Cracking the coronavirus code
Israeli doctors and scientists look back at how the country has handled COVID-19 and predict what might happen next
Israel must prepare for the next wave of the novel coronavirus, SARS-CoV-2, which doctors and scientists believe will likely strike in the early winter at the same time as the seasonal flu.
“We could have the flu and coronavirus together,” warned Dr. Shuki Shemer, chairman of the board of the Assuta Medical Centers, the largest private hospital network in Israel. “Then we have a problem because there will be tons of sick people,” who pose the risk of overwhelming the country’s health system.
Shemer told The Jerusalem Post this week that until now, most of the steps that Israel has taken in its war against coronavirus have been focused on ensuring Israel does not end up in a situation like the United States or Italy, in which doctors had to choose who would get intubated and who wouldn’t. Come winter, the situation could become increasingly more challenging.
Even before COVID-19, hospital occupancy rates in Israel were the highest in the developed world.
“In a normal winter, just with the flu, we do not have enough room for patients in our wards, and people are unfortunately hospitalized in corridors,” Shemer said, which has impacted Israel’s mortality rates from infectious diseases, rates that doubled in the past two decades alone and that are not only higher than in every other developed country, but are 73% higher than the second-ranked country. “If we have the flu and COVID-19 at the same time, we might not have enough resources to take care of both epidemics. There might even be patients who contract both diseases, although we don’t have exact data on such a clinical course.”
He said that Israel should start preparing now through a two-pronged approach. First, the country will need to obtain enough influenza vaccines for four million people, at a time when the demand for the vaccine will be higher than usual.
“The whole world will be looking for these vaccines, and Israel will need to do whatever it can to get them,” he said, noting that on average only around 2.5 million Israelis are vaccinated for seasonal flu. He believes that more Israelis will want to be treated this year, and that flu vaccination will be an important aspect of managing any second wave of coronavirus.
Furthermore, he recommended that Israel expand its intensive care and internal medicine wards by earmarking more beds but also by training the nurses and other staff needed to man them.
“We have to remember that when we build ICU beds, these are not just beds, buildings and equipment, they are staff. For every 1,000 ICU beds, you need another 3,000 nurses to handle them.”
Israel is woefully understaffed when it comes to all medical professionals, the statistics show, but especially when it comes to nurses. Israel has nearly the lowest number of nurses per capita compared with other OECD countries and nearly the lowest number of nursing school graduates.
At the onset of coronavirus, Israel was not prepared, Shemer added. The country lacked not only ICU beds but personal protective equipment and ventilators, and the Mossad, Defense and Health ministries and the Prime Minister’s Office were forced to scramble and carry out clandestine missions to get what Israel needed.
Now, Israel should look back and learn from that experience, said Arnon Afek, deputy director-general of Sheba Medical Center. He said the Health Ministry should already be working on projections for how many patients Israel might have and stockpiling accordingly.
“Israel was able to stop the spread of the virus, and the number of people who died is relatively low, although each person is a world and we have to remember the difference between statistics and human beings lost,” Afek told the Post.
What was Israel’s secret sauce?
According to Shemer, many of what historically have been challenges for the State of Israel worked to its advantages in the fight against corona.
First, Israel is a small nation of only nine million people, which makes it easier to manage. At the same time, the country’s lack of open and unhindered passage across its borders has allowed it to control coronavirus breaking in from the outside. Israel was among the first to completely close its borders to foreigners, and Shemer said that swift reaction among others helped stop the spread.
Another benefit Israel has is that it is a young nation. Shemer said the median age is 30, which means half of society is under this age – quite different from Israel’s European counterparts, where more than half the population is over the age of 45.
“Coronavirus is a sickness of older people,” Shemer said. “Ninety-seven percent of the dead were above the age of 60, and 10% were above 95.”
ACCORDING TO Ronni Gamzu, CEO of Tel Aviv Sourasky Medical Center, another reason for Israel’s success is that it’s a disciplined nation – a nation used to war.
“Israelis understand the key to continuing to normalize our lives is to keep precautions,” he told the Post.
Of course, there could be other factors that contributed to the decline of COVID-19, such as the incoming summer weather. Afek said that Sheba researchers found that, in general, in countries where the weather warmed up, there was less infection.
Businessman Ran Namerode has pointed out that the virus has a periodicity of a classic Gaussian bell-curve shape wherever it appears, and its life cycle is only around six to eight weeks, regardless of efforts.
But there were also things that could have been done better, said Afek, such as testing more people earlier on for the virus, or taking more proactive steps to support those living in senior centers before the pandemic spread.
“Everyone comes up with a model, and each is correct and incorrect at the same time,” Shemer said. “This is a virus that no one understands, and we have to assess our response to the pandemic in a very careful and modest way.”
Afek noted that we will likely need to maintain the Health Ministry’s guidelines such as wearing masks, maintaining distance and washing our hands at least through next winter.
At the same time, citizens will need to continue getting screened for coronavirus. The Health Ministry announced earlier this week that it plans to test as many as 100,000 people per day for the novel virus, using serological or antibody tests that determine whether a patient has been exposed to SARS-CoV-2, and if so, whether the patient has developed antibodies against it.
Specifically, serological tests identify immunoglobulin M (IgM) and immunoglobulin G (IgG) antibodies. The body quickly produces IgM antibodies for the initial fight against infection. IgG antibodies remain longer in the body, suggesting possible immunity.
The ministry said tests will be conducted through local health funds when patients come in for any reason.
Shemer explained that so long as Israel maintains an infection rate of one to less than one, restrictions will continue to be lifted. If the rate hits even 1:1.1 or 1:1.2, then another lockdown could be necessary. He also said that the ministry could use the increased testing to monitor for hot spots and implement smaller-scale restricted zones, which would allow the economy to continue operating.
He also said that the serological tests would help determine whether Israelis have developed “herd immunity,” which is what happens when so many people in a community become immune to an infectious disease that it stops the disease from spreading.
Gamzu said there is cause for optimism.
Earlier this week, the Defense Ministry revealed that the Israel Institute for Biological Research has completed a groundbreaking scientific development, identifying an antibody that neutralizes SARS-CoV-2.
Scientists at MIGAL Galilee Research Institute are developing a vaccine against the coronavirus, after successfully completing a coronavirus vaccine for poultry. MIGAL predicts it will be able to test its oral vaccine in humans by around June 1.
Haifa-based Pluristem’s novel placenta-derived cellular therapy has already begun to demonstrate that its immunomodulatory and cytoprotective properties could play a meaningful role in mitigating the tissue-damaging effects of COVID-19 on the lungs.
Of course, there are additional efforts in Israel and the world.
Gamzu said that he believes the education the public has gotten in social distancing and proper hygiene – the same steps needed to stop the spread of influenza – alongside high usage of the flu vaccine “could allow us to have the best or easiest winter season regarding infectious disease. We can have an optimistic viewpoint.”
Still, he cautioned not to relax too quickly.
“Israel paid a lot in economic and social strength by allowing ourselves not to become Italy, China, Spain or New York,” Gamzu said. “After paying this price... it would be a tragedy not to stay focused and to have an uncontrolled second wave.”