Narrowing the treatment gap with equitable access: mid-term outcomes of a community case management program in Cameroon.

Coverage of case management interventions remains low and inadequate to achieve millennium development goal (MDG) target reductions in child mortality. Children living in the poorest households are particularly disadvantaged. Community case management (CCM) uses trained and supervised community health workers to improve access to, quality of and demand for effective case management. Evidence that CCM programs can achieve equitable improvements in coverage is limited. This cross-sectional study uses a quasi-experimental design with intervention and comparison areas. Outcomes of a CCM program for malaria and diarrhoea operating in two districts of Cameroon were measured after 1 year of implementation. A household census (N = 16 954) provided measurement of treatment-seeking behaviour for recent episodes of fever and diarrhoea. Results were compared between areas using chi-square tests. Intervention-area children with fever or diarrhoea were nearly nine times more likely to receive treatment with artemisinin combination therapy or oral rehydration salts, respectively, vs neighbouring comparison-area children. High levels of effective treatment were equitable across socioeconomic status in intervention areas, whereas disparities were observed in neighbouring comparison areas. CCM can achieve rapid and equitable improvements in coverage of case management for malaria and diarrhoea, and is a promising strategy for achieving MDG 4. Improved access to treatment, quality of care and caregiver demand were achieved in two districts of Cameroon. CCM must be scaled up to demonstrate outcomes and impact at scale.

Molecular epidemiology of malaria in Cameroon. XXI. Baseline therapeutic efficacy of chloroquine, amodiaquine, and sulfadoxine-pyrimethamine monotherapies in children before national drug policy change.

The availability of epidemiologic data on drug-resistant malaria based on a standardized clinical and parasitological protocol is a prerequisite for a rational therapeutic strategy to control malaria. As part of the surveillance program on the therapeutic efficacy of the first-line (chloroquine and amodiaquine) and second-line (sulfadoxine-pyrimethamine) drugs for the management of uncomplicated Plasmodium falciparum infections, non-randomized studies were conducted in symptomatic children aged less than 10 years according to the World Health Organization protocol (14-day follow-up period) at 12 sentinel sites in Cameroon between 1999 and 2004. Of 1,407 children enrolled in the studies, 460, 444, and 503 were treated with chloroquine, amodiaquine, or sulfadoxine-pyrimethamine, respectively. Chloroquine treatment resulted in high failure rates (proportion of early and late failures, 48.6%). Amodiaquine was effective at all study sites (proportion of failures, 7.3%). Sulfadoxine-pyrimethamine therapy was less effective than amodiaquine (P < 0.05), with failures observed in 9.9% of patients. Chloroquine is no longer a viable option and has been withdrawn from the official drug outlets in Cameroon. Amodiaquine and, to a lesser extent, sulfadoxine-pyrimethamine monotherapies are still effective in Cameroon, but further development of resistance to these drugs should be delayed by the novel strategy using artemisinin-based combination therapy. Our findings indicate that amodiaquine is the most rational partner for artesunate. Studies on the efficacy of artesunate-amodiaquine combination are currently being undertaken at several sites in the country.

Molecular epidemiology of malaria in Cameroon. XI. Geographic distribution of Plasmodium falciparum isolates with dihydrofolate reductase gene mutations in southern and central Cameroon.

The DNA sequence of the dihydrofolate reductase (dhfr) gene, a molecular marker for pyrimethamine resistance, was determined for 178 field isolates of Plasmodium falciparum collected along the east-west axis in southern Cameroon. The proportion of isolates having the wild-type dhfr allele varied from 48.1% in the east (city of Bertoua) to 11.3-15.7% in central provinces (Yaounde and Eseka) and 0% in the littoral region (port city of Douala). Isolates with a single Asn-108 mutation or double mutations (Ile-51 or Arg-59 and Asn-108) constituted approximately 10% of the samples. Isolates with triple mutations (Ile-51, Arg-59, and Asn-108) were present in an equal proportion (48.1%) as the wild-type isolates in the east (Bertoua), while triple mutations predominated in Yaounde (62.3%), Eseka (62.7%), and Douala (78.9%). The distribution of triple dhfr mutations along the east-west axis in southern Cameroon suggests the presence of a decreasing gradient from the west coastal region to the central region and then to the east towards the interior of the country.