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Stroke burden in Egypt: data from five epidemiological studies

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ISSN: 0020-7454 (Print) 1543-5245 (Online) Journal homepage: http://www.tandfonline.com/loi/ines20

Stroke burden in Egypt: data from five

epidemiological studies

Foad Abd-Allah, Eman Khedr, Mohammed I Oraby, Ahmed Safwat Bedair,

Shady Samy Georgy & Ramez Reda Moustafa

To cite this article: Foad Abd-Allah, Eman Khedr, Mohammed I Oraby, Ahmed Safwat
Bedair, Shady Samy Georgy & Ramez Reda Moustafa (2018): Stroke burden in Egypt:
data from five epidemiological studies, International Journal of Neuroscience, DOI:
10.1080/00207454.2017.1420068

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 INTERNATIONAL JOURNAL OF NEUROSCIENCE, 2018
https://doi.org/10.1080/00207454.2017.1420068

ORIGINAL ARTICLE

Stroke burden in Egypt: data from five epidemiological studies

Foad Abd-Allaha, Eman Khedrb, Mohammed I Orabyc, Ahmed Safwat Bedaird, Shady Samy Georgyd and
Ramez Reda Moustafad
a
Department of Neurology, Cairo University, Cairo, Egypt; bDepartment of Neurology, Assiut University, Assiut, Egypt; cDepartment of
Neurology, Beni-Suef University, Beni Suef, Egypt; dDepartment of Neurology, Ain Shams University, Cairo, Egypt

ABSTRACT ARTICLE HISTORY

Purpose: Accurate data on the epidemiology of stroke in Egypt is scarce. The aim of this review is to Received 21 August 2017
address this issue based on available community-based studies and compare the resulting findings Revised 14 November 2017
to those of other regional and international studies. Accepted 12 December 2017
Method: A systematic literature search was conducted to identify population-based KEYWORDS
epidemiological studies of stroke in Egyptians. Original articles published in English between 1990 Stroke; epidemiology; Egypt;
and 2016 were included. Five studies from five different governorates in southern Egypt fulfilled incidence; prevalence
the study criteria (Qena, Sohag, Assiut, New Valley and Red Sea).
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Results: The mean and median crude prevalence rates (CPRs) across the five studies, which were
conducted in southern Egypt were 721.6/100,000 and 655/100,000, respectively. The mean and
median crude incidence rates (CIRs) were 187/100,000 and 180.5/100,000, respectively. The
average CPR weighted by sample population size was 613/100,000 and the average CIR weighted
by sample population size was 202/100,000.
Conclusion: The incidence and prevalence of stroke in Egypt are high. More population-based
studies are urgently needed in northern Egypt and in Cairo – the capital of Egypt.

Introduction Methods
The epidemiology of stroke is changing rapidly and the Search strategy
global stroke burden continues to increase worldwide [1].
We performed an initial MEDLINE search using the Medi-
Stroke is a major health problem in the Egyptian pop-
cal Subject Heading (MeSH) terms ‘stroke, Egypt, popula-
ulation; furthermore, although Egypt is the most popu-
tion-based, risk factors, stroke epidemiology’ to retrieve
lous nation in the Middle East, there is no active
all potentially relevant publications (Figure 1). English-
nationwide registry for stroke and accurate data on
language publications from 1 January 1990 to 1 January
stroke epidemiology are scarce [2]. However, research
2016, were included. After the initial MEDLINE search
on this topic is essential for planning appropriate man-
was validated, the search was expanded to other primary
agement programmes, effectively applying primary
databases to retrieve abstracts that had not been identi-
prevention strategies and improving health resources
fied using MEDLINE. In addition, papers were identified
in Egypt.
via a manual search using references cited in original
Egyptian governorates, the top tier of the country’s
papers and reviews. With respect to inclusion criteria,
five-tiered jurisdictional hierarchy, are either fully urban
studies were included if theyaddressed stroke and tran-
or urban/rural and have a population density ranging
sient ischemic attacks (TIAs) that were identified using
from less than 2 per km2 to more than 1000 per km2. A
standard World Health Organization (WHO) definitions
number of community-based studies, particularly investi-
[3]; were prospective community- or population-based
gations conducted in governorates in Upper (southern)
studies; assessed a clearly defined population in Egypt;
Egypt between 1992 and 2013, have reported the inci-
were not limited to a subset of the study population;
dence and prevalence of stroke in Egyptian regions. The
had available age- and gender-specific data; and
aim of this systematic review is to address the epidemiol-
reported original data. Five studies fulfilled the study cri-
ogy of stroke in Egypt based on these studies and to
teria. These studies reported the incidence and preva-
compare the resulting findings to those of other regional
lence of stroke in five different governorates in southern
and international studies.

