Israel’s Year of COVID Vaccines: Fervor, Fatigue and Uncertainty

Ido Efrati
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Vaccines
Ido Efrati
Ido Efrati
Ido Efrati
Ido Efrati

December 12, 2020 may well be remembered as a milestone in the history of the coronavirus pandemic. On that day, the U.S. Food and Drug Administration gave emergency approval to Pfizer's COVID vaccine to be administered to those 16 and older. It was the first vaccine approved by U.S. regulators.

Israel's vaccination campaign began a week later, just as what was initially dubbed the U.K. variant – later relabeled alpha – was starting to spread. Israel’s rapid purchase of vaccines and its robust public health system allowed it to embark on an aggressive campaign to put shots into arms.

Since then, some 6.5 million Israelis have gotten at least one dose, 5.8 million of them have received a second one, and 4.1 million have received a booster shot. Nevertheless, the first year of vaccination has presented the government with no small number of challenges. A constantly changing situation and the emergence of new variants have shown how complicated it is to vaccinate a population and just how stubborn the virus is.

It's difficult to imagine what this year would have looked like without the coronavirus vaccine, but the future is also unclear. What new variants might emerge? Can the vaccines overcome them? What will the vaccination routine look like? How high is the price we’re going to pay?

December 20, 2020
The campaign begins
Then-Prime Minister Benjamin Netanyahu receving a vaccine, last year.

On the night of Saturday, December 19, then-Prime Minister Benjamin Netanyahu arrived at Sheba Medical Center with his health minister, Yuli Edelstein. They became the first two people in Israel to be given the Pfizer vaccine. “This is a small shot for a man and a big step for the health of all of us,” Netanyahu said, paraphrasing Neil Armstrong.

The vaccination campaign got underway the next day. At first, the vaccines were given to medical staff, people aged 60 and the immunocompromised. The first days of the drive saw other high-profile vaccinations – then-President Reuven Rivlin, military Chief of Staff Lt. Gen. Aviv Kochavi and senior healthcare officials – with the aim of encouraging the public to get a shot. At the time, the number of new confirmed daily cases was running at more than 3,000, mainly driven by the arrival of the alpha variant. That variant was 60 percent more contagious than the initial form of the virus. It took several weeks to determine the effect of the vaccines

January 2021
Vaccine hunters
Lines at a vaccine drive in Tel Aviv, in January.

The public demand for vaccines was strong over January, with more than 200,000 people getting the shot every day. Those under 60, who were not yet eligible for the vaccine, looked for locations where there were excess supplies of the vaccine in the hopes of getting a surplus dose that would have otherwise been thrown away. By the middle of the month, some 2 million Israelis were reported to have received a shot.

At the same time, however, a third COVID wave emerged, driven by the alpha variant. January became the worst month of the pandemic, with 1,440 people dying and more than 4,000 becoming seriously ill. The number of confirmed cases soared to more than 8,000 a day, and sometimes to more than 10,000. At the end of December 2020, a third lockdown had been imposed and was tightened further on January 8; only a month later did Israel begin exiting it.

Israel was the first country to quickly vaccinate a large part of its population, and thus data conclusively showing the vaccines' effectiveness outside of a lab had yet to accumulate. Rising numbers of infections caused many experts to worry that the vaccine wouldn’t be effective enough against alpha, since it hadn’t been developed with that variant in mind. But starting January on 20, the first signs of a drop in infection rates were seen, eventually becoming a clear and consistent downward trend.

February 2021
Signs of complacency
The coronavirus ward in Shaare Zedek Medical Center in Jerusalem, in February.

The number of new cases began to decline at the start of February, enabling the government to ease lockdown rules. But this coincided with a decline in vaccinations. About 40 days into the vaccine campaign, approximately 3.2 million Israelis had been vaccinated (1.4 million of them with two doses). In February, however, the number of people getting either their first or second shot dropped to about 110,000 a day. That wasn’t enough, especially since at the end of January people 35 and over had become eligible for vaccination, as had those 16 and over at the start of February.

“Every time we lower the age group, the response is reduced,” a senior official at a health maintenance organization (HMO) told Haaretz at the time. The explanation offered by experts was that younger people were less worried about the virus, and that in contrast to the early days of the drive, vaccine supplies were now plentiful. “There’s a psychological element at work here that didn’t exist at the start of the campaign,” said a source at one of the HMOs at the time. “People are saying to themselves, ‘It’s not urgent – I'll do it later.’”

