Burden, Risk Factors and Management of stroke in Cameroon: A Systematic

Review

By Nzoutchoum Flore

ABSTRACT

Background: The burden of stroke in Cameroon is high with rising mortality and disability.
Stroke is the fourth leading cause of death in Cameroon. Despite this, the quality of the
management of stroke in Cameroon is inadequate due to the unavailability of epidemiological
data, national management guidelines, adequate technical platforms, and essential drugs.
Objective: To investigate the burden, risk factors and management of stroke in Cameroon.
Methodology: The PubMed, Scorpius, Medline, google scholar databases were searched using
keywords like stroke, prevalence, incidence, mortality, risk factors, management, prevention,
Cameroon. Articles published between the year 1990 and 2021 and had stroked related
information for Cameroon were included and a total of 24 out of 56 publications were used.
Results were reported as presented in the original publications, no quantitative analysis was
conducted.
Results: Nine articles were observational cohort studies, five were cross-sectional studies, two
were case control studies, three were review studies, and four were published reports. The
prevalence of stroke ranged from 0.71% to 33.3%, with ischemic stroke being the most frequent.
The length of hospital stay ranged from 1-37 days. Stroke mortality in 2020 was 4.98% and the
DALY has increased by 19% over 10 years. High blood pressure, prior stroke, diabetes, old age,
tobacco smoking, excess alcohol consumption, physical inactivity, poor diet, obesity and atrial
fibrillation were major risk factors for stroke. Data on non-modifiable risk factors for stroke is
sparse. Policies, diagnostics like head CT scans, medications like statins, rehabilitation and
prevention services are being used in the management of stroke, though limited and unevenly
distributed.
Conclusion: Stroke is a major public health problem in Cameroon which is undermined and
inadequately managed. Multi sectorial efforts should be engaged to implement primary,
secondary and tertiary prevention strategies in an integrated manner with community
participation.
Keywords: Burden, Cameroon, Management, Risk Factors, Stroke.
ABBREVIATIONS
CT: Computer Tomography

CVD: Cardiovascular Diseases

DALY: Disability Adjusted Life Years

HICs: High Income Countries

LMICs: Low and Middle Income Countries

NIHSS: National Institutes of Health Stroke Scale

OR: Odds Ratio

SSA: Sub Saharan Africa

WHO: World Health Organization

1. INTRODUCTION

Stroke is a medical emergency that occurs when brain cells cannot get the oxygen and nutrients
they need as a result of an interrupted or reduced blood supply to the brain. This can cause
lasting brain damage, long-term disability, or even death [1,2]. After ischemic heart disease,
stroke is the second leading cause of death and disability worldwide with more than 13million
new cases and 5.5million deaths occurring each year [2,3]. The annual death toll is expected to
reach 6.7million if not appropriately controlled [3]. The three main types of strokes include;
ischemic stroke which is most common and accounts for 87% of the 80 million stroke survivors
in the world, hemorrhagic stroke and Transient ischemic attack or mini stroke [4].

The burden of stroke in low- and middle-income countries (LMICs) is higher than in high
income countries with two out of every three persons who suffer from stroke living in LMICs
[4]. About 87% of both case fatality and disability-adjusted life-years occur in LMICs where
hemorrhagic strokes and stroke related deaths at younger ages are prominent [5]. Stroke is the
fourth leading cause of death in Cameroon with 10,475 deaths in 2020, accounting for 4.98% of
total deaths [6]. The age adjusted death rate of 106.51 per 100,000 of population ranked
Cameroon 49th in the world [6].

Globally, high systolic blood pressure is the largest single risk factor for stroke accounting for
57.3% of stroke burden [7]. Other metabolic risks like high fasting plasma glucose, high total
cholesterol, and low glomerular filtration rate account for 72.1% of stroke burden [7]. Modifiable
risk factors for stroke include; unhealthy diet (51.1%), high BMI (23.6%), smoking (23.4%),
excess alcohol consumption (11.9%) and low physical activity (4.5%) [7,8]. Genetic disposition,
family history, age and gender are non-modifiable risk factors for stroke [8]. Effectively
controlling modifiable risk factors can significantly reduce the burdens of stroke [7].

Currents events have shown that epidemiological transition is not unidirectional but rather a
continuous transformation process with some diseases disappearing and others re-emerging like
in Sub Saharan Africa (SSA) where infectious diseases are still prominent and re-emerging [9].
As a consequence, there is an apparent reluctance on the part of policy makers to divert scarce
resources towards emerging non communicable diseases [10, 11].
The world health organization (WHO) action plan recognized access to elements of stroke unit
care as essential in the control of non-communicable diseases [12]. The stroke units in LMICs
are limited and other factors like the delay in hospital arrival, lack of stroke experts, shortage of
medications, and cost have contributed to the poor stroke treatment outcomes in these countries
[8,13-16].

Appropriate knowledge of national stroke epidemiology is required for adequate allocation of

resources to reduce the burden in LMICs [17]. The scarcity of published data and unreliability of
reporting systems pose a challenge to apprehend the burden of stroke in Cameroon. Thus, this
systematic review sought to investigate the incidence, prevalence, mortality and management of
stroke in Cameroon by using the following questions:

1. What is the burden of stroke in Cameroon?

2. How does the burden of stroke vary geographically in the rural and urban communities,
with patient characteristics, specifically age and gender, and over time?
3. What are the risk factors of stroke?
4. How is the country managing stroke in terms of availability, allocation and accessibility
of resources, prevention, hospitalization and treatment?
2. METHODOLOGY

This review was conducted following the Preferred Reporting Items for Systematic Reviews and
Meta-Analyses guidelines that aims to help authors improve the reporting of systematic reviews
and meta-analyses [18].

2.1 Systematic search strategies

Google chrome, Mozilla Firefox, and Microsoft edge search engines were used for this review.
The PubMed, Scorpius, Medline, google scholar, Elsevier, ScienceDirect, BioMed Central, and
Science Publishing Group online data bases were explored to locate articles in journals using key
words which were categorized based on the following: Location (Cameroon), Outcome
(incidence, prevalence, mortality, risk factors, hospitalization, disability, treatment, prevention,
control, morbidity, epidemiology, stroke, cardiovascular diseases, noncommunicable diseases).
Keywords were combined using linking words like ‘and’ ‘in’ and ‘or’. Information on key health
systems features and local policies initiated to address NCDs like stroke was also retrieved.
Reference lists from the retrieved articles were also examined for relevant studies. Furthermore,
stroke related data were extracted from national and international organization websites (WHO,
World Health Rankings, International development research center, MINSANTE), conference
proceedings, scientific blogs and print media. No language, age, design, sampling, or diagnostic
criteria limitations were applied during the search. Articles published in different languages were
translated to English by the authors.

