Year : 2007 | Volume
: 10 | Issue : 3 | Page : 130--136
UN millennium development goals: Can we halt the stroke epidemic in India?
Praful Dalal, Madhumita Bhattacharjee, Jaee Vairale, Priya Bhat
Lilavati Hospital and L.K.M.M. Trust Research Centre, Mumbai - 400 050, India
Municipal Bldg. No. 3, Flat 18, Clerk Road, Haji Ali, Mumbai - 400 034
India will soon have to bear an enormous socioeconomic burden due to the costs of the rehabilitation of stroke survivors; this is because the population is now surviving through the peak years (age 55-65) for the occurrence of stroke or cerebrovascular accident (CVA). Community surveys from many regions show crude prevalence rates for stroke (presumed to be of vascular origin) in the range of 90-222 per 100,000 persons. In India, the major risk factors identified have been hypertension (>95 mm Hg diastolic), hyperglycemia, tobacco use, and low levels (<10 gm%) of hemoglobin. The Global Burden of Disease (GBD) Study, in 1990, reported 9.4 million deaths in India, of which 619,000 deaths were due to stroke, suggesting a mortality rate of 73 per 100,000 persons. This mortality rate was almost 22 times greater, and the disability adjusted life years lost was nearly six times higher, than that due to malaria. For effective prevention strategies, the existing mass media must be used to build up public awareness and impart health education on the warning symptoms of hypertension and stroke. In the absence of facilities such as computerized tomography in rural areas, primary health care doctors should receive training on the nomenclature and clinical diagnosis of stroke. Community surveys to detect «SQ»stroke-prone«SQ» subjects should be undertaken wherever feasible and medico-social workers should remain in contact with such patients to ensure intake of preventive medicines. Changes in lifestyle and dietary habits, and intensive campaigns against tobacco use, will prove rewarding. National councils should interact with various agencies (health, industry, finance, etc.) to coordinate activities at all levels.
|How to cite this article:|
Dalal P, Bhattacharjee M, Vairale J, Bhat P. UN millennium development goals: Can we halt the stroke epidemic in India?.Ann Indian Acad Neurol 2007;10:130-136
|How to cite this URL:|
Dalal P, Bhattacharjee M, Vairale J, Bhat P. UN millennium development goals: Can we halt the stroke epidemic in India?. Ann Indian Acad Neurol [serial online] 2007 [cited 2020 Sep 19 ];10:130-136
Available from: http://www.annalsofian.org/text.asp?2007/10/3/130/34791
Poverty has a direct relationship with ill health. Without adequate financial resources people cannot meet their basic human needs (i.e., food, water, sanitation, and housing) or access health care services. Often, governments do not address the health care issues or needs of the poor or intervene for prevention of disease. The United Nations Millennium Development Goals (UNMDGs) addresses this issue by advocating interventions tailored to local (socioeconomic) conditions and proposes to achieve, by the year 2015, improved levels of human development and health in the developing nations. Sustainable follow-up poverty alleviation programmes are mandatory.  In this context, poverty and ill health should not be viewed as matters of economic and public policy, but as a violation of fundamental human rights in a civil society.
The World Health Organization's goal of 'Health for All' by the year 2000 AD was perhaps unrealistic, because there was a failure in comprehending the impact that cultural, social, and religious traditions could have on health policies . Furthermore, there was inadequate allocation of funds for primary health care and population issues. Therefore, to achieve the goals set for the year 2015 we will have to reorient ourselves to bridge the gap between the country's health policy and the health care needs of the poor. In this paper, an attempt is made to review the demographic and epidemiologic data on the magnitude of the stroke burden in India.
India: Demographic and epidemiologic transitions
India is going through a period of epidemiologic and demographic transition  [Table 1]; [Figure 1],[Figure 2], resulting from the decline in the infant mortality rate and the increase in the life expectancy of an ageing population.
Infectious diseases (e.g., tuberculosis, malaria, HIV/AIDS, etc.) are still major health problems and, in addition, there is the problem of the emergence of newer or drug resistant strains of microorganisms [Table 2].  On the other hand, smallpox has been eradicated and poliomyelitis and leprosy are likely to be eliminated in the near future; as infectious diseases are brought under control, more young people will survive, only to be exposed to the risk of noncommunicable diseases.  Rapid urbanization and changing lifestyles, with the ill effects of changes in diets, physical inactivity, tobacco addiction, and stress, will aggravate the situation
The stroke epidemic: India and other developing countries
Worldwide, approximately 20 million people suffer from stroke each year; of them, only 15 million survive. Of those who survive, five million will be disabled by their stroke.  'An estimated 5.7 million people died from stroke in 2005, and 87% of these deaths were in low-income and middle-income countries. Without effective interventions, the number of global deaths is projected to rise to 6.5 million in 2015.' 
