Determinants of healthcare workers’ willingness to receive the influenza vaccine in Tunisia

Background

Influenza is a contagious respiratory disease that may lead to severe illness. Given their frequent contact with ill individuals, healthcare workers (HCWs) are at elevated risk of developing influenza and of transmitting the disease to their patients. We aimed in this study to assess flu vaccination intention among Tunisian HCWs and to identify its determinants.

Methods

A cross sectional study was conducted among Tunisian HCWs with direct patient contact during the 2018-2019 influenza season. Participants were recruited in primary and secondary healthcare facilities according to a self-weighted multistage sampling. Factors associated with influenza vaccination intention were assessed using a multivariate logistic regression analysis.

Results

In this study, 1231 HCWs were enrolled with a mean age of 44.5±9.3 years and a sex ratio equal to 0.25. Among respondents, 43.1% (95% CI: [40.0-45.8]) declared their willingness to receive the IV if recommended for HCWs and provided for free. Participants who received the IV during the 2018-2019 influenza season ((ORa=34.42 [16.41-72.21]), who knew that IV is indicated annually for HCWs (ORa=1.66 [1.21-2.30]), who had high confidence regarding IV efficacy (ORa=1.99 [1.48-2.68]), who believed that IV should be mandatory for HCWs (ORa=2,36 [1.76-3.18]) and that HCWs' vaccination against influenza is important in order to protect patients (ORa=1.92 [1.37-2.69]) were more likely to be willing to receive the IV. However, nurses were less likely to be willing to receive the vaccine than physicians (ORa=0.66 [0.44-0.98]).

Conclusions

Less than half of participants reported their willingness to receive the IV. Our results suggest that flu vaccination acceptance is associated with higher IV uptake and with favorable attitudes regarding influenza vaccination. This highlights the need to implement regular flu awareness campaigns in healthcare facilities aiming to encourage vaccination among HCWs.

Key messages

Majority of healthcare workers reported their unwillingness to receive the influenza vaccine. Educating health personnel about the benefits of influenza vaccination to themselves and their patients is necessary.

Willingness of healthcare workers to recommend seasonal influenza vaccine to patients- Tunisia, 2019

Background

Most countries of the Eastern Mediterranean Region have low influenza vaccination coverage mainly among high risk groups. Advice to receive the influenza vaccine by healthcare workers (hcws) seems to be an important motivator for vaccine acceptance among patients. In this study, we aimed to describe the willingness of Tunisian hcws to recommend the seasonal influenza vaccine to patients and to assess its determinants.

Methods

A cross-sectional questionnaire-based study was conducted in Tunisian primary and secondary healthcare facilities during the 2018-2019 influenza season. A multivariate logistic regression was used to assess the factors associated with the willingness of hcws to recommend the influenza vaccine to patients.

Results

In the present study, 1231 hcws were included with a mean age of 44.5±9.3 and a sex ratio (Male/Female) equal to 0.25. Among respondents, more than three quarter (79.1%, 95% CI: [76.7-81.3]) declared their willingness to recommend the influenza vaccine to patients if available. In multivariate analysis, belief that influenza vaccine is a severe illness that may lead to death (adj.OR = 2.9, 95% CI: [1.9-4.1]) and previous influenza vaccine uptake among health professionals (adj.OR = 2.4, 95% CI: [1.5-3.9]) were independently associated with the willingness of hcws to recommend the flu vaccine to patients.

Conclusions

This study showed that hcws with a history of influenza immunization and those who were aware of influenza severity were more likely to be willing to recommend the influenza vaccine to patients. These findings should be considered in future educational programs to enhance hcws' recommendation of influenza vaccine.

Key messages

Majority of Tunisian healthcare workers declared their willingness to recommend the influenza vaccine to patients. Healthcare workers’ awareness of influenza severity and history of influenza vaccine uptake were associated with a higher willingness to recommend the flu vaccine.

