The Sky Has Its Limits in COVID-19 Testing.

At the time of writing, in July 2020, the COVID-19 pandemic has already inflicted dramatic international restrictions, including airports closing and limiting international travel. It has been suggested that re-opening of airports should involve and even rely on testing travelers for COVID-19. This paper discusses the methodology of estimating the detection and diagnostic accuracy of COVID-19 tests. It explains the clear distinction between the technical characteristics of the tests, the detection measures, and the diagnostic measures that have clinical and public health implications. It demonstrates the importance of the prevalence of COVID-19 in terms of determining the ability of a test to yield a diagnosis. We explain the methodology of evaluating diagnostic tests, using the predictive summary index (PSI), and the minimum number of tests that need to be performed in order to correctly diagnose one person, which is estimated by 1/PSI. In a population with low prevalence, even a high-sensitivity test may lead to a high percentage of false positive diagnoses, resulting in the need for multiple high-cost tests to achieve a correct diagnosis. Thus, basing a policy for opening airports on diagnostic testing, even with the best test for COVID-19, has some limits.

Morbidity and mortality from road injuries: results from the Global Burden of Disease Study 2017.

BACKGROUND: The global burden of road injuries is known to follow complex geographical, temporal and demographic patterns. While health loss from road injuries is a major topic of global importance, there has been no recent comprehensive assessment that includes estimates for every age group, sex and country over recent years. METHODS: We used results from the Global Burden of Disease (GBD) 2017 study to report incidence, prevalence, years lived with disability, deaths, years of life lost and disability-adjusted life years for all locations in the GBD 2017 hierarchy from 1990 to 2017 for road injuries. Second, we measured mortality-to-incidence ratios by location. Third, we assessed the distribution of the natures of injury (eg, traumatic brain injury) that result from each road injury. RESULTS: Globally, 1 243 068 (95% uncertainty interval 1 191 889 to 1 276 940) people died from road injuries in 2017 out of 54 192 330 (47 381 583 to 61 645 891) new cases of road injuries. Age-standardised incidence rates of road injuries increased between 1990 and 2017, while mortality rates decreased. Regionally, age-standardised mortality rates decreased in all but two regions, South Asia and Southern Latin America, where rates did not change significantly. Nine of 21 GBD regions experienced significant increases in age-standardised incidence rates, while 10 experienced significant decreases and two experienced no significant change. CONCLUSIONS: While road injury mortality has improved in recent decades, there are worsening rates of incidence and significant geographical heterogeneity. These findings indicate that more research is needed to better understand how road injuries can be prevented.

European Electronic Personal Health Records initiatives and vulnerable migrants: A need for greater ethical, legal and social safeguards.

The effective collection and management of personal data of rapidly migrating populations is important for ensuring adequate healthcare and monitoring of a displaced peoples' health status. With developments in ICT data sharing capabilities, electronic personal health records (ePHRs) are increasingly replacing less transportable paper records. ePHRs offer further advantages of improving accuracy and completeness of information and seem tailored for rapidly displaced and mobile populations. Various emerging initiatives in Europe are seeking to develop migrant-centric ePHR responses. This paper highlights their importance and benefits, but also identifies a number of significant ethical, legal and social issues (ELSI) and challenges to their design and implementation, regarding (1) the kind of information that should be stored, (2) who should have access to information, and (3) potential misuse of information. These challenges need to be urgently addressed to make possible the beneficial use of ePHRs for vulnerable migrants in Europe.

Detection and Diagnostic Overall Accuracy Measures of Medical Tests.

