The National Immunization Technical Advisory Group in Israel.

National Immunization Technical Advisory Groups (NITAGs) are defined by the World Health Organization as multidisciplinary groups of health experts who are involved in the development of a national immunization policy. The NITAG has the responsibility to provide independent, evidence-informed advice to the policy makers and national programme managers, on policy issues and questions related to immunization and vaccines.This paper aims to describe the NITAG in Israel. The Israeli NITAG was established by the Ministry of Health in1974. The NITAG's full formal name is "the Advisory Committee on Infectious Diseases and Immunizations in Israel". The NITAG is charged with prioritizing choices while granting maximal significance to the national public health considerations. Since 2007, the full minutes of the NITAG's meetings have been publicly available on the committee's website (at the Ministry of Health website, in Hebrew).According to the National Health Insurance Law, all residents of Israel are entitled to receive universal health coverage. The health services basket includes routine childhood immunizations, as well as several adult and post - exposure vaccinations. The main challenge currently facing the NITAG is establishing a process for introducing new vaccines and updating the vaccination schedule through the annual update of the national health basket. In the context of the annual update, vaccines have to "compete" with multiple medications and technologies which are presented to the basket committee for inclusion in the national health basket. Over the years, the Israeli NITAG's recommendations have proved essential for vaccine introduction and scheduling and for communicable diseases control on a national level. The NITAG has established structured and transparent working processes and a decision framework according to WHO standards, which is evidence-based and country-specific to Israel.The recent global COVID-19 pandemic is a major concern for all countries as well as a challenge for NITAGs. Currently, the NITAGs have a key role in advising both on sustainment of the routine immunization programs and on planning of the COVID-19 vaccination campaigns, with ongoing updates and collaboration with the Ministry of Health and health organizations.

Different Reasons for Not Completing Routine Vaccinations Among Jewish and Arab Children in Israel.

Minority communities are at high risk for low childhood vaccination coverage rates. This paper compared the rate of children not fully vaccinated and the reasons for that between Jewish (majority) and Arab (minority) children in Israel. This cross-sectional study screened the medical files of 14,232 children (12,360 Jewish and 1872 Arab), registered at Mother-Child Health Clinics in two large geographical area, to identify children who did not complete the last dose of hepatitis B and DTaP or first dose of MMR vaccines. We compared the reasons for not completing the vaccine schedule registered by the nurses between Jewish and Arab children. We identified 1052 children who did not complete at least one of the vaccines: 975 Jewish children and 77 Arab children. Four causal categories were identified: medical reasons, parental decision, parental behaviour, and organizational reasons. Multinomial logistic regression analysis was performed to analyze the reasons for not completing the vaccination protocol. Arab children compared to Jewish children were more likely not to complete the vaccination protocol due to medical reasons (OR 3.81, CI 1.53-9.49) and less likely due to the reason parental decision (OR 0.35, CI 0.13-0.96). Therefore, patterns of reasons for not completing vaccinations vary, depending on population. Interventions to reduce the number of children not fully vaccinated should be tailored to the specific population.

Epidemiologic Surveillance in Israel of Cryptosporidium, a Unique Waterborne Notifiable Pathogen, and Public Health Policy.

BACKGROUND: Cryptosporidium is a major threat to water supplies worldwide. Various biases and obstacles in case identification are recognized. In Israel, Cryptosporidiosis was included among notifiable diseases in 2001 in order to determine the burden of parasite-inflicted morbidity and to justify budgeting a central drinking water filtration plant. OBJECTIVES: To summarize the epidemiologic features of 14 years of Cryptosporidium surveillance and to assess the effects of advanced water purification treatment on the burden of disease. METHODS: From 2001 to 2014, a passive surveillance system was used. Cases were identified based on microscopic detection in stool samples. Confirmed cases were reported electronically to the Israeli Ministry of Health. Overall rates as well as age, gender, ethnicity and specific annual incidence were calculated per 100,000 population in five age groups: 0-4, 5-14, 15-44, 45-64, > 65 years. RESULTS: A total of 522 Cryptosporidium cases were reported in all six public health districts. More cases were detected among Jews and among males, and mainly in young children, with a seasonal peak during summer. The Haifa sub-district reported 69% of the cases. Most were linked to an outbreak from the summer of 2008, which was attributed to recreational swimming pool activity. Cases decreased after installation of a central filtration plant in 2007. CONCLUSIONS: As drinking water in Israel is treated to maximal international standards, the rationale for further inclusion of Cryptosporidium among mandatory notifiable diseases should be reconsidered. Future surveillance efforts should focus on timely detection of outbreaks using molecular high-throughput testing.

