A Prospective cohort study of zoonotic cutaneous leishmaniasis in tunisia: Clinical and Immunological features and immune correlates of protection.

BACKGROUND: This study aimed to define immunological markers of exposure to L. major parasites and identify correlates of protection against infection. METHODS: We analyzed a cohort of 790 individuals at risk of developing ZCL living in endemic areas with varying L. major infection prevalence. One area had a high infection prevalence indicated by high proportions of leishmanin skin test (LST) positive subjects, while the other areas were recent foci with lower infection prevalence. Blood samples were collected before the transmission season to measure Interferon gamma (IFN-γ), Interleukin 10 (IL-10), and Granzyme B (GrB) levels in response to parasite stimulation in peripheral blood mononuclear cells. A one-year follow-up period involved active detection of new ZCL cases to estimate disease incidence after a transmission season and identify immune correlates of protection. RESULTS: The study population showed heterogeneity in parasite contact, evident from specific scars and/or positive LST results, significantly higher in the old focus compared to recent foci. IFN-γ and GrB were markers of parasite exposure and reliable indicators of immunity to L. major. Positive correlations were observed between IFN-γ/IL-10 and GrB/IL-10 ratios and LST results. Unexpectedly, only 29 new ZCL cases (4%) appeared after a transmission season, with 27 cases reported in recent foci and 2 in the oldest focus. Our findings indicate that individuals in L. major endemic areas are likely to develop ZCL regardless of their LST status. We showed that high pre-transmission season levels of IFN-γ and GrB produced by PBMC, along with a high IFN-γ/IL-10 ratio, were associated with protection. CONCLUSION: This study on a large cohort at risk of ZCL confirmed IFN-γ and GrB as protective factors against the disease. A high IFN-γ/IL-10 ratio, but not GrB/IL-10 ratio was associated with resistance. These results are valuable for developing and evaluating of a vaccine against human leishmaniasis.

Comparison of the clinical features and outcomes of severe seasonal influenza and COVID-19 patients in Tunisia between 2021 and 2022.

Background: We compared patients diagnosed at a SARI (severe acute respiratory infections) surveillance site with COVID-19 and those with seasonal influenza to investigate the clinical differences, common features, and outcomes. Methods: We conducted a descriptive, retrospective study in the Medical Intensive Care Unit (ICU) at Abderrahman Mami Hospital between September 2021 and April 2022. Demographic, clinical, and biological data as well as outcomes were recorded for all patients. Results: Among 223 SARI patients, 83 were confirmed COVID-19, and 22 were influenza positive. The distribution according to gender was similar; but patients with influenza were younger than those suffering from COVID-19(mean age 60.36 SD 17.28 vs. 61.88 SD 17.91; P = 0.601). In terms of underlying chronic diseases, the frequency was 84.3% in the COVID-19 group and 72.7% in the influenza group. COVID-19 patients had a longer duration of hospitalization (mean [SD], 9.51 days [8.47 days] vs. 7.33 days [8.82 days]; P = 0.003), and a more frequent need for invasive ventilation (80 [97.4%] vs. 20 [92.3]). Case fatality was also higher among this group compared to the latter (39 [47%] vs. 6 [27.3%], P = 0.01). Conclusion: This exploratory study suggests higher severity of COVID-19 compared to seasonal influenza among SARI hospitalized patients even during the Omicron wave. Further research on higher sample sizes is required to confirm this conclusion.

Epidemiology and burden of Severe Acute Respiratory Infections (SARI) in the aftermath of COVID-19 pandemic: A prospective sentinel surveillance study in a Tunisian Medical ICU, 2022/2023.