BACKGROUND: Overall accuracy measures of medical tests are often used with unclear interpretations. OBJECTIVES: To develop methods of calculating the overall accuracy of medical tests in the patient population. METHODS: Algebraic equations based on Bayes' theorem. RESULTS: A new approach is proposed for calculating overall accuracy in the patient population. Examples and applications using published data are presented. CONCLUSIONS: The overall accuracy is the proportion of the correct test results. We introduce a clear distinction between the overall accuracy measures of medical tests that are aimed at the detection of a disease in a screening of populations for public health purposes in the general population and the overall accuracy measures of tests aimed at determining a diagnosis in individuals in a clinical setting. We show that the overall detection accuracy measure is obtained in a specific study that explores test accuracy among persons with known diagnoses and may be useful for public health screening tests. It is different from the overall diagnostic accuracy that could be calculated in the clinical setting for the evaluation of medical tests aimed at determining the individual patients' diagnoses. We show that the overall detection accuracy is constant and is not affected by the prevalence of the disease. In contrast, the overall diagnostic accuracy changes and is dependent on the prevalence. Moreover, it ranges according to the ratio between the sensitivity and specificity. Thus, when the sensitivity is greater than the specificity, the overall diagnostic accuracy increases with increasing prevalence, and vice versa, that is, when the sensitivity is lower than the specificity, the overall diagnostic accuracy decreases with increasing prevalence so that another test might be more useful for diagnostic procedures. Our paper suggests a new and more appropriate methodology for estimating the overall diagnostic accuracy of any medical test. This may be important for helping clinicians avoid errors.

Global Burden of Multiple Myeloma: A Systematic Analysis for the Global Burden of Disease Study 2016.

Introduction: Multiple myeloma (MM) is a plasma cell neoplasm with substantial morbidity and mortality. A comprehensive description of the global burden of MM is needed to help direct health policy, resource allocation, research, and patient care. Objective: To describe the burden of MM and the availability of effective therapies for 21 world regions and 195 countries and territories from 1990 to 2016. Design and Setting: We report incidence, mortality, and disability-adjusted life-year (DALY) estimates from the Global Burden of Disease 2016 study. Data sources include vital registration system, cancer registry, drug availability, and survey data for stem cell transplant rates. We analyzed the contribution of aging, population growth, and changes in incidence rates to the overall change in incident cases from 1990 to 2016 globally, by sociodemographic index (SDI) and by region. We collected data on approval of lenalidomide and bortezomib worldwide. Main Outcomes and Measures: Multiple myeloma mortality; incidence; years lived with disabilities; years of life lost; and DALYs by age, sex, country, and year. Results: Worldwide in 2016 there were 138 509 (95% uncertainty interval [UI], 121 000-155 480) incident cases of MM with an age-standardized incidence rate (ASIR) of 2.1 per 100 000 persons (95% UI, 1.8-2.3). Incident cases from 1990 to 2016 increased by 126% globally and by 106% to 192% for all SDI quintiles. The 3 world regions with the highest ASIR of MM were Australasia, North America, and Western Europe. Multiple myeloma caused 2.1 million (95% UI, 1.9-2.3 million) DALYs globally in 2016. Stem cell transplantation is routinely available in higher-income countries but is lacking in sub-Saharan Africa and parts of the Middle East. In 2016, lenalidomide and bortezomib had been approved in 73 and 103 countries, respectively. Conclusions and Relevance: Incidence of MM is highly variable among countries but has increased uniformly since 1990, with the largest increase in middle and low-middle SDI countries. Access to effective care is very limited in many countries of low socioeconomic development, particularly in sub-Saharan Africa. Global health policy priorities for MM are to improve diagnostic and treatment capacity in low and middle income countries and to ensure affordability of effective medications for every patient. Research priorities are to elucidate underlying etiological factors explaining the heterogeneity in myeloma incidence.

The Risk of Cancer Might be Lower Than We Think. Alternatives to Lifetime Risk Estimates.

