Phenotyping Stroke in Sub-Saharan Africa: Stroke Investigative Research and Education Network (SIREN) Phenomics Protocol

Non-cigarette Tobacco Use and Stroke Among West Africans: Evidence From the SIREN Study

INTRODUCTION

Non-cigarette tobacco (NCT) represents a form of tobacco use with a misperceived significance in chronic disease events. Whether NCT use is sufficient to promote stroke events, especially among Africans, is yet to be understood. This study assessed the relationship between NCT use and stroke among indigenous Africans.

METHODS

A total of 7617 respondents (NCT users: 41 vs. non-NCT: 7576) from the Stroke Investigative Research and Educational Network (SIREN) study were included in the current analysis. NCT use was defined as self-reported use of smoked (cigars or piper) or smokeless (snuff or chewed) tobacco in the past year preceding stroke events. Stroke was defined based on clinical presentation and confirmed with a cranial computed tomography/magnetic resonance imaging. Multivariable-adjusted logistic regression was applied to estimate the odds ratio (OR) and 95% confidence interval (CI) for the relationship of NCT with stroke at a two-sided p < .05.

RESULTS

Out of the 41 (0.54%) who reported NCT use, 27 (65.9%) reported using smokeless NCT. NCT users were older than non-NCT users (62.8 ± 15.7 vs. 57.7 ± 14.8 years). Overall, NCT use was associated with first-ever stroke (OR: 2.08; 95% CI: 1.02, 4.23) in the entire sample. Notably, smokeless NCT use was independently associated with higher odds of stroke (OR: 2.74; 95% CI: 1.15, 6.54), but smoked NCT use (OR: 0.16; 95% CI: 0.02, 1.63) presented a statistically insignificant association after adjusting for hypertension and other covariates.

CONCLUSIONS

NCT use was associated with higher odds of stroke, and public health interventions targeting NCT use might be promising in reducing the burden of stroke among indigenous Africans.

IMPLICATIONS

A detailed understanding of the relationship between NCT use and stroke will likely inform well-articulated policy guidance and evidence-based recommendations for public health prevention and management of stroke on the African continent.

Stroke occurrence by hypertension treatment status in Ghana and Nigeria: A case-control study

BACKGROUND

Hypertension is preeminent among the vascular risk factors for stroke occurrence. The wide gaps in awareness, detection, treatment, and control rates of hypertension are fueling an epidemic of stroke in sub-Saharan Africa.

PURPOSE

To quantify the contribution of untreated, treated but uncontrolled, and controlled hypertension to stroke occurrence in Ghana and Nigeria.

METHODS

The Stroke Investigative Research and Educational Network (SIREN) is a case-control study across 16 study sites in Ghana and Nigeria. Cases were acute stroke (n = 3684) with age- and sex-matched stroke-free controls (n = 3684). We evaluated the associations of untreated hypertension, treated but uncontrolled hypertension, and controlled hypertension at BP of <140/90 mmHg with risk of stroke occurrence. We assessed the adjusted odds ratio and population-attributable risk of hypertension treatment control status associated with stroke occurrence.

RESULTS

The frequencies of no hypertension, untreated hypertension, treated but uncontrolled hypertension and controlled hypertension among stroke cases were 4.0%, 47.7%, 37.1%, and 9.2% vs 40.7%, 34.9%, 15.9%, and 7.7% respectively among stroke-free controls, p < 0.0001. The aOR and PAR (95% CI) for untreated hypertension were 6.58 (5.15-8.41) and 35.4% (33.4-37.4); treated but uncontrolled hypertension was 9.95 (7.60-13.02) and 35.9% (34.2-37.5); and controlled hypertension 5.37 (3.90-7.41) and 8.5% (7.6-9.5) respectively. Untreated hypertension contributed a PAR of 47.5% to the occurrence of intracerebral hemorrhage vs 29.5% for ischemic stroke. The aOR of untreated hypertension for stroke occurrence was 13.31 (7.64-23.19) for <50 years; 7.14 (4.51-11.31) for 50-64 years; and 3.48 (2.28-5.30) for 65 years or more.

CONCLUSION

The contribution of untreated hypertension and treated but uncontrolled hypertension to stroke occurrence among indigenous Africans is substantial. Implementing targeted interventions that address gaps in hypertension prevention and treatment, involving the local population, healthcare providers, and policymakers, can potentially substantially reduce the escalating burden of strokes in Africa.

Dietary patterns associated with hypertension among stroke-free indigenous Africans: insights from the Stroke Investigative Research and Educational Network study

BACKGROUND

The dietary factors associated with the high burden of hypertension among indigenous Africans remain poorly understood. We assessed the relationship between dietary patterns and hypertension among indigenous Africans.

METHOD

In this study, 1550 participants with hypertension matched (for age: ± 5 years, sex and ethnicity) with 1550 participants without hypertension were identified from the stroke-free population in the Stroke Investigative Research and Educational Network study in Ghana and Nigeria. Food consumption was assessed using a food frequency questionnaire, and dietary information was summarized using principal component analysis to identify seven dietary patterns. Conditional logistic regression was applied to compute the odds ratio (OR) and 95% confidence interval (CI) for the risk of hypertension by tertiles of dietary patterns adjusting for age, education, income, smoking, alcohol use, physical inactivity, family history of cardiovascular diseases, obesity and salt intake at a two-sided P less than 0.05.

RESULTS

Multivariable-adjusted OR [95% confidence interval (CI)] for risk of hypertension by second and third tertiles [using the lowest (first) tertile as reference] of dietary patterns were 0.62 (0.48-0.80), 0.70 (0.54-0.90) for whole grains and fruit drinks; 0.87 (0.68-1.12), 0.83 (0.64-1.08) for fruits; 0.85 (0.65-1.10), 0.97 (0.75-1.26) for vegetables, legumes and potatoes; 0.78 (0.60-1.00), 0.84 (0.65-1.08) for fried foods and sweetened drinks; 1.13 (0.88-1.45), 0.80 (0.62-1.03) for poultry product and organ meat; 1.11 (0.86-1.43), 0.88 (0.68-1.14) for red meat; and 1.14 (0.88-1.48), 1.09 (0.84-1.43) for processed foods ( P  < 0.05).

CONCLUSION

A higher adherence to dietary consumption of whole grains and fruits was inversely associated with low odds of hypertension in this population.

Novel functional insights into ischemic stroke biology provided by the first genome-wide association study of stroke in indigenous Africans

BACKGROUND

African ancestry populations have the highest burden of stroke worldwide, yet the genetic basis of stroke in these populations is obscure. The Stroke Investigative Research and Educational Network (SIREN) is a multicenter study involving 16 sites in West Africa. We conducted the first-ever genome-wide association study (GWAS) of stroke in indigenous Africans.

METHODS

Cases were consecutively recruited consenting adults (aged > 18 years) with neuroimaging-confirmed ischemic stroke. Stroke-free controls were ascertained using a locally validated Questionnaire for Verifying Stroke-Free Status. DNA genotyping with the H3Africa array was performed, and following initial quality control, GWAS datasets were imputed into the NIH Trans-Omics for Precision Medicine (TOPMed) release2 from BioData Catalyst. Furthermore, we performed fine-mapping, trans-ethnic meta-analysis, and in silico functional characterization to identify likely causal variants with a functional interpretation.

RESULTS

We observed genome-wide significant (P-value < 5.0E-8) SNPs associations near AADACL2 and miRNA (MIR5186) genes in chromosome 3 after adjusting for hypertension, diabetes, dyslipidemia, and cardiac status in the base model as covariates. SNPs near the miRNA (MIR4458) gene in chromosome 5 were also associated with stroke (P-value < 1.0E-6). The putative genes near AADACL2, MIR5186, and MIR4458 genes were protective and novel. SNPs associations with stroke in chromosome 2 were more than 77 kb from the closest gene LINC01854 and SNPs in chromosome 7 were more than 116 kb to the closest gene LINC01446 (P-value < 1.0E-6). In addition, we observed SNPs in genes STXBP5-AS1 (chromosome 6), GALTN9 (chromosome 12), FANCA (chromosome 16), and DLGAP1 (chromosome 18) (P-value < 1.0E-6). Both genomic regions near genes AADACL2 and MIR4458 remained significant following fine mapping.

CONCLUSIONS

Our findings identify potential roles of regulatory miRNA, intergenic non-coding DNA, and intronic non-coding RNA in the biology of ischemic stroke. These findings reveal new molecular targets that promise to help close the current gaps in accurate African ancestry-based genetic stroke's risk prediction and development of new targeted interventions to prevent or treat stroke.

Factors associated with frequency of fruit and vegetable consumption among selected sub-Saharan African populations: evidence from the Cardiovascular H3Africa Innovation Resource Project

BACKGROUND

Frequent fruit and vegetable consumption is considered a promising dietary behaviour that protects health. However, most existing studies about the factors associated with this phenomenon among Africans are based on single-country reports, apart from one meta-regression combining smaller studies. This study harmonized large datasets and assessed factors associated with the frequency of fruit and vegetable consumption in this population.

METHODS

Individual-level data on sociodemographics, lifestyle and diet from 20 443 participants across five African countries (Burkina Faso, Ghana, Kenya, South Africa and Nigeria), from the Stroke Investigative Research and Educational Network (SIREN) and Africa Wits-INDEPTH partnership for Genomic Research (AWI-Gen) studies, were harmonized. Total frequency of fruit and vegetable consumption (in portions/week) was classified as 'low' (≤6), 'moderate' (7-14) and 'high' (≥15). Adjusted odds ratios (aORs) and 95% confidence intervals (CIs) of factors associated with the total frequency of fruit and vegetable consumption (using 'low' consumption as the reference) were estimated using multinomial regression models.