Determinants of influenza vaccination intention among Tunisian elderly

Background

Influenza vaccination coverage among elderly remains unsatisfactory even in developed countries. Since attitudes are predictors of behavior, understanding factors influencing the intention to receive influenza vaccine (IV) among elderly may orientate interventions to increase vaccination rate. The aim of the current study was to identify factors associated to willingness to receive IV next season among Tunisian elderly.

Methods

During 2018 -2019 flu season a cross-sectional study was conducted among older persons aged 60 years and over with chronic disease attending primary and secondary health care facilities. The intention to get vaccinated against influenza was measured by means of a face to face questionnaire. Factors that affect willingness to receive IV were identified using a multiple logistic regression analysis.

Results

Of the 1191 older persons included, 19.4% [17.1-21.9] participants received IV in 2018-2019 flu season, 64.7% [61.9-67.3] expressed willingness to be vaccinated next season. Willingness to receive IV was more likely among persons with chronic pulmonary disease (ORa=2.6), those suffering from diabetes (ORa=1.6), those who received IV in 2018-2019 flu season (ORa=16.5), those who feel that they get enough information about vaccines and their safety (ORa=2.9) and persons who trust the advice of their health care providers (ORa=4.5).

Conclusions

Vaccination status was the most determinant factor associated to willingness to receive the vaccine. Therefore, sustainable efforts to promote IV may lead to cumulative increase of influenza vaccination coverage year by year. Doctors should be involved more in advocating IV and providing elderly with the necessary information about IV, but that could not be effective without a climate of trust between patients and health care providers.

Key messages

Positive self-experience of older persons with IV may change their perception about it and encourage them to adhere to the vaccine in the future. Elderly should be provided with the necessary information about IV in terms of effectiveness and safety.

Influenza immunization among Tunisian health care workers in the 2018-2019 influenza season

Background

Given the nature of their activities, health care workers (hcws) are at higher risk of contracting influenza and transmitting the disease to their patients. Influenza vaccine (IV) remains the most effective way to prevent influenza and its complications. To the best of our knowledge, no national data on IV coverage among hcws is available in Tunisia. The present study aimed to assess the flu vaccination coverage among Tunisian hcws in the 2018-2019 influenza season and factors associated with IV uptake through a study of knowledge and attitudes related to influenza vaccination.

Methods

A cross sectional study was conducted in Tunisian primary and secondary health care facilities from March to May 2019. Hcws with direct patient contact were recruited according to a self-weighted multistage sampling. Survey data collection was based on a face to face questionnaire containing both open and closed questions.

Results

A total of 1231 hcws were enrolled in this study. Among respondents, 15.3% (95% CI: [12.3-17.2]) were vaccinated against influenza during the 2018-2019 influenza season. High confidence regarding vaccine efficacy (OR = 3.5, 95%CI: 2.5-4.8), belief that hcws' influenza immunization may decrease illness and deaths among patients (OR = 1.7, 95% CI: 1.2-2.3) and belief that influenza vaccination can reduce work absenteeism (OR = 1.7, 95% CI: 1.2-2.4) were associated with a higher IV uptake among hcws. In addition, participants who mentioned hcws as a target group for influenza vaccination (OR = 2.0, 95% CI: 1.5-2.8) and who were agree that IV is indicated annually for hcws (OR = 3.1, 95% CI: 1.9-4.9) were more likely to receive the IV.

Conclusions

Influenza vaccination coverage among Tunisian health professionals in 2018-2019 was low. Our findings suggest that knowledge and attitudes regarding influenza vaccine influence vaccine compliance among hcws and should thus be targeted by vaccination campaigns to promote flu vaccine uptake in the health community.

Key messages

Vaccination coverage among Tunisian healthcare workers was low in the 2018-2019 influenza season. Our findings suggest that knowledge and attitudes regarding influenza vaccine influence vaccine uptake among Tunisian health care workers.

Prevalence of seasonal Influenza vaccination among Tunisian elderly

Background

Surveys to determine the uptake of influenza vaccine (IV) among the at-risk groups are required to evaluate the advancement of national vaccination strategies and the level of awareness in the surveyed population. In this context, the present study aimed to estimate influenza vaccination uptake in elderly in Tunisia during 2018-2019 influenza season and to assess their perceptions toward influenza and IV.

