Environmental Health in Israel 2020 Environment and Health Fund Ministry of Health
Rivka 11, Jerusalem, Israel 9346117 Yirmiyahu 39, Jerusalem, Israel 9101002 Website: www.ehf.org.il/en Website: https://www.gov.il/en/departments/ministry_of_health
Material from this report may be reproduced on condition that it is cited as: Environment and Health Fund and Ministry of Health (2020). Environmental Health in Israel 2020.
A digital copy of this report can be found on the:
Environment and Health Fund website Ministry of Health website www.ehf.org.il/en https://www.gov.il/en/departments/ministry_of_health
About the Environment and Health Fund
The Environment and Health Fund (EHF) is committed to expanding expertise in and knowledge about environmental health in Israel. EHF builds capacity and capabilities by supporting inter-disciplinary research, in-service professional training, and workshops and conferences. EHF helps connect Israeli scientists and policy makers to a network of international experts in environmental health research and policy. EHF works with scientists and professionals, government and the private sector to broaden stakeholder involvement in reducing exposure to environmental hazards and improving public health.
Cover photo: Udi Katzman Environmental Health in Israel 2020 Environmental Health in Israel 2020
Editor-in-chief Authors Dr. Sari Rosen Dr. Tamar Berman Environment and Health Fund Department of Environmental Health, Ministry of Health
Editing and production Dr. Zohar Barnett-Itzhaki Maya Popper Department of Environmental Health, Ministry of Health
Advisor Additional authors (by order of chapters) Dr. Ruth Ostrin Dr. Isabella Karakis Environment and Health Fund Department of Environmental Epidemiology, Ministry of Health
Research assistant Dr. Ziva Hamama Einav Horev National Food Service, Ministry of Health Environment and Health Fund Dr. Shay Reicher National Food Service, Ministry of Health Translation Ira Moskowitz Hadas Vagman The Israeli National Information Center for Non-Ionizing Language editing Radiation (“TNUDA”), Gertner Institute for Epidemiology Naftali Greenwood and Health Policy Research
Dr. Tali Berman Graphic design Mimshak Fellow, Ministry of Health Navi Katzman Noam Hirsh Department of Environmental Health, Ministry of Health
Ilana Taler Department of Environmental Health, Ministry of Health
- 2 - Table of Contents
Preface Dr. Ruth Ostrin 4
Introduction Prof. Itamar Grotto 6
Chapter 1 Ambient Air Quality 9 Chapter 2 Indoor Air Quality 27 Chapter 3 Environmental Tobacco Smoke 35 Chapter 4 Chemical Parameters in Drinking Water 43 Chapter 5 Reclaimed Wastewater 53 Chapter 6 Pesticides 59 Chapter 7 Chemical Food Contaminants 71 Chapter 8 Chemicals in Consumer Products 77 Chapter 9 Human Biomonitoring 85 Chapter 10 Non-Ionizing Radiation 95 Chapter 11 Climate Change 105 Chapter 12 Planning 119 Chapter 13 Vulnerable Populations 129 Chapter 14 Environmental Health Indicators and Trends 137
Conclusions and Recommendations Dr. Linda S. Birnbaum 151
Appendix 1 Progress Since 2017 and Future Challenges 158 Appendix 2 Environmental Health and COVID-19 165
Acknowledgments 168
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Preface
Writing the preface to the third edition of Environmental Health in Israel is both an honor and a challenge. The report is the fruit of a continuing and extremely productive collaboration, more than a decade long, between the Environment and Health Fund and the Ministry of Health. The private/public partnership reflected in this collaboration demonstrates the partners’ respect and trust for one another. With each iteration, the report has seen improvements in form and content. We believe that these reports provide high quality, meticulously researched and reviewed data regarding environmental health research and policies. The current report is descriptive, providing a snapshot of the state of environmental health in Israel in 2020, and prescriptive, outlining current challenges and recommending future directions. Its fourteen chapters span a range of environmental factors that affect human health. It is indeed an honor to be involved in such an ambitious, comprehensive, and forward-looking project.
Yet one cannot write anything at this time without experiencing some degree of anxiety. The appearance of the novel coronavirus, COVID-19, and subsequent efforts to deal with the pandemic have introduced uncertainty into all aspects of our lives. The ways in which our government, our society, and particularly our healthcare system are all challenged at this time, along with the politicization of public health decision-making, have sidelined much of the most essential environmental health research and policy. The threats of environmental hazards to public health in Israel, however, will not disappear simply because they have escaped from the spotlight as all attention is focused on the pandemic.
In fact, one may argue that the opposite is the case. Exposure to environmental pollutants increases the severity of COVID-19. People in polluted areas are far more likely to die from the new coronavirus than are those living in cleaner areas. This knowledge should be leveraged to decide how to deploy resources to deal with the pandemic and how to ease back toward normalcy after lockdown.
How exposure to environmental pollutants influences individual susceptibility to coronavirus infection has yet to be determined. One theory is that exposure to environmental chemicals or other environmental pollutants weakens immune defenses and/or compromises the functioning of organs targeted by the coronavirus, including the
- 4 - Preface respiratory tract, the cardiovascular system, and the brain. Alternatively, environmental chemical exposures may indirectly exacerbate COVID-19 related disease by increasing individual risk to health issues associated with the heightened risk of death from COVID-19. For example, pre-existing asthma, diabetes, obesity, and cardiovascular disease worsen the prognosis of those with COVID-19, and each of these disease and health conditions has been linked to exposure to environmental chemicals and other pollutants in both animal models and human epidemiological studies.
The lessons we are learning during the current pandemic highlight the need to enforce and even strengthen existing environmental pollution regulations. We have also learned the importance of access to open green spaces, particularly in the built urban environment. The urgency of considering the health implications of planning processes has been highlighted by the pandemic. Implementing policies and lifestyle changes to reduce human exposure to chemicals and other environmental pollutants that compromise our health and resistance to pathogens will be a critical component in preparing for the next viral threat.
I would like to thank the many individuals who contributed to this volume. Professor Itamar Grotto, the outgoing Deputy Director General of the Ministry of Health, has been the single most significant figure in promoting issues of environmental health in the Israeli government for more than a decade now. Thanks to Dr. Tamar Berman, whose hard work and commitment to this project, among many, has been extraordinary. We also thank Dr. Zohar Barnett-Itzhaki for his contribution to the writing of the report and Dr. Udi Kaliner for reviewing the entire report. Maya Popper worked tirelessly as project manager and editor. Many, many contributors wrote, edited, and reviewed the chapters and deserve our gratitude. Professors Mark Nieuwenhuijsen and Mike Brauer greatly improved the report by participating in a kick-off workshop in January 2020 (MN) and offering comments on an earlier draft (MB). Dr. Linda Birnbaum, the recently retired Director of the National Institute of Environmental Health Sciences, once again read, reviewed, and commented on every chapter, every challenge, and every graph in this report, and again expressed her clear and concise wisdom in the Conclusions and Recommendations chapter. Finally, I thank my colleague, Dr. Sari Rosen. Although she is formally recognized as Editor-in- chief of this volume, that does not do justice to the time, effort, painstaking attention to detail, commitment to clarity, and uncompromising standards of excellence in everything she touches. Every aspect of this report was improved by Sari’s involvement.
Ruth Ostrin, PhD Director Environment and Health Fund
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Introduction
The third edition of Environmental Health in Israel was written in 2020, the year when the COVID-19 pandemic dominated public health work globally and in Israel. The publication of this report at the end of 2020 is fitting: It demonstrates that even when public and political attention is directed elsewhere, pressing environmental health problems persist and need to be addressed. Accordingly, this report describes the most pressing environmental health problems in Israel and progress in addressing them in both research and policy.
Despite parliamentary paralysis throughout 2019 and amid the COVID-19 crisis in 2020, impressive progress was made in several aspects of environmental health in Israel, including reducing air pollution, expanding biomonitoring capabilities, and closing gaps in regulating chemicals in consumer products. Additional hard work is needed to ensure that the full public health benefits of these milestones are realized and that the findings of research and surveys continue to be translated into policy. In light of new findings on the presence of perfluorinated chemicals in groundwater in industrial hotspots in Israel, for example, there is an urgent need for policy to prevent environmental contamination and public exposure to this class of chemicals.
One of the results of the parliamentary paralysis and the COVID-19 crisis is that major environmental health policy reforms have been delayed. As Israel emerges from these crises, it must advance much needed environmental health policies, including restrictions on the sale and use of highly toxic pesticides and updating national air quality and drinking water standards.
Many challenges that were highlighted in the 2014 and 2017 reports persist and remain unresolved, such as enforcing the ban on smoking in public places and addressing the lack of magnesium in desalinated drinking water. We also need to address worrying national trends such as the gradual reduction in access to green open spaces and the increasing intensity and frequency of heat waves and extreme weather events. If these trends are not addressed, there will be major ramifications for public health in Israel.
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Several newly proposed policy reforms may have major impacts on environmental health in Israel. Draft legislation for chemical management, spearheaded by the Ministry of Environmental Protection, is an important step because Israel lags behind the EU and the U.S. in registering and approving chemicals. The urgent importance of comprehensive chemical management in Israel is clear in view of new evidence on PFAS contamination in Israel and lack of regulatory restrictions on these compounds. Another proposed reform, championed by the Ministry of Economy and Industry, would reduce the testing of imported consumer products. Unless this reform is accompanied by far-reaching government inspection and oversight, it may result in increased exposure of the Israeli population to toxic chemicals in imported consumer products.
Despite growing economic and political pressure, environmental health regulatory requirements in Israel should not be loosened or reversed. Future budget cuts should not lead to reductions in government oversight and spending in the field of environmental health. Israel’s efforts to recover and rebuild public health resilience following the pandemic need to integrate efforts to build environmental health resilience, including steps to limit the public’s exposure to toxic agents in air, water, consumer products, and food, and to increase access to green open space. As the public health threats of climate change loom, Israel has no time to waste in preparing for the next crisis.
I wish to thank Drs. Ruth Ostrin and Sari Rosen from the Environment and Health Fund for their hard work on this report and their unfailing dedication to this challenging project. Dr. Linda Birnbaum has been a crucial part of this project from the beginning; here, as in the 2014 and 2017 reports, her insightful comments and recommendations are key to the success of the project. Gratitude is also owed to Drs. Tamar Berman and Zohar Barnett-Itzhaki, who led the preparation of the report.
Prof. Itamar Grotto, MD, MPH, PhD Deputy Director General Israel Ministry of Health
- 7 - Environmental Health in Israel 2020 Chapter 1
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Ambient Air Quality Chapter 1 Ambient Air Quality
Ambient air pollution is the major environmental health risk factor in Israel.1 Ambient air quality in Israel is affected by various sources of pollution, some natural (such as desert dust) and others anthropogenic (such as emissions from industry, transportation, and biomass combustion). Exposure to ambient air pollutants is associated with adverse health effects such as respiratory diseases, cardiovascular morbidity, Type 2 diabetes, cancer, and adverse developmental outcomes including small for gestational age (SGA) and low birth weight. Ambient air pollutants include particulate matter (PM) of different diameters, ozone (O3), nitrogen oxides (NOx), sulfur oxides (SOx), lead, carbon monoxide (CO) and volatile organic compounds (VOCs).
Ambient air quality is monitored by the Air Quality Division at the Ministry of Environmental Protection (MoEP) through a network of over 150 air quality monitoring stations, including widely deployed fixed and mobile units that continually monitor criteria pollutants (such as PM and ozone). MoEP also conducts biweekly sampling at nineteen permanent sampling sites for non- criteria pollutants such as VOCs, metals, and dioxins.
Ambient air quality in Israel is regulated under the Clean Air Law of 2008, which went into effect in January 2011. The statute set air quality values for numerous pollutants; MoEP updates them periodically in collaboration with the Ministry of Health (MoH) and other stakeholders, most recently in 2016. The two main values are: (a) target values—exceedance of which may harm human health or the quality of human life, property, or the environment, including soil, water, flora, and fauna; an effort should be made to meet these target values although they are not mandated by law; and (b) environmental values—exceedance of which constitutes severe or unreasonable air pollution. Although the environmental values are based on the target values, they are more lenient because they take into account the best available technologies and the feasibility of preventing exceedance of the target values. Notably, for many ambient air pollutants there is evidence of adverse health effects even at levels below the target values. Table 1 shows the environmental standards of selected pollutants listed in the Clean Air Law and compares them with EU and U.S. standards and World Health Organization (WHO) guidelines.2
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Ambient Air Quality Standards for Selected Criteria Pollutants in Israel Compared with Standards in the EU and U.S. and with WHO Guideline Values Table 1 Time Israel EU U.S. WHO Guideline 3 3 3 3 Negev, 2020 2 Interval (μg/m ) (μg/m ) (μg/m ) Values (μg/m )
24 h 130 50 150 50 PM10 Annual 50 40 — 20
24 h 37.5 — 35 25 PM2.5 Annual 25 25 12 10
Ozone 8 h 140 120 138 100
Nitrogen 1 h 200 200 188 200 Dioxide (NO2) Annual 40 40 98 40
10 min — — — 500
Sulfur 1 h 350 350 197 — Dioxide (SO2) 24 h 50 125 — 20
Annual 20 — — —
Progress since 2017
The Environmental Health in Israel 2017 report defined challenges related to Ambient Air Quality. Progress achieved in this area during the past three years is outlined below.
The challenge: Develop a strategy for regular sampling of contaminants that cannot be monitored continuously
In short: Monitoring and biweekly sampling Challenge for the coming years: Continue of dozens of air pollutants began in 2015. The monitoring and extend it to additional sites. nineteenth monitoring site was added in 2018.
Under the Clean Air Law, twenty-eight criteria ambient air pollutants (including O3, SO2, PM2.5, PM10, NOX, NO2, CO, benzene) and non-criteria pollutants (including VOCs, poly-aromatic- hydrocarbons [PAHs], aldehydes, metals, ammonia, and hydrogen sulfide) are monitored. Contaminants that reach concentrations of approximately one-tenth of their target or environmental values are sampled throughout the year on a biweekly basis. Monitoring began in 2015 at fourteen sites. In 2016, four additional monitoring sites were added; the nineteenth monitoring site was added in 2018. In total, some twenty air pollutants have been sampled in Israel since 2015 on a biweekly basis, including formaldehyde, PAHs, heavy metals, and ammonia.
Legend: Significant progress Some progress Little or no progress
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Ambient Air Quality The challenge: Full implementation of the National Plan for the Prevention and Mitigation of Air Pollution
In short: Most of the National Plan has been Challenge for the coming years: Complete the implemented. implementation of the National Plan and develop a follow-up plan for further mitigation of air pollution in Israel.
In 2013, the National Plan for the Prevention and Mitigation of Air Pollution in Israel (Government Resolution 707) was approved and goals were set for 2015 and for 2020.3 The plan has been almost fully implemented. According to a report on the implementation of the plan, presented to the Government, the sections for which MoEP was responsible were implemented and other parts have yet to be applied: The 2008 plan to scrap old vehicles was renewed in 2018 for old diesel-powered vehicles only. According to MoEP estimates, diesel-powered vehicles are responsible for ~80% of traffic- related air pollution. The Ministry of Finance, in consultation with the Minister of Environmental Protection and the Minister of Transport, has not presented the Government with proposed tools and measures for reducing travel in leased vehicles. The Minister of Finance, in consultation with the Minister of Environmental Protection, has not set differential tax rates for different types of fuel.
MoEP is developing a follow-up plan for reducing air pollution in Israel.
The challenge: Reduce ambient concentrations of PM10 and ozone in metropolitan areas where concentrations exceed environmental values
In short: PM concentrations and ozone Challenge for the coming years: Continue precursors have decreased somewhat but ozone reducing emissions of PM (PM2.5 and PM10) concentrations have not. and of ozone precursors.
Based on data reported to the MoEP managed Pollution Emissions Inventory, PM10 emissions decreased by 57% between 2012 and 2018 following a downturn in the use of coal for energy production along with other regulatory requirements. The main sources of PM10 emissions in Israel are industry (20%), transportation (33%), and waste incineration (20%).4
Data from air monitoring stations in Israel indicate that annual average concentrations of PM10 and PM2.5 in different parts of the country exceed the target values (20 and 10 µg/m3, respectively) but not the environmental values (50 and 25 µg/m3, respectively). Although the number of exceedances in PM2.5 concentrations at various monitoring stations, including those close to roads, has been decreasing, PM2.5 concentrations remain relatively high, ranking Israel thirty-seventh among forty OECD countries.5 Ozone precursors including NOx have also been decreasing. Unlike other air pollutants that have seen declining concentrations over the years (such as SO2 and NO2),
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concentrations of PM10 and ozone show no downward trend (Figure 1).6 Moreover, according to an assessment published in 2020 and based on 2016 exposure data, the entire population of Israel is exposed to PM10 concentrations that exceed the target value while falling short of the environmental value.7
According to the Global Burden of Disease database the mortality rate from PM exposure in Israel has remained constant in recent years and was 26.4 per 100,000 people in 2017.1 Based on OECD data, this rate stood at 28.41.8 The distribution of mortality attributed to PM exposure in 2017 was 35% from cardiovascular diseases, 22% from diabetes, 18% from non-malignant respiratory diseases, 12% from lung cancer, and 13% from other causes. Notably, a PM exposure mortality assessment tailored to Israel is needed because the composition of PM in Israel is different from that in Europe and the U.S. (i.e., high dust levels) and may be less toxic. The death rate from chronic obstructive pulmonary disease (COPD) attributed to ozone exposure in Israel has also remained constant in recent years (3.0 per 100,000 people in 2017).
Trends in Air Pollutant Concentrations (Annual Averages) at Selected Sights in Israel, 2001–2018
Figure 1 PM2.5 Israel Ministry of Environmental 35 Protection6
30
25 Environmental value
3 20 µ g/m
15
10 Target value
5
0
Year 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018
Legend: Haifa Haifa Holon Ashdod Tel Aviv Gedera Neve Shaanan Ahuza Industrial zone Antokolsky
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Ambient Air Quality
10 90 PM
80
70
60
Environmental 3 50 value µ g/m 40
30
20 Target value 10
0
Year 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018
Legend: Haifa Jerusalem Beer Yavne Tel Aviv Western Neve Shaanan Safra Sheva Yad Avner Galilee
O3 100
90
80 3 70 µ g/m
60
50
0
Year 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018
Legend: Haifa Jerusalem Beer Modiin Kerem Kiryat Sprinzak Safra Sheva Maharal
Western Gush Karmei Givat Galilee Etzion Yosef Hamoreh
* No annual target and environmental values were defined for ozone.
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NO2
50
40 Environmental value
3 30 µ g/m
20
10
0
Year 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018
Legend: Haifa Jerusalem Petah Tikva Nesher Tel Aviv Efrata Neve Shaanan Safra Road Yad Avner
80 NO2 (traffic monitoring stations)
70
60
50 3
40 µ g/m
30 Environmental value
20
10
0
Year 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018
Legend: Haifa Jerusalem Petah Tikva Tel Aviv Atzmaut Bar-Ilan Ahad Ha’am Amiel
Tel Aviv Rishon Bnei Brak Ironi Dalet Lezion Remez
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Ambient Air Quality
25 SO2
20 Environmental value
15 3 µ g/m
10
5
0
Year 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018
Legend: Haifa Haifa Pardes Tel Aviv Neve Shaanan Igud Hanna Antokolsky
Ashdod Hadera Ashkelon Igud Igud
In rural areas that have high concentrations of ozone, no decrease in concentrations was recorded. Moreover, the population-weighted mean exposure to ozone in Israel is significantly higher than the global average, the OECD average, and the European average (Figure 2).1 Therefore, it is essential to reduce emissions of ozone generating sources (hydrocarbons and NOx), including by promoting the use of renewable energy, encouraging green transportation, and implementing the updated National Plan for the Prevention and Mitigation of Air Pollution in Israel.9
Average Population-Weighted Ozone Exposure in Various Countries 60 Figure 2 Global Health Data 50 Exchange 20201
40 3
30 µ g/m
20
10
0
Year 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2004 2005 2003
Legend: OECD Global Europe West U.S. (avergae) (average) (average) Europe
Israel Australia UK China
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The challenge: Update target and environmental values for a range of air pollutants
In short: The target and environmental values of Challenge for the coming years: Continue some air pollutants are being updated. to update the target and environmental values periodically (in a five-year cycle).
The target and environmental values of twenty-eight contaminants were last determined in 2011 and are supposed to be updated every five years. MoEP is expected to submit the next update by the beginning of March 2022. As part of this process, MoEP prioritized the chemicals that have target values in need of updating and reviewed new information published by regulatory organizations such as the WHO, the European Environment Agency (EEA) and the U.S. Environmental Protection Agency (U.S. EPA). The process also includes discussions on updating the target values of seven air pollutants: toluene, styrene, nickel, NOx, suspended particulate matter (SPM), sulfate, and settling dust. MoEP is conducting an assessment of the environmental values of nine air pollutants (toluene, styrene, nickel, SO2, 1,2-dichloroethane, tetrachloroethylene, hydrogen sulfide, vanadium and arsenic). The assessment is expected to be completed in 2021. When the process of updating target and environmental values is completed, MoEP will present the Internal Affairs and Environment Committee of the Knesset with a proposal for its approval.
The challenge: Improve the spatial distribution of air monitoring stations
In short: In recent years, several monitoring Challenge for the coming years: Establish stations began operating in northern and additional air monitoring stations throughout the southern Israel; models were employed that country, especially in southern Israel. indicate the distribution of air pollutants in places far from established monitoring stations.
MoEP continues to establish new air quality monitoring stations and upgrade existing stations in order to monitor additional pollutants on the basis of two main criteria: areas with large or dense populations and proximity to emission sources. In recent years, monitoring stations were established in Ketura, Ashdod Port, Zikhron Yaakov, Atlit, Caesarea, and Tel Hai. (For a map of air monitoring stations in Israel, visit the MoEP website.)10 MoEP also set up air pollution monitoring stations east of the Leviathan natural gas rig for continual measurement of benzene. Another monitoring station is planned in the near future at Haifa Port. It is important to improve the spatial distribution of the air monitoring stations and to add stations in less populated places such as the Negev in order to include the populations of these areas in epidemiological studies and assist geo-climatic research that can validate and enhance the national models used in public health studies in Israel.
Notably, annual assessments of air pollutant concentrations and daily forecasts are based not only on information from these monitoring stations but also on computerized models of pollutant dispersion (CHIMERE), with which air pollutant levels in areas far from monitoring stations can be assessed.
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Ambient Air Quality The challenge: Improve planning of sustainable transport
In short: Several initiatives that support the Challenge for the coming years: Expand the transition to sustainable transport have been initiatives to additional cities, primarily in low- promoted in recent years. emission areas, and examine the impact of a low- emission zones on air pollution and public health.
MoEP, in collaboration with the Ministry of Transport, is leading several initiatives to improve and advance sustainable transport. Examples follow: support for low-emission zones - Several cities (Haifa and Jerusalem, for example) have imposed restrictions on diesel vehicles that fail to meet the Euro 4 air pollution standard or have not been fitted with a dedicated particulate filter for reducing air pollution. In Jerusalem, MoEP invested NIS 24 million to assist the municipality with this project, subsidizing the installation of filters for car owners and helping the Egged bus company to buy ten electric buses for use in the city11; promoting the use of electric buses - MoEP is offering public transport companies NIS 23 million in support for purchasing new electric buses (some eighty in all) for countrywide use12; promoting on-demand shuttle services such as Bubble;
promoting transition to electric or hybrid taxis - This project, in collaboration with the Jewish National Fund (KKL-JNF), provides a subvention of up to NIS 20,000 for taxis that switch to hybrid propulsion13; opening carpool lanes to reduce road congestion and traffic-related air pollution; supporting the transition of heavy vehicles to natural gas propulsion; implementing a NIS 260 million program for reducing emissions from old diesel trucks (by installing particulate filters and by scrapping)14; promoting the installation of particulate filters in trains; promoting installation of particulate filters in garbage trucks with NIS 10 million investment (in collaboration with KKL–JNF).15, 16
The challenge: Integrate epidemiological data from studies conducted in Israel into assessments of the burden of disease from air pollution and associated costs
In short: MoEP is funding several studies on the Challenge for the coming years: Publish the burden of disease in Israel from exposure to air findings as part of a burden of disease assessment pollution, focusing on the Haifa Bay area. on air pollution and the associated costs; expand the studies to other geographic regions.
In recent years, MoEP has funded eight epidemiological studies related to exposure to air pollution in Israel. Most studies under way focus on the population in the Haifa Bay area and compare it with populations elsewhere in the country. The studies span a range of research fields: biomonitoring, pregnancy outcomes, infant respiratory morbidity, incidence of cancer and heart disease, and economic assessments of the costs of exposure to ambient air pollutants.
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In addition, MoH has been examining asthma hospitalization rates in children and adults in Israel, by region, for more than twenty years (1996–2018). In collaboration with Clalit Health Services (which insures about 60% of Israel’s population), MoH is also assessing the incidence and prevalence of asthma in children (aged 2–18) and adults (25–54) by regions and districts in 1998–2015.
Since 2012, MoEP has been publishing assessments of the external costs of air pollution and greenhouse gas emissions in Israel, including the estimated cost of damage due to increased morbidity (Disability-Adjusted Life Years—DALYs) and mortality and to environmental impacts. At the present writing, MoEP is updating these assessments on the basis of the latest research and, in particular, the most recent WHO publications on the impact of air pollution on human health.17, 18 The update includes an assessment of external costs based on recently defined values in EU countries; presentation of a range of values for air pollution from industry and transport; forecasts of the impact of climate change (in order to reflect the uncertainty that attends to such assessments); weighting by per capita GDP and population density; adjusting costs to the Consumer Price Index; distinguishing between smokestacks higher than 100 meters and shorter ones; and applying a conservative approach to assessing the external cost of greenhouse gases based on the cost of damage.
The challenge: Collect data on the contribution of different sources to air pollution in Israel, using source apportionment techniques
In short: MoEP significantly expanded the list of Challenge for the coming years: Collect emission sources. information on the contribution of additional sources to air pollution in Israel; simulate chemical transport models.
The list of emission sources that MoEP collects and publishes has been expanded to include many additional sources: trains, ships, waste incineration, animal husbandry, burning of biomass in agriculture, and use of fireplaces.
MoEP is also studying strategies for reducing air pollution from shipping vessels at Haifa and Ashdod ports. A feasibility study commissioned by MoEP indicated that vessels at these ports are responsible for significant emissions of air pollutants that can affect air quality in populated areas near the ports. Moreover, vessels at Israel’s seaports accounted for about 16% of total SOx emissions, 8% of NOx emissions, and about 7% of PM2.5 emissions in 2018. In response, MoEP drafted recommendations on technological and regulatory measures that may mitigate emissions from these sources.19
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Research on Ambient Air Quality in Israel Ambient Air Quality
Exposure to Ambient Air Pollutants Researchers from the Technion Center of Excellence in Exposure Science and Environmental Health (TCEEH) have developed a modeling framework for estimating exposure to air pollutants among a representative sample of working Israeli adults (N ∼ 168,000) for whom both residential and workplace addresses were available. They found exposure misclassification that varies throughout the day, largely on account of intra-individual movement (between work, home, and other places). They also showed that short stays in areas with high concentrations of ambient air pollutants have a relatively small impact on overall exposure to pollutants.20
Researchers from MoEP and MoH, employing a hybrid model to assess the exposure of Israel’s population to various air pollutants, found that the entire population is exposed to concentrations of PM2.5 and PM10 that exceed target values though not environmental values and that over 1.5 million residents are exposed to concentrations of NOx that exceed target values.7
Researchers from Ben-Gurion University of the Negev and Soroka University Medical Center, studying the pattern of association between exposure to anthropogenic and non-anthropogenic PM and adverse health outcomes, found a linear correlation between exposure to PM10 and asthmatic exacerbations in asthma patients not related to a PM source.21
Several MoEP funded studies on exposure to ambient air pollutants in the Haifa Bay area are underway: (a) biological monitoring of air pollutants in blood donors living in the Haifa Bay area22; (b) associations between air pollutants and heart disease—heart failure and acute coronary syndrome; and (c) an economic assessment of the health impacts of exposure to air pollutants in the Haifa Bay area.
Researchers from TCEEH have launched a source apportionment study focusing on fine PM, in particular its varying spatiotemporal patterns and the atmospheric processes that govern these changes. The study aims to characterize and develop models of the chemical composition and of the distribution of the sources of PM emission in the Haifa Bay area. Its results may shed further light on the sources of fine particulate pollution and enhance the quality of the data used for exposure and risk assessment and for mitigation strategies.
Pregnancy and Childbirth Researchers from Ben-Gurion University of the Negev, in collaboration with colleagues from the Hebrew University of Jerusalem and Mount Sinai Hospital in New York, studied whether the exposure of pregnant women to ambient air pollutants and to extreme temperatures is associated with low birth weight and premature birth among the population of southern Israel. In the study, encompassing over 56,000 live births, it was found that exposure to below average temperatures during pregnancy may increase the risk of adverse birth outcomes such as low birth weight and premature birth, while exposure to above average temperatures may decrease the risk of premature birth.23
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Researchers from Maccabi Health Services and Tel Aviv University examined the head circumference of newborns in the Haifa Bay area using Maccabi Health Services’ database and did not find a higher prevalence of microcephaly (small head circumference in newborns) in Haifa Bay area in comparison with other areas in Israel.24
University of Haifa researchers evaluated a model for spatial identification of environmental health hazards potentially associated with observed reduced birth weight and reduced head circumference patterns. The researchers identified a site in Haifa’s industrial zone as a significant source of risk.25
Researchers from the Hebrew University of Jerusalem, TCEEH, Ben-Gurion University of the Negev, and MoH, in collaboration with colleagues from Columbia University and Harvard University, studied whether the exposure of pregnant women to traffic-related air pollutants is associated with miscarriages. The research population included pregnant women from Boston and from Tel Aviv District. In both populations, an association between exposure to high concentrations of traffic-related air pollution and miscarriage, particularly between the tenth and twentieth weeks of pregnancy, was found.26
A Ben-Gurion University of the Negev researcher reviewed the contribution of green infrastructure (urban vegetation such as trees, hedges, and bushes, green walls, and green roofs) to mitigating the risk of adverse birth outcomes—with an emphasis on premature birth—as a result of exposure to high ambient temperatures and air pollutants. Exposure to PM and extreme temperatures during pregnancy (especially during the first and third trimesters) was found to be associated with increased rates of premature birth whereas green infrastructure lowers PM and prevents the formation of urban heat islands. Thus, green infrastructure mitigates the adverse effects of exposure to PM and high temperatures on birth outcomes.27
Researchers from the Hebrew University of Jerusalem, Ben-Gurion University of the Negev, the University of Haifa, Tel Aviv University, Rambam Health Care Campus and Maccabi Health Services are analyzing “big data” of pregnancies and births in the Haifa Bay area, with data from 1998–2017 (~750,000 births). The project examines environmental effects (including exposure to ambient and indoor air pollution) on fetal development in Haifa Bay area in comparison with other areas in Israel.28
Researchers from the Hebrew University of Jerusalem, TCEEH, and the Harvard School of Public Health studied the link between traffic-related air pollution and autism spectrum disorder (ASD). The researchers examined whether mothers’ exposure to NO2 during pregnancy and newborns’ post-natal exposure to this pollutant were associated with a risk of ASD in children born in 2005–2009. It was found that exposure of newborns and toddlers to NO2, but not that of pregnant women, was associated with increased risk of developing ASD.29
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Ambient Air Quality In a follow-up study, researchers from the Hebrew University of Jerusalem, Columbia University, and Harvard University suggested two explanations for their findings on the inverse relationship between exposure to ambient air pollutants during pregnancy and ASD (relevant to live births). The first explanation attributes other ASD risk factors in addition to mother’s exposure to air pollutants; the second explanation relates to miscarriages of fetuses susceptible to ASD as a result of exposure to air pollutants.30
Three MoEP funded studies are under way on the following topics: (a) biological monitoring of organic pollutants and heavy metals in mothers and their children, and examination of the effects of exposure to ambient air pollutants during pregnancy on pregnancy outcomes; (b) examining the association between respiratory illness in infants and exposure to ambient air pollutants during pregnancy and infancy; (c) examining the association between environmental exposure to ambient air pollutants and fetal growth.
Biochemical and Physiological Outcomes Researchers from Tel Aviv University, the Ministry of Agriculture and Rural Development, Ben- Gurion University of the Negev, and Sheba Medical Center at Tel Hashomer developed a method for exposing primary epithelial cells to PM under laboratory conditions in a way that simulates nasal respiration. They found that this exposure triggers a physiological response expressed in heightened excretion of cellular molecules such as IL-8.31
Researchers from the Weizmann Institute of Science and Peking University studied the biochemical mechanism in which the Nrf2 transcription factor operates. Nrf2 can protect lung cells from the toxic effects of PM2.5 exposure. Lung cells silenced for Nrf2 become hypersensitive to PM and exposure to PAHs increases mortality in silenced cells. The researchers showed that silencing the factor induced accelerated mitochondrial activity and that exposure to various pollutants led to lower mitochondrial membrane potential and a lower mitochondrial DNA copy number. They concluded that Nrf2 serves as a mediator for mitochondrial activity following PM2.5 exposure.32
Researchers from Tel Aviv University, Bar-Ilan University, and the University of Haifa studied the impact of exposure to noise, different temperatures, and CO concentrations on the heart rates of Jewish and Muslim women in different environments (a green space such as a park, a city center, and a residential area). They demonstrated the positive effect of visiting green spaces, where CO levels are negligible, on the women’s heart rates.33
Respiratory Morbidity University of Haifa researchers reported on the prevalence of asthma among young men in urban areas in Israel (Tel Aviv, Haifa, Hadera) that have multiple sources of air pollution (industrial, traffic-related). They found that exposure to both industrial- and traffic-related air pollution have a negative effect on asthma risk in young males.34
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University of Haifa researchers developed a model for reducing morbidity caused by exposure to ambient air pollutants. The model involves removing the sources of emission from densely populated areas and replacing them with a green environment. Applying the model to the Haifa Bay area, they showed that relocating sources of emission would reduce the asthma morbidity rate among children in the area by about 70%.35
Researchers from the University of Haifa and the Israel Defense Forces (IDF) studied associations between exposure to various air pollutants (NO2 and SO2) and asthma morbidity. Examining data from over 137,000 candidates for military service (seventeen-year-old males) in 1999–2008 and using several models to assess the extent of exposure to these pollutants based on their place of residence, they found a strong direct correlation between exposure to NO2 and asthma morbidity in this population and a weaker direct correlation between exposure to SO2 and asthma morbidity.36
Cancer and Cardiovascular Diseases Researchers from Tel Aviv University, TCEEH, the Hebrew University of Jerusalem, and Hadassah, Beilinson and Hasharon medical centers studied the link between chronic exposure to traffic-related air pollutants and new cases of cancer in a population of 10,000 people suffering from coronary artery disease. They showed that a 10-ppb increase in mean exposure to NOx (indicating a traffic-related source) was associated with a higher risk of all types of cancer, particularly of the breast, lung, kidney, prostate, and bladder.37 In another study, the researchers found an association between a 10-ppb increase in mean exposure to NOx and increased risk of all-cause mortality among coronary-heart-disease patients (hazard ratio = 1.13).38
In a follow-up study, the same group of researchers used various models to examine the association between exposure to traffic-related air pollutants (NOx) and cancer. They found a statistically significant association between exposure to these pollutants and the incidence of cancers that had previously been linked to exposure to traffic-related pollutants (lung, breast and prostate cancer) but did not find an association between this exposure and other types of cancer.39
An MoEP funded study, under way, is investigating the association between exposure of seventeen-year-olds to environmental air pollutants in the Haifa Bay area and cancer incidence in adulthood.
Future Challenges
Recent years have seen progress in monitoring and studying ambient air pollutants and in reducing the emissions of some. However, improving air quality in Israel continues to pose significant challenges, primarily related to changes in the country’s energy economy. In late 2019, natural gas began to flow from the Leviathan rig, located about ten kilometers west of Haifa, opposite the
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Ambient Air Quality Zikhron Yaakov shore. Preparing for the flow of gas, MoEP set up monitoring stations to measure benzene, toluene, and ethylbenzene. According to MoEP, the rig will have an inconsequential effect on ambient air pollution, contributing only 1% of the benzene environmental value.40 Nevertheless, it is important to continue to monitor emissions from the rig along with other air pollutants along Israel’s coastline. The flow of natural gas to Israel offers additional opportunities in the field of energy, including the construction of gas-fired power stations (trigeneration plants) in new residential neighborhoods.41 Although trigeneration plants may reduce air pollutants in Israel overall, it is important to monitor pollutants emitted from these plants due to their proximity to population centers.
Most solid waste in Israel (76%) is sent to landfills. Incineration of waste in landfills is a major source of emissions of suspected or known carcinogens (about 60% of air emissions in 2018),4 and the expansion of this practice will likely lead to an increase in air emissions of carcinogens and population exposure to these contaminants. Given Israel’s dwindling land reserves, MoEP has been working during the past decade to reduce use of landfills and to encourage environmental alternatives for waste treatment. One such alternative is controlled waste incineration, in which energy is produced. This would entail the construction of three waste incineration facilities in close proximity to the populated areas that generate the waste, in order to reduce the cost and environmental harm involved in transporting waste.42 Despite the energy potential of the plan, a health impact assessment is required before it can be implemented.
In addition to industrial, transport, and natural air pollution, livestock farms emit air pollutants including PM, ammonia, NOx, and VOCs. Concerns about air pollutants emitted by livestock farms have been raised by the EEA and U.S. EPA. Israel needs to monitor air quality near livestock farms and conduct studies on the impact of this potential source of emissions.
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References
(1) Global Health Data Exchange (GHDx). GBD results tool. http://ghdx.healthdata.org/gbd-results-tool (retrieved July 2020).
(2) Negev, M. (2020). Air pollution policy in Israel. Atmosphere, 11(10), 1065. https://doi.org/10.3390/atmos11101065
(3) Israel Ministry of Environmental Protection (2013). National plan to prevent and reduce air pollution in Israel: Proposal for decision, Appendix 148, Revised Second Version (Hebrew). http://www.sviva.gov.il/subjectsEnv/SvivaAir/Documents/AirpollutionNationalPlan148.pdf (retrieved June 2020).
(4) Israel Ministry of Environmental Protection (2020). Assessing the current state of affairs, June 2020 (Hebrew).
(5) OECD better life index. Israel. http://www.oecdbetterlifeindex.org/countries/israel/ (retrieved October 2020).
(6) Israel Ministry of Environmental Protection. National Air Monitoring Array website–real-time data on air quality (Hebrew). https://www.svivaaqm.net/Default.rtl.aspx (retrieved June 2020).
(7) Levy, I., Karakis, I., Berman, T., Amitay, M., & Barnett-Itzhaki, Z. (2020). A hybrid model for evaluating exposure of the general population in Israel to air pollutants. Environmental Monitoring and Assessment, 192, 4. https://doi.org/10.1007/s10661-019-7960-8
(8) Global Burden of Disease and Organisation for Economic Co-operation and Development (2020). Air pollution effects (indicator). https://data.oecd.org/air/air-pollution-effects.htm#indicator-chart (retrieved June 2020).
(9) Israel Ministry of Environmental Protection. National plan for the prevention and mitigation of air pollution in Israel (Hebrew). http://www.sviva.gov.il/subjectsEnv/SvivaAir/Pages/NationalPlan.aspx (retrieved June 2020).
(10) Israel Ministry of Environmental Protection. Air quality monitoring stations map (Hebrew). http://www.sviva.gov.il/subjectsEnv/SvivaAir/AirQualityData/NationalAirMonitoing/Pages/MonitoringStationsMap.aspx (retrieved October 2020).
(11) Israel Ministry of Environmental Protection (updated September 2019). Ministry of Environmental Protection and Municipality of Jerusalem are promoting a low-emissions zone in Jerusalem (Hebrew). https://www.gov.il/he/departments/news/low_emission_zone_jerusalem (retrieved June 2020).
(12) Israel Ministry of Environmental Protection (updated May 2019). Electric buses (Hebrew). https://www.gov.il/he/departments/general/electric_buses (retrieved June 2020).
(13) Israel Ministry of Environmental Protection (updated June 2019). Low-pollution taxis – hybrid taxis (Hebrew). https://www.gov.il/he/Departments/Guides/hybrid_taxis (retrieved June 2020).
(14) Israel Ministry of Environmental Protection (2016). For the first time: State investment in reducing air pollution exceeds NIS 1.4 billion, with a new NIS 260 million program led by the Ministry of Environmental Protection to reduce air pollution from transport (Hebrew). http://www.sviva.gov.il/InfoServices/NewsAndEvents/ MessageDoverAndNews/Pages/2016/August2016/national-plan-vehicle-pollution.aspx (retrieved June 2020).
(15) Israel Ministry of Environmental Protection (updated March 2020). Reducing air pollution from diesel vehicles (Hebrew). https://www.gov.il/he/departments/guides/heavy_diesel_engines_program?chapterIndex=4 (retrieved June 2020).
(16) Israel Ministry of Environmental Protection (2017). 52 garbage trucks have already joined the revolution, with particulate filters installed! (Hebrew). http://www.sviva.gov.il/InfoServices/NewsAndEvents/ MessageDoverAndNews/Pages/2017/August2017/Installation-of-particle-filters-in-garbage-trucks.aspx (retrieved June 2020).
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Ambient Air Quality (17) Israel Ministry of Environmental Protection (updated March 2020). Documents for public comments: External costs of air pollutants and greenhouse gases – draft for public comments (Hebrew). https://www.gov.il/he/departments/publications/Call_for_bids/pc_external_costs_of_air_pollution (retrieved June 2020).
(18) Israel Ministry of Environmental Protection (2020). The Green Book – Assessment and measurement of environmental costs. External costs of air pollutants and greenhouse gases (Hebrew). https://www.gov.il/BlobFolder/reports/green_book_external_costs_air_pollutants_greenhouse_gases/he/ sustainability_economy_green_book_external_costs_air_pollution.pdf (retrieved August 2020).
(19) Israel Ministry of Environmental Protection (updated November 2019). A feasibility survey funded by the Ministry of Environmental Protection: Ships at the ports of Ashdod and Haifa generate severe air pollution of nitrogen and sulfur oxides (Hebrew). https://www.gov.il/he/departments/news/air_pollution_haifa_ashdod (retrieved June 2020).
