Vaccination roll-out update; with Deputy Minister

Meeting report

The Chairperson conveyed her condolences to Member of Parliament, Ms Dimakatso Maleka, who lost her brother the night before. She congratulated the new Minister and Deputy Minister.

Deputy Minister overview
Health Deputy Minister, Dr Sibongiseni Dhlomo, communicated the apology of the Minister, who was briefing the National Coronavirus Command Council on what the Department would brief the Select Committee in this meeting.

In February 2021, there was concern about there being enough vaccines and enough vaccination sites in the country. Presently, there were enough vaccines and more vaccination sites had been opened, including in shopping centres, drive-throughs and pension pay-points. Hesitancy was posing a challenge to the uptake of vaccinations. The President made a pronouncement a few weeks before that he wanted to see the country vaccinate up to 300 000 South Africans per day. The country reached 275 000 on 21 July 2021, hopefully the country would get to 300 000. Recently it had gone down to about 175 000 vaccinations per day. This was concerning. The uptake in the over 60-year-olds should ideally reach over 70% . The uptake in the group 50 years and above had not been impressive. There had been minimal uptake in the population group over 35 years. There had been a noticeable gender difference in the uptake with more females than males vaccinated. The vaccine prevented life-threatening complications. In other parts of the world, stadiums had started to open.

Mitigating the impact of the COVID-19 pandemic: Vaccination Roll-out
Deputy Director General (DDG) Dr Nicholas Crisp of the National Department of Health (NDoH), responsible for coordinating the COVID-19 vaccination roll-out in South Africa, presented:

Vaccination Programme: Four main areas of action
1. Vaccine supply security
2. Population demand generation
3. Execution vaccination administration
4. Oversight, planning, marshalling resources and communication

What shapes vaccination uptake
- What people think and feel: perceived risk, worry, confidence, trust and safety concerns.
- Social processes: Provider recommendation, social norms, gender norms and equity, information sharing, rumours.
- Motivation: readiness, willingness, intention and hesitancy.
- Practical Issues: vaccine availability, accessibility, costs, service quality and satisfaction, requirements, incentives and intervention fatigue.
- Registration: Schedule appointment, consent, accept vaccine, delay, refuse.
- Vaccination: Consent, accept vaccine, delay, refuse
- Main determinants of social gradient of health in South Africa: Income, place of residence, disability and nationality

Key strategies for driving demand
- Create value: enable users to be informed and feel supported from registration to post-vaccination
- Reduce the social gradient of uptake by empowering local organisation and mobilisation.

Refer to presentation for graphs.

Conclusion
- The programme has lost momentum and needs everyone to create demand from the public
- Besides the non-pharmaceutical interventions (NPI) vaccination is the major mitigating intervention of the impact of the COVID-19 pandemic
- Covid-19 mutates frequently and immunity from one variant may not be effective against the next variant
- Protection of the most vulnerable (older persons) is the strategy to keep people protected from severe illness, hospitalisation and death
- Herd (or community) immunity will remain illusive and requires the majority of the population to be vaccinated and immune
- Covid-19 will be with the world for years to come

Discussion
Mr M Bara (DA, Gauteng) noted that he was going for his second vaccination the following day; he hoped that everyone would take the opportunity to get the vaccinations as required. On the news the previous day, there was a 12-year-old who died of COVID-19. He was aware of three 17-year-olds infected with COVID-19. Given the slow uptake, at what point would it be decided that vaccinations be opened up to all age groups? His concern was that, if a 12-year-old passed on because of COVID-19, it meant that COVID-19 had no ‘age-limit.’ His other concern was that people were still dying despite the vaccine being available. What methods were being used by NDoH to communicate with people in rural areas about where to get vaccinated.

Ms S Luthuli (EFF, KZN) noted that in KwaZulu Natal the number of infections were increasing. What strategy was in place to ensure that the numbers go down? There was a lot of fake news on social media about the vaccines which was creating panic. What was NDoH doing to clarify and respond to fake news? A lot of people were not getting vaccinated because they were scared. Some of the fake news said that people would ‘die two years after getting the vaccination.’ She requested statistics of COVID-19 infections amongst the vaccinated population.

