Foodborne botulism: an international outbreak

We report an outbreak of fishborne botulism caused by type E Clostridium botulinum. The eight cases, six in Israel and two in New York City, resulted from the consumption of ribbetz or kapchunka, a freshwater whitefish soaked in brine and air-dried, that was processed commercially in New York. Half the cases were males; the age range was 9 to 77 years. Five of the victims were hospitalized; the oldest died, and two others required ventilatory assistance. Laboratory confirmation of botulism was obtained in three cases. Prolonged lack of refrigeration during transatlantic flight and packaging contributing to an anaerobic environment were felt to be contributing environmental factors in the Israeli cases. Rapid communication and full cooperation between Israeli and US health authorities limited the extent of the outbreak. Despite adequate understanding of how foodborne botulism may be avoided, outbreaks still occur, particularly among people consuming certain high-risk or ethnic foods.

Rise in the incidence of viral hepatitis in Israel despite improved socioeconomic conditions

The incidence of viral hepatitis (mostly type A) in Israel, an area highly endemic for the disease, was examined between 1951 and 1985. During a period of improved standards of living, the overall reported incidence of the disease increased. In the Jewish population, the age of peak incidence shifted from 1-4 y to 5-9 y; this change is compatible with improved sanitation. However, whereas the absolute incidence declined among children 1-4 y old, it doubled among those 5-9 y old over the same period. The peak incidence in the non-Jewish population remains in children 1-4 y old. One possible explanation for the rise in overall incidence is an increase in the ratio of clinical to subclinical infections due to a shift of peak incidence to an older age group. Seasonal patterns have persisted against a background of changing morbidity, with the maximal incidence from late summer to midwinter. An unexplained, consistent excess incidence among males is observed for all age groups.

[An outbreak of hepatitis B associated with acupuncture]

2 clusters of between 5 and 11 cases of hepatitis B virus infection were associated with acupuncture by a physician late in 1986. The source of the infection is believed to have been an Ethiopian immigrant, a known HBsAg carrier. While he was being operated on a nurse cut her finger on a scalpel blade. During the prodromal period of hepatitis which followed, she was treated by acupuncture. The acupuncture needles were supposedly sterilized by dry heat for 80 minutes at 200 degrees. However, there were apparently breaks in technique which were responsible for the spread of the infection to at least 4 other women, ranging in age from 26 to 80 years. We stress the need for strict enforcement of correct sterilization procedures whenever needles are used to pierce skin. This should be performed only by licensed practitioners of officially recognized occupations, some of which are not as yet covered by our national health regulations.

Child-bearing after induced abortion: reassessment of risk

We reviewed 1791 singleton pregnancies of women with a history of previous induced abortion and compared them with 14,857 pregnancies in mothers with no previous induced abortions. Therapeutic termination of pregnancy was associated with a statistically significant increase in the incidence of low birth weight infants and bleeding in the first trimester of pregnancy. When other variables were examined, no significant differences were found between the two groups, except for a significantly higher rate of stillbirths among women who had not had a prior induced abortion. There were no increases in major or minor congenital malformations.

An acupuncture-associated outbreak of hepatitis B in Jerusalem

Two clusters of between five and eleven cases of hepatitis B associated with acupuncture treatment by a physician occurred in Jerusalem in late 1986. The origin of the outbreak is believed to have been an Ethiopian immigrant surgical patient, a known HBsAg carrier, who infected an operating room nurse during a surgical procedure. This is the first recorded instance of transmission of HBV from an Ethiopian immigrant to the local Israeli population. We reiterate the need for the enforcement of correct sterilization techniques in all skin-piercing settings, a step which in many countries will require the licensing of a variety of occupations not presently covered by health regulations.

Birth order and birth weight reexamined

We studied the longitudinal association of birth order and birth weight in two series of very large sibships, each consisting of at least seven children, and compared the findings with those based on analysis of cross-sectional data from a large population-based survey, the Jerusalem Perinatal Study. The birth weights of the cross-sectional sample were adjusted by multiple linear regression for a number of factors known to confound cross-sectional studies, including maternal age, education, marital status, religion, smoking, height and prepregnant weight, gestational age, and sex of the newborn. Birth weight increased with increasing birth order in both adjusted cross-sectional and socioeconomically homogeneous longitudinal data.

