In July 2000, then president Thabo Mbeki opened the International Aids Conference in Durban with a speech that ignored well-established facts and doubted that HIV caused Aids. With the world watching, he walked out on 11-year-old HIV activist Nkosi Johnson, who from the stage was pleading with him for access to antiretroviral (ARV) treatment.

At the time, a month’s supply of ARVs cost about R2 400, an amount out of reach for most people who needed medicine — like Johnson. Experts estimate the Mbeki administration’s Aids denialism and delayed response cost roughly 330 000 people their lives unnecessarily between 2000 and 2005.

But the government’s HIV dissidence at that fateful meeting achieved exactly the opposite of what Mbeki intended: instead of leading to delegates casting doubt on HIV science, it started a “treatment revolution”, with experts vowing to get treatment to everybody. 

Twenty-five years later, after long-standing activism and a famous 2002 court case that forced the government to provide HIV-positive pregnant women with medicine that stopped them from infecting their unborn babies, and which in the process mobilised access to treatment for everyone, we’re there.

South Africa now has the biggest HIV treatment programme in the world, with around 6-million people on anti-HIV medication — and it’s free. New HIV infections have dropped by 75%, from about 1 463 a day in 2000 to roughly 370 daily infections now.

In a quarter of a century, our understanding of HIV science has evolved — and along with it our toolbox to fight the epidemic. 

Learning about different ways in which the virus attacks the body meant newer, better drugs with fewer side effects could be developed. ARVs became cheaper as generic licenses were issued to companies who started to compete for the market.  

U=U — having undetectable levels of virus in your body because of sticking to treatment, and it therefore being untransmittable — became a thing. Medical male circumcision helped to slash infections in men (because it removes tissues with the cells the virus loves to invade). And medicine to prevent HIV-negative people from getting infected became available — first a pill, a monthly ring, then a two-monthly jab and now a six-monthly shot that’s in the process of being registered with regulators. 

But the epidemic is not over, Mitchell Warren of the international HIV advocacy organisation Avac told Bhekisisa this week. 

“HIV is still an issue,” he says. Despite three-quarters of people with HIV being on treatment, “we still have 1.3-million new infections [in the world] every year”. Although that’s about half of what it was 15 years ago, “the worry is that the declines in the past five or so years have begun to plateau”, so the number of new infections isn’t coming down fast enough to end Aids as a public health threat by 2030 — and that’s “a cause for great concern”. 

That’s why, says Warren, the six-monthly anti-HIV injection needs to become widely available. “The world cannot afford to squander” this chance, he says.

For World Aids Day 2024, we’ve put together a timeline of how South Africa’s HIV response has evolved over the past 25 years — and 15 years since the government vowed to “start to turn the tide in the battle against Aids”.

Click on and drag the event showing on the timeline or use the scroll bar below the cards. Hovering over a card will show our stories linked to events from the past 15 years. 

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In 2018, at the last high-level meeting on the fight against tuberculosis (TB) world leaders adopted aspirational goals to end TB by 2030.

Five years later, the talks at the United Nations General Assembly have been on again — in the shadow of much of the progress in reducing the burden of TB since then having been reversed because of the Covid-19 pandemic.

Despite at least some progress in tackling TB over this period, none of the targets set out in 2018 have been met — something the delegates at today’s discussion say is “deeply concerning” in a draft declaration. 

In 2021, about 10.6-million people contracted TB and 1.6-million died. But TB is a preventable and curable disease — if it’s caught early. Worryingly, the number of cases of  multidrug-resistant TB (MDR-TB) rose by 3.1% in 2021, which the declaration says poses “a critical challenge that could reverse the progress made against the disease”.

MDR/RR-TB, a type of TB for which standard treatment doesn’t work, often develops because people get onto treatment too late — be it because of unfair pricing or struggling to get tested. 

In an unprecedented move, South Africa’s Competition Commission announced last week that it will investigate the American drugmaker Johnson & Johnson (J&J) for the high price it has been charging the country for bedaquiline, as well as for extending the tablets’ 20-year patent until 2027 to block cheaper generics from entering the country.

Bedaquiline is used to treat MDR-TB and is mostly used in combination with other medicines. It has to be taken for six months and is considered a game changer because it has replaced treatment — up to two years of long, painful injections with serious side effects (such as hearing loss) — with lower cure and higher death rates.

We’ve put together three people’s stories on how TB — and the struggle for access to medicines — has affected their lives. It’s accounts like these that underscore the importance of leaders being held accountable for following through on commitments made at high-level discussions such as today’s.

I survived the most deadly type of TB, but it cost me a lung 

“One day in 2012 I started coughing up blood. It was a Monday.

“My doctor sent me to a public clinic where they took my sputum [sputum is another word for phlegm — the mucus that people cough up from the lungs]. I went back on the Friday and they told me I had multidrug-resistant tuberculosis. It meant that the usual TB treatment available then [a course of antibiotics for about six months] wouldn’t have worked for me. 

“The doctors and nurses assumed I had had TB before and had stopped taking my medication, and that’s why I got this form of the disease. They blamed me for it. 

“But I have never been on TB medicine before. I had contracted a drug-resistant bug from the start.  

“About three days later, I went back to the clinic to start my treatment. 

“When I saw the doctor, he had to go look at a flip chart behind the door [to see how to treat me]. 

“I was shocked that the chart seemed hidden away. It showed me that the health workers in that clinic didn’t really care to know more about the condition. 

“It was as if they expected people with MDR-TB to die. 

“I had to get an injection of kanamycin [an antibiotic] every day for nearly six months [along with four other drugs, which had to be taken for 18 more months].

“Towards the end of my treatment, the drugs stopped working. The doctors told me I now had extensively drug-resistant TB [also known as XDR-TB], a very serious variant of the disease that wouldn’t respond to even the most powerful TB medication clinics had at the time.  

“They had no idea why this happened. For months I had responded well to the treatment, they said. 

“The only option was to take a drug called linezolid. But it wasn’t widely available in the country at the time and you had to wait for about a month to get it. 

“By the time I got my first dose of this medicine, the TB bacteria had already destroyed my one lung. 

“Fearing that the disease would spread [to other parts of my body], the doctors removed my damaged lung. 

“I was put on a new course of medicines, which included bedaquiline, delamanid and linezolid. Eventually, after four years of TB treatment, I was cured.

“I nearly collapsed when my doctor phoned me with the news, because I had started thinking that I’ll have to take up to 40 tablets every day — like I had done for most of my treatment period — for the rest of my life. 

“I’m afraid of contracting the disease again. I would rather die than to go back on all that  medication [even though treatment for MDR-TB is only nine months today].  

“My journey with TB pushed me into activism. Many people still think that it’s only those with HIV who can get TB. 

“But everyone is at risk. As long as you can breathe, you can get TB. As an activist, I believe that we need to change attitudes and educate people on the disease as a community.” 

Although TB is curable, its consequences linger long after treatment for 20 to 30% of TB survivors; in poorer countries the number might be even higher. The tentacles of the disease reach beyond just the airways, though — scientists are researching how post-TB lung disease affects other body parts ( joints, muscles and the spine), mental health and patients’ quality of life. 

I took on Big Pharma and won 

“I remember getting sick in 2010, around the time of the soccer World Cup. 

“I was a university student at the time. I did not have symptoms like coughing and sweating [which are typical signs of TB], but I was losing weight dramatically. 

“At the campus clinic, the nurse could not find what was wrong with me, so she told me to go see a private doctor. 

“The doctor could not find what was wrong with me either. He suggested I get tested for TB.  

