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[08/05/2005]
 Tunisia
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Authors: Dr Francis Louis, Yaounde, Cameroon – 
Acknowledgments : Dr Pierre Ambroise-Thomas, Grenoble - Dr Slaheddine Bel Hadj, Tunis - Pr Mohamed Zribi, Sfax 
Last updated: 23rd June 2000



> General Statistics | > Epidemiological Facies | > Vectors | > Chemoresistance | > Vector Control | > The National Anti-Malaria Program | > Research | > Advice to Travelers | > Bibliography

 General Statistics

Area: 164,150 km² 
Population: 8,400,000 inhabitants
Capital: Tunis
Currency: Tunisian Dinar
Official Language: Arabic
Bordering Countries: Algeria, Libya 

Out of 192 countries Tunisia ranks 103rd for life expectancy, 112nd for infant mortality, 86th for GNP, 35th for daily calorie intake, 136th for literacy, 99th for the percentage of children in full-time education (source: Atlas Encyclopédique Mondial, Nathan Ed., Paris 1996, pp.562-563). 

Concerning climate, the country can be divided into 2 parts: the north with a Mediterranean climate and the south with a desert-like one.

 Epidemiological Facies

1. From 1903 to 1938
The first wave of anti malaria action commenced under the direction of Charles Nicolle and Edmond and Etienne Sergent (6). At the time, the entire country suffered from the disease and a number of wide spread epidemics had been recorded (1911, 1918, 1921, 1924, 1928). Three species of parasite co-existed: Plasmodium falciparumPlasmodium vivax andt Plasmodium malariae. The combined efforts of an anti larvae program, an anti adult parasite program and a quinine prophylaxis program started producing significant results as of 1935 (figure 1). 
Figure 1 - Evolution of Malaria cases in Tunisia from 1934 to 1938 (6) 

2. From 1944 to 1966: 
The anti-malaria organizations disbanded during the second world war and in 1948, more than 16,000 cases of malaria were declared by the Health Service. In 1959, a ‘Service d'Éradication du Paludisme’ (Malaria Eradication Program) was created which set up an inter-domestic home dousing and spraying plan, an Anti-larvae program, and a program for the distribution of antimalarial drugs. Although these measures were quite successful, they were insufficient and many epidemics still occurred, the last one being in 1966 (Fig. 2). 

Figure 2: Evolution of malaria cases in Tunisia from 1944 to 1967 (6) 

In 1967 a malaria eradication campaign was put in place, coordinated by the Ministry of Public Health and the World Health Organization. It targeted malaria vectors and the screening / treating of patients. The exemplary conditions of the collaboration during this period are worthy of a special mention as this is unfortunately not an everyday occurrence. 
In 1972, only 15 cases of malaria were diagnosed (Fig. 3). 

Figure 3: Evolution of Malaria cases in Tunisia from 1966 to 1972 (6) 

The last site was that of Jendouba were 16 cases of malaria due to Plasmodium vivax were reported in 1975 and 6 cases in 1976. The last autochthonous case was reported in 1979 (6). 
Since 1979, only imported cases of malaria have been recorded: 
51 cases from 1978 to 1984 (6),in other words 7.2 cases per year
245 cases from 1980 to 1995 (11), in other words 15.3 cases per year
133 cases from 1991 to 1998 (12), in other words 16.6 cases per year

There is a progressive increase trend therefore. More than 80% of the cases diagnosed are caused by Plasmodium falciparum (12). Almost 93% of the cases originate from Africa, namely West Africa (12). 

One case of Plasmodium  vivax malaria contracted in Tunis was reported in 1988 by A. Fisch et al. (8)

 Vectors
According to M.S. Ben Rachid et al., the two principal malaria vectors in Tunisia are Anopheles maculipennis var. labranchiae in the north where the malaria transmission season falls from June to October, and Anopheles sergenti in the south, where the malaria transmission season occurs from May to November (5). Other less important species are: Anopheles algeriensis, 
Anopheles claviger, Anopheles coustani, Anopheles marteri, Anopheles broussei, Anopheles hispaniola, Anopheles multicolor, Anopheles d'thali and Anopheles superpictus
.
 Chemoresistance
There have been no published findings of chemoresistance, but it is likely that introduced parasite strains will present a chemoresistance in accordance to their country of origin.
 Vector Control
Anopheles is still found in Tunisia but the systematic fight for vector control has been abandoned for a number of years, leading many to fear a long term revival of native malaria due to increasing numbers of introduced cases (12).
 The National Anti-Malaria Program
There is no national program in Tunisia. However, a Malaria Representative has been nominated, Docteur Moncef SIDHOM, Director of Basic Health Care for ‘”ministère de la Santé Publique”, 31 rue Khartoum, 1002 Tunis.
 Research
There is no research program running at present.
 Advice to Travelers
No chemoprophyaxis is necessary. Simple measures of individual protection against insect bites are largely sufficient.
 Bibliography
(only the first author is mentioned) 

1. BAUDIN A.L. - Situation épidémiologique du gouvernorat de Sousse en 1970. La Tunisie médicale 1971 ; 49: 213-217. 

2. AMBROISE-THOMAS P. - Longitudinal sero-epidemiological studies on malaria in Tunisia. Doc. WHO/MAL/74.834, 1974, 54 p. 

3. AMBROISE-THOMAS P. - etude séro-épidémiologique longitudinale sur le paludisme en Tunisie. Bull. OMS 1976 ; 54: 355-367.

4. NICOLLE P. - Alphonse Laveran et Charles Nicolle. Archs. Inst. Pasteur Tunis 1981 ; 58: 265-279.5. BEN RACHID M.S. - Géographie des parasitoses majeures en Tunisie. Archs. Inst. Pasteur Tunis 1984 ; 61: 17-41. 

6. CHADLI A. - Le paludisme en Tunisie: historique et état actuel. Bull. Soc. Pathol. Exot. 1985 ; 78: 844-851. 

7. CHADLI A. - Les campagnes d'éradication du paludisme en Tunisie: historique et situation actuelle. Archs. Inst. Pasteur Tunis 1986 ; 63: 35-50.

8. FISCH A. - Paludisme à Plasmodium vivax sur la côte tunisienne. Presse Med. 1988 ; 17: 1364. 

9. GAVAGHAN H. - Tunisian institute to tackle secrets of malaria genome. Nature 1994 ; 371: 732. 

10. BEL HADJ S. - Réflexions sur le paludisme d'importation en Tunisie. Maghreb Médical 1996 ; n°308: 12-13. 

11. BOURATBINE A. - Le paludisme d'importation en Tunisie. Bull. Soc. Pathol. Exot. 1998 ; 91: 203-207. 

12. BEL HADJ S. - Bilan des cas de paludisme diagnostiqués au CHU La Rabta de Tunis (1991-1998). In: Troisième Congrès de la Société Tunisienne de Parasitologie-Mycologie, Monastir, Tunisie, 26-29/06/1999.
 

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