Recent decline in gonorrhea incidence in Israel: possible association with the AIDS pandemic

The effect of the AIDS pandemic on the sexual behavior of the general population has not been clearly established. Since trends in the incidence of other sexually transmitted diseases may be a good marker of such behavioral changes, gonorrhea incidence in the civilian and military populations in Israel was examined during the period 1963-87. In the civilian population, the rates were relatively stable until 1967, when they increased to a peak in 1970 and then declined to the earlier levels. In 1982 a further decline began, which accelerated considerably in 1986 when the rates declined by 38%. During 1987 the decline was even more dramatic, with a drop of 60% compared with the rate of the previous year. A similar trend has been noted in the military population. The recent sharp decline in gonorrhea incidence may be related, at least partly, to a change in sexual behavior associated with the fear of AIDS. If so, its magnitude suggests that such changes have not been restricted to high-risk groups.

Accuracy of mothers' recall of birthweight and gestational age

Information on the birthweight and gestational age of previous siblings is usually dependent upon maternal recall. This information is of importance in assessing the current risk of perinatal morbidity and mortality. The validity of maternal recall of birthweight and gestational age of 880 children born to 97 multiparas was examined by comparison with hospital records. About 75% of all reported birthweights were accurate to within 100 g and a similar proportion of reported gestational ages was correct to within 1 week. Recall was most accurate for most recent births as well as for earliest births and was not related to maternal age or education. There was a tendency for the smallness of low birthweight infants to be exaggerated by mothers. We conclude that within defined limitations, maternal recall of birthweight and gestational age of previous children is sufficiently accurate for clinical and even for epidemiological use.

The price of better diagnostic accuracy in suspected appendicitis in Jerusalem

We studied changes in diagnostic accuracy and in perforation rates in cases of suspected appendicitis at two major Jerusalem hospitals. In females, a major improvement in accuracy was observed over the past decade which was not accompanied by higher perforation rates. In males, on the other hand, the reduction in the rate of negative appendectomies was accomplished at the expense of a large increase in perforations. At the end of the decade of observation, diagnostic accuracy in males was still far better than for females, but the perforation rate in males had become worse than the rate for females. We conclude from our work and that of others that at high baseline negative appendectomy rates much improvement is possible without causing higher perforation rates, whereas at relatively low negative appendectomy rates, further decreases will, perforce, cause more perforations, a poor trade-off in the opinion of most investigators.

Knowledge of cardiopulmonary resuscitation in Jerusalem: is the community prepared to handle cardiac arrest?

A survey of 434 adults was conducted to determine the percentage of persons trained in cardiopulmonary resuscitation (CPR) in Jerusalem. Of the total, 211 (48.6%) indicated they had been trained in CPR. Increased prevalence of CPR training was seen in men under 50 and women under 40 years of age. Half of those surveyed did not know the emergency number for summoning an ambulance, but CPR-trained persons were more likely to know than were nontrained individuals. As has been shown elsewhere, increasing the frequency of bystander-initiated CPR should lead to increased survival from out-of-hospital cardiac arrest.

Effects of the Israel doctors' strike on hypertension control in Ashdod

We examined hypertension control during the Israel doctors' strike in a defined insured population of known hypertensives enrolled in a nurse-based hypertension control program. The strike was associated with a measurable increase in the prevalence of uncontrolled hypertension which was limited to males of relatively higher social class. No strike-related changes in hypertension control were seen for women or lower social class males. We infer from this finding that the presence of a physician is a necessary component of good hypertension control in the sub-group of males of higher socioeconomic status. The incidence of hypertension-related complications in this relatively non-compliant subpopulation needs further investigation.

Predictive value of sputum cytology

A 60 year old woman non-smoker with bronchial asthma of 6 years' duration, treated with aminophylline, salbutamol, and oral corticosteroids, was admitted because of increasing dyspnoea and productive cough. On examination she was in moderate respiratory distress with inspiratory and expiratory wheezes. Her chest radiograph was interpreted as normal. Two consecutive sputum examinations requested by a junior doctor reveal "malignant" cells.

