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.

The Prevalence, Genotype Distribution and Risk Factors of Human Papillomavirus in Tunisia: A National-Based Study.

There are limited national population-based studies on HPV genotypes distribution in Tunisia, thus making difficult an assessment of the burden of vaccine-preventable cervical cancer. In this context, we conducted a national survey to determine the HPV prevalence and genotypes distribution and the risk factors for HPV infections in Tunisian women. This is a cross-sectional study performed between December 2012 and December 2014. A liquid-based Pap smear sample was obtained from all women and samples' DNAs were extracted. Only women with betaglobin-positive PCR were further analysed for HPV detection and typing by a nested-PCR of the L1 region followed by next-generation sequencing. A multiple logistic regression model was used for the analysis of associations between the variables. A total of 1517 women were enrolled in this study, and 1229 out of the 1517 cervical samples were positive for the betaglobin control PCR and tested for HPV. Overall HPV infection prevalence was measured to be 7.8% (96/1229), with significant differences between the grand regions, ranging from 2% in the North to 13.1% in Grand Tunis. High-risk HPV genotypes accounted for 5% of the infections. The most prevalent genotypes were HPV 31 (1%), 16 (0.9%), 59 (0.7%). HPV18 was detected only in four cases of the study population. Potential risk factors were living in Grand Tunis region (OR: 7.94 [2.74-22.99]), married status (OR: 2.74 [1.23-6.13]), smoking habit (OR: 2.73 [1.35-5.51]), occupation (OR: 1.81 [1.09-3.01]) and women with multiple sexual partners (OR: 1.91 [1.07-3.39]). These findings underscore the need to evaluate the cost effectiveness of HPV vaccine implementation, contribute to the evidence on the burden of HPV infections, the critical role of sexual behaviour and socioeconomic status, and call for increased support to the preventive program of cervical cancer in Tunisia.

The value of West Nile virus RNA detection by real-time RT-PCR in urine samples from patients with neuroinvasive forms.

INTRODUCTION: Routine laboratory screening is based on the detection of WNV specific IgM and IgG in blood and cerebrospinal fluid. Confirmation is then classically applied by real time RT-PCR (rRT-PCR) in Cerebrospinal fluid (CSF), which often gives negative results due to too short virorachia and late sampling. rRT-PCR was applied-for the first time for routine diagnosis purpose-on urine samples. METHODS: During 2018 outbreak in Tunisia, 107 patients presented WNV neurologic symptoms and were positive for WNV serology. Of them, 95 patients were sampled for urine and 35 were sampled for CSF. Qualitative rRT-PCR was performed on both type of samples. RESULTS: WNV RNA was detected in 50.5% of urine samples (48/95) and in 2.8% of CSF samples (1/35). WNV RNA was detectable from day 1 to day 41 from symptom onset, however, positive urine rate was 53.1% during the first 10 days from symptom onset. The proportions of urine-positive and urine-negative samples, based on day of collection, showed no statistical difference (p > 0.005). Cycle threshold (Ct) values ranged from 12 to 39, with no correlation with the day of collection. The lowest Ct value was detected for urine sampled on day 5 after symptom onset. A statistically significant difference was found between age groups of confirmed and non confirmed cases (p < 0.001). DISCUSSION/CONCLUSION: Our study reported the use of rRT-PCR on urine samples as a confirmatory diagnostic tool for WNV "probable cases" during an outbreak. Our findings underlined the reliability and the rapidity of this confirmatory tool, even late, and showed its superiority on CSF investigation.

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 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.

Genetic characterization of West Nile Virus strains during neuroinvasives infection outbreak in Tunisia, 2018.

West Nile Virus (WNV) is an arbovirus transmitted by mosquito bite involving birds as reservoirs, humans and equines as accidental hosts. Eight distinct lineages (WNV-1 to WNV-8) have been identified: WNV-1 and WNV-2 infect humans and animals, and WNV-3 to WNV-8 have been identified only in vectors. WNV has been implicated in neuroinvasives infections, especially meningitis and encephalitis. Tunisia experienced three epidemics in 1997, 2003 and 2012. Serological studies on humans, equines and birds as well as the detection of the virus in the vector favour a fairly frequent circulation in the country. A new epidemic has been observed in Tunisia between August and November 2018. The obtained sequences of the VWN from Tunisia 2018 grouped in a distinct monophyletic group within the Mediterranean subtype in Cluster 1, with a maximum of 2% nucleotide divergence. These sequences were clearly distinct from the Tunisia 1997, which grouped with sequences mainly from USA in Cluster 2. This work reports the genetic characterization of the Tunisia 2018 strain in comparison with the previously identified strains in Tunisia and worldwide. The epidemic virus Tunisia 2018 was genetically close to the Mediterranean basin and Eastern Europe sequences but distinct from the Tunisia 1997 closely related to the American sequences.

