Implementation of the One Health approach to fight arbovirus infections in the Mediterranean and Black Sea Region: Assessing integrated surveillance in Serbia, Tunisia and Georgia

Background In the Mediterranean and Black Sea Region, arbovirus infections are emerging infectious diseases. Their surveillance can benefit from one health inter-sectoral collaboration; however, no standardized methodology exists to study One Health surveillance. Methods We designed a situation analysis study to document how integration of laboratory/clinical human, animal and entomological surveillance of arboviruses was being implemented in the Region. We applied a framework designed to assess three levels of integration: policy/institutional, data collection/data analysis and dissemination. We tested the use of Business Process Modelling Notation (BPMN) to graphically present evidence of inter-sectoral integration. Results Serbia, Tunisia and Georgia participated in the study. West Nile Virus surveillance was analysed in Serbia and Tunisia, Crimea-Congo Haemorrhagic Fever surveillance in Georgia. Our framework enabled a standardized analysis of One Health surveillance integration, and BPMN was easily understandable and conducive to detailed discussions among different actors/institutions. In all countries, we observed integration across sectors and levels except in data collection and data analysis. Data collection was interoperable only in Georgia without integrated analysis. In all countries, surveillance was mainly oriented towards outbreak response, triggered by an index human case. Discussion The three surveillance systems we observed prove that integrated surveillance can be operationalized with a diverse spectrum of options. However, in all countries, the integrated use of data for early warning and inter-sectoral priority setting is pioneeristic. We also noted that early warning before human case occurrence is recurrently not operationally prioritized

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

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

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

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

Overall adiposity : overweight and obesity gender contrasts among Tunisian 35–70 years adults by area and socio-demographic variables (n = 4963).

<p>1- RPR: within category of environmental or socio-demographic variable, Women vs. Men crude or adjusted Relative Prevalence Proportion Ratio of 25≤ Body Mass Index <30 vs. Body Mass Index <25. 2- RPR: within category of environmental or socio-demographic variable, Women vs. Men crude or adjusted Relative Prevalence Proportion Ratio of Body Mass Index ≥30 vs. Body Mass Index <25. 3- Adjusted for age, marital status, level of education, profession, household economic proxy: multivariate model including all main effects and interactions with gender. 4- Crude or adjusted P-value for gender x variable interaction: null hypothesis of identical gender contrasts (Women vs. Men Relative Prevalence Proportion Ratio) in all categories of environmental or socio-demographic variable.</p

Anthropometric characteristics of 35–70 years Tunisian adults by gender (n = 5343).

1<p>Mean for interval variables, prevalence proportion for binary variables (weighted estimates accounting for unequal probabilities of selection and differential response rates).</p>2<p>Standar error of estimates taking into account sampling design.</p>3<p>Women vs Men difference of means for interval variables, Women vs. Men Prevalence Proportion Odds-Ratio (OR) for binary variables.</p>4<p>P = 0.95 confidence interval adjusted for sampling design.</p>5<p>P-value for Women vs. Men contrast.</p>6<p>Waist circumference ≥94 cm for men, ≥80 cm for women.</p>7<p>Waist circumference ≥102 cm for men, ≥88 cm for women.</p

Overall and abdominal obesity gender contrasts among tunisian 35–70 years adults by area and socio-demographic variables (complete case analysis, n = 4963).

1<p>Weighted prevalence proportions of obesity (accounting for unequal probabilities of selection and differential response rates).</p>2<p>Adjusted for age, marital status, level of education, profession, household economic proxy : multivariate model including all main effects and interactions with gender.</p>3<p>OR: Crude or adjusted Women vs. Men prevalence proportion odds-ratio within category of socio-demographic variable.</p>4<p>OR 0.95 confidence interval.</p>5<p>Crude or adjusted P-value for gender x variable interaction : null hypothesis of identical gender contrasts (OR) in all categories of socio-demographic variable.</p

Distribution of environmental and socio-demographic factors among 35–70 years Tunisian adults, by gender (n = 5343).

1<p>Number of subjects.</p>2<p>Weighted proportions (accounting for unequal probabilities of selection and differential response rates).</p>3<p>Null hypothesis of identical distribution in women vs. men (P-value adjusted for sampling design).</p

Abdominal adiposity: Waist for Height Ratio polytomous contrasts among Tunisian 35–70 years adults by area and socio-demographic variables (n = 4963).

<p>1- RPR: within category of environmental or socio-demographic variable, Women vs. Men crude or adjusted Relative Prevalence Proportion Ratio of 0.5≤ Waist to Height Ratio <0.6 vs. Waist to Height Ratio <0.5 2- RPR: within category of environmental or socio-demographic variable, Women vs. Men crude or adjusted Relative Prevalence Proportion Ratio of Waist to Height Ratio ≥0.6 vs. Waist to Height Ratio <0.5 3- Adjusted for age, marital status, level of education, profession, household economic proxy: multivariate model including all main effects and interactions with gender. 4- Crude or adjusted P-value for gender x variable interaction: null hypothesis of identical gender contrasts (Women vs. Men Relative Prevalence Proportion Ratio) in all categories of environmental or socio-demographic variable.</p

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

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