[Prescribing and dispensing generic drugs in the Mambéré-Kadéï health district of the Central African Republic]. / Prescription et dispensation des médicaments essentiel génériques dans la Préfecture Sanitaire de la Mambéré-Kadéï (République centrafricaine).

Good drug prescription and distribution practices are pre-requisites for rational use of essential generic medications. However few studies have been conducted on this topic in sub-Saharan Africa especially in rural areas. The purpose of this study in the Mambéré-Kadei health district of the Central African Republic was to evaluate drug use patterns with special attention to prescribing and dispensing, as a basis for assisting policy makers in planning and identifying intervention strategies. The transverse descriptive survey was undertaken in 14 public health facilities in the Mambéré-Kadéï health district. Data were collected by interviewing care providers and patients immediately after consultation and at the exit of the dispensary. The indicators recommended by the World Health Organization (WHO) for investigating drug use patterns in Communities were used for data collection. A total of 512 prescriptions were analysed. The average number of drugs prescribed per consultation was 3.5. Most drugs (68.6%) were prescribed by generic name. Antibiotic use (31.4% of consultations) was frequent and 29% of patients received injections. 82.1% of the drugs were compliant with the national essential drug list. The distribution survey showed that 79.46% of prescriptions were completely filled. No serious distribution errors occurred but 21.5% of the dispensed drugs were inadequately labelled. Patients understood the modalities of use for 69.6% of prescribed drugs. The average consultation and distribution times were 8.3 and 5 minutes respectively. Excessive use of antibiotics and injections and blunderbuss therapy is still observed in Mambéré-Kadei. Many drugs not included on the essential drug list and non-generics are prescribed. Other prescription and distribution problems identified in this survey include poor information on drug use, inadequate labelling of dispensed drugs, and lack of access to standard drug use tools such as a locally adapted essential drug list, formularies and standard treatment guidelines. To improve the system, caregivers must receive more training on the rational use of essential generic drugs and the population must be better informed.

Prescription et dispensation des medicaments essentiels generiques dans la Prefecture Sanitaire de la Mambere-Kaderei (Republique Centrafricaine)

Les bonnes pratiques de prescription et de dispensation sont des prerequis a l'usage rationnel des medicaments essentiels generiques. Cependant; il y a peu d'etudes sur le sujet en Afrique subsaharienne; en particulier en zone rurale. Cette etude descriptive transversale a ete realisee a partir d'un echantillon representatif de 14 formations sanitaires de la prefecture de Mambere- Kadei. Les donnees ont ete collectees par interview des soignants et des patients juste apres la consultation et a la sortie du point de dispensation. Les indicateurs OMS de l'utilisation des medicaments ont ete employes pour la collecte de donnees. 512 prescriptions ont ete analysees. Le nombre moyen de medicaments par consultation etait 3;5; 68;6de medicaments ont ete prescrits par la Denomination Commune Internationale. Les prescriptions des antibiotiques (31;4) etaient frequentes; et 29des patients ont recu des injections. 82;1de medicaments prescrits sont conformes a la liste nationale des medicaments essentiels. Concernant la dispensation; les medicaments prescrits ont ete dispenses pour 79;5de prescriptions. 21;5de medicaments delivres avaient un etiquetage inadequat. 69;6des patients connaissaient la posologie correcte des prescriptions. La duree moyenne de consultation et de dispensation etait respectivement de 8;3 et de 5 minutes. Dans la Mambere- Kadei; on observe la polypharmacie; un usage excessif des antibiotiques et des injections. Les medicaments ne figurant pas sur la liste des medicaments essentiels et les specialites restent eleves. En termes d'interventions; les programmes de formations sur l'usage rationnel des medicaments essentiels generiques pour les soignants et des campagnes de sensibilisations des populations semblent necessaires

Acute lower respiratory infections among children hospitalized in Bangui, Central African Republic: toward a new case-management algorithm.

To measure the performance of the current WHO algorithm in identifying children at higher risk of death, children aged 2-59 months who presented with cough and/or difficult breathing and were admitted into the paediatric hospital of Bangui (Central African Republic) during a 1-year period (1996/97) were investigated. Among children with subcostal indrawing, mortality and severity of oxygen desaturation were identical whether or not they also had tachypnoea. Among children with a 'severe pneumonia', those who also fulfilled the 'very severe disease' definition had a higher risk of death (31/132, 23.5%) than those who did not (12/106, 11.3%, P = 0.02). However, this 'very severe disease' definition did not predict death when used in children who did not have severe pneumonia. To identify variables that would better predict death, combinations of symptoms and signs were examined among the subgroup of children with indrawing. Nine combinations had both a sensitivity and specificity over 60%. 'Grunting and/or nasal flaring' had a sensitivity of 72% and a specificity of 66% in predicting death, and might be easier to use by primary health care personnel than other combinations. A new algorithm is proposed for the management of children aged 2-59 months presenting with cough and/or difficult breathing. The definition of pneumonia would be unchanged (tachypnoea). Severe pneumonia would remain defined on indrawing regardless of respiratory rate, except that indrawing should be lower chest wall and/or intercostal. In health facilities where intravenous antibiotics, chloramphenicol and/or oxygen are available, entry into a 'very severe pneumonia' category would be based on 'grunting and/or nasal flaring' among children with indrawing. In our study population, the mortality rates in the categories based on these definitions were 0.8% (1/127) in children with no pneumonia, 0.9% (1/116) in children with pneumonia, 7.7% (12/156) in children with severe pneumonia and 31.1% (33/106) in children with very severe pneumonia.

