[Neisseria meningitidis invasive infections in children in Tunis: about 79 cases]. / Les infections invasives a Neisseria meningitidis chez l'enfant a Tunis : a propos de 79 cas.

We conducted a retrospective study of meningococcal invasive diseases (MID) contracted in children in Tunis between January 1997 and January 2006. The purpose of this study is to specify the clinical, epidemiological, therapeutic and evolutionary features of these infections and to determine antimicrobial susceptibility and the antigenic formula of N. meningitidis isolates. During the study period, we have collected 79 cases of MID arising in children aged 3 days to 11 years. The majority of children's were less than of 4 years (57.3%). We note a frequency of the MID in winter and in spring. The most frequent clinical shape was meningitis (53%). Twenty one patients (26.6%) had a fulminant meningococcal disease. In our series, the rate of lethality was equal to 17.7%. Among the 46 meningococcal isolates, the most frequent serogroup was the B (73%) followed by C and A. A high heterogeneousness of the antigenic formulae was observed The most frequent phenotype was NT: NST for the group B isolates and 4:P1.13 for the group C ones. N meningitidis with reduced susceptibility to penicillin and to amoxicillin account for 54% and 10% of all isolates respectively. The cefotaxim and the rifampin were uniformly active.

[Imported malaria in Tunisia: consequences on the risk of resurgence of the disease]. / Paludisme d'importation en Tunisie: conséquences sur le risque de réintroduction de la maladie.

Although malaria has been eradicated in Tunisia since 1979, the disease is still a health issue due to the persistence of mosquitoes and coexistence with a potential parasite reservoir in the form of imported cases. From 1999 to 2006, 98 cases of imported malaria were diagnosed at the Pasteur Institute in Tunis where nearly 30% of national cases are recorded. Tunisians accounted for 24.5% of these cases versus 75.5% involving foreigners. The occurrence rate has steadily increased in volunteer workers, businessmen, diplomats and athletes who together accounted for 41.7% of cases in 1995 as compared to only 17.4% in 1980 (p<0.01). Most cases (96.5%) were imported from sub-Saharan Africa. The most frequent countries involved in importation were Cote d'Ivoire (23 cases) and Mali (8 cases) that are now linked to Tunisia by regular flights. About one third of patients were asymptomatic at the time of diagnosis. This finding underlines the importance of recommending systematic screening in high-risk groups. Fever (70.6%) and gastro-intestinal manifestations (27.9%) were the most frequent clinical findings in the 69 symptomatic cases. Plasmodium falciparum (71.4%) was the most common species followed by Plasmodium ovale (19.4%). Gametocytes were detected in 9.2% of subjects, thus creating a theoretical source of infection for mosquitoes especially since 60.2% of all cases were recorded between June and October when mosquitoes are active in Tunisia. Due to increasing exchange with endemic malaria areas in Africa that has resulted in a higher incidence of imported cases and a futher risk of introduction of tropical mosquito species as well as to global warming that promotes plasmodium transmission, greater vigilance is necessary to ensure eradication of malaria in Tunisia.

[Distribution of surgical hydatidosis in Tunisia, results of 2001-2005 study and trends between 1977 and 2005]. / L'incidence chirurgicale du kyste hydatique: en Tunisie: resultats de l'enquete 2001-2005 et tendance evolutive entre 1977-2005.

We have performed an exhaustive retrospective study in all surgical wards (54 services in 35 hospitals) which usually carry out surgical treatment of hydatic cysts in the country, covering the period between January 2001 and December 2005, in order to determine the annual surgical incidence of human cystic hydatidosis in Tunisia. A total of 6249 surgical interventions were recorded during the period 2001-2005. The highest proportion was recorded in the hospitals of Tunis District (42.9%). The service of thoracic surgery from Ariana hospital occupies the first rank (95%). The yearly incidence rate varies between 11 and 13.6 per 100,000. Calculated over the 5 years period, the incidence rate is 63.2 per 100,000 inhabitants, which means an average yearly incidence rate of 12.6 per 100,000 [12.28-12.99]. Governorates of the North West and the Western Central regions of the country are the most endemic area with an average annual incidence rates varying between 19.2 and 33.9 per 100,000, which is at least once and half higher than the national level. After 30 years (1977-2005), the average annual incidence rate slightly dropped, from 15 to 12.6 per 100,000, proving that such zoonosis remains a problem of public health in Tunisia. In order, to control in more or less short term this heavy burden disease and public health expenditure, the only efficient way is the prevention of the diseases with a mass treatment campaign of dogs, principal host of the parasite.

