Weekly Briefing, Vol. 38, No. 3 (Sl), March 2021
Mass vaccine rollout and related obstacles
Summary
After the vaccination programme for mass vaccination of people against Covid-19 related illness started in late December 2020, the initial plans to reach a 60% vaccination rate in population before spring soon turned out to be overly optimistic. Several obstacles appeared: the unexpectedly slow rate of vaccine supply, government decision to abstain from the purchase of large quantities of Pfizer BioNTech, unclear and changing official vaccination agenda, irregularities in vaccine distribution and the fears regarding the potential Astrazeneca vaccine related serious side effects. Although effort have been made in late March to speed up the vaccine rollout to reach 60% vaccination rate before the summer, the success of this plan is still not guaranteed.
Background: current situation
Slovenia took part in the EU-organized joint purchases of Covid-19 vaccines from three first producers whose vaccines got approved by the European Medicines Agency (EMA). After Pfizer/BioNTech vaccine was approved on December 21, the first 11,700 doses of this vaccine arrived in Slovenia on December 26. First 1200 doses of Moderna vaccine arrived on January 12, while the 9600 doses of AstraZeneca arrived On February 6. After that, all three vaccines were arriving in small batches with the AstraZeneca vaccine deliveries being lower than previously negotiated, the same situation that affected other European countries as well. By April 1, Slovenia received a total of 476,280 doses of vaccines – 285,480 of Pfizer/BioNTech, 144,000 of AstraZeneca and 46,800 of Moderna vaccine. The results in the first four months of vaccine rollout are still disappointing, the percentage of fully vaccinated people on national level is only 5.7%. This number varies slightly between statistical regions, with Goriška having the highest percentage of fully vaccinated people (6.7%) and South-Eastern Slovenia having the lowest percentage (4.9%). Total number of people vaccinated with two doses is 118,765 and the total number of those vaccinated once is 284,027. The numbers in this regard do not adequately reflect the immunisation, since according to current national criteria, people vaccinated with first dose of AstraZeneca vaccine are considered vaccinated between 3 weeks days and 12 weeks after vaccination, since in the case of this vaccine the protection after the first dose (with the second only scheduled in 3 months) is comparably high. Among those fully protected with two doses of vaccine 110,823 have been vaccinated with Pfizer/BioNTech vaccine, 7,728 with Moderna and only 214 with AstraZeneca vaccine. This last number is not surprising, since it has been recommended to wait for the whole 12 weeks before the second dose to obtain the highest immunity and the vaccine has only started being used in Slovenia in early February. The numbers of vaccinated people also show some gender differences (74,244 women have been fully vaccinated compared to only 44,521 men), most probably due to the vaccination of very advanced age individuals over 85 years of age, where the ratio of women is considerably higher than that of men. Due to the strategy of vaccinating elderly citizens first, especially the residents of nursery homes and others from the age group over 80 years of age, this age segment shows a high vaccination rate – 39.8% have been full vaccinated in the group over 90, 47.7% in the group between 85 and 89, 52.1% between 80 and 84 and 30.7% between 75 and 79. For managing the current third wave of the epidemic these numbers are a welcome achievement, but the opposite in unfortunately true for the next age segment which has not been sufficiently vaccinated, although they are still at high risk of Covid-19 related complications. The segment of population between 70 and 74 years is vaccinated only in 4.4%, while the situation is even worse for those between 60 and 70, which have the lowest vaccination rate of the whole Slovenian population over 25 years (only 1.5% between the ages 65 and 69, and 2% between 60 and 64). The results of this process and the unfortunate imbalance in vaccination rates is also reflected in lowering of the average rate of COvid-19 hospitalized patients, which was 72 during the second wave of the epidemic but has now dropped to 67.
