We are 18 months into the coronavirus pandemic and the current situation – as has generally been the case for the entire period of the pandemic – is confusing. The number of seriously ill patients is still low and far from what would overload Israel’s hospital system, but the pace at which new infections are being diagnosed continues to rise.
The extent of the effectiveness of the vaccine against the delta variant is unclear and countries are taking different approaches to the situation. When it comes to decision-making in the face of uncertainty, it seems the fourth wave poses no less a challenge than previous waves.
But one thing is abundantly clear: Right now, in the absence of government decisions on restrictions and preventive measures, personal responsibility and individual decision-making by everyone in Israel are more important than ever.
With the help of Prof. Ran Balicer, who directs Clalit Health Services’ research institute and heads a panel of experts advising the Health Ministry, Haaretz explains the situation and the steps that should be taken to address it. (This interview was conducted last week.)
What is the situation with regard to the incidence of coronavirus infection in Israel at the moment?
“Despite the number of confirmed [infections] and patients, which are still small compared to prior waves, the delta variant is spreading exponentially, as we saw at the beginning of prior waves. The R number [the rate at which an average infected patient will infect others] as of last Wednesday morning was 1.42 – a high rate, which indicates an exponential spread in the number of confirmed infections, which means the multiplication of the number of [new cases] every period of just over a week.”
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On the other hand, we are being told that the number of seriously ill patients is stable.
“That’s not correct. At the moment, there is an exponential increase in the number of confirmed cases, which is multiplying itself every week to two weeks. And in the past two weeks, we’re also seeing it translated into seriously ill patients – to the extent that this can be seen in the current small numbers of seriously ill patients.”
The question that has to be asked of course is – what about the vaccines? They were supposed to prevent precisely this.
“If there weren’t vaccines, the rate of spread would have been much more rapid, the rate of confirmed cases and the pace of spread would have been much higher and faster, and more patients would have deteriorated into a serious condition.
“You can see what’s happening in other countries where the delta variant has arrived that are less vaccinated than Israel, such as Indonesia.”
So can it be confidently said that thanks to the vaccine, the rate of confirmed cases that result in serious condition is lower than in the past?
“Among patients who have been vaccinated and have gotten sick, we’re seeing that few deteriorate into serious condition, and also that vaccinated people get infected less. But this difference is eroding all the time, due to the pace of infection.”
Your name is on the original research published in the New England [Journal of Medicine] about such a high effectiveness for the Pfizer vaccine [a 94 percent reduction in infection and 92 percent in serious illness], but it’s already clear that that reality has changed and the effectiveness has declined. What are we really able to say about that at the moment?
“The entry into Israel of the delta variant has brought us to a new reality. The fact that the delta [variant] entered Israel via populations and regions characterized by a very high level of vaccination makes it difficult for us to properly determine the effectiveness of the vaccine at this stage.
“There was a supplement to original research on the original strain of the coronavirus, according to which in older populations and among those suffering from chronic illnesses, the vaccine was a little less effective – with prevention of serious illness of about 80 percent.
“The significance is that even if we were still [confronted] with the [original] alpha variant, the elderly would be less protected from infection. So we’re not totally surprised that in the circumstances of the delta variant, we’re seeing vaccinated people becoming seriously ill.”
As of now, it looks like ‘the secular wave.’ Most of the red cities [with high rates of infection] and orange ones [the category just below red] have been from among the general population.
“The initial mechanism of spread in this current wave was via people who had come from abroad to certain areas of the general population [as opposed to the Arab or ultra-Orthodox communities] and the disease spread there. There is no reason to assume that if the disease continues to spread, it won’t reach other locations.”
One of the assumptions being heard now is that the ultra-Orthodox and Arab communities have herd immunity because they became ill to a much greater extent and many of them are also vaccinated and also recovered [from COVID].
“I don’t think there’s a community in Israel with immunity to the delta variant. The immunity of a population consists of people who have gotten sick and recovered and whose immunity is very good and of people who have been vaccinated – and whose immunity to the delta variant we are still trying to gauge. What is clear is that the chances of vaccinated people getting infected is lower than those who are not vaccinated, and that if they do get infected, their chances of serious illness are lower – but not negligible. Therefore, if you belong to an older population [group] or have a significant chronic disease, it’s important to exercise caution even if you are vaccinated.”
Is there a great deal of uncertainty about the efficacy of the vaccines?
“The message is complicated, but it can be said with certainty that people who have been vaccinated are significantly more protected than those who have not – both in terms of becoming infected and becoming severely ill with the delta strain. It’s still hard to assess the extent of protection in Israel, but in the U.K. it is believed to be good.
“With all that, in a time when there is a great deal of infection in the community – and now there are many infections – the risk to the population at high risk is far from negligible. And so I call on them to use common sense. If, for example, you have to go to a large wedding in an enclosed space – think about it. If there is a chance of going to a place where there is a crowd – think twice. It’s also important to wear a mask.”
