by Klara Lorenz-Dant

In Germany, the COVID-19 vaccines have not yet (18 December 2020) been authorised. However, it is anticipated that the vaccine will become available on 27 December 2020. It is expected that initially there will be 400,000 doses available. During the first quarter of 2021 this is expected to increase to 11-13 million doses, allowing about 6.5 million people to receive the vaccination.[1]  

The Federal Ministry of Health had asked a joint working group made up of members of the standing committee on vaccination (STIKO), the German Ethics Council and the National Academy of Science Leopoldina to develop a position paper how access to the COVID-19 vaccine should be regulated.

The working group points out that it will be unlikely that, at least at first, enough doses will be available to vaccinate everyone willing to take the vaccination. For this reason, prioritisation based on medical-epidemiological findings, as well as ethical and legal consideration will need to be put in place. Based on systematic literature analyses STIKO identified old age as the ‘most pronounced most easily identifiable generic risk factor’ (p.3). Other groups identified based on statistical analysis of empirical data include:

• people at heightened risk of fatal disease progression due to their age or underlying medical conditions who also experience increased contact density (e.g. people living in residential care settings).
• Health care professionals (including staff working in inpatient and outpatient health care settings and geriatric facilities) assisting people with COVID-19 infections and who are at greater risk of transmission and increased exposure to the virus. This group, if infected, also poses a risk of infecting vulnerable people they care for.
• People in key positions ensuring the maintenance of central state functions (‘e.g. employees of local health authorities, police and security agencies, fire brigades, teachers and educators’ (p.3))[2]

On 17 December 2020 STIKO has published a more precise hierarchy of the framework above, based on scientific data. This will enable to communicate transparently the evidence-based rationale of the priority levels given to different groups. This hierarchy organised into six groups is expected to be updated throughout the pandemic, as the situation develops and more evidence and resources (e.g. new vaccines) become available:

Group 1 includes people living in care and nursing homes, people aged 80 years and older, staff working in health care settings with particularly high risk of exposure (e.g. A&E, staff caring for COVID-19 patients), staff in health care setting in close contact with groups at particularly high risk (e.g. Haemato-oncology, transplant medicine), care workers in domiciliary and residential long-term care for older people and others working in care and nursing homes in contact with residents. It is estimated that this group amounts to 8.6 million people.[3]

Group 2 includes people aged 75 to 79 years, staff in medical care settings with high risk of exposure, people with dementia and mental disabilities living in residential care settings, people working domiciliary and residential care with people with dementia or people with mental disabilities as well as people living with Down-Syndrome. This group includes an estimated 7 million people.[4]

Group 3 covers approximately 5.7 million people[5]  and includes those aged 70 to 74 years, people who have had an organ transplant; people with pre-existing conditions and who are at high risk, people living in sheltered accommodation/refuges and staff; close contacts of pregnant women; close contacts/family carers of people at high risk; staff at moderate risk of exposure in health care settings and in positions relevant to maintaining hospital infrastructure; parts of the public health authorities.

Group 4 (approximately 4.9 million people[6]) consists of those aged 65 to 69 years; people with pre-existing conditions who are at moderate risk and their closest contacts, staff working in health care settings with low risk of exposure, teachers, educators, people in precarious work or living situations.

People aged 60 to 64 years, staff in key local and federal government positions, people working in retail; people required to maintain public security with heightened risk of exposure and people working in critical infrastructure fall into Group 5 (about 8.4 million people[7]).

The final group consists of the remaining population aged younger than 60 years (approximately 45 million people[8]).

The document outlines that widening access to the different groups will depend on availability of the vaccine and will be decided at local level.[9]

On 18 December the Federal Minister of Health announced vaccination regulations that slightly differ from the priorities outlined by STIKO. In the announcement he outlined that there will be three priority groups instead of six as outlined above.

The group that will be given highest priority includes those 80 years and older, people living and working in care homes, domiciliary care workers, staff working in intensive care units, A&E and emergency services.

The second group considered high priority consists of people aged 70 year and older, people with Trisomy 21, people living with dementia, transplant patients, riot police, residents of homeless and asylum shelters as well as close contacts of people with care needs and pregnant women.

The third priority group includes those aged 60 years and older, people with selected chronic conditions, police, fire brigade, educators, teachers, people working in retail and people with especially relevant positions in state institutions.[10]

In the first instance the COVID-19 vaccine will be provided through vaccination centres mandated by the federal states. This ensure access to vaccination regardless of health insurance status. There will also be mobile vaccination teams to facilitate the process in hospitals and residential care settings.[11] The Federal Ministry of Health adds that once enough vaccine doses become available COVID-19 vaccinations will be provided through GP surgeries as vaccines against other diseases.[12]

Germany will offer vaccination against COVID-19, but will not make it a requirement.[13] The paper points out that social acceptance of the vaccination currently is relatively low and the population needs to be provided with accessible information to enable people to make informed decisions about the benefits and risks.[14]

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[1] https://www.aerztezeitung.de/Medizin/Impfstart-in-Deutschland-am-27-Dezember-415681.html

[2]  https://www.ethikrat.org/fileadmin/Publikationen/Ad-hoc-Empfehlungen/englisch/joint-position-paper-stiko-der-leopoldina-vaccine-prioritisation.pdf

[3] https://www.zdf.de/nachrichten/politik/corona-impfungen-spahn-zulassung-100.html

[4] https://www.zdf.de/nachrichten/politik/corona-impfungen-spahn-zulassung-100.html

[5] https://www.zdf.de/nachrichten/politik/corona-impfungen-spahn-zulassung-100.html

[6] https://www.zdf.de/nachrichten/politik/corona-impfungen-spahn-zulassung-100.html

[7] https://www.zdf.de/nachrichten/politik/corona-impfungen-spahn-zulassung-100.html

[8] https://www.zdf.de/nachrichten/politik/corona-impfungen-spahn-zulassung-100.html

[9]https://www.rki.de/DE/Content/Infekt/EpidBull/Archiv/2021/Ausgaben/02_21.pdf?__blob=publicationFile

[10] https://www.bundesregierung.de/breg-de/aktuelles/spahn-impfverordung-1829996

[11] https://www.ethikrat.org/fileadmin/Publikationen/Ad-hoc-Empfehlungen/englisch/joint-position-paper-stiko-der-leopoldina-vaccine-prioritisation.pdf

[12] https://www.bundesregierung.de/breg-de/themen/coronavirus/coronavirus-impfung-faq-1788988

[13] https://www.bundesregierung.de/breg-de/themen/coronavirus/coronavirus-impfung-faq-1788988

[14] https://www.ethikrat.org/fileadmin/Publikationen/Ad-hoc-Empfehlungen/englisch/joint-position-paper-stiko-der-leopoldina-vaccine-prioritisation.pdf