Organization of stroke care in Japan

Takafumi Kubota^1,2, Arsalan Anwar^3, and Sidra Saleem³

1.     Department of Neurology, Teine Keijinkai Hospital, Sapporo, Japan
2.     Department of Neurology, University Hospitals of Cleveland Medical Center/Case Western Reserve University, OH, U.S.A.
3.     Department of Internal Medicine, Dr. Ruth Pfau Hospital, Karachi, Pakistan.

Abstract

In Japan, stroke is one of the major health problems. In particular, stroke has become a major factor in disability-adjusted life-years as the population ages, and is a significant burden on medical expenses. Therefore, Japan makes many efforts to lower age-adjusted mortality from stroke and extend a healthy life expectancy.

Stroke is the second most common cause of mortality and disability-adjusted life-years (DALYs), worldwide [1]. In Japan, the mortality rate of stroke has declined from 180 per 10000 in 1970 to 87 per 10000 in 2018, however, it still remains the fourth most common cause of death after cancer, cardiovascular disease, and senility [2]. The DALYs impact produced by this disease is 30% of the Japanese population. Therefore, the economic health care burden produced by stroke is 1.56 trillion dollars in health costs and 1.74 trillion dollars in nursing care costs [3]. The subtypes of ischemic stroke have also been changing. In the last four decades, as a result of changes in the salty traditional diet to the western fatty diet as well as the prevention of hypertension, the incidence of lacunar infarction in ischemic stroke steadily declined by 59% for men and by 28% for women [4]. On the other hand, the percentage of cardio-embolic and atherothrombotic stroke in ischemic stroke increased from 44.9% in 1984-1998 to 60.7% in 1998-2000 [5]. 

  The decline in stroke incidence is due to the contribution of Japan Stroke Society (JSS), which was established in 1975. It has provided a wide range of initiatives such as acute care, prevention, education, and rehabilitation. Currently, the JSS works with the Japanese Circulation Society (JCS) on two main goals to improve individual lives and reduce the economic burden. The first goal is to lower age-adjusted mortality from stroke and cardiovascular disease by 5% in 5 years and by 10% in 10 years.  The second goal is extending a healthy life expectancy. To achieve these two goals, the JSS has five strategies as follows; (1) Human resource development, (2) Enhancement of the medical system, (3) Promotion of registration business, (4) Prevention, and (5) Strengthening of clinical and basic research [6].   

  In Japan, there are 1,369 certified training institutions of the Japan Neurosurgical Society, the Japanese Society of Neurology, and/or the JSS. The institutions are divided into two types of the center. First, the primary stroke center (PSS) can perform standard evaluations such as MRI or CT and treatment including recombinant tissue plasminogen activator (rtPA) at any time in twenty-hour seven.  The necessary requirements for PSS were published in 2017, and the application of the primary stroke center was started in July 2019. Second, the comprehensive stroke center (CSC) is capable of advanced neurosurgery, endovascular surgery, stroke care unit and/or intensive care unit in addition to PSS requirements. The distribution, number, and mutual relationship of each other will be organized within a few years [3,7-9].

  For functional recovery after acute stroke care, rehabilitation medicine for stroke in Japan has improved since the beginning of the convalescent rehabilitation ward in 2000.  The patients can be hospitalized for rehabilitation up to 180 days with national health insurance, 3 hours per day including weekends of rehabilitation.  The convalescent rehabilitation hospitals have increased up to 1,348 hospitals and 76,631 beds (60 beds per 100,000) in 2015 which can cover the demand of 25 beds per 100,000 [10].  After being discharged from the convalescent rehabilitation hospitals, the patients are treated by the regional comprehensive care system such as outpatient clinics, visiting nursing stations, and home rehabilitation [7].

  The JSS also actively works to prevent stroke through lifestyle modifications and educating people about prevention. The prevention is primarily divided into four stages based on the severity as follows; (1) Improvement of lifestyle through public education, (2) Intervention for lifestyle-related diseases through primary care, (3) Early detection and intervention of stroke, and (4) Decrease in the mortality associated with stroke.  The JSS sets each goal in four stages and monitors the results [7].

