Alteplase (rtPA) now included on the WHO’s List of Essential Medicines (EML) for acute ischemic stroke

Alteplase (rtPA) has made it on to the WHO’s List of Essential Medicines (EML) for acute ischemic stroke

 In the last 25 years, several studies have shown the efficacy of alteplase for acute ischemic stroke. If given within three hours, about one in four patients will have a reduced long-term handicap. This important effect of alteplase already includes its haemorrhage risk of 3-4%.

Despite this important reduction of brain damage, alteplase is only available in two thirds of countries and remains much underused in low and middle income countries. In order to increase access and use of thrombolysis around the globe, the World Stroke Organization (WSO) assembled 13 stroke experts from five continents under the leadership of Patrik Michel (Switzerland) and Michael Brainin (Austria). In 2018, this group submitted a 30 page application to the World Health Organization (WHO) for alteplase to be included in the EML (https://apps.who.int/iris/handle/10665/325771) describing all the pros, cons, conditions, and costs of alteplase.

This week, the WHO informed the WSO that the application was successful: alteplase is now included in the 21st EML, to be used in specialized diagnostic or monitoring facilities and with specialist medical care, as described for example in the WSO's Road Map for Quality Stroke Care.

This new inclusion of alteplase in the EML marks a major step forward for better stroke treatment worldwide, in particular in less affluent countries. All UN-member states are now encouraged to offer thrombolysis for a reasonable cost or for free, such as through Universal Health Coverage (UHC).

And in other good news for the stroke community, the new EML also increases the options for stroke prevention: it now lists fixed-dose dual combinations of antihypertensives, and four direct oral anticoagulants (dabigatran, apixaban, edoxaban and rivaroxaban) as essential medicines. Furthermore, a WSO expert group is currently working with WHO on a list of Priority Medical Devices for stroke prevention and treatment.

These new treatment options are likely to have an important impact on stroke incidence and long-term outcome worldwide, especially in combination with health policy, organized stroke care systems and lifestyle changes. 

World Stroke Organization welcomes WHO stroke classification and definition in ICD 11

The World Stroke Organization has welcomed the recent release by the World Health Organization (WHO) of the ICD 11. The ICD is the global system for clinicians, administrators, and governments to report health statistics at all levels. 

In the newly released ICD 11, cerebrovascular diseases form a single block under diseases of the nervous system. This is a major change compared to the previous classification, in which stroke was placed under diseases of the circulatory system. Furthermore, the new ICD 11 provides precise definitions of stroke and other cerebrovascular diseases for global use. 

WSO works to improve stroke prevention, treatment and support globally. It represents over 50,000 stroke experts worldwide and hasadvocated for the change.  In welcoming the classification, Prof Werner Hacke, President of WSO said ‘By categorizing stroke correctly under diseases of the Nervous System, WHO is supporting global efforts by stroke professionals, survivors and carers to increase public recognition of stroke and to improve access to stroke treatment and care. Stroke is a leading cause of death and disability worldwide, accountable for 14m deaths and 116 DALYs in 2016.  We firmly believe that correct classification will help to save millions of lives and reduce the massive individual and global impact of stroke-related disabilities in years to come. With the world now focused on reducing the burden of Non-Communicable Diseases, this is a timely and important step.’

In recent years, opportunities to improve stroke outcomes have improved due to the development of effective acute stroke treatments such as thrombolytic therapy and thrombectomy. Access to effective acute therapies such as these are contingent upon the early recognition of symptoms from the brain and fast access to appropriately designed stroke treatment facilities with the appropriate neurovascular expertise. ‘Classifying stroke as a disease of the brain is important to facilitate awareness and early recognition, and reporting stroke accurately is instrumental to recognize the true burden of stroke among the spectrum of diseases.’ Said Prof Bo Norrving, Chair of the WSO Global Policy Committee, member of the ICD 11 neurology advisory group and Chair of the working group on cerebrovascular diseases.

Stroke and heart disease share most risk factors and several heart and circulatory conditions increase individual risk of stroke. Strokes and TIAs (mini-stroke) are also leading contributors to cognitive decline and dementia.

WSO will continue to prioritize clinical and public education on the linkages between stroke and heart disease, dementias and other Non-Communicable Diseases. The Organization already works in close partnership with the World Heart Federation and the World Hypertension League and partners in the wider non-communicable disease space as a member of the NCD Alliance and in the Coalition for Vascular Health. It will continue to advocate strongly for improved primary prevention policy to address common NCD risk factors, as well as for increased and more equitable access to screening and treatment for conditions including hypertension (high blood pressure), atrial fibrillation (irregular heartbeat) and hyperlipidemia (high cholesterol) all of which are specifically associated with higher stroke risk.

Shifting the mindset from health spending to health investment

Launch of the Lancet Taskforce on Non-Communicable Diseases

Evidence of the closely wrought relationship between poverty, economic development and health is longstanding, so it’s perhaps unsurprising that diseases of poverty have been the concern of public health researchers and policy makers for many decades. More recently however, attention has been turning to diseases that have been traditionally viewed as ‘diseases of wealth’, which include stroke, heart disease, diabetes, chronic respiratory disease and cancers. 

