The landscape of stroke care has begun to change as a direct response to the growing research and breakthroughs in the approach to stroke treatment, in terms of therapy and overall organisation. Of course, the levels of stroke care and approach to it varies across the globe, with some regions tackling the issue head on, and other regions falling behind. In this three-part feature, NeuroNews looks at the burden of stroke from a global perspective, with leading interventional neuroradiologists and stroke care providers across the world addressing the level of stroke care in their region, the need, what is being done to address this and where they see stroke care advancing over the next five years.
Sub Saharan Africa
By Allan Taylor, South Africa
What level of stroke care is currently available?
Most Sub Saharan African countries spend less than US$150 per person per year on healthcare. When comparing this to the per capita health spend of countries like the USA (US$8000) and Western European countries at around US$4000, it is understandable that access to stroke care is limited. Most countries in the region have no organised acute or rehabilitative stroke care. Organising stroke care is further compromised by fragmented healthcare services. Private care may offer good service but is limited to a small number of patients and often falls short of having all the experts available for acute stroke care. Government care is focused on other disease burdens such HIV, tuberculosis and malaria and where stroke units exist they offer supportive care only. South Africa is an exception to this, with most large cities having stroke units offering comprehensive care including mechanical thrombectomy. National guidelines for stroke care exist but require updating given the new data available for mechanical thrombectomy. The South African Stroke Society plans to have stroke units accredited independently according to their criteria in 2018. Kenya also has a trained neurointerventionist who is able to offer mechanical thrombectomy.
What is the need based on the number of strokes versus the number of centres/stroke physicians?
Low and middle income countries have had an increasing incidence of stroke since the 1970’s. The age standardised incidence in Sub Saharan Africa is currently around 140 to 160 new ischaemic strokes per 100,000 persons per year. An estimated number of new strokes per year based on a Sub Saharan population of almost one billion would be at least 1.5 million patients per year. Looking at South Africa only, this would be 90,000 strokes per year. There are currently less than 35 stroke units in South Africa offering intravenous t-PA and only 10 able to perform mechanical thrombectomy. It might seem that the solution is to provide more stroke units, however, many of the available units are not currently currently operating at capacity. Unfortunately public and physician awareness that stroke treatment is available is low and many patients arrive at hospital too late or are not referred. Increasing treatment rates will primarily require organising rapid transport to centres with dedicated stroke care pathways.
What steps are being taken to improve the level of care available?
The global burden of disease study among others has focused attention on the burden of stroke in low income countries and there is now a Lancet commission looking at ways to reduce the incidence of stroke in LMIC.Understanding why stroke affects younger patients in Africa, the role communicable diseases may play and treating risk factors like hypertension will go a long way to helping. On top of this there is a need to improve access to stroke units able to offer acute treatment. This will require an approach starting with national guideline development appropriate to each country’s resources. Stroke units need to be certified and access to these units improved. In South Africa the national stroke society is doing this in conjunction with private and public hospitals.
Where do you hope to see stroke care in your region in five years’ time?
A realistic goal in the Sub Saharan region would be to see primary care improve and a reduction in the incidence of stroke. There have been regional successes in the care of HIV showing that when research and resources are focused on a particular disease progress can be made. In contrast to HIV, however, acute stroke requires rapid treatment with the minimum resource of a CT scanner. Given the large geographic areas and that the majority of countries have less than 50% of their populations in urban areas it is unlikely that many will have access to t-PA or thrombectomy. However, as a neurointerventionist working in South Africa, I am sure that in five years we will have many more certified stroke units and I hope all units offering thrombectomy are operating at capacity.
By Wickly Lee, Singapore
Acute stroke care systems in Southeast Asian (SE Asia) countries are at various stages of development, and therefore exhibit heterogeneity and diversity in terms of treatment availability and practices for both intravenous thrombolysis and endovascular therapy (EVT). With the publications of successful endovascular therapy trials over the past few years, the pressure for acute stroke care in Southeast Asian countries to meet the heightened focus has become greatly magnified. Acute stroke care systems in SE Asia also faces the unique challenge of high stroke burden, on a background of an ageing population, and differing political and healthcare systems in these countries. Based on existing published data, multinational interactions and collaboration efforts over the past few years, collective data on acute stroke systems in Southeast Asian region are slowly emerging.