  In conclusion, Japan is aware of the impact of stroke on individual life and economic burden. In the last 40 years, Japan makes many efforts to lower age-adjusted mortality from stroke and improve the outcomes.

Reference

[1]  Johnson CO, Nguyen M, Roth GA, Nichols E, Alam T, Abate D, Abd-Allah F, Abdelalim A, Abraha HN, Abu-Rmeileh NM, Adebayo OM. Global, regional, and national burden of stroke, 1990–2016: a systematic analysis for the Global Burden of Disease Study 2016. The Lancet Neurology. 2019 May 1;18(5):439-58.

[2]  Statistics and Information Department, Ministry of Health, Labor and Welfare (MHLW), Japan. Overview of Demographic Statistics Monthly Report  2018. https://www.mhlw.go.jp/toukei/saikin/hw/jinkou/geppo/nengai18/dl/gaikyou30.pdf.  (accessed Dec 23, 2019).

[3]      Toyoda K, Sonoda K, Sato S, Yoshimura Sl. The Japan Stroke Databank Current stroke care in Japan and ideal stroke registries. Shinkeichiryo 2018;35(3)192. https://www.jstage.jst.go.jp/article/jsnt/35/3/35_188/_pdf/-char/ja. (accessed Dec 23, 2019).

[4]     Kubo M, Kiyohara Y, Ninomiya T, Tanizaki Y, Yonemoto K, Doi Y, Hata J, Oishi Y, Shikata K, Iida M. Decreasing incidence of lacunar vs other types of cerebral infarction in a Japanese population. Neurology 2006;66:1539–1544

[5]      Yukito Shinohara. Regional Differences in Incidence and Management of Stroke – Is There Any Difference between Western and Japanese Guidelines on Antiplatelet Therapy?. Crebrovasc Dis 2006;21(suppl 1):17–24 DOI: 10.1159/000090358

[6]      Kokubo K.  Changes in stroke Japan and other countries.  Japanese Journal of Cardiovascular Disease Prevention 2017; 52(3) 223-232.  http://www.jacd.info/library/jjcdp/review/52-3_01_%20kokubo.pdf. (accessed Dec 23, 2019).

[7]      The Japan Stroke Society.  5-year plan to overcome stroke and cardiovascular diseases. http://www.jsts.gr.jp/img/five_year_plan.pdf.  (accessed Nov 23 2019).

[8] Iihara K, Nishimura K, Kada A, Nakagawara J, Ogasawara K, Ono J, Shiokawa Y, Aruga T, Miyachi S, Nagata I, Toyoda K. Effects of comprehensive stroke care capabilities on in-hospital mortality of patients with ischemic and hemorrhagic stroke: J-ASPECT study. PloS one. 2014 May 14;9(5):e96819.

[9] Toyoda K, Inoue M, Koga M. Small but steady steps in stroke medicine in Japan. Journal of the American Heart Association. 2019 Aug 20;8(16):e013306.

[10]      Miyai I.  Update on stroke rehabilitation.  Shinkeichiryo 2016;33(3)389-393. https://www.jstage.jst.go.jp/article/jsnt/33/3/33_389/_pdf. (accessed Dec 23, 2019).

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Seven minutes in stroke - Dr Xia Wang

Dr Xia Wang in collaboration with Dr Tom Moullaali and Professor Rustam Salman at the University of Edinburgh submitted the article 

‘Who will benefit more from low - dose alteplase in acute ischaemic stroke?’ to the International Journal of Stroke. Dr Wang answered our Seven minutes in stroke giving us a little insight into where our stroke researchers and clinicians began their relationship with stroke.

1. What inspired you towards neuroscience?

Neuroscience is pretty cool! It is one of the last great frontiers of knowledge spanning from molecules, through cells and pathways, all the way up to complex human behaviour. Clever neuroscience tricks have been applied to all the aspects of our lives. For example, Instagram used it in the logo design to appeal to human being’s subconscious minds. The thick white line of the camera on the logo against the rich colourful background creates high levels of eye-catching visual saliency. Designs that are visually salient get looked at earlier, more often, and for longer.

