Preconceptional diet quality is associated with birth outcomes among low socioeconomic status minority women in a high-income country.

PURPOSE: Studies of the association between maternal nutrition and birth outcomes have investigated differing nutrients, maternal socioeconomic conditions, and timing within the reproductive cycle; and have produced inconsistent results. We evaluated the association of preconceptional maternal dietary intake with birth outcomes among low socioeconomic status ethnic minority women in a high-income country. METHODS: In this prospective cohort study, habitual preconceptional dietary intake was assessed among pregnant Bedouin Arab women in Israel (n = 384), using a short culturally specific, targeted food frequency questionnaire. Multiple nutrients (protein, lysine, calcium, iron, zinc, folate, omega-3 fatty acids) were evaluated simultaneously via a diet quality score derived from principal component analysis. Multivariable logistic regression was used to test associations between the diet quality score and a composite adverse birth outcomes variable, including preterm birth, low birth weight and small for gestational age. RESULTS: Sixty-nine women (18%) had adverse birth outcomes. Women with low preconceptional diet quality scores had low intakes of nutrient-rich plant foods, bioavailable micronutrients, and complete proteins. In multivariable analysis, a woman at the 10th percentile of the diet quality score had a 2.97 higher odds (95% CI 1.28-6.86) of an adverse birth outcome than a woman at the 90th percentile. CONCLUSION: Low diet quality during the preconceptional period was associated with adverse birth outcomes among low socioeconomic status minority women in a high-income country. The results have implications for the development of appropriate intervention strategies to prevent adverse birth outcomes, and the promotion of adequate nutrition throughout the child-bearing years.

Sex effect on growth faltering in an indigenous ethnic minority population of infants in Israel.

OBJECTIVE: We examined sex effects on growth faltering in an indigenous population of Bedouin Arab infants born in Israel, an economically developed country. DESIGN: Retrospective cohort study. Height-for-age Z-score (HAZ) at age 6, 12, 18 and 24 months was calculated for full-term, normal-birth-weight Bedouin infants born during years 2000-2009 and attending maternal and child health (MCH) clinics. Multivariate linear regression analysis (MLRA) was used to calculate the association between sex and HAZ, controlling for year of birth, birth weight (BW) and residence by type of settlement (established settlement (ES); non-established settlement (NES)). SETTING: Bedouin are an indigenous poor community of semi-nomadic Arabs, with the highest infant mortality rate in Israel. Fifty per cent of Bedouin infants live in NES with inadequate access to running water, electricity, and rubbish and sewage disposal. All Bedouin receive free well-baby care in community-based MCH clinics. PARTICIPANTS: Full-term, normal Bedouin infants (n 5426) born during 2000-2009 and attending computerized MCH clinics who had growth measurements at age 6, 12, 18 and 24 months. RESULTS: At all ages, girls had significantly higher mean HAZ than boys (P < 0·05). Increasing birth year, residence in ES and increasing BW were positively associated with HAZ (P < 0·05) at all ages. In MLRA controlling for birth year, BW and type of settlement, sex still had a significant effect, with lower HAZ among boys at 6, 12, 18 and 24 months of age (P < 0·001 at all ages). CONCLUSIONS: Our results indicated that sex effects on growth faltering can occur in an indigenous population with low socio-economic status within an economically developed country.

Maternal and child health in Israel: building lives.

