Incidence, management, and reporting of severe and fatal Plasmodium falciparum malaria in secondary and tertiary health facilities of Alipurduar, India in 2009.

BACKGROUND & OBJECTIVES The proportion of malaria cases that are complicated and fatal are not well described in India. Alipurduar sub-division of Jalpaiguri district in West Bengal is highly endemic for malaria. We constructed a retrospective cohort of severe malaria patients admitted in the secondary and tertiary care facilities in Alipurduar to determine the incidence, assess the management, and evaluate the reporting of severe and fatal malaria. METHODS We reviewed routine surveillance data and the case records of all the malaria patients admitted in all secondary and tertiary care facilities, both public and private. We defined severe malaria cases as Plasmodium falciparum infection with clinical signs and symptoms of organ involvement in a resident of Alipurduar admitted during January to December 2009. We compared clinical and demographic characteristics of severe malaria cases that died with those who survived. We also reviewed human resources and laboratory facilities available for the treatment of severe malaria in these health facilities. RESULTS During 2009, 6191 cases of P. falciparum in Alipurduar were reported to the malaria surveillance system. We identified 336 (5.4%) cases of severe malaria among which 33 (9.8%) patients died. Four malaria deaths were also recorded from primary health centres. Only 17 of the 37 (46%) total deaths recorded were reported to the routine surveillance system. Most severe cases were males (65%), aged >15 years (72%), and nearly half were admitted to secondary care hospitals (48%). In multivariate analysis, the risk factors associated with death included increased delay fever onset and hospitalization, treatment in a secondary level hospital, younger age, and multi-organ involvement. The secondary level public hospital had too few physicians and nurses for supporting severe malaria patients as well as inadequate laboratory facilities for monitoring such patients. CONCLUSIONS Severe and fatal malaria continue to burden Alipurduar and record keeping in health facilities was poor. Many malaria deaths were not routinely reported even in the public sector. Improved surveillance and increased human and laboratory resources are needed to reduce malaria mortality.