DE National COVID 19 Vaccination Strategy long.pdf

National Vaccination Strategy

Strategy to Introduce and Evaluate a Sars-CoV-19

Vaccine in Germany

Last updated: 06 November 2020

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Background

The development and widespread use of safe and effective Covid-19 vaccines is seen as a
realistic option for ending the current pandemic and controlling SARS-CoV-2 infection
rates in the longer term. Vaccination enables immunity to be achieved in large parts of the
population. The aim is to counter the spread of the virus and reduce the potential health-
related consequences of Covid-19 infections. Developing a new vaccine is, however, chal-
lenging and can take months or even years.
The objective is to provide safe and effective vaccines as soon as possible and in sufficient
quantities.  More  than  200  different  Covid-19  vaccine  candidates,  some  on  the  basis  of
novel  vaccine  platforms,  are  currently  being  developed.  Yet,  it  remains  unclear  as  to
which of these candidates will successfully pass preclinical and clinical trials all the way
through to approval. It furthermore remains unclear when these vaccines will be avail-
able in sufficient quantities to enable their broad public use. The first Phase 3 trials to
demonstrate efficacy and safety with different vaccine candidates were approved in July
2020. It has been announced that approval applications for two or three vaccine develop-
ments will be submitted to the European Medicines Agency later this year.
The Federal Government of Germany is actively engaged in the procurement of vaccines
to be able to provide sufficient quantities of a reliable vaccine with the ultimate aim to
offer them the entire population once they have been approved. To start with, however, it
is likely that only limited quantities of different vaccines will be available. As a result, in its
vaccination  recommendations,  the  Standing  Committee  on  Vaccination  at  the  Robert
Koch  Institute  (STIKO)  calls  for  the  prioritisation  of  specific  population  groups  who
should be vaccinated first.  Given  the  initial  prioritisation  of  target  groups,  the  limited
number  of  vaccine  doses  and  the  potentially  challenging  product  properties  of  certain
vaccines (e.g. storage and transport conditions, filling of the vaccine into multi-dose con-
tainers), it makes sense in a first phase to conduct the vaccinations in central vaccination
centres supported by mobile teams. As soon as sufficient quantities of a vaccine are avail-
able, the aim is to transfer vaccination activities to the regular healthcare system.
In light of the pandemic situation, the use of novel vaccine platform technologies, high
public expectations and the fact that several vaccines with different product properties
will no doubt be used simultaneously, proactive communication and scientific support
is  needed  to  ensure  safe  and  successful  implementation  of  the  COVID-19  vaccination
strategy.
This document sets out the key components of a national Covid-19 vaccination strategy
and describes the systems which will ensure vaccination of the German population ac-
cording to uniform standards along with timely evaluation of the vaccines during their
broad application.
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It serves as a guide, assists planning and allows for possible gaps that may still exist to be
addressed by the responsible stakeholders. Table 1 gives an overview of the components
of and stakeholders involved in the holistic vaccination strategy.
Table 1: Overview – Elements of a holistic vaccination strategy and relevant stakeholders
Components
Stakeholders
Vaccine development
Federal Ministry of Education and Research (BMBF), universi-
ties, pharmaceutical companies
Vaccine approval
Paul Ehrlich Institute (PEI), European Medicines Agency
(EMA) and the European Commission, pharmaceutical compa-
nies
Vaccine recommendations and
Standing Committee on Vaccination at the Robert Koch Insti-
prioritisation
tute (STIKO), Robert Koch Institute (RKI), Leopoldina (Na-

tional Academy of Sciences), German Ethics Council
Production and procurement
European Commission, EU member states, BMBF, Federal

Ministry for Economic Affairs and Energy (BMWi), BMG, phar-
maceutical companies
Distribution, storage and logis-
BMG, Federal Ministry of Defence (BMVg)/German Armed
tics (supply chain management)
Forces, Länder governments, logistics companies, pharmaceu-
tical wholesalers, (hospital) pharmacies
Organisation and implementa-
Länder governments, Public Health Service (ÖGD), National
tion of vaccination activities
Association of Statutory Health Insurance Physicians (KBV),

