Mobilizing communities to help prevent and control malaria in Cameroon

Dr Achu, could you please provide a quick overview of the malaria situation in Cameroon, as well as an overview of trends in prevalence and mortality in recent years?

Malaria is highly endemic in Cameroon, meaning our entire population of 27 million people is exposed to the disease on a regular basis. Every year, we register around 6 million cases of malaria, and our health facilities record about 4000 deaths, most of which occur in children below the age of 5. However, not all cases and deaths are recorded, and WHO estimates that about 11 000 people die from malaria in Cameroon every year. Around 30% of all out-patient visits to health care facilities are for malaria, making it a disease of importance in our country. On the positive side, we have witnessed a drop in in the proportion of deaths attributed to malaria, from 18% in 2019 to 13.5% today, according to national surveillance reports.

That’s encouraging to hear of the reduction in mortality, especially for young Cameroonian children. How was that accomplished?

I think I can point to 3 main reasons here. First, we’ve intensified our malaria prevention efforts, including by rolling out two mass long-lasting insecticide treated bed net (LLINs) distribution campaigns in the past 6 years to ensure that every household has nets. We’ve also been using seasonal malaria chemoprevention in the two northern regions of the country where malaria prevalence is seasonal.

Door-to-door distribution of insecticide-treated nets in Cameroon. © Ministry of Health, Cameroon

Second, we are improving case management via a network of community health workers who help detect cases early, and either provide treatment or refer patients to health facilities. We’ve found that this approach helps us identify and treat cases early enough to prevent deaths.

Finally, we’re improving the quality of diagnosis, and in the process, we noticed that many of the deaths being recorded as malaria deaths were in fact not caused by malaria.

When it comes to malaria prevention, has your Ministry implemented any new approaches in recent years?

At the height of the COVID-19 pandemic, we had to rethink how we deliver some of our interventions, especially the distribution of bed nets and seasonal malaria chemoprevention. In the past, we’ve relied on fixed post distributions, meaning that we distributed from a central point, with large numbers of people assembling to come and collect nets.

With COVID-19 and the need to ensure the safety of our health care workers and of communities, we moved to door-to-door distribution of bed nets. While the approach is more expensive, it has allowed us to deliver prevention tools to hard-to-reach populations that might otherwise not have accessed fixed distribution points.

During our last bed net distribution campaign in 2020, we achieved very high coverage rates, which has translated into greater net use. The door-to-door approach has also allowed community health workers to engage with families more directly, and ensure they understand why, and how, they should use bed nets. COVID-19 forced us to adapt, and that adaption led to positive outcomes, so we plan on continuing to use this approach.

When it comes to seasonal malaria chemoprevention, what are some of the challenges you’ve faced, and how have you overcome them?

In recent years, we’ve tested different methods to improve adherence to treatment. One of the greatest issues with chemoprevention is that while community health workers can observe administration of the first dose, the second and third doses are given by the caregiver without supervision. As we’re not able to send community health workers to households that frequently to verify administration, we’ve worked to identify “leader” households to act as mentors within each village, and whose role it is to remind parents or caregivers to give their children their second and third doses.

We’ve also been using women’s associations networks, training them and equipping them with messages they can carry into their communities to encourage mothers to adhere to the treatment schedule for their children. We’re still in the process of evaluating the impact of these innovative methods, but we’ve noticed generally that the women themselves are very enthusiastic, and they are ready to help and support their peers.  

How important is disease surveillance to your malaria prevention, treatment and control efforts?

While it’s still a work in progress, we’ve successfully worked with health facilities across the country to ensure that they are able to report data more regularly through our national health information system platform, giving us wider visibility on the trends in morbidity and mortality. What we are focusing on now is data quality: we want to ensure that data is not just collected but that it’s also corrected. We do that by organizing quarterly data validation meetings at district, regional and central levels.

Another fundamental thing we are working on is improving the quality of diagnosis. Historically, that has been an issue in Cameroon, and we’ve been worried that reported incidence and mortality rates don’t reflect reality. Microscopy (a key malaria detection tool) has been an issue because many technicians are not properly trained, which leads to mistakes in the way they prepare and read the slides. We also have had issues with the quality of microscopes themselves, and of the reagents that are used to stain the blood sample to help with visualization of malaria parasites.  

Due to lack of supervision, lots of errors go unidentified, and make their way into surveillance reports. We’re therefore working to put in place a quality assurance system that will help to validate microscopy results being reported by health facilities. We do this via trainings and refresher courses, but also by putting in place laboratory mentors that help validate results.

Finally, we are in the process of putting in place sentinel surveillance, identifying specific health districts and facilities that will be able to consistently provide high-quality diagnosis, care and reporting, allowing us to register actual trends in malaria burden and mortality. At the moment, we’ve selected the sites, developed a training module for staff, and are now planning to roll out trainings and starting to collect data.

What does your programme hope to achieve over the next 12 months?

We’re committed to finding ways for everyone in the country to have better access to malaria prevention and care. Concerning case management, we are scaling up the mentoring of healthcare workers to improve diagnosis and management of malaria cases, especially severe cases, in a bid to further reduce mortality.

More broadly, we’re also working to integrate malaria services into the proposed universal health coverage package in Cameroon. At the moment, many of those services, including diagnosis or treatment, are paid for out-of-pocket, making them unaffordable for a large part of the population.

To achieve all this, the Minister of Public Health, Dr Manaouda Malachie, has launched a 12-month national advocacy campaign championed by the First Lady, Mrs Chantal Biya, to engage community leaders and other sectors to get more involved in control measures and to help mobilize more domestic resources to address the identified gaps.

Launch of the 12-month national advocacy campaign in Cameroon. © Ministry of Health, Cameroon