Booster Covid-19 vaccine doses for healthcare workers and immunocompromised people aged 18 and older may need to be considered before teenagers in South Africa become eligible for vaccination, says Nicholas Crisp, the health department’s acting director-general. 

The South African Health Products Regulatory Authority (Sahpra) announced on Friday that it had approved the use of Pfizer-BioNTech’s Covid-19 jab, Comirnaty, for everyone of 12 years and older. The Section 21 approval, or emergency-use authorisation, came through on August 11, Sahpra’s Silverani Padayachee said on Bhekisisa and Newzroom Afrika’s television programme Health Hub on Sunday. Previously, the vaccine was only authorised for people of 18 years and older. 

“Our primary objective remains to get the people who are the most likely to end up in hospital or die of Covid-19 vaccinated first,” Crisp says. “Part of the balancing act at the moment is when to boost the vaccinations of those who have already been vaccinated, particularly healthcare workers who have been vaccinated since February 17th [as part of the Sisonke implementation study, which used the Johnson & Johnson Covid-19 jab, and also in the national roll-out with Pfizer’s vaccine].”   

Studies have increasingly shown that the immunity that some Covid-19 vaccines induce wanes after six to eight months and that a booster dose about eight months after the second dose increases a vaccinated person’s immunity.  

Israel, China, Russia, the US, Germany and France all either already offer booster shots or plan to do so this month. In August, the US medicines regulator, the Food and Drug Administration (FDA), approved the use of booster shots of Pfizer and Moderna’s vaccines in immunocompromised people such as organ transplant recipients. The country, however, plans to offer everyone who received a two-dose Pfizer or Moderna vaccine a third shot from late September, eight months after they had received their second dose. 

The US government’s Centers for Disease Control (CDC) says people who had received a one-dose Johnson & Johnson (J&J) jab were also likely to require a booster dose, but it is waiting for more data before making a decision.  

Booster doses are, however, not South Africa’s main concern right now. Rather, we need to first get as many older people, who are more vulnerable to falling seriously ill with Covid-19, jabbed, before vaccinations start for younger people, who are less likely to end up in hospital or to die of Covid-19.  

By the end of Sunday, South Africa had fully vaccinated about 18% of adults with either one shot of J&J or two doses of Pfizer’s jab. 

“But that does not mean that we will necessarily exclude children [of 12 years and older] while we’re waiting for those [older] groups to up their numbers,” Crisp explains. 

“We are weighing up in which sequence to do these various interventions and what implications that would have for vaccine supply. It’s possible that we could start to vaccinate teenagers this year, but I don’t want to say so conclusively when we don’t yet know in which month that will be.”  

How vulnerable are teenagers to falling seriously ill with Covid-19?  

About 8.5% of Covid-19 cases reported globally have been in children under 18 years old, according to the World Health Organization. But these cases tend to be less severe than those seen in adults. 

As of August, children between 12 and 15 made up 4% of cases in the US, but none of them had died. 

South African data from the National Institute for Communicable Diseases (NICD) showed a substantial increase in the number of children tested during the country’s second wave, which was driven by the Beta variant. Similarly, there was also an increase in cases among children. During the second wave, around 2% of cases were in children between the ages of 10 and 14 and another 4% were in those aged 15 to 19. 

The report only tracks data until the end of June so it doesn’t provide a full picture of what happened during South Africa’s third wave, when the Delta variant began to dominate. But the data do show a further increase in Covid-19 cases among children, with the numbers jumping up to 4% in the 10 to 14 age bracket and 7% in those 15 to 19 years old. 

It is, however, still too early to tell if this increase in cases is because of the Delta variant itself or due to other factors, such as increasing vaccination rates among adults or more children being tested for Covid-19. 

At the start of the pandemic, children were thought to be at lower risk of being infected with SARS-CoV-2, the virus that causes the disease Covid-19. They were also not seen as the primary drivers of transmission, meaning that children were believed to be less likely to spread the virus to others. 

But newer studies have since overturned this assumption, according to the CDC. The CDC found outbreaks among children, particularly at camps or school, proving that younger people are still able to be infected and to spread the virus. 

The CDC’s data from February 2020 until May 2021 show that children have comparable infection rates to adults aged 18 to 49, and they are more likely to be infected and to develop symptomatic disease than those over 50 years old. 

But children are still less likely to develop severe disease as a result of infection. The CDC’s studies found that those under the age of 17 are far less likely to be hospitalised or die of Covid-19. 

In South Africa, the NICD’s July report revealed that of the 11,129 hospital admissions among children from the beginning of the pandemic in March 2020 until June 2021, roughly 90% were discharged. It was also found that children are almost seven times less likely to die of Covid-19 after being admitted to hospital than adults. 

Of the children hospitalised, 380 died because of Covid-19. Around half of these deaths were in children that had at least one underlying health condition, particularly HIV infection or diabetes. 

A June study in the Journal of the American Medical Association collected data on children admitted to more than 800 hospitals in the US and found that certain underlying health conditions, such as diabetes and heart problems increased the risk of developing severe disease. 

What is South Africa’s goal with vaccination? 

