Three Waves, Two New Strains and 6,000 Dead: Israel's Year of COVID-19

Ido Efrati
Ido Efrati
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A visitor holds a coronavirus patient's hand in the coronavirus ward at Hadassah University Hospital, Ein Karem, earlier this year.
A visitor holds a coronavirus patient's hand in the coronavirus ward at Hadassah University Hospital, Ein Karem, earlier this year.Credit: Ohad Zwigenberg
Ido Efrati
Ido Efrati

Israel marked its first COVID-19 death on March 20, 2020 – Arie Even, an 88-year-old Holocaust survivor from Jerusalem, who died in Shaare Zedek Medical Center after he got infected and his condition deteriorated. In the days before his death, during which each infection was given a personal number, Even was designated “case number 45.”

By the end of that month, 19 more people died. Another 203 died last April. In the year since the first case, over 700,000 Israelis have tested positive for the virus, while on Sunday the death toll passed 6,000, equivalent to about 15 percent of the number of people who die of all causes in a normal year.

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Coronavirus death statistics over the past year have shown different trends. The reasons for the changes are many and varied. They reflect the learning curve for managing the crisis, lockdowns, stress on hospitals, impact of strains that got into Israel and of course the three-month-old vaccination campaign.

The third coronavirus wave in Israel brought record rates of infection, serious cases and deaths, as well as the third lockdown. January was the harshest month of the pandemic in Israel, with 1,444 deaths, and while that number fell to 900 in February, it was still the third highest monthly toll after January and the 957 deaths last October.

At Jerusalem’s Hadassah University Hospital, Ein Karem, one of the busiest hospitals handling the coronavirus, staffers have recently begun analyzing findings from the 4,000 COVID-19 patients it has treated over the past year, including the fatal cases.

“We checked the medical files of 150 coronavirus fatalities to examine how many of them died of complications from the illness, and how many were coronavirus patients who died of other causes,” said Prof. Dror Mevorach, head of Hadassah Ein Karem’s coronavirus unit. “We saw a steep rise in mortality during the third wave, when 90 percent of them had the British strain.”

An arrival gets a coronavirus test at Ben-Gurion International Airport, this week.Credit: Hadas Parush

The explanation for the rise in infection and mortality is attributed by many health system and Health Ministry officials to the arrival and spread of the British variant, which is known to be significantly more infectious than the strain that had been common here up to that point. The British strain, which now accounts for 90 percent of confirmed cases, sent the number of daily cases and the infection rate soaring, starting in December, to new records, and in turn serious cases and then death rates rose. The spread of the more infectious British strain not only had a statistical impact but also a clinical one, expressed by more serious symptoms and a faster rate of decline.

Mevorach said many factors explain the surge in deaths in early 2021, combining wider spread because of the British strain, more serious cases and the consequent stress on the hospitals. “If the death rate of hospitalized patients was about 6.5 percent during the first and second waves, that figure rose to over 10 percent during the third wave,” he said. “We saw many people with a very severe illness. Some waited too long at home before arriving at the hospital. For others, it developed very rapidly.”

Strains take over

The British strain, which is more infectious and likely more destructive, too, reached Israel at the end of 2020 and started spreading rapidly. Now responsible for 90 percent of new cases, it draws much interest in the health system. However, it was preceded by another mutation – called D614G – which includes changes in the protein surrounding the virus. An article published in the journal Nature last October described the D614G mutation as being more aggressive in replicating the virus “in human lung ... cells and primary human airway tissues.”

A medical worker prepares a COVID vaccine shot in the Jadeidi-Makr, this month.Credit: rami shllush

“In the findings of our samples, we clearly saw the processes of the mutations taking control and dominating,” Mevorach said. “We saw a clear rise from February last year through the summer of the D614G variant gaining control in many countries. It’s a domineering mutation but less significant regarding morbidity and infection. Starting last November, we saw the British strain’s dominating trend. There are many mutations, but what’s important in the end is if they dominate or not. If there’s a more aggressive strain but its presence is negligible, it has no dramatic effect on morbidity.”

Vaccination impact

Health system experts concur that vaccinations are effective and decisively impact morbidity. The health maintenance organizations have published many findings confirming this position. “It started with patients 60 and over, who’d had the highest mortality rates,” said Mevorach about the declines in morbidity, “and now it’s common in more and more populations.”

Mevorach said the change in the mix of ages among patients doesn’t indicate that the virus is targeting younger people or that young people are sicker, but rather that there’s been a reduction in infection rates among people 60 and over. “It’s not that 40-year-olds suddenly started dying and the disease had changed,” he said. “When we compared the average age of patients, we saw that it ranges around 50 to 53. We simply saw during the third wave many more patients, so the number of young people increased. The risk of death remains with older people.

Dying in rehab

According to Health Ministry statistics, 929 Israelis died of the coronavirus between February 4 and March 9. The average victim was 75 years old, compared to 82 years old during the first two waves. The median age was 77, compared to 79 in the previous waves. Among the victims, 582 had yet to receive a vaccine shot, 211 had gotten their first shot, 45 died within a week of their second shot and 91 died a week or more after the second shot. There has been a steady, steep decline in daily fatalities from the peak, when 76 people died in one day on January 24, to about 15 a day now.

Israel’s R factor – the number of people a person sick with COVID infects – has dropped to 0.78, a five-month low, a Military Intelligence report published Sunday shows.“There is greater consensus today among the doctors giving care regarding the treatment of hospitalized patients – there is more agreement about what can work better,” said the director of a coronavirus intensive care unit in a central Israeli hospital. “We understand today that there is still no way to control the disease with anti-viral therapies, and we need to deal with patients whose status gets worse even under treatment. We are doing this mainly by using anti-inflammatory drugs. However, there is still no unified protocol or full agreement among doctors regarding the dosage and timing of therapies.”

A woman wearing a face mask walks in Jerusalem, this month.Credit: Emil Salman

The director said it looks like vaccinations are a very meaningful step, and that his staff is seeing a very significant decline in serious cases and a change in the mix of ages. “The patients are younger, and we understood that the significant therapeutic steps have to happen at an early stage, before the lung infection worsens, and that the illness demands a string of treatments even after the patient leaves the ward for further rehabilitation,” he said. “The rehab ward is now dealing with patients arriving with a more profound, more serious illness than what they were previously used to. So we see continued mortality among rehab patients, sometimes deriving from other infectious diseases.”

According to Health Ministry statistics, there are currently 626 Israelis in serious condition – down from 750 two weeks ago. On Saturday 773 people tested positive for the virus, after 2.9 percent of tests conducted came back positive.At the end of February, the Health Ministry recorded a rise in the R factor from 0.83 to 0.9 in two days. The increase began about two weeks after preschools and lower grades reopened in areas where the rate of infection was lowest, and a few days after the second stage of reopening began with more children back in school and shops reopening.The rise in the infection rate was expected following the lockdown exit, which raises exposure to the virus. The spread of the British and South African variants and the absence of vaccination for children under 16 has refocused the attention of health professionals on the education system. Due to the high immunization rate among the adult population, the composition of those infected and critically ill in Israel changed last month. Children and adolescents aged 0 to 19 constituted more than 43 percent of all new patients, and those aged 20 to 39 constituted 35 percent of them.

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