[Neonatal screening of G6PD deficiency in Tunisia]. / Depistage neonatal du deficit en G6PD en Tunisie.

The Glucose-6-phosphate dehydrogenase (G6PI) deficiency is the most common enzymopathy worldwide. WHO had classified Tunisia among countries that are moderately affected by this affection. However, no mass-screening reflecting the real incidence was realized. The aim of this study is to determine the prevalence of this enzymopathy and its molecular basis in Tunisia. A total of 1102 neonates, born in CMNT center of Maternity and of Neonatology of Tunis during the going periods from April, 2005 till May, 2005 and from June, 2006 till September, 2006, have been enclosed in the study. The samplings included 953peripheral venous blood and 149 blood cordon. Among 1102 samplings, only 976 were of use to the screening. In our mass-screening, we consider all newborns that were born in the CMNT during the period of study and were included in the screening. A dosage of the enzymatic activity was realized using spectrophotometric method. G6PD electrophoresis and molecular study by PCR/RFLP were realized for the overdrawn newborn children. Among 976 screening neonates, 43 individuals (4.4%) were found to be G6PD deficient by quantitative enzyme assay. Newborn affected were distributed in 23 boys and 20 girls (sex ratio of 1.15). The electrophoretic mobility and the molecular biology were realized for the affected newborn. Molecular characterization of 30 G6PD deficient neonates revealed that the G6PD A- was the most common and was detected in 20 of 43 individuals (66.7%), followed by G6PD Mediterranean that was detected in 6 (13.3%). At least, 4 other unknown mutations were not able to be determined by PCR/RFLP (n=4). In conclusion G6PD deficiency is frequent in our country, justifying a systematic neonatal screening, to avoid the arisen of grave consequences of this affection. The African variant is the most frequent in our country followed by the Mediterranean one.

[The current risk factors for hydatidosis in Tunisia]. / Les facteurs actuels d'endémicité de l'hydatidose en Tunisie.

Hydatidosis is a major public health problem in Tunisia. The presence of numerous stray dogs, widespread practice of sheep rearing and frequent slaughter of animals outside slaughterhouses are the main risk factors for spread of this zoonotic disease. Human behaviour associated with poor understanding of the parasite life cycle also has a negative impact. Health education is crucial for effective control. It should emphasize the damaging effects of uncontrolled slaughter, the exact role of dogs in parasite transmission and above all the need for adequate measures to sterilize infested viscera.

[Epidemiology of Leishmania (L.) infantum, L. major and L. killicki in Tunisia: results and analysis of the identification of 226 human and canine isolates]. / Epidémiologie de Leishmania (L.) infantum, L. major et L. killicki en Tunisie: résultats et analyse de l'identification de 226 isolats humains et canins et revue de la littérature.

The epidemiological situation of leishmaniasis in Tunisia is characterised by the co-existence in a very limited territory (165,000 km2, Sahara included), of 4 clinical forms: the infantile visceral leishmaniasis (VL) and 3 cutaneous leishmaniasis (CL) forms (sporadic, zoonotic and chronic). In addition to the useful epidemiological data, identification of the causative parasitic species is essential to determine the geographic distribution of each form and to select appropriate therapeutic procedure and suitable control measures. 226 Leishmania isolates, 135 human's coming from 59 VL cases and 76 CL cases and 91 canine's were identified by the isoenzyme electrophoresis reference technique. Results confirm the endemicity of the 4 forms mentioned above. The sporadic CL, confined to the North of the country is principally caused by L. infantum MON-24 (72.2%). VL which has reached the southern ridge in the central area of Tunisia, in the governorate of Kairouan (36 typed isolates), presents an unusual high proportion of L. infantum MON-24. In fact, this zymodeme, rather dermotropic is responsible for 47.2% of the cases vs 13% in the other regions of the country where L. infantum MON-1 remains predominant with 78.3% of typed isolates, the difference being statistically significant (P < 0.01). A third zymodeme, L. infantum MON-80 is sporadically pointed out during VL or in sporadic CL. Despite the high number of canine isolates (n=91) coming from 6 governorates, only the zymodeme L. infantum MON-1 was identified, letting hypothetic the reservoir of the 2 other zymodemes of the species identified in humans. Those absences may be related to cross infections, with a low sensitivity to L. infantum MON-24 leading to a selection of MON-1 at the time of culture passages. Hence it is important to develop molecular tools of direct identification on initial biological samples without going through cultures. Zoonotic CL remains the predominant cutaneous form in the central and southern area of Tunisia. However L. killicki, agent of the chronic CL, is confirming its presence out of its original focus of Tataouine in the southern-east of the country in both zoonotic CL and VL areas.

