Green Pass and COVID-19 Vaccine Booster Shots in Israel

Green Pass and COVID-19 Vaccine Booster Shots in Israel

Oz Koren, Shoshy Altuvia, Retsef Levi 6.10.2021

Green Pass and COVID-19 Vaccine Booster Shots in Israel

– A More ‘Realistic’ Empirical Assessment Analyzing the Airport Data

By Oz Koren1, MM, Shoshy Altuvia2, Retsef Levi3 Oct 3, 2021
Since the 3rd week of June 2021 Israel has been experiencing another wave of COVID-19 infections, as seen in Graph A4.

This wave has continued in spite the implementation of a strict “Green Pass” policy that required any unvaccinated individuals above the age of 3 to show a recent (last 24 hours) negative COVID- 19 test in order to be able to enter restaurants, shows, sport events and other public settings and events. In fact, similar policy is now implemented by many work places.

Due to the rapidly increasing number of confirmed cases and resulting hospitalizations and deaths, the Ministry of Health (MOH) has concluded5 that the Pfizer-BioNTech vaccine’s efficacy is waning over time to the extent that it is necessary to administer a booster shot (3rd dose of the Pfizer- BioNTech vaccine). On July 30, 2021, Israel launched an aggressive booster vaccination campaign starting with the over 60 population and rapidly expanding to all ages above 12. As of September 20, 2021, the booster shot was administered to nearly 3.1 million people as can be seen in the Graph B6.



As can be seen from Graph C7, as of September 20, 74% of the over 60 population received the booster. Similarly, 58% of the 50-59 population, 47% of the 40-49, 35% of the 30-39 population,

28% of the 20-29 population and 19% of the 16-19 population.

The New Green Pass Eligibility in Israel
Following the aggressive booster vaccination campaign, as of October 3, 2021 the Israel MOH has changed the eligibility criteria8 for Green Pass holders, requiring anyone that received the second dose of the Pfizer vaccine more than 6 months ago to get vaccinated with a booster shot or otherwise lose their Green Pass. Additionally, individuals who recovered more than 6 months ago will also be required to vaccinate. To summarize this change, the new definition of Vaccinated and Unvaccinated is as follows:

Anyone who has received the 3rd dose (booster) more than 7 days ago.
Anyone who has received 2 doses more than 7 days ago, but less than 6 months ago.
Anyone who recovered after testing positive (PCR test), or shows recovery signals on a serological test, and has received 1 dose more than 7 days ago.


Anyone who did not receive 2 doses at least 7 days ago. (note that this includes completely unvaccinated individuals).
Anyone who has received their 2nd dose more than 6 months ago.

The Israel MOH justifies the epidemiologic rationale of the new Green Pass policy based on several studies that show that the protection of the initial 2 doses of the Pfizer vaccine against infection wanes over time9 and that the booster presumably regains this protection level back.


Thus, it is effectively ‘safe’ to let Vaccinated individuals (based on the new definition) to enter public settings with no tests and require Unvaccinated individuals (again see above) to be tested.

In particular, on Sep. 15, 2021 a group of researchers, including Dr. Sharon Alroy-Preis, Head of Public Health Services in Israel Ministry of Health (MOH) published a study of the booster efficacy10 based on data collected by the MOH during the campaign. The study asserts that the booster achieves a 11.3 (95% confidence interval [CI], 10.4 to 12.3) relative reduction in the risk of COVID-19 infection11 among the over 60 population, compared to the original 2 vaccine doses.

Overall, the paper follows 1,137,804 individuals ages 60 or older, who were eligible for a booster dose (who received their second dose before March 1, 2021) between July 30 (when the booster campaign was launched) and August 31, 2021. The study compares the rates of infection and severe COVID-19 outcomes per person-days at risk between two cohorts to estimate the booster efficacy, using Poisson regression, adjusting for possible confounding factors.

