Israel’s Massive Immunization Campaign Pricked By Soaring COVID-19 Infections 
Drop-in testing COVID-19 clinic in the ultra-orthodox Jewish city of Bnei Brak; Defiant ultra-Orthodox communities resisting lockdown restrictions are  driving a virus surge that is confounding a successful vaccine campaign.

JERUSALEM – As the countries around the globe watch Israel’s massive COVID-19 vaccine rollout to see if it can really beat back the virus, once soaring hopes that vaccines, on their own, could offer an easy way out of the pandemic are now coming back down to ground.

On the positive side, the vaccine itself appears to be about as effective as reported in clinical trials.  And yet at the same time, new COVID-19 cases reached yet another record of 10,000 new infections daily this week in Israel – which now has the dubious honor of boasting one of the highest infection rates per capita in the world. The infection surge led to a government decision on Tuesday to extend a lockdown in effect until 1 February. 

The virus is running rampant, despite the fact that nearly one quarter of the Israeli population have now received at least one dose of the vaccine – and health officials are trying to figure out why. Some have blamed it on the fact that most peole have only been administered one dose so far, others have attributed it to the rampant violations of social distancing rules among the ultra-Orthodox Jewish community.  Another factor is likely the many Israelis who returned from abroad over the past month, passing unchecked, through the airport – with the virus. 

The lesson to other countries, however, which is emerging, appears clear.  Vaccines are important tools – but they will not curb the pandemic on their own, at this stage. In fact, they have to remain part of a broader strategy that includes the so-called “non-pharmaceutical measures” like masking and social distancing.

Efficacy of First Dose Now Under Debate

Initial analyses of some 460,000 Israelis vaccinated have suggested that the first dose was providing roughly 50-60% protection – but only after two weeks.  Still, health officials yesterday were suggesting the protective quality of the first dose may be less than previously believed- although they didn’t offer concrete data to back that up. 

“Many people have been infected between the first and second injections of the vaccine,” Nachman Asch told Israel’s Army Radio station, adding that the first dose seemed to be  “less effective than we thought” and “lower than [the data] presented by Pfizer.”

Israel has the higest vaccination rate in the world, by far – but it also has one of the highest rates of daily infections .
More than 80% of Israelis Over Age 70 Received One Dose 

As of Wednesday, a total of 2.3 million out of 9 million Israelis had received the first dose of the vaccine to date. And nearly half a million people had received both doses, according to Israel’s Health Ministry. More than 80 percent of Israelis over 70 have received at least one dose of the vaccine, along with 68 percent of those aged 60 to 69, and 50 percent of those aged 50 to 59. 

Among those fully-immunized, efficacy appears to be reassuringly high – in the 95% range as per Pfizer’s clinical trial results. In one study of 1,000 health workers by Tel Aviv’s Sheba hospital, a group heavily exposed to the SARS-COV-2 virus,  protection was as high as 98% after the second dose. 

Confidence in the vaccine’s safety record has also been such that Israel’s Ministry of Health on Wednesday began recommending that pregnant women at risk of COVID-19 exposure be immunized – even though Pfizer’s clinical trials didn’t include pregnant women at all. 

The decision was defended in light of the fact that numbers of COVID- positive pregnant women being hospitalized in critical condition has doubled from December to January. 

The trend of more serious cases in pregnancy, however, is only a small part of a larger picture that has seen Israel’s rate of new SARS-COV-2 infections rise to become one of the highest per capita in the world. 

Per capita, Israel rates of new cases are now second in the world, only to Spain, and higher than the United States and United Kingdom, which was the first to report the appearance of a new, and more infectious coronavirus variant.
Vaccine Supply Chain Oiled By Novel Data-Sharing Agreement With Pfizer 

The  infection rate has been rising – despite the stunning achievement of Israel’s national health system, in which its four public health maintenance organizations, managed to get first vaccine doses into the arms of nearly one quarter of the population in just one month. 

The impressive vaccine campaign has been facilitated by large and frequent supplies of vaccines from Pfizer – in exchange for an Israeli commitment to share data about safety and efficacy – as some 60% of the population, or 5.2 million people, are vaccinated by the end of March. 

Israeli officials were quick to underline that the agreement with Pfizer, published this week in a redacted form, commits only to providing Pfizer with data disaggregated by age, gender and ethnic identity – but safeguarding individuals’ private medical information.   