The factors associated with maternal consent to human papillomavirus vaccination among adolescents in Israel.

Purpose: To evaluate the knowledge and attitudes toward the human papillomavirus (HPV) vaccine among mothers of 8th graders in Israel, and to determine the factors associated with maternal consent to the HPV vaccine.Methods: We conducted a cross-sectional study among mothers of 8th grade students in 27 schools in Haifa and Northern districts of Israel during the 2016-17 school year. Data were collected using a structured telephone questionnaire.Results: 313 mothers answered the questionnaire (response rate = 91.8%). The mean knowledge level score was low (3.96 points [out of 10] ±2.68). Knowledge level was positively associated with Jewish nationality, being secular in religious practice and higher education. The attitude mean score was low-moderate (11.22 points [out of 18] ± 5.01). Attitude score was positively associated with Arab nationality. No significant association was found between knowledge level and attitudes. According to multivariate analysis, mothers' consent to the HPV vaccine was associated with the knowledge level score (OR = 0.82; 95%CI 0.68-0.98), the attitude score (OR = 1.76; 95%CI 1.53-2.02) and nationality (OR = 27.86, 95%CI 3.41-227.56).Conclusions: The knowledge level and attitudes toward the HPV vaccine were found to be unsatisfactory with racial disparities between Arabs and Jews. Jewish mothers compared with Arab mothers, mothers with a higher knowledge level or less positive attitudes were less likely to consent to the vaccine. These findings could contribute toward adapting programs to the different Israeli sectors in order to improve the rates of HPV vaccine receipt among adolescents.

What affects pediatric healthcare providers to encourage receipt of routine childhood vaccinations? Results from the Northern District of Israel, 2016.

BACKGROUND: Pediatric healthcare providers (HCPs) are a major resource which helps parents make decisions about their children's vaccinations. It is important to assess their behavior to encourage the receipt of routine vaccines. OBJECTIVES: (1) To evaluate the knowledge level of and attitudes towards routine childhood vaccinations among pediatric HCPs; (2) To assess their behavior to encourage the receipt of routine vaccinations and associated predictors; (3) To examine their willingness to receive immunization training and to improve their skills to cope with vaccine-hesitant parents. STUDY DESIGN AND SETTINGS: This is a cross-sectional study among pediatric physicians and nurses working at primary clinics (curative service) and mother-child health clinics (preventive service) in Jewish localities in the Northern District of Israel. METHODS: A structured, anonymous, self-administered questionnaire was used. RESULTS: The study included 271 HCPs (response rate = 72.2%). An insufficient knowledge level about vaccines was demonstrated among participants (mean score: 5.2 ±â€¯0.91 and 4.71 ±â€¯1.21 points out of 6 in the preventive and curative services, respectively; p = 0.000). The overall attitude towards vaccinations was positive (mean score: 45.40 ±â€¯5.98 and 42.95 ±â€¯6.84 points out of 56 in the preventive and curative services, respectively; p = 0.002). The two predictors that were associated with the behavior of HCPs to encourage childhood vaccinations were workplace (preventive vs. curative service) and the number of parents encountered by the HCP who opposed or feared vaccines. No association was found between the behavior and the knowledge level and the attitudes. Of the HCPs, 79.3% were interested in immunization training and 66.1% in participating in workshops to improve their communication skills to cope with vaccine-hesitant parents. CONCLUSIONS: There is a need to increase the commitment of HCPs to encourage parents to vaccinate their children with routine vaccines, to improve their knowledge about vaccines, and to provide them with communication tools to deal with vaccine-hesitant parents.

