Quality indicators of public maternity units in the governorate of Monastir (Tunisia).

INTRODUCTION: Increasing access to healthcare for expectant mothers is a national goal. In Monastir, Tunisia, some Peripheral Maternity Units (PMUs) required assessment. Our goals were to describe the delivery activities in MUs (maternity units) and to assess whether some of PMUs need to have their activities replaced. METHOD: We analyzed aggregate data of deliveries in Monastir from 2015 to 2020. The gouvernorate's seven public MUs were included. Only the morning activity was allotted for obstetricians and gynecologists, in RMUs 1 and 2, whereas they were not available in all PMUs. Data was gathered from the reports of the National Perinatal Program. Both the availability of Comprehensive Essential Obstetric Care (CEOC) and Basic Essential Obstetric Care (BEOC) were calculated. Trends were calculated using Joinpoint software. The Annual Percent Change (APC) was calculated. RESULTS: The number of births decreased from 2015 to 2020 (APC= -4.3%: 95%CI : -6; -2.4; p = 0.003). The largest significant decreases in APCs of deliveries were reported in PMU 2 (APC = -12.6% (95%CI : -20; -4.4; p = 0.014), in PMU 3 (APC = -29.3% (95%CI : -36.5; -21.4; p = 0.001), and in PMU 4 (APC = -32.9% (95%CI: -49.1; -11.5); p = 0.016). If PMU 3 and 4 were no longer operating as maternity facilities, BEOC and CEOC standards would still be adequat. For accessibility, both PMU 3 and PMU 2 are accessible from PMU 4 and PMU 1, respectively. CONCLUSIONS: Pregnant women prefer to give birth in obstetric services with ability to perform emergency caesarean at the expense of PMU. Nowadays, it appears that accessibility is less important than the presence of qualified human resources when a pregnant woman choose a maternity hospital.

Spirometry as a motivator for smoking cessation among patients attending the smoking cessation clinic of Monastir.

BACKGROUND: The choice of spirometry, a biomarker of lung health, as a motivator for smoking cessation is based on its fidelity in emphasizing tobacco adverse effects. Yet, there is a paucity of evidence on its efficacy, and the findings are currently inconclusive. The aim of this study was to determine whether a spirometry and lung age communication has an effect on smoking cessation rates. METHODOLOGY: We conducted a randomized controlled trial among patients who attended the smoking cessation clinic (SCC) at Fattouma Bourguiba University Hospital in Monastir, from June 2017 to February 2020. Participants were assigned into two groups, a control arm receiving standard program and intervention arm receiving a spirometry and lung age announcement along with usual care. The primary outcomes were the smoking cessation rates after one year of follow-up between the intervention arm and the control arm. RESULTS: At one-year endpoint, a total of 456 were reachable for assessment, 236 in control group and 220 in spirometry group, which leads to a loss rate equal to 8.8%. One-year smoking cessation rate was higher among the intervention group than among control group (25.5% versus 16.5%), with a considerable statistical significance (p = 0.019). Lung age was significantly higher at paired comparison with chronological age. CONCLUSION: Smoking cessation is still a challenging procedure with a high risk of relapse, making very valuable any approach that may increase motivation in both unmotivated and motivated smokers. This study is an additional evidence for spirometry and lung age announcement as motivators for smoking cessation. TRIAL REGISTRATION: Pan African Clinical Trial Registry database ( PACTR202110595729653 ), 06/10/ 2021.

Animal bites and post-exposure prophylaxis in Central-West Tunisia: a 15-year surveillance data.

