Socioeconomic and ethnic disparities along five waves of the COVID-19 pandemic: Lessons we have not yet learnt.

PURPOSE: The COVID-19 pandemic, now in its third year, has served as a magnifying glass, exposing the inequitable impact of the outbreak. The study aims to analyze the relationships between the socioeconomic and ethnic characteristics of the population and COVID-19 testing, infection, and vaccination throughout the first five pandemic waves. DESIGN: A secondary analysis of an existing national database was conducted in Israel from March 2020 to May 2022. During the study period, Israel underwent 5 pandemic peaks or waves (March-April 2020, September-October 2020, January-February 2021, September 2021, and January-February 2022). METHODS: Data on tests performed, confirmed COVID-19 cases, and uptake of vaccine doses one through four during the study period, were analyzed by the socioeconomic (SE) cluster (scale of 1 to 10) and ethnicity (Jewish, Arab, mixed Jewish- Arab ethnicity) of the residents' local authority. RESULTS: COVID-19 testing rate gradually increased from the lowest to the highest SE clusters, with rates 3.2 times higher in the second highest, compared with the lowest cluster. People living in Jewish localities were tested twice more than those in Arab or mixed localities. The rate of confirmed cases was 1.9, 3.0, 6.3, and 4.3 times higher, respectively, among cluster 1 (the lowest) compared with cluster 9 (second highest) in the first, second, third, and fourth pandemic waves, respectively. Rates among people living in Arab or mixed localities were higher compared with those living in Jewish localities in 3 of the 5 waves. Vaccine uptake revealed a clear social gradient, with the percentage of the population being vaccinated gradually increasing from cluster 1 (the lowest) to the higher clusters. The relative difference between the lowest and highest SE clusters increased from 2.4 in the first vaccine dose to 5.5 in the third and fourth doses. Ethnic disparities also grew with vaccine dose, with a Jewish to an Arab rate ratio of 1.1, 1.2, 1.6, and 4.5 for vaccine doses 1,2,3, and 4, respectively. CONCLUSIONS: Covering 26 consecutive months of the COVID-19 pandemic at the national level, the current study demonstrates that despite high accessibility of tests and vaccines to the entirety of the population and tailored outreach efforts, socioeconomic, and ethnic disparities not only failed to diminish, but they even widened along the five pandemic waves. CLINICAL RELEVANCE: The pandemic exposed the vulnerability of the weakest segments of the population. Therefore, the combined action of the Ministry of Health, health providers, and local authorities is required to further adapt health messages to the cultural characteristics of diverse populations, to equip the health professionals with practical tools to promote healthy choices among the vulnerable populations, and to build communities that promote healthy lifestyles. The pandemic has highlighted the importance of reducing health disparities and building trust between vulnerable populations and the healthcare system during "normal" or routine times, to better prepare for times of emergencies, such as the current pandemic.

COVID-19 Vaccination, Morbidity, and Mortality During a 12-Month Period in Israel: Can We Maintain a "Herd Immunity" State?

Despite widespread vaccination, the COVID-19 pandemic continues to cause global disruption. Authors describe the pace of COVID-19 vaccination in Israel and examine differences in morbidity and mortality rates over time between vaccinated and unvaccinated populations. Retrospective data were obtained between December 2020 and December 2021 on daily vaccine uptake by age group (20-39, 40-59, 60+ years): rate of hospitalized severely ill cases, vaccination status and age group, and death rate per 100,000 by date and vaccination status. Uptake of first and second doses was slower in 20-59-year olds, whereas in 60+-year olds, it occurred without delay. Once most adults were vaccinated, a gap appeared with much higher severe cases and deaths in unvaccinated versus vaccinated populations; this gap attenuated by late May with very low rates in both vaccinated and unvaccinated populations until mid-July, when rates began to rise again. A herd-immunity-like period occurred in Spring 2021, with unvaccinated benefitting from a highly vaccinated population. Staggered vaccine uptake led to unsynchronized high immunity, which contributed to the fourth pandemic wave. Population vaccination within a shorter timeframe or shorter intervals between boosters may be important to reduce viral transmission.

