Stroke incidence in rural and urban Tanzania: a prospective, community-based study

Program for the epidemiological evaluation of stroke in Tandil, Argentina (PREVISTA) study: rationale and design

The availability of population-based epidemiological data on the incident risk of stroke is very scarce in Argentina and other Latin American countries. In response to the priorities established by the World Health Organization and the United Nations, PREVISTA was envisaged as a population-based program to determine the risk of first-ever and recurrent stroke and transient ischemic attack incidence and mortality in Tandil, Buenos Aires, Argentina. The study will be conducted according to Standardized Tools for Stroke Surveillance (STEPS Stroke) methodology and will enroll all new (incident) and recurrent consecutive cases of stroke and transient ischemic attack in the City of Tandil between May 1st, 2013 and April 30, 2015. The study will include patients with ischemic stroke, non-traumatic primary intracerebral hemorrhage, subarachnoid hemorrhage, and transient ischemic attack. To ensure the inclusion of every cerebrovascular event during an observation period of two years, we will instrument an 'intensive screening program', consisting of a comprehensive daily tracking of every potential event of stroke or transient ischemic attack using multiple overlapping sources. Mortality would be determined during follow-up for every enrolled patient. Also, fatal community events would be screened daily through revision of death certificates at funeral homes and local offices of vital statistics. All causes of death will be adjudicated by an ad-hoc committee. The close population of Tandil is representative of a large proportion of Latin-American countries with low- and middle-income economies. The findings and conclusions of PREVISTA may provide data that could support future health policy decision-making in the region.

Hypertension prevalence, awareness, treatment and control in Dakar (Senegal)

The prediction of risk profile trends associated with non-communicable diseases in developing countries is among the greatest global health challenges. The aim of this study is to estimate prevalence, awareness, treatment and control of hypertension in Dakar (Senegal). This study was carried out between January and June 2009 on a population sample of 600 individuals living in the department of Dakar. This sample was constructed using the quota method in order to strive for representativeness. Sociodemographic characteristics, hypertension, hypertension awareness, treatment and control, and body mass index of individuals were collected during face-to-face interviews. Statistical analyses used were χ2-tests and binary logistic regressions. Prevalence of hypertension was 27.50%. Prevalence of awareness, treatment and control among hypertensives were 27.88%, 16.97% and 5.45%, respectively. Logistic regression showed that the prevalence, awareness and treatment of hypertension increased with increasing age. Overweight and obese subjects were more often hypertensive but did not differ from others in awareness and treatment. This could be linked to the social valorization of stoutness in West Africa, which explains that excess weight is not perceived as a risk factor for hypertension. In conclusion, given the very low rates of awareness, treatment and control in our sample, developing strategies for averting a hypertension epidemic must be a priority objective.

Global cardiovascular disease and the academic public health curriculum

The epidemic of cardiac risk factors and cardiovascular disease in developing regions has reached sub-Sahara Africa. This global reality needs to energize the academic public health establishment to incorporate this phenomenon in its curriculum. The focus for control of these risk factors and illnesses will need to be on their cultural, political, and economic upstream drivers. The schools of public health will need to collaborate with a broad array of university disciplines to craft a focused and appropriate curriculum with which to train the next generation of global health professionals.

The epidemiology of cardiovascular diseases in sub-Saharan Africa: the Global Burden of Diseases, Injuries and Risk Factors 2010 Study

The epidemiology of cardiovascular diseases in sub-Saharan Africa is unique among world regions, with about half of cardiovascular diseases (CVDs) due to causes other than atherosclerosis. CVD epidemiology data are sparse and of uneven quality in sub-Saharan Africa. Using the available data, the Global Burden of Diseases, Risk Factors, and Injuries (GBD) 2010 Study estimated CVD mortality and burden of disease in sub-Saharan Africa in 1990 and 2010. The leading CVD cause of death and disability in 2010 in sub-Saharan Africa was stroke; the largest relative increases in CVD burden between 1990 and 2010 were in atrial fibrillation and peripheral arterial disease. CVD deaths constituted only 8.8% of all deaths and 3.5% of all disability-adjusted life years (DALYs) in sub-Sahara Africa, less than a quarter of the proportion of deaths and burden attributed to CVD in high income regions. However, CVD deaths in sub-Saharan Africa occur at younger ages on average than in the rest of the world. It remains uncertain if increased urbanization and life expectancy in some parts of sub-Saharan African nations will transition the region to higher CVD burden in future years.

