Heterosexual men who purchase sex and attended an STI clinic in Israel: characteristics and sexual behavior.

BACKGROUND: Commercial sex shares a role in HIV and sexually transmitted infections (STI) transmission. Men who pay for sex (MPS) may transmit HIV/STI to other populations which are low-risk. This study aimed to test our hypothesis that MPS engage in high-risk sexual behaviors associated with HIV/STI transmission more so than non-MPS. METHODS: This cross-sectional study included heterosexual men who attended an STI clinic between 2003 and 2010. Demographic, clinical, behavioral and laboratory data were compared between MPS and non-MPS to identify factors associated with high-risk sexual behavior and STI-burden. RESULTS: Of the first visits of 6156 heterosexual men who attended the STI-clinic during the study period, 1649 (26.7%) were MPS. MPS were more commonly older, married and non-Israeli born compared with non-MPS. MPS were more likely to engage in risk-behaviors associated with HIV/STI-transmission, including a greater number of lifetime sexual partners, substance use and previous STI diagnoses. Determinants associated with STI-diagnoses at the current visit included being non-Israeli born, presenting with STI symptoms, reporting a greater number of lifetime sexual partners and having sexual encounters with non-Israeli individuals. CONCLUSIONS: Approximately 25% of all men who attended the clinic were MPS. They were more likely to engage in risk-behaviors associated with HIV/STI transmission compared to non-MPS. These findings highlight the need to establish interventions for MPS that both continue to encourage condom use and address the potential perils pertaining to risky sexual behaviors.

Medical condition and care of undocumented migrants in ambulatory clinics in Tel Aviv, Israel: assessing unmet needs.

BACKGROUND: Approximately 150,000 undocumented migrants (UM) who are medically uninsured reside in Israel, including ~50,000 originating from the horn of Africa (MHA). Free medical-care is provided by two walk-in clinics in Tel-Aviv. This study aims to compare the medical complaints of UM from different origins, define their community health needs and assess gaps between medical needs and available services. METHODS: This cross-sectional study included a random sample of 610 UM aged 18-64 years, who were treated in these community clinics between 2008 and 2011. The study compared UM who had complex medical conditions which necessitated referral to more equipped medical settings with UM having mild/simple medical conditions, who were treated at the clinics. RESULTS: MHA were younger, unemployed and more commonly males compared with UM originating from other countries. MHA also had longer referral-delays and visited the clinics less frequently. UM with complex medical conditions were more commonly females, had chronic diseases and demonstrated longer referral-delays than those who had mild/simple medical conditions. The latter more commonly presented with complained of respiratory, muscular and skeletal discomfort. In multivariate analysis, the variables which predicted complex medical conditions included female gender, chronic illnes and self-referral to the clinics. CONCLUSIONS: The ambulatory clinics were capable of responding to mild/simple medical conditions. Yet, the health needs of women and migrants suffering from complex medical conditions and chronic diseases necessitated referrals to secondary/tertiary medical settings, while jeopardizing the continuity of care. The health gaps can be addressed by a more holistic social approach, which includes integration of UM in universal health insurance.

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.

The yield of tuberculosis screening of undocumented migrants from the Horn of Africa based on chest radiography.

BACKGROUND: Since 2006 more than 60,000 migrants arrived in Israel from the Horn of Africa (HoA: Sudan, Eritrea, Ethiopia). They were detained in prison and screened for tuberculosis (TB) by means of an interview and chest X-ray (CXR). OBJECTIVES: To evaluate the yield of this screening process. METHODS: This cross-sectional study evaluated the validity of CXR in a random sample of 1087 of the 5335 HoA migrants (20.4%) who arrived in 2009, and assessed its related costs. RESULTS: Sixty-two migrants (5.7%) had CXRs with TB-suspicious findings, and 11 of them were finally diagnosed with TB (17.7% of all TB-suspicious CXRs). TB point-prevalence was 1000 cases per 100,000 migrants (1.0%). As no additional TB cases were diagnosed on arrival, CXR sensitivity, specificity and positive predictive value were 100%, 96.1% and 17.7%, respectively. The interview did not contribute to the detection of migrants with TB. Direct costs related to the detection of single TB cases in prison was 17,970 shekels (US$ 4585), lower than the treating cost of 28,745 shekels ($7335). During 2008-2010, 88 HoA migrants who had been screened at the prison after crossing the border were later diagnosed with TB in the community. The average annual TB incidence was 132 cases/100,000 migrants. We traced 56 (63.6%) of the CXRs that were performed during detention. Of those, 41 (73.2%) were unremarkable, 8 (14.2%) were TB suspicious and 7 (12.5%) had non-TB-related abnormalities. CONCLUSIONS: CXR-based screening is a valid and cost-saving tool for screening HoA migrants for TB; the interview has significant limitations.