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.

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.

Contribution of verbal autopsy in the study of cancer mortality among reproductive-age women in Tunisia.

Background In Tunisia, the information system on medical causes of death  is based on the use of standard death certificate model based on international model recommended by the World Organization started in January 2001. However, this system is still burdened with a major death causes of under-registration. Only specific surveys on mortality have FAR generate reliable mortality indicators. Objectives to study the use of verbal autopsy in order to assess cancer mortality among Tunisian women in reproductive age (WRA) . Methods A retrospective   national RAMOS survey (Reproductive Age Mortality Study). This survey was conducted in 2010 and included all deaths of women aged 15-49 years which occurred in 2008 and were due to cancer. Data were collected from civil status records and information gathered from families and from health institution's registers. For all deaths of women aged 15-49 years, the detailed circumstances and the sequence of events leading to death were grouped on a folder called "clinical record of verbal autopsy" .Then; all folders were submitted to the independent expert. Results During the study period, 1729 deaths among women of reproductive age (WRA) were the subject of a verbal autopsy against only 708 recorded by the National death information system (NDIS). Cancer is the leading cause of death among WRA .The specific rate of cancer mortality is 17.83 per 100 000 WRA against only 7.91 per 100 000 WRA estimated by the NDIS. Breast cancer is the leading cause with 35% of all cancers and specific death rate of 6.3 per 100,000 WRA against 2.48 per 100,000 WRA recorded by the NDIS. Conclusion Verbal autopsies Verbal autopsy remains an interesting method for measuring cancer mortality in women of a reproductive age especially in countries with a defective national death information system.

Prevalence, Genotype Distribution and Risk Factors for Cervical Human Papillomavirus Infection in the Grand Tunis Region, Tunisia.

Implementation of Human Papillomavirus (HPV) vaccination should be considered a key cervical cancer prevention strategy in Tunisia, where Pap smear screening is not efficient. This study aims to estimate the prevalence and to identify risk factors associated with HPV infection among women from Grand Tunis, Tunisia. We conducted a cross-sectional study, between December 2012 and May 2013. Eligible women for this study were those aged 18-65 years, sexually active, who sought medical attention at their primary health care centre or clinic in Grand Tunis, Tunisia and who gave written consent. A liquid-based Pap smear sample was obtained from all women using a cervical brush. Only women with betaglobin positive test were further analysed for HPV detection and typing. A nested-PCR of the L1 region was performed followed by reverse line blot hybridization to facilitate the specific detection of 31 HPV genotypes. Multiple logistic regression modeling was used for the analysis of associations between variables with some considered possible confounders after checking for interactions. A total of 391 women were enrolled in this study and 325 out of the 391 cervical samples were positive for the betaglobin test. Overall HPV prevalence was 13.2% [9.8%-17.5%], with the following most prevalent HPV genotypes: HPV6 (40%), HPV40 (14%), HPV16 (12%), HPV52 (9%), HPV31 and HPV59 (7%), followed by HPV68 (4%). Mean age of HPV positive women was 40.7±0.92 years. Independently associated risk factors of HPV infection were smoking (OR:2.8 [0.8-9.6]), low income (OR:9.6 [1.4-63.4), bad housing type (OR:2.5 [1-6.8]), partner with multiple sexual relationship (OR:4.5 [0.9-22.9]) and single women (widowed, divorced, separated, never married) (OR:6.9 [1.1-42.2]). This study provides the first national-based estimate of HPV prevalence in Tunisia. Our findings contribute to the evidence on the current burden of HPV infection, the critical role of sexual behaviour and socioeconomic status and call for increased support for the screening program in Tunisia to prevent cervical cancer. These results allow us to evaluate the cost-effectiveness of vaccine program implementation in Tunisia in future.

Abdominal vs. overall obesity among women in a nutrition transition context: geographic and socio-economic patterns of abdominal-only obesity in Tunisia.