2. Why stroke?

Stroke is the leading cause of death in China, with the country accounting for roughly one third of worldwide stroke mortality. Stroke burden is much higher in northern rural area where I am from. Compared with other parts of China, the prevalence of major risk factors for stroke remains high; the salt intake is much higher; tobacco use is highly prevalent; the awareness rate, treatment rate, and control rate of hypertension and diabetes are low. After stroke, stroke care quality and secondary prevention are all in a very low quality therefore the recurrent stroke rate is higher. Stroke research could help me to understand this area more and helpful to tackle the great challenge in my hometown.

3. What have been the highs so far?

I have produced 20 publications in the last 2 years including in lead international journals – NEJM, Lancet, Lancet Neurology, and JAMA Neurology.  The new knowledge I produced has been recognised by 39 countries across 5 continents of Asia, Europe, North America, South America, and Australia.  It has been adopted by 160 academic institutes/industries and influenced beyond medicine area in other 12 area including Engineering, Agricultural and Biological Sciences, and Computer Science.

The paper I co-authored – from the ENhanced Control of Hypertension And Thrombolysis strokE stuDy (ENCHANTED) – has been cited by multiple clinical practice guidelines including the American Heart Association (AHA)/American Stroke Association (ASA). Australian Commission on Safety and Quality in Health Care found a profound reduction of healthcare cost of ADU $50 million per year through improvements in patient outcomes by applying ENCHANTED findings in Australia (http://apo.org.au/node/100526). I presented a subgroup analysis in the plenary session in European Stroke Conference in Milan in May.

4. What have been the lows?

Pressure from multiple applications including grants and fellowship to do every year, hard feelings from rejections and insecurity of funding.

5. How do you balance work life with the needs of home life?

I like cooking and swimming in my spare time, really look forward to hanging out with friends on the weekend.

6. Who are your most important mentors and how did you find them?

Professor Craig Anderson.

An email attached my resume with emphasis on excellent statistical skills reached Professor Craig Anderson in 2012. Then he decided to offer me an opportunity to be the statistician for INTERACT2, moved me from HIV research to stroke.

7. What are your most important collaborations and how have you built them?

Collaboration with Dr Tom Moullaali and Professor Rustam Salman at the University of Edinburgh

I co-supervised Dr Tom Moullaali while he was undertaking the visiting scholar at the George Institute Australia in 2016 and 2018. We worked on individual patient data (IPD) meta analysis on blood pressure (BP) lowering treatment for acute intracerebral haemorrhage and the paper has been accepted by Lancet Neurology. Prof Rustam Salman, the supervisor of Dr Tom Moullaali, worked closely with me during his sabbatical leave at the George Institute Australia in 2014. We have co-authored some papers. I have applied an exchange award from the National Heart Foundation, if successful, it would be a great opportunity to visit them and immerse myself in a different research institute environment.

Be a stroke superhero – Be FAST

Recognising the signs of stroke and getting fast access to treatment is vital in saving lives and improving outcomes for stroke survivors. Awareness of the FAST message is a core strand of World Stroke Campaign and of the WSO’s members around the world.  But one important audience for this message - and one which has not been traditionally included in awareness programs - is children. 

While the prevalence of stroke in children is much lower than in the adult population, with the global lifetime risk of stroke now standing at 1 in 4, equipping kids with basic knowledge about what stroke looks like and what to do in an emergency could prove life-saving.

This is why WSO has recently endorsed the FAST Heroes program and will be working to pilot and evaluate this kindergarten-level education initiative and help with localisation of resources and activities for communities around the world.  

The FAST Heroes program has created an animated character-based education program with a central character, Timmy, who becomes a FAST Hero by learning how to beat the Evil Clot and save the Grandheroes in his life (his grandparents). Resources for use in class are age appropriate and include learning materials such as short film animations, classroom activities and take-home materials to literally hit the message home. There are even ideas to help schools and communities raise funds to broaden participation and make the program more sustainable in the longer-term.

Michael Brainin, President of WSO said of the partnership, ‘We’re excited to pilot this program which we hope will not only convey life-saving information but will also help us to understand how to better work with children to support broader community awareness of stroke and FAST.’

