Josephine van Dongen

Chapter 8 188 observe a reduction in cumulative days hospitalized or incidence of acute respiratory illness, as would be expected on the basis of trained immunity mechanisms. Finally, the implementation strategy used for the RIVAR project yielded a vaccination coverage of 52% (95%CI 51;54%) with a wide variation in coverage between infants with different MRCs and between hospitals ( chapter 7 ). In the Netherlands, routine childhood vaccinations are delivered via youth health care professionals in well-baby clinics. Setting the indication for, and administering rotavirus vaccination selectively to medical risk infants required a different infrastructure.We therefore implemented this targeted vaccination program in secondary and ter tiary pediatric medical care centers. Based on evaluation surveys among parents and health care professionals (HCP), and in-depth interviews with involved HCP we provided suggestions for improvement of a hospital-based targeted rotavirus vaccination program for medical risk infants. This included an elaborate educational program with a dedicated on-site physician to raise awareness, nationally implemented recommendations to avoid too much variability in local hospital policies and, dependent on the existing local immunization structure and setting, involvement of youth HCP for counseling and vaccine delivery. General discussion The decision making process on rotavirus vaccination in the Netherlands has been a long and bumpy road.What we have learned throughout the RIVAR project and from its results is ultimately reflected in the reversed ministerial decree on implementation of rotavirus vaccination, and a renewed request to the Dutch Health Council to revise its advisory statement. 8 The first rotavirus vaccination advisory statement, years before the RIVAR study star ted, dated from 2007 and concluded that there was insufficient evidence for the added value of universal rotavirus vaccination, given unknowns about genotype epidemiology and cost-effectiveness in the Netherlands. 9 In 2013 rotavirus vaccination was again reviewed by the Health Council, however no consensus was reached and a formal repor t was never published. 10,11 In 2017, the Health Council advised to implement rotavirus vaccination, at least for infants with MRC. 12 A year later, the Ministry of Health decided to implement a selective rotavirus vaccination program by 2019, which was later postponed to 2020. 13,14 While preparations were in progress, the preliminary results of the RIVAR project were communicated to the National Institute of Public Health and the Ministry of Health. This led to the decision on 30 April 2020 to cancel the implementation and to request an updated advice from the Health Council, incorporating lessons learned from the RIVAR project. 8,15 At the time of writing of this discussion, the new advisory statement is pending and no rotavirus vaccination program is implemented in the Netherlands, contrary to the situation in over 100 countries worldwide ( figure 1 ). 16