BACKGROUND: Most assessments of the burden of obesity in nutrition transition contexts rely on body mass index (BMI) only, even though abdominal adiposity might be specifically predictive of adverse health outcomes. In Tunisia, a typical country of the Middle East and North Africa (MENA) region, where the burden of obesity is especially high among women, we compared female abdominal vs. overall obesity and its geographic and socio-economic cofactors, both at population and within-subject levels. METHODS: The cross-sectional study used a stratified, three-level, clustered sample of 35- to 70-year-old women (n = 2,964). Overall obesity was BMI = weight/height(2) ≥ 30 kg/m(2) and abdominal obesity waist circumference ≥ 88 cm. We quantified the burden of obesity for overall and abdominal obesity separately and their association with place of residence (urban/rural, the seven regions that compose Tunisia), plus physiological and socio-economic cofactors by logistic regression. We studied the within-subject concordance of the two obesities and estimated the prevalence of subject-level "abdominal-only" obesity (AO) and "overall-only" obesity (OO) and assessed relationships with the cofactors by multinomial logistic regression. RESULTS: Abdominal obesity was much more prevalent (60.4% [57.7-63.0]) than overall obesity (37.0% [34.5-39.6]), due to a high proportion of AO status (25.0% [22.8-27.1]), while the proportion of OO was small (1.6% [1.1-2.2]). We found mostly similar associations between abdominal and overall obesity and all the cofactors except that the regional variability of abdominal obesity was much larger than that of overall obesity. There were no adjusted associations of AO status with urban/rural area of residence (P = 0.21), education (P = 0.97) or household welfare level (P = 0.94) and only non-menopausal women (P = 0.093), lower parity women (P = 0.061) or worker/employees (P = 0.038) were somewhat less likely to be AO. However, there was a large residual adjusted regional variability of AO status (from 16.6% to 34.1%, adjusted P < 0.0001), possibly of genetic, epigenetic, or developmental origins. CONCLUSION: Measures of abdominal adiposity need to be included in population-level appraisals of the burden of obesity, especially among women in the MENA region. The causes of the highly prevalent abdominal-only obesity status among women require further investigation.

Prevalence of diabetes in Northern African countries: the case of Tunisia.

BACKGROUND: Although diabetes is recognized as an emerging disease in African and Middle East, few population-based surveys have been conducted in this region. We performed a national survey to estimate the prevalence of type 2 diabetes (T2D) and to evaluate the relationship between this diagnosis, demographic and socioeconomic variables. METHODS: The study was conducted on a random sample of 6580 households (940 in each region). 7700 subjects adults 35-70 years old were included in the analyses. T2D was assessed on the basis of a questionnaire and fasting blood glucose level according to the WHO criteria. Access to health care and diabetes management were also assessed. RESULTS: Overall, the prevalence of T2D was 15.1%. There were sharp urban vs. rural contrasts, the prevalence of diabetes being twice higher in urban area. However, the ratio urban/rural varied from 3 in the less developed region to 1.6 in the most developed ones. A sharp increase of prevalence of T2D with economic level of the household was observed. For both genders those with a family history of T2D were much more at risk of T2D than those without. Awareness increase with age, economic level and were higher amongst those with family history of T2D. Drugs were supplied by primary health care centers for 57.7% with a difference according to gender, 48.9% for men vs. 66.0% women (p < 0.001) and area, 53.3% on urban area vs. 75.2% on rural one (p < 0.001). CONCLUSIONS: Through its capacity to provide the data on the burden of diabetes in the context of the epidemiological transition that North Africa is facing, this survey will not only be valuable source for health care planners in Tunisia, but will also serve as an important research for the study of diabetes in the region where data is scarce. In this context, NCDs emerge as an intersectoral challenge and their social determinants requiring social, food and environmental health policy.

[National survey of maternal mortality of 2010 : data of Tunisia]. / L'enquête Nationale Tunisienne sur la mortalité maternelle de 2010 : A propos des données de Tunis.

