Prof Saurabh Sinha is an electronics engineer and Deputy Vice-Chancellor: Research and Internationalisation, University of Johannesburg (UJ); Prof Refilwe Phaswana-Mafuya is an epidemiologist and Professor of Public Health, Faculty of Health Sciences, UJ; and Prof Bettine van Vuuren is a zoologist (ecological genomics and wildlife conservation) and Senior Director: Strategic Initiatives and Administration, UJ. The authors write in their personal capacity; this is an opinion piece and does not replace medical advice.

One of the authors of this article recently experienced the death of a person close to them shortly after receiving a Covid-19 vaccination.

In such a situation, it is natural to question a potentially causal relationship with the Covid-19 vaccination. In this case and somewhat contrary to presumption, the autopsy process clarified that death was due to Covid-19, with the individual most likely receiving the vaccine while being Covid-19 positive or contracting the virus shortly after vaccination.

This is not an isolated case; there is additional anecdotal evidence on vaccine or related complications which may slow vaccine uptake. Implementation research is needed so that adaptations and improvements are made as the vaccine implementation process evolves and gains momentum in South Africa. Furthermore, clarification of isolated instances such as the one outlined above is critical to ensure continued vaccine uptake and quell misinformation or uncertainties.

First and foremost, it is important to understand that vaccinations protect the overwhelming majority of the population and are an absolute requirement for breaking the Covid-19 transmission chain. Particularly for countries classified as emerging economies, breaking the transmission chain is vital as a compromised economy is fertile ground for various other challenges, including the compounded knock-on effects for short- and long-term health implications. One such implication is compromised immunity due to a lack of mental wellbeing (stress caused by the social and economic impact of Covid-19).

There are valuable lessons to be learnt from the recent personal experience mentioned above and also other anecdotal reports. Although we are well accustomed to dealing with viral outbreaks (the yearly cold and flu epidemics as examples), nothing in our lifetime could have prepared us for the current pandemic. Our exposure to coronaviruses in general, and also severe acute respiratory syndrome (SARS) in particular, are not new, but the virus causing Covid-19, SARS-CoV-2, is a novel virus.

(1) First and foremost, before entering a vaccination site, persons need to understand their individual health conditions, for example, whether and when the person has had a previous infection and the severity thereof. Such an infection could include a Covid-19 infection or reinfection, Covid-19 or related symptoms, whether the person has allergies or autoimmune diseases, a tendency to blood clotting, or other conditions that may prevent vaccination.

Importantly also, whether the person may have recently received a different vaccination such as an influenza jab. Some individuals may feel reluctant to disclose that they have had Covid-19 due to stigma, anxiety, negative social media or fear of being forced to quarantine (especially relevant to low-income workers) as they may lose income.

A person with Covid-19 illness or associated symptoms should not be vaccinated during this time — as this may cause vaccine complications. Ideally, a Covid-19 test before taking the vaccine would be best, but it would be expensive, logistically complex and could introduce vaccine access and equity difficulties.

(2) Many people infected with Covid-19 are often asymptomatic for the first few days (some remain asymptomatic for the entire duration of their Covid-19 encounter) — such a person may have entered the vaccination site with an infection. This is why vaccination sites are careful and require additional safety protocols — such as double masking, multiple sanitisation stations, and so on. Notwithstanding any negative connotations, it is essential to correctly answer the questions on medical history at the vaccination site. This allows for further onsite advice from healthcare workers. To reduce risk to others at a vaccination site, individuals with Covid-19 symptoms must seek medical assistance from their local health provider before going to vaccination sites. If one suffers from the so-called “long-term Covid-19”, you should also seek medical advice before or when considering vaccination.

(3) Upon vaccination, staff at the vaccination site must recap the side effects and management thereof. Many will experience flu-like symptoms, headaches, and/or tiredness after the vaccination (particularly upon a second or booster shot). Some of these symptoms are quite like Covid-19. As in the case referred to, the individual thought the symptoms were merely side effects of a first vaccination shot. In fact, in this case, the Covid-19 infection was advancing, rather rapidly, to full-blown disease. While mRNA vaccines (such as Pfizer-BioNTech) represent a significant scientific advancement towards a universal vaccine format, more public education is required as to their side effects. Also, given their novelty, more education is needed on mRNA vaccines specifically versus other vaccines, so the mode of action is better understood.

