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How is Israel vaccinating so quickly?

January 9, 2021

Man receiving an injection
Photo credit: Marco Verch

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The vaccines have arrived. The world now has three approved vaccines (Pfizer and BioNTech's Comirnaty, Moderna's mRNA-1273, and the Beijing Institute of Biological Products's Sinopharm), and an additional seven vaccines with early or limited approval. The next challenges are in manufacturing, and then distributing, vaccines to countries around the world.

In the month since the first patient received a vaccination, significant variation in countries' vaccination rates has emerged. As of January 9, more than 23 million vaccine doses worldwide have been administered, 67% of which were in the United States or China.

Yet an important outlier has emerged: as of January 7, Israel has vaccinated nearly 20% of its population. This rate is many times higher than the United States (2%) or China (less than 1%).

What sets Israel apart? We had a look at some hypotheses for why it has been so much more successful than anywhere else, including the United States.

Did Israel purchase vaccinations early?

Israel was one of the first countries to receive vaccines, in part by paying a premium for the doses. Although procurement details are confidential, according to one source the Israeli government paid "around $30 per vaccine dose, or around twice the price abroad." This strategy, as well as assuring Pfizer and BioNTech that it would serve as an example of a quick rollout, helped the small country acquire vaccines as early as possible.

Nonetheless, the United States received its own vaccines in a similar timeframe. Israel received its first batch of vaccines December 10, while in the United States all 50 states had received shipments of vaccine by December 15. Although a five-day head start works to Israel's favor, the United States did not lag far behind in buying the shots.

Did Israel buy more vaccines?

If the United States simply did not have enough vaccines, it could explain the lag. Yet according to the Duke Global Health Innovation Center, the United States purchased more vaccines per-capita than did Israel. As of the end of December, the U.S. had confirmed purchases of vaccines for 200% of its population (note that this takes into account the fact that two shots are required per person). By contrast, Israel had 122% coverage. As such, by the end of 2020, both countries had signed and finalized deals for more than enough vaccine to cover their entire populations.

Vaccination population coverage, based on confirmed purchased doses

Source: Data are from the Launch and Scale Speedometer in the Duke Global Health Innovation Center. Data as of December 29, 2020. Graphic adapted from NPR (December 3, 2020).

Does Israel have more healthcare workers?

Delivering vaccines to an entire country is dependent on the availability of nurses, doctors, and other health professionals to do the work. We looked at data from the Organization for Economic Co-operation and Development (OECD) to see if Israel was able to achieve more rapid vaccine delivery by virtue of employment more healthcare personnel.

In fact, Israel has a smaller number of health and social workers per capita than does the United States (about 50 per 1,000 in Israel and 65 per 1,000 in the United States). Although Israel did call 700 reserve military paramedics to join healthcare workers in vaccine distribution efforts, the role of the Army is more limited now than it was in the early phases of the epidemic. Even with additional military support, it is unlikely that they have surpassed the United States in total health workforce coverage.

Number of health and social workers per 1,000 (2018)

Source: Organisation for Economic Co-operation and Development (OECD). 2018. Total health and social employment density per 1,000 population.

Was Israel's healthcare system less devastated by COVID-19?

The COVID-19 pandemic has placed an immense burden on healthcare systems. If one country has faced a much heavier burden than the other, its weakened infrastructure would likely prevent it from successfully conducting a large-scale vaccination campaign.

Yet both countries have seen a similar impact from the virus. Cumulatively, nearly 5.7% of the United States has been diagnosed with COVID-19. In Israel, this figure is 4.7%, ranking Israel as one of the most impacted OECD country. Although the number of diagnoses is higher in the United States, Israel is nonetheless in its third national lockdown, facing 4,000 new daily infections and the emergence of the new variant identified in the United Kingdom. It's not clear that the relative scale of the pandemic in the two countries is driving differences in vaccination rates.

Cumulative per-capita COVID-19 diagnoses, by country (2020)

Source: European Centre for Disease Prevention and Control (ECDC). COVID-19 situation update worldwide, as of week 52 2020.

Are they better at delivering vaccines in general?

A country well-practiced in delivering other vaccinations would probably have an advantage when delivering the COVID-19 vaccines. We looked at the influenza vaccine, which is delivered annually in both countries. Based on OECD data, which measures influenza vaccination rates among people over 65 (an important target group, since most influenza-related deaths happen among the elderly), we see that the United States actually has higher flu vaccination rates than does Israel.

However, there is evidence that Israel was actively preparing for vaccine delivery in ways the United States was not. Months before the COVID-19 vaccine was available, Israel used its annual flu vaccination efforts as a practice run in delivering vaccines outside of clinics. These vaccine delivery compounds would eventually be the ones used for the coronavirus vaccine roll-out.

Finally, Israel benefited from the recent experience of national emergency vaccination campaigns for poliovirus (in 2013) and swine flu (in 2009).

Influenza vaccination rates, adults 65+ (2019)

Source: Organisation for Economic Co-operation and Development (OECD). 2019 or latest available. Influenza vaccination rates in population aged 65 and older.

Are Israelis more willing to get vaccinated?

Israel appears to have successfully overcome vaccine hesitancy in many populations. Although in the early phases, many Israelis were resistant to vaccination, reports indicate a drop in this sentiment and a "rise in national pride that Israel is leading the world." Those who are vaccinated receive an electronic 'green passport' after vaccination, exempting individuals from some restrictions related to quarantine and movement, and serving as an incentive to accept the shots.

