An Estimate of the Incidence and Prevalence of Stroke in Africa: A Systematic Review and Meta-Analysis
Identifieur interne : 000218 ( Pmc/Corpus ); précédent : 000217; suivant : 000219An Estimate of the Incidence and Prevalence of Stroke in Africa: A Systematic Review and Meta-Analysis
Auteurs : Davies AdeloyeSource :
- PLoS ONE [ 1932-6203 ] ; 2014.
Abstract
Stroke is increasingly becoming a challenging public health issue in Africa, and the non-availability of data has limited research output and consequently the response to this burden. This study aimed to estimate the incidence and prevalence of stroke in Africa in 2009 towards improved policy response and management of the disease in the region.
A systematic search of Medline, EMBASE and Global Health for original population-based or hospital-based studies on stroke was conducted. A random effect meta-analysis was conducted on crude stroke incidence and prevalence rates, and a meta-regression-like epidemiological model was applied on all data points. The fitted curve generated from the model was used to estimate incident cases of stroke and number of stroke survivors in Africa at midpoints of the United Nation population 5-year age groups for the year 2009.
The literature search yielded a total of 1227 studies. 19 studies from 10 African countries were selected. 483 thousand new stroke cases among people aged 15 years or more were estimated in Africa in 2009, equivalent to 81.2 (13.2–94.9)/100,000 person years. A total of 1.89 million stroke survivors among people aged 15 years or more were estimated in Africa in 2009, with a prevalence of 317.3 (314.0–748.2)/100000 population. Comparable figures for the year 2013 based on the same rates would amount to 535 thousand (87.0–625.3) new stroke cases and 2.09 million (2.06–4.93) stroke survivors, suggesting an increase of 10.8% and 9.6% of incident stroke cases and stroke survivors respectively, attributable to population growth and ageing between 2009 and 2013.
The findings of this review suggest the burden of stroke in Africa is high and still increasing. There is need for more research on stroke and other vascular risk factors towards instituting appropriate policy, and effective preventive and management measures.
Url:
DOI: 10.1371/journal.pone.0100724
PubMed: 24967899
PubMed Central: 4072632
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PMC:4072632Le document en format XML
<record><TEI><teiHeader><fileDesc><titleStmt><title xml:lang="en">An Estimate of the Incidence and Prevalence of Stroke in Africa: A Systematic Review and Meta-Analysis</title><author><name sortKey="Adeloye, Davies" sort="Adeloye, Davies" uniqKey="Adeloye D" first="Davies" last="Adeloye">Davies Adeloye</name><affiliation><nlm:aff id="aff1"></nlm:aff></affiliation></author></titleStmt><publicationStmt><idno type="wicri:source">PMC</idno><idno type="pmid">24967899</idno><idno type="pmc">4072632</idno><idno type="url">http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4072632</idno><idno type="RBID">PMC:4072632</idno><idno type="doi">10.1371/journal.pone.0100724</idno><date when="2014">2014</date><idno type="wicri:Area/Pmc/Corpus">000218</idno><idno type="wicri:explorRef" wicri:stream="Pmc" wicri:step="Corpus" wicri:corpus="PMC">000218</idno></publicationStmt><sourceDesc><biblStruct><analytic><title xml:lang="en" level="a" type="main">An Estimate of the Incidence and Prevalence of Stroke in Africa: A Systematic Review and Meta-Analysis</title><author><name sortKey="Adeloye, Davies" sort="Adeloye, Davies" uniqKey="Adeloye D" first="Davies" last="Adeloye">Davies Adeloye</name><affiliation><nlm:aff id="aff1"></nlm:aff></affiliation></author></analytic><series><title level="j">PLoS ONE</title><idno type="eISSN">1932-6203</idno><imprint><date when="2014">2014</date></imprint></series></biblStruct></sourceDesc></fileDesc><profileDesc><textClass></textClass></profileDesc></teiHeader><front><div type="abstract" xml:lang="en"><sec><title>Background</title><p>Stroke is increasingly becoming a challenging public health issue in Africa, and the non-availability of data has limited research output and consequently the response to this burden. This study aimed to estimate the incidence and prevalence of stroke in Africa in 2009 towards improved policy response and management of the disease in the region.</p></sec><sec><title>Methods</title><p>A systematic search of Medline, EMBASE and Global Health for original population-based or hospital-based studies on stroke was conducted. A random effect meta-analysis was conducted on crude stroke incidence and prevalence rates, and a meta-regression-like epidemiological model was applied on all data points. The fitted curve generated from the model was used to estimate incident cases of stroke and number of stroke survivors in Africa at midpoints of the United Nation population 5-year age groups for the year 2009.</p></sec><sec><title>Results</title><p>The literature search yielded a total of 1227 studies. 19 studies from 10 African countries were selected. 483 thousand new stroke cases among people aged 15 years or more were estimated in Africa in 2009, equivalent to 81.2 (13.2–94.9)/100,000 person years. A total of 1.89 million stroke survivors among people aged 15 years or more were estimated in Africa in 2009, with a prevalence of 317.3 (314.0–748.2)/100000 population. Comparable figures for the year 2013 based on the same rates would amount to 535 thousand (87.0–625.3) new stroke cases and 2.09 million (2.06–4.93) stroke survivors, suggesting an increase of 10.8% and 9.6% of incident stroke cases and stroke survivors respectively, attributable to population growth and ageing between 2009 and 2013.</p></sec><sec><title>Conclusion</title><p>The findings of this review suggest the burden of stroke in Africa is high and still increasing. There is need for more research on stroke and other vascular risk factors towards instituting appropriate policy, and effective preventive and management measures.</p></sec></div></front><back><div1 type="bibliography"><listBibl><biblStruct><analytic><author><name sortKey="Feigin, Vl" uniqKey="Feigin V">VL Feigin</name></author><author><name sortKey="Forouzanfar, Mh" uniqKey="Forouzanfar M">MH Forouzanfar</name></author><author><name sortKey="Krishnamurthi, R" uniqKey="Krishnamurthi R">R Krishnamurthi</name></author><author><name sortKey="Mensah, Ga" uniqKey="Mensah G">GA Mensah</name></author><author><name sortKey="Connor, M" uniqKey="Connor M">M Connor</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Chin, Jh" uniqKey="Chin J">JH Chin</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Beaglehole, R" uniqKey="Beaglehole R">R Beaglehole</name></author><author><name sortKey="Bonita, R" uniqKey="Bonita R">R 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<front><journal-meta><journal-id journal-id-type="nlm-ta">PLoS One</journal-id><journal-id journal-id-type="iso-abbrev">PLoS ONE</journal-id><journal-id journal-id-type="publisher-id">plos</journal-id><journal-id journal-id-type="pmc">plosone</journal-id><journal-title-group><journal-title>PLoS ONE</journal-title></journal-title-group><issn pub-type="epub">1932-6203</issn><publisher><publisher-name>Public Library of Science</publisher-name><publisher-loc>San Francisco, USA</publisher-loc></publisher></journal-meta><article-meta><article-id pub-id-type="pmid">24967899</article-id><article-id pub-id-type="pmc">4072632</article-id><article-id pub-id-type="publisher-id">PONE-D-14-10479</article-id><article-id pub-id-type="doi">10.1371/journal.pone.0100724</article-id><article-categories><subj-group subj-group-type="heading"><subject>Research Article</subject></subj-group><subj-group subj-group-type="Discipline-v2"><subject>Medicine and Health Sciences</subject><subj-group><subject>Epidemiology</subject><subj-group><subject>Cardiovascular Disease Epidemiology</subject></subj-group></subj-group><subj-group><subject>Vascular Medicine</subject><subj-group><subject>Stroke</subject></subj-group></subj-group></subj-group></article-categories><title-group><article-title>An Estimate of the Incidence and Prevalence of Stroke in Africa: A Systematic Review and Meta-Analysis</article-title><alt-title alt-title-type="running-head">Incidence and Prevalence of Stroke in Africa</alt-title></title-group><contrib-group><contrib contrib-type="author"><name><surname>Adeloye</surname><given-names>Davies</given-names></name><xref ref-type="aff" rid="aff1"></xref><xref ref-type="corresp" rid="cor1"><sup>*</sup></xref></contrib></contrib-group><aff id="aff1"><addr-line>Centre for Population Health Sciences, University of Edinburgh Medical School, Edinburgh, Midlothian, United Kingdom</addr-line></aff><contrib-group><contrib contrib-type="editor"><name><surname>Kiechl</surname><given-names>Stefan</given-names></name><role>Editor</role><xref ref-type="aff" rid="edit1"></xref></contrib></contrib-group><aff id="edit1"><addr-line>Innsbruck Medical University, Austria</addr-line></aff><author-notes><corresp id="cor1">* E-mail: <email>Davies.Adeloye@ed.ac.uk</email></corresp><fn fn-type="conflict"><p><bold>Competing Interests: </bold>The author has declared that no competing interests exist.</p></fn><fn fn-type="con"><p>Conceived and designed the experiments: DA. Performed the experiments: DA. Analyzed the data: DA. Contributed reagents/materials/analysis tools: DA. Wrote the paper: DA.</p></fn></author-notes><pub-date pub-type="collection"><year>2014</year></pub-date><pub-date pub-type="epub"><day>26</day><month>6</month><year>2014</year></pub-date><volume>9</volume><issue>6</issue><elocation-id>e100724</elocation-id><history><date date-type="received"><day>11</day><month>3</month><year>2014</year></date><date date-type="accepted"><day>27</day><month>5</month><year>2014</year></date></history><permissions><copyright-year>2014</copyright-year><copyright-holder>Davies Adeloye</copyright-holder><license><license-p>This is an open-access article distributed under the terms of the <ext-link ext-link-type="uri" xlink:href="http://creativecommons.org/licenses/by/4.0/">Creative Commons Attribution License</ext-link>, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.</license-p></license></permissions><abstract><sec><title>Background</title><p>Stroke is increasingly becoming a challenging public health issue in Africa, and the non-availability of data has limited research output and consequently the response to this burden. This study aimed to estimate the incidence and prevalence of stroke in Africa in 2009 towards improved policy response and management of the disease in the region.</p></sec><sec><title>Methods</title><p>A systematic search of Medline, EMBASE and Global Health for original population-based or hospital-based studies on stroke was conducted. A random effect meta-analysis was conducted on crude stroke incidence and prevalence rates, and a meta-regression-like epidemiological model was applied on all data points. The fitted curve generated from the model was used to estimate incident cases of stroke and number of stroke survivors in Africa at midpoints of the United Nation population 5-year age groups for the year 2009.</p></sec><sec><title>Results</title><p>The literature search yielded a total of 1227 studies. 19 studies from 10 African countries were selected. 483 thousand new stroke cases among people aged 15 years or more were estimated in Africa in 2009, equivalent to 81.2 (13.2–94.9)/100,000 person years. A total of 1.89 million stroke survivors among people aged 15 years or more were estimated in Africa in 2009, with a prevalence of 317.3 (314.0–748.2)/100000 population. Comparable figures for the year 2013 based on the same rates would amount to 535 thousand (87.0–625.3) new stroke cases and 2.09 million (2.06–4.93) stroke survivors, suggesting an increase of 10.8% and 9.6% of incident stroke cases and stroke survivors respectively, attributable to population growth and ageing between 2009 and 2013.</p></sec><sec><title>Conclusion</title><p>The findings of this review suggest the burden of stroke in Africa is high and still increasing. There is need for more research on stroke and other vascular risk factors towards instituting appropriate policy, and effective preventive and management measures.</p></sec></abstract><funding-group><funding-statement>The author has no support or funding to report.</funding-statement></funding-group><counts><page-count count="14"></page-count></counts><custom-meta-group><custom-meta id="data-availability"><meta-name>Data Availability</meta-name><meta-value>The author confirms that all data underlying the findings are fully available without restriction. Relevant data are included within the Supporting Information files.</meta-value></custom-meta></custom-meta-group></article-meta><notes><title>Data Availability</title><p>The author confirms that all data underlying the findings are fully available without restriction. Relevant data are included within the Supporting Information files.