Twenty-first century palliative care: a tale of four nations

Hospice and palliative care development, in terms of availability and services, occur to varying degrees in the developing world. In this paper, the evolution of palliative care practices in four developing nations (Nigeria, Georgia, Ethiopia and Tanzania) is described. By highlighting common problems as well as the unique individual perspectives of each country's practice, this paper aims at increasing global awareness of palliative care in the developing world. While the call for palliative care to become a fundamental human right is sustained, it is also hoped that this article will stimulate a global discussion on the best possible way to encourage the establishment and growth of palliative care services in other developing countries where hitherto it has not been in existence, with policymakers and healthcare professionals taking the lead through the institution of sound national policies to promote and provide palliative care to all citizenry.

The prevalence of dementia in rural Tanzania: a cross-sectional community-based study

OBJECTIVES

Despite the growing burden of dementia in low-income countries, there are few previous data on the prevalence of dementia in sub-Saharan Africa. The aim of this study was to estimate the prevalence of dementia in those who are 70 years and older in the rural Hai District of Tanzania.

METHODS

This was a two-phase cross-sectional survey. Using census data, we screened individuals aged 70 years and older from six rural villages using the Community Screening Instrument for Dementia in Phase I. In Phase II, a stratified sample of those identified in Phase I were clinically assessed using the DSM-IV criteria.

RESULTS

Of 1198 people who fulfilled the inclusion criteria, 184 screened positive for probable dementia, and 104 screened positive for possible dementia using the Community Screening Instrument for Dementia. During clinical assessment in Phase II, 78 cases of dementia were identified according to the DSM-IV criteria. The age-standardised prevalence of dementia was 6.4% (95% confidence interval: 4.9 to 7.9). Prevalence rates increased significantly with increasing age.

CONCLUSIONS

The prevalence of dementia in this rural Tanzanian population is similar to that reported in high-income countries. Dementia is likely to become a significant health burden in this population as demographic transition continues. Further research on risk factors for dementia in sub-Saharan Africa is needed to inform policy makers and plan local health services.

Stroke risk factors, subtypes, and 30-day case fatality in Abuja, Nigeria

Background:

Stroke is the second leading cause of death and the leading cause of adult disability worldwide. A better understanding of stroke risk factors and outcome may help guide efforts at reducing the community burden of stroke. This study aimed to understand stroke risk factors, imaging subtypes, and 30-day outcomes among adult Nigerians.

Materials and Methods:

We prospectively recruited all patients presenting with acute stroke at the National Hospital Abuja between January 2010 and June 2012. We assessed clinical and laboratory variables, as well as brain computerized tomography, magnetic resonance imaging, and carotid Doppler ultrasound scans. We also assessed case fatality and functional outcome at 30 days after stroke.

Results:

Of 272 patients studied, 168 (61.8%) were males. Age at presentation (mean ± standard deviation) was 56.4 ± 12.7 years in males and 52.9 ± 14.8 years in females (P = 0.039). Neuroimaging was obtained in 96.7% patients, revealing cerebral infarction (61.8%), intracerebral hemorrhage (ICH) (34.8%), and subarachnoid hemorrhage (SAH) (3.4%). Carotid plaques or stenosis ≥50% were detected in 53.2% patients with cerebral infarction. Stroke risk factors included hypertension (82.7%), obesity (32.6%), diabetes (23.5%), hyperlipidemia (18.4%), atrial fibrillation (9.2%), and cigarette smoking (7.7%). At 30 days after stroke, case-fatality rate was 18.8%, whereas modified Rankin Scale (mRS) scores for cerebral infarction, ICH, and SAH were 3.71, 4.21, and 4.56, respectively. Atrial fibrillation, a previous stroke, and age older than 50 years were all associated with worse mRS scores at 30 days.

Conclusion:

Although hypertension, obesity, diabetes mellitus, and atrial fibrillation were important stroke risk factors, in many patients, these were detected only after a stroke. While the commonest stroke subtype was cerebral infarction, observed in almost two-third of patients, SAH was associated with the highest case-fatality rate at 30 days of 44.4%. Larger population-based studies may provide additional data on stroke incidence and outcome among Nigerians.

