scholarly journals Vitamin D status in exclusively breastfed infants and their mothers

2021 ◽  
Vol 8 (10) ◽  
pp. 1675
Author(s):  
C. R. Vignesh Kumaran ◽  
K. V. Sivakumar ◽  
R. Suresh Kumar
Keyword(s):  
Vitamin D ◽  
Vitamin D Deficiency ◽  
Significant Positive Correlation ◽  
Hypovitaminosis D ◽  
Descriptive Study ◽  
Vitamin D Status ◽  
Breastfed Infants ◽  
Tropical Area ◽  
The Mean ◽  
Breast Fed

Background: The prevalence of hypovitaminosis D in exclusively breastfed infants was found to be 82%, 52% and 20 % from UAE, Pakistan and China respectively but there is a paucity of data from India regarding the same.Methods: Prevalence of subclinical Hypovitaminosis D in exclusive breastfed babies and their mothers. This study was a descriptive study conducted among breastfed infants and their mothers to reconnoitre the vitamin D level status. All exclusively breast fed healthy term babies with birth weight >2.5 kg who are less than 6 months of age and its mothers. The existence of correlation in the mean vitamin D level between the exclusively breastfed mothers and its infants.Results: The infants status of vitamin D deficiency and insufficient was 91.9% and 8.1% respectively. The mothers status of vitamin D deficiency and insufficient was 78.3% and 21.7% respectively.Conclusions: Hypovitaminosis D was highly prevalent among mothers living in tropical area irrespective of diet habits or socioeconomic group. There was a significant positive correlation in the mean Vitamin D level of the mothers and their exclusively breastfed infants.

scholarly journals Vitamin D Status in Pregnancy: Fetomaternal Outcome and Correlation with Cord Blood Vitamin D

2017 ◽  
Vol 21 (1) ◽  
pp. 42-48
Author(s):  
Sanjay Jain ◽  
Arijit Debnath ◽  
Somosri Ray
Keyword(s):  
Vitamin D ◽  
Cord Blood ◽  
Pregnant Women ◽  
Vitamin D Deficiency ◽  
Hypovitaminosis D ◽  
P Value ◽  
Strong Positive Correlation ◽  
Vitamin D Status ◽  
The Mean ◽  
In Pregnancy

ABSTRACT Introduction Hypovitaminosis D in pregnancy has been reported to cause various maternal effects, i.e., hypocalcemia, subclinical myopathy, increased risk of preeclampsia (PE), gestational diabetes mellitus (GDM), cesarean sections, and fetal effects, i.e., neonatal tetany, hyperbilirubinemia congenital rickets, infantile rickets, etc. Only few Indian studies are available in this regard. Objective To estimate serum vitamin D levels in pregnant women, cord blood, and study fetomaternal outcomes. Materials and methods A prospective observational study was conducted on 54 consecutive pregnant women and their newborn babies. Serum 25-hydroxy vitamin D [25(OH)D] level was estimated in all women at the time of admission in labor ward. They were followed up to delivery and 48 hours postpartum. Vitamin D was also estimated in cord blood collected during delivery. All results were recorded and analyzed statistically. Results The mean 25(OH)D level in pregnancy was 6.81 ± 7.38 ng/mL. The mean 25(OH)D level in their babies (cord blood) was 6.34 ± 7.05 ng/mL. There was very strong positive correlation between maternal and fetal serum 25(OH)D levels (p-value 0.001, r-value 0.9). Vitamin D deficiency was strongly associated with obesity, PE, and GDM (p-value 0.001). Neonatal jaundice and tetany were also significantly associated with severe vitamin D deficiency. Conclusion Low levels of vitamin D have been observed in pregnant women and their newborn babies. Hypovitaminosis D has been associated with adverse fetomaternal outcomes. As there is a strong correlation of maternal and neonatal levels, supplementing vitamin D in a pregnant women might improve these adverse pregnancy outcomes. How to cite this article Gupta M, Debnath A, Jain S, Saini V, Ray S. Vitamin D Status in Pregnancy: Fetomaternal Outcome and Correlation with Cord Blood Vitamin D. Indian J Med Biochem 2017;21(1):42-48.

scholarly journals Vitamin D deficiency among patients with COVID-19: case series and recent literature review

