Qualifying coronavirus disease 2019 convalescent plasma donors in Israel.

BACKGROUND AND OBJECTIVES: Passive immunization using investigational COVID-19 convalescent plasma (CCP) is a promising therapeutic strategy and could improve outcome if transfused early and contain high levels of anti-SARS-CoV-2 antibodies. We report the management of a national CCP collection and distribution program in Israel. MATERIALS AND METHODS: From 1 April 2020 to 15 January 2021, 4020 volunteer donors donated 5221 CCP units and 837 (20.8%) donors donated more than once. Anti-nucleocapsid IgG antibodies were determined using chemiluminescent immunoassay method (Abbott). A statistical model based on repeated IgG tests in sequential donations was created to predict the time of antibody decline below sample/cut-off (S/CO) level of 4.0. RESULTS: Ninety-six percent of CCP donors suffered a mild disease or were asymptomatic. Older donors had higher antibody levels. Higher antibody levels (S/CO ≥4) were detected in 35.2% of the donors. Low positive (S/CO ≥1.4-3.99) were found in 37%, and 27.8% had undetectable antibodies (S/CO ≤1.4). The model predicted decrease antibody thresholds of 0.55%/day since the first CCP donation, providing guidance for the effective timing of future collections from donors with high antibody levels. CONCLUSIONS: An efficient CCP collection and distribution program was achieved, based on performing initial and repeated plasma collections, preferably from donors with higher antibody levels, and only antibody-rich units were supplied for therapeutic use. The inventory met the quantity and quality standards of the authorities, enabled to respond to the growing demand of the medical system and provide a product that may contribute to improve prognosis in patients with COVID-19.

The Israeli public health response to wild poliovirus importation.

In 2013, a silent wild poliovirus type 1 importation and sustained transmission event occurred in southern Israel. With the aim of preventing clinical poliomyelitis and ensuring virus re-elimination, the public health response to the importation event included intensification of clinical and environmental surveillance activities, enhancement of vaccine coverage, and supplemental immunisation with a bivalent oral polio vaccine against wild poliovirus types 1 and 3. A national campaign launched in August, 2013, resulted in vaccination of 943,587 children younger than 10 years (79% of the eligible target population). Expanded environmental surveillance (roughly 80% population coverage) documented a gradual disappearance of wild poliovirus type 1 in the country from September, 2013, to April, 2014. No paralytic poliomyelitis case was detected. A prompt extensive and coordinated national public health response, implemented on the basis of evidence-based decision making, successfully contained this serious importation and sustained transmission event of wild poliovirus to Israel. On April 28, 2015, WHO officially declared Israel as a polio-free country.

Field study of fecal excretion as a decision support tool in response to silent reintroduction of wild-type poliovirus 1 into Israel.

BACKGROUND: Israel has used an inactivated polio vaccine (IPV)-only schedule since 2005 (95% coverage). Silent reintroduction of wild type poliovirus 1 (WPV1) into Israel in early 2013 was detected in Southern Israel via routine environmental surveillance without clinical cases. OBJECTIVES: To estimate the rate of WPV1 excretion by age and residence and inform decision-making regarding supplemental immunization with OPV. STUDY DESIGN: A convenience sample of Bedouin and Jewish residential areas in the epicenter of the incident, focusing on under 8 year-olds who not previously given OPV. Fecal samples were directly tested for WPV1 RNA using a novel qRT-PCR assay. Positive samples were confirmed by gold standard cell culture and subject to genotyping. RESULTS: Overall, 2196 non-duplicate fecal samples were collected and analyzed. WPV1 was detected in 61 samples (2.8%), 55 of which (90.2%) were from Bedouins. WPV1 excretion rates were 5.4% among Bedouins and 0.6% among Jewish individuals. Respective age-specific rates among Bedouin and Jewish children were 4.9% and 0.2% for 0-2 years and 7.2% and 1.7% for 2-8 years. Molecular testing had 89.5% sensitivity (higher than culture) and 100% specificity. CONCLUSION: The rapid performance of a field study to evaluate WPV1 excretion unequivocally demonstrated substantial WPV1 infection rates among children under 8 years in Southern Israel, thus informing the decision to vaccinate this age group with bOPV and risk communication to both healthcare personnel and the public. Rapid development and implementation of molecular screening can thus underpin risk assessment and management in complex epidemiological situations.