Länder-level associations of SHI-accredited physicians (Kas-
senärztliche Vereinigungen der Länder), medical personnel
Financing
BMG, Länder, Statutory Health Insurance Funds (GKV), Private

Health Insurance Funds (KV)
Communication, specialist train- Federal Centre for Health Education (BZgA), RKI, PEI, BMG,
ing and public information
Länder, Academy of Public Health Services, specialist associa-
tions
Vaccine rate monitoring
RKI

Surveillance of vaccine efficacy
RKI, PEI, EMA, pharmaceutical companies
and vaccine safety
International coordination and
Federal Government, EU, scientific forums
cooperation

Lessons learnt
Federal Ministry of Health

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1. Overview: Covid-19 vaccines and vaccine development
Vaccine development spans across different phases, from the explorative and pre-clinical
phase with trials on laboratory animals, to clinical phases 1, 2 and 3 with trials on humans,
to marketing authorisation and market introduction.
Figure 1: Overview of the phases of vaccine development
Explorative
Pre-clinical
Clinical
Clinical
Clinical
Phase
Phase
Phase 1
Phase 2
Phase 3
Market-
• Aim:
• Aim: Identification of
• Aim: Safety,
• Aim: Dose
• Aim: Proof of
ing auth-
Identification of
safe vaccine
tolerance
optimisation
efficacy and
vaccine
candidates, production
safety
orisation
candidates
in good manufacturing
practice

After producing a potential vaccine candidate in the research laboratory, initial  animal
and cell culture experiments are conducted to assess whether, in addition to its tolerabil-
ity, it is suitable for producing a protective effect against the target pathogen or the infec-
tious disease caused by it, where an animal model exists for this purpose. Subsequently,
toxicological  and  pharmacological  properties  are  evaluated  in  various  animal  models.
Only when there is no doubt as to its safety for use on humans is a first clinical trial per-
formed to assess its safety on healthy human adult volunteers (Phase 1). In the subsequent
clinical trial phases, the optimal dosage and vaccination schedule are tested in a larger
number of volunteers (several hundred) (Phase 2) and then the  efficacy and side-effect
profile  of  the  vaccine  are  determined  in  a  large,  randomised,  controlled  clinical  study
(Phase 3) with several thousand volunteers from different age groups.
Several novel vaccine candidates (e.g. mRNA and DNA vaccines) are currently being de-
veloped and clinically tested on different manufacturing platforms. The Federal Govern-
ment promotes vaccine research and production and, seeing it as a global responsibility,
advocates fair global distribution of vaccines.
Table 2 lists the Covid-19 vaccine candidates for which, according to the current status of
knowledge, marketing authorisation is being sought in the EU and for which early availa-
bility may be possible or a sufficient number of vaccine doses could be made available to
begin a nationwide vaccination campaign for prioritised groups.
  The Federal Government (BMBF, BMG) promotes research activities.
  Pharmaceutical companies and research institutes develop vaccines.



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Table 2: Overview of vaccine candidates and current status of development (manufacturer’s information, as of November
2020), subject to change
Com-
Vaccine Type
No. of
Vaccine Vol- Status:
Planned ap-
pany
Doses
ume
Clinical Development
plication for
Vac-
Application*
EU approval
cination
Inter-
val*
Oxford/  Vector-based
(1-)2
1 dose
Phase 1/2: UK
Start of Roll-
Astra-
ChAdOx1, not
doses
à 0.5ml
Phase 3: UK, Brazil,
ing Review
Zeneca
replicating
0, 28
IM
South Africa, India,
October 2020
days
US

