Towards new perspectives Support for Prevention to the National Health System in Tunisia

"Prevention", a component of primary health care since Alma Ata's declaration (1978), has been a strategic axis of health policy in Tunisia for four decades. If the Tunisian Revolutionary Constitution (2014) declared in its Article 38 that "the State guarantees prevention", the regulatory texts, organizing preventive structures and its operational programs, have today become ill-suited with the global burden of disease and current scientific evidence. The analysis of current preventive practices in Tunisia, based on the "health continuum", the taxonomy of "preventive strategies" and the identification of "vulnerable populations", has shown the need to implement prevention activities. "Primordial" and "quaternary" (for the management of cardiovascular diseases and cancers), extension of the fields of health education and epidemiological surveillance, towards Therapeutic Education of Patients / Health Promotion, and health monitoring, and coverage of new groups at risk: adolescents and the elderly. Faced with the multitude of prevention structures and the fragmentation of health programs, the reform of the national preventive policy and its practices should be based on the principles of integration, relevance and efficiency, through the establishment of a National Health Protection Agency (NHPA). This ANP is called upon to launch new prevention support projects including integrated preventive medicine centers (providing periodic health examinations), hospital patient therapeutic education services and home care units. Such a reform, announcing the birth of a new generation of preventive basic health care activities in Tunisia, should be reinforced by a legal, organizational and educational basis.

Typology of morbidity diagnosed in a pediatric department of a secondary care center (Msaken, Sousse, Tunisia)

INTRODUCTION

Pediatric services are tracer services for the assessment of the integration and performance of the national health system.

OBJECTIVES

Describe the typology of morbidity notified to the Pediatrics department of the Msaken regional hospital (Sousse, Tunisia) and the flow of its patients.

METHODS

This is a descriptive and exhaustive study, covering all the patients hospitalized in the pediatric ward of Msaken, during the year 2015. The data were collected through medical files and medical registers. admission, based on the Minimum Clinical Summary (RCM) form. The notified diagnoses were coded according to the WHO ICD-10 classification. The main diagnosis was defined by the major pathology that led to the hospitalization. Early readmission was retained before 28 days.

RESULTS

A total of 521 children were hospitalized, with a sex ratio of 1.04 and a mean age of 2 ± 3 years; 70% of the patients came from the administrative center of the governorate and 62% were infants (age <two years). Entry was provided via the emergency room in 58% of cases. The main diagnoses reported were diseases of the respiratory system (37%) including acute bronchiolitis, and diseases of the genitourinary system (28%) including urinary tract infections. About one in four patients (23%) were former patients of the department. The readmission rate was 18.7%. The average length of stay for hospitalized children was 4.5 ± 4 days. The transfer rate to university hospitals was 1.9%.

CONCLUSION

The morbidity profile of the regional pediatric ward of Msaken illustrates the new health needs of infants, dominated by infections of the respiratory and urinary tracts. Hence the importance of strengthening primary health care and referral / referral system between the pediatric services of district, regional and university hospitals, for an integrated and efficient national health system.

Cardiovascular risk factors in the Maghreb. A systematic review

OBJECTIVE

To assess the distribution of cardiovascular risk factors in Maghreb's countries.

METHODS

It is a systematic review including articles and reports that applied the WHO "STEPwise" approach, or a similar approach, studying cardiovascular risk factors in the Maghreb countries: Tunisia, Morocco, Algeria, Libya and Mauritania between 2004 and 2018.

RESULTS

We selected five articles, a report for each country. The prevalence of smoking was between 13.4% (12.2-14.6) in Morocco and 29.4% (28.3-30.4%) in Tunisia. 50.6% of the population of Mauritania had insufficient physical activity. The prevalence of high blood pressure was highest in Libya (40.6%) The prevalence of obesity was up to 41.1% (37-43.3) for women and 21.4% (19-23.8) in men in Libya. The prevalence of diabetes mellitus was between 10.6% (9.7-11.6) in Morocco and 16.4% (14.7-19.1) in Libya.

