Search

Background: Despite increasing evidence on COVID-19, few studies have been conducted in humanitarian settings and none have investigated the direct and indirect effects of the pandemic in the Central African Republic. We studied the COVID-19 epidemiology, health service utilization, and health care seeking behavior in the first year of the pandemic in Bangui and surrounding areas. Methods: This mixed-methods study encompasses four components: descriptive epidemiological analysis of reported COVID-19 cases data; interrupted time series analysis of health service utilization using routine health service data; qualitative analysis of health care workers' perceptions of how health services were affected; and health care seeking behavior of community members with a household survey and focus group discussions. Results: The COVID-19 epidemiology in CAR aligns with that of most other countries with males representing most of the tested people and positive cases. Testing capacity was mainly concentrated in Bangui and skewed towards symptomatic cases, travelers, and certain professions. Test positivity was high, and many cases went undiagnosed. Decreases in outpatient department consultations, consultations for respiratory tract infections, and antenatal care were found in most study districts. Cumulative differences in districts ranged from − 46,000 outpatient department consultations in Begoua to + 7000 in Bangui 3; − 9337 respiratory tract infections consultations in Begoua to + 301 in Bangui 1; and from − 2895 antenatal care consultations in Bimbo to + 702 in Bangui 2. Consultations for suspected malaria showed mixed results while delivery of BCG vaccine doses increased. Fewer community members reported seeking care at the beginning of the pandemic compared to summer 2021, especially in urban areas. The fear of testing positive and complying with related restrictions were the main obstacles to seeking care. Conclusions: A large underestimation of infections and decreased health care utilization characterized the first year of the COVID-19 pandemic in Bangui and surrounding area. Improved decentralized testing capacity and enhanced efforts to maintain health service utilization will be crucial for future epidemics. A better understanding of health care access is needed, which will require strengthening the national health information system to ensure reliable and complete data. Further research on how public health measures interact with security constraints is needed. [ABSTRACT FROM AUTHOR]

Background: CAR is one of the poorest countries in the world. While UN statistics suggest that there is no health emergency in the country, two recently published mortality surveys contradict this. Moreover, recent accusations of massive scale human rights abuses by mercenaries suggested the need for a nationwide mortality survey. Methods: Two stage cluster surveys were conducted in two different strata: one in the roughly half of the country within the Government's control, and one in the areas mostly outside of the Government's control. We randomly selected 40 clusters of 10 households in each stratum. The survey included questions on vital events with open-ended questions about health and household challenges at the beginning and end of each interview. Results: 70 of 80 selected clusters were successfully visited. We interviewed 699 households, containing 5070 people. 11 households (1.6%) refused to be interviewed and approximately 18.3% of households were absent at the time of visitation, mainly in the safer Government controlled areas. Interviewed households had a birth rate of 42.6 /1000 / year (95%CI 35.4–59.7) and a crude mortality rate (CMR) of 1.57 /10,000/day (95%CI: 1.36–1.78). The birth rate was lower and the death rate markedly higher in the strata outside of Government control. Families described malaria or fever, and diarrhea as the primary reported causes of death with violence accounting for 6% of all deaths. Conclusions: CAR is experiencing a severe health emergency, with the highest measured nationwide mortality in the world to our knowledge. UN published death rate estimates appear to be less than one fourth of reality. There is a desperate need for food aid in the form of general distributions in CAR, along with the accompanying work programs, seed and tool distributions needed to restart local economies. This is of particular importance in rural areas outside of the Government control. While some humanitarian actors are doing their best to respond, the crisis level mortality rate suggests that the needs in CAR are being largely unmet. [ABSTRACT FROM AUTHOR]