BioN-
mRNA coated in
2 doses
1 dose
Phase 1/2: DE, US
Start of Roll-
Tech/
lipid-nanoparti-
0, 21
à 0.3ml
Phase 3: US, Brazil, Ar-
ing Review
Pfizer
cles
days
IM
gentina, Turkey, DE
October 2020
J&J/Jans Vector-based
(1-)2
1 dose
Phase 1/2: BE, US
2021
sen
Ad26,
doses
à 0.5 ml
Phase 2: DE
not replicating
0, 56
IM
Phase 3: Global
days
SP/GSK  Recombinant, ad- 2 doses
1 dose
Phase 1/2: US
2021
juvanted
0, 28
à 0.5ml
Phase 3: US
days
IM
Modern
mRNA coated in
2 doses
1 dose
Phase 3: US
Possibly end
a/
lipid-nanoparti-
0, 28
à 0.5ml
2020
Lonza
cles
days
IM
Novavax  Recombinant, ad- 2 doses
1 dose
Phase 1: Australia
Possibly end
juvanted
0, 21
à 0.5 ml
Phase 2: US, Australia,
2020
days
IM
South Africa
Phase 3: UK
Curevac  mRNA coated in
2 doses
1 dose
Phase 1: BE, DE
Unknown
lipid-nanoparti-
0, 28
0.6%
Phase 2: Peru, Panama
cles
days
IM
*Note: Preliminary information based on current knowledge
2. Covid-19 vaccine approval
Approval of the Covid-19 vaccine candidates listed in Table 2 for all EU member states is
to be granted by the European Commission following a centralised assessment procedure
coordinated by the EMA. An approval procedure is used to demonstrate the efficacy, phar-
maceutical quality and safety of the vaccine, thus  ensuring that the products adminis-
tered to patients are of appropriate quality and demonstrate a positive risk-benefit ratio.
It is possible that Covid-19 vaccines could be evaluated as part of an accelerated procedure.
However, even under accelerated approval procedures, the efficacy, pharmaceutical qual-
ity and safety of the vaccine as well as a positive risk-benefit ratio must nonetheless be
proven. Individual data packages may also be submitted to the EMA for evaluation as soon
as they are available (rolling review).
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If sufficient data is available to assess the quality, efficacy and safety of a vaccine in terms
of its risk-benefit ratio, the Committee for Medicinal Products for Human Use will recom-
mend to the EMA that it be approved if the risk-benefit ratio is favourable. Based on that
recommendation, the European Commission grants EU-wide approval.
The first data packages for rolling review have already been submitted in the EU. Assuming
that a favourable risk-benefit ratio can be confirmed, the first approvals are expected in
Q1/2021 at the earliest.
The Paul Ehrlich Institute tests vaccine batches before they are placed on the market and
approves  them  for  release  in  Germany  in  accordance  with  section  32  of  the  Medicinal
Products Act (AMG).
  Marketing authorisation for Covid-19 vaccines at EU level is usually granted by the
European Commission.
  The Paul Ehrlich Institute tests vaccine batches and approves their release in Ger-
many in accordance with section 32 of the Medicinal Products Act (AMG).

3. Vaccine recommendations and vaccine requirements
Based at the Robert Koch Institute, the Standing Committee on Vaccination (STIKO) in
its capacity as a legally established commission has the task of drawing up and issuing vac-
cine recommendations for Germany. While the safety, efficacy and quality of a new vac-
cine are the main focus of the approval process, STIKO decides how an approved vaccine
can best be applied within the population. This goes beyond an individual risk-benefit as-
sessment and also takes in the potential effects on the population (e.g. maximum reduc-
tion in the number of deaths or a reduction in virus transmission) into account.
All STIKO recommendations are based on a detailed and thorough evaluation of the
available evidence. In particular, this includes the assessment of risk factors (for infection
or serious illness) and the safety and efficacy of the vaccine.
When vaccinating against Covid-19, it can be assumed that in the beginning, there will not
be sufficient vaccine quantities available to meet overall needs. Priority should thus be
given to defining risk groups (e.g. staff in residential care homes and medical staff, senior
citizens, persons with existing diseases) who are especially vulnerable or have a particu-
larly high risk of exposure or are involved in transmitting the virus in some specific way
and who should be vaccinated first. Prioritisation of the target groups is based on epide-
miological and ethical criteria, and both the German Ethics Council and the National
Academy of Sciences Leopoldina will be consulted. An initial vaccination recommenda-
tion is currently being prepared and will be finalised as soon as data is made available from
the Phase 3 vaccine trials.
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It is possible that SARS-CoV-2 will continue to cause illness in the population even after
the pandemic, so that vaccination against Covid-19 may also be necessary in the longer
term (in the post-pandemic phase).
  STIKO is working on a recommendation for the use of available, approved Covid-
19 vaccines.
  The recommendation will be continuously adapted and aligned in accordance with
the current status of evidence and the available vaccines.
  Initially,  it  will  be  necessary  to  prioritise  groups  of  persons  who  should  be  vac-
cinated first. STIKO, in collaboration with the German Ethics Council and the Acad-
emy  of  Sciences  Leopoldina,  is  developing  ethical  guidelines  to  aid  that
prioritisation.