CONCLUSION

The distribution of cardiovascular risk factors in the Maghreb countries shows that the level of cardiovascular risk is high, particularly in the central Maghreb. This attests to the fairly advanced epidemiological transition related to the rapid modernization of the Arab countries, hence the importance of launching an integrated project for the fight against cardiovascular diseases based on the global experience.

Morbidity diagnosed in an internal medicine department of a secondary care center (Msaken, Sousse, Tunisia)

INTRODUCTION

Internal Medicine is an essential component of the clinical platform of regional hospitals (relay between district hospitals and reference university hospitals).

OBJECTIVE

To describe the morbidity diagnosed at Medicine department of the regional hospital of Msaken (Sousse, Tunisia), taken as a tracer of intermediate hospitals.

METHODS

This descriptive study covered all of the patients hospitalized, during the year 2015, in the Internal Medicine department of the Msaken regional hospital. The data were disseminated through a "Minimum Clinical Summary". Morbidity was classified according to ICD-10. Hospital readmission was tested with reference to <28 days.

RESULTS

A total of 594 patients were hospitalized in Internal Medicine, with a sex ratio of 0.95 and a median age of 67 years [54-78]. "Diseases of the respiratory system" were the first category of diagnosed morbidity (58%), dominated by acute bronchitis, followed by "endocrine, nutritional and metabolic diseases" in women (including insulin-dependent diabetes) and category of infectious diseases in men (including erysipelas). The former patients of the service (49%) were twice as numerous among people ≥60 years old (57% vs 30% in those under 60 years). The readmission rate was 19% (29% for men versus 8% for women). The mean length of stay was 7 ± 5.7 days. The transfer rates and hospital mortality were 11.3% and 1.2%, respectively.

CONCLUSION

The morbidity diagnosed at the Internal Medicine department of the Msaken regional hospital was dominated by the triad: acute bronchitis, diabetes mellitus and erysipelas, particularly in the elderly. Hence the need to strengthen the training of future family doctors in pulmonology, diabetology and infectious diseases.

Maghreb doctors need capacity building in epidemic investigation and control

OBJECTIVE

Describe the training needs of young Maghreb doctors in epidemic management.

METHODS

This is a study to quantify the need for medical training on "epidemic management". The study population was formed by residents and assistant professors of the French-speaking faculties of medicine in the Greater Maghreb, hospital-university professors, who were invited to respond to an online questionnaire. The "need" for learning a skill was defined by the perception of its importance, of its low coverage by the curricula and its poor mastery. A grid with 20 items, coded according to the Likert scale of 1 to 5 points, was specially developed for the measurement of need, retained beyond the thresholds of 45/90 points for the two dimensions "confirmation" and "investigation", 60/120 points for the "control" dimension, and 150/300 for the total sum.

RESULTS

A total of 121 young Maghreb doctors answered the questionnaire to assess the needs for learning epidemic management skills. The median overall scores for the chapters "importance", "coverage" and "performance" were 76, 40 and 48 respectively out of 100 points. The median scores for training "needs" were 54/90, 48/90 and 67/120 points, respectively, for the dimensions "confirmation", "investment" and "control", giving a global median score of 168 / 300.

CONCLUSION

Capacity building in epidemic management is a need felt by young Maghreb doctors, partially covered by current medical school programs, and consequently altering their professional performance.

Family Medicine (General Medicine): What academic and professional specificities?

Family Medicine, a true scientific and academic discipline, has been defined by the World Organization of National Colleges, Academies and academic associations of general practitioners / family physicians (WONCA) since 2002, as being a "clinical specialty oriented towards primary care". This paper details the specificities of Family Medicine: a horizontal specialty, primary care, providing comprehensive and continuous care, patient-centered and community-oriented. The promotion of Family Medicine in the Maghreb countries requires a multi-axial strategy based on the social marketing of Family Medicine, the recognition of Family Medicine as a medical specialty and of Family Medicine as a gateway to national health system, the establishment of a quality approach in basic health centers and free practice offices (centers of health centers) and regular validation of the Family Medicine diploma.

