Klara Lorenz-Dant1 (@LorenzKH) , Stefanie Ettelt1,2 (@s_ettelt)
1 Associate Researcher, Care Policy and Evaluation Centre, London School of Economics and Political Science
2 Honorary Associate Professor, London School of Hygiene and Tropical Medicine
After a year of turmoil and despair, 2020 ended on a high note: Vaccines against Sars-CoV-2 were no longer only on the horizon, but a number of them had shown highly promising results in trials. By the end of December, the frontrunner had received the stamp of approval from the European Medicines Agency (EMA). Plans were made for a speedy roll-out, in Germany and elsewhere, and priorities defined to get the vaccine swiftly to those with the highest risks of illness and death from Covid-19.
But it did not quite go to plan. For all intents and purposes, Germany – with its population of 83 million – has ordered a large supply of vaccine doses: 94.1 million doses from BioNTech/Pfizer alone (through the EU mechanism and unilaterally) and over 50 million each from Moderna, CureVac, AstraZeneca and Sanofi/GSK, plus over 36 million from Johnson&Johnson. However, by early February, only the mRNA and AstraZeneca produced vaccines are authorised in the EU. BioNTech/Pfizer and AstraZeneca have issued warnings of significant delays in production, taking policy-makers by surprise who had failed to appreciate the challenge of scaling up production at such speed. STIKO, the commission advising the Government on vaccines and vaccination hosted by the Robert Koch Institute (RKI), also advised against the use of the AstraZeneca vaccine in people over the age of 65 years, due to concerns about the small amount of efficacy data available for this age group. In consequence, efforts to roll out quickly have been hampered by a shortage of vaccine doses experienced up and down the country.
The Federal Government’s vaccination strategy sets out three phases of implementation. The first phase focuses on the most vulnerable groups, identified by STIKO, in a targeted, centralised approach to organising mass vaccination. These groups include people over the age of 80 and people living in residential care and nursing homes, as well as health and care personnel. In a second phase, the approach to organising vaccination is still targeted but expanded to more groups, again following prioritisation. In both instances, vaccination will be delivered through local vaccination centres and mobile teams associated with these centres, organised at district-level or by the states. Mobile teams will visit care homes and other institutions in the first instance.
Due to the shortage of vaccines many vaccination centres that have been established at speed currently operate a reduced service or have postponed their opening altogether.
The third phase of the strategy aims to offer vaccination to the entire population and is planned to be delivered in a decentralised approach through general practitioners, hospitals and other medical providers, but also at the workplace if this is feasible. An overview of the German vaccination strategy can be found here.
State-level organisation of vaccination centres
The federal structure of Germany means that the local implementation of the vaccination campaign varies between states. In most states (Länder), people in the relevant risk groups can book appointments through an online system or over the phone (Baden-Wurttemberg, Bavaria, Brandenburg, Hesse, North Rhine-Westphalia, Rhineland-Palatinate, Saarland, Saxony, Saxony-Anhalt, Schleswig-Holstein, Thuringia), while in other states at risk individuals receive a letter with an appointment (Berlin, Mecklenburg Wester-Pomerania, Lower Saxony). The city states of Bremen and Hamburg decided to send eligible people a personalised code or invitation to book an appointment.
Due to complex cooling chains required at least for the first vaccine available in Germany (BioNtech/Pfizer), the country has opted to install large vaccination centres across the country instead of distributing the vaccines to doctor’s offices. Most Länder have set up one vaccination centre per districts or towns. The district authorities and the regional Associations of Statutory Health Insurance Physicians (usually the conduit for payments between social health insurance funds and ambulatory providers) are key partners in the organisation and running of the centres. In some Länder not-for-profit welfare organisations also carry responsibility (table 1). Distribution of vaccines between the 16 Länder is proportionate to population density.