RESULTS

Mean age of participants was 54.3 ± 11.8 years, 10 641 (52.1%) were female, and the median (interquartile range) frequency of total fruit and vegetable consumption was 10.0 (4.0, 21.0) portions/week. Participants with a family history of cardiovascular disease [moderate (aOR, 0.92; 95% CI, 0.85, 1.00) and high (aOR, 0.85; 95% CI, 0.78, 0.92)], current smokers [moderate (aOR, 0.83; 95% CI, 0.74, 0.94) and high (aOR, 0.78; 95% CI, 0.69, 0.88)], current alcohol users [moderate (aOR, 0.92; 95% CI, 0.85, 1.00) and high (aOR, 0.82; 95% CI, 0.76, 0.89)] and physically inactive participants [moderate (aOR, 0.85; 95% CI, 0.75, 0.96) and high (aOR, 0.80; 95% CI, 0.70, 0.90)] were less likely to consume fruits and vegetables frequently.

CONCLUSION

Africans with lifestyle risk factors for cardiovascular disease were less likely to consume fruit and vegetables frequently.

Clinical and neuroimaging factors associated with 30-day fatality among indigenous West Africans with spontaneous intracerebral hemorrhage

BACKGROUND

Spontaneous intracerebral hemorrhage (ICH) is associated with a high case fatality rate in resource-limited settings. The independent predictors of poor outcome after ICH in sub-Saharan Africa remains to be characterized in large epidemiological studies. We aimed to determine factors associated with 30-day fatality among West African patients with ICH.

METHODS

The Stroke Investigative Research and Educational Network (SIREN) study is a multicentre, case-control study conducted at 15 sites in Nigeria and Ghana. Adults aged ≥18 years with spontaneous ICH confirmed with neuroimaging. Demographic, cardiovascular risk factors, clinical features and neuroimaging markers of severity were assessed. The independent risk factors for 30-day mortality were determined using a multivariate logistic regression analysis with an adjusted odds ratio (OR) and 95% confidence interval (CI).

RESULTS

Among 964 patients with ICH, 590 (61.2%) were males with a mean age (SD) of 54.3(13.6) years and a case fatality of 34.3%. Factors associated with 30-day mortality among ICH patients include: Elevated mean National Institute of Health Stroke Scale(mNIHSS);(OR 1.06; 95% CI 1.02-1.11), aspiration pneumonitis; (OR 7.17; 95% CI 2.82-18.24), ICH volume > 30mls; OR 2.68; 95% CI 1.02-7.00)) low consumption of leafy vegetables (OR 0.36; 95% CI 0.15-0.85).

CONCLUSION

This study identified risk and protective factors associated with 30-day mortality among West Africans with spontaneous ICH. These factors should be further investigated in other populations in Africa to enable the development of ICH mortality predictions models among indigenous Africans.

Risk Assessment Score and Chi-Square Automatic Interaction Detection Algorithm for Hypertension Among Africans: Models From the SIREN Study

BACKGROUND

This study aimed to develop a risk-scoring model for hypertension among Africans.

METHODS

In this study, 4413 stroke-free controls were used to develop the risk-scoring model for hypertension. Logistic regression models were applied to 13 risk factors. We randomly split the dataset into training and testing data at a ratio of 80:20. Constant and standardized weights were assigned to factors significantly associated with hypertension in the regression model to develop a probability risk score on a scale of 0 to 1 using a logistic regression model. The model accuracy was assessed to estimate the cutoff score for discriminating hypertensives.

RESULTS

Mean age was 59.9±13.3 years, 56.0% were hypertensives, and 8 factors, including diabetes, age ≥65 years, higher waist circumference, (BMI) ≥30 kg/m2, lack of formal education, living in urban residence, family history of cardiovascular diseases, and dyslipidemia use were associated with hypertension. Cohen κ was maximal at ≥0.28, and a total probability risk score of ≥0.60 was adopted for both statistical weighting for risk quantification of hypertension in both datasets. The probability risk score presented a good performance-receiver operating characteristic: 64% (95% CI, 61.0-68.0), a sensitivity of 55.1%, specificity of 71.5%, positive predicted value of 70.9%, and negative predicted value of 55.8%, in the test dataset. Similarly, decision tree had a predictive accuracy of 67.7% (95% CI, 66.1-69.3) for the training set and 64.6% (95% CI, 61.0-68.0) for the testing dataset.

CONCLUSIONS

The novel risk-scoring model discriminated hypertensives with good accuracy and will be helpful in the early identification of community-based Africans vulnerable to hypertension for its primary prevention.

Developing Clinical Phenotype Data Collection Standards for Research in Africa

Modern biomedical research is characterised by its high-throughput and interdisciplinary nature. Multiproject and consortium-based collaborations requiring meaningful analysis of multiple heterogeneous phenotypic datasets have become the norm; however, such analysis remains a challenge in many regions across the world. An increasing number of data harmonisation efforts are being undertaken by multistudy collaborations through either prospective standardised phenotype data collection or retrospective phenotype harmonisation. In this regard, the Phenotype Harmonisation Working Group (PHWG) of the Human Heredity and Health in Africa (H3Africa) consortium aimed to facilitate phenotype standardisation by both promoting the use of existing data collection standards (hosted by PhenX), adapting existing data collection standards for appropriate use in low- and middle-income regions such as Africa, and developing novel data collection standards where relevant gaps were identified. Ultimately, the PHWG produced 11 data collection kits, consisting of 82 protocols, 38 of which were existing protocols, 17 were adapted, and 27 were novel protocols. The data collection kits will facilitate phenotype standardisation and harmonisation not only in Africa but also across the larger research community. In addition, the PHWG aims to feed back adapted and novel protocols to existing reference platforms such as PhenX.

Knowledge and perspectives of community members on risk assessment for stroke prevention using mobile health approaches in Nigeria

OBJECTIVES

To assess the knowledge of community dwelling adults on stroke risk and their willingness to use mobile health (mHealth) technology in assessing their stroke risk.

MATERIALS AND METHODS

A cross-sectional study was conducted among adults (≥18 years old) using survey questionnaires designed by neurologists and health promotion experts and administered by trained study staff. Logistic regression models were used to assess factors associated with receptivity toward knowing individual stroke risk score and willingness to use a mobile application (App) to assess stroke risk.

RESULTS

The survey was administered to 486 participants in Nigeria, with a mean age of 47.4 ± 15.5 years, comprising 53.5% females. Up to 84% of participants wanted to know their risk for developing stroke but only 29.6% of respondents had ever previously had their stroke risk assessed. Factors associated with willingness to know stroke risk were age [aOR (95% CI): 0.97 (0.95 - 0.99)], and Hausa tribe [16.68 (2.16 - 128.92)]. Up to 66% of participants wanted to know their immediate risk of stroke, compared with 6.6% and 2.1% who wanted to know their 5-year or 10-year future stroke risks respectively. Regarding locations, participants preferred stroke risk assessment to be performed at a health facility, at home by health professional, on their own using mHealth (stroke risk calculator application), or at communal gatherings (decreasing order). About 70% specifically wished to learn about their stroke risk via an mHealth application.

CONCLUSIONS

Community dwelling Nigerians wanted to know their immediate risk of stroke using digital platforms, such as a mobile phone stroke risk calculator application. Clinical trials are needed to assess the effectiveness of such a strategy for primary prevention of stroke in sub-Saharan African communities.

Determinants of First-Ever Stroke Severity in West Africans: Evidence From the SIREN Study

Background Baseline stroke severity is probably partly responsible for poor stroke outcomes in sub-Saharan Africa. However, there is a paucity of information on determinants of stroke severity among indigenous Africans. We sought to identify the factors associated with stroke severity among West Africans in the SIREN (Stroke Investigative Research and Educational Networks) study. Methods and Results Stroke was diagnosed clinically and confirmed with brain neuroimaging. Severe stroke was defined as a Stroke Levity Scale score of ≤5. A multivariate logistic regression model was constructed to identify factors associated with stroke severity at 95% CI and a nominal cutoff of 5% type 1 error. A total of 3660 stroke cases were included. Overall, 50.7%% had severe stroke, including 47.6% of all ischemic strokes and 56.1% of intracerebral hemorrhage. Factors independently associated with severe stroke were meat consumption (adjusted odds ratio [aOR], 1.97 [95% CI, 1.43-2.73]), low vegetable consumption (aOR, 2.45 [95% CI, 1.93-3.12]), and lesion volume, with an aOR of 1.67 (95% CI, 1.03-2.72) for lesion volume of 10 to 30 cm³ and aOR of 3.88 (95% CI, 1.93-7.81) for lesion volume >30 cm³. Severe ischemic stroke was independently associated with total anterior circulation infarction (aOR, 3.1 [95% CI, 1.5-6.9]), posterior circulation infarction (aOR, 2.2 [95% CI, 1.1-4.2]), and partial anterior circulation infarction (aOR, 2.0 [95% CI, 1.2-3.3]) compared with lacunar stroke. Increasing age (aOR, 2.6 [95% CI, 1.3-5.2]) and lesion volume >30 cm³ (aOR, 6.2 [95% CI, 2.0-19.3]) were independently associated with severe intracerebral hemorrhage. Conclusions Severe stroke is common among indigenous West Africans, where modifiable dietary factors are independently associated with it. These factors could be targeted to reduce the burden of severe stroke.

Capacity-Building for Stroke Genomic Research Data Collection: The African Neurobiobank Ethical, Legal, and Social Implications Project Experience

Background: The fields of stroke genomics, biobanking, and precision medicine are rapidly expanding in sub-Saharan Africa. However, the ethical, legal, and social implications (ELSI) of emerging neurobiobanking and genomic data resources are unclear in an emerging African scientific landscape with unique cultural, linguistic, and belief systems. Objective: This article documents capacity-building experiences of researchers during the development, pretesting, and validation of data collection instruments of the African Neurobiobank for Precision Stroke Medicine-(ELSI) Project. Methods: The African Neurobiobank for Precision Stroke Medicine-ELSI project is a transnational, multicenter project implemented across seven sites in Ghana and Nigeria. Guided by the Community-Based Participatory Research framework, we conducted three workshops with key stakeholders to review the study protocol, ensure uniformity in implementation; pretest, harmonize, and integrate context-specific feedback to ensure validity and adaptability of data collection instruments. Workshop impact was assessed using an open-ended questionnaire, which included questions on experience with participation in any of the workshops, building capacity in Genetic and Genomic Research (GGR), level of preparedness toward GGR, the genomic mini-dictionary developed by the team, and its impact in enhancing understanding in GGR. Data were analyzed qualitatively using a thematic framework approach. Results: Findings revealed the usefulness of the workshop in improving participants' knowledge and capacity toward GGR implementation. It further identified local, context-specific concerns regarding quality data collection, the need to develop culturally acceptable, genomic/biobanking data collection tools, and a mini-dictionary. Participants-reported perceptions were that the mini-dictionary enhanced understanding, participation, and data collection in GGR. Overall, participants reported increased preparedness and interest in participating in GGR. Conclusion: Capacity-building is a necessary step toward ELSI-related genomic research implementation in African countries where scholarship of ELSI of genomics research is emerging. Our findings may be useful to the design and implementation of ELSI-GGR projects in other African countries.