Unfortunately, there are multiple methodological problems with this study, the most significant of which is the fact that there is no appropriate control for the number of respective tests conducted among the members of each cohort. Moreover, the resulting respective positivity rates are not reported. This is a major potential source of an upward bias of the booster efficacy against infection, since there are all reasons to assume that the booster cohort was tested in significantly lower intensity, and in fact there are data in the MOH paper itself to support this assumption. The different intensity is the result of both individual behavior (i.e., individuals who are vaccinated with the booster will be less concerned about infections and will test less frequently) as well as the MOH testing policy.
Estimating of the Green Pass Efficacy Based on Data from Israel Airport
Recently, the MOH introduced a new “widget” to the public online Control Dashboard12 that presents detailed data on individuals entering into Israel. The data includes information on the vaccination status as well as the number of positive cases as a function of the vaccination status.

Graphs D & E present the aforementioned ‘widgets’ in the MOH Dashboard related to the individuals that indeed provide, for each day, the exact number in each group, as well as the number of positive cases, whereas positive cases constitute of individuals who tested positive within the first 10 days of their return date. Note that in spite of the difference in testing between the two groups of Vaccinated and Unvaccinated mentioned above, at least in this setting all individuals must take a test upon entering Israel.


Table 113 below shows the respective data of the above-mentioned airport widget for 45 days throughout September 25. There were 3016 confirmed cases among 314,369 Vaccinated, which is 0.96% positivity rate. Additionally, there were 4776 confirmed cases among 308,494 Unvaccinated which is 1.55% positivity rate. This implies that the relative risk of infection among the Vaccinated is reduced by a factor of 1.61, which is significantly lower than the 11.3-fold reduction estimate presented in the MOH’s paper.

Furthermore, it is important to note September 9-10, 2021 as unique days that capture an event where thousands of Orthodox Jews returned from Uman (Ukraine) and many falsified hundreds of PCR results prior to coming back to Israel. These two days represent an outlier and omitting them and the following 10 days (accounting for the 10 day period after arrival over which they consider positive cases) from the analysis further reduces the estimated efficacy of the booster vaccine to 1.35.

Based on high booster vaccination rates, it is reasonable to assume that at least 40 percent of the newly defined Vaccinated cohort (see above) are vaccinated with a booster and most of the rest are more recently vaccinated individuals with 2 doses. If one takes a conservative assumption that the relative protection of the individuals who are vaccinated with 2 doses (less than 6 months ago) is at least 20 percent (1.25-fold), it follows that the relative protection of the booster is at most 2.75- fold). In fact, assuming that the booster shot indeed provides protection of 11-fold implies that those vaccinated with 2 doses have no additional relative protection (less than 1-2 percent).

All of these conclusions follow from the fact that the overall relative efficacy of the Vaccinated cohort seems to be around 1.61-fold and the insight that the relative protection of the Vaccinated cohort is closely approximated by the weighted average (based on the relative proportion within the Vaccinated cohort) of the respective relative protection of each of the sub-cohort (boosters and 2 doses). Considering the recovered individuals who are known to have extremely high protection against infection will make this analysis even less favorable with respect to the booster efficacy.

More generally, the analysis above makes it very clear that the Green Pass policy epidemiological rationale is highly questionable. Considering all individuals over 12 who are vaccine-eligible, the


current Vaccinated cohort is 1.6 times larger than the Unvaccinated cohort. Thus, the absolute number of infected individuals from the Vaccinated cohort is likely to be at least as large as the number within the Unvaccinated cohort. Moreover, since these individuals will not be tested and be less likely to have symptoms or attribute their symptoms to being infected with the COVID-19 virus, it is quite likely that they will interact with many more contacts and run a significant risk to infect others. This risk is underscored by consistent findings that vaccinated individuals, once infected, can have high viral load14.

In conclusion, the analysis above suggests that the relative protection against infection between the individuals in the newly defined Vaccinated and Unvaccinated cohorts based on the new Green Pass policy is only 1.61 or even less. This suggests that unless the protection of the 2 doses have completely waned within less than 6 months, the relative protection of the booster shot is significantly lower than the MOH estimates of 11-fold, probably at most 2.75-fold.

