…or so asks a group of malaria researchers in an accompanying comment to a new – and very controversial – research paper by Neeraj Dhingra and co-authors now available online at the Lancet.

Malaria is a major public health problem in India, however, the WHO estimates that there are only 15,000 malaria deaths a year in India.  Important, but given that we are talking about a population of over a billion people, this is really just a drop in the bucket.  The WHO estimates are based on statistics reported from the Indian Government, which are based on facility based reports of deaths.

But using cause-of-death estimates generated from the use of new verbal autopsy methods in the nationally representative Sample Registration System, researchers estimated that it is possible that deaths from malaria could actually range from 125,000 to 277,000 deaths a year – or roughly 10 times higher than the WHO estimates!

Measuring morbidity and mortality from malaria has always been tricky.  The main symptom of malaria – fever – is a common symptom of many illnesses, so attributing cause of death when fever is present can be difficult.  As well, malaria is actually reasonably easy to treat if prompt treatment is given, but prompt treatment is rarely given if malaria is not diagnosed, so many malaria deaths may be underreported.  In addition, many malaria deaths occur in rural areas where many deaths occur outside of facilities are are not always reported.

No method is going to be perfect, and there are likely substantial measurement issues associated with the use of verbal autopsy methods, but given the huge discrepancy between the measures, it does suggest that something else is at play here.  If we believe these new estimates, under reporting of malaria deaths in India alone accounts represents 20-25% of the estimated global mortality from malaria.  These findings also raise some serious doubts about the WHO’s estimates from other countries.  How could the WHO’s estimates be so wrong?

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17 Responses to “How could the WHO's malaria reports be so wrong?”

  1. RT @owenbarder: Karen: what's your answer? RT @KarenGrepin: How could the WHO's #malaria reports be so wrong? http://bit.ly/dmlzOp #glob …

  2. Devi Sridhar says:

    @KarenGrepin I'm wondering the same thing! RT: How could the WHO's #malaria reports be so wrong? http://bit.ly/dmlzOp #globalhealth

  3. Owen Barder says:

    Karen: what's your answer? RT @KarenGrepin: How could the WHO's #malaria reports be so wrong? http://bit.ly/dmlzOp #globalhealth

  4. How could the WHO's #malaria reports be so wrong? http://bit.ly/dmlzOp #globalhealth by Karen

  5. Devi Sridhar says:

    Karen, I have been keen to hear your thoughts on this because it would seem (from a non-malaria expert point of view) that the verbal autopsy method would be more reliable than relying on hospital records given that such a small percentage of the population end up in hospitals. Do you agree?

  6. Karen Grepin says:

    I was actually going to ask you your opinion, I don't think anyone truly believes that administrative data anywhere is an accurate estimate of malaria deaths but in most places I thought adjustments were being made to take this into account.

    The fact that India's data are so much lower than what is perhaps reality suggests that deliberate under reporting was happening. If ten times more deaths are occurring than what was reported I suspect most public health officials would have some sense of this even if available statistics did not reflect this reality.

    I just don't know that much about the political economy of health in India to guess, but it actually reminded me a bit of some of the passages from your book on undernutrition.

    What are your thoughts as why this might be happening?

  7. RT @KarenGrepin: How could the WHO's #malaria reports be so wrong? http://bit.ly/dmlzOp #globalhealth

  8. Gwenyth says:

    How could the WHO's malaria reports be so wrong?: …or so asks a group of malaria researchers in an accompanying … http://bit.ly/cxws7I

  9. MW says:

    I don't know about India, but a doctor friend is volunteering in Uganda this year and people there seem to view malaria similarly to the way we in the U.S. view a cold or flu. She says that if someone walks into the clinic feeling sick, the first question asked is "Do you have malaria?" and the answer's usually "yes" and everyone's matter-of-fact about it. In a situation like that, it seems to me it would be easy for deaths from malaria not to be reported.

  10. Devi Sridhar says:

    Karen, I think the larger issue (beyond India) is that we neglect adult mortality from malaria. It's become depicted (by donors and the media) as a major killer of children, and while true, also takes a heavy toll on adults in their most productive years.

  11. Devi Sridhar says:

    #Malaria Mortality in #India- new blog post, http://bit.ly/bApy9w. See also @KarenGrepin http://bit.ly/dmlzOp #globalhealth

  12. Karen Grepin says:

    RT @devisridhar: #Malaria Mortality in #India http://bit.ly/bApy9w See also @KarenGrepin http://bit.ly/dmlzOp #globalhealth

  13. RT @devisridhar: #Malaria Mortality in #India http://bit.ly/bApy9w Also @KarenGrepin http://bit.ly/dmlzOp #globalhealth

  14. How could the WHO's malaria reports be so wrong? http://bit.ly/b7a5PL, estudio muestra que muertes x malaria en India podrían ser 10 veces +

  15. […] fall, I blogged about a seemingly alarming new research findings published in the Lancet by Dhingra and co-authors […]

  16. […] The Lancet recently released a study estimating adult and child malaria mortality in India. The findings have made headlines around the world due to a huge difference in these estimates compared to WHO’s. This study found 85,000 deaths before age 14 and 120,000 between ages 15-69, while WHO’s previous estimates were a total of 15,000 deaths per year. The question on everyone’s mind is: how could WHO get it so wrong? […]

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