Some two months have passed since Israel established a special investigatory body to facilitate rapid epidemiologic investigations of confirmed coronavirus patients and a disruption of the chain of infection, a move hailed as central in the national plan for preventing further outbreak of the virus. But while the panel advising the National Security Council on the pandemic is trying to introduce this protocol, the Health Ministry appears reluctant to pitch in. Sources familiar with the matter describe intentional sabotage efforts that began even before the establishment of this external body.
Many people in the NSC, the defense establishment and the Weizmann Institute of Science who are involved in addressing the pandemic in Israel say the clashes have been there from the start. Some argue that public health officials resent what they see as a kind of trespassing on their turf by members of the external testing and monitoring program, which is currently led by a retired air force general, Eran Zeligman.
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Supporters of the program, however, argue that the recent transmissions that have been identified in students and staff members at a number of schools across the country underline the need for a system that can respond quickly to focal outbreaks. They say that a trained team can trace contacts to allow for focused virus testing that is effective and prevents testing laboratories from unnecessary overload.
The claim is that the Health Ministry is uncooperative, reducing the team's ability to become a significant force in taming the pandemic, at a time when a resurgence of localized outbreaks cries out for a swift response. Officials in many health agencies in the country say they've never heard about this program, while others question why it is needed.
It was only on Monday, weeks after the program's establishment was first discussed, that its members first met with the Health Ministry's district physicians, who are key figures in conducting epidemiologic investigations and curbing the spread of the virus in the community. The country's health maintenance organizations, which operate enormous testing laboratories and have the authority to approve tests, have not drawn up protocols for cooperating with the panel. Some have not yet met with members of the team.
The main purpose of the rapid response team – the creation of which was championed by the expert panel advising the National Security Council on the pandemic, led by Prof. Eli Waxman of the Weizmann Institute – is to sever the chain of infection within 48 hours at the most. The team is responsible for tracking down suspected patients, test them, conduct an epidemiologic investigation to determine whether they infected anyone else, and ensure they enter quarantine. The assumption is that every delay in tracing contacts widens the circles of transmission.
Health Ministry officials, however, have a different take on things. In a letter sent Monday by Prof. Siegal Sadetzki, the head of public health services at the ministry, to mayors and local council heads, she wrote that students or school staff members who came into contact with a confirmed COVID-19 patient will be tested for the virus four to seven days after their last contact with the patient "in order to allow for minimal incubation time on one hand and reduce the possibility of transmission on the other."
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Since mid-April, when the establishment of the investigating body officially began, the manner of its creation, composition and modus operandi were cloaked in secrecy. It is part of the new command and control center that has a mandate through the end of 2021 to prepare for and address any renewed outbreaks of the virus. The center reports to the director general of the Health Ministry and includes additional agencies, such as the Coronavirus National Information and Knowledge Center. The control center has been allotted a few buildings on the campus of Sheba Medical Center, Tel Hashomer. Plans call for its eventual relocation to Airport City.
"The team's role is to help the Health Ministry with monitoring and breaking cycles [of transmission], particularly when many people are involved, like in schools,” Health Minister Deputy Director General Prof. Itamar Grotto explained. "It is complex work that includes many players and coordination among 32 laboratories or between the [Health Ministry] district offices and the HMOs, which currently conduct most of the tests," Grotto added.
The team that set up the new testing and monitoring program was led by another retired Israel Air Force general, Ori Seiffert. "They made very thorough preparations that included assistance from industrial and management engineers," said a source closely familiar with the team’s work.
"The team did a thorough analysis of the single points of failure in the system," the source said, referring to aspects of the process where a failure would bring down the entire system, "and drew up flowcharts and processes that would allow the team to work like a uniform, well-oiled production line."
