Resources for World Malaria Day 2013

April 25, 2013

Not a word about condemning Rachel Carson.  No plea to use DDT to try to poison Africa or Asia to health.  That’s a great start.

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Mother and son under a protective bednet, the most efficient method to prevent malaria.  Columbia University MVSim image

Mother and son under a protective bednet, the most efficient method to prevent malaria. Columbia University MVSim image


Still no ban on DDT: Treaty monitors allow DDT use to continue

December 16, 2012

Real news on a topic like DDT takes a while to filter into the public sphere, especially with interest groups, lobbyists and Astro-Turf groups working hard to fuzz up the messages.

News from the DDT Expert Group of the Conference of the Parties to the Stockholm Convention was posted recently at the Stockholm Convention website — the meeting was held in early December in Geneva, Switzerland.

Stockholm Convention on Persistent Organic Pol...

Logo of the Stockholm Convention on Persistent Organic Pollutants (POPs Treaty) Wikipedia image

In the stuffy talk of international relations, the Stockholm Convention in this case refers to a treaty put into effect in 2001, sometimes known as the Persistent Organic Pollutants Treaty (POPs).  Now with more than 152 signatory nations and 178 entities offering some sort of ratification (not the U.S., sadly), the treaty urges control of chemicals that do not quickly break down once released into the environment, and which often end up as pollutants.  In setting up the agreement, there was a list of a dozen particularly nasty chemicals branded the “Dirty Dozen” particularly targeted for control due to their perniciousness — DDT was one of that group.

DDT can still play a role in fighting some insect-carried diseases, like malaria.  Since the treaty was worked out through the UN’s health arm, the World Health Organization (WHO), it holds a special reservation for DDT, keeping DDT available for use to fight disease.   Six years ago WHO developed a group to monitor DDT specifically, looking at whether it is still needed or whether its special provisions should be dropped.  The DDT Expert Group meets every two years.

Here’s the press release on the most recent meeting:

Stockholm Convention continues to allow DDT use for disease vector control

Fourth meeting of the DDT Expert Group assesses continued need for DDT, 3–5 December 2012, Geneva

Mosqutio larvae, image from WHO

Mosqutio larvae, WHO image

The Conference of the Parties to the Stockholm Convention, under the guidance of the World Health Organization (WHO), allows the use of the insecticide DDT in disease vector control to protect public health.

Mosquito larvae

The Stockholm Convention lists dichlorodiphenyltrichloroethane, better known at DDT, in its Annex B to restrict its production and use except for Parties that have notified the Secretariat of their intention to produce and /or use it for disease vector control. With the goal of reducing and ultimately eliminating the use of DDT, the Convention requires that the Conference of the Parties shall encourage each Party using DDT to develop and implement an action plan as part of the implementation plan of its obligation of the Convention.

At its fifth meeting held in April 2011, the Conference of the Parties to the Convention concluded that “countries that are relying on DDT for disease vector control may need to continue such use until locally appropriate and cost-effective alternatives are available for a sustainable transition away from DDT.” It also decided to evaluate the continued need for DDT for disease vector control at the sixth meeting of the Conference of the Parties “with the objective of accelerating the identification and development of locally appropriate cost-effective and safe alternatives.”

The DDT Expert Group was established in 2006 by the Conference of the Parties. The Group is mandated to assess, every two years, in consultation with the World Health Organization, the available scientific, technical, environmental and economic information related to production and use of DDT for consideration by the Conference of the Parties to the Stockholm Convention in its evaluation of continued need for DDT for disease vector control.

The fourth meeting of the DDT Expert Group reviewed as part of this ongoing assessment:

  1. Insecticide resistance (DDT and alternatives)
  2. New alternative products, including the work of the Persistent Organic Pollutants Review Committee
  3. Transition from DDT in disease vector control
  4. Decision support tool for vector control.

The DDT expert group recognized that there is a continued need for DDT in specific settings for disease vector control where effective or safer alternatives are still lacking. It recommended that the use of DDT in Indoor Residual Spray should be limited only to the most appropriate situations based on operational feasibility, epidemiological impact of disease transmission, entomological data and insecticide resistance management. It also recommended that countries should undertake further research and implementation of non-chemical methods and strategies for disease vector control to supplement reduced reliance on DDT.

