The findings of this study suggest that, at 66% of the prevalence level, uncomplicated malaria was overdiagnosed in the Jakiri Health Centre from 2006 to 2021. These results corroborate earlier reports by Mangham et al. (2012), Sayang et al. (2009) and Ndong et al. (2015) that malaria is still overdiagnosed in Cameroon. These acts of misdiagnosis led to unnecessary treatments being prescribed to patients who did not carry the parasite or who were not receiving beneficial treatment for other illnesses and infections [32–34]. The advent of RDTs and the need to confirm all suspected cases before treatment where possible, as recommended by the WHO, have led to a reduction in the level of overtreatment in many settings [35].
This study revealed that anti-malaria agents and antibiotics were prescribed in different combinations, such as ACT + AB, Q + AB, FS + AB + ACT, FS + AB + Q, and FS + AB. However, no combinations of ACTs and quinine were recorded. The prescription of ACTs and quinine for malaria case management fluctuated over time. These results are in line with the reports of Ndong and colleagues [1], except that in the latter, in some cases, both ACT and quinine were prescribed to some patients.
There seems to have been no prescription of ACT for the treatment of uncomplicated malaria during the period from 2006 to 2011, as quinine was the only antimalarial agent prescribed along with antibiotics to febrile patients confirmed to have malaria. This is in contrast to the findings of Sayang et al. (2009), where 15% of febrile patients were prescribed ACTs, and another 2012 report, where ACTs were prescribed to 51% of febrile patients [21, 23, 36]. This finding might suggest that although ACTs were adopted in Cameroon in 2004, the implementation of the policy was much slower in some health facilities than in others despite the efforts of the National Malaria Control Programme. It is not clear whether this is because the health workers in this facility were not up to date with the new treatment guidelines and preferred to use quinine, which they were comfortable with, or because the cost of treatment with ACTs posed a challenge or because of patient preference [36]. It could also be that confirmed cases were being treated for severe malaria. These results, however, do not fit with any previous study conducted between 2006 and 2011 on malaria case management where no ACTs were used. Instead, cases of underuse and overuse of ACTs were recorded in various epidemiological settings in Cameroon, which was attributed to either nonadherence to the treatment guidelines or the presumptuous prescription of drugs to febrile patients, respectively [21, 23, 36]. There is a need for rigorous monitoring when putting in place a new treatment policy.
Until 2011, only quinine was prescribed to febrile patients. In 2012, when the first doses of ACTs were prescribed, quinine prescription decreased drastically until 2013, after which no prescription was recorded until 2020 and 2021, when 0.2% and 0.1% of quinine prescriptions were recorded, respectively. This finding is in line with the report by Ndong and colleagues, who reported that quinine and ACT prescription fluctuated alternatively [1]. These results suggest that after 2013, ten years after its adoption in 2004, the first-line malaria treatment guidelines for the use of ACTs for the treatment of uncomplicated malaria were adhered to at the Jakiri Health Centre. Under this policy, quinine was reserved for severe cases. Another possible explanation for the sharp decline in quinine prescriptions over time could be the decrease in severe malaria cases in the area. This is reflected in the fact that in 2019 and 2020, a few cases of quinine use were recorded.
Over 90% of ACTs were prescribed to patients who were confirmed to be positive for malaria. Children between 5 and 15 years of age received the most ACTs (42.3%), followed by children aged 1 to < 5 years (31.6%). This percentage is lower than that reported by Sayang and colleagues, who reported that 61% of patients < 5 years old were prescribed ACTs. This is in line with findings from Zambia (50%) and Uganda (66%), where < 5 children have been reported to receive higher proportions of ACT prescriptions [37]. This, however, contrasts with the findings of Ndong and colleagues, who reported that patients aged < 1 year received the most ACTs. These results show improvements in malaria treatment in this health facility, as more than three-quarters of anti-malaria prescriptions were received by patients who were confirmed to have malaria. This shows a gradual but steady shift from the earlier practice where prescribers do not adhere to test results, as reported in Cameroon [1, 23], Ghana [38] and Tanzania [26].
Approximately two-thirds of antibiotics were prescribed to patients with a negative result for malaria. This finding is consistent with reports by Ndong et al. (2014) and Reyburn et al. (2007). Between 2006 and 2012, all febrile patients who visited the Jakiri Health Centre were prescribed an antibiotic except in 2015 and 2017, when the proportions of antibiotics prescribed were 45% and 73%, respectively. The proportions of patients who were prescribed antibiotics ranged from 86 to 99%. The proportion of patients with confirmed malaria diagnosis who received antibiotics was lower than that of patients who were negative for malaria. This suggests that antibiotics were highly overprescribed, especially for malaria patients, at the Jakiri Health Centre. However, it is not clear whether these confirmed malaria cases were coinfections of the malaria parasite and the bacteria.
The findings further suggest that there was excessive overprescription of analgesics (100%) to confirmed malaria-positive patients and more than 95% to patients confirmed to be negative for malaria. This not only results in inappropriate treatment but also places a tremendous financial burden on patients and the health system.
The results presented in this study show malaria case management at the Jakiri Health Centre. The data used were collected retrospectively over a 16-year period and were not randomly selected; hence, the data may not represent the entire population. Additionally, these data were collected from one public health center; including data from confessional and private health facilities could further improve the findings. We did not assess bacterial or viral infections over the study period, which would have improved the findings.