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BACKGROUND: In most countries rates of immunizations of health care workers with recommended vaccines are not satisfactory. OBJECTIVES: To identify reasons behind the low rates of compliance of Israeli nurses in Mother and Child Healthcare Centers (MCHC) with an official request for pertussis vaccination. METHODS: Three focus groups were conducted. Qualitative analysis identified themes that could explain the nurses' non-compliance. RESULTS: Trust in health authorities was low, mainly following the A/H1N1 purported influenza pandemic. In addition, nurses did not see the importance of being role models for the public and demanded the autonomy to decide whether to receive vaccinations. The nurses differentiated between their role as nurses and their personal life, expressed fear of new vaccines and exhibited low levels of risk perception. Misconceptions regarding vaccinations were expressed by the nurses. CONCLUSIONS: Antivaccinationist ideas were expressed by MCHC nurses and these attitudes may have led to non-compliance with vaccination guidelines.

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The incidence of acute hepatitis A in Israel has decreased 25 folds in less than a decade, following the introduction of a two-dose universal toddler's hepatitis A immunization in July 1999. This retrospective study describes demographic data and behavioural determinants of hepatitis A patients following the implementation of a vaccination programme. All records of hepatitis A patients reported to the Ministry of Health during the years 2003 through 2005 were reviewed, and an epidemiological investigation was conducted. During the study period, 420 hepatitis A patients were reported, representing an average annual incidence of two per 100,000 population. Case fatality rate was 0.5%. The majority of the patients were younger than 15 years of age, males and non-Jewish. The highest incidence was recorded in east Jerusalem, where vaccine coverage is relatively low. After exclusion of 165 east Jerusalem patients, 133 (52.2%) patients were available for an interview. Of those, 16 (6%) had possible occupational exposure, 37 (27.8%) travelled to endemic areas, 44 (17%) were contacts of hepatitis A cases, and 3 male patients had sex with men. No known risk determinant was identified in 33 (24.8%) patients. Four patients (3%) were previously immunized with one dose, and none had two doses. The introduction of universal toddler hepatitis A vaccination decreased morbidity. Most of the patients who were detected 4-6 years after the implementation of the vaccination programme could be classified into one of the known risk groups for hepatitis A infection or living in a partly vaccinated community.

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We report an evaluation of the Israeli national immunization programme for hepatitis B in the Haifa subdistrict. We used a convenience sample of blood tests reported positive for HBsAg over a 6-year period from children who were born after routine immunization began in 1992. We identified 11 children with presumed chronic hepatitis B virus infection who were residents of the Haifa subdistrict, three of whom were born in Israel. All three were immunized at the appropriate age and are thus considered vaccination failures rather than failure to vaccinate. The remaining eight were born abroad, had emigrated to Israel as children and were not immunized at birth. We estimate the rate of chronic hepatitis B virus infection for children born since 1998 to be 0.24/10,000 births. For all children resident in the subdistrict under the age of 12 years, the period prevalence is estimated to be 1.26/10,000. The rate of chronic infection in children younger than 12 years was significantly less than that of older cohorts and less than that of historical controls before the start of immunization. Although the reported rates are probable underestimates of actual rates, the fact that they are based on testing carried out in clinical settings increases the likelihood of positive findings and thus reduces the degree of error. The fact that most young carriers are foreign born points to the importance of timely catch-up programmes. In countries with low and intermediate rates of chronic infection, serosurveys of immunized children need to be large and are therefore costly. Monitoring HBsAg positive tests from routine testing carried out in clinical settings is an inexpensive way to monitor chronic infection rates.

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Tuberculosis (TB) outbreaks present a public health challenge. Six cases of active TB emerged in a boarding school in Israel during 1 yr. An epidemiological outbreak investigation was performed, followed by implementation of control measures. The investigation included interviews, tuberculin skin test (TST) and chest radiographs of the students. Close contact (n = 155) was defined as being in the same class or dormitory with a patient. Remote contact (n = 246) was defined as being in the school. An epidemiological association was detected among five of the cases and a distinct pattern was found in molecular analysis. TST was performed in 398 (99.2%) students. Repeated (two-step) TST was applied to the close contacts. The degree of contact, country of origin and previous bacille Calmette-Guérin vaccination were significantly associated with TST reactions. Preventive directly observed therapy was completed by 157 (91.3%) students. During 5 yrs follow-up, no additional cases emerged. While investigating a tuberculosis outbreak, the definition of degree of contact is a significant predictor for detecting positive tuberculin test. Immigration from an endemic country, as well as previous bacille Calmette-Guérin vaccination have a major effect on tuberculin skin-test results. The directly observed therapy approach was found to be successful in preventing further morbidity.