Patient-level and system-level determinants of stroke fatality across 16 large hospitals in Ghana and Nigeria: a prospective cohort study

BACKGROUND

Every minute, six indigenous Africans develop new strokes. Patient-level and system-level contributors to early stroke fatality in this region are yet to be delineated. We aimed to identify and quantify the contributions of patient-level and system-level determinants of inpatient stroke fatality across 16 hospitals in Ghana and Nigeria.

METHODS

The Stroke Investigative Research and Educational Network (SIREN) is a multicentre study involving 16 sites in Ghana and Nigeria. Cases include adults (aged ≥18 years) with clinical and radiological evidence of an acute stroke. Data on stroke services and resources available at each study site were collected and analysed as system-level factors. A host of demographic and clinical variables of cases were analysed as patient-level factors. A mixed effect log-binomial model including both patient-level and system-level covariates was fitted. Results are presented as adjusted risk ratios (aRRs) with respective 95% CIs.

FINDINGS

Overall, 814 (21·8%) of the 3739 patients admitted with stroke died as inpatients: 476 (18·1%) of 2635 with ischaemic stroke and 338 (30·6%) of 1104 with intracerebral haemorrhage. The variability in the odds of stroke fatality that could be attributed to the system-level factors across study sites assessed using model intracluster correlation coefficient was substantial at 7·3% (above a 5% threshold). Stroke units were available at only five of 16 centres. The aRRs of six patient-level factors associated with stroke fatality were: low vegetable consumption, 1·19 (95% CI 1·07-1·33); systolic blood pressure, 1·02 (1·01-1·04) for each 10 mm Hg rise; stroke lesion volume more than 30 cm3, 1·48 (1·22-1·79); National Institutes of Health Stroke Scale (NIHSS) score, 1·20 (1·13-1·26) for each 5-unit rise; elevated intracranial pressure, 1·75 (1·31-2·33); and aspiration pneumonia, 1·79 (1·16-2·77).

INTERPRETATION

Studies are needed to assess the efficacy of interventions targeting patient-level factors such as aspiration pneumonia in reducing acute stroke fatality in this region. Policy directives to improve stroke unit access are warranted.

FUNDING

US National Institutes of Health.

TRANSLATIONS

For the Twi, Yoruba and Hausa translations of the abstract see Supplementary Materials section.

Sociodemographic and behavioural risk factors for obesity among community-dwelling older adults in Ghana and Nigeria: A secondary analysis of data from the SIREN study

OBJECTIVES

To explore the prevalence and risk factors of obesity among older adults from low- and middle-income countries (LMICs).

METHODS

This is a secondary analysis of data obtained from the SIREN study through in-person interviews and measurements from healthy stroke-free older adults (≥60 years). Overweight/obesity was defined as body mass index ≥25 kg/m². Abdominal obesity was defined as waist-to-hip ratio (WHR) of >0.90 for males and >0.85/females or waist circumference (WC) of >102 cm for males/>88 cm for females. Adjusted odds ratio (aORs) with 95% confidence interval (CIs) of the relationship between obesity and sociodemographic factors were assessed at P < 0.05.

RESULTS

Overall, 47.5% of participants were overweight/obese, 76.6% had a larger than recommended WHR, and 54.4% had a larger than recommended WC. Abdominal obesity (WC; aOR: 9.43, CI: 6.99-12.50), being a Nigerian (aOR: 0.55; CI: 0.42-0.72), living in an urban setting (aOR: 1.92; CI: 1.49-2.46), earning >$100/month (aOR: 1.53; CI: 1.19-1.96), and having formal education (aOR: 1.42; CI: 1.08-1.87) were associated with overweight/obesity.

CONCLUSION

Living in urban settings, earning a higher income, and having a formal education were associated with a higher odds of obesity among older adults from LMICs.

Mission thrombectomy 2020 (MT2020+) surveys of Caribbean stroke services: A call for action in our region

Stroke is the leading cause of death and adult-onset disability in the Caribbean region. Despite the tremendous advances in acute stroke care in the past 25 years, treatment in the Caribbean lags stroke standards of care. Mission Thrombectomy 2020+ (MT2020+) is a metrics based global campaign focused on increasing access to organized stroke care and mechanical thrombectomy. We conducted two consecutive online surveys across the MT2020+ Caribbean Region assessing access to thrombolytics, mechanical thrombectomy and stroke centers. The first survey - Mechanical Thrombectomy Access-Caribbean sub-study, allowed a comparison between global services and those in the MT2020+ Caribbean region. This survey provided a snapshot of the current state of stroke centers worldwide and confirmed lower available stroke resources in the MT2020+ Caribbean Region which has one certified stroke center, and 9 mechanical thrombectomy capable centers. The second survey - MT2020+ Caribbean Region infrastructure survey - was designed to determine the availability of stroke resources that are key components of stroke care in participating hospitals. Key infrastructural components such as 24/7 computerized tomographic scanners, access to thrombolytic therapy and access to mechanical thrombectomy capable centers were scarce. There were low volumes of mechanical thrombectomy performed in the Caribbean compared to other countries around the world. Limited resources and inadequate stroke infrastructure remains a major challenge in the Caribbean. We advocate for governmental support and investment, public and private partnerships and legislation to increase access and availability to acute stroke treatments to allow for equal access to care for all Caribbean citizens.

Frequent vegetable consumption is inversely associated with hypertension among indigenous Africans

AIMS

The relationship between vegetable consumption and hypertension occurrence remains poorly characterized in sub-Saharan Africa. This study assessed the association of vegetable consumption with odds of hypertension among indigenous Africans.

METHODS AND RESULTS

We harmonized data on prior vegetable consumption and hypertension occurrence (defined as one of the following conditions; systolic blood pressure ≥140 or diastolic blood pressure ≥90 mmHg or previous diagnosis or use of antihypertensive medications) from 16 445 participants across five African countries (Nigeria, South Africa, Kenya, Ghana and Burkina Faso) in the Stroke Investigative Research and Educational Network and Africa Wits-INDEPTH partnership for Genomic studies. Vegetable consumption (in servings/week) was classified as 'low' (<6). 'moderate' (6-11), 'sufficient' (12-29), and 'high' (≥30). Odds ratios (ORs) and 95% confidence interval (CI) of hypertension were estimated by categories of vegetable consumption (using 'low' consumption as reference), adjusting for sex, age in years, family history of cardiovascular diseases, education, smoking, alcohol use, physical inactivity, body mass index, diabetes mellitus and dyslipidaemia using logistic regressions at P < 0.05. The mean age of participants was 53.0 ( ± 10.7) years, and 7552 (45.9%) were males, whereas 7070 (42.9%) had hypertension. In addition, 6672(40.6%) participants had 'low' vegetable consumption, and 1758(10.7%) had 'high' vegetable consumption. Multivariable-adjusted OR for hypertension by distribution of vegetable consumption (using 'low' consumption as reference) were 1.03 (95% CI: 0.95, 1.12) for 'moderate' consumption; 0.80 (0.73, 0.88) for 'sufficient', and 0.81 (0.72, 0.92) for 'high' consumption, P-for-trend <0.0001.

CONCLUSION

Indigenous Africans who consumed at least 12 servings of vegetables per week were less likely to be found hypertensive, particularly among males and young adults.

Secondhand smoke exposure is independently associated with stroke among non-smoking adults in West Africa

BACKGROUND

Stroke is a leading cause of disability and mortality worldwide, but little is known about the contribution of secondhand smoke exposure (SHSE) to stroke epidemiology among indigenous Africans.

OBJECTIVE

To evaluate the association of SHSE with stroke among indigenous Africans.

METHODS

We analyzed the relationship of SHSE with stroke among 2990 case-control pairs of adults who had never smoked (identified in the SIREN study) using conditional logistic regression at a two-sided P < 0.05.

RESULTS

Multivariable-adjusted odds ratio and 95% confidence interval; 1.25 (1.04, 1.50; P = 0.02) revealed SHSE was positively associated with stroke independent of stroke subtypes.

CONCLUSION

Culturally relevant primary prevention strategies targeted at SHSE might be promising in preventing stroke among Africans.

Differential associations between pre-diabetes, diabetes and stroke occurrence among West Africans

BACKGROUND

There are limited data from Africa on the burden and associations between pre-diabetes (pre-DM), diabetes mellitus (DM) and stroke occurrence in a region experiencing a profound rise in stroke burden.

PURPOSE

To characterize the associations between stroke and dysglycemic status among West Africans.

METHODS

The Stroke Investigative Research and Educational Network (SIREN) is a multicenter, case-control study involving 15 sites in Ghana and Nigeria. Cases include adults aged ≥18 years with clinical and radiological evidence of an acute stroke. Controls were age-and-gender matched stroke-free adults. Detailed evaluations for vascular factors were performed. Pre-diabetes was defined as HBA1c of 5.7%-6.4% or Fasting blood glucose (FBG) 5.6-7.0 mmol/L and DM as HBA1c >6.5% or FBG>7.0 mmol/L. We used conditional logistic regression to estimate adjusted odds ratios (aOR) with 95% Confidence Interval.

