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CARDIOVASCULAR JOURNAL OF AFRICA • Volume 29, No 2, March/April 2018
AFRICA
69
resulting in increased risk factors and burden of cerebrovascular
disease (hereafter referred to as stroke). According to the World
Health Organisation (WHO), low- and middle-income countries
bear the heaviest (86%) global stroke burden,
1
with 8% of all
first-ever strokes occurring in Africa and 5% of the 30 million
stroke survivors worldwide living in Africa.
2
There are limited clinico-epidemiological data on stroke
from sub-Saharan Africa to effectively inform policy and guide
intervention efforts. Cardiovascular disease (CVD) is the second
leading cause of morbidity and mortality in Kenya. The Kenya
Health Sector Strategic Plan (KHSSP) estimates mortality rate
due to CVD at 6.1%, while the WHO estimates it at 8%. Autopsy
studies suggest that more than 13% of cause-specific deaths
among adults could be due to CVD.
2-4
Implementationof surveillance systems is necessary tomonitor
trends and inform prevention and management programmes.
5,6
Although the WHO recommends establishment of an in-country
system of surveillance and monitoring of non-communicable
diseases, these systems have not been well executed in Africa,
largely owing to resource constraints. This study sought to
establish the nature of stroke cases (types) seen in Kenya’s two
leading referral hospitals, Kenyatta National Hospital (KNH)
and Moi Teaching and Referral Hospital (MTRH). It also
sought to establish the prevalence of known cerebrovascular
risk factors for the stroke subtypes, and ascertain the proportion
of first-ever-in-a-lifetime stroke patients and recurrent cases
in an effort to provide baseline data for the development of a
stroke registry in Kenya. This article highlights the key findings
and opportunities for advancing neuroscience in Kenya and
sub-Saharan Africa.
Methods
The study was carried out at KNH located in Nairobi, the capital
city of Kenya, and MTRH located in Eldoret, western Kenya.
KNH is the leading public tertiary hospital in Kenya with a
bed capacity of 1 800, whose occupancy can go up by 300%.
The hospital is frequented by patients from all over Kenya, but
mostly from the urban areas (Nairobi and its surroundings).
MTRH is the second largest public tertiary hospital with an
850-bed capacity that serves patients mainly from the western
and Rift Valley regions in Kenya, which are predominantly rural.
Permission to conduct this study was obtained from the
Kenya Medical Research Institute (KEMRI) Scientific and
Ethics Review Unit (SSC No. 2851), the MTRH institutional
research and ethics committee (IREC/2014/213 approval number
0001279) and the Kenyatta National Hospital/University of
Nairobi ethics review committee (study registration number
MED/029/2015). Informed consent was obtained from each
subject or guardian prior to participation in the study. Additional
protection for vulnerable populations was put in place to ensure
protection of patients’ rights and welfare.
This was a prospective cohort study in which patients
were recruited upon admission, and general information on
demographics, stroke events and case management was collected
using the WHO Stroke STEPS instrument.
7
Follow up involved
assessing clinical outcome at day 10 and 28, and month 3, 6 and
9 using the Modified Rankin Scale,
8
and gathering information
on patient management after discharge.
The study population included all stroke patients diagnosed
and/or attended to in KNH and MTRH for the 12-month
period between February 2015 and January 2016. The inclusion
criteria were confirmed cases of stroke [based on computerised
tomography (CT) scan and/or magnetic resonance imaging]
treated in out-patient clinics or admitted in hospitals, and
in-hospital patients who suffered stroke while on treatment for
other illnesses.
The sample size required for the study was based on an
unknown proportion of most prevalent stroke type (therefore
50% assumed), a desired precision for the indicator of 5%,
and 95% confidence level. Fisher’s formula
9
for estimating the
minimum sample size for descriptive studies was used, giving a
minimum sample of 385. The current sample size comprised all
recruited stroke patients from the two hospitals in the one-year
period.
The combination approach using hot (i.e. active, on-going
recruitment) and cold (i.e. retrospective record review) case-
finding methods was used to ensure complete identification
of stroke cases. Patients were identified from the hospital
registry, out-patient clinics, in-patient wards, emergency room
and intensive care units. Referrals to specialist physicians or
neurologists, physiotherapists, speech or occupational therapists
were alsomonitored to avoidmissing any cases. Discharge records
and death certificates were scrutinised for stroke diagnosis. Care
was taken to avoid duplicate reporting of cases by counter-
checking with the hospital electronic database.
The study utilised a modified WHO STEP-wise approach
to stroke surveillance tool designed to collect in a standardised
manner, basic epidemiological data on incidence, major risk
factors, morbidity and mortality trends, and intervention
strategies in recent (acute) stroke.
10
The tool was administered
through face-to-face interviews with patients and/or the contact
person(s). Follow-up interviews were done where possible
physically and/or by telephone.
Data were collected on all aspects of stroke, including
information on patient demographic details (gender, age and
residence), date of stroke diagnosis, stroke subtype (ischaemic
or haemorrhagic), single or multiple strokes, and history of
cigarette smoking prior to the current stroke. Information related
to care, such as whether or not a CT scan was done was also
collected. Regular follow up visits were done every three months
to ascertain the patient status after discharge.
Statistical analysis
Data were analysed using SPSS version 20, with
p
<
0.05
considered statistically significant. Results are expressed as
means
±
SD or as proportions (%). For categorical variables, the
chi-squared test and Fisher’s exact probability were used. Linear
associations were calculated using the Spearman correlation
coefficient.
Results
A total of 691 patients with confirmed stroke [KNH 406 (males:
40.9%; females: 59.1%); MTRH 285 (males: 44.6%; females:
55.4%)] were recruited; 293 (42.4%) were males and 398 (57.6%)
were females, giving a male:female ratio of 1:1.4. The median
age was 60 years [interquartile range (IQR): 45–73 years], with a
minimum of 18 and maximum of 115 years.