Top scientists who have put together a plan for SA's Covid-19 vaccine rollout say it could be a “sustainable turning point” in the pandemic.
But they warn that without co-ordination, the rollout will bring “chaos and duplications of effort similar to those that were evident at the beginning of our local epidemic”.
Writing in the SA Medical Journal, the scientists say: “We cannot only rely on the national department of health and the public sector. We need the private sector, labour, and entities such as Médecins Sans Frontières, the Red Cross and Gift of the Givers to support the national rollout of vaccines.
“This is an endeavour that requires all our resources and effort.”
Fifteen scientists led by Glenda Gray, president of the SA Medical Research Council, say the “enormous hope” offered by the “spectacular achievement” of vaccine developers requires a “smart, ambitious and effective plan” to vaccinate the population in the shortest possible time.
They have developed a 10-point plan starting with expediting the registration and licensing of vaccines and concluding with “going to scale to end our epidemic”.
1. Registration and licensing
The SA Health Products Regulatory Authority (Sahpra) can fast-track access to vaccines in several ways, according to the “Scientists' Collective” that drew up the plan.
These include emergency permission and conditional registration. Sahpra can also rely on the work of organisations such as the US Food and Drug Administration and the World Health Organisation.
“Once a vaccine is registered in-country, the state can put out tenders or utilise sole-source service provision to procure the vaccine from the manufacturer or pharmaceutical company for the state sector,” say the scientists.
“The state can use its infrastructure to make it available through the health system, the education system, correctional services etc, and through mass vaccination strategies at community level.
“If licensed in-country, the vaccine could also be made available at out-of-pocket cost to the individual, through medical aids or workplace vaccination programmes.”
However, the scientists say vaccine supply is likely to be “highly restricted” at least until the end of 2021. “There needs to be prioritisation of who to target for vaccination, at least until adequate supply becomes more predictable,” they say.
2. Financing mechanisms
Vaccinating the whole population with the Pfizer vaccine — already being administered in countries including the US, UK and Canada — would cost R36bn, the scientists say.
The cheapest option, at around R14.4bn, is likely to be the AstraZeneca vaccine being developed with Oxford University, which is being tested in SA and “is likely to be the most accessible in the early part of 2021".
To achieve herd immunity, between 40% and 60% of the population needs to be vaccinated and/or to have recovered from Covid-19.
“Adopting the 40% vaccine coverage assumption, the cost of an effective vaccination strategy may range between R2.9bn and R18.6bn,” the scientists say, adding that a herd immunity strategy will probably succeed only by 2022.
In 2021, “while 20% coverage is not enough to achieve herd immunity, it should result in the vaccination of the population most susceptible to severe forms of the disease, front-line health workers and other high-risk individuals”.
This would cost between R1.4bn and R9.3bn, and the next question to answer is how vaccines should be split between the cash-starved public sector and the private sector, in which medical aid schemes had “saved billions” in 2020 because of lower demand for health care as a result of lockdown.
“While these funds cannot be expropriated for public use, they can be accessed to ensure that government does not pay for any vaccine expenses that can be funded by medical schemes on behalf of their members,” say the scientists.
“If the private sector foots the vaccination bill for their members [the minister of health would be required to add the Covid-19 vaccine as a prescribed minimum benefit], the budget for public sector vaccination of 20% coverage using the lowest-priced vaccines on the market would be R1.4bn, a ninth of what one day of the level 5 lockdown cost SA.
“During 2021, medical schemes would only need to spend R200m to fund 20% of members. Even using the most expensive vaccine (Moderna), the total cost for 2021 would come to less than one day of the general lockdown.”
3. Deployment for maximum impact
The scientists say: “To maximise the impact of a Covid-19 vaccine, SA needs to focus on both effective scale-up and deployment of the vaccine, in addition to strategies that will give us maximum public health impact.
“In the immediate future, in the context of likely limited supply of Covid-19 vaccine throughout 2021, these efforts need to be focused on safeguarding our health-care systems and protecting individuals at greatest risk of morbidity and mortality.
“We propose a sequential immunisation strategy that balances both public health benefit and individual benefit.” (See table below).
4. Communication of the access plan
The scientists say “special measures” are needed to communicate the rollout plan properly and to deal with “myths and misconceptions”.
“There is currently wide speculation about vaccination plans, with some of the opinion that SA has no plan, no money, and no clue about how to finance and distribute a vaccine,” they say.
“These perceptions are important, as they shape the public view on vaccination and result in lack of confidence in vaccination programmes.
“To build confidence, the governmental structures dedicated to vaccine rollout should immediately ... draft a road map as to how SA will access and roll out vaccines. Included in this should be the issue of vaccine hesitancy.”
The scientists also want a “concerted effort” by the government “to build trust and share information on plans to procure vaccines”.
They add: “These are important issues. Vaccine hesitancy has the ability to undermine our efforts to control Covid-19 in SA, as a vaccine can only work if the greater proportion of the populace firmly believe in the benefits.”
5. Access strategy
The scientists are sceptical about the World Health Organisation's Covax initiative — aimed at making vaccines affordable for low and middle-income countries — being the entire answer for SA.
