[THE NEED FOR REDUCING DISPARITIES IN SARS-COV-2 IMMUNIZATION: THE ULTRAORTHODOX AND ARAB POPULATIONS IN ISRAEL].

INTRODUCTION: Immunization against coronavirus disease 2019 (COVID-19) in Israel began on December 2020, using the BNT162b2 mRNA vaccine. Individuals aged 60 years or older and medical staff were prioritized in COVID-19 immunization, and currently individuals aged 16 years or older are eligible to receive the vaccine. To achieve levels of community immunity (herd immunity) immunization of 60-70% of the population is required. As of mid-February 2021, about 42% of the population in Israel received the first vaccine dose, and the coverage exceeded 70% in individuals aged 50 years or older. Despite this success, the rates of COVID-19 immunization are lower in the ultraorthodox and Arab populations compared to the general Jewish population. We reviewed factors that might affect acceptance of COVID-19 vaccines. Factors that might influence the individual's willingness to be vaccinated against COVID-19 include concerns about the safety of the vaccine, recommendations by employers and treating physicians. Moreover, differences were found in the willingness to be vaccinated according to socio-demographic characteristics, such as employment, age and gender groups, and even political affiliation. Minority populations are vulnerable to misinformation about vaccines. The Arab and the ultraorthodox populations are the main minority groups in Israel, and characterized by lifestyle, and low socio-economic status, which increased, among other factors, the incidence of COVID-19 in these populations. To improve vaccine uptake in the ultraorthodox and Arab populations, there is an urgent need for better tailored solutions to the unique needs of these minority populations, which comprise main risk groups for misinformation related to COVID-19 vaccines. Moreover, a better understanding of the reasons for low uptake of COVID-19 vaccine in these populations is warranted. These activities should be undertaken in parallel to continuous efforts towards reducing socio-economic disparities between sub-population groups.

[MEASLES VACCINATION IN CONTEMPORARY HALAKHAH].

INTRODUCTION: One of the features of the recent measles outbreak world-wide has been the resurgence of the opposition to vaccination in the religious Jewish community. The present article presents the positions of a broad spectrum of Orthodox rabbinical rulings ranging from Haredi to National Religious to Modern Orthodox on this issue. The overwhelming majority of the halakhic authorities cited are in favor of the vaccination of both adults and children. It is noteworthy that in their decisions the rabbis rely on mainstream medical expertise in relation to the threat to both individual and public health as a result of non-vaccination. They also demonstrate awareness of the arguments of those opposed to vaccination and find ways to refute them. Nevertheless, there are vaccinations such as the one against human papillomavirus infection that are not approved by many rabbis. In order to ensure adequate vaccination-induced immunity to highly infectious diseases in Israel it is vital that the medical community is aware of the normative halakhic position, and is able, if necessary, to explain it to the religious population. This need is even more pressing in the midst of the present COVID-19 pandemic, since the success of the vaccination program depends upon the voluntary cooperation of all sectors of the population, and statistically, the religious community would appear to have a comparatively higher infection rate than other groups.

[THE VACCINATION CONTROVERSY IN THE JEWISH COMMUNITY IN LONDON IN THE LATE 19TH CENTURY: "NOTHING IS NEW UNDER THE SUN"].

INTRODUCTION: In the last decade of the 19th century, some hundred years after the introduction of the smallpox vaccine, a heated controversy broke out in London regarding the compulsory vaccination of children against the disease. Amongst those affected by the legislation, mandating the immunization of children against smallpox was a Jewish father who was eventually imprisoned for refusing to have his son vaccinated. His grounds for refusal were his religious beliefs and it is with his case and its aftermath that the present article is concerned. The two major protagonists in the controversy were Chief Rabbi of England, Dr. Herman Adler and Mr. J. H. Levi. According to the Chief Rabbi, members of the Anglo-Jewish community were required to comply with the law of the land and act in accordance with mainstream medical opinion regarding the vaccination of their children as a matter of their Jewish faith. Levi who was a prominent economist at London University and a champion of liberalism and individual freedom, strongly opposed the Chief Rabbi's ruling on Jewish as well as general grounds. The debate between the two protagonists as it emerges from newspaper clippings and articles of the period is similar in many ways to the contemporary vaccination controversy in both London and Israel. One salient feature of the 19th century debate is the failure of the health authorities to publish precise and ongoing reports on the importance and effectiveness of vaccination throughout the year and not only prior to anticipated outbreaks of the disease. One of the lessons to be learned from the present article is the need for the medical establishment to acquire expertise in the areas of communication and media in order to deal successfully with the phenomenon of vaccine refusal. Amongst the issues that would need to be confronted is that of the halakhic objections, if any, to compulsory vaccination, which is a central theme of this article.

