3. Providing health services effectively
The section on PROVIDING HEALTH SERVICES EFFECTIVELY describes approaches for service delivery planning and patient pathways for suspected COVID-19 cases. It also considers efforts by countries to maintain other essential services during periods of excessive demand for health services.
3.1 Planning services
In many hospitals, especially in the areas where the outbreak is most severe, all non-urgent medical procedures have been postponed. All face-to-face consultations, if possible, are reverted into telephone consultations. Open capacity due to postponements is used to support COVID-19 patients. Currently there are no hospitals exclusively treating COVID-19 patients.
The extent to which the postponements will affect various patient groups is not yet known. For instance, chemotherapy can be postponed, because this treatment weakens the immune system and if the patient contracts COVID-19, they may be more vulnerable. Some people hesitate to contact emergency services for other emergencies, such as pain in the chest, because they think the emergency department is too busy with COVID-19 and/or they fear contracting COVID-19 in the hospital. (https://www.volkskrant.nl/nieuws-achtergrond/afgezegde-zorg-dreigt-meer-levens-te-kosten-dan-corona~b64d16ef/; https://www.nrc.nl/nieuws/2020/03/23/de-patienten-liggen-in-een-tent-voor-het-ziekenhuis-a3994613; https://nos.nl/artikel/2328656-spoed-is-spoed-denk-niet-ze-zijn-vast-te-druk.html)
Since the pressure on care facilities is diminishing due to the lower number of admitted COVID-19 cases, regular non-urgent care will gradually resume (see Section 3.3 – Maintaining essential services).
The first point of contact for suspected COVID-19 patients is the GP or the GP out-of-hours service (unless the situation is an emergency, in that case 112 will be contacted). GPs ask patients to only visit in-person if they have an appointment, and if a patient has COVID-19 symptoms they should not go the facility but to contact the GP by phone. The GP will then decide whether the patient should go the hospital. GPs are advised to organize separate office hours for patients with respiratory complaints, abolish walk-in office hours, and use video instead of face-to-face consultations whenever possible. The waiting room should be reorganized to facilitate the 1.5 meter distance rule. Hygiene advices are provided to GPs. (https://www.nhg.org/coronavirus/organisatie-van-de-zorg)
Preparing for vaccination
The Dutch government asked the Dutch Health Council for advice on whom to vaccinate first. From the perspective of preventing severe disease and mortality from COVID-19, the Health Council advised to start the vaccination campaign by vaccinating those aged 60 years and over and those at risk of severe disease due to underlying medical conditions. If these persons cannot be vaccinated, their carers should be vaccinated to prevent transmission. The Health Council published several advices, all with the same emphasis on starting with the most vulnerable people. These advices have not been followed. Another group that qualifies for early vaccination are care personnel with direct patient contact, because they are at a high risk of contracting COVID-19 and thus contribute to the burden of disease compared to groups in society without a higher risk of infection. If there are insufficient vaccines available for these first groups, priority should be given to those aged 60 and over with underlying medical conditions and within this group the oldest age groups. The Health Council stresses that the current advice is based on the current (limited) knowledge of the vaccine. In practice, vaccination will start for residential home personnel. This will be done by the public health services at 25 dedicated vaccination sites. The Minister of Health stresses that vaccination is voluntary and will not become mandatory.
The Minister of Health has commissioned the Dutch Institute of Public Health and the Environment (RIVM) to organize the vaccination campaign. The Institute of Public Health aims to use those channels that are used already for other vaccination campaigns, such as the influenza vaccination campaign. This would imply that people in nursing homes get vaccinated by the nursing home physician, vulnerable persons living at home by their GP and health care personnel by their occupational physician. The practical organization of this will be done at local level (by for instance GPs and the local public health services). Large scale vaccination events are only foreseen when the healthy population under the age of 60 will be vaccinated. The Institute for Public Health is working on a registration system to register who is vaccinated and by which vaccine (batch). The system will be used to register side effects, to ensure that a person gets the same vaccine in the second round, and to monitor vaccine coverage. The intention is to facilitate the registration within the GP and public health services information systems.