Phlebotominae (Diptera: Psychodidae) of human leishmaniosis sites in Tunisia.

In order to identify the phlebotomine sandfly populations in Tunisian leishmaniosis foci, an entomological survey was carried out through three entomological seasons (2002-2003-2004) in 19 visceral and cutaneous leishmaniosis areas, located in six bioclimatic zones. Sandfly collections were based on light and sticky traps placed around human leishmaniosis cases. 8,722 phlebotomine sandflies belonging to 12 species were collected. The dominance of subgenus Larroussius species in northern foci, Phlebotomus papatasi in south-western foci and their co-dominance in the centre of the country is in accordance with the distribution of Leishmania infantum and L. major in Tunisia. The low density found in the historical zoonotic cutaneous leishmaniosis focus of Metlaoui in the south-west may indicate the high competence of the local populations. Studied phlebotomine settlements have showed a low specific diversity in most of the studied sites. In L. infantum areas, the dominant species were respectively: P. perfiliewi in the cutaneous leishmaniosis site of the humid bioclimatic stage, P. perniciosus in the cutaneous and visceral leishmaniosis foci of semi-arid and arid bioclimatic stages and P. longicuspis in the visceral leishmaniosis focus of saharan bioclimate. In the zoonotic cutaneous leishmaniosis foci, P. papatasi was a dominant species. In the well-known south-eastern foci of cutaneous leishmaniosis due to L. killicki, P. sergenti was a dominant species with P. perniciosus. In the central emerging foci of L. killicki, P. perniciosus was a dominant species in some sites whereas it was very rare in others. In these sites, the subgenus Paraphlebotomus was always present with a higher abundance of P. alexandri than P. sergenti.

[Sero-epidemiologic profile of toxoplasmosis in northern Tunisia]. / Profil séro-épidémiologique de la toxoplasmose au nord de la Tunisie.

Toxoplasma antibodies prevalence was studied in the north of Tunisia where a mild climate prevails. Two groups of individuals were investigated: 857 living in rural area and 564 living in urb town. Sera were analysed by ELISA and indirect immunofluorescence. The overall prevalence was 58.4%. It roses from 24.5% at ten years to 52.1% at 20 years of age. A maximum level, around 70%, was reached by about 30 years. The risk of acute infection after this age seemed low as judging by the proportion of high antibodies titers observed in this group (14.2% before 30 years vs 3.7% after). A significantly higher prevalence was detected in urban residents (67% vs 52.8%). In this group, the rate of seroconversion seems the highest between ten and 20 years of age and the majority of women are infected before reaching childbearing age. In the rural area, the seropositivity is lower between ten-20 years and many women at childbearing age still susceptible to toxoplasmosis. The risk of acute infection seems higher in the youngest ones as showed by the proportion of high antibodies titers observed in the 18-30 age group (9.2%) compared to the one observed after 30 years (1.9%).

[Receptivity of the Tunisian to malaria after its eradication: analysis of the situation for adequacy of the surveillance]. / Réceptivité de la Tunisie au paludisme après son éradication: analyse de la situation pour une adéquation de la surveillance.

