Neurological disorder burden in Faisalabad, Punjab-Pakistan:data from the major tertiary carecenters of the city
V O L .
Neurological disorder burden in Faisalabad, Punjab-Pakistan:data from the major tertiar y carecenters of the city
Ghulam Hussain 0 1
Shahid Mahmood Baig 0 1
PIEAS 0 1
Faisalabad 0 1
Pakistan 0 1
0 Government College University , Faisalabad , Pakistan
1 COMSATS Institute of Information Technology , Islamabad , Pakistan
Follow this and additional works at: https://ecommons.aku.edu/pjns Part of the Neurology Commons Recommended Citation
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Neurological disorder burden in Faisalabad, Punjab-Pakistan:data from the
major tertiary carecenters of the city
Corresponding to: Ghulam Hussain, Department of Physiology, Liaquat Block, 1st Floor. New campus, Government College University, Jhang Road, 3800 Faisalabad.
Contact: +923006654101 Email:
The mortality rate and burden of disability caused by
NDs is higher than any other major disease
worldwide–25. The overall prevalence of NDs is 6.5%
and incidence trends have shown an alarming rate of
increase over time3. Demographic, geographic, and
socioeconomic conditions are major factors that affect
the epidemiology oNDs. Previous us research has
shown that prevalence and incidence of NDs is
positively correlated with the economic condition of a
given country. The burden of NDs increases as a
country expands economically3,6. In lower-income
countries,the reported prevalence of NDs ranges from
4% to 5%,whileprevalence in countrieswith higher
GDP is 10-11%2,3,7. The higher rate of NDs in
developed countries may be due to their more
robust system of public health services and
healthrelated facilities that screen and provide health
services for the average patient. It has been
documented that 6.75% of the American population
and6% of the Population have been diagnosed with
In recent years, the burden of Nds in developing
countries has continued to increase; this grow this
correlated with increasing epidemiological data,
prolonged life expectancy, improved health facilities,
facilitated access to healthcare centers, provision of
advanced diagnostic technology, and a trend in
urbanization among the population. Although there are
data regarding the incidence and prevalence of ND sin
developing countries of Asia, such as China, India, and
Sri Lanka, these data may not be generalizable to
Pakistan, due to differing social, geographical,
religious, cultural, and ethnic aspects unique to those
countries. Therefore, it is necessary to conduct
epidemiological studies in Pakistan to collect and
analyze reliable data for this region of the world .
The prevalence of Nds in India ranges from
967–4,070/100,000 with a mean of 2,394/100,000
population. Such prevalence indicates that over 30
million people are living with NDs in this country with
the second largest population in the world. The
prevalence of common disorders, such as stroke,
epilepsy, tremors, Parkinson's disease (PD), and
mental retardation, is not uniform across the different
regions of the country .
The overall crude prevalence of NDs in Saudi Arabia
was reported to be 131/1,000population .Recent
reports indicate about68.5/10,000 prevalence of NDs
in the pediatric population of Saudi Arabia .
Published data regarding the epidemiology of major
NDs in Pakistan is limited, and most available
information are hospital-based estimations or
physician-collected data, limited to a few cities. These
data are likely not nationally representative . In
comparison to neighboring countries, it maybe
possible to determine aggregation of the existing,
disparate data sources. The existing information the
prevalence of NDs in Pakistan based concerning the
prevalence of NDs in selected cities of Pakistan
indicate that the burden of NDs is a serious concern.
Epidemiological data concerning selected Nds are
available, but this information is limited to particular
locations and, therefore, cannot be generalized to
determine the overall burden of NDs in Pakistan
nationally. Most available data are from the city of
Karachi, while prevalence and incidence in the other
mega-cities of Pakistan have yet to be investigated. In
the present study, we focused our evaluation of NDs in
Faisalabad, the third largest city of Pakistan. To our
knowledge, this is the first study concerning the
prevalence and burden of NDs at the leading tertiary
care centers of this mega-city.
MATERIALS AND METHODS
In the present study, study subjects were recruited
from the patient population at the outpatient neurology
and psychiatry departments of Allied Hospital, DHQ
Hospital, Aziz Fatima Trust Hospital, Faisal Hospital,
and Al-Noor Hospital in Faisalabad, Punjab-Pakistan.
The inclusion criteria for selecting the hospitals were
that the facility was well-equipped, possessed
functional basic and advanced facilities for diagnosis
of complicated NDs, and had a sufficient patient
population for recruitment at the outpatient facility. The
selected tertiary care centers are the highest-volume
centers in Faisalabad district. The health care centers
were selected from4 different corners of the city in
order to acquire representative data from each region
of the district. Furthermore, a mix of government and
private-sector hospitals were selected to ensure the in
clusion of an economically divers ecohort that would
be more representative of the population in general. A
structured questionnaire was used to gather basic data
about the patients receiving care in the selected
The data were collected from March 2015 to May 2015.
