Cameroon

Malaria facts

Malaria is the most widespread endemic disease in Cameroon, annually responsible for greater than two million reported cases as well as absenteeism from school and work. The country has three epidemiological zones: the Sahelian, Sudano-Sahelian and the equatorial. Transmission of malaria is highest from July to October. Cameroon is among the 11 High Burden High Impact countries bearing 70 percent of the global burden of malaria as reported by the World Health Organization (WHO). [1]

At the national level, malaria is responsible for 50 percent of hospitalizations in health facilities (NMCP Annual Report, 2021) with 65 percent of cases being children under five years of age. The incidence of malaria is highest in the East region, while malaria mortality remains highest in the North and Far North regions. Cameroon’s Health Sector Strategy 2016-2027 prioritizes the fight against malaria. [1] 

Overall, Cameroon is among the 15 highest burden malaria countries, with 2.7% of all global malaria cases and deaths, and 2.3% of malaria deaths in 2021 [2]; this represents the 3rd highest number of malaria cases in Central Africa (12% of cases in 2021).[2]  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 2020 and 2021, case numbers decreased by 1.6%, from 249 to 245 per 1000 of the population at risk.[2] Mortality rates also fell by 7% in the same period,  from 0.55 to 0.51 per 1000 of the population at risk.[2] 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. [3] 

Cameroon is in the process of putting in place the prerequisites for the launch of Universal Health Coverage (UHC). [3] 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 

First line treatment for malaria has switched to artemether-lumefantrine (AL) rather than artesunate-amodiaquine (AS/AQ) in the north and far north regions due to SMC implementation. 

Other case management actions include pre-referral intervention of severe malariawith artesunate rectal capsules at the community level, followed by referral, scale-up of integrated community case management (iCCM), pharmacovigilance, and supply chain strengthening. A quality assurance/quality control system will ensure strengthened diagnostics throughout the country.  

Eligibility of districts for SMC implementation was determined using rainfall data. SMC implementation is currently limited to the districts in the north and far north regions. 

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] 

Innovative approaches are being targeted at reducing the cost of SMC by providing routine delivery instead of campaign style delivery and empowering local authorities to lead the fight against malaria through community dialogues.  

The NMCP’s malaria Strategic Plan promotes SMC as a malaria prevention intervention in areas with highly seasonal malaria transmission. SMC is implemented in all 47 eligible districts in the North and Far North regions, including procurement of SPAQ to meet the needs of the eligible population as well as all aspects of implementation with four SPAQ cycles during the rainy season (July to October) using a door-to-door strategy. The approach requires community distributors to directly observe administration of the first dose of SPAQ and leave treatment doses for administration by the caregiver on days two and three for all cycles. 

Perennial Malaria Chemoprevention

Recent HBHI subnational tailoring exercises have recommended perennial malaria chemoprevention for infants under two years of age in areas of Cameroon not implementing SMC for this population. During vaccination sessions in health facilities, these infants will receive five doses of SP at specific intervals corresponding to their vaccination schedule (10 weeks, 14 weeks, 6 months, 9 months, and 15 months).  

At the same time, a pilot implementation of eight doses will be done in six other health districts in the Center region. In this pilot, there will be an assessment of the impact of eight doses (10 weeks, 14 weeks, 6 months, 9 months, 12 months, 15 months, 18 months, and 23 months) instead of five doses as in the other health districts. This intervention is expected to reduce the incidence of malaria by an additional 20 percent. 

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] 

Challenges

Vector insecticide resistance, limited access to quality health services in many parts of the country, and limited multisectoral collaboration are challenges to malaria elimination. Overdiagnosis of severe malaria and irrational use of injectable artesunate are a recognized ongoing problem in Cameroon. This is probably because of the preference for injectable treatments by both patients and health providers.  

Cameroon faces an unprecedented humanitarian crisis in the Far North, East, North-West and South-West regions, caused by armed and ethnic and intercommunal conflicts. The main challenge there is to ensure implementation and coverage of high-impact interventions.