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High mortality in Carnot city Central African Republic January-July 2012 ESCAIDE, 6 November 2013. Nelly Fournet, EPIET cohort 2011. Economical and geographical background. CAR: 4 millions inhabitants 80% of population < 2 $ / day 45% of adults are illiterate

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High mortality in carnot city central african republic january july 2012 escaide 6 november 2013

High mortality in Carnot city Central African RepublicJanuary-July 2012ESCAIDE, 6 November 2013

Nelly Fournet, EPIET cohort 2011


Economical and geographical background
Economical and geographical background

  • CAR: 4 millions inhabitants

  • 80% of population < 2 $ / day

  • 45% of adults are illiterate

  • Political instability / Isolated

  • Life of expectancy: 48 years


Carnot city
Carnot city

  • 61 790 inhabitants

  • Agriculture replaced progressively by diamond mining

  • 2009 : diamond mining restricted → crisis

    → MSF opened a programme for acute malnutrition in children

    • 2010 : MSF opened an HIV programme


Health situation in carnot city
Health situation in Carnot city

  • January-July 2011 : retrospective mortality survey

  • Crude Death Rate 3x higher than emergency threshold*:

    • CDR = 3.7/10,000/day (CI95% 3.0 – 4.6)

    • 0-5 DR = 7.0/10,000/day (CI95% 5.3 – 9.,3)

      → MSF actions:

      → Primary health care

      → Paediatric ward

      → Measles mass vaccination campaign

      → Mortality surveillance system

*CDR = 1 death / 10,000 inhabitants / day

0-5 DR = 2 deaths / 10,000 children <5 y / day


Objectives
Objectives

Main objective:

  • Estimate the crude death rate (CDR) and the specific death rate among children <5y (0-5 DR) in Carnot city between January and July 2012

    Secondary objective:

  • Estimate the main causes of deaths

    → In order to re-adjust MSF interventions


Study design
Study design

  • Cross-sectional retrospective survey

  • Recall period: January 2012 – July 2012

  • Information collected:

    • Number of persons in the household at the date of the survey

    • Number of deaths / births / who joined / left the household + dates

    • Cause of death (simplified verbal autopsy)

    • Study population:

      • Population: all persons living more than 1 month in Carnot

      • Household: all persons sharing the same meal and under the responsibility of the same person


Methods
Methods

  • Two-stage cluster sampling

    • Stage one: selection of the neighbourhoods (clusters) proportional to population size

    • Stage two: within each cluster, selection of the households with the EPI method

  • Sample size:

    • Sample size: 3,717 persons = 710 households

    • 30 clusters selected: 24 households per cluster

  • Survival analysis:

    • CDR and 0-5 DR estimations and CI95%

    • Trends over the time



Death rates
Death Rates

2011:

  • CDR = 3.7/10,000/day (CI95% 3.0 – 4.6)

  • Emergency threshold: CDR = 1/10,000/day

  • 0-5 DR = 7.0/10,000/day (CI95% 5.3 – 9.,3)

  • Emergency threshold: 0-5 DR = 2/10,000/day


Trends over the recall period
Trends over the recall period

Specific death rate among children <5 years from January to July 2012, Carnot city, CAR


Main causes of deaths
Main causes of deaths

  • Children <5 years

    • 35% malaria

    • 10% neonatal deaths (without associated causes)

    • 7% diarrhoea

  • Adults >15 years

    • 30% HIV

    • 13% malaria

    • 10% accident (poisoning, trauma, bite…)


Conclusion
Conclusion

  • Limitations:

    • Recall bias

    • Cause of deaths reported by verbal autopsy

    • Results specific to Carnot City, not generalize to CAR

  • Crude death rate and the specific death rate among children <5y decreased half compared to 2011

  • Above emergency threshold

  • Main cause of death: HIV among adults and malaria among children


Recommendations
Recommendations

-> Strengthen collaboration with health local authorities

-> Improve access and coverage of health care centres

-> Improve paediatric and neonatal health care

-> Improve malaria and HIV diagnosis, treatment and prevention

  • March 2013 : rebellion in Bangui (capital)

    → Overthrow of the government

    → Priority: care of injured persons


Acknowledgement
Acknowledgement

  • Carnot city population

  • All Interviewers from CAR

  • MSF team in Carnot City

  • Sandra Cohuet, Epicentre, Paris

  • KlaudiaPorten, Epicentre, Paris

  • Susan Hahné, RIVM, the Netherlands



Definition of the main causes of deaths
Definition of the main causes of deaths

  • Duration of the illness

  • Death linked with the pregnancy / the delivery

  • Neonatal death (<28 days)

  • Diarrhoea

  • Coughing / Respiratory troubles

  • Neurologic troubles

  • Malaria

  • Isolated fever

  • Measles

  • Trauma, injury

  • Pain in the mouth / difficulty to eat

  • Cutaneous problems / permanent scratching

  • Major loss of weight

  • Other


Case definition of hiv and tb
Case definition of HIV and TB*

HIV

  • Duration of the illness > 2 months before death

  • Associated with:

    • diarrhoea >1 month

    • or difficulty to eat

    • or cutaneous problems

    • or major loss of weight

  • Without associated TB diagnosis

    TB

  • Duration of the illness > 2 months before death

  • Associated with coughing > 1 month and loss of weigh

    *Tassie JM, Savignoni Alexia et al. Retrospective mortality survey in Rusinga Island, Suba district, Nyanza province, Kenya. Avril 2002. Rapport final In. Paris: Epicentre; 2002.


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