30 Oct, 2020

Decades ago, when there was a police strike in New York City, the crime rate plummeted. And today, Israeli epidemiologists have found that during the first wave of the COVID-19 pandemic, the death rate decreased overall mortality. How could it be? Will the phenomenon repeat itself in the second wave of the coronavirus plague?

So far, nearly 1,400 Israelis have perished as a result of the pandemic.

A team of researchers from the Hebrew University (HU) of Jerusalem and Ben-Gurion University (BGU) of the Negev in Beersheba have concluded that the decrease in workload in Israeli hospitals during the first closure weeks had a decisive effect on the decrease in overall mortality at that time. This stresses the importance of home hospitalization as an alternative to hospitalization, which can promote deaths from infection in the wards and medical errors. 

In countries like France, Spain and Italy that became the most severe hotspots during the first wave of the Corona virus, overall mortality rates were high during the first months of the outbreak. In these countries, the closure did not contribute to a reduction in the number of deaths, and the death rate only increased. Whenever hospitals in these countries worked on a limited or emergency basis during lockdowns, as during holiday periods or weekends, a significant increase in overall mortality data could be seen. 

But the new study conducted by a group of Israeli researchers found that during the first closure in Israel, when hospitals worked in an emergency format, overall mortality rates were actually significantly lower compared to routine periods without holidays. 

Following the high death rates in Italy and Spain during the first wave, the Israeli researchers decided to investigate what was happening in their own country. The research team decided to look at the period of the Israeli first closure as a unique test case – a period that is not an actual Jewish holiday. The only thing that was similar between the holiday periods and the first closure in Israel was that the hospitals worked on a very limited basis. The Israeli researchers assumed that, as in other countries overseas, during the first closure there would be an increase in the total number of deaths, while reducing the number of medical services and hospital activities. To their surprise, they found that the opposite was true. 

The researchers had good reason to believe that the closure would contribute to an increase in the overall mortality rate – because some patients chose not to undergo many medical treatments during this period and because their health condition rapidly deteriorated as a result. Numerous studies have shown that elderly populations in many US states avoided seeking medical treatment during the first closure due to fear of being infected in hospitals treating COVID-19 patients. In addition, during this period, other medical conditions were not diagnosed and may have caused more death. Finally, when there is a new disease like corona, the resulting deaths are added to the existing mortality data every year in the population, so it is expected that in any case there will be an increase in overall mortality. 

In a recent study published on the MedRXiv medical website, researchers compiled all mortality reports from across Israel that had been recorded by the Health Ministry between January 2000 and May 2020, including holidays, weekends and the first closure period and divided them into weeks. The results were normalized according to the general population-size rates each year. Among other things, a comparison was made between the weekly mortality rates during the first Corona closure, compared with the weekly mortality rates in the weeks without holidays. The conclusions of the article are unequivocal

 — The average weekly death rates were significantly lower during the weeks of the first closure compared to weeks without holiday vacations.

Although the health services operated in the first closure in a very limited format, the heavy weekday burden on the Israeli health system was almost non-existent. In a routine situation, according to the scientific article, the average occupancy of hospital beds is about 94% throughout the year, with an average of only 2.2 beds per 1,000 people. 

For comparison, the average occupancy rate of hospital beds in OECD countries is 77% and the occupancy rate in the US is 64%. In addition, Israel ordinarily has fewer doctors and nurses on average per 1,000 people, compared with the OECD average. This burden contributes to an increase in the number of deaths associated with secondary (nosocomial)  infections acquired during hospitalization. The Health Ministry in Jerusalem has report that between 4,000-6,000 people die in Israel each year due to nosocomial infections.

When there was less crowding in hospitals during the first lockdown in Israel, fewer patients may have been exposed to hospital infections, and as a result, overall mortality rates fall. “This is a possible explanation for the phenomenon,” the researchers wrote in their study, “thus the importance of bolstering other treatment option, such as home hospitalizations and community medical services.” People should not be in hospital if they don’t have to be there. 

Although the study did not deal with the second closure that is currently taking place in Israel, it is difficult to compare the first and second lockdowns at such an early stage. The starting point of the two closures in terms of morbidity in the population is different. crowding in the hospitals, the authors suggested, will not decrease. As a result, it can be assumed at the moment that there will not be a lower death rate similar to that during the first lockdown, they concluded.