[Epidemiology of high risk pregnancy in Sousse, Tunisia]. / Profil épidémiologique des grossesses à risque à Sousse (Tunisie).

This descriptive study assessed the frequency of selected risk factors for high risk pregnancy (HRP) among women in Sousse region. All pregnant women (beyond 28 weeks gestation) giving birth in 4 public maternity hospitals between 15 February 2005 and 15 August 2005 and who had at least 1 risk factorwere enrolled. Data were collected within 24 hours of birth from obstetric and antenatal records and by interview. Of 4660 pregnant women, 1194 (25.6%) had at least 1 risk factor and were considered at-risk pregnancies. Mean age of the at-risk women was 31.3 (SD 5.4) years, 73% were urban residents, 38% had secondary education or higher and 75% were housewives. The mean number of risk factors was 1.5 per woman. The majority of women (59.3%) had 1 risk factor and 30.4% had 2. The mean number of prenatal visits was 4, 68.6% were seen by an obstetrician and 43% used the private sector. Certain factors were inadequately screened: age >35 years, parity >4, previous low birth weight and neonatal death, excessive fundal height and anaemia.

Epidemiology of high risk pregnancy in Sousse, Tunisia

This descriptive study assessed the frequency of selected risk factors for high risk pregnancy [HRP] among women in Sousse region. All pregnant women [beyond 28 weeks gestation] giving birth in 4 public maternity hospitals between 15 February 2005 and 15 August 2005 and who had at least 1 risk factor were enrolled. Data were collected within 24 hours of birth from obstetric and antenatal records and by interview. Of 4660 pregnant women, 1194 [25.6%] had at least 1 risk factor and were considered at-risk pregnancies. Mean age of the at-risk women was 31.3 [SD 5.4] years, 73% were urban residents, 38% had secondary education or higher and 75% were housewives. The mean number of risk factors was 1.5 per woman. The majority of women [59.3%] had 1 risk factor and 30.4% had 2. The mean number of prenatal visits was 4, 68.6% were seen by an obstetrician and 43% used the private sector. Certain factors were inadequately screened: age > 35 years, parity > 4, previous low birth weight and neonatal death, excessive fundal height and anaemia

Survival of Escherichia coli strains in Mediterranean brackish water in the Bizerte lagoon in northern Tunisia.

This study investigated survival and virulence of Escherichia coli strains exposed to natural conditions in brackish water. Two E. coli strains (O126:B16 and O55:B5) were incubated in water microcosms in the Bizerte lagoon in northern Tunisia and exposed for 12 days to natural sunlight in June (231 to 386 W/m2, 26 +/- 1 degrees C, 30 g/L) and in April (227 to 330 W/m2, 17 +/- 1 degrees C, 27 g/L) or maintained in darkness for 21 days (17 +/- 1 degrees C, 27 g/L). The results revealed that sunlight was the most significant inactivating factor (decrease of 3 Ulog within 48 hours for the two strains) compared to salinity and temperature (in darkness). Survival time of the strains was prolonged as they were maintained in darkness. Local strain (E. coli O55:B5) showed better survival capacity (T90 = 52 hours) than E. coli O126:B16 (T90 = 11 h). For both, modifications were noted only for some metabolic activities of carbohydrates hydrolysis. Cytotoxicity of the two strains, tested on Vero cell, was maintained during the period of survival.

[Practice of large scale mammography in the Ariana area of Tunisia: prelude to a mass screening?]. / Pratique de la mammographie à grande échelle dans le gouvernorat de l'Ariana en Tunisie: un préalable à un dépistage de masse organisé?

