The Lancet Neurology
De: procor-bounces@healthnet.org [mailto:procor-bounces@healthnet.org] Em nome de Coleman, Catherine
Enviada em: terça-feira, 23 de janeiro de 2007 17:28
Para: procor@healthnet.org
Assunto: [ProCOR] Lancet Neurology: Stroke in developing countries: can theepidemic be stopped and outcomes improved?
["Two-thirds of the global burden of stroke occurs in low-income and middle-income countries, but accurate data on stroke incidence in these countries are scarce. Stroke surveillance systems--which are absent in virtually all resource-poor countries--are essential to obtain an accurate picture of the burden of stroke and to enable policymakers to plan cost-effective strategies....There have been attempts to collect reliable data, and there is a will to do so, but the lack of sound methodology and effective surveillance render studies uninformative or incomparable. As an entry point for countries to begin registration of patients with stroke, WHO recommends a stepwise approach to stroke surveillance (STEPS Stroke). This approach enables researchers to gather information on stroke through identification of the three major subsets of patients that comprise a population's stroke burden: those admitted to hospital (step 1); those who have stroke events that are fatal before admission to hospital (step 2); and those with non-fatal strokes who are cared for entirely in the community (step 3). ("STEPS in the right direction," The Lancet Neurology 2007;
6(2): 93).]
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The article below, "Stroke in developing countries: can the epidemic be stopped and outcomes improved?" appears (free full text) in the current issue of The Lancet Neurology. Link to the issue at http://neurology.thelancet.com. For those who cannot access the articles online, excerpts are provided below. We welcome your comments.
To help people who want to establish either hospital-based or population- based stroke registers, WHO provides resources at www.who.int/chp/steps/stroke, including a manual which explains in detail how to develop such a register and an application form/criteria for free access to a Data Entry Tool.
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"Stroke in developing countries: can the epidemic be stopped and outcomes improved?"
Valery L Feigin
Free full text:
http://www.thelancet.com/journals/laneur/article/PIIS1474442207700078/fulltext
Excerpts:
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 first 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 first-ever strokes, 62 million stroke survivors, 51 million DALYs, and
5*7 million deaths in 2005. Without additional population-wide interventions, figures are predicted to increase to a staggering 23 million first-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.
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What can we learn from these studies? First, we are witnessing an epidemic of stroke in developing countries. The burden of stroke will be even greater if appropriate measures are not taken. Second, there is a lack of reliable and comparable data on stroke incidence, prevalence, causes, trends, management, and outcomes to inform efficient and sustainable health care and prevention strategies in developing countries. The gap in knowledge on stroke epidemiology between developed and developing countries is also widening. Third, despite apparent differences in the patterns of stroke types and risk factor profiles between developed and developing countries, most occurrences of stroke and cardiovascular disease can be attributed to conventional risk factors, [7,8] and some prevention and management strategies are likely to be equally applicable to all countries and populations. The question is whether we should wait until further evidence on stroke epidemiology, prevention, and management is available from developing countries or act now to stop the stroke epidemic and improve outcomes. On the basis of the available evidence, we should act now. Stroke must be a priority on the health agenda in all countries. This leads us to the next logical questions. How best should we proceed to stop the epidemic and improve stroke outcomes in developing countries, given their very limited resources and many competing demands? How best can we monitor the effects of these interventions at the population level in developing countries? What are the directions of future applied stroke research in these countries?
Given the limited resources available for health care in developing countries, it would be logical to place emphasis on effective population-wide interventions to control or reduce exposure to leading risk factors, such as raised blood pressure, smoking, high cholesterol, low fruit and vegetable intake, physical inactivity, and alcohol excess. [9] Population-wide efforts to reduce salt intake and tobacco use through multiple economic and educational policies and programmes have been suggested as cost-effective primary prevention interventions in developing countries. [7]
Primary prevention measures should be complemented with proven secondary prevention measures, such as early aspirin use in patients with acute ischaemic cerebrovascular events, prescription of blood-pressure-lowering drugs to all patients with stroke, and basic multidisciplinary acute stroke units in hospitals that provide emergency care for patients. Development of consensus statements and national stroke guidelines by recognised experts from the region to address local issues on the basis of the best available evidence should also be encouraged and their use supported. Effective strategies to improve stroke awareness (including campaigns to remove stigma associated with stroke) and training of healthcare workers in the regions need to be developed and implemented on a larger scale. [7,10]
Further research is needed to trial other affordable and potentially widely applicable primary and secondary prevention strategies, such as a polypill containing aspirin, blood-pressure-lowering drugs, statin, and perhaps folic acid. [11] More research also needs to be done to assess indigenous medicines and compare various capacity-building strategies. [7] Emphasis should be placed on effectiveness and efficiency of the interventions in the specific context of developing countries. [7,10] Monitoring of effects of interventions at the population level and obtaining comparable and reliable data on stroke incidence, prevalence, and risk factors in developing countries deserves further attention.
[7,12] The ascertainment of numbers of hospitalised stroke patients in the WHO STEPwise approach to stroke surveillance [13] seems feasible, but the other two suggested steps (ascertainment of fatal stroke events in the same community, and especially the ascertainment of non-fatal, non-hospitalised stroke events in the same community) may be challenging in many low and middle-income countries. An alternative approach for studying stroke incidence and prevalence in countries with very limited resources could include a combination of a stroke prevalence survey (eg, door-to-door study) with a study of death certificates (verbal autopsy procedures) in the same community (figure). The key idea of this approach is that nonfatal first-ever stroke events within the preceding 3 years in the defined population are identified among prevalent cases of stroke (prevalence survey) and then combined in the analysis with fatal first-ever stroke events in the same population for the same study period to calculate cumulative stroke incidence rates. The standard WHO definition of stroke should be used to allow comparisons. [14] This design for studying stroke incidence has been used in Italy [15] and China [16] and shown to be valid. [15]
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Only through a comprehensive approach, combining applied stroke research with sustainable, affordable and context-specific evidence-based prevention and management strategies will it be possible to stem the global stroke epidemic, improve outcomes, monitor burden, and save millions of lives around the world.
Valery L Feigin
Clinical Trials Research Unit, School of Population Health, The University of Auckland, New Zealand
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