Incidence and risk factors of post COVID-19 syndrome: a Tunisian cohort study

BACKGROUND

It has become increasingly clear that SARS-CoV-2 infection can lead to persistent physical and mental health problems lasting weeks or months, requiring prolonged periods of clinical care and increasing the burden on the healthcare system. This phenomenon, known as post COVID-19 syndrome (PCS), is a relatively new condition, its incidence is still unclear and differs between studies.

OBJECTIVES

In this cohort study, we aimed to estimate the incidence of PCS and to identify its risk factors in the Tunisian population.

METHODS

This is a prospective cohort study that enrolled patients diagnosed with COVID-19 from the triage unit of the University Hospital of Monastir, Tunisia. between April 2021 and June 2022. Patients were contacted by phone for a follow-up evaluation of PCS 12- weeks after the diagnosis date.

RESULTS

A total of 1451 individuals diagnosed with COVID-19 during the study period, responded to the follow-up evaluation after 3 months. The incidence of PCS was found to be 44.03% (95% CI [41.47; 46.58]), with fatigue being the most common symptom (21.5%), followed by cognitive impairment (10.3%), including memory loss and difficulty concentrating. Multivariate analysis revealed that the main associated factors to PCS were female gender (RR = 1.54; CI95% [1.30 - 1.82]), pre-existing comorbidities (RR = 1.30; CI95% [1.10 - 1.52]), duration of acute COVID-19 illness (days) (RR = 1.02; CI95% [1.01 - 1.03]), hospitalization (RR = 1.27; CI95% [1.05 - 1.53]), number of COVID-19 episodes (RR = 1.46; CI 95% [1.28 - 1.67]) and patients having receive two or more doses of vaccine prior to COVID-19 infection (RR = 0.82; CI95% [0.70 - 0.96]).

CONCLUSION

Our study allowed to estimate the incidence and identify risk factors of PCS. Recognizing these factors could help to better understand the underlying mechanisms and guide interventions for prevention and management of this condition.

Comparison of time to negative conversion of SARS-CoV-2 between young and elderly among asymptomatic and mild COVID-19 patients: a cohort study from a national containment center

Objective

We aimed to study the relationship between age and time to negative conversion of SARS-CoV-2 in patients with asymptomatic and mild forms of COVID-19.

Methods

We conducted a cohort study including all patients diagnosed with COVID-19 from the national COVID-19 containment center of Tunisia. Patients were subdivided into two cohorts: (under 60 years) and (over 60 years) and were followed up until PCR negativization. Log rank test and Cox regression were applied to compare time to negative conversion between the old group and the young group.

Results

The study included 289 patients with non-severe forms of COVID-19. Age over 60 was significantly associated with delayed negative conversion in male sex (Hazard ratio (HR): 1.9; 95% CI: 1.2-3.07) and among patients with morbid conditions (HR:1.68; 95% CI: 1.02-2.75) especially diabetics (HR: 2.06; 95% CI: 1.01-4.21). This association increased to (HR:2.3; 95% CI: 1.13-4.66) when male sex and comorbidities were concomitantly present and rose to (HR: 2.63; 95% CI: 1.02-6.80) for men with diabetes. Cox regression analysis revealed a significantly delayed negative conversion in symptomatic patients. Significant interaction was observed between gender and age and between age and chronic conditions.

Conclusion

Age is associated with delayed negative conversion of viral RNA in certain subgroups. Identifying these subgroups is crucial to know how prioritize preventive strategies in elderly.

Burden and predictions of hospitalized injuries in a low-middle income country: results from a Tunisian university hospital

Injuries are responsible for a high premature mortality and disability. They are poorly explored in low and middle income-countries. We aimed to estimate the burden of hospitalized injuries in the Monastir governorate (Tunisia) according to the nature of the injury, trends and projections of hospitalizations for injuries up until 2024, and to identify the distribution of this disease burden based on age and sex. We performed a descriptive study from 2002 to 2012 including all hospitalizations for injuries. Data were collected from morbidity and mortality register of the University Hospital of Monastir (Tunisia). We estimated the burden of injuries using the Disability Adjusted Life Years (DALYs). We described injuries (crude prevalence rate (CPR) and age standardized prevalence rate (ASR)), related mortality (lethality and standardized mortality ratio (SMR)), trends and prediction for 2024. A total of 18,632 hospitalizations for injuries representing 10% of all hospitalizations during study period were recorded. Per 1000 inhabitants per year, CPR was 3.36 and the ASR was 3.44. The lethality was of 17.5 deaths per 1000 injured inpatients per year and the SMR was of 2.95 (Confidence Interval of 95%: 2.64-3.29). Burden related to injuries was 2.36 DALYs per 1000 population per year, caused mainly by Years of Life Lost (83.4%), most frequent among men aged under 40 years. The predicted ASR for 2024 was 4.46 (3.81-5.23) per 1000 person-years. Injuries to the head was the most prevalent (20.7%) causing 67.7% of DALYs; and increasing by 226% through 2024. Injuries had a high prevalence and an important burden in a Tunisian university hospital. Prediction showed increased prevalence for 2024. Preventive measures and a trauma surveillance register should be implemented soon.

Quality indicators of public maternity units in the governorate of Monastir (Tunisia)

INTRODUCTION

Increasing access to healthcare for expectant mothers is a national goal. In Monastir, Tunisia, some Peripheral Maternity Units (PMUs) required assessment. Our goals were to describe the delivery activities in MUs (maternity units) and to assess whether some of PMUs need to have their activities replaced.

METHOD

We analyzed aggregate data of deliveries in Monastir from 2015 to 2020. The gouvernorate's seven public MUs were included. Only the morning activity was allotted for obstetricians and gynecologists, in RMUs 1 and 2, whereas they were not available in all PMUs. Data was gathered from the reports of the National Perinatal Program. Both the availability of Comprehensive Essential Obstetric Care (CEOC) and Basic Essential Obstetric Care (BEOC) were calculated. Trends were calculated using Joinpoint software. The Annual Percent Change (APC) was calculated.

RESULTS

The number of births decreased from 2015 to 2020 (APC= -4.3%: 95%CI : -6; -2.4; p = 0.003). The largest significant decreases in APCs of deliveries were reported in PMU 2 (APC = -12.6% (95%CI : -20; -4.4; p = 0.014), in PMU 3 (APC = -29.3% (95%CI : -36.5; -21.4; p = 0.001), and in PMU 4 (APC = -32.9% (95%CI: -49.1; -11.5); p = 0.016). If PMU 3 and 4 were no longer operating as maternity facilities, BEOC and CEOC standards would still be adequat. For accessibility, both PMU 3 and PMU 2 are accessible from PMU 4 and PMU 1, respectively.

CONCLUSIONS

Pregnant women prefer to give birth in obstetric services with ability to perform emergency caesarean at the expense of PMU. Nowadays, it appears that accessibility is less important than the presence of qualified human resources when a pregnant woman choose a maternity hospital.

The effectiveness of a health education intervention to reduce anxiety in quarantined COVID-19 patients: a randomized controlled trial

INTRODUCTION

The COVID-19 pandemic is regarded as a serious public health concern that boosts levels of stress and anxiety which could be explained by several reasons, including social isolation. In this regard, we aimed to assess the impact of health education on the anxiety level of COVID-19 patients during the isolation period.

METHODS

This is a randomized controlled trial conducted between February 2021 and June 2021. Patients tested positive for Covid-19 with mild to moderate forms were randomized to Education (n = 267) or control (n = 269). The education group received a phone health education session on day 1 (D1) following the diagnosis. The three components of the health education intervention were an explanation of the coronavirus disease, what to do in the event of complications, and the recommended preventive measures. The two groups received a telephone evaluation of their Hospital Anxiety and Depression scores on D1 and day seven D7 following the positive diagnosis. The primary outcome was the rate of anxiety reduction in each group on D7 based on a HAD-A score ≥ 8. Secondary outcomes were the rate of anxiety reduction on D7 based on a HAD-A score ≥ 11, the percentage of people complying with isolation and the scores of adherences to preventive measures during the isolation in each group.