Israel is home to a child-oriented society that values strong family ties, universal child benefits, and free education for all children from 3 years of age to school grade 12. Alongside the universal health-care services that are guaranteed by the National Health Insurance Law and strong, community-based primary and preventive care services, these values have resulted in good maternal and child health. In 2015, infant and maternal mortality (3·1 deaths per 1000 livebirths and 2·0 deaths per 100 000 livebirths, respectively) were lower than the mean infant and maternal mortality of countries within the Organisation for Economic Co-operation and Development. Israel has already exceeded the developed regions' Sustainable Development Goal 2030 targets for maternal mortality, neonatal mortality, and mortality in children younger than 5 years in all population groups. Yet these accomplishments are marred by Israel's high prevalence of child poverty (more than 30%), particularly among Arabs (63%) and ultra-Orthodox Jews (67%). Although infant mortality has improved in all subpopulations since Israel was founded in 1948, infant mortality among Arabs is still more than twice as high as among Jews. To address these disparities in health, the Israeli Ministry of Health has created a special division and has funded an intervention programme to reduce the infant mortality among Bedouin Arabs. Other interventions include targeted and culturally appropriate health-care programmes and services for communities with a high number of at-risk children and young adults, dental health service for all children up to 15 years, and improved collaboration between health, education, and welfare services. The challenges faced by the Israeli health-care system include a growing trend towards medicalisation of prenatal care, ensuring staff are trained to treat developmental, behavioural, and psychosocial issues in children and their families, securing sustainable funding for health promotion and injury prevention programmes, expanding and improving the coordination of services for children with special needs or who are at risk, and programme assessment. Ensuring adequate funding for dedicated, preventive paediatric care and taking action on a nationwide scale to reduce child poverty are essential for maintaining health gains in children. In this Series paper, we describe the health indices, highlight disparities, and discuss the challenges in delivering and maintaining maternal and child health care in Israel.

Understanding utilization of outpatient clinics for children with special health care needs in southern Israel.

To understand the pattern of utilization of ambulatory care by parents of children with special health care needs (CSHCN) and to explore parental challenges in coping with health maintenance of their infants after discharge from a neonatal intensive care unit (NICU). CSHCN require frequent utilization of outpatient ambulatory clinics especially in their first years of life. Multiple barriers are faced by families in disadvantaged populations which might affect adherence to medical referrals. Our study attempts to go beyond quantitative assessment of adherence rates, and capture the influence of parental agency as a critical factor ensuring optimal utilization of healthcare for CSHCN. A prospective, mixed-methods, cohort study followed 158 Jewish and Bedouin-Arab infants in the first year post discharge from NICU in southern Israel. Rates of utilization of ambulatory clinics were obtained from medical records, and quantitative assessment of factors affecting it was based on structured interviews with parents at baseline. Qualitative analysis was based on home visits or telephone in-depth interviews conducted about 1 year post-discharge, to obtain a rich, multilayered, experiential perspectives and explained perceptions by parents. Adherence to post-discharge referrals was generally good, but environmental, cultural, and financial obstacles to healthcare, magnified by communication barriers, forced parents with limited resources to make difficult choices affecting utilization of healthcare services. Improving concordance between primary caregivers and health care providers is crucial, and further development of supportive healthcare for CSHCN in concordance with parental limitations and preferences is needed.

Impact of multiple micronutrient supplementation ("sprinkles") on iron deficiency anemia in Bedouin Arab and Jewish infants.

BACKGROUND: A high prevalence of iron deficiency anemia persists in Bedouin Arab and Jewish pediatric populations in southern Israel. OBJECTIVES: To compare the effect of daily use of the micronutrient supplementation (MMS), "Sprinkles," a powdered formulation of iron, vitamins A and C, folic acid and zinc, with liquid iron and vitamins A and D on iron deficiency at 12 months of age. METHODS: The 621 eligible Bedouin and Jewish infants in the study were assigned to the MMS and control arms and received supplementations from age 6 to 12 months. We examined the change in hemoglobin, hematocrit, mean cell volume, red blood cell distribution, serum ferritin and transferrin saturation. In addition, we used the high Iron Deficiency Index (IDI) if two or more of the above six parameters showed abnormal levels. RESULTS: Rates of anemia decreased significantly over the 6 month period, from 58.8% to 40.6% among Bedouin infants (P = 0.037) and from 40.6 to 15.8% among Jewish infants (P = 0.017). In Bedouin infants the prevalence of high IDI decreased significantly from 79.2% to 67.4% (P = 0.010) in the MMS group, but there was no change in the controls. Among Jewish infants, the high IDI prevalence decreased from 67% to 55.6% with no statistically significant difference in the two study arms. In the multivariate analysis in Bedouin infants MMS use was associated with a reduced risk of 67% in high IDI at age 12 months as compared to controls (P = 0.001). Fewer side effects in the intervention groups in both ethnic populations were reported. CONCLUSIONS: MMS fortification of home food can be recommended as an effective and safe method for preventing iron deficiency anemia at 12 months of age.

Human brucellosis outbreak acquired through camel milk ingestion in southern Israel.