“Inadvertently, the Covax facility would undermine the ability of government in SA to access a large number of doses of Covid-19 vaccines at a more competitive price through bilateral agreements than what will be sourced through the Covax facility,” they say.
“This is an oddity that SA [purportedly the country most affected by the Covid-19 pandemic on the continent] cannot afford — even if it inadvertently breaches a show of solidarity with other African countries.”
Other access mechanisms include agreements with manufacturers. “The state should prioritise these deals and ensure that locally produced vaccine is also destined for the local market,” say the scientists.
“The Covid-19 vaccine trials being undertaken in SA should offer an opportunity for government to negotiate early access to meaningful quantities of vaccines at an affordable price with the companies whose vaccines are being evaluated.
“Appended to this should be a programme to ensure that local manufacture capacity is poised to act as soon as a decision is made on which vaccine(s) will be rolled out. However, local manufacture of a Covid-19 vaccine is unlikely to materialise before 2022.”
6. Supply-chain management
The cold chain is key, with vaccines needing to be kept at between 8ºC and -70ºC, and planning must start immediately, say the scientists.
“Transport conditions will need to be more sophisticated, requiring electronic support, together with cold-chain monitoring and confirmation of delivery,” they say.
“There are several systems that could be co-opted to assist: current medicine delivery routes, and laboratory transport capacity in both the public and private sectors.
“Significant planning and innovative delivery mechanisms will be required. New design applications for monitoring the process are already available for review.”
7. Alternative delivery systems
The platforms of large e-commerce companies are a good option, the scientists say. Airlines' grounded passenger planes could also be used.
Vaccinating health workers would be straightforward but “the elderly and those with comorbidities will be a more difficult group to access”.
Strategies should include the use of clinics, social grant delivery points, old-age homes and churches. “Community health worker outreach teams have huge potential here. This is a massive operation and will require detailed planning and resourcing.
Many thousands of people could be vaccinated in a single day.
“The schools and universities have the ability to play an important role in reaching the adolescent and young adult populations that are globally proving unable to abide by non-pharmaceutical interventions.
“Targeting this population could be key to breaking the cycles of transmission in many communities and within families, and the order in which they are prioritised will be influenced by estimates of the public health benefits of vaccinating this group for the benefit of the entire population.”
The scientists warn that innovative solutions are vital to speed up vaccine delivery. This could even include using the infrastructure, organisation and IT capability of the Electoral Commission.
“All that would be needed is an ID document that is scanned to record participation and a nurse in the polling booth. Many thousands of people could be vaccinated in a single day,” they say.
8. Capturing proof of vaccination
The scientists say: “Digital technologies to monitor vaccine uptake and usage of doses will be critical to ensure continuity and integrity of the logistic supply chain.
“These could be linked to electronic dashboards that provide a nationwide view of vaccine uptake, which could then be further useful to monitor incidence of disease.
“Similar dashboards already exist to monitor diagnosis of infectious diseases such as tuberculosis. Data systems would also enhance the country’s ability to evaluate long-term safety and efficacy of the vaccine.”
9. Dealing with anti-vaxxers
The anti-vaccination movement risks delaying herd immunity in SA, the scientists say, and needed a serious response.
“We need to build basic, simple communication of the evidence, delivered to the public in a way that maximises its transfer and its impact.
“That will include bringing all facets of society with us on this journey and ensuring that trusted givers of information are prioritised, be they traditional healers, respected leaders in civil society, religion and government, role models, ‘influencers’, clinicians, public health specialists, or scientists.
“Westernised traditional forms of communication need to be augmented with informal means such as oral, folk and theatrical delivery of accurate information, woven into a culture- and context-specific model.”
10. Going to scale
“If we don’t have any vaccine by winter, our country will not be able to go back to normal,” say the scientists.
“If we put vaccines together with all the tools we have, we could reduce mortality and stop transmission and get our lives back. We cannot afford to let this opportunity go to waste.
“We need all hands on deck. This is an endeavour that requires all our resources and effort.”
As well as Gray, the Scientists' Collective comprises:
- Alex van der Heever, Wits School of Governance;
- Shabir Madhi, Medical Research Council Vaccines and Infectious Diseases Analytics Research Unit;
- James McIntyre, Anova Health Institute, Johannesburg, and School of Public Health and Family Medicine, University of Cape Town;
- Bavesh Kana, Wits University of and National Health Laboratory Service;
- Wendy Stevens, Wits University and National Health Laboratory Service;
- Ian Sanne, Right to Care and Wits University;
- Guy Richards, Faculty of Health Sciences, Wits University;
- Fareed Abdullah, Medical Research Council;
- Marc Mendelson, University of Cape Town;
- Aslam Dasoo, Progressive Health Forum;
- Jeremy Nel, Faculty of Health Sciences, Wits University;
- Adrienne Wulfsohn, Inkosi Albert Luthuli Central Hospital, Durban;
- Lucille Blumberg, National Institute for Communicable Diseases; and
- Francois Venter, Faculty of Health Sciences, Wits University.