A path analysis model suggesting the association between health locus of control and compliance with childhood vaccinations.

Despite vaccines benefits, parent's vaccine hesitancy is growing. Health locus of control (HLOC) may affect decision making regarding child vaccinations. The aim of this study was to investigate the relationship between parents' HLOC and compliance with routine childhood immunization programs. A cross-sectional survey was conducted among 731 parents of children aged 3-4 years. Internal HLOC, powerful others and chance HLOC (dimensions of external HLOC), reliability of information sources, and attitudes towards vaccines were measured. Path analysis was conducted to explore direct and indirect associations between HLOC and vaccination's compliance. The results show that High powerful others HLOC has a direct association with vaccination compliance (ß = 0.23, p < 0.001). High internal and chance HLOC have indirect associations through parents' attitudes regarding vaccines. Perceived reliability of information sources was associated with not complying with vaccines (ß = -0.07, p < 0.05). For conclusions, Interaction between internal and external HLOC may explain vaccination compliance. Decreasing levels of chance HLOC and increasing powerful others HLOC may increase levels of compliance with childhood vaccinations.

[SOCIAL-ECONOMIC-DEMOGRAPHIC DIFFERENCES IN REASONS NOT TO COMPLY IN TIME WITH ROUTINE CHILDHOOD VACCINATIONS].

BACKGROUND: In recent years, there has been an increase in parents who do not comply with recommended routine vaccines. The vaccination coverage rates in Israel are known, but the reasons for not completing immunizations are unknown. The aim of this study was to assess the extent of failure to complete the routine vaccinations in time and the reasons among different population groups. METHODS: This is a retrospective case-control cohort study, among children born in 2009. A total of 14,232 medical records of children who received services at Mother-Child Health Clinics were checked. The children who received all three core vaccines (3th Hepatitis B, 4th DTaP and MMR vaccines) were considered fully compliant and those missing at least one vaccination were considered non-compliant. Six reasons for not complying were identified: medical reasons, parental refusal to vaccinate, requests for a deferred schedule of vaccinations, parental behavior, organizational reasons and others. The differences between groups were analyzed by univariate analysis and logistic regression. RESULTS: In this study, 7.4% of children, were not fully compliant with all three core vaccines within two years. The main reasons in the Jewish population were: refusal and requests for variation in scheduling (44.3%) and in the Arabic population: parental behavior (40.8%). The risk for not completing the vaccinations was higher in children of Jewish mothers, residence in the Hadera sub-district, parents who had an academic education and older parents. CONCLUSIONS: There are differences between Arab and Jewish populations in the reasons for not complying in time with childhood vaccinations. In order to obtain herd immunity in the Israeli population, we need to tailor interventions suitable for each population group according to their characteristics.

Striking ethnic variations in the epidemiology of Chlamydia trachomatis in Haifa District, Israel, throughout the years 2001-2015.

Our objectives were to examine trends in the incidence of chlamydia over an extended period and compare the epidemiology of the infection between two distinct ethnic groups in Israel: Jews and Arabs. We examined the incidence rate of Chlamydia trachomatis infection among residents of Haifa District, northern Israel from 2001 to 2015, by reviewing archives of the Department of Epidemiology, Ministry of Health. Notified cases were stratified by age group, gender, and ethnic group. The overall incidence rate of Chlamydia was 10.8 cases per 100,000 population per year. The annual rate increased dramatically from 5.1 per 100,000 population in 2001, to an all-time high of 18.5 cases per 100,000 population in 2015 (P < 0.001), representing an increase of 362.7%. The most affected age group was 25-34 years of age. The estimated rate among Jewish inhabitants was ninefold higher than among Arabs. Only 3% recurrent episodes of Chlamydia were registered. The prevalence of HIV positivity among Chlamydia-infected patients was similar to that of the general population. In conclusion, Chlamydia in Haifa has been continuously increasing since 2001 and the infection is much more prevalent among patients of Jewish ethnicity, mainly due to more hazardous sexual practices in this population.