BACKGROUND: Severe Acute Respiratory Infections (SARI) caused by influenza and other respiratory viruses pose significant global health challenges, and the COVID-19 pandemic has further strained healthcare systems. As the focus shifts from the pandemic to other respiratory infections, assessing the epidemiology and burden of SARI is crucial for healthcare planning and resource allocation. Aim: to understand the impact of the post-pandemic period on the epidemiology of SARI cases, clinical outcomes, and healthcare resource utilization in Tunisia. METHODS: This is a prospective study conducted in a Tunisian MICU part of a national sentinel surveillance system, focusing on enhanced SARI surveillance. SARI cases from week 39/2022, 26 September to week 19/2023, 13 May were included, according to a standardized case definition. Samples were collected for virological RT-PCR testing, and an electronic system ensured standardized and accurate data collection. Descriptive statistics were performed to assess epidemiology, trends, and outcomes of SARI cases, and univariate/multivariate analyses to assess factors associated with mortality. RESULTS: Among 312 MICU patients, 164 SARI cases were identified during the study period. 64(39%) RT-PCR were returned positive for at least one pathogen, with influenza A and B strains accounting for 20.7% of cases at the early stages of the influenza season. The MICU experienced a significant peak in admissions during weeks 1-11/2023, leading to resource mobilization and the creation of a surge unit. SARI cases utilized 1664/3120 of the MICU-stay days and required 1157 mechanical ventilation days. The overall mortality rate among SARI cases was 22.6%. Age, non-COPD, and ARDS were identified as independent predictors of mortality. CONCLUSIONS: The present study identified a relatively high rate of SARI cases, with 39% positivity for at least one respiratory virus, with influenza A and B strains occurring predominantly during the early stages of the influenza season. The findings shed light on the considerable resource utilization and mortality associated with these infections, underscoring the urgency for proactive management and efficient resource allocation strategies.

Telemedicine in non-communicable chronic diseases care during the COVID-19 pandemic: exploring patients' perspectives.

Purpose: This study aimed to explore challenges facing patients using Telemedicine consultations in non-communicable chronic disease clinics in primary care settings and to evaluate their satisfaction and willingness to use this service in the future. Methods: This is an analytical cross-sectional study enrolling participants who were randomly selected from representative primary care centers in Bahrain and providing Telemedicine consultations. A semi-structured questionnaire permitted data collection using telephone interviews. Results: A total of 251 individuals participated in the study of whom the majority were Bahraini (90.04%), and the mean age was 54.48 ± 10.78 years. Most of the participants 231 (92.03%) were satisfied with the Telemedicine consultation while only 142 (56.80%) were willing to use this service in the future. The main perceived challenges related to Teleconsultations were the lack of physical examination, inadequate time of TM consultation, fear of medical errors, and lack of privacy. The willingness to use TM consultation in the future was mainly determined by the degree of comfort to tell private information (p < 0.01) and to less extent the ease of the communication tool (p = 0.005) on multivariate analysis. Conclusion: TM consultations could be a good complement to conventional consultation formats in the future. The sustainability of this innovative healthcare delivery tool requires addressing acceptability by users, ease of use, patient-centeredness, and technological advances to ensure privacy.

Super-spreading social events for COVID-19 transmission: evidence from the investigation of six early clusters in Bahrain.

Introduction: This study aimed to characterize six early clusters of COVID-19 and derive key transmission parameters from confirmed cases that were traced between April and June 2020 in Bahrain. Methods: Pairs of "infector-infectee" allowed us to map the clusters and estimate the incubation period serial interval as the secondary attack rate. The chi-squared test, with a p-value computed using the Monte Carlo test, measured associations between categorical variables. Statistical analysis was performed using R software and the "data.tree, tidyverse" libraries. Results: From 9 April to 27 June 2020, we investigated 596 individuals suspected of COVID-19, of whom 127 positive cases were confirmed by PCR and linked in six clusters. The mean age was 30.34 years (S.D. = 17.84 years). The male-to-female ratio was 0.87 (276/318), and most of the contacts were of Bahraini citizenship (511/591 = 86.5%). Exposure occurred within the family in 74.3% (411/553), and 18.9% of clusters' cases were symptomatic (23/122 = 18.9%). Mapped clusters and generations increased after 24 May 2020, corresponding to "Aid El-Fitr." The mean incubation period was 4 days, and the mean serial interval ranged from 3 to 3.31 days. The secondary attack rate was 0.21 (95% C.I.) = [0.17-0.24]. Conclusion: COVID-19 transmission was amplified due to the high number of families mixing during "Aid El Fitr" and "Ramadhan," generating important clusters. Estimated serial intervals and incubation periods support asymptomatic transmission.

Influenza vaccine uptake in Tunisia from two high-risk groups' perception and attitudes: a qualitative study.