BACKGROUND: Rabies is a disease that still exists in developing countries and leads to more fatalities than other zoonotic diseases. Our study aimed to describe the profile of human exposures to animals over fifteen years and to assess the post-exposure prophylaxis (PEP) practices in the governorate of Kasserine (Tunisia) on pre- and post-revolution (2011). METHODS: We carried out a descriptive study using surveillance data from a region in Central-West Tunisia. All humans exposed to animals, residents in Kasserine Governorate and declared to the regional directorate of primary health care (RDPH) from January 1st, 2004 to December 31st, 2018 were included. RESULTS: A total of 45,564 cases of human exposures to animals were reported over the fifteen-year period of the study with an annual average of 3089.2 ± 403.1. The standardized incidence rate (SIR) of human exposures to animals was 694 per year per 100,000 inhabitants (inh). The most listed offending animal was the dog (91.3%) and the most reported type of exposure was bites (63.7%). The trend in human exposures to animals increased significantly over time. The number of exposures by vaccinated dogs decreased significantly and by unvaccinated and stray dogs increased steeply. When comparing pre-and post-revolution periods, the yearly average of animal exposures post-2011 was significantly greater than the average prior to 2011 (3200 ± 278.5 vs 2952.8 ± 483) (p < 0.001). The yearly average of animal bites post-2011 was significantly greater than the average prior to 2011 (2260.5 ± 372.1 vs 1609.8 ± 217.9) (p < 0.001). The average number of vaccine doses per animal exposure was 2.4. Concerning PEP protocols, protocol A (2 and 3 doses) was indicated in 79% of animal exposures cases. From 2004 to 2018, a downward trend was noted for protocol A (r = - 0.29, p < 0.001) and an upward trend for protocol B (3 and 5 doses) (r = 0.687, p < 0.001). During our study period, 5 fatal cases of human rabies were declared. CONCLUSION: Rabies remains a major public health problem in Tunisia. The political dynamics had an impact on the health care system and rabies control. Preventive measures should be applied adequately to decrease the burden of this disease.

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.

Management of acute coronary syndrome in emergency departments: a cross sectional multicenter study (Tunisia).

BACKGROUND: We aimed to describe diagnosed acute coronary syndrome (ACS) and its care management and outcomes in emergency departments (EDs) and to determine related cardiovascular risk factors (CVRFs). METHODS: We conducted a cross sectional multicenter study that included 1173 adults admitted to EDs for acute chest pain (ACP) in 2015 at 14 sites in Tunisia. Data included patients' baseline characteristics, diagnosis, treatment and output. RESULTS: ACS represented 49.7% of non-traumatic chest pain [95% CI: 46.7-52.6]; 74.2% of ACS cases were unstable angina/non-ST-segment-elevation myocardial infarction (UA/NSTEMI). Males represented 67.4% of patients with ACS (p < 0.001). The median age was 60 years (IQR 52-70). Emergency medical service transportation was used in 11.9% of cases. The median duration between chest pain onset and ED arrival was two hours (Inter quartile ranges (IQR) 2-4 h). The age-standardized prevalence rate was 69.9/100,000 PY; the rate was 96.24 in men and 43.7 in women. In the multivariable analysis, CVRFs related to ST segment elevation myocardial infarction were age correlated to sex and active smoking. CVRFs related to UA/NSTEMI were age correlated to sex, familial and personal vascular history and type 2 diabetes. We reported 27 cases of major adverse cardiovascular events (20.0%) in patients with STEMI and 36 in patients with UA/NSTEMI (9.1%). CONCLUSION: Half of the patients consulting EDs with ACP had ACS. Emergency medical service transportation calls were rare. Management delays were acceptable. The risk of developing an UA/NSTEMI was equal to the number of CVRFs + 1. To improve patient outcomes, it is necessary to increase adherence to international management guidelines.

Expanded program of immunization in the Maghreb. Case study of Tunisia.Systematic review of the literature.

BACKGROUND: Vaccination is the most cost-effective intervention for primary prevention. The Maghreb countries had joined the The Expanded Programme on Immunization (EPI). Tunisia had also introduced the vaccine against hepatitis B and Haemophilus influenzae type B (Hib). OBJECTIVE: To describ, through a systematic review, the specific documentation on the EPI in Tunisia. METHOD: Target publications were collected using Medline database and Google Scholar from published articles from January 01 1998 to December 12 2017. The synthesis of the data was done according to four axes: "input", "process", "output" and "outcome". RESULTS: 17 articles were analyzed, with an average of 4 publications every 5 years. The author's specialty was community and preventive medicine in 56% of cases. Six articles focused on the "input" vaccination program, five related to the immunization process and the other five articles examined output and outcomes. CONCLUSION: Tunisian publications concerning vaccination were rare, their efficiency and impact on the change of national vaccination strategy was crucial. Research coordination between Maghreb countries is highly recommended to meet the growing information needs.

