By Aminateh Nkemngu, first published in The Post newspaper and online at Journal de Cameroun.
Despite a 66% reduction in mortality between 2000 and 2015, malaria remains a major global public health problem, affecting mostly Sub-Saharan Africa. According to the 2016 Global Malaria Report, there were 212 million new cases of malaria worldwide in 2015. Africa alone accounted for most global cases of malaria (90%), followed by the South-East Asia Region (7%) and the Eastern Mediterranean Region (2%). In 2015, there were an estimated 429,000 malaria deaths. 92% of these deaths occurred in Africa, followed by the South-East Asia Region (6%) and the Eastern Mediterranean Region (2%). According to the World Health Organisaiton (WHO), "Malaria is by far the world's most important tropical parasitic disease, and kills more people than any other communicable disease except tuberculosis. In many developing countries, and in Africa especially, malaria exacts an enormous toll in lives, in medical costs, and in days of labour lost".
Malaria prevalence in Cameroon
Cameroon remains endemic to malaria, with about 41% suffering at least one episode of malaria, annual overall mortality of 30-35% and 67% childhood mortality. Cameroon government's subsidy on artemisinin combination therapy (ACT) for uncomplicated malaria, intermittent preventive treatment for pregnant women (IPTp), free distribution of insecticide treated bed nets (ITNs) to pregnant women and under-fives have been more of a top-down approach, with the affected communities mainly at the receiving end. Challenges of failed adherence to test results, drug and insecticide resistance, substandard and self-medication, low ITN ownership and utilisation have been identified, especially in the rural areas.
Malaria is a major public health problem in Cameroon. Over 900,000 clinical cases occur yearly and are responsible for 40–45% hospital consultations, 20% hospital admissions and 35–40% deaths. Children less than five years old are the most affected. Despite efforts made by the National Malaria Control Programme to curb the disease burden, the prevalence is seemingly on the increase. Previous studies have attributed this to the increasing spread of drug resistance in the parasite, insecticide resistance in the vectors, inadequate and inconsistent allocation of resources for control and the presence of very efficient mosquito vectors of Plasmodium falciparum.
The Ministry of Public Health in Cameroon notes that this has become even more challenging since some malaria parasites have become resistant to commonly used drugs like chloroquine and the vector has become resistant to commonly used insecticides such as DDT. Malaria is a heavy burden to Cameroonians, a major cause of high infant and maternal mortality, work loss and a serious impediment to economic development and productivity. The epidemiology of malaria is influenced by attributes of the mosquito vectors, which in turn are closely linked to environmental conditions. Malaria afflicts mostly the poor, who tend to live in malaria endemic areas and in dwellings that offer little or no protection against mosquitoes and by sapping their health, strength and productivity it further marginalizes and impoverishes them. Efforts to combat malaria in Cameroon are hindered by the poor sanitations in most regions of the country, wide spread poverty, economic crisis, high birth rates, unstable political system in addition to health problems posed by other diseases such as AIDS, tuberculosis, typhoid fever and sleeping sickness.
Inadequate control measures
Malaria vector control activities in Cameroon focus mainly on the use of insecticide-treated bed nets. However, the implementation of effective vector control strategies requires requisite information on the vector population structure, their distribution and efficiency in malaria transmission. Previous studies in Cameroon have shown that the intensity and duration of transmission, as well as the vector species, vary greatly between different eco-zones of the country, from perennial transmission in the southern forested regions to seasonal and unstable transmission in the northern Sudano-savannah and Sahelian savannah regions.
The control of malaria by the National Malaria Control Program (NMCP) in Cameroon involves among others vector control such as combining treated bed net use and indoor residual spraying, free distribution of intermittent preventive treatment to pregnant women and free treatment of children aged under five with artemisinin-based combination therapy.
Prevention of malaria in Cameroon encompass a variety of measures, which include protection against infection, and development of diseases in infected individuals with some degree of environmental control. Measures of protection against infection are directed against mosquito control both at the personal and community levels. Personal protection by individual Cameroonians involves the use of insecticides or environmental management to control transmission, as well as mosquito coils, mostly imported from China.