2020 ◽  
Vol 48 (1) ◽  
Author(s):  
Rizaldy Taslim Pinzon ◽  
Angela ◽  
Andryawan Wahyu Pradana
Keyword(s):  
Vitamin D ◽  
Vitamin D Deficiency ◽  
Clinical Symptoms ◽  
Case Series ◽  
Hypovitaminosis D ◽  
Vitamin D Insufficiency ◽  
Vitamin D Status ◽  
Vitamin D Levels ◽  
Laboratory Examinations ◽  
The Mean

Abstract Background The world is now challenging the pandemic of COVID-19 infection. This is the third and most extensive pandemic. Previous studies showed the plausibility of vitamin D prophylaxis and therapy for COVID-19, particularly in settings where hypovitaminosis D is frequent. Recent study from Indonesian showed that the prevalence of vitamin D deficiency was 23.0%. The examination of vitamin D status is not a routine in the Indonesian clinical setting. Methods This study is a case series from confirmed cases of COVID-19 in Bethesda Hospital Yogyakarta Indonesia. The data of clinical symptoms, signs and laboratory examinations were obtained from the electronic medical records. The vitamin D status was measured by Enzyme-Linked Fluorescent Assay (ELFA) method. We searched PubMed and Google Scholar for studies that included terms for Vitamin D and COVID-19. Results The data were obtained from 10 participants consisting of 50% male and 50% female. The mean age was 49.6 years. The prevalence of vitamin D deficiency in this study was 90% (vitamin D levels < 20 ng/mL) and 10% of insufficiency (vitamin D levels < 30 ng/mL). Patients in this study had various symptoms such as fatigue (60%), fever (50%), dry cough (40%), non-specific headache (10%), and diarrhea (10%); have no symptoms (20%); and also had the various chronic diseases as comorbidity such as hypertension (40%), diabetes (10%), COPD (10%), and post stroke (10%). Conclusions All of the COVID-19 patients in this study had hypovitaminosis D. The prevalence of vitamin D deficiency in this case series is 90% and only 1 patient (10%) had vitamin D insufficiency. There are many health benefits of vitamin D and very few adverse effects. Randomized controlled trials need to determine and evaluate this recommendation in preventing or treating COVID-19. Clinicians should continue to treat people with vitamin D deficiency especially in managing COVID-19 patients.

scholarly journals A study to evaluate serum 25-hydroxy vitamin D3 and calcium levels in maternal and cord blood and their effect on pregnancy outcome

2019 ◽  
Vol 8 (4) ◽  
pp. 1575
Author(s):  
Radha B. P. Thangappah ◽  
Ursula Sampson ◽  
Amrin Azad ◽  
Rathna Arumugam ◽  
Smriti Anand ◽  
...  
Keyword(s):  
Vitamin D ◽  
Cord Blood ◽  
Vitamin D Deficiency ◽  
Vitamin D3 ◽  
Vitamin D Status ◽  
Blood Samples ◽  
South Indian ◽  
The Mean ◽  
Very High ◽  
Pregnant Mothers

Background: To determine the prevalence of vitamin D deficiency among pregnant mothers and their neonates and to study the effect of vitamin D deficiency on maternal and perinatal outcome.Methods: This prospective cohort study conducted in a teaching hospital included 223 pregnant mothers and their offspring born in 2017. Detailed history was taken to ascertain the causes of vitamin D deficiency.   vitamin D3 and calcium levels were estimated in maternal and cord blood samples. To study the association between the vitamin D status and the various maternal and neonatal parameters.Results: 91.9 % of women were house wives involved in indoor activities. Pre-eclampsia and GDM were seen in 4.5% of cases each. 5.41% were obese and 84%  were of medium complexion,  and 8% were  dark. 93.7% were non- vegetarians,  and fish, egg and milk consumption was adequate in 61.3% , 64% and 71% respectively. Only 5.40% of women had adequate exposure to sunlight.  The mean birth weight was 3.08± 0.36 Kg. and 14 babies were admitted to NICU for neonatal asphyxia.77.40% had deficient levels of vitamin D  <20 ng/ml. Only four pregnant mothers (1.8%) had sufficient levels vitamin D. There was no statistically significant association between vitamin D deficiency and various maternal and neonatal parameters.Conclusions: This study has shown that the prevalence of vitamin D deficiency among south Indian pregnant mothers and their newborn is very high and the ways to improve the vitamin D status among pregnant mothers should be looked at.