“The test results came back after three weeks. They were negative. 

“I was eventually diagnosed with TB after the doctors did an X-ray of my chest. They found holes in my lungs. I started treatment [with a series of antibiotics] immediately. 

“The medicines made no difference.  

“The doctors tested me a second time and found that I had MDR-TB. They explained what it is [a type of TB for which the normal antibiotics don’t work]. I didn’t care. I just wanted to get better. 

“The nurses told me I couldn’t go home because I could infect other people. 

“I had to start a new treatment course with different antibiotics. After four months of taking these medicines, I woke up one morning and could not hear. 

“One of the drugs [that was used to treat my form of TB], kanamycin, can cause deafness. No one had told me this before I started [taking the medicine]. My hearing loss was permanent.” 

Kanamycin is given as an injection deep into a muscle, which is painful. The treatment for MDR-TB has since changed and a drug called bedaquiline is now used. Hearing loss is not linked to taking bedaquiline.  

“At the time I lost my hearing, I had developed pre-extensively drug-resistant TB (pre-XDR-TB). [This is a forerunner to a form of TB in which very few of the drugs used to treat the disease will still work.] 

“I was moved to [a special] ward. Doctors also found an abscess [a pocket full of pus] on my one lung. They cut it away in an operation, but it left me with broken ribs and a collapsed lung. 

“After nine more months of treatment, the medication stopped working again. I now had full-blown XDR-TB. My doctors said I had a 20% chance of surviving.

“But there was [a new] drug they could try, they said. It was a medicine called linezolid. 

“I had nothing to lose. I could choose between dying slowly without medication or taking a chance on the new drug.

“Nearly four years after I was first diagnosed with TB, I was cured of XDR-TB.”

Voices from civil society groups are important in the world’s TB fight. For example, in March, the Indian government rejected an application from J&J to extend their patent on bedaquiline. One of the things that helped the officials reach their decision was a petition Phumeza Tisile, who had extremely drug resistant (XDR-TB), filed along with Indian TB activist Nandita Venkatesan in 2019. Without the patent that allows J&J to be the only manufacturer, generic versions of bedaquiline can now be made by other pharmaceutical companies — which means the medication can sell for much cheaper. 

I survived TB five years ago but the stigma still follows me around

“In 2010, my fiancé passed away from tuberculosis. His doctors told me to go to the clinic immediately if I had symptoms like his.

“So in 2012, when I started coughing and losing weight, I got tested. I was diagnosed with MDR-TB, a form of the disease for which one of the normal antibiotics, rifampin, does not work.

“I was admitted to the Fort Grey TB hospital [which has since been closed] for three months. 

“When doctors tested me again [after this treatment], they found I had extensively drug-resistant TB (XDR-TB). [This is a form of TB in which very few of the drugs used to treat the disease will still work.] I only started recovering once I was given [a new type of drug called] linezolid. 

“In 2015, I tested negative for TB. I was finally discharged.

“That same year, I moved to Cape Town. I felt fresh and healthy. I even gained weight.

“The feeling didn’t last long, though. A few months later, I started coughing up blood while on my lunch break at work.

“I was rushed to hospital, and a chest X-ray showed that I had an abscess [a pocket filled with pus] on my left lung. The abscess had been there for a long time.

“Again I was admitted. This time around I spent two years at Brooklyn Chest Hospital [in Cape Town]. The XDR-TB was back. 

“Doctors told me they couldn’t operate on my lungs to remove the abscess [because my body was too weak for surgery]. So they taught me how to do postural drainage [lying or sitting in a series of positions while coughing to get fluid out of the lungs]. 

“I did this three times a day.  

“I was cured of TB in 2018. But my lungs have been damaged and I still struggle to breathe. 

“I’ve not had a steady job since my first diagnosis in 2012. Even though I was cured in 2018, I had to go for regular check-ups for two years afterwards. 

“I had work for a time in 2020, but the stigma of TB still follows me. 

“Employers are hesitant to hire me and they want written confirmation from my doctor that I’ve been cured.

“The state of my lungs also limits where I can work. For example, I can’t work in cold places, because my lungs won’t be able to cope. 

“Two years after my last check-up, I’m still looking for work. My age is starting to worry me. I’m turning 36 this year — and the gap in my CV is getting longer.” 

A 2022 study in South Africa found that TB   makes poor people even poorer. Like Zine Konwayo, people diagnosed with TB often struggle to earn an income because they can no longer do physical work or have to go for lengthy treatment. The cost of being ill with TB equals, on average, 58% of a patient’s individual income, which includes spending money on transport to get to treatment centres and buying food. 

But TB rarely affects just the individual. For households caring for a TB patient, the disease amounts to 39% of the home’s collective income. Even though treatment for TB is free in South Africa, buying nutritious food and struggling to get a disability grant make life harder for many TB patients who are already vulnerable.

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1. Desperately ill patients at government hospitals don’t get the specialist care they need. 

2. Other doctors become overworked since they’re forced to pick up the slack for their corrupt colleagues.

3. Specialists-in-training (called registrars) get compromised training as the specialists who are supposed to supervise them aren’t around.

Experts worry that moonlighting could cast a long shadow over the future of specialist care in South Africa.

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In June, the United States (US) government took an unprecedented step. The first African head of the President’s Emergency Plan for Aids Relief, Pepfar, was sworn in. 

John Nkengasong, a virologist from Cameroon and the former head of the Africa Centres for Disease Control, is now the head of the world’s largest government fund to fight HIV. The scientist is, of course, also a US citizen — a requirement for most federal US government positions — and it’s not his first time working for an American government agency. Nkengasong worked for the US Centres for Disease Control (CDC) from the mid-1990s until the mid-2000s in Washington, DC and Abidjan in Côte d’Ivoire.

Pepfar has invested more than $100-billion in fighting HIV in more than 50 countries and was created in 2003 during the administration of former president George W Bush. In 2021, the fund spent R7.5-billion in South Africa; the programme is the largest contributor to the Global Fund to Fight Aids, Tuberculosis and Malaria.

But Nkengasong’s appointment comes at a challenging time when the “ongoing COVID-19 pandemic has overshadowed HIV” and current Pepfar legislation is ending in 2023, according to the Pepfar Extension Act of 2018.

Pepfar has also not been run without contention.

The fund was initially controversial because of Bush’s Republican government’s strong support for conservative, non-evidence-based approaches to curb the disease, such as provisions that prevented organisations from receiving funding if they supported the decriminalisation of sex work and favouring projects and governments who supported abstinence from sex before marriage as opposed to condom use.

But Pepfar’s policies have since evolved and today the fund is widely credited with having played a meaningful role in making antiretroviral treatment available in Africa and a consequent decline in HIV-related deaths.

Because the programme also invests in the upskilling of health workers and improvement of health systems, its impact stretches far beyond HIV: studies have found that, compared to countries who don’t receive Pepfar funding, Pepfar-supported countries showed significant drops in deaths among children below five years of age, pregnant people and those who give birth between 2004 and 2018.

Such countries also showed a decline in general mortality rates (so also deaths not specifically related to HIV) and increases in the proportion of children getting vaccinated against childhood diseases.

Pepfar, however, becomes controversial each time there’s a Republican administration, as the party doesn’t endorse self-intiated abortion and then implements a regulation commonly referred to as the “gag rule”, which requires funded organisations to disassociate themselves from pregnancy terminations as well.

