Introducing ROTAVAC® to the occupied Palestinian Territories: Impact on diarrhea incidence, rotavirus prevalence and genotype composition.

BACKGROUND: Rotavirus infection remains an important cause of morbidity and mortality in children. The introduction of vaccination programs in more than 100 countries has contributed to a decrease in hospitalizations and mortality. This study investigates the epidemiological impact of the rotavirus vaccine ROTAVAC® in the Palestinian Territories, the first country to switch from ROTARIX® to this new vaccine. METHODS: Clinical surveillance data was collected fromchildren younger than 5attendingoutpatient clinics throughout Gaza withdiarrhea between 2015 and 2020. The incidence of all-cause diarrhea was assessed using an interrupted time-series approach. Rotavirus prevalence was determined at the Caritas Baby Hospital in the West Bank usingELISA on stool specimen of children younger than 5with diarrhea. Genotyping was performed on 325 randomly selected rotavirus-positive samples from January 2015 through December 2020 using multiplex PCR analysis. RESULTS: Average monthly diarrhea casesdropped by 16.7% annually fromintroduction of rotavirus vaccination in May 2016 to the beginning of the SARS-CoV-2 epidemic in March 2020 for a total of 53%. Case count declines were maintained afterthe switchto ROTAVAC® in October 2018. Rotavirus positivity in stool samples declined by 67.1% over the same period without change followingthe switch to ROTAVAC®. The distribution of predominant genotypes in rotavirus-positive stool samples changed from a pre-vaccination G1P [8] to G9P[8] and G12P[8] during the ROTARIX® period and G2P[4] after the introduction of ROTAVAC®. CONCLUSION: ROTAVAC® has shown epidemiological impact on par with ROTARIX® after its introduction to the national immunization schedule in the Palestinian Territories. A molecular genotype shift from a pre-vaccination predominance of G1P[8] to a current predominance of G2P[4] requires more long-term surveillance.

Gestational age recorded at delivery versus estimations using antenatal care data from the Electronic Maternal and Child Health Registry in the West Bank: a comparative analysis.

BACKGROUND: Estimated dates of delivery have important consequences for clinical decisions during pregnancy and labour. The Electronic Maternal and Child Health Registry (MCH eRegistry) in Palestine includes antenatal care data and birth data from hospitals. Our objective was to compare computed best estimates of gestational age in the MCH eRegistry with the gestational ages recorded by health-care providers in hospital delivery units. METHODS: We obtained data for pregnant women in the West Bank registered in the MCH eRegistry from Jan 1, 2017 to March 31, 2017. Best estimates of gestational age in the registry are automated and based on a standard pregnancy duration of 280 days and ultrasound-based pregnancy dating before 20 weeks' gestation or the woman's last menstrual period date. Hospital recorded gestational ages are reported by care providers in delivery units and are rounded to the nearest week. We calculated proportions of gestational ages (with 95% CIs) from both sources that fell into the categories of term, very preterm (24-32 weeks' gestation), preterm (33-37 weeks), or post-term (>42 weeks). FINDINGS: 1924 women were included in the study. The median hospital recorded gestational age was 39 weeks (IQR 38-40 weeks) and according to MCH eRegistry estimates was 39 weeks and 5 days (IQR 38 weeks and 1 day to 40 weeks and 5 days). Proportions of very preterm, preterm, and post-term deliveries were higher based on MCH eRegistry estimates than on hospital recorded gestational ages (very preterm 3%, 95% CI 2-4 vs 2%, 1-2; preterm 6%, 5-7 vs 5%, 3-6 ; post-term 6%, 5-7 vs 1%, 1-2). INTERPRETATION: In addition to clinical care, the proportions of term, very preterm, preterm, and post-term births can have implications for public health monitoring. The proportion of deliveries within the normal range of term gestation was calculated to be higher by care providers in delivery units than by MCH eRegistry estimates. Extending the access of hospitals to information from antenatal care in the MCH e-Registry could improve continuity of data and better care for pregnant women. FUNDING: European Research Council, Research Council of Norway.