4. Production and procurement
To ensure the timeliest availability of Covid-19 vaccines in sufficient quantities in Ger-
many, the Federal Government procures vaccines centrally via a joint EU procurement
mechanism. In the event of promising R&D projects, advance purchase agreements are
agreed with manufacturers.
These agreements ensure that citizens have early access to successfully tested, safe vac-
cines as soon as they are approved for use in the EU. They also enable manufacturers to
build up production capacity in line with scientific development of the vaccines, allowing
faster supply and delivery following approval.
The EU has already secured access to as many as 800 million doses for the EU population
from various manufacturers. These doses will be distributed to the EU member states in
proportion to their respective populations. Some vaccine manufacturers have announced
that the first deliveries of vaccine doses to EU member states may be possible before the
end of 2020, provided that the vaccines are authorised for marketing in the EU.
  BMG/Federal Government procure Covid-19 vaccines via a common EU procure-
ment mechanism. As part of that process, Germany is participating in the EU Com-
mission’s Vaccine Initiative.

5. Distribution, storage and logistics
Proper  and  safe  transport  is  necessary  to  ensure  that  the  potential  Covid-19  vaccines
reach those to be vaccinated in all 16 German states undamaged and intact.
During planning, special requirements for transport and storage conditions must be taken
into  account:  Certain  vaccine  candidates  (e.g.  mRNA  vaccines)  require  special  storage
conditions (e.g. cool chain, temperatures < -60°C). It is also expected that the vaccines will
be delivered in multi-dose containers and that required vaccination accessories (syringes,
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cannulas) and any necessary solvents (e.g. 0.9% NaCl solution) will not be included in de-
livery.  As  a  result,  the  provision  of  vaccination  equipment  and  any  necessary  solvents
should be ensured by the Länder (federal states).
The agreements the EU Commission has reached with the vaccine manufacturers so far
stipulate that the manufacturers deliver vaccine doses to central locations in EU member
states. In Germany, vaccine doses will be distributed to central locations designated by the
Länder proportionate to the population of the respective state. BMG is currently examin-
ing a range of options to ensure safe distribution of the vaccines to the various Länder.
  BMG/Federal Government organise the distribution of possible Covid-19 vaccines
to designated locations in each state.
  The Länder are responsible for correct and safe storage and distribution of vaccines
at local level, and for procuring and maintaining stocks of the necessary vaccine
equipment and supplies.

6. Organising and implementing vaccinations

Figure 2: Organisation and implementation
Phase I A
Phase I B
Phase II
Targeted,
Expanded,
Widespread,
centralised vaccination
centralised vaccination
decentralised vaccination
• Limited quantities of vaccine available
• Greater quantities of vaccine available
• Vaccine widely available
• Some complex storage and logistics
• Some complex storage and logistics
• Less challenging storage and logistics
requirements (e.g. cooling <-60 C)
requirements (e.g. cooling <-60 C)
requirements (e.g. cooling 2 C)
• Multi-dose containers
• Multi-dose containers
• Single dose vials
• Different vaccine types available
• Different vaccine types available
• Different vaccine types available
• Very limited experience with the
• Limited experience with the vaccine
• Broad-based vaccination based on
vaccine
• Prioritised vaccination based on
STIKO-recommendation
• Highly targeted, highly prioritised
STIKO-recommendation in
vaccination based on STIKO-
consultation with Leopoldina &
recommendation in consultation with
German Ethics Council
Leopoldina & German Ethics Council
Vaccination centers with mobile teams
Medical institutions,
(Number and locations to be determined by the Länder)
general pracitioners, company doctors

