????? ???'?

1
?????? ????? ???? ?- 21?????? , ?????? ???????
?????

• ????' ???? ????? ??' ???? ??????
  ??' ???? ?????
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• ????? ?????? ??????
• ???? ???????
• ????? ???'? ???? 2004

2
10 ??????? ??????? ?? ?????? ?????? ????'?
1999-1990 (JAMA, ?????? 2000)

• ???????
• ?????? ??????
• ?????? ??????? ??????
• ???? (?????) ????? ????????
• ????? ?????? ?????? ?? ???? ????
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• ????? ??????? ????? ???? ????????

3
??????? ??????? ??????? ?????? ?????? ?????
1992- 2002

• ????? ??????? ?????? ?????? ?????
• ????? ???????- ????? ?- 40
• ??????? ??? ???? ??? ?????? B ???????? ????? ???
  ???? ??? ?????? A- ????? ???? ???? ?? ????? ???
• ????? ??? Hib ???????? ?????????? B ??????
  ?????
• ??????? ???????? ?????? ????? ????? ?????? ?????
  ????? (????? ????? ????? ??????)
• ????? ???????? ?? ???? ??????? ???? ??? ?????
  ????
• ????? ???? ?????? ????? ??????????? DOTS

4
????? ???? ????????

• ?????? ??????? ???? ????? ???????? ??? ????
  ???????? (??? ????? ??????? ????? ??? ??????)
• ?? ????? ???? ????? ???????? ???????
• ?? ?? ??, ?????? ????? ????
• "... ???? ??? ?? ????? ???? ???? ????"
• ".... ?? ?? ?? ????"

5
????? ?????? ?????? ???? ????? ?? ????? "????"
??? ??????? (1)
2
1
3

• 1. ?????? ?????? ??????? ???? ????? ???? ??????
  ?? ???? ?? ?????
• 2. ????? ?????? ?? ?????? ??? ????? ??? ????
• 3. ??? ???? ????? ?? ??? 120 ???
• ????? ????? ??? ???? ????? ???? ?-19 !!

6
????? ?????? ?????????? ????? ?? ????? "????"
??? ??????? (2)
1
2

• 1. ?????? ?????, ??????, ??? ????
• 2. ??? ????? ??????? ???????

7
????? ??? ?? ????? ??????? ?????? ???????? ??????
????? ????????

• ??????? ?? ??????? ?????? ?????? ???? ?????
• ?????? ??????? ????'?, ????? ??????? ?????
• ?????? ??????? ?????? ???????? ????? ?? ?????
  ??????
• 1. ???? ??? ?????? A
• 2. ????? ?-Hib ????? ????? ???? ????
• ???????? ???????

8
????? ?????? ??????? ?????? ??????? ????'?
???? ???????, ????? ?????? ??????
9
Control of Polio in the U.S. (????
?????????????? ????? ?????)
???? ???????, ????? ?????? ??????
10
Polio in Israel, 1950-2003 (???? ??????????????
????? ????? )
???? ???? ????? ????? ???? ???? ?????? ????? ?-
50 ????? ???? ???? ?????? ????? ????????
IPV, 1957
OPV, 1961
11
Diphtheria in Israel, 1950-69 (???? ?????
???????)
Vaccine, 1951
12
???? ????'?)) Reported Measles Cases U.S.A. -
CDC
vaccine
13
Measles in Israel 1950-2003 (????)
????? ???? ?? ???? ?- 700,000 ??? ???? ?????
Vaccine
?-2003 ???? ??????? ????? ????? 60 ??? ?????
????? ?????? ????? ?????? ????????
14
Pertussis in Israel1950-2003 (????)
Vaccine, 1957
15
Tetanus in Israel 1950-2003(???? ?????)
Vaccine, 1955
16
MMR1
MMR2
??? ????? 2 ???? ????? ?? ??? ?? ????
17
??????? ??????? ????? ????????.....
18
Improved living standards
Vaccine licensed, 1992
Vaccine routine, 1994
??? ????? ?????? ???? ?????? ??? ??- 100 ????,
????? ?-5
19
Improving Sanitation
Vaccine, 1.7.99
??? ????? ?????? ????? ?? gt 90 ???????
20
????? ???? ???????? ??????

• ??? ???????? ????
• ???????? ???? ??????? ????-???????
• ???????? (????? ????? ????? ???? ???????)
• ????? ????? (????? ?? ?????)
• ???????
• ?????? ???????

21
???? ???????? ?? "????" (1)

• ????? ???? ??????? ?????? ????? ?????, ?????????
  ????????
• ... ????? ????? ?????? ????? ?????
• ????????? ???? ????????
• ??????? ????? ????
• ?????? ?????? ?????? ??????????? ???????? ??????
  ?????, ???????, ??? ???? ??????? ??????? ????? ??
  ??????? ???????

