Postpartum depression and infant development up to 24 months: A nationwide population-based study.

AIMS: Postpartum depression (PPD) is the most common complication women experience after delivery. We aimed to examine the association of maternal PPD with delays in child development, in a population-based study, in the first two years of life. METHODS: A nation-wide population-based historical cohort study in the setting of the Mother and Child Health Clinics in Israel, where infants are routinely evaluated for growth and development. Data were retrieved on 96,623 infants born in 2014-2015 whose mothers had PPD screening. Logistic regressions were used to estimate the associations of PPD with the achievements of developmental milestones, controlling for potential confounders. RESULTS: PPD was identified in 4,268 mothers (4.7%). PPD was associated with delays in language skills, including the production of voices in dialogue (OR=1.88, 95% CI: 1.41-2.52) and speaking 2-3 words (OR=1.24, 95% CI: 1.13-1.37). PPD was associated with about 1.5 times increased odds of delays in personal-social skills, including reacting to voices (OR=1.43, 95% CI: 1.22-1.67) and pointing to selected objects (OR=1.47 95% CI: 1.10-1.97). Associations were also seen with delays in fine motor and adaptive skills, such as pinching (OR=1.50, 95% CI: 1.20-1.86), and gross motor skills, such as ground crawling (OR=1.36, 95% CI: 1.15-1.60). CONCLUSIONS: In this population-based large cohort study, PPD as estimated in a national screening program, was associated with delays in early child development, which were shown in all assessed domains. Future studies should confirm our results and intervention programs should be developed to effectively minimize these gaps.

Real-time genomic investigation underlying the public health response to a Shiga toxin-producing Escherichia coli O26:H11 outbreak in a nursery.

Shiga toxin-producing Escherichia coli (STEC) is a significant cause of gastrointestinal infection and the haemolytic-uremic syndrome (HUS). STEC outbreaks are commonly associated with food but animal contact is increasingly being implicated in its transmission. We report an outbreak of STEC affecting young infants at a nursery in a rural community (three HUS cases, one definite case, one probable case, three possible cases and five carriers, based on the combination of clinical, epidemiological and laboratory data) identified using culture-based and molecular techniques. The investigation identified repeated animal contact (animal farming and petting) as a likely source of STEC introduction followed by horizontal transmission. Whole genome sequencing (WGS) was used for real-time investigation of the incident and revealed a unique strain of STEC O26:H11 carrying stx2a and intimin. Following a public health intervention, no additional cases have occurred. This is the first STEC outbreak reported from Israel. WGS proved as a useful tool for rapid laboratory characterization and typing of the outbreak strain and informed the public health response at an early stage of this unusual outbreak.

Public health response to the silent reintroduction of wild poliovirus to Israel, 2013-2014.

During 2013/14, Israel witnessed the silent reintroduction and sustained transmission of wild poliovirus type 1 (WPV1) detected through routine environmental surveillance performed on sewage samples. The public health response to silent poliovirus transmission in a population with high inactivated polio vaccine (IPV) coverage poses an emerging challenge towards the 'End Game' of global poliovirus eradication. This paper reviews the risk assessment, risk management and risk communication aspects of this poliovirus incident. Special emphasis is placed on the use of scientific data generated in the risk assessment phase to inform the public health response. Reintroducing a live vaccine in supplemental immunization activities in response to transmission of WPV or vaccine-derived poliovirus should be considered close to the 'End Game' of polio eradication, especially if targeting the population at risk is feasible. Such circumstances require a comprehensive contingency plan that will support the generation of important public health evidence at the risk assessment stage, thereby allowing to tailor the risk management approaches and underpin appropriate risk communication.

Socioeconomic status and vaccine coverage during wild-type poliovirus emergence in Israel.