Due to lobbying activities of the hospital sector in December 2020, the vaccination strategy was adapted to first vaccinate all hospital personnel that work in COVID-19 wards and ICU units, followed by nursing home personnel and GPs. This was against the advice of the Health Council. The rationale to vaccinate home nursing personnel and not nursing home residents was that the available vaccine (by Pfizer) has to be stored at a very low temperature and it would be a logistical challenge to quickly distribute them to nursing home residents. For personnel, it was possible to travel to a central place to get vaccinated. In the meantime, organizations representing vulnerable groups are worried about the postponement of the vaccination for the most vulnerable persons.
Operation of the vaccination campaign
The first vaccination in the Netherlands was provided on 6 January 2021.
The vaccination strategy as of 13 January 2021 is the following:
• First quarter of 2021, vaccination will start for:
o Personnel of acute care departments of hospitals and of nursing homes (1st priority)
o Inhabitants of nursing homes and homes for people with intellectual disabilities (2nd priority)
o Home/community nurses, personnel of homes for disabled people and personnel of psychiatric hospitals
o (Non-mobile) elderly living at home (from oldest to youngest)
o People from 18-60 years with an underlying medical condition
o GPs (added on 22 January 2021). GPs may vaccinate themselves when they start vaccinating the patients on their list who are at risk (https://www.rijksoverheid.nl/actueel/nieuws/2021/01/22/huisartsen-vanaf-vandaag-gevaccineerd-thuiswonende-90-plussers-uitgenodigd).
• Second quarter of 2021, vaccination will start for:
o People from 18-60 years without an underlying medical condition
o All other medical personnel.
The government hopes to have the entire population vaccinated by the end of the third quarter of 2021. The speed of vaccination will depend on the availability of the different vaccines and the suitability of a specific vaccine for the target group (https://www.rijksoverheid.nl/documenten/publicaties/2021/01/04/vaccinatiestrategie-flowchart).
To speed up the vaccination campaign, on 20 January 2021 the government chose to relax the principle that for each first vaccination, the second should be left in stock to assure the availability of the second dose. Instead of 100% storage, only 50% should remain in storage for a second vaccination. Additionally, the timing for the second vaccination has been extended from three weeks to six weeks.
The vaccine spillage has been adjusted from 10% to 5% based on experiences in practice. Furthermore, the expected attendance rate of 75% appeared in practice to be 85%. Both experiences are expected to speed up the vaccination campaign as well. (https://www.rijksoverheid.nl/onderwerpen/coronavirus-vaccinatie/nieuws/2021/01/20/corona-vaccinatie-sneller-meer-mensen-beschermen)
At the end of January 2021, the Netherlands is still among the EU countries with the lowest vaccination rate. The Netherlands started relatively late. According to a statement of the Minister of Health on 30 December 2020, starting earlier was not possible because of implementation problems. He thought that other countries had started only symbolically and not yet on a large scale. Later, on 29 January 2021, the (now stepped down) Minister admitted that although the Netherlands had been slow and not agile enough, the real problem at the moment was the limited availability of vaccines.
As a result of the shortage of vaccines, and the problem of distributing vaccines because of the low storage temperatures, the vaccination strategy constantly changes. Before the start of the vaccinations, the strategy was that the elderly should get priority. However, due to the aforementioned problems and successful lobbying of hospital and nursing home personnel, the healthcare workforce were the first to actually get vaccinated. Hospitals had a good system in place to distribute the vaccinations (and were able to start as soon as the vaccines became available) and nursing home personnel were able to travel to central vaccination venues, whereas the residents could not. Finally, the logistics to vaccinate on location was solved and nursing home residents became vaccinated.