2.2 Eligibility Criteria

Articles that were published between the year 1990 and 2021 and had stroked related information
for Cameroon were included in this review. The exclusion criteria were as follows: Animal
subjects, non-Cameroonian participants, mechanical stroke outcomes (heat, electronic or
position), unpublished data.

2.3 Study Selection

Out of the 56 publications extracted from the online search, 12 duplicates were removed
manually by the authors. The authors independently screened the remaining publications based
on titles and 7 were excluded because they were irrelevant for this study. Further screening done
on summaries using the exclusion criteria yielded 26 relevant publications. Publications without
summaries but with relevant titles were retained. The remaining publications were screened
based on the content of their full text and those that met the inclusion criteria were used for this
review (Figure 1).

Figure 1: PRISMA flow diagram of study selection

2.4 Quality Assessment of Review Articles

The Newcastle-Ottawa Scale was used to assess the quality of each article [19]. It was based the
following criteria: Appropriateness and reporting of inclusion and exclusion criteria, exposure
assessment, outcome assessment, control of confounding variables, and evidence of bias. Scores
greater than 7 were considered high quality.

2.5 Data Extraction

The authors independently extracted the data and resolved disagreements by discussing. The
following information was extracted from the reviewed publications (table 1): Author and
publication year, title, study setting and location (urban or rural), study design, study population
and sample characteristics, sampling technique, Stroke type, diagnostic technique, incidence,
prevalence, mortality, hospitalization days, prevention, treatment and control of stroke, risk
factors, stroke complications, and predictors of mortality, inferential statistics (p value,
confidence intervals, OR). Furthermore, the study sites were marked on the Cameroon map
(Figure 2).

Figure 2: Map of Cameroon/Study locations

2.6 Data Synthesis and Presentation

Following extraction, the results were reported as presented in the original publications. General
trends were described if information was available from multiple sources; no quantitative
analyses were conducted to pool estimates.
3 RESULTS

