There is clear scientific evidence that environmental risk factors affect human health and are significant contributors to the global burden of disease (GBD). Based on global estimates, the leading environmental risk factors include ambient air pollution from particulate matter (PM), indoor air pollution, and environmental tobacco smoke (ETS)(3). It is estimated that 7 million premature deaths globally each year (over 10% of deaths worldwide) are attributable to the combined effects of ambient and indoor air pollution. Exposure to ambient air pollution contributes to the growing global burden of chronic obstructive pulmonary disease (COPD) and other respiratory and cardiovascular diseases. According to estimates, exposure to ETS caused 603,000 deaths globally in 2004 - about 1% of worldwide mortality, as well as lower respiratory infections and asthma in children(14). The GBD in 2004 from exposure to lead was 143,000 deaths and 600,000 new cases of children with intellectual disabilities(19). Exposure to additional environmental chemicals, including methylmercury, arsenic, and pesticides, also contributes to the GBD. An analysis of data from six European countries, published in 2014, indicates that about 3%-7% of the annual burden of disease in the participating countries was associated with environmental risk factors – primarily ETS, fine particulate pollution (PM2.5), and pollution from traffic, noise, and radon(6). Exposure to endocrine-disrupting chemicals (EDCs), phthalates, bisphenol A (BPA), polybrominated diphenyl ethers (PBDEs), organochlorines, and organophosphate pesticides also contributes to the GBD and is associated with a decline in IQ, reduced fertility, autism, attention deficit hyperactivity disorder (ADHD), obesity, diabetes, and testicular cancer(1).
In 2015, exposure to air pollution was ranked in the top ten contributors to the burden of disease in Israel by the Global Burden of Disease Study. There are an estimated 2,500 premature deaths a year linked to exposure to air pollution(5), as well as 780 deaths attributed to exposure to ETS(4). The burden of disease due to exposure to pesticides, EDCs, heavy metals, and other environmental exposures has not been analyzed to date.
Environmental health indicators, based on proven cause-effect relationships, serve as important tools for identifying potential risks to human health and for policymaking. Environmental health indicators are particularly important for:
- Monitoring trends in environmental exposures;
- Monitoring trends in health outcomes linked to environmental hazards and exposures;
- Comparing countries in terms of environmental health status in order to target action and allocate resources;
- Monitoring the effectiveness of policies and other interventions on environment and health;
- Raising awareness about environmental health issues.
Data Sources and Availability
A wealth of data in Israel is potentially available for developing environmental health indicators. Israel is unique in that each citizen has an ID number that can be used to link various registries. Every citizen has national health insurance and medical records that are stored electronically by health maintenance organizations (HMOs) for many years. In addition, there are several national databases and registries:
- The 1940 Public Health Ordinance requires reporting for selected diseases and health outcomes, including cancer, birth defects, and selected infectious diseases. There is also a perinatal registry that includes data on low birth weight. The National Cancer Registry at the Ministry of Health (MoH) is considered 97% reliable with respect to data on solid tumors, and it has consistently maintained a high level of coverage since its inception.
- The Israel Center for Disease Control manages registries on type 1 diabetes in children ages 0-17, based on outpatient clinic data, as well as on diabetes in all age groups, based on HMO data. There are additional registries on end-stage renal disease and kidney transplants, and cardiac surgeries. The MoH’s National Cerebrovascular Transient Ischemic Attack (TIA) Registry is based on hospitalization data. Statistical data on fertility treatments in Israel have been collected since 1990.
- The MoH established a database on causes of death and maintains databases on emergency room visits and hospitalizations. This hospitalization database includes information on more than 90% of all hospitalizations throughout the country - demographic information, hospital admission and discharge dates, as well as all information on patient diagnoses.
- Data on various chronic diseases in Israel, including asthma, type 2 diabetes, stroke, and cardiovascular disease, are available from national surveys (Knowledge, Attitudes, and Practices Survey [KAP], Israel National Health Interview Survey [INHIS], Acute Coronary Syndrome Israeli Survey [ACSIS], National Acute Stroke Israeli Survey [NASIS]). In addition, data on exposure to ETS are collected in these surveys.