Does grand multiparity affect fetal outcome?

Low birthweight and stillbirth rates of 16,647 Jerusalem deliveries were examined by birth-order comparing longitudinal to cross-sectional data. Six hundred fifty-seven complete sibships of 7 or more were assessed, including 95 sibships from the socio-economically homogeneous ultraorthodox Jewish community of Mea Shearim. In both cross-sectional and longitudinal studies grandmultiparas were not at increased risk for low birthweight, but did have a higher frequency of stillbirths.

Usefulness of the gastric aspirate examination in the diagnosis of neonatal infection

We examined the efficacy of gastric aspirate examination (GAE) in the diagnosis of neonatal infection in 140 high-risk newborns, using positive blood culture as our definitive criterion for infection. The sensitivity of GAE in diagnosing sepsis was 75% and the specificity 68%. Six out of 48 babies with positive GAE proved to be septic while only two of 92 with negative GAE were septic. Gastric aspirate examination is useful in the diagnosis of neonatal sepsis in high risk babies, although it is not a perfect screening test and will not replace the judgement of the clinician.

Should the Mobile Intensive Care Unit respond to pediatric emergencies?

Between October 1982 and October 1985, the Mobile Intensive Care Unit (MICU) in Jerusalem responded to 625 pediatric emergencies, representing 5% of the total MICU case load. The most common medical problem was seizures, diagnosed in 205 cases (33%). The second most frequent group related to trauma (175 cases; 28%). There were 71 cases (11.4%) of cardiac arrest. Resuscitation was attempted in 37, but there were no long-term survivors. Almost all cardiac arrest patients were found in asystole, and most had antecedent serious medical problems. Compared with the adult population, children were less likely to require or benefit from an advanced level of prehospital care. When resources for advanced care are limited, priority should be given to adult emergencies.

Neonatal advantage of epidural anesthesia in elective and emergency cesarean sections: a report of 531 cases

In 147 elective and 384 non-elective cesarean sections, the need for neonatal respiratory assistance at birth was significantly greater for babies born under general anesthesia compared to epidural anesthesia, and the differences could not be explained by differences in pre-operative risk factors. For 114 babies on whom blood gas data were gathered prospectively, a greater proportion born under general anesthesia were acidemic and hypercarbic. Our results complement a growing body of retrospective and clinical data suggesting that epidural anesthesia is preferable to general in all but a few cesarean sections. Ideally, this suggestion should be tested in a randomized clinical trial.

Demographic and socio-economic patterns of hospitalization for infectious diseases in Israel

Hospitalization rates in Israel for five common enteric communicable diseases were computed according to age, sex, religion, origin and place of residence. Higher rates were found for non-Jews of both sexes and males of all origins. Higher rates were also found for settlements inhabited by new immigrants of low socio-economic classes. These findings suggest that more emphasis should be placed upon sanitary improvements and education for better health, rather than on merely improving the health delivery system.

Factors affecting hospitalization for selected diseases in Israel

Hospitalization rates in Israel for five communicable and four noncommunicable diseases were computed according to age, sex, religion, origin, and place of residence. Higher rates for communicable diseases were generally found for all males and for Oriental Jews and Jews living in rural areas. Higher rates were also found for settlements inhabited by low socioeconomic populations. With few exceptions, hospitalization rates for Arabs were higher for both communicable and noncommunicable diseases, but rates for rural Arab populations were very low. These findings suggest that in a society such as Israel's, with a well-developed medical care delivery system, improvement in the health status of less privileged groups will depend more on health education than on the addition of resources to the health delivery system.

Drug hoarding in a Jerusalem community

We carried out a drug hoarding survey of an Israeli urban neighbourhood. Large quantities of drugs were stored by most families, particularly families with children and the elderly. The commonest drugs held were analgesics-antipyretics, but cardioactive drugs, antibiotics and cough preparations were also held in large numbers. Two-thirds of drugs held were not in current use. Drug-labelling was illegible, although most patients knew the purpose of the drugs they kept. Expiration dates were absent from most drug packages. Drug packaging and storage in families with children was generally unsafe. Physicians and pharmacists have the responsibility to educate patients to store drugs correctly and to use stored drugs safely.