Cardiovascular Journal of Africa: Vol 31 No 5 (September/October 2020)

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CARDIOVASCULAR JOURNAL OF AFRICA • Volume 31, No 5, September/October 2020 272 AFRICA
The National Tunisian Registry of Atrial Fibrillation
(NATURE-AF) collects data from patients with AF to define
the prevalence of various cardiovascular incidences leading to
death. NATURE-AF will reveal the outcomes, frequency and
quality of oral anticoagulation in these patients. Through this
registry, unique data on the management and outcomes of AF
patients on treatment will become available.13
Article 38 of the new 2014 constitution ensures preventative
and curative health services receive priority, including social
protection and free healthcare for low-income populations and
the provision of sufficient resources towards quality services.27
Essential medicines are also available free of charge in the public
health sector.26
Tunisia, along with Rwanda, South-Africa and Senegal, is
one of the few countries in our project with a system to measure
the quality of care provided to people who have suffered
acute cardiac events.12 The country has an integrated tobacco
programme, also warning people against its dangers through
mass media campaigns.22
Threats
Tunisia’s premature CVD mortality rate (11%) is higher than
seven of the 12 countries under investigation but lower than the
12% of Cameroon, Namibia and Nigeria and the 14% of South
Africa.3,6 In 2016, the proportional mortality rate of all deaths
was 44% for CVD.7 The total CVD mortality rate is also much
higher than any of the other countries in this project, at 51.5%.
The same picture is revealed in the percentage of DALYs as a
result of CVD, at almost 22%.
Tunisian men are also the heaviest tobacco users in our study,
with more than 65% following this practice. Another CVD
indicator that needs attention is Tunisia’s high prevalence of
raised cholesterol levels. The prevalence of obesity and diabetes is
high and driven by environmental factors, nutritional transition
and a Westernised lifestyle, which are reasons for concern.34
Weaknesses
Clinical guidelines for CVD prevention within the last five years
are lacking, and not all of the essential CVD medicines are
available in the public sector.9 Although CVD risk stratification
and secondary prevention of rheumatic fever and RHD are
available at the primary healthcare level, these data have not yet
been recorded on the GHO database.
Although a national strategy exists that addresses CVD and
their risk factors, there is no dedicated budget to implement the
plan. Tunisia has also not implemented a national surveillance
system that includes CVD and their risk factors.21 No legislation
exists mandating health financing for CVD or court orders
that protect patients’ rights and improved CVD interventions,
facilities, health system procedures or resources.
There is an overall lack of information regarding stakeholder
action in the advocacy, prevention and management of CVD/
NCD or the development and implementation of plans to curb
these burdening diseases.
Priorities
Priorities include educating the population through lifestyle
modification and improved training of healthcare practitioners
to diagnose and treat patients with diabetes and other NCD,
which are urgently needed.34
Since cardiovascular risk factors such as hypertension are
highly prevalent in Tunisia, an urgent need to implement
innovative strategies to improve awareness, treatment and control
of the resultant conditions are encouraged.35 Involvement of civil
society and NGOs in the national multi-sectoral co-ordination
mechanism for NCD/CVD should be advocated.
This publication was reviewed by the PASCAR governing council and
approved by the president of the Tunisian Heart Foundation.
References
1. Mohamed AA, Fourie JM, Scholtz W, et al. Sudan Country Report:
PASCAR and WHF Cardiovascular Diseases Scorecard project.
Cardiovasc J Afr 2019; 30: 305–310.
2. Dzudie A, Fourie JM, Scholtz W, et al. Cameroon Country Report:
PASCAR and WHF Cardiovascular Diseases Scorecard project.
Cardiovasc J Afr 2020; 31(2): 103–110.
3. PASCAR WHF. The World Heart Federation and Pan-African Society
of Cardiology Cardiovascular Disease Scorecard project for Africa.
Cardiovasc J Afr 2020; 31(4)(Suppl): 1–56.
4. World Bank. [Online] 2020.
5. National Institute of Statistics. Extreme poverty rate by place of resi-
dence. Statistiques Tunisie. [Online] 2015; 07/12/2017 (updated). http://
6. World Health Organization. CVD World Monitor. [Online] 2012. http://
7. World Health Organization. Noncommunicable Diseases (NCD)
Country Profiles. [Online] 2018.
tun_en.pdf?ua=1.
8. Institute for Health Metrics and Evaluation (IHME). GHDx. Global
Health Data Exchange. [Online] 2017.
results-tool.
9. World Health Organization. The Global Health Observatory (GHO).
WHO. [Online] 2020.
10. World Health Organization. Global Report on Mortality Attributable
to Tobacco. Geneva, Switzerland: World Health Organization, 2012.
11. International Diabetes Federation (IDF). IDF Diabetes Atlas, 9th edn.
[Online] 2019.
12. Saidi O, Malouche D, O’Flaherty M, et al. Assessment of cardiovas-
cular risk in Tunisia: applying the Framingham risk score to national
survey data. Br Med J Open 2016; 6: e009195.
13. Halima AB, Ouali S, Mourali MS, et al. Design and rationale of the
national Tunisian registry of atrial fibrillation: protocol for a prospec-
tive, multicenter trial. JMIR Res Protoc 2018; 7(10): e181.
14. Hraoui M, Boubaker BB, Doloy A, et al. Epidemiological markers of
Streptococcus pyogenes strains in Tunisia. Clin Microbiol Infect 2011;
17: 63–68.
15. World Health Organization. The World Health Organization frame-
work convention on tobacco control (FCTC). Tunisia_2018_report.pdf.
[Online] 2018. Available:
16. World Health Organization. Diabetes country profiles – Tunisia. [Online]
2016.
17. Ghannem H. The challenge of preventing cardiovascular disease in
Tunisia. Prev Chronic Dis 2006:
jan/05_0069.htm.
18. World Health Organization. Tunisia: Drug prices, availability, afford-