[INFLUENZA VACCINATION AMONG HEALTHCARE WORKERS - THE DATA AND THE DUTY].

INTRODUCTION: Seasonal influenza is a significant disease affecting public health due to substantial morbidity and mortality and a high economic burden. in view of its high propensity for genetic mutations, the virus can easily evade preexisting immunity acquired from prior exposure to it, thereby causing severe seasonal epidemics. Influenza vaccination has been shown to be safe and effective. In many countries, including Israel, it is recommended to all members of the population aged 6 months and older, especially those with a higher risk of developing severe complications. Its adverse effects are mostly minimal, local and systemic. No evidence-based relationship between the vaccination and neurological syndromes was found. Infected health care workers (HCWs) may transmit influenza to patients, many of whom have serious underlying conditions that increase their risk of complications. Therefore, influenza vaccination among HCWs is recommended in the United States and in >40 other countries including Israel. In spite of that, the vaccination coverage rates remain low in Israel and in many countries. The reasons include low levels of awareness to the disease severity, to the safety and effectiveness of the vaccine and low levels of trust in authorities. The effectiveness and safety of the vaccine in preventing influenza among the recipients is well documented. High quality evidence on the effectiveness of the vaccine in preventing the disease among patients and family members of HCWs who receive the vaccine is limited. However, combining the existing evidence and the clear biological plausibility lead to the conclusion that the recommendation for vaccinating health care workers against influenza to protect patients is a well-based policy. This is the policy of the WHO, CDC and health authorities in most developed countries. The Ministry of Health in Israel will continue to promote programs to increase vaccine compliance rates among HCWs and to define the uptake of vaccination as a moral duty.

Knowledge and recommendation regarding routine childhood vaccinations among pediatric healthcare providers in Israel.

BACKGROUND: A recommendation by pediatric healthcare providers (HCPs) is a major factor influencing parents' decision to vaccinate their children. Consequently, it is important to understand the motives behind the HCPs' recommendations to vaccinate children according to the routine immunization program. OBJECTIVES: To study the association of pediatric HCPs' knowledge about and attitudes towards childhood vaccinations and of their professional and demographic characteristics, with two variables: 1. Their recommendations to parents regarding adherence to the routine immunization program. 2. Their choices concerning routine immunization of their own children. STUDY DESIGN AND SETTINGS: We conducted a cross-sectional study of pediatric nurses and physicians working at Mother-Child Health Clinics (MCHCs) in Haifa and Tel-Aviv districts and at a hospital in Hadera City, Israel. METHODS: A structured, anonymous self-administered questionnaire was used. RESULTS: The overall response rate was 60%, totaling 218 participants. 92% of whom were nurses. Misconceptions related to vaccine safety were found among a high percentage of the participants. The HCPs knowledge level was associated with the HCPs vaccinating their own children according to the recommended immunization program (OR=1.32; CI95% 1.06-1.64), but not with their recommendation to parents to adhere to the program. No association was found between attitudes and these variables. Workplace (MCHCs versus hospital) correlated with the above mentioned two dependent variables (OR=1.89; CI95% 1.21-2.97 and OR=2.42; CI95% 1.73-3.4, respectively). CONCLUSIONS: Amplifying the knowledge of HCPs and addressing their concern about vaccinations can improve their adherence to the routine immunization program regarding their own children. This may lead to better adherence of other parents who are frequently interested in the HCPs' behavior and consider them as a role model. In general, there is a need to emphasize the HCP's responsibility for the successful implementation of the immunization program in the community and at hospitals.

Parents with high levels of communicative and critical health literacy are less likely to vaccinate their children.