3.1 Description of Included Studies

Out of the 24 publications identified and reviewed, 20 were scientific research articles [20-29,32-
36;38-41;43] and 4 were published reports [30,31,37;42]. Eighty-eight percent of the records
were published after the year 2010 [23-43], two were published in 2006 [21,22] while one was
published in 1994 [20]. The study design, sample population, and geographic setting varied
considerably among the selected studies. Nine were observational cohort studies (prospective or
retrospective), with sample sizes ranging from 35 to 3,140 [20, 24-26,28,29,32;38;41]; five were
observational cross-sectional studies with ages ranging from 7mths to 70 years [22,27,33,36;39];
two were case control studies with a 1:1 ratio [21,35]; three were review studies [23,34;43] and
four were published reports [30,31,37;42]. For the observational cohort studies that reported
length of follow-up most had at least 1 year of follow-up, while only 3 studies had below 12mths
of follow-up [28;38;41]. Most studies were hospital based except two community-based studies
in the Northern [27,36] and only one study was conducted among indigenous populations in a
rural area [27]. However, the review studies and published reports presented data between across
urban and rural areas. Three studies covered specifically ischemic stroke [20,21,28], Four studies
presented data on the two types of strokes [22,24,25;39], two presented data on first ever and
recurrent stroke [29,35], and the remaining publications did not differentiate on the stroke type.
Most of the studies presented data on the burden and risk factors and management of stroke
except for two studies which looked at essential drug availability and affordability; and cost of
management [33;39]. Few hospital-based studies used CT scan for the confirmed diagnosis of
stroke [20-22,28;41]; and all the review articles and published reports including three studies
[22,33,35;40;42;43] presented data on the management and prevention of stroke, and health
system policies (Table 1).
 Table 1: Summary characteristics of included studies
Citation/Author/Year of Setting Design Sample characteristics Stroke type Burden of stroke Risk factors/Predictors Management of stroke
publication/Title
[20] Obama/1994/Stroke in Hospital Retrospective 35 (6-15yrs) Ischemic Mortality:2.9% Sickle cell disease, -
Children in Yaoundé Cameroon. (urban) cohort (1984- malaria, heart disease
1990)
[21] Njamshi et al./2006/Chronic Hospital Case control 64 cases, median age Ischemic Prevalence: 78.7% Chronic chlamydia -
chlamydia pneumonia infection (urban) (1:1) 60yrs pneumonia infection
and stroke in Cameroon: A case
control study.
[22] Njamnshi et Hospital Descriptive 120 homozygous sickle Ischemic Prevalence:6.67% Ischemic (age<20yrs) -Hyperhydration of
al./2006/Epidemiology of stroke (urban) cross-sectional cell patients aged 7mths- Hemorrhagic Ischemic: 75% Hemorrhagic patients, administration of
in sickle cell patients in Yaoundé 35yrs Hemorrhagic:25% (age>20yrs) NSAIDS, cerebral
Cameroon. Annual recurrence: oxygenators (Almitrine
25% bismesilate sulfate).
-Inadequate stroke
management practices, lack
of prophylaxis, and missed
diagnosis by attending
physician (25%)
[23] Tcheugui & Cameroon Review - Stroke - Obesity, physical Health system policy, fiscal
Kengne/2011/Chronic inactivity, alcohol and regulatory
noncommunicable diseases in consumption, interventions, community
Cameroon: Burden, determinants dyslipidemia. interventions, secondary
and current policies. prevention, essential
medicines.
[24] Mapoure et Hospital Prospective 325 Patients in the Ischemic 318 new cases HBP, alcohol -
al./2013/Epidemiology of stroke (urban) cohort neurologic and intensive Hemorrhagic Ischemic: 53.8% consumption, diabetes,
in a teaching hospital in Sub- (January2010- care units Hemorrhagic: 46.2% tobacco, atrial
Saharan Africa: 3 years December2012) Mean duration of fibrillation, dyslipidemia,
prospective study in Douala, hospital stay: sleep apnea, overweight,
Cameroon. 8.56±6.35 days embolic cardiopathy.
Mortality: 26.4% Predictor of mortality:
sepsis
[25] Mapoure et Hospital Prospective 325 patients aged >15yrs Ischemic - Predictors of mortality: -
al/2014/Predictors of in hospital (urban) cohort with established diagnosis Hemorrhagic sepsis, GCS<8,
mortality for stroke in Douala, of stroke hyperglycemia,
Cameroon. hemorrhagic stroke
[26] Nkoke et al./2015/Stroke Hospital Prospective 254 patients recently Stroke Mortality at Predictors of mortality: -
mortality and its determinants in a (urban) cohort (12mths) diagnosed with stroke 1mth:23.3% fever, swallowing
resource limited setting, Yaoundé. 6mths:31.5%, difficulties, HBP
12mths:32.7%
 Table 1: Summary characteristics of included studies con't
Citation/Author/Year of Setting Design Sample characteristics Stroke type Burden of stroke Risk factors/Predictors Management of stroke
publication/Title
[27] Nyuyki et Community Cross-sectional 1921 adults aged ≥20yrs Stroke - Underweight, physical -
al/2016/Distribution and based inactivity, poor diet, high
patterning of noncommunicable (rural) level alcohol
disease risk factors in indigenous consumption, cigarette
Mbororo and non-autochthonous smoking, age≥40yrs,
populations in Cameroon HBP.
[28] Nonga et al/2016/Prevalence Hospital Prospective 35 consenting stroke Ischemic Prevalence: 46% HBP, age, cardiac -
of significant carotid stenosis and (urban) cohort (10mths) patients with acute onset arrythmia, high
other risk factors in patients with of neurological deficit. cholesterol.
ischemic stroke in Yaoundé.
[29] Lekoubou et Hospital Retrospective 1678 participants First ever Prevalence Old age, diabetes, atrial -
al/2017/Recurrent stroke and (urban) cohort (1999- Recurrent First ever stroke: fibrillation, smokers.
early mortality in an urban 2012) 85.5% Odds of mortality in
medical unit in Cameroon. Recurrent stroke: recurrent stroke patients
14.5% was 1.43.
Mortality
First ever stroke:
19.6%
Recurrent stroke:
20.6%
[30] Tassou et al/2017/Analysis Cameroon Report - Stroke - - NCD policy landscape and
of noncommunicable disease risk factor control policies.
prevention policies in Cameroon.
[31] Cameroon Report - Stroke - - Proportion of primary
WHO/2018/Noncommunicable health facilities with
disease profile in Cameroon. guidelines for NCD
management (none),
essential drugs (3/10), risk
stratification (<25%),
essential technologies (4/6))
[32] Nkoke et Hospital Retrospective 3140 adult patients Stroke Prevalence:33.3% Predictor of fatality: -
al/2019/Epidemiology of (urban) cohort (January admitted for Hospital stay:1-37days Gender (women).
cardiovascular disease related 2016-December cardiovascular diseases in Case fatality: 21.7%
admissions in a referral hospital in 2017) medical unit
the South West region,
Cameroon.
 Table 1: Summary characteristics of included studies con't
Citation/Author/Year of Setting Design Sample characteristics Stroke type Burden of stroke Risk factors/Predictors Management of stroke
publication/Title
[33] Dzudie et Hospital Audit survey 63 medicine outlets of CVDs - - -Aspirin, digoxin,
al/2020/Availability, cost, and (Both) public/private/confessional including furosemide, nifedipine were
affordability of essential CVD facilities, and community stroke affordable.
medicines in the South West pharmacies. -Costs were highest in
region of Cameroon. community pharmacies and
lowest in public facilities.
- Availability: 33%
-Availability ranged from
25.3% in public to 49.2% in
community pharmacies,
and higher in urban and
semi urban outlets.
[34] Dzudie et al/2020/PASCAR Cameroon Review - - - Tobacco and alcohol Health system capacity
and WHF CVDs scorecard consumption, HBP, high policy response, essential
project. cholesterol, physical medicines, secondary
inactivity, overweight, prevention interventions.
obesity, diabetes.
[35] Kamgang et Hospital Case control 100 patients at least 5yrs Single and Single stroke:75% History of stroke, HBP, -Antihypertensives, acetyl
al/2021/Recurrent ischemic and (urban) (1:1) removed from their first Recurrent Recurrent:25% sedentary lifestyle, salicyclic acid,
hemorrhagic stroke in Cameroon. stroke event who stroke events Median time from alcohol and tobacco antidiabetics,
consulted at the neurologic index stroke to second consumption, diabetes, antidepressants.
and cardiology department stroke: 15mths and high cholesterol, -Medication adherence
of Yaoundé central decrease with hyperglycemia, gout, suboptimal
hospital from January 15, underlying CVDs like congestive heart failure. -No secondary stroke
2019. HBP. prophylaxis.
[36] Olivier et Community Cross-sectional Adult population of Stroke Prevalence:0.74% Family and personal -Diagnosis: Self reporting
al./2021/Prevalence of stroke, based Ngoundere aged >20yrs history of HBP, diabetes, and judgement of a
coronary artery disease, (rural) and living in the city for stroke and cardiac cardiologist according to
arrythmias, and heart failure in the last 1yr. diseases. physical examination.
Northern Cameroon. Overweight, obesity.
[37] World Health Cameroon Report - Stroke Prevalence: 0.71% - -
Rankings/2021/Stroke in Deaths: 10,475;
Cameroon. Mortality: 4.98; World
rank: 49; Age adjusted
death rate:106.51 per
100,000 population.
 Table 1: Summary characteristics of included studies con't
Citation/Author/Year of Setting Design Sample characteristics Stroke type Burden of stroke Risk factors/Predictors Management of stroke
publication/Title
[38] Wafeu et al/2020/Medium- Hospital Prospective 66 patients were enrolled Stroke overall mortality High systolic blood -
term Survival Following Stroke in (urban) cohort (90 of which 54 were followed rate:23.2%, more than pressure and a low
Yaoundé, Cameroon. days) up to 90 days two-thirds of the Glasgow coma score on
deaths occurred within admission were
the first 30 days. The independent risk factors
mortality rates at of mortality at
days 14, 30, 60 day 90 days
were 9.1%, 14.3% and
21.1% respectively.
[39] Aminde et al/2021/ Hospital prevalence- 850 patients with Ischemic ischaemic stroke (n = having of diabetes -
Estimation and determinants of (urban) based cost-of- ischaemic heart disease, Hemorrhagic 317, 37.3%), mellitus predicted higher
direct medical costs of ischaemic illness study ischaemic stroke, haemorrhagic stroke costs in
heart disease, stroke and haemorrhagic stroke and (n = 193, 22.7%) patients with ischaemic
hypertensive heart disease: hypertensive heart X average annual stroke (β = 0.188; 0.052,
evidence from two major disease (HHD) from two direct medical costs of 0.324).
hospitals in Cameroon major hospitals between care per patient XAF
2013 and 2017 932,700 (US$ 1600)
for ischaemic stroke,
XAF 815,400 (US$
1400) for
haemorrhagic stroke

