South Africa has the highest number of COVID-19 cases on the African continent. It has more than 50,000 reported deaths. This may be an underestimate, looking at excess death statistics. The economic cost of the pandemic is evident on the streets and healthcare facilities have been under considerable strain during the waves of the pandemic.
It was with much relief, elation and a renewed sense of hope that many healthcare workers enrolled in the Johnson and Johnson vaccination trial mid-February and received their much-anticipated vaccination.
But the relief and elation has given way to frustration and disillusionment. The country’s rollout is proceeding at a pace much slower than expected.
To date just over 293,000 South Africans have had their jab, which represents only a fraction of the 1,25 million healthcare workers who are first in line. This adds up to about 0.5% of the general population. The initial target of having 67% of the country’s citizens vaccinated by the end of 2021 is now unlikely to be achieved.
The new rollout plan promises to vaccinate 1.5 million by the end of May 2021. Phase 2 is set to happen between May and October 2021 with the aim of an additional 13 million vaccinated in that time frame.
Several factors have contributed to South Africa’s halting start. These include global health inequality, South Africa’s delay in joining the global race for procurement, delays in the rollout plan as well as uncertainty around efficacy and side effects of vaccines that were procured.
At the current vaccination pace it will take over a decade for South Africa to reach herd immunity, with many lives lost along the way.
The biggest challenge has been access. Like other developing countries, South Africa has really struggled to get doses.
The WHO director, Tedros Adhanom Ghebreyesus, put it succinctly when he said:
Even as they speak the language of equitable access, some countries and companies continue to prioritise bilateral deals, … driving up prices and attempting to jump to the front of the queue. This is wrong.
Ghebreyesus was referring to the fact that developing country governments have procured and hoarded vaccines for their own populations. Even before many of the COVID-19 vaccines had received final approval, some countries had procured several million doses of those that held promise.
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An additional factor was South Africa’s slow start. The government has been criticised for not actively engaging in vaccine procurement through other avenues at an earlier stage. By mid-January 2021 the country’s participation in the COVAX vaccine scheme only secured enough doses for around 10% of the population.
On top of this, there has been a series of problems with vaccines South Africa managed to secure. And the evolution of new variants and uncertainties around the efficacy of vaccines to emerging variants has slowed the country’s efforts to overcome this pandemic through prevention.
For example, the planned rollout of the Oxford University-AstraZeneca vaccine from the Serum Institute of India was abruptly halted when locally generated data showed decreased efficacy against the B.1.351 variant first identified in the country.
Then the Johnson and Johnson hit a roadblock. The rollout was recently halted following the FDA-mandated suspension of its use in the US. This has posed another challenge to vaccination efforts. The halt spoke to safety concerns and allowed the South African Health Products Regulatory Authority to evaluate the scientific evidence and establish appropriate risk to benefit ratios. Last week, it was announced that the Johnson and Johnson rollout would be allowed to resume.
Another big issue that is likely to slow down the momentum of the country’s vaccination programme is vaccine mistrust. In a survey done by the University of Johannesburg, up to a third of South Africans said that they would refuse a COVID-19 vaccine if it was offered to them.
This could be echoing a deterioration in trust in the handling of the pandemic as a whole.
Misinformation, exaggeration and de-contextualisation of facts on various social media platforms have led to a large degree of vaccine mistrust among people. Aside from conspiracy theories and grossly inaccurate misrepresentations of facts, there is an increasing mistrust in science, pharmaceutical companies and authorities.
The road ahead
Balancing efficacy, safety, storage requirements and sustainability when it comes to vaccine selection is no easy task. But some countries have managed it better than others.
South Africa is one of the countries that is lagging far behind.
The human and economic cost of passively allowing the pandemic to run its course in an era where vaccines are available is unacceptable. In addition, the emergence of variants is a compelling reason to step up vaccination efforts. Suboptimal levels of immunity will mean more people get ill and die. It will also increase the likelihood of new variants emerging.
The South African government needs to shift gear on a number of fronts.
It needs to make vaccine procurement a budget priority and procure more vaccines.
Secondly, it needs to clarify urgently what the requirements are for the involvement of private medical providers in the vaccine rollout. It also needs to expand the number of platforms (such as local clinics, GP practices, pharmacies, and private and state facilities) on which the vaccines are rolled out. If ever there was a need for public-private collaboration it is now – both in terms of funding vaccines and in providing platforms. This would enable large-scale vaccination to occur at the pace needed to turn the tide against COVID-19 in South Africa.
The government also needs to do more to raise public awareness and dispel myths at community level.
Clearly this will have to be a collaborative effort between all stakeholders – from international efforts for equity, to engagement by the pharmaceutical industry, procurement by government, the involvement of private sector players and widespread information and education of the general public.