scholarly journals Assessment of risk factors associated with vitamin D status among children of an urban and a rural areas of Bangladesh

2020 ◽  
Vol 46 (2) ◽  
pp. 134-141
Author(s):  
Anamika Saha ◽  
Md Salim Shakur ◽  
Runa Laila ◽  
Salomee Shakur ◽  
Md Sohel Shomik ◽  
...  
Keyword(s):  
Risk Factors ◽  
Vitamin D ◽  
Vitamin D Deficiency ◽  
Hypovitaminosis D ◽  
Urban Children ◽  
Outpatient Department ◽  
P Value ◽  
Rural Children ◽  
Vitamin D Status ◽  
Factors Associated

Background: Vitamin D deficiency is one of the most common micronutrient deficiency in children worldwide, even in Bangladesh. However, to date, the prevalence of vitamin D deficiency among children of different region of Bangladesh is less reported. Objective: This study was conducted to assess vitamin D status of urban and rural Bangladeshi children including the risk factors associated with vitamin D deficiency are also evaluated. Methods: A multi-centre (urban and rural based), cross sectional study was done from July 2016 to June 2017, using serum 25(OH) vitamin D3 as a marker of nutritional vitamin D status. Urban and rural children were taken from Paediatric Outpatient Department, United Hospital Limited. Dhaka and Medical Outpatient Department, Upazila Health Complex, Ghatail, Tangail respectively. Children of 1-10 years age attending OPD with mild undernutrition (<–1 SD z score) and/or clinical features suggestive of vitamin D deficiency were included in the study. Results: A total 150 children were studied with 102 (68.0%) urban and 48 (32.0%) rural children. Hypovitaminosis D (25-OHD <30ng/ml) was found in 75.0% of children. Hypovitaminosis D was found significantly more in urban children (81.0%) compared to rural (62.0%) children (OR=0.382, 95% CI: 0.177-0.822, p value <0.05). Inadequate exposure to sunlight was significantly associated with hypovitaminosis D compared to adequate sun exposure and it was about 2.5 times higher (OR=2.475, 95% CI: 1.139-5.380, p value <0.05). No significant associations of vitamin D deficiency were detected with skin color of children, covering clothes of mother, exclusive breast feeding, limb pain and anthropometric status. Children of higher educated mother (above Secondary School Certificate) (OR=0.412, 95% CI: 0.189-0.900) were more associated with vitamin D deficiency. Conclusion: Vitamin D deficiency (VDD) is prevalent among Bangladeshi children, urban children being more vulnerable to VDD. Adoption of a screening programme for children of all age group and implementation of preventive strategies for VDD through public health policies are strongly recommended. Bangladesh Med Res Counc Bull 2020; 46(2): 134-141

scholarly journals Vitamin D status among immigrant mothers from Pakistan, Turkey and Somalia and their infants attending child health clinics in Norway

2008 ◽  
Vol 101 (7) ◽  
pp. 1052-1058 ◽  
Author(s):  
Ahmed A. Madar ◽  
Lars C. Stene ◽  
Haakon E. Meyer
Keyword(s):  
Vitamin D ◽  
Child Health ◽  
Vitamin D Deficiency ◽  
Positive Association ◽  
Vitamin D Status ◽  
Limited Information ◽  
Immigrant Mothers ◽  
Health Clinics ◽  
Vitamin D Supplements ◽  
Breast Fed

High prevalences of vitamin D deficiency have been reported in non-Western immigrants moving to Western countries, including Norway, but there is limited information on vitamin D status in infants born to immigrant mothers. We aimed to describe the vitamin D status and potentially correlated factors among infants aged 6 weeks and their mothers with Pakistani, Turkish or Somali background attending child health clinics in Norway. Eighty-six healthy infants and their mothers with immigrant background were recruited at the routine 6-week check-up at nine centres between 2004 and 2006. Venous or capillary blood was collected at the clinics from the mother and infant, and serum separated for analysis of 25-hydroxyvitamin D (s-25(OH)D) and intact parathyroid hormone (s-iPTH). The mean maternal s-25(OH)D was 25·8 nmol/l, with 57 % below 25 nmol/l and 15 % below 12·5 nmol/l. Of the mothers, 26 % had s-iPTH>5·7 pmol/l. For infants, mean s-25(OH)D was 41·7 nmol/l, with 47 % below 25 nmol/l and 34 % below 12·5 nmol/l. s-25(OH)D was considerably lower in the thirty-one exclusively breast-fed infants (mean 11·1 nmol/l; P < 0·0001). Use of vitamin D supplements and education showed a positive association with maternal s-25(OH)D. There was no significant association between mother's and child's s-25(OH)D, and no significant ethnic or seasonal variation in s-25(OH)D for mothers or infants. In conclusion, there is widespread vitamin D deficiency in immigrant mothers and their infants living in Norway. Exclusively breast-fed infants who did not receive vitamin D supplements had particularly severe vitamin D deficiency.

