Open Access Research article

Stroke in urban and rural populations in north-east Bulgaria: incidence and case fatality findings from a 'hot pursuit' study

John Powles1*, Philip Kirov2, Nevijana Feschieva3, Marin Stanoev3 and Virginia Atanasova3

Author Affiliations

1 Department of Public Health and Primary Care, Institute of Public Health, Cambridge, CB2 2SR, UK

2 Acute Stroke Unit, University Hospital, Varna, Bulgaria

3 Varna Diet and Stroke Study, c- Department of Social Medicine, Medical University of Varna, Marin Drinov 55, Varna 9002, Bulgaria

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BMC Public Health 2002, 2:24  doi:10.1186/1471-2458-2-24

Published: 25 September 2002



Bulgaria's official stroke mortality rates are higher for rural than urban areas. Official mortality data has indicated that these rates are amongst the highest in Europe. There has been a lack of studies measuring stroke incidence in urban and rural populations.


We established intensive notification networks covering 37791 residents in Varna city and 18656 residents (55% of them village-dwellers), all aged 45 to 84, in 2 rural districts. From May 1, 2000 to April 30, 2001 frequent contact was maintained with notifiers and death registrations were scanned regularly. Suspected incident strokes were assessed by study neurologists within a median of 8 days from onset.


742 events were referred for neurological assessment and 351 of these, which met the WHO criteria for stroke, were in persons aged 45 to 84 and were first ever in a lifetime. Incidence rates, standardised using the world standard weights for ages 45 to 84, were 909 (/100000/year) (95% CI 712–1105) and 597 (482–712) for rural and urban males and 667 (515–818) and 322 (248–395) for rural and urban females. Less than half were admitted to hospital (15% among rural females over 65). Twenty-eight day case fatality was 35% (123/351) overall and 48% (46/96) in village residents. The excess case fatality in the villages could not be explained by age or severity.


Rural incidence rates were over twice those reported for western populations but the rate for urban females was similar to other western rates. The high level and marked heterogeneity in both stroke incidence and case fatality merit further investigation.