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PREFACE – Fobang Foundation
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Malaria infection has been one of the major health issues in Africa for decades. Over 780.000
people die from malaria each year worldwide and more than 90% of cases occur in Sub Saharan
Africa (SSA). Every 45 seconds a child dies of this scourge. While the disease affects mostly
children, malaria also severely affects pregnant women, eSPecially during their first pregnancy.
The number one killer disease is the first reason for consultation in health facilities; it drains
households' incomes and it is the first cause of absenteeism at school and at work. Several methods
for prevention and treatment have been developed and refined, notably long lasting insecticidal net
(LLIN) and Artemisinin-Based Combination Therapies (ACTs), reinforced by indoor residual
SPraying (IRS) and their use in high scale initiative have let to a steady progress towards control but
not enough regarding the disease present impACTs. Our knowledge of the state of the art, that is:
malaria management, prevention and social behaviour trends, transmission risk, to sum up malaria
epidemiology and research, will immensely help to identify not only successes, but also gaps and to
develop comprehensive strategies. It is in line with this that the fobang foundation (ff) in
collaboration with the National Malaria Control Program and the Malaria Consortium-Cameroon
Coalition Against Malaria (MC-CCAM) have decided to develop this document titled: Cameroon
malaria research and control report 2008-2011.
This report was developed from information present in a number of published documents
among which the NMCP activities reports (2008 and 2009), 5th Multilateral Initiative Pan-African
Malaria conference Report (2009), the Study of the ACT subsidy in Cameroon final report, Patient
Exit Pool and Provider Practices: Research on the Economics of ACTs, Access to and delivery of
malaria treatment in Cameroon and a number of recent scientific articles. In the process of
developing this document five surveys were conducted to appraise the level of malaria indicators in
some health districts of three regions.
The Cameron malaria research and control report has four parts. The first part, malaria
epidemiology and control, gives the trends of morbidity, mortality, prevention and management,
confronting/putting side by side 2008 and 2009 statistics. The second part, malaria research,
delineates first the different and most recent malaria research themes which have been investigated
and gives summaries for their findings; it also presents the state of antimalarials drugs and
insecticide resistance across the country with a good mapping of resistant genes. The third part,
study results on the provision and the economics of Artemisinin-Based Combination Therapies
(ACTS), is focusing on ACTs, evaluating the outcome of ACTs subsidies at the level of sale points,
examines the distribution channels of these medicines and highlights impediments to their access
and delivery to the people. More so, the REACT study, which has brought to light the necessity of
carefully design strategies for appropriate interventions for malaria case management in Cameroon
as it has been signified and recommended by the W.H.O in their operational Manual of 2009. These
interventions mostly apply to facilities that are involved in this multi-scale task as this will enable
the cost-effectiveness of ACTs deployment to target and reach those who actually need the
appropriate treatment. The REACT study also embarks on the socio-economic aSPect and makes
one to understand that combating malaria is of multidimensional interest as people from/with
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different backgrounds are all required to push the fight one step forth. Therefore an earnest attempt
to achieve these goals needs to be thrown on people's education, communication, training etc about
all if not most of the concepts pertaining to this threat. It is also of interest to stress that malaria case
management can also be appropriately shaped or structured, and encouraged in the context of
Home-Based Management as signified by the W.H.O. Again each and everyone have something to
put in to make it possible and it starts in the family milieu which constitutes the core of the society.
And finally the fourth part, Results of malaria survey in four health districts in Cameroon, presents
malaria prevention indicator in five health district selected from Center, Adamawa and South west
regions. From part one to five, the reader will progressively have knowledge of the trends of malaria
prevalence and mortality, control efforts undertaken by the government and their outcome, then get
aCQuainted with researcher findings in various domains. This report will therefore be of interest to
the general public and particularly to NGO workers and public health workers who will find in it a
panoramic picture of malaria control efforts and get first hand information on ACTs economics and,
to researchers who will graSP here key findings in malaria research and identify proSPective areas
of research. The knowledge of the state of art in malaria control and research will greatly help all of
us, stakeholders, to consolidate successes and reinforce efforts and commitments for a Cameroon
free of malaria. Government's endorsement is more than ever needed eSPecially for the application
of the data herein mentioned to design once more again a suitable policy with the means that
accompany it. The regularization of the flow of medicines in all sectors, in medicine retailers
facilities and eSPecially unofficial vendors remain one of the most burning issues in this domain as
this represent an unneeded cost for government looking at the implications of drug-resistance.
FF President
Prof. Wilfred F. Mbacham, MS, DS, MPH, ScD (Harvard)
PREFACE – MINSANTE
Commendable Initiative
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Malaria continues to be a major public health hazard that put Cameroon's 18 Million people
at risk of the infection. The Ministry of Public Health through the National Malaria Control
Program has conducted a number of strategic moves since 2002 to contain the diseases and this
build up has led to successful rounds with the Global Fund to fight Malaria. In the documentation
that follow information that the NMCP had guided the development of the National Malaria
Strategic Plans for 2002 -2006 then 2007 to 2010 and a a number of actions to improve prevention
and case management were achieved with encouraging results but also demonstrated that there
were emerging issues related to the achievement of set targets. Recently in 2011 the government
launched of a nation wide distribution of Long Lasting Insecticide treated Nets (LLINs) in to reach
such a coverage that will definitively lead to a reduction in incidence. To achieve this the NMCP
needs partners to continuous add to the efforts of information gathering and thus the NMCP judged
it worthwhile to merge efforts and encourage the Fobang Foundation in their efforts to rally such
information eSPecially from the research domain that gets locked up in drawers or in forging
journals
This report is a laudable initiative and I encourage the Fobang foundation to conduct policy
meetings to further identify the gaps for general appreciation by the NMCP. The information is
informative and hope that she continues to work to make subsequent reports even more
comprehensive. The research results are encouraging and may be through such efforts more
partners will be brought on board t o improve on issues such as case management because we would
have understood more about the disease. The conduct of surveys is quite expensive and we
appreciate the resources mobilised for this. We hope that a part of quality control in information
they will be able to choose some sentinel sites in which to conduct similar surveys so that the
comparison with what the NMCP is able to put in place to survey the malaria indicators can be
compared. We believe that it is only through accurate information that policies can be based on
evidence and this report, the first of its kind, is a step in the right direction.
We applaud this initiative and hope that its contributions is an eye opener to the rest of partners who
must continue to act in positive ways in providing assistance tot eh efforts of the government in the
fight against malaria.
The Secretary of State for Health
MINSANTE
PREFACE- MC-CCAM
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The struggle to reduce the burden of malaria in Cameroon is a continuous one and being able
to trace the evolution of the epidemiology of this illness as well as identifying through research
adequate management approaches, new tools, including vaccines, new drugs, improved diagnostics
and vector management approaches is crucial for the future. History demonstrates that since 2002
the country had completed two four-year programs for malaria control, moving from the early
eradication objectives to integrated control, readjusting strategies to contain better results. The
identification of gaps, weaknesses and opportunities is thus important. Malaria advocacy for long
term sustainability relies on fACTs for timely change of policies discussions, and action. It is in this
light that the MC-CCAM subscribed to the idea of contributing alongside this initiative of the
Fobang Foundation, to the synthesis of a Cameroon Malaria Research and Control Report SPanning
the years 2008 -2011 as a first joint endeavour.
This report is recommended to all stakeholders and particularly those in public health, civil society
organization and researchers and academic domains. A glance at the progress of epidemiological
parameters of the disease in situates the changing nature of t disease, the interventions that led to the
present statistics and reasons why much success was not achieved. Research is given an important
attention here with various research areas and the findings in brief. Parasites and vector resistance
are very present e danger of a surge in incidence. The third part puts light on issues related to case
management and what could be done to change this situation. Part four presents results on surveys
of malaria indicators in some sentinel health district of the country.
We believe that it is only through such information sharing that policies could be developed. This
report, the first of its kind, will be stimulatory in its further development towards a comprehensive
common agenda.
Prof Rose FG Leke
EXECUTIVE DIRECTOR MC-CCAM
PREFACE- WHO
A Laudable Effort
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Nowadays scaling up of interventions against the disease, known to be one without borders,
has moved to regional levels and to the hands of leaders of communities. Supported by
international organizations malaria treatment and vector control among others have set consensual
control targets that require a thorough management of information. These targets, which align with
those of the MDGs, could be achieved if consistent interventions are backed by accurate knowledge
on the epidemiology of the illness, the gaps in control efforts and opportunities that research
findings provide. There is therefore a need to constantly aim to achieve the targets set by the UN
for universal access to essential interventions. The African Union (AU) on the Abuja declaration
and plan of action resolved that the WHO governing bodies will not relent efforts to combat this
deadly scourge. Universal access is achievable if strategies and gaps, plans and programs are
frequently reviewed and updated to match up the changing nature of the epidemic. This reinforces
the urgent need for identifying pitfalls in execution and knowledge gaps and so this Cameroon
Malaria Research and Control Report, produced by the Fobang Foundation is an initiative to be
applauded. In collaboration with other stakeholders is this report was compiled from several
SPecific documents on malaria control and research in Cameroon and tries to provide a
comprehensive overview of who does what and where. The report provides a fair balance of
progress made between 2008 to 2011 in malaria control and research in Cameroon
Malaria epidemiology is changing with new interventions and this report serves as the base
for noting progress that will be made in the current efforts of Global Fund R9. Malaria research is
covered in this production and that for the first time has highlighted some of the important work that
is done and hidden from public view because there are either in drawers of researchers or are
published in inaccessible journals It is the hope that as is seen in other African countries such as
Ghana, Kenya, Madagascar, Niger, Nigeria, United Republic of Tanzania and Uganda, the
Affordable Medicines Facility for Malaria (AMFm) launch will ensure access to quality ACTs in
private sector facilities and such information as is captured will improve on the discussions with the
distribution of fake drugs. Such information will raise public awareness and set the pace for further
discussion on policy matters. This will enhance policy leading to change in control efforts.
I salute the Fobang Foundation on this first edition of the Cameroon Malaria Control and Research
Report
Dr Fatima Charlotte NDIAYE
WHO Representative, Cameroon
ACKNOWLEDGMENTS
The Malaria Control and Research Report was written and produced by the Fobang Foundation (ff),
under the leadership of its president Professor Wilfred Mbacham. The ff wishes to acknowledge the
contribution of some people and organizations who in one way or the other participated in the
construction of this report, and without whom this work would not have been completed.
The data provided by the National Malaria Control Program (NMCP) on Malaria Epidemiology and
Control from 2008 to 2009 was compiled by Akindeh Mbuh Nji, Tamsa Arfao Antoine, Ekollo
Mbange Aristid and Pierre Fongho Suh.
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The Multilateral Initiative on Malaria (MIM), through its secretary Abanda Ngu, made
available most recent abstrACTs on malaria research to depict the state of malaria research in
Cameroon. The section on Parasite Resistance was done by Wilfred Mbacham, Ekollo Mbange
Aristid and Pierre Fongho Suh; Vector Resistance was done by Fondjo Etienne and reviewed by
Wilfred Mbacham, Ekollo Mbange Aristid and Pierre Fongho Suh.
Mbacham Wilfred, Mangham LJ, Cundill B, Achonduh OA, Ambebila JN, Lele AK, Metoh
TN, Ndive SN, Ndong IC, Nguela RL, Nji AM, Orang-Ojong B, Wiseman V and Pamen-Ngako J
designed and undertook the study on ACT subsidy in the Center, South West and North West
Regions of the country. Patient Exit Pool and Provider Practices: Research on the Economics of
ACTs study was conducted by Tchekontouo Odile,Lele Albertine, Orang Ojonj, Achu James,
Ngako Pamen, Daga Donatien, Metth Theressia, Akindeh Nji, Lilian Mosi, Mokijika Anwin, Olivia
Achonduh, abang Ngui, Nguela Rachel, Ndong Ignatus, Mba Robert, Sara Namundo, Amberbillz
Joel and Wilfred Mbacham.
Akindeh Nji., Tamsa Arfao Antoine, and Pierre Fongho Suh designed and measured malaria
prevention and control indicators in Cité Verte (health district), Buea (health district), and
Ngaoundéré (rural and urban health districts). Additional information on malaria prevention and
control indicators, this time in Obala health district was provided by Esther Tallah, Eteme
Emmanuel, Tsagmo Yves Ronny, Vannie Djounguep, Tchakounte Happi William, Alima Olomo
Etienne, Akere-Maimo, Teclaire Mekeukiounoi, Rose Leke, Wilfred Mbacham and Gervais Andze.
Akere Maimo, Ekollo Mbange Aristid and Pierre Fongho Suh for reviewing the report,
graphic design, layout and editing, and Victoria Tatah , Daniel, Roland and Takam Patrick for their
administrative support in the course of the report project.
We finally thank Synergies Africaines, Chantal Biya founadation, Cameroon
Telecommunications, Mobile Telephone Network and Orange Cameroon who kindly supported the
production and dissemination of this report.
TABLE OF CONTENT
PREFACE-Fobang Foundation.......................................................................................................ii
PREFACE-MINSANTE ................................................................................................................. iv
PREFACE - MC-CCAM ...................................................................................................................v
PREFACE- WHO ............................................................................................................................vi
ACKNOWLEDGMENTS................................................................................................................vii
CONTENTS ...................................................................................................................................viii
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LIST OF
FIGURES.........................................................................................................................................xi
LIST OF TABLES ..........................................................................................................................xii
ANNEXES ......................................................................................................................................xii
LIST OF ABBREVIATIONS........................................................................................................xiii
INTRODUCTION ...........................................................................................................................1
PART I: MALARIA EPIDEMIOLOGY AND CONTROL..............................................................2
1.1. EPIDEMIOLOGICAL PROFILE...............................................................................................3
1.1.1. Malaria Morbidity....................................................................................................................3
1.1.2. Malaria Mortality.....................................................................................................................6
1.2. Malaria Control ..........................................................................................................................9
1.2.1 Malaria Prevention ...................................................................................................................9
1.2.2. Case Management .................................................................................................................10
1.2.3. Case Management in Health Facilities...................................................................................10
1.2.4. Home based management of malaria .....................................................................................11
PART 2: MALARIA RESEARCH..................................................................................................13
2.1. MALARIA RESEARCH FINDINGS IN CAMEROON..........................................................14
2.1.1. Malaria epidemiology ............................................................................................................14
2.1.2. Pathogenesis ..........................................................................................................................17
2.1.3. Parasite biology......................................................................................................................19
2.1.4. Genomics ...............................................................................................................................19
2.1.5.Antimalaria drugs ...................................................................................................................22
2.1.6. Malaria treatment and control ................................................................................................25
2.1.7. Vector biology and control.....................................................................................................26
2.1.8. Malaria vaccines ....................................................................................................................31
2.1.9. Health research ethics ............................................................................................................31
2.1.10. Socio-economic aspects .......................................................................................................32
2.2. MALARIA PARASITES AND VECTORS RESISTANCE ................................................33
2.2.1. Malaria Parasite Resistance....................................................................................................33
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2.2.2. Malaria vectors resistance......................................................................................................50
PART 3: STUDY RESULTS ON THE PROVISION AND THE ECONOMICS
OFARTEMISININ-BASED COMBINATION THERAPY (ACTS) ……………….....................60
3.1. CHALLENGES OF ACT SUBSIDY: THE CAMEROON CASE FILE ...........................61
3.1.1 Methodology ..........................................................................................................................61
3.1.2 Results ....................................................................................................................................62
3.2. PATIENT EXIT POOL AND PROVIDER PRACTICES: RESEARCH ON THE
ECONOMICS OF ACT.........................................................................................................…..67
3.2.1 Patients' characteristics ...........................................................................................................68
3.2.2 Health facility and health workers characteristics ..................................................................69
3.2.3 Prescribed treatment for malaria (assessed for health workers and patients) ...........................71
3.2.4 Malaria testing and appropriate treatment...............................................................................74
3.3 ACCESS TO AND DELIVERY OF MALARIA TREATMENT IN CAMEROON .................78
3.3.1. Treatment practices of providers............................................................................................78
3.3.2. Proportion of patients who were prescribed/received the correct dose and advice on the
regimen ............................................................................................................................................79
3.3.3. Variations in service delivery ................................................................................................79
PART 4: RESULTS OF MALARIA SURVEY IN FOUR HEALTH DISTRICT IN CAMEROON
..........................................................................................................................................................81
4.1. MALARIA INDICATORS IN BUEA HEALTH DISTRICT ..................................................82
4.1.1. Malaria prevention .................................................................................................................82
4.1.2. Malaria prevention during pregnancy ....................................................................................83
4.2. MALARIA INDICATORS IN CITÉ VERTE HEALTH DISTRICT ......................................85
4.2.3. Malaria cases and management in children under the age of five..........................................87
4.3. MALARIA INDICATORS IN NGAOUNDERE URBAN HEALTH DISTRICT ..................87
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4.3.3. Malaria cases and management of children under the age of five .........................................89
4.4. MALARIA INDICATORS IN NGAOUNDÉRÉ RURAL HEALTH DISTRICT: DANG AND
BEKAHOSSERE HEALTH AREAS ..............................................................................................89
4.4.1. Malaria prevention ................................................................................................................89
4.4.3 Malaria cases and management of children under the age of five...........................................90
4.5. MALARIA INDICATORS IN OBALA HEALTH DISTRICT ...............................................91
4.5.1. Cases of fever and malaria treatment ....................................................................................91
4.5.2 Malaria Prevention in Obala....................................................................................................92
4.5.3. Pregnant women ....................................................................................................................93
4.5.4. Children aged less than five years .........................................................................................93
4.6. AKONOLINGA HEALTH DISTRICT, MALARIA CONTROL PROJECT (BY PLAN
CAMEROUN) ….........................................................................................................................….94
RÉFÉRENCE....................................................................................................................................98
ANNEXE .........................................................................................................................................104
FIGURES
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Figure 1: Malaria Morbidity Rates Recorded At Health Facilities In 2008 And 2009...........................................................18
Figure 2: Malaria Morbidity (Uncomplicated And Severe) In Children Under 5 Recorded At Health Facilities In 2008
And 2011 ......................................................................................................................................................................18
Figure 3: Malaria Morbidityamong Pregnant Women In Health Facilities In 2008 And 2009 .............................................19
Figure 4: Percentages Of Hospitalized Children Under 5, Pregnant Women And Other Grouupas A Result Of Severe....20
Figure 5: Evolution Of Malaria Cases (All Groups Put Together) Throughout 2009 ............................................................21
Figure 6: Evolution Of Malaria Cases In Pregnant Women Throughout The Year 2009 ......................................................21
Figure 7: Evolution Of Malaria Cases Throughout The Year 2009 In Children Aged Under Five.......................................21
Figure 8: Distributon Of Persons Above Five Years (Minus Pregnant Women) Treated With Acts In 2008 And 2009 ....25
Figure 9: Distribution Of Children Under Five Treated With Acts In 2008 And 2009 ..........................................................25
Figure 10: Number Of Persons Treated By Communautary Relay Workers In 2009 ............................................................26
Figure 11: Antimalarials Drug Resistance In Cameroon (CQ And MQ-R) ............................................................................49
Figure 12: Rising Resistance To Spand AQ In Cameroon .......................................................................................................49
Figure 13: Pfcrt And Pfmdr1 Mutations Profile In Cameroon .................................................................................................51
Figure 14: Dhps And Dhfr Mutations Profile In Cameroon .....................................................................................................52
Figure 15: Geographical Distribution Of Dhfr Triple Mutant Alleles Irn In 11 Localities Of Cameroon ............................53
Figure 16: Distribution Of Dhfr Gene Wild Types And Mutant Alleles In 13 Areas Of Cameroon.....................................54
Figure 17: The African Distribution Of Dhps Resistant Lineages ...........................................................................................55
Figure 18: The Distribution Of The Major Dhps Alleles Across Sub-Saharan Africa ...........................................................56
Figure 19: Antimalarial Drug Resistance Markers ...................................................................................................................57
Figure 20: Therapeutic Efficacy Of Chloroquine In Cameroonian Children, 1999-2001 ......................................................58
Figure 21: Therapeutic Efficacy Of Amodiaquine In Cameroonian Children, 1999-2003 ....................................................59
Figure 22: Therapeutic Efficacy Of Sulfadoxine-Pyremithamine In Cameroonian Children, 1999-2004 ............................59
Figure 23: Efficacy Of AQ, Spand AQ-SP In Cameroon On Day 14 .....................................................................................60
Figure 24: Adequateclinicalandparasitologicalresponses(Acprs) Inthe28daytrialformon-Artemisinin ................................61
Figure 25: Acprs In The 28 Day Trial For Combination Therapies Before And After Pcr Correction From 2005-2007 In62
Figure 26: Evaluation Of Acts Efficacy On Different Treatment Periods With Arthemether-Lumefantrine (Al) As .........63
Figure 27: Malaria Transmission Periods In Different Ecological Zones Of Cameroon .......................................................65
Figure 28: Geographical Distribution And Relative Frequencies Of An. Gambiae S.S Molecular Forms In Cameroon ....66
Figure 29: Geographical Distribution And Species Frequencies Of The An. Gambiae Complex In Cameroon ..................66
Figure 30: Geographical Distribution Of An. Funestus In Cameroon .....................................................................................67
Figure 31: Geographical Distribution Of An. Nili In Cameroon .............................................................................................67
Figure 32: Geographical Distribution Of An. Moucheti In Cameroon ....................................................................................68
Figure 33: Geographical Distribution Of An. Gambiae S.I. Population According To Resistance To Ddt..........................68
Figure 34: Geographical Distribution Of An. Gambiae S.I. Population According To Resistance Status To Delthametrin70
Figure 35: Geographical Distribution Of An. Gambiae S.I. Population According To Resistance Status To Permethrin ..70
Figure 36: Geographical Distribution Of An. Gambiae S.I. Population To Lambdacyhalothrin ..........................................71
Figure 37: Geographical Distribution Of An. Gambiae S.I. Population According To Resistance Status To Bendiocarb .71
Figure 38: Ideal Flow Chart Of Drug Procurement In The Health System Of Cameroon .....................................................72
Figure 39: Actual Flow Chart Of Drug Procurement In The Health System Of Cameroon ..................................................75
Figure 40: Pricing Per Pack In Cfa Francs ................................................................................................................................76
Figure 41: Frequency Of Antimalarials Found In The Different Drug Outlets ......................................................................78
Figure 42: Mean Price Per Tablet Of Acts From Drug Outlets................................................................................................79
Figure 43: Patients Who Recalled To Have Received Act Or Anyantimalarial In All Facilities ..........................................79
Figure 44: Availability Of Antimalarials In All Facilities ........................................................................................................81
Figure 45: Availability Of Artemisinin Based Combination Therapies (Acts) In All Facilities............................................82
Figure 46: Assessment Of Health Workers Performance In Health Facilities ........................................................................83
Figure 47: Patients Reported Consultation In All The Facilities .............................................................................................84
Figure 48: Percentage Of All Patients Who Were Prescribed Or Received Malaria Treatment............................................85
Figure 49: Types Of Treatment Requested By Patients In All Facilities ................................................................................85
Figure 50: Dosage And Advice (Patient Knowledge) Given For Act Dispensed In All Facilities ........................................86
Figure 51: Presumptive Malaria Treatment Prescribed Or Received In Public Facility ........................................................87
Figure 52: Presumptive Malaria Treatment Prescribed In Private Facility .............................................................................87
Figure 53: Presumptive Malaria Treatment Prescribed Or Received In Medicine Retailers .................................................88
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Figure 54: Appropriate Treatment Of Malaria Received In Accordance With Rdt Result ....................................................89
Figure 55: Treatment Prescribed To Patients Tested/Not Tested During Patient Consultation .............................................90
Figure 56: Targeted Health District For The Assessment Of Malaria Indicators ...................................................................91
Figure 57: ITN Possession And Use In Households .................................................................................................................96
Figure 58: Intermittent Preventive Treatment Use Assesment.................................................................................................97
Figure 59: Malaria Morbidity And Itns Use In Children Under Five In Buea Town Health District ...................................98
Figure 60: ITN Possession And Use Households Of Cite Verte Health District ....................................................................98
Figure 61: ITN Possession And Use Among Pregnant Women And IPT2p Use Assessment...............................................99
Figure 62: Malaria Management In Children Younger Than Five Years And ITN Possession ......................................... 100
Figure 63: ITN Possesession In Households .......................................................................................................................... 100
Figure 64: ITN Possession And Use In Pregnant Women And IPT2p Assessment ............................................................ 101
Figure 65: Malria Mangement In Ngaoundere Rural Health District: Dang And Bekahossere Health Areas................... 102
Figure 66: ITN Possessionanduseinhouseholds ..................................................................................................................... 102
Figure 67: ITN Possession And Use Among Pregnant Women And IPT2p Use Assessment............................................ 103
Figure 68: Malaria Management In Children Younger Than Five Years And ITN Possession ......................................... 104
Figure 69: Case Of Fever And Malaria Treatment ................................................................................................................ 104
Figure 70: Households Bed Net Possession And Use............................................................................................................ 106
Figure 71: Percentages Of Pregnant Women That Used Bed Netand Too IPT2 During Pregnancy .................................. 107
Figure 72: Pregnant Women And Children Under Five Sleepnig Under A Bed Net .......................................................... 107
Figure 73: Households With Llins .......................................................................................................................................... 109
Figure 74: IPT2 Coverage........................................................................................................................................................ 109
LIST OF TABLES
Table 1: Malaria Related Deaths Reported In Health Facilities Per Region And Per Group ................................................21
Table 2: Entomological Inoculation Rate Of The Major Infective Vector Species In Cameroon .........................................64
ANNEXES
Annexe 1: Epidemiological Profile Of Malaria In Cameroon ............................................................................................... 117
Annexe 2: Pricing Of Acts In The Public And Private Sectors ............................................................................................. 118
ABBREVIATIONS
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ACPR
Adequate Clinical and Parasitological Response
ACTs
Artemisinins based combination Therapies
CCAM
Cameroon Coalition Against Malaria
CENAME
National Drug Procurement Centre
EIR
Entomological Inoculation Rate
ff
Fobang Foundation
GFATM
Global Fund against AIDS Tuberculosis and Malaria
HWs
Health Workers IPT2i Intermittent Preventive
Treatment in infancy
ITNs
Insecticides Treated Nets
ITPp
Intermittent Preventive Treatment in pregnancy
LLINs
Long Lasting Insecticides Treated Nets
MIM
Multilateral Initiative on Malaria
NMCP
National Malaria Control Program
REACTs
Research on Economics to Artemisinin Based
Combination Therapies
W.H.O
World Health Organization
INTRODUCTION
Malaria remains a major cause of death in sub Saharan Africa. Pregnant women and children under
five are the most vulnerable groups. According to the WHO, every 30 seconds a child dies of
malaria. The world recognized the burden of this scourge to humanity and is now united to kick
malaria out. In Cameroon, the National Malaria Control Program (NMCP) and many nongovernmental organizations had carried out several actions which have yield significant impact.
