Acute stroke in a districthospital in Madagascar

Pål StenumgårdAvdeling for geriatri

St. Olavs Hospital

Definition of Stroke(the WHO clinical criteria)

Rapidly developing signs of focal or global disturbance of cerebral function, leading to death or lasting more than 24 hours, with no apparent cause other than vascular origin.

The World Health Organization MONICA Project. J Clin Epidemiol 1988; 41: 105-14

Ischemic stroke

Hemorrhagic stroke

STROKE WARNING SIGNS

AVC (Accident Vasculaire Cérébrale) VITE le 15!

• Visage paralysé

• Inertie d’un membre

• Trouble de la parole

• En urgence appelle le 15

Global death ranks with 95%UIs for the top 25 causes in 1990 and 2010

Lancet December 15, 2012; 380: 2095-128

The Global Burden of Disease Study 2010: Key findings

Lancet December 15, 2012;380

• Life expectancies are increasing

• Shift from communicable to non-communicable diseases

• Shift from premature deaths (YLLs) to years lived with disability (YLDs)

• Significant regional heterogeneity of mortality and morbidity

Age-adjusted and sex-adjusted stroke mortality ratesLancet Neurology, April 2009; 8: 345-54

Age-adjusted

stroke incidence

rates per 100 000

person-years

across the four

study periods

(A) High-income

countries.

(B) Low to middle

income countries.

Solid line is regression

trend line.

The regression line is

based on a regression

of average incidence

on study period.

Worldwide stroke incidence

and early case fatality

reported in 56 population-

based studies. Lancet Neurology 2009; 8: 355–69

Early (21-day to 1

month) stroke case

fatality by study year

(A) High-income

countries.

(B) Low to middle

income countries.

Solid line is a linear

regression line

Worldwide stroke incidence

and early case fatality reported

in 56 population-based studies:

a systematic review

Lancet Neurol 2009; 8: 355-69

Why is the burden of stroke increasing in low to middle income countries?

Feigin VL et al. Lancet Neurol 2009; 8:355-69

• The average age of the populations increases

• Exposure to cardiovascular risk factors increases:– Smoking

– Raised blood pressure

– Raised blood glucose concentrations

– Westernised diets• Low in fruit and vegetables

• High in fat and salt

– Physical inactivity

Stroke in Madagascar

• Prevalence: 1.6 times higher than in France

• More frequent in the urban population

• Mean age: 60.75 ± 14 years

• 10% of hospital morbidity

• Case fatality rate: 28%

• Most frequent cause of death in hospitals (21%)

Politique Nationale de Prevention et Lutte Integrees contre les Maladies Chroniques Non Transmissibles

Ministere de la Sante et du Planning Familial. Repoblikan’ I Madagasikara et OMS (WHO)

Madagascar

• Land area: 587,040 km²

• Population: 23.6 mill.

• Life expectancy at birth: ♀ 65.1 y ♂ 62.2 y (Lancet 2012;380:2071-94)

• GNI per capita: 440 $ Low income (World Bank Group 2014)

• Poverty headcount ratio at $1.25 a day: 87.7% (World Bank Group 2010)

• HIV prevalence: 0.3% (UNAIDS 2014)

• Political crisis since 2009

• Democratic elections 2013

Antsirabe

• 1500m ASL

• Population: 238,000

• Main city of the Vakinankaratra region with an estimated population of 1.8 mill.

• Hospitals– Hôpital Luthérien

Andranomadio (HLA)

– Centre Hospitalier de Référence Régional (CHRR), public hospital (CT scan)

Centre Hospitalier de RéférenceRégional du Vakinankaratra (CHRR)

• Departments:– Emergency unit (16 beds –

medicine and surgery)– Medicine (20 beds – 10

women + 10 men)– BRM (4 beds)– + +

• 147 patients with acute stroke January to September 2015– ~ 16 patients/month

• CT scan– 25% of stroke patients (2015)– CT brain without contrast:

240,000 MGA ≈ 600 NOK

Hôpital Luthérien Andranomadio (HLA)

• Departments:Medicine, BRM, Surgery, BRC, Maternity, Pediatrics, TB, Laboratory, Radiology, Dental Clinic, Out-patient Clinic

• 130 beds (medicine: 53) • 130 employees:

– 14 doctors– 45 nurses– 6 midwives

• Annual budget (2010): – 1 188 864 187 MGA– ≈ 3.3 mill NOK

• No CT scan

HôpitalLuthérienAndranomadio2014

Socio-demographic and clinical data on 30 patients with acute stroke

Key components of an equitable approach to stroke services

Bo Norrving, Brett Kissela, Neurology 2013; 80: 5-12

• Primary care assessment and management of cardiovascular risk and TIA

• Secondary prevention measures

• Education of the public and health care providers about stroke prevention and management

• Access to stroke care and rehabilitation services

• Community and family support for patients with stroke and their caregivers

Potential population effect of stroke interventions in a district of one million population

P Langhorne, L de Villiers, J D Pandian. Lancet Neurol 2012; 11: 341-48

Key components of stroke unit-careP Langhorne, L de Villiers, J D Pandian. Lancet Neurol 2012; 11: 341-48

Effect of stroke unit in low-income and middle-income countries

P Langhorne, L de Villiers, J D Pandian. Lancet Neurol 2012; 11: 341-48

Multidisciplinary stroke care in a secondary-level hospital in South Africa (GF Jooste Hospital)

L de Villiers, S Z Kalula, V C Burch. Int J Stroke 2009; 4: 89-93

• 200-bed hospital, township, Cape Town• Estimated population of 1.5 million• 6600 medical patients annually• 400 have stroke as a primary diagnosis• Stroke Unit (SU) opened March 2002• Data for all stroke patients admitted 3 months before

opening the SU and 3 month after

• The GF Jooste Hospital was closed down 2014

Multidisciplinary stroke care in a secondary-level hospital in South Africa (GF Jooste Hospital)

L de Villiers, S Z Kalula, V C Burch. Int J Stroke 2009; 4: 89-93

• 94 patients in General Ward (GW)

• 101 patients in Stroke Unit (SU)

• Inpatient mortality: 33% vs 16% (P = 0.005)

• The length of stay: 5.1 vs 6.8 days (P = 0.01)

• Conclusion: Multidisciplinary stroke care can be successfully implemented in a resource-constrained setting