(20) Shafran-Nathan, R., Yuval, & Broday, D. M. (2018). Impacts of personal mobility and diurnal concentration variability on exposure misclassification to ambient pollutants. Environmental Science & Technology, 52(6), 3520–3526. https://doi.org/10.1021/acs.est.7b05656
(21) Novack, L., Shenkar, Y., Shtein, A., Kloog, I., Sarov, B., & Novack, V. (2020). Anthropogenic or non- anthropogenic particulate matter: Which one is more dangerous and how to differentiate between the effects? Chemosphere, 240, 124954. https://doi.org/10.1016/j.chemosphere.2019.124954
(22) Hassan, L., Moser, A., Rorman, E., Groisman, L., Naor, Y., Shinar, E., ... Novack, L. (2020). Human biologic monitoring based on blood donations to the National Blood Services. BMC Public Health, 20(1), 469. https://doi.org/10.1186/s12889-020-08588-7
(23) Kloog, I., Novack, L., Erez, O., Just, A. C., & Raz, R. (2018). Associations between ambient air temperature, low birth weight and small for gestational age in term neonates in southern Israel. Environmental Health, 17(1), 76. https://doi.org/10.1186/s12940-018-0420-z
(24) Koren, G., Katz, R., & Shalev, V. (2018). Skull circumference of newborns in areas of pollution in the Gulf of Haifa. Harefuah, 157(10), 643–645 (Hebrew). https://cdn.doctorsonly.co.il/2018/10/10_gidon-koren_haifa.pdf
(25) Svechkina, A. & Portnov, B. A. (2019). Spatial identification of environmental health hazards potentially associated with adverse birth outcomes. Environmental Science and Pollution Research, 26(4), 3578–3592. https://doi.org/10.1007/s11356-018-3800-6
(26) Kioumourtzoglou, M. A., Raz, R., Wilson, A., Fluss, R., Nirel, R., Broday, D. M., ...Weisskopf, M. G. (2019). Traffic-related air pollution and pregnancy loss.Epidemiology, 30(1), 4–10. https://doi.org/10.1097/EDE.0000000000000918
(27) Kloog, I. (2019). Air pollution, ambient temperature, green space and preterm birth. Current Opinion in Pediatrics, 31(2), 237–243. https://doi.org/10.1097/MOP.0000000000000736
(28) Golan, R., Kloog, I., Almog, R., Gesser-Edelsburg, A., Negev, M., Jolles, M., ... Levine, H. (2018). Environmental exposures and fetal growth: The Haifa pregnancy cohort study. BMC Public Health, 18(1), 132. https://doi.org/10.1186/s12889-018-5030-8
(29) Raz, R., Levine, H., Pinto, O., Broday, D. M., Yuval, & Weisskopf, M. G. (2018). Traffic-related air pollution and Autism Spectrum Disorder: A population-based nested case-control study in Israel. American Journal of Epidemiology, 187(4), 717–725. https://doi.org/10.1093/aje/kwx294
(30) Raz, R., Kioumourtzoglou, M. A., & Weisskopf, M. G. (2018). Live-birth bias and observed associations between air pollution and autism. American Journal of Epidemiology, 187(11), 2292–2296. https://doi.org/10.1093/aje/kwy172
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(31) Elad, D., Zaretsky, U., Avraham, S., Gotlieb, R., Wolf, M., Katra, I., Sarig, S., & Zaady, E. (2018). In vitro exposure of nasal epithelial cells to atmospheric dust. Biomechanics and Modeling in Mechanobiology, 17, 891–901. https://doi.org/10.1007/s10237-017-0999-y
(32) Pardo, M., Xu, F., Shemesh, M., Qiu, X., Barak, Y., Zhu, T., & Rudich, Y. (2019). Nrf2 protects against diverse PM2.5 components-induced mitochondrial oxidative damage in lung cells. Science of the Total Environment, 669, 303–313. https://doi.org/10.1016/j.scitotenv.2019.01.436
(33) Saadi, D., Agay-Shay, K., Tirosh, E., & Schnell, I. (2018). A comparison of the effects of selected mono-ethnic urban environments on the autonomic functions of Muslim and Jewish women in Israel. Environmental Monitoring and Assessment, 190, 627. https://doi.org/10.1007/s10661-018-7000-0
(34) Greenberg, N., Carel, R. S., Dubnov, J., Derazne, E., & Portnov, B. A. (2019). Prevalence of asthma among young men residing in urban areas with different sources of air pollution. Israel Medical Association Journal, 12(21), 785–789. https://www.ima.org.il/FilesUploadPublic/IMAJ/0/393/196926.pdf
(35) Broitman, D. & Portnov, B. A. (2020). Forecasting health effects potentially associated with the relocation of a major air pollution source. Environmental Research, 182. https://doi.org/10.1016/j.envres.2019.109088
(36) Greenberg, N., Carel, R. S., Derazne, E., Tiktinsky, A., Tzur, D., & Portnov, B. A. (2017). Modeling long- term effects attributed to nitrogen dioxide (NO2) and sulfur dioxide (SO2) exposure on asthma morbidity in a nationwide cohort in Israel. Journal of Toxicology and Environmental Health, Part A, 80(6), 326–337. https://doi.org/10.1080/15287394.2017.1313800
(37) Cohen, G., Levy, I., Yuval, Kark, J. D., Levin, N., Witberg, G., ... Gerber, Y. (2018). Chronic exposure to traffic-related air pollution and cancer incidence among 10,000 patients undergoing percutaneous coronary interventions: A historical prospective study. European Journal of Preventive Cardiology, 25(6), 659–670. https://doi.org/10.1177/2047487318760892
(38) Cohen, G., Steinberg, D. M., Keinan-Boker, L., Yuval, Levy, I., Chen, S., ... Gerber, Y. (2020). Preexisting coronary heart disease and susceptibility to long-term effects of traffic-related air pollution: A matched cohort analysis. European Journal of Preventive Cardiology. https://doi.org/10.1177/2047487320921987
(39) Cohen, G., Steinberg, D. M., Yuval, Levy, I., Chen, S., Kark, J. D., ... Gerber, Y. (2019). Cancer and mortality in relation to traffic-related air pollution among coronary patients: Using an ensemble of exposure estimates to identify high-risk individuals. Environmental Research, 176, 108560. https://doi.org/10.1016/j.envres.2019.108560
(40) Israel Ministry of Environmental Protection. Gas production from the Leviathan rig - The position of the Ministry of Environmental Protection (Hebrew). https://www.sviva.gov.il/subjectsEnv/SeaAndShore/GassOilSea/gas_production_from_leviathan_rig/ Pages/moep_position_gas_production_from_leviathan.aspx (retrieved July 2020).
(41) Gutman, L. (2017, December 9). Soon: Mini power plants will generate electricity in residential neighborhoods (Hebrew). Calcalist. https://www.calcalist.co.il/local/articles/0,7340,L-3726966,00.html (retrieved December 2020).
(42) Israel Ministry of Environmental Protection (2018). A policy paper for developing waste to energy facilities in Israel (Hebrew). https://www.gov.il/BlobFolder/generalpage/tama_16_4/he/land_public_services_tama_16_4_1.pdf (retrieved June 2020).
- 26 - Chapter 2 Indoor Air Quality Indoor Air Quality
Indoor air quality (IAQ) refers to air quality inside closed environments such as buildings and their surroundings—private homes, offices, public buildings (for example, schools and hospitals), and mass transport systems. Poor IAQ may adversely affect the health of individuals who live or work in or around a building. Exposure to indoor air pollution creates a health risk because the majority of people in developed countries spend most of their time indoors and in enclosed spaces.
Indoor air pollutants include various types of chemicals: toxic gases such as carbon dioxide (CO2) and radon, volatile organic compounds (VOCs) such as benzene and formaldehyde, respirable particles, combustion products, pesticides, tobacco smoke, and microbial biological pollutants, among which are hundreds of strains of bacteria and fungi that thrive indoors in sufficiently damp conditions.1
Four factors affect IAQ: (a) indoor sources of pollutants including indoor biofuel for cooking and heating, materials used in construction and furniture, and products that emit VOCs; (b) the quality of ambient air entering the closed environment; (c) the rate of air exchange between the indoor environment and the outdoor environment; and (d) ventilation systems, which themselves often contain pollutants.
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Spending time in a closed building with poor IAQ may result in adverse short-term health outcomes such as upper and lower respiratory tract infections, allergic reactions, irritation of the eyes, nose and throat, headaches, dizziness, and even cognitive impairment.2 In addition, most exposure to polluted ambient air occurs when ambient air penetrates the indoor space. This may result in adverse long-term health outcomes such as respiratory diseases (asthma, chronic obstructive pulmonary disease [COPD] , bronchitis), heart disease, cancer, and diabetes.3 Certain population groups, like the elderly and nursing home residents, are considered particularly sensitive to indoor air pollution due to their age or underlying health conditions and the long hours they spend indoors.
Although there is no overarching legislation on IAQ in Israel, there are standards and regulations pertaining to indoor air (radon, ventilation requirements), some specified in building and planning codes and standards.4 Government ministries primarily address IAQ indirectly, by dealing with ambient air and establishing committees that regulate consumer products and furniture. Green building committees exist as well.
Israel’s warm climate poses challenges, especially related to home ventilation. Apartment air conditioners are widely used amid rising local living standards and global warming. Thus, Israelis are transitioning from natural ventilation (by opening windows) to more extensive use of air conditioners, most of which recirculate air. Despite the country’s warm climate, fireplaces and other means of open fire heating with biogenic fuel are also used in Israel.
Progress since 2017
The Environmental Health in Israel 2017 report defined challenges related to Indoor Air Quality. Progress in tackling them in the past three years is outlined below.
The challenge: Conduct a pilot study on indoor air pollution in schools
In short: Researchers at the Technion are researching VOC exposure in daycare centers in the Haifa Bay area.
Researchers at the Technion Center of Excellence in Exposure Science and Environmental Health (TCEEH) are studying VOC exposure in daycare centers in the Haifa Bay area, including research on the relationship between ambient air quality and IAQ. According to interim results, indoor concentrations of more than twenty VOCs exceeded the simultaneously measured outdoor concentrations of the same VOCs. The surfeit of VOC concentrations indoors is related to emissions from indoor sources and the slower breakdown of organic matter in a protected indoor environment than in an outdoor environment, caused, among other factors, by less photochemical decomposition
Legend: Significant progress Some progress Little or no progress
- 28 - Indoor Air Quality 5 1 Figure Zhang et al., 2020 GIvat Haim Ichud Kibbutz Einat Number of particles with diameters of 2.5–10 µm - 29 - Elad – Rashbi Elad – Raabad 5 : Study the health impacts of indoor air quality and the and the impacts of indoor air quality : Study the health Number of particles with diameters less than 2.5 µm Elad – Ben Zakai
: Several studies have been conducted. : Several studies have
0 0.5 1.5 1.0 2.0 IOR Legend: relationship between ambient air pollution and indoor air quality ambient air pollution and between relationship In short The challenge pub, emission of VOCs from polyurethane mattresses under different sleeping conditions, and the and the sleeping conditions, under different mattresses polyurethane from VOCs emission of pub, childhood and early to air pollution (indoor and outdoor) during pregnancy of exposure effect diseases. on respiratory Other studies focus on the impact of smoking outside a pub on PM concentrations inside the the inside PM concentrations a pub on smoking outside impact of the on Other studies focus Ratio of Indoor to Outdoor PM of Various Diameters, at Several Sites in Israel Diameters, at Several Sites in Israel Ratio of Indoor to Outdoor PM of Various University of Jerusalem found that indoor and outdoor PM concentrations (with diameters less less that indoor and outdoor PM concentrations (with diameters found of Jerusalem University 1 displays Figure area. similar in the same 2.5 to 10 µm) were than 2.5 µm and ranging from particles enter the the more (IOR): the higher the ratio, the ratio of indoor to outdoor particles and Kibbutz Einat, Kibbutz locations), in the city of Elad (three are The ratios shown building. Haim Ichud. Givat In recent years, several studies have been conducted on the relationship between ambient ambient between been conducted on the relationship studies have several years, In recent the Hebrew from researchers In one study, of IAQ. and the health effects air and indoor air in centers that extensively used natural ventilation (including those located near roads) than in than in near roads) those located (including ventilation used natural that extensively in centers other contaminants, and not on VOCs on only focused this study however, Importantly, others. matter (PM). such as particulate and oxidation due to the lack of direct sunlight. The study also found a strong effect of the rate of the rate effect a strong also found The study sunlight. the lack of direct due to and oxidation lower were concentrations VOC namely, in the daycares; concentrations VOC on of air exchange Environmental Health in Israel 2020 Chapter 2
The challenge: Formulate and publish recommendations for the public on ways of reducing exposure to indoor air contaminants
In short: The Ministry of Health published Challenge for the coming years: Leverage two documents: (a) recommendations for the the publications and raise public awareness of public on ways of reducing exposure to indoor indoor air contaminants. contaminants, and (b) raising public awareness of ways of reducing dampness and mold in buildings.
The Ministry of Health (MoH) published a factsheet on indoor air pollutants, focusing on the types and sources of pollution. The document presents a series of recommendations for reducing exposure to these contaminants, such as refraining from smoking inside the home and from using wood-burning fireplaces, assuring ventilation, avoiding dampness, and spending less time in underground parking garages.6
In late 2019, the National Council for Planning and Construction formulated a recommendation for the Minister of Finance on standards to protect against dampness.7
The challenge: Establish a central national authority to address indoor air quality
In short: No progress in meeting this challenge has been made.
To date, no central government authority has been established to address IAQ. Consequently, the topic receives neither priority nor funding. It is instructive to examine what other countries are doing: In the U.S., for example, a federal interagency committee on IAQ brings together representatives of various government agencies and departments, including the U.S. Environmental Protection Agency (U.S. EPA), the Department of Energy, the Occupational Safety and Health Administration (OSHA) and the Consumer Product Safety Commission (CPSC).8 In Germany, a national committee has been formed—the German Committee on Indoor Guide Values—to define values of indoor air pollutants.9 In South Korea, the government is instituting strict regulations on a wide range of indoor air contaminants.10
The challenge: Conduct research on residential dust
In short: No progress in meeting this challenge has been made.
- 30 - Indoor Air Quality - and ranging from 2.5 to 10 µm) were similar similar to 10 µm) were 2.5 and ranging from 31 - 12 report. One reason for this is the lack of a central governmental governmental central a of lack the is this for reason One report. 11 5 13 concentrations) and found that high temperature was the primary cause of increased VOC VOC the primary cause of increased was temperature that high found concentrations) and 2 Services are analyzing “big data” of pregnancies and births in the Haifa Bay area from 1998–2017 1998–2017 from area Bay Haifa the in births and pregnancies of data” “big analyzing are Services ambient to (including exposure effects environmental examines The project (~750,000 births). in comparison with another area Bay in the Haifa development and indoor air pollution) on fetal in Israel. area and outdoor PM concentrations in schools and residences. They found that indoor and outdoor that indoor and outdoor found They and residences. and outdoor PM concentrations in schools less than 2.5 µm PM concentrations (with diameters area. in the same Negev, the of University Ben-Gurion Jerusalem, of University Hebrew the from Researchers Health Campus and Maccabi Rambam Health Care University, Aviv Tel of Haifa, the University Researchers from the Hebrew University of Jerusalem examined the association between indoor indoor the association between examined of Jerusalem University the Hebrew from Researchers PM inside the pub. By measuring particle number concentrations with special sensors installed installed sensors concentrations with special particle number By measuring PM inside the pub. outside the and in a designated smoking area inside the pub, at the entrance to a pub in Haifa, in particle and an increase outside the pub smoking between an association found they pub, concentrations inside the pub. number emissions from the mattresses. emissions from and area Bay Haifa in the centers in daycare exposure VOC studying are TCEEH from Researchers ambient air quality and IAQ. between the relationship examining concentrations of outside of a pub affects smoking whether TCEEH examined from Researchers the Negev are studying associations between respiratory diseases and exposure to air pollution air pollution to and exposure diseases respiratory between associations studying are the Negev childhood. and in early during pregnancy (outdoor and indoor) polyurethane of types eight from VOCs eighteen of emissions TCEEH examined from Researchers and humidity levels, temperatures, conditions (different environmental under varied mattresses CO Researchers from TCEEH, the Hebrew University of Jerusalem, and Ben-Gurion University of of University and Ben-Gurion of Jerusalem, University TCEEH, the Hebrew from Researchers
impact on health. Such assessments may help shape relevant policy in Israel and formulation of of in Israel and formulation policy relevant help shape may impact on health. Such assessments schools in the context sites for in choosing safe example, planning committees—for guidelines for fields and industrial plants. of pollution, such as agricultural and other sources of main roads Environmental Health in Israel 2017 Israel in Health Environmental another is lack of support the issue; to address task force authority or joint inter-ministerial to indoor and outdoor air the particular sensitivity of children in this field. Given research for air pollution in schools in Israel, expand pilot studies on indoor pollution, it is essential to promote and assess their of these contaminants in schools, identify the sources of such research, the purview Future Challenges Challenges Future air pollution on public health has been of the harmful impact of indoor Although awareness highlighted in the has been made in tackling the challenges little progress years, in recent growing Research on Indoor Air Quality in Israel on Indoor Research Environmental Health in Israel 2020 Chapter 2
Another challenge is to gain a better understanding of indoor air pollutants in Israel. For example: Are there sources of indoor air pollution that are unique to Israel? Which indoor micro- environments are more affected than others by air contaminants? How do the climatic conditions (wind, humidity, and temperature) in Israel affect the dispersion of contaminants inside high-rise buildings and the relationship between ambient air quality and IAQ?
Green building is gaining momentum in Israel and in the world, contributing to environmental quality and energy savings and thus contributing to public health as well. Israel’s current green building standards, however, do not include separate criteria for indoor air pollution. Furthermore, the principles of green building may sometimes have an adverse effect on IAQ. For example, the emphasis on sealing and energy conservation comes at the expense of ventilation of rooms. Therefore, it is important to address these aspects and to explicitly incorporate criteria on indoor air pollution into green building standards. The standard that relates to adequate ventilation in buildings with no central ventilation systems focuses on the size and location of openings (such as windows). In the current reality, however, with the widespread use of apartment air conditioners, this standard may not attain its objective and should be re-evaluated.
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pdf . (1), 132. (Hebrew).
. (3), 344–352.
Decisions of the National Decisions of the National BMC Public Health, 18 (Hebrew). Environmental Science & Technology, Environmental Science & Technology, Environmental Management, 64 - 33 - החלטות-המועצה-הארצית-לתכנון-ובניה-עדכון-תמא- Assessing the current state of affairs, June 2020 June of affairs, Assessing the current state 10 (4), 529–534. https://doi.org/10.4103/jnrp.jnrp_123_18 (10), 1074. https://doi.org/10.3390/atmos11101074 International Journal of Hygiene and Environmental Health, of Hygiene and Environmental Health, International Journal /2019/12/ Atmosphere, 11 Atmosphere, , 105. Abstract presented at the annual conference of the International of the International conference at the annual , 105. Abstract presented Journal of Neurosciences in Rural Practice, 9 in Rural Practice, of Neurosciences Journal (3), 347–354. https://doi.org/10.1016/j.ijheh.2018.12.012 (15), 9171–9180. https://doi.org/10.1021/acs.est.9b01557 Drahler, D. & Fishbain, B. (2019). Spatiotemporal distribution of air particulate pollution in a pub. in a pub. (2019). Spatiotemporal distribution of air particulate pollution & Fishbain, B. D. Drahler, https://doi.org/10.1097/01.EE9.0000606852.85876.01 Yang, J., Seo, J. H., Jeong, N. N., & Sohn, J. R. (2019). Effects of legal regulation on indoor air quality in in on indoor air quality regulation of legal R. (2019). Effects & Sohn, J. N., N. H., Jeong, J. Seo, J., Yang, compound emissions from organic Volatile (2019). Y. & Dubowski, S., M., Sabach, Bareket, Kira, O., Israel Ministry of Health. Indoor air quality (Hebrew). Planning and Construction (2019). National Council for Israel Planning Authority, World Health Organization. Ambient air pollution: Health impacts. Ambient air pollution: Health Organization. World 2020). May (retrieved https://www.who.int/airpollution/ambient/health-impacts/en/ (2020). Protection Israel Ministry of Environmental ratio of particle of the indoor-to-outdoor (2020). Predictors M., & Raz, R. D. Broday, Yuval, S., Zhang, United States Environmental Protection Agency. Introduction to indoor air quality. Introduction Agency. Protection Environmental United States (2018). G. S. & Kumar, M. G., M., Majella, Sakthivel, K., Sivaranjini, G., Sarveswaran, Y., Krishnamoorthy, polyurethane mattresses under variable environmental conditions. conditions. environmental under variable mattresses polyurethane approach to regulate indoor air contaminants. indoor air contaminants. to regulate approach 222 Korea. in Seoul, populations: A field study sensitive for facilities https://doi.org/10.1007/s00267-019-01195-2 (retrieved June 2020). 2020). June (retrieved air quality committee on indoor Federal interagency Agency. Protection United States Environmental https://www.epa.gov/indoor-air-quality-iaq/federal-interagency-committee-indoor-air-quality 2020). April (retrieved The German M. (2019). Kraft, M., & Kolossa-Gehring, H., Röhl, C., Sagunski, H., Debiak, M., Fromme, (retrieved April 2020). 2020). April (retrieved 3, 2019 635, December Meeting No. Planning and Construction, Council for https://mpro.co.il/wp-content/uploads number concentrations in Israel. concentrations number https://www.epa.gov/indoor-air-quality-iaq/introduction-indoor-air-quality (retrieved May 2020). May (retrieved https://www.epa.gov/indoor-air-quality-iaq/introduction-indoor-air-quality South Puducherry, among adults in Rural impairment indoor air pollution and cognitive Association between India. Environmental exposures and fetal growth: The Haifa pregnancy cohort study. cohort study. pregnancy The Haifa growth: and fetal exposures Environmental https://doi.org/10.1186/s12889-018-5030-8 53 3 Environmental Epidemiology, The Netherlands. (ISEE), Utrecht, Epidemiology Environmental Society for https://www.health.gov.il/Subjects/Environmental_Health/Environmental_contaminants/Pages/intern-structural.aspx Golan, R., Kloog, I., Almog, R., Gesser-Edelsburg, A., Negev, M., Jolles, M., ... Levine, H. (2018). M., ... Levine, H. (2018). M., Jolles, A., Negev, R., Gesser-Edelsburg, I., Almog, (13) Golan, R., Kloog, (12) (10) (11) (8) (9) (6) (7) (3) (4) (5) (1) (2) References References Environmental Health in Israel 2020 Chapter 3
- 34 - Chapter 3 Tobacco Smoke Environmental Environmental Tobacco Smoke
Exposure to environmental tobacco smoke (ETS), also referred to as secondhand smoke or passive smoking, increases the risk of lung cancer. In adults, exposure to ETS increases the risk of ischemic heart disease, asthma, and reduced lung function. In children and fetuses, it is causally associated with negative respiratory and developmental effects including low birth weight, Sudden Infant Death Syndrome (SIDS), lower respiratory tract infections, middle ear infections, upper airway sensitization, asthma, and lifelong cardiovascular effects.1 Childhood exposure to ETS is also associated with Type 2 diabetes and obesity.
There is evidence that exposure to ETS increases the risk of breast cancer, nasal sinus cavity cancer, and nasopharyngeal cancer in adults, and of leukemia, lymphoma, and brain tumors in children.2
In Israel, smoking is banned in most closed public places including hospitals, schools and areas adjacent to them, trains and buses, restaurants, pubs, places of worship, and government buildings, as well as in some open public spaces such as playgrounds, zoos, swimming pools, railway station platforms, sports stadiums, and 75% of outdoor areas in pubs, restaurants, and wedding halls. Smoking is still permitted in designated areas in pubs, restaurants, and wedding halls, and there are special smoking rooms in the Knesset. The prohibitions on smoking in public places also apply to new tobacco products, such as electronic cigarettes and heat-not-burn tobacco products.
Despite extensive legislation to prevent exposure of the non-smoking population to ETS, surveys and studies show that over 50% of the Israeli population (including non-smokers and children) is exposed to ETS.3
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Progress since 2017
The Environmental Health in Israel 2017 report defined challenges related to Environmental Tobacco Smoke. Progress in meeting them during the past three years is outlined below.
The challenge: Validate analytical techniques to measure cotinine levels in blood, urine and saliva samples
In short: The Ministry of Health’s public health Challenge for the coming years: laboratory has validated and implemented a Continue to use the method. method for measuring cotinine levels in urine.
In 2018–2019, staff at the Ministry of Health’s public health laboratory implemented an analytical method for measuring urinary cotinine levels. The method was validated in an international quality assessment program and is being used in biomonitoring studies in Israel.
The challenge: Measure urinary cotinine levels in children
In short: Significant progress was achieved in Challenge for the coming years: measuring urinary cotinine levels in children. Continue biomonitoring cotinine as part of the National Biomonitoring Program.
In the National Health and Nutrition Survey (Rav-MABAT) in 2015–2016, urine samples were collected from 103 Jewish and Arab children aged 6–11, and urinary cotinine levels were measured to detect ETS exposure in the twenty-four hours prior to the sampling.4, 5 Cotinine was detected in 59% of the children’s urine samples, indicating exposure to ETS. This contrasts with parents’ self-report, according to which fewer than 40% of the children were exposed to ETS. Among the children sampled, cotinine levels among those exposed to ETS at home exceeded cotinine levels of the others. Cotinine levels were higher in children of low socioeconomic status in both the Jewish and Arab populations.
In an international comparison of average cotinine levels, the findings among Israeli children exceeded those among children in Canada, Germany, England and Cyprus (Figure 1).5
Recently published data from the Rav-MABAT survey (2015–2016) among over 1,500 children indicated that, according to parental reporting, 8.2% of children aged 2–11 were exposed to secondhand smoke to a large or very large extent (Jews: 3.9%, Arabs: 22.1%), while 22.3% were exposed to secondhand smoke to a small extent (Jews: 20.2%, Arabs: 29.4%) and 69.4% were not exposed at all (Jews: 76.0%, Arabs: 48.5%).6 It is possible the urinary measures of cotinine did not reflect differences in ETS exposure between Jewish and Arab children due to the small sample size of the study.
Legend: Significant progress Some progress Little or no progress
- 36 - 3, 7 Tobacco Smoke
In the same survey, cotinine levels were measured in urine samples of 200 adults. Focusing on a Environmental sub-population of 133 non-smokers, urinary cotinine was detected in about 60% of the samples, indicating exposure to ETS. Both the scope and the level of exposure to ETS in non-smokers were unchanged relative to the findings of a similar study in Israel in 2011. Average cotinine levels in non-smoking adults were higher among the Arab population than among the Jewish population. Furthermore, the percentage of non-smoking Arabs who reported being exposed to ETS at home was higher than the percentage of non-smoking Jews who reported such exposure.
Geometric Mean of Urinary Cotinine Levels in Children in Israel and in Selected Countries
1.8 Figure 1 1.6 Berman et al., 20185
1.4
1.2
1
0.8
0.6
0.4 Urinary concentration (μg/g) 0.2
0
Canada* Sweden Germany Ireland UK Cyprus Portugal Israel Poland Hungary
* Concentrations below the detection threshold were found in over 40% of the children; therefore, a geometric mean was not calculated.
The challenge: Measure urinary cotinine levels in pregnant women
In short: A study conducted at the Hadassah Challenge for the coming years: Continue Medical Center measured cotinine levels in biomonitoring cotinine levels in pregnant women pregnant women and in newborns. and in newborns from different population groups in Israel.
In a study conducted at the Hebrew University-Hadassah Braun School of Public Health and Community Medicine in collaboration with Ministry of Health (MoH) researchers, cotinine levels were measured in urine samples collected from 265 pregnant non-smoking women and ninety- seven newborns. Cotinine was detected in the urine of about 40% of the women and 29% of the newborns. No association was found between the women’s cotinine levels and those of the newborns. (Notably, the urine samples were collected from the women during their pregnancy and from the newborns—soon after their birth.) Higher cotinine levels were found among women whose husbands smoked. The researchers found an inverse correlation between cotinine levels in newborns and their birth weight and head circumference. That is, newborns who had been exposed to ETS during their mother’s pregnancy were born with smaller head circumference and lower body weight than those of newborns not exposed to ETS.8
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The challenge: Enforce legislation banning smoking in schools
In short: Legislation enacted in 2016 bans Challenge for the coming years: Collection of smoking in schools; enforcement has begun but data on smoking in schools in order to evaluate needs to be expanded. the need for enforcement.
A 2016 amendment to the Prevention of Smoking in Public Places and Exposure to Smoking Law completely banned smoking in schools, schoolyards, and anywhere within ten meters of a school entrance. In April 2018, the Director General of the Ministry of Education issued a circular regarding the implementation of the law and the enforcement policy concerning pupils and staff in the education system. The Ministry began to monitor enforcement in 360 elementary schools and anti-smoking curricular materials were updated and developed for different age groups— primary, junior-high, and senior-high.
The challenge: Collect and publish national data on the prevalence of asthma in children and on asthma medication use
In short: Data on asthma hospitalization Challenge for the coming years: Continue trends in 1996–2015 show a decline in asthma monitoring the prevalence of asthma in children, hospitalization rates among children. hospitalization rates, the prevalence of asthma medication use and doctor’s visits.
An MoH study that examined asthma hospitalization rates in children (aged 0–14) between 1996–2015, analyzed by regions, found a significant downward trend in rates over the years.9 A joint study by MoH and Clalit Health Services is examining trends in asthma incidence and prevalence among children aged 2–18 between 1998–2015.
The challenge: Enforce legislation banning smoking in public places
In short: Enforcement by municipal government Challenge for the coming years: Bolster is insufficient. municipal government enforcement of the ban on smoking in public places.
In 2018, new regulations expanded the ban on smoking in public places to open areas where over fifty people gather and to playgrounds, zoos, and parking garages. The injunction against smoking in public places was also extended to electronic cigarettes. Despite the expansion of anti-smoking regulations and various initiatives by local governments and the Israel Defense Forces (IDF), enforcement at the municipal level is insufficient and encounters a range of obstacles.
In 2018, municipal inspectors issued over 6,000 fines for violating the Prevention of Smoking in Public Places and Exposure to Smoking Law, mostly for smoking in restaurants and in hospitals (Figure 2).10 In many cities (Eilat, Haifa, Tur’an, Kefar Sava, Mevaseret Zion, Ma’ale Adumim, Nes Ziona, Acre, Afula, and Ramle), municipal inspectors were trained to enforce the law but few of those trained actually engage in enforcement.
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Number of Fines for Violating the Prevention of Smoking in Public Places and Exposure to Environmental Smoking Law, by Place of Violation, 2018 1,800 1,792 Figure 2 1,704 Israel Ministry of 1,600 Health10
1,400
1,200 1,084 1,000
800
Number of fines 600
443 480 400 364
200 226 98 27 29 0
Wedding Swimming Workplace Shopping Pub/ Other Stadium Train/bus Hospital Restaurant hall pool mall club station
As of 2019, seven municipalities (Herzliya, Kiryat Gat, Ashdod, Eilat, Ramle, Kefar Sava, and Ma’ale Adumim) joined the “Smoke-Free City” initiative, in which cities establish and enforce clear policies to ensure a smoke-free environment. Initiatives to bolster enforcement include Project Mahush (Promoting Innovation and Partnership), a collaborative effort involving municipal government, central government, and the public. The project aims to analyze patterns of ETS exposure, identify obstacles to enforcement and weaknesses in legislation, and jointly work to reduce ETS exposure.
In 2017, the IDF launched an intervention program aimed at reducing smoking and ETS exposure in the army. The program includes revisions of army policies and regulations, efforts to raise awareness of the harmful effects of smoking and to help soldiers quit smoking, and a gradual ban on selling smoking products on IDF bases. It was first applied on open bases and is gradually being expanded to other bases countrywide.
Research on Exposure to Environmental Tobacco Smoke in Israel
Researchers from Tel Aviv University examined parents’ views regarding the exposure of their children to ETS. They found that the parents’ awareness of their children’s exposure to ETS was based on sensory perception in the context of the physical environment (whether smoke can be smelled or inhaled).11 The same group of researchers examined an intervention program aimed at reducing the exposure of children to ETS; the program includes measurement of nicotine in children’s hair.12, 13
- 39 - Environmental Health in Israel 2020 Chapter 3
Tel Aviv University researchers asked what Israelis (smokers and non-smokers) know about cigarettes and found widespread ignorance of the harmful health effects of exposure to ETS. For example, 20% of the participants in the study did not know that ETS can cause lung cancer.14
Researchers from MoH and the Israel Center for Disease Control analyzed cotinine levels in urine samples collected from 103 children and 200 adults (unmatched) who participated in the Rav- MABAT survey in 2015–2016. Cotinine was found in the urine samples of 59% of the children and about 60% of the non-smoking adults.4, 7
In a joint study by researchers from the Hebrew University-Hadassah Braun School of Public Health and Community Medicine and MoH, cotinine levels were analyzed in urine samples of 265 pregnant non-smoking women and ninety-seven newborns. Cotinine was detected in the urine of about 40% of the women and 29% of the newborns.8
Researchers from the University of Haifa found a correlation between ETS exposure and an increased risk of breast cancer in Arab women.15
Researchers from the Weizmann Institute of Science, in collaboration with colleagues in the U.S. and Japan, studied cellular defense mechanisms in mice exposed to cigarette smoke. They showed that certain molecules enable cells that were exposed to cigarette smoke to avoid cell death by triggering autophagy (orderly degradation of non-vital cellular components).16
Researchers from Tel Aviv University and Mount Sinai Hospital in New York showed that ETS exposure affects atherosclerosis morbidity and is causally associated with coronary heart disease.17
Future Challenges
Several countries have adopted new policies that further restrict smoking in order to reduce exposure of non-smokers to ETS: Smoking has been banned in cars when children are present (New Zealand in 2020, Puerto Rico and several U.S. states: Arkansas, Louisiana, California, Utah, Oregon, and Vermont). In the U.S., smoking was banned in multi-unit public housing in 2018 and, in various counties in California, in shared areas of multi-unit buildings (in 2006 and onwards). In Ireland, Scotland, England, and several states in the U.S. (New York, Michigan, and Minnesota), smoking was completely banned in restaurants and pubs (2004–2009). Israel should consider adopting similar new restrictions and re-examining exceptions in existing restrictions on smoking in public places.
- 40 - Tobacco Smoke
New MoH legislation from December 2018 limits the advertisement of tobacco products, requires Environmental uniform packs without advertisements, and expands the ban on smoking in public places.18 The legislation also subjects electronic cigarettes to all restrictions and requirements that apply to tobacco products and restricts nicotine content in electronic cigarette liquids. It is important to study the longitudinal impact of the new legislation on smoking, vaping, and ETS exposure among the non-smoking public. It is also important to update the 2011 National Tobacco Control Plan to include ETS from regular cigarettes, electronic cigarettes, and heat-not-burn tobacco products. As vaping becomes increasingly popular among youth in Israel (26% of whom smoked electronic cigarettes as of 2019), it is important to enforce the restriction on nicotine content in electronic cigarette liquids to prevent early nicotine addiction.
To strengthen enforcement of the smoking ban in public places, MoH should create a dedicated unit and develop innovative tools for reporting on smoking in public places. It is critically important to increase municipal involvement in controlling smoking in public places.
In addition to bolstering enforcement and raising the general population’s awareness of the hazards of smoking and ETS exposure, the focus should be on high-risk populations—including the Arab population, low socioeconomic status groups, pregnant women, and people with mental illness living in hostels in the community.
References
(1) Centers for Disease Control and Prevention (updated 2020). Health effects of secondhand smoke. https://www.cdc.gov/tobacco/data_statistics/fact_sheets/secondhand_smoke/health_effects/ (retrieved May 2020).
(2) National Cancer Institute (updated 2018). Secondhand smoke and cancer. https://www.cancer.gov/about-cancer/causes-prevention/risk/tobacco/second-hand-smoke-fact-sheet (retrieved May 2020).
(3) Berman, T., Barnett-Itzhaki, Z., Mery, N., Keinan-Boker, L., Shimony, T., Goldsmith, R., ... Rosen, L. (2018). Exposure to environmental tobacco smoke in non-smoking adults in Israel: Results of the second Israel biomonitoring survey. Israel Journal of Health Policy Research, 7(1), 33. https://doi.org/10.1186/s13584-018-0229-9
(4) Israel Ministry of Health, Israel Center for Disease Control and Public Health Services (2018). Exposure of children to environmental tobacco smoke 2015–2016 (Hebrew). https://www.health.gov.il/PublicationsFiles/Exposing_children_environmental_tobacco_smoke_2015_2016.pdf (retrieved May 2020).
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(5) Berman, T., Barnett-Itzhaki, Z., Axelrod, R., Keinan-Boker, L., Shimony, T., Goldsmith, R., ... Rosen, L. (2018). Socioeconomic inequalities in exposure to environmental tobacco smoke in children in Israel. Environment International, 121(1), 643–648. https://doi.org/10.1016/j.envint.2018.09.034
(6) Israel Ministry of Health, Israel Center for Disease Control (2019). National child nutrition and health survey: First national nutrition and health survey of children 2-11 years old, 2015–2016, publication no. 391 (Hebrew). https://www.health.gov.il/publicationsfiles/mabat_kids2_11_2015-2016_full.pdf (retrieved May 2020).
(7) Israel Ministry of Health, Israel Center for Disease Control and Public Health Services (2018). Exposure of non- smoking adults to environmental smoking, 2015–2016 (Hebrew). https://www.health.gov.il/PublicationsFiles/cotinine2015_2016.pdf (retrieved May 2020).
(8) Ein-Mor, E., Berman, T., Barnett-Itzhaki, Z., Göen, T., Ergaz-Shaltiel, Z., Natsheh, J., ... Calderon-Margalit, R. (2019). Newborn infant urinary cotinine and birth outcomes in the Jerusalem Environment Mother and Child Cohort Study. International Journal of Hygiene and Environmental Health, 222(7), 1054–1058. https://doi.org/10.1016/j.ijheh.2019.07.006
(9) Israel Ministry of Health (2018). Regional disparities and trends in hospitalization for asthma in children, 1996–2015 (Hebrew). https://www.health.gov.il/NewsAndEvents/SpokemanMesseges/Documents/13122018.pdf (retrieved May 2020).
(10) Israel Ministry of Health (2020). Minister of health’s report on smoking in Israel 2019 (Hebrew). https://www.health.gov.il/PublicationsFiles/smoking_2019.pdf (retrieved November 2020).
(11) Rosen, L. J., Lev, E., Guttman, N., Tillinger, E., Rosenblat, S., Zucker, D. M., & Myers, V. (2018). Parental perceptions and misconceptions of child tobacco smoke exposure. Nicotine & Tobacco Research, 20(11), 1369–1377. https://doi.org/10.1093/ntr/ntx169
(12) Myers, V., Shiloh, S., & Rosen, L. (2018). Parental perceptions of children's exposure to tobacco smoke: Development and validation of a new measure. BMC Public Health, 18(1), 1031. https://doi.org/10.1186/s12889-018-5928-1
(13) Rosen, L., Guttman, N., Myers, V., Brown, N., Ram, A., Hovell, M., ... Zucker, D. (2018). Protecting young children from tobacco smoke exposure: A pilot study of Project Zero Exposure. Pediatrics, 141(1), 107–117. https://doi.org/10.1542/peds.2017-1026N
(14) Rosen, L. J., Rier, D. A., Schwartz, R., Talitman, M., & Zwanziger, L. (2019). Knowledge and risk perceptions of Israelis towards combustible cigarettes: The need for immediate remedial action. Israel Journal of Health Policy Research, 8(1), 10. https://doi.org/10.1186/s13584-018-0276-2
(15) Regev-Avraham, Z., Baron-Epel, O., Hammond, S. K., & Keinan-Boker, L. (2018). Passive smoking, NAT2 polymorphism, and breast cancer risk in Israeli Arab women: A case–control study. Breast Cancer, 25, 176–184. https://doi.org/10.1007/s12282-017-0809-5
(16) Mizumura, K., Justice, M. J., Schweitzer, K. S., Krishnan, S., Bronova, I., Berdyshev, E. V., ... Petrache, I. (2018). Sphingolipid regulation of lung epithelial cell mitophagy and necroptosis during cigarette smoke exposure. The FASEB Journal, 32(4), 1880–1890. https://doi.org/10.1096/fj.201700571R
(17) Yankelevitz, D. F., Cham, M. D., Hecht, H., Yip, R., Shemesh, J., Narula, J., & Henschke, C. I. (2017). The association of secondhand tobacco smoke and CT angiography-verified Coronary Atherosclerosis.JACC: Cardiovascular Imaging, 10(6), 652–659. https://doi.org/10.1016/j.jcmg.2016.07.003
(18) Rosen, L., Kislev, S., Bar-Zeev, Y., & Levine, H. (2020). Historic tobacco legislation in Israel: A moment to celebrate. Israel Journal of Health Policy Research, 9(1), 22. https://doi.org/10.1186/s13584-020-00384-3
- 42 - Chemical Parameters
Chapter 4 in Drinking Water Chemical Parameters in Drinking Water
Exposure to chemical contaminants in drinking water is associated with adverse health effects in human populations. Exposure to the disinfection byproducts trihalomethanes (THMs), for example, has been linked to increased risk of bladder cancer and exposure to lead in drinking water is associated with impaired cognitive development.
Drinking water contains essential minerals that serve as trace elements (micronutrients) in human nutrition and in the food chain. Desalinated seawater is low in mineral content because minerals are removed during the desalination process. Consumption of drinking water with low concentrations of certain minerals—such as calcium, magnesium, iodine, and fluoride—may have adverse effects on health. There is evidence, for example, of a relation between low concentrations of magnesium in drinking water and increased risk of cardiovascular disease and between low calcium content in drinking water and a higher risk of bone fractures in children, certain neurological diseases, preterm birth and low birth weight, and some types of cancer.1 This issue is particularly relevant in Israel due to the growing use of low-mineral desalinated water in the drinking water systems of most areas of the country.
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The chemical quality of drinking water in Israel is regulated by standards promulgated in 1974 and updated in 2013. The standards set maximum permitted levels of more than ninety chemical contaminants including metals, pesticides, radionuclides, and industrial organic pollutants. The standards require drinking water suppliers to conduct periodic testing for these contaminants in their sources (surface water, groundwater, and desalinated water) and to report the results to the Ministry of Health (MoH). While there is a requirement to add calcium to desalinated water, to date there is no requirement to add magnesium and iodine and the requirement to add fluoride is not implemented. Israel’s drinking water standards include mandatory testing of supply systems for metals (iron, copper, and lead), water treatment chemicals (such as chlorine), and disinfection byproducts (total THMs, chlorite, and chlorate).
Even if the drinking water source is contaminant-free, the supply system can harm the quality of the consumer’s tap water if, for example, pipes leach heavy metals. Therefore, all products that come into contact with drinking water (pipes, faucets, fixtures, and household drinking water systems) must meet the requirements of Israeli Standard 5452, which includes restrictions on lead content and leaching of heavy metals.
Progress since 2017
The Environmental Health in Israel 2017 report defined challenges relating to Chemical Parameters in Drinking Water. Progress achieved in this area during the past three years is outlined below.
The challenge: Conduct an updated survey to examine lead levels in tap water in residences and institutions, including schools
In short: In 2018, the MoH conducted a survey to quantify levels of heavy metals (including lead) in over 1,300 samples from drinking water taps in schools.
In 2018, MoH conducted a survey to quantify the levels of heavy metals in drinking water in schools (including kindergardens) throughout Israel, taking 1,379 drinking water samples in major cities and small towns in central Israel and in the periphery and analyzing them for lead, iron, and copper content. The concentrations of lead were below the standard in 99.6% of the samples, of iron in 99.7% of the samples, and of copper in 99.9% of the samples (Figure 1).2 In the few exceedances that were found, an investigation was conducted, flaws were repaired, and the water was resampled until the concentrations met the standard. There was no evidence of higher lead concentrations in samples containing both groundwater and desalinated water compared to those composed of groundwater only.3 The survey results indicate that lead concentrations in drinking water are lower in Israeli schools than in other countries. Although no surveys of lead in tap water are planned for the coming years, municipal authorities must routinely measure lead and other heavy metals in the supply system and make the findings available on an interactive online platform.
Legend: Significant progress Some progress Little or no progress
- 44 - Chemical Parameters in Drinking Water
2 1 Figure Israel Ministry of Health 7 0.4 92.6 Lead Lead : Enforce Israeli Israeli : Enforce Above standard - 0.3 33.9 65.8 Iron Iron 45 - Challenge for the coming years among awareness 5452; increase Standard water suppliers, contractors, and the public, and installing of the importance of purchasing meet the standard. that products Detected, below standard 0.1 80.5 19.4 Copper Copper : Develop requirements to limit the lead content of products to : Develop requirements Below level of detection : Israeli Standard 5452 was updated 5452 was updated : Israeli Standard
0%
30% 20% 10% 60% 50% 40% 90% 80% 70% 100% Percent of tested samples tested of Percent Legend: into contact with drinking water. into contact with drinking water. The challenge in contact with drinking water In short to limit lead content to to include requirements that come 0.25% in plastic and metal products 2011, to limit lead content to a maximum of 0.25% of product content. The mandate pertaining The mandate pertaining content. of 0.25% of product 2011, to limit lead content to a maximum went products 2018, and that pertaining to metal in March into effect went to plastic products 2020. in March into effect Following a joint effort by MoH and the Ministry of Economy and Industry (MoE), Israeli and Industry (MoE), Israeli MoH and the Ministry of Economy by a joint effort Following with updated was in contact with drinking water products plastic and metal 5452 for Standard Act, Water Reduction of Lead in Drinking modeled after the U.S. of a requirement, the addition Distribution of Metal Concentrations in Drinking Water in Israeli Schools Relative to Permitted Schools Relative in Israeli Water in Drinking of Metal Concentrations Distribution Standards Water Levels in Drinking Maximum Environmental Health in Israel 2020 Chapter 4
The challenge: Study the public health effects of consuming desalinated drinking water with low-mineral content
In short: Several studies examined the impact Challenge for the coming years: Continue to of consuming low-mineral desalinated water on research the public health effects of consuming cardiovascular diseases and thyroid function. low-mineral desalinated water.