Many other initiatives are underway for achieving a sustained control over malaria surge. Yet,
challenges to this quest restrain efforts and having up to date information on malaria control and
research is highlighted by most stakeholders as key to making a steady progress towards control.
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The need for a document that compiles this information was therefore expressed by most
organizations. The Fobang foundation (ff), a not-for-profit organization, in collaboration with the
National Malaria Control Program and the Cameroon Coalition Against Malaria (CCAM), has
endeavoured to put together some of these information in the present report. This report is the first
ever attempt to reSPond to this need. It is a compilation of information, including malaria research
findings, results of surveys assessing malaria indicators in the four health district in three regions of
Cameroon and malaria partners, from various sources.
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PART I:
Malaria epidemiology and control
This section is a summary of malaria epidemiological and control statistics sampled from
health facilities and households by the NMCP in 2008 (the situation of malaria control in 2008,
progress report N°2 June 2009) and 2009 (Activities report of the NMCP, 2009). It describes
malaria indicators such as morbidity and mortality rates by region with emphasis on vulnerable
groups (pregnant women and, children under the age of five) as well as bed net coverage and use,
IPT2 coverage and malaria management in health facilities and at home. Gaps correSPonding to the
2010 NMCP SP targets are highlighted here.
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1.1 Epidemiological profile
1.1.1. Malaria Morbidity
In Cameroon, malaria morbidity rate stood at 41% for the whole population in 2008, this
statistic dropped to 38.38% in 2009. Pregnant women and children under five paid the highest
tribute. These groups' morbidity rates were 49% and 56% reSPectively for the year 2008 against
44% and 54% in 2009. Out of a thousand malaria cases reported in 2008, 679 were patients with
uncomplicated malaria; about the same number (673) was reported in 2009. The northern part of the
country (Far north, north and Adamawa) remains the most affected in both periods (Figure 1).
According to NMCP the size of the population and an improvement in data collection and
transmission system in that region, could explain these trends. At health facilities in 2008, severe
malaria accounted for more than 13% of patients in outpatient clinics (Figure 2). The infection rate
varies from one region to another.
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Of all malaria cases reported in health facilities, children under-five year constituted 39.0%
in 2008 and 38, 3% in 2009. In figure 2 we can appreciate the evolution of the uncomplicated and
severe forms of malaria in children under five.
As concerns pregnant women, their morbidity rate falls from 49% in 2008 to 44% in 2009.
The Adamawa, Far North, East, North West and West regions are the one reSPonsible for this
reduction (Figure 3). These interesting results could be attributed to the efforts of the Cameroon
government and its partner's namely Global fund and UNICEF to improve maternal health. Free of
charge Sulfadoxine-Pyriméthamin, free distribution of LLINs and periodical SASMIN even are
among actions taken.
5
Malaria has been the main reason for admission in hoSPital in 2009. It was reSPonsible for
more than 50% of annual hoSPitalizations in most regions. Malaria is the leading cause of
hoSPitalization in pregnant women in all 10 regions. The north-west region has the lowest rate,
probably because women of this region use effectively malaria prevention tools. As for children
under the age of five, we note that in five regions (Adamawa, East, Far north, North and west) at
least 60% of children hoSPitalized are children with severe malaria (Figure 4).
6
1.1.2. Malaria Mortality
Statistics from health facilities across the national territory showed a mortality rate of 43%
in 2008. In 2009 it dropped to 29% (table 1). This decrease is attributed partly to the improvement
of data quality. But children fewer than five still remain the most affected as they represented 67%
of all malaria related deaths.
Table1: Malaria related deaths reported in health facilities per region and per group.
Regions
All
Deaths
%
death
related to
deaths
cases
malaria
related
malaria
of
to
Malaria
%
Malaria
%
Malaria
%
related
malaria
related
malaria
related
malaria
related
deaths in ˃5
related
deaths
deaths in
and adults
deaths in ˃5
pregnant
deaths
and adults
women
pregnant
death
<5
in
of
<5
of
in
of
related
in
women
7
Adamawa
964
343
36%
211
62%
104
30%
28
8%
Centre
1 241
404
33%
210
52%
138
34%
56
14%
East
952
230
24%
146
63%
79
34%
5
2%
Far north
3 705
1 793
48%
1 354
76%
391
22%
48
3%
Littoral
1 536
179
12%
88
49%
40
22%
51
28%
North
2 693
1 119
42%
828
74%
284
25%
7
1%
North-west
2 988
220
7%
89
40%
130
59%
1
0%
West
1 883
318
17%
216
68%
89
28%
13
4%
South
258
148
57%
79
53%
56
38%
13
9%
South-west
913
189
21%
110
58%
56
30%
23
12%
Total
17 133
4 943
29%
3 331
67%
1 367
28%
245
5%
Evolution of malaria cases throughout 2009
From January to July 2009, the number of cases, all groups included, varied around 150.000.
The morbidity rate then rises from September to November, reaching a pic in October (Figure 5). In
the group of children aged fewer than five, the evolution of cases throughout the year is similar to
the previous one; from January to July monthly reported cases varied between 50.000 and 60.000.
The rate rises from August, reaching its peak in October (Figure 6). In pregnant women the
tendency is different; the average rate per month varied from 8000 to 12000 (Figure 7).
8
Figure 5: Evolution of malaria cases throughout 2009, all groups put together in 2009.
Figure 6: Evolution of malaria cases throughout the year 2009 in pregnant women 2009.
Figure 7: Evolution of malaria cases throughout the year 2009 in children aged under five.
1.2. Malaria control
1.2.1. Malaria Prevention
Within the framework of the 2007-2010 NMCSP two strategic approaches for malaria prevention
were retained.
a)
Vector control
It combines treated bed net use and Indoor Residual SPaying. These interventions are locally
improved with larvae control and environmental management.
9
As far as bed net is concerned, a total of 1928648 ITNs have been distributed since 2005 to
Households with at least one child under-five. The distribution continued in 2009 in west and
littoral regions since they were not covered during the previous campaign. A total of 430606 LLINs
were distributed to 415480 households with at least one child aged under five. The distribution was
as follows: 217606 in west region for 219414 households and 213 000 in littoral region for 196066
households.
Pregnant women have also benefited from free of charge ITNs. In 2009, under PPTE funds women
of centre and east regions received 49257 ITNs. These funds, made available for regional delegate
of the ministry of public health, will also be used for treating Bed net. It should be noted that under
the scaling Up Malaria Prevention project more than 200.000 common bed nets were treated with
insecticide in 8 regions. The Adamawa was not part of this initiative since it expected some funds
from UNICEF for that purpose; as for the second region, the south, it did not have a regional head at
that moment to manage the activities.
Ten health districts of the country that represent the different malaria epidemiological features were
selected for the pilote phase of IRS at a much bigger scale. The launching ceremony was done in
Etam-Bafia, center region and a total 1887 dwellings were SPrayed with insecticide by
professionals.
b)
Free distribution Intermittent Preventive Treatment for pregnant women
Sulfadoxine - Pyrimethamine (SP) is the recommended medicine for malaria prevention during
pregnancy. In 2008 the proportion of pregnant women who have taken IPT21 was 48, 42%. But it
fell in 2009 to 32.62%. The proportion of pregnant women who have taken a second dose of IPT2
is 28.68% in 2008 and 22.68% in 2009. The south and south west regions could hardly reach 20%
coverage of the population of pregnant women expected. According the NMCP this reduction is due
to irregularities related to some intensive campaigns such as SASNIM.
1.2.2. Case Management
In 2008 the ministry of Health through the NMCP made available 1814725 subsidized doses of
ACTs to improve accessibility of ACTs to populations. About 67.10% cases of uncomplicated
malaria were treated with ACTs; this gape is attributable to the low proportion of trained health
personnel in malaria management and insufficient communication. (Source: the situation of malaria
10
control in 2008, progress report N°2 June 2009). In 2009, only 1299240 doses of ACT were made
available; this reduction is in accordance with decrease of the number of cases (Figure 3). Out of
765052 cases of uncomplicated malaria reported from health facilities, 60.41% were treated with a
combination therapy ASAQ.
1.2.3. Case Management in Health Facilities
The percentage of people aged above 5 and other than pregnant women that had malaria and was
treated with ACTs stood at 60.01% in 2009, moving from 56.81% in 2008. Adamawa region has
made the best progress by scoring 56.39% in 2009 against 7.44% in 2008of this group treated with
ACT (Figure8).
Like the previous group, there is an increase in the percentage of children aged under five
that had malaria and was treated with ACT; from 57.85% in 2008, we reached 61.00% in 2009
(Figure 9). The Adamawa is notably the best performer. This significant progress is not a result of a
particular intervention; the NMCP suggest that the performance of the Adamawa was not well
assessed in 2008 due to the inaccuracy of data as well as to the low completeness of data
transmission.
11
1.2.4. Home based management of malaria
Home based management of malaria, as part of case management of malaria, is a community
centered and implemented activity carry out with the support of the health system for the well being
of the population. NMCP has trained about 15500 community relay workers to ensure proper
management of cases at home. It has significantly increased the percentage of people treated with
ACTs in 2008 but fell in 2009.According to the NMCP 142.000malaria cases (correSPonding to
11% of all uncomplicated malaria cases nationwide) were attended at home in 2008 against 54599
(correSPonding to 4.31% of all uncomplicated malaria cases nationwide) in 2009.The Far north,
west, north and north west recorded the highest number of people with malaria treated at home in
2009 (Figure 10).
12
13
PART 2:
Malaria research
Part 2 is intended to give a comprehensive picture of malaria research in Cameroon. It presents
findings, in abstrACTs, of the most recent scientific studies carried on malaria and grouped in
categories among which malaria epidemiology, parasite biology, pathogenesis, vaccine, genomics,
malaria treatment and control and vector biology. A particular attention is subsequently given to
parasite and vectors resistance, a review of present knowledge on the issue in Cameroon. This
review is followed by the presentation of the results of some studies on ACT subsidy, access and
delivery in Cameroon as well as on the assessment of malaria prevention indicators. The end of part
II is dedicated to the descrIPT2ion of all research institutions that work on malaria in Cameroon,
their objectives, areas of expertise and major most recent achievements.
14
2.1.
Malaria Research findings in Cameroon
2.1.1. Malaria epidemiology
Abstract 1: Plasmodium/Intestinal helminths co-infections among pregnant Cameroonian Women
Gillian N. Asoba, Kenneth J.N. Ndamukong* and Eric A. Achid
The study sought to investigate the prevalence of Plasmodium/intestinal helminth co-infections and assess the effects of
these infections on the incidence of anaemia in pregnant women attending antenatal clinic in Buea, Muea and
Mutengene. Blood and stool samples were collected from 206 pregnant women during three consecutive visits of each
participant to the clinic, and used for identification and quantification of malaria parasites and eggs of soil-transmitted
nematodes. The results revealed that 58 (28.2%) of the women harboured both intestinal helminths and malaria
parasitaemia on the first antenatal visit, 35 (17%) on the second visit and 5 (2.4%) on the third visit. The difference was
significant (P<0.02). Primigravidae registered a higher frequency of co-infections during the three consecutive antenatal
visits than multigravidae, the difference being significant on the first and second visits (P<0.001 and P<0.05
reSPectively). Single women were more significantly co-infected on the first visit than married women
(P<0.001).Women attending clinic in Muea registered a higher prevalence of co-infections on the first visit compared to
the rate in Buea and Mutengene (P<0.001).The rate was significantly higher in Mutengene during the second (P<0.01)
and third visits (P<0.05) than in Buea or Muea. Women harbouring Plasmodium/helminth co-infections had the highest
prevalence of anaemia (PCV<31%), followed by those harbouring helminths only. The implications of these results are
discussed.
Email address for correSPondence: [email protected]
Abstract 2:Using the Rapid Urban Malaria Appraisal (ruma) method to elucidate the epidemiology of malaria in
the city of Douala, Cameroon
Dickson Nsagha
Malaria used to be a disease of rural areas but urban malaria is an emerging disease in Africa. We used the Rapid Urban
Malaria Appraisal (RUMA) method: literature review, health facility survey and an observational checklist to identify
malaria high risk area for the implementation of home-based management of malaria with ACTsamongthe under-fives
in the city of Douala. From chart review in 2005, the highest number of malaria cases was in the Bonassama health
district (14,588) and the highest number of malaria deaths in the Log Babah health district (26). The correSPonding
figures for the under fives in these areas were 5444 (2.83%) and 5 (0.25), reSPectively. From the health facility survey,
the highest percentage of feverish children with positive malaria parasite among all feverish children who attended
health facilities were as follows: Deido (56.32%), Bonassama (45.01%) and Cite des Palmiers (42.58%). Literature
review and health facility survey gave conflicting results; hence we designed an observational checklist of malaria risk
factors. The results of the health facility survey, literature review and environmental malaria risk factors identified the
Nkomba health area in the Bonassama health district as the malaria high risk area in Douala city for the implementation
of home-based management of malaria with ACT among the under-fives. A clear picture of the malaria burden in the
city of Douala is difficult because of under-reporting but using RUMA; the Nkomba health area is the highest malaria
risk area in the city of Douala.
Email address for correSPondence:[email protected]
15
Abstract 3: Malaria and HIV/AIDS co-infection in a rural setting of Cameroon: Assessment of some
parasitological and clinical parameters
Theresa Nkuo-Akenji, Frankline Nzang Ajoeh, Etienne Emgilbert Tevoufouet, Isaac Ngide Ebong
Co-infection with malaria and HIV/AIDS in a rural plantation setting such as Muyuka is expected. This study
investigated the effect of co-infection on parasitological and clinical parameters over a one year period. 867 adults
attending the Muyuka hoSPital comprised the study population. Parasitaemia was detected by microscopy. HIV
infection was diagnosed using test kits. Prevalence of malaria, HIV-1 and co-infection was 90.7%, 27.0% and 25.6%
reSPectively. GMPD was higher in co-infected (3103.4 ±773.3) than in malaria patients (2140.2 ±291.9) (P<0.004).
Mean illness duration (days) was longer (25.8 ±3.5) in co-infected patients followed by those with malaria (12.4 ±1.0)
and HIV/AIDS mono-infections (4.0 ±0.7) (P<0.001). Mean Hb concentration (g/dl) in co-infected patients was 11.4
±0.3 compared with 12.1 ±0.2 for malaria patients (P<0.05). Fever was higher in co-infected (73.0%) than in malaria
patients (60.6%) (P=<0.05). Mean CD4+ count in co-infection was lower (384.5 ±25.9) than that for mono-infection
with HIV/AIDS (467.8 ±84.8). While none of those solely infected with HIV/AIDS was in the advanced stage, 13.5%
of co-infected patients fell in this category. CD4+ counts in febrile co-infected patients (346.6 ±20.8) were lower than
for those afebrile (475 ±47.3) (P<0.005). The GMPD in co-infected patients with CD4+ counts <200 was 5539.9 ±235.1
when compared with 2987.1 ±1118.7 and 2015.7 ±530.0 for those with counts in the range of 200-499 and >500
reSPectively (P<0.062). Co-infection was more associated with lower CD4+ counts, high parasitaemia, high fever
frequency, longer illness duration and low Hb concentration.
Abstract 4:Assessment of factors contributing to the heterogeneity of asymptomatic malaria in the mount
Cameroon region
Ebanga E. Joan Eyong, Helen K. Kimbi, Lum Emmaculate, Judith L. Ndamukong, Nicholas Tendongfor, Samuel Wanji
Knowledge of climatological and physical factors, housing type and level of urbanization are essential to the study of
insect-borne diseases such as malaria. This study was designed to assess factors contributing to malaria heterogeneity in
the Mount Cameroon region. A geographical positioning system (GPS) unit was used at each locality, to collect altitude,
latitude and longitude data. A sketch map of the area was generated. Blood samples were collected from participants in
each locality using sterile blood lancets and blood films produced. Slides were stained with 5% Giemsa and read for the
presence of Plasmodium SPecies. Data generated were analyzed using SPSS. Chi square test of heterogeneity was used
to assess the differences of malaria prevalence in the study area. A logistic regression analysis was used to determine the
significance of factors contributing to malaria in the region. One thousand three hundred and nineteen samples were
included. Seven hundred and eighty-six samples were positive for malaria yielding a prevalence of 59.59%. Ekona, a
low altitude locality, recorded the highest (92.34%) prevalence of malaria while Bonakanda, at the highest altitude
recorded the lowest (12.33) malaria prevalence, (p=0.001). Logistic regression analysis suggested that altitude, and
relative humidity were the factors contributing to malaria heterogeneity in this region. These results suggest that malaria
prevalence in the mount Cameroon region is heterogeneous. Malarial infection is significantly associated to altitude and
relative humidity. The analyses in this work can be used by public health workers in allocating resources for malaria
control.
