Epidemiology and medical cost of hospitalization due to rotavirus gastroenteritis among children under 5 years of age in the central-east of Tunisia.

Data on the economic burden of rotavirus infection in Tunisia are needed to inform the decision to include rotavirus in routine childhood immunizations. This study aimed to describe the epidemiological profile of rotavirus disease in central-east Tunisia and to estimate its hospital cost. In the first stage - the prospective collection of epidemiological data - we enrolled all patients < 5 years old who were hospitalized for acute diarrhoea at 5 university paediatric departments in central-east Tunisia during the period 2009-2011. Rotavirus was responsible for 65 (23.3%) of the 279 cases enrolled. In the second stage, cost data were collected retrospectively using an activity-based costing method from the medical records of the children who were positively diagnosed with rotavirus. The average cost of care per child was TD 433 (SD 134). This is a significant economic burden in Tunisia, where a safe and effective vaccine is available but not yet introduced to the immunization schedule.

Epidemiological and chronological profile of preterm birth in the region of Monastir (Tunisia) between 1994 and 2012.

Data about the profile and risk factors of premature births in Tunisia are scarce. The objective of this study was to describe the epidemiological profile of preterm births in Monastir, Tunisia, and to study the chronological trends of associated factors over the years 1994-2012. A population-based study was conducted using data from the regional births database on all deliveries in public maternity units. The overall prevalence of preterm births among the 161 116 deliveries in the 19-year period was 5.60% (95% CI: 5.13%-6.07%). The rate of preterm births and of adequate prenatal care increased significantly over the study period. Extremes of maternal age (≤ 19 and ≥ 35 years), having a twin pregnancy and the occurrence of complications during pregnancy were significant predictors of prematurity in the final regression model. Efforts should be made to improve the quality of health care in the region, especially for high-risk pregnancies.

[Profile and trends of pediatric hospital morbidity in the region of Monastir (Tunisia) for a decade]. / Profil et tendances de la morbidité hospitalière pediatrique au niveau de la region de Monastir (Tunisie) pendant une décennie.

INTRODUCTION: Hospital morbidity studies allow us to draw the hospital pathological profile of a region and to follow its evolution. This study aims to describe the profile and the main trends of pediatric diseases within public structures in the region of Monastir between 2000 and 2010. MATERIEL AND METHODS: A descriptive study which concerns all pediatric hospitalizations of public structures in the region of Monastir between 2000 and 2010. Informations were collected from the regional register of hospital morbidity implanted at the Department of Preventive Medicine and Epidemiology of the University Hospital of Monastir. RESULTS: A total of 52.443 hospitalizations were collected between 2000 and 2010 with a means annual hospitalization rate of 3,9 %. The mean age was 7,2 ± 5,4 years and 15,3 % had not exceeded the first year of life. Major diagnostic categories (MDC) were dominated by diseases of the digestive and respiratory systems with 14,4 and 14 % respectively. Main chronological trends have shown that the rate of childhood asthma rise significantly from 0,2 %. in 2000 to 2,5 %. in 2010 and Hydatid Cyst whose rate increased also from 0,2 %. in 2000 to 1,8 %. in 2010 (P < 0,05). CONCLUSION: This morbidity profile incites managers to focus their efforts to improve the management of most important diseases.

[Integrated management of mother and child health in the region of Monastir (Tunisia)]. / Piese en charge intégrér de la santé de la mere et de L'Enfant dans la région de Monastir (Tunisie).

The programme of integrated management of child health (IMCI) was established in Tunisia in 2002 in some health districts. This study evaluated the management of children under 5 years of age and their mothers using the IMCI programme in Zeramdine, a town 20 km south-west of Monastir. A cross-sectional study was conducted on a convenience sample of 526 medical records of children under 5 years attending the Zeramdine maternal and child health centre. The study evaluated preventive and curative aspects of child health. The mean age was 21.9 (SD 16.7) months. On the curative side, respiratory diseases were the leading reason for consultation (71.2%) followed by diarrhoea (15.4%). For preventive services, physicians systematically checked the child's immunization status and height and weight on the growth charts, and screened for strabismus and anaemia. The contribution to child health of IMCI is undeniable; it allows comprehensive care of the child, develops staff skills, upgrades the health system and improves family and community practices.

Epidemiological profile of health-care-associated infections in the central-east area of Tunisia.