BACKGROUND: Human brucellosis is common in southern Israel among the semi-nomadic Bedouin, a population that consumes unpasteurized dairy products. Though camel milk ingestion is a known mechanism for brucellosis acquisition, only a few reports of sporadic cases have been published in the medical literature. OBJECTIVES: To describe a local brucellosis outbreak in 15 extended Bedouin family members, following ingestion of infected camel milk. METHODS: Data regarding patient's clinical manifestations, laboratory findings, treatment and outcome were collected from the hospital and the health fund clinics' computerized database. Camel's blood and milk were tested for Brucella serology and culture. Cases were defined by positive Rose Bengal test, symptoms correlating with brucellosis, and consumption of infected camel milk. RESULTS: Fifteen patients were diagnosed with acute brucellosis from March to June 2011. Sixty percent of cases had serum agglutination test titers of 1:160 or higher and 4/8 (50%) had positive blood culture for Brucella melitensis. Arthralgia and fever were the most consistent clinical manifestations. Blood and milk serology and milk culture taken from the female camel were positive for Brucella melitensis. CONCLUSIONS: The treating physicians must consider the possibility of infected camel milk ingestion as the mode of infection, both in sporadic cases and in outbreaks of brucellosis.

Rapid assessment tools for ranking pregnant minority women into multi-nutrient exposure groups.

OBJECTIVE: To develop a targeted FFQ (TFFQ) and evaluate its effectiveness for ranking minority women by their intake of multiple nutrients important to a healthy pregnancy. DESIGN: In Stage 1, food groups derived from 24 h recall dietary data were entered into a stepwise multiple regression model to identify 'discriminating' foods for the TFFQ; in Stage 2, the TFFQ and a 24 h recall were administered to pregnant women. The TFFQ data were used to create a Habitual Multi-Nutrient Intake Scale (H-MNIS) for ranking the women. The effectiveness of the ranking was tested against women's reported nutrient intakes on the 24 h recall. SETTING: Southern Israel. SUBJECTS: In Stage 1, 519 Bedouin Arab adults; in Stage 2, 404 pregnant Bedouin women. RESULTS: Of the ninety-three food groups included in the regression analysis, twenty-eight explained >80 % of the between-person variability in the intake of the target nutrients. Whole-wheat bread was a main discriminator for protein, Fe, Zn, Ca and folate. Fish, poultry and canned tuna explained ≥88 % of the between-person variation in DHA and EPA intakes. The mean daily intakes of pregnant Bedouin women from the 24 h recall data differed significantly across H-MNIS quartiles (P < 0·01) for all but three target nutrients (folate, EPA, DHA); and the P for trend was significant (P < 0·02) for all but EPA. CONCLUSIONS: The TFFQ and H-MNIS represent rapid assessment tools for studying maternal nutrition on a multi-nutrient basis, and effectively ranked pregnant Bedouin women into exposure groups by their intake of the target nutrients.

Efficacy of multiple micronutrient supplementations on child health: study design and baseline characteristics.

BACKGROUND: The rates of anemia in children in southern Israel are high despite the current prevention strategy. A daily dose of "Sprinkles" (SuppleForte, Heinz, Canada), a micronutrient home supplementation, was proven effective for the treatment of anemia worldwide. OBJECTIVES: To assess the efficacy of Sprinkles, a novel supplementation formulation, in the primary prevention of anemia in infants who have free access to health care services. METHODS: A two-arm open-labeled cluster randomized controlled clinical trial was performed in 6 month old Bedouin and Jewish infants. The Sprinkles arm received sachets with iron, vitamins A and C, folic acid and zinc, and the control arm received standard treatment (liquid iron and vitamins A and D). The infants were from families attending Mother and Child Health clinics during 2005-2007. Intervention and follow-up were conducted for babies aged 6-12 months. Health outcomes (hematologic and nutritional indicators, growth parameters, morbidity rates) were evaluated at 12 and 18 months. RESULTS: The final study population numbered 621 infants (328 Bedouin and 293 Jewish); of the parents approached 88.5% agreed to participate. Hemoglobin > 11 g/dl was found in 55% of Bedouin and 40% of Jewish infants (P < 0.01). Bedouin infants had significantly lower serum concentration of iron, folic acid and zinc. All background, hematologic and micronutrient indicators were similar in the two study arms except for a slightly but not clinically significant difference in hemoglobin and hematocrit levels in Bedouins. CONCLUSIONS: Our findings indicate the need to improve the micronutrient status of infants living in the Negev. A cluster randomized trial in MCH clinics is a feasible option.