CONTACT Foad Abd-Allah foad.abdallah@kasralainy.edu.eg

© 2018 Informa UK Limited, trading as Taylor & Francis Group
 2 F. ABD-ALLAH ET AL.
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Figure 1. Flow chart of the search methodology and review process.
Egypt (Qena, Sohag, Assiut, New Valley and Red Sea).
Qena, Sohag and Assiut are river Nile Valley governo-
rates, while New Valley and Red Sea are desert area
governorates.
Data extraction and analysis
The identified articles were reviewed and data were ana-
lysed in a descriptive manner. The data extracted from
the included papers were annual stroke incidence, stroke
prevalence, patient sex, patient age, demographic data
and stroke subtypes. Meta-analysis was not attempted
due to significant variability in both data sources and
study methodologies. Simple averages and averages
weighted by sample population size (for example,
(N1P1 + N2P2)/(N1 + N2), where N represents a sample
population size, and P is the corresponding prevalence
in that population) were calculated for incidence and
prevalence rates.
Results
Five population-based studies [4–8] satisfied our search
criteria (Table 1). In all of these studies, stroke and TIAs
were identified using WHO criteria [3]. A total sample
population of 134,815 was examined via door-to-door
surveys conducted in five different governorates (Figure 2)
in Upper (southern) Egypt (Qena, Sohag, Assiut, New Val-
ley and Red Sea). There were almost equal numbers of
males and females, and the examined populations were
 INTERNATIONAL JOURNAL OF NEUROSCIENCE 3

Table 1. Characteristics of the studies included in the review.

Sample
Reference/year Location Dates Study design size Males/females Urban/rural
Khedr et al., Qena governorate September 2011 to Community-based, three-phase, door-to- 8027 4172 (52%)/ 4427 (55.2%)/
2014 [5] August 2013 door 3855 (48%) 3600 (44.8%)
Farghaly et al., Al-Kharga, New Valley June 2005 to May Community-based, three-phase, door-to- 62,583 32,165 (51.4%)/ 44,600 (71.3%)/
2013 [4] governorate 2009 door of all inhabitants of the district 30,418 (48.6%) 17,983 (28.7%)
El Tallawy et al., El Quseir city, Red Sea July 2009 to January Door-to-door survey of every household 33,285 16,428 (49.5%)/ –
2013 [8] governorate 2012 in the district 6857 (50.6%)
Khedr et al., Assiut governorate January 2010 to Cross-sectional community-based study, 5920 3066 (51.8%)/ 3660 (61.8%)/
2013 [6] December 2010 three-phase door-to-door survey 2854 (48.2%) 2260 (38.2%)
Kandil et al., Sohag governorate January 1992 to Door-to-door survey 25,000 – 8464 (33.9%)
2006 [7] April 1993 Urban
5305 (21.2%)
Suburban
11,231 (44.9%)
Rural

from a mixture of urban and rural communities. Certain
data from two of the included studies were reported sep-
arately in a later publication [9].
The crude incidence rate (CIR) of stroke ranged from
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(New Valley). The crude prevalence rate (CPR) of stroke
ranged from 508/100,000 in Sohag to 963/100,000 in
Assiut. The prevalence of stroke was generally higher
among men than among women, with a male-to-female

137/100,000 in Qena to 250/100,000 in Al-Wadi Al-Gadid ratio ranging from 1.1 in Sohag to 1.8 in Red Sea. In

Figure 2. Map of Egypt showing the locations of the five studies included in this review (respective governorates are highlighted).
 4 F. ABD-ALLAH ET AL.