In Tunisia, there has been no local transmission of malaria since 1979. Although the disease has been eradicated, its re-emergence is not considered impossible. An epidemiological evaluation has been conducted in order to evaluate the current level of receptivity. A. labranchiae and A. sergenti, the former vectors of malaria in the country, are still present and the anopheline population in the country is increasing following the building of dams and manmade lakes. It is hoped that Tunisian vectors are refractory to sub-Saharan strains of malaria parasites. According to the data collected regarding malaria history, climate, geography and socio-economic development, we assume that the receptivity level of the country is low and the risk of re-emergence of local foci is small.

[For a better estimation of the prevalence of intestinal parasitism in the Tunis region]. / Pour une meilleure estimation de la prévalence du parasitisme intestinal dans la région de Tunis.

The prevalence of intestinal parasitism is generally based on the results of a single stool specimen which probably underestimates the real situation. In order to propose a coefficient for correction, we examined three stool specimens taken from 112 asymptomatic children. Intestinal parasites other than Enterobius vermicularis were detected in 29 subjects (26%). For those specimens that tested positive, 41% of children had infection detected in all three stool specimens; 21%--in two specimens and 38%--in only one. If we assume that the sensitivity of three stool specimen examinations is 100%, then the calculated sensitivity of one examination is equivalent to 68%. This gives an underestimation of the prevalence of 32%. This underestimation is not homogenous for all species. As regards Giardia intestinalis it is 35%, but for other species it would have to be calculated from a larger sample.

[Imported malaria in Tunisia]. / Le paludisme d'importation en Tunisie.

Thanks to the national programme of malaria eradication carried out between 1968 and 1972, there has been no active transmission of the parasitosis in Tunisia since the last indigenous case in 1979. Since 1980, with the increase in international exchanges especially with sub-Saharian countries, only imported cases of malaria have been reported in Tunisia. A retrospective and thorough survey of malaria cases diagnosed in the laboratory of parasitology of the Pasteur Institute in Tunis from 1980 to 1995 determined the epidemiological characteristics of this imported parasitosis. All in all, during the sixteen years following eradication, 245 cases were registered. The majority of cases (86.2%) was diagnosed by a systematic control of groups at risk within the national programme of malaria eradication. The remaining 13.8% cases sought medical advice when clinical symptoms appeared after their return from endemic countries. The population most affected by imported malaria were men (sex-ratio: 6.8) aged between 20 and 40 years (76% of cases); 38% were Tunisians having sojourned in an endemic country, essentially students from sub-Saharian Africa. The presumed country of contamination was African in 92.7% of the cases. Entrance into Tunisia by patients was mainly by air; 4% of the registered cases had come by land from Algeria. Sound knowledge of the epidemiological characteristics of imported malaria would make for a better follow-up of the affected population and thus reduce the probability of repeated transmission.

[Availability and use of emergency services in Tunisia: principal results of an exhaustive national survey]. / L'offre et l'utilisation des services d'urgence en Tunisie : principaux résultats d'une enquête nationale exhaustive.

In order to assess hospital emergency rooms, a comprehensive national epidemiological investigation was conducted in all 155 public emergency structures in Tunisia. Here we present the main results of the levels of availability and use of emergency services. Coverage of the population by services is adequate (one emergency service per 60,000 people). Emergency wards admit about 2,500,000 patients every year (a quarter of the population of the country). The university hospital emergency services are the most heavily used (150 patients per day on average). Emergency services are sought for medical (60%), surgical (18%), paediatric (14%) and gynaecological reasons (5%). It would be useful to assess the quality of care delivered and the satisfaction of citizens and health workers.

[Role of direct agglutination test (DAT) in the diagnosis of visceral leishmaniasis in Tunisia]. / Apport du test d'agglination directe (DAT) dans le diagnostique de la leishmaniose viscerale en Tunisie.

Direct agglutination test (DAT) is a simple ans economical technique for visceral leishmaniasis diagnosis. An evaluation, held in Tunisia with 41 confirmed visceral leishmaniasis cases and 58 negative controls, showed a sensitivity of 95.1% and a specificity of 96.5%. These results were highly correlated with those of ELISA and fluorescent antibody test. The use of DAT in our country will be very relevant, mainly in district hospitals, where others classical tests are not available. It will also be useful during sero-epidemiological studies on both human and canine visceral leishmaniasis.