The effect of universal toddlers-only hepatitis A virus vaccination program on seropositivity rate in unvaccinated toddlers: evidence for reduced virus circulation in the community.

BACKGROUND: In July 1999, a national toddler-only hepatitis A virus (HAV) vaccination program was introduced in Israel. Passive and active surveillance showed a large reduction in disease rate, but an objective measurement was needed. We hypothesized that toddler's vaccination in a population living in an endemic area would reduce virus circulation, resulting in reduced HAV seropositivity rates in unvaccinated toddlers. METHODS: The study was conducted among Bedouin children in southern Israel, for whom HAV vaccine coverage reached 85.5% and 74.9% for first and second HAV vaccine doses, respectively, in 2000. Toddlers received 2 doses of HAV vaccine at 18 and 24 months. Data on vaccine coverage was received from well-baby clinics. Sera were obtained from healthy unvaccinated 16- to 20-month-old toddlers. Anti-HAV immunoglobulin (Ig)G concentrations were tested by enzyme-linked immunosorbent assay. RESULTS: A total of 629 sera were tested (209 obtained in 1991-2000 and 420 obtained in 2001-2002). Seropositivity rates of > or =100 mIU/mL ranged from 16.2% to 19.6% in 1991 through 2000 (children born before immunization program). These rates dropped to 2% in 2001-2002 and to 0% in 2003 through 2007. Furthermore, IgG concentrations were significantly lower (P < 0.001) in samples taken in 2000, only a few months after beginning of vaccination, than in those taken before initiation of the HAV immunization program (1991-1998), suggesting a marked reduction in circulating HAV resulting in natural boosting. CONCLUSIONS: Because HAV vaccines are licensed in children > or =12 months old, rates of anti-HAV seropositivity in unvaccinated toddlers can be an objective and sensitive tool to evaluate the effect of immunization program on virus circulation. This method is of special value in communities where no appropriate surveillance is in place.

Life prevalence of upper respiratory tract diseases and asthma among children residing in rural area near a regional industrial park: cross-sectional study.

INTRODUCTION: The study described was initiated by the Israel Ministry of Health as an effort to respond to and deal with public concern about possible health disorders related to odorous emissions (composed of a great many of organic and inorganic chemicals) from the regional industrial park (IP) in the Negev, southern Israel. Previous ecological studies found that adverse health effects in the Negev Bedouin population were associated with residential proximity to the IP. The objective of the current study was to investigate a hypothesis concerning the link between the IP proximity and life prevalence (LP) of upper respiratory tract chronic diseases (URTCD) and asthma in children aged 0-14 years living in rural Negev, Israel, in small agricultural communities. METHODS: The cross-sectional study was conducted in 7 localities simultaneously during 2002. The following indirect exposure indicators were used: (1) distance (less than 20 km/ more than 20 km) from the IP ('distance'); (2) presence (yes/no) of the dominant wind direction being from the IP toward a child's locality ('wind direction'); and (3) the child's mother having made odour complaints (yes/no) related to the IP ('odour complaints'). A 20 km cut-off point was used for 'distance' dichotomization as derived from the maximum range of 'odour complaints'. This gave 3 proximal and 4 distant localities, and division of these by the 'wind direction' gave one versus two localities. The study population consisted of 550 children born in the localities. Medical diagnoses were collected from local clinic records. The following were included in the interviewer-administered questionnaire for a child's parents: (1) demography (the child's birth date, gender, mother being married or not, parental origin and education, number of siblings); (2) the child's birth history (pregnancy and delivery) and breast-feeding duration; (3) the child's parental respiratory health; and (4) environmental factors (parental smoking and occupational hazardous exposure, domestic use of pesticides, domestic animals, outdoor odour related to the IP emissions). For statistical analysis, Pearson's chi(2), t-tests and multivariate logistic regressions were used, as well as adjusted odds ratios (OR) within a 95% confidence interval. RESULTS: The multivariate analysis showed that increased LP of URTCD in children of proximal localities was statistically significant when associated with odour complaints (OR = 3.76 [1.16, 12.23]). In proximal localities, LP of URTCD was higher (at borderline level statistical insignificance p = 0.06) than in distant localities (OR = 2.31 [0.96, 5.55]). The following factors were found to be related to the excess of the LP of URTCD: (1) father's lower education (by distance: OR = 2.62 [1.23, 5.57]; by wind direction: OR = 4.07 [1.65, 10.03]); (2) in-vitro fertilization (by distance: OR = 3.03 [1.17, 7.87]; by wind direction: OR = 4.34 [1.48, 12.72]). In proximal localities, the increase in asthma LP was associated with: (1) wind direction (OR = 1.95 [1.01, 3.76]); (2) a child's male gender (OR = 2.95 [1.48, 5.87]); and (3) a child's mother's having had an acute infectious disease during pregnancy (OR = 4.84 [1.33, 17.63]). CONCLUSIONS: An increased LP of chronic respiratory morbidity among children living in small agricultural localities in the Negev was found to be associated with indirect measurements of exposure (distance, wind direction and odour complaints) to IP emissions. These results, in conjunction with previously reported findings in the Negev Bedouin population, indicate a need for environmental protection measures, and monitoring of air pollution and the health of the rural population.

