Characteristics and prognostic factors of COVID-19 among infected cases: a nationwide Tunisian analysis.

BACKGROUND: The outbreak of coronavirus disease (COVID-19) continues to constitute an international public health concern. Few data are available on the duration and prognostic factors of the disease. We aimed to study the recovery time among a Tunisian cohort of COVID-19 confirmed patients and identify the prognostic factors. METHODS: A retrospective, nationwide study was conducted from March 2 to May 8, 2020, recruiting all patients who were diagnosed with COVID-19, by RT-PCR methods, in Tunisia. Data were collected via phone call interview. Kaplan-Meir Methods and Cox proportional hazards regression models were, respectively, used to study the recovery time and estimate its prognostic factors. RESULTS: One thousand and thirty patients with COVID-19 (aged 43.2 ± 18.2 years, 526 female (51.1%)) were enrolled. Among them 141 (14.8%) were healthcare professionals. Out of 173 patients (17.8%) admitted to the hospital, 47 were admitted in an intensive care unit. Among 827 patients who didn't require specialized care, 55.5% were self-isolated at home, while the rest were in specialized centers. Six hundred and two patients were symptomatic. A total of 634 (61.6%) patients have recovered and 45 (4.4%) patients died. The median duration of illness was estimated to be 31 days (95% CI: [29-32]). Older age (HR = 0.66, CI:[0.46-0.96], P = 0.031) and symptoms (HR = 0.61, CI:[0.43-0.81], P = 0.021) were independently associated with a delay in recovery time. Being a healthcare professional (HR = 1.52, CI: [1.10-2.08], P = 0.011) and patients in home isolation compared to isolation centers (HR = 2.99, CI: [1.85-4.83], P < 10¯3) were independently associated with faster recovery time. CONCLUSION: The duration of illness was estimated to be 1 month. However, this long estimated duration of illness may not equate to infectiousness. A particular attention must to be paid to elderly and symptomatic patients with closer monitoring.

Identification of transmission chains and clusters associated with COVID-19 in Tunisia.

BACKGROUND: The aim of this study was to characterize the transmission chains and clusters of COVID-19 infection in Tunisia. METHODS: All cases were confirmed by Reverse Transcriptase Polymerase Chain Reaction of a nasopharyngeal specimen. Contact tracing is undertaken for all confirmed cases in order to identify close contacts that will be systematically screened and quarantined. Transmission chains were identified based on field investigation, contact tracing, results of screening tests and by assessing all probable mode of transmission and interactions. RESULTS: As of May 18, 2020, 656 cases out of a total of 1043 confirmed cases of Coronavirus disease 2019 belong to 127 transmission chains identified during the epidemic (mean age 42.36 years, Standard deviation 19.56 and sex ratio 0.86). The virus transmission is the most concentrated in the governorate of Tunis (31.5%), Ariana (10.2%) and Ben Arous (10.2%). Virus transmission occurred 50 times (9.72% of secondary transmission events) between two different governorates. A maximum of seven generations of secondary infection was identified, whereas 62% of these secondary infections belong the first generation. A total of 11 "super spreader" cases were identified in this investigation. Four large clusters have been identified. The evolution of secondary cases highlighted two peaks: one in 2nd April and a second in 16 th April whereas imported cases caused local transmission of virus during the early phase of the epidemic. CONCLUSION: Correct contact tracing and early active case finding is useful to identify transmission chains and source of infection in order to contain the widespread transmission in the community.

Characteristics, onset, and evolution of neurological symptoms in patients with COVID-19.