The Global Burden of Disease (GBD) Study  reported 9.4 million deaths in India, of which 619, 000 were from stroke. The disability adjusted life years (DALYs) that were lost amounted to almost 28.5 million-nearly six times higher than that due to malaria. When these figures were projected for the year 2020, Murray and Lopez  reported that 61 million DALYs are likely to be lost due to stroke; of this, 52 million (84%) will be in the developing countries.  Thus, epidemics of stroke are beginning in most developing nations, whereas stroke mortality rates are declining or stabilizing in the developed countries. ,,
The regional differences in the burden of cardiovascular diseases are shown in [Table 3]. ,,,
Lifestyle changes and stroke mortality in India
India is an emerging economy. With rapid urbanization and industrialization the ageing population is now increasingly exposed to the risk factors of stroke, e.g., obesity, high blood pressure, diabetes mellitus, tobacco use, etc. Consumption of high-energy foods with little dietary fiber and micronutrients will predispose to nutritional disorders and stroke deaths. Rising tobacco consumption will only aggravate the situation. Thus, the three transitions-demographic, lifestyle, and socioeconomic-have contributed significantly to the emergence of the stroke epidemic in India and in the developing countries.
Burden of stroke: Current estimates
Annual incidence rates (for Asia/ India)
Reliable data, obtained using verifiable methods, on the annual incidence of stroke per 100,000 population in different parts of India are not available. For example, the population-based stroke study (1969-71) in Vellore, India, quotes an annual incidence rate of 13/100,000 people.  Likewise, the WHO Stroke Study (1971-74) quotes for Rohtak (India), an annual incidence of 33/100,000 population for all ages .  On the other hand, the recent prospective, population-based Mumbai Stroke Registry (2005), using the standardized WHO STEPS stroke protocol found an overall annual incidence of 148/100,000 population, 95% CI: 120-170; (age-adjusted SEGI 154 /100,000, 95% CI :134-174).  Available data on annual incidence rates from other population-based studies from the Asia-Pacific region are shown in [Table 4].  It reemphasizes the need for population-based prospective surveys, using uniform methodologies for inter-regional comparisons, to assess the burden of stroke for India / Asia.
Stroke surveillance: Population-based study (Mumbai Registry)
The prospective community-based WHO Stroke Surveillance protocol has been recommended for finding out incidence rates. The objectives of the Mumbai Registry was (1) to estimate the annual incidence rate of new 'stroke events' in a census-defined community (H ward) in Mumbai and (2) to assess the clinical profile and the associated risk factors. The manual on WHO STEPwise approach to stroke surveillance (STEPS; http://www.who.int/chp/steps/stroke) was the operational protocol; it defines terminologies and methodologies for evaluation and assessment of a recent stroke case. A well-defined community (H ward), having verifiable census data (2004) and representative of the population structure (by percentage distribution of sex and age bands) of Mumbai (Bombay), was selected. Of the total of 337,391 permanent residents, 156,861 subjects between the ages of 25 and 95 years who were eligible for the survey were screened. As per the protocol definition, people under the age of 25 years (180,530 subjects) and those with a history suggestive of transient ischemic attacks (TIAs) were excluded.
During the year 2005, 232 new stroke cases (128 males and 104 females) were identified, indicating an annual incidence rate of 148 per 100,000 persons per year (95% CI: 120-170; age-adjusted SEGI  154/100,000; 95% CI: 134-174 /100,000) as shown in [Figure 3].
One hundred and ninety patients (82%) attended health care or diagnostic centers, whereas 42 (18%) did not avail of such facility. The mean age was 67.7 ± 11.89 (SD) years; female patients were older as compared to the male patients (mean age 69.9 ± 11.65 [SD] years vs 65.9 ± 11.84 [SD] years, respectively). By the diagnostic test (CT), 180 (77%) had ischemic strokes, 47 (21%) had hemorrhagic strokes, and 5 (2%) were of unspecified type. There was no gender difference and 15% had a history of a previous stroke. Complete data for risk factor analysis were available in 120 'in-hospital' cases: hypertension, either alone or in combination with various other diseases, was present in 102 cases (85%). At 28 days after a stroke event, 146 (63%) of the 232 cases were alive, whereas 86 (37%) had died. Of the 146 surviving patients, 82 (35.3%) had moderate to severe disability. It is suggested that similar population-based surveys in well-defined communities in different regions of India should be initiated (using the STEPS stroke protocol) to assess the overall burden of stroke and to plan effective intervention and prevention strategies.
Stroke prevalence studies in India
The published information on crude prevalence rates for hemiplegia, presumed to be due to stroke, is summarized in [Table 5].  The overall rate ranged from 90-220/100,000 persons for 'completed strokes.' It is evident that there are significant regional differences between urban and rural areas. The need for prospective surveys, using uniform methodology, for validation of such estimates and for inter-regional comparisons is, therefore, reemphasized. 