22
???? ???????? ?? "????" (2)

• ?????
• ??????? ?????? ?????? ????? ?? ?????
• ??????, ????? ????-????????, ?????, ?????,
  ???????, ??? ??????,
• ???? ???? ????, ????, ?????, ???? (LUPUS) ????
  ????? (MS)
• ??????
• ??? ?? ???? ???? ?????? ???
• ?????? ?????? ????? ????? ????? ??????
• ??? ??? ????? ?? ?? ???????? ?????? ?????
• ?????? ?????? ?????? ???? ?????
• ???????? ?????? ?????????? ??????? ?????? ?????
  

23
???? ???????? ?? "????"

• ???? ????? ???????? B ?????? ???????,
• ??? ?? ????? ????????
• ????? ?? ?- 2-1 ?????? (?- 2,000 ???? ??????)
• ??????? B ????? ??? ???? ???
• ????? ??????? ?- 140,000 ?????? ??? ???, ????
  ??????? ???????? ?????? ???? ?????
• ???? ???? ?????? ???? ???? ?????

24
????? ???????? ??????? ?? ???? ???

• ???????? ??????- ??? ???? ???? ?????? ?"? ?????
  ?????? (???? ???-???????)
• ????? ????? ????? ???? ???? ??????? ??????
  ??????? ?? ???? ?- 50, ????? ?????? ??????, ??
  ????? ?? ???? ????? ???? ?? ????
• ?????? ??????? ?- HIb ??-100 ???? ???? ???? ????
  ???? ??- 2-4 ???? ??? 1994
• ?????? ??????? ???????? A (????? ???? 96 ???? 3
  ????!!)

25
???? ?? ?????? ????????

• ?? ??? ?????? , ?????? ???? ??? ???
• ??? ??????
• ??????? ????? ?????? !
• ??? ?????? ?????? ???????? ?? ???????? ???? ????
  ???
• ??? ???? ???? ????? ????? ?? ??? ?? ?????? ?

26
?????? ??????? ??????? ???????? ?? ??? ???
??????? ???? 1-4 ??????, ??? 2001

• ????? ????? ???? ???? ?????? ????
• ?? ??? ??? ?? 2
• ?? ??? ??? 75,314/????
• ??? 4-1 32,606/ ????

????? (????? ?- 1000 ?????) ??? 2000 ?? 14 ??
??? ??? 5.6 4-1???? 0.4
????? ?????? ?????? ?? ??? ??? ?? 2.2 ?? ???
??? 6.5 ??? ??? 4-1 2.9 ??? ??? 4-1 0.3
27
???? ??? ????? ????? ???????????

• ?????? ???? (Whole cell) ???? ???????? ??????????
  ??????
• ?- 1974 ??????? ?????? ????? ?? ???? ??? ????
  ????
• ??? ????? ?????? ?????? ?- DTP (?- 70),
  ?????? ?? ?- 1978 ???? ????? ?? 102,500 ????? ?-
  36 ??????
• ????? ???? ??????
• ?- National Childhood Encephalopathy Study ???
  ??? ???????

28
??? ?? ??? ??? ??????? ??????? ? (1)

• ?????
• ?????? ?????? ????? ????? ??????? ???? ????? 30
  ???, ???? ????????
• ?????
• ????? ?????? ??? ??????? ?????? ?? ??????,
  ??????? ????? ??????
• ??????? ?????? ?? ?????? ?????? ??????
  ??????????? ??????
• ?????? ??????? ???? ?? ????

29
??? ?? ??? ??? ??????? ??????? (2)???? ??????
2002 New England Journal of Medicine

• ?????? ??????????? ????? 1998-1991
• ?????? ?? ??? ????? ??? ????? ??????
• 440,655 ??? ????MMR (82), 96,648 ?? ?????
• ??"? 316 ?? ??????, ?- 422 ?? ???????? ????????
• ?????? ??????? ??? ???????? 0.92
• ?????? ????????? ???????? ??? ???????? 0.83
• ?? ???? ??? ??? ???? ???? ????? ??????? ????
  ??????

30
??? ?? ??? ??? ??????? ??????? (3)
Et al, BMJ. 2001 Feb 24322(7284)460-3., ickH
Mumps, measles, and rubella vaccine and the
incidence of autism recorded by general
practitioners a time trend analysis

• ???????, ?? ??? ??????? ??????? ?????? ??????
  ?????
• ?????? ????? ???? ?????? ????
  ??????? .....

