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Despite considerable efforts to control tuberculosis (TB) among Ethiopian immigrants in Israel, an outbreak of TB among second-generation Ethiopian immigrants that involved native Israelis occurred between January 2011 and December 2019. The aim of this article is to report on this outbreak and discuss the patient and health system barriers that led to its propagation. Overall, 13 culture-positive TB patients were diagnosed in this outbreak. An additional 36 cases with identical mycobacterium tuberculosis genotypes were identified through cross-checking with the National TB Laboratory Registry. Among the 32 close contacts of the index case, 18 (56.3%) reported for screening and treatment of latent TB infection (LTBI) was recommended for 11 (61.1%) of them. However, none completed treatment and eight eventually developed TB. Of the 385 close contacts identified in this outbreak, 286 (74.3%) underwent contact investigation, 154 (53.8%) were recommended LTBI treatment, but only 26 (16.9%) completed the treatment. Routine contact investigation and treatment practice measures failed to contain the cascade of infection and disease, leading to the spread of the infecting strain of TB. This report highlights the challenges to identify the high-risk group and address barriers to care among such a vulnerable population.

Background: Atypical presentation of tuberculosis (TB) during pregnancy may cause diagnostic delay and adversely influence pregnancy outcome., Objectives: To examine the incidence and clinical and epidemiological features of TB during pregnancy and investigate infection control measures at delivery and during the postpartum period., Methods: We retrospectively evaluated all reported cases of TB diagnosed during pregnancy to 6 months postpartum in Israel's Northern Health District (2002-2012)., Results: Active TB was detected in six patients; all were negative for human immunodeficiency virus (HIV). Two patients were diagnosed in the postpartum period, and four had pulmonary involvement. The average incidence during this period (3.9 per 100,000 pregnancies) was similar to that in the general population. Five patients were at high risk of contracting TB due to either recent immigration from a high-burden country or being in contact with another individual with active TB. Patients with pleuropulmonary involvement had prolonged cough and abnormal chest X-rays, without fever. Diagnosis was delayed for 3 to 7 months from symptom onset. Investigation of the newborn to rule out intrauterine infection was conducted in only one of four relevant cases. All patients were infected with organisms susceptible to all first-line drugs, and all were cured with standard therapy., Conclusions: There was a considerable delay in the diagnosis of TB among pregnant women, and investigation of the newborn upon delivery to rule out TB infection was routinely omitted. Effective management of TB during pregnancy and the postpartum period requires a multidisciplinary approach including an obstetrician, pediatrician, TB specialist, and public health physician.

Tuberculosis (TB) outbreaks in congregate settings pose a public health concern and a clinical challenge. We report a TB outbreak involving 6 cases of active TB among 28 recent Ethiopian immigrants (EIs) in an immigrant reception center in Israel. The outbreak erupted several weeks after a meticulous pre-immigration TB screening of this group. All five culture-positive TB patients were infected with the CAS1_DELHI family, SIT 25 strain. Pulmonary involvement manifested as only a persistent cough without systemic symptoms. This outbreak occurred because of miscommunication among healthcare staff and between healthcare staff and the EI index case. It was fuelled by the staff ignorance of the social bonds within the group, and the sluggish once-monthly schedule of the on-site TB clinic operated at the reception center, which further lacked radiography facilities. This outbreak highlights the challenges of screening for active TB among immigrants and hard to reach groups.

A tuberculosis (TB) outbreak with six definite and four probable cases, caused by a Beijing strain isolate, occurred in an Arab rural community in north Israel. Using epidemiological investigation and strain genotyping, we identified the source case as an incarcerated immigrant. This outbreak illustrates how a systematic breakdown in TB prevention and control measures at multiple levels, within prisons and upon exiting prison, can result in rapid, cross-ethnic transmission of TB to a low-risk population. The close social bonds in this rural community and downsizing of the regional TB clinic staff may also have contributed to the magnitude of this outbreak.

Background: During the last decade, Israel, a country with low tuberculosis rates, absorbed some 900,000 new immigrants from TB-endemic countries., Objectives: To analyze the specific impact of our screening procedures on active TB among children in Israel., Methods: We conducted a retrospective analysis of epidemiologic and clinical data of all children (aged 0-17) with TB notified to the Ministry of Health between 1990 and 1999., Results: There were 479 children with TB (male/female ratio 1.36). Most cases (81.8%) were foreign born, predominantly (88.2%) immigrants from Ethiopia and, therefore, huge differences existed in TB incidence rates according to countries of origin. Some 80% were diagnosed within 3 years of arrival, mainly due to active case-finding. Pulmonary TB, with infiltrates on chest X-ray, was found in 49.5%. Extra-pulmonary TB sites were: intra-thoracic lymphadenitis (31.1%), extra-thoracic lymphadenitis (12.5%), bones (3.6%), pleura (1.3%), meninges (1%), and others (1%). Seventy percent had a tuberculin skin test reaction > or =10 mm in size. Two (non-immigrant) children died of TB meningitis., Conclusions: Most of the pediatric TB cases occurred in recent immigrants and were diagnosed within 3 years of immigration. These data support our policy of active case-finding among new immigrants from Ethiopia and extensive contact evaluation for all TB cases.

