Stroke in developing countries: can the epidemic be stopped and outcomes improved?

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94 Vol 6 February 2007 Stroke in developing countries: can the epidemic be stopped and outcomes improved? According to WHO estimates, death from stroke in developing (low and middle-income) countries in 2001 accounted for 85·5% of stroke deaths worldwide, and the number of disability-adjusted life years (DALYs), which comprises years of life lost and years lived with disability, in these countries was almost seven times that in developed (high-income) countries. 1 Stroke burden is likely to increase as a result of ageing and population growth if action is not taken now to remove or reduce the well-established determinants of stroke. Although good-quality data on the epidemiology, prevention, and management of stroke are rapidly accumulating for economically developed countries, particularly over the past two decades, there is a lack of reliable data for developing countries. These issues and the future of applied stroke research and implementation strategies in these countries are the focus of a series of Review articles, the fi rst of which is published in this issue of The Lancet Neurology. On the basis of the recent WHO re-assessments of the original Global Burden of Disease (GBD) study and the WHO 2002 mortality estimates, with substantial improvements in data availability and some new methods for dealing with incomplete and biased data, Strong and colleagues 2 review current and projected stroke mortality and burden (as measured in DALYs) for the world, World Bank income groups, and selected countries for the period from 2005 to 2030. The authors estimate that the current global burden of stroke is 16 million fi rst-ever strokes, 62 million stroke survivors, 51 million DALYs, and 5·7 million deaths in 2005. Without additional population-wide interventions, fi gures are predicted to increase to a staggering 23 million fi rst-ever strokes, 77 million stroke survivors, 61 million DALYs, and 7·8 million deaths by 2030. Strong and colleagues' data also show that stroke is already a leading cause of death and disability in low and middle-income countries and in the global population under age 70 years, and that 87% of global stroke mortality in 2005 (a 1·5% increase compared with 2001) occurred in these countries, with Russia at the top of the list. However, if there were a 2% reduction per annum in stroke mortality (due to better management), this would result in 6·4 million fewer deaths from stroke between 2005 and 2015, with most deaths averted and years of life gained in low and middle-income countries. The experience of high-income countries has shown the feasibility of such reductions. The authors advocate a wider use of early administration of aspirin for ischaemic stroke in low and middle-income countries. However, they also correctly argue that the most important contribution to the reduction of stroke mortality in these countries is likely to come from primary prevention, with the emphasis on the major risk factors common to stroke, heart disease, diabetes, and other chronic diseases. A very thorough systematic review of the published studies on stroke incidence, prevalence, and early case fatality in sub-Saharan Africa by Connor and colleagues 3 suggests that age-adjusted stroke mortality and disabling stroke prevalence in black people in sub-Saharan Africa is similar to those in developed countries, although the overall prevalence of stroke is less and the early case fatality is higher. The authors note that recent stroke prevalence studies in this region have arguably provided the most accurate measures of stroke burden in recent years. On the basis of this they conclude that the burden of stroke in this region will increase to epidemic proportions unless eff ective interventions are put in place. Lavados and colleagues 4 provide an overview of studies on stroke epidemiology and prevention and management strategies in Latin America and the Caribbean (published in English, Spanish, and Portuguese). There is a paucity of information for implementing evidence-based management strategies in these regions and stroke has become a major health problem in Latin American and Caribbean countries. Although stroke incidence and outcomes show little geographical variation in the region and seem to be similar to those in developed countries, the proportional frequency of intracerebral haemorrhages and lacunar infarctions are somewhat greater and the prevalence of major cardiovascular risk factors

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