RESULTS

Among 2,935 stroke cases the mean age was 60.0 ± 14.2 years with 55.2% being males. By glycemic status, 931 (31.7%) were euglycemic, 633 (21.6%) had Pre-diabetes and 1371 (46.7%) had DM. Of the age- and sex-matched stroke-free controls 69.2% were euglycemic, 13.3% had pre-DM and 17.5% had DM. Pre-DM [aOR (95% CI): 3.68(2.61-5.21)] and DM [4.29 (3.19-5.74)] were independently associated with stroke. The aOR of Pre-DM for ischemic stroke 3.06 (2.01-4.64)] was lower than 4.82 (3.37-6.89) for DM. However, the aOR of Pre-DM for hemorrhagic stroke 6.81 (95% CI: 3.29 - 14.08)] was higher than 3.36 (1.94-5.86) for DM. Furthermore, the aOR of pre-DM for ischemic stroke subtypes were 9.64 (1.30-71.57) for cardio-embolic stroke, 3.64 (1.80-7.34) for small-vessel occlusive disease and 4.63 (0.80-26.65) for large-vessel disease.

CONCLUSION

Pre-DM is strongly and independently associated with stroke in Africans. Improving glycemic control through screening, healthy lifestyle and pharmacotherapy at a population level may be strategic in reducing the rising burden of stroke in Africa.

Determinants of metabolic syndrome and its prognostic implications among stroke patients in Africa: Findings from the Stroke Investigative Research and Educational Network (SIREN) study

BACKGROUND

The prognostic implications of metabolic syndrome (METS) among African stroke patients are poorly understood. This study aimed to investigate the determinants of METS and its prognostic implications among Africans with newly diagnosed stroke in the SIREN study.

METHODS

We included stroke cases (adults aged >18 years with CT/MRI confirmed stroke). The validated tools comprehensively evaluated vascular, lifestyle, and psychosocial factors. We used logistic regression to estimate adjusted odds ratios (OR) with 95% CIs for the association between METS and risk factors. We also computed the prediction power of the domain of covariates in a sequential manner using the area under the receiver operating curve (ROC) curve.

RESULTS

Among 3998 stroke subjects enrolled in the study, 76.8% had METS by at least one of the clinical definitions. Factors associated with METS were age > 50 years (OR- 1.46, CI-1.19-1.80), male gender (OR 4.06, CI- 3.28-5.03), income >100USD (OR1.42, CI-1.17-1.71), stress (OR1.46, CI-1.14-1.87), family history of diabetes mellitus (OR1.38, CI-1.06-1.78), and cardiac disease (OR1.42, CI-1.18-1.65). Stroke severity was higher among those with METS (SLS = 5.8 ± 4.3) compared with those without METS (6.2 ± 4.5) at p = 0.037. METS was associated with higher odds (aOR 1.31, CI-1.08-1.58) of one-month fatality after adjusting for stroke severity, age > 50 years, and average monthly income >100USD.

CONCLUSION

METS is very common among African stroke patients and is associated with stroke severity and worse one-month fatality. Lifestyle interventions may prevent METS and attenuate its impact on stroke occurrence and outcomes.

Incidence and characteristics of stroke in Zanzibar–a hospital-based prospective study in a low-income island population

Background

Stroke in adults is a critical clinical condition and a leading cause of death and disability globally. Epidemiological data on stroke in sub-Saharan Africa are limited. This study describes incidence rates, stroke types and antecedent factors among patients hospitalized with stroke in Zanzibar.

Methods

This was a prospective, observational study of stroke patients at hospitals in Unguja, Zanzibar. Socioeconomic and demographic data were recorded alongside relevant past medical history, medicine use and risk factors. The modified National Institute of Health Stroke Scale (mNIHSS) was used to assess admission stroke severity and, when possible, stroke was confirmed by neuroimaging.

Results

A total of 869 stroke admissions were observed from 1st October 2019 through 30th September 2020. Age-standardized to the World Health Organization global population, the yearly incidence was 286.8 per 100,000 adult population (95%CI: 272.4–301.9). Among these patients, 720 (82.9%) gave consent to participate in the study. Median age of participants was 62 years (53–70), 377 (52.2%) were women, and 463 (64.3%) had a first-ever stroke. Known stroke risk factors included hypertension in 503 (72.3%) patients, of whom 279 (55.5%) reported regularly using antihypertensive medication, of whom 161 (57.7%) had used this medication within the last week before stroke onset. A total of 460 (63.9%) participants had neuroimaging performed; among these there was evidence of intracerebral hemorrhage (ICH) in 140 (30.4%). Median stroke severity score using mNIHSS was 19 (10–27).

Conclusion

Zanzibar has high incidence of hospitalization for stroke, indicating a very high population incidence of stroke. The proportion of strokes due to ICH is substantially higher than in high-income countries. Most stroke patients had been in contact with health care providers prior to stroke onset and been diagnosed with hypertension. However, few were using antihypertensive medication at the time of stroke onset.

www.ClinicalTrial.gov registration NCT04095806.

Carotid and Vertebral Atherosclerosis in West African Stroke Patients: Findings from the Stroke Investigative Research and Education Network

Background

We evaluated the characteristics of carotid and vertebral atherosclerosis in indigenous West Africans with stroke.

Methodology

Of the 3778stroke patients recruited between 01/2014 and 08/2017, 1070 (28.3%) received carotid and vertebral artery evaluation with B-mode Ultrasound. Carotid and vertebral intima-media thickness (IMT) using multiple site technique were measured bilaterally and plaque frequency was determined. Descriptive and comparative analyses between stroke types and vessels were carried out.

Results

There were 809 (75.6%) patients with ischemic stroke. The prevalence of intima-media thickening in the study population was 84.0% (898/1070) [95% CI: 81.7-86.1], being higher in the ischemic stroke (688/809, 85.0%) [95% CI: 82.4-87.3] than in the hemorrhagic stroke group (211/261, 80.8%) [95% CI: 75.6-85.2]. Overall prevalence of plaques which was 26.1% [95% CI: 23.5-28.8], was found also to be higher in ischemic than hemorrhagic stroke (29.8%[95% CI: 26.7-33.0] vs. 14.6% [95% CI: 10.8-19.4], p < 0.05). The mean IMT (carotids: 2.01+1.33 mm; vertebrals: 0.96+0.54mm, p<0.001) and prevalence of plaques (carotids: 8.8%; vertebrals: 1.7%,p<0.001) were higher in carotid than vertebral arteries. Age, hypertension, level of formal education, history of smoking, average monthly income, and family histories of hypertension and stroke were associated with intima-media thickening in the carotids (all p< 0.05) in the ischemic stroke patients while family history of hypertension, diabetes mellitus, and level of formal education were independently associated with intima-media thickening in the carotids (all p< 0.05) in the hemorrhagic stroke patients. No CVRF showed an independent association with the presence of plaque in the carotid and vertebral arteries both stroke types.

Conclusions

One off our stroke patients in our cohort had atherosclerotic plaques, with ischemic patients being twice as likely to have this burden compared to hemorrhagic patients, and carotid atherosclerosis being five times as frequent as vertebral atherosclerosis.

Pre-Stroke Depression in Ghana and Nigeria: Prevalence, Predictors and Association With Poststroke Depression

OBJECTIVES

Depression is a risk factor for stroke. There is a knowledge gap on the predictors of prestroke depression in stroke survivors living in low- and middle-income countries (LMICs). We estimated prevalence and predictors of prestroke depression, as well as its association with poststroke depression (PSD) in the largest study of stroke in Africa.

METHODS

We evaluated information collected as part of the Stroke Investigative Research and Education Network (SIREN) study, a multicentre, case-control study conducted at 15 sites in Ghana and Nigeria. Prestroke depression status was ascertained in stroke survivors using a validated self-report tool, while PSD was assessed using a stroke specific screening tool for depression ("HRQOLISP-E"). Independent associations were investigated using complementary log-log regression and binary logit models.

RESULTS

Among 1,977 participants, prestroke depression was found in 141 (7.1%). In multivariate analyses, prestroke depression was significantly associated with tachycardia (OR = 2.22, 95% CI = 1.37-3.56) and low consumption of green leafy vegetables (OR = 1.91, 95% CI = 1.12-3.24). Forty-one (29.1%) of the prestroke depression sub-sample developed PSD. However, prestroke depression was not significantly associated with PSD.

CONCLUSION

The findings should energize before-the-stroke identification and prioritization of limited treatment resources in LMICs to persons with depression who have multiple, additional, risks of stroke.

Risk Factor Characterization of Ischemic Stroke Subtypes Among West Africans

BACKGROUND AND PURPOSE

To identify the qualitative and quantitative contributions of conventional risk factors for occurrence of ischemic stroke and its key pathophysiologic subtypes among West Africans.

METHODS

The SIREN (Stroke Investigative Research and Educational Network) is a multicenter, case-control study involving 15 sites in Ghana and Nigeria. Cases include adults aged ≥18 years with ischemic stroke who were etiologically subtyped using the A-S-C-O-D classification into atherosclerosis, small-vessel occlusion, cardiac pathology, other causes, and dissection. Controls were age- and gender-matched stroke-free adults. Detailed evaluations for vascular, lifestyle, and psychosocial factors were performed. We used conditional logistic regression to estimate adjusted odds ratios with 95% CI.

RESULTS

There were 2431 ischemic stroke case and stroke-free control pairs with respective mean ages of 62.2±14.0 versus 60.9±13.7 years. There were 1024 (42.1%) small vessel occlusions, 427 (17.6%) large-artery atherosclerosis, 258 (10.6%) cardio-embolic, 3 (0.1%) carotid dissections, and 719 (29.6%) undetermined/other causes. The adjusted odds ratio (95% CI) for the 8 dominant risk factors for ischemic stroke were hypertension, 10.34 (6.91-15.45); dyslipidemia, 5.16 (3.78-7.03); diabetes, 3.44 (2.60-4.56); low green vegetable consumption, 1.89 (1.45-2.46); red meat consumption, 1.89 (1.45-2.46); cardiac disease, 1.88 (1.22-2.90); monthly income $100 or more, 1.72 (1.24-2.39); and psychosocial stress, 1.62 (1.18-2.21). Hypertension, dyslipidemia, diabetes were confluent factors shared by small-vessel, large-vessel and cardio-embolic subtypes. Stroke cases and stroke-free controls had a mean of 5.3±1.5 versus 3.2±1.0 adverse cardio-metabolic risk factors respectively (P<0.0001).

