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

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

Evaluation of a possible inflammatory response after appendectomy for non-perforated appendicitis in children.

BACKGROUND: The inflammatory process in the post-appendectomy period is not well characterized. In a pilot study, we prospectively followed the kinetics of different inflammatory mediators before and after appendectomy in children, and compared the results of the groups open appendectomy (OA) and laparoscopic appendectomy (LA). MATERIAL AND METHODS: Levels of sP-selectin, tPA, MCP-1, IL-6, IL-8, sVCAM-1, and sCD40L were measured before appendectomy and on the next three consecutive days in the serum of 25 children (16 males and 9 females) aged 7 - 16 years (mean 12.6+/-2.47 years) with non-perforated acute appendicitis. RESULTS: LA and OA were performed in 16 and 9 patients respectively. None of the markers of inflammation differed significantly by surgical approach at any point of observation. However, sP-selectin, MCP-1 and sVCAM-1 levels were found to have significantly different postoperative kinetics with a trend towards higher values in the laparoscopic group compared to the open appendectomy group (p=0.034, p=0.016 and p=0.025, respectively). CONCLUSIONS: The cytokines sP-selectin, MCP-1 and sVCAM-1 may play a role in the possible post-appendectomy cytokine activation after non-perforated appendicitis. Since this phenomenon is more evident after LA than after OA, the contribution of the different LA procedures has to be further investigated.

Intestinal immunity following a combined enhanced inactivated polio vaccine/oral polio vaccine programme in Israel.

Intestinal immunity was studied in a polio-free community immunised with a combined enhanced inactivated/oral polio vaccine (EIPV/OPV) vaccination programme. Poliovirus excretion was evaluated in three groups of infants primed with a partial (2 EIPV+2 OPV) or complete (3 EIPV+3 OPV) dose schedule. Poliovirus replicated in the gut of 59.8-55.8% of infants in the three groups 7 days after administration of an additional OPV dose. Significant decreases in the percent of type-specific-virus excreters appeared after 14 and 21 days for serotypes 1 and 2, and after 21 and 28 days for serotype 3. The percent of excreters was inversely correlated with pre-challenge neutralising antibody (NA) titers (p<0.05). Intrafamilial virus transmission to mothers and siblings was minimal. The principal factor for interruption of disease and virus transmission in the community was a strong and persistent humoral immunity with immunological memory. A satisfactory level of family hygiene contributed towards breaking the chain of transmission of poliovirus to contacts.

SCCmec and spa types of methicillin-resistant Staphylococcus aureus strains in Israel. Detection of SCCmec type V.

Molecular characterization of methicillin-resistant Staphylococcus aureus isolates from three hospitals in Israel was the aim of the study presented here. We identified 11 distinct genetic clones by pulsed-field gel electrophoresis. Molecular typing identified four different SCCmec types-I, II, IV, and V-and nine spa types. Spa type t002 was the most common.

PFAPA syndrome: new clinical aspects disclosed.

BACKGROUND: The recently described PFAPA (Periodic Fever, Aphthous stomatitis, Pharyngitis and Adenitis) syndrome is characterised by periodic fever, aphthous stomatitis, pharyngitis and adenitis. However, there are currently relatively few data on the natural history of this syndrome. OBJECTIVE: To describe the presentation, clinical course, doctors' awareness, therapeutic response and long-term follow-up of children with PFAPA syndrome. METHODS: Children with PFAPA syndrome referred over a 5-year period (from January 1999 to January 2004) were enrolled in the study. Data were gathered from medical records, parents' interviews, physical examination and telephone calls. RESULTS: 54 patients with PFAPA syndrome were evaluated. Our patients had a higher rate of abdominal pain (65%) and a lower rate of aphthous stomatitis (39%) than those in previous reports. Four different patterns of disease evolution were identified, including the relatively common (n = 14, 26%) and newly described course of alternating remissions and relapses. The remissions lasted 8.5 months on average (range 4-36 months). Diagnosis was established by primary paediatricians in 30 of 54 (56%) patients. However, a substantial delay in diagnosis was apparent (mean 15 months). Episodes were curtailed by a much lower dose of prednisone or equivalent corticosteroid (mean 0.6 mg/kg/day, range 0.15-1.5 mg/kg/day) than reported previously. Tonsillectomy was successful in the prevention of recurrence of further episodes in all six patients who underwent the procedure. CONCLUSIONS: We describe several new characteristics of PFAPA syndrome in children, contributing to our knowledge of this relatively unrecognised but troublesome syndrome. Early diagnosis and appropriate treatment can markedly improve the quality of life of both patients and families.

