Industry Trend Analysis - Stroke Prevention Will Be Vital In Asia's Emerging Markets - JUNE 2017

BMI View: T he burden of stroke is particularly serious in Asia , but acute treatment will be limited in the region ' s emerging markets. Focus will be on preventive actions, both primary and secondary, and this represents an opportunity for drugmakers.

Although stroke incidence in high-income countries decreased over the past four decades, it increased dramatically in low- and middle-income countries [1]. Of 35mn deaths attributable to chronic non-communicable diseases that occurred worldwide in 2005, stroke was responsible for 5.7mn (16.6%) deaths, and 87% of these deaths occurred in low-income and middle-income counties. Driven by increasing size and ageing of populations, and escalating prevalence of risk factors such as hypertension, tobacco use, unhealthy diet, physical inactivity, and obesity, stroke is becoming a major cause of premature death and disability in developing countries [2].

Emerging Markets Seeing Rising Stroke Deaths
Stroke, Total, Deaths In Select Countries
Source: World Health Organization (WHO), BMI

Although stroke is a worldwide problem, the burden of stroke is particularly serious in Asia; its mortality is higher than in Europe or North America [3]. Stroke in Asian patients accounts for more than two-thirds of the overall incidence of stroke worldwide. Compared to Caucasians, Asians have been reported to have a higher incidence of stroke and a higher mortality rate. In higher income countries such as Japan, Korea, and urban China, a declining stroke mortality has been increasingly reported. However, in some countries with limited resources such as India, Pakistan, and Indonesia, high fatality rates are still evidenced [4 ].

The financial burden placed on countries in the Asia-Pacific region by stroke is believed to be immense. Total lifetime cost for all ischaemic and haemorrhagic strokes, based on data from the North East Melbourne Stroke Incidence Study (NEMESIS), was estimated at approximately AUD2bn (USD2bn). Estimates from the South Korea National Health Insurance Claims Database for 2005 show that the total cost for the treatment of stroke in the nation was KRW3,737bn (USD3.3bn), including direct costs of KRW1,130bn (USD1.0bn) and indirect costs of KRW2,606bn (USD2.3bn). In 2003, the direct medical cost for ischaemic stroke in China was calculated as CNY23,732bn (USD3,787bn) and in 2009, the cost of stroke to the Japanese healthcare system was calculated as JPY1,786bn (USD22bn; source: 'Atrial Fibrillation-Related Stroke across the Asia-Pacific Region: A Preventable Problem', October 2012).

Acute Treatment Of Stroke Will Be Limited In Asia's Emerging Markets

About 80 out of 100 strokes are ischaemic strokes. Intravenous (IV) tissue plasminogen activator (tPA; 0.9mg/kg) has been the only proven effective medical treatment for acute ischaemic stroke (AIS) during the past 20 years. However, there is still a controversy on what the optimal doses of IV tPA should be. Many neurologists in Asia consider that lower doses of IV tPA are better for Asian patients with stroke because of the racial difference in coagulation and fibrinolysis responses [5]. tPA should be given within three hours (and up to 4.5 hours in certain eligible patients) of the time symptoms first started; this short-time window means the need for a rapid diagnosis and treatment. As noted by Gabe Rijpma, Health and Social Services Industry Director Public Sector Group Microsoft Asia Pacific Singapore, Asia is increasingly challenged by the social disparities between its urban and rural populations due to the massive growth it has experienced in recent years; of the region's 4bn people, 80% live in rural areas often without adequate access to education and healthcare [6]. Although a possibility for stroke management in high-income countries, tPA may not be an option in certain areas in low- and middle-income countries due to delayed presentation and cost[ 1].

Rural Location Impacts Access To Treatment
Rural Population, % Of Total, In Select EMs In Asia (2016 Estimate)
Source: National Sources, BMI

The most widely used strategy for stroke diagnosis is immediate CT scanning. However, the expense of CT equipment for healthcare facilities and the cost of individual use of CT scanning for patients are still high for low-resource countries and areas [1]. Effective acute stroke management depends on availability of an acute stroke service in the emergency room (especially urgent CT scan and tPA), and on access to dedicated stroke care units [7]. In high-income countries in Asia, the proportion of neurologists per unit population is high. The number ranges from one neurologist per 15,000 in Japan to one per 85,000 in Singapore. In contrast, in low-income countries like Pakistan, there is one neurologist for every 2mn patients. However, in real life situations, most neurologists are concentrated in urban areas especially in capital cities. Therefore, the ratio of the neurologists per unit population may be much lower in rural areas. When compared to 1999, a two- to three-fold increase in the number of neurologists was observed in all countries. This indicates the growing number of neurology training facilities in the region [4].

Asia Has Varied Stroke Care Resources
Neurologists Per 1,000,000 Population
Source: Neurology India, 2016;64[7]:46-51, BMI

Focus Will Be On Prevention

Increasing disease awareness and education, and taking preventive actions will be vital to tackle the burden of stroke in Asia, particularly in the region's emerging markets. The main primary preventive approaches for stroke are the promotion and maintenance of a healthy lifestyle, and blood pressure control. A healthy lifestyle includes not smoking (and smoking cessation for smokers), no binge drinking, being physically active, and a healthy diet [1]. Secondary prevention of stroke is also important due to high risk of recurrent stroke, which occurs in approximately one-third of stroke survivors in five years.

Pharmaceutical-based prevention of stroke represents an opportunity for drugmakers. As well as smoking cessation drugs, this includes pharmaceutical means to address hypertension, dyslipidaemia, and atrial fibrillation. Furthermore, digital health technology, such as tablet-based risk assessment tools, mobile-phone apps for physicians, and text messaging interventions, represents a new approach for stroke prevention and control [1]. With ageing populations and rising healthcare demand, governments will be looking to contain costs and stroke prevention will become an increasing focus.

[1] eNeurologicalSci, 2016;2:21-30

[2] Stroke, 2009;40:1212-1218

[3] Int J Stroke, 2014;9[7]:856-7

[4] Neurology India, 2016;64[7]:46-51

[ 5] Stroke and Vascular Neurology, October 25 2016, 10.1136/svn-2016-000033


[7] Nature Reviews Neurology, 2014;10:135-143