Background: Pregnant women (PW) and older adult with chronic diseases (ECD) are priority groups for the influenza vaccination. This study was designed to have a better insight into the influenza perceptions and barriers of the vaccine uptake from these groups' perspectives. Methods: This qualitative study consisted of 20 focus group discussions (FGDs) enrolled from five governorates across the country (north, center, and south) between March 18 and July 10, 2019, in urban and rural areas. FGDs were conducted in Arabic (Tunisian dialect) and following the topic guide. Data were transcribed in the local language then translated into English and analyzed using Nvivo12 Software. This permitted the analysis thematic approach, using codes determined by the focus groups. Results: A total of 170 individuals participated in the FGDs (84 ECD and 86 PW). Both groups recognized the weakness of the immune system as key determinant for severity. While PW raised the lack of information about the vaccine, the ECD emphasized accessibility problems. Five main barriers to influenza vaccination were identified: cultural barriers and use of traditional medicine, misleading or lack of information about influenza and the vaccine, advice against its uptake, problems of availability and accessibility of the vaccine as well as mistrust towards the vaccine including adverse effects, vaccine composition and effectiveness. Conclusion: The study provided refined information from the perspectives of users to orient the policies regarding the promotion of influenza vaccine by decision makers among these two high risk groups.

Insomnia and Related Factors During the Delta Wave of the COVID-19 Pandemic in the Kingdom of Bahrain: A Cross-Sectional Study.

Purpose: This study aims to estimate the prevalence of insomnia and related risk factors during the Delta wave of the COVID-19 pandemic in the Kingdom of Bahrain. Methods: An analytical cross-sectional study included 646 individuals from the general population aged 18 years and over, living in the Kingdom of Bahrain during the Delta wave of the pandemic. Data were collected by an anonymous online questionnaire using the snowball-sampling technique between June and August 2021. We used the Insomnia Severity Index (ISI) and the generalized anxiety disorder scale (GAD-7) to measure the level of insomnia and anxiety, respectively. Results: A total of 646 individuals participated in the study. Most of the participants were females (86%). The mean age was 38.7 ± 12.7 years (age range 18-89) and around half of the participants were 35 years or older. Clinical insomnia was reported by 20% [95% CI, 16.9-20.0] of the participants, and 50.1% [95% CI, 46.2-50.1] had subclinical insomnia according to ISI. The proportion of insomnia was significantly higher among females, healthcare workers, participants with lower educational levels, a lower or decreased monthly income during the pandemic, or participants who reported anxiety symptoms (all P < 0.01). Scales of anxiety and insomnia revealed a high correlation (r2 = 0.347, P< 0.01). The logistic regression model confirmed that factors independently associated with insomnia are female gender (OR=1.94, 95% CI, 1.00-3.76, P < 0.050) as well as presence of anxiety (GAD-7 score ≥ 5) [OR=12.98, 95% CI, 5.61-30.00, P < 0.001]. Conclusion: The burden of insomnia was significant among the general population in the Kingdom of Bahrain during the Delta wave of the COVID-19 pandemic despite the low severity of this variant. Mental health programs are a high priority during the pandemic and afterward. Detection of insomnia could be used to treat some mental health problems at an early stage.

Healed Lesions of Human Cutaneous Leishmaniasis Caused By Leishmania major Do Not Shelter Persistent Residual Parasites.

In human cutaneous leishmaniasis (HCL) caused by Leishmania (L.) major, the cutaneous lesions heal spontaneously and induce a Th1-type immunity that confers solid protection against reinfection. The same holds true for the experimental leishmaniasis induced by L. major in C57BL/6 mice where residual parasites persist after spontaneous clinical cure and induce sustainable memory immune responses and resistance to reinfection. Whether residual parasites also persist in scars of cured HCL caused by L. major is still unknown. Cutaneous scars from 53 volunteers with healed HCL caused by L. major were biopsied and the tissue sample homogenates were analyzed for residual parasites by four methods: i) microscope detection of amastigotes, ii) parasite culture by inoculation on biphasic medium, iii) inoculation of tissue exctracts to the footpad of BALB/c mice, an inbred strain highly susceptible to L. major, and iv) amplification of parasite kDNA by a highly sensitive real-time PCR (RT-PCR). Our results show that the scars of healed lesions of HCL caused by L. major do not contain detectable residual parasites, suggesting that this form likely induces a sterile cure at least within the scars. This feature contrasts with other Leishmania species causing chronic, diffuse, or recidivating forms of leishmaniasis where parasites do persist in healed lesions. The possibility that alternative mechanisms to parasite persistence are needed to boost and maintain long-term immunity to L. major, should be taken into consideration in vaccine development against L. major infection.

First Report of Two Jaculus Rodents as Potential Reservoir Hosts of Leishmania Parasites in Tunisia.

