In an article published in the Lancet Public Health just in advance of World Stroke Day 2021, a WSO-led expert group have set out a global analysis of the global costs of stroke and an actionable ten-year primary prevention roadmap that could reduce stroke incidence by at least half.
The analysis presented in the paper shows that stroke remains the second biggest cause of death and third leading cause of disability globally with the number of people having strokes increasing by 70% in the past three decades. The number of people living with stroke worldwide has going up by 85%, mortality rates have increased by 43% and years of life lived with disability (DALYS) have increased by almost a third over the same period.
The driving risk factors, and overwhelming impact of stroke has not however been universally distributed. While populations living in low and middle-income countries experienced a 48% growth in stroke DALYs, for those living in high-income countries with higher levels of access to quality acute stroke care, disability levels dropped by 25% across the same period. People living in low- and middle-income countries continue to bear most of the growing burden of stroke, as they live in countries with fewer financial and healthcare resources to respond. Given that a person living in a low-income country is likely to have their first stroke when they are 15 years younger than their wealthier counterparts, the impact of stroke is felt at their peak of productivity with devastating individual and socioeconomic impacts.
In the first ever analysis of the global cost of stroke, the lifetime direct costs of treatment, rehabilitation, social care and informal caregiving are calculated at I$393 billion, with the costs of household income losses due to premature death or disability standing at a conservative I$576 billion. These costs are significant and place a significant brake on sustainable development goals, accounting for at least 10% of economic growth over the past decade.
These data trends, set against a backdrop of lagging progress against government commitments to the address NCDS, suggest the need for clearly articulated primary stroke prevention at global and national level. Evidence supporting the case for investment in population-based primary prevention strategies targeting the top five drivers of stroke (high blood pressure, body mass index, diabetes, air pollution and smoking) suggests a significant returns on investment. Just $1 per person a day in low-income countries and $3 a day in middle income countries would reduce global stroke mortality by 10% save U$25 billion a year. Population wide primary prevention of stroke and cardiovascular disease has already been identified as an investment with 10-fold rate of return and stroke prevention strategies are likely to yield even higher returns, given that they will impact positively on the risk of heart disease, diabetes and some cancers.
Whilst some progress can be made through identification of individuals at high risk through clinical screening, the evidence suggests this widely used strategy cannot achieve the necessary rate of progress required. An estimated 80% of stroke incidence would not be identified through high-risk cardiovascular screening. A significant barrier to the high-risk prevention strategy approach is that people living in countries with the highest stroke incidence are also those least likely to have access to necessary screening and tests. The recent WHO-WSO survey of stroke services found that while 96% of healthcare providers in high-income settings countries provided comprehensive tests and procedures to identify cardiovascular disease risk, this was only the case in 16% of low-income countries. An effective and equitable way to accelerate progress on prevention is more likely to be found through the combination of population-based prevention strategies in tandem with clinical screening, especially when the latter can be delivered with low-cost point of care solutions.
Allocating funding and resources to support development and adoption of national stroke prevention strategies is a practical first step to making progress on stroke prevention. These strategies should provide financially sustainable action plans, supported by culturally appropriate guidelines, freely available and validated mobile technologies for management of risk factors (such as the Stroke Riskometer), task shifting from highly educated health professionals to trained community health care workers to support risk factor identification and education across the lifespan and the development of improved access to pharmacological and surgical procedures to manage conditions that lead to stroke, including hypertension, diabetes and atrial fibrillation.
Governments should provide adequate health services, improve socioeconomic conditions, reduce inequities, and implement policies to influence environmental (e.g., air pollution) and lifestyle factors such as smoking, vaping, processed food and alcohol. In addition, health systems should identify, screen, and manage for individual risk factors. Revenues from taxation of harmful products should be re-invested into the public health sector, including research to improve health. Governments should be transparent about the proportion of health budgets that are focused on prevention and should work to develop intersectoral funding and population buy-in.
If implemented, these interventions are likely to halve the burden of stroke globally saving millions of lives each year and creating a direct and indirect improvement on the quality of life and well-being of millions more.
V Feigin & A Wiseman
Achieving our vision of a life free from stroke is a task that WSO cannot achieve alone. We are committed to building our partnerships at the global, regional and national level to scale up and deliver improvements in prevention, treatment and support to reduce the burden of stroke.