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Stroke burden in Egypt: data from five epidemiological studies Article  in  International Journal of Neuroscience · December 2017 DOI: 10.1080/00207454.2017.1420068

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International Journal of Neuroscience

ISSN: 0020-7454 (Print) 1543-5245 (Online) Journal homepage: http://www.tandfonline.com/loi/ines20

Stroke burden in Egypt: data from five epidemiological studies Foad Abd-Allah, Eman Khedr, Mohammed I Oraby, Ahmed Safwat Bedair, Shady Samy Georgy & Ramez Reda Moustafa To cite this article: Foad Abd-Allah, Eman Khedr, Mohammed I Oraby, Ahmed Safwat Bedair, Shady Samy Georgy & Ramez Reda Moustafa (2018): Stroke burden in Egypt: data from five epidemiological studies, International Journal of Neuroscience, DOI: 10.1080/00207454.2017.1420068 To link to this article: https://doi.org/10.1080/00207454.2017.1420068

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Date: 07 January 2018, At: 12:27

INTERNATIONAL JOURNAL OF NEUROSCIENCE, 2018 https://doi.org/10.1080/00207454.2017.1420068

ORIGINAL ARTICLE

Stroke burden in Egypt: data from five epidemiological studies Foad Abd-Allaha, Eman Khedrb, Mohammed I Orabyc, Ahmed Safwat Bedaird, Shady Samy Georgyd and Ramez Reda Moustafad

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a Department of Neurology, Cairo University, Cairo, Egypt; bDepartment of Neurology, Assiut University, Assiut, Egypt; cDepartment of Neurology, Beni-Suef University, Beni Suef, Egypt; dDepartment of Neurology, Ain Shams University, Cairo, Egypt

ABSTRACT

ARTICLE HISTORY

Purpose: Accurate data on the epidemiology of stroke in Egypt is scarce. The aim of this review is to address this issue based on available community-based studies and compare the resulting findings to those of other regional and international studies. Method: A systematic literature search was conducted to identify population-based epidemiological studies of stroke in Egyptians. Original articles published in English between 1990 and 2016 were included. Five studies from five different governorates in southern Egypt fulfilled the study criteria (Qena, Sohag, Assiut, New Valley and Red Sea). Results: The mean and median crude prevalence rates (Rs) across the five studies, which were conducted in southern Egypt were 721.6/100,000 and 655/100,000, respectively. The mean and median crude incidence rates (CIRs) were 187/100,000 and 180.5/100,000, respectively. The average R weighted by sample population size was 613/100,000 and the average CIR weighted by sample population size was 202/100,000. Conclusion: The incidence and prevalence of stroke in Egypt are high. More population-based studies are urgently needed in northern Egypt and in Cairo – the capital of Egypt.

Received 21 August 2017 Revised 14 November 2017 Accepted 12 December 2017

Introduction

Methods

The epidemiology of stroke is changing rapidly and the global stroke burden continues to increase worldwide [1]. Stroke is a major health problem in the Egyptian population; furthermore, although Egypt is the most populous nation in the Middle East, there is no active nationwide registry for stroke and accurate data on stroke epidemiology are scarce [2]. However, research on this topic is essential for planning appropriate management programmes, effectively applying primary prevention strategies and improving health resources in Egypt. Egyptian governorates, the top tier of the country’s five-tiered jurisdictional hierarchy, are either fully urban or urban/rural and have a population density ranging from less than 2 per km2 to more than 1000 per km2. A number of community-based studies, particularly investigations conducted in governorates in Upper (southern) Egypt between 1992 and 2013, have reported the incidence and prevalence of stroke in Egyptian regions. The aim of this systematic review is to address the epidemiology of stroke in Egypt based on these studies and to compare the resulting findings to those of other regional and international studies.