Methods

It was a national cross-sectional study conducted in 2019 in primary and secondary health care facilities, among persons aged 60 years and over with chronic disease. Data were collected using a standard administered questionnaire including questions about IV uptake, general knowledge and attitudes about influenza and IV. Perceptions of participants toward general statements about influenza and IV were compared by vaccination status using chi square test.

Results

In total, 1191 older persons were included. Nearly one third of participants (34.8% [32.2-37.6]) were vaccinated at least once at the past and 19.4% [17.1-21.9] received the vaccine during 2018-2019 influenza season. Compared to unvaccinated elderly, vaccinated persons were significantly more convinced that influenza is more dangerous for elderly people (90.0% vs. 82.2%, p = 0.008), that IV is recommended for older persons (88.7% vs. 70.1%, p < 0.001) and for those with chronic disease (86.1% vs. 64.1%, p < 0.001) and that IV can protect elderly persons (87.9% vs. 71.9%, p < 0.001) and those with chronic disease (88.3% vs. 66.3%, p < 0.001). Regarding attitude about the safety of the vaccine, while 14.4% of unvaccinated persons agreed that IV is not safe for older persons, only 9.5% of vaccinated elderly approved that statement (p = 0.060).

Conclusions

Our study showed a low influenza vaccination rate among Tunisian elderly. In order to promote IV, campaigns should focus on educating elderly regarding the seriousness of influenza and the efficiency and the safety of IV.

Key messages

Efforts must be invested to improve influenza vaccination coverage among Tunisian elderly especially those with chronic diseases. Educating elderly regarding influenza and IV is necessary since knowledge is a basis for adopting relevant attitudes and practices.

Diagnostic de la COVID-19 : expérience du laboratoire national de référence

Introduction

Le diagnostic de la COVID-19 se base sur la détection d’une ou de deux régions spécifiques du génome de SARS-CoV-2 par RT-PCR en temps réel. Le Laboratoire national de référence (LNR) de surveillance de la grippe et des autres viroses respiratoires a été désigné pour assurer cette tâche jusqu’au 27 mars, date à laquelle le réseau des laboratoires a été élargi pour augmenter la capacité nationale du testing.

La présente étude rapporte l’expérience du LNR pendant la période où il a assuré à lui seul le diagnostic de la COVID-19 (6 février au 26 mars).

Matériels et méthodes

Après optimisation de la technique de RT-PCR en temps réel se basant sur le protocole de Hong Kong (gènes cibles N et ORF1b), l’analyse de 1913 prélèvements nasopharyngés a été réalisée. Les résultats étaient quotidiennement adressés à l’Observatoire national des maladies nouvelles et émergentes (ONMNE) pour assurer la surveillance, l’investigation et le contact tracing en cas de détection de cas positifs et ce afin de limiter l’extension de la maladie.

Résultats

Au cours de cette période, 229 (12 %) cas positifs ont été colligés. Le 2 mars, le premier cas a été diagnostiqué. Il s’agissait d’un cas importé d’Italie. Ce dernier a été placé en confinement. Le 10 mars, les deux premiers cas autochtones ont été identifiés. La capitale et les villes avoisinantes étaient les régions les plus touchées avec 113 (49,3 %) cas. Le sex-ratio était de 1,14 soit 122 hommes (53,3 %) et 107 de femmes (46,7 %). La moyenne d’âge était de 46,18 ans avec des extrêmes allant de 6 mois à 85 ans. La tranche d’âge entre 15 et 45 ans était la plus touchée avec une fréquence de 48,9 %. La transmission était autochtone chez 117 (51,1 %) patients, versus 112 (48 %) cas importés. La majorité des cas étaient symptomatiques (82,5 %). La fièvre (93 %), la toux (77 %) et l’asthénie (43 %) étaient les symptômes les plus rapportés. Les cas symptomatiques étaient significativement plus fréquents parmi les cas importés 93 % contre 72,6 % des cas autochtones avec un OR de 4,9 et un intervalle de confiance 95 % = [2,14–11,23]. Les mesures prises pour les malades asymptomatiques étaient l’auto-isolement à domicile (64,2 %) ou l’hébergement dans des centres de confinement (16,6 %). Quarante quatre (19,2 %) patients avaient nécessité une hospitalisation dont 20 (43,5 %) en réanimation avec un taux de létalité de 7,4 % (17 décès sur 229). Le personnel de santé représentait 12,2 % (28 cas) du total des personnes infectées par le SARS-CoV-2, avec une transmission majoritairement autochtone (75 %).