CONCLUSIONS

Traditional vascular risk factors demonstrate important differential effect sizes with pathophysiologic, clinical and preventative implications on the occurrence of ischemic stroke among indigenous West Africans.

African Rigorous Innovative Stroke Epidemiological Surveillance: Protocol for a Community-Based Mobile-Health Study

Despite projections of stroke being a leading cause of mortality in Africa, reliable estimates of stroke burden on the continent using rigorous methods are not available. We aimed to implement a mobile-Health community-based interactive Stroke Information and Surveillance System to sustainably measure stroke burden and improve stroke health literacy and outcomes in urban and rural sites in Nigeria. African Rigorous Innovative Stroke Epidemiological Surveillance (ARISES) is an observational cohort study, which will be conducted in urban (Ibadan North LGA Ward 3) and rural (Ibarapa Central LGA) sites with a combined base population of over 80,000 people. The study will use a consultative approach to establish an mHealth-based Stroke Information and Surveillance System comprising a Stroke Alert System and a Stroke Finding System. These systems will enable the community to report stroke events and the research team/health workers find stroke cases using phone calls, short message service, and Voice Over Internet Protocols (VoIP). We will update community household data and geo-locate all households. Over the 5 years of the study, the system will collect information on stroke events and educate the community about this disease. Reported stroke cases will be clinically adjudicated at home and in prespecified health facilities. Baseline and endline community surveys will be conducted to assess stroke occurrence and other important study variables. The proportion of strokes alerted and found will be determined over the study period. Focus group discussions and key informant interviews will be conducted to understand community stroke literacy and perspectives. The study will also assess any impact of these efforts on time from stroke onset to referral, community uptake of orthodox health services for stroke patients. ARISES is anticipated to establish proof of concept about using mHealth for stroke surveillance in Africa. The potential impact of the SISS on improving patient outcomes will also be determined.

Influence of age on links between major modifiable risk factors and stroke occurrence in West Africa

Background The burden of stroke in Africa is high. Understanding how age associates with major modifiable stroke risk factors could inform tailored demographic stroke prevention strategies. Purpose To quantify the magnitude and direction of the effect sizes of key modifiable stroke risk factors according to three age groups: <50 years (young), 50-65 years (middle age) and > 65 years (elderly) in West Africa. Methods This was a case-control study involving 15 sites in Ghana and Nigeria. Cases included adults aged ≥18 years with CT/MRI scan-typed stroke. Controls were age-and gender-matched stroke-free adults. Detailed evaluations for vascular, lifestyle and psychosocial factors were performed. We estimated adjusted odds ratios (aOR) using conditional logistic regression and population attributable risk (PAR) with 95% Confidence Interval of vascular risk factors by age groups. Results Among 3553 stroke cases, 813 (22.9%) were young, 1441 (40.6%) were middle-aged and 1299 (36.6%) were elderly. Among the 5 co-shared risk factors, dyslipidemia with PAR and aOR (95%CI) of 62.20% (52.82-71.58) and 4.13 (2.64-6.46) was highest among the young age group; hypertension with PAR of 94.31% (91.82-96.80) and aOR of 28.93 (15.10-55.44) was highest among the middle-age group. Diabetes with PAR of 32.29%(27.52-37.05) and aOR of 3.49 (2.56-4.75); meat consumption with PAR of 42.34%(32.33-52.35) and aOR of 2.40 (1.76, 3.26); and non-consumption of green vegetables, PAR of 16.81%(12.02-21.60) and aOR of 2.23 (1.60-3.12) were highest among the elderly age group. However confidence intervals of risk estimates overlapped across age groups. Additionally, among the young age group cigarette smoking, psychosocial stress and cardiac disease were independently associated with stroke. Furthermore, education, stress, physical inactivity and salt intake were associated with stroke in the middle-age group while cardiac disease was associated with stroke in the elderly age group. Conclusion There is a differential influence of age on the associations of major risk factors with stroke in this West African cohort. Targeting modifiable factors predominant within an age group may be more effective as a stroke prevention strategy.

Frequency and factors associated with post-stroke seizures in a large multicenter study in West Africa

BACKGROUND

Post-stroke seizures (PSS) are associated with significant morbidity and mortality across the globe. There is a paucity of data on PSS in Africa.

PURPOSE

To assess the frequency and factors associated with PSS by stroke types across 15 hospitals in Nigeria and Ghana.

METHODS

We analyzed data on all stroke cases recruited into the Stroke Investigative Research and Educational Network (SIREN). We included adults aged ≥18 years with radiologically confirmed ischemic stroke (IS) or intracerebral hemorrhage (ICH). PSS were defined as acute symptomatic seizures occurring at stroke onset and/or during acute hospitalization up until discharge. We used logistic regression to estimate adjusted odds ratios (aOR) with 95% Confidence Interval.

RESULTS

Among 3344 stroke patients, 499 (14.9%) had PSS (95% CI: 13.7-16.2%). The mean duration of admission in days for those with PSS vs no PSS was 17.4 ± 28.6 vs 15.9 ± 24.7, p = 0.72. There were 294(14.1%) PSS among 2091 ischemic strokes and 159(17.7%) among 897 with ICH, p = 0.01. The factors associated with PSS occurrence were age < 50 years, aOR of 1.59 (1.08-2.33), National Institute of Health Stroke Score (NIHSS), 1.29 (1.16-1.42) for each 5 units rise and white cell count 1.07 (1.01-1.13) for each 10^3 mm3 rise. Factors associated with PSS in ischemic were NIHSS score, aOR of 1.17 (1.04-1.31) and infarct volume of 10-30 cm3 aOR of 2.17(1.37-3.45). Among ICH, associated factors were alcohol use 5.91 (2.11-16.55) and lobar bleeds 2.22 (1.03-4.82).

CONCLUSION

The burden of PSS among this sample of west Africans is substantial and may contribute to poor outcomes of stroke in this region. Further longitudinal studies are required to understand the impact on morbidity and mortality arising from PSS in Africa.

A Novel Afrocentric Stroke Risk Assessment Score: Models from the Siren Study

BACKGROUND

Stroke risk can be quantified using risk factors whose effect sizes vary by geography and race. No stroke risk assessment tool exists to estimate aggregate stroke risk for indigenous African.

OBJECTIVES

To develop Afrocentric risk-scoring models for stroke occurrence.

MATERIALS AND METHODS

We evaluated 3533 radiologically confirmed West African stroke cases paired 1:1 with age-, and sex-matched stroke-free controls in the SIREN study. The 7,066 subjects were randomly split into a training and testing set at the ratio of 85:15. Conditional logistic regression models were constructed by including 17 putative factors linked to stroke occurrence using the training set. Significant risk factors were assigned constant and standardized statistical weights based on regression coefficients (β) to develop an additive risk scoring system on a scale of 0-100%. Using the testing set, Receiver Operating Characteristics (ROC) curves were constructed to obtain a total score to serve as cut-off to discriminate between cases and controls. We calculated sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) at this cut-off.

RESULTS

For stroke occurrence, we identified 15 traditional vascular factors. Cohen's kappa for validity was maximal at a total risk score of 56% using both statistical weighting approaches to risk quantification and in both datasets. The risk score had a predictive accuracy of 76% (95%CI: 74-79%), sensitivity of 80.3%, specificity of 63.0%, PPV of 68.5% and NPV of 76.2% in the test dataset. For ischemic strokes, 12 risk factors had predictive accuracy of 78% (95%CI: 74-81%). For hemorrhagic strokes, 7 factors had a predictive accuracy of 79% (95%CI: 73-84%).

CONCLUSIONS

The SIREN models quantify aggregate stroke risk in indigenous West Africans with good accuracy. Prospective studies are needed to validate this instrument for stroke prevention.

Neurological disorders encountered at an out-patient clinic in Ghana's largest medical center: A 16-year review

Background

With a rising age of its population, sub-Saharan Africa(SSA) is currently experiencing an unprecedented rise in burden of neurological disorders. There is limited data on the demographic profile of neurological diseases in SSA.

Objective

To describe the spectrum of neurological disorders at the adult neurology clinic at Ghana's leading medical center.

Methods

This retrospective study was conducted at the adult neurology clinic at the Korle Bu Teaching Hospital between 2003 and 2019. We retrospectively reviewed charts of all cases seen at the clinic over the period to document main neurological diagnosis, and captured age and sex of participants. Neurologic diseases were classified using the revised International Statistical Classification of Diseases and Related Health Problems ICD 11 tool.

Results

There were 7950 patients sought consultation over the period with 7076 having a primary neurological disorder. The mean age ± SD of patients included in the analysis was 43.0 ± 19.8 years with 3777 (53.4%) being males. The frequencies of the top 5 neurological disorders were epilepsy (23.0%), peripheral neuropathies (19.6%), movement disorders (14.7%), cerebrovascular diseases (11.1%) and headache disorders (7.7%). Neurocognitive disorders, autoimmune demyelinating disorders of the nervous system, and motor neuron disorders were infrequently observed.

Conclusion

A wide spectrum of neurological disorders were encountered in this clinic, similar to previous report from other centers in SSA. There is an urgent need to build local capacity to provide optimal care to meet the demand of the rising burden of neurological diseases in Ghana.

Advancing non-communicable diseases research in Ghana: key stakeholders' recommendations from a symposium

There has been a growing increase in the prevalence of non-communicable diseases (NCDs) globally with reports suggesting that the fastest increase in NCD deaths in the world will occur in sub-Saharan Africa (SSA) over the next 5 to 15 years. Despite the projected increase in NCD-related deaths, there is little coordinated research in many West African nations, including Ghana, to quantify and study this burden and to translate the research findings into policy and practice. To address these challenges, the Noguchi Memorial Institute for Medical Research and the Navrongo Health Research Centre, both in Ghana, with support from the Wits NCD Research Leadership Training Program organized a two-day symposium to discuss the advancement of NCD research in the West African sub-region. The aim was to propose the way forward for strengthening applied research that can inform the development of health policies and programs focused on NCDs. Participants were drawn from academia, research and health institutions, early career researchers and postdoctoral fellows. We present the key themes that emerged from the symposium and some strategies for advancing NCD research in West Africa. These include interdisciplinary collaboration between NCD researchers in the region, generation of accurate data on disease burden and strengthening stakeholder and public engagement on NCDs.