Several studies in recent years examined the health effects of consuming desalinated drinking water with low-mineral content. Some of them investigated the association between morbidity and residence in a particular geographic area. Importantly, these studies were not based on individualized indices of mineral consumption by the study participants. Furthermore, residence in a particular geographic area yields limited information on consumption of desalinated water because the national water network provides a dynamic mix of desalinated water, water from the National Water Carrier, and groundwater, making it difficult to predict average mineral content in each geographic area.
Researchers from Bar-Ilan University and Sheba Medical Center at Tel Hashomer examined magnesium concentrations in tap water and in the blood of 380 patients who had been hospitalized for myocardial infarction in 2015–2017 and monitored the patients’ morbidity and mortality for a year. In areas where much of the water supply is based on desalinated water, lower concentrations of magnesium were measured in tap water and in patients’ blood whereas in areas where the water supply was based on groundwater or surface water higher magnesium concentrations were found (Figure 2). After a year of monitoring, the researchers found a non-significant increase in the risk of severe cardiac events and mortality in areas where much of the water supply was based on desalinated water.4
Researchers from Bar-Ilan University, Sheba Medical Center, and Clalit Health Services explored whether increased consumption of desalinated water was followed by an increase in adverse health outcomes (heart disease, diabetes, and high cholesterol) in Clalit patients aged 25–76 in 2004–2013. They found that the risk of heart disease rose in those years, following the substantial increase in the supply of desalinated water in Israel, while the risk of diabetes and high cholesterol remained unchanged.5
Researchers from the Hebrew University of Jerusalem studied the impact of desalinated water consumption on concentration of magnesium in blood, thyroid hormones, and use of cardiac medications among residents of Kefar Sava, Nes Ziona, and Rehovot. They found that switching to desalinated water consumption resulted in a decrease in magnesium in blood and thyroid hormone levels and an increase in use of cardiovascular medications.6
- 46 - Chemical Parameters in Drinking Water 4 2 Figure Shlezinger et al., 2019 ) 23 (n= 25.1±3.4 Areas based on groundwater or surface water on groundwater based Areas - 47 -
) 8 47 (n= Standard deviation Standard 7 5.1±2.2 Areas based on desalinated water based Areas Concentration of magnesium
5 0 15 10 30 25 20 mg/L Legend: only about 9% of the recommended daily iodine intake. They also found that only a negligible a negligible only that also found They iodine intake. daily 9% of the recommended about only containing iodine. 52% took supplements iodized salt and only consumed of women percentage was iodine intake Low 92% had iodine deficiency. supplements, did not take Among those who function. with thyroid associated significantly not receive desalinated water. not receive Medical Center and Barzilai University of Jerusalem University the Hebrew from Researchers receiving primarily area an in living women pregnant 105 among study cross-sectional a conducted iodine content provided with low that drinking water and found desalinated drinking water Services studied concentrations of hormones associated with thyroid function in 400,000 function in 400,000 hormones associated with thyroid Services studied concentrations of 2014–2016 with comparison in desalination) in upsurge the (before 2010–2013 in patients in various of hypothyroidism in the prevalence no changes found They (after the upsurge). differences no found they Likewise, desalination. in upsurge the after and before populations quantities larger received that areas geographic from in patients morbidity hypothyroidism in did that areas geographic from patients with comparison in 2013) (since water desalinated of As part of a study on the effects of iodine deficiency, researchers from Maccabi Health Health Maccabi from researchers deficiency, iodine of effects the on study a of part As Concentration of Magnesium in Tap Water in the Homes of Patients with Myocardial Infarction with Myocardial Homes of Patients in the Water in Tap of Magnesium Concentration Environmental Health in Israel 2020 Chapter 4
The challenge: Establish a central database of emerging contaminants in drinking water
In short: Data was collected on concentrations of Challenge for the coming years: Collect data drinking water contaminants that are not included on the presence of per- and polyfluoroalkyl in the drinking water standards, e.g., bromacil (a substances and disinfection byproducts herbicide) and carbamazepine (a pharmaceutical). (haloacetic acids) in drinking water in Israel.
The 2013 drinking water standards include over ninety chemical contaminants including metals, pesticides, radionuclides, and industrial organic pollutants.9
The MoH’s public health laboratory and other laboratories (e.g., that of Mekorot, the national drinking water supplier) have been testing water with new analytical techniques in order to detect chemicals not included in the drinking water standards. MoH is using data collected by the labs to create a database of contaminants in drinking water. This includes data on volatile and semi-volatile organic micropollutants from different sources and all metals in the supply systems. The data serve as a decision support tool for regulatory activities.
The MoH database includes, for example, data collected by MoH’s public health laboratory in 2017–2018 that indicated the presence of the herbicide bromacil in 43% of drinking water wells, with an average concentration of 0.3 µg/L. In addition, MoH calls for monitoring the presence of the pharmaceutical carbamazepine (CBZ) and other organic micropollutants in wells at continual risk of contamination (in dense residential areas). The presence of these substances in wells may indicate the possibility of groundwater pollution from sewage. Between 2012 and 2020, only 160 of 711 collected water samples had quantifiable concentrations of CBZ (>10 ng/L); the concentration of CBZ in the other 551 samples was not quantifiable. MoH also monitors toxins released by cyanobacteria in Lake Kinneret (the Sea of Galilee). Cylindrospermopsin, a cyanotoxin, is unregulated in Israel but is carefully monitored in drinking water, especially during seasons in which concentrations are elevated.
There is currently no comprehensive data in Israel on concentrations of per- and polyfluoroalkyl substances (PFAS) in drinking water. The Water Authority conducted a survey in wells (not supplying drinking water) in vulnerable locations (such as fuel tank farms, landfills, and military airfields) and found high concentrations of perfluorooctanoic acid (PFOA)—as much as 25,000 ng/L—and perfluorooctanesulfonic acid (PFOS)—as much as 610,000 ng/L, along with evidence of contamination with other PFAS chemicals (PFBS, PFHxA, PFHxS, PFHpA, PFNA). In a second survey, which included drinking water wells, the Water Authority found lower PFAS concentrations: The maximum PFOA value was 47 ng/L and the maximum PFOS value was 330 ng/L, compared with the Canadian drinking water standard of 200 ng/L for PFOA and 600 ng/L for PFOS. The Water Authority and MoH are planning additional surveys.
- 48 - Chemical Parameters in Drinking Water ; 5 10 : Reinstate : Reinstate and magnesium in blood; thyroid in blood; thyroid and magnesium 8 - 49
6 - Challenge for the coming years Challenge of desalinated drinking compulsory fluoridation water in Israel.
11 ; iodine intake and thyroid function and thyroid ; iodine intake 7 : Assess the impact of discontinuing fluoridation on children’s on children’s fluoridation the impact of discontinuing : Assess : Develop a model to estimate mineral content (iodine and content (iodine and : Develop a model to estimate mineral : No progress was made due to lack of funding. was made : No progress : HMO data shows a 100% increase in in shows a 100% increase : HMO data hormones; and use of cardiovascular medications. hormones; and use of cardiovascular hypothyroidism When tested with both artificial and real life datasets, the algorithm demonstrated high detection detection demonstrated high the algorithm datasets, real life When tested with both artificial and alarm rates. false and low of consuming desalinated drinking the health effects examined above, mentioned studies, Several and high cholesterol mineral content on rates of heart disease, diabetes, with low water Researchers from the Technion and Mekorot developed an algorithm for rapid detection of detection of rapid for an algorithm developed and Mekorot Technion the from Researchers (including nitrites and nitrates) using a UV spectrophotometer. contamination drinking water The challenge and points of consumption magnesium) at central mixing junctions In short In short with dental treatments the number of pediatric dental caries. sedation and a rise in The challenge status of low socioeconomic children especially among dental heath,
Research on Drinking Water Quality in Israel on Drinking Water Research According to nationwide data collected by the School Dental Service among twelve-year-olds, the the among twelve-year-olds, the School Dental Service data collected by to nationwide According in 2015 to 23% in 2017. 26% without dental caries declined from of children percentage compared to 38% of children in a 2014 national survey. The 2019 survey found an increase in in an increase found The 2019 survey in a 2014 national survey. to 38% of children compared in minerals is low Since desalinated water localities but not in Bedouin ones. caries in Jewish who drink in Bedouin localities, concluded that the children researchers (including fluoride), the by the discontinuation affected not adversely were that contains natural fluoride, groundwater of fluoridation. the year before fluoridation was discontinued, fewer than 5,000 children up to age five underwent underwent five age up to children than 5,000 fewer was discontinued, fluoridation before the year the of fluoridation, after the discontinuation years with anesthesia. In 2018, four dental procedures 100%. of over 10,000, an increase exceeded group age of pediatric dental sedations in this number Rahat, and Mitzpe Ramon, in southern Israel (Beer Sheva, of kindergartens In a 2019 survey dental caries, that 33% of them had no and found 283 children MoH examined Kuseife), Drinking water has not been fluorinated in Israel since 2014. According to HMO data from 2013, to HMO data from Israel since 2014. According has not been fluorinated in Drinking water Environmental Health in Israel 2020 Chapter 4
Researchers from Ben-Gurion University of the Negev, in collaboration with Dutch and British colleagues, developed a sensor for monitoring toxic compounds in water using genetically engineered (non-pathogenic) bacteria that respond to changes in water quality by emitting luminescence. The sensor was successfully tested in laboratory conditions and at the Meuse River in the Netherlands.12
Researchers from Mekorot and the Geological Survey of Israel, in collaboration with French researchers, developed a technique for monitoring the “isotopic fingerprints” of water (concentrations of isotopes of various elements, such as boron). The technique makes it possible to monitor desalinated water and reclaimed wastewater (such as that treated at the Shafdan facility) and facilitates the analysis of the water cycle (i.e., which water reaches which areas). It may be helpful in planning Israel’s water economy.13
Future Challenges
Theoretical work for a pilot study on the feasibility of adding magnesium to desalinated water was completed in 2020 and the on-site study is planned for 2021. A challenge for the coming years is to track the results of the pilot study and translate the findings into policy—compulsory addition of magnesium and an optimal level of this mineral in drinking water. In light of the rapid increase in consumption of low-mineral desalinated water, there is a need to examine the intake of micronutrients in Israel—including iodine, magnesium and fluoride—by using nutritional biomarkers. It is also important to study the effects of using low-mineral water in agriculture on the nutritional value of agricultural produce.
In 2018–2020, the EU issued recommendations on updating drinking water standards. The recommendation to lower the lead standard in drinking water to 5 μg/L will go into effect within fifteen years of its approval. One challenge for Israel in the coming years is to toughen its own standard on lead content in drinking water. Based on lead monitoring in the supply network, 99.6% of results comply with the standard. However, about 150 small localities do not routinely monitor lead in the supply network as required. It is imperative that all localities monitor lead in their supply networks in accordance with requirements in the drinking water standards. In addition, standards need to be set for new contaminants, such as haloacetic acid disinfectant byproducts and PFAS. To accomplish this, it will be necessary to collect data on the presence of haloacetic acid disinfectant byproducts and PFAS countrywide. Preliminary data from Water Authority surveys shows significant PFAS groundwater contamination in hotspots in Israel.
THMs are disinfection byproducts that are formed during chlorination of water with high levels of organic matter (such as surface water). Given the range of drinking water sources used in Israel (desalinated water, groundwater and surface water), each with its own level of organic
- 50 - Chemical Parameters in Drinking Water - 51 - (2012–2014), atrazine concentrations in drinking water sources have decreased but simazine but simazine decreased have sources in drinking water (2012–2014), atrazine concentrations monitoring concentrations of atrazine, not. It is important to continue concentrations have contamination. groundwater pesticides with potential for simazine, and additional additional toxic disinfection products, chlorite and chlorate. Efforts to reduce THMs, chlorite and chlorite and THMs, reduce to Efforts chlorite and chlorate. products, disinfection toxic additional of the Israeli a reassessment is also a need for There should be monitored. chlorate concentrations byproducts. these disinfection for standards major contaminants of drinking water been have the pesticides atrazine and simazine Historically, of the use of simazine the use of atrazine and discontinuation in the reduction in Israel. Following sampling results exceeded the standard of 100 µg/L in the summer of 2020. Due to the high high to the 2020. Due of summer µg/L in the 100 of the standard exceeded results sampling although brominated, THMs are of the that much it is likely content of the Sea of Galilee, bromate to methods several introduced has Mekorot Israel. in monitored routinely not is bromoform and a shift to time, of stagnation reduction stations, evaporation including THM levels reduce of two in the formation result may use of chlorine dioxide Notably, disinfection. chlorine dioxide material, there are major geographical and temporal fluctuations in concentrations of THMs. In In THMs. concentrations of fluctuations in and temporal major geographical are there material, of 5% Galilee, over the Sea of from water surface Israel that receive in northern communities Environmental Health in Israel 2020 Chapter 4
References
(1) World Health Organization (2009). Calcium and magnesium in drinking water: Public health significance. http://apps.who.int/iris/bitstream/10665/43836/1/9789241563550_eng.pdf (retrieved May 2020).
(2) Israel Ministry of Health (2018). Survey of metals in drinking water in educational institutions in Israel 2018 (Hebrew). https://www.health.gov.il/PublicationsFiles/Survey_of_Metals_in_Drinking_Water_in_Educational_- Institutions_in_Israel_2018.pdf (retrieved June 2020).
(3) Barnett-Itzhaki, Z., Eaton, J., Hen, I., & Berman, T. (2019). Heavy metal concentrations in drinking water in a country heavily reliant on desalination. Environmental Science and Pollution Research, 26, 19991–19996. https://doi.org/10.1007/s11356-019-05358-w
(4) Shlezinger, M., Amitai, Y., Goldenberg, I., Atar, S., & Shechter, M. (2019). Acute myocardial infarction severity, complications, and mortality associated with lack of magnesium intake through consumption of desalinated seawater. Magnesium Research, 32(2), 39–50. https://www.jle.com/10.1684/mrh.2019.0449
(5) Shlezinger, M., Amitai, Y., Akriv, A., Gabay, H., Shechter, M., & Leventer-Roberts, M. (2018). Association between exposure to desalinated sea water and ischemic heart disease, diabetes mellitus and colorectal cancer: A population-based study in Israel. Environmental Research, 166, 620–627. https://doi.org/10.1016/j.envres.2018.06.053
(6) Siman Tov, O. (April 2020). The health consequences of desalinated water consumption (master’s thesis). The Robert H. Smith Faculty of Agriculture, Food and Environment, The Hebrew University of Jerusalem.
(7) Koren, G., Amitai, Y., Shlezinger, M., Katz, R., & Shalev, V. (2018). Sea water desalination and removal of iodine: Effect on thyroid function. Journal of Water and Health, 16(3), 472–475. https://doi.org/10.2166/wh.2018.372
(8) Rosen, S. R., Ovadia, Y. S., Anteby, E. Y., Fytlovich, S., Aharoni, D., Zamir, D., Gefel, D., & Shenhav, S. (2020). Low intake of iodized salt and iodine containing supplements among pregnant women with apparently insufficient iodine status – time to change policy?Israel Journal of Health Policy Research, 9(1), 9. https://doi.org/10.1186/s13584-020-00367-4
(9) Israel Ministry of Health (2013). Collection of regulations, no. 7262, June 26, 2013. Public Health Regulations 2013. The sanitary quality of drinking water and drinking water facilities. https://www.health.gov.il/Subjects/Environmental_Health/drinking_water/Documents/Briut47-Eng.pdf (retrieved October 2020).
(10) Israel Ministry of Health, Dental Health Department (May 2020).
(11) Asheri Arnon, T., Ezra, S., & Fishbain, B. (2019). Water characterization and early contamination detection in highly varying stochastic background water, based on Machine Learning methodology for processing real- time UV-Spectrophotometry. Water Research, 155, 333–342. https://doi.org/10.1016/j.watres.2019.02.027
(12) Woutersen, M., van der Gaag, B., Abrafi Boakye, A., Mink, J., Marks, R. S., Wagenvoort, A. J., ... Heringa, M. B. (2017). Development and validation of an on-line water toxicity sensor with immobilized luminescent bacteria for on-line surface water monitoring. Sensors (Basel), 17(11), 2682. https://doi.org/10.3390/s17112682
(13) Kloppmann, W., Negev, I., Guttman, J., Goren, O., Gavrieli, I., Guerrot, C., ... Burg, A. (2018). Massive arrival of desalinated seawater in a regional urban water cycle: A multi-isotope study (B, S, O, H). Science of the Total Environment, 619–620, 272–280. https://doi.org/10.1016/j.scitotenv.2017.10.181
- 52 - Chapter 5 Wastewater Reclaimed Reclaimed Wastewater
Most raw wastewater (sewage) in Israel is treated in treatment plants. The treatment process includes biological, chemical, and physical methods to lower contaminant concentrations. In Israel, agricultural irrigation is the principal use (85%) of reclaimed wastewater (RWW). Roughly half of all water allocated for irrigation is RWW. Irrigation with RWW that meets the required Israeli quality standards is considered safe, however there is information on pathogens and organic contaminants, such as residues of pharmaceuticals or chemicals not routinely monitored, that may be absorbed by crops or may seep into groundwater. There is also concern that a temporary malfunction at a wastewater treatment plant could contaminate agricultural produce, streams, groundwater, and seawater.
Current RWW quality regulations in Israel address potential risks to public health that may result from transmitting pathogens and other contaminants from RWW to crops, groundwater, streams, and seawater, and ultimately to the public. The regulations also address the potential risks of metal concentrations in RWW to public health, environmental health, and agriculture. The Ministry of Health (MoH) and the Ministry of Environmental Protection (MoEP) jointly set quality standards for irrigation with RWW and discharge of effluents into streams. In addition, guidelines on irrigation with RWW require barriers between the water and the irrigated crops (for example, the use of drip irrigation or a specified minimal time interval between irrigation and harvest). Nevertheless, regulations have not been passed on monitoring and restricting a range of organic contaminants and micro-pollutants, such as pharmaceutical residues in RWW.
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Progress since 2017
The Environmental Health in Israel 2017 report defined challenges related to Reclaimed Wastewater. Progress achieved in this area during the past three years is outlined below.
The challenge: Conduct additional studies on potential exposure to pharmaceuticals and other contaminants via produce irrigated with reclaimed wastewater
In short: A study conducted found higher urinary Challenge for the coming years: concentrations of carbamazepine in populations Study potential exposure to additional micro- that consumed more vegetables; recent studies pollutants in crops irrigated with RWW. indicate the accumulation of carbamazepine in plants irrigated with RWW.
Researchers from the Hebrew University Center of Excellence in Agriculture and Environmental Health quantified urinary levels of carbamazepine (CBZ) and their metabolites in a reference group of healthy omnivorous adults and various sub-populations: children, pregnant women, the elderly, and vegetarians and vegans. High levels of CBZ were found among vegetarians, vegans, and other participants who consumed larger quantities of vegetables (Figure 1).1
Distribution of CBZ Urinary Concentrations in Sub-Populations in Israel 100% Figure 1 Schapira et al., 20201 90% 16 22 24.5 80% 34
70% 26
60% 32 38.7 50% 80.4
40% 52 30% 58 Percent of participants Percent 20% 46 36.7 10% 19.6 14 0% 65.8 92.6
Reference Pregnant women Vegetarians Elderly Children
Legend: Below LOD Between LOD and LOQ Above LOQ
Researchers from the Hebrew University of Jerusalem studied the uptake, transport, and metabolism of CBZ in various agricultural crops, in different parts of the plant, and compared crops irrigated with freshwater and fertilized with biosolids with those irrigated with RWW. They showed that the crops irrigated with RWW tended to accumulate higher concentrations of CBZ.2
Legend: Significant progress Some progress Little or no progress
- 54 - Wastewater
The challenge: Create a database that integrates chemical and microbial Reclaimed monitoring in sewage, reclaimed wastewater, in the field, and in agricultural produce
In short: The database, with monitoring data on Challenge for the coming years: Expand sewage and RWW, was created and is expected information in the database on chemical to be launched soon. monitoring in the field and in agricultural produce; consider data collection on antibiotic resistance from these sources and from hospitals.
MoH, MoEP and the Water Authority have created an integrated database that includes monitoring data on various contaminants in sewage, RWW, and sludge. The database, in advanced stages of development, allows direct data feed from accredited labs. The system includes a portal for online input of data from control procedures conducted by plant operators and allows for data analysis. At the present writing, the database contains tens of thousands of entries from some 400 wastewater treatment plants nationwide.
In addition to the information collected in the database, it may be useful to collect data on antibiotic resistant bacteria and antibiotic resistant genes in sewage, RWW, fields, and agricultural produce, and to cross reference them with data on antibiotic resistance from hospitals.
The challenge: Conduct a risk assessment of chemical contaminants in reclaimed wastewater
In short: No risk assessment on chemical contaminants in RWW, other than CBZ, has been conducted.
Research thus far has focused on CBZ. Studies on CBZ concentrations in plants irrigated with RWW have not shown that these concentrations pose a risk to public health. It is presumed, however, that RWW contains many other chemicals (micro-pollutants and pharmaceutical residues) that are not routinely monitored. Despite the widespread use of RWW to irrigate agricultural crops in Israel, no comprehensive risk assessment on the effects of these contaminants has been conducted. The regulations for RWW quality for agricultural irrigation in Israel comport with the World Health Organization’s (WHO) 2006 risk assessment, which focused primarily on heavy metals and pathogens. Risk assessments dealing with chemical micro-pollutants in RWW are very few in number.
Research on Reclaimed Wastewater in Israel
Researchers from the Hebrew University of Jerusalem exposed chicken eggs to low environmental concentrations of CBZ (0.02–0.2 pg/mg), resembling concentrations measured in RWW, and found that exposure to even low environmental concentrations induced increased embryonic mortality and teratogenic effects.3
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Researchers from the Hebrew University Center of Excellence in Agriculture and Environmental Health quantified urinary levels of CBZ and their metabolites in children, pregnant women, the elderly, vegetarians, and vegans. High levels of CBZ were found among vegetarians, vegans, and participants who consumed larger quantities of vegetables.1
Researchers from the Hebrew University of Jerusalem studied the uptake, transport, and metabolism of CBZ in various agricultural crops, in different parts of the plant, and compared crops irrigated with freshwater and fertilized with biosolids with those irrigated with RWW. They showed that the crops irrigated with RWW tended to accumulate higher concentrations of CBZ.2
Researchers from the Hebrew University of Jerusalem, in collaboration with colleagues from the University of Leeds and Al-Quds University in eastern Jerusalem, conducted a holistic analysis that included an assessment and examination of the transfer pathways of pharmaceuticals found in RWW used in agricultural irrigation. Attempting to assess the impact of these pollutants on human health and on ecological systems, the researchers concluded that broad research is needed to understand these effects.4
Researchers from Tel Aviv University analyzed regulation in various countries for monitoring and removing pharmaceuticals from various water sources—regulation that does not exist in Israel. Focusing on Switzerland, Austria, Singapore, and the U.S., where RWW is also used as a source of drinking water, the researchers offered several proposals for monitoring and treating these pollutants in Israel’s water systems, with emphasis on RWW, in order to reduce potential exposure of the public.5 Notably, no regulation exists anywhere in the world for monitoring and removing pharmaceuticals in RWW used for agricultural irrigation.
Researchers from Tel Aviv University showed that the use of ethanol-activated granular aerogel was effective in adsorbing persistent organic pollutants (POPs) in hospital raw wastewater.6
Researchers from the Hebrew University of Jerusalem, in collaboration with colleagues at the University of Chicago, studied the impact of RWW irrigation on a microbial community of soil and roots and on the growth of agricultural crops (tomato and lettuce). They found that in comparison with freshwater irrigation, RWW irrigation raised the level of soil acidity (pH) and increased the concentrations of various elements, such as potassium and sodium, in the soil. They also found that irrigation with RWW resulted in lower plant fruit and shoot weight and altered the plant’s soil and root microbiome.7
Researchers from the Agricultural Research Organization’s Volcani Center and the Hebrew University of Jerusalem found no correlation between the presence of certain antibiotic resistant genes (intl1) in RWW and their presence in soil irrigated with this wastewater, with the exception of sandy soils. They also found no evidence that antibiotic resistant genes were transferred from the RWW to the soil or to the plant.8
- 56 - Researchers from Ben-Gurion University in the Negev, in collaboration with colleagues from Wastewater the Volcani Center, the Newe Ya’ar Research Center, and from the Environmental Protection Reclaimed and Research Institute – Gaza, studied the role of physical barriers (drip irrigation or plastic mulch) in preventing bacterial transmission from irrigation water (with an emphasis on treated wastewater) to agricultural crops. The researchers quantified the concentrations of fecal bacteria in cucumber and melon plants irrigated with treated wastewater or potable water, with and without these barriers. No association was found between the type of barrier or water source and the concentrations of fecal bacteria in the soil or the crops.9
Future Challenges
Raw wastewater in Israel is treated regularly and, for the most part, efficiently. The existing wastewater treatment infrastructure, however, is insufficient for dealing with increasing loads, and with events involving exceptionally large quantities of raw wastewater, for example, during heavy rain. In such cases, excess untreated wastewater from the treatment plants is discharged to the environment, potentially exposing the population in Israel to a broad range of contaminants. In addition, the capacity of wastewater storage systems is inadequate (particularly during the winter, when there is no agricultural consumption of RWW). In these cases, wastewater is discharged into streams, posing a potential risk to public health. Consequently, it is necessary to improve the infrastructure for sewage treatment and RWW storage in Israel, and to adapt it to the steadily increasing volume of sewage and RWW.
In 2020, the Water Authority (via Mekorot, the national drinking water supplier, and in coordination with MoH and MoEP), launched a pilot facility for advanced treatment of RWW at the Shafdan plant—a preliminary step toward building an industrial facility for treating some RWW (5,000 m3/h) without soil aquifer treatment (SAT). The facility will utilize advanced technologies such as membrane bioreactor (MBR), ozonation, biological activated carbon filtration, and UV to remove a large range of micro-pollutants known as “contaminants of emerging concern” (CECs), including pharmaceuticals, per- and polyfluoroalkyl substances (PFAS), and other industrial pollutants. The facility is expected to treat about a quarter of the secondary treated effluent at the Shafdan site and to remove more than 80% of these contaminants. MoH, MoEP and the Water Authority are working to enhance control of micro-pollutant concentrations in industrial sewage, especially in the pharmaceutical industry.
Risk assessments are needed, as are holistic analyses that integrate data collected in the new database, monitoring of data from the field (soil and agricultural produce), and monitoring of biological data (for example, CBZ in urine). It is important that the risk assessments address exposure to a large number of chemicals and pharmaceuticals in RWW (by using, for example, additive or synergistic models). In light of growing evidence that municipal wastewater is a source of PFAS10 and POPs including flame retardants and organochlorine pesticides, it would also be worthwhile to consider monitoring other contaminants, such as PFAS, and POPs in RWW and sludge.
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References
(1) Schapira, M., Manor, O., Golan, N., Kalo, D., Mordehay, V., Kirshenbaum, N., … Paltiel, O. (2020). Involuntary human exposure to carbamazepine: A cross-sectional study of correlates across the lifespan and dietary spectrum. Environment International, 143, 105951. https://doi.org/10.1016/j.envint.2020.105951
(2) Ben Mordechay, E., Tarchitzky, J., Chen, Y., Shenker, M., & Chefetz, B. (2018). Composted biosolids and treated wastewater as sources of pharmaceuticals and personal care products for plant uptake: A case study with carbamazepine. Environmental Pollution, 232, 164–172. https://doi.org/10.1016/j.envpol.2017.09.029
(3) Kohl, A., Golan, N., Cinnamon, Y., Genin, O., Chefetz, B., & Sela-Donenfeld, D. (2019). A proof of concept study demonstrating that environmental levels of carbamazepine impair early stages of chick embryonic development. Environment International, 129, 583–594. https://doi.org/10.1016/j.envint.2019.03.064
(4) Carter, L. J., Chefetz, B., Abdeen, Z., & Boxall, A. B. A. (2019). Emerging investigator series: Towards a framework for establishing the impacts of pharmaceuticals in wastewater irrigation systems on agro- ecosystems and human health. Environmental Science: Processes & Impacts, 21(4), 605–622. https://doi.org/10.1039/c9em00020h
(5) Miarov, O., Tal, A., & Avisar, D. (2020). A critical evaluation of comparative regulatory strategies for monitoring pharmaceuticals in recycled wastewater. Journal of Environmental Management, 254, 109794. https://doi.org/10.1016/j.jenvman.2019.109794
(6) Prasanna, V. L., Mamane, H., Vadivel, V. K., & Avisar, D. (2020). Ethanol-activated granular aerogel as efficient adsorbent for persistent organic pollutants from real leachate and hospital wastewater.Journal of Hazardous Materials, 384, 121396. https://doi.org/10.1016/j.jhazmat.2019.121396
(7) Zolti, A., Green, S. J., Ben Mordechay, E., Hadar, Y., & Minz, D. (2019). Root microbiome response to treated wastewater irrigation. Science of the Total Environment, 655, 899–907. https://doi.org/10.1016/j.scitotenv.2018.11.251
(8) Marano, R. B. M., Zolti, A., Jurkevitch, E., & Cytryn, E. (2019). Antibiotic resistance and class 1 integron gene dynamics along effluent, reclaimed wastewater irrigated soil, crop continua: Elucidating potential risks and ecological constraints. Water Research, 164, 114906. https://doi.org/10.1016/j.watres.2019.114906
(9) Obayomi, O., Ghazaryan, L., Ben-Hur, M., Edelstein, M., Vonshak, A., Safi, J., Bernstein, N., & Gillor, O. (2019). The fate of pathogens in treated wastewater-soil-crops continuum and the effect of physical barriers. Science of the Total Environment, 681, 339–349. https://doi.org/10.1016/j.scitotenv.2019.04.378
(10) Coggan, T. L., Moodie, D., Kolobaric, A., Szabo, D., Shimeta, J., Crosbie, N. D., ... Clarke, B. O. (2019). An investigation into per- and polyfluoroalkyl substances (PFAS) in nineteen Australian wastewater treatment plants (WWTPs). Heliyon, 5(8), e02316. https://doi.org/10.1016/j.heliyon.2019.e02316
- 58 - Chapter 6 Pesticides Pesticides
Pesticides are substances or mixtures of substances that are meant to prevent, destroy, repel, or mitigate pests. They include products for use in agricultural plant protection and in rural and urban environments to control weeds and protect humans from pests and vector-borne diseases.
Acute exposure to high doses of certain pesticides, whether occupational or by accidental poisoning, can cause severe adverse health effects including neurological impacts and even death. Even chronic low-dose exposure to pesticides has been associated with neurological, respiratory, reproductive, and endocrine effects as well as cancer. Toxicological and epidemiological studies indicate that fetuses, infants, and children are especially vulnerable to the adverse effects of pesticides.
New classes of biological pesticides (containing bacteria or fungi), as well as chemical pesticides such as pyrethroids and neonicotinoids, are increasingly replacing pesticides that are known to be toxic for humans—for example, carbamates and organophosphates (OPs). Evidence of the toxicity of these new classes of chemical pesticides, however, has been emerging.1, 2
Four government authorities are responsible for registering pesticides in Israel: The Plant Protection and Inspection Services unit at the Ministry of Agriculture and Rural Development (MoAg) registers pesticides for plant protection. The Veterinary Services unit at MoAg registers pesticides and disinfectants for use in animals and animal husbandry. The Ministry of Environmental Protection (MoEP) registers pesticides used for sanitation purposes—that is, for controlling mosquitoes, rodents, and other pests harmful to humans and their property—in and around buildings and in open spaces. The Ministry of Health (MoH) registers pesticides that are applied on the human body, e.g., for lice treatment or mosquito repellant for topical use.
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Most of the pesticides sold in Israel are for plant protection—more than six tons of active ingredients in 2016—along with 135,000 kilograms of active ingredients for sanitation and 33,780 kilograms of active ingredients for veterinary use.3
The authorities responsible for registering pesticide formulations also share responsibility for monitoring their use. MoAg and MoH monitor pesticide residues in food—MoAg in local produce at the farm level, MoH in products on the market as well as food imports.4 MoEP oversees the use of pesticides for sanitation; MoAg oversees their veterinary and plant protection use. Since MoAg is the authority that registers herbicides, commonly known as weed killers, it also bears responsibility for overseeing herbicide use outside of agricultural areas, e.g., in cities.
MoEP and MoAg are jointly responsible for two standards that establish mandatory minimum distances from buildings that must be maintained when applying pesticides from the ground and air. MoEP is responsible for ensuring that these distances are maintained when pesticides are sprayed from the air or in proximity to water reservoirs and streams. The Ministry of Labor and Social Welfare is responsible for the safety of agricultural workers.
The environmental NGO Adam Teva V’din (the Israel Union for Environmental Defense) is advocating legislation that would require the government to prepare a national plan for reducing the use of pesticides. In the absence of regular Knesset committee hearings in 2019 (due to the political impasse), however, the initiative did not move forward. Even without a national plan, MoAg is promoting initiatives to reduce pesticide use—for example, a project targeting the Mediterranean fruit fly that includes non-chemical pest control.4
Progress since 2017
The Environmental Health in Israel 2017 report defined challenges related to Pesticides. Progress achieved in this area during the past three years is outlined below.
The challenge: Conduct periodic re-evaluation of all active ingredients approved for plant protection
In short: MoAg, in conjunction with the inter- Challenge for the coming years: As part of ministerial advisory committee on pesticide the phaseout of active ingredients, the advisory formulations for plant protection, re-evaluated committee should study pesticide substitutes; forty-six active substances used in 130 different furthermore, pesticides registered in Israel for pesticide formulations. These substances are many years that have not been evaluated in the registered in Israel but not in Europe. revisions should be re-evaluated.
In 2017–2019, MoAg and the inter-ministerial advisory committee on pesticide formulations for plant protection re-evaluated forty-six active ingredients that are registered in Israel but not in Europe.5
Legend: Significant progress Some progress Little or no progress
- 60 - Pesticides 5 1 Table Israel Ministry of and Rural Agriculture Development
June 2020 November 2018 June 2019 December 2020 December 2019 November 2019 September 2020 Last Date for Selling Formulations Formulations Last Date for Selling Containing the Active Ingredient June 2020 - 61 - Following this re-evaluation MoAg published a MoAg published a this re-evaluation Following
Carcinogenic Carcinogenic and harms fertility Carcinogenic and in the in Europe Not registered U.S.; acute toxicity Lack of agricultural need Carcinogenic Main Reason for Phaseout a toxicity (classified as Chronic mutagen, harms fertility) chronic high acute toxicity, Very disease) toxicity (Parkinson’s Harms the developing fetus
In a re-evaluation of urban use of glyphosate, MoAg allowed the continued use of use of the continued MoAg allowed of urban use of glyphosate, In a re-evaluation
6
Alachlor Guatazine Tetradifon Maneb Propargite Iprodione Carbendazim Paraquat Active Active Ingredient
prohibited. areas. in Israel, including in non-agricultural this ingredient the use of four active ingredients and banned the use of one – diniconazole-M. and banned the use of one – diniconazole-M. ingredients active the use of four such as towns, areas herbicides used in non-agricultural addressed Another re-evaluation reservoirs. and the vicinity of water roadsides, their use is permitted or and cited places where use in such areas for list of herbicides approved The re-evaluation in 2017–2019 followed earlier rounds, including an evaluation of eleven active active of eleven an evaluation including earlier rounds, in 2017–2019 followed The re-evaluation MoAg restricted the latter evaluation, Following in 2016–2017. the triazole family from ingredients the use of eight active ingredients (Table 1). Decisions on the other active ingredients are slated to slated to are ingredients 1). Decisions on the other active (Table ingredients the use of eight active of 2020. course be published in the Phased Out in Israel Pesticides Plant Protection active ingredients are herbicides; another third are insecticides and acaracides. MoAg published MoAg published and acaracides. insecticides are third herbicides; another are ingredients active to pesticide manufacturers asked it others, For five ingredients. active decisions on thirty-two ingredients active the forty-six Of further evaluation. for documentation submit additional the use of discontinuing committee recommended the in Israel and not in Europe, registered phasing out MoAg was 2020, as of March recommendations, Based on the committee’s seventeen. The list of ingredients was not compiled on the basis of toxicity or potential public health risk; health risk; or potential public of toxicity on the basis not compiled was ingredients The list of of these About one-third in Europe. is not registered that the ingredient was the sole criterion Environmental Health in Israel 2020 Chapter 6
The challenge: Conduct biomonitoring of organophosphates
In short: In recent years, data have been Challenge for the coming years: Expand published on the scope of exposure of adults biomonitoring to additional groups of pesticides. and sub-populations (children, pregnant women, and newborns) in Israel to organophosphate pesticides.
In recent years, data have been published on the Israeli public’s exposure to OP pesticides.
Researchers from the Hebrew University-Hadassah Braun School of Public Health and Community Medicine, collected urine samples from 273 pregnant women and from 107 newborns in 2012–2016, and measured OP metabolites. Researchers found a ~35% decrease in the concentration of total OP metabolites in the samples from both population groups during the period studied. No decrease was observed in the concentration of diethyl phosphate (DEP) metabolites.7 Similar findings were reported in an MoH study, part of the 2015–2016 National Health and Nutrition Survey (Rav-MABAT), that measured concentrations of urinary OP metabolites in 200 adults and 103 children. The researchers found a statistically significant decrease in urinary OP metabolites among adults compared with 2011 (Figure 1).8 As in the findings on OP pesticides among pregnant women and newborns, no decrease in the concentration of DEP metabolites was observed. The OP decrease was apparently the result of restrictions imposed on the agricultural use of certain OPs in 2012–2014. The quantity of OPs sold for agricultural use in Israel dropped from an average of 164 tons/year in 2008–2010 to 103 tons/year in 2012–2016.3 However, the fact that there was no decrease in concentrations of DEP metabolites raises concerns that the use of certain active ingredients such as chlorpyrifos and dimethoate did not decline.
Biomonitoring results in recent years in Israel indicate an association between fruit consumption and OP exposure. Among pregnant women who reported eating fruit in the twenty-four hours preceding urine collection, the concentration of a specific chlorpyrifos metabolite (TCPy) was twice as high as in women who did not report eating fruit before urine collection (3.0 μg/L versus 1.5 μg/L).9 Among children, concentrations of OP metabolites were higher in those who consumed large quantities of fruit than in those who consumed smaller quantities.10
As part of the National Biomonitoring Program, an additional survey to monitor public exposure to OP and pyrethroid pesticides began in 2020.
- 62 - Pesticides
8 1 Figure Israel Ministry of Health : Continue to : Continue to 2018) shows that in in that 2018) shows – 2015 - 63 - Challenge for the coming years conduct risk assessments of additional groups of pesticides, and in additional vulnerable groups such as women of childbearing age. A multi-year comparison (2013 comparison A multi-year 11 2011 : Conduct risk assessment on pesticides based on children’s diet based on children’s : Conduct risk assessment on pesticides 12 2018, there was a relative increase in the percentage of exceedances, along with a along with a of exceedances, in the percentage increase a relative was 2018, there – : MoH conducted a risk assessment on : MoH conducted a risk assessment on
0 10 60 50 40 30 20 90 80 70
100 Year
g/g) µ ( concentration Urinary The challenge In short to OP pesticides based on children’s exposure diet. residues in 2017; half of them were not considered exceedances when compared with standards with standards compared when exceedances not considered in 2017; half of them were residues in EU countries. pesticide residues in 36.7% of the samples. pesticide residues 2017 the years 2). (Figure found were residues no pesticide of samples in which in the percentage decrease pesticide tested for in 11% of the samples found were exceedances to a MoAg report, According MoAg and appeared in an MoH position paper on chlorpyrifos. in an MoH position paper MoAg and appeared pesticide of based on the results partly was assessment exposure the aforementioned Importantly, MoH of markets, in Israel. In its monitoring marketed produce farm monitoring of fresh residue in 2017–2018 and detected no 2,000 samples taken in 12.7% of approximately exceedances found Based on dietary data from the 2015–2016 Rav-MABAT survey, MoH assessed the risks associated MoH assessed the risks associated survey, Rav-MABAT the 2015–2016 Based on dietary data from and to chlorpyrifos exposure that children’s to pesticides and found exposure with children’s set by Intake—ADI) Daily (Acceptable values the health reference exceeded pesticides dimethoate to presented were of the risk assessment results The (EFSA). Authority Safety Food the European Concentrations of Total Non-Specific Organophosphate Metabolites in Urine in Adults in Israel, in Urine in Metabolites Non-Specific Organophosphate of Total Concentrations 2015 vs. 2011 Environmental Health in Israel 2020 Chapter 6
Pesticide Residues in Food—Ministry of Health Monitoring Results, 2013–2018 Figure 2 100% Israel Ministry 4 8 7 11 11 of Health 90% 13
80% 33 28 24 70% 46
60% 50
50%
40% Percent of samlpes Percent
30% 63 64 65 20% 47 37 10%
65.8 0% Year 2013 2014 2015 2016 2017–2018
Legend: No residue detected Below maximum residue level Exceedances
The challenge: Establish a national database on pesticide poisoning in Israel
In short: In Israel, there is no systematic collection of data on all cases of pesticide poisoning.
There is no systematic collection of data on all cases of pesticide poisoning in Israel. However, the Israel Poison Information Center at the Rambam Health Care Campus collects and publishes data on inquiries from the public and from physicians. Importantly, the Center’s data do not distinguish between cases of poisoning from agricultural pesticides and those from sanitation pesticides.
According to data on pesticide poisoning in 2018, there were over 1,200 inquiries concerning poisoning from insecticides, about eighty concerning poisoning from herbicides, and more than 100 concerning poisoning from rodenticides. Eleven of the seventy-seven inquiries related to OP poisoning were cases of severe toxicity. Also reported were 589 cases of poisoning from exposure to pyrethroid insecticides, thirty-three from glyphosate formulations, and fourteen from paraquat, two of them severe. Although the number of inquiries received by the Israel Poison Information Center has been increasing in recent years, the number of OP pesticide-related poisonings has been decreasing (Figure 3).13
- 64 - Pesticides 13 3 Figure 2019 Bentor, Pyrethroids 2018 Paraquat Paraquat (herbicide) 2017 - Glyphosate Glyphosate (herbicide) 65 - 2012 Rodenticides 14 2007 : Monitor pesticides in the air near schools and residences : Monitor pesticides in the air near schools and residences : Improve enforcement of sale and use of agricultural pesticides of sale enforcement : Improve Organophosphates : There is no government plan in Israel for monitoring pesticides near schools and residences, is no government plan in Israel for monitoring pesticides near schools and residences, : There : Legislation is needed to improve oversight in this area. No significant progress has been made made has been No significant progress oversight in this area. : Legislation is needed to improve
0
Year 200 100 600 500 400 300 Number of poison exposure cases exposure poison of Number Legend: The challenge In short no academic studies in this field. are and there In short use of toxic pesticides. in advancing legislation to limit the sale and The challenge the concentrations of these substances in the air decreased but remained higher than the level than the level higher remained but decreased the air in substances these of concentrations the detected during spraying. A study initiated by the Regional Councils Center at Emek Hefer measured air concentrations air concentrations measured Hefer the Regional Councils Center at Emek initiated by A study community the Bat Hefer Ma’abarot, Kibbutz Hefer: localities in Emek of pesticides near three of pesticides the adsorption examining The researchers, Local Council. and Elyakhin settlement, and spirotetramat, pendimethalin pesticides, of two higher air concentrations found on filters, after spraying, hours Twenty-four spraying. than before after spraying eight hours about for those labeled for use by the public. In the absence of regular Knesset committee hearings in in hearings committee Knesset regular of absence the In public. the by use for labeled those the Israel Union for by Legislation proposed not approved. were these measures 2019, however, addresses Risk,” Reducing Pesticide Law: Protection titled “Public Health Defense, Environmental submitted to the bill, The pesticides. dangerous particularly handle who workers the need to train paralysis. also stalled due to the Knesset’s Knesset in late 2017, was Under the proposed Safety Regulations at Work (Occupational Hygiene and Workers’ Health in Health in Workers’ and Hygiene (Occupational Work at Regulations Safety the proposed Under pesticides except or purchase apply may trained professionals specially 2018, only Pesticides), Pesticide Poisoning in Israel, by Type of Pesticide, 2007–2018 of by Type Poisoning in Israel, Pesticide Environmental Health in Israel 2020 Chapter 6
In August 2017, MoEP issued professional guidelines for pest control in and around schools.15 The guidelines prohibit pesticide and herbicide use when children are present. Pesticide application in a school is permitted only after approval of the responsible official in the local government and in coordination with the principal of the school. However, there are no available data on the extent of implementation of the new guidelines by schools and local authorities.
