More than six weeks after Israel began a COVID-19 vaccine rollout that has left the rest of the world trailing in its wake, public health experts are breathing a sigh of relief as the effects finally seem to be kicking in.
Early this week, with the country reporting a clear and sustained drop in the number of people age 60 and older who are severely ill, experts became confident they were seeing the effects of the vaccine. People over 60 were prioritized in the initial stages of Israel’s vaccine rollout, so this was where the signal was expected to show up in national COVID-19 statistics.
“We say with caution, the magic has started,” tweeted data scientist Eran Segal of the Weizmann Institute of Science in Rehovot, Israel, on Feb. 1, noting that COVID-19 cases, hospitalizations, and severe illness were all falling among the over-60s.
What’s more, follow-up studies conducted by one of Israel’s largest HMOs, Maccabi Healthcare Services, suggest that Pfizer’s COVID-19 vaccine, which has been used for most of the shots given so far, is working almost as well in the real world as it did in clinical trials, with over 90% efficacy after two doses. This was not a guarantee: Drugs and vaccines may perform slightly differently outside of the controlled bounds of clinical testing.
That’s good news for the US and other countries that hope to emulate Israel’s success in delivering COVID-19 vaccines to their populations. But the data emerging from Israel also reveals the challenges that lie ahead.
Israeli experts interviewed by BuzzFeed News had hoped that these positive results would show up more quickly. They attributed the delay in large part to the fact that the Middle Eastern nation has been battling the highly transmissible B.1.1.7 coronavirus variant first seen in the UK — now thought to account for more than 70% of Israeli cases. And while both Pfizer and Moderna have reported that their vaccines effectively block the B.1.1.7 variant, other variants first identified in South Africa and Brazil seem less susceptible to current vaccines, so could undermine further progress if they or new variants with similar mutations become dominant.
Meanwhile, Israel has been criticized by human rights organizations for not extending its vaccination program to the occupied Palestinian territories. And the rollout has been slower among Palestinian Arab citizens of Israel and ultra-Orthodox Jewish communities — which is worrying because these are the groups that have been hit hardest by COVID-19.
That concerns health experts watching the Israeli rollout from the US, because it’s happening despite the fact that the Israeli government launched a big communications effort, involving religious and other community leaders, to try to address vaccine hesitancy among Arab and ultra-Orthodox communities.
In the US, Black Americans have been disproportionately killed and sickened by COVID-19, and are already falling behind in the US vaccination campaign. And while Black Americans have good reasons to distrust the medical establishment given a legacy of racism within the healthcare system, there’s been nothing in the US like Israel’s communications push to convince skeptical groups of the benefits of getting vaccinated, Peter Hotez, a leading vaccine researcher at Baylor College of Medicine in Houston, told BuzzFeed News.
Hotez fears a terrible toll among Black communities if vaccine rollout remains low and more dangerous coronavirus variants take hold. “We’re losing a generation of mothers and fathers and brothers and sisters,” he said.
Israel owes its rapid vaccine rollout to a healthcare system that requires every citizen to be a member of one of four HMOs, which collectively operate clinics almost everywhere in the small, densely populated country. Having secured vaccine supplies from both Pfizer and Moderna, the nation was able to use this solid healthcare infrastructure to push ahead with vaccination faster than any other: As of Wednesday, Israel had given roughly 59 shots per 100 people in the country, while the US had given almost 10.
The rules for who is eligible for vaccines in Israel have also been much simpler than in the US, where decisions have been left up to the states based on factors including age, occupational exposure to the virus, and preexisting medical conditions. Instead, Israel prioritized older people, encouraged everyone to get shots, and opened call centers to streamline appointments. And even with its existing infrastructure, it opened massive outdoor immunization centers.
“They made it very easy to sign up,” said Ann Blake, a colleague of Hotez’s at Baylor who trained as a doctor and in public health in Israel. “If there is vaccine left over at the end of the day, you have clinic secretaries blasting text messages.”
Israel’s vaccine rollout leads the world
The US, with a much more fragmented healthcare system and many people with no health insurance, faces huge challenges matching Israel’s vaccination drive. Blake argued that the nation needs to learn from what has worked in Israel, opening more huge vaccination centers and simplifying the rules for vaccine eligibility.
“We need to be opening stadiums across the country,” she said. “We are starting to do that. We need to be doing that on a massive scale”
But Israel has been less effective at controlling the spread of the virus. The start of the vaccination campaign, on Dec. 19, came in the early stages a big surge in cases driven by the now-dominant B.1.1.7 variant. A nationwide lockdown followed on Dec. 27, making it difficult for scientists to distinguish the protective effects of the vaccine from the reduced transmission resulting from the lockdown.