Sociodemographic disparities in COVID-19 burden: changing patterns over four pandemic waves in Israel.

BACKGROUND: Worldwide, the COVID-19 pandemic hit weakest populations hardest, with socioeconomic (SE), racial and ethnic disparities in COVID-19 burden. The study aimed to analyse patterns of SE and ethnic disparities in morbidity, hospitalisation, and vaccination throughout four pandemic waves. METHODS: A retrospective-archive study was conducted in Israel from 11 March 2020 to 1 December 2021, with data on confirmed cases, hospitalisations, mortality and vaccinations (three doses), obtained from the Israeli Ministry of Health's open COVID-19 database, covering 98.8% of the population, by SE and ethnic characteristics of localities. FINDINGS: At the outbreak of the pandemic, there was a higher caseload in Jewish, compared with Arab localities. In the second and third waves, low SE and Arab minority populations suffered 2-3 times higher morbidity, with a similar but attenuated pattern in the fourth wave. A similar trend was observed in hospitalisation of confirmed patients. COVID-19-associated mortality did not demonstrate a clear SE gradient.A strong social gradient in vaccine uptake was demonstrated throughout the period, with 71% and 74% double vaccinated in the two highest SE clusters, and 43% and 27% in the two lowest clusters by December 2021. Uptake of the third dose was 57%-60% in the highest SE clusters and 31%-25% in the lowest clusters. SE disparities in vaccine uptake were larger among the younger age groups and gradually increased from first to third doses. CONCLUSIONS: Israel was among the first to lead a rapid vaccination drive, as well as to experience a fourth wave fuelled by diminishing immunity and the delta variant. SE and ethnic disparities were evident throughout most of the pandemic months, though less so for mortality. Despite higher COVID-19 burden, vaccine uptake was lower in disadvantaged groups, with greater disparities in the younger population which widened with subsequent doses.

Covid-19 in children aged 5-11: Examining the issues surrounding vaccination and public health policy.

BACKGROUND: Children under 12 are now the largest unvaccinated group. Following FDA approval, vaccination of 5-11 year olds is now being encouraged in some countries. We present data on child COVID-related morbidity in Israel and discuss the complexities surrounding vaccinating children aged 5-11. METHODS: Data were obtained from Israel's open COVID database regarding new confirmed daily COVID-19 cases, severe hospitalized cases and deaths by age group in Israel from February 2020-November 2021, as well as vaccination rate and adverse events following vaccination. RESULTS: In 5-11 year olds, there were 460 hospitalizations, including 72 moderate to critical (0.007% population rate), with 3 deaths (0.0003% population rate). Children (0-19) made up the largest proportion (41%) of cases, but comprised just <0.1% of deaths, and <1% of severe cases. Post-vaccine myocarditis was much lower than severe COVID risk except in boys aged 12-19 where it was equivalent to the risk of mechanical ventilation due to COVID in boys aged 10-19 (12 per 100,000). High numbers of children were quarantined. CONCLUSIONS: COVID risk is minimal for most children though rare complications do occur. Israeli and US pediatric associations have recommended vaccinating children, particularly in high-incidence scenarios where risk-benefit balance is more clear-cut. However only a quarter of eligible parents have vaccinated their children. Parents may consider health grounds but also restrictions on children, population vaccination levels, waning immunity and new variants, and should be provided with clear information to help them make an informed decision. Policymakers should reevaluate the need for isolations, testing and mask-wearing in school age children, which are detrimental to their wellbeing.

Uptake of coronavirus disease 2019 (COVID-19) vaccination among general hospital staff in Israel.

Data from all general hospitals in Israel to April 2021 show that the mean hospital rate of staff vaccination was 84.4% for the first dose and 77.1% for the second dose, which are lower than general population rate, with mean 7% who did not complete their vaccinations. Healthcare workers have an important role in influencing the wider community.

