A retrospective cohort analysis of treatment outcomes of patients with tuberculosis who used substances in Tel Aviv, Israel.

AIMS: To outline the demographic, clinical, laboratory characteristics, and treatment outcomes of tuberculosis (TB) patients who used substances. METHODS: This retrospective cohort study compared 50 TB patients who used substances with a matched random sample of 100 TB patients who did not use substances between 2007 and 2017. Treatment failure was defined as a sputum smear or culture that tested positive after 5 months of treatment, loss to follow-up, unevaluated patients, or death. RESULTS: TB patients who used substances were typically younger, experienced homelessness, smokers, and had fewer chronic diseases than those who did not use substances. They also were hospitalized for longer periods, their treatment durations were longer, had higher rates of multidrug resistant strains, increased rates of treatment failure, and higher mortality. Individuals whose treatment failed predominantly originated from the former Soviet Union, experienced homelessness, and had chronic diseases compared with those whose treatment was successful. In the multivariate analysis, homelessness [odds ratios (OR) = 6.7], chronic diseases (OR = 12.4), and substance use (OR = 4.0) were predictors of treatment failures. CONCLUSIONS: TB patients who used substances were more likely to have treatment failure. Targeted interventions, including early diagnosis and enhanced support during treatment, are essential to achieve treatment success in this vulnerable population, in addition to TB-alcohol/drug collaborative activities.

Emerging lessons from the COVID-19 pandemic about the decisive competencies needed for the public health workforce: A qualitative study.

The global COVID-19 crisis exposed the critical need for a highly qualified public health workforce. This qualitative research aimed to examine public health workforce competencies needed to face COVID-19 challenges and identify the gaps between training programs and the competency demands of real-world disasters and pandemics. Through a sample of thirty-one participant qualitative interviews, we examined the perspectives of diverse stakeholders from lead public health organizations in Israel. Grounded Theory was used to analyze the data. Six themes emerged from the content analysis: public health workforce's low professional status and the uncertain future of the public health workforce; links between the community and Higher Education institutions; the centrality of communication competencies; need to improve health promotion; the role of leadership, management, and partnership, and innovation in public health coherence. Increasing the attractiveness of the profession, professional and financial support, and improving the working conditions to ensure a sustainable and resilient PH system were deemed necessary. This paper describes and cultivates new knowledge and leadership skills among public health professionals, and lays the groundwork for future public health leadership preparedness programs.

Identifying the Gaps Between Public Health Training and Practice: A Workforce Competencies Comparative Analysis.

Objectives: The study aimed to generate insights on how best to enhance the compatibility between Public Health training program competencies and the implementation of competencies required by employers to address current and emerging public health needs. Methods: A survey adapted from the WHO-ASPHER Competency Framework for the Public Health Workforce was conducted online among Israeli public health managers from August to November 2021. The survey was formulated to mirror Essential Public Health Operations. Forty-nine managers participated (37.6% response rate) in an assessment of 44 public health competencies and the core organizational public health operations. Results: Analysis of Essential Public Health Operations revealed a notably high deficiency reported for Advocacy Communication and Social Mobilization for health competencies. Collaborations and Partnership and, Leadership and System Thinking were the most reported insufficient competencies, particularly in health departments and research institutes. Governmental offices reported Organizational Literacy and Adaptability competencies being deficient. Deficiencies were more impactful as the level of expertise increased. Conclusion: There is a clear need for public health professionals to acquire versatile and innovative competencies in response to the ever-changing health threats.

The Future Public Health Workforce in a Changing World: A Conceptual Framework for a European-Israeli Knowledge Transfer Project.

Health services quality and sustainability rely mainly on a qualified workforce. Adequately trained public health personnel protect and promote health, avert health disparities, and allow rapid response to health emergencies. Evaluations of the healthcare workforce typically focus on physicians and nurses in curative medical venues. Few have evaluated public health workforce capacity building or sought to identify gaps between the academic training of public health employees and the needs of the healthcare organizations in which they are employed. This project report describes the conceptual framework of "Sharing European Educational Experience in Public Health for Israel (SEEEPHI): harmonization, employability, leadership, and outreach"-a multinational Erasmus+ Capacity Building in Higher Education funded project. By sharing European educational experience and knowledge, the project aims to enhance professionalism and strengthen leadership aspects of the public health workforce in Israel to meet the needs of employers and the country. The project's work packages, each jointly led by an Israeli and European institution, include field qualification analysis, mapping public health academic training programs, workforce adaptation, and building leadership capacity. In the era of global health changes, it is crucial to assess the capacity building of a well-qualified and competent workforce that enables providing good health services, reaching out to minorities, preventing health inequalities, and confronting emerging health challenges. We anticipate that the methods developed and the lessons learned within the Israeli context will be adaptable and adoptable by other countries through local and cultural adjustments.