Accuracy of mortality statistics in Palestine: a retrospective cohort study.

OBJECTIVE: To examine the accuracy of mortality statistics in Palestine, to identify gaps and to provide evidence-based recommendations to improve mortality statistics in Palestine. STUDY DESIGN AND SETTING: A retrospective death registry-based study that examined a stratified random sample of death notification forms (DNFs) of patients who died in hospitals in Palestine was reported in 2012. We randomly selected 600 deceased from the Cause of Death Registry: 400 from the West Bank and 200 from the Gaza Strip. Analysis was based on the randomly selected deaths that we were able to retrieve the medical records for; 371 deaths in the West Bank and 199 deaths in the Gaza Strip. RESULTS: Data in the Palestinian Health Information Centre (PHIC) registry had a low degree of accuracy: less than half of the underlying causes stated the correct cause of death. In general, deaths due to malignant neoplasms were more accurately reported on DNFs than other causes of death, and metabolic diseases (including diabetes) were the most problematic. Issues with coding and classification at the PHIC were most apparent for perinatal conditions and congenital anomalies. CONCLUSION: Procedures for coding and classification at the PHIC deviate considerably from the international norms defined in the International Statistical Classification of Diseases and Related Health Problems (ICD) and account to a considerable extent for the discrepancies between the cause of death determined on the medical data on the death extracted from the deceased patient's hospital records and the cause of death coded by the PHIC. We recommend the introduction of international coding software for coding and classification, and a review to improve data handling in hospitals, especially those with electronic patient records.

Diversity, ecology, and seasonality of sand flies (Diptera: Psychodidae) of the Jenin District (Palestinian Territories).

The diversity, ecology, and seasonality for sand flies from two localities in Jenin District, the Palestinian Territories, were studied. A total of 12,579 sand flies (5,420 Phlebotomus and 7,159 Sergentomyia) were collected during the study period. The genera Phlebotomus and Sergentomyia are represented by 13 and nine species and subspecies, respectively. Species account was given for all collected species. CDC light traps yielded 7,649 (60.8%) of the total captured sand flies, while sticky traps and aspirators contributed to 36.4 and 2.8% of the total collected specimens, respectively. Phlebotomus sergenti and P. syriacus showed two peaks, one in July and one in October. Phlebotomus tobbi showed one peak towards the end of the summer in September and August, while P. papatasi showed a bimodal peaks pattern, one in June and one in October. Phlebotomus canaaniticus showed a peak in August. P. perfiliewi transcaucasicus and P. neglectus showed a peak in October. Sergentomyia dentata showed one peak in August and increasing numbers from June to August, declining afterwards. Other species, such as S. theodori, had one peak in June, S. taizi had steady numbers across the summer, and S. christophersi had a peak in August.

Ethnic variation in medical and lifestyle risk factors for B cell non-Hodgkin lymphoma: A case-control study among Israelis and Palestinians.

