Research A stepwise approach to stroke surveillance in Brazil: the EMMA (Estudo de Mortalidade e Morbidade do Acidente Vascular Cerebral) study Alessandra C. Goulart 1,2à , Iara R. Bustos 1 , Ivana M. Abe 1 , Alexandre C. Pereira 2 , Ligia M. Fedeli 3 , Isabela M. Bensen ˜ or 1,2,3 and Paulo A. Lotufo 1,3 Background: Stroke mortality rates in Brazil are the highest in the Americas. Deaths from cerebrovascular disease surpass coronary heart disease. Aim: To verify stroke mortality rates and morbidity in an area of Sa ˜ o 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 surveil- lance. The hospital-based data comprised fatal and nonfatal stroke (Step 1). We gathered stroke-related mortality data in the community using World Health Organization question- naires (Step 2). The questionnaire determining stroke pre- valence 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 classi- fied 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 character- istics were similar in the three steps, except in terms of age and gender. Conclusion: 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. Key words: concepts, design, prevention, stroke, surveillance Introduction Stroke is a leading cause of long-term disability and mortality worldwide. In Brazil, in the 1960s, the death rate from cerebrovascular and coronary heart diseases surpassed those for infectious diseases, and the stroke mortality rates in Brazil are the highest in Latin America (1, 2). The burden of mortality due to stroke is twice as common among people living in neighbourhoods with low socioeconomic indicators com- pared with those living in more affluent neighbourhoods and among African descendents (3, 4). The categorisation of stroke as a neglected disease in Brazil is justified, considering that spending for hospitalisation for acute stroke represents only 1% of the Brazilian National Health System budget (5). In order to plan preventive strategies for stroke, the World Health Organization (WHO) organised a stepwise approach to stroke surveillance (STEPS Stroke). This is a standardised tool for collecting data on fatal and nonfatal stroke (6). This approach enables researchers to capture information from the three major subsets:  stroke events admitted to the hospital (Step 1)  fatal stroke events in the community (Step 2), and  nonfatal stroke events in the community (Step 3) (6–8). Despite the significant consequences of stroke on the Brazilian public health system, there is a predominance of mortality studies addressing specific stroke subtypes, as well as ethnic, socioeconomic and gender aspects (3, 4, 9–12). Re- search focusing on the incidence, case fatality and prevalence rates of stroke has only been published in two towns (13–15). DOI: 10.1111/j.1747-4949.2010.00441.x Funding: The study was funded by the Brazilian National Research Council (CNPq), Brası ´lia, Brazil, Fundac ¸a ˜o de Amparo a Pesquisa do Estado de Sa ˜o Paulo (FAPESP), Sa ˜o Paulo, SP, Brazil, and Centro de Pesquisa Clı ´nica do Hospital Universita ´rio da Universidade de Sa ˜o Paulo, Sa ˜o Paulo, SP, Brazil. Conflicts of interest: Dr Bensenor and Dr Lotufo are recipients of a grant for established investigator from Conselho Nacional de Pesquisa (CNPq), Brası ´lia, Brazil. Correspondence: Alessandra C. Goulart à , Hospital Universita ´rio, Av. Lineu Prestes 256, Butantan, Cidade Universita ´ ria, EP 05508-900 – Sa ˜o Paulo, SP, Brazil. E-mail: agoulart@hu.usp.br 1 Hospital Universitario, University of Sa ˜o Paulo, Sa ˜o Paulo, SP, Brazil 2 Hospital das Clı ´nicas, University of Sa ˜o Paulo, Sa ˜o Paulo, SP, Brazil 3 Faculdade de Medicina, University of Sa ˜o Paulo, Sa ˜o Paulo, SP, Brazil & 2010 The Authors. 284 Journal compilation & 2010 World Stroke Organization International Journal of Stroke Vol 5, August 2010, 284–289