Search strategy

Foad Abd-Allah

[email protected]

© 2018 Informa UK Limited, trading as Taylor & Francis Group

KEYWORDS

Stroke; epidemiology; Egypt; incidence; prevalence

We performed an initial MEDLINE search using the Medical Subject Heading (MeSH) ‘stroke, Egypt, population-based, risk factors, stroke epidemiology’ to retrieve all potentially relevant publications (Figure 1). Englishlanguage publications from 1 January 1990 to 1 January 2016, were included. After the initial MEDLINE search was validated, the search was expanded to other primary databases to retrieve abstracts that had not been identified using MEDLINE. In addition, papers were identified via a manual search using references cited in original papers and reviews. With respect to inclusion criteria, studies were included if theyaddressed stroke and transient ischemic attacks (TIAs) that were identified using standard World Health Organization (WHO) definitions [3]; were prospective community- or population-based studies; assessed a clearly defined population in Egypt; were not limited to a subset of the study population; had available age- and gender-specific data; and reported original data. Five studies fulfilled the study criteria. These studies reported the incidence and prevalence of stroke in five different governorates in southern

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F. ABD-ALLAH ET AL.

Figure 1. Flow chart of the search methodology and review process.

Egypt (Qena, Sohag, Assiut, New Valley and Red Sea). Qena, Sohag and Assiut are river Nile Valley governorates, while New Valley and Red Sea are desert area governorates.

(N1P1 + N2P2)/(N1 + N2), where N represents a sample population size, and P is the corresponding prevalence in that population) were calculated for incidence and prevalence rates.

Data extraction and analysis

Results

The identified articles were reviewed and data were analysed in a descriptive manner. The data extracted from the included papers were annual stroke incidence, stroke prevalence, patient sex, patient age, demographic data and stroke subtypes. Meta-analysis was not attempted due to significant variability in both data sources and study methodologies. Simple averages and averages weighted by sample population size (for example,

Five population-based studies [4–8] satisfied our search criteria (Table 1). In all of these studies, stroke and TIAs were identified using WHO criteria [3]. A total sample population of 134,815 was examined via door-to-door surveys conducted in five different governorates (Figure 2) in Upper (southern) Egypt (Qena, Sohag, Assiut, New Valley and Red Sea). There were almost equal numbers of males and females, and the examined populations were

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Table 1. Characteristics of the studies included in the review.

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Reference/year Khedr et al., 2014 [5] Farghaly et al., 2013 [4] El Tallawy et al., 2013 [8] Khedr et al., 2013 [6] Kandil et al., 2006 [7]

Location Qena governorate

Dates September 2011 to August 2013 Al-Kharga, New Valley June 2005 to May governorate 2009 El Quseir city, Red Sea July 2009 to January governorate 2012 Assiut governorate January 2010 to December 2010 Sohag governorate January 1992 to April 1993

Study design Community-based, three-phase, door-todoor Community-based, three-phase, door-todoor of all inhabitants of the district Door-to-door survey of every household in the district Cross-sectional community-based study, three-phase door-to-door survey Door-to-door survey

from a mixture of urban and rural communities. Certain data from two of the included studies were reported separately in a later publication [9]. The crude incidence rate (CIR) of stroke ranged from 137/100,000 in Qena to 250/100,000 in Al-Wadi Al-Gadid

Sample size 8027 62,583 33,285 5920 25,000

Males/females 4172 (52%)/ 3855 (48%) 32,165 (51.4%)/ 30,418 (48.6%) 16,428 (49.5%)/ 6857 (50.6%) 3066 (51.8%)/ 2854 (48.2%) –

Urban/rural 4427 (55.2%)/ 3600 (44.8%) 44,600 (71.3%)/ 17,983 (28.7%) – 3660 (61.8%)/ 2260 (38.2%) 8464 (33.9%) Urban 5305 (21.2%) Suburban 11,231 (44.9%) Rural

(New Valley). The crude prevalence rate (R) of stroke ranged from 508/100,000 in Sohag to 963/100,000 in Assiut. The prevalence of stroke was generally higher among men than among women, with a male-to-female ratio ranging from 1.1 in Sohag to 1.8 in Red Sea. In

Figure 2. Map of Egypt showing the locations of the five studies included in this review (respective governorates are highlighted).

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F. ABD-ALLAH ET AL.