Attitudes of Israeli medical students towards the medical treatment of uninsured migrants.

BACKGROUND: Undocumented migration to developed countries poses practical concerns, as migrants are not medically insured. This cross-sectional study aims to appraise the attitudes of Israeli medical students towards the uninsured migrant population. METHODS: Participants from five medical schools in Israel completed anonymous questionnaires in Hebrew, based on the "Medical Students' Attitudes Toward the Underserved" (MSATU), which assessed students' attitudes regarding the professional responsibility and societal expectations towards the migrants. It also evaluated students' views of the migrants as eligible for expensive medical procedures. RESULTS: A total of 891 students completed the survey with a median age of 28 years. The majority were Jews (N = 816, 91.6%) and singles (N = 681, 68.5%). Participants in the pre-clinical years were likely to be female and unmarried compared to those in clinical training. They also demonstrated higher scores on professional responsibilities and societal expectations than students in clinical training, but no significant differences were found in their views on expensive medical services. Students of minorities (non-Jews and migrants) scored higher on professional responsibilities and societal expectations. The scores for professional responsibilities and societal expectations decreased as students progressed in their medical training (Spearman coefficient p = 0.04 and p = 0.01, respectively). This trend was more apparent in males rather than females. CONCLUSION: MSATU scores declined as students progressed through medical school, with females maintaining more favorable attitudes than males. Medical schools should attempt to maintain the enthusiasm and idealism that students possess as they enter medical training and provide clinical experience with migrant populations that allows for cross-cultural communication.

Growth, developmental achievements and vaccines timeliness of undocumented migrant children from Eritrea compared with Israelis.

INTRODUCTION: Israel has absorbed >40,000 Eritrean undocumented migrants since 2007, while the majority live in the southern neighborhoods of Tel-Aviv. As non-citizens and citizens infants in Israel receive free preventive treatment at the mother and child health clinics (MCHC), this study aimed to compare development and growth achievements between children of Eritrean mothers (CE) to children of Israeli mothers (CI), and assess their compliance to routine follow-up and vaccination-timeliness. METHODS: This cohort study included all Israeli-born CE between 2009 and 2011, compared with a random sample of CI and treated at the same MCHC and followed-up to the age of 30-months. Dependent outcomes included anthropometric measurements, developmental achievements and adherence to immunization schedule. RESULTS: Of all 271 CE who were compared with 293 CI, no statistically significant differences were found in birth anthropometric measurements. Yet, CE had increased weight and length than CI after reaching one year of age (p<0.05). CE were more likely to fail in tests assessing fine-motor skills, linguistic and socio-emotional domains than CI, while no statistical difference was found in gross-motor achievements. At the end of follow-up, 203 (74.9%) of the CE and 271 (74.1%) of the CI completed the vaccination schedule, p = 0.9. CONCLUSION: CE had greater anthropometric measurements than CI after one year of age, and showed higher impairments in fine motor, linguistic and socio-emotional domains. Adherence to vaccination was similar. The inequalities in child health should be responded in the MCTC, and Eritrean mothers should be trained with the current recommendations for child well-being.

Medical condition and care of undocumented migrants in ambulatory clinics in Tel Aviv, Israel: assessing unmet needs.

BACKGROUND: Approximately 150,000 undocumented migrants (UM) who are medically uninsured reside in Israel, including ~50,000 originating from the horn of Africa (MHA). Free medical-care is provided by two walk-in clinics in Tel-Aviv. This study aims to compare the medical complaints of UM from different origins, define their community health needs and assess gaps between medical needs and available services. METHODS: This cross-sectional study included a random sample of 610 UM aged 18-64 years, who were treated in these community clinics between 2008 and 2011. The study compared UM who had complex medical conditions which necessitated referral to more equipped medical settings with UM having mild/simple medical conditions, who were treated at the clinics. RESULTS: MHA were younger, unemployed and more commonly males compared with UM originating from other countries. MHA also had longer referral-delays and visited the clinics less frequently. UM with complex medical conditions were more commonly females, had chronic diseases and demonstrated longer referral-delays than those who had mild/simple medical conditions. The latter more commonly presented with complained of respiratory, muscular and skeletal discomfort. In multivariate analysis, the variables which predicted complex medical conditions included female gender, chronic illnes and self-referral to the clinics. CONCLUSIONS: The ambulatory clinics were capable of responding to mild/simple medical conditions. Yet, the health needs of women and migrants suffering from complex medical conditions and chronic diseases necessitated referrals to secondary/tertiary medical settings, while jeopardizing the continuity of care. The health gaps can be addressed by a more holistic social approach, which includes integration of UM in universal health insurance.