This study aimed to estimate the prevalence and risk factors for health-care-associated infection (HAl) in all 9 hospitals of the central-east area of Tunisia in 2005. Of 1373 patients admitted for more than 48 hours, 74 developed HAI, a prevalence of 5.4% (95% CI: 4.2%-6.6%). The prevalence was significantly higher in the intensive care units (18.4%) and neonatal departments (12.7%). There were 79 infections and the most frequent sites of infection were respiratory tract and urinary tract. Microbiological examination was performed for 25 cases of HAl and Pseudomonas aeruginosa was identified in 8 cases. Multiple logistic regression analysis indicated that HAl was linked to diabetes (OR = 2.0), immunosuppression (OR = 3.3), length of stay (OR = 4.5), central venous catheter (OR = 2.5) and peripheral venous catheter (OR= 10.2). We conclude that HAls are of concern in this area of Tunisia.

[Epidemiological and chronological profile of the low birth weight in the region of Monastir (Tunisia) between 1994 and 2007]. / Caractéristiques épidémiologiques et chronologiques du faible poids de naissance dans la région de monastir (Tunisie) entre 1994 et 2007.

In Tunisia, despite the activities of national programs of maternal and child health, low birth weight (LBW) remains common. The aim of this study is to draw up the epidemiological profile of the LBW in the region of Monastir and to study the chronological trends of the associated factors during a period of 14 years (1994-2007). We conducted a population study which interest 97.630 live births (from 26 to 43 weeks) in the public maternities of the region of Monastir. The mean's age of pregnant women was 28.7 +/- 5.5 years. Among them 14.2% were aged 35 and older and 40% were primipara. Newborns were in term in 94.7% of cases. Maternal age, prenatal care, twin pregnancies and fetal complications were the factors independently associated with the occurrence of LBW in term newborns. However, only prenatal care and twin pregnancies were independently associated to LBW in preterm newborns. During the fourteenth years of the study the parturient mean age and the frequency of preterm birth increased significantly (P < 0.001) while the frequency of multiparty decreased significantly (P < 0.001). We found that the risk factors of LBW (advanced age, multiparty, etc.) are still common in our country and require targeted interventions.

Comparison of Two Different Methods for the Extraction of Outer Membrane Vesicles from the Bordetella pertussis as a Vaccine Candidate.

Despite the availability of a vaccine, pertussis is still a worldwide health problem. Outer membrane vesicles (OMVs) in gram-negative bacteria can stimulate the immune system due to several outer membrane proteins and are very good candidates in vaccine development. OMVs obtained from Bordetella pertussis contain several antigens, which are considered immunogenic, and could make them a potential candidate for vaccine production. The current study aimed to compare the current OMV extraction method (with ultracentrifuge) and a modified extraction method (without ultracentrifuge) and to evaluate the physicochemical properties as well as the expression of their main virulence factors. Vaccinal strain BP134 grown on Bordet Gengo agar were inoculated in Modified Stainer-Scholte medium for mass cultivation. OMVs were prepared using two different methods. They were then stained and examined with a transmission electron microscope. Protein contents were measured by the Bradford method, and then the protein profile was evaluated by SDS-PAGE. The presence of immunogenic antigens was detected by Western blotting. The size and shape of the OMVs obtained from the modified method without the use of ultracentrifuge were similar to the current method and had a size between 40 and 200 nm. The total protein yields of the OMV isolated using the current and modified methods were 800 and 600 µg/ml, respectively. Evaluating the protein profile of extracted OMVs showed the presence of different proteins. Finally, the presence of PTX, PRN, and FHA was observed in OMVs extracted from both methods. Comparison of the two OMV extraction methods showed that the obtained vesicles have a suitable and similar shape and size as well as the expression of three important pathogenic factors as immunogens. Despite the relatively low reduction in protein yield as the modified method does not require ultracentrifuge, this extraction method can be used as a suitable alternative for extracting the outer membrane vesicles from B. pertussis, especially in developing countries. It should be noted that further experiments including immunogenicity determination of OMVs obtained as vaccine candidates in animal models are required.

Graphic model of birth weight and gestational age in Monastir, Tunisia.

