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Hechaichi A, Bouguerra H, Letaief H, Safer M, Missaoui L, Cherif A, Farah S, Jabrane H, Atawa T, Yahia H, Hamdouni H, Zitoun K, Chahed K, Laamouri R, Daaboub J, Rabhi M, Salah AB, Chahed MK, Bouafif Ben Alaya N. Outbreak Investigation of Typhoid Fever in the District of Gabes, South of Tunisia. Epidemiologia (Basel) 2023; 4:223-234. [PMID: 37489494 PMCID: PMC10366729 DOI: 10.3390/epidemiologia4030023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Revised: 04/28/2023] [Accepted: 05/08/2023] [Indexed: 07/26/2023] Open
Abstract
Typhoid fever is a significant public health concern in many parts of the world, particularly in developing countries with poor sanitation and hygiene conditions. In July 2016, an outbreak of typhoid fever occurred in Ghannouche, located in the south of Tunisia. This paper reports the results of a field investigation undertaken to identify possible transmission pathways and risk factors in order to propose control and preventive measures. A retrospective cohort study including a passive and active case finding, as well as an environmental and bacteriological investigation was conducted from July to September 2016. A case was defined as a person residing or having stayed in Ghannouche and having presented from the beginning of June clinical signs suggestive of typhoid fever, with, for a confirmed case, laboratory isolation of S.Tyhi, and for a probable case, an epidemiological link with a confirmed case. Attack rates were determined, and risk ratios were estimated with respect to exposures. Unadjusted and adjusted odds ratios were estimated using binary logistic regression. Among the 628 subjects investigated, 102 cases of typhoid fever were identified (74 confirmed and 28 probable) with an overall attack rate of 16.24%. Over 56% of cases were male and those under 10 years old were most affected (38.2%% of cases) with a median age of 12 years (interquartile range 5 to 25 years). The main clinical signs were fever (95%) and diarrhea (57%). Young age (adjusted OR = 0.95 and 95% CI = 0.93-0.97), low level of education (adjusted OR = 4.76 and 95% CI = 1.34-16.81), and the habitat type Arab or rudimentary house (adjusted OR = 4.93 and 95% CI = 2.61-8.27) were the socio-demographic factors independently associated with typhoid fever. Typhoid fever was found to be associated with drinking softened water (adjusted OR = 2.64 and 95% CI = 1.16-4.82), eating raw fruit and vegetables from family gardens (adjusted OR = 6.13 and 95% CI = 3.66-11.06), and using uncontrolled waste disposal (adjusted OR = 3.52 and 95% CI = 2.03-6.94). A total of 110 drinking water samples were analyzed; out of the 38 samples of softened water, 12 were non-compliant and 5 were positive for Salmonella. The screening activity identified two asymptomatic carriers, one of whom was a softened water seller. We concluded that drinking softened water from informal or unauthorized sale units, consuming fruit and vegetables from family gardens, uncontrolled dumping of household waste, and poor socio-economic conditions increase the risk of typhoid fever in this region. Many recommendations were implemented to stop this outbreak and to prevent further episodes.
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Affiliation(s)
- Aicha Hechaichi
- National Observatory of Emerging Diseases, Ministry of Health, Diplomat Building, 5-7 Khartoum Street, Le Belvédère, Tunis 1002, Tunisia
- Preventive Medicine Department, Faculté de Médecine de Tunis, Université de Tunis El Manar, Tunis 1007, Tunisia
- Preventive Medicine Department, Faculté de Médecine de Tunis, Université de Tunis El Manar, LR01ES04 Epidémiologie et Prévention des Maladies Cardiovasculaires en Tunisie, Tunis 1007, Tunisia
| | - Hind Bouguerra
- National Observatory of Emerging Diseases, Ministry of Health, Diplomat Building, 5-7 Khartoum Street, Le Belvédère, Tunis 1002, Tunisia
- Preventive Medicine Department, Faculté de Médecine de Tunis, Université de Tunis El Manar, Tunis 1007, Tunisia
- Preventive Medicine Department, Faculté de Médecine de Tunis, Université de Tunis El Manar, LR01ES04 Epidémiologie et Prévention des Maladies Cardiovasculaires en Tunisie, Tunis 1007, Tunisia