- Since 1967, data are available on the health status of adolescents (age 17), based on the mandatory examination of candidates for military enlistment. This includes diagnosis and assessment of the severity of asthma cases, based on a comprehensive medical evaluation. This database does not include certain segments of the population, such as subgroups that are not recruited for military service.
- The Israeli National Insurance Institute (INII), a government organization responsible for the social security of Israel’s residents, collects data on autism and other cognitive developmental disorders.
- The National Program for Quality Indicators in Community Healthcare (QICH) was launched in 2004 to provide policymakers and consumers with information on the quality of community healthcare in Israel. The QICH publishes data on 28 quality indicators, including asthma, cancer screening, cardiovascular health, pediatric health, diabetes, and immunization in the elderly population. This data can be analyzed by age, gender, and socioeconomic status in order to identify at-risk populations.
Candidate Indicators for Environmental Health in Israel
In 2015, the MoH developed a list of candidate indicators for environmental health in Israel. The list is based primarily on indicators identified by the World Health Organization (WHO), United States Centers for Disease Control and Prevention (CDC), and WHO/Europe’s Environment and Health Information System (ENHIS). Table 1 presents selected indicators that are uniquely relevant to environmental health in Israel, and the availability of the data. These indicators include exposure indicators, chronic disease indicators, climate change indicators, and early childhood health indicators.
Available Data on Chronic Diseases and Conditions in Israel
Environmental and occupational risk factors have been linked to many types of cancer, primarily lung cancer, leukemia, mesothelioma, and melanoma. Recent evidence from a study on new immigrants and the risk of Hodgkin's lymphoma suggest that there may be an environmental component in the etiology of the disease, possibly due to preconception exposure, prenatal exposure, or exposure in early stages of life to changes in lifestyle and environment, and the interaction between this exposure and susceptibility genes(13).
In 2014, the most common types of cancer among Israeli men were prostate cancer (in Jews) and lung cancer (in Arabs). Among women, breast cancer was the most common in both Jews and Arabs(11). There has been a significant decrease in the incidence of invasive cancer (all sites) in Jewish men since 2008 and in Jewish women since 1990 (Figure 1). In the Arab population, there has been a decrease in the incidence of cancer among Arab men since 2006; among women, the rate has remained stable since 2006. Compared to other Organization for Economic Co-operation and Development (OECD) countries, Israel has higher-than-average cancer incidence rates; on the other hand, mortality rates from cancer are lower than the OECD average.
Asthma development and exacerbation can be triggered by exposure to a variety of indoor and outdoor environmental factors, including PM, ozone, ETS, dust mites, mold, and allergens.
Based on QICH data, the incidence of chronic asthma among people ages 5-44 was 0.8% in 2015(17). According to data published in 2017, drawn from an analysis of a computerized database of Clalit Health Services (the largest HMO in Israel), adult asthma prevalence in 2014 was 5.7%(18). According to data from the 2013-2015 INHIS, 7.4% of the adult population reported having asthma (an increase from 5.8% in the previous survey in 2007-2010)(9). The discrepancy in estimates apparently stems from the differences in data collection methodology (self-reporting versus data based on medical records) and from differences in the type of asthma included in the estimate.
The most recent data on asthma prevalence in children is from a survey conducted by the Israel Center for Disease Control in 2008. According to that survey (based on self-report), the prevalence of asthma among children ages 13-15 was 7.2% of Jewish children and 7.0% of Arab children. Asthma rates among Jewish students have remained stable since 1997. In the Arab, Bedouin and Druze populations, a steep rise in asthma rates has been observed(10).
In a study on the prevalence of asthma in 17-year old boys eligible for army service, lifetime asthma prevalence decreased steadily, from 9.7% in 1999 to 8.1% in 2008. The largest decrease in this age group was of moderate-to-severe persistent asthma (down from 0.9% in 1999 to 0.4% in 2008)(2).