OBJECTIVE: To investigate the relationship between parents' health literacy and decision-making regarding child vaccinations. METHODS: A cross-sectional survey was conducted among 731 parents of children aged 3-4 years. Functional, communicative, and critical health literacy (HL), knowledge, beliefs, reliability of the vaccine's information resources, and vaccine's attitudes were measured. Attitudes included three types: pro-vaccine attitudes, anti-vaccine attitudes, and attitudes regarding mandatory vaccination. Path analysis was conducted to explore direct and indirect associations of compliance with childhood vaccinations and HL. RESULTS: Communicative HL has a significant negative direct association with compliance with vaccinations (ß=-0.06, p<0.05). High functional and critical HL have significant negative indirect associations with vaccinations through parents' attitudes regarding vaccines. Higher levels of perception of reliability of informal information resources are associated with non-compliance. CONCLUSIONS: The results indicate that parents with high functional, communicative, and critical HL are more at risk of not vaccinating their children. The results are contrary to expectations in which people with high HL adopt more positive health behaviors. PRACTICAL IMPLICATIONS: Public health professionals may need more sophisticated communication methods to transfer messages regarding vaccines to parents in order to prevent decline in vaccine coverage rates, taking into account levels of trust and health literacy.

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.

Intent-to-adhere and adherence to malaria prevention recommendations in two travel clinics.

Malaria infects 30,000 travelers annually worldwide. At greatest risk are those who travel for long duration. Prevention of malaria includes chemoprophylaxis. This prospective study on 121 travelers who visited two travel clinics shows that adherence to prophylactic treatment was low, especially in long duration trips, and that adherence rate could be predicted by the much more available intent-to-adhere rate.

Variables correlated with elderly referral from nursing homes to general hospitals.

BACKGROUND: Referring patients from nursing homes to general hospitals exposes them to nosocomial diseases, and may result in the development of a broad spectrum of physical, mental and social damages. Therefore, minimizing the referring of nursing home patients to hospitals is an important factor for keeping the elderly healthy and minimizing health expenditures. In this study we examined the variables related to the referral rates from nursing homes to general hospitals and the relationship between the referral and the mortality rates among the elderly who live in nursing homes in the Haifa Sub-district. METHODS: Thirty-two nursing homes were included in a cross-sectional study. All medical directors and head nurses were interviewed using a structured questionnaire between November 2006 and October 2007. Statistical analysis, including the ANOVA and the nonparametric Spearman tests, were employed to determine the factors that influence referral rates and the correlation between referral rates and mortality rates. RESULTS: The referral rate ranged between 18 and 222 per 100 financed elderly in a single year. In the multivariate analysis, the absence of a physician from the nursing home at the time of the referral to general hospitals was the only significant variable related to referral rates. No significant relationships were found between referral rates and mortality rates. CONCLUSIONS: Absence of a significant relationship between referral rates and mortality rates may indicate that high referral rates do not necessarily protect the elderly from death. Therefore, any recommendations issued by the Ministry of Health (MOH) should emphasize in-house treatment rather than hospitalization. Clear instructions on referral from nursing homes to general hospitals need to be constructed by the MOH. The MOH should increase the presence of physicians in the nursing homes, especially, when the need to refer a patient arises. Further quantitative and epidemiologic studies should be conducted in order to, more fully and reliably, create guidelines for policy recommendations.

Trust and the demand for autonomy may explain the low rates of immunizations among nurses.

Rates of vaccinations of healthcare workers with recommended vaccines are generally low in the developed countries. Our goals were to identify attitudes associated with self-reported vaccinations against pertussis and seasonal influenza among Israeli nurses in Mother and Child Healthcare Centers (MCHC) in the Haifa District. Over 100 nurses answered a self-administered questionnaire. Forty two percent of the nurses reported receiving the pertussis vaccine in the last five years and 44% reported receiving the influenza vaccine during the previous year. Attitudes toward the importance of vaccinating nurses, trust in the public health authorities and demand for autonomy were associated with receiving the pertussis vaccine. Attitudes toward the importance of vaccinating nurses and trust were associated with receiving the influenza vaccine in a bivariant analysis. However, in the logistic regression models only attitudes toward the importance of vaccinating nurses were associated with vaccinations [odds ratio (OR)- 3.66, 95% confidence interval (CI)- 1.4-9.6 for pertussis and OR- 4.53, CI-1.6-13.0 for influenza]. Jewish nurses reported more often receiving the influenza vaccine compared with the Arab nurses, whereas there was no difference between them in receiving the pertussis vaccine. Low levels of positive attitudes toward the importance of vaccinating nurses may inhibit nurses in MCHC from receiving vaccines. The demand for autonomy and low levels of trust may, in part, form these low levels of positive attitudes toward the importance of vaccinating nurses.