Ms D Christians (DA, Northern Cape) said that the number of COVID-19 infections had increased amongst children. The infections also seemed to be getting more severe amongst children. What was being done to bring more information to schools, the general public and parents so that parents could safeguard their children? Those rates had increased in the Northern Cape as well as in other provinces. Dr Crisp had stated that in the Northern Cape, the vaccination rate stood at 37% . That was extremely problematic. Taking into consideration the scope and vastness of the Northern Cape, it was the province that was ‘not going to the people.’ What was being done to reach people in rural areas? At the beginning of the vaccination roll-out it was stated that the ‘vaccine should go to the people and not the people to the vaccine.’ It was imperative that, especially in rural provinces, the provincial health departments needed to ensure that the vaccine went to the people.

The public was extremely emotional and frightened of getting their COVID-19 vaccinations. What was being done to allay the public’s fears? Government had not embarked on an information campaign to allay the fears of the public. This was one reason that the vaccination rate was so low. The following questions were often asked, due to limited information, ‘Despite the vaccine, people still get infected.’ ‘What was the vaccination’s effectiveness against other mutations?’ ‘What was the likelihood of the need for booster shots in the future – was the country geared for that?’ There were questions about herd immunity, such as how many people needed to be vaccinated to achieve herd immunity, especially against the Delta variant?

Mr E Nchabaleng (ANC, Limpopo) noted the reference made to Europe’s vaccination levels and re-opening of in-person stadium games. It was encouraging, what would it take to get there? He had got his two doses. Over the previous weekend, he was impressed to hear that Limpopo Health Department was arranging at a district level to establish vaccination sites in various institutions. It was impressive that ‘the vaccinations were going to the people.’ ‘To the Limpopo Health Team, well done, keep it up!’ He noted that only two vaccines were being used in South Africa; what was the progress in getting other vaccines from other countries? Did South Africa need them or not?

Ms N Ndongeni (ANC, Eastern Cape) asked what NDoH would do if the vaccine registration numbers continued to decrease. Was there a plan? Since there were enough vaccines, could additional sites be opened up in rural areas, such as in schools. Many of the existing vaccination sites in rural areas were too far; many people did not have enough money to travel to the sites.

The Chairperson thanked NDoH for what they were doing. South Africa was currently in the third wave of the COVID-19 pandemic; reports suggest that the country was awaiting a fourth wave. Were there plans in place to ensure that the fourth wave was contained or controlled better than the current or previous waves? Reports indicated that 28 million of 39 million adults would need to be vaccinated to meet the government’s target to vaccinate 70% of the adult population by December 2021. The Department of Health recently reported that vaccination registration numbers were decreasing, which was concerning. How was it planning to reach its population vaccination target by the end of 2021? What would it do if the vaccination registration numbers continued to decrease? How was NDoH monitoring the adverse effects, if any, suffered by recipients of vaccines used in South Africa? What were the adverse effects and how severe were they? There were reports on WhatsApp and Facebook indicating that ‘some people died after receiving the vaccination doses.’ Was there empirical data to substantiate or refute those reports? How was NDoH dealing with the social media reports? These reports might be fuelling the vaccine hesitancy amongst certain members of the population. There were more females than males getting vaccinated – what could be the reason behind the low vaccine uptake among males?

During July 2021, the country witnessed violent protests in KZN and Gauteng. These violent protests resulted in vandalism and looting of public and private property, including pharmacies. The South African Pharmacy Council (SAPC) reported that approximately 931 pharmacies had been destroyed and 80% of those were based in KZN. This would lead to a situation in which many people were unable to access their medication. It would be helpful for the Committee to have some sense of the damage caused by the violent protests in the two provinces. What was NDoH's initial understanding of the extent of the damage? More importantly, what were the concrete plans for getting those facilities operating again, especially for people with chronic diseases? There seemed to be an increase in the number of COVID-19 cases in KZN, could this be linked to the large gatherings during the unrest? Was there a targeted approach to accelerate the vaccine programme, especially in the affected provinces of KZN and Gauteng? NDoH reported that it wanted to inoculate 1.2 million people in the health sector before moving on to other population groups. What was the current number or percentage of healthcare workers fully vaccinated against COVID-19?

She echoed the concerns about COVID-19 cases in children in the country. She asked that NDoH share research done and the impact of COVID-19, especially the Delta variant, on children. She was glad to see that the Overberg region, where she was based, was amongst the top five areas for vaccination roll-out in the country. She urged NDoH to ask the top regions/district municipalities to share best practices, so that those practices could be communicated to other districts. She urged Members to set an example and encourage people to get vaccinated. No one knew how the virus would impact the country when it first presented. A lot of lessons had been learnt since. Faith fraternities and traditional healers played a big role in influencing the uptake of the vaccinations. Facts needed to be given.

