[Contribution of verbal autopsy in the study of cancer mortality among reproductive-age women in Tunisia]

Background: In Tunisia, the information system on medical causes of death is based on the use of standard death certificate model based on international model recommended by the World Organization started in January 2001. However, this system is still burdened with a major death causes of under-registration. Only specific surveys on mortality have FAR generate reliable mortality indicators

Objectives: to study the use of verbal autopsy in order to assess cancer mortality among Tunisian women in reproductive age [WRA]

Methods: A retrospective national RAMOS survey [Reproductive Age Mortality Study]. This survey was conducted in 2010 and included all deaths of women aged 15-49 years which occurred in 2008 and were due to cancer. Data were collected from civil status records and information gathered from families and from health institution's registers. For all deaths of women aged 15-49 years, the detailed circumstances and the sequence of events leading to death were grouped on a folder called "clinical record of verbal autopsy". Then; all folders were submitted to the independent expert

Results: During the study period, 1729 deaths among women of reproductive age [WRA] were the subject of a verbal autopsy against only 708 recorded by the National death information system [NDIS]. Cancer is the leading cause of death among WRA .The specific rate of cancer mortality is 17.83 per 100 000 WRA against only 7.91 per 100 000 WRA estimated by the NDIS. Breast cancer is the leading cause with 35% of all cancers and specific death rate of 6.3 per 100,000 WRA against 2.48 per 100,000 WRA recorded by the NDIS

Conclusion: Verbal autopsies Verbal autopsy remains an interesting method for measuring cancer mortality in women of a reproductive age especially in countries with a defective national death information system

[National survey of maternal mortality of 2010: data of Tunis]

Tunisia has investigated maternal mortality in 2010 to determine maternal mortality ratio [MMR] nationally and regionally, in addition to the identifying main causes of this mortality. Describe methodology of this study and its principal findings in the region of Tunis and discuss the national maternal mortality strategy. This is a Ramos study [Reproductive Ag Mortality Studies] that consists on identifying maternal deaths from reproductive age group [RAG] women deaths. We started by the a rehearsal and targeting of [RAG] women deaths, then we investigated a next of kin person of the decedent women by verbal autopsy, thereafter we identified maternal deaths to be confidentially investigated to judge the potential avoidability of the death. The study took place in 2010, it was carried out by 5 couples of investigators supervised by a coordinator doctor. A total of 200 deaths of [RAG] women were found in Tunis, 7 deaths among them were maternal deaths, that corresponds to an MMR of 41/100000 live births. The mean age of the deceased women was 35 years. The main causes of maternal deaths were hemorrhage [3/7], thrombo-embolic diseases [2 times for7] and HELLP syndrome [1/7]. Four of a total of 4 deaths [3 deaths were not marked], were avoidable. The majority of late women had a satisfying educational level, 4 of 7 had financial autonomy. All of them had pregnancy monitoring, 5 times of 7 in university hospital. All the childbirth were medically assisted, Caesarean section was carried in 6 of 7 cases. Nationally, the MMR was estimated to 44.8/100 000 LB, that to say a decrease of 35% compared to 1993. The decrease was significant for all the regions of the country, except the great Tunis where opposite trend was recorded. This could be more likely related to quality of care rather than socio-economic conditions seeing that social determinants in Tunis are favorable. In fact, the Tunisian maternal mortality strategy had essentially focused on the monitoring system of maternal deaths rather than the quality of care improvement interventions, results were disappointing due to the lack of institutional engagement. The achievement of the OMD5 objectives is compromised, due to socio-economic constraint especially in certain regions, poor governance and lack of engagement of ministry of health in reducing maternal mortality. Tunisian maternal mortality strategy should be revised and adapted to regional context, also should include multisectoral interventions. Priority would be given to quality of care improvement, by launching the experience of care setting accreditation in one hand, and in the other improving partnership between different levels of care

Surveillance des facteurs de risque des maladies cardiovasculaires en Tunisia: Methodologie et principaux resultats