</p></notes></front><body><sec id="s1"><title>Introduction</title><p>The burden of stroke is increasing in many low- and middle-income countries (LMIC) <xref rid="pone.0100724-Feigin1" ref-type="bibr">[1]</xref>, and due to high fatality rates and overwhelming resource incurred by the health systems, stroke and many non-communicable diseases (NCDs) are now targeted public health priorities in these regions <xref rid="pone.0100724-Chin1" ref-type="bibr">[2]</xref>, <xref rid="pone.0100724-Beaglehole1" ref-type="bibr">[3]</xref>. Globally, about 16 million new cases of stroke and 62 million stroke survivors were estimated in 2005, with deaths from stroke accounting for 9.7% of all global deaths, and this is expected to increase to over 23 million new stroke cases and 7.8 million stroke deaths by 2030 in the absence of significant global public health response <xref rid="pone.0100724-Strong1" ref-type="bibr">[4]</xref>, <xref rid="pone.0100724-World1" ref-type="bibr">[5]</xref>.</p><p>It has been estimated that LMIC account for over 87% disability adjusted life years (DALYs) from stroke, which is about seven times the DALYs lost in high-income countries (HIC) <xref rid="pone.0100724-Johnston1" ref-type="bibr">[6]</xref>. Africa is particularly worst hit, owing to population growth, unchecked industrialization and increased consumption of western diets, leading to a rise in many modifiable vascular disease risk factors including smoking, harmful use of alcohol, physical inactivity and unhealthy diets, and invariably resulting in increased prevalence of hypertension, diabetes and obesity <xref rid="pone.0100724-Connor1" ref-type="bibr">[7]</xref>, <xref rid="pone.0100724-ODonnell1" ref-type="bibr">[8]</xref>. In 2000, two African countries, although recorded low stroke prevalences, had remarkably high stroke incidence rates <xref rid="pone.0100724-Truelsen1" ref-type="bibr">[9]</xref>. According to GBD 2002 estimates, three African countries (Angola, Liberia and Sierra Leone) recorded the highest stroke mortalities and DALYs worldwide <xref rid="pone.0100724-World1" ref-type="bibr">[5]</xref>, <xref rid="pone.0100724-World2" ref-type="bibr">[10]</xref>. Between 2002 and 2004, estimates further revealed an increasing prevalence with 8% of new stroke cases and 5% of stroke survivors occurring in Africa <xref rid="pone.0100724-World1" ref-type="bibr">[5]</xref>, <xref rid="pone.0100724-Truelsen2" ref-type="bibr">[11]</xref>. Even with this increasing burden, the public health response, accesses to health services and treatment options in many African countries have been poor <xref rid="pone.0100724-Connor1" ref-type="bibr">[7]</xref>, <xref rid="pone.0100724-Wahab1" ref-type="bibr">[12]</xref>. Specifically, the lack of functional stroke units, neurologists, health workers, cranial computed tomography (CT) scans, magnetic resonance imaging (MRI) machines and echo-doppler machines, among many others, has negatively affected stroke outcomes <xref rid="pone.0100724-Chin1" ref-type="bibr">[2]</xref>, <xref rid="pone.0100724-Wahab1" ref-type="bibr">[12]</xref>. Moreover, the high cost of medical care in a relatively low-income African society could have resulted in high stroke fatalities, as some studies have indicated that stroke prevalence and deaths in Africa increased due to an overtly poor socioeconomic status <xref rid="pone.0100724-Johnston1" ref-type="bibr">[6]</xref>. For example, a recent study revealed the incidence of stroke in HIC decreased by over 40% between 1970 and 2008, but with actual number of stroke cases increasing due to ageing of the population <xref rid="pone.0100724-Feigin2" ref-type="bibr">[13]</xref>, while in Africa and many LMIC, stroke incidence rose by over 100% over the same period <xref rid="pone.0100724-Feigin2" ref-type="bibr">[13]</xref>. Furthermore, due to the high proportion of undiagnosed hypertension in Africa especially among the younger population <xref rid="pone.0100724-Mensah1" ref-type="bibr">[14]</xref>, stroke incidence has also been reported to be more severe and higher among the active and productive population age groups <xref rid="pone.0100724-Walker1" ref-type="bibr">[15]</xref>.</p><p>Meanwhile, the World Health Organization (WHO) technically supported her member countries with methods for improved data collation and registration of hospital stroke cases <xref rid="pone.0100724-Mathers1" ref-type="bibr">[16]</xref>. Notwithstanding, another set-back in the response to the management of stroke in Africa is the lack of data and low research output <xref rid="pone.0100724-Connor1" ref-type="bibr">[7]</xref>, <xref rid="pone.0100724-Mensah1" ref-type="bibr">[14]</xref>. Stroke case ascertainment and survey methodologies have not, in most cases, complied with international protocols <xref rid="pone.0100724-Connor1" ref-type="bibr">[7]</xref>. Published research studies are characterized by poorly organized community-based studies, difficulties in making retrospective diagnosis, and overlapping cases of first and recurrent strokes <xref rid="pone.0100724-Connor1" ref-type="bibr">[7]</xref>, <xref rid="pone.0100724-Sudlow1" ref-type="bibr">[17]</xref>. The few studies on stroke, therefore, could have been marked by under-estimation of the stroke burden in Africa. In view of this high burden of stroke, its public health importance, and the relatively low research output in Africa, this study aimed to estimate the incidence and prevalence rates of stroke in Africa in order to attempt to quantify the burden and inform decision regarding policy responses and health system interventions across many countries in the region.</p></sec><sec sec-type="methods" id="s2"><title>Methods</title><sec id="s2a"><title>Search strategy and selection criteria</title><p>After identification of relevant Medical Subject Headings (MESH) and keywords, a final search strategy was developed. Searches were conducted in three main databases: Medline, EMBASE and Global Health. The search date was set from January 1970 to December 2013. An additional search was conducted on Google Scholar and reference lists of relevant studies to identify publications that could have been omitted in the database searches. The search terms employed on Medline are shown in <xref ref-type="table" rid="pone-0100724-t001"><bold>Table 1</bold></xref>, while those employed on other databases are shown in <bold>Table S1</bold> and <bold>Table S2</bold> in <bold><xref ref-type="supplementary-material" rid="pone.0100724.s001">File S1</xref></bold>.</p><table-wrap id="pone-0100724-t001" orientation="portrait" position="float"><object-id pub-id-type="doi">10.1371/journal.pone.0100724.t001</object-id><label>Table 1</label><caption><title>Search terms (Medline).</title></caption><alternatives><graphic id="pone-0100724-t001-1" xlink:href="pone.0100724.t001"></graphic><table frame="hsides" rules="groups"><colgroup span="1"><col align="left" span="1"></col><col align="center" span="1"></col></colgroup><thead><tr><td align="left" rowspan="1" colspan="1">#</td><td align="left" rowspan="1" colspan="1">Searches</td></tr></thead><tbody><tr><td align="left" rowspan="1" colspan="1"><bold>1</bold></td><td align="left" rowspan="1" colspan="1">africa/or africa, northern/or algeria/or egypt/or libya/or morocco/or africa, central/or cameroon/or central african republic/or chad/or congo/or "democratic republic of the congo"/or equatorial guinea/or gabon/or africa, eastern/or burundi/or djibouti/or eritrea/or ethiopia/or kenya/or rwanda/or somalia/or sudan/or tanzania/or uganda/or africa, southern/or angola/or botswana/or lesotho/or malawi/or mozambique/or namibia/or south africa/or swaziland/or zambia/or zimbabwe/or africa, western/or benin/or burkina faso/or cape verde/or cote d'ivoire/or gambia/or ghana/or guinea/or guinea-bissau/or liberia/or mali/or mauritania/or niger/or nigeria/or senegal/or sierra leone/or togo/</td></tr><tr><td align="left" rowspan="1" colspan="1"><bold>2</bold></td><td align="left" rowspan="1" colspan="1">exp vital statistics/or exp incidence/</td></tr><tr><td align="left" rowspan="1" colspan="1"><bold>3</bold></td><td align="left" rowspan="1" colspan="1">(incidence* or prevalence* or morbidity or mortality).tw.</td></tr><tr><td align="left" rowspan="1" colspan="1"><bold>4</bold></td><td align="left" rowspan="1" colspan="1">(disease adj3 burden).tw.</td></tr><tr><td align="left" rowspan="1" colspan="1"><bold>5</bold></td><td align="left" rowspan="1" colspan="1">exp "cost of illness"/</td></tr><tr><td align="left" rowspan="1" colspan="1"><bold>6</bold></td><td align="left" rowspan="1" colspan="1">exp quality-adjusted life years/</td></tr><tr><td align="left" rowspan="1" colspan="1"><bold>7</bold></td><td align="left" rowspan="1" colspan="1">QALY.tw.</td></tr><tr><td align="left" rowspan="1" colspan="1"><bold>8</bold></td><td align="left" rowspan="1" colspan="1">Disability adjusted life years.mp.</td></tr><tr><td align="left" rowspan="1" colspan="1"><bold>9</bold></td><td align="left" rowspan="1" colspan="1">(initial adj2 burden).tw.</td></tr><tr><td align="left" rowspan="1" colspan="1"><bold>10</bold></td><td align="left" rowspan="1" colspan="1">exp risk factors/</td></tr><tr><td align="left" rowspan="1" colspan="1"><bold>11</bold></td><td align="left" rowspan="1" colspan="1">2 or 3 or 4 or 5 or 6 or 7 or 8 or 9 or 10</td></tr><tr><td align="left" rowspan="1" colspan="1"><bold>12</bold></td><td align="left" rowspan="1" colspan="1">stroke/or brain infarction/or brain stem infarctions/or cerebral infarction/or stroke, lacunar/</td></tr><tr><td align="left" rowspan="1" colspan="1"><bold>13</bold></td><td align="left" rowspan="1" colspan="1">cerebrovascular accident.mp.</td></tr><tr><td align="left" rowspan="1" colspan="1"><bold>14</bold></td><td align="left" rowspan="1" colspan="1">cerebrovascular disease.mp.</td></tr><tr><td align="left" rowspan="1" colspan="1"><bold>15</bold></td><td align="left" rowspan="1" colspan="1">CVA.mp.</td></tr><tr><td align="left" rowspan="1" colspan="1"><bold>16</bold></td><td align="left" rowspan="1" colspan="1">12 or 13 or 14 or 15</td></tr><tr><td align="left" rowspan="1" colspan="1"><bold>17</bold></td><td align="left" rowspan="1" colspan="1">1 and 11 and 16</td></tr></tbody></table></alternatives></table-wrap><p>Studies included for further screening were mainly population/community- and hospital-based studies on stroke in Africa, conducted on or after 1970 and providing numerical estimates on the incidence and/or prevalence of stroke in the region. African countries were as defined by the World Bank list of economies (October 2013) <xref rid="pone.0100724-World3" ref-type="bibr">[18]</xref>. Studies conducted before 1970, without numerical estimates, on non-human subjects, and that were mainly reviews were excluded. Studies with well-defined stroke diagnostic criteria and survey protocols were further retained. Due to the paucity of data, varying sources of information including demographic health surveys, community-based door-to-door surveys, hospital records and outpatient clinics were allowed. However, the final stroke case ascertainment complied with the standard WHO definition, defined as “rapidly developing clinical signs of focal (or global) disturbance of cerebral function lasting longer than 24 hour, unless interrupted by death, with no apparent cause other than that of vascular origin” <xref rid="pone.0100724-Hatano1" ref-type="bibr">[19]</xref>, <xref rid="pone.0100724-WHO1" ref-type="bibr">[20]</xref>. According to experts, new cases of stroke were defined as number of people presenting with first ever stroke in a given period, while stroke survivors were the total number of people who have had stroke or living with its sequelae at a given time <xref rid="pone.0100724-WHO1" ref-type="bibr">[20]</xref>, <xref rid="pone.0100724-World4" ref-type="bibr">[21]</xref></p></sec><sec id="s2b"><title>Data extraction and statistical analysis</title><p>An independent parallel search and double extraction was conducted and all extracted data was stored in a Microsoft Excel file format. Data were abstracted systematically on study location, study period, mean age or age range, person years or sample size, incident cases of stroke or number of stroke survivors, and their respective age- and sex-specific incidence or prevalence rates. These were sorted into population-based or hospital-based data separately for analysis. For studies conducted on the same study site, population or cohort, the first chronologically published study was selected, and all additional data from other studies were compared for consistency and included in the selected paper.