Two-dose measles immunization as a strategy to eliminate measles in the Middle East and Israel.

The data presented above show that most countries of the Middle East (Israel and countries of the Eastern Mediterranean Region of the WHO) are progressing towards achieving WHO goals for improving immunization coverage for measles immunization to over 90%, along with the introduction of a two-dose immunization strategy. There has been corresponding progress in the reduction of incidence of measles. However, the goal of the WHO to eliminate measles has not been achieved and is unlikely to be in the near future.

[Routine immunizations as a tool to reduce inequalities in health].

The effectiveness and safety of immunization against the varicella-zoster virus (vzv) has been established after decades of use in the Far East and the U.S. It has been licensed in Israel since 1999. Nevertheless, it has not yet been included in the routine immunizations provided free through Maternal and Child Health ("Tipat Halav") clinics. This is one of the causes of increasing inequalities in health since immunization against vzv is only available via a large co-payment. The Ministry of Health has decided to include immunization against vzv in its routine immunization program for children born in 2007. This is an important step towards implementing the goals of the Ministry of Health's program "Healthy Israel 2020". The Tipat Halav clinics provide universal and equitable community-based services to the whole population, regardless of socio-economic status. This system needs to be strengthened in order to further reduce inequalities in health in Israel.

Elimination of hepatitis a infection outbreaks in day care and school settings in southern Israel after introduction of the national universal toddler hepatitis a immunization program.

BACKGROUND: In 1999, Israel became the first country to begin universal toddler immunization against hepatitis A infection with a 2-dose schedule at 18 and 24 months. The effect of the Israeli program on outbreaks of Hepatitis A in day care and school settings was studied. METHODS: The records of all hepatitis A illness outbreaks in day care and school settings reported to the Ministry of Health in Southern Israel during 1993 through 2005 were reviewed. The number of exposed contacts for whom postexposure prophylaxis was administered was retrieved from records of epidemiologic investigations. Rates of immunization coverage were extracted from records of Maternal and Child Health Clinics. RESULTS: Three hundred nineteen cases of hepatitis A illness during the years 1993 through 2005 were associated with 113 outbreaks in day care and school settings of which 92% occurred before the institution of universal toddler immunization. Since 2000, no hepatitis A infection outbreaks have been reported in any day care and school settings in the region. An average of 732 children received immunoglobulin prophylaxis yearly because of exposure to an outbreak in an educational setting during the preimmunization period, 106 in 2000 and zero in the 5 years since 2001. The data showed marked herd immunity since school-aged children born before 1999 were not immunized, but elimination of outbreaks occurred equally in that age group. Immunization coverage was 86.4% for one dose of hepatitis A vaccine by age 3 years and 77.3% for 2 doses among the birth cohort of 2000. CONCLUSIONS: Universal hepatitis A immunization of toddlers was associated with disappearance of outbreaks in educational settings. This included cohorts of nonimmunized children representing marked herd immunity.

