Focus vaccines on over-50s to survive a fourth wave – SA health experts

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Residents in Paarl getting vaccinated at the Mbekweni Community Hall Vaccination Site earlier this year.  (Photo by Gallo Images/ER Lombard)
Residents in Paarl getting vaccinated at the Mbekweni Community Hall Vaccination Site earlier this year. (Photo by Gallo Images/ER Lombard)


As experts warn of the likelihood of another wave of Covid-19 infections, only 54% of people in South Africa older than 50 have received at least one Covid-19 jab, with significant variation between provinces.

Because older people are at greatest risk of serious illness or death if they contract Covid-19, they will be particularly vulnerable during a fourth wave.

Accordingly, various local experts agree that accelerating the vaccination programme is paramount.

Professor Debbie Bradshaw, chief specialist scientist at the SA Medical Research Council (SAMRC), says:

Vaccine coverage of older folk is pretty important in terms of loss of life via Covid-19. Every vaccination counts in slowing down the pandemic, especially those into older arms, which will reduce the overall loss of life.

Meanwhile, vaccinologist and dean of the faculty of health sciences at Wits University, Professor Shabir Madhi, has called for the vaccination campaign to focus almost exclusively on people older than 50 to avoid the possible overwhelming of hospitals around the festive season and to mitigate the worst effects of another wave.

A total of 49% of those between the ages of 50 and 59 in South Africa have received at least one dose of the vaccine. For people 60 and older, this figure stands at 59%.

Preparing as if a fourth wave is certain

Director-general of the department of health, Dr Nicholas Crisp, concedes that the two-jab vaccine coverage of older people is still too low:

We can’t avoid a fourth wave if there is another mutation. What we can do is minimise the destruction and clogging of hospitals with people who could have been protected.

However, he has a caveat: “From a clinical perspective, Professor Madhi is correct, and that’s our focus. But from a public perspective, we need to maintain the ‘everyone’ message. We’ve seen child infections in this [Delta] wave, which we did not see before, and we’ve seen many children die this time. We can’t cherry-pick a handful of comorbidities, so we need people to be able to come for vaccination if they feel at risk.”

In numbers: province by province

Health department statistics show that by September 22, Mpumalanga was the worst-performing province when it came to vaccinating the 50- to 59-year-old age group, with a low 39.6%.

North West is second-worst with 40.43%, followed by Gauteng with 45.3%.

In the over-60 category, the Northern Cape (South Africa’s least-populated province) has 45.8% jabbed, followed by Mpumalanga with 49.1% and North West with 49.4%. Limpopo has the best figures in the category, with 71.7%, followed by the Western Cape with 65.66%.

In the 50- to 59-year-old category, the Eastern Cape has 59% of people jabbed, followed by the Western Cape with 53.3%.

Crisp says that, while district-level health data is available, it is not very helpful because people tend to move to the most accessible vaccination station, which is often in another district, and are thus incorrectly counted geographically.

Real jab percentages lower

Emeritus Professor Rob Dorrington of the University of Cape Town’s Centre for Actuarial Research points out that few of the 60-plus group were fully vaccinated before South Africa’s third wave hit.

READ: What is behind Limpopo’s vaccination numbers?

He warns that vaccination figures for those fully vaccinated in this group will be at least 10% or more lower than the single-dose figures to the end of this month.

“The difference will be even bigger for the 50 to 59 age group [which was only eligible for vaccination later],” he adds.

Of Limpopo’s success with the most vulnerable age group, Bradshaw says: 

Right in the beginning they went from village to village and were strong on community outreach. I don’t think we’ve tried that in all areas.

Literacy and access biggest barriers

Bradshaw doubts that vaccine hesitance or anti-vaccination sentiment was behind the overall low vaccination figures in the older age groups.