Associated factors with adherence to preventive behaviors related to COVID-19 among medical students in the university of Monastir, Tunisia.

INTRODUCTION: Medical students should act as a model for the community in terms of compliance with preventive practices toward COVID-19. The aim of this study was to assess adherence to preventive behaviors related to COVID-19 among medical students and to identify its associated factors. POPULATION AND METHODS: We conducted a cross-sectional survey in October 2020 in the faculty of medicine of Monastir. We included a representative sample of medical students during registration days for the 2020-2021 academic year. The data were collected through a self-administered anonymous questionnaire. Eleven items related to preventive practices against COVID-19 were assessed (respiratory hygiene practices (Six Item), hand hygiene practices (Three Items) and social distancing (two items)). Items were evaluated using a Likert scale of five points (from 0: (Never) to 4: (Always)). The score obtained from the sum of these items allowed to classify students into two categories: "Good compliance" if the score was ≥ 80% and "Poor compliance" if the score was less than 80%. Scores were compared according to the study population characteristics. Multivariate analysis was used to identify associated factors with good practices. The threshold of statistical significance was set at p < 0.05. RESULTS: We included 678 medical students. The average age was 21.76 (SD = 1.89 years) with a sex ratio of 0.40. The protection measures most respected by the participants were related to the respiratory hygiene: correct coverage of the nose and mouth with the mask (80%), wearing masks regardless of the presence of symptoms (73.3%) and coverage of the mouth during coughing or sneezing (76.6%). Adherence to hand hygiene measures ranged from 51.4% to 66.3%. The least respected measures were related to social distancing: distancing of at least one meter from others (31.2%) and avoiding crowded places (42.5%). An overall score ≥ 80% was obtained among 61.5% of students. Referring to multivariate analysis, variables that positively affected the overall score of preventive measures related to COVID-19 were the female sex and living alone, with Beta coefficients of 3.82 and 1.37 respectively. The perceived level of stress, E-cigarette and Chicha consumption negatively affected the score with Beta coefficients of (-0.13), (-5.11) and (-2.33) respectively. CONCLUSION: The level of adherence to good practice among medical students was overall moderate. Awareness programs would be needed in this population, especially for men and those who smoke and vape.

Burnout syndrome among health care workers during the COVID-19 pandemic. A cross sectional study in Monastir, Tunisia.

BACKGROUND: Burnout syndrome may affect the safety of frontline healthcare care workers (HCW) and patients. We aimed to measure the prevalence of burnout among HCW in care facilities in Tunisia during the Covid-19 pandemic and to identify its associated factors. METHODS: We conducted a cross-sectional study among HCW practicing during the covid-19 pandemic in health care facilities in the governorate of Monastir. Data collection was carried out using an anonymous self-administered questionnaire composed by three sections: epidemiological and clinical characteristics, professional conditions and the Maslach Burn out Inventory (MBI-HSS). RESULTS: This study included 371 HCW. The prevalence of burnout was 77.9% (CI 95%: 73.6% - 82.1%). The severe level was found in 71 participants (19.1%), the moderate level in 115 (31%) and the low level in 103 (27.8%). The distribution of the levels of the burnout dimensions among the participants was as follows: high emotional exhaustion (EE) (57.4%), high depersonalization (DP) (39.4%) and low personal accomplishment (22.6%). The main determinants of burnout among healthcare professionals during COVID 19 pandemic were: working more than 6 hours per day (OR = 1.19; CI95% [1.06; 1.34]), physician function (OR = 1.17; CI 95% [1.05; 1.31]), feeling a negative impact of work on family life (OR = 1.40; 95% CI [1.13; 1.73]), and high personal estimation of COVID 19 exposure (OR = 1.15; CI95% [1.02; 1.29]). CONCLUSION: During the COVID19 pandemic, the prevalence of burnout among health professionals was high. It was related to hard implication in COVID 19 management. Interventions like adjusting working hours, reducing workload, and providing psychological support should be taken.