[EPIDEMIOLOGICAL AND CLINICAL ASPECTS OF SMALLPOX IN THE LIGHT OF JEWISH SOURCES IN THE PERIOD PRIOR TO MODERN VACCINATION].

INTRODUCTION: Europe was affected by a particularly severe outbreak of smallpox during the 17th and 18th centuries. In the early 18th century, the use of vaccines began to spread. The vaccines in use at that time were not risk free, and both post-vaccine mortality and the risk of spreading the disease to the non-vaccinated population were a matter of public concern. The Jewish documents reviewed in this article present epidemiological and clinical information on smallpox among European Jewish communities in the last decades of the 18th century. These documents provide a useful tool for historical research in that they shed light on, and provide a source of information about the spread of the disease, and the various measures aimed at preventing its spread including vaccination, among Jewish communities at the time.

[ON THE OCCUPATIONAL HEALTH ASPECTS IN THE REGULATIONS OF JEWISH TRADE UNIONS AND RELIGIOUS ASSOCIATIONS IN EUROPE].

INTRODUCTION: Trade unions (guilds) became an important socio-economic-religious institution in Jewish communities of Eastern Europe since the beginning of the modern era. These unions mainly regulated economic matters, but also functioned as religious organizations and regulated matters in this field. A somewhat similar phenomenon was that of religious-voluntary associations, whether founded for the purpose of engagement in specific religious-social-communal affairs such as the treatment of the deceased and sick, and whether for the purpose of engagement in specific religious-pietistic affairs. Like the trade unions, these associations also became common since the early modern era, in Europe and in the Mediterranean Basin, and regulated the membership terms and duties in detail. Despite the comprehensive regulation of various issues and problems, the records and documents of these unions (from the 16th to the 19th century) do not contain real evidence for dealing with questions of occupational medicine and preventive medicine in the areas of employee health. These findings are consistent with the general trends and developments in the awareness and regulation of these areas. Regarding the religious-voluntary associations: regulations dealing with Association members' health can be found in the regulations of the associations for the treatment of the deceased and sick, namely regulations dealing with the question of avoiding treatment of dangerous patients. This reflects awareness of the specific issue of avoiding highly contagious diseases rather than an actual approach to occupational medicine issues.

[THE USE OF FUNCTIONAL TESTS IN FITNESS FOR WORK ASSESSMENTS IN THE RESPONSA LITERATURE].

INTRODUCTION: Employment-related performance tests have been known since ancient times. In this article, we have demonstrated how functional tests were used in the responsa literature over years, when making decisions on the ability of working people. In contrast to the conservative approach that exists in the responsa literature, according to which the very existence of the eclipse of tremor in the hands leads to the disqualification of a shohet or mohel from continuing his work without taking into account other variables, individual fitness decisions were presented which used functional tests or visited the employee's place of work in order to determine his ability to continue working. The use of functional tests as described in the responsa literature is also of great importance in the world of the occupational doctor's practice in the modern era.

Discussion group networks in occupational medicine: A tool for continuing education to promote the integration of workers with disabilities.

BACKGROUND: Despite their legal rights, individuals with disabilities face numerous obstacles to integration in the workplace which can result in their discharge from the labor force. Currently occupational physicians have few resources to help decide whether to integrate disabled workers in pre-placement, or in cases of return-to-work. METHODS: A network of 13 discussion groups comprised of the occupational physicians of each regional clinic of a large Health Maintenance Organization (HMO) in Israel was created to deal with disability management dilemmas. A moderator compiles and shares the physicians' opinions and experiences with all network members thus assisting the consulting physician in decision-making. RESULTS: Successful management of three representative cases is described to illustrate real-life implementations of this network. CONCLUSION: The network enables both the consulting and other physicians to tap a large knowledge base and decision-making experience concerning cases of occupational disability management, contributing to professional development and improved service delivery.

Adherence to Voice Therapy Recommendations Is Associated With Preserved Employment Fitness Among Teachers With Work-Related Dysphonia.

