South Africa is one of the leading countries in Africa in terms of COVID vaccine rollout, along with Mauritius, Tunisia and Morocco. It has, however, had its fair share of challenges. Shabir A. Madhi has been a key player in shaping the country’s response. Ina Skosana and Ozayr Patel asked him for an assessment of plans to vaccinate adolescents, and next steps.
Should South Africa be vaccinating adolescents?
I don’t believe this is the most efficient use of the vaccines. In a country like South Africa, we’d be much better off offering a third dose of the Pfizer/BioNTech vaccine to the 65% of adults above the age of 65 who have been vaccinated, and intensifying efforts at vaccinating the elderly and high risk groups who have not yet received even a single dose.
We shouldn’t be using these vaccines to give to children between 12 to 17 years a single dose.
Young children rarely get severe disease from COVID-19. Vaccinating children with a single dose of the Pfizer vaccine is unlikely to provide much value to the child in terms of individual protection, unless they have underlying medical conditions pre-disposing them to severe COVID-19. If this is the case they should receive the full two dose schedule. A single dose also doesn’t work too well in reducing the ability of a person to transmit the virus.
This is the main reason being given for vaccinating 12 to 17 year olds.
South Africa might be banking on the fact that a large percentage of the population – estimates are between 70% to 80% – might have been infected already. In that context, a single dose of vaccine is probably all you require to protect against severe COVID-19.
This hybrid immunity, where you start off with your immune system being primed by natural infection followed by a vaccine, induces quite potent immunity. Consequently, people that have passed infection probably only require a single dose of any vaccine. That’s the only way South Africa can really justify using a single dose of vaccine in the 12 to 17 year old age group. Needless to say, waiting to get infected and risking developing long-COVID, being hospitalised for COVID-19 or dying from COVID-19 is not really a bright idea.
The liberal rollout of COVID-19 vaccines in South Africa to low risk groups, such as young children, appears to be more about chasing after numbers rather than deriving the maximal protection against severe disease and deaths.
I’m not saying that you shouldn’t vaccinate children. There’s a time and place. But that time and place is not right now in South Africa, or globally in the context of the tragic inequity of vaccine access.
Starting to vaccinate children against COVID-19 (and use of booster doses in healthy adults) is more than just a country specific decision. Most countries on the continent have less than 5% of the adult population vaccinated, and in fact, less than 10% of people above the age of 60 are vaccinated.
This is being perpetuated by countries with access to vaccines using them liberally.
Would you recommend a booster for the general population?
Absolutely. For certain groups of adults.
We now understand that the first two doses of vaccine provide good protection against severe disease in people above the age of 65 and those with other underlying medical conditions. However, it is also apparent that people older than 65 or with underlying immunosupressive medical conditions require a third dose of the mRNA vaccines, such as by Pfizer/Biontech. This is required to boost their immune response and enhance their protection even against severe COVID-19.
The primary goal of vaccination therefore needs to be on reducing severe disease and death. This requires targeted strategies on who to prioritise.
Evidence from the US is that a two dose schedule of the Johnson & Johnson vaccine is superior in protecting against hospitalisation than a single dose. And if you want durability of protection, you need to boost, which can be done with another dose of Johnson & Johnson.
My own preference is to boost with one of the messenger RNA vaccines. In South Africa this is the Pfizer vaccine. The evidence is clear that the type of immune responses from this approach is superior to two doses of the J&J vaccine and possibly even two doses of the Pfizer vaccine.
Is vaccine coverage high enough to justify boosters?
Absolutely. If we can justify providing vaccines to the 12 to 17 year old age group, it means we’ve got vaccines that we don’t know what to do with.
In my view it would be much better offering these doses to boost adults above the age of 55. In particular, people older than 65 do require an additional dose of the Pfizer vaccine after they’ve had two shots. The same thing goes for other risk groups such as people with kidney transplants, or people with cancer and on chemotherapy, people with any other sort of underlying immunosuppressive condition.
South Africa is, once again, going against the World Health Organisation which is recommendating booster doses of such high risk groups, and instead vaccinating young children.
Is South Africa in a stable position vis-a-vis another surge?
The main thing that’s going to determine how well the country manages another resurgence is the percentage of people above the age of 50 who have been vaccinated. We need to get 85% to 90% of this age group vaccinated and 80% of those with underlying medical conditions.
If we don’t reach those marks, when we do have a resurgence – and we will have a resurgence in the next two to three months – it will end up with hospitals coming under pressure once again.
What’s in South Africa’s favour is the high percentage of the population that’s been infected with the virus. Natural infection does seem to confer protection against severe disease.
So this combination of natural immunity – probably 75% to 80% of the population has now have developed some level of natural immunity – coupled with vaccine induced immunity and a hybrid of the two probably puts South Africa in a relatively stable position in relation to severe cases likely to be lower with a future resurgence than experienced in the past. This could, however, change if there are new major immune-evasive mutations in the virus.
What’s been learnt from the vaccine roll-out in South Africa?
We’ve learned that rolling out a vaccine is as complex as securing supplies. And we’ve missed some targets.
For example, we were meant to have vaccinated the majority of people above the age of 60 by July this year. Currently we’re sitting at around about 62% to 63% of people above the age of 60. In the 50 to 59 year age group we are looking at just over 50%.
The reasons are multiple. But part of it speaks to the issue of planning and rollout, not just in South Africa, but in many countries. People don’t appreciate what it entails, starting from community engagement, adequate communication around what the vaccines are about, what the purpose of the vaccine programme is, and then finally being able to implement.
The other challenge was that the initial planning for the rollout was top down. The expectation was that people were going to rush forward to register on the electronic vaccine data system without really understanding how adaptable it was for South Africa. The system was inaccessible to most people.
There was a quick escalation in coverage once walk ins were set up for targeted age groups. Also, the use of pop up facilities is beginning to play a big part in increasing vaccine coverage rates.
This also speaks to the issue of community sensitisation and engagement of community structures. Unfortunately resources set aside for this purpose were siphoned off by corruption.
Also, South Africa hasn’t had enough champions across the spectrum of society. In other countries support this has been a major contributor to success.
On the plus side, South Africa secured adequate supplies of vaccine. That in itself was quite an achievement, considering the poor planning until Government came under pressure early in January 2021. The challenge now is being able to use the doses wisely before they expire.
Shabir A. Madhi, Dean Faculty of Health Sciences and Professor of Vaccinology at University of the Witwatersrand; and Director of the SAMRC Vaccines and Infectious Diseases Analytics Research Unit, University of the Witwatersrand