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.

Epidemiologic patterns of hepatitis A infection during the pre-vaccination era: A population-based survey in Tunisia in 2015.

BACKGROUND: In the 1980s, Tunisia was considered a country of high endemicity for hepatitis A virus (HAV). Since 2000, an epidemiologic shift has led to an increased incidence of symptomatic and severe forms of HAV infection. OBJECTIVES: In 2015, we conducted a cross-sectional nationwide household-based hepatitis A virus (HAV) seroprevalence study in the total population regardless of age, sex, or geographic origin using a stratified sampling design to make an overview of the HAV epidemiologic situation in Tunisia before vaccine implementation. RESULTS: A total of 6,322 individuals were enrolled. The HAV prevalence was 78.8%. The anti-HAV IgG seropositivity rate increased from 16% for ages 5-9 years to 45% for ages 10-14 years, 67% for ages 15-19 years, 87% for ages 20-24 years, and >90% for older age groups, which suggested an age at midpoint of population immunity (AMPI) in late adolescence. It was significantly higher in rural areas (P < 10-3) and varied significantly between and within regions (P < 10-4). CONCLUSIONS: In this study, although the overall AMPI suggestsintermediate endemicity, the regional AMPI varies from intermediate to very high endemicity profiles attributable to different socioeconomic determinants and conditions of sanitation and hygiene. In addition, it provides insights for the best decisions in terms of vaccination strategies.

Knowledge attitudes and practices toward seasonal influenza vaccine among pregnant women during the 2018/2019 influenza season in Tunisia.

BACKGROUND: The uptake and acceptance of the influenza vaccine (IV) among pregnant women remain unknown in Tunisia despite the increased influenza-related complications and death. The present study aimed to assess the IV uptake and acceptability and to describe related knowledge and attitudes among pregnant women in Tunisia. METHODS: A cross-sectional study was conducted in 84 Tunisian healthcare facilities over a period of three months (from March to May 2019). All pregnant women aged ≥18 years who sought antenatal care in related health structures were included in this study based on a multistage self-weighted sampling. We measured knowledge and attitudes towards the IV and assessed factors related to willingness for its uptake. RESULTS: The questionnaire was completed by 1157 pregnant women. More than half of the participants (60.2%; 95% confidence interval [CI] [57.3%-63.0%]) reported awareness about the IV. Among included PW, only 4.6%; 95% CI [3.5%-6.1%] received it during their current pregnancy. However, (36.8%; 95% CI [34.0%-39.6%]) declared their willingness to receive the vaccine in the next pregnancy. Recommendation by healthcare providers, identified to be the most trustful source of information, was the main reason for acceptance. However, the intention to accept the IV by pregnant women was significantly associated with such recommendation and perceived safety and effectiveness of this vaccine. CONCLUSION: Antenatal care visits are a precious opportunity that should not be missed by health care providers and especially gynecologists to promote the IV uptake by pregnant women in Tunisia.

Burden of breast and gynecological cancers in Tunisia between 1990 and 2030: Trend and projection.

AIM: To describe the burden of breast and gynecological cancers in Tunisia in 2017, to analyze the trend between 1990 and 2017 and to performit's prediction by 2030. METHODS: This was a study using data estimated by the Institute for Health Metrics and Evaluation (IHME) for years of life by breast cancer and gynecological cancers: ovary, cervix and uterus (endometrium and other unspecified parts of the uterus) in Tunisia in 2017.The trend analysis of age standardized DALYrate between 1990 and 2017 was analyzed by using Join Point software.The projection of number of DALY and YLL by 2030 was conducted by SPSS software using Age-Period-Cohort (APC) models. RESULTS: In 2017, the age standardized DALYs rate for breast and gynecological cancers was 538.5/100,000 women. Breast cancer proved observed the highest rate of standardized DALY rate with 378.5/100,000 women followed by ovarian cancer (rate standardized DALY=72.7/100,000 women).The standardized DALY rate increased between 1990 and 2017 except for cervix cancer and uterine cancer which have been on a downward trend. According to the same conditions between 1990 and 2017, the age standardized DALY rate in 2030 will reach 674.6/100,000 women (95% CI=667.2/100,000-682.1/100,000). CONCLUSION: Strengthening prevention strategy against cancer in general and women's cancers in particularis strongly recommended to reduce cancer burden and to changeits trend.

Eating disorders in type 1 diabetic adolescent.