President Joe Biden’s Democratic government revoked the rule in January 2021, but the US Supreme Court’s overturning of the Roe v Wade ruling in June, which guaranteed Americans’ consitutional right to abortion, now complicates matters, as Pepfar has to follow US laws, Nkengasong told Bhekisisa’s Mia Malan in an interview for the centre’s television programme, Health Beat. 

Malan asked Nkengasong how he’ll address inequality, one of the biggest contributors to the spread of HIV, what lessons the US can learn from Africa and if Pepfar will intervene to make HIV prevention injections available on the continent as soon as possible.  

American Secretary of State, Antony Blinken, recently visited South Africa and said the United States will treat African countries as equal partners. What lessons can the US learn from Africa?

John Nkengasong: There’s a lot that the US can learn from Africa, including in the field of HIV and Aids.  For example, Botswana, has just announced that they have exceeded the 95-95-95 targets. These targets mean [by 2025]  95% of the population infected with HIV need to know their status, 95% of those who have been diagnosed need to be on treatment, and 95% of those on treatment should have a viral load [the amount of HIV in someone’s blood] below detection level.

That’s a unique situation, especially when you know where Botswana was a few years ago, looking at the burden of the disease. Colleagues in the United States, where I’m based, should be able to go to Botswana to learn how they got there. Also, the Omicron variant was identified by researchers in South Africa [and Botswana]. That’s a lesson for the world, not just the United States, to learn how Africans worked together in a network to identify the emergence of such a new variant.

Before joining Pepfar, you were the head of the Africa Centres for Disease Control (CDC). How will you apply the lessons that you learned during that time, especially with regards to Covid-19, to your new position?

There are so many parallels: know the pathogens, which in this case are HIV and [SARS-CoV-2]. [With] Covid, we still continue to learn the variants and HIV has many genetic subtypes. Having the right policies is also very important. We saw in the Covid response how good politics can enhance a country’s ability to fight the pandemic and how bad politics can lead to [an insufficient] response.

Which African country used “good politics” to respond to COVID-19?

At a regional level, President Cyril Ramaphosa was the chair of the African Union when Covid just hit the continent and I was the director of the Africa CDC. In my 32 years of working in global health, he has, in my view, been the most effective political leader with regards to guiding the continental response. He convened his peers — heads of states — nearly every month to discuss the pandemic. President Ramaphosa was the one who set up the African Vaccine Acquisition Task Force. The task force promoted vaccine acquisition on the continent and resulted in 400-million doses of vaccines being  acquired in Africa at a time when there were absolutely no vaccines for the continent. He also set up the Africa Medica Supplies Platform, which is a platform like amazon.com, where you can  click on products to put them into your basket, pay and go. That’s how we unlocked the challenges that we had early on. That’s good politics.

We now live in an era where there are simultaneous pandemics, as we’ve seen with HIV and Covid. Other pandemics set back efforts to fight  HIV. How will that influence your Pepfar strategy?

We saw how disruptive the Covid pandemic was to our ability to offer services to HIV patients, including enrolling new patients and even dispensing medication to patients who were already on treatment. We also know that Covid infection in HIV patients with lower CD4 counts [a high CD count is associated with a strong immune system and a low CD 4 count with a weak system], makes it difficult for them to fight the virus. That means we have to look at HIV programming [within the context of] how we [can] strengthen health systems that can protect the HIV gains by warding off [new] outbreaks early enough — so that new outbreaks don’t disrupt HIV service delivery. That is one of the cornerstones of my reimagining of Pepfar: how do we strengthen health systems that can fight HIV [and] position them in such a way that they can very quickly be used to respond to new disease outbreaks, that is, monkeypox or Covid-19.

The latest UNAids report pointed to the many ways that inequality fuels the spread of HIV. How will you as the African head of Pepfar address inequality on the continent?

Each time we fail to address inequalities the virus wins.

We need policies that will  result in better outcomes. HIV/Aids is a generational disease, the burden of the disease is in young people. We have to position young people in a way that will lead to the reduction of inequality [among them].

We have a unique opportunity to address inequalities by ensuring that the Global Fund [to fight Aids, Tuberculosis and Malaria] is replenished at $18-billion [by] September. That will give us the resources to continue to address some of the inequalities.

What can African leaders do to show more political commitment to fight HIV?

Many countries in Africa are already showing strong political commitment and political will. South Africa,  contributes about 77% of the resources that are required to fight HIV/Aids in the country. Botswana, contributes in excess of 80% of such resources. Is that the trend across the board in Africa? No. We want to see those countries that have not leveraged their own domestic resources, step up to the plate and say, “this is about our people and [although] we can do this in partnership with Pepfar and the Global Fund, we have to increase our own resource envelope”.

A two-monthly HIV prevention injection, cabotegravir, has been developed and is working even better than the daily HIV-prevention pill. But Africa can’t afford it.  Following pressure from activists, ViiV healthcare, the company that makes the injection, has said they will sell it at a lower price to African countries until a generic version of the injection becomes available. But we still don’t know at which price. What can Pepfar do to get pharmaceutical companies to put people ahead of profits?

Pepfar cannot do it alone, so it means we have to rely on the power of partnerships [and] of collaboration. For the new long-acting pre-exposure prophylaxis (PrEP), Pepfar is already in discussion with multiple groups with whom we’re going to sit around the table and look at ways to shape the market. This is not the first time we are dealing with a drug that comes on the market at an unaffordable price. When antiretrovirals [used to treat HIV] were first introduced in1996, it cost $10 000 [about R163 000] to treat one patient for a year. But look at where we are today. [South Africa’s health department pays about R888 for a year’s treatment per patient]. I’m optimistic that if we bring the right partners together, we can sit down with Viiv Healthcare to look at ways that we can bring the prices down as it looks like that long-acting injectable PrEP could be a game changer.

How long do you think those negotiations will take?

It’s quite urgent. We are not talking years, it should be a question of months. We should aggressively work on it as a priority so that in months, not years, we can begin to roll out the injection in Africa.

Reproductive rights, such as access to contraception and safe abortion, are connected to women’s vulnerability to contracting HIV. But abortion is a controversial issue in the US because of the overturning of the Roe v Wade ruling. How do you see those rights playing out in the Pepfar programme?

Pepfar is governed by the laws of the United States. We have to follow the rules and regulations we are governed by. We will be looking at [reproductive rights] closely in partnership with the countries we work in. If there are things that we cannot do with Pepfar programming [such as funding abortion services], then countries can also lead in that direction or look for additional partners who can leverage the limits and work with us to complete the areas that Pepfar cannot provide funding for.

The recent changes in the US are very new. We at Pepfar are still discussing these and we still need to ask questions for clarity where the need exists.

The Covid pandemic showed us how research conducted by African countries wasn’t always taken as seriously as studies from the Global North. Do Western countries take HIV research from Africa seriously enough?

Based on my own experience as someone of African origin, my answer is yes, colleagues in advanced countries do respect scientists from Africa. Is there room for improvement? Yes. But room for improvement should go both ways.

African scientists should also promote their own findings or create platforms to promote their findings. For example, we should] have African respected journals where you can publish high-quality data from the continent. We should also have conferences on the continent where African scientists can share such information. When I was at the US CDC I addressed some of these gaps. I created the African Society For Lab Medicine in March 2011 and it became the premier platform for sharing laboratory knowledge and science. We don’t need permission from anybody to do that.

I also [helped to] create, The Journal of Public Health in Africa and the African Journal of Laboratory Medicine, top notch journals where Africans can publish their findings and disseminate it across the continent. My advice to African scientists is: count on your own strength, count on your networking. Create platforms that can promote your science and learn from each other. If you do that, countries  in Europe, Asia and the United States will be eager to come and learn from Africa.

