Series
Preventing stroke: saving lives around the world
Lancet Neurol 2007; 6: 182–87
See Reflection and Reaction
page 94
This is the first in a Series of
five articles about stroke
in developing countries
Department of Chronic
Diseases and Health Promotion
(K Strong PhD) and Department
of Measurement and Health
Information Systems
(C Mathers PhD), WHO, Geneva,
Switzerland; and University of
Auckland (R Bonita PhD),
Auckland, New Zealand
Correspondence to:
Dr Kathleen Strong, Department
of Chronic Diseases and Health
Promotion, WHO, 20 Avenue
Appia, Geneva 27, CH-1211,
Switzerland
strongk@who.int
182
Kathleen Strong, Colin Mathers, Ruth Bonita
Stroke caused an estimated 5·7 million deaths in 2005, and 87% of these deaths were in low-income and middle-
income countries. Without intervention, the number of global deaths is projected to rise to 6·5 million in 2015 and to
7·8 million in 2030. The rising burden of stroke, especially in low-income and middle-income countries, leads us to
propose a worldwide goal for stroke: a 2% reduction each year over and above that which may happen as a result of
better case management and treatment. The experience of high-income countries indicates that sustained interventions
can achieve at least the required 4% annual average decline in stroke mortality for people age 60–69 years. Achieving
this goal for stroke would result in 6·4 million fewer deaths from stroke from 2005 to 2015. More of these deaths will
be averted in low-income and middle-income countries than in high-income countries.
Introduction stroke deaths alone would have on worldwide chronic
Heart disease and stroke are the two leading causes of disease death rates.
mortality in adults age 15 years and over, and the third In this paper, we first present current and projected
and fourth leading causes of disease burden (as measured stroke mortality and burden of disease for the world,
in disability-adjusted life years [DALYs]) after HIV/AIDS World Bank income groups, and for selected countries,
and unipolar depressive disorders.1 An estimated for the period 2005 to 2030. We then assess the mortality
5·7 million people died from stroke in 2005. Among reductions and years of life saved from meeting the
adults age 45–69 years, heart disease and stroke are the global goal of an additional 2% reduction each year in
leading causes of DALYs lost and deaths worldwide. stroke death rates, and discuss the feasibility and
The burden of chronic, non-communicable diseases, challenges of meeting this bold goal by 2015.
including stroke, has remained stable, at about 85% of
the total disease burden, in high-income countries over Methods
the past 10 years. However, demographic and Global epidemiology and burden of stroke
epidemiological shifts have resulted in stroke becoming In recent years, WHO has undertaken a progressive
a major health problem in low-income and middle- reassessment of the Global Burden of Disease (GBD) for
income countries. Indeed, these countries have the years 2002–30, with consecutive revisions and
experienced a rise in the burden of chronic diseases, to updates published annually in WHO World Health
almost 50% of total disease burden over the past decade. Reports.3 These updates draw on a wide range of data
This increase can be attributed to population ageing and sources to develop internally consistent estimates of
changes in the distribution of known, modifiable risk incidence, severity, duration, and mortality for over
factors of cardiovascular diseases. These modifiable risk 130 major causes, for 14 subregions of the world. The
factors and the ways in which they contribute to methods used here are generally similar to those of the
premature deaths are known and well documented. They original GBD study, albeit with substantial improvements
include tobacco use, poor diet leading to people being in data availability and some new methods for dealing
overweight or obese, raised blood pressure, raised with incomplete and biased data.1,4 Disease burden is
cholesterol, and physical inactivity. A global goal for quantified in terms of DALYs. One DALY is 1 year of
reducing deaths and burden of disease by an additional “healthy” life lost and the burden of disease is a
2% annually on projected declines from chronic diseases measurement of the gap between the current health of a
worldwide has been proposed to inspire increased population and an ideal situation in which everyone in
international effort to prevent chronic diseases.2 If the population lives to old age in full health.
reached, this goal would avert 36 million chronic disease Death registration data provided to WHO by
deaths—including those from stroke, heart disease, 107 Member States contained usable information on
diabetes, cancers, and chronic respiratory diseases—by cause of death distributions, most of these in high-
2015. As part of this global goal, about a sixth of the income countries in the Americas, the Caribbean,
deaths averted would be deaths from stroke. Europe, and central Asia. Including the urban and
We propose a specific global goal for reduction of sample registration systems of India and China,
deaths from and burden of stroke as an advocacy tool to comprehensive cause of death information was available
communicate the size and scope of the burden of disease for around 72% of the world’s population. Population-
that stroke represents worldwide. We quantify the health based epidemiological studies, disease registers, and
gains from achieving this goal with global and regional notifications systems also contributed to the estimation
projections of stroke mortality and burden (in DALYs) of mortality due to 21 specific causes of death, particularly
from 2005 to 2030. We compare the results of the global for sub-Saharan Africa. To address information gaps
goal for reducing chronic disease deaths with the relating to other causes of death, improved models were
outcome that an additional reduction of 2% a year in developed for estimating broad cause-of-death patterns
http://neurology.thelancet.com Vol 6 February 2007
 Series