scholarly journals Vitamin D Status and Its Associated Risk Factors among Adults in the Southwest Region of Cameroon

2018 ◽  
Vol 2018 ◽  
pp. 1-9 ◽  
Author(s):  
Delphine A. Tangoh ◽  
Tobias O. Apinjoh ◽  
Yasir Mahmood ◽  
Robert V. Nyingchu ◽  
Beatrice A. Tangunyi ◽  
...  
Keyword(s):  
Risk Factors ◽  
Vitamin D ◽  
Vitamin D Deficiency ◽  
Hypovitaminosis D ◽  
Vitamin D Status ◽  
West Region ◽  
South West ◽  
Study Population ◽  
Associated Risk Factors ◽  
South West Region

Background. Vitamin D has been shown to exert its actions on the musculoskeletal, gastrointestinal, prostate, renal, endocrine, immune, and cardiovascular systems. Current reported data of hypovitaminosis D reveals a global pandemic, with an estimated one billion people worldwide presenting with hypovitaminosis D. Objective. This study aimed at investigating the vitamin D status and its associated risk factors in Cameroonians from the South West Region. Method. The study was a community- and hospital-based prospective longitudinal study. It was carried out during the dry and rainy seasons between the months of July and December 2015 in the South West Region of Cameroon involving 372 participants aged 35 years and above. After obtaining informed consent, a structured questionnaire was used to capture demographic data and risk factors of vitamin D deficiency. Blood samples were collected from the volunteer participants in the peak months of the rainy season and dry season, and the serum used to analyse for vitamin D by ELISA and calcium by spectrophotometry. 25(OH)D levels ≥75 nmol/L (≥30 ng/mL) were considered sufficient while levels <75 nmol/L were considered as hypovitaminosis D (insufficiency/deficiency). Results. Hypovitaminosis D (deficiency/insufficiency) was prevalent in 25.8% (96) of the study population, with only 3.2% (12) deficiency and 22.6% (84) insufficiency. There was a significant inverse relationship r=−0.119,p=0.02 between age and 25(OH)D levels; however, this relationship was not significant when controlled for gender, number of hours spent outdoors, and percentage of body covered. Gender, ethnic origin, percentage of body covered, time spent outdoors, and season did not influence serum vitamin D levels. Conclusion. Results of this study suggest that the prevalence of hypovitaminosis D is relatively low in this study population and only age is a risk factor of vitamin D deficiency.

scholarly journals The Prevalence of Hypovitaminosis D and Its Associated Risk Factors Among Women of Reproductive Age in Saudi Arabia: A Systematic Review and Meta-Analysis

2018 ◽  
Vol 11 ◽  
pp. 1179562X1876788 ◽  
Author(s):  
Riyadh A Alzaheb
Keyword(s):  
Risk Factors ◽  
Vitamin D ◽  
Saudi Arabia ◽  
Vitamin D Deficiency ◽  
Meta Analysis ◽  
Hypovitaminosis D ◽  
Reproductive Age ◽  
Vitamin D Status ◽  
Women Of Reproductive Age ◽  
Associated Risk Factors