This shift in attention isn’t driven by a sudden lack of concern for the poor, or indeed the successful elimination of poverty, but rather by the growing understanding of the complex relationship between poverty, health and economic development. The burden of NCDs is growing and has a disproportionate impact on mortality and in economic development in Low- to Middle-Income Countries (LMICs). 

Report of EAN /WSO / AAN/IBRO/WFN / EHF/LINF 9th Regional Teaching Course (RTC) on Neurology in Sub - Saharan Africa . Ougadougou, Burkina Faso 8 - 11th November 2017

The 9th Regional Teaching Course (RTC) took place in Ouagadougou Burkina Faso on November 8 – 11, 2017. The meeting was hosted by Prof. Jean Kabore, Head of the Neurological Department of the Yalgado Ouedrago Hospital of Ouagadougou together with Prof. Athanase M ilogo, Head of the Neurology Department of the Sanou Sourou hospital in Bo Bo Dialasso and Prof. Christian Napon, head of the Neurology Department of the District Hospital of Bogodogo, Ouagadougou. The RTC took place at the National Hospital “Blaise Compa ore”.

Tenfold increase in childhood and adolescent obesity in four decades: new study by Imperial College London and WHO

The world will have more obese children and adolescents than underweight by 2022

The number of obese children and adolescents (aged five to 19 years) worldwide has risen tenfold in the past four decades. If current trends continue, more children and adolescents will be obese than moderately or severely underweight by 2022, according to a new study led by Imperial College London and the World Health Organization (WHO).

The study was published in The Lancet ahead of World Obesity Day (11 October). It analysed weight and height measurements from nearly 130 million people aged over five years (31.5 million people aged five to 19, and 97.4 million aged 20 and older), making it the largest ever number of participants involved in an epidemiological study. More than 1000 contributors participated in the study, which looked at body mass index (BMI) and how obesity has changed worldwide from 1975 to 2016.

Tobacco control with Lubna Bhatti for the World Health Organisation

Tobacco control with Lubna Bhatti for the World Health Organisation

Carmen Lahiff-Jenkins spoke to Lubna Bhatti from the World Stroke Organisation 

Annual meeting of WHO’s regional committee for Europe (11-14 Sept 2017 in Budapest)

In this annual meeting, health ministers and delegates of the European countries worked on the implementation of WHO decisions in European countries. The WSO participated together with other non-governmental organisations in order to increase visibility and awareness of stroke.

World Stroke Organization welcomes WHO decision on stroke classification

After sixty-two years of officially categorizing stroke as a Disease of the Circulatory System, WHO has taken the major step of recognizing stroke as a Disease of the Nervous System. The decision has been warmly welcomed by the World Stroke Organization, which has actively advocated for the change, arguing that correct classification is fundamental to global efforts to address the massive challenge of stroke. The change will be reflected in ICD11 the latest document to provide the basis for classifying and monitoring diseases globally. The ICD 11 is expected to be adopted by the World Health Assembly and released in 2018

To find out why the WSO has made it a priority to achieve this change, we talked to Bo Norrving, Chair of the organization’s Global Policy Committee. Bo has also been chair of the Cerebrovascular Diseases group for the ICD 11 and is a member of the WHO Neurology Topical Advisory Group, chaired by Raad Shakir.

Why does it really matter that stroke is classified as a brain disease, not a disease of the circulatory system – aren’t the two closely related?

It’s true that there are close links between cardiovascular disease and stroke; many risk factors are shared and primary prevention will target both disorders jointly.  But the simple fact is that when strokes happen, they happen in the brain.

Delivering stroke treatment early and efficiently with effective acute therapies such as thrombolytic therapy and thrombectomy, depends on the early recognition of symptoms from the brain and early actions to call an ambulance. This is why many countries campaign to increase public knowledge of stroke symptoms (like the FAST campaign) have been conducted in recognition that ‘time is brain’. Similarly, providing early treatment of transient ischemic attacks (TIAs), which are linked to stroke, depend on public knowledge of the symptoms and rapid admittance to hospital.

The impact of delivering effective treatment for acute stroke and the opportunity to prevent a stroke where someone has had a TIA are huge and opportunities should not be missed. Understanding the role of the brain in residual symptoms and disabilities from stroke is also important to providing patients with effective long-term rehabilitation and support.  

Having had stroke under diseases of the circulatory system has put stroke in the shadows regarding the essential recognition of the brain symptoms of stroke as a crucial element in delivering effective therapies.  We are delighted that this is no longer the case.

How do you think this change will help with the achievement the global goal to reduce avoidable deaths from stroke? 

Stroke is the second biggest killer and the largest single cause of disability worldwide and yet still struggles to get the policy attention and resources commensurate with its global impact. Identifying stroke as a disease of the brain and pulling all types of cerebro-vascular diseases into a single block in the ICD 11 will, we believe, guide policy attention

to the right place and enable us to develop 21^st Century services for stroke. Stroke is probably the best example there is of a non-communicable disease that is highly preventable and highly treatable, more so than almost any other NCD. With the right focus and commitment to stroke we can make a massive impact on the achievement of sustainable development goals for health.

Ø  Visit the World Stroke Organization website for more information about our work and our members

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Ø  Visit the World Stroke Campaign website for information about the global campaign for better stroke prevention, treatment and support

April 4 2017