CONCLUSIONS Because the incidence of autism
among 2 to 5 year olds increased markedly among
boys born in each year separately from 1988 to
1993 while MMR vaccine coverage was over 95 for
successive annual birth cohorts, the data provide
evidence that no correlation exists between the
prevalence of MMR vaccination and the rapid
increase in the risk of autism over time. The
explanation for the marked increase in risk of
the diagnosis of autism in the past decade
remains uncertain.
31
??????? ?? ????? ?? WAKEFIELD

• ????? ????? ?? ????? "????" ?????? ?? ?????? ??
  Wakefield ???' ?- Lancet ?? ??? ??? ????? ?????
  ???????, ?? ??? ?????? ????? ?? ???? ??????
  ?????? ????? MMR ?????? ?? ??????.
• ?????? ????? ?- 18 ??????? 2004 ?????? ?????
  ?????? Lancet ?? ??? ??????? ?????? ??.
• ????? ?? Wakefield ???? ????? ?? ??????, ?????
  ?????? ????? ????????? ??? ????? ???? ???? ????
  ????.
• ?????? ?? Wakefield ?????? ?? ?????? ???
  ???????
• ????? ?????? ?????? ???? ????
• ??? ??? ?????? ?????? ??? ???? ????? ?????
• ?????? ?? ??? ??????

32
????? ?? ??????? ?????? ???????? ??????? /
??????? ?

• ????? ???????? ??????? ????? ????????.....

???? ???????, ????? ?????? ??????
33
????? ???????? ?????? ????? ?????? ????? ?-
100,000 ????? ?? ????? ????, ????, ?????????-
?????, ??????- ????? (????? ???' ?????????????
????? ??????? ?? ?????? ??????? ????? ???? 2003)
?? ??????
34
Dysentery in U.S., 1955-93 No Effect of
Improved Hygiene
35
Typhoid Fever in the U.S., 1971-2001Effect of
Improved Sanitation ?
36
Meningococcal Disease in the U.S., 1955-93
Effect of Improved Nutrition Less Crowding
37
????? ??????? ?????? ????? ????? ?????
MMR
MM
?- 1985 ???? ???? ????? ?????, ?????? ?????
???????. ?- 8 1987 ?????? ????? ?????, ????
???? ???????. ????? ???? ??????? ?????? ?????
??????
38
??????? ?? ???? ????? ??? ???????

• ??? ??? ???? ? 700,000 ????? ????? ?????
• ????? ????? ???? ?? ???? ?????? (AIDS), ?? ?????
• ????? ? BAVARIA ??????? ???? 2002 ?
  1,000 ???? ???? ?????? ????? ?????? ???????? ?
  76
• ??????? ???? ???????? ????? ??? ?????? ??????
  ??????-??? 2003

39
COMMUNITY (HERD) IMMUNITY "?????? ????"

• ?? ???? ?????? ?????
• ?? ? 90 ?????? ?????????

40
?????? ?? ??????? ?????? ????? ???????

• ???????? ?? "?????? ????" ????????? ?? ?? ???
  "??????" ?????? ???? ?????? ????? ?? ?????
  ??????? ????? ???? ????? ????????, ????
• ????? ?????? ???????? ????? ?????????
• ????? ?????????, ???? ????? ????? ??????, ?????,
  ?????? ????, ???????, ??????? ????? ???????
  (????? ??? ??? ??????...) ????? ?????? ?????
  ?????
• ????????? ?? ???? ????? ????? ?????? ?- 2002
  ????????? ?- 2003 ????? ?????? ?????? ???

41
?????? ?????? ????????(1)

• ??????? ??? "?? ?????"
• Moral Imperative
• ??? ??????? ?????? ??? ?????? ?????? ????
• A Human right"

42
?????? ?????? ???????? (2)

• ??? ???? ????? ??????? ?????
• - ????? ?????? "????? ??????", ?? ???
• ?????? ??????
• ??? ??????? "?????? ????" ?? ??? ?? ????????
• ??????? ??????? ??????

43
????? ?????? ?????? ????????????

• ?????? ????? ???????????? ?????? ???, ????
  ????????? ???? ?? ??????? ?????? ????????????,
  ?????? ?? ?????? ???????????? ????? ????? ?????!
• ??????? ?????? ???????????? ?????? ?????????,
  ????????? ????
• ????' ?????? ????? "....??????? ??? ????? ?????
  ???? ????????"
• FEVER IS NOT A CEFUROXINE DEFICIENCY STATE"

???????? ??????? ????? ?? ?????? ????????????
44
????? ??????, ???? ???????

• ???????? ??? ?????????? ??????? ?????? ?????
• ???????? ??? ?????????? ??????? ?????? ?????
• ?? ?????? ????? ????????
• ???? ?????? / ?????? ?????/ ??????? ???????
• ???? ???? 1 ?? ?????? ?????? ???? ??????

45

• ????? ?????? ??????
• ???? ???????
• ???? ???'? ??? 2004