Continued vigilance - development of an online evaluation tool for assessing preparedness of medical facilities for biological events.

OBJECTIVE: Effective response to biological events necessitates ongoing evaluation of preparedness. This study was a bilateral German-Israeli collaboration aimed at developing an evaluation tool for assessing preparedness of medical facilities for biological events. METHODS: Measurable parameters were identified through a literature review for inclusion in the evaluation tool and disseminated to 228 content experts in two modified Delphi cycles. Focus groups were conducted to identify psychosocial needs of the medical teams. Table-top and functional exercises were implemented to review applicability of the tool. RESULTS: One hundred seventeen experts from Germany and Israel participated in the modified Delphi. Out of 188 parameters that were identified, 183 achieved a consensus of >75% of the content experts. Following comments recommended in the Delphi cycles, and feedback from focus groups and hospital exercises, the final tool consisted of 172 parameters. Median level of importance of each parameter was calculated based on ranking recommended in the Delphi process. Computerized web-based software was developed to calculate scores of preparedness for biological events. CONCLUSION: Ongoing evaluation means, such as the tool developed in the study, can facilitate the need for a valid and reliable mechanism that may be widely adopted and implemented as quality assurance measures. The tool is based on measurable parameters and indicators that can effectively present strengths and weaknesses in managing a response to a public health threat, and accordingly, steps can be implemented to improve readiness. Adoption of such a tool is an important component of assuring public health and effective emergency management.

West Nile fever in Israel: the reemergence of an endemic disease.

BACKGROUND: As a crossroads for bird migration between Africa and Eurasia and with its long history of human infection, Israel has been a major focus of attention during the continuing global spread of West Nile fever (WNF). This article reviews the background and reemergence of WNF in Israel; the recent epidemiology of WNF among Israelis; and the disease-control strategies being used to combat the disease. METHODS: Employing the comprehensive base of case data that are reported to the Ministry of Health, an epidemiological record was constructed that details the incidence and distribution of WNF cases in Israel in recent years. RESULTS: After decades of small, intermittent outbreaks, nearly 1400 cases of WNF were reported in Israel between 2000 and 2012. Incidence was consistently highest in the coastal cities, among elderly patients, and in the late summer months and early autumn. A broad range of control measures to prevent human infection has been implemented, and attention has been given to issues such as the protection of the national blood bank and the occurrence of long-term sequelae. CONCLUSIONS: The reemergence of WNF in Israel is likely the result of a combination of factors including past immunity to the virus among the human population, a marked increase in awareness of WNF among physicians, and more frequent requests for the laboratory testing of suspected cases. In the absence of effective vaccine to protect humans from WNF, the best disease-control strategies include intensive vector-control measures, the continued development of techniques to forecast outbreaks, and effective public education programs that are targeted toward the high-risk elderly population.

Rubella in Israel after the MMR vaccine: elimination or containment?

Since 1996, after the full institution of the two-dose measles, mumps, and rubella vaccine (MMR) regimen in Israel, rubella incidence has declined dramatically and has remained extremely low. Cyclical outbreaks ended; the two brief outbreaks that did occur were quickly contained; and epidemiological data indicate that the disease is practically absent from the country. But similar steep declines in the incidence of measles and mumps, the two other MMR-preventable diseases, were followed by major outbreaks in 2007 and 2010. Epidemiological analyses show that undervaccination of subgroups within the Jewish ultra-orthodox population, both in Israel and abroad, and virus importation into Israel, continue to be risk factors for all three MMR-preventable diseases. Israel's public health system, therefore, should focus on a policy of containment: improve MMR coverage among undervaccinated subgroups and assure that virus importation is no longer a risk. Then the goal of rubella elimination will become feasible. We discuss how the Israeli experience may contribute to the World Health Organization Initiative to eliminate simultaneously measles and rubella.