Table 2. Crude Prevalence Rate (R) and Crude Incidence Rate (CIR) of stroke in the five population-based studies included in this review. Stroke CIR per 105 137

CIR of IS/HS/TIA per 105 –

Stroke R per 105 922

R of IS/HS/TIA per 105 797/125/62

Sex-specific R per 105 (M/F) 1103/729

Residence-specific R per 105 (R/U) 1111/768

Literacy-specific R per 105 (IL/L) 3567/704

Farghaly et al., 2013 New Valley

250

190/55/5

560

480/83/6

610/501

520/580

–

El Tallawy et al., 2013 Red Sea

181

170/5/5

655

585/60/15

860/480

–

–

Khedr et al., 2013 Assiut

–

–

963

895/63/–

1174/736

902/1062

357/2413

Kandil et al., 2006 Sohag

180

100/43/ 25

508

310/110/36

520/490

410/540/590 suburban

–

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Reference/year/ governorate Khedr et al., 2014 Qena

Age-specific R per 105 (years) 1315 among >20 years 43 among 20–29 years 231 among 30–39 years 1115 among 40– 49 years 2464 among 50– 59 years 6204 among 60– 69 years 8392 among >70 years 26 among <20 years 90 among 20–40 years 990 among 40–60 years 5380 among >60 years 26 among 20–40 years 806 among 40–60 years 3702 among >60 years 250 among 30–39 years 709 among 40–49 years 2364 among 50– 59 years 5882 among 60– 69 years 4867 among >70 years 16 among <20 years 260 among 20–40 years 1390 among 40– 60 years 3080 among >60 years

Note: IS = Ischemic stroke, HS = Hemorrhagic stroke, TIA = Transient Ischemic Attack, M = Male, F = Female, IL = Illiterate, L = Literate.

addition, higher prevalences of stroke were observed for urban populations, literate communities and older populations (Table 2). Two of the included studies reported age-adjusted prevalences of stroke in addition to crude prevalences. In the Qena study [5], the local age-adjusted (Qena 2006 census) prevalence rate was 777/100,000, and the prevalence rates after adjusting for age with respect to the Egyptian and world populations were 567/100,000 and 1222/ 100,000, respectively. In the Assiut study [6], the local ageadjusted prevalence rate was 699/100,000, and the prevalence rate after adjusting for age with respect to the world population was 981/100,000. The mean and median Rs across the five studies were 721.6/100,000 and 655/

100,000, respectively. The mean and median CIRs were 187/100,000 and 180.5/100,000, respectively. When weighting for sample population size, the average R and CIR were 613/100,000 and 202/100,000, respectively. In all of the included studies, incidence and prevalence were much higher for ischemic stroke than for hemorrhagic stroke or TIAs. Ischemic stroke ed for 81%–93% of all strokes, whereas hemorrhagic stroke ed for 7%–13% of all strokes in all studies, except for the Sohag study [7], which reported an unusually high prevalence of hemorrhagic stroke (24%). Vascular risk factors associated with stroke were reported in four studies (Table 3). Hypertension (62%–66%), hyperlipidemia (53%) and diabetes mellitus

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Table 3. Vascular risk factors in stroke patients in two studies of our population-based studies. Reference Khedr et al., 2014 Khedr et al., 2013 El Tallawy et al., 2015

Hypertension 62.2%

DM 36.5%

TIA 6.8%

IHD 9.5%

66% 64%

38.6% 34.4%

8.8% –

12.3%

RHD 5.4%

Family history 10.8%

–

– 5%



Others 1.4% SLE – 53.2% hyperlipidemia

Note: DM = Diabetes Mellitus, TIA = Transient Ischemic Attack, IHD = Ischemic Heart Disease, RHD = Rheumatic Heart Disease, SLE = Systemic Lupus Erythematosus. Reporting on combined data from the Red Sea and New Valley studies. Reported as 8.6% for all ‘heart diseases.’

(34%–38%) were the most prevalent stroke risk factors identified in those studies.