BACKGROUND: Tunisia has investigated maternal mortality in 2010 to determine maternal mortality ratio (MMR) nationally and regionally, in addition to the indentifying main causes of this mortality. OBJECTIVES: Describe methodology of this study and its principal findings in the region of Tunis and discuss the national maternal mortality strategy. METHODOLOGY: This is a Ramos study (Reproductive Ag Mortality Studies) that consists on identifying maternal deaths from reproductive age group (RAG) women deaths. We started by the a rehearsal and targeting of (RAG) women deaths , then we investigated a next of kin person of the decedent women by verbal autopsy, thereafter we identified maternal deaths to be confidentially investigated to judge the potential avoidability of the death. The study took place in 2010, it was carried out by 5 couples of investigators supervised by a coordinator doctor. RESULTS: A total of 200 deaths of (RAG) women were found in Tunis, 7 deaths among them were maternal deaths, that corresponds to an MMR of 41/100000 live births. The mean age of the deceased women was 35 years. The main causes of maternal deaths were hemorrhage (3/7), thrombo-embolic diseases (2 times for7) and HELLP syndrome (1/7). Four of a total of 4 deaths (3 deaths were not marked), were avoidable. The majority of late women had a satisfying educational level, 4 of 7 had financial autonomy. All of them had pregnancy monitoring, 5 times of 7 in university hospital. All the childbirth were medically assisted, Caesarean section was carried in 6 of 7 cases. Nationally, the MMR was estimated to 44.8/100 000 LB, that to say a decrease of 35% compared to 1993. The decrease was significant for all the regions of the country, except the great Tunis where opposite trend was recorded. This could be more likely related to quality of care rather than socio-economic conditions seeing that social determinants in Tunis are favorable. In fact, the Tunisian maternal mortality strategy had essentially focused on the monitoring system of maternal deaths rather than the quality of care improvement interventions, results were disappointing due to the lack of institutional engagement. The achievement of the OMD5 objectives is compromised, due to socio-economic constraint especially in certain regions, poor governance and lack of engagement of ministry of health in reducing maternal mortality. CONCLUSION: Tunisian maternal mortality strategy should be revised and adapted to regional context, also should includ multisectoral interventions. Priority would be given to quality of care improvement, by launching the experience of care setting accreditation in one hand, and in the other improving partnership between different levels of care.

Obesity and association with area of residence, gender and socio-economic factors in Algerian and Tunisian adults.

INTRODUCTION: The epidemiological transition has resulted in a major increase in the prevalence of obesity in North Africa. This study investigated differences in obesity and its association with area of residence, gender and socio-economic position among adults in Algeria and Tunisia, two countries with socio-economic and socio-cultural similarities. METHODS: Cross-sectional studies used stratified, three-level, clustered samples of 35-70 year old adults in Algeria, (women n = 2741, men n = 2004) and Tunisia (women n = 2964, men n = 2379). Thinness was defined as Body Mass Index (BMI) = weight/height <18.5 kg/m(2), obesity as BMI ≥30, and abdominal obesity as waist circumference/height ≥0.6. Associations with area of residence, gender, age, education, profession and household welfare were assessed. RESULTS: Prevalence of thinness was very low except among men in Algeria (7.3% C.I.[5.9-8.7]). Prevalence of obesity among women was high in Algeria (30.1% C.I.[27.8-32.4]) and Tunisia (37.0% C.I.[34.4-39.6]). It was less so among men (9.1% C.I.[7.1-11.0] and 13.3% C.I.[11.2-15.4]).The results were similar for abdominal obesity. In both countries women were much more obesity-prone than men: the women versus men obesity Odds-Ratio was 4.3 C.I.[3.4-5.5] in Algeria and 3.8 C.I.[3.1-4.7] in Tunisia. Obesity was more prevalent in urban versus rural areas in Tunisia, but not in Algeria (e.g. for women, urban versus rural Odds-Ratio was 2.4 C.I.[1.9-3.1] in Tunisia and only 1.2 C.I.[1.0-5.5] in Algeria). Obesity increased with household welfare, but more markedly in Tunisia, especially among women. Nevertheless, in both countries, even in the lowest quintile of welfare, a fifth of the women were obese. CONCLUSION: The prevention of obesity, especially in women, is a public health issue in both countries, but there were differences in the patterning of obesity according to area of residence and socio-economic position. These specificities must be taken into account in the management of obesity inequalities.

Prevalence and determinants of the metabolic syndrome among Tunisian adults: results of the Transition and Health Impact in North Africa (TAHINA) project.

