R. S, V. S. B, Loganathan S, Dalavaikodihalli Nanjaiah N, Hegde T, Prasad K, Garady L, Akashanand A, Poddar P, Jayabalan M, Madan I, Medhi U, Arun A. Population-based cohort across stroke life course in India-The NIMHANS-NH-SKAN stroke project: A study protocol

BACKGROUND

Stroke is a leading cause of death and disability worldwide. In India, it is the fourth leading cause of death and fifth leading cause of disability, posing a major public health concern. National surveys reveal an increasing trend in stroke risk factors such as tobacco use, physical activity, alcohol use, hypertension, and dyslipidemia. However, knowledge regarding the combined effect of these risk factors and their various combinations is limited. Understanding the individual, combined, and synergistic effects of known risk factors, along with new risk factors, is essential to address gaps in stroke epidemiology. This study aims to examine the effect of various risk factors of acute stroke and their association with stroke occurrence and its outcomes (survival, disability and quality of life).

METHODS

This retrospective-prospective cohort will be conducted in one taluka of Kolara district and two urban wards of Bengaluru with a total population of ~400,000. All stroke-free individuals above 30 years of age ~200,000 individuals in the selected sites will be participants of stroke-free period and all first ever stroke patients in the community will be part of stroke and post-stroke period respectively. The study subjects will be recruited through a complete house-to-house survey at baseline and undergo annual follow-ups during the stroke-free period, with specific assessments at defined time points during the stroke and post-stroke period for a period of one year. Efforts are implemented to minimize loss to follow-up, including community engagement, a helpline number, and hospital-based surveillance.

DISCUSSION

This large population-based cohort study addressing stroke epidemiology in the country, is one -of-its-kind, attempting to fill certain critical gaps in the natural history, management, and outcomes of stroke in India. This research has the potential to provide important insights into the effect of novel risk factors of stroke and various combinations of risk factors of stroke. Furthermore, the development of a stroke risk predictability calculator will add value to the existing Indian National Programme for Prevention & Control of Non-Communicable Diseases (NP-NCD) and offers a model for similar countries once developed.

Stroke in Asia

BACKGROUND

There is a significant burden of stroke in Asia. Asia has the largest population in the world in 2023, estimated at 4.7 billion. Approximately 9.5-10.6 million strokes will be anticipated annually in the backdrop of a diverse group of well-developed and less developed countries with large disparities in stroke care resources. In addition, Asian countries are in varying phases of epidemiological transition.

SUMMARY

In this review, we examined recent epidemiological features of ischaemic stroke and intracerebral haemorrhage in Asia with recent developments in hyperacute stroke reperfusion therapy and technical improvements in intracerebral haemorrhage. The article also discussed the spectrum of cerebrovascular diseases in Asia, which include intracranial atherosclerosis, intracerebral haemorrhage, infective aetiologies of stroke, moyamoya disease, vascular dissection, radiation vasculopathy, and cerebral venous thrombosis.

KEY MESSAGES

The review of selected literature and recent updates calls for attention to the different requirements for resources within Asia and highlights the breadth of cerebrovascular diseases still requiring further research and more effective therapies.

Surveillance of stroke: a South-East Asia Region (SEAR) perspective

Surveillance of stroke is critical to track its burden and assess progress in prevention and treatment. We reviewed the literature to evaluate stroke surveillance efforts in the South-East Asia Region (SEAR) countries, identify progress and assess gaps. Epidemiological data on all the major parameters such as the incidence, prevalence and mortality of stroke were available for India and Thailand but for none of the other SEAR countries. Most of the epidemiological data came from investigator-initiated studies. National stroke surveillance was present only in India in the form of a National Stroke Registry Programme and Thailand has a national database that was used to obtain epidemiological data for stroke. Research on novel methods for stroke registration, such as using information technology, was absent. This review identified serious gaps in the monitoring and surveillance of stroke in SEAR countries. Systematic efforts are needed to fill those gaps.

Stroke in India: A systematic review of the incidence, prevalence, and case fatality

BACKGROUND

The burden of stroke is increasing in India; stroke is now the fourth leading cause of death and the fifth leading cause of disability. Previous research suggests that the incidence of stroke in India ranges between 105 and 152/100,000 people per year. However, there is a paucity of available data and a lack of uniform methods across published studies.