This study shows, for the first time, natural Leishmania infection among Jaculus spp. in an endemic region of Tataouine, South Tunisia. To better characterize the transmission cycles in this complex focus of mixed transmission, Leishmania detection and species identification were performed by direct examination, internal transcribed spacer-1 (ITS1)-PCR-restriction fragment length polymorphism (RFLP), and sequencing of Jaculus (J.) jaculus (Linnaeus, 1758) and J. hirtipes (Lichtenstein, 1823) rodent species, which are frequently encountered in this area. Leishmania parasites were observed in 19 (41.3%) smears, while DNA parasites were detected in 28 (60.9%) Jaculus spp. spleens; among them, 12 (54.5%) were from 22 J. jaculus individuals and 16 (66.7%) were from 24 J. hirtipes individuals. Leishmania parasites were confirmed as Leishmania (L.) killicki (syn. L. tropica) in two J. hirtipes individuals (4.3%) and L. major (n = 24; 52.2%) in 10 J. jaculus and 14 J. hirtipes individuals. This finding represents the first evidence of natural infection with Leishmania parasites in rodents belonging to the Jaculus genus, providing the rationale to consider them as potential reservoir hosts of Old World Leishmania parasites in Tunisia and North Africa.

Evaluation of the Utility of Online Objective Structured Clinical Examination Conducted During the COVID-19 Pandemic.

Background: The COVID-19 pandemic led to profound restrictions on the face-to-face learning and assessment in all educational institutions, particularly the medical schools. The College of Medicine and Medical Sciences of the Arabian Gulf University (CMMS-AGU) conducted the final exams, both theoretical and clinical components, for its MD students online. This study was conducted to evaluate the utility of online clinical exams held at CMMS-AGU. Methods: This is a cross-sectional, mixed method study that included samples from final year medical students, examiners, and heads of clinical departments. Data were collected through surveys, structured interviews, documents' review, and calculation of online examination's psychometrics. Descriptive statistics were used. Quantitative data were presented in the form of means and standard deviations. Responses of heads of clinical departments in the structured interview were transcribed and analyzed thematically based on three pre-established themes. Results: Quantitative and qualitative data on the utility (validity, reliability, acceptability, educational impact, and cost and feasibility) of online objective structured clinical examination (OSCE) were collected. Content validity of the online clinical examination was established through high mean scores of content representativeness, which was confirmed by the heads of clinical departments regarding the proper coverage of clinical skills. Criterion validity was established through a high correlation between clinical and theoretical exam results (r = 0.75). Reliability of the exam was established through an acceptable Cronbach's alpha value (0.70 to 0.78) over the four days of the examinations. The examinations were perceived as highly acceptable by both students and examiners. High educational impact was inferred from students' responses and review of documents. The examination was found to be feasible and of reasonable cost. Conclusion: Online OSCE might be a good alternative of conventional clinical assessments in times of crises and impossibility of having in-person contact between students, examiners, and patients. An important major drawback is still present in such initiatives, which is the inability to assess students' physical examination skills.

Intra-Specific Diversity of Leishmania major Isolates: A Key Determinant of Tunisian Zoonotic Cutaneous Leishmaniasis Clinical Polymorphism.

The clinical expression of zoonotic cutaneous leishmaniasis (ZCL) caused by Leishmania (L.) major parasites has a broad spectrum ranging from asymptomatic infection to self-limited cutaneous sores or severe disease. In concert with the host immune responses, the vector variability and the number of bites, genetic variation between L. major isolates might impact on the clinical output of the disease. We investigated herein the intra-specific variability of L. major field isolates independently of host or vector factors and then tried to correlate parasite variability to ZCL severity in corresponding patients. Several assays were applied, i.e., in vivo pathogenicity of promastigotes in a BALB/c mice model, resistance/sensibility to complement lysis, in vitro growth kinetics, and expression of different lectins on the promastigote surface. Combining all these parameters allowed us to conclude that the resistance to complement lysis and PNA/Jacalin lectins binding to parasite surfaces are important markers of parasite virulence. These factors correlate significantly with clinic polymorphism of ZCL and modestly with genetic micro-heterogeneity, a characteristic we previously revealed with a MLMT profile.

Evaluation of the Taxonomic Status of Lesser Egyptian Jerboa, Jaculus jaculus: First Description of New Phylogroups in Tunisia.