OBJECTIVE: To study and analyse the results of breast cancer mammography screening program in the Ariana state and to try to determinate its feasibility and reproducibility on a broader scale. MATERIALS AND METHODS: A pilot study on the mammography feasibility of screening with large scales was initiated, by Family and Population National Office, in September 2003. The duration of the study was fixed at 5 years. The adopted protocol takes account of epidemiologic and socialcultural specificities of Tunisian environment that is in the selection and in the mode of recruitment of the target population as well as in the choice of the adopted radiological protocol. RESULTS: 8244 women were screened in the first round. The majority of sensitized women was recruited in residence and in the reproductive and health centers. Nevertheless, recruitment in residence was proved to be heavy, not very effective and no reproducible in a broader scale. The participation rate was weak (9.6%). The channels of sensitizing used made it possible to touch in manner more important the "young" women (Middle Age 48.6 years). The absence of radiologist on the spot involved the recall of 18.1% of the women for which a complementary assessment was necessary, has to contribute to increase the stress among certain women and to increase the average time of reading which was, in this case, 61.7 days. The majority of the women profited from the double reading of the tests (99.4%). On the whole 50 women presented a cancer including 40 detected by the program and 10 interval cancers. CONCLUSIONS: This study has permitted to study the feasibility of mammography study. Except the topic of the cost, the two hand conditions of his feasibility binds in the systematic invitation of the women as well as in the wider uses of sensitization and information ways of the population.

[Results and evaluation of 3 years of a large scale mammography program in the Ariana area of Tunisia]. / Résultats et évaluation de 3 années de pratique mammographique à grande échelle dans le gouvernorat de l'Ariana en Tunisie.

OBJECTIVE: To asses and analyse the results of 3 years large scale mammography screening of breast cancer in Ariana state in Tunisia. MATERIALS AND METHODS: This program, managed by the Family and Population National Office, was addressing to women aged from 49 to 69 years old residing in a area with adds up a population of 459 700 inhabitants including 52,729 women in the target age population. The screening was including a breast clinical examination and a mammography with two incidences face and external profile. The women was invited at their residence or were sensitized in the reproductive health centers, care and base health centers or by a close relation which heard of the program. An enlightened assent was submitted to the women who wished to profit from the screening. RESULTS: In three years, 9093 mammography were carried out of which 8244 were retained in the analyses, that is to say a rate participation of 9.6%. The rate of women recalled for suspect test was of 18.1% and it was of 13.1% among women of more than 50 years. The rate of practiced surgical biopsies was of 0.5% and the positive predictive value was of 45.5%. The average time between the date of screening and the result of the screening was 9.7 days, more important in the event of tests requiring a complementary assessment (61.7 days). On the whole 40 cancers were detected by the program, that is to say a rough rate of detected cancers, of 4.9 per thousand, in conformity with the recommendations. The percentage of invasive cancers < or = 10 mm was of 24.3 whereas percentages of in situ cancers and of cancers without ganglionic invasion were respectively of 7.7% and of 50.0%. CONCLUSIONS: The weakness of our study lay primarily in the rate of participation which remained weak. The methodology adopted for the sensitizing of the women is proven not very effective and did not allow inviting all eligible women. Results of the study are encouraging in spite of its limited impact and made it possible to detect an important rate of cancers of which cancers infra-private clinics.

[Preliminary results and analysis of the feasibility of mammographic breast cancer screening in women younger than 50 years of the Ariana area in Tunisia]. / Résultats préliminaires et faisabilité du dépistage mammographique du cancer du sein chez les femmes de moins de 50 ans du gouvernorat de l'Ariana en Tunisie.

OBJECTIVE: To report the preliminary results of the feasibility of breast cancer mammographic screening among women younger than 50 years from the l'Ariana state of Tunisia. MATERIAL AND METHODS: The National office of the Family and Population (ONFP) launched a protocol on feasibility of breast cancer mammographic screening targeting asymptomatic women aged 40-69 years, from the l'Ariana state in Tunisia. We practiced two oblique and face incidences at the mammography screening unit of the ONFP, whose equipment and control system of quality answered to the European Communitiy for breast cancer screening. RESULTS: We did 5325 mammograms between April 2004 and March 2006. Our targeted population had a 48.9 years mean age (CI 95% = [48.7-49.1]), 60.3% of them younger than 50 years. There were more young women with high breast denisty (8.2%) compared to the group from 50 to 69 years (2.1%). The women arising from the 40-49 years cohort had a socio-economic and educational level higher. The complementary rate of examination/explorations was higher in this cohort (19.5%) vs 11.5% for the 50-69 years. The youngest women presented a more often positive test (7.0 vs 5.2%) than the oldest women (p<0.01). CONCLUSION: The option to screen breast cancer by mammography in women younger than 40 years in Tunisia is partially justified by the relatively high frequency of this cancer in this age group. Our feasibility poorly useful in screening will be used to sensibilise females to the problematic of breast cancer to obtain a better compliance compared to the older age group of 50-59 years.

