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RIVM
Thermometer as an aid in interpretation
COVID-19 situation
A. van Leeuwenhoeklaan 9
Appendix 1 to the RT advice Thermometer and Measures Ladder - August
3721 MA Bilthoven
29, 2022
PO Box 1

3720 BA Bilthoven

Question VWS www.rivm.nl

There is a need for a 'thermometer' as a support tool for public communication

in the interpretation of the coronavirus. Is it possible to develop such a thermometer T 088 689 8989
that primarily relates to the epidemiological situation, compliance with measures lci@rivm.nl
and accessibility of care? The thermometer would then indicate, on the basis of a
qualitative weighting of a number of quantitative indicators, at which stage
('temperature') the Netherlands is with regard to the development of COVID-19. This
thermometer should preferably be updated weekly for publication on the Corona
dashboard.

Advice
The response team (RT) facilitates the development of a thermometer for public
communication, as a visual summary of the explanation of the epidemiological
situation with regard to the coronavirus. The position of this thermometer is
updated during the meetings of the RT.

The epidemiological indication on which the reading of a thermometer is

based is a qualitative weighting based on available information (such as
measured infection pressure read from, for example, sewage surveillance,
tests and virological weekly statements, the circulating virus variant(s), immunity
among the population after a previous infection or vaccination and impact on care
chain and society (e.g. absenteeism due to illness)). This involves an assessment
of short-term developments based on modeling and the experience and expertise
of the RT. The thermometer is a national indicator, in which expectations for the
entire country based on developments in the regions will be included. Relevant
differences between regions will be mentioned in the weekly explanation of the
epidemiological overview.

Due to the dynamics in the above parameters, it is not possible to use

standardized quantitative indicators for the epidemiological interpretation in the
current situation. After all, there may be successive new virus variants with as
yet unknown effects on the escape from immunity and with possibly varying disease
severity, varying influence of accumulated and decreasing

immunity in the population, uncertainty about succession to the coming

vaccination campaign, and last but not least uncertainty about compliance with the
basic rules and possible additional measures. Finally, the applied switching points
of, for example, load on the care chain are also not

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static data, but depending on how care partners experience and report the load.
One of the co-determining factors in this regard is, for example, the loss of care
employees due to absenteeism and the possibility of spreading the care pressure.
The latter is different for hospital care than for, for example, nursing home care.

The interpretation of the epidemiological situation and short-term expectations (ie,

a few weeks in advance) will be determined on the basis of triangulation of
information from different sources (see the explanation for a description of the
different sources). Where possible and necessary, this is supported with modelling.
In this, both the degree of circulation of the virus, circulating and emerging virus
variants and the (expected) consequences of this (e.g. the pressure on the
healthcare chain and society) are taken into account. Finally, the experience in
infectious disease control and the assessment of experts will also be involved.

As indicated above, the RT considers it important to include available information

about perceptions about and compliance with measures, including follow-up of
vaccination, in the expectations regarding developments. After all, the infection
pressure is partly determined by recommended measures and compliance with
them. The basis on which this is made transparent is under pressure. After all,
behavioral research into compliance with measures and associated determinants
has recently been scaled down by a decision of the ministry. For the time being,
the next cohort measurement into behavior & well-being will only take place in
September
and in the following months two more trend studies into compliance with and
support for the basic measures. As a result, the most up-to-date information on
perceptions and compliance will not always be available.
As mentioned, the position of the thermometer is primarily based on the overall
epidemiological interpretation and takes into account whether - and if so to what
extent and in what period of time - an increase in the infection pressure and disease
burden is to be expected. Whether such an increase also occurs naturally depends
on whether and to what extent measures are taken. The decision to do so rests
with policy and the gradation of the thermometer cannot be translated one-to-one
into a step of one ladder of measures. This is partly due to the sector and context
sensitivity of the ladder of measures and the further implementation of the logic of
infectious disease control in the ladder (see Appendix 2 of the RT advice on this,
which is sent at the same time as this advice about a thermometer). After all, the
risks of virus transmission differ significantly between sectors, as does the potential
return of measures, for example. But the effect of measures also differs between
the sectors. The choice of where and in what intensity measures will be taken
therefore rests with policy. The interpretation therefore has no direct relationship
with the ladder of measures or phasing in sector plans. VWS uses

this ladder/phasing and can decide on this on the basis of the

epidemiological interpretation. Communication about this must be unambiguous.
The thermometer also has no relationship with the WRR scenarios, such
scenarios are not included in the interpretation. In principle, therefore, within a
WRR scenario there can be a varying thermometer indication.

