Cameroon

Malaria facts

Malaria is the most widespread endemic disease in Cameroon. Plasmodium falciparum is the predominant malaria parasite species; Anopheles gambiae s.l. is the primary vector responsible for transmission.[1] the Government of Cameroon has made the fight against malaria a priority, with a highlight in the country’s Health Sector Strategy, and the adoption of the High Burden High Impact stratification exercise in the National Malaria Strategic Plan. [2] Cameroon’s current National Strategic Plan (NSP) for malaria control covers the period 2019–2023 and is the fifth iteration of a national strategy. 

Overall, Cameroon is among the 15 highest burden malaria countries, with 2.9% of all global malaria cases and deaths, and 2.4% of malaria deaths in 2020 [1]; this represents the 3rd highest number of malaria cases in Central Africa (12.6% of cases in 2020).[1]  Suspected malaria cases caused 30% of all medical consultations, and 21 % of visits to health facilities resulted in a diagnosis of laboratory-confirmed malaria.[1] National statistics from 2015 note that in health facilities, 19% of deaths were attributed to malaria, and 48 % of all hospital admissions were due to the suspicion of severe malaria.[1] 

Between 2017 and 2020, case numbers increased by 3.8%, from 250 to 260 per 1000 of the population at risk.[2] Mortality rates increased slightly by 0.8% in the same period,  from 0.55 to 0.56 per 1000 of the population at risk.[1] Less than 30% of children who reported having fever were tested for malaria.[2] 

Under the High Burden High Impact (HBHI) approach, a malaria risk stratification was developed by combining prevalence, incidence, and all-cause mortality rates. Based on this criterion, the country's 189 health districts are classified into: (i) very high risk (21 percent); (ii) high risk (31 percent); (iii) medium risk (27 percent); and (iv) low risk (21 percent). The very high risk and high risk health districts are distributed throughout almost all of the country's regions, but with a high concentration in the East, Adamawa, Central and South regions. Medium risk and low risk districts are concentrated in the Far North, Northwest and West regions. [5] 

Cameroon is in the process of putting in place the prerequisites for the launch of Universal Health Coverage (UHC). [5] The objective is to consolidate various free and subsidized care/treatment packages implemented throughout the country. The specifics of how malaria will be integrated into Phase 1 are still pending, but the National Malaria Control Program (NMCP) is engaged in the UHC development process. Malaria partners anticipate that UHC will increase access and quality of malaria service delivery for the Cameroonian population.[1] 

Insecticide-treated nets 

Between 2011 and 2018, the proportion of the population with access to an insecticide-treated net increased from 21% to 59%. Over the same period, use of ITNs by children and pregnant women increased similarly, from 21% in 2011 to 60% in 2018.  The Far North and North regions of the country have tended to show the highest net use. 

Malaria in young children 

Between 2015–2018, incidence among children aged under 5 years rose from 188 to 218 cases per 1,000 children, and the mortality rate from 66.6 to 77.6 deaths per 100,000 children. The increase in incidence may be linked both to systematic screening for malaria among pregnant women seen in antenatal consultation (ANC), contrary to national guidelines, and to inadequacies in prevention. The increase in the mortality rate for children under 5 is linked to difficulties in case management, in particular delayed access to care and prolonged stock-outs of drugs (injectable artesunate) during the season of high transmission. 

Case management 

Cameroon’s strategy for case management for 2019-2023 includes: [1] 

• An intensification of trainings/refreshers for health personnel on updated national case management guidelines; 
• Sensitization of both public and private sector providers on national guidelines; 
• Extend integrated community case management (iCCM) to all health districts (including 22,000 CHWs in 109 districts not currently covered) to assure good geographic coverage of the population; 
• Implement quality control of commodities 

Baseline assessments of case management practices were conducted in 135 health facilities in 13 districts in the North and Far North in September 2019. Conclusions included: [1] 

• 70 percent of facilities performed diagnostic tests (RDTs or microscopy) before providing treatment for malaria. 
• Fifty-three percent of health providers had not received training in case management for malaria. 
• 81 percent of confirmed severe malaria cases were treated with injectable artesunate, intramuscular (IM) artemether or injectable quinine. All cases of malaria in pregnant women are treated as severe. 

Case management of uncomplicated and complicated malaria in children under five was free in only 39 percent of health facilities. The NMCP conducted a study on the policy of free diagnosis and treatment of uncomplicated and severe malaria in Cameroon from July-August 20185. Findings included: 

• National treatment guidelines were respected for only 39 percent of severe malaria cases. 
• Significant overuse of severe malaria medications to treat uncomplicated cases was evident. 
• Intravenous quinine was a common treatment given for treatment of severe malaria. 

Severe malaria case management in pregnancy 

The 2014–2018 National Strategic Malaria Control Plan advised that all cases of malaria in pregnancy be treated as severe malaria, although this was not recommended by the WHO. [1] In the first trimester of pregnancy, intravenous quinine is to be used for the first 24 hours; this is subsequently followed by oral quinine for up to seven days. From the second trimester, the first-line treatment is injectable artesunate; recommended second-line treatments are injectable quinine or intramuscular artemether.  [1] This treatment is not free, but subsidized. This presents a hurdle for many pregnant women needing to access malaria interventions. 

 

Prevention of malaria in pregnancy 

IPTp with sulfadoxine-pyrimethamine (SP) administered at ANC was adopted in 2007. The policy was updated in 2012 to increase the number of doses of SP administered during pregnancy from at least two doses total to at least three doses total, one dose at each ANC beginning at 16 weeks and continuing monthly until birth. The policy was further updated in 2020 to start SP earlier at 13 weeks, and continued monthly during ANC visits.[2] 

In 2018, 54% of pregnant women received at least two doses of intermittent preventative treatment of malaria in pregnancy (IPTp2), similar levels to those in 2014 (53%). The proportion of pregnant women who received at least three doses (IPTp3) increased from 26% in 2014 to 32% in 2018. [1] 

The low coverage of IPTp (and the general lack of inclusion of this intervention in ANC services) was reportedly due to the following:[1] 

• frequent stock outs at the health facility level due to procurement delays and issues with inventory management; 
• noncompliance by health workers; 
• poor management of antenatal care services at health facilities, 
• delayed start of antenatal care services by pregnant women (some as late as seven months), 
• and financial barriers, even though SP(the intervention used for IPTp) is supposed to be provided free of charge. 

Seasonal Malaria Chemoprevention 

Cameroon introduced SMC in 2016 with SP and amodiaquine (SPAQ) to roughly 1.1 million children of eligible age (children 3–59 months old) living in the 45 health districts of the North and Far North regions, with a coverage of 86 percent. [1] 

In 2017, four cycles of SPAQ (SP + amodiaquine), the combination of antimalarials used for SMC, were administered to 1.5 million children aged 3–59 months old (94.5% of children in that age group).[2] About 3.5 million children were administered with SMC in 2018. [1] Preliminary data from the first two SMC cycles (2017) in the northern region suggested that SMC contributed to preventing malaria in over 95% of children aged 3-59 months.[1] 

In view of the SMC programmes in the northern part of the country, the first-line ACT for that part of the country was switched to artemether-lumefantrine (AL) rather than artesunate-amodiaquine (ASAQ) to mitigate against potential drug resistance to amodiaquine. The other eight regions will maintain ASAQ as the first-line treatment.[1] 

Vulnerable populations 

Vulnerable populations such as displaced persons, nomads, orphans, prisoners, and refugees continue to have limited access to antimalarial services. Additionally, data is of poor quality and there is limited integration of private-sector care providers.[1]