BACKGROUND: A wide range of neurological manifestations has been described in COVID-19. METHODS: In this nationwide retrospective observational study, patients in Tunisia diagnosed with COVID-19 between the 2nd of March and the 16th of May 2020 were contacted by telephone. We collected demographic and clinical data and specified characteristics and evolution of main neurological symptoms. RESULTS: Of 1034 confirmed COVID-19 patients, 646 were included (mean age 42.17 years old) and 466 (72.1%) had neurological symptoms. Neurological symptoms were isolated 22.7% (n = 106). Headache was the most frequent neurological symptom (n = 279, 41.1%): mainly frontotemporal (n = 143, 51.1%) and mild or moderate (n = 165, 59.1%). When associated with fever (n = 143, 51.3%), headache was more likely to be severe and present at onset. Recovery was reported in 83.2%. Smell and taste impairment were found in 37.9% (n = 245) and 36.8% (n = 238) respectively. Among them, 65.3% (156/239) were anosmic and 63.2% (146/231) were ageusic. A complete improvement was found in 72.1% (174/240) of smell impairment and in 76.8% (179/233) of taste impairment. Myalgia (n = 241, 37.3%) and sleep disturbances (n = 241, 37.3%) were also frequent. Imported cases had more neurological symptoms (p = 0.001). In 14.5%, neurological symptoms preceded the respiratory signs (RS). RS were associated with more frequent (p = 0.006) and numerous (p < 0.001) neurological symptoms. CONCLUSIONS: Neurological symptoms in COVID-19 are frequent, can be isolated and present at onset. A total recovery is the most recorded outcome. RS are predictive of neurological symptoms. Studies in to virus and host genetics should be considered to understand the different phenotypes.

Estimating transmission dynamics and serial interval of the first wave of COVID-19 infections under different control measures: a statistical analysis in Tunisia from February 29 to May 5, 2020.

BACKGROUND: Describing transmission dynamics of the outbreak and impact of intervention measures are critical to planning responses to future outbreaks and providing timely information to guide policy makers decision. We estimate serial interval (SI) and temporal reproduction number (Rt) of SARS-CoV-2 in Tunisia. METHODS: We collected data of investigations and contact tracing between March 1, 2020 and May 5, 2020 as well as illness onset data during the period February 29-May 5, 2020 from National Observatory of New and Emerging Diseases of Tunisia. Maximum likelihood (ML) approach is used to estimate dynamics of Rt. RESULTS: Four hundred ninety-one of infector-infectee pairs were involved, with 14.46% reported pre-symptomatic transmission. SI follows Gamma distribution with mean 5.30 days [95% Confidence Interval (CI) 4.66-5.95] and standard deviation 0.26 [95% CI 0.23-0.30]. Also, we estimated large changes in Rt in response to the combined lockdown interventions. The Rt moves from 3.18 [95% Credible Interval (CrI) 2.73-3.69] to 1.77 [95% CrI 1.49-2.08] with curfew prevention measure, and under the epidemic threshold (0.89 [95% CrI 0.84-0.94]) by national lockdown measure. CONCLUSIONS: Overall, our findings highlight contribution of interventions to interrupt transmission of SARS-CoV-2 in Tunisia.

Bibliometric profile of Tunisian medical publications written in English and indexed in Medline.

BACKGROUND: English is becoming nowadays the universal language of science. Rresearch published in English can be considered as a bibliometric indicator of the scientific productivity. AIM: We sought to describe the evolution of the Tunisian medical publications written in English over the period from 2004 to 2014. METHODS: Medline's database was consulted using a research query associating the names of the country and the main university cities both in French and in English. The articles with a Tunisian health affiliation were retained but the articles of dentistry, pharmacy and non-medical fields were not included. RESULTS: We counted 979 English language Tunisian medical articles published during the three tracer years of the study: 2004, 2009 and 2014. The increase rate was about 38% between 2004 and 2014. The contribution of medical fields in English language publications was important but showed a clear decrease over time. The retrieved articles did not have the same distribution according to the specialties and the institutions. The distribution according to the journals showed that these articles were mainly published by foreign journals with an increasing impact factors between 2004 and 2014. CONCLUSION: The English language Tunisian medical productivity had shown an important increase over time but many specialties and institutions still not enough implicated in this production.Therefore, increasing research funding, improving the physicians' research methodology and English writing capacities are likely needed to improve the Tunisian medical output.

Radiology department performance: case study of CT scan at Sahloul Hospital (Tunisia).