Vitamin D deficiency is currently a worldwide epidemic. Middle Eastern countries, including Saudi Arabia, have high vitamin D deficiency prevalence, most prominently among women, despite their plentiful year-round sunshine. Previous research investigating vitamin D status among Saudi women of reproductive age (15-49 years) is scarce, and no study has used a nationally representative sample, so this review quantified overall hypovitaminosis D prevalence among women in Saudi Arabia and explored the associated risk factors. The Web of Science, Scopus, and Medline databases were searched for prior studies in Saudi Arabia exploring vitamin D status among women of reproductive age, published between January 1, 2000 and May 25, 2017. Data were extracted from the identified studies, and a random effects model meta-analysis established the overall hypovitaminosis D prevalence. The initial search yielded 223 possibly relevant articles; 13 were confirmed as eligible, with samples totaling 2877 women aged between 15 and 49 years. Meta-analysis revealed a mean serum 25-hydroxyvitamin D, 25(OH)D, level of 13.1 ng/mL (95% confidence interval [CI]: 11.6-14.6) and an overall prevalence of hypovitaminosis D, defined as 25(OH)D < 30 ng/mL, of 77.4% (95% CI: 63.2-87.3), mostly due to insufficient sunlight exposure and low dietary vitamin D intake. There is therefore a need for a national strategy to raise vitamin D levels among women in Saudi Arabia by advising them on natural vitamin D sources, and recommending the timing and duration of sun exposure, while also defining a national approach to vitamin D fortification and supplementation.

scholarly journals Effect of Vitamin D supplementation and outdoor activity on serum 25-Hydroxyvitamin D among children in North China: an observational study

2020 ◽  
Author(s):  
Xuguang Zhang ◽  
Yanping Chen ◽  
Shanshan Jin ◽  
Xinxin Bi ◽  
Dongkai Chen ◽  
...  
Keyword(s):  
Vitamin D ◽  
Vitamin D Deficiency ◽  
Lower Risk ◽  
North China ◽  
Pediatric Population ◽  
Hypovitaminosis D ◽  
Vitamin D Supplementation ◽  
High Latitudes ◽  
Vitamin D Status ◽  
Outdoor Activity

Abstract Background Living at high latitudes is one of the risk factors for vitamin D deficiency in children. However, evidence on vitamin D improvement for this pediatric population to date is limited. This study aims at evaluating the effect of different supplementation methods and outdoor activity time on the vitamin D status of children in North China. Methods A total of 55,925 children aged 1 month to 18 years old were recruited from pediatric outpatient departments from July 2016 to June 2017. Data on demographics, anthropometric measurements, vitamin D supplementation, and outdoor time were recorded. The serum levels of 25-hydroxycholecalciferol (25(OH)D) were determined by high performance liquid chromatography tandem–mass spectrometry. Logistic regression analysis was performed to assess the association of vitamin D supplementation or outdoor time with blood vitamin D status, adjusted for age, gender, BMI for age, and seasons. Results The overall rate of hypovitaminosis D was 65.60%. Of the children’s outdoor time, 35.63%, 31.95%, and 32.42% were below 30 min/d, 30–60 min/d and over 60 min/d, respectively. Furthermore, the proportion of iatrogenic supplementation, voluntary supplementation and no vitamin D supplementation among the children was 16.48%, 32.87%, and 50.65%, respectively. After adjusted for confounding factors, vitamin D supplementation was associated with a lower risk of hypovitaminosis D, with OR (95% CI) of 0.191 (0.180, 0.202) in children with iatrogenic supplementation and 0.423 (0.404, 0.443) in those with voluntary supplementation, compared with children without vitamin D supplementation. In addition, longer outdoor time was associated with a lower risk of hypovitaminosis D [0.479 (0.456, 0.504) for 60 min/d, 0.737 (0.701, 0.776) for 30–60 min/d], independent of vitamin D supplementation. Conclusions High prevalence of vitamin D deficiency was found in children living at high latitudes. Vitamin D supplementation and outdoor time are all negatively associated with children’s vitamin D deficiency. Routine 25(OH)D testing combined with vitamin D supplementation might be an effective approach to prevent hypovitaminosis D among children living at high latitudes.

scholarly journals Association of serum 25-Hydroxyvitamin D with Vitamin D Intervention and outdoor activity among children in North China: an observational study

2020 ◽  
Author(s):  
Xuguang Zhang ◽  
Yanping Chen ◽  
Shanshan Jin ◽  
Xinxin Bi ◽  
Dongkai Chen ◽  
...  
Keyword(s):  
Vitamin D ◽  
Observational Study ◽  
Vitamin D Deficiency ◽  
Lower Risk ◽  
North China ◽  
Pediatric Population ◽  
Hypovitaminosis D ◽  
High Latitudes ◽  
Vitamin D Status ◽  
Outdoor Activity