| | - Hajer Letaief
- National Observatory of Emerging Diseases, Ministry of Health, Diplomat Building, 5-7 Khartoum Street, Le Belvédère, Tunis 1002, Tunisia
- Preventive Medicine Department, Faculté de Médecine de Tunis, Université de Tunis El Manar, Tunis 1007, Tunisia
- Preventive Medicine Department, Faculté de Médecine de Tunis, Université de Tunis El Manar, LR01ES04 Epidémiologie et Prévention des Maladies Cardiovasculaires en Tunisie, Tunis 1007, Tunisia
| | - Mouna Safer
- National Observatory of Emerging Diseases, Ministry of Health, Diplomat Building, 5-7 Khartoum Street, Le Belvédère, Tunis 1002, Tunisia
- Preventive Medicine Department, Faculté de Médecine de Tunis, Université de Tunis El Manar, Tunis 1007, Tunisia
- Preventive Medicine Department, Faculté de Médecine de Tunis, Université de Tunis El Manar, LR01ES04 Epidémiologie et Prévention des Maladies Cardiovasculaires en Tunisie, Tunis 1007, Tunisia
| | - Lamia Missaoui
- National Observatory of Emerging Diseases, Ministry of Health, Diplomat Building, 5-7 Khartoum Street, Le Belvédère, Tunis 1002, Tunisia
| | - Amal Cherif
- National Observatory of Emerging Diseases, Ministry of Health, Diplomat Building, 5-7 Khartoum Street, Le Belvédère, Tunis 1002, Tunisia
| | - Saffar Farah
- National Observatory of Emerging Diseases, Ministry of Health, Diplomat Building, 5-7 Khartoum Street, Le Belvédère, Tunis 1002, Tunisia
| | - Houcine Jabrane
- Direction Régionale de Santé Gabès, Place du Gouvernorat, Gabès 6000, Tunisia
| | - Taoufik Atawa
- Direction des Soins de Santé de Base, Ministry of Health, 31 Khartoum Street, Tunis 1002, Tunisia
| | - Hamdi Yahia
- Direction Régionale de Santé Gabès, Place du Gouvernorat, Gabès 6000, Tunisia
| | - Hayet Hamdouni
- Direction des Soins de Santé de Base, Ministry of Health, 31 Khartoum Street, Tunis 1002, Tunisia
| | - Khadija Zitoun
- Direction Régionale de Santé Tunis, 9 Rue Ibn El Haythem, Tunis 1002, Tunisia
| | - Karim Chahed
- National Observatory of Emerging Diseases, Ministry of Health, Diplomat Building, 5-7 Khartoum Street, Le Belvédère, Tunis 1002, Tunisia
| | - Ramzi Laamouri
- National Observatory of Emerging Diseases, Ministry of Health, Diplomat Building, 5-7 Khartoum Street, Le Belvédère, Tunis 1002, Tunisia
| | - Jaber Daaboub
- Direction de L'hygiène du Milieu et de la Protection de L'environnement, Ministry of Health, Bab Saadoun, Tunis 1006, Tunisia
| | - Mohamed Rabhi
- Direction de L'hygiène du Milieu et de la Protection de L'environnement, Ministry of Health, Bab Saadoun, Tunis 1006, Tunisia
| | - Afif Ben Salah
- Graduate Studies and Research, Arabian Gulf University, Road 2904 Building 293, Manama 329, Bahrain
| | - Mohamed Kouni Chahed
- Preventive Medicine Department, Faculté de Médecine de Tunis, Université de Tunis El Manar, Tunis 1007, Tunisia
| | - Nissaf Bouafif Ben Alaya
- National Observatory of Emerging Diseases, Ministry of Health, Diplomat Building, 5-7 Khartoum Street, Le Belvédère, Tunis 1002, Tunisia
- Preventive Medicine Department, Faculté de Médecine de Tunis, Université de Tunis El Manar, Tunis 1007, Tunisia
- Preventive Medicine Department, Faculté de Médecine de Tunis, Université de Tunis El Manar, LR01ES04 Epidémiologie et Prévention des Maladies Cardiovasculaires en Tunisie, Tunis 1007, Tunisia
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Safer M, Letaief H, Hechaichi A, Harizi C, Dhaouadi S, Bouabid L, Darouiche S, Gharbi D, Elmili N, Ben Salah H, Hammami M, Talmoudi K, Moussa R, Charaa N, Termiz H, Ltaief F, Tounekti H, Makhlouf M, Belguith Sriha A, Ben Fredj M, Khalfallah S, Jabrane H, Mchirgui S, Amich C, Dabghi R, Anez Z, Abdelkader L, Mhamdi M, Ouerfeli N, Zoghlami S, Bougatef S, Chahed MK, Bouafif Ben Alaya N. Identification of transmission chains and clusters associated with COVID-19 in Tunisia. BMC Infect Dis 2021; 21:453. [PMID: 34011266 PMCID: PMC8132040 DOI: 10.1186/s12879-021-06107-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Accepted: 04/22/2021] [Indexed: 12/12/2022] Open
Abstract
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.