Recent advances in the epidemiology, outcome, and prevention of myocardial infarction and stroke in sub-Saharan Africa

The early part of the new millennium witnessed reports of a growing burden of cardiovascular disease in Sub-Saharan Africa (SSA). However the contribution of ischemic heart disease and stroke to this increasing burden relative to that caused by hypertensive heart disease, cardiomyopathy and rheumatic heart disease was not clear. Over the last decade, data from the continent has begun to clarify this issue and suggests three main points. The burden of ischemic heart disease relative to other causes of heart disease remains low particularly in the black Africans majority. Stroke caused predominantly by hypertension is now a major cause of disability and premature death. Third, the burden of risk factors for atherosclerosis is increasing rapidly in most urban and some rural regions. A concerted effort to understand the primary drivers of this increase in cardiac risk factors is required to prevent a future epidemic of atherosclerosis and its sequelae.

Prevalence, awareness and control of hypertension in Uganda

BACKGROUND

Prevention and control of hypertension are critical in reducing morbidity and mortality attributable to cardiovascular diseases. Awareness of hypertension is a pre-condition for control and prevention. This study estimated the proportion of adults who were hypertensive, were aware of their hypertension and those that achieved adequate control.

METHODS

We conducted a community based cross sectional survey among people ≥ 15 years in Buikwe and Mukono districts of Uganda. People had their blood pressure measured and were interviewed about their social-demographic characteristics. Hypertension was defined as systolic blood pressure ≥ 140 mmHg, or diastolic blood pressure ≥ 90 mmHg, or previous diagnosis of hypertension. Participants were classified as hypertensive aware if they reported that they had previously been informed by a health professional that they had hypertension. Control of hypertension among those aware was if systolic blood pressure was <140 mmHg and diastolic blood pressure was <90 mmHg.

RESULTS

The age standardized prevalence of hypertension was 27.2% (95% CI 25.9-28.5) similar among females (27.7%) and males (26.4%). Prevalence increased linearly with age, and age effect was more marked among females. Among the hypertensive participants, awareness was 28.2% (95% CI 25.4-31.0) higher among females (37.0%) compared to males (12.4%). Only 9.4% (95% CI 7.5-11.1) of all hypertensive participants were controlled. Control was higher among females (13.2%) compared to males (2.5%).

CONCLUSION

More than a quarter of the adult population had hypertension but awareness and control was very low. Measures are needed to enhance control, awareness and prevention of hypertension.

Dementia prevalence estimates in sub-Saharan Africa: comparison of two diagnostic criteria

Background

We have previously reported the prevalence of dementia in older adults living in the rural Hai district of Tanzania according to the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV) criteria. The aim of this study was to compare prevalence rates using the DSM-IV criteria with those obtained using the 10/66 diagnostic criteria, which is specifically designed for use in low- and middle-income countries.

Methods

In phase I, 1,198 people aged 70 and older were screened for dementia. A stratified sample of 296 was then clinically assessed for dementia according to the DSM-IV criteria. In addition, data were collected according to the protocol of the 10/66 Dementia Research Group, which allowed a separate diagnosis of dementia according to these criteria to be established.

Results

The age-standardised prevalence of clinical DSM-IV dementia was 6.4% (95% confidence interval [CI] 4.9–7.9%) and of ‘10/66 dementia’ was 21.6% (95% CI 17.5–25.7%). Education was a significant predictor of ‘10/66 dementia’, but not of DSM-IV dementia.

Conclusions

There are large discrepancies in dementia prevalence rates depending on which diagnostic system is used. In rural sub-Saharan Africa, it is not clear whether the association between education and dementia using the 10/66 criteria is a genuine effect or the result of an educational bias within the diagnostic instrument. Despite its possible flaws, the DSM-IV criteria represent an international standard for dementia diagnosis. The 10/66 diagnostic criteria may be more appropriate when identification of early and mild cognitive impairment is required.

Electrocardiographic assessment of coronary artery disease and stroke risk factors in rural and urban Tanzania: a case-control study

BACKGROUND

Although the association between cerebrovascular and coronary artery disease (CAD) is well known in high-income countries, this association is not well documented in black Africans.

AIMS

The aim of this study was to document electrocardiographic (ECG) evidence of CAD in stroke cases and controls and to identify other common ECG abnormalities related to known stroke risk factors in a community-based population of incident stroke cases in Tanzania, East Africa.

