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Issue 20, 17 June 2021

The newsletter on COVID-19 vaccination is an RIVM National Institute for Public Health and the Environment publication with up-to-date information for professionals involved in COVID-19 vaccination.

Progress report on the COVID-19 vaccination campaign

COVID-19 vaccination has been very effective: in the first eight weeks after the start of the vaccination programme, a huge drop in the number of positive COVID-19 tests, hospital admissions and deaths was observed among older people living at home and among nursing home residents.

As of last Monday, people born in 1994 can schedule an appointment for COVID-19 vaccination. They will be vaccinated by the Municipal Public Health Service (GGD) with the Pfizer/BioNTech or Moderna vaccine. As of this week, people born in 1995, 1996, 1999 and 2000 can also schedule their COVID-19 vaccination.

Explaining COVID-19 vaccination to woman

Working with the Central Agency for the Reception of Asylum Seekers (COA) and Asylum Seeker Healthcare (GZA), the GGD has also launched a public information campaign about the importance of COVID-19 vaccination, designed for people living in residential centres for asylum seekers. Since the last week of May 2021, asylum seekers born in 1961-2003 who have a medical indication are being vaccinated with the Moderna vaccine.

First COVID-19 vaccine approved for children aged 12 and older

At the end of May 2021, the COVID-19 vaccine made by Pfizer/BioNTech (Comirnaty®) was the first to receive a positive recommendation from the European Medicines Agency for children aged 12 years and older. The vaccine had already been approved for people aged 16 years and older. The European Commission adopted that recommendation this week. The Health Council of the Netherlands is expected to publish an advisory report sometime in June regarding the use of this vaccine for the age groups of 12-15 years and 16-18 years who are not in medical high-risk groups.

Advisory reports of the Health Council

The Health Council has recommended using mRNA vaccines (Pfizer/BioNTech and Moderna) for younger groups of people for the first COVID-19 vaccination. This is because these vaccines seem to be more effective than the virus vector vaccines (AstraZeneca and Janssen). Moreover, the very rare combination of blood clots with low levels of blood platelets after a first vaccination with a virus vector vaccine (Thrombosis with Thrombocytopenia Syndrome, TTS) occurs slightly more often among younger people. Sufficient supplies of the mRNA vaccines are now available. The risk of severe illness resulting from COVID-19 is relatively minor in these younger age groups, so vaccination with an mRNA vaccine has a better risk-benefit ratio and is therefore preferred. Groups that are difficult to reach for a second vaccination may benefit more from receiving the Janssen vaccine, due to the single-dose administration.

The recommendation to use the AstraZeneca vaccine for people over 60 years old remains unchanged. The vaccine can still be used for the second vaccination for people who already received their first vaccination with AstraZeneca, regardless of age.

The Health Council advises that young people aged 12-17 years (born in 2004 through 30 June 2009) who have health problems should be vaccinated against COVID-19. This involves people in that age group with Down’s syndrome or obesity, as well as those who are eligible for the annual seasonal flu jab. In exceptional, individual cases involving substantial direct or indirect health effects, the treating physician may also provide a indication for vaccination for other reasons. In the context of ‘ring vaccination’, young people aged 12 years and older may also be vaccinated if they are household members of people who are unable to be vaccinated themselves for medical reasons, or who may not be protected after vaccination.

The Health Council had already advised vaccinating young people aged 16 and 17 years old who are in the medical high-risk groups. An advisory report on vaccinating healthy teens aged 12-17 years will be published soon.
 

Ministerial decrees on vaccination strategy

Due to the rapid pace of vaccination, the Minister of Health, Welfare and Sport (VWS) has decided not to designate pregnant women as a priority group for COVID-19 vaccination.

People aged 65 years and older who have not yet been vaccinated according to the records in the COVID-19 vaccination Information and Monitoring System (CIMS) will receive a reminder in the next few weeks, sent in order from old to young. They can schedule an appointment with the GGD and be vaccinated with an mRNA vaccine.

From Saturday 5 June 2021 on, people aged 60-64 years who were originally offered the AstraZeneca vaccine via their GP and have not yet been vaccinated can make an appointment for GGD vaccination with the Pfizer/BioNTech or Moderna vaccine. This was initially announced via the media. A reminder letter will be sent to this group later this month.

The Minister has decided to follow the recommendations of the Health Council regarding the use of the Janssen and AstraZeneca vaccines (see above). In addition, he plans to look into whether it is possible to offer the Janssen vaccine as an optional choice for people over 18 years old who prefer that option.

The Minister has also decided to follow the recommendations of the Health Council regarding ring vaccination and young people in medical risk groups. The Association of Dutch General Practitioners (LHV) has indicated that GPs can make a selection of young people aged 12 years and older who are eligible for the seasonal flu vaccination or have Down’s syndrome. These young people will be vaccinated by the GGD with the Pfizer/BioNTech (or via a modified route for people who are not mobile enough to travel to the GGD vaccination sites). In specific settings, such as residential institutions, the institutional physicians will make a selection of young people who are in the specified medical risk groups. Alternative solutions are still being considered for inviting young people with obesity and young people who should be invited in the context of ring vaccination.