The hospitalization rate due to asthma among people of ages 5-74 decreased steadily between 1999 and 2008, from 13.02 to 7.59 per 10,000 individuals - a reduction of 42%. There was a significant decrease in the hospitalization rate in all age groups (Figure 2). This decrease is likely attributable to the decrease in asthma prevalence and to improved asthma care in primary care settings.
The asthma mortality rate in Israel dropped by 41% during this period (1999-2008), from 2.1 to 1.4 per 100,000 population. The researchers suggest that this decline may be attributed to reduced exposure to tobacco smoke (less smoking and ETS in public places as a result of legislation and information campaigns), increased use of corticosteroids, and decreases in NOx, NO2, and SO2 emissions and in annual grass pollen counts.
In 2016, the MoH started a joint project with Clalit Health Services, an HMO that serves over 50% of the Israeli public. The project includes collection of data on the incidence of asthma among adults and children by districts, and in relation to various environmental hazards.
Cardiovascular diseases are associated with exposure to air pollution, heavy metals such as lead, and ETS. Based on data from the 2013-2015 INHIS, 4.7% of the adult population reported having a cardiac condition, including myocardial infarction, chest tightness, and heart failure.
Obesity is defined as a body mass index (body weight divided by the square of body height [kg/m2]) of 30 or more. While the major risk factors for obesity are generally considered behavioral (high-calorie diets combined with a sedentary lifestyle), the risk of obesity is also related to genetic and environmental factors. There is increasing evidence that early-life exposure to environmental chemicals plays a significant role in the global obesity epidemic.
According to data from the 2013-2015 INHIS, 37.6% of the adult population is overweight (a body mass index of 25.0-29.9) and 17.8% is obese. Similar data was published in the 2013 KAP survey report and in QICH findings from 2015. MoH data from 2015-2016 indicate that 1 in 4 children in grades 7-12 is overweight or obese, with the highest rates among Arab boys(16).
Exposure to EDCs has been linked to type 2 diabetes and pre-diabetic disturbances. For example, exposure to high levels of dioxins has been associated with an increased risk of diabetes mellitus or altered glucose metabolism. There is evidence that the prevalence of autoimmune disorders, including type 1 diabetes, is increasing and that environmental factors may play a role in this increase.
According to data from the 2013-2015 INHIS, 8.4% of the adult population reported having diabetes(9). Data published in 2014 by Clalit Health Services show that from 2004 to 2012, there was a consistent but gradually diminishing upward trend in the prevalence of diabetes, with a cumulative increase of 34.3% over nine years. There were 343,554 diabetes cases in 2012 (14.4%) among the 2,379,712 HMO members, ages 26 and up(12).
An Israel Center for Disease Control report on diabetes indicates that among children of ages 0-17, the incidence rate of type 1 diabetes in 2015 was 13.8 per 100,000. Between 1997 and 2015, there was a 43.6% increase in the incidence of type 1 diabetes(7).
Several studies have found associations between the risk of autism spectrum disorder (ASD) and environmental exposures, including exposure to air pollution, pesticides, and heavy metals during pregnancy, but more research is required in order to understand the etiology of autism. In 2011, the cumulative incidence of ASD among the total population of 8-year-olds born in Israel was 0.49% (1 in 203 children). The incidence of ASD increased tenfold (from 0.049% to 0.49%) between 2000 and 2011(15). Changes in diagnostic methods can explain part, but not all, of this increase.
Despite the wealth of data collected from national registries and surveys, from candidates for military enlistment, and in electronic databases collected by Israel’s four HMOs, there are significant data gaps in candidate indicators of environmental health in Israel. Data on many health indicators is not available (such as asthma prevalence in children 0-5 and heat stress hospitalizations), while data on other health indicators is available but reflects severe underreporting (for example, poisonings in children). There is no data available on several exposure indicators (such as indoor air quality in schools, heavy metal intake in adults from food). The available data on many indicators are sporadic or not up-to-date (for example, asthma hospitalizations). Delays in analyzing and reporting data from registries pose another obstacle.