METHODS

This was a case-control study. Incident stroke cases were identified by the Tanzanian Stroke Incidence Project. Age- and sex-matched controls were randomly selected from the background population. Electrocardiograms were manually analyzed using the Minnesota Coding System, looking for evidence of previous myocardial infarction (MI), atrial fibrillation (AF) or atrial flutter (AFl), and left ventricular hypertrophy (LVH).

RESULTS

In Hai, there were 93 cases and 241 controls with codable electrocardiograms, and in Dar-es-Salaam, there were 39 cases and 72 controls with codable electrocardiograms. Comparing cases and controls, there was a higher prevalence of MI and AF or AFl (but not LVH) in cases compared with controls.

CONCLUSIONS

This is the first published study of ECG assessment of CAD and other stroke risk factors in an incident population of stroke cases in sub-Saharan Africa. It suggests that concomitant CAD in black African stroke cases is more common than previously suggested.

The prevalence of neurological disorders in older people in Tanzania

OBJECTIVES

There are few data on neurological disorders prevalence from low- and middle-income countries, particularly sub-Saharan Africa (SSA) and none specific to the African elderly. We aimed to determined the prevalence of neurological disorders in those aged 70 years and over in a rural African community.

MATERIALS AND METHODS

This study was a cross-sectional two-phased community epidemiological survey set in the rural Hai district of Tanzania. Screening was performed with a validated screening questionnaire with high sensitivity and specificity. Positive responders to screening underwent full neurological history and examination to confirm or refute the presence of neurological disorders and to classify the disorder using the International Statistical Classification of Diseases and Related Health Problems 10th Revision (ICD-10).

RESULTS

Of 2232 participants, there were 384 neurological diagnoses amongst 349 people. The age-adjusted prevalence of people with neurological diagnoses was 154.1 per 1000 (95% CI 139.2-169.1). The age-adjusted prevalence per 1000 of the most common neurological disorders were tremor (48.2), headache (41.8), stroke (23.0), peripheral polyneuropathy (18.6), upper limb mononeuropathy (6.5) and parkinsonism (5.9).

CONCLUSIONS

This is the first published community-based neurological disorders prevalence study specifically in the elderly in SSA. It reveals a high prevalence of neurological morbidity and demonstrates the contribution neurological disorders make to the non-communicable disease epidemic. This is likely to increase as the population of low-income countries ages constituting a public health dilemma.

Rates of diagnosis and treatment of neurological disorders within a prevalent population of community-dwelling elderly people in sub-Saharan Africa

Background: The prevalence of neurological disorders in those aged 70 years and over in the Hai district of Tanzania has been previously reported. The following research reports rates of patient’s: treatment seeking, diagnosis and treatment within this prevalent population.

Methods: All people identified as having at least one neurological disorder in the prevalence study were questioned regarding whether they had sought treatment for their disorder, whether they had had a previous correct diagnosis and whether they were being currently treated.

Results: From a background population of 2232 people, 349 people had neurological disorders, of whom 225 (64.5%) had sought treatment for their symptoms. Of the 384 disorders identified in these 349 people, only 14.6% had been diagnosed and only 9.9% were receiving appropriate treatment. Males were significantly more likely to have been diagnosed and were more likely to have been treated appropriately.

Conclusions: Levels of diagnosis and treatment were low, with some gender inequality. Reasons for this may include a lack of recognition of the condition within the local population and lack of access to appropriate services. In the absence of effective primary and secondary preventative measures, and effective treatment, the burden of neurological disorders is likely to increase with further demographic ageing.

Stroke incidence in the South West District of the Penang Island, Malaysia: PEARLs: Penang Acute Stroke Research Longitudinal Study

OBJECTIVES

This community based incidence study aims to report the stroke incidence in the south-west region of the Penang Island.

METHODS

All strokes occurring in the population of residents in the southwest region of the Penang Island, Malaysia during a period of 12 months, from April 2010 to March 2011 were screened and assessed. Standard definitions for stroke were used. All stroke cases were ascertained using multiple overlapping sources. Incidence rate was based on first ever in a lifetime stroke cases. All recurrent strokes were excluded from the incidence count.

RESULTS

The overall stroke incidence rate in the study region during the study period was 67 per 100,000 after age adjustment to 2010 Malaysian population.

CONCLUSION

This study provides the first stroke incidence data in Malaysia and is vital for effective health system planning.