Development of vaccination agendas and systems
Before the vaccines arrived in late December, there have been many open questions about how to proceed with the registering of the individuals who wish to be vaccinated and how to develop and implement a clear system of priority groups for vaccination. In December an e-application system was opened via the national e-administration system, where all individuals could express their interest in receiving a vaccine when it would become available. Parallel to this system, what was expected to be the priority groups (elderly and chronically ill patients) could also apply via their doctor (GP). The first national strategy was also adopted in early December, determining the priority groups. First the vaccines would be distributed among the residents and the staff in nursery homes, then to those working in medical institutions, chronically ill patients, and those over the age of 60. The vaccines were planned to be distributed on equal basis in all parts of Slovenia. This vague strategy was in place until the beginning of March, when the second and third strategies were adopted on March 1 and 11 respectively, while the last and current one was adopted on April 1. The two March strategies advised the priority vaccination of several high—contact professional groups (teachers, officials, police etc.), while the last one, adopted at the rise of the third wave, skipped these priorities to focus on improving the vaccination rate in the age group over 60.
Obstacles for the success of the vaccine rollout
First and foremost, the rather low rate of vaccination is due to the lack of available vaccine. One of the factors is the failing supply of the AstraZeneca vaccine which is consistently lower than the agreed amounts. On top of that, as it became public in March, Slovenia has also decided not to purchase an extra amount of half million doses of Pfizer/BioNTech vaccine, which was offered to Slovenia in December. At the time this happened, the information was not available to the public. When faced with criticism over this decision, the Prime Minister Janez Janša, at that time also serving as the acting Minister of Health (after the resignation of Tomaž Gantar), only explained his decision with the fact that they chose to rely on the promised large quantities of the cheaper AstraZeneca vaccine. The lack of vaccines, however, was made worse due to the lack of a clear vaccination registration and distribution system. As it became evident in the first weeks of the vaccine rollout, the unclear guidelines of the first vaccination strategy along with the lack of a central system of registration led to a large number of irregularities and violations of the key vaccination priorities. In several medical institutions they vaccinated the relatives of the staff, private medical institutions skipped the waiting line for the vaccination and the rate with which the vaccination became available to different priority groups mostly depended on the ingenuity of the local administration or medical institutions. The lack of centralized IT system coordinating the registration and distribution became the bottleneck of the system, which became most obvious when a case of the municipality of Kočevje was exposed as having already vaccinated much more people that other municipalities and regions, primarily due to establishing a well-managed local IT system for the vaccine rollout. To the general surprise, the national vaccination coordinator (formerly the government PR representative) Jelko Kacin voiced harsh criticism of the Kočevje case, thereby provoking a wide public debate on the efficacy of the national vaccination policies. The vaccination strategies suffered another issue with the crisis related to the suspected AstraZeneca side effects. Having only started with the large-scale AstraZeneca vaccination for the high-contact professional groups, the news that European Medicines Agency started a revision of the safety of the vaccine was an unwelcome problem. After many European countries decided to halt the vaccination with this vaccine in mid-March and to wait for the decision of EMA, Slovenia did the same on March 15, and restarted the vaccination on March 19 after it was confirmed as safe by EMA. After the EMA report several other countries have opened the debate on the potential blood-clotting cases and a new report is expected in mid-April. Slovenian expert group is currently advising that the AstraZeneca vaccination should be halted again for age group below 60 years of age until the next EMA position is announced. With the change of strategy on April 1, the high-contact groups being left out from the priority list, the AstraZeneca vaccine is now used primarily for the vaccination of the population over 60.
Conclusions
Despite the initial government plans that Slovenia would reach high Covid-19 vaccination rates by spring, the situation after the first three months of vaccination is disappointing. With only 5.7% of population fully vaccinated and the population between 60 and 70 almost completely unprotected, the situation will need to be improved at a fast pace to stop the growing third wave of the epidemic. One of the major tests for the government and the national health authorities will be if they will be able to secure enough vaccines and to implement a clear strategy and a well-working IT system to improve those rates in the coming months.