A national strategic plan for reducing the burden of sexually transmitted infections in Israel by the year 2025.

BACKGROUND: There is on ongoing debate in the literature regarding the real burden of STIs (sexually transmitted infections) in Western countries and the proper strategies needed to estimate and to prevent them. Our purpose is to present an evidence-based national strategic plan for STI prevention in Israel through assessing the current burden of illness, leading international preventive strategies, and practical policymaking experience. METHODS: Epidemiologic and health policy data on STIs were analyzed from various sources: a) systematic national surveillance data for the years 2002-2014; b) the international scientific literature (published between 2002-16; keywords: Sexually Transmitted Diseases (STD) (or STI) AND prevention AND intervention AND gonorrhea OR chlamydia OR syphilis; c) internal Ministry of Health (MOH) analyses and reports, and d) expert opinion. RESULTS: Incidence rates in Israel of Chlamydia trachomatis (chlamydia), Neisseria gonorrhea (gonorrhea) and Treponema pallidum (syphilis) are lower than in most Western countries. However, rates vary among population subgroups: chlamydia, gonorrhea and syphilis are higher in Jews than in non-Jews, and this gap has increased for chlamydia over the past decade. Primary and secondary syphilis rates have increased among men having sex with men (MSM). It is likely that STIs are under-reported and that incidence is even rising due to migration. A key recommendation is the establishment of an active surveillance system of STIs, utilizing active case finding in high risk populations, along with regular contact with STI clinics run by the four national health management organizations and by the MoH. As with most European countries, the low prevalence of chlamydia and gonorrhea does not justify population-wide screening. Conversely, the increasing incidence of syphilis among MSM should lead to regular screening among this group. CONCLUSIONS: A national STIs prevention strategy for the year 2025 was presented. Although the current burden of illness is low relatively to other Western countries, this is thought to reflect a certain degree of underreporting. These and other gaps suggest a need for focused epidemiologic and health services research to better characterize health risk behaviors as well as provider practice patterns. Innovative implementation strategies have been described, together with the capacity building components needed for developing specific and implementable policy recommendations for the year 2025.

Migration as a social determinant of health for irregular migrants: Israel as case study.

More than 150,000 irregular migrants reside in Israel, yet data regarding their utilization of and perceived barriers to health care services are limited. Drawing on semi-structured interviews conducted with 35 irregular migrant adults between January and September 2012, this article analyzes the role of migration as a social determinant of health for irregular migrants, and especially asylum seekers. We analyze two kinds of barriers faced by migrants when they attempt to access health care services: barriers resulting directly from their migration status, and barriers that are common among low-income communities but exacerbated by this status. Migration-related barriers included a lack of clear or consistent legislation; the threat of deportation; the inability to obtain work permits and resulting poverty and harsh living and working conditions; and discrimination. Barriers exacerbated by migrant status included prohibitive cost; poor and confusing organization of services; language barriers; perceived low quality of care; and social isolation. These findings support recent arguments that migrant status itself constitutes a social determinant of health that can intersect with other determinants to adversely affect health care access and health outcomes. Findings suggest that any meaningful effort to improve migrants' health will depend on the willingness of clinicians, public health officials, and policymakers to address the complex array of upstream political and socio-economic factors that affect migrants' health rather than focusing on narrower questions of access to health care.

HIV/AIDS prevalence in Israeli prisons: Is there a need for universal screening?

This study aimed to assess HIV/AIDS point-prevalence among inmates and evaluate costs related to universal screening as currently practiced and appraise its necessity. All inmates newly incarcerated in Israel (2003-2010) underwent HIV tests and their medical files were cross-matched the with the national HIV/AIDS registry to who had been newly infected and detected on prison entry. They were classified by key risk-groups. Of 108,866 new inmates during the period, 215 (0.2 per cent) were diagnosed with HIV/AIDS, 44 of those (0.04 per cent) were not aware of their infection. A large majority (94.2 per cent) of the infected inmates were members of a key-risk group: drug-users, homosexuals, or originating from a high-HIV prevalence country. The direct cost of detecting a single HIV-infected inmate who was not previously recorded was [euro ]12,386. The HIV/AIDS-screening process can be improved by interviewing the new inmates and performing targeted HIV-testing for those who are members of a known risk-group. These data from Israel are pertinent to developed countries with low HIV prevalence, because they present a picture of all newly infected inmates over an 8-year period within the paradigm of a fully functional HIV surveillance system.

