A systematic evaluation of stroke surveillance studies in low- and middle-income countries

Objective: Reliable quantification of the burden of stroke in low- and middle-income (LMI) countries is difficult as population-based surveillance reports are scarce and may vary considerably in methodology. We aimed to evaluate all available primary stroke surveillance studies by applying components of a benchmark protocol (WHO STEPwise approach to stroke surveillance) and quantify the reported burden of stroke in LMI settings. Methods: Electronic databases Medline, Embase, Scopus, and Web of Knowledge were searched for population-based surveillance studies. Studies conducted in the LMI countries that reported on incident stroke were included. Data were extracted from each study using a prestructured format. Information on epidemiologic measures including crude and age-adjusted incidence rates, person-years, admission rates, case fatality rates, death certification, autopsy rates, measures of disability, and other study-specific information, in line with WHO STEPS stroke protocol, were recorded. Age-adjusted incidence rate data of stroke were combined using random-effects meta-analyses. Results: We identified 7 studies that reported on burden of stroke in 9 LMI countries, including aggregate information from 1,711,372 participants collected over 5,240,923 person-years. The age-adjusted incidence rates across the LMI countries varied widely, with the burden of total first-ever strokes ranging from 41 to 909 events per 100,000 person-years. Conclusions: Systematic evaluation of all available primary surveillance studies, particularly in the context of WHO STEPS guidelines, indicates inadequate adherence to standardized surveillance methodology in LMI countries. Incorporation of standardized approaches is essential to enhance generalizability and estimate stroke burden accurately in these resource-poor settings.

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