Varied utilisation of health provision by Arab and Jewish residents in Israel.

INTRODUCTION: Provision of healthcare is considered a basic human right. Delivery and uptake is affected by many complex factors. Routine vaccinations are provided free of charge in Israel to all residents. The Palestinian Israeli Collaborative Research (PICR) group conducted research on vaccine impact at eight primary care facilities in east Jerusalem (EJ) and central Israel (IL) which allowed assessment and comparison of interactions of these Arab and Jewish populations, respectively, with healthcare services. METHODS: Families attending clinic with a child under five years old were invited to participate. Utilisation of healthcare was assessed using data from standardise questionnaires completed after enrolment, using proxies of vaccination status, antibiotic use, primary care physician and hospital visits as well as demographics such as household size. Differences between EJ and IL were assessed using chi squared tests; univariate analyses identified potential confounders which were tested in a multiple logistic regression model for any independent associations between region and outcome. RESULTS: Children in EJ were significantly more likely to live in larger households, with tobacco smokers, to have been breastfed, hospitalised and used antibiotics recently than those in IL, who were significantly more likely to have recently seen a primary care physician (all p < 0.01). Receipt of routine vaccinations, given at well baby clinics, was similar between the regions at above 95% (p = 0.11), except for influenza which was delivered separately at primary physician clinics to 5% (EJ) and 12% (IL). Receipt of pneumococcal vaccine when paid for separately was significantly higher in IL than EJ (3% vs 31%). Multivariate analysis identified the most important independent predictors of these differences as region, age and household size. CONCLUSIONS: Healthcare in Israel is of a very high standard, but it is not uniformly utilised within the community in all geographical areas, though in some key areas, such as uptake of most routine childhood vaccination, equality seems to be achieved. To ensure excellent healthcare is achieved across the population, inequalities must be addressed, for instance in health promotion and other activities, which could improve and normalise health outcomes.

Reduction in antibiotic use following a cluster randomized controlled multifaceted intervention: the Israeli judicious antibiotic prescription study.

BACKGROUND: Antibiotic overuse is of great public health concern. This study assessed whether intervention among physicians and their treated population could achieve a sustained reduction in antibiotic use, specifically in classes known to promote antibiotic resistance among children in a community setting. METHODS: We performed a cluster randomized controlled multifaceted trial among 52 primary care pediatricians and the 88,000 children registered in their practices. The intervention was led by local leaders and engaged the participating physicians. It included physician focus group meetings, workshops, seminars, and practice campaigns. These activities focused on self-developed guidelines, improving parent and physician knowledge, diagnostic skills, and parent-physician communication skills that promoted awareness of antibiotic resistance. The main outcome measure was the change in annual antibiotic prescription rates (APRs) of children treated by the intervention group physicians as compared with rates among those treated by control group physicians. The study comprised a 2-year pre-intervention period, a 3-year intervention period, and a 1-year follow-up period. Mixed-effect models were used to assess risk ratios to account for the clustered study design. RESULTS: A decrease in the total APR among children treated by the intervention physicians compared with those treated by the control physicians was observed in the first intervention year (APR decrease among control physicians, 40%; APR decrease among intervention physicians, 22%; relative risk [RR], .76; 95% confidence interval [CI], .75-.78). This reduction crossed over all antibiotic classes but was most prominent for macrolides (macrolide prescription rate among control physicians, 58%; macrolide prescription rate among intervention physicians, 27%; RR, .58; 95% CI, .55-.62). The effect was sustained during the 4 following years. CONCLUSIONS. Multifaceted intervention that engages the physicians in an educational process is effective in reducing APRs and can be sustained. CLINICAL TRIALS REGISTRATION: NCT01187758.

Changing parents' opinions regarding antibiotic use in primary care.