Table 2. Crude Prevalence Rate (CPR) and Crude Incidence Rate (CIR) of stroke in the five population-based studies included in this
review.
CIR of CPR of Sex-specific
Reference/year/ Stroke CIR IS/HS/TIA Stroke CPR IS/HS/TIA CPR per 105 Residence-specific Literacy-specific Age-specific CPR
governorate per 105 per 105 per 105 per 105 (M/F) CPR per 105 (R/U) CPR per 105 (IL/L) per 105 (years)
Khedr et al., 2014 137 – 922 797/125/62 1103/729 1111/768 3567/704 1315 among >20
Qena years
43 among 20–29
years
231 among 30–39
years
1115 among 40–
49 years
2464 among 50–
59 years
6204 among 60–
69 years
8392 among >70
years
Farghaly et al., 250 190/55/5 560 480/83/6 610/501 520/580 – 26 among <20
2013 years
New Valley 90 among 20–40
years
990 among 40–60
years
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5380 among >60

years
El Tallawy et al., 181 170/5/5 655 585/60/15 860/480 – – 26 among 20–40
2013 years
Red Sea 806 among 40–60
years
3702 among >60
years
Khedr et al., 2013 – – 963 895/63/– 1174/736 902/1062 357/2413 250 among 30–39
Assiut years
709 among 40–49
years
2364 among 50–
59 years
5882 among 60–
69 years
4867 among >70
years
Kandil et al., 2006 180 100/43/ 508 310/110/36 520/490 410/540/590 – 16 among <20
Sohag 25 suburban years
260 among 20–40
years
1390 among 40–
60 years
3080 among >60
years
Note: IS = Ischemic stroke, HS = Hemorrhagic stroke, TIA = Transient Ischemic Attack, M = Male, F = Female, IL = Illiterate, L = Literate.

addition, higher prevalences of stroke were observed for
urban populations, literate communities and older popu-
lations (Table 2).
Two of the included studies reported age-adjusted
prevalences of stroke in addition to crude prevalences. In
the Qena study [5], the local age-adjusted (Qena 2006 cen-
sus) prevalence rate was 777/100,000, and the prevalence
rates after adjusting for age with respect to the Egyptian
and world populations were 567/100,000 and 1222/
100,000, respectively. In the Assiut study [6], the local age-
adjusted prevalence rate was 699/100,000, and the preva-
lence rate after adjusting for age with respect to the world
population was 981/100,000. The mean and median CPRs
across the five studies were 721.6/100,000 and 655/
100,000, respectively. The mean and median CIRs were
187/100,000 and 180.5/100,000, respectively. When
weighting for sample population size, the average CPR
and CIR were 613/100,000 and 202/100,000, respectively.
In all of the included studies, incidence and preva-
lence were much higher for ischemic stroke than for
hemorrhagic stroke or TIAs. Ischemic stroke accounted
for 81%–93% of all strokes, whereas hemorrhagic stroke
accounted for 7%–13% of all strokes in all studies, except
for the Sohag study [7], which reported an unusually
high prevalence of hemorrhagic stroke (24%).
Vascular risk factors associated with stroke were
reported in four studies (Table 3). Hypertension
(62%–66%), hyperlipidemia (53%) and diabetes mellitus

Table 3. Vascular risk factors in stroke patients in two studies of our population-based studies.
Reference Hypertension DM
Khedr et al., 2014 62.2% 36.5%
Khedr et al., 2013 66% 38.6%
El Tallawy et al., 2015 64% 34.4%
Note: DM = Diabetes Mellitus, TIA = Transient Ischemic Attack, IHD = Ischemic Heart Disease, RHD = Rheumatic Heart Disease, SLE = Systemic Lupus
Erythematosus.

Reporting on combined data from the Red Sea and New Valley studies.