RESULTS

Hundred and ninety-six patients in the intervention group and 206 patients in the control group completed the study. The sociodemographic, clinical, and initial anxiety level features of the intervention and control groups were comparable at baseline (p ≥ 0.05). On D7, the education group's anxiety level (HAD-A ≥ 8) decreased from 26 to 16.3% (p = 0.013) while in the control group it increased from 19.4 to 22.8% (p = 0.37). Thus, the percentage change in anxiety between D1 and D7 (delta D7 - D1) was - 9.7% in the Education group and + 3.4% in the Control group. Using the HAD-A ≥ 11 thresholds, the percentage of anxiety decreased from 15.3 to 11.2% (p = 0.26) between D1 and D7, while it increased in the control group from 9.7 to 15.7% (p = 0.045). Thus, the education group's change in anxiety (delta D7 - D1) was - 4.1%, while the control group's change was + 6%.

CONCLUSION

During an outbreak, providing health education to quarantined patients may be beneficial to reduce the psychological impact of the disease.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov Identifier: NCT05715593, retrospectively registered on 8/02/2023 https://clinicaltrials.gov/ct2/results?term=NCT05715593&Search=Search .

Associations of psychological factors, parental involvement, and adverse health behaviors with bullying among tunisian middle school students

BACKGROUND

Bullying is a serious problem that significantly affect adolescent well-being and health, needing the attention of teachers, school administrators, parents and public health professionals. In this study, we aimed at estimating the prevalence of bullying, from the perspective of victims in middle school students in the region of Monastir Tunisia, as well as analyzing its association with individual and family context variables.

METHODS

This is a cross-sectional study conducted in December 2017 and January 2018 among a sample of students from two middle schools in the region of Monastir (Tunisia), using the Global School-based Student Health Survey (GSHS) self-answered questionnaire. We defined bullying victimization as being bullied in at least one day in the previous 30 days. Binary logistic regression model was used to identify factors associated with being bullied.

RESULTS

Out of 802 students included in this study, nearly half (43.4%) reported having been bullied in the past month with CI _95%: 38.9-48.2. Gender did not interact with this behavior: (44.5%; CI _95%: 38.1-51.7) in boys versus (43.4% ; CI _95%: 37.2-50.2) in girls. Univariate analysis indicated significant differences regarding some individual factors such as physical fight, cigarette smoking, feeling lonely and being worried, in terms of prevalence of being bully victims. There were no significant differences in parental factors between the two groups (being bullied or not). Multivariate analysis showed the following factors as independently associated with bullying: being involved in physical fight (OR = 2.4; CI_95%:1.77-3.25), feeling lonely (OR = 3.38; CI_95% :2.04-5.57) and being worried (OR = 2.23; CI _95%:1.44-3.43).

CONCLUSION

Bullying victimization was common among school-going adolescents and was linked with physical fight and psychosocial distress. This study highlights the need for school-based violence prevention programs to address this problem among the students.

COVID-19 during pregnancy: case report and literature review

The current coronavirus disease 2019 (COVID-19) pneumonia pandemic, caused by the newly discovered coronavirus is a serious public health emergency and a highly infectious disease. Evidence to date suggests that there are groups of people who are at a higher risk of getting severe COVID-19 disease such as pregnant women and their fetuses. We reported 4 cases of pregnant women with COVID-19 admitted in the national containment center, Tunisia (3 imported cases and one local case). The age range of the patients was 27-35 years and the range of gestational weeks at admission was 16 weeks to 32 weeks. None of the patients had underlying diseases. All four cases were totally asymptomatic and presented no complications. Two of them gave birth one by vaginal and the other by cesarean delivery, neonates presented no symptoms and no adverse outcomes. The current report does not present significant differences in the disease prognosis in the pregnant women´s group compared with the general women´s population. Careful observation, data collection and consecutive research are necessary.

Effect of vitamin D supplementation versus placebo on recovery delay among COVID-19 Tunisian patients: a randomized-controlled clinical trial

INTRODUCTION

The present study aimed to determine the impact of vitamin D supplementation (VDs) on recovery delay among COVID-19 patients.

METHODS

We performed a randomized controlled clinical trial at the national COVID-19 containment center in Monastir (Tunisia), from May to August 2020. Simple randomization was done in a 1:1 allocation ratio. We included patients aged more than 18 years who had confirmed reverse transcription-polymerase chain reaction (RT-PCR) and who remained positive on the 14th day. The intervention group received VDs (200,000 IU/1 ml of cholecalciferol); the control group received a placebo treatment (physiological saline (1 ml)). We measured the recovery delay and the cycle threshold (Ct) values in RT-PCR for the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The log-rank test and hazard ratios (HR) were calculated.

RESULTS

A total of 117 patients were enrolled. The mean age was 42.7 years (SD 14). Males represented 55.6%. The median duration of viral RNA conversion was 37 days (95% confidence interval (CI): 29-45.50) in the intervention group and 28 days (95% CI: 23-39) in the placebo group (p=0.010). HR was 1.58 (95% CI: 1.09-2.29, p=0.015). Ct values revealed a stable trend over time in both groups.

CONCLUSION

VDs was not associated with a shortened recovery delay when given to patients for whom the RT-PCR remained positive on the 14th day.

TRIAL REGISTRATION

This study was approved by the Human Subjects Protection Tunisia center (TN2020-NAT-INS-40) on April 28, 2020, and by ClinicalTrial.gov on May 12, 2021 with approval number ClinicalTrials.gov ID: NCT04883203 .

Burnout syndrome among health care workers during the COVID-19 pandemic. A cross sectional study in Monastir, Tunisia

BACKGROUND

Burnout syndrome may affect the safety of frontline healthcare care workers (HCW) and patients. We aimed to measure the prevalence of burnout among HCW in care facilities in Tunisia during the Covid-19 pandemic and to identify its associated factors.

METHODS

We conducted a cross-sectional study among HCW practicing during the covid-19 pandemic in health care facilities in the governorate of Monastir. Data collection was carried out using an anonymous self-administered questionnaire composed by three sections: epidemiological and clinical characteristics, professional conditions and the Maslach Burn out Inventory (MBI-HSS).

RESULTS

This study included 371 HCW. The prevalence of burnout was 77.9% (CI 95%: 73.6% - 82.1%). The severe level was found in 71 participants (19.1%), the moderate level in 115 (31%) and the low level in 103 (27.8%). The distribution of the levels of the burnout dimensions among the participants was as follows: high emotional exhaustion (EE) (57.4%), high depersonalization (DP) (39.4%) and low personal accomplishment (22.6%). The main determinants of burnout among healthcare professionals during COVID 19 pandemic were: working more than 6 hours per day (OR = 1.19; CI95% [1.06; 1.34]), physician function (OR = 1.17; CI 95% [1.05; 1.31]), feeling a negative impact of work on family life (OR = 1.40; 95% CI [1.13; 1.73]), and high personal estimation of COVID 19 exposure (OR = 1.15; CI95% [1.02; 1.29]).

CONCLUSION

During the COVID19 pandemic, the prevalence of burnout among health professionals was high. It was related to hard implication in COVID 19 management. Interventions like adjusting working hours, reducing workload, and providing psychological support should be taken.