Aetiology of urethral discharge in Bangui, Central African Republic.

OBJECTIVES: To determine the aetiology of urethritis in Bangui, Central African Republic. METHODS: 410 men presenting with urethral discharge and 100 asymptomatic controls were enrolled. Urethral swabs were obtained and processed by gonococcal culture and polymerase chain reaction for the detection of Neisseria gonorrhoeae, Chlamydia trachomatis, Mycoplasma genitalium, Trichomonas vaginalis, and Ureaplasma urealyticum. RESULTS: In multivariate analyses, M genitalium and C trachomatis were significantly associated with urethral discharge when comparing cases of non-gonococcal urethritis (NGU) with controls. T vaginalis was also more common in cases than in controls, but this reached statistical significance only among cases in whom N gonorrhoeae was also detected. U urealyticum was not associated with urethritis. The gonococcus was found in 69% of cases of urethral discharge. M genitalium was the predominant pathogen in patients with NGU, being found in 42% (53/127) of such patients while C trachomatis was found in only 17% (22/127). T vaginalis was found in 18% (23/127) of patients with NGU, but also in 15% (43/283) of patients with gonococcal urethritis, and two thirds of patients with T vaginalis also had the gonococcus. Multiple infections were common. M genitalium caused a syndrome similar to chlamydial urethritis, with a less severe inflammation than in gonococcal infection. No behavioural or clinical characteristic could discriminate between the various aetiological agents. CONCLUSIONS: M genitalium is more prevalent than C trachomatis and is the most common cause of NGU in BANGUI: It causes a syndrome similar to chlamydial urethritis. T vaginalis is weakly associated with urethritis, and is often found along with other pathogens.

Quality of sexually transmitted disease treatments in the formal and informal sectors of Bangui, Central African Republic.

BACKGROUND: Interventions for upgrading sexually transmitted disease (STD) management in sub-Saharan Africa have focused on the public sector, and to a much lower extent on private medical practitioners and pharmacies. However, in most African cities there is a large informal sector that provides care to many patients with STD symptoms. GOAL: To compare the quality of treatments offered to patients with major STD syndromes in the public sector, pharmacies, and the informal sector of the same city. STUDY DESIGN: Healthcare providers in health centers, pharmacies, private laboratories, and market drug peddlers in Bangui, Central African Republic, were asked to complete a short form for every patient consulting them with genital complaints. The treatments they ordered were evaluated for their potential efficacy against the major etiologic agents of the syndrome for which the patient consulted. RESULTS: The majority of male patients with STDs preferred to seek care in pharmacies and in the informal sector. The STD treatments offered to patients with urethral discharge or genital ulcers in pharmacies and in the informal sector tended to focus on a single etiologic agent. The quality of STD treatments offered by drug peddlers and private laboratories was poor, apart from adequate coverage of syphilis in patients with genital ulcers and of candidiasis in women with vaginal discharge. For instance, 41% and 34% of patients with urethral discharge managed by drug peddlers and private laboratories did not receive a drug active against either Neisseria gonorrhoeae or Chlamydia trachomatis, whereas this proportion was 22% in pharmacies and 14% in health centers. For patients with genital ulcers, the proportion offered a drug active against Haemophilus ducreyi was 2% if seen by drug peddlers, 0% in laboratories, 10% in pharmacies, and 25% in health centers. For each syndrome and each category of provider, between one fourth and two thirds of patients had already received another ineffective treatment elsewhere. CONCLUSION: National STD and HIV control programs will have to improve STD management in pharmacies and in the informal sector if they are to have any impact on the dynamics of HIV infection in urban centers.

Risk factors for mortality among children hospitalized because of acute respiratory infections in Bangui, Central African Republic.