The challenge: Advance uniform and comprehensive legislation on registration and use of all types of pesticides (including the establishment of an umbrella committee on pesticide registration and/or unification of registration committees)
In short: The inter-ministerial steering committee on pesticide registration has discussed the issue, without result.
The Israel Union for Environmental Defense is advocating a reform that would help to standardize registration requirements and working methods for all active ingredients and pesticide formulations and would require revision every few years based on clear criteria—for example, the level of risk posed by the pesticide.
Research on Exposure to Pesticides in Israel
Researchers from Ben-Gurion University of the Negev examined the effects of prenatal exposure to chlorpyrifos in mice and found that exposure to this OP impairs social skills. The impairment is different in males compared with females.16 The researchers also found that prenatal exposure to chlorpyrifos causes behavioral disorders similar to autism.17
Researchers from Tel Aviv University and the Technion Center of Excellence in Exposure Science and Environmental Health (TCEEH), examining the environmental behavior of chlorpyrifos after it is sprayed on leaves, found that the environmental half-life of chlorpyrifos on leaves is 0.9–6.9 hours.18
Researchers from the Agricultural Research Organization’s Volcani Center and Kimron Veterinary Institute measured pesticide residues in cherry tomatoes as a function of irrigation water salinity, household rinsing, and storage. They found that washing the tomatoes for thirty seconds under running water was ineffective in removing pesticide residues from the peel.19
Researchers from the Hebrew University Center of Excellence in Agriculture and Environmental Health, MoAg, and Volcani Center studied the effects of the herbicide atrazine on sperm quality and the impact of early exposure to food additives on these effects in goats. They found that exposure to atrazine harms sperm quality and that early exposure to the food additive pistacia lentiscus mitigates the toxic effect of atrazine among goats to some extent.20 Researchers from the Hebrew University of Jerusalem, examining the effect of atrazine exposure on bovine sperm, found that sperm cells are particularly sensitive to atrazine.21
- 66 - Pesticides 22 7 - 67 - 8, 10 Quds University in eastern Jerusalem, Al-Hussein Governmental Hospital in Beit Jala, and Augusta and Augusta Jala, Hospital in Beit Governmental Al-Hussein Jerusalem, in eastern Quds University and Palestinian in the Jewish pesticides organochlorine to Hospital studied exposure Victoria and lymphoma non-Hodgkin’s an association between found researchers The populations. Arab population only. Arab (DDE) in the Palestinian to dichlorodiphenyldichloroethylene exposure Researchers from the Hebrew University-Hadassah Braun School of Public Health and Public Health and Braun School of University-Hadassah the Hebrew from Researchers in and 107 newborns women 273 pregnant collected urine samples from Medicine Community metabolites. and non-specific urinary OP specific 2012–2016, and measured Al- in Montreal, General Hospital Jewish of Jerusalem, University the Hebrew from Researchers Researchers from MoH measured concentrations of urinary OP metabolites in 200 adults and 200 adults and in urinary OP metabolites concentrations of MoH measured from Researchers survey. as part of the Rav-MABAT 103 children
pesticide residues). Thus, food may enter Israel even if it was treated with a pesticide that is with a pesticide that is treated if it was enter Israel even may food Thus, pesticide residues). example, committee (for the inter-ministerial by to a risk assessment use pursuant banned for this issue. solution is needed to address certain OPs). A regulatory maximum permissible residue levels. MoAg also supports the gradual phaseout of critical uses of of critical uses of phaseout the gradual MoAg also supports levels. permissible residue maximum sectors. agricultural harm to certain and immediate direct to avoid in order formulations imported to Residues), 1991, food to the Public Health Regulations (Food) (Pesticide According for (the international standard Alimentarius or the Codex the Israeli standard meet Israel must Several active ingredients that are especially toxic and at the same time very effective, including including effective, very time and at the same toxic especially that are ingredients active Several economic and Therefore, phaseout in the coming years. slated for paraquat and carbendazim, are the accelerated registration MoAg favors substitutes. needed to develop are incentives regulatory countries in developed been registered already that have or substitute formulations of less toxic on also entail adopting international regulation This would and the U.S.). Europe (primarily The results of various analyses—monitoring pesticide residues in food, biomonitoring urinary urinary biomonitoring food, in residues pesticide analyses—monitoring various of results The the need to tighten diet—indicate based on children’s and assessing OP exposure OPs in children, is also a need to There measures. use in Israel and to adopt enforcement of pesticide oversight them. to public exposure pesticides and of the use reduce to order in outreach information expand cooperate. must MoH and MoAg, particularly entities, all relevant bring this about, To pesticide, mainly in orchards and vineyards, and residue exceedances are still found in agricultural in agricultural still found are exceedances and residue and vineyards, in orchards pesticide, mainly committee advisory the inter-ministerial characteristics of chlorpyrifos, the toxicological Given produce. of chlorpyrifos canceling the registration recommended protection plant for on pesticide formulations the use of this pesticide altogether. in Israel. MoAg should consider banning formulations Future Challenges Future While plant protection. for of the OP pesticide chlorpyrifos In December 2019, the EU banned the use it still permits use of this be applied, may chlorpyrifos which for the list of crops Israel has narrowed Environmental Health in Israel 2020 Chapter 6
A regulatory framework is needed for prohibiting the sale of especially toxic pesticides to the public and restricting their use. Both the Ministry of Labor and Social Affairs and the Israel Union for Environmental Defense have proposed regulatory solutions that have not advanced due to the political impasse in 2019.
As part of its re-evaluation of the OP chlorpyrifos, MoH presented data from biomonitoring studies and a risk assessment based on children’s diet. The challenge in the coming years is to expand the use of these tools to additional groups of pesticides, including pyrethroids and neonicotinoids, and to additional groups of vulnerable populations including women of childbearing age.
References
(1) Eskenazi, B., An, S., Rauch, S. A., Coker, E. S., Maphula, A., Obida, M., ... Chevrier, J. (2018). Prenatal exposure to DDT and pyrethroids for malaria control and child neurodevelopment: The VHEMBE Cohort, South Africa. Environmental Health Perspectives, 126(4), 047004. https://doi.org/10.1289/EHP2129
(2) Caron-Beaudoin, É., Viau, R., & Sanderson, J. T. (2018). Effects of neonicotinoid pesticides on promoter- specific aromatase (CYP19) expression in Hs578t breast cancer cells and the role of the VEGF pathway. Environmental Health Perspectives, 126(4), 047014. https://doi.org/10.1289/EHP2698
(3) Israel Central Bureau of Statistics (2019). Table 3: Pesticides sold for use in agriculture–active ingredients, by usage purpose and by chemical family, 2008-2016. https://www.cbs.gov.il/he/publications/DocLib/2019/1744/t03.pdf (retrieved March 2020).
(4) Israel Ministry of Agriculture and Rural Development, Plant Protection and Inspection Services (2019). Summary of conference: “Pesticides in Agricultural Produce—Not What You Thought.” November 6, 2019 (Hebrew). https://www.moag.gov.il/ppis/Yechidot/chimistry/rishum_rishuy/pirsumim/2019/Documents/sikum_ kenes_hadbara_27%2011%2019.pdf (retrieved March 2020).
(5) Israel Ministry of Agriculture and Rural Development. Reexamination (revision) of pesticides (Hebrew). https://www.moag.gov.il/ppis/Yechidot/chimistry/rishum_rishuy/pirsumim/2018/Pages/behina_ mehadash_hadbara.aspx (retrieved August 2020).
(6) Israel Ministry of Agriculture and Rural Development, Plant Protection and Inspection Services (2018). Redefinition of the term “fallow areas” that appears on labels of weed killers (Hebrew). https://www.moag.gov.il/ppis/Yechidot/chimistry/rishum_rishuy/Documents/shithei_bor_michtav.pdf (retrieved March 2020).
(7) Ein-Mor, E., Ergaz-Shaltiel, Z., Berman, T., Göen, T., Natsheh, J., Ben-Chetrit, A., Haimov-Kochman, R., & Calderon-Margalit, R. (2018). Decreasing urinary organophosphate pesticide metabolites among pregnant women and their offspring in Jerusalem: Impact of regulatory restrictions on agricultural organophosphate pesticides use? International Journal of Hygiene and Environmental Health, 221(5), 775–781. https://doi.org/10.1016/j.ijheh.2018.03.013
(8) Israel Ministry of Health, Israel Center for Disease Control and Public Health Services (2018). Exposure to organophosphate pesticides among adults in Israel 2015-2016. Part A: Trends and international comparison (Hebrew). https://www.health.gov.il/publicationsfiles/organic_phosphates_2015_2016.pdf (retrieved March 2020).
- 68 - Pesticides . , 2. , 2. Behavioral and Brain Functions, 15 Behavioral and Brain Functions, (retrieved March 2020). March (retrieved (12), 800. , 108739. , 74–80. - Analysis of pesticide residue monitoring in food of pesticide residue monitoring in food Analysis , 117–123. 69 - Ten principles for using pesticides in and around using pesticides in and around principles for Ten (Hebrew).
Agronomy, 9 Agronomy, , 43. https://doi.org/10.1186/s12940-017-0251-3 Chemosphere, 171 Chemosphere,
Theriogenology, 140 Theriogenology, Environmental Research, 182 Research, Environmental , 395–402. https://doi.org/10.1016/j.chemosphere.2018.09.069 National Food Service (2020). National Food Service
(Hebrew). (Hebrew). https://www.health.gov.il/PublicationsFiles/pest_findings2017-2018.pdf https://www.health.gov.il/PublicationsFiles/pest_findings2017-2018.pdf (Hebrew). Environmental Health, 16 Exposures and poisonings from pesticides: Data from the Israel Poison Information Center Information from pesticides: Data from the Israel Poison Exposures and poisonings , 124858. https://doi.org/10.1016/j.chemosphere.2019.124858 Chemosphere, 213 Chemosphere, https://doi.org/10.1016/j.chemosphere.2016.12.013 https://www.moag.gov.il/ppis/Yechidot/chimistry/rishum_rishuy/pirsumim/2019/Documents/seker_ https://doi.org/10.1016/j.envres.2019.108739 https://doi.org/10.1016/j.theriogenology.2019.08.026 https://doi.org/10.3390/agronomy9120800 https://www.gov.il/BlobFolder/generalpage/safe_extermination_in_schools/he/PestControl_PestControl_ Calderon, R. (February, 2020), personal communication. 2020), personal R. (February, Calderon, Nekudat Hen (in press). Monitoring pesticides in the air as a basis for agreement in the agricultural- agreement Monitoring pesticides in the air as a basis for Nekudat Hen (in press). Bentor, Y. (2019). Y. Bentor, Israel Ministry of Health, Israel Ministry of Health, Israel Ministry of Agriculture and Rural Development, Plant Protection and Inspection Services (2019). and Inspection Services (2019). Plant Protection and Rural Development, Israel Ministry of Agriculture 2017 produce, in local farm Survey of pesticide residues Goldsmith, R. (2020). Organophosphate pesticide exposure in children in Israel: Dietary associations and associations and in Israel: Dietary children in pesticide exposure R. (2020). Organophosphate Goldsmith, risk assessment. for implications in Israel, 2017-2018 2020). March (retrieved Berman, T., Barnett-Itzhaki, Z., Göen, T., Hamama, Z., Axelrod, R., Keinan-Boker, L., Shimony, T., & & T., L., Shimony, R., Keinan-Boker, Hamama, Z., Axelrod, T., Z., Göen, Barnett-Itzhaki, T., Berman, Palestinians. Palestinians. Komsky-Elbaz, A., Zubov, A., & Roth, Z. (2019). Effect of the herbicide atrazine and its major metabolite, of the herbicide atrazine and its major metabolite, & Roth, Z. (2019). Effect A., A., Zubov, Komsky-Elbaz, sperm cryotolerance. on bovine DACT, O. R., Choshen-Cohen, L., Abdeen, Z., Hussein, E., ... Paltiel, Abu Seir, Kleinstern, G., A. J., Klil-Drori, and in Israeli Jews study A case-control lymphoma: and non-Hodgkin (2018). Serum organochlorines distribution kinetics of pesticides in cherry tomato peel, pulp, and fruit as a function of irrigation water water function of irrigation and fruit as a peel, pulp, distribution kinetics of pesticides in cherry tomato regimen. and storage household rinsing, salinity, & Roth, Z. (2019). S., Y. H., Landau, Azaizeh, N., Argov-Argaman, Biran, D., M., A., Saktsier, Komsky-Elbaz, feed. polyphenol-enriched by extent spermatozoa is alleviated to some in goat Atrazine-induced toxicity 236 Chemosphere, Lan, A., Kalimian, M., Amram, B., & Kofman, O. (2017). Prenatal chlorpyrifos leads to autism-like deficits deficits leads to autism-like chlorpyrifos (2017). Prenatal O. & Kofman, Lan, A., Kalimian, M., Amram, B., in C57Bl6/J mice. of the the fate affecting processes environmental (2017). Key Y. Dubowski, & O., Zivan, S., Sabach, Y., Lester, to leaves. applied insecticide chloropyrifos & Fallik, E. (2019). Residual Y., Kaye, S., R., Barel, Sperling, Y., Chena, V., A., Bommuraj, Shimshoni, J. principles_application_pesticide_educational_institutions.pdf social innate and conditioned (2019). Impaired O. & Kofman, D., Toiber, M., Portillo, Lan, A., Stein, D., to chlorpyrifos. exposed in adult C57Bl6/J mice prenatally behavior https://doi.org/10.1186/s12993-019-0153-3 Oral presentation, Israel Ministry of Agriculture and Rural Development conference: “Pesticides in in “Pesticides conference: Rural Development and Ministry of Agriculture Israel Oral presentation, (Hebrew). Israel Beit Dagan, Thought.” You What Produce—Not Agricultural (Hebrew). interface community (2017). Protection Israel Ministry of Environmental educational institutions hadbara_totzeret_tria_2017.pdf (retrieved in March 2020). 2020). in March (retrieved hadbara_totzeret_tria_2017.pdf
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(18) (19) (12) (13) (11) (9) (10 (21) (22) (20) (17) (16) (14) (15) Environmental Health in Israel 2020 Chapter 7
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Chapter 7 Chemical Food Contaminants Chemical Food Contaminants
Chemical food contaminants are substances that are not intentionally added to food but may be present in various food products. They include inorganic and organic substances that enter the food chain from a range of sources, such as environmental pollution, agricultural methods, storage conditions, production and processing procedures, and packaging. Some of these contaminants are formed naturally in the soil, water or air; others are byproducts of the processing and production process itself.
Toxic substances such as dioxins, per- and polyfluoroalkyl substances (PFAS), polychlorinated biphenyls (PCBs), polybrominated biphenyls (PBBs), mycotoxins, alkaloids, heavy metals, and polycyclic aromatic hydrocarbons (PAHs) are present almost everywhere in the environment. They can be found in animal feed and, consequently, in food products of animal origin. In addition, veterinary pharmaceuticals and pesticides are used in animal husbandry and, thus, may be present in animal-based food products.
For many of these chemical food contaminants there is no safe threshold value. However, international organizations such as the Joint FAO/WHO Expert Committee on Food Additives (JECFA) and regional organizations such as the European Food Safety Authority (EFSA) have calculated acceptable exposure values for many of them. Exposure to these contaminants above a certain level may adversely affect human health depending on the type of contaminant, the level and duration of exposure, and the specific characteristics of the exposed individual.
In Israel, as in many places in the Western world, each food company is responsible for taking the necessary measures to reduce the levels of chemical food contaminants to a minimum. Responsibility for producing, importing, and selling safe food is set forth in the Public Health Protection (Food) Law, enacted in 2015. The Ministry of Health (MoH) has set maximum permitted levels for food contaminants such as heavy metals, dioxins, PCBs, PAHs, and mycotoxins.
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Progress since 2017
The Environmental Health in Israel 2017 report defined challenges related to Chemical Food Contaminants. Progress achieved in this area during the past three years is outlined below.
The challenge: Conduct a survey of aluminum in baby food
In short: The survey was conducted. Levels of aluminum above the limit of quantification were found in all samples of plant-based infant formulae and in about 60% of samples of milk-based formulae.
Human exposure to aluminum takes place primarily through food. Toxicological research on animals has shown that several aluminum compounds may cause neurotoxicity and affect the male reproductive system. In human studies conducted on dialysis patients, neurological effects were observed in prolonged exposure to high concentrations of aluminum compounds. Several studies revealed an association between exposure to aluminum and degenerative diseases but were not sufficiently robust.
Infants are a vulnerable population whose food consumption is not varied. To assess their exposure to aluminum, the National Food Service (NFS) at MoH conducted a survey to quantify aluminum in infant formulae. The formulae sampled were those commonly used in the Israeli market and in hospitals, including powder for preparation at home and ready-to-feed liquid. The survey included an exposure assessment that compared aluminum levels with the threshold value set by JECFA and EFSA. Levels of aluminum above the limit of quantification (LOQ) were found in all samples of plant-based infant formulae and were not found in about 40% of samples of milk-based formulae. The aluminum levels in plant-based infant formulae were higher on average than those found in milk-based formulae. Aluminum in infant formulae may originate in packaging, soybeans (which naturally accumulate aluminum), aluminum residue from other ingredients of soy-based formulae, and contamination in processing the formula.
The challenge: Conduct a survey of phthalates in baby food
In short: Packages of imported formula were tested and found to meet the Israeli standard, making the survey unnecessary.
Phthalates, a group of chemicals used to increase the strength and flexibility of plastic products, can contaminate food and beverages by migrating from food packaging.
Standard 5113, a mandatory Israeli standard for plastic packaging that comes into contact with food, applies to aluminum packaging with plastic coating, the kind typically used for infant formula. The standard has been updated several times since 2017 and now establishes maximum
Legend: Significant progress Some progress Little or no progress
- 72 - Chemical Food Contaminants - 73 - : Create a database of food consumption based on periodic on periodic of food consumption based a database : Create : Establish a Total Diet Study (TDS) project in Israel Diet Study (TDS) project : Establish a Total : Due to budgetary and logistical constraints, no decision has yet been made on no decision has yet been made on : Due to budgetary and logistical constraints, : Data from national health and nutrition surveys were used to assess exposure to to used to assess exposure surveys were national health and nutrition : Data from The challenge In short in Israel. establishing the project pesticides. Funding was approved for essential preparatory work toward the creation of a database of a database the creation work toward for essential preparatory pesticides. Funding was approved A tender for this work will be issued in these surveys. on food consumption, based on data from the future. The challenge exposure accurate more conduct and surveys, nutrition and health national sub-populations such as the general population and for assessments for women and pregnant children In short thus yielding a more accurate picture of exposure to chemicals in food. Accordingly, several several Accordingly, chemicals in food. to of exposure picture accurate more thus yielding a TDS projects. initiated national countries have contaminants, natural toxins, substances that migrate from food packaging, and more. The goal The goal and more. packaging, food from substances that migrate natural toxins, contaminants, the public of chemicals to which assessment a quantitative is to produce of this sort of project helpful in very in the population. Such data are subgroups by parsed food, from is exposed has TDS approach The to contaminants in food. assessing the potential health impact of exposure peeling or cooking), after rinsing, example, (for as it is consumed of testing the food an advantage A Total Diet Study project examines all food that an individual consumes and the way it is is it way the and consumes individual an that food all examines project Study Diet Total A population and sub-populations the general by consumed This includes sampling food consumed. and consuming it, of way conventional the in food the preparing markets, various the from examined samples are These mixed composite samples. into several combining the types of food environmental including pesticides, to identify and quantify contaminants originating in food, of the population in Israel. To use the collected data to assess the exposure of the general general of the data to assess the exposure use the collected To of the population in Israel. reported the foods contaminants that originate in food, population and sub-populations to the Rav- In addition, their ingredients. by down be broken participants must the survey by of in children of pesticide exposure assessments being used in preliminary data are MABAT groups. age various As part of the National Health and Nutrition Survey (Rav-MABAT), data on food consumption consumption data on food (Rav-MABAT), Survey As part of the National Health and Nutrition sample comprise a representative sub-populations that together different collected from were Ordinance, are tested to determine whether they meet Standard 5113. In these tests, no excessive no excessive tests, 5113. In these Standard meet they whether tested to determine are Ordinance, most of and since findings, In light of the to the standard. relative found were of phthalates levels to to conduct a survey unnecessary decided that it was in Israel is imported, NFS formula infant formulae. phthalates in infant identify and quantify permitted levels for phthalates in food packaging that are consistent with European regulation. regulation. with European consistent that are packaging in food phthalates for levels permitted Import with the Free and, in accordance imported to Israel are formula of infant Packages Environmental Health in Israel 2020 Chapter 7
To establish its own TDS project, Israel must develop a sampling plan that represents food consumption countrywide, prioritize the chemicals that are important to check, write clear protocols for food sampling and preparation, build an array that accounts for preparing food in the way it is consumed, develop the logistical capacity for transporting and storing food, and establish laboratory capacity for testing the requisite substances according to their prioritization. These phases, taken together, entail substantial personnel and budgetary resources. Due to budget constraints, the project has yet to be initiated.
Research on Chemical Food Contaminants in Israel
Researchers from the Agricultural Research Organization’s Volcani Center examined the effects of phosphine fumigation on stored wheat grain and on the wheat grain microbiome, including mycotoxigenic fungi. The use of phosphine induced changes in the composition of the bacterial community: As the number of phosphine treatments increased, the diversity of the bacterial community in the stored wheat decreased. However, no similar effect on fungal diversity was detected. Mycotoxin analysis of the treated wheat revealed the presence of Fusarium toxins, primarily deoxynivalenol.1
Following the discovery of ergot disease in sorghum fields for the first time in Israel, a large amount of produce from the affected fields had to be destroyed. Researchers from the Volcani Center examined and identified the ergot alkaloid profile in the infected fields and, for the first time, detected dihydrolysergol as a significant ergot alkaloid component. In an assessment of the infected sorghum silages, taking the alkaloid profile into consideration, the silage was found to be safe for use as animal feed.2
In a study conducted by researchers at the Volcani Center and the Kimron Veterinary Institute, a method was developed for detecting a range of mycotoxigenic fungi and mycotoxins in wheat.3
Researchers from Volcani Center examined samples of bovine and goat milk sold in markets in Israel and detected pesticides and pharmaceutical residues. In about 50% of the milk samples tested, residues from several pesticides were found in the same sample.4
Future Challenges
Estimating exposure to contaminants originating in food is an important step in the process of assessing the risks that these contaminants present, and the use of food consumption data is important for tailoring exposure assessments to the population of Israel. Although extensive food consumption data is collected routinely in Israel in nutrition surveys (such as Rav-MABAT), these data are currently underutilized in assessing the risk of food contaminants. Conducting exposure assessments for contaminants such as heavy metals, on the basis of Rav-MABAT surveys and biomonitoring data, is an ongoing challenge.
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5 - 75 - in Israel with the format of the WHO database and plans to submit data to this international and plans to submit data to this international WHO database of the in Israel with the format regularly. database databases such as that of the World Health Organization (WHO), which includes monitoring data includes monitoring data (WHO), which Health Organization World such as that of the databases Alimentarius the Codex governments, yields information—for database The contaminants. on food of and trends public—on levels and the general institutions, Commission and other relevant public and their implications for to total human exposure, their contribution contaminants, food contaminants sampled NFS has begun to align data on food health and international commerce. average adult exposure was calculated for dioxins, furans and dioxin-like PCBs. NFS is planning is planning NFS PCBs. furans and dioxin-like dioxins, for calculated was adult exposure average an in Israel and to perform in food to identify and quantify dioxins survey to conduct a new of the survey. based on the results assessment exposure contaminants in Israel to international on food surveys is to submit data from Another goal Dioxins are byproducts of uncontrolled combustion including those in industrial processes. including those in industrial processes. combustion of uncontrolled byproducts are Dioxins Prolonged and food. precipitation, water, soil, air, including everywhere been found have Dioxins system on nervous effects and adverse effects is associated with immunotoxic to dioxins exposure published The most recent and the risk of cancer. the endocrine system, fertility, development, of that survey, published in 2013. Based on findings in Israel was in food on dioxins survey exceedances were found and residues of cadmium and mercury were detected in about 50% of 50% of in about detected were of cadmium and mercury and residues found were exceedances the permitted (below Residues of cadmium maximum). the permitted below the samples (at levels poultry samples. 40% of fattened samples and over in 98% of turkey also found were maximum) risk in plant-based and animal-based foods, metals to heavy potential exposure account for To (MoH and MoAg) is needed. agencies regulatory different on data collected by based assessment Services unit at the Ministry of Agriculture (MoAg) is needed. A survey conducted by this unit this unit conducted by (MoAg) is needed. A survey Services unit at the Ministry of Agriculture of animal origin indicated that the consumption in food metals to identify and quantify heavy residues arsenic 2018, In metals. to heavy exposure of source a be may food animal-based of in 49% of the found was mercury and fish 65% of samples of pond-bred in about found were arsenic numerous In samples of seafish, than the permitted maximum). lower samples (at levels the growing knowledge in this field and progress in the analytical capacity to identify and quantify to identify capacity the analytical in in this field and progress knowledge the growing by setting existing legislation expand and significantly to update NFS is planning mycotoxins, categories. food more and adding types of mycotoxins additional for levels maximum guidelines existing the converting by food content in metal heavy regulate to planning is also NFS Veterinary with the collaboration in-depth more such regulations, promote To into regulations. As part of an effort to increase transparency, NFS intends to publish these data. intends to publish NFS transparency, to increase an effort As part of already have levels rising mycotoxin fungi; of toxigenic the proliferation is affecting Climate change permitted sets maximum Israeli law places in the world. in various in edible crops been observed Given and legumes. grains, milk, such as nuts, categories food in several of major mycotoxins levels NFS conducts periodic surveys on food contaminants (including mycotoxins in food, arsenic in in arsenic in food, (including mycotoxins contaminants on food periodic surveys NFS conducts unpublished. currently of these data are Some food). in baby and aluminum products, rice and rice Environmental Health in Israel 2020 Chapter 7
PFAS are a group of man-made chemicals that have been used for many years in a wide range of industries worldwide. They are very persistent in the environment and are not metabolized in the human body; therefore they accumulate over time. Prolonged exposure to PFAS may lead to adverse health effects including high cholesterol, thyroid disease, immunotoxic effects, and certain types of cancer. The food we consume may contain PFAS that originates in polluted soil, animals’ drinking water, irrigation water, food packaging, or food processing equipment that contains these substances. While preliminary data is being collected on PFAS contamination in drinking water in Israel, no data on PFAS in food are available. A survey to measure the levels of PFAS in food in Israel is planned.
References
(1) Solanki, M. K., Abdelfattah, A., Britzi, M., Zakin, V., Wisniewski, M., Droby, S., & Sionov, E. (2019). Shifts in the composition of the microbiota of stored wheat grains in response to fumigation. Frontiers in Microbiology, 10, 1098. https://doi.org/10.3389/fmicb.2019.01098
(2) Shimshoni, J. A., Cuneah, O., Sulyok, M., Krska, R., Sionov, E., Barel, S., & Meller Harel, Y. (2017). Newly discovered ergot alkaloids in Sorghum ergot Claviceps africana occurring for the first time in Israel. Food Chemistry, 219, 459–467. https://doi.org/10.1016/j.foodchem.2016.09.182
(3) Sadhasivam, S., Britzi, M., Zakin, V., Kostyukovsky, M., Trostanetsky, A., Quinn, E., & Sionov, E. (2017). Rapid detection and identification of mycotoxigenic fungi and mycotoxins in stored wheat grain. Toxins, 9(10), 302. https://doi.org/10.3390/toxins9100302
(4) Bommuraj, V., Chen, Y., Gal, O., Ben Ari, J., Kertsnus-Banchik, E., Barel, S., & Shimshoni, J. A. (2020). Human pharmaceutical and pesticide residues in Israeli dairy milk in association with dietary risk assessment. Food Additives & Contaminants. Part B, Surveillance, 1–11. https://doi.org/10.1080/19393210.2020.1764114
(5) Israel Ministry of Agriculture and Rural Development, Veterinary and Livestock Health Services Unit (2019). 2016-2018 Report (Hebrew). https://www.moag.gov.il/vet/dochot-shnatiim/Documents/doch_shnati_2016-2018.pdf.pdf (retrieved June 2020).
- 76 - Consumer Products Chapter 8 Chemicals in Chemicals in Consumer Products
Consumer products are potential sources of exposure to heavy metals, endocrine disrupting chemicals (EDCs), and volatile organic compounds (VOCs).1
Heavy metals—including lead, mercury, and arsenic—may be present in toys, paint, jewelry, and personal care products. Cases of acute lead poisoning following exposure to toys and paint containing high levels of lead have been reported.2
There is increasing evidence that consumer products contribute significantly to cumulative exposure to EDCs such as phthalates, flame retardants, per- and polyfluoroalkyl substances (PFAS), and triclosan, and that chronic exposure may be associated with adverse health effects.1 For example, triphenyl phosphate (TPHP), an organophosphate flame retardant (OPFR) commonly used in consumer products, has been associated with altered thyroid function. PFAS used in consumer products—for example, in water repellant and stain resistant coatings for textiles—have been associated with cancer, thyroid disruption, immune system impairment, and reduced fertility.3
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Paint, polyvinyl chloride (PVC), and wood products may emit VOCs including formaldehyde. Exposure to these consumer products has been associated with increased risk of allergic reactions and respiratory difficulties in children.4
Progress since 2017
The Environmental Health in Israel 2017 report defined challenges related to Chemicals in Consumer Products. Progress achieved in this area during the past three years is outlined below.
The challenge: Improve regulatory enforcement for consumer products (enforcement in markets and not only at point of import)
In short: Oversight and enforcement of consumer Challenge for the coming years: Establish an products’ standards in markets in Israel have integrating authority (inter-ministerial committee) improved thanks to stronger cooperation among to improve and strengthen supervision and regulators. Supervision and enforcement efforts enforcement of regulation of consumer products were extended to product groups identified in sold in Israel. market surveys as posing a potential danger to public health.
The Ministry of Economy and Industry (MoE) has ministerial responsibility for supervision and enforcement of compliance with relevant mandatory standards for consumer products sold in Israel. In recent years, professional collaboration between the Ministry of Health (MoH) and MoE has expanded. Researchers from the University of Haifa, the Standards Institute of Israel (SII), and MoH, in collaboration with the Environment and Health Fund (EHF), initiated several studies on the presence of chemicals in consumer products and shared the initial findings with MoE for further action and enforcement. Although MoE uses such findings to target and focus enforcement, there is no regulation or mechanism designed to ensure cooperation among the relevant ministries, i.e., MoE, MoH, and the Ministry of Environmental Protection (MoEP). The creation of a joint statutory inter-ministerial committee to formulate annual work plans and objectives would improve oversight and enforcement and would focus the limited resources on products that pose the greatest potential danger to public health.
MoE recently launched an online portal for safety of consumer products that conveys information on consumer products that entered the domestic market and were found to be non-compliant and removed from the shelves (recalled).5 Despite this improvement, there is still no data published on the scope and results of testing.
Legend: Significant progress Some progress Little or no progress
- 78 - Chemicals in Consumer Products : Continue : Continue : Set a uniform - 79 - Challenge for the coming years involvement in adopting MoH to increase advanced more international that are standards and stricter than those in place today. Challenge for the coming years Challenge for the coming labeling standard for specified chemicals in for specified chemicals labeling standard on products with an emphasis consumer products, and children. designed for infants, toddlers, : Re-evaluate the role of the Ministry of Health in of the Ministry of Health in : Re-evaluate the role : Require labeling of selected consumer products indicating indicating products consumer labeling of selected : Require : There is now a mandatory standard to to is now a mandatory standard : There : MoH is taking the initiative to become public health In short and in adopting new standards involved more the to improve ones in order existing revising safety of consumer products. The challenge that protect of standards guaranteeing the adoption and implementation In short or absence the presence include information on chemicals on the labels of retardant of flame and textile carpets. mattresses The challenge meet the standard that they standard for lead in paint, and promoting revisions for a range of standards of consumer goods goods of consumer of standards a range for revisions lead in paint, and promoting for standard changing high chairs, strollers, including cribs, and children toddlers, infants, designed for and playgrounds. tables, MoH has expanded its involvement in SII committee deliberations on consumer product product deliberations on consumer in SII committee its involvement MoH has expanded which it participated, MoH has based on the findings of studies in Furthermore, standards. standards— of existing and the revision standards the adoption of new been promoting and a comprehensive jewelry in children’s metals heavy for setting a standard example, for comprehensive requirement for uniform labeling of specific chemicals in all consumer products products of specific chemicals in all consumer labeling uniform for requirement comprehensive sold in Israel. The trend of reducing the use of flame retardant chemicals is expected to spread to other to other expected to spread is chemicals retardant the use of flame of reducing The trend to is no requirement date, there To electronics. home and such as furniture goods consumer products consumer in many chemicals retardant of flame or absence indicate the presence is still no There pillows. and nursing car seats, including strollers, and children, infants for required, the presence or absence of these chemicals must be indicated on the product label so so label on the product be indicated these chemicals must of or absence the presence required, as is preferences, with their personal in accordance purchases informed can make that consumers to indicate mandatory it is now example, for Thus, countries. customary in almost all developed infant of adult mattresses, chemicals on the labels retardant of flame or absence the presence carpets. and textile mattresses, MoH initiated a broad-based reassessment of the need for added flame retardants in a variety variety in a retardants flame added for of the need reassessment MoH initiated a broad-based associated with using potentially health effects that adverse and found products of consumer this Following these chemicals offer. advantage exceed the safety chemicals retardant flame was no longer products relevant to the retardants flame to add the requirement reassessment, but not chemicals is allowed retardant flame adding to which Instead, in products mandatory. Environmental Health in Israel 2020 Chapter 8
The challenge: Advance comprehensive regulation of chemicals in consumer products
In short: The Israel National Council for the Challenge for the coming years: Promote a Child is promoting a legislative framework legislative framework for consumer products for consumer products that will integrate and designed for infants, toddlers and children. reconcile the requirements of the relevant standards, with emphasis on consumer products designed for infants, toddlers, and children.
Israel still lacks a regulatory framework for the systematic evaluation and registration of chemicals, even though such a structure exists in all other OECD member countries except Turkey. In addition, as opposed to the U.S. and Europe, Israel has no comprehensive regulatory framework for chemicals in consumer products.6
Currently, the Israeli regulatory framework for consumer products is based on non-binding standards and mandatory standards that apply to specific products only. Uniform and comprehensive framework legislation on chemicals in consumer products could help fill regulatory gaps that might not be addressed in the existing system of product-specific standards. In October 2020, MoEP published a bill that would create a chemicals registration system in Israel. The bill would leave regulatory authority for consumer goods with MoE but would give MoEP regulatory authority to promulgate standards in cases of regulatory gaps.
Given the special sensitivity of certain populations to chemicals, the National Council for the Child and EHF decided to focus their efforts on consumer products designed for infants, toddlers, and children. The two organizations formulated a proposal for dedicated legislative framework for chemicals in consumer products designed for these populations.
The challenge: Conduct additional surveys of chemicals in consumer products in the market in Israel; conduct a systemic review of requirements pertaining to chemicals in consumer products abroad versus those in Israel
In short: On the basis of several studies Challenge for the coming years: Identify conducted, relevant regulation was promoted regulatory gaps for particular consumer products, with the aim of reducing the public’s exposure to compare regulatory requirements in Israel with chemicals in consumer products. those in other developed countries.
A joint research group of MoH, the University of Haifa, and SII, in collaboration with EHF, conducted several studies to test for the presence of chemicals in consumer products. One such study tested for the presence of heavy metals (primarily lead) in toys, children’s jewelry,7 and paint, including paint used for the painting and upkeep of playground equipment.8 A research conducted in 2019–2020 checked for the presence of chemicals in play mats for children, parquet flooring, and synthetic grass. The findings of these studies are helpful in identifying regulatory gaps and addressing them by adopting new standards, revising existing standards or promoting requests for non-binding standards to be made mandatory. By identifying disparities in regulatory requirements between Israel and other developed countries, these studies will create a basis for promoting mandatory regulation of specific consumer products.
- 80 - Chemicals in Consumer Products : Define, in : Define, in 9 The same group of of group The same 10 - 81 - Challenge for the coming years Challenge or legislation, the maximum amount procedures publication of a standard of time allowed between and declaring it as mandatory. effective January 2021. 2021. January effective 8 : Shorten the bureaucratic process of declaring new or or of declaring new process the bureaucratic : Shorten : in conjunction with MoE MoH is working samples, levels of lead in paint exceeded the maximum set forth in U.S. regulation (90 ppm). As (90 ppm). As regulation in U.S. set forth the maximum of lead in paint exceeded levels samples, was updated and lead was Varnishes) and 1343 (Paints Israeli Standard of these findings, a result banned in paint, including industrial paint, researchers is measuring concentrations of phthalates and DINCH in the urine of 136 women concentrations of phthalates and DINCH in the urine of 136 women is measuring researchers (IVF). fertilization in vitro underwent who of lead and SII studied the presence of Haifa, MoH, the University team from A joint research in Israel. In 88% of the and public areas in playgrounds paints and on painted surfaces in spray Centers for Disease Control (CDC), measured concentrations of thirty-one chemicals (including concentrations of thirty-one chemicals (including (CDC), measured Disease Control for Centers Fourteen chemicals— women. fifty pregnant phthalates and phenols) in urine samples from in the urine found and benzophenone-3—were parabens, various including bisphenol A (BPA), bisphenol S (BPS) and DINCH (a Other chemicals—including 90% of the participants. of over among 30%–63% of the participants. found phthalate substitute)—were effect of using aluminum-based deodorant on aluminum concentrations in breast milk. Fifty- in breast concentrations on aluminum deodorant of using aluminum-based effect of the use between found was association No significant participated in the study. eight women milk. in breast deodorant and concentrations of aluminum aluminum-based and MoH, in Hashomer, Tel Sheba Medical Center at University, Aviv Tel from Researchers and the U.S. Columbia University, University, Harvard from with researchers collaboration Researchers from Tel Aviv University and Shamir Medical Center (Assaf Harofeh) examined the the examined (Assaf Harofeh) and Shamir Medical Center University Aviv Tel from Researchers In short for completing the to shorten the time required process. The challenge mandatory standards revised
Research on Chemicals in Consumer Products in Israel in Israel on Chemicals in Consumer Products Research in paint and heavy metals in children’s jewelry) have been declared in expedited proceedings. proceedings. in expedited declared been have jewelry) in children’s metals in paint and heavy of each stage for completing should be specified timeframe Still a limited and reasonable SII the after possible as soon as effect into go may standards updated that so process the them. committees approve Many months (and, in extreme cases, even years) may pass between the revision of a standard of a standard the revision pass between may years) even cases, (and, in extreme months Many and mandatory as standard a of declaration the between and publication, its and SII by of a defined the lack stems in part from The delay Ordinance. Trade Free including it in the of the assessment disclose their ministries’ must in charge ministers the in which timeframe needed, the process are assessments ministers’ several When (consent or opposition). standard those on lead content example, (for standards several years, In recent longer. even take may Environmental Health in Israel 2020 Chapter 8
An Israeli research group in collaboration with researchers from Canada and the U.S. examined the regulation of chemicals in children’s products and studied how U.S. and European regulations would impact a small market like Israel. The study highlighted the lack of comprehensive framework legislation for all children’s products and the difficulty in adopting American and European standards in view of their different approaches and requirements.11
Researchers from the University of Haifa and MoH studied the impact of standards in Israel on promoting environmental policy, with standards for consumer products designed for infants, toddlers, and children as the case study. The conclusions of the study underline the inherent tensions that exist between safety and health issues, on the one hand, and economic and commercial interests, on the other. The researchers proposed solutions that would improve the decision-making process in a way that would place greater weight on health and environmental considerations.12
Future Challenges
Direct online shopping poses a major challenge in regulating consumer products in Israel and abroad. Israel has the highest rate of per capita growth in e-commerce among OECD countries and has developed a significant gap between the volume of packages ordered for private consumption without oversight and regulated commercial imports. In 2018, over 50% of online orders were placed via the AliExpress website.13
Official commercial importation of consumer goods gives regulators a certain level of control over product safety and standards; personal importation of products purchased online presents regulators with a significant challenge in this context. In practice, the Personal Import Ordinance, effective 2019, exempts all consumer goods (with several specific exceptions) from having to meet the official and mandatory standards that apply in Israel. The ordinance provides a sweeping, structured exemption from supervision of consumer products purchased online or brought to Israel via personal importation—up to thirty units of the same type if the total value of the shipment does not exceed $1,000, and up to five units of the same type if the total value exceeds that sum.14 Public service campaigns should be initiated to reduce the potential risk of online shopping to consumer safety and health. Publication of regulatory guidelines and recommendations for the public would enable consumers to make informed online purchases.
Like the Personal Import Ordinance, the cosmetics reform in Israel was designed to lower the cost of living and alleviate the regulatory burden. The reform shifts the responsibility for the safety, quality, and effectiveness of cosmetics to manufacturers and importers, leaving MoH with enforcement and oversight duties as opposed to registration of cosmetics.15 The potential impact
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6 substances has been mounting in recent years. The challenge going forward is to continue to to is to continue forward going The challenge years. substances has been mounting in recent and to evaluate in Israel products to these substances via consumer potential exposure study measures. potential regulatory it will be important to monitor changes in the quality of imported products, with emphasis on with emphasis on in the quality of imported products, to monitor changes it will be important chemicals. of toxic the presence products. in consumer in Israel on concentrations of PFAS no data is currently There textiles, including products, consumer in many used are substances These water-resistant to these exposure from health effects Evidence of adverse and cookware. packaging, food in general is also a regulatory challenge. is also a regulatory in general relax that would Ordinance Import to the Free amendment a proposed In 2020, MoE published will to MoE, the reform According products. consumer certain imported for testing requirements into effect, goes After the reform inspection and enforcement. in an increase be accompanied by of the reform on the public’s exposure to chemicals in cosmetics, however, needs to be studied. studied. needs to be however, to chemicals in cosmetics, exposure on the public’s of the reform products consumer and nanomaterials in cosmetics and the risks of nanotechnology Mitigating Environmental Health in Israel 2020 Chapter 8
References
(1) Li, D. & Suh, S. (2019). Health risks of chemicals in consumer products: A review. Environment International, 123, 580–587. https://doi.org/10.1016/j.envint.2018.12.033
(2) Hauptman, M., Bruccoleri, R., & Woolf, A. D. (2017). An update on childhood lead poisoning. Clinical Pediatric Emergency Medicine, 18(3), 181–192. https://doi.org/10.1016/j.cpem.2017.07.010
(3) Rappazzo, K. M., Coffman, E., & Hines, E. P. (2017). Exposure to perfluorinated alkyl substances and health outcomes in children: A systematic review of the epidemiologic literature. International Journal of Environmental Research and Public Health, 14(7), 691. https://doi.org/10.3390/ijerph14070691
(4) Tagiyeva, N. & Sheikh, A. (2014). Domestic exposure to volatile organic compounds in relation to asthma and allergy in children and adults. Expert Review of Clinical Immunology, 10(12), 1611–1639. https://doi.org/10.1586/1744666X.2014.972943
(5) Israel Ministry of Economics and Industry (updated May 2020). The Israeli portal for consumer product safety (Hebrew). https://www.gov.il/he/Departments/Units/consumer-products-safety (retrieved May 2020).