OBJECTIVE: To determine the prevalence of metabolic syndrome (MetS) and its components and to evaluate the relationship between this diagnosis and cardiovascular risk factors, demographic and socio-economic variables. DESIGN: A cross-sectional study using a questionnaire including information on sociodemographic and CVD risk factors. Blood pressure, anthropometric indices, fasting glucose and lipid profile were measured. MetS was defined according to the criteria of the National Cholesterol Education Program, Adult Treatment Panel III. SETTING: The whole Tunisian territory; Transition and Health Impact in North Africa (TAHINA) project. SUBJECTS: A total of 4654 individuals (1840 men and 2814 women), aged 35 to 74 years, who participated in the Tunisian national survey. RESULTS: The overall prevalence of MetS was 30·0 %, higher in women (36·1 %) than in men (20·6 %; P < 0·001). In both genders MetS prevalence increased significantly with age (P < 0·001), but this increase was more important in women. Multiple regression analyses showed that the odds for MetS increased significantly with urban area for both men and women (P < 0·05 and P < 0·001, respectively). The multivariate models showed also that the odds for MetS increased significantly with increasing level of education and in those with a family history of CVD for men (both P < 0·05) and after the menopausal transition for women (P < 0·05). CONCLUSIONS: The study highlights the MetS problem in a middle-income developing country. There is an urgent need for a comprehensive, integrated, population-based intervention programme to ameliorate the growing problem of MetS in Tunisians.

Gender obesity inequities are huge but differ greatly according to environment and socio-economics in a North African setting: a national cross-sectional study in Tunisia.

INTRODUCTION: Southern Mediterranean countries have experienced a marked increase in the prevalence of obesity whose consequences for gender related health inequities have been little studied. We assessed gender obesity inequalities and their environmental and socio-economic modifiers among Tunisian adults. METHODS: Cross-sectional survey in 2005; national, 3 level random cluster sample of 35-70 years Tunisians (women: n = 2964, men: n = 2379). Overall adiposity was assessed by BMI = weight(kg)/height(m)(2) and obesity was BMI≥30, WHtR = waist circumference to height ratio defined abdominal obesity as WHtR≥0.6. Gender obesity inequality measure was women versus men Prevalence Proportion Odds-Ratio (OR); models featuring gender x covariate interaction assessed variation of gender obesity inequalities with area (urban versus rural), age, marital status or socio-economic position (profession, education, household income proxy). RESULTS: BMI was much higher among women (28.4(0.2)) versus men (25.3(0.1)), P<0.0001) as was obesity (37.0% versus 13.3%, OR = 3.8[3.1-7.4], P<0.0001) and abdominal obesity (42.6% versus 15.6%, 4.0[3.3-4.8], P<0.0001). Gender obesity inequalities (women versus men adjusted OR) were higher in urban (OR = 3.3[1.3-8.7]) than rural (OR = 2.0[0.7-5.5]) areas. These gender obesity inequalities were lower for subjects with secondary education or more (OR = 3.3[1.3-8.6]), than among those with no schooling (OR = 6.9[2.0-23.3]). They were also lower for those with upper/intermediate profession (OR = 1.4[0.5-4.3]) or even employees/workers OR = 2.3[1.0-5.4] than those not professionaly active at all (OR = 3.3[1.3-8.6]). Similar results were observed for addominal obesity. CONCLUSION: The huge overall gender obesity inequities (women much more corpulent than men) were higher in urban settings, but lower among subjects of higher education and professional activity. Reasons for gender inequalities in obesity and their variation with socio-economic position should be sought so that appropriate policies to reduce these inequalities can be implemented in Tunisia and similar settings.

Hypertension among Tunisian adults: results of the TAHINA project.

We performed a national survey to determine the prevalence, awareness, treatment and control of hypertension, one of the main cardiovascular risk factors, among the adult population in Tunisia. A total of 8007 adults aged 35-70 years were included in the study. Blood pressure (BP) measurements were taken by physicians with a mercury sphygmomanometer, and standard interviewing procedures were used to record medical history, socio-demographic and cardiovascular disease (CVD) risk factors. Hypertension was defined as a systolic BP ≥140 mm Hg and/or diastolic BP ≥90 mm Hg or current treatment with antihypertensive drugs. The prevalence of hypertension was 30.6%, higher in women (33.5%) than in men (27.3%). Multiple logistic regression analyses identified a higher age, urban area, higher body mass index, type 2 diabetes and family history of CVD as important correlates to the prevalence of hypertension. Only 38.8% of those with hypertension were aware of their diagnosis, of which 84.8% were receiving treatment. BP control was achieved in only 24.1% of treated hypertensive persons. Women were more aware than men (44.8 vs. 28.8%), but the rates of treatment and control of hypertension did not differ between the two genders. Higher age, being female, lower education level and urban area emerged as important correlates of hypertension awareness. The study highlights the hypertension problem in a middle-income developing country. There is an urgent need for a comprehensive integrated population-based intervention program to ameliorate the growing problem of hypertension in Tunisians.

Relationship of C-reactive protein with components of the metabolic syndrome in a Tunisian population.