We describe how Israel effected new tuberculosis programs and policies beginning in the early 1990s. We explain how the epidemiology of the disease, particular events, and a small number of people influenced the creation of new policy. We believe that this story may be useful to other program managers and policymakers interested in changing course.

Setting: Right of entry may sometimes be denied to immigrants because of the threat of tuberculosis. During 1990-2000 some 1050000 immigrants, mostly from countries highly endemic for TB, arrived in Israel, a low prevalence country. Nevertheless, TB rates in Israel have remained low., Objective: To emphasise the challenge beyond technical competence for TB control for immigrants from the perspective of Israel's National Tuberculosis Programme (NTP)., Materials and Methods: We defined criteria for an NTP geared to immigration, and analysed our implementation of the European Task Force recommendations on international migration and TB control. We interviewed immigrants and health care workers to identify barriers to diagnosis, prevention and treatment of TB among immigrants. We used classical epidemiology to evaluate the impact of immigration on TB rates in the host population., Results: Until now there has been no evidence of significant spread of TB from immigrants to the host population. Successful outcome of treatment has been noted in over 75%, although a sub-population of immigrant substance abusers is proving more difficult to treat., Conclusions: The risk of TB for the host country is very low and it seems possible to enhance TB control in immigrants with measures designed to address their cultural needs.

Background: The rise in the incidence of TB in Israel, mostly due to immigration from endemic areas, led to the establishment of a new TB control program which follows the guidelines of the World Health Organization (WHO). Reorganization of the TB infrastructure was enabled by specific legislative, administrative and budgetary measures initiated by the Ministry of Health (MOH) in conjunction with the Sick Funds., Aim: To present the theoretical and practical aspects of this new program to the physicians of Israel., Program Outline: The essence of this program is the use of directly observed therapy (DOT) for all patients together with centralization of TB care in nine national centers, closely supervised by the MOH. This centralization allows a critical mass of patients to be seen in each clinic, thus enabling the labor-intensive task of modern TB treatment, including the supervision and/or the administration of DOT, to be performed in a cost-effective manner. Day to day treatment is conducted by general community clinics and supervised by District Health Offices. Hospitalization, a relatively rare necessity in the new program, is available in two dedicated centers with modern isolation facilities. Centralized laboratory services provide timely susceptibility testing. Billing is simplified according to disease categories, using a global assessment of costs negotiated with the Sick Funds. Management and quality control of the program are carried out on an ongoing basis by the Department of TB and AIDS at the MOH., Preliminary Outcome: In the first two years that have elapsed since the inception of the program, almost 93% of cases have documented evidence of completion of treatment (under DOT), compared to 54% (without any treatment supervision) before the program came into effect.

Background: In the last decade, tuberculosis (TB) has re-emerged as a major worldwide disease and also as a significant disease in Israel, particularly in the context of public health. In 1993, TB was declared a "global emergency" by the World Health Organization and in 1996, it was declared a "dangerous infectious disease" by the Israeli Ministry of Health., Aim: This article aims to provide an epidemiological update on TB to the practicing physician in Israel. We present the perspective of the global situation together with relevant data on TB in Israel for use in clinical decision making., Methods: All local data are from the ongoing epidemiological surveillance of TB conducted by the Department of Tuberculosis and AIDS in the Israeli Ministry of Health. Other data are cited from international sources., Results: TB is greatly influenced by immigration (some 80-90% of TB cases are foreign-born and at least 65% are among new immigrants). Between 1989-1996 the incidence of TB by cohort analysis for year of immigration ranged from 38-172/100,000 (for new immigrants from the Former Soviet Union) to 500-3,000/100,000 (for new immigrants from Ethiopia). During this period incidence in the veteran population (Israeli-born and immigrants at least 5 years in the country) was, at the most. 4/100,000. Some 80% of TB cases were pulmonary. The rate of drug resistance is increasing some 20% of the isolated strains were resistant to at least one drug and some 8% were resistant to both Isoniazid and Rifampicin. (MDR, multi-drug-resistant). Tuberculosis associated with AIDS has increased in the last decade due to immigration from sub-Saharan Africa. Contrary to the belief existing in the general public, the number of TB cases among foreign workers was relatively low (7.6% of the cases reported in 1998)., Conclusion: In the clinical context, a practicing physician is most likely to diagnose TB in a recent immigrant. Thus since the symptoms of early TB are non-specific, diagnostic efforts (which are labor intensive and expensive) should be guided by a high index of suspicion in that particular population group. Furthermore, this epidemiological data provided the rationale for determining TB control policy as described in the second article on this subject.