For the time being, no second vaccination for young people following previous infection

It is known that systemic adverse reactions are worse after a second mRNA vaccination. There have been reported cases of myopericarditis, especially after the second vaccination with an mRNA vaccine such as Comirnaty® (Pfizer/BioNTech) and at younger ages. There is insufficient data to determine whether there is a link to the vaccinations. The Pharmacovigilance Risk Assessment Committee (PRAC) of the European Medicines Agency (EMA) is investigating this possibility. Partly for that reason, it has been decided to exercise caution in administering a second vaccination after previous COVID-19 in all young people, even if they are immunocompromised.

Convenient overview of syringe and needle combinations

RIVM National Institute for Public Health and the Environment and GGD GHOR have co-designed a poster displaying the recommended syringe and needle combinations for COVID-19 vaccination by the GGDs. This poster makes it easy for the vaccine preparation teams to see at a glance which syringe and needle combinations are recommended for each type of vaccine and how many doses can be drawn from a vial. A QR code links to the latest instructions for preparing each vaccination and syringe/needle combination, available on the RIVM site.

The poster has been distributed to all GGDs as a PDF and in A4 print format. They then send the poster to the vaccine preparation teams in their organisation and hang it up in the room where the vaccines are prepared. The poster will be updated when new syringes and needles are available and/or when new guidelines are provided. The latest version of the poster is always available here.

Frequently asked questions

If the recommended interval between the first and second vaccinations with an mRNA vaccine is exceeded, is the vaccination still effective?

After the first vaccination, the body develops protection against COVID-19, which then decreases again over time. For that reason, it is recommended to administer a second vaccination after 5-6 weeks. If the second vaccination is given later, there will be a period after the first vaccination during which the person is slightly less well protected. However, the immune system will respond at least as strongly after a second vaccination. For that reason, the end result for protection after the second vaccination will be the same or possibly even better after a longer interval.

If a person has consumed alcohol before the vaccination, can the vaccine still be administered?

Alcohol consumption does not have any clear impact on the immune response after vaccination. In that context, the threshold for consuming alcohol is difficult to determine. However, it may make it more difficult to assess any adverse reactions to the vaccine. In addition, rules regarding the consumption of alcohol (and other substances) are in effect at the vaccination sites.

Can someone who had their first dose with Vaxzevria® (AstraZeneca) receive a second dose with Comirnaty® (Pfizer/BioNTech)?

The recommendation at this time is to complete a vaccination series with the same vaccine (homologous series) and not to use different vaccines (heterologous series). Insufficient data is currently available on the safety and efficacy of administering an mRNA vaccine as the second dose. See also: https://lci.rivm.nl/richtlijnen/covid-19-vaccinatie#8-1-uitwisselbaarheid-van-vaccins.

Can someone who had their first dose with Vaxzevria® (AstraZeneca) and is currently pregnant receive a second dose with Vaxzevria®?

Women who received Vaxzevria® as their first vaccination and are now pregnant have sufficient temporary protection against severe COVID-19 and are advised to wait for their second vaccination. During pregnancy, it is recommended to use mRNA vaccines for COVID-19 vaccination. However, insufficient data is currently available on the immunogenicity and safety of a heterologous vaccination series (using different vaccines for the first and second dose). New data on vaccination with Vaxzevria® (AstraZeneca) followed by an mRNA vaccine will be available soon. The current recommendation on the second vaccination may be updated based on that data. See also: https://lci.rivm.nl/richtlijnen/covid-19-vaccinatie#4-6-zwangerschap.

Can I breastfeed after being vaccinated?

Yes, you can. The package leaflet states that there is an absence of safety data for the COVID-19 vaccine when breastfeeding. However, it is plausible that little to no COVID-19 vaccine will end up in breast milk and that there is no reason not to vaccinate. See also: COVID-19 vaccination | LCI guidelines (in Dutch) and Standpunt-Vaccinatie-tegen-COVID-19-rondom-zwangerschap-en-kraambed-versie-22-april-2021-def.pdf (nvog.nl).

Updated implementation guidelines for COVID-19 vaccination

The implementation guidelines for COVID-19 vaccination 2021 have been updated. The latest version of the implementation guidelines is always available online (in Dutch). Section 1.3 outlines all major changes compared to the previous version; more minor interim changes are listed under Version Management (at the end of the document).

The policy for vaccination after previous COVID-19 has been updated: the 6-month period before a single vaccination has been discontinued. Click here for more background information.

Adverse reactions

Pharmacovigilance Centre Lareb has posted a new update about reports of possible adverse events following immunisation with COVID-19 vaccines which were reviewed by experts up to and including 6 June 2021. These primarily involve known and expected adverse reactions such as headache, feeling ill, muscle pain and tiredness. So far, Lareb has received 20 reports of the rare adverse reaction known as ‘Thrombosis with Thrombocytopenia Syndrome (TTS)’ out of approximately 2.1 million AstraZeneca (Vaxzevria®) vaccines administered. Three people died. Lareb has not received any reports of this adverse reaction out of some 250,000 Janssen vaccines administered.

Public communication

As of Saturday 5 June, the ampoule and syringe used for the first COVID-19 vaccination administered in the Netherlands are on display in the Rijksmuseum Boerhaave, the national museum of the history of science and medicine in Leiden, as part of the Infected! exhibit.

editors

Editors: Vaccination implementation, National Coordination Centre for Communicable Diseases Control (LCI).

For questions and/or comments about this newsletter, healthcare professionals can send a message to vaccin-covid@rivm.nl.

Private citizens can call the public information number 0800 - 1351 with their questions.