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Malaria mortality exceeds WHO estimates in India
Dhingra N. Lancet. 2010;doi:S0140-6736(10)60831-8.
Hay SI. Lancet. 2010;doi:10.1016/S0140-6736(10)61084-7.
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Recent data indicating that malaria causes 205,000 deaths per year in India sharply contrast with WHO’s estimated 15,000, suggesting the organization’s potentially vast underestimation of malaria mortality worldwide.
To determine plausible ranges of malaria deaths in India — the most populous country in which malaria is prevalent — researchers from several institutions had trained physicians assess verbal autopsies supplied by the Registrar General of India and code underlying causes of death. At least two physicians analyzed each case, with anonymous adjudication or reconciliation resolving differences of opinion on diagnoses.
Verbal autopsies consisted of half-page narratives plus answers to specific questions about severity and course of any fevers collected by full-time nonmedical field workers. They gleaned information from families or respondents regarding 122,000 deaths from 2001 to 2003 in 6,671 randomly selected areas of India.
Results indicated that 3.6% of 75,342 deaths among people aged 1 month to 70 years were attributable to malaria. These numbers suggested that 205,000 malaria deaths occur nationally per year in this age group, the researchers wrote, with 55,000 occurring in early childhood, 30,000 in children aged 5 to 14 years and 120,000 in those aged 15 to 69 years. The cumulative probability of death was 1.8% for people aged younger than 70 years.
Data also suggested that the annual lower national estimate for malaria-related deaths in those aged younger than 70 years was 125,000 (99% CI, 117,000-133,000) and the upper bound estimate was 277,000 (99% CI, 265,000-289,000).
The researchers also said malaria accounted for about 1.3 million unattended infectious disease-related deaths in which fever was the major symptom among people aged younger than 70 years.
Further, they said 90% of deaths occurred in rural areas and 86% happened outside of health care facilities.
In an accompanying editorial, researchers from the University of Oxford in the United Kingdom said they were concerned about these findings, noting that many malaria deaths may be overlooked by health reporting systems.
“Beyond India, this evidence emphasizes the inadequacies in the way WHO reports global malaria cases, a process that depends heavily on routine health-reporting data,” they wrote, noting that similar discrepancies could exist for WHO’s estimated malaria burden in other countries. “As countries strive to improve their measurement of disease and deaths attributable to malaria, independent studies play a crucial part in drawing attention to the inadequacies of national statistics.”