Jan van der Merwe, Project Lead for the Angels Initiative in Europe which supports the FAST Heroes program commented.  “Since launching the Angels Initiative, we realized that there are two big issues that somehow need to be addressed. The first of which is that patients arrive too late for treatment. This can be due to misdiagnosis or not seeing the symptoms as serious enough to warrant going to a hospital. The second big issue is that too many patients go to and are then admitted to hospitals that are not “Stroke Ready”. Both of these mistakes very often result in much worse outcomes post stroke. To help solve one of these issues, the Angels Initiative supported The Department of Educational and Social Policy of the University of Macedonia to develop the FAST Hero program. 

Stroke steals lives, and through engaging children and their families we can do something to make sure that when stroke strikes we are as prepared as we can be. This could be the difference not only between life and death, but also between “life as we know it” and a life lived with permanent disablity.”

Pilot FAST Hero programs will be delivered in partnership with WSO members in a number of countries including Brazil, Singapore and South Africa. For more information about participating in the WSO FAST Heroes program, please contact campaigns@world-stroke.org

WSO President welcomes WHO inclusion of hypertension ‘polypill ‘on essential medicines list

On July 9^th the WHO added fixed-dose combination anti-hypertension medication to its list of essential medicines.  WSO has welcomed the announcement as a watershed moment, which has the potential to address the single biggest risk factor for stroke worldwide. 

In a WSO jointly authored letter, published in The Lancet on 15^th July, WSO President Michael Brainin (alongside the American Heart Association, European Society of Hypertension, International Society of Hypertension, Lancet Commission on Hypertension Group, Latin American Society of Hypertension, Resolve to Save Lives, World Heart Federation and the World Hypertension League) expressed support for the inclusion of single pill combination treatment as a way to improve access to effective treatment for hypertension; particularly in low- and middle-income countries where rates of hypertension, are on the increase and where the proportion of people receiving treatment is low.

Currently 1.4 billion people worldwide have hypertension (classified as measurements equal or over 130/80) but only 1 in 7 have their blood pressure effective treated and controlled. Controlling hypertension often requires more than one medication which can create challenges for healthcare systems and for patients. Combining generic treatments is a safe and affordable way to overcome these; firstly, by making procurement and prescribing easier in low resource settings and secondly, by making it easier for patients to keep track of and comply with their medication ‘regime’.

WSO President Michael Brainin indicated that the decision by WHO may offer further encouragement to WSO's emergent stroke prevention strategy. ‘The decision by WHO to include a hypertension ‘polypill’ in their essential medicines list, is not only a massive boost to our global effort to prevent stroke, but potentially paves the way for the future inclusion of single pill combinations to address a number of stroke risk factors. WSO is currently working with an international network of researchers to explore the potential for such treatments alongside development of community healthworker networks and mobile technologies as an integrated strategy to improve diagnosis of clinical stroke risk factors and to improve access to preventive treatment. While we will continue to push that work forward, it is clear that it is now time for governments around the world to take action and to start putting in place policies and systems that will put single-pill combinations in the hands of patients who need them.’

The ammunition to fight stroke and NCDs together

A Call to Action and Ammunition Needed to Beat Stroke and NCDs

By Prof Bo Norrving, WSO Global Policy Committee Chair

Next week I will be in Montréal, alongside 2500 stroke leaders and stakeholders spanning clinical practice, research, rehabilitation and patient and caregiver organizations. The expertise and individual interests represented at the biennial World StrokeCongress may be diverse, but our common commitment is the same – to fight stroke and reduce its devastating impact on individuals and society.

As the world’s second largest cause of death and disability it is a battle well worth fighting, but one that we don’t have to – not should we - take on alone. Globallly, regionally and nationally there are networks and alliances working to break down the traditional siloes between disease groups in order to increase the speed at which the world addresses the diseases that are most likely to kill us.  We know, that by connecting the dots and coordinating our efforts with others who have a shared investment in beating NCDs, we can achieve more, maximise our investments and move faster than we can individually. When investments have been slow to come, and governmental commitments to change continue to disappoint, this could be the key to making progress.

