The implementation guidelines for COVID-19 vaccination 2021 have been modified in a number of sections. A summary of the most important changes is provided below. (See also Section 1.3 of the guidelines.)

Points for attention in the context of obesity

In administering mRNA vaccines, intramuscular (i.m.) vaccination is important for the vaccine to be properly effective; subcutaneous injections should be avoided. When using the proper vaccination technique, i.m. vaccination is usually possible with a 25 mm needle, even in people who have more subcutaneous fat. In the event of severe obesity, it will be necessary to use a longer needle (38 mm) These needles are not included in the standard supplies, so they must be kept in stock at the location.
It is recommended to vaccinate with a longer needle (38 mm) if:
1. Weight: women >90 kg or men >118 kg
2. BMI >40

If in doubt about the correct needle length: take a fold of skin between thumb and forefinger and assess the thickness. If the needle is shorter than half the skin fold, a longer needle is needed.

Note: If someone comes in for the 2nd vaccination, and turns out to need a longer needle (but a longer needle was not used for the 1st vaccination), then a 3rd vaccination will be offered. The 3rd vaccination must be with the same vaccine (brand) and administered after the regular interval according to the guidelines.

Stricter anticoagulant policy

The treating medical specialist only needs to be consulted prior to the vaccination in cases of congenital coagulation disorder, thrombopathy or thrombocytopaenia.

Intramuscular (i.m.) vaccination is possible when using coumarin derivatives (also known as Vitamin K antagonists) and a stable INR. In the event of a variable INR that needs to be checked regularly by the anticoagulation clinic, i.m. vaccination is only permitted if the INR was <3.5 in the 7 days prior to vaccination.
I.m. vaccination is possible if other anticoagulant medication is used, as long as the timing between taking the medication and receiving the vaccination is followed as described in the guidelines. In addition, it may be necessary to put pressure on the injection site for at least 10 minutes after the vaccination.

COVID-19 after 1st vaccination

People who have already had the 1st COVID-19 vaccination, and then get COVID-19 or test positive for COVID-19, are subject to the same interval of at least 4 weeks after the onset of symptoms or the positive test result. This is not only to make it possible to differentiate between symptoms relevant to the course of the disease and symptoms that may be caused by the vaccination, but primarily also because receiving the 1st vaccination as well as having COVID-19 has already activated the immune response twice within a short time frame. For that reason, it is better to postpone the booster shot (2nd vaccination) until at least 4 weeks after the onset of symptoms. If this interval is longer than the currently recommended time, that is not a problem. The person is probably sufficiently protected, and can still get the 2nd vaccination later.

Number of doses per vaccine vial

It has been agreed with the Medicines Evaluation Board (CBG-MEB) that, if it can be managed, one dose more may be taken from a vaccine vial than is stated in the package leaflet, as long as it is a full dose. For Pfizer/BioNTech’s Comirnaty®, this means that a maximum of 6 to 7 full doses may be taken from a vaccine vial; for Moderna’s vaccine, this means a maximum of 11 full doses. 
Hospital pharmacists have a few more options for getting the maximum number of doses out of the vial. However, they are not allowed to prepare the vaccines in the injection syringes to then distribute outside their own organisation, because vaccine which is already in the syringe cannot be transported to another location. This is due to the significant fragility of the mRNA.