In August 2013, a nationwide vaccination campaign with bivalent oral polio vaccine (bOPV) was initiated after isolation of wild-type poliovirus type 1 (WPV-1) in routine sewage surveillance in Israel. The campaign started in the Southern district and later extended to the entire country. This study examined the association between socioeconomic status (SES), and compliance with bOPV vaccine during the campaign. Nationwide data relating to SES by geographical cluster were correlated with vaccine coverage rates in the same areas. All analyses were conducted separately for Jews and Arabs. Coverage with the bOPV vaccination campaign in the Arab population (92·4%) was higher than in the Jewish population (59·2%). This difference was consistently present in all SES clusters. In the Jewish population there was an inverse correlation between SES and vaccination coverage rates (R = -0·93, P < 0·001). Lower vaccination coverage with supplemental vaccine activities in higher SES groups is a challenge that needs to be addressed in future public health events and emergencies in order to achieve satisfactory protection rates for the public.

Design and application of a core genome multilocus sequence typing scheme for investigation of Legionnaires' disease incidents.

Sequence-based typing (SBT) for Legionella pneumophila (Lp) has dramatically improved Legionnaires' disease (LD) cluster investigation. Microbial whole genome sequencing (WGS) is a promising modality for investigation but sequence analysis methods are neither standardised, nor agreed. We sought to develop a WGS-based typing scheme for Lp using de novo assembly and a genome-wide gene-by-gene approach (core genome multilocus sequence typing, cgMLST). We analysed 17 publicly available Lp genomes covering the whole species variation to define a core genome (1,521 gene targets) which was validated using 21 additional published genomes. The genomes of 12 Lp strains implicated in three independent cases of paediatric humidifier-associated LD were subject to cgMLST together with three 'outgroup' strains. cgMLST was able to resolve clustered strains and clearly identify related and unrelated strains. Thus, a cgMLST scheme was readily achievable and provided high-resolution analysis of Lp strains. cgMLST appears to have satisfactory discriminatory power for LD cluster analysis and is advantageous over mapping followed by single nucleotide polymorphism (SNP) calling as it is portable and easier to standardise. cgMLST thus has the potential for becoming a gold standard tool for LD investigation. Humidifiers pose an ongoing risk as vehicles for LD and should be considered in cluster investigation and control efforts.

Nitrogen Dioxide pollution and hazardous household environment: what impacts more congenital malformations.

Nitrogen Dioxide (NO2) is a product of fuel combustion originating mainly from industry and transportation. Studies suggest an association between NO2 and congenital malformations (CM). We investigated an independent effect of NO2 on CM by adjusting to individual factors and household environment in 1024 Bedouin-Arab pregnant women in southern Israel. This population is characterised by high rates of CMs, frequent consanguineous marriages, paternal smoking, temporary housing and usage of open fire for heat cooking. Information on household risk factors was collected during an interview. Ambient measurements of 24-h average NO2 and meteorological conditions were obtained from 13 local monitors. Median value of daily NO2 measured in the area was 6.78ppb. CM was diagnosed in 8.0% (82) of offspring. Maternal NO2 exposure during the 1st trimester >8.6ppb was significantly associated with minor CM (RR=2.68, p=0.029). Major CM were independently associated with maternal juvenile diabetes (RR=9.97, p-value=0.002) and heating by open fire (RR=2.00, p-value=0.049), but not NO2 exposure. We found that NO2 emissions had an independent impact only on minor malformations, whereas major malformations depended mostly on the household environment. Antepartum deaths were associated by maternal morbidity.

Severity of pneumococcal versus non-pneumococcal acute otitis media in children.