BACKGROUND: Risk factors for B-cell non-Hodgkin lymphoma (B-NHL) have not been assessed among Palestinian Arabs (PA) and Israeli Jews (IJ). METHODS: In a case-control study we investigated self-reported medical and lifestyle exposures, reporting odds ratios (ORs) and 95% confidence intervals [CIs], by ethnicity, for overall B-NHL and subtypes. RESULTS: We recruited 823 cases and 808 healthy controls. Among 307 PA/516 IJ B-NHL cases (mean age at diagnosis = 51 [±17] versus 60 [±15] years, respectively) subtype distributions differed, with diffuse large B-cell lymphoma (DLBCL) being prominent among PA (71%) compared to IJ (41%); follicular lymphoma (FL), was observed in 14% versus 28%, and marginal zone lymphoma, in 2% versus 14%, respectively. Overall B-NHL in both populations was associated with recreational sun exposure OR = 1.43 [CI:1.07-1.91], black hair-dye use OR = 1.70 [CI:1.00-2.87], hospitalization for infection OR = 1.68 [CI:1.34-2.11], and first-degree relative with hematopoietic cancer, OR = 1.69 [CI:1.16-2.48]. An inverse association was noted with alcohol use, OR = 0.46 [CI:0.34-0.62]. Subtype-specific exposures included smoking (FL, OR = 1.46 [CI:1.01-2.11]) and >monthly indoor pesticide use (DLBCL, OR = 2.01 [CI:1.35-3.00]). Associations observed for overall B-NHL in PA only included: gardening OR = 1.93 [CI:1.39-2.70]; history of herpes, mononucleosis, rubella, blood transfusion (OR>2.5, P<0.01 for all); while for IJ risk factors included growing fruits and vegetables, OR = 1.87 [CI:1.11-3.15]; and self-reported autoimmune diseases, OR = 1.99 [CI:1.34-2.95]. CONCLUSIONS: In these geographically proximate populations we found some unique risk factors for B-NHL. Heterogeneity in the observed associations by ethnicity could reflect differences in lifestyle, medical systems, and reporting patterns, while variations by histology infer specific etiologic factors for lymphoma subtypes.

Predicted efficacy of the Palestinian wheat flour fortification programme: complementary analysis of biochemical and dietary data.

OBJECTIVE: To utilize complementary biochemical and dietary data collected before the initiation of national flour fortification to (i) identify micronutrient insufficiencies or deficiencies and dietary inadequacies in Palestinian women and children in vulnerable communities and (ii) assess the suitability of the current wheat flour fortification formula. DESIGN: Quantitative dietary intake questionnaires were administered and fasting venous blood samples collected in randomly selected households in Gaza City and Hebron. The impact of fortification was simulated by estimating the additional micronutrient content of fortified wheat flour. SETTING: Households in Gaza City and Hebron that were not receiving food aid from social programmes. SUBJECTS: Non-pregnant women (18-49 years) and children aged 36-83 months. RESULTS: The micronutrients with highest prevalence of insufficiency were vitamin D in women (84-97 % with serum 25-hydroxyvitamin D <50 nmol/l) and vitamin B12 in women and children (43-82 % with serum B12 <221 pmol/l). Deficiencies of vitamin A, Fe and Zn were also of public health concern. Current levels of wheat flour fortificants were predicted to improve, but not eliminate, micronutrient intake inadequacies. Modification of fortificant concentrations of vitamin D, thiamin, vitamin B12, Zn and folic acid may be indicated. CONCLUSIONS: Micronutrient insufficiencies or deficiencies and intake inadequacies were prevalent based on either biochemical or dietary intake criteria. Adjustments to the current fortification formula for wheat flour are necessary to better meet the nutrient needs of Palestinian women and children.

Streptococcus pneumoniae from Palestinian nasopharyngeal carriers: serotype distribution and antimicrobial resistance.

Infections of Streptococcus pneumoniae in children can be prevented by vaccination; left untreated, they cause high morbidity and fatalities. This study aimed at determining the nasopharyngeal carrier rates, serotype distribution and antimicrobial resistance patterns of S. pneumoniae in healthy Palestinian children under age two prior to the full introduction of the pneumococcal 7-valent conjugate vaccine (PCV7), which was originally introduced into Palestine in a pilot trial in September, 2010. In a cross sectional study, nasopharyngeal specimens were collected from 397 healthy children from different Palestinian districts between the beginning of November 2012 to the end of January 2013. Samples were inoculated into blood agar and suspected colonies were examined by amplifying the pneumococcal-specific autolysin gene using a real-time PCR. Serotypes were identified by a PCR that incorporated different sets of specific primers. Antimicrobial susceptibility was measured by disk diffusion and MIC methods. The resulting carrier rate of Streptococcus pneumoniae was 55.7% (221/397). The main serotypes were PCV7 serotypes 19F (12.2%), 23F (9.0%), 6B (8.6%) and 14 (4%) and PCV13 serotypes 6A (13.6%) and 19A (4.1%). Notably, serotype 6A, not included in the pilot trial (PCV7) vaccine, was the most prevalent. Resistance to more than two drugs was observed for bacteria from 34.1% of the children (72/211) while 22.3% (47/211) carried bacteria were susceptible to all tested antibiotics. All the isolates were sensitive to cefotaxime and vancomycin. Any or all of these might impinge on the type and efficacy of the pneumococcal conjugate vaccines and antibiotics to be used for prevention and treatment of pneumococcal disease in the country.