AIM

To identify high-quality prospective studies reporting the epidemiology of stroke in India.

SUMMARY OF REVIEW

A search strategy was modified from the Cochrane Stroke Strategy and adapted for a range of bibliographic databases from January 1997 to August 2020. From 7717 identified records, nine studies were selected for inclusion; three population-based registries, a further three population-based registries also using community-based ascertainment and three community-based door-to-door surveys. Studies represented the four cities of Mumbai, Trivandrum, Ludhiana, Kolkata, the state of Punjab, and 12 villages of Baruipur in the state of West Bengal. The total population denominator was 22,479,509 and 11,654 (mean 1294 SD 1710) people were identified with incident stroke. Crude incidence of stroke ranged from 108 to 172/100,000 people per year, crude prevalence from 26 to 757/100,000 people per year, and one-month case fatality rates from 18% to 42%.

CONCLUSIONS

Further high-quality evidence is needed across India to guide stroke policy and inform the development and organization of stroke services. Future researchers should consider the World Health Organization STEPwise approach to Surveillance framework, including longitudinal data collection, the inclusion of census population data, and a combination of hospital-registry and comprehensive community ascertainment strategies to ensure complete stroke identification.

Epidemiology of young stroke in the ludhiana population-based stroke registry

Objective:

The objective of the study was to determine incidence, risk factors, and short-term outcomes of young stroke in Ludhiana city, Northwest India.

Methods:

Data were collected on first-ever stroke in patients of age ≥18 years, from hospitals, diagnostic imaging centers, general practitioners, and municipal corporation during March 2011–March 2013 in Ludhiana city, using the World Health Organization Stepwise Approach to Surveillance (WHO STEPS). Outcome was documented using the modified Rankin Scale at 28 days.

Results:

Of 2948 patients, 700 (24%) were in the age group 18–49 years. Annual incidence in this age group was 46/100,000 person-years (95% confidence interval [CI], 41–51/100,000). Hypertension (84%), diabetes mellitus (48%), and atrial fibrillation (AF) (12%) were found more common in >49 years age group, as compared with 18–49 years age group. Drug abuse (8.7% vs. 6% in age >49 years; P = 0.04) and tobacco intake (8.7% vs. 5.6% in age >49 years; P = 0.02) was more common in young people, that is, 18–49 years age group in comparison to older patients, >49 years age group. Recovery was better in younger subjects (60% vs. 46% in age >49 years P < 0.001). In a multivariable analysis, younger people were more often literate (odds ratio [OR] 2.52; 95% CI, 1.68–3.77; P < 0.001), employed (OR 3.92; 95% CI, 2.20–5.21; P < 0.001), and 374 (60%) had good clinical outcome, modified Rankin Scale <2 at 28 days follow-up as compared with 938 (46%) older patients (OR 1.52; 95% CI, 1.15–2.00; P = 0.003).

Conclusion:

Hypertension, diabetes mellitus, drug addiction, and tobacco intake were significantly associated with young stroke. Outcome was also better in younger people.

Transient Ischemic Attack (TIA) Incidence with Geographic Information Systems (GIS) Mapping for Stroke Prevention Interventions

Objectives:

GIS mapping as a public health tool has been increasingly applied to chronic disease control. While evaluating TIA incidence from an existing regional stroke registry in Ludhiana city, India, we aim to apply the innovative concept of regional TIA GIS mapping for planning targeted stroke prevention interventions.

Methods:

TIA patient data was obtained from hospitals, scan centers and general practitioners from March 2010 to March 2013 using WHO-Stroke STEPS based surveillance as part of establishing a population-based stroke registry in Ludhiana city. From this registry, patients with TIA (diagnosed by MRI image-based stroke rule-out, or clinically) were chosen and data analyzed.

