The coronavirus disease 2019 (COVID-19) pandemic in Israel continues to be a ‘roller-coaster’ with dramatic ups and downs on an almost daily basis. Although this is true for many countries, I will try to emphasize issues that may be more unique to Israel.

As of October 2021, Israel is hopefully beginning to see the waning of our fourth wave of disease. The first wave occurred in March–May 2020, the second in September–October 2020, the third in February–March 2021 and the present wave from August to October 2021 (ongoing). To date (October 2021), the overall number of people reported to have contracted COVID-19 in Israel is 1,291,808 cases. The total population of Israel is 9.3 million, and the number of infected people per million population is reported to be 138,337 (14th highest worldwide). The COVID-19-related number of deaths is 7821,839/million population (82nd worldwide).1

The first wave of COVID-19 in Israel was accompanied by nationwide lockdown. The overall case number was relatively low and the death rate was remarkably low in comparison to most European countries and to the United States. The reason for this is not clear, but may be explained in part by the young age of the population in Israel. The most striking feature of the first wave was that the largest numbers of cases and deaths were amongst Israel's minority populations, the Arab population (21.1% of the total population) and the ultra-orthodox Jewish population (12.6%). This was attributable to reticence amongst these population groups to follow health authority guidelines, as a manifestation of the general mistrust amongst these groups of Israel's formal institutions. This was rapidly recognized and rectified by specifically targeting educational programmes for these groups and active involvement of minority group leaders in the national effort to ensure social distancing.

The second wave was accompanied by a higher number of cases and mortality rates. This was partly due to the general relaxing of social distancing by the public who had grown tired of the restrictions imposed by the pandemic and especially by the grave financial costs borne by large sections of the work sector (tourism, restaurants and entertainment) with only partial government compensation. The second and especially the third waves of the pandemic were associated with high number of cases, including significant demand on hospital beds and intensive care services. For some weeks, daily case and fatality rates per population were amongst the highest worldwide. The hospital system in Israel suffers from long-standing underfunding and neglect. Israel has one of the lowest number of beds and lowest number of doctors and nurses per capita amongst Organisation for Economic Cooperation and Development (OECD) member countries. The situation is even worse with regard to intensive care beds. Despite the high demands on inpatient and intensive care unit (ICU) care, particularly in relation to ICU nursing and medical staff, the Israeli medical system has not yet been overwhelmed by the COVID-19 pandemic.

Israel was fortunate in being amongst the first countries to initiate and implement a national vaccination programme, which began at the end of December 2020. Almost all of those vaccinated received two doses of the BNT162b2 Pfizer-BioNTech vaccine. Small numbers have received alternative vaccines, including an Israeli manufactured vaccine. Overall, 5,654,522 have received two doses of vaccine, 80% of the adult (>16) population and >85% of those over age 60 (Figure 1). Israel's experience regarding efficacy of the BNT162b2 mRNA Covid-19 vaccine in reducing both rates and severity of disease in a nationwide mass vaccination setting was published in the New England Journal of Medicine in April 2021.2 The vaccine was offered to 12–15-year olds from June 2021 and 43% of this age-group have received two doses of the vaccine. The success of the vaccination programme as a whole can be explained by the fact that Israel has an excellent, well-organized ambulatory healthcare system that is in the hands of four insurance providers and which provides full access to ambulatory care for all citizens. Funding is derived from a medical tax, and is therefore relatively ‘free’ at the time of provision of service. These providers have easy and rapid access to the entire population, which allowed for rapid and relatively high rates of vaccination in the community.

Percentage of Israeli population who have received COVID-19 vaccination by age group. Blue, three doses; light green, two doses; dark green, one dose.

Source: Israel Ministry of Health data,1 3 October 2021

In addition, the health providers have excellent computerized databases that have facilitated rapid, reliable and comprehensive evaluation of medical data, including case numbers and vaccination statistics. Israel has therefore been able to provide reliable epidemiological data during the pandemic, particularly in relation to the effectiveness of vaccination programmes.

Israel has also been the first country to offer a booster vaccine (a third dose), initially to those over age 60 and to immunocompromised patients, but subsequently to the entire population over age 16, provided that at least 5 months have elapsed since the administration of the previous two doses. The decision to give the third dose was taken as the fourth wave began and was based on small number of studies showing a marked increase in serum antibody titres following a booster. At the time of this decision, there was obviously no clinical evidence that this strategy would reduce case numbers or disease severity. Almost all cases in Israel in the fourth wave are due to the Delta variant, which may have accounted for the resurgence of disease. To date, 3.54 million people have received the third dose, including 75% of the population over age 60. A recent NEJM publication3 presents Israel's experience with the booster in patients over age 60 and reports a significant increase in protection from disease and severe disease relative to those who had received two doses. In the present wave, hospitalization and death rates from COVID-19 have been predominantly in unvaccinated individuals, particularly in those below age 60.

Almost 2 years into this pandemic, we have learnt how little we know and can predict about how COVID-19 behaves. We are proud of our effective ambulatory health system and computerized patient databases and of Israel's position at the forefront of vaccination. At the same time, we are reminded once again that our public hospitals are underfunded and understaffed.