During the study period, the average total number of annual births in the Negev district in southern Israel was ≈15,000. Over 95% of the children in the district are born and receive medical services at the SUMC. In the Negev district, the Jewish and the Bedouin populations live side-by-side. The socioeconomic conditions and the lifestyles of the 2 groups differ, but both have access to the same medical services. The Jewish population, mainly urban, resembles developed populations, whereas the Bedouin population, formerly desert nomads in transition to a Western lifestyle, resembles developing populations, with a high occurrence of infectious diseases including pneumococcal disease and complex OM (6,7,9). Contact between the children of the 2 populations is rare. During the study period, ≈50% of children <2 years of age in southern Israel were Jews and 50% were Bedouins. Our data derived from 5 prospective active surveillance projects.

This study, initiated in 2011, included nasopharyngeal cultures obtained from healthy children <2 years of age who were brought to the maternal and child healthcare centers in southern Israel for vaccination. A nasopharyngeal swab specimen was obtained after parents gave written informed consent.

This study, initiated in 2009, included cultures obtained from the PER of SUMC. Each workday, healthcare workers obtained nasopharyngeal cultures from the first 4 Jewish and 4 Bedouin children who were <2 years of age, residents of the Negev, and brought to the PER for any reason (9). We defined 2 groups in that surveillance: carriage in non-LRTI (children seen at the PER for any disease except those necessitating chest radiography); and carriage in LRTI (children with LRTI from whom a chest radiography was obtained) (6).

The study population included children <24 months of age who were residents of the Negev region, received a diagnosis of acute conjunctivitis in a community clinic or at SUMC (either PER or hospitalized), and had a conjunctival culture sent to the Clinical and Microbiology Laboratory of the SUMC since 2009.

The study population included children <24 months of age who were residents of the Negev region and had OM judged to necessitate middle ear fluid (MEF) culture. Cultures were obtained by tympanocentesis or by swab of the external canal of children with acute (<7 days) spontaneous otorrhea. Most of the children had complex OM (nonresponsive, recurrent, spontaneous perforation, or chronic ear effusion) (7,12,13). Children found to have pneumococcal MEF isolates during 2009–2017 were included (7).

This nationwide study was conducted in all 27 medical centers routinely obtaining cerebrospinal fluid (CSF) and blood cultures from children <24 months old in Israel; sites included 26 hospitals and 1 outpatient health maintenance organization (14). This setting enabled us to cover all culture-confirmed IPD cases among the population of Israel and calculate national incidence. No CSF cultures and <1% of blood cultures were obtained outside these centers. Data in our study were for IPD episodes identified since 2009.

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