Prior authorization was sought from the hospital
administration for collection of data. The physicians
and psychiatrists of participating patients were
requested to make a detailed diagnosis based on the
available medical tests for the possible ND. Patients
were interviewed and data were recorded on
questionnaires. Patients undergoing their first clinical
visit were excluded, as their clinical diagnosis may not
have been fully determined. Patients with confirmed
diagnoses were included in the study, and data were
collected from the subjects after obtaining consent of
either the patient or his/her care giver. The available
record of medications and treatment was also
collected for further verification as needed.
Information about gender, age, marital status, type of
disorder, familial history for the disorders of interest,
and consanguineous marriage were collected for
further analysis of related risk factors.
INSTITUTIONAL REVIEW BOARD APPROVAL
The Institutional Review Board (IRB) of Government
College University, Faisalabad-Pakistan carefully
reviewed and granted approval for this study.
The overall burden of NDs in Faisalabad District was
assessed in the 3,068 study participants. The rate of
each ND reported in this population was as follows: .
depression 19.6% (n = 602), epilepsy 16.6% (n = 508),
migraine 15.2 % (n = 466),disc prolapse 8.8% (n =
269), paralysis 8.5% (n = 262), trauma 5.3% (n = 163),
P A K I S T A N J O U R N A L O F N E U R O L O G I C A L S C I E N C E S
brain hemorrhage 5% (n = 153), PD3% (n = 92),
schizophrenia 2.7% (n = 83), congenital anomaly 2.2%
(n = 68), tumor 1.6% (n = 50), dementia 1.7% (n = 52),
mania 0.8% (n = 25), acute psychological disorder
1.4% (n = 43), disruptive behavior disorder 0.6% (n =
19), bipolar affective disorder 0.7% (n = 22), and
miscellaneous 6.2% (n = 191) (Figure 1).
20.0 19 .616 .521
The rate of Nds among the population varied by the
towns of Faisalabad, with rates as follows,
Lyallpurtown30.7% (n = 863), Jinnahtown15.0% (n =
421), Iqbal town 19.3% (n = 542), Madina town 17.7%
(n = 498), Chak Jhumra town 2.2% (n = 63), Jaranwala
Town 8.6% (n = 243), Samundri town 4.5% (n = 126),
and Tandliyanwala town 1.9% (n = 54) (Figure 2).
Chak Jhumra Town
There were 382 patients (27%) for which a family
history of mental illness was noted. The percentage of
patients with positive family history by disease
category was 80% (n = 4)PD, 23.5% (n = 4)
schizophrenia, 76.9% (n = 10) disc prolapse, 11.5% (n
= 15) depression,30.8% (n = 37) epilepsy, and33% (n =
Nds were more prevalent in the female group as
compared to the male group in Faisalabad. Among the
study population, 41.5% (n = 1300) were male gender
and 58.5% (n = 1829) were female gender.
Depression, migraines, disc prolapse, brain
hemorrhage, PD, dementia, mania, and other mental
illnesses were more common in the female group
(67.1%, n = 444; 75.4%, n = 352; 61.7%, n = 262;
52.3%, n = 80; 63.0%, n = 58; 51.9%, n = 27; 60.0%, n =
15; 56.0%, n = 154, respectively) than in the male
group(32.9%, n = 218; 24.6%, n = 115; 38.3%, n = 103;
47.7%, n = 73; 37.0%, n = 34; 41.8%, n = 25; 40.0%, n =
10; 44.0%, n = 121, respectively). Epilepsy, paralysis,
and trauma were more common in the male group
(53.0%, n = 269; 53.4%, n = 140; 55.8%, n = 91) than in
the female group (47.5%, n = 239; 46.6%, n = 122;
44.2%, n = 72). The burden of schizophrenia,
congenital anomaly, tumor, and dementia was
approximately equivalent between the female group
(50.6%, n = 42; 48.5%, n = 33; 50.0%, n = 25; 51.9%, n
= 27, respectively) and the male group (49.4%, n = 41;
51.5%, n = 35; 50.0%, n = 25; 48.1%, n = 25,
The study subjects were divided into 4 age groups,
group I (10-30 years), group II (31-50 years), group III
(51-70 years), and group IV (70-90 years),in order to
capture the burden of ND sat early or late age onset.
