Context: Characterization of severe malaria cases on arrival to hospital may lead to early recognition and improved management. Understanding of symptoms, signs, and laboratory parameters which are associated with high case-fatality rate (CFR) can help in appropriate and early management of cases. Aims: To study the profile, symptoms, signs, and laboratory parameters of malaria death cases. Materials and Methods: Information about deaths due to malaria, as reported to malaria Department of Ahmedabad Municipal Corporation by three municipal corporation hospitals and civil hospital Ahmedabad between January 2007 and December 2007, was used to locate details of those deaths in respective hospitals. Indoor case papers and death reports of those cases were obtained from Medical Record Section of respective hospitals and were analyzed by using appropriate statistical software. Results: A total of 57 malaria deaths occurred in the abovementioned four hospitals. Overall CFR was 3.03% for indoor malaria cases. Complete information could be obtained for about 42 cases. Mean age of cases was 36.50 years. There were 45.23% of patients falling in the age group >=40 years. There were 57.1% males and 42.9% females. Fifty-five cases were positive for Plasmodium falciparum, one case for Plasmodium vivax, and one case was having mixed infection. Average duration of hospital stay was 2.87 days and average total duration of illness was 6.82 days. The most common presenting symptom was intermittent fever with vomiting and altered sensorium in 38.88% of cases. Acute renal failure was the most common complication seen in 45.2% of the cases. Paired t-test was applied on the investigations carried out on the day of admission and those carried out on the day or before a day of death and found significant for the levels of hemoglobin, blood urea, and serum bilirubin. Conclusions: Malaria still remains one of the important causes of admission and mortality. In view of changes in antimalarial drug policy artemisinin combination therapy and accurate, rapid diagnostic tools are necessary to target treatment to people in need.
Keywords: Case-fatality Rate, Case Profile, Clinical Presentation, Complications, Malaria
Malaria is a disease which can be transmitted to people of all ages. It is caused by parasites of the species Plasmodium that are spread from person to person through the bites of infected female Anopheles mosquitoes. The common first symptoms–fever, headache, chills, and vomiting–appear 10 to 15 days after a person is infected. If not treated promptly with effective medicines, malaria can cause severe illness that is often fatal. 
Of the 350 to 550 million malaria cases that are estimated to occur in the world every year, around 1 to 2% are severe or life threatening. However, this small proportion represents an enormous malaria death toll per year, especially in sub-Saharan Africa, where more than 90% of the malaria deaths are thought to take place every year, affecting mainly children and pregnant women. Malaria is still a major health problem in India. North-Eastern states, Bihar, Jharkhand, Orissa, Gujarat, Maharashtra, Goa, and Madhya Pradesh contributing most of the malaria cases, whereas Assam, Orissa, and West Bengal are contributing the most to malaria mortality.  Nevertheless, severe malaria features may change according to a number of factors including the genetic characteristics of the population, malaria epidemiology, health-seeking behavior, non-malaria comorbidity, clinical assessment, and the local case management. India has uniform treatment guidelines which stipulate that any patient with fever without evidence of other diseases should treated for malaria even with a negative blood smear for malaria parasites. In India, as in other sub-Saharan African countries, malaria represents the main cause of outpatient consultations and admissions to hospital. A comprehensive picture of the clinical and epidemiological characteristics of severe malaria is necessary to prioritize public health interventions and to guide national policies. Improvement of treatment-seeking for malaria will depend partly on how different socioeconomic groups perceive the ease of accessing and utilizing malaria treatment services from different healthcare providers. 
In view of all the above facts, the present study was carried out to study the profile, symptoms, signs, complications, case-fatality rate (CFR), and changes in selected laboratory parameters among cases of deaths due to malaria.
Ahmedabad city has got three teaching hospitals which are run by Municipal Corporation, namely V.S. General Hospital, LG hospital, and Sardaben hospital, and one civil hospital for the purpose of provision of health and medical services besides many corporate and private hospitals and other peripheral institutes as well as private practitioners. The Malaria Department of Ahmedabad Municipal Corporation receives regular reports about morbidity and mortality due to malaria. The malaria deaths among indoor malaria cases during the year 2007 from the three corporation hospitals and civil hospital Ahmedabad were included in the current study. The details of these cases were obtained from the Medical Record Sections of the respective hospitals and were subsequently analyzed. A total of 57 deaths due to malaria occurred in the abovementioned four hospitals and of which 42 were included in the present study and rest were dropped due to nonavailability of the complete records of those cases.
A total of 1 876 cases were admitted during the year 2007 in the abovementioned four hospitals and 57 patients died of them. The overall CFR among indoor malaria cases was 3.03%. The CFR in Civil hospital was lowest (1.74%), whereas it was highest (4.27%) in LG hospital. The CFR of Civil Hospital was significantly lower as compared with overall CFR (P < 0.05) [Table 1].
No malarial deaths were reported in the months of January, February, April, and June.
Majority of deaths (47, 82.45%) due to malaria occurred during the months of July to November which are the high transmission months looking at its seasonal trend. Fifty-five (96.5%) cases had P. falciparum infection and one case had mixed infection. Only one case died of infection due to P. vivax [Table 2].