BACKGROUND: C-reactive protein (CRP) is an independent risk factor of diabetes and cardiovascular disease and it is proposed as a component of metabolic syndrome (MS). This study was undertaken to investigate the relationship between CRP and various characteristics of the MS in a sample of the Tunisian population METHODS: One hundred and forty nine patients with MS and 152 controls, aged 35-70 years were recruited. Waist circumference (WC), blood pressure, HDL-cholesterol (HDL-C), triglycerides (TG), glucose, insulin and CRP were measured. Insulin resistance was assessed by homeostasis model assessment of insulin resistance (HOMA-IR). MS was defined by NCEP-ATPIII report RESULTS: CRP levels were significantly higher in MS group (4.41±3.73 mg/L vs. 2.68±2.59 mg/L, p<0.001) compared to without MS group. For both sexes, CRP increased as the number of MS components increased (p=0.015 for men and p<0.001) after adjustment for age, smoking, alcohol intake and, for women, menopause. There were statistically significant positive correlations for log CRP with WC, log TG, and log HOMA-IR in both sexes adjusted for confounding factors listed above. A significant negative correlation was found between HDL-C and log CRP only in women. In both sexes, WC was identified, by multiple linear regression models, as significant independent predictor of CRP level variability. HDL-C showed also a significant contribution only in women CONCLUSIONS: The present study provides evidence that CRP levels are elevated in MS subjects. In addition, WC and HDL-C are significant predictors of the CRP elevation.

Association between C-reactive protein and type 2 diabetes in a Tunisian population.

The aim of this study was to investigate the association of CRP levels with type 2 diabetes (T2D) and its related variables in a sample of the Tunisian population. Our sample included 129 patients with T2D and 187 control subjects. Body mass index (BMI), plasma lipids, glucose, insulin, and CRP concentrations were measured for each participant. Homeostasis model assessment of insulin resistance (HOMA-IR) was calculated. T2D was defined as a fasting plasma glucose (FPG) level ≥ 7.0 mmol/L, the use of anti-diabetic drugs, or both. Statistical analyses were performed using SPSS 11.5. A significant difference in mean values of BMI, plasma lipids, FPG, insulin, and HOMA-IR was observed between subjects with and without T2D. CRP level was significantly higher in subjects with T2D than those without (p = 0.023), and this result persisted even after adjustment for age, gender, BMI, smoking, and alcohol consumption. In both diabetes statuses, log CRP was significantly associated with FPG, insulin, and HOMA-IR. Subjects with elevated CRP levels (>5 mg/L) had an increased risk of T2D (OR = 2.02, 95% CI 1.18-3.46, p = 0.010) than those whose CRP levels were less or equal to 5 mg/L. Even after adjustment for potentially confounding factors, the risk of T2D was still increased in subjects with elevated CRP levels (OR = 1.91, 95% CI 1.08-3.36, p = 0.025). These results suggest that elevated CRP levels are independently associated with T2D.

The Apolipoprotein B/Apolipoprotein A 1 ratio in relation to metabolic syndrome and its components in a sample of the Tunisian population.

OBJECTIVE: This study was undertaken to investigate the relationship between the Apolipoprotein B/Apolipoprotein A 1 (ApoB/ApoA 1) ratio and various characteristics of the metabolic syndrome (MetS) in a sample of the Tunisian population. METHODS: The study included 330 adults aged 35-74 (172 patients with MetS and 158 controls). Waist circumference (WC), blood pressure (BP), HDL-cholesterol (HDL-C), triglycerides (TG), glucose, insulin, and apolipoprotein concentrations were measured. Homeostasis model assessment (HOMA) was used to assess insulin resistance (IR). MetS was defined by NCEP-ATPIII report. RESULTS: The ApoB/ApoA 1 ratio was significantly higher in patients with MetS versus normal control subjects (p<0.001). Mean values of ApoB/ApoA 1 ratio increased significantly as the numbers of MetS components increased in men (p<0.001) and women (p<0.001). ApoB/ApoA 1 ratio showed statistically significant associations with WC, HDL-C, TG, systolic and diastolic BP, and HOMA-IR. After adjusting for age and gender, the high ApoB/ApoA 1 ratio was significantly associated with the presence of MetS (odds ratio [OR]=6.10), IR (OR=1.88), and with each of the MetS components, including: high WC (OR=2.43), High TG (OR=6.14), and low HDL-C (OR=6.92). CONCLUSIONS: Our findings suggest that the ApoB/ApoA 1 ratio is strongly associated with MetS and its components, as well as with IR.