Case Ascertainment of Measles during a Large Outbreak-Laboratory Compared to Epidemiological Confirmation.

Measles is a highly contagious viral disease, and hence, sufficient herd immunity is obligatory to prevent infection transmission. Measles is still a cause of considerable disease burden globally, mainly in children. During a national measles outbreak in Israel in 2018-2019, the peak incidence rates occurred in the Jerusalem district. Most measles cases in the Jerusalem district (75.5%, 1702) were observed in children younger than 15 years of age, 49.2% (1109) were in children under 5 years of age, and 18.9% (425) were in infants under 1 year of age. The routine measles vaccination schedule includes two doses at 1 and 6 years of age. Most cases (1828, 81.1%) were unvaccinated (zero measles vaccine doses). These cases comprised the 425 affected infants under 1 year of age, who were ineligible for vaccination, along with the 1403 children over 1 year of age, who were otherwise unvaccinated. This study aimed to describe the epidemiologic and laboratory features of this measles outbreak, and to investigate case ascertainment (laboratory confirmed compared to epidemiologically confirmed cases). The study population included 2254 measles cases notified during the period spanning June 2018 to May 2019 in the Jerusalem district (incidence rate 176 per 10,000 population). Of the 2254 cases, 716 (31.8%) were laboratory confirmed, and 1538 (68.2%) were confirmed as epidemiologically linked. Most laboratory confirmed cases (420, 58.7%) underwent real-time PCR tests. Serological tests (measles IgM and IgG) were used in 189 (26.4%) cases, and a combination of RT-PCR and serology was used in 107 (14.9%) cases. In a multivariate model analysis, the variables significantly associated (after adjustment) with higher odds for laboratory confirmation included month of disease onset (late), additional measles cases in the household (single case), place of medical treatment (hospital; either emergency department, or hospitalization) and vaccination status (at least one prior vaccine dose). The measles outbreak described demonstrates the urgency of addressing vaccination gaps with appropriate outbreak prevention programs. The road to measles elimination needs to be paved with robust public health infrastructure, excellent field epidemiology for outbreak surveillance, investigation, and control, and laboratory proficiency.

SARS-CoV-2 infection characteristics among students and staff in a large high school COVID-19 outbreak and secondary transmission in households.

Background: SARS-CoV-2 clinical presentation is associated with the patients' age group. Overall, young individuals present higher proportions of asymptomatic or mild COVID-19 infection, compared to adults. Data on secondary COVID-19 transmission in households, according to the cases' age group, are accumulating. Methods: We performed a follow-up cohort study including all COVID-19 real-time polymerase chain reaction (RT-PCR)-confirmed cases (adolescent students and school staff) diagnosed in an epidemiological investigation of a large high school outbreak. We compared the adolescent and adult groups regarding clinical symptoms, time to negative COVID-19 RT-PCR tests, and infection transmission in households. Results: The study population included 817 persons. The confirmed COVID-19 RT-PCR outbreak cases (n = 178) were followed (students aged 12-19 years, median age 14 years, n = 153, school staff aged 24-67 years, median age 39 years, n = 25) and the cases' household close contacts (n = 639) were tested. The adolescents had lower symptomatic infection rates, shorter time to negative COVID-19 RT-PCR tests, and lower transmission rates to household members, compared to the adults. The general transmission rate among household contacts was 13.5%, (86/639) ranging from 8.6% in asymptomatic students' contacts to 27.3% in symptomatic staff contacts. COVID-19 transmission rates were significantly higher in contacts of symptomatic cases compared to asymptomatic cases (odds ratio: 2.06, 95% CI 1.26-3.4) and higher in adults compared to adolescents (odds ratio: 2.69, 95% CI 1.43-4.89). Conclusions: Adolescents and adults diagnosed in an outbreak investigation differ as to COVID-19 clinical presentation and transmission. As adolescents may show mild or no symptoms, COVID-19 prevention in school settings is challenging. Implementing nonpharmaceutical measures and promoting vaccination programs in eligible staff and students should be considered.

Pertussis outbreak mainly in unvaccinated young children in ultra-orthodox Jewish groups, Jerusalem, Israel 2023.

Despite being a vaccine-preventable disease for decades, pertussis control is still a public health challenge. A pertussis outbreak emerged in Jerusalem (n = 257 cases, January to June 2023). Most cases were young children (median age 1.5 years), and 100 were infants under 1 year. The hospitalisation rate of infants was 24%, which was considerably higher than that of cases aged 1 year and above (3.8%). There was one fatality in an unvaccinated, 10-week-old infant whose mother had not received pertussis vaccination during pregnancy. Most children were unvaccinated and resided in Jewish ultra-orthodox neighbourhoods in Jerusalem district. An intervention programme and vaccination campaign are ongoing.

