Diagnosis of Imported Monkeypox, Israel, 2018.

We report a case of monkeypox in a man who returned from Nigeria to Israel in 2018. Virus was detected in pustule swabs by transmission electron microscopy and PCR and confirmed by immunofluorescence assay, tissue culture, and ELISA. The West Africa monkeypox outbreak calls for increased awareness by public health authorities worldwide.

Lessons to be Learned from Recent Biosafety Incidents in the United States.

During recent months, the Centers for Disease Control and Prevention (CDC) announced the occurrence of three major biosafety incidents, raising serious concern about biosafety and biosecurity guideline implementation in the most prestigious agencies in the United States: the CDC, the National Institutes of Health (NIH) and the Federal Drug Administration (FDA). These lapses included: a) the mishandling of Bacillus anthracis spores potentially exposing dozens of employees to anthrax; b) the shipment of low pathogenic influenza virus unknowingly cross-contaminated with a highly pathogenic strain; and c) an inventory lapse of hundreds of samples of biological agents, including six vials of variola virus kept in a cold storage room for decades, unnoticed. In this review we present the published data on these events, report the CDC inquiry's main findings, and discuss the key lessons to be learnt to ensure safer scientific practice in biomedical and microbiological service and research laboratories.

Tactical medicine -- the Israeli revised protocol.

Limited conflicts and the war against terrorism, in particular, have changed the emphasis in the present trend from preparing to cope with full-scale wars to the need to combat in limited conflicts. This shift has affected significantly medical units' preparations. Law enforcement organizations have come together with medical first responders in a combined new model. This model is supposed to be adopted and utilized in combat and evolved from the civilian model toward a modus operandi that combines the tactical and medical protocols into a single algorithm, the "Tactical Combat Casualty Care" (TCCC). This TCCC model is believed to enhance the mutual understanding and cooperation of tactical and medical forces in combat and especially amongst special military units. Utilizing the model will be achieved by the development of well-matched standard operating procedures and sharing drills. All these acts are hoped to improve safety of the participating units and hopefully also the medical outcomes.

Monitoring Group Activity of Hamsters and Mice as a Novel Tool to Evaluate COVID-19 Progression, Convalescence, and rVSV-ΔG-Spike Vaccination Efficacy.

The COVID-19 pandemic initiated a worldwide race toward the development of treatments and vaccines. Small animal models included the Syrian golden hamster and the K18-hACE2 mice infected with SARS-CoV-2 to display a disease state with some aspects of human COVID-19. A group activity of animals in their home cage continuously monitored by the HCMS100 (Home cage Monitoring System 100) was used as a sensitive marker of disease, successfully detecting morbidity symptoms of SARS-CoV-2 infection in hamsters and in K18-hACE2 mice. COVID-19 convalescent hamsters rechallenged with SARS-CoV-2 exhibited minor reduction in group activity compared to naive hamsters. To evaluate the rVSV-ΔG-spike vaccination efficacy against SARS-CoV-2, we used the HCMS100 to monitor the group activity of hamsters in their home cage. A single-dose rVSV-ΔG-spike vaccination of the immunized group showed a faster recovery than the nonimmunized infected hamsters, substantiating the efficacy of rVSV-ΔG-spike vaccine. HCMS100 offers nonintrusive, hands-free monitoring of a number of home cages of hamsters or mice modeling COVID-19.

The neutralization potency of anti-SARS-CoV-2 therapeutic human monoclonal antibodies is retained against viral variants.

A wide range of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) neutralizing monoclonal antibodies (mAbs) have been reported, most of which target the spike glycoprotein. Therapeutic implementation of these antibodies has been challenged by emerging SARS-CoV-2 variants harboring mutated spike versions. Consequently, re-assessment of previously identified mAbs is of high priority. Four previously selected mAbs targeting non-overlapping epitopes are now evaluated for binding potency to mutated RBD versions, reported to mediate escape from antibody neutralization. In vitro neutralization potencies of these mAbs, and two NTD-specific mAbs, are evaluated against two frequent SARS-CoV-2 variants of concern, the B.1.1.7 Alpha and the B.1.351 Beta. Furthermore, we demonstrate therapeutic potential of three selected mAbs by treatment of K18-human angiotensin-converting enzyme 2 (hACE2) transgenic mice 2 days post-infection with each virus variant. Thus, despite the accumulation of spike mutations, the highly potent MD65 and BL6 mAbs retain their ability to bind the prevalent viral mutants, effectively protecting against B.1.1.7 and B.1.351 variants.

Therapeutic antibodies, targeting the SARS-CoV-2 spike N-terminal domain, protect lethally infected K18-hACE2 mice.