BACKGROUND: Birth weight for gestational age curves provide to clinicians available references to assess fetal growth in individual infants and in populations. In Tunisia, until now, only North American based references were used. The objective of this study was to create national reference curves for birth weight and to compare these to those actually used in our maternities. METHODS: A retrospective population based study was performed over a period of 11 years (from January 1994 to December 2004) using the register of births database of the region of Monastir. We studied a total of 75,751 births. Gestational age of infants ranged from 28 to 43 weeks. Fifth, tenth, 25th, 50th, 75th, 90th and 95th percentiles for weight were calculated by polynomial linear regression of the following general form to construct the clinical curves (Y=a+bX+cX(2)). RESULTS: The database included 38,646 males and 37,105 females (sex ratio: 1.04). The resulting male and female curves provide smoothed percentiles cutoffs for defining small and large for gestational age births. An actual difference does exist between our curves and those routinely used. CONCLUSION: These constructed smoothed gestational curves can be used as a useful tool for assessing birth weight and to evaluate clinical or public health interventions to enhance fetal growth.

[New criteria and quality of health care services in the governorate of Monastir, Tunisia]. / Les nouveaux critères et la qualité des services de soins de santé dans le gouvernorat de Monastir (Tunisie).

In 2005 new quality criteria (7 items) were introduced for services provided to mother and child under the national perinatality programme. We evaluated this new version in a descriptive study conducted among a random sample of 400 parturient women from Monastir governorate. Mean age was 29.3 (SD 5) years and 42% were primipara. Although prenatal care was adequate in terms of number of antenatal visits for 82.5% of women, for only 21% were all 7 quality criteria fulfilled. The rates of caesarean section and premature birth were significantly higher in women who received quality care (P < 0.05). In logistic regression analysis, age and parity were the only factors independently associated with the quality of care. Additional efforts are needed to ensure good maternal and infant quality of care.

[Paramedical staff knowledge and practice related to the blood transfusion safety]. / Connaissances et pratiques du personnel soignant en matière de sécurité transfusionnelle.

Blood transfusion is a complex activity, involving many actors. It is a high risk activity which couldn't be controlled without the use of specific methods. Health care workers beliefs and organisational factors are two major issues for the blood transfusion safety. Our study objectives were to describe the paramedical staff's knowledge and practice regarding blood transfusion safety and to identify factors that are related to them. We carried out a cross sectional study. The information was gathered by using a questionnaire. The latter was developed by foreign teams and adapted to the local context. Two outcome measures were used: the knowledge and practice score and the proportion of true answers. The study showed that only 15% of the interviewed persons have had a score less than 30 (scale range from 0 to 100), i.e. only 15% have had appropriate knowledge and practice with no negative consequences for the patient safety. 13.8% of the study population provided right answers related to the biologic exams required before red cells transfusion and 34% for the abnormal reaction circumstances. These results underscores the importance of strategies improving the quality and the safety of blood transfusion, i.e. the continuous medical education, implementing a blood transfusion information system and the use of transfusion practice guidelines.

[Analysis of the appropriateness of hospitalizations in Monastir, Tunisia]. / Analyse de la pertinence des hospitalisations dans la région de Monastir (Tunisie).

We aimed to measure the extent of inappropriate hospital admissions and to identify factors associated with inappropriate hospital use. A descriptive study was carried out on a randomized sample of 411 hospitalizations in 3 regional hospitals. The appropriateness of admissions was assessed using the Appropriateness Evaluation Protocol (AEP). We found 21% (95% CI: 17%-25%) of the admissions were avoidable according to the AEP. Inappropriate admissions were associated with the hospital (P = 0.005), patient age (P = 0.003), length of stay and diagnosis (P < 0.001). The most frequent reasons for appropriate admissions were parenteral therapy, an acute or progressive sensory motor circulatory or respiratory condition sufficient to incapacitate the patient and severe electrolyte or blood gas abnormality. Our study highlights the need to improve hospital management and to develop alternatives to hospitalization.

[Epidemiology of Haemophilus influenzae meningitis in Tunisia]. / Epidémiologie des méningites à Haemophilus influenzae en Tunisie.

The incidence of Haemophilus influenzae b meningitis (Hib) in children < 5 years in Tunisia was studied through a surveillance system set up in June 2000 and followed for 14 months. Population-based surveillance began in 3 governorates and sentinel surveillance in 2. Children < 5 years suspected of meningitis had lumbar puncture, macroscopic exam, blood count, chemical analysis and culture carried out. In the 14 months, 80 cases of meningitis were recorded. From the population-based surveillance most cases were children < 1 year (73.6%) and boys (64%). H. influenzae was isolated in 38% of cases, pneumococci in 13% and meningococci in 7%. The incidence of confirmed Hib was 14.4/100 000 children. The estimated cost of identifying and treating Hib meningitis and its complications was greater than the cost of vaccine introduction. Based this study, the Ministry of Health has decided to introduce Hib vaccination.

