Mumps outbreak in Israel's highly vaccinated society: are two doses enough?

Mumps outbreaks in recent years have given rise to questions about the effectiveness of the mumps vaccine. This study examined the epidemiological data from a recent mumps outbreak in Israel and from outbreaks in other countries with high vaccination coverage, and considered whether long-established vaccination policies designed to protect against mumps are in need of revision. Of over 5000 case patients in the Israeli outbreak, half of whom were in the Jerusalem health district, nearly 40% were aged ≥15 years and, of those whose vaccination status was known, 78% had been fully vaccinated for their age - features similar to those in recent mumps outbreaks in Europe and North America. The epidemiological and laboratory evidence suggests that many previously vaccinated adolescents and young adults are now susceptible to mumps because their vaccine-based immunity has waned. Booster vaccination programmes for those at high risk of infection during mumps outbreaks - particularly those in congregate living environments - merit priority consideration.

Clinical manifestations of Bordetella pertussis infection in immunized children and young adults.

STUDY OBJECTIVES: The incidence and prevalence of pertussis in adults have increased in recent years. It has been shown that previously immunized adults and adolescents are the main sources of transmission of Bordetella pertussis. The aim of this study was to describe the clinical presentation and the clinical course of pertussis in children and young adults who were immunized previously against B pertussis. DESIGN: Retrospective study. SUBJECTS: Children and young adults who were reported by local physicians to the Department of Epidemiology in the Israeli Ministry of Health with serologically confirmed pertussis and who were immunized previously were included. Information sought included personal data, epidemiologic data, signs and symptoms, laboratory results, initial diagnosis, and treatment. RESULTS: In the 95 previously immunized patients with serologically confirmed pertussis (mean age [+/- SD], 8.9 +/- 4.4 years old; range, 5 to 30 years old), the mean duration from onset of symptoms until the final diagnosis of pertussis was 23 +/- 15 days. The disease was usually atypical and generally mild. All the described patients had cough, usually prolonged, lasting 4 +/- 3.6 weeks. Only 6% had the classic whoop. The mean WBC count was 8.7 +/- 2.6 cells/mm6, and the lymphocyte count was 40 +/- 12%. Two patients were admitted to the hospital for severe pneumonia. Among the reported cases, the proportion of patients between the ages of 10 and 45 years increased from 6.5% during the period from 1971 to 1980, to 26% during the period from 1980 to 1990, and to 38% during a 1989 outbreak. CONCLUSIONS: Pertussis in previously immunized individuals is usually characterized by an atypical and relatively mild clinical course. Patients suffer mainly from a prolonged and persistent cough. Early diagnosis may lead to prompt administration of therapy. Prophylaxis of exposed persons might be effective in decreasing both severity and transmission of the disease.

Decay of maternally derived measles antibody in a highly vaccinated population in southern Israel.

The introduction of live attenuated measles vaccine in Israel during 1967 dramatically decreased the incidence of measles. However, cases still occur in periodic outbreaks and epidemics, with an increasing proportion of infants and children younger than 2 years of age. We examined the decay of maternally derived measles antibody during the first year of life in the Jewish population of Israel which represents a highly vaccinated population with immunization rates exceeding 90%. We used sera of healthy full term infants born in 1988 and 1989. Fifty specimens for each of the following age groups were used: 0 (cord blood), 2, 4, 6, 7 and 12 months. Three assays for each specimen were used: enzyme-linked immunosorbent assay (ELISA); hemagglutination-inhibition test (HI); and neutralization test (NT). Good correlation among all 3 tests was found. All cord blood specimens were positive by at least 2 assays. Seropositivity rates declined rapidly with age. Fifty percent of all 4-month-old infants and < 30% of all 6-month-old infants were positive by 1 test or more; at 12 months of age none of the tested specimens was positive by HI or NT and only 1 of 50 infants was positive by ELISA. In infants younger than 6 months of age, 5 (22%) of 23 specimens negative both by ELISA and by HI were positive by NT, but in 6-month-olds, only 2 (7%) of 28 negative by ELISA and HI were positive by NT, and in 12-month-olds none was positive. The results from southern Israel are similar to those obtained in North America and provide evidence that infants older than 6 months of age in a well-immunized population may be poorly protected against measles. On the basis of this information and epidemiologic data, the Israel Ministry of Health has recommended lowering the immunization age for measles, mumps and rubella from 15 months to 12 months.

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.

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.

Breast cancer in Israel: laterality and survival.