[General physicians and general medicine: social image and public opinion]. / Médecin généraliste et médecine générale: image sociale et représentation de la population.

During the last two decades, importance of general practice of medicine was more recognised. The kind of interest was different between Health decision makers and population. For Health decision makers, revalorisation of general medicine is the better solution we could develop in order to improve efficiency of the health care financing systems. However, From the side of population social image of the general physician is going down. In order to investigate the population view point about general practitioner, we conduct a trial next to 289 persons living Tunis area. Peoples recognized to the general practitioner some qualities: Useful for first aid, he integrates all aspects of the morbidity, initiates best relations with his patients and appropriately manages medical files. In the other side, He's less qualified than the specialist to take appropriate decision, for monitoring and for the quality of communication with patients. He' also lack of technicality and investigation procedures. Ours results indicate how it is urgent to lead a reform of teatching of general medicine in the country.

[Are there health risks for travel among Tunisians? What type of medical care should be assured?]. / Le voyage du tunisien à l'étranger y-a-t-il risque pour la sante? Quel type d'encadrement médical faut-il assurer?

The present work aims to assess the importance of the international travels of Tunisians, their destinations, the risks they face as well as the means to reduce them. Therefore, data related to the period from 1989 to 1998, were collected from official organisms involved in this area. Results revealed an increase of the number of Tunisians travelling outside the country of 23% between 1989 and 1998, with a mean progress of 5.7% per year since 1993. Main destinations were Maghrebin countries (65.7%), Europe (30%) and Middle East (4%). The number of persons leaving to high risk destinations remains difficult to assess and shows the importance of implementing a surveillance system to insure an adequate medical follow-up of this category of travellers. The structures actually involved in the health management of Tunisian travellers have a weak recruitment which demonstrates the importance to strengthen the sensitization of general practitioners to this subject and the promotion of the immunization ward of "Institut Pasteur" to a national centre of travelling medicine.

[Importance of amastigote forms morphology to differentiate Leishmania infantum and Leishmania major species]. / Apport de la morphologie des formes amastigotes dans la différenciation des espèces Leishmania infantum et Leishmania major.

The microscopic study of the dermal smears of 62 cases of cutaneous leishmaniose, 27 infected by Leishmania (L.) infantum and 35 by L. major, showed that the amastigotes of L. infantum are meaningfully smaller (p < 0.001). This criteria is a simple pary alternative to distinguish these 2 species which have completely different epidemiology, recovery delay and prophylactic dispositions.

[Efficacy of intra-lesional glucantime in the treatment of zoonotic cutaneous leishmaniasis in basic health care conditions]. / Efficacité du traitement de la leishmaniose cutanée zoonotique par le glucantime en intra-lésionnel, dans les conditions des soins de santé de base.

A randomized placebo-controlled trial treating cutaneous lesions due to Leishmania major with intralesionnel glucantime, was conducted in El Guettar between december 1994 and June 1995, in order to assess efficacy of this therapy under field conditions. It included 109 patients: 52 were administrated glucantime and 57 received local treatment (eosin 5% and alcohol 95%). Prognostic factors were similar in both groups. Results did not reveal a significant difference between glucantime and eosin regarding the rapidity of the healing of lesions. However, scars seem to be of better quality among the glucantime group. Bacterial super infection was noticed among 57.6% of humid lesions sampled among 33 patients. Isolated strains included group A streptococcus (22%), staphylococcus aureus (16.7%) or an association of both agents (61.1%). Resistance profile indicated that streptococcus and staphylococcus respond well to macrolids compared to other antibiotic groups.

[Availability and use of emergency services in Tunisia: main results of a comprihensive national survey]

In order to assess hospital emergency rooms, a comprehensive national epidemiological investigation was conducted in all 155 public emergency structures in Tunisia. Here we present the main results of the levels of availability and use of emergency services. Coverage of the population by services is adequate [one emergency service per 60,000 people]. Emergency wards admit about 2,500,000 patients every year [a quarter of the population of the country]. The university hospital emergency services are the most heavily used [150 patients per day on average]. Emergency services are sought for medical [60%], surgical [18%], paediatric [14%] and gynaecological reasons [5%]. It would be useful to assess the quality of care delivered and the satisfaction of citizens and health workers