Is the Maternal and Child Health (MCH) handbook effective in improving health-related behavior? Evidence from Palestine.

OBJECTIVE: This study examines the effect of the Maternal and Child Health (MCH) handbook--a home-based health record--on women's knowledge and behavior in the Jericho and Ramallah Governorates of Palestine. METHODS: This study uses a repeated, cross-sectional data set in which pre- and post-intervention situations are incorporated on two groups: those exposed and those not exposed to the MCH handbook. We employed a difference-in-difference regression analysis utilizing a pre-tested knowledge, attitude, and practice survey of women at 24 MCH 'treatment' centers (N=260, 270, pre-/post-) in comparison with the women at 6 MCH centers (N=70, 70, pre-/post-) where the MCH handbook was not released. A trained facilitator conducted a series of focus group discussions with 42 women who were the clients of MCH services and 25 health providers, both from the intervention area, to confirm the results obtained from the quantitative study. FINDINGS: Knowledge related to MCH such as the importance of exclusive breastfeeding and how to cope with the risks of rupture of membranes during pregnancy increased among MCH handbook users, especially among less-educated women. The MCH handbook may be an effective tool for communication with health providers and husbands, for both highly educated and less-educated women during their first pregnancy. Our results suggest that although less-educated women rarely read the handbook themselves at home, they became familiar with health information and options related to MCH through personalized guidance that was provided by health providers at health facilities utilizing MCH handbook. CONCLUSION: The MCH handbook may be an effective tool to improve (i) communication between the client and the health provider and (ii) women's knowledge- and health-seeking behaviors related to maternal, newborn, and child health.

Erratum to: The prevalence of HIV, HBV, HCV, and HIV-related risk-taking behaviors among Palestinian injecting drug users in the East Jerusalem Governorate.

The objective of the study was to determine HIV, HBV, HCV seroprevalence and to assess HIV risks among Palestinian injecting drug users (IDUs) in the East Jerusalem Governorate. Following formative research, a bio-behavioral survey using respondent-driven sampling was carried out in 2010 among 199 IDUs aged 19-56 years (M = 41.33, SD = 8.09). Venous blood was drawn for biological testing. Data on drug abuse and sexual behaviors were collected by face-to-face interviewing. No HIV + cases were found. Five participants were infected with Hepatitis B and 84 participants (estimated population proportion of 40.3%) tested positive for Hepatitis C. A great majority of the surveyed IDUs (90.4%) reported using sterile injecting equipment the last time they injected. In a multivariate assessment, age (OR = 2.52, p < .05), education (OR = 6.67, p < .01), personal network size (OR = .18, p < .001), and the frequency of drug injecting in the past month (OR = .20, p < .001) were associated with using sterile injecting equipment in the past week. Condom use at most recent sexual intercourse was reported by about a third (34.2%) of IDUs. The study documented substantial exposure to HIV risks among Palestinian IDUs whose vulnerability is inseparable from sociopolitic and socioeconomic characteristics of their social environment.

The prevalence of HIV, HBV, HCV, and HIV-related risk-taking behaviors among Palestinian injecting drug users in the East Jerusalem Governorate.