Lessons learned from the fight against COVID-19 in the Great Maghreb. Five lessons for a better response

OBJECTIVE

Identify the lessons learned in the Greater Maghreb, during the first semester of the fight against the COVID-19 pandemic, in the field of response.

METHODS

During the first week of May 2020, a consultation of experts was conducted, using the "Delphi" technique, through an email asking each of them, the drafting of a good practice recommendation for "Public health". The Group coordinator finalized the text of the lessons, later validated by the signatories of the manuscript.

RESULTS

Five lessons of good «response» against epidemics have been deduced and approved by Maghreb experts, linked to the following aspects: 1. Total reservation of hospital beds for patients; 2. Clinical management of the response; 3. Discreet conflict of interest; 4. Community participation in the response; 5. Contextualization of the global fight strategy.

CONCLUSION

Based on the finding of low relevance of the Maghreb response against COVID-19, this list of lessons would help support the performance of Maghreb health systems in the management of epidemics.

Effectiveness of hand hygiene in an epidemic context. Systematic review

OBJECTIVE

To assess the effectiveness of Hand Hygiene (HH) in preventing infections and the transmission of pathogens, in an epidemic context, in community and hospital settings.

METHOD

It is a systematic review of the literature based on a document request, conducted on PubMed, using the following search equation: "(" Hand Hygiene "[All Fields] OR" Hand Disinfection "[All Fields]) AND ("Epidemics" [All Fields] OR "Pandemics" [All Fields]) ". All publications related to the effectiveness of the preventive intervention for HH in an epidemic setting were Included.

RESULTS

A total of 16 publications were included, of which the majority proved the effectiveness of HH and its promotion in reducing infections during an epidemic. In a clinical trial, promoting HH in an intervention group significantly reduced the prevalence of infections (24.4% vs. 11.1%). Two systematic reviews have shown the effectiveness of HH in preventing the transmission of germs with ORs between 0.52 and 0.62. Four case-control studies and three cross-sectional studies concluded with the protective effect of HH with ORs varying between 0.06 and 0.71. A cohort study showed that low adherence to HH recommendations was associated with a higher infection rate (77.5% vs 95%; p = 0.02). A single systematic review did not conclude that HH was effective in the epidemic setting.

CONCLUSION

The effectiveness of HH in the fight against epidemics has been demonstrated. It is dependent on the engagement and the active participation of the different intervenient. Hence the need to increase accessibility to different methods of HH and to promote the importance of this prevention strategy could be assured through education and awareness.

The satisfaction of patients hospitalized in the surgical departments of a general hospital. Case study of Sahloul hospital in Sousse (Tunisia)

OBJECTIVE

Measure the overall and specific satisfaction rates of patients hospitalized in surgical services in Sahloul University Hospital in Sousse during the year 2018.

METHODS

The study population was recruited by a quota sample of hospitalized patients in the surgical departments of Sahloul University Hospital in Sousse. Data collection was done via a patient satisfaction questionnaire, administered to outgoing patients. The questionnaire was composed of 33 items exploring technical, administrative, logistical and relational dimensions. Overall patient satisfaction, called "reactivity", was defined by a concomitant positive response to the three questions exploring satisfaction, recommendation and loyalty.

RESULTS

A total of 735 patients hospitalized in six surgical departments were included (general surgery, orthopedics, maxillofacial surgery, urology, neurosurgery and cardiovascular surgery). The rates of "satisfaction", "recommendation" and "loyalty" of the patients were 71%, 70% and 69% respectively, equivalent to an "overall positive reactivity" of 62%, 95% CI [58,5%-65.5%], particularly low in the orthopedic department (43%). The logistics dimension was the least appreciated by patients, including room's condition, with almost 23% overall and 17% in the orthopedic department.

