Multiple Sclerosis in Africa: An Overview 

 

By: Rukhsar Jabbar. M.Sc. Physiotherapy. Freelance Health Writer and Datelinehealth Africa (DLHA) volunteer. Medical review and editorial support provided by the DLHA Team.

 

Smiley student in a wheel chair as a consequence of nerve damage from multiple sclerosis. Smiley student image from Freepik.

 

 

What is Multiple Sclerosis and why should you know about it?

 

Multiple sclerosis (MS) is a disease in which your body’s immunity attacks the protective coverings of nerves (myelin) in your brain and spinal cord. The spinal cord is a continuation of nervous system content in the skull (I.e., the brain) into the canal of the bones of your back (i.e. vertebral canal).

 

Multiple sclerosis is commoner in women than in men especially those in the age group of 20 – 40 years. It may start with a sneaky flu-like attack and it may run different courses.

 

A tiny percentage of MS patients will experience a mild course with little to no disability, whereas the majority will experience brief flare-ups that are followed by extended periods of relative inactivity or dormancy, with either a partial or complete recovery. Another small group of patients may experience gradual worsening through off-and-on flare-ups that are continuos and cause increasing disability over time. The majority of MS patients have normal life expectancies, and the condition is rarely fatal. [2]

 

It is important that you know about multiple sclerosis because in most of sub-Saharan Africa, there is very low awareness of the disease and more importantly, the condition can be hard to diagnose as its symptoms mimic many other diseases of the body.

 

This lay article aims to improve awareness and education about multiple sclerosis among the general public and healthcare professionals in sub-Sahara Africa by providing readers with a broad overview of the condition; ranging from its prevalence, causes, risk factors, symptoms, diagnosis, treatment, and prevention.

 

 

How Common is Multiple Sclerosis in Africa?

 

Data on how common multiple sclerosis is across many sub-Saharan African countries are very few and originate primarily from South Africa. An estimate of one to two per 1000 people has been reported. [1]

 

Consistent with data from other parts of the world, epidemiological data from South Africa indicate that MS is three times more common in females than in males. It is also more common in the 20 – 40 years age group and the white population than in the blacks. [9] Many social determinant factors may be responsible for the racial skewing of MS in South Africa.

 

In the past, it was thought that the prevalence or occurrence of MS was extremely low in Sub-Saharan Africa, (SSA) maybe as a result of a lack of awareness about it and also a lack of access to advanced equipment like the Computerised Tomography Scanner (CT scan) and the Magnetic Resonance Imaging machine (MRI) to detect it.

 

More research is needed to ascertain the accurate incidence and prevalence of MS in the different countries of sub-Saharan Africa.

 

 

What causes Multiple Sclerosis?

 

The exact cause or causes of MS is not known, but doctors believe that a combination of environmental and genetic factors is most likely responsible for the condition. A germ (virus), the Epstein-Barr virus has been implicated as a possible cause. The evidence for a genetic predisposition to MS, is also supported by epidemiological studies that show that relatives of MS patients have a higher risk of developing the disease. [6]

 

MS targets the so-called "white matter," or myelin-protected axons in the brain and spinal cord (central nervous system). In addition, MS harms the fibres of the nerve (optic nerve) that carries visual information from the eye to the brain. The name "multiple sclerosis" describes the characteristic patches of scar tissue (sclerosis), also known as plaques or lesions that result from the immune system's attack on myelin. [2]

 

 

What May Place You at Risk for Multiple Sclerosis?

 

The following may increase your risk of having Multiple Sclerosis [6]:

• Obesity

• Female gender

• Working night shifts 

• Infection (with the Epstein-Barr virus)

• Living in a very cold environment

• Smoking and organic solvent exposure

• Low Vitamin D

 

 

Types of Multiple Sclerosis

 

MS starts in 1 of 2 general ways: with individual relapses (or worsening attacks) or with gradual progression.

 

• Relapsing-remitting MS

 

Eight to nine out of ten MS patients have a diagnosis of the relapsing-remitting kind.

 

Relapses are periods when a person with relapsing-remitting MS experiences either new or worsened symptoms.

 

This type of MS usually gets worse over a few days, persists for days, weeks or months, and then gradually gets better over a comparable amount of time. Relapses frequently happen suddenly, although they can also be linked to periods of illness or stress.

 

Relapse symptoms can go away completely with or without therapy, but some symptoms frequently linger, with recurrent episodes occurring over a period of years.