[40] Juma et al./2018/ Non- Cameroon Qualitative document reviews and key Stroke - - Country-level policy
communicable disease prevention multiple case informant interviews with process has been relatively
policy process in five African study design national-level decision- slow and uneven.
countries makers in various Physical activity policies
sectors are not well
developed. Have developed
NCD strategic plans
consistent with WHO
global
NCD Action Plan but these
policies have not been
adequately implemented
due to inadequate political
commitment, inadequate
resources and technical
capacity as well as industry
influence.
 Table 1: Summary characteristics of included studies con't
Citation/Author/Year of Setting Design Sample characteristics Stroke type Burden of stroke Risk factors/Predictors Management of stroke
publication/Title
[41] Kuate/2016/Stroke mortality Hospital prospective 120 Patients (mean age Stroke case fatality rate was predictors of mortality -
and its determinants in a tertiary (urban) study 60.5 ± 12.78 years) with a 26.7% at one month were
care Hospital at Douala for six months diagnosis of stroke, with and 31.7% at 3 months Glasgow coma scale less
(Cameroon) CT-Scan than 8/15 (P = 0.001), a
confirmation were modified Rankin score
recruited and followed up greater than 5 (P =
during 0.001), a
hospitalization, at one and white blood cell count
three months greater than 10,000 /
mm3 (P =
0.004) and a pneumonia
(P = 0.001).
[42] Cockburn et al/2014/Best Cameroon Report - Stroke - - Best practice guidelines
practice guidelines for stroke in which provided an
Cameroon: An innovative and overview of the provision
participatory of stroke rehabilitation
knowledge translation project services in the region,
practice recommendations
to improve these services
[43] Nkoke et al/2015/Post-stroke Cameroon Review - Stroke - - Home-based post-stroke
care: an alternative model to care
reduce stroke related
morbidity in sub-Saharan Africa
3.2 Burden of Stroke

3.2.1 Morbidity

Cameroon continues to suffer the burden of stroke with a prevalence of 0.71% reported in 2019
[37]. Data on national prevalence and incidence of stroke is limited. Prevalence rates of 6.67%,
33.3%, and 0.74% were reported in a hospital based cross sectional study, a community based
cross sectional study and a two-year retrospective cohort study respectively [22,32,36]. The
incidence of stroke in Cameroon is quite high as seen in a prospective cohort study whereby
there were 318 new cases of stroke out of 325 sample participants [24].

Ischemic stroke is seemingly more frequent with a prevalence ranging from 46% to 78.7%
[21,28]. Studies which looked at both types of stroke showed a significantly higher occurrence of
ischemic stroke than haemorrhagic stroke as seen in figure 3 below [22,24,39]. The proportion of
recurrent stroke patients which ranged from 14.5% to 25% was lower than first ever stroke
patients, 75% to 85.5% [29,35]. Njamnshi et al. in 2006 showed an annual recurrence rate of
25% among stroke patients in a hospital in Yaoundé [22]. The median time from index stroke to
a second stroke attack was about 15months and it decreased with the presence of an underlying
diseases like hypertension, cardiovascular diseases, and psychological disorders [35].

80 75

70

60 53.8
50 46.2

40 37.3

30 25
22.7
20

10

0
Njamnshi et al. [22] Mapoure et al. [24] Aminde et al. [39]

Ischemic stroke Hemorrhagic stroke

Figure 3: Incidence of ischemic and Haemorrhagic stroke in three studies

Stroke morbidity differs across the regions of Cameroon with the Northern region having the
lowest prevalence compared to all other regions studied [36]. The South West and Center regions
had prevalence rates much higher than the estimated national prevalence of stroke [22,32]. The
prevalence of ischemic stroke has however decreased over time across the different studies
conducted in the country’s capital as seen in figure four [21,28,39]. After the year 2016, the
prevalence decreased at a steady rate.

90

80 78.7
70

60

50 46
40
37.3
30

20

10

0
2006 [21] 2016 [28] 2021 [39]

Figure 4: Trend in prevalence of ischemic stroke in Yaoundé

3.2.2 Length of Hospital Stay

The mean duration of hospital stay for stroke patients in Cameroon was estimated at 8.56±6.35
days and the mean delay for consultation was 27.19 ± 97.52 hours [24]. Nkoke et al. in 2019
reported a hospital stay range of 1-37 days for stroke patients in a referral hospital in the South
West region of Cameroon with a median length of hospital stay of 7 days [32]. Age, underlying
medical complications, and severity of stroke can increase the length of stay of stroke patients in
hospitals [24]. Furthermore, the presence of hypertension, diabetes or heart diseases adversely
affect the functional outcome and length of hospital stay of stroke patients [24].

3.2.3 Stroke related Mortality

According to the World Health Rankings, there were 10,475 stroke related deaths in Cameroon
in 2020, with a mortality rate of 4.98% [37]. The age adjusted death rate was 106.51 per 100,000
population and Cameroon was ranked 49th in the global stroke related mortality classification
[37]. In 2019, stroke was the 6th cause of death in Cameroon [37].