OBJECTIVES: Referral to voice therapy and recommendations for voice rest and microphone use are common interventions in occupational medicine aimed at preserving the working capability of teachers with occupation-related voice problems. Research on the impact of such interventions in terms of employment is lacking. This study examined changes in fitness (ie, ability) to work of dysphonic teachers referred to an occupational clinic and evaluated employment outcomes following voice therapy, voice rest, and microphone use. STUDY DESIGN: A historical prospective study was carried out. METHODS: Of 365 classroom teachers who were first referred to a regional occupational medicine clinic due to dysphonia between January 2007 and December 2012, 156 were sampled and 153 were followed-up for an average of 5 years (range 2-8). Data were collected from medical records and from interviews conducted in 2014 aimed at assessing employment status. Logistic regression models were used to assess associations between interventions and employment outcomes. Survival analyses were performed to evaluate the association between participating in voice therapy and length of retained employment fitness. RESULTS: Thirty-four (22.2%) teachers suffered declines in working capabilities due to dysphonia. Voice therapy was demonstrated as being a protective factor against such declines (odds ratio = 0.05 [0.01-0.27]). Adherence to recommendation of voice therapy was <50%. Most of the decline in working fitness among nonadherent teachers occurred within 20 months after referral. Unlike voice therapy, voice rest and microphone use were not associated with retention of working capabilities. CONCLUSIONS: Voice therapy, especially when instituted early, is a strong predictor for retaining fitness for employment among dysphonic teachers.

Long-Term Outcomes of Medication Intervention Using the Screening Tool of Older Persons Potentially Inappropriate Prescriptions Screening Tool to Alert Doctors to Right Treatment Criteria.

OBJECTIVES: To compare 24-month outcomes of participants of a prospective randomized controlled trial (RCT) assigned to undergo a medication intervention of orally communicated recommendations based on Screening Tool of Older Persons potentially inappropriate Prescriptions (STOPP) and Screening Tool to Alert Doctors to Right Treatment (START) (intervention group) with outcomes of those assigned to undergo written medication review (control group). DESIGN: Retrospective cohort study. SETTING: Chronic care geriatric facility. PARTICIPANTS: Of 359 participants from a prospective RCT conducted between April 2012 and September 2013, 306 were evaluable for another 12-month follow-up. MEASUREMENTS: Outcomes at 24-month follow-up included quality of prescribing (assessed according to STOPP/START), hospitalizations, falls, costs of medications, and all-cause mortality. Outcomes were compared with those reported at the beginning (baseline) and end (12-month follow-up) of the RCT. RESULTS: There was a significant rise in potentially inappropriate prescriptions (PIPs) (P = .01) and potentially prescriptions omissions (PPOs) (P < .001) in the intervention group between 12 and 24 months, although the prevalence of PIPs was significantly lower in the intervention group (33.3%) than the control group (48.4%) at 24-month follow-up (P = .02). Costs of medications were significantly lower in the intervention group than the control group (P < .001) at 24-month follow-up. The average number of falls in both groups dropped significantly between baseline and study closure (P = .04 and P = .008, respectively). There was no significant difference in hospitalizations and mortality between the two groups at 24-month follow-up. CONCLUSION: The effect of an orally communicated medication intervention with the STOPP/START criteria on falls was maintained over time. Direct communication between pharmacists and prescribing physicians is more efficient than written medication review and is recommended every 6 months in geriatric facilities.

Key Strike Forces and Their Relation to High Level of Musculoskeletal Symptoms.

BACKGROUND: This study aimed to investigate the relation between key strike forces and musculoskeletal symptoms (MSS). Moreover, this study presents a key strike force measurement method to be used in a workplace setting. The correlation between key strike force characteristics and MSS was previously studied, but the measurement methods used either a single-key switch or force platforms applied under the keyboard. Most of the studies were conducted in a laboratory setting. The uniqueness of measurement methods in the current study is their ability to measure forces applied to a specific key in a workplace setting and to provide more information about specific key strike forces during typing. METHODS: Twenty-four healthy computer workers were recruited for the study. The demographic questionnaire, and self-reported questionnaires for psychosocial status (General Nordic Questionnaire for Psychological and Social Factors at Work) and for detecting MSS were filled up, which later helped in dividing the participants into two groups (12 participants with pain and 12 without pain). Participants typed a predetermined text that utilized the instrumented keys multiple times. The dynamic forces applied to the keys were recorded and collected, using four thin and flexible force sensors attached to the preselected keys according to their location. RESULTS: The results demonstrated that participants with high levels of MSS, specifically in the back and neck, in the last year exerted significantly higher key strike forces than those with lower levels of symptoms (p < 0.005). CONCLUSION: The key strike force exerted while typing on a keyboard may be a risk factor for MSS, and should therefore be considered in ergonomic evaluations and interventional programs.

[THE RESPONSA LITERATURE IN THE RESEARCH OF THE HISTORY OF OCCUPATIONAL MEDICINE].