BACKGROUND: The privileged recourse to CT-scan prescription in our current medical practice engender massive request which can alter not only the stability of the operating budgets of the public hospitals but also the clinical and managerial performance of these medical-technical departments. AIM: To audit the quality of CT-scan delivery in radiology Department at University Hospital of Sahloul in 2013. METHODS: Five quality indicators for the CT scan delivery were measured, three of which refer to period of time: A (deposit), B (perform CT-Scan) and C (final report recovery), and two evaluating the conformity of the radiological documents of the CT scan (request form and radiological report) using two grids composed of 12 iso-weighted items (one point), and was found satisfactory beyond 10 points. RESULTS: A total of 1141 CT scan request forms were included in the study which 1 111 (97%) were from Sahloul hospital departments and particularly from urology (16,2 %). Filling of CT- scan application form was conform only in 25.6 % of cases. For outpatient clinics the means (±SD) of period of time (in days) were: A: 0.2± 1.8. B: 59± 24.6. C: 14±9.2. D: 69.9±30.3 and E: 70± 30.1 versus A: 0.2± 1.8; B: 4.4± 3.9; C: 4.7 ± 6.5; D: 7.9± 8.6 and E: 8± 8.8 for hospital departments. Final reports were satisfactory in 87% and 52% of cases respectively in outpatient clinics and emergency. CONCLUSION: The performance of the CT scan examination, at Sahloul University Hospital, was limited mainly by excessive times of its realization and unsatisfactory quality of the final reports, hence there is a need of a radiology information system.

Patient satisfaction in a tertiary care center (Tunisia, 2015-2016).

INTRODUCTION: Patient satisfaction is one of the most commonly used indicators in healthcare service quality evaluation. The aim of the study was to measure overall and specific patient satisfaction rates and to identify determinants of satisfactionin Sahloul University hospital during 2015 and 2016. METHODS: This is a cross-sectional study which included a random sample of patients hospitalized in Sahloul University Hospital between 2015 and 2016. The survey was conducted through an original self-administered questionnaire. Four specific dimensions of satisfaction were explored: administrative, technical, logistic and relational. Overall and specific satisfaction rates were calculated and then patient satisfaction associated factors were identified through a multivariate analysis using a logistic regression model. RESULTS: A total of 1897 patients were included in the study with a mean age of 42.4 years (SD =20.5 years) and a sex ratio of 0.94.Overall patient satisfaction rate was about 67%. Items of satisfaction concerned mainly the relational dimension: the respect of the patient intimacy and the quality of information given. Those of dissatisfaction were mainly logistic: The physical environment in the hospital room, the cleanliness of toilets and waiting times.Determinants of patient satisfaction were mainly related to the quality of access and reception, the accommodation conditions, the technical care, the quality of information and the respect of patient intimacy. CONCLUSION: This study is a pioneering action to measure the quality of care in Tunisia. It highlighted the causes of patient dissatisfaction at Sahloul University Hospital. Appropriate measures to correct these deficiencies should be undertaken.

Alcohol consumption among health sciences students at the University of Monastir (Tunisia, 2014).

BACKGROUND: Studies conducted on characteristics of alcohol consumption and associated risk factors among health occupations students are scarce in the southern shore of the Mediterranean. The aim of this study was to assess the prevalence of alcohol use and misuse across a large sample of college students in Monastir university. METHODS: A cross sectional study was performed between April 2013 and September 2013. An anonymous self-administered questionnaire was filled out by health occupations students from pharmacy, dentistry and medicine faculties .Data on socioeconomic characteristics and lifestyle were collected. Alcohol consumption patterns was studied via AUDIT-C and ADOPSA scales in order to assess respectively risky alcohol consumption and alcoholic disorder. RESULTS: A total of 974 students were included. The mean age of students was 22.8 years (SD = 2.2) with a male-female ratio of 0.43. The overall prevalence of alcohol consumption, risky alcohol consumption, alcoholic disorder were respectively 14.1% (95%) CI [12.2-16.5]; 52.5% (95%) CI [43.4-61.2] and 79.1% (95%) CI [71.9-85.6]. CONCLUSION: This study highlights that health occupations students are not speared from presenting unhealthy behaviors like alcohol use and misuse Although prevalence of alcohol consumption is low the risky patterns of this consumption is alarming. and higher than described in similar population in other countries.

Smoking behavior among students of health sciences at the university of Monastir (Tunisia).