Results:

A total of 138 TIA patients were included in the final analysis. The annual TIA incidence rate for Ludhiana city was 7.13/100,000 (95% confidence interval: 5.52 to 8.74) for 2012-2013. Mean age was 58.5 ± 13.9 years (range: 22-88 years) and 87 (63%) were men. Majority of the TIA cases had anterior circulation TIAs. Hypertension (87.4%) was the most common risk factor. Using Geographic Information System (GIS) mapping, high TIA incidence was seen in central, western, and southern parts and clustering of TIA cumulative incidence was seen in the central part of Ludhiana city.

Conclusion:

Incidence rate of TIA was lower than that expected from a low- and middle-income country (LMIC). TIA GIS mapping, looking at regional localization, can be a novel option for developing targeted, cost-effective stroke prevention programs.

Rural Stroke Surveillance and Establishment of Acute Stroke Care Pathway Using Frontline Health Workers in Rural Northwest India: The Ludhiana Experience

BACKGROUND AND PURPOSE

The role of community health workers (CHWs) in stroke surveillance and in establishing the stroke care pathway has not been studied. The aim of the study was to evaluate the feasibility of using CHWs in the public health system to identify stroke patients for population-based stroke registration and to study the establishment of acute stroke care pathway in rural areas of Ludhiana, Punjab, Northwest India.

METHODS

Two rural blocks in Ludhiana district, comprising 164 villages and a population of 259,778, were selected. Phase-1 (feasibility study) was from August to November 2016 and phase-2 from December 2016 to November 2018. All first-ever stroke cases in adults (aged ≥18 years) were included. The accredited social health activists (ASHAs) were trained to identify stroke patients in the community, who were later evaluated by a neurologist. Stroke characteristics were recorded, and the outcome was assessed at 6 months using modified Rankin scale (0-2, good outcome).

FINDINGS

During phase-2, 359 first-ever stroke patients and 102 stroke mimics were identified. The age-standardized incidence rate was 218.5/100,000 and 197∙6/100,000 for each year. Half (52.4%) of the patients reached health-care facilities within 4.5 h, yet none of them received thrombolysis. Very few patients (1.9%) utilized free government 108 ambulance service to reach a health-care facility. Out of 359 stroke cases, the majority (306, 85.23%) were reported by ASHAs and 14.77% were reported by other sources. Brain imaging was available in 127 (35.4%) patients, and 100 (78.7%) had ischemic stroke. The most common risk factor was hypertension (320, 89%) and drug abuse (154, 42.9%). At 6 months, 168 (64%) patients had a good outcome.

CONCLUSION

ASHAs were able to identify stroke patients in the villages. Despite high numbers of patients reaching health-care facilities within a window period, the hospitals were unable to provide acute stroke treatment like thrombolysis. The health-care system needs to be strengthened to improve stroke care.

National Stroke Registry Programme in India for Surveillance and Research: Design and Methodology

The burden of stroke is increasing, and India lacks comparable long-term data on stroke incidence and mortality. Disease surveillance using a registry model can provide long-term data on stroke for linking with public health interventions in stroke prevention, treatment, and rehabilitation. The objectives of the National Stroke Registry Programme (NSRP), India, are to generate reliable data on the incidence of first-ever stroke events in defined populations through a population-based stroke registry (PBSR) and to describe the patterns of care and outcomes of patients with stroke in different treatment settings through a hospital-based stroke registry (HBSR). Continuous systematic collection on a standardized format of diagnostic, treatment, and outcome information on stroke events in persons of defined population (PBSR) and those who attend hospitals (HBSR) is conducted through active data abstraction from review of records from all health facilities and imaging centres that cater to stroke patients. Data are ICD coded, verified, and completed by obtaining survival status of registered patients. IT tools are used for data collection,management and analysis. The NSRP shall establish a standardized stroke surveillance system that would reliably measure stroke incidence, subtypes, treatment patterns, complications, disability, case fatality, and survival. This evidence shall inform health planning of stroke interventions and control activities. It would facilitate improvement in stroke services to improve quality of care and outcomes of stroke. A thrust for research on stroke would be encouraged based on evidence-based hypothesis generation.

Incidence & prevalence of stroke in India: A systematic review

BACKGROUND & OBJECTIVES

There has been more than 100 per cent increase in incidence of stroke in low- and middle-income countries including India from 1970-1979 to 2000-2008. Lack of reliable reporting mechanisms, heterogeneity in methodology, study population, and small sample size in existing epidemiological studies, make an accurate estimation of stroke burden in India challenging. We conducted a systematic review of epidemiologic studies on stroke conducted in India to document the magnitude of stroke.