[Epidemiology of cholelithiasis in central Tunisia. Prevalence and associated factors in a nonselected population]. / Epidémiologie de la lithiase biliaire dans le centre de la Tunisie.

OBJECTIVES: The prevalence of cholelithiasis is still unknown in Tunisia. The aim of this study was to assess the prevalence and selected risk factors of cholelithiasis METHODS: Two thousand citizens over the age of 19 in a small town in the center of Tunisia were evaluated. Following a structured interview of each subject, an ultrasound examination was performed. Height, weight and blood levels of glucose and cholesterol were determined by standard methods. RESULTS: The response rate was 56% (746 women and 377 men). Of the 1123 persons evaluated, 19 had undergone previous cholecystectomy. Crude prevalence of cholelithiasis was 4% (5.4% in women and 1% in men). Typical biliary colic was the only symptom significantly associated with cholelithiasis (specificity: 97.6%). Presence of gallstones was associated with age (P=0.02), sex (P=0. 00045) and multiparity (P<0.0002). Neither body mass index, diabetes mellitus or hypercholesterolemia were risk factors. CONCLUSION: The prevalence of cholelithiasis in central Tunisia is low. The risk factors are similar to those in occidental surveys.

[Mother-child transmission of hepatitis B virus in the Tunisian Sahel]. / Etude de la transmission mère-enfant du virus de l'hépatite B dans le Sahel tunisien.

In order to assess the importance of mother-child transmission of the hepatitis B virus (HBV) in the Tunisian Sahel, 81 HBsAg-positive mothers have been selected at delivery in a representative sample of 1940 who delivered in maternities of this region. Each HBsAg-positive mother was matched for age and parity particularly with two HBsAg-negative mothers. Children born to these 66 HBsAg+ and 120 HBsAg- mothers were traced at 28 months and tested by ELISA for HBV serologic markers (HBsAg, anti-HBs and anti-HBc). The distribution of these markers was significantly different according to the maternal status for HBsAg. The overall prevalence rate of HBV markers was higher in children born to HBsAg+ mothers as compared to children born to HBsAg- mothers (33.3% vs 13.3%, OR = 2.5, 95% CI:1.4-4.2). For HBsAg, the figures were 27.3% and 9.2% respectively (OR = 2.9, 95% CI: 1.5-5.9). Given the prevalence rate of HBsAg in mothers (4.2%), the role of mother-child transmission in the spread of HBV infection and the intensity and precocity of horizontal transmission, systemic vaccination against HBV at birth should be recommended in the Tunisian Sahel in the context of the EPI. However this decision should take into account, in terms of cost/efficacy ratio, the other public health problems concerning this area.

[Sentinel surveillance of diarrhea in Ksar-Hellal (Tunisia)]. / Surveillance sentinelle de la diarrhée à Ksar-Hellal (Tunisie).

BACKGROUND: In order to simplify the national data collection related to diarrhea, a sentinel surveillance system was implemented in the Ksar-Hellal district (Tunisia). POPULATION AND METHODS: This system was based on 461 cases of diarrhea collected from health centers and hospitals between June 1994 and December 1995. RESULTS: The collected information confirmed the previous data provided by the national system: frequency of diarrhea in health centers (4.14%), occurrence of the disease especially in the summer period, rate of hospitalization (10%) and low proportion of severe dehydration. The system also gave some new information related to the proportion of persistent diarrhea (7.1%), the low frequency of malnutrition (11%) and the etiology. CONCLUSION: The sentinel surveillance system validates information previously provided by the National Surveillance System. It also gave new information not obtained by the classical surveillance system.

[Smoking behavior and attitude to smoking of medical students (Tunisian Sahel)]. / Comportement tabagique et attitudes des étudiants en médecine à Monastir en regard du tabac (Sahel tunisien).

Prevention of smoking is a public health goal recognized worldwide. Though the role played by physicians is an important one, data in the literature indicate that medical school is a poor place to learn it. In 1997, we conducted a study among medical students at Monastir Tunisia to examine their smoking behavior and attitudes towards smoking and their participation in prevention. The study included 93.3% (N = 501) of the students in their 1st, 4th and 5th years of medical school. One-third of the students (33%) were smokers, including 15% occasional smokers. The students recognized the effect of smoking on coronary arteries and bronchi but two-thirds of them were unaware of its role in bladder cancer. The students did not warn their patients unless they had a disease related to smoking. Half of the students felt they were not sufficiently prepared for caring for smokers and desired specific training. These findings suggest medical school authorities should design and implement appropriate basic training aimed at better preparing medical students for their role in prevention of smoking.

