October 21, 2010
The global health community may be severely underestimating the number of deaths due to malaria in India, according to a study in today’s Lancet. “Adult and child malaria mortality in India: a nationally representative mortality survey” places malaria deaths somewhere in the range of 205,000 per year in India a far cry from the World Health Organization’s estimate of 15,000.
The study, funded by the US National Institutes of Health, Canadian Institute of Health Research, and the Li Ka Shing Knowledge Institute, and co-authored by CDDEP director Ramanan Laxminarayan, undertook a large field survey to capture a more comprehensive picture of causes of death in India. As the authors point out early on, there are several reasons to suspect that malaria deaths in the country are underestimated. First, if malaria is properly diagnosed, it is most often cured, so diagnosed malaria is less likely to be fatal. Second, malaria is often mistaken for other common diseases that also present with fever. Third, episodes in rural areas (often where malaria is most common) do not frequently receive medical interventions, and so the cause of death is not certified.
To capture a more accurate picture of malaria mortality, the research group conducted interviews regarding each of 122,000 deaths between 2001 and 2003 in randomly selected areas of India. Each report was then analyzed by two trained physicians and coded with a cause (discrepancies in coding were accounted for with upper and lower bounds of 125,000 and 277,000 deaths, respectively). The results were striking–even the lower bound is still 8 times the estimate from the WHO. The study also suggests an overall 1.8% probability of dying of malaria before age 70. In Orissa, the most-affected region, the probability rises to 12.5%.
There is a great deal of uncertainty surrounding such retrospective classifications of the cause of death, particularly in the context of numerous diseases that present with fever. The authors acknowledge this uncertainty, but still, note that the difference between the WHO estimate and the survey data warrants a long look. A more thorough understanding of the burden of malaria would better inform public health strategies, and as the authors point out provide a more rational foundation for the current debates about funding for preventive measures, the need for more rapid access to malaria diagnosis, and about affordable access in the community to effective antimalarial drugs for children and adults.
Image credit: Flickr: calamur