Deleterious impact of COVID-19 pandemic: Male fertility was not out of the bag.

BACKGROUND: The emergence and the spread of coronavirus disease (COVID-19) induced by the SARS-CoV-2 virus has multiple consequences in all countries around the world. Male germ cells of infertile patients which are shown to be vulnerable to many environmental conditions, could be particularly vulnerable to such an exceptional pandemic situation. We aimed through the current study to investigate the potential variations in sperm quality of infertile patients during the COVID-19 pandemic in Tunisia. METHODS: This was a cohort study including 90 infertile patients addressed to Laboratory of Cytogenetics and Reproductive Biology of Monastir Department of Maternity and Neonatology in Monastir, during the two first COVID-19 waves in Tunisia and who already have a spermogram before the pandemic period. RESULTS: We have pointed out a significant decrease in both total and progressive sperm motility during COVID-19 pandemic (p<0.0001 and p = 0.001 respectively). The percentage of morphologically abnormal spermatozoa increased from 90.99±7.38 to 93.67±4.55% during the pandemic (p< 0.001). The remaining sperm parameters were similar between the two compared timepoints. Interestingly, the univariate analysis didn't show any other associated factor to the observed impairment in sperm mobility and morphology. CONCLUSION: These data highlight the severe impact of the pandemic of the male reproductive health of hypofertile patients. Delaying infertility investigations and management after pandemic waves is recommended to hope a better gamete quality and hence to improve conception potential.

Effect of vitamin D supplementation versus placebo on recovery delay among COVID-19 Tunisian patients: a randomized-controlled clinical trial.

INTRODUCTION: The present study aimed to determine the impact of vitamin D supplementation (VDs) on recovery delay among COVID-19 patients. METHODS: We performed a randomized controlled clinical trial at the national COVID-19 containment center in Monastir (Tunisia), from May to August 2020. Simple randomization was done in a 1:1 allocation ratio. We included patients aged more than 18 years who had confirmed reverse transcription-polymerase chain reaction (RT-PCR) and who remained positive on the 14th day. The intervention group received VDs (200,000 IU/1 ml of cholecalciferol); the control group received a placebo treatment (physiological saline (1 ml)). We measured the recovery delay and the cycle threshold (Ct) values in RT-PCR for the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The log-rank test and hazard ratios (HR) were calculated. RESULTS: A total of 117 patients were enrolled. The mean age was 42.7 years (SD 14). Males represented 55.6%. The median duration of viral RNA conversion was 37 days (95% confidence interval (CI): 29-45.50) in the intervention group and 28 days (95% CI: 23-39) in the placebo group (p=0.010). HR was 1.58 (95% CI: 1.09-2.29, p=0.015). Ct values revealed a stable trend over time in both groups. CONCLUSION: VDs was not associated with a shortened recovery delay when given to patients for whom the RT-PCR remained positive on the 14th day. TRIAL REGISTRATION: This study was approved by the Human Subjects Protection Tunisia center (TN2020-NAT-INS-40) on April 28, 2020, and by ClinicalTrial.gov on May 12, 2021 with approval number ClinicalTrials.gov ID: NCT04883203 .

Burden and predictions of hospitalized injuries in a low-middle income country: results from a Tunisian university hospital.

