Stroke burden and stroke care system in Asia
Correspondence Address: Source of Support: None, Conflict of Interest: None DOI: 10.4103/0028-3886.178042
Source of Support: None, Conflict of Interest: None
Background: Stroke is a major cause of death and disability. Asia is the largest and mostly populated continent of the world. The Asian Stroke Advisory Panel (ASAP) consists of stroke neurologists from 12 different countries in 13 Asian regions. It has been established for 17 years, and holds regular meetings for reviewing the stroke activities in Asia. It also helps in conducting several multinational research projects. This study is one of the ASAP projects and aims to explore stroke care systems in member countries in Asia.
Keywords: Asia; stroke; stroke care
Globally, stroke is a major cause of death and disability. It creates psychological and economical complexities for patients and their families. The stroke victims are a major burden on the healthcare system. The incidence of stroke is still increasing in the developing countries in contrast to the developed countries.
Asia is the largest and mostly populated continent of the world. Asians account for more than half of the world's population. The Asian countries are highly heterogeneous in terms of size, population, race, culture, and economy. Stroke in Asian patients accounts for more than two-thirds of the overall incidence of stroke worldwide. Compared to Caucasians, Asians have been reported to have a higher incidence of stroke and a higher mortality rate. In higher income countries such as Japan, Korea, and urban China, a declining stroke mortality has been increasingly reported. However, in some countries with limited resources such as India, Pakistan, and Indonesia, high fatality rates are still evidenced. With the longer life expectancy in general population worldwide, an increasing number of stroke cases are expected in most countries. ,,
The Asian Stroke Advisory Panel (ASAP) consists of stroke neurologists from 12 different countries in 13 Asian regions. The group has been established for 17 years and holds regular meetings for reviewing the stroke activities in Asia as well as in conducting several multinational research projects. ,,,, The meeting offers a platform where members can communicate with each other and share knowledge on stroke-related issues in Asia.
This study is one of the ASAP projects and aims to explore stroke care systems in member countries in Asia through the collection of data on stroke with special emphasis on epidemiology, risk factors, and the effective utilization of country's resources in the care of patients with stroke.
We conducted a survey among leading stroke neurologists who are members of the ASAP group from 12 countries (13 regions) in Asia. Data were primarily collected from the statistics and previously published data from each country. However, personal communication for unpublished data was also gathered using a survey. The collected data regarding stroke care resources in this study represents information gathered in 2012.
The survey is categorized into five main parts including the general country information, stroke epidemiology, stroke risk factors, stroke care systems, and national stroke professional societies. The general country data were mainly extracted from the published World Bank databases which include population, income per capita, life expectancy, and percentage of aged population. ,, The general stroke information including incidence, prevalence, and percentage of the ischemic and hemorrhagic stroke was collected. Stroke care resources in each country, the number of neurologists, availability of investigations such as neuroimaging machines, number of stroke units, availability of thrombolytic treatment, and clinical practice guidelines were also collected. We also obtained information on the major risk factors of stroke such as hypertension, diabetes, dyslipidemia, presence of atrial fibrillation, and smoking among stroke patients. Finally, the presence of the national stroke society and the number of its members were recorded. Data were compared with previous surveys from the ASAP group among 9 Asian countries in 1999. 
The data were collected from existing publications and personal communications with leading stroke neurologists from 13 regions in Asia that included 6 countries in South East Asia (Indonesia, Malaysia, Philippines, Singapore, Thailand, and Vietnam), 5 in East Asia (China, Hong Kong, Japan, South Korea, and Taiwan), and 2 in South Asia (India and Pakistan).
Country-specific general information is shown in [Table 1]. ,, The representative countries consist of countries with small-to-large populations with varying income levels.
The incidence of stroke was available in some countries, and the number varied according to the studied population. ,,,,,,,,,,,,,,,,,,,, A higher proportion of ischemic stroke in comparison to hemorrhagic stroke was found in all countries. ,,,,,, The incidence and prevalence of stroke are shown in [Table 2], and the ratio of ischemic and hemorrhagic stroke is shown in [Figure 1].
Stroke care resources
The number of neurologists, the number of computed tomography (CT) scan/magnetic resonance imaging (MRI), the use of intravenous thrombolysis, and stroke unit facilities are summarized in [Table 3]. ,,,,,, The number of neurologists per 1000,000 population is shown in [Figure 2].
Stroke risk factors
The common stroke risk factors among the general population and stroke patients are presented in [Table 4]. ,,,,,,,,
A professional stroke society is established in most countries. The name of each society, the year of establishment, and the number of members in 2012 are shown in [Table 5].
As the world's population is growing and the proportion of elderly subjects is increasing, more stroke patients are projected especially among Asians. The total population of the participating countries is approximately 3.3 billion, which is almost half of the world's population (7.06 billion). The participating countries in this study represent a wide range of countries. There are countries with low-middle, middle, and high incomes, according to the World Bank economic classification. There are countries with huge populations such as China and India, as well as smaller countries such as Singapore.
Among the 12 representative countries in Asia, China is the most highly populated country with a population of 1.35 billion whereas Singapore is the least populated (with only 5.3 million inhabitants). The income per capita varies widely. Singapore has the highest income per capita, and it is 17 times higher than Vietnam, which has the lowest income per capita. According to the new classification by the World Bank, five countries are in the category of lower-middle income countries such as India, Indonesia, Pakistan, Philippines, and Vietnam. Three countries are considered as belonging to the upper-middle income group: China, Malaysia, and Thailand. Finally, three countries are classified as being in the high-income country group: Japan, Korea, and Singapore.
