VACCINATION ROLLOUT

Vaccination reviewed

In the last article written, “Vaccination in 2021”, reference was made to the envisaged roll out of a vaccination program with the Minister of Health, Dr Zweli Mkhize indicating that, to achieve herd or population immunity, it would be necessary to immunise some 31,000 people per day to reach the target of vaccinating 67% of the population within deadline.

By Peter Bagshawe

In round figures, achieving herd immunity would mean immunising some 40 million people. In early January 2021 figures presented to Parliament were that it was planned to draw vaccine stocks from multiple manufacturers being Moderna (5%), Pfizer (5%), 70% from AstraZeneca and Johnson & Johnson (20%). The various vaccines hold costing differentials, varying storage requirements and dosing. Logistically, the most challenging of the vaccines are the Moderna and Pfizer products that require storage at substantial below zero, which needs sophisticated storage and transport facilities.

In the interim, the Ministry of Health proceeded with putting in place a vaccination registration system for healthcare workers which has been extended to include traditional healers, kitchen, cleaning and housekeeping staff in hospitals as well as medical students having been identified as included in the Phase 1 roll out. This has increased the number of Phase 1 staff above the initially indicated 1,250,000 front line workers. The Department of Health considers their registration portal the beginning of a complete vaccination information system, from registration to certification and, as it levers off existing digital infrastructure, it should be robust and stable.

The first 1,000,000 units of the AstraZeneca vaccine arrived in South Africa from the Serum Institute of India on 1 February 2021, with a further 500,000 units expected to land in South Africa within the month. In the interim it has become apparent that the serum stock delivered has an April expiry date and the South African Government has initiated talks with the Serum Institute of India to investigate the possibility of exchanging at least a large proportion of the serum. This has obviously given political capital to opposition parties and trade unions, one of which is calling for investigation into the sourcing of vaccine from Russia and Cuba. Mathematically, and using an assumption of a 60 day cycle being available from the use of the initial Serum Institute delivery, South Africa would need to administer in excess of 166,000 vaccinations per day. The initial projected number of doses per day given by the Minister of Health was 31,000. This represents 19% of the approximated total needed to be given before the expiry date of the serum.

Logistically this is not possible. The emergence of the 501.V2 variant, also known as the South African Covid-19 variant, led to early uncertainty around the efficacy of vaccines against the new strain. The the need for further testing was highlighted by local immunologists prior to delivery of vaccination units from India and, as detailed in recent research, it has been reported that AstraZeneca program has indicated that their vaccine only afforded limited protection against mild disease caused by the 501.V2 variant. The variants that are of primary concern worldwide are the so-called South African, Brazilian and British variants that appear to spread more rapidly than the initial Covid strain. AstraZeneca have undertaken a limited scale investigation using 2,026 subjects of whom half were from the placebo group that indicated limited efficacy (given as 22% efficiency in the research delivered by the University of Witwatersrand) against mild disease primarily due to the B.1.351 South African strain. AstraZeneca have stated that the test group were largely young and healthy adults, none of whom were hospitalised or died and that, in conjunction with Oxford University, have started adapting the vaccine against the 501.V2 variant with projected delivery of this in the third quarter of 2021.

Against this background, Professor Shabir Madhi, Dean of Health Sciences at Wits University, has confirmed that the AstraZeneca vaccine provides minimal protection against mild to moderate Covid-19 symptoms from the 501.V2 variant. Following from this, Minister Mkhize announced that the rollout of the AstraZeneca vaccine, which had been scheduled to begin in February, was now on temporary hold. Healthcare workers will, going forward, be vaccinated with the Johnson & Johnson (which only requires one dose) and Pfizer vaccines in order to provide protection to front line and associated workers while the use or disposition of the AstraZeneca vaccinations is considered. This is an obvious setback and, again, political capital has been made from the delay in the program. The World Health Organisation has expressed confidence that the composition of the antigens in the AstraZeneca vaccine can be rapidly changed to be more effective. Going forward there is a debate on whether the AstraZeneca vaccinations (which requires two doses) should be used to vaccinate the older or those with comorbidities, in the interim, while decisions are made by the Health Portfolio Committee. Dr Glenda Gray, CEO of and president of the South African Medical Research Council and chair of the Research Sub-Committee of the Ministerial Advisory Committee referred to the Johnson & Johnson vaccine as being a potential “silver bullet” given the change in stance on the AstraZeneca serum. At the time of writing, an emergency application is in process through the South African Healthcare Products Regulatory Authority to enable the emergency use of the Johnson & Johnson vaccine, targeting healthcare workers. On 10 February, Minister Mkhize has confirmed that ratification of the Johnson & Johnson vaccine program has been requested from parliament and expedited delivery of the shipment was in progress. From here it becomes a timing problem that will need careful management.

A further factor to consider is the position that can be taken by employers, once the vaccination program has gone forward sufficiently, for a return to work to be permitted by Government. President Ramaphosa has already announced that vaccination will not take place against any person’s will while, reinforcing this, Section 12(2) of the South African Constitution provides “everyone has the right to bodily and psychological integrity, which includes the right to security in and control over their body.” The only example of compulsory inoculations that exist locally is in the case of yellow fever required for international travel. Employers should now start to consider the options available for putting in place a workplace document on their requirements for inoculation and, more particularly, in light of the fact that employees’ rights cannot be infringed. There is an anti-vaccine grouping that has been in place in South Africa for a period of time that has been vocal. Given the lack of clarity around the various vaccine products, the speed with which these were prepared and approved, uncertainty certainly already exists locally and internationally.

The prospect of a third wave – of minimising or avoiding the third wave – and the necessity of stabilising the economy has been debated openly in South Africa and internationally. The South African vaccination program is central to both of these and further delays in the roll out of the program cannot be countenanced by the government.

PETER BAGSHAWE holds a Bachelor of Law degree from the former University of Rhodesia and a Bachelor of Laws degree from the University of the Witwatersrand.