Several studies have shown stroke mortality across different parts of the country. Mapoure et al
in Douala showed a mortality of 26.4%, Nkoke et al. in the South West showed a case fatality of
21.7%, while Wafeu et al in Yaoundé reported a mortality of 23.2% [24,28,32]. Mortality from
first ever stroke attacks (19.6%) was lower than recurrent stroke attacks (20.6%) in Lekoubou et
al’s study in 2017 [29]. Stroke mortality has significantly increased over the years in Cameroon
with a positive percent change of 21.7% from 2009 to 2019 [37]. A Study in Yaoundé published
in 2020 showed a higher fatality rate (23.2%) than an earlier study in 1994 (2.9%) in the same
town [20,28]. Stroke mortality was 23.3% at 1 month, 31.5% at 6 months and 32.7% at 12
months in a study conducted by Nkoke et al. in a resource limited setting, Yaoundé [26]. Wafeu
et al who assesses medium-term Survival following stroke in Yaoundé showed more than two-
thirds of the deaths occurring within the first 30 days; the mortality rates at days 14, 30, and 60
were 9.1%, 14.3% and 21.1% respectively, Figure 5 shows the survival curve of the patients
[38]. The case fatality rate in a tertiary care hospital in Douala was 26.7% at one month and
31.7% at 3 months [41].

Figure 5: Survival curve of stroke patients on day 90 [38].

3.2.4 Stroke Complications and Disability

Data regarding stroke DALYs in Cameroon is sparse. Stroke is the 8th cause of most deaths and
disability combined in Cameroon and the DALY has increased substantially from 2009 to 2019
by 19% [37]. Stroke complications include neurological, psychiatric or other systemic
manifestations that occur in the acute, subacute or chronic phases of a stroke.

Motor impairment of one half of the body was a commonest clinical feature seen in 97.1% of the
stroke cases in a study in Yaoundé [20]. Other complications were facial paralysis (62.9%) and
aphasia (28.6%), and all the cases had neurological deficit after a mean hospital stay of 15 days
[20].

The signs and symptoms of stroke patients in another study at the Yaoundé General Hospital
were predominantly neurological, with motor deficit found in all patients, followed by
headaches, fever and respiratory distress in 70% of patients (p < 0.001). Forty percent of the
patients had total right hemiplegia with aphasia, 50% had severe left hemiplegia, and only one
patient had a discrete motor deficit (left hemiparesis and fast recovery). The median consultation
time for motor deficit was 14hours with extremes ranging from 2 to 36 hours [44]. Depression
was one of the neuropsychiatric manifestations identified in acute stroke patients [35].

3.3 Risk Factors of Stroke

Several studies have reported that high blood pressure, prior stroke, diabetes, high cholesterol,
old, age, tobacco smoking, alcohol consumption, physical inactivity, poor diet, obesity and atrial
fibrillation are major risk factors for stroke in Cameroon [22-24, 27-29, 34-36].

Stroke recurrence was associated with modifiable factors such as elevated abdominal
circumference (P < 0.01), blood glucose level (P <0.01) in Kamgang et al case control study at
the Yaoundé Central Hospital [35]. A three-year prospective study in Douala showed that the
major risk factors before stroke were high blood pressure (69.6%), alcohol consumption (28%),
diabetes mellitus (20.4%), tobacco (16%), heart disease including atrial fibrillation (11.3%),
dyslipidemia (8.5%), and sleep apnea constituting 3.1% [24]. The first-ever stroke patients in an
urban medical unit in Cameroon were older (median age 65.0 years versus 62.0 years, P = .024),
had a worse stroke risk profile (prevalent diabetes 17.5% versus 12.0%, P = .018; atrial
fibrillation 3.7% versus 1.1%, P = .002; hypertension 91.7% versus 63.9%, P<.0001), and were
smokers. Hypertension was the most important modifiable risk factor of stroke in Nonga et al.’s
study in 2016 [28]. Non modifiable risk factors like family history, age and gender were also
reported in few studies [29,36]. No study on the genetic predisposition of stroke in Cameroon
was identified.

3.3.1 Prevalence of Modifiable Risk Factors of Stroke

The prevalence of tobacco consumption in adult men and women (15+ years old) was 43.8% and
0.9% respectively [34]. The average recorded alcohol consumption per capita (15+ years), in
three years (2015–17), was 6.5 litres [34]. In 2015, 31.3% of men and 30.8% of women had high
blood pressure (BP) levels (systolic BP ≥ 140 mmHg or diastolic BP ≥ 90 mmHg) and the age-
standardized estimate for adults who were insufficiently active (< 150 minutes of moderate-
intensity physical activity per week, or < 75 minutes of vigorous-intensity physical activity per
week) was 28.5% [34]. The prevalence of age-adjusted (20–79 years) diabetes was 6.0% in 2019
[34]. In 2017, the prevalence of overweight [body mass index (BMI) ≥ 25 to < 30 kg/m2] in
adult men and women 25 years and older was 15.3% and 19.4% respectively while for obesity
(BMI ≥ 30 kg/m2), the prevalence was 7.7 and 18%, for men and women respectively (Table 2)
[34].
Table 2: Prevalence of modifiable risk factors of stroke in Cameroon [31]

3.3.2 Stroke Comorbidity

Strokes have been seen to occur alongside other medical conditions in Cameroon. The most
common comorbidities reported include hypertension, diabetes mellitus, and diabetes mellitus
[24,28,29,34-36,38,39] The results of the case control study at the Yaoundé Central hospital
found that stroke recurrence was associated with right handedness (OR = 0.23, 95% CI = 0.16–
0.33), congestive heart failure (OR = 3.45, 95% CI = 1.16–10.28), gout (OR = 4.34, 95% CI =
1.09–18.09), dysarthria (OR = 4.34, 95% CI = 1.30–14.54), and facial palsy (OR = 3.96, 95% CI
= 1.49 –10.51).
Sickle cell disease is increasingly occurring with high frequency in Cameroon. It has been
reported to be associated with stroke in children, accounting for up to 6.7% of cases in with an
annual recurrence of 25% in sickle cell anemia patients (mean age 16.6 ± 11.2 years) [22].
Another retrospective cohort study among patients aged 6-15 years found stroke with sickle cell
anemia (62%), malaria (14%) and heart diseases (17%) comorbidities [20].

Stroke and infectious disease comorbidities have also been identified in some studies. In
particular, HIV infection (3.1%), Chronic chlamydia pneumonia infection (78.7%), sepsis, and
respiratory infections like pneumonia and COVID-19 [21,24,41,44].