The responsa literature assembles the majority of Jewish Law Literature in the post Talmudic era. The responsa literature has a major contribution to the research of Jewish history. In this review, the use of the responsa literature in research of the history of occupational medicine is demonstrated by comparing the decision-making process of fitness for work presented in the response literature, to the decisions on fitness for work taken by the modern occupational physicians.

The impact of hospitalization on potentially inappropriate prescribing in an acute medical geriatric division.

BACKGROUND: Screening Tool of Older Person's Prescriptions (STOPP) and the Screening Tool to Alert doctors to Right Treatment (START) have been increasingly used to evaluate potentially inappropriate prescriptions (PIPs) and potentially prescription omissions (PPOs). The impact of hospitalization on PIPs/PPOs has not been investigated in depth. OBJECTIVE: To compare the prevalence of PIPs/PPOs in elderly patients on hospital admission and discharge and to identify associated risk factors. SETTING: An acute medical geriatric division of the Tel Aviv Medical Center (Israel). METHOD: This retrospective cross-sectional study included patients admitted from 12/2011 to 12/2012 aged ≥65 years. Data from patients' records included demographic details, diagnoses and medications at admission and discharge. STOPP/START criteria were applied to each patient's record. MAIN OUTCOME MEASURE: Prevalence of PIPs/PPOs on hospital admission and discharge. RESULTS: Three hundred patients were included (mean ± SD age 81.9 ± 7.2 years). Admission PIPs prevalence was 39.3 % (118 patients, 172 PIPs) and it increased to 46.0 % (138 patients, 209 PIPs) at discharge (P = 0.009). Admission PPOs prevalence was 41.0 % (123 patients, 153 PPOs) and it decreased to 28.3 % (85 patients, 99 PPOs) at discharge (P < 0.001). Having at least one PIP/PPO at discharge but not at admission was associated with length of hospital stay (OR 1.02, 95 % CI 1.001-1.03). History of falls increased the risk of being a "new PIP patient" (OR 2.25, 95 % CI 1.03-4.9), whereas diabetes increased the risk of being a "new PPO patient" (OR 3.86, 95 % CI 1.2-12.5). CONCLUSION: Hospitalization in a geriatric division resulted in an increase in PIPs and a decrease in PPOs. Strategies to reduce PIPs need to be implemented, especially for patients with longer hospital stay and a history of falls.

Intervention with the screening tool of older persons potentially inappropriate prescriptions/screening tool to alert doctors to right treatment criteria in elderly residents of a chronic geriatric facility: a randomized clinical trial.

OBJECTIVES: To assess the effect of a Screening Tool of Older Persons potentially inappropriate Prescriptions/Screening Tool to Alert doctors to Right Treatment (STOPP/START) medication intervention on clinical and economic outcomes. DESIGN: Parallel-group randomized trial. SETTING: Chronic care geriatric facility. PARTICIPANTS: Residents aged 65 and older prescribed with at least one medication (N = 359) were randomized to receive usual pharmaceutical care or undergo medication intervention. INTERVENTION: Screening medications with STOPP/START criteria followed up with recommendations to the chief physician. MEASUREMENTS: The outcome measures assessed at the initiation of the intervention and 1 year later were number of hospitalizations and falls, Functional Independence Measure (FIM), quality of life (measured using the Medical Outcomes Study 12-item Short-Form Health Survey), and costs of medications. RESULTS: The average number of drugs prescribed was significantly lower in the intervention than in the control group after 1 year (P < .001). The average drug costs in the intervention group decreased by 103 shekels (US$29) per participant per month (P < .001). The average number of falls in the intervention group dropped significantly (P = .006). Rates of hospitalization, FIM scores, and quality of life measurements were similar for both groups. CONCLUSION: Implementation of STOPP/START criteria reduced the number of medications, falls, and costs in a geriatric facility. Their incorporation in those and similar settings is recommended.

Validity of the modified RULA for computer workers and reliability of one observation compared to six.

Awkward body posture while typing is associated with musculoskeletal disorders (MSDs). Valid rapid assessment of computer workers' body posture is essential for the prevention of MSD among this large population. This study aimed to examine the validity of the modified rapid upper limb assessment (mRULA) which adjusted the rapid upper limb assessment (RULA) for computer workers. Moreover, this study examines whether one observation during a working day is sufficient or more observations are needed. A total of 29 right-handed computer workers were recruited. RULA and mRULA were conducted. The observations were then repeated six times at one-hour intervals. A significant moderate correlation (r = 0.6 and r = 0.7 for mouse and keyboard, respectively) was found between the assessments. No significant differences were found between one observation and six observations per working day. The mRULA was found to be valid for the assessment of computer workers, and one observation was sufficient to assess the work-related risk factor.