Abstract 5:Co-infections of malaria and intestinal helminths in Ekona and Great Soppo: Two areas with
contrasting levels of urbanisation in the Mount Cameroon Region
Lum Emmaculate, Muh Bernice Fien, Mbuh V. Judith, Samuel Wanji, Helen K. Kimbi
16
Malaria infections do co-exist with helminth infections and it has been SPeculated that urbanization alters the frequency
and transmission dynamics of malaria as well as helminth infections. The overall objective of this study was to assess
the impact of urbanization on co-infections of malaria and intestinal helminths and to establish if any relationship exist
between these co-infections in school children in the Mount Cameroon Region. A total of 235 and 208 children from
Ekona and Great Soppo reSPectively of both sexes aged 4-14 years were enrolled into a cross-sectional study between
January and June 2007. Capillary blood samples were collected for detection and determination of malaria parasitaemia
as well as PCV. Stool samples were also collected and examined by Kato-Katz technique for the presence and intensity
of intestinal helminths (Ascaris lumbricoides, Trichuris trichuria and hookworm). Helminth infections were more
prevalent in Ekona than Great Soppo. The most prevalent helminth infection in Ekona was Ascaris, followed by
Trichuris and then hookworm. In Great Soppo, Trichuris was the most prevalent helminth SPecies followed by Ascaris,
then hookworm. More children had co-infections of malaria and helminths in Ekona than in Great Soppo. The most
prevalent co-infecting SPecies were Ascaris/P. falciparum and Trichuris/P. falciparum in Ekona while in Great Soppo
Trichuris /P. falciparum infections were most prevalent. More children were infected with malaria and intestinal
helminths as well as these co-infections in Ekona probably due to increased urbanization in Great Soppo than Ekona.
Abstract 6: Genetic variability of Plasmodium falciparum during SPorogonic development
H.P. Awono-Ambene, W. Toussile, S. Nsango, R. Tabué, A. Berry, I. Morlais
The SPorogonic development of Plasmodium falciparum parasites was monitored in local malaria vector mosquitoes to
assess genetic diversity and parasite-vector compatibility in Cameroon. Feeding experiments of our local mosquito
strain were performed using gametocyte containing blood from children recruited in Mfou, an area of stable malaria
transmission. Plasmodium falciparum samples were collected from gametocyte isolates, oocysts and salivary glands.
Gametocytes were isolated at the feeding day, and oocysts and SPorozoites were obtained following mosquito
dissection at day 9 and day 14 post infection, reSPectively. DNAs were extracted and submitted to P. falciparum
microsatellitte amplification at 6 loci. PCR products were genotyped using GeneMapper software and analyses were
done using FSTAT and MixMoGenD. Experimental infections were carried on in 2008. Infection rates in the Ngousso
strain ranged from 0 to 92%, depending on the gametocyte densities, sex-ratio and gamete maturity. Preliminary results
indicate 25% of single gametocyte infections in the studied area. We observed high genetic polymorphism with an
average of 10 alleles per locus. Our data will help for a better knowledge of P. falciparum genetic differentiation
through the SPorogonic development, which is crucial to understand the SPread of parasite resistances to drugs and
vaccines.
Abstract 7 : Infection à Plasmodium falciparum chez les élèves Camerounais
Ponka Roger, Fokou Elie
17
Le paludisme reste un problème de santé publique au Cameroun car il est la première cause de mortalité et de morbidité.
Ainsi, cette étude recherche les facteurs nutritionnels en relation avec l’infection à Plasmodium falciparum, chez les
élèves camerounais de Ngali II. 211 et 200 élèves âgés de 5-18 ans ont été recrutés reSPectivement en saison des
pluies et en saison sèche après accord de leurs parents. Leurs apports alimentaires ont été déterminés. Le sang prélevé
sur ces sujets a permis de déterminer la parasitémie, l’eSPèce plasmodiale, L’hématocrite la zincémie et la cuprémie
90,7% des sujets sont parasités en saison des pluies et 81,3% en saison sèche. Les infections sont dues à Plasmodium
falciparum à plus de 70%. Les corrélations négatives et significatives sont observées entre les apports en énergie, zinc,
cuivre, vitamine A, ainsi que la zincémie, cuprémie et la parasitémie chez les enfants d’une part et les apports en
zinc, la zincémie, la cuprémie et la parasitémie chez les adolescents d’autre part . Les corrélations positives et
significatives sont observées entre les apports en fer et la parasitémie chez les enfants et chez les adolescents. Ainsi,
une carence en vitamine A, zinc et en cuivre se traduit par une augmentation de la parasitémie. En effet la vitamine A,
le zinc et le cuivre sont impliqués dans le fonctionnement du système immunitaire. Une carence en fer se traduit par la
réduction de la parasitémie.
2.1.2. Pathogenesis
Abstract 8:Malaria and helminthic infections alongside haemoglobin levels amongst school children in Bello subdivision Cameroon.
Anna Njunda
Malaria is one of the most deadly diseases while helminthe cause the most prevalent parasitic infections. These two
infections co-exist, with anaemia being an overlapping symptom. Aim: To investigate the impact of malaria and
helminth co-infection on anaemia amongst school children in Bello, Cameroon. 112 apparently healthy school children
aged 3-11 years were enrolled into the study. There were 40(35.7%) from the nursery section and 72(64.3%) from the
primary section. Amongst these 53(47.3%) boys and 59 (52.75) girls. With parent’s consent, blood films were made
from finger prick samples and stained with 10% Giemsa. Fresh stool sample were collected from each child and
immediately examined for helminthes and protozoAn. All 112 had malaria parasite with concentrations ranging from
1,600p/ul to 11,200p/ul and a mean parasitaemia of 5,785p/ul. High malaria parasitaemia ( > 5000p/ul) was found in
71.2% of nursery school children as compared to 50% of those in primary school. There was no significant correlation
between malaria parasitaemia and gender. Malaria and helminthes co-infection was recorded in 38.3% of the children.
Intestinal helminthes included Ascaris lumbricoides (25.6%), Trichuris trichuria(5.1%) and the protozoan E. histolytica
(36%). Haemoglobin concentrations were negatively correlated with levels of malaria parasitaemia (r = -1; P= 0.04) but
positively correlated with age (r = + 1;).Of the 54(48.2%) children found to be anaemic, 52 (96.2%) had mild anaemia
and 2 (3.3%), severe anaemia symptomatic malaria is still endemic amongst school children in Bello and is significantly
associated to anemia.
Abstract 9:Clinical and physiopathological features of cerebral malaria in Douala town, Cameroon
Pankoui M. Joel, Gouado Inocent, Fotso K Honore, Zambou Odette, Nguele Pulcherie, Combes Valery, Grau E.
Georges, Amvam Z. Paul Henri
18
Cerebral malaria (CM) is the most severe neurological complication of infection with Plasmodium falciparum. Insights
into the processes leading to these severe forms might lead to new interventions that address pathophysiological
processes causing malaria’s peculiar morbidity and mortality. We set out to investigate the link between some clinical
and immunological factors which may be helpful for it better understanding. Throughout the year 2007, children 0 to 15
years old were recruited after informed consent in 4 hoSPital institutions in Douala (Cameroon). Cerebral malaria was
defined as impaired consciousness (Blantyre coma score ≤ 2) not attributable to any other cause in a patient with a
positive malaria smear. Clinical, nutritional and laboratory indices were assessed. Later on, Microparticles (MP)
determination was investigated using flow cytometry CM patients were significantly younger than those with severe
malaria anemia (SMA) or uncomplicated malaria (UCM), P=0.0107. On admission, 36% of CM patients had
hyperpyrexia and all were prostrated. None of them had severe undernutrition, however, 48% had mild undernutrition as
assessed by the WAZ score. CM patients showed also an important increase in MP levels, particularly from platelets,
erythrocytes, endothelium and monocytes. This study highlights peculiarities in clinical presentation and outcome, as
well as in some physiopathological parameters of CM patients. This is helpful for a better understanding of the
immunologic interactions incidental to CM. Furthermore it could lead to new avenues for prevention and/or therapy and
to the investigation of new targets for drugs design.
Abstract 10: Assessment of packed cell volume (pcv) and plasma iron levels following treatment for malaria and
helminthic infections in children in rural Muea, Cameroon.
Moses Samje, Irene Sumbele, Anna Njunda, Elsy Mankah, Lucien Kamga, Theresa Nkuo Akenji
In many tropical regions, anaemia, iron deficiency, malaria and helminth infections co-exist and are interrelated. To
investigate the effect of malaria and soil-transmitted helminthic (STH) infections on anaemia and plasma iron levels,
203 children (< 15 years) residing in rural Muea were enrolled into a longitudinal study in which they were followed up
weekly for six weeks between April and October 2006. Malaria parasitaemia was determined microscopically, packed
cell volume (PCV) was determined using a haematocrit and plasma iron levels by SPectrophotometry. Stool samples
were prepared by the Kato-Katz technique and examined microscopically for the presence and intensity of intestinal
helminths. Overall, 99% of the children had malaria parasites while 53.7% were infected with STH. The prevalence of
anaemia (PCV<31%) and plasma iron deficiency (plasma iron<50µg/dL) was reSPectively, 43.4% and 50.2%. Of the
worm-infected children 54.1% and 51.4% were anaemic and iron deficient reSPectively. Following appropriate malaria
and worm treatment mean PCV increased progressively from 31.14 ± 5.24 to 35.23 ± 5.04 and mean plasma iron levels
from 65.05 ± 68.56 to 68.57 ± 84.05 on day 0 and day 42 reSPectively. The difference between pre-and post-treatment
mean PCV was significant (P<0.05). Our findings indicate that malaria and helminth infections have an impact on PCV
and plasma iron levels. The co-existence of these infections in this community contributes to the severity of anaemia
and iron deficiency. The population has to be educated on the benefits of prompt and proper treatment of these parasitic
diseases.
2.1.3. Parasite biology
Abstract 11:Comparison of field-based xenodiagnosis and laboratory assays for estimating malaria parasite
infectivity to mosquitoes in Western Burkina Faso
19
Louis Clement Gouagna, Germana Bancone, Frank Yao, Bienvenue Yameogo, Rock Dabiré, Jean Bosco Ouedraogo,
David Modian
Several techniques have been used to study host infectiousness, including the experimental membrane and direct skin
feeding. Only few studies have compared the relative efficacy of the membrane feeding method with the straightforward
xenodiagnosis of indoor resting mosquitoes that have fed on available hosts. As allowed within the constraints of the
approved ethical protocol, randomly selected children slept individually in different sentinel houses over nights (12
nights/child) from 6pm to 6am in Soumousso, a village 35 km from Bobo Dioulasso. Following each night, indoor
resting and blood fed Anopheles SP mosquitoes were collected and kept alive in the insectary under ambient conditions.
Oocyst prevalences were subsequently determined on day 7 postfeeding. In parallel, the infectiousness of the same
children was estimated based on whole-blood membrane feeding procedure using An. gambiae that emerged from fieldcollected larvae cohorts. Data from 80 children aged 4–15 years were analysed. After controlling for the background
infection in host seeking mosquitoes, the xenodiagnosis gave significantly higher infection rate (23.6 % vs. 10.4%)
(p<0.05) and oocyst counts (7.4 + 3.2 vs. 3.92 + 1.8) (p = 0.02) than the membrane feeding assay. Overall, the
prevalence of oocysts in wild An. gambiae collected after they had fed on hosts, correlated with the range of values
expected for host infectiousness in the membrane feeding assay. This study suggests that the xenodiagnosis proves to be
an even more convenient, precise and powerful way to estimate host infectiousness.
2.1.4. Genomics
Abstract 12: Bionomic and population genetic structure of the malaria vector AnophelesMoucheti in the
equatorial forest region of Africa: an update
Christophe Antonio-Nkondjio, Cyrille Ndo, Pierre Kengne, Parfait Awono-Ambene, Didier Fontenille, Frédéric Simard
Anopheles Moucheti is a major malaria vector in forested areas of Africa. However, deSPite its important
epidemiological role, it remains poorly known and insufficiently studied. Here, we report data on its bionomics and
population genetic structure using mosquito populations sampled throughout its distribution range in Central Africa. An.
Moucheti samples were collected from Cameroon, the Democratic Republic of Congo, Nigeria and Uganda.
Microsatellite data and rDNA sequences were used to estimate genetic diversity within populations and their level of
genetic differentiation. Bionomic studies consisted on the determination of mosquito epidemiological role, biting habit
and feeding habits. All SPecimens collected in Tsakalakuku (Democratic Republic of Congo) were identified as A. m.
Bervoetsi, those collected in Akaka Nigeria were An. m. nigeriensis while the rest consisted of A. m. Moucheti. High
levels of genetic differentiation were recorded between A. m. bervoetsi, An. m. nigeriensis and each A. m. Moucheti
sample using both microsatellite markers and rDNA sequences. Within An. m. Moucheti samples a low to high genetic
differentiation was detected. Using sequence variation of ITS1 rDNA a diagnostic polymerase chain reaction technique
was set up for a reliable identification of members of this group. An. bervotsi and An.Moucheti were highly
anthropophilic and were found infected by Plasmodium falciparum. High levels of genetic differentiation supports
complete SPeciation of A. m. bervoetsi and An. m. nigeriensis. Much attention has to be given to members of this group
which could support malaria endemicity in areas where An. gambiae is absent or scarce.
Abstract 13: Genetic polymorphism in odorant binding proteins (OBP-olfac) genes between incipient SPecies of
the African malaria vector Anopheles gambiae
P. Kengne, A. Arnal, C. Brengues, H. Bassene, C. Sokhna, D. Fontenille, F. Simard, K.R. Dabire
20
Olfaction plays a critical role in the host-seeking behaviors of insects, and may promote assortative mating between
incipient SPecies. We assessed the level of genetic variability and divergence in gene sequences and encoded peptides
of an Odour Binding Protein (OBP), among sympatric SPecimens of the M and S form of An. gambiae and An.
arabiensis. Mosquitoes were sampled in Dielmo (Senegal) from July to November 2007 and were identified
morphologically as An. gambiae s.l. Genomic DNA was extracted from legs and analysed by PCR to determine the
SPecies and molecular forms. The candidate OBP, LIM, localized on chromosome 2L, was PCR-amplified using
primers designed from the Pest strain genome. PCR products were cloned, sequenced and analyzed in Mega4 and
DNASP. Out of 224 An. gambiae s.l. collected, 38% (n=87) were S form, 11% (n=24) M form, 42% (n=94) An.
arabiensis and 1% (n=3) M/S hybrids. A 1,601bp of OBP gene (6 exons and 5 introns) was obtained from four
mosquitoes in each of the three taxa. The analysis of DNA sequence revealed a high number of polymorphisms
(Pi=0.016; Hd=0.82) and significant genetic structure (Fst=0.98, P<0.01). Among the 48 parsimony informative
mutations observed, eleven were fixed between the M and S forms and distributed over the six exons of OBP. Eight of
them were replacement substitutions, encoding different peptides in the M and S. Consistence of this pattern at a wider
geographical scale and the impact of replacement substitutions on the structure and function of the protein will be
discussed.
Abstract 14: Genetic identification of Plasmodium falciparumparasite virulence markers according to local
populations
Carole Eboumbou, Amadou Niangaly, Ghyslain Mombo-Ngoma, Eric Achidi, Albert Same Ekobo, Peter Kremsner,
Saadou Issifou, Amed Ouattara, Ogobara Doumbo, Christophe Rogier
The mechanisms of the heterogeneous courses of severe malaria (SM) are not clearly understood but are thought to
involve a complex combination of human host factors under the influence of his genetic background and parasiteSPecific factors. Their incidence varies greatly among people and epidemiological conditions. Our aim was to identify
P. falciparum genetic factors associated with pathogenicity in several local populations. We are performing combined
epidemiological, clinical and genetic analysis of more than 60 falciparum isolates from uncomplicated malaria (UM)
and SM cases from three countries (Mali, Cameroon, Gabon). Parasite loci associated with pathogenicity will be
identified using a genome wide gene mapping approach. The P. falciparum genotypes associated with severity and
clinical presentation will be presented. Linkage disequilibrium blocks and susceptibility haplotypes should characterize
parasite genetic factors that are involved in the pathogenesis of SM. These findings could benefit clinical decisionmaking process in allowing early identification of mild clinical cases that are more susceptible to become severe. They
could also generate new hypothesis about the pathogeneisis of SM and suggest new therapeutic approaches.
Abstract 15: Cytokine profile in murine model of pregnancy-associated recrudescence
Rosette Megnekou, Trine Staalsoe, Lars Hviid
Pregnancy-associated malaria (PAM) causes maternal anemia, intra-uterine growth retardation, pre-term deliveries
(PTDs) and low birth weight. Poor pregnancy outcome and placental pathology in humans are associated with cytokine
changes. It is known that pregnant P. berghei K173-infected Balb/c mice develop higher parasitemias unlike nonpregnant, but the etiology is obscure. We used samples from pregnant and non pregnant immune female Balb/c mice. P.
berghei K173 parasitemia was determined microscopically and hemoglobin levels measured using Hemocue. Histology
study for parasite accumulation in different organs was conducted and the cytokine levels measured by luminex assay.
Recrudescence rates were lower during the 2nd than the 1st pregnancy and pregnancy-associated recrudescence
decreased with increasing parity. Hemoglobin levels and the proportion of anemic mice correlated with parity
(P<0.001). Correlations were observed with reSPect to parasitemia (P<0.001 and P= 0.009). There was accumulation of
the parasites in the kidney and placenta. Placental parasitemia was higher (p=< 0.001) than peripheral. In primigravidae,
except for IL-10 (P = 0.16), concentrations of other 5 cytokines correlated with hemoglobin level (P =<0.001).
Correlations were observed with reSPect to parasitemia with the same cytokines (P =<0.001), IL-10 (P =0.23). While
IL-10 decreased with increasing parity (P= 0.004). other cytokines increased (P= <0.001). Elevated IL-10 and decrease
of other cytokines significantly associated with PTDs. lteration in cytokine levels may strongly contribute to poor
pregnancy outcome. Our mouse model reproduces pathogenesis of women PAM and may be useful to study PAMrelated research questions that are difficult to conduct in women.
Abstract 16: Differential recognition of Plasmodium falciparum MSP1-19 antigen by antibodies from subjects
residing in a rural malaria endemic area of South west Cameroon.
D.N. Anong, T. Nkuo-Akenji, S.K. Mbandi, V.P.K. Titanji
21
The aim this study was to establish the profile of immunoglobulin (IgG) antibody isotypes in immune reSPonses in
individuals to MSP1-19 antigen a vaccine candidate. Serum samples from 240 individuals were analysed by ELISA for
the presence of IgG subclasses. Individuals were placed in 3 age groups: 1-5 years, 10-14 years and ≥18 years. Each age
group comprised an equal number of infected and uninfected subjects. In the age group < 5 years and 10-14years the
mean IgG1 and IgG3 levels were significantly higher in those who were positive for malaria when compared with those
who were negative (P<0.0001). In the age group 10-14 years, the mean IgG1 and IgG3 levels of malaria negative
subjects was higher when compared with the mean values of malaria positive subjects and the difference was also
statistically significant (p <0.05).In adults (≥18), although the mean IgG1 and IgG3 levels were higher in malaria
negative adults when compared with malaria positive adults the difference was statistically significant only for IgG1
reSPonses (p< 0.05). Mean IgG2 levels were significantly higher (p<0.05) in positive than in negative individuals in
all age groups. In all malaria positive subjects with fever, there was a negative correlation observed in the mean IgG1
and IgG3 reSPonses with fever while there was a positive correlation between mean IgG2 and mean IgG4 with
fever.These data suggest that immune reSPonses to MSP1-19 are protective and are mainly cytophilic antibodies of the
IgG1 and IgG3 subclasses. This work was SPonsored by WHO/TDR grant 990965 and IPICS CAM-01 project.
Abstract 17: The impact of the current preventive measures on placental malaria parasiteamia and newborn
immune reSPonses at delivery at the district hoSPital of Mfou, an area with stable malaria
transmission in Cameroon
Viviane H.M. Tchinda, Eric A. Achidi, Grace M. Tchinda, Philomina Nyonglema, Josephine Fogako, Nadege Obam,
Ndam Mama, Elisabeth O. Enohtanya, Roger S. Moyou, Rose G.F. Leke
Malaria infection during pregnancy has adverse consequences for both the mother and foetus. This study seeks to assess
the impact of intermittent preventive treatment with sulphadoxine-pyrimethamine (IPT2-SP) in combination with other
preventive measures on placenta parasitaemia and newborn’s immune reSPonses at delivery. Pregnant women who
provided informed consent were recruited during their third trimester and information on use of malaria prevention
methods was documented. At delivery, maternal peripheral blood, placental biopsy and cord blood samples were
collected to determine the presence of malaria parasites and study the functional heterogeneity of CD4+ T cell
(Th1&Th2) in vitro using ELISPOT assay. Maternal and cord plasma were used to determine levels of antimalarial
total IgG by ELISA using crude P.falciparum antigen. A total of 75 pregnant women were recruited into the study. They
included 24(32%) primigravidae and 51(68%) multigravidae. The use of at least one dose of IPT2-SP before delivery
was 96% and 70,7% used IPT2-SP in association with other measures. The prevalence at delivery of peripheral and
placental parasitemia (microscopy&histology) was reSPectively 24, 33.3 and 46.2%. Infected women were significantly
younger (P<0.001) than their non-infected counterparts. They also showed significant lower PCV (P=0.03) and
antimalarial total IgG levels (P=0.047). The ELISPOT assay showed a predominant Th2 reSPonse (higher IL-10&low
IFN-γ) in cord blood from infected and non-infected mothers. These results suggest a high prevalence of both peripheral
and placental parasitaemia at delivery, probably due to the high transmission intensity or lack of efficacy of the
preventive methods used.
Key words: Plasmodium falciparum, Placenta malaria, pregnant women, ELISPOT assay.