3.3.3 Predictors of Stroke Mortality

The variables associated with the risk of death in a prospective observational cohort study in
Yaoundé were age greater than 58 years (p = 0.026), the presence of dysphagia on admission
(p<0.001), the presence of detrusor-external sphincter dyssynergia (p<0.001), admission
parameters including Glasgow coma score (p<0.001), systolic blood pressure (p=0.03),
respiratory rate (p = 0.006), temperature (p = 0.001) and the NIHSS (p = 0.004). In patients with
cerebral hematoma, the presence of ventricular flood was associated with the risk of death
(p<0.001) [26].

The adjusted odds ratio of mortality from recurrent stroke was 1.43 (95% CI: 1.03-1.99) in a
study conducted by Lekoubou et al. [29]. Meaning stroke survivors had a 43% higher risk of
dying after a recurrent stroke compared to those with first ever stroke patients.

Determinants of stroke mortality in a resource limited setting included fever, swallowing

difficulties, and admission NIHSS at one month, 6 and 12 months. High systolic blood pressure
predicted mortality at one month while elevated diastolic blood pressure was a predictor of
mortality at one month in participants with hemorrhagic stroke. Low hemoglobin levels on
admission only predicted long term mortality [26].

The predictors of stroke mortality were Glasgow coma scale less than 8/15 (P = 0.001), a
modified Rankin score greater than 5 (P = 0.001), a white blood cell count greater than 10,000 /
mm3 (P = 0.004) and a pneumonia (P = 0.001) in a tertiary care hospital in Douala [41].
Independent predictors of in-hospital stroke mortality were Glasgow Coma Scale lower than 8
(HR = 2.17 95% CI 4.86–36.8; 𝑃 = 0.0001), hyperglycaemia at admission (HR = 3.61 95% CI
1.38–9.44; 𝑃 = 0.009), and hemorrhagic stroke (HR = 5.65 95% CI 1.77–18; 𝑃 = 0.003) in a
study conducted by Mapour et al. in Douala [25].

3.4 Management of Stroke in Cameroon

3.4.1 Health Service Standard

The health system in Cameroon is structured in three levels forming a pyramid whose functional
relationships are specified in the table 3 below. It has three sub-sectors: a public sub-sector,
private sub-sector and traditional sub-sector [23].

Table 3: Different levels of the health system in Cameroon

There is over than 4000 public and private health facilities with 0.9 physicians and 0.058 nurses
per 10 000 of the population, and 13 hospital beds for every 10 000 people [34]. The number of
health facilities at the operational level is satisfactory, but their geographical distribution in the
country is inequitable as most hospitals providing specialized care are found in urban areas [34].

The health sector has been segmented into three vertical components (health promotion, disease
prevention and case management) and two horizontal or transversal components (health system
strengthening and governance and strategic steering) which have been schematized in figure 6
below [23].
 Figure 6: Components and subcomponents of the health system in Cameroon.

The management of cardiovascular diseases including stroke is done in 1st to 4th category health
facilities. Third and fourth category health facilities provide specialized care in surgery,
pediatrics, obstetrics and gynecology, medical imaging, dental care and hemodialysis. Other
specialized care and services are concurrently delivered by 1st and 2nd category hospitals [30].
Access to specialized care is low due to the high cost of the services. However, some medical
procedures such as x-ray are subsidized [34]. Yet, the quality of care remains insufficient
because of poor infrastructure and technical platforms (equipment and health workforce) [30].

Non-governmental organizations (NGOs) that advocate for cardiovascular disease policies and
programs in Cameroon include: Clinical Research Education, Networking and Consultancy
(CRENC), Cameroon Heart Foundation, Fondation Coeur et Vie, and other civil society
organizations (CSOs) such as the National Multi-sectoral Committee for Tobacco Control and
NCD Alliance [30].

The population also makes recourse to other types of services and care for stroke such as:
traditional medicine and alternative medicine in an environment filled with charlatans [30].

3.4.2 Policies for the response to Stroke in Cameroon

There are several global and national policies which have been developed and implemented for
the control of noncommunicable diseases like stroke and their predisposing factors (Table 4) [30,
40]. Some national policies were adopted from recommendations of international policies, for
instance the policy requiring health warnings on cigarette packages and the policy on the taxation
of cigarettes in Cameroon came about specifically because of the WHO framework Convention
on Tobacco Control [30].

Table 4: Non-communicable disease prevention and controls policies in Cameroon [30,40]

Area Year Aspect Policy
Global 2004 Tobacco WHO Framework Convention on Tobacco Control.
Diet and Global Strategy on Diet, Physical Activity and Health.
Physical
activity
2010 NCDs The Adoption of the Resolution of the UN General Assembly on
the Prevention and Control of NCDs.
Africa 2010 Alcohol Reduction of the Harmful Use of Alcohol: A Strategy for the
WHO African Region.
2011 Alcohol Strategic Plan for Non-Communicable Diseases Prevention and
Control 2011-2015 WHO-AFRO.
Cameroon 1998 Tobacco Decision No. 0222/P/ MSP/SGF/DMSP of 08 November 1988
prohibiting smoking in all structures of the Ministry of Public
Health.
Alcohol Law No. 68/004 of 4 April 1998 on the orientation of education;
Prohibition of sales, distribution and consumption of alcoholic
beverages; ban on opening drinking spots, within or in the
outskirts of schools.
2006 Diet Food and Nutrition Policy that defines main strategies for
improved food and nutrition.
2007 Tobacco Circular No. 19/07/MINESEC / SG/HR/SDSSAPPS of 11
September 2007 on the establishment of anti-tobacco clubs in
schools and making schools “non-smoking areas”.
Order No. 967 Ministry of Public Health and Ministry of
Commerce of 25 June 2007 regarding health warnings on
packages of tobacco products.
2009 NCDs Vision 2035 to fight against NCDs in an integrated manner in
order to reduce disease burden, especially among the poor and
vulnerable populations.
2013 Physical Order No. 002/MINSPE of 17 October 2013 on the official
exercise programming of teaching physical education in continuous
training.
2014 Alcohol Law No. 2014/026 of 23 December 2014 on the finance law to
increase taxes on alcohol and alcoholic beverages Cameroon for
the 2015 financial year.
2016 NCDs The Health Sector Strategy (2016-2027) to reduce the
prevalence of NCDs by 10%, ameliorate diagnoses of cancers,
decentralize care of chronic NCDs.
3.4.3 Evaluation of Health Facilities

3.4.3.1 Consultations

Studies have shown that stroke patients consult in health facilities within 3-6 hours of onset of
symptoms [22,25,28,38]. The mean delay from the onset of stroke and the initial consultation
was 47.36 ± 18.48 hours (1- 441.75 hours) among patients in a study at General hospital Douala
[25].