Refuah Shlema: a cross-cultural programme for promoting communication and health among Ethiopian immigrants in the primary health care setting in Israel: evidence and lessons learned from over a decade of implementation.

The Refuah Shlema programme was established to reduce health disparities, promote health literacy and health indicators of the Ethiopian immigrant community in Israel, and included: (i) integrating Ethiopian immigrant liaisons in primary care as inter-cultural mediators; (ii) in-service training of clinical staff to increase cultural awareness and sensitivity; and (iii) health education community activities. Qualitative and quantitative evidence showed improvements in: (i) clinic staff­patient relations; (ii) availability and accessibility of health services, and health system navigation without increasing service expenditure; (iii) perception of general well-being; and (iv) self-care practice with regards to chronic conditions. Evidence significantly contributed to sustaining the programme for over 13 years.

Containment of a country-wide outbreak of carbapenem-resistant Klebsiella pneumoniae in Israeli hospitals via a nationally implemented intervention.

BACKGROUND: During 2006, Israeli hospitals faced a clonal outbreak of carbapenem-resistant Klebsiella pneumoniae that was not controlled by local measures. A nationwide intervention was launched to contain the outbreak and to introduce a strategy to control future dissemination of antibiotic-resistant bacteria in hospitals. METHODS: In March 2007, the Ministry of Health issued guidelines mandating physical separation of hospitalized carriers of carbapenem-resistant Enterobacteriaceae (CRE) and dedicated staffing and appointed a professional task force charged with containment. The task force paid site visits at acute-care hospitals, evaluated infection-control policies and laboratory methods, supervised adherence to the guidelines via daily census reports on carriers and their conditions of isolation, provided daily feedback on performance to hospital directors, and intervened additionally when necessary. The initial intervention period was 1 April 2007-31 May 2008. The primary outcome measure was incidence of clinically diagnosed nosocomial CRE cases. RESULTS: By 31 March 2007, 1275 patients were affected in 27 hospitals (175 cases per 1 million population). Prior to the intervention, the monthly incidence of nosocomial CRE was 55.5 cases per 100,000 patient-days. With the intervention, the continuous increase in the incidence of CRE acquisition was halted, and by May 2008, the number of new monthly cases was reduced to 11.7 cases per 100,000 patient-days (P<.001). There was a direct correlation between compliance with isolation guidelines and success in containment of transmission (P=.02). Compliance neutralized the effect of carrier prevalence on new incidence (P=.03). CONCLUSIONS: A centrally coordinated intervention succeeded in containing a nationwide CRE outbreak after local measures failed. The intervention demonstrates the importance of strategic planning and national oversight in combating antimicrobial resistance.

A cluster of deaths following influenza vaccination, Israel, 2006.

When four deaths occurred in one week among influenza vaccine recipients, the Israeli Health Ministry suspended its 2006 influenza vaccination campaign pending investigation of the causes of death. Medical histories of the deceased vaccinees, quality control reports, and laboratory test results were examined. Prior vaccine use that season and a risk assessment of the vaccinated population were also considered. All four decedents had been treated for cardiac and other chronic diseases, and none had experienced post-injection symptoms suggesting adverse reaction to influenza vaccine. Quality control and laboratory reports confirmed vaccine batch safety, and no adverse effects had been reported among any other vaccine recipients. Investigators found no causal connection between the deaths and the vaccine, and the Health Ministry resumed the campaign. Israeli public health officials viewed the investigation as vital to maintaining broad confidence in the public health system, and in future vaccination campaigns.

A framework for developing an evidence-based, comprehensive tobacco control program.