</p><p>From reported overall crude incidence or prevalence of stroke in a given cohort, a random effect meta-analysis was conducted with pooled effect of stroke expressed per 100,000 person years or population respectively. The overall data estimates of age- and sex-specific prevalence and incidence from all studies were used in our modelling (see <bold>Table S3</bold> in <bold><xref ref-type="supplementary-material" rid="pone.0100724.s001">File S1</xref></bold>). A meta-regression-like epidemiological model in the form of a bubble graph was applied (done separately for males and females), adjusted for mean ages and the crude prevalence and incidence rates of stroke from all studies, with the size of the bubble corresponding to the given sample size. The fitted curve explaining the largest proportion of variance (best fit) was applied. From all data points, the median year of study was estimated, and the equations generated from the modelled curves were then separately used to estimate the new cases of stroke and number of stroke survivors at midpoints of the United Nation (UN) population 5-year age groups for the estimated median year. Africa populations were determined from the 2012 United Nations population demographics <xref rid="pone.0100724-United1" ref-type="bibr">[22]</xref>. All statistical analyses were conducted on Stata 13.1 (Copyright 1985-2013 StataCorp LP).</p></sec></sec><sec id="s3"><title>Results</title><sec id="s3a"><title>Systematic review</title><p>The literature search returned 1227 publications from Medline (286), EMBASE (731) and Global Health (210). A further 5 studies were included from other sources (Google Scholar and reference lists of relevant publications). 927 studies remained after removing duplicates. On screening titles for relevance (stroke studies conducted primarily on African populations), 839 studies were excluded, giving a total of 88 full texts that were assessed. After applying the quality criteria, 69 studies were further excluded (32 articles did not provide numerical estimates on incidence and/or prevalence of stroke, and 37 articles did not clarify study designs and survey methodologies). A total of 19 studies were finally retained for the review (<xref ref-type="fig" rid="pone-0100724-g001"><bold>Figure 1</bold></xref>).</p><fig id="pone-0100724-g001" orientation="portrait" position="float"><object-id pub-id-type="doi">10.1371/journal.pone.0100724.g001</object-id><label>Figure 1</label><caption><title>Flow diagram of search strategy.</title></caption><graphic xlink:href="pone.0100724.g001"></graphic></fig></sec><sec id="s3b"><title>Study characteristics</title><p>The retained 19 studies <xref rid="pone.0100724-TekleHaimanot1" ref-type="bibr">[23]</xref>–<xref rid="pone.0100724-Danesi2" ref-type="bibr">[41]</xref> were conducted across the main regions of Africa (east, north, west and south), but with Northern Africa having the highest output (7 studies). 10 African countries were represented; Egypt and Nigeria ranked highest with 4 studies each, Libya, South Africa and Tanzania had two studies each, while Benin, Ethiopia, Mozambique, Tunisia and Zimbabwe had one study each. Most studies (84.2%) were completed within one year period and the median year of study from all data points was 2009. About 57.9% of studies were conducted in predominantly urban settings. The total sample size from all retained studies was over 6.3 million, with a mean and median sample size of 332,276.5 and 60,820 respectively. 14 studies were population-based, of which 8 were community-based door-to-door surveys and 2 studies each were based on demographic health surveys, population/community-based stroke registries and cross-sectional population-based surveys. There were 5 hospital-based studies with only one from a hospital-based stroke registry. Studies comply with the WHO case ascertainment or a modified definition, while some studies employed cranial computed tomography (CT) or magnetic resonance imaging (MRI) to confirm diagnosis (<xref ref-type="table" rid="pone-0100724-t002"><bold>Table 2</bold></xref>). Most studies were conducted on the entire study population with an overall mean age of 55.9 years. Across retained studies, age determination of subjects were determined from documented age-verification records, and in the absence of such, historical landmarks were employed.</p><table-wrap id="pone-0100724-t002" orientation="portrait" position="float"><object-id pub-id-type="doi">10.1371/journal.pone.0100724.t002</object-id><label>Table 2</label><caption><title>Overall characteristics of retained studies.</title></caption><alternatives><graphic id="pone-0100724-t002-2" xlink:href="pone.0100724.t002"></graphic><table frame="hsides" rules="groups"><colgroup span="1"><col align="left" span="1"></col><col align="center" span="1"></col><col align="center" span="1"></col><col align="center" span="1"></col><col align="center" span="1"></col></colgroup><thead><tr><td align="left" rowspan="1" colspan="1">Country, Location, Setting</td><td align="left" rowspan="1" colspan="1">Author, Year</td><td align="left" rowspan="1" colspan="1">Study period</td><td align="left" rowspan="1" colspan="1">Survey method</td><td align="left" rowspan="1" colspan="1">Case definition</td></tr></thead><tbody><tr><td colspan="5" align="left" rowspan="1"><bold>EASTERN AFRICA</bold></td></tr><tr><td align="left" rowspan="1" colspan="1">Ethiopia, Rural communities <xref rid="pone.0100724-TekleHaimanot1" ref-type="bibr">[23]</xref></td><td align="left" rowspan="1" colspan="1">Tekle-Haimanot et al. 1990</td><td align="left" rowspan="1" colspan="1">1986–88</td><td align="left" rowspan="1" colspan="1">A door-to-door survey</td><td align="left" rowspan="1" colspan="1">WHO definition</td></tr><tr><td align="left" rowspan="1" colspan="1">Tanzania, Hai District, Rural <xref rid="pone.0100724-Dewhurst1" ref-type="bibr">[24]</xref></td><td align="left" rowspan="1" colspan="1">Dewhurst et al. 2013</td><td align="left" rowspan="1" colspan="1">1 November 2009 and 31 July 2010</td><td align="left" rowspan="1" colspan="1">Point prevalence of stroke estimated from a cross-sectional two-phased community epidemiological survey.</td><td align="left" rowspan="1" colspan="1">WHO International Statistical Classification of Diseases and Related Health Problems 10th Revision (ICD-10)</td></tr><tr><td align="left" rowspan="1" colspan="1">Tanzania, Hai district & Dares Salaam, Mixed Rural and Urban <xref rid="pone.0100724-Walker2" ref-type="bibr">[25]</xref></td><td align="left" rowspan="1" colspan="1">Walker et al. 2010</td><td align="left" rowspan="1" colspan="1">2003–06</td><td align="left" rowspan="1" colspan="1">Stroke Incidence measured in two well defined demographic surveillance sites (DSS) over a 3-year period. Patients who had first-ever or recurrent strokes were included. Patients were excluded in suspected cases of infection or a space-occupying lesion</td><td align="left" rowspan="1" colspan="1">WHO definition</td></tr><tr><td colspan="5" align="left" rowspan="1"><bold>NORTHERN AFRICA</bold></td></tr><tr><td align="left" rowspan="1" colspan="1">Egypt, Al Kharga district, Mixed <xref rid="pone.0100724-Farghaly1" ref-type="bibr">[26]</xref></td><td align="left" rowspan="1" colspan="1">Farghaly et al. 2013</td><td align="left" rowspan="1" colspan="1">June 1, 2005 to May 31, 2009</td><td align="left" rowspan="1" colspan="1">A door-to-door screening including every door was carried out using a standardized questionnaire</td><td align="left" rowspan="1" colspan="1">WHO definition</td></tr><tr><td align="left" rowspan="1" colspan="1">Egypt, Al Quseir. Urban <xref rid="pone.0100724-ElTallawy1" ref-type="bibr">[27]</xref></td><td align="left" rowspan="1" colspan="1">El Tallawy et al. 2013</td><td align="left" rowspan="1" colspan="1">July 1, 2009 to January 31, 2012</td><td align="left" rowspan="1" colspan="1">A door-to-door survey of every household in the district</td><td align="left" rowspan="1" colspan="1">WHO definition</td></tr><tr><td align="left" rowspan="1" colspan="1">Egypt, Assuit, Urban <xref rid="pone.0100724-Khedr1" ref-type="bibr">[28]</xref></td><td align="left" rowspan="1" colspan="1">Khedr et al. 2013</td><td align="left" rowspan="1" colspan="1">January 1 2010 - December 31 2010</td><td align="left" rowspan="1" colspan="1">Community-based study using a three phase door-to-door survey</td><td align="left" rowspan="1" colspan="1">WHO definition</td></tr><tr><td align="left" rowspan="1" colspan="1">Egypt, Sohag, Mixed Urban and Rural <xref rid="pone.0100724-Kandil1" ref-type="bibr">[29]</xref></td><td align="left" rowspan="1" colspan="1">Kandil et al. 2006</td><td align="left" rowspan="1" colspan="1">January 1st 1992 to April 30, 1993</td><td align="left" rowspan="1" colspan="1">Multistage, systematic random sampling using a door-to-door survey</td><td align="left" rowspan="1" colspan="1">WHO definition. Diagnosis confirmed by CT scan and other laboratory investigations creatinine</td></tr><tr><td align="left" rowspan="1" colspan="1">Libya, Benghazi, Urban <xref rid="pone.0100724-ElZunni1" ref-type="bibr">[30]</xref></td><td align="left" rowspan="1" colspan="1">El Zunni et al. 1995</td><td align="left" rowspan="1" colspan="1">January 1991 to December 1993</td><td align="left" rowspan="1" colspan="1">Survey conducted on patients referred from the walk-in polyclinics to the four university hospitals and to a rehabilitation center for the handicapped.</td><td align="left" rowspan="1" colspan="1">Cranial CT scan was performed on all cases within the first week of onset of stroke</td></tr><tr><td align="left" rowspan="1" colspan="1">Libya, Benghazi, Urban <xref rid="pone.0100724-Ashok1" ref-type="bibr">[31]</xref></td><td align="left" rowspan="1" colspan="1">Ashok et al. 1986</td><td align="left" rowspan="1" colspan="1">November 1, 1983 and October 31, 1984</td><td align="left" rowspan="1" colspan="1">Hospital-based survey conducted on referred patients with neurological problems</td><td align="left" rowspan="1" colspan="1">Cranial CT was performed on cases within the first week of onset of stroke. Survey based on the US National Survey of Stroke guidelines</td></tr><tr><td align="left" rowspan="1" colspan="1">Tunisia, Kelibia, Mixed Urban and Rural <xref rid="pone.0100724-AttiaRomdhane1" ref-type="bibr">[32]</xref></td><td align="left" rowspan="1" colspan="1">Attia Romdhane et al. 1993</td><td align="left" rowspan="1" colspan="1">1985</td><td align="left" rowspan="1" colspan="1">Population-based survey</td><td align="left" rowspan="1" colspan="1">WHO definition and neurologic tool</td></tr><tr><td colspan="5" align="left" rowspan="1"><bold>SOUTHERN AFRICA</bold></td></tr><tr><td align="left" rowspan="1" colspan="1">Mozambique, Maputo, Urban <xref rid="pone.0100724-Damasceno1" ref-type="bibr">[33]</xref></td><td align="left" rowspan="1" colspan="1">Damasceno et al. 2010</td><td align="left" rowspan="1" colspan="1">August 1, 2005, to July 31, 2006</td><td align="left" rowspan="1" colspan="1">Hospital-based survey using the STEPS Stroke questionnaire. Both first-ever and recurrent stroke events were registered</td><td align="left" rowspan="1" colspan="1">WHO definition: “a focal (or at times global) neurological impairment of sudden onset, and lasting more than 24 hours (or leading to death), and of presumed vascular origin.”