Table 1. Overview vaccination centres in the Länder
| Land | Vaccination centres | Responsible organisations |
| North Rhine- Westphalia | 53, one per district | Organised by the districts. Registration, vaccination information and vaccination are organised by the Associations of Statutory Health Insurance Physicians. Some districts receive support from the Red Cross. |
| Baden-Wurttemberg | 9 central vaccination centres and 50 district vaccination centres | The state government and the regional association of towns and villages coordinate the distribution of centres. |
| Bavaria | 99 vaccination centres across all districts | District authorities can outsource the management of the vaccination centres to external service providers (so far involved in 66 centres), such as the Red Cross. |
| Hesse | 28 vaccination centres covering all districts | District authorities receive assistance from the taskforce vaccination coordination that is part of the Hesse crisis team |
| Berlin | 6 vaccination centres | Centres are operated by not-for-profit welfare organisations (German Red Cross, the Workers’ Samaritan Federation, the Order of St John, the Order of the Knights of Malta). |
| Hamburg | 1 vaccination centre | The Association of Statutory Health Insurance Physicians of Hamburg responsible for managing the centre |
| Rhineland-Palatinate | 31 vaccination centres | The district authorities are responsible for managing the centres. |
| Saxony | 13 vaccinations centres; one in each of the large towns and one in each of the districts. | The Red Cross Saxony is responsible for managing the centres. |
| Lower Saxony | 50 vaccination centres | The state has asked the Disaster Management Teams in towns and districts to put together suggestions for location and management of centres |
| Schleswig-Holstein | 29 vaccination centres | Responsibility sits with towns and districts |
| Saarland | 3 vaccination centres | The districts are responsible, for setting up and running of the centre. |
| Brandenburg | 11 vaccination centres | The ministry of health of Brandenburg is in charge of logistics, the rooms are organised by the Association of Statutory Health Insurance Physicians and district authorities. Mobile vaccination teams are managed by the German Red Cross. |
| Mecklenburg Wester-Pomerania | 12 vaccinations, one each per district | The districts and towns are responsible for organising the centres with different partners (e.g. red cross, hospitals) |
| Saxony-Anhalt | One vaccination centre per district and as in three main towns. | The districts are responsible for operating the centres. |
| Bremen | 2 vaccination centres | The municipal authorities are responsible. |
| Thuringia | 29 vaccination centres. One in each of the 23 districts | The Association of Statutory Health Insurance Physicians in Thuringia is responsible for the vaccination centres. |
Vaccination centres are required to provide real-time data directly to the RKI to allow the Federal Government and state governments to monitor progress. Data reported include the age, sex, place of residence of people who have received the vaccine, as well as information about their risk status, the place and date of vaccination, the type of vaccine received and whether this was the first or second jab. This information is made publicly available on a daily basis through the vaccination dashboard, run by the Federal Ministry of Health and the RKI. A current map of the location of the vaccination centres is included in this article (in German).
The costs of the vaccines are covered by the Federal Government, while the Länder cover the costs of medical equipment (e.g. syringes). Costs of setting up and operating the vaccination centres are shared between the Federal Government and the Länder.
As a result of the shortage of vaccines many centres have opened later than expected. For example, in Thuringia available vaccines were initially provided to hospital staff (90% of the first two available deliveries of vaccines) and staff and patients in nursing homes. Only half of the vaccination centres are likely to be in operation in February. Similarly, North-Rhine Westphalia prioritised nursing home residents and staff as well as hospital staff, and centres only opened in February.
Access to vaccination for older people
More than 950,000 doses of vaccine have been distributed to nursing home residents as of early (8th) February. Using data available from the RKI, we estimate that 67% of nursing home residents (649,811 received first doses; 307,231 received both doses by 7 February 2021) in Germany have received the first jab, and 32% have received both (based on 2019 estimate of 969,553 available nursing home places ).
Across the country mobile vaccination teams have been despatched to visit residential care and nursing homes and to provide residents and staff with the COVID-19 vaccine. Based on RKI data, we estimate that people living in nursing homes (649,811 first doses by 7 February 2021) and people with classified as ‘exposed due to their occupation’ (such as health and care workers; 1,082,323 first doses by 7 February 2021,) have received almost 53% of the first doses provided so far (first doses provided by 7 February 2021: 2,295,221).