BACKGROUND: Tobacco control is an area where the translation of evidence into policy would seem to be straightforward, given the wealth of epidemiological, behavioural and other types of research available. Yet, even here challenges exist. These include information overload, concealment of key (industry-funded) evidence, contextualization, assessment of population impact, and the changing nature of the threat. METHODS: In the context of Israel's health targeting initiative, Healthy Israel 2020, we describe the steps taken to develop a comprehensive tobacco control strategy. We elaborate on the following: a) scientific issues influencing the choice of tobacco control strategies; b) organization of existing evidence of effectiveness of interventions into a manageable form, and c) consideration of relevant philosophical and political issues. We propose a framework for developing a plan and illustrate this process with a case study in Israel. RESULTS: Broad consensus exists regarding the effectiveness of most interventions, but current recommendations differ in the emphasis they place on different strategies. Scientific challenges include integration of complex and sometimes conflicting information from authoritative sources, and lack of estimates of population impact of interventions. Philosophical and political challenges include the use of evidence-based versus innovative policymaking, the importance of individual versus governmental responsibility, and whether and how interventions should be prioritized.The proposed framework includes: 1) compilation of a list of potential interventions 2) modification of that list based on local needs and political constraints; 3) streamlining the list by categorizing interventions into broad groupings of related interventions; together these groupings form the basis of a comprehensive plan; and 4) refinement of the plan by comparing it to existing comprehensive plans. CONCLUSIONS: Development of a comprehensive tobacco control plan is a complex endeavour, involving crucial decisions regarding intervention components. "Off the shelf" plans, which need to be adapted to local settings, are available from a variety of sources, and a multitude of individual recommendations are available. The proposed framework for adapting existing approaches to the local social and political climate may assist others planning for smoke-free societies. Additionally, this experience has implications for development of evidence-based health plans addressing other risk factors.

[The five commandments for preparing the Israeli healthcare system for emergencies].

In the last decade, the Israeli healthcare system dealt with many casualties that resulted from terrorist actions and at the same time maintained preparedness for other potential hazards such as natural disasters, toxicological, chemical, radiological and biological events. There are various models for emergency preparedness that are utilized in different countries. The aim of the article is to present the structure and the methodology of the Israeli healthcare system for emergencies. Assuring emergency preparedness for the different scenarios is based on 5 major components that include: comprehensive contingency planning; control and command of operations; central control of readiness; capacity building; coordination and collaboration among the numerous emergency agencies. CLose working relationships between the military and civilian systems characterize the operations of the emergency system. There is a mutual sharing of information, coordinated operations to achieve risk assessment and determine priorities, and consensual allocation of resources. The ability of the medical system to operate in optimal coordination with interface bodies, including the Israel Defense Forces, is derived from three main elements: the shortage of resources necessitate that all agencies work together to develop an effective response to emergencies; the Israeli society is characterized by transition of personnel from the military to the civilian system which promotes joint operations, whereas in most other countries these systems are completely separated; and also developing mechanisms for continuous and coordinated operation in routine and emergency times, such as the Supreme Health Authority. The Israeli healthcare system was put to the test several times in the Last decade, during the terror wave that occurred between 2001-2006, the 2nd Lebanon War and in operation "Cast Lead". An extensive process of learning lessons, conducted during and following each of these periods, and the existence of a mechanism which facilitated the definition of a systematic policy and the examination of its implementation, enabled the healthcare system to provide medical services to the population and to improve its preparedness by an ongoing process.

[Looking back but facing ahead: implementing lessons learned from the 2nd Lebanon War].

The medical system utilizes a structured culture for learning lessons in order to improve the supply of services. Various tools are utilized to evaluate performance. The aim of the article is to describe the processes for learning lessons which were carried out following the Second Lebanon War and the major lessons that were identified and implemented. Three processes were performed: a process of learning Lessons of the heaLthcare system, initiated and led by the Supreme HeaLth Authority (SHA); After action review (AAR), initiated and led by the military Medical Corps and; at a later stage, a critique, initiated and led by the State Comptroller, that examined the performance of the medical system, as part of a critique on the preparedness of the home front. The following elements were defined as highly prioritized for improvement to elevate the preparedness for a future war: (1) deployment of unified clinics in conflict areas; (2) supply of medical services to the population in shelters; (3) deploying emergency medicine services, including the relationship between the Ministry of Health (MOH) and the Home Front Command (HFC); (4) defining the relationships between the MOH and HFC in deploying the community health services in emergencies; (5) protecting medical facilities and personal protection equipment for medical teams and; (6) treating acute stress reactions. The AAR, critique and learning lessons signify three different processes that can sometimes be contradictory. Nevertheless, it is possible to achieve organizational improvement white integrating between these three processes, as was displayed by the SHA.