2.1.5. Antimalaria drugs
Abstract 18: Clinical Efficacy and Safety of AmodiAQuine+Artesunate (Arsucam) and ArtemetherLumefantrine (Coartem) against Uncomplicated Malaria in Northern Cameroon
22
Ali M. Innocent, Mbacham F. Wilfred, Evehe M. Bebandoue, Akindeh M. Nji, Ndikum Valentine, Netongo M. Palmer,
C. Tagne Jules, Ebong E. Clifford, Brian Greenwood, Geoff Targett
Malaria treatment policy changed to Artemisinin based combinations in 2004 in Cameroon against a backdrop of 6-18%
resistance observed with amodiAQuine. We set out to investigate the efficacy and safety of amodiAQuine +artesunate
(AQ+AS) and artemether-lumefantrine (AL) in a Guinea Savannah with lowlands in northern Cameroon. Three hundred
and twenty children aged 6 to 120 months with acute uncomplicated falciparum malaria were enrolled for the study in
two peripheral clinics in northern Cameroon. They were randomized (240 in AQ+AS and 80 in AL) to receive weight
based doses of each drug over three days. The 2003 W.H.O protocol for evaluating efficacy of antimalarial drugs was
used to classify treatment outcomes. Parasite genotyping was used to distinguish re-infections from recrudescence.
Severity of adverse events was scored using common toxicity tables. 209 and 71 children completed the follow up in the
AQ+AS and AL arms reSPectively. Crude adequate clinical and parasitological reSPonse by day 14 were 98.3% for
AQ+AS and 100% for AL and by day 28, these figures were 96.9% and 96.1% reSPectively. PCR-corrected cure rates
by day 28 were 98.6% for AQ+AS and 97.3% for AL. These results show a non-significant superiority of AQ+AS over
AL. A SAE of a 17months infant resulted in death in the AQ+AS arm with decreased neutropenia and scarification
marks. This was considered unlikely drug-related. Both drugs are efficacious and well tolerated in the study area. This
study demonstrates the non-inferiority of AQ+AS over AL in northern Cameroon.
Abstract 19:IL-22 SNP implications in Clearance of Drug Resistant P. falciparum in Cameroon?
Wilfred F. Mbacham, Evehe Marie Solange, Honoré Ngora, Palmer M. Netongo, Irenee Domkam, Akindeh Nji, Diakite
Mahamadou, Dominic Kwiatkowski, Lisa Ranford-Cartwright, Baldip Khan, Geoff Targett, Brian Greenwood
The ability of the body to clear parasites when given drugs is contingent on a functional immune system yet increasing
reports demonstrate that certain children deSPite their less developed immunity still clear parasites with mutations
mutations that confer resistance to anti-malaria drugs. We therefore set out to determine the relationship of SNPs on
immune molecules among children in Cameroon being administered SP, AQ and SP/AQ. A randomised double-blind
control study in the towns of Garoua, Yaounde and Mutengene in Cameroon amongst 750 children between the ages of
6 and 59 months was performed. Patients were followed up for 28 days and scored using the WHO 2003 protocol.
Molecular markers were investigated by PCR-restriction or the dot blot for mutations on dhfr, dhps, pfcrt and pfmdr.
Allelle frequencies were calculated for 67 SNPs on 17 chromosomes for their possible implication to clear (ACPR) or
not to clear resistant parasites with the triple mutations of pfcrt76T, pfmdr86Y and Pfmdr1042N (TYN). PCR corrected
ACPR for D28 were AQ, 36.4%; SPAQ, 15.4%; SP, 18.1%. One SNP within IL-22 could influence the ability of
children to clear resistant parasites, with a chi-squared p-value of 0.02 and an odds ratio of the C allele of 1.4[95% CI
(OR) of 1.06-1.95; p < 0.05]. IL-22 is a pro-inflammatory cytokine related to IL-10 that is produced by T cells. In
West Africa, a large case-controlled study of 2 haplotypes of the IL-22 was shown to be associated with susceptibility
and resistance to malaria.
Abstract 20:Antiplasmodial activity and phytochemical analysis of volatile extrACTs from Cleistopholis patens
Engler & Diels and Uvariastrum pierreanum Engl. (Engl. & Diels) (Annonaceae)
Fabrice Fekam Boyom, Vincent Ngouana, Eugenie Aimée Madiesse Kemgne, Paul Henri Amvam Zollo, Chantal
Menut, Jean Marie Bessiere, Jiri Gut, Philip Jon Rosenthal.
23
In a search for alternative treatment for malaria, plant-derived essential oils extracted from the stem barks and leaves of
Cleistopholis patens and Uvariastrum pierreanum (Annonaceae) were evaluated in vitro for antiplasmodial activity
against the W2 strain of Plasmodium falciparum. The oils were obtained from the stem barks and leaves reSPectively
with the following yields: 0.23% and 0.19% for Cleistopholis patens; 0.1% and 0.3% for Uvariastrum pierreanum (w/w
relative to dried material weight). Analysis by gas chromatography and mass SPectrometry identified only terpenoids in
the oils, with over 81% sesquiterpene hydrocarbons in Cleistopholis patens extrACTs and Uvariastrum pierreanum stem
bark oil, while the leaf oil from the latter SPecies was found to contain a majority of monoterpenes. For Cleistopholis
patens, the major components were found to be a-copaene, d-cadinene and germacrene D for the stem bark oil and bcaryophyllene, germacrene D and germacrene B for the leaf oil. The stem bark oil of Uvariastrum pierreanum was
found to contain mainly b-bisabolene and a-bisabolol, while a and b-pinenes were more abundant in the leaf extract. The
four oils were active against Plasmodium falciparum in culture, with IC50 values of 9.19 µg/mL and 15.19 µg/mL for
the stem bark and leaf oils of Cleistopholis patens, and 6.08 µg/mL and 13.96 µg/mL for those from Uvariastrum
pierreanum. These results indicate that essential oils may offer promising alternative for the development of new
antimalarials.
Key Words: Cleistopholis patens; Uvariastrum pierreanum; Annonaceae; Malaria; Plasmodium falciparum; Essential
oil; Terpenes
Abstract 21: Antiplasmodial activity of extrACTs from seven medicinal plants used in malaria treatment in
Cameroon
Fabrice Fekam Boyom, Eugénie Madiesse Kemgne, Roselyne Tepongning, Wilfred Fon Mbacham, Etienne Tsamo,
Paul Henri Amvam Zollo, Jiri Gut, Philip J. Rosenthal.
Because the evolution of drug resistance is likely to compromise every drug in time, the demand for new antimalarial
therapies is continuous. Accordingly, a vibrant drug discovery pipeline is needed to help to ensure the availability of
new products that will reduce mortality and morbidity resulting from malaria. To this end, we have carried out an
ethnopharmacological study to evaluate the susceptibility of cultured Plasmodium falciparum to extrACTs and fractions
from seven Cameroonian medicinal plants used in malaria treatment. We also explored inhibition of the P. falciparum
cysteine protease falcipain-2. The majority of plant extrACTs were highly active against P. falciparum in vitro, with
IC50 values lower than 5µg/ml. Annonaceous extrACTs (acetogenins-rich fractions and interface precipitates) exhibited
the highest potency. Some of these extrACTs exhibited modest inhibition of falcipain-2. These results support continued
investigation of components of traditional medicines as potential new antimalarial agents.
Keywords: Malaria; Uvariopsis congolana; Polyalthia oliveri; Enantia chlorantha; Artocarpus communis; Dorstenia
convexa; Croton Zambesicus; Neoboutonia glabrescens; Acetogenin; Antiplasmodial
Abstract 22: Comparative study of the quality and efficiency of artemisinin drug based and artemisia annua
grown in Cameroon.
R.D. Chougouo Kengne, J. Kouamouo, R. Moyou Somo, A. Penge On’Okoko
24
Malaria is the leading cause of death worldwide, eSPecially in the Sub of Saharan Africa. Its treatment has been a
problem because of resistance. The Western part of Cameroon has 33% of counterfeit drugs in the market and Artemisia
annua is a plant known for its antimalarial effect because containing artemisinin. In order to compare the antimalarial
activity of artemisinin from Aartemisia annua and other antimalarial drugs: artesunate and artesunate + amodiAQuine.
The WHO protocol was used. Artemisinin was extracted from the plant using the soxlhet method of extraction of Zao et
al. Identification and determination of artemisinin were done using thin layer and gas-phase Chromatography. The
concentration of artesunate in the drug was determined by protometry. The results of the comparative study showed a
significantly higher sensitivity of artemisia annua concoction (0 % of ETT) compared with that of artesunate (12.5% of
ETT) and the artesunate combined with amodiAQuine (14.30% of ETT). The concoction intake for 7 days was 0% of
ETT, significantly lower than that of 5 days intake (28.5%). Like RTPA, the bi-therapy had a higher sensitivity
(85.70%) than mono-therapy (81.25%). The artemisinin level in A. annua in Cameroon was 1.3%. The RTPA is above
80% for the 3 protocols indicating the absence of warning according to WHO criteria. The concoction of Artemisia
annua is a good treatment of malaria seeing the results. To improve its effectiveness, it must be taken for at least 7 days
or in combination with other antimalarial drugs.
Abstract 23: Efficacy and safety of amodiAQuine+artesunate (arsucam®) and arthemether-lumefantrine
(coartem®) against uncomplicated malaria in the south west province of Cameroon.
Mbacham F. Wilfred, N. Marcel Moyeh, Akindeh M. Nji, Netongo M. Palmer, Brian Greenwood, Jeff Targett
The rapid onset and SPread of parasites resistant to most of the easily available and effective drugs has led to the
implementation of the combination therapy for treatment of uncomplicated malaria. ACTs have been embraced by many
countries without region SPecific evidence based data to support such a move. This study was thus carried out to
determine the efficacy and safety of artesunate plus amodiAQuine (AS-AQ) and Artemether Lumifantrine (AL) in the
South west province. The study was carried out in the Baptist HoSPital in Mutengene. The study recruited children aged
6 months to 10 years with uncomplicated malaria, mono infection with P. falciparum with parasitaemia 1000-100000
parasites per microliter of blood, history of fever or axillary temperature above 37.50C and no severe malaria. Patients
were randomized to take AS-AQ or AL and followed up for 28 days. A total of 280 patients took part in the study and
randomized into one of the two arms. 212 children received the AS-AQ and 68 received the AL. both combinations
were well tolerated and effected rapid fever and parasite clearance. The ACPR were 95.39% (n=181) for AS-AQ and
92.86% (n=52) for AL. these findings provide enough evidence that both drugs are very effective and well tolerated by
the age group under study.
2.1.6. Malaria treatment and control
Abstract 24: The efficacy of malartin/sulphadoxine-pyrimethamine (fansidar) combination in the treatment of
uncomplicated falciparum malaria in a rural setting of the mount Cameroon region
Helen Kimbi, Theresa Nkuo Akenji, Mesame Ntoko, Nelson Ntonifor, Emmaculate Lum, John Egbe
25
The WHO now recommends the use of artemisinin-based combination therapy in the treatment of malaria in order to
slow down the development of drug resistance against the parasite. The aim of this study was to assess the in vivo
efficacy and tolerability of a combination of Malartin (artesunate) and Fansidar in the treatment of uncomplicated
falciparum malaria in Dibanda, a rural setting in Southwest Cameroon. 197 subjects were recruited into the study, after
meeting the inclusion criteria. They were then administered the appropriate doses of the drugs for 3 days and followed
up on days 3, 7 and 14. A total of 174 subjects were successfully followed-up. The drug combination was effective in
clearing parasitaemia, fever and improving on the anaemia status of the patients. The overall success rate (ACPR) was
92.5% (161/174), and therapeutic failure was experienced in 07.5% (13/174) of the subjects. Parasite density decreased
during the follow-up period in the different age groups and sexes. The prevalence of anaemia was 23.0 % at enrolment
and decreased to 10.0 % on day 14. The drug combination was well tolerated as most of the side effects were selflimiting and disappeared by day 14. This study demonstrated that a combination of Malartin and Fansidar is effective
and well tolerated in the treatment of uncomplicated falciparum malaria in this part of Cameroon. This confirms that
artemisinin derivatives remain very potent and rapidly acting antimalarials to which the malaria parasite has not yet
developed resistance.
Abstract 25: Lipid peroxidation and variation of some antioxidant enzymes and major antioxidant vitamins in
Plasmodium falciparum malaria infected patients.
Z. Ndongmo, S. Tiyong Ifoue, W. Abia, I. Gouado
Malaria infection is accompanied by increase production of reactive oxygen SPecies (ROS) that are produced both by
the parasite and the human host. This production of ROS leads to the induction of an oxidative stress on the host cells.
These biochemical injuries caused by oxidative stress represent a key factor in the physiopathology of malaria. The
measurement of the activity of antioxidant enzymes as well as the status of antioxidant vitamins may give the possibility
of a SPecific prevention of malaria based on nutrition.The objective of this work was to investigate the possible
alterations in antioxidant enzymes superoxide dismutase (SOD) and Catalase, and in some major antioxidant vitamins
(E and C). Plasma Thiobarbituric acid reactive substances (TBARS) were quantified as malondialdehyde (MDA) level.
Activities of SOD and catalase were measured and the Total antioxidant capacity (TAC) was estimated to determine the
status of the antioxidant vitamins. Plasma MDA level was significantly increased in malaria patients compared to
controls. Activities of SOD and catalase as well as the antioxidant vitamins E and C were decreased significantly in
malaria patients when compared to healthy controls. The general depression in antioxidant levels in malaria patients
suggest that nutritional improvements of antioxidant capacities may be a therapeutical strategy to prevent the occurrence
of oxidative stress and thus a concomitant decrease in severity of malaria. Hence, a significant reduction of the risk of
lost of the over 2 million lives to malaria in sub-Saharan Africa every year.
Abstract 26: The CyScope®-DAPI fluorescence microscopy can considerably improve malaria diagnosis
Leopold Gustave Lehman, Jürgen Weidner, Hervé Nyabeyeu Nyabeyeu, Christian Ngouadjio Nguetse, Asah Humphrey
Gah, Wolfgang Göhde
26
Rapid and accurate parasite based diagnosis is important for a prompt management of malaria in both endemic and nonendemic areas. 248 blood samples of patients with presumptive malaria after medical consultation were analysed on a
4’,6-diamidino-2-phénylindole (DAPI) pre-coated slide using a novel compact fluorescence microscope CyScope®. The
study took place from December 2008 to February 2009 in four medical centers of Douala-Cameroun to compare the
CyScope®-DAPI fluorescence microscopy technique (CyScope®-DFMT) to May Grünwald-Giemsa stain, a recently
introduced immunochromatographic-based test and qRT-PCR. The sensitivity was calculated by taking into account
positive PCR results as gold standard. Plasmodium falciparum was the unique SPecies identified. 80% of PCR-positiv
samples were positiv with the CyScope®-DFMT. The Giemsa stain showed a sensitivity of 60 % and the
mmunochromatographic-based test 43%. As compared to the CyScope®-DAPI, only 49 % of the samples were also
positive after Giemsa staining. This study shows that the CyScope®-DAPI fluorescence method can be used for the
screening of people with low malaria parasitaemia and for routine diagnosis as a better alternative to standard
microscopy and RDTs.
2.1.7. Vector biology and control
Abstract 27: Altitudinal and latitudinal variations in SPecies composition of Anopheles gambiae complex
(DIPT2era: Culicidae) along the volcanic Line of Cameroon
Timoléon Tchuinkam, ESPerance Lélé-Défo, Billy Téné-Fossog, Samuel Wanji, Etienne Fondjo, Mpoame Mbida,
Frédéric Simard, Didier Fontenille
Cameroon is considered as Africa in miniature and one main reason of this assertion is that it diSPlays from the
southern tropical humid forest to the northern arid savannah, a gradient of ecosystems and facies. The country therefore
offers excellent opportunity to study variations in the sibling SPecies within Anopheles gambiae complex. Mosquitoes
were collected in three geographical regions along the Cameroon Volcanic Line, characterized by their topography: the
Mount Cameroon region, the Bamileke plateau and the Mandara-Kapsiki Mountains. In each of these zones, An
gambiae sl was sampled over an altitudinal transect by: dipping, human landing and pyrethrum SPray catches. DNA of
SPecimens were extracted from legs, amplified in a PCR-rDNA and identified to sibling SPecies. A PCR-RLFP was
performed to distinguish between molecular forms M/S of An gambiae ss. Two members of An gambiae complex were
detected at Debundscha coast in Mount Cameroon region: 93.2% An gambiae ss (100% of M molecular form), and
6.8% An melas. Only An gambiae ss was found at midway, both in Mutengene where M and S molecular forms were
present at comparable rates (45.8% and 54.2 reSPectively), and in Meanja with a higher rate for S form (87.5%).
DeSPite of the sympatry of the two molecular forms here, no hybrid was found. Uphill at Likoko and Ewonda, An
gambiae ss was still the single SPecies, but with 100% of S molecular form. There was homogeneity in the composition
of An gambiae complex on the Bamileke plateau, as all SPecimens were detected to be An gambiae ss, with high
predominance of about 98% of S molecular form in the plain of Santchou and on the plateau of Dschang, but 100%
uphill at Djuttitsa. In the Mandara-Kapsiki Mountains there was again two sibling SPecies An gambiae ss and An
arabiensis, with a predominance of An arabiensis both in lowland of Godola and at the elevated site of Mokolo, 60.3
and 93% reSPectively. The S molecular form of An gambiae ss was present in higher rate, 85.7 and 96% in Godola and
Mokolo reSPectively. An melas was found at the lowest altitude and latitude point in tropical humid forest, although at
a low rate and in sympatry with An gambiae ss, but disappeared relatively quick as we moved away from the sea coast ,
confirming thus that larvae stages of this SPecies are definitely adapted to sea water. The M molecular form of An
gambiae ss was widely SPread in this southern tropical forest and was progressively substituted by the S form as we
moved farther both latitudinally within the continent and altitudinally at the same geographical region. The absence of
hybrid of molecular forms at Mutengene indicates a completion of the SPeciation. The ecological conditions here seem
to be appropriated for the two molecular forms. The S form was widely adapted to the savannah region of the continent
and progressively replaced by An arabiensis upwards and northwards. An gambiae sl exhibited an adaptive flexibility in
reSPonse to environmental and climatic changes, in the form of genetic variations, both latitudinally and altitudinally,
with a ratio of altitudinal changing distance 1000-fold the latitudinal one, and giving successively: An melas, An
gambiae ss –M, An gambiae ss-S and An arabiensis. The nature of the selection pressures is still to be determined at the
different changing points.
Abstract 28: Distribution and larval habitat characterization of AnophelesNili and An.Moucheti along river
networks in southern Cameroon
27
Christophe Antonio-Nkondjio, Cyrille Ndo, Carlo Costantini, Parfait Awono-Ambene, Didier Fontenille, Frédéric
Simard
DeSPite their importance as malaria vectors in central Africa, little is known on larval ecology of Anopheles Nili and
An. Moucheti. We explored the SPatial distribution of their larval habitats and associated environmental parameters
along river systems in Cameroon. Larvae were collected by dipping in 24 locations across the dense hydrographic
network of southern Cameroon. Larval habitats were characterized visually and by the use of hand-held electronic
probes for physical water parameters measurements. Detrended CorreSPondence Analysis (DCA) and Canonical
CorreSPondence Analysis (CCA) were used to determine key ecological factors associated with mosquito distributions.
A total of 2269 anopheline mosquito larvae at the late instars were collected, including An.Nilis.s. (47.4%), An.Moucheti
(22.6%), An. carnevalei (5.6%), An. ovengensis (2.9%) and An. somalicus (0.1%). Five environmental variables were
significantly associated with SPecies’ distribution and abundance: river flow (lotic/lentic), sunlight exposure
(sunny/shady), vegetation (presence/absence), temperature, and debris (presence/absence). Using CCA, it appeared that
lotic rivers, exposed to sunlight, with vegetation or debris were the best predictors of An.Nili larval abundance, whereas
An. Moucheti and An. ovengensis were associated with lentic river flows, lower temperature, and floating vegetation.
The distribution of An. Nili conforms to that of a generalist SPecies that is able to exploit a variety of environmental
conditions, whereas An. Moucheti, An. ovengensis and An. carnevalei appear as more SPecialized forest mosquitoes.
Abstract 29: Estimation of infection rates and entomological inoculation rates (EIR), in the
malaria vector: when should CSP-ELISA be the ultimate?
African
J.D. Bigoga, L. Manga, R. Leke
Although CSP ELISA is considered as standard by most laboratories for infectivity and EIR determination, it is widely
known to overestimate CSP rates. However, in many studies particularly in Africa the results are further confirmed
using PCR, which is costly and expertise demanding. This study proposes a thresh hold cut-off value for positive CSP
ELISA that should not require further confirmation by PCR. Indoor resting mosquitoes collected during three months in
Douala, were comparatively assayed for P. falciparum infection using three methods (classical salivary gland
dissections, CSA ELISA confirmed by PCR and the Vectest) and EIR determined. CSA ELISA SPecimens were
assayed in three batches and the cut-off positive values for optical density (OD) readings taken at OD+2SD, OD+3SD,
and at OD+4SD reSPectively. Positive ELISA SPecimens were re-examined by PCR. The CSP rates by ELISA and
Vect test were similar (5.8% and 7.5% reSPectively). Both methods were comparable in identifying P. falciparum CSA
in mosquitoes. However, ELISA was more sensitive with regards to the number of infections detected. All positive CSP
ELISAs at OD+4SD were PCR positive while there was a 50% decrease in PCR compared to ELISA at OD+2SD and
25% decrease at OD+3SD. The findings suggest that cutoff values for CSP ELISA set at OD+2SD are largely prone to
producing false positive infections. However, cut off values set at OD+4SD is tantamount to obtaining PCR positive
results on the mosquitoes and should therefore not warrant PCR confirmation.
Abstract 30: Field evaluation of three commercial repellent formulations against malaria mosquitoes of a forest
area in Cameroon
P. Nwane, J. Etang, C. Costantini, F. Batomen, C. Antonio-Nkondjio, R. Mimpfoundi, I. Morlais, F. Simard
28
Application of repellents to the skin is a common personal protection practice for preventing mosquito-borne diseases.