BACKGROUND: Adolescents with type1 diabetes appear to be at greater risk for developing eating disorders (ED) which are often associated with impaired metabolic control of diabetes. AIM: To estimate the prevalence of ED in a population of adolescents with type 1 diabetes (T1D) and to identify risk factors associated with this disorder in order to propose preventive measures. METHODS: A cross-sectional, population-based study involved 102 adolescents with type 1 diabetes, aged 11-18 years, recruited from the National Institute of Nutrition in Tunis, Tunisia over a period of one-year January 2017-January 2018. RESULTS: The prevalence of ED was 33.3%. It was significantly higher among girls (46.2% vs 20%, p = 0.005). Unspecified ED were predominant with a prevalence of 29.4%. Independent factors associated with ED were female sex, abdominal obesity and quality of life. The risk of developing ED was multiplied by 3.5 for women (adjusted OR = 3.5 and CI95% [1.4-8.6]) and by 5.6 for patients with abdominal obesity (Adjusted OR = 5.6 and CI95% [1.5-20.4]). Impaired quality of life and specifically anxiety about diabetes increased significantly the risk of developing ED in our patients. However, we didn't find significant association between ED and age, family characteristics, duration of diabetes, metabolic balance, treatment and complications of diabetes. CONCLUSION: We concluded that ED should be always suspected in adolescents with T1D especially in girls. Unspecified ED are more common in this group of patients. Treatment of diabetes requires a multidisciplinary care approach including diabetologist, dietician and psychiatrist in order to promote healthy eating and to improve quality of life of adolescents with T1D.

Applying the moving epidemic method to determine influenza epidemic and intensity thresholds using influenza-like illness surveillance data 2009-2018 in Tunisia.

BACKGROUND: Defining the start and assessing the intensity of influenza seasons are essential to ensure timely preventive and control measures and to contribute to the pandemic preparedness. The present study aimed to determine the epidemic and intensity thresholds of influenza season in Tunisia using the moving epidemic method. METHODS: We applied the moving epidemic method (MEM) using the R Language implementation (package "mem"). We have calculated the epidemic and the different intensity thresholds from historical data of the past nine influenza seasons (2009-2010 to 2017-2018) and assessed the impact of the 2009-2010 pandemic year. Data used were the weekly influenza-like illness (ILI) proportions compared with all outpatient acute consultations. The goodness of the model was assessed using a cross validation procedure. RESULTS: The average duration of influenza epidemic during a typical season was 20 weeks and ranged from 11 weeks (2009-2010 season) to 23 weeks (2015-2016 season). The epidemic threshold with the exclusion of the pandemic season was 6.25%. It had a very high sensitivity of 85% and a high specificity of 69%. The different levels of intensity were established as follows: low, if ILI proportion is below 9.74%, medium below 12.05%; high below 13.27%; and very high above this last rate. CONCLUSIONS: This is the first mathematically based study of seasonal threshold of influenza in Tunisia. As in other studies in different countries, the model has shown both good specificity and sensitivity, which allows timely and accurate detection of the start of influenza seasons. The findings will contribute to the development of more efficient measures for influenza prevention and control.

Anaplasma platys-like strains in ruminants from Tunisia.

Molecular diagnosis of Anaplasma platys and related strains (A. platys-like) in carnivores and ruminants is challenging due to co-infections with cross-reacting strains, and require post-amplification sequencing of the hemi-nested PCR products traditionally generated by targeting the groEL gene. In this study, a Restriction Enzyme Fragment Length Polymorphism (RFLP) assay coupled to hemi-nested groEL PCR was developed to discriminate among A. platys and genetically related strains. This novel approach was used for investigating A. platys-like infection in 963 domesticated ruminants (241 goats, 355 sheep, and 367 cattle) from 22 delegations located in North Tunisia. Overall prevalence rates of A. platys-like were 22.8, 11, and 3.5% in goats, sheep, and cattle, respectively. Alignment, identity comparison, and phylogenetic analysis of the groEL sequence variants obtained in this study confirmed RFLP data suggesting that Tunisian ruminants are infected by novel unclassified Anaplasma strains genetically related to A. platys. Compared to sequencing, RFLP assay allows fast detection of A. platys and A. platys-like pathogens in the same sample and has a potential value especially when screening ticks, cats and ruminants, which can be a common host for these two bacteria. This newly developed molecular technique would provide valuable molecular tool for epidemiological studies related to A. platys as well as remove concern over specificity of serological and molecular methods routinely used to identify diverse Anaplasma strains and species in wild and domestic ruminants.