Tuberculosis screening in immigrants from high-prevalence countries: interview first or chest radiograph first? A pro/con debate.

Immigration from high tuberculosis (TB) prevalence countries has a substantial impact on the epidemiology of TB in receiving countries with low TB incidence. Cross-border migration offers an ideal opportunity for active case finding that will result in a lower caseload in the host country and a reduced spread of disease to both the indigenous and migrant populations. Screening strategies can start 'offshore', thereby indirectly assisting and empowering public health systems in the source countries, or be performed at ports of entry with or without long-term engagement of 'onshore' facilities and systems to provide either preventive therapy or surveillance for reactivation of latent TB. The chest radiograph seems to be playing a key role in this process, but questions remain regarding when, where and in whom radiographs are best done for optimal yield and cost-effectiveness, and with what other tests they might best be combined to further increase the usefulness of transborder TB control.

Chest radiography validity in screening pulmonary tuberculosis in immigrants from a high-burden country.

BACKGROUND: Chest x-ray (CXR) is widely used for diagnosing and screening pulmonary tuberculosis (PTB), yet its validity is debatable and its costs are relatively high. This study aimed to determine the validity of CXR screening in detecting radiological findings compatible with active PTB or with old healed tuberculosis (OHTB). METHODS: All Ethiopian immigrants to Israel between 2001 and 2005 were radiographed before emigration. Immigrants whose CXR demonstrated PTB or OHTB were evaluated, treated, and followed for one year after arrival. The end point of this historical cohort study was a diagnosis of active pulmonary disease within the study period. RESULTS: CXR was performed on 13,379 immigrants. Changes suggesting PTB were identified in 150 (1.1%) of those, and 46 were diagnosed with active PTB. Sensitivity, specificity, and positive predictive value of a CXR suggesting PTB were 80.1%, 99.2%, and 31%, respectively. As PTB prevalence in this cohort is 0.4%, post-test odds for CXR suggestive of PTB were 75.5. Changes suggesting OHTB were identified in 257 (1.9%) immigrants. Of those, 15 (5.8%) developed active PTB within one year following arrival. Sensitivity, specificity, and positive predictive value of CXR suggestive of OHTB were 17.2%, 98.2%, and 5.8%, respectively, when active PTB during the first year was the end point. In this study, 291 CXR were required to detect one active PTB patient, costing $5,802. CONCLUSIONS: CXR is a valid and cost-saving tool for screening active PTB in immigrants originating in high-burden countries, and is beneficial in detecting OHTB in immigrants who are at a higher risk for developing active PTB.

High-risk behaviour in steady and in casual relationships among men who have sex with men in Israel.

OBJECTIVE: To explore the differences in sexual risk behaviour between men who have sex with men (MSM) with steady partners versus casual partner(s) in the gay community. METHODS: This online cross-sectional convenience-sampling study assessed MSM practices, their knowledge and their motivation regarding safe sex. Participants not knowing their HIV status or who performed insertive or receptive unprotected anal intercourse (UAI) or with a sex partner whose HIV status was unknown or discordant were considered 'at-risk'. RESULTS: Of all 2569 participants who completed the questionnaire, 907/2569 (35.3%) had a steady partner, and 896/2569 (34.9%) had a casual partner(s) in the past 6 months. 262/907 (28.9%) with steady partners and 248/896 (27.7%) with casual partners demonstrated at-risk sexual behaviour. Of all participants with steady partners, 108/907 (11.9%) performed UAI with their partner without undergoing mutual HIV testing. Of all participants with steady partners, 476/907 (52.5%) had a concurrent casual partner, and 144/476 (30.3%) performed UAI with both the steady and the casual partner. Of all participants with steady partners, 775/907 (85.4%) negotiated the possibility of sex outside their relationship with their main partner. The length of the steady relationship correlated with the number of concurrent casual partners. CONCLUSIONS: At-risk sexual behaviour was associated with insufficient negotiation skills, difficulties in condom use and a general risk-taking profile. Health educators should encourage MSM with steady partners to perform HIV testing before practising UAI, to improve their negotiation skills during the contact and to support open discussions with regard to sexual contact besides the steady relationship, as it may not be monogamous.