The RT facilitates the development of a thermometer and has chosen to give the
thermometer four possible positions, which as indicated, are updated at least
every two weeks:
1. Limited pressure on care chain and society; without (additional) measures no
risk of significant impact on pressure on healthcare

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and expected disease burden. Advice: for now no further actions in

addition to the basic measures.
2. Limited pressure on healthcare chain and society, but increased risks for
vulnerable groups can be expected. Recommendation: action for/ by
vulnerable groups (as described in detail in OMT 125 starting on page 5).

3. Observed and/or expected increasing or increased pressure on the care chain

and society; without (additional) measures to expect a relevant impact on
pressure on the care chain and the burden of disease, as expressed in
absenteeism. Advice: action(s) desired to mitigate or temporize the situation.

4. Established and/or threatened serious pressure on the care and

society; without (additional) measures expected to have a serious impact on
pressure on the healthcare chain and the burden of disease. Advice:
society-wide actions, urgent, to reverse the overload of the care chain and
society.

Ad 1. The fact that no (additional) measures are recommended at this position

does not mean that there is no impact on the healthcare chain and the burden of
disease at this level of virus circulation, both due to acute and post-acute ('post
COVID', previously also known as referred to as 'lung COVID') complaints arising
from a SARS-CoV-2 infection.

The thermometer will be updated during response team

meetings. These now take place every two weeks.
In this way, the situation and the effect of any interim measures that may
have been introduced are evaluated and determined iteratively. If the
epidemiological situation or expectation necessitates this, this will take place on a
weekly basis and with it the thermometer indication. This also indicates the period of
time to which the interpretation refers.
Following this RT advice, the thermometer and its explanation in
communications will need to be further elaborated and coordinated.

Explanation
The thermometer will provide an estimate of the degree of circulation of the virus in
combination with the estimated consequences of this on the burden on the healthcare
chain and society in the short term (ie, the coming weeks). Any uncertainties caused
by a new variant are also taken into account in this.

Sources for the epidemiological interpretation

In order to understand the epidemiological situation, a variety of surveillance
sources are discussed during response team meetings. These are further
explained below.
It is important to state in advance that the Dutch figures are not considered in
isolation, but take into account similar information that is exchanged from weekly
bilateral and multilateral contact with European sister organizations.

Monitoring circulation virus

• Sewage Surveillance: In the sewage surveillance at all sewage treatment plants
in the Netherlands (more than 300 locations) the

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RNA of SARS-CoV-2 virus measured. These virus particles are excreted through the faeces.
The number of virus particles per 100,000 inhabitants is called the virus load and this is
monitored via sewage surveillance. Since November 8, 2021, sampling will take place three to
four times a week at all locations and the samples will be analyzed for virus loads and
occurrence of variants. Sewage surveillance can quickly detect an upsurge of the SARS-CoV-2
virus.

• Infection radar: This surveillance tool of the RIVM aims

to map complaints that may indicate a SARS-CoV-2 infection. The complaints tracked are
fever, cough, shortness of breath, sudden loss of smell or loss/change of taste. This definition
of complaints corresponds to the definition used by ECDC. Participants receive a weekly
questionnaire in which they indicate whether they have had any complaints and which
complaints these have been. In addition, people with complaints are asked whether they have
tested themselves, what type of test was used and what the result was. Every week,
approximately 8,000-9,000 participants from all age groups and all provinces pass on this
data. Since there is no longer an indication for everyone to be tested in a GGD test street,

Infection radar provides additional insight into the course of complaints that are consistent with
a SARS-CoV-2 infection. In September 2022, the Infection Radar will be expanded in terms of
numbers and with self-tests and self-swabs (in participants with a positive self-test and in a
sample of participants with a negative self-test) followed by laboratory research (PCR and
sequencing). If testing in test lanes continues to decline, this will still provide a good picture of
changes in infection pressure and the emergence of new variants. In addition, with this
extension of the Infection Radar we can identify possible problems with regard to the accuracy
of self-tests for SARS-CoV-2 and monitor the occurrence of other pathogens of respiratory
complaints in the general population.

• Germ surveillance for virus variants: For germ surveillance, laboratories across the country
supply a weekly sample of positive PCR samples to RIVM, where the building blocks of the
virus are mapped (sequence analysis). Every week (the sequences of) a sample of
approximately 1,500 samples are analyzed across the country. In this way, the emergence
of new virus variants is monitored, the ratio of the variants found and whether extra
vigilance is necessary for certain variants. This is important information for forecasting new
variants with models. • In addition, information is collected through the diagnostic center
Saltro (and formerly Synlab) about the emergence of variants with variant PCR. Variant
PCR data is available slightly faster than the germ surveillance sequences. Variant PCR data
indicates the presence of variants but does not establish them

fixed with certainty.