CONCLUSION

The responsiveness of patients hospitalized in the surgical services of Sahloul University Hospital was low, particularly for items related to the hotel services in the hospital. Furthermore, plans to improve the quality of care and support the performance of public hospitals should pay close attention to the logistical dimension of patients' hospital stays.

Lessons learned from the fight against COVID-19 in the Great Maghreb.Five lessons for better resilience

OBJECTIVE

To compile the lessons learned in the Greater Maghreb, during the first six months of the fight against the COVID-19 pandemic, in the field of "capacity building" of community resilience.

METHODS

An expert consultation was conducted during the first week of May 2020, using the "Delphi" technique. An email was sent requesting the formulation of a lesson, in the form of a "Public Health" good practice recommendation. The final text of the lessons was finalized by the group coordinator and validated by the signatories of the manuscript.

RESULTS

A list of five lessons of resilience has been deduced and approved : 1. Elaboration of "white plans" for epidemic management; 2. Training in epidemic management; 3. Uniqueness of the health system command; 4. Mobilization of retirees and volunteers; 5. Revision of the map sanitary.

CONCLUSION

Based on the evaluation of the performance of the Maghreb fight against COVID-19, characterized by low resilience, this list of lessons could constitute a roadmap for the reform of Maghreb health systems, towards more performance to manage possible waves of COVID-19 or new emerging diseases with epidemic tendency.

Lessons learned from the fight against COVID-19 in the Greater Maghreb. Five lessons for better preparation

OBJECTIVE

To compile the lessons learned in the Greater Maghreb, during the first six months of the fight against the COVID-19 pandemic, in the field of preparation of health systems.

METHODS

An expert consultation was conducted during the first week of May 2020, using the "Delphi" technique. An email was sent to them requesting the formulation of a lesson, in the form of a "Public Health" good practice recommendation. The final text of the lessons was finalized by the group coordinator and validated by the signatories of the manuscript.

RESULTS

A list of five lessons for the preparation of the national health systems of the Greater Maghreb for the fight against epidemics, was deduced and approved: 1. Liberal health systems are incapable of managing epidemics; 2. The specialties of "Public Health" are often marginalized; 3. Health personnel in the Maghreb are doubly devalued; 4. Flagrant regional disparities in the field of health care are still observed; 5. A general shortage of preventive equipment and medical devices has been noted.

CONCLUSION

Based on the evaluation of the performance of the Maghreb fight against COVID-19, characterized by the vulnerability of the preparation of health systems, this list of lessons could constitute a roadmap for the reform of health systems. Maghrebian health, towards more performance in managing possible waves of COVID-19 or new emerging diseases with epidemic tendency.

Youth violence in Maghreb countries. A systematic review

OBJECTIVE

To determine the prevalence, risk factors as well as consequences of exposure to violence among youth in Maghreb countries.

METHODS

This is a systematic review. The documentary request was done on 2 October 2019 and no filters were used. It examined all scientific publications indexed in Medline database via Pubmed using the following search equation: ("Violence"[Mesh] OR "suicide"[Mesh] OR "crime victims"[Mesh] OR "Child abuse"[Mesh]) AND ("Young Adult"[Mesh] OR "Adolescent"[Mesh] OR "Child"[Mesh]) AND ("Tunisia"[Mesh] OR "Algeria"[Mesh] OR "Morocco"[Mesh] OR "Libya"[Mesh] OR "Mauritania"[Mesh]).

RESULTS

A total of 16 articles were included. Most of them (68.7%) were published in Uganda, United States and England. The most common type of violence was physical abuse (43.8%). Adolescent boys were mostly affected by physical violence. However, girls were more exposed to emotional violence (63% vs 51%). The suicide rate increased after the social and political Tunisian revolution in 2011. Parental conflicts, school failure and social problems were more frequent among victims of violence. In addition, tobacco and alcohol use, substance abuse and suicide attempt (ranging from 5% to 38%) were higher.

CONCLUSION

Exposure to violence, especially emotional and physical, is becoming more frequent among youth in Maghreb countries. There is an urgent need for future survey to provide temporal data about violence, especially sexual abuse, in order to implement more effective prevention strategies.