Breast cancer incidence and predictions (Monastir, Tunisia: 2002–2030): A registry-based study

Introduction

Breast cancer is a major public health problem worldwide. It is the leading cause of cancer deaths in females. In developing countries like Tunisia, the frequency of this cancer is still growing. The aim of this study was to determine the crude and standardized incidence rates, trends and predictions until 2030 of breast cancer incidence rates in a Tunisian governorate.

Methods

This is a descriptive study including all female patients diagnosed with breast cancer in Monastir between 2002 and 2013. The data were collected from the cancer register of the center. Tumors were coded according to the 10^th version of international classification of disease (ICD-10). Trends and predictions until 2030 were calculated using Poisson linear regression.

Results

A total of 1028 cases of female breast cancer were recorded. The median age of patients was 49 years (IQR: 41–59 years) with a minimum of 16 years and a maximum of 93 years. The age-standardized incidence rate (ASR) was of 39.12 per 100000 inhabitants. It increased significantly between 2002 and 2013 with APC of 8.4% (95% CI: 4.9; 11.9). Prediction until 2030 showed that ASR would reach 108.77 (95% CI: 57.13–209.10) per 100000 inhabitants.

Conclusion

The incidence and the chronological trends of breast cancer highlighted that this disease is of a serious concern in Tunisia. Strengthening preventive measures is a primary step to restrain its burden.

Health system saturation in managing COVID-19 patients in Monastir, Tunisia

Background

COVID-19 emerged in late 2019 and quickly became a serious public health problem worldwide. This study aimed to determine the average length of stay, occupancy bed rate and bed turnover rate for COVID-19 patients in Monastir university hospital between the 1st October 2020 and 28th february 2021.

Methods

This is a cross-sectional study that enrolled all hospitalizations for COVID19 in Monastir University hospital, the unique third level healthcare in this region, between the 1st October 2020 and 28th february 2021. The following indicators: the average length of stay, the occupancy bed rate and the bed turnover rate were calculated during the study period.

Results

We included 762 hospitalizations for COVID-19 during the study period. The average age of our population was 64,22 years (standard deviation= 14,17). Male predominance was noted with sex ratio=1,63. The median length of stay was significantly longer in the intensive care unit (ICU) than in the other departments (11 (7;16) days, versus 7(2;14) days), p = 0.008. The average number of beds available for COVID-19 patients during the study period was 13 in the ICU and 65 in the other wards. The bed turnover rate and the bed occupancy rate per month were respectively 2,66 patient/bed/month and 96,26% in the ICU versus 1,74 patient/bed/month and 62,26% in the other wards. The occupancy bed rate in the ICU exceeded the 100% during the outbreak of January and February 2021 (129,72% and 120,66% respectively).

Conclusions

Despite the efforts by the health services and social isolation measures in Tunisia, this study highlighted the saturation of our health system with an overload in intensive care units.

Key messages

Length of stay for patients with Covid-19 was significantly the longest in ICU. The occupancy bed rate, exceeding 100% in ICU, highlighted the health system collapse in managing COVID-19 patients.

Spirometry feedback as a motivational tool for tobacco cessation

Background

Tobacco use remains a major public health problem especially in developing countries and emerging economies. The evidence about the effect of spirometry on smoking cessation is still controversial. The aim of this study was to determine whether a spirometry and lung age announcement were a motivator for smoking cessation.

Methods

We conducted a randomized controlled trial among patients who attended the smoking cessation clinic (SCC) at Fattouma Bourguiba University Hospital in Monastir, from June 2017 to February 2020. Participants were assigned into two groups, a control arm receiving standard program and intervention arm receiving standard program and lung age announcement. The primary outcome was the smoking cessation rates after one year of follow-up between the intervention arm and the control arm.

Results

A total of 500 patients were recruited and randomized with 250 patients in each group. At one-year endpoint, a total of 456 patients were reachable for assessment, 236 in control group and 220 in spirometry group. The loss rate was equal to 8.8% (54/500). Six months smoking rate was 78 (33.1%) in control group and 106 (48.0%) in intervention group (p = 0.002). One-year smoking cessation rate was higher in the intervention group than the control group (25.5% versus 16.5%), with a considerable statistical significance (p = 0.019). Spirometric lung age was significantly higher at paired comparison with chronologic age (58.81vs 46.54; p<.001); the mean difference was 10.24 years but with considerable inter-individual variability.

Conclusions

Smoking cessation is still a challenging procedure with a high risk of relapse. This study is an additional evidence for spirometry and lung age announcement as motivators for cessation.

Key messages

Spirometry increased the motivation of smoking cessation. The equipment of smoking cessation centers by spirometry may contribute on tobacco control.

Comparison of SARS-CoV-2 RNA clearance between elderly and young patients with COVID-19

Background

The SARS-CoV-2 outbreak in 2020 caused a highly transmissible disease with a significant impact on the elderly. Understanding viral clearance duration of COVID-19 is important to tailor prevention strategies to this vulnerable category. We aimed to investigate the SARS-CoV-2 infection duration and associated factors to prolonged viral clearance among elderly people comparatively to young people.

Methods

We conducted a cohort study of asymptomatic and mild forms of COVID-19 patients admitted to the designated national COVID-19 center in Monastir, Tunisia. Patients included in the study were divided into two cohorts: (elderly group: ≥ 60 years old) and (young group: < 60 years old) and were followed up to their RNA viral conversion. Stratified cox regression was performed to determine associated factors with prolonged viral SARS-CoV-2 RNA clearance in elderly subgroups.

Results

The study included a total of 289 patients with asymptomatic and mild forms of COVID-19. The median term of viral shedding was 20 days (IQR; 16 - 32 days) for the young group, and 21 days (IQR; 17 - 33 days) for the elderly group. The stratified cox regression showed that Age ≥ 60 was an associated factor to prolonged viral shedding in male sex (HR (Hazard Ratio): 1.91; 95% CI: 1.19 - 3.07) and patients with comorbidities (HR:1.68; 95% CI: 1.02 - 2.75) especially diabetics (HR: 2.06; 95% CI: 1.01 - 4.21).

Conclusions

This study, focused on the factors associated with a prolonged duration of viral RNA clearance in elderly with COVID-19. These Potential factors will help planners to chalk out effective strategies among this vulnerable category.

Key messages

Old age is associated with a prolonged duration of viral RNA clearance in specific subgroups.

Identifying these subgroups is important to know how prioritize preventive strategies in elderly.

Social stigma among COVID-19 patients after quarantine in Sousse, Tunisia

Background

Assessing stigma related to COVID-19 is crucial to better understand the pandemic's impacts and establish effective stigma-reducing interventions. The aim of this study was to screen for stigma and evaluate its associated factors among adults with COVID-19 living in the governorate of Sousse (Tunisia).

Methods

A cross sectional study was conducted among a representative sample of patients with COVID-19 between the 6th of November and the 12th of December 2020 in the governorate of Sousse. The 12-item HIV stigma scale was translated in Arabic and then adapted to the Tunisian context.Three pre-trained medical doctors administrated the pre-tested Arabic questionnaire to each participant by phone calls. Higher scores reflect a higher level of perceived Covid-19-related stigma.

Results

Responses of 346 participants with COVID-19 infection were obtained. The majority of participants were females (60.4%) with a median age of 40 years (interquartile range, 30 to 54.5 years). Among them, 12.7% were health professionals and 12.5% had at least secondary educational level. Because of COVID-19 illness, 17.1% reported financial deterioration. We found mean scores of 14.6 ±4.07, 6.8±2.39 and 6.2±1.95 for social stigma, disclosure concerns and negative self-image dimensions respectively. Social stigma score was significantly higher among adults (14.9±3.9 versus 13.05±4.4 among elderly; p = 0.01) and people with low socioeconomic level (15.8±4.8 versus 14.3±3.8; p = 0.02). Lower scores of social stigma were found among health caregivers (13.3±2.6 versus 14.8±4.2; p = 0.002). Those factors remained as predictors of social stigma after linear regression analysis.

