Viral hepatitis in Israel: morbidity and mortality data

The past, present, and future of public health surveillance

This paper provides a review of the past, present, and future of public health surveillance-the ongoing systematic collection, analysis, interpretation, and dissemination of health data for the planning, implementation, and evaluation of public health action. Public health surveillance dates back to the first recorded epidemic in 3180 B.C. in Egypt. Hippocrates (460 B.C.-370 B.C.) coined the terms endemic and epidemic, John Graunt (1620-1674) introduced systematic data analysis, Samuel Pepys (1633-1703) started epidemic field investigation, William Farr (1807-1883) founded the modern concept of surveillance, John Snow (1813-1858) linked data to intervention, and Alexander Langmuir (1910-1993) gave the first comprehensive definition of surveillance. Current theories, principles, and practice of public health surveillance are summarized. A number of surveillance dichotomies, such as epidemiologic surveillance versus public health surveillance, are described. Some future scenarios are presented, while current activities that can affect the future are summarized: exploring new frontiers; enhancing computer technology; improving epidemic investigations; improving data collection, analysis, dissemination, and use; building on lessons from the past; building capacity; enhancing global surveillance. It is concluded that learning from the past, reflecting on the present, and planning for the future can further enhance public health surveillance.

Long-term trends in hepatitis A incidence following the inclusion of Hepatitis A vaccine in the routine nationwide immunization program

For many years hepatitis A was one of the most common vaccine preventable diseases in Israel. In 1999, Israel became the first country to introduce an inactivated hepatitis A vaccine into its national childhood vaccination program. The objectives of the present study were to study trends in disease incidence after the implementation of the new vaccination policy and to assess vaccination coverage among children and adults in Israel. We used the databases of the second largest HMO in Israel (1.7 million members) to identify patients who had evidence of hepatitis A in 1998 and 2007 and to collect information on all subjects who received at least one dose of hepatitis A vaccine during the study period. Hepatitis A vaccination coverage in children <5 years and 5-14 years of age increased from 9% and 15% in 1998 to 89% and 68% in 2007, respectively. During this period the annual incidence of hepatitis A dropped from 142.4 per to 7.6 per 100 000. The most prominent reduction in the age-specific annual incidence rates was calculated in children <5 years from 239.4 per 100 000 in 1998 to 2.2 per 100 000 in 2007 and from 310.3 per 100 000 to 3.0 per 100 000 in children aged 5-14 years. In endemic areas, vaccination of infants and children against hepatitis A can greatly reduce the total burden of the disease.

The shifting epidemiology of hepatitis A following routine childhood immunization program in Israel

OBJECTIVES

In 1999 Israel became the first country to introduce immunization against hepatitis A to its national childhood vaccination program. The study objectives were to assess the uptake of hepatitis A vaccine following the new policy and to examine the incidence of hepatitis A and the number of prevented cases.

METHODS

Data on incidence of hepatitis A and vaccination rates were obtained from a large health maintenance organization in Israel covering 1.6 million members. We identified all members that were diagnosed by a primary care physician as suffering from hepatitis A, had a positive hepatitis A virus-IgM test result, or were hospitalized due to hepatitis A between 1998 and 2004.

RESULTS

The results indicate that 5 years following its inclusion in the national childhood immunization program, vaccination coverage levels with at least one dose of hepatitis A vaccine for children aged under 5 years and 5-14 years were 87% and 51%, respectively. During this period the annual incidence rates declined by 88% from 142.4 to 17.3 per 100,000. The most significant reduction in morbidity was observed among children.

CONCLUSIONS

In endemic areas, vaccination of infants and children against hepatitis A may be efficient to greatly reduce the total burden of the disease.

Cost-benefit analysis of a nationwide neonatal inoculation programme against hepatitis B in an area of intermediate endemicity

STUDY OBJECTIVE

The aim was to estimate the costs and benefits of a nationwide neonatal vaccination campaign against hepatitis B in Israel for the 1990-2034 period.

DESIGN

Using morbidity, mortality, utilisation, and cost data from Israeli and international sources, a spreadsheet model was constructed to carry out the cost-benefit analysis.

SETTING

The entire State of Israel, an area of intermediate endemicity.

PARTICIPANTS

The population of Israel from 1990-2034.

MAIN RESULTS

A policy of immunising all Israeli neonates would, for a cost of $13.8 million, reduce the number of cases of hepatitis B during the 1990-2035 period in the cohort from 359,000 to 166,000 and save the nation around $21.5 million in health resources alone, $16.6 million in averted work absences, and a further $0.6 million in averted premature mortality costs. Even when the savings to the health services ($0.6 million) arising from the reduction in hepatocellular carcinoma are excluded, the direct benefit to cost ratio is 1.51/1, still in excess of unity.

CONCLUSIONS

The decision to adopt a nationwide neonatal inoculation policy, starting in January 1992, appears to be not only medically but also economically justifiable.