Challenges and obstacles implementing evidence-based food fortification policy in a high-income country.

The World Health Organization (WHO) recognizes food fortification as one of the most cost-effective and beneficial public health measures available. Mass fortification policies and regulations can reduce health disparities, including in high-income countries, by improving micronutrient intake among food-insecure or high-risk populations without changing their diet or behavior. While international health organizations have traditionally prioritized technical assistance and grants to medium and low-income countries, it is important to recognize that micronutrient deficiencies may also pose an important yet underappreciated public health problem in many high-income countries. Nevertheless, some high-income countries, including Israel, have been slow to adopt fortification, due to a variety of scientific, technological, regulatory, and political barriers. Overcoming these barriers requires an exchange of knowledge and expertise among the all stakeholders to achieve cooperation and broad public acceptance within countries. Similarly, sharing the experience of countries where the matter is in play may help inform efforts to advance fortification globally. Here we share a perspective on progress and barriers to achieve this goal in Israel, to inform efforts made to avoid the regrettable waste of unrealized human potential from prevalent yet preventable nutrient deficiency conditions, in Israel and beyond.

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.

Risk Factors for Recurrent Tuberculosis among Successfully Treated Patients in Israel, 1999-2011.

BACKGROUND: Recurrent tuberculosis (TB) is one of the indices used to assess the effectiveness of the Israeli National TB Programs (NTP). OBJECTIVES: To estimate the incidence of recurrent TB in Israel and to identify the associated risk factors. METHODS: We conducted a retrospective cohort study of all TB patients who were Israeli citizens and diagnosed between 1999 and 2011 with a treatment outcome recorded as "success." We compared those who had recurrent TB with those who did not. In addition, a nested case-control study included all those who had recurrent TB with a random sample from this cohort matched by age, gender, and year of TB diagnosis. RESULTS: Of 3515 TB patients diagnosed between 1999 and 2011, 37 (1.05%) had recurrent TB during the follow-up period, with an incidence rate of 1.55 cases per 1000 person-years (PY). Male gender [hazard ratio (HR) 3.2, 95% confidence interval (95%CI) 1.4-7.4], human immunodeficiency virus (HIV) infection (HR 3.9, 95%CI 1.5-10.4), positive sputum culture [odds ratios (OR) 2.7, 95%CI 1.1-6.9], and low adherence to anti-TB treatment (OR 3.2, 95%CI 1.0-10.3) were found to be risk factors for recurrent TB. CONCLUSIONS: Male gender, HIV infection, positive sputum culture, and low adherence to anti-TB drugs during the initial TB episode were risk factors for developing recurrent TB.

[The Levinsky Walk-in Clinic in Tel Aviv: holistic services to control sexually transmitted diseases in the community].

The Israeli Ministry of Health inaugurated two walk-in community sexually transmitted disease (STD) clinics in 2002. This review focuses on the Levinsky Clinic in Tel Aviv. The clinics were established as a response to the increase in N. gonorrhea morbidity during the late 1990's, especially in the Tel Aviv district and following the rise in trafficking of women into Israel. The target populations were later extended to include other individuals at risk of developing STD, such as prostitutes, drug addicts, men who have sex with men, persons who have multiple sex partners or individuals considering themselves to be at high-risk. The clinic is operated by a multi-professional team, including physicians, nurses, social and community workers, and volunteers. Each patient is interviewed by a nurse or social-worker to stratify her/his risk of acquiring STD. Laboratory tests and physical examinations are performed as indicated. The services are free of charge and the clients have the option to remain anonymous in order to hamper possible barriers in accessing the clinic. The medical and psycho-social services of the Levinsky Clinic are tailored for the target populations. Therefore, some of the services are provided by a mobile unit outreaching the streets, brothels, shelters for trafficked women and refugees, correctional facilities, gay venues and drug trade locations. The staff employs the harm reduction strategy, is sensitive to the status of the individual in the community, and attentive to the influence of the environment over the clients' ability to control their risks of acquiring STD. The staff encourages an open and direct conversation with the clients about sex and sexuality, in a non-judgmental and respectful fashion. Many of those interventions are provided by community workers, who are familiar with the unique social behaviors, language, values and life style of the vulnerable populations, and aware of the limitations in adopting safe sex practices.