CGHR.ORG

ADULT AND CHILD MALARIA MORTALITY IN

INDIASources of support:

ICMR and RGI (India); FIC, NIH (US); LKSKI, IDRC & CIHR (Canada); CTSU & MRC (UK)

Prabhat.jha@utoronto.ca

Prabhat Jha, on behalf of MDS Collaborators

CGHR.ORG

Conclusions• Malaria deaths should not occur with basic

health services: prompt diagnosis and treatment are effective

• India had over 200,000 avoidable malaria deaths (55,000 child, 30,000 at ages 5-14, 120,000 ages 15-69) in 2005

• Reconsider WHO total of 5,000 child and 10,000 adult malaria deaths in India and 100,000 adult malaria deaths worldwide

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What’s new about this research?

• Large, nationally representative sample of all deaths based on household interviews with families

• The study results reflects the whole of India• This is NOT a study of properly treated

malaria patients (in whom few deaths occur)

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Nationally representative sample(Sample Registration System)

• 6,671 of these small areas randomly chosen from all parts of India (each with about 1000 people per area)

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How was the study done?

800 Registrar of General India field workers interviewed 122 thousand families of people who

had died in 2001-2003

Written reports each coded independently by at least two physicians to attribute a probable

cause to each death (i.e. malaria)

Coded malaria deaths likely represent malaria, despite the potential for misclassification

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How was the study done?

Calculate proportion of malaria deaths in each age group within the study

Combine with national 2005 UN totals of deaths in each age group

Produce national (and state) estimates of numbers of malaria deaths at various

ages

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Malaria-attributed deaths in the present study by age

Study deaths, 2001-2003

Age range Malaria deaths/ all

coded deaths

Proportion malaria

<1 months 4/10892 0·0%

1-59 months 587/12260 4·2%

5-14 years 349/3881 8·3%

15-29 years 388/9121 3·6%

30-44 years 319/10872 2·5%

45-59 years 500/18133 2·6%

60-69 years 538/21136 2·5%

Subtotal, ages 0-69 years (lower, upper bounds)

2685/86773 2·8%(2.0 , 3.7)

70 + 972/36057 2·7%

3·6% at ages 1 month-

69 years

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Malaria deaths before age 70 in the study

• 90% (2422/2685) were in rural areas

• 86% (2315/2685) did not occur at a health facility

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All India, 2005

Age rangeDeaths

(thousands)Death rate per 100 000 (lakh)

<1 months 0 44

1-59 months 55

5-14 years 29 12

15-29 years 25 8

30-44 years 22 10

45-59 years 37 27

60-69 years 37 75

Subtotal, ages 0-69 years (lower, upper bounds)

205(125, 277)

18

70 + 71 236

Malaria-attributed deaths: estimated national totals, by age

120 thousand at ages 15-69

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*

WHO indirect estimates of Indian malaria mortality rates

Study-attributed Indian malaria mortality rates

Age-specific all-India malaria-attributed death rates estimated from the present study, and those estimated

indirectly for WHO * No. of study deaths per age class (in red)

Malaria mortality rates were high in early childhood and in later middle

age

CGHR.ORG* Malaria death rates, India 2005, standardised to population aged 0-69

~100

Half of the malaria deaths were in a few high-malaria states in eastern

India

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Risk of a newborn Indian dying from malaria before

age 70 (at current rates, in the absence of other

disease)

• About 2% overall in India• Over 12% in Orissa

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Malaria deaths occurred where the most dangerous type (Plasmodium falciparum) of

malaria parasite occurs

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Malaria deaths did not occur in states where dengue or meningitis or typhoid * were common

(1)

* These diseases can be confused with malaria

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Malaria deaths did not occur in states where dengue or meningitis or typhoid * were common

(2)

* These diseases can be confused with malaria

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Fever deaths in India, 2005< age 70, n=1.8M (18 lakh)

• 1.3 M (13 lakh) UNDIAGNOSED, mostly untreated FEVER deaths in RURAL India

• Malaria is a significant minority of these fever deaths, but more so in high-malaria states

Causes of fever deaths < age 70

Pneumonia 28%

Tuberculosis 17%

Diarrhoea 16%

MALARIA 11%

Fever of unknown origin 7%

Other 20%

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Conclusions• Malaria deaths should not occur with basic

health services: prompt diagnosis and treatment are effective

• India had over 200,000 avoidable malaria deaths (55,000 child, 30,000 at ages 5-14, 120,000 ages 15-69) in 2005

• Reconsider WHO total of 5,000 child and 10,000 adult malaria deaths in India and 100,000 adult malaria deaths worldwide

CGHR.ORG

www.cghr.org/malaria

1.The Lancet Paper and Web appendix2. Press and video releases: English,

Hindi, Oriya and Assamese (plus B-roll)3. Lancet Press release4. Quotes from noted scientists5. Frequently-asked questions6. PowerPoint slides7. Pictures of malaria

19

Million Death Study CollaboratorsIndian Academic Partners (in alphabetical order):

Clinical Epidemiology Resource and Training Centre Trivandarum: KB Leena, KT Shenoy (until 2005)