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Discussion This study systematically reviewed the prevalence and incidence rates of stroke in Egypt, a developing country with a troubled economic situation. This review, which included five population-based studies, showed rather high CIRs and Rs in five governorates that mainly cover southern Egypt. To date, these investigations are the only Egyptian studies that have examined stroke epidemiology using a population-based perspective rather than a hospital-based approach. Although the results of this study cannot be epidemiologically generalized to the Egyptian population as a whole, they shed light on important findings. The highest R per 100,000 for stroke was recorded in Assiut (963), followed closely by Qena (922) and then by El Quseir (655) and New Valley (560). The lowest R per 100,000 was recorded in Sohag (508).The high prevalence rates observed in Assiut and Qena may be attributed to more stressful lifestyles in these growing industrial governorates, while in the other governorates the lifestyles are simple and less stressful. In Sohag and Assiut, the R per 100,000 for stroke was higher for urban residents than for rural residents, whereas the opposite relationship was observed in the Qena study. The rise in incidence of stroke in urban regions can be attributed to increased prevalences of modifiable risk factors such as hypertension, diabetes mellitus and smoking as well as a lack of prevention strategies in these regions. In contrast, there may be reduced incidence rates of stroke in rural regions where subjects have not yet been exposed to conventional risk factors [10]. The studies conducted in El Quseir and New Valley by El Tallawy et al. [8] and Farghaly et al. [4], respectively, produced representative results for these regions given that the entire governorate population was included in these studies. With respect to weather and environmental conditions, these two governorates differ from the governorates where the other three studies were

performed and from most of Egypt; in particular, due to the harsh desert conditions in these two governorates, inhabitants have greater exposure to extreme hot weather in the summer and extreme cold in the winter. A separate review by El Tallawy et al. details the results of the two aforementioned studies [9]. Although definite, evidence-based, temporal trends of stroke prevalence and/or incidence over time cannot be drawn from the data from the five included studies, the later studies appear to report lower incidences and generally higher prevalences than the earlier studies (Figure 3). This finding may mirror official stroke mortality statistics, which indicates that deaths attributable to stroke have been rising steadily over the past decade [2]. As noted in many studies, the prevalence and incidence of stroke vary widely across countries. Part of this variance is explained by geography, population age and urbanization; however, a significant portion of this variance remains unexplained. There is emerging evidence that compared with high-income countries, low-income countries have a greater stroke burden with respect to incidence of stroke, proportion of strokes involving intracerebral hemorrhage, case mortality and age at stroke onset [11]. The incidences and prevalences reported in the present study place Egypt in the high incidence/ prevalence strata relative to other countries (see [12] for a comprehensive review). Egypt is a Middle Eastern, Arabian and African country. With respect to comparisons of Egypt with other Middle Eastern countries, in their systematic review of all stroke-related articles published in the Middle East between 1980 and May 2015, which included 64 papers, El-Hajj et al. found that among these countries, Egypt and Iran had the highest and lowest incidences of stroke, respectively [1]. In their systematic review of 31 articles published from 1983 to 2008 from 10 Arabian countries that did not include Egypt, Benamer and Grosset found that the annual incidences of stroke in these countries ranged from 27.5 to 63 per 100,000, with prevalences of stroke between 42 and 68 per 100,000; these values were far lower than the corresponding incidence and prevalence of stroke in Egypt [13].

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F. ABD-ALLAH ET AL.

Figure 3. Crude incidence and prevalence of stroke in the five studies. A trend of rising prevalence and declining incidence can be seen.

In addition, in other African countries, prevalence rates ranged from 114 per 100,000 in Nigeria [14] to 870 per 100,000 in Benin after age adjustments for WHO population data for sub-Saharan Africa [15]. Again, these indices are lower than the corresponding indices for Egypt. The alarming increase in the incidence of stroke in Egypt emphasizes the need for the establishment of effective action plans by the government and the participation of community societies to minimize this burgeoning epidemic. Research is needed to clarify whether limited resources, low public awareness and underutilization of healthcare services alone for unsatisfactory rates of risk factor control in Egypt or whether Egypt-specific genetic and ethnic differences also contribute to these high stroke indices [2]. The main limitation of this review is that the available data were only from southern Egypt. Therefore, the findings may not be representative for the entire Egyptian population due to socioeconomic and demographic differences among Egyptian regions.