Injuries are responsible for a high premature mortality and disability. They are poorly explored in low and middle income-countries. We aimed to estimate the burden of hospitalized injuries in the Monastir governorate (Tunisia) according to the nature of the injury, trends and projections of hospitalizations for injuries up until 2024, and to identify the distribution of this disease burden based on age and sex. We performed a descriptive study from 2002 to 2012 including all hospitalizations for injuries. Data were collected from morbidity and mortality register of the University Hospital of Monastir (Tunisia). We estimated the burden of injuries using the Disability Adjusted Life Years (DALYs). We described injuries (crude prevalence rate (CPR) and age standardized prevalence rate (ASR)), related mortality (lethality and standardized mortality ratio (SMR)), trends and prediction for 2024. A total of 18,632 hospitalizations for injuries representing 10% of all hospitalizations during study period were recorded. Per 1000 inhabitants per year, CPR was 3.36 and the ASR was 3.44. The lethality was of 17.5 deaths per 1000 injured inpatients per year and the SMR was of 2.95 (Confidence Interval of 95%: 2.64-3.29). Burden related to injuries was 2.36 DALYs per 1000 population per year, caused mainly by Years of Life Lost (83.4%), most frequent among men aged under 40 years. The predicted ASR for 2024 was 4.46 (3.81-5.23) per 1000 person-years. Injuries to the head was the most prevalent (20.7%) causing 67.7% of DALYs; and increasing by 226% through 2024. Injuries had a high prevalence and an important burden in a Tunisian university hospital. Prediction showed increased prevalence for 2024. Preventive measures and a trauma surveillance register should be implemented soon.

Distinguishing swept-source optical coherence tomography findings in active toxoplasmic retinochoroiditis.

OBJECTIVE: To define the swept-source optical coherence tomography (SS-OCT) features which distinguish ocular toxoplasmosis (OT) from other forms of retinochoroiditis. METHODS: This is a prospective diagnostic study enrolling 43 eyes of 43 patients with active toxoplasmic (TOXO) retinochoroiditis matched to 54 eyes (54 lesions) with non-TOXO retinochoroiditis evaluated by structural SS-OCT. RESULTS: The finding of retinal hyper-reflective round deposits, sub-lesional choroidal thickening, and sub-lesional retinal pigment epithelium elevation were more likely to be found in TOXO lesions with a positive likelihood ratio of 45.2 (95% CI: 6.45-316.56), 23.86 (95% CI: 6.09-93.36), and 9.79 (95% CI: 4.22-22.7), respectively. The presence of each of these findings was associated with a high level for positive predictive value (PPV) (88.63-97.29), negative predictive value (NPV) (88.3-92.45), sensitivity (83.72-90.69), and specificity (90.74-98.14). Two-parameter model binary logistic regression suggested that sub-lesional retinal pigment epithelium elevation and sub-lesional choroidal thickening were significant predictors of the diagnosis of OT (Wald = 11.905, p < 0.001; Wald = 14.881, p < 0.001; respectively). By adding hyper-reflective round deposits along the posterior hyaloid or the retinal surface the model improved its performance with very good diagnostic accuracy with area under the curve (AUC) values of 0.96 (95% CI: 0.9-0.99) for two parameters model and 0.98 (95% CI: 0.93-0.99) for the three parameters model. CONCLUSIONS: Our results show that three OCT findings including retinal hyper-reflective round deposits, sub-lesional choroidal thickening, and sub-lesional retinal pigment epithelium elevation are more likely to occur in OT patients as compared with non-OT patients.

Breast cancer incidence and predictions (Monastir, Tunisia: 2002-2030): A registry-based study.

INTRODUCTION: Breast cancer is a major public health problem worldwide. It is the leading cause of cancer deaths in females. In developing countries like Tunisia, the frequency of this cancer is still growing. The aim of this study was to determine the crude and standardized incidence rates, trends and predictions until 2030 of breast cancer incidence rates in a Tunisian governorate. METHODS: This is a descriptive study including all female patients diagnosed with breast cancer in Monastir between 2002 and 2013. The data were collected from the cancer register of the center. Tumors were coded according to the 10th version of international classification of disease (ICD-10). Trends and predictions until 2030 were calculated using Poisson linear regression. RESULTS: A total of 1028 cases of female breast cancer were recorded. The median age of patients was 49 years (IQR: 41-59 years) with a minimum of 16 years and a maximum of 93 years. The age-standardized incidence rate (ASR) was of 39.12 per 100000 inhabitants. It increased significantly between 2002 and 2013 with APC of 8.4% (95% CI: 4.9; 11.9). Prediction until 2030 showed that ASR would reach 108.77 (95% CI: 57.13-209.10) per 100000 inhabitants. CONCLUSION: The incidence and the chronological trends of breast cancer highlighted that this disease is of a serious concern in Tunisia. Strengthening preventive measures is a primary step to restrain its burden.