Preventing mumps outbreaks in confined settings: comprehensive ring vaccination as a containment strategy.

Even among vaccinated cohorts, prevention and control of mumps outbreaks remain a challenge, owing to sub-optimal population immunity. This is especially true in confined settings, where a single case could be the index for an imminent outbreak. Efficacy of post-exposure prophylaxis has not been demonstrated, while early identification of mumps and comprehensive vaccination of populations in confined settings during outbreaks may enable containment of mumps and disrupt further spread. However, we are not aware of official international guidelines concerning vaccination of exposed individuals during an outbreak, especially in a confined setting. In this article we present our experience with mumps containment during outbreaks through vaccination campaigns in the Israeli civilian and military populations and discuss lessons for containment efforts in other settings.  Our analysis shows that a comprehensive ring vaccination should be considered in any case of mumps in confined settings.

Factors affecting Varicella vaccine uptake among children 1-17 years old in the Haifa District in 2007.

The Israeli National Vaccination Program (INVP) is aimed mainly at the pediatric age group. Till 2008 the program did not include routine administration of vaccine against Varicella (chickenpox). For the past 7 years, however, vaccine against Varicella has been available to the public and subsidized through the health maintenance organizations (HMOs). On the eve of probable introduction of the Varicella Zoster Vaccine (VZ-V) into the INVP a study was conducted to examine factors postulated to be of importance in vaccination uptake. These factors can be assessed while the vaccine is only administered through active choice, as opposed to administration by default as part of INVP. The study group comprised the communities in the District of Haifa. The aim of the study was to assess vaccination rates and contributing factors in the decision to vaccinate or not vaccinate against VZ. The study showed that uptake of VZ-V was in correlation with: 1. Population group (i.e. religious denomination)--Jews were more likely to vaccinate (OR=3.88). 2. Level of education--parents with higher level of education were more likely to vaccinate. (OR=1.91). 3. Level of religious observance--non-observant parents were more likely to vaccinate (OR=2.7) 4. Complementary insurance (reimbursement of cost)--parents with complementary insurance were more likely to vaccinate (OR=3.41). 5. A physician's recommendation to vaccinate--when a physician recommendation was given for vaccination the likelihood of vaccination was increased (OR=2.94).

Influenza vaccination coverage determinants among employees of the Nazareth Hospital in Israel.

BACKGROUND: Health care workers bear the risk of both contracting influenza from patients and transmitting it to them. Although influenza vaccine is the most effective and safest public health measure against influenza and its complications, and despite recommendations that HCWs be vaccinated, influenza vaccination coverage among them remains low. OBJECTIVES: To characterize influenza vaccination coverage and its determinants among employees in an Arab hospital in Israel. METHODS: An anonymous self-administered questionnaire was distributed among employees involved in patient care in the winter of 2004-2005 at Nazareth Hospital in Israel. The questionnaire included items related to health demographic characteristics, health behaviors and attitudes, knowledge and attitude concerning influenza vaccination, and whether the respondent had received the flu shot during the previous winter or any other winter. RESULTS: The overall rate of questionnaire return was 66%; 256 employees participated in the study. The immunization coverage rate was 16.4%, similar to that reported for other hospitals in Israel. Logistic regression analysis demonstrated that influenza vaccination coverage was significantly and solely associated with the presence of chronic illness and influenza vaccination. CONCLUSIONS: Influenza vaccination coverage among Nazareth Hospital health care workers was low. They did not view themselves as different from the general population with regard to vaccination. Three years after the study, an intervention program was launched with the aim of increasing knowledge on the efficacy and safety of the vaccine; it stressed the importance of vaccinating HCWs and administering the vaccine at the workplace. The program led to a 50% increase in vaccination coverage.