Factors associated with hypertension among stroke-free indigenous Africans: Findings from the SIREN study

Hypertension is one of the most important risk factors for stroke and cardiovascular diseases (CVD) globally. Understanding risk factors for hypertension among individuals with matching characteristics with stroke patients may inform primordial/primary prevention of hypertension and stroke among them. This study identified the risk factors for hypertension among community-dwelling stroke-free population in Ghana and Nigeria. Data for 4267 community-dwelling stroke-free controls subjects in the Stroke Investigative Research and Education Network (SIREN) study in Nigeria and Ghana were used. Participants were comprehensively assessed for sociodemographic, lifestyle and metabolic factors using standard methods. Hypertension was defined as a previous diagnosis by a health professional or use of an anti-hypertensive drug or mean systolic blood pressure ≥ 140 mmHg and/or diastolic blood pressure ≥ 90 mmHg. Logistic regression analysis was used to estimate adjusted odds ratios (aOR) of hypertension and their 95% confidence intervals (CI) at p < .05. Overall, 56.7% of the participants were hypertensive with a higher proportion among respondents aged ≥60 years (53.0%). Factors including physical inactivity (aOR: 9.09; 95% CI: 4.03 to 20.53, p < .0001), diabetes (aOR: 2.70; CI: 1.91 to 3.82, p < .0001), being ≥60 years (aOR: 2.22; 95% CI: 1.78 to 2.77, p < .0001), and family history of CVD (aOR 2.02; CI: 1.59 to 2.56, p < .0001) were associated with increased aOR of hypertension. Lifestyle factors were associated with hypertension in the current population of community-dwelling stroke-free controls in west Africa. Community-oriented interventions to address sedentary lifestyles may benefit this population and reduce/prevent hypertension and stroke among them.

Stroke in Africa: profile, progress, prospects and priorities

Stroke is a leading cause of disability, dementia and death worldwide. Approximately 70% of deaths from stroke and 87% of stroke-related disability occur in low-income and middle-income countries. At the turn of the century, the most common diseases in Africa were communicable diseases, whereas non-communicable diseases, including stroke, were considered rare, particularly in sub-Saharan Africa. However, evidence indicates that, today, Africa could have up to 2-3-fold greater rates of stroke incidence and higher stroke prevalence than western Europe and the USA. In Africa, data published within the past decade show that stroke has an annual incidence rate of up to 316 per 100,000, a prevalence of up to 1,460 per 100,000 and a 3-year fatality rate greater than 80%. Moreover, many Africans have a stroke within the fourth to sixth decades of life, with serious implications for the individual, their family and society. This age profile is particularly important as strokes in younger people tend to result in a greater loss of self-worth and socioeconomic productivity than in older individuals. Emerging insights from research into stroke epidemiology, genetics, prevention, care and outcomes offer great prospects for tackling the growing burden of stroke on the continent. In this article, we review the unique profile of stroke in Africa and summarize current knowledge on stroke epidemiology, genetics, prevention, acute care, rehabilitation, outcomes, cost of care and awareness. We also discuss knowledge gaps, emerging priorities and future directions of stroke medicine for the more than 1 billion people who live in Africa.

Qualitative study of comprehension of heritability in genomics studies among the Yoruba in Nigeria

BACKGROUND

With growth of genomics research in Africa, concern has arisen about comprehension and adequacy of informed consent given the highly technical terms used in this field. We therefore decided to study whether there are linguistic and cultural concepts used to communicate heritability of characters, traits and diseases in an indigenous African population.

METHODS

We conducted Focus Group Discussions among 115 participants stratified by sex, age and socio-economic status and Key Informant Interviews among 25 stakeholders and Key Opinion Leaders among Yoruba living in Ibadan, Nigeria. We used Atlas-ti v.8.3.17 software to analyze the data, using thematic approach.

RESULTS

The study participants identified several linguistic and cultural concepts including words, proverbs, and aphorisms that are used to describe heritable characters, traits and diseases in their local dialect. These included words that can be appropriated to describe dominant and recessive traits, variations in penetrance and dilution of strength of heritable characteristics by time and inter-marriage. They also suggested that these traits are transmitted by "blood", and specific partner's blood may be stronger than the other regardless of sex.

CONCLUSIONS

Indigenous Yoruba populations have words and linguistic concepts that describe the heritability of characters, traits and diseases which can be appropriated to improve comprehension and adequacy of informed consent in genomics research. Our methods are openly available and can be used by genomic researchers in other African communities.

Antecedent febrile illness and occurrence of stroke in West Africa: The SIREN study

BACKGROUND

Acute infections have been posited as potential precipitants or triggers of the occurrence of stroke among adults with traditional vascular risk factors. We evaluated associations between stroke occurrence and reported febrile illness within 4 weeks (potential antecedent infections) among West Africans.

METHODS

The Stroke Investigative Research and Educational Network (SIREN) is a multicenter, case-control study involving 15 sites in Ghana and Nigeria. Cases include adults aged ≥18 years with radiologically confirmed strokes. Controls were stroke-free adults matched with cased by age, gender and ethnicity. Detailed evaluations for vascular, lifestyle and psychosocial factors were performed. Participants were asked for evidence of any febrile illness within the past 4 weeks. We used conditional logistic regression to estimate adjusted odds ratios (aOR) with 95% Confidence Interval.

RESULTS

Among 3588 stroke cases recruited in Ghana and Nigeria between August 2014 and July 2018, 363 cases (10.1%) reported having a febrile illness within the 4 weeks prior to stroke occurrence. Having an antecedent infection was associated with stroke occurrence with an unadjusted OR of 1.19 (1.00-1.51) but aOR of 0.83 (0.59-1.17) upon adjusting for traditional vascular risk factors. Stress, aOR of 4.69 (2.59-8.50) and consumption of green vegetables 2.27 (1.35-2.85) were associated with antecedent febrile illness.

CONCLUSION

1 in 10 stroke cases reported antecedent history of febrile illness prior to occurrence of stroke but no independent association was observed in this study. Infectious exposures may be important triggers of cardiovascular events requiring further exploratory studies to better understand the role of this emerging risk factor.

Vascular-brain Injury Progression after Stroke (VIPS) study: concept for understanding racial and geographic determinants of cognitive decline after stroke

Cognitive impairment and dementia (CID) are major public health problems with substantial personal, social, and financial burdens. African Americans are at a heightened risk for Vascular Cognitive Impairment (VCI) compared to European Americans. Recent lines of evidence also suggest a high burden of Post-stroke VCI among indigenous Africans. A better understanding of the cause(s) of the racial disparity in CID, specifically VCI, is needed in order to develop strategies to reduce it. We propose and discuss the conceptual framework for a unique tri-population, trans-continental study titled The Vascular brain Injury Progression after Stroke (VIPS) study. The overarching objective of the VIPS Study will be to explore the interplay of multiple factors (racial, geographical, vascular, lifestyle, nutritional, psychosocial and inflammatory) influencing the level and trajectory of post-stroke cognitive outcomes and examine whether differences between indigenous Africans, African Americans and European Americans exist. We hypothesize that differences which might be due to racial factors will be observed in African Americans versus European Americans as well as Indigenous Africans versus European Americans but not in African Americans versus Indigenous Americans; differences due to geographical factors will be observed in Indigenous Americans versus African Americans and Indigenous Africans versus European Americans but not in African Americans versus European Americans. This overarching objective could be accomplished by building upon existing National Institutes of Health investments in the REasons for Geographical And Racial Differences in Stroke (REGARDS) study (based in the United States of America) and the Stroke Investigative Research and educational Network (SIREN) study (based in Sub-Saharan Africa).

Regional Patterns and Association Between Obesity and Hypertension in Africa: Evidence From the H3Africa CHAIR Study

Hypertension and obesity are the most important modifiable risk factors for cardiovascular diseases, but their association is not well characterized in Africa. We investigated regional patterns and association of obesity with hypertension among 30 044 continental Africans. We harmonized data on hypertension (defined as previous diagnosis/use of antihypertensive drugs or blood pressure [BP]≥140/90 mmHg/BP≥130/80 mmHg) and obesity from 30 044 individuals in the Cardiovascular H3Africa Innovation Resource across 13 African countries. We analyzed data from population-based controls and the Entire Harmonized Dataset. Age-adjusted and crude proportions of hypertension were compared regionally, across sex, and between hypertension definitions. Logit generalized estimating equation was used to determine the independent association of obesity with hypertension (P value <5%). Participants were 56% women; with mean age 48.5±12.0 years. Crude proportions of hypertension (at BP≥140/90 mmHg) were 47.9% (95% CI, 47.4-48.5) for Entire Harmonized Dataset and 42.0% (41.1-42.7) for population-based controls and were significantly higher for the 130/80 mm Hg threshold at 59.3% (58.7-59.9) in population-based controls. The age-adjusted proportion of hypertension at BP≥140/90 mmHg was the highest among men (33.8% [32.1-35.6]), in western Africa (34.7% [33.3-36.2]), and in obese individuals (43.6%; 40.3-47.2). Obesity was independently associated with hypertension in population-based controls (adjusted odds ratio, 2.5 [2.3-2.7]) and odds of hypertension in obesity increased with increasing age from 2.0 (1.7-2.3) in younger age to 8.8 (7.4-10.3) in older age. Hypertension is common across multiple countries in Africa with 11.9% to 51.7% having BP≥140/90 mmHg and 39.5% to 69.4% with BP≥130/80 mmHg. Obese Africans were more than twice as likely to be hypertensive and the odds increased with increasing age.