OBJECTIVE: Measure the prevalence of smoking among students of health sciences Faculties in Monastir (Tunisia) and identify factors associated with smoking behavior. METHODS: A cross-sectional study based on a self-administered questionnaire conducted among students registered in their second, fourth and sixth year at the Faculties of Medicine and Pharmacy in Monastir, in 2013. Smoker was the subject who, at the time of the survey, smoked at least one cigarette per day. Academic difficulties were used to denote any of the following incidents that a student may experience: passing exams at the retake session, revalidating an internship or repeating a school year. A logistic regression analysis was used to identify factors associated with smoking. RESULTS: The number of participants was 634 (285 Medical students and 349 Pharmacy students); they were 170 males and 464 females. The prevalence of smoking was 15%; 95% IC [12.1-17.7]. It was nearly five times higher among male compared to female students (35.3%; 95% IC [28.1-42.5]) vs 7.5%; 95% IC [5.1-9.9]); It was also higher among Pharmacy students than among Medical students (18.9%; 95% IC [14.8-23.0]) vs 10.2%; 95% IC [6.7-13.7]). In the multivariate analysis, the Faculty of Pharmacy (ORa=3.081; 95% IC=[1.7-5.7]), the male sex (ORa=6.929; 95% IC [3.9-12.0]) and the academic difficulties (ORa=1.854; 95% IC [1.02-3.38]) were found to be significantly associated with smoking. CONCLUSION: The level of tobacco use found among Medical and Pharmacy students is alarming. This serious problem has a negative impact on their behavior and can hinder their role model as future health professionals. Greater efforts are needed to develop anti-smoking programs, to educate students and to offer psychological support to deal with school difficulties.

Vaccine effectiveness against COVID-19: A test negative case-control study in Tunisia, August 2021.

BACKGROUND: In response to the COVID-19 pandemic, multiple vaccines to protect against COVID-19 disease have been developed rapidly. Precise estimates of vaccine effectiveness (VE) vary according to studies design, outcomes measured and circulating variants. The aim of this study was to evaluate the anti-covid-19 vaccine effectiveness in Tunisia. METHODS: We conducted a matched case-control study from 2nd to 15th August 2021. Cases and controls were subjects over 60 years of age, selected from the National testing database, regardless vaccine status. A standardized questionnaire was administered for cases and controls to collect information about vaccination status. For cases, vaccination status was defined based on the number of doses received before becoming ill and excludes doses received during the previous two weeks. For matched controls, a reference date based on the case's date of illness onset was defined in order to look at the control's vaccination status before its corresponding case became ill. The odds-ratio was calculated using simple conditional logistic regression. The VE (95 % confidence intervals) was calculated as (1 - odds ratio for vaccination) × 100 %. RESULTS: A sample of 977 matched peers for age and Gender, were included between August 2, and August 15, 2021. The overall vaccine effectiveness (VE) was 70 % [95 % CI 62.8-75.8 %]. Among our sample, 68.1 % of the male population and 56.4 % of the female population were vaccinated with a VE of 73 % [95 % CI 62.9-80.3 %] and 67 % [95 % CI 55.8-75.3 %] respectively, regardless vaccine scheme (complete or incomplete). VE was higher for the age group [60-70 years[ (72.3 % [95 % CI 62.8-79.3 %]). VE was 77.6 % [95 % CI 70.9-82.8 %] to prevent both symptomatic and asymptomatic forms of the disease. Moreover, in prevention from severe forms (treated with oxygen-therapy or admission to an Intensive-care-unit) VE was 86.6 % [95 % CI 75.6-92.7 %] and 98.4 % [95 % CI [79.2-99.8 %] in prevention from COVID-19 deaths with a complete anti-Covid vaccination scheme. CONCLUSION: The results of our study showed that the anti-Covid-19 vaccines used in Tunisia are efficient to prevent both SARS-COV-2 infections and severe forms related to the disease. This study provided important data on the performance of vaccines in real-world settings that guide decisions about vaccine sustained use.

Genomic Surveillance of SARS-CoV-2: Data Analysis and Assessment of Tunisian Strategy from January 2021 to February 2022.

Due to the emergence of the SARS-CoV-2 B.1.1.7 (Alpha) variant in the UK in 2020 and its risk of increased transmission, the Ministry of Health in Tunisia implemented a sequencing surveillance strategy for SARS-CoV-2. The aim of this study was to analyze SARS-CoV-2 genomic surveillance data in Tunisia (January 2021-February 2022) and to assess the implementation of the sequencing strategy for SARS-CoV-2 in accordance with national recommendations and the guidance for SARS-CoV-2 genomic surveillance for public health goals. A descriptive study of all sequenced RT-PCR samples sequenced (January 2021-February2022). An internal audit was also done to assess the compliance against standards covering national recommendations and the Guidance for SARS-CoV-2 genomic surveillance for public health goals. A total of 12 simple or composite requirements related to the following areas were included in the audit standards: sampling (one requirements); data collection/analysis (six requirements); partnership (one requirement); and ethical considerations (one requirement). A total of 4819 samples were sent to laboratories and 4278 samples were sequenced. A total of 3648 samples were classified. Positive variants of concern (VOC) samples were 80.92%, differentiated as follows: Alpha, 40.24%; Beta, 0.24%; Gamma, 0.03%; Delta, 45.26%; and Omicron, 14.19%. Three principal phases of VOCs per ISO-week were shown: Alpha 3/2021-25/2021; Delta 26/2021-2/2022; and Omicron 3/2022-6/2022. Levels of compliance were identified; from a total of 12 requirements, 7 were considered as "not met", 4 as "partially met", and 1 as "fully met" but including not totally achieved objectives. In conclusion, the internal audit of the national SARS-CoV-2 sequencing strategy revealed an overall "not met" level of compliance. The results offered a trigger to collaborate with all stakeholders to develop a surveillance strategy for early detection and response to outbreaks caused by VOCs.

