In a February 2021 update Dr. Howard Zucker, the Commissioner of health of New York State, recalls a story of an earlier vaccination challenge that should inform on many levels. It recounts how the challenge of a small Smallpox outbreak in New York City in 1947 was met by an extraordinarily successful vaccination of the entire population of New York City (6,350,000 people) in a single month.

Dr. Zucker recounts:

The great challenge of vaccinations at this scale has repeatedly called to my mind a little-remembered crisis faced by New York City in 1947—a small but potentially devastating outbreak of smallpox, which hadn’t been seen in the city in years. Smallpox is probably the deadliest communicable disease that the World Health Organization officially declared eradicated. But that was in 1980. Thirty-three years before, it was found to have been brought to New York by a man traveling from Mexico City. Thanks to the actions of Health Commissioner Israel Weinstein, New York City managed to vaccinate 6,350,000 people in its five boroughs in less than a month. Mayor William O’Dwyer urged all New York residents to receive the vaccine, and he rolled up his sleeve and was vaccinated by Dr. Weinstein. Only one person died from the disease other than Patient Zero, and there were only 12 infections.

This is an amazing story for public health: vaccinations were administered to millions in public and private hospitals, clinics, and police stations. But the truly amazing aspect to consider in 2021 is public engagement. In 1947, individuals of all ethnicities willingly waited for hours in the rain to get their smallpox vaccination. President Truman when he was in town rolled up his sleeve to get vaccinated. My father, a pediatrician practicing in the Bronx, was delighted to have the honor of vaccinating the boxing champ and American hero Joe Louis.

New York City’s magisterial response to the threat of an incipient smallpox outbreak in 1947 emphasizes the several important facets that will enable success, 1) a willing public and 2) enhanced execution during the “Last Mile”. Israel’s world-leading success in vaccinating a higher proportion of its population than any other country against COVID-19 holds many valuable lessons for the United States, the EU and the rest of the world.

Among the lessons we should adopt is Israel’s simplified system for deciding who would be prioritized for the vaccine, which mandated that age is the single determining factor, except for health care workers and first responders. Prioritizing people 75 years and older for first vaccinations after healthcare workers seems a no-brainer; after all, Covid-19 destroys is most apt to kill our most experienced and knowledgeable residents. Current data across countries suggests that the elderly are most at risk for contracting COVID-19. A breakdown of the Case fatality Rate (CFR) by age group across various countries who have made demographic data on confirmed cases and deaths available demonstrates very large differences of the CFR by age. As we know well, for many infectious diseases, young children are most at risk. For instance, in the case of malaria, the majority of deaths (57% globally) are in children under five. In contrast for COVID-19 cases the opposite seems to be true. The elderly are at the greatest risk of dying, if infected with this virus. It may not simply be that the older you get, the more at risk you are, though. Older persons are more likely to have underlying health conditions, such as cardiovascular diseases, respiratory diseases or diabetes, which is likely to constitute part of the reason why the elderly are most at risk from COVID-19.

Another important lesson to be learned is the success achieved by having Israeli health officials set up decentralized vaccination centers, in hospitals, pharmacy chains, pop-up centers and drive-thru sites. In contrast the dysfunction experienced in the initial months of the rollout in the United States, in Israel a centralized IT system governed the booking of vaccinations, with text-message reminders sent about appointments and second doses, utilizing a 24/7 call center. To facilitate the final “jab in the arm”, local community nurses and paramedics were drafted to participate and help with the rollout.

“Those who do not learn from the lessons of history are condemned to repeat them.” – George Santayana

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