April 2021
The third wave ends
A party celebrating the end of the outdoor mask mandate, in Jerusalem, in April.

The Israeli economy fully reopened as the third lockdown came to an end. The outdoor mask mandate was dropped and infections continued to decline to very low levels at the start of the month, when 52 percent of the population was vaccinated. Vaccination stations were now serving 20,000-30,000 people daily, a third of them first-timers and the rest coming for their second dose. The vaccination rate for those aged 50 and older was now 87 percent (with another 3 percent having recovered from the virus), but in the 16-19 age group, the rate was just 55 percent.

Meanwhile, the first cases of the delta variant emerged, but at this stage few were predicting the kind of surge it would cause.

May 2021
Relief and jubilation
A movie theatre in Jerusalem, in May.

May was the most optimistic month since the outbreak of the pandemic. After more than a year of illness, death and lockdowns, Israelis felt liberated. Everything appeared to be going according to plan. Some 55 percent of the entire population had received two doses of the vaccine, and more than 5 million Israelis now had a certificate confirming that. The number of new confirmed cases had fallen to just a few dozen a day.

This situation really had an effect on the vaccination drive: The sense of urgency on the part of both the healthcare system and the public dropped precipitously. At the start of May, close to a million Israelis aged 16 and up had yet to be vaccinated, including 250,000 people 50 and over. Vaccination stations were now serving at most a few thousand people daily. Over the entire month, fewer than 55,000 Israelis were vaccinated for the first time.

The trend continued into June, as Israel dropped virtually all its last remaining COVID restrictions. On June 6, only six new cases were confirmed, the lowest number since the first days of the pandemic. In the middle of the month, the Health Ministry ended the indoor mask mandate.

June 2, 2021
The vaccination drive is expanded
A vaccination site in Givatayim, in June.

The FDA approved COVID vaccines for young people aged 12-15 on May 11, and about three weeks later the Israeli Health Ministry extended eligibility to include 640,000 young people. The approval process had been delayed over what would begin to emerge as a significant issue – fears that the vaccine was causing myocarditis, mainly in boys receiving the second dose.

An expert team led by Prof. Dror Mevorach of Hadassah University Hospital, Ein Kerem was formed to study this phenomenon. It examined Israel’s entire vaccinated population and concluded that the link between the vaccine and myocarditis was strongest for those aged 16-19 and shrank progressively among older people. It also found that the side effect was mild in most cases and lasted no more than a few days.

A study published in The New England Journal of Medicine examined Israel’s entire vaccinated population through May 2021 and found that the frequency of myocarditis among those 16 and older was very low, with a total of just 142 cases. The researchers estimated that the risk for myocarditis in Israel's overall vaccinated population was one in 26,000 for males and just one in 218,000 for females. In addition, the researchers estimated that in the 16-19 age group, the risk of inflammation was one of 6,637 vaccinated boys and one in 99,853 vaccinated girls.

After vaccinations were approved for ages 12-15, the inoculation rate for that age group reached 60 percent (380,000 people).

June 18, 2021
Delta emerges
People being tested for the coronavirus in Binyamina, in June.

Several days after the mask mandate was lifted, the first warning lights went on. On June 18, the first case of the delta variant was reported at a school in Binyamina. Another 45 people who were infected as a result rapidly led to reports of an emerging fourth wave. Within a week, the number of confirmed cases had reached 300 a day.

With a contagion rate 60 percent higher than the alpha variant, delta (initially called the Indian variant) began spreading quickly in Israel. Delta presented a new challenge, as the fourth wave generated at its peak more than 10,000 new confirmed cases daily. The vaccination rate, on the other hand, was still 55 percent, making it difficult for Israel to contend with the new variant.

July 5, 2021
Concerns about the vaccine’s efficacy
A man being tested for the coronavirus at an assisted-living home in Jerusalem, in July.

The outbreak of the delta variant following a long period during which vaccination rates remained unchanged raised serious questions about its efficacy in the face of the new challenge. On July 5, the Health Ministry released worrying data showing that the vaccine’s efficacy versus delta was just 64 percent. At the same time, however, Britain was reporting 88 percent. In addition, Israel’s Health Ministry said the vaccine’s efficacy against serious cases was 93 percent.  

Initially, experts believed that the decline in efficacy was due to delta’s great virulence, but over time it became clear that the critical variable was a decline in its attenuation and a drop in the levels of neutralizing antibodies of the vaccinated some months after receiving the second dose. This was seen, for example, with the elderly, the first to be vaccinated, who suffered more cases with serious COVID symptoms. Research published in the following months showed a dramatic drop in antibodies and protection against COVID five to six months after the second dose. The decline was observable in all age groups.