When the health department launched its national vaccination plan in January, the plan was to immunise 40 million people (the number of people in SA aged 18 years and older, and about 67% of the country’s total population), which the department estimated would ensure South Africa reached “herd immunity”. 

Herd immunity is the point where each infected person is unlikely to transmit a particular germ (in this case the virus SARS-CoV-2) to anyone else. This way the germ will no longer spread within a population. 

In May, however, South Africa switched to a “containment” strategy. The goal is to achieve a level of immunisation that will cause the least amount of strain on the country’s health system, says Barry Schoub, who chairs South Africa’s ministerial advisory committee on Covid-19 vaccines.  

Ideally, Covid-19 cases would put no more pressure on the country’s hospitals than a winter illness might, he says. 

Crisp explains: “That’s why we’re prioritising older people before teenagers, because they’re the most likely to fall ill and end up in hospital or die.”  

The reason for the switch?  

The emergence of variants, vaccine supply issues and other hiccups meant herd immunity became a moving target that South Africa was unlikely to reach. Read more about it here. 

In short, the new goal is to keep as many Covid-19 patients out of hospital beds as possible.  

Young people have made up a small fraction of hospitalisations so far.  

Teenagers between the ages of 15 and 19 made up on average 1.4% of Covid-19-related hospital admissions during all three waves of SARS-CoV-2 infections in South Africa, NICD data show. 

There’s also a bit of brutally honest mathematics to go with this argument. 

Since younger people are less likely to end up in hospital in the first place, the health system needs to vaccinate far more of them before any money is saved.  

For instance, 1,538 vaccinated men between the ages of 30 and 49 would prevent just one admission to hospital. This is according to calculations presented during the national health department’s weekly meeting to discuss the roll-out. 

When people older than 65 get vaccinated, the health system gets a lot more bang for its buck. 

Just 83 men aged 65 and up need to be vaccinated for one Covid-19-related hospital admission to be prevented. 

One vaccine in the arm of a man 65 and older saves R843.  

Immunising a man between the ages of 30 and 49, meanwhile, only saves R45. 

How do we know Pfizer’s vaccine is safe and effective to use on teenagers?

In August, Pfizer’s Covid-19 vaccine was fully approved for use in people aged 16 and up by the FDA with the same dosages as for adults.  

Children between the ages of 12 and 15 are not included in the full approval. But these age groups are being vaccinated in the US under an emergency use authorisation. 

This decision was based on data from a US clinical trial of more than 2,000 children between the ages of 12 and 15, half of whom were given the vaccine while the other half received a placebo or dummy drug. The study found that this group had a similar reaction to the vaccine to those aged 16 and up, and that the benefits of vaccinating these teenagers outweighed the risks. 

Pfizer and BioNTech continuously submit new data to Sahpra about their vaccine. Sahpra’s updated approval for the jab for use on people of 12 and older in South Africa happened as part of this process. 

“This was as a consequence of the review of updated safety and efficacy information submitted as conditions of the Section 21 [emergency-use authorisation] initially authorised on 16 March 2021,” Saphra said in a press release. 

According to Sahpra’s Padayachee, no other vaccine manufacturer has yet applied with the regulator for approval to have their jab used on people below 18 years of age. 

When will South Africa be ready to roll out vaccines for teenagers? 

At the time the US roll-out was broadened to include children 12 and up, the country had fully vaccinated 34% of its population and a further 11% had been partially immunised. 

South Africa has, however, only vaccinated 18% of its adults, or about 12% of its entire population. “We still need to get through to another 30% of people of 60 and older in some provinces and up to 40% in others,” Crisp says.  

He acknowledges that Covid-19 has affected children in South Africa more in the current third wave than in previous waves, and that there may therefore be a need to vaccinate teens. 

“We clearly don’t know what will happen in the fourth wave, but we do know that it is coming, so it will be important to protect children… but we need to make sure we have enough vaccines in the country and that we are clear on the protocols.”  

The decision-making process around opening up vaccinations for teenagers involves several committees and departments such as the Covid-19 vaccine ministerial advisory committee, government departments, such as the education and social development departments, and other government bodies involved in the roll-out, such as the inter-ministerial advisory committee and the National Coronavirus Command Council.  

Crisp concludes: “The health department will make recommendations to the inter-ministerial committee. When a decision is made there, we will be in a position to announce when teenagers will get vaccinated.”  

Will you be able to apply to get your teen vaccinated under special circumstances? 

South Africa currently doesn’t have a mechanism to record vaccinations for people younger than 18, says Crisp. 

“But what we do have is an advisory from the Covid-19 vaccine ministerial advisory committee this past week on how to manage people who are immunocompromised, particularly those who are in age groups that are not yet eligible for vaccination. 

“We will be discussing that in the department this week, and we will be looking at the implications and processes that might become available. But those types of vaccinations would have to run outside of the mainstream vaccination programme, because that would involve blood and other tests, so that we make sure we don’t put children who have particular immunocompromised disorders at some kind of risk. Such situations would need to be managed very closely in collaboration with the clinicians who care for them.” DM/MC

This story was produced by the Bhekisisa Centre for Health Journalism. Sign up for the newsletter.