[Management of breast cancer detected by a mammography program in the Ariana area of Tunisia]. / Prise en charge des cancers du sein issus du programme mammographique du gouvernorat de l'Ariana en Tunisie.

OBJECTIVE: To report the epidemiological and anatomoclinical features of breast cancers referred to a department of gynecology from the screening program of l'Ariana state in Tunisia. MATERIAL AND METHODS: A longitudinal retrospective Study was done over a period of 4 years (2004-2006 ) at the unit "A" gynecology department of the maternity of Tunis. We collected all the cases with histologically confirmed breast cancer diagnosed within the mammography screening program of l'Ariana state, referred to our unit for treatment. RESULTS: 10 patients with histologically confirmed breast cancer were collected during the study period, treated at our unit. Mean age of patients was of 48.8 years. Clinical examination was initially negative in 50% of cases. Mean clinical tumor size was 18 mm, while invasive ductual carcinoma represents the most frequent histological type. One patient (10%) had histological axillary involvement. Conservative surgery was performed for 8 (80%) of the 10 patients. CONCLUSION: This pilot study of mammography screening confined to a Tunisian state, precludes to the future profile of BC In Tunisia, showing that an early diagnosis can lead to a dramatic reduction of mean clinical tumor size, less histological poor prognostic features, more conservative surgery and a slight improvement of survival. A structured extended screening program must be installed to achieve these goals but requires an important financial and human investment.

[Surgical treatment of breast lesions: preliminary results of the screening program of the Ariana area]. / Traitement chirurgical des lésions mammaires infracliniques: résultats préliminaires du programme de dépistage de l'Ariana.

OBJECTIVE: To report clinical, radiological and histological characteristics of the infraclinical breast lesions patients recruited via the large scale mammography breast cancer screening of l'Ariana state in Tunisia. MATERIALS AND METHODS: Retrospective study over a period of 2 years. The recruitment of patients made on the occasion of the program of breast cancer screening. RESULTS: During this period, 22 patients in our unity had had a surgical excision after wire localization. Ten patients were recruited by means of systematic breast cancer screening. In these cases, the mammographic findings were classified B.I.R.A.D.S 4 in 7 cases and BIRADS type 5 in 3 cases. Definitive histology concluded to benign disease in 4 cases and malignancy 6 cases. This collaboration enables the diagnosis an invasive ductal carcinoma in three cases. CONCLUSION: The surgical excision after wire localization for non palpable breast lesions allows diagnosis of high-risk benign lesions and low-stage breast cancer. It is a reliable technique which indications have to be based on clinical and radiological strict criteria. This procedure is at present, and in developed countries, widely outstripped with the stereotactic core needle biopsy.

[Patient satisfaction of women involved in the pilot program of large scale mammography in the Ariana area of Tunisia]. / Enquête de satisfaction auprès des femmes du projet pilote de dépistage du cancer du sein du gouvernorat de l'Ariana en Tunisie.

OBJECTIVE: Evaluate the degree of satisfaction of women included in the large scale mammography program of breast cancer screening in the state of Ariana in Tunisia. MATERIAL AND METHODS: [corrected] Within the women explored by mammography, we have contaced 112 patients who had a positif screening requiring histological checking. We have established a questionnaire concerning: the invitation, the clinical examination, the result announcement and the therapeutic management. RESULTS: The average age of patients was 49 years. 64% had a primary education level. 80 women or 71.4% were satisfied with the process of screening and the method of announcement. The main cause of dissatisfaction for patients with cancer diagnosis was delay and difficult access to adjuvant treatments. Among patients who had histological diagnosis: 47.3% had a malignant disease (53 cases) against 37.5% of benign (42 cases). 100% of patients who had a pathological result reassuring are satisfied at the end of the screening program. DISCUSSION: The psychosocial impact of screening must be considered for the development of new programs. The waiting and announcement of results are essential factors that allow us to judge the success of the project, because of patient satisfaction will depend the quality of monitoring and adherence to screening.

Implementing a quality improvement programme in a family planning centre in Monastir, Tunisia.

