Imported malaria from Ethiopia--end of an era?

The immigration of Ethiopian Jews to Israel in the 1980s resulted in the importation of over 2,000 cases of malaria, a major challenge to clinicians and public health officials alike. In contrast, in the massive airlift from Ethiopia in May 1991 and in the sporadic immigration that followed it, malaria prevalence was extremely low, reflecting the routing of the more recent immigrants through nonendemic areas. The dramatic fall in the appearance of new imported malaria cases should not lead to complacency, however, as malaria may still appear in Ethiopians and other immigrants as well as in Israelis returning from regions of the world where the disease is still highly prevalent. A corollary of this caveat is that vigilance in finding and eliminating Anopheles breeding places in Israel must not be allowed to falter.

Multiphasic screening: an idea whose time has passed

The theory of screening for preclinical disease requires that early diagnosis and treatment will lead to an outcome which is more favorable than that resulting when treatment is initiated after symptoms appear. In practice, this requirement is met for a surprisingly small number of diseases. Early detection components of "health packages" must be developed, therefore, strictly on the basis of proven effectiveness. Existing programs should be revised in accordance with international guidelines, and adapted as needed to the local incidence and prevalence of disease and anticipated population compliance, so that the maximum benefit of early detection can be realized and the numerous hazards of screening avoided.

Mortality in Israel during the Persian Gulf war--initial observations

During the 6-week-long 1991 Persian Gulf war, in which the civilian population was subjected to 18 separate missile attacks and the constant threat of nonconventional warfare, crude mortality rates in Israel were no higher than in the previous decade. Although the results are preliminary and need to undergo more sophisticated epidemiologic analysis, it appears that our population was able to tolerate the subacute period of psychological stress without excess mortality.

The epidemiology of echinococcosis in Israel

Shifts in population and employment patterns in Israel since 1948 have been accompanied by profound changes in the distribution of echinococcal disease. Formerly, it was most commonly imported with the mass immigration of Jews after 1948 from the Arab countries of North Africa and Asia Minor, and appeared to be relatively uncommon in Israel-born Jews and Arabs. In 1980 the disease was made notifiable, and this paper presents a review of the years 1981-1989. The prevalence pattern that prevailed after the end of mass immigration has reversed so that cases are now twice as common in Arabs as in Jews. Among the Arabs the disease appears most commonly in the north of the country, especially among the Druze, less commonly among Christians and least in Muslims. We suggest that this prevalence pattern is related largely to home slaughter of sheep, to differing attitudes to dogs, and possibly also to the hunting of wild pig. Targetted education and better enforcement of existing regulations can lead to a reduction in disease.

Can decision analysis help in the management of giant hemangioma of the liver?

We explore the trade-off between the risk and expected benefits from resection of giant liver hemangioma (GLH), one larger than 4 cm in diameter. We searched the English-language literature for studies of the postoperative mortality after resection of GLH and of the outcome of expectantly treated patients. The results of the data synthesis showed an operative mortality of 1.5% (90% confidence intervals, 0.1-3.0%) and an early surgical morbidity of up to 13%. Mortality among the 37 reported cases with ruptured GLH was 78%. There were no cases of spontaneous or traumatic rupture of unresected GLH during a follow-up of a total of 282 patient years. The main source of ambiguity regarding the management of GLH is the uncertain risk of its rupture. Rough estimates of this risk based on published data suggest that surgical resection is not justified in asymptomatic GLH. Yet, although rare, rupture of GLH does occur with disastrous consequences. Future research may attempt to define patient subsets whose GLHs are at higher risk of rupture, and in whom preventive resection may improve survival.

Malaria in Israel: the Ethiopian connection

Over 2,000 cases of imported malaria were diagnosed in Israel in the last decade, the vast majority in immigrants from Ethiopia, making malaria a continuing public health problem of significance. In 1988, more than one- fifth of imported cases were caused by chloroquine-resistant Plasmodium falciparum. Since the Anopheles vector is still present in many areas of the country, it is necessary to detect and treat all cases quickly and effectively and to strengthen anti-malaria vector activities if local transmission is to be prevented. Despite massive and continuous importation of the disease, the Ministry of Health has had substantial success in the area of malaria control, through administration of presumptive treatment to Ethiopian immigrants, rapid diagnosis of imported cases and strict vector control.