Changes in vaccination strategy over time:
• As of 19 November 2020, the Dutch Health Council advised the Minister of Health to start vaccinating targeted at diminishing severe illness and mortality:
o The first vaccinations should be administered to the elderly over the age of 60 with underlying medical conditions, starting with the oldest first. Then those aged 60 and over, starting with the oldest first and then people under the age of 60 who have underlying conditions that increases the risk on severe illness. The highest health gain is expected for the oldest elderly. If the elderly cannot be vaccinated, their carers (including informal carers) should be vaccinated.
o The second group are care personnel with direct patient contact
• As of 24 December 2020, the Health Council once again advised to start vaccination in the elderly, with the oldest old going first. The Pfizer vaccine should be used for this group as it appears to be safe and highly effective in this age group. The AstraZeneca vaccine expected to be delivered in the first quarter of 2021 can be used for healthcare personnel
• In December 2021, the hospital representatives argued that in the light of increasing infection rates and high sick leave rates in hospitals, as well as readiness of hospitals to vaccinate, healthcare personnel should get vaccinated first.
• On 2 January 2021 the Minister of Health decides that acute care hospital personnel should be vaccinated first. According to the Minister, this does not change the vaccination strategy, but is only a small detour.
• On 4 January 2021, the Health Council and the Outbreak Management Team of RIMV in a common advice to the Minister of Health advise the following:
o Start with the elderly, the 75 years of age and older first (as the total group of 60+ is large and vaccine availability probably limited). Reserve at least 90% of the available vaccines for this group and use the other 10% to solve problems of workforce availability in the healthcare sector, but only if the continuation of care is at risk.
o It is important to start as soon as possible.
• The start of the vaccination campaign began on 8 January 2021 for acute care hospital personnel
• 14 January: the Health Council and the Outbreak Management Team in a common advice think that the current policy of keeping the second vaccination in store should be released and that if necessary, the timing between the two vaccinations of Pfizer and Moderna can be stretched to a maximum of 6 weeks.
• Due to shortages and delayed delivery, the planned vaccination of GPs working in emergency care was postponed. GPs said that the Minister had promised that they would be vaccinated at the end of January, but the Minister of Health disputes this. The Minister decided that GPs will be vaccinated with AstraZeneca, the delivery of which is yet uncertain.
• As of 15 January 2021, also nursing home personnel can be vaccinated at one of the 25 vaccination locations in the country.
• End of January: start of vaccination for nursing home residents and mobile elderly aged 90 and over, followed by the younger age groups in age bands of 5 years. Mobile means that they are capable of traveling to central vaccination facilities.
• On 3 February 2021, the Minister announces the following strategies to increase vaccination coverage:
o The timing between first and second vaccination for Moderna can be 4 weeks, for Pfizer 6 weeks.
o The number of vaccinations in storage should be sufficient to continue vaccination for 5 days in case of non-delivery. For AstraZeneca, no ‘safe’ storage is needed, because of the longer interval between the two doses of this vaccine.
o The Minister plans to surge the vaccination capacity to 100 locations, capable of vaccinating 450,000 persons per day in April 2021 and 750,000 per day in May 2021.
• At 4 February, the Health Council advised on the use of the AstraZeneca vaccine. The advice was to use this vaccine for those 60-64 years of age and people with Down syndrome, people with neurological conditions with compromises breathing and people with morbid obesity (BMI>40). The other high risk groups (people with blood cancer, kidney failure, organ or bone marrow transplants or primary immune deficiency) should be vaccinated with an mRNA vaccine. Other people at risk (largely those who qualify for an influenza vaccination) and those aged 50-59 should be the following group to be vaccinated (starting with the oldest persons first).
• GPs will start with the COVID-19 vaccinations on 16 February 2021. The vaccination rollout will be done regionally, starting with the province of Zeeland (south-west of the Netherlands) and working up to the provinces in the upper east corner of the country. GPs will vaccinate their own personnel, all persons born between 1956 and 1957 (persons born before 1956 will be vaccinated by the Public Health Service), all people with Down syndrome living at home, all persons with morbid obesity (BMI>40), born between 1956 and 2002. These persons will be vaccinated with the AstraZeneca vaccines. Invitations for the vaccination are send by the GP practice. For those with neurological conditions, the medical specialist will be in charge of identifying them. The route for vaccination of these persons is not yet (21 February 2021) known.