using a dataset of 1613 country-years of observation of
cause-of-death distributions from 58 countries between
1950 and 2001.5
Because country-reported information on stroke is
scarce, especially in low-income and middle-income
countries,6,7 the GBD study developed a model for stroke
epidemiology from available population data, both on
case fatality within 28 days for incident cases of first-ever
stroke, and on long-term survival in cases surviving this
initial period, which has the highest risk of mortality.4
Regional case fatality rates were estimated with data from
published and unpublished studies, identified by
searches of MEDLINE, PubMed, the authors’ own files,
and expert advice. Only papers published in English from
1980 onwards were reviewed. 35 population-based studies
were used in analysis, although 15 hospital-based studies
were also examined for confirmatory evidence.4
Consistent epidemiological models for the regional
incidence of first-ever stroke and prevalence of stroke
survivors were then estimated by use of an incidence–
prevalence–mortality model.8
Projections of mortality for 2005, 2015, and 2030
WHO has prepared updated mortality projections from
2003 to 2030, with methods similar to those applied in
the original GBD study. A set of simple models were
used to project future health trends for baseline,
optimistic, and pessimistic scenarios, largely on the
basis of projections of economic and social development,
and by use of the historically observed relations of these
with cause-specific mortality rates.9 The data inputs for
the projection models take into account more countries
reporting death registration data to WHO, especially
low-income and middle-income countries, as well as
updated projections for HIV/AIDS and the tobacco-
related epidemic. For the projections reported here,
historical death registration data for 107 countries
between 1950 and 2002 were used to model the
relationship between death rates for all major causes
(excluding HIV/AIDS) and the following variables:
average income per capita; the average number of years
of schooling in adults; and time, a proxy measure for
the effect of technological change on health status.
changes in incidence rates (reflecting changes in risk
factor exposures and prevention activities) and to changes
in case fatality rates (reflecting improving treatment
effectiveness).
A global goal
Projected annual rates of change in age-specific and sex-
specific death rates for all chronic disease causes were
calculated for the mortality projections from 2005 to 2015
and then adjusted by subtraction of an additional 2% per
annum. Death rates for years 2006 to 2015 were then
recomputed by use of the adjusted annual trends for age-
sex-specific rates. The final death rates for cerebrovascular
disease in 2015, assuming that the global goal was
achieved, are substantially lower than the base projections,
because the additional 2% annual declines are cumulative.
Population numbers were projected with the new death
rates under the global-goal scenario.
Years of life gained under the global-goal scenario were
estimated by calculating total years of life lost (without
discounting or age weighting) for each year between 2005
and 2015 under the global-goal scenario and subtracting
these from the years of life lost under the base-projections
scenario. In order to estimate the years of life gained
solely because of an additional 2% per annum decline in
stroke mortality between 2005 and 2015, an additional
scenario was modelled in which the additional 2% per
annum decline was applied only to projected stroke
mortality, not to other chronic disease causes.
Results
We estimate that there were 16 million first-ever strokes
and 5·7 million stroke deaths in 2005. In the absence of
additional population-wide interventions, these numbers
are expected to rise to 18 million first-ever strokes and
6·5 million deaths in 2015, and to 23 million first-ever
Number (millions) Rate per 1000
2005 2015 2030 2005 2015 2030
Deaths
0–59 0·8 0·8 0·8 0·1 0·1 0·1
60–69 1·1 1·2 1·3 3·0 2·5 2·0