Prevention strategy of hepatitis B virus infection among the Ethiopian community in Israel

Between 1980 and 1985, over 16,000 immigrants from Ethiopia, a population at high risk for hepatitis B virus (HBV) infection, arrived in Israel. The present study was designed to provide epidemiological information necessary for developing prevention strategies against HBV infection. Among the 144 subjects studied in an absorption center in Israel, only 32% had no detectable HBV markers and were therefore susceptible to infection. The prevalence rate of HBsAg was 19% compared with 42% for anti-HBs and 7.6% for anti-HBc alone. The percentage of subjects with no HBV marker decreased sharply with age, and there was similarly an age-linked increase in anti-HBs, indicating the importance of horizontal transmission in HBV infection. The distribution of HBV markers was similar in both sexes. Evidence of mild liver disease was found in only three subjects. All newborns and new arrivals less than 2 years of age in the Ethiopian community are vaccinated against HBV infection to prevent vertical and early horizontal transmission. The data obtained in our study suggest that this means of prevention of HBV infection is insufficient. We suggest that the vaccination of all children aged 2-7 without prevaccination screening, and the vaccination of children aged 8-18 found to be susceptible on anti-HBc screening, would substantially lower HBV transmission in this community.

Analysis of historical epidemiological data to guide intervention policy in the face of an infectious disease outbreak: poliomyelitis in Israel in 1988

During the 1988 outbreak of 15 cases of Type 1 poliomyelitis mainly among previously vaccinated young adults in Israel, there were conflicting views on the need for and timing of mass vaccination. Since there was a possibility that the initially localized outbreak may spread more widely, it was felt that an early decision on vaccination policy should be made. Public health officials were faced with varied interpretations of the existing data on the extent of the immune status of the population; some indicating that as many as 15% of young adults lacked immunity to the Type 1 virus. Two major questions posed were whether or not the outbreak was a purely localized event in a single subdistrict, and whether the seasonality of the disease would limit its spread. Based on historical data, probability analysis of three cases occurring outside the subdistrict at the time of the outbreak suggested more widespread dispersion of the virus. Further analysis indicated very limited seasonality of the disease in this region, suggesting that the onset of colder weather would have little impact on the spread of the virus. Careful analysis of the local epidemiology of the disease is an important tool for guiding urgent decisions on mass intervention policy in outbreak situations.

Four decades of shigellosis in Israel: epidemiology of a growing public health problem

Despite the improved standard of living in Israel, shigellosis remains a common disease. Examination of trends in the incidence of shigellosis in Israel between 1951 and 1987 showed a period of declining rates followed by an increase in the reported incidence beginning around 1969. This increase was mainly due to Shigella sonnei; rates of infection with Shigella flexneri remained relatively constant. Trends showed marked differences between age groups and between ethnic groups. In comparison, the rates in the United States--much lower than those in Israel--began to decline in the early 1950s and have remained low. The incidence in Israel is now about 20 times higher than that in the United States. Thus shigellosis remains a major and growing public health problem in Israel, a country that has enjoyed a dramatic improvement in basic sanitary services and infrastructure over the past few decades. This disturbing finding lends urgency to efforts to control the disease.

Measles in Israel, the West Bank, and Gaza: continuing incidence and the case for a new eradication strategy

Measles continues to occur in epidemic waves in Israel, Gaza, and the West Bank, causing morbidity and mortality. In Israel, immunization of infants against measles began in 1967, and 90% had been immunized by the mid-1980s. In Gaza and the West Bank, where immunization of infants against measles began in 1973 and 1976, respectively, the immunization rate reached 75% in the late 1970s and increased to greater than 90% in the 1980s. Measles epidemics, which previously had occurred in 5- to 7-year cycles, occurred every 2-4 years in the 1980s and affected individuals who were older than those affected in previous years. Israel's commitment to eradicating measles by 1992 will require a substantially expanded immunization program in comparison with the traditional program that requires immunization of infants alone. The benefits of several alternative immunization strategies considerably exceed their costs. A new, two-dose immunization will be needed as a minimal strategy, and a campaign for administering booster doses to school-aged children may be required as well to achieve control and eradication of measles. Measles is a serious but preventable public health problem; appropriate strategies must be devised by national and international public health officials to control the disease in developing and developed countries.

Prevalence of hereditary properdin, C7 and C8 deficiencies in patients with meningococcal infections

High incidence of hereditary complement (C) deficiencies was found among 101 patients who had a meningococcal disease. This study revealed 11 non-related patients with complete C deficiency: five deficient in C7, three in C8, two in properdin and one in C2. Additional C-deficient individuals, most of them with no history of severe bacterial infections, were detected in family studies. The C8-deficient patients were found to have a selective deficiency of the C8-beta subunit and a reduced expression of the alpha/gamma subunit. Only a few families with properdin deficiency have been described so far. However, it is likely that frequent analysis of the activity of the alternative C pathway in survivors of severe bacterial infections will disclose numerous properdin-deficient patients. All our C7-, C8- and properdin-deficient patients are Sephardic Jews whose families originated from Morocco, Yemen (C7 and C8 deficient) or Tunisia (properdin deficient). This and other findings indicate that the type of complement abnormality found in association with meningococcal infections varies with the ethnic origin of the patient.