Attitudes of health professionals towards the response to the COVID-19 pandemic in Maghreb

OBJECTIVE

Measuring the attitudes of health professionals in two Maghreb countries (Tunisia and Algeria) with regard to the response to COVID-19 during the first quarter of 2020.

METHODS

This scoping study was based on a "Google Form" covering three constituents of the response plan against COVID-19: responders, activities and crisis communication. The attitudes of health professionals who are working in Tunisia and Algeria were measured through the Likert scale with four propositions, grouped in pairs, during the analysis.

RESULTS

The study population consisted of 280 health professionals, 170 of whom are Tunisians along with 110 Algerians. The medians of age and that of professional seniority are, respectively, 37 and 10 years. The role of "health workers", "Mass Media" and "civil society associations" was found to be satisfactory according, respectively, to 92%, 71%, and 55% of the respondents. As far as 72% of health professionals are concerned, the "barrier measures" were respected by the population. Approximately, seven in ten respondents were satisfied with the quality of communication occuring between the Ministries of Health and its epidemiological structures.

CONCLUSION

Health professionals of the Maghreb working in Tunisia and Algeria had a generally positive perception of the role of population responders, community engagement, and the quality of official communication in regards to the response plan against COVID- 19. This perception would be a prerequisite for the success of community participation and multisectoral action as well as essential in the strategy of prevention and control of this pandemic and of possible other health emergencies.

Counter-COVID- 19 pandemic strategy in the Maghreb Central. Qualitative study of the perceptions of health professionals

CONTEXT

The Maghreb Central, like all the countries of the world, was strongly mobilized (governments, ministries of health, population, civil society) in the response against COVID-19, immediately after the registration of the first cases on its territory (end of February, beginning of March) and according to pre-established control strategies.

OBJECTIVES

Describe the perceptions of health professionals in the Central Maghreb (Tunisia, Algeria and Morocco) as to the Strengths/Opportunities and Weaknesses/Threats of the national response plans against COVID-19, during the first weeks of their execution, and report their proposals for optimizing the performance of control strategies.

METHODS

This is a qualitative study of the perceptions of health professionals in the Maghreb Central regarding their experience of the first six weeks of fighting the COVID-19 pandemic. The data was collected using the "Delphi" technique in one turn, based on an electronic form such as "Google Form", developed according to SWOT analysis. The respondents' verbatim was grouped into homogeneous groups of items, the occurrence of which was subsequently measured.

RESULTS

A total of 382 health professionals from the Maghreb Central participated in this study, with a median age of 37 years and a median professional tenure of 10 years. The major force of the Maghreb response strategies, the most shared by the respondents, was the performance of the human resources mobilized (doctors, biologists, nurses, etc.) who succeeded in quickly learning from the international epidemiological expertise accumulated in Asia and in Europe. The fight against COVID-19 in the Central Maghreb was confronted with the general and chronic fragility of the national health systems and the low support of the general population for the recommendations of the steering committees of response, threatening the capacity of the Maghreb to confront new epidemics.

CONCLUSION

The success of the national response plans against COVID-19 and of possible epidemics or pandemics in the Central Maghreb, is strongly attributed to the commitment of health professionals and to community participation, necessitating the launch of assistant motivation programs. and development of health personnel and mobilization and loyalty of civil society.

Thirty years of Tunisian publication of «case reports» in General Surgery (1989-2018)

OBJECTIVE

To describe the bibliometric profile of Tunisian "case report" publications in general surgery over the last thirty years (1989-2018).

METHODS

This is a descriptive bibliometric study on "case reports", general surgery, Tunisian affiliation, indexed in the Medline database, between January 1, 1989 and December 31, 2018. The themes of Search articles were defined by referring to their major keywords used for their indexing.

