On May 15, 2021, Israel decided it had conquered COVID-19 and did away with the last restriction – the mandate to wear masks in closed spaces. The decision, which came two weeks after the cancellation of the Green Pass and as part of the de facto disbanding of the Magen Israel program (the national COVID-19 command and control center), was based on accumulated evidence to wide population protection – reaching close to herd immunity.
Indeed, a steady, exponential decline in infection and illness over a period of three months, despite a gradual lifting of all the restrictions, led to a welcome historic low in infections as well as two consecutive weeks without a single person dying from the virus in Israel.
Three months later, incidence rates are once again among the highest globally: 1,000 new cases a day per million in the population, and about 20 people dying every day – about one sixth of the expected daily death toll during this season. How did we reach this point and what can be done from here on?
A perfect storm
The high vaccine uptake rate we reached in June was a direct result of the world’s fastest vaccination campaign. The over tenfold reduction in the risk of being infected (and infecting others) among those vaccinated was established in Israel not only in large retrospective studies published in the highest-tier medical journals shortly after vaccination, but also in a broad, prolonged follow-up local study. In this study, Clalit Health Services conducted repeated PCR tests on over 1,000 vaccinated and unvaccinated health workers over several months – and it was shown that the vaccines prevent over 90 percent of infections, even after three months.
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Yet in the background were looming three critical vulnerabilities: the risk of the appearance of new and infectious variants; the risk of the weakening of protection from the vaccination; and the risk of the appearance of a new variant immune to the vaccine.
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And indeed, the protective effect of the two vaccine doses gradually was waning, and earlier than expected by the experts at the time. After the fact, we know that vaccine effectiveness weakened gradually until June, but this effect remained hidden, since in combination with the additional restrictions (Green Pass, masks, the activity of the Alon Command Center epidemiological investigations), the partial residual immunity was sufficient to suppress outbreaks driven by variants that were not highly infectious, such as alpha.
In June, the delta variant, which is 1.5 times as infectious as its predecessor, entered the hidden and widening crack in the population’s “wall” of protective immunity, caused by weakening vaccination effect and lifting of all restrictions. This triple combination of widespread waning immunity of a population vaccinated at the same time, the removal of restrictions in face of the usual crowded and proximity conditions in Israel, and the emergence of the most infectious variant to date led to unique circumstances – “a perfect storm.”
A nurse readies a Pfizer COVID vaccine at a clinic in Tel Aviv last week. Moti Milrod
We know what happened next. Delta became the dominant variant in Israel at record speed in the first two weeks of June, and led to an exponential increase of cases for eight consecutive weeks, until we reached the world record high incidence rates in which we have become “stuck” now with R=1, for weeks of waves of infection that have yet to die down.
It should be noted that not only are infection rates in Israel are high, we are also among the top of the list of in hospitalizations and deaths among developed countries.
It should be noted that because we were first in mass-vaccinating the population, the events taking place first in Israel are expected to repeat themselves this winter in every country that doesn’t implement in time the lessons that are currently being learned here at a high price.
Will the booster save us?
In an effort to avoid the restrictions on movement and assembly that would negatively impact on the economy, and in the face of the risk (that was actualized) of a continued spread of the illness, the Israeli government mainly set its sights on the campaign to administer a third dose of the vaccine, in the expectation of two main effects: first, reducing serious illness by vaccinating the elderly; second, an epidemiological barrier to curb infection spread by vaccinating the young.
The vaccination of the elderly (85 percent uptake to date) with a booster shot can already be considered a success. A sharp decline was registered in the rates of those aged 60-plus among the infected, from 15 percent in early August to less than 4 percent now. Studies, some of which have already been published, prove that the vaccine provides protection from serious illness, which is as good as we could have hoped for.
A young person gets ready to receive a COVID vaccine, in Tel Aviv last week.Moti Milrod
But on the level of the population as a whole, the effect of the step to reduce the total amount of serious illness is turning out to be limited so far, since vaccinated older people are now being replaced by unvaccinated young people, who continue to become infected in large numbers.
Over two-thirds of the cases of serious illness, 50 a day, are now found among the unvaccinated, half of them young people, and eight patients under the age of 40 are now connected to cardiopulmonary support machine.
These data call for attention to the following guidance: If you have been infected with COVID-19 and you feel ill for more than two or three days, or the fever doesn’t go down – don’t delay approaching your physician for assessment and advice. Do not rely on home self-therapy at that point such as oxygenators without the monitoring advised by the HMO. A delay in reaching the hospital, especially among the unvaccinated and at-risk populations, largely reduces the chances of recovery.