The findings of the DDT Expert Group’s will be presented at the sixth meeting of the Conference of the Parties, being held back-to-back with the meetings of the conferences of the parties to the Rotterdam and Basel conventions, from 28 April to 11 May 2013, in Geneva.

Nothing too exciting.  Environmentalists should note DDT is still available for use, where need is great.  Use should be carefully controlled.  Pro-DDT propagandists should note, but won’t, that there is no ban on DDT yet, and that DDT is still available to fight malaria, wherever health workers make a determination it can work.  If anyone is really paying attention, this is one more complete and total refutation of the DDT Ban Hoax.

Rachel Carson’s ghost expresses concern that there is not yet a safe substitute for DDT to fight malaria, but is gratified that disease fighters and serious scientists now follow the concepts of safe chemical use she urged in 1962.

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NIH notes progress against malaria on World Malaria Day 2012

April 28, 2012

Press release from the National Institutes of Health, for World Malaria Day (April 25, 2012):

For Immediate Release
Tuesday, April 24, 2012

NIH statement on World Malaria Day – April 25, 2012

B. F. (Lee) Hall, M.D., Ph.D., and Anthony S. Fauci, M.D.
National Institute of Allergy and Infectious Diseases

On World Malaria Day, we stand at a critical juncture in our efforts to control a global scourge. This year’s theme “Sustain Gains, Save Lives: Invest in Malaria” stresses the crucial role of continued investment of resources to maintain hard-won gains. Lives have indeed been saved. According to World Health Organization (WHO) estimates, annual deaths from malaria decreased from roughly 985,000 in 2000 to approximately 655,000 in 2010. Improvements were noted in all regions that WHO monitors, and, since 2007, four formerly malaria-endemic countries — the United Arab Emirates, Morocco, Turkmenistan and Armenia — have been declared malaria-free. However, about half of the world’s population is at risk of contracting malaria, and the disease continues to exact an unacceptably high toll, especially among very young children and pregnant women.

The National Institute of Allergy and Infectious Diseases (NIAID), part of the National Institutes of Health (NIH), is committed to maintaining the research momentum needed to eradicate this mosquito-borne parasitic disease. Our investments include programs designed to strengthen research capacity in those countries most affected by malaria. For example, through the 2010 International Centers of Excellence for Malaria Research initiative, NIAID has established 10 research centers in malaria-endemic regions around the world. NIAID also provides access for U.S. and international scientists to multiple research resources as well as training for new investigators. Additionally, NIAID supports the Global Malaria Action Plan (GMAP), an international framework for coordinated action designed to control, eliminate and eradicate malaria.

NIAID’s research portfolio includes an array of projects aimed at better understanding the disease process and finding new and improved ways to diagnose and treat people with malaria, control the mosquitoes that spread it, and prevent malaria altogether through vaccination.

Earlier this month, an international team including NIAID-funded investigators reported that resistance to artemisinin — a frontline malaria drug — has spread from Cambodia to the border of Thailand and Burma, underscoring the importance of continued efforts to detect artemisinin resistance and slow its spread. Other grantees have identified a major region of the malaria parasite genome associated with artemisinin resistance, raising the possibility that scientists will have a new way to monitor the spread of drug resistance in the field.

The spread of artemisinin-resistant malaria highlights the need for new and improved malaria drugs. Two recently completed drug screening projects offer some hope. In one project, NIH scientists screened nearly 3,000 chemicals, and found 32 that were highly effective at killing numerous genetically diverse malaria parasite strains. Another screening project identified a new class of compounds that inhibits parasites in both the blood stage and in the liver. The research could lead to the development of malaria drugs that attack the parasite at multiple stages in its lifecycle, which would hamper the parasite’s ability to develop drug resistance.

Work continues on a novel anti-malaria compound, NITD609, first described by NIAID-supported researchers in 2010. A mid-stage clinical trial to assess NITD609′s activity in people began in Thailand this year. Research on NITD609 is a continuing collaboration among NIH-funded scientists, the pharmaceutical company Novartis, and the nonprofit Medicines for Malaria Venture.

Because the risk of childhood malaria is related to exposure before birth to the malaria parasite through infected mothers, NIAID scientists recently initiated a program on malaria disease development in pregnant women and young children that could yield new preventive measures and treatments for these most vulnerable groups.

The mosquitoes that spread malaria are also the target of NIAID-supported science. In 2011, researchers identified bacteria that render mosquitoes resistant to malaria parasites. Further study is needed, but it may one day be possible to break the cycle of infection by reducing the mosquito’s ability to transmit malaria parasites to people.