• Sentinel stations of Nivel Care Registries Primary Care: The Nivel GP sentinel stations
register the number of patients with a

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flu-like illness or other acute respiratory infections. Every week, swabs are also taken from
some patients, which are examined by the RIVM for respiratory viruses. In addition to SARS-
CoV-2, research is also underway for influenza virus, RSV, rhinovirus, enterovirus, other human
coronaviruses, para influenza virus, and human meta-pneumovirus. The results of this
surveillance source provide insight into which viruses are circulating in

people who come to the GP for a consultation with an (acute) respiratory infection or
a flu-like illness. The number of practices that are sentinel stations for respiratory
surveillance was about 40 before the COVID-19 pandemic and has increased in the past
year.
expanded to approximately 140. This makes available a larger number of samples from
patients with respiratory complaints with better national coverage, which means that
significant signals about SARS-CoV-2 and other respiratory pathogens in the general population
are picked up earlier.

• The number of reports of persons with a positive SARS

CoV-2 test result. Because there is no more generally applicable advice to be tested at the
GGD since April 11, 2022, the number of reports does not give a good picture of the number of
infections. Because residents of institutions are not tested in the GGD test streets, trends in
numbers of infections in nursing homes can be monitored on the basis of reports, whereby
positive tests of people tested elsewhere are also included. The reports are therefore an
important source for monitoring trends in numbers of infections in nursing homes. In line with the
current phase of the epidemic, an amendment to the reporting obligation has been proposed
with a focus on the vulnerable and serious illness, whereby reporting should only be made for
the vulnerable in an institution, hospitalized and deceased as a result of SARS-CoV -2.

• Via laboratories that report to the virological weekly statements ,

the number of tests and positive tests are monitored. For some of the laboratories, this can
be monitored for different groups: by applicant (hospital, nursing home, GGD, other), with a
partial further breakdown for hospital by employee and patient.

• Calculation of the reproduction number based on positive tests, hospital and ICU admissions.

Severity of the virus

• The number of hospital and ICU admissions: The number of hospital and ICU admissions
due to a SARS-CoV-2 infection (source: NICE) gives an idea of how many people become
seriously ill as a result of infections. The number of admissions (including transfers) as
measured by LCPS provides more timely information about the number of admissions.
However, the LCPS data do not provide insight into the distribution of admissions as a result
of infection with SARS-CoV-2 or admissions for another reason with also a SARS-CoV-2
infection.

contamination, as indicated in the NICE data. • Whether - and if so, to

what extent - there is excess mortality and in which groups (age groups and whether use is made of
the Act

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long-term care) also provides information about the severity of infections.

Press care

• By looking at the number of occupied beds in the clinic and in the ICU (source: LCPS), it can
be checked whether there is still enough capacity to accommodate the people who need
hospital care. Because the National Care Chain Monitor is being further developed, we will
soon have a better picture of the accessibility of the lines of our care system.

Sick leave

- Monitoring absenteeism provides information about the pressure of the virus on society, per
business sector. This is especially important in these times of staff shortages, as a result of
which extra sick leave can lead to very high work pressure, also in vital sectors such as
healthcare.

Immunity

• The relative risk reduction for the chance of infection, admission and death according to
vaccination status is important to signal a decrease in protection in mainly risk groups.
The relative risk reduction for the chance of hospital and ICU admission is reported
monthly. This information can be used to consider whether a new round for a repeat
injection has added value. This information is also related to the vaccination coverage
(and where known immunity as a result of vaccination and/or infection) to indicate how much
added value could be gained from increasing the vaccination coverage of current vaccination
rounds.

It is also important to be able to take into account changes in vaccination readiness and
the actual expected turnout, since this can be subject to change.

In addition, we follow the international literature, we obtain information from abroad via ECDC, WHO or
through direct contacts, and we include new information from ongoing studies (VASCO, Smart Corona,
Long Covid) in the interpretation.

References
Letter to parliament 13 June 2022

Appendix to OMT 144 part 1 Policy regarding the obligation to report BCO in transition period
Weekly update epidemiological situation of SARS-CoV-2 in the Netherlands

Weekly explanation of the COVID-19 epidemic by the COVID-19 response team

Sewage Research

Infection Radar

Current weekly figures for disorders – Surveillance (Nivel)

Kiemsurveillance

Trend research behavior

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Results of research on behavioral rules and well-being | RIVM

Figures COVID-19 vaccination program | RIVM

Protection of corona vaccines against hospitalization | RIVM

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