Groups I and II, covering the age ranges of 10-50
years, manifested a similar rate of ND burden (37.8%
and 37.5%, n = 1073 and n = 1065, respectively). The
burden was remarkably lower in age groups III and IV
(20.7%, n = 587 and 4%, n = 115, respectively).
Depression was higher in group II as compared to
other groups. Majority of epileptic patients feel in
younger age group as compared to older age group.
Half of the patients with migraine were in group II 207
(45.1%), followed by migraine in group I 39.7% (n =
182). Disc prolapse was more common in group II
46.9% (n = 122)while group III manifested the highest
value of paralysis 40.2% (n = 103).Trauma was more
abundant in group I 40.6% (n = 63) than in any other
group, while brain hemorrhage was mostly noted
ingroup III 52.0% (n = 78).Schizophrenia60.2% (n =
50) and tumor 42.1% (n = 16) were recorded mostly in
the young population belonging to group I. The
subjects of group III manifested highly level of
Dementia63.5% (n = 33).The proportion of patients
suffering from mania was high in group I 44.0% (n = 11)
and group II 44.0% (n = 11) respectively (Figure 5).
In developing countries, prevalence and incidence of
ND sare underestimated due to lack of data and
awareness about the burden and impact. Most of NDs,
such as meningitis, encephalitis, and cerebral malaria,
the on set of the condition is acute in nature and
frequently lethal in a short course of time. Mortality due
to many of these NDs could be prevented by early
diagnosis and providing effective treatment. Other
NDs are chronic in nature, for example epilepsy, and, in
addition to the morbidity experienced by the patient,
this illness carries a socioeconomic burden and
stigmatization is commonly observed in many cases,
which also affects the broader family.
Timely and accurate diagnosis of such cases may
facilitate provision of effective treatment and help
prevent the chronicity and post-disease effects on
patients and their families .
In developing countries, such as Pakistan, diagnosis of
complex NDs is challenging due to lack of
infrastructure and expertise, which creates a hurdle in
determining and providing proper treatment. The
present study is the first hospital based study of NDs
conducted in Faisalabad, the third largest city of
Depression accounted for as substantial portion
(19.6%) of the NDs among the study subjects, 11.5% of
which were in youth with at least 1 parent who also had
depression. This value was close to the global burden
(20%), and local burden of depression in Karachi
(2023%)– . The higher proportion off depression among
the female group(67.1%), as compared to the male
group (32.9%), was in accordance with previous
studies by various authors . The heritability and burden
of ND among the younger generation (10-30 years of
age) is reported here for the first time in Pakistan, and
highlights an issue of pressing concern. The
substantial proportion of NDs among younger
generations in Faisalabad suggests that national rates
of NDs may be higher than previously assumed and
affect more of the population, posing a serious health
Epilepsy appeared to be the second most common
ND, accounting for 16.6% of cases. One third of cases
were found to have a positive family history, and
slightly more of the male group (53%) than female
group (47%)experienced epilepsy. There was also a
higher proportion among patients in the age range of
10-30 years, which is in accordance with
previouslyreported data .
We also found that of the 15.2% of subjects with a
diagnosis of migraine, one third had a positive family
history, and the female group (75.4%) accounted for a
larger proportion of cases compared to the male group
(24.6%). The age groups 10-30 and 30-50 years of age
experienced the highest proportion of cases.
Age Group 10-30
Age Group 51-70
Age Group 31-50 Age Group 71-90
Our results regarding headache and migraine are not
in accordance with other studies conducted elsewhere
in Pakistan – . This contradiction of ND burden
observed in our results is possibly due to demographic
factors, parameters, and the methodology used in
those studies. Although specific aspects of our findings
differ from previous studies, the trend of NDs in gender
and age groups of patients appear similar to data
The number of patients with PD in Asian countries is
expected to reach 6.17 million in a few decades . The
presence and increasing burden of PD in some cities of
Pakistan has also been documented – , but the
nationwide data on prevalence of PD is limited. In the
present study, our finding that 3% of the study
population has a diagnosis of PD has not been
validated in the literature and is higher than the
worldwide prevalence of PD of about 1% . A majority of
cases in this study was found to demonstrate an
inherited pattern of transmission, and the female group
experienced a higher proportion of NDs (63%) than the
male group (37%).Of concern, the age group 31-50
years were noted to account for a high proportion of
cases (38.9%) as compared to other age groups,
although NDs are generally a late onset disorder .
Schizophrenia affects about 1% of the population and
is among the top 25 leading causes of disability
worldwide. Its prevalence varies by region and ethnic
group .Our study has found that 2.7% of the study
population has been diagnosed with schizophrenia,
out of which almost 25% have a positive family history.