Major congenital malformations and residential proximity to a regional industrial park including a national toxic waste site: an ecological study.

BACKGROUND: Public concern about exposure to emissions from the regional industrial park (IP), including 17 chemical plants and the national industrial toxic waste site, initiated this study of the possible association between major congenital malformations (MCM) and residence near the IP in Israel's Southern District. METHODS: The study was conducted during the period 1995-2000 and included 63,850 deliveries. Data on deliveries and MCM detected at births were obtained from the regional medical center, and stratified by ethnicity and type of locality. As exposure indicator we used distance categories (proximal and distant) and predominant wind direction from the IP. Distance stratification was based on the geographical distribution of the localities and complaints about the odor related to IP emissions. Based on these complaints, localities up to 20 km from the IP were considered proximal to the IP. RESULTS: Average rates of MCM were 5.0% and 4.1% for Bedouin and Jewish newborns, respectively. The rate of MCM for Bedouin from proximal localities was significantly greater compared with distant localities (5.6% vs. 4.8%; RR = 1.17 with 95% CI: 1.04-1.29). In the proximal Bedouin permanent localities, the MCM rate reached 8.2 %, which was significantly higher than in distant areas (RR = 1.63, 95% CI: 1.39-1.80). Significant risk increase of central nervous system MCM was found in these localities, compared to distant ones (RR = 2.27, 95% CI: 1.44-3.60). Among newborns from the traditional tribal settlements, proximity to the IP was associated with increased rates of the following MCM: 1) all combined, 2) those associated with chromosomal abnormalities, and 3) those defined as "others unclassified MCM." Comparison of autosomal recessive disease rates by proximity to the IP in Bedouin newborns indicates that the observed increased risk of MCM is not explained by consanguineous marriages. The rates of MCM in the Jewish population were similar among "exposed" and "unexposed" inhabitants. CONCLUSION: Residential proximity to the IP is associated with increased rates of MCM among Arab-Beduin but not in Jewish populations. These observations indicate the need for public health protection of a vulnerable society in transition, although the relative importance of chemical exposure and health care utilization requires further study.

Risk of transmission of leptospirosis from infected cattle to dairy workers in southern Israel.

BACKGROUND: Leptospirosis is a zoonotic disease that occurs worldwide, found predominantly in agricultural workers, port workers and dairy workers. OBJECTIVE: To investigate the risk of disease transmission to dairy workers following an outbreak in 1999 of Leptospirosis hardjo in the dairy herds of two kibbutzim in southern Israel. METHODS: A seroepidemiologic survey of all the dairy workers from these two kibbutzim was conducted, including individual interview and examination. Data were collected on the presence of clinical symptoms of leptospirosis during the previous month. One month later the medical personnel on the two kibbutzim were contacted in order to determine if any worker had subsequently developed clinical signs or symptoms of leptospirosis. All dairy workers had blood drawn for serology. Those workers whose initial serology had been borderline for leptospirosis had a repeated serology test between 2 and 4 weeks later. Doxycycline was given prophylactically to all dairy workers on one kibbutz only. RESULTS: Either with or without chemoprophylaxis, no dairy workers exposed to herds infected with Leptospira hardjo showed evidence of seroconversion or disease. This indicated a low risk of transmission of this serovar from cows to dairy workers. CONCLUSION: Since human illness with leptospirae can cause illness associated with significant morbidity, we recommend that physicians make an informed decision regarding doxycycline prophylaxsis for dairy workers exposed to cattle herds infected with Leptospira hardjo.

Bedouin-Arab women's access to antenatal care at the interface of physical and structural barriers: A pilot study.

Since 2000, the Israeli Public Health Services have established eight Maternal-and-Child-Health (MCH) stations in unrecognised Bedouin-Arab villages in South Israel in order to reduce barriers to healthcare. The goals of this pilot study were: (1) to explore the new MCH stations' impact on antenatal care (ANC) accessibility; and (2) to compare access to ANC between women from villages with MCH stations and women from villages without MCH stations. The study combined quantitative and qualitative methods including structured interviews with 174 MCH service users, review of 158 ANC records and 16 in-depth interviews with Bedouin-Arab women. The establishment of MCH stations in unrecognised villages has improved physical access to ANC and secondarily diminished other barriers related to financial and sociocultural dimensions of women's access to healthcare, thus enhancing women's options for independent healthcare-seeking; yet, limited opening hours, staff shortages and communication problems hamper ANC delivery at the new MCH stations. This pilot study indicates that the MCH stations' establishment in unrecognised villages was a successful intervention, which improved women's access to ANC. Even though current service delivery challenges need to be overcome to achieve the intervention's full potential, its replication should be considered in further villages.

