Some of the members of the Scientists Collective are acknowledged as world leaders in the vaccine field, and are in a position to consider and provide answers to the difficult questions about meeting one of the greatest challenges South Africa has faced, the mass vaccination of the population.

Over the next few months, we expect to have further information on the safety and effectiveness of a range of other Covid-19 vaccines. 

We can’t do full justice to all the intricacies of vaccines and how they work, but in this advisory we will link you to trustworthy and relevant information (see our article on misinformation here), together with safe links to trusted sites. 

In the meantime, here is the headline news on the new Covid-19 vaccines.

Millions of South Africans are alive and healthy today thanks to modern vaccines. Vaccines are right up there with clean water and sanitation, safe food, antibiotics and effective anaesthesia in saving lives. 

Over the last 100 years, vaccines have had a huge impact on human and animal health, resulting in the greatest effect on health and longevity than almost any other intervention throughout recorded history. Vaccines have changed the trajectory of generations, improved the prospects for all classes of society, generated prosperity through freedom from many debilitating diseases and allowed more people than ever before to have the opportunity to live full and healthy lives. They have brought diseases, such as smallpox, polio, measles and diphtheria, which had our great-grandparents living in justifiable fear, under almost complete control. 

For an entertaining history podcast about one of the founders of many modern vaccines and the huge efforts vaccines take, click here.

To achieve control of Covid-19, a safe and effective vaccine would be enormously helpful in getting us beyond the pandemic – “natural” infection, even in the worst affected areas, has not reached levels where population-wide immunity is reached – which is why one should ignore arguments for letting the virus simply spread naturally. 

In addition, natural infection carries substantial health risks that do not apply to vaccines.

Do the Covid-19 vaccines work? 

They seem to work very well, at least for the early candidates, results for which seem very promising: these vaccines have stopped people getting sick, and reduced the severity of the disease in those with “breakthrough” infections. 

Initially, results were released through press statements, which is not the same as independent or “peer” review, the scientific standard that applies. The data on two of the vaccine trials have now been published in highly regarded scientific journals, and the results look promising. 

At the time of writing, three countries, the US, Britain and Canada, issued Emergency Use Authorisation (EUA); the US and UK have already started vaccinating high-risk people. Germany will follow suit. China and Russia have similarly started vaccination programmes for certain designated groups with their candidate vaccines, although the full trial data on these have not yet been internationally reviewed.

There are lots of questions about these vaccines, mainly about how long the immunity will last. 

Some vaccines last for a lifetime, some have a steadily waning (decreasing) immunity that needs a “top-up” or booster shot, or possibly even a new one every so often. It is unclear at this time in which category the Covid-19 vaccines will fall, and how long the immunity will last (they have only been trialled for a few months!). 

Over time, we will understand more about these vaccines: how protective they are, how long immunity lasts for, what impact they have on disease progression and death; the level of protection in the older as compared with younger populations, and safety in use in pregnant women, and children. Each successful vaccine will need to be carefully evaluated on an ongoing basis by the South African Health Products Regulatory Authority (SAHPRA), and plans will need to be made for their proper and effective distribution.

But are they safe?

The data thus far show that they all seem to be safe. 

The side-effects we have seen have generally been what anyone who has had any vaccine will relate to – some pain at the injection site, and occasionally some chills, which disappear after a few days. These can scare people if they are not prepared, like any side-effects, so counselling recipients will be important. Even in sicker people – frail or people with other illnesses – the vaccines seem safe for now. One vaccine has been associated with some allergic symptoms, some serious, in a very small number of those vaccinated who had previous allergies.

We always weigh safety against benefit with any medical intervention, including vaccines, and the safety bar for any vaccine is set very high, far higher than for tablets or other injections. Ideally, more safety data are required – and this will come – but this pandemic is serious enough to push forward with getting them into people, while keeping a very close eye on all safety data, something every regulator and hordes of researchers are doing.

SARS-CoV-2, the virus that causes Covid-19, provides much cause for concern – highly infectious with a high death rate among older people and people with serious illnesses like diabetes. In addition, we are concerned about the condition referred to as “long Covid” – a constellation of symptoms possibly related to the acute illness, which persist after the acute illness subsides. (see our advisory providing information about long Covid). 