</td></tr><tr><td align="left" rowspan="1" colspan="1">South Africa, Agincourt Health and Population Unit, Limpopo province, Rural <xref rid="pone.0100724-Connor2" ref-type="bibr">[34]</xref></td><td align="left" rowspan="1" colspan="1">Connor et al. 2004</td><td align="left" rowspan="1" colspan="1">August 2001- October 2002</td><td align="left" rowspan="1" colspan="1">Point prevalence of stroke survivors measured through door-to-door demographic health survey. Person's first-ever-in-a-lifetime event was recorded</td><td align="left" rowspan="1" colspan="1">WHO definition: “rapidly developing signs of focal (or global) disturbance of cerebral function, leading to death or lasting longer than 24 hours, with no apparent cause other than vascular”. Person's first-ever-in-a-lifetime event was recorded</td></tr><tr><td align="left" rowspan="1" colspan="1">South Africa, Atteridgeville and Mamelodi suburban areas of Pretoria, Urban <xref rid="pone.0100724-Rosman1" ref-type="bibr">[35]</xref></td><td align="left" rowspan="1" colspan="1">Rosman 1986</td><td align="left" rowspan="1" colspan="1">May 1 1984-April 30 1985</td><td align="left" rowspan="1" colspan="1">Prospective hospital-based survey. Included all strokes (first-ever and recurrent)</td><td align="left" rowspan="1" colspan="1">Diagnosis confirmed by cranial CT</td></tr><tr><td align="left" rowspan="1" colspan="1">Zimbabwe, Harare, Urban <xref rid="pone.0100724-Matenga1" ref-type="bibr">[36]</xref></td><td align="left" rowspan="1" colspan="1">Matenga 1997</td><td align="left" rowspan="1" colspan="1">Jan- Dec 1991</td><td align="left" rowspan="1" colspan="1">A hospital-based stroke registry survey. Only first-ever strokes were included</td><td align="left" rowspan="1" colspan="1">Stroke was defined according to the WHO definition. None had CT</td></tr><tr><td colspan="5" align="left" rowspan="1"><bold>WESTERN AFRICA</bold></td></tr><tr><td align="left" rowspan="1" colspan="1">Benin, Cotonou, Urban <xref rid="pone.0100724-Cossi1" ref-type="bibr">[37]</xref></td><td align="left" rowspan="1" colspan="1">Cossi et al. 2012</td><td align="left" rowspan="1" colspan="1">September 15, 2008- May 15, 2009</td><td align="left" rowspan="1" colspan="1">A three-phase door-to-door study was performed</td><td align="left" rowspan="1" colspan="1">Diagnosis of stroke was confirmed by CT scan evaluation</td></tr><tr><td align="left" rowspan="1" colspan="1">Nigeria, Ibadan, Urban <xref rid="pone.0100724-Osuntokun1" ref-type="bibr">[38]</xref></td><td align="left" rowspan="1" colspan="1">Osuntokun et al. 1979</td><td align="left" rowspan="1" colspan="1">1973–75</td><td align="left" rowspan="1" colspan="1">Population-based stroke registry survey</td><td align="left" rowspan="1" colspan="1">WHO definition</td></tr><tr><td align="left" rowspan="1" colspan="1">Nigeria, Igbo-Ora, Rural <xref rid="pone.0100724-Osuntokun2" ref-type="bibr">[39]</xref></td><td align="left" rowspan="1" colspan="1">Osuntokun et al. 1987</td><td align="left" rowspan="1" colspan="1">1982</td><td align="left" rowspan="1" colspan="1">Community-based door-to door survey</td><td align="left" rowspan="1" colspan="1">WHO definition</td></tr><tr><td align="left" rowspan="1" colspan="1">Nigeria, Lagos, Urban <xref rid="pone.0100724-Danesi1" ref-type="bibr">[40]</xref></td><td align="left" rowspan="1" colspan="1">Danesi et al. 2013</td><td align="left" rowspan="1" colspan="1">January 1st and December 31<sup>st</sup> 2007</td><td align="left" rowspan="1" colspan="1">Prospective community-based stroke registry enrolling hospitalized and non-hospitalized first-ever in a lifetime stroke cases presenting at all health facilities</td><td align="left" rowspan="1" colspan="1">Stroke was defined using the WHO clinical criteria ‘sudden onset of focal neurological deficit lasting longer than 24 h or leading to death with no other cause other than a vascular event'</td></tr><tr><td align="left" rowspan="1" colspan="1">Nigeria, Lagos, Urban <xref rid="pone.0100724-Danesi2" ref-type="bibr">[41]</xref></td><td align="left" rowspan="1" colspan="1">Danesi et al. 2007</td><td align="left" rowspan="1" colspan="1">June 1, 2005, and May 30, 2006</td><td align="left" rowspan="1" colspan="1">Population-based, door-to-door survey using modified WHO questionnaire</td><td align="left" rowspan="1" colspan="1">Stroke defined as “a focal (or at times global) neurological impairment of sudden onset, and lasting more than 24 hours (or leading to death), and of presumed vascular origin.”</td></tr></tbody></table></alternatives><table-wrap-foot><fn id="nt101"><label></label><p>CT: computed tomography, ICD: International Classification of Disease, WHO: World Health Organization</p></fn></table-wrap-foot></table-wrap></sec><sec id="s3c"><title>Pooled estimates of reported crude stroke incidence and prevalence rates</title><p>Across studies reporting crude incidences of stroke, there were 6 population/community-based and 5 hospital-based studies. Population-based incidence rates were generally higher ranging from 25.2/100,000 person years (py) and 26.0/100,000 py in Lagos and Ibadan Nigeria in 2007 and 1979 respectively <xref rid="pone.0100724-Osuntokun1" ref-type="bibr">[38]</xref>, <xref rid="pone.0100724-Danesi1" ref-type="bibr">[40]</xref>, to 250/100,000 py in Al-Kharga Egypt in 2007 <xref rid="pone.0100724-Farghaly1" ref-type="bibr">[26]</xref>. The hospital-based studies reported lower incidence rates ranging from 30/100,000 py in Harare Zimbabwe in 1991 <xref rid="pone.0100724-Matenga1" ref-type="bibr">[36]</xref>, to 148.7/100,000 py in Maputo Mozambique in 2006 <xref rid="pone.0100724-Damasceno1" ref-type="bibr">[33]</xref> (<xref ref-type="table" rid="pone-0100724-t003"><bold>Table 3</bold></xref>). The random effect meta-analysis of population-based incidence rates was 112.94/100,000 py (95% CI = 90.7–135.17, I<sup>2</sup> = 97.5%, p = 0.000) (<xref ref-type="fig" rid="pone-0100724-g002"><bold>Figure 2</bold></xref>). The hospital-based meta-analysis was lower with a pooled estimate of 77.39/100,000 py (95% CI = 51.31–103.48, I<sup>2</sup> = 99.1%, p = 0.000) (<xref ref-type="fig" rid="pone-0100724-g003"><bold>Figure 3</bold></xref>).There were 11studies (all population/community-based) reporting crude prevalences of stroke survivors with prevalence rates ranging from 15/100,000 population in Ethiopia in 1988 <xref rid="pone.0100724-TekleHaimanot1" ref-type="bibr">[23]</xref>, to 963/100,000 population in 2010 <xref rid="pone.0100724-Khedr1" ref-type="bibr">[28]</xref> (<xref ref-type="table" rid="pone-0100724-t004"><bold>Table 4</bold></xref>). Random effect meta-analysis yielded a pooled prevalence rate of 387.93/100,000 population (95% CI = 284.16–491.70, I<sup>2</sup> = 98.8%, p = 0.000) (<xref ref-type="fig" rid="pone-0100724-g004"><bold>Figure 4</bold></xref>). A Tanzanian study reported a prevalence of 2300/100,000 among people aged 70 years above in Hai district in 2010 <xref rid="pone.0100724-Dewhurst1" ref-type="bibr">[24]</xref>, this was not included in the meta-analysis as other studies were mostly based on the general population with mean age ranging between 50 and 60 years (<xref ref-type="table" rid="pone-0100724-t004"><bold>Table 4</bold></xref>).</p><fig id="pone-0100724-g002" orientation="portrait" position="float"><object-id pub-id-type="doi">10.1371/journal.pone.0100724.g002</object-id><label>Figure 2</label><caption><title>Pooled crude incidence rates of stroke from population-based studies.</title></caption><graphic xlink:href="pone.0100724.g002"></graphic></fig><fig id="pone-0100724-g003" orientation="portrait" position="float"><object-id pub-id-type="doi">10.1371/journal.pone.0100724.g003</object-id><label>Figure 3</label><caption><title>Pooled crude incidence rates of stroke from hospital-based studies.</title></caption><graphic xlink:href="pone.0100724.g003"></graphic></fig><fig id="pone-0100724-g004" orientation="portrait" position="float"><object-id pub-id-type="doi">10.1371/journal.pone.0100724.g004</object-id><label>Figure 4</label><caption><title>Pooled crude prevalence rates of stroke survivors from population-based studies.</title></caption><graphic xlink:href="pone.0100724.g004"></graphic></fig><table-wrap id="pone-0100724-t003" orientation="portrait" position="float"><object-id pub-id-type="doi">10.1371/journal.pone.0100724.t003</object-id><label>Table 3</label><caption><title>Summary of data from studies reporting crude incidence of stroke.</title></caption><alternatives><graphic id="pone-0100724-t003-3" xlink:href="pone.0100724.t003"></graphic><table frame="hsides" rules="groups"><colgroup span="1"><col align="left" span="1"></col><col align="center" span="1"></col><col align="center" span="1"></col><col align="center" span="1"></col><col align="center" span="1"></col><col align="center" span="1"></col><col align="center" span="1"></col><col align="center" span="1"></col><col align="center" span="1"></col><col align="center" span="1"></col><col align="center" span="1"></col><col align="center" span="1"></col></colgroup><thead><tr><td align="left" rowspan="1" colspan="1">Author</td><td align="left" rowspan="1" colspan="1">Year</td><td align="left" rowspan="1" colspan="1">Age (years)</td><td align="left" rowspan="1" colspan="1">Cases (All)</td><td align="left" rowspan="1" colspan="1">Sample size (All)</td><td align="left" rowspan="1" colspan="1">Incidence/100000 py (All)</td><td align="left" rowspan="1" colspan="1">Cases (Male)</td><td align="left" rowspan="1" colspan="1">Sample size (Male)</td><td align="left" rowspan="1" colspan="1">Incidence/100000 py (Men)</td><td align="left" rowspan="1" colspan="1">Cases (Female)</td><td align="left" rowspan="1" colspan="1">Sample size (Female)</td><td align="left" rowspan="1" colspan="1">Incidence/100000 py (Women)</td></tr></thead><tbody><tr><td colspan="12" align="left" rowspan="1"><bold>POPULATION/COMMUNITY-BASED</bold></td></tr><tr><td align="left" rowspan="1" colspan="1"><bold>Danesi et al. 2013</bold></td><td align="left" rowspan="1" colspan="1">2007</td><td align="left" rowspan="1" colspan="1">All</td><td align="left" rowspan="1" colspan="1">189</td><td align="left" rowspan="1" colspan="1">750000</td><td align="left" rowspan="1" colspan="1">25.2</td><td align="left" rowspan="1" colspan="1">118</td><td align="left" rowspan="1" colspan="1">417000</td><td align="left" rowspan="1" colspan="1">28.3</td><td align="left" rowspan="1" colspan="1">71</td><td align="left" rowspan="1" colspan="1">333000</td><td align="left" rowspan="1" colspan="1">21.3</td></tr><tr><td align="left" rowspan="1" colspan="1"><bold>El Tallawy et al. 2013</bold></td><td align="left" rowspan="1" colspan="1">2012</td><td align="left" rowspan="1" colspan="1">20+</td><td align="left" rowspan="1" colspan="1">36</td><td align="left" rowspan="1" colspan="1">19848</td><td align="left" rowspan="1" colspan="1">181</td><td align="left" rowspan="1" colspan="1">21</td><td align="left" rowspan="1" colspan="1">9916</td><td align="left" rowspan="1" colspan="1">212</td><td align="left" rowspan="1" colspan="1">15</td><td align="left" rowspan="1" colspan="1">9932</td><td align="left" rowspan="1" colspan="1">150</td></tr><tr><td align="left" rowspan="1" colspan="1"><bold>Walker et al. 2010a</bold></td><td align="left" rowspan="1" colspan="1">2006</td><td align="left" rowspan="1" colspan="1">All</td><td align="left" rowspan="1" colspan="1">453</td><td align="left" rowspan="1" colspan="1">159814</td><td align="left" rowspan="1" colspan="1">94.5</td><td align="left" rowspan="1" colspan="1">532</td><td align="left" rowspan="1" colspan="1">71916</td><td align="left" rowspan="1" colspan="1">106.7</td><td align="left" rowspan="1" colspan="1">10</td><td align="left" rowspan="1" colspan="1">87898</td><td align="left" rowspan="1" colspan="1">76.7</td></tr><tr><td align="left" rowspan="1" colspan="1"><bold>Walker et al. 2010b</bold></td><td align="left" rowspan="1" colspan="1">2006</td><td align="left" rowspan="1" colspan="1">All</td><td align="left" rowspan="1" colspan="1">183</td><td align="left" rowspan="1" colspan="1">56517</td><td align="left" rowspan="1" colspan="1">107.9</td><td align="left" rowspan="1" colspan="1">266</td><td align="left" rowspan="1" colspan="1">25433</td><td align="left" rowspan="1" colspan="1">115.2</td><td align="left" rowspan="1" colspan="1">122</td><td align="left" rowspan="1" colspan="1">31084</td><td align="left" rowspan="1" colspan="1">99.7</td></tr><tr><td align="left" rowspan="1" colspan="1"><bold>Osuntokun et al. 1979</bold></td><td align="left" rowspan="1" colspan="1">1975</td><td align="left" rowspan="1" colspan="1">All</td><td align="left" rowspan="1" colspan="1">318</td><td align="left" rowspan="1" colspan="1">1223077</td><td align="left" rowspan="1" colspan="1">26</td><td align="left" rowspan="1" colspan="1">229</td><td align="left" rowspan="1" colspan="1">538462</td><td align="left" rowspan="1" colspan="1">25</td><td align="left" rowspan="1" colspan="1">89</td><td align="left" rowspan="1" colspan="1">684615</td><td align="left" rowspan="1" colspan="1">13</td></tr><tr><td align="left" rowspan="1" colspan="1"><bold>Kandil et al. 2006a</bold></td><td align="left" rowspan="1" colspan="1">1993</td><td align="left" rowspan="1" colspan="1">All</td><td align="left" rowspan="1" colspan="1">39</td><td align="left" rowspan="1" colspan="1">25000</td><td align="left" rowspan="1" colspan="1">180</td><td align="left" rowspan="1" colspan="1">21</td><td align="left" rowspan="1" colspan="1">21000</td><td align="left" rowspan="1" colspan="1">100</td><td align="left" rowspan="1" colspan="1">18</td><td align="left" rowspan="1" colspan="1">21176</td><td align="left" rowspan="1" colspan="1">85</td></tr><tr><td align="left" rowspan="1" colspan="1"><bold>Kandil et al. 2006b</bold></td><td align="left" rowspan="1" colspan="1">1993</td><td align="left" rowspan="1" colspan="1">All</td><td align="left" rowspan="1" colspan="1">11</td><td align="left" rowspan="1" colspan="1">8464</td><td align="left" rowspan="1" colspan="1">150</td><td align="left" rowspan="1" colspan="1">7</td><td align="left" rowspan="1" colspan="1">7778</td><td align="left" rowspan="1" colspan="1">90</td><td align="left" rowspan="1" colspan="1">4</td><td align="left" rowspan="1" colspan="1">7547</td><td align="left" rowspan="1" colspan="1">53</td></tr><tr><td align="left" rowspan="1" colspan="1"><bold>Kandil et al. 2006c</bold></td><td align="left" rowspan="1" colspan="1">1993</td><td align="left" rowspan="1" colspan="1">All</td><td align="left" rowspan="1" colspan="1">20</td><td align="left" rowspan="1" colspan="1">11228</td><td align="left" rowspan="1" colspan="1">210</td><td align="left" rowspan="1" colspan="1">9</td><td align="left" rowspan="1" colspan="1">9278</td><td