South Africa recently passed the peak of the fourth wave of Covid-19 at a national level. Against this backdrop, the Department of Health is trying to strike a balance between protecting those who are fully vaccinated through booster shots and encouraging those who are unvaccinated or partially vaccinated to vaccinate.

The J&J boosters were made available to eligible members of the public from 24 December, and the Pfizer shots from 28 December, according to department spokesperson Foster Mohale. As of 10 January 2022, 12,221 doses of the Pfizer booster had been administered, according to the department’s latest vaccine statistics.

“The numbers [of administered booster shots] have been very low because this was only opened during the middle of the festive period, and we expect the number to increase as people return to work and students return to schools,” said Mohale.

Both the J&J and Pfizer booster shots have been approved, under some conditions, by the South African Health Products Regulatory Authority. A person is eligible for a J&J booster two months after the primary dose, and preferably before the end of six months, said Mohale. However, a Pfizer booster shot may only be received six months after the second dose.

“Roughly, this means that the boosters will be available to older adults, as this group was the first to receive vaccines,” said Susan Cleary, associate professor in health economics at the University of Cape Town (UCT). “Targeting vaccines towards older people makes a lot of sense: the vaccines are primarily intended to reduce severe illness and those of older age are more likely to experience severe illness.”

The department’s latest statistics show that more than 6,208,000 people have received the J&J vaccine, while more than 12,280,000 have received the Pfizer first dose and more than 9,181,000 have had the second. About 39% of the adult population of South Africa is fully vaccinated.

Booster shots are “unavoidable during this period of the pandemic” for those who have been fully vaccinated for more than six months, as the primary doses tend to wane over time, according to Mohale.

In light of the ongoing resurgence of Covid-19 cases due to the Omicron variant, the National Institute for Communicable Diseases (NICD) recommends vaccinations, including booster shots, to reduce severe disease, according to Professor Adrian Puren of the NICD. 

“We have seen that in the current resurgence there were a large number of infections, but the consequence of previous exposures and vaccinations was a lower [amount] of severe disease. The result is that the hospitals are not under strain, and also a significant decrease in mortality,” said Puren.

Table showing the number of active Covid-19 cases and Covid-related deaths in South Africa between 5 and 10 January 2021 and 2022. (Data source: National Department of Health’s latest Covid-19 figures; National Institute for Communicable Diseases’ alerts)

Booster shots for any vaccine are intended to improve the robustness of the immune response, according to Dr Marvin Hsiao, associate professor and consultant virologist at UCT. However, since Covid-19 is relatively new, scientists are still working out what is required to have robust protection against the infection and disease caused by the virus.

“What happened prior to Omicron is that most of the protection against disease, and also some protection against infection, was adequate with just the usual two doses of the mRNA vaccines, or in some other cases, a single dose of, for example, the Johnson & Johnson vaccine,” said Hsiao. “But with Omicron, what has been observed is that the […] level of the antibodies that’s induced by the two doses is insufficient.”

As a result, many countries have implemented a booster shot to boost the level of antibodies, he said. This has served to improve protection against infection and disease.

“We are still calling it a booster, but for me it is not entirely out of the question that [in] the future of these so-called two-dose vaccines, the full primary course – the number of doses required to protect us against disease or infection – is actually three doses,” said Hsiao. “But that hasn’t been worked out yet, because things are changing so quickly.”

Those who contract Covid-19 will have to wait a minimum of 30 days after infection before being vaccinated with a primary dose or receiving a booster shot, said Mohale.

The state announced that the Electronic Vaccination Data System had been opened for the second Pfizer dose for 12- to 17-year-olds on 9 December 2021. While the number of people in this group who have had their second vaccine is not yet available, the latest statistics show that more than 951,000 have had their first dose. 

Bringing vaccination to the people

While attention has been paid to making vaccines accessible across socioeconomic groups, there are still groups within the South African population that have chosen not to receive them, said Cleary, adding that international anti-vax campaigns on social media are a factor behind this.

“There are many factors behind low vaccine uptake, and we continue to use different strategies, including incentive programmes and taking vaccines to the people, as part of our efforts to encourage people to protect themselves and their loved ones against this pandemic,” said Mohale.

Among the strategies that need to be adopted to increase vaccine uptake are providing services closer to communities, addressing valid concerns of those who are vaccine hesitant and educating the public about why vaccines are essential, according to Puren.

There is currently excess capacity in the country’s vaccine programme, with supply exceeding demand. (Photo: Tamsin Metelerkamp)

Hsiao emphasised that being fully vaccinated, without the booster shot, will provide substantial protection against severe disease if a person contracts Covid-19. Therefore, while people should take a booster shot if it is available to them, this should not come at a cost to someone who needs the first or second dose of a vaccine, he said.

“It’s an issue of prioritisation,” said Hsiao. “But obviously, when we have a lot of vaccines and not enough people, [when] the demand is the problem… I think it is fair to advocate for booster shots in that situation.”

There is currently excess capacity in the country’s vaccine programme, with supply exceeding demand, according to Cleary. Under these circumstances, it makes sense to make the option of a booster shot available to those South Africans who would benefit from it, she said.

“We are well aware of the number of vaccinated people,” said Mohale. “We wouldn’t have introduced booster shots if we did not have capacity in terms of vaccines and manpower.” DM