Interim Report for the First 18 Months of the Covid-19 Pandemic in Israel: Infection, Testing and Hospitalization According to City and Sector

The fourth wave of Covid-19 in Israel is apparently drawing to a close, while at the same time, the emergence of the Omicron variant is bringing with it discussions of a potential fifth wave. While discussions about closures, vaccination of children and new medications to prevent serious illness are at the forefront of public debate, it is useful to take a step back consider how Israel has weathered the coronavirus pandemic up to this point on the public health front.

A study carried out by Professor Alex Weinreb entitled, “Variation in Covid Testing, Infections and Hospitalization by Town and Population Sector”,which was published last month, provides an interim report for the first 18 months since the outbreak of the pandemic. It describes the main patterns of the pandemic in Israeli society and sheds light on some important lessons that should be considered in the future response to pandemics.

The main questions examined by the study concern the variation in per capita rates of testing, infection and hospitalization across 205 towns and cities in Israel and across the main population groups. These 205 towns/cities represent a population of about 8 million (about 88 percent of Israel’s population as of mid-2020). A multivariate analysis looked at the relationship between per capita rates of testing, infection and hospitalization and a number of towns/cities’ characteristics, including socioeconomic ranking (as determined by the CBS), population density and the percentage of the citys population aged 65+.

The cities were also classified according to their dominant population group into seven sectors: non-ultra-Orthodox Jewish, ultra-Orthodox, Arab, Bedouin, Druze, mixed Arab-Jewish and mixed ultra-Orthodox/non-ultra-Orthodox jewish.

The findings of the study indicate that the highest rates of testing were found, on average, in non-ultra-Orthodox Jewish towns/cities: 324,000 tests per 100,000 residents. In contrast, the lowest rate of testing—at less than half of the national average of 2.70 tests per capita—was 115,000 tests per 100,000 residents which was found in the Bedouin settlements. The average rates of testing were also relatively low in the Arab and Druze towns/cities: 210,000 and 217,000 per 100,000 residents, respectively. The rate of testing in the ultra-Orthodox sector was in the vicinity of the national average.

The ranking of different population groups in terms of infection per capita looked quite different. The highest rates of infection were found in the ultra-Orthodox towns/cities: the rate of confirmed infections in the ultra-Orthodox sector was 31 percent as compared to the national average of 13.7 percent. The ultra-Orthodox cities of Rechasim and Beitar Illit led in confirmed infections with about 40 and 38 percent, respectively. After controlling for poverty, population density, the percentage of residents aged 65 and over and other characteristics, per capita infection rates in the ultra-Orthodox cities remained 2.4 times higher than the rates in non-ultra-Orthodox Jewish cities. Furthermore, outside the nine ultra-Orthodox towns/cities, a high correlation was found between rates of infection and the proportion of ultra-Orthodox residents in mixed cities.

A high level of variation was found in infection rates in the Arab sector. The cumulative infection rate in the Bedouin sector stood at only 8.4 percent. Within the non-Bedouin sector, some of the most peripheral communities had very low rates—notably, the lowest cumulative infection levels in Israel were found in Israel’s only Alawite settlement, ’Ajar, which is located on the Lebanese border. These low rates may stem from these towns’ relative social isolation. Or they may also be the result of low testing rates, which in turn are an indication of relatively limited access to healthcare services. The highest levels of infection in the Arab sector (over 18 percent of the population infected) were found in Kfar Kassem, Abu Ghosh and Maale Eiron, all of which are close to larger urban areas and are located on major roads.

The third main pattern examined by Professor Weinreb is the rate of Covid hospitalization. Among  the main risk factors for serious morbidity are a history of cardiovascular disease or diabetes, and obesity. These can explain the high rates of hospitalization in the non-Bedouin Arab and Druze towns/cities, where these risk factors are more prevalent. This is particularly the case for Type II diabetes and obesity, which, according to estimates, is three times more prevalent in these towns than in the Jewish sector. Fourteen of the top twenty cities in Israel in terms of Covid hospitalization are from the Arab sector. Abu Ghosh topped the list with 1.2 percent of its population having been hospitalized. A higher-than-expected hospitalization rate relative to the rate of confirmed infections was also found in the Bedouin sector. In contrast, despite its high rate of infection, the risk of hospitalization in the ultra-Orthodox sector was much lower. This is due to the fact that the population in the ultra-Orthodox sector is for the most part relatively young and only a small percentage of its population is over 65: only one percent in Modiin Illit, 1.3 percent in Beitar Illit and 2 percent in Elad, as compared to the national average of 14 percent. Thus, even if more young people were infected it is likely that they were asymptomatic and did not require testing or hospitalization.

The study also looked at the connection between socioeconomic variables, such as poverty, population density, and the percentage of elderly in the population, and differences in testing, infections, and hospitalization. Findings indicate that the lowest rates of testing per capita are to be found in towns/cities with the lowest socioeconomic status, and the highest rates of confirmed infections are to be found in towns/cities with a socioeconomic ranking of 1 to 4. These poor towns/cities also had the highest rates of hospitalization per capita. Finally, the percentage of residents aged 65 and over had an effect on rates of testing, infection and hospitalization: towns/cities with a high proportion of residents aged 65 and over had high testing rates and low rates of infection and hospitalization, an indication of the success of efforts to lower rates of infection in these locations.

As mentioned, this study serves as a kind of interim report for theititial  18-month period of the Coronavirus pandemic in Israel. Two main lessons can be drawn from this for dealing with future waves, or a different epidemic: first, the need to facilitate greater access to healthcare services in marginalized areas and the allocation of resources in the form of clinics and manpower (which should perhaps be local manpower in order to achieve greater trust among residents); and second, the adoption of a consistent approach to the enforcement of regulations to limit the spread of viruses. The selective enforcement adopted by the government of Israel indirectly facilitated the spread of the virus, and it would be worthwhile for the government to restore its authority in areas where it has eroded.