The taxonomy of the Lesser Egyptian jerboa, Jaculus (J.) jaculus (Dipodinae subfamily), was recently reevaluated, and the taxonomic status was defined by the presence of two cryptic species, J. jaculus (Linnaeus 1758) and J. hirtipes (Lichtenstein, 1823), with a higher genetic divergence in the sympatric North African populations than in other studied parapatric populations. Using phylogenetic analysis of the cytochrome b (Cytb) gene from 46 specimens, we confirmed the new status in Tunisia; rodents were collected from two different biotopes belonging to the same locality at the ecological level (mountainous vs. Saharan) in the south of the country. The study of the eye lens weight of these specimens allowed the definition of a cutoff value (58.5 g), categorizing juveniles from adults. Moreover, this study confirmed the phylotaxonomic status of J. jaculus in Tunisia, as recently illustrated, into two distinct species, J. jaculus and J. hirtipes, and recorded for the first time the presence of two phylogroups among each of these rodent species. The lack of clear micro-geographical structure and biotope specificity between the two rodent species and their phylogroups was also highlighted.

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.

Influenza vaccination knowledge, attitudes, and practices among Tunisian elderly with chronic diseases.

BACKGROUND: Generally, seasonal influenza does not cause severe infection in healthy adults, but for the elderly, an infection can pose a serious health concern. Although several measures can help prevent influenza, vaccination is considered the most effective. This study aimed to assess influenza vaccine uptake among elderly with chronic diseases in Tunisia during the 2018-2019 influenza season, and to identify knowledge, attitudes and barriers associated with influenza vaccine uptake. METHODS: During influenza season of 2018-2019, we conducted a national cross-sectional study among elderly with chronic disease who were attending primary and secondary health care facilities in Tunisia. We collected data regarding practices, general knowledge and attitudes related to influenza and influenza vaccine, using a standardized questionnaire. A multivariate analysis by logistic regression was performed to assess the factors influencing willingness to receive influenza vaccine. RESULTS: Among the 1191 surveyed elderly, 19.4% (95%CI 14.1-21.9) were vaccinated during the 2018-2019 influenza season and 64.7% (61.9-67.3) expressed willingness to be vaccinated in the next season regardless of vaccination status in the 2018-2019 season. Previous vaccination in the 2018-2019 influenza season was the most significantly associated factor with willingness to receive influenza vaccine (adjusted OR = 16.5 [3.7-72.4]). Significant associations were also observed between knowledge of influenza severity for the elderly as well as for those with chronic diseases and willingness to be vaccinated (p < 0.01). Likewise, participants who were convinced by flu vaccine effectiveness and those who were not concerned about vaccine side effects were more likely to be vaccinated (p < 0.001). The main reason that may lead to vaccine acceptance was a doctor's recommendation (41.1%), while the two main reasons that may lead to vaccine refusal were concerns about side effects (71.5%) and a belief that vaccine was ineffective in averting influenza illness (33.9%). Doctors were the most trusted source for information about influenza vaccine (91.5%). CONCLUSION: Our study revealed low influenza vaccination coverage among Tunisian elderly with chronic diseases believed to be at higher risk for severe acute respiratory infections and death if infected with influenza. Treating physicians' role in promoting influenza vaccination in this high-risk group seems to be crucial.

Knowledge, attitudes and uptake related to influenza vaccine among healthcare workers during the 2018-2019 influenza season in Tunisia.

BACKGROUND: The influenza vaccine (IV) is considered the most effective strategy to prevent seasonal influenza infection and annual vaccination of healthcare workers (HCWs) is recommended by the World Health Organization given their high mixing with patients. We assessed IV uptake among HCWs in the 2018-2019 season and explored their knowledge and attitudes regarding influenza immunization. METHODS: A cross-sectional study was conducted in 150 representative Tunisian health facilities from March to May 2019. We recruited 1231 HCWs with direct patient contact using self-weighted multistage sampling. Univariate and multivariate logistic regression analyses permitted to assess the factors associated with IV uptake in the 2018-2019 influenza season. RESULTS: Among 1231 health professionals enrolled in this study, less than half (36.6, 95% confidence interval [CI]: 33.9-39.4) received the IV at least once in their lives and only 15.3% (CI: 13.3-17.4) were vaccinated against influenza in the 2018-2019 influenza season. High confidence regarding IV efficacy, belief about the mandatory character of influenza vaccination for HCWs, and IV uptake in the 4 years preceding the 2018-2019 influenza season were independently associated with higher IV uptake by multivariate analysis. However, participants with high educational level were less likely to receive the IV than those with the lowest educational level. CONCLUSIONS: Our study revealed a low vaccination rate among Tunisian HCWs confirming the importance of tailored education programs targeting this population.

