Hepatitis E, Central African Republic

Objective To analyse the characteristics, frequency, drivers, outcomes and stakeholders of health workers’ strikes in low-income countries. Methods We reviewed the published and grey literature from online sources for the years 2009 to 2018. We used four search strategies: (i) exploration of main health and social sciences databases; (ii) use of specialized websites on human resources for health and development; (iii) customized Google search; and (iv) consultation with experts to validate findings. To analyse individual strike episodes, pre-existing conditions and influencing actors, we developed a conceptual framework from the literature. Results We identified 116 records reporting on 70 unique health workers’ strikes in 23 low-income countries during the period, accounting for 875 days of strike. Year 2018 had the highest number of events (17), corresponding to 170 work days lost. Strikes involving more than one professional category was the frequent strike modality (32 events), followed by strikes by physicians only (22 events). The most commonly reported cause was complaints about remuneration (63 events), followed by protest against the sector’s governance or policies (25 events) and safety of working conditions (10 events). Positive resolution was achieved more often when collective bargaining institutions and higher levels of government were involved in the negotiations. Conclusion In low-income countries, some common features appear to exist in health sector strikes’ occurrence and actors involved in such events. Future research should focus on both individual events and regional patterns, to form an evidence base for mechanisms to prevent and resolve strikes.

Drug resistance is probably the greatest challenge to most malaria-control programs. Given the limited resources for other malarial-control measures, rational drug used is crucial. Molecular markers for parasite resistance such as pfcrt, pfmdr-1, and dhfr have the potential to be used in an integrated fashion to provide timely information that is useful to policy makers. Therefore, we evaluated polymorphisms in these genes from Plasmodium falciparum and their association with in vitro antimalarial drug resistance to 135 parasites samples collected in Bangui in 2004. For the dhfr gene, we found a strong association between the dhfr genotype and chemosensitivity to pyrimethamine. For the pfcrt gene, we found that haplotypes with mutant-type alleles led to significant changes in the IC50 values for chloroquine, monodesethylamodiaquine, and quinine. We found no correlations for the pfmdr1 gene. These findings suggest that a regular monitoring and screening for resistance markers for antifolates and for chloroquine could act as an adjunct to in vivo trials.

We used an in vitro isotopic drug sensitivity assay to assess the sensitivity of Plasmodium falciparum isolates collected in Bangui, Central African Republic between March and July 2004. We tested antimalarials that are currently in use in this country (chloroquine, amodiaquine, quinine, and pyrimethamine), antimalarials that will become available in this region in the future (artemisinin and halofantrine), and prophylactic antimalarials (mefloquine, doxycycline, and atovaquone). The proportions of resistant isolates were 37% for chloroquine, 15.9% for amodiaquine, 0% for quinine, 0% for dihydroartemisinin, 1.6% for mefloquine, 3.8% for halofantrine, 4.0% for atovaquone, and 38.3% for pyrimethamine. No multi-resistant isolates (showing resistance to more than three drugs) were found. A positive correlation was found between the 50% inhibitory concentrations values for the following drugs: chloroquine and amodiaquine; quinine and halofantrine; chloroquine and dihydroartemisinin; chloroquine and halofantrine; amodiaquine and dihydroartemisinin; dihydroartemisinin and mefloquine; chloroquine and quinine; and quinine and dihydroartemisinin. These findings suggest that the Ministry of Health should recommend a interim policy with the amodiaquine plus sulfadoxine-pyrimethamine combination as the first-line antimalarial drug in Bangui until better alternative treatments such as artemisinin-based combination therapies become available at low prices in the Central African Republic.

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