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This article deals with five cases of imported malaria among Haifa District citizens in 1999. Two patients died from multi-organ failure secondary to the infection. Malaria continues to be a serious health risk for travelers returning from endemic areas. Travelers require detailed advice on appropriate chemoprophylaxis against malaria and personal protection against mosquito bites. There has, however, been poor compliance to drug prophylaxis. Physicians should encourage travelers to seek advice from an accredited travelers clinic in advance of the trip. It is advisable for the physician to stress the importance of taking the recommended chemoprophylaxis.

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BACKGROUND: Hepatitis B is a major problem worldwide. Israel has intermediate endemicity for hepatitis B virus, and an annual carrier rate of 1-3%. OBJECTIVE: To evaluate both the prevalence of HBV infection among family members of HBV carriers and the competence of family practitioners in performing a comprehensive assessment. METHODS: A total of 152 HB surface antigen-positive blood donors were discovered in our subdistrict during the years 1993-97. Their family physicians were questioned regarding the patients' family members. Specific information on 85 spouses and 200 children was also obtained. RESULTS: Among the 85 married carriers, 5 of the spouses (5.9%) were found to be HBsAg positive. None of the 200 children was HBsAg positive. We found that in a third (n = 52) of the patients, the sexual partner had never been tested by a primary care physician. Patients were not routinely tested for HB e antigen or anti-HBe antibodies. Neither the parents nor the siblings had undergone any serological evaluation. However, most family members of the carriers had received an HBV vaccine from their family physicians. CONCLUSIONS: Our findings show that horizontal transmission of HBV among spouses of HBV carriers still exists. We did not find any vertical transmission, probably due to male predominance and previous vaccination. Family physicians should be trained to perform an extensive serological evaluation of family members of patients with chronic HBV infection, including parents and siblings, and should vaccinate seronegative family members.

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The epidemiology and control of hepatitis A virus was investigated during an outbreak of hepatitis A in a village in Israel. Postexposure administration of immune globulin to contacts was ineffective in controlling the outbreak. However, within 2 weeks of starting a mass immunization campaign with hepatitis A vaccine, the incidence of hepatitis A declined dramatically; the last case occurred 6 weeks after the immunization program began. The study demonstrated that while postexposure administration of immune globulin may diminish but not entirely arrest transmission of hepatitis A virus, active hepatitis A vaccination is a safe and effective intervention that can be used safely in hepatitis A virus antibody-positive children.

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OBJECTIVE: To describe the secular trends in the prevalence rates of iron-deficiency anemia (IDA) in infants in Israel, identify population group differences and assess the effectiveness of the 1985 Public Health directives on iron supplementation and avoidance of cow's milk in the first year of life. DESIGN: A systematic analysis of published and unpublished cross-sectional studies. METHODS: IDA rates in 1-y-old infants between 1946 and 1997 were assessed from published papers and reports. Rates for Arab infants were available from 1984. Data on routine hemoglobin tests on 1-y-old infants for Arabs and Jews separately were obtained from four health districts for the period 1987 to 1997. Analyses were done for the periods prior to and following the Public Health directives. RESULTS: The prevalence of IDA in Jewish infants declined from 68% in 1946 to 50% in 1985 at an average annual rate of -1.43%. Following the iron supplementation directives, the average annual rate of decline increased to -4.0% and reached a prevalence of about 11% in 1996. IDA rates in Arab infants declined by an annual average of -3.7%, and were consistently almost twice as high as for Jewish infants. CONCLUSIONS: Despite the contribution of the iron supplementation program to the reduction in TDA, the persistently high rates indicate inadequate iron content in the diet. This emphasizes the important role of a national food fortification program, using staple foods commonly consumed.