Reported as 8.6% for all ‘heart diseases.’
(34%–38%) were the most prevalent stroke risk factors
identified in those studies.
Discussion
This study systematically reviewed the prevalence and
incidence rates of stroke in Egypt, a developing country
with a troubled economic situation. This review, which
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included five population-based studies, showed rather
high CIRs and CPRs in five governorates that mainly
cover southern Egypt. To date, these investigations are
the only Egyptian studies that have examined stroke epi-
demiology using a population-based perspective rather
than a hospital-based approach. Although the results of
this study cannot be epidemiologically generalized to
the Egyptian population as a whole, they shed light on
important findings.
The highest CPR per 100,000 for stroke was recorded
in Assiut (963), followed closely by Qena (922) and then
by El Quseir (655) and New Valley (560). The lowest CPR
per 100,000 was recorded in Sohag (508).The high preva-
lence rates observed in Assiut and Qena may be attrib-
uted to more stressful lifestyles in these growing
industrial governorates, while in the other governorates
the lifestyles are simple and less stressful.
In Sohag and Assiut, the CPR per 100,000 for stroke
was higher for urban residents than for rural residents,
whereas the opposite relationship was observed in the
Qena study. The rise in incidence of stroke in urban
regions can be attributed to increased prevalences of
modifiable risk factors such as hypertension, diabetes
mellitus and smoking as well as a lack of prevention
strategies in these regions. In contrast, there may be
reduced incidence rates of stroke in rural regions where
subjects have not yet been exposed to conventional risk
factors [10].
The studies conducted in El Quseir and New Valley by
El Tallawy et al. [8] and Farghaly et al. [4], respectively,
produced representative results for these regions given
that the entire governorate population was included in
these studies. With respect to weather and environmen-
tal conditions, these two governorates differ from the
governorates where the other three studies were
INTERNATIONAL JOURNAL OF NEUROSCIENCE 5
TIA IHD RHD Family history Others
6.8% 9.5% 5.4% 10.8% 1.4%
SLE
8.8% 12.3% – – –
–  
5% 53.2% hyperlipidemia
performed and from most of Egypt; in particular, due to
the harsh desert conditions in these two governorates,
inhabitants have greater exposure to extreme hot
weather in the summer and extreme cold in the winter.
A separate review by El Tallawy et al. details the results
of the two aforementioned studies [9].
Although definite, evidence-based, temporal trends
of stroke prevalence and/or incidence over time cannot
be drawn from the data from the five included studies,
the later studies appear to report lower incidences and
generally higher prevalences than the earlier studies
(Figure 3). This finding may mirror official stroke mortal-
ity statistics, which indicates that deaths attributable to
stroke have been rising steadily over the past decade [2].
As noted in many studies, the prevalence and inci-
dence of stroke vary widely across countries. Part of this
variance is explained by geography, population age and
urbanization; however, a significant portion of this vari-
ance remains unexplained. There is emerging evidence
that compared with high-income countries, low-income
countries have a greater stroke burden with respect to
incidence of stroke, proportion of strokes involving intra-
cerebral hemorrhage, case mortality and age at stroke
onset [11]. The incidences and prevalences reported in
the present study place Egypt in the high incidence/
prevalence strata relative to other countries (see [12] for
a comprehensive review).
Egypt is a Middle Eastern, Arabian and African coun-
try. With respect to comparisons of Egypt with other
Middle Eastern countries, in their systematic review of all
stroke-related articles published in the Middle East
between 1980 and May 2015, which included 64 papers,
El-Hajj et al. found that among these countries, Egypt
and Iran had the highest and lowest incidences of stroke,
respectively [1].
In their systematic review of 31 articles published
from 1983 to 2008 from 10 Arabian countries that did
not include Egypt, Benamer and Grosset found that the
annual incidences of stroke in these countries ranged
from 27.5 to 63 per 100,000, with prevalences of stroke
between 42 and 68 per 100,000; these values were far
lower than the corresponding incidence and prevalence
of stroke in Egypt [13].
 6 F. ABD-ALLAH ET AL.
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Figure 3. Crude incidence and prevalence of stroke in the five studies. A trend of rising prevalence and declining incidence can be seen.