Occupational exposure to hepatitis C virus infection and associated factors among healthcare workers in Fattouma Bourguiba University Hospital, Tunisia.

BACKGROUND: Healthcare workers (HCWs) are at high risk of hepatitis C virus (HCV) infection. Indeed, they are exposed to blood and body fluid which put them at an important risk of transmission of various blood borne pathogens including HCV. The goal of this study was to determine the magnitude of occupational exposure to hepatitis C virus infection as well as the factors associated to this exposure among HCWs at a Tunisian University Hospital in 2017. METHODS: A hospital-based cross-sectional study was carried out at Fattouma Bourguiba University Hospital in Monastir Governorate (Tunisia) from 01 June 2017 to 31 August 2017. Data were collected using an anonymous questionnaire. To determine factors associated with occupational exposure to hepatitis C virus infection, we performed multivariate analysis. RESULTS: Among the 1493 included participants, more than half (56.7) had at least one exposure to blood or body fluid. A history of needle stick injury was reported by 48.3% of the respondents. Exposure to blood or body fluid splash into the face was announced by 32.1% HCWs. Doctors had the highest risk of exposure (AOR = 12.425; 95% CI: [05.310-29.075]). Participants working at surgical departments were the most exposed comparing to workers at others departments (AOR = 7.440; 95% CI: [4.461-12.408]). Two exposed female HCWs were tested positive corresponding to a HCV infection prevalence of 0.13% (95% IC: [0.11-0.16%]). CONCLUSION: Occupational exposure to hepatitis C virus infection was high at the university hospital of Monastir. Despite the low magnitude of HCV infection, preventive actions should be taken to promote the safety of health care personnel.

Social and early life adversity and chronic health conditions among Tunisian adults.

Early life adversities (ELAs) are shown as significant risk factors for chronic health conditions (CHCs). ELAs include multiple types of abuse such as the social abuse (peer, community, and collective violence). The purpose is to describe the relationship between childhood social abuse and chronic conditions in adulthood among a sample of adults in Tunisia and to investigate the role of obesity and tobacco use as mediators of this association. A cross-sectional study was conducted in Tunisia, from January to June 2016 using the Arabic Adverse Childhood Experiences International Questionnaire (ACE-IQ). Items of social abuse (peer violence, witnessing community violence, and exposure to collective violence) were analyzed. A total of 2,120 adults were enrolled. After adjustment for age, gender, and intrafamilial ELA, social adversities were associated significantly with the selected CHC. Experiencing more than two social ELA increase the risk of occurrence of hypertension and coronary diseases. After accounting for the indirect effect of body mass index, statistically significant partial mediation effects were observed for the cumulative number of social ELA as the exposure variable and chronic diseases as the outcome variable (p ≤ .001; % mediated = 44.5%). These findings support an association between many chronic health disorders and childhood social abuse, independently of intrafamilial ACEs.

Trends and health burden of hospitalized acute respiratory infections and impact of Haemophilus influenza immunization in a Tunisian university hospital: a twelve-year study.