Lipopolysaccharide hyporesponsiveness as a risk factor for intensive care unit hospitalization in infants with respiratory syncitial virus bronchiolitis.

Factors such as genetic heterogeneity in the immune response contribute to respiratory syncytial virus (RSV) bronchiolitis severity. Such heterogeneity may manifest by an aberrant proliferation of phytohaemagglutinin (PHA)-stimulated peripheral blood mononuclear cells (PBMC) in response to lipopolysaccharide (LPS). The proliferation of PBMC was analysed in 52 infants: 21 ambulatory infants with mild RSV bronchiolitis (group I), 26 hospitalized infants with RSV bronchiolitis on ward (group II) and five intensive care unit (ICU) hospitalized infants (group III). Proliferation was analysed in response to negative control, PHA (LPS) and LPS/PHA. The TLR4 mutations were genotyped using reverse-transcriptase-polymerase chain reaction. The optical density (OD) post-LPS/PHA of group II (1.27 +/- 0.63) was significantly higher than group II (0.65 +/- 0.38, P = 0.005) or group I (0.63 +/- 0.33, P = 0.003), suggesting hyporesponsiveness to the LPS attenuation effect. None of the ICU hospitalized infants demonstrated OD readings post-LPS/PHA under the 0.75 threshold as opposed to group I (67% under 0.75) and group II (69%) (P < 0.05). The responses to negative-control, LPS and PHA stimulation alone were similar across groups. The presence of TLR4 mutations (Asp299Gly and Thr399Ile) were associated with severe RSV bronchiolitis and were significantly over-represented in groups II and III. These findings suggest that impairments of PBMC function manifested by hyporesponsiveness to LPS as well as the presence of TLR4 mutations are associated with an increased risk for more severe RSV bronchiolitis in previously healthy infants. A certain threshold of LPS hyporesponsiveness may have a very high negative predictive value for ICU hospitalization, even better than the determination of known TLR4 mutations for this purpose.

Vacuum extraction and herpes simplex virus infection.

OBJECTIVE: To search for an association between delivery by vacuum extraction and an increased neonatal risk for herpes simplex virus (HSV) infection. METHODS: In a cross-sectional, descriptive, controlled study, the study (vacuum extraction) and control (spontaneous delivery) groups each included 50 consecutive women with no history of HSV infection. Cultures for HSV were obtained from the genital tracts of all parturient women and the scalps of their newborns. RESULTS: Following operative vaginal delivery, two newborns (4%) had scalp vesicles and cultures were positive for HSV for both mothers and newborns; two newborns (4%) had scalp vesicles and cultures were negative for HSV; and two newborns (4%) without scalp vesicles had cultures positive for HSV. Following spontaneous delivery, cultures were positive for HSV for four women and their newborns (8%). CONCLUSION: Herpes simplex virus isolated from the scalps of newborns may often result from colonization rather than infection.

Influenza vaccine coverage in paediatric population from central Israel.

OBJECTIVES: The aim of this study was to estimate the influenza vaccine coverage among children attending paediatric ER. METHODS: The parents of patients attending paediatric ER during the winter of 2003-2004 were inquired about their children's influenza vaccination status, whether the vaccine was recommended by the primary paediatrician recommendation, the medical history, and about several epidemiological details. RESULTS: Total of 557 questionnaires were completed. Mean age was 5.8 years. Only 23 of the 557 patients were vaccinated (4.1% coverage). Vaccine coverage in the 107 children from high risk groups was 6.5% and vaccination rate in the 144 infants aged 6-24 months was 2.7%. Influenza vaccine was recommended by the primary paediatricians in 59 cases (10.6%). Vaccine was recommended to 22.4% of patients from high risk groups, to 7.6% of infants aged 6-24 months of age and to 7.8% of the other children. CONCLUSIONS: Influenza vaccine coverage among Israeli children is low, including patients from high-risk groups, and awareness of the primary paediatricians seems to be unsatisfactory.

Cost containment analysis of childhood vaccination against varicella in Israel.

