Prevalence of stroke in China: overestimated? – Authors' reply
Authors: Hualiang Lin, Maigeng Zhou, Simon I Hay
Journal: The Lancet Public Health (2022)

We thank Wen-Jun Tu and colleagues for their interest and concern that the prevalence of stroke might have been overestimated in China in the Global Burden of Disease Study Injuries, and Risk Factors Study (GBD) 2019.1Ma Q Li R Wang L et al.Temporal trend and attributable risk factors of stroke burden in China, 1990–2019: an analysis for the Global Burden of Disease Study 2019.Lancet Public Health. 2021; 6: e897-e906Summary Full Text Full Text PDF PubMed Scopus (44) Google Scholar Here we discuss the possible reasons for the differences in the stroke prevalence from the GBD 2019 and the China Stroke Prevention Project Committee.Of note, accurate estimates of stroke burden require prospective population-based studies that meet gold standard criteria.2Feigin VL Norrving B Mensah GA Global burden of stroke.Circ Res. 2017; 120: 439-448Crossref PubMed Scopus (1005) Google Scholar The China Stroke Prevention Project Committee is one of the most representative and comprehensive efforts to prevent stroke in China, and the results of the project were used by the GBD 2019 stroke collaborators to generate estimates. In addition, several other resources associated with stroke incidence, prevalence and outcomes, and other resources from hospital and community-based stroke registries in China, were also considered in estimating stroke burden in GBD 2019.3Roth GA Johnson CO Nguyen G et al.Methods for estimating the global burden of cerebrovascular diseases.Neuroepidemiology. 2015; 45: 146-151Crossref PubMed Scopus (34) Google Scholar, 4GBD 2019 Stroke CollaboratorsGlobal, regional, and national burden of stroke and its risk factors, 1990–2019: a systematic analysis for the Global Burden of Disease Study 2019.Lancet Neurol. 2021; 20: 795-820Summary Full Text Full Text PDF PubMed Scopus (329) Google Scholar Of these resources, the China National Stroke Screening Survey between 2013 and 2014 reported an adjusted stroke prevalence rate of 2·06% in adults aged 40 years and older.5Guan T Ma J Li M et al.Rapid transitions in the epidemiology of stroke and its risk factors in China from 2002 to 2013.Neurology. 2017; 89: 53-61Crossref PubMed Scopus (124) Google ScholarMoreover, the National Epidemiological Survey of 480 687 adults aged 20 years and older estimated that there were 11 million prevalent stroke cases in China in 2013.6Wang W Jiang B Sun H et al.Prevalence, incidence, and mortality of stroke in China: results from a nationwide population-based survey of 480 687 Adults.Circulation. 2017; 135: 759-771Crossref PubMed Scopus (1148) Google Scholar In 2020, the China Stroke Prevention Project Committee estimated that the number of patients with stroke in China was 17·88 million.7Chao BH Tu WJ Wang LD Initial establishment of a stroke management model in China: 10 years (2011–2020) of Stroke Prevention Project Committee, National Health Commission.Chinese Med J. 2021; 134: 2418-2420Crossref PubMed Scopus (9) Google Scholar According to estimates by the committee, the annual average increase in the number of stroke cases was about 1 million per year from 2013 to 2020. In GBD 2019, the number of people who did not die due to their stroke increased from 22·44 million in 2013 to 28·76 million in 2019, with an average increase of 1·05 million people per year.1Ma Q Li R Wang L et al.Temporal trend and attributable risk factors of stroke burden in China, 1990–2019: an analysis for the Global Burden of Disease Study 2019.Lancet Public Health. 2021; 6: e897-e906Summary Full Text Full Text PDF PubMed Scopus (44) Google Scholar The average increase in stroke cases per year from 2013 to 2019 was generally consistent between the GBD 2019 and the China Stroke Prevention Project Committee. Moreover, in 2013, the age-standardised prevalence rate of stroke was 1·38% in GBD 2019 similar to the 1·11% reported by the China Stroke Prevention Project Committee.6Wang W Jiang B Sun H et al.Prevalence, incidence, and mortality of stroke in China: results from a nationwide population-based survey of 480 687 Adults.Circulation. 2017; 135: 759-771Crossref PubMed Scopus (1148) Google Scholar We observed that the difference in the age-standardised prevalence rate estimated in the GBD 2019 and by the China Stroke Prevention Project Committee was smaller than the difference in the number of people who did not die due to stroke in 2013.Despite differences, which we attribute largely to the more comprehensive use of all available data in GBD 2019, both studies shared similar conclusions: although the disease burden of stroke is still severe in China, the observed decrease in age-standardised incidence and mortality rates suggest that substantial progress has been made with the current stroke prevention and treatment strategy. However, future efforts in the advancement of public awareness, improvement of medical treatment and services, and management of stroke risk factors are still needed. It will also be important to measure stroke burden proactively in the future to help better understand the full effect of the China Stroke Prevention Project Committee initiatives. We thank Wen-Jun Tu and colleagues for their interest and concern that the prevalence of stroke might have been overestimated in China in the Global Burden of Disease Study Injuries, and Risk Factors Study (GBD) 2019.1Ma Q Li R Wang L et al.Temporal trend and attributable risk factors of stroke burden in China, 1990–2019: an analysis for the Global Burden of Disease Study 2019.Lancet Public Health. 