The new year brought with it a new hope of preventing the dreadful COVID-19 infection that had taken over 2020—The COVID-19 vaccines.
But having a vaccine was only half the battle won. Early 2021 was spent by countries across the world trying to figure out the logistics of approving, transporting, distributing and administering vaccines all while trying to ration the limited supply in the most utilitarian way possible, and also combatting vaccine hesitancy on the side.
One country that seemed to have figured it all out very early on was Israel. With swift early uptake, Israel was well on its way to becoming the first country in the world to fully vaccinate all its citizens.
Cut to mid-2021, the even more fast spreading Delta variant has taken over, and Israel is faced with a near crisis situation with one of the highest daily infection rates in the world, recording over 8000 cases a day, with many vaccinated people getting infected (breakthrough infections).
What went wrong? What does the spike in COVID cases in the country tell us about breakthrough infections? Should India be taking notes?
A Closer Look at Israel’s COVID Response
Was early action enough?
Although the country was able to manage a good vaccination coverage, with a little over 60 percent of Israel’s total population fully vaccinated, "that’s not enough to prevent a surge in cases and hospitalisations," says Dr Swapneil Parikh, internal medicine specialist in Mumbai, and author of ‘The Coronavirus: What You Need to Know About the Global Pandemic’.
Moreover, a large chunk of the young population still remains unvaccinated—either because they aren't eligible or because of hesitancy.
Those below the age of 12 (except vulnerable groups) are still ineligible, and only 2 - 4 percent of 12-15 year olds have received the vaccine since it was allowed to them in June, according to Reuters.
The Case of Israel's Breakthrough infections
"Multiple factors are acting together to result in the surging cases and hospitalizations in Israel."Dr Swapneil Parikh, Internal medicine specialist, Mumbai
"Israel started vaccinating very early, and there is some emerging data that protection has reduced with time in those vaccinated earliest. Israel also used a short spacing between doses," he adds.
According to data from Israel's health ministry released in July, the Pfizer vaccine was just 39 percent effective against preventing infection in the country in late June and early July, compared with 95 percent from January to early April.
Dr Parikh also adds, "Israel has a lot of social mixing and social contact in its population and while the vaccine are amazing, they are not a replacement for other public health measures. Vaccines are needed in addition to other measures during a surge."
In the case of Israel, nearly half of the COVID patients currently hospitalised in the country are ones who were fully vaccinated with the Pfizer vaccine. Although, it must also be noted that most of them are over the age of 60 with comorbidities.
"The vaccinated patients are older, unhealthy, often they were bedridden before infection, immobile and already requiring nursing care," Noa Eliakim-Raz, head of the coronavirus ward at Rabin Medical Centre in Petach Tikva was quoted as saying by Reuters.
How Does it Compare to India?
According to Epidemiologist Dr JP Muliyil, the case of Israel is interesting for two reasons, first is that they have an efficient system of documentation which allows for accurate data, and second is that a large percentage got their immunity through vaccination.
"Now, in India," he says, "From whatever I can see, the majority of Indians acquired immunity through natural infection, which seems to be much more robust than vaccines."
"Even though delta is an extremely infectious variant, bulk of population who are infected in the first wave, like the Dharavi population, hardly anybody got reinfected (in the second wave), very few."Dr Muliyil, epidemiologist
"Of course, some of us human beings cannot create antibodies and there will be exceptions. But by and large, we are in great shape," he adds.
Dr Parikh on the other hand says, while natural infection can lead to reinfections, "the combination of immunity from past infection and vaccine elicited immunity appears to be the most robust immune response."
"Antibodies titers, memory responses and cellular responses were significantly higher in individuals with this 'hybrid immunity’," he adds.
"You shouldn't worry about breakthrough infections (after vaccination) because that infection itself will act as a booster dose to make your immune response better in the future."Dr JP Muliyil, Epidemiologist
Making a case for Booster Shots?
Citing the surge in breakthrough infections, Israel started offering booster doses to those over the age of 60, which has since been brought down to 30 on Tuesday, 24 August.
The studies from Israel have also been cited by the US while approving a third booster shot for all to slow down the surge of Delta variant.
But not all experts are on board.
Both Dr Parikh and Dr Muliyil agree that some vulnerable groups such as cancer patients and transplant recipients, could require boosters. But they are sceptical about extending this to the general population.
"This is a very complex issue. My one line answer would be 'no, there isn’t adequate evidence that boosters are needed for all groups to reduce risk of severe disease, hospitalisation and death'. Currently, there is very limited evidence that boosters are needed for such a purpose in the general population," say Dr Parikh.
"In fact, there is very sparse evidence that boosters are needed to protect against severe disease, deaths and hospitalisation in the general population."Dr Swapneil Parikh, Internal medicine specialist, Mumbai
Data from Israel also shows that the efficacy of the Pfizer vaccine is 97.5 percent in preventing severe illness.
This leads us to the question...
What do we want from the COVID-19 vaccine?
Is it preventing infection or disease?
A distinction, that Dr Parikh thinks is very important to make.
"What they (the vaccine companies) promised was the vaccine will prevent serious infection and that they're doing that. Booster doses are being taken to prevent infection, and in my opinion that won't work."Dr JP Muliyil, epidemiologist
"The antibody level going up will happen, but does not necessarily correlate with protection against infection," he adds.
In Israel, more than 1.3 million people of a population of 9.3 million have received three doses of Pfizer. Some of them have also had breakthrough infections, reports Al Jazeera.
"Taking 4 doses over a short period of time may not provide more benefit than 2, but it depends on the endpoint. Is it to have the highest antibody response or protection from disease?" says Dr Parikh.
"Perhaps there is a marginal benefit in terms of reducing the risk of infection and mild disease," he says.
But both Dr Parikh and Dr Muliyil agree there isn't enough evidence yet to say a third booster dose would prevent hospitalisation and death any better than the second dose.
"Given vaccine scarcity, it is extremely clear that the net benefit of maximizing first doses in as many countries as possible exceeds the marginal benefit of a third dose in a few countries."Dr Swapneil Parikh, Internal medicine specialist, Mumbai