Conclusions

Screening for stigma is required in order to identify the most vulnerable patients and could prevent among them social repercussions. Psychological assistance of patients with social stigma would help them to overcome this crisis.

Key messages

Being adult with low socioeconomic level and not being health worker were determinants of social stigma.

Psychological assistance for COVID-19 patients is crucial to prevent social stigma repercussion during this outbreak.

Validation of the 12-item HIV-stigma scale adapted for use among Tunisian COVID-19 patients

Background

Although, there is a rapidly accumulating body of studies on the various aspects of COVID-19, little interest was given to develop valid specific scales measuring COVID-19-related stigma. The current study aims to testvalidity and reliability ofa modified version of the 12-item HIV Stigma Scale, adapted for adults with COVID-19 infection living in the region of Sousse (Tunisia).

Methods

A cross sectional study was conducted among patients with COVID-19 infection between November and December 2020. The 12-item HIV stigma scale was translated in Arabic and then adapted to the Tunisian context. A preliminary version with twenty items covering the four dimensions of COVID-19 stigma was tested (Personalised stigma, disclosure concerns, concerns with public attitudes and negative self-image). The psychometric evaluation included internal consistency as well as principal component analysis (PCA).

Results

Responses of 346 COVID-19 patients were obtained.Among participants, 60.4% were women with a median age of 40 years (interquartile range, 30 to 54.5 years). Evidence for internal validity was supported by a PCA, suggesting a three factor solution with fourteen items. The 14-item scale demonstrated good internal consistency. The global Cronbach'sα was 0.91, with values of 0.94, 0.93 and 0.98 for social stigma, negative self-image and disclosure concerns respectively.

Conclusions

The results suggest construct validity and reliability of the 14-item stigma scale measuring three aspects related to COVID-19 infection in Tunisia.

Key messages

The 14-item stigma scale is a good psychometric tool to be used in assessing COVID-19 related stigma in Tunisia.

Monitoring COVID-19 stigma with a valid and reliable would guide its prevention actions.

Incidence and predictor of tobacco experimentation among high-school adolescents of Sousse, Tunisia

Background

Tobacco use is considered one of the leading risk factors for early morbidity and mortality especially in developing countries. Initiation of tobacco use occurs usually during adolescence which is responsible for a longer time of exposure to nicotine and other constituents of tobacco products. The aim of this study is to determine the incidence and the factors associated with tobacco experimentation among high school students in the governorate of Sousse between 2017/2018 and 2018/2019.

Methods

A prospective longitudinal study was conducted in 4 high schools in the governorate of Sousse during the 2018-2019 school year. Pre-trained medical doctors ensured data collection using anonymous self-administered questionnaire. Collected data included socio-demographic and educational features, tobacco use, alcohol use, second hand smoking, illicit substances use, problematic internet use and mental health disorders.

Results

A total of 404 students were included in our study. The sex-ratio was 0.49 and the mean age of high school students was 16.4 (±1.1) years. At the end of the follow up, the incidence of tobacco experimentation among high school students was 9.7%. Problematic internet use was observed among the 36 (100%) adolescents who experimented tobacco while it was observed in 250 (79.9%) of who did not experiment tobacco during the follow up (p = 0.003). Otherwise, maternal tobacco use was the most influential factor on tobacco experimentation among participants with an odds ratio of: 7.1; 95% CI: 1.5-32.8) (p = 0,013).

Conclusions

Incidence of tobacco experimentation among the high school adolescents of Sousse is high. Second hand smoking and other addictive behaviors should be considered in order to reinforce the national prevention program of tobacco use.

Key messages

Reinforcement of the existing prevention program of tobacco use in Tunisia is required. Comprehensive prevention program of tobacco use taking into consideration the other addictive behaviors among adolescent and their entourage would be more effective.

Assessment of cardiovascular risk factors in the health care centers among a Tunisian adults

Background

Almost one third of deaths worldwide are attributable to cardiovascular diseases (CVD). In Tunisia, although a national strategy for the management of high blood pressure and diabetes has been implemented since 1999, CVD still represent a common cause of death. Purpose: To evaluate the assessment of cardiovascular risk factors in the health care centers among the adults of the governorate of Sousse, Tunisia.

Methods

Cross-sectional study was conducted in 2014 among 1977 adults living in 16 districts randomly selected from the delegations of the governorate of Sousse. Data collection was performed by trained doctors using a pre-tested questionnaire administered by interview to participants in their homes. Blood pressure and anthropometric measures were taken after each interview.

Results

The mean age of the participants was 39.8 (± 13.8) years. The sex ratio F/M was 1.54. Among patients with hypertension, 72% of were unbalanced; while 26.2% of participants without a history of hypertension had high blood pressure. Assessment of physical activity, dietary behaviors and weight in the health centers during the previous year, were reported by 28.3%, 32.6% and 36.5% of participants respectively. Assessment of smoking status and waist circumference were rarer with frequencies of 13.5% and 5.6% respectively.

Conclusions

The current national Tunisian program for diabetes and hypertension management should be reformed. Healthy life style promotion should integrate this national program.

Key messages

Dispite thenational strategy for the management of high blood pressure and diabetes in Tunisia; Cardio vascular disease still represent a common cause of death. The current national Tunisian program for diabetes and hypertension management should be reformed.

Smoking cessation adherence:recurrent cardiovascular events after five years of first manifestation

Background

Smoking is an established risk factor for cardiovascular events, such as myocardial infarction, stroke and cardiovascular death. Although the harmful effects of smoking on health are widely known. Smoking is highly addictive and cessation can be extremely difficult, even after a life-threatening vascular event.

Objective

The present study aimed to assess the relation between smoking status and risk of recurrent Cardiovascular events 5 years after the first hospitalization for acute coronary syndrome.

Methods

A cross sectional study was conducted in the Smoking Cessation Service at University Hospital of Monastir, Tunisia during February 2020. The smoking status and recurrent cardiovascular events were assessed 5 years after the first hospitalization for acute coronary syndrome by phone call among patients attended the tobacco cessation consultation. The statistical analysis was conducted with SPSS software, version 21.0. A p value of &lt; 0.05 was considered statistically significant.

Results

A total of 112 patients were included in our study. All participants were male and the mean age was 56 ±10 years. Most patients (67%) had a high level of nicotine dependence. The rate of smoking abstinence declined from 35.7% at one year to 21.1% at 5 years. During the study period, 4 patients died(3.5%) and 17 (15.17%) had a recurrent cardiovascular event. The recurrent cardiovascular event occurred more in smoking patients but the difference was not significant.

Conclusions

Smoking cessation after a first cardiovascular event should be a key objective for both patients and physicians to reduce the risk for recurrent vascular events. More efforts are needed to maintain smoking cessation in patients at very high cardiovascular risk.

Key messages

Smoking cessation consultation can increase adherence to smoking cessation and helps in reducing the excess risk of recurrent cardiovascular events. Smoking is highly addictive and cessation can be extremely difficult, even after a life-threatening vascular event.

Impact of Haemophilus influenza immunization on hospitalized acute respiratory infections

Background

Immunization is the most cost-effective measure to combat communicable diseases in childhood. Haemophilus influenza (Hib) vaccine was included in the Tunisian expanded program of immunization for the first time in 2002 (Hib Vaccine monovalent) and is currently combined with the pneumococcal vaccine(Hib vaccine pentavalent combination) since April 2019. We aimed to assess impact of Hib vaccine on Respiratory Infection(RI) admissions in children aged up to 3 years.