The sense that together we are stronger, is certainly the driving force for collaboration between the NCD Alliance and the World Stroke Organization (WSO) and the rationale behind our latest partnership collaboration Acting on Stroke and NCDs. The aim of this policy brief, which will be launched at the World Stroke Congress in Montréal, is to clearly articulate the shared prevention and treatment issues for NCD stakeholders and to set out key priorities for action at global, regional and national level. It is our hope that Acting on Stroke and NCDs provides not just a call to action, but the ammunition needed to beat NCDs.

The publication clearly sets out the contribution to stroke to global NCD mortality and identifies the shared and specific gaps in current approaches to addressing stroke and NCDs. When only 6% of all people who have a stroke have no comorbidities and when comorbidities result in not only higher healthcare, individual and social costs, this policy brief sets out a strong evidence-based argument and some clear action points that will turn the tide on stroke and NCDs .

How to respond to the challenge of stroke and NCDs

Invest in prevention

Given that 90% of strokes are linked to 10 modifiable risk factors, several of which are shared by a number of NCDs, investing human and financial resources in diagnosis, education and risk reduction will deliver advances across the board

Ensure access to acute and chronic speciality care

People need to be treated in services and by clinicians in accordance with clinical practice guidelines for NCDs. Access to stroke units and to acute therapies is a backbone in stroke care, as is rehabilitation and long-term support.

Strengthen the primary healthcare network

Access to a solid primary care network is essential to effective prevention and long-term treatment of stroke and NCD. Financial barriers and out of pocket costs for prevention, diagnosis and treatment needs to be reduced. Universal health coverage should cover essential diagnostic and treatment.

Implement the WHO HEARTS Technical package

Taking the seven steps set out in this package would ensure that the right medicine reaches stroke patients at the right time and at an affordable rate.

Every 2 seconds, someone somewhere in the world has a stroke, the clock is ticking and we don’t have time to wait – strengthened actions on stroke and NCDs are urgently needed. Let’s gather our allies, target our actions and work for upscaled efforts. We have had ENOUGH on political inertia on NCDs.

The air we breathe

29 September 2018, World Heart Day

Nearly one in five deaths from CVD and stroke are caused by air pollution... a total of 3 million deaths globally every year

Today on World Heart Day, WSO is standing with our partners in circulatory disease prevention, the World Heart Federation (WHF) to raise awareness of the strong link between the air we breathe, cardiovascular disease and stroke.

Outdoor and household air pollution are an increasingly important risk factor for CVD: according to recent research, air pollution is the cause of 19% of all CVD deaths, accounting for more than 3 million deaths each year. Recent stroke data shows an even stronger overall association between air pollution and stroke, with over 29% of the burden of stroke attributed to air pollution.
An estimated 7 million people die prematurely every year from air pollution: 1.4 million of these will be from stroke and over 2 million from heart disease. 

According to the WHO, 91% of the world’s population live in areas where air pollution exceeds the WHO guidelines limits. While the problem is clearly geographically widespread, the impact varies depending on where you live and your level of income.

In south Asia and eastern and central sub-Saharan Africa, air pollution is the third highest contributor to stroke, accounting for almost 40% of the stroke burden. In China and India, almost 22% of stroke burden (as measured by DALYs) in 2013 were attributed to ambient PM2.5 air pollution. Although household air pollution from solid fuels did not contribute to stroke burden in high-income countries, almost a fifth of stroke burden in low-income and middle-income countries was attributed to household air pollution in 2013 (especially in Asia and sub-Saharan Africa).
Professor David Wood, WHF President, comments: “Reducing exposure to air pollution has become a crucial challenge that the world needs to face if we are to continue advancing in our goal to reduce the impact of non-communicable diseases, especially cardiovascular disease - the world's biggest killer. On World Heart Day, we are raising awareness of poor outdoor and household air quality as an increasingly important risk factor, and bringing together all those involved in cardiovascular health from every country in the world in the fight to reduce CVD."