align="left" rowspan="1" colspan="1">97</td><td align="left" rowspan="1" colspan="1">11</td><td align="left" rowspan="1" colspan="1">9244</td><td align="left" rowspan="1" colspan="1">119</td></tr><tr><td align="left" rowspan="1" colspan="1"><bold>Farghaly et al. 2013</bold></td><td align="left" rowspan="1" colspan="1">2007</td><td align="left" rowspan="1" colspan="1">All</td><td align="left" rowspan="1" colspan="1">156</td><td align="left" rowspan="1" colspan="1">62583</td><td align="left" rowspan="1" colspan="1">250</td><td align="left" rowspan="1" colspan="1">86</td><td align="left" rowspan="1" colspan="1">32165</td><td align="left" rowspan="1" colspan="1">270</td><td align="left" rowspan="1" colspan="1">70</td><td align="left" rowspan="1" colspan="1">30418</td><td align="left" rowspan="1" colspan="1">230</td></tr><tr><td colspan="12" align="left" rowspan="1"><bold>HOSPITAL-BASED</bold></td></tr><tr><td align="left" rowspan="1" colspan="1"><bold>Ashok et al. 1986</bold></td><td align="left" rowspan="1" colspan="1">1984</td><td align="left" rowspan="1" colspan="1">15+</td><td align="left" rowspan="1" colspan="1">329</td><td align="left" rowspan="1" colspan="1">518745</td><td align="left" rowspan="1" colspan="1">63</td><td align="left" rowspan="1" colspan="1">184</td><td align="left" rowspan="1" colspan="1">267590</td><td align="left" rowspan="1" colspan="1">69</td><td align="left" rowspan="1" colspan="1">145</td><td align="left" rowspan="1" colspan="1">251155</td><td align="left" rowspan="1" colspan="1">58</td></tr><tr><td align="left" rowspan="1" colspan="1"><bold>Damasceno et al. 2010</bold></td><td align="left" rowspan="1" colspan="1">2006</td><td align="left" rowspan="1" colspan="1">15+</td><td align="left" rowspan="1" colspan="1">651</td><td align="left" rowspan="1" colspan="1">437794</td><td align="left" rowspan="1" colspan="1">148.7</td><td align="left" rowspan="1" colspan="1">342</td><td align="left" rowspan="1" colspan="1">197007</td><td align="left" rowspan="1" colspan="1">173.6</td><td align="left" rowspan="1" colspan="1">309</td><td align="left" rowspan="1" colspan="1">240787</td><td align="left" rowspan="1" colspan="1">128.3</td></tr><tr><td align="left" rowspan="1" colspan="1"><bold>El Zunni et al. 1995</bold></td><td align="left" rowspan="1" colspan="1">1993</td><td align="left" rowspan="1" colspan="1">15+</td><td align="left" rowspan="1" colspan="1">921</td><td align="left" rowspan="1" colspan="1">1918750</td><td align="left" rowspan="1" colspan="1">48</td><td align="left" rowspan="1" colspan="1">379</td><td align="left" rowspan="1" colspan="1">1196154</td><td align="left" rowspan="1" colspan="1">52</td><td align="left" rowspan="1" colspan="1">322</td><td align="left" rowspan="1" colspan="1">722596</td><td align="left" rowspan="1" colspan="1">42</td></tr><tr><td align="left" rowspan="1" colspan="1"><bold>Matenga. 1997</bold></td><td align="left" rowspan="1" colspan="1">1991</td><td align="left" rowspan="1" colspan="1">All</td><td align="left" rowspan="1" colspan="1">273</td><td align="left" rowspan="1" colspan="1">889250</td><td align="left" rowspan="1" colspan="1">30.7</td><td align="left" rowspan="1" colspan="1">142</td><td align="left" rowspan="1" colspan="1">478114</td><td align="left" rowspan="1" colspan="1">29.7</td><td align="left" rowspan="1" colspan="1">131</td><td align="left" rowspan="1" colspan="1">411136</td><td align="left" rowspan="1" colspan="1">32</td></tr><tr><td align="left" rowspan="1" colspan="1"><bold>Rosman 1986</bold></td><td align="left" rowspan="1" colspan="1">1985</td><td align="left" rowspan="1" colspan="1">20+</td><td align="left" rowspan="1" colspan="1">116</td><td align="left" rowspan="1" colspan="1">114931</td><td align="left" rowspan="1" colspan="1">101</td><td align="left" rowspan="1" colspan="1">65</td><td align="left" rowspan="1" colspan="1">60343</td><td align="left" rowspan="1" colspan="1">108</td><td align="left" rowspan="1" colspan="1">51</td><td align="left" rowspan="1" colspan="1">54588</td><td align="left" rowspan="1" colspan="1">93</td></tr></tbody></table></alternatives><table-wrap-foot><fn id="nt102"><label></label><p>Walker et al. 2010a: Hai district (rural setting), Walker et al. 2010b: Dares Salaam district (urban setting)</p></fn></table-wrap-foot></table-wrap><table-wrap id="pone-0100724-t004" orientation="portrait" position="float"><object-id pub-id-type="doi">10.1371/journal.pone.0100724.t004</object-id><label>Table 4</label><caption><title>Summary of data from studies reporting crude prevalence of stroke survivors (all population/community-based).</title></caption><alternatives><graphic id="pone-0100724-t004-4" xlink:href="pone.0100724.t004"></graphic><table frame="hsides" rules="groups"><colgroup span="1"><col align="left" span="1"></col><col align="center" span="1"></col><col align="center" span="1"></col><col align="center" span="1"></col><col align="center" span="1"></col><col align="center" span="1"></col><col align="center" span="1"></col><col align="center" span="1"></col><col align="center" span="1"></col><col align="center" span="1"></col><col align="center" span="1"></col><col align="center" span="1"></col></colgroup><thead><tr><td align="left" rowspan="1" colspan="1">Author, year</td><td align="left" rowspan="1" colspan="1">Year</td><td align="left" rowspan="1" colspan="1">Age (years)</td><td align="left" rowspan="1" colspan="1">Cases (All)</td><td align="left" rowspan="1" colspan="1">Sample size (All)</td><td align="left" rowspan="1" colspan="1">Prevalence/100000 (All)</td><td align="left" rowspan="1" colspan="1">Cases (Men)</td><td align="left" rowspan="1" colspan="1">Sample size (Men)</td><td align="left" rowspan="1" colspan="1">Prevalence/100000 (Men)</td><td align="left" rowspan="1" colspan="1">Cases (Women)</td><td align="left" rowspan="1" colspan="1">Sample size (Female)</td><td align="left" rowspan="1" colspan="1">Prevalence/100000 (Men)</td></tr></thead><tbody><tr><td align="left" rowspan="1" colspan="1"><bold>Connor et al, 2004</bold></td><td align="left" rowspan="1" colspan="1">2002</td><td align="left" rowspan="1" colspan="1">15+</td><td align="left" rowspan="1" colspan="1">103</td><td align="left" rowspan="1" colspan="1">42378</td><td align="left" rowspan="1" colspan="1">243</td><td align="left" rowspan="1" colspan="1">37</td><td align="left" rowspan="1" colspan="1">20042</td><td align="left" rowspan="1" colspan="1">185</td><td align="left" rowspan="1" colspan="1">66</td><td align="left" rowspan="1" colspan="1">22336</td><td align="left" rowspan="1" colspan="1">296</td></tr><tr><td align="left" rowspan="1" colspan="1"><bold>Cossi et al. 2012</bold></td><td align="left" rowspan="1" colspan="1">2009</td><td align="left" rowspan="1" colspan="1">15+</td><td align="left" rowspan="1" colspan="1">70</td><td align="left" rowspan="1" colspan="1">15155</td><td align="left" rowspan="1" colspan="1">460</td><td align="left" rowspan="1" colspan="1">38</td><td align="left" rowspan="1" colspan="1">6293</td><td align="left" rowspan="1" colspan="1">610</td><td align="left" rowspan="1" colspan="1">32</td><td align="left" rowspan="1" colspan="1">8862</td><td align="left" rowspan="1" colspan="1">360</td></tr><tr><td align="left" rowspan="1" colspan="1"><bold>Danesi et al. 2007</bold></td><td align="left" rowspan="1" colspan="1">2006</td><td align="left" rowspan="1" colspan="1">All</td><td align="left" rowspan="1" colspan="1">15</td><td align="left" rowspan="1" colspan="1">13127</td><td align="left" rowspan="1" colspan="1">114</td><td align="left" rowspan="1" colspan="1">11</td><td align="left" rowspan="1" colspan="1">7295</td><td align="left" rowspan="1" colspan="1">151</td><td align="left" rowspan="1" colspan="1">4</td><td align="left" rowspan="1" colspan="1">5832</td><td align="left" rowspan="1" colspan="1">69</td></tr><tr><td align="left" rowspan="1" colspan="1"><bold>Dewhurst et al. 2013</bold><xref ref-type="table-fn" rid="nt103">*</xref></td><td align="left" rowspan="1" colspan="1">2010</td><td align="left" rowspan="1" colspan="1">70+</td><td align="left" rowspan="1" colspan="1">51</td><td align="left" rowspan="1" colspan="1">2232</td><td align="left" rowspan="1" colspan="1">2300</td><td align="left" rowspan="1" colspan="1">29</td><td align="left" rowspan="1" colspan="1">976</td><td align="left" rowspan="1" colspan="1">2971</td><td align="left" rowspan="1" colspan="1">22</td><td align="left" rowspan="1" colspan="1">1256</td><td align="left" rowspan="1" colspan="1">1752</td></tr><tr><td align="left" rowspan="1" colspan="1"><bold>El Tallawy et al. 2013</bold></td><td align="left" rowspan="1" colspan="1">2012</td><td align="left" rowspan="1" colspan="1">All</td><td align="left" rowspan="1" colspan="1">130</td><td align="left" rowspan="1" colspan="1">19848</td><td align="left" rowspan="1" colspan="1">655</td><td align="left" rowspan="1" colspan="1">85</td><td align="left" rowspan="1" colspan="1">9916</td><td align="left" rowspan="1" colspan="1">860</td><td align="left" rowspan="1" colspan="1">48</td><td align="left" rowspan="1" colspan="1">9932</td><td align="left" rowspan="1" colspan="1">480</td></tr><tr><td align="left" rowspan="1" colspan="1"><bold>Farghaly et al. 2013a</bold></td><td align="left" rowspan="1" colspan="1">2009</td><td align="left" rowspan="1" colspan="1">All</td><td align="left" rowspan="1" colspan="1">351</td><td align="left" rowspan="1" colspan="1">62583</td><td align="left" rowspan="1" colspan="1">560</td><td align="left" rowspan="1" colspan="1">196</td><td align="left" rowspan="1" colspan="1">32165</td><td align="left" rowspan="1" colspan="1">610</td><td align="left" rowspan="1" colspan="1">155</td><td align="left" rowspan="1" colspan="1">30418</td><td align="left" rowspan="1" colspan="1">510</td></tr><tr><td align="left" rowspan="1" colspan="1"><bold>Farghaly et al. 2013b</bold></td><td align="left" rowspan="1" colspan="1">2009</td><td align="left" rowspan="1" colspan="1">All</td><td align="left" rowspan="1" colspan="1">257</td><td align="left" rowspan="1" colspan="1">44600</td><td align="left" rowspan="1" colspan="1">580</td><td align="left" rowspan="1" colspan="1">142</td><td align="left" rowspan="1" colspan="1">22908</td><td align="left" rowspan="1" colspan="1">620</td><td align="left" rowspan="1" colspan="1">115</td><td align="left" rowspan="1" colspan="1">21692</td><td align="left" rowspan="1" colspan="1">530</td></tr><tr><td align="left" rowspan="1" colspan="1"><bold>Farghaly et al. 2013c</bold></td><td align="left" rowspan="1" colspan="1">2009</td><td align="left" rowspan="1" colspan="1">All</td><td align="left" rowspan="1" colspan="1">94</td><td align="left" rowspan="1" colspan="1">17983</td><td align="left" rowspan="1" colspan="1">520</td><td align="left" rowspan="1" colspan="1">54</td><td align="left" rowspan="1" colspan="1">9257</td><td align="left" rowspan="1" colspan="1">580</td><td align="left" rowspan="1" colspan="1">40</td><td align="left" rowspan="1" colspan="1">8726</td><td align="left" rowspan="1" colspan="1">458</td></tr><tr><td align="left" rowspan="1" colspan="1"><bold>Kandil et al. 2006a</bold></td><td align="left" rowspan="1" colspan="1">1993</td><td align="left" rowspan="1" colspan="1">All</td><td align="left" rowspan="1" colspan="1">127</td><td align="left" rowspan="1" colspan="1">25000</td><td align="left" rowspan="1" colspan="1">508</td><td align="left" rowspan="1" colspan="1">65</td><td align="left" rowspan="1" colspan="1">12500</td><td align="left" rowspan="1" colspan="1">520</td><td align="left" rowspan="1" colspan="1">62</td><td align="left" rowspan="1" colspan="1">12500</td><td align="left" rowspan="1" colspan="1">490</td></tr><tr><td align="left" rowspan="1" colspan="1"><bold>Kandil et al. 2006b</bold></td><td align="left" rowspan="1" colspan="1">1993</td><td align="left" rowspan="1" colspan="1">All</td><td align="left" rowspan="1" colspan="1">35</td><td align="left" rowspan="1" colspan="1">8464</td><td align="left" rowspan="1" colspan="1">410</td><td align="left" rowspan="1" colspan="1">20</td><td align="left" rowspan="1" colspan="1">4348</td><td align="left" rowspan="1" colspan="1">460</td><td align="left" rowspan="1" colspan="1">15</td><td align="left" rowspan="1" colspan="1">4116</td><td align="left" rowspan="1" colspan="1">470</td></tr><tr><td align="left" rowspan="1" colspan="1"><bold>Kandil et al. 2006c</bold></td><td align="left" rowspan="1" colspan="1">1993</td><td align="left" rowspan="1" colspan="1">All</td><td align="left" rowspan="1" colspan="1">61</td><td align="left" rowspan="1" colspan="1">11228</td><td align="left" rowspan="1" colspan="1">540</td><td align="left" rowspan="1" colspan="1">29</td><td align="left" rowspan="1" colspan="1">5686</td><td align="left" rowspan="1" colspan="1">510</td><td align="left" rowspan="1" colspan="1">32</td><td align="left" rowspan="1" colspan="1">5542</td><td align="left" rowspan="1" colspan="1">570</td></tr><tr><td align="left" rowspan="1" colspan="1"><bold>Khedr et al. 2013</bold></td><td