Trends in socio-demographic disparities in COVID-19 vaccine uptake by vaccine dose and time after the introduction of COVID-19 vaccination in Israel: epidemiological and policy analysis study.

Abstract

Background: Evidence on sociodemographic disparities in COVID-19 booster vaccine uptake remains limited. We examined disparities in COVID-19 vaccine uptake among the Arab, ultraorthodox Jewish, and general Jewish populations in Israel (January 2021-August 2022), focusing on vaccine dose, community characteristics, and policy analysis.

Methods: Publicly available COVID-19 data from 135 cities (≥ 10,000 residents) were analyzed. Cumulative vaccine uptake by dose was assessed by age and population group across 3 periods (period-1: to June 2021, period-2: to December 2021, period-3: to August 2022). Policy analysis was conducted using Walt and Gilson's Policy Triangle framework, drawing on the literature, government reports, official websites, and media coverage.

Results: Data from 76 predominantly non-ultraorthodox Jewish cities, 10 ultraorthodox Jewish cities, and 49 Arab cities were included. Compared to the general Jewish population, dose 1 uptake was lower in ultraorthodox (incidence rate ratio (IRR) = 0.51, 95% CI 0.26-0.99) and Arab cities: IRR = 0.76, 0.53-1.09), with similar gaps for dose 2. Disparities widened with boosters: for dose 3, uptake was significantly lower in ultraorthodox cities (period-2 IRR = 0.38 [0.20-0.74], period-3: IRR = 0.39 [0.20-0.75]); and Arab cities (period-2 IRR = 0.55 [0.38-0.79], period-3 IRR = 0.56 [0.39-0.81]). For dose 4, gaps were largest in adults aged ≥ 60 years (ultraorthodox: IRR = 0.24 [0.12-0.47]; Arab: IRR = 0.15 [0.10-0.22]). Higher socioeconomic status was consistently associated with uptake, particularly for boosters. The peripherality index was associated with lower dose 4 uptake, suggesting geographic disparities and access barriers. Policy analysis highlighted Israel's rapid mass vaccination rollout and evidence-based booster adoption, but also declining booster uptake and widening sociodemographic inequities. The primary campaign relied on centralized mass vaccination efforts and intensive public messaging, achieving high coverage, while the booster phase was mainly integrated into existing infrastructure, with more targeted outreach and reduced media emphasis, shifting from infection prevention to severe-disease prevention policy.

Conclusions: Persistent disparities in COVID-19 vaccine uptake widened during the booster phase in Israel. While rapid, centralized rollout achieved high initial coverage, sustaining equitable uptake proved challenging. These findings highlight the need for ongoing, equity-focused strategies, including targeted outreach and culturally tailored interventions throughout all phases of public health emergencies, particularly in the long-term phase, to strengthen existing healthcare infrastructure.