Measles in a highly vaccinated society: the 2007-08 outbreak in Israel.

BACKGROUND: Despite success in controlling measles through a national immunization program, Israel recently experienced its largest measles outbreak since 1994. METHODS: Using data reported by health district offices to the Ministry of Health, an epidemiological analysis of the 2007-08 measles outbreak was performed. RESULTS: 1467 measles cases were reported in Israel, primarily among ultra-orthodox Jewish communities in the Jerusalem Health District and to a lesser extent in other areas. The highest age-specific incidence rate (122.5 per 100,000) occurred among infants. 38.6% of all measles patients were under the age of five, and 53.4% were under the age of ten. 186 patients (12.7%) were hospitalized; there were no fatalities. Only 4.6% of measles patients had been fully vaccinated for their age. CONCLUSION: To minimize the risk of future outbreaks in Israel, successful marketing of the MMR vaccine to under-vaccinated sub-groups is essential.

Smallpox revaccination of 21000 first responders in Israel: lessons learned.

OBJECTIVES: Between July 2002 and April 2003, over 21000 individuals were revaccinated against smallpox by the Israeli Ministry of Health. The objectives of the campaign were to create an immunized core of first responders, to review vaccination techniques, and to produce vaccinia immune globulin (VIG). METHODS: The Lister strain of vaccinia virus was used at a concentration of approximately 10(7) pock-forming units (PFU)/ml, and was administered by the multiple-puncture technique. The revaccinees were from varied ethnic backgrounds, almost all were aged 25-64 years, and all participants had been vaccinated against smallpox in the past. RESULTS: The proportion of clinical take was 66.1% (95% CI: 65.2%, 67.0%), similar to past vaccination programs when take also occurred in approximately two thirds of vaccinees. An antibody response occurred in 77.7% (95% CI: 74.8%, 80.6%) of all revaccinees: 94.4% (95% CI: 91.8%, 96.3%) of those with clinical take and 56.6% (95% CI: 51.3%, 61.8%) of those without clinical take. The most common side effects corresponded to symptoms of non-specific viral diseases, and only a few revaccinees reported serious side effects. CONCLUSIONS: The campaign achieved all its basic goals and provided useful lessons for any mass-vaccination programs that might be necessary in the future.

A targeted population carrier screening program for severe and frequent genetic diseases in Israel.

A national carrier screening program targeted at communities in which severe genetic diseases are present with a frequency higher than 1/1000 live births, has been in existence in Israel since 2002. Within the communities at risk, carrier screening is voluntary whereas genetic counseling and testing is provided free of charge. During the first 5 years of the program more than 13 000 tests were performed, and at the end of 2007 it was offered in 35 different localities/communities for a total of 36 diseases. Many of the couples identified to be at risk opted for prenatal diagnosis and in two cases an affected pregnancy was terminated. In some cases the couples declined prenatal diagnosis and two of those families gave birth to an affected child. Based on the experience learnt from this targeted screening program it appears that a knowledge-based, voluntary screening program operated within the community is an effective way to provide genetic services and test referrals. The community program directed toward couples in their reproductive period does not seem to have led to stigmatization at either the individual or the community level.

What should be given a priority - costly medications for relatively few people or inexpensive ones for many? The Health Parliament public consultation initiative in Israel.