A vaccine to prevent malaria has been frustratingly elusive, and so initial positive results reported last year by the PATH Malaria Vaccine Initiative, GlaxoSmithKline Biologicals and their collaborators came as welcome news. In a late-stage clinical trial in approximately 6,000 African children, the candidate vaccine, known as RTS,S, reduced malaria infections by roughly half. Currently, eight other vaccine candidates are being tested in NIAID-supported clinical trials. One of them uses live, weakened malaria parasites delivered intravenously to prompt an immune response against malaria. An early-stage clinical trial of this vaccine candidate began at NIH earlier this year.

Whether the remarkable returns on investment in malaria control will continue in years ahead depends on our willingness to commit needed financial and intellectual resources to the daunting challenges that remain. On World Malaria Day, we join with our global partners in affirming that commitment and rededicating ourselves to the efforts to defeat malaria worldwide.

For more information on malaria, visit NIAID’s malaria Web portal.

Lee Hall, M.D., Ph.D., is Chief of the Parasitology and International Programs Branch in the NIAID Division of Microbiology and Infectious Diseases. Anthony S. Fauci, M.D., is Director of the National Institute of Allergy and Infectious Diseases at the National Institutes of Health in Bethesda, Maryland.

NIAID conducts and supports research — at NIH, throughout the United States, and worldwide — to study the causes of infectious and immune-mediated diseases, and to develop better means of preventing, diagnosing and treating these illnesses. News releases, fact sheets and other NIAID-related materials are available on the NIAID Web site at http://www.niaid.nih.gov.

About the National Institutes of Health (NIH): NIH, the nation’s medical research agency, includes 27 Institutes and Centers and is a component of the U.S. Department of Health and Human Services. NIH is the primary federal agency conducting and supporting basic, clinical, and translational medical research, and is investigating the causes, treatments, and cures for both common and rare diseases. For more information about NIH and its programs, visit www.nih.gov.

NIH…Turning Discovery Into Health


Hoaxing Congress: Claiming DDT as pixie dust

March 9, 2011

Tuesday morning, March 8,  the Republican-controlled House of Representatives Committee on Energy and Commerce opened hearings on global warming, staging an assault on science with a series of witnesses, some of whom recently have made a career out of mau-mauing scientists.

One witness took after the EPA directly and Rachel Carson by implication, with a specious claim that DDT is harmless.  Donald Roberts is a former member of the uniformed public health service.  Since retiring, and perhaps for a while before, he started running with a bad crowd.  Of late he’s been working with the Merry Hoaxsters of the unrooted Astroturf organization Africa Fighting Malaria (AFM), a group dedicated to publishing editorials tearing down the reputation of Rachel Carson, the World Health Organization (WHO) and the Environmental Protection Agency (EPA).

(That would all be purple prose, were it not accurate in its description of people, organizations and their actions.)

Here’s a link to Roberts’ written testimony at the committee website.

(Here’s a link to all the other written stuff from the March 8 hearing.)

Why was Roberts testifying at a hearing on global warming?  He’s carrying water for the anti-science, “please-do-nothing” corporate crowd.  It’s a tactic from the old tobacco lobbyist book:  Roberts claims that scientists got everything wrong about DDT, and that the ban on DDT done in error has wreaked havoc in the third world.  Therefore, he says, we should never trust scientists.  If scientists say “duck!” don’t bother, in other words.

Roberts is in error.  Scientists, especially Rachel Carson, were dead right about DDT.  Because corporate interests refused to listen to them, the overuse and abuse of DDT rendered it ineffective in the fight against malaria, and DDT use as part of a very ambitious campaign to eradicate malaria had to be abandoned in 1965.  The entire campaign had to be abandoned as a result, and more than 30 million kids have died since.

So don’t grant credence to Roberts now.  He’s covering up one of the greatest industrial screw-ups in history, a screw up that, by Roberts’ own count, has killed 30 million kids.  What in the world would motivate Roberts to get the story so wrong, to the detriment of so many kids?

Roberts said:

Putting issues of EPA budget aside, I want to introduce my technical comments with a quote from a recent Associated Press article with a lead statement “none of EPA’s actions is as controversial as its rules on global warming.”  In my opinion, this is wrong.

