Elsevier

The Lancet Neurology

Volume 6, Issue 3, March 2007, Pages 269-278
The Lancet Neurology

Series
Burden of stroke in black populations in sub-Saharan Africa

https://doi.org/10.1016/S1474-4422(07)70002-9Get rights and content

Summary

Sub-Saharan Africa is undergoing epidemiological transition. Stroke and other vascular diseases increasingly contribute to the burden of disease. There are no systematic reviews of stroke mortality, prevalence, incidence, and case fatality. We combined a thorough search and critical assessment of the published research. Stroke mortality is as high, perhaps higher, than in high-income regions and increases with age in sub-Saharan Africa as in high-income countries, but the absolute number of stroke deaths remains low. There are no adequate community-based stroke incidence studies. Hospital-based incidence is lower than in high-income regions, but higher in young people, possibly due to hospital admission bias. There are no community-based data on case fatality, but hospital-based case fatality is higher than elsewhere. The prevalence of stroke is lower than in high-income regions, but disabling stroke is as prevalent. As the region develops economically, the incidence of stroke and other vascular diseases will increase unless interventions are implemented. Only community-based incidence studies will accurately reveal the burden of stroke.

Introduction

In high-income countries, stroke has been recognised as an important cause of death and disability for many years. The importance of stroke in low-income and middle-income (developing) countries has recently become better appreciated, highlighted by the recently updated estimate from the Global Burden of Disease study that over 80% of all stroke deaths occur in low-income and middle-income regions of the world.1, 2 Moreover, the burden of stroke and other vascular diseases is likely to increase substantially over the next few decades in these lower-income countries because of their expected health and demographic transition, initially adding to the infectious and poverty-related disease burden and later becoming the dominant causes of death and disability.3, 4, 5

Sub-Saharan Africa (figure 1) currently faces an enormous burden of infectious disease including HIV/AIDS, perinatal disease, and nutritional disease. However, if the region is to develop appropriate prevention and treatment strategies for stroke and other vascular diseases, and so avoid moving into the later stages of health transition (a shift from diseases of poverty to degenerative diseases including vascular diseases) experienced in high-income countries, then accurate estimates of the present burden of disease as well as region-specific risk factors and causes must be determined.3, 4, 6, 7

Because there are no systematic reviews of existing knowledge of stroke in sub-Saharan Africa, we systematically gathered all the publications that relate to stroke in the region to assess what is known about the burden (mortality, prevalence, incidence, and case-fatality) of stroke (cost and long-term disability are beyond the scope of this review). Epidemiological studies in sub-Saharan Africa are, of course, fraught with practical as well as political difficulties and so, although we considered it important to assess the available studies against accepted quality criteria, we were as concerned about including an accurate representation of the relevant published literature on the subject as about the methodology used in the studies. We have therefore tried to combine a thorough search and critical assessment of the data8 with a narrative review,9 highlighting the quality of the evidence throughout.

Section snippets

Methods

We searched MEDLINE from 1966 to mid-November 2006 and EMBASE from 1980 to mid-November 2006, we used detailed search terms for stroke, or related disease, combined with terms relevant to sub-Saharan Africa. We combined 42 terms that might be used to describe stroke with the articles retrieved from a second search designed to find all publications of any type related to Africa (webpanels 1 and 2).

We obtained articles from before 1966 and other relevant published articles from reference lists of

Vital registration data

In high-income countries, death certificate data provide easily available, but not necessarily very accurate, information on stroke mortality.34 The Global Burden of Disease study used available vital registration data to estimate all cause mortality in 1990.10 However, such data are seldom available in sub-Saharan Africa and when they are available, they tend to be very unreliable.15, 35, 36 In the updated Global Burden of Disease estimates of all-cause mortality in 2001, high coverage (≥85%)

Summary of data on stroke burden in sub-Saharan Africa

On the basis of very small studies, age-adjusted stroke mortality in adults in sub-Saharan Africa seems rather similar to that in high-income regions, although the absolute number of stroke deaths remains low as a result of the population structure in sub-Saharan Africa (about 44% of people are under 15 years of age). Stroke mortality may be increasing, but there are no accurate longitudinal data from regions with good vital registration or where verbal autopsies are done.

There are no

Comment

As risk factors for vascular disease increase, and the populations age, so the burden of vascular disease will certainly increase in sub-Saharan Africa. Indeed, without intervention, stroke and heart-disease-related deaths are expected to increase from 3 million in 1998 to 5 million in 2020 in WHO developing regions.83, 84 Typically, the pattern of vascular disease in sub-Saharan Africa fits the basic outline given by Omran's theory of health or epidemiological transition52—stroke leads the

References (84)

  • TE Sokrab et al.