OBJECTIVES: The low cost of safe and effective vaccines prompted a cost-containment evaluation of a nationwide vaccination campaign against varicella. METHODS: A model incorporating demographic, epidemiologic and economic data from Israeli sources (supplemented by data from International literature) was constructed to estimate the decrease in morbidity and the consequent reductions in treatment costs and time-off work of a nationwide programme vaccinating children at 12 months. RESULTS: A policy of aiming to immunize a cohort of all 1-year-olds in Israel in the year 2002, for an annual cost of $1.10 million to the health services and $1.27 million to society (including lost work and transport costs), would reduce the number of cases of varicella during the lifetime of a cohort from 123,984 to 10,170 cases. This morbidity reduction would reduce national expenditures by $1.80 million in health service resources alone and by $24.5 million to society, mainly due to inaverted work absences. In addition an estimated 0.93 lives, representing 38.6 life years will be saved in the cohort. CONCLUSIONS: Under an assumption of neutrality relating to the potential effects of vaccination on herpes zoster virus, our model based calculations show that a national varicella vaccination programme is likely to be cost saving, not only from a societal perspective but also from the narrower health service perspective.

Successful treatment of recalcitrant warts in pediatric patients with carbon dioxide laser.

AIM: Warts are difficult to treat and none of the several modes of treatment suggested for their cure has been proven to be the most effective. We evaluated the efficacy of a modification of the CO (2) laser technique for recalcitrant warts in pediatric patients. PATIENTS AND METHODS: During a period of 5 years, 40 consecutive pediatric patients (average age: 12.7 +/- 2.8 years) were treated by CO (2) laser for 54 recalcitrant warts. Previous treatments were caustic and/or surgical procedures (average 2.7 procedures). Local anesthesia or digital block was performed in all patients, with intravenous sedation in two patients. The laser was used at 5 W in super-pulse mode throughout the procedure. The skin was cut with the focused laser beam in a circular fashion, about 5 mm around the wart, until all the layers of the skin down to the subcutaneous tissue were penetrated. The lesion was drawn aside and excised, using the laser beam as a scalpel. No curettage was used. The base of the wart was then vaporized with the laser in a defocused fashion, until a clean surgical field was obtained. Follow-up was weekly up to 1 month, and at 3, 6, and 12 months. RESULTS: Warts were located on fingers (24 cases), in the plantar area (10 cases), on hands (9 cases), knees, and legs (4 cases each), arms (2 cases) and elbow (1 case). Twenty-seven patients (67.5 %) had a solitary wart and the other 13 children had multiple warts (up to 6) at one or more locations. Fingers were the most common location of multiple warts (10 cases). All patients underwent the procedure in one session. No case of intractable operative bleeding, local infection, or prolonged exudative drainage was encountered. One patient complained of severe transient postoperative pain. The healing time was 4 to 5 weeks. At 12 months, there was no recurrence of the warts. No significant or disabling scarring was noticed, but hypopigmentation was noted in 11 cases (27.5 %). CONCLUSION: This technique provides a high success rate with minimal side effects and is well tolerated by young patients.

An outbreak of echovirus 13 meningitis in central Israel.

Until recently, echovirus 13 has been a very rare cause of aseptic meningitis. We investigated an outbreak of echovirus 13 in central Israel during the summer of 2000 using a prospective case control study and a retrospective study. Echovirus 13 was isolated from 79 cerebrospinal fluid (CSF) specimens from different medical centres in central Israel. Patients' ages ranged from 10 days to 41 years (95% < 15 years, M/F ratio 62/38). A total of 128 patients with clinical aseptic meningitis were admitted to the Department of Pediatrics during the outbreak (aged 10 days to 18 years, mean 5.4 years), and 58 CSF samples were processed for viral cultures. Thirty of them did not grow any virus, 26 samples yielded echovirus 13, and 2 samples echovirus 7. The clinical features of patients with echovirus 13 in the CSF were similar to those in whom no virus was isolated or those infected with other enteroviral strains except for higher rate of fever on admission, and prolonged time with fever following the diagnosis in the echovirus 13 patients. CSF cell count varied from 4 to 2,333 cells/mm3 with polymorphonuclears (PMN) predominant in 90% of our patients. In a case-control study there was no significant difference between patients and matched controls with regard to parameters such as: day care attendance, recreation in summer camp, swimming pools and at the beach, and consumption of tap water. All the patients in our series recovered fully with no neurological abnormalities. The illness caused by echovirus 13 was benign and involved mainly patients younger than 15 year of age. Several features that characterized this outbreak include relatively high WBC in the blood and a minent CSF PMN response.

The burden of uncomplicated cases of chickenpox in Israel.

