Malarial deaths in India grossly underestimated by WHO

Published in The Hindu on October 21, 2010

How many people die of malaria every year in India? According to the estimates of World Health Organisation (WHO), 15,000 (10,000 adults and 5,000 children) malarial deaths occur each year.

But a study published online today (Oct 21) in The Lancet points out that the numbers could be as high as 2,05,000 per year. The upper limit is around 2,77,000 and the lower limit is nearly 1,25,000.

This number for India alone is much higher than WHO’s estimate of 1,00,000 deaths per year worldwide.

Trend already seen

The study underlines the fact that WHO estimates are a gross underestimation. Several studies in the past have shown that the number of deaths is more than WHO estimates.

The reason could be that WHO takes into account only those deaths that have been confirmed cases, and restricted to those seeking healthcare facilities. Also, the statistics are limited to a few high prevalent States (Orissa, Chhattisgarh, Jharkhand) and northeast.

Can the results from small studies undertaken in select States or in select subpopulations, and only from those families that had access to healthcare facilities be extrapolated to arrive at a national estimate?

Indeed assessing national estimates for malaria is challenging given the many limitations.

The paper shows how wrong the estimates can be if the current protocol is used. For instance, The Lancet paper shows that the majority of deaths occur in rural areas and in people who do not seek medical assistance.

Easily preventable

It must be remembered that deaths due to malaria can be easily prevented with prompt treatment, and those cases that are diagnosed properly will not result in deaths.

The authors used full-time non-medical field workers trained by the Registrar-General of India to interview the families where deaths have happened.

The procedure was followed in 6,671 randomly selected areas to find the cause of death of 1,22,000 people during 2001-03. Two physicians then had to confirm the cause of death based on the data provided by the fieldworkers.

Of the total number of deaths, 2,681 were found to be due to malaria. 90 per cent of these deaths had happened in rural areas and 86 per cent were not in health-care facility.

Study limitations

The study indeed has some limitations, though. The authors agree that their study has a degree of “uncertainty” as the cause of death is deduced in those people who were never properly diagnosed or treated. “The major source of uncertainty in estimates arises from the possible misclassification of malaria deaths as deaths from other diseases, and vice versa,” they state.

The comment piece in the same issue of the journal notes that “deaths from malaria are predominantly unnoticed by the health-reporting system.”

The comment piece goes further to state: “Many workers have also noted that the health management information system in India is not fit for the purpose of recording malaria morbidity and mortality.”

The study underlines that true estimates of malarial deaths in India remain uncertain. In any case, WHO estimates, both for India and worldwide, are way off the mark.

The implications of such gross underestimation are unimaginable. For one, it results in complacency and wrong disease control strategies. If the numbers are indeed much higher than WHO estimates, then serious re-evaluation of disease control strategies is required.

Also, as the authors note, there is an urgent need to concentrate on rural areas where healthcare facilities are poor. At a global level, it calls for enhanced funding to fight malaria, efforts to develop easy and rapid access to better diagnostics and effective drugs.