HIV infection and stroke: current perspectives and future directions

HIV infection can result in stroke via several mechanisms, including opportunistic infection, vasculopathy, cardioembolism, and coagulopathy. However, the occurrence of stroke and HIV infection might often be coincidental. HIV-associated vasculopathy describes various cerebrovascular changes, including stenosis and aneurysm formation, vasculitis, and accelerated atherosclerosis, and might be caused directly or indirectly by HIV infection, although the mechanisms are controversial. HIV and associated infections contribute to chronic inflammation. Combination antiretroviral therapies (cART) are clearly beneficial, but can be atherogenic and could increase stroke risk. cART can prolong life, increasing the size of the ageing population at risk of stroke. Stroke management and prevention should include identification and treatment of the specific cause of stroke and stroke risk factors, and judicious adjustment of the cART regimen. Epidemiological, clinical, biological, and autopsy studies of risk, the pathogenesis of HIV-associated vasculopathy (particularly of arterial endothelial damage), the long-term effects of cART, and ideal stroke treatment in patients with HIV are needed, as are antiretrovirals that are without vascular risk.

Validity of a screening instrument for neurologic disability in resource-poor African communities

BACKGROUND

There have been no recent population-based studies on all-cause adult neurological morbidity in sub-Saharan Africa. We have developed a screening survey to improve the feasibility in performing these studies.

METHODS

Our screening instrument contains both history questions and examination items. We pilot tested this instrument in the Hai District, Tanzania, and Butajira, Ethiopia using trained individuals from the local communities. To measure sensitivity, we applied the instrument blindly to 25 previously-identified subjects with Parkinson's disease, stroke or epilepsy. To measure specificity, we examined 42 randomly selected previously screened subjects. We also compared the validity of the entire instrument to the history-only section.

RESULTS

There were 669 adult subjects screened in both communities (150 screen-positives, and 519 screen-negatives). The sensitivity of the instrument was 100% (95% CI 84.2-100%) and the specificity was 82.4% (95% CI 66.1-92.0%). However, when restricting the instrument to the history-only section, the sensitivity remained unchanged, but the specificity became 91.2% (95% CI 76.3-97.7%; p=0.48).

CONCLUSIONS

We have created a valid tool to screen adults for neurologic morbidity in resource-poor communities. The use of the history-only section of the tool is adequate as a screen and will improve feasibility.

Prevalence of active epilepsy in rural Tanzania: a large community-based survey in an adult population

PURPOSE

To estimate the prevalence of active epilepsy in adults in an established demographic surveillance site in rural Tanzania. To describe the clinical characteristics of epilepsy and to estimate the treatment gap in this population.

METHODS

A pilot study established that a previously validated screening questionnaire was sensitive for detecting cases of epilepsy in a Kiswahili-speaking Tanzanian population. A door-to-door census of the adult population (total 103,026) used the screening questionnaire to identify possible cases of epilepsy, who were then assessed by a research doctor to establish a diagnosis of epilepsy or otherwise. The prevalence of active epilepsy in this population was estimated with age-standardisation to the WHO standard population. Seizure types and epilepsies were classified according to current recommendations of the International League Against Epilepsy. The treatment gap for epilepsy was estimated based on antiepileptic drug use as reported by cases.

RESULTS

Two hundred and ninety-one cases of active epilepsy, all with convulsive seizures, were identified. The age-standardised prevalence was 2.91/1000 adults (95% CI 2.58-3.24); the crude prevalence adjusted for non-response was 3.84/1000 adults (95% CI 3.45-4.20). Focal-onset seizures accounted for 71.5% of all cases identified. The treatment gap was 68.4% (95% CI 63.0-73.7).

CONCLUSIONS

This is one of the largest community-based studies of the prevalence of epilepsy in adults conducted in sub-Saharan Africa to date. We identified a lower prevalence than has previously been described in this region. The high proportion of focal onset seizures points to a large burden of acquired, and possibly preventable, epilepsy in this population. A treatment gap of 68.4% confirms that interventions to raise awareness of the treatable nature of epilepsy are warranted in this and similar populations.

Is stroke incidence in low- to middle-income countries driven by economics?

