Israeli Health Officials Seek Consensus Before Approving Second COVID Booster

As omicron keeps rapidly spreading, Health Ministry officials are deliberating the administration of a fourth COVID vaccine dose, as data increasingly shows waning immunity around four months after first booster

Ido Efrati
Ido Efrati
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A nurse prepares to administer the fourth COVID vaccine to health care workers at Sheba Medical Center, Tel Hashomer, on Tuesday.
A nurse prepares to administer the fourth COVID vaccine to health care workers at Sheba Medical Center, Tel Hashomer, on Tuesday.Credit: Gil Cohen-Magen
Ido Efrati
Ido Efrati

A week has elapsed since the Health Ministry’s panel of experts recommended a second COVID-19 booster shot for populations at risk, but ministry officials are still deliberating over the issue. The ministry’s director general, Prof. Nachman Ash, has not ratified the recommendation, and plans to implement it are being delayed.

The panel recommended giving a second booster shot to those 60 and over, in addition to healthcare workers and immunocompromised patients. It made the decision after being presented preliminary evidence of the waning of the first booster shot’s effect after four months, in light of the rapid spread of the omicron variant.

According to healthcare officials, there is indecision regarding the necessity of a fourth dose – a second booster shot – for now, despite evidence of the waning effectiveness of the third dose, and since the spread of the omicron variant doesn’t appear to be affecting hospitalizations or causing a spike in severe cases.

As was the case with the first booster shot, if Israel proceeds with a second booster, it would be setting a precedent on an issue over which there isn’t yet a treatment protocol. And as with the first booster, the expectation is that a second booster would substantially improve the vaccine protection of those who receive it within a few days to a week, along with an increase in patients’ antibody levels.

“The indecision,” a Health Ministry official said, “relates to the general characteristics of the illness from omicron. The decision over a fourth shot requires monitoring its effect of the current wave of infections on the hospital system and what its impact is at various ages. Even if there is a waning of the third dose, what is ultimately decisive is the level of protection that does remain against significant illness.”

Other officials believe that what is delaying the ministry’s decision on a fourth dose is opposition among a portion of the Israeli medical community to such a dose now, due to an absence of more information – regarding both the illness caused by omicron and the waning of the third dose even after a few months.

“The ministry is having difficulty deciding due to the reservations of other doctors, and it’s possible that this will lead to a compromise decision that will be made following a delay,” a member of the ministry advisory panel said. “I have no doubt that at one stage or another, we will see more demand on emergency rooms and hospitalizations. There’s clearly a dilemma. It’s not a sharp and clear decision, but the question, of course, is the price of a mistake and also the amount of time that is passing.”

A Health Ministry official said, “At the ministry, they are waiting for additional information about the waning of the vaccine, about the severity of the illness, but they mostly would prefer to make it in an atmosphere of consensus among the experts to the extent possible.”

On Tuesday of last week, the panel released its recommendation after deliberations involving the participation of more than 90 professionals. A clear majority of them supported recommending that Israelis 60 and over get a second booster shot, in addition to healthcare workers and immunocompromised patients. According to data presented to the panel, the risk of infection of those vaccinated with the booster at least four months previously was three times that of those who had been newly vaccinated with a booster.

Nurse at a newly opened COVID ward in Jerusalem, on Monday.Credit: Ohad Zwigenberg

The data also showed that there are about 850,000 Israelis 60 and over who received their booster shot more than four months ago and another 260,000 in that age range who were vaccinated with a booster more than three months ago.

At a news conference convened by the panel the following day, the committee’s chairman, Dr. Boaz Lev, said the recommendation was made amid uncertainty and based on preliminary figures. But he noted that the R numbers with the omicron variant – the number of people that the average infected person infects – are higher than what was seen with prior variants. “It is becoming dominant in all the countries where it appears, and I think that it quickly seems to be overtaking the delta” variant.

In light of the rapid spread of the new variant, the time element is critical, Lev added, and what guided the panel was the price of a mistake in not administering another booster compared to the price of giving one that was unnecessary. The concern is that failing to give it would exact a price in more serious cases and more deaths.

“If we vaccinate, and it wasn’t necessary to do so, the price that we would pay is the side effects from the vaccine. So in managing risk and weighing the [committee’s] decision, the price is higher if we don’t vaccinate,” he said.

At the time, there were 371 confirmed omicron cases in Israel. By Sunday of this week, five days later, the figure had risen to 1,118, and there is now a wide consensus that omicron is what drove up the number of COVID cases and the R number in the space of a week. Within the next two weeks, it is expected to completely dominate the case numbers and result in the disappearance of the delta variant.

Vaccine drive at a Jerusalem mall, last week.Credit: Ohad Zwigenberg

But the past week has also deepened the dilemma. Omicron has spread quickly in the month since it first surfaced, but there is still no sign of an increase in hospitalizations and serious cases of illness. When it comes to those 60 and over – who would now get a second booster shot – they represent between 7 and 10 percent of the new cases.

In Israel’s hospitals as of this writing, 37 of the 85 seriously ill coronavirus patients are 60 or older, including 27 who are entirely unvaccinated, three whose vaccination has expired and seven who received a booster shot. “We also know this dynamic from prior variants. The initial outbreaks occur among children who usually don’t become seriously ill, and it’s only later that it moves into the older population. A wave of outbreaks in nursing homes could change the situation,” said one member of the committee who is an expert on infectious diseases.

“Even if the rate of serious cases is lower with omicron, widespread infection could lead to [hospital] crowding such as we saw in prior waves, and therefore the decision regarding the fourth dose and improving vaccine protection is acute,” he added.

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