Death rates were then projected by use of World Bank 70+ 3·8 4·5 5·7 12·5 12·1 10·4

estimates of income per capita, and WHO projections All ages 5·7 6·5 7·8 0·89 0·91 0·98
of average years of schooling and smoking intensity. (6·4–6·8) (7·7–8·4) (0·89–0·96) (0·95–1·08)
For the optimistic and pessimistic scenarios, growth DALYs
rates of income per capita were assumed to be around 0–59 20·5 20·6 19·8 0·4 0·3 0·3
50% higher and lower than under the baseline scenario, 60–69 13·6 15·0 16·7 3·8 3·2 2·6
as well as more optimistic and pessimistic assumptions 70+ 16·7 18·3 24·4 54·8 49·5 44·6
for human capital and tobacco smoking.9 All ages 50·8 53·8 60·9 7·9 7·6 7·7
The mortality projections were also used as the basis (50·8–56·7) (54·8–66·2) (7·1–8·0) (6·8–8·5)
for projections of the global burden of disease from 2002 Ranges shown in brackets represent projected numbers and rates for all ages under the optimistic and pessimistic
to the year 2030. For cerebrovascular disease projections, projection scenarios.
incidence rates were assumed to decline at half the rates
Table: Projected deaths and DALYs for stroke, numbers and rates by age for 2005, 2015, and 2030
projected for mortality.9 In other words, projected trends
(baseline scenario)
in stroke mortality were assumed to be equally due to

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 Series

death from stroke for all ages combined from 89 per

All ages (5·75 million) Under age 70 years (1·93 million) 100 000 in 2005, to 98 per 100 000 in 2030. The projected
global death rates for stroke in 2030 under the optimistic
and the pessimistic scenarios range from –4% to +10% of
the baseline projections (table). The range of projected
stroke burden (DALYs per 1000) is around –11% to +10%.
Among people age 60 years and older, stroke accounted
for 13% of the global burden of disease in the population
in 2005, and 38% of the burden of cardiovascular diseases
in the same age group. The total years of healthy life lost
due to stroke, as measured by DALYs, is greater in those
Low income age 0–59 years than for ages 60–69 years and ages beyond
Middle income 70 years, although the DALY rate increases with age
High income
(table). Two-thirds of the burden of stroke occurs in
people under age 70 years. Projected age-specific DALY
Figure 1: Percentage stroke deaths by World Bank income group for all ages and for people under age 70 years rates for 2015 and 2030 are declining overall but are
higher for all ages combined, reflecting global population
200 ageing. DALY rates for stroke will likely decline at a
180
slower rate than mortality rates, reflecting the assumption
that half the decline in mortality is caused by declines in
Age-standardised death rate per 100 000

160 incidence and half by declines in case fatality rates. The

140 prevalence of stroke survivors, whether or not disabled as
a result of the stroke, was estimated to be 62 million
120
globally in 2005, and projected to rise to 67 million in
100 2015 and 77 million in 2030.
80 For the year 2005, 87% of deaths from stroke for people
of all ages (figure 1) are in low-income and middle-
60
income countries. The percentage of deaths from stroke
40 coming from these countries rises to 94% for stroke
deaths in people under age 70 years. In contrast, high-
20
income countries contribute only 13% (all ages) and 6%
0 (under 70 years) of deaths from stroke.
Russian Nigeria Tanzania India China Pakistan Brazil UK Canada
Federation Stroke death rates among people age 30–69 years for nine
selected countries that represent all regions of the world
Figure 2: Age-standardised death rates from stroke per 100 000 for ages 30–69 years, selected countries, and all income groups are shown in figure 2. Age-
projections for 2005
standardised death rates are highest in the Russian
Federation and higher in other low-income and middle-
5
income countries than in Canada or the UK. In terms of
Middle income
Low income
premature death and years of life lost, stroke is a greater
4 High income problem in low-income and middle-income countries than
in high-income countries.
Total deaths (millions)

3 Stroke mortality is projected to increase faster in

middle-income and low-income countries than in high-
2 income countries (figure 3). Any global goal for reducing
mortality from stroke will have a larger effect on number
1 of lives saved in these countries than on lives saved in
high-income countries.
0
2000 2005 2010 2015 2020 2025 2030 Potential achievements of the global stroke goal
When the global goal of reducing chronic disease deaths by
Figure 3: Projected trends for stroke deaths by World Bank income group an additional 2% was first proposed in 2005, we estimated
2002–30
that it would result in 36 million fewer deaths between
2005 and 2015 and a cumulative benefit of 500 million life-
strokes and 7·8 million deaths by 2030 (table). Although years saved between 2005 and 2015.2 Among these 36
the age-specific death rates are projected to decline million fewer deaths, there would be 5·7 million fewer
slightly between 2005 and 2030, population ageing stroke deaths. Achieving the same mortality reduction for
worldwide will result in an overall increase in rates of stroke alone would result in 6·4 million fewer deaths from