Given the special circumstances surrounding the pandemic, in a first phase vaccinations
against Sars-CoV-2 will be carried out in vaccination centres to which mobile vaccina-
tion teams may also be assigned. As already mentioned, the reasons behind this approach
are the special transport and (long-term) storage requirements, vaccine supply in multi-
dose containers, the need for prioritisation in the event of initial limited availability of
vaccine doses, the expected availability of different vaccines and the need for increased
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control measures, including centrally organised data-supported monitoring of vaccina-
tions  as  a  component  of  pandemic  management.  Under  these  conditions,  centralised
structures facilitate a vaccination campaign that is controlled, efficient and effective.
For centralised Covid-19 vaccinations, the Länder are responsible for organising and set-
ting up the vaccination centres. They will set up and operate them with the support of
general  practitioners,  in  particular  the  Länder-level  SHI-accredited  physicians  associa-
tions (Kassenärztliche Vereinigungen) and, where appropriate, medical staff from hospi-
tals  or  other  institutions.  Preparation  and  implementation  can  be  supported  by  other
external stakeholders such as aid organisations, the German Armed Forces and logistics
companies.
As soon as the conditions allow and sufficient quantities of vaccine are available with
suitable storage  conditions,  the  aim  is  to  transfer vaccination activities to the regular
supply system (decentralised via pharmacies, GPs and company doctors).
  The Länder are responsible for organising and setting up the vaccination centres and
for ensuring that the vaccines are properly distributed to and administered to those
in the priority vaccination groups with the involvement of local stakeholders.

7. Financing
Potential Covid-19 vaccines are to be made available free of charge. Financing of Covid-
19 vaccination in vaccination centres should be made simple and effective to achieve high
vaccination rates and speedy vaccination.
It is planned that after consulting STIKO and the German Federal Association of Health
Insurance Funds (Spitzenverband Bund der Krankenkassen), BMG will issue a statutory
order stating that persons with statutory health insurance and also persons without stat-
utory health insurance are entitled to receive a Covid-19 vaccination. With this approach,
BMG ensures timely access to the vaccination programme for the group of persons cov-
ered by the STIKO recommendation.
To promote rapid set-up and smooth, lean-management procedures in the vaccination
centres, the running costs incurred are to be invoiced in the form of a lump-sum amount.
The costs of setting up and organising vaccination centres are to be borne jointly by the
Länder and using funds from the statutory health insurance funds (health fund’s liquid-
ity  reserve)  and,  where  appropriate,  the  private  health  insurance  funds.  The  Federal
Government supplies the vaccination centres with the federally-procured vaccines with-
out the need for refinancing.
  BMG issues a statutory order on proportional financing by the statutory health in-
surance funds.

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8. Communication, specialist training and public information
In the course of the pandemic so far, proactive communication with the public and target
group-specific  information  campaigns  have  contributed  significantly  to  both  the  ac-
ceptance and the implementation of measures to deal with the pandemic (e.g. the AHA-
formula (based on the German for “masks, hand-washing, distance”) for the general public
and the testing strategy specialists). A transparent, proactive and targeted communication
campaign is of particular importance to foster the vaccination strategy’s success.
To ensure uniform and targeted communication, a federal level Communications Man-
agement Committee featuring among others, BMG, BZgA, PEI and RKI has been set up.
Management of communications on Covid-19 vaccination, including development of the
structure and the schedule, is the responsibility of the executive level at the Ministry of
Health. The aim is to coordinate and harmonise the overall measures, including PR work,
addressing target groups such as healthcare staff, vulnerable groups and the general pub-
lic. From the outset, the focus is placed on transparency and on involving and communi-
cating with significant social groups.
  Establishment of a Communications Management Committee under the leadership
of BMG.