The safety of vaccines is highly regulated by the relevant authorities, in our case SAHPRA. Before a vaccine can be licensed or registered in a country, the regulators examine all the data from all the studies. Long-term evaluation for safety and efficacy is important and is monitored by the regulators in tandem with the manufacturers.

As scientists and health practitioners, we are reassured that these vaccines have been tested in tens of thousands of people, some in relatively diverse populations (including in people with HIV), and some in South Africa. This gives us confidence that they will be effective in our setting and for all our people.

That sounds all very reassuring. So, we will be able to control the virus and get back to normal?

Regrettably, the answer, for now, is no.  

At this time, there is a lack of information from the government on detailed plans to procure and distribute Covid-19 vaccines. The development of a safe and effective vaccine is only the first step. The trial results are better than we dared hope for (so far), but that is only the first step in what is a massive project, possibly greater than anything the country has attempted before. The scale rivals that of the preparations for the Fifa World Cup of 2010 and the rollout of ARVs for HIV-positive people. But our experience and the know-how we developed there should stand us in good stead.

Preparations for vaccine distribution and access in South Africa

We are concerned that there is insufficient planning by the government thus far, considering the magnitude of the project ahead and an inadequate sense of urgency regarding the vaccination project. It is possible, of course, that the government may well be far down the road, but the lack of communication and information on these possible developments equally create unease.

At the time of writing, the vaccination has begun in the US and UK, with other countries in Europe and Asia expected to follow soon. We have been assured that at this time, there is sufficient money available to vaccinate about 10% of the population.  We are concerned that despite world-class vaccinology talent, substantial financial commitment in the Department of Health budget to other vaccines, a history of successful vaccination for children and a Ministerial Advisory Committee solely focused on Covid-19 vaccines, the lack of information detailing a comprehensive vaccination programme is not yet on the table. 

At the time of writing, not a single advisory of the Vaccine MAC has been published.

We are all heavily invested as scientists, health workers, and the population of SA that we are beholden to, to ensure our best efforts to control this pandemic. We are pleased to offer some practical suggestions, based on our experience from other pandemics, vaccines and health systems interventions. (If you are interested, read the full published article in the SA Medical Journal, on which this advisory is based, for all the detail, including probable costs, some of the assumptions, possible scenarios and some excellent articles, including a scary editorial).

In order to get the ball rolling, two urgent decisions have to be made. 

First, South Africa has to swiftly identify a candidate or a portfolio of candidate vaccines and ensure they are speedily registered for use locally. We must pro-actively engage directly with manufacturers and work with other countries to ensure we are not left behind in the queue to get vaccines.

Second, there should be an engagement with big business, local philanthropic foundations, high-net-worth individuals, banks and medical schemes, with the express aim of developing public-private partnerships that will negotiate, finance, procure and deploy vaccines in our country. 

Initially, we will have to buy the vaccines from international manufacturers and possibly acquire some vaccine doses through the WHO’s Covax scheme. We must be aware that we are competing with the whole world for these vaccines and against far richer governments that have already bought up massive amounts of stock. (Canada, for example, has bought up to 10 times the amount of doses needed for its population, although they have announced that a significant amount of excess doses will be given to poorer countries in need.)

South Africa dismantled its robust capacity to make vaccines for some reason in the early 1990s, relying instead on importing vaccines from overseas manufacturers. We have some capability to be part of a tech-transfer agreement to locally scale up vaccine availability, and this should be part of our long-term plan. But it is unlikely to result in any local manufacture of vaccines during the course of 2021.

It is also vitally important that the government decisively secures the finances for vaccine access. 

We can acquire the vaccine via three mechanisms: 

1. Through the Covax facility; 
2. Bilateral agreements with manufacturers; and 
3. Via bilateral agreements with other countries e.g. those with excess vaccine stock. 

The Solidarity Fund is providing the initial deposit for the government’s procurement through the Covax scheme, in which it will be allocated vaccines according to various criteria at prices set by Covax. But the government must also simultaneously negotiate directly with vaccine manufacturers in order to remain in control of direct procurement outside of Covax.

Who should be vaccinated first?

While we are waiting for the vaccine, there needs to be discussion about how we prioritise vaccine allocation. 

Healthcare workers, the elderly, other frontline essential workers and those with comorbidities should be the first recipients of the vaccine. We can’t afford to have our healthcare workers and frontline workers ill if we are going to face recurrent surges. Ideally, we would then steadily vaccinate from the most vulnerable to the least in a systematic rollout over the months following the receipt of vaccine stock. 

