New research suggests that malaria is a much bigger killer in India than we thought: the investigators said every year about 205,000 people in India die from the disease, which is more than 13 times the current estimate from the World Health Organization (WHO), the public health arm of the United Nations.
The WHO disputed the figure, saying that the methods used by the researchers are not sufficiently reliable, but the researchers said even allowing for the uncertainties of trying to get reliable figures in a country where most of the deaths occur at home with no medical intervention, the WHO figure is a gross under-estimate and should now be revised.
You can read about the research, by co-lead author Dr Prabhat Jha and an international team of researchers from India, Canada and the UK, working on the Million Death Study, in the 21 October issue of The Lancet.
Jha is the director of the Centre for Global Health Research (CGHR) at St. Michael’s Hospital and the University of Toronto. He said in a statement that this is the first study that has collected data on causes of death directly from communities all over India.
“It shows that malaria kills far more people than previously supposed. Most of these deaths are in the few Indian states where the most dangerous type of malaria parasite is common,” he added.
Deaths from malaria are difficult to estimate on a nationwide basis because if reliably diagnosed, then it is likely to be cured, leaving undiagnosed deaths open to being attributed to other causes of fever.
The Million Death Study (MDS) in India is a collaboration of the Registrar General of India’s Sample Registration System (SRS), a nationwide routine demographic survey, in close partnership with the CGHR, the Indian Council of Medical Research, and other leading academic centres in India and elsewhere.
The MDS is following the lives and deaths of 1.1 million households all over India until 2014 and is collecting data on risk factors and causes of death for members of these households.
The data for the study came from non-medical field workers who interviewed family members and others to collect information on causes of death for each of 122,000 deaths that occurred during 2001 and 2003 in 6,671 randomly selected areas of India, each with about 200 households.
The interviewers asked general and specific questions about the severity and course of any fevers, and each report was independently analyzed and coded by two trained physicians to identify underlying causes. Any discrepancies were resolved either by “anonymous reconciliation or adjudication”, wrote the authors.
After analyzing the adjudicated results, the researchers estimated that malaria accounts for about 205,000 deaths per year in India before the age of 70 years, with 55,000 of these occuring under the age of five, 30,000 at ages 5 to 14 years, and 120,000 at ages 15 to 69 years.
This gave a cumulative probability of 1·8% of dying from malaria before the age of 70 years, wrote the researchers.
They argued that even the plausible lower bound of their estimate, based on the initial coding only, would give a figure of 125,000 a year. They estimated the upper bound to lie at around 277,000 deaths a year.
205,000 Indian deaths caused by malaria every year is 13 times the current 15,000 deaths estimated by the WHO. It even exceeds the WHO’s estimate of malaria deaths worldwide: 100,000 people a year, reported Reuters.
Dr. Simon Hay of Oxford University in the UK is co-founder of the Malaria Atlas Project. He wrote in an accompanying editorial that the WHO estimate most likely excludes the many cases where malaria symptoms develop quickly and are never seen by a health worker.
He commented that these cases, are effectively “invisible to the health reporting system”.
The researchers noted that 90 per cent of the Indian deaths in their estimate were in rural areas and 86 per cent occurred at home without any sort of medical attention.
They found that the state of Orissa had more malaria deaths than any other Indian state, 50,000 a year. Other states with a high death rate to malaria were also in eastern India: Chhattisgarh, Jharkhand and Assam.
Jha and colleagues concluded that:
“Despite uncertainty as to which unattended febrile deaths are from malaria, even the lower bound greatly exceeds the WHO estimate of only 15,000 malaria deaths per year in India (5,000 early childhood, 10,000 thereafter).”
They suggested that the WHO estimates should now be reconsidered, both for Indian malaria deaths and worldwide.
If these prove, as they believe, to be under-estimates, then this could “could substantially change disease control strategies, particularly in the rural parts of states with a high malaria burden”, they added, noting also that better estimates of malaria deaths in India, Africa and other regions could set a more rational basis for affordable access to community treatments for children and adults.
Dr V M Katoch, who is secretary of the Indian Department of Health Research and also the director-general of the Indian Council of Medical Research, said what was striking about the new study’s figures was that “unlike AIDS or cancer, malaria is curable if treated promptly”.
“We have safe, effective and inexpensive drugs that can quickly cure malaria patients. What we need is rapid access to healthcare facilities,” he added.
Kenneth J Arrow, Professor of Economics at Stanford University and who won the Nobel Prize in Economics in 1972 said that:
“Artemisinin combination therapies are strongly efficacious and can be available at low cost through the Affordable Medicines Facility for Malaria.”
“The treatment should be made easily accessible to both children and adults through public and/or private distribution channels,” he added.
Funds for the study came from the US National Institutes of Health, the Canadian Institute of Health Research, and the Li Ka Shing Knowledge Institute of St. Michael’s in Toronto.
“Adult and child malaria mortality in India: a nationally representative mortality survey.”
Neeraj Dhingra, Prabhat Jha,Vinod P Sharma,Alan A Cohen, Raju M Jotkar, Peter S Rodriguez, Diego G Bassani,Wilson Suraweera, Ramanan Laxminarayan, Richard Peto, for the Million Death Study Collaborators.
DOI: 10.1016/S0140-6736(10)60831-8
Additional sources: CGHR, University of Toronto, Reuters.
Written by: Catharine Paddock, PhD