  Launch of the general vaccination campaign when the vaccine becomes availabie
9. Vaccine rate monitoring
Valid data on vaccination uptake (vaccination rates) provides the basis for analysing vac-
cination behaviour and the success of the accompanying information campaign. Infor-
mation  on  target  group-specific  vaccination  rates  enable  both  management  and
adaptation  of  the  vaccination  strategy.  For  example,  the  information  campaign  can  be
adapted if vaccination rates are particularly low in certain population groups or if there
are large regional differences between the Länder. The vaccination rates also serve as a
“common denominator” in classifying efficacy and safety (differentiating between indi-
vidual  cases  versus  representative  cases  based  on  the  total  number  of  all  persons  vac-
cinated) (see Section 10).
For the purpose of vaccination rate monitoring, the following non-personal data  is re-
quired:
  Details concerning the person receiving the vaccine – age, gender, place of residence
(Land/district), indications concerning the vaccinated person
  Details concerning the vaccination – place of vaccination, date of vaccination, vaccine
product (name and batch number), vaccination dose administered (first vaccination or
follow-up vaccination where applicable)
In order to ensure both timely analysis of and transparency in the implementation of
Covid-19 vaccinations, the vaccination centres must forward this data to RKI, preferably
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in real time. A web-based data portal is to be used for this purpose. The portal is to be
developed by RKI prior to the launch of the vaccination campaign in Germany.
In addition to online real-time documentation and reporting, other components will en-
able integrated monitoring of vaccination rates in Germany (Table 3). The outputs will be
made available to other stakeholders (BMG, PEI, BzgA, the Länder) in aggregated form.
Table 3: Components of an integrated approach to vaccination rate monitoring in Germany (As of: 04 November 2020)
Components
Description
Central, online    Near-real time documentation and reporting of non-personal data on take-
system
up (vaccination rates): All vaccination centres must collect the minimum da-
taset and transmit it in aggregated form
  System being developed by RKI
  High data protection standards and statutory instrument as a basis
Regular, repre-   14-day surveys in the form of a representative sample of the population
sentative pop-
  Survey preparation by RKI
ulation surveys    The minimum dataset enables collection of the reasons for non-vaccination,
vaccination intention and vaccination acceptance
Documenting
  Adaptation of the OkAPII system (originally created to record influenza vac-
the vaccina-
cination rates) to Covid-19 vaccination with a shortened survey interval of
tion status of
one month
hospital staff
  Documenting the Covid-19 vaccination status and surveying vaccination ac-
using OkAPII
ceptance/vaccination barriers in the core target group of hospital staff
RKI vaccina-
  Established and legally-embedded routine system for vaccination rate moni-
tion surveil-
toring based on health insurance fund data
lance using
  Not suitable for Phase I of pandemic vaccination in vaccination centres as
health insur-
based on individual invoices and a delay of 3-6 months
ance fund data    In the transition to the decentralised routine vaccination system (Phase II):
Use of the system based on health insurance fund data to validate the data
from online real-time monitoring (in addition, estimation of vaccination effi-
cacy, duration of vaccination protection, long-term adverse effects)

  RKI is responsible for monitoring the vaccination rates.
  RKI develops an online vaccination rate monitoring system for nation-wide use in
vaccination centres and by mobile teams.
  RKI designs and conducts parallel studies and surveys on vaccination rate monitor-
ing.

10.  Surveillance: Evaluating  the  safety  and  efficacy  of  Covid-19
vaccines
When new Covid-19 vaccines are introduced, active surveillance of the safety and effi-
cacy of the vaccine product(s) is absolutely essential. Large clinical trials on the clinical
efficacy and safety of the vaccines are ongoing worldwide and are being evaluated for ap-
proval.  Only  vaccines  with  a  proven  positive  risk-benefit  ratio  will  be  approved  and
made available. Due to the fast development and the limited duration of observation in
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the trials, continuous monitoring and collection of further data during widespread use is
necessary to identify any potential risks caused by the vaccines as quickly as possible.
Vaccine benefit and risk assessment is a continuous process ranging from vaccine devel-
opment, to pre-approval clinical trials to post-marketing surveillance. While pre-market-
ing clinical trials provide important information on the safety and efficacy of vaccines,
post-marketing studies are essential to obtain further information on the safety and effi-
cacy of the vaccine (e.g. occurrence of rare adverse effects) in larger and more heterogene-
ous populations that have not been studied in pre-approval clinical trials.
Post-marketing surveillance of the efficacy, safety and also the duration of protection of
vaccines ensures that the positive risk-benefit profile established at the time of approval
can be continuously reviewed as the vaccine becomes widely used and that vaccination
recommendations can be adapted where needed to reflect the new findings.
Table 4: Overview of the proposed systems and studies for use in evaluating vaccine efficacy and safety in Covid-19 vaccina-
tions in Germany