“I think it’s all about vaccination literacy and access. The government’s literacy campaign virtually coincided with the start of vaccination. They’ve been late with the entire programme. In December last year, scientists like [Madhi] and Glenda [Gray, CEO of the SAMRC] had to rattle the cage just to get them to think about vaccination. This duo wrote a paper for the SA Medical Journal where they literally had to say, ‘this is what you have to do to get a vaccination programme … here are the 10 essential steps’,” says Bradshaw.

Asked if she knew of any specific subgroups and geographic districts where vaccine uptake was particularly low, Bradshaw says there was a paucity of data: 

but it seems to me that uptake in the white areas is greater than in other areas, and I think vaccine literacy probably plays a big part in that. It’s been left to government across the country and it’s very uneven, with several areas where not nearly enough is being done.

She expresses concern about townships, but cautions that her knowledge centres on the Cape metropole townships.

“Khayelitsha [Cape Town’s biggest township with an estimated 1.2 million inhabitants, had a very bad first wave with a much lower second wave, but the third [Delta] wave hit them hard again. Nobody’s reached out to townships like this to make sure they get full access,” she says.

Waves hard to predict

Bradshaw parts company somewhat with Madhi on the likelihood of a fourth wave by Christmas.

“I’m not convinced there’s going to be a fourth wave – it all depends on the variants and it’s so random. I honestly don’t know that you can predict it from our data. I think the nature of viruses is they mutate. So, yes, it’s going to happen sometime. There seems to be a lot of certainty about it, when I think there aren’t really grounds for it. You have to see it against a backdrop of [a] heck of a lot of people infected, so the level of immunity when combined with vaccination is growing,” she says.

“She’s right,” Crisp agrees: 

If Delta remains dominant and there is no new variant, there will be protection via both vaccination and from the natural immunity in people who’ve been infected and recovered. But this virus mutates and we need to be on our guard.

Asked if South Africa was “sort of okay until next winter”, Crisp’s answer was an unequivocal “no”.

“From where I sit, we need to be prepared for anything. We cannot make rapid plans if things change – we need to be ready now. As much as I pray for a reprieve for our colleagues at the coalface, I am afraid that now is the time to fortify defences, not slack off and hope for the best. Better to be pleasantly surprised than caught off-guard,” he says.

“The message must be clear: vaccinate to save the health system and to save lives.”

Hard to quantify

While there is wide agreement that vaccinations have and will continue to save lives, the exact impact is hard to quantify.

Dorrington says he has tried to tease out the impact of vaccines on excess deaths, using the numbers of people testing positive and comparing the trend over time of the 60-plus age group excess deaths with that of the under-60 age group deaths.

READ: Vaccination rate should not determine lockdown level – virologist

“Neither produced results that I had much confidence in or made much sense provincially,” he says.

He said the reasons for this probably included “significant uncertainty” around the estimates of confirmed cases and the very different pattern of confirmed cases, by age, between the second and third waves.

More teens getting infected

Meanwhile, Dorrington says that the highest current percentage of Covid-19-positive people is in the 10- to 19-year-old age band.

Health Minister Joe Phaahla recently acknowledged a decision by the health products regulator to approve Pfizer’s Covid-19 vaccine for children older than 12. He said that, depending on the number of adults vaccinated by the end of next month, government would review its policy on vaccinating people younger than 18.

“Even though we know the Pfizer vaccine has been approved [for children], we want to remain focused on the high-risk people as of now. If we can reach 70% of the 50 and older age group [fully vaccinated], when the next wave comes, our hospitals will not be as overwhelmed as they have been,” he said.

READ: Take the jab now: it’s the only way to get herd immunity

Phaahla said government was aware of pressure from schools to have children vaccinated. Other factors that would be considered were the local government elections on November 1, which could result in a high number of transmissions and an excess vaccine supply that would allow the under 18 age group to be targeted.

“We think it will be very risky to be all over and start just vaccinating people everywhere. Let’s manage the schools and keep on pushing the elderly to get vaccinated,” he said.

This article was produced by Spotlight – health journalism in the public interest.

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