BACKGROUND: Acute respiratory infections are the most common cause of death in children in developing countries. Little information is available on risk factors for mortality among African children presenting with symptoms compatible with acute respiratory infections. OBJECTIVE: To identify risk factors for death among children hospitalized for respiratory complaints who satisfy the WHO clinical definition for pneumonia or severe pneumonia. METHODS: Children <5 years of age who presented with cough and/or difficult breathing and were hospitalized in Bangui during a 1-year period were investigated for risk factors for mortality. The study population consisted of 395 children who satisfied the WHO clinical definition for pneumonia/severe pneumonia. The associations between death and demographic, nutritional, socioeconomic, laboratory and clinical variables were examined. RESULTS: Of the 49 (12.4%) children who died, all but one had had indrawing of the chest which, in univariate analysis, was the risk factor most strongly associated with death [odds ratio, 22.99; 95% confidence interval (CI), 3.81 to 935.2]. In a multivariate model the independent risk factors for death were indrawing of the chest [adjusted odds ratio (AOR) 8.35, CI 1.04 to 66.82], hepatomegaly (AOR 6.72, CI 2.35 to 19.21), age between 2 and 11 months (AOR 6.37, CI 2.18 to 18.59), grunting (AOR 4.53, CI 1.96 to 10.45), a moderate/severe alteration of general status (AOR 3.23, CI 1.17 to 8.94) and acute malnutrition (AOR 2.74, CI 0.96 to 7.78). CONCLUSIONS: These findings could be used in flow charts for the management of children with respiratory complaints to identify children at increased risk of death who need to receive aggressive therapy.

Providing low-cost sexually transmitted diseases services in two semi-urban health centers in Central African Republic (CAR): characteristics of patients and patterns of health care-seeking behavior.

BACKGROUND: While treatment of symptomatic sexually transmitted diseases (STDs) has been shown to reduce the incidence of HIV infection, there are few published reports describing the delivery of high quality STD care in Africa. GOAL: To test the feasibility of providing comprehensive, affordable STD services through the existing primary care infrastructure. DESIGN: STD treatment services using a syndromic' approach were established in two semi-urban hospital outpatient departments (OPD) in Central African Republic (CAR). A dedicated paramedical provider took a clinical history, performed an examination, explained the diagnosis and the importance of referring partners, dispensed drugs, and offered partner referral vouchers. A fee-for-service system was used to resupply drugs initially purchased with project funds. RESULTS: Of 9,552 visits by index patients and partners over a 28-month period starting in October 1993, 60% were made by women; of these women, 90% were symptomatic, 77% had "vaginal discharge," 70% "lower abdominal pain," and 7% "genital ulcer." Among men, 64 % were symptomatic, 38 % had "urethral discharge," and 14% "genital ulcer." Half of all symptomatic patients presented within 1 week of the onset of symptoms; 44% of men compared to 18% of women had sought care elsewhere before the clinic visit. The average cost per STD treated with recommended drugs was $3.90. Etiologic data from subpopulations in both sites suggest that a high proportion of patients was infected with an STD. CONCLUSIONS: Comprehensive yet affordable care for STDs in persons (and their partners) who recognize symptoms is feasible and should be widely implemented in primary care systems to prevent the spread and complications of STDs and HIV in Africa.

PIP: This study examines the feasibility of providing comprehensive, low-cost sexually transmitted disease (STD) services through the existing primary care infrastructure in two semi-urban health centers in the Central African Republic. The results showed that out of the 9552 visits made by index patients and partners over a 28-month period, 60% were made by women. Among these women, 90% were symptomatic, 77% had vaginal discharge, 70% had lower abdominal pain, and 7% had genital ulcer. In addition, 44% of men, as compared to 18% of women, had looked for treatment elsewhere prior to the clinic visit. The average cost per STD treated with the recommended drugs was $3.90. Furthermore, condom use was low in both areas and etiologic data suggest that a large proportion of patients was infected with an STD. The findings suggest that a comprehensive and affordable model for STD control can be implemented in primary care systems to prevent the spread of STDs in Africa.

Patient-led partner referral enhances sexually transmitted disease service delivery in two towns in the Central African Republic.

In Bambari and Bria, 2 towns in the Central African Republic (CAR), we analysed a patient-led partner referral programme within enhanced sexually transmitted disease (STD) services. New (index) patients received syndromic management, counselling about notifying and treating contacts, and vouchers for distribution. From October 1993 to February 1996, 5232 and 4320 patient visits, of which 1814 (35%) and 4320 (30%) were contact referral visits, were logged in Bambari and Bria, respectively. Vouchers were distributed for at least 90% of contacts. Index and contact patients had similar age and sex distributions. In both towns, having a spouse (Bambari: odds ratio [OR] 1.5, 95% confidence interval [CI] 1.4-1.7; Bria: OR 1.9, 95% CI 1.5-2.3) was a factor associated with successful referral of a partner. Successful referral was accomplished by both male and female patients. Appropriate counselling techniques and vouchers facilitated partner referral. Further research on how to reach casual partners would enhance STD control efforts using patient-led partner referral.

Predictors of rape in the Central African Republic.

