An Epidemiological Study of Hemiplegia due to Stroke in South India

An Epidemiological Study of
Hemiplegia due to Stroke in South India
BY J. ABRAHAM, M.D., P. S. S. RAO,* S. G. INBARAJ.f G. SHETTY, M.D., AMD C. J.
JOSE, M.D.
Abstract:
An
Epidemiological
Study of
Hemiplegia
due to
Stroke in
South India
• The findings of a preliminary epidemiological survey of Vellore, South
India, and adjoining rural areas are presented. The prevalence of "completed
strokes" and hemiplegias due to any cause is 56.9 per 100,000. The high
incidence of hemiplegia in the young has been pointed out. The need for
concerted efforts for a proper evaluation of the incidence of cerebrovascular
disease in India seems imperative.
ADDITIONAL KEY WORDS
puerperal phlebothrombosis
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• The incidence of cerebrovascular disease
varies in different parts of the world, and this
group of disorders has become of vital
importance in world health with increasing age
of populations. Data regarding the incidence of
cerebrovascular disease in India are not
available through any population-based studies, although some information on hospital
incidence of stroke* is available from a few
centers in India.1"6 It is generally agreed that
hospital incidence of a disease is a fallacious
figure by which to judge the prevalence of the
disease in a population. Therefore, an
epidemiological study covering a population of
about 200,000 in and around Vellore, South
India, was undertaken during 1968 and 1969
by the Departments of Neurological Sciences
and Biostatistics of the Christian Medical
College Hospital, Vellore, to assess the
prevalence of hemiplegia. All cases of
completed stroke with hemiplegia due to
cerebrovascular disease or any other etiology
From the Departments of Neurological Sciences and
Biostatistics, Christian Medical College Hospital,
Vellore-4, South India. #Chief, DepL of Biostatistics;
fstatistician.
•The word stroke as is used in this article is taken
to mean hemiplegia due to any etiology in this
population. Approximately 85% were completed
strokes, 13% had infantile hemiplegia, and 2% occurred from miscellaneous causes.
Slrokt, Vol. I, Nov«mbor-0ec«mb»r 7970
cerebral infarction
prevalence rate
were included in the study. General findings
from this study are reported herein.
Geography
Vellore (area 11.65 sq km) lies between 11°
55' and 13° 15' of the northern latitude and
78° 2(Y and 79° 507 of the eastern longitude.
The weather is warm throughout the year; the
temperature varies from 15°C in December
and January and to 42°C in May and June. The
average rainfall in the district is about 101 cm
annually. The relative humidity varies between
35% to 90% but averages around 60% most
of the year.
Diet
A majority of the population are nonvegetarian, but consumption of meat is infrequent due
to economical considerations. The average per
capita consumption per day of protein is 35 to
60 gm, of fats (mainly vegetable) 7 to 35 gm,
and of carbohydrates 300 to 400 gm, giving a
total caloric intake of 1,600 to 2,100. The
ratio of fats to protein to carbohydrate is
21:47:370.6
Religion
Of the total population, 91.17% are Hindus,
6.32% are Muslims, 2.15% are Christians,
0.29% are Jains, and other religions make up
the remaining 0.07%.
477
ABRAHAM, RAO, INBARAJ, SHETTY, JOSE
TABLE 1
Age onof Sex Distribution of Population Surveyed
Population
Fcmat*
Aga group
(yean)
Mole
0-9
10-19
20-29
30-39
40-49
50-59
60-69
70 and above
34,941
26,872
20,932
18,291
13,708
8,679
5,281
2,705
37,743
23,856
21,783
16,013
11,978
8,132
5,142
2,520
72,684
50,728
42,715
34,304
25,686
16,811
10,423
5,225
131,409
127,167
258,576
Total
Total
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Occupation
The main occupation in the rural area is
agriculture; petty business and cottage industries come second. In the town, trade and
commerce of various grains, tobacco and
commodities such as jaggery, vegetables, cloth,
brassware and ornaments are the occupations
of a sizeable section of the community. In
Vellore, an equally large number of persons
are engaged in professional, technical and
white-collar jobs. The average per capita
income of the population per annum is $44.
Methods
The entire town of Vellore and two of the
adjacent rural blocks of about 10.5 sq km area
were included for this study. The total population
actually surveyed in both the urban (Vellore
town) and the rural areas was 258,576. The agesex distribution of the sampled population is given
in table 1.