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OBJECTIVE: To determine the vaccination rates among healthcare workers in the Haifa subdistrict and to assess factors associated with vaccination uptake among them. METHODS: The study was conducted in the three general hospitals in Haifa City, and in five nursing homes in the Haifa subdistrict. Self-administered questionnaires were distributed to 1,014 employees of whom 71% were females, 34% were nurses, 27% were physicians and 28% were non-professional workers. RESULTS: The crude response rate was 66%. Response rates were higher in females (71%) than in males (49%), in nurses (70%) than in physicians (43%), and in staff of internal and pediatric departments than in workers of surgery departments and emergency rooms. The overall vaccination rate among the respondents was 11%, which was higher among males (15%) than among females (10%). No significant relationship between vaccination rate and age, occupation and department was found. The vaccination rate among employees with chronic illness was very low (7%). Influenza vaccine was actively recommended to 29% of the employees. The main reasons for non-compliance were low awareness of the severity of the disease and of the vaccine's efficacy and safety, and unavailability of the vaccine within the workplace. CONCLUSIONS: Educational efforts and offering the vaccine at the workplace at no cost are the most important measures for raising influenza vaccination rates.

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BACKGROUND: Postexposure prophylaxis, adequately applied after exposure to a rabid animal, is highly effective in prevention of human disease. Deviations from the recommended vaccination postexposure treatment protocol have been associated with vaccination failure and human mortality. We investigated an incident in which seven Israel Defense Forces soldiers were bitten by a rabid fox and initially treated not in accordance with the recommended vaccination protocol. METHODS: The soldiers received modified anti-rabies postexposure prophylaxis, including a higher dosage of both the active and the passive vaccines. The humoral antibody response was monitored subsequently. RESULTS: All soldiers showed a satisfactory increase (above 0.5 UE/ml by ELISA) in serum anti-rabies antibody titers. None developed the disease more than a year after follow-up. CONCLUSIONS: Strict adherence to the treatment guidelines following an injury by a rabid animal is of utmost importance. We suggest possible compensatory management after a potentially lethal deviation from protocol.

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BACKGROUND: Universal hepatitis B vaccination in infancy was implemented in Israel in 1992. The program consists of active vaccination at birth and at 1 and 6 months of age, without hepatitis B surface antigen (HBsAg) screening during pregnancy. Infants of HBsAg carrier mothers do not receive specific hepatitis B immunoglobulin in addition to vaccine at birth. The recently arrived Jewish immigrants from Ethiopia are the group with the highest rate of HBsAg carriage (approximately 10%) in Israel. AIM: The objective of this study was to evaluate whether the present policy is effective against perinatal HBV transmission from mothers of Ethiopian origin to their infants. METHODS: The study group included 411 Israeli born children, offspring of mothers of Ethiopian origin. All infants were fully vaccinated starting at birth. Sera were collected from the children at the age of 9 to 36 months and from their mothers. Tests for HBsAg, antibodies to HBsAg (anti-HBs) and antibodies to hepatitis B core antigen (anti-HBc) were performed. RESULTS: Eighty-nine percent of the children had detectable anti-HBs, including 82.2% with protective anti-HBs concentrations (> or =10 mIU/ ml). Although 24 mothers (6.2%) were HBsAg carriers, none of the children was HBsAg-positive. Seven of 394 infants (1.7%) tested positive for anti-HBc. This test became negative in 5 of 6 who were followed for 12 months. The percentage of infants with protective anti-HBs concentrations decreased significantly from 91.4% at 9 to 12 months to 70.1% at 31 to 36 months of age. The mother's infection status was not associated with the infant's response to vaccine. Calculation based on the above data suggests that screening for HBsAg in pregnancy in that group is not cost-effective. CONCLUSIONS: Our results suggest that the Israeli vaccination program against HBV infection is effective, even in a high risk population, and additional measures are not cost-effective.

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BACKGROUND: The purpose of this project was to look for an association between microbial quality of drinking water and those gastrointestinal diseases that are known to be also waterborne. METHODS: For this purpose available databases of the Israeli Ministry of Health were used: (1) Registry of notifiable diseases and (2) microbial quality of drinking water. The association was examined by regressing incidence rates of salmonellosis, shigellosis, and hepatitis on three measures of microbial water quality and calculating the coefficient of determination (r2). Analysis was carried out for the years 1985-1992. RESULTS: Significant dependence of disease incidence on water quality was found for 1988 and, for hepatitis, also for 1989-92. This dependence is shown to be the result of the coincidence of high disease rate with high proportion of polluted water samples in two small subdistricts. CONCLUSIONS: The general lack of dependence of morbidity on water quality suggests that the water route contributes only slightly to these diseases in Israel. For a more meaningful analysis, a higher geographic resolution of morbidity reporting is recommended.