Methods

It was a cohort study from January 1, 2002 to December 31, 2013. All Respiratory Infection (RI) admissions in children aged up to 3 years in the university hospital of Monastir(Tunisia) were enrolled.

Results

Admissions for RI represented 17.6% (CI95%: 17.3-18.1) of all communicable diseases hospitalizations (n = 6 061/34 289). The median age was 22 years (IQR: 3-52). Admission for Pneumonia with Streptococcus Pneumoniae (SP) increased significantly during study period (b = 25.9 (p &lt; 0.0001)) especially in children up to 5 years old (b = 10.6) and in elderly (b = 6.0). Among children up to 3 years old, the Crude incidence rate per 100,000 for Hib pneumonia admission were 11.6 in Non-Vaccinated Cohort (NVC), 10.6 in Vaccinated Cohort (VC) by protocol 1 (Hib Vaccine monovalent) and 0.80 in VC by protocol 2 (Hib vaccine pentavalent combination).The relative risk reduction was 99% for protocol 2 (p &lt; 0.001).

Conclusions

Admissions for RI in a tertiary level hospital were common with an increasing trend. The Hib immunization program, in particular the second protocol (pentavalent combination), has had a positive impact on the reduction of related acute diseases.

Key messages

The Hib immunization program, has had a positive impact on the reduction of related acute diseases. The “Hib vaccine pentavalent combination “is more efficient than “Hib Vaccine monovalent”.

Cannabis use in high school adolescents of SousseTunisia: Incidence and predictors

Background

Adolescence is a period of physical, psychological and social transformation. It is during adolescence that people are introduced to psychoactive substances such as cannabis. Understanding the predictors of this risk behavior, would help dealing with this problem more efficiently. The current study aimed to determine the incidence and the predictors of cannabis use among high school students in Sousse governorate between 2017/2018 and 2018/2019

Methods

A prospective longitudinal study was conducted in four high schools in the governorate of Sousse during the period from 15/09/2017 to 30/06/2019. Pre-tested self-administered questionnaire served to collect data anonymously among participants about their socio-demographic characteristics, cannabis use, tobacco use, use of electronic cigarettes, illicit substances use, sedentary behavior and mental health disorders among them.

Results

A total of 404 students were included in our study. The average age of participants was 16.4 (±1.1) years. The cumulative incidence of cannabis use among high school students was 2.2%, (95%CI: 0.8%-3.6%). School failure, anxiety problem, cigarette smoking, vaping and illlicit substances use among friends were found to be significantly associated with cannabis experimentation among them. Whereas its most influential factors were: Current cigarette smoking and current vaping with adjusted odds ratio of: 12.9; 95% CI: 2.4-70.2) and 7.2; 95% CI: 1.3-38.8 respectively.

Conclusions

This study highlights the association between cigarette and e-cigarette smoking and cannabis use. Future prevention interventions should focus on these risk behaviors with regard to the environmental context.

Key messages

Cannabis use is not rare among the adolescents of Sousse, Tunisia. Adolescents represent vulnerable sub-group that merit special attention regarding substances use.

Tobacco use among middle school pupils in Sousse, Tunisia across three years of monitoring

Background

Tobacco use represents a major risk factor for incident disability-adjusted life years among adolescents especially in developing countries. In Tunisia, a national strategy to reduce tobacco use was set up since 2008. However, no surveillance system was implemented to evaluate it.

Objective

To examine trends in tobacco use among middle school children in Sousse, Tunisia between 2014 and 2016 and to determine predictors of its experimentation.

Methods and findings

Three cross-sectional studies were conducted in 2013/2014, 2014/2015 and 2015/2016 school years among middle school-children randomly selected from the governorate of Sousse-Tunisia. The required sample size for each study was 760 participants. Each year, the same procedure was used to recruit pupils from the same middle schools. The same pre-tested questionnaire was self-administered anonymously to participants in their classrooms.

Results

Lifetime tobacco use rose from 11% in 2013/2014 to 17.3% in 2015/2016 (p = 0.001). Across the three years of survey, predictors of lifetime tobacco use were: The male gender (OR, 95% CI: 4.4 [3.2-6.1]), age above 13 (OR, 95% CI:2.3 [1.7-3.1]), lifetime illicit substances use (OR, 95% CI: 3.9 [1.1- 13.8), lifetime inhalant products use (OR, 95% CI:2.2 [1.2-4.3]), tobacco use among the father (OR, 95% CI:2.2 [1.2-4.3]), tobacco use among siblings (OR, 95% CI:1.7 [1.2-2.4]) and current anxiety problem (OR, 95% CI: 1.8 [1.4-2.4]).

Conclusions

Tobacco experimentation is in expansion among the young adolescents of Sousse. Its prevention should integrate a comprehensive substances use prevention program with emphasis on second hand smoking and the associated mental health problems.

Key messages

More attention should be paid to young adolescents in order to prevent tobacco and other substances use among them. Second hand smoking and mental health problems should be considered when planning for prevention programs of tobacco use.

Compliance with home-quarantine and prognosis of COVID-19 among a cohort of Tunisian patients

Background

The COVID-19 disease has a spectrum ranging from asymptomatic infection to multi-organ dysfunction. Most patients with mild symptoms are isolated at home until recovery. However, compliance with home-quarantine and recovery are not warranted especially in developed countries where health capacity is poor. The purpose of the current study is to evaluate compliance with home-quarantine and the prognosis of COVID-19 among a cohort of patients isolated at home in the Governorate of Sousse, Tunisia.

Methods

Prospective longitudinal study of three months was led among a cohort of 375 patients with COVID-19 isolated at home. Participants were randomly selected from the new declared cases in the governorate of Sousse. Data were collected using a pre-established and pre-tested questionnaire administered during phone calls interviews with trained medical doctors.

Results

The median age of participants was 40.0 (IQR: 29.75-54.25) years. Females represented 60% of them. The average duration between close contact with symptomatic person and onset of symptoms was 4.01(±1.9) days. The most commonly reported symptoms were asthenia (51.7%), smell disturbance (50.4%), myalgia (41.9%) and ageusia (40.8%). Thirty two (8.5%) participants required hospitalization and 4 (1.0%) were transferred to intensive care units.The median delay for recovery was 18 days (IQR 17.1-18.9). Otherwise, 95 (25.4%) declared not respecting the quarantine and 111 (29.6%) of participants transmitted the infection to their family members.

Conclusions

Complications and intra-family transmission are frequent among COVID-19 patients isolated at home in Sousse. Accelerating the implementation of the Tunisian telemedicine law would provide a cost-effective solution for this problem.

Key messages

Isolation at home of COVID-19 patients should be associated with close monitoring by health professionals.

Individual prevention measures should be reinforced among patients isolated at home to limit intra-family spread of COVID-19.

Animal bites and post-exposure prophylaxis in Central-West Tunisia: a 15-year surveillance data

BACKGROUND

Rabies is a disease that still exists in developing countries and leads to more fatalities than other zoonotic diseases. Our study aimed to describe the profile of human exposures to animals over fifteen years and to assess the post-exposure prophylaxis (PEP) practices in the governorate of Kasserine (Tunisia) on pre- and post-revolution (2011).

METHODS

We carried out a descriptive study using surveillance data from a region in Central-West Tunisia. All humans exposed to animals, residents in Kasserine Governorate and declared to the regional directorate of primary health care (RDPH) from January 1st, 2004 to December 31st, 2018 were included.

RESULTS

A total of 45,564 cases of human exposures to animals were reported over the fifteen-year period of the study with an annual average of 3089.2 ± 403.1. The standardized incidence rate (SIR) of human exposures to animals was 694 per year per 100,000 inhabitants (inh). The most listed offending animal was the dog (91.3%) and the most reported type of exposure was bites (63.7%). The trend in human exposures to animals increased significantly over time. The number of exposures by vaccinated dogs decreased significantly and by unvaccinated and stray dogs increased steeply. When comparing pre-and post-revolution periods, the yearly average of animal exposures post-2011 was significantly greater than the average prior to 2011 (3200 ± 278.5 vs 2952.8 ± 483) (p < 0.001). The yearly average of animal bites post-2011 was significantly greater than the average prior to 2011 (2260.5 ± 372.1 vs 1609.8 ± 217.9) (p < 0.001). The average number of vaccine doses per animal exposure was 2.4. Concerning PEP protocols, protocol A (2 and 3 doses) was indicated in 79% of animal exposures cases. From 2004 to 2018, a downward trend was noted for protocol A (r = - 0.29, p < 0.001) and an upward trend for protocol B (3 and 5 doses) (r = 0.687, p < 0.001). During our study period, 5 fatal cases of human rabies were declared.

CONCLUSION

Rabies remains a major public health problem in Tunisia. The political dynamics had an impact on the health care system and rabies control. Preventive measures should be applied adequately to decrease the burden of this disease.

Syndromic surveillance of female sexually transmitted infections in primary care: a descriptive study in Monastir, Tunisia, 2007─2017

BACKGROUND

Sexually Transmitted Infections (STIs) are a public health problem, especially for reproductive-age women. The aim of this study was to determine the incidence and trend of STIs during 11 years in Tunisia (2007-17).

METHODS

We conducted a descriptive study including all women with curable STIs (chlamydia, gonorrhea, syphilis and trichomoniasis) diagnosed with the syndromic approach in all basic health care centers of the Governorate of Monastir (Tunisia) from 2007 to 2017. Syndromes included, Pelvic Pain (PP), Vaginal Discharge (VD) and Genital Ulceration (GU).

RESULTS

We analyzed 40,388 episodes of curable STIs with a crude incidence rate and age standardized incidence rate of 1393 (95% Confidence Interval (CI); 1348-1438) / 100,000 Person Year (PY) and 1328 (95%CI; 1284-1372) /100,000 PY respectively. The incidence rate showed a positive trend over 11 years for all age groups and syndromes. VD was the most common syndrome with a crude incidence rate of 1170/100,000 PY. For all syndromes, women aged 20 to 39 were the most affected age group (p < 0.001).

CONCLUSION

In conclusion, the incidence rate of STIs episodes among women diagnosed with the syndromic approach was high, consistent with the global evidence. Focusing on reviewing STIs surveillance system in low and middle-income countries could allow the achievement of the ending of STIs epidemics by 2030.

Factors associated with a prolonged negative conversion of viral RNA in patients with COVID-19

Objectives

The aim of this study was to identify the factors influencing the delay in severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) RNA negative conversion.

Methods

A cohort study was conducted that included patients with coronavirus disease 2019 (COVID-19) admitted to the Tunisian national containment center. Follow-up consisted of a weekly RT-PCR test. Multivariate Cox regression analysis was performed to determine independent predictors associated with negative RNA conversion.

Results

Among the 264 patients included, the median duration of viral clearance was 20 days (interquartile range (IQR) 17–32 days). The shortest duration was 9 days and the longest was 58 days. Factors associated with negative conversion of viral RNA were symptoms such as fatigue, fever, and shortness of breath (hazard ratio (HR) 0.600, 95% confidence interval (CI) 0.401–0.897) and face mask use when exposed to COVID-19 cases (HR 2.006, 95% CI 1.247–3.228). The median time to RNA viral conversion was 18 days (IQR 16–21 days) when using masks versus 23 days (IQR 17–36 days) without wearing masks, and 24 days (IQR 18–36 days) for symptomatic patients versus 20 days (IQR 16–30 days) for asymptomatic patients.

Conclusions

The results of this study revealed that during SARS-CoV-2 infection, having symptoms delayed viral clearance, while wearing masks accelerated this conversion. These factors should be taken into consideration for the strategy of isolating infected patients.

Trends and health burden of hospitalized acute respiratory infections and impact of Haemophilus influenza immunization in a Tunisian university hospital: a twelve-year study

BACKGROUND

We aimed to describe the episodes and trends of admissions for community-acquired Respiratory Infections (RI) over a 12-year period and to assess the impact of Haemophilus influenza type b (Hib) vaccine on RI admissions in children aged up to 3 years.

METHODS

We conducted a twelve-year retrospective observational study on all community-acquired RI admitted to Fattouma Bourguiba Hospital in Monastir Governorate (Tunisia) from 1 January 2002 to 31 December 2013. RI cases were selected from the Regional Registry of Hospital Morbidity. Data were coded according to ICD-10. To assess the impact of the Hib vaccine, three cohorts were defined based on vaccine status (unvaccinated cohort, first vaccinated cohort (VC) by monovalent form and second VC by pentavalent combination).

RESULTS

Admissions for RI represented 17.6% (CI95%: 17.3-18.1) of all communicable diseases hospitalizations (n = 6 061/34 289). The crude incidence rates (CIR) per 100,000 inh were 24.2 for upper RI (URI) and 77.5 and for Lower RI (LRI) (p < 0.0001). Pneumonias represented 53.9% of LRI. Sex-ratio (male/female) was 1.12 for URI and 1.64 for LRI (p < 0.0001). At admission, the median age was 22 years (IQR: 3-52). Admission for Pneumonia increased significantly during study period (slope 'b' = 5.16; p < 0.0001) especially in children up to 5 years old (slope 'b' = 5.53) and in elderly (slope 'b' = 2.13). Among children up to 3 years old, the CIRs per 100,000 for Hib pneumonia admission were 11.6 in Non-Vaccinated Cohort (NVC), 10.6 in Vaccinated Cohort (VC) by protocol 1 (Hib Vaccine monovalent) and 0.80 in VC by protocol 2 (pentavalent vaccine combination).The relative risk reduction was 99% for protocol 2 (p < 0.001).

CONCLUSION

Admissions for RI in a  tertiary level hospital were common with an increasing trend. The Hib immunization program, in particular the pentavalent combination, has had a positive impact on the reduction of related acute diseases.

Trends in cardiovascular disease in the region of Monastir (Tunisia) over 12 years

Background

Cardiovascular diseases (CVDs) are the major cause of morbidity and mortality worldwide. However, CVD prevalence trends is still weakly documented in Tunisia. The objective of this study is to examine trends in the prevalence of CVDs in the Monastir region between 2002 and 2013.

Methods

Data were collected from the regional register of hospital morbidity. The register refers to the WHO International Classification of Diseases, 10th revision (ICD-10). Data were verified and analyzed using IBM SPSS Statistics version 22.0 software. Linear regression was used to calculate the slope 'b' of the least-squares line to estimate admission trends for each CVD category according to sex and age group. A p-value of 5% was considered statically significant.

Results

From 2002 to 2013, cardiovascular diseases accounted for 21,240 hospital admission in the region of Monastir, representing more than a quarter (28.7%; CI 95%: 28.1-29.3%) of all Non Communicable Disease admissions in adults. Males represented 55.9%. The median age at admission was 64 years (IQR 54-71 years). The CVD crude prevalence rate (CPR) was 3.60 /1,000 inh. The age-standardised CVD rate (ASR) was 4.56 per 1000 PY and it was higher in men than in women (5.41 vs. 3.72, respectively, p &lt; 0.001). CVD prevalence rate increased over time (b = 17.78; p&lt;.001). This increase was significant in men (b = 33.69; p &lt; 0.001) and in age groups over 40-years-old (b = 15.30; p &lt; 0.001). However, it declined significantly in women (b= -16.32; p &lt; 0.001). Coronary heart diseases (CHD) were the most prevalent CVD categories (47.7%).

Conclusions

Hospital admissions for CVD increased over the study period, in particular in men and in age groups over 40-years-old. CHDs were the prevalent disease. A comprehensive prevention strategies focused on lifestyle habits such as unhealthy diets, physical inactivity and tobacco consumption are greatly recommended to improve this prevalence trends.

Key messages

Over a 12-year period, CVD prevalence increased in men but not in women at the university hospital of Monastir. A comprehensive prevention strategies focused on lifestyle habits such as unhealthy diets, physical inactivity and tobacco consumption are greatly recommended to improve this prevalence trends.

Epidemiological aspects of human exposure cases to rabies by in the central west region of Tunisia

Introduction

Rabies is a major public health problem in several countries in the South and East of the Mediterranean and in the Middle East. The objectives of this study were to describe the epidemiological profile of human exposures to rabies by a dog, as well as the profile of aggressive dogs during a period of 15 years in a region in the central west region of Tunisia.

Methods

We have included all cases of human exposure to a dog, reported between 2004 and 2018 in the Kasserine area. The source of the data was the directorate of primary health care in Kasserine.

Results

A total of 41,850 human exposure cases to a dog have been reported over the fifteen year study period with an annual average of 1937.5 cases. Among them, 29,062 cases (69.4%) were attacked by a bite. The crude incidence of dog bite cases was 441 per 100,000 population. The vaccination status of attacking dogs was unknown in 15.4% of the cases (n = 6423). Among all attacking dogs with a known vaccination status (n = 35427), 45.2% were vaccinated (n = 16017) and 54.7% (n = 19392) were unvaccinated. A significant increase in human exposure cases to dogs was noted from 2004 to 2018 (β = 11.7, p = &lt;10-3). The number of exposures by an unknown dog or a known unvaccinated dog increased significantly (β = 28.02; p = &lt;10-3 and b = 69.9, p = &lt;10-3; respectively). However, the number of cases attacked by a known vaccinated dog decreased significantly (β = -86.4, p = &lt;10-3). During the study period, five cases of human rabies were identified in the study area.

Conclusions

In Tunisia, human exposure to rabies by a dog has been on the rise. It could be linked to the period of popular and political movement that the country is going through.

Key messages

In this study, human exposures cases to rabies by unvaccinated dog is significantly increasing. It is crucial to strengthen appropriate preventive measures, such as mass vaccination and dog castration programs.

Lifestyle habits among a sample of middle school adolescents in Tunisia

Introduction

Adolescent health is a major global concern today. In fact, adolescence is the period of life where different risky behaviors can take hold and is therefore the best prevention phase to guarantee healthy lifestule in adulthood. We aimed to assess the lifestyle of middle school adolescents and to highlight the main behaviors such as the eating habits, the physical activity and the personal hygiene.

Methods

We carried out a cross sectional study among a sample of adolescents from December 2017 to January 2018 and we involved two middle school schools in the region of Monastir in Tunisia. The questionnaire GSHS (the Global school-based student health survey) was used.

Results

In total, 802 participants were enrolled with a mean age of 13.6 ±1.9 years, ranged from 11 to 16 years old. Females represented 51.9% of the study population. More than one third of the students (36%) reported rarely or never eating breakfast with a significant difference in girls more than in boys (62.8% vs 37.2%, p &lt; 10-3). Almost half of students (46.2%) reported drinking sugary sodas at least once a day and 86.3% of them reported consuming fast food more than two times per week. In addition, 59.4% of middle school students reported eating fruit more than twice a day and 24.3% eating vegetables at least three times a day. Regarding physical activity, our results showed that 24.4% of middle school students were physically active (1 hour minimum during the day) every day for the last 7 days, boys more than girls (56.5% vs 43.5%, p = 0.02). In addition, 39.7% of students declared they sit at least three hours a day. As for personal hygiene, our study found that 9.3% of students never, or rarely, washed or brushed their teeth; boys more than girls (69.3% vs 30.7%, p = &lt;0.001).

Conclusions

Our results provide additional evidence on the need to combat sedentary lifestyle and encourage healthy nutrition and physical activity among adolescents.

Key messages

Understanding the health needs and concerns of young people contribute to implement effective health programs. Interventions in young people should act on various aspects of the lifestyle to ensure an optimal effect.

Factors associated with diabetic foot among type 2 diabetes in the region of Monastir (Tunisia)

Background

The diabetic foot (DF) has actually a high rate of disability leading to impaired quality of life and even mortality. Glycemic control among Tunisian adults with diabetes mellitus remains poor. However the relationship between glycemic control and foot complication have not been clearly established. The aim of the present study was to assess the relationship between diabetic foot lesions and glycemic control and the diabetic duration in the people with DT2.

Methods

A cross-sectional survey was conducted in five Primary Health care Centers (PHC) in the region of Monastir (Tunisia) from March 2016 to April 2017. Data were collected using interviewer administered structured questionnaire. Validated questionnaire was used to assess diabetic foot diseases.nA multivariate logistic regression analysis was conducted to assess the relationship between glycemic control, diabetic duration and the DF lesions. A p-value of &lt; 0.05 was considered statistically significant.

Results

In total 383 patients were recruited, of whom 258 (67.9%) were men. The mean age of participants was 60.7±11.3. Poor glycemic control (HbA1c ≥ 7.0%) increased the risk of abnormal patellar reflex (aOR=7.07; CI95% 1.65-30.1; p = 0.03) and calf claudication (aOR=7.07; CI95% 1.65-30.1). The long duration of diabetes (10 years and more) was a significant factor associated with an abnormal Achill reflex (aOR=2.31; CI95% 1.12-4.76; p = 0.02), a needle-stick perceptual disorder(aOR=2.08; CI95% 1.14-3.78; p = 0.01), a vibration sensibility perceptual disorder (aOR=2.02; CI95% 1.01-4.08; p = 0.04), a negative monofilament test (aOR=2.69; CI95% 1.04-5.16; p = 0.003), an absent dorsalis pedis artery pulsation(aOR=2.35; CI95% 1.09-5.05;p=0.02) and an absent posterior tibial artery pulsation (aOR=3.06; CI95% 1.28-7.28; p = 0.01).

Conclusions

This study identified that disease duration and poor glycemic control are significant risk factors related to DF development in the current T2DM population.

Key messages

Disease duration and poor glycemic control are significant risk factors related to DF development in the T2DM population in the region of Monastir. Prevention programs should be focused on patient education about modifiable risk factors in particular glycemic control and adequate and regular foot care.

Burden of cardiovascular diseases in the region of Monastir (Tunisia)

Background

Cardiovascular disease (CVD) is the leading cause of death in Tunisia. The aim of this study was to analyze CVD burden from 2002 to 2013 in the region of Monastir.

Methods

Using the Global Burden of Disease methodology, cardiovascular disease mortality and disability-adjusted life years (DALYs) were analyzed by age group and sex for all admissions at the university hospital of Monastir, using standardized approaches for data processing and statistical modeling. Data were retrieved from the regional register of hospital morbidity in Monastir and were analyzed from January 2002 to December 2013.

Results

CVDs caused 519 in-hospital deaths during the study period, accounting for 43.3 % (CI 95%: 40.6-46.1%) of all in-hospital non-communicable diseases-related mortality (n = 1197). The crude mortality rate of CVDs was 8.81 per 100,000 inh. The highest rate was recorded among patients aged ≥ 60 years-old. The age-standardized mortality rate was 11/100,000 PY (14 in men and 8 in women). CVD DALY per 100,000 was 176.4 (199.4 in men and 152.7 in women). The highest CVD DALY was in the age groupe of 60 years and older (929.7/100,000). The leading causes of DALYs for both sexes are coronary heart diseases and stroke with DALY rate of 112.6 and 47.4 per 100,000 inh, respectively.

Conclusions

The CVD burden was heavy in the study population, in particular in the elderly and in men. Prevention and control of modifiable risk factors should be taken actively to improve health for Tunisian adults.

Key messages

CVD burden was heavy in the region of Monastir. More efforts are needed to improve cardiovascular health in Tunisian adults.

Being bullied and associated factors among middle school students in the region of Monastir, Tunisia

Introduction

The phenomenon of bullying among adolescents is a worldwide issue. The trend of this behavior is increasing in developed countries as well as in developing countries, with the creation of new forms such as cyberbullying. This study aimed to determine the prevalence of being bullied and to analyze the association between being bullied and some individual and familial factors.

Methods

This is a cross-sectional study conducted in two middle schools belonging to the region of Monastir in Tunisia in December 2017 and January 2018. The Global School-based Student Health Survey (GSHS) was administered for students. All present students from the two recruited schools were included.

Results

A total of 802 students were enrolled in the study. Just under half of the study group (44.0%) reported having been bullied in the past month with 95% CI [40.66%-47.57%]. The predominant type of bullying was being made fun of with sexual jokes, comments or gestures (9.1%), followed by being kicked, pushed, shoved or locked indoors (3.6%). In multivariate analysis, physical fight was an independent associated factor with being bullied (OR [CI]95%: 2.04[1,77-3,25]), p = 0.001. Lonely students had nearly 3.38 higher risk of undergoing bullying (OR [CI]95%: 3.38 [2.05-5.57]), p = 0.001). In addition, being worried was also an independent factor associated with being bullied (OR [CI]95%: 2,23 [1,45-3,43]), p = 0.001.

Conclusions

Our results support an association between existing mental health problems and bullying. Additional studies are needed to understand the factors associated with school bullying and to

Key messages

In this study, the prevalence of bullying was relatively high. Program education in schools should focus on life skills education in order to develop the self-confidence and the self-esteem of students.

Occupational exposures to blood and body fluids among health care workers in Tunisia

Background

Occupational exposures to blood and body fluid are among the most frequent occupational accidents in healthcare. They put healthcare workers (HCWs) at high risk of transmission of many blood borne pathogens mainly hepatitis B virus (HBV), hepatitis C virus HCV and HIV. The aim of this study was to determine the prevalence of occupational exposures to blood and body fluids and its associated factors among HCWs at the university hospital of Monastir (Tunisia) in 2017.

Methods

An exhaustive cross-sectional study was conducted from 01 June 2017 to 31 August 2017 at the university hospital in Monastir Governorate (Tunisia). An anonymous self-administered questionnaire was used to collect data on demographic characteristics, self-reported exposures and their circumstances. We performed a multivariate analysis to determine the associated factors to these occupational exposures.

Results

A total of 1493 HCWs (34.6% nurses 22% technicians and 21.6% doctors) were included corresponding to a response rate of 74%. The median age of the participants was of 36 years (IQR: 31- 46 years). The sex ratio was of 0.36. Responders from medical and surgical departments represented respectively 40.5% and 39%. Among interviewed HCWs, 56.7% reported having at least one exposure to blood or body fluid with 35.4% of them exposed twice or more. Almost half (48.3%) of the respondents had a history of needle stick injury and 32.1% had a history of blood or body fluid splash into the face.The multivariate analysis showed that doctors had the highest risk of exposure comparing to other HCWs with (AOR = 12.425; 95% CI: 05.310 - 29.075) and participants working at surgical departments were at higher risk of exposure than those at others departments (AOR=7.440; 95% CI: 4.461 - 12.408).

Conclusions

Health occupational exposures to blood and body fluids are a serious problem at the university hospital of Monastir. Preventive measures should be strengthened to alleviate this problem.

Key messages

Doctors had the highest risk of exposure to blood and body fluids comparing to other HCWs at the university hospital of Monastir. Preventive measures should be strengthened to alleviate this problem.

Three COVID-19 cases with a long-term viral shedding period in Tunisia

Novel coronavirus disease (COVID-19) caused by severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) has become a public health emergency of international concern. This was first emerged in Wuhan, Hubei Province, China, and then has become widespread all over the world. We report 3 cases (2 imported cases and 1 local case) with documented viral shedding (based on reverse transcription-polymerase chain reaction (RT-PCR) testing) of SARS-CoV-2 for 55, 59 and 63 days. Viral shedding duration was defined as the date of return from the COVID-19 pandemic countries for imported cases and from the first positive RT-PCR test for local cases, up to the second negative nasopharyngeal RT-PCR swab. These cases demonstrate that viral shedding after COVID-19 diagnosis can be prolonged.

BCG vaccination and tuberculosis prevention: A forty years cohort study, Monastir, Tunisia

We aimed to describe incidence, trends of tuberculosis (TB) over 18 years and to evaluate the impact of the BCG vaccine after four decades of immunization program according to three protocols. We performed a cohort study including declared cases in Monastir from January 1, 2000 to December 31, 2017. We reported 997 cases of TB. The predominant site was pulmonarylocalization (n = 486). The age standardized incidence of pulmonary and lymph node TB per 100,000 inh were 5.71 and 2.57 respectively. Trends were negative for pulmonary TB (PTB) (b = - 0.82; r = -0.67; p<10⁻³) and positive for lymph node localization (b = 1.31; r = 0.63; p<10⁻³). We had not notified cases of HIV associated with TB. Crude incidence rate (CIR) of PTB per 100,000 inh was 8.17 in Non-Vaccinated Cohort (NVC) and 2.85 in Vaccinated Cohort (VC) (p < 0.0001). Relative risk reduction (RRR) of BCG vaccination was 65.1% (95%CI:57.5;71.4) for pulmonary localization and 65% (95%CI:55; 73) for other localizations. We have not established a significant RRR of BCG vaccination on lymph node TB. Protocol 3 (at birth) had the highest effectiveness with a RRR of 96.7% (95%CI: 86.6%; 99.2%) and 86% (95%CI:71%;91%) in patients with PTB and other localizations TB respectively. In Cox regression model the HR was 0.061 (95% CI 0.015–0.247) for PTB and 0.395 (95% CI 0.185–0.844) for other localizations TB in patients receiving protocol 3 compared to NVC. For lymph-node TB, HR was 1.390 (95% CI 1.043–1.851) for protocol 1 and 1.849 (95% CI 1.232–2.774) for protocol 2 compared to NVC. Depending on the three protocols, the BCG vaccine had a positive impact on PTB and other TB localizations that must be kept and improved. However, protocols 1 and 2 had a reverse effect on lymph node TB.

Expanded program of immunization in the Maghreb. Case study of Tunisia.Systematic review of the literature

BACKGROUND

Vaccination is the most cost-effective intervention for primary prevention. The Maghreb countries had joined the The Expanded Programme on Immunization (EPI). Tunisia had also introduced the vaccine against hepatitis B and Haemophilus influenzae type B (Hib).

OBJECTIVE

To describ, through a systematic review, the specific documentation on the EPI in Tunisia.

METHOD

Target publications were collected using Medline database and Google Scholar from published articles from January 01 1998 to December 12 2017. The synthesis of the data was done according to four axes: "input", "process", "output" and "outcome".

RESULTS

17 articles were analyzed, with an average of 4 publications every 5 years. The author's specialty was community and preventive medicine in 56% of cases. Six articles focused on the "input" vaccination program, five related to the immunization process and the other five articles examined output and outcomes.

CONCLUSION

Tunisian publications concerning vaccination were rare, their efficiency and impact on the change of national vaccination strategy was crucial. Research coordination between Maghreb countries is highly recommended to meet the growing information needs.