The effect of the COVID-19 pandemic on non-COVID respiratory ED visits in Israel.

BACKGROUND: The COVID 19 pandemic has had a crucial effect on the patterns of disease and treatment in the healthcare system. This study examines the effect of the COVID-19 pandemic on respiratory ED visits and admissions broken down by age group and respiratory diagnostic category. METHODS: Data on non-COVID related ED visits and hospitalizations from the ED were obtained in a retrospective analysis for 29 acute care hospitals, covering 98% of ED beds in Israel, and analyzed by 5 age groups: under one-year-old, 1-17, 18-44, 45-74 and 75 and over. Diagnoses were classified into three categories: Upper respiratory tract infections (URTI), pneumonia, and COPD or asthma. Data were collected for the whole of 2020, and compared for each month to the average number of cases in the three pre-COVID years (2017-2019). RESULTS: In 2020 compared to 2017-2019, there was a decrease of 34% in non-COVID ED visits due to URTI, 40% for pneumonia and a 35% decrease for COPD and asthma. Reductions occurred in most age groups, but were most marked among infants under a year, during and following lockdowns, with an 80% reduction. Patients over 75 years old displayed a marked drop in URTI visits. Pediatric asthma visits fell during lockdowns, but spiked when restrictions were lifted, accompanied by a higher proportion admitted. The percent of admissions from the ED visits remained mostly stable for pneumonia; the percent of young adults admitted with URTI decreased significantly from March to October. CONCLUSIONS: Changing patterns of ED use were probably due to a combination of a reduced rate of viral diseases, availability of additional virtual services, and avoidance of exposure to the ED environment. Improved hygiene measures during peaks of respiratory infections could be implemented in future to reduce respiratory morbidity; and continued provision of remote health services may reduce overuse of ED services for mild cases.

Developing a National Set of Health Equity Indicators Using a Consensus Building Process.

BACKGROUND: Considerable health inequities documented in Israel between communities, populations and regions, undermine the rights of all citizens to optimal health. The first step towards health equity is agreement on a set of national indicators, reflecting equity in healthcare provision and health outcomes, and allowing monitoring of the impact of interventions on the reduction of disparities. We describe the process of reaching a consensus on a defined set of national equity indicators. METHODS: The study was conducted between January 2019 and June 2020, in a multistage design: (A) Identifying appropriate and available inequity measures via interviews with stakeholders. (B) Agreement on the screening criteria (public health importance; gap characteristics; potential for change; public interest) and relative weighting. (C) Constructing the consultation framework as an online, 3-round Delphi technique, with a range of experts recruited from the health, welfare and education sectors. RESULTS: Participants were of diverse age, gender, geographic location, religion and ethnicity, and came from academia, healthcare provision, government ministries and patient representative groups. Thirty measures of inequity, presented to participants, represented the following domains: Health promotion (11 indicators), acute and chronic morbidity (11), life expectancy and mortality (2), health infrastructures and affordability of care (4), education and employment (2). Of the 77 individuals contacted, 75 (97%) expressed willingness to participate, and 55 (73%) completed all three scoring rounds. The leading ten indicators were: Diabetes care, childhood obesity, adult obesity, distribution of healthcare personnel, fatal childhood injuries, cigarette smoking, infant mortality, ability to afford care, access to psychotherapy and distribution of hospital beds. Agreement among raters, measured as intra-class correlation coefficient (ICC), was 0.75. CONCLUSION: A diverse range of consultants reached a consensus on the most important national equity indicators, including both clinical and system indicators. Results should be used to guide governmental decision-making and inter-sectoral strategies, furthering the pursuit of a more equitable healthcare system.

National and regional trends in MRI utilization in the face of the ongoing COVID-19 pandemic.