Among most Israelis, keen to get vaccinated and see life return to normal, the milestone understanding was met with only mild interest.  In any case, digitized records of every Israeli’s medical history are maintained by the four national health funds that provide universal health coverage.  And that data is constantly being scrutinized by teams of local researchers, looking at trends and risks. 

But the accord, handled by the Prime Minister’s office without any invovlvement of Ministry of Health professionals, was not without criticism in some quarters. Professor Eyan Friedman, chairman of Israel’s Helsinki Committee,the statutory body that reviews proposals on human medical trials, initially protested that the agreement should have been submitted first to the Helsinki Committee.  In a follow-up statement, he hastened to add that he supported the vaccine campaign. 

“It is vital to make clear that we support the Covid-19 vaccination effort, only that we ask that the rights of Israeli citizens are protected under the deal struck between Israel and U.S drugmaker Pfizer,” said Friedman, in an interview with an Israeli biotech magazine

Variants & Defiance Of Lockdown Restrictions Now Driving Virus Surge 
Waiting after vaccination at Tel Aviv’s mobile vaccine station operating in a large city partk.

Such debates have also been perceived as largely academic in light of the way that the virus, and its new variants, have been rampaging through unvaccinated groups with ever greater speed and ferocity.  

While the common wisdom held that once older, more vulnerable people were largely vaccinated, serious cases would decline because younger people don’t become as sick, Israeli hospitals have remain packed. Intensive care units are treating nearly 1,200 critical cases, well above a “red line” of 800 set by the government months ago.  But as cases rises so steeply in absolute terms, the virus is still managing to surcharge the hospitals,hitting more and more younger people, as well as pockets of older people who haven’t been reached by vaccines. 

International Travel as a Virus Vector 

It has been estimated that some 25-30% of cases in Israel may also now be due to new COVID-19 variants, imported by wanderlust Israelis returning from abroad. Israelis traveled to and returned from the United Kingdom, Europe, the United States and Latin America – around the fall and winter holiday seasons.

And in a brief interlude, after the establishment of diplomatic relations, when travel was permitted between Tel Aviv and Dubai, Israelis on weekend trips where they shed social distancing inhbitions altogether, returning with still more COVID-19 infections, including the 501Y.V2 varian, first identified in South Africa. The only requirement for returnees was a declaration of quarantine – which many people violated. Only yesterday, did the government finally decide to require anyone entering the country to present the results of a negative COVID-19 test before boarding a flight – following on from new US Centers for Disease Control guidance.

Ultra Orthodox Jewish Groups Defiant In Mass Gatherings & Crowded Schools

But it is not travel or variants alone, that are responsible for the coroavirus surge.  Health officials also are pointing the finger at the small, but significant sectors of the ultra-Orthodox Jewish public that have resisted social distancing and lockdown orders. Although the ultra-Orthodox only comprise about 10% of the population, they now represent some 30% of new COVID cases – three times their weight in numbers. Positive COVID test rates in some ultra-Orthodox communities are running at 20-30% – well above that in the rest of the population. 

The more extreme sects have confronted police in violent demonstrations and battles over COVID-related restrictions on in-person schooling and mass gatherings for prayers, weddings and other ritual events. Social media posts by indignant secular Israelis have documented the crowding that accompanied likely superspreader events, such as a recent wedding in the ultra-Orthodox city of Bnai Brak, attended by hundreds of people. 

Police enforcement in the ultra-Orthodox communities has, meanwhile, been restrained by political considerations – which are in turn driven by a government coalition where ultra-Orthodox parties hold inordinate sway over Prime Minister Benjamin Netanyahu. And Netanyahu is more dependent than ever on the good will of his ultra-Orthodox political allies  – as he stands once more for parliamentary elections to be held in March, following the collapse of a unity government coalition.  

Serious COVID cases are also higher among Israel’s Arab citizens – who make up about 20% of Israel’s population – but for different reasons. Higher overall levels of chronic diseases among older people leave them more vulnerable to serious COVID disease, officials explain. And vaccination rates have been lower than average – due to partly to greater vaccine hesitancy and partly to initial shortcomings in initial outreach – which health funds and Arab political leaders are scrambling to address. 

No Vaccines So Far – But Palestinians Infection Rates Remain Lower  
Infection trends in West Bank and Gaza show lower rates of new infections than in Israel and decline in new cases since mid-December

Paradoxically, rates of new infections in the Occupied Palestinian Territories of the West Bank and Gaza are far lower than those in Israel, and at least according to the official data, on the decline – despite the fact that the Palestinian Authority has yet to get access to any COVID vaccines. 