[Value of vaccination data analysis at the district level]. / Intérêt de l'analyse des données de vaccination à l'échelle du district.

This study aimed to demonstrate the importance of analysing local immunization data to improve performance of national prevention programmes. From the immunization registers kept in basic health centres, we identified 1271 children receiving their first vaccine at 3 months. Examination of the age at the subsequent vaccinations and time intervals between vaccinations showed that 81.9% had received all the vaccines required by the Ministry of Health but only 48.5% had received immunization meeting the requirements for age and time interval. The analysis also helped identify health centres with best performance (fewer children lost to follow-up and better implementation of immunization schedule) and those vaccinations needing the greatest attention from health professionals.

[Essential drugs: availability and prescription in Monastir (Tunisia) health district]. / Les médicaments en première ligne: disponibilité et prescription dans le district sanitaire de Monastir (Tunisie).

Shortages in the availability of some drugs are sometimes noted in primary health care (PHC) centres in spite of the steady increase in the drug budgets in Tunisia. We conducted a survey therefore in 1998 in the health district of Monastir to study the availability of certain essential drugs (n = 15) in PHC centres and the main features of the drug prescription. We found that the drugs lacking were generally those prescribed for chronic diseases and as well as oral antibiotics. Antibiotic treatment constituted 71.8% of public prescriptions and 32.3% of these prescriptions were for an injectable treatment.

[Antibiotic therapy in general medicine in Monastir, Tunisia]. / L'antibiothérapie en médecine générale à Monastir, Tunisie.

In order to determine the cost and frequency of antibiotic prescription by general practitioners, we studied 563 outpatients from health centres in Monastir (Tunisia). All patients had acute diseases. Antibiotics were prescribed to 50.4%. Single antibiotics were generally prescribed, but 52.8% of these patients did not have any laboratory tests. The more frequently used antibiotics were penicillin G and A. Antibiotics cost represented 34.7% of medicinal cost borne by patients and 49.7% of the cost borne by the public sector. Rationalization of medicinal prescription would have a positive impact on household and state budgets.

[Prenatal surveillance and determinants of prenatal follow-up in the Monastir health district]. / Surveillance prénatale et déterminants du suivi prénatal dans la circonscription sanitaire de Monastir.

Prenatal monitoring is a prime strategy to improve the end of pregnancy. To estimate the prevalence rate and the conditions determining such a monitoring, the authors carried out a survey on 1190 pregnant women in the Monastir district (Tunisia). The rate of satisfactory monitoring (4 check-up and more) is 45.8 p.c. Age and high parity have a negative influence, but instruction, occupation and a bad out come of the last pregnancy favour a satisfactory prenatal monitoring.

PIP: In Tunisia, a survey was conducted of 1190 women who delivered at the maternity ward of the Fattouma Bourguiba University Hospital Center in Monastir during September 1988 to August 1989 to evaluate, in an Arab-Moslem context, the coverage rate of prenatal care and to identify the determinants of correct prenatal follow-up among users of the central maternity ward. 45.8% of the women received adequate prenatal care (i.e., 4 prenatal visits). 14.4% received no prenatal care. The frequency of adequate prenatal care decreased with age (51.78% for 15-24 years, 45.29% for 25-34 years, and 35.51% for 35 and over; relative risk [RR] = 1.34). Based on occupation, mothers who did not work received the least amount of prenatal care (40.47% vs. 55.63% for moderate profession and 51.76% for superior profession; RR = 1.36). Women who received the least amount of prenatal care were illiterate women (39.89% vs. 53.18% for secondary education and 67.69% for higher education; RR = 1.86). Women whose last pregnancy had a poor outcome (fetal death or miscarriage) were more likely to receive adequate prenatal care than those whose last pregnancy had a good outcome (54.7% vs. 33.6%; RR = 1.47). Women who experienced a medical condition during pregnancy were more likely to receive adequate prenatal care than those who had no such problem (53.7% vs. 45.2%). Primiparous women were more likely to receive adequate prenatal care than multiparous women (55.7% vs. 38.7% for parity 2-4 and 21.7% for parity 5; RR = 1.77). The influence of parity continued even when the researchers controlled for age (p 0.0003).