Breast cancer screening in Tel Aviv

Optimal breast cancer screening includes both physical examination and mammography. In anticipation of the addition of routine mammographic screening to Israel's 25-year-old early breast cancer detection program, we examined the demographic characteristics of almost one thousand women attending a breast cancer screening examination in Tel Aviv for the first time. The specific objective of the survey was to see whether women attending screening were those who stood a good chance of benefiting from it. Only half the women were aged 40 or older, and there was a preponderance of women of Western origin. Almost half had a breast-related complaint at the time of the visit. Targeted public education and appropriate administrative measures are necessary to ensure that women who can benefit from screening attend screening clinics and that clinics are not filled to capacity by women needing diagnostic evaluation and followup rather than routine screening. Tel Aviv general practitioners appeared to be aware of the advantages of breast cancer screening.

Tetanus in Israel, Judea/Samaria and Gaza, 1968-89: progress and challenge

During the 1950s tetanus was a major public health concern in Israel, with incidence rates of up to 2/100,000 occurring predominantly among farmers and infants (tetanus neonatorum). These rates have declined considerably since then, with an average of 2 cases per year in recent years, and 5 cases in 1988. There has been a major decline in tetanus incidence in Judea/Samaria and Gaza, due to a successful vaccination program reaching over 90% of infants and schoolchildren and to educational programs. In Judea/Samaria and Gaza, prevention of tetanus neonatorum has improved as a result of the increasing number of hospital deliveries (now 62% in the West Bank and 80% in Gaza), and the widespread immunization of pregnant women and adolescent girls of childbearing age. Special efforts were given to the education of traditional birth attendants (dayas). Prevention of adult tetanus was achieved through immunization of high school students and laborers. Recent cases in all three areas are equally distributed between newborns and elderly persons. Because of the persistence of the incidence of tetanus, a review of Israel's immunization policy is indicated, focusing on high risk groups such as Bedouin women of childbearing age and the elderly.

Poliomyelitis outbreak in Israel in 1988: a report with two commentaries

An outbreak of 15 cases of paralytic poliomyelitis caused by type 1 poliovirus between July and October, 1988, prompted mass vaccination of the whole Israeli population under the age of 40 years. The focus of the outbreak (12 cases) was the Hadera subdistrict, one of two subdistricts where enhanced inactivated poliovaccine (eIPV) had been the only poliovaccine used for infants since 1982. 9 of the 15 victims were 15 years or older, and 9 had previously been immunised with at least three doses of oral poliovaccine (OPV). The authors are divided in their interpretation of the findings. One group considered that the likely causative factors were the greater susceptibility of young adults previously vaccinated with OPV as well as transmission of wild poliovirus to susceptible people by children with low gut immunity against poliovirus after vaccination with eIPV; they concluded that a vaccination programme combining eIPV with OPV is the best option for Israel in future. The other group believed the causative factors were exposure to contaminated sewage or close social contact within the epidemic foci, the presence of an epidemic strain differing from the wild Mahoney and Sabin type 1 vaccine strains, and the lower seropositivity rates and geometric mean titres of neutralising antibodies to the epidemic than to vaccine strains; they believe that eIPV is the means to achieve effective control of poliomyelitis in Israel.

Cost-benefit analysis of routine mumps and rubella vaccination for Israeli infants

Until January 1989, mumps vaccine was not routinely administered in Israel, and rubella immunization was restricted to adolescent girls. The theoretical effect of combined mumps-rubella vaccination was applied to a population consisting of a cohort of 1-year-old children followed for 13 years. Assuming 90% compliance and 95% vaccine efficacy, projected clinical cases of mumps, rubella, encephalitis and thrombocytopenia would be reduced by 4,144; 3,109; 13; and 1 respectively. We anticipate a benefit to cost ratio of between 1.17 and 1.77 for the program. Since only 10-20% of cases are reported, the true benefit to cost ratio is likely to be at least 5.85. The benefit to cost ratio based on health service benefits alone is between 0.34 and 0.52; however, after adjusting for under-reporting, benefits are expected to exceed costs. Expenditures for laboratory testing, a factor not previously considered in such an analysis, would be reduced by approximately $2,750 per year. These results justify the initiation in January 1989 of nationwide routine vaccination.