Here, we tested the efficacy and persistence of three commercial repellent formulations against the bites of malaria
vectors. The study was conducted in a suburban village near Yaoundé. Four target doses (0.1mg/cm²; 0.3 mg/cm²;
0.6mg/cm² and 0.8mg/cm²) of each repellent ie 30%DEET (Buzz-Off™) and 25%IR3535 (Cinq-sur-Cinq™ and
Prébutix™) or 90% ethanol as control were applied on the legs of volunteers who performed human landing catches to
determine repellent efficacy. Effective dosages and persistence of each repellent were estimated by fitting a logistic
plane model. A total of 2,072 malaria mosquitoes were collected during 48 tests nights: An. gambiae s.s (7.8%), An.
Funestus (8.5%), An. Moucheti (45.8%), An.Nili (18.7%) and An. ziemanni (19.2%). After 8h exposure to mosquito
bites, percentages of repellency provided by each of the three formulations were quite variable, ranging from 20 to 80%.
Because of sample size constraints, the effective dosages and persistence were estimated only for An.Moucheti. The
median and 95% effective dose (ED50 and ED95) estimates of the IR3535-based repellents were lower than those of the
DEET-based formulation. The estimated effective half-lives for the IR3535-based repellents were between 3.1 and 3.6
hours. Our results confirm the heterogeneity in the reSPonse of malaria mosquitoes to insect repellents, showing the
relevance of evaluating efficacy and persistence profiles of different formulations in SPecific environmental contexts.
Abstract 31: PrediSPosed to adapt? Urbanization and diversification of Anopheles gambiae in the African
equatorial forest
Colince Kamdem, Frédéric Simard, Joachim Etouna, Franc¸ ois- Xavier Etoa, Didier Fontenille, Nora J. Besansky,
Carlo Costantini
Humans represent the most disruptive biotic selective force on earth, by altering virtually every environment at
unprecedented rates and extent. Our interest lies in understanding how such profound modifications of natural
ecosystems contribute to the ecological, behavioural, and phylogenetic diversification of mosquitoes, and ultimately to
the creation of new SPecies, with particular reference to members of the Anopheles gambiae cryptic SPecies complex,
the most important vectors of human malaria in Africa. Such knowledge will be important for developing better
strategies to control malaria transmission, and to predict the epidemiological impact of global changes in humandominated ecosystems. We have used ecological niche modelling; combining geoSPatial SPecies data with layers of
remotely sensed environmental data and logistic regression in a Geographic Information System to investigate the
causal link between divergence on low-dimensional niche axes and SPeciation. We demonstrate the existence of a link
between ecological divergence and adaptive SPeciation within the nominal taxon of the complex, Anopheles gambiae
Giles sensu stricto (DIPT2era: Culicidae), driven by the recent transformation of the African equatorial forest due to
urbanization. Adaptation of incipient SPecies to the novel urban ecosystem might progressively change the degree of
exposure of the human population to malaria vectors, thereby affecting the epidemiology of malaria in this ecogeographical domain.
Email address for correSPondence: kamdem [email protected]
Abstract 32: SPatial distribution and dynamics of Anopheles gambiaesl larval habitats in the city of Yaoundé,
central Cameroon
Billy Tene fossog, Christophe Antonio-Nkondjio, Phillipe Bousses, Collince Kamdem, Nora J. Besansky, Frederic
Simard, Carlo Costantini
29
Increasing urbanization in Africa refocuses the attention of public health managers on urban malaria and begs the
question of whether the vectors can adapt to the environmental conditions encountered in the most densely populated
cities. A longitudinal survey was conducted in the town of Yaoundé, in the forest domain of central Cameroon, to assess
the distribution of An. gambiae s.l. larval habitats and its relation with human activities. Larval habitats were examined
monthly from May to December 2008 during the course of one week in 16 neighborhoods ranging from the centre to the
rural outskirts of Yaoundé. Mosquito larvae were sampled by dipping. Larval habitats were characterized based on size,
type of breeding site, water quality, location, and their relation with human activities. A total of 2449 potential mosquito
breeding sites were examined: 482 (19.7%) contained An. gambiae s.l. larvae. Anopheline larval habitats were more
abundant in urban than in rural or periurban areas. Large drains, swamps and gutters were associated with no or low
larval densities. Human activities such as market gardening, house construction in swampy areas and road construction
were associated with potential breeding sites for An. gambiae. Unexpectedly, anopheline larvae were collected in urban
breeding sites highly polluted with organic matter. PCR identification revealed that only the M molecular form of An.
gambiae was present in the most urbanized areas, where the S molecular form was the most abundant in periurban and
rural sites. These findings confirm that the malaria vector An. gambiae s.s. is adapting to the urban environment, and
clearly partition the distribution of An. gambiae s.s. molecular forms M and S between urban and peripheral or rural
areas.
Abstract 33: Bionomic and population genetic structure studies on AnophelesNili group of malaria vectors in
Africa
Cyrille Ndo, Christophe Antonio-Nkondjio, Parfait H. Awono- Ambene, Diego Ayala, Anna Cohuet, Pierre Kengne,
Pierre Ngassam, Isabelle Morlais, Didier Fontenille, Frédéric Simard
Mosquitoes belonging to the AnophelesNili group are recognized as important human malaria vectors in tropical Africa.
However, deSPite their important epidemiological role, few studies have been conducted on this SPecies. Here, we
report data on bionomic and genetic studies from vector populations collected in Central and West Africa. Mosquito
blood feeding preferences and infectious status were determined by ELISA. Eleven microsatellite loci were used to
compare the level of genetic diversity and differentiation between 16 populations from Cameroon, Senegal, Burkina
Faso, Ivory Coast, Nigeria and Democratic Republic of Congo. An. Nili was found to be highly anthropophilic and
exophagic and was the only member of the group collected above Cameroon. Conversely, An. ovengensis and An.
carnevalei were highly exophagic and exophilic. All these SPecies were found infected by Plasmodium falciparum, with
Is ranging between 0.7 to 6.1. All 11 microsatellite loci were successfully amplified within An. Nili samples while 8 and
9 loci were amplified in An. carnevalei and An. ovengensis populations reSPectively. Allelic richness and
heterozygosity were high for all An. Nili populations but low for An. carnevalei and An. ovengensis. High and
significant pairwise genetic differentiation estimates were recorded between An. Nili, An. carnevalei and An. ovengensis
populations (0.19≤Fst≤0.53, P<0.001). Within An. Nili, populations from Kenge (DRC) and Moloundou (Cameroon)
appeared more differentiated from the rest.This study confirms An. Nili as an important human malaria vector in Africa.
Genetic structure analysis fully support morphologic descrIPT2ions and provide further evidence for recent taxonomic
classification within this group.
Abstract 34: Kdr based insecticide resistance in Anopheles gambiae from Cameroon;origin, SPread and level of
resistance
Josiane Etang, Jose L. Vicente, Philippe Nwane, Mouhamadou Chouaibou, Isabelle Morlais, Virgilio E. Do Rosario,
Frederic Simard, Parfait Awono-Ambene, Jean Claude Toto, Maureen Coetzees, Joao Pinto
30
Knockdown resistance (kdr) mutations in Anopheles gambiae s.s. populations from Cameroon were first reported in
2003. This report questionned of the origins, SPread and levels of insecticide resistance induced in the local mosquito
populations. Surveys were conducted between 2005 and 2007, to (1) update the geographic distribution of kdr genes and
their ellelic frequencies, (2) to assess the levels of conferred resistance and explore the number of mutational events
originating kdr alleles. Females Anopheles gambiae s.l. were sampled, from 17 sites located across the main geographic
areas and used for molecular analysis: SPecies and molecular form identification, kdr depiction and sequencing of
intron 1 of the voltage gated sodium channel gene. Adults from larvae collections were use for WHO susceptibility
tests. Both 1014S and 1014F kdr alleles were widely distributed in the S-form (frequencies up to 0.87). They were also
found in the M form, but at lower frequencies (0.02-0.4). Most of the populations showing high frequencies of kdr
alleles diSPlayed high level resistance to DDT and pyrethroids. Bio assays using synergists (4% PBO, 8% DEM, and
0.25% DEF) highly suggested co-involvement of detoxifying enzymes (oxidases, esterases or glutathione Stransfersases). Analysis of a 455bp region of intron-1 upstream the kdr locus revealed four independent mutation
events originating kdr alleles, as well as evidence for mutual introgression of kdr 1014F allele between the two
molecular forms. This study emphasized the ongoing process of kdr resistance in Cameroon and call attention to a better
management of insecticide resistance.
Key words: Anopheles gambiae, intron-1, insecticide resistance, mutations, malaria, Cameroon
Abstract 35: C - Reactive Protein Levels, Microcytemia/Hypochromia and ReSPonse to Antimalarials in
Yaounde – Cameroon
Justin Komguep, Olivia Achonduh, Priscille Flore Kanouo, Palmer Netongo, Akindeh Nji, Irenée Domkam, Sarah
Riwom, Wilfred Mbacham
As an acute-phase reactant, C-reactive protein (CRP) levels can provide a simple measure of disease severity, the
efficacy of therapy and the severity of complications. Hemoglobin “Constant SPring” mutation (16p13.3 - α2,
TAA142CAA) is one of the most wide-SPread α-thalassemia variant with a relatively severe impact on the homozygous
carrier and an in vitro decreasing effect on the sensitivity of malaria parasites, infecting the erythrocytes with such
carrier. The relationship between levels of CRP, presence of Hb “CS” mutation and reSPonse to antimalarials in patients
recruited at the same site for monotherapy and artemisinin –based clinical trials reSPectively was determined. D0 serum
from 180 malaria patients recruited for SP/AQ clinical trial was evaluated for levels of CRP using immunoturbidimetric
kits. Human genomic DNA extracted from 46 patients recruited for COARTEM® and COARINATE®) clinical trial on
the basis of the persistence of microcytemia (MCV<86 fl) and hypochromia (MCH<27 pg) was analyzed by PCR-RFLP
to detect the presence of the Hb « CS » mutation. There was no significant correlation between CRP levels, the age of
patient, parasitaemia and temperature on D0 and D3 (p=0.05). However, the level of CRP was observed to vary slightly
with temperature above 39°C on D3 after treatment. Of the two (4.35%) patients who showed heterozygoty for the Hb «
CS » mutation, none of these was associated with a particular treatment reSPonse (p >0.05). Absence of correlation
could be due to interaction with other factors which influence inflammatory reSPonse during an infection.
2.1.8. Malaria vaccines
Abstract 36: Analysis of T-cell reSPonses against UB05 and synthetic peptides of Plasmodium falciparum
Melvin A. Ambele, Fidelis Cho-Ngwa, Peter Nde Fon, Eric Ngalle Mbua, Stanley K. Mbandi, Ivo A. Foba, Kingsley G.
Nchamukong, Rubin Wang, Vincent P.K. Titanji
31
An important drawback in developing a suitable vaccine against malaria has been the incomplete knowledge of the
mechanisms underlying protective immunity against the disease. In a given endemic area, not all exposed adults living
normal lives are susceptible to malaria attacks to the same extent. Semi-immune individuals may be recognizing
antigens different from, or in a way different from the recognition by the less immune ones. we therefore undertook to
describe the T cell IFN-γ production patterns of two cohorts of individuals with different degrees of susceptibility to
malaria following stimulation by a number of malarial antigens. Peripheral Blood Mononuclear Cells (PBMCs) from
parasitized and semi-immune randomly selected adults from Bolifamba, a hyper endemic area in Fako Division,
Cameroon, were stimulated with a P. falciparum recombinant antigen UB05 (Gene Bank ID DQ235690), synthetic
peptides (PCS48, D43) and P. falciparum crude extrACTs at 10 μg/ml in Human Interferon-γ ELISPOT PRO assays
(MABTECH, Sweden). Samples were incubated for 61 hours (5% CO2, 37◦C) and the developed SPots counted using
an AID ELISPOT reader at the Biotechnology Unit of the University of Buea. The data were analyzed using SPSS for
windows, version 11.5 (SPSS Inc. Chicago, IL, USA) and Microsoft Excel programme. Differences in group means
were analysed using the Mann-WhITNey U test. Statistical significance was set at p≤ 0.05. Semi-immune individuals
produced consistently more IFN-gamma in reSPonse to all the malarial antigens tested compared to their parasitized
counterparts. Mean parasite density decreased with age. There was positive correlation between the stimulatory indices
for UB05 (r = 0.44), PCS48 (r = 0.62), D43 (r = 0.28) and P. falciparum crude extract (r = 0.69) of semi-immune
individuals and the duration after last malaria attack. By contrast, no correlation was observed between the stimulatory
index and the duration after last malaria attack or parasite density in parasitized subjects. This study showed that: 1)
Higher levels of IFN-γ production in reSPonse to parasite antigens may be reSPonsible for higher resistance to malaria
attacks by some individuals living in hyper endemic areas. 2) UB05 and the synthetic peptides (PCS48 and D43) are
potent T-cell stimulators and could be potential T-cell relevant vaccine candidates for malaria. 3) Positive correlation
between stimulatory indices and duration after last malaria attack means higher levels of this cytokine mediate
protection against malaria supporting the idea that this cytokine mediates immune protection to this disease.
2.1.9. Health research ethics
Abstract 37: The Declaration of Helsinki (2008): What researchers in Africa should note
Godfrey Tangwa
Another version of the Declaration of Helsinki (DoH) has recently been adopted in Seoul, South Korea, on 11 October
2008, by the 59th General Assembly of the World Medical Association. Although the buildup to this eighth revision of
the DoH was not as noisily contentious and controversial as that of its immediate predecessor in 2000, the very same
issues were at the background and it is already evident, given the various reactions to the new version of the
Declaration, that these issues have not, perhaps cannot, be laid to rest once and for all. In this presentation, I will
highlight what is new in the 2008 version of the DoH by comparison with the 2000 version and then draw attention to
the underlying issues which have conditioned reactions and attitudes to Helsinki 2008. I will argue that the main
contentious issues in this version of the DoH remain connected with Articles 29 and 30 of the 2000 version and that this
explains why a body like the US Food and Drug Administration (FDA) has quietly withdrawn from the DoH in
preference for the ICH-GCP. These issues particularly concern industrialized world research in the developing world,
particularly in sub-Saharan Africa. I will conclude by underlining the de facto moral authority of the DoH around the
world and pointing out that, in SPite of possibly misleading language and inevitably ambiguous expressions, which are
present in nearly all the paragraphs of the Declaration, that simple good will is enough to graSP the categorical ethical
imperative in each of the guidelines of the Declaration as it is, without further complicating and obscuring them with
needless rewordings and clarifications. In my understanding, the Declaration is not meant to be a thumb book of
practical rules for medical research but rather a set of abstract ethical principles that can effectively guide practice and
actions.
Abstract 38: The Scope of Misconduct in Scientific Research
C. Chi Primus
32
In the past two decades, the volume of scientific research carried out in Africa has been on an increasing scale. In
designing and implementing these researches, the inclusion of fundamental ethical principles remains an essential
ingredient. However, the vast majority of scientists doing research have had no formal training in research ethics. This
growing volume of research carried out by scientists with little or no formal training in research ethics has engendered a
serious and widely acknowledged ethical issue of scientific misconduct; the violation of the standard codes of scholarly
conduct and ethical behaviour in professional scientific research. The ethical issue of scientific misconduct cuts across
all the categories of scientific research; be it physical, chemical, biological or otherwise. Although scientists generally
acknowledge that scientific misconduct is unethical, experience has however shown that there is some disagreement on
their appreciation of the scope of scientific misconduct. The paper will diligently address the conditions favouring the
practice of scientific misconduct as well as the consequences, detection, management and prevention of this unethical
practice. Furthermore, online resources offering free training courses on research ethics will equally be provided.
Materials for the paper will be obtained from the review of training curricula on research ethics, scientific publications,
codes of ethics of professional scientific organizations and other online resources. It is hoped that the paper will
sensitizes young scientists on the scope of scientific misconduct and nurture within them a culture of integrity in
scientific research.
Email address for correSPondence: chi [email protected]
2.1.10. Socio-economic aSPects
Abstract 39: Communication for behaviour change and investigative journalism training on malaria reporting
reveal low bed net use in Bafut, Cameroon.
Wain Paul Ngam, Pierre Fongho Suh, Tsagmo Yves, Tamsa Antoine, Esther Tallah
Communication for behaviour Change remains a difficult reality for developing nations that must achieve the most
impact with the least means. It is evident for HIV/AIDS patients that behaviour is everything with managing the
disease. For malaria it is seldom perceived as such deSPite the incomplete use of drugs, the non use of bed nets and
presumptive therapy. With the establishment of the Cameroon Media Against malaria, we set out to train journalist on
malaria reporting in Cameroon CAMAM was created in 2007, as an offshoot of the Cameroon Coalition Against
Malaria (CCAM), a brain child of the GSK/Malaria Consortium SPonsorship. Training on basic concepts in malaria
epidemiology and disease management, was done through workshops and monthly malaria press clubs. Journalist
further developed questionnaires on various topics and went out for investigations. The association has about 203
members SPread across 10 provincial chapters. 90 journalists have been trained. Media reporting on malaria rose by
30% within the public institutions and by 10% in the private sector between 2006 and 2008. Investigation of bed net
use in the Bafut health district of the NW region of Cameroon revealed that 87% of the interviewed population (n=297)
knew of bednets, 52% possessed them and 29% used them. Low use of bed nets warrants that communication for
behaviour change be intensified to achieve better use of these interventions.
Abstract 40: The social constrains of Direct Observed Treatment for pregnant women. A research from private
non-for-profit health facilities (Far North region of Cameroon)
Estelle Kouokam Magne
33
In Cameroon, one of the local strategies is the promotion of the direct observed treatment for the pregnant women. The
purpose of this research was to examine relationships between the public and the private sector of the health system.
The intermittent preventive treatment is one of the elements of this partnership. We made our fieldwork in religious
related health services situated in Sir and Mayo-Ouldémé, villages of the region of Far North from 2006 to 2007. The
tools were semi-structured interviews and direct observations. We had interviews with 10 caregivers in charge of
antenatal care on their experiences on Direct observed treatment and in depth interviews with 80 the pregnant women.
During antenatal clinics, women are supposed to swallow the Sulfadoxine–Pyrimethamine. Women come far from the
health center and they let their home before 07 AM. They do not have the time to take their breakfast. Regarding their
experience on women complains of side effects, caregivers prefer to give the medicines for home care. The direct
observed treatment should fit the diet habits of users. In addition, the dialogue between public-private sectors of the
health system is necessary to minimize the burdens of Malaria amongst pregnant women.
2.2. Malaria parasites and vectors resistance
The road to a sustainable malaria control and eradication is very perilous, with numerous
impediments; an environment (vegetation and climate/micro-climate) conducive for disease
development, parasite and vector resistance to drugs and insecticide reSPectively. Various
epidemiological studies have so far given a picture of what the state of parasite and vector resistance
in Cameroon looks like.
2.2.1. Malaria Parasite Resistance
Chloroquino-resistant Plasmodium falciparum is now wideSPread in Africa, and antifolate-resistant
P. falciparum is emerging in some regions (WHO, 2005). Cameroon, like many other countries, had
been forced, following the increasing resistance of chloroquine (Mbacham et al., 2005) (Figure 11),
to adopt AmodiAQuine and Sulphadoxine-pyremithamine as first- and second- line drugs in 2002
and 2004, reSPectively. Unfortunately the fall of the cure rate of the latter (AmodiAQuine and
Sulphadoxine-pyremithamine or Fansidar) were proven to deteriorate (Mbacham et al., 2005)
(Figure 12) as monotherapies in five study sites of Cameroon. In this view there was therefore an
increasing need to shift this time to the adoption of combination therapies in 2004 with ArtesunateAmodiAQuine (AS-AQ, Co-Arsucam™) as 1st line drug treatment and in 2006 with Arthemeter-
Lumefantrine (AM-LM or AL, Coartem®) as alternative therapy. Monitoring of drugs resistance is
of crucial importance to the anticipation of massive treatment failures and a rapid surge in morbidity
rate.
Molecular markers screening and characterization, and evaluation of drug efficacies
(assessment of clinical and parasitological reSPonses to drug treatment in malaria infected patients)
are available methods for describing the epidemiology of drug-resistant Plasmodium falciparum.
The second approach is used to measure the cure rate. Both approaches have been used in
Cameroon to determine the distribution of markers of resistance across the country as well as drug's
efficacy patterns indiSPensable for an effective treatment policy and for the determination of
alternative drugs.
34
Figure 11: Antimalarial Drug Resistance in Cameroon (CQ and
MQR).RED BAR (CQR, 2002),GREEN BAR(MQR, 1985),
CQR: Chloroquine resistance, MQR: Mefloquine resistance (Mbachamet al.
2005).
35
Figure 12: Rising resistance to SP and AQ in Cameroon. GREEN BAR
(AQR, 2005), BLUE BAR (SPR, 2005),
AQR: AmodiAQuine rsistance, SPR: sulfadoxine-pyrimethamine resistance
(Mbachamet al. 2005).

Parasite resistance assessed with molecular makers
Biomarkers such as dyhydropteroate Synthase (Dhps), dihydrofolate reductase (Dhfr), Plasmodium
falciparum chloroquine resistance (Pfcrt), and Plasmodium falciparum multidrug resistance (Pfmdr1) are
commonly used to assess the efficacy or the degree of resistance of antimalarials drugs. In fact,
occurrence of SNPs (Single Nucleotides Polymorphisms) within these genes (biomarkers) is reSPonsible
for the resistance to antimalarials drugs. Sulfadoxine-Pyrimethamine which is still recommended for
Intermittent Preventive Treatment in pregnancy (IPT2p) and Intermittent Preventive Treatment in infancy
(IPT2i) in some regions of Africa is a combination of two antifolates compounds that act at two sites of
parasite's folate pathway. It has been used as a substitute to choloroquine. Sulphadoxine inhibits
36
dihydropteroate synthase (dhps) gene, whereas Pyremithamine inhibits dihydrofolate reductase (dhfr)
gene in the folate pathway of the parasite. This combination ACTs in synergy. Resistance to this therapy
is due to the accumulation of mutations (SNPs) in codons 108, 164, 59 and 51 (Plowe et al. 1996). These
mutations alter the configuration of the active site and consequently reduce the affinity for active
compound. Dhfr mutations can be SPecific or interact with dhps codon 437 and initiate resistance to SP.