On Tuesday, 19 January, there were only 538 newly reported new cases among the roughly 5 million West Bank and Gazan Palestinians, according to the latest WHO data. 

That’s roughly one-tenth of the levels of new infections being reported daily in Israel, which has about 9.3 million residents.  The Palestinian Authority, which has limited health and intensive care facilities to care for COVID patients, in comparison to Israel, has placed the West Bank under periodic, strict COVID restrictions of its own, as has the Hamas government in the Gaza Strip.  

The close proximity of Palestinians – whose borders are tightly controlled by Israel, health services are less well equipped, and vaccines unavailable – to higher-income Israelis, where vaccination is in full swing but so are infections from both imported variants and local transmission,  illustrates yet again the complex dynamics driving transmission in other more and less affluent parts of the world. 

After peaking in early December, rates of new COVID-19 infections in the Occupied Palestinian Territories have gradually declined
Initial Palestinian Shipments of Russia’s Sputnik Vaccine Due to Arrive This Week

The Palestinian Authority is naturally keen to begin immunizing health workers and people at risk – both to ward off a surge like those being seen in Israel and to relax COVID social restrictions; the PA was thus due to receive this week its first dispatch of Russian-manufactured Sputnik vaccine doses, UN sources in Jerusalem confirmed to Health Policy Watch

That first symbolic shipment of 5,000 doses had initially been due arrive on Tuesday, after senior Palestinian Authority official Hussein al-Sheikh visited Russia last weekend, meeting with Russian Foreign Minister Sergei Lavrov and signing contracts for the purchase of the 4 million doses procured by the Palestinian Authority. But a technical glitch delayed transport at the last minute.  

 PA Ambassador to Russia, Abdel Hafiz Nofal told the Palestinian Ma’an News Agency that he expects the problem to be resolved by Friday.  A larger shipment of some 100,000 doses is also expected to be delivered in the next two weeks. 

Israel Says It Will Facilitate Delivery – But Not Responsible For Palestinian Health Services  

Israel has said it will facilitate the delivery of the Russian vaccine orders to the PA – but that health services for Palestinians are the PA’s responsiblity, in line with interim peace agreements signed in the 1990s.  

“According to the Oslo Accords and the Paris Agreement, the Palestinian Authority is solely responsible for health regarding the residents of the PA.  In fact, the Interim Agreements of 1995 explicitly mention the PA’s responsibility regarding vaccinations,” stated an Israeli spokesperson in Geneva.

Human rights advocates have said it’s not quite that simple. Those accords were meant to be interim arrangements, but Israel still controls all of the Palestinian borders – as well as occupying large chunks of the West Bank bank outright.  As an occupying power, it still holds ultimate responsibility for Palestinian health – particularly in a pandemic.  And the Oslo Accords, also call upon both sides to cooperate. 

“It is of course in Israel’s interest that the Palestinian population be vaccinated, and we will do all that we can to facilitate the transfer of vaccines the PA will obtain, either from COVAX or from bilateral agreements reached with pharmaceutical companies (a first shipment from Sputnik V vaccines should arrive today),” said Israel’s Geneva Mission spokesperson, responding to a query from Health Policy Watch. “Note as well that Israel is vaccinating thousands of Palestinians workers who enter Israel every day, especially those working in the health and education systems,” the spokesperson added. 

The Palestnian Authority is also hoping to receive more vaccine doses via the WHO co-sponsored COVAX facility, in the first quarter of 2021. 

Israel is also a member – but after ordering more than enough doses on the private market – its shares in COVAX, may be redirected, the Israeli Mission source said. 

“Israel has been one of the first States to join COVAX, because we indeed believe in the importance of equitable access to vaccines. Note that COVAX, which has not been joined by all WHO Members, does not prevent bilateral agreements to be reached with pharmaceutical companies. Moreover, all doses Israel won’t need from COVAX will be available to other populations.

“Israel supports international solidarity efforts against COVID, and especially the Facility. We hope it will promptly deliver doses, including to the Palestinian people.”

In the pandemic petri dish that this small slice of the world represents, the policies and politics around COVAX distribution will certainly be watched closely by everyone as well.

Image Credits: Israel Ministry of Health, Our World in Data, Our World In Data , World Health Organization, Eastern Mediterranean Regional Office .

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