BACKGROUND AND PURPOSE: Marked reductions in imaging exams have been documented during the COVID-19 pandemic. The study aimed to examine the effect of the two waves of COVID-19 on magnetic resonance imaging (MRI) utilization at the national and regional level. MATERIALS AND METHODS: A retrospective-archive study was conducted in Israel, comparing March-December 2020 with March-December 2018 and 2019. Data on MRI utilization were obtained from the national MRI registry, while data on confirmed COVID-19 cases, by place of residence, were obtained from the Israeli Ministry of Health open COVID-19 database. RESULTS: The number and rate of MRI examinations decreased during the first COVID-19 wave, with the steepest drop in April 2020: 47.5% relative decrease compared to April 2019, and 42.2% compared to 2018. This was followed by a compensatory increase between the waves and a return to almost pre-pandemic levels of use, with just a modest decrease, during the second, more intense COVID wave, compared with the previous year. Existing differences between regions increased during the pandemic. The rate ratio of MRI exams between Tel-Aviv and the Northern periphery increased from 2.89 in April 2019 to 3.94 in April 2020. Jerusalem metropolitan region, with the largest burden of COVID disease, demonstrated only a modest decrease (1%) in MRI utilization during the first 10 months of the pandemic. CONCLUSIONS: At the national level, time trends in reduced MRI utilization followed the first wave of COVID-19, and were accompanied by increased regional disparities. These changes were not explained by differences in the burden of COVID-19 disease but might be explained by unequal distribution of MRI scanners among regions. Reduced utilization was not evident during the second wave, nor at the beginning of the third wave, despite higher COVID-19 case load, demonstrating adaptation to the new normal. Patterns of MRI utilization might help policy-makers and healthcare managers predict the behavior of imaging as well as other sectors, such as elective surgical procedures, during an ongoing pandemic. This forecast might help to manage the lasting effects of the pandemic, including extended waiting times, in the months and years following its remission. In preparation for future national emergencies, timely and detailed data on MRI utilization can serve as a "sensor" for a wide array of diagnostic and interventional medical activities, providing policy-makers with an updated snapshot to guide their response at the regional and national levels.

Changes in infectivity, severity and vaccine effectiveness against delta COVID-19 variant ten months into the vaccination program: The Israeli case.

We present epidemiological data to examine trends in COVID-19 incidence, morbidity and mortality in Israel as well as changes in vaccine effectiveness, and discuss the impact of the delta variant and the third, "booster", vaccine. A retrospective-archive study was conducted from February 27th 2020 to October 16th, 2021. Data were obtained from the Israeli Ministry of Health's open COVID 19 database, including PCR-confirmed cases, number hospitalized - including severe cases, death rate, all by age and vaccination status, case fatality rate and changing effectiveness of the vaccine. After three COVID waves, confirmed cases rose from under 30 new daily cases in mid-June to a high of 11,000 in early September 2021. Severe hospitalized cases and death rates were lower than in previous waves and largely restricted to those not fully vaccinated. In the first three months of the vaccination campaign, non-vaccinated population demonstrated much higher morbidity rates. Four months after vaccination began, this gap was attenuated, with low rates of infection and hospitalization in all groups. The gap was regained following uptake of the third vaccine. Data from the fourth wave show reduced hospitalizations and mortality compared to previous waves and suggest that this may be related to high vaccine coverage. These trends suggest that countries with high vaccination might adopt a more permissive approach towards COVID even in the face of new variants.

Socioeconomic gradient in COVID-19 vaccination: evidence from Israel.

BACKGROUND: Low socioeconomic status (SES) groups have been disproportionately affected by the COVID-19 pandemic. We aimed to examine COVID-19 vaccination rate by neighborhood SES and ethnicity in Israel, a country which has achieved high vaccination rates. METHODS: Data on vaccinations were obtained from the Israeli Ministry of Health's open COVID-19 database, for December 20, 2020 to August 31, 2021. Correlation between vaccination rate and neighborhood SES was analyzed. Difference in vaccination rate between the first and second vaccine dose was analyzed by neighborhood SES and ethnicity. FINDINGS: A clear socioeconomic gradient was demonstrated, with higher vaccination rates in the higher SES categories (first dose: r = 0.66; second dose: r = 0.74; third dose: r = 0.92). Vaccination uptake was lower in the lower SES groups and in the Arab population, with the largest difference in uptake between Jewish and Arab localities for people younger than 60, and with the gap widening between first and third doses. CONCLUSIONS: Low SES groups and the Arab ethnic minority demonstrated disparities in vaccine uptake, which were greater for the second and third, compared with the first vaccine dose. Strategies to address vaccination inequity will need to identify barriers, provide targeted information, and include trust-building in disadvantaged communities.

