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The prevalence of multiple sclerosis in the north Caucasus region of Turkey: door-to-door epidemiological field study/Multipl skleroz prevelansi: Turkiye'nin kuzey dogusunda epidemiyolojik saha calismasi.

Introduction

Multiple sclerosis (MS) is an inflammatory demyelinating, chronic disease, affecting the central nervous system (CNS), with presumed autoimmune etiology. It affects mostly young adults, leading to the emergence of various signs and symptoms, often disabling, with no estimated duration and possible remission (1,2).

Genetic and environmental factors are unequivocally related to susceptibility and expression of the disease. MS displays a unimodal distribution between 20-40 years of age, with a higher incidence in females and Caucasians (3).

There are different results revealed by prevalence studies conducted on MS in different parts of the world, being higher in regions located between the paralels 44 and 64N. Areas considered as of high prevalence are those with more than 30 cases per 100000, average prevalence areas with 5 to 30/100000, and low prevalence areas less than 5/100000. Studies carried out recently report increased MS prevalence rates (4-11).

There is a limited number of studies conducted in our country; no data for north-eastern Turkey are available. Studies were performed in the western Turkey where there are high social-economic state and similar geographic features. Both studies were done with different methodology. The first study carried out in Edirne in 2003 (12), a neighboring city of Istanbul, showed a prevalence rate of 33.9/100000 based on hospital records. In the second study that was carried out in Maltepe, a district of Istanbul, the prevalence rate was 104.1/100000 based on a door-to-door epidemiological survey (6).

In this study, we aimed at identifying MS prevalence in Kars province in north-east Turkey, a region differing from other regions with its climatic and geographical characteristics and low socio-economical status.

Method

The project was carried out as a descriptive cross-sectional field study in Kars, a city in north east Turkey, from November 2008 to May 2009. Approval of the ethics committees of Kafkas University Medical Faculty and informed consent of the patients and healthy individuals were obtained. The study was designed as follows.

Geographical and Social-Demograp hical

Characteristics of Kars

Kars is a province located in north east Turkey with geographic coordinates of 40[degrees] 00'N latitude and 43[degrees]50'E longitude, at altitude of 1768 meters. There are 76.992 inhabitants in Kars (13). Geographic and climatic conditions of the region greatly differ from those of western provinces of Turkey. Extreme climate changes are observed between the seasons, where winters are extremely cold (annual temperature varies between -43[degrees]C and +30[degrees]C). Socioeconomic level is very low in Kars and its environs (Figure 1).

Target Population

In the literature, the prevalence of MS in Mediterranean countries appears as 50/100000 (7,8,9,10,11). We calculated this figure using a 95% confidence level and a deviation range of 5 perq 10000; the number of persons needed to be interviewed was 6983.

Screening Forms

The questionnaire covered a total of 26 questions in 2 sections. The first section assessed the knowledge about MS, while the second dealt with MS symptoms. The questions inquired about the presence of present and past symptoms, motor and sensory dysfunction, walking ability, sphincter control, sleep, balance disturbances, ataxia, depression, increased fatigability and memory disturbances.

Establishment of the Neuroepidemiological Field

Teams and the Study Procedure

Two teams which consisted of five persons each (one neurologist, 4 nurse per team) were set up in order to obtain reliable and precise data with a correct provisional diagnosis.

The teams conducting the field interviews received practical training. The interviewers were informed about the steps of the procedure to be followed, that is, which doors to knock on, what to do if nobody answers the door, the methods of intervention how to address the questions and how to fill in the forms. They were trained by neurologists and public health specialists for two days on both theoretical and practical aspects. The teams conducted their visits between 08:30 a.m. and 05:00 p.m. both on weekdays and over the weekend.

In order to ensure unbiased selection of the numbers of streets and houses like 3rd street, 3rd apartment etc., a key number '3' was taken from the random numbers table. The study started in front of the local administrative authority offices in each neighborhood. The team, by turning their back to the office building turned right, visited the third house, block of flats, office or public office and then continued on to the next third building.

When they could not find anyone at a given location, they moved onto the next one. When there were more than 12 people in a particular location they visited, they interviewed them consecutively starting from the youngest person. The interviews with children or elderly who could not be communicated effectively were performed with the help of their caregivers. In instances where someone refused to participate, the interviewers simply moved on to the next location.