We aimed to improve the quality of family planning and reproductive health services in a family planning centre though implementation of a quality improvement programme. Clients were surveyed to identify quality-related problems. Health care teams then analysed the causes of the problems, developed solutions for 3 selected ones and established a quality assurance framework. The selected issues were: long waiting time at the centre; insufficient integration of family planning and reproductive health services; and lack of a holistic approach. The final phase was aimed at testing and implementing corrective measures.

Molecular typing of Salmonella enterica serovars Enteritidis, Corvallis, Anatum and Typhimurium from food and human stool samples in Tunisia, 2001-2004.

During the period from 2001 to 2004, a total of 72 isolates of Salmonella enterica serovars: Anatum (n=40), Enteritidis (n=18), Corvallis (n=8), and Typhimurium (n=6), of various origins (mainly food and diarrhoeagenic stool samples), were collected and further characterized by antibiotic resistance, plasmid analysis, and pulsed-field gel electrophoresis (PFGE). Forty-five isolates presented multidrug resistance to antibiotics. Among which one S. enterica serovar Anatum isolate was resistant to 11 antibiotics, and one S. enterica serovar Typhimurium DT104 isolate was resistant to eight antibiotics. Plasmid profiling identified eight plasmid profiles (with 1-5 plasmids) among the isolates, of which one plasmid profile (P01) was predominant. XbaI PFGE analysis revealed the presence of a predominant clone of the four studied Salmonella serovars circulating in Tunisia throughout the years 2001-2004.

Implementing a quality improvement programme in a family planning centre in Monastir, Tunisia

We aimed to improve the quality of family planning and reproductive health services in a family planning centre though implementation of a quality improvement programme. Clients were surveyed to identify quality-related problems. Health care teams then analysed the causes of the problems, developed solutions for 3 selected ones and established a quality assurance framework. The selected issues were: long waiting time at the centre; insufficient integration of family planning and reproductive health services; and lack of a holistic approach. The final phase was aimed at testing and implementing corrective measures

Carriage by the housefly (Musca domestica) of multiple-antibiotic-resistant bacteria that are potentially pathogenic to humans, in hospital and other urban environments in Misurata, Libya.

Using standard microbiological procedures, bacteria that are potentially pathogenic to humans were isolated from 150 houseflies collected in the Libyan city of Misurata (50 flies each from the Central Hospital, streets and abattoir). Salmonella spp., Yersinia enterocolitica and Edwardsiella tarda were isolated from flies collected on the streets and in the abattoir but not from those collected in the hospital. Shigella sonnei was detected in just one fly, which was collected in the abattoir. Of the flies collected in the hospital, streets and abattor, 42%, 42% and 32% were positive for Escherichia coli, 70%, 50% and 62% for Klebsiella spp., 2%, 20% and 10% for Aeromonas spp., 96%, 36% and 34% for Pseudomonas spp., 20%, 12% and 16% for Staphylococcus spp., and 24%, 22% and 18% for Streptococcus spp., respectively. When the antibiotic susceptibilities of the fly isolates were investigated, the Enterobacteria isolated from the houseflies collected in the hospital were found to be resistant to significantly more of the commonly used antibiotics that were tested than the Enterobacteria isolated from the flies caught in the streets or abattoir. Whatever the source of the flies from which they were collected, the Pseudomonas isolates frequently showed resistance to multiple antibiotics, with >50% each being resistant to at least 10 antimicrobial agents. Two isolates of Sta. aureus (both from flies collected in the hospital) were resistant to methicillin. The present study supports the belief that the housefly is a potential vector of multiple-antibiotic-resistant, pathogenic bacteria, including methicillin-resistant Sta. aureus, in the hospital environment. Given their mobility, it seems likely that houseflies carry such pathogens from hospitals to surrounding communities, and vice versa.

[Characterization of Escherichia coli strains isolated from man and seafood]. / Caractérisation de souches d'Escherichia coli isolées chez l'homme et dans le milieu marin.