Enhanced surveillance for detection and management of infectious diseases: regional collaboration in the middle East.

Formed before international negotiations of the revised International Health Regulations (IHR), the Middle East Consortium for Infectious Disease Surveillance (MECIDS) is a regional collaboration aimed at facilitating implementation of the revised IHR and, more broadly, improving the detection and control of infectious disease outbreaks among neighboring countries in an area of continuous dispute. Initially focused on enhancing foodborne disease surveillance, MECIDS has expanded the scope of its work to also include avian and pandemic influenza and other emerging and re-emerging infectious diseases. Here, we describe the history and governance of MECIDS, highlighting key achievements over the consortium's seven-year history, and discuss the future of MECIDS.

Tuberculosis screening in immigrants from high-prevalence countries: interview first or chest radiograph first? A pro/con debate.

Immigration from high tuberculosis (TB) prevalence countries has a substantial impact on the epidemiology of TB in receiving countries with low TB incidence. Cross-border migration offers an ideal opportunity for active case finding that will result in a lower caseload in the host country and a reduced spread of disease to both the indigenous and migrant populations. Screening strategies can start 'offshore', thereby indirectly assisting and empowering public health systems in the source countries, or be performed at ports of entry with or without long-term engagement of 'onshore' facilities and systems to provide either preventive therapy or surveillance for reactivation of latent TB. The chest radiograph seems to be playing a key role in this process, but questions remain regarding when, where and in whom radiographs are best done for optimal yield and cost-effectiveness, and with what other tests they might best be combined to further increase the usefulness of transborder TB control.

[Tuberculosis and AIDS in labor migrants in Israel--are we really facing a new challenge?].

Israel has absorbed labor migrants (LM), mostly originating from developing countries endemic for tuberculosis and AIDS. This trend has increased in the last 4 years, and included LM from the horn of Arica. Public opinion towards LM is ambivalent and is based on incomplete data and prejudice. Those who support LM deportation emphasize the burden of infectious diseases (ID) and raise concerns regarding possible exposure of Israeli citizens. This article will elucidate the process of data monitoring and the risk of ID transmission to the citizens of the hosting country. Of all individuals infected with tuberculosis and AIDS in Israel, 13% and 17% respectively are LM. LM are screened prior to arrival or upon incarceration in Israel Female LM are advised to perform an HIV test during their pregnancy. As a consequence of the active screening, more LM are diagnosed than Israelis, who are not routinely tested. The risk of ID transmission to the citizens of the hosting country is Limited, as M. tuberculosis is transmitted only to close (mainly domestic) contacts and HIV is mainly transmitted during sexual contact. These intimate contacts are rare between LM and Israelis. The Israeli Ministry of Health operates services for LM and supports treatment for tuberculosis patients and for pregnant HIV-infected females. Nevertheless, the unique medical needs of LM should be addressed and health authorities should appropriate a health infrastructure to support LM. Early detection of infectious diseases will lead to correct treatment and will reduce the risk of ID transmission in the community.

Chest radiography validity in screening pulmonary tuberculosis in immigrants from a high-burden country.

BACKGROUND: Chest x-ray (CXR) is widely used for diagnosing and screening pulmonary tuberculosis (PTB), yet its validity is debatable and its costs are relatively high. This study aimed to determine the validity of CXR screening in detecting radiological findings compatible with active PTB or with old healed tuberculosis (OHTB). METHODS: All Ethiopian immigrants to Israel between 2001 and 2005 were radiographed before emigration. Immigrants whose CXR demonstrated PTB or OHTB were evaluated, treated, and followed for one year after arrival. The end point of this historical cohort study was a diagnosis of active pulmonary disease within the study period. RESULTS: CXR was performed on 13,379 immigrants. Changes suggesting PTB were identified in 150 (1.1%) of those, and 46 were diagnosed with active PTB. Sensitivity, specificity, and positive predictive value of a CXR suggesting PTB were 80.1%, 99.2%, and 31%, respectively. As PTB prevalence in this cohort is 0.4%, post-test odds for CXR suggestive of PTB were 75.5. Changes suggesting OHTB were identified in 257 (1.9%) immigrants. Of those, 15 (5.8%) developed active PTB within one year following arrival. Sensitivity, specificity, and positive predictive value of CXR suggestive of OHTB were 17.2%, 98.2%, and 5.8%, respectively, when active PTB during the first year was the end point. In this study, 291 CXR were required to detect one active PTB patient, costing $5,802. CONCLUSIONS: CXR is a valid and cost-saving tool for screening active PTB in immigrants originating in high-burden countries, and is beneficial in detecting OHTB in immigrants who are at a higher risk for developing active PTB.

Comparing three basic models for seasonal influenza.