Neutralizing antibodies represent a valuable therapeutic approach to countermeasure the current COVID-19 pandemic. Emergence of SARS-CoV-2 variants emphasizes the notion that antibody treatments need to rely on highly neutralizing monoclonal antibodies (mAbs), targeting several distinct epitopes for circumventing therapy escape mutants. Previously, we reported efficient human therapeutic mAbs recognizing epitopes on the spike receptor-binding domain (RBD) of SARS-CoV-2. Here we report the isolation, characterization, and recombinant production of 12 neutralizing human mAbs, targeting three distinct epitopes on the spike N-terminal domain of the virus. Neutralization mechanism of these antibodies involves receptors other than the canonical hACE2 on target cells, relying both on amino acid and N-glycan epitope recognition, suggesting alternative viral cellular portals. Two selected mAbs demonstrated full protection of K18-hACE2 transgenic mice when administered at low doses and late post-exposure, demonstrating the high potential of the mAbs for therapy of SARS-CoV-2 infection.

Post-exposure protection of SARS-CoV-2 lethal infected K18-hACE2 transgenic mice by neutralizing human monoclonal antibody.

The coronavirus disease 2019 (COVID-19) pandemic, caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), exhibits high levels of mortality and morbidity and has dramatic consequences on human life, sociality and global economy. Neutralizing antibodies constitute a highly promising approach for treating and preventing infection by this novel pathogen. In the present study, we characterize and further evaluate the recently identified human monoclonal MD65 antibody for its ability to provide protection against a lethal SARS-CoV-2 infection of K18-hACE2 transgenic mice. Eighty percent of the untreated mice succumbed 6-9 days post-infection, while administration of the MD65 antibody as late as 3 days after exposure rescued all infected animals. In addition, the efficiency of the treatment is supported by prevention of morbidity and ablation of the load of infective virions in the lungs of treated animals. The data demonstrate the therapeutic value of human monoclonal antibodies as a life-saving treatment for severe COVID-19 infection.

[Military tract of medicine--the need and the vision].

Establishing the Military Tract in the Hebrew University School of Medicine is an opportunity to enrich the medical curriculum with contents relevant to better training of military physicians. Subjects such as hyperbaric medicine, hypobaric physiology, terror medicine, mass casualty event (MCE) and management of non-conventional injuries will be added to the regular M.D. curriculum. Medical education based on the elements of excellence: Judaism, Zionism, humanism and leadership, will be the foundations for the future generation of medical leaders in Israel for both the military and civilian systems. This leadership will be articulated in the clinical, research and administrative fields.

A single holiday was the turning point of the COVID-19 policy of Israel.

OBJECTIVES: Despite an initial success, Israel's quarantine-isolation COVID-19 policy has abruptly collapsed. This study's aim is to identify the causes that led to this exponential rise in the accumulation of confirmed cases. METHODS: Epidemiological investigation reports were used to reconstruct chains of transmission as well as assess the net contribution of local infections relative to imported cases, infected travelers arriving from abroad. A mathematical model was implemented in order to describe the efficiency of the quarantine-isolation policy and the inflow of imported cases. The model's simulations included two scenarios for the actual time series of the symptomatic cases, providing insights into the conditions that lead to the abrupt change. RESULTS: The abrupt change followed a Jewish holiday, Purim, in which many public gatherings were held. According to the first scenario, the accumulation of confirmed cases before Purim was driven by imported cases resulting in a controlled regime, with an effective reproduction number, Re, of 0.69. In the second scenario, which followed Purim, a continuous rise of the local to imported cases ratio began, which led to an exponential growth regime characterized by an Re of 4.34. It was found that the change of regime cannot be attributed to super-spreader events, as these consisted of approximately 5% of the primary cases, which resulted in 17% of the secondary cases. CONCLUSIONS: A general lesson for health policymakers should be that even a short lapse in public responsiveness can lead to dire consequences.

Group activity of mice in communal home cage used as an indicator of disease progression and rate of recovery: Effects of LPS and influenza virus.

Large numbers of rodents are often used in the study of disease progression and in the evaluation of its potential treatments. To avoid subjective observation and to minimize home cage interference, we developed a computerized home cage monitoring system (HCMS100) based on a standard cage rack adapted with a single laser beam and a detector mounted on each cage, enabling to monitor mice movements based on laser beam interruptions. This retrofit system provided continuous and uninterrupted monitoring of spontaneous movement of a group of mice in a home cage. Validity was evaluated using disease state induced by LPS modelling bacterial infection and by influenza virus. RESULTS: Spontaneous activity of different number of mice (2-8) per cage showed the expected circadian rhythm with increased activity during the night, and its extent dependent on the number of mice in the cage. Females and males show similar circadian rhythm. Intranasal LPS administration and pulmonary infection with live influenza virus resulted in major reduction of mice activity along disease progression. Increase in activity over time was a good indicator of the recovery process from both LPS exposure and the flu infection. CONCLUSIONS: HCMS100 was shown to be a reliable, inexpensive, easy to use system that requires no changes in the common housing of various experimental animals (mice, hamsters, rats etc.). With minimal intervention, HCMS100 provides a continuous record of group activity with clear pattern of circadian rhythm, allowing long term recording of home cage activity even in restricted access environments.