184 http://neurology.thelancet.com Vol 6 February 2007


A
2·50
0–69 years
Total deaths averted (millions)
2·00 70 years and over
1·50
1·00
0·50
0·00
High income
B assumptions. Furthermore, these projections are driven
45
40
Years of life gained (millions)
35
30
25
20
15
10
5
0
High income
Figure 4: Cumulative deaths averted and years of life gained by an additional
2% annual reduction in stroke death rates, 2006–15
stroke in the same time period, and 5·4 million fewer
deaths overall. The latter figure is lower than the total
averted stroke deaths because the extra people alive and the
lower stroke mortality results in somewhat higher numbers
of deaths from other causes.
The 5·4 million fewer deaths in total under the global-
stroke-goal scenario would result in 75 million years of
life gained cumulatively from 2006 to 2015; 46 million
(65%) of the years of life gained are for people under age
70 years (figure 4). Most deaths averted and years of life
gained would therefore be for people in low-income and
middle-income countries.
Discussion
We present the mortality and burden of disease
projections for stroke using the WHO 2002 mortality
estimates as a baseline. These are based on an expanded
empirical database compared with the original 1990 GBD
study, with the incorporation of much new data and a
greater understanding of the limitations of routinely
available datasets. Even so, there is substantial uncertainty
about the comparative burden of diseases and injuries in
many parts of the world. In particular, for regions with
limited death-registration data such as the eastern
Mediterranean region, sub-Saharan Africa, and parts of
Asia and the Pacific, there is considerable uncertainty in
estimates of deaths by cause. The 95% uncertainty
intervals for stroke mortality in 2001 range from around
12% in developed countries, to 18% in East Asia and the
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Series
Pacific region, and 30% in sub-Saharan Africa.10 For some
countries, only limited information on mortality is
available from sources such as the Demographic and
Health Surveys and from cause-specific mortality
estimates for causes such as HIV/AIDS, malaria,
tuberculosis, and vaccine-preventable diseases. The GBD
approach included results for these regions, albeit with
wider uncertainty ranges, on the basis of the best possible
assessment of the available evidence.11
The mortality and burden of disease projections are
less firm than the base year assessments, and provide
Middle income Low income
“business as usual” projections under specified
to a large extent by World Bank projections of future
growth in income per capita and do not specifically take
account of trends in major stroke risk factors apart from
tobacco smoking. If risk factor exposures increase in low-
income and middle-income countries, rather than decline
with economic development and with improving health
systems, then our projections of deaths and DALYs in
these countries will be underestimates.
Uncertainty in projections has been addressed not
Middle income Low income through an attempt to estimate confidence intervals, but
Country group through preparation of pessimistic and optimistic
projections under alternate sets of input assumptions.
Projected stroke mortality is not highly sensitive to a
reasonably broad range of assumptions about future
economic growth and trends in the tobacco epidemic.
Under pessimistic and optimistic projection scenarios,
projected stroke mortality in 2030 ranges from 7·7 million
to 8·4 million.9 Because the estimates of deaths averted
and life-years gained under the global-goal scenario are
calculated from the difference between two projection
scenarios, the uncertainty around these estimates is
lower than for the projections themselves.
Our calculations have assumed equal contributions to
the projected decline in mortality from improved incidence
(primary prevention), and from prolonging lives after the
acute event (secondary prevention resulting in improved
case fatality). These assumptions were based on the
findings from the WHO MONICA (Multinational
Monitoring of Determinants and Trends in Cardiovascular
Disease) project, which monitored the trends and
determinants of stroke in 17, mostly European, countries
during the 1980s and 1990s.12,13 Part of the explanation for
the reported declines in case fatality could be a shift to
stroke becoming more mild.14 Despite the scientific
progress made over the past few decades in imaging and
other technologies, only the use of aspirin and
management in stroke units is in widespread use.15 Early
aspirin treatment for ischaemic stroke reduces death or
dependency by 12 people per 1000 treated,16 and coordinated
care in stroke units by 56 per 1000 receiving such
treatment.17 In low-income and middle-income countries
where the bulk of strokes occur, health systems are already
stretched and stroke units, although the gold standard for
acute management, may not be feasible. Aspirin, which is
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For more information on the
feasibility of STEPS Stroke see
Articles page 134
186
readily available, is not routinely given in low-income and
middle-income countries.18 If new technologies and new
acute treatments are to have any effect on the stroke goal,
they will need to be widely diffused in low-income and
middle-income countries where most strokes occur. The