Knowledge, Attitudes, and Practice among Women and Doctors Concerning the Use of Folic Acid.

Background and Objective. Daily folic acid intake, prior to conception and in early pregnancy, significantly reduces neural tube defects (NTDs). We compared folic acid consumption among Jewish and Bedouin women and the recommendations of family physicians and gynecologists. Methods. We compared 64 Muslim Bedouin women and 65 Jewish women. We also compared 39 gynecologists and 60 family physicians. Results. Fifty-one Jewish women (78.5%) took folic acid during pregnancy, but only seven (10.8%) before conception. Sixty Bedouin women (93.75%) took folic acid during pregnancy, but only four (6.25%) before conception (P < .05). Five Jewish women (7.7%) and two Bedouin women (3.1%) took folic acid three months before conception. Thirty-three gynecologists (87%) recommend preconception folic acid compared with thirty-six family physicians (60%) (P < .05). Conclusions. The majority of women use folic acid during pregnancy, but only few do so to prevent NTDs. There is a significant difference between doctors' recommendations and actual practice.

Adherence with oseltamivir chemoprophylaxis among workers exposed to poultry during avian influenza outbreaks in southern Israel.

OBJECTIVES: To determine adherence with recommended pre- and post-exposure oseltamivir prophylaxis (OP) among workers exposed to poultry during five simultaneous avian influenza (AI) H5N1 outbreaks in poultry farms in southern Israel in March 2006, as well as the efficiency of the distribution system of oseltamivir in the community. DESIGN: Epidemiological investigation identified 201 workers exposed to poultry during AI outbreaks. They were interviewed by a public health nurse regarding adherence with recommended OP, symptoms, and possible side effects. Data were collected on type of exposure, age, sex, rate of adherence with OP, and reasons for non-adherence. For eight workers, paired sera were drawn for the determination of antibodies to H5. Data were collected on the efficiency of the distribution of oseltamivir tablets to workers in the community. RESULTS: High adherence with OP (87.6%) was found among poultry workers during outbreaks of AI, with no difference by type of exposure, age, or sex. There was a low rate of side effects of OP (1.5%). No exposed workers developed AI and none of the eight who had paired sera drawn showed seroconversion. The distribution of OP in the community was inefficient, with 27.7% of the tablets 'lost' or returned unusable. CONCLUSIONS: These data emphasize the importance of developing efficient targeted distribution systems in the community for OP, in order to prevent human infection during AI outbreaks.

Mortality in the bedouin population and proximity to a regional industrial complex.

BACKGROUND: The study was initiated by public concern about exposure to an industrial park (IP) emission. The study examined whether mortality in the Bedouin population in the southern part of Israel is associated with the residential distance to the IP. MATERIAL AND METHODS: Ecological study during 1995-2001 included the entire Bedouin population. Mortality data was obtained from the Central Bureau of Statistics. As an indirect measurement of exposure we used residential distance to the IP (with 20 km radius as a cut-of-point) based on residents' complaints about odor related to the IP. Differences in mortality rates by distance were assessed by the Mantel-Haenszel relative risk (M-H RR) within the 95% CI. The country Arab population served as a reference for calculation of the age-adjusted standardized mortality ratio (SMR). RESULTS: Increased mortality rates due to symptoms/ill-defined conditions and non-external causes were observed in the Bedouin population of both sexes, residing up to 20 km from the IP, compared to those living in more remote areas. Corresponding M-H RR (plus 95% CI) were 1.66 (1.17-2.36), 1.24 (1.06-1.44) in females, and 1.55 (1.15-2.10), 1.32 (1.15-1.52) in males. CONCLUSIONS: The study results suggest an association between residential proximity to the regional IP and increased mortality rates in the Negev Bedouin population. These findings have been accepted by the authorities as an issue for community health protection.