Deputy Minister response
Deputy Minister Dhlomo stated that in his previous position as the Chairperson of the Portfolio Committee on Health, the Committee had been about to embark on an oversight visit to KZN and Gauteng. He had missed that and he had not had a briefing on the situation. The officials accompanying him would be able to respond to that.

He responded to the question about social media influencers. He encouraged Members of Parliament to share their experiences of getting vaccinated, which might encourage people to do the same. The scientific world was saying that the vaccines were safe to use for those older than 18 years. Children could not be vaccinated at present.

The communication of information was a priority of the new Minister. The Minister had encouraged everyone to put their heads together and maximise communication. Best practices from Limpopo suggested that the role of faith leaders was important. Leaders had openly taken the vaccine which may have contributed to the positive vaccine uptake in Limpopo.

On the recent unrest in KZN and if it had contributed to the upsurge in COVID-19 cases in the province, he replied that it was a possible cause.

There was information coming in from scientists stating that if one had the first dose, one was close to 80% protected against getting a severe COVID-19 infection. This was good news.

He responded to the question about protecting children, saying there were other methods besides that of the vaccine. There were a number of success stories in Limpopo, which was a rural province. He was wary of the information out there which caused vaccine hesitancy amongst South Africans – some measures had been taken against that but much more needed to be done. The opening up of the economy, tourism and sporting activities depended on this. Countries that were close to herd immunity had sporting events in stadiums where spectators sometimes wore or did not wear masks. South Africans were still encouraged to wear masks after being vaccinated. Even if they got infected, it would not be a severe infection. In winter time, people who were vulnerable usually took a flu vaccine. It did not stop them getting the flu during winter, it stopped them having a severe case of flu and prevented the need to be admitted to the intensive care unit (ICU). The same principle applied to the COVID-19 vaccine. What the country did in the next four months with the vaccination roll-out would determine what would happen to the country’s chances of tourism, business and sports activities in 2022.

Across the world, females were more likely to seek healthcare. Males were less likely. Females were more likely to go for health checkups at clinics. The same principle and trend was seen in the case of the vaccines, where more females than males had been vaccinated.

Health Department response
DDG Dr Nicholas Crisp stated that NDoH was very impressed that rural areas had performed so well, especially in the Eastern Cape and Limpopo. This was likely because those two provinces had tailor-made their strategies based on understanding how the communities behaved. Those lessons had been shared with the other provinces. There had been a very good exchange of information in the last ten days. The Western Cape had a dedicated meeting with Limpopo. Limpopo had made a presentation to NDoH to explain how they managed to get their figures up.

The main way to reduce infections was to avoid gatherings, wear a mask and wash hands. That would be the mainstay. Those messages needed to continue to go out. The message was not clear that everybody needed to continue wearing masks, avoid big gatherings and socially distance. The country was not at a point where it could let its guard down. Fake news was a very pertinent concern. The Department did respond and rebut fake news as often as possible. It was extremely difficult on social media. The Department would encourage everybody who had stature and status in their communities to assist by rebutting such news. Information could be sourced from the Department of Health and brought to the attention of anyone spreading false stories. It was true that people who had been vaccinated could still get infected. One's chances of getting severely sick after having the vaccination were extremely small. As outlined by the Deputy Minister, it was the same with the flu vaccine. There could be breakthrough infections in those who had been vaccinated but the chances of being severely ill were reduced.

The country did not have vaccines that were registered for use for people under the age of 18 years. Most countries were not doing that yet. There was a lot of research going on all over the world. The Department had received a presentation from one of the vaccine manufacturers, showing the research they were doing on vaccinations in children. NDoH did expect to get some research findings and proposals in the next two or three months, on children between the ages of 12 and 18 years. There was research being conducted amongst the group aged two to 12 years. That would not be ready before 2022. In the meantime, what needed to be done was to get as many adults vaccinated as possible until it was ensured that vaccinations were safe enough to be used in children. NDoH was anticipating that vaccines would be required for both children and for booster doses in the future. Currently there was no evidence that booster doses were needed, research was being conducted in South Africa and other parts of the world. Knowing how other vaccines behaved and how immunity waned over time, it was likely that annual booster doses would be needed in the future. That needed to be planned for.