 

Remission times are those in between attacks. These can continue for several years. [7]

 

Many, but not all, of those with relapsing-remitting MS, go on to acquire secondary progressive MS after many years (sometimes decades).

 

• Secondary progressive MS

 

The symptoms of this kind of MS progressively deteriorate over time without any noticeable attacks. Even at this point, some people continue to relapse sometimes. [7] About two-thirds of patients with relapsing-remitting multiple sclerosis will advance to secondary MS.

 

• Primary progressive MS

 

About one to two out of every ten MS patients have a progressive worsening of their symptoms right from the initial attack.

 

Primary progressive MS does not have remission periods; instead, patients typically experience periods during which their condition seems to stabilise. Symptoms gradually deteriorate and build over several years. [7]

 

The disability and death rate from primary progressive MS is higher than in the other types.

 

 

What are the Common Symptoms Experienced by People with Multiple Sclerosis?

 

It is challenging to forecast the natural course of multiple sclerosis because it varies from person to person. Depending on the particular type, MS symptoms might vary in duration and start over a few days and disappear rapidly, or they can develop more slowly over several years. [2]

 

Early signs of multiple sclerosis (MS) can include: [2]

• Visual issues like double or blurred vision, due to optic neuritis, which causes pain while moving the eyes and quickly impairs vision.

• Muscle weakness, frequently in the hands and legs, and stiffness coupled with excruciating muscle spasms. This may result in partial or complete paralysis. The use of a wheelchair is common in severe forms of the disease or in those left untreated.

• Tingling feelings in the arms, legs, trunk, or face are associated with numbness, or pain.

• Clumsiness, particularly having trouble maintaining balance when walking.

• Issues with bladder control.

• Persistent lightheadedness.

Other MS symptoms include:

• Pain in the face or pain of sciatica.

• Fatigue, either physical or mental.

• Mood swings like despair or trouble expressing or controlling one's emotions.

• Cognitive dysfunction is characterised by issues with focus, multitasking, learning, memory, and judgment.

 

 

How is Multiple Sclerosis Diagnosed?

 

The diagnosis of MS cannot be made with a single test. A high level of clinical suspicion is needed as a result of awareness of how variable the condition may appear in different individuals.

 

Clinical diagnosis is commonly achieved when all other possible explanations for the presenting signs and symptoms of the condition have been excluded through history taking and detailed examination of the nervous and other systems of the body.

 

Different tests are used by doctors to confirm a definitive diagnosis of MS. These include:

• CT or MRI scans of the brain and spinal cord to detect the distinctive lesions (sclerotic plagues) associated with multiple sclerosis. It is possible to improve brain imaging of active MS lesions by injecting a specific dye or contrast agent into a vein.

• A lumbar puncture, often known as a spinal tap, is used to remove a sample of cerebrospinal fluid that surrounds and protects the brain and spinal cord and analyse it for disease-related proteins and inflammatory cells. Spinal tap analysis can also rule out conditions that could mimic multiple sclerosis.

• Electrical tests termed evoked potential tests are used to examine the speed and accuracy with which nerve fibres in the spinal cord for example conduct painless electrical impulses applied to the superficial nerves in the limbs to the brain. [2]

 

 

What Are the Challenges Faced by People with Multiple Sclerosis in Africa?

 

The management of MS in Africa is hampered by several factors, including the following: [1]

 

• Cultural barriers.

• Low awareness and education about the disease among the public and healthcare providers.

• Limited resources for rehabilitation.

• Limited access to palliative care.

• Financial constraints

• Poor diagnostic resources

• Limited availability of treatment options

• Sociocultural factors

• Poor infrastructure

• Limited research, and

• Limited resources for palliative care.

 

It is challenging for patients to obtain an accurate diagnosis and suitable therapy when they are unaware of the signs and symptoms of multiple sclerosis.

 

Patients' access to healthcare is further hampered by a lack of basic infrastructure, such as hospitals, clinics, and roads; cultural barriers, such as traditional beliefs and mistrust of modern medicine; and limited access to specialised medical care and trained healthcare professionals in many areas.

 

Financial limitations, which include the price of prescription drugs and other medical care, can also be a significant obstacle for patients limiting access to care, especially in low income nations.