Department of Community Medicine Gujarat Medical College Ahmedabad: DV Bala, P Seth KN Trivedi

Department of Community Medicine Kolkatta Medical College Kolkatta: SK Roy

Department of Community Medicine Regional Institute of Medical Sciences Imphal: L Usharani

Department of Community Medicine S.C.B. Medical College Cuttack Orissa: Dr. B Mohapatra

Department of Community Medicine SMS Medical College Jaipur: AK Bharadwaj, R Gupta

Epidemiological Research Center Chennai: V Gajalakshmi, CV Kanimozhi

Gandhi Medical College Bhopal: RP Dikshit, S Sorangi

Healis-Seskarhia Institute of Public Health Mumbai: PC Gupta, MS Pednekar, S Sreevidya

Indian Institute of Health & Family Welfare, Hyderabad: P Bhatia

Institute of Health Systems Research Hyderabad: P Mahapatra (until 2004)

St. John’s Research Institute St. John’s Academy of Health Sciences Bangalore: A Kurpad, P Mony, M Vaz, R Jotkar, S Rao-Seshadri, S Shrihari, S Srinivasan

King George Medical College Lucknow: S Awasthi

Najafgarh Rural Health Training Centre Ministry of Health Government of India New Delhi: N Dhingra, J Sudhir, I Rawat (until 2007)

National Institute of Mental Health and Neurosciences Bangalore: G Gururaj (until 2004)

North Eastern Indira Gandhi Institute of Regional Medical Sciences Shillong Meghalaya: FU Ahmed (until 2005), DK Parida

Regional Medical Research Center ICMR Institute Bhubaneshwar: AS Karketta, SK Dar

School of Preventative Oncology Patna: DN Sinha

School of Public Health Post Graduate Institute of Medical Education and Research Chandigarh: N Kaur, R Kumar, JS Thakur

Tata Memorial Hospital Mumbai: RA Badwe, RP Dikshit, K Mohandas

Lead Partners:

Office of the Registrar-General India RK Puram New Delhi India: C Chandramouli (Registrar General of India [RGI]), RC Sethi, B Mishra, S Jain (until 2008), DK Dey (until 2009), AK Saxena, MS Thapa, N Kumar, JK Banthia and DK Sikri (former RGIs)

Million Death Study Coordinating Centre for Global Health Research (CGHR) Li Ka Shing Knowledge Institute Keenan Research Centre St. Michael’s Hospital Dalla Lana School of Public Health University of Toronto Canada: DG Bassani, P Jha (Principal Investigator), R Jotkar, R Kamadod, B Pezzack, S Rao-Seshadri, P Rodriguez, J Sudhir, C Ramasundarahettige, W Suraweera

Affiliated Partners:

Indian Council of Medical Research New Delhi India: VM Katoch (Director General or DG from 2008), NK Ganguly (DG to 2008), L Kant, B Bhattacharya

School of Population Health The University of Queensland Australia: AD Lopez, C Rao

World Health Organisation Geneva and SEARO Office New Delhi: T Boerma, T Evans, A Fric, S Habayeb (former WHO Representative-India), S Khanum, C Mathers, DN Sinha, N Singh, P Singh (Deputy Regional Director)

Clinical Trial Service Unit and Epidemiological Studies Unit (CTSU) University of Oxford England: N Bhala, J Boreham, Z Chen, R Collins, R Peto, G Whitlock

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Background slides

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Key messages• First nationally representative study of the causes of

all deaths in India • Of 75 342 study deaths at ages 1 month to 70

years, 2681 (3.6%) were attributed to malarial fever• Malaria caused about 200 thousand (2 lakh) deaths

before age 70 in 2005 in India as a whole• This is far more than the WHO estimate of only 15

thousand at all ages • Of malaria deaths:• 55 thousand <age 5 years• 30 thousand at 5-14 years old• 120 thousand (1.2 lakh) in adults 15-69 years old• Malaria mortality rates were high in early childhood

and in later middle age

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Key messages• 90% of malaria deaths were in rural areas and 86%

were not in any health facility• Half the malaria-attributed deaths were in a few

high-malaria states in eastern India (Orissa, Chhattisgarh, Jharkhand, Assam and its smaller neighbours)

• At current malaria death rates, an average Indian baby would have a 2% chance of dying from malaria before age 70, but this risk is much greater in the high-malaria states

• Malaria deaths occurred in the states where the Indian malaria control program finds a high prevalence of the most dangerous type (Plasmodium falciparum) of malaria parasite

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Geographical variation in absolute numbers of malaria deaths in the different populations studied

by the MDS and NVBDCP

State MDS malaria-attributed deaths

before age 70, 2001-03

NVDCP slide-positive, clinically-confirmed

malaria deaths, 2000-05

No.% No. %

Orissa823

31% 2102 37%

Northeast468

17% 1023 18%

Chhattisgarh131

5% 109 2%

Jharkhand118

4% 152 3%

Madhya Pradesh217

8% 262 5%

All other states928

35% 1999 35%

All India268

5

100% 5647 100%

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Age patterns of malaria deaths in Africa and India

GBD WHO ASSUMPTIONS

ACTUAL AGE PATTERNS: INDIA and AFRICA