The Northern Cape had a unique challenge and that was the vast distance between settlements. When NDoH planned the original roll-out to the Northern Cape, the plan was to use Johnson and Johnson (J&J) vaccines. This would have meant that it had to administer only one dose per person in isolated areas. When the country did not have J&J vaccines, the Northern Cape Health Department had to completely redesign its delivery system. It meant changing the fridges, needles and syringes to accommodate a far more difficult vaccine to work with. It had to be at colder temperatures and required two doses. Now that the country had J&J vaccines, these were being prioritised for rural areas, where it was extremely difficult to get back to the same people twice.

It was absolutely true that people were frightened, there was a lot of scaremongering. It was important to counter inaccurate information. As leaders in various communities, Members of Parliament needed to make their voices heard to overcome that.

On herd immunity, he had read an article that morning about herd immunity in the United States of America. There were formulas of how herd immunity could be calculated based on the ‘r’ factor, the replication of viruses. The truth was that they did not know, especially because the number of new variants could not be anticipated. The Department would like to administer 35 million doses (25/26 million people) by the end of the year. At the rate of current vaccinations, it would be a tall task. The country had the capability and vaccines to do it, but people needed to see the value of vaccinations and be able to get to the vaccination stations. The Department was aiming to vaccinate at least 70% of the adult population. At the end of the day, these were just numbers, and the ‘human element’ could not be anticipated. There were at least two sites that were open in each province over weekends, some of the provinces had more than that.

There were currently two vaccines in the country, the mainstay being Pfizer, and the second being J&J. The Department had done a lot of work on Sinovac and AstraZeneca. AstraZeneca was the first vaccine received in South Africa, that was during the time of the Beta variant, it was shown that the Beta variant did not respond well to the AstraZeneca vaccine. Thus, the country did not proceed with AstraZeneca. However, AstraZeneca did seem to be effective against the Delta variant – not as good as J&J and Pfizer, based on the figures but it did provide some protection. Sinovac was in a similar position; it had reasonable coverage and immune response to the Delta variant. It was a vaccine that the country was looking at as a third option. It was registered, with conditions for entry into South Africa, including some additional research. The country was busy with that research together with the Medical Research Council (MRC) and NDoH of Science and Innovation. They would conduct a ‘rolling review.’ There were other vaccines but they tended to be very expensive.

All provinces were opening more sites all the time. The Department, together with provinces and the private sector, analysed where there were gaps, i.e. where there were lots of people and few vaccinations. That information was passed to the provinces and private sector to look for additional sites that could be viable. Not all vaccination sites were in health facilities. There were many in shopping centres, schools, tribal offices, local municipal offices. It depended on where the province was able to secure sites that were accessible. He appreciated the compliments given by the Chairperson about NDoH, particularly given the flack they often received from the media.

Globally, countries that were part of the World Health Organisation’s (WHO) Assembly monitored all adverse events relating to all vaccines. The Department had been monitoring events following immunisation for many years in South Africa and were part of that global reporting structure. When such an event occurred it was reported and went through the National Immunisation Safety Expert Committee (NISEC), a group of independent individuals who examined such events and determined if there was a causal link between a vaccine and the outcome or whether it was just an association that happened at the same time. That information then went to the South African Health Products Regulatory Authority (SAHPRA), that reported globally, contributing to the global knowledge of what types of adverse events/side effects happened from vaccines. SAHPRA had put together a website that would go live later in the week. That website contained a lot of information about adverse events, how to report them, what had been reported so far and issues around the deaths that had been reported. SAHPRA reported the day before that of the 29 deaths that occurred after vaccination, so far not one had been determined to be causally linked to either of the vaccines. The Department wanted that information in the public domain so that it was transparent.

Approximately one million healthcare workers had been vaccinated to date (that included the broader definition of healthcare workers, expanded toward the end of the Sisonke study). Students entering their clinical practical years were still being vaccinated. South Africa was sharing best practices which was starting to bear fruit. A more intensive plan about influencers and faith leaders had taken place over the previous couple of days. The Department was working closely with Government Communication and Information System (GCIS) and a group of people designated from Business for South Africa (B4SA) to have the private and public sectors working closely on a programme of communication.