However, reports indicate practices for the control of malaria have been unsatisfactory despite the serious adverse effects of the disease.
The Post Newspaper No 02030 of Friday 30 August 2019 reports that "it is feared that some 1.3 million mosquito nets destined for Cameroon’s households might not meet the required global standards. According to compliance protocols set by the WHO, long lasting insecticidal nets known by the abbreviation LLINS must sustain optimal efficiency for at least three years. Nonetheless, the Ministry of Public Health is unable to affirm whether previous batches of such treated nets as well as future deliveries are of acceptable quality."
To date repeated enquiries made by The Post newspaper at the Ministry of Public Health remain unanswered. One official at the Communication cell of the Ministry told the Newspaper that "we are not authorized to give such information. It is a matter on which only higher-ups in the hierarchy are able to comment on".
According to The Post newspaper, the Ministry is not alone in keeping silent on this burning issue. Local bodies specialized in public health have shied away from enquiries on the treated mosquito nets paid for by donor countries. From the National Malaria Control Programme to the Cameroon office of the international NGO, Malaria No More, there have been no responses to the issue despite requests for these organizations to comment.
In February this year, Cameroon’s Minister of Public Health, Manaouda Malachie, revealed that close to 15 million treated mosquito bed nets will be distributed nationwide this year during a campaign dubbed, "Treated mosquito bed nets for the entire family, every night".
The third phase of the exercise targeting the Centre, North West, South West Regions and 11 district hospitals in the Littoral Region was slated to begin on 4 September.
However, an official at the South West Regional Delegation of Public Health says the last distribution of free mosquito nets in the health districts of the region took place in 2016 and 2018. He said another distribution of treated nets will occur this year. However, the official, who declined to be named said, "I don’t know the exact date for the 2019 distribution."
Chinese mosquito coils breaking new ground
Among other alternatives there is a rapidly growing interest in the use of Chinese mosquito coils/repellents in many malaria and mosquito infested areas in Cameroon despite increasing calls for the use of treated mosquito nets, and even their free distribution to the population by the National Malaria Control Programme.
Research conducted by Antwi-Agyei Philip and Obiri Danso Kwasi in 2016 indicates that "the use of mosquito coils and repellents, mostly imported from China has gained widespread patronage in malaria-endemic countries, especially Cameroon, even though it is not a recommended preventive measure for avoiding mosquitoes. Mosquito coils contain insecticides, which are expected to vaporize slowly once the coil is lit, to provide protection against the mosquito. The mosquito coil base material contains a variety of compounds capable of burning slowly to gradually release the insecticide. The mosquito coil smoke, however, is potentially a source of indoor air pollution with implications for acute respiratory infections (ARI) and other illnesses."
"Children and their parents in residences are often protected by insecticides from nuisance and disease-bearing mosquitoes. The annual worldwide consumption of the four major types of residential insecticide products -- aerosols, mosquito coils, liquid vaporizers, and vaporizing mats -- is in the billions of units. Coils consist of an insecticide/repellent, organic fillers capable of burning with smoldering, binder, and additives such as synergists, dyes, and fungicide. The number of coil users in China is in the millions".
Most Cameroonians especially those in mosquito endemic areas utilise mosquito coils to avoid bites from the mosquito. When these coils are burnt in bedrooms at night the smoke keeps the insects away or kills the insects when they fly through the smoke. The coils are not very expensive and are especially useful early in the evening when people sit outdoors. However these coils have been associated with certain respiratory disorders and as such are not the best method of control. As a result, mosquito coils to reduce the incidence of malaria in Cameroon is very unsustainable since they are a health concern.
In the locality of Mambanda, a peripheral community that is inhabited by the urban poor in Cameroon’s economic capital Douala, drainage remains a serious problem, leaving room for standing water and poor public hygiene that breed mosquitoes.
Wamba Serge Alain, a roadside hawker in this neighbourhood explains that sales of Chinese mosquito coils is one of the most lucrative components of his business. He explains that most of his customers show up in the early hours of the evenings and buy between two and three coils at 100 frs (US$0.17) each for a night while others prefer to buy an entire packet of 10 coils for 400 frs (US$0.68).
