with a focus on areas relevant to the African context. The aim of the post-graduate diploma is to establish safe practice and not to train accredited epileptologists. In Africa, most child health practitioners who manage children with neurologic disorders must address the comprehensive needs of the child inclusive of the other health issues, such as co-infections, nutritional deficits, and social challenges (Figures 2 a, b).

At the current time in most African settings, it is not viable to work as an epileptologist without addressing these other health care issues (Figures 3 a, b). However as a result of more cost-effective neurophysiology equipment, and through equipment donations, there are an increasing number of EEG machines that are potentially being operated and interpreted by health practitioners with no pediatric training. This training program was devised out of the needs that this situation created. The audit of the preliminary findings of a pilot study on the impact of the training course while it was being established is in press. The audit confirmed that access to a basic handbook improved EEG interpretation skills, but that the optimal outcomes were seen in those doctors who had additional one-on-one training.

Figure 2.a. – Children attending the neurology clinic at Red Cross War Memorial Children's Hospital, enjoying a donation of new reading books.	Figure 2.b – One of the neurology patients occupied in puzzle play in the waiting area.

Between 2013 and 2014, three doctors from Nigeria, Tanzania and Ghana entered the APFP for formal training to become accredited child neurologists. Tanzania has no accredited child neurologists and Ghana has two. These trainees, in addition to completing the full post-graduate clinical master's degree in child neurology, also are completing research in areas relevant to the context they work in. The doctor from Tanzania is heading a prospective study to review the effects on bone mineral density in children on antiepileptic drugs in the African setting. Vitamin D supplementation is not part of standard care of these patients and it is hoped that the findings from this study will lead to data to support lobbying for this intervention to be part of standard practice. The doctor from Ghana will complete a study assessing the neurobehavioral influences on children from antiretroviral therapy. The doctor from Nigeria has completed a large prospective study assessing the efficacy of attaining sleep EEGs in children using melatonin.

In the next training cycle it is hoped that there will be funding to support applicants from Sierra Leone, Zimbabwe, Uganda, Kenya, Sudan and Zambia.

The training curriculum, while in line with international templates, also accommodates approaches novel to Africa, such as the neurological care for children with tuberculous meningitis, HIV, malaria and neurocysticercosis. The perinatal complication rates remain high in Africa with significant numbers of neonates suffering hypoxic ischaemic encephalopathy. Other neuroinsults are seen from the effects of central nervous system infections and motor vehicle accidents. The training must accommodate these areas in depth as well. The returning trainee must often function in all areas from social welfare to rehabilitation, the training is adjusted for this.

Figure 3.a. – Mothers attending the Queen Elizabeth Hospital, Blantyre, in Malawi, taken during an APFP site visit in 2013. This is the main teaching hospital in the country, which has one paediatric neurologist for the total population.	Figure 3.b. – Child-care workshop for children with motor disabilities at the Child Rehabilitation Unit, Harare Hospital, Zimbabwe, taken during the APFP site visit to the referring units in the country in 2014.

Prevention and early intervention is one of the major aims for this project and all trainees in the program are facilitated in the knowledge gained during their training and assess its relevance to their home setting, how to introduce these skills to the optimal benefit to child health care and how these interventions can extend across all levels of health care—from primary to tertiary.

On the trainee's return to their home center they maintain contact with their supervisor, and site visits are scheduled as needed to provide local input into service development and local training (Figure 3 a, b). Research collaborations also continue. These trainees are having a real impact in their home centers and are becoming voices in Africa lobbying to promote child health. One of the child neurology trainees who completed training in 2009 and returned to Kenya now sits on the national Kenyan paediatric body, assists selection of ongoing APFP trainees referred from the country, and is also on the Paediatric Commission for the International League Against Epilepsy. This trainee is part of a team developing its own subspecialty training program for East African doctors. This is viewed as a major future aim of the APFP. In order to grow and to fulfil the health care needs for the continent, more training sites are needed. It is important these remain within Africa with training relevant to the diseases of the region. There is much to learn from the approaches many innovative African centers undertake to cope with the challenges of scare resources.

While training experience in overseas centers offers obvious gains in skills development, the local relevance of the training may be questionable and the risk of the "brain drain" is high. A number of overseas specialists have opted to spend time working, training and lecturing in African centers. This is a superb way to assist skills development in African centers. Building on these relationships with regular visits develops sustained skills where often none existed before.

References

1. Wilmshurst JM, Badoe E, Wammanda RD, Mallewa M, Kakooza-Mwesige A, Venter A, Newton CR. Child neurology services in Africa. J Child Neurol. 2011 Dec; 26(12):1555-63.
2. Wilmshurst JM, Cross JH, Newton C, Kakooza AM, Wammanda RD, Mallewa M, Samia P, Venter A, Hirtz D, Chugani H. Children With Epilepsy in Africa: Recommendations From the International Child Neurology Association/African Child Neurology Association Workshop. J Child Neurol. 2013; 28 633-644

At time of print, Dr. Wilmshurst is the head of paediatric neurology, Red Cross War Memorial Children's Hospital, University of Cape Town, South Africa, and the director of the APFP.