Much hope for curbing the wave of infections was pinned on giving young people a booster shot, but it is still unclear if that is a sufficiently powerful counterweight to opposing vectors, such as school year opening and this month’s Jewish holidays. The news from the United States about the recommendation of the FDA advisory committee to limit at this stage administering the third dose to people aged 65 and over and to younger people with existing medical conditions is not expected to help the local efforts at encouraging vaccinations among the younger population in the near future, though we can assume that there too, the recommendation will gradually broaden as more and more “veteran” vaccinated people reach the waning stage, exactly as happened in Israel.
A local modeler suggested 3 million as the threshold number of people vaccinated with a third shot that would bring about a sharp decline in infection. We reached 3 million vaccinated people last week. Let’s hope this prediction will prove to be accurate.
Stopping the wave
At this stage, there is seemingly no choice but to stop the spread with additional measures. The growing daily burden on the health system is bringing us closer to the point at which the burnout of health-care workers and the burdens of treatment will lead to a decline in the quality of treatment in schools and the community, and to an additional exacerbation in the cumulative price we are already paying in the health of thousands of seriously ill patients a month.
At the same time, and beyond the health-related aspects, the large number of those infected and quarantined every day is creating a significant burden on the economy (which will be felt with the return to work at the end of the month). This requires expensive tests on an increasingly large scale, and makes it difficult to activate means of stopping the spread, such as epidemiological investigations.
Nevertheless, what can be done in order to sharply lower the rates of illness and the complications?
* The most important thing is to increase the uptake of the first two COVID shots. Surveys have shown that most of this population is not opposed to vaccination in principle, but is hesitant, and epidemiological models point to this component as the most important for stopping the illness. This complex challenge requires better tools for public education, the publication of information and additional studies about the safety of the vaccine, and a reduction to the bare minimum of the effort required to get vaccinated – by means of vaccination stations at shopping centers, places of work, etc. It is important to inform the reluctant of the individual impact of the statistical risk. We have seen too many heartrending stories of families who are blaming themselves a moment too late.
* To complete the vaccination campaign with the third shot: 10 to 15 cases of serious illness are taking place daily in the population that became infected before having the booster. Although these vaccinated people did everything asked of them, they are now at risk and we must recognize that it’s impossible to bargain with the reality even if it isn’t fair. The reality is that after six months, there is a marked weakening in protection against serious illness, and there is the need for an affirmative step in the guise of another vaccination.
We don’t know yet if the third shot will provide protection for years, as with other vaccines, or whether it will weaken within months and require further doses. We must conduct a follow-up and repeated tests in order to enable an early warning this time around.
* The Green Pass that was designed to protect participants at mass events from becoming infected will have to be updated. In light of the record number of infections in the community, and in light of the data pointing to a significant decline (15-fold) in protection from infection among those vaccinated six months ago or more, it would be correct to require even those vaccinated people who are not interested in a third shot to present the results of a COVID-19 test in order to enter Green Pass sites safely.
* Temporarily, and until we attain a prolonged decline, it would be correct to restrict larger assemblies, especially in places that are not crucial for the functioning of the economy.
* The plan for operating schools will have to be upgraded, with planning for the return to studies taking a more cautious format. Stricter attention to ventilating the classrooms and widespread activation of the preventive testing schema among schoolchildren in high-risk areas are also needed.
Living with COVID-19
Ultimately, and after the fourth wave is halted, all will have to understand that we must live with COVID-19 for a long time – months and years. But living with the virus does not mean ignoring it and its consequences. The long-term objective of the government policy must, in my opinion, bring us safely (a minimum of cumulative serious illness) and economic prosperity (insofar as possible), to the point in which most of the population of all ages are vaccinated and protected when they encounter the virus. And they will. At that point in time, our encounter with the virus will be a natural booster shot.
The minority that is not protected because of a weakening vaccine or due to an insufficient reaction to the vaccine will by then receive the indirect protection provided by the immune protected majority, and the daily conduct of business (thanks to the Green Pass) will further reduce the risk of exposure in high-risk settings.
There will be a status quo in which the illness will be maintained at a low endemic level of infection, which preserves the immunity of the population with limited outbreaks from time to time due to immune-evasive and/or highly-infectious new variants, waning immunity, or a combination of the two. A meticulous border control policy is meant to identify and hopefully delay the entry of new variants and to buy precious time for dealing with any unusual incident of this kind. Serious illness will exist at lower rates and mainly be found among those who insist on not being vaccinated, who will bear the consequences of their decision.
In parallel, efforts to develop advanced and pioneering tools will continue, including fast and cheaper rapid home tests, an effective test to estimate the individual’s immunity level, an effective affordable medication to prevent complications among the ill, and a multi-variant vaccine that will reduce the fear of future variants and perhaps at the same time offer a solution for additional illnesses such as the flu.
I believe COVID-19 will not continue to be such a central element in our lives in this new Jewish year that just began. By joining forces, observing mutual responsibility, reliance on science and staying away from false information and fake news, we will be sure to overcome the challenges awaiting us.
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