Christmas | Fourth

Fourth wave by Christmas unless 90% of SA above 35 gets vaccine – Prof Shabir Madhi

The South African government has been severely criticised for its handling of the Covid-19 vaccine rollout. Although South Africans between 18 and 35 can now be vaccinated, many citizens (of all ages) are still hesitant to get the jab. Professor Shabir Madhi of Wits University says that if we are to avoid a fourth wave by November or December, we need to get 90% of the population vaccinated. “Extending vaccinations to the 18-35-year-old group won’t prevent another wave in November and December. If we want to return to a normal lifestyle, it’s not about counting the numbers vaccinated daily, or progressively vaccinating each age group downwards. We need to get 90% of those above 35, especially those above 50, vaccinated,” he says. Barriers to this process include the government’s centralised vaccination programme, a lack of a cohesive voice amongst experts, and the ANC’s “inadequate” education and awareness campaign, as Chris Bateman describes below. – Claire Badenhorst

How we can duck the 4th wave

By Chris Bateman* 

The government can avoid the overwhelm of health services and minimise death in an impending fourth COVID-19 wave in November/December by getting 90% of South Africans over 35 years old vaccinated before then. Life could then return to normal by Christmas, even with ongoing SARS-CoV-2 circulation, contends top vaccinologist, Professor Shabir Madhi.

Speaking in a Discovery Health webcast attended by about 1,000 healthcare professionals, Prof Madhi said the quickest way to reduce severe infection and death would be to primarily target people above 35, including those with underlying conditions – immediately.

“Extending vaccinations to the 18-35-year-old group won’t prevent another wave in November and December. If we want to return to a normal lifestyle, it’s not about counting the numbers vaccinated daily, or progressively vaccinating each age group downwards. We need to get 90% of those above 35, especially those above 50, vaccinated.”

He was in conversation with top bioethicist, Professor Ames Dhai, Vice-Chair of the Ministerial Advisory Committee for COVID-19 Vaccines, and Dr Noluthando Nematswerani, Head of Clinical Excellence at Discovery Health.

Both Dhai and Madhi, the Dean of the Faculty of Health Sciences at Witwatersrand University, were highly critical of the government’s belated and “inadequate” COVID-19 education and awareness campaign, saying it contributed to growing vaccine hesitancy and disinformation, with pseudo-science taking hold.

Conflicting expert views confusing

Said Madhi, “People also hear different voices of experts and there is blame this side and that and the public loses confidence in us as scientists. The debate should be behind closed doors, but with transparency about decision-making”.

Both professors said government has failed in communicating a single, clear, well-crafted message about Covid and vaccination, resulting in a free-for-all with disinformation and confusion spreading rapidly. Both were adamant that healthcare professionals who express harmful views on Covid vaccination should be bought to book. They said the Health Professions Council, HPCSA, was failing dismally in its legislated task to guide the professions and protect the public, keeping a very loud silence when it should be acting to prevent harm.

Added Dhai, “We should not allow our personal beliefs and convictions to cloud our judgment when it comes to sound objective management of patients”.

Madhi said another contributor to growing vaccine hesitancy was the summary removal of experts from the Ministerial Advisor Committee on COVID-19 whenever their views diverged from the official line.

He said starting community COVID-19 education programs when the vaccination rollout first began was ridiculous. The government should have been planning this in August last year already. All current hurdles to vaccination could have been minimised and government should be taking vaccinations to the people instead of the other way round.

Dhai agreed, saying that with at least 40% of the population unemployed, expecting people to spend R40 taxi fare to get to a vaccination site when the money could rather be spent feeding their children was a major barrier.

Let the private sector vaccinate the poor

Madhi said unless the government allowed private sector sites to vaccinate people not on medical aid, it was “simply maintaining inequities”.

A classic example of improving vaccine access was the high vaccination rate at SA Social Security Agency, (SASSA), pay points, he added.

Asked by Nematswareni about the legal and ethical route of mandatory vaccination, Dhai said it was “sad but necessary” that the government was moving to introduce this in the workplace when a proper communication strategy would have left vaccination voluntary.