A novel alternative to environmental monitoring to detect workers at risk for beryllium exposure-related health effects.

The purpose of this study was to describe a methodology for surveillance and monitoring of beryllium exposure using biological monitoring to complement environmental monitoring. Eighty-three Israeli dental technicians (mean age 41.6 ± 1.36 years) and 80 American nuclear machining workers (54.9 ± 1.21 years) were enrolled. Biological monitoring was carried out by analyzing particle size (laser technique) and shape (image analysis) in 131/163 (80.3%) induced sputum samples (Dipa Analyser, Donner Tech, Or Aquiva, Israel). Environmental monitoring was carried out only in the United States (Sioutas impactor, SKC, Inc., Eighty Four, Pa.). Pulmonary function testing performance and induced sputum retrieval were done by conventional methods. Sixty-three Israeli workers and 37 American workers were followed up for at least 2 years. Biological monitoring by induced sputum indicated that a >92% accumulation of <5 µm particles correlated significantly to a positive beryllium lymphocyte proliferation test result (OR 3.8, 95% CI 1.2-11.4, p = 0.015) among all participants. Environmental monitoring showed that beryllium particles were <1 µm, and this small fraction (0.1-1 µ) was significantly more highly accumulated in nuclear machining workers compared to dental technicians. The small fractions positively correlated with induced sputum macrophages (r = 0.21 p = 0.01) and negatively correlated with diffusion lung carbon monoxide single breath (DLCO-SB r = 0.180 p = 0.04) in all subjects. Years of exposure were positively correlated to the number of accumulated particles 2-3 µ in diameter (r = 0.2, p = 0.02) and negatively correlated to forced expiratory volume in one second/forced vital capacity findings (r = -0.18, p = 0.02). DLCO was decreased in both groups after two years of monitoring. Biological monitoring is more informative than environmental monitoring in the surveillance and monitoring of workers in beryllium industries. Induced sputum is a feasible and promising biomonitoring method that should be included in the surveillance of exposed workers.

Biological exposure metrics of beryllium-exposed dental technicians.

Beryllium is commonly used in the dental industry. This study investigates the association between particle size and shape in induced sputum (IS) with beryllium exposure and oxidative stress in 83 dental technicians. Particle size and shape were defined by laser and video, whereas beryllium exposure data came from self-reports and beryllium lymphocyte proliferation test (BeLPT) results. Heme oxygenase-1 (HO1) gene expression in IS was evaluated by quantitative polymerase chain reaction. A high content of particles (92%) in IS >5 µ in size is correlated to a positive BeLPT risk (odds ratio [OR] = 3.4, 95% confidence interval [CI]: 0.9-13). Use of masks, hoods, and type of exposure yielded differences in the transparency of IS particles (gray level) and modulate HO1 levels. These results indicate that parameters of size and shape of particles in IS are sensitive to workplace hygiene, affect the level of oxidative stress, and may be potential markers for monitoring hazardous dust exposures.

Potentially inappropriate prescribing among older residents in a geriatric hospital in Israel.

BACKGROUND: STOPP/START ("screening tool of older persons potentially inappropriate prescriptions"/"screening tool to alert doctors to right treatment") criteria were formulated to identify potentially inappropriate prescriptions (PIP) and potential prescription omissions (PPO) in older people. OBJECTIVE: To determine the prevalence of PIP and PPO using STOPP/START criteria and to identify associated risk factors. METHOD: Data were prospectively collected from 382 residents' records in an Israeli geriatric hospital. The study population included subjects ≥ 65 years of age who were taking at least one medication. Data on demographics, medical histories, current diagnoses, current medications and biochemistry results were collected and analyzed. STOPP/START criteria were applied to each medical file. RESULTS: A total of 359 residents comprised the study group (mean age [± SD] 82.7 ± 8.7, 66.6 % females). STOPP identified 430 instances of PIP in 243 (67.7 %) residents, and START identified 151 PPO in 122 (34 %) residents. The number of medications (OR: 1.2, 95 % CI 1.11-1.3), falls (OR: 1.16, 95 % CI 1.021-1.32) and hospitalizations (OR: 1.25, 95 % CI 1.025-1.53) were identified as predictors for STOPP-defined PIP. The Charlson Comorbidity Index (OR: 1.4, 95 % CI 1.17-1.7) was associated with START-defined PPO. CONCLUSION: A high prevalence of PIP/PPO was found among geriatric patients and was associated with number of medications, falls, hospitalizations and Charlson Comorbidity Index score.