To assess the Cardiovascular risk factors trend in a community based surveys. Method: Two population surveys were conducted in 1996-97 and 2000-01 in the Ariana region among 7608 adults 35-70 years aged. The surveys were based on: I- a questionnary, 2- an anthropometrical and physical examination, 3- a biological investigation, and 4 - an ECG registration for the second cohort. Relative to the first survey, the prevalence of hypertension, diabetes, hypercholesterolemia didn't change significantly while border line cholesterol increased on both genders, tobacco smoking decreased and ex-smokers increased on men. In both genders, hypertension and diabetes prevalence is low before 50 years but it increased after this age. Risk factors association is common: about 35% have more than two risk factors. This association is more common on women and diabetes-hypertension is the most frequent. These two surveys integrated in a global surveillance program has contributed to assess the CVDs burden and to identify priorities and intervention relevant to epidemiological region context

Prevalence des cardiopathies ischemiques: Resultats d'un depistage en population

A cross - sectional population survey was carried out in the Ariana region in 2000-01. The aim of this study is to report the prevalence of CHD as indicated by ECG Minnesota coding. Method: A randomly selected sample included 1837 adults 40-70 years. Data on socio-economic status, demographic, medical history, health behavior, clinical and biological investigations were recorded. Risk factors [hypertension, dyslipedemia, obesity, diabetes] are defined according to WHO criteria's. Standard supine 12 lead ECGs were recorded. All ECGs are red and classified according to the Minnesota codes criteria on CHD probable, CHD possible and on Major abnormalities and minor abnormalities. CHD prevalence was higher on women. Major abnormalities are more common on women [20,6% vs 13%], while minor abnormalities prevalence was higher on men [15,5% vs 7,5%] [p<0,0001]. The prevalence increased with age in both genders. This study tested how feasible is the population approach on CVDs surveillance. It highlighted the burden of cardiovascular diseases and support that women are at risk as men are. The value of ECG findings must be integrated in the cardiovascular diseases surveillance to identify high risk population

Delai de prise en charge et acces aux soins de l'infarctus du myocarde dans les structures hospitalieres

We aimed to assess the acute myocardial infarction management in Tunis public hospitals during one year [from March 2000 to February 2001]. Method: A standard questionnaire was designed to record prospective data on 740 patients with a follow up during 28 days. Multivariate analysis was performed using the logistic regression model with all-factors as well as age, gender, CHD risk factors as predictors of the delay and fatality. 54% of patients were admitted during the first 6 hours after the onset of symptoms. In multivariate analysis, the delay of consultation is significantly correlated with gender [OR=2.3, p<0.001], age [OR=l.02, p<0.01] and health insurance [OR=1.5, p<0.01]. 90% of patients consulted in emergency wards. The emergency ambulance transported 19.6% of patients. 48% of patients underwent early revascularization of thrombolysis, 51% on men vs 31% on women [p <0.01]. The fatality rate was higher on women 14% vs 6.4% on men [p<0.01] at 5 days and 27.2% vs 13.6% at 28 days. In multivariate analysis, the principal fatality predictive factor was age [RR=l.08, p < 0,001] and delay [2.56 p <0.001] and tobacco smoking [RR=2,83, p <0.0001]. this study highlighted the problem of acute myocardial infarction management in public hospitals in Tunisia and it constitutes a baseline to assess different interventions focusing on cardiovascular diseases control and surveillance

Prevalence, connaissance, traitement et controle de l'hypertension arterielle: Resultats d'une enquete populationnelle

The study objective was to assess the prevalence, level of awareness of treatment, and control of hypertension in a general population. We conducted a cross-sectional survey on 1837 adults 40-69 years old. Hypertension and control level are defined according to the WHO/ISH recommendations. HBP is defined as SBP> =140 and or DBP> = 90 mm Hg and the use of blood pressure-lowering medication. Hypertension is controlled by medication if SBP < 140 and DBP < 90 mm Hg. We conduct analysis by socio demographic variable, medical history and CHDs risk factors. 44,3% of adults was hypertensive. The prevalence of hypertension was higher among women [48,2% versus 38,7% on men.] and it increases in both genders with age, body mass index. Only 41,% of the hypertensive were aware of having hypertension, among them, 74,1%declare that they are treated but only 13.2% were controlled. The study highlights the problem of the hypertension in a developing country. It contributes to identify the huge iceberg of this CVDs risk factor. The national strategy must focus on the population life style and drugs management. The question is how much will be the cost of HBP and CVDs control for a country which has a limited resources