In addition, in other African countries, prevalence Conclusion

rates ranged from 114 per 100,000 in Nigeria [14] to 870
The incidence and prevalence of stroke are high in Egypt.
per 100,000 in Benin after age adjustments for WHO
This review can be considered a ‘kick-off’ investigation
population data for sub-Saharan Africa [15]. Again, these
that sets up larger epidemiological studies. There is a
indices are lower than the corresponding indices for
need for additional community-based studies from other
Egypt.
parts of Egypt, particularly Cairo, Alexandria and the
The alarming increase in the incidence of stroke in
northern (delta) governorates, to provide more accurate
Egypt emphasizes the need for the establishment of
representations of stroke epidemiology across the Egyp-
effective action plans by the government and the partici-
tian population. There is also an urgent need to establish
pation of community societies to minimize this burgeon-
a national registry to prospectively collect accurate epide-
ing epidemic.
miological data on strokes in Egypt and to identify trends
Research is needed to clarify whether limited resour-
in stroke incidence and prevalence over time.
ces, low public awareness and underutilization of health-
care services alone account for unsatisfactory rates of
risk factor control in Egypt or whether Egypt-specific Acknowledgments
genetic and ethnic differences also contribute to these
We acknowledge all the authors of the 5 studies mentioned in
high stroke indices [2].
our review for their extreme support and cooperation.
The main limitation of this review is that the available
data were only from southern Egypt. Therefore, the find-
ings may not be representative for the entire Egyptian Disclosure statement
population due to socioeconomic and demographic dif- The authors have no conflicts of interest to disclose and this
ferences among Egyptian regions. work was not supported or funded by any organization.

References
[1] El-Hajj M, Salameh P, Rachidi S, et al. The epidemiology of
stroke in the Middle East. Euro Stroke J. 2016;1(3):180–198.
[2] Abd-Allah F, Moustafa RR. Burden of stroke in Egypt: Current
status and opportunities. Int J Stroke. 2014;9(8):1105–1108.
[3] Aho K, Harmsen P, Hatano S, et al. Cerebrovascular disease
in the community: results of a WHO collaborative study.
Bull World Health Organ. 1980;58(1):113–130.
[4] Farghaly WM, El-Tallawy HN, Shehata GA, et al. Epidemiol-
ogy of nonfatal stroke and transient ischemic attack in Al-
Kharga district, New Valley, Egypt. Neuropsychiatr Dis
Treat. 2013;9:1785–1790.
[5] Khedr EM, Fawi G, Abdela M, et al. Prevalence of ischemic
and hemorrhagic strokes in Qena governorate, Egypt:
Community-based study. J Stroke Cerebrovasc Dis.
2014;23:1843–1848.
[6] Khedr EM, Elfetoh NA, Al Attar G, et al. Epidemiological
study and risk factors of stroke in Assiut governorate,
Egypt: Community-based study. Neuroepidemiology.
2013;40:288–294.
[7] Kandil MR, Farawez HM, Khalifa G, et al. Epidemiology
Downloaded by [196.154.7.178] at 12:27 07 January 2018
of cerebrovascular stroke and TIA in Upper Egypt
(Sohag) – relative frequency of stroke in Assiut Univer-
sity Hospital. Egypt J Neurol Psychiatr Neurosurg.
2006;43:593–602.
View publication stats
INTERNATIONAL JOURNAL OF NEUROSCIENCE 7
[8] El-Tallawy HN, Farghaly WM, Shehata GA, et al. Epidemiol-
ogy of non-fatal cerebrovascular stroke and transient
ischemic attacks in El Quseir, Egypt. Clin Interv Aging.
2013;8:1547–1551.
[9] El Tallawy HN, Farghaly WM, Badry R, et al. Epidemiology
and clinical presentation of stroke in Upper Egypt (desert
area). Neuropsychiatr Dis Treat. 2015;11:2177–2183.
[10] O’Donnell M, Xavier D, Liu L, et al. Risk factors for ischae-
mic and intracerebral haemorrhagic stroke in 22 countries
(the INTERSTROKE study): a case-control study. Lancet.
2010;376:112–123.
[11] Sposato LA, Saposnik G. Gross domestic product and
health expenditure associated with incidence, 30-day
fatality, and age at stroke onset: a systematic review.
Stroke. 2012;43:170–177.
[12] Thrift AG, Cadilhac DA, Thayabaranathan T, et al. Global
stroke statistics. Int J Stroke. 2014;9(1):6–18.
[13] Benamer HT, Grosset D. Stroke in Arab countries: A sys-
tematic literature review. J Neurol Sci. 2009;284(1):18–23.
[14] Danesi M, Okubadejo N, Ojini F. Prevalence of stroke in an
urban, mixed-income community in Lagos, Nigeria. Neu-
roepidemiology. 2007;28:216–223.
[15] Cossi MJ, Gobron C, Preux P, et al. Stroke: prevalence and
disability in Cotonou, Benin. Cerebrovasc Dis. 2012;33
(2):166–172.