METHODS

All population-based, cross-sectional studies and cohort studies from India which reported the stroke incidence rate or cumulative stroke incidence and/or the prevalence of stroke in participants from any age group were included. Electronic databases (Ovid, PubMed, Medline, Embase and IndMED) were searched and studies published during 1960 to 2015 were included. A total of 3079 independent titles were identified for screening, of which 10 population-based cross-sectional studies were considered eligible for inclusion. Given the heterogeneity of the studies, meta-analysis was not carried out.

RESULTS

The cumulative incidence of stroke ranged from 105 to 152/100,000 persons per year, and the crude prevalence of stroke ranged from 44.29 to 559/100,000 persons in different parts of the country during the past decade. These values were higher than those of high-income countries.

INTERPRETATION & CONCLUSIONS

A paucity of good-quality epidemiological studies on stroke in India emphasizes the need for a coordinated effort at both the State and national level to study the burden of stroke in India. Future investment in the population-based epidemiological studies on stroke would lead to better preventive measures against stroke and better rehabilitation measures for stroke-related disabilities in the country.

Stroke profile and outcome between urban and rural regions of Northwest India: Data from Ludhiana population-based stroke registry

Introduction

The objective of this study is to compare the clinical profile, risk factors, type and outcome of stroke patients in urban and rural areas of Punjab, India.

Methods

The primary data source was from the Ludhiana urban population-based stroke registry. The data of first-ever stroke patients with age ≥18 years were collected using WHO stepwise approach from all hospitals, general practitioners, physiotherapy and scan centres between 26 March 2011 and 25 March 2013.

Results

A total of 4989 patients were included and out of 4989 patients, 3469 (69%) were from urban areas. Haemorrhagic stroke was seen more in rural as compared to urban regions (urban 1104 (32%) versus rural 552 (36%); p = 0.01). There were significant differences seen in stroke risk factors; hypertension (urban 1923 (84%) versus rural 926 (89%); p = 0.001) and hyperlipidaemia (urban 397 (18%) versus rural 234 (23%); p = 0.001) between two groups. In the multivariable analysis the rural patients were more likely to be younger (age < 40 years) (OR: 1.82; 95% CI: 1.24-2.68; p = 0.002), Sikhs (OR: 2.57; 95% CI: 1.26-5.22; p = 0.009), farmers (OR: 9.41; 95% CI: 5.36-16.50; p < 0.001), housewives (OR: 2.71; 95% CI: 1.45-5.06; p = 0.002), and consumed alcohol (OR: 1.57; 95% CI: 1.19-2.06; p = 0.001) as compared to urban patients. In addition, use of imaging was higher in rural patients (OR: 1.99; 95% CI: 1.06-3.74; p = 0.03) as compared to urban patients.

Discussion and Conclusion

In this large cohort of patients, rural and urban differences were seen in risk factors and type of stroke. Stroke prevention strategies need to take into consideration these factors including regional sociocultural practices.

An Examination of Stroke Risk and Burden in South Asians

BACKGROUND

South Asians (India, Pakistan, Sri Lanka, Bangladesh, Nepal, and Bhutan) are at a disproportionately higher risk of stroke and heart disease due to their cardiometabolic profile. Despite evidence for a strong association between diabetes and stroke, and growing stroke risk in this ethnic minority-notwithstanding reports of higher stroke mortality irrespective of country of residence-the explanation for the excess risk of stroke remains unknown.

METHODS

We have used extensive literature review, epidemiologic studies, morbidity and mortality records, and expert opinions to examine the burden of stroke among South Asians, and the risk factors identified thus far.

RESULTS

We summarize existing evidence and indicate gaps in current knowledge of stroke epidemiology among South Asian natives and immigrants.

CONCLUSIONS

This research focuses attention on a looming epidemic of stroke mainly due to modifiable risk factors, but also new determinants that might aggravate the effect of vascular risk factors in South Asians causing more disabling strokes and death.