There is a light at the end of the tunnel - analysis

The crisis in Bnei Brak will be recorded in epidemiology textbooks.

Assuta staff rush a patient to the hospital through its emergency entrance (photo credit: ODED KARNI)
Assuta staff rush a patient to the hospital through its emergency entrance
(photo credit: ODED KARNI)
The first Israeli was diagnosed with COVID-19 on February 20, seven weeks after the first incidence of COVID-19 in the world, which gave the country an advantage in preparing for the menacing epidemic. At that time, it became clear that the major risk factors for complications and deaths related to the COVID-19 were age and background ailments, and that young healthy people who were contracting the disease were oftentimes asymptomatic or only mildly sick. For people over 65 who contract the virus, a much larger percentage require hospitalization and to be anaesthetized and put on ventilators. In addition, the death rate for this age group and for people with background ailments is double -and sometimes even triple - that of younger people.
Over 200 countries around the world have been forced to carry out unplanned and uncontrolled ‘clinical trials’ to treat the novel virus, without fully understanding its clinical features. Each country has been dealing with its own unique political, social, ethnic, economic and genetic structure, as well the way its medical services are organized. It’s important to learn how other countries are dealing with the crisis, but each country doesn’t necessarily need to imitate others’ operations.
Israel has proven that the preventative measures it has taken have been successful, as Israel is in the forefront of effective pandemic treatment, alongside South Korea, Taiwan and Germany. We’ve gained a great amount of time, which is enabling us to handle the crisis in a more organized fashion. In this article, I will present what we have learned so far and the milestones we are likely to come across on the road ahead of us.
The natural infection rate of the virus determines the number of people who get sick at any given point in time. If the proper actions are taken, the spread can be controlled. The estimated exponential growth rate of infection is how quickly people get sick within a short period of time, and for this reason, tremendous efforts are being carried out to ‘flatten the curve’, such as isolating sick patients in an effort to slow the spread of the virus. This will prevent the collapse of the health system and enable medical staff to treat patients to the best of their ability.
It’s important to remember that in the absence of a vaccine, the best way to stop the spread of the virus is through herd immunity, which is when a large percentage of a population has become immune to an infection. A society reaches herd immunity when enough people who are immune to the disease, and so the outbreak fades and finally disappears. The best way to accomplish this is for all the young and healthy members of a population to become infected.
In Israel, it would be possible to achieve herd immunity in an extremely short amount of time, keeping hospitalization, mortality and economic harm to a minimum by adhering to the following four principles:
A.   Safeguarding adults and sick people by imposing a total community-wide closure, in an effort to prevent the spread of the virus and thereby prevent complications, hospitalizations and mortality.
B.    Imposing restrictions on dense population centers with a high risk of infection, in an effort to prevent them from becoming a focal point of the outbreak, which would overwhelm the health system.
C.    Protecting medical teams and the elderly though active monitoring and testing, in an effort to enable the medical staff to continue working without worrying about becoming infected or infecting other patients.
D.    To allow young and healthy people to achieve herd immunity in a controlled fashion.
Compared to other countries, Israel has many advantages when managing epidemics: Israel has a small population, clear borders that are easily sealed, a robust health system, a strong military and security establishment that are experienced in dealing with emergency situations. And most importantly – our population is overwhelmingly young. Only 11% of our population is over 65, and half of Israel’s residents are under the age of 30, which is reflected in the small number of hospitalizations and low mortality rate in Israel, which are among the lowest in the world.
Countries with low death rates and hospitalizations of severely ill patients, such as South Korea, Taiwan and Germany, have adopted aggressive testing policies and made wearing a mask mandatory. In addition, these countries have engaged in massive public proclamations and gone to great efforts to educate the entire population with methods for preventing contagion.
South Korea, for example, has 51 million residents, with a higher median age than Israel (44). Nonetheless, it has effectively managed to prevent the spread of the virus without harming its economy and without disrupting the routine of most residents. As a result, its mortality rate is among the lowest in the world. Moreover, as of the writing of this article, South Korea has just over 55 severe cases, with only 4 deaths per million people and just over 200 total deaths.
One of the most prominent ways South Korea has dealt with the spread of COVID-19 has been mass diagnosis of people who tested positive for the virus. South Korea tested more than 20,000 people a day in over 120 different locations around the country. In all, they have carried out close to half a million tests. This has helped them identify locations that could potentially become a focal point for outbreak. They then sent extra medical teams with proper equipment and field hospitals to these areas before an outbreak could occur. Mapping the outbreak focal points and accurately estimating morbidity and mortality rates, and their characteristics, enables decision makers to formulate fact-based policies.