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Affiliation(s)
- Mouna Safer
- National Observatory of New and Emerging Diseases, Ministry Of Health, Tunis, Tunisia.
- Cardio Vascular Disease Epidemiology and Prevention Research Laboratory, Faculty of Medicine, University of Tunis El Manar, Tunis, Tunisia.
| | - Hejer Letaief
- National Observatory of New and Emerging Diseases, Ministry Of Health, Tunis, Tunisia
- Cardio Vascular Disease Epidemiology and Prevention Research Laboratory, Faculty of Medicine, University of Tunis El Manar, Tunis, Tunisia
| | - Aicha Hechaichi
- National Observatory of New and Emerging Diseases, Ministry Of Health, Tunis, Tunisia
- Cardio Vascular Disease Epidemiology and Prevention Research Laboratory, Faculty of Medicine, University of Tunis El Manar, Tunis, Tunisia
| | - Chahida Harizi
- Department of Epidemiology and Statistics, Abderrahman Mami Hospital, Ariana, Tunisia
| | - Sonia Dhaouadi
- National Observatory of New and Emerging Diseases, Ministry Of Health, Tunis, Tunisia
| | - Leila Bouabid
- National Observatory of New and Emerging Diseases, Ministry Of Health, Tunis, Tunisia
| | - Sondes Darouiche
- National Observatory of New and Emerging Diseases, Ministry Of Health, Tunis, Tunisia
| | - Donia Gharbi
- National Observatory of New and Emerging Diseases, Ministry Of Health, Tunis, Tunisia
| | - Nawel Elmili
- National Observatory of New and Emerging Diseases, Ministry Of Health, Tunis, Tunisia
| | - Hamida Ben Salah
- National Observatory of New and Emerging Diseases, Ministry Of Health, Tunis, Tunisia
| | - Mongi Hammami
- National Observatory of New and Emerging Diseases, Ministry Of Health, Tunis, Tunisia
| | - Khouloud Talmoudi
- National Observatory of New and Emerging Diseases, Ministry Of Health, Tunis, Tunisia
| | - Rim Moussa
- Public Health Surveillance Regional Departments, Tunis, Tunisia
| | - Nejib Charaa
- Public Health Surveillance Regional Departments, Tunis, Tunisia
| | - Hasna Termiz
- Public Health Surveillance Regional Departments, Tunis, Tunisia
| | - Fethi Ltaief
- Public Health Surveillance Regional Departments, Tunis, Tunisia
| | - Habib Tounekti
- Public Health Surveillance Regional Departments, Tunis, Tunisia
| | | | - Asma Belguith Sriha
- Department of Community and Preventive Medicine Faculty of Medicine, University of Monastir Tunisia, Tunis, Tunisia
| | - Manel Ben Fredj
- Department of Community and Preventive Medicine Faculty of Medicine, University of Monastir Tunisia, Tunis, Tunisia
| | | | - Houcine Jabrane
- Public Health Surveillance Regional Departments, Tunis, Tunisia
| | - Selma Mchirgui
- Public Health Surveillance Regional Departments, Tunis, Tunisia
| | - Chedli Amich
- Public Health Surveillance Regional Departments, Tunis, Tunisia
| | - Radhia Dabghi
- Public Health Surveillance Regional Departments, Tunis, Tunisia
| | - Zid Anez
- Public Health Surveillance Regional Departments, Tunis, Tunisia
| | | | - Moncef Mhamdi
- Public Health Surveillance Regional Departments, Tunis, Tunisia
| | - Nabil Ouerfeli
- Public Health Surveillance Regional Departments, Tunis, Tunisia
| | - Salah Zoghlami
- Public Health Surveillance Regional Departments, Tunis, Tunisia
| | - Souha Bougatef
- National Observatory of New and Emerging Diseases, Ministry Of Health, Tunis, Tunisia
- Cardio Vascular Disease Epidemiology and Prevention Research Laboratory, Faculty of Medicine, University of Tunis El Manar, Tunis, Tunisia
| | - Mohamed Kouni Chahed
- Department of Epidemiology and Public Health, Faculty of Medicine of Tunis, Tunis El-Manar University, Tunis, Tunisia
| | - Nissaf Bouafif Ben Alaya
- National Observatory of New and Emerging Diseases, Ministry Of Health, Tunis, Tunisia
- Cardio Vascular Disease Epidemiology and Prevention Research Laboratory, Faculty of Medicine, University of Tunis El Manar, Tunis, Tunisia
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