Roberts is correct here in his opinion.  It is simply wrong that EPA’s rules on global warming and controls of the pollutants that cause it should be controversial.  Among air pollution scientists the rules are not controversial.  Among climate scientists the rules are not controversial.  Roberts and his colleagues at the so-called Competitive Enterprise Institute, Africa Fighting Malaria (AFM), and American Enterprise Institute (AEI) work hard to manufacture controversy where the science does not support their case.

It is wrong.  Roberts should be ashamed.

Roberts said:

Almost forty years ago EPA banned DDT in the United States. Its action against DDT was extraordinarily controversial, and still is. As activists advanced fearful claims against DDT, the EPA was warned, over and over again, a ban would destroy critically important disease control programs and millions upon millions of poor people in developing countries would die as consequence. Leaders of the World Health and Pan American Health Organizations, and even the U.S. Surgeon General warned against the ban. The EPA banned DDT anyway, and the doomsday predictions of those public health leaders proved prescient.

Hmmm.  Roberts signed a “truth in testimony” statement — but that’s not the truth, even if no one paid him to fib.

EPA’s ban on DDT in the U.S. was limited to the United States.  Roberts doesn’t say it flat out, but he implies that the U.S. ban on spraying DDT on cotton fields in Texas and Arkansas — and cotton was about the only crop where DDT was still used — somehow caused a ban on DDT in Africa, or Asia, or South America, or other places where malaria still occurs.

Not so.

In fact, EPA Director William Ruckelshaus defied two federal courts who had ordered a complete ban on DDT use and manufacturing — and left U.S. manufacturing to continue for export markets.  This met all objections to the U.S. ban from all health officials.  DDT use could be allowed in the U.S. for health reasons, or for other emergencies (DDT was used in the Pacific Northwest against the tussock moth in 1974, after the “ban”).  Because U.S. DDT manufacturing was dedicated to export, the ban on domestic use of DDT effectively multiplied the stocks of DDT available to fight malaria, or river blindness, or any other insect vector disease.

I’m also not sure that health officials “pleaded” to stop the U.S. ban on any grounds, but certainly they did not plead with Ruckelshaus to keep spraying DDT on cotton.  Roberts is making stuff up in effect, if not in intent.

Probably more to the point, health officials had stopped significant use of DDT in Africa in 1965, seven years before EPA acted in the U.S., because overuse of DDT on crops in Africa had bred mosquitoes that were resistant and immune to the stuff. Since 1955, in close cooperation with the malaria-fighting experts from the Rockefeller Foundation including the great Fred Soper, WHO carried on a methodical, militant campaign to wipe out malaria.  The program required that public health care be beefed up to provide accurate malaria diagnoses, and complete treatment of human victims of the parasitic disease.  Then an army of house sprayers would move in, dosing the walls of houses and huts with insecticide.  Most malaria-carrying mosquitoes at the time would land on the walls of a home or hut after biting a human and getting a blood meal, pausing to squeeze out heavy, excess water to make flight easier.  If the wall were coated with an insecticide, the mosquito would die before being able to bite many more people, maybe before becoming capable of spreading malaria.

DDT was Soper’s insecticide of choice because it was long-lasting — six months or more — and astonishingly deadly to all small creatures it contacted. 

But, as Malcolm Gladwell related in his 2001 paean to Soper in The New Yorker, Soper and his colleagues well understood they were racing against the day that mosquitoes became resistant enough to DDT that their program would not work.  They had hoped the day would not arrive until the late 1970s or so — but DDT is such an effective killer that it greatly speeds evolutionary processes.  In the mid-1960s, before an anti-malaria campaign could even be mounted in most of Subsaharan Africa, resistant and immune mosquitoes began to stultify the campaign.  By 1965, Soper’s crews worked hard to find a substitute, but had to switch from DDT.  By 1972 when the U.S. banned DDT use on cotton in the U.S., it was too late to stop the resistance genes from killing WHO’s anti-malaria program.  In 1969 WHO formally abandoned the goal of malaria eradication.  The fight against malaria switched to control.

Roberts claims, implicitly, that people like those who worked with Soper told EPA in 1971 that DDT was absolutely essential to their malaria-fighting efforts.  That could not be accurate.  In 1969 the committee that oversaw the work of the UN voted formally to end the malaria eradication project.  In effect, then, Roberts claims UN and other health officials lied to EPA in 1971.  It is notable that Soper is credited with eradicating malaria from Brazil by 1942, completely without DDT, since DDT was not then available.  Soper’s methods depended on discipline in medical care and pest control, and careful thought as to how to beat the disease — DDT was a help, but not necessary.