BACKGROUND: Estimates of lifetime cancer risk are commonly used in the clinical setting and in health-care evaluations. These measures are based on lifetime cancer risk estimates and may create an unrealistically frightening perception of cancer risk for an individual. We suggest using two new measures of cancer risk to complement the cancer lifetime risk measure, namely estimates of cancer risk from birth to a specific age or from a specific age to life expectancy. METHODS: We calculated risks using incidence density data from the Israel National Cancer Registry of 2013, applying a well-known formula for calculating risk, for a follow-up time. The joint disease-free survival probability is calculated for several age intervals, and hence the risk (i.e. 1-survival) for the intervals. RESULTS: The risk of cancer to age 80 in Jewish men and women, respectively, ranged from about 0.336 and 0.329 at age 0, to 0.279 and 0.237 at age 60. The risk of cancer from birth up to an age in Jewish men and women, respectively, ranged from 0 and 0 at birth to 0.088 and 0.129 at age 60. The risk of cancer to age 80 in Arab men and women, respectively, ranged from 0.298 and 0.235 at age 0 to 0.249 and 0.161 at age 60. The risk of cancer from birth up to an age in Arab men and women, respectively, ranged from 0 and 0 at age 0 to 0.074 and 0.095 at age 60. In Jewish and Arab women, breast cancer risk to age 80 decreased from about 0.127 in Jewish women at age 40 to 0.079 at age 60 and from 0.080 to 0.043 in Arab women; the risk from birth up to a specific age ranged between 0 and 0.056, and 0 and 0.040, respectively. CONCLUSION: The two proposed new estimates convey important additional information to patients and physicians. These estimates are considerably lower than the frequently quoted 33% lifetime cancer risk and are more relevant to patients and physicians. Similarly, breast cancer risk estimates up to or from a specific age differ considerably from the frequently quoted lifetime risk estimates of 1 in 8 women.

Lower Cancer Rates Among Druze Compared to Arab and Jewish Populations in Israel, 1999-2009.

The Druze are a small ethnic minority in Israel amounting to about 130,000 residents (or 1.7 % of the total population of the country). Unlike other population groups, the Druze strive to keep their own traditions and marry mainly inside their own community. During the last decade, cancer morbidity among both Jews and Arabs in Israel has been increasing, while data on the Druze are little known and have not been analyzed and compared to other population groups to date. To compare cancer morbidity rates among Druze, Arabs and Jews in Israel during 1999-2009, gender-specific and age-standardized incidence rates of all site cancers and specific cancers of three population groups (Jews, Arabs and Druze) were received from the Israel National Cancer Registry for the period 1999-2009. Based on these rates, periodical incidence rates were calculated and mutually compared across the groups stratified by gender. As the analysis shows, the Druze had significantly lower cancer rates compared to both Arabs and Jews. Thus, for all site cancers, there were significantly higher cancer rates in Jewish males versus Druze males (RR = 1.39, 95 % CI = 1.16-1.65) and in Jewish females versus Druze females (RR = 1.53, 95 % CI = 1.27-1.85), but not statistically significant for Arab males versus Druze males (RR = 1.12 95 % CI = 0.93-1.35). Lung cancer rates in Arab males were also higher compared to Druze males (RR = 1.84, 95 % CI = 1.13-3.00). Jewish males had statistically significant higher rates of prostate cancer compared to Druze males (RR = 2.47, 95 % CI = 1.55-3.91). For thyroid and colon cancers, risks were not significantly different at the 95 % CI level; however, the risks were significantly different at the 90 % CI level (RR = 3.62, 90 % CI 1.20-11.02 and RR = 1.69, 90 % CI = 1.03-2.77, respectively). Jewish females had significantly higher rates of invasive breast cancer (RR = 2.25, 95 % CI = 1.55-3.25), in situ cervical cancer (RR = 4.01, 95 % CI = 1.27-12.66) and lung cancer (RR = 3.22, 95 % CI = 1.12-9.24) compared to Druze females. We thus observed lower cancer rates among Druze versus Arab and Jewish populations in Israel. A reason for these differences may be due to different nutritional habits. Druze still keep a less processed nutritional lifestyle, than is common in industrial society. There may also be other reasons that have not been identified yet.

Application of the double kernel density approach to the analysis of cancer incidence in a major metropolitan area.