(6) Israel Ministry of Environmental Protection (2020). Assessing the current state of affairs, June 2020 (Hebrew).
(7) Negev, M., Berman, T., Reicher, S., Sadeh, M., Ardi, R., & Shammai, Y. (2018). Concentrations of trace metals, phthalates, bisphenol A and flame retardants in toys and other children’s products in Israel. Chemosphere, 192, 217–224. https://doi.org/10.1016/j.chemosphere.2017.10.132
(8) Berman, T., Barnett-Itzhaki, Z., Reicher, S., Ardi, R., Shammai, Y., Aruas, L., & Negev, M. (2018). Lead in spray paint and painted surfaces in playgrounds and public areas in Israel: Results of a pilot study. Science of the Total Environment, 637–638, 455–459. https://doi.org/10.1016/j.scitotenv.2018.05.005
(9) Rochman, M., Mandel, D., Berkovitch, M., Kohn, E., Abu Hamad, R., Mangel, L., & Lubetzky, R. (2019). Aluminum content of human breast milk in breastfeeding mothers using regular deodorant versus breastfeeding mothers using aluminum-free deodorant. Poster presented at Environment and Health Fund annual conference, Environment and Health: Complex Interactions, Tel Aviv, Israel.
(10) Machtinger, R., Berman, T., Adir, M., Mansur, A., Baccarelli, A. A., Racowsky, C., ... Nahum, R. (2018). Urinary concentrations of phthalate metabolites, bisphenols and personal care product chemical biomarkers in pregnant women in Israel. Environment International, 116, 319–325. http://doi.org/10.1016/j.envint.2018.04.022
(11) Negev, M., Berman, T., Reicher, S., Balan, S., Soehl, A., Goulden, S., ... Diamond, M. L. (2018). Regulation of chemicals in children’s products: How U.S. and EU regulation impacts small markets. Science of the Total Environment, 616–617, 462–471. https://doi.org/10.1016/j.scitotenv.2017.10.198
(12) Goulden, S., Negev, M., Reicher, S., & Berman, T. (2019). Implications of standards in setting environmental policy. Environmental Science & Policy, 98, 39–46. https://doi.org/10.1016/j.envsci.2019.05.002
(13) Israel Postal Company (2019). Spokesperson’s Announcement No. 949. Tonight at midnight: Chinese Singles’ Day. A new survey by Shiluv I2R for the Israel Postal Company: 78% of those who buy from overseas sites will make purchases on shopping holidays.
(14) Israel Ministry of Economics and Industry (updated December 2019). Personal Import Ordinance, 2019 (Hebrew). https://www.gov.il/he/departments/legalInfo/order_personal_import (retrieved May 2020).
(15) Israel Ministry of Health (2019). The reform in cosmetics continues: The consultation with the public process has begun. https://www.health.gov.il/English/News_and_Events/Spokespersons_Messages/Pages/09122019_3.aspx (retrieved May 2020).
- 84 - Chapter 9 Biomonitoring Human Human Biomonitoring
Human biomonitoring (HBM) is a tool for assessing exposure to environmental chemicals by measuring concentrations of substances, their metabolites, and biological markers at the cellular or molecular level, in biological fluids and in tissues such as urine, blood, breast milk, and hair. HBM has emerged as a powerful tool for assessing cumulative exposure to mixtures of chemicals; it can be used to assess environmental exposures of individuals and of population groups. HBM data can also be combined with environmental data to identify exposure pathways and with clinical data to find evidence of associations between exposure to chemicals and health outcomes.
HBM data have many uses in environmental and health research and in policymaking. They can be used to identify populations that are more exposed than others to environmental contaminants, support the formulation of policies designed to reduce exposure to contaminants, and assess policy effectiveness. Thus, many countries—including the U.S., Canada, Germany, France, Belgium, Spain, Italy, the Czech Republic, and South Korea—have developed national biomonitoring programs. In addition, twenty-eight countries, including Israel, are collaborating in the HBM4EU consortium, a project that promotes the use of HBM and the application of its results in policymaking in Europe.
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Progress since 2017
The Environmental Health in Israel 2017 report defined challenges related to Human Biomonitoring. Progress achieved in this area during the past three years is outlined below.
The challenge: Join a regional or international human biomonitoring project
In short: Israel joined the HBM4EU consortium, Challenge for the coming years: Promote a European HBM project. Within this framework, Israel’s continued involvement in regional and Israel shares information on biomonitoring research international HBM initiatives. and biomonitoring data with the International Platform for Chemical Monitoring.
Israel’s involvement in the HBM4EU consortium includes sharing information on research and data from biomonitoring studies conducted in Israel. For example, Israel shared data on the exposure of women to bisphenol A (BPA) for a meta-analysis of sources of exposure to bisphenols among women in Europe. In addition, information on six HBM studies in Israel, including surveys by the Ministry of Health (MoH) and birth cohort studies, was uploaded to the International Platform for Chemical Monitoring (IPCHEM).1 Israel is also participating in discussions on promoting the sustainability of HBM in Europe, including the use of biomonitoring data in risk assessment and advancement of environmental health policy.
HBM4EU’s activity was planned and funded for five years (2017–2021). As the end of the project approaches, the participants are weighing whether to create follow-up programs or join parallel programs. Either way, it is important that Israel continues to participate in such international projects.
The challenge: Develop laboratory capacity for human biomonitoring
In short: The staff of the National Biomonitoring Challenge for the coming years: Utilize tools Laboratory at MoH validated protocols for developed for monitoring and research; continue measuring cotinine, organophosphate pesticides, validating measurement techniques for other pyrethroids, and heavy metals in urine and whole contaminants. blood.
The staff at MoH’s National Biomonitoring Laboratory validated protocols for measuring various environmental contaminants in human biological samples (Table 1). There is also a plan to validate analytical techniques for measuring per- and polyfluoroalkyl substances (PFAS) and flame retardants.
Legend: Significant progress Some progress Little or no progress
- 86 - Analytical Capacity at the National Biomonitoring Laboratory* Biomonitoring Human Contaminant Category Analyte (biological media) Table 1 Israel Ministry Pesticides Organophosphate (OP) metabolites — Dialkylphosphates (urine) of Health Chlorpyrifos metabolite — TCPy (urine) Pyrethroid metabolites (urine)
Heavy metals Arsenic, cadmium, lead, mercury, chromium, nickel, selenium, and thallium (urine) Lead, mercury, cadmium, and nickel (whole blood)
Environmental tobacco Cotinine (urine) smoke
Other (nutritional biomarkers) Iodine (urine)
* As of December 2020
In 2019 and 2020, the laboratory passed quality assurance tests conducted by an international quality assessment program for analyses in biological materials. During 2019, it conducted measurements of environmental contaminants in more than 400 biological samples.
The challenge: Establish and fund a government framework for human biomonitoring
In short: The National Biomonitoring Program Challenge for the coming years: began in 2020 and there is a commitment to A. Fully implement the National Program. fund it through 2030. B. Use the program as a platform for monitoring nutritional biomarkers. C. Incorporate the analysis of blood samples into the program.
The National Biomonitoring Program, established with the support of the Environment and Health Fund (EHF), outlines a framework for the next decade including three rounds of collecting biological samples and measuring environmental contaminants. Contaminants of interest were chosen following preliminary prioritization, in which relevant experts ranked thirty-five chemicals and chemical groups under five criteria (such as indication of population exposure in Israel and potential regulatory use of data). The target populations and contaminants are displayed in Table 2. As part of the program, children (ages 4–11) and adults (ages 18–65) will be recruited from the general Jewish and Arab population in a nationwide convenience sample. The main objectives of the program are to provide data on trends of exposure to environmental contaminants, sources of exposure, and subpopulations at risk of high exposure. The program will also yield exposure data for use in quantitative risk assessment and environmental health policy analysis.
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Outline of the National Biomonitoring Program in Israel, 2020–2030 Table 2 Year 2020–2021 2024–2025 2029–2030 Israel Ministry Contaminants Target 200 children 400 adults of Health population 200 adults (pregnant women?)
Cotinine + + OP pesticides + Pyrethroid pesticides + Not yet decided Heavy metals + + Benzophenones, flame retardants, and emerging + chemicals of interest such as PFAS
The challenge: Develop a framework for using human biomonitoring data in quantitative risk assessment
In short: Data on the concentration of urinary Challenge for the coming years: Expand the organophosphate metabolites in children was use of HBM data in risk assessment for exposure used in a quantitative risk assessment. to metals and additional groups of pesticides, for example pyrethroid pesticides.
Using data on the concentration of urinary OP metabolites in 103 children, MoH researchers calculated the children’s estimated daily intakes (EDI) of OP pesticides. The urine samples were collected as part of the 2015–2016 National Health and Nutrition Survey (Rav-MABAT). The researchers compared the EDI with the acceptable daily intake (ADI)—a value expressing the level of exposure below which no adverse health effect is expected—as defined by the European Food Safety Authority (EFSA). According to this calculation, about 15% of the children were exposed to the pesticide chlorpyrifos at a level exceeding the ADI (Table 3).2
Acceptable Daily Intake, Estimated Daily Intake, and Percentage of Children with Daily Intake Above Tolerated Dose—for Six OP Pesticides
Acceptable Daily % of Children with Estimated Daily Table 3 Pesticide Berman et al., 20202 Intake as Defined Daily Intake Above Intake (μg/kg of body by EFSA (μg/kg of body the Tolerated Dosage weight per day) weight per day)
Diazinon 0.2 79.4% 0.02–10.73
Chlorpyrifos 1 14.7% 0.01–9.06
Phosmet 10 2.9% 0.09–50.08
Malathion 30 4.9% 0.32–173.79
Dimethoate 1 22.5% 0.05–28.14
Phorate 0.7 17.6% 0.01–7.87
- 88 - The challenge: Expand the process of selecting and prioritizing chemicals Biomonitoring for human biomonitoring by including representatives from academia, Human government, and the public
In short: Israel participated in this process at the European level within the framework of the HBM4EU program. No similar process was implemented in Israel.
The National Biomonitoring Program includes a plan to present the selection and prioritization of chemicals for HBM to representatives from academia, government, and the public, in order to improve the transparency of the process in Israel. It is essential to conduct a periodic reassessment of the prioritization and to consider including additional contaminants, such as OP flame retardants and PFAS.
Human Biomonitoring Research in Israel
In a pilot study, researchers from Ben-Gurion University of the Negev quantified environmental contaminants in pooled urine samples of pregnant women from the Negev. They found heavy metals in all urine samples and metabolites of OP pesticides and OP flame retardants in some. No significant differences between Bedouin women and Jewish women were found.3
Researchers from Shamir Medical Center (Assaf Harofeh), Tel Aviv University, Dana-Dwek Children’s Hospital, Kimron Veterinary Institute, and Columbia University studied the association between intrauterine exposure to polychlorinated biphenyls (PCBs) and 1) thyroid hormone levels (TSH) in pregnant women and newborns and 2) anogenital distance (AGD) in newborns. The mean maternal serum concentrations were 2.95 ng/g, 4.62 ng/g, 7.67 ng/g and 5.10 ng/g for congeners 118, 138, 153 and 180, respectively. The researchers found no association between PCB exposure and TSH levels in pregnant women in the study. Among women with a low weight-to-height ratio, however, a significant association between PCB exposure and TSH was reported.4 Higher maternal concentrations of PCBs were found to be associated with reduced AGD in male infants.5
The Ministry of Environmental Protection is funding several studies on epidemiological aspects of exposure to air pollution in the Haifa Bay population, including research with an emphasis on HBM (including biomonitoring of heavy metals and organic contaminants in pregnant women, and heavy metals in blood donors6).
Exposure to Chemicals in Consumer Products Researchers from Tel Aviv University, Sheba Medical Center at Tel Hashomer, and MoH, in collaboration with colleagues from Columbia University, Harvard University, and the U.S. Centers for Disease Control and Prevention (CDC), measured concentrations of thirty-one chemicals including phthalates and phenols in the urine of fifty pregnant women. Fourteen chemicals,
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including BPA, various parabens, and benzophenone-3 were found in the urine of over 90% of the participants. Other chemicals, including bisphenol S (BPS) and DINCH (a phthalate substitute), were detected in the urine of 30%–63% of the participants. Concentrations of benzophenone-3, a component in sunscreen, were low in comparison with populations in other countries, even though most of the adult population in Israel reports using sunscreen.7
Researchers from Sheba Medical Center, in collaboration with colleagues from Harvard University, Columbia University, and the University of Milan, measured concentrations of phenols and phthalates in the urine of 130 women who underwent in vitro fertilization (IVF) and analyzed miRNA molecules found in follicular fluid. They found an association between concentrations of eight miRNA molecules that play a role in the development of ovarian follicles and oocytes, and concentrations of phenols and phthalates. They concluded that exposure to chemicals from consumer products may change the concentrations of cellular regulatory molecules that play a role in female fertility.8
Researchers from Sheba Medical Center, in collaboration with colleagues from Harvard University, Columbia University, and the CDC, measured urinary concentrations of phthalates and DINCH in the same cohort of women who underwent IVF. They found several phthalates of which concentrations were inversely associated with several IVF outcomes: total number of retrieved oocytes, number of mature oocytes, number of fertilized oocytes, and number of top quality embryos. Conversely, no association between concentrations of DINCH and IVF outcomes was found.9
Exposure to Pesticides
Researchers from MoH, measuring urinary OP levels in children during 2015–2016, found higher concentrations of several metabolites in children’s urine in Israel than in other Western countries. They also found associations between fruit consumption and concentrations of several OP metabolites (DMP, DMTP and DETP) and between cucumber consumption and concentrations of DEP and DETP.2
MoH researchers, measuring urinary OP levels in adults in Israel in 2015–2016, found a statistically significant decrease in concentrations of most urinary OP metabolites relative to the findings of a survey conducted in 2011. The average concentrations, however, were still high relative to populations in the U.S., Denmark, and Canada.10, 11
Researchers from the Hebrew University-Hadassah Braun School of Public Health and Community Medicine measured concentrations of urinary OP metabolites in 273 pregnant women and 109 newborns. The urine samples were collected during a four-year period (2012– 2016) in which stricter regulations were imposed on the use of OPs in Israel. The researchers found that average concentrations of dialkyl phosphates (DAPs) in the women decreased by about 40% during those years (from 248 nM/L to 148 nM/L). A similar trend was observed among the newborns.12
- 90 - Exposure to Environmental Tobacco Smoke Biomonitoring
MoH researchers, measuring urinary cotinine concentrations in children in 2015–2016, found Human cotinine in the urine of over 60% of the children even though only 40% of parents reported that their children were exposed to environmental tobacco smoke (ETS). These concentrations are much higher than corresponding concentrations among children in several Western countries.13
Researchers from the Hebrew University-Hadassah Braun School of Public Health and Community Medicine and MoH measured urinary cotinine levels in 265 non-smoking pregnant women and ninety-seven newborns. Most of the participants were of high socioeconomic status. The researchers found cotinine in the urine of 37.7% of the women and 29% of the newborns. No association was found between the maternal and infant cotinine levels. The researchers found an inverse association between cotinine levels in the newborns and their birth weight.14
MoH researchers, measuring urinary cotinine concentrations in urine samples collected from adults in 2015–2016, found cotinine in the urine of over 60% of non-smoking participants. Urinary cotinine levels were higher among Arab participants than among Jewish participants and higher among non-smoking participants who reported exposure to ETS at home than among non-smoking participants who reported no exposure to ETS at home.15
Researchers from Sheba Medical Center, the Hebrew University of Jerusalem, and MoH examined the association between self-reported smoking among 125 fertility patients and cotinine levels in their urine. The research population comprised eighty-three women who self-reported as non-smokers and forty-two who self-reported as smokers. Importantly, the sample does not represent the percentage of smokers among women who underwent IVF at Sheba (18%, according to polling). High urinary cotinine values (>150 µg/L) were found in 4.8% of the eighty-three women who defined themselves as non-smokers.
Future Challenges
The establishment of the National Biomonitoring Laboratory and the development of the National Biomonitoring Program are significant milestones in advancing the field of HBM in Israel. Full implementation of the program—including regular collection of biological samples, analysis of the samples in the national laboratory, and publication of the data and their application in shaping policy in Israel—are the main challenges for the coming years. Within the framework of the program, it is also important to improve collaboration between researchers in academia and the government personnel who collect HBM data and to utilize the data appropriately in planning, management, and budgeting.
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While the National Biomonitoring Program focuses on exposure to harmful environmental chemicals, it is also important to note the centrality of HBM in assessing beneficial dietary metabolic exposures (for example, folates, vitamins, iodine, and magnesium). There is currently no national system for regular monitoring of the nutritional status of the population in Israel, and no coordination between the system that monitors chemical exposures and that which monitors nutritional exposures. Nutritional HBM should be conducted in coordination with the National Biomonitoring Program.
Public interest in HBM results has grown in recent years. An MoH conference in 2019 on exposure to ETS focused on HBM data and analytical techniques for measuring exposure to ETS. Increasing public interest in the HBM findings and publishing data in a way that is accessible to the public is key. For this purpose, a strategy for reporting National Biomonitoring Program data to the public and to decision-makers should be developed. In addition, it is vital to develop a strategy for providing access to HBM data and using HBM data to advance environmental health policy.
Beyond their use by decision-makers, HBM data may influence ordinary individuals’ behavior, as in the context of reducing childern’s exposure to ETS. It is important to examine the clinical use of HBM (for example, in asthma or well-baby clinics) as a tool for identifying infants or children who are exposed to ETS.
Potential public exposure to PFAS—in water, consumer products, and food—raises the need to incorporate tests for these contaminants into the National Biomonitoring Program. A combination of environmental analyses and HBM analyses can facilitate research on the primary sources of exposure to these contaminants.
References
(1) European Commission (updated March 2019). Information Platform for Chemical Monitoring (IPCHEM). https://ipchem.jrc.ec.europa.eu/RDSIdiscovery/ipchem/index.html (retrieved March 2020).
(2) Berman, T., Barnett-Itzhaki, Z., Göen, T., Hamama, Z., Axelrod, R., Keinan-Boker, L., Shimony, T., & Goldsmith, R. (2020). Organophosphate pesticide exposure in children in Israel: Dietary associations and implications for risk assessment. Environmental Research, 182, 108739. https://doi.org/10.1016/j.envres.2019.108739
(3) Wainstock, T. & Sheiner, E. (2019). Selected environmental chemicals level among pregnant women in the Negev: Preliminary results from the Negev Pregnancy Cohort. Poster presented at Environment and Health Fund annual conference, Environment and Health: Complex Interactions, Tel Aviv, Israel.
- 92 - (4) Berlin, M., Barchel, D., Brik, A., Kohn, E., Keidar, R., Livne, A., ... Berkovitch, M. (2019). Intrauterine Biomonitoring
exposure to polychlorinated biphenyls (PCBs) and thyroid hormones in Israeli women: Data from EHF- Human Assaf Harofeh-Ichilov birth cohort. Poster presented at Environment and Health Fund annual conference, Environment and Health: Complex Interactions, Tel Aviv, Israel.
(5) Sheinberg, R., Siegel, E. L., Keidar, R., Mandel, D., Lubetzky, R., Kohn, E., … Levy, A. (2020). Associations between intrauterine exposure to polychlorinated biphenyls on neonatal ano-genital distance. Reproductive Toxicology, 96, 67–75. https://doi.org/10.1016/j.reprotox.2020.06.005
(6) Hassan, L., Moser, A., Rorman, E., Groisman, L., Naor, Y., Shinar, E., ... Novack, L. (2020). Human biologic monitoring based on blood donations to the National Blood Services. BMC Public Health, 20(1), 469. https://doi.org/10.1186/s12889-020-08588-7
(7) Machtinger, R., Berman, T., Adir, M., Mansur, A., Baccarelli, A. A., Racowsky, C., ... Nahum, R. (2018). Urinary concentrations of phthalate metabolites, bisphenols and personal care product chemical biomarkers in pregnant women in Israel. Environment International, 116, 319–325. https://doi.org/10.1016/j.envint.2018.04.022
(8) Martinez, R. M., Hauser, R., Liang, L., Mansur, A., Adir, M., Dioni, L., ... Machtinger, R. (2019). Urinary concentrations of phenols and phthalate metabolites reflect extracellular vesicle microRNA expression in follicular fluid.Environment International, 123, 20–28. https://doi.org/10.1016/j.envint.2018.11.043
(9) Machtinger, R., Gaskins, A. J., Racowsky, C., Mansur, A., Adir, M., Baccarelli, A. A., Calafat, A. M., & Hauser, R. (2018). Urinary concentrations of biomarkers of phthalates and phthalate alternatives and IVF outcomes. Environment International, 111, 23–31. https://doi.org/10.1016/j.envint.2017.11.011
(10) Israel Ministry of Health, Israel Center for Disease Control and Public Health Services (2018). Exposure to organophosphate pesticides among adults in Israel 2015–2016. Part A: Trends and international comparison (Hebrew). https://www.health.gov.il/publicationsfiles/organic_phosphates_2015_2016.pdf (retrieved March 2020).
(11) Israel Ministry of Health, Israel Center for Disease Control and Public Health Services (2019). Exposure to organophosphate pesticides among adults in Israel 2015-2016. Part B: Demographic and nutritional factors (Hebrew). https://www.health.gov.il/publicationsfiles/organic_phosphates_2015_2016b.pdf (retrieved March 2020).
(12) Ein-Mor, E., Ergaz-Shaltiel, Z., Berman, T., Göen, T., Natsheh, J., Ben-Chetrit, A., Haimov-Kochman, R., & Calderon-Margalit, R. (2018). Decreasing urinary organophosphate pesticide metabolites among pregnant women and their offspring in Jerusalem: Impact of regulatory restrictions on agricultural organophosphate pesticides use? International Journal of Hygiene and Environmental Health, 221(5), 775–781. https://doi.org/10.1016/j.ijheh.2018.03.013
(13) Berman, T., Barnett-Itzhaki, Z., Axelrod, R., Keinan-Boker, L., Shimony, T., Goldsmith, R., ... Rosen, L. (2018). Socioeconomic inequalities in exposure to environmental tobacco smoke in children in Israel. Environment International, 121(1), 643–648. https://doi.org/10.1016/j.envint.2018.09.034
(14) Ein-Mor, E., Berman, T., Barnett-Itzhaki, Z., Göen, T., Ergaz-Shaltiel, Z., Natsheh, J., ... Calderon-Margalit, R. (2019). Newborn infant urinary cotinine and birth outcomes in the Jerusalem Environment Mother and Child Cohort Study. International Journal of Hygiene and Environmental Health, 222(7), 1054–1058. https://doi.org/10.1016/j.ijheh.2019.07.006
(15) Berman, T., Barnett-Itzhaki, Z., Mery, N., Keinan-Boker, L., Shimony, T., Goldsmith, R., ... Rosen, L. (2018). Exposure to environmental tobacco smoke in non-smoking adults in Israel: Results of the second Israel biomonitoring survey. Israel Journal of Health Policy Research, 7(1), 33. https://doi.org/10.1186/s13584-018-0229-9
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- 94 - Chapter 10 Non-Ionizing Radiation Non-Ionizing Radiation
Non-ionizing radiation (NIR) refers to electromagnetic fields (EMF) that range from low frequencies (LF) to ultraviolet (UV) frequencies. This radiation is not powerful enough to change the structure of atoms or molecules through ionization.
NIR may have a biological effect via other mechanisms. Tissue heating is a proven and well- known effect of NIR, primarily within the range of radio frequencies (RF). In most personal devices that emit NIR, however, the heating effect does not pose a risk of significant damage due to their low output power (as in wireless telephones, Wi-Fi, and Bluetooth) or sufficient protection from the source of radiation (as in microwave ovens). Public discussion of the topic focuses mainly on the non-thermal effects of NIR, which involve a different mechanism through which a magnetic or electric field operates, or which involve another characteristic of radiation that affects the living body.
Studies examining the effects of NIR exposure on human health, particularly its carcinogenicity, have yet to determine whether exposure to NIR causes non-thermal adverse health effects. In 2001, the World Health Organization (WHO) determined that NIR at extremely low frequencies (ELF) is possibly carcinogenic,1 and in 2011 added RF to this classification.2 Most countries, including Israel, have adopted the precautionary principle, which calls for measures in cases of potential risk even if the causal association between exposure and a harmful effect has not been proven. Exposure thresholds in Israel are ten times stricter than those established by the WHO.
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Researchers have examined the possible association between NIR exposure in a range of frequencies and health outcomes. In the RF range, for example, effects on fertility (sperm quality), cognitive function, the cardiovascular system, hearing loss, and saliva composition have been investigated. In the LF range, research on the effects on birth outcomes (miscarriages and low birth weight), cognitive functions, heart diseases, and neurodegenerative diseases has been conducted. The results of these studies are equivocal.
Progress since 2017
The Environmental Health in Israel 2017 report defined challenges related to Non-Ionizing Radiation. Progress achieved in this area during the past three years is outlined below.
The challenge: Monitor devices emitting non-ionizing radiation (such as transformers and power lines) in public spaces
In short: Continuous monitoring of radiation from Challenge for the coming years: Adopt 4G cellular transmission sites was expanded. measures to reduce exposure to radiation, such as promoting the use of wired communication and developing and implementing technological tools to transfer data more efficiently.
The Non-Ionizing Radiation Law of 2006 authorizes the Ministry of Environmental Protection (MoEP) to issue licenses and supervise and enforce restrictions on devices that emit NIR, including transmission sites operated by cellular companies. In this capacity, MoEP regularly monitors the level of radiation produced by cellular transmission sites. Its surveillance system monitors the activity of about 60,000 antennas and checks them for compliance with the transmission power levels stipulated in their licenses. Currently, the system that examines 3G antennas has been expanded to monitor 4G transmission sites (Long Term Evolution [LTE] technology).
MoEP, with support from the Ministry of Communication, initiated a regulatory policy of sharing cellular sites that caused the number of active transmission sites in Israel to decline steadily by 20% from 2014 to 2020. Cellular coverage also improved as the sites enlarged their capacity for serving a large number of users simultaneously (Figure 1).3 In addition, the levels of exposure to radiation around these sites rose by only about 50% from 2013 to 2019, while the amount of data transferred via the cellular networks increased by a factor of 14.5 (Figure 2).
Legend: Significant progress Some progress Little or no progress
- 96 - Non-Ionizing Radiation
3 2 Figure Israel Ministry of Environmental Protection 1 Figure Knesset Research and Information Center; Israel Ministry of Environmental Protection 2020 2019 2019 2018 2018 2017 2017 - 2016 2016 97 - 2015 2015 2014 2014 2013 2013 2012 0
Year Year 200 600 400 800
1,000 7,500 7,000 8,500 8,000 9,500 9,000 10,000
Data consumption (PB) consumption Data Number of sites of Number Data Consumption over Cellular Networks in Israel, 2013–2019 Data Consumption over Cellular Networks Cellular Transmission Sites in Israel, 2012–2020 Sites in Cellular Transmission Environmental Health in Israel 2020 Chapter 10
The challenge: Re-evaluate standards in light of new findings regarding health outcomes of exposure to non-ionizing radiation
In short: Current studies, worldwide and in Israel, Challenge for the coming years: Conduct have not yet been able to establish an association multidisciplinary research in Israel and maintain between exposure to NIR and adverse health involvement in international studies that will serve outcomes. Therefore, at this stage, re-evaluation of as a basis for risk assessment. the current standards is not justified.
The possible association between NIR exposure and adverse health outcomes has been studied for many years; the scientific evidence, however, indicates that this association has yet to be established.
In March 2020, the International Commission on Non-Ionizing Radiation Protection (ICNIRP) updated its guidelines on limiting exposure to EMF in the RF range of 100 kHz–300 GHz. The threshold values for cellular frequencies and Wi-Fi were not revised. Importantly, the recommendations on exposure limits pertain only to thermal effects (i.e., proven effects). According to the ICNIRP, thresholds cannot be set in the absence of proven scientific evidence; therefore, long-term non-thermal effects are not taken into account.
In October 2019, the Institute of Electrical and Electronics Engineers (IEEE) issued a new international safety standard for human exposure to NIR in the 0 Hz–300 GHz frequency range. The standard updated the levels of exposure in accordance with new physical models that provide a more accurate assessment of the effect of environmental exposure to EMF on the human body. The update did not revise existing standards for exposure to power frequency fields (50Hz), current generation cellular frequencies, and Wi-Fi frequencies.
Notably, with regard to the public’s exposure, MoEP adopted the ICNIRP’s restrictions on exposure to NIR but added strictures of its own. The threshold for exposure to radiation from broadcasting sites, for example, should not exceed 10% of the exposure level determined in the ICNIRP recommendations for areas where people spend prolonged periods of time, such as residential areas and offices, and no more than 30% of the exposure level determined in the ICNIRP recommendations for areas where people spend short periods of time, such as sidewalks and roads.
The challenge: Increase public awareness of the potential adverse health outcomes of non-ionizing radiation, the need to reduce exposure, and the potential risks from exposure
In short: The Israeli National Information Center Challenge for the coming years: Continue for Non-Ionizing Radiation (TNUDA) published working to raise public awareness of the potential updated recommendations for educated use of cell adverse health outcomes, and guide the public on phones, including by toddlers and children. educated use of technology involving NIR.
In 2019, TNUDA updated and expanded its recommendations for the educated use of cell phones, including by toddlers and children, in view of the time that had elapsed since the Ministry of
- 98 - Non-Ionizing Radiation : Reach : Reach For this purpose, TNUDA TNUDA For this purpose, 4 - 99 - Challenge for the coming years among all stakeholders on maximum agreement permitted levels and establish them in law. Therefore, the strength of the study is limited. of the study the strength Therefore, 5 : Establish mandatory regulations regarding permissible permissible regarding : Establish mandatory regulations published its recommendations (2008), the increase in the public’s use of devices use of devices in the public’s (2008), the increase its recommendations published : an stakeholders have yet to reach The and 5,601 healthy people who served as a control group), few were exposed to EMF at the to EMF at the exposed were few group), as a control served people who and 5,601 healthy 1% and around at their workplaces RF range to EMF in the 10% exposed about workplace: (IF) fields. frequency to intermediate exposed including the development of brain tumors. The results did not show an increased risk of risk of an increased did not show The results of brain tumors. including the development However, to EMF. exposure due to occupational malignant or benign brain tumors developing observed was glioma (and less so meningioma) risk of developing an indication of increased in the four occurred the exposure of RF when percentile) (upper level at the highest exposure (3,978 patients with brain tumors study in this large even the disease. Notably, preceding years Within the framework of the international INTEROCC study, researchers in seven countries, countries, in seven researchers study, of the international INTEROCC the framework Within outcomes, to EMF and subsequent health exposure occupational including Israel, examined The challenge levels of non-ionizing radiation In short have been legislated. and no standards agreement
Research on Exposure to Non-Ionizing Radiation in Israel to Non-Ionizing Radiation in Israel on Exposure Research recommendations, however, were never translated into legally binding regulations. In 2015, In 2015, binding regulations. translated into legally never were however, recommendations, in Israel (Malraz), of Noise and Air Pollution the Prevention the Public Council for an NGO, case is still 2020, the As of August this. Court to instruct MoEP to correct petitioned the Supreme pending in court. The 2006 Non-Ionizing Radiation Law is designed to protect the public from effects of exposure of exposure effects the public from is designed to protect The 2006 Non-Ionizing Radiation Law to the installation and operation of radiation-emitting relating to NIR and includes directives levels that set maximum joint recommendations MoEP and MoH formulated In 2011, sources. The exposure. and prolonged continuous and 4 mG for exposure momentary of 2,000 mG for guiding principles: distance from the body, duration of exposure, and power of transmission. of transmission. and power duration of exposure, body, the distance from guiding principles: so that they simplest way to the public in the the recommendations is to convey The objective to distraction while also relate The recommendations and assimilated. understood will be widely asleep, to falling conducive and patterns sleeping habits (healthy hygiene driving and sleep among children). especially and sleep environment, and quantity, sleep quality asleep, staying conducted an extensive survey of the latest recommendations for educated use of cell phones phones cell of use educated for recommendations latest the of survey extensive an conducted guidelines of existing include revisions recommendations The updated countries. in various instead of making message to send a text it is preferable For example, guidelines. and new prolonged during a the body at a distance from phone should be kept a phone call and the under three organized to radiation are exposure on reducing transmission. Recommendations Heatlh (MoH) Heatlh (MoH) and use patterns. in technology changes RF radiation, and that emit Environmental Health in Israel 2020 Chapter 10
The international MOBI-Kids study, launched in 2009 and involving sixteen research centers including an Israeli research team, examined the association between cell phone use and the risk of developing brain tumors in children and adolescents. At the present writing, the researchers have processed the data and are writing a summary report and scientific articles. Within the framework of the study, the Israeli research team was also asked to investigate a possible association between mothers’ exposure to NIR during pregnancy and childbirth (including exposure to ELF radiation during pregnancy—for example, from using an electric blanket) and newborns’ risk of developing brain tumors in childhood and adolescence.
Researchers from the Gertner Institute for Epidemiology and Health Policy Research are examining the possible effects of fetal exposure to MRI on neurodevelopmental, behavioral, and hearing outcomes in childhood. This innovative study compares the results of tests that examine developmental and behavioral disorders such as ADHD among children who were exposed prenatally to MRI, with those of an individually matched unexposed group. The research results will contribute to the limited knowledge on the safety of MRI tests and will help to establish guidelines for the safe use of MRI as a diagnostic tool.
Another study underway at the Gertner Institute on the long-term health effects of MRI investigates the possibility of a carcinogenic effect of exposing children and adolescents to MRI. This study, based on data from Clalit Health Services, examines a possible association between the exposure of children up to age seventeen to MRI and the development of cancer— particularly malignancies of the brain, the circulatory system, and the lymphatic system. In this case-control study, cancer incidence rates among a group of individuals who underwent MRI examination in childhood were compared with those of a control group of unexposed children who were matched for sex and age.
Researchers from the Soreq Nuclear Research Center conducted a study in which detailed measurements of power frequency magnetic fields were taken at 222 computer workstations in twelve computer classrooms in three schools. The background levels before the computers were turned on were very low in nine of the classrooms (median and mean smaller than 0.25 mG) and slightly higher in the other three (0.7–1.2 mG). Connecting the computers to the network and operating them had a negligible impact in ten classrooms (<-0.1 mG), raised the median level by 0.2 mG in one classroom, and by 0.7 mG in another. In the overwhelming majority of measurements, field strength was homogeneous in all parts of the body (legs, chest, hands, and head).
Another study by researchers from Soreq Center measured adolescents’ levels of exposure to power frequency magnetic fields. In this study, eighty-four students in grades 6–10 had a meter attached to their body that measured the magnetic field every 1.5 seconds for twenty-four hours. The students also kept a journal documenting their whereabouts. The study yielded copious statistical data on the participants’ exposure: 0.59 mG geometric mean of average daily exposure, 0.73 mG arithmetic mean, and 1–15 minutes spent at levels above 4 mG. The average daily exposure of three participants (3.6%) was measured at more than 2 mG. The lowest exposures were measured while the students were at home (0.3 mG geometric mean). The findings are comparable to those in other countries.6
- 100 - Non-Ionizing Radiation build 7 - 101 - use new technologies that allow data to be transferred faster and more more and faster data to be transferred that allow technologies use new this range of frequencies and few studies have looked into the implications of exposure to to into the implications of exposure looked studies have and few of frequencies this range conditions in the field (under laboratory on human health. Further studies waves millimeter required. and among populations) are Scientific knowledge on the health implications of exposure to radiation in this RF range is is to radiation in this RF range exposure on the health implications of Scientific knowledge is disputed. non-thermal health effects of potential adverse and the existence equivocal as as well generations of current will operate near the frequencies The 5G technology waves). of millimeter (in the range of ten or more a factor higher by that are frequencies to radiation in the public has not been exposed in use; therefore, is not yet This technology agreed to introduce Wi-Fi into the school for various reasons. Although some expressed concern concern expressed some Although reasons. various school for into the Wi-Fi to introduce agreed because their exposure Wi-Fi to it pointless to object considered they risks, radiation about to radiation elsewhere. exposed already were children of Wi-Fi radiation in schools. The study, comprised of an analysis of media discourse, social social discourse, of media of an analysis comprised The study, in schools. radiation Wi-Fi of in primary of children parents with sixty-seven interviews and in-depth discussions, media the subject expressed items on this 70% of published articles and news that found schools, and view, the same expressed media on social comments 52% of NIR is dangerous, that view interviewed were who The parents an opposing view. expressed comments 27% of social media Researchers from the Technion Faculty of Education in Science and Technology examined the the examined Technology Science and of Education in Faculty Technion the from Researchers perceptions on parents’ focusing risks, NIR-related of and perceptions understanding public’s
enable transmission in a narrow and precise beam that focuses on end devices. Antennas that use Antennas on end devices. that focuses beam and precise transmission in a narrow enable to radiation—unnecessarily. wider areas beam that exposes transmit a broad earlier technology to radiation significantly. exposure reduces the of the MIMO antennas efficiency The high energy reasons: for several to 5G radiation, exposure of It is difficult to assess the health effects of sites and expanding their deployment within buildings, exposure to radiation from personal personal to radiation from exposure within buildings, their deployment of sites and expanding the with to communicate less effort because the devices will require cellular devices can be reduced in use of mobile the increase However, power). less transmission (and expend transmission source will technology the of efficiency greater the Furthermore, power. transmission increase may devices shortening thus at a higher rate with better use of transmission power, data to be transferred allow antennas that MIMO uses massive The 5G technology of NIR exposure. the duration and strength the level of exposure to radiation. MoEP expects this volume to increase by some 50% per year. 50% per year. some by to increase this volume to radiation. MoEP expects of exposure the level 1) radiation: to exposure in increase the prevent or mitigate to ways main two are There sites; 2) transmission more technologies new these of full deployment and the introduction assessment, MoEP’s In efficiently. the number By increasing cellular sites. from of NIR exposure uniformity in greater will result Future Challenges Future of cellular communications— generation designated the next have including Israel, countries, Many The and implementation. advancement for technological generation (5G)—as a target the fifth thus increasing year, every is rising steadily via cellular communication of data consumed volume Environmental Health in Israel 2020 Chapter 10
There is a need to collect data and track the accumulated knowledge on exposure from multiple radiation sources. Furthermore, the publication of health research should be monitored in order to update existing standards as this technology is implemented.
The use of LED lighting in Israel and in the world is expanding because of the advantages it offers, including energy savings and a reduction in air pollution. In recent years, however, some concern has arisen that the use of LED lighting, especially in exposure to its blue light component, may have adverse effects such as disrupting metabolism and circadian rhythms and causing damage to the skin and eyes. Expanding scientific knowledge on these potential adverse effects would give policymakers a basis for decision-making.
In addition to concern about exposure to NIR, parents, educators, health experts, and researchers in Israel and abroad are increasingly worried about the possible adverse health effects of the use of digital media by children and adolescents, such as poor nutritional habits and obesity, headaches and backaches, impaired vision and eye diseases, sleep disturbances, depression, and anxiety. The scientific literature on the health implications of prolonged screen time indicates that the scientific knowledge is not yet sufficiently established.8 To address this concern, some countries (including Israel) and health organizations 9–12 have recommended limiting screen time exposure for small children, while others have refrained from defining hour limits due to the scientific uncertainty that surrounds the matter.13, 14 Given the increasing use of screens and growing health concerns related to them, additional research is needed in order to establish a scientific basis for recommendations.
References
(1) World Health Organization, International Agency for Research on Cancer (2002). Non-ionizing radiation, part 1: Static and Extremely Low-Frequency (ELF) electric and magnetic fields. IARC monographs on the evaluation of carcinogenic risks to humans, volume 80. https://publications.iarc.fr/Book-And-Report-Series/ Iarc-Monographs-On-The-Identification-Of-Carcinogenic-Hazards-To-Humans/Non-ionizing-Radiation-Part- 1-Static-And-Extremely-Low-frequency-ELF-Electric-And-Magnetic-Fields-2002 (retrieved April 2020). (2) World Health Organization, International Agency for Research on Cancer (2011). Press release no 208: IARC classifies radiofrequency electromagnetic fields as possibly carcinogenic to humans. https://www.iarc.fr/wp-content/uploads/2018/07/pr208_E.pdf (retrieved April 2020). (3) Knesset Research and Information Center (2018). Cellular antenna infrastructure in Israel—update (Hebrew). https://fs.knesset.gov.il/globaldocs/MMM/f9cb6b39-4ac6-e811-80e1-00155d0a98a9/2_f9cb6b39-4ac6- e811-80e1-00155d0a98a9_11_10798.pdf (retrieved June 2020).