OBJECTIVE: The aim of this study was to assess the direct medical burden and work loss associated with uncomplicated chickenpox in Israel. METHODS: A total of 155 otherwise healthy children and adolescents with chickenpox were recruited from 10 physician offices in central Israel. Direct and indirect medical burdens were determined by caregiver interview. RESULTS: Mean age was 3.3 +/- 2.3 years. 51% of the patients were under three years of age. Each patient made on average 1.15 visits to a general practitioner. Most patients were taken to the Doctor's office only once during the illness while 23 patients (15%) were seen twice. Three patients were referred to the emergency room. Antihistamines (39%) and Calamine lotion (28%) were the most frequently prescribed medications, followed by acyclovir (17%) and antibiotics (6%). Following the patient's illness there were 72 cases of secondary spread of varicella to household members. The individuals who cared for the child missed a combined total of 2.5 days from work (on average per varicella episode). CONCLUSIONS: Israeli children acquire chickenpox at a younger age than children in North America and England and consume more prescribed medications. While the work loss in the present study was comparable to previous reports, the direct medical costs inflicted by this infection in Israel are not negligible even for uncomplicated cases.

Excision with primary closure and suction drainage for pilonidal sinus in adolescent patients.

Controversy persists regarding the treatment of pilonidal sinus (PS). To evaluate the efficacy of excision with primary closure and closed-suction drainage in adolescent patients, between 1990 and 1999, 34 consecutive patients aged 13-18 years (mean 16.4) underwent PS excision with primary closure and suction drainage. Anesthesia was general in 16 (47%) and spinal in 18 (53%) with a statistical age difference ( P< 0.001) (15.5 vs 17.2 years, respectively). No complications due to the anesthetic were observed. Twenty-one patients (61.8%) had day-case surgery while the others were hospitalized for 2 to 4 days (average 2.3 days). The drain was removed on postoperative day 2 to 6 (average 2.2). Primary healing with no postoperative complications occurred in 30 patients (88.2%); 1 underwent partial opening of the wound because of rupture of the drainage tube during its removal. Postoperative infections requiring incision, drainage, and lay-open occurred in 3 cases (9.1%). No recurrence was found at 12-month follow-up. One recurrence (2.9%) was noted 3 years after surgery. Excision with primary closure and closed-suction drainage as an ambulatory procedure is thus a simple and effective method of treatment of uncomplicated PS in adolescents.

Food allergy is a matter of geography after all: sesame as a major cause of severe IgE-mediated food allergic reactions among infants and young children in Israel.

OBJECTIVE: To determine the prevalence, importance, and the order of frequency of IgE-mediated food allergens among infants and young children in Israel. STUDY DESIGN AND PATIENTS: In a cross-sectional study, the prevalence of IgE-mediated food allergy was investigated in 9070 infants and young children (0-2 years) who were followed-up at 23 Family Health Centers (FHCs) in central Israel. Patients with suspected IgE-mediated food allergic reactions, were recruited for further evaluation (detailed questionnaire and skin-prick test (SPT)). RESULTS: We identified 150 out of 9070 (1.7%) patients with suspected IgE-mediated food allergy. Among them, 102/150 (67%) [59 males, 43 females; mean age 10.3 months] completed a detailed questionnaire and underwent SPT. Evaluation revealed 131 positive SPTs in 78/102 (76.5%) patients. Twenty-seven positive SPTs in 18 patients were considered clinically irrelevant based on previous consumption of the relevant foods without clinical symptoms. Thus, there were 104 relevant positive SPTs in 78 patients. The overall prevalence of clinically relevant IgE-mediated food allergic reactions among these patients is estimated to be 1.2% (104/9070). The most common food allergens were egg, cow's milk, and sesame. Anaphylaxis was the presenting symptom in 14/78 (18%) including six sesame-induced cases. A history of other atopic diseases was reported in 27 (35%) patients. In addition, 22 (28%) had a history of atopy in first-degree family members. CONCLUSIONS: We found sesame to be a major cause of IgE-mediated food allergy in Israel. In fact, it is second only to cow's milk as a cause of anaphylaxis. We recommend that testing for food allergens be tailored to each community based on local experience and should include sesame in appropriate populations.

An intradermal skin test for determination of immunity to varicella.