Laterality was examined in 10,702 cases of breast cancer in Israeli Jewish women. The overall left-right ratio was 1.04 and was higher in women over 60. The only population group with a left-right ratio less than 1 was the group of women born in Asian and Middle Eastern countries outside of Israel. There were no differences between the survival curves of women with right- or left-sided breast cancers at any stage. It is concluded that laterality of tumor is not an indicator of survival in breast cancer.

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.

Coeliac disease in the Rehovot-Ashdod region of Israel: incidence and ethnic distribution.

The data from a large group of children with biopsy proved coeliac disease born in the Rehovot-Ashdod region of Israel and treated in a regional hospital provided us with the basis for the determination of the annual birth cohort incidence of coeliac disease for the period 1968-81. The findings show a minimum birth cohort incidence of 1.71/1000 live births. The highest incidence rate was in children of Asian origin and the lowest in second generation Israel born. The incidence of coeliac disease rose sharply during the study period.

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.

Validity of maternal reporting of breast feeding history and the association with blood lipids in 17 year olds in Jerusalem.

The validity of mothers' reporting of the breast feeding history of their children more than 20 years after their birth was studied in a Jerusalem population. Among 74 study subjects, duration of breast feeding as ascertained from an interview was well correlated with that recorded in mother and child health clinic charts. Concordance was of similar magnitude in subgroups of ethnicity, mother's education, family size, and sex of child. Duration of breast feeding in 101 youngsters was inversely associated with plasma cholesterol in 17 year old girls, though not in boys, which was statistically significant on univariate analysis and of borderline significance on multivariable analysis. Among 17 year old boys, though not in girls, a statistically significant inverse association for plasma triglyceride was apparent on multivariable analysis. Reported breast feeding history derived from interview of mothers may be a useful instrument for study of possible long term effects of breast feeding in their adolescent or adult progeny.

Patient recall of induced abortion.

15 of 92 women who underwent induced abortions and subsequently gave birth denied their abortions in a medical interview. Religious women and women with fewer children were more likely to deny than others. Obstetricians as well as investigators examining the effects of induced abortions must be aware that women may fail to provide accurate abortion histories.

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.

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.

PIP: The effect of grand multiparity on low birthweight and stillbirth rates was investigated in 16,647 deliveries in Jerusalem, Israel, comparing longitudinal to cross-sectional data. An advantage of longitudinal studies is that entire sibships are examined, diminishing the confounding effects of social class and ethnic differences. 1069 (6.4%) of infants in the cross-sectional study population of the 16,647 single births delivered by West Jerusalem women in the 26-month study period were low birthweight (2500 gm or less). Primiparas were at a higher risk for low birthweight compared to all other birth orders. In the longitudinal study population of 562 complete sibships of 7 or more births, there were 250 (5.7%) low birthweight infants. Low birthweight rates were highest for 1st born infants and lowest for birth orders 3 and 4. In the Mea Shearim longitudinal subpopulation comprised of ultraorthodox Jews, there was a low birthweight rate of 4.9%, with the highest rate found in birth order 2. The overall stillbirth rate in the cross-sectional study was 7.9/1000 live births. Stillbirth was more frequent in 1st births, less frequent in 2nd and 3rd births, and then rose with increasing birth order to pass at birth order 8-9 the rate in primiparas. The stillbirth rate in the longitudinal study population was 5.0/1000; the lowest such rate was found in birth orders 3 and 4, while the highest rate was recorded in birth order 7. These findings suggest that grand multiparas are not at increased risk for low birthweight, but do have a higher frequency of stillbirths. These conclusions are strengthened in this study because they derive in part from a model population in which parity is not related to socioeconomic status. Because of its long-term socioeconomic homogeneity and stability, the Mea Shearim subgroup is an excellent model for examining perinatal risk and grand multiparity.

Requests for abortion and outcomes of pregnancy in Jerusalem, Israel.

Outcomes of pregnancy were examined for 480 women who requested abortions at a Jerusalem hospital during the years 1972 to 1975. Of 149 women denied abortions, 80 apparently obtained illegal ones. Since illegal abortions performed by physicians are easily and safely obtained in Israel, the liberalization of Israel's abortion laws will not have a major impact upon Israel's population growth.

The effect of abortion method on the outcome of subsequent pregnancy.