The objective of the study was to determine HIV, HBV, HCV seroprevalence and to assess HIV risks among Palestinian injecting drug users (IDUs) in the East Jerusalem Governorate. Following formative research, a bio-behavioral survey using respondent-driven sampling was carried out in 2010 among 199 IDUs aged 19-56 years(M=41.33, SD=8.09). Venous blood was drawn for biological testing. Data on drug abuse and sexual behaviors were collected by face-to-face interviewing. No HIV+cases were found. Five participants were infected with Hepatitis B and 84 participants(estimated population proportion of 40.3 %) tested positive for Hepatitis C. A great majority of the surveyed IDUs (90.4 %) reported using sterile injecting equipment the last time they injected. In a multivariate assessment, age (OR=2.52, pG.05), education(OR=6.67, pG.01), personal network size (OR=.18, pG.001), and the frequency of drug injecting in the past month (OR=.20, pG.001) were associated with using sterile injecting equipment in the past week. Condom use at most recent sexual intercourse was reported by about a third (34.2 %) of IDUs. The study documented substantial exposure to HIV risks among Palestinian IDUs whose vulnerability is inseparable from sociopolitic and socioeconomic characteristics of their social environment [corrected].

HIV/AIDS among Palestinians: detection, clinical presentation, prognosis and HIV testing patterns, 1994-2010.

OBJECTIVES: To describe the detection, clinical presentation, and prognosis of West Bank and East Jerusalem Palestinians infected with HIV/AIDS, and HIV testing patterns of Palestinians in the Jerusalem area. DESIGN AND METHODS: This was a case-control analysis comparing all 33 Palestinian HIV/AIDS patients who were referred to the Hadassah AIDS Center (HAC) over 17 years (1994-2010) with 77 non-Palestinian patients seen over the same period. The systematic sampling method was used to select the control group. Patterns of HIV testing were observed for the years 2002 and 2007. RESULTS: Many Palestinian patients (36%) were diagnosed during their initial hospitalization, while 47.1% of non-Palestinians were diagnosed as outpatients. Significantly more opportunistic infections were detected during diagnosis among Palestinians (48.5%) than among non-Palestinians (9.1%, p<0.001). Overall mortality among Palestinian patients was 36.4% (12/33) vs. 6.5% (5/77) among non-Palestinians (p<0.001). No significant differences in the initial CD4 counts and viral load levels were noted between Palestinians and non-Palestinians (256/mm(3) and log 4.58 copies/ml vs. 271/mm(3) and log 4.49 copies/ml, respectively). Follow-up visits were more infrequent among Palestinians than among non-Palestinians: 9.8 (± 1.0) compared with 23.4 (± 12.9), respectively (p<0.001), over a median follow-up of 2.7 years for Palestinians and 8.1 years for non-Palestinians (p<0.001). With regard to HIV testing, 7.3% (72/989) of individuals tested in 2002 and 10.9% (202/1851) in 2007 were Palestinians. The most frequent reason for being tested among Palestinians was 'medical' (e.g., before in vitro fertilization, 69.4% in 2007); among non-Palestinians it was 'intimate relationships' (31% in 2007). CONCLUSION: These results show that despite an overall small number of Palestinian HIV/AIDS patients, late diagnosis and high mortality are very much in evidence.

Pulmonary tuberculosis in the West Bank, Palestinian Authority: molecular diagnostic approach.

OBJECTIVE: To compare the effectiveness and feasibility of an insertion sequence (IS6110)-based polymerase chain reaction (PCR) assay with conventional methods of detecting Mycobacterium tuberculosis and to analyse mutations present in the hot spot region of the RNA polymerase B subunit (rpoB) gene associated with rifampin resistance by DNA sequencing. METHODS: Ninety-five sputum samples from 84 clinically suspected cases of tuberculosis were tested for mycobacterial infections by Ziehl Neelsen smear examination, Lowenstein-Jensen culture and IS6110-based PCR assay. RESULTS: Sensitivity and specificity of the PCR were 94%; the sensitivity of culture was 65%, and of smear tests, 59%. Both smear microscopy and culture had 100% specificity. DNA sequencing data of the 305-bp fragment of the rpoB gene for nine clinical isolates revealed one point mutation at position I572F and double mutations at position S531F in two isolates obtained from two patients who did not respond to the anti-tuberculosis therapy. CONCLUSION: IS6110-based PCR can be used routinely in clinical laboratories for rapid detection of Mycobacterium tuberculosis and thus allow early diagnosis and treatment of any contacts by the cheapest method currently available in the Palestinian Authority region. Rapid detection of rifampin resistance isolates will enable efficient treatment of patients and assist in eradication of the disease in the Palestinian territories.