Conclusion The incidence and prevalence of stroke are high in Egypt. This review can be considered a ‘kick-off’ investigation that sets up larger epidemiological studies. There is a need for additional community-based studies from other parts of Egypt, particularly Cairo, Alexandria and the northern (delta) governorates, to provide more accurate representations of stroke epidemiology across the Egyptian population. There is also an urgent need to establish a national registry to prospectively collect accurate epidemiological data on strokes in Egypt and to identify trends in stroke incidence and prevalence over time.

Acknowledgments We acknowledge all the authors of the 5 studies mentioned in our review for their extreme and cooperation.

Disclosure statement The authors have no conflicts of interest to disclose and this work was not ed or funded by any organization.

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References [1] El-Hajj M, Salameh P, Rachidi S, et al. The epidemiology of stroke in the Middle East. Euro Stroke J. 2016;1(3):180–198. [2] Abd-Allah F, Moustafa RR. Burden of stroke in Egypt: Current status and opportunities. Int J Stroke. 2014;9(8):1105–1108. [3] Aho K, Harmsen P, Hatano S, et al. Cerebrovascular disease in the community: results of a WHO collaborative study. Bull World Health Organ. 1980;58(1):113–130. [4] Farghaly WM, El-Tallawy HN, Shehata GA, et al. Epidemiology of nonfatal stroke and transient ischemic attack in AlKharga district, New Valley, Egypt. Neuropsychiatr Dis Treat. 2013;9:1785–1790. [5] Khedr EM, Fawi G, Abdela M, et al. Prevalence of ischemic and hemorrhagic strokes in Qena governorate, Egypt: Community-based study. J Stroke Cerebrovasc Dis. 2014;23:1843–1848. [6] Khedr EM, Elfetoh NA, Al Attar G, et al. Epidemiological study and risk factors of stroke in Assiut governorate, Egypt: Community-based study. Neuroepidemiology. 2013;40:288–294. [7] Kandil MR, Farawez HM, Khalifa G, et al. Epidemiology of cerebrovascular stroke and TIA in Upper Egypt (Sohag) – relative frequency of stroke in Assiut University Hospital. Egypt J Neurol Psychiatr Neurosurg. 2006;43:593–602.

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[8] El-Tallawy HN, Farghaly WM, Shehata GA, et al. Epidemiology of non-fatal cerebrovascular stroke and transient ischemic attacks in El Quseir, Egypt. Clin Interv Aging. 2013;8:1547–1551. [9] El Tallawy HN, Farghaly WM, Badry R, et al. Epidemiology and clinical presentation of stroke in Upper Egypt (desert area). Neuropsychiatr Dis Treat. 2015;11:2177–2183. [10] O’Donnell M, Xavier D, Liu L, et al. Risk factors for ischaemic and intracerebral haemorrhagic stroke in 22 countries (the INTERSTROKE study): a case-control study. Lancet. 2010;376:112–123. [11] Sposato LA, Saposnik G. Gross domestic product and health expenditure associated with incidence, 30-day fatality, and age at stroke onset: a systematic review. Stroke. 2012;43:170–177. [12] Thrift AG, Cadilhac DA, Thayabaranathan T, et al. Global stroke statistics. Int J Stroke. 2014;9(1):6–18. [13] Benamer HT, Grosset D. Stroke in Arab countries: A systematic literature review. J Neurol Sci. 2009;284(1):18–23. [14] Danesi M, Okubadejo N, Ojini F. Prevalence of stroke in an urban, mixed-income community in Lagos, Nigeria. Neuroepidemiology. 2007;28:216–223. [15] Cossi MJ, Gobron C, Preux P, et al. Stroke: prevalence and disability in Cotonou, Benin. Cerebrovasc Dis. 2012;33 (2):166–172.