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) CGHR.ORG

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) CGHR.ORG

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 CGHR.ORG

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

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 Deaths (thousands) Death rate per 100 000 (lakh) <1 months 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 75 Subtotal, ages 0-69 years (lower, upper bounds) 205 (125, 277) 18 70 + 71 236 120 thousand at ages 15-69 CGHR.ORG

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

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 CGHR.ORG

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 CGHR.ORG

Malaria deaths occurred where the most dangerous type (Plasmodium falciparum) of malaria parasite occurs CGHR.ORG

Malaria deaths did not occur in states where dengue or meningitis or typhoid * were common (1) * These diseases can be confused with malaria CGHR.ORG

Malaria deaths did not occur in states where dengue or meningitis or typhoid * were common (2) * These diseases can be confused with malaria CGHR.ORG

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% 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

www.cghr.org/malaria The Lancet Paper and Web appendix Press and video releases: English, Hindi, Oriya and Assamese (plus B-roll) Lancet Press release Quotes from noted scientists Frequently-asked questions PowerPoint slides Pictures of malaria CGHR.ORG

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) 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

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 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 CGHR.ORG

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. % 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 All other states 928 35% 1999 All India 2685 100% 5647 CGHR.ORG

Age patterns of malaria deaths in Africa and India ACTUAL AGE PATTERNS: INDIA and AFRICA GBD WHO ASSUMPTIONS CGHR.ORG