BACKGROUND: Pneumococcal acute otitis media (AOM) has been previously considered as a more severe disease than that caused by other otopathogens, based on clinical and/or otologic scores. We sought to test this hypothesis in the pneumococcal conjugated vaccine (PCV) era. METHODS: Children <6 years who presented with 'severe' AOM episodes with middle ear fluid (MEF) cultures during 2008-2013 were retrospectively identified. 'Severe' AOM episodes were considered if tympanocentesis was required or if spontaneous otorrhea was present. Data were extracted for demographics, clinical and laboratory tests. Children were categorised according to their PCV status as 'unimmunised' or 'PCV7/PCV13 immunised' and according to their MEF culture results into the 'pneumococcal' or the 'non-pneumococcal' group. Leukocytosis was defined as white blood cells (WBC) count >15 000/µL, and elevated C-reactive protein (CRP) level was considered as >50 mg/L. RESULTS: Of 295 eligible AOM episodes, 106 (36%) were culture positive. Children in the pneumococcal group (65, 61%) had a significantly higher WBC counts and higher CRP levels, were more often <2 years old and were more prone to complicate with acute mastoiditis (AM), compared to children in the non-pneumococcal group, P = 0.03, P = 0.02, P = 0.04 and P = 0.03, respectively. In the pneumococcal group, unimmunised children had higher WBC counts when compared with PCV13-immunised children (P = 0.04), but there were no appreciable differences in CRP levels between unimmunised and PCV7/PCV13-immunised children. CONCLUSION: Pneumococcal AOM is associated with higher leukocytosis and CRP levels than non-pneumococcal AOM. Circulating Streptococcus pneumoniae strains causing 'severe' AOM in PCV13-immunised children yielded lower inflammatory responses when compared with unimmunised children.

Gym exercising patterns, lifestyle and high-risk sexual behaviour in men who have sex with men and in heterosexual men.

OBJECTIVE: Lifestyle may be associated with risk behaviours. This study compares gym exercise and sexual risk behaviour between men who have sex with men (MSM) and heterosexual men. The research was based on the assumption that men who become muscular and physically attractive increase their number of sex partners and consequently their risk of HIV or other sexually transmitted infections (STIs). SETTING: Five gyms in central Tel Aviv, Israel. PARTICIPANTS: In 2012, a sample of 182 (48%) MSM and 197 (52%) heterosexual men who train in gyms completed anonymous questionnaires regarding their training, health and sexual behaviours. OUTCOMES: Participants in this cross-sectional study who exercised more than the median number of anaerobic training hours were defined as performing intensive anaerobic training (IAT), and those who had performed more than one act of unprotected anal/vaginal intercourse in the preceding 6 months with a partner whose HIV status was unknown were defined as high risk. RESULTS: MSM showed a stronger desire to become muscular than heterosexual men, were more likely to perform IAT, and used protein powders or anabolic steroids. They reported that improving their body shape and increasing their self-confidence were their main reasons for training, whereas heterosexual men indicated weight loss and health improvement as the main reasons for training. MSM engaged in riskier sexual behaviour than heterosexual men. Of all the high-risk men, 61.9% (N=70) performed IAT, while 38.1% (N=43) performed moderate anaerobic training (p<0.01). The association between IAT and sexual risk was stronger in MSM than in heterosexual men (p<0.01 vs p=0.05, respectively). The interaction between MSM and IAT in high-risk participants was multiplicative. CONCLUSIONS: MSM practised more IAT than heterosexual men, and their interaction between IAT and sexual risk was multiplicative. The MSM community could benefit from a holistic approach to sexual health and its association with body image and IAT. The gym MSM culture demonstrates how internal dynamics and social norms are possible factors driving MSM to high-risk behaviour for HIV/STI. STUDY REGISTRATION: The study was approved by the Wolfson Hospital Review Board, Holon, Israel (WOMC-0058-09).

Molecular epidemiology of silent introduction and sustained transmission of wild poliovirus type 1, Israel, 2013.

