Israel’s Astounding Vaccine Rollout Success – what can we learn?

Israel has vaccinated almost 30% of its citizens, which is more people per capita than any other country in the world. Israel has a population of approximately 9.25 million, 11.65% of which are over 65 years of age, living in an area of only 22,145 km squared. Countries the world over have marvelled at Israel’s success with such a feat.

Recently the Israeli Ministry of Health briefed international media on Israel’s vaccination campaign success. People from all over the world joined this fascinating webinar in which people could openly learn from Israeli expertise and ask questions.

The briefing was presented by Dr. Asher Yeshaihu Salmon, who currently serves as the Head of the Department of International Relations at the Israeli Ministry of Health. He is a member of the OECD (Organisation for Economic Co-operation and Development) Health Bureau and of the Israeli National Health Council, and is a Focal Point for the WHO. His previous roles include Deputy Director of the Hadassah University Hospital in Jerusalem, Deputy CEO and Medical Director of the Barzilai Medical Center, and Head of the Oncology Ward at the Sharett Institute of Oncology.

After studying medicine at the Israel Institute of Technology, Salmon went on to complete a PhD in molecular biology at the Hebrew University of Jerusalem. Salmon also completed his MA in Health Administration summa cum laude in 2010. His key fields of interest include breast cancer, endocrine tumors, cancer genetics, and health economy, and he continues to publish extensively on these.

Dr Salmon’s substantial experience and expertise made for a fascinating presentation and discussion.

Aspects of the vaccine rollout success

1. Israel’s Healthcare System

Israel has a successful universal healthcare system, which has elements of public and private health care. It was established with the State of Israel, and its current structure is based on the 1994 Israeli National Health Law. Israel ranks exceptionally highly in terms of life-expectancy, health efficiency and the health of the general population.

Israel has 4 Health Maintenance Organizations (HMOs) and every resident must join one of these health insurance organizations which are run as non-profits. Private insurance for extra cover options can be purchased. Basic health care is treated as a fundamental right.

2. Preparation as soon as information was available

Israel had its first official patient at the end of February 2020. Preparations were made from mid-January as soon as information from Wuhan, China, was available. Training hospital staff and putting guidelines in place are some examples of preparations. Israel was the first country to close the skies to China and the Far East, and then to Western Europe and the US. Dr Salmon mentioned that this was unfortunately 5 days too late, and that Israel did receive a massive number of patients mostly from New York, but also from London and Paris. Israel peaked in its first wave at the end of March 2020.

3. Investigation of Vaccine options in April

Israel started discussions with AstraZeneca in April. Soon after that there was discussion with Moderna and many other companies. The first agreement was with Moderna and a few others and Pfizer came into the practical plan later in November, as Pfizer was willing to push ahead into Israel with a substantial amount of vaccines, with the understanding that Israel is prepared, ready and organized to start vaccinating immediately as there is regulatory permission.

4. Key Principles Adopted

1. Vaccinating as quickly as possible to reduce morbidity and mortality
2. Properly prioritize groups of individuals within the country
   Medical staff and at the same time all those over the age of 60 were immediately prioritized, and a certain amount of first responders (ambulance drivers, paramedics, policemen, etc) even though they tend to be relatively young. The reason for this is to not let any doses go to waste. The process is to find out how many doses are left over at the end of the day, which won’t be used the same day, and get the first responders vaccinated with those “leftover” vaccines. Almost 90% of fire brigade personnel in the country were vaccinated in this way.
3. Media and information dissemination
   Information on why it is important to be vaccinated was made widely available, showing the public that there is enough evidence that these vaccines are safe. Creating transparency on everything that is happening, and creating trust was imperative.
4. Tracking side effects and risk management
   Tracking all relevant information in an efficient, centralized, electronic system. Israel has a strong ICT sector and could do this well without ‘pen and paper’.
   

The challenges

1. Ultra cold storage requirements
   The Pfizer vaccine needs to be stored at -80 degrees celsius. This is challenging regardless of the size of the country. A decision was made to keep all vaccines in one national storage site, at the logistics site of the biggest pharmaceutical company in the country, Teva, situated in the centre of the country.
2. Short vaccine shelf-life
   Once out of the deep-freeze, the vaccine has a shelf-life of 120 hours and needs to be kept between -2 and -8 degrees. A decision was made not to let it be unused for more than 96 hours.
3. Limited information on product stability and portability
   Liposome based vaccines like Pfizer’s and Moderna’s are very sensitive to vibration or movement shocks. They therefore need to be transported with specialized technology, and transported only once.
4. Unknown “demand” and unclear supply
   It was of vital importance to be able to plan supply properly.
5. Strict regulations
   There are strict regulations to which the Israeli government needs to adhere (such as details around quality and batches for example) and there was a need to wait for the FDA to make its decisions around emergency licensing before the Israeli government made its local regulations.