We have already seen that vaccinated people not only catch the delta variant, but they also infect others with it, even if to a lesser extent than the unvaccinated. But there have been no instructions for a vaccinated person who was exposed to a confirmed infected person regarding isolation, testing or even recommending means of caution. How can an outbreak be stopped this way?
“My recommendation to the cabinet regarding directives to vaccinated people who have been exposed was to conduct a differential policy: On the one hand, don’t isolate them; but on the other, they should be told not to take part in mass events and not to enter crowded spaces. Going to work or school is alright, but going to a wedding is irresponsible if a vaccinated person has been exposed to a sick person in their household.”
When the previous variant was dominant, we experienced a long period here of almost no infections thanks to the vaccines. It seems that the delta variant is much more infectious and the vaccine less effective against it. Does this mean that the state’s primary goal is to vaccinate as many unvaccinated people as possible?
“There is a strategic question of where everything is going. In my opinion, the virus, over a period of months or years, will catch up with us all eventually. The question is whether it will meet us vaccinated or not.”
And also, will it meet all of us together or gradually?
“True. And therefore the aspiration should be that it meets us vaccinated and gradually. At the moment, we have a challenge of unvaccinated people – and this is their time to be vaccinated. If people think that vaccinated people will protect them by herd immunity – that worked well with the alpha variant, but it won’t work with the delta and certainly not with the strain that will come after it. If they want to prevent themselves having serious complications, or less serious but long-term, this is the time to get vaccinated.”
Do we know whether vaccinated people who become infected will also experience long COVID?
“There’s biological logic in this, but it still hasn’t been proven by research. We’re still waiting for the results that will show whether these phenomena are common among people who are vaccinated and contract the disease.”
Beyond the personal benefit of vaccination that you speak of, is there a chance that if tens of thousands and hundreds of thousands more people are vaccinated, we’ll return to a kind of herd immunity?
“At the start of the current wave, there was an unusually high rate of young people who were not vaccinated and were infected, and we saw that older age groups who were vaccinated were less involved. This helps us understand that, apparently, vaccinating more people will also have a positive impact on the spread of the disease, though it’s too early to tell whether we can return to an indirect level of protection as it was with the alpha strain.”
Can we say at the moment, though it hasn’t been announced, that the policy in Israel is very similar to the British policy: Going on with life almost without restrictions, except for wearing masks and restrictions at large events, and hope that the high level of vaccination will help? Aren’t we hesitating in our response?
“The current existing restrictions have proven over recent weeks that they do not stop the spread of the disease in Israel. The government has to decide strategically whether a continued rise like this is a policy. And if so, it has to be taken into account that if they regret it later, the variety of tools available to stop the spread will be more limited – and will include only means that do extreme damage to the economy and society.”
What’s the alternative?
“To enact now a broader set of tools for stopping the spread that do not harm the economy. For example, a ‘soft’ Green Pass. The Green Pass in the previous round included two components: who could enter a place; and how many people would be allowed to be present in a place. This numerical restriction directly hurts the ability of a business owner to make a living. But the restriction on who is allowed, in a situation in which most people are vaccinated and tests are widely available – this shouldn’t hurt business owners or the people themselves.
“Under the present circumstances, a situation may occur in which a person doesn’t want to be vaccinated and doesn’t want to get infected – and could still be allowed to enter an enclosed space together with older and vulnerable people. That is an unreasonable situation economically, socially and epidemiologically, and I don’t understand why this is still the situation.”
People are skeptical about the Green Pass because even inoculated people can become infected and infect others.
“That’s true, but as far as we know, they infect others much less than unvaccinated people. Even when we wear our seat belt, there are fatal accidents and they don’t protect us 100 percent. Does that mean we shouldn’t wear them? Of course we should. In this case, it’s even more important to wear them. It’s like smoking. It’s like the right of a person to enter a restaurant with a lit cigarette.
“In a situation in which the risk to others is greater from unvaccinated people and there’s a very significant problem with infection in the community – any delay makes this step less relevant in stopping the spread of the disease, because at the same time the efficacy of other means of stopping the spread is reduced. When the numbers go up into the thousands – the whole issue of investigating and breaking the chains of infection is less effective, for example. And when the numbers rise further – then, too, the tool called isolation will become a huge burden on the economy and the education system. And so this is the time to act.”
The prime minister called on people not to fly abroad this summer, but people are asking why not if the delta variant is spreading quickly in Israel.
“It’s a matter of personal risk management. At this time, people who want to keep their children from becoming infected should avoid sitting for hours in an airplane with another large group of people, or from spending time in crowded places. Personally, I wouldn’t want my child to get COVID if he’s not vaccinated, with all the manifestations of the disease. Not in terms of the rare risks and not in terms of the risks that are less rare. And so it’s important to continue protecting them until there’s a vaccination for them as well.”