Abstractobjective To investigate the quality of malaria case management in Cameroon 5 years after the adoption of artemisinin-based combination therapy (ACT). Treatment patterns were examined in different types of facility, and the factors associated with being prescribed or receiving an ACT were investigated.methods A cross-sectional cluster survey was conducted among individuals of all ages who left public and private health facilities and medicine retailers in Cameroon and who reported seeking treatment for a fever. Prevalence of malaria was determined by rapid diagnostic tests (RDTs) in consenting patients attending the facilities and medicine retailers.results Among the patients, 73% were prescribed or received an antimalarial, and 51% were prescribed or received an ACT. Treatment provided to patients significantly differed by type of facility: 65% of patients at public facilities, 55% of patients at private facilities and 45% of patients at medicine retailers were prescribed or received an ACT (P = 0.023). 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 < 0.001), were examined by the health worker (OR = 1.88, P = 0.021), had not previously sought an antimalarial for the illness (OR = 2.29, P = 0.001) and sought treatment at a public (OR = 3.55) or private facility (OR = 1.99, P = 0.003). Malaria was confirmed in 29% of patients and 70% of patients with a negative result were prescribed or received an antimalarial.conclusions Malaria case management could be improved. Symptomatic diagnosis is inefficient because two-thirds of febrile patients do not have malaria. Government plans to extend malaria testing should promote rational use of ACT; though, the introduction of rapid diagnostic testing needs to be accompanied by updated clinical guidelines that provide clear guidance for the treatment of patients with negative test results.

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Enhanced clinician training, designed to translate knowledge into prescribing practice and improve quality of care, has the potential to halve overtreatment in public and mission health facilities in Cameroon. Basic training is unlikely to be sufficient to support the behaviour change required for the introduction of RDTs.

Introducing RDTs with enhanced training was more cost-effective than RDTs with basic training when each was compared with current practice.

Resistance in malaria vectors is likely to be caused by the massive use of insecticides in agriculture. Anopheles gambiae s.l. collected from breeding grounds in two cabbage growing areas within Accra were assessed for levels of resistance to 0.75% permethrin, 0.05% deltamethrin, 5% malathion and 4% DDT using standard WHO susceptibility test kits. Pyrethroid and organophosphate residue levels in soil and runoff water from these cabbage farms were determined and possible association between resistance and residue levels were established. Compared to the susceptible 'Kisumu' strain, both Korle-Bu and Airport populations were highly resistant to DDT and gave resistance levels which were over nine-fold for permethrin and over 2.5-fold for deltamethrin. Both wild and susceptible populations showed full susceptibility to malathion. The S and M forms of A. gambiae s.s. were found to occur in sympatry in the two study sites with a higher frequency of S form in the Airport area. Toxicity testing of extracts of soil and runoff water from these cabbage farms, using brine shrimp lethality tests, showed high level of toxicity, indicative of the presence of residues of insecticides. Differential fractionation of these extracts using solid phase extractor (SPE) suggests that the bulk of residues in these extracts may be pyrethroids and organophosphates. No correlation was observed between either residue levels or residual bioactivity in soil and runoff water, and resistance levels in A. gambiae s.l. populations, collected from breeding grounds within the farms under investigation. It is proposed that resistance in A. gambiae larvae in these breeding sites contaminated with agricultural insecticides may have occurred over time due to continuous exposure to sub-lethal doses.