As late as 9 pm, several residents take turns to buy their coils. Wamba Serge Alain has two big sacks of the "Black Panther" mosquito coils in front of him this Friday evening. He puts it right on his legs as the frequency of purchase is quite high. Before long,one of the sacks is half gone.
Several other roadside hawkers in the neighbourhood and even medium size shops have different brands of coils on sale.
Enchou Deh, a female resident of the locality explains that her household uses mosquito coils in the early hours of the evening – between 6pm and when they go to bed. She admits that she goes for the coils because they render the mosquitoes unable to bite even though they are not killed. Enchou adds that at bedtime, they spread out their mosquito nets and switch on their fans to mitigate the incidence of heat associated with bed nets.
In the living room of Vincent Acha, another resident of the area, there is an entire table locker where mosquito coils are kept. Even though there are two bed nets in the two bedrooms of his apartment, the father of three admits that his family is obliged to use mosquito coils in the early hours of the evenings while in the sitting room. He prefers using mosquito coils especially in the dry season. With the city of Douala recording very high temperatures in the dry season, Vincent says his family prefers sleeping on mattresses in the sitting room and using mosquito coils rather than in the bedroom under mosquito nets.
Across in the Dockyard neighbourhood of Limbe in the South West Region, local fishermen tear up mosquito nets and use them to protect small gardens of vegetables behind their plank houses to protect the gardens from ruminants like goats. Here the fishermen live in swamps where fish scales are jettisoned, creating a breeding ground for mosquitoes.
The use of Chinese mosquito coils, known locally as "Moon Tiger", is also a very common practice here. Each evening they stroll to the small shops at the beach front and purchase coils that they use for the night.
All along the Cameroon coast especially in communities like Idenau, Munyenge, Ekondo Titi, Mundemba, right down to the creeks of Bakassi on the Cameroon-Nigeria border, the use of Chinese mosquito coils, some imported from neighbouring Nigeria, is on the rise. Traders importing goods into Cameroon at the Idenau Custom post admit delivering huge quantities of coils bought in Nigeria to communities along the Cameroon coast. Awani Angoh, one of such traders explains that he has a warehouse in the locality of Idenau, in the West Coast District from where he sells mosquito coils in bulk to local retailers.
A study jointly conducted by Laboratoire de Recherche sur le paludisme, Organisation de Coordination pour La Lutte Contre Les Endemies En Afrique Central, the Faculty of Sciences at the Univesity of Yaounde 1 and Vector Group at the Liverpool School Of Tropical Medicine entitled "Awareness, Attitudes and Prevention of Malaria in the cities of Yaounde and Douala-Cameroon" has revealed an increase in the use of mosquito coils by Cameroonian households despite the availability of free treated mosquito nets provided by the government. The study notes that these cities are situated within the Congo-Guinean phytogeographic zone characterized by a typical equatorial climate with two rainy seasons extending from March to June and from September to November. Average annual prevalence of Plasmodium falciparum in the general population of these two cities is estimated to vary between 34% to 50% from the city centre to the periphery.
The research found that the proportion of families using coils was significantly important in Douala (16.3%) and Yaoundé (8.4%). About one quarter of families owning bed nets in Douala (24.4%) and 16.9% in Yaoundé declared also using coils. Coils were more frequently used by families residing in the districts of Malangue, Bonaberi, PK8, Bessengue, Cité des Palmiers in Douala and Messa in Yaoundé. Investigations in the city of Yaoundé were conducted in fifteen districts: Ahala, Biyem-Assi, Mballa 2, Melen, Messa, Mokolo, Mvogada, Etoug-Ebe, Mvogbeti, Mvogbi, Nkolbisson, Nkomkana, Obili, Tsinga and Nkolkumu. In Douala, investigations took place in fourteen districts: Bonaberi, Bessengue, Beedi, Bonamoussadi, Bonangang, Cité des palmiers, Nylon, Ndogbong, Dakar, Makepé, Malangue, New-Bell, PK8, Village. Selected districts were distributed from the periphery to the city centre and included highly populated, well urbanized, and spontaneously urbanized districts. Some of the problems experienced by families using ITN were the difficulty to find chemicals for retreatment of nets (47%), insufficient financial means to buy new bed nets to replace old ones (24.5%) or, to provide bed nets to everybody in the household (19.4%) and the sensation of feeling excessive heat when sleeping under a bed net (5%).
