Introduction
The incidence rates of the three main sexually transmitted infections (STIs) (other than HIV) in Israel-
Chlamydia trachomatis (chlamydia),
Neisseria gonorrhea (gonorrhea), and
Treponema pallidum (syphilis) are lower than those in most western countries [
1,
2]. However, these rates may actually be higher due to under-reporting of new cases. Additionally, if appropriate preventive and therapeutic measures are not implemented in a timely fashion, rates may rise due to the following factors: (1) importation of additional cases by migrants from countries with either high prevalence levels of STIs or from countries experiencing recent epidemic outbreaks followed by dissemination within the veteran population; (2) international travel by a native and migrant residents; (3) a significant prevalence of commercial sex work (CSW) in urban areas [
2].
Meeting these challenges requires a thorough mapping of the STI epidemiology in Israel, the development of a comprehensive preventive strategy, as well as a practicable implementation program. These challenges have been addressed within the context of a national prevention initiative entitled ‘Healthy Israel 2020’, which aims to increase the life expectancy and the quality of life of Israel’s citizens, while reducing health inequity (specific recommendations for STIs have been postponed to 2025). Topic areas for the entire initiative were selected on the basis of their respective burdens of disease [
3]. One of the topic areas covered the prevention of infectious diseases; a subcommittee thereof focused on the prevention of Tuberculosis (TB), HIV, and STIs. Recommendations on the topics of TB-HIV have been published elsewhere [
4]. The current integrative article focuses on the development of national targets and objectives for the reduction of the disease burden due to STIs by the year 2025, as well as an evidence-based, and implementable strategic plan to achieve that aim.
Methods
Data on the epidemiology, preventive interventions and best practice implementation strategies for the prevention of the three main STIs in Israel were analyzed and accessed from various sources. Systematic surveillance data collected by the Division of Epidemiology in the Israeli Ministry of Health (MoH) for the years 2002–2014 was used to describe epidemiological STI data on the Israeli population in addition to internal MOH analyses and reports (“grey literature”). Country-level STI incidence rates were collected from the databases of the World Health Organization (WHO) Regional Office for Europe, the US CDC, and the Australian National Notifiable Disease Surveillance System. Primary and secondary preventive interventions to reduce the burden of STIs published between 2002 and 2016 were accessed from the English language scientific literature by entering the following keywords into PubMed: Sexually Transmitted Diseases (STD) (or STI) AND prevention AND intervention AND gonorrhea OR chlamydia OR syphilis. Twenty one articles describing preventive interventions were retrieved, primarily from European countries and the United States (US) for each specified STI (gonorrhea, chlamydia or syphilis). Particular attention was focused on data/recommendations issued by evidence-based international and other national preventive health oriented organizations such as, the WHO, the Cochrane collaboration, the US Preventive Services Task Force, the Task Force for Community Preventive Services, as well as various European countries.
Throughout our investigation, numerous discussions were held between the MoH staff, several stakeholders (both governmental and non-governmental), and senior medical professionals; these were further elaborated upon by the Healthy Israel 2020 sub-committee on STIs in order to develop a coherent, evidence-based national plan to reduce the burden of STIs in Israel.
Conclusions
A national STI (chlamydia, gonorrhea, and syphilis) prevention strategy for the year 2025 is presented. Although the current burden of STIs is relatively low compared to other Western countries, this is thought to be a partial result of underreporting. These and other gaps suggest a need for focused epidemiologic and health services research utilizing strategies such as active surveillance and field surveys to better characterize health risk behaviors as well as provider practice patterns. Primary preventive counseling is recommended for adolescents and younger adults. Due to the low prevalence of chlamydia and gonorrhea, only case finding in high risk populations is recommended. Screening with the VDRL test or the ELISA test is suggested for pregnant women, MSM, those exchanging sex for drugs, and CSW. Innovative implementation strategies include: cross-training of existing MoH TB personnel, enhanced training and interface with community clinical specialists, and procurement of more advanced diagnostic and analytic tools at all levels of care, in conjunction with expanded authorization of healthcare personnel to avail themselves of these tools.