BACKGROUND: In the past two decades, government and civic organizations have been implementing a wide range of deliberative public consultations on health care-related policy. Drawing on these experiences, a public consultation initiative in Israel called the Health Parliament was established. GOALS: To implement a public consultation initiative that will engage members of the public in the discussion of four healthcare policy questions associated with equity in health services and on priorities for determining which medications and treatments should be included in the basket of national health services. METHOD: One hundred thirty-two participants from the general population recruited through a random sample were provided with background materials and met over several months in six regional sites. Dilemma activities were used and consultants were available for questions and clarifications. Participants presented their recommendations in a national assembly to the Minister of Health. OUTCOMES: Across the regional groups the recommendations were mostly compatible, in particular regarding considering the healthcare system's monetary state, even at the expense of equity, but for each policy question minority views were also expressed. A strong emphasis in the recommendations was pragmatism. CONCLUSION: Participants felt the experience was worthwhile; though the actual impact of their recommendations on policy making was indirect, they were willing to participate in future consultations. However, despite enthusiasm the initiative was not continued. Issues raised are whether consultation initiatives must have a direct impact on healthcare policy decisions or can be mainly a venue to involve citizens in the deliberation of healthcare policy issues.

Association between consumption of Herbalife nutritional supplements and acute hepatotoxicity.

BACKGROUND/AIMS: Nutritional supplements are frequently considered to be harmless but indiscriminate use of unlabelled ingredients may lead to significant adverse reactions. METHODS: In 2004, identification of four index cases of acute hepatitis associated with Herbalife intake led to a ministry of health investigation in all Israeli hospitals. Twelve patients with acute idiopathic liver injury in association with consumption of Herbalife products were investigated. RESULTS: Eleven of the patients were females, aged 49.5+/-13.4 y. One patient had stage I primary biliary cirrhosis and another had hepatitis B. Acute liver injury was diagnosed after 11.9+/-11.1 months of initiation of Herbalife consumption. Liver biopsies demonstrated active hepatitis, portal inflammation rich with eosinophils, ductular reaction and parenchymal inflammation with peri-central accentuation. One patient developed sub-fulminant and two fulminant episodes of hepatic failure. Hepatitis resolved in eleven patients, while one patient succumbed to complications following liver transplantation. Three patients resumed consumption of Herbalife products following normalization of liver enzymes, resulting in a second bout of hepatitis. CONCLUSIONS: An association between intake of Herbalife products and acute hepatitis was identified in Israel. We call for prospective evaluation of Herbalife products for possible hepatotoxicity. Until then, caution should be exercised by consumers, especially among individuals suffering from underlying liver disease.

Preparedness of the Israeli health system for a biologic warfare event.

The threat of a disease outbreak resulting from biologic warfare has been of concern for the Israeli health system for many years. In order to be prepared for such an event the health system has formulated doctrines for various biologic agents and defined the logistic elements for the procurement of drugs. During the last 4 years, and especially after the West Nile fever epidemic in 2000, efforts to prepare the healthcare system and the relevant organizations were accelerated. The Director-General of the Ministry of Health nominated a Supreme Steering Committee to fill in the gaps and upgrade the preparedness of the health system for an unusual disease outbreak. This committee and its seven subcommittees established appropriate guidelines, communication routes among different organizations, and training programs for medical personnel. The anthrax outbreak in the United States found the healthcare system in the hub of the preparation process, and all modes of action were intensified. Further work by hospitals, primary care clinics and all other institutes should be increased to maintain a state of proper preparedness.

When is an epidemic an epidemic?

BACKGROUND: The large number of cases of West Nile fever diagnosed in Israel in 2000 once again brought into focus the confusion that frequently accompanies the use of the term "epidemic." OBJECTIVES: To examine the different definitions of the term "epidemic" and to propose ways in which it can be used to both improve communication among professionals and provide the public with a better sense of the associated risks. METHODS: The literature was reviewed for the various definitions of the terms "epidemic" and "outbreak." Sources included popular and medical dictionaries, ancient documents, epidemiology texts, legal texts, and the medical literature. RESULTS: The term epidemic is variously defined. The broad definition given by epidemiologists--namely, more disease than is anticipated by previous experience--is less meaningful to the general public. In some ways it conflicts with the definitions found in the popular literature, which generally imply danger to the public and a very large number of victims. CONCLUSIONS: The interpretation of the term epidemic may vary according to the context in which it is used. For risk communication, we suggest that every effort be made to add descriptive terms that characterize the epidemic.