JERUSALEM – Racing ahead in a relentless vaccine campaign that has made it a global leader, Israel has now administered an initial COVID-19 jab to nearly 2 million people – about 20% of its population, including 70% of people over the age of 60.

And it is set to have some 5.2 million people completely vaccinated by mid- or late-March – after obtaining a commitment from Pfizer to rush millions more doses of its vaccine to the country this month – in exchange for fresh data on vaccine safety and efficacy from a country that is becoming the world’s largest live vaccine laboratory. 

While smaller in size than Los Angeles County, Israel’s population is ethnically highly diverse and has long been a popular place for medical research. Its largest communities of Middle Eastern Jews and Palestinian Arabs hail from the immediate region. But there are also huge populations of recent or distant immigrants from Europe and the Americas, as well as Asia and Africa. So researchers and policymakers elsewhere are also watching to see if the vaccines can really work their magic – in a place that also has been haunted by one of the highest rates of new SARS-CoV2 infections in the world.

Initial results coming out have good news and bad – suggesting that vaccine efficacy is high just two weeks after the first dose. But the data also suggests that a very high rate of overall immunization may be required to halt and reverse infection trends. Until that can happen, the reopening of schools and cultural activities will be cautious and staged, authorities warn. Continued adherence to social distancing guidance along with other restrictions on social gatherings, travel and economies may still remain sad facts of life for some time to come. 

And along with that, equity issues are in stark display here. Most of Israel’s 5 million Palestinian neighbors have had almost no access to the COVID vaccines. The exceptions have been the Palestinian residents of Israeli-controlled East Jerusalem who hold official Israeli residency and thus also belong to Israeli health funds. 

As a first-world country mixing daily with lower-income Palestinians, who live in a patchwork of West Bank areas controlled to varying degrees by the Israel military and the Palestinian Authority, as well as in Hamas-controlled Gaza, Israel may also have to learn the hard way that as per the maxim of WHO Director General Dr Tedros Adhanom Ghebreyesus: “no one is safe until everyone is safe.”

60% Reduction in Infections 13 Days After First Pfizer Dose – As Real World Results Begin To Emerge  

Looking forward, Israel appears set to maintain very high pace of vaccinations – administering between 100,000 and 200,000 doses daily – after clinching a deal with Pfizer for the expedited delivery of millions more doses from now through March.  While that deal was ostensibly secured in exchange for an agreement on data-sharing, in fact, Israeli researchers are already beginning to crunch the numbers on the vaccine campaign independently. And initial findings reflect both hope and challenges that lay ahead. 

On the hopeful side – a review of disease incidence among the first 460,000 Israelis over the age of 60 to receive the first dose of the Pfizer vaccine showed that infection rates among those getting the jab had dropped by 60% 13 days after receipt of the first dose. 

That research, conducted by the Maccabee Health Fund’s KSM Research Center, suggests that there is a strong protective quality even to the first vaccine – among older, and higher-risk groups. Another broader Israeli Ministry of Health analysis of data from all four national health funds that are managing the large-scale vaccine campaign yielded similar results – a decline of some 50% in SARS-CoV2 infections, two weeks after the first dose was received.  

At the same time, Israel is still seeing record rates of new infections daily – with over 9,600 newly reported cases on Wednesday. And among the most serious 1,000 COVID cases in intensive care, some 180 are people who had already received one vaccine dose, according to Israel’s Health Ministry. This reflects the fact that one dose on it’s own cannot guarantee protection from serious COVID disease – particularly if you were exposed to the SARS-CoV2 virus before you were immunized or shortly thereafter. 

“In the competition between the vaccines and the disease, the disease is still winning,” observed former Israeli Director General Moshe Bar Siman-Tov, speaking on Israeli television Tuesday evening. He said he had been ‘optimistic’ about the vigour of the vaccine drive, but was more cautious now. 

