Vaccine delay 'means third killer wave', warn medical experts

Prof Shabir Madhi, one of the sidelined medical experts, has raised alarm over the delay and secrecy around the procurement of the vaccine.
CHECKING UP Prof Shabir Madhi, one of the sidelined medical experts, has raised alarm over the delay and secrecy around the procurement of the vaccine.
Image: Wits University

SA's delayed Covid-19 vaccination programme means a third wave of the virus in three to four months will cut another swath through high-risk groups.

"It seems to me that the government only started planning in early January after a media backlash," said vaccinologist professor Shabir Madhi, who was among a group of experts dropped from the Covid-19 ministerial advisory committee (MAC) in September.

"Even after this [second wave] resurgence dies down we'll get another one, and vaccine deployment will be too late for high-risk groups then."

Madhi and other sidelined colleagues, including South African Medical Research Council president professor Glenda Gray, said it remained unclear when vaccines would arrive and how they would be rolled out.

In a statement on Friday, after repeatedly saying the first batch of vaccines from India would be in the country this month, health minister Zweli Mkhize said only that "all is on track" for vaccinations to be received in the first quarter of the year. His department did not respond to requests for details.

There is also no clarity on how the vaccines will be paid for. Addressing the ANC national executive committee lekgotla on Friday, President Cyril Ramaphosa said the government would be the primary funder and may have to borrow the money.

This was the third option put forward. Two weeks ago, the government said the budget would be reprioritised, and last weekend National Treasury director-general Dondo Mogajane hinted at a tax increase.

What's unclear is what happens when the vaccine land - what is the distribution plan?
Prof Ian Sanne, Right to Care and MAC member

The confusion follows Mogajane's admissions in a letter on Monday to Corruption Watch that until January 3 all the government's vaccine hopes were pinned on the Covax initiative.

Two sources familiar with the budgeting process said vaccines should have been part of non-discretionary costs in the budget alongside items such as salaries, social grants and debt repayments.

"A question about why vaccines weren't treated in this manner makes absolute sense and government should account," said one. Final details of vaccine funding are expected only in finance minister Tito Mboweni's budget speech on February 24.

Secrecy about the vaccination programme falls far short of the "transparent communication" needed to promote public trust and overcome vaccine hesitancy, recommended in a 10-point proposal in the South African Medical Journal by 15 scientists, including Madhi.

The proposal, published on December 14, provides guidelines on transparency, but Gray said: "There has been a lot of secrecy around the deployment and a lack of transparency. As far as we know, only one of the vaccines, AstraZeneca, has been tied down."

Professor Ian Sanne, who heads Right to Care and sits on the MAC, said there had been transparency on the engagement with the Serum Institute in India on the procurement of the first 1.5-million vaccines.

"What's unclear, though, is what happens when vaccines land - what is the distribution plan?" he said.

"We have not gone the next step of elucidating exactly where the people are who would benefit from the first 1.5-million doses ... we should be working on those logistics."

Speaking on January 3, five days after saying SA was still weighing its vaccine options, Mkhize unveiled a vaccine acquisition task team chaired by Discovery founder Adrian Gore, and said two-thirds of the population would be inoculated this year.

But professor Mark Mendelson, head of infectious diseases at Groote Schuur Hospital in Cape Town, said this target was "unrealistic", especially in light of the late start.

There was still confusion about the scale of the rollout, he said. The number of people "earmarked for vaccination in phase two is 16.6-million" but to do that 32.4-million doses will be required, "and government tells us it has procured 20-million doses [12-million from Covax] which would still leave us 12.4-million doses short, even for phase two".

Professor Francois Venter, Ezintsha CEO and Wits University infectious diseases specialist, said regulatory authorities had been galvanised to review approvals in record time, but he was concerned that experts such as Madhi and Gray had been sidelined. "We really need people like Shabir and Glenda sitting in high-level meetings advising [the health department]."

Gray said she hoped "common sense will prevail to unlock obstacles and that we will use innovative ways to get the vaccine out", and she thought the decision to use the Biovac Institute distribution infrastructure initially was pragmatic. "It doesn't make sense to reinvent the wheel now. This has been their bread and butter for decades and they understand distribution," she said.

From Biovac depots, the vaccine could be dispersed to hospitals, clinics, National Health Laboratory Service sites and pharmacies for the first phase of the vaccination programme for health workers.

Madhi said Biovac has "been involved in vaccines in the country" for two decades and has had "success in the deployment of childhood vaccines", but the Covid-19 jabs would be a "much more expensive programme over a much narrower period of time".

Acting more quickly and putting the contract out to tender would have meant other suitably qualified companies could also have been considered. He said "someone also needs to explain why the procurement of the vaccine is close to US$5 [R75]" when the cost in the EU is $2.

SA's involvement in the AstraZeneca trial "doesn't count for much now", said Madhi, but "could have helped the government to use it as leverage in earlier stages of bilateral discussions".