Interestingly, the only citation Roberts offers is to his own, nearly-self-published book, in which he indicts almost all serious malaria fighters as liars about DDT.

Can Roberts’ testimony be trusted on this point?  I don’t think we should trust him.

In fact, DDT and the eradication campaign had many good effects.  In 1959 and 1960, when DDT use was at its peak in the world, malaria deaths numbered about 4 million annually.  The eradication campaign ultimately was ended, but it and other malaria-fighting efforts, and general improvements in housing and sanitation, helped cut the annual death toll to 2 million a year by 1972.

After the U.S. stopped spraying DDT on cotton, mosquitoes did not migrate from Texas and Arkansas to Africa.  As noted earlier, the EPA order stopping agricultural use, left manufacturing untouched, to increase U.S. exports.  So the ban on DDT in the U.S. increased the amount of DDT available to fight malaria.

Malaria fighting, under Soper’s standards, required great discipline among the malaria fighters — the sort of discipline that governments in Subsaharan Africa could not provide.  Had WHO not slowed its use of DDT because of mosquito resistance to the stuff, WHO still would not have been able to mount eradication campaigns in nations where 80% of residences could not be sprayed regularly.

Advances in medical care, and better understanding of malaria and the vectors that spread it, helped continue the downward trend of malaria deaths.  There was a modest uptick in the 1980s when the parasites themselves developed resistance to the drugs commonly used to treat the disease.  With the advent of pharmaceuticals based on Chinese wormwood, or artemisinin-based drugs, therapy for humans has become more effective.  Today, the annual death toll to malaria has been cut to under a million, to about 900,000 per year — a 75% drop from DDT’s peak use, a 50% drop from the U.S. ban on farm use of DDT.

With the assistance of WHO, most nations who still suffer from malaria have adopted a strategy known as Integrated Vector Management, or IVM (known as integrated pest management or IPM in the U.S.).  Pesticides are used sparingly, and insect pests are monitored regularly and carefully to be sure they are not developing genetic-based resistance or immunity to the pesticides.  This is the method that Rachel Carson urged in 1962, in her book, Silent Spring.  Unfortunately, much of the malaria-suffering world didn’t come to these methods until after the turn of the century.

Progress against malaria has been good since 2001, using Rachel Carson’s methods.

Don Roberts’ blaming of science, EPA, WHO, and all other malaria fighters is not only misplaced, wrong in its history and wrong in its science, but it is also just nasty.  Is there any way Roberts could not know and understand the facts?

These are the facts Roberts works to hide from Congress:

  1. “Science” and scientists were right about DDT.  DDT is a dangerous substance, uncontrollable in the wild according to federal court findings and 40 years of subsequent research.  If we were to judge the accuracy of scientists about DDT, we would have to conclude that they were deadly accurate in their judgment that use of DDT should be stopped.
  2. If the ban on DDT was controversial in 1972, it should not be now.  All research indicates that the judgment of EPA and its director, William Ruckelshaus, was right.
  3. EPA was not warned that a ban on agricultural use of DDT would harm public health programs, in the U.S., nor anywhere else in the world.  In any case, EPA’s jurisdiction ends at U.S. borders — why would WHO say anything at all?
  4. DDT use to fight malaria had been curtailed in 1965, years before the U.S. ban on farm use, because overuse of DDT on crops had bred DDT-resistant and DDT-immune mosquitoes.  Consequently, there was not a huge nor vociferous lobby who warned that health would be put at risk if DDT were banned.  Claims that these warnings were made are either false or grossly misleading.
  5. Malaria death rates declined to less than 50% of what they were when DDT was banned from farm use in the U.S. — there was no “doomsday” because the U.S. stopped spraying DDT on cotton, and there never has been a serious shortage of DDT for use against malaria, anywhere in the world.

How much of the rest of the testimony against doing something about global warming, was complete hoax?

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[Editor's note:  My apologies.  I put this together on three different machines while conducting other activities.  On proofing, I find several paragraphs simply disappeared, and edits to make up for the time of composing and fix tenses, got lost.  It should be mostly okay, now, and I'll add in the links that disappeared shortly . . . oh, the sorry work of the part-time blogger.]


