1. 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
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2. 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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3. 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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4. Nationally representative sample (Sample Registration System)
6,671 of these small areas randomly chosen from all parts of India (each with about people per area)
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5. How was the study done?
800 Registrar of General India field workers interviewed 122 thousand families of people who had died in
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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6. 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
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7. Malaria-attributed deaths in the present study by age
Study deaths,
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
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8. 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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9. Malaria-attributed deaths: estimated national totals, by age
All India, 2005
Age range
Deaths (thousands)
Death rate per
(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
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10. 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)
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11. 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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12. 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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13. Malaria deaths occurred where the most dangerous type (Plasmodium falciparum) of malaria parasite occurs
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14. 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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15. 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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16. 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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17. 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

18. 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
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19. 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

20. Background slides
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21. Key messages
First nationally representative study of the causes of all deaths in India
Of 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 years old
Malaria mortality rates were high in early childhood and in later middle age
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22. 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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23. 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,
NVDCP slide-positive, clinically-confirmed malaria deaths,
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
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24. Age patterns of malaria deaths in Africa and India
ACTUAL AGE PATTERNS: INDIA and AFRICA
GBD WHO ASSUMPTIONS
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