RESULTS

During 30 years of study, Medline indexed 188 papers in "General Surgery" type "case reports", signed by 80 authors in first position and 71 authors in last position, belonging to ten academic specialties and 19 professional affiliations. These papers were published by 60 journals, including the Ugandan magazine "Pan African Medical Journal", which published 23% of these "case reports" alone. The number of major indexing keywords was 299 words, mainly "Echinococcosis", "Pancreatic Cancers" and "Echinococcosis of the liver", together accounting for 18.1% of articles.

CONCLUSION

The plethora of "case reports" in Tunisian general surgery publications over the last three decades was accompanied by a preferential edition in the journal "Pan Afr Med J" and a thematic focus on hydatid cysts and cancers pancreatic. Hence the importance of strengthening the capacity of Tunisian surgeons in research methodology and scientific medical writing.

Bibliometrics of Tunisian publications on respiratory tract diseases from 2010 to 2014

AIM

To describe the bibliometric characteristics of Tunisian publications on respiratory tract diseases, during the quinquennium 2010-2014.

METHODS

This is a descriptive bibliometric study of respiratory medicine publications, indexed in "Medline", based on their MSDSs. All included articles were written by Tunisian researchers regardless of their position in the list of co-authors. The topics of the publications were explored through their "major" and "generic" keywords.

RESULTS

A total of 340 publications was captured in Medline. These articles were co- authored by 218 authors in first position and 163 in last position. They were signed by pulmonologists, in first and last position respectively in 21.5% and 22.4% of articles. The A. Mami Hospital was the major affiliation of the first authors in 19.7% of the publications. These articles were published by 138 journals including "La Tunisie Medicale" in 11.8% of cases. They were "case reports" and written in English respectively in 44.4% and 54.1% of cases. Among 639 major keywords indexing, three were dominant: «Lung Neoplasms» (Tumeurs du poumon), «Chronic Obstructive Pulmonary Disease» (Broncho-pneumopathie chronique obstructive) and «Tuberculosis, Pulmonary» (Tuberculose pulmonaire), in 13.5%, 10.3% and 7.4% of articles respectively.

CONCLUSION

Tunisian research on respiratory tract diseases has been thematically concordant with the public health needs. However, it has often been of low-level evidence and published in low-impact factor journals.

Ramadan and Health. Bibliometric study of the biomedical literature indexed in «Medline» database

OBJECTIVE

To describe both editorial and thematic profile of biomedical publications related to the theme «Ramadan and Health», indexed in «Medline» database till December 31th 2018.

METHODS

This is a bibliometric study via «Medline» database using the following documentation query: «Fasting» [Majr] AND («Islam» [Majr] OR Ramadan [All Fields]). Data was collected through the «Medline» Material Safety Data Sheets from the NLM Library. Publications' themes have been defined by major descriptors (Majr). The generic descriptor corresponded to the Majr word hierarchically superior in the «Medline» Mesh descriptor thesaurus.

RESULTS

A total of 508 articles were captured, of which 13% were reviews and 5% were randomized controlled trials. These publications were published by 272 journals belonging to 38 countries, and signed by 108 authors in first position and 398 in last position. The number of major descriptors used to index these publications related to «Ramadan and Health» was 484. Endocrine System Diseases (Diabetes mellitus) and Human Activities (Exercise) were the main major generic keywords, indexing respectively 28% and 20% of this literature.

CONCLUSION

«Ramadan and Health» is increasingly, a theme of scientific and biomedical research of great interest worldwide in order to manage health problems, especially diabetes mellitus. Expanding the scope of its applications to other global burden of disease's areas would be useful.

Disciplinary and thematic mapping of Maghreb publications in "infectiology". Bibliometric study (Tunisia, 2010-2014)

AIM

To describe the essential bibliometric characteristics of Tunisian publications in "infectiology", during the five-year period 2010-2014.

METHODS

This is a descriptive bibliometric study, on the papers of "infectiology", indexed in "«Medline»", based on their data sheets. Were included all the articles written by Tunisian researchers regardless of their position in the list of co-signers. The themes of the publications were explored through the key words "major" and "generic" in the three chapters of the descriptors: "Bacterial Infections and Mycoses", "Parasitic Diseases", and "Viral Diseases".

