Malaria deaths in India 13 times higher than WHO estimate, study says

"Malaria kills around 205,000 people in India each year, more than 13 times the estimate made by the World Health Organization, researchers said on Thursday," Reuters reports (Ee Lyn, 10/20).

The WHO has estimated that about 15,000 die of malaria each year in India, "the most populous country where the disease is endemic," Agence France-Presse writes. The study, published in the journal Lancet, "says the WHO's reporting method is flawed, as it depends indirectly on patients who have been diagnosed by a doctor. Many deaths in India occur at home, rather than in a hospital or a clinic, which means the underlying cause of many malaria fatalities is likely to be misattributed, it says" (10/20).

To calculate the total number of malaria deaths in India, "international experts examined 122,000 deaths from 2001 to 2003 in 6,671 parts of India thought to be representative of the entire country. Trained workers interviewed family members or friends about the deaths, asking questions about things like the symptoms people had before they died and if they got any treatment," the Associated Press/Washington Post reports (Cheng, 10/20). Those findings were "then analysed separately by two physicians, who each gave an independent opinion of the underlying cause of death. A review board adjudicated in cases where there was a dispute," AFP notes (10/20). The study found that 3.6 percent of people between the age of one month and 70 years old probably died from malaria. It also found that "90 percent of people who died [of malaria] were in rural areas and 86 percent were not treated in any health facility," the AP/Washington Post writes (10/20).

According to the researchers, the findings indicate that WHO malaria death estimates for other countries might also be significantly off, AFP writes. "If WHO estimates of malaria deaths in India or among adults worldwide are likely to be serious underestimates, this could substantially change disease control strategies, particularly in the rural parts of states with high malaria burden," the authors wrote in the study (10/20). According to Bloomberg, WHO currently estimates that "[m]alaria infects about 250 million people each year and kills almost 1 million, mostly children living in Africa" (Narayan, 10/20).

"When I first saw the results, I thought, 'This can't be right,'" said study co-author Prabhat Jha, director of the Centre for Global Health Research at the University of Toronto. "But the more we looked, the more the pattern seemed to fit," he said, the AP/Washington Post reports.

WHO Global Malaria Programme Director Robert Newman "said WHO had serious doubts about the Lancet study and questioned the validity of diagnosing malaria based on the recollections of family members or friends. ... 'While routine reports of malaria cases and deaths in India are certainly incomplete, the new estimate of 200,000 deaths appears too high,' Newman said. 'The findings of this study cannot be accepted without further validation.'"

The study was funded by the NIH, the Canadian Institute of Health Research and the Li Ka Shing Knowledge Institute, the news service reports (10/20).

In a comment also published in the Lancet on Thursday, "experts not involved in the study" highlighted the finding that 86 percent of malaria deaths in India "did not occur in any formal healthcare facility linked to the national disease reporting system," Reuters reports. "The true effect of the malaria burden in India remains uncertain but evidence is increasing that the scale of the burden has been greatly underestimated," wrote Bob Snow of the KEMRI-University of Oxford-Wellcome Trust Collaborative Programme in Kenya and colleagues (10/20). 

In the comment, the authors note the study's use of verbal autopsies: "[T]hey remain an imperfect method for the estimation of malaria mortality, and the unexpected findings reported today therefore require further investigation." But they write that the findings are a reason to "pause for thought" and note that malaria death underestimates "could exist in other heavily populated, remote regions that are exposed to malaria and have unreliable access to health care, such as Burma, Bangladesh, Pakistan, Afghanistan, and Indonesia" (Hay et al., 10/21).