Southeast Asia comprises of 10 countries: Indonesia (IND), Philippines (PHL), Vietnam (VNM), Thailand (THA), Myanmar (MMR), Malaysia (MYS), Cambodia (KHM), Laos (LAO), Singapore (SGP) and Brunei (BRN). Southeast Asia covers about 4.5 million km2 (1.7 million mi2), which is 10.5% of Asia or 3% of earth’s total land area. Its total population is more than 641 million, about 8.5% of the world’s total population. It is the third most populous geographical region in the world after South Asia and East Asia. According to a new classification by the World Bank (2017), the income per capita of these countries varies widely: Six of its member countries are in the lower-middle income group (LMICs) [IND, PHL, VNM, MMR, KHM, LAO], two member countries in the upper-middle income group [MYS, THA] and two member countries in the high-income group [SGP, BRN].
A much needed survey was conducted in the third quarter of 2017 among leading interventional neuroradiologists (INRs) active in providing acute stroke EVT in SE Asia. Only six out of the 10 countries have EVT service setups. These six countries are Indonesia, Philippines, Vietnam, Thailand, Malaysia and Singapore. There are a total of 43 EVT sites, only 28 EVT sites with 24/7 coverage, with a large proportion (up to 37%) of these EVT sites contributed by the private sector. It is also noted that most of these EVT sites are located in city centres with large under-served rural areas. The number of EVT sites at present is not in keeping with the effective coverage in terms of the individual countries land size and population.
With regards to the number of INRs active in EVT, there are approximately 83 INRs active in this region, again an inadequate number to meet the demand. Most of the INR practitioners are site-specific and do not cross-cover. Based on the common consensus that the optimal coverage of one INR per one million population, the majority of the countries in this region still do not meet this requirement.
From 2015 to 2Q 2017, we have seen an increase of more than 100% in the number of EVT procedures performed in SE Asia. There have been a total of approximately 2,300 cases performed over this two and half year period. In terms of number of procedures performed per 100,000 populations, the majority of the countries do not even perform one procedure per 100,000 population per year, which is far below the expected demand for EVT. The number of procedures performed per INR will have future implications in terms of reaccreditation to ensure quality balanced against the need and speed for training of new INR practitioners.
SE Asia countries also face unique challenge of ICAD (intracranial atherosclerotic disease) related stroke disease. An estimated 20–30% of all stroke in the Asian population are ICAD-related, compared to 2.5–10% in the Caucasian population. The incidence of ICAD increases with age, involves the posterior circulation more often than the anterior circulation, and is more severe when the posterior circulation is involved. ICAD complicates EVT efforts, in terms of case selection, choice of EVT techniques, increases EVT failure and complication rates, and raises the need for intra-procedural angioplasty and stenting.
Long-term outlook in the next five years should be focused on issues of accessibility, affordability, quality and sustainability of EVT services in this region. Specifically, large land masses and population places a strain on the present acute stroke system for effective coverage of rural underserved regions. Strategic placement of comprehensive stroke centres away from city centres and improvement in ambulance transportation services are main areas to address issue of accessibility. Ambulance diversion and telestroke are potential strategies. The disproportionate distribution of private vs. public EVT sites suggests that more can be done in terms of government support in these countries. Up-to-date and informed government healthcare policies to boost infrastructure and manpower development for acute stroke therapy will ensure quality of acute stroke care. Fiscal policies looking at improved subvention programmes for thrombectomy devices will ensure availability and affordability for the general public. Long-term sustainability of acute stroke care hinges on planning and availability of resource allocation and manpower projections. Medical and neuroscience training is at different levels in different SE Asian countries. Due to high level of demand and complexity of stroke care in both acute and post stroke management settings, the training needs to be comprehensive, up-to-date and consistent to ensure quality care in the long run.