Equally the analysis raises fundamental questions regarding the rationale of imposing the new Green Pass policy as it seems that it is not going to be effective in truly eliminating infections, especially considering the expected decline in the booster efficacy over time. In fact, the Green Pass policy could support the wrong perception within high risk patients that they are protected around vaccinated individuals, whereas those can be infected and infect them.

Table 1 was created on Sep 25, 2021 to reflect the most current data.

Group A: “Vaccinated”

Pos A: the number of confirmed cases (absolute number) among Group A

Group B: “Unvaccinated”

Pos B: the number of confirmed cases (absolute number) among Group B

1 Mr. Oz Koren, MM, BGSU, Bowling Green, OH

2 Professor Shoshy Altuvia, PhD, Department of Microbiology and Molecular Genetics, The Hebrew University, Jerusalem, Israel

3 Professor Retsef Levi, PhD, MIT Sloan School of Management, Cambridge, MA (

4 Taken from

5 Waning immunity of the BNT162b2 vaccine: A nationwide study from Israel

6 Taken from the Israel MOH dashboard:

7 Taken from the Israel MOH dashboard:


9 Waning of BNT162b2 vaccine protection against SARS-CoV-2 infection in Qatar (

10 Protection of BNT162b2 Vaccine Booster against Covid-19 in Israel

11 The study also reports the rate of severe illness was lower by a factor of 19.5 (95% CI, 12.9 to 29.5).


13 Table 1 was created on Sep 25, 2021 to reflect the most current data. Group A: “Vaccinated”

Pos A: the number of confirmed cases (absolute number) among Group A Group B: “Unvaccinated”

Pos B: the number of confirmed cases (absolute number) among Group B

14 Shedding of Infectious SARS-CoV-2 Despite Vaccination (

This is how Pfizer managed to obtain the FDA's emergency authorization for children

This is how Pfizer managed to obtain the FDA's emergency authorization for children

Yaffa Shir-Raz 3.06.2021

Analysis and comparison of the review document submitted by Pfizer to the US Food and Drug Administration… reveal concerning findings, including violations of the protocol established by Pfizer itself,

Thoughts of a psychologist in the time of Corona

Thoughts of a psychologist in the time of Corona

Clinical psychologist, Dr Simon Kuttner 28.02.2021

…One of the central roles of the psychologist is to help the client create a more balanced life of soul. Balance and perspective are the foundation of mental health
We need perspective, not in order to convince but in order to foster our mental health

Something Isn't Right

Something Isn't Right

Site Staff 24.01.2021

Here is a fact-based topic-by-topic assessment of the mainstream Covid perspective

Founding Document-Emergency Covid19 Council

Founding Document-Emergency Covid19 Council

Dr. Yoav Yehezkeli 29.12.2020

Founding Document-Emergency Covid19 Experts Council

A third Lockdown is not an option, and should be taken off the table Immediately

A third Lockdown is not an option, and should be taken off the table Immediately

Dr. Yoav Yehezkelli 15.12.2020

Focusing on the Pareto of illness and mortality, on protecting the vulnerable population, on a differential approach for areas with higher infection rates and on the careful reopening of all activities where Infection rate is low are essential for correct handling of the crisis .

It’s heartbreaking to see the small business owners whose businesses have collapsed, the unemployed and the children still withering at home, the destruction and suffering brought on by the second lockdown and the continuing Coronavirus measures in Israel. The collateral damage to our health, our emotional well-being, our society and our economy is immense. As is the way of crises, at first resources are mobilized to combat the danger, but these run out as the crisis continues, and so the worst of the damage is still before us, in the form of depression, anxiety, despair, loneliness, loss of livelihood, neglected treatment of chronic diseases, domestic violence and a general breakdown of trust.

Does the damage caused by the response to the pandemic, a result of government policy, equal or even exceed that of the natural damage of the pandemic itself? Is the decision to adopt a strategy of suppression of the virus at all cost justified and realistic? Has the government been trapped in a misconception in its dealing with the crisis?