A plethora of studies have considerably reported on resistance to drugs such as chloroquine (CQ),
Quinoline, Mefloquine (MQ), Artemisinins, AmodiAQuine (AQ), Lumefantrine (L), Quinine etc.
associated with SNPs in these markers. It was noticed that Pfcrt 76 T is highly associated with CQ
resistance (Lopes et al., 2002) and Pfmdr1 86N to MQ and lumefantrine (Sisowath et al. 2005). Djimde et
al. (2001) reported Pfmdr1 86 Y as an important modular for CQ resistance; the mutation does not itself
confer resistance to CQ. Other mutations, namely Pfmdr1 184 F and 1246 Y, have also been reported to
be highly associated with increase resistance to CQ (Foote et al. 1990).
In Cameroon, the mutations profile of these markers, notably Pfcrt and Pfmdr1 has been done in
three sites namely Garoua, Yaounde and Limbe (Mbacham et al. ManuscrIPT2 in prep). Results showed
that mutations in Pfmdr1 86 Y/ 184 F and Pfcrt 76 T predominated in the three sites with the exception of
Pfcrt 76 T and Pfmdr1 86 Y less marked in Garoua. AmodiAQuine resistance (AQR) was also less
marked in the three study sites and the Pfmdr1 1246 Y mutation was very low (Figure 13). The following
observations were made:

The triple IRN mutation could not be conveniently associate to treatment failure

Presence of Pfcrt 76T in parasite was not associated with AQSP or AQ failure

Presence Pfmdr-1 86Y was not associated with AQSP or AQ failure

Presence of Pfcrt 76T plus Pfmdr 1 86Y (TY) in parasite was not associated with AQSP or AQ
failure

Presence Pfmdr 1 86Y plus Pfmdr 1 184F plus Pfmdr 1 1246Y (YFY haplotype) mutations in
parasite was not associated with AQ or AQSP failure.
37
Figure 13: Pfcrt and Pfmdr1 Mutations profile in Cameroon (Mbacham et al. ManuscrIPT2 in
prep)
The aforementionned study (Mbacham et al. ManuscrIPT2 in prep) went forth to establish that there was
a positive relationship between SGK resistant allele (Serine-Glycine-Lysine) and SP clinical failure.
Besides, it was noticed that SGK and AGK alleles were highly represented in Limbe (Figure 14), which
seems to prediSPose Limbe to SP clinical failure. It should be noted that SGK resistance is associated
with dhps biomarker, with serine, glycine and lysine mutations at codons 436, 437 and 540 of this gene,
reSPectively.
38
Figure 14: dhps and dhfr mutations profiles in Cameroon (Mbacham et al. ManuscrIPT2 in prep).
As concerns dhfr gene mutation, the triple mutant allele IRN (Ile-51, Arg-59, Asn-108) was found to be
predominant in the centre and Southern region, littoral, and Western region with an overall percentage of
62.2% in the Country (Figure 15). The North of Cameroon (Ngaoundéré, Maroua, and Garoua) had the
lowest rate of mutation for dhfr, followed by the Eastern region (Bertoua, 42% in 1999).
39
Figure 15: Geographical distribution of Dhfr triple mutant alleles IRN in 11 localities of Cameroon.
Mutation rate: Manjo (Littoral) > Djoum (South)> Sangmelima (South)> Bafoussam (West) > Bertoua
(East) > Yaoundé (Centre) > Mengang (South) = Ndop (North West) > Ngaoundéré > Maroua > Garoua.
IRN: I represent isoleucine with mutation at position 51; R, Arginine – 59; and N, ASParagine – 108 (Ile
– 51/Arg – 59/Asn – 108).
Source: Adapted from Tahar and Basco. (2006).
Wild-type was mainly marked in Northern region (Ngaoundere, Garoua (2001), Maroua) (Tahar
and Basco. 2006) (Figure 16).
40
Figure 16: Distribution (%) of Dhfr gene wild types and mutant alleles in 13 areas of
Cameroon.
Legend: Asn: ASParagine, Arg: Arginine, Ile: Isoleucine.
Source: Adapted from Tahar and Basco. (2006)
Compared to the triple mutation (I51/R59/ N108) that has no great impact on the sensitivity of
chlorproguanil-dapsone (CD) another potent antifolate combination (Watkins et al. 1997, NzilaMounda et al. 1998), strong resistance to CD and to SP, has also been ascribed to a quadruple
mutant form (N108/I51/R59/I164L) of the dhfr gene as reported in Asia and Latin American
countries (Wichmann et al. 2003). Plowe et al. (1998) reported that in this fourth mutation the
enzyme is about a 1,000 fold less sensitive to pyremithamine. The presence of this mutation
(quadruple mutant) in Plasmodium falciparum isolates imported from Central, West, South, EastAfrica and Madagascar, to Europe, has been assessed and none was found among these isolates
(Wichmann et al. 2003). In Cameroon, a study realized on this aSPect showed no association
between the quadruple mutant genotypes and SP or AQSP failures and besides, if any, the
frequencies of quadruple genotypes were very low (Mbacham et al. ManuscrIPT2 in prep).
Nevertheless, a strong recommendation is still required for a continuous surveillance (Wichmann
et al. 2003) as the diSPersal of resistance patterns across regions could also be due to population
movements and therefore parasite migration patterns as suggested by Pearce et al. (2009).
To investigate the evolutionary origins of dhps mutations, Pearce et al. (2009) examined
diversity at microsatellites markers flanking the gene and characterized five major lineages with
the geographical distribution of dhps resistant alleles mutations: SGK (Serine-Glycine-Lysine),
AGK (Alanine-Glycine-Lysine), and SGE (Serine-Glycine-Glutamate) (Figure 17), wild-type
41
alleles AAK (Alanine-Alanine-Lysine) and SAK (Serine-Alanine-Lysine), (Figure 18B) in
various regions of Africa. The authors suggested that from the frequencies of resistance lineages
expressed in the pie chart map there has been diSPersal throughout west and central Africa from
their original foci, with Cameroon at the confluence of west, central, and southwest African gene
pools (Figure 17). In Cameroon it was found that the resistant haplotypes AGK/SGK 3 was
mostly predominant compared to other geographical regions with mainly AGK/SGK 1(Central
and Souhteast African sites) and AGK/SGK 2 (West African sites) (Figure 17). These results
may express a likely difference in antifolate sensitivity as underlined by the authors.
Figure 17: The African distribution of dhps resistance lineages (Pearce et al. 2009).
In Cameroon, AGK /SGK alleles were mostly marked in Mutengene, followed by Yaounde and
Garoua (Figure 18A) whereas wild-type alleles (SAK and AAK) were mostly marked in Garoua,
Yaounde and Mutengene respectively. The result with SGKcorroborates that of Mbacham et al.
(2010) (Figure 19).
A)
42
B)
Figure 18: The distribution of the major dhps
alleles across sub-Saharan Africa.
Resistant alleles (A); the upper map shows the
relative proportions of the three major resistance
alleles, SGK, AGK, and SGE. Wild-type alleles
(B); the lower map shows the ratio of SAK and
AAK alleles among wild-type dhps alleles
(Pearce et al. 2009).
Figure 18: The distribution of the major dhps
alleles across sub-Saharan Africa.
43
Figure 19: Antimalarial drug resistance Markers.
T represents the threonine (T) mutation on codon 76 (76T) of the Pfcrt gene. Y represents
tyrosine (Y) mutation at codon 86 (86Y) of the Pfmdr1 gene as putative markers for
AmodiAQuine failure (AQF (D28)). Sulphadoxine-pyrimethamine failure (SPF (D28)) whose
molecular markers, IRN represents the isoleucine, arginine and aSParagines mutations at codons
51, 59 and 108 (IRN) of the dhfr gene and SGK represents the serine, glycine and lysine
mutations at codon 436, 437 and 540 of the dhps gene.
(Source: Mbacham et al. 2010).
Various studies have suggested that triple dhfr mutations with or without additional mutations in
dhps gene, are associated with clinical resistance to SP in Africa (Basco et al. 2000, Nzila et al.
2000, Mockenhaupt et al. 2005, Mbacham et al. manuscrIPT2 in prep, Pearce et al. 2009, ). This
may have great impact as SP is still recommended in most African regions as IPT2p (Intermittent
preventive treatment for pregnant women) and/or IPT2i (Intermittent Preventive Treatment for
infants).
Parasite resistance evaluated by clinical assessment of drug efficacy
As previously mentioned drug efficacy can be assessed with principal outcome as ACPR (Acute
Clinical and Parasitological ReSPonse) on D28 or D14 as recommended by W.H.O. Other
variables include the ETF (Early Treatment Failure), LCF (Late Clinical Failure), LPF (late
parasitological failure) and LTF (Late Treatment Failure).On these grounds, various studies have
reported on the efficacy of both non-Artemisinins and Artemisinins based combination therapies
for malaria treatment.
As part of surveillance program on the therapeutic efficacy of the first line (CQ and AQ)
and second line (SP) drugs for the management of uncomplicated Plasmodium faciparum
infections, Basco et al. (2006) conducted non randomized studies in symptomatic children aged
less than 10 years according to the W.H.O protocol (14 day follow up period) at 12 sentinel sites
in Cameroon between 1999 and 2004. A total of 1,407 patients were included in the studies. Of
these patients, 460, 444, and 503 were assigned to CQ, AQ, or SP treatments groups,
44
reSPectively. Chloroquine resulted in high overall failure rates (ETF + LCF + LPF, 48.6%)
(Figure 20). Chloroquine was ineffective in Central, Southern, Eastern and Western regions of
the country. Though the number of sites was limited there seemed to be a gradient with
decreasing failures rates towards the Sahelian North (from 38% in Ngaoundéré to 20% in Garoua
and 16% in Maroua). AmodiAQuine was highly effective in all study sites (Figure 21). The
overall cure rate (i.e. ACPR) was 92.7% on Day 14. Most of the failure rates were due to LPF. In
Yaoundé, AQ efficacy was evaluated in 1999 and 2003. There was no indication of change in the
efficacy of the drug between these two time periods. Compared with AQ, SP was less effective,
with 47 of 475 (9.9%) patients failing to reSPond to the treatment. Close to half of these patients
(20 of 47 failures, 43%) required an alternative treatment on or before day 3 due to ETF. SP
efficacy was evaluated in Yaoundé in 1999 and 2003, and in Hévécam in 2001 (no failure) and
2004 (11.1% failure).
45
This finding has also been comforted by Whegang et al. (2010) in the comparison of AQ, SP and
AQ-SP efficacy on D14 in three sites of Cameroon, namely Yaounde, Bertoua and Garoua. The
overall
cure
rate
(CR)
of
AQ-SP
on
D14
(PCR
uncorrected)
was
93%
for
Yaoundé/Bertoua/Garoua (Figure 23). AQ-SP CR was however, not statistically different from
AQ, and SP was less effective than AQ-SP, with an overall CR of 87%.
Figure 21: Efficacy of AQ, SP and AQ-SP in Cameroon on D14 (Whegang et al. 2010).
46
As reported by the latter author, AQ monotherapy is still effective in Cameroon but should be
protected with artesunate (or SP) to delay the emergence of resistance. The current trend in
Africa is to reserve SP for the intermittent preventive treatment in pregnant women (Newman et
al. 2003). During the transition period before the implementation of the new drug policy based
on ACT, AQ-SP combination has been proposed by some malaria experts to be an effective,
alternative non-ACT combination (WHO, 2001). The results showed that AQ-SP combination
was more effective than AQ and SP monotherapies. AQ-SP was as effective as AS-AQ
combination, as already shown in a meta-analysis in Africa (Obonyo et al. 2007). The
advantages of AQ-SP combination include its high efficacy, good tolerance, suitability for young
children, immediate availability of both drugs in many areas in Africa, and relatively low price
of the generic drugs (Whegang et al. 2010). Therefore, this non-ACT would have been a useful
alternative during the transition period towards the full implementation of ACT to mutually
protect AQ and SP in African countries where these two drugs are still effective. Nevertheless,
Mbacham et al. (2010), as they were assessing the efficacy of AQ, SP and AQ-SP for the
treatment of uncomplicated malaria on D28 found that these molecules drugs were highly
associated with in vivo failures and high prevalence of resistant genes pfcrt, pfmdr I, dhfr, and
dhps. Though a relatively high efficacy was observed as shown in figure 24, this seems not to be
enough according to W.H.O (2005). The latter, recommends that an antimalarial drug should be
as efficacious as 95%. This finding reinforced the position of Cameroon government in the
recommendation for changing its first line treatment from monotherapies to ACTs.
47
Figure 24: Adequate clinical and parasitological reSPonses (ACPRs) in the 28 day trial for nonartemisinin combination therapy (AQ-SP), AQ, and SP after PCR correction in three zones of
Cameroon (Mbacham et al. 2010).
It should be noted that, the recommended follow-up duration for malaria treatment in clinical trials is ≥ 28
days in areas of high as well as low to moderate transmission. In effect, a significant proportion of
treatment failures do not appear until day after D14. Thus, shorter observations periods lead to a
considerable overestimation of the efficacy of the tested drug (W.H.O. malaria treatment guidelines
2006).
As combination treatments mostly and commonly recommended for Africa we have non-Artemisinins
combination such as AQ-SP, and ACTs such as AS-AQ, AS-SP, AM-LM. Other forms of ACTs include
AS-MQ, DH-PP, AS-CD, Artesunate pyronaridine, Artesunate-atovAQuone-proguanil. The study
realized by Whegang et al. (2010) focused on the efficacy of all the above-cited antimalarials as the aim
to provide a rational basis to consolidate the implementation of ACTs throughout Cameroon and also to
provide a baseline data for possible adjustments and modifications in the national antimalarial drug policy
in the future. The results obtained suggested AS-AQ to be as effective as, AS-SP, AM-LM, AS-MQ, ASCD and DH-PP. AM-LM appeared to be the most effective followed by DH-PP (Figure 25).
48
Figure 25: Adequate clinical and parasitological reSPonses (ACPRs) in the 28 day trial for
combination therapies before and after PCR correction from 2005-2007 in Yaoundé Cameroon
(Per Protocol and intention to treat ITT) (Whegeang et al. 2010).
For an alternative drug regimen, Whegang et al. (2010) observed that, AM-LM has
potential advantages over other forms of ACT although it requires six doses, rather than three
doses for other artemisinin-based combinations. She recommended further studies to evaluate the
clinical efficacy and tolerance of these combinations in different epidemiological context. It is
worthwhile noting that the evaluation of drug efficacy should not only be assessed as the ACPR
on D28 or D14 as recommended by W.H.O guidelines but also in the ease of administration,
which is a key determinant of compliance, thus efficacy with shorter courses and fewer tablets
being preferred over the current minimum of three days and multiple tablets a day for most forms
of ACTs. As recommended by W.H.O experts, the ideal anti-malarial drug should have an
efficacy of at least 95% as measured over 28 days of follow-up. They also recommend that re-
infection in that period should be restricted to a few pills administered as a single dose and
should have a short treatment duration (Mendis K. 2005). A fixed-dose ACT (FDC) would be
able to improve compliance of the treatment and reduce the cost of malarial treatment in endemic
countries. Thus to improve the existing ACT, (AS) was combined with sulphamethoxypyrazinepyremithamine (SMP/Co-Arinate®) in a co-blister, taken once daily (two tablets simultaneously)
for over three days. This combination is available as a prescrIPT2ion drug in many African
countries. As reported by other studies, the dosing interval of Co-Arinate could be reduced to 12
hours enabling a 24-hour treatment (Adam et al. 2006, Penali et al. 2008). As back as 2009,
Sagara et al. (2009) investigated on the effectiveness of this dosage regimen compared with the
same treatment given over 48 hours (dose interval of 24 hours) using as standard therapy
Coartem® (AL FDC, the six dose regimen). For this to be done four African countries namely
Cameroon, Mali, Sudan and Rwanda were included. As for Cameroon the efficacy measured by
the ACPR on D28 (after PCR correction) per protocol analysis is given on the figure below
(Figure 26). AS-SMP three days or AS-SMP 24 hours are as efficacious as ArthemetherLumefantrine, and well tolerated. However, slight adverse effects such as vomiting and diarrhoea
were observed in the AS-SMP 24-hours group. This finding also provides basis for
implementation of alternatives ACTs for policy change as in the case of others ACTs as
previously mentioned by (Whegang et al. 2010).
100
98.8
98.7
AS-SM P (3
days )
AS-SM P (24
hours )
98.6
90
80
A
C
P
R
(%
)
49
70
60
50
40
30
20
10
0
AL (3 days )
Treatment period
Figure 24: Evaluation of ACTs efficacy on different treatment periods with AL as standard.
AS: artesunate, SMP: sulphamethoxypyrazine-pyremithamine, AL: Arthemether-Lumefantrine.
(Sagara et al. 2009)
2.2.2. Malaria vectors resistance
2.2.2.1. Geographical distribution of malaria vectors in Cameroon
In Cameroon, there are 13 SPecies of Anopheles known to harbor malaria parasites Anopheles gambiae
s.s., An. Funestus s.s., An. Moucheti, An. arabiensis, An. Nili, An. hancocki,An. paludis, An. marshalli,
An. coustani, An. wellcomei, An. ovengensis, An. ziemanni, and An. pharoensis. An. gambiensis
complex plays a major role in malaria transmission. Its population decreases as we move from forest to
savanna and to Sahel. While that of An. arabiensis is the opposite. (NMCP, 2002-2003)
Malaria transmission in Cameroon varies with reSPect to the major climatic zones, which correSPond to
three main ecological facies: the sudani-sahalian facies, the equatorial forest, and the savannah facies
50
(Figure 27). Entomological studies realized so far, reveal that the dynamic of transmission follows three
modalities. The continual transmission (7 to 12 months) in forest zone where the EIR (entomological
inoculation rates) can reach 100 per person per unit time, the long seasonal transmission (4 to 6 months)
in Adamaoua and West where the EIR can reach 20, and the short seasonal transmission (1 to 3 months)
in the North where transmission occurs during the rainy season (1 to 3 months).The table below (Table 2)
indicates the EIR according to Anopheles SPecies in Cameroon. EIR is defined as the number of
mosquitoes-bites received per person and per unit time.
Table 2: Entomological Inoculation Rates (EIR) of the major infective vectors SPecies in Cameroon
Anopheles SPecies
EIR
An. gambiae s.s.
10 to 105
An. Arabiensis
1 to 165
An. Funestus
65 to 150
An. Moucheti
1 to 300
An. Nili
1 to 275
Climatic conditions favor the development of malaria vectors and parasites. In Cameroon, there
are five (5) major SPecies of Anopheles that transmit malaria: the An. gambiae, An. arabiensis,
An. Funestus, An. Nili, and An. Moucheti. The complex Anopheles gambiae s.I. is made up of
three SPecies: An. melas, An. arabiensis, An. gambiae s.s. The geographic distribution of the
An. gambiae complex in Cameroon (Figure 29) has been reported (the ministry of public health,
Cameroon, 2010).Anopheles gambiae is widely distributed across the country and two molecular
forms (“M” and “S”) have been reported within this SPecie. The M form is mainly distributed in
the South of Cameroon and S form almost across all the country (Figure 28). An. Funestus is
found in almost all the country but at distributed in the country is mostly found along fast water
current (Figure 31). An.Moucheti is found in the equatorial zone and mostly along slow water
current (Figure 32).
51
.
Figure 27: Malaria transmission periods in different ecological zones of Cameroon.
(Source: profil entomologique du paludisme au Cameroun, Ministere de la santé publique).
52
Figure 28: Geographical distribution and relative frequencies
of An. Gambiae s.s molecular forms in Cameroon (Source:
profil entomologique du paludisme au Cameroun, Ministere de la santé
publique).
Figure 29: Geographical distribution and SPecies frequencies
of the An. Gambiae complex in Cameroon (Source: profil
entomologique du paludisme au Cameroun, Ministere de la santé
publique).
53
Figure 30: Geographical distribution of An. Funestus in
Cameroon (Source: profil entomologique du paludisme au Cameroun,
Ministere de la santé publique).
Figure 31: Geographical distribution of An. Nili in Cameroon
(Source: profil entomologique du paludisme au Cameroun, Ministere de la
santé publique).
54
Figure 32: Geographical distribution of An. Moucheti in Cameroon
(Source: profil entomologique du paludisme au Cameroun, Ministere de la santé
publique).
2.2.2.2. Sensitivity of vectors to insecticides in Cameroon
Sensitivity to insecticides in Cameroon has been realized on the major five vectors
cited above. Resistance of An. Gambiae s.I. to dieldrine was done during the years 1960
and reactualized in 2000 (2% mortality in Mbalmayo and 61.2 % in Kaélé). The figures
below indicate the sensitivity of Anopheles gambiae s.I. complex (An. melas,
An.arabiensis, An. gambiae s.s.) to DDT, Deltamethrine, permethrine, Lambda
cyhalothrine and Bendiocarb, obtained during the last decade (Figure 33 – 37). Findings
obtained from 2007 and 2010 have shown that An. gambiae is still sensitive to Bendiocarb,
though resistance has been suSPected in Littoral region (Njombe). Recent data have
Confirmed the implication of two molecular forms (M & S) of An. gambiae s.s. in the
transmission of malaria. Bigoga et al.(2007), assessed the susceptibility of An. gambiae
complex (An. gambiae s.s. (M) and An. melas) population recorded only in Limbe and
Idenau localities was susceptible to the four insecticides. Anopheles gambiae M form from
all three villages was 100 % susceptible to deltamethrin and permethrin, but showed 6.3 %
survival on 4 % DDT in Tiko village. Resistance in An. gambiae M form to carbosulfan
was found at all three sites, with mortality rates ranging from 53 to 90 %. Resistance to
DDT, Deltamethrine, Permethrine, and Lamdacyhalothrine seems to be due to the two
molecular forms (M & S) of An. gambiae and the twin form of An. arabiensis. The
evaluation of the sensitivity of other SPecies (An. Funestus, An. Nili, An. Moucheti) to
56
DDT and pyrethroids has shown that these vectors are still sensitive.