Coding-Complete Genome Sequences of Two SARS-CoV-2 Isolates from Early Manifestations of COVID-19 in Israel.

We announce the genome sequences of two strains of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) isolated in Israel, one imported by a traveler who returned from Japan and the second strain collected from a patient infected by a traveler returning from Italy. The sequences obtained are valuable as early manifestations for future follow-up of the local spread of the virus in Israel.

A panel of human neutralizing mAbs targeting SARS-CoV-2 spike at multiple epitopes.

The novel highly transmissible human coronavirus SARS-CoV-2 is the causative agent of the COVID-19 pandemic. Thus far, there is no approved therapeutic drug specifically targeting this emerging virus. Here we report the isolation and characterization of a panel of human neutralizing monoclonal antibodies targeting the SARS-CoV-2 receptor binding domain (RBD). These antibodies were selected from a phage display library constructed using peripheral circulatory lymphocytes collected from patients at the acute phase of the disease. These neutralizing antibodies are shown to recognize distinct epitopes on the viral spike RBD. A subset of the antibodies exert their inhibitory activity by abrogating binding of the RBD to the human ACE2 receptor. The human monoclonal antibodies described here represent a promising basis for the design of efficient combined post-exposure therapy for SARS-CoV-2 infection.

A single dose of recombinant VSV-∆G-spike vaccine provides protection against SARS-CoV-2 challenge.

The COVID-19 pandemic caused by SARS-CoV-2 imposes an urgent need for rapid development of an efficient and cost-effective vaccine, suitable for mass immunization. Here, we show the development of a replication competent recombinant VSV-∆G-spike vaccine, in which the glycoprotein of VSV is replaced by the spike protein of SARS-CoV-2. In-vitro characterization of this vaccine indicates the expression and presentation of the spike protein on the viral membrane with antigenic similarity to SARS-CoV-2. A golden Syrian hamster in-vivo model for COVID-19 is implemented. We show that a single-dose vaccination results in a rapid and potent induction of SARS-CoV-2 neutralizing antibodies. Importantly, vaccination protects hamsters against SARS-CoV-2 challenge, as demonstrated by the abrogation of body weight loss, and  alleviation of the extensive tissue damage and viral loads in lungs and nasal turbinates. Taken together, we suggest the recombinant VSV-∆G-spike as a safe, efficacious and protective vaccine against SARS-CoV-2.

Identification and genetic characterization of a novel Orthobunyavirus species by a straightforward high-throughput sequencing-based approach.

Identification and characterization of novel unknown viruses is of great importance. The introduction of high-throughput sequencing (HTS)-based methods has paved the way for genomics-based detection of pathogens without any prior assumptions about the characteristics of the organisms. However, the use of HTS for the characterization of viral pathogens from clinical samples remains limited. Here, we report the identification of a novel Orthobunyavirus species isolated from horse plasma. The identification was based on a straightforward HTS approach. Following enrichment in cell culture, RNA was extracted from the growth medium and rapid library preparation, HTS and primary bioinformatic analyses were performed in less than 12 hours. Taxonomical profiling of the sequencing reads did not reveal sequence similarities to any known virus. Subsequent application of de novo assembly tools to the sequencing reads produced contigs, of which three showed some similarity to the L, M, and S segments of viruses belonging to the Orthobunyavirus genus. Further refinement of these contigs resulted in high-quality, full-length genomic sequences of the three genomic segments (L, M and S) of a novel Orthobunyavirus. Characterization of the genomic sequence, including the prediction of open reading frames and the inspection of consensus genomic termini and phylogenetic analysis, further confirmed that the novel virus is indeed a new species, which we named Ness Ziona virus.

Role of nurses in a university hospital during mass casualty events.

Mass casualty events due to terror attacks have escalated throughout Israel since September 2000, with a high proportion of these events occurring in the Jerusalem area. Immediately after news of a large-scale terror attack is received, family/public information centers are set up in all local hospitals to meet the needs of members of the public who call or arrive at hospitals anxious to obtain information about relatives who may have been at the site of the attack. The most urgent task facing these centers is the quick and accurate identification of victims whose identity is in question. To date, some 3000 casualties have been treated at Hadassah Hebrew University Medical Center (Hadassah), a level I trauma center. This number accounts for nearly half of Israel's total number of casualties from terror attacks during this period. Extensive experience has led the hospital to develop a unique organizational model for its family/public information center; in this model, members of the nursing staff identify casualties. The experience and knowledge gained in dealing with terror events also can be applied to other types of mass casualty events, such as major road or work accidents.