Introduction: In the Central African Republic (CAR), HIV/AIDS is the main cause of death in women aged 15–49 years. Increased testing coverage is essential in prevention of HIV/AIDS, especially in areas where conflict hinders access to health care. Socio-economic status (SES) has been shown to be associated with HIV testing uptake. We investigated whether "Provider-initiated HIV testing and counselling" (PITC) could be implemented in a family planning clinic in an active conflict zone in the Central African Republic to reach women of reproductive age and assessed whether socioeconomic status was associated with testing uptake. Methods: Women aged 15–49 years were recruited from a free family planning clinic run by Médecins Sans Frontières in the capital Bangui. An asset-based measurement tool was created based on analysis of qualitative in-depth interviews. Measures of socioeconomic status were constructed from the tool, also by using factor analysis. Logistic regression was used to quantify the association between SES and HIV testing uptake (yes/no), while controlling for potential confounders: age, marital status, number of children, education level and head of household. Results: A total of 1419 women were recruited during the study period, where 87.7% consented to HIV testing, and 95.5% consented to contraception use. A total of 11.9% had never been tested for HIV previously. Factors negatively associated with HIV testing uptake were: being married (OR = 0.4, 95% CI 0.3–0.5); living in a household headed by the husband as opposed to by another person (OR = 0.4, 95% CI 0.3–0.6), and lower age (OR = 0.96, 95% CI 0.93–0.99). Higher level of education (OR = 1.0, 95% CI 0.97–1.1) and having more children aged under 15 (OR = 0.92, 95% CI 0.81–1.1) was not associated with testing uptake. In multivariable regression, testing uptake was lower in the higher SES groups, but the differences were not significant (OR = 0.80, 95% CI 0.55–1.18). Conclusions: The findings show that PITC can be successfully implemented in the patient flow in a family planning clinic, without compromising contraception uptake. Within the PITC framework in a conflict setting, socioeconomic status was not found to be associated with testing uptake in women of reproductive age. [ABSTRACT FROM AUTHOR]

Background: Unstable settings present challenges for the effective provision of antiretroviral treatment (ART). In this paper, we summarize the experience and results of providing ART and implementing contingency plans during acute instability in the Central African Republic (CAR) and Yemen. Case presentation: In CAR, MSF has provided HIV care in three conflict-affected rural regions; these were put on hold throughout the acute phase of violence. "Run-away bags" containing 3 or 4 months of ART were distributed to patients at MSF facilities. Among 1820 HIV patients enrolled into care, 1440 (79%) initiated ART. By December 2016, 782 (54%) patients were still under ART, 354 (25%) have been lost to follow up and 182 (13%) had died. In 2013, when violence disrupted services, 683 patients were receiving ART. Between September–December 2013, 594 (87%) patients received runaway bags and by February 2014, 313 (53%) of these patients returned to the clinic. In Yemen, when violence erupted, patients received a health card that included a helpline to call in case of drug shortages in admission to emergency stocks; this was not possible in CAR due to lack of a functioning telephone network. One thousand six hundred fifty-five PLWHA have been enrolled in care and 1470 (89%) initiated ART; 1056 (72%) are still followed on ART, 126 (9%) were lost to follow up, and 288 (20%) died. In January 2011 clashes began and by April 2011 MSF medical activities were interrupted. Of the 363 patients receiving ART, 363 (100%) received emergency bags to cover 9 months and by February 2012, 354 (98%) patients returned to care. In March 2015 a new wave of conflict affected Yemen, forcing HIV activities to revert to contingency planning. Conclusions: This experience provides further evidence that provision of HIV treatment and emergency drug stocks can be successfully provided to most patients in both conflict-affected settings. [ABSTRACT FROM AUTHOR]

The Central African Republic (CAR) is one of the world's poorest and most fragile countries. Maybe there is no nation on the planet where the official health statistics are so poor. Evidence presented in this Conflict and Health themed collection to document humanitarian needs in CAR, suggests that UN statistics dramatically under-estimate the birth and death rates in conflict settings. To be current and valid, health indicator data in violent settings require more frequent measurement, more triangulation and granular exploration, and creative approaches based on few assumptions. In a world increasingly dependent on model driven data—data often inaccurate in conflict settings—we hope that this collection will allow those service providers and researchers operating in CAR to share their work and help us better learn how to learn. We particularly invite research from professionals working in CAR that documents humanitarian needs and presents indicators of population health where official estimates might not articulate the true extent of the health crisis. [ABSTRACT FROM AUTHOR]

