Panorama

Burden of stroke in Indonesia

Y. Kusuma1,2, N. Venketasubramanian3, L. S. Kiemas1, and J. Misbach1

Stroke is the leading cause of death among Indonesians above five years of age, comprising 15.4% of all deaths, agegender-standardised death rate 99/100 000, and age gender-standardised disability-adjusted life years lost 685/ 100 000. Stroke prevalence is 0.0017% in rural Indonesia, 0.022% in urban Indonesia, 0.5% among urban Jakarta adults, and 0.8% overall. Frequent risk factors include hypertension, smoking and hypercholesterolaemia. The mean age of stroke patients is 58.8 years. Subarachnoid haemorrhage is found in 1.4% of patients, intracerebral haemorrhage in 18.5%, and ischaemic stroke in 42.9%. Only city hospitals have neurology, neurosurgery and neuroimaging services. Indonesia has 40 stroke units. Commonly used medications for stroke are easily available. Hospital-based rehabilitative services are available in large hospitals. Traditional medicine is widely practiced. Efforts to combat stroke include education, more stroke units and rehabilitative services especially in the rural areas.

Key words: burden, epidemiology, morbidity, mortality, stroke

Indonesia is the worlds largest archipelago with 17 508 islands covering 19 million square miles in 33 provinces (1). Of the population of 256 million, those in the western regions are largely of Malay ethnicity while those in the east are Papuans; approximately, 3% are Chinese.

Stroke epidemiology
We performed a literature search for recent publications on stroke epidemiology with large samples, and added data from a recent survey by our Department of Health.
Correspondence: Professor Jusuf Misbach, Department of Neurology, University of Indonesia, Cipto Mangunkusumo Hospital, Jl. Salemba Raya 6, Jakarta 10530, Indonesia. E-mail: jusufmisbach@yahoo.com 1 Department of Neurology, University of Indonesia, Department of Neurology Cipto Mangunkusumo Hospital, Jakarta, Indonesia 2 Department of Neurology, National Neuroscience Institute, Singapore General Hospital Campus, Singapore, Singapore 3 Division of Neurology, National University Hospital, Singapore, Singapore

A community-based Basic Health Research survey performed by the Ministry of Health enrolled 98 7205 subjects from 258 366 households in 33 provinces (2). Stroke was the leading cause of death among those aged 45 years, comprising 154% of all deaths (3). Data from the World Health Organisation showed that in 2002, the crude death rate from stroke was 56/100 000, agegender-standardised death rate was 99/ 100 000, crude disability-adjusted life years (DALYs) lost due to stroke was 1311/100 000 while agegender-standardised DALYs was 685/100 000 (4). Stroke prevalence was evaluated in a community-based survey in 120 districts comprising 4 269 629 subjects. It was 00017% in rural Kabupaten, and 0022% in urban Kotamadya Bogor (5, 6). Male stroke survivors outnumbered females (768 vs. 232%), aged 594 and 606 years, respectively, with hypertension (6608%) and cardiac diseases (1786%) being the prominent risk factors. A community-based survey in three districts in urban Jakarta of 2073 randomly selected people aged 2564 years, revealed stroke sequale in 05% (7). The Ministry of Health study found a stroke prevalence of 08%, ranging from 166% in Nanggroe Aceh Darussalam to 038% in Papua (2). Vascular risk factors in urban Jakarta included hypertension (149%), cigarette smoking (599% of males, 59% of females), hypercholesterolaemia (134%), and regular alcohol intake (27%) (7). The Ministry of Health study found the prevalence of hypertension was 298% among those aged above 18 years, diabetes was 57% among those aged above 15 years, and smoking was 237% among those aged above 10 years (2). A hospital-based survey of 28 hospitals included 2065 acute stroke patients, mean age 588years, male-to-female ratio 117 : 1, with the more common risk factors being hypertension (739%), diabetes (173%), smoking (204%), heart disease (199%) and previous stroke (199%) (8). Braincomputed tomography performed in 619% found subarachnoid haemorrhage in 14%, intracerebral haemorrhage in 185% and ischaemic stroke in 429%.

