Olfa Saidi

Analyzing Recent Coronary Heart Disease Mortality Trends in Tunisia between 1997 and 2009

Background In Tunisia, Cardiovascular Diseases are the leading causes of death (30%), 70% of those are coronary heart disease (CHD) deaths and population studies have demonstrated that major risk factor levels are increasing. Objective To explain recent CHD trends in Tunisia between 1997 and 2009. Methods Data Sources: Published and unpublished data were identified by extensive searches, complemented with specifically designed surveys. Analysis Data were integrated and analyzed using the previously validated IMPACT CHD policy model. Data items included: (i)number of CHD patients in specific groups (including acute coronary syndromes, congestive heart failure and chronic angina)(ii) uptake of specific medical and surgical treatments, and(iii) population trends in major cardiovascular risk factors (smoking, total cholesterol, systolic blood pressure (SBP), body mass index (BMI), diabetes and physical inactivity). Results CHD mortality rates increased by 11.8% for men and 23.8% for women, resulting in 680 additional CHD deaths in 2009 compared with the 1997 baseline, after adjusting for population change. Almost all (98%) of this rise was explained by risk factor increases, though men and women differed. A large rise in total cholesterol level in men (0.73 mmol/L) generated 440 additional deaths. In women, a fall (−0.43 mmol/L), apparently avoided about 95 deaths. For SBP a rise in men (4 mmHg) generated 270 additional deaths. In women, a 2 mmHg fall avoided 65 deaths. BMI and diabetes increased substantially resulting respectively in 105 and 75 additional deaths. Increased treatment uptake prevented about 450 deaths in 2009. The most important contributions came from secondary prevention following Acute Myocardial Infarction (AMI) (95 fewer deaths), initial AMI treatments (90), antihypertensive medications (80) and unstable angina (75). Conclusions Recent trends in CHD mortality mainly reflected increases in major modifiable risk factors, notably SBP and cholesterol, BMI and diabetes. Current prevention strategies are mainly focused on treatments but should become more comprehensive.

Forecasting Tunisian type 2 diabetes prevalence to 2027: validation of a simple model.

BackgroundMost projections of type 2 diabetes (T2D) prevalence are simply based on demographic change (i.e. ageing). We developed a model to predict future trends in T2D prevalence in Tunisia, explicitly taking into account trends in major risk factors (obesity and smoking). This could improve assessment of policy options for prevention and health service planning.MethodsThe IMPACT T2D model uses a Markov approach to integrate population, obesity and smoking trends to estimate future T2D prevalence. We developed a model for the Tunisian population from 1997 to 2027, and validated the model outputs by comparing with a subsequent T2D prevalence survey conducted in 2005.ResultsThe model estimated that the prevalence of T2D among Tunisians aged over 25 years was 12.0% in 1997 (95% confidence intervals 9.6%–14.4%), increasing to 15.1% (12.5%–17.4%) in 2005. Between 1997 and 2005, observed prevalence in men increased from 13.5% to 16.1% and in women from 12.9% to 14.1%. The model forecast for a dramatic rise in prevalence by 2027 (26.6% overall, 28.6% in men and 24.7% in women).However, if obesity prevalence declined by 20% in the 10 years from 2013, and if smoking decreased by 20% over 10 years from 2009, a 3.3% reduction in T2D prevalence could be achieved in 2027 (2.5% in men and 4.1% in women).ConclusionsThis innovative model provides a reasonably close estimate of T2D prevalence for Tunisia over the 1997–2027 period. Diabetes burden is now a significant public health challenge. Our model predicts that this burden will increase significantly in the next two decades. Tackling obesity, smoking and other T2D risk factors thus needs urgent action. Tunisian decision makers have therefore defined two strategies: obesity reduction and tobacco control. Responses will be evaluated in future population surveys.

Trends in Secondary Prevention of Coronary Heart Disease in Tunisia: Prevention of Recurrences of MI and Stroke