Morbidity and mortality estimates
Case-specific and cause-specific morbidity and mortality data, based on uniform terminologies and methodologies, for comparing the burden of disease across and between nations are not available.  Precise morbidity and mortality estimates for stroke are not always possible because of (1) incomplete death certification, (2) incorrect death classification, and (3) uncertainty regarding the etiology in cases of sudden deaths.  Rural estimates based on verbal autopsy are highly unreliable. For example, in a survey of 1407 villages (selected primary health care centers) spread over 23 states, stroke accounted for only 0.5% of all rural deaths.  However, a recent report on mortality data by verbal autopsy on 1354 deaths in 45 villages (population of 180,162) in rural Andhra Pradesh has recorded a crude death rate of 7.5/1000, and the leading cause of death in 32% of the cases was ischemic heart disease and stroke.  In the absence of reliable statistics, the burden of diseases is difficult to assess. Similar difficulties are encountered in morbidity surveys where errors in sampling design and sample size, and lack of standardization in measurements, are major obstacles.
Clinical profile and risk factors for stroke in India
Indian Collaborative Acute Stroke Study (ICASS)
The ICASS  is a prospective multicentric study on unselected, CT-confirmed cases of acute (less than 72 h) stroke admitted to major university hospitals in India (in Chandigarh, New Delhi, Mumbai, Pune, Bangalore, Chennai, and Hyderabad). In the ICASS, the WHO STEPS Stroke, version 1.1, was incorporated as operational protocol. Prior to initiation of the study, the investigators met to define various terminologies and the methodologies to be adopted. The pilot phase confirmed uniformity in case identification and data collection.
During the study period, 2002-2004, reliable information was available in 2162 acute stroke cases (CT-confirmed). [Figure 4] shows the distribution by age, sex, and type of stroke in these 2162 cases. [Figure 5] shows the data on associated risk factors, such as hypertension (HT), diabetes mellitus (DM), ischemic heart disease (IHD), either alone or in various combinations, in 1559 cases. The morbidity/mortality pattern, with correlation between NIH score on admission and the Barthel Index at 12 weeks, as available in 847 subjects, is shown in [Table 6]. It suggests a trend that mild neurologic deficit (NIH score less than 7) was associated with minimal disability, whereas moderate or severe neurologic deficit was associated with significant disability in stroke survivors. However, in stroke epidemiology, in well-defined populations, the DALYs lost and the disability status at 28 days would be more meaningful.
Issues in health policy for strokes in developing countries
Strong and colleagues estimate the current global burden of stroke at 16 million first-ever strokes, 62 million stroke survivors, 51 million DALYs lost and 5.7 million deaths in 2005.  Without effective interventions, the stroke burden will increase by the year 2030 to 23 million first-ever strokes, 77 million stroke survivors, 61 million DALYs lost and 7.8 million deaths. This burden will predominantly affect low and middle-income countries.  It has been suggested that interventions like primary prevention and control of risk factors can achieve a 2% reduction per annum in overall stroke mortality.  However, there is a paucity of reliable and comparable data on stroke incidence, prevalence, clinical profile, trends, management, and outcome, which is necessary for designing sustainable primary or secondary prevention programmes. However, risk factors for stroke are mainly conventional  and interventions targeting raised blood pressure, smoking, high cholesterol, physical inactivity, and alcohol excess should prove effective. Health education on low salt intake and stopping tobacco use are cost-effective methods. A national health policy in support of the above objectives is highly recommended.
On account of scarce resources, modern stroke care (with the optimum use of intensive care units, neuroimaging, thrombolytics, etc. for evaluation and management) is beyond the reach of most patients in developing nations. , The ethical dilemmas in diverting scarce health care resources from control of infectious and nutritional disorders to the control of cardiovascular diseases and stroke continues to be debated. 
To reduce burden of stroke, some practical approaches are suggested: 
The implementation of mass screening surveys to identify 'hypertensives' and 'stroke-prone' subjects (e.g., subjects with TIA) should be undertaken to allow prescription of simple, practical, and cost effective remedies.The patients' compliance with clinic referral is usually unsatisfactory. Therefore, medico-social or multipurpose workers should endeavor to remain in constant contact with these stroke-prone individuals to ensure that they follow advice on regular intake of medicines and control of risk factors.Health education and socioeconomic development, community-awareness programmes on lifestyle modifications to reduce risk of disease, health promotion, and physical activity are all desirable.It is also vital that national councils liaison with various agencies (health, industry, finance, etc.) and coordinate activities at all levels. Political effort to legislate the National Health Policy in support of the above objectives is highly recommended.
We are thankful to Dr. Narendra Trivedi, Vice President (Medical) of L.K.M.M. Trust Research Centre and Lilavati Hospital, for permission and unstinted support at all stages. We thank the directors and administrative staff and nursing staff of all hospitals, and the research officers, medico-social workers and participating centers for their help. Dr. A. Nanivadekar provided statistical advice. In the population-based study, family physicians practicing in the area helped the research officers in identifying, verifying, and evaluation of new stroke events. Family members of the patients cooperated in the verbal autopsy. [Figure 4] and [Figure 5]  and [Table 6]  have been reproduced with kind permission from Wiley-Blackwell Publishing Ltd., UK. [Table 5]  has been reproduced with due acknowledgement and kind permission from Journal of Association of Physicians of India.
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