- 102 - Non-Ionizing Radiation
. United United (1), 12–22. (1), . Environmental Environmental
Research in Science Education, 135 Research . https://assets.publishing.service. (6), 402–408. Position paper: Exposure to screens and Position paper: Exposure to screens and OECD education working papers, no. 195. 195. no. papers, OECD education working - 103 - The health impacts of screen time: A guide for clinicians clinicians The health impacts of screen time: A guide for Occupational and Environmental Medicine, 75 Medicine, Environmental and Occupational Paediatrics & Child Health, 24 Guidelines on physical activity, sedentary behaviour and sleep for children children sedentary behaviour and sleep for Guidelines on physical activity, . (Hebrew). (5), e20162591. https://doi.org/10.1542/peds.2016-2591 , 295–300. https://doi.org/10.1016/j.envres.2017.06.027 https://www.rcpch.ac.uk/sites/default/files/2018-12/rcpch_screen_time_guide_-_final.pdf . https://www.ima.org.il/userfiles/image/Ne144_kidsAndScreens.pdf (retrieved April 2020). (retrieved https://www.ima.org.il/userfiles/image/Ne144_kidsAndScreens.pdf https://doi.org/10.1093/pch/pxz095 https://doi.org/10.1787/8296464e-en (retrieved April 2020). April (retrieved https://doi.org/10.1787/8296464e-en (retrieved April 2020). April (retrieved https://www.tnuda.org.il/en/tips-publications/full-recommendations-educated-use-cellphones Kingdom Chief Medical Officers’ commentary on ‘Screen-based activities and children and young people’s children and young people’s on ‘Screen-based activities and Kingdom Chief Medical Officers’ commentary wellbeing: A systematic map of reviews’ mental health and psychosocial gov.uk/government/uploads/system/uploads/attachment_data/file/777026/UK_CMO_commentary_on_ 2020). April (retrieved screentime_and_social_media_map_of_reviews.pdf children’s health children’s and Child Health (2019). of Paediatrics College Royal 2020). April (retrieved World Health Organization (2019). Health Organization World under 5 years of age https://apps.who.int/iris/bitstream/handle/10665/311664/9789241550536-%20eng.pdf?sequence=1&isAllowed=y 2020). April (retrieved Quality in Medicine (2020). Israel Medical Association, Institute for Impacts of technology use on children: Exploring on the brain, cognition and well-being literature Impacts of technology use on children: minds. young and Media (2016). Media and Communications on Council Pediatrics, of Academy American 138 Pediatrics, use screen healthy Promoting (2019). Digital media: Force Task Digital Health Society, Canadian Paediatric and adolescents. children in school-aged exposure to Power Frequency Magnetic Fields in adolescents - Results of a National Survey. Survey. Fields in adolescents - Results of a National Magnetic Frequency to Power exposure 158 Research, with (2019). Public engagement A. Baram-Tsabari, & Y., Ben-David, Barel D., Orr, A. J., Sharon, K., Dalyot, radiation risks in schools. Wi-Fi of Perceptions life: science in everyday https://doi.org/10.1007/s11165-019-09894-w (2019). Co-operation and Development Economic for Organisation McElvenny, D. M., van Tongeren, M., Turner, M. C., Benke, G., Figuerola, J., Fleming, S., ... Cardis, E. (2018). E. (2018). ... Cardis, S., Fleming, J., Figuerola, G., Benke, M. C., Turner, M., Tongeren, M., van D. McElvenny, to selected combustion exposure and occupational Risk of meningioma study: case-control The INTEROCC agents. chemical other and dusts products, http://dx.doi.org/10.1136/oemed-2016-104280 of monitoring 24-h personal L. (2017). & Kheifets, M., Kandel, S., R., Riven, I., Hareuveny, Eliyahu, TNUDA (updated June 2019). Full recommendations for educated use of cellphones. educated use of for 2019). Full recommendations June (updated TNUDA and parents (2019). Office of the Chief Medical Officer of Health and Social Care, United Kingdom Department (13) (14) (11) (12) (9) (10) (7) (8) (5) (6) (4) Environmental Health in Israel 2020 Chapter 11 Moshe Milner, Press The Government Office Photography Department
- 104 - Climate Change The The 4 Changes in the Changes 1, 2 Finally, changes in weather patterns in weather changes Finally, 3 - 105 - 2 1, 2 1, 2 emphasized the vulnerability of children to climate change: to climate change: of children emphasized the vulnerability The Lancet Countdown Unless greenhouse gases are substantially reduced, a child born today will live in a world that is that is in a world will live a child born today reduced, substantially are gases Unless greenhouse of period, to the detriment Revolution the pre-Industrial Celsius hotter than in at least 4 degrees old age. through infancy his or her health from Climate change affects members of the public differentially. Some populations—including populations—including Some of the public differentially. members affects Climate change more socioeconomic status (SES) and outdoor workers—are people of low the elderly, children, of climate change the effects WHO, to the According others. than are to its dangers exposed 2030 to 2050. in the years 250,000 deaths annually to cause an additional expected are 2019 issue of (livestock and crops) and increase the risk of food spoilage due to the proliferation of bacteria and due to the proliferation spoilage the risk of food and increase and crops) (livestock may season due to high temperatures flowering of plants and a longer flowering mold. Premature allergies. from suffer the condition of people who exacerbate to them. human exposure and transport and increase can impact pollutant formation In addition to their direct effects on human health, environmental changes induced by climate change climate change by induced changes environmental health, on human effects to their direct In addition such as the Asian of disease transmitting vectors impacts including the proliferation indirect have in water and changes viruses, and Chikungunya can transmit the Dengue which mosquito, tiger composition, and air quality. nutritional and it’s quantities of food availability, output diminish agricultural can severely events heat or cold weather or extreme regime precipitation exposure to extreme temperatures include physiological harm such as sunstroke and dehydration, and dehydration, such as sunstroke harm include physiological temperatures to extreme exposure births, in rate of preterm an increase damage, and renal neurological heart function, impaired and respiratory conditions such as cardiovascular of chronic and aggravation changes, cognitive and wildfires sandstorms, waves, heat floods, such as drought, climate events disease. Extreme death. injury and even can cause physical Climate change poses a great challenge to humanity and significantly affects public health. The The health. public affects significantly to humanity and challenge poses a great Climate change the 21st in global health to threat greatest “the it called (WHO) has Health Organization World of effects on public health. Direct effects and indirect direct have may Climate change century.” Climate Change Climate Chapter 11 Environmental Health in Israel 2020 Chapter 11
The effects of climate change and their severity depend on a population’s geographic location, demographic composition, SES, and preparedness for various climatic phenomena.1 Populations in areas heavily affected by climate change may have to migrate to other areas (“climate migration”). Rising temperatures in sub-Saharan Africa in conjunction with inferior health and environmental conditions may lead to refugee migration to Israel. If this occurs, Israel’s healthcare system will need to provide refugees with medical care.5, 6
In September 2015, the member states of the United Nations, including Israel, adopted the 2030 Agenda for Sustainable Development and its seventeen sustainable development goals (SDGs). In 2019, Israel reiterated its commitment to this agenda in Government Resolution 4631, incorporating the UN development goals and undertaking to improve governance and governmental strategic planning processes.7 One of the key SDGs is no. 13: “Take urgent action to combat climate change and its impacts.” This goal includes developing national strategies for coping with climate change, raising awareness regarding these changes and promoting mechanisms for dealing with them. In 2019, the Israeli government issued a report on its progress in implementing these goals.8 The same year the OECD published its own report on this issue and found that Israel falls very short of meeting the UN development goals (Figure 1) and is farther from the SDG targets than the average in OECD countries.9
Distance from Selected UN Development Goals, Israel in Comparison with the Average in OECD Countries Figure 1 0.0 OECD OECD, 2019 9
0.5
1.0
1.5 Distance
2.0
2.5
3.0 65.8 92.6 Eradicate Food Health Education Gender Water Sustainable Climate Oceans Biodiversity poverty equality production
People Planet
The distance from attaining the goal is measured in standardized units: 0 indicates that the target level for 2030 has been attained; 3 is the distance that most OECD countries have traveled so far. The columns show Israel’s performance relative to a particular SDG (that is, the distance traveled toward the goal), distinguishing between people-related goals (in blue) and planet- related goals (in green). The diamond indicates the average performance in OECD countries.
The Israeli government’s response to climate change focuses on two topics: reducing greenhouse gas emissions (mitigation) and preparing for climate change (adaptation).
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Reducing Greenhouse Gas Emissions Climate Change In the Paris Agreement, signed at the UN Climate Conference in 2015, the Government of Israel declared a national goal of reducing greenhouse gas emissions to 8.8 tons per capita in 2025 and 7.7 tons per capita in 2030. In late 2018, the Minister of Energy presented a plan with goals for the energy sector for 2030, focusing on discontinuing the use of coal for energy generation and transitioning to transportation powered by electricity and natural gas. In response to the Ministry of Energy’s claim that these steps would significantly reduce greenhouse gas emissions and enable Israel to meet its emissions goals, the scientific community in Israel called for a re-evaluation of the expanded use of natural gas and advocated a transition to renewable energy sources.10, 11 Notably, according to an OECD report published in 2020, emissions have been rising in Israel in recent years and will rise by another 23.6% by 2030 if the current trajectory continues.12 Some of the measures for reducing emissions provide the co-benefits of mitigating climate change and benefiting public health. They include transitioning to renewable energy and clean transportation and reducing meat consumption. (See the “Planning” chapter for more information on planning issues related to transportation and energy.)
Preparing for Climate Change In Government Resolution 4079—Preparedness for Adapting to Climate Change: Implementing Government Recommendations on a National Strategy and Action Plan13—approved in 2018, the Israeli government acknowledged the need to prepare for climate change by implementing action plans and policy measures that would mitigate the health, environmental, and economic risks of climate change. The strategy includes three tiers: a) strengthening research and reducing knowledge gaps; b) incorporating climate change considerations into everyday economic activities; (c) pursuing a “no regret” policy.
Pursuant to the government resolution, an Interministerial Administration for Climate Change Adaptation was formed, headed by the Ministry of Environmental Protection (MoEP). The new administrative body is responsible for inter-ministerial coordination, monitoring execution of the national strategy for adaptation, implementing adaptation plans, and updating them from time to time. The thirty-five members of the administration, including representatives of government ministries and other entities, are divided into seven committees that address the key recommendations for a national action plan and strategy for climate change (Figure 2).
Committees at the Interministerial Administration for Climate Change Adaptation Figure 2 Energy, Natural Resources, Science Emergency and Technology and Agriculture and and Closing Health Infrastructure Water Knowledge Gaps
Strategic Integration Information and Local Committee Education Government
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The Strategic Integration Committee ranked the effects of climate change on various economic sectors based on the gravity of the effects in order to create a basis for prioritizing projects and choosing primary courses of action. Thirty experts in various fields participated in the ranking process, which identified the most critical effects of climate change in Israel: increased frequency of extreme heat waves and droughts, a greater number of hot days in the year, desiccation of riverbeds and moist habitats, desertification, and decreased replenishment of natural water sources. With respect to the effects on human health and safety, increased frequency of wildfires, harm to vulnerable populations and urban heat islands were ranked as most critical.
According to an Israel Meteorological Service (IMS) report from 2020, which included possible scenarios for climate change in Israel, in the severe scenario the average temperature in Israel will rise by 4 degrees Celsius by the end of the current century. According to the moderate scenario, from 2040 to the middle of the century the average temperature will rise by 1.5 degrees Celsius and will then level off.14
Progress since 2017
The Environmental Health in Israel 2017 report defined challenges related to Climate Change. Progress achieved in this area during the past three years is outlined below.
The challenge: Implement the National Plan to Combat Cutaneous Leishmaniasis
In short: The National Plan to Combat Cutaneous Challenge for the coming years: Raise public Leishmaniasis began in 2012. At the end of 2018, awareness. MoEP allocated an additional NIS 30 million to support the plan.
Leishmaniasis is caused by the Leishmania parasite, which is transmitted to humans by the female sand fly, which can get infected after stinging an infected animal. This vector’s activity may be affected by climate warming because ambient temperatures impact spatiotemporal sand fly activity patterns.15 Two main parasites are implicated: Leishmania tropica, whose host animal in Israel is the hyrax, and Leishmania major, hosted by various rodents including several types of gerbils.16 The Ministry of Health (MoH) data indicate a decrease in incidence rates of leishmaniasis since 2014 (Figure 3), with 432 cases reported to MoH from 2018 through July 2019. Notably, however, there is substantial underreporting and the real scope of morbidity is unknown.17
Legend: Significant progress Some progress Little or no progress
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3 Figure of Israel Ministry Health Incidence rate per 100,000 per rate Incidence
0.0 1.0 9.0 8.0 7.0 6.0 5.0 4.0 3.0 2.0 10.0
2019
2017
2015
2013
2011 18
2009
2007
2005
2003
2001
1999
1997
1995
- 1993
109
1991 -
1989
1987 1985
Incidence rate per 100,000 1983
1981
1979
1977 1975
30 million in support of the plan (in addition to an earlier allocation to an earlier allocation of the plan (in addition 30 million in support
1973
1971 1969
The plan offers professional assistance for local governments and funding for funding for and governments local for assistance professional offers plan The
1967
17
1965 Number of cases
1963
1961 Year
0
50 100 200 150 350 300 250 Number of cases of Number Legend: funds to local governments for clearing stones that hyraxes use as habitats. For reasons of medical of medical For reasons use as habitats. clearing stones that hyraxes for funds to local governments reports on patients’ location (receiving precise receive MoEP does not however, confidentiality, to destroy. habitats the target precisely impossible to it localities), making their of the names only reporting to MoEP. for specific procedures MoH is developing Subsequently, The National Plan to Combat Cutaneous Leishmaniasis was launched in 2012. At the end of launched in 2012. At the end of Leishmaniasis was The National Plan to Combat Cutaneous 2018, MoEP allocated NIS sum). same the of the of the Leishmania parasite during study including a spatiotemporal epidemiological research, for and accessible molecular diagnosis of rapid past decade in southern Israel, and development that MoEP transferred revealed State Comptroller of the Israel The 2020 report species. various Cutaneous Leishmaniasis in Israel—Cases and Incidence Rates, 1961–2019 Incidence Rates, Israel—Cases and Leishmaniasis in Cutaneous Environmental Health in Israel 2020 Chapter 11
The challenge: Develop a national action plan to cope with climate change
In short: In July 2018, the Israeli government Challenge for the coming years: The National approved the National Program for Adaptation Program for Adaptation to Climate Change to Climate Change (without funding its defines basic principles for coping with climate implementation by government ministries). change. However, specific operative measures for implementing the program’s goals (including health-related goals) have yet to be defined and the program has yet to be funded.
As noted, the government has approved a national action and adaptation program for coping with climate change (Government Resolution 4079, July 2018) and established an Interministerial Administration for Climate Change Adaptation, headed by MoEP.13 The program aims to mitigate the adverse effects of climate change, including water shortages, droughts and an increase in extreme climatic events. The program includes assessing risks, developing methodological models for prioritizing challenges and actions relevant to Israel, monitoring morbidity and mortality (with an emphasis on vulnerable populations), incorporating climate change adaptation in decision-making processes, and promoting relevant collaborative initiatives.
Importantly, although the government has approved the National Program, it has yet to fund it. Consequently, the various ministries have limited personnel and funding for advancing the strategic program. The Administration for Climate Change Adaptation plays an integrative role but lacks authority vis-à-vis the participating government ministries.
As part of the adaptation to climate change, MoH was tasked with developing an operative action plan to prepare the healthcare system for potential scenarios stemming from the evolving climate situation. MoH’s mandate also includes formulating a strategy for real-time data collection, developing morbidity forecasts in various extreme weather scenarios, and defining work procedures for coping with them. MoH’s readiness for climate change focuses on responding to the immediate health impact of extreme climate events such as heat waves, cold waves, and floods. In this context, it has elaborated a program to improve the adaptation of hospitals and medical services as part of emergency preparedness. MoH has also published information on climate change, including recommendations for coping with heat waves and extreme cold, with emphasis on recommendations for the general public and for vulnerable populations such as the elderly and the chronically ill.19–21
The Emergency and Health Committee, established under the Interministerial Administration for Climate Change Adaptation, has begun its work and is expected to recommend steps to prepare the healthcare system for climate change in both the short and the long terms. As part of this effort, MoH is conducting a comprehensive review of the health consequences of climate change and actions being taken internationally to address them. The review indicates that the greatest threats to human health from climate change include morbidity due to heat stress, aggravation of chronic diseases, diminished food security, and the spread of vector-borne infectious disease.22
- 110 - Climate Change 23 Israel Ministry of Israel Ministry of Construction & Housing 4 Figure 1 2 2018 1 2017 23 1 1 2 5 2016 1 2 5 2015 1 4 2014 Extreme heat stress* Extreme 3 2013 - 111 - 1 2012 Drought Drought 2 2011 1 1 2010 Wildfires 1 2009 2008 : Create a national database that includes exposure metrics metrics exposure a national database that includes : Create : Develop specific climate change indicators specific climate : Develop : Strengthen collaboration between the Israel Meteorological collaboration between the Israel Meteorological : Strengthen 1 2007 Storms and floods : No progress was made in meeting this challenge. was made in meeting this challenge. : No progress : In 2019, MoH and IMS held several meetings but did not achieve significant progress in tackling in tackling : In 2019, MoH and IMS held several meetings but did not achieve significant progress : An initial list of specific climate change indicators has been compiled. been compiled. change indicators has of specific climate : An initial list
2 1 0 7 6 5 4 3 9 8
10 Year Number of events of Number high humidity. Celsius with relatively 30 degrees above to temperatures refers heat stress Extreme outbreaks of vector-borne diseases; of vector-borne outbreaks climatic conditions. extreme harm caused by physical emergency room hospitalizations due to respiratory problems and stroke during heat waves; and stroke problems due to respiratory hospitalizations room emergency diseases; and water-borne of food- outbreaks * Legend: and health indicators related to climate change and health indicators related In short In short this challenge. The challenge The challenge climate events for extreme to prepare Service and the Ministry of Health in order In short The challenge
Extreme Climate Events in Israel, 2007–2018 Extreme in of Natural Disasters the Study Center for the Information to data published by According 4). in 2018 (Figure events climate extreme three experienced Israel, the country MoH is in the initial stages of defining health-related climate change indicators, including: including: indicators, climate change of defining health-related stages MoH is in the initial Environmental Health in Israel 2020 Chapter 11
Research on Climate Change in Israel
Researchers from the Shamir Research Institute and the University of Haifa, examining how temperature changes affect the activity of Leishmania tropica vectors (Phlebotomus sergenti and Phlebotomus arabicus sand flies), found a positive correlation between air temperature at the beginning of the night and the number of active adult sand flies. As temperature at those hours increased, there were more active adult sand flies, thus increasing the risk of human infection.15
Researchers from Tel Aviv University, the University of Haifa, and MoH, studying morbidity caused by the Campylobacter bacterium (a food-borne bacterium that causes gastrointestinal diseases) in 1999–2010, found that higher temperatures during the year (above 27 degrees Celsius) increase the risk of morbidity in the general population and particularly among young children.24
Researchers from Tel Aviv University, Ben-Gurion University of the Negev, the University of Haifa, and MoH, studying patterns of morbidity caused by the Campylobacter bacterium in Israel, found that the risk of developing Campylobacter-infection is higher in the spring than in the winter. They also found, however, that the risk of illness is affected by several variables including population density and temperature. The researchers concluded that there is a spatiotemporal ambient temperature effect on Campylobacter morbidity.25
Researchers from MoH, the Ministry of Agriculture and Rural Development, Clalit Health Services, Ben-Gurion University of the Negev, the Hebrew University of Jerusalem, the Israel Institute for Biological Research, the Israel Nature and Parks Authority, the Israel Defense Forces (IDF), and Mekorot, the national drinking water supplier, analyzed the outbreak of leptospirosis that occurred in August 2018 in the streams of northeastern Israel. The disease is caused by exposure to Leptospira bacteria in the urine of infected animals. The researchers reported that the drop in stream levels and reduction in water quality following the drought in 2018 and previous years contributed to the outbreak.26, 27
Researchers from MoH and Lev Academic Center analyzed patterns of shigellosis morbidity in Israel in 2002–2015. Shigellosis is transmitted through contact with Shigella bacteria in food or water or through human contact. The researchers showed that shigellosis morbidity in Israel has significantly declined, especially since 2010. They also found that most incidence of shigellosis occurred during the warm months of the year, implying that climate change and rising temperatures in Israel may spur an increase in shigellosis morbidity.28
Researchers from MoH, Tel Aviv University, and several medical centers—Assaf Harofeh, Barzilai, Meir, Kaplan, HaEmek, Rambam, Laniado, and Sheba—found an association between the outbreak of West Nile fever in 2015 and extreme heat waves that year.29
- 112 - Climate Change than than (days (days
30 hamsin hamsin
32 33 - 113 - 34 31 . Allergy sufferers experience stronger symptoms during a stronger experience sufferers . Allergy days in Israel and the Middle East. in Israel and the Middle days hamsin hamsin
35 number of number of high temperature and low humidity), on hot days (high temperature and high humidity), humidity), and high (high temperature on hot days humidity), and low of high temperature in the highest concentrations of dust particles and found temperature) (low and on cold days the air during a in the brings on an increase as climate change worsen and these symptoms may on other days, trimester of pregnancy increase the risk of developing preeclampsia. Preeclampsia can occur in can occur in Preeclampsia preeclampsia. the risk of developing increase pregnancy of trimester in reallocation resulting due to perturbations in maternal heat homeostasis, high temperatures to the fetus. and their availability resources of energy preterm birth among pregnant women in southern Israel. They found that exposure to high to high that exposure found They in southern Israel. women birth among pregnant preterm birth, with a higher risk of preterm associated is 32–39 of pregnancy in weeks temperatures fetuses. among female especially of the University Ben-Gurion Medical Center, University Soroka from of researchers A group or third during the first temperatures that high mean found University and Harvard Negev, Researchers from the Hebrew University of Jerusalem, Ben-Gurion University of the Negev and and of the Negev Ben-Gurion University of Jerusalem, University the Hebrew from Researchers and temperatures extreme the association between Medical Center studied University Soroka behavior, especially among patients with a psychiatric diagnosis or with previous attempts at attempts at or with previous diagnosis among patients with a psychiatric especially behavior, suicide. A study conducted by researchers from Soroka University Medical Center and Harvard Medical Center and Harvard University Soroka from researchers conducted by A study Celsius a 5 degrees an association between found of Beer Sheva among 2,338 residents University The researchers subsequent days. and suicide attempts during the two in temperature spike of suicidal has a substantial impact on the likelihood concluded that a steep rise in temperature for extreme weather. weather. extreme for an association found University Medical Center and Harvard University Soroka by research Joint in Israel incidents of snakebite and the number humidity with low high temperatures between of snakebites led to a higher frequency that heat waves also found The researchers in 2008–2015. seasons. in both the cold and warm Researchers from the University of Haifa and the Hebrew University-Hadassah Braun School Braun School University-Hadassah and the Hebrew of Haifa the University from Researchers climate to extreme urban resilience examining Medicine are of Public Health and Community are system and its healthcare while Haifa The initial findings indicate that in Haifa. events made no specific preparations have they or earthquake, such as war emergencies for prepared and the University of Córdoba compared concentrations of dust particles during a particles dust of concentrations compared of Córdoba the University and Researchers from the University of Haifa, Meuhedet Health Services, the University of Tulsa Tulsa of University the Meuhedet Health Services, of Haifa, the University from Researchers between high environmental temperatures in the summer and the risk of stroke. They found found They the risk of stroke. and in the summer temperatures high environmental between of risk the days, subsequent in of stroke risk the increase may days hot summer while that widens. temperatures and nighttime daytime as the disparity between decreases stroke Researchers from the University of Haifa, Rambam Health Care Campus, and the Israel Center Israel Center and the Campus, Care Rambam Health of Haifa, the University from Researchers the association Registry to examine Stroke the National from data analyzed Control Disease for
Environmental Health in Israel 2020 Chapter 11
Future Challenges
In recent years, Israel has made some progress in preparing to adapt to climate change. The Interministerial Administration for Climate Change Adaptation and its committees were established; the Administration worked to rank the criticality of climate change effects as a basis for prioritizing projects and making decisions on primary courses of action. It appears that the main emphasis on health at the Administration for Climate Change Adaptation is on short-term effects such as heat waves, cold waves, and floods.
It is also important to prepare for the long-term effects of climate change on public health— for example, the expected increase in the spread of food pests, mosquitoes, and other vectors. Effective response is needed in case of spread of vector-borne infectious diseases such as leishmaniasis, Zika fever, dengue, West Nile fever, and rabies. Also needed are preparations for unknown viral, bacterial, and parasitic threats potentially related to climate change. In bracing for additional long-term effects of climate change, it is important to ensure that the nutritional value of food is preserved and that the impact of climate change on mental health is addressed.
While climate change may significantly affect public health in Israel, epidemiological research in Israel in this field is still in its very early stages. In particular, there is a lack of interdisciplinary research on the health effects of climate change with emphasis on morbidity and mortality among various populations—for example, examining the association between environmental temperature and hospitalization of chronically ill adults. Also needed is research in the fields of economics, the social sciences, and healthcare system management in the context of climate change. It would be useful, for example, to examine the health effects of climate change using co-benefit models, both in the contexts of mitigation and adaptation. To promote research in this field, relevant data must be systematically collected, and this requires the creation of a digital system capable of gathering the data in real time.
From a broader perspective, legislative action is needed in order to better cope with climate change and its impact on health. MoEP is drafting a “Climate Bill”—a statute that would make Israel’s emission targets binding for the first time.36 Also, measurements and assessments of climate change should be incorporated into decision-making processes such as those related to planning. Additional partners should be enlisted in the effort to address the health implications of climate change. This includes HMOs and medical centers, which can collect data and raise medical teams’ awareness of the health effects of climate change as well as methods for treatment and prevention; and government ministries, which can advance adaptation plans for heat waves.
Local governments have a central role to play in preparing for climate change. As part of the EU’s Clima-Med program, representatives of forty Israeli local authorities participated in 2019 in a workshop on preparing and coping with the steady increase in consumption of energy resources. The local government committee of the Interministerial Administration for Climate Change Adaptation prepared an adaptation action plan at the local level that would, among other things, identify risks according to climatic regions. One of the challenges in the coming years is to raise involvement of local authorities in mitigation and preparedness for climate change.
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A call by A call by Ecology & (Hebrew). (10211), 1836–1878. Trends in temperature in temperature Trends International Journal of of International Journal . OECD Publishing, Paris. . OECD Publishing, Lancet, 394 Accelerating climate action in Israel: action in Israel: Accelerating climate Measuring distance to the SDG Targets MeasuringTargets SDG the to distance - 115 - . OECD Publishing, Paris. . OECD Publishing, Health risks assessment for the Israeli population following the the the Israeli population following Health risks assessment for (4), 72–78 (Hebrew). Implememation of sustainable development goals. National review. National review. Implememation of sustainable development goals. (2), 311–314. https://doi.org/10.1016/j.ijheh.2018.10.004 (Hebrew). https://ims.gov.il/sites/default/files/%D7%9E%D7%92%D (Hebrew). (1), 21–51. https://doi.org/10.1080/23739770.2020.1749965 . https://old.ecopeaceme.org/wp-content/uploads/2019/05/Gaza-Health-Report_ENG.pdf Ecology & Environment, 10 (4), 81–83 (Hebrew). http://www.magazine.isees.org.il/ArticlePage.aspx?ArticleId=905 http://www.magazine.isees.org.il/ArticlePage.aspx?ArticleId=905 (4), 81–83 (Hebrew). https://mfa.gov.il/MFA/PressRoom/2019/Documents/Israel%20SDG%20national%20review.pdf . https://doi.org/10.1787/a8caf3fa-en (retrieved June 2020). June (retrieved https://doi.org/10.1787/a8caf3fa-en https://www.who.int/news-room/fact-sheets/detail/climate-change-and-health (retrieved June 2020). 2020). June (retrieved https://www.who.int/news-room/fact-sheets/detail/climate-change-and-health http://www.magazine.isees.org.il/ArticlePage.aspx?ArticleId=903 (retrieved June 2020). June (retrieved http://www.magazine.isees.org.il/ArticlePage.aspx?ArticleId=903 Israel Prime Minister’s Office (2019). Incorporating UN development goals for improving governance and and governance for improving goals Office (2019). Incorporating UN development Minister’s Israel Prime World Health Organization (2018). Climate change and health. change (2018). Climate Health Organization World Israel Prime Minister’s Office (2018). Israel’s preparedness for adapting to climate change: Implementing Implementing to climate change: for adapting preparedness Office (2018). Israel’s Minister’s Israel Prime change in Israel, forecasts up to 2100 up in Israel, forecasts change 7%9E%D7%95%D7%AA%20%D7%94%D7%98%D7%9E%D7%A4%D7%A8%D7%98%D7%95%D October 2020). 7%A8%D7%94%20%D7%A2%D7%93%202100.pdf (retrieved Refocusing mitigation policies for the electricity, residential and transport sectors the electricity, mitigation policies for Refocusing October 2020). (retrieved https://doi.org/10.1787/fb32aabd-en 4079, Resolution No. and action plan. Government a national strategy for recommendations government 2020). June (retrieved https://www.gov.il/he/departments/policies/dec4079_2018 29, 2018 (Hebrew). July Service (2020). Israel Meteorological and Road Safety, Transport Israel Ministry of the scientific community to reconsider expanding the use of natural gas in the energythe scientific community to reconsider expanding market 2020). July (retrieved https://www.haaretz.co.il/embeds/pdf_upload/2019/20191119-124637.pdf commitments. of its international climate change implementation Israel’s promises: A. (2020). Unkept Tal, 14 of Foreign Affairs, Israel Journal (2020). Economic Co-operation and Development for Organisation Israel 2019 2020). June (retrieved (2019). Development and Co-operation Economic for Organisation 2019: An assessment of where OECD countries stand (2019). ... Ben Ishai, P. G., Dagan, D., Yakir, A., Kribus, D., Shechtman, Y., A., Aumann, Tal, Hygiene and Environmental Health, 222 14, 2019 (Hebrew). 4631, July Resolution No. Government in the government. strategic planning processes 2020). June (retrieved https://www.gov.il/he/departments/policies/dec4631_2019 (2019). Affairs Israel Ministry of Foreign Hermesh, B., Maya, M., & Davidovitch, N. (2019). N. M., & Davidovitch, Maya, B., Hermesh, sanitary crisis in Gaza 2020). June (retrieved of (2019). Adaptation N. & Davidovitch, C., Rosenthal, A., Levine, H., Lew-Levy, N., Teschner, M., Negev, gap. in Sub-Saharan Africa: Closing the migration health systems to climate-related https://doi.org/10.1016/S0140-6736(19)32596-6 sufferers. condition of allergy the will aggravate change I. (2019). Climate Helfman-Hertzog, Environment, 10 2020). June (retrieved Paz, S., Negev, M., & Davidovitch, N. (2019). The effects of climate change on public health in Israel: public health in Israel: on of climate change The effects (2019). N. M., & Davidovitch, Negev, S., Paz, Science and policy. … Montgomery, P., M., Byass, K., Boykoff, Belesova, S., Ayeb-Karlsson, Amann, M., Arnell, N., N., Watts, that Ensuring and climate change: on health Lancet Countdown The of The 2019 report H. (2019). by a changing climate. is not defined today the health of a child born
(13) (14) (11) (12) (9) (10) (7) (8) (5) (6) (3) (4) (1) (2) References References Environmental Health in Israel 2020 Chapter 11
(15) Waitz, Y., Paz, S., Meir, D., & Malkinson, D. (2018). Temperature effects on the activity of vectors for Leishmania tropica along rocky habitat gradients in the Eastern Mediterranean. Journal of Vector Ecology, 43(2), 205–214. https://doi.org/10.1111/jvec.12304
(16) Israel Ministry of Health (updated July 2017). Leishmaniasis (Hebrew). https://www.health.gov.il/Subjects/disease/Pages/Leishmaniasis.aspx (retrieved June 2020).
(17) Israel State Comptroller and Ombudsman (2020). The health system’s treatment of recurrent outbreaks of diseases. Annual report 70a (Hebrew). https://www.mevaker.gov.il/sites/DigitalLibrary/Pages/Reports/3246-6.aspx (retrieved June 2020).
(18) Israel Prime Minister’s Office (updated September 2017). Assistance plan for local governments in reducing leishmaniasis hazards. Government Resolution No. 1973, September 27, 2016 (Hebrew). https://www.gov.il/he/Departments/policies/2016_dec1973 (retrieved June 2020).
(19) Israel Ministry of Health. Recommendations for coping with hot weather (Hebrew). https://www.health.gov.il/Subjects/Geriatrics/HealthPromotionAndPreventiveMedicine/Pages/heat_injuries.aspx (retrieved June 2020).
(20) Israel Ministry of Health (2018). Recommended actions for the elderly and infants to prevent risks and harm from the cold (Hebrew). https://www.health.gov.il/NewsAndEvents/SpokemanMesseges/Pages/03012018-2.aspx (retrieved June 2020).
(21) Israel Ministry of Health. Climate change and extreme heat—Infographic (Hebrew). https://www.health.gov.il/Subjects/Environmental_Health/Environmental_contaminants/Pages/Heat.aspx (retrieved June 2020).
(22) Israel Ministry of Health, Israel Ministry of Environmental Protection and The Israel Society of Ecology and Environmental Sciences (2020). Climate change and public health: Literature review, mapping of health indicators and recommendations for action in preparation for establishing a ministry of health work plan (Hebrew). https://www.gov.il/he/departments/publications/reports/climate_change_and_public_health_2020 (retrieved November 2020).
(23) Israel Ministry of Construction and Housing (2019). Sustainable development goal 11: Sustainable cities and communities. Implementation of SDG11 in Israel: Challenges and future prospects. https://www.gov.il/BlobFolder/reports/sdg11_israel_report_2019/he/documents_tichnun_ironi_sdg11_israel_ report_2019.pdf (retrieved December 2020).
(24) Rosenberg, A., Weinberger, M., Paz, S., Valinsky, L., Agmon, V., & Peretz, C. (2018). Ambient temperature and age-related notified Campylobacter infection in Israel: A 12-year time series study. Environmental Research, 164, 539–545. https://doi.org/10.1016/j.envres.2018.03.017
(25) Rosenberg, A., Weinberger, M., Paz, S., Valinsky, L., Rokney, A., Kloog, I., & Peretz, C. (2019). Spatio-temporal analysis of Campylobacter incidence in Israel, 1999–2010. Environmental Epidemiology, 3, 309–310. https://org.doi/10.1097/01.EE9.0000609372.12933.d2
(26) Dadon, Y., Haas, E. J., Kaliner, E., Anis, E., Singer, S. R., Atiya-Nasagi, Y., ... Moran-Gilad, J. (2018). Outbreak of human leptospirosis linked to contaminated water bodies in Northern Israel, June to August 2018. Eurosurveillance, 23(38), 1800486. https://doi.org/10.2807/1560-7917.ES.2018.23.38.1800486
(27) Israel Ministry of Health. Leptospirosis (Hebrew). https://www.health.gov.il/Subjects/disease/Pages/Leptospirosis.aspx (retrieved June 2020).
(28) Adamker, G., Holzer, T., Karakis, I., Amitay, M., Anis, E., Singer, S. R., & Barnett-Itzhaki, Z. (2018). Prediction of Shigellosis outcomes in Israel using machine learning classifiers.Epidemiology and Infection, 146(11), 1445–1451. https://doi.org/10.1017/S0950268818001498
- 116 - Climate Change (1), 76. , 109678. (Hebrew). Travel Medicine and and Medicine Travel , 109314. The Journal of Emergency of Emergency The Journal , 497–511. Environmental Health, 17 Environmental Research, 187 Environmental Research, Aerobiologia, 34 - 117 - Environmental Research, 184 Environmental Research, Assessing the current state of affairs, June 2020 June Assessing the current state of affairs, (5), e0232877. https://doi.org/10.1371/journal.pone.0232877 , 41–45. https://doi.org/10.1016/j.tmaid.2018.07.008 (6), 819–826. https://org.doi/10.1016/j.jemermed.2018.02.002 PloS One, 15 PloS One, https://doi.org/10.1016/j.envres.2020.109314 (2020). Protection Israel Ministry of Environmental https://doi.org.10.1007/s10453-018-9526-6 Yarza, S., Vodonos, A., Hassan, L., Shalev, H., Novack, V., & Novack, L. (2020). Suicide behavior and and L. (2020). Suicide behavior & Novack, V., H., Novack, A., Hassan, L., Shalev, Vodonos, S., Yarza, hot and arid climate. characteristics in meteorological conditions on airborne pollen in Jerusalem and Tel Aviv (Israel). Aviv Tel and conditions on airborne pollen in Jerusalem heat The association between E. (2018). & Jaffe, V., M., Sonkin, R., Novack, Yitshak-Sade, S., Shashar, Study. Israel National and snakebites: parameters and other meteorological waves 54 Medicine, https://doi.org/10.1186/s12940-018-0420-z and Temperature L. (2020). & Novack, B., M., Sarov, Yitshak-Sade, Shtein, A., O., I., Erez, Kloog, S., Shashar, pregnancy affects that perturbation in maternal heat homeostasis evidence Epidemiological preeclampsia: outcome. weather impact of Sharav The (2018). T. & Hefer, E., Galán, C., H., Levetin, I., Kutiel, Helfman-Hertzog, Infectious Disease, 28 Disease, Infectious in summer ambient temperature (2020). High G. Weinstein, I., & Zucker, D., Tanne, M., Negev, S., Paz, S., Vered, in Israel. A national study or transient ischemic attack: and risk of stroke https://doi.org/10.1016/j.envres.2020.109678 low ambient air temperature, between & Raz, R. (2018). Associations A. C., Just, O., L., Erez, I., Novack, Kloog, term neonates in southern Israel. in age gestational and small for birth weight Salama, M., Amitai, Z., Lustig, Y., Mor, Z., Weiberger, M., Chowers, M., ... Leshem, E. (2019). Outbreak (2019). Outbreak M., ... Leshem, E. Chowers, M., Weiberger, Z., Mor, Y., Amitai, Z., Lustig, Salama, M., of notified cases. analysis A retrospective disease in Israel (2015): Virus Nile West of (35) (36) (34) (32) (33) (30) (31) (29) Environmental Health in Israel 2020 Chapter 12
- 118 - Chapter 12 Planning Planning
Urban and transportation planning are closely linked to human health. Planning plays an important role in preventing health hazards and sanitation problems in the urban space, and contributes to ensuring drinking water quality, sewage and waste treatment, and open green spaces in cities. In 1946, the World Health Organization (WHO) defined the term “health” as “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.” Urban planning has a critical impact on public health because a healthy environment means not only an environment free of air pollution, noise, water pollution, and other hazards that directly endanger public health but also an environment that encourages physical, community, and social activity.1
Studies have shown that the urban environment—including transportation infrastructure, neighborhoods, buildings, parks and open public spaces—affects an individual’s health. The extent to which an individual is exposed to air pollution, noise, temperature, and green areas encourages or inhibits daily physical activity.2 There is evidence that living near industrial areas and main roads increases exposure to air pollution and noise and raises the risk of morbidity and early mortality, whereas living in proximity to green spaces contributes to mental health and healthy birth outcomes and reduces rates of cardiovascular morbidity and early mortality. Several factors have been identified that encourage people to go out into the urban space, take walks, and ride bicycles—including low building density, mixed-use planning that enables use of resources throughout most of the day, and the accessibility and availability of frequent and reliable public transportation. These variables, where present, create an infrastructure that facilitates walkability, bikeability, and a neighborhood that encourages a healthy and active urban lifestyle.
Israel is one of the world’s most densely populated countries and has the highest rate of population growth among developed countries. At its current rate of growth, its population is expected to double by the middle of this century. (Figure 1).3 This rapid population increase, however, is not evenly distributed across the population and is accompanied by an alarming reduction in open space. When looking at the past twenty years, the rate of reallocation of open space to developed land peaked in 2014–20174 and is expected to lead to an overall reduction in access to quality open space countrywide.
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Population Density in Israel and Selected Countries, 1980–2050 Figure 1 Zafuf, 20203 700
600 2
500
400
300 Number of people/m 200
100
0
Year 1980 1990 2000 2010 2020 2030 2040 2050
Legend: Israel Japan Netherlands Belgium South China Switzerland Korea
Progress since 2017
The Environmental Health in Israel 2017 report defined challenges related to Planning in Israel. Progress achieved in this area during the past three years is outlined below.
The challenge: Promote shading in open public spaces
In short: The Planning and Construction Challenge for the coming years: Raising Regulations (Playground Shading) went into effect awareness of the importance of shading and in 2019; the amended Planning and Construction continuing to install shading in the public sphere in Regulations (Calculating Land-to-Building Ratio in order to create climatic comfort in public spaces. Plans and Permits) went into effect in 2020.
The Planning and Construction Regulations (Playground Shading), effective September 2019, mandate the shading of 70% of playground facility areas. An amendment to the Planning and Construction Regulations (Calculating Land-to-Building Ratio in Plans and Permits) (1992), effective 2020, encourages the installation of shading in open public spaces such as public gardens, paths, beaches, promenades, city squares, sports and recreation facilities, parks, trails,
Legend: Significant progress Some progress Little or no progress
- 120 - Planning 5 1 Table Israel Ministry of Construction and Housing and others 290 1,178 Weighted Weighted Average 721 172 : Improve : Improve + 290 3,433 65 2,971 172 64 – - 45 290 1,684 1,221 172 5 121 Challenge for the coming years connectivity between bicycle paths and urban riding on dedicated paths or intersections; enforce only. on roads - 44 – 16 137 172 260 600 : Promote plans for paving bicycle paths : Promote The document was intended to help planners and planning offices learn how and planning offices learn how intended to help planners was The document 6 : Paths for bicycles and other alternative : Paths for bicycles and other alternative 3,433 per year. The maximum benefit is gained by someone The maximum benefit is gained by someone 600–NIS 3,433 per year. The benefit of physical activity is estimated at NIS “active” status (about 150 minutes per week). status to regularly “inactive” who moves from * Adjusted life years added system Savings for the healthcare gain Productivity annual benefit Total Age Group The challenge In short being planned and built means of transport are with the planning guidelines of the in accordance Ministry of Transport.
plan to build paths for bicycles and other alternative means of transport (electric bicycles, bicycles, transport (electric of means alternative other and bicycles for build paths plan to and pedestrians in order motor vehicles from separating them and Segways), electric scooters, the district in in plan is to link all communities The road users. conflicts among to prevent policy document examining the degree to which urban planning is oriented toward the use of the use of urban planning is oriented toward to which the degree examining document policy public transport. the potential urban use of public transport. to realize a Committee is promoting Planning and Construction The Central District (Machoz Merkaz) Sound urban planning includes a dense network of streets, sidewalks, and shading that and shading that sidewalks, of streets, Sound urban planning includes a dense network the quality of urban life. improves and and cycling walking facilitates at the Ministry of Finance (MoF) published a (IPA) 2020, the Israel Planning Authority In April all yielding health and economic benefits (Table 1). and economic benefits (Table all yielding health of Shading (NIS) Physical Activity as a Result Person from Annual Benefit per calculation of land-to-building ratios. of land-to-building calculation (MoH), by the Ministry of Health prepared in Israel, jointly of shading A cost-benefit analysis that shading found and Housing, and the Ministry of Construction Hai Academic College, Tel activity— physical and increase the risk of skin cancer, mitigate levels, pollution helps to lower city boulevards, and open public areas, as well as open private property for which plans include include plans which for property open private as as well areas, and open public city boulevards, the of shading from means exclude regulations the amended Notably, right of way. a public Environmental Health in Israel 2020 Chapter 12
order to give bicycle riders efficient access to central train stations, employment zones, and education institutions. The plan is part of a comprehensive effort by the District Planning Office and the Ministry of Transport (MoT) to encourage the use of public transportation, including creating public transport lanes, building park-and-ride facilities, and strengthening connectivity between train stations and employment zones. The plan envisions three networks for bicycle riders—metropolitan, secondary, and local—that would stretch across 1,351 kilometers in this district.
In addition, a new national master plan for land transport infrastructure, TAMA 42, includes areas with detailed plans for bike paths. In March 2020, the National Council for Planning and Construction decided to submit the plan to the government for its approval.
The challenge: Conduct Health Impact Assessments on large-scale projects
In short: By government resolution, an inter- Challenge for the coming years: Approve ministerial committee was formed that began to methodologies for examining the public health develop and apply an approved methodology for impact of building plans as part of formulating planning of mining and quarrying projects. national policy.
The Planning and Building Law requires an Environmental Impact Assessment (EIA) as part of the planning and construction process in plans that could significantly affect the environment. An EIA, however, does not address expected health effects and implications, leaving the health impact of various plans unclear. MoH sees great importance in including health considerations in the planning processes by incorporating an Health Impact Assessment (HIA) into the planning of future projects. For several years, MoH has been advocating for mandatory HIAs, unsuccessfully so far.
The purpose of an HIA is to prevent or minimize harm to public health that might result from implementing the proposed plan. An HIA offers many advantages, including a broad perspective of health (physical, mental, and social well-being), a comprehensive and in-depth review of the direct and indirect health effects of construction and development projects, public involvement in decisions that affect citizens’ lives and health, and an examination of several alternatives. It also conveys recommendations on maximizing positive health benefits, minimizing negative effects, and narrowing health disparities.7
In May 2018, the government formed an inter-ministerial team with representatives from MoH, MoF (IPA), the Ministry of Environmental Protection (MoEP), the Ministry of Energy (MoE) and MoT and tasked it with formulating and implementing a methodology for examining the health aspects of mining and quarrying projects.8 MoH contends that every plan relating to national infrastructure projects—such as power plants, airfields, or quarries—should require an HIA on the part of the planning organization.