Detection of Trichomonas vaginalis in Vaginal Swab Clinical Samples from Palestinian Women by Culture.

Background. Trichomoniasis is a common sexually transmitted disease caused by Trichomonas vaginalis. It is a major health problem worldwide. The World Health Organization (WHO) has estimated that 180 million infections are acquired annually worldwide. Methodology. Vaginal swabs (1207) were cultured for T. vaginalis on Trichomonas Medium no. 2 (Oxoid) soon after specimen collection. The cultures were examined daily using a light microscope to detect the presence of T. vaginalis. Results. The prevalence of T. vaginalis was 13.6% (164/1207). The infection rate was the highest during pregnancy, 28.1%, and the lowest among women whose spouses use condoms, 8.6%. Conclusions. The culture method was used in this study to accurately determine the prevalence of this parasite in the West Bank, Palestine. The results of the study will eliminate ambiguities concerning trichomoniasis in this country and will contribute to better management and proper treatment.

Brucellosis in the West Bank, Palestine.

OBJECTIVE: To identify the risk factors for brucellosis in Palestine, to estimate their association with the disease and to recommend appropriate prevention measures. METHODS: An unmatched case-control study was conducted in the West Bank of Palestine. A total of 450 subjects (150 cases and 300 controls) chosen from all districts were investigated. Data were collected during the year 2000. Subjects were interviewed using a standard questionnaire acquiring demographic and risk factor information. Laboratory results were also recorded on the questionnaire. Data were analyzed calculating the odds ratio and the confidence intervals for the studied variables. A logistic regression model was used to explore the association between disease status and the studied variables. RESULTS: Several variables were significantly associated with brucellosis involving both direct and indirect transmission such as consumption of unpasteurized milk and dairy products, herding, lambing and others. CONCLUSION: Most of the risk factors for being infected with brucellosis are modifiable. Efforts should be directed to the prevention of this major public health problem in Palestine utilizing the information obtained in this study.

Microbiological quality of food samples from restaurants and sweet shops in developing countries: a case study from the Occupied Palestinian Territory.

The aim of this paper is to review the microbiological quality of food samples taken from a wide range of cooked and raw foods obtained from restaurants and sweet shops in the Ramallah and al-Bireh district, and to identify the gaps in food inspection and handling that can be realistically improved. Utilizing food sample test results of the Palestinian Ministry of Health, records pertaining to the years 1995, 1996, 2000, 2002, and the first 2 months of the year 2003 reveal that only 60.9%, 44.0%, 63.8%, 93.6%, 51.8%, 83.8%, and 50.4% of the food samples tested for total aerobic count, total Coliform, faecal Coliform, Staphylococcus aureus, faecal Streptococci, moulds, and yeasts respectively are within the limits of the Palestinian and International standards. None of the tested samples for Salmonellae or Clostridium perfringes were positive. Analysis of the data indicates an irregular rather than systematic process to testing. For example, 60.4% of the tested food samples in 2000 came from sweet shops, while the relative percentage of sweet shops is 21.4% out of the total restaurants and sweet shop figures in the area at the time. In contrast to what would be expected, most of the samples were collected during the cold season, raising questions as to the suitability of testing procedures and guidelines. Systemic and procedural gaps were identified by the analysis that can be addressed to at least contain, if not completely eliminate the presence of foods in the market that are unacceptable for consumption.