“On the one hand, the Health Funds, which have been around for about 100 years, are performing extremely well – you reserve an appointment, you come and get the vaccine. On the other hand, we have the rising rate of infections among young people and children, who were not supposed to be vaccinated at all.”  

Israel’s ‘Secret’ Formula  – Universal Health Coverage Simply  

If anything, Israel’s success in the vaccine rollout is based on key principles of Universal Health Coverage (UHC), anchored in community-based, primary health care systems, which the World Health Organization has been preaching about for years and aspires to extend to most countries by 2030. A sophisticated management of medical records and data has also been key – along with a ready available pharma capacity to support cold chain management. More specifically: 

• Public health funds are leading the drive. Every Israeli resident must belong to one of four public health funds. While these funds are heavily subsidized – people also get to choose which fund to join – and a small monthly membership fee is deducted from the paychecks of people who are employed. 
• While highly centralized – the four health funds are also deeply rooted in communities with primary health care branches. Every community has at least one clinic. Large towns and cities having multiple branches of all of the funds. The community-based system has enabled the creation of multiple vaccine distribution points – which are local enough to be accessible. 
• Central management has enabled huge efficiencies of scale. In larger cities, health funds and some hospitals have also set up vaccine stations in gyms, arenas, hospitals and public parks – ensuring ample space to receive and vaccinate large numbers of people everyday.  
• Digitalization of all Israeli medical records means that people can sign up to be vaccinated online, and their ID will immediately show if they are eligible (in terms of age), allowing them to book a slot. There is no need for a consultation – although people can of course turn to their health care providers first before they are vaccinated – most make a decision on their own to roll up their sleeves. 
• Quick-turn around is prioritized over personalized services – at vaccine delivery points, people simply read and sign an information form about potential allergic conditions before the jab – and then wait in a large room for 30 minutes after the vaccine to ensure there are no adverse reaction afterwards. 
• Supply chain and distribution logistics support from a large and experienced pharma firm – in this case Teva Pharmaceuticals – Israel’s generics pharma manufacturer. The support has helped ensure the superfreeze conditions required by the Pfizer vaccine to point of delivery. The involvement underlines a broader point on the importance of fostering domestic pharma industries to maintain healthy product supply chains. This is an issue that is gaining more recognition as a global health issue, and which WHO member states plan to discuss in more detail at next week’s bi-annual meeting of the WHO Executive Board, the organization’s key governing body. 

Vaccine Eligbility – Strict Criteria with Some Flexibility 

In terms of the thorny question of vaccine eligibility – strict criteria have been established – beginning with vaccinations for people aged 60+ and health care workers. But flexibility is proving to be an advantage – both in terms of efficiencies and vaccine acceptance.

For instance, Israelis who don’t meet the age limit have still been able to get vaccinated simply by hanging out at the vaccine stations at the end of the 12-hour day. The spontaneous vaccination of drop-ins when there are lulls or cancellations have helped boost vaccine acceptance in Israeli ultra-orthodox and Israeli Arab communities, where vaccine turnout was initially low – but a stream of younger vaccine wannabes have helped inspire turnout among older people in the same community. 

Along with older people, health workers and chronically ill people, Israeli teachers are now being prioritized in an effort to get children back to school as quickly as possible. As the immunization drive for teachers began, however, the vaccine age limit for others eligible was also dropped to 50.

“This makes good use of the vaccines available,” said the head of one Israeli health fund, Meuchedet (United). “Teachers are a limited group and they will come in spurts, so we don’t want to be wasting time or doses meanwhile.”  

Other countries are now looking at the Israeli model. In the United States, decisions by some states to begin expanding the eligibility criteria for vaccination were taken after informal consultations with Israel’s Minister of Health Yuli Edelstein about what that might mean. Edelstein has been sharing insights and advice with his European counterparts, where vaccine campaigns got off to a much slower start. 

Israelis are also watching Europe and pondering why the pace there has been slower – in health systems that are widely admired as a kind of global gold standard.