Should more international conferences be held in Africa to avoid excluding voices from the developing world like we saw at the 2022 Aids conference in Canada?

Absolutely, but Africa should also create its own international conferences. Nonetheless, Aids conferences for which Africans can’t get visas are simply inappropriate. It’s not in the spirit of fighting HIV together.

On a personal note, you’re now based in Washington, DC. What will you miss about living in Africa?

The warmness, not just in temperature, but warmness of the heart. People are willing to share whatever they have. The culture is just so rich.

Watch the full interview with John Nkengasong

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South Africa has enough Covid jabs to vaccinate up to half of the country’s 6.5-million children between the ages of 12 and 17 with one dose of Pfizer’s vaccine before they return to school after the December holidays or begin their tertiary education in 2022.  

That’s according to the health department’s acting director general, Nicholas Crisp, who announced on Friday that teenagers will become eligible for one Pfizer shot on Wednesday.

Crisp said the department’s goal is to have 3.25-million children between 12 and 17 years old vaccinated by mid-January. “Matrics will be prioritised, so that they have enough time to recover from possible side effects before their exams [which start on 27 October],” he said.  

Pfizer’s Covid-19 vaccine is the only jab that has received approval from the South African Health Products Regulatory Authority (Sahpra) for use for people of 12 years and older. Johnson & Johnson’s (J&J) jab — the other shot used in South Africa’s roll-out — can, so far, only be given to people 18 or older.

Why are teenagers in line for a Covid jab?

Although teenagerss are less likely than adults to fall seriously ill with Covid, vaccinating them will help to reduce absenteeism in classrooms and lower the risk of Covid outbreaks in schools.

Crisp says teenagers will not be vaccinated at school premises this year, but that the country’s vaccination programme may expand to include such a component in 2022. Instead, adolescents, who make up 11% of South Africa’s population, will, for now, be able to go to any private or public vaccination site to receive their shot.

There’s also no need for teenagers’ parents to approve their immunisations, because children between 12 and 17 years old can consent to medical treatment and surgery, according to the Children’s Act. This age group can, for example, also consent to terminating a pregnancy, the Act stipulates.

Why are teenagers receiving only one dose?

Teenagers will, however, only receive one shot of the Pfizer vaccine — unlike the two doses, six weeks apart, that adults in South Africa currently receive.

This is because the country’s ministerial advisory committee on Covid vaccines wants to allow more time for additional safety data to be gathered about potential side effects in this group, because of a very small risk of inflammation of the heart muscle or outer lining of the heart.

These two conditions are, respectively, also known as myocarditis or pericarditis, and they occur more frequently among boys than girls. 

June data from the US government’s Centers for Disease Control (CDC), shows that over a four-month period, for every million Pfizer second doses given to 12- to 17-year-old boys, between 56 and 69 developed myocarditis or pericarditis; in the case of girls, eight to 10 developed these conditions for every million jabs administered. Most people who develop these conditions as a result of vaccination recover within a few days.

But scientists agree that the benefits of vaccinating teens far outweigh the risks, because studies have shown Pfizer’s jab is safe to use in teenagerss and provides very high levels of protection against developing symptomatic Covid, as well as against Covid-related hospitalisation.

Like South Africa, the UK has also decided to vaccinate teenagers between 12 and 17 years old with only one jab — for now.

The UK’s health officials based this decision on US data, which showed that reports of myocarditis among teens and young men were six to seven times lower after their first dose of the Pfizer vaccine, according to an independent report published by the country’s joint committee on vaccination and immunisation.

UK children with underlying conditions that make them more likely to fall seriously ill with Covid are, however, given two doses eight weeks apart and will be monitored closely.

What happened to the department’s original vaccination plan?

Until now, South Africa’s roll-out has mostly focused on reaching the groups of people who are most likely to end up in hospital or die of Covid-19 (that is, those older than 50 years).

Although it is still important that older people continue to come in for their shots, opening the immunisation programme for younger South Africans can help to increase the overall protection within the population.

At the moment, South Africa is vaccinating about 200 000 people per day. This is only half of the expected daily vaccinations promised by the health department in July.

The country plans to vaccinate 70% of adults (people 18 years and older) with at least one dose of vaccine by the end of the year. With only two-and-a-half months left to go, we’re only halfway with that goal — just more than  35% of adults have received either one shot of J&J or Pfizer.  

In September, the health department said teenagers would have to wait for health workers and older people to receive booster shots before they would become eligible for a vaccine.

On Friday, the department announced that health workers who were vaccinated with one dose of J&J between February and May during the Sisonke implementation trial will be receiving a second J&J booster dose, as part of a new leg of the Sisonke study, as soon as Sahpra has approved the trial’s updated protocol. 

But boosters for older people are not yet available, although the vaccine ministerial advisory committee has advised that people with compromised immune systems — for instance, those who have had organ transplants or are undergoing dialysis, be offered additional vaccine doses (although no date has yet been announced).

What’s slowing down SA’s vaccine uptake?

Crisp says the country has enough unused vaccines to begin vaccinating teenagers.

A 13 October health department report notes several reasons why jabs are not being used fast enough, including reluctance to be vaccinated from people between the ages of 18 to 34 in some provinces, and the cost of transport to vaccine sites. In Mpumalanga, the high unemployment rate may be behind slow uptake, the report says, because people may be focusing on finding work first.

Misinformation is also hampering the uptake of Covid jabs in Namaqualand in the Northern Cape. The report recommends that communication teams need to be sent out to such areas urgently to dispel myths and create more demand for vaccines.

Nonetheless, Crisp says the department has noticed that families are coming in to get their jabs together, particularly in cases where extended families live together.

Vaccinating teenagers will also allow matriculants to be protected ahead of their final exams, says Crisp, and help to reduce absenteeism in classrooms. 

“There is no reason not to proceed with vaccination of this group,” he says. 

They may be less likely to die of Covid — but kids can still spread it

At the beginning 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 main drivers of transmission, meaning that kids were believed to be less likely to spread the virus to others.

​​But newer studies have since overturned this assumption, according to the CDC. Although children are unlikely to fall seriously ill with Covid, they can still spread the SARS-CoV-2 virus to other people. The CDC detected outbreaks among children, particularly at camps or schools, proving that younger people are still able to be infected and to spread the virus.

The main pro for getting children on board in the vaccine roll-out, the CDC says, is that it can help to reduce the spread of the virus within the general population. That’s because the jabs make people less likely to spread Covid, because the vaccines reduce transmission of the SARS-CoV-2 virus.

The CDC’s data from February 2020 until May 2021 shows 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 people who are 50 years and older.

But children are still less likely to develop severe disease when they become infected. The CDC’s studies, for example, found that those younger than 17 years are far less likely to be hospitalised or die of Covid-19.

In South Africa, almost 12% of Covid cases are in children under the age of 19 — this age group accounts for about 5% of hospital admissions in the country, August data from the National Institute for Communicable Diseases (NICD) shows. At the same time, fewer than 1% of in-hospital deaths are among children.

Variants of the virus could pose a higher risk to children

Some studies show that a higher proportion of children are becoming infected with the Delta variant — the form of the SARS-CoV-2 virus that drove South Africa’s third wave and is still the dominant variant in the country — than with the Beta variant, which dominated South Africa’s second wave; or the original form of the virus, which dominated the first wave. But although kids are more easily infected with Delta, the variant doesn’t make them sicker (that is, cause more severe disease), data from the UK shows.