Parents' wish for antibiotics is a significant determinant of antibiotic prescription for their children. The objective of the study was to assess the effect of an educational intervention on parents' attitudes towards antibiotic use. Parents accompanying their children to primary pediatric clinics of Jerusalem-Hashfela District of Maccabi Healthcare Services responded to a survey regarding their wish for antibiotic treatment. Two groups of parents were surveyed: A (control) in a pre-intervention period and B (intervention) during the intervention period. The intervention included posters, pamphlets, and drawing booklets for children in the waiting rooms. A per-protocol analysis that included from group B only parents that stated they noticed the educational material (B1) was also performed. Eight hundred and sixty-eight parents were surveyed during the pre-intervention period and 688 parents during the intervention period. Children's median age was 4 years (8 days-16 years). Most (86%) of the parents were mothers. Groups were similar in socio-demographic characteristics and children's medical complaints. Factors associated with parent's low expectation for antibiotics were a general negative attitude to antibiotics (OR 1.66, 95% CI 1.20-2.30), current upper respiratory tract symptoms (OR 0.29, 95% CI 0.21-0.39), advanced knowledge regarding antibiotics (OR 1.72, 95% CI 1.26-2.34), and being in group B (intervention) (OR 1.47, 95% CI 1.08-2.00). The effect of the intervention was greater in the per-protocol analysis (OR 1.75, 95% CI 1.20-2.55). A simple educational intervention was effective in reducing parents' expectation for antibiotics but was significantly more effective when parents reported they noticed the campaign. Improving parents' knowledge regarding antibiotics can reduce parents' wish for antibiotic treatment.

The impact of PCV7/13 on the distribution of carried pneumococcal serotypes and on pilus prevalence; 14 years of repeated cross-sectional surveillance.

BACKGROUND: S. pneumoniae carriage by children is a major source of pneumococcal transmission, and the initial step prior to infection. Pilus type 1, reported in ~30% of pneumococcal strains in the pre-vaccine era, contributes to pneumococcal colonization and virulence. In this study, we report the impact of the pneumococcal conjugate vaccine (PCV), PCV7/PCV13 sequential implementation on serotype distribution, and on the prevalence of piliated strains among carried pneumococci during the pre- and post-vaccine eras. METHODS: During 2002-2016, 12 repeated cross-sectional surveillances of nasopharyngeal S. pneumoniae carriage were conducted among 8,473 children <5.5 years old visiting primary care physicians in Central Israel. Seven biannual surveillances in the pre-PCV period, 2 surveillances after PCV7 was licensed but before implementation in the National Immunization Plan, and 3 additional surveillances in the post-PCV period. S. pneumoniae serotype distribution and prevalence of piliated strains were assessed. RESULTS: Carriage of S. pneumoniae was relatively stable (45.4%). The prevalence of serotypes included in PCV13 was 65.7%, in the pre-vaccine period and the pilus was present in 26.4% of isolates. The distribution of serotypes and the pilus prevalence in the pre-PCV period was relatively stable except for a decrease in prevalence of piliated 19F, observed following the first study year. Following PCV7/PCV13 implementation, vaccine type 13 (VT13) strains were nearly eliminated to 3.3% by 2016. Piliated strains, which were primarily of VT13 serotypes, initially followed a similar trend and were nearly eliminated by 2014 (1.7%). Yet, two years later, pilus prevalence re-emerged among non-VT strains to 12.8% of all pneumococci. CONCLUSIONS: Following PCV implementation, a dramatic and rapid decrease in VT strains prevalence was observed with a concomitant increase in non-VT strains. Piliated strains were nearly eliminated, yet re-emerged 7 years following PCV7/PCV13 implementation in various non-VT strains. This suggests that the pilus confers an advantage in colonization.

Long-term assessment of pulmonary function tests in pediatric survivors of acute respiratory distress syndrome.

BACKGROUND: The aim of the study was to evaluate long-term pulmonary function tests in pediatric survivors of acute respiratory distress syndrome (ARDS). MATERIAL/METHODS: Observational study based on a telephone poll of retrospectively identified post ARDS children who were hospitalized in a pediatric intensive care unit (PICU) in a general 1200-bed teaching, tertiary, regional referral center for children. RESULTS: Follow-up pulmonary function tests were achieved in only 7 children, with a mean age of 7.3+/-4.3 years (range 3-12) and following 5.6+/-4.3 years after PICU discharge. The etiology for ARDS included: lymphoma (n=2), pneumonia (n=2), aspiration (n=1), petrol ingestion (n=1) and snake envenomation (n=1). The children had been ventilated for 9.4+/-7.3 days and their worst PaO2/FiO2 ratio was 65.1+/-17.0 mm Hg. The follow-up pulmonary functions in all the children was within normal limits except for one child who had mildly reduced DLCO and one who had mild exercise-induced hypoxemia (oxyhemoglobin saturation of 94%). Neither of the two nor the others showed subjective symptoms or clinical physical limitations. CONCLUSIONS: Children who survive ARDS apparently enjoy long-term normal pulmonary function. Some, however, may present subclinical dysfunction that persists for many years after the acute episode and evoked only by sophisticated lung tests.