Association between white matter hyperintensities and stroke in a West African patient population: Evidence from the Stroke Investigative Research and Educational Network study

BACKGROUND

This study is part of the Stroke Investigative Research and Educational Network (SIREN), the largest study of stroke patients in Africa to date, with computed tomography (CT) or magnetic resonance (MR) imaging data for each patient to confirm stroke. Prior imaging studies performed using high-field MR (≥1.5T) have shown that white matter hyperintensities (WMH), signs of microangiopathy in the subcortical brain, are correlated with many stroke risk factors as well as poor stroke outcomes. The aim of this study was the evaluation of MR images (0.3T-1.5T) from the SIREN study to determine associations between WMH volumes in West African patients and both stroke outcomes and stroke risk factors identified in the SIREN study.

MATERIALS AND METHODS

Brain MR images of 130 Western African stroke patients (age ​= ​57.87 ​± ​14.22) were processed through Lesion Segmentation Toolbox of the Statistical Parametric Mapping software to extract all areas of hyperintensity in the brain. WMH was separated from stroke lesion hyperintensity and WMH volume was computed and summed. A stepwise linear regression and multivariate analysis was performed between patients' WMH volume and sociodemographic and clinical indices.

RESULTS

Multivariate analysis showed that high WMH volume was statistically significantly positively correlated with age (β ​= ​0.44, p ​= ​0.001), waist/hip ratio (β ​= ​0.22, p ​= ​0.03), and platelet count (β ​= ​0.19, p ​= ​0.04) after controlling for head size in a Western African stroke population.

CONCLUSION

Associations between WMH and age and waist/hip ratio previously identified in Western countries were demonstrated for the first time in a resource-limited, homogeneous black African community using low-field MR scanners.

Home Assessment of Indoor Microbiome (HAIM) in Relation to Lower Respiratory Tract Infections among Under-Five Children in Ibadan, Nigeria: The Study Protocol

The association between household air pollution and lower respiratory tract infections (LRTI) among children under five years of age has been well documented; however, the extent to which the microbiome within the indoor environment contributes to this association is uncertain. The home assessment of indoor microbiome (HAIM) study seeks to assess the abundance of indoor microbiota (IM) in the homes of under-five children (U-5Cs) with and without LRTI. HAIM is a hospital- and community-based study involving 200 cases and 200 controls recruited from three children’s hospitals in Ibadan, Nigeria. Cases will be hospital-based patients with LRTI confirmed by a pediatrician, while controls will be community-based participants, matched to cases on the basis of sex, geographical location, and age (±3 months) without LRTI. The abundance of IM in houses of cases and controls will be investigated using active and passive air sampling techniques and analyzed by qualitative detection of bacterial 16SrRNA gene (V3–V4), fungal ITS1 region, and viral RNA sequencing. HAIM is expected to elucidate the relationship between exposure to IM and incidence of LRTI among U-5Cs and ultimately provide evidence base for strategic interventions to curtail the burgeoning burden of LRTI on the subcontinent.

Unraveling the risk factors for spontaneous intracerebral hemorrhage among West Africans

OBJECTIVE

To characterize risk factors for spontaneous intracerebral hemorrhage (sICH) occurrence and severity among West Africans.

METHODS

The Stroke Investigative Research and Educational Network (SIREN) study is a multicenter case-control study involving 15 sites in Ghana and Nigeria. Patients were adults ≥18 years old with CT-confirmed sICH with age-, sex-, and ethnicity-matched stroke-free community controls. Standard instruments were used to assess vascular, lifestyle, and psychosocial factors. Factors associated with sICH and its severity were assessed using conditional logistic regression to estimate odds ratios (ORs) and population-attributable risks (PARs) with 95% confidence intervals (CIs) for factors.

RESULTS

Of 2,944 adjudicated stroke cases, 854 were intracerebral hemorrhage (ICH). Mean age of patients with ICH was 54.7 ± 13.9 years, with a male preponderance (63.1%), and 77.3% were nonlobar. Etiologic subtypes of sICH included hypertension (80.9%), structural vascular anomalies (4.0%), cerebral amyloid angiopathy (0.7%), systemic illnesses (0.5%), medication-related (0.4%), and undetermined (13.7%). Eight factors independently associated with sICH occurrence by decreasing order of PAR with their adjusted OR (95% CI) were hypertension, 66.63 (20.78-213.72); dyslipidemia, 2.95 (1.84-4.74); meat consumption, 1.55 (1.01-2.38); family history of CVD, 2.22 (1.41-3.50); nonconsumption of green vegetables, 3.61 (2.07-6.31); diabetes mellitus, 2.11 (1.29-3.46); stress, 1.68 (1.03-2.77); and current tobacco use, 14.27 (2.09-97.47). Factors associated with severe sICH using an NIH Stroke Scale score >15 with adjusted OR (95% CI) were nonconsumption of leafy green vegetables, 2.03 (1.43-2.88); systolic blood pressure for each mm Hg rise, 1.01 (1.00-1.01); presence of midline shift, 1.54 (1.11-2.13); lobar ICH, 1.72 (1.16-2.55); and supratentorial bleeds, 2.17 (1.06-4.46).

CONCLUSIONS

Population-level control of the dominant factors will substantially mitigate the burden of sICH in West Africa.

Evaluating the promise of inclusion of African ancestry populations in genomics

The lack of representation of diverse ancestral backgrounds in genomic research is well-known, and the resultant scientific and ethical limitations are becoming increasingly appreciated. The paucity of data on individuals with African ancestry is especially noteworthy as Africa is the birthplace of modern humans and harbors the greatest genetic diversity. It is expected that greater representation of those with African ancestry in genomic research will bring novel insights into human biology, and lead to improvements in clinical care and improved understanding of health disparities. Now that major efforts have been undertaken to address this failing, is there evidence of these anticipated advances? Here, we evaluate the promise of including diverse individuals in genomic research in the context of recent literature on individuals of African ancestry. In addition, we discuss progress and achievements on related technological challenges and diversity among scientists conducting genomic research.

Differential Impact of Risk Factors on Stroke Occurrence Among Men Versus Women in West Africa

Background and Purpose- The interplay between sex and the dominant risk factors for stroke occurrence in sub-Saharan Africa has not been clearly delineated. We compared the effect sizes of risk factors of stroke by sex among West Africans. Methods- SIREN study (Stroke Investigative Research and Educational Networks) is a case-control study conducted at 15 sites in Ghana and Nigeria. Cases were adults aged >18 years with computerized tomography/magnetic resonance imaging confirmed stroke, and controls were age- and sex-matched stroke-free adults. Comprehensive evaluation for vascular, lifestyle, and psychosocial factors was performed using validated tools. We used conditional logistic regression to estimate odds ratios and reported risk factor specific and composite population attributable risks with 95% CIs. Results- Of the 2118 stroke cases, 1193 (56.3%) were males. The mean±SD age of males was 58.1±13.2 versus 60.15±14.53 years among females. Shared modifiable risk factors for stroke with adjusted odds ratios (95% CI) among females versus males, respectively, were hypertension [29.95 (12.49-71.77) versus 16.1 0(9.19-28.19)], dyslipidemia [2.08 (1.42-3.06) versus 1.83 (1.29-2.59)], diabetes mellitus [3.18 (2.11-4.78) versus 2.19 (1.53-3.15)], stress [2.34 (1.48-3.67) versus 1.61 (1.07-2.43)], and low consumption of green leafy vegetables [2.92 (1.89-4.50) versus 2.00 (1.33-3.00)]. However, salt intake and income were significantly different between males and females. Six modifiable factors had a combined population attributable risk of 99.1% (98.3%-99.6%) among females with 9 factors accounting for 97.2% (94.9%-98.7%) among males. Hemorrhagic stroke was more common among males (36.0%) than among females (27.6%), but stroke was less severe among males than females. Conclusions- Overall, risk factors for stroke occurrence are commonly shared by both sexes in West Africa favoring concerted interventions for stroke prevention in the region.

Unraveling the Ethical, Legal, and Social Implications of Neurobiobanking and Stroke Genomic Research in Africa: A Study Protocol of the African Neurobiobank for Precision Stroke Medicine ELSI Project

The ethical, legal, and social implications (ELSI) of emerging neurobiobanks and data resources are unclear in an African scientific landscape with unique cultural, linguistic, and belief systems. The overarching goal of the African Neurobiobank for Precision Stroke Medicine-ELSI Project is to identify, examine, and develop novel approaches to address ELSI issues of biobanking and stroke genomic research in sub-Saharan Africa (SSA). To accomplish the goal we will (1) explore knowledge, attitude, perceptions, barriers, and facilitators influencing ELSI issues related to biobanking and stroke genomic research; (2) use information obtained to craft a community intervention program focused on ELSI issues; and (3) build capacity and careers related to genomics and biobanking for effective client/community engagement while enhancing regulatory, governance, and implementation competences in biobanking science in SSA. A community-based participatory research and mixed-methodological approach, focused on various levels of the social ecological model, will be used to identify and examine relevant ELSI issues. Contextual intervention tools, platforms, and practices will be developed to enhance community understanding and participation in stroke biobanking and genomics research activities while facilitating enduring trust, and equitable and fair utilization of biobanking resources for genetic and trans-omics research. A concurrent capacity building program related to genetic counseling and biobanking will be implemented for early career researchers. The huge potential for neurobiobanking and genomics research in Africa to advance precision medicine applicable to stroke and other neurological disorders requires addressing ELSI challenges while building sustainable research, career, and regulatory capacities in trans-omics and biobanking science.

Blueprint for building a biorepository in a resource-limited setting that follows international best practices

BACKGROUND

Genetic diversity is abundant on the African continent. However, genomic research has been hampered by a lack of high quality and extensively annotated biospecimens and the necessary infrastructure to support such a technology-intensive effort.

OBJECTIVE

The Institute of Human Virology Nigeria (IHVN) partnered with the H3Africa Consortium and the Coriell Institute for Medical Research to build an internationally recognised biorepository for the receipt, processing, storage and distribution of biospecimens for biomedical research. Here, the authors describe the procedures, challenges and results encountered.