AIMS: To evaluate the usefulness of a diluted, inactivated solution of attenuated varicella vaccine in predicting susceptibility to varicella and its correlation with specific antibody titre to varicella. METHODS: In a prospective blinded study, 63 healthy subjects (aged 2-43 years) were studied. Skin test solution was prepared from vials of OKA strain virus which was inactivated by exposure of the vials to room temperature for 10 days; solution was diluted at 1/50 with normal saline and kept at 4 degrees C until used for skin testing. The material was injected intradermally. Serum samples were drawn prior to skin testing and kept at -70 degrees C until analysis for antibody assay by the indirect fluorescent antibody (IFA) method. RESULTS: Forty three patients were IFA antibody positive; 41 of them reacted to the skin test. One of the 20 IFA negative patients reacted to the skin test. Sixteen patients had two serological tests performed, one month apart. Four out of these 16 patients tested negative with the skin test. All four had negative serology on both samples. Six of the 12 IFA positive patients showed a boost in the antibody titre one month after application of the skin test. The specificity and sensitivity of the skin test compared to the IFA assay were both 95%, and the positive and negative predictive values were 97% and 90% respectively. CONCLUSIONS: Results suggest that a varicella skin test prepared using this simple and relatively cheap method is a safe, sensitive, and specific tool by which to assess immunity to varicella.

An outbreak of echovirus 11 in a children's home.

An outbreak of echovirus 11 infection was observed in a children's home that housed 16 children. Nine children younger than 1 year shared a large room on the first floor, which contained a large basin. Three of them presented with aseptic meningitis with CSF and stool samples positive for echovirus 11. The other six infants who shared the room were asymptomatic but their stools were positive for echovirus 11. Seven infants aged 1-2 years stayed on the second floor and were asymptomatic. One of them had positive stool culture for echovirus 11. No virus was isolated from stool samples taken from the 26 staff members. However, serology was suggestive for recent echovirus 11 infection in seven asymptomatic staff members. All seven worked either exclusively on the first floor or alternately on both floors. Our survey demonstrated that echovirus 11 may spread very efficiently in children's homes. The rate of meningitis in the infected infants was 30% while all the recently infected adults were asymptomatic.

Chronic urticaria in children: expanding the "autoimmune kaleidoscope".

Most cases of chronic urticaria (CU) are considered idiopathic. It has recently been accepted that autoimmunity plays a critical role in the pathogenesis of CU in some of these patients. Although urticaria is common in the pediatric population, the knowledge regarding CU-associated autoimmunity is very limited. We describe the association of CU with a wide spectrum of clinical and laboratory autoimmune disorders in 2 children and emphasize the concept that CU is another manifestation of the "autoimmune kaleidoscope."

Pertussis infection in fully vaccinated children in day-care centers, Israel.

We tested 46 fully vaccinated children in two day-care centers in Israel who were exposed to a fatal case of pertussis infection. Only two of five children who tested positive for Bordetella pertussis met the World Health Organization's case definition for pertussis. Vaccinated children may be asymptomatic reservoirs for infection.

Hospitalization for primary varicella-zoster virus infection and its complications in patients from Southern Israel.

BACKGROUND: We conducted this study to determine the impact of chickenpox on two different ethnic populations in southern Israel: Jews and Bedouins. METHODS: Hospital records of 113 patients discharged from the Soroka Medical Center with the diagnosis of varicella during a 4.5-year period were reviewed. RESULTS: Mean age was 9.2 years and the average hospital stay was 5.4 days. Bacterial skin or soft tissue infections were the most common complications (30%), followed by pneumonia (17%) and central nervous system complications (11.5%). There were no fatal cases throughout the study period. The calculated hospitalization rate for varicella was one in every 319 cases. Major differences between Jews and Bedouins included an older mean age of Bedouin patients (13.9 years versus 4.5 years); higher hospitalization rate (relative risk [R.R.]: 2.8, 95% confidence interval: 1.9-4.2), and higher risk for complicated varicella (R.R.: 2.1, 95% confidence interval: 1.3-3.4). CONCLUSION: Hospitalization of patients with varicella in southern Israel is common and varicella infection in Bedouins is associated with greater morbidity compared with that in Jews in southern Israel.

Ceftazidime versus aztreonam in the treatment of pseudomonal chronic suppurative otitis media in children.

In a prospective, open, randomized trial, ceftazidime was given to 15 children and aztreonam to another 15 children with chronic suppurative otitis media without cholesteatoma (CSOM). Patients enrolled to the study had a pure culture of Pseudomonas aeruginosa growing in middle ear discharge. The subjects' mean age was 56 months in the ceftazidime group and 48 months in the aztreonam group. Success rate, defined as complete disappearance of discharge, was 84.6% in the ceftazidime treated patients and 67% in the aztreonam group (p value not significant). The number of days required for complete dryness of the ear was 7.9 and 8.4 respectively. Two patients in each group had recurrence of suppurative discharge within 90 d from discontinuation of antibiotic treatment. These results suggest that aztreonam is an optional alternative systemic treatment for paediatric patients with pseudomonal CSOM, especially in subjects allergic to penicillin.