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The incidence of unexpected death in infancy (UDI) (2 weeks-12 months) in the Haifa area is 1.17 per 1000 live births. We found a significant interethnic difference between Israeli Jews and Arabs. The incidence among Arabs was 4 per 1000, but was only 0.77 per 1000 among Jews (p < 0.01). When the UDI Jewish group was compared to both the group of infants dying of known causes and the surviving group, the only significant factors related to UDI were found to be: young maternal age and low maternal education. No such association was evident among Arabs. Following logistic regression analysis, low maternal age and low socioeconomic status, but not ethnicity, were significantly associated with UDI as compared to the non-UDI infants. In comparison to non-UDI, UDI was significantly more prevalent during the cold season. UDI incidence has apparently been stable over the past 15 years. Demographic risk factors are similar to those reported from other communities, and ethnicity is possibly mediated through those factors.

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During spring 1984, 2334 second and 2000 fifth-grade schoolchildren living in three Haifa Bay areas on the eastern Mediterranean coast with different levels of air pollution were studied. The parents of these children filled out American Thoracic Society and National Heart and Lung Institute health questionnaires, and the children performed the following pulmonary function tests (PFT); FVC, FEV1, FEV1/FEV, PEF, FEF50, and FEF75. A trend of higher prevalence of most reported respiratory symptoms was found for schoolchildren growing up in the medium and high pollution areas as compared with the low pollution area. Part of the reported respiratory diseases were significantly more common among children from the high pollution area. Models fitted for the respiratory conditions that differed significantly among the three areas of residence also included background variables that could be responsible for these differences. Relative risk values, which were calculated from the logistic models, were in the range of 1.38 for sputum with cold and 1.81 for sputum without cold for children from the high pollution area as compared with 1.00 for children from the low pollution area. All the measured values of PFT were within the normal range. There was no consistent trend of reduced pulmonary function that characterized any residential area.

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An outbreak of 15 cases of paralytic poliomyelitis caused by type 1 poliovirus between July and October, 1988, prompted mass vaccination of the whole Israeli population under the age of 40 years. The focus of the outbreak (12 cases) was the Hadera subdistrict, one of two subdistricts where enhanced inactivated poliovaccine (eIPV) had been the only poliovaccine used for infants since 1982. 9 of the 15 victims were 15 years or older, and 9 had previously been immunised with at least three doses of oral poliovaccine (OPV). The authors are divided in their interpretation of the findings. One group considered that the likely causative factors were the greater susceptibility of young adults previously vaccinated with OPV as well as transmission of wild poliovirus to susceptible people by children with low gut immunity against poliovirus after vaccination with eIPV; they concluded that a vaccination programme combining eIPV with OPV is the best option for Israel in future. The other group believed the causative factors were exposure to contaminated sewage or close social contact within the epidemic foci, the presence of an epidemic strain differing from the wild Mahoney and Sabin type 1 vaccine strains, and the lower seropositivity rates and geometric mean titres of neutralising antibodies to the epidemic than to vaccine strains; they believe that eIPV is the means to achieve effective control of poliomyelitis in Israel.

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The efficient use of hospital resources is an important issue. In order for the hospital management to identify definite areas where and why this use is inefficient, the Appropriateness Evaluation Protocol is used. The rate of unnecessary hospitalization days was thus studied during 1984 in two government general hospitals in Israel. Two simultaneous studies, cross-sectional and longitudinal, were conducted by the same team in the general medicine, surgery and gynecology wards. Unnecessary hospitalizations were found in both hospitals. The rate was particularly high in the surgery departments of the university hospital where there were 2.5-3 times more unnecessary days than in the community hospital. The major reasons for these unnecessary days in the university hospital were internal (problems concerning the use of diagnostic facilities, operating rooms and consultants), whereas in the community hospital they related mainly to discharge planning. The study identified definite areas in which hospital authorities could possibly take action to reduce the wastage.

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We studied the incidence and mortality of stroke in northern Israel to determine possible reasons for the differences previously found in mortality from this condition between the sex and ethnic groups in Israel as a whole. We identified 1,149 cases of stroke during 1984. While the age-standardized incidence was higher in men, the case-fatality rate was twice as high in women. After controlling for ethnic origin, we found that incidence was higher only in men of Western origin, while the female rates were higher in women of Asian and North African extraction. The case-fatality rate was substantially higher in women in all ethnic groups. These differences, especially in relation to the case-fatality rate, have important implications for health services in relation to both possible preventive action and to management of the acute disease phase.

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