RATIONALE: Although cancer is a main cause of human morbidity worldwide, relatively small numbers of new cancer cases are recorded annually in single urban areas. This makes the association between cancer morbidity and environmental risk factors, such as ambient air pollution, difficult to detect using traditional methods of analysis based on age standardized rates and zonal estimates. STUDY GOAL: The present study investigates the association between air pollution and cancer morbidity in the Greater Haifa Metropolitan Area in Israel by comparing two analytical techniques: the traditional zonal approach and more recently developed Double Kernel Density (DKD) tools. While the first approach uses age adjusted Standardized Incidence Ratios (SIRs) for small census areas, the second approach estimates the areal density of cancer cases, normalized by the areal density of background population in which cancer events occurred. Both analyses control for several potential confounders, including air pollution, proximities to main industrial facilities and socio-demographic attributes. RESULTS: Air pollution variables and distances to industrial facilities emerged as statistically significant predictors of lung and NHL cancer morbidity in the DKD-based models (p<0.05) but not in the models based on SIRs estimates (p>0.2). CONCLUSION: DKD models appear to be a more sensitive tool for assessing potential environmental risks than traditional SIR-based models, because DKD estimates do not depend on a priory geographic delineations of statistical zones and produce a smooth and continuous disease 'risk surface' covering the entire study area. We suggest using the DKD method in similar studies of the effect of ambient air pollution on chronic morbidity, especially in cases in which the number of statistical areas available for aggregation and comparison is small and recorded morbidity events are relatively rare.

Challenges in Recruiting Aging Women Holocaust Survivors to a Case Control Study of Breast Cancer.

Older adults are underrepresented in medical research for many reasons, including recruitment difficulties. Recruitment of older adults for research studies is often a time-consuming process and can be more challenging when the study involves older adults with unique exposures to traumatic events and from minority groups. The current article provides a brief overview of (a) challenges encountered while recruiting aging women Holocaust survivors for a case control study and (b) strategies used for meeting those challenges. The case group comprised women Holocaust survivors who were recently diagnosed with breast cancer and the control group comprised healthy women from a Holocaust-survivor community in Israel.

A web-based program to increase knowledge and reduce cigarette and nargila smoking among Arab university students in Israel: mixed-methods study to test acceptability.

BACKGROUND: Among Arab citizens in Israel, cigarette and nargila (hookah, waterpipe) smoking is a serious public health problem, particularly among the young adult population. With the dramatic increase of Internet and computer use among Arab college and university students, a Web-based program may provide an easy, accessible tool to reduce smoking rates without heavy resource demands required by traditional methods. OBJECTIVE: The purpose of this research was to examine the acceptability and feasibility of a pilot Web-based program that provides tailored feedback to increase smoking knowledge and reduce cigarette and nargila smoking behaviors among Arab college/university students in Israel. METHODS: A pilot Web-based program was developed, consisting of a self-administered questionnaire and feedback system on cigarette and nargila smoking. Arab university students were recruited to participate in a mixed-methods study, using both quantitative (pre-/posttest study design) and qualitative tools. A posttest was implemented at 1 month following participation in the intervention to assess any changes in smoking knowledge and behaviors. Focus group sessions were implemented to assess acceptability and preferences related to the Web-based program. RESULTS: A total of 225 participants-response rate of 63.2% (225/356)-completed the intervention at baseline and at 1-month poststudy, and were used for the comparative analysis. Statistically significant reductions in nargila smoking among participants (P=.001) were found. The intervention did not result in reductions in cigarette smoking. However, the tailored Web intervention resulted in statistically significant increases in the intention to quit smoking (P=.021). No statistically significant increases in knowledge were seen at 1-month poststudy. Participants expressed high satisfaction with the intervention and 93.8% (211/225) of those who completed the intervention at both time intervals reported that they would recommend the program to their friends, indicating excellent acceptability and feasibility of the intervention. This was further emphasized in the focus group sessions. CONCLUSIONS: A tailored Web-based program may be a promising tool to reduce nargila smoking among Arab university students in Israel. The tailored Web intervention was not successful at significantly reducing cigarette smoking or increasing knowledge. However, the intervention did increase participants' intention to quit smoking. Participants considered the Web-based tool to be an interesting, feasible, and highly acceptable strategy. TRIAL REGISTRATION: ISRCTN registry ISRCTN59207794; http://www.isrctn.com/ISRCTN59207794 (Archived by WebCite at http://www.webcitation.org/6VkYOBNOJ).