Data suggest that in many states the number of staff vaccinated is much larger than the number of older people receiving the vaccine in care homes. A survey conducted by a media consortium in late January suggests that only 29% of doses were used in residents of care homes, while 41% were allocated to care personnel. In NRW, the percentage of older people in nursing homes among those immunised is 47%, whereas in Baden-Wurttemberg the percentage is 17% only. This may in part be due to difficulties experienced with the logistics of obtaining informed consent, especially if people do not have capacity to consent and consent is required from a legal guardian.
In principle, older people living at home also fall into the first priority group (aged 80 and older), however, organising access to vaccination has been problematic. To date, only about 1.2 million doses have been provided to the more than 5.6 million people aged 80 years and older in Germany. However, in the data is unclear whether the people who have received the vaccine live in their own homes or residential care settings.
Most states require people to make their appointment online or by telephone. Yet not everyone will be familiar with using online booking services, particularly perhaps members of the older age group. Media reports suggest that the system has not been able to meet the initial spike in demand. A national telephone hotline was overwhelmed and the number was not always well communicated, so some people did not know how to make an appointment. There have also been concerns about people making appointment in areas that are not their place of residence. One district, Burgenlandkreis in Sachsen-Anhalt, decided to exit the scheme as it was felt that too many people access the service from outside their area.
Many older people will need help from family members or friends to make an appointment. Access to appointments will be easier for people in Berlin, Mecklenburg Western-Pomerania and Lower Saxony where eligible individuals are invited by post. In Lower Saxony, concerns about data protection have led the state government initially to use address details available from the subsidiary of the postal service, which happened to be incomplete, instead of utilising official registry data.
Distances to vaccination centres can be extensive, especially in rural areas. Many older people are required to travel long distances and rely on the support from friends and relatives to be able to get to a centre. Only in a few locations have arrangements been made to organise transport for older people or to provide additional funding to cover transport costs.
It is not yet clear how people who are unable to leave their homes will receive the vaccine. In principle, they should be visited by a mobile team but various logistic problems, some of which relate to the storage requirements of the BioNTech/Pfizer vaccine, and the general shortage of supply have hindered efforts.
Access to vaccination for health and care workers
The German vaccination dashboard records that in total more than 1.6 million doses of vaccine being provided to people working in health and long-term care, roughly 48% of all doses provided.
There have been claims that health and care workers are less willing to take the jab than the average population, although this claim is hotly contested, and the debate is generally marked by conjecture. A study referred to by the RKI notes that willingness to receive the vaccine is slightly lower in health and care professionals than the general population; these data were collected in December 2020. It was reported that in some hospitals and care homes, up to 80% of staff have received the vaccine while in other facilitates uptake was only 20%. It has also been suggested that the willingness to be vaccinated has increased over time, possibly reflecting more information being made available about the efficacy and possible side-effects of the vaccines.
Access to vaccination is likely to be more difficult for domiciliary care workers. They need to organise an appointment for themselves and are currently waiting for appointment to become available. Unpaid carers supporting relatives and friends at home are currently not given priority. Unless they are in a higher risk group themselves (e.g. due to old age) they find themselves in risk group 3 and therefore will have to wait their turn until more vaccines become available.
Access will be particularly challenging for people who have come to work in Germany from abroad. A large, yet unknown number of people (estimated to be 100,000 or more) are understood to work as ‘live-in’ carers in Germany, usually with a work contract in the country of their origin, which is possible within the EU. An expert from the German Institute for Integration and Migration Research (Deutsches Zentrum für Integrations- und Migrationsforschung) warned that this group of workers is currently not well represented in the national vaccination strategy. More importantly perhaps, these workers are typically not covered by German social health insurance (GKV), as they do not have a German employment contract. This should not matter in principle, as the vaccine is paid from by taxation rather than contribution fees; however, these workers are likely to be under the radar of the authorities, which may provide an organisational barrier.