(4) Being vaccinated does not mean immediate or complete immunity. It can take up to two weeks after vaccination (and the second vaccination shot in the case of Pfizer-BioNTech) to build up immunity, and this immunity is not necessarily full immunity. In other words, some individuals who are vaccinated may still contract Covid-19 (especially when considering the number of variants currently circulating) — in many cases, the infection will not progress to disease (severe illness), and hospitalisation is unlikely. This is perhaps the most compelling reason for getting vaccinated — the vaccination prevents, for most, the severe form of the disease and therefore also reduces the burden on the healthcare system. Should vaccination and Covid-19 infection occur at a (near) similar time or the person was asymptomatic at the time of vaccination, care should be taken as the vaccination may not be effective against the infection progression and may, in fact, fuel the body’s response to the vaccine. This is also one explanation why some persons who have been recently vaccinated have succumbed to Covid-19.

(5) Booster vaccination. While studies are emerging to propose a third shot (in the case of Pfizer-BioNTech) or booster shots for single vaccines — the vaccination of the whole global population must remain the top priority. Booster vaccinations or a third shot might be prioritised for persons who are over 60 and/or have comorbidities and/or have higher exposure to Covid-19 (such as frontline workers). Although the body’s reaction to vaccines, including our natural immune responses, is complex, there is nonetheless considerable scientific knowledge documenting both typical and atypical responses. While antibodies will reduce over time (as they should), our bodies will retain the knowledge to recognise the spike proteins resembling that of the SARS-CoV-2. In essence, the body will have a memory of the antibody approach, and the memory cells will expedite a future immune response. The memory cells also bring about some coverage for the variants (as the spike proteins are still a common feature of all the variants). Furthermore, the mRNA vaccinations will be adjusted based on the most common or concerning variant at the time. Currently, the most common variant is the Delta variant. It is quite possible that, like the flu vaccination, the Covid-19 vaccination may become an annual occurrence.

(6) Covid-19 tests. While the aspect of tests is not directly related, in the case referred to here, the individual had obtained a Covid-19 antigen test (or the so-called rapid Covid-19 test) before the vaccination. It is important to understand that there is no test with 100% accuracy; hence the need for accurate patient medical history, including previous tests, possible differential diagnosis, with the final diagnosis being derived from this. Tests represent only one aspect of a full diagnosis; they are important but not 100% definitive. First, it is important to understand that there are various kinds of Covid-19 tests — the two most common are the antigen and RT-PCR tests. As with all test results, the disclaimer of a possible “false negative” should be kept in mind. An antigen test is rapid but may be less reliable than RT-PCR. Let us take the scenario: person X receives the first vaccination shot, subsequently tests positive for Covid-19 (this is referred to as a “breakthrough” infection), recovers from the disease, and is now due for the second shot. This person must keep in mind the recent Covid-19 infection, the severity of this infection, the time since getting infected and seek the second vaccination only after full recovery (one recommendation is to wait for 30 days after full recovery). Because of the already described reasoning, a person infected with Covid-19 in early 2020 may test negative during a Covid-19 antibody test. While antibodies may have reduced below the critical test threshold, the person will most likely still benefit from the memory cells when being exposed to a future infection. Regarding this, one perspective in the journal Science talks to hybrid immunity.

(7) Vaccination is not a treatment. There is a myth that taking a vaccination will counter the Covid-19 disease. Vaccination is a preventative measure — to strengthen one’s immune system and response. As a general rule, vaccination should never be taken during the course of an illness. Also, vaccination efficacy regarding infection and disease does differ; the general view thus far is that any approved Covid-19 vaccination will assist towards building one’s immunity and contribute towards herd immunity.

(8) Fake news and misinformation around vaccinations, in general, are not new. As history shows time and again, including for polio vaccinations, infodemics, like a pandemic, grow exponentially and leverage sceptical individuals. Misinformation often takes the ride of famous individuals, celebrities and others who may have experienced an extreme reaction. Just as travel supports the spread of pandemics, social media today provides a perfect platform for the spread of infodemics (both accurate and inaccurate information spread; unfortunately, inaccurate information may spread more rapidly with increased uptake by sceptics).

(9) The US Centres for Disease Control and Prevention (CDC) had initially proposed that vaccinated persons do not need to continue wearing masks. Given the virulence of the new variants, the CDC has reviewed its decision — it has once again proposed wearing masks irrespective of vaccination status. Masks protect both the individual and others.

(10) The authors particularly recognise both the national and Gauteng provincial departments of health, which took an efficient and coordinated approach in investigating the case referred to in this article. The swift pace of such investigations remains critical to managing any broader risks and, as in our own experience, to reinforcing public confidence in the vaccination programme and making necessary adaptations. Although there was some prior knowledge around vaccination programmes, the current Covid-19 outbreak requires one to be especially adaptable. The ongoing updating of information — where there is scientific consensus — in real time, remains crucial.

We recommend further education, particularly with religious and traditional community leaders to fast-track uptake, on the importance of the vaccination programme and the multifaceted nature of Covid-19. Furthermore, the education on Covid-19, including on vaccinations, continues to evolve. DM