 

Also, treatment delays might result from diagnostic difficulties, as the symptoms of MS are similar to those of other illnesses. [1]

 

Treatment adherence, delayed diagnosis, and lack of access to healthcare can also be caused by sociocultural factors including stigma and ignorance regarding MS in addition to the disease's limited treatment options. [1]

 

Although it is essential to diagnose MS accurately to start the right course of treatment and enhance the quality of life for patients, unfortunately, MS diagnostic skills and proficiency are not universally available across sub-Saharan Africa. [1]

 

 

How is Multiple Sclerosis managed?

 

It is not possible to cure multiple sclerosis. The goals of treatment usually include:

• Managing MS symptoms.

• Minimising occurrence of clinical relapses.

• Facilitating recovery from attacks, and

• Delaying the disease's progression.

 

Note that the symptoms of MS may be so mild in some people that they don't require medical attention. [3]

 

I. Treatment to Manage MS symptoms

 

A variety of treatments are available to manage the symptoms of multiple sclerosis. These include:

• Pharmaceutical therapies (e.g., therapy for pain, or medicine for spasticity);

• Anxiety or depression management strategies (e.g., learning to pace oneself to minimise exhaustion);

• Rehabilitation, which has the potential to enhance daily life.

Depending on your needs, this may include services like cognitive rehabilitation therapy, speech and language therapy, physiotherapy, or occupational therapy.

• An occupational therapist may also provide you with equipment or aids that can assist with complementary and alternative medicines. These include non-conventional treatments like acupuncture, pilates, and mindfulness which have been shown to improve both physical and mental wellbeing; [5]

• Complementary therapies

The following are a few of the complementary and alternative approaches that are commonly used in MS.

• Diet

Though none of the above diets have been proven to be effective for everyone with MS, several have been promoted as being helpful. Everyone benefits from eating a balanced diet, but MS patients may find it especially crucial.

By preserving energy levels and preventing additional weight from being placed on joints, keeping a healthy weight can help with symptoms like pain and weariness. Bladder and bowel problems can be avoided by making sure your diet has adequate water and fibre. In addition, since heart disease and elevated blood pressure can potentially affect MS patients, maintaining a healthy heart is crucial. [5]

• Exercise 

Numerous studies have shown that physical activity can improve both your physical and mental health, as well as help with MS symptoms. This might be something more cardiovascular-based or vigorous, like swimming, running, or dancing; it could also be something mild, like yoga, Pilates, or Tai Chi, which emphasise flexibility, strength, and balance. Exercise can help you stay in a healthy weight range, increase your range of motion, and improve your emotional well-being. [5]

• Relaxation techniques

Techniques like mindfulness, meditation, or breathing exercises can be beneficial if you're depressed, anxious, or feeling under pressure. Additionally, they may serve as a diversion from pain and spasticity symptoms. Reflexology, massage, and aromatherapy may also be beneficial. [5]

 

II. Treatment to Minimise the Occurrence of Clinical Relapses and Other Goals

 

Treatments for MS attacks

• To lessen nerve irritation, doctors use corticosteroids such as intravenous methylprednisolone and oral prednisone. Insomnia, elevated blood pressure, elevated blood glucose, mood fluctuations, and fluid retention are possible side effects of these types of drugs.

• The exchange of plasma (plasmapheresis). If your symptoms are new, severe, and unresponsive to steroids, plasma exchange may be performed. [3] In performing this treatment, your blood's liquid component, or plasma, is extracted and divided from your blood cells. After being combined with albumin, a protein solution, the blood cells are reintroduced into your body.

 

Note that numerous disease-modifying treatments for multiple sclerosis come with serious health hazards. The best course of treatment for you will be determined after carefully weighing several variables, such as the length and severity of your illness, the success of prior MS treatments, any coexisting medical conditions, cost, and your ability to bear children. [3]

 

 

Can I prevent getting Multiple Sclerosis?

 

There are certain lifestyle changes that you can incorporate into your daily routine to prevent multiple sclerosis. These include: [8]

• Taking vitamin D supplements during pregnancy.

• Ensuring regular exposure to sunlight.

• Quitting smoking.

• Adopting a diet low in saturated fats.

• Introducing omega-3 fatty acid supplements into the diet.

• Learning and practising stress management techniques such as meditation and mindfulness.

 

 

The Importance of Advocacy for MS Awareness in Africa

 

Improving MS patient care and management in Africa requires raising awareness of the disease. Patients' quality of life may suffer significantly as a result of delays in diagnosis and treatment brought on by a lack of knowledge and comprehension of the illness. [1]
 

• Running public health campaigns is one strategy to raise awareness. Creating and carrying out public health initiatives that inform people about multiple sclerosis (MS) and its symptoms can aid in raising awareness and comprehension of the illness.