Conclusion

Les mesures judicieuses entreprises au cours de cette période ont permis d’établir un plan de prévention et de riposte au risque de diffusion du SARS-CoV-2. Ceci est étroitement lié à la collaboration entre les différents intervenants de tous les secteurs.

Epidemiology of pertussis in Tunisia; results of five years 2013-2017

Background

Pertussis or whooping cough, is a highly contagious respiratory disease caused by a bacteria gram negative mainly Bordetella pertussis. It is globally endemic despite a high vaccination coverage. In 2014, the World Health Organization estimated the total number of affected persons to 16 million and the number of child deaths reached 190 000. Since 2012, many countries have experienced a resurgence of pertussis including Tunisia. Our objective was to describe the epidemiological situation of pertussis in Tunisia from 2013 to 2017.

Methods

Our study was a retrospective descriptive study based on data of the surveillance system of Mandatory Reporting Diseases in Tunisia from 2013 to 2017. Data were collected using the declaration standardized forms which included in addition to the socio-demographic data, information regarding vaccination status, date of onset of symptoms and laboratory results (culture and PCR). Data entry was using EpiData and data analysis using SPSS-20.

Results

During the study period, a total of 252 cases were notified. Males were more affected (55.1%). Age was in average 89 days (3 months). Almost the third were hospitalized in Intensive Care Unit (32.2%). Most cases were reported during 2013 and 2014 (35.7% et 55.5% respectively) and the lethality rate reached 7.2% in 2014. Half cases were notified in the Grand Tunis region. PCR was positive in 74.1% of the cases and bacterial culture was positive in 14.3%, isolating Bortedella pertussis. Vaccination status was mentioned in 70.5% of the cases: it was up-to-date in only 35.7% of the cases and incomplete in 9.8% of the cases.

Conclusions

Our results showed that pertussis has known a considerable increase the last years, especially in 2013 and 2014. This prompts us to be more vigilant regarding this disease, which has been neglected the last decades. Education of population as well as health professionals is extremely important, particularly the importance of vaccination and preventive measures.

Key messages

From 2013 to 2017, number of pertussis cases in Tunisia varied with a considerable increase in 2013 and 2014. With the increase of pertussis cases and severity, preventive measures should be taken especially the importance of vaccination.

Human papillomavirus infections and cervical cancer screening in Tunisian women

Background

Human papillomavirus (HPV) infections are a significant public health problem with global estimations over 520 000 new cases and 274 000 deaths due to cervical cancer. In Tunisia, cervical cancer is the third cause of cancer in women but only a few prevalence studies conducted in specific populations are available. The present study aims to estimate the national prevalence of HPV infection and cervical cancer testing among Tunisian women.

Methods

We conducted a population-based cross-sectional study in 2014. We included all sexually active women aged 18 years and older, present in primary health care centers the day of the study. Data collection was based on a standardized questionnaire including socio-demographic data, high-risk behaviors and previous cervical screening. HPV detection and typing was only done for betaglobin positive PCR-test. Ethical considerations were respected.