Invasive Disease Due to Neisseria meningitidis: Surveillance and Trends in Israel Prior to and during the COVID-19 Pandemic.

Invasive meningococcal disease (IMD) is a devastating disease with significant mortality and long-term morbidity. The COVID-19 pandemic and containment measures have affected the epidemiology of infectious pathogens. This study's aim was to assess IMD trends in Israel prior to and during the COVID-19 pandemic. The Neisseria meningitidis invasive infection is a notifiable disease in Israel. Laboratory analysis includes serogrouping and molecular characterization. The overall national IMD incidence rate (1998-2022) was 0.8/100,000 population. The IMD incidence rates declined during the pandemic years (0.3/100,000 in 2020-2022 vs. 0.9/100,000 in 1998-2019). The number of notified IMD cases declined by 65% in 2020-2022. The case fatality rate among laboratory-confirmed IMD cases was 9% (47/521, 2007-2022). Mortality risk markers included cases' age (older) and socio-economic status (lower). Overall, most Neisseria meningitidis isolates were of serogroup B (62.6%), and the most prevalent clonal complex (CC) was CC32 (24.2%). Serogroup B prevailed in cases aged 0-9 years (74.5%) and less in cases aged 10 years and above (39%). Neisseria meningitidis serogroups and CC distribution altered recently with a decline in serogroup B fraction, an increase in serogroup Y, and a decline in CC32. Ongoing IMD surveillance is necessary to assess trends in circulating strains and support decision-making on meningococcal vaccination programs.

Utilization of the Public Health Ordinance to prevent nosocomial spread in a case of acute measles-associated psychosis.

Measles is a highly contagious disease. A 24 years old patient, recently exposed to measles (unvaccinated), presented in the emergency department with severe agitation, compatible with an acute psychotic episode, during the measles epidemic which spread in Israel in 2018-2019. Upon hospital admission, strict isolation was instructed, yet, without compliance, probably due to the patient's status. Measles diagnosis was promptly confirmed. As measles transmission was eminent, public health measures were employed through immediate implementation of the section 15 of the Public Health Ordinance, allowing for compulsory short-term isolation. The patient's condition improved within a few days and the measures were no longer necessary. This measles case occurred in the pre-Coronavirus disease 2019 (COVID-19) epidemic when use of a Public Health Ordinance was considered an extreme measure. This is in contrast to the current global use of Public Health laws to enforce strict quarantine and isolation on persons infected or potentially exposed to COVID-19. Nevertheless, minimizing infectious diseases transmission is a core function of public health law. Utilizing legal enforcement in circumstances of immediate public health hazard, such as nosocomial measles transmission, necessitates careful consideration. The integrative clinical and public health approach and prompt measures employed in this exceptional case, led to prevention of further infection spread.

A large COVID-19 outbreak in a high school 10 days after schools' reopening, Israel, May 2020.

On 13 March 2020, Israel's government declared closure of all schools. Schools fully reopened on 17 May 2020. Ten days later, a major outbreak of coronavirus disease (COVID-19) occurred in a high school. The first case was registered on 26 May, the second on 27 May. They were not epidemiologically linked. Testing of the complete school community revealed 153 students (attack rate: 13.2%) and 25 staff members (attack rate: 16.6%) who were COVID-19 positive.

Community-Oriented Epidemic Preparedness and Response to the Jerusalem 2018-2019 Measles Epidemic.

Measles epidemics are still a public health challenge worldwide, necessitating a rapid response. The Jerusalem District Health Office applied a community-oriented intervention during the 2018-2019 epidemic (2150 notified cases). Program development targeted the socioeconomic and cultural characteristics of high-incidence Jewish ultraorthodox communities. Health care and community collaboration led to coverage rates of measles vaccination increasing from 80% to 95% within three months and a significant decline in incidence. Epidemic preparedness calls for maintaining the infrastructure of countermeasures combined with sustaining immunization coverage.

Invasive meningococcal disease epidemiology and characterization of Neisseria meningitidis serogroups, sequence types, and clones; implication for use of meningococcal vaccines.