These results cannot be compared with other studies,
due to unavailability of existing epidemiological data
regarding schizophrenia in Pakistan. Regarding
schizophrenia, the burden did not vary significantly by
gender and most patients belonged to the 10-30-year
age group. The substantial burden of this
psychological disorder affecting youth highlights the
morbidity experienced in this age group, as well as the
expected life-long, future morbidity. Previous studies
have reported that birth order, gender difference sand
age of on set influence diagnosis and disease
trajectory for schizophrenia in Pakistan population – .
About 2% of cases were found to be congenital
anomalies, and distribution was similar between males
and females. Due to varying results from different
regions of Pakistan, the present results are in
accordance with some studies, 2.9% reported by Khan
et. al., 2015 , and contradictory to other results, for
example Hussain et. al., 2014 , who reported that
about 7% of neonates had congenital anomalies. In
UK, researchers have noted that babies born to
mothers of Pakistani origin are more prone to be
affected with congenital anomalies as compared to
babies of mothers from other regions . Various factors
such as malnutrition, consanguineous marriages,
illiteracy, and unavailability of adequate health care
facilities in Pakistan may explain the higher rate of Nds
Dementia has increased and is approaching epidemic
levels in Pakistan, and requires timely, focused
resources. Prevalence of dementia is projected to be
much higher in the future – . Dementia accounted for
1.7% of the NDs among study subjects, similar to
previous findings of a1.9 % prevalence of dementia in
South Asia .The available prevalence data about
dementia is limited and prior studies report 8% and 7%
of elderly people are suffering from dementia– .
Although other disorders,such disc prolapse (8.8%),
paralysis (8.5%), trauma (5.3%), brain hemorrhage
( 5 % ) , m a n i a ( 0 . 8 % ) , t u m o r ( 1 . 6 % ) , a c u t e
psychological illness (1.4%), disruptive behavior
disorder (0.6%), bipolar affective disorder (0.7%) and
other miscellaneous minor diseases (6.2%)account for
more than one quarter of the NDs among the study
population, other studies with which to compare the
finding at a national level are unavailable.
The presence of major neurological, psychological,
and neurodegenerative disorders in Pakistan, the sixth
largest population in the world, should not be assumed
to be absentnor speculated upon, due to the lack of
epidemiological data. Due to an improved health
infrastructure and facilitated access to health facilities,
life expectancy in Pakistan is increasing, which leads
to an increasing population vulnerable to late onset
neurodegenerative disorders such as Alzheimer's
disease (AD), Huntington's disease (HD), Amyotrophic
Lateral Sclerosis (ALS),and PD. These diseases may
be prevalent in elderly people of Pakistan, but
available data do not exist to describe the
epidemiology and describe the population burden.
Although the presence of multiple sclerosis (MS) and
PD, in Karachi and Peshawar, has been documented
at the hospital level.
The present study lays a foundation of data regarding
ND burden in this region to build a bank of data and
address the gap in existing information about this
neglected area of disease epidemiology. In the health
policy framework of Pakistan, there is little focus on
management and treatment of NDs due to lack of data
regarding the epidemiology of NDs. It is recommended
to conduct community based epidemiological studies
in Pakistan. The findings of such studies will pave the
way for health policies and fund ingallocation for
research, eradication, and improved treatment of NDs
We are indebted to Prof. Dr. Imtiaz Ahmad Dogar, Dr.
Azam Aslam, Dr. Naeem Ur Rehman, Dr.Muhammad
Irfan Ullah, Dr. Khalid Mahmood Yahya, Dr. Faisal
Ghafoor, Dr. Irum Farooq, Mr. Muhammad Ilyas and
Dr. Amir Sharif for their cooperation and support
regarding data collection. We also extend our thanks to
Mr. Usama Nadeem and the pioneer batch studentS of
the Department of Physiology, GCUF for their help.
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Ghulam Hussain; concept, data collection, data analysis, manuscript writing, manuscript review
Asif Shehzad; data collection, data analysis, manuscript writing, manuscript review
Haseeb Anwar; data analysis, manuscript writing, manuscript review
Muhammad Umar Sohaildata analysis, manuscript writing, manuscript review
Shahid Mahmood Baig; data analysis, manuscript writing, manuscript review
Asghar Shabbir; data analysis, manuscript writing, manuscript review
Jose-Luis GONZALEZ DE AGUILAR;manuscript writing, manuscript review
Jawed Iqbal; data analysis, manuscript review
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Funding disclosure: The study was supported by Higher Education Commission of Pakistan under the grant Number : 21 - 391 SRGP /R&D/HEC/2015