During South Africa’s first wave, in June last year, people of 19 years and younger accounted for 8.7% of all Covid cases. But by the end of the third wave in August, this age group made up 13.7% of cases.

Although children were almost 12 times less likely to be hospitalised for Covid than adults, there was still a spike in infections among this age group. The NICD report found that more people under the age of 19 began testing positive for Covid, particularly when schools were open — with cases in teenagers between 15 and 19 years old actually surpassing those in adults by mid-August.

Moreover, 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 their risk of falling seriously ill with Covid-19.

The vaccine is safe for kids: Here’s what we know

In August, Pfizer’s Covid vaccine was fully approved by the US government’s medicines regulator, the Food and Drug Administration, for use in the US in people aged 16 and older — with the same dosages as for adults.  

Children between the ages of 12 and 15 are not included in the full approval; 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 about 2 000 children between the ages of 12 and 15, half of whom were given the vaccine, with the remainder receiving a placebo or dummy drug. The study found that children between 12 and 15 years of age had a similar reaction to the vaccine as those who were 16 years and older and that the benefits of vaccinating these teenagers outweighed the risks of doing so.

Pfizer’s jab was originally only approved for emergency emergency use in South Africa for people 18 years and older. But in September, Sahpra approved the use of the jab, known as Comirnaty, for everyone 12 years and older. This approval recommended that everyone who uses it gets two shots. 

As a precautionary measure, the vaccine ministerial advisory committee has, however, advised that children be given only one dose of the Pfizer jab — for now. This way, South Africa makes sure that more safety data on second shots can be gathered about potential side effects among teens. Once the committee is satisfied that there is enough information, it will decide if and when teenagers should return for their second dose.

Why are there concerns about second shots?

Some cases of myocarditis and pericarditis have been observed in a small proportion of people (particularly young men) receiving two Pfizer shots. Both are typically your body’s response to an infection, and people who develop these symptoms after being vaccinated tend to fully recover within a few days.

It’s extremely rare for people to experience myocarditis or pericarditis after vaccination, but it can occur.

CDC data shows 2 574 people in the US reported that they experienced some form of heart inflammation after being vaccinated, as of 18 August. This was most commonly seen in those who had been immunised with two Pfizer shots, with men at higher risk than women. Most cases occurred in men between the ages of 12 to 24.

To put that into perspective, June data from the CDC found that only 1 226 people of the nearly 300-million people vaccinated reported heart inflammation. That means this extremely rare side effect was found only in 0.0004% of vaccinated people.

Two recent studies from Israel published in the New England Journal of Medicine have also confirmed that the risk of heart inflammation after vaccination is extremely low.

One study found 304 reported cases among about five million people who received two shots of  Pfizer’s vaccine; 136 of the cases were linked to the vaccine itself, with 95% of cases being mild.

The second study looked at about 2.5-million people older than 16 years who had been immunised with two doses of the Pfizer jab — only 54 cases of heart inflammation were reported in the group.

The risk of experiencing heart inflammation post-vaccination seems to increase after receiving two shots of the vaccine. The CDC’s June data showed that among the just more than 1 000 cases reported, about three-quarters were in people who had received their second dose of either Pfizer or Moderna.

A September presentation from the CDC reported that two of a million men (aged 18 to 28) experienced myocarditis after their first dose. That increased to 24 of a million after the second dose of the Pfizer vaccine. This data also showed that men in this age group were 12 times more likely to develop heart inflammation than their female counterparts.

Will children be able to travel internationally with one shot of Pfizer?

Crisp says parents will have to check with the country their teen is travelling to if it will accept one Pfizer shot as proof of full vaccination for adolescents, because all governments have their own policies.

But, he says, because several countries, including Hong Kong, the UK and Norway, have recommended only one dose of Pfizer’s vaccine for children between 12 and 17, they’re likely to have adjusted definitions of “full vaccination” for this group that will allow for entry into those countries.

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“The best thing to do is to get as many people vaccinated as quickly as possible,” said immunologist Anthony Fauci, , the director of the National Institute of Allergy and Infectious Diseases and the chief medical adviser to the United States president, of achieving herd immunity.

Early on during Covid-19 vaccine trials, surveys showed that more than two-thirds of adults globally said they were willing to get the jab when a vaccine became available. In South Africa one poll showed similar results, yet so far only about 32% of the population have actually followed through with getting at least one vaccine dose.

There is some good news, though.

Many people described as “vaccine hesitant” are not outright resistant to getting the jab, but are simply waiting for the right nudge, according to a report in the New England Medical Journal. Of the almost 140 000 people surveyed, 40% had already been vaccinated and 11% were hardline refusers, who said they were very unlikely to get the jab. This means close to half of the sample were sitting on the fence.

Here are six things to consider to help turn the “vaccine ready” into go.

1. Know who you’re talking to

To persuade people to get vaccinated, messages have to be tailored for the intended audience.

For example, a study in the United Kingdom showed that people who are vaccine ready and actively looking to get the shot may be receptive to messages about the public health benefits of being vaccinated — meaning they want to get vaccinated to protect themselves and others. In contrast, people who are hesitant appear to be less interested in the greater good and respond better to learning what’s in it for them.

A 2021 study in the United States had a similar result. Messages focused on personal benefits were more effictive in convincing people to get vaccinated. 

2. Get the word out — quickly

A study published in the journal Nature in August found that the timing of vaccine messages can boost appointments and subsequent vaccinations. In this study, participants in the US were randomly assigned to one of two groups and were then sent a text message inviting them to schedule their vaccine appointment shortly after they became eligible to register.

One group received the message one day after they became eligible for getting their shot and the other group got the message eight days after they could make an appointment. Both messages included a link to a website allowing the recipients to book vaccine appointments. The earlier prompt nudged 1.5 times as many people to make appointments than the later one.

Simply making the booking also boosted follow-through. Nearly 90% of participants who made a booking after receiving the nudge kept their appointments — and almost everyone who received their first dose also booked for their second.

This points to the importance of encouraging people to schedule their first shot. A similar trend was seen in an earlier study designed to boost uptake of the flu vaccine. Vaccination reminders sent to people before their regular, unrelated primary healthcare visits increased vaccination rates by 5%.

3. Allay people’s fears — first with empathy, then with evidence

The flip side of the unprecedented speed with which Covid-19 vaccines were rolled out is that it has contributed to questions being raised about their safety.

Studies about people’s attitudes towards vaccines, from countries as diverse as Jordan and the US, show that fears about ingredients, safety and what many perceive as rushed approval processes deter people from getting vaccinated.

Inadequate data and a general lack of transparency about Covid-19 vaccine trials, coupled with murky procurement agreements between governments and pharmaceutical companies, further fuel reluctance to get the shot.

Although there is overwhelming evidence that the vaccines are safe and effective, it is important to acknowledge that people’s fears are valid. Showing empathy when talking to people who are reluctant or uncertain may help to make them more receptive to balanced, evidence-based messages.

It’s equally important to be honest about issues such as the common occurrence of minor side-effects — and to use evidence to contextualise the extremely rare risk of severe side-effects. For instance, the scaremongering media coverage about blood clots developing after getting the Johnson & Johnson (J&J) or AstraZeneca vaccine created the impression that blood clots occur far more often than what they actually do.

International medicine regulators’ investigations showed that the risk of developing a blood clot after getting the jab was very low — less than one in a million for J&J and between four and six in a million for AstraZeneca. Typically a very rare adverse event after taking a medicine is defined as affecting fewer than one in 10 000 people, but in this case the chances of developing blood clots were deemed really slim, and the vaccines were cleared for use after the temporary pause.  