BACKGROUND AND AIMS: Neisseria meningitidis (N. meningitidis) is a Gram-negative bacterium that can cause life-threatening invasive infections referred to as invasive meningococcal disease (IMD). In the last decade the incidence of IMD in Israel is about 1/100,000 population annually. We aimed to describe the epidemiology of IMD in Israel combining epidemiological data and characterization of N. meningitidis isolates. METHODS: Invasive infection caused by N. meningitidis is a notifiable disease in Israel. Data were collected by epidemiological investigations and control measures were employed. Laboratory work-up included serogrouping, N. meningitides molecular characterization and whole-genome sequencing. RESULTS: During 1998-2017, 1349 cases of IMD were notified in Israel (mean annual incidence rate 0.94/100,000). The peak incidence rates were observed in infants under 1 year of age (10.9/100,000). Case fatality rate was 9.7%. The majority of the N. meningitidis isolates were of serogroup B (67.9%). During 2007-2017, three clonal complexes (CC) 32, 41/44 and 23 (hyper-invasive clonal complexes) were the leading CC (61%). CC32 was the leading CC causing meningococcemia and mortality. In 2017, 35 isolates were tested for 4CMenB antigens variants; of the serogroup B isolates tested 46.7% showed a match to one or more antigens (fHbp or PorA:VR1), most were ST32 (CC32). CONCLUSIONS: Preliminary analysis based on limited number of samples suggests that the 4CMenB coverage would be about half the strains; further research is necessary. Integration of clinical, epidemiological and laboratory data is essential to support decision-making on the introduction of the novel MENB vaccines in Israel.

Ongoing mumps outbreak in Israel, January to August 2017.

In Israel, 262 mumps cases were registered between 1 January and 28 August 2017 despite a vaccine coverage of ≥ 96%. The majority (56.5%) of cases were adolescents and young adults between 10 and 24 years of age. Nearly twice as many cases were reported in males than in females. Sequence information identified genotype G and suggested specific transmission chains in different religious communities, with the Muslim population in Jerusalem being most severely affected.

Association of HIV and syphilis seropositivity with transit stay in urban areas among Ethiopian immigrants to Israel.

BACKGROUND: Ethiopian immigration to Israel was initiated in 1981. Most immigrants were rural dwellers who migrated first to Addis Ababa or Gondar, where they waited for eligibility status from Israel to leave Ethiopia. Soon after arriving in Israel, all immigrants were offered screening tests for human immunodeficiency virus (HIV) and syphilis. OBJECTIVES: To evaluate the association of age, gender, marital status and length of time spent in urban areas in Ethiopia with the prevalence of HIV and syphilis seropositivity. METHODS: All adult Ethiopian immigrants who arrived at the Jerusalem immigration center between 1999 and 2002 and consented to HIV and syphilis screening tests were interviewed. RESULTS: Altogether, 678 immigrants (51% females) were screened; 39 (5.8%) were seropositive for HIV and 33 (4.9%) for syphilis. The length of time the immigrants spent in Ethiopian cities before leaving for Israel was significantly associated with HIV: odds ratio (OR) 2.76, 95% confidence interval (CI) 1.13-6.71, and syphilis seropositivity OR 3.87, 95%CI 1.56-9.62. CONCLUSIONS: The length of transit time Ethiopian immigrants from rural areas spend in Ethiopian cities is significantly associated with HIV and syphilis seropositivity. Efforts should be made to shorten this time in order to reduce the risk of infection

The clinical features and long-term sequelae of invasive meningococcal disease in children.

We evaluated the outcome of invasive meningococcal disease in children <15 years of age (n = 181). Neisseria meningitidis serogroup B comprised 78% of bacterial isolates. Case fatality rate was 11.6%. In follow-up interviews (115/160 survivors, 72%), at least 1 long-term sequela was reported in 38/115 children (33%), including learning-academic difficulties (22.6%), hearing impairment (7%), neurologic (12.2%), behavioral (14.8%) and motor (10.4%) deficits.

The impact of additional pertussis vaccine doses on disease incidence in children and infants.