Common presenting complaints on admission included; a sudden focal motor deficit, an altered
level of consciousness, motor aphasia, nausea, severe headache, vertigo, memory loss, facial
palsy, convulsions, hemoplagia, hemiparesia, aphasy, and Carotid murmur [22, 25, 28, 38].
Stroke patients usually have more than one presenting complaint and misdiagnosis by attending
healthcare provider is common as stroke has similar clinical manifestations with other
cardiovascular diseases [22].

3.4.3.2 Diagnosis

The main diagnostic facilities for the diagnosis of causes, types and complications of stroke and
other neurologic deficits are radiological investigations like CT scan of the head, magnetic
resonant imaging (MRIs); electrocardiogram; echocardiogram; and Carotid duplex ultrasound
[22,25,28,38,41,43].

The common clinical presentations from CT scans in past studies were hypo densities and diffuse
cortical atrophy suggestive of a middle cerebral artery lesion [28,41]. While brain imaging
indicated partial anterior circulation syndrome, total anterior circulation syndrome, posterior
circulation syndrome, and lacunar infarct [38,43].

3.4.3.5 Treatment

There is no standard guideline for the treatment of stroke in health facilities in Cameroon. The
treatment of stroke is mainly focused on the cause and clinical manifestations. The general
treatment of patients during the stroke phase identified consisted of hyperhydration of the
patients, administration of a nonsteroidal anti-inflammatory drug (Aspirin), and cerebral
oxygenators (Almitrine bis mesilate sulfonate and dihydroergokryptine mesylate), anticoagulants
(aspirin and heparin) [22,34,35]. Patients with stroke recurrences were put on daily oral salicylic
acid while CTT or hydroxyurea were used for secondary stroke prophylaxis [22]. Stroke patients
may or may not require blood transfusions [22]. Rehabilitation services are also provided to
stroke survivors to reincorporate them into their normal activities in the society [42]. Nkoke et
al. showed the effectiveness of homebased post stroke care in limiting disability in stroke
patients [43].

3.4.3.6 Prevention and control of stroke in Cameroon

The policies and strategic plans governing the prevention and control of non-communicable
diseases in Cameroon incorporated cerebrovascular diseases like stroke.

The National Integrated and Multi-sector Strategic Plan for the Control of Chronic NCD
(NIMSPC-CNCD) of 2011–2015 included CVDs and risk factors, such as hypertension,
diabetes, tobacco use, unhealthy diets, physical inactivity and the harmful use of alcohol [30].
Vision 2035 planned that the fight against the noncommunicable diseases will continue in an
integrated manner, with the essential objective of considerably reducing the disease burden,
especially among the poor and vulnerable populations [30]. The 2016-2027 Health Sector
Strategy (SSS) Number two on disease prevention provides as one of the specific objectives, the
reduction of at least 10% in the prevalence of the main non-communicable diseases including
stroke [30].

About 50 district hospitals carry out educational activities for the prevention of cardiovascular
diseases including stroke (figure 7) [34].
 Tertiary prevention
(rehabillitation) to prevent
disabilities is minimally practiced
in the country
Secondary prevention
Development and implementation of a
national cardiovascular disease screening
and prevention programs, identification of
high-risk groups and reduction in cost of
support examinations and first line
treatments
Primary prevention activities;
strengthening of awareness messages and creation of new
message for health promotion to include the main risk factors for
cardiovascular disease, intensification of media campaigns through
television and internet, strengthening of health programs in
schools and professional settings, in health education and in health
promotion activities.

Figure 7: Primary, secondary and tertiary prevention of Stroke in Cameroon [30].

3.4.4 Tracer services

Table 5: Findings from tracer services [31, 33].

Category Findings
Proportion of primary health care centres reported Less than 25%
as offering CVD risk stratification 2017
Proportion of primary health care centres reported None
having CVD guidelines that are utilized in at least
50% of health facilities 2017
Number of essential NCD medicines reported as 3 out of 10
“generally available” 2017
Number of essential NCD technologies reported 4 out of 6
as “generally available” 2017
The pharmacist ratio per capita Varies from 1 per 6,920 to 1 per 177,051
inhabitants with an unequal distribution between
rural and urban areas
Availability of essential drugs Ranged from 25.3% (public facility outlets) to
49.2% (community pharmacies) for all medicines.
This was higher in urban and semi-urban
compared to rural outlets.
Cost of medicines Highest in community pharmacies and lowest in
public facility outlets.
An audit survey conducted in 2020 indicated that medications like long-acting penicillin had a
high availability at 92.1%, and >80% in all sectors and categories respectively; glyceryl trinitrate
and isosorbide dinitrate were completely absent; hydrochlorothiazide was more than 70%
available in all sectors and categories; spironolactone and verapamil were only found in
confessional and private community outlets; atorvastatin, amiloride, bisoprolol, clopidogrel and
simvastatin were only found in private community outlets; while neither aspirin 100mg nor
81mg was found in public facility outlets [33]. The percentage availability of stroke medications
within outlets is shown in Table 6.

Table 6: Availability of stroke medications within health facility outlets [33].

The cost of medications was highest in community pharmacies and lowest in public facility
outlets. The most affordable medications were aspirin, digoxin, furosemide, hydrochlorothiazide
and nifedipine (cost a day’s wage or less, of the lowest paid unskilled government worker, for 30
days of chronic treatment) [33]. Beta blockers and angiotensin converting enzyme inhibitors
required 2 to 5 days’ wages, while statins required 6 to 13 days’ wages.