- 122 - Planning : Add : Add the : Increase - 123 share of renewable sources in energy generation generation in energy sources of renewable share Formulate that of polluting sources. and reduce governmenta coherent policy that encourages Set a sources. renewable generation from energy the use of polluting fuels for reducing clear target until their use is completely eliminated. Challenge for the coming years Challenge on the planning committees to representatives processes. MoH influence on planning ensure Challenge for the coming years - bringing about a dramatic reduction in emissions in emissions a dramatic reduction bringing about 10 Energy sector plans such as TAMA 41 have a decisive impact impact a decisive 41 have TAMA sector plans such as Energy 9 : Develop policies to reduce emissions of heat, radiation, and of heat, radiation, and emissions : Develop policies to reduce : Give representatives of the Ministry of Health broader of Health broader of the Ministry : Give representatives : There has been a clear transition from : has been a clear transition from There : MoH participants in the The number of greenhouse gases gases greenhouse In short using coal and polluting fuels to generate electricity sources. to using natural gas and renewable The challenge In short of as has the number committees has grown, at the ministry. planning professionals The challenge the planning committees powers in In recent years, electricity generation in Israel has been shifting from coal and polluting fuels to coal and polluting fuels to in Israel has been shifting from electricity generation years, In recent 2), (Figure sources and renewable natural gas in emissions of carbon. of local pollutants and a decrease principles toward shutting down the country’s coal-fired plants or converting them to natural them to natural plants or converting coal-fired the country’s down shutting principles toward to retain electricity, decided to stop using coal to generate In 2020, the Minister of Energy gas. This coal to natural gas. plants from option and to convert as an emergency only this capability decade. of the next the middle by implementation transition is scheduled for In 2018, the Minister of Energy announced a vision for ending coal use for energy generation generation energy ending coal use for announced a vision for In 2018, the Minister of Energy in order alternatives at MoE on energy work by followed was within a decade. His statement 1996, the minister Law, with the Electricity Sector Acting in accordance to attain the goal. defining policy consultation on professional for the Public Electricity Commission approached for energy generation facilities and dealing with the energy produced. The goal is to create a a is to create goal The produced. and dealing with the energy facilities generation energy for and long-term sustainable, an integrative, planning from infrastructure energy for framework the on facilities energy of the impact limiting emphasizes the program Concurrently, perspective. and on public health. environment different and soil, and affect water, pollute air, can facilities on public health because energy ones. vulnerable especially populations, IPA is promoting a strategic national master plan for the energy sector, TAMA 41. The goal of of The goal 41. TAMA sector, the energy for a strategic national master plan is promoting IPA infrastructure building and protecting planning principles and rules for the plan is to establish planning procedures at all levels has expanded. However, in several national planning institutions national planning institutions in several However, has expanded. at all levels planning procedures to their ability rights; therefore, without voting substitutes or observers are MoH representatives is limited. in planning policy influence lead and exert Since 2017, two planning professionals have joined MoH and the ministry’s contribution to to contribution joined MoH and the ministry’s have planning professionals Since 2017, two Environmental Health in Israel 2020 Chapter 12
Importantly, however, natural gas is a fossil energy source that pollutes the air and contributes to greenhouse gas emissions; thus, an effort to reduce its use should be made. Indeed, along with the decision to stop using coal to generate electricity, consideration is being given to expanding the target for electricity generation from renewable sources from 17% to 25%–30% by 2030. If this is done, emissions and air pollution are expected to decline significantly.
The Changing Mix of Fuels in 2010–2019 and Forecast for 2025 100 Forecast Figure 2 * Israel Electricity 90 Authority10 80 13% 70 5% 8%
60 7%
50 15%
39% 35% 44% 53% 17% 50% 61% 83% 40 63% 67% 64% 68%
30
Electricity generation (TWh) 20 59% 59% 61% 52% 49% 10 45% 36% 32% 30% 30% 24%
0 3%
Year 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020* 2025*
Legend: Coal Gas Solar Other Renewable energy
The challenge: Improve the efficiency of public transportation
In short: Some progress has been made in Challenge for the coming years: Develop an advancing plans for mass transit systems—light interface among public transportation systems, rail systems in Tel Aviv and Jerusalem and a make public transportation reliable and frequent, metro in metropolitan Tel Aviv. and increase the number of buses.
MoEP estimates the annual external cost of the health effects of traffic-related air pollution at over NIS 12 billion.11
Recent years have seen growing use of private vehicles—including hybrids—in Israel. Details of the country’s transportation situation at the end of 2019 are presented below11–13: There are about 3,600,600 motor vehicles in Israel, including approximately 3,085,300 private vehicles. From 2018 to 2019, the national fleet of motor vehicles grew by 3% and that of private vehicles by 3.6%. 14.2% of motor vehicles and 5.4% of private vehicles are diesel-fueled. There are about 175,200 private hybrid vehicles in Israel, in addition to 1,642 hybrid taxis—45% more than in 2018.
- 124 - Planning and is conducive to to and is conducive 14 30 million per year from from 30 million per year 86 million per year in cumulative in cumulative 86 million per year - 125 -
4 Only eighty-four electric buses, fewer than 1% of all buses, are currently operating in Israel. Israel. operating in currently are 1% of all buses, than fewer electric buses, eighty-four Only 2018, 1,196 in 2019). (655 in surged cars electric of private In 2019, the number NIS bus generates to MoEP data, an urban diesel According NIS pollution) as against air from health effects costs (adverse external an electric bus. The motorization rate in Israel rose from 390 vehicles per 1,000 residents in 2018 to 394 in in in 2018 to 394 per 1,000 residents vehicles 390 from rose rate in Israel The motorization countries. to other developed compared rate is low 2019, this
In light of the major challenges posed by climate change, it is increasingly important to include important to include it is increasingly climate change, posed by In light of the major challenges construction example, for This includes, of urban planning. health considerations at all levels planning to a reality adapting paths in open and shaded public spaces, walking that integrates order to mitigate health inequality and emphasize health as a primary value and goal at all levels. levels. all at goal and value primary a as health emphasize and inequality health mitigate to order city” to that of a “sustainable linked is closely city” approach The “healthy is There gases. greenhouse radiation, and of heat, emissions reducing at aimed policies promoting city.” defining a “healthy and set criteria in Israel for a methodology a need to develop All aspects of planning should aim to maximize the amount of green, open, high quality public open, high quality public All aspects of planning should aim to maximize the amount of green, on school the use of areas example, uses of these areas—for multiple spaces in cities and enable the concept of a it is important to introduce public. In this context, the general by grounds in social environment and its physical improve city seeks to continually A healthy city.” “healthy Urban planning has a significant impact on public health at all stages of life, including early including early of life, on public health at all stages Urban planning has a significant impact of siting possible, whenever prevent, to guidelines develop to imperative is It childhood. of available Due to the shortage to main roads. and schools in close proximity kindergartens and schools will be located near kindergartens some in Israel, however, development land for space along the or open public greenery detailed plans should require In these cases, main roads. distance. at a greater kept with classrooms roads, Future Challenges Future light rail lines in Jerusalem and metropolitan Tel Aviv have been promoted in recent years. Plans Plans years. in recent been promoted have Aviv Tel and metropolitan light rail lines in Jerusalem being allocated for ahead and dedicated lanes are also moving lines are transit (BRT) bus rapid for in the to improvements In addition passengers. with at least two and cars vehicles high-capacity in parking and decrease charges congestion traffic transportation, however, of public efficiency needed. allocations are Analysis of data reported from car manufacturers shows that the percentage of high-emission of high-emission that the percentage shows car manufacturers from of data reported Analysis has decreased. vehicles of public the efficiency a need to improve is clearly there above, presented In light of the data additional Plans for public transportation systems. between interfaces transportation and develop Environmental Health in Israel 2020 Chapter 12
in which more and more people are in homes (to avoid extreme temperatures), placing commerce in shaded settings or storefronts that include colonnades, and also distributing, and dividing business hours so that they suit the climate. Such planning also includes amending plans for water and sewage infrastructure in order to prevent flooding, reducing energy consumption, and pursuing renewable energy solutions. The final shutdown of the coal-fired power plants in Hadera and Ashkelon is a welcome and important step, but the alternative—using natural gas—should be closely examined in order to avoid making it a permanent solution in Israel. Natural gas, while less of a polluter than coal, still pollutes. MoE and the Israel Electricity Authority should promote a transition plan for energy generation from renewable sources and for construction of energy storage facilities.
In March 2020, the National Council for Planning and Construction recommended that the Minister of Finance issue planning and construction regulations that adopt Israeli Standard 5281 for sustainable construction (green building). All new buildings—residences, offices, stores, healthcare facilities, schools, public institutions, etc.—will be required to comply with the regulations starting from a target date that has yet to be determined. The standard encourages construction near centers of public transportation but does not sufficiently promote walking in the public sphere, within buildings, and in open spaces. A challenge for the coming years is to address additional relevant issues for sustainable construction and sustainable environment that the standard omits, such as making drinking fountains and public toilets more accessible, using landscaping that is economical in terms of water use and waste (cuttings), and encouraging the installation of solar energy production units on rooftops.
An additional challenge is to promote urban planning that incorporates public transportation (transit-oriented development). The ability to link different means of public transportation depends on the ability to bring public transportation to within 500 meters of the places where people live, work, or engage in recreation. Guidelines for integrating public transportation infrastructure and urban development were published. IPA is considering making such guidelines mandatory, meaning that a district committee or the National Committee for Preferred Areas for Housing (VATMAL) would not approve any plan that lacks a commitment by the developer to integrate public transportation into the plan.
At the beginning of 2018, the National Council for Planning and Construction called for the preparation of TAMA 49—a national master plan for the healthcare system that updates policy for healthcare system structures and spatial deployment of healthcare services by the year 2040. The challenge for the coming years is to prepare and approve the plan in order to outline the healthcare system’s development needs. This includes the land needed for building healthcare institutions, promotion of strategic social principles in healthcare institutions (for example, reducing inequality in access to healthcare services), and designing the hospital complex to include urban nature as a means of shortening recovery times and creating a pleasant work environment.
- 126 - Planning f (Hebrew). (Hebrew). (Hebrew). (3), 16–23 (Hebrew). (3), 16–23 (Hebrew). (1), 38. (Hebrew). (Hebrew). , First International Conference on on Conference International , First (Hebrew). - Ecology 10 & Environment, Air pollution from transportation: Ministry of of Air pollution from transportation: Ministry 127 Environmental Health, 15 Environmental Health, - Activities of the Ministry of Environmental Protection for Activities of the Ministry of Environmental Protection for Assessing the current state of affairs, June 2020 June of affairs, Assessing the current state (Hebrew). (Hebrew). Motor vehicles in Israel in 2019 Motor vehicles Summary on examining health aspects in plans—TAMA 14/B Master 14/B Master Summary on examining health aspects in plans—TAMA Ottawa Charter for Health Promotion for Charter Ottawa The electricity market status report for 2019 The electricity for market status report (Hebrew). A healthy and sustainable city, principles and implementation guidelines A healthy and sustainable city, Cost-Benefit Analysis of Shading in Israel Cost-Benefit Analysis http://transportation.org.il/sites/default/files/pirsum/rpl_plyyshmn_-_pylvt_hmshrd_lhgns_lmbr_ of Statistics (2020). Israel Central Bureau 2020). June (retrieved https://www.cbs.gov.il/he/mediarelease/DocLib/2020/129/27_20_129b.pdf and Heschel Center for Cities Network Israel Healthy Protection, Israel Ministry of Environmental Israel Ministry of Environmental Protection (2019). Protection Israel Ministry of Environmental Israel Ministry of Environmental Protection (2019). Protection Israel Ministry of Environmental https://www.gov.il/BlobFolder/pmopolicy/dec3627_2018/he/3627.png (retrieved June 2020). 2020). June (retrieved https://www.gov.il/BlobFolder/pmopolicy/dec3627_2018/he/3627.png 2020). June (retrieved https://www.gov.il/he/Departments/General/tama_41 Israel Ministry of Finance, Israel Planning Authority (updated September 2019). Planning oriented toward 2019). Planning oriented toward September (updated Israel Ministry of Finance, Israel Planning Authority (retrieved June 2020). https://www.gov.il/he/departments/general/planning_public_transp_sustainable_mov Zafuf—The Israel Forum for Population, Environment and Society. Shahar, I., personal communication communication I., personal Shahar, and Society. Environment Population, for Zafuf—The Israel Forum (2020). Protection Israel Ministry of Environmental Hai Academic College Tel and Israel Ministry of Health, and Housing, Israel Ministry of Construction 2020). June (retrieved https://www.gov.il/BlobFolder/reports/research_1079/he/documents_r1079.pdf http://www.who.int/healthpromotion/conferences/previous/ottawa/en/ (retrieved June 2020). June (retrieved http://www.who.int/healthpromotion/conferences/previous/ottawa/en/ and health-new exposures environmental planning, (2016). Urban and transport M. J. Nieuwenhuijsen, https://doi.org/10.1186/s12940-016-0108-1 http://www.healthycities.co.il/upload/infocenter/info_images/25122010192704@ir%20briaumekaiemet.pdf http://www.healthycities.co.il/upload/infocenter/info_images/25122010192704@ir%20briaumekaiemet.pdf 2020). June (retrieved lvtvbvsym_khshmlyym.pdf (retrieved July 2020). 2020). July (retrieved lvtvbvsym_khshmlyym.pdf (2010). Sustainability %D7%90%D7%95%D7%95%D7%99%D7%A8%20%D7%9E%D7%AA%D7%97%D7%91 %D7%95%D7%A8%D7%94%20-%20%D7%A1%D7%A7%D7%99%D7%A8%D7%AA%20 %D7%94%D7%9E%D7%A9%D7%A8%D7%93%20%D7%9C%D7%94%D7%92%D7%A0%D7%AA%20%D7%9 4%D7%A1%D7%91%D7%99%D7%91%D7%94%20%D7%9C%D7%9E%D7%9E%D7%A9%D7%9C%D7%94.pd 2020). July (retrieved the transition to electric buses Israel Electricity Authority (2020). Israel Electricity Authority https://www.gov.il/BlobFolder/generalpage/dochmeshek/he/Files_doch_meshek_hashmal_doch_meshek_2019.pdf December 2020). (retrieved cabinet meeting Environmental Protection review for https://infospot.co.il/Content/UserFiles/Upload/%D7%96%D7%99%D7%94%D7%95%D7%9D%20 Israel Prime Minister’s Office (2018). Minister’s Israel Prime 3, 2018 3627, May Government Resolution Mining and Quarrying. Plan for 41—National TAMA 2018). November (updated Planning Authority of Finance, Israel Israel Ministry (Hebrew). Infrastructure Energy Master Plan for public transportation and sustainable movement (Hebrew). movement public transportation and sustainable as a tool for The health-impact assessment on public health: The impact of public policy M. (2019). Negev, incorporating health considerations in decision-making. 2020). June (retrieved http://www.magazine.isees.org.il/Abstract.aspx?ArticleId=866 (July 2020). (July (2019). World Health Organization (1986). (1986). Organization Health World 1986. Canada, Ontario, Health Promotion, health in cities. tools to improve and methods concepts, (13) (14) (12) (10) (11) (8) (9) (6) (7) (3) (4) (5) (1) (2) References References Environmental Health in Israel 2020 Chapter 13
- 128 - Chapter 13 Populations Vulnerable Vulnerable Populations
In the context of environmental health, vulnerable populations include various groups that are more likely than the general population to experience adverse health effects following exposure to environmental contaminants. This vulnerability can be characterized by two types of factors: (a) intrinsic factors that usually cannot be altered, such as age, pregnancy, gender, ethnicity, and genetic polymorphisms, and (b) extrinsic factors that usually can be altered, such as socioeconomic status (SES), health status, eating habits, lifestyle, and geographic proximity to sources of exposure.
The main population groups affected by intrinsic factors are fetuses, infants, children, pregnant women, the elderly, and people with a specific genetic polymorphism or a chronic illness such as cardiac or pulmonary disease. Population groups affected by extrinsic factors include people of low SES, who generally have higher smoking rates, less access to high quality healthcare services, and work conditions that are hazardous to health; people with poor nutrition; people who live near sources of exposure to potential contaminants such as agricultural fields, heavy industry, contaminated sites or highways; workers in chemical-intensive industries and people who do not reside in permanent structures.
Environmental health policy in Israel aims to protect vulnerable populations and takes them into account when setting standards for air, drinking water, and food. Furthermore, in cases of severe air pollution, the Ministry of Environmental Protection (MoEP) and Ministry of Health (MoH) issue advisories and recommendations for the general public as well as specific recommendations for vulnerable populations. Many mandatory consumer product standards in Israel target products intended for infants and children, including toys, baby bottles, beds, mattresses, eating utensils, and children’s jewelry.
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Progress relevant to vulnerable populations has been achieved in many areas of environmental health in Israel. Standards that limit heavy metal content in children’s jewelry and lead in paint, including paint used for playground equipment, have been approved as mandatory. Biomonitoring research pertinent to vulnerable populations, such as children and pregnant women, has seen significant progress. (See the “Human Biomonitoring” and “Chemicals in Consumer Products” chapters.) A survey on lead and other heavy metals in tap water in educational institutions throughout Israel was conducted in 2018. (See the “Chemical Parameters in Drinking Water” chapter).
Progress since 2017
The Environmental Health in Israel 2017 report defined challenges related to Vulnerable Populations. Progress achieved in this area during the past three years is outlined below.
The challenge: Enhance collaboration between government ministries and civil society organizations to improve the flow of information regarding environmental hazards and to promote mechanisms of public participation
In short: MoH and MoEP engage in collaborative Challenge for the coming years: Intensify efforts vis-à-vis civil society organizations. collaboration, including joint funding of research and projects.
Following an open call for proposals, the Environment and Health Fund (EHF) and MoH are jointly funding the National Biomonitoring Program, including an assessment of children’s exposure to environmental contaminants. (See the “Human Biomonitoring” chapter.) In another collaborative project, EHF and the Israel National Council for the Child are promoting a legislative framework designed to protect infants, toddlers, and children from exposure to chemicals in consumer products. (See the “Chemicals in Consumer Products” chapter.)
There is also collaboration between MoEP and civil society organizations on environmental issues relevant to vulnerable populations. For example, MoEP and the Jewish National Fund (KKL-JNF) launched the “Easy to Breathe” national environmental program in 2017, designed to reduce pollution and environmental hazards and improve air quality in Israel. The program provides NIS 390 million in funding for four green transportation projects, including investment in electric public transport, hybrid vehicles, and installation of particle filters on garbage trucks. It also funds green energy projects (energy efficiency) and planning initiatives (renovating housing and installing solar energy infrastructure).
Legend: Significant progress Some progress Little or no progress
- 130 - Vulnerable Populations 1 Figure Israel Ministry of Health
: Translate the the : Translate
1 Gerographic Gerographic areas Children - 131 Challenge for the coming years Challenge findings into specific objectives and research activities of government ministries. - SES Pregnancy Pregnancy Arab population and childbirth : Conduct research on genetic variability and other on genetic variability and other : Conduct research : Identify vulnerable populations in Israel and adapt specific goals adapt specific in Israel and vulnerable populations : Identify : study was published on this topic. One : Several studies that are helpful in helpful in that are : Several studies In short The challenge populations to identify vulnerable in order vulnerability predictors In short populations have been identifying vulnerable no specific years. However, conducted in recent been defined for these goals and objectives have plan. in the context of the national groups The challenge Plan) Health National Environmental the context of the to them (in and objectives women and newborns, children, and residents of various geographic areas. Some address other address Some areas. geographic of various and residents children, and newborns, women 1). Table 1 and (Figure SES groups population and low populations in Israel, such as the Arab vulnerable Populations in Israel, by Sub-population, Studies on Vulnerable Health Research Environmental 2017–2020 Research on Vulnerable Populations in Israel on Vulnerable Research on pregnant mostly focusing populations, vulnerable health studies address environmental Many There has been little research on genetic variability and vulnerable populations in recent populations in recent and vulnerable variability on genetic research has been little There to exposure the association between examined of Haifa the University from Researchers years. of the N-Acetyl- (polymorphisms variability (ETS) and genetic tobacco smoke environmental women. among Israeli Arab cancer and the risk of breast 2 enzyme), transferase Recent studies in Israel that are helpful in identifying vulnerable populations are presented in Table 1. Table in presented are populations in identifying vulnerable helpful that are Recent studies in Israel Environmental Health in Israel 2020 Chapter 13
Environmental Health Research Studies on Vulnerable Populations in Israel, by Sub-population, 2017–2020 Table 1 Population Research Topic Chapter Israel Ministry of Health Effect of traffic-related air pollution on risk of pregnancy Ambient air loss 2 quality
Effect of air pollution on fetal development 3 Ambient air quality
Association between prenatal and postnatal exposure to Ambient air particulate matter and autism spectrum disorder 4 quality
Effect of air pollution on head circumference of newborns Ambient air in the Haifa Bay area5 quality
Association between exposure of pregnant women and Ambient air infants up to the age of nine months to air pollutants, and quality autism spectrum disorder 6, 7
Contribution of green infrastructure to mitigating risk of Ambient air adverse birth outcomes8 quality
Association between exposure of pregnant women Ambient air to particulate matter and risk of congenital transient quality hypothyroidism (CTH) among newborns9
Effect of exposure to ambient and indoor air pollution Indoor air during pregnancy and early childhood on respiratory quality Pregnant women, morbidity nursing mothers, and newborns Effect of ambient and indoor air pollution on fetal Indoor air development, focusing on the Haifa Bay area quality
Effect of using aluminum-based deodorant on aluminum Chemicals concentration in breast milk10 in consumer products
Measuring concentrations of phthalates and phenols in Human urine of pregnant women11 biomonitoring
Effect of exposure to phthalates on fertility treatment Human outcomes12 biomonitoring
Association between expression of miRNA molecules in Human follicular fluid and urinary concentrations of phenols and biomonitoring phthalates among women of reproductive age13
Exposure of pregnant women and newborns to Human organophosphate pesticides14 biomonitoring
Exposure of pregnant women and newborns to ETS15 Human biomonitoring
Biomonitoring of heavy metals, pesticides and flame Human retardants among pregnant women in the Negev16 biomonitoring
Correlation between intrauterine exposure to Human polychlorinated biphenyls (PCBs) and 1) thyroid hormone biomonitoring levels among pregnant women and newborns17 and 2) neonatal anogenital distance18
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Human Human Ambient Ambient air quality and biomonitoring Climate change Climate change Ambient air quality and Planning Environmental tobacco smoke Environmental tobacco smoke Pesticides Planning Ambient air quality Ambient air quality Chapter Human biomonitoring Climate change Climate change Indoor air quality Environmental tobacco smoke Human biomonitoring
21
27 24 19 - 29 133 - 22 26 25 23
28 20 1 among Jewish and Arab women at age seventeen to air pollutants in the of exposure Effect on cancer morbidity in adulthood Haifa Bay area An economic assessment of impact of air pollution in the Haifa Bay area in Biomonitoring of air pollutants in blood donors residing the Haifa Bay area contaminants to environmental Assessment of exposure living in the Haifa Bay among Jewish and Arab children area concentrations of carbon dioxide on the heart rate of rate of concentrations of carbon dioxide on the heart Jewish and Arab women and genetic polymorphism (the of ETS exposure Effect breast N-Acetyl-transferase 2 enzyme) on the risk of cancer with Jews in Arabs compared ETS exposure pesticides on non- to organochlorine of exposure Effect morbidity among Jewish and Arab lymphoma Hodgkin’s populations on visits to outdoor urban environments of short Effect psychological, physiological, and cognitive indicators Parents’ perceptions of their children’s exposure to ETS to exposure of their children’s perceptions Parents’ to ETS and SES Exposure to organophosphate exposure Assessment of children’s pesticides in Israel on temperature of rising environmental Effect Campylobacteriosis among young children on campylobacter of SES and ambient temperature Effect and salmonella infection with negligible environment of a green Effect Research Topic Research and mercury, of heavy metals (lead, Biomonitoring pregnant pollutants (BTEX) in organic cadmium) and women, newborns, and fathers on fetal development of temperature Effect in on risk of high blood pressure of temperature Effect pregnancy compounds in to volatile organic Assessment of exposure and the relationship centers in the Haifa Bay area, daycare air pollutants between indoor and outdoor Geographic areas Arab population Socioeconomic Socioeconomic status Children Pregnant women, women, Pregnant nursing mothers, and newborns Population
Environmental Health in Israel 2020 Chapter 13
Future Challenges
The population in Israel is growing rapidly despite limited land resources, and is expected to increase by 48% between 2035 and 2100.30 Consequently, new residential neighborhoods are being built in locations close to agricultural fields and airfields. The people who move into these neighborhoods are likely to become vulnerable populations in the context of environmental health. Communities living near agricultural fields, for example, may have higher exposure to pesticides sprayed on the ground or from the air, and communities living near airports may face increased exposure to noise and, possibly, to air pollution.
Along with the expected increase in the size of the general population, the elderly population is expected to grow dramatically (by 117%). For this reason and in view of the limited research in Israel on the health impacts of environmental pollution on the elderly, data on the burden of disease from environmental pollution among this population are needed, as are steps to reduce this burden.30
The air monitoring network in Israel has expanded and covers broader geographical areas than in the past. However, there are still some populated areas, especially in the periphery, including Bedouin settlements in southern Israel, that are not regularly monitored. Consideration should be given to expanding the monitoring network to cover these areas.
Other vulnerable populations include the migrant and refugee populations in Israel. These populations are generally characterized by relatively low SES, less access to medical services, and the likelihood of exposure to various environmental contaminants such as ETS. They should be included in plans to promote environmental health and reduce exposure to environmental pollutants.
Consideration should be given to establishing an interdisciplinary inter-ministerial committee to develop a national intervention plan on environmental health among vulnerable populations, on the basis of findings from recent research in Israel and abroad.
- 134 - Vulnerable Populations (2), (2), .
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(13) (14) (11) (12) (9) (10) (7) (8) (5) (3) (4)
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(15) Ein-Mor, E., Berman, T., Barnett-Itzhaki, Z., Göen, T., Ergaz-Shaltiel, Z., Natsheh, J., ... Calderon-Margalit, R. (2019). Newborn infant urinary cotinine and birth outcomes in the Jerusalem Environment Mother and Child Cohort Study. International Journal of Hygiene and Environmental Health, 222(7), 1054–1058. https://doi.org/10.1016/j.ijheh.2019.07.006 (16) Wainstock, T. & Sheiner, E. (2019). Selected environmental chemicals level among pregnant women in the Negev: Preliminary results from the Negev Pregnancy Cohort. Poster presented at Environment and Health Fund annual conference, Environment and Health: Complex Interactions, Tel Aviv, Israel. (17) Berlin, M., Barchel, D., Brik, A., Kohn, E., Keidar, R., Livne, A., ... Berkovitch, M. (2019). Intrauterine exposure to polychlorinated biphenyls (PCBs) and thyroid hormones in Israeli women: Data from EHF- Assaf Harofeh-Ichilov birth cohort. Poster presented at Environment and Health Fund annual conference, Environment and Health: Complex Interactions, Tel Aviv, Israel. (18) Sheinberg, R., Siegel, E. L., Keidar, R., Mandel, D., Lubetzky, R., Kohn, E., … Levy, A. (2020). Associations between intrauterine exposure to polychlorinated biphenyls on neonatal ano-genital distance. Reproductive Toxicology, 96, 67–75. https://doi.org/10.1016/j.reprotox.2020.06.005 (19) Kloog, I., Novack, L., Erez, O., Just, A. C., & Raz, R. (2018). Associations between ambient air temperature, low birth weight and small for gestational age in term neonates in southern Israel. Environmental Health, 17(1), 76. https://doi.org/10.1186/s12940-018-0420-z (20) Shashar, S., Kloog, I., Erez, O., Shtein, A., Yitshak-Sade, M., Sarov, B., & Novack, L. (2020). Temperature and preeclampsia: Epidemiological evidence that perturbation in maternal heat homeostasis affects pregnancy outcome. PloS One, 15(5), e0232877. https://doi.org/10.1371/journal.pone.0232877 (21) Rosen, L. J., Lev, E., Guttman, N., Tillinger, E., Rosenblat, S., Zucker, D. M., & Myers, V. (2018). Parental perceptions and misconceptions of child tobacco smoke exposure. Nicotine & Tobacco Research, 20(11), 1369–1377. https://doi.org/10.1093/ntr/ntx169 (22) Berman, T., Barnett-Itzhaki, Z., Axelrod, R., Keinan-Boker, L., Shimony, T., Goldsmith, R., ... Rosen, L. (2018). Socioeconomic inequalities in exposure to environmental tobacco smoke in children in Israel. Environment International, 121, 643–648. https://doi.org/10.1016/j.envint.2018.09.034 (23) Berman, T., Barnett-Itzhaki, Z., Göen, T., Hamama, Z., Axelrod, R., Keinan-Boker, L., Shimony, T., & Goldsmith, R. (2020). Organophosphate pesticide exposure in children in Israel: Dietary associations and implications for risk assessment. Environmental Research, 182, 108739. https://doi.org/10.1016/j.envres.2019.108739 (24) Rosenberg, A., Weinberger, M., Paz, S., Valinsky, L., Agmon, V., & Peretz, C. (2018). Ambient temperature and age-related notified Campylobacter infection in Israel: A 12-year time series study.Environmental Research, 164, 539–545. https://doi.org/10.1016/j.envres.2018.03.017 (25) Peretz, C. (2019). Campylobacter and salmonella infection in Israel and its positive correlation with environmental temperature. Ecology and Environment, 10(4), 79–80 (Hebrew). http://www.magazine.isees.org.il/ArticlePage.aspx?ArticleId=904 (retrieved May 2020). (26) Saadi, D., Agay-Shay, K., Tirosh, E., & Schnell, I. A. (2018). A comparison of the effects of selected mono- ethnic urban environments on the autonomic functions of Muslim and Jewish women in Israel. Environmental Monitoring and Assessment, 190(11), 627. https://doi.org/10.1007/s10661-018-7000-0 (27) Berman, T., Barnett-Itzhaki, Z., Mery, N., Keinan-Boker, L., Shimony, T., Goldsmith, R., ... Rosen, L. (2018). Exposure to environmental tobacco smoke in non-smoking adults in Israel: Results of the second Israel biomonitoring survey. Israel Journal of Health Policy Research, 7(1), 33. https://doi.org/10.1186/s13584-018-0229-9 (28) Klil-Drori, A. J., Kleinstern, G., Abu Seir, R., Choshen-Cohen, L., Abdeen, Z., Hussein, E., ... Paltiel, O. (2018). Serum organochlorines and non-Hodgkin lymphoma: A case-control study in Israeli Jews and Palestinians. Chemosphere, 213, 395–402. https://doi.org/10.1016/j.chemosphere.2018.09.069 (29) Saadi, D., Schnell, I., Tirosh, E., Basagana, X., & Agay-Shay, K. (2020). There’s no place like home? The psychological, physiological, and cognitive effects of short visits to outdoor urban environments compared to staying in the indoor home environment, a field experiment on women from two ethnic groups. Environmental Research, 187, 109687. https://doi.org/10.1016/j.envres.2020.109687 (30) Israel Ministry of Environmental Protection (2020). Assessing the current state of affairs, June 2020 (Hebrew).
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Indicators and Trends Environmental Health Chapter 14 Environmental Health Indicators and Trends
Exposure to environmental pollutants can adversely affect quality of life and can cause morbidity and mortality. Environmental risk factors include ambient and indoor air pollution, drinking water and soil contaminants, environmental tobacco smoke (ETS), heavy metals, pesticides, and endocrine disrupting chemicals (EDCs).
Environmental health indicators are important tools for monitoring potential risks to human health from environmental pollution and for guiding policymaking. Reflecting the association between environmental factors and health outcomes, they include exposure indicators (for example, the concentration of an environmental pollutant or the percentage of the population exposed to a pollutant) and health indicators (for example, incidences of morbidity, hospitalization, and medication use). The selected indicators are generally associated with an environmental issue that significantly affects the health of the general population or a particular sub-population. Environmental health indicators should be based on available data published regularly and frequently and should be sensitive enough to reflect changes in trends. They should also be consistent enough to allow international comparisons and study of trends over time.1 Therefore, environmental health indicators are very important for monitoring trends in environmental exposure and health outcomes related to environmental hazards and exposures, comparing environmental health status among countries and among sub-populations within a country, monitoring the effectiveness of policy measures and other intervention programs in the field of environmental health, and raising awareness of environmental health issues.2
Many professional organizations—the World Health Organization (WHO), the U.S. Centers for Disease Control and Prevention (CDC), and the European Environment and Health Information System (ENHIS) in the WHO European Region, among others—have compiled lists of selected environmental health indicators. Several countries, including the U.S. and New Zealand, have created environmental health indicator programs that include databases available to the public and to decision-makers.1, 2 The program enables, for example, identification of populations at risk of developing diseases associated with environmental pollution, as well as trends in morbidity or in exposure to environmental pollution.
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A wealth of environmental and health data are collected in Israel. Environmental data are collected and monitored continuously, periodically or in surveys of contaminants in the air, water, and food. The health data are collected in national databases and registries that allow tracking and monitoring of selected diseases (cancer, stroke, diabetes, kidney disease including dialysis and transplants, congenital anomalies, and infectious diseases). A perinatal registry records data on low birth weight (less than 1,500 grams) and on emergency room visits and hospitalizations. There are also data on the health status of adolescents (age seventeen) who are candidates for military service. Copious data are stored in the electronic databases of the country’s four HMOs. The National Program for Quality Indicators in Community Healthcare (QICH) publishes data on twenty-eight quality indicators including asthma rates, cancer screening, cardiovascular health, pediatric health, diabetes, and immunization among the elderly.3
Despite this wealth of data, however, Israel has no databases that combine environmental and health data to help identify possible causal associations. In addition, there are few published assessments in Israel of the burden of disease resulting from exposure to environmental pollution. Various global projects—the Global Burden of Disease (GBD), State of Global Air, Global Alliance on Health and Pollution, and the WHO/UNICEF Joint Monitoring Programme for Water Supply, Sanitation and Hygiene, among others—provide useful data that can support the planning and assessment of measures to reduce the burden of disease in Israel.
Progress since 2017
The Environmental Health in Israel 2017 report defined challenges related to Environmental Health Indicators and Trends. Progress achieved in this area during the past three years is outlined below.
The challenge: (1) Formulate integrated environmental health indicators (2) Collect and publish data on various environmental health indicators
In short: Israel has yet to produce a final list of Challenge for the coming years: Formulate environmental health indicators. Progress has a final list of environmental health indicators; been made in collecting and publishing data on continue to collect data. several candidate indicators.
The Environmental Health in Israel 2017 report defined and categorized candidate indicators for environmental health in Israel on the basis of indicators developed by WHO, CDC, and ENHIS: exposure, chronic disease, and climate change indicators as well as those relating to early childhood. In recent years, data for numerous indicators—primarily related to exposure to lead in drinking water, children’s exposure to ETS, and adults’ exposure to organophosphate (OP) pesticides—have been synthesized and published. For other indicators, however, such as the
Legend: Significant progress Some progress Little or no progress
- 138 - Environmental Health Indicators and Trends 1 Table Israel Ministry of Health
Ongoing collection Collaboration between the Ministry of Health and Clalit Health Services to synthesize available data — 2020 (measuring lead concentrations in urine and adults) of children 2020 Ongoing collection Ongoing collection Ongoing collection Ongoing collection Ongoing collection Plans for Future Plans for Future Data Collection — — 2020
— — — — A statistically significant decrease in concentrations of most OP metabolites in urine in adults — — — were In 2019, there over 3,500 emergency visits for room and heat stress dehydration, with peak numbers in July and August — Primary Findings 99.6% of water samples in educational institutions meet the for lead standards concentrations — ~60% of children in the sample are exposed to ETS - 139 -
2016
–
Year in which in which Year Latest Published Data was Collected 2014 2018 2015 (see “Human (see “Human Biomonitoring” chapter) 2018 2018 2018 2019 “Chemical Parameters in Drinking Water” chapter) — 2015 (see “Environmental Smoke” Tobacco chapter) — 1998–2000 2015–2016 2018 – Educational institutions (see
hospitalizations of certain Prevalence congenital anomalies Number of poisonings among reported under the children age of five of asthma Prevalence in and allergies children population with population with concentrations of urinary OP metabolites above level of quantification Incidence of certain types of cancer, including childhood leukemia Asthma hospitalizations and among children adults vector- Deaths from borne disease Heat-stress to indoor air Exposure pollutants in schools of infants Percentage exposed and children to ETS Intake of heavy metals in food among adults Lead levels in blood children’s of Percentage Indicator Lead in drinking water (tap) Early Childhood Health Indicators Climate Climate Change Indicators Chronic Chronic Disease Indicators Exposure Exposure Indicators health indicators. Table 1 displays these indicators, the year when the relevant data for each each for data the relevant when the year these indicators, 1 displays Table health indicators. years. recent findings in and primary last updated, indicator was Status Health, Data Availability for Environmental Candidate Indicators prevalence of asthma and allergies in children, no data have been synthesized in recent years, years, synthesized in recent been data have no in children, of asthma and allergies prevalence data on environmental and synthesis of periodic collection and lack of regular due to the partly Environmental Health in Israel 2020 Chapter 14
The challenge: Publish data collected by government authorities on environmental pollutants and health outcomes and make them accessible to researchers, policymakers, and the public in a timely fashion
In short: There is a regulatory requirement to publish some of the environmental data collected by government authorities (for example, on the quality of air and drinking water). This requirement does not apply to much of the environmental health data, which remains unavailable to the public and to researchers.
Data on Risk Factors and Trends
As noted, despite the importance of up-to-date and long-term data for examining environmental health indicators, no environmental health indicators program has been established in Israel. Such a program would be instrumental, for example, in integrating and managing data of relevance to all of the indicators in Table 1. Some data, however, are available on several exposure indicators, chronic disease indicators (cancer rates, asthma hospitalization), and vector-borne diseases, allowing for time trend analysis. In addition, the GBD project facilitates the study of principal risk factors for morbidity and mortality in various countries and of trends in the burden of morbidity and mortality. The GBD database provides information on chronic morbidity indicators, sanitation- and hygiene-related health risks, and vector-borne diseases in Israel. According to these data, exposure to particulate air pollution is one of the ten leading risk factors for mortality in Israel (Figure 1).4
Principal Risk Factors for Mortality in Israel, 2019 Figure 1 High systolic blood pressure Global Health Data Exchange 20204 High fasting plasma glucose
Tobacco
High body mass index
Dietary risks
Impaired kidney function
High LDL cholesterol
Air pollution
Low physical activity
Alcohol use
Occupational risks
Other environmental risks
1,000 2,000 3,000 4,000 5,000 6,000 7,000 8,000
Number of deaths
Legend: Communicable, maternal, neonatal, and nutritional diseases Non-communicable diseases Injuries
- 140 - Environmental Health Indicators and Trends 4 4 3 Figure Global Health Data Exchange 2020 2 Figure Global Health Data Exchange 2020
95+ years 95+
90-94 years 90-94
85-89 years 85-89 80-84 years 80-84
Diabetes and Diabetes and kidney disease
2,500 years 75-79
70-74 years 70-74
65-69 years 65-69 60-64 years 60-64
2,000 55-59 years 55-59
Chronic respiratory respiratory Chronic disease 50-54 years 50-54
4 45-49 years 45-49 -
1,500 40-44 years 40-44 141 Number of deaths
- Neoplasms
35-39 years 35-39
30-34 years 30-34
25-29 years 25-29
1,000
20-24 years 20-24
15-19 years 15-19 10-14 years 10-14
500 Respiratory infections Respiratory infections and tuberculosis 5-9 years 5-9
4 years 1-4
28-364 days 28-364 7-27 days 7-27
Cardiovascular Cardiovascular disease 0-6 days 0-6 0 50
200 150 100 400 350 300 250 500 450
Age Years lived with disability with lived Years Legend: Ozone Particulate matter part of the disease burden caused by ETS falls on children. on ETS falls caused by part of the disease burden to ETS, by Age Lived with Disability due to Exposure Years Exposure to Environmental Tobacco Smoke Smoke Tobacco to Environmental Exposure Israel in deaths 500 about for to ETS is responsible exposure database, the GBD to According 3 shows, As Figure (DALYs). Years Life 14,500 Disability-Adjusted and a loss of some year every from ozone (Figure 2). ozone (Figure from in Israel by Disease Type to Particulate Matter and Ozone Mortality Attributable pulmonary disease, cardiovascular morbidity, specific malignancies, adverse neurodevelopmental neurodevelopmental adverse specific malignancies, morbidity, disease, cardiovascular pulmonary disorders. and cognitive obesity, 2 diabetes, Type birth outcomes, adverse effects, from caused burden disease is the primary disease cardiovascular to the GBD database, According disease is the primary disease burden respiratory chronic in Israel, while particulate air pollution Exposure to Air Pollution in Israel in Israel to Air Pollution Exposure obstructive asthma and chronic diseases such as with respiratory to air pollution is associated Exposure Environmental Health in Israel 2020 Chapter 14
Asthma Morbidity Exposure to a range of environmental factors inside or outside the home, including particulate matter, ozone, ETS, dust mites, mold and allergens can lead to development or aggravation of asthma.
In 2018, the Ministry of Health (MoH) published data on trends in the hospitalization rate of children due to asthma in 1996–2015. The data show a decrease in the asthma hospitalization rates of infants, toddlers, and children up to age fifteen (Figure 4). Higher rates of hospitalization were found only in the Haifa, Kinneret, and Golan districts. The authors of the report hypothesized that the higher rates in Haifa can be explained by environmental exposures whereas those in the Kinneret and Golan districts can be explained by a lack of primary care pulmonary experts, leading to higher hospitalization rates.5
Trends in Asthma Hospitalization Rates in Israel Among Children Aged 5–14, 1996–2015 1.2 Figure 4 Israel Ministry of 5 Health 1.0
0.8
0.6
0.4
Rates of hospitalization (per 1,000) 0.2
0
Year 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015
According to a report published in 2019 by QICH, the incidence of persistent asthma among people aged 5–45 remained constant in 2016–2018 (0.8%–0.9%). The rate was twice as high among those of high socioeconomic status (SES) than among those of low SES (1.0% and 0.5%, respectively).6
Researchers from the University of Haifa and the Israel Defense Forces (IDF) studied the incidence of asthma in relation to place of residence among about 13,800 boys aged 16–19. The asthma rates found were 7.1% among the research population (with 3.8% suffering moderate-to-severe persistent illness), 8.76% in Tel Aviv, 6.96% in Haifa, and 6.09% in Hadera. The researchers concluded that exposure to industrial and traffic-related air pollution is associated with asthma prevalence.7 The disparity between the estimate reported in the study and the QICH findings apparently stems from differences in data collection methodology and in the type of asthma included in the estimate.
