Prevalence of stroke in China: overestimated?

In their Article, Ma and colleagues1Ma 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 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,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 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.2GBD 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 Ma and colleagues1Ma 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 used the GBD 2019 data to estimate the trends of the disease burden of stroke in China. However, the prevalent cases of stroke have caught our attention.The National Epidemiological Survey of Stroke indicated annual estimates of 11 million prevalent stroke cases in China in 2013.3Wang 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 This survey shows that the number of patients with stroke in China has increased by 17·76 million in the past 6 years; an average increase of 2·96 million per year. Furthermore, Ma and colleagues1Ma 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 found 3·94 million new stroke cases and 2·19 million deaths in China in 2019, meaning prevalent stroke cases increased by 1·75 million.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 In addition, the China Stroke Prevention Project Committee estimates that the number of patients with stroke in China in 2020 was 17·88 million, 3·48 million less than the 21·36 million patients forecasted by the World Bank in 2011.4Chao 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.Chin Med J. 2021; 134: 2418-2420Crossref PubMed Scopus (9) Google Scholar To meet the stroke challenge, the China Stroke Prevention Project Committee was established by the Chinese Ministry of Health in April, 2011, to lead and improve stroke prevention and treatment.5Chao BH Yan F Hua Y et al.Stroke prevention and control system in China: CSPPC-stroke program.Int J Stroke. 2021; 16: 265-272Crossref PubMed Scopus (74) Google Scholar Since 2011, the committee's technical programme for screening and comprehensive intervention for patients at a high-risk of stroke has been implemented in 245 cities (1671 screening points) in 31 provinces across China, covering more than 2% of the target population.4Chao 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.Chin Med J. 2021; 134: 2418-2420Crossref PubMed Scopus (9) Google Scholar Furthermore, the stroke outcomes appear to have improved from 2002 to 2013, possibly due to improvements in hospital-based stroke care.6Wu S Wu B Liu M et al.Stroke in China: advances and challenges in epidemiology, prevention, and management.Lancet Neurol. 2019; 18: 394-405Summary Full Text Full Text PDF PubMed Scopus (547) Google ScholarThus, the prevalent cases of stroke in China might be overestimated by Ma and colleagues. More data are required across time and regions—particularly for rural areas—to provide an unbiased overview of stroke burden in China. According to the work of the Stroke Prevention Project Committee, we estimated there were around 18 million prevalent cases of stroke in China in 2019. As the burden of stroke increases, more prevention and control strategies need to be implemented. However, overestimating stroke burden is very unfavourable for the implementation of the country's chronic non-communicable disease prevention and control strategy and will have a negative effect on the effective implementation of the Healthy China 2030 plan. In their Article, Ma and colleagues1Ma 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 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,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 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.2GBD 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 Ma and colleagues1Ma 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 used the GBD 2019 data to estimate the trends of the disease burden of stroke in China. However, the prevalent cases of stroke have caught our attention. The National Epidemiological Survey of Stroke indicated annual estimates of 11 million prevalent stroke cases in China in 2013.3Wang 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 This survey shows that the number of patients with stroke in China has increased by 17·76 million in the past 6 years; an average increase of 2·96 million per year. Furthermore, Ma and colleagues1Ma 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 found 3·94 million new stroke cases and 2·19 million deaths in China in 2019, meaning prevalent stroke cases increased by 1·75 million.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 In addition, the China Stroke Prevention Project Committee estimates that the number of patients with stroke in China in 2020 was 17·88 million, 3·48 million less than the 21·36 million patients forecasted by the World Bank in 2011.4Chao 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.Chin Med J. 2021; 134: 2418-2420Crossref PubMed Scopus (9) Google Scholar To meet the stroke challenge, the China Stroke Prevention Project Committee was established by the Chinese Ministry of Health in April, 2011, to lead and improve stroke prevention and treatment.5Chao BH Yan F Hua Y et al.Stroke prevention and control system in China: CSPPC-stroke program.Int J Stroke. 2021; 16: 265-272Crossref PubMed Scopus (74) Google Scholar Since 2011, the committee's technical programme for screening and comprehensive intervention for patients at a high-risk of stroke has been implemented in 245 cities (1671 screening points) in 31 provinces across China, covering more than 2% of the target population.4Chao 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.Chin Med J. 2021; 134: 2418-2420Crossref PubMed Scopus (9) Google Scholar Furthermore, the stroke outcomes appear to have improved from 2002 to 2013, possibly due to improvements in hospital-based stroke care.6Wu S Wu B Liu M et al.Stroke in China: advances and challenges in epidemiology, prevention, and management.Lancet Neurol. 2019; 18: 394-405Summary Full Text Full Text PDF PubMed Scopus (547) Google Scholar Thus, the prevalent cases of stroke in China might be overestimated by Ma and colleagues. More data are required across time and regions—particularly for rural areas—to provide an unbiased overview of stroke burden in China. According to the work of the Stroke Prevention Project Committee, we estimated there were around 18 million prevalent cases of stroke in China in 2019. As the burden of stroke increases, more prevention and control strategies need to be implemented. However, overestimating stroke burden is very unfavourable for the implementation of the country's chronic non-communicable disease prevention and control strategy and will have a negative effect on the effective implementation of the Healthy China 2030 plan. 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? – Authors' replyWe 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) 2019.1 Here we discuss the possible reasons for the differences in the stroke prevalence from the GBD 2019 and the China Stroke Prevention Project Committee. Full-Text PDF Open Access