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Making cerebral palsy visible across the globe

In 2014, the epidemiologist Maureen Durkin wrote that cerebral palsy (CP) is ‘. . . an invisible public health problem in most of the world’. Nearly all our information about CP – its root causes, manifestation, and consequences – come from studies performed in just a handful of countries. Ongoing surveillance of CP is established in much of Europe and Australia, but even in some high-income countries (HICs) such as the USA, CP surveillance is limited and occasional. Durkin could find just seven population-based studies of CP from lowto middle-income countries (LMICs) published between 1987 and 2012. Since then, some useful papers have been published, notably from Uganda, where a population-based surveillance study was performed with as much rigor as any study performed in an HIC. That investigation began to lift the veil from CP in LMICs, finding that CP with a background of preterm birth was rare. The authors speculated (and the commenters agreed), that the rarity of CP in infants born preterm was due to the high mortality of severely ill infants in locations where newborn infant intensive care is unavailable. This finding is partially replicated in the report by Jahan et al., which adds to the modest literature on CP in LMICs by summarizing some early findings from CP registries in Bangladesh, Nepal, Indonesia, and Ghana. The three cohorts that are population-based (all but Ghana) also found fewer than expected cases of CP in infants born preterm. Jahan et al. suggest some other themes that differentiate CP in LMICs from CP in HICs. First, educational and rehabilitative services are much less available to children with CP than would be ideal. Second, poverty plays an even stronger role as a social antecedent of CP than it does in HICs, in part because of a high prevalence of home deliveries without trained birth attendants. Third, cases are skewed towards high severity, no doubt reflecting the difficulty of ascertaining milder cases. Even with fewer milder cases, and fewer surviving infants born preterm, CP prevalence is likely to be higher in LMICs than in HICs. This preliminary report does not give prevalence figures, but a study from Bangladesh showed a prevalence of 3.5 per 1000 live births and the Uganda study found a prevalence of 2.7 per 1000, both figures higher than in most HICs. The Uganda finding of a high proportion of post-neonatal cases – likely due to cerebral malaria – was replicated only in the Indonesian cohort where viral infections were thought responsible. A high percentage of CP in LMICs could be remedied with effective public health and primary care services. Bilirubin and anoxic encephalopathies could be prevented or managed. As Durkin pointed out in 2014, ‘. . . human development and the brain development of infants and children in LMICs are being compromised globally each day because of exposures and causes we know how to prevent’.