• For the very high risk group for severe COVID-19, that was identified by the Health Council at 4 February 2021 (people with transplantations, severe kidney disorders, hematologic malignities, primary immune deficiency, and neurological conditions with compromised breathing) the vaccination campaign has started as of 29 March. Vaccines are provided at the hospital.
As of 15 March, the vaccination with the AstraZeneca vaccine is stopped because of suspection of severe side effects. After advice of EMA that the vaccine can be used and that the risks of a COVID-19 infection outweigh the risk on the (extremely) rare complication, on 24 March 2021 the public health authorities started providing the vaccine again.
The scattering of the responsibility for vaccinating different groups lead to some undesired effects. In nursing homes, those residents that fell under the (medical) responsibility of the medical specialist for the elderly were vaccinated by these physicians, whereas residents in the same home that fell under a GP had to wait until the GP came to vaccinate them. The guidelines were later adjusted, so that all residents could be vaccinated in one event. In another occasion, where all residents and care personnel were vaccinated, informal carers could not obtain the left over doses of the vaccine, because they were not eligible at that moment according to the vaccination strategy and the vaccine was discarded. Now the guidelines have been adjusted with a route to whom can be vaccinated and an email address to inform the Institute of Public Health about left overs, so that no available vaccine doses will be wasted.
Distribution and administration of the vaccine
The Netherlands Institute of Public Health and the Environment (RIVM) is tasked with the governance of the vaccination campaign. They take care of developing guidelines, preparing and communicating about the COVID-19 vaccine to professionals and monitoring and evaluating the vaccination campaign. The RIVM commissions organisations for the implementation of the vaccination campaign. They also monitor the efficacy and safety of the vaccine. The vaccination campaign is solely publicly organized.
The Public Health Services (25 regional independent organisations) takes care of initiating the vaccination, scheduling and ensuring the 2nd dose appointment and administering the jab. When a dosage is spilled or left-over, the RIVM should be contacted. Registered nurses are qualified to administer the jab. Others are also allowed to do so, when they are trained and when a physician is present. There is a special helpline in place for professionals that are involved in the vaccination campaign, with special lines for logistic, medical, registration questions and questions concerning the vaccination of medical personnel. The helpline is organized by the RIVM.
For residents of nursing homes, the vaccination is provided by nursing home personnel. For transportation of the vaccines between different locations of a nursing home, the nursing home is required to hire a qualified logistics organization or a pharmacy. The RIVM provided instructions for nursing homes.
Logistics is coordinated by the RIVM. They have contracted parties that take care of storage and transportation. The RIVM ensures that the necessary supply is present at the vaccination location. The Public Health Service prepares the syringes and administers the jab. For the vaccination of hospital personnel, the hospital pharmacist prepares the syringes for vaccination. At each location, an epi-pen is present for unexpected allergic reactions.
Vaccine coverage and access
In the Netherlands, the COVID-19 vaccines are provided free of charge at the point of care. Everyone who is registered as an inhabitant of the Netherlands can be vaccinated. The vaccination of undocumented migrants is currently under consideration. In one municipality (Utrecht) this is taken care of already (provided that the vaccines are available, situation of 21 February 2021).
The government made a roadmap for the vaccinations that can change depending on availability. Once eligible, mobile people receive an invitation from the Public Health Service. They have to contact the Public Health Service themselves to make an appointment. There can be a waiting time and sometimes people cannot go to a vaccination facility in their own environment because of a lack of capacity and they have to travel to another facility (situation in the middle of February 2021). At the Dutch Wadden Isles, the elderly will be vaccinated on the island, and they do not have to travel to the main land.
The Ministry of Health decided to change the presentation of the number of vaccinations. At first, the number of vaccinations were based on actual administered vaccines that were reported to the National Institute of Health (RIVM). As there may be a lag between administering and reporting, the Ministry of Health decided, as of 30 January 2021, to estimate the number of administered vaccines based on numbers of delivered vaccines to the authorities that provide them, and assume that they will be administered within three days. This resulted in a sudden increase in number of vaccinations with over 120,000 doses in one day (an increase of about 50%).