Data collection in real time or near-
Data collection in the medium and longer
real time
term
Vaccine ef-
  Case reports under the Protection    Hospital-based case-control studies
ficacy
against Infection Act (IfSG)
(efficacy, period of protection)
(breakthrough infections)
  Outbreak studies as cohort studies
  Screening methods
Vaccine
  Routine pharmacovigilance (indi-
  Hospital-based case-control studies
safety
vidual-based reporting)
  Evaluation of digital health data
  Cohort studies, including app-
  Surveillance of pregnant women
based

10.1. Vaccine efficacy
As part of the reporting obligation under the Protection against Infection Act, information
on reported Covid-19 cases, including the vaccination status, is transmitted to the Robert
Koch Institute. In the short term, by  comparing the proportion of vaccinated persons
among the Covid-19 cases reported (breakthrough infections) with the proportion of
vaccinated persons in the population, it is possible to estimate the efficacy of the vaccina-
tion (screening method).
In the longer term, a hospital-based case-control study will be used to measure the effi-
cacy of Covid-19 vaccines used in Germany by including Covid-19 patients (vaccinated
and unvaccinated). In particular it will look at protection in exposure to hospitalised or
severe cases of Covid-19 infection, the duration of protection provided and whether in
relation to these parameters there are differences between the available vaccines.
Outbreaks  in  special  facilities  (e.g.  care  institutions,  community  facilities)  or  at  events
where the group of exposed persons can be easily defined should also be investigated using
a standardised methodology and data collection tools. In such settings, depending on the
institution involved and especially as regards particularly vulnerable groups, the efficacy
of vaccination can be determined as part of a retrospective cohort study.
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10.2. Vaccine safety
Routine pharmacovigilance is based on established real-time monitoring of possible side
effects or vaccination-related complications in accordance with sections 6, 8 and 11 of the
Protection against Infection Act (IfSG) and section 63 (c) of the Medicinal Products Act
(AMG) predominantly based on individual-based reporting.
In the short term, a  cohort study using a smartphone app will prospectively track the
frequency  and  severity  of  adverse  effects  and  of  SARS-CoV-2  infections  in  vaccinated
adults over a period of one year.
In the longer term, the hospital-based case-control study to investigate the efficacy of
vaccination in hospitalised Covid-19 patients (vaccinated and unvaccinated, see 10.1) will
also investigate the severity of the clinical course of the infection and look for possible
indications that could suggest a worsening of the infection following vaccination.
Furthermore, an evaluation of digital health data on the safety of Covid-19 vaccines will
also be conducted. The electronic data from four large health insurance funds, which cover
about 70% of statutory insured persons in Germany, will serve as a basis. Data on potential
risk signals from Phase 1-3 studies and new risk signals detected during widespread use
after approval are examined on a quarterly basis. Modelling and AI methods are used to
estimate the risks for subsequent quarters. In the design phase, an assessment should be
made as to whether and, if necessary, how in order to aid these evaluations the perfor-
mance and billing data could be linked with the data recorded at the time of vaccination.
To study the safety of the vaccines in the vulnerable group of pregnant women, most of
whom are not included in pre-marketing clinical trials surveillance of pregnant women
will  be  conducted  (pregnancy  complications  in  pregnant  women  who  have  been  vac-
cinated shortly before or during pregnancy – such as abortion, premature birth, stillbirth
and eclampsia, compared with unvaccinated pregnant women – fetal malformations, low
birth weight, postnatal adaptation disorders compared to non-exposed newborns).
  Within the scope of their remits, the higher federal institutions RKI and PEI actively
shape the monitoring of efficacy and safety of COVID-19 vaccines.



