An Epidemiological Study of Stroke Hospitalizations in Maputo, Mozambique A High Burden of Disease in a Resource-Poor Country

Already a major cause of death and disability in high-income countries, the burden of stroke in sub-Saharan Africa is also expected to be high. However, specific stroke data are scarce from resource-poor countries. We studied the incidence, characteristics, and short-term consequences of hospitalizations for stroke in Maputo, Mozambique. Methods­Over 12 months, comprehensive data from all local patients admitted to any hospital in Maputo with a new stroke event were prospectively captured according to the World Health Organization's STEPwise approach to stroke surveillance program. Disability levels (pre- and posthospital discharge) and short-term case-fatality (in-hospital and 28 days) were also studied. Results­Overall, 651 new stroke events (mean age 59.113.2 years and 53% men) were captured by the registry with 601 confirmed by CT scan (83.4%) or necropsy (8.9%). Crude and adjusted (world reference population) annual incidence rates of stroke were 148.7 per 100 000 and 260.1 per 100 000 aged 25 years, respectively. Of these, 531 (81.6%) represented a first-ever stroke event comprising 254 ischemic (42.0%) and 217 (36.1%) an intracerebral hemorrhage. Before admission, 561 patients (86.2%) had hypertension and 271 (41.6%) had symptoms for 24 hours. In-hospital and 28-day case-fatality were 33.3% and 49.6% (72.3% for hemorrhagic stroke), respectively. From almost no preadmission disability, 64.4% of 370 survivors at 28 days had moderate-to-severe disability. Conclusions­The burden of disease associated with stroke is high in Maputo, emphasizing the importance of primary prevention and improvement of the standards of care in a developing country under epidemiological transition

Triggering of stroke by ambient temperature variation: a case-crossover study in Maputo, Mozambique.

OBJECTIVES: The effect of ambient temperature as a stroke trigger is likely to differ by type of stroke and to depend on non-transient exposures that influence the risk of this outcome. We aimed to quantify the association between ambient temperature variation and stroke, according to clinical characteristics of the events, and other risk factors for stroke. METHODS: We conducted a case-crossover study based on a 1-year registry of the hospital admissions due to newly occurring ischemic and hemorrhagic stroke events in Maputo, Mozambique's capital city (N=593). The case-period was defined as the 7 days before the stroke event, which was compared to two control periods (14-21 days and 21-28 days before the event). We computed humidity- and precipitation-adjusted odds ratios (OR) and 95% confidence intervals (95%CI) using conditional logistic regression. RESULTS: An association between minimum temperature declines higher than 2.4 °C in any two consecutive days in the previous week and the occurrence of stroke was observed only for first events (OR=1.43, 95%CI: 1.15-1.76). Stronger and statistically significant associations were observed for hemorrhagic stroke (OR=1.50, 95%CI: 1.07-2.09) and among subjects not exposed to risk factors, including smoking, high serum cholesterol or atrial fibrillation. No differences in the effect of temperature were found according to the patients' vital status 28 days after the event. CONCLUSIONS: First stroke events, especially of the hemorrhagic type, were triggered by declines in the minimum temperature between consecutive days of the preceding week.

The effect of season and temperature variation on hospital admissions for incident stroke events in Maputo, Mozambique.

BACKGROUND: Identifying locale-specific patterns regarding the variation in stroke incidence throughout the year and with atmospheric temperature may be useful to the organization of stroke care, especially in low-resource settings. GOAL: We aimed to describe the variation in the incidence of stroke hospitalizations across seasons and with short-term temperature variation, in Maputo, Mozambique. METHODS: Between August 1, 2005, and July 31, 2006, we identified 651 stroke events in Maputo dwellers, according to the World Health Organization's STEPwise approach. The day of symptom onset was defined as the index date. We computed crude and adjusted (humidity, precipitation and temperature) incidence rate ratios (IRRs) and 95% confidence intervals (CIs) with Poisson regression. RESULTS: Stroke incidence did not vary significantly with season (dry versus wet: crude IRR = .98, 95% CI: .84-1.15), atmospheric temperature at the index date, or average atmospheric temperature in the preceding 2 weeks. The incidence rates of stroke were approximately 30% higher when in the previous 10 days there was a decline in the minimum temperature greater than or equal to 3 °C between any 2 consecutive days (variation in minimum temperature -5.1 to -3.0 versus -2.3 to -.4, adjusted IRR = 1.31, 95% CI: 1.09-1.57). No significant associations were observed according to the variation in maximum temperatures. CONCLUSIONS: Sudden declines in the minimum temperatures were associated with a higher incidence of stroke hospitalizations in Maputo. This provides important information for prediction of periods of higher hospital affluence because of stroke and to understand the mechanisms underlying the triggering of a stroke event.