Background: One of the measures adopted in Israel since 1959 as part of the tuberculosis control program was screening children aged 12-13 years old. The screening comprised single-step tuberculin skin testing using the Mantoux method., Objectives: To assess the efficacy of tuberculin skin screening for TB in schoolchildren in southwestern Israel as well as the compliance to treatment for latent tuberculosis infection., Methods: We retrospectively reviewed the records of children in the Ashkelon region who underwent a tuberculin skin test during the period 1995-99., Results: Of the 28,016 eligible children, 27,232 were tested. In 923 children, mostly from the former USSR and Ethiopia, an induration of 10 mm or more was found. Only 52 Israeli-born children tested positive. Tuberculosis was found in seven children with a positive test, five of whom were from Ethiopia. All children who tested positive were referred to the local TB clinic; only 266 children (28.8%) presented. Only 151 completed the recommended treatment of isoniazid for 6 months. Thus, although screening included most of the targeted children aged 13, only a third of them presented to a TB clinic, and of these only about half completed treatment for latent infection., Conclusions: Our results indicate that the current policy of screening for latent TB in our region is ineffective in terms of implementation of the recommended treatment. We suggest that only high risk groups be screened, and that a concerted effort be made to implement treatment.

Background: Sensing an inadequacy of tuberculosis control due to an influx of TB associated with immigration, we analyzed TB treatment outcome in Israel by population groups., Objectives: To provide an epidemiological basis necessary for any new national TB control policy, and to bring it to the attention of the medical profession in Israel and abroad since its results led to a change in Israel's TB control policy., Methods: We reviewed all TB cases notified during the period 1990 to September 1992. "New cases" (820 cases, 93.5%) and "re-treatment cases" (57 cases, 6.5%) were analyzed according to three mutually exclusive groups: "successful outcome," "death," and "potentially unsatisfactory outcome" (according to WHO/IUATLD definitions)., Results: Of 820 "new cases," 26.6% had a "satisfactory outcome," 68.5% had a "potentially unsatisfactory outcome" and 4.9% died; compared to 47.4%, 45.6% and 7% among 57 "re-treatment cases," respectively. Using logistic regression analysis, outcome was associated with the district health office (P < 0.0001), the TB "experience" of the notifying clinic (P < 0.0001), and the form of TB (P = 0.02). No significant relationships were obtained for population groups, gender and age, interval between arrival in Israel and TB notification, and bacteriological results., Conclusions: Non-supervised TB treatment resulted in poor outcomes regardless of population groups. Better outcomes occurred in the larger TB clinics. Therefore, in addition to measures such as adequate drug supplies, reorganization of TB laboratories and training of TB personnel, we recommend the "directly observed treatment short-course" for all cases as well as reducing the number of treatment centers thereby increasing their case load.

The objective of this study was to determine the prevalence of positive skin tests amongst the staff of a 200 bed geriatric hospital in Haifa, Israel. By comparing the findings with those of a study performed five years previously, we hoped to ascertain the number of conversions which had occurred in the period studied. This was undertaken in order to assess a new policy from the Israel Ministry of Health regarding skin testing for health care workers. We also hoped to decide upon the frequency of skin testing required and to compare data from recent immigrants from countries with a high prevalence of TB. In 1997, we performed two-step skin testing (TSST) on 318 health care workers. We ascertained the number of positive reactions on the first and second testing and calculated the number of subjects who showed significant boosting. We also compared the results to those obtained in a study in 1992 and calculated the rate of conversion. We used multivariate analysis to examine the effects of age, gender, country of origin, years in Israel, previous BCG vaccination, previous exposure to contagious TB, work site and area of residence in the city, on the response to TSST. Between 1990 and 1996, 655 000 immigrants from the former USSR arrived; 'recent immigration' was defined from that date onward. The final number of positive reactions out of 282 subjects, who were either positive or negative on step 1 and presented for step 2, was 171 (60%). Booster effect was not significantly associated with any of the variables examined. The size of reaction in TSST was related to country of origin and recent immigration. The 83 recent immigrants from the former USSR had more frequent (61%) and larger reactions (mean (sd): 9.0 (6.46) mm) than the 114 native-born Israelis with 39% positive reactions (6.2 (5.89) P= 0.009). Comparison with 1992 revealed 26 (31%) of previous negatives as positive. Conversion was associated with age. All conversions save one were in individuals younger than 50 years (P= 0.07). In conclusion, TSST, performed to enable detection of recent infection after exposure to contagious TB, was relevant for 40% of health care workers (HCWs). Second step testing contributed an additional 23% positive reactions. New immigrants had larger initial reactions. Conversion occurred mostly in younger workers and could be either due to unrecognized TB in the hospital or to exposure in the community., (Copyright 2000 The Hospital Infection Society.)