Abstract Background: Living at high latitudes is one of the risk factors for vitamin D deficiency in children. However, evidence on vitamin D improvement for this pediatric population to date is limited. This study aims at evaluating the association of different vitamin D intervention methods and outdoor activity on the vitamin D status of children in North China. Methods: In this observational study, a total of 55,925 children aged 1 month to 18 years old were recruited from pediatric outpatient departments from July 2016 to June 2017. Data on demographics, anthropometric measurements, vitamin D intervention (either prescribed by physicians or given by parents) and outdoor activity were recorded. The serum levels of 25-hydroxycholecalciferol (25(OH)D) were determined by high performance liquid chromatography tandem–mass spectrometry. Logistic regression analysis was performed to assess the association of vitamin D intervention or outdoor activity with blood vitamin D status, adjusted for age, gender, BMI for age, and seasons.Results: The overall rate of hypovitaminosis D was 65.60%. Of the children’s outdoor activity, 35.63%, 31.95%, and 32.42% were below 30min/d, 30-60 min/d and over 60min/d, respectively. Furthermore, the proportion of therapeutic intervention, supplementation intervention and no vitamin D intervention among the children was 16.48%, 32.87%, and 50.65%, respectively. After adjusted for confounding factors, vitamin D intervention was associated with a lower risk of hypovitaminosis D, with OR (95% CI) of 0.191 (0.180, 0.202) in children with therapeutic doses and 0.423 (0.404, 0.443) in those with supplementation doses, compared with children without vitamin D intervention. In addition, longer outdoor time was associated with a lower risk of hypovitaminosis D [0.479 (0.456, 0.504) for 60 min/d, 0.737 (0.701, 0.776) for 30–60 min/d], independent of vitamin D intervention. Conclusions: High prevalence of vitamin D deficiency was found in children living at high latitudes. Vitamin D intervention and outdoor activity are all negatively associated with children’s vitamin D deficiency. Routine vitamin D intervention combined with increased outdoor time might be an effective approach to prevent hypovitaminosis D among children, especially those at school, living at high latitudes.

scholarly journals VITAMIN D STATUS IN A HEALTHY TUNISIAN POPULATION

2022 ◽  
Author(s):  
Asma KRIR ◽  
Afef BAHLOUS ◽  
Mehdi MRAD ◽  
BOUKSILA Mouna ◽  
KALAI Safa ◽  
...  
Keyword(s):  
Vitamin D ◽  
Vitamin D Deficiency ◽  
Rural Areas ◽  
Hypovitaminosis D ◽  
Vitamin D Supplementation ◽  
Tunisian Population ◽  
Diabetic Patients ◽  
Dietary Intakes ◽  
Vitamin D Status ◽  
Vitamin D Levels

Vitamin D deficiency is one of the most common medical conditions worldwide. In Tunisia, several studies evaluated Vitamin D status, but this was concerning specific populations (pregnant women, obese or diabetic patients and children with asthma). The only study that evaluated Vitamin D status in a healthy Tunisian population was conducted by Meddeb and al. in 2002. The update of data available, based on the currently recommended limits, is necessary. This study aimed to estimate the prevalence of hypovitaminosis D in a healthy Tunisian population, and correlate the values with potential risk factors. It was conducted on 209 Tunisian healthy subjects. Data collected included clinical characteristics and dietary intakes. We measured 25-hydroxyvitamin D (25(OH)D), parathyroid hormone (PTH), glycemia, creatinine, calcium, phosphorus, proteins and alkaline phosphatase levels. Hypovitaminosis D was retained for 25(OH)D concentrations <30ng/ml. Vitamin D deficiency was defined by 25(OH)D concentrations <10 ng/ml. The prevalence of hypovitaminosis D and vitamin D deficiency were respectively 92.3% and 47.6%. The main factors that were significantly associated with low vitamin D levels in our multivariate analysis were veiling, living in rural areas and sunscreen use. However, sex, age, socioeconomic level, phototype, solar exposure score, smoking and bone mass index, were not statistically associated with hypovitaminosis D. The study of relationship between vitamin D status and serum PTH levels showed a significative and negative correlation (p< 0.005). Given the high prevalence of vitamin D, an adapted health policy is essential. A widespread vitamin D supplementation and food fortification seems to be necessary in Tunisia.

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