Also, Cameroon’s armed conflict currently raging in the South West and North West Regions of the country has created an enabling environment for local peoples to buy and depend on Chinese mosquito coils to prevent malaria.
Several village communities such as Kwa-Kwa, Bole Nake, Munyenge, Bova, Konye, Malende, Mbalangi, Ediki, Matoh, Mabonji among several other villages have been razed to ashes. Thousands of local inhabitants have lost their homes and properties including mosquito bed nets that were freely donated to them by local services of the Ministry of Public Health.
Many of these farm families now live in makeshift structures on their farms which are inside tropical forests where mosquitoes are endemic.With no access to any other form of protection from mosquitoes, the only way out is to secure huge quantities of Chinese mosquito coils which are available and affordable.
Ibekwe Simon, an internally displaced person from Munyenge village which is now completely razed as a result of the conflict has found new livelihood transporting and selling essential goods to other internally displaced persons living in makeshift structures on their cocoa farms in the forests of Masone, on the periphery of the once buoyant Munyenge cocoa farming community.
Ibekwe explains that each time he has to buy and transport goods on bike from Muyuka to Masone, he must ensure huge quantities of mosquito coils which are in high demand in these new settlements. "Several women are delivering babies, many of the children there are living under precarious conditions and malaria infections are very high. So, the only way out is to use mosquito coils to help control the situation", he says.
This is further compounded by the fact that the government’s 13 billion frs (US$22 million) humanitarian assistance programme is limited to essential food supplies. Health supplies constitute less than 20%. The mosquito nets traditionally supplied by government for free are not part of the humanitarian package. Cameroon’s Minister of the Interior, Paul Atanga Nji who is in charge of managing the aid has not commented on this loophole in the assistance programme.
The United Nations Office for the Coordination of Humanitarian Affairs notes that "as of the end of June 2019, WHO supported community-based surveillance activities in the South West have ended due to lack of funding. There are no surveillance activities taking place in the North West. The risk of an outbreak of preventable diseases in the region is high."
The UN agency adds that "insecurity has forced more than 530,000 people to flee their homes since the conflict erupted in late 2016. Continuous armed clashes, civilian casualties and the burning of houses, hospitals and other infrastructures continue to cause further displacements."
Under this precarious situation, many of the displaced families are turning to Chinese mosquito coils to prevent mosquitoes and stop their children from dying from preventable malaria.
Despite the increasing use of mosquito coils in malaria endemic regions of Cameroon, statistics of the quantity imported into the country are hard to come by.
Lum Mirabel, a retailer of mosquito coils in Bonaberi Douala estimates that the quantity is undeniably huge.Most of the importers are Chinese businessmen who are often very reluctant to release information on the amount of coils imported.
Lum Mirabel further explains that the most widely used brand of mosquito coils in the city is the “Black Panther” brand.A visit to several retail shops in Douala indicates that they all have the Black Panther Mosquito coils in stock.These coils are usually displayed at very prominent locations in the shop.
Investigations further revealed that some of the companies involved in the importation and marketing of mosquito coils include the Jinjiang Sweat Dream Commodity Limited and the Xiaomi Mijia Company whose products are marketed online by Jumia Cameroon.The price quotes on the Jumia Online Marketing platform range from nine US Dollars to 50 US Dollars.This therefore indicates that this platforms markets to mosquito coils in bulk to smaller retailers who in turn sell it to households.
Given that the use of mosquito coils in the control of the malaria vector is not officially recognized by the government of Cameroon, there are no statistics on the quantity imported and the scale of its use amongst the population. It is hoped that the government of Cameroon will soon document the scale and extent of use of Chinese mosquito coils in malaria endemic regions of the country.