Professor Mohamed Soussi Soltani: Leader, Innovator and Researcher in Public Health.

Mohamed Soussi SOLTANI (June 27, 1953 - March 2, 2016) is Professor of Preventive and Community Medicine at the Faculty of Medicine of Monastir (Tunisia). The objective of this paper is to present, to new generations of the specialty in the Greater Maghreb, this leading teacher from the Center-East of Tunisia (Monastir), through the testimonies of his companions, and his indexed publications. All the colleagues of the late SOLTANI testified to his high human and professional qualities, particularly perseverance, commitment, forward thinking, integrity and professionalism. The scientific life of the late Professor Soltani was oriented towards two major themes: Public Health and Family Medicine. Indeed, the deceased has developed several new preventive activities in first-line structures such as anonymous and free HIV screening, family planning, rational use of drugs, breast cancer screening, smoking cessation, prevention of rheumatic heart disease. Pr SOLTANI welcomed general practitioners from the Monastir region to the Faculty's Community Medicine Department, creating with them a movement to advocate for the academic and professional development of general medicine into an authentic specialty of family medicine. Out of the 34 publications of Professor SOLTANI, indexed on PubMed, 11 were signed by himself in first position, mainly relating to maternal health (prenatal surveillance, education for maternal health, pregnancy referral system) and infant (low birth weight, vaccination, mother-to-child transmission of hepatitis B, meningitis due to Haemophilus influenzae). Thus, with a life prospering by innovations and research in public health, Professor SOLTANI will always remain a model for young people in the specialty of Preventive and Community Medicine. His followers have an obligation to write his complete biography, to safeguard it and pass it on to new generations of public health.

Seroprevalence of hepatitis A virus infection in Central-West of Tunisia.

Hepatitis A infections still represent a major global health concern. During the past years, a transition pattern of the hepatitis A epidemiology was noted in many parts of the world. In Tunisia, there is not a recent survey on age-specific hepatitis A virus seroprevalence. This study aimed to investigate the seroprevalence of hepatitis A virus infection in Central-West Tunisia, representative of regions with lowest socioeconomic level in the country, before vaccine implementation. Sera obtained from the blood samples of subjects were screened for the detection of hepatitis A virus. The seroprevalence was evaluated by detection of total antibodies to hepatitis A virus using commercially available immunoassay kits. A total of 1379 subjects, aged 5-75 years (mean age: 29.0 ± 17.3 years) were studied. The global anti-hepatitis A virus seroplevalence was 84.7% (95% confidence interval: [82.6-86.5]). A higher hepatitis A virus seroprevalence was showed in subjects aged 10-14 years compared to those aged less than 10 years (50.0% vs. 31.0%). In subjects aged 20-29 years, a rapid increase in the hepatitis A virus prevalence was noted; it reached 97.0%. The seroprevalence of anti-hepatitis A virus differed by zone of residence (81.1% in rural area vs. 72.4% in urban area, p = .005) and increased significantly with lower level of education (p = .019). There was no statistical significant seroprevalence difference between male and female: 84.2% versus 85.2%, respectively. Our study confirm the transition pattern of the hepatitis A virus endemicity in Tunisia from high to intermediate and provide an evaluation of the hepatitis A virus epidemiological situation before vaccine implementation.

Psycho-social impacts, experiences and perspectives of patients with Cutaneous Leishmaniasis regarding treatment options and case management: An exploratory qualitative study in Tunisia.

Although non-fatal and mostly self-healing in the case of Leishmania (L.) major, cutaneous leishmaniasis (CL) is mainly treated to reduce lesion healing time. Less attention is paid to the improvement of scars, especially in aesthetically relevant areas of the body, which can dramatically affect patients' wellbeing. We explored patients' perspectives about treatment options and the social and psychological burden of disease (lesion and scar). Individual in-depth interviews were conducted with ten confirmed CL patients at two L. major endemic sites in Southern Tunisia (Sidi Bouzid and Gafsa). Participants were selected using a sampling approach along a spectrum covering e.g. age, sex, and clinical presentation. Patients' experiences, opinions and preferences were explored, and their detailed accounts gave an insight on the impact of CL on their everyday lives. The impact of CL was found to be considerable. Most patients were not satisfied with treatment performance and case management. They expected a shorter healing time and better accessibility of the health system. Tolerance of the burden of disease was variable and ranged from acceptance of hidden scars to suicidal thoughts resulting from the fear to become handicapped, and the stress caused by close relatives. Some believed CL to be a form of skin cancer. Unexpectedly, this finding shows the big gap between the perspectives of patients and assumptions of health professionals regarding this disease. This study provided valuable information for better case management emphasizing the importance of improving communication with patients, and accessibility to treatment. It generated context-specific knowledge to policy makers in Tunisia to implement effective case management in a country where access to treatment remains a challenge due to socio-economic and geographic barriers despite a long tradition in CL control.