Issues surrounding incentives and penalties for COVID-19 vaccination: The Israeli experience.

The purpose of this study was to examine patterns of COVID-19 vaccination in Israel and how these relate to different proposals made about benefits for those vaccinated, and to present the legal and ethical dilemmas surrounding these issues. A retrospective study of COVID-19 vaccination rates in Israel was conducted, with data obtained from the Ministry of Health (MOH). Information on benefits proposed or offered for vaccination and restrictions for non-vaccination were obtained from the MOH and presented in a timeline. By March 1st, 51% of the total population, and 91% of those aged 60 and over, had received their first COVID-19 vaccine. Exemption from quarantine was granted to vaccinated or recovered people from 17th January 2021. The 'green pass' incentive scheme, granting access to social, cultural and sporting events for those fully vaccinated or immune, was proposed in December 2020, and came into effect on February 21st 2021. Incentive schemes which impose limitations on those who choose not to vaccinate may motivate some people to take action. Policymakers should use a measured approach to protect public health, with minimum infringement on citizens' rights. Providing transparent and culturally appropriate information on immunization and ensuring maximal and equitable access to COVID-19 vaccines may help build trust.

Tipping the scales: a theoretical model to describe the differential effects of the COVID-19 pandemic on mortality.

BACKGROUND: The COVID-19 pandemic has resulted in changes in almost every aspect of life. The fatal consequences of the pandemic have been clearly reported, with direct and indirect effects; however, there is some evidence of a positive secondary impact, such as fewer motor accidents, lower influenza burden and reduced air pollution. METHODS/MODEL: We present a model to describe the differing effects of the COVID-19 pandemic on mortality, taking into account external pressures and internal resources and their relationship with resilience and health behaviors, which affect mortality risk, inspired by elements of the salutogenic model. Individuals with lower resources and from more deprived communities are likely to be more negatively affected by the external changes occurring, while those with more resources may be more likely to experience the benefits. Both individual and community resources affect coping and influence both mental and physical health. CONCLUSIONS: Decision makers should consider ways to incorporate the positive changes which occurred as part of the exit strategy. Societies should invest in building resources to improve both individual and community resilience to help people be better prepared and more able to cope and adapt in times of crisis. Special emphasis should be given to weaker populations most affected by external changes, including older people, low socioeconomic groups, those with mental health issues and minority groups, in order to reduce disparities.

Effect of Socioeconomic and Ethnic Characteristics on COVID-19 Infection: the Case of the Ultra-Orthodox and the Arab Communities in Israel.

BACKGROUND: During infectious disease outbreaks, the weakest communities are more vulnerable to infection and its deleterious effects. In Israel, the Arab and Ultra-Orthodox Jewish communities have unique demographic and cultural characteristics that place them at higher risk of infection. OBJECTIVE: To examine socioeconomic and ethnic differences in rates of COVID-19 testing, confirmed cases and deaths, and to analyze patterns of transmission in ethnically diverse communities. METHODS: A cross-sectional ecologic study design was used. Consecutive data on rates of COVID-19 diagnostic testing, lab-confirmed cases, and deaths collected from March 31 through May 1, 2020, in 174 localities across Israel (84% of the population) were analyzed by socioeconomic ranking and ethnicity. RESULTS: Tests were performed on 331,594 individuals (4.29% of the total population). Of those, 14,865 individuals (4.48%) were positive for COVID-19 and 203 died (1.37% of confirmed cases). Testing rate was 26% higher in the lowest SE category compared with the highest. The risk of testing positive was 2.16 times higher in the lowest socioeconomic category, compared with the highest. The proportion of confirmed cases was 4.96 times higher in the Jewish compared with the Arab population. The rate of confirmed cases in 2 Ultra-Orthodox localities increased relatively early and quickly. Other Jewish and Arab localities showed consistently low rates of confirmed COVID-19 cases, regardless of socioeconomic ranking. CONCLUSIONS: Culturally different communities reacted differently to the COVID-19 outbreak and to government measures, resulting in different outcomes. Socioeconomic and ethnic variables cannot fully explain communities' reaction to the pandemic. Our findings stress the need for a culturally adapted approach for dealing with health crises.