RESULTS

Key requirements for a high-quality biorepository were identified: (1) institutional support of infrastructure and services, (2) on-site trained staff with primary commitment to the biorepository, (3) reliance on best practices from globally recognised biorepository groups, (4) early implementation of a quality management system, (5) adoption of a laboratory information management system with demonstrated versatility in functions, (6) collaboration with external experts and sharing of experience through abstracts, newsletters, published manuscripts, and attendance at meetings and workshops, (7) strict adherence to local and national ethical standards and (8) a sustainability plan that is reviewed and updated annually.

CONCLUSION

Utilising published best practices of globally recognised experts in the biorepository field as a benchmark, IHVN expanded and reorganised its existing laboratory facility and staff to take on this new purpose.

Echocardiographic Abnormalities and Determinants of 1-Month Outcome of Stroke Among West Africans in the SIREN Study

Background

Little is known about the relationship between echocardiographic abnormalities and outcome among patients with acute stroke. We investigated the pattern and association of baseline echocardiographic variables with 1‐month disability and mortality among patients with stroke in the SIREN (Stroke Investigative Research and Education Network) study.

Methods and Results

We enrolled and followed up consecutive 1020 adult patients with acute stroke with baseline transthoracic echocardiography from west Africa. To explore the relationship between echocardiographic variables and 1‐month disability (using modified Rankin scale >3) and fatality, regression models were fitted. Relative risks were computed with 95% CIs. The participants comprised 60% men with a mean age of 59.2±14.6 years. Ischemic stroke was associated with smaller aortic root diameter (30.2 versus 32.5, P=0.018) and septal (16.8 versus 19.1, P<0.001) and posterior wall thickness at systole (18.9 versus 21.5, P=0.004). Over 90% of patients with stroke had abnormal left ventricular (LV) geometry with eccentric hypertrophy predominating (56.1%). Of 13 candidate variables investigated, only baseline abnormal LV geometry (concentric hypertrophy) was weakly associated with 1‐month disability (unadjusted relative risk, 1.80; 95% CI, 0.97–5.73). Severe LV systolic dysfunction was significantly associated with increased 1‐month mortality (unadjusted relative risk, 3.05; 95% CI, 1.36–6.83).

Conclusions

Nine of 10 patients with acute stroke had abnormal LV geometry and a third had systolic dysfunction. Severe LV systolic dysfunction was significantly associated with 1 month mortality. Larger studies are required to establish the independent effect and unravel predictive accuracy of this association.

The Sub-Saharan Africa Conference on Stroke (SSACS): An idea whose time has come

Stroke is a leading cause of global morbidity and mortality. Sub-Saharan Africa (SSA), where an unprecedented rise in stroke burden is currently raging, has the highest age-standardized stroke incidence, stroke prevalence, and stroke mortality rates. This is in sharp contrast to the relative decline in stroke incidence in high-income countries over the past four decades through better awareness and control of vascular risk factors. Compared to other groups, Africans tend to have a higher risk of stroke, higher percentage of the hemorrhagic type and much poorer outcomes. Indeed, stroke levies a heavy toll on the developing SSA economy by affecting a relatively younger age group. In this commentary, we examine the disproportionately high burden of stroke in the setting of grossly inadequate resources and evidence-based interventions. We propose an annual pan-regional stroke conference (starting in 2020) to harness global resources and local talent with the goal of galvanizing action to tackle this escalating burden. We anticipate that a successful conference series could become a rallying point for the eventual establishment of an African Stroke Organization.

Age, sex, and setting in the etiology of stroke study (ASSESS): Study design and protocol

RATIONALE

Stroke etiology and risk factors vary by age, sex, setting (hospital or community-based) and by region. Identifying these differences would improve our understanding of stroke etiology, diagnosis, and treatment.

AIM

The Age, Sex and Setting in the Etiology of Stroke Study (ASSESS) is a multicenter cohort study to assess differences in stroke etiology.

METHODS AND DESIGN

Data from all centers will be categorized according to age, sex, setting, stroke subtypes. Centers with extensive hospital- or community-based data regarding stroke from Argentina, Australia, Canada, India, Iran, Italy, Ghana, Nigeria, Thailand, the United Kingdom and the United States have agreed to participate so far.

STUDY OUTCOMES

The primary outcome includes differences in stroke etiology in study centers. The secondary outcomes include stroke incidence, risk factors, preventive strategies, and short- and long-term outcomes.

CONCLUSION

ASSESS will enable comparisons of data from different regions to determine the age and sex distribution of the most common causes of stroke in each setting. This will help clinicians to tailor the assessment and treatment of stroke patients on the basis of their specific local characteristics. It will also empower stroke epidemiologists to design preventive measures by targeting the specific characteristics of each population.

Knowledge, attitudes and practices of West Africans on genetic studies of stroke: Evidence from the SIREN Study

BACKGROUND

It is crucial to assess genomic literacy related to stroke among Africans in preparation for the ethical, legal and societal implications of the genetic revolution which has begun in Africa.

OBJECTIVE

To assess the knowledge, attitudes and practices (KAP) of West Africans about stroke genetic studies.

METHODS

A comparative cross-sectional study was conducted among stroke patients and stroke-free controls recruited across 15 sites in Ghana and Nigeria. Participants' knowledge of heritability of stroke, willingness to undergo genetic testing and perception of the potential benefits of stroke genetic research were assessed using interviewer-administered questionnaire. Descriptive, frequency distribution and multiple regression analyses were performed.

RESULTS

Only 49% of 2029 stroke patients and 57% of 2603 stroke-free individuals knew that stroke was a heritable disorder. Among those who knew, 90% were willing to undergo genetic testing. Knowledge of stroke heritability was associated with having at least post-secondary education (OR 1.51, 1.25-1.81) and a family history of stroke (OR 1.20, 1.03-1.39) while Islamic religion (OR=0.82, CI: 0.72-0.94), being currently unmarried (OR = 0.81, CI: 0.70-0.92), and alcohol use (OR = 0.78, CI: 0.67-0.91) were associated with lower odds of awareness of stroke as a heritable disorder. Willingness to undergo genetic testing for stroke was associated with having a family history of stroke (OR 1.34, 1.03-1.74) but inversely associated with a medical history of high blood pressure (OR = 0.79, 0.65-0.96).

CONCLUSION

To further improve knowledge of stroke heritability and willingness to embrace genetic testing for stroke, individuals with less formal education, history of high blood pressure and no family history of stroke require targeted interventions.

Knowledge, attitudes and practices related to stroke in Ghana and Nigeria: A SIREN call to action

INTRODUCTION

Stroke is a prominent cause of death, disability, and dementia in sub-Saharan Africa (SSA). The Stroke Investigative Research and Education Network works collaboratively with stroke survivors and individuals serving as community controls to comprehensively characterize the genomic, sociocultural, economic and behavioral risk factors for stroke in SSA.

PURPOSE

In this paper, we aim to: i) explore the attitudes, beliefs, and practices related to stroke in Ghana and Nigeria using the process of qualitative description; and ii) propose actions for future research and community-based participation and education.

METHODS

Stroke survivors, their caregivers, health care professionals, and community representatives and faith-based leaders participated in one of twenty-six focus groups, which qualitatively explored community beliefs, attitudes and practices related to stroke in Ghana and Nigeria. Arthur Kleinman's Explanatory Model of Illness and the Social Ecological Model guided the questions and/or thematic analysis of the qualitative data. We hereby describe our focus group methods and analyses of qualitative data, as well as the findings and suggestions for improving stroke outcomes.

RESULTS AND DISCUSSION

The major findings illustrate the fears, causes, chief problems, treatment, and recommendations related to stroke through the views of the participants, as well as recommendations for working effectively with the SIREN communities. Findings are compared to SIREN quantitative data and other qualitative studies in Africa. As far as we are aware, this is the first paper to qualitatively explore and contrast community beliefs, attitudes, and practices among stroke survivors and their caregivers, community and faith-based leaders, and health professionals in multiple communities within Nigeria and Ghana.

Risk factors for stroke occurrence in a low HIV endemic West African country: A case-control study

BACKGROUND

HIV infection is an emerging vascular risk factor associated with stroke occurrence. The weight of evidence from sub-Saharan Africa in support of this has accrued from countries with high HIV prevalence. Our objective was to assess the contribution of HIV sero-positivity to the occurrence and outcomes of stroke in a West African country with low HIV prevalence.

METHODS

A case-control study design conducted at a tertiary medical center in Ghana involved in the Stroke Investigative Research & Educational Networks (SIREN) epidemiological study. Stroke cases were adults (aged ≥18 years) with CT or MRI confirmed stroke and stroke-free controls were age-matched and recruited from communities in the catchment areas of cases. Standard instruments were used to assess vascular and lifestyle factors and serological screening for HIV antibodies was conducted for all study participants. Stroke patients were followed for in-patient mortality outcomes. Associations between HIV, demographic and vascular risk factors and stroke occurrence and outcomes were assessed using logistic regression analysis.

RESULTS

We enrolled 540 stroke cases and 540 control subjects with a mean (± SD) age of 60.8 ± 15.5 years (cases) and 60.0 ± 15.5 (controls). Among stroke cases, the frequency of HIV was 12/540 (2.2%, 95% CI: 1.3% - 3.6%) versus 15/540 (2.8%, 95% CI: 1.7% - 4.6%) among stroke-free controls, p = .70. However, the median (IQR) age of Persons Living with HIV (PLWH) with stroke was significantly lower at 46.5 (40-65.3) years versus 61.0 (50-74) years, p = .03 among HIV- stroke patients. Stroke among PLWHA was predominantly hemorrhagic in 7 out of 12 cases and ischemic in 5 of 12 with notable clustering of established factors such as hypertension, (100%), dyslipidemia, 83.3%, central obesity, 50.0%, diabetes mellitus, 33.3%, cardiac diseases, 8.3% in this group. None of the PLWH with stroke were receiving antiretroviral therapy.

CONCLUSION

We found no associations between HIV infection and stroke occurrence among Ghanaians. However a clustering of cardio-metabolic factors in the context of HIV may promote stroke occurrence in younger individuals.