4. Don’t be afraid to drop a name or two

If Elvis could do it, so can you.

In 1956, the then rising rock ’n’ roll star Elvis Presley appeared on public television getting his polio shot at a time when vaccine uptake was precariously slow. The Elvis effect seemed to have helped to spur US teenagers to launch campaigns to recruit their friends. Vaccinations surged, and by the next year active cases of polio had dropped from 15 140 to 5 485. Five years later, fewer than 1 000 cases were reported.

Studies about social influence on boosting the uptake of flu vaccines suggest that talking about other people getting their shots might help to improve the uptake for Covid-19 vaccines too. It need not be only social influencers; even examples from a peer group can help to nudge people to get on board.

5. Don’t focus on hardline refusers; try to convince those sitting on the fence 

A small percentage of people say that they will never get the jab and studies suggest that chances are slim that they will change their minds. In the US, this number is about one in eight people; in South Africa it’s about one in 15 (although the proportion may differ in pockets of the population).

Actual uptake among vaccine-ready people can change over time, but hardline anti-vaxxers almost never change their minds. It’s more effective to focus on people who are vaccine ready and receptive to new information.

6. Understand people’s realities

Historically, vaccination campaigns focused on busting myths and providing evidence-based information about vaccine safety and benefits. Yet opposition to Covid-19 vaccines (and also non-pharmaceutical interventions such as wearing masks and social distancing) seems more strongly rooted in people’s lack of institutional trust, and even a mistrust of government in general when faced with a large-scale epidemic.

A separate but valid  issue is a distrust of vaccines that stem from historical injustice and inequality. For example, American intelligence services used a vaccination campaign in Pakistan as a cover to capture Osama bin Laden, which affected subsequent vaccination drives in that country.

Historic racism has also contributed to lower trust and has been so pervasive that the effect is seen even among healthcare workers. Low levels of trust are compounded by people still experiencing obstacles when trying to get medical care for Covid-19. 

In the end, turning nudges into numbers may be more about how we talk to the unvaccinated than what we say.

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Every day the department of health posts the latest information from its vaccine statistics dashboard on its SA Coronavirus website.The numbers shown are a snapshot as at 17:00 on a particular day. We use data from the dashboard in this vaccinations table to track the proportion of adults (people 18 years and older) in each province who have received a vaccine.

This is the target population of the vaccination roll-out. The estimated number of people in this age group used in the table was obtained from Statistics South Africa.

South Africa is using two vaccines, the one-dose Johnson & Johnson shot and the two-dose Pfizer. 

The health department vaccination dashboard has a disclaimer that states: “Data displayed in this dashboard only contains vaccination records captured on the live Electronic Vaccination Data System (EVDS) and excludes vaccination records captured on paper within the last 24 hours. Totals will be adjusted as back-capturing and data validation are done.”

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Achieving full community protection, or herd immunity, against Covid-19 through vaccinations by 2022 is no longer on the table for South Africa. The country now sets its sights on a less lofty goal called “containment”, which aims to immunise just enough people so that Covid hospital admissions put no more strain on the health system than any other illness would, experts say. 

Health Minister Zweli Mkhize initially aimed to immunise 41-million people by the end of 2021. 

Nearly halfway through 2021, however, South Africa’s vaccination roll-out has immunised only just over a million people with one dose of Covid vaccine. Only about half of them — the 479 768 who received the Johnson & Johnson (J&J) jab through the Sisonke trial; the vaccine consists of one dose only — are fully vaccinated. The other half have received only one jab of Pfizer’s two-dose jab. In other words, only 479 768 people, which works out to 0.8% of the population, have been fully vaccinated against Covid. 

The immunisation drive has faced various hurdles, starting with the February news from a small study that found AstraZeneca’s vaccine is mostly ineffective against the 501Y.V2 variant dominant in South Africa (the Beta variant, as per the World Health Organisation’s new labelling system) — as a result, the health department sold the AstraZeneca shots. 

Researchers then rushed to get an implementation study up and running to immunise healthcare workers with the J&J jab instead. But the study lost out on two weeks of its vaccination time, when it was temporarily paused while the country’s medicine regulator, the South African Health Products Regulatory Authority (Sahpra), investigated unusual blood clots linked to the J&J shot. 

The stop-start nature of the roll-out is not the only reason herd immunity is an unrealistic goal for this year — a scarce supply of vaccines and new variants of concern circulating in the country play a role too. 

We explain the maths behind herd immunity and containment with the help of Barry Schoub, chair of South Africa’s ministerial advisory committee on Covid-19 vaccines. 

How is herd immunity calculated?

A community can be protected from an infectious disease such as Covid through herd immunity. This means enough people in the community develop a resistance to the disease, which prevents them from falling ill. This resistance means that the spread of the disease is slowed down throughout the community. 

Herd immunity is calculated based on how many people become infected from one person who already has a germ (also known as the reproductive number) — in the case of Covid-19 the germ is the SARS-CoV-2 virus. The goal is to get to a point at which each infected person is unlikely to spread the disease to anyone else. This way the virus can be contained and will no longer be spreading within a population.

South Africa had estimated that 67% of people in the country would need to be vaccinated in order to reach this point — but some scientists have argued that the figure is actually much higher.

Here’s how Schoub breaks down how to calculate the number of people that need to be vaccinated:

• The reproductive number in South Africa (factoring in the Beta variant) is 1.97;
• The calculation for herd immunity is: 1 – (1/Rt);
• So for South Africa it looks like this: 1 – (1/1.97) = 1 – 0.51 = 0.49; and
• That number needs to be multiplied by 100 to get the percentage: 49%

Now here’s where it gets a bit tricky — because you start making assumptions.

We don’t yet know how many people won’t become reinfected because they have protection (in other words, their bodies have produced antibodies that can fight off SARS-CoV-2) from previously being infected.

So, based on the assumption that some people will have immunity, you can lower the estimate for how many remaining people need to be vaccinated to 46%.

You work out what 46% of the total population of South Africa is (the population is estimated to be about 59.62-million people), which gives you 27.43-million.

This number then needs to be put into the context of the adult population in South Africa (which is 40.35-million people, according to data provided by Discovery Health), because these are the people who will actually receive the vaccine.

So, if you divide 27.43-million by 40.35-million, we get to the end goal of needing to vaccinate 68% of the adult population in South Africa.

But these calculations are not perfect and the numbers can vary, depending on what the epidemic looks like.

“The estimate for herd immunity isn’t based on hard science. It’s based on what we know about other viruses and we’ve just kind of extrapolated it to SARS-CoV-2,” Schoub says. 

How many people you actually need to reach with a vaccine to reach herd immunity also depends on the level of protection the jab can provide — and this varies, depending on which jab is being used. You can calculate how much immunity you’ll have by multiplying the vaccine’s efficacy by the amount of people you’ll be vaccinating.

For example, the J&J vaccine has an efficacy of 64% against the 501Y.V2 or Beta variant and we’re planning to vaccinate 67% of the population. Multiplying these two numbers gives you a population immunity level of 43%.

In the case of the Pfizer jab — the other vaccine that South Africa will be using — its efficacy is about 91% against Covid-19 (not caused by the Beta variant), so the level of protection would be 61%. Unlike J&J, Pfizer concluded its clinical trial before the emergence of the variant, meaning that there is limited data on the level of protection its jab can provide against this new form of the virus. 