OBJECTIVES The survival benefits achieved by prescription of antiplatelet agents, B-adrenoreceptor antagonists (beta-blockers), angiotensin II receptor blockers (ARB), and lipid lowering agents in patients surviving the myocardial infarction (MI) have been well documented in large clinical trial. Despite well-established benefits, these pharmacological agents continue to be underutilized. The main objective of this study was to evaluate the progress of cardiovascular secondary prevention practices in Tunisia. METHODS The PREMISE (Prevention of Recurrence of Myocardial Infarction and Stroke) is a descriptive, cross-sectional study conducted in Tunisia in two phases (2002 and 2009). Seven hundred eighty two patients were recruited. The recruitment criteria were: previous MI, stable angina, unstable angina, percutaneous transluminal coronary angioplasty (PTCA), coronary artery bypass graft (CABG), stroke, transient ischemic attack (TIA) or carotid endarterectomy. This analysis is limited to coronary heart disease (CHD) patients. Five hundred hospital patients were interviewed and their medical records were reviewed: 250 in 2002 and 250 in 2009. Patients were included if they had confirmed diagnosis of MI, angina, CABG or PTCA, and if their first cardiovascular event had occurred more than one month but not later than 3 years ago. We compared the total of both patient groups, using the prevalence of Cardio-Vascular Risk Factors (CVRF) and the treatment prescribed at hospital discharge. RESULTS The proportion of patients with reported hypertension, diabetes, hypercholesterolemia and current smoker patients had decreased. Concerning pharmacological prescriptions, a significant increase was observed in prescribing statins (38.9% vs. 70.3%) and ACE inhibitors (49.3% vs. 69.9%), non pharmacological prescriptions as healthy diet or tobacco cessation had opposite trends. Adherence to treatment did not change substantially. CONCLUSION Although the use of cardioprotective drugs had increased in CHD patients, there are still gaps in secondary prevention in Tunisia. The recommended strategies of secondary prevention need to be applied more intensively in clinical practice.

Contrasting cardiovascular mortality trends in Eastern Mediterranean populations: Contributions from risk factor changes and treatments

BACKGROUND Middle income countries are facing an epidemic of non-communicable diseases, especially coronary heart disease (CHD). We used a validated CHD mortality model (IMPACT) to explain recent trends in Tunisia, Syria, the occupied Palestinian territory (oPt) and Turkey. METHODS Data on populations, mortality, patient numbers, treatments and risk factor trends from national and local surveys in each country were collated over two time points (1995-97; 2006-09); integrated and analysed using the IMPACT model. RESULTS Risk factor trends: Smoking prevalence was high in men, persisting in Syria but decreasing in Tunisia, oPt and Turkey. BMI rose by 1-2 kg/m(2) and diabetes prevalence increased by 40%-50%. Mean systolic blood pressure and cholesterol levels increased in Tunisia and Syria. Mortality trends: Age-standardised CHD mortality rates rose by 20% in Tunisia and 62% in Syria. Much of this increase (79% and 72% respectively) was attributed to adverse trends in major risk factors, occurring despite some improvements in treatment uptake. CHD mortality rates fell by 17% in oPt and by 25% in Turkey, with risk factor changes accounting for around 46% and 30% of this reduction respectively. Increased uptake of community treatments (drug treatments for chronic angina, heart failure, hypertension and secondary prevention after a cardiac event) accounted for most of the remainder. DISCUSSION CHD death rates are rising in Tunisia and Syria, whilst oPt and Turkey demonstrate clear falls, reflecting improvements in major risk factors with contributions from medical treatments. However, smoking prevalence remains very high in men; obesity and diabetes levels are rising dramatically.

Assessment of cardiovascular risk in Tunisia: applying the Framingham risk score to national survey data

Objective This paper aims to assess the socioeconomic determinants of a high 10 year cardiovascular risk in Tunisia. Setting We used a national population based cross sectional survey conducted in 2005 in Tunisia comprising 7780 subjects. We applied the non-laboratory version of the Framingham equation to estimate the 10 year cardiovascular risk. Participants 8007 participants, aged 35–74 years, were included in the sample but effective exclusion of individuals with cardiovascular diseases and cancer resulted in 7780 subjects (3326 men and 4454 women) included in the analysis. Results Mean age was 48.7 years. Women accounted for 50.5% of participants. According to the Framingham equation, 18.1% (17.25–18.9%) of the study population had a high risk (≥20% within 10 years). The gender difference was striking and statistically significant: 27.2% (25.7–28.7%) of men had a high risk, threefold higher than women (9.7%; 8.8–10.5%). A higher 10 year global cardiovascular risk was associated with social disadvantage in men and women; thus illiterate and divorced individuals, and adults without a professional activity had a significantly higher risk of developing a cardiovascular event in 10 years. Illiterate men were at higher risk than those with secondary and higher education (OR=7.01; 5.49 to 9.14). The risk in illiterate women was more elevated (OR=13.57; 7.58 to 24.31). Those living in an urban area had a higher risk (OR=1.45 (1.19 to 1.76) in men and OR=1.71 (1.35 to 2.18) in women). Conclusions The 10 year global cardiovascular risk in the Tunisian population is already substantially high, affecting almost a third of men and 1 in 10 women, and concentrated in those more socially disadvantaged.