align="left" rowspan="1" colspan="1">2010</td><td align="left" rowspan="1" colspan="1">All</td><td align="left" rowspan="1" colspan="1">57</td><td align="left" rowspan="1" colspan="1">5920</td><td align="left" rowspan="1" colspan="1">963</td><td align="left" rowspan="1" colspan="1">36</td><td align="left" rowspan="1" colspan="1">3066</td><td align="left" rowspan="1" colspan="1">1174</td><td align="left" rowspan="1" colspan="1">21</td><td align="left" rowspan="1" colspan="1">2854</td><td align="left" rowspan="1" colspan="1">736</td></tr><tr><td align="left" rowspan="1" colspan="1"><bold>Attia Romdhane et al. 1993</bold></td><td align="left" rowspan="1" colspan="1">1985</td><td align="left" rowspan="1" colspan="1">All</td><td align="left" rowspan="1" colspan="1">15</td><td align="left" rowspan="1" colspan="1">34874</td><td align="left" rowspan="1" colspan="1">42</td><td align="left" rowspan="1" colspan="1">-</td><td align="left" rowspan="1" colspan="1">-</td><td align="left" rowspan="1" colspan="1">-</td><td align="left" rowspan="1" colspan="1">-</td><td align="left" rowspan="1" colspan="1">-</td><td align="left" rowspan="1" colspan="1">-</td></tr><tr><td align="left" rowspan="1" colspan="1"><bold>Osuntokun et al. 1987</bold></td><td align="left" rowspan="1" colspan="1">1982</td><td align="left" rowspan="1" colspan="1">All</td><td align="left" rowspan="1" colspan="1">11</td><td align="left" rowspan="1" colspan="1">18954</td><td align="left" rowspan="1" colspan="1">58</td><td align="left" rowspan="1" colspan="1">-</td><td align="left" rowspan="1" colspan="1">-</td><td align="left" rowspan="1" colspan="1">-</td><td align="left" rowspan="1" colspan="1">-</td><td align="left" rowspan="1" colspan="1">-</td><td align="left" rowspan="1" colspan="1">-</td></tr><tr><td align="left" rowspan="1" colspan="1"><bold>Tekle-Haimanot et al. 1990</bold></td><td align="left" rowspan="1" colspan="1">1988</td><td align="left" rowspan="1" colspan="1">20–85</td><td align="left" rowspan="1" colspan="1">9</td><td align="left" rowspan="1" colspan="1">60820</td><td align="left" rowspan="1" colspan="1">15</td><td align="left" rowspan="1" colspan="1">-</td><td align="left" rowspan="1" colspan="1">-</td><td align="left" rowspan="1" colspan="1">-</td><td align="left" rowspan="1" colspan="1">-</td><td align="left" rowspan="1" colspan="1">-</td><td align="left" rowspan="1" colspan="1">-</td></tr></tbody></table></alternatives><table-wrap-foot><fn id="nt103"><label></label><p>*not included in meta-analysis, a: mixed setting, b: urban setting, c: rural setting.</p></fn></table-wrap-foot></table-wrap></sec><sec id="s3d"><title>Modelled estimates of stroke incidence and prevalence rates in Africa</title><p>Based on the UN population demographics and bubble graphs derived from all data points, incident cases and number of stroke survivors were estimated for the year 2009, which was our estimated median year of study.</p><p>There were over 483 thousand new cases of stroke in Africa in 2009 among people aged 15 years or more equivalent to 81.2 (13.2–94.9)/100,000 py, with about 305 thousand and over 178 thousand new cases of stroke equivalent to 103.3 (20.7–109.2)/100,000 py and 59.5 (6.9–84.3)/100,000 py among men and women, respectively (<xref ref-type="table" rid="pone-0100724-t005"><bold>Table 5</bold></xref> and <xref ref-type="fig" rid="pone-0100724-g005"><bold>Figure 5</bold></xref>). Comparable figures for the year 2010 and 2013 based on the same incidence rates would amount to 496 (80.6–579.7) and 535 (87.0–625.3) thousand new stroke cases respectively, suggesting an increase of 10.8% between 2009 and 2013 that is attributable to growth and ageing of the African population alone.</p><fig id="pone-0100724-g005" orientation="portrait" position="float"><object-id pub-id-type="doi">10.1371/journal.pone.0100724.g005</object-id><label>Figure 5</label><caption><title>Bubble graph showing relationship between age and crude incidence of stroke, with size of bubble corresponding to sample size.</title></caption><graphic xlink:href="pone.0100724.g005"></graphic></fig><table-wrap id="pone-0100724-t005" orientation="portrait" position="float"><object-id pub-id-type="doi">10.1371/journal.pone.0100724.t005</object-id><label>Table 5</label><caption><title>Estimated new stroke cases and incidence rates in Africa in 2009 (estimates derived from bubble graph model and United Nations population figures).</title></caption><alternatives><graphic id="pone-0100724-t005-5" xlink:href="pone.0100724.t005"></graphic><table frame="hsides" rules="groups"><colgroup span="1"><col align="left" span="1"></col><col align="center" span="1"></col><col align="center" span="1"></col><col align="center" span="1"></col><col align="center" span="1"></col><col align="center" span="1"></col><col align="center" span="1"></col></colgroup><thead><tr><td align="left" rowspan="1" colspan="1">Age (years)</td><td colspan="2" align="left" rowspan="1">Both sexes</td><td colspan="2" align="left" rowspan="1">Men</td><td colspan="2" align="left" rowspan="1">Women</td></tr><tr><td align="left" rowspan="1" colspan="1"></td><td align="left" rowspan="1" colspan="1">Incidence (per 100,000 py) = 1.8928e<sup>0.0793x</sup></td><td align="left" rowspan="1" colspan="1">Stroke cases (000)</td><td align="left" rowspan="1" colspan="1">Incidence (per 100,000 py) = 0.9001e<sup>0.0889x</sup></td><td align="left" rowspan="1" colspan="1">Stroke cases (000)</td><td align="left" rowspan="1" colspan="1">Incidence (per 100,000 py) = 0.7204e<sup>0.0887x</sup></td><td align="left" rowspan="1" colspan="1">Stroke cases (000)</td></tr></thead><tbody><tr><td align="left" rowspan="1" colspan="1"><bold>15–19</bold></td><td align="left" rowspan="1" colspan="1">7.3</td><td align="left" rowspan="1" colspan="1">7.744</td><td align="left" rowspan="1" colspan="1">4.1</td><td align="left" rowspan="1" colspan="1">6.028</td><td align="left" rowspan="1" colspan="1">3.3</td><td align="left" rowspan="1" colspan="1">1.715</td></tr><tr><td align="left" rowspan="1" colspan="1"><bold>20–24</bold></td><td align="left" rowspan="1" colspan="1">10.8</td><td align="left" rowspan="1" colspan="1">10.312</td><td align="left" rowspan="1" colspan="1">6.4</td><td align="left" rowspan="1" colspan="1">7.910</td><td align="left" rowspan="1" colspan="1">5.1</td><td align="left" rowspan="1" colspan="1">2.402</td></tr><tr><td align="left" rowspan="1" colspan="1"><bold>25–29</bold></td><td align="left" rowspan="1" colspan="1">16.1</td><td align="left" rowspan="1" colspan="1">13.131</td><td align="left" rowspan="1" colspan="1">9.9</td><td align="left" rowspan="1" colspan="1">9.919</td><td align="left" rowspan="1" colspan="1">7.9</td><td align="left" rowspan="1" colspan="1">3.212</td></tr><tr><td align="left" rowspan="1" colspan="1"><bold>30–34</bold></td><td align="left" rowspan="1" colspan="1">23.9</td><td align="left" rowspan="1" colspan="1">16.034</td><td align="left" rowspan="1" colspan="1">15.5</td><td align="left" rowspan="1" colspan="1">11.933</td><td align="left" rowspan="1" colspan="1">12.3</td><td align="left" rowspan="1" colspan="1">4.101</td></tr><tr><td align="left" rowspan="1" colspan="1"><bold>35–39</bold></td><td align="left" rowspan="1" colspan="1">35.6</td><td align="left" rowspan="1" colspan="1">19.141</td><td align="left" rowspan="1" colspan="1">24.1</td><td align="left" rowspan="1" colspan="1">14.009</td><td align="left" rowspan="1" colspan="1">19.2</td><td align="left" rowspan="1" colspan="1">5.132</td></tr><tr><td align="left" rowspan="1" colspan="1"><bold>40–44</bold></td><td align="left" rowspan="1" colspan="1">52.9</td><td align="left" rowspan="1" colspan="1">23.261</td><td align="left" rowspan="1" colspan="1">37.7</td><td align="left" rowspan="1" colspan="1">16.668</td><td align="left" rowspan="1" colspan="1">29.9</td><td align="left" rowspan="1" colspan="1">6.593</td></tr><tr><td align="left" rowspan="1" colspan="1"><bold>45–49</bold></td><td align="left" rowspan="1" colspan="1">78.7</td><td align="left" rowspan="1" colspan="1">29.061</td><td align="left" rowspan="1" colspan="1">58.7</td><td align="left" rowspan="1" colspan="1">20.316</td><td align="left" rowspan="1" colspan="1">46.6</td><td align="left" rowspan="1" colspan="1">8.744</td></tr><tr><td align="left" rowspan="1" colspan="1"><bold>50–54</bold></td><td align="left" rowspan="1" colspan="1">116.9</td><td align="left" rowspan="1" colspan="1">36.059</td><td align="left" rowspan="1" colspan="1">91.6</td><td align="left" rowspan="1" colspan="1">24.532</td><td align="left" rowspan="1" colspan="1">72.6</td><td align="left" rowspan="1" colspan="1">11.527</td></tr><tr><td align="left" rowspan="1" colspan="1"><bold>55–69</bold></td><td align="left" rowspan="1" colspan="1">173.8</td><td align="left" rowspan="1" colspan="1">43.290</td><td align="left" rowspan="1" colspan="1">142.9</td><td align="left" rowspan="1" colspan="1">28.622</td><td align="left" rowspan="1" colspan="1">113.1</td><td align="left" rowspan="1" colspan="1">14.668</td></tr><tr><td align="left" rowspan="1" colspan="1"><bold>60–64</bold></td><td align="left" rowspan="1" colspan="1">258.4</td><td align="left" rowspan="1" colspan="1">50.181</td><td align="left" rowspan="1" colspan="1">222.9</td><td align="left" rowspan="1" colspan="1">32.166</td><td align="left" rowspan="1" colspan="1">176.2</td><td align="left" rowspan="1" colspan="1">18.016</td></tr><tr><td align="left" rowspan="1" colspan="1"><bold>65–69</bold></td><td align="left" rowspan="1" colspan="1">384.2</td><td align="left" rowspan="1" colspan="1">54.939</td><td align="left" rowspan="1" colspan="1">347.6</td><td align="left" rowspan="1" colspan="1">33.881</td><td align="left" rowspan="1" colspan="1">274.5</td><td align="left" rowspan="1" colspan="1">21.058</td></tr><tr><td align="left" rowspan="1" colspan="1"><bold>70–74</bold></td><td align="left" rowspan="1" colspan="1">571.2</td><td align="left" rowspan="1" colspan="1">57.775</td><td align="left" rowspan="1" colspan="1">542.2</td><td align="left" rowspan="1" colspan="1">34.087</td><td align="left" rowspan="1" colspan="1">427.7</td><td align="left" rowspan="1" colspan="1">23.688</td></tr><tr><td align="left" rowspan="1" colspan="1"><bold>75–79</bold></td><td align="left" rowspan="1" colspan="1">849.1</td><td align="left" rowspan="1" colspan="1">52.338</td><td align="left" rowspan="1" colspan="1">845.6</td><td align="left" rowspan="1" colspan="1">29.437</td><td align="left" rowspan="1" colspan="1">666.4</td><td align="left" rowspan="1" colspan="1">22.901</td></tr><tr><td align="left" rowspan="1" colspan="1"><bold>80+</bold></td><td align="left" rowspan="1" colspan="1">1601.3</td><td align="left" rowspan="1" colspan="1">69.783</td><td align="left" rowspan="1" colspan="1">1722.0</td><td align="left" rowspan="1" colspan="1">35.059</td><td align="left" rowspan="1" colspan="1">1355.0</td><td align="left" rowspan="1" colspan="1">34.724</td></tr><tr><td align="left" rowspan="1" colspan="1"><bold>Total 15+</bold></td><td align="left" rowspan="1" colspan="1">81.2 (13.2–94.9)</td><td align="left" rowspan="1" colspan="1">483.050</td><td align="left" rowspan="1" colspan="1">103.3 (20.7–109.2)</td><td align="left" rowspan="1" colspan="1">304.567</td><td align="left" rowspan="1" colspan="1">59.5 (6.9–84.3)</td><td align="left" rowspan="1" colspan="1">178.482</td></tr></tbody></table></alternatives><table-wrap-foot><fn id="nt104"><label></label><p>py: person years, x = midpoint of age group.</p></fn></table-wrap-foot></table-wrap><p>The estimated number of stroke survivors in Africa in 2009 was 1.89 million among people aged 15 years or more with a prevalence of 317.3 (314.0–748.2)/100000 population. There were about 990 thousand and 898 thousand stroke survivors equivalent to 335.5 (302.3–702.7)/100,000 and 299.3 (268.4–579.0)/100,000 among men and women, respectively (<xref ref-type="table" rid="pone-0100724-t006"><bold>Table 6</bold></xref> and <xref ref-type="fig" rid="pone-0100724-g006"><bold>Figure 6</bold></xref>). Based on the same prevalence rates, comparable figures for the year 2010 and 2013 would amount to 1.94 (1.90–4.57) and 2.09 (2.06–4.93) million stroke survivors respectively, also suggesting an increase of 9.6% between 2009 and 2013 that is attributable to growth and ageing of the African population alone.</p><fig id="pone-0100724-g006" orientation="portrait" position="float"><object-id pub-id-type="doi">10.1371/journal.pone.0100724.g006</object-id><label>Figure 6</label><caption><title>Bubble graph showing relationship between age and crude prevalence of stroke survivors, with size of bubble corresponding to sample size.</title></caption><graphic xlink:href="pone.0100724.g006"></graphic></fig><table-wrap id="pone-0100724-t006" orientation="portrait" position="float"><object-id pub-id-type="doi">10.1371/journal.pone.0100724.t006</object-id><label>Table 6</label><caption><title>Estimated number of stroke survivors and prevalence in Africa in 2009 (estimates derived from bubble graph model and United Nations population figures).