Dynamic of SARS-CoV-2 variants circulation in Tunisian pediatric population, during successive waves, from March 2020 to September 2022.

The emergence of SARS-CoV-2 variants has led to several cases among children. However, limited information is available from North African countries. This study describes the SARS-CoV-2 strains circulating in Tunisian pediatric population during successive waves. A total of 447 complete sequences were obtained from individuals aged from 13 days to 18 years, between March 2020 and September 2022: 369 sequences generated during this study and 78 ones, available in GISAID, previously obtained from Tunisian pediatric patients. These sequences were compared with 354 and 274 ones obtained from Tunisian adults and a global dataset, respectively. The variant circulation dynamics of predominant variants were investigated during the study period using maximum-likelihood phylogenetic analysis. Among the studied population, adolescents were the predominant age group, comprising 55.26% of cases. Twenty-three lineages were identified; seven of which were not previously reported in Tunisia. Phylogenetic analysis showed a close relationship between the sequences from Tunisian adults and children. The connections of sequences from other countries were variable according to variants: close relationships were observed for Alpha, B1.160 and Omicron variants, while independent Tunisian clusters were observed for Delta and B.1.177 lineages. These findings highlight the pivotal role of children in virus transmission and underscore the impact of vaccination on virus spread. Vaccination of children, with booster doses, may be considered for better management of future emergences.

Outbreak Investigation of Typhoid Fever in the District of Gabes, South of Tunisia.

Typhoid fever is a significant public health concern in many parts of the world, particularly in developing countries with poor sanitation and hygiene conditions. In July 2016, an outbreak of typhoid fever occurred in Ghannouche, located in the south of Tunisia. This paper reports the results of a field investigation undertaken to identify possible transmission pathways and risk factors in order to propose control and preventive measures. A retrospective cohort study including a passive and active case finding, as well as an environmental and bacteriological investigation was conducted from July to September 2016. A case was defined as a person residing or having stayed in Ghannouche and having presented from the beginning of June clinical signs suggestive of typhoid fever, with, for a confirmed case, laboratory isolation of S.Tyhi, and for a probable case, an epidemiological link with a confirmed case. Attack rates were determined, and risk ratios were estimated with respect to exposures. Unadjusted and adjusted odds ratios were estimated using binary logistic regression. Among the 628 subjects investigated, 102 cases of typhoid fever were identified (74 confirmed and 28 probable) with an overall attack rate of 16.24%. Over 56% of cases were male and those under 10 years old were most affected (38.2%% of cases) with a median age of 12 years (interquartile range 5 to 25 years). The main clinical signs were fever (95%) and diarrhea (57%). Young age (adjusted OR = 0.95 and 95% CI = 0.93-0.97), low level of education (adjusted OR = 4.76 and 95% CI = 1.34-16.81), and the habitat type Arab or rudimentary house (adjusted OR = 4.93 and 95% CI = 2.61-8.27) were the socio-demographic factors independently associated with typhoid fever. Typhoid fever was found to be associated with drinking softened water (adjusted OR = 2.64 and 95% CI = 1.16-4.82), eating raw fruit and vegetables from family gardens (adjusted OR = 6.13 and 95% CI = 3.66-11.06), and using uncontrolled waste disposal (adjusted OR = 3.52 and 95% CI = 2.03-6.94). A total of 110 drinking water samples were analyzed; out of the 38 samples of softened water, 12 were non-compliant and 5 were positive for Salmonella. The screening activity identified two asymptomatic carriers, one of whom was a softened water seller. We concluded that drinking softened water from informal or unauthorized sale units, consuming fruit and vegetables from family gardens, uncontrolled dumping of household waste, and poor socio-economic conditions increase the risk of typhoid fever in this region. Many recommendations were implemented to stop this outbreak and to prevent further episodes.