Knowledge and uptake of genital cancer screening methods among Tunisian women

Genital cancers are amajor public health problem in Tunisia. There is limited research exploring Tunisian women’s understanding of these diseases. The aim of the present study was to assess the knowledge and uptake of genital cancer screening methods among a population of Tunisian women to investigate associations with socioeconomic status. A national cross-sectional survey of 4590 women aged 35–70 years was conducted between April and September, 2005. The protocol was approved by the Committee of the Tunisian National Council of Statistics. All participants gave informed consent. Questions on knowledge anduptake of genital cancer screeningmethodswere asked during an interview with each participant. Statistical calculations were performed using SPSS version 13.0 (SPSS Inc, Chicago, IL, USA). P b 0.05 was considered statistically significant. Overall, awareness among the participants that cancer could be located in the breasts or cervix was 69.1% (n = 3027) and there was a contrast in this awareness between urban and rural regions (78.1% vs 57.2%; P b 0.001). Among the women who were aware that cancer could be located in the genital organs, 46.9% (n = 1580) declared that they did not know any of the symptoms associatedwith genital cancers, whereas 32.5% (n = 1092) knew of more than one symptom. Only 26.3% (n= 1207) knew of one or more screening methods for genital cancers. The best known screening method was the Pap smear (41.6%; n = 463) followed by self-breast examination (40.0%; n = 445). Mammography was the least known (18.2%; n = 203). A higher level of education was associated with an increased knowledge of screeningmethods: 52.6% of womenwith a higher level of education knew of the Pap smear compared with 4.1% of women with no formal schooling (P b 0.001). In Hong Kong, level of education had no influence on knowledge of mammography and housewives were more likely to have heard of it than nonhousewives [1]. These findings suggest the importance of media as a source of information [2]. In the present study, only 22.4% (n = 971) of women declared that they had received at least one clinical breast examination. There was a significant difference according to area (27% [n = 667] urban vs 16.3% [n = 304] rural; P b 0.001); age (30.9% [n = 512 aged 34–44 years vs 11.3% [n = 138] aged N54 years; P b 0.001); and economic level (high 39.9% [n = 371] vs low 13% [n = 213]; P b 0.001) (Table 1). Almost 50% (n=2138) of women did not practice self-breast examination. The percentage who did perform self-examination was higher among urban women than rural women (56.7% [n = 1415] vs 38.6% [n = 723]) and among women aged 34–44 years compared with those aged 45–54 years or older than 54 years (59.4% [n = 991], 51.7% [n= 762], and 31.4% [n= 385]), P b 0.001). The highest percentage performing self-breast examination was observed in the most developed (according to socioeconomic indicators) region (69.8%; n = 409); and among the highest economic level group compared with the lowest (68.8% [n = 665] vs 35% [n = 578] P b 0.001). Only 8.6% (n = 368) of women declared that they had received at least one mammography screening. Similar low percentages have been observed [3] and factors that have been shown to influence the uptake of mammography are economic level and lack of health insurance [4]. In the present study, younger, more educated women from the highest economic level and those living in the coastal region have better access to mammography. Only 17% (n= 708) of women declared that they had undergone at least one Pap test. There was a significant difference according to area (21.6% [n = 515] urban vs 10.8% n = 193] rural; P b 0.001); age (21.4% [n = 344] aged 34–44 years vs 9% [n = 105] aged N54 years; P b 0.001); region (34.3% [n = 198] in most developed vs 10.3% [n = 65] in least developed); and economic level (32.7% [n = 305 highest vs 8.3% [n = 129] lowest). Assessment of women’s knowledge about screening methods is needed to understand their subsequent practices. Knowledge and uptake of genital cancer screening methods are still very low despite the implementation of a national program. The results of the present study elucidate several factors relevant for consideration in the national prevention and control program for genital cancers in Tunisia, and highlight inequity in access to screening.

Graphical interaction models to extract predictive risk factors of the cost of managing stroke in Tunisia

Managing stroke is a real public health problem. This study has mainly two purposes. First to evaluate the medical cost of managing this disease and to identify risk factors that influence its variation in Tunisia. We have then used a prospective study of 630 patients hospitalized for stroke in 2010 at the National Institute of Neurology of Tunis. We have assessed three different kinds of costs: in-hospital, post-hospitalization and annual costs. Afterward we have noticed huge variations in these different costs. We have then used an unsupervised clustering algorithm called the EM-algorithm to cluster the patients according to each kind of cost. We have obtained homogenous cost-clusters where each type of cost seems to be sampled from a normal distribution. Our second purpose was to identify the factors that make these costs high. We have then used a statistical technic called graphical interaction models. We mainly assume that the variables composing the data are jointly sampled from a conditional Gaussian distribution and where the interactions between the variables can be represented by an undirected graph where the vertices are the variables and where any separation statement implies a conditional independence between the concerned variables according to a specific protocol. Once these graphs are estimated we are able to determine direct and undirect factors that influence the increasing of the disease cost.