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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_at_utoronto.ca
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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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Whats 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
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Malaria-attributed deaths in the present study by
age
Study deaths, 2001-2003 Study deaths, 2001-2003 Study deaths, 2001-2003
Age range Malaria deaths/ all coded deaths Proportion malaria
lt1 months 4/10892 00
1-59 months 587/12260 42
5-14 years 349/3881 83
15-29 years 388/9121 36
30-44 years 319/10872 25
45-59 years 500/18133 26
60-69 years 538/21136 25
Subtotal, ages 0-69 years (lower, upper bounds) 2685/86773 28 (2.0 , 3.7)
70 972/36057 27
36 at ages 1 month-69 years
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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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Malaria-attributed deaths estimated national
totals, by age
All India, 2005 All India, 2005 All India, 2005 All India, 2005
Age range Deaths (thousands) Death rate per 100 000 (lakh)
lt1 months 0 44
1-59 months 55 44
5-14 years 29 12
15-29 years 25 8
30-44 years 22 10
45-59 years 37 27
60-69 years 37 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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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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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)
These diseases can be confused with malaria
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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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Fever deaths in India, 2005lt age 70, n1.8M (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 lt age 70 Causes of fever deaths lt age 70
Pneumonia 28
Tuberculosis 17
Diarrhoea 16
MALARIA 11
Fever of unknown origin 7
Other 20
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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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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. Johns Research Institute St. Johns 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

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Background slides
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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 ltage 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

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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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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 MDS malaria-attributed deaths before age 70, 2001-03 NVDCP slide-positive, clinically-confirmed malaria deaths, 2000-05 NVDCP slide-positive, clinically-confirmed malaria deaths, 2000-05
State 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
All India 2685 100 5647 100
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Age patterns of malaria deaths in Africa and India
ACTUAL AGE PATTERNS INDIA and AFRICA
GBD WHO ASSUMPTIONS
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