The incidence of stroke in low- to middle-income countries now exceeds that in high-income countries. These low- to middle-income countries also have greater case fatality and a younger age of stroke onset, factors that contribute to a high stroke burden. Macroeconomic indicators of socioeconomic status, such as health expenditure, appear to be inversely associated with stroke incidence. However, there are often large socioeconomic gradients between regions such as between urban and rural regions. This article emphasizes that macroeconomic indicators are likely to mask regional disparities in stroke incidence. Public health messages and prevention strategies must therefore be targeted regionally rather than nationwide. Without a comprehensive and multifaceted approach to prevention, the epidemic of stroke will continue.

Verbal autopsy for neurological diseases

Verbal autopsy is an interview-based technique to determine the cause distribution of death in a population. The use of verbal autopsy for understanding neurological diseases is crucial to burden of disease analyses in many countries, particularly in locations where civil registration systems are non-functioning or absent. We review the purposes, strengths, and weaknesses in the use of verbal autopsy for neurological diseases.

Post-stroke carotid ultrasound findings from an incident Tanzanian population

BACKGROUND

Carotid artery stenosis is not thought to be a major cause of stroke in sub-Saharan Africa, though data are limited. The aim of this study was to use Duplex ultrasonography to establish the prevalence of significant carotid artery stenosis in an incident stroke population in Tanzania.

METHODS

Duplex ultrasound scan was carried out on consecutive cases of stroke, in the latter part of a stroke incidence study, who survived long enough to undergo investigation. As part of the wider incidence study, demographic data, social history, medical history, levels of current disability and findings from computer tomography scan and electrocardiogram were recorded.

RESULTS

132 incident stroke cases were identified over the whole study period, of whom 56 (42.4%) underwent Duplex ultrasound. Only 1 case (female, aged 56 years) had evidence of right internal carotid artery stenosis, with a mild degree of stenosis of around 50%. There was no evidence of stenosis of either common carotid artery or of the left internal carotid artery in any cases.

CONCLUSIONS

Carotid artery stenosis was rare in our cohort and does not appear to be a significant cause of stroke in our incident cohort.

Non-communicable diseases in sub-Saharan Africa: what we know now

BACKGROUND

Sub-Saharan Africa (SSA) has a disproportionate burden of both infectious and chronic diseases compared with other world regions. Current disease estimates for SSA are based on sparse data, but projections indicate increases in non-communicable diseases (NCDs) caused by demographic and epidemiologic transitions. We review the literature on NCDs in SSA and summarize data from the World Health Organization and International Agency for Research on Cancer on the prevalence and incidence of cardiovascular diseases, diabetes mellitus Type 2, cancer and their risk factors.

METHODS

We searched the PubMed database for studies on each condition, and included those that were community based, conducted in any SSA country and reported on disease or risk factor prevalence, incidence or mortality.

RESULTS

We found few community-based studies and some countries (such as South Africa) were over-represented. The prevalence of NCDs and risk factors varied considerably between countries, urban/rural location and other sub-populations. The prevalence of stroke ranged from 0.07 to 0.3%, diabetes mellitus from 0 to 16%, hypertension from 6 to 48%, obesity from 0.4 to 43% and current smoking from 0.4 to 71%. Hypertension prevalence was consistently similar among men and women, whereas women were more frequently obese and men were more frequently current smokers.

CONCLUSIONS

The prevalence of NCDs and their risk factors is high in some SSA settings. With the lack of vital statistics systems, epidemiologic studies with a variety of designs (cross-sectional, longitudinal and interventional) capable of in-depth analyses of risk factors could provide a better understanding of NCDs in SSA, and inform health-care policy to mitigate the oncoming NCD epidemic.

Stroke: a realistic approach to a growing problem in sub-Saharan Africa is urgently needed

Stroke is an increasing problem in sub-Saharan Africa, even in children. High rates of hypertension, diabetes, alcohol abuse, smoking, insufficient fruit and vegetable consumption, sickle cell disease, HIV infection, antiretroviral use and race are likely contributing factors. Although often considered as related to increasing wealth, stroke is more strongly related to poverty, and in turn increases it. Case-fatality rates are high and premature death and years of life lost are a major problem. We propose an approach to stroke prevention and treatment that takes into account the real situation on the ground and can be applied in sub-Saharan Africa, an area where stroke units are largely not feasible and many patients do not reach hospitals. Involvement of community and faith-based organisations, use of simple diagnostic tests, emphasis on clinical examination to differentiate between haemorrhagic and ischaemic stroke, prompt initiation of aspirin therapy and training of community nurses on essential management of stroke should be urgently implemented.