The effect of the COVID-19 pandemic on ED referrals and care for stroke patients: A four-year comparative study.

PURPOSE: To examine the impact of the COVID-19 pandemic on the presentation and care provided to patients with acute ischemic stroke (AIS) at the emergency department (ED). METHOD: A retrospective-archive study was conducted between January-April 2020, compared with the parallel months in 2017-2019, in a comprehensive stroke center. We compared the time from symptoms onset to ED arrival, the number of neurologic consultations completed in the ED, patients diagnosed with AIS, patients receiving acute treatment and hospital mortality. RESULTS: During January-April 2020, we found an increase in the proportion of stroke patients arriving at the ED within 6 h of symptom onset: 68-100% per month during the study period, compared with 28-42% per month in the previous years. The number of patients admitted to the ED with suspected AIS declined by 41%, compared to the parallel period in 2019. An increase was noted in the number of patients diagnosed with AIS who underwent treatment, with the number of s endovascular thrombectomy increasing throughout the examined year. CONCLUSION: During the COVID-19 pandemic, we observed a significant decline in the number of AIS patients admitted to the ED. Paradoxically, we have seen an increase in the proportion of patients who arrived shortly after the onset of symptoms and received timely treatment. Future studies might investigate the medical mechanism and ramifications of this phenomenon.

Coping with the COVID-19 pandemic - the role of leadership in the Arab ethnic minority in Israel.

BACKGROUND: The Arab ethnic minority makes up 21% of Israel's population, yet comprised just 8.8% of confirmed cases and 3.6% of deaths from COVID-19, despite their higher risk profile and greater burden of underlying illness. This paper presents differences in patterns of morbidity and mortality from COVID-19 in the Arab, ultra-Orthodox and overall populations in Israel, and suggests possible reasons for the low rates of infection in the Arab population. METHODS: Data were obtained from the Israeli Ministry of Health's (MOH) open COVID-19 database, which includes information on 1270 localities and is updated daily. The database contains the number of COVID-19 diagnostic tests performed, the number of confirmed cases and deaths in Israel. RESULTS: In the first 4 months of Israel's COVID-19 outbreak, just 2060 cases were confirmed in the Arab population, comprising 8.8% of the 23,345 confirmed cases, or 2.38 times less than would be expected relative to the population size. In contrast, the ultra-Orthodox made up 30.1% of confirmed cases yet just 10.1% of the population. Confirmed case rate per 100,000 was twice as high in the general Jewish population compared to the Arab population. The Arab mortality rate was 0.57 per 100,000, compared to 3.37 in the overall population, and to 7.26 in the ultra-Orthodox community. We discuss possible reasons for this low morbidity and mortality including less use of nursing homes, and effective leadership which led to early closure of mosques and high adherence to social distancing measures, even during the month of Ramadan. CONCLUSIONS: Despite a disproportionate burden of underlying illness, the Arab population did not fulfil initial predictions during the first wave of the COVID-19 outbreak and maintained low numbers of infections and deaths. This contrasts with reports of increased mortality in ethnic minorities and economically disadvantaged populations in other countries, and with high rates of infection in the ultra-Orthodox sector in Israel. Effective leadership and cooperation between individuals and institutions, particularly engagement of community and religious leaders, can reduce a group's vulnerability and build resilience in an emergency situation such as the current pandemic.