Estimating annual deaths from stroke in adults under 70 years of age in Freetown Sierra Leone: A comparative analysis of a hospital-based stroke register and a population-based verbal autopsy study

Background: In Sub-Saharan Africa (SSA), most stroke epidemiological data comes from hospital-based registers, which are prone to selection bias, and data may be unrepresentative of stroke burden at the population level. The degree of incompleteness and bias in hospital-based registers has been assessed in high-income countries but not in an SSA country. Aims: The study describes and compares estimates of annual deaths from stroke under 70 years of age, from a hospital-based stroke register and a population-based verbal autopsy (VA) study. We describe the sociodemographic and clinical differences between patients captured and those missed by a hospital-based register and estimate the completeness of a hospital-based register in Sierra Leone. Methods: We compared people under 70 years of age who died from stroke in the Stroke in Sierra Leone (SISLE) prospective longitudinal hospital-based register to the Healthy Sierra Leone (HEAL-SL) population-based VA study which sampled 2.5% of households in the Western Area. We included participants from SISLE and HEAL-SL who died within the same dates (1st May 2019 until 30th September 2021) and geographical area. We conducted data linkage using probabilistic matching and manual clerical review by two authors. To assess selection bias, we used univariable analysis to identify variables associated with capture by the hospital register. To estimate annual deaths from stroke, two-source capture-recapture analysis was conducted using the Lincoln-Petersen-Chapman estimator. Estimates of completeness were adjusted for undermatching and for the positive predictive value of VA for stroke diagnosis. Deaths rates from stroke were calculated as deaths per 100,000 individuals, with population estimates sourced from the 2021 Mid-term Population and Housing Census. Results: A total of 345 participants were identified in the SISLE dataset, 46 in the VA dataset, and 4 in both datasets. Excluding individuals captured in both datasets, individuals identified by VA had a mean age of 58 years compared to 55 years in SISLE ( p = 0.07), 59.5% were male compared to 50.7% in SISLE ( p = 0.28), and 52.3% had no formal education compared to 39.0% ( p = 0.09) in SISLE. Individuals identified by VA were more likely to be employed 36.7% vs 59.5% ( p = 0.002), were less likely to have sought formal healthcare 48.5% vs 100% ( p < 0.001), more likely to have died suddenly 14.3% vs 4.1% ( p < 0.001), and less likely to have died in hospital 19.0% vs 67.5%. Estimates of annual deaths from stroke using capture-recapture methods ranged from 41 to 106/100,000. The completeness of SISLE register for fatal stroke ranged from 10.6% (95% CI: 9.6%–11.7%) to 27.2% (95% CI: 24.8%–30.0%). Discussion: In this setting, a hospital-based stroke register underestimated deaths from stroke in adults younger than 70 years to a much greater degree than estimates from high-income country settings. For people who died from SISLE, employed people, people who did not seek formal healthcare, and people who died within 24 hours were less likely to be included in the hospital-based stroke register. Investment in routine death registration systems and population-based stroke surveillance is essential to provide accurate estimates of population-level stroke burden in our setting.

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