Despite reports on the increasing prevalence of diseases and conditions linked to environmental factors, such as type 1 diabetes, autism, ADHD, and obesity, there are few published studies based on a national analysis of the link between environmental exposures and health outcomes in Israel. HMO databases are an important potential resource for environmental health data and research. These databases include data on doctor visits, diagnoses, laboratory tests, subscribed medications, and purchased medications. The population treated at HMOs is stable in size, and there is standardized data reporting in computerized medical records used across all care settings within the HMOs. This enables consistency and completeness of the data, and makes it possible to track trends in diseases. Several HMOs have conducted large studies on national trends in diseases (such as asthma and diabetes) and have developed methods to study the long-term effects of medical exposures (such as MRI). These methodologies have not yet been applied to study environmental health trends and risk factors. Legal and ethical problems impede the use of computerized databases at HMOs to examine and analyze links between health and the environment. The lack of access to such health databases and registries by researchers poses an ongoing challenge.
The compulsory health examination that most Israelis undergo at age 17 is a potentially rich source of data for identifying environmental health trends (for example, asthma prevalence) and for research on associations between early life exposures and diseases in later life. In recent years, this data source is being used to examine associations between air pollution and adverse health outcomes, including cancer and asthma. However, there are many obstacles - and major challenges - involved in working with this data source, primarily related to privacy and ethical issues.
There is a clear need for increased cooperation among the different government entities that collect health and environmental data and the HMOs. Making the collected data on environmental factors and health endpoints accessible - to researchers, policymakers, and the wider public, in a timely fashion - continues to be a major challenge.
The MoH launched the “Psifas” program to collect health data from volunteers. The program involves collecting questionnaires, genetic information, and data from biosensors, and establishing a research database. This database may also have potential use for environmental health research, including research on gene-environment interactions.
This chapter and all other chapters in the report was written by a team of scientists and professionals from the Ministry of Health, in collaboration with Environment and Health Fund.
(1) Attina, T. M., Hauser, R., Sathyanarayana, S., Hunt, P. A., Bourguignon, J. P., Myers, J. P., ...Trasande, L. (2016). Exposure to endocrine-disrupting chemicals in the USA: A population-based disease burden and cost analysis. The Lancet Diabetes & Endocrinology, 4(12), 996-1003. https://doi.org/10.1016/S2213-8587(16)30275-3
(2) Cohen, S., Berkman, N., Avital, A., Springer, C., Kordoba, L., Haklai, Z., ...Picard, E. (2015). Decline in asthma prevalence and severity in Israel over a 10-year period. Respiration, 89(1), 27-32. https://doi.org/10.1159/000368613
(3) GBD 2015 Risk Factors Collaborators (2016). Global, regional, and national comparative risk assessment of 79 behavioral, environmental and occupational, and metabolic risks or clusters of risks, 1990-2015: A systematic analysis for the Global Burden of Disease Study 2015. The Lancet, 388(10053), 1659-1724. https://doi.org/10.1016/S0140-6736(16)31679-8
(4) Ginsberg, G. M., & Geva, H. (2014). The burden of smoking in Israel - attributable mortality and costs (2014). Israel Journal of Health Policy Research, 3, 28. https://doi.org/10.1186/2045-4015-3-28
(5) Ginsberg, G. M., Kaliner, E., & Grotto, I. (2016). Mortality, hospital days and expenditures attributable to ambient air pollution from particulate matter in Israel. Israel Journal of Health Policy Research, 5, 51. https://doi.org/10.1186/s13584-016-0110-7
(6) Hänninen, O., Knol, A. B., Jantunen, M., Lim, T. A., Conrad, A., Rappolder, M., ...EBoDE Working Group (2014). Environmental burden of disease in Europe: Assessing nine risk factors in six countries. Environmental Health Perspectives, 122(5), 439-446. http://dx.doi.org/10.1289/ehp.1206154
(7) Israel Center for Disease Control, Israel Ministry of Health (2017). Diabetes registry report, ages 0-17, 2015 (Hebrew). https://www.health.gov.il/PublicationsFiles/diabetes_0-17_2015.pdf.pdf (retrieved November 2017).