The survey was conducted by 16 field
workers and four supervisors who underwent a
training and orientation program for six weeks.
The training included case demonstration of
hospitalized stroke patients and practice and
familiarization with the proforma to be used in
the survey. In addition they were taught to use the
sphygmomanometer to record blood pressure. The
emphasis, however, was to orient the field workers
to detect any form of paralysis or lack of
movement of a limb.
The plan of survey consisted of an interview
with a responsible member in each family, usually
the wife of the head of the household. Repeated
visits were made by the field workers, and every
effort was made to survey all the families in the
geographically defined area. Over the period of
one year it was thus possible to obtain
information for the entire population included in
the study. A specially prepared proforma was used
during the interview to ascertain whether any
member of the family had, or ever had had, any
paralysis or weakness of the limbs or, if following
a febrile illness, had developed weakness in one or
more limbs. If affirmative, then details were noted
as to the side affected, whether the upper and
lower limbs were affected, and whether the face
was involved. Also, whether the attack of
paralysis was associated with loss of consciousness, the period of the year when it occurred, and
whether the ailment still persisted. The interviewers also checked to determine whether any case of
paralysis had occurred among any member of the
family who had migrated or died during the
previous year.
The cases of paralysis identified by the field
interviewers were termed "suspects," and each of
them was given a referral slip to attend the
Neurological Clinic at the Christian Medical
College Hospital, Vellore. Confirmation of the
diagnosis of stroke was made at the Clinic. The
"suspects" who failed to attend the Clinic were
visited at their homes by one of the neurologists
and the diagnosis was ascertained. It was possible
to examine all the "suspects."
TABLE 2
Number of Suspected and Confirmed Stroke Cases by Age and Sex
Age group
(years)
0-9
10-19
20-29
30-39
40-49
50-59
60-69
70 and above
478
Suspected
stroke cases
F • male
Male
75
58
72
51
90
90
87
51
49
59
133
139
105
79
66
41
Confirmed stroke
cases
Female
Mate
6
3
4
7
13
16
19
22
4
6
4
6
12
7
6
12
Percenta oe of stroke
cases to the suspects
Male
Female
8.0
5.2
5.5
13.7
14.4
17.8
21.8
43.1
8.2
10.2
3.0
4.3
11.4
8.9
9.1
29.3
Stroke, Vol. I , November-December 1970
HEMIPLEGIA DUE TO STROKE
TABLE 3
Age-Sex Specific Prevalence of Stroke
Prevotonice rote per
100,000
Female
Age group
Tyeori)
Male
0-9
10-14
15-19
20-24
25-29
30-39
40-49
50-59
60-69
70 and above
17.2
7.3
15.2
9.5
28.8
38.3
94.8
184.4
359.8
813.3
10.6
16.9
33.3
27.8
9.1
37.5
100.2
86.1
116.7
476.2
13.1
11.7
23.9
18.8
18.7
37.9
97.3
136.8
239.9
650.7
68.5
44.8
56.9
Total
Total
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The diagnostic criteria used for confirmation
of a case were based on a history of an ictus
following which there was paralysis of one side of
the body, or any episode of illness which was
followed by hemiplegia. This was then checked by
a careful neurological examination. No attempt to
categorize the cerebrovascular accidents into
embolic, thrombotic or hemorrhagic was made
nor was there any attempt made to identify
specific etiological factors in the confirmed
hemiplegics.
Findings
A total of 1,245 persons were identified as
suffering from paralysis, paresis, inability to
use a limb, bed-ridden, etc., and were classified
as "suspects" by the field workers. Of the
1,245 "suspects," 147 were identified as
genuine strokes with hemiplegia by the
neurologists.
The number of suspects and the
percentage confirmed to the total suspects in
each age and sex group are presented in table
2. From this table it is observed that a
relatively smaller percentage of cases in the
lower age groups were ultimately confirmed to
be patients suffering from strokes. It is also
observed that 40 of the confirmed hemiplegics
among the 147, or nearly 25%, were under 40
years of age.
The prevalence rate per 100,000 population is 68.5 in males and 44.8 in females. The
age-sex specific rates are indicated in table 3
and figure 1. It is evident that the prevalence
rate increases with age and that there is a
statistically significant male preponderance in
the age groups above 50 years (P < 0.01).