We also need a public debate as to who else is regarded as frontline – taxi drivers, waiters, food-till operators? 

Healthcare workers and other essential workers should get their vaccine through workplaces. For the elderly, strategies to vaccinate them will include deploying nurses and other qualified medical staff to offer vaccination at pension points, in communities and primary healthcare centres where people with chronic illnesses like diabetes and hypertension get their medication. Mass immunisation strategies in rural areas would have to be developed at district level in recurrent rollout programmes. Using existing networks, such as private pharmacies, makes sense for broader distribution.

We will have to distribute the vaccine throughout the country. 

This will require massive logistical coordination – one vaccine has extremely stringent refrigeration requirements, generally only found in research laboratories. Many of the other candidates require less onerous refrigeration, but still a cold chain – in a country where reliable electricity is a challenge. For a fascinating and sobering podcast on these logistics (which involve jet airliners, glass, dry ice and trucks, listen here). Getting this right will require skilled planning.

Finally, the benefits of being vaccinated must be visible and noticeable to encourage people to get vaccinated – some vaccine candidates need to be vaccinated twice, a few weeks apart. 

To get to the levels of immunity we need to breathe freely again, known as population immunity, where there is sufficient suppression of the virus to allow near-normal activity to resume, we probably require 60%-70% of the population to develop immunity. For young children, it is fairly easy to offer Covid vaccination through the South African vaccination programme. However, no country in the world has successfully vaccinated adults at this scale – even for adult vaccines such as influenza, numbers are small in even the most highly vaccine-accepting societies. We will need to learn from other countries and innovate locally to reach scale.

Collaboration and coordination on a grand scale

To be able to vaccinate 60%-70% of the population will require deep collaboration among social partners and expert coordination. Vaccines will need to be delivered to and properly stored at clinics, pharmacies and all health facilities, public and private, that render care in the normal course. South Africa is blessed with thousands of such facilities, widely distributed throughout the land. They will all have to be made available and logistical coordination and support from all sectors of society will have to be mobilised. Organisations such as the Red Cross, Gift of the Givers, MSF and others with technical skill and capability must be enlisted in this effort, as well.

Ethical obligations

As scientists and clinicians, we are obliged to invest the programme with ethical obligations that must be diligently applied. 

Vaccine access must be equitable and fair. There should not be an opportunity for exclusive access by the privileged and those with means only, as was the case in the early phase of the Aids pandemic. This underscores the need for the deep collaboration between, in particular, the private and the public health sectors. 

There must be full inclusion into the vaccination programme of all those within our borders, including documented and undocumented foreign nationals, asylum seekers and refugees. It will be intolerable from an ethical point of view to subject foreign nationals to the exclusion that currently bedevils their access to public health. Such xenophobia would defeat the public health goal of controlling infection. 

Vaccine prices must be transparent, fair and equitable. 

The secrecy and lack of transparency that governments and manufacturers employ must not be a feature of this vaccine procurement, or it will not only jeopardise access but will be the subject of rightful anger. The government and manufacturers must think long and hard before going with business as usual in a pandemic, as this lack of transparency will undermine trust, and reinforce the hands of anti-vaxxers. 

Pharmaceutical companies should share technology, policymakers need to tackle patents that are barriers to access, and profits assessed against substantial public investment that has gone into many vaccines. 

We need an urgent communication strategy that deals with vaccine hesitancy, that builds public trust and participation.

Are vaccines all we have available to us?

There are drugs and other interventions being evaluated that may provide both protection and treatment (as we have for malaria, flu, hepatitis B and HIV). None has proved successful yet for mild or asymptomatic Covid-19, although we have some interventions that work for severe disease. But keep an eye on the NICD, WHO and other trustworthy websites – and the press is likely to be flooded with reports if one comes through. We’re all holding thumbs and many of us are busy with this research.

In the meantime – physical distance, try your best to move social events and gatherings outdoors, avoid crowds both indoors and outdoors where physical distancing is not possible, wear a mask around others, and wash your hands regularly. 

These methods really do prevent new infections.

If the vaccine works, can we go back to 2019?

We would so like to say yes, but that is unlikely, at least for the foreseeable future. 