Notably, however, although COVID-19 vaccination acceptance rates are about 75% in the general population, only 20% of Israel's Arab population are willing to receive the shot, due in part to misinformation and mistrust.

In the United States, COVID-19 vaccine hesitancy is in line with most other high-income countries, with somewhere between 67% and 75% of Americans reporting being willing to receive the shot. Yet the United States is facing conspiracy theories spread by anti-vaccine activists (and amplified by a massive political divide), with one-third of Americans believing the death toll of the virus is exaggerated and that harmful effects of the vaccination are deliberately withheld from the public (as of late October). This hesitancy is already visibly playing out, where as many as 50% of healthcare workers in some hospitals are reportedly refusing the injection.

Has Israel better managed vaccine control and distribution?

In Israel, the health system's response has been managed by the Ministry of Health, which coordinates all surveillance and reporting and has a well-detailed pandemic preparedness plans (from 2007), which detail the country's plans for stockpiling, risk communication, data and surveillance, and health facility preparedness. In January 2020, the Ministry of Health's powers were expanded to enable it to better respond to COVID-19. In addition, the country has a unique civilian-defense emergency response system, in which the Ministry of Defense is responsible for preparedness and response to emergency health scenarios. Finally, Israel benefits from a universal healthcare system and a highly digitized health system, facilitating outreach to patients.

Importantly, Israel has also benefited from a Teva Pharmaceutical vaccine repackaging platform capable of converting large frozen shipments of vaccine into smaller insulated batches for redistribution. Smaller batches of vaccine have proven more easily distributed to local vaccination sites, since thawed doses cannot be re-frozen if unused. By contrast, in the United States Pfizer has reportedly required hospitals and health-care providers to order nearly one thousand doses per request, leading to waste in small facilities.

In the United States, the Global Health Security and Biodefense unit, established during the 2014 Ebola epidemic and which previously served as the White House's pandemic response team, was disbanded in 2018. After the emergence of COVID-19, a new intergovernmental public-private partnership called "Operation Warp Speed" was announced on May 15, 2020, with the aim of accelerating "the development, manufacturing, and distribution of COVID-19 vaccines, therapeutics, and diagnostics."

However, the ultimate role of distribution in the United States ultimately falls to the individual states. Yet over the last decade, spending for state and local public health departments has dropped by 16% and 18%, respectively. Budget cuts have left public health infrastructure weak in the middle of a pandemic, with CDC director Robert Redfield calling our failure "over decades to effectively invest in public health" to be his "biggest regret." Although the Centers for Disease Control has awarded states $350 million for vaccination roll-out, the funds amount to just $1 per citizen; an additional $8 billion has proven slow to reach states.

People receiving first vaccine dose, per 100,000

Source: The Washington Post. Data as of January 8, 2021.

Currently each state is allocated a number of vaccines, using a formula based on its adult population. Jurisdictions can then distribute their available doses to a pre-approved network of providers. Signing up healthcare facilities to receive vaccine is reportedly bureaucratically challenging, and as of mid-December only half of states had successfully enrolled all the providers they needed. Currently, vaccination sites have struggled with hours of wait time.

Of the vaccines that have been delivered to the final healthcare provider for distribution, vaccines in the United States are slow to go out. By one estimate, around 70% of doses delivered to states remain on pharmacy shelves, with distribution seemingly chaotic and poorly-communicated.

In part, this may be due to too-narrow eligibility criteria and challenges finding enough recipients, due perhaps to unwillingness in some populations to receive the vaccine or challenges contacting patients without a universal healthcare system or reliable appointment systems). While in Israel leftover doses at the end of each day can be administered to patients' family members, in the United States many leftover doses have gone to waste. New York City, for example, has reported wasted and discarded doses, ultimately leading to Governor Cuomo expanding its eligibility criteria. Nonetheless, having vaccinated more than 2% of its population, New York State has a higher vaccination rate than about 60% of all states.

So what sets Israel apart?

There are many factors impacting the ability of both countries to successfully deliver the vaccination, and there are always challenges comparing two very different countries.

But based on this set of questions, we find several key differences between Israel and the United States. Among the strengths of the Israeli response include better public acceptance and enthusiasm for vaccination, recent experience with emergency vaccination campaigns, and the use of a novel small-batch cold chain technology. A sophisticated electronic medical records infrastructure has facilitated identifying and scheduling eligible patients for the vaccine.

Early planning activities made the healthcare system better ready to deliver the vaccine, and recent experience with large-scale emergency vaccination campaigns provided important institutional knowledge. Finally, local jurisdictions appeared to face fewer bureaucratic challenges assembling healthcare workers to deliver the shot.

Of course, while Israel's early successes should be applauded, the Israeli government has faced criticism from human rights groups for failing to extend its vaccination program to Palestinians, with the Israeli government reportedly refusing to deliver vaccines to frontline workers in the occupied West Bank and the Gaza Strip. In addition, there remains a high level of vaccine scepticism in the country's ultra-Orthodox community, where infection rates have been especially high. While Israel has served as an important example of a successful early vaccination program, its ultimate success in controlling the virus will depend on delivering the vaccine to its entire population.

Want to see for yourself? All our data are on GitHub.

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