A prospective cohort study of Cutaneous Leishmaniasis due to Leishmania major: Dynamics of the Leishmanin skin test and its predictive value for protection against infection and disease.

BACKGROUND: Leishmanin Skin Test (LST) is considered as a useful indicator of past infection by Leishmania parasites. However, the temporal dynamics of a positive LST under different epidemiologic scenarios and whether it relates to the protection against the recurrence of an overt disease are not fully documented. METHODOLOGY/PRINCIPAL FINDINGS: We report here on a population based prospective study conducted on 2686 individuals living in two foci located in Central Tunisia, to assess over a one-year epidemiologic season, the incidence of Leishmania (L.) major infection and disease and changes in LST reactivity. The two foci were both endemic for Cutaneous Leishmaniasis (CL) due to L. major, but contrasted in their history for this disease (ie: an old focus versus a recent focus). We found that most infections occurred in the new focus (290/1000; 95% CI: 265-315 person-years) with an incidence rate of CL lesions 2.4 times higher than in the old focus. Likewise, the rates of LST reactivity reversion and loss, in the new focus, were 99/1000[38-116] person-years and 14/1000[8-21] person-years, respectively. Loss of LST reactivity was not noticed in the old focus. Interestingly, the incidence rates of symptomatic infection did not differ significantly according to the LST status at enrolment (negative versus positive) between the combined foci and the new one. CONCLUSIONS/SIGNIFICANCE: Our findings confirm LST as a good tool for assessing L. major cryptic infection. However, the instability of the LST positivity in new foci should be considered as an important confounder of the outcome of this infection when developing a research protocol for vaccine trial.

Hepatitis a virus infection in Central-West Tunisia: an age structured model of transmission and vaccination impact.

BACKGROUND: The epidemiological pattern of hepatitis A infection has shown dynamic changes in many parts of the world due to improved socio-economic conditions and the accumulation of seronegative subjects, which leads to possible outbreaks and increased morbidity rate. In Tunisia, the epidemiological status of hepatits A virus is currently unknown. However, over the past years higher numbers of symptomatic hepatitis A virus infection in school attendants and several outbreaks were reported to the Ministry of Health, especially from regions with the lowest socio-economic levels in the country. The aim of this study was to investigate the current seroprevalence of hepatitis A virus antibodies in central-west Tunisia and assess the impact of hepatitis A virus vaccination on hepatitis A epidemiology. METHODS: Serum samples from 1379 individuals, aged 5-75 years, were screened for hepatitis A virus antibodies. Adjusted seroprevalence, incidence and force of infection parameters were estimated by a linear age structured SEIR (Susceptible-Exposed-Infectious-Recovered) compartmental model. A vaccine model was then constructed to assess the impact on hepatitis A virus epidemiology of 3 scenarios of vaccination strategies: one dose at 12-months of age, one dose at 6-years and one dose at 12-months and another at 6-years of age during 6 years. RESULTS: A rapid increase in anti-hepatitis A virus seroprevalence was noted during infancy and adolescence: 47% of subjects under 10-years-old are infected; the prevalence increases to 77% at 15-years and reaches 97% in subjects aged 30-years. The force of infection is highest between 10 and 30-years of age and the incidence declines with increasing age. The vaccine model showed that the 3-scenarios lead to a significant reduction of the fraction of susceptibles. The two doses scenario gives the best results. Single-dose vaccination at 6-years of age provides more rapid decrease of disease burden in school-aged children, as compared to single-dose vaccination at 12-months, but keeps with a non-negligible fraction of susceptibles among children < 6-years. CONCLUSIONS: Our study confirms the epidemiological switch from high to intermediate endemicity of hepatitis A virus in Tunisia and provides models that may help undertake best decisions in terms of vaccinations strategies.