The QuantiFERON-TB-GOLD assay for tuberculosis screening in healthcare workers: a cost-comparison analysis.

The aim of this study was to assess the costs of screening healthcare workers (HCWs) for tuberculosis (TB) using the novel interferon-gamma release assay QuantiFERON((R))-TB Gold In-tube (QFT) versus the tuberculin skin test (TST). We used a prospective observational study with a cost-comparison analysis. The study was conducted at a regional center for ambulatory TB treatment. The study included 100 Israeli HCWs who were referred for routine TB screening. The participants were tested with both TST and QFT. For the TST, induration of 10 mm or more was considered a positive test. For the QFT, a threshold of 0.35 IU/ml interferon-gamma above background levels was a positive test. We developed a computerized model of the present TST-only screening method versus the QFT either alone (instead of the TST) or as a confirmatory test for a positive TST. Of the 100 subjects, 34 had a positive TST result and 17 had a positive QFT result. There was poor agreement between the TST and the QFT (kappa = 0.19). Assuming adherence to treatment of 50%, costs were minimized by using the QFT to confirm a positive TST (4155). The QFT-only model was cheaper than the TST-only model (7280 vs. 8217, respectively). The QFT-only method required the fewest clinic visits (121) compared to the TST (344). Adherence to treatment in the QFT-positive group was 47% compared with 12% for the TST-positive group. Screening HCWs with the QFT test compared to the TST resulted in fewer possible cases being identified, lower costs, and increased adherence to treatment. Costs were minimized by using the QFT to confirm a positive TST. A QFT-based screening program for HCWs is feasible and should be evaluated systematically.

[Morbidity and the economic burden of influenza in children in Israel--a clinical, virologic and economic review].

BACKGROUND: A survey of winter morbidity revealed a high incidence of childhood influenza. A clinical, virologic and economic survey of childhood influenza morbidity was conducted to characterize this morbidity. METHODS: Incidence of respiratory disease and influenza-like symptoms was determined among 9,300 children in the Tel Aviv area in the 1997-8 influenza season, and viral cultures performed from nasal swabs. A telephone survey was conducted among the patients' families to determine the family dynamics of the illness and the number of working days lost. RESULTS: Among the study population, 38% had influenza-like symptoms. The highest incidence was among kindergarten and school-age children. Upper respiratory tract infections (URTI) were common in the 0-2 years age group (27.4%). In contrast, 83% of children with influenza-like illness (ILI) were aged 3-15 years (p < 0.01). Of 180 valid viral culture samples, 93 (51%) were positive for influenza, which represents 22% of all children surveyed. Extrapolation to a national level reveals that of approximately two million children in the country, 440,000 would have positive laboratory evidence of influenza infection. In 49 of 52 (90%) families surveyed, the child was the initial patient in the household, and, on average, 66% of family members became ill. The average income lost was NIS 300 per family; at a national level that extrapolates to a loss of NIS 132 million. CONCLUSIONS: Influenza-like illness is common among children, particularly in the peak period of influenza activity. As opposed to upper respiratory infections, influenza-like disease is particularly common in the 3-15 year age group (kindergarten and school age). The incidence of children diagnosed with influenza (22%) is much higher than in the general population. Children are the first in the family to become ill and infect other family members. Cost-effectiveness analysis justifies mass childhood influenza immunization.

[The time has come to change the influenza vaccination strategy].

The traditional approach of immunizing defined risk groups for influenza has not achieved the desired results, and the disease incidence remains high. The reasons for this, among others, include the low vaccination coverage and the limited efficacy of the vaccine, particularly among the elderly. Immunizing populations other than risk groups, such as healthy children of kindergarten and school age (2-18 years) would reduce the incidence of morbidity in the general population--in particular those at risk. Children are infected relatively easily and transmit the infection very rapidly to a wide range of contacts at their homes and in the community. In Japan, immunization of school aged children for influenza reduced the incidence of influenza and pneumonia amongst adults. Similar outcomes have been observed with other vaccines, such as the septavalent pneumococcal vaccine administered to infants in the United States, and the introduction of the hepatitis A vaccine into the routine immunization schedule for toddlers in Israel. Those strategies have led to a decrease in the incidence among age groups other than those vaccinated. A policy change of this kind would increase the demand for the vaccines, and would require reorganization and rethinking. Therefore, the authors suggest the use of the nasal live attenuated influenza vaccine, as the ease of use would increase its acceptance.