Cancer incidence among physicians in Israel.

BACKGROUND: Physicians' occupational environment includes exposures to potential carcinogenic factors on a regular basis. The prevalence of specific tumor types and subsequent mortality are reported to be elevated in physicians. OBJECTIVES: To assess the incidence of various cancer types among Israeli physicians of various specialties, as compared with the general population, and to determine the role, if any, of gender and ethnicity. METHODS: This historical retrospective cohort analysis incorporated data on Israeli officially licensed physicians and information retrieved from the Israel National Cancer Registry database (INCR). Physicians were divided into five groups: non-specialists, internists, pediatricians, surgeons, and potentially at-risk specialties. Data were collected retrospectively for the years 1980-2007. RESULTS: The study cohort comprised 37,789 physicians, of whom 33,393 (88.37%) were Jews and 4396 (11.63%) were Arabs. Comparing Jewish physicians to the general population revealed higher rates of: a) breast cancer among female specialized physicians, and b) melanoma among specialized male and female physicians. All cancer types were more prevalent in the Arab physicians than in the general Arab population. CONCLUSIONS: This study revealed incidences of specific cancer types among different medical specialties as compared to the general population. Hopefully, these findings will prompt changes in the occupational environment of physicians of particular specialties in order to reduce their high risk for cancer occurrence.

Bridging cross-cultural gaps: monitoring herbal use during chemotherapy in patients referred to integrative medicine consultation in Israel.

INTRODUCTION: The high prevalence of the use of traditional herbs among patients with cancer is a cause for concern with regard to potentially adverse interactions with conventional oncology treatments. In this study, we explore herbal use among patients with cancer in northern Israel who are referred by their health care providers to complementary and traditional medicine (CTM) consultations provided to them within the conventional oncology department. The study's objectives were to identify which herbs patients use and to examine the scope of current research on the efficacy and safety regarding the identified herbs. PATIENTS AND METHODS: Herbal use by patients receiving oncology care was assessed prospectively from July 2009 to July 2012 by integrative physicians (IPs) trained in herbal medicine. Historical, ethnobotanical, basic research, and clinical data regarding the identified herbs were explored by using a keyword search in PubMed and Middle Eastern ethnohistorical literature. RESULTS: Disclosure of herbal use was reported by 154 of the 305 patients (50.5 %) interviewed by IPs. The use of 85 single herbs and 30 different herbal formulas was documented during the initial or follow-up IP assessments. Patients reported 14 quality of life-associated indications for herbal use. The ten most prevalent herbs displaying in vitro/in vivo anticancer activity and nine other herbs were preliminarily assessed concerning potential risks, safety, and interaction with chemotherapy. CONCLUSIONS: Herbal use by patients with cancer in northern Israel is widespread and calls for further study in order to address issues of safety and effectiveness. We recommend constructing a multinational and multidisciplinary team of researchers with ethnopharmacological and clinical expertise that will explore the use of herbs among patients with cancer in a cross-cultural perspective attuned with patients' affinity to traditional herbal medicine.

Green spaces and adverse pregnancy outcomes.

OBJECTIVE: The objective of this study was to evaluate the associations between proximity to green spaces and surrounding greenness and pregnancy outcomes, such as birth weight, low birth weight (LBW), very LBW (VLBW), gestational age, preterm deliveries (PTD) and very PTD (VPTD). METHODS: This study was based on 39,132 singleton live births from a registry birth cohort in Tel Aviv, Israel, during 2000-2006. Surrounding greenness was defined as the average of satellite-based Normalised Difference Vegetation Index (NDVI) in 250 m buffers and proximity to major green spaces was defined as residence within a buffer of 300 m from boundaries of a major green space (5000 m(2)), based on data constructed from OpenStreetMap. Linear regression (for birth weight and gestational age) and logistic regressions models (for LBW, VLBW, PTD and VPTD) were used with adjustment for relevant covariates. RESULTS: An increase in 1 interquartile range greenness was associated with a statistically significant increase in birth weight (19.2 g 95% CI 13.3 to 25.1) and decreased risk of LBW (OR 0.84, 95% CI 0.78 to 0.90). Results for VLBW were in the same direction but were not statistically significant. In general, no associations were found for gestational age, PTD and VPTD. The findings were consistent with different buffer and green space sizes and stronger associations were observed among those of lower socioeconomic status. CONCLUSIONS: This study confirms the results of a few previous studies demonstrating an association between maternal proximity to green spaces and birth weight. Further investigation is needed into the associations with VLBW and VPTD, which has never been studied before.

