A white tent was set up last week in the parking lot of Sheba Medical Center at Tel Hashomer; it has two rows of beds and a sign in Hebrew and English saying “men’s ward.” Right next to it is a cabinet containing disinfectants, gloves and masks. The tent was put up for those who will be diagnosed with the coronavirus, something the Health Ministry assumes is only a matter of time.
But the list of countries that the Health Ministry considers at risk is growing, and medical sources fear that Israel isn’t at all ready to handle an outbreak of the virus if it occurs. Efforts like the isolation tent in Tel Hashomer near Tel Aviv look meager at best.
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While the Health Ministry stresses that it’s closely monitoring the spread of the virus abroad, taking preventive measures and issuing daily bulletins and instructions, out in the field the uncertainty is rising. Interviews with medical professionals make clear that most have no clue what they’re supposed to do if the concerns become reality.
So far around 140 people in Israel have been tested for the coronavirus but all the results have been negative. If any of them had been positive, the consequences could be harsh for anyone around them. Sheba has put up another, smaller tent outside its emergency room, which admits everyone who arrives with suspicious symptoms and who has visited one of the “forbidden” countries.
“During the weekend storm the tent kind of went flying,” said Prof. Galia Rahav, the head of Sheba’s infectious diseases department. But even when it stands, it provides only a partial solution. “We have no place to isolate these patients until we get the lab results back,” Rahav said. “We send them to home quarantine to await the answer and we tell them by telephone.”
She said Sunday her people had already seen 11 patients with symptoms that morning, but there were days they had seen as many as 16. “Now, with Thailand coming into the picture, it’s turning into a catastrophe,” Rahav said.
Many hospitals have been handling suspected cases of coronavirus, but Sheba is at the forefront as the largest hospital in the center of the country, and the site of the only lab in the country that’s testing for the virus. On Tuesday the Health Ministry announced that in a few days three other medical centers will be able do the tests – Soroka Medical Center in Be’er Sheva, Hadassah in Jerusalem and Rambam Medical Center in Haifa.
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But doctors told Haaretz that now that Thailand is on the list of infected countries, the numbers of suspected infections here will shoot up, and Israel’s cities, towns and rural communities have to be set up for speedy diagnoses.
People in the health care system agree that not much is known about the coronavirus and how it spreads. Experts are grabbing every piece of information they can get – epidemiological surveys, case analyses, the virus’ genetic traits and reports of initial efforts to find a remedy – most of which are coming from China.
According to Dr. Yasmin Maor, director of the infectious diseases unit at Wolfson Medical Center in Holon, one thing known is that the average age of those infected is 56, and the average age of patients coming to emergency rooms with serious symptoms is 66. It is also known that the first week after symptoms appear is relatively mild, then the situation deteriorates.
“The rate of new cases in China is quick and the illness is very contagious, but when compared to the two previous outbreaks of corona the mortality rate is very low – 2 percent – compared with 30 percent for the MERS virus and 10 percent for SARS. So this is a milder disease,” Maor said. Those two viruses, like the current one, are three of seven viruses of the corona family that are known to science.
But while the virus is familiar, its characteristics are another story. According to Prof. Dana Wolf, director of the clinical virology unit at Hadassah University Hospital, Ein Karem, in Jerusalem, at this stage it isn’t clear what determines how virulent the virus will get.
“What we do know for certain is that a very important role is played by the virus’ interaction with us, the host,” she said. “One of the viruses’ damage mechanisms causes an overreaction of the infected person’s immune system, which can lead to what we refer to professionally as a ‘cytokine storm’ – a very serious inflammatory reaction that can cause serious pneumonia and total system failure. That’s the picture with some corona patients.”
Another question concerning researchers is the incubation period. Until this week the average was thought to be five and half days (with a range of two to 14 days). But a new report argues that the period can be as long as 24 days.
Meanwhile, the corona outbreak seems to be less common among children, and those who do get infected develop relatively mild symptoms. This might be good news for parents, but experts say this could make it difficult to stop the virus’ spread.
“The morbidity in children is the tip of the iceberg; they’re mildly ill and apparently we won’t identify them in most cases, which is why they can be spreaders of the virus,” said Dr. Michal Stein, director of the infectious diseases department at Hillel Yaffe Medical Center in Hadera. “We don’t yet know why the virus has mercy on children.”
No vaccine in sight
Despite the many resources devoted worldwide to combating the virus, key questions remain unanswered about its aggressiveness, survival on inanimate objects, and incubation and contagious periods.
“Even the most optimistic estimates don’t forecast a coronavirus vaccine in the coming months,” said Prof. Eyal Leshem, the head of the travel medicine and tropical diseases center at Sheba Medical Center. “Which is why we should use the existing and known means to contain epidemics – rapid diagnosis, immediate isolation and quarantine. The question is if Israel is capable of that.”
On the face of it, the containment and speedy termination of an outbreak are possible. The only question is at what cost. In February 2003, after the first case of SARS was identified in Singapore, the authorities reacted quickly.
“They managed in three months to contain the epidemic and end the crisis,” Leshem said. A mechanism to spot and quarantine suspect cases was set up, and all medical professionals at risk of exposure wore full protective gear at all times.
“Employees walked around with thermometer stickers and were required to report their temperature twice a day,” Leshem said. “They preferred to err on the side of caution: Anyone with a fever was instructed to stay home. In a short time they quarantined 12,000 people; only 60 of them were discovered to have SARS.”
Leshem added: “They approached it on the national level. Even their secret service was part of the operations.”
Israel seems ill-equipped for Singapore-level containment and its economic, legal and ethical ramifications. The gap between Singapore’s efficiency in 2003 and Israel’s today might be wide especially regarding the flow of information to medical professionals. While hospitals are getting into the rhythm of testing for the coronavirus, at community clinics doctors are concerned about their safety and the safety of the staff.
“We don’t know if we’re sitting across from asymptomatic carriers or not,” said Dr. Ian Miskin of the general practitioners’ union. “In a situation like this, it’s very hard to be a family doctor, and I have no way to help.” According to Miskin, a clear protocol must be established that would also reduce the patient load in hospitals. “For instance, they should set up a pavilion at Teddy Stadium in Jerusalem and test for the virus there,” he said.
While the Health Ministry is focusing on the national level – tracking developments worldwide, issuing travel warnings and updating the media – medical professional believe the efforts on the ground are lacking.
“We have precious little time to organize and we must use it,” said Prof. Hagai Levine, head of the union of public health doctors. “In outbreaks like this, the rule of thumb is to be as prepared as you can while leaving some room for flexibility. We must take into account that we will suffer some losses.”
According to Levine, there are many steps authorities can and should take. “Now’s the time to organize and drill the teams and look into the possibility of setting up mobile teams for rapid diagnosis,” he said. The authorities must decide whether to instruct the public to wear face masks when entering a clinic or whether separate entrances into medical facilities for symptomatic patients must be set up.
The coronavirus crisis has caught Israel’s public health services at an unprecedented low after years of neglect. As Levin put it, “Even if the prime minister gave orders to develop a vaccine and Israel manage to do that, there won’t be anyone to give it out to the people in including school kids.”