In all countries, the life expectancy is greater in the female population with an average life expectancy of 77.5 years (68-86 years). The average male life expectancy is 72.3 years (64-81 years). The longest life expectancy was found in Hong Kong followed by Japan.
With the growing number of aging population, Asia is the area that is most affected by a rising prevalence of stroke. More than one-fifth of the Japanese population is older than 65 years. However, the average percentage of elderly (older than 65) subjects among countries included in this study population was 9.5%. The results of the present study are compared to the previous survey among nine Asian countries by the same ASAP group in 1999. At that time, the survey included data from Hong Kong, India, Indonesia, Korea, Malaysia, Philippines, Singapore, Taiwan, and Thailand. The life expectancy and the number of subjects belonging to the aging population have markedly increased in all countries. In 13 years, the average increase in life expectancy has been 4 years. However, in Indonesia, the life expectancy, when compared with the data in 1999, is 9 and 10 years longer in the female and male population, respectively. Therefore, there is no doubt that more stroke patients are expected in the region due to a larger number of subject belonging to the aging population group.
The annual data on the incidence of stroke is available in some countries, and the number varies between various studies and the studied population. The overall incidence of stroke is between 116 and 483/100,000 per year. The prevalence of stroke among each country depends on the age of studied population.
Among the major types of stroke, a higher proportion of ischemic stroke when compared to hemorrhagic stroke, is found in all countries. The percentage of ischemic stroke ranges from 59% in Vietnam to 90% in Hong Kong. The median percentage of ischemic stroke is 75. Interestingly, when compared with the previous study in 1999, the proportion of ischemic stroke has increased in all countries. This may represent a better control of hypertension, which is the major risk factor of hemorrhagic stroke. Also, the increasing proportion of ischemic stroke may relate to the westernized lifestyle and diet, which have become more common in Asians.
Hypertension is the most common risk factor among stroke patients and accounts for 63-85% of the cases. This is comparable with other parts of the world. The second and third most common risk factors are dyslipidemia and diabetes mellitus, respectively. Smoking is still common in the population and also forms a major risk factor.
The overall stroke care system can be assessed at least partly by the number of neurologists present, the number of imaging facilities in the country, the incidence regarding the use of thrombolytic agents, and the availability of stroke units. The number of neurologists varies greatly among each country. China, which has the largest population, also has the greatest number of practicing neurologists, whereas many smaller countries have <100 neurologists. In high-income countries, the proportion of neurologists per unit population is high. The number ranges from one neurologist per 15,000 in Japan to one per 85,000 in Singapore. In contrast, in low-income countries like Pakistan, there is one neurologist for every 2 million patients. However, in real life situations, most neurologists are concentrated in urban areas especially in capital cities. Therefore, the ratio of the neurologists per unit population may be much lower in rural areas. When compared to 1999, a 2-3-fold increase in the number of neurologists was observed in all countries. This indicates the growing number of neurology training facilities in the region.
CT scan and MRI facilities are available in all countries. However, in China and Japan, there are more than 10,000 CT scanners and more than 6,000 MRI scanners in the country. When compared to 1999, the number of CT and MR scanners has markedly increased.
For acute stroke management, there are more than 600 stroke units with more than 10,000 beds in the studied regions. Almost half of the units are located in China. There was at least one stroke unit per country, and the number of stroke units has increased between 1999 and 2012. Among countries in which comparative data are available, Thailand has the largest growing number of stroke units (from 1 to 116) between the year 1999 and 2012.
Intravenous thrombolysis with recombinant tissue plasminogen activator is available for acute stroke management (stroke fast track) in all countries. Thailand was the first to start this treatment since 1996. In most countries, the dosage of 0.9 mg/kg is used. However, 0.6 mg/kg is used as a standard dose in Japan, Pakistan, Vietnam, and in some cases, in the Philippines and India. At the year of survey (2012), there were more than 17,000 patients who received intravenous thrombolysis for acute stroke in the Asian population and Japan had the highest number of cases.
The national stroke guidelines for management of stroke in local languages were made available in all countries. Singapore was the first to have its own guideline in 1999. Most countries had established their own national stroke society. These stroke societies are mainly for professionals, with some educational activities being organized for the public, except for the Singapore National Stroke Association which has educational activities mainly for the public. This represents awareness about stroke among specialists and the effort to enhance collaboration among professionals and public through health education. ,,,
We are aware of the limitations of this study especially related to the fallacies in interpreting epidemiological data from each country, which may not be truly comparable due to the different studied populations and lack of standardized population sample collecting methodologies. However, we strongly believe that information on stroke care resources and management will provide a broader perception about the stroke situation in Asia. Asia as a whole is facing problems of an aging society. In countries with more resources and with higher standards of care, the decreasing case fatality rate will result in more numbers of stroke survivors, who will constitute a larger burden on the society. Other countries with fewer resources still struggle with the fundamental problems of resource limitation including insufficient stroke neurologists, and limited imaging facilities and organized stroke units. However, when compared to 1999, there is a favorable trend in all Asian countries regarding the need to increase the number of neurologists and facilities to effectively administer stroke care.
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Conflicts of interest
There are no conflicts of interest.
[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]