In this paper we report the use of the open source Spatiotemporal Epidemiological Modeler (STEM, www.eclipse.org/stem) to compare three basic models for seasonal influenza transmission. The models are designed to test for possible differences between the seasonal transmission of influenza A and B. Model 1 assumes that the seasonality and magnitude of transmission do not vary between influenza A and B. Model 2 assumes that the magnitude of seasonal forcing (i.e., the maximum transmissibility), but not the background transmission or flu season length, differs between influenza A and B. Model 3 assumes that the magnitude of seasonal forcing, the background transmission, and flu season length all differ between strains. The models are all optimized using 10 years of surveillance data from 49 of 50 administrative divisions in Israel. Using a cross-validation technique, we compare the relative accuracy of the models and discuss the potential for prediction. We find that accounting for variation in transmission amplitude increases the predictive ability compared to the base. However, little improvement is obtained by allowing for further variation in the shape of the seasonal forcing function.

Recent trends in human brucellosis in Israel.

BACKGROUND: The majority of human brucellosis cases in Israel are caused by the ingestion of unpasteurized dairy foods produced from unlicensed family-owned flocks whose products are sold door-to-door at low prices. Exposure to infected farm animals is another major cause of infection. OBJECTIVES: To determine, by examining recent incidence data and brucellosis control programs, whether a reduction in the incidence of human brucellosis in Israel can be sustained. METHODS: Case information is reported to the Health Ministry and national data are compiled and analyzed by the Division of Epidemiology. The current study focuses on data from 1998 through 2009 and discusses several of the major prevention and health education programs that have been implemented. RESULTS: An incidence decline of almost 70% during the period 1998-2002 was followed by a return to previously existing levels, although the incidence has remained consistently lower than in past decades. The disease is mostly limited to certain sectors of the rural Arab population. In 2009 the incidence rate per 100,000 population was 7.0 among Arabs compared with 0.2 among Jews. Between 1998 and 2009, 63% of cases were from the Beer Sheva and Acre health districts, which together comprise 15.5% of the Israeli population. Control programs--including efforts to combat brucellosis in animals and to discourage the sale of unpasteurized homemade dairy products--have met with partial success. CONCLUSIONS: Without routine vaccination of all family-owned flocks, more effective restraints on the market for unpasteurized dairy foods and improved regional cooperation, human brucellosis will continue to be a contained, but persistent, health problem in Israel due to cultural behavior, socioeconomic factors, and the regional political environment.

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.

Pandemic influenza preparedness and response in Israel: a unique model of civilian-defense collaboration.

In April 2009, the World Health Organization announced the emergence of a novel influenza A(H1N1-09) virus and in June 2009 declared the outbreak a pandemic. The value of military structures in responding to pandemic influenza has become widely acknowledged in recent years. In 2005, the Israeli Government appointed the Ministry of Defense to be in charge of national preparedness and response for a severe pandemic influenza scenario. The Israeli case offers a unique example of civilian-defense partnership where the interface between the governmental, military and civilian spheres has formed a distinctive structure. The Israeli pandemic preparedness protocols represent an example of a collaboration in which aspects of an inherently medical problem can be managed by the defense sector. Although distinctive concepts of the model are not applicable to all countries, it offers a unique forum for governments and international agencies to evaluate this interface within the context of pandemic influenza.

[Omega-3 fatty acids: the science and the beliefs].

The importance of Omega-3 fatty acids intake from dietary supplements or from food sources (mainly fish) has recently become "common knowledge" in the mass media as well as in popular science magazines and advertisements. Therefore, the authors wish to review the updated evidence-based literature regarding the relationship between Omega-3 fatty acid intake and morbidity and its preventative effects in cardiovascular, bone, kidney autoimmune, GI tract diseases, CNS and mental diseases, cancer, diabetes, asthma, ophthalmological health, organ transplants and child and maternal health. Recommendations regarding optimal intake of these fatty acids throughout the lifecycle by various health authorities are cited. The conclusion presents the authors' recommendations for optimal Omega-3 intake in Israel: Recommendations for the general population is to consume at least two weekly portions of fatty fish. For patients with hypertriglyceridemia, dietary supplements containing fish oil, in addition to the above diet, can be considered to be part of the complete medical treatment and follow-up. Limiting fish consumption in risk group populations, such as pregnant women, will also be considered.

[Pandemic A/H1N1 2009 as an international health event with a global impact].