“With all these strong winds pushing things in different directions, it’s hard to discern the effect of the vaccine,” Uri Shalit, a data scientist at the Technion in Haifa who specializes in studying healthcare, told BuzzFeed News.
As recently as last week, Shalit and other experts were still looking anxiously for differences between trends in this lockdown compared to the previous one that ended in October. But by this week, it was clear that Israel was seeing a decline in the number of older people with severe COVID-19 that began even as severe cases continued to rise among younger people.
Israelis with severe COVID-19, by age group
As the charts above and below show, the decline in severe cases began in mid-January, shortly after a steep rise in the number of older Israelis getting their second vaccine shots. Right now, more than 75% of the over-60s have had two shots, although the increase has slowed in recent days — to the alarm of some scientists. “You’ve exhausted the early adopters,” Yaniv Erlich, a computer scientist at the Interdisciplinary Center Herzliya, who has been tracking data on COVID-19, told BuzzFeed News.
Percentage of Israelis vaccinated, by age group
Still, follow-up studies by Israel’s HMOs are adding to the hopeful picture. In an early research paper posted online on Jan. 29 that has not yet been peer-reviewed, researchers with Maccabi Healthcare Services followed up with more than 350,000 Israeli adults 13–24 days after they had their first dose of the Pfizer vaccine, estimating that it was 51% effective in preventing infection.
And in so far unpublished data, the Times of Israel reported last week that Maccabi researchers had found the vaccine was 92% effective after two doses, based on a comparison of 163,000 fully vaccinated Maccabi patients with an unvaccinated group. If these results stand up, it means the Pfizer vaccine is performing almost as well in the real world as it did in clinical trials.
Erlich and others warned that these results may overestimate the vaccine’s effects. One issue is that Israeli couples have typically gotten vaccinated together, giving additional protection within families that doesn’t occur with volunteers in a clinical trial.
But Cyrille Cohen, an immunologist and vice dean of life sciences at Bar-Ilan University in Ramat Gan, was delighted with the reports. “It is on a par with what was predicted,” he told BuzzFeed News. “I’m always cautious, but so far this is very good news.”
Less encouraging are the lower rates of vaccination in ultra-Orthodox Jewish communities and in cities with large Arab Israeli populations. Many ultra-Orthodox Jews are skeptical of vaccines and oppose restrictions to limit the spread of the coronavirus — highlighted by the attendance of thousands of mourners at the funeral of a prominent rabbi in Jerusalem on Jan. 31, in defiance of the country’s current lockdown.
And by the end of January, less than 70% of the over-60s in Nazareth, sometimes called the “Arab capital” of Israel, had been given their initial vaccine dose — lagging well behind the national average. In Nazareth and other Israeli cities with large Arab populations, the low uptake of vaccines is thought to be linked to wider distrust of Israel’s government.
Another contentious issue is vaccination for Palestinians in the occupied territories. Israel has maintained that under the Oslo Accords, health is the responsibility of the Palestinian National Authority, which reportedly plans to buy 100,000 doses of the Sputnik V vaccine, developed by Russia’s Gamaleya Research Institute.
Pressured by groups including Human Rights Watch, which argues that the Fourth Geneva Convention requires Israel to provide medical supplies, Israel has begun to send a small number of vaccines to the Palestinians. The move has also been spurred by concerns that a regular flow of unvaccinated people across checkpoints — tens of thousands of Palestinians work in Israel — will undermine the nation’s own vaccination drive.
The gaps in Israel’s vaccine rollout mean that even the world’s leader in COVID-19 immunization will have elements of its population where the coronavirus is still freely circulating. That includes children: Pfizer’s vaccine is currently only authorized for children 16 and older. “We will not vaccinate kids under the age of 16 until we get results from the clinical trials being done by Pfizer,” said Cohen, who sits on the committee advising the Israeli Ministry of Health on COVID-19 vaccine clinical trials.
As long as the virus is circulating, there is the potential for new variants, some of which may evade current vaccines, to emerge. Pfizer and Moderna are both testing options to respond to the variants, including additional booster shots or entirely new vaccine formulations. But that means that some social distancing measures will likely continue to be necessary, especially if emerging variants cause future coronavirus surges.
This worries Hagai Rossman, a researcher in Segal’s group at the Weizmann Institute, who fears that there will be poor compliance with further stringent restrictions. “The public will not accept another hard lockdown after the vaccination campaign,” Rossman said.