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Review
. 2013 Feb 12;80(7):677-84.
doi: 10.1212/WNL.0b013e318281cc6e.

A systematic evaluation of stroke surveillance studies in low- and middle-income countries

Ayesha Sajjad  1 , Rajiv Chowdhury, Janine F Felix, M Arfan Ikram, Shanthi Mendis, Henning Tiemeier, Jonathan Mant, Oscar H Franco
Affiliations
Review

A systematic evaluation of stroke surveillance studies in low- and middle-income countries

Ayesha Sajjad et al. Neurology. .

Abstract

Objective: Reliable quantification of the burden of stroke in low- and middle-income (LMI) countries is difficult as population-based surveillance reports are scarce and may vary considerably in methodology. We aimed to evaluate all available primary stroke surveillance studies by applying components of a benchmark protocol (WHO STEPwise approach to stroke surveillance) and quantify the reported burden of stroke in LMI settings.

Methods: Electronic databases Medline, Embase, Scopus, and Web of Knowledge were searched for population-based surveillance studies. Studies conducted in the LMI countries that reported on incident stroke were included. Data were extracted from each study using a prestructured format. Information on epidemiologic measures including crude and age-adjusted incidence rates, person-years, admission rates, case fatality rates, death certification, autopsy rates, measures of disability, and other study-specific information, in line with WHO STEPS stroke protocol, were recorded. Age-adjusted incidence rate data of stroke were combined using random-effects meta-analyses.

Results: We identified 7 studies that reported on burden of stroke in 9 LMI countries, including aggregate information from 1,711,372 participants collected over 5,240,923 person-years. The age-adjusted incidence rates across the LMI countries varied widely, with the burden of total first-ever strokes ranging from 41 to 909 events per 100,000 person-years.

Conclusions: Systematic evaluation of all available primary surveillance studies, particularly in the context of WHO STEPS guidelines, indicates inadequate adherence to standardized surveillance methodology in LMI countries. Incorporation of standardized approaches is essential to enhance generalizability and estimate stroke burden accurately in these resource-poor settings.

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Conflict of interest statement

A. Sajjad received a scholarship from The Cambridge Commonwealth Trust. She currently works in ErasmusAGE, which is funded by a grant from Pfizer Nutrition. R. Chowdhury is supported by Gates Cambridge PhD scholarship. J. Felix works in ErasmusAGE, which is funded by a grant from Pfizer Nutrition. M.A. Ikram, H. Tiemeier, and J. Mant report no disclosures. S. Mendis is a staff member of the World Health Organization. The author alone is responsible for the views expressed in the publication and they do not necessarily represent the decisions or policies of the World Health Organization. O.H. Franco works in ErasmusAGE, which is funded by a grant from Pfizer Nutrition. Go to Neurology.org for full disclosures.

Figures

Figure 1
Figure 1. Flow diagram of literature search
*Studies were not available in the archives and no contact with the authors was established to retrieve full texts.
Figure 2
Figure 2. Descriptive protocol of an ideal stroke surveillance strategy adapted from WHO STEPwise approach to stroke surveillance
ER = emergency room; GP = general practitioner; NIHSS = NIH Stroke Scale.
Figure 3
Figure 3. Features of studies included in the review
LMI = low and middle income; mRS = modified Rankin Scale.
Figure 4
Figure 4. Age-adjusted incidence rates (95% confidence interval) for incident stroke in low- and middle-income countries, based on available studies
Random-effects meta-analyses of age-adjusted incidence rates in low- and middle-income countries included in this review. Studies included in this meta-analysis collected stroke incidence data on all ages in their respective populations except for Bulgaria and Mumbai, which were based on restricted age bands. Age bands for each study: Ukraine: 0–44, 45–54, 55–64, 65–74, 75–84, ≥85; Georgia: 0–44, 45–54, 55–64, 65–74, 75–84, ≥85; Bulgaria: 45–54, 55–64, 65–74, 75–84; Brazil: <45, 45–54, 55–64, 65–74, ≥75; India (Rohtak): ≤44, 45–54, 55–64, 65–74, ≥75; India (Mumbai): 25–34, 35–44, 45–54, 55–64, 65–74, 75–84, 85–>94; Sri Lanka: ≤44, 45–54, 55–64, 65–74, ≥75; Mongolia: ≤44, 45–54, 55–64, 65–74, ≥75; Tanzania: 0–44, 45–54, 55–64, 65–74, 75–84, ≥85; Nigeria: ≤44, 45–54, 55–64, 65–74, ≥75. CI = confidence interval.
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