She said studies by the Human Sciences Research Council, (HSRC), the Medical Research Council, (MRC), and the Department of Science and Innovation, exposed major gaps in vaccine literacy, trust (and thus a lack of vaccine uptake), and a dire lack of individual and community agency.

“We need to stop pussyfooting around. The funding was there for communication, but it was misspent. It’s OK to make vaccination mandatory in the workplace, but unfair to impose it on the general population when there’s been a huge economic collapse, worsened by COVID 19, that has impacted agency,” she added.

The state had a duty to ensure functional literacy first.

Existing studies also showed a high degree of unsubstantiated fear around vaccination and its side effects, with distrust in scientists and the government and much greater trust in frontline medical workers, to whom she appealed to take the time to educate people.

“A mandatory part of the conversation ought to be vax literacy for our patients. Take a few minutes more and engage with them on why they should take the vaccination,” she pleaded.

Competing legal rights on vaccination

Too many anti-vaxxers were focussing on the right to bodily integrity and religious beliefs but forgetting about legal principles that limited these rights in the wider public interest.

As an example of comparative law, she cited a recent USA judgement after Indiana University’s hospital at which medical students trained made it mandatory to be vaccinated against COVID 19. Seven students took the medical school to court arguing that this violated their right to bodily integrity. The trial judge held in favour of the training hospital, basing his ruling on a 1905 judgement on a similar application involving smallpox, saying it was for the public good and that their individual rights were limited by this.

Madhi hit out at those who blamed COVID-19 vaccination for death and adverse events saying the South African Health Products Authority, (SAHPRA), had investigated 28 reported cases so far – with not one linked to inoculation.

“Things happen after vaccination. People have pre-existing conditions, and many may be infected but asymptomatic when they’re vaccinated at the peak of the resurgence which could progress to severe Covid-19 a few days later. It’s completely co-incidental. You could get knocked down by a bus after being vaccinated and some would blame the vaccination,” he said.

He said swabs taken at the time of the peak of the 1st wave when healthy asymptomatic volunteers were enrolling into the AstraZeneca vaccine trial found 15% of those injected tested positive for COVID-19, only discovering their infection status when given the results a day after being vaccinated.

“When being vaccinated at the peak of the resurgence, one in ten are probably infected by the virus, most of them asymptomatic – it’s been a big thing in Gauteng and probably now in KwaZulu Natal as they approach their infection peak,” he revealed.

Second jab debate

Madhi called for a single booster dose of Pfizer for healthcare workers who receive the single Johnson and Johnson dose. He says that this is likely to confer much higher immunity against mild disease, as suggested by studies of the AZ vaccine followed by the Pfizer vaccine. Increasing protection against infection and mild Covid in healthcare workers not only provided individual protection but also reduced the chances of them infecting others in the hospital who might be immunocompromised and not fully protected against even severe Covid – despite having been vaccinated. He argues that with adequate security of vaccine supply, this can be immediately embarked on without their being ethical issues around equity.

Dhai differed with him, however, saying it was a moral imperative to get as many doses into as many arms as quickly as possible, especially those people with lower incomes and less access to vaccines. Using up supplies on boosters could leave lower-income people vulnerable.

“We can talk about boosters once we’ve got as many jabs into as many arms as possible,” she added.

Professor Glenda Gray, CEO of the SA Medical Research Council, said fresh data emerged last week showing that a second jab of J&J vaccine substantially increased immune responses, while a single jab already conferred up to nine months of immunity.

She disagreed with Madhi about the second jab being Pfizer, saying there was currently insufficient data to support this – while supporting his view that healthcare workers were critical to prioritize.

“We need data to inform boosting with Pfizer and there is none available at present regarding dosage, timing, immunogenicity, or safety. Also, we need regulatory discussions on this.”

“There’s a difference between an expert opinion and good data,” she added.

Gray strongly backed mandatory workplace vaccination, saying that if rumours of an imminent gazetting to this effect were true, “it would be amazing”, given that ongoing vaccine supplies now seemed secure. However, she doubted that government would grasp the nettle, given the pushback it might evoke.

She agreed with her colleagues about increasing vaccination hesitancy, describing it as “huge”, much of it coalescing around the pro-Ivermectin lobby.

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