Explained Gabi Barbash, a former Ministry of Health director general as well as hospital director, and now a popular TV commentator on the virus and vaccine rollout: “More of Europe’s systems are based around private doctors’ offices – these aren’t as well equipped to receive and handle the vaccines,” explaining that such fragmentation also makes rollout more challenging. 

In addition, each Israeli health fund maintains a centralized medical data registry on every patient that is enrolled. That makes it comparatively easier to register people for vaccines, harder for people that don’t qualify to cut the line – and it also facilitates rapid assessment of vaccine results and trends in real-time.  

Some factors are clearly beyond the control of any government, however – including geography and weather. Israel is tiny and its population is small – particularly in comparison to the vast spaces and populations of Europe and the Americas where campaigns are advancing much more slowly. Most of the northern hemisphere (where most of the vaccine rollouts are taking place in the world’s richest countries) is also wrapped in winter. That has included snowstorms seen in places like Spain. In comparison, weather in the eastern Mediterranean region has been particularly dry and mild; some of Israel’s vaccine stations have even been set up outdoors in under huge tents.   

Success is Not Guaranteed  – Virus Variants & Geopolitics 

But even this massive vaccine drive, and gratifying public response, is still no guarantor of success. And this, experts say, illustrates how vaccines alone are not going to be a panacea for the COVID-19 pandemic.  

Nearly a week after declaring a strict lockdown, Israel was still seeing rising levels of new COVID-19 cases – reaching record highs.    

With new virus variants that were first identified in Great Britain and South Africa now surfacing here, as they have in Europe, Africa, Asia and the Americas, the country is also set to become a test case of whether the vaccine can hold against a wide range of new SARS-CoV2 mutations. Of particular concern are the mutations from the virus that may change the protein structures of the characteristic coronavirus ‘spike’ that could allow the virus to elude the vaccine. Those variants are now being closely monitored to see how widespread they become in the general population – and the extent to which they do or do not infect people who have been vaccinated.   

But one thing is becoming clear, and that is vaccinating older people may no longer be enough – thanks to the emergence of new and more infectious variants – that also infect younger people more widely. 

With the new mutations in play, vaccine rates would need to approach 80% or 90% to reach herd immunity, rather than the 70% of previous estimates, some researchers in Israel as well as in the United States are saying. 

“I was more optimistic, now I am a little more concerned,” said Bar Siman-Tov in his TV interview, who says that he is seeing “more symptomatic infections among younger people and children.”  

To halt the spread of those mutations, Israel may need to vaccinate almost everyone right down to the age of 16, the minimum allowed for the vaccine, said Eran Nir-Paz, a professor of infectious diseases at Jerusalem’s Hadassah Medical Center, in an interview on Tuesday with Israel public radio.   

“We will want to immunize 80% of the population to stop mutations and illness in younger groups – and if we don’t immunize the younger groups, the virus will eventually rebound on older people again,” he warned.  

Palestinians  – No Vaccine Access Yet 

In addition, even if 80% of Israelis are immunized, their next door neighbors, Palestinians in the occupied West Bank and Hamas-controlled Gaza, have not yet even begun to vaccinate – with questions still circling around how and when the Palestinian Authority (PA) will access vaccine supplies.   

On Monday, PA Health Minister Mai al-Kaila announced that the PA had authorized use of the Russian Sputnik vaccine produced by the Gamalaya Institute, along with that of the UK-approved Oxford University/AstraZeneca vaccine. All in all, she said that deals with three pharma firms to cover some 70% of Palestinians with vaccines had been signed.  

But she also threw cold water on reports that vaccines being procured by the PA from AstraZeneca – which is among the three COVID vaccines recently approved by the British regulatory authority – could arrive as early as 15 February. 

“There is not yet a definite deadline for the arrival of the coronavirus vaccine, although it is probable that they will arrive in the first quarter of this year,” al-Kaila said in a press relesase, 

Israeli and Palestinian human rights groups have meanwhile asserted that Israel has a legal obligation to ensure Palestinian vaccine access – under the Geneva Conventions that call for an occupying power to ensure the health and well-being of people living in occupied territories. 