BACKGROUND: Pertussis remains a cause of considerable morbidity in children worldwide. Due to the resurgence of the disease, two vaccine doses for schoolchildren were added to the routine Israeli schedule. In 2005 a 5th dose was introduced for second-graders (aged 7-8), and in 2008 an additional catch-up dose in the eighth grade (13-14 year-olds). METHODS: Population-based epidemiologic study of pertussis in the Jerusalem district. RESULTS: 1736 pertussis cases were reported from 1990 to 2009. The pertussis incidence rates increased sharply from 2.6/100,000 in 1990, to 10/100,000 in 2000, peaking at 28.8/100,000 in 2006, then declining to 22/100,000 in 2008 and to 15.7 in 2009 (2006 vs. 2009, p=0.0001). Most cases (74.4%, 1134/1524 during 1998-2009) were under 20 years. Infants under one year had the highest average incidence rate (72.3/100,000; 12.5% of cases); specifically those under 6 months (84.3% of cases under one year). The case distribution among 1-4, 5-9, 10-14, and 15-19 year-olds was: 11%, 18%, 24.1%, and 8.9%. The vaccination status (age-appropriate) was: unvaccinated--19.2%, partially vaccinated--7.6%, and fully vaccinated--73.2%. The overall hospitalization rate was 5.4%; infants--33.5%. Household transmission occurred in 16.1% of cases. The two age groups showing significant decline were children aged 5-9 (61.5% reduction) and 10-14 years (73.9% reduction); there is as yet no significant decline in other age groups. CONCLUSIONS: The recent marked decline in pertussis incidence among the 5-14 year-olds is encouraging. Young infants still constitute a significant disease burden, and the incidence in this age group should be followed closely.

Salmonella enterica outbreak in a banqueting hall in Jerusalem: the unseen hand of the epidemiological triangle?

BACKGROUND: Foodborne Salmonella enterica outbreaks constitute both a threat to public health and an economic burden worldwide. OBJECTIVES: To characterize the pathogen(s) involved and possible source of infection of an outbreak of acute gastroenteritis in a banqueting hall in Jerusalem. METHODS: We conducted interviews of guests and employees of the banqueting hall, and analyzed food items, samples from work surfaces and stool cultures. RESULTS: Of 770 persons participating in three events on 3 consecutive days at a single banqueting hall, 124 were interviewed and 75 reported symptoms. Salmonella enterica, serovar Enteritidis, phage type C-8, was isolated from 10 stool cultures (eight guests, one symptomatic employee and one asymptomatic employee) and a sample of a mayonnaise-based egg salad. Pulsed-field gel electrophoresis of the isolates revealed an identical pattern in the outbreak isolates, different from SE C-8 controls. A culture-positive asymptomatic employee was linked to all three events. After a closure order, allowing for cleaning of the banqueting hall, revision of food preparation procedures and staff instruction on hygiene, the banqueting hall was reopened with no subsequent outbreaks. CONCLUSIONS: It is often difficult to pinpoint the source of infection in S. enterica outbreaks. Using molecular subtyping methods, a link was confirmed between patients, a food handler (presumably a carrier) and a food item--all showing an identical specific Salmonella enterica serovar Enteritidis. Testing asymptomatic as well as symptomatic food handlers in outbreak investigations is imperative. Pre- and post-hiring screening might be considered as preventive measures; hygiene and sanitation education are essential.

Onchocerciasis among Ethiopian immigrants in Israel.

BACKGROUND: Onchocerciasis results from infestation by the nematode Onchocerca volvulus, and is characterized clinically by troublesome itching, skin lesions and eye manifestations. Since 1992, approximately 9,000 immigrants have arrived in Israel from the Kuwara province of northwest Ethiopia where the prevalence of onchocerciasis is particularly high. OBJECTIVES: To determine whether onchocerciasis is the cause of cutaneous and ocular symptoms among recent immigrants from the Kuwara province in Ethiopia. METHODS: We examined 1,200 recent immigrants from the Kuwara province residing at the Mevasseret Zion immigration center outside Jerusalem. Among them, patients with cutaneous signs suggestive of onchocerciasis underwent a skin-snip biopsy and a thorough eye examination. RESULTS: In the detailed skin examination performed in 83 patients, the most common skin finding was chronic papular onchodermatitis, found in more than 46 patients (55%); depigmentation and atrophy was found in 13 (15%) and 12 (14%), respectively. In 40 patients (48%), living microfilaria were detected in their skin snips. Of the 65 patients who underwent a through eye examination, 45 patients (66%) had ocular complaints. Corneal abnormalities were found in 55 of the 130 eyes (42%), active anterior segment intraocular inflammation and live microfilariae were found in 4 eyes (3%) and lens changes in 16 eyes (1%). Eleven eyes (9%) showed retinal or choroidal changes. CONCLUSIONS: Skin and eye manifestations associated with onchocerciasis are prevalent among symptomatic Ethiopians who immigrated to Israel from the Kuwara province.