</title></caption><alternatives><graphic id="pone-0100724-t006-6" xlink:href="pone.0100724.t006"></graphic><table frame="hsides" rules="groups"><colgroup span="1"><col align="left" span="1"></col><col align="center" span="1"></col><col align="center" span="1"></col><col align="center" span="1"></col><col align="center" span="1"></col><col align="center" span="1"></col><col align="center" span="1"></col></colgroup><thead><tr><td align="left" rowspan="1" colspan="1">Age (years)</td><td colspan="2" align="left" rowspan="1">Both sexes</td><td colspan="2" align="left" rowspan="1">Men</td><td colspan="2" align="left" rowspan="1">Women</td></tr><tr><td align="left" rowspan="1" colspan="1"></td><td align="left" rowspan="1" colspan="1">Prevalence (per 100,000) = 10.045e<sup>0.0738x</sup></td><td align="left" rowspan="1" colspan="1">Stroke cases (000)</td><td align="left" rowspan="1" colspan="1">Prevalence (per 100,000) = 3.5546e<sup>0.093x</sup></td><td align="left" rowspan="1" colspan="1">Stroke cases (000)</td><td align="left" rowspan="1" colspan="1">Prevalence (per 100,000) = 1.9743e<sup>0.0979x</sup></td><td align="left" rowspan="1" colspan="1">Stroke cases (000)</td></tr></thead><tbody><tr><td align="left" rowspan="1" colspan="1"><bold>15–19</bold></td><td align="left" rowspan="1" colspan="1">35.2</td><td align="left" rowspan="1" colspan="1">14.747</td><td align="left" rowspan="1" colspan="1">17.3</td><td align="left" rowspan="1" colspan="1">9.250</td><td align="left" rowspan="1" colspan="1">10.4</td><td align="left" rowspan="1" colspan="1">5.497</td></tr><tr><td align="left" rowspan="1" colspan="1"><bold>20–24</bold></td><td align="left" rowspan="1" colspan="1">50.9</td><td align="left" rowspan="1" colspan="1">21.209</td><td align="left" rowspan="1" colspan="1">27.5</td><td align="left" rowspan="1" colspan="1">13.149</td><td align="left" rowspan="1" colspan="1">17.0</td><td align="left" rowspan="1" colspan="1">8.060</td></tr><tr><td align="left" rowspan="1" colspan="1"><bold>25–29</bold></td><td align="left" rowspan="1" colspan="1">73.8</td><td align="left" rowspan="1" colspan="1">29.183</td><td align="left" rowspan="1" colspan="1">43.9</td><td align="left" rowspan="1" colspan="1">17.899</td><td align="left" rowspan="1" colspan="1">27.8</td><td align="left" rowspan="1" colspan="1">11.284</td></tr><tr><td align="left" rowspan="1" colspan="1"><bold>30–34</bold></td><td align="left" rowspan="1" colspan="1">106.6</td><td align="left" rowspan="1" colspan="1">38.546</td><td align="left" rowspan="1" colspan="1">69.7</td><td align="left" rowspan="1" colspan="1">23.461</td><td align="left" rowspan="1" colspan="1">45.3</td><td align="left" rowspan="1" colspan="1">15.085</td></tr><tr><td align="left" rowspan="1" colspan="1"><bold>35–39</bold></td><td align="left" rowspan="1" colspan="1">154.1</td><td align="left" rowspan="1" colspan="1">49.752</td><td align="left" rowspan="1" colspan="1">110.9</td><td align="left" rowspan="1" colspan="1">29.985</td><td align="left" rowspan="1" colspan="1">73.9</td><td align="left" rowspan="1" colspan="1">19.768</td></tr><tr><td align="left" rowspan="1" colspan="1"><bold>40–44</bold></td><td align="left" rowspan="1" colspan="1">222.9</td><td align="left" rowspan="1" colspan="1">65.282</td><td align="left" rowspan="1" colspan="1">176.7</td><td align="left" rowspan="1" colspan="1">38.691</td><td align="left" rowspan="1" colspan="1">120.5</td><td align="left" rowspan="1" colspan="1">26.591</td></tr><tr><td align="left" rowspan="1" colspan="1"><bold>45–49</bold></td><td align="left" rowspan="1" colspan="1">322.4</td><td align="left" rowspan="1" colspan="1">88.022</td><td align="left" rowspan="1" colspan="1">281.3</td><td align="left" rowspan="1" colspan="1">51.095</td><td align="left" rowspan="1" colspan="1">196.7</td><td align="left" rowspan="1" colspan="1">36.927</td></tr><tr><td align="left" rowspan="1" colspan="1"><bold>50–54</bold></td><td align="left" rowspan="1" colspan="1">466.2</td><td align="left" rowspan="1" colspan="1">117.911</td><td align="left" rowspan="1" colspan="1">447.8</td><td align="left" rowspan="1" colspan="1">66.938</td><td align="left" rowspan="1" colspan="1">320.9</td><td align="left" rowspan="1" colspan="1">50.973</td></tr><tr><td align="left" rowspan="1" colspan="1"><bold>55–69</bold></td><td align="left" rowspan="1" colspan="1">674.3</td><td align="left" rowspan="1" colspan="1">152.945</td><td align="left" rowspan="1" colspan="1">712.8</td><td align="left" rowspan="1" colspan="1">85.030</td><td align="left" rowspan="1" colspan="1">523.5</td><td align="left" rowspan="1" colspan="1">67.914</td></tr><tr><td align="left" rowspan="1" colspan="1"><bold>60–64</bold></td><td align="left" rowspan="1" colspan="1">975.2</td><td align="left" rowspan="1" colspan="1">191.641</td><td align="left" rowspan="1" colspan="1">1134.8</td><td align="left" rowspan="1" colspan="1">104.301</td><td align="left" rowspan="1" colspan="1">854.1</td><td align="left" rowspan="1" colspan="1">87.341</td></tr><tr><td align="left" rowspan="1" colspan="1"><bold>65–69</bold></td><td align="left" rowspan="1" colspan="1">1410.5</td><td align="left" rowspan="1" colspan="1">226.648</td><td align="left" rowspan="1" colspan="1">1806.7</td><td align="left" rowspan="1" colspan="1">119.754</td><td align="left" rowspan="1" colspan="1">1393.4</td><td align="left" rowspan="1" colspan="1">106.894</td></tr><tr><td align="left" rowspan="1" colspan="1"><bold>70–74</bold></td><td align="left" rowspan="1" colspan="1">2039.9</td><td align="left" rowspan="1" colspan="1">257.559</td><td align="left" rowspan="1" colspan="1">2876.2</td><td align="left" rowspan="1" colspan="1">131.654</td><td align="left" rowspan="1" colspan="1">2273.3</td><td align="left" rowspan="1" colspan="1">125.905</td></tr><tr><td align="left" rowspan="1" colspan="1"><bold>75–79</bold></td><td align="left" rowspan="1" colspan="1">2950.3</td><td align="left" rowspan="1" colspan="1">252.359</td><td align="left" rowspan="1" colspan="1">4579.0</td><td align="left" rowspan="1" colspan="1">124.904</td><td align="left" rowspan="1" colspan="1">3708.9</td><td align="left" rowspan="1" colspan="1">127.455</td></tr><tr><td align="left" rowspan="1" colspan="1"><bold>80+</bold></td><td align="left" rowspan="1" colspan="1">5324.5</td><td align="left" rowspan="1" colspan="1">381.003</td><td align="left" rowspan="1" colspan="1">9635.8</td><td align="left" rowspan="1" colspan="1">172.991</td><td align="left" rowspan="1" colspan="1">8116.9</td><td align="left" rowspan="1" colspan="1">208.012</td></tr><tr><td align="left" rowspan="1" colspan="1"><bold>Total 15+</bold></td><td align="left" rowspan="1" colspan="1">317.3 (314.0–748.2)</td><td align="left" rowspan="1" colspan="1">1886.806</td><td align="left" rowspan="1" colspan="1">335.5 (302.3–704.7)</td><td align="left" rowspan="1" colspan="1">989.099</td><td align="left" rowspan="1" colspan="1">299.3 (268.4–579.0)</td><td align="left" rowspan="1" colspan="1">897.708</td></tr></tbody></table></alternatives><table-wrap-foot><fn id="nt105"><label></label><p>x = midpoint of age group.</p></fn></table-wrap-foot></table-wrap></sec></sec><sec id="s4"><title>Discussion</title><p>Some systematic reviews have been published on the burden of stroke in Africa but without a continent-wide estimate of stroke incidence and prevalence rates <xref rid="pone.0100724-Connor1" ref-type="bibr">[7]</xref>, <xref rid="pone.0100724-Kengne1" ref-type="bibr">[42]</xref>. There are also global reviews of stroke with few studies on Africa population included <xref rid="pone.0100724-Feigin2" ref-type="bibr">[13]</xref>, <xref rid="pone.0100724-Feigin3" ref-type="bibr">[43]</xref>, <xref rid="pone.0100724-Aho1" ref-type="bibr">[44]</xref>. For example, in a systematic review of 56 population-based studies globally, only one African site (Ibadan, Nigeria) was considered. The result from this survey may not necessarily reflect the overall burden of stroke in Africa <xref rid="pone.0100724-Feigin2" ref-type="bibr">[13]</xref>. However, to the best knowledge, this study provides the first continent-wide estimate of the incidence and prevalence rates of stroke in Africa. The estimates were strictly based on a simple statistical analysis with appropriate consideration of reported mean ages and sample sizes from individual studies. Moreover, having applied the UN population demographics in our final model, the current estimates fairly reflect the, albeit very limited, available published data on incidence and prevalence rates of stroke in Africa, and may help policymakers across several African countries institute effective public health response to the growing burden.</p><p>Generally, crude incidences of stroke from population/community based-studies were higher with the two low incidence rates recorded obtained from population-based stroke registries in Nigeria <xref rid="pone.0100724-Osuntokun1" ref-type="bibr">[38]</xref>, <xref rid="pone.0100724-Danesi1" ref-type="bibr">[40]</xref> (<xref ref-type="table" rid="pone-0100724-t003"><bold>Table 3</bold></xref>). Despite over 3 decades of potential improvement in stroke registration between the two studies (1975–2007), the low incidence rates may still be indicative of incompleteness of stroke registries in many Africa settings, and that data obtained from these registries may be unreliable and inappropriate for estimation of stroke burden. In contrast, in many high income countries where there is active registration of stroke cases, population-based stroke registries have been reliable sources of data for estimation of stroke incidences <xref rid="pone.0100724-Connor1" ref-type="bibr">[7]</xref>, <xref rid="pone.0100724-The1" ref-type="bibr">[45]</xref>. In this study, the pooled crude incidence rate from community-based studies was higher at 112.9 per 100,000 person years compared to 77.4 from hospital-based studies. The difference suggests a likely under-estimation of stroke incidences from hospital-based studies, which has also been observed by some studies, particularly due to the very few stroke cases presenting to standard health facilities <xref rid="pone.0100724-Chin1" ref-type="bibr">[2]</xref>. The observed prevalence rates of stroke survivors were generally high (all prevalence studies were population-based) with a pooled crude prevalence rate of 387.9/100,000 population. The low prevalence rate recorded in Ethiopia in 1988 may not be unconnected with the high mortality rates from stroke, which has generally been reported in many parts of Africa <xref rid="pone.0100724-TekleHaimanot1" ref-type="bibr">[23]</xref>, <xref rid="pone.0100724-Bonita1" ref-type="bibr">[46]</xref>. Moreover, the Ethiopian study was broadly a survey of neurological disorders in the community, which could possibly imply that active case recognition of specific stroke cases may be less rigorous.</p><p>The modelling showed a rising incidence and prevalence rates of stroke with increasing age and higher figures recorded among men, which is in keeping with several research findings on stroke burden <xref rid="pone.0100724-Dewhurst1" ref-type="bibr">[24]</xref>. Over 483 thousand new cases of stroke with an incidence rate of 81.2/100,000 py (men 103.3, women 59.5), and about 1.89 million stroke survivors with a prevalence rate of 317.3/100000 population (men 335.5, women 299.3), both among people aged 15 years or more were estimated in 2009. A report in 2004 suggested that that about 8% of all first-ever strokes (about 5 million) occurred in Africa and 5% of over 30 million stroke survivors worldwide were in Africa <xref rid="pone.0100724-World1" ref-type="bibr">[5]</xref>, <xref rid="pone.0100724-Truelsen2" ref-type="bibr">[11]</xref>, and this amounts to about 400 thousand new stroke cases and 1.5 million stroke survivors. A systematic review in sub-Saharan Africa on studies published between 1966–2006 showed age-standardized prevalence rates of 114–315/100,000 populations and 154–281/100,000 population among men and women, respectively <xref rid="pone.0100724-Connor1" ref-type="bibr">[7]</xref>. Another review in 2006 showed that the prevalence of stroke survivors ranges from 200–300/100,000 population in sub-Saharan Africa, and incidence rates ranges from 15–68/100,000 py <xref rid="pone.0100724-Kengne1" ref-type="bibr">[42]</xref>. These figures are comparable with the current estimates, which further underpins a near representation of the burden of stroke in Africa. The minor differences may probably be due to the study periods, age groups, fewer data-points, focus on sub-Saharan Africa, and the fact that these were largely qualitative reviews and not based on a detailed statistical synthesis. However, according to the 2014 GBD estimates by Feigin and colleagues, over a 100% increase in the total number of new stroke cases and stroke survivors was recorded between 1990 and 2010 in LMIC, with an estimated incidence rate of 281.1/100,000 py and prevalence rate of 393.4/100,000 population in 2010 <xref rid="pone.0100724-Feigin1" ref-type="bibr">[1]</xref>. While it is understandable that not all LMIC have contextual similarities with African countries and direct comparisons may be inappropriate, it may however still be logical to conclude that the estimates from this study reflect the current stroke burden in many LMIC.