Baseline Seroprevalence of SARS-CoV-2 Specific Antibodies in Hot Spot Areas of Great Tunis, up to 3 Months Post Disease Onset in Tunisia.

The extent of the SARS-CoV-2 circulation and the COVID-19 epidemic in Tunisia three months after virus circulation was unknown. The aim of this study was to determine the extent of SARS-CoV-2 infection among household contacts of confirmed COVID-19 cases living in Hot spot areas of Great Tunis, Tunisia by estimating the seroprevalence of antibodies anti SARS-CoV-2 and to identify factors associated to seroprevalence at the first stage of the pandemic in order to guide decision making and to constitute a baseline for further longitudinal analysis of protective immunity to SARS-CoV-2. The National Observatory of New and Emerging Diseases (ONMNE), Ministry of Health Tunisia (MoH), with the support of the Office of the World Health Organization Representative in Tunisia and the WHO Regional Office for the Eastern Mediterranean (EMRO)), conducted a household cross-sectional survey on April 2020 in Great Tunis (Tunis, Ariana, Manouba and Ben Arous). The study was based on the WHO seroepidemiological investigation protocol for SARS-CoV-2 infection. SARS-CoV-2 specific antibodies (IgG and IgM) were qualitatively detected using a lateral immunoassay that detect SARS-CoV-2 nucleocapsid protein and administered by the interviewers. The included subjects were confirmed COVID-19 cases and their households contacts resided in hot spot areas (cumulative incidence rate ≥ 10 cases/100,000 inhabitants) of Great Tunis. Results: In total, 1165 subjects were enrolled: 116 confirmed COVID-19 cases (43 active cases and 73 convalescents cases) and 1049 household contacts resided in 291 households. The median age of participants was 39.0 with 31 years' interquartile range (Min = 8 months; Max = 96 years). The sex ratio (M/F) was 0.98. Twenty-nine per cent of participants resided in Tunis. The global crude seroprevalence among household contacts was 2.5% (26/1049); 95% CI 1.6-3.6%, 4.8%; 95% CI 2.3-8.7% in Ariana governorate and 0.3%; 95% CI 0.01%-1.8% in Manouba governorate. In multivariate analysis, the associated factors independently related to seroprevalence were age ≥25 years (aOR = 5.1; 95% CI 1.2-22.0), history of travel outside Tunisia since January 2020 (aOR = 4.6; 95% CI 1.7-12.9), symptomatic illness in the previous four months (aOR = 3.5; 95% CI 1.4-9.0) and governorate of residence (p = 0.02). The low seroprevalence estimated among household contacts in Great Tunis reflect the effect of public health measures early taken (national lockdown, borders closed, remote work), the respect of non-pharmaceutical interventions and the efficacy of COVID-19 contact-tracing and case management at the first stage of the pandemic in Tunisia.

[Clinical and epidemiological features of COVID-19-related deaths in Tunisia before the emergence of VOCs (March 2020-February 2021)]. / Caractéristiques cliniques et épidémiologiques des décès COVID-19 en Tunisie avant l'émergence des VOCs (mars 2020-février 2021).

Introduction: the purpose of this study was to describe the clinical and epidemiological features of COVID-19-related deaths in Tunisia notified at the ONMNE (National Observatory of New and emerging Diseases) between 2nd March 2020 and 28th February 2021 and to compare COVID-19-related deaths recorded in Tunisia with the international data. Methods: we conducted a national prospective longitudinal descriptive study of data collected from the National Surveillance System of SARS-CoV-2 infection of the ONMNE, Ministry of Health. All COVID-19-related deaths that occurred in Tunisia between March 2020 and February 2021 were included in this study. Data were collected from hospitals, municipalities and regional health departments. Death notifications were collected from multiple data sources (triangulation): The Regional Directorate of Basic Health Care, the ShocRoom (Strategic Health Operations Center), public and private health facilities, the Crisis Unit of the Presidency of the Government, the Directorate for Hygiene and Environmental Protection, the Ministry of Local Affairs and the Environment, as part of the follow-up of confirmed cases by the ONMNE team, positive RT-PCR / TDR post mortem results. Results: during this study, 8051 deaths were recorded, corresponding to a proportional mortality of 10.4%. The median age was 73 years, with an interquartile range of 17 years. Sex-ratio (M/F) was 1.8. The crude death rate was 69.1/100 000 inhabitants and fatality rate was 3.5%. The analysis of the epidemic curve showed 2 peaks of deaths on 29th October 2020 and 22nd January 2021, with 70 and 86 deaths notified respectively. The spatial distribution of mortality showed that the southern Tunisian region had the highest mortality rate. Patients aged 65 and over were most affected (73.7% of cases) with a crude mortality rate of 570.9/100,000 inhabitants and a fatality rate of 13.7%. Conclusion: prevention strategy based on public health measures must be reinforced by the rapid deployment of anti-COVID-19 vaccination, especially for people at risk of death.

