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In a new report, ICMR has reported the incidence of stroke in five regions based on registries it set up there in 2018.
Of them, the highest incidence has been reported from Cuttack, Odisha.
Cuttack also reported the highest figures for hypertension among stroke patients and for current tobacco use – both important risk factors.
Stroke, one of the top of the non-communicable diseases, is India’s third-leading cause of death. In an effort to capture stroke incidents, the Indian Council of Medical Research (ICMR) set up population-based stroke registries in five centres in different parts of the country in 2018.
In a new report, entitled ‘Stroke Incidence and Mortality: A Report of the Population-based Stroke Registries, India’, ICMR reported the stroke incidence rates in these regions based on these registries. The rate ranged from 96.6 to 187.6 per lakh population per year. The highest figure was reported from Cuttack, Odisha.
The report is as such a wake up call for Cuttack, and for Odisha: the state needs to urgently, and in a sustained manner, address the severe shortage of stroke units, poor diagnostics facilities, and high prevalence of risk factors.
The five population-based stroke registries are in Cuttack, Odisha; Cachar, Assam; Tirunelveli, Tamil Nadu; Kota, Rajasthan; and Varanasi, Uttar Pradesh. Together, they cover more than 23 lakh people.
Cause for concern
Some of the report’s findings point to areas that could improve through better policy focus.
For example, of the five registries, Cuttack has the highest percentage (25.1%) of first stroke cases in men older than 75 years. The next highest for the same demographic is Tirunelveli (15.8%) for the same demographic. Rural Cuttack also reported a higher incidence of stroke compared to urban parts of the district.
Cuttack also fares poorly on stroke diagnosis. The basic requirement here is neuroimage recording, followed by confirmation by computerised tomography (CT) or magnetic resonance imaging (MRI). In Cuttack, according to the registry, only 1.4% of cases were diagnosed by MRI. The ‘clinical only’ diagnosis of stroke in Cuttack was the highest, at 18.4% in men and 16.7% in women. (These were the two sole sexual groups specified in the report.)
The stroke follow-up is also worrying. Follow-up means ascertaining the vital status of people who have suffered a stroke 28 days after its onset. The follow-up could be at the hospital, at home, by telephone or in writing. The Cuttack registry reported the highest home visits – 20.1%; Kota was a distant second at 1%.
Risk factors for noncommunicable diseases include hypertension, diabetes, tobacco and alcohol use, diet and (lack of) physical activity. Correspondingly, according to ICMR’s report, Cuttack reported the highest figures for hypertension among stroke patients (74.6% M, 75.6% F) and current tobacco use (68.4% M, 53.6% F). The district reported the second-highest number of stroke patients with diabetes.
By type of stroke – Cuttack had the most men who had suffered ischaemic and haemorrhagic stroke and who also had hypertension and diabetes.
Lessons for action
The burden of stroke is higher in low and middle-income countries (LMICs), including in India. The country-wide incidence rate was 108-172 per lakh population in 2019. In the same year, about 7 lakh deaths were attributed to stroke, out of 12.9 lakh cases. The reasons for these high numbers include resource shortages, poor awareness, lack of access to rapid care, low-reliability brain imaging and inadequate stroke units.
Studies have shown that within India, the burden of stroke is highest in the eastern states of Assam, Chhattisgarh, Odisha Tripura and West Bengal. So the ICMR report has found about Cuttack, and in fact Odisha by proxy, is in line with previous findings.
By way of solutions, Cuttack, and Odisha with it, desperately needs more stroke units. These are specialised centres with a dedicated number of beds and a purpose-designated team of physicians, physiotherapists and nurses for managing stroke patients’ symptoms.
There were only about 35 stroke units in India in 2013, most of which continue to be operated by the private sector and only in large cities. Both the cost of setting up and maintaining such units and availability of skilled personnel are challenges to be overcome, we must establish more stroke units in government hospitals, period.
This would be a long-term solution. In the nearer period, the state and Central governments must avail CT-equipped mobile stroke units, adequate supply of drugs in government hospitals, fellowships in neuro-intervention and telestroke programmes. Major public and private hospitals could also come together to set up hubs designed to serve patients from remote parts of the state.
Taking cue from the report, Odisha needs to pay attention to the elderly population, the rural sector and diagnostics facilities – and it needs to address the risk factors for stroke, especially diabetes, hypertension and tobacco use. Only such concerted efforts, over shorter and longer terms, can allow Odisha to take the challenge of reducing stroke incidence head on.
Sambit Dash teaches in Melaka Manipal Medical College, Manipal Academy of Higher Education (MAHE), Manipal. He comments on public policy, healthcare, science and issues of social interest. He tweets at @sambit_dash.