- 142 - Environmental Health Indicators and Trends 9 5 Figure Israel Ministry of Health
2017 2016 2015 9 2014 2013 Arab women 2012 2011 2010 2009 2008 Arab men - 2007 143 2006 - 2005 2004 2003 Jewish women 2002 2001 2000 1999 1998 1997 Jewish men 1996 0
8 10 30 20 50 40 60
year
Age-adjusted incidence (per (per incidence Age-adjusted ) 100,000 Diagnosis Diagnosis Legend: Trends in Rates of Selected Malignancies, by Gender and Population Group, Israel, 1996–2017 Gender and Population Group, in Rates of Selected Malignancies, by Trends Lung Cancer The cancer rate in Israel exceeds the world average but ranks last among fifty countries with the but ranks last among fifty countries with the average the world The cancer rate in Israel exceeds (in all in the incidence of leukemia a decrease was to MoH data, there According highest rates. 5). 1996 and 2017 (Figure in Israel between men) (among and mesothelioma groups) asthma. Cancer Morbidity specific malignancies—primarily with associated are factors risk occupational and Environmental and mesothelioma. leukemia, lymphoma, non-Hodgkin’s lung cancer, among those born in 1976–1980 and a decrease in these rates among those born in 1980–1990. 1980–1990. those born in in these rates among and a decrease born in 1976–1980 among those birth 1976–1980 the among low was however, asthma, moderate-to-severe of incidence The between association an found also study The group. 1986–1990 the in high very and cohort underweight association between an and girls, in boys asthma and obesity moderate-to-severe and mild living in a rural environment between and a correlation males and mild asthma, Researchers from Shaare Zedek Medical Center and the IDF, examining the incidence of asthma of asthma incidence the examining IDF, the Center and Medical Zedek Shaare from Researchers asthma of mild persistent in rates increase an 1976–1990, found born in Israel in in people Environmental Health in Israel 2020 Chapter 14
Non-Hodgkin’s Lymphoma
18
16 ) 14
100,000 12
10
8
6
Age-adjusted incidence (per 4
2
0
Diagnosis 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 year
Legend: Jewish men Jewish women Arab men Arab women
Leukemia
18
16 ) 14
100,000 12
10
8
6
Age-adjusted incidence (per 4
2
0
Diagnosis 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 year
Legend: Jewish men Jewish women Arab men Arab women
- 144 - Environmental Health Indicators and Trends 2017 2016 2015 2014 2013 2012 2011 2010 Given that different countries countries that different Given 4 2009 2008 - 2007 145 2006 - 2005 2004 2003 Morbidity and mortality resulting from Type 1 diabetes 1 diabetes Type from Morbidity and mortality resulting 6 Women 2002 ) is a known risk factor for diabetes. In addition, exposure to to exposure In addition, diabetes. for risk factor ) is a known 2001 2.5 PM 2000 1999 1998 1997 Men 1996
0
0.4 0.2 0.8 0.6 1.2 1.0 1.4 year
Age-adjusted incidence (per (per incidence Age-adjusted ) 100,000 Diagnosis Diagnosis Legend: mortality rates between Israel and other countries may trace to different coding practices. coding practices. trace to different Israel and other countries may mortality rates between from Type 2 diabetes increased in the OECD countries. In Israel, despite an increase in these rates in these rates In Israel, despite an increase in the OECD countries. increased 2 diabetes Type from due to (perhaps years in the following 2000, morbidity and mortality decreased prior to the year Type Still, it should be emphasized that the mortality rate per 100,000 from treatment). improved 6 and 7). (Figures in Israel surpasses the OECD average 2 diabetes disparities in diabetes as the cause of death, the coding diabetes rules for different follow factors may be implicated. may factors ages children among of diabetes incidence the QICH report, aforementioned to the According (0.1%) in 2014–2018. stable 2–17 was Morbidity and mortality in 1990–2017 in Israel and in other OECD countries. down trended Exposure to air pollution ( to air pollution Exposure to exposure For example, disturbances. and pre-diabetic 2 diabetes Type EDCs is associated with metabolic from stemming diabetes of risk increased an with associated is dioxins of levels high of autoimmune is evidence that the prevalence There glucose metabolism. disturbances or altered and that environmental the world around is increasing 1 diabetes, Type including disorders, Diabetes Diabetes Mesothelioma Environmental Health in Israel 2020 Chapter 14
Disability Adjusted-Life Years (DALYs) Associated with Diabetes, Israel and OECD Countries, 1990–2015 Figure 6 1,000 Global Health Data Exchange 20204 900
800
700 )
600 100,000
500
400 DALYs (per DALYs
300
200
100
0
year 1990 1995 2000 2005 2010 2015
Legend: Israel, both sexes, all ages, OECD countries, both Israel, both sexes, all ages, OECD countries, both diabetes mellitus Type 1 sexes, all ages, diabetes diabetes mellitus Type 2 sexes, all ages, diabetes mellitus Type 1 mellitus Type 2
Diabetes Mortality Rates, Israel and OECD Countries, 1990–2015 Figure 7 40 Global Health Data Exchange 20204 30
25 )
20 100,000
15 Deaths (per 10
5
0
year 1990 1995 2000 2005 2010 2015
Legend: Israel, both sexes, all ages, OECD countries, both Israel, both sexes, all ages, OECD countries, both diabetes mellitus Type 1 sexes, all ages, diabetes diabetes mellitus Type 2 sexes, all ages, diabetes mellitus Type 1 mellitus Type 2
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10, 11 14 15 Barzilai, Meir, Kaplan, HaEmek, Laniado, and Sheba), analyzing the 2015 outbreak of West West of the 2015 outbreak and Sheba), analyzing Laniado, HaEmek, Kaplan, Barzilai, Meir, that heat waves and extreme the disease outbreak an association between found Nile fever, 8). (Figure year Vector-borne Diseases Diseases Vector-borne systems in water problems as infrastructure as well such as climate change factors Environmental diseases. the risk of vector-borne increase may (Assaf Harofeh, centers medical and several University, Aviv Tel MoH, from Researchers and Harvard University, using NII data to study the prevalence of ASD in children, found a a found of ASD in children, the prevalence using NII data to study University, and Harvard born before among children in prevalence An increase of 0.64% in eight-year-olds. prevalence higher in higher- that ASD incidence was found The researchers off afterwards. 2009 leveled families. income of the Negev, examining data on more than two million singleton births in 2000–2014 and births in 2000–2014 and million singleton than two data on more examining of the Negev, newborn in trend upward an identified period, that during outcomes birth in trends tracking newborns. in the birth of underweight trend and a downward weight (NII) Institute National Insurance the of Jerusalem, University the Hebrew from Researchers the abdominal wall, and in the rates of genetic anomalies. The rates of malformations in the in the The rates of malformations anomalies. and in the rates of genetic wall, the abdominal system, and in the rates system and digestive respiratory skeleton, system, muscles, nervous declines. all showed anomalies, of chromosomal Ben-Gurion University and of Haifa, the University University, MoH, Bar-Ilan from Researchers from 14.8 per 1,000 live births in the year 2000 to 11.1 per 1,000 live births in 2014. It It 2014. in births live 1,000 per 11.1 to 2000 year the in births live 1,000 per 14.8 from lead to pregnancy in Israel that made are diagnoses prenatal that many should be emphasized of pregnancies be associated with the termination may decrease that the termination, meaning in an increase half of the 2000s, In the first malformations. of fetal the detection following seen was increase An 2006. in reversed trend the However, observed. was anomalies congenital system, and urinary eyes, organs, genital of the heart, blood vessels, in rates of malformations congenital anomalies and autism spectrum disorder (ASD), and environmental exposures, with with exposures, and environmental (ASD), disorder and autism spectrum anomalies congenital to air pollution. emphasis on exposure MoH on data collected in 2000–2014, anomalies in Israel based on congenital In a report in Israel, anomalies reported rate of congenital in the trend a downward found researchers Early Childhood Health Indicators Health Indicators Early Childhood including health indicators, childhood early between an association found have studies Several Environmental Health in Israel 2020 Chapter 14
Cases of West Nile Fever in Israel in Relation to Maximum, Minimum, and Average Weekly Temperatures in 2015
50 40 Figure 8 Heat wave Salama et al., 201915 45 35 Heat wave 40 30 35 )
25 C
30 º
100,000 25 20
20 15 Temperature ( Temperature Rate per
15 10 10
5 5
0 0 4.1.15 1.2.15 1.3.15 7.6.15 5.7.15 2.8.15 3.1.16 18.1.15 15.2.15 10.5.15 8.11.15 6.12.15 15.3.15 29.3.15 12.4.15 26.4.15 24.5.15 21.6.15 19.7.15 16.8.15 30.8.15 13.9.15 27.9.15 11.10.15 25.10.15 22.11.15 20.12.15
Legend: Number of cases Max temperature Average temperature Min temperature
Future Challenges
Rapid urbanization and an increase in population density in Israel are leading to accelerated construction, growing traffic congestion, and destruction of green spaces—all posing risks to health. Therefore, it is important to establish environmental health indicators such as distance of homes from green spaces and main traffic arteries, exposure to noise, and the amount of time Israel residents spend on the roads. Adding cognitive indicators such as trends in ASD and in Attention Deficit Hyperactivity Disorder (ADHD) would also be useful.
Most environmental health indicators are based on analyses of direct health databases (birth, hospitalization, morbidity, and mortality data). But it is also possible to learn about environmental health trends on the basis of indirect databases that include data on physician visits, medication use, or social media traffic. Accordingly, additional indicators based on indirect databases should be formulated.
In Israel, causes of death are recorded by the Central Bureau of Statistics. These records, however, like those in other countries, are not sensitive enough to monitor mortality caused by environmental exposure or climate change. Monitoring causal associations with mortality is challenging because environmental exposures generally cause morbidity, which, in turn, may increase mortality risk; in addition there is frequently a lag between the environmental
- 148 - Environmental Health Indicators and Trends - 149 - The GBD project publishes data on the burden of disease in Israel resulting from exposure to to exposure from of disease in Israel resulting data on the burden publishes The GBD project of assessments are Also necessary including air pollution and ETS. pollutants, environmental metals—a and heavy EDCs, to pesticides, exposure in Israel caused by of disease the burden the special Given on these topics. literature limited and evolving of the view in challenging task of on the burden to collect data efforts pollutants, to environmental children of vulnerability on this population. should focus health indicators disease and environmental the direct cause of death is recorded—with the exception of very extreme events, such as the as the such events, extreme of very exception the recorded—with cause of death is the direct in the temperatures low exceptionally by was occasioned that upturn in mortality significant data with exposure to cross-check is needed research epidemiological Therefore, winter of 1992. variables. these two the association between reflect accurately that would way mortality data in a exposure and the increase in mortality. Even in cases of extreme air pollution and extreme heat, heat, extreme air pollution and of extreme in cases Even in mortality. and the increase exposure Only and mortality. exposures environmental associations between to monitor it is challenging Environmental Health in Israel 2020 Chapter 14
References
(1) Environmental Health Indicators New Zealand, Massey University. What are environmental health indicators? https://www.ehinz.ac.nz/indicators/overview/about-the-indicators/ (retrieved July 2020). (2) Centers for Disease Control and Prevention (updated April 2019). National environmental public health tracking. Indicators and data. https://ephtracking.cdc.gov/searchMetadata (retrieved July 2020). (3) The Israel National Program for Quality Indicators in Community Healthcare. Areas of Measures. https://en.israelhealthindicators.org/measures (retrieved July 2020). (4) Global Health Data Exchange (GHDx). GBD results tool. http://ghdx.healthdata.org/gbd-results-tool (retrieved October 2020). (5) Israel Ministry of Health (2018). Regional differences and trends in asthma hospitalization rates among children, 1996–2015 (Hebrew). https://www.health.gov.il/NewsAndEvents/SpokemanMesseges/Documents/13122018.pdf (retrieved July 2020). (6) Israel Ministry of Health, the Israel National Institute for Health Policy Research (2019). National program for quality indicators in community healthcare. Report for the years 2016–2018 (Hebrew). https://48fc89f4-e14d-48de-bdc0-ec96de79873e.filesusr.com/ugd/ebbef0_f04ca22668b14cd7bfe8051fd13716cb.pdf (retrieved July 2020). (7) Greenberg, N., Carel, R. S., Dubnov, J., Derazne, E., & Portnov, B. A. (2019). Prevalence of asthma among young men residing in urban areas with different sources of air pollution. The Israel Medical Association Journal, 12(21), 785–789. https://www.ima.org.il/FilesUploadPublic/IMAJ/0/393/196926.pdf (8) Machluf, Y., Farkash, R., Fink, D., & Chaiter, Y. (2018). Asthma severity and heterogeneity: Insights from prevalence trends and associated demographic variables and anthropometric indices among Israeli adolescents. The Journal of Asthma, 55(8), 826–836. https://doi.org/10.1080/02770903.2017.1373809 (9) Israel Ministry of Health, National Cancer Registry and Israel Center for Disease Control. Update of data on cancer incidence and mortality for 2017, ahead of International Cancer Day, 2020 (Hebrew). https://www.health.gov.il/PublicationsFiles/ICR_2020.pdf (retrieved July 2020). (10) Raz, R., Levine, H., Pinto, O., Broday, D. M., Yuval, & Weisskopf, M. G. (2018). Traffic-related air pollution and autism spectrum disorder: A population-based nested case-control study in Israel. American Journal of Epidemiology, 187(4), 717–725. https://doi.org/10.1093/aje/kwx294 (11) Farhi, A., Boyko, V., Almagor, J., Benenson, I., Segre, E., Rudich, Y., Stern, E., & Lerner-Geva, L. (2014). The possible association between exposure to air pollution and the risk for congenital malformations. Environmental Research, 135, 173–180. https://doi.org/10.1016/j.envres.2014.08.024 (12) Israel Ministry of Health, Mother, Child and Adolescent Department, Information Branch (2017). Congenital malformations in Israel 2000––2014. Quality test and trends over time (Hebrew). https://www.health.gov.il/publicationsfiles/birth_defects2000_2014.pdf (retrieved July 2020). (13) Agay-Shay, K., Rudolf, M., Rubin, L., Haklai, Z., & Grotto, I. (2018). Trends in fetal growth between 2000 to 2014 in singleton live births from Israel. Scientific Reports, 8(1), 1089. https://doi.org/10.1038/s41598-018-19396-w (14) Segev, A., Weisskopf, M. G., Levine, H., Pinto, O., & Raz, R. (2019). Incidence time trends and socioeconomic factors in the observed incidence of autism spectrum disorder in Israel: A nationwide nested case-control study. Autism Research, 12(12), 1870–1879. https://doi.org/10.1002/aur.2185 (15) Salama, M., Amitai, Z., Lustig, Y., Mor, Z., Weiberger, M., Chowers, M., ... Leshem, E. (2019). Outbreak of West Nile Virus disease in Israel (2015): A retrospective analysis of notified cases.Travel Medicine and Infectious Disease, 28, 41–45. https://doi.org/10.1016/j.tmaid.2018.07.008
- 150 - Recommendations
Conclusions and
Conclusions and Recommendations
Linda S. Birnbaum, PhD, D.A.B.T., A.T.S.
Scientist Emeritus and Former Director, National Institute of Environmental Health Sciences and National Toxicology Program Scientist in Residence, Nicholas School of the Environment, Duke University
Environmental Health in Israel 2020 clearly demonstrates the improvements in environmental health that have occurred in Israel not only since the 2017 report but even more so since the first report in 2014. Scientific research has led to many important new findings. The establishment of several prospective longitudinal birth cohorts is the first step in understanding the health of the Israeli public and the long-term impacts of environmental exposures. Many of these new studies involve multiple Israeli institutions, both academic and governmental, and several involve international collaborations. Israel has been regarded as a powerhouse in scientific research for many years, but its environmental health research is now gaining recognition. Presentations at international meetings and publication in top-tier journals have played a significant role.
Much progress has been made in both the implementation of the national plan to prevent and reduce air pollution in the past three years, as well as an increase in stationary monitoring sites. There is recognition that more are needed, especially in the north of Israel. While ozone, NOx, and both PM10 and PM2.5 are being monitored, there are other ambient air pollutants which should be followed such as lead and carbon monoxide. The decrease in sulfur oxides is good news and does likely reflect the reduction in the use of dirty coal from China. The environmental targets for Israel should be put in context of international ones, such as WHO or the EU. In some cases, such as PM10 which can be elevated because of dust, the targets should be related to other countries with desert areas.
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The good news is that levels of PM2.5 are decreasing, but the levels of NO2 are still too high, and there seems no improvement in ozone. Monitoring and epidemiological studies need to be conducted in many places in Israel, not only in Haifa which has had problems with ambient pollution due to the concentration of industrial sites near the port and the Carmel mountains creating a bowl effect. Ambient air pollution is associated with a plethora of adverse health effects – nearly every organ system is impacted, and the developmental and obesogenic effects clearly would benefit from more attention. Additional attention to source apportionment and economic impacts are warranted.
There has been some improvement since 2017 in addressing the role of indoor air pollution in environmental health in Israel. This is good news as not only do most people, even in Israel, spend much of their time indoors, but indoor air pollution is a significant contributor to ambient levels as well. Measuring VOC levels in schools is a step in the right direction, but all types of air pollution need to be looked at in a variety of indoor environments, including day care centers, senior citizen residences, healthcare facilities, and so on. Indoor air also contributes to the presence of contaminants in dust, which are significant sources of oral, dermal, and inhalation exposure and should be examined. No progress has been made in this area. The role of indoor air in the transmission of SARS-CoV-2 is gaining appreciation worldwide and has implications to indoor exposure to other microbial pathogens. It is disappointing that there has been no progress in making indoor air quality a priority within the structure of the Israeli government agencies.
So long as people smoke, there will be concern with environmental tobacco smoke. Children and pregnant women are uniquely vulnerable to second-hand smoke. Thus, enforcement of the smoking ban in schools is essential, as it is in public places. Continued monitoring of urinary cotinine as a biomarker of smoking exposure should be expanded as Israeli government scientists now have that capability. Anti-smoking campaigns should be expanded, with special attention to vulnerable communities. More attention should be given to the use of electronic cigarettes as serious health consequences of vaping are being recognized. It is likely that young people have adopted this practice as cigarette smoking has declined.
Israel is a leader in desalination to provide safe drinking water. The recognition that there are critical minerals removed by this process has led to significant research efforts to understand the potential health consequences of drinking water without adequate magnesium, calcium, and iodide. Investigation of possible adverse cardiac effects needs to be continued, as do studies of thyroid status in pregnant women. An educational campaign encouraging the use of iodized salt would be appropriate to consider. The effects of using desalinated water in agriculture requires investigation. There are many chemicals which contaminate drinking water, in addition to lead and other heavy metals, which should be examined. These include products of disinfection, e.g., trihalomethanes (both chlorinated and brominated), personal care products, pharmaceuticals, pesticides, and per- and polyfluoroalkyl substances (PFAS). There are literally thousands of PFAS so it is important that more than just PFOA and PFOS be measured. If the drinking water comes from an area near a military site, it is likely there will be increased contamination.
- 152 - Recommendations
Israel is also a leader in the use of reclaimed wastewater (RWW), but this requires regulations. Conclusions and Israel could be the first country in the world to develop such regulations as well as methods to remove contaminants, both chemical and microbial, from RWW. There is ample evidence that certain contaminants are taken up by plants, and thus can serve as an exposure source to people. This is not limited to pharmaceuticals, but applies to a multitude of chemicals, including PFAS, brominated flame retardants, and legacy POPs. Biosolids produced during wastewater treatment can also serve as a source of contamination in agriculture and should be examined. A readily searchable database should be developed for the contaminants present in RWW.
Pesticides are used extensively in Israel. Re-evaluation of their registration is a good idea, but it is concerning that so many pesticides used in Israel are not registered in the EU. Organophosphate pesticides continue to be used, and the exposure of pregnant women is of great concern and should be studied. Israel is a small country and as long as chlorpyrifos is used in agriculture, children living nearby will be exposed. Chlorpyrifos is clearly of concern, but so are many other pesticides. Many of their adverse effects on children are associated with in utero exposure. It appears that most of the government concern is for acute pesticide exposure in workers, but there are also long-term effects of many different pesticides associated with low-dose exposure during vulnerable periods of life. Israel may wish to reconsider its use of glyphosate. Additional studies are needed on pesticide exposure from multiple sources (e.g., drinking water, house dust, diet) and the impact of exposure to many different pesticides that are still used in Israel as well as those more recently introduced, such as pyrethroids and neonicotinoids. Ongoing monitoring of residue levels in the food supply is essential, as is biomonitoring of children living in agricultural areas. Establishment of a national database of pesticide poisonings in Israel is required. The lack of progress on enforcement of sale and use of agricultural pesticides is problematic, as is the lack of a plan for monitoring pesticides near schools and homes.
Food can be contaminated by many chemicals and contamination may occur at every step of food production. Periodic surveys of food contamination, including microbial, metal, pesticides, POPs, pharmaceuticals, and so on, are needed. Contaminants of special concern seem to be mycotoxins, aluminum, arsenic, pesticides, and dioxins. Attention should also be paid to chemicals such as phthalates and PFAS that are used in food packaging and can migrate into prepared foods. To date, much of the focus appears to be on baby formula; this attention needs to be expanded to all kinds of baby food (including human breast milk) as well as fresh fruit and vegetables, fish, meat, and dairy for children and adults. Conduct of a Total Diet Study is essential and it is disappointing that this has not yet been achieved.
Some of the same kinds of chemicals that can contaminate food—metals, phthalates, phenols, PFAS, flame retardants, etc.—are present in consumer goods. Consumers are entitled to know what chemicals are present in the products they purchase. There has been some improvement in this area but greater transparency is needed. While there have been some additional regulations concerning consumer products, the length of time for regulations to be implemented needs
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to be shortened. This could be further improved through closer cooperation among multiple government ministries and, especially, the inclusion of the Ministry of Health. Attention needs to be paid to imported products to ensure that they meet, or exceed, the regulatory requirements of Israel.
There have been several significant achievements in human biomonitoring during the past three years. One is the involvement of Israel in a major EU consortium (HBM4EU); the other is the establishment of its own national biomonitoring program. This has been facilitated by the establishment of a national human biomonitoring laboratory. This capability should continue to develop so there is additional capacity as well as enhanced measurement capabilities. Monitoring of nutritional biomarkers needs to be added to that of chemical contaminants. The laboratory should have the ability to monitor for a wide variety of compounds in blood, urine, and breast milk. The national commitment to this resource needs to be ongoing – the need will not disappear in ten years. There should be more involvement of the public as well as academics and government in choosing what to monitor and in whom. The numbers of people monitored should be increased and their diversity in terms of age, sex, ethnicity, SES , and so on must be ensured. Clear communication among scientists, regulators, and citizens needs to be developed and expanded.
Israel is a leader in research on non-ionizing radiation (NIR). Its extensive monitoring is appropriate but should be expanded as 5G comes online. While the science is not conclusive regarding adverse non-thermal health effects of NIR, a precautionary approach would be the most appropriate. Overuse of digital equipment by children and regulation of such use is a societal issue.
Climate change is the existential threat of the 21st century. Mitigation involves more than just climate mitigation, and adaptation is not only technological. Israel needs to make a greater effort to meet the sustainable development goals of the UN. There is no reason that Israel is not moving more rapidly toward renewable energy given its climate and amount of sunshine. As the planet warms, disease vectors will be found in different locations, and attention is needed to food security as the nutritional value of crops will decrease with increasing CO2. Approaches to agriculture beyond just using more or different pesticides should be explored. Heat waves are becoming more frequent, as are extreme weather events, including flooding and droughts—both of which have been recently seen in Israel. While there is much research on climate change in Israel, health needs to be brought into the picture. This could be facilitated by a national database on exposure metrics and health indicators.
Greater understanding of, and appreciation for, the built environment is essential. Mass transit and biking need to be encouraged both by economic incentives and by physical opportunities. Health should be a key player in environmental impact assessments and in planning new buildings and roads. Recent studies clearly show the importance of “greenness” around places where people live and work—for mental as well as physical health.
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There are different kinds of vulnerability: age, sex, SES, ethnic, religious, genetic, and so on. Conclusions and Similar environmental exposures may have varied impacts on different populations. Israel needs to determine for itself the level of protection that it wants, and for whom. Given the different ethnic groups of which the Israeli population is composed, there are multiple biological variables to be examined. Genetic variability may play a major role in differential vulnerability. Infants, children, and the elderly are often the most vulnerable members of society. It appears that there is extensive research in Israel on ambient air pollution and biomonitoring in relation to the country’s vulnerable populations, and clear research opportunities exist to deepen our understanding of the impacts of indoor air, climate change, and pesticides on them. Enhanced involvement of various advocacy groups as well as scientific and government groups should improve plans related to vulnerability in environmental health in Israel.
The public is entitled to have information on the trends in environmental health. Readily accessible databases would benefit everyone, including researchers who would gain more support. Environmental health requires clean air, clean water, and clean soil. Israel really must formulate a list of environmental health indicators. The burden of disease from all environmental problems needs to be measured and communicated broadly.
The COVID-19 pandemic has brought much of the world to a halt. Israel is no exception. Several studies clearly demonstrate how air pollution increases both susceptibility to, and the severity of, COVID-19. What about other kinds of environmental pollution? And what about overuse of antibiotics in treating the associated pneumonias? Will this lead to an increase in antibiotic resistant microbes? What about the use of antimicrobial disinfectants, which are toxic by themselves? And what about the increased use of plastics that now contaminate our entire world and all of us? We have much to learn as we go forward in relating our health to that of our environment.
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- 156 - APPENDICES
- 157 - Environmental Health in Israel 2020 Appendix 1
Appendix 1 Progress since 2017 and Future Challenges
Chapter 1 Ambient Air Quality
Progress on Challenges presented in Environmental Health in Israel 2017 Challenge Progress
Develop a strategy for regular sampling of contaminants that cannot be monitored continuously
Full implementation of the National Plan for the Prevention and Mitigation of Air Pollution
Reduce ambient concentrations of PM10 and ozone in metropolitan areas in which concentrations exceed environmental values
Update target and environmental values for a range of air pollutants
Improve the spatial distribution of air monitoring stations
Improve planning of sustainable transport
Integrate epidemiological data from studies conducted in Israel in the assessment of burden of disease from air pollution and associated costs
Collect data on the contribution of different sources to air pollution in Israel, using source apportionment techniques
Future Challenges
Continue to monitor gas rig emissions along with other air pollutants along Israel’s coastline
Conduct Health Impact Assessments on pollution emitted from trigeneration plants and from new waste incineration facilities due to their proximity to population centers
Monitor air quality and conduct studies on the impact of livestock farms on air pollutant emissions
Legend: Significant progress Some progress Little or no progress
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Appendix 1 Chapter 2 Future Challenges Indoor Air Quality Appendix 1
Progress on Challenges presented in Environmental Health in Israel 2017
Challenge Progress
Conduct a pilot study on indoor air pollution in schools
Study the health impacts of indoor air quality and the relationship between ambient air pollution and indoor air quality
Formulate and publish recommendations for the public on ways to reduce exposure to indoor air contaminants
Establish a central national authority to address indoor air quality
Conduct research on residential dust
Future Challenges
Address indoor air quality considerations in green building standards
Chapter 3 Environmental Tobacco Smoke
Progress on Challenges presented in Environmental Health in Israel 2017 Challenge Progress
Validate analytical techniques to measure cotinine levels in blood, urine and saliva
Measure urinary cotinine levels in children
Measure urinary cotinine levels in pregnant women
Enforce legislation banning smoking in schools
Collect and publish national data on the prevalence of asthma in children and on asthma medication use
Enforce legislation banning smoking in public places
Future Challenges
Study the long-term impact of the smoking legislation enacted in December 2018
Update the National Tobacco Control Plan of 2011 to include environmental tobacco smoke (ETS) from cigarettes, electronic cigarettes and heat-not-burn tobacco products
Design targeted interventions to reduce environmental tobacco smoke exposure in high-risk populations
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Chapter 4 Chemical Parameters in Drinking Water
Progress on Challenges presented in Environmental Health in Israel 2017 Challenge Progress
Conduct an updated survey to examine lead levels in tap water in residences and institutions, including schools
Develop requirements to limit the lead content of products in contact with drinking water
Study the public health effects of consuming desalinated drinking water with low-mineral content
Establish a central database of emerging contaminants in drinking water
Assess the impact of discontinuing fluoridation on children’s dental heath, especially among children of low socioeconomic status
Develop a model to estimate mineral content (iodine and magnesium) at central mixing junctions and at points of consumption
Future Challenges
Complete the pilot study on adding magnesium to desalinated water and translate the findings into policy
Set a stricter standard for lead content in drinking water in Israel and ensure that all localities monitor lead in the supply network
Collect data on haloacetic acid disinfectant by-products and per- and polyfluoroalkyl substances (PFAS) in drinking water and consider adoption of new standards for these contaminants
Reduce trihalomethane concentrations and chlorite and chlorate concentrations in drinking water, and reassess the standards for these substances
Chapter 5 Reclaimed Wastewater
Progress on Challenges presented in Environmental Health in Israel 2017 Challenge Progress
Conduct additional studies on potential exposure to pharmaceuticals and other contaminants via produce irrigated with reclaimed wastewater
Create a database that integrates chemical and microbial monitoring in sewage, reclaimed wastewater, in the field, and in agricultural produce
Conduct a risk assessment on chemical contaminants in reclaimed wastewater
Future Challenges
Improve the infrastructure for sewage treatment and reclaimed wastewater storage so that it has capacity for the increasing volume of sewage and reclaimed wastewater
Improve oversight of micro-pollutant concentrations in industrial sewage, especially in the pharmaceutical industry
Perform risk assessments that address combined exposure to a large number of chemicals and pharmaceuticals via reclaimed wastewater
Monitor PFAS and other persistent organic pollutants in reclaimed wastewater and sludge
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Chapter 6 Future Challenges Pesticides Appendix 1
Progress on Challenges presented in Environmental Health in Israel 2017
Challenge Progress
Conduct periodic re-evaluation of all active ingredients approved for plant protection
Conduct biomonitoring of organophosphates
Conduct risk assessment on pesticides based on children’s diet
Establish a national database on pesticide poisoning in Israel
Improve enforcement of sale and use of agricultural pesticides
Monitor pesticides in the air near schools and residences
Advance uniform and comprehensive legislation on registration and use of all types of pesticides (including the establishment of an umbrella committee on pesticide registration and/or unification of registration committees)
Future Challenges
Ban the use of chlorpyrifos
Introduce a rapid registration process for less toxic or substitute formulations that are already registered in developed countries (primarily in Europe and the U.S.)
Expand the use of biomonitoring and risk assessment tools for assessing exposure to additional pesticide groups, including pyrethroids and neonicotinoids, and to additional vulnerable groups
Chapter 7 Chemical Food Contaminants
Progress on Challenges presented in Environmental Health in Israel 2017 Challenge Progress
Conduct a survey of aluminum in baby food
Conduct a survey of phthalates in baby food
Create a database of food consumption based on periodic national health and nutrition surveys, and conduct more accurate exposure assessments for the general population and for sub-populations such as children and pregnant women
Establish a Total Diet Study (TDS) project in Israel
Future Challenges
Conduct exposure and risk assessments for contaminants such as heavy metals, based on foodstuff monitoring data, nutritional survey data, and biomonitoring data
Increase transparency and publish periodic surveys on chemical food contaminants
Update and significantly expand the existing legislation concerning mycotoxins
Conduct new surveys and exposure assessments on dioxins and PFAS in food
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Chapter 8 Chemicals in Consumer Products
Progress on Challenges presented in Environmental Health in Israel 2017 Challenge Progress
Improve regulatory enforcement for consumer products (enforcement in markets and not only at point of import)
Require labeling of selected consumer products indicating that they meet the standard
Re-evaluate the role of the Ministry of Health in guaranteeing the adoption and implementation of standards that protect public health
Advance comprehensive regulation of chemicals in consumer products
Conduct additional surveys of chemicals in consumer products in the market in Israel; conduct a systemic review of requirements pertaining to chemicals in consumer products abroad versus those in Israel
Shorten the bureaucratic process of declaring new or revised standards mandatory
Future Challenges
Initiate public service campaigns to reduce the potential risk to consumer safety and health from online purchases of products
Study the potential impact of the cosmetics reform on the public’s exposure to chemicals in cosmetics
Study potential exposure to PFAS via consumer products in Israel and evaluate potential regulatory measures
Chapter 9 Human Biomonitoring
Progress on Challenges presented in Environmental Health in Israel 2017 Challenge Progress
Join a regional or international human biomonitoring project
Develop laboratory capacity for human biomonitoring
Establish and fund a government framework for human biomonitoring
Develop a framework for using human biomonitoring data in quantitative risk assessment
Expand the process of selecting and prioritizing chemicals for human biomonitoring by including representatives from academia, government, and the public
Future Challenges
Full implementation of the National Biomonitoring Program
Monitor nutritional biomarkers in coordination with the National Biomonitoring Program
Examine the clinical use of human biomonitoring (for example, in asthma or well-baby clinics) as a tool for identifying infants or children who are exposed to environmental tobacco smoke
Monitor PFAS exposure in the framework of the National Biomonitoring Program
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Chapter 10 Future Challenges Non-Ionizing Radiation Appendix 1
Progress on Challenges presented in Environmental Health in Israel 2017
Challenge Progress
Monitor devices emitting non-ionizing radiation (such as transformers and power lines) in public spaces
Re-evaluate standards in light of new findings regarding health outcomes of exposure to non-ionizing radiation
Increase public awareness of the potential adverse health outcomes of non-ionizing radiation, the need to reduce exposure, and the potential risks from exposure
Establish mandatory regulations regarding permissible levels of non-ionizing radiation
Future Challenges
Control growing exposure to radiation from the increasing volume of data consumed by cellular communication
Expand the scientific knowledge on the potential adverse effects of LED lighting and translate the findings into policy
Expand research on the use of digital media by children and adolescents as a scientific basis for recommendations concerning limitations on screen time exposure
Chapter 11 Climate Change
Progress on Challenges presented in Environmental Health in Israel 2017 Challenge Progress
Implement the National Plan to Combat Cutaneous Leishmaniasis
Develop a national action plan to cope with climate change
Develop specific climate change indicators
Strengthen collaboration between the Israel Meteorological Service and the Ministry of Health in order to prepare for extreme climate events
Create a national database that includes exposure metrics and health indicators related to climate change
Future Challenges
Expand epidemiological research in the field of climate as well as research in economics, the social sciences, and health systems management in the context of climate change
Pass a “Climate Law”
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Chapter 12 Planning
Progress on Challenges presented in Environmental Health in Israel 2017 Challenge Progress
Promote shading in open public spaces
Promote plans for paving bicycle paths
Conduct Health Impact Assessments on large-scale projects
Give representatives of the Ministry of Health broader powers in the planning committees
Develop policies to reduce emissions of heat, radiation, and greenhouse gases
Improve the efficiency of public transportation
Future Challenges
Establish guidelines for planning of schools in relation to main roads
Develop a methodology and a set of criteria for defining a “healthy city”
Improve planning of water and wastewater infrastructure to prevent flooding
Chapter 13 Vulnerable Populations
Progress on Challenges presented in Environmental Health in Israel 2017 Challenge Progress
Enhance collaboration between government ministries and civil society organizations to improve the flow of information regarding environmental hazards and to promote mechanisms of public participation Identify vulnerable populations in Israel and adapt specific goals and objectives to them (in the context of the National Environmental Health Plan) Conduct research on genetic variability and other vulnerability predictors to identify vulnerable populations
Future Challenges
Collect data on the burden of disease from environmental pollution among the elderly Expand the air monitoring network to cover populated areas, especially in the periphery, that are not regularly monitored, including Bedouin settlements in southern Israel
Chapter 14 Environmental Health Indicators and Trends
Progress on Challenges presented in Environmental Health in Israel 2017 Challenge Progress
1. Formulate environmental health indicators 2. Collect and publish data on various environmental health indicators
Publish data collected by the authorities on environmental pollutants and health outcomes and make them accessible to researchers, policymakers, and the public in a timely fashion
- 164 - Environmental Health Appendix 2 and COVID-19 Appendix 2
Environmental Health and COVID-19
Environmental Health in Israel 2020 was written in the first half of 2020, at the beginning of the worldwide outbreak of the coronavirus (COVID-19) pandemic. This global crisis, believed to have resulted from human pressure on the environment and the consequent increase in risk of zoonotic disease, has been described by the World Health Organization (WHO) as the greatest global shock in decades, affecting many aspects of our lives including environmental health.
The topics covered in this report reflect the traditional issues that come under the heading of environmental health—topics that have been on both the scientific and the regulatory agendas for many years in Israel, as well as in other countries. The coronavirus pandemic, in contrast, is novel and, as of this writing, ongoing. Knowledge regarding its health effects and its possible connections with the environment and environmental pollution is being updated continuously and rapidly.
Some of the earliest reported impacts of the pandemic on environmental health were the result of the lockdowns that were imposed and the consequent lifestyle changes. Social distancing and travel restrictions, for example, highlighted the importance of urban green spaces and the need for urban planning that provides pedestrians and bikers with dedicated spaces and paths, especially in densely populated cities.1 As a result, more and more cities worldwide, including Tel Aviv, are promoting the replacement of some roads and car parks with green spaces and infrastructure for bikers and pedestrians.2, 3 While the crisis may carry the potential of urban changes that would promote physical activity, it has also led to a drastic and lengthy reduction in the use of public transportation and greater reliance on private vehicles.
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In Israel, the coronavirus crisis has highlighted a problematic regulatory gap: Even as the use of disinfectants became compulsory in closed public spaces including schools and kindergartens, Israel, unlike the U.S. and Europe, has no regulatory framework within which these disinfectants may be approved. Disinfectant tunnels were installed at the entrances of several public buildings in Israel. While the Israel Ministry of Health has discouraged this potentially dangerous use of disinfectants, it lacks the regulatory authority to ban the practice.
We have yet to understand the full environmental health implications of the pandemic, such as the impact of ambient air pollution and exposure to immunotoxic environmental chemicals on COVID-19 vulnerability, morbidity, and mortality; the potential contribution of the pandemic to antibiotic resistance due to the unnecessary use of harmful antimicrobial chemicals; the impact of long-term changes in remote work and learning on the reduction of commuting and traffic, and the effect of the crisis on political attention to and action regarding climate change.
In its manifesto on healthy and green recovery from the pandemic, the WHO laid down the following principles4:
Protect and preserve nature, the source of human health—including mitigating climate change, preventing air pollution, and implementing chemical management. Invest in essential services, from water and sanitation to clean energy in healthcare facilities. Ensure a quick healthy transition to renewable energy sources. Promote healthy, sustainable food systems. Build healthy, livable cities. Stop using taxpayers’ money to fund pollution.
A report of the Ministry of Environmental Protection reinforced these guidelines and noted the opportunity, when coming out of the coronavirus crisis and the subsequent economic crisis, to strengthen the ecological system by avoiding projects that harm nature.5
The EU has already unveiled a proposed recovery plan from the crisis that takes the opportunity to strengthen both health systems and environmental sustainability.6 There are early signs that in Israel the pandemic and the consequent economic crisis might result in the weakening of pollution regulations based on the claim that such steps will help businesses affected by the crisis.7 This is unfortunate, given that the pandemic has highlighted the economic implications of poor public health (chronic diseases and the environmental exposures that contribute to them) and poor public health infrastructure as well—both of which have direct consequences for the economy.8 It is time for Israel to develop the ability to analyze the economic benefits of mitigating exposures to environmental hazards, thereby improving public health as a strategy to strengthen the economy. Improving environmental health should also be part of a broader strategy to improve public health, public resilience, and preparedness for future national, regional, or global shocks.
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References and COVID-19 Appendix 2
(1) Nieuwenhuijsen, M. J. (2020). Why cities need green space more than ever? The Barcelona Institute for Global Health (ISGlobal).
https://www.isglobal.org/en_GB/healthisglobal/-/custom-blog-portlet/-por-que-las-ciudades-necesitan- espacios-verdes-mas-que-nunca-/4735173/0 (retrieved July 2020). (2) Climate Interactive (2020). Recovery policies and actions. Section 1. Plans that have been adopted. A. City level. https://www.climateinteractive.org/ci-topics/great-recovery-policies/#section-1-city (retrieved July 2020). (3) Municipality of Tel Aviv Yafo. 11 additional streets around the city will be closed to motorized traffic and remain open solely for pedestrians and cyclists (Hebrew). https://www.tel-aviv.gov.il/Pages/MainItemPage.aspx?WebID=3af57d92-807c-43c5-8d5f- 6fd455eb2776&ListID=81e17809-311d-4bba-9bf1-2363bb9debcd&ItemId=1054 (retrieved July 2020). (4) World Health Organization (2020). WHO Manifesto for a healthy recovery from COVID-19. https://www.who.int/news-room/feature-stories/detail/who-manifesto-for-a-healthy-recovery-from-covid-19 (retrieved July 2020). (5) Israel Ministry of Environmental Protection (2020). Assessing the current state of affairs, June 2020 (Hebrew). (6) European Commission (2020, May 27). Europe's moment: Repair and prepare for the next generation. Press release. https://ec.europa.eu/commission/presscorner/detail/en/ip_20_940 (retrieved November 2020). (7) Surkes, S. (2020, July 9). Government set to weaken pollution regulations to help business. The Times of Israel. https://www.timesofisrael.com/government-set-to-weaken-pollution-regulations-to-help-business/ (8) Dash, P., Dorling, G., Linzer, K., Ramdorai, A., Remes, J., Rutter, K-A., & Singhal, S. (2020). How prioritizing health could help rebuild economies. McKinsey Global Institute. https://www.mckinsey.com/industries/healthcare-systems-and-services/our-insights/how-prioritizing- health-could-help-rebuild-economies?cid=other-eml-alt-mgi-mck&hlkid=e4197390a3d349a2a4796fe79c3d 7a8f&hctky=12115283&hdpid=1f9c67f8-fc5f-4357-b3fd-c4ed217bbfc6# (retrieved July 2020).
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Acknowledgments
The authors would like to thank the following reviewers for their helpful comments and corrections:
Chapter 1 Prof. David Broday, Faculty of Civil and Environmental Engineering, Ambient Air Quality Technion, Israel Institute of Technology Prof. Itai Kloog, Department of Geography and Environmental Development, Ben-Gurion University of the Negev Dr. Levana Kordova-Biezuner, Ministry of Environmental Protection Dr. Ilan Levy, Ministry of Environmental Protection
Chapter 2 Prof. Yael Dubowski, Faculty of Civil and Environmental Engineering, Indoor Air Quality Technion, Israel Institute of Technology Dr. Raanan Raz, School of Public Health and Community Medicine, The Hebrew University of Jerusalem – Hadassah Ms. Ilana Taler, Ministry of Health
Chapter 3 Mr. Haim Geva-Haspil, Ministry of Health Environmental Prof. Leah Rosen, School of Public Health, Tel Aviv University Tobacco Smoke
Chapter 4 Dr. Shai Ezra, Mekorot Ltd. Chemical Parameters Dr. Luda Groisman, Ministry of Health in Drinking Water Prof. Ovadia Lev, Institute of Chemistry, The Hebrew University of Jerusalem Prof. Aron Troen, Faculty of Agriculture, Food and Environment, The Hebrew University of Jerusalem
Chapter 5 Prof. Benny Chefetz, Faculty of Agriculture, Food and Environment, Reclaimed The Hebrew University of Jerusalem Wastewater Dr. Pniela Dotan, Ministry of Environmental Protection Ms. Anat Lowengart-Aycicegi, Ministry of Agriculture and Rural Development
Chapter 6 Dr. Sagi Gavriel, Ministry of Environmental Protection Pesticides Adv. Tal Granot, Israel Union for Environmental Defense Dr. Laila Sheeney-Haj-Ichia, Ministry of Agriculture and Rural Development
Chapter 7 Dr. Riva Ben-Ezra, Ministry of Agriculture and Rural Development Chemical Food Prof. Ronit Endevelt, Ministry of Health; Contaminants School of Public Health, University of Haifa Dr. Jakob Shimshoni, Agricultural Research Organization, Volcani Center
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Chapter 8 Dr. Maya Negev, School of Public Health, University of Haifa Chemicals in Ms. Ludmila Neiman, Ministry of Economy and Industry Consumer Products Ms. Dalia Yarom, The Standards Institution of Israel
Chapter 9 Prof. Ronit Machtinger, Department of Obstetrics and Gynecology, Human Sheba Medical Center at Tel Hashomer Biomonitoring Prof. Ora Paltiel, School of Public Health and Community Medicine, Hadassah – Hebrew Universtiy of Jerusalem Prof. Aron Troen, Faculty of Agriculture, Food and Environment, The Hebrew University of Jerusalem
Chapter 10 Eng. Gil Cohen, Ministry of Environmental Protection Non-Ionizing Radiation Prof. Stelian Gelberg, Ministry of Environmental Protection
Chapter 11 Prof. Nadav Davidovitch, School of Public Health, Climate Change Ben-Gurion University of the Negev Prof. Alon Tal, Department of Public Policy, Tel Aviv University
Chapter 12 Adv. Amit Bracha, Israel Union for Environmental Defense Planning Ms. Shulamith Gertel, Ministry of Construction and Housing Dr. Emily Silverman, Institute of Urban and Regional Studies, The Hebrew University of Jerusalem
Chapter 13 Prof. Ilana Belmaker, Faculty of Health Sciences, Ben-Gurion University of the Negev Vulnerable Prof. Ilana Shoham-Vardi, Faculty of Health Sciences, Ben-Gurion University of the Negev Populations
Chapter 14 Prof. Ronit Calderon-Marglit, School of Public Health and Community Medicine, Environmental Health Hadassah – Hebrew Universtiy of Jerusalem Indicators and Trends Prof. Lital Keinan-Boker, Israel Center for Disease Control, Ministry of Health; School of Public Health, University of Haifa
Full Report Dr. Ehud Kaliner, Ministry of Health
International Dr. Linda S. Birnbaum, Nicholas School of the Environment, Duke University Review Prof. Michael Brauer, School of Population and Public Health, British Columbia University
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