2021; 6: e897-e906Summary Full Text Full Text PDF PubMed Scopus (44) Google Scholar Here we discuss the possible reasons for the differences in the stroke prevalence from the GBD 2019 and the China Stroke Prevention Project Committee. Of note, accurate estimates of stroke burden require prospective population-based studies that meet gold standard criteria.2Feigin VL Norrving B Mensah GA Global burden of stroke.Circ Res. 2017; 120: 439-448Crossref PubMed Scopus (1005) Google Scholar The China Stroke Prevention Project Committee is one of the most representative and comprehensive efforts to prevent stroke in China, and the results of the project were used by the GBD 2019 stroke collaborators to generate estimates. In addition, several other resources associated with stroke incidence, prevalence and outcomes, and other resources from hospital and community-based stroke registries in China, were also considered in estimating stroke burden in GBD 2019.3Roth GA Johnson CO Nguyen G et al.Methods for estimating the global burden of cerebrovascular diseases.Neuroepidemiology. 2015; 45: 146-151Crossref PubMed Scopus (34) Google Scholar, 4GBD 2019 Stroke CollaboratorsGlobal, regional, and national burden of stroke and its risk factors, 1990–2019: a systematic analysis for the Global Burden of Disease Study 2019.Lancet Neurol. 2021; 20: 795-820Summary Full Text Full Text PDF PubMed Scopus (329) Google Scholar Of these resources, the China National Stroke Screening Survey between 2013 and 2014 reported an adjusted stroke prevalence rate of 2·06% in adults aged 40 years and older.5Guan T Ma J Li M et al.Rapid transitions in the epidemiology of stroke and its risk factors in China from 2002 to 2013.Neurology. 2017; 89: 53-61Crossref PubMed Scopus (124) Google Scholar Moreover, the National Epidemiological Survey of 480 687 adults aged 20 years and older estimated that there were 11 million prevalent stroke cases in China in 2013.6Wang W Jiang B Sun H et al.Prevalence, incidence, and mortality of stroke in China: results from a nationwide population-based survey of 480 687 Adults.Circulation. 2017; 135: 759-771Crossref PubMed Scopus (1148) Google Scholar In 2020, the China Stroke Prevention Project Committee estimated that the number of patients with stroke in China was 17·88 million.7Chao BH Tu WJ Wang LD Initial establishment of a stroke management model in China: 10 years (2011–2020) of Stroke Prevention Project Committee, National Health Commission.Chinese Med J. 2021; 134: 2418-2420Crossref PubMed Scopus (9) Google Scholar According to estimates by the committee, the annual average increase in the number of stroke cases was about 1 million per year from 2013 to 2020. In GBD 2019, the number of people who did not die due to their stroke increased from 22·44 million in 2013 to 28·76 million in 2019, with an average increase of 1·05 million people per year.1Ma Q Li R Wang L et al.Temporal trend and attributable risk factors of stroke burden in China, 1990–2019: an analysis for the Global Burden of Disease Study 2019.Lancet Public Health. 2021; 6: e897-e906Summary Full Text Full Text PDF PubMed Scopus (44) Google Scholar The average increase in stroke cases per year from 2013 to 2019 was generally consistent between the GBD 2019 and the China Stroke Prevention Project Committee. Moreover, in 2013, the age-standardised prevalence rate of stroke was 1·38% in GBD 2019 similar to the 1·11% reported by the China Stroke Prevention Project Committee.6Wang W Jiang B Sun H et al.Prevalence, incidence, and mortality of stroke in China: results from a nationwide population-based survey of 480 687 Adults.Circulation. 2017; 135: 759-771Crossref PubMed Scopus (1148) Google Scholar We observed that the difference in the age-standardised prevalence rate estimated in the GBD 2019 and by the China Stroke Prevention Project Committee was smaller than the difference in the number of people who did not die due to stroke in 2013. Despite differences, which we attribute largely to the more comprehensive use of all available data in GBD 2019, both studies shared similar conclusions: although the disease burden of stroke is still severe in China, the observed decrease in age-standardised incidence and mortality rates suggest that substantial progress has been made with the current stroke prevention and treatment strategy. However, future efforts in the advancement of public awareness, improvement of medical treatment and services, and management of stroke risk factors are still needed. It will also be important to measure stroke burden proactively in the future to help better understand the full effect of the China Stroke Prevention Project Committee initiatives. We declare no competing interests. Temporal trend and attributable risk factors of stroke burden in China, 1990–2019: an analysis for the Global Burden of Disease Study 2019The disease burden of stroke is still severe in China, although the age-standardised incidence and mortality rates have decreased since 1990. The stroke burden in China might be reduced through blood pressure management, lifestyle interventions, and air pollution control. Moreover, because substantial heterogeneity of stroke burden existed in different provinces, improved health care is needed in provinces with heavy stroke burden. Full-Text PDF Open AccessPrevalence of stroke in China: overestimated?In their Article, Ma and colleagues1 assessed the disease burden of stroke and its risk factors at national and provincial levels in China from 1990 to 2019. The results showed that in 2019, there were 3·94 million new stroke cases and 28·76 million prevalent cases of stroke in China,1 suggesting that the disease burden of stroke is still severe in China. The Global Burden of Disease Study Injuries, and Risk Factors Study (GBD) 2019 Stroke Collaborators compared the disease burden of stroke and its risk factors over time from 1990 to 2019 across locations and by sex and age. Full-Text PDF Open Access