August 1, 2021
A global precedent
Prime Minister Naftali Bennett receiving a booster shot, in August.
Prime Minister Naftali Bennett receiving a booster shot, in August.Credit: Kobe Gideon/GPO

Israel’s decision to begin administering booster shots set a global precedent, but it was accompanied by concerns and criticism that the FDA hadn’t yet approved them. Despite that, the experts warned that delaying a booster campaign would have negative repercussions. “The high risk of serious illness in older people is greater than any concern about administering a third dose or any side effects,” said one expert. Experts noted that 4,000 Israelis had already received a booster without any unusual reactions or serious side effects.

Other countries, whose vaccination drives began after Israel’s, weren’t yet feeling the decline in the vaccine’s efficacy. The World Health Organization even called for delaying booster campaigns, saying vaccines should first go to Third World countries, where vaccination rates remained very low.

September 2021
A COVID wave of the unvaccinated
An intensive care unit in Beilinson Hospital in Petah Tikva, in September.

The delta variant continued to infect many people even as Israel’s booster drive was underway. But by September and October a clear division was becoming evident between the vaccinated and unvaccinated. In contrast to previous coronavirus waves, more among the relatively young were suffering serious cases because they weren’t vaccinated or had been vaccinated with a second dose more than five months earlier.

On September 22, for example, 40 patients in life-threatening condition were placed on ECMO machines. Eight of them were in their thirties and the rest in their forties and fifties. 34 of them hadn’t been vaccinated at all, four with two doses and only two had been vaccinated recently enough to be considered breakthrough cases. At the start of October, the number of patients on ECMO devices had reached a high of 58, prompting concerns that the hospitals would soon reach capacity.

October 3, 2021
New Green Pass conditions
A demonstration against Green Pass restrictions, in Tel Aviv, in October.

Green Pass rules were amended on October 3 to reflect the new vaccine policy: the pass would only be given to those who had received a third dose or a second dose less than five months earlier. For the first time, the Health Ministry said people who had been infected with COVID would also be required to take one dose five months after they recovered. The new criteria caused 1.6 million vaccinated Israelis and 400,000 who had recovered from COVID to lose their Green Passes. Their status became vaccinated but past expiry.

November 23, 2021
Children vaccinated, too
A vaccination site in Rosh Ha'ayin, in December.

On October 29, the FDA gave emergency approval for the Pfizer vaccine to be administered to children aged five to 11. The low rate of infection in Israel and parents' concerns about inoculating their children prompted debate about the immediate need for child vaccinations. The Health Ministry launched an informational campaign and even held public hearings before convening a meeting with its vaccines committee and pandemic team to weigh the issue.

Child vaccinations were approved in Israel on November 10, and a national campaign got underway two weeks later. The drive has seemingly been conducted halfheartedly, and Prime Minister Naftali Bennett called the rate of vaccination “pathetic.”

November 26, 2021
Omicron reaches Israel
A COVID-19 testing area in Ben-Gurion Airport, in November.

The first case of the B.1.1529 variant, dubbed omicron, was reported in Israel on November 26. It spread rapidly due to its improved contagiousness (three times that of delta) and 50 genetic mutations, quickly putting the world on guard. Since the first identified omicron case in Israel, hundreds of others have been confirmed or suspected. Healthcare authorities believe that the numbers will continue to increase rapidly, and are working to raise the vaccination rate.

December 2021
What next?
COVID-19 vaccines, this month.

A year after Israel’s vaccination drive got underway, uncertainty about the future remains. Researchers across the world are trying to understand to what extent the vaccines protect against omicron and how much that protection depends on another booster shot. Initial findings show the vaccine's efficacy is somewhat lower than against the delta variant, mainly at preventing infection, but that its efficacy is much better at preventing serious illness. Initial research also shows that boosters continue to offer protection against omicron. At the same time, COVID patients report that omicron produces milder symptoms, but that has yet to be proven in research.

Despite attempts to predict the effects of omicron and the intensity of the fifth wave, Israel may now face a new reality. Three million Israelis are still not protected against the variant, complicating the fight against COVID and putting the country’s vaccine defenses to the test. It may be that the way of coping with the new situation is to amend Israel’s vaccine strategy to include a policy of customized vaccines or periodic vaccinations.

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