RESULTS

A total of 846 publications in "Infectiology" were analyzed, of which 66% were written in English and 31% were "case reports". They were signed by 536 authors in first position belonging mainly to microbiology (20.7%), parasitology (20.1%) and virology (7.1%). The 391 co-signatories in last position belonged to 44 specialties, of which pediatrics, internal medicine and infectious diseases respectively occupy the 4th, the 9th and the 10th positions. These publications were edited in 258 journals, mainly "Tunisie Medicale" (9%) and "Pan African Medical Journal" (3.8%). The greatest interest of the Tunisian researchers in infectious diseases have been staphylococcal / tuberculosis infections, chronic viral hepatitis C / human influenza, and echinococcosis / leishmaniasis.

CONCLUSION

In Tunisia, infectious diseases research has been relatively prolific and concordant with the population's health needs. Infectious diseases physicians should build their network of care, research and education with biologists, while focusing their research on multicenter and high-level studies.

Metabolic effects of Ramadan fasting in patients at high risk of cardiovascular diseases

Background and aim

The effects of Ramadan fasting on health are a little controversial. The present study is aimed at evaluating the metabolic effects on a group of 517 patients with ≥2 cardiovascular risk factors over a period running from 2012 to 2014.

Methods

Each patient was assessed at three visits: before, during, and after Ramadan. Demographical, clinical and biological tests were performed at each visit.

Results

Metabolically, we noted a significant and discrete rise in blood glucose level (+1.2 mmol/L), triglycerides (+0.3 mmol/L), cholesterol (+0.12 mmol/L) and creatinine (+3 µmol/L) during Ramadan. These disturbances decreased significantly after Ramadan. The same variations were observed among diabetics (n=323). However, there was a significant decrease in HbA1c after Ramadan (9.0% vs 7.6%, p<0.001). Our findings also revealed there was no significant correlation between variations of metabolic parameters and dietary intake. No acute metabolic incidents were reported during the study period.

Conclusion

The current study showed that Ramadan is responsible for a transient but well tolerated disturbance of metabolic parameters followed by a significant post-Ramadan improvement. These changes did not seem to be directly related to dietary intake.

Bibliometrics of Tunisian publications in "General Surgery" (Medline, 2009-2018)

OBJECTIVE

To describe the bibliometric characteristics of Tunisian publications in "General Surgery", indexed in "Medline" database from 2009 to 2018.

METHODS

This is a bibliometric study conducted through a comprehensive documentary query applied to the "Pubmed" portal and using the "Medline" database. The essential themes of a publication have been defined by referring to its major keywords.

RESULTS

A total of 173 publications were included in this study, representing a productivity rate of 14 articles / 100 surgeons' teachers-year. These publications were co-authored by 65 authors in first position and published by 55 journals in 15 countries, including mainly the national journal "Tunis Med" during the first five-year period 2009-2013 (27%) and the Ugandan magazine "Pan Afr Med J" during the second five-year period 2014-2018 (33%). Case reports were the most widespread type of publication in Tunisian "General Surgery", during the two periods of the study, respectively in 63% and 51% of cases. English was the major language with 57% of publications. Among the 259 major descriptors used to index the "General Surgery" articles, the occurrence of "Pancreatic Neoplasms" and "Echinococcosis, Hepatic" was respectively 3% and 2%.

CONCLUSION

During the decade 2009-2018, the Tunisian research in "General Surgery" was not very prolific and was mainly "case reports" but it was directed toward population health problems; Hence the interest of a thorough training of surgeons in research methodology and scientific medical writing.

Management crisis of health personnel in the great Maghreb. Mauritania case study

OBJECTIVE

To describe the number and distribution of health personnel in Mauritania during 2017, according to their academic grades and administrative assignments.