President of the World Stroke Organization, Prof Werner Hacke added, 'Stroke is associated with a several heart conditions and an estimated 80% of premature deaths from both stroke and CVD could be prevented. This is why we are committed to collaborating with WHF and our partners the Global Coalition for Circulatory Health to deliver a robust prevention agenda. This includes not only increasing public awareness of the links between CVD and stroke, but also working with governments to put in place population-based policies and investments that will scale up improvements in the health of our communities.’

The case of air pollution shows us that reducing stroke and CVD can't be achieved through individual lifestyle change alone. While there are things that we can all do as individuals to reduce our stroke risk, turning the tide on the global tsunami of CVD, stroke and other non-communicable diseases will happen much faster if action is taken at government and individual level.’

On World Heart Day, WHF is calling on each and every one of us to make a commitment to heart health. WSO's hand on heart promise is to continue to strengthen our partnership work so that together we can address shared risk factors for CVD and stroke and help people live longer and healthier lives.’

REFERENCES:

¹Source: GBD 2016 Risk Factors Collaborators. Global, regional, and national comparative risk assessment of 84 behavioural, environmental and occupational, and metabolic risks or clusters of risks, 1990–2016: a systematic analysis for the Global Burden of Disease Study 2016. Lancet 390, 1345–1422 (2017).

²Source: WHO

³Source :WHO

⁴Source: Nature Reviews Cardiology volume 15, pages 193–194 (2018).

⁵https://vizhub.healthdata.org

WSO President calls for quick and decisive action on NCDs at UN High Level Meeting

Today the the UN world leaders are gathered to agree and commit to a programme of action to accelerate progress on NCDs. While the proposed outcome document for the UN High Level Meeting on NCDs doesn't go far enough, it is perhaps our best opportunity to date to address the diseases which - world-over - are most likely to kill us and cause immeasurable suffering. WSO President Werner Hacke will attend the meeting and has prepared this oral statement calling for fast and decisive action and offer support to Member States in their work to tackle the risk factors for stroke and other NCDs.

President's Statement for UN High Level Meeting on Prevention and Control of Noncommunicable Diseases, 27th September 2018

My name is Werner Hacke, a Neurologist from Germany and I speak here as the President of the World Stroke Organization.

Every year, almost 15 million human beings die of stroke and many more survive with a lifelong burden of physical, cognitive, mental, and socio-economic impairment. This cruel tragedy leaves families desperate and could be avoided. Stroke is both preventable and treatable.

Stroke shares the same risk factors as cardiac diseases and other NCDs such as smoking, high blood pressure, diabetes, obesity, lack of execise, alcohol abuse and unhealthy foods.

These facts have been well known for decades and the solutions are obvious and cost effective, but actions are slow and reluctant.

Any further delay caused by lack of political will and weak compromises, will result in a massive increase of patients suffering and dying from stroke and other NCDs, especially in poor societies. We have had enough futile discussions about facts that no one can seriously deny.

For many scientists and NGOs, the proposed outcome document may look repetitive, timid and not like a big break through- but at least it's a signal.

Its time to act now and take quick and clear decisions. Otherwise unnessary premature deaths and suffering will grow dramatically, and the responsibility for this unfortunate development will rest with us.

Therefore the WSO will support all member states in their efforts to improve prevention, get rid of dangerous lifestyles, provide access to medical services, broaden health coverage and access to essential drugs, not only for stroke.

Driving Sustainable Action for Circulatory Health

This week World Stroke Organization President Werner Hacke, along with Vice President Michael Brainin, Global Policy Chair Bo Norrving and Chief Executive Mia Grupper, are in New York to attend the Third UN High Level Meeting on Non-Communicable Diseases (#UNHLM3).

The meeting, taking place on the 27th September, is focused on accelerating progress and identifying actions required to deliver on priorities that UN Members States committed to over five years ago.

While the title of the meeting may sound rather dry and the UN might feel a bit distant, there could not be more at stake. This could be our best opportunity to tackle the diseases that are most likely to kill us in the next 10 years.

The HLM will be attended by Heads of State and Minsters from around the world. This is a critical opportunity to hold them to account and to ensure that they use the evidence of what works to drive action on NCDs.