• Enhancing accessibility to MS medicines and diagnostic instruments is another crucial step. This can be achieved by creating and implementing national MS management standards, as well as by making medications and rehabilitation programmes accessible and cheap. [1]

 

 

Tips for living with MS for patients and their families

 

To cope with the illness-

• You and your family need to acquire basic information about the nature of the sickness.

• You should learn to minimise stress and relish time with your loved ones.

• You should take a rest when feeling worn out.

• You should stick to a regular schedule while keeping an eye on your health.

• You should steer clear of heated environments including the sun, hot showers, and hot air.

• You should keep your weight in check, and eat a healthy, balanced diet.

• You should take time to exercise daily.

• You should manage your mood and keep a positive attitude.

• Avoid challenging jobs; if necessary, ask for assistance.

• Employ contemporary technology to document significant occurrences in your life and to complete assignments. Alternatively, write them down and store them in a visible location or set a voice alert.

• Speak with experts about your worries, issues, and concepts.

• Join support groups to connect with others who share your medical condition. [4]

 

 

Conclusion

 

Multiple Sclerosis (MS) is a complex and multifaceted neurological disorder that significantly impacts the lives of those affected. This overview has highlighted the key aspects of MS, including its underlying causes, symptoms, diagnosis, and available treatments and prevention approaches.

 

There is insufficient information to assess the incidence and prevalence of MS in Africa because of underdiagnosis and underreporting.

 

Significant obstacles also exist in the delivery of healthcare, including societal attitudes, lack of understanding, restricted access to treatments and diagnostic equipment, poor coordination, and absence of support networks. However, it is possible to improve MS management and the lives of those affected by MS in Africa by raising awareness of the disease, educating people about it, facilitating multidisciplinary collaborations, improving access to diagnostic tools and treatments, and encouraging and supporting research on the disease. [1]

 

 References
 

1. Aderinto N, Muili AO, Opanike J. Navigating the journey of multiple sclerosis management in Africa, overcoming hurdles and harnessing opportunities: a review. Ann Med Surg (Lond) [Internet]. 2023 [cited 2024 Feb 29]; 85(5):1774–9. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10205356/.

2. Multiple Sclerosis | National Institute of Neurological Disorders and Stroke [Internet]. [Cited 2024 Feb 29]. Available from: https://www.ninds.nih.gov/health-information/disorders/multiple-sclerosis.

3. Multiple sclerosis - Diagnosis and treatment - Mayo Clinic [Internet]. [Cited 2024 Mar 9]. Available from: https://www.mayoclinic.org/diseases-conditions/multiple-sclerosis/diagnosis-treatment/drc-20350274.

4. World Multiple Sclerosis (MS) Day. Africa Health Organisation [Internet]. 2020 [cited 2024 Mar 9]. Available from: https://aho.org/events/world-multiple-sclerosis-ms-day/

5. Trust MS. How is MS treated? | MS Trust [Internet]. [Cited 2024 Mar 9]. Available from: https://mstrust.org.uk/information-support/ms-drugs-treatments/how-is-ms-treated.

6. Rodriguez Maura S, Fares MF, Quintana FJ. The Immune Response in Multiple Sclerosis. Annul Rev Pathos Mach Dies [Internet]. 2022 [cited 2024 Mar 10]; 17(1):121–39. Available from: https://www.annualreviews.org/doi/10.1146/annurev-pathol-052920-040318.

7. Multiple sclerosis. nhs.uk [Internet]. 2017 [cited 2024 Mar 10]. Available from: https://www.nhs.uk/conditions/multiple-sclerosis/.

8. MS Prevention | How To Prevent Multiple Sclerosis | Overcoming MS [Internet]. [cited 2024 Mar 13]. Available from: https://overcomingms.org/recovery-program/prevention-family-members#:~:text=Lifestyle%20changes%20for%20preventing%20MS&text=Get%20regular%20exposure%20to%20sunlight,a%20low%2Dsaturated%20fat%20diet.

9. Mode G, Mochan A, du Toit Madelein, SI. Multiple sclerosis in South Africa. [Internet]. SAMJ, S. Afr. med. j.  [Internet]. 2008  May  98( 5 ): 391-393. [Cited  2024  Mar  14]. Available from: http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742008000500024&lng=en.

 

 

Published: March 17, 2024

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