DDG Dr Anban Pillay, of NDoH of Health: Health Regulation and Compliance, responded to the question about COVID-19 and the younger population. The first variants of COVID-19 predominantly affected the adult population more than children. However, with the emergence of the Delta variant, that finding had been changed significantly. Many more children were being infected and hospitalised. The thinking at the time was that the COVID-19 virus attached to the ACE2 Receptor within the respiratory tract and multiplied causing infection. This receptor was not as well developed in children compared to adults, consequently that was thought to be the reason behind the difference in infection rates. The Delta variant had changed a lot of that thinking. With the Alpha and Beta variants one presented with a cough and loss of taste and smell, in the case of the Delta variant that was less common. It seemed that headaches, fever and runny nose were dominant symptoms. There were significant differences with the Delta variant, specifically how it presented and the age groups it affected. The vaccines were not approved for use in persons below the age of 18 years. There were a number of studies taking place and hopefully those would be positive and allow the vaccinations to be extended to the younger population.

He responded to the questions about the fourth wave and situation in KZN. The country was still in the throes of the third wave. The inland provinces had largely experienced the brunt of the third wave. Gauteng had a large third wave which also affected the Free State, North West province, Northern Cape and Limpopo severely. The coastal provinces were now experiencing it, being the Western Cape, Eastern Cape and KZN. The Department’s approach, be it the third or fourth waves, was to increase the testing using both PCR testing and the rapid antigen tests. Both the tests would continue to be used. When people were identified to be positive they were encouraged to go into quarantine. Those that may be exposed were encouraged to isolate. A lot of contact tracing took place. The problem was that those that were infected needed to communicate to NDoH who their close contacts were – and people seemed to be reluctant to share that information. It was not intended to be punitive, it was to encourage people to go into isolation as they might be infected. Mask wearing, social distancing and discouraging gatherings (particularly funerals and close contact). The Delta variant was highly transmissible relative to all the other variants. It was unknown what other variants would emerge globally or in South Africa. The best way to protect oneself was to use masks, social distance, avoid gatherings or other behaviours that would result in the excessive spread of the virus.

He clarified that the vaccines were not sterilising – being vaccinated did not mean that one could not get infected. If one was exposed to someone that was infected, and in close contact with them, one would breathe in the viral particles, which would land in your respiratory tract and eventually start multiplying. The benefit of the vaccine was that one’s immune system was being trained to respond to the virus when it started multiplying. If one got infected, after having the vaccine, ones body was able to mount a response to the infection, which prevented one from getting severely ill or hospitalised. That was the main benefit of the vaccine.

The Department of Health in both KZN and Gauteng had been able to manage the situation and at this stage a number of facilities had opened. There were a few that were damaged and would require some repair and maintenance in order to get back online. Staff at those facilities had been moved to other facilities in order to be able to deliver services, which included providing access to medicines and other treatments that might be required. It had set the country back with vaccinations and routine health services, particularly as many communities needed to travel greater distances due to the unrest and violence.

Further discussion
The Chairperson asked about the positive cases seen in children and the relationship between the Departments of Health and Basic Education. Parents and teachers had expressed concern about the Department of Basic Education proposal to reduce the recommended social distance from one metre to half-a-metre. Taking into consideration that the virus was affecting children, what was NDoH’s contribution in this proposal? What impact would it have in schools?

Deputy Minister Dhlomo stated that he was listening to some other interviews where people were debating if schools should be closed. The closure of schools was really a no-go option, despite the challenges faced, as children would be far behind in their learning if schools were to close. Non-pharmaceutical protocols would need to be relied upon where the vaccine could not be administered. Non-pharmaceutical measures needed to be preached to that population. Some schools were challenged by space, a rotational programme might be most appropriate, where schools were open for longer hours. That would impact social distancing. The Department would rely upon ongoing discussions.

The Chairperson said that the Deputy Minister’s response would likely ease parents and teachers concerns – that there were ongoing discussions on the matter between the Departments of Health and Basic Education.

The Deputy Minister and Department were excused.

Committee Reports, Minutes, Programme: adoption
The Committee adopted its Committee Reports on the Department of Health Budget Vote and the Department of Social Development Budget Vote

The minutes of the closed Committee Meeting of 15 July 2021 were adopted. This meeting dealt with the consideration and finalisation of the National Youth Development Agency (NYDA) Board recommendations.

The Committee adopted its 3rd Term Programme

The meeting was adjourned.