This is a study of women in the Central African Republic (CAR) whose first sexual encounter was the result of rape. The analyses presented here are based on a national HIV/AIDS survey conducted in 1989. Respondents were selected through multistage cluster sampling, where census districts and households within districts were randomly selected. A total of 1307 females responded to the question regarding the circumstances of their first intercourse. Nearly 22% of female respondents reported that their first experience with intercourse was rape. Bivariate analyses found that rape during first intercourse was significantly related to the following respondent characteristics at the time of the survey: age, marital status, having a child, education, occupation, urban versus rural living, ethnic group, age at first date, and consumption of alcohol. Rape was not significantly related to ability to read, religion, and years in current village or town. Rape during first intercourse was found in a stepwise logistic regression to be related to age, marital status, occupation, and ethnic group. These data indicate that the incidence of rape is higher than previously reported in Africa, there are specific risk factors, and there are serious negative consequences.

Evaluation of an AIDS training program for traditional healers in the Central African Republic.

Training designed to improve AIDS knowledge, attitude, and practice was delivered to 96 traditional healers in the Central African Republic. The training (17 to 36 hours) was conducted by traditional healers with the assistance of staff from the Ministry of Health. Training included the following topics: prevention of HIV transmission during traditional practice; diagnosis, treatment, and prevention of sexually transmitted diseases; condom promotion; AIDS education at the community level; psychosocial support for people with AIDS; and promotion of a positive image for traditional healers. The evaluation of the training consisted of a prospective assessment of knowledge and attitude immediately prior to and after training. These assessments were conducted using structured interviews. Improvement in knowledge and/or attitudes was observed in all areas assessed except for prevention of HIV transmission during traditional practice. We concluded that AIDS training can be successfully delivered to traditional healers.

Multiple sexual partners: results of a national HIV/AIDS survey in the Central African Republic.

OBJECTIVES: To determine the prevalence and characteristics of individuals with more than one sexual partner in the Central African Republic during the previous 12 months. DESIGN: A national survey. METHODS: A stratified sample of 2589 individuals aged 15-50 years was interviewed in late 1989. The 157-question survey questionnaire was a modified version of a questionnaire developed by the World Health Organization Global Programme on AIDS. RESULTS: Thirty-four per cent of men and 17% of women reported having sex with more than one partner during the previous 12 months. For both men and women, logistic regression indicated that the risk of having multiple partners increased with being single compared with being married; being employed in a profession other than agriculture compared with being a farmer, unemployed, a housewife, or a student; living in an urban rather than a rural area; rape being part of their first sexual encounter; and combining sex with alcohol. Risk increased with increasing ability to read for men and with decreasing age and drinking alcohol for women. CONCLUSIONS: These findings can be used to develop and target HIV/AIDS prevention and control programmes and to improve mathematical models of the epidemic.

Avancee du front epidemique de l'infection a VIH1 en Afrique centrale

Pour limiter l'expansion de l'infection a VIH une etude socio-spaciale s'avere necessaire. En Afrique Centrale; la prevalence presente une situation contrastee; d'un cote l'expansion est rapide et lente de l'autre. Malgre une relative accalmie dans les grandes metropoles; on note une nette expansion dans les centres urbains secondaires

Attitudes; opinions et pratiques des praticiens relatives a l'annonce du resultat serologique VIH

Le Programme National de Lutte contre le SIDA de la Republique Centrafricaine a initie une enquete aupres du personnel de sante pour evaluer leurs attitudes; opinions et pratiques envers les personnes atteintes du SIDA; ceci dans le but d'analyser les conditions de la prise en charge de ces malades et d'apprecier les reactions relatives a l'annonce du diagnostic. Les reponses recues de cette enquete sont controversees. Pendant que certains preferent taire la verite d'autres pensent plutot qu'il faut la livrer. Ce dialogue constitue toutefois une base pour la la formation du personnel de sante

[Polychemotherapy of leprosy in the Central African Republic, 1987]. / La polychimiothérapie de la lèpre en République Centrafricaine, en 1987.

The Central African Republic, which once had the highest Hansen disease prevalence rate in the Central African States, had exemplary results in the control carried out on the basis of sulfonic monotherapy since 1958. In 1983, a cluster sample survey in Upper-Sangha seemed to show that the prevalence of the disease was underestimated. It then became necessary to adopt a new national strategy whose objective would be to reduce the prevalence of leprosy in the country by 50% within five years. For this, a "National Programme for the Control of Leprosy in C.A.R." has been developed; in part it foresees the setting up of polychemotherapy for patients. These treatment protocols should insure healing of paucibacillary forms within six months and of multibacillary forms within twenty-four months. The new strategy of screening and decentralized treatment required retraining personnel and combining health education at individual and collective levels. The preliminary results of a national survey for the evaluation of the prevalence of leprosy are presented.