World War II-related post-traumatic stress disorder and breast cancer risk among Israeli women: a case-control study.

BACKGROUND: Several studies have suggested that post-traumatic stress disorder (PTSD) is related to adverse health outcomes. There are limited data on PTSD and cancer, which has a long latency period. We investigated the association between World War II (WWII)-related PTSD and subsequent breast cancer (BC) risk among Jewish WWII survivors and examined whether this association was modified by exposure to hunger during WWII. METHODS: We compared 65 BC patients diagnosed in 2005 through 2010 to 200 population-based controls who were members of various organizations for Jewish WWII survivors in Israel. All participants were born in Europe, lived at least six months under Nazi rule during WWII, and immigrated to Israel after the war. We estimated PTSD using the PTSD Inventory and applied logistic regression models to estimate the association between WWII-related PTSD and BC, adjusting for potential confounders. RESULTS: We observed a linear association between WWII-related PTSD and BC risk. This association remained significant following adjustment for potential confounders, including obesity, alcohol consumption, smoking, age during WWII, hunger exposure during WWII, and total number of traumatic life events (OR = 2.89, 95% CI = 1.14-7.31). However, the level of hunger exposure during WWII modified this effect significantly. CONCLUSIONS: These findings suggest an independent association between WWII-related PTSD and subsequent BC risk in Jewish WWII survivors that is modified by hunger, a novel finding. Future research is needed to further explore these findings.

Parkinson's disease patients first treated at age 75 years or older: a comparative study.

BACKGROUND: Parkinson's disease (PD) first diagnosed at older age reportedly has different clinical characteristics and survival rates than when it is first diagnosed at younger age. We compared these features among PD patients who initiated anti-parkinsonian drugs at age 75-85 years (elderly) with those who started treatment at age 50-74 years (younger). METHODS: We used a population-based cohort of 4449 incident cases of PD patients aged 50-85 at treatment initiation, based on a pharmacy registry of Maccabi Health Maintenance Organization, with definite/probable/possible certainty of having PD. Mean follow-up was 3.9 ± 2.6 years. The two age groups were compared for time/risk to levodopa and to death, using Kaplan-Meier curves and Cox regression. Gender-specific standardized mortality rates (SMRs) accounting for Israeli death rates were also compared. RESULTS: One-half of the entire cohort (n = 2148) were elderly (>75 years) and more likely to be given levodopa (Hazard Rate (HR) = 1.48, P < 0.05), had a significantly higher frequency of comorbidities (e.g., heart disease, hypertension and cancer), and had a 3-fold increased risk to die (HR = 2.97, P < 0.05) within the same follow-up time as the youngers. Accounting for the general Israeli population death rates, female PD patients had a significantly lower risk to die compared to males especially females who were elderly at treatment initiation (SMR = 1.53 for females vs. 1.73 for males, P < 0.05). CONCLUSIONS: PD patients first diagnosed and treated at >74 years of age comprise a unique cluster for inclusion into drugs studies, mortality risk analyses and for projection of disease burden.

Cancer incidence and survival among infants in Israel, 1998-2007.