    Acute stroke type, risk factors, and early outcome in a developing country: A view from Sudan using a hospital-based sample

    J Stroke Cerebrovasc Dis

    (2002)
  • F Sene Diouf et al.

    Pronostic fonctionnel des accidents vasculaires cerebraux dans les pays en voie de developpement : Senegal

    Ann Readapt Med Phys

    (2006)
  • CD Mathers et al.

    The burden of disease and mortality by condition: data, methods and results for 2001

  • CP Howson et al.

    Control of cardiovascular diseases in developing countries: research, development, and institutional strengthening

    (1998)
  • P Bovet

    The cardiovascular disease epidemic: global, regional, local

    Trop Med Int Health

    (2002)
  • HH Vorster

    The emergence of cardiovascular disease during urbanisation of Africans

    Public Health Nutr

    (2002)
  • N Unwin

    Non-communicable disease and priorities for health policy in sub-Saharan Africa

    Health Policy Plan

    (2001)
  • MA van der Sande et al.

    A template for improved prevention and control of cardiovascular disease in sub-Saharan Africa

    Health Policy Plan

    (2001)
  • DF Stroup et al.

    Meta-analysis of observational studies in epidemiology: a proposal for reporting: Meta-analysis Of Observational Studies in Epidemiology (MOOSE) group

    JAMA

    (2000)
  • WHO

    World Health Report 1999: making a difference

    (1999)
  • JA Salomon et al.

    The epidemiological transition revisited: Compositional models for causes of death by age and sex

    Popul Dev Rev

    (2002)
  • WHO

    The World Health Report 2004: changing history

    (2004)
  • K Kahn et al.

    Stroke in rural South Africa—contributing to the little known about a big problem

    S Afr Med J

    (1999)
  • AC Chukwumeka et al.

    Are cardiovascular diseases important causes of mortality in Africa? Results of a WHO/UGMS cardiovascular disease follow-up study over a five-year period in a suburb of Accra

    Trop Cardiol

    (1982)
  • AR Walker

    Mortality from coronary heart disease and from cerebral vascular disease in the different racial populations in South Africa

    S Afr Med J

    (1963)
  • CH Wyndham

    Mortality from cardiovascular diseases in the various population groups in the Republic of South Africa

    S Afr Med J

    (1979)
  • BO Osuntokun et al.

    Incidence of stroke in an African City: results from the Stroke Registry at Ibadan, Nigeria, 1973–1975

    Stroke

    (1979)
  • K Aho et al.

    Cerebrovascular disease in the community: results of a WHO collaborative study

    Bull World Health Organ

    (1980)
  • J Matenga

    Stroke incidence rates among black residents of Harare—a prospective community-based study

    S Afr Med J

    (1997)
  • KD Rosman

    The epidemiology of stroke in an urban black population

    Stroke

    (1986)
  • DRW Haddock

    Neurological disorders in Tanzania

    J Clin Invest

    (1965)
  • PK Nyame et al.

    Current trends in the incidence of cerebrovascular accidents in Accra

    West Afr J Med

    (1994)
  • J Joubert

    The MEDUNSA stroke data bank: an analysis of 304 patients seen between 1986 and 1987

    S Afr Med J

    (1991)
  • RW Walker et al.

    Mortality and recovery after stroke in the Gambia

    Stroke

    (2003)
  • BO Osuntokun et al.

    Research protocol for measuring the prevalence of neurologic disorders in developing countries: results of a pilot study in Nigeria

    Neuroepidemiology

    (1982)
  • BO Osuntokun et al.

    Neurological disorders in Nigerian Africans: a community-based study

    Acta Neurol Scand

    (1987)
  • AC Longe et al.

    Prevalence of neurological disorders in Udo, a rural community in Southern Nigeria

    Trop Geogr Med

    (1989)
  • R Tekle-Haimanot et al.

    Community-based study of neurological disorders in rural central Ethiopia

    Neuroepidemiology

    (1990)
  • RW Walker et al.

    Age specific prevalence of impairment and disability relating to hemiplegic stroke in the Hai District of northern Tanzania

    J Neurol Neurosurg Psychiatry

    (2000)
  • MD Connor et al.

    Prevalence of stroke survivors in rural South Africa: results from the Southern Africa Stroke Prevention Initiative (SASPI) Agincourt field site

    Stroke

    (2004)
  • CP Warlow

    Epidemiology of stroke

    Lancet

    (1998)
  • S Bah

    A note on the quality of medical certification of deaths in South Africa, 1997-2001

    S Afr Med J

    (2003)
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