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11. International coordination and cooperation
The SARS-CoV-2 pandemic is a challenge of global scale. Coordination and cooperation
with international partners is thus an essential component of the vaccination strategy in
order to accelerate the development of and access to effective and innovative responses
and solutions.
The German Federal Ministry of Health works closely with its partners in the European
Union on the joint procurement of vaccines. It also maintains regular bilateral and multi-
lateral exchange with various other stakeholders.
BMG is actively involved in various international forums and promotes cooperation be-
tween stakeholders from the foundation system as well as from the public and private sec-
tors. In addition, BMG, in collaboration with the respective authorities, provides support
within  the  boundaries  of  their  remit  (RKI  and  PEI)  to  aid  the  international  transfer  of
knowledge. This includes, among others, the project and committee-based work outlined
below.
RKI is represented in the WHO/Europe Regional Working Group on Covid-19 Vaccination
and Deployment and also in the WHO SAGE Working Group on Covid-19 Vaccines. In the
ECDC-coordinated EU Network of National Vaccination Commissions, RKI is the lead or-
ganisation in a “living systematic review” on the efficacy and safety of the Covid-19 vac-
cines  and  thus  provides  key  input  to  aid  decision-making  concerning  the  Covid-19
vaccination strategies in other EU countries.
As a collaboration centre for vaccines and blood products, PEI supports, among others, the
WHO, the regulatory authorities in African partner countries, WHO Afro and regulatory
bodies of the African Union in establishing structures and procedures to promote the ap-
proval and implementation of clinical trials for medicines and vaccines and to establish
effective pharmacovigilance in the use of medical products.
  The Federal Government is responsible for cooperation and coordination at inter-
national level.
  The authorities that fall within BMG’s remit (RKI and PEI) conduct specific projects
for international cooperation, including in relation to the vaccination strategy.

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Covid-19 Pandemic Vaccination – Implementation in 2 Phases
Phase I A
Phase I B
Phase II
Targeted,
Expanded,
Widespread,
centralised vaccination
centralised vaccination
decentralised routine vaccination
• Requirements
• Limited quantity of vaccine available
• Greater quantities of vaccine available
• Vaccine widely available
•
Vaccine availability
• Some complex storage conditions (e.g. cooling
• Some complex storage conditions (e.g. cooling
• Less challenging storage and logistics (e.g.
•
Storage conditions
<-60 C)
<-60 C)
cooling 2 C)
•
Supply
• Multi-dose vials
• Multi-dose vials
• Single dose vials
•
Management
•
Experience
• Highly targeted, highly prioritised vaccination
• Prioritised vaccination
• Broad-based vaccination according to
• Different vaccine types available
• Different vaccine types available
vaccination recommendation
• Very limited experience with the vaccine
• Limited experience with the vaccine
• Different vaccine types available
Target group
• For example, vulnerable groups (STIKO-
• For example vulnerable groups (STIKO-
• For example, members of the adult population
*Based on STIKO
recommendation and consultation with Ethics
recommendation and consultation with Ethics
(subject to STIKO recommendation, pending)
recommendation
Council and Leopoldina pending)
Council and Leopoldina pending)
Organisation
Vaccination centres with mobile teams
Medical institutions,
Locations and number determined by the Länder (federal states) (subject to availability)
general practitioners, company doctors
Procurement
Decentral: Doctors,
Central: Federal Government and EU (joint procurement)
wholesalers, pharmacies
Storage and
Federal Government delivers vaccines to max. 60 locations in all German states; distribution proportionate
distribution
Wholesalers, pharmacies
to state population, other storage and logistics at local level by the Länder
Financing
Vaccine by Federal Government, equipment/supplies by the Länder,
Health insurance funds (statutory and private),
Vaccination centres jointly by the statutory health insurance funds and the Länder
Civil service subsidy funds (Beihilfeträger)
Vaccination rate
Online transmission (near-real time, not yet implemented)
Health insurance fund data (3-6 month delay)
monitoring
Supported by surveys
Supported by surveys
Safety and Efficacy
Reporting by doctor (individual-based)
Evaluation
Supported by surveys and studies (population-based) and online documentation (PEI app)
STIKO = Standing Committee on Vaccination at the Robert Koch Institute | Länder = Federal states
SRISD
Last updated: 06 November 2020 (S.D.)

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