In Israel’s COVID-19 wards, doctors are learning which vaccinated patients are most vulnerable to severe illness, amid growing concerns about instances in which the vaccines provide less protection against the worst forms of the disease.
About half of Israel’s 600 patients presently hospitalized with severe illness have received two doses of Pfizer-BioNTech’s COVID-19 vaccine, a rare occurrence out of 5.4 million fully vaccinated people.
The majority of these patients received two vaccine doses at least five months ago, are aged 60 or older and have chronic illnesses known to exacerbate a COVID-19 infection.
Illustration: Yusha
They range from diabetes to heart disease and lung ailments, as well as cancers and inflammatory diseases that are treated with immune-system suppressing drugs, according to interviews with 11 doctors, health specialists and officials.
Such “breakthrough” cases have become central to a global debate over whether highly vaccinated countries should give booster doses of COVID-19 vaccines — and to which people.
Israel began offering booster doses to people aged 60 or older last month, and has since expanded that eligibility.
Citing data from Israel and other findings, the US on Wednesday last week said that it would make booster doses available to all Americans from next month.
Other countries, including France and Germany, have so far limited their booster plans to elderly people and those with weak immune systems.
“The vaccinated patients are older, unhealthy, often they were bedridden before infection, immobile and already requiring nursing care,” said Noa Eliakim-Raz, head of the coronavirus ward at Rabin Medical Center in Petach Tikva, Israel.
By contrast, the “unvaccinated COVID-19 patients we see are young, healthy, working people and their condition deteriorates rapidly,” she said. “Suddenly they’re being put on oxygen or on a respirator.”
Last week, the Israeli Ministry of Health raised new concerns with a report showing that the effectiveness of the Pfizer-BioNTech vaccine against severe disease appeared to drop from more than 90 percent to 55 percent in people aged 65 or older who received their second dose in January.
Disease experts have said that it is not clear how representative the figures are, but agree that it is concerning, given evidence that overall vaccine protection against infection is waning.
They cannot say whether that is due to the amount of time that has passed since inoculation, the ability of the highly contagious Delta variant of SARS-CoV-2 to evade protection, the age and underlying health of the people vaccinated, or a combination of all of these factors.
Health officials in the UK and the US, two other nations with high vaccination rates and a spike in Delta infections, have reported similar trends.
In the UK, about 35 percent of the people hospitalized with a Delta case in the past few weeks had received two doses of a COVID-19 vaccine, while nearly three-quarters of US breakthrough infections that led to hospitalization or death were among people aged 65 or older, US government data showed.
US officials said that their booster plan is based on concern that over time, the vaccines would provide less protection against severe disease, including among younger adults.
“We are watching other countries carefully and [are] concerned that we too will see what Israel is seeing, which is worsening infections over time” among vaccinated people, US Centers for Disease Control and Prevention Director Rochelle Walensky told a news conference on Wednesday last week.
The WHO has repeatedly urged wealthy nations to refrain from providing boosters while much of the world has yet to access their first COVID-19 vaccine doses.
IMMUNE RESPONSE
The Delta variant, first identified in India, has become the dominant version of SARS-CoV-2 globally, accelerating a pandemic that has killed more than 4.4 million people.
In Israel, daily new cases have increased from the single digits in June to about 8,000 since the arrival of the Delta variant. About half of the cases — the majority of them mild to moderate — are in vaccinated people.
Those vaccinated first in Israel were at high-risk, including people aged 60 or older. The immune response of some might have weakened by the time the Delta variant hit Israel, but the vaccine might not have kicked in at all for others with underlying health conditions.
“For some of them, the vaccine did not trigger an immune response. They had no antibodies, because of the illness itself or because they are treated with medication that suppresses the immune system,” said Dror Mevorach, head of the COVID-19 ward at Hadassah Hospital in Jerusalem.
Mevorach cited examples such as chronic lymphocytic leukemia and lymphoma.
Among 3 million vaccinated Israelis covered by Clalit, the country’s largest healthcare provider, 600 have had severe breakthrough cases since June.
About 75 percent of them were aged 70 or older and had received their second dose at least five months earlier, Clalit chief innovation officer Ran Balicer said, adding that nearly all of them had chronic illnesses.
“We are hardly seeing young vaccinated people in severe condition,” Balicer said.
In the UK, doctors described similar characteristics among vaccinated patients who fall severely ill.
“In those people who come in, because of their age, because of their co-morbidities, they might be people that you would expect the vaccine to be less efficacious for than other age groups,” said Tom Wingfield, a clinical lecturer at the Liverpool School of Tropical Medicine.
A new surge in US COVID-19 cases and deaths has been fueled by the Delta variant, particularly in states where vaccination rates remain low. Among vaccinated patients who become infected, there is evidence of older people being hit harder.
In Texas, 92 percent of the vaccine breakthrough cases that resulted in death were in people aged 60 or older and 75 percent had a known underlying condition that put them at high risk from COVID-19, a state public health department spokesperson said.
Initial data from Israel show a greater reduction in infection risk for those administered a booster shot in the past few weeks than for those who only received two doses.
Even without boosters, Israeli doctors have said that vaccinated patients tend to recover more quickly.
“The vaccinated patients I’ve treated usually left the ICU [intensive care unit] in about three days. The unvaccinated patients took a week or two until they stabilized,” said Yael Haviv-Yadid, head of the critical care ward at the Sheba Medical Center near Tel Aviv.
Even if the vaccine did not stop them from getting ill, it might have mitigated their illness, said Alex Rozov, head of the COVID-19 ward at the Barzilai Medical Center in Ashkelon, Israel.
“Our cautious impression is that the vaccinated patients suffer an easier course of illness — the treatment is more effective among those who have antibodies,” Rozov added.
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