Since the end of April 2009, in proximity with the decline of the seasonal flu season, the world has been acquainted with an outbreak of influenza of a new type of A/H1N1 in Mexico and the USA. The virus has spread throughout the world and become a pandemic flu, for the first time since 1968. This article addresses the global aspects of the outbreak of this new pandemic influenza, starting from the first event of "Avian Flu" in 1997 in Hong Kong, through the outbreaks of SARS in 2003, and the Avian Flu, which also began in 2003, and is still endemic in some countries. This article overviews the International Health Regulations (IHR), which were endorsed by all Member States in 2005, and have been in effect since June 2007. For the first time in history, the Member States of World Health Organization (WHO) were prepared for the upcoming pandemic flu by establishing national preparedness plans and stockpiling anti-viral drugs, even without knowing when and where the first outbreak would take place. The IHR has delegated authority to the WHO to act and lead countries in coping with the various phases of the pandemic in a centralized fashion, starting with formulating the epidemiological surveillance and reports, indications and step-by-step declarations on the alert levels from 4 to 6 announced on June 11th, 2009. The article examines the performances of the WHO and its Director General in exercising the IHR for the first time and leading the event in a professional, harmonized and respectful fashion. Nevertheless, currently, the pandemic A/H1N1 2009 seems to be a mild disease clinically, although causing death, but it has not yet eased, and there are still major question marks concerning its future. Its future spread and severity, together with the WHO response will impact the WHO's ability to conduct global initiatives. Regional cooperation with the Palestinian Authority and Jordan before and after this pandemic influenza outbreak is noted.

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.

Public health in Estonia 2008: an analysis of public health operations, services and activities

Since the end of the twentieth century, both public health as a discipline and public health services inEurope have faced unprecedented challenges. Estonian public health services (PHS) have undergoneextensive reform since 1990, as part of broader health sector reforms. Following European Unionaccession, the landscape of public health has been reshaped in many areas, most importantly through thenew National Health Plan 2009–2020, which sets out the basis of further improvements. This hascoincided with the evaluation of PHS undertaken by a team of the WHO Regional Office for Europe, at theinvitation of the Ministry of Social Affairs and its Public Health Department. The growing challenges to thehealth system in Estonia are mainly public health challenges: addressing the high incidence (which peakedin 2001) and prevalence of HIV, and addressing and reversing lifestyle and behavioural factors thatcontribute to ill health, such as tobacco use, alcohol consumption, low levels of physical activity andobesity.

Regional infectious disease surveillance networks and their potential to facilitate the implementation of the international health regulations.

The International Health Regulations (IHR) 2005 present a challenge and opportunity for global surveillance and control of infectious diseases. This article examines the opportunity for regional networks to address this challenge. Two regional infectious disease surveillance networks, established in the Mekong Basin and the Middle East, are presented as case studies. The public-private partnerships in the networks have led to an upgrade in infectious disease surveillance systems in capacity building, purchasing technology equipment, sharing of information, and development of preparedness plans in combating avian influenza. These regional networks have become an appropriate infrastructure for the implementation of the IHR 2005.

["Injecting clean or being clean?" The international and Israeli experiences of Syringe Exchange Programs among injecting drug users].

Injecting drug users (IDU) are a hard-to-reach population. The treatment objectives are to reduce their risk factors, to guide them to total abstinence or to antagonist treatment. When IDU are not ready for detoxification, they are referred to Syringe Exchange Programs (SEP). The objective of SEP is harm reduction of blood-borne viruses (of HIV, HBV, HCV). The authors aimed to define the issues related to harm reduction, to discuss the results of SEP in the world, and to describe our experience. We analyzed the world literature and our experience. In this article, we describe the rehabilitation school of thought (which supports complete drug abstinence), the harm reduction school of thought (which refers to drug addiction as a chronic disease), and the possible continuum between these two schools of thought. The AIDS pandemic and the epidemiology of world drug addiction by injection are described, together with the principles of SEP and their evaluation in the world. In addition, we describe drug use in Israel and HIV infection among IDU. Finally, we analyze our preliminary results of the SEP pilot in Israel, during the years 2004-2005, and included 462 IDUs. In conclusion, considering the difficulties that exist with IDUs, most articles emphasize the importance of SEP in this population while sometimes also expressing its effectiveness in preventing transmissions of blood-borne viruses. In Israel, a pilot project has existed since the end of 2003, and has expanded progressively to three cities. An overall evaluation of this program is under preparation.

[The fortification of salt with iodine worldwide and its implication in Israel].

Iodine deficiency disorders (IDD) are still a major public health concern in many populations worldwide. In the last century different kinds of foods (mainly salt) were used as vehicles for iodine fortification programs. Iodization of salt was first introduced in the 20s, but this strategy of universal salt iodization was adopted by the international health organizations only in the 90s as the method of choice for IDD elimination. This review describes the reasons for preferring this method to others, forms of iodine formulas currently available for use, the accepted criteria for assessing iodine status in the population, and a summary of the situation in certain countries worldwide regarding: iodine status in the population, salt and/or other food fortifications with iodine and legislation, if existing. The wealth of experience worldwide will assist decision-makers in Israel regarding salt fortification programs in this country. The article describes the known data existing in Israel and suggests strategies for iodine fortification in the country.