The collection of 100 Escherichia coli strains isolated in clinical samples (30), healthy carriers (30) and seafood (40), was characterized by conventional tests on API 20 E gallery and on specific reactive media. These strains were examined by full biotyping with 10 tests, serotyped using 12 monovalent sera and tested with 11 antibiotics. Six persons harboured higher percentages of resistant E. coli strains than seafood. Primary and secondary biotypes based on the use of four primary tests and six secondary tests were prospected. The most frequently encountered primary biotypes were: biotype 1 (42%), 11 (16%) and 9 (12%). These biotypes belonged to 32 secondary biotypes and 43 complete biotypes. The pathogenic serotypes isolated during this survey were O126B16 (3%), O26B6 (2%), O119B14 (2%), O86B7 (2%), O111B4 (2%), O55B5 (1%), O114K90 (1%) and O128B12 (1%). Two strains of E. coli were enteroinvasive by the test of Sérény. Results suggested that these typing methods may be used for discriminating strains of E. coli.

Influence of host related factors on the antibody response to trivalent oral polio vaccine in Tunisian infants.

The low efficiency of trivalent oral polio vaccine (TOPV) in inducing protective antibody titres to polio3 is a problem of great importance in many regions of the world. A prospective study was conducted in 121 Tunisian infants aged 3 months during routine immunization with TOPV under carefully controlled conditions. Seroconversion rates to polio1, polio2 and polio3, one month after the third dose, were 94.7, 100 and 89.5%, respectively. The kinetics of the antibody response showed delayed and more difficult responses to polio3 compared to polio2 and polio1. The following host related factors, previously suggested to interfere with the immune response, were assessed: maternal antibodies; breast-feeding; concurrent enteric infections; and other illnesses. The main factor associated with the lack of seroconversion was concurrent infection with non-polio enteroviruses (NPE) which was found in 50% of non-responders to polio1 and/or to polio3 during the vaccination protocol whereas no NPE was isolated in vaccine responders. The other studied factors seemed not to interfere in the infants according to the locally adopted vaccination schedule and to the specific socio-economic conditions.

[Salmonella isolated from food products of animal origin between 1989 and 1993 in the town of Tunis]. / Salmonelles isolées de denrées alimentaires d'origine animale entre 1989 et 1993 dans la ville de Tunis.

Among 260 strains of the genus Salmonella isolated by the "laboratoire de la municipalité de Tunis" from red meats or poultry sampled from public stores or slaughterhouse in Tunis township between 1989 and 1993, S. Agona, S. Enteritidis and S. Corvallis are the most frequent serovars. S. Agona is more frequent in food from bovine and equine origin, S. Enteritidis in poultry (phage type 35, "french classification", being more frequent). S. Corvallis ("new" serovar in Tunisia) is rather proceeding from turkeys.

[Etiological study of acute gastroenteritis in children in Tunisia]. / Etude étiologique des gastroentérites aiguës de l'enfant en Tunisie.

This study was aimed at identifying the relative importance of the various agents responsible for gastroenteritis and to contribute to the etiopathogeny of this condition. Four hundred and two samples of stools of patients and 209 of control subjects, all under 3 years of age, were submitted to bacteriological, parasitologic and virologic examinations. An enteral etiology of gastroenteritis was found in 50% of the children. It consisted of enteropathogenic bacteria in 11%, rotaviruses in 29% and both associated in 19% of cases. There was a significant difference between patients and controls for bacterial (p less than 0.0001) and viral (p less than 0.00001) infestation. The most frequently isolated bacteria consisted overall of Escherichia coli. Eighty-seven isolated strains of E. Coli were tested for their enterotoxinogenic capacities. Four strains were bearing the attachment factor (EAF) and 14 were toxinogenic. Shiga-like toxin (or vero toxin) was detected in 4 strains. Campylobacter was isolated as frequently in patients as in controls and was often associated with other bacteria or rotaviruses. The presence of parasites and candidas was not significantly different in patients and in controls. Giardia intestinalis was the most frequently isolated parasite.

[Escherichia coli in acute diarrhea in a population of infants]. / Escherichia coli dans les diarrhées aigues d'une population de nourrissons.

The incidence of Escherichia coli EPEC and ETEC had been studied on 555 infants from Tunis area. 193 of them do not present any diarrhea. Frequency of EPEC is 9.14% in infants with diarrhea and 3.10% in the group without diarrhea. Analysis of 87 Escherichia coli strains using genetic probes showed that 4 EPEC strains present effacing attachment factor (EAF) and one EPEC strain produce verotoxin. The frequency of ETEC isolated is 18.05%, the majority of them produced ST enterotoxin. Only colonization factor antigen I (CFAI) was found in ETEC strains.