Together, heart disease, stroke diabetes and kidney disease represent the single largest cause of death worldwide, accounting for around 20 million deaths and staggering total of 374 million years of life lost to death and disability in one year alone. Stroke accounted for 116 million years of life lost in 2016 alone. While people of all ages and all continents are at risk, the burden of disease is felt disproportionately in low to middle income countries where individual suffering is compounded by access barriers and capacity of healthcare and where social and economic development is hampered poor health of the population.

The good news is that because these diseases share several common risk factors, coordinated action on prevention and treatment can result in major gains - and at a much lower cost than dealing with the consequences. WHO and World Economic Forum have identified key policy 'Best Buys' and a recent Lancet Taskforce series on NCD economics economics has indicated dollar for dollar returns that would come from addressing in NCDs now. We also know that where governments haven take responsibility and put in place policies and programmes, progress has been made.

This is why, in addition to raising awareness of specific issues in stroke prevention, treatment and support, the WSO is working as a key partner in the Global Coalition for Circulatory Health to push for more urgent focus and to support coordinated efforts by governments and other stakeholders.

Our joint calls are captured in a White Paper which was launched at a UN side event today.  Driving Sustainable Action for Circulatory Health sets out the key pillars of action that will ensure delivery of global goals on disease reduction:

Pillar 1: Prioritising multi-sectoral and cost-effective interventions

Pillar 2: Fostering access to the prevention and care of circulatory diseases

Pillar 3: Mobilising resources for circulatory health

Pillar 4: Measuring and tracking progress

About the Global Coalition for Circulatory Health

Up Again After Stroke

This year the focus of World Stroke Day is on life after stroke. Around 80 million people living in the world today have experienced a stroke and over 50m survivors live with some form of permanent disability as a result. 

While for many, life after stroke won’t be quite the same, our campaign aims to show that, with the right care and support, a meaningful life is still possible. As millions of stroke survivors show us every day, it is possible to get #UpAgainAfterStroke.

While the impact of stroke is different for everyone on 29th October 2018, we want to focus the world’s attention on what unites stroke survivors and caregivers; their resilience and capacity to build on the things that stroke can’t take away and their determination to keep going on the recovery journey.

Join with us

Our website has resources and key messages to help you raise awareness of life after stroke issues on World Stroke Day. Here's how you can join with us and show support and solidarity with stroke survivors on World Stroke Day:

• Download campaign social media resources from the campaign website www.worldstrokecampaign.org; If you have some design skills and software and want to adapt materials for local use contact campaign@world-stroke.org
• Change the heading pictures on your account and share social posts with your networks.
• Share your personal experience as a stroke survivor or caregiver on Facebook and twitter. Be sure to include the campaign hashtag #UpAgainAfterStroke so that your experience is seen and shared.
• If you don’t use social media, share your story of stroke recovery on the World Stroke Campaign website. 

REPORT Educational Stroke Program in Brazil

Endorsed by World Stroke Organization 

The Ministry of Health of Brazil published on April 12th 2012 a national policy for stroke. The policy included the organization of stroke care in local networks integrating all points of care for stroke assistance (primary care professionals, pre-hospital Emergency Medical System and hospitals), development of stroke units, payment of tPA for the government and better reimbursement for stroke patients treated in stroke units.

To help the Ministry of Health implement this policy, we launched on June 20th 2012, an Educational Stroke Program, a partnership between the Brazilian Stroke Society, Brazilian Academy of Neurology, Brazilian Stroke Network, Brazilian Medical Association and the Ministry of Health and endorsed by the World Stroke Organization.

The educational program consisted of two sections; firstly an online component and secondly via a face to face meeting.

The lectures were prepared by stroke neurologists, based on international practice guidelines, and has trained all professionals linked to stroke assistance, including primary care professionals to improve primary and secondary prevention.

The online course is free.

Our online course trained more than 6000 doctors and 4000 other health professionals.








In 2017 we had several in person training:
* pre-hospital - SAMU (8)
* stroke centers (39)
* community hospitals (5)
* primary attention (2)
* neurologists (2)

Now in 2018 we are planning to renew the online lectures.




Dr Sheila Martins