Poliovirus vaccine coverage in Israel is over 90%. The last nine birth cohorts have been vaccinated exclusively with inactivated polio vaccine (IPV). However, between February and July 2013 type 1 wild poliovirus (WPV1) was detected persistently in 10 and intermittently in 8 of 47 environmental surveillance sites in southern and central Israel and in 30 stool samples collected during July from healthy individuals in southern Israel. We report results of sequence and phylogenetic analyses of genes encoding capsid proteins to determine the source and transmission mode of the virus. WPV1 capsid protein 1 nucleotide sequences were most closely related to South Asia (SOAS) cluster R3A polioviruses circulating in Pakistan in 2012 and isolated from Egyptian sewage in December 2012. There was no noticeable geographical clustering within WPV1-positive sites. Uniform codon usage among isolates from Pakistan, Egypt and Israel showed no signs of optimisation or deoptimisation. Bayesian phylogenetic time clock analysis of the entire capsid coding region (2,643 nt) with a 1.1% evolutionary rate indicated that Israeli and Egyptian WPV1-SOAS lineages diverged in September 2012, while Israeli isolates split into two sub-branches after January 2013. This suggests one or more introduction events into Israel with subsequent silent circulation despite high population immunity.

Intensified environmental surveillance supporting the response to wild poliovirus type 1 silent circulation in Israel, 2013.

An emergency response was triggered by recovery of wild poliovirus type 1 (WPV1) of the South Asia (SOAS) lineage from sewage in southern Israel in April 2013 during routine environmental surveillance. Public health risk assessment necessitated intensification of environmental surveillance in order to facilitate countrywide monitoring of WPV1-SOAS circulation. This involved increasing sampling frequency and broadening the geographical area, for better coverage of the population at risk, as well as modifying sewage testing algorithms to accommodate a newly developed WPV1-SOAS-specific quantitative real-time RT-PCR assay for screening of RNA extracted directly from sewage concentrates, in addition to standard virus isolation. Intensified surveillance in 74 sites across Israel between 1 February and 31 August 2013 documented a sustained high viral load of WPV1-SOAS in sewage samples from six Bedouin settlements and two cities with Jewish and Arab populations in the South district. Lower viral loads and intermittent detection were documented in sampling sites representing 14 mixed communities in three of the five health districts in central and northern Israel. Environmental surveillance plays a fundamental role in routine monitoring of WPV circulation in polio-free countries. The rapid assay specific for the circulating strain facilitated implementation of intensified surveillance and informed the public health response and decision-making.

Silent reintroduction of wild-type poliovirus to Israel, 2013 - risk communication challenges in an argumentative atmosphere.

Israel has been certified as polio-free by the World Health Organization and its routine immunisation schedule consists of inactivated poliovirus vaccine (IPV) only. At the end of May 2013, the Israeli Ministry of Health (MOH) has confirmed the reintroduction of wild-type poliovirus 1 into the country. Documented ongoing human-to-human transmission necessitated a thorough risk assessment followed by a supplemental immunisation campaign using oral polio vaccine (OPV). The unusual situation in which ongoing poliovirus transmission was picked up through an early warning system of sewage monitoring without active polio cases, brought about significant challenges in risk communication. This paper reviews the challenges faced by the MOH and the communication strategy devised, in order to facilitate and optimise the various components of the public health response, particularly vaccination. Lessons learned from our recent experience may inform risk communication approaches in other countries that may face a similar situation as global polio eradication moves towards the 'End game'.

Demographic and dietary predictors of urinary bisphenol A concentrations in adults in Israel.

BACKGROUND: To date, there is scarce data on levels of exposure to bisphenol A (BPA) in the general population in Israel and the region. The goal of the current study was to measure urinary levels of BPA in the general adult population in Israel and to determine the demographic and dietary predictors of exposure. METHODS: We recruited 249 individuals (ages 20-74) from five different regions in Israel. We collected urine samples and questionnaire data including detailed dietary data and analyzed urine samples for BPA concentrations. RESULTS: Eighty nine percent of the study population had urinary BPA concentrations equal to or above the level of quantification (0.3 µg/L). Median creatinine adjusted BPA urinary concentrations in the study population (2.3 µg/g) were slightly higher than those reported for the general population in the US (1.76 µg/g) and Canada (1.47 µg/g), and were comparable to those reported for the general population in Belgium (2.25 µg/g) and Korea (2.09 µg/g). BPA concentrations were higher in Jews compared to Arab and Druze (prevalence ratio (PR)=2.34; 95%CI 1.56-3.49), in individuals with higher education (PR=1.70, 1.11-2.62), in individuals consuming mushrooms (PR=2.08, 1.07-4.05), and in smokers (PR=1.43, 1.00-2.05). CONCLUSIONS: We found that the general adult population in Israel is widely exposed to BPA. Our findings on higher BPA levels in Jews compared to Arabs and Druze and in individuals with higher education highlights the fact that predictors of BPA exposure vary across populations.