3.4.5 Investments and Expenditures

The total amount of health funding in 2011 stood at FCFA 728 billion, representing 5.4% of the
GDP. The main sources of funds for health in Cameroon as seen in figure 8 below are
households (70.6%) the State (14.6%), the private sector (7.7%) and donors (6.9%). The
proportion of the State budget allocated to health varies between 6 and 8% [34].
 Figure 8: Funding sources for health in Cameroon [34]

Aminde et al., in their estimation of direct medical costs of ischaemic heart disease, stroke and
hypertensive heart disease, stated that the total cost for these CVDs was XAF 676,694,000
(approximately US$ 1,224,918). The average annual direct medical costs of care per patient were
XAF 932,700 (US$ 1600) for ischaemic stroke and XAF 815,400 (US$ 1400) for haemorrhagic
stroke (Table 7) [39]. Diabetes mellitus predicted higher costs in patients with ischaemic stroke
(β=0.188; 95% CI=0.052, 0.324) [39]. The mean annual cost for haemorrhagic stroke patients
was XAF 827,400 (~US$ 1497) per acute case and XAF 776,900 (~US$ 1406) per prevalent
case, while for ischaemic stroke patients, it was XAF 920,000 (~US$ 1665) and XAF 960,600
(~US$ 1738) per acute and prevalent case respectively. The inpatient costs for haemorrhagic
stroke (XAF 743,100; ~US$ 1345) was higher than ischaemic stroke (XAF 612,500; ~US$ 1108)
[39]. Higher costs in acute stroke cases were mostly driven by imaging, medication, and
physiotherapy costs [39].
Table 7: Annual direct medical costs for patients with ischaemic heart disease, ischaemic stroke,
and haemorrhagic stroke by disease stage attending two hospitals in Cameroon, 2013–2017 [39].

4. DISCUSSION

The rapid development of the Cameroon economy has contributed to the increase in many
chronic diseases such as stroke, due to change in dietary habits and lifestyles of individuals [36].
The prevalence of stroke ranged from 0.7% to 33.3% with ischaemic stroke being the most
common event and age and high blood pressure being major risk factors; presenting a public
health burden. Similar findings have been seen in other LMICs, but the estimates are
considerably higher than those of some HICs [45,46]. The synthesis of data identified from
studies showed a decrease in incidence of stroke over time; especially in the center region. This
may be due to recent adoption of modern preventative treatments such as antiaggregants, statins,
and antihypertensives, which are prescribed to reduce the risk of cardiovascular and
cerebrovascular diseases [34].
The case fatality was high in the different studies and has increased over the years in Cameroon.
Predictors of mortality included age, length of stay in the hospital, stroke type, comorbidity, and
medical care provided. This concurs with studies which revealed that mortality relating to stroke
in a population depends on the incidence of stroke in the population, the quality of medical care
available to individuals who have suffered a stroke, and the prevalence of cardiovascular disease
and comorbidities that can affect the likelihood of patients surviving stroke events [47].

The management of stroke in Cameroon is often inadequate because of the unavailability of

national management guidelines, lack of adequate technical platforms, especially at the
operational level, and infrastructural imbalance between different regions. The availability of
stroke essential medicines was lower than WHO recommendations, and some medicines were
unaffordable [33]. Primary prevention coupled with increased availability and affordability of
medicines especially for public facilities would be beneficial in curbing the stroke burden.

Legislation that mandates health financing for cerebrovascular diseases and their essential
medicines at affordable prices is lacking [34]. The proportion of the State budget allocated to
health is below the commitment made by African leaders during the Abuja Summit in April 2001
[34]. Most of the total health expenditures come from household contribution, making it the third
largest contribution in Sub-Saharan Africa after Sudan and Nigeria [34]. The system of out-of-
pocket payment exposes households to high expenditures and is a barrier to the access of health
services [30].

5. LIMITATIONS OF THE REVIEW

The few numbers of studies included in this review and variations in study methods makes it to
generalize the findings from the included studies to the entire country. The studies were
heterogeneous in terms of participant selection, case definition; diagnostic methods and
methodology. The data from the studies included in this review are likely conservative estimates
of the true stroke burden. Future researchers should consider using multiple methods including
meta-analysis of estimates to provide pooled rates and ensure complete case ascertainment.
6. CONCLUSION

The burden of stroke in Cameroon is high with rising mortality and disability. Despite this; the
quality of the management of stroke in Cameroon is often inadequate due to the unavailability of
national management guidelines, lack of adequate technical platforms, infrastructural imbalance
between different regions, unavailability and unaffordability of essential drugs.

Epidemiological data on stroke in Cameroon was limited, representing cities in only four
regions; Southwest, Littoral, Center, and North Regions, leaving the vast majority of Cameroon
without high-quality epidemiological stroke data. Whereas, such research is vitally essential to
plan for appropriate management programs to be set up, effective implementation of primary
prevention strategies and proper allocation of health resources in this area. This highlights the
need for a focused and coordinated effort at the regional and national levels to study the extent of
stroke in Cameroon.

7. RECOMMENDATIONS

First, the epidemiological surveillance of stroke can be improved by the establishment of a

framework for regular monitoring and evaluation of stroke (including burden and risk factors)
and health services at the national level. The framework could involve a combination of
community- based surveys and national surveillance systems.

Also; stroke registries can be important reservoirs of stroke information. The government-
regulated, State and national population-based stroke registries could include all possible stroke
detection facilities and ensure real-time documentation of stroke in the facilities, which would
benefit the community in the following ways: Epidemiological information obtained from
population-based registries can be used to enable evidence-informed advocacy and policy
changes for the allocation of funds for stroke-related programs, the data on risk factors and most
prevalent stroke subtypes would guide in the preparing stroke treatment protocols according to
the prevalence of various etiologies/risk factors in a community, and the data on mortality would
facilitate evaluation of standards and efficacy of acute post-stroke treatment.

Home-based rehabilitation for stroke is more acceptable, affordable and accessible, and has a
functional outcome for stroke survivors. Families and caregivers could be educated on how to
care for stroke victims at home and provide home-based rehabilitation and tailor care to patient’s
disability. This could help in palliating the scarcity of rehabilitation services and reduce stroke
related disabilities.

Effective planning of acute stroke care services, including workforce training and capacity-
building, can improve stroke care.

Future stroke studies in Cameroon should develop better preventive measures against stroke and
related mortality, cost-effective stroke care services and better rehabilitation measures to address
the unmet needs of the stroke survivors.

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