Cancer during the first year of life is relatively rare and often has clinical and biological properties different from those of the same histologic type of cancer occurring in older children. The aim of this study was to find differences in epidemiology and survival between infants and older children and to compare the percentage of distribution of infant cancer types in Israel with that reported in the United States. We collected infant <1 year of age cases diagnosed between 1998 and 2007 as having cancer from the database of the Israel National Cancer Registry, a total of 309 cases with an incidence rate of 228.5 cases per million. The largest group was diagnosed with neuroblastoma (35%) with an incident rate of 80 per million, followed by leukemia (15.9%), with acute lymphoid leukemia and acute myeloid leukemia accounting for most of this group and central nervous system malignancies comprised 10.7% of infant cancer. One hundred and fifty four new cases of infant girls was diagnosed compared to 155 infant boys with an incidence rates of 234 cases per million for girls and 224.7 for boys, not statistically significant (F:M rate ratio of 1.04). The 5-year survival rates seen in the different groups were leukemia: 55.3%, lymphoma: 71%, CNS tumors: 53.3%, neuroblastoma: 93.4%, retinoblastoma: 94.7% renal tumors: 90.9%, hepatic tumors: 63.3%, soft tissue sarcoma: 76.2%, germ cell neoplasms: 83.3%, and other epithelial neoplasms: 100%. Our study did not find survival differences with statistical significance upon comparing survival rates between different genders and ethnic groups.

Against all odds: genocidal trauma is associated with longer life-expectancy of the survivors.

Does surviving genocidal experiences, like the Holocaust, lead to shorter life-expectancy? Such an effect is conceivable given that most survivors not only suffered psychosocial trauma but also malnutrition, restriction in hygienic and sanitary facilities, and lack of preventive medical and health services, with potentially damaging effects for later health and life-expectancy. We explored whether genocidal survivors have a higher risk to die younger than comparisons without such background. This is the first population-based retrospective cohort study of the Holocaust, based on the entire population of immigrants from Poland to Israel (N = 55,220), 4-20 years old when the World War II started (1939), immigrating to Israel either between 1945 and 1950 (Holocaust group) or before 1939 (comparison group; not exposed to the Holocaust). Hazard of death - a long-term outcome of surviving genocidal trauma - was derived from the population-wide official data base of the National Insurance Institute of Israel. Cox regression yielded a significant hazard ratio (HR = 0.935, CI (95%) = 0.910-0.960), suggesting that the risk of death was reduced by 6.5 months for Holocaust survivors compared to non-Holocaust comparisons. The lower hazard was most substantial in males who were aged 10-15 (HR = 0.900, CI (95%) = 0.842-0.962, i.e., reduced by 10 months) or 16-20 years at the onset of the Holocaust (HR = 0.820, CI (95%) = 0.782-0.859, i.e., reduced by18 months). We found that against all odds genocidal survivors were likely to live longer. We suggest two explanations: Differential mortality during the Holocaust and "Posttraumatic Growth" associated with protective factors in Holocaust survivors or in their environment after World War II.

Occupational exposures and symptoms among firefighters and police during the carmel forest fire: the Carmel cohort study.

BACKGROUND: From 2 to 5 December 2010, Israel experienced the most severe forest fire In its history, resulting in the deaths of rescue workers. Little research exists on the health risks to emergency responders during forest fires, and there is no published research to date on occupational health among firefighters in Israel. OBJECTIVES: To describe the exposures experienced by emer gency responders to smoke, fire retardants and stress; the utilization of protective equipment; and the frequency of corresponding symptoms during and following the Carmel Forest fire. METHODS: A cohort of 204 firfighers and 68 police who took part in rescue and fire-abating activites during the Carmel Forest fire were recruited from a representative sample of participating stations throughout the country and interviewed regarding their activities during the fire and their coinciding symptoms. Unpaired two-sample t-test compared mean exposures and symptom frequency for firefighters and police. Chi-square estimates of OR and 95%CI are provided for odds of reporting symptoms, incurring injury or being hospitalied for various risk factors RESULTS: Of the study participants, 87% reported having at least one symptom during rescue work at the Carmel Forest fire,with eye irritation (77%) and fatigue (71%) being the most comon. Occupational stress was extremely high during the fire; the average length of time working without rest was 18.4 hours among firefighters. CONCLUSION: Firefighter and police were exposed to smoke and ocupational stress prolonged periods during the fire. Further research is needed on the residual health effects from exposure to forest fires among emergency responders, and to identify areas for improvement in health preparedness.