Procurement

Israel has a National Procurement Scheme with multi-Ministry cooperation, including the Prime Minister’s Office, the Ministry of Health and the Ministry of Defense. This multidisciplinary approach, efficiency, transparency of various leaderships and the ability to work together, is what brings quick, creative solutions in all spheres of life in Israel. This culture is also part of what makes Israeli innovation such a success.

All procurement was coordinated through the Ministry of Health’s Covid-19 Command Center, ensuring a smooth vaccine rollout.

It is also important to note that negotiations with suppliers were started very early, and contracts were signed and agreed upon even before regulatory approval, in order to support quick supply.

Operation and Logistics Guidelines

All logistics are coordinated through the abovementioned Covid-19 Command Center.

With the single storage unit, and transportation challenges tackled, each and every weekend, the Covid-19 Command Center plans the deliveries for the coming week based on demand for each specific point. Deliveries are made 3 times a week to avoid any expiration issues, and they go out in the very early hours of the morning.

There are 350 vaccination points all over the country mostly in large common locations like stadiums, shopping malls and such, and in smaller, rural areas HMOs generally worked together to open vaccination centers.

Training personnel was done mostly by Zoom. First there was a “train the trainer” program in each HMO, mostly nurses and also paramedics, and then each HMO trained their own personnel.

Clinics, community centers and public hospitals were then asked to vaccinate their own medical staff, and also asked to assist with the national initiative to vaccinate the entire population. As time moved on more effort was placed on the communities and less on the hospitals.

At the same time there is an outreach project for nursing homes. There are more than 600 nursing homes in Israel. The goal was to vaccinate everyone in the nursing homes, including staff, within a month.

At this point there is an initiative being discussed for how to vaccinate those being looked after at home long-term, such as elderly, disabled or sick people which mostly cannot be transported to vaccination centers.

Lessons Learned

1. There was a need to create smaller cases for distribution
   The standard Pfizer case is for 960 vaccination doses. For remote areas where, for example, 50 or 60 doses are needed, other cases needed to be made.
2. A stable and accurate information system is critical for:
   • Side-effect tracking
   • Documentation and information – the ability to accurately upload someone’s information to their electronic health profile on the National Central Registry. This also enables the person to receive communication, for example: a text about when and where to have their 2nd shot.
   • Inventory and avoiding vaccine expiration at each and every site.
3. Call-centers for vaccination professionals and for the public
   • To assist the professionals vaccinating – this is a 24-7 line for any questions or assistance needed, which reduces errors and any unnecessary losses of vaccines.
   • To assist the general public with any queries such as side effects, which reduces unnecessary visits to emergency rooms and gives transparency.
4. Syringes and needles are equally important and must always be planned for adequately.
5. Technological tools for enabling the public to schedule vaccination appointments on the Internet or through their HMO apps on their smartphones, have aided the success of the vaccination program. The apps are also used to send reminders and communicate. For those who don’t easily use smartphones, such as the older generations and some small communities, the call-centers and other communication methods from local HMO branches were used.
6. Targeted media campaigns were crucial in getting the word out and educating the public to ensure maximum participation. The campaign encouraged the public to come as early as possible when they are entitled to receive the vaccine. For certain communities resistant to participating, such as, for example, some ultra-orthodox communities and some small, rural Arab communities, other forms of communication and public diplomacy were used. Dr Salmon stated that a massive effort is being put into the Arab population as there are lower numbers of people trusting / wanting the vaccine and so there is a lower number of compliance with getting the vaccine.
7. A good Patient-HMO relationship has been central to the vaccination program success.
8. Training EMTs and Paramedics to administer the vaccine added capacity.

Getting all sections of the population vaccinated

Israel has a major interest to see the Palestinian population being vaccinated as soon as possible. Dr Salmon mentioned that it is both from humanitarian and clinical perspectives and said “they are our closest neighbours”. Around 100,000 Palestinian people move back and forth through the border into Israel every day. Dr Salmon explained that at this point Israel is vaccinating its own citizens, as each country would do, and at the same time they are very aware of a major effort being done for the Palestinians and big contracts are being signed with Gamaleya Russia and AstraZeneca. This means that shortly the Palestinian population will receive millions of vaccines. It is relevant to note that this is in accordance with the 1995 Oslo accords that the Palestinian Authority Government takes responsibility for the Health of its citizens, and so the Palestinian Health Ministry did make a statement that this is what they wanted and planned to do with the aid of the WHO.

All prisoners in Israeli prisons will be vaccinated, regardless of nationality or origin. Palestinian health workers were vaccinated together with all Israeli health workers. Other Palestinian workers, such as in the construction industry, for example, are expected to be vaccinated by the Palestinian Authority.

Foreign workers in Israel will also be vaccinated, as will asylum seekers. It is interesting to note that there are discussions underway to get illegal immigrants vaccinated, in the interest of an adequate percentage of population being vaccinated.

The realistic goal, which does seem like it will be achieved, is to vaccinate around 70% of the population by the end of March or mid-April.