Medical services
The 33 provinces in Indonesia are each sub-divided into districts, each district into sub-districts with at least one health

& 2009 The Authors. & 2009 World Stroke Organization International Journal of Stroke Vol 4, October 2009, 379380

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The total expenditure on health per capita (Intl $ 2006) was 87, the total expenditure on health as % of GDP (2006) was 22 (4). All of the large cities have public and privately owned hospitals that have neurology, neurosurgery and neuroimaging services. Most of the 1200 neurologists and neurosurgeons practice in the cities. The approximately 40 stroke units are in large private and government hospitals. Such services are unavailable in rural areas, with small hospitals staffed by junior neurologists and no imaging facilities. Commonly used medications such as antiplatelets (mostly aspirin), statins and first-generation angiotensin-converting enzyme inhibitors are easily available. Traditional medicine is widely practiced. Rehabilitative services are available in the large city hospitals, and lesser available in the countryside.
Stroke unit at Cipto Mangunkusumo Hospital, Jakarta, Indonesia.

Tackling the burden due to stroke

More needs to be done to reduce the burden of stroke. Public education on what stroke is, the risk factors and the importance of risk factor control for prevention are needed. More awareness is needed on the symptoms and the need to seek urgent medical attention. More stroke units are needed, as are rehabilitative services in the rural regions. Staff training on how to manage stroke needs to be regularly conducted. The concerted effort requires the cooperation of all parties public, healthcare professionals, government, and pharmaceutical companies.

Acknowledgements
Opening ceremony of the Stroke unit at Cipto Mangunkusumo Hospital, Jakarta, Indonesia.

We wish to thank Dr Jofizal Jannis for the Riset Kesehatan Dasar (RISKESDAS) 2007 report, Ministry of Health, Indonesia.

centre each headed by a doctor, usually supported by two or three sub-centres, the majority of which are headed by nurses (4). Health centres provide services to underserved populations in urban and remote rural areas. In the villages, the integrated Family Health Post provides preventive and promotive services. These Health Posts are established and managed by the community with the assistance of the health centre staff. There were 1215 hospitals nationally, with 130 214 hospital beds in 2002 (06 beds/1000 population) (4). The number of public health facilities was 7309 units, with 21 790 public health sub-centres and 5638 moving public health centres. Subsidised healthcare services are available in government hospitals in the cities and larger towns. Healthcare insurance is uncommon, with most patients paying for their medical bills.

References
1 Available at http://www.indonesia.go.id (accessed 1 April 2009). 2 Ministry of Health. Riset Kesehatan Dasar (RISKESDAS). Indonesia: Ministry of Health, 2007. 3 Indonesia: Stroke and TB are lead killers. [cited 2009 April 1]. Available at http://www.irinnews.org/report.aspx?ReportId=81883 4 Available at http://www.who.int (accessed 1 April 2009). 5 Misbach J. Morbidity survey of neurological diseases in Bogor area: a population-based study. J Indones Med Assoc 2001; 51:18791. 6 Misbach J. Stroke morbidity in Bogor area and surroundings: a prospective observational analysis. J Indones Med Assoc 2001; 51: 32831. 7 Boedhi-Darmojo R, Setianto B, B Sutedjo et al. A study of baseline risk factors for coronary heart disease: results of population screening in a developing country. Rev Epidemiol Sante Publique 1990; 38:48791. 8 Misbach J, Ali W. Stroke in Indonesia: a first large prospective hospitalbased study of acute stroke in 28 hospitals in Indonesia. J Clin Neurosci 2001; 8:2459.

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& 2009 The Authors. & 2009 World Stroke Organization International Journal of Stroke Vol 4, October 2009, 379380