Results

The total number of surveyed women was 1494 and the overall prevalence of HPV infection was 7.5% IC95% [5.9%-9.0%]. The most common genotypes were HPV6 (21.9%) and HPV16 (11.5%). Prevalence of high-risk HPV was higher than low-risk HPV; 4.8% IC95% [3.7%-6.2%] and 3.8% IC95% [2.8%-4.8%] respectively. The prevalence of previous cervical screening was 36.6% (95% CI [34.3%-39.2%]). This rate was significantly associated with age (p < 10-3); from 13.9% among those <30 years to 49.3% among those ≥ 50 years.

Conclusions

Our survey provides an important overview of the current situation of HPV infection among Tunisian women. National prevalence of HPV infection was 7.5% but only 36.6% of women had a previous cervical cancer screening. This coverage remains poor, thus the need of targeted education and encouraging strategies to reduce cervical cancer burden in Tunisia.

Key messages

National prevalence of HPV infection is not negligeable in Tunisia, especially high risk HPV infections. Cervical screening is still low among Tunisian women, hence the need for education targeted to this population.

[Evaluation and contribution of OptiMAL-IT® test for the diagnosis of imported malaria in Tunisia]

The rapid test OptiMAL-IT® was evaluated in the diagnosis and the screening of imported malaria in Tunisia in comparison with microscopic techniques. This prospective study focused on 500 individuals recruited from September 2010 to September 2012 in laboratory of Parasitology of Pasteur Institute of Tunis. They include 192 patients with clinical manifestations suggestive of malaria and 308 students originating from endemic areas. Microscopy of thick-and-thin blood smears and OptiMAL-IT® test were systematically performed on blood samples of all participants. Sixty individuals revealed infected by Plasmodium (12%). Positivity rates were respectively 20.3% in patients (44 cases) and 5.2% among asymptomatic students (16 cases) (p<0.01). The sensitivity and specificity of the OptiMAL-IT® test were respectively 88.6% and 100%. The concordance kappa was 0.92. The sensitivity and specificity during the screening of asymptomatic subjects were respectively 68.8% and 98.3% with a concordance of 0.67.

[The intestinal parasites in the food handlers of Tunis area: study of 8502 stool samples (1998-2008)]

The food handlers control is one of the major measures of the National program against intestinal parasitoses in Tunisia. The collected data allow regular updates of the prevalence and profile of the involved parasitic species and note possible evolutions in time. From 1998 to 2008, 8502 stool samples of food handlers working in Tunis area were examined in the laboratory of Parasitology, Pasteur Institute of Tunis. The mean prevalence of intestinal parasites was 13.5% (1152 positive samples). The protozoa were the most detected parasites (93% of the species observed). Among the pathogenic or potentially pathogenic parasites, Dientamoeba fragilis (15.5%) and Giardia intestinalis (7.6%) were the most frequently encountered. Entamoeba (E.) histolytica/dispar was diagnosed in 41 subjects (a prevalence of 05%). Hymenolepis nana was the most frequent helminth (45% of the whole parasites). Therapeutic failures were noticed in 43.8% of infection by this cestode because of the lack of the appropriate antihelminthic. The identification using PCR of cysts and/or vegetative forms of E. histolytica/dispar revealed the exclusive presence of E. dispar.

[Relationship between temperature and mortality in the city of Tunis: 2005-2007]

The influence of thermal stress on health is proved. In the light of the current climate change this relationship should be extensively investigated. This study aims to describe the relationship between temperature and total mortality in the city of Tunis over a period of three years, from 2005 to 2007 using time series analysis. The form of the relation (crude and adjusted) between mortality and temperatures was investigated using Poisson generalized additive models (GAM). Confounders included in the models were pollutant, trend, calendar month, day of the week, the period of Ramadan, and holidays. The adjusted relationship between mortality and temperature was "V" shaped with a steeper slope for low temperatures than for high temperatures. The impact of heat on mortality will be further analyzed to refine our findings and to contribute to the elaboration of guidelines for preventive strategies.

[Seroprevalences of hepatitis A and E infections in Tunisia]

OBJECTIVE

Viral hepatitis A (HAV) and E (HEV) infections are still frequent in many regions of the world, particularly in developing countries where sanitary conditions and socioeconomic level are frequently low. In this work, we have studied seroprevalences of these two infections in Tunisian children, teenagers and young adults.