The outbreak of a contagious disease has certain natural dynamics which depend on the characteristics of the disease and of the population. The severity of the disease, the immunity of the population and the availability of treatment and vaccines determine the number of cases and of deaths, as well as the shape of the
morbidity curve along the time axis. An epidemic continues until it has consumed its natural fuel, infections in the susceptible population, and until immunity is reached.

According to present knowledge, the mortality rate from COVID-19 (the infection fatality rate – or ratio of deaths to the number of people infected in the population) in the age bracket of 20-49 is 0.0002, while mortality above the age 70 is 0.054: Far from being a deadly disease like the great epidemics of plague and smallpox.

In the absence of a vaccine or treatment, the strategy is to limit the extent of illness by decreasing contact between people. However, a lockdown does not lower the number of deaths from an epidemic, it only delays it. Lockdowns, physical distancing and limitations on gatherings can flatten the infection curve over time, but will not change the ultimate number of infections and deaths, because the area under the curve remains the same. The attempt to suppress the virus at all cost is therefore foolish, destined to fail and damaging.

There are currently several vaccines undergoing emergency approval processes, which may be available to some of the population in the near future. However, mass production will take time, and the vaccine will not have any real effect on the spread of the epidemic in the coming months, and this will still be determined
by the natural immunity caused by infection. In addition, the vaccine studies will have to continue for a long period of time to ensure that their use is safe and there are no long-term side effects

The question is, how do we deal with this reality. There are two main strategies for combating an epidemic: The suppression strategy, which aims to eliminate the virus at all cost and bring the infection rate down to zero, and the containment strategy, which acknowledges the limitations of our power and strives to reduce

illness and mortality to bearable rates, which means a reproduction number (R) of between zero and one.

The asserted aim of “flattening the curve” was preventing a collapse of the health system due to an overload of patients. We can now say that at no stage, including at the height of the second wave, was the health system even close to its full capacity, since even non-urgent activities continued as usual. The “red line” of 800 severe patients was to begin with an unbased figure, and when this was exceeded, the bar was raised overnight to 1,500 severe patients. We can therefore say that even if the aim of protecting the health system was a valid one, the criterion that was set in order to attain it was mistaken.

Every step taken to eliminate the pandemic should be evaluated according to its cost in relation to its value. For this reason, “breaking the chain of transmission”, which involves enormous investment in a humongous system, is unavoidably limited in efficiency when there is transmission by asymptomatic patients.

Likewise, the acquisition of thousands of respirators, adding more hospital beds or building new departments in underground hospital parking areas are all useless if there is no additional professional personnel to staff them. The necessary and correct investment in the health system at this time is not in useless machines, but in the bolstering of exhausted and overburdened health care workers and in the modification of treatment strategies, such as planned referral of moderately ill patients to home hospitalization.

From what we’ve learned, there is dramatic variability in the risk the virus poses for the population: from a light to an asymptomatic illness in the young and healthy, to a severe and dangerous illness in those over 70 or with underlying disease or obesity. In addition, there are differences in the transmission of the disease for different social groups and depending on situations such as living conditions, family size and lifestyle characteristics. One can either ignore this variability and treat the population as homogenous, as has been done in Israel so far, but at the same time, this can provide an opportunity for informed risk management, containment of the disease and the continuation of reasonably normal life alongside it.

Focusing on the Pareto of illness and mortality, on protecting the vulnerable population, on a differential approach for areas with higher infection rates and on the careful reopening of all activities where Infection rate is low are essential for correct handling of the crisis. By all these measures, the Israeli government has so far received a failing grade, first, because the professional appointees have fallen into a cognitive trap of tunnel vision, focusing on eliminating the Coronavirus while ignoring other aspects of public health, and second, because expert opinions have been pushed aside for political and sectorial reasons.

After months of combating the Coronavirus, it’s time to define a goal for this battle, an attainable goal, instead of the futile attempt to eradicate the disease.