Infants born to women following a previous induced abortion, primarily by the D&C method, showed an excess of low birth weight. However, when women with medical illnesses were excluded, the excess was very slight. The data suggested that the greater the dilatation at D&C, the lower the birth weight. Women requiring induced abortions should have them as early as possible to minimize cervical damage and its consequences.

PIP: The literature on possible long-term sequelae of induced abortion, particularly related to the outcome of future desired pregnancies, is reviewed. In addition, the results of a historical prospective study of the late sequelae of induced abortion in Jerusalem are reported. Information on women who had undergone legal, induced abortions during 1967-76 was used in the study and compared with hospital records for subsequent pregnancies. Infants of women who had undergone a previous induced abortion, particularly a D and C (dilatation and curettage), exhibited an excess of low birth weight. The birth weight of the subsequent infants was directly related to the amount of dilatation, which would be correlated with cervical damage. Low gestation ages, leading to low birth weights, were also evident among the infants of women who had undergone previous induced abortions. The abortion group also demonstrated a higher rate of postpartum bleeding as compared to the nonabortion group. Women should aim for an induced abortion as early in pregnancy as possible in order to minimize the danger of cervical damage.

Increased neonatal risk from the use of general anesthesia in emergency cesarean section. A retrospective analysis of 374 cases.

Three hundred seventy-four consecutive cases of cesarean section were reviewed retrospectively for differences in neonatal outcome with respect to method of anesthesia used. In 205 elective sections no difference in neonatal outcome was observed irrespective of anesthesia method. However, in 169 nonelective operations the proportion of neonates needing respiratory assistance at birth was twice as high in the group who received general anesthesia as in the group who received epidural anesthesia (25.3% vs. 12.8%). These preliminary results suggest that general anesthesia may increase the degree of central depression of the fetus already compromised by hypoxia before surgery. An investigation of this question on other sets of data and in a prospective trial should be done.

Need for urgent medical care in a Jerusalem neighborhood: a population-based study.

We conducted a population-based survey of an urban community in Jerusalem to estimate the incidence of urgent and emergency medical events and to characterize the response of the populace to various medical episodes. We found deficiencies in the ability of the population to identify an urgent event, resulting in long delays in seeking professional care, as well as inappropriate choice of source of care, in a substantial proportion of subjects. These deficiencies can and should be corrected by inexpensive educational programs.

Patterns of emergency department use during the Israel doctors' strike.

We studied changes in emergency department utilization at a major Jerusalem regional hospital during the 4-month-long Israel doctors' strike. The number of ED visits was increased by 35% over control levels. There were larger increases in female visitors than male and larger increases in visits by children and in women of childbearing age. Use of laboratory tests, ECGs, and x-rays were increased minimally, and hospital admissions via the ED were unchanged. We conclude that the vast majority of excess strike-related ED visits were for trivial illnesses and that very large numbers of persons with medical symptoms elected not to seek any medical attention at all during the strike.

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.

Epidemiological analysis of tuberculosis treatment outcome as a tool for changing TB control policy in Israel.

BACKGROUND: Sensing an inadequacy of tuberculosis control due to an influx of TB associated with immigration, we analyzed TB treatment outcome in Israel by population groups. OBJECTIVES: To provide an epidemiological basis necessary for any new national TB control policy, and to bring it to the attention of the medical profession in Israel and abroad since its results led to a change in Israel's TB control policy. METHODS: We reviewed all TB cases notified during the period 1990 to September 1992. "New cases" (820 cases, 93.5%) and "re-treatment cases" (57 cases, 6.5%) were analyzed according to three mutually exclusive groups: "successful outcome," "death," and "potentially unsatisfactory outcome" (according to WHO/IUATLD definitions). RESULTS: Of 820 "new cases," 26.6% had a "satisfactory outcome," 68.5% had a "potentially unsatisfactory outcome" and 4.9% died; compared to 47.4%, 45.6% and 7% among 57 "re-treatment cases," respectively. Using logistic regression analysis, outcome was associated with the district health office (P < 0.0001), the TB "experience" of the notifying clinic (P < 0.0001), and the form of TB (P = 0.02). No significant relationships were obtained for population groups, gender and age, interval between arrival in Israel and TB notification, and bacteriological results. CONCLUSIONS: Non-supervised TB treatment resulted in poor outcomes regardless of population groups. Better outcomes occurred in the larger TB clinics. Therefore, in addition to measures such as adequate drug supplies, reorganization of TB laboratories and training of TB personnel, we recommend the "directly observed treatment short-course" for all cases as well as reducing the number of treatment centers thereby increasing their case load.