Mobilizing emergency medical services for mass COVID-19 vaccine administration: The Israeli experience.

As of September 5, 2021, COVID-19 has infected over 220 million people worldwide, resulting in over 4.5 million deaths [1]. Although a number of effective vaccines have reached the market, their distribution, especially to the socioeconomically vulnerable, remains a challenge [2]. For example, homebound individuals and the elderly may have difficulty reaching vaccination centers.

Israel's Ministry of Health (MOH) decided to charge Magen David Adom (MDA), the national emergency medical service (EMS), with organizing the vaccination administration program for many of the most vulnerable. Although EMS is usually associated with prehospital ambulance response, MDA had already taken a major non-traditional role in helping tackle COVID-19, including operating border control checkpoints in the pre-pandemic phase, manning a dedicated COVID-19 call center, performing home sampling, and staffing nationwide drive-through testing centers [[3], [4], [5]]. Very recently, MDA completed a campaign to vaccinate over 90% of the elderly in nursing homes and assisted living facilities [6].

MDA runs a sophisticated technological command-and-control platform that allows rapid triage, ambulance dispatch, and automatic mobilization of the nearest first responders. MDA is staffed with 3000 salaried workers and 30,000 volunteers. The volunteers have proven crucial for everyday tasks as well as in mass-casualty events [7,8]. In times of a pandemic, MDA's combination of experienced professional staff, an expandable volunteer-based workforce, and cutting-edge technology has helped lead Israel's effective response against COVID-19.

For Israel's COVID-19 vaccination program, MDA, in conjunction with the MOH, chose to focus on several vulnerable groups, including the elderly, persons with disabilities, Palestinian laborers, prisoners, and those in the country's outlying areas. They also included certain boarding school youth and factory workers, as well as diplomats. At the time, only people at least 16 years old were being vaccinated. MDA's strategy for administering the vaccinations was as follows:

Manpower: Paramedics and emergency medical technicians (EMTs) were prepared to perform the vaccinations via a mandatory training session, including two hours of virtual didactics and additional hands-on practice. The staff were then divided into teams, each headed by a paramedic who supervised EMTs in administering the vaccines. The paramedics were responsible for diluting the vials according to the manufacturers' instructions, and the medics were responsible for injecting the vaccines.

Logistics: MDA developed a dedicated COVID-19 emergency medical records system and implemented procedures to maximize vaccine usage. MDA's cloud-based information system was able to synchronize with the MOH database and could be accessed from the field. The system, which takes advantage of the unique identification number that every Israeli has, includes background medical history and vaccine administration data. It also allows for scheduling an appointment for the second vaccine administration. MDA was able to maximize the use of limited vaccines by coordinating with the vaccination sites. Calls were made in advance to estimate the necessary number of vaccines and to determine the teams' registration and work areas. Refrigerated trucks, subcontracted from a company that specializes in the transport of pharmaceutical products, brought the vaccines to the sites where they were diluted and administered [9].

Location: For the elderly and those with disabilities, the vaccines were mostly administered at their places of residence, including nursing homes. For the thousands of foreign Palestinian laborers who work in Israeli communities and return home on a regular basis, the teams deployed to 13 border crossings. Prisoners, factory workers, and at-risk youth in boarding schools were vaccinated in their prisons, places of employment, and schools, respectively. Other citizens in outlying areas were vaccinated in their areas of residence. Diplomats were administered the vaccine at the Ben Gurion International Airport. While some of the diplomats returned to their posts after a 48-h isolation period in Israel, others stayed in Israel for three weeks to receive their second vaccine dose. Families of diplomats were also prioritized to reduce virus transmission.

For the prisoners and Palestinian laborers, MDA administered the first dose to help provide some immunity while the second dose was provided by private agencies.

Between December 22, 2020, and March 20, 2021, MDA administered over 600,000 COVID-19 vaccinations. The initial program, from December 22, 2020, through January 31, 2021, began with the elderly in nursing homes and various geriatric facilities as previously described [6]. This was expanded to include persons with disabilities and other older adults with a total of 312,254 vaccines administered to this group. Next, MDA reached out to outlying areas of the country where they administered 164,168 vaccines. A total of 11,553 vaccinations were administered to prisoners during an 11-day period in mid-January.

For the Palestinian foreign laborers, a pilot was conducted on March 4 where 695 vaccinations were administered. Subsequently, from March 8, 2021, through March 18, 2021, MDA administered the first dose of the vaccine to an additional 86,351 Palestinian workers.

Additional groups that were vaccinated included factory workers (21,353 doses),

boarding school students (3235 doses), and an additional small group of citizens (3441 doses) many of whom received their vaccine at MDA stations (See Fig. 1 and Table 1) .

Fig. 1

Vaccinations Administered by MDA Between 12/22/20 and 3/20/21.

Table 1

Groups vaccinated by Magen David Adom between 12/22/20 and 3/20/21

Group Vaccinated	Dates	First Dose	Second Dose	Total Doses	Average Doses Per Week
Elderly and Persons with a Disability	12.22.20-03.18.21	178,398	133,856	312,254	24,020
Citizens of Outlying Areas	12.30.21-03.20.21	100,294	63,874	164,168	13,681
Prisoners	01.15.21–01.25.21	11,553	–	11,553	3851
Othera	01.26.21-03.18.21	–	–	3441	430
Diplomats	02.11.21-03.17.21	856	429	1285	214
Factory Workers	02.11.21-03.18.21	12,947	8406	21,353	3559
Boarding School Students	02.14.21–03.18.21	2123	1112	3235	647
Palestinian Laborers	03.04.21-03.18.21	87,046	–	87,046	29,015
Total	12.22.20-03.20.21	294,618	207,677	604,335	46,487

The division between first and second doses is unknown.

This process of “bringing the vaccine to the patient” is critically important as the vulnerable groups are generally unable to come to a clinic setting for vaccination. The elderly (especially those in long-term care facilities), prisoners, Palestinian laborers, youth in boarding schools, factory workers and citizens living in outlying areas, and diplomats and their families were included in the MDA vaccination campaign because of their increased risk of severe disease, their increased risk of transmitting the disease, and/or their decreased access to standard clinic-based vaccination efforts in Israel.

The role of EMS in targeting these different populations helped Israel at the time lead the world in per-capita COVID-19 vaccine administration [10].

While Israel is a relatively small country with a nationwide EMS system, a similar approach may be implemented on a more local level wherever EMS infrastructure exists. This may be particularly effective for those populations who are both more vulnerable to severe sequelae of infection and have more difficulty reaching medical clinics.

Declaration of Competing Interest

None.

This study received no financial support and there are no conflicts of interest.

The authors confirm contribution to the paper as follows:

Evan Avraham Alpert contributed to the study conception and design, analysis and interpretation of results, manuscript preparation, and writing the manuscript.

Ari M. Lipsky contributed to the study conception and design, analysis and interpretation of results, manuscript preparation, and writing the manuscript.

Itamar Abramovich contributed to the project management and data collection and reviewing the manuscript.

Eli Jaffe contributed to the study conception and design, analysis and interpretation of results, manuscript preparation, and writing the manuscript.

All authors reviewed the results and approved the final version of the manuscript.