ADULT AND CHILD
MALARIA MORTALITY IN
INDIA
Sources of support:
ICMR and RGI (India); FIC, NIH (US); LKSKI, IDRC & CIHR (Canada); CTSU & MRC (UK)
Prabhat Jha, on behalf of MDS Collaborators
Prabhat.jha@utoronto.ca
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
CGHR.ORG
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
CGHR.ORG
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%
CGHR.ORG
3·6% at
ages 1
month69 years
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
CGHR.ORG
Malaria-attributed deaths:
estimated national totals, by age
All India, 2005
Age range
<1 months
Deaths (thousands)
Death rate per
100 000 (lakh)
0
44
1-59 months
55
5-14 years
29
15-29 years
25
30-44 years
22
45-59 years
37
60-69 years
37
75
205
(125, 277)
18
71
236
Subtotal, ages 0-69
years (lower, upper
bounds)
70 +
CGHR.ORG
12
120
thousand at
ages 15-69
8
10
27
Malaria mortality rates were high in
early childhood and in later middle age
*
Study-attributed
Indian malaria
mortality rates
WHO indirect estimates of
Indian malaria mortality rates
Age-specific all-India malaria-attributed death rates estimated from the present study, and those estimated
CGHR.ORG
indirectly for WHO
* No. of study deaths per age class (in red)
Half of the malaria deaths were in a few
high-malaria states in eastern India
~100
* Malaria death rates, India 2005, standardised to population aged 0-69
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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)
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* These diseases can be confused with malaria
Malaria deaths did not occur in states where dengue
or meningitis or typhoid * were common (2)
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* These diseases can be confused with malaria
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
CGHR.ORG
Pneumonia
28%
Tuberculosis
17%
Diarrhoea
16%
MALARIA
11%
Fever of unknown origin
7%
Other
20%
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 appendix
2. Press and video releases: English, Hindi,
Oriya and Assamese (plus B-roll)
3. Lancet Press release
4. Quotes from noted scientists
5. Frequently-asked questions
6. PowerPoint slides
7. Pictures of malaria
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Million Death Study Collaborators
Indian 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)
19
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
Background slides
CGHR.ORG
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
CGHR.ORG
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 highmalaria 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 highmalaria 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
CGHR.ORG
Geographical variation in absolute numbers of malaria
deaths in the different populations studied by the MDS
and NVBDCP
State
MDS malariaattributed deaths
before age 70,
2001-03
NVDCP slide-positive,
clinically-confirmed
malaria deaths,
2000-05
No.
%
No.
%
Orissa
823
31%
2102
37%
Northeast
468
17%
1023
18%
Chhattisgarh
131
5%
109
2%
Jharkhand
118
4%
152
3%
Madhya Pradesh
217
8%
262
5%
All other states
928
35%
1999
35%
2685
100%
5647
100%
All India
CGHR.ORG
Age patterns of malaria deaths in
Africa and India
ACTUAL AGE
PATTERNS: INDIA
and AFRICA
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GBD WHO
ASSUMPTIONS