(8) Israel Center for Disease Control, Israel Ministry of Health (2017). Highlights of health in Israel 2016. Publication 371. http://online.fliphtml5.com/ginu/djej/#p=52 (retrieved September 2017).
(9) Israel Center for Disease Control, Israel Ministry of Health. Israel National Health Interview Survey, INHIS-3, 2013-2015 (Hebrew). http://www.health.gov.il/PublicationsFiles/INHIS_3main_findings.pdf (retrieved November 2017).
(10) Israel Center for Disease Control, Israel Ministry of Health. Monitoring Asthma morbidity in teens (Hebrew). https://www.health.gov.il/UnitsOffice/ICDC/Chronic_Diseases/asthma/Pages/AsthmaInTeens.aspx (retrieved November 2017).
(11) Israel Ministry of Health (2014). Data update on cancer morbidity and mortality incidence, 2014 (Hebrew). https://www.health.gov.il/PublicationsFiles/cancer2014_01022017.pdf (retrieved November 2017).
(12) Karpati, T., Cohen-Stavi, C. J., Leibowitz, M., Hoshen, M., Feldman, B. S., & Balicer, R. D. (2014). Towards a subsiding diabetes epidemic: Trends from a large population-based study in Israel. Population Health Metrics, 12, 32. https://doi.org/10.1186/s12963-014-0032-y
(13) Levine, H., Leiba, M., Bar Zeev, Y., Keinan-Boker, L., Derazne, E., Leiba, A., & Kark, J. D. (2017). Risk of Hodgkin lymphoma according to immigration status and origin: A migrant cohort study of 2.3 million Jewish Israelis. Leukemia and Lymphoma, 58(4), 959-968. http://dx.doi.org/10.1080/10428194.2016.1220552
(14) Oberg, M., Jaakkola, M. S., Woodward, A., Peruga, A., & Prüss-Ustün, A. (2011). Worldwide burden of disease from exposure to second-hand smoke: A retrospective analysis of data from 192 countries. The Lancet, 377(9760), 139-146. https://doi.org/10.1016/S0140-6736(10)61388-8
(15) Raz, R., Weisskopf, M. G., Davidovitch, M., Pinto, O., & Levine, H. (2015). Differences in autism spectrum disorders incidence by sub-populations in Israel 1992-2009: A total population study. Journal of Autism and Developmental Disorders, 45(4), 1062-1069. https://doi.org/10.1007/s10803-014-2262-z
(16) Rubin, L., Belmaker, I., Somekh, E., Urkin, J., Rudolf, M., Honovich, M., ...Grossman, Z. (2017). Maternal and child health in Israel: Building lives. The Lancet, 389(10088), 2514-2530. https://doi.org/10.1016/S0140-6736(17)30929-7
(17) The Israel National Institute for Health Policy Research (NIHP), Israel Ministry of Health (2016). National program for quality indicators in community healthcare. Report for 2013-2015 (Hebrew). http://healthindicators.org.il/wp-content/uploads/2017/03/2013-2015.pdf (retrieved November 2017).
(18) Varsano, S., Segev, D., & Shitrit, D. (2017). Severe and non-severe asthma in the community: A large electronic database analysis. Respiratory Medicine, 123, 131-139. http://dx.doi.org/10.1016/j.rmed.2016.12.017
(19) World Health Organization (2009). Global health risks: Mortality and burden of diseases attributable to selected major risks. http://www.who.int/healthinfo/global_burden_disease/global_health_risks/en/index.html (retrieved September 2017).