The Field Study

Phase 1. For the adults and children with the ability to cooperate, the questions were asked directly and the questionnaires were filled in. For those who could not cooperate, the questions were asked to people accompanying them. If a person answered affirmatively to one or more of the questions in the section about MS symptoms, the neurology resident in the team examined this person.

Phase 2. The patients who were provisionally diagnosed with demyelinating disease, MS, optic neuritis or paraplegia during the field visits by the field teams were invited to the hospital to be examined by a neurologist blinded to the study. Those unable to come were visited and examined in their homes.

Diagnosis

Previous examination results and MRI images were studied. All patients were examined and the findings were recorded. If needed, further investigation (such as immunological screening, MRI, evoked potential) was conducted at our hospital. The Barkhof-Tintore criteria (14,15) were used to classify any MRI abnormalities. The results were assessed by using the McDonald's criteria (16), and the diagnosis was established. The Kurtzke Expanded Disability Status Score (EDSS) was used to assess disability levels (17).

Data Analysis

All data collected by the field teams were entered daily by using SPSS version 11.05 for statistical analysis.

Results

The field study lasted for three weeks. With door-to-door visits, we covered a total of 7249 (female: 3622, male: 3627) people with a mean age of 28.26 [+ or -] 17.49 years. Fortunate for us, everybody agreed to take part in this study.

[FIGURE 1 OMITTED]

We examined those giving at least one positive response to the questionnaire for suspected MS. Four (3 females, 1 male) people had a previous diagnosis of MS, and we confirmed their diagnosis. The remaining patients had clinically and radiologically definite MS based on the McDonald criteria (16). Of the patients who were diagnosed as having MS, four had at least two previous cranial MRs performed and four had at least one cervical MRI available.

Three people (2 females, 1 male) with a suspicion of MS were questioned and examined thoroughly; the man was found to have cerebrovascular disorder, one of the women had experienced sensory complaints once. She has been previously diagnosed with vasculitis. The other woman was considered as having possible MS. This patient complained of hypoesthesia in the facial region. Her cranial MR images showed 5-6 demyelinating plaques and the CSF examination was found normal.

During the field visit, one patient was diagnosed with MS for the first time; she had a 3-year history of symptoms. She was experiencing an attack at that time. She was asked to come to the hospital for the treatment of this episode, and she was given IV methylprednisolone for 10 days. Her cranial MR images were obtained in our clinic and contrast-enhancing demyelinating lesions compatible with MS were found.

We have detected a total of five MS patients during the study.

Spinal tapping was performed in four patients and IgG levels and oligoclonal bands were examined in cerebrospinal fluid (CSF) samples. 3 patients had positive oligoclonal bands. Of the 5 MS patients, 4 were women and 1 was man and the mean age was 35.1 [+ or -] 10.2 years.

The prevalence of MS in Kars province was calculated as 68.97/100000. The prevalence was 110/100000 for women and 27.5/100000 for men. The age at the onset of the disease was 27.3 years on average and the mean disease duration was identified as 7.25 [+ or -] 2.6 years. The distribution of epidemiological data from patients with MS in Kars is given in Table 1.

During the course of the illness, there were sensory symptoms in 5 (100%), brainstem-related signs in 4 (80%), cerebellar signs in 1 (20%), motor signs in 4 (80%), optic neuritis in 2 (40%), sphincter disturbance in 1 (20%) and cerebral signs in 1 (20%) patient. The mean final EDSS score for all patients diagnosed with MS was calculated as 1.5 [+ or -] 0.7 (0.5-2.0).

Discussion

We found a prevalence rate of 68.97/100000 for MS in Kars, which is located in the north eastern region of Turkey. In a similar study that was recently performed in Maltepe, a district of Istanbul, the prevalence rate was 104.1/100000 based on a door-to-door epidemiological survey (6), carried out with the methodology same as in the current study. The prevalence rate in our study was lower compared to that study. However, according to the hospital records, Edirne (2003) (12), a neighboring city to Istanbul, had a prevalence rate of 33.9/100000. Our study had higher figures than that one. Hospitalbased and population-based studies yield different results. Furthermore, Kars is a province at a high altitude and with extreme climatic conditions. It has severe winters, while summers are short with relatively low temperatures. We think that climate could have influenced the figures we have obtained.