Background: The Central African Republic (CAR) suffers a protracted conflict and has the second lowest human development index in the world. Available mortality estimates vary and differ in methodology. We undertook a retrospective mortality study in the Ouaka prefecture to obtain reliable mortality data. Methods: We conducted a population-based two-stage cluster survey from 9 March to 9 April, 2020 in Ouaka prefecture. We aimed to include 64 clusters of 12 households for a required sample size of 3636 persons. We assigned clusters to communes proportional to population size and then used systematic random sampling to identify cluster starting points from a dataset of buildings in each commune. In addition to the mortality survey questions, we included an open question on challenges faced by the household. Results: We completed 50 clusters with 591 participating households including 4000 household members on the interview day. The median household size was 7 (interquartile range (IQR): 4—9). The median age was 12 (IQR: 5—27). The birth rate was 59.0/1000 population (95% confidence interval (95%-CI): 51.7—67.4). The crude and under-five mortality rates (CMR & U5MR) were 1.33 (95%-CI: 1.09—1.61) and 1.87 (95%-CI: 1.37–2.54) deaths/10,000 persons/day, respectively. The most common specified causes of death were malaria/fever (16.0%; 95%-CI: 11.0–22.7), violence (13.2%; 95%-CI: 6.3–25.5), diarrhoea/vomiting (10.6%; 95%-CI: 6.2–17.5), and respiratory infections (8.4%; 95%-CI: 4.6–14.8). The maternal mortality ratio (MMR) was 2525/100,000 live births (95%-CI: 825—5794). Challenges reported by households included health problems and access to healthcare, high number of deaths, lack of potable water, insufficient means of subsistence, food insecurity and violence. Conclusions: The CMR, U5MR and MMR exceed previous estimates, and the CMR exceeds the humanitarian emergency threshold. Violence is a major threat to life, and to physical and mental wellbeing. Other causes of death speak to poor living conditions and poor access to healthcare and preventive measures, corroborated by the challenges reported by households. Many areas of CAR face similar challenges to Ouaka. If these results were generalisable across CAR, the country would suffer one of the highest mortality rates in the world, a reminder that the longstanding "silent crisis" continues. [ABSTRACT FROM AUTHOR]

Background: Measuring human rights violations is particularly challenging during or after armed conflict. A recent nationwide survey in the Central African Republic produced estimates of rates of grave violations against children and adults affected by armed conflict, using an approach known as the "Neighborhood Method". Methods: In June and July, 2009, a random household survey was conducted based on population estimates from the 2003 national census. Clusters were assigned systematically proportional to population size. Respondents in randomly selected households were interviewed regarding incidents of killing, intentional injury, recruitment into armed groups, abduction, sexual abuse and rape between January 1, 2008 and the date of interview, occurring in their homes' and those of their three closest neighbors. Results: Sixty of the selected 69 clusters were surveyed. In total, 599 women were interviewed about events in 2,370 households representing 13,669 persons. Estimates of annual rates of each violation occurring per 1000 people in each of two strata are provided for children between the ages of five and 17, adults 18 years of age and older and the entire population five years and older, along with a combined and weighted national rate. The national rates for children age five to 17 were estimated to be 0.98/1000/year (95% CI: 0.18 - 1.78) for recruitment, 2.56/1000/year (95% CI: 1.50 - 3.62) for abduction, 1.13/1000/year (95% CI: 0.33 - 1.93) for intentional injury, 10.72/ 1000 girls/year (95% CI: 7.40 - 14.04) for rape, and 4.80/1000 girls/year (95% CI: 2.61 - 6.00) for sexual abuse. No reports of any violation against a person under the age of five were recorded and there were no reports of rape or sexual abuse of males. No children were reported to have been killed during the recall period. Rape and abduction were the most frequently reported events. Conclusions: The population-based figures greatly augment existing information on human rights violations in CAR, and represent a step forward in quantifying the protection needs of Central Africans. Government, donors, and international organizations should make use of this data to better inform advocacy, prevention, and response programs, to assist in fundraising, and to develop surveillance activities to monitor child protection concerns. [ABSTRACT FROM AUTHOR]