Molecular epidemiology of Legionnaires' disease in Israel.

National surveillance of Legionnaires' disease (LD) is important to inform control measures and facilitate international networking for timely reporting. This study is the first to describe the molecular epidemiology of LD in Israel. Case notifications for 2006-2011, collated through mandatory reporting, were identified and demographic, clinical and laboratory data were extracted. Unrelated clinical and environmental Legionella pneumophila strains were characterized using standard procedures, Dresden panel of monoclonal antibodies and the ESCMID Study Group for Legionella Infections (ESGLI) Sequence-Based Typing scheme. In all, 294 cases were reported (crude incidence 0.67 cases/100 000; age-standardized incidence 1/100 000). LD epidemiological trends and features largely resembled those of the EU, except for a larger proportion of nosocomial cases. Of 28 clinical and 23 environmental strains analysed, 71.4% and 21.7% were serogroup (sg) 1 and the most common immunological subgroup was OLDA/Oxford (64%). Of the clinical strains, OLDA/Oxford, ST1 was the most common (43%) followed by Allentown/France, ST40 (14%). The unusual sg 3 ST338 was found in 17.4% of environmental strains. Novel STs were detected amongst 23.5% of strains. These findings warrant further molecular investigation. Molecular epidemiology data generated from neighbouring countries newly adopting the ESGLI typing scheme for L. pneumophila contribute to understanding of regional strain diversity.

Insidious reintroduction of wild poliovirus into Israel, 2013.

Israel was certified as polio-free country in June 2002, along with the rest of the World Health Organization European Region. Some 11 years later, wild-type polio virus 1 (WPV1) was isolated initially from routine sewage samples collected between 7 and 13 April 2013 in two cities in the Southern district. WPV1-specific analysis of samples indicated WPV1 introduction into that area in early February 2013. National supplementary immunisation with oral polio vaccine has been ongoing since August 2013.

Urinary concentrations of organophosphate pesticide metabolites in adults in Israel: demographic and dietary predictors.

Exposure to organophosphate pesticides (OPs) in agricultural and urban populations has been associated with a range of adverse health effects. The purpose of the current study was to estimate exposure to OPs in the general adult population in Israel and to determine dietary and demographic predictors of exposure. We measured six non-specific organophosphate pesticide metabolites (dialkyl phosphates) in urine samples collected from 247 Israeli adults from the general population. We collected detailed demographic and dietary data from these individuals, and explored associations between demographic and dietary characteristics and urinary dialkyl phosphate concentrations. OP metabolites were detectable in all urine samples. Concentrations of several dialkyl phosphate metabolites (dimethylphosphate, dimethylthiophosphate, diethylphosphate) were high in our study population relative to the general populations in the US and Canada and were comparable to those reported in 2010 in France. Total dialkyl phosphates were higher in individuals with fruit consumption above the 75th percentile. In a multivariate analysis, total molar dialkyl phosphate concentration increased with age and was higher in individuals with high income compared to individuals with the lowest income. Total diethyl metabolite concentrations were higher in females and in study participants whose fruit consumption was above the 75th percentile. In conclusion, we found that levels of exposure to OP pesticides were high in our study population compared to the general population in the US and Canada and that intake of fruits is an important source of exposure.

Urinary concentrations of environmental contaminants and phytoestrogens in adults in Israel.