Maximum number of cases, i.e., 12 (28.6%) were residing in the East Zone of Ahmedabad followed by equal numbers from South and New-West zones. Three cases had migrated from nearby states and were not the residents of Ahmedabad. Males predominated females with M : F ratio of 4 : 3. Majority were falling in the age group of 15 to 30 years, with mean age of 36.5 years and standard deviation of 24.43 years [Table 3].
Information about the duration of illness before admission to the foresaid hospital could be obtained about 36 cases and the majority (17, 47.3%) had duration before admission of 2 to 4 days. However, the mean duration of illness before admission was 4.26 ± 2.7 days. Majority (44, 77.2%) died within five days of admission, with mean duration of hospitalization of 2.87 ± 3.07 days. Total duration of illness was 5 to 10 days in 16 (44.5%) of the cases and majority (30, 83.4%) had the total survival of less than 10 days. Mean survival time was 6.82 ± 5.3 days, suggesting that we have roughly 7 days to take actions to prevent such deaths [Table 4].
Information about presenting symptoms and complications could be obtained for about 42 cases of deaths due to malaria. As far as presenting symptoms are concerned, intermittent fever was the most common symptom as 31 (73.8%) cases had history of this at the time of admission. Vomiting and altered sensorium were the next important presenting symptoms as 38.1% and 33.3% patients, respectively, had these symptoms at the time of admission. Headache, breathlessness, jaundice, and decreased urinary output were other presenting symptoms. The most common complications preceding death among the patients were acute renal failure and acute respiratory distress syndrome in 45.2% and 35.7% of the patients, respectively. Anemia and thrombocytopenia were among the other important complications preceding death in the patients [Table 5].
The investigations were done at the time of admission and were repeated during the course of stay in the hospital. A comparison was done between the baseline investigation results at the time of admission and the last investigation results immediately preceding death. The mean and standard deviation of the investigation results show that the level of hemoglobin and SiO2 decreased, whereas the levels of total counts, platelets, random blood sugar, serum urea, and total bilirubin increased. There was not much of difference between the two values of serum creatinine, Ph, serum sodium, and potassium. Paired t-test showed a significant decrease in level of hemoglobin (P < 0.027) and significant increase in level of blood urea (P0 < 0.007) and serum total bilirubin (P < 0.041) [Table 6].
CFR due to malaria varied from 1.74 to 4.27%, with an average CFR of 3.03% . In a study at Mozambique among indoor malaria cases among children of less than 15 years of age, CFR varied from 1.6 to 4.4%.  Case fatality ratio was 3.5% in another study at Ghana.  In a study among Gabonese children, the CFR was 8.9%.  Majority of deaths in the current study were reported during the months of July to November which is the high transmission season for malaria. In another study, 70.4% of cases occurred in high transmission season.  The observed pattern points to the fact that increase in vector breeding following the raining season is responsible for the upsurge in the malarial cases and mortality. Similar pattern of difference in CFR with season was observed in a study in
Ghana.  However, study among Gabonese children revealed no seasonal difference in mortality suggesting perennial transmission of malaria in that region.  Males accounted for 57.1% of total death cases and this finding is similar to findings of other studies. , Sixty-seven percent deaths occurred in the age group less than 45 years. In a study of malaria prevalence in Cambodia, the majority of malaria cases were in the age group of 0 to 39 years.  Mean duration of survival after hospitalization was approximately 3 days in current study and mean duration of illness was roughly 7 days. In another study, the median duration of survival after hospitalization was 3 days and majority of deaths due to severe malaria occurred in the first 48 hours of admission.  Intermittent fever, vomiting, altered sensorium, and breathlessness were the most common presenting symptom in the present study. Severe anemia was most common presentation in the study in Ghana,  fever was the most common presentation in a study by Dzeing-Ella et al.,  whereas Bassat et al. reported severe prostration, respiratory distress, and severe anemia as the common presentation in severe malaria.  The symptoms most frequently reported by suspected malaria patients presenting to the health facility were headache, fever, joint pain, loss of appetite, vomiting, and general weakness in a study at Uganda by Ndyomugyenyi et al. Severe anemia was not an independent predictor of in-hospital mortality. ,, Acute renal failure, acute respiratory distress syndrome, and thrombocytopenia were most common complications as observed in present study, whereas in a study in Ghana, cerebral malaria (46.7%), severe anemia (36.7%), respiratory distress (60%), and hyperlactatemia (61.5%) were the common complications observed in malaria death cases.  The mean hemoglobin level in malaria death cases was 6.52 gm/dl in the present study and Oduro et al. reported mean hemoglobin of 7.0 gm/ dl.  Bassat et al. reported that hypoglycemia and respiratory distress were independent risk factors for death and presented high associated CFRs. 
Malaria still represents the principal cause of admission and an important cause of in-hospital deaths. Early recognition of severe malaria cases at home or at the community level and prompt pre-referral treatment, along with effective and early referral to higher level of healthcare, may improve their survival likelihood. Furthermore, prompt and appropriate classification (based on symptoms, signs, and laboratory investigations) and treatment of malaria help identify the most severely ill patients. Although hospital-based results underestimate the real burden of disease and are greatly influenced by health-seeking behavior, nevertheless, hospital-based data are often the only available data and are useful indicators of the health status of a population.
Source of Support: None, Conflict of Interest: None
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]