Strok;
Vol. 1, Novembur-Docember 1970
The rural and urban differences in
prevalence are shown in table 4. While the
female rates are lower in both rural and urban
areas, the rural rates are lower than urban.
Further analysis on this difference is under
way.
Discussion
This study was undertaken to assess the
prevalence of hemiplegia in all age groups.
That the sample population studied is not
biased is shown in figure 2, where the
population according to age and sex in India
during the 1961 census is compared to the
population studied. The surveyed population in
Vellore and in the surrounding rural areas
represents quite adequately the conditions of
villages and towns in southern India, barring
the major cities such as Madras. The southern
states in India, which include Andhra Pradesh,
Tamil Nadu, Pondicherry, Mysore and Kerala,
had an estimated population of 131 million in
1969. Thus, we could expect at least 75,000
persons to be affected with hemiplegia due to
stroke. Though the other parts of India might
differ from the southern areas in terms of both
FIGURE I
AGE SPECIFIC PREVALENCE RATE BY SEX
(RATE PER 100, 000 POPULATION)
4 00.0
3 0 0.0 Z'Z
2 0 0.0
MALE
FEMALE
TOTAL
///
100.0-
40.0-
3 0.0-
20.0-
10.0-
/ //
jf'-A Ui
V
/ \
;
/
10
\
\
20
30
40
50
60
ACE
479
ABRAHAM, RAO, INBARAJ, SHETTY, JOSE
TABLE 4
Prevalence of Stroke (per 100,000) According to
Region and Sex
Region
Male
Female
Urban
Rural
74
64
53
38
63
31
Total
69
45
57
Total
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climatic factors and dietary habits, one could
reasonably expect similar conditions with
regard to environmental and social conditions.
We might, therefore, expect at least 300,000
affected persons in the whole of India. Even
though this is a pilot study and probably the
first of its kind in India, it focuses attention on
the tremendous need for further concerted
efforts to study the problem of stroke on a
nationwide basis.
The total number of people who suffer
from cerebrovascular disease of all types will
naturally be considerably higher. However, as
autopsy and morbidity studies have not been
done in India, the exact extent of this disease is
unknown.
A unique finding in this study was that
FIGJICUMULATIVE PERCENTAGE DISTRIBUTION OF
AGE FOR MALES I FEMALES FOR ALL INDIA
I CURRENT STUDY
100
ALL-INDIA (1961)
80
<
z
Acknowledgment
60
Part of the expenses for this study were met by the
grant No. VRA-IND-29-67 and from the Social and
Rehabilitation Service, United States Department of
Health, Education and Welfare.
UJ
u
25% of the stroke patients were below the age
of 40 years. This is further corroborated by the
findings of a prospective study of strokes done
in this department which show a similar
incidence of stroke in the younger age group.7
The high incidence of stroke in the younger age
group is also seen in some studies reported
from other Indian centers.8-8 Therefore, this
finding is not peculiar to the South alone. The
etiological factors at play in the younger age
group are perhaps different from the older age
groups, and ongoing studies examining this are
under way. The higher prevalence rate among
women in the early childbearing period (the
late teens) is obviously due to puerperal
phlebothrombosis or thrombophlebitis,* but the
factors which predispose to the development of
this condition require further study.
The prevalence rate of 13.1 per 100,000
in the 0 to 9-year age group is disconcerting.
This large number denotes that birth injuries
and early infective lesions leaving hemiplegia
as a sequela are still important factors. Unless
the etiology is understood and proper
preventive measures taken, this group of
patients with a fairly long life expectancy will
only serve to increase the demands on an
already economically overburdened society.
A prospective longitudinal study to
evaluate the incidence of stroke and to assess
the influence of factors such as hypertension,
diabetes, syphilis, diet and the weather is
necessary to obtain a broader and truer
conception of some of the aspects of
cerebrovascular disease as it exists in India.
40
Q.
0.
References
20
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ACE CROUP (TEARS)
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Vol. 1, November-December 7970
HEMIPLEGIA DUE TO STROKE
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Strok;
Vol. 1, Noyember-Dtctmbtr 1970
481
An Epidemiological Study of Hemiplegia due to Stroke in South India
J. ABRAHAM, P. S. S. RAO, S. G. INBARAJ, G. SHETTY and C. J. JOSE
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Stroke. 1970;1:477-481
doi: 10.1161/01.STR.1.6.477
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