With newspaper headlines announcing “Israel’s worrying fourth wave” and “Israel, Once the Model for Beating Covid, Faces New Surge of Infections” concerns are growing that vaccination will not be as effective as hoped in helping us emerge from the COVID-19 pandemic. (1) (2)
At face value, the resurgence of cases in a country that was at the forefront of the vaccination roll-out would seem to suggest that the vaccines are not working as well as expected.
However, as is always the case with headlines, they aim for attention rather than scientific accuracy.
The main thrust of media reporting is that Israel now has one of the highest infection rates in the world, a worrying trend in what is regarded as one of the most vaccinated countries in the world. Alongside this, deaths from COVID-19 in Israel have risen over the past month, especially in those who received early vaccinations. So just how bad is it now in Israel? And what does this mean for the rest of the world?
The Real Figures
Vaccinations
Has Israel vaccinated more of its population than any other country in the world?
The short answer is “No.”
63% of Israelis have received one dose of vaccine, 68% are double vaccinated. Most of the Palestinian people in the West Bank and Gaza are yet to receive any vaccine.
In the UK 61% of the total population have received one dose, 70% are double vaccinated. In the USA the figures are 51% and 60% respectively. Most of Western Europe, including France, Italy, Portugal and Spain have vaccinated a higher percentage of their populations than Israel. (3)
(NB all these percentages are for the total populations of each country, not adults only.)
To be clear, Israel remains at the forefront of vaccination rollouts but it sits alongside many other countries when the data is correctly analysed, rather than ahead of them. When the media claims that it has vaccinated more of its population than anywhere else in the world it is simply not true. They are in fact in a very similar position to the UK and the UK is also dealing with a surge in its cases, primarily because of the Delta variant.
Cases and Deaths
The Worldometer data for Israel shows two large peaks in case numbers in September 2020 and February 2021. Both peaks were accompanied by an associated peak in the number of deaths. (4)
Case numbers are now climbing again to the same levels seen in these previous waves but the ratio of cases to deaths has improved with far fewer associated deaths. The graph for the death figures appears steep but it has been sat at zero for much of July making the increase look more dramatic than the reality. In terms of the number of deaths per one million people, Israel is in 79th position worldwide, much lower than many other places including the UK, Europe and the USA. (5)
The Implications of the Israeli data
Time between vaccine doses matters
Although the data shows that some of the more fear-inducing headlines are not grounded in reality, the fact remains that Israel (along with the UK and many others) is seeing a surge in COVID-19 cases despite running a successful vaccination programme.
Israel is unique in that its entire vaccination programme has been with the Pfizer vaccine. Israel secured early access to the Pfizer vaccine in exchange for sharing all its data on the outcomes of its use. This has allowed detailed analysis to take place about the effectiveness of the Pfizer vaccine.
The trend emerging is that six to eight months after the second dose is given, immunity starts to drop off, particularly in the elderly. However, as the elderly received their vaccines first it is too soon to know if this drop off will be replicated in younger people.
The Israeli Health Ministry have released a tentative figure for the Pfizer vaccine offering 55% protection against severe illness from the Delta variant in those who received their second doses in January. However, this figure is open to debate with other researchers saying it may still be around 80% effective at preventing serious illness. Because the overall numbers of serious illness in the double vaccinated remain relatively low it makes it harder to identify solid trends in data. (6)
The UK, like many countries, has rolled out its vaccination programme with multiple vaccines. The UK is currently using Pfizer, AstraZeneca and Moderna. The results for Israel’s vaccination programme cannot easily be extrapolated to other countries. It is possible that the immunity from the AstraZeneca and/or Moderna vaccines could prove more long lasting, we simply don’t have that data available yet.
It is of particular note that the vaccine protocols adhered to in Israel for the Pfizer vaccine had significant differences to those in many other countries, the UK included. The Pfizer vaccine was administered as two doses three weeks apart in Israel, in keeping with how Pfizer carried out their vaccine trials. Several countries, the UK included, extended this gap to 12 weeks in order to reach as many as people as possible with a first dose. It is now clear that this longer gap between doses increases the immune response. (7)
Unlike the AstraZeneca vaccine (which was trialled with different time intervals between its two doses) Pfizer had not compared longer and shorter gaps between doses so it was logical for Israel, as the first country to use Pfizer, would adhere strictly to the dosing protocols. However, with the benefit of hindsight, we now know that this may have diminished the immune response of recipients. (8) (9)
Immunity from prior COVID-19 infection may not be sufficient to offer long term protection
An Israeli study early on in the pandemic boosted the belief that people who had already been infected with COVID-19 mounted a much stronger immune response after their first dose of vaccine than those who had never been infected. Researchers at Bar-Ilan University found that people who had had COVID-19 mounted the same immune response to their first vaccine dose as that seen after the second dose in people who had never been infected. (10)
It was therefore recommended that people who had recovered from COVID-19 should not be vaccinated. (11)
We now know that people who have had COVID-19 infection and/or received only one dose of vaccine are not fully protected. Two doses of vaccine are needed. (12)
The clinically vulnerable and older people should be prioritised for vaccine boosters
The Israeli Ministry of Health prioritised medical staff, nursing homes for the elderly and their caregivers and people over the age of 60 living in the community at the start of its vaccination roll out. A lower priority was given to people in known at-risk groups such as those with diabetes, immunosuppressed patients, the recipients of organ transplants and cancer patients.
Israel was not the only country to do this, the UK also prioritised by age but started vaccinating the clinically vulnerable once it had done the over 75s. (13)
Israeli doctors are finding that the current serious COVID-19 cases are mostly in older patients with underlying medical problems.
The majority of the double vaccinated patients in hospital with COVID-19 have several things in common. They were vaccinated at least five months ago, are over the age of 60 and have serious underlying health problems such as diabetes, heart and lung disease and cancers. In light of this, Israel began offering booster doses to all people age 60 and over in July 2021 plus its clinically vulnerable people.
Speaking to Reuters, Noa Eliakim-Raz, the head of the COVID-19 ward at Rabin Medical Centre in Petach Tikva, said: "The vaccinated patients are older, unhealthy, often they were bedridden before infection, immobile and already requiring nursing care, whereas in contrast the unvaccinated COVID patients we see are young, healthy, working people and their condition deteriorates rapidly."
It is difficult to know how many of the infections in the vaccinated are happening because their immunity has waned with time or if their health problems pre-disposed them to infection. The Delta variant is also complicating the overall picture.
The UK and USA, who both have similar vaccination rates to Israel, are also seeing a spike in infections, again primarily in the over 65s with health problems, because of the Delta variant.
The data about booster shots in Israel is promising, they appear to be reducing the risk of infection in older people. Doctors are also finding that those who have been double vaccinated, even if they need intensive care, are recovering quicker than those who have not been vaccinated at all.
Yael Haviv-Yadid is the head of the critical care ward at Sheba Medical Centre near Tel Aviv and told Reuters: "The vaccinated patients I've treated usually left the ICU in about three days. The unvaccinated patients took a week or two until they stabilized." (14) (15)
In Conclusion
In many ways the data coming out of Israel is telling us what we already know - that vaccines alone will not eradicate COVID-19 and the elderly and clinically vulnerable are most at risk of serious illness. However, despite cases of COVID-19 occurring in people who have been double vaccinated, the vaccines continue to offer a high level of protection against serious illness and death and the vaccinated are still far less vulnerable than those who have not been vaccinated even in the face of the Delta variant.