Implementation of these recommendations will require a commitment to reasonably increase the capacity of the Department of TB and AIDS and satellite organizations including increased staffing, development of specific training modules for infectious disease and primary care professionals, and major improvements of the existing technical infrastructure, including improvement in efficient and overall quality of laboratory diagnostic capabilities.
This should provide a strong foundation upon which to develop specific and implementable national STI prevention policy recommendations by 2025.
Acknowledgements
We would like to acknowledged the contribution of the ‘Healthy Israel 2020’ “Tuberculosis, HIV and STI’s” subcommittee members for their important contribution in the situation analysis and in the preliminary phase of setting priorities: Chemtob D (Chair), Chowers M, Dan M, Gandacu D, Shitrit D, Yust I. Thanks also to Dr. Emilia Anis, Chair of the Healthy Israel 2020 committee on “Infectious Diseases”.
We would also like to thank the teams of the Division of Epidemiology (and specially Mr. Ruslan Gosinov) and of the District Health Offices for collecting and managing the data analyzed in this article, and all those who have notified these cases. Special thanks also to Ms. Nechama Averick for editorial support.
Dr. Daniel Chemtob MD, MPH, DEA, is a senior Public Health physician (MPH and DEA), with additional expertise in anthropology (DEA). Dr. Chemtob established the Department of Tuberculosis (TB) and AIDS at the Ministry of Health (in 1996) and the National TB program (in 1997) and continues to manage them. Dr. Chemtob has over 23 years of international experience in the fields of TB and HIV/AIDS, including 2 years as a TB Medical Officer at WHO-HQ. Dr. Chemtob has 1 year of graduate education and spent 2 years in the Post-Doctoral Fellowship at the Department of Epidemiology at the John Hopkins Bloomberg School of Public Health, Baltimore, USA and partly focused his activities on STIs prevention and treatment. Dr. Chemtob is a Senior Lecturer at the School of Public Health of Hebrew University of Jerusalem, Israel. daniel.chemtob@moh.health.gov.il.
Dr. Dan Gandacu MD, MPH is a senior Public Health practitioner and was in charge of the STI prevention and treatment in the past two decades until his retirement at the Division of Epidemiology, Ministry of Health, Jerusalem, Israel. dan.gandacu@moh.health.gov.il.
Dr. Zohar Mor MD, MPH, MHA, is a senior Public Health practitioner. He is currently a researcher at the Tel Aviv District Health Office and a senior lecturer at Tel Aviv University, Israel. zohar.mor@telaviv.health.gov.il.
Prof. Itamar Grotto MD, MPH, PhD, is a senior Public Health practitioner and the Director of the Israeli Public Health Services at the Ministry of Health for the past 9 years. He is a professor of Medicine and Epidemiology at the Department of Public Health at Ben-Gurion University, Beer Sheva, Israel. itamar.grotto@moh.health.gov.il.
Dr. Emilia Anis MD, MPH, is a senior Public Health practitioner and the Director of the Division of Epidemiology at the Ministry of Health. She is a senior lecturer at the Hebrew University of Jerusalem, Israel. emilia.anis@moh.health.gov.il.
Dr. Elliot Rosenberg MD, MPH, is a senior Public Health and General Preventative Medicine specialist. He serves as the head of the Department of Occupational Health at the Ministry of Health. He also serves as the National Coordinator of the ‘Healthy Israel 2020’ initiative, tasked with creating a national preventative health blueprint for Israel over the decade spanning 2010–2020. In addition, he is a long-standing member of the Israeli Task Force for Health Promotion and Disease Prevention. eli.rosenberg@moh.health.gov.il.
The opinions expressed in this article are those of the authors and do not purport to represent the opinions of the agencies with which they are associated.