However, just days after his appointment, Seiffert announced that he was stepping down. A few days later he retracted his resignation. Sources attributed his decision to resign to a lack of cooperation from the Health Ministry's Department of Public Health. He recanted after news of his resignation was leaked to the media, but even after he returned to the post, cooperation from the department was partial at best. Sources say that from the earliest stages of the program's establishment it was rumored that department employees, including in the district offices, were given the message that they should avoid cooperating with Seiffert's team.
Seiffert recently completed his planned term with the team with the completion of the program's establishment. He submitted a report to the Health Ministry, which has not been publicly released, specifying necessary improvements to ensure that the the monitoring and testing program can severance of the chain of transmission.
The success of the program depends on proper coordination and cooperation among a large number of entities. It involves procurement, logistics, transportation, testing materials, epidemiologic investigations carried out by the district offices and locating the people whom the patients came into contact with. Then there is the administration of tests by HMOs, the Magen David Adom emergency service or hospitals, the shipment of the testing samples to the labs, and reporting of the results.
The vast scope of operations must be executed quickly, with minimum glitches and large amounts of information collected in real time to see the broader picture – beyond the information that a single patient can provide – in order to spot new outbreaks.
According to Prof. Avi Waxman, who headed the team that advised the National Security Council and supervised the team that advised the establishment of the external program, the current pace of testing is slow, the epidemiological investigations are lagging and inefficient and the information being gathered is not creating a reliable, real-time picture of the situation. Waxman stressed that a single entity is required to manage operations quickly and efficiently, adding that unless the necessary authority is delegated and can act rapidly, performing these investigations is virtually useless.
“A body that can provide a rapid response and break the chain of infection is essential in our situation,” Waxman said. “Carrying on with daily routine in the shadow of the coronavirus is dependent upon the behavior of the public and the capacity to halt the chain of infection within 48 hours. This capacity is essential to avoid a lockdown, and so the existence of such a body is crucial. Countries like South Korea and Taiwan handled the pandemic in the same manner, influenced from the lessons they learned from prior epidemics, including SARS.”
Waxman said that currently, the time it takes to complete the process — five days or more — is much longer than necessary. He added that the system is not sufficiently efficient given that for about 45 percent of patients the source of infection remains unknown.
“The main gap today is not in carrying out a specific step, but rather in the management,” he said. “To meet our goal of breaking the chain of infection within 48 hours and with an 80 percent effectiveness rate the entire process must be managed by a single body."
But Prof. Grotto took exception to the claim that the program is not working. “They’ve already been involved in several incidents,” he said. “It’s still in process and is constantly being improved.” About half of the efforts to sever the chain of infection are meeting the targets that were set, he said. “We would like it to reach 90 percent, but we’re still not there.”
Staff at the Health Ministry’s district offices were outraged by Waxman’s allegations that the pace of the epidemiologic investigations is slow. One doctor at a district office said she was “heartsick” by claims that their work is antiquated and ineffective. “The investigations are quick and professional and are completed within about 24 hours. We have dozens of dedicated doctors and nurses whose job is to deal with epidemics and who investigate both the coronavirus and the causes of other diseases that we deal with simultaneously, at the highest level possible – and they are being disrespected,” she said.
“I can say that at the level of our district, which is responsible for more than one and a half million people, things are running in perfect coordination with the local authorities,” she added. “I’m not opposed to coordination and assistance, but it’s not clear to me why so much is being outsourced. There are also computer and information divisions in the districts and a rapid response capability. Maybe it would have been possible to improve it with more staffing and infrastructure.”
Calling the external program “wasteful, inefficient and unnecessary,” Prof. Hagai Levine, who chairs the Israel Association of Public Health Physicians, expressed the view that rather than involving an outside entity, the existing system should be better staffed. “It’s the same logic as setting up a team of epidemiologists to oversee the operations of the air force to make it more efficient. We don’t need more managers and supervisors. We need more personnel and resources.”
Levine said the professional thinking behind the program is also faulty. “We don’t need just to ‘break the chain.’ We also need to identify coronavirus hot spots and to contain them.”