METHODS

This is a quantitative study of the number and uses of health human resources in Mauritania, based on the 2017 data from the Personnel Register of the Ministry of Health. The number of doctors, midwives and nurses in the six administrative regions of Mauritania and its "wilayas", were standardized according to the size of the population (health workers /10 000 inhabitants). Interregional inequalities in the allocation of health personnel have been studied through the correlation between the percentages of the health professions and the populations of the regions affected.

RESULTS

In 2017, the number of health workers in all categories was 6608 in Mauritania, a ratio of 17.5 / 10000 health workers / inhabitants, ranging from 8.6 in "Gargot" wilaya to 37.3 in the wilaya of "Inchiri". The densities of specialist physicians, general practitioners, midwives and nurses were respectively 0.9, 0.84, 1.8, and 3.32 per 10,000 inhabitants, respectively. In the Nouakchott region, covering 28.5% of the Mauritanian population, 76.5% of specialist doctors and 56.8% of midwives, had ratios (health workers / 10 000 inhabitants) two and three times higher than national levels.

CONCLUSION

This study documented on the one hand the persistence of the shortage of health personnel in Mauritania in 2017, in all its professional categories, and on the other hand the inequalities of their distribution in its administrative zones, with a relative abundance in the region of Nouakchott.

Cancers in the Central Maghreb: epidemiology from 1990 to 2017 and trends in 2040

OBJECTIVE

To describe the epidemiology of cancers in terms of global burden of disease, incidence, prevalence and typology in the three Central Maghreb countries from 1990 to 2017, as well as their trends from 2017 to 2040.

METHODS

This is a descriptive and predictive study of the epidemiology of cancers in the Central Maghreb (Tunisia, Algeria and Morocco) from 1990 to 2040. The epidemiological data: incidence, prevalence, specific mortality rate and Disability Adjusted Life Years were collected via the Global Burden of Disease Database created by the Institute of Heath Metrics and Evaluation. These parameters were expressed in terms per 100,000 inhabitants.

RESULTS

In 2017 and for the three Central Maghreb countries, cancers represented the second leading cause of death, with an overall specific mortality rate of 69/100,000 and an overall incidence rate of 116/100,000 inhabitants. The Disability Adjusted Life Years rate varied from 1516/100,000 in Algeria to 1992/100,000 in Morocco. In the three Central Maghreb countries and during the year 2017, lung cancer was the first cancer in terms of mortality, regardless of age and sex, followed by colorectal cancer in Tunisia and breast cancer in Algeria and Morocco. These three cancers will remain in 2040 the most important in terms of mortality rate with lung cancer topping the list in Tunisia and Morocco with respective mortality rates of 30 and 16/100,000.

CONCLUSION

Cancers are currently, and in the next two decades, an important component of the GlobalBurden of Disease in Central Maghreb countries. The typology is dominated by lung, breast and colorectal cancers. The establishment of a Maghreb cancer registry would be a fundamental component of the Maghreb cancer plan.

For a honest Maghreb care system. Systematic Review of the International Literature on Corruption in the Health care System

INTRODUCTION

Corruption in the health care system is a universal phenomenon, putting at risk the health of populations. The purpose of this work was to synthesize the international literature on corruption in the health sector.

METHODS

This is a systematic review of literature dealing with articles on health corruption practices, published between July 2008 and June 2018, via two search engines: PubMed and Google Scholar. The extracted data were narratively summarized in three major areas: defining the concept of corruption in health, its typology / manifestations and anti-corruption interventions.

RESULTS

A total of 23 articles were selected for final analysis. The articles that defined health corruption shared two key aspects: "abuse of power" and "benefit". The main types of corruption were "abuse of therapeutic indication", followed by "bribes" and "falsification". The anti-corruption interventions were synthesized into seven types: creation of an independent multi-interventional agency, support for scientific research, law enforcement, awareness raising, detection, reporting and institutional commitment.

CONCLUSION

Based on the use of power, corruption in health is a complex phenomenon whose struggle requires a specific and contextualized strategy integrating information, detection and punishment.