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Why has South Africa been slow to start COVID-19 vaccinations?

In many parts of the world, COVID-19 vaccination programmes are at an advanced stage. In South Africa they are yet to begin. Shrikant Peters explains some of the reasons for the government’s cautious approach to mass vaccination.

In 2020, South Africans became used to the flurry of information from government regarding the COVID-19 pandemic. In contrast, this year has been marked by an almost-eerie ‘radio-silence’ from national government, especially on the issue of the nationwide vaccination roll-out to the public.

If anything, the little public information mostly conveys another. The reaction is a collective groan of despair while we follow the news of nations with impressive rates of vaccine coverage very early into 2021.

The balance between reactive and proactive communication

On the one hand, pandemic modellers are cautious to make further predictions, especially after the surprise second resurgence in November last year, and the lack of a predicted upswing after the Easter holiday period. No politician wishes to stick their neck out on information which may, once again, prove to be flawed.

The South African government also received criticism for its decision to buy (and then sell) the AstraZeneca vaccine doses. Previously, government was criticized for its tardiness in acquiring any vaccine doses. Now it is being lambasted for being too hasty to buy a vaccine that is ineffective against the viral variants circulating in South Africa. Later criticism revolved around the sale of the same vaccine to other African nations, instead of using it at home.

Cautious trials ahead of mass roll out

Despite this, vaccinations have begun in South Africa. But there is much debate whether the current vaccination phase is a ‘roll-out’ or a trial. A national vaccination campaign may have a looser definition, but a trial must adhere to very specific ethical regulations.

In this regard, the current vaccination of healthcare workers is most definitely a trial, requiring stoppages if safety concerns arise, as we have seen this past week. Several patients in the United States experienced blood clotting after receiving the vaccine. Each of them, however, had other risk factors, meaning that there is no causal link between the vaccine and the blood clots. As such, the Sisonke trial has resumed the vaccination of healthcare workers.

Although the average person may be fearful, criticism of the government’s use of Johnson & Johnson vaccines has thankfully been muted. All medications balance risk and benefit, and when provided at scale to an entire population, there will more adverse events simply by coincidence.

On 16 April, the government opened the vaccine registration portal to those older than age 60. As opposed to the complex formulae used to prioritize different cadres of healthcare staff, Phase II is administratively simpler — vaccinating by age, noting that both risk of adverse COVID outcomes and co-morbidities increase with age.

Concerns around vaccine efficacy

However, vaccine doses alone do not a national vaccine campaign make. Trial data from South Africa showed that the AstraZeneca vaccine was only 10.4% effective against mild to moderate disease caused by the 501Y.V2 variant, which appeared in our second pandemic wave.  This trial also excluded the elderly, meaning results may be even worse than the trial results.

For rollout, WHO recommends vaccines that are at least 50% effective. The AstraZeneca vaccine clearly underperforms in this country. The government would prefer to not roll out vaccines which may have low efficacy and could result in the erosion in public trust in the vaccines and the vaccination process in general.

Other complicating factors are the fact that the AstraZeneca vaccine requires two doses 120 days apart to reach maximum efficacy. Brazil has found that patients who received the Pfizer vaccine — which requires two doses to be taken 21 days apart — defaulted on the second dose, leaving them under protected as the country struggles with a new wave of infection.

Widescale logistics required for national vaccine rollout

The setbacks of vaccine procurement related to our variants are not the only obstacles to a national vaccine roll out. Phase II of the National Vaccination Campaign will be the largest urgent health intervention undertaken in this country (with the exception to the long HIV-campaign). It will require equipment, transport infrastructure, logistics, staffing, venues, and process management to ensure fast and effective administration of doses to as many people as possible.

It will be expensive, but it is a necessary investment in the health of individuals and the nation’s economy as well. Never has a government incentive been so tightly aligned between protecting the economy and the welfare of the people.

The emphasis on vaccinations and COVID care, however, increases delays in routine and urgent care. However, if we are to reach herd immunity, the Phase II National Vaccine Campaign will need to vaccinate up to 300,000 people a day if we to reach our vaccination targets.

As such, there has been much work behind the scenes to prepare for the vaccination campaign.  The government has been burnt several times in the past year by rushing in (to be seen to be doing something), whilst considerable uncertainty made planning difficult.

This campaign will require its own dedicated personnel. Up until now, healthcare facilities used otherwise dedicated personnel in the vaccine centres. This is not a feasible model for a national high-volume system.

The national government is appointing healthcare and technical staff to run vaccinations and coordinate this high-volume service in adapted community venues across the country. A nationally coordinated programme such as this is unprecedented, given that curative and preventative healthcare services in the country are normally the remit of the provincial departments of health.

National, provincial and district coordination will work with dedicated planners and staff on the ground to administer the vaccines. Preparation is underway at community venues to prepare them for large queues and ensure the enforcement of screening, hygiene sanitation and mask-wearing.

Private pharmacies and medical aids are also preparing to distribute and administer the Johnson & Johnson and Pfizer/BionTech vaccines countrywide. Cold chain management will be particularly important when planning distribution of the Pfizer vaccines.

Further delays are possible

The government hopes to have administered the first Phase II jab by mid-May. As we have seen over the past year, a lot can happen in a few weeks, and plans may change again before then. We should expect more waves, the size and shape of which we cannot predict. It is imperative that the government and its partners focus on safely distributing and administering high efficacy vaccines at volume, with speed and efficiency, to the entire population by simple prioritization.

With the pandemic still raging in countries across the world, notably India, Brazil, and parts of Europe, we remain at risk. Most recently, closer to home, there are flare-ups in the Northern Cape, the Free State and the North-West. It is only a matter of time before these embers ignite a third wave in other parts of the country.

Vaccination is the best way to decrease the wave and severity of infections. Individual vaccination contributes to the greater good. Religious and localized communities can assist government in the mammoth task by promoting the vaccination drive and helping people to overcome their fears around vaccination.

Above all, for the rest of this year and on into the future, the same dictum applies – take universal precautions, and get vaccinated as soon as you can.

* The opinions expressed here by Spotlight.Africa contributors and editors are their own and not official statements of the Society of Jesus in South Africa or of the Catholic Church unless explicitly stated.