Phylogenetic and amino acid signature analysis of the SARS-CoV-2s lineages circulating in Tunisia.

Since the beginning of the Coronavirus disease-2019 pandemic, there has been a growing interest in exploring SARS-CoV-2 genetic variation to understand the origin and spread of the pandemic, improve diagnostic methods and develop the appropriate vaccines. The objective of this study was to identify the SARS-CoV-2s lineages circulating in Tunisia and to explore their amino acid signature in order to follow their genome dynamics. Whole genome sequencing and genetic analyses of fifty-eight SARS-CoV-2 samples collected during one-year between March 2020 and March 2021 from the National Influenza Center were performed using three sampling strategies.. Multiple lineage introductions were noted during the initial phase of the pandemic, including B.4, B.1.1, B.1.428.2, B.1.540 and B.1.1.189. Subsequently, lineages B1.160 (24.2%) and B1.177 (22.4%) were dominant throughout the year. The Alpha variant (B.1.1.7 lineage) was identified in February 2021 and firstly observed in the center of our country. In addition, A clear diversity of lineages was observed in the North of the country. A total of 335 mutations including 10 deletions were found. The SARS-CoV-2 proteins ORF1ab, Spike, ORF3a, and Nucleocapsid were observed as mutation hotspots with a mutation frequency exceeding 20%. The 2 most frequent mutations, D614G in S protein and P314L in Nsp12 appeared simultaneously and are often associated with increased viral infectivity. Interestingly, deletions in coding regions causing consequent deletions of amino acids and frame shifts were identified in NSP3, NSP6, S, E, ORF7a, ORF8 and N proteins. These findings contribute to define the COVID-19 outbreak in Tunisia. Despite the country's limited resources, surveillance of SARS-CoV-2 genomic variation should be continued to control the occurrence of new variants.

Molecular Epidemiology of SARS-CoV-2 in Tunisia (North Africa) through Several Successive Waves of COVID-19.

Documenting the circulation dynamics of SARS-CoV-2 variants in different regions of the world is crucial for monitoring virus transmission worldwide and contributing to global efforts towards combating the pandemic. Tunisia has experienced several waves of COVID-19 with a significant number of infections and deaths. The present study provides genetic information on the different lineages of SARS-CoV-2 that circulated in Tunisia over 17 months. Lineages were assigned for 1359 samples using whole-genome sequencing, partial S gene sequencing and variant-specific real-time RT-PCR tests. Forty-eight different lineages of SARS-CoV-2 were identified, including variants of concern (VOCs), variants of interest (VOIs) and variants under monitoring (VUMs), particularly Alpha, Beta, Delta, A.27, Zeta and Eta. The first wave, limited to imported and import-related cases, was characterized by a small number of positive samples and lineages. During the second wave, a large number of lineages were detected; the third wave was marked by the predominance of the Alpha VOC, and the fourth wave was characterized by the predominance of the Delta VOC. This study adds new genomic data to the global context of COVID-19, particularly from the North African region, and highlights the importance of the timely molecular characterization of circulating strains.

The Delta variant wave in Tunisia: Genetic diversity, spatio-temporal distribution and evidence of the spread of a divergent AY.122 sub-lineage.