BACKGROUND: We aimed to describe the episodes and trends of admissions for community-acquired Respiratory Infections (RI) over a 12-year period and to assess the impact of Haemophilus influenza type b (Hib) vaccine on RI admissions in children aged up to 3 years. METHODS: We conducted a twelve-year retrospective observational study on all community-acquired RI admitted to Fattouma Bourguiba Hospital in Monastir Governorate (Tunisia) from 1 January 2002 to 31 December 2013. RI cases were selected from the Regional Registry of Hospital Morbidity. Data were coded according to ICD-10. To assess the impact of the Hib vaccine, three cohorts were defined based on vaccine status (unvaccinated cohort, first vaccinated cohort (VC) by monovalent form and second VC by pentavalent combination). RESULTS: Admissions for RI represented 17.6% (CI95%: 17.3-18.1) of all communicable diseases hospitalizations (n = 6 061/34 289). The crude incidence rates (CIR) per 100,000 inh were 24.2 for upper RI (URI) and 77.5 and for Lower RI (LRI) (p < 0.0001). Pneumonias represented 53.9% of LRI. Sex-ratio (male/female) was 1.12 for URI and 1.64 for LRI (p < 0.0001). At admission, the median age was 22 years (IQR: 3-52). Admission for Pneumonia increased significantly during study period (slope 'b' = 5.16; p < 0.0001) especially in children up to 5 years old (slope 'b' = 5.53) and in elderly (slope 'b' = 2.13). Among children up to 3 years old, the CIRs per 100,000 for Hib pneumonia admission were 11.6 in Non-Vaccinated Cohort (NVC), 10.6 in Vaccinated Cohort (VC) by protocol 1 (Hib Vaccine monovalent) and 0.80 in VC by protocol 2 (pentavalent vaccine combination).The relative risk reduction was 99% for protocol 2 (p < 0.001). CONCLUSION: Admissions for RI in a  tertiary level hospital were common with an increasing trend. The Hib immunization program, in particular the pentavalent combination, has had a positive impact on the reduction of related acute diseases.

Prediction of cardiovascular events in primary Health care: a cross sectional study (Monastir-Tunisia).

INTRODUCTION: We aimed to determine the prediction of cardiovascular events in patients with hypertension and diabetes using the 10-year Framingham score. METHODS: We conducted a cross sectional study in two primary health care centers in Monastir. We included patients with at least one conventional cardiovascular factors. Prediction of cardiovascular event were expressed by median and inter quartile range. RESULTS: We included 409 patients. Age mean was 64 years (SD: 12.3), the sex ratio was 0.44. Patients with type 2 Diabetes were 278 (68%) and 295 had hypertension (72.1%). The global risk prediction at 10 years for cardiovascular diseases was 26.3%, It was 36.6% (26.4-46.8) for tobacco users, 29.7% (18.2-42.5) for patients with hypertension and 29.1 % (18.8-43.3) for those with diabetes. It increased significantly with the number of cardiovascular risk factors. The risk prediction for cardiovascular events, were significantly higher in men than in women (p < 0.01) and in non-controlled patients than in controlled patients (p <0.001). The risk prediction for cardiovascular diseases death was 3.6% (1.3-8.6). CONCLUSION: Thirty percent of patients with hypertension or diabetes will develop cardiovascular diseases in 10 years. We suggest renforcing preventive actions to balance cardiovascular risk factors, including hypertension and diabetes.

Acute coronary syndrome: factors predicting smoking cessation.

BACKGROUND: Few randomized controlled trials have examined the efficacy time of smoking cessation in hospitalized patients with acute coronary syndrome, either during hospitalization or after discharge. AIMS: To assess smoking cessation rates at 24 weeks among patients with acute coronary syndrome. Group A had begun nicotine replacement therapy during hospitalization, and Group B after discharge. We also determined factors predicting success. METHODS: We conducted a randomized controlled trial in the Cardiology Department and Smoking Cessation Service at University Hospital of Monastir, Tunisia from January 2015 to June 2016. Participants were randomly assigned to the above 2 groups. The endpoint assessment was smoking abstinence at 24 weeks, defined as self-reported abstinence in the past week, confirmed by measured exhaled carbon monoxide (CO) ≤ 8 ppm. We analysed data by intention to treat. We used a binary logistic regression model to determine factors predicting abstinence. RESULTS: All participants were male and mean (standard deviation) age was 55 (11) years. At 24 weeks there was no significant difference in smoking cessation rate between the 2 groups: 54.5% [95% confidence interval (CI): 44.7-64.3%] in Group A and 45.5% (95% CI: 35.7-55.3%) in Group B (P = 0.81). High level of nicotine dependence [odds ratio (OR): 0.72; 95% CI: 0.54-0.96) and good compliance during follow-up (OR: 6.56; 95% CI: 2.07-20.78) were predictive factors for abstinence. CONCLUSIONS: Smoking cessation rate after acute coronary syndrome was high regardless of the start date. Good compliance during follow-up was the key predictive factor for success.