Schoub explains that calculating the herd-immunity threshold requires considering a number of factors, including how effective a vaccine is, which variants are circulating and how people behave.

Moving towards containment

Within the context of these variables — in calculating a herd immunity threshold and also the barriers standing in the way of achieving it — South Africa has now moved towards a containment strategy.

This means the country is trying to achieve a level of immunisation which will cause the least amount of strain on the country’s healthcare system, Schoub says — in much the same way a winter illness might.

Previously, South Africa tried to use other diseases, such as measles, as a guide for how to respond to Covid.

Schoub says: “For many of those acute viral infections, we can define herd immunity quite precisely. In the early days, we thought that we could do the same for Covid. But now with all those variables …  it’s become apparent that it’s going to be impossible to precisely define that figure of herd immunity. So what we are aiming at is containing the virus to a tolerable level, to a level where it doesn’t cause too much hardship.”

Schoub believes South Africa could reach this level of containment by 2022, provided “the vaccine roll-out goes without too many hitches”.

Calculating what the country’s herd immunity threshold should be is tricky — but achieving herd immunity is even trickier.

Here’s a closer look at some of the hurdles standing in the way.

1. Challenges in South Africa’s roll-out

Schoub says that the supply of vaccines is one of the challenges preventing the country from  achieving herd immunity. 

The country’s staggered roll-out of vaccines has been noted as a point of concern by the South African Medical Association’s chairperson, Angelique Coetzee.

“We really need to be vaccinating about one million people a month, but at the current rate that will not happen,” Coetzee said in a press release issued earlier this year. “We must have a proper vaccination plan in place to meet the demand to ensure we vaccinate as many people as possible in the shortest possible time frames.”

The limited global supply of vaccines means that it’s likely that South Africa will reach its goal of vaccinating only 41-million people by the first quarter of 2022, warns Schoub.

Implementation of the roll-out plan poses a possible challenge too. Early registration for a vaccine on the country’s electronic vaccination data system (EVDS) was interrupted by load-shedding, requiring vaccinators to update the system manually. Miscommunication of appointments has also been noted, with people arriving to receive booked vaccinations and being turned away because of glitches in the system.

Despite these early snags, Schoub remains optimistic, pointing to the successes of South Africa’s antiretroviral programme. 

“That’s gone up pretty successfully. I think we’re a world leader,” Schoub argues. “And I think we can reach those goals [with Covid vaccinations] if all the effort is put into it”.  

Vaccine hesitancy could also pose a problem. The National Income Dynamics Study – Coronavirus Rapid Mobile Survey (Nids-Cram), is a nationally representative telephonic study of the socioeconomic trends of South Africa. The latest wave of the study found that 29% of South African adults were hesitant to get vaccinated. Most hesitant respondents said they were worried about the side-effects of the vaccines (31%), believed the jabs weren’t effective (21%) or didn’t trust vaccines in general (18%).

2. Vaccine nationalism and an uneven supply of vaccines

Wealthy countries hoarding vaccine supplies affects the pace at which we reach herd immunity globally. Half of the world’s vaccine supply is currently held by the wealthiest countries, which account for only 14% of the global population.

Delays in South Africa’s own roll-out are in part because of the fact that wealthier countries secured vaccines from manufacturing companies very early on in their development — mostly before results showing if the jabs worked. As a result, less well-off countries, which couldn’t afford to do the same, were placed in a situation in which they had to join the back of the queue and wait for more jabs to become available.

This hoarding of vaccines means there will always be regions in the world where the SARS-CoV-2 virus remains circulating, Schoub says.

This poses its own risk, because as long as there are countries that are not able to protect enough of their population and continue to experience new infections, the virus will continue to spread across borders.

Another concern is that this uneven distribution of vaccines around the world could give rise to new variants.

3. The rise of new variants

In the early stages of the pandemic, the coronavirus was thought to be relatively stable. But that changed when new variants — in which the virus had mutated and evolved — began emerging in late 2020.

South Africa announced that it had identified a variant — called 501Y.V2, B.1.351 or Beta — in December last year, which drove the country’s second wave of infections.

Some of the new variants, such as Beta, are able to spread more easily from person to person and, importantly, can also evade protection provided from previous infection. This means that even people who may have natural immunity to the original form of the virus can still become sick once again.

The rise of new variants poses a problem for reaching herd immunity, because the more infectious the virus becomes, the more people need to be protected to stop it from spreading.

Early studies suggested that vaccines could potentially be ineffective at protecting against infection with the Beta variant. 

But new evidence found that most Covid vaccines can provide at least some protection against these variants. For example, South Africa’s roll-out uses both the J&J and Pfizer jabs, with results showing that they work against the 501Y.V2 variant.

Schoub points out that because the Beta variant is one of the more resistant variants, it  means that if you develop immunity against it, the antibodies your body produces could potentially provide protection against other variants too.

4. People may not be protected forever

Calculating herd immunity depends to some extent on the number of people in a population that have natural immunity. But the catch is that we don’t yet know for how long that protection lasts  — and the same is true for people who develop immunity through vaccination.

There is, however, some promising data emerging that shows that protection could potentially last for several years. 

But for now, we only have evidence that shows that vaccine immunity lasts for six months, epidemiologist Salim Abdool Karim told Bhekisisa in April.

Why? Because Covid vaccines haven’t been around for long enough — we’d require a longer period of time to gauge how effective vaccines are in the long run.

“What I think will happen is that we’ll find that the antibody levels will remain high for a substantial period, meaning for a few years — after that we might find the antibodies waning,” Abdool Karim said.

This matters for herd immunity because it affects how often people would need to be vaccinated to remain protected against Covid.

What does this mean for SA?

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This project is a collaboration among Bhekisisa, Media Hack and the Canon Collins Trust, which awarded Bhekisisa the 2020 Sylvester Stein Fellowship.

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Eighty thousand Johnson & Johnson (J&J) jabs will touch down at OR Tambo International Airport today and be distributed to 16 sites across the country where healthcare workers will be vaccinated.

This marks the start of South Africa’s new, adjusted vaccine roll-out plan, in which vaccinations will be given as part of an implementation study conducted by the South African Medical Research Council (SAMRC) and the department of health. The implementation study will focus on “real-life” environment roll-out issues and also gather additional data on side effects and the protection the jab offers against severe Covid-19 disease caused by the new SARS-CoV-2 (the virus that causes Covid-19) variant, 501Y.V2, which is now dominant in South Africa.

We break down everything you need to know about the Johnson & Johnson vaccine: how well it works against the new variant, how many doses will be going to which sites (check out our interactive map), and how many more vaccines will be arriving and when. 

1. How well does the J&J vaccine work?

The Johnson & Johnson vaccine is the only jab — at least so far — for which we have clinical trial data on the kind of protection it provides against severe Covid-19 disease caused by the new variant, 501Y.V2.

Why are we interested in protection against severe disease? Because that’s the type of Covid that leads to people ending up in hospital or dying. Reducing these cases means our health system doesn’t get overwhelmed, and the effect of the pandemic on our economy when breadwinners, for instance, die, is alleviated. In the case of health workers, who are on the frontline taking care of people with severe Covid and most vulnerable to infection, we want to protect them as much as possible.

Johnson & Johnson tested its vaccine in eight countries — the United States, Argentina, Brazil, Chile, Columbia, Mexico, Peru and South Africa. Fifteen percent, or 6 567 of the study’s 43 783 participants, were from South Africa.