In the countries neighboring Turkey, the prevalence rate was 38.9/100000 in Greece (2003) (18) and 39.3/100000 in Bulgaria (1997) (19). Our results were higher than those of the neighboring countries. When we compare these results with others from Mediterranean countries, our prevalence rate was much higher than in any previously reported study such as that from Spain (20), Cyprus (21) or the other Mediterranean countries (7,10,11). The prevalence rate in Northern Europe (46 [degrees] N) is higher than in Southern Europe on average, with rates often over 100/100000 (5). Rates from Southern Europe (between latitudes of 36[degrees]00'N and 46[degrees]00'N) are generally lower than those from the north and range between 26 and 83 per 100000 (22). A study recently performed in Germany, another Middle European country, reported a prevalence of 111 per 100000 (23).

Studies performed in Iran (24) and Iraq (25), neighboring Turkey in the Middle East, revealed increased prevalence as well. However, they were hospital-based observational studies. Similarly, a recent hospital-based study in Jordan, covering a certain time period, found a prevalence of 39/100000 (26). Nevertheless, in countries like Turkey, some hopeless MS patients may quit the treatment and continue to live at home for years without attending the hospital. That is why hospital-based studies are far from reflecting the reality. Furthermore, in these countries and ours health inventories and filing systems are insufficient and hospitalbased studies do not yield correct results.

Based on the previous reports by World Health Organization, the prevalence rate in Turkey is high as well (4). There might be different reasons for that, first of all, a more rapid diagnosis is possible thanks to the advances in health care and in imaging modalities. Moreover, prevalence rates should be interpreted in the context of the geographical, climatic and economical conditions of the region the study was performed.

Kars province is situated in a geographical location with low socio-economic characteristics. Those with economical capabilities migrate to larger regions when confronted with chronic diseases. In fact, the actual prevalence may be much higher when migration is taken into consideration. When we pay attention to the economical and social progress Turkey has made during recent years, we can anticipate the prevalence studies to be performed in future to yield different results.

Conflict of interest: The authors reported no conflict of interest related to this article.

Cikar catismasi: Yazarlar bu makale ile ilgili olarak herhangi bir cikar catismasi bildirmemislerdir.

DOI: 10.4274/npa.y6152

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Recep ALP [1], Selen ILHAN ALP [2], Yilmaz PLANCI [3], Zuhal YAPICI [4], Ulku TURK BORU [5]

[1] Namik Kemal University Faculty of Medicine, Department of Neurology, Tekirdag, Turkey

[2] Government Hospital Department of Neurology, Tekirdag, Turkey

[3] Dicle University Faculty of Medicine, Department of Public Health, Diyarbakir, Turkey

[4] Istanbul University Faculty of Medicine, Department of Neurology, Istanbul, Turkey

[5] Dr. Lutfi Kirdar Kartal Research and Education Hospital, Department of Neurology, Istanbul, Turkey

Correspondence Address/Yazisma Adresi: Dr. Recep Alp, Namik Kemal University Faculty of Medicine, Department of Neurology, Tekirdag, Turkey

Gsm: +90 532 482 85 65 E-mail: recepalphotmail.com Gelis tarihi/Received: 27.04.2011 Kabul tarihi/Accepted: 19.10.2011
Tablo 1. Distribution of epidemiological data

 Gender

Epidemiological data Female n Male n Total n

Disease duration

 <1 year -- -- --
 1-5 years 1 -- 1
 5-10 years 3 1 4

Clinical forms

 Relapsing remitting 4 1 5
 Secondary progressive -- -- --
 Primary progressive -- -- --

Initial symptom

 Optic neuritis 2 1 3
 Brainstem/cerebellum 2 -- 2
 Sensory 2 1 3
 Motor 1 -- 1
 Others 2 1 3
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Article Details
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Title Annotation:Research Article/Arastirma Makalesi
Author:Alp, Recep; Alp, Selen Ilhan; Planci, Yilmaz; Yapici, Zuhal; Boru, Ulku Turk
Publication:Archives of Neuropsychiatry
Article Type:Report
Date:Dec 1, 2012
Words:2957
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