Determinants of early case-fatality among stroke patients in Maputo, Mozambique and impact of in-hospital complications.

The burden of stroke is increasing in developing countries that struggle to manage it efficiently. We identified determinants of early case-fatality among stroke patients in Maputo, Mozambique, to assess the impact of in-hospital complications. Patients admitted to any hospital in Maputo with a new stroke event were prospectively registered (n = 651) according to the World Health Organization's STEPwise approach, in 2005-2006. We assessed the determinants of in-hospital and 28-day fatality, independently of age, gender and education, and computed population attributable fractions. In-hospital mortality was higher among patients with Glasgow score at admission ≤ 6 (more than fivefold) or needing cardiopulmonary resuscitation during hospitalization (approximately 2.5-fold). Pneumonia and deep vein thrombosis/other cardiovascular complications during hospitalization were responsible for 19.6% (95% confidence interval, 5.3 to 31.7) of ischaemic stroke and 15.9% (95% confidence interval, 5.8 to 24.9) of haemorrhagic stroke deaths until the 28th day. Ischaemic stroke patients with systolic blood pressure 160-200 mmHg had lower in-hospital mortality (relative risk = 0.32, 95% confidence interval, 0.13 to 0.78), and, for those with haemorrhagic events (haemorrhagic stroke), 28-day mortality was higher when systolic blood pressure was over 200 mmHg (hazard ratio = 3.42; 95% confidence interval, 1.02 to 11.51), compared with systolic blood pressure 121-140 mmHg. Regarding diastolic blood pressure, the risk was lowest at 121-150 mmHg for ischaemic stroke and at 61-90 mmHg for haemorrhagic stroke. Early case-fatality was mostly influenced by stroke severity and in-hospital complications. The allocation of resources to the latter may have a large impact on the reduction of the burden of stroke in this setting.

An epidemiological study of stroke hospitalizations in Maputo, Mozambique: a high burden of disease in a resource-poor country.

BACKGROUND AND PURPOSE: Already a major cause of death and disability in high-income countries, the burden of stroke in sub-Saharan Africa is also expected to be high. However, specific stroke data are scarce from resource-poor countries. We studied the incidence, characteristics, and short-term consequences of hospitalizations for stroke in Maputo, Mozambique. METHODS: Over 12 months, comprehensive data from all local patients admitted to any hospital in Maputo with a new stroke event were prospectively captured according to the World Health Organization's STEPwise approach to stroke surveillance program. Disability levels (pre- and posthospital discharge) and short-term case-fatality (in-hospital and 28 days) were also studied. RESULTS: Overall, 651 new stroke events (mean age 59.1 ± 13.2 years and 53% men) were captured by the registry with 601 confirmed by CT scan (83.4%) or necropsy (8.9%). Crude and adjusted (world reference population) annual incidence rates of stroke were 148.7 per 100,000 and 260.1 per 100,000 aged ≥ 25 years, respectively. Of these, 531 (81.6%) represented a first-ever stroke event comprising 254 ischemic (42.0%) and 217 (36.1%) an intracerebral hemorrhage. Before admission, 561 patients (86.2%) had hypertension and 271 (41.6%) had symptoms for > 24 hours. In-hospital and 28-day case-fatality were 33.3% and 49.6% (72.3% for hemorrhagic stroke), respectively. From almost no preadmission disability, 64.4% of 370 survivors at 28 days had moderate-to-severe disability. CONCLUSIONS: The burden of disease associated with stroke is high in Maputo, emphasizing the importance of primary prevention and improvement of the standards of care in a developing country under epidemiological transition.