Discovery Health chief commercial officer Ronald Whelan said SA's pharmaceutical supply chain was well developed and the intention was to leverage a handful of distributors and wholesalers who had a national footprint and the ability to make daily deliveries to vaccination points.

Whelan said: "There is enormous work happening in the background. There are two big technical teams who are working on this day and night, literally, one within Business for SA, the other within the department of health . this is moving very fast."

He said work on an electronic system to keep track of vaccinations and issue certificates was under way and was "very advanced in terms of the design and engaging with the partners to build it".

It had already been built in other countries, he said, adding that Netcare and Discovery Health were leading the private sector task team in providing technical support to the health department on building the system. In SA, nearly a third of the population live in the five biggest cities and it would make sense to start vaccinations there, Venter said.

Gray said using venues such as stadiums could be an option when the vaccine becomes widely available. "We have to think out of the box. We could bring hundreds of health-care workers into stadiums and people could file through for vaccinations."

Martin Kingston, who chairs the Business for SA steering committee supporting the government in the vaccine rollout, said that if waste, corruption or incompetence were taken out of the equation, "the cost [of vaccines] is not a material consideration ... because the impact on the economy of continued lockdowns is so much larger. You don't need to do the maths.

"On the upside, SA is negotiating or has contracted for approximately 50% of the overall doses required. However, beyond the initial 1.5-million doses secured for delivery due in January and February, it is not clear what the delivery timetable is for the remainder of the doses that have been secured.

"Although there is likely to be significantly more supply available globally in the second half of 2021, SA urgently needs sufficient supply in the short term - particularly given the risks posed by the new variant and ongoing impact of Covid-19 on the economy."

Timeline of SA's vaccine procurement

A timeline of SA's vaccine procurement efforts shows it took six months for the health department to appoint vaccine advisers and two more months for the Treasury to consider the department's request to obtain vaccines from Covax.

On December 29, health minister Zweli Mkhize said SA was still weighing its options. Five days later, after the Progressive Health Forum aimed a stinging rebuke at the government over its vaccine plan, Mkhize unveiled an acquisition task team led by Discovery founder Adrian Gore. Within three more days, his department had sought and obtained permission to buy vaccines from four manufacturers.

March 5 2020: SA's first confirmed case of Covid-19.

March 16: Four volunteers in Seattle, US, are injected with a Covid-19 vaccine candidate.

May 5: Pfizer starts human trials of its vaccine.

June 5: Launch of Covax, which aims to provide equal access for up to 2-billion vaccine doses by the end of 2021.

June 24: The first of three South African vaccine trials begins under the supervision of Wits University's professor Shabir Madhi.

July 1: Pfizer says its vaccine has shown potential.

August 3: Bloomberg reports that wealthy countries have already locked up more than a billion doses of coronavirus vaccines.

September: The government establishes an expert ministerial advisory committee on vaccines. In its first report, the committee recommends participation in Covax.

September 29: The health department asks the Treasury for permission to deviate from procurement processes to obtain Covax vaccines.

October 28: Finance minister Tito Mboweni's medium-term budget policy statement mentions the vaccine once: "Under the leadership of the minister of health, government is exploring greater participation in [Covax]."

November 2: Aspen Pharmacare says it has signed a deal to produce Johnson & Johnson's vaccine in Port Elizabeth, but CEO Stephen Saad says the health department has no advance purchase agreement.

November 19: Health department affordable medicines director Khadija Jamooldien says several companies developing vaccines have approached the government.

November 23: Treasury grants permission for health department to deviate from procurement processes to obtain Covax vaccines.

December 22: Health department says the Solidarity Fund has made a R283m down payment to Covax.December 29: Health minister Mkhize says SA is still weighing its vaccine options.

January 3: The Progressive Health Forum says: "The stunning reality is that [SA] has neither a secured vaccine supply nor a plan for mass inoculation in the foreseeable future that can withstand scrutiny." That evening, Mkhize announces a vaccine acquisition task team and says 67% of the population will be vaccinated in 2021.

January 6: Health department gets Treasury permission to deviate from procurement processes to obtain vaccines from Pfizer, AstraZeneca, Moderna and Johnson & Johnson.

January 7: Health department gets Treasury permission to deviate from procurement processes in order to appoint the Biovac Institute to handle storage and distribution of vaccines for health-care workers for three months, and to issue a closed bid to four companies to store and distribute vaccines for six months. Health department says it is talking to Aspen about access to the Johnson & Johnson vaccine. Mkhize tells MPs the first 1-million doses of a vaccine for health workers will arrive from India in January.

January 11: President Cyril Ramaphosa says the government has been negotiating with vaccine manufacturers for six months and20-million doses have been secured. January 19: Ramaphosa says he has appointed Deputy President David Mabuza to lead an interministerial committee that will oversee procurement and distribution of the vaccine - described by political analyst JP Landman as "a daunting logistical task - more so than the 2010 World Cup or the 1994 election".

January 22: Mkhize says "all is on track" for the delivery of vaccines from India.