title: A stepwise approach to stroke surveillance in Brazil: the EMMA (Estudo de Mortalidade e Morbidade do Acidente Vascular Cerebral) study.
abstract: BACKGROUND
  Stroke mortality rates in Brazil are the highest in the Americas. Deaths from cerebrovascular disease surpass coronary heart disease.
  
  
  OBJECTIVE
  To verify stroke mortality rates and morbidity in an area of São Paulo, Brazil, using the World Health Organization Stepwise Approach to Stroke Surveillance.
  
  
  METHODS
  We used the World Health Organization Stepwise Approach to Stroke Surveillance structure of stroke surveillance. The hospital-based data comprised fatal and nonfatal stroke (Step 1). We gathered stroke-related mortality data in the community using World Health Organization questionnaires (Step 2). The questionnaire determining stroke prevalence was activated door to door in a family-health-programme neighbourhood (Step 3).
  
  
  RESULTS
  A total of 682 patients 18 years and above, including 472 incident cases, presented with cerebrovascular disease and were enrolled in Step 1 during April-May 2009. Cerebral infarction (84.3%) and first-ever stroke (85.2%) were the most frequent. In Step 2, 256 deaths from stroke were identified during 2006-2007. Forty-four per cent of deaths were classified as unspecified stroke, 1/3 as ischaemic stroke, and 1/4 due to haemorrhagic subtype. In Step 3, 577 subjects over 35 years old were evaluated at home, and 244 cases of stroke survival were diagnosed via a questionnaire, validated by a board-certified neurologist. The population demographic characteristics were similar in the three steps, except in terms of age and gender.
  
  
  CONCLUSIONS
  By including data from all settings, World Health Organization stroke surveillance can provide data to help plan future resources that meet the needs of the public-health system.
authors.affiliation: Hospital Universitario, University of São Paulo, São Paulo, SP, Brazil. agoulart@hu.usp.br
authors.forename: Alessandra C
authors.initials: AC
authors.lastname: Goulart
authors.forename: Iara R
authors.initials: IR
authors.lastname: Bustos
authors.forename: Ivana M
authors.initials: IM
authors.lastname: Abe
authors.forename: Alexandre C
authors.initials: AC
authors.lastname: Pereira
authors.forename: Ligia M
authors.initials: LM
authors.lastname: Fedeli
authors.forename: Isabela M
authors.initials: IM
authors.lastname: Benseñor
authors.forename: Paulo A
authors.initials: PA
authors.lastname: Lotufo
mesh_terms: D000293:Adolescent; D000368:Aged; D001938:Brazil / Q000453:epidemiology; D002318:Cardiovascular Diseases / Q000453:epidemiology; D003625:Data Collection; D005260:Female; D006760:Hospitalization / Q000706:statistics & numerical data; D006801:Humans; D008297:Male; D008875:Middle Aged; D011153:Population; D011159:Population Surveillance / Q000379:methods*; D012042:Registries; D012107:Research Design; D012959:Socioeconomic Factors; D020521:Stroke / Q000453:epidemiology* / Q000401:mortality; D011795:Surveys and Questionnaires; D014944:World Health Organization