However, Israel has claimed that the 1995 Oslo II Accord delegates the Palestinian Authority with responsibility for health care – even if Israel’s military controls large swathes of the West Bank.

The PA, keen to project its image as a national authority, has also not formally requested Israeli support. In fact, up until the pandemic, the PA had always imported its own vaccines for routine childhood immunizations – often via large procurement deals with UNICEF and other global health bodies.  

However, the Oslo treaty also obligates the two sides to “cooperate” in fighting epidemics – and that’s what many people say is now needed in the vaccine drive.

Israel says it has indeed cooperated in providing PPE and training to the PA. But mass vaccinations would require a whole new level of coordination – which also opens up thorny issues of Palestinian access to health services more generally.

Palestinian Access to Health Services a Longstanding Issue 

Current Israeli limitations on Palestinian movement around the West Bank – as well as into East Jerusalem, where more specialized Palestinian health services are located – have long been a barrier. Even more problematic is access in and out of the Hamas-controlled Gaza, under a longstanding Israeli military blockade, which Israel in turn says is needed to reduce the frequency of Hamas missile and military attacks.

“Israel might also be afraid that offering Palestinians vaccines might imply that it is taking a responsibility that would extend to other health services later on,” speculated one leading human rights advocate.  

According to one report, about 100 vaccines have indeed been shipped to the PA for their highest-risk health workers – although that has been denied by both sides. 

In addition to the wider issue, there is also an appeal to Israel’s Supreme Court to get the government to vaccinate some 4,000 Palestinian prisoners who are being held in Israeli jails. Those vaccinations have been mandated by Israel’s attorney general – but the hardline Minister of Internal Security, Amir Ohana, has refused to implement the order.  

Another Supreme Court appeal, by the family of a missing Israeli soldier whose body is reportedly being held by Hamas authorities in Gaza, aims to bar Israel from facilitating Gazans’ access to vaccines at all until the soldier’s body is returned.   

Particularly with regards to Gaza, the appeal illustrates how deeply entangled vaccine access may become in geopolitical issues. 

“A big problem is the optics,” one source told Health Policy Watch, underlining how quickly the issue can become politicized by both sides. “Israel has been so successful with its vaccine programme and the Palestinians are left behind.” 

No One is Safe Until Everyone Is Safe – WHO Attempting to Mediate 

At the same time, some leading Israeli physicians and even some senior Ministry of Health officials have said that medical ethics and equity factors mean that Israel should help ensure and facilitate broad Palestinian vaccine access. 

Boaz Lev, a Ministry of Health official in charge of setting criteria for Israelis to access vaccines, told Health Policy Watch that, “while I don’t represent the government’s position in that respect, if you ask me as a physician, then I think that people should be vaccinated. It’s very important for Israel and for the Palestinians to be vaccinated. Period.” 

“Equitable access to vaccines is an issue everywhere – but here it is something very immediate,” said Gerald Rockenschaub, who heads up the WHO Office in Jerusalem for Occupied Palestinian territory – West Bank and Gaza, in an interview with Health Policy Watch. 

“What we are trying to do is to advocate for Israel to consider to closely collaborate with the Palestinians to facilitate vaccine availability on the Palestinian side, both for pubilc health and equity reasons. We obviously are in close consultations with both regional offices and with headquarters.”

He said that WHO had spoken recently with Israeli official sources about shifting some of the vaccines that Israel is receiving to Palestinian hospitals where front-line health workers are also facing high levels of COVID-19 infections and risks. 

“The initial feedback was that they are looking into it, but it requires some further discussion, also on their side,” Rockenshaub said. 

However, he added that “the discussions were before these new [Pfizer vaccine] supplies became available – we will also need to engage other levels of the Organization to facilitate the dialogue with the Israelis.” 

Image Credits: Israel Television N12 .