major contribution to the reduction in stroke deaths will
therefore likely come from primary prevention. Greater
efforts need to be placed on integrated and comprehensive
approaches within the context of improvements in the
major risk factors common to stroke, heart disease,
diabetes, and other chronic diseases.19
Primary and secondary prevention of stroke in more
developed countries has reduced stroke mortality but has
increased the number of people who require rehabilitation
and admittance to long-term care facilities. If the
prevalence and severity of disability among stroke
survivors remains nearly constant over the next
10–20 years, then disability due to stroke, and the demand
for rehabilitation and long-term care, will increase by
around 24% between now and 2030.
How realistic is it to propose a global goal of an
additional 2% reduction in stroke mortality rates per
annum over the next decade? Under the baseline
projections, stroke death rates for the 60–69 year and
70–79 year age groups are projected to decline by an
annual average of 3% and 2% respectively for high-
income countries, and by 2% and 1% respectively for
low-income and middle-income countries. So the global
goal is an annual average decline of 4% in the stroke
mortality rate for the 60–69 year age-group, and 3% for
the 70–79 year age group. Over the 10 years from 2005 to
2015, this would represent overall declines of 18% and
11% respectively.
The experience of high-income countries clearly shows
what can be achieved with sustained interventions.
Stroke death rates for the 60–69 year age group in the
1990s declined by an annual average greater than 4% in
several high-income countries including Australia,
Germany, Israel, Italy, the Republic of Korea, and Spain.
For the 70–79 year age group, average annual declines in
stroke death rates exceeded 3% for several countries,
including Austria, France, Germany, Israel, Italy,
Portugal, the Republic of Korea, and Spain. Stroke death
rates for people age 65–84 years in Australia have declined
by 70% from 1970 to 2000, representing an annual
average decline of over 4%.20
Estimates of the joint effects of the leading stroke risk
factors (tobacco use, raised blood pressure, and poor diet)
indicate that over 60% of stroke mortality in low-income
and middle-income countries, as well as high-income
countries, is attributable to a few modifiable risks.21 In
particular, high blood pressure causes an estimated 54%
of stroke mortality in low-income and middle-income
countries, followed by high serum cholesterol (15%) and
tobacco smoking (12%).
Interventions to reduce the effects of the major risk
factors on population-level disease burden and mortality
reduce the risk of heart disease and stroke.14,22 These
include government actions to reduce tobacco use,23,24
efforts to lower intake of salt and saturated and trans
fats25,26—in both manufactured and home-cooked foods—
and increasing the appeal of fruit and vegetable intake27
and physical activity.28 These actions, although widely
acknowledged in both medical journals and the popular
press, are not widely used by national governments in all
parts of the world, perhaps as a result of two common
public-health myths: that cardiovascular diseases,
including stroke, are diseases of affluence, and that stroke
is a disease of people over age 70 years who will die soon
anyway. Nothing could be farther from the truth. As we
show here, stroke is a leading cause of death and disability
in low-income and middle-income countries and
worldwide in people under age 70 years. This
misunderstanding, in turn, has economic and social
consequences for individuals, their families and the
societies in which they live.
Monitoring of the effects of interventions at the
population level is challenging but possible, even in
developing countries.29 In an effort to assist low-income
and middle-income countries to get started in establishing
surveillance of stroke, WHO recommends a stepwise
approach through the use of standardised tools and
methods for ongoing stroke data collections.30–32 STEPS
stroke sequentially captures information about stroke by
identifying the three different groups of patients who
form the basis of a population’s stroke burden: stroke
patients admitted to health facilities (step 1), fatal stroke
events in the same community (step 2), and non-fatal
stroke events in the same community (step 3). Our
purpose in establishing a worldwide stroke goal, and
revealing the effect that a small reduction in mortality
could achieve, is to help focus prevention and control
efforts in the international public-health community and
among clinicians and to encourage efforts towards
improvements in data collection. Achieving the global
stroke goal would result in millions of lives being saved
around the world.
Contributors
KS, CM, and RB wrote the report. CM developed a framework and
methods for analysis.
Conflicts of interest
We have no conflicts of interest.
Acknowledgments
We wish to acknowledge the many WHO staff and external collaborators
who have contributed to the global burden of disease revisions for years
2000 and later. The authors alone are responsible for the views expressed
in this publication, which do not necessarily reflect the decisions or the
stated policy of WHO or of its member states.
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