Malaria deaths in India under-reported? Bad news for pro-DDT partisans

October 22, 2010

Good news from the war on malaria has been that annual deaths are calculated to be fewer than 1 million annually, as low as 880,000 a year — the lowest human death toll from malaria in human history.

Researchers in India suggest that deaths there are grossly underreported, however — not the 15,000 estimated by the World Health Organization, but closer to 200,000 deaths a year, nearly 15 times as great.

Reading that news, DDT partisans might get a little race of the pulse thinking that this might improve the urgency for the case for using more DDT, as advocated in several hoax health campaigns and media, such as the recent film “3 Billion and Counting.”

The problem, though, is that India is one of the few places where DDT manufacturing continues today, and India is one of the nations where DDT use is relatively unregulated and heavy.  In short, if DDT were the miracle powder it’s claimed to be, any finding that malaria deaths are 15 times greater than reported by WHO is nails in the coffin of DDT advocacy.

Bloomberg News reported:

Researchers based their estimate on interviews with family members of more than 122,000 people who died between 2001 and 2003. The numbers “greatly exceed” the WHO estimates of 15,000 malaria deaths in India each year, the researchers wrote in the study, published today in the journal The Lancet.

“It shows that malaria kills far more people than previously supposed,” said one of the study authors, Prabhat Jha of the Center for Global Health Research in Toronto, in a statement. “This is the first nationwide study that has collected information on causes of death directly from communities.”

Remote regions may have an undocumented malaria burden, because conventional methods of tracking the disease are flawed, according to the authors. In India, the government malaria data, which is used by the Geneva-based WHO, only counts patients who had tested positive for the disease at a hospital or clinic. Others who died of symptoms closely resembling the malady but didn’t get a blood test aren’t included, co-author Vinod Sharma of the Indian Institute of Technology in New Delhi said in an interview today.

The lack of accurate data may hinder efforts by governments and aid organizations to provide diagnosis and treatment to the population at risk, the authors said.

Watch.  Advocates of poisoning Africa and Asia will claim scientists and environmental activists are somehow to blame for any underreporting, and they will call for more DDT use, claiming a ban has made India a refuge for malaria.  Those reports will fail to mention India’s heavy DDT use already, nor will they suggest an ineffectiveness of the nearly-sacred powder.

The article in the Lancet became available on-line on October 21 — it’s a 4.5 megabyte .pdf document:  “Adult and child malaria mortality in India: a nationally representative mortality survey.” A team of researchers is listed as authors of the study:  Neeraj Dhingra, Prabhat Jha, Vinod P Sharma, Alan A Cohen, Raju M Jotkar, Peter S Rodriguez, Diego G Bassani, Wilson Suraweera,Ramanan Laxminarayan, Richard Peto, for the Million Death Study Collaborators.

Accurate counts of infections and deaths provide essential information for effective programming of the fight against the disease.  Researchers point no particular fingers, but make the case in the article that better methods of counting and estimating malaria deaths must be found.

There are about 1·3 million deaths from infectious diseases before age 70 in rural areas in which fever is the main symptom. If there are large numbers of deaths from undiagnosed and untreated malaria in some parts of rural India then any method of estimating overall malaria deaths must rely, directly or indirectly, on evidence of uncertain reliability from non-medical informants and, although our method of estimating malaria mortality has weaknesses, indirect methods may be even less reliable. The major source of uncertainty in our estimates arises from the possible misclassifi cation of malaria deaths as deaths from other diseases, and vice versa. There is no wholly satisfactory method to quantify the inherent uncertainty in this, and indeed the use of statistical methods to quantify uncertainty can convey a false precision. However, even if we restrict our analyses to deaths immediately classifi ed by both physician coders as malaria, WHO estimates (15 000 deaths per year at all ages)1 are only one-eighth of our lower bound of malaria deaths in India (125 000 deaths below the age of 70 years; of which about 18 000 would have been in health-care facilities).

Our study suggests that the low WHO estimate of malaria deaths in India (and only 100 000 adult malaria deaths per year worldwide) should be reconsidered. 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. Better estimates of malaria incidence and of malaria mortality in India, Africa, and elsewhere will provide a more rational foundation for the current debates about funding for preventive measures, about the need for more rapid access to malaria diagnosis, and about affordable access in the community to effective antimalarial drugs for children and adults.

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