Most trial participants were older than 60 years (33.5% over 60, 19.6% over 65, 3.5% over 75, 1% over 80). This helped the researchers to obtain better data on how the vaccine fared against severe Covid (because people who are older than 60 years are more likely to develop severe Covid disease than those who are younger than 60).

The study showed that the jab was 85% effective in preventing severe disease in people who were 18 years and older in all the countries that were studied. The protection kicked in 28 days after the shot was given. What is more, the protection the jab provided against severe disease increased over time — 49 days after a jab was given, not a single case of severe Covid was reported in people who had been vaccinated.

Moreover, the jab demonstrated 100% protection against Covid-related death: 28 days post-vaccination, no trial participant had died.

So, how do the study’s investigators know that the Covid cases in the South African arm of the trial were caused by 501Y.V2? They took a sample of the cases and sent them for genomic sequencing, which allowed them to decode the genes of the virus and establish which variant it was. The results showed that about 94% of the Covid cases from South Africa were caused by the variant, one of the two co-principal investigators of the local Johnson & Johnson trial, Glenda Gray, said in a presentation on 7 February. Gray is also the president of the SAMRC.

But the trial data also showed the study’s researchers that the Johnson & Johnson vaccine offers less protection against moderate to severe Covid caused by 501Y.V2 than against severe Covid. The jab offered 57% protection against moderate to severe disease, which was lower than the protection provided in countries in which the 501Y.V2 variant was not dominant. The 57% is, so far, however, the best protection we’ve got in a vaccine against moderate to severe disease caused by 501Y.V2 — both the Novavax and AstraZeneca jabs showed less than 50% protection, which is the World Health Organisation’s threshold for a Covid vaccine to be considered effective.

2. Has the data been peer-reviewed? 

Before a scientific study can be accepted for publication in a reputable academic journal, the research goes through a process called peer review. This means a committee of “peers” — in other words, other academics or researchers — examine the data and methodology of the study, to make sure it is sound.

This process can take months to complete.

During the Covid pandemic, research moved considerably faster than usual, because of the need to find treatments and vaccines fast. This means that study results are often released in the form of preprint studies (that have not been peer-reviewed) or press releases.

In the case of the Johnson & Johnson vaccine, the study results have not been peer-reviewed. The data was released as a press release on 29 January. This means there is limited data available about the exact numbers being looked at and we don’t yet know how many of the Covid cases that were recorded during the trial occurred in which of the eight countries where the trial was conducted.

3. How many shots do you need? 

So far, the Johnson & Johnson jab is the only Covid vaccine that requires just one shot. All the other jabs that are currently available require two shots. This makes the Johnson & Johnson vaccine considerably easier to administer because health workers don’t have to spend time and resources on ensuring that people return for their second shot.

Potentially, later down the line, researchers could test if a second “booster shot”, designed to protect against the 501Y.V2 variant, could increase the protection provided.

4. How many Johnson & Johnson doses are we getting — and when?

For now, we’ll be receiving four batches of vaccines, once every two weeks, says Linda-Gail Bekker, the other co-principal investigator of the Johnson & Johnson study. The first three batches will consist of 80 000 doses, and the fourth of 60 000 doses. When we’ve received 300 000 doses (the total of the first four batches) and showed that we were able to administer all of them, we will have the option of asking Johnson & Johnson for another 200 000 doses.

All these doses (500 000 in total) will be provided to South Africa free of charge by Johnson & Johnson. Why? Partly solidarity, and partly because they come from research stock that Johnson & Johnson won’t be using, Bekker says.

In addition to the free vaccines, South Africa has procured a batch of nine-million doses from Johnson & Johnson, which, according to a January presentation by President Cyril Ramaphosa, is expected to arrive in the second quarter of this year. Media reports on 9 February stated that an additional 20-million doses are under negotiation, but this has not been officially confirmed.

For these doses, South Africa, will, however, need to pay. And when we receive these will depend on two things: when Johnson & Johnson has stock available, and when our medicine regulator, the South African Health Products Regulatory Authority (Sahpra), is able to conclude Johnson & Johnson’s application for approval to use the vaccine for a wider roll-out (the approval we received for the first 500 000 doses is for use in a research setting, which is different from the type of approval required for wider use, and also a much simpler and quicker process).

5. When will the roll-out start? 

Bekker says, “if all goes well, we’ll start with the first vaccinations by midday on Wednesday, 17 February”.

6. Who is receiving the vaccine?

Only healthcare workers can get vaccinated for now — until all of the country’s estimated 1.25-million health workers have been covered. Health workers are considered the most vulnerable to infection because they deal with infected patients daily. That is why they are the only group targeted in phase one of South Africa’s vaccine roll-out.

The first batch of 80 000 vaccines will be distributed to 17 sites across nine provinces, says  Bekker, who is also the director of the Desmond Tutu HIV Centre at the University of Cape Town.

Each province will have two vaccination sites — all are public hospitals. One site (Pelonomi Hospital in the Free State), is however, not yet ready to vaccinate, and will, therefore, be phased in later, health department spokesperson Popo Maja told Bhekisisa.

So how many doses of the 80 000 doses will each site receive?

Bekker says the numbers will be calculated based on the number of trained staff available at a site and the burden of disease (that is, the number of infections in the area). “Additional training will also be done to increase the amount of people able to administer the jab beyond just healthcare workers,” she says.

For the second consignment of 80 000 doses, some of the vaccines will be distributed to private-sector healthcare sites, which will then be added to expand the list of 17 vaccination sites. As more vaccines arrive, the number of sites will further increase. 

Bhekisisa obtained a list from the health department with the names of the 16 vaccination sites that are ready to operate and the number of doses they will each receive. We’ve turned it into an interactive map to make it easy to understand.

7. How do you let the health department know you’d like to be vaccinated?

Everyone who wants to be vaccinated needs to register on an online system called the electronic vaccination data system (EVDS). This system will record your name, ID number,  address, whether you have medical aid, and a few other details, and then let you know if you’re eligible to be vaccinated. when you’ve been identified as eligible, you will receive a text message that will tell you where to go, and then you will be vaccinated. You will also receive a unique code, which you will have to give to the vaccinator, together with your ID. When you’ve received your jab, you will receive an electronic vaccination certificate.

Registration for health workers on the EVDS has started. By 1 pm on 15 February, 351 213 (28%) of the country’s 1.25-million health workers had registered on the platform, according to health department data.

8. So why are we doing a research study on the J&J vaccine if we already have data that shows it works against 501Y.V2? 

The short answer: because getting a vaccine approved for use in a research setting is considerably faster than getting it approved for wider use and, if we have to wait for the latter, we’re likely to start with roll-out only in about two months.

The long answer: Johnson & Johnson has submitted a rolling application with Sahpra to enable it to roll-out the vaccine on a large scale. But, according to Gray, the approval process is likely to conclude only in about three months.

This is because Sahpra has to review loads of data to ensure the vaccine is safe and as effective as Johnson & Johnson says it is. Another complicating factor is that, to speed up this process during a pandemic, Sahpra makes use of a strategy called a reliance mechanism. This means it leans heavily on the findings of other large regulators, such as the United States Food and Drug Administration (FDA) and the European Medicine Agency. But the Johnson & Jonson vaccine is new, so no other country has yet approved it. The FDA has scheduled an independent review for 26 February.

So, while Johnson & Johnson is waiting for approval for wider use of its vaccine, the company is conducting an implementation study — because it’s the only way that health workers can get earlier access to Covid vaccinations with this jab. But it will also provide the pharmaceutical manufacturer with more data.

“This type of research is called an implementation study — where you study how an intervention performs under real-world conditions,” Gray says