BACKGROUND: The Ministry of Health Biomonitoring Study estimated exposure of individuals in the Israeli population to bisphenol A (BPA), organophosphate (OP) pesticides, phthalates, cotinine, polycyclic aromatic hydrocarbons (PAHs), and the phytoestrogenic compounds genistein and daidzein. METHODS: In 2011, 250 individuals (ages 20-74) were recruited from five different regions in Israel. Urine samples were collected and questionnaire data were obtained, including detailed dietary data (food frequency questionnaire and 24hour recall). Urinary samples were analyzed for BPA, OP metabolites (dialkyl phosphates), phthalate metabolites, cotinine, PAH metabolites, genistein, and daidzein. RESULTS AND DISCUSSION: BPA urinary concentrations were above the limit of quantification (LOQ) in 89% of the samples whereas urinary concentrations of phthalate metabolites were above the LOQ in 92-100% of the samples. PAH metabolites were above the LOQ in 63-99% of the samples whereas OP metabolites were above the LOQ in 44-100% of the samples. All non-smoking participants had detectable levels of cotinine in their urine; 63% had levels above the LOQ, and the rate of quantification was high compared to the general non-smoking population in Canada. Median creatinine adjusted concentrations of several OP metabolites (dimethyl phosphate, dimethyl thiophosphate) were high in our study population compared to the general US and Canadian populations. Median creatinine adjusted urinary BPA concentrations in the study population were comparable to those in Belgium and Korea; higher than those reported for the general US, German, and Canadian populations; and very low compared to health-based threshold values. Phthalate concentrations were higher in our study population compared to the general US population but values were very low compared to health-based threshold values. Median creatinine adjusted PAH concentrations were generally comparable to those reported for the general US population; median creatinine adjusted daidzein concentrations were high in our population compared to the general US population whereas genistein concentrations were comparable. CONCLUSIONS: We interpreted observed urinary contaminant levels observed in our study by comparing values with health-based threshold values and/or values from international human biomonitoring studies. Using this data interpretation scheme, we identified two contaminants as being of potential public health concern and high priority for public health policy intervention: environmental tobacco smoke (ETS) and OP pesticides. We used the data collected in this study to support public health policy interventions. We plan to conduct a follow-up biomonitoring study in 2015 to measure ETS and OP exposure in the general population in Israel, to evaluate the effectiveness of relevant policy interventions.

Epidemiology of extra-pulmonary tuberculosis in Israel, 1999-2010.

SETTING: The Israeli national tuberculosis (TB) surveillance system. OBJECTIVES: To describe the epidemiology of extra-pulmonary tuberculosis (EPTB) in Israel between 1999 and 2010 and identify more susceptible populations. DESIGN: Data were retrieved from the National Tuberculosis Registry and the Israeli Bureau of Statistics. RESULTS: During the study period, 995 EPTB patients were notified, corresponding to 19.6% of all TB cases. The average annual male:female ratio was 0.8, and the human immunodeficiency virus (HIV) infection rate was 5%. Most EPTB affected the lymph nodes (39.8%), pleura (16.9%) and urinary system (11.1%). Most EPTB patients (81.8%) were non-Israeli born. The estimated average annual incidence in Israeli-born citizens, non-Israeli-born citizens and migrant workers was respectively 0.23, 2.2 and 7.5 per 100,000 population. The ratio of non-Israeli-born migrant workers to non-Israeli-born citizens with EPTB decreased from 1:6.3 in 1999 to 1:0.78 in 2010. Culture results were obtained for 624 (62.9%) of all cases. Of these, 41 (6.6%) were resistant to at least one first-line anti-tuberculosis drug and 8 (1.3%) were multidrug-resistant. Treatment success was achieved in 86.5%. CONCLUSIONS: Physicians should be aware of the possibility of EPTB in older patients, especially in the non-Israeli-born. Innovative screening procedures should be implemented for migrants from high-burden countries.

Increasing trend of HIV/AIDS among Arab and Jewish male persons in Israel, 1986-2010.