Hepatitis B birth vaccination, cohort study, Tunisia 2000-2017.

We aimed to compare the efficiency of the first dose of Hepatitis B (HB) vaccine: at Birth versus at 3 months and to evaluate the efficacy of HB vaccine. We conducted a cohort study in the governorate of Monastir. Vaccinated Cohort (VC) included populations receiving the first dose at 3 months (Protocol 1), and at birth (HepB-BD) (Protocol 2). First dose was followed by at least two doses. We collected, from January 2000 to December 2017, cases diagnosed by serological markers (hepatitis B surface antigen (HBsAg) and anti-HBc). We calculated Absolute Risk (AR) per 100,000 PY and the Relative risk reduction (RRR). Twenty-five cases were notified among VC and 1501 cases among not vaccinated cohort (NVC). Twenty-three cases were notified among the cohort receiving the first dose at 3 months and two cases in Protocol 2. The AR per 100,000 PY was 5.67 (CI95%: 3.36-7.99) in Protocol 1 and 0.11 (CI95%: 0.001-0.26) in Protocol 2. The RRR was 77% (95% CI: 66; 85) in Protocol 1 and 99.4% (95% CI: 97.8; 99.9) in Protocol 2. We identified 4 HB cases for children aged between 5 and 11 who benefited from protocol 1 (born between 2000 and 2006) and zero cases for children of the same age group benefiting from protocol 2 (born between 2011 and 2017). The annual number of HB has decreased from 112 in 2000 to 48 in 2017. We predicted 40 new cases of HB in 2030. HepB-BD was 99.4% effective at preventing HB. The continuity of HepB-BD worldwide would achieve WHO's goal of eliminating HB as a threat to health by 2050. ABBREVIATIONS: AR: Absolute Risk; ARR: Absolute Risk Reduction; G1: Group1; G2: Group2; HB: Hepatitis B; HepB-BD: Hepatitis B Birth Dose; MENA: Middle East and North Africa; NNV: Number Needed to Vaccine; HIV: Human Immunodeficiency Virus; NVC: Not Vaccinated Cohort; PY: Person Year; RRR: Relative Risk Reduction; RR: Relative Risk; VC: Vaccinated Cohort; WHO: World Health Organization.

Hospital cost of invasive pneumococcal disease in children aged under 15 years old in Tunisia.

BACKGROUND: Pneumococcal infections are an important cause of morbidity and mortality in the world and in Tunisia. Data on the economic burden of these infections are needed to inform decision-making to include pneumococcal vaccinations in routine childhood immunization. AIMS: This study aimed to estimate the medical cost of hospitalizations due to invasive pneumococcal disease (pneumonia and meningitis) among children aged under 15 years old in Tunisia. METHODS: A prospective multicentre study was conducted in 15 paediatric departments, across different socio-economic areas of Tunisia, from June 2014 to May 2015. All children aged under 15 years old who were hospitalized for pneumococcal pneumonia or confirmed bacterial meningitis were enrolled. A case report form was completed for every eligible case. Activity Based Costing method was used to estimate the hospital cost. Data entry and statistical analysis were conducted using SPSS, version 20.0. RESULTS: During the study period, 727 children were hospitalized for pneumococcal pneumonia and 60 children were hospitalized for bacterial meningitis, among them 21(35%) had confirmed pneumococcal meningitis. The median hospital cost for pneumococcal pneumonia was 353.910 Tunisian Dinars (TND) and TND 1680.632 for pneumococcal meningitis. Using overall data extrapolation, it was estimated that nearly 1091 hospitalizations for pneumococcal pneumonia and 69 hospitalizations for pneumococcal meningitis occurred each year in Tunisian children aged under 15 years of age, incurring total costs of TND 502 079.408. CONCLUSION: The economic burden of pneumococcal infections seems to be substantial in Tunisia. The estimated costs does not reflect the real costs of this infection. Cost-effectiveness studies would be helpful to inform policy-makers to take appropriate decisions.