The purpose of the effort should be minimizing mortality from the disease while maintaining normal life as best we can. From this aim, we can draw the measures of our success in the battlefield: Not the number of confirmed cases on a day to day basis, but the mortality rate, which we should strive to minimize; and at the same time, the levels of activity in education, society and the economy, which should be encouraged and enhanced whenever possible. Once the main goal is defined correctly and realistically, the mindset which has overtaken the government will be freed, new ways of coping will be found, trust can be re-established and the public can be encouraged to rejoin the effort.

The main challenge in dealing with an epidemic crisis of this scale is mental. Denial of reality, fear and avoidance are natural human responses, but when they infiltrate decision making, the outcome for the public can be devastating. Policy should be guided by a broad vision of public health, not a narrow one, in line with
the definition of health by the World Health Organization as “a state of complete physical, mental and social well- being and not merely the absence of disease or infirmity”. Livelihood means health, social relations mean health, and education means health.

Just as we wouldn’t consider closing all roads to traffic in order to avoid traffic accidents, or closing all hospitals in order to prevent acquired infections, or for that matter staying home so as not to get caught in the rain, so it is unreasonable to lock everyone at home in order to avoid disease that is for the most part unpreventable. A third lockdown is not an option, and should be taken off the table Immediately. The illness we have at present, which is mostly mild, brings the public closer to immunity, providing we protect the vulnerable population, for whom the disease is more dangerous.

The continual attempt to avoid the unavoidable and suppress the virus at all and any cost to the population is foolish, futile and harmful. The acceptance of unpreventable disease is not a fatalistic approach that sees the epidemic as destiny, but a realistic attitude based on factual risk assessment, which aims to implement universal and proportional measures – such as social distancing, or masks in closed spaces and not out in the open air – alongside strengthening the real capacities needed to deal with the illness.

It’s time the policy makers freed themselves of the limiting mindsets that have been hampering them, in order to find the flexibility that is crucial to navigating the crisis along a different course. A redefinition of the goals of the battle against the Coronavirus will enable us to reach a new and sustainable equilibrium which acknowledges the values of life and health in their full sense.


The world and the coronavirus – the conviction stands

The world and the coronavirus – the conviction stands

Prof. (emeritus) Eyal Shahar 8.12.2020

In the spring of 2020, an experiment in public health was carried out which would not have passed an ethics committee even in an out-of-the-way small town in the U.S. 

Routine Days in the Department of Emergency Medicine –  An Island of Tranquility in a Stormy Sea of Pandemic Panic

Routine Days in the Department of Emergency Medicine – An Island of Tranquility in a Stormy Sea of Pandemic Panic

Dr. Amir Shahar 7.12.2020

The scientific truth:
 Most of those tested “positive” are not sick. A respiratory virus has passed through their throat, like many other viruses, and did not cause any illness.

Not for general closure, yes for behavioral change and personal responsibility

Not for general closure, yes for behavioral change and personal responsibility

Dr. Yoav Yechezkeli 31.08.2020

Half a year after the onset of the COVID-19 epidemic, morbidity in Israel is on the rise (the important figure is the number of serious patients) and a decision was made by the government to impose a general re-closure, as if it were the most effective and effective measure available to us. A general closure, after which the innovative system for “amputation of the infection chains” will be activated, followed by the vaccine, whose development in Israel is expensive and unnecessary, and will come to the rescue. But like the “exit strategy” from quarantine in the first wave, these are actions whose effectiveness is unclear and whose implementation in the field is unlikely to succeed.

The increase in morbidity and the imposition of a second closure are the result of the failure of the Israeli government to treat the epidemic. The delays in decision-making, their politicization and the loss of public trust, for which the government is responsible, are events that thwart the eradication of the epidemic. Would it have been conceivable during a war that the government would delay for weeks a decision on an action plan offered to it by the military professional echelon? This is exactly what happened with the projector’s traffic light plan appointed by the government itself, which did not receive its backing.