As we are likely to have more waves and hotspots in the future, the physical distancing and masks are likely to be with us until at least two-thirds of the population develop immunity against Covid-19. It will take months to years to vaccinate even two-thirds of South Africans (“normal” infection rates as we indicate above, are not nearly high enough to give population immunity), and then there is the issue of being able to access sufficient quantities of vaccines in the foreseeable future.

Some commentators have asked: “Well, if we can’t get rid of the masks, what is the point?’’ The point is to ensure older and more vulnerable people do not die of a scary virus, and the rest of us not be nervous of long-Covid symptoms. Vaccines won’t take away the nuisance of masks and physical distancing perhaps for most of 2021. With HIV, condoms played and continue to play a major role in stopping transmission, even when drugs are so effective they behave as a vaccine. Consider masks as the “condoms” of Covid.

Unfortunately, unlike SARS and MERS, it is highly unlikely that the virus which causes Covid-19 is going to disappear anytime soon, if ever. There may also be a future where the vaccines and natural infections eventually provide enough community protection for us to return to approximate normalcy. But it is fair to say that this pandemic, like all the other pandemics throughout history, will leave society on a different footing, with new ways of living to be adopted and new opportunities for remaking society on offer. 

For additional trusted resources (and some fascinating history on the development of vaccines), visit these websites:

https://www.nicd.ac.za/

https://covid19.who.int/ 

https://thevaccinetracker.com/

https://www.covid-19vaccinetracker.org/

https://www.sahpra.org.za/news-and-updates/information-and-guidance-on-the-identification-and-reporting-of-adverse-events-following-immunization-with-the-new-covid-19-vaccines/ 

https://www.cdc.gov/coronavirus/2019-ncov/index.html

https://www.cdc.gov/vaccinesafety/ensuringsafety/history/index.html 

https://www.immune.org.nz/vaccines/vaccine-development/brief-history-vaccination 

See other advisories by the Scientists Collective below:

Distance, Dose, Dispersion: An experts guide on Covid-19 risks in South African and how to manage them

How long should I isolate or quarantine for?

Practical guidance on disinfecting

Testing for Covid-19? All you need to know about antibody tests

Children, Covid-19 and Classrooms: A 10-point Plan for Making Schooling Safe

Staying safe while you exercise: The Covid-19 sport and gym advisory

Anticipating a ‘Second Wave’ — and when and how South Africa should try to prevent or mitigate it

Have you heard about Long-Covid? It sticks around for a while

How to go on holiday safely in the time of Covid-19: A practical guide

Different types of Covid-19 tests put under the microscope 

Fake news and misinformation kill: how can you trust what you are told about Covid-19? 

The following people contributed to this advisory:

Professor Glenda Gray, University of the Witwatersrand and Medical Research Council.

Professor Shabir Madhi, Respiratory and Meningeal Pathogens Research Unit, University of the Witwatersrand.

Professor Marc Mendelson, University of Cape Town.

Dr Jeremy Nel, University of the Witwatersrand.

Professor Wolfgang Preiser, University of Stellenbosch.

Dr Aslam Dasoo, Progressive Health Forum.

Nkuli Mashabane, Dr Esther Bhaskar, Dr Karlien Moller, Dr Bronwyn Bosch, Dr Jo Woods, Celicia Serenata, Professor Francois Venter, all at Ezintsha, University of the Witwatersrand.

Dr Dulcy Rakumakoe, private practice

Professor Wendy Stephens, Head, Department of Molecular Medicine and Haematology, University of the Witwatersrand

Professor Eric Decloedt, Stellenbosch University.

Dr Francesca Conradie, University of the Witwatersrand.

Professor Alex Van Den Heever, University of the Witwatersrand

Dr Regina Osih, infectious disease specialist.

Professor James McIntyre, Anova.

Professor Morgan Chetty, Visiting Prof Health Sciences, Durban University of Technology.

Dr Elijah Nkosi, private practice.

Professor Lucille Blumberg, University of Stellenbosch.

Adrienne Wulfsohn, Emergency Medicine Physician, UKZN

Dr Jantjie Taljaard, Tygerberg Hospital and Stellenbosch University.

Andy Gray, University of KwaZulu-Natal

Dr Nomathemba Chandiwana, MPH

Dr Fareed Abdullah SAMRC

Prof Guy Richards Wits University

Prof Bavesh Kana NHLS and Wits University

Prof Ian Sanne RTC and Wits University

The Scientists Collective acknowledges the input of Ms Fatima Hassan in this advisory.

DM/MC