The crisis in Bnei Brak will be recorded in epidemiology textbooks. The city represents a high density and natural closure, and is characterized by a relatively young population (50% under the age of 18, compared with the national average of 50% under the age of 30). Nonetheless, there is great concern that thousands of adults in Bnei Brak have contracted the virus.
The treatment of high-risk cities such as Bnei Brak, Elad, Modiin Ilit and Or Yehuda, as well as a number of neighborhoods in Jerusalem, require special attention, including closure in some areas, augmented welfare services and extensive testing. It’s possible that since Bnei Brak is the most densely populated city in Israel, it might have already achieved herd immunity. If it hasn’t yet, it will be an appropriate place to begin carrying out serological tests, which measure the amount of antibodies a person have. It’s possible that the mortality rate among Bnei Brak residents will remain low due to the city’s overwhelmingly young median age, so long as older residents remain quarantined.
Similarly, it’s possible that Singapore, one of the most densely populated countries in the world, with a relatively young population (only 10% over the age of 65 and a median age of 35) has also successfully achieved herd immunity, with an extremely small number of deaths or residents who’ve become seriously ill.
We must also pay extra close attention to the elderly living in nursing homes in Israel. This is the next ticking bomb, which could result in a fatal outbreak and become an unbearable burden on hospitals. Nursing home administrators should pool their resources in an effort to control the spread. Nursing home managers, who do holy work on a daily basis, do not have the capabilities to manage the virus, conduct the appropriate epidemiological tests, and identify which staff members have become infected. This requires coordination between the Israel Ministry of Health, Magen David Adom, the various health funds, municipal welfare agencies, the IDF and Israel Police.
In my estimation, if IDF soldiers were used to provide proper control, in coordination with the municipal welfare agencies, we would be in a much better position to manage, treat and disinfect nursing homes, as well as save Israel’s elderly population, most of whom have background ailments. We cannot just give up and let our elderly die.
As of now, Israel’s hospitals are managing to care for all of the people who’ve contracted COVID-19, and the curve is expected to remain steady, provided we don’t experience any unexpected or dramatic outbreaks. A number of proposals and methods have been proposed for reactivating the economy. However, unless we are capable of testing tens or even hundreds of thousands of Israel’s residents, it will be difficult to implement any of them. All of the methods for returning to life as usual include the following principles:
A.   Full acquiescence by the entire community to wear face masks in public spaces and workplaces without exception.
B.    A continuation of social distancing until the virus has been fully eliminated.
C.    Carrying out testing of groups of ten thousand healthy young people who are working (for the first time) using two consecutive PCR tests every three weeks, and checking the results two weeks later. This would act as a trial and error method to identify new outbreaks. The next week, twice as many tests should be carried out among a different group, and so on. Serological tests will certainly ease approval of asymptomatic young people who’ve already caught COVID-19 and who test positive for its antibodies. Of course, as many restrictions as possible should be removed, starting with the last and then continuing on to the first. Success can be achieved using this method in just a few short months.
Patients with sicknesses other than COVID-19 (cancer, heart disease, diabetes, hypertension, etc.) are unfortunately being neglected during this difficult period. On average 5,500 women a year are diagnosed with breast cancer, 3,000 people with colon cancer, 3,000 with prostate cancer, and 260 with cervical cancer using early detection tests. What price will they have to pay by not receiving diagnoses in time due to the epidemic?
Delayed diagnosis and neglect of these critical patients will come back to haunt us in the future. The number of non-COVID-19 patients who will get sick and die in Israel’s hospitals will grow exponentially, and will be a great burden for Israel’s health system, as well as a big drain on hospitals’ budgets. Routine activity in Israel’s public and private hospitals has been reduced by 50% since the start of the epidemic. The number of patients who’re on ventilators is not a justification for this change, and it’s not certain that this will be justified in the future either.
The medical personnel who are doing holy work have shown outstanding dedication and commitment. We must go to great efforts to provide them with the proper protective equipment and enable them to work in an environment that is safe for them and all the patients. Medical personnel should be the first people checked for the virus using PCR and serological tests.
In summary, I believe we can already glimpse the light at the end of the tunnel, and there is room for optimism. The numbers, as of the writing of this article (April 5) are encouraging, and we can be hopeful that the restrictions over Passover in the entire country, and especially in high-risk locations, will bring about calm and slow the spread. Nonetheless, we must remain soberly cautious in our estimations, since there are still many more unknown factors than there are known.
Wishing everyone the best on this Passover, the holiday freedom, which coincides with the blossoming of beautiful flowers. If we are willing, we will indeed achieve freedom.
Prof. Shuki Shemer is Chairman of the Board of Assuta Medical Center.
Translated by Hannah Hochner.