Terror-related injuries: a comparison of gunshot wounds versus secondary-fragments-induced injuries from explosives.

BACKGROUND: Terror-related injuries caused by secondary fragments (SF) from explosive devices show a distinctive pattern in severity, distribution, outcomes of assault, and health-system resource use as compared with terror-related penetrating injuries caused by gunshot wounds. STUDY DESIGN: A case-comparison study conducted in a tertiary university hospital and the only Level I trauma center in the Jerusalem vicinity. During a period of 4 years, over 1,500 casualties of terror-related injuries were treated in one Level I trauma center. The study included 533 patients who were admitted for hospitalization. Excluded from the study were victims who were dead on arrival or who succumbed to their injuries within 30 minutes of arrival at the emergency department. Data were collected from trauma registry records. RESULTS: Gunshot-wound victims were mostly men, aged 19 to 30, and SF victims were more evenly distributed between the genders and across the age spectrum. Injury Severity Score (ISS) was considerably higher in SF victims, although critical mortality rates were higher in gunshot-wound victims. More than 40% of SF victims were injured in three or more body regions, as opposed to < 10% in gunshot-wound victims. Use of imaging modalities and ICUs was considerably higher for SF victims. CONCLUSIONS: Terror victims suffering from SF wounds have more complex, widespread, and severe injuries than victims suffering from gunshot wounds. They tend to involve multiple body regions and use more in-hospital resources. Attenuation of bus seats and protective vests can lead to a reduction in severity of these injuries.

The influence of electroconvulsive therapy on pain threshold and pain tolerance in major depression patients before, during and after treatment.

Despite the findings that pain and depression are not always directly linked, enough evidence suggest that a complex relationship between pain and depression exists. Using an electronic pressure algometer placed on the sternum, the changes in pressure pain threshold (PPThr) and pressure pain tolerance (PPTol) were evaluated in 19 patients affected by refractory major depression without psychotic features, throughout a full course of electroconvulsive therapy (ECT) treatment. Measurements were done before the first treatment, after the 6th treatment and after the last treatment. After the 6th treatment, mean (+/- SD) PPThr increased significantly from 11.48 (+/- 4.81) kg/cm2 at baseline, to 13.7 (+/- 5.59) kg/cm2 (p=0.0076) while PPTol did not change significantly (from 18.46 (+/- 6.75)kg/cm2 to 17.4 (+/- 8.1)kg/cm2). At the end of the treatment course, mean (+/- SD) PPThr did not increase further significantly (15.06 (+/- 5.21)kg/cm2 (p=0.0234)) while PPTol increased significantly to 21.34 (+/- 7.8)kg/cm2 (p=0.0047). ECT's efficacy was measured with the 21-item Hamilton Rating Scale for Depression (21-HAM-D). Mean (+/- SD) 21-HAM-D scores decreased significantly from 30.9 (+/- 4.15) at baseline, to 10.47 (+/- 5.78) (p=0.0001) after the 6th treatment, with no further significant change at the end of the treatment course (9.94 +/- 3.07; p=0.0254). Both pain threshold and pain tolerance increased following the alleviation of the depressive disorder and a possible usefulness of ECT may be postulated for treating severe, chronic pain syndromes. However, a more significant conclusion is that the increase of the PPThr noted early during ECT treatment may serve as an early outcome possible detector of ECT efficacy in depressed patients.

The experience of one institution dealing with terror: the El Aqsa Intifada riots.

BACKGROUND: During a period of 13 months--1 October 2000 to 31 October 2001--586 terror assault casualties were treated in the trauma unit and emergency department of Hadassah University Hospital (Ein Kerem campus); 27% (n = 158) were hospitalized and the rest were discharged within 24 hours. OBJECTIVES: To analyze the special requirements of a large number of victims who received treatment during a short period. METHODS: Data were attained from the main admitting office and the trauma registry records. Factors analyzed included age, gender, mechanism of injury, anatomic site of injury, Injury Severity Score, and length of stay. RESULTS: Males comprised 81% of the hospitalized patients. The majority of the injuries (70%) were due to gunshot wounds and 31% of the hospitalized patients were severely injured (ISS > or = 16). Twelve patients died, yielding a mortality rate of 7.5%. CONCLUSION: The nature of the injuries was more complex and severe than trauma of other etiologies, as noted by the mean length of stay (10.2 vs. 7.2 days), mean intensive care unit stay (2.8 vs. 0.9 days), and mean operations per patient (0.7 vs. 0.5). The mean insurance cost for each hospitalized terror casualty was also higher than for other trauma etiologies (US$ 3,200 vs. 2,500).