A study realized by Wondji et al. (2005), evaluated the susceptibility of Anopheles
arabiensis in Simatou (Sahelian region of Cameroon) population to DDT, permethrine and
deltamethrin before and after ITNs (Insecticide-treated bed nets). First, it was found that
this population was completely susceptible to these different insecticides. In August 2002,
17 months after implementation of ITNs, susceptibility was evaluated for deltamethrin only
since it was used to treat the nets. Of 80 SPecimens tested, the survival rate obtained was
8.75 % (07/80) after the 24-hours observation period, indicating a decrease in susceptibility
to deltamethrin. This finding agrees with the standards procedures for vectors control in
Cameroon, which states that if < 95% mortality of Anopheles out of 80 SPecimens tested is
obtained then the status of the implicated insecticide is resistant (the case of deltamethrin in
this study). More interesting the above mentioned study found Kdr genes (implicated in the
resistance to insecticides) to be homogeneous (no significant variation was recorded among
genetic parameters like the number of alleles per locus), which could provide an advantage
of malaria control programme. The standard procedure manual also states that in the
evidence of resistance, mechanisms should be elucidated by molecular and biochemical
methods. Mutations in the Kdr gene (Leucine-Phenyalanine, and Leucine-Serine)
conferring crossed-resistances to DDT and pyrethroids have been found in the Coastal zone
of Cameroon, Centre, Bertoua, Douala, Yaounde. In the North Cameroon an increase in
metabolic resistance by esterases, oxydases, glutathione-S-transferase, has been found to be
the main cause of resistance to insecticides, implicating An. gambiae s.s. and An.
arabiensis.
57
Figure 33: Geographical distribution of An. Gambiae s.I.
population according to resistance to DDT (Source: profil
entomologique du paludisme au Cameroun, Ministere de la santé
publique).
Figure 34: Gographical distribution of An. Gambiae s.I.
population according to resistance status to delthamethrin
(Source: profil entomologique du paludisme au Cameroun, Ministere
de la santé publique).
58
population according to resistance status to permethrin (Source:
profil entomologique du paludisme au Cameroun, Ministere de la santé
publique).
population
according
to
resistance
status
to
lambdacyhalothrin (Source: profil entomologique du paludisme
au Cameroun, Ministere de la santé publique).
59
Figure 37: Geographical distribution of An. Gambiae s.I. population according to
resistance status to bendiocarb. (Source: profil entomologique du paludisme au Cameroun,
Ministere de la santé publique).
60
PART 3:
Study results on the provision of treatment (ACTs) and
malaria prevention indicators
Part 3 describes results of studies on ACTs. The first gone appraises the subsidy from the
distribution channels to the point of sale of ACT; a descrIPT2ion of the current anti-malarial
market and of the actual prices paid is done from 3 zones (North West, South West and Centre
regions) among other. The second investigated patient knowledge on malaria treatment and
compared malaria cases management in public and private health facilities in Yaounde and
Bamenda. And the last one points out most of the problems that hinder the delivry of ACT.
3.1. Challenges of ACT subsidy: The Cameroon Case File
Prof Wilfred Mbacham*,***; Mr. Akindeh Nji*; Dr. Paschal Awah**
61
*Fobang foundation,**FFISH consultancy group, ***University of Yaoundé 1
Study done by the Fobang Foundationand SPonsored by the DALBERG group through the
Malaria Consortium
Cameroon revised its treatment policies for the treatment of uncomplicated malaria since 2004,
moving from monotherapies, such as chloroquine now subject to resistance, to Artemisinin based
combination therapy (ACT). About three years passed before the first massive deployment of
ACTs through the public sector outlets was recorded. In order to increase access to malaria
drugs, Cameron received and used subsidy funds of the GFATM, Round 5 funds, to subsidize the
purchase and the distribution of ACTs in private and public sectors with different mark up rates.
This study sought to understand if the subsidy passed on through the distribution channels
reached the point of sale; to describe the current anti-malarial market and the GFATM project
and annual ACT import quantities; to establish data on actual prices paid; to describe the ACT
pricing& availability data from 3 zones (North West, South West and Centre regions).
3.1.1 Methodology
The study was carried out from October to December, 2007 and the methodology consisted of a
cross-sectional survey in three of the ten regions of Cameroon: Centre region (excessive drug
pressure); North West region (self-reliant development efforts); Southwest region (trade
influence with neighbouring Nigeria).
Structured questionnaires were used to collect data from pharmacies and wholesale distribution
units. For each serving public hoSPital pro-pharmacy in the main urban centers of Yaounde,
Bamenda and Buea, the pro-pharmacy and 4 outlets around it were studied. Three outlets
inaddition to the propharmacy per serving hoSPital or clinic were studied for each small city. In
each rural mystery shopper survey to determine actual prices paid by consumers was done. Data
was also collected from importers/wholesalers/central medical store level to determine uptake of
ACT through the private sector.
3.1.2 Results
62
3.1.2.1 National Drug Procurement System
Cameroon's population is about 18 579 499 and are served by just 280 functional
pharmacies making 66356 persons per pharmacy. Of these there are no chains of pharmacies.
CENAME, Central warehouse of the Ministry of Health, is the only supplier of subsidized ACT
registered with AS-AQ and Art-Lum references. Distribution of these products begins from
CENAME and radiates towards the regions and subsequently to the health facilities and then the
patients. There is a parallel drug procurement scheme either - The SPecial Drug Fund operating
in the North West and South West regions or the black market drugs from which all providers
including private faith-based or illicit street vendors procure drugs (Figure 38).
National Drug Procurement
Center (CENAME)
National referral hoSPitals
Provincial Distribution Unit
Faith-based Health Boards
Provincial hoSPital, District HoSPitals (Public and
private), Private non-profit making health facilities,
integrated health centres (Public and private)
Figure 38: Ideal flow chart of drug procurement in the health system in Cameroon.
National Drug Procurement Center
(CENAME)
National referral
hoSPitals
Provincial
Distribution Unit
Faith-based Health
Boards
Provincial hoSPital, District HoSPitals (Public and
private), Private non-profit making health facilities,
integrated health centres (Public and private)
63
Parallel Drug Procurement Units
(function as business units), Import
and donations to FBO
Faith-based Health Boards,
Private profit making
wholesale distributors
Faith-based HoSPitals, Private
profit and non-profit making
health facilities, integrated
health centres (Public and
private)
Figure 39: Actual flow chart of drug procurement in the health system in Cameroon.
The above diagrams (figure 38 and 39) illustrate an ideal drug distribution network in Cameroon
and present the actual situation with a parallel drug distribution network. The unidentified
network functions well whenever the government distribution network is unable to satisfy the
needs of the health facilities and compete favourably.
3.1.2.2. Current Antimalarial Market
Within the GFATM program the companies supplying the ACTs to CENAME were as follows CIPLA (70% of AS-AQ (co-blister), SANOFI-Aventis (30% of AS-AQ (FDC)) and MISSION
Pharma (100% of Art-Lum). The MOH allocated 5,562,916 USD (1USD=500CFA) for the
purchase of 4147149 doses of the different presentations of ACTs. The rate of subvention was
36.5% for the combination AS-AQ and 67.15% for the combination AL to allow for whole sale
pricing equilibration. Subsidies were fixed by decision number 03621/D/MSP/CAB of 05
February 2007 to vary from 140FCFA (28US Cents) to 600 FCFA (1.2USD). The mechanism is
expected to take into account the final costs fixed by the MOH. This arrangement leaves the
following mark ups for ACTs
1/. CENAME to Provinces 10%,
2/. Provincial Distributors to Health Facilities – 8% and
3/. Health facilities to Patients – 10%
Pricing of ACT in the public & private sectors: See Annex.
3.1.2.3. ACT supplies to public and private sectors 2007
Supplies of ACT to public and private sectors in 2007 are 89.7% and 10.3% reSPectively.
These stocks were depleted within 4 months of deployment. This depletion was slower than
stocks of Artemether-Lumefantrine (AL) which just “sublimed” for reasons of perceived side
64
effects of AS-AQ and the flight to neighbouring countries of AL.
3.1.2.4. Private distribution networks
There are 10 Private wholesalers supplied by the CENAME and include both 5 mission bodies
and 5 sub-wholesalers. Both the Cameroon Baptist Convention and the Presbyterian Church in
Cameroon buy drugs from many international institutions in addition to the government-owned
drug reseller CENAME and resell to its satellite institution (CBC) and hoSPital and health
centres (CPC) with a 10-20 % mark up who themselves add an additional 30% mark up to the
price charged to patients but do not receive or sell the ACTs at comparable prices to those
provided by the Southwest Provincial SPecial Fund for Health. Its customer prices are 2 times
more than that for the government public health facilities.
The catholic health service has a central drug purchase service and buys only registered
drugs that are on the EML and sells to its peripheral services through its provincial outlet. It does
a 35% mark up for provincial distributor and churches medicine outlets do a further 15% mark
up. If drugs are imported donations, they do a 13% mark up at wholesale and a further 20%
mark up at retail.
The black market parallel distribution unit has many sources. Drugs are purchased from India,
Pakistan and Nigeria. Some pharmacies whose drugs are about to expire sell their drugs through
these network. The black market supplies ACT to a wide variety of retailers: some of who are
faith-based or non-profit making health facilities, some private profit making pharmacies and
patent medicine store retailers and most often to neighbouring countries where these drugs are
not subsidized.
Actual prices paid
The following diagram just indicates 500FCFA and 2000FCFA as the dominating prices per
pack (Figure 40).
65
Figure 40: Pricing per “Pack” in FCFA
Monotherapies were still found in the course of the survey and so are represented in the diagram
below (Figure 41). In addition there is not a dominant name in the market but quinine seems to
be slightly more present that the others.
66
Mean price per tablet of ACTs from drug outlet
The survey revealed that the Centre province always had the lowest pricing per drug than the
South-West or North-West provinces perhaps reflecting the distance to the provincial centre
(Figure 41). Prices for example varied between 26F ($0.05) and 333($0.67) per tablet for AS-AQ
under different trade names. In 80% of private drug outlets “convenient packs” (with incomplete
doses) were sold as per the purchasing strength of the client: Subsidy benefits seems to work
only in Yaoundé with the lowest cost per tablet and particularly for Atemether Lumefantrine in
all three provinces surveyed (Figure 42).
Figure 42: Mean price per tablet of ACTs from drug outlets.
3.2. Patient Exit Pool and Provider Practices: Research on the Economics of ACTs
Mangham LJ, Cundill B, Achonduh OA, Ambebila JN, Lele AK, Metoh TN, Ndive SN, Ndong
IC, Nguela RL, Nji AM, Orang-Ojong B, Wiseman V, Pamen-Ngako J, and Mbacham WF.
The malaria case management operational manual was published in 2009 by the World Health
Organization (W.H.O) with the aim of providing substantial and practical skills to those
67
reSPonsible for the national malaria control program. The manual was also meant to ensure that
malaria control program at national, regional, district and community levels are efficiently and
effectively organized to allow early diagnosis and prompt effective treatment. The NMCP
therefore, should defined a clear malaria treatment policy based on surveillance of drug efficacy
and states which medicines are to be used as first and second lines treatments for uncomplicated
and severe malaria. Since its policy change between 2004 and 2006 for malaria treatment,
Cameroon NMCP has undertaken to disseminate this shift in all regions to inform health workers
at public mission and private health facilities. However, much still need to be done as very few is
known about malaria case management in Cameroon (Sayang et al 2009 b, c), as compared to
other regions of Africa and given that few health facilities and health workers were aware of the
policy change. Deficiencies in the practices of both public and private providers compromise the
effectiveness and cost-effectiveness of malaria case-management. In this view comes into play
the REACT project that evaluates the cost-effectiveness and equity implications of interventions
designed to improve the ability of health providers to deliver effective treatment for
uncomplicated malaria (LSHTM, 2008-2009).
A cross-sectional study was thus conducted by the REACT team of the Laboratory for Public
Health Research Biotechnologies (LAPHER-Biotech), in two sites of Cameroon; Yaoundé
(Centre Region) and Bamenda (North-West region) between July and November2009 (Mangham
et al. 2011). Outcomes for this study were classified for Patients characteristics, Facilities, Health
workers, and Malaria testing. More SPecifically, the essentials components (W.H.O. 2009) of
Malaria case management namely Diagnosis and treatments patterns, were described in public,
private and medicine retailers and the factors associated with being prescribed or receiving an
ACT were also investigated.
3.2.1 Patients' characteristics
Though malaria control seems also to be hampered by erroneous/traditional beliefs, it
should be noted that an effective communication strategy is necessary for appropriate healthseeking behavior, as people would be reached more effectively when information and message
are shaped with reSPect to their needs (W.H.O. 2009, IRESCO. 2011). As a matter of fact the
REACT's study investigated on aSPects of socioeconomic status (SES) and level of education
68
and found that more than half (544/59%) sought treatment for malaria episode for the first time,
182 (19%) sought treatment on the same day or the date following the onset of symptoms. This
means very few knew about malaria symptoms. For those who recalled to have previously
received treatment, few recalled to have received ACT mainly in private and public as presented
in Figure43.
Figure 43: Patients who recalled to have received ACT or any antimalarial in all facilities.
(Mangham et al., 2011)
3.2.2 Health facility and health workers characteristics
3.2.2.1 Health facility
Health facilities were audited for diagnostic services such as microscopy and RDTs
(Rapid Diagnostics Tests) and also for the availability of antimalarials. Both public and private
facilities were reported to be well equipped with microscopy availability of 90.5% (36/43) and
100% (43/43) reSPectively. Quinine and SP were also greatly available in all the facilities as
shown in figure 44 . As concerns antimalarials (both ACTs and non-ACTs), public facilities
tended to stock more artesunate-amodiAQuine though other types of ACT including
arthemether-lumefantrine and DHAP were available at private facilities and medicine retailer
(figure 45).
69
Figure 44: Availability of antimalarials in all facilities (Mangham et al., 2011)
70
Figure 45: Availability of Artemisinin based Combination Therapies (ACTs) in all
facilities (Mangham et al., 2011).
3.2.2.2 Health workers characteristics
Like in the case of patients, health workers or caregivers should be well trained for a
better management of malaria. These skills go with training on diagnostics tests (Microscopy and
RDTs) as the prescribed antimalarial, at a correct dose regimen, depends on clinical and
parasitological diagnosis. More so, parasitological diagnosis has the advantage to avoid
unnecessary use of antimalarials medicines in parasite-negative patients, thereby reducing sideeffects, drug interactions, selection pressure for drug resistance, eSPecially in view of the high
cost of ACTs, and also confirmation of treatment failures (treatment received at last place sought
treatment). In this line the react study has investigated on the recommended practices (treatment
guidelines) for treating uncomplicated and severe malaria, access to in-service training in
different settings private, public and medicine retailers. With reSPect to these it was found that
80% of HWs accurately reported ACTs as the recommended treatment for UM, 49.2% attended
malaria training in the past three years, and 54.8% had access to malaria treatment guidelines;
mostly represented in the public sector (Figure 46).
71
Figure 46: Assessment of health workers performances in all facilities (Mangham et al.,
2011).
3.2.3 Prescribed treatment for malaria (assessed for health workers and patients)
This aSPect involves both patients with knowledge on treatment to be prescribed after
consultation and Health workers. As earlier mentioned patients who get consulted as earlier as
the beginning of symptoms will have the advantage to be taken in charge promptly by health
workers (trained staff on the prescrIPT2ion of anti-malarials drugs) for a better management. As
such, it was found that patients reported consultations differed by type of facility, with health
workers at public and private facilities more likely to ask about symptoms, examine and test the
patient than health workers at medicine retailers (Figur47). Patients were more likely to request
anti-malarials (37.3%), including ACT (25.2%), at medicine retailers, while those attending
private facilities were more likely to be tested for malaria (44.4%) (Figure 49). When the
assessment was done for health workers (prescribers), it was found that patients at private
(84.5%) and public (78.3%) facilities were mostly prescribed antimalarials of any type
meanwhile ACTs were mostly prescribed in public followed by private and medicine retailers
facilities (Figure 48). Quinine and SP were mostly prescribed or received in private and
requested by patients in medicine retailer. In the same line, patients who were not tested for
malaria received or were prescribed ACTs at more than 60% for both private and public sectors
and 45% at medicine retailer and averagely 71.5% of any antimalarials, they received.
72
Figure 47: Patients reported consultation in all the facilities (Mangham et al., 2011).
Figure 48: Percentage of all patients who were prescribed or received malaria treatment
(Mangham et al., 2011).
73
Figure 49: Types of treatment requested by patients in all facilities (Mangham et al., 2011).
It is also worth noting that febrile patients were highly prescribed or received antipyretics and
antibiotics. Currently, as discussed by the REACT study there is no consensus on how to manage
febrile patients with malaria negative/positive tests and the study suggest revising the treatment
guidelines by defining clear clinical directives for these cases to be properly handled so as to
avoid over/under-treatment. It is also important that symptomatic diagnosis be taken away
(depending on the setting) because most of febrile patients found (more than 2/3) do not always
have malaria as it was confirmed by RDTs in the present study.
Definitely, the odds of a febrile patient being prescribed or receiving an ACT were
significantly higher for patients who asked for an ACT (OR= 24.1, P < 0.0001), were examined
by the HW (0R = 1.88, P = 0.021), had not previously sought an antimalarial treatment (0R =
2.29, P = 0.001) and sought treatment at a public (0R = 3.55) or private facility (0R = 1.99, P =
0.003). Moreover, in a univariate analysis the study found that the odds that febrile patients were
prescribed or received an ACT were significantly associated with facilities that had one or more
health workers who had attended training on malaria, and knew ACT is recommended.
Treatment practices at medicine retailers were significantly worse than at public and private
facilities though some of these patients often asked for an ACT.
Another essential factor in malaria case management is about counseling and follow-up
of patients. The study investigated on two aSPects which are the accuracy of treatment or dosage
of ACTs and evaluation of patients' knowledge on treatment regimen (Figure 50).
74
Figure 50: Dosage and advice (patient knowledge) given for ACT diSPensed in all
facilities. (Mangham et al., 2011)
3.2.4 Malaria testing and appropriate treatment
In order to establish an appropriate treatment, the prevalence of malaria in the study
population was evaluated in 746 patients and RDTs used for malaria confirmation.
In public facilities, overall, for all facilities those who were positive for malaria, 59%
received an ACT; 75.6% from public, 56.7% from private, 47.8% from medicine retailers. Of
those negative for malaria, overall, 48% received an ACT; 61.5% from public, 57.4% from
private, and 39.0% from medicine retailers (Figure 52,52 and 53). For those who were prescribed
or received an antimalarial it was found that nearly 70% received or were prescribed antimalarial
in total with 73.8% in public, 85% in private and 61.5% in medicine retailer (Figures). Rapid
Diagnostic Tests permitted to rule out the malaria negative cases among those that were
presumptively diagnosed as malaria positive on the basis of symptoms. Overall, 28.6% were
RDT positive for all facilities, with 33.0% in public, 33.6% for private, and 24.3% in medicine
retailer.
75
Figure 51: Presumptive malaria treatment prescribed or received in public facility
Figure 52: Presumptive malaria treatment prescribed in private facility (Mangham et
al., 2011).
76
Figure 53: Presumptive malaria treatment prescribed or received in medicine retailers
To sum up, RDT tests results permitted to establish the percentage of patients who actually
received the appropriate treatment. Thirty-nine percent of these 746 patients received appropriate
treatment with 43% in public facilities, 29% in private facilities and 41% in medicine retailers.
Figure 54: Appropriate treatment of malaria received in accordance with RDT result
As a final point, based on RDTs results, majority of patients (61%) were prescribed or
received antimalarials they did not need, and thus many patients received ineffective medicines
and incurred unnecessary costs obtaining treatment. Over-diagnosis also has adverse cost
implications for the Cameroon government, which subsidizes ACT at public facilities (Mangham
et al. 2011)
An assessment of health workers during consultation for appropriate treatment prescribed
to patients tested or not tested by RDT was also conducted by the REACT team on the field. It
should be noted that patients-reported results were unreliable as they mentioned that they did not
know their test result and the results considered were those of the REACT team. So it was found
that there was no great difference for patients who were tested during the consultation as shown
77
in figure 54.
Figure 55: treatment prescribed to patients tested/not tested during patient consultation
Increasing the use of malaria testing has the potential to promote the rational use of ACT
and appropriate treatment of non-malarial febrile illness (Sayang et al. 2009). The REACT study
also suggests that attention should be given to the role of testing within therapeutic process to
ensure uptake of RDTs and prescrIPT2ions that adhere to the test result.
The results of this study also indicate that there is a reason of continuing disseminating
the policy change in the country as it has been found that the use of quinine in simple malaria has
fallen substantially since 2005 (Sayang et al. 2009 b, c), countless the others aSPects this study
has shed light unto (health providers, febrile case management etc).
3.3. Access to and delivery of malaria treatment in Cameroon
This section is a summary of some key issues addressed by the Research for Economy on
ACT, namely access to and delivery of ACTs for malaria treatment in Cameroon.
The Cameroon government has issued guidelines for the rational use of ACT in order to
prevent development of resistance. According to this guideline, patients can have access to
subsidized ACT from two sources: community relays and from the health facilities. A number of
78
conditions for benefiting from these drugs have been published and among which patients should
have been consulted by a qualified health personnel in a health unit diSPensing ACT and hold a
prescrIPT2ion properly filled and signed by a doctor. As for community relay where logistics is
often limited, delivery of ACT is done after observation of clinical signs associated with malaria
from patient and if possible a rapid test should be carried out. The average availability of ACT
across the national territory stood at 87.79%, in 2008 (NMCP, 2008). Problems had been
identified as hindrance to drugs delivery: the poor road infrastructures network and the financial
inaccessibility of the drugs even at subsidized prices to many populations; as a result many resort
to traditional medicine or get cheaper but fake drugs from unauthorized outlets (NMCP, 2008).