A general closure has not been shown to prevent mortality from an epidemic. It just “flattens the curve” and repels the disease and eventually the area under the curve does not change. A full closure has devastating health, social and economic side effects. The loneliness, anxiety, depression, neglect in balancing chronic diseases, the delay in treating urgent situations, the educational deprivation among children and the violence in closed homes are an unbearable health price to pay for a full closure. This is a price that has not yet been researched and quantified enough, but anyone who works in the field in the first line and treats people, and does not sit in front of the plasmas with the graphs, until he daily and feels it in his flesh. On the heavy economic and social price I think there is no exaggeration. A night curfew is generally a step devoid of any professional logic, as the reduction in contacts he achieves is minimal.

The new corona virus has a special feature that makes dealing with it particularly challenging. Patients with the virus are also contagious when they have no disease markers or in the two days before the first signs of the disease appear. This is why the effectiveness of epidemiological investigations in identifying and isolating contacts is limited in stopping the spread of the disease. The concept of “cutting off the chains of infection” may therefore turn out to be a failed brand, and the huge investment in the huge investigation system that has been established, important as it is, therefore deserves further examination.

What can be done? When in trouble return to base. The basis for stopping disease transmitted from person to person through the air are the physical distance measures, 2 meters and masks indoors, the same behavioral change that the public has not yet understood and internalized its importance, due to lack of trust in the establishment. When we set up the epidemic treatment team in the late 1980s, its members included a psychologist who specializes in population behavior, so that the treatment of behavioral aspects and the public’s involvement in the right actions will be reflected in crisis management. At this time there is no proper treatment of this critical component, the central condition for achieving which is the existence of credible leadership. In the absence of confidence in decision-making and financial compensation for the harm to livelihoods, the public’s willingness to cooperate with a draconian move as a full closure is questionable. Imposing a decree that the public will not abide by and mass disobedience can have heavy implications.

Professional logic must underpin the plan and be clear, understandable and assimilated in each and every one of us, in day-to-day behavior, personal responsibility and mutual guarantee. The responsibility of the younger generation, who are immune to a serious illness, for the older generation is much more vulnerable to the complications of the disease and mortality from it. The distinction between closed spaces and the open air should also be emphasized in the guidelines. The safest in the open air: As long as there is no crowded crowd, there is no professional need to wear a mask outside. On the other hand, wearing a mask indoors is very important.

After the first wave the health system did not receive the resources needed to reinforce it. Precious time went down the drain. Reinforcement, as much as is done at all, today focuses on “irons” instead of the human aspect, on the addition of beds instead of focusing on the addition of manpower and concern for the well-being of worn-out crews and their safety. The limiting factor in the health system’s failure is not the respirators and beds, but the shortening of the breathing of the doctors and nurses. There is something to be done: Recruiting physicians and retired nurses for bureaucratic tasks that do not involve direct contact with patients due to the risk of releasing medical staff to care for patients. Reducing elective surgical activity will make it possible to strengthen the staffs in the internal medicine departments. Hospital administrators still bear the trauma of the Ministry of Health’s decision, then wrong, to shut down elective activity in the first wave of revenue loss that involved, but if they knew they would be fully compensated for such a move economic considerations would not prevent them from making the right decision now.

There has been a lot of talk in recent days about a red flag that the health system has waved to the government in the face of the difficulty. The health care system is busy, the staffs are worn out, but it is far from collapsing. The message that needs to be conveyed is a message of resilience. The real red flag that medical teams wave is to the Israeli government, for the neglect of the health care system, for the politicization of decision-making in the professional field and for the abandonment of medical staff.

The World Health Organization defines health as follows: “Health is a state of perfect physical, mental and social well-being, and not just the absence of disease.” Decision-makers need to see the big picture, so that we do not pay in public health to prevent disease. There is no need for a full closure at this time. Leadership is needed that knows how to make brave decisions, based on professional rather than political considerations, and withstand pressure. Physical distance measures, in which deep professional and logical thought is invested, with uniform criteria for all, and which true leadership will know how to harness the public to follow, may restore public confidence and achieve a better overall result.