OBJECTIVES: The aim of the study was to compare the HIV/AIDS burdens in Jewish and Arab Israeli males, as HIV/AIDS affects different population groups disproportionally. METHODS: The National HIV/AIDS Registry (NHAR) was used as the source of HIV/AIDS infection records, while the Israeli Central Bureau of Statistics was used to determine group-specific disease rates. RESULTS: Between 1986 and 2010, 3499 HIV/AIDS-infected male Israelis were reported to the NHAR: 3369 (96.3%) Jews and 130 (3.7%) Arabs, with an average annual incidence of 5.5 and 0.8 per 100 000 of the population, respectively (P = 0.05). Of the Jews, 1018 (29.9%) were born in Ethiopia, while 2389 were Jews who were not Ethiopian-born (JNE). Most of the Arabs (n = 99; 74.8%) were Muslims, followed by Christians (21; 16.2%) and Druze (13; 10%). AIDS rather than HIV infection at the time of reporting was diagnosed in 568 (23.8%) of the JNE and 31 (23.8%) of the Arabs (p = 1). The most affected age group was those aged 25-34 years among the JNE and those aged 20-24 years among the Arabs, and the respective cumulative death rates were 24.9% (n = 594) and 32.5% (n = 40) (P = 0.1). The point prevalences in 2010 were 58.4 and 11.4 per 100 000 for JNE and Arabs, and in adults aged 15-59 years they were 71.5 and 26.3 per 100 000, respectively. In Muslims, Christians and Druze, the point prevalences were 4.2, 11.2 and 7.1 per 100 000, and in adults aged 15-59 years they were 22.6, 42.9 and 29.4, respectively. The most common risk group among JNE was men who have sex with men (MSM; n = 1223; 51.2%), followed by injecting drug users (n = 661; 27.7%), while among Arabs it was MSM (n = 63; 48.1%), followed by heterosexuals (n = 36; 27.3%). CONCLUSIONS: The HIV/AIDS burden in Israeli Arab males was significantly lower than that in Jews, and in both populations the most common risk group was MSM, with the proportion of MSM increasing with time.

Adult tuberculosis in Israel and migration: trends and challenges between 1999 and 2010.

BACKGROUND: Israel absorbs many migrants from countries with a high prevalence of tuberculosis (TB). OBJECTIVES: To describe the epidemiology of TB among adults in Israel between 1999 and 2010 and identify populations with a high TB burden. DESIGN: Data were retrieved from the National Tuberculosis Registry and the Israeli Bureau of Statistics. RESULTS: A total of 4652 adult TB patients were notified during the study period, with rates decreasing annually from 7.5 per 100,000 population in 1999 to 4.3 in 2010. Most (n = 3745, 80.5%) had pulmonary TB, the average female:male ratio was 1:1.4, and 227 (5.1%) were infected with the human immunodeficiency virus. Of all TB patients, 4079 (87.6%) were born outside Israel; of these, 3338 were citizens and 741 non-citizen migrant workers (MWs). The average annual rates of TB among Israeli-born citizens, foreign-born citizens and MWs were respectively 0.86, 11.9 and 27/100,000. The ratio of MWs to foreign-born citizens fell from 1:11.7 in 1999 to 1:1.5 in 2010. TB was diagnosed 13.9 ± 7.5 years following entry to Israel, mostly during the first year. Of 3551 isolates, 222 (4.5%) were multidrug-resistant; most (95.6%) were from foreign-born patients. The average treatment success rate for smear-positive pulmonary TB was 84.3%. CONCLUSION: TB rates have decreased, while the proportion of foreign-born subjects, particularly MWs, has increased. Adherence to preventive treatment can prevent TB in these cases.

Humidifier-associated paediatric Legionnaires' disease, Israel, February 2012.

We report a fatal case of community-acquired Legionnaires' disease in an infant aged under six months. Epidemiological and microbiological investigations suggested that a free-standing cold water humidifier using domestic tap water contaminated with Legionella pneumophila serogroup 1 served as a vehicle for infection. These findings were corroborated by sequence-based typing (SBT). Humidifier-associated Legionnaires' disease can be prevented by appropriate control measures. This case also illustrates the emerging role of SBT in the investigation of legionellosis.