3.3.1. Treatment practices of providers
Adherence to guidelines for prescribing ACT to patient depends on individual providers.
Ongolo-zogo and colleagues (2008) reported that the reasons for violation of the guidelines are:
the lucrative aSPect of other treatments, the drugs stock and shortages of national recommended
drugs, marketing pressure and a slow administrative system; some providers said they only
reSPond to patients' demand. Between 2006 and 2007, 70% of all children with fever were
treated with anti-malaria drugs and 40% of which took it on the same day or the following day
and none were given ACTs (INS, 2006). In 2008, a nationwide study on malaria treatment using
ACT for children under five and above five years was done by the NMCP showed discrepancies
among regions (see Figure 9 and annexe).
3.3.2. Proportion of patients who were prescribed/received the correct dose and advice
on the regimen
According to MIC III (2006), Artesunate-AmodiAQuine combination was scarcely used in
the treatment of malaria (1%) for children less than five years who had a fever. The situation was
worse in the North and Far North regions, where only 32% and 34% of children were
appropriately treated and 9% and 22% in the 24 hours following the appearance of the first
symptoms reSPectively1% of children aged less than five years.
3.3.3. Variations in service delivery
79
The quality of service delivery to patient varies from one provider to the other. Many patients
do refer to confessional and private health facilities deSPite the price margin of drugs. They find
them more comfortable and deem the services to be of higher quality as compare to public
facilities. Like health facility preferences, quality of treatment received also varies from one
population group to the other; urban dwellers receive their first dose of treatment earlier after the
appearance of the symptoms than the rural dwellers do; only 29% of rural children received an
anti-malarial in the 24 hours following the symptoms whereas up to 53% of urban children do so
(Kiawi et al., 1997; Yomi and Koumaga, 2001; INS, 2006). In addition, reference delay to health
center in rural areas is estimated on average to be 3 days. The reasons for this delay are
underestimation of the disease, timing to auto medication with medicinal plan or from family
pharmacy box, absence of finance and distance to health facilities (Ongolo-Zogo et al., 2008).
DiSParities in access to care are also related to the absence of dialogue between the health care
provider and the patients (Ongolo-Zogo et al., 2008). It was noted that educational level of
mothers has no influence on the prevalence of fever in the child (Kiawi et al., 1997; INS, 2006).
Knowledge gaps
Data on the incidence of fever in persons other than pregnant women and children under the
age of five;
Data on the number of people seeking treatment at the formal sector, who took medicines or
an anti-malarial of a type before coming to the hoSPital.
Data on the correct dose and advice on the regimen. Also, the distribution of these indicators
to the other population groups other than pregnant women and children under the age of five;
Knowledge on the successes and failures of the intervention (NMCP, 2008) designed by the
National Malaria Control Programme on improving access to and delivery of ACTs in
Cameroon.
80
81
PART 4:
Results of malaria survey in four health district in
Cameroon
The fobang foundation, in collaboration with its partners, carried out three surveys on malaria
from March to April 2010 in Cité verte, Buea town and Ngaoundéré urbain health districts
including two health areas of Ngaoundéré rural health district (Dang and Bekahossere) as
indicated in figure 48. Obala survey was conducted by the Cameroon Coalition Against Malaria
during the month of February 2010. These surveys were designed to measure malaria prevention
indicators. The LQAS methodology was used to measure the indicators. Surveys yield qualitative
information per health district and helps identify health areas that perform well or not. Children
under the age of five, pregnant women and other groups were targeted. Participation in the
surveys was voluntary and consent was sought before interviews.
82
Figure 56: Targeted Health district for the assessment of malaria indicators
4.1. Malaria Indicators in Buea Health District
Prof. Wilfred Mbacham*, Akindeh Nji*, Pierre FONGHO SUH**, TAMSA ARFAO Antoine**
*fobang foundation, ** university of Yaoundé 1
4.1.1. Malaria prevention
Studies revealed that among 147 households sampled, 49.66% possessed at least one
mosquito net. 71.43% of bed net owners used effectively mosquito net during the previous night.
Lysoka and molyko health areas rank last with 10.53% and 15.79% reSPectively on possession
while Bova and and Muea had 61.11% and 57.89% reSPectively. Bova, Buea town and Tole
have the highest rate of use of mosquito net with 92.31%, 85.71% and 85.71% reSPectively
(Figure 57).
83
4.1.2. Malaria prevention during pregnancy
Of all women of children younger than 5 years interviewed on their last pregnancy, 56.25%
remembered having taken twice medicine, to prevent malaria during pregnancy (Figure 58). Two
health areas presented percentages below 50: Molyko (42, 11%) and Muea (29, 41%).
84
The study showed that, of the 149 parents of children less than five years questioned in the
survey, 30 (20.13%) reported that their infant had had malaria episode within the past two weeks
from the date of the survey. Of all cases, 43.33% were attended properly with ACT treatment for
three days. Buea road and Molyko got 100% each in proper management of malaria in children
less than five. A high diSParity was obtained for Bokwoango and Lysoka, where 0% of children
with malaria were adequately attended (Figure 59).
Considering the objectives of National Malaria Control Program (80% of population at risk sleep
under Insecticide treated net), malaria prevention by effective use of ITN is not well observed by
the communities. Thus, it has been showed that 71.43% of households slept under the mosquito
net during the previous night, and only 34.90% of households declared that their children (under
five year) have an ITN.
4.2. Malaria indicators in Cité verté health District
In this district, 208 households were targeted and it was found that less than half (48.61%) had at
85
least one ITN. Briqueterie health area ranked last with about 22.22% while Tsinga and
Ekoumdoum had 63.16%each. It was reported that among those who possessed an ITN, 66.65%
used them the previous night. The rate of ITN use among pregnant women varies among health
areas; we noted that in Nkolbisson, Mokolo, Tsinga and Carriere health areas, more than 80% of
ITN owners use them, whereas 5 health areas out of 11 have at most 50% of ITNs users among
owners (Figure 60). Of all the 208 pregnant women interviewed, 36.95% had an ITN and out of
the 11 health areas of the health District, 7 had more than 80% of pregnant women with ITN who
slept under it the previous night. Only 32.61% of children under five were reported to have an
ITN of which 76.44% slept under the ITN the previous night. The use varies much within the
Health District: In Cité verte, Messa, Mokolo and Carriere we recorded at least 80% of ITN use.
86
Women with children less than five years were interviewed on their last pregnancy and as result
48.10% remembered having taken medicine twice, to prevent malaria during pregnancy (Figure
61).
4.2.3. Malaria cases and management in children under the age of five
Out of 208 children sampled, 48.48% had malaria within the past two weeks before the survey
and, 20.71% received adequate treatment (ACT for Three days). This means that the majority of
children aged less than five year with malaria were not properly attended (Figure 62).
87
4.3. Malaria indicators in Ngaoundéré Urban Health Districts
In Ngaoundéré Urban Health Districts, of the 78 households sampled in the survey, 61.53% had
at least one ITN and 84.09% of adults interviewed in these households slept under it the previous
night. Among the pregnant women interviewed, 29.13% declared owing an ITN and up to
89.73% of these pregnant women slept under their bed net the previous night (Figure 63).
Meanwhile 39.53% of all children under the age of five included in the survey had an IT, of
which 89.72% of them slept under their ITN the night before the survey.
88
Women of children < 5 years were interviewed, and 47.05% remembered having taken medicine
twice, to prevent malaria during pregnancy (Figure 64).
4.3.3. Malaria cases and management of children under the age of five
Of all the 78 children under five included in the survey, 16 (20.30%) had a malaria episode within the
past two weeks from the survey date. Only 25% of them received adequate malaria treatment (ACT for
three days) (Figure 65).
89
4.4. Malaria indicators in Ngaoundéré rural Health district: Dang and Bekahossere health areas
Dang health area has a low rate (21.05%) of households with at least one ITN as compare to Bekahossere
(68.42%). But 100% of ITNs owner slept under it the previous night in Dang and 79.92% in Bekahossere
(Figure 66). Of the 15.79 % of pregnant women who possessed an ITN in Dang, half of them used them
the previous night whereas 71.43% of them in Bekahossereslept under it the previous night (Figure 66).
As concerns children aged less than five years, 5.26% of them possessed an ITN in Dang health area
meanwhile Bekahossere scored 31.58%. Bed net use stood at 50% and 100% in Dang and Bekahossere
reSPectively.
90
In both health areas, the percentage of women, mothers of children aged fewer than five that remembered
having taken twice a medicine to prevent malaria during their last pregnancy is given below 35% (Figure
67).
4.4.3
Malaria cases and management of children under the age of five
Among children aged less than five years who had a malaria episode within the past two weeks before the
survey, none had received adequate malaria treatment (Figure 68).
91
4.5. Malaria indicators in Obala
Esther Tallah1, Eteme Emmanuel2, Tsagmo Yves Ronny3, Vannie Djounguep1, Tchakoutei Happi
William3, Alima Olomo Etienne2, Akere-Maimo1, Teclaire Mekeukiounoi1, Prof Rose Leke1/3, Prof
Wilfred Mbacham1/3, Prof Gervais Andzec
1 MC-Cameroon Coalition Against Malaria; 2ADESC association; 3University of Yaoundé 1
4.5.1. Cases of fever and malaria treatment
Up to 75% households included in the survey declared cases of fever within the last two weeks
and most cases of fever were children aged less than five years.
92
Even though more than half cases of fever seek health care from health facilities in Obala, they were, in
the majority not adequately treated with the lifesaving and efficient Artemisinine Combination Therapies
(ACTs), which have been adopted by the Ministry of Public Health as first line treatment for malaria in
Cameroon. And even when ACT is used to treat malaria, onset is delayed with only 28% starting
treatment within 24 hours of onset of treatment. This means that many children in Obala were still
exposed to developing complicated malaria, which is reSPonsible for deaths by taking wrong treatment
and delaying onset of correct treatment. All the health areas were poor performers on this indicator
(Figure 69).
4.5.2 Malaria Prevention in Obala
Majority of households (80.10%) reported owning at least one insecticide treated mosquito net and up to
299 nets were inSPected in 216 households, giving an average of 1.4 mosquito nets per household. It
should also be noted that same majority of households (87.86%) reported the use of mosquito nets the
previous night. Children aged fewer than five and pregnant women do sleep under mosquito nets.
Mosquito net use is a good habit in Obala Health District.
The health areas of Efok and Batchenga had acceptable levels of insecticide treated nets ownership in
households (Figure 70). The other health areas can learn from what they do, to maintain these high levels.
93
4.5.3. Pregnant women
Pregnant women in Obala slept under mosquito nets and 67% of mothers of children aged less than five
years reported having taken medicine to prevent malaria (Intermittent Preventive Treatment during
pregnancy, IPT2p) at least twice during their last pregnancy (Figure 71).
4.5.4. Children aged less than five years
Children were most hardly hit by fever among the 75%households, which declared fever occurred in
children. Only a small percentage, 1 out of 4 received the right treatment with ACTs and only 1 out of 5
started treatments within 24 hours of onset of symptoms. Children in Obala were or are still exposed to
complications and death due to malaria. Malaria prevention by sleeping under mosquito net is a good
practice in Obala with 84% households, which declared children aged fewer than five slept under the
mosquito net the previous night. However, the efficacy of this practice is jeopardized by holes on nets and
majority of them being untreated nets.
4.6. Akonolinga Health district, malaria control project (By PLAN Cameroun)
Plan International is a child-centered community development organization that has been operating in
Cameroon since 1996. Beginning in 2005, Plan Cameroon, in collaboration with the ministry of health
and Natexis Bank (France), implemented a three-year malaria control project whose aim was to reduce by
94
50 % morbidity and mortality rates due to malaria in the Akonolinga health district by: Raising the
awareness of 350 communities on the causes of malaria; easing both financial and geographical access to
LLINs for at least 60% of children under five years old and pregnant women; promoting effective use of
LLINs by at least 60% of children under five years old and pregnant women and fostering involvement of
350 youth group/community-based organization actors in malaria control in Akonolinga health district.
To achieve this goal, the following interventions were being carried:
1.
Role-plays, sketches, theater and health talks on malaria control during public ceremonies by
youth
2.
Clean-up campaigns to drain stagnant water, fill up pot hole and clear bushes
3.
Exchange visits to learn from well-performing youth groups on malaria control
4.
Free distribution of LLINs to under-five children and pregnant women (3,667)
5.
Regular home visits conducted by youth and CBO members to ensure effective use of bed nets
and IPT2 uptake for pregnant women.
RESULTS
The project outcome was higher than targets in general.
Bed net use among pregnant women and children under the age of five
At the end of the three year project, the percentages of pregnant women and children under the aged of
five sleeping under ITN exceeded 80% moving from a baseline of 13% and 5% reSPectively (Figure 72).
The figure below shows the trend from the period 2005-2008.
95
The number of households with LLINs also increased from the baseline (Figure 73).
The coverage of pregnant women with IPT2 increased from the baseline from the project period
2005-2008 (Figure 74).
96
Continuous sensitizations on behavioral change and on the use of LLINs can greatly ameliorate
or reduce malaria situation amongst vulnerable population, which are pregnant women and
children under five.
As keys to success Plan underlines:
 the important roles played by Youth in community-based management of malaria,
 the Role-plays, dramas, and sketches in the dissemination of community-based messages.
The involvement of community leaders and women's groups as critical in creating and enabling
environment.
As conclusions:
Youth participation is an effective tool in the control of malaria
Use of LLINs is enhanced by frequent home visits by youth and CBO members
Youth participation is not only effectual but cost-effective. Cost is less than US$2 per
beneficiary
Malaria interventions can offer immense economic benefit: target household SPending on health
dropped by 80%.
Recommendations
* Carry out massive campaign to promote the use of ACTs and prompt treatment of malaria
* Sensitization first, to incite people to own at least an insecticide treated bed net and to use it
regularly. A particular emphasis should be put on children under 5 to increase ITN possession.
* Promote Intermittent Preventive Treatment of malaria during pregnancy (IPT2p) to reach the
100% coverage of the global objective.
* Behavior Change Communication in favor of appropriate home management of malaria
97
* Experience of best performing health areas to be transferred to poor performing zones
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ANNEXE I: Epidemiological profile of malaria in Cameroon ((the situation of malaria
control in 2008, progress report N°2 june 200 and Activities report of the NMCP, 2009)
Malaria morbidity rates recorded at health facilities in 2008 and 2009
Regions
Numbers of patients
consulted in 2008
Numbers of patients
consulted in 2009
Number of malaria cases
(uncomplicated and severe
malaria) in 2008
Adamawa
Centre
186,379
615,114
230,142
778,294
87,691
250,544
105,127
319,279
62,914
186,672
74,723
231,082
East
Far North
268,814
601,963
277,853
749,863
117,052
284,926
114,165
330,471
81,797
175,664
75,530
203,927
Littoral
North
529,702
453,333
685,677
544,973
163,126
224,601
198,664
243,889
106,925
158,689
133,682
166,305
North-West
South
473,083
447,642
648,052
98,260
150,154
194,275
180,860
39,769
110,033
123,335
132,930
27,238
South-West
West
99,396
389,428
473,620
419,656
40,147
138,233
172,753
178,222
29,248
85,914
119,609
101,482
4,064,854
4,906,390
1,650,749
1,883,199
1,121,191
1,266,508
Total
104
Regions
Adamawa
Centre
East
Far North
Littoral
North
North-West
South
South-West
West
Total
Regions
Adamawa
Centre
East
Far North
Littoral
North
North-West
South
South-West
West
Total
REGIONS
Adamawa
Centre
East
Far North
Littoral
North
North-West
South
South-West
West
Total
Number of malaria cases
(uncomplicated and severe
malaria) in 2009
number of cases of
uncomplicated malaria
in 2008
Malaria morbidity in children under 5 years in health facilities in 2008 and 2009
Numbers of under-fives
Numbers of under-fives
Number of malaria cases in 2008
consulted in 2008
consulted in 2009
52,202
165,209
78,593
221,435
121,321
183,614
91,376
117,220
27,631
91,189
1,149,790
65,082
219,524
86,430
268,443
154,923
190,249
116,975
28,868
104,602
105,780
1,340,975
number of cases of
uncomplicated malaria in
2009
Number of malaria cases in 2009
31,846
101,132
46,191
119,900
52,705
110,782
48,454
71,277
16,209
45,279
643,775
Malaria Morbidity among pregnant women in health facilities in 2008 and 2009.
Numbers of pregnant women
Numbers of pregnant women
% of malaria
consulted for all reasons in 2008
consulted for all reasons in 2009
cases in 2008
9,611
13,454
79%
32,151
48,283
52%
18,396
21,819
42%
35,276
44,152
65%
25,036
34,721
29%
26,242
25,618
41%
14,074
18,808
33%
21,907
6,632
40%
5,755
24,052
42%
23,043
22,935
71%
211,491
260,474
49%
40,151
115,037
48,208
139,428
65,411
113,930
60,057
16,294
58,252
64,030
720,798
% of malaria cases in 2009
Percentages of hoSPitalized children under five and pregnant women as result of severe malaria, per region in 2009
Nber of
Nber of hoSPitalized
% of hoSPitalized persons
hoSPitalized
% of hoSPitalized
Nber of
persons older than five
older than five years
under five
under five
hoSPitalized
% of hoSPitalized
years (excluding pregnant
(excluding pregnant
children for
children for
pregnant women
pregnant women
women) for malaria in all
women) for malaria in all
severe malaria in
severe malaria in
for malaria in all
for malaria in all
hoSPitalized persons older
hoSPitalized persons older
all under five
all under five
hoSPitalized
hoSPitalized
than fiive excluding
than fiive excluding
hoSPitalization
hoSPitalization
pregnant women
pregnant women
pregnant women
pregnant women
8620
62%
29.22
61%
15713
46%
26031
57%
95.92
71%
47778
46%
8440
64%
28.86
64%
14477
46%
30767
65%
8727
74%
40095
48%
31793
48%
10628
59%
69260
36%
15898
69%
4436
54%
26343
47%
23448
47%
8817
36%
86040
28%
4555
54%
1549
64%
6087
50%
17013
54%
4791
70%
37816
32%
40227
60%
9935
66%
64611
52%
206792
57%
64283
62%
408220
41%
56%
59%
28%
43%
35%
44%
29%
52%
42%
45%
44%
105
Percentage of under five, and persons above five (pregnant women excluded) treated with ACT during a malaria episode 2008 and 2009
Regions
Number of
Number of
% of
% of
Number of
% of persons
Number of
% of persons
under fives under fives underunder-fives persons above
above five
persons above
above five
treated
treated
fives
treated
five excluding
excluding
five excluding
excluding
with ACTs
with ACTs treated
with ACTs
pregnant
pregnant
pregnant
pregnant women
in 2008
in 2009
with ACTs
in 2009
women treated women treated women treated
treated with
in 2008
with ACTin
with ACTin
with ACTin
ACTin 2009
2008
2008
2009
Adamawa
1,485
16,782
6.03%
56.47%
2,851
7.44%
25375
56.39%
Centre
37,423
37,321
46.75%
41.05%
52,838
49.56%
63677
45.48%
East
22,564
63,762
65.68%
73.53%
32,605
68.73%
80545
68.72%
Far North
59,004
23,576
78.88%
70.70%
71,278
70.67%
30251
71.71%
Littoral
20,265
26,815
58.54%
61.40%
40,510
56.02%
50824
56.47%
North
43,231
54,303
54.04%
67.73%
43,023
54.67%
57121
66.32%
NorthWest
24,207
30,422
64.84%
66.39%
49,466
68.04%
63594
73.01%
South
25,294
6,813
53.98%
57.48%
39,096
51.12%
9588
62.32%
SouthWest
7,084
26,927
60.65%
62.00%
10,398
59.19%
43094
56.57%
West
21,973
19,845
74.48%
53.83%
37,051
65.68%
34417
53.27%
61.00%
458486
60.01%
Total
262,530
306,566
57.85%
379,116
56.81%
ANNEXE II:Pricing of ACTs in public & private sectors
(Study of the ACT subsidy in
Cameroon)
Product
(International Nonproprietary Name)
Dosage
Estimated
(Incoterm
CIF
Douala)
Unit selling
price
at
CENAME
Level
Cost at
CENAM
E with
subsidy
36.5%67.15%
Unit selling price at
CAPPs to Public facilities
Unit selling price at CAPPs
to Private profit making
Selling price
at
health
facilities
–
Peripheral
level
of
private
nonprofit
making
Intermedi
ary level
(With an
8% mark
up)
Peripheral
level (With a
10%
mark
up)
Intermediar
y
level
(With
a
24% mark
up)
Peripheral
level (With a
59%
mark
up)
With a 45%
mark up
Imports
With 10%
mark up
ArtesunateAmodiAQuine
50mg + 153, tablets
50mg + 153, tablets
50mg + 153, tablets
ArtemetherLumefantrine 20mg
+ 120mg, tablets
+ 120mg, tablets
+ 120mg, tablets
+ 120mg, tablets
6
tablets
(infants)
168 844
186
118
127
140
146.5
235
175
12
tablets
(children)
272 140
299
194
209
230
240.5
385
285
24
tablets
(Adults)
484 260
533
337
364
400
418
665
490
6
tablets
(infants)
527 914
581
236
255
280
293
470
345
12
tablets
(children)
819 000
901
337
364
400
Undetermin
ed
Undetermine
d
Undetermined
18
tablets
(adolescents)
1 105 353
1216
421
454
500
522
830
615
24
tablets
(Adults)
1 398 500
1538
505
546
600
626.2
1000
733

i

Transcription

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