</p><p>While this study aimed to provide an evidence-based continent-wide estimation of stroke incidence and prevalence rates in Africa through simple statistical analysis, the study has some important limitations. In particular the low research output and quality of selected studies from Africa constrained the overall analysis. There were 19 studies covering only 10 countries in Africa with an overall sample size of over 6.3 million. Moreover, stroke case ascertainment were not well defined across some studies, and this has been documented in some reviews <xref rid="pone.0100724-The1" ref-type="bibr">[45]</xref>. Due to these limited data and with some full texts assessed showing evidence of a detailed epidemiological exercise, an inclusion of some of these studies in our final analysis was allowed. In addition, some reported stroke incidence data were based on both first stroke and recurrent stroke events, and not all reported prevalence rates were strictly based on stroke survivors. However, having ensured all studies showed evidence of a degree of epidemiological survey rigour, and all extracted data points included in our modelling (refer to <xref ref-type="table" rid="pone-0100724-t002"><bold>Table 2</bold></xref>, and <bold>Table S3</bold> in <bold><xref ref-type="supplementary-material" rid="pone.0100724.s001">File S1</xref></bold>), the current estimates could still give a near representation of the burden of stroke in Africa.</p><sec id="s4a"><title>Public health response to stroke in Africa</title><p>The prevention of stroke and many non-communicable diseases in Africa has been affected mainly by weak health systems and poor government response <xref rid="pone.0100724-Bonita1" ref-type="bibr">[46]</xref>. To date, the priorities of many African countries remain infectious diseases: mainly HIV/AIDS, malaria and tuberculosis <xref rid="pone.0100724-Beaglehole1" ref-type="bibr">[3]</xref>, <xref rid="pone.0100724-Chan1" ref-type="bibr">[47]</xref>, despite the availability of affordable and cost effective stroke prevention initiatives <xref rid="pone.0100724-Walker3" ref-type="bibr">[48]</xref>, <xref rid="pone.0100724-Mensah2" ref-type="bibr">[49]</xref>. For example, Walker and colleagues reported that African countries do not have national strategies to address smoking, alcohol, physical inactivity and unhealthy diets including reducing salt and fat contents of processed foods <xref rid="pone.0100724-Walker3" ref-type="bibr">[48]</xref>; and stroke units, where the awareness on these risk factors could have been raised, are rarely available <xref rid="pone.0100724-Wahab1" ref-type="bibr">[12]</xref>, <xref rid="pone.0100724-Kolapo1" ref-type="bibr">[50]</xref>. The INTERSTROKE study findings show that hypertension is the main risk factor of all stroke subtypes with odds of about 2.64 <xref rid="pone.0100724-ODonnell1" ref-type="bibr">[8]</xref>, this is more prominent among young Africans who present with stroke unaware of their high blood pressure status <xref rid="pone.0100724-Walker1" ref-type="bibr">[15]</xref>. Truelsen argues that the prevalence of stroke in Africa might increase due to substantial changes in major stroke risk factors in the presence of a biased focus on the prevention and control of infectious diseases, at the expense of many NCDs <xref rid="pone.0100724-Truelsen3" ref-type="bibr">[51]</xref>.</p><p>The diagnosis of stroke in many African settings remain a huge challenge <xref rid="pone.0100724-Kengne1" ref-type="bibr">[42]</xref>. Some hospital surveys in sub-Saharan Africa have shown that CT scans are only conducted on less than half of patients presenting with stroke, and this is mainly among those that can afford it <xref rid="pone.0100724-Kengne1" ref-type="bibr">[42]</xref>, <xref rid="pone.0100724-Olubunmi1" ref-type="bibr">[52]</xref>. In fact, experts have reported that the unavailability and/or high costs of cranial CT imaging in many parts of Africa have limited information on the pathologic profiles of different stroke types in the continent, with this often affecting the diagnosis, treatment and the overall management of the disease <xref rid="pone.0100724-Olubunmi1" ref-type="bibr">[52]</xref>. Reports further show that in some areas with better population-wide access to CT scans, as the case in Tanzania, Ghana, and the Medical University of Southern African (MEDUNSA) Stroke Data Bank (MSDB), there have been improvements in diagnosis of stroke, with varying cases of ischaemic and haemorrhagic strokes reported <xref rid="pone.0100724-Joubert1" ref-type="bibr">[53]</xref>–<xref rid="pone.0100724-Nyame1" ref-type="bibr">[55]</xref>. Moreover, the challenges of appropriately distinguishing first from recurrent stroke episodes have also affected stroke case ascertainment, especially during epidemiological surveys <xref rid="pone.0100724-Connor1" ref-type="bibr">[7]</xref> Neurologists have noted the importance of proper planning during community surveys, active registration and follow-up of new stroke cases identified, and training and re-training of health workers on stroke diagnosis <xref rid="pone.0100724-Sudlow1" ref-type="bibr">[17]</xref>; arguing that the absence of these in many African settings have resulted in increased number of stroke cases in the community who have never had contact with standard health facilities, and inability to categorize these as first or recurrent strokes, including relating such existing stroke cases to a particular period during surveys <xref rid="pone.0100724-Connor1" ref-type="bibr">[7]</xref>, <xref rid="pone.0100724-Sudlow1" ref-type="bibr">[17]</xref>.</p><p>As noted earlier, a systematic review has suggested that income is a strong predictor of stroke risk and fatalities <xref rid="pone.0100724-Johnston1" ref-type="bibr">[6]</xref>. For example, the average cost of a cranial CT in Ugandan was approximately $60 USD between 2000 and 2010 <xref rid="pone.0100724-Chin1" ref-type="bibr">[2]</xref>. This is expensive in most African population groups where many still live below the poverty index of less than $1.25/day <xref rid="pone.0100724-World5" ref-type="bibr">[56]</xref>. The high cost of health services in the absence of an effective health insurance schemes and adequate resources allocated for stroke prevention and management has affected healthcare seeking behaviour in some African settings <xref rid="pone.0100724-Connor1" ref-type="bibr">[7]</xref>, <xref rid="pone.0100724-Walker4" ref-type="bibr">[57]</xref>. Many stroke patients have been managed at home due to lack of hospital funds, with only few presenting to standard health facilities several days after the onset of symptoms having tried low-priced under-resourced clinics <xref rid="pone.0100724-Chin1" ref-type="bibr">[2]</xref>. For those who manage to get to standard health facilities, there are also challenges arising from poor quality of care, as several studies have reported massive gaps exist in the management of acute stroke in Africa compared to many high income countries <xref rid="pone.0100724-Lemogoum1" ref-type="bibr">[58]</xref>, <xref rid="pone.0100724-Adoukonou1" ref-type="bibr">[59]</xref>.</p><p>The unavailability of data with low research output has been a major setback in the management of stroke in Africa <xref rid="pone.0100724-Truelsen3" ref-type="bibr">[51]</xref>. Experts have reported that reliable data from which evidence-based policy decisions can be made are sparse in Africa <xref rid="pone.0100724-Owolabi1" ref-type="bibr">[60]</xref>. Many have argued that no study in Africa can be regarded as an ideal stroke study <xref rid="pone.0100724-Sudlow1" ref-type="bibr">[17]</xref>, adding that there were no proper stroke registries and demographic health surveys which invariably limit active registration, follow-up of cases and conduct of community-based studies <xref rid="pone.0100724-The1" ref-type="bibr">[45]</xref>. Based on the current findings, hospital-based studies and door-to-door surveys were mainly conducted in Africa and despite the rigour of these few epidemiological surveys, gaps have been identified with regards to case ascertainment and study protocols <xref rid="pone.0100724-Bonita1" ref-type="bibr">[46]</xref>.</p><p>Our findings suggest an increasing burden of stroke in Africa. However, with the current low availability of data, there is still need for more research on stroke, and related vascular disease risk factors to appropriately quantify this burden. An investment in research capacity, basically to conduct and fund higher quality research may help raise awareness on stroke burden in Africa. An awareness and fair understanding of stroke burden and disease pattern in Africa may further prompt appropriate policy response and scale up current intervention programmes.</p></sec></sec><sec sec-type="supplementary-material" id="s5"><title>Supporting Information</title><supplementary-material content-type="local-data" id="pone.0100724.s001"><label>File S1</label><caption><p><bold>Table S1.</bold> Search terms (EMBASE). <bold>Table S2.</bold> Search terms (Global Health). <bold>Table S3.</bold> All data points employed in modelling.</p><p>(DOC)</p></caption><media xlink:href="pone.0100724.s001.doc"><caption><p>Click here for additional data file.</p></caption></media></supplementary-material><supplementary-material content-type="local-data" id="pone.0100724.s002"><label>Checklist S1</label><caption><p>PRISMA Checklist.</p><p>(DOC)</p></caption><media xlink:href="pone.0100724.s002.doc"><caption><p>Click here for additional data file.</p></caption></media></supplementary-material></sec></body><back><ack><p>The author wishes to thank Professors Harry Campbell and Igor Rudan for reviewing the models, and ‘Funke Davies-Adeloye for proof-reading the manuscript.</p></ack><ref-list><title>References</title><ref id="pone.0100724-Feigin1"><label>1</label><mixed-citation publication-type="journal"><name><surname>Feigin</surname><given-names>VL</given-names></name>, <name><surname>Forouzanfar</surname><given-names>MH</given-names></name>, <name><surname>Krishnamurthi</surname><given-names>R</given-names></name>, <name><surname>Mensah</surname><given-names>GA</given-names></name>, <name><surname>Connor</surname><given-names>M</given-names></name>, <etal>et al</etal> (<year>2014</year>) <article-title>Global and regional burden of stroke during 1990–2010: findings from the Global Burden of Disease Study 2010</article-title>. <source>Lancet</source><volume>383</volume>: <fpage>245</fpage>–<lpage>255</lpage>.<pub-id pub-id-type="pmid">24449944</pub-id></mixed-citation></ref><ref id="pone.0100724-Chin1"><label>2</label><mixed-citation publication-type="journal"><name><surname>Chin</surname><given-names>JH</given-names></name> (<year>2012</year>) <article-title>Stroke in Sub-Saharan Africa: An Urgent Call For Prevention</article-title>. <source>Neurology</source><volume>78</volume>: <fpage>1007</fpage>–<lpage>1008</lpage>.<pub-id pub-id-type="pmid">22454267</pub-id></mixed-citation></ref><ref id="pone.0100724-Beaglehole1"><label>3</label><mixed-citation publication-type="journal"><name><surname>Beaglehole</surname><given-names>R</given-names></name>, <name><surname>Bonita</surname><given-names>R</given-names></name>, <name><surname>Alleyne</surname><given-names>G</given-names></name>, <name><surname>Horton</surname><given-names>R</given-names></name>, <name><surname>Li</surname><given-names>L</given-names></name>, <etal>et al</etal> (<year>2011</year>) <article-title>UN High-Level Meeting on Non-Communicable Diseases: addressing four questions</article-title>. <source>Lancet</source><volume>378</volume>: <fpage>449</fpage>–<lpage>455</lpage>.<pub-id pub-id-type="pmid">21665266</pub-id></mixed-citation></ref><ref id="pone.0100724-Strong1"><label>4</label><mixed-citation publication-type="journal"><name><surname>Strong</surname><given-names>K</given-names></name>, <name><surname>Mathers</surname><given-names>CD</given-names></name>, <name><surname>Bonita</surname><given-names>R</given-names></name> (<year>2007</year>) <article-title>Preventing stroke: saving lives around the world</article-title>. <source>Lancet Neurol</source><volume>6</volume>: <fpage>182</fpage>–<lpage>187</lpage>.<pub-id pub-id-type="pmid">17239805</pub-id></mixed-citation></ref><ref id="pone.0100724-World1"><label>5</label><mixed-citation publication-type="other">World Health Organization (2004) Global Burden of Disease (GBD) 2002 estimates. 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