MATERIAL AND METHODS

The studied population included 3357 individuals from different regions of Tunisia and distributed in three groups 1 (n=1145), 2 (n=707) and 3 (n=1505) with a mean of age of 6.94, 12.84 and 20.71 years, respectively.

RESULTS

Rates of HAV infection prevalence of 84.0, 90.5 and 91.7% were found within groups 1, 2 and 3, respectively. These rates are lower than those previously found in the country; thus, primary infection with HAV in Tunisia is progressively shifting to older ages, which is probably due to the improvement of sanitary conditions. Lower anti-HAV prevalences were found in costal regions as compared to the rest of the country. This difference may be due to the higher socioeconomic level of the population living in costal regions. Antibodies against HEV were assessed in individuals of group 3. A seroprevalence of 4.3% was found which indicates that, despite the absence of epidemics, the virus is circulating among the Tunisian population as sporadic cases.

CONCLUSION

The present work contributes to a better knowledge of HAV and HEV infections in Tunisia and highlights the need of the establishment of a national program for virological surveillance of hepatitis cases and of further studies to monitor changes in the epidemiology of these infections.

Contrasting patterns of hepatitis C virus infection in two regions from Tunisia

This report is a population-based study describing the pattern of hepatitis C virus (HCV) infection in two distinct regions in Tunisia. The study included a total of 11,507 individuals sampled in 1996 from both genders, all age groups, urban and rural settings belonging to 2,973 families. HCV infection was assessed by commercial enzyme immunoassay (EIA) and immunoblot assays and detection of HCV RNA by PCR. HCV genotypes and subtypes were determined by sequencing in the 5'-untranslated region (UTR) viral genomic region and the INNO-LiPA HCVII genotyping kit. Genetic relatedness between HCV strains was assessed by sequencing of a portion of the NS5B region. HCV prevalence was significantly higher in the North-Western region than in the Southern one: 1.7% versus 0.2% (P < 10(-3), chi(2) = 8,506). There was no difference in positivity according to gender or living in rural or urban settings; the only significant risk factor was advanced age. HCV prevalence among household contacts of HCV positives was not significantly higher than the prevalence in the whole study population. These results indicate a heterogeneity in the geographical distribution of HCV in Tunisia. An increased HCV transmission occurs in the North-Western region with large predominance of genotype 1b (88%) and low contribution of intrafamilial transmission.

[Health indicators in Tunisia, trends in regional disparities over the last thirty years]

The measure of health indicators on a regional-scale seems more interesting then the measure on a national-scale. It allows us to study differences between regions and their evolution. In order to know the time trend's disparities between regions, we have studied seven indicators, concerning different types of the World Health Organisation's classification, using data from yearly statistics and results of decennial census. Regional disparities are evaluated by a ratio between the highest regional value and the lowest regional value. This study showed us a global trend to the decline of regional disparities about indicators that we have studied. The improvement of health care resources indicators and socioeconomic's indicators, in the process of time, is associated with the improvement of health status indicators. The study of regional disparities makes possible to target actions for health in order to promote health's equity between regions.

[Study of the incidence and cost of nosocomial infections in general surgery]

Nosocomial infection incidence and its cost were study. We have identified 61 infected patients and 75 infectious episodes, is an incidence of 9.4% infected for 100 hospitalized by trimester. Operative site infections are the most frequent (60%), operative site infection (9.1%), inferior respiratory ways infections (2.2%). Incriminated germs are represented essentially by negative gram Bacillus (77.3%) with predominance of enterobacterias (59%). Invasive technique usage, surgery types and contamination classes have been identified as risk factors of nosocomial infection occurrence. The supplementary stay duration estimated by simple comparison between infected group and no-infected one is 9.3% days, responsible of an over cost of 336 TD by infected patient and 273 TD by infectious episode. The curative antibiotic costs have been estimated at 70 TD by infected patient being equivalent to two hospitalization days and to 57 TD by infectious episode.