Adding proactive and reactive case detection into the integrated community case management system to optimise diagnosis and treatment of malaria in a high transmission setting of Cameroon: an observational quality improvement study

OBJECTIVE: Integrated community case management (iCCM) of childhood illness is a powerful intervention to reduce mortality. Yet, only 29% and 59% of children with fever in sub-Saharan Africa had access to malaria testing and treatment between 2015 and 2017. We report how iCCM+ based on incorporating active case detection of malaria into iCCM could help improve testing and treatment. DESIGN: A community-led observational quality improvement study. SETTING: The rural community of Bare-Bakem in Cameroon. PARTICIPANTS: Children and adults with fever between April and June 2018. INTERVENTION: A modified iCCM programme (iCCM+) comprising a proactive screening of febrile children <5 years old for malaria using rapid diagnostic testing to identify index cases and a reactive screening triggered by these index cases to detect secondary cases in the community. PRIMARY AND SECONDARY OUTCOME MEASURES: The proportion of additional malaria cases detected by iCCM+ over iCCM. RESULTS: We screened 501 febrile patients of whom Plasmodium infection was confirmed in 425 (84.8%) cases. Of these cases, 102 (24.0%) were index cases identified in the community during routine iCCM activity and 36 (8.5%) cases detected passively in health facilities; 38 (8.9%) were index cases identified proactively in schools and 249 (58.6%) were additional cases detected by reactive case detection—computing to a total of 287 (67.5%) additional cases found by iCCM+ over iCCM. The likelihood of finding additional cases increased with increasing family size (adjusted odd ratio (aOR)=1.2, 95% CI: 1.1 to 1.3) and with increasing age (aOR=1.7, 95% CI: 1.5 to 1.9). CONCLUSION: Most symptomatic cases of malaria remain undetected in the community despite the introduction of CCM of malaria. iCCM+ can be adopted to diagnose and treat more of these undiagnosed cases especially when targeted to schools, older children and larger households.