Introduction: The Delta variant posed an increased risk to global public health and rapidly replaced the pre-existent variants worldwide. In this study, the genetic diversity and the spatio-temporal dynamics of 662 SARS-CoV2 genomes obtained during the Delta wave across Tunisia were investigated. Methods: Viral whole genome and partial S-segment sequencing was performed using Illumina and Sanger platforms, respectively and lineage assignemnt was assessed using Pangolin version 1.2.4 and scorpio version 3.4.X. Phylogenetic and phylogeographic analyses were achieved using IQ-Tree and Beast programs. Results: The age distribution of the infected cases showed a large peak between 25 to 50 years. Twelve Delta sub-lineages were detected nation-wide with AY.122 being the predominant variant representing 94.6% of sequences. AY.122 sequences were highly related and shared the amino-acid change ORF1a:A498V, the synonymous mutations 2746T>C, 3037C>T, 8986C>T, 11332A>G in ORF1a and 23683C>T in the S gene with respect to the Wuhan reference genome (NC_045512.2). Spatio-temporal analysis indicates that the larger cities of Nabeul, Tunis and Kairouan constituted epicenters for the AY.122 sub-lineage and subsequent dispersion to the rest of the country. Discussion: This study adds more knowledge about the Delta variant and sub-variants distribution worldwide by documenting genomic and epidemiological data from Tunisia, a North African region. Such results may be helpful to the understanding of future COVID-19 waves and variants.

Quality indicators of hip fracture management. A systematic review.

OBJECTIVE: To identify standards and quality indicators of hip fracture management from the medical literature. METHODS: We conducted a "systematic review" on the topic of quality indicators of hip fracture management using PubMed database, during 15 years from 2001 to 2015. The collected publications were studied by two readers to extract the different quality indicators of hip fracture management. These indicators were stratified according to their type (process or outcome) and to the time of health care (pre, per or post-operative). RESULTS: A total of 41 articles were included in the study: The analysis of these articles highlighted a predominance of Anglo-Saxon papers, an increasing rate of publication over time, a dominance of evaluative studies and a multiplicity of guidelines. A total of 46 quality indicators were identified through these articles. Two third were classified as procedural items and 60% were about post-operative hip fracture management. The most assessed indicators and standards, among those related to the preoperative care, were time to surgery (34%) and patient clinical condition assessment (11%). During the operation time, the most assessed indicator was the proportion of patients who have had spinal anesthesia (73%). For the postoperative care, the most common  indicators and standards were length of hospital stay (12%), osteoporosis treatment prescription (8%), mattresses use to prevent pressure ulcer (7%), pressure sores occurring (7%) and in hospital mortality (7%). CONCLUSION: This systematic review allowed to identify the main indicators recommended to evaluate the management of hip fracture. The continuous monitoring of these indicators should be generalized in maghrebian countries using strategic dashboards in all hospitals and clinics treating this pathology.

Eating disorders: Prevalence and associated factors among health occupation students in Monastir University (Tunisia).

BACKGROUND: Despite their high prevalence and severity among youth, national researches concerning eating disordered behavior among undergraduate students remains rare. Hence, it is imperative to determine the amplitude and to identify the risk factors of eating disorders (ED) to enable effective interventions. AIM: To assess prevalence and associated factors of (ED) among health occupation students in the university of Monastir during 2013. METHODS: A cross sectional study using a self-administered questionnaire which was distributed by approaching directly students. The following items were collected: demographic, socioeconomic and educational characteristics; self-esteem; previous dieting; perceived stress score(Cohen's scale); depression (Beck Depression); sleep quality; sport practice; cyber addiction (Orman scale) and alcohol regular use (CRAFT-ADOPSA questionnaire). SCOFF questionnaire was used to identify students at risk of ED. RESULTS: A total of 974 students were included in the study. The mean age of students was 22.8 (Standard Deviation=2.2) with a sex ratio of 0.43. The prevalence of ED according to SCOFF questionnaire was 35%; 95% CI [32.0-38.5]. It was higher among female (39.8; 95% CI [35.8-43.7]) compared to male (24.3; 95% CI [18.8-29.7]) with a statistically significant difference (p<10-3). The risk factors associated independently with an eating disorder were "Previous dieting" (aOR=4.13; 95% CI [2.79-6.12]),"Sex" (aOR=1.77. 95% CI [1.13-2.77]) and "Repeat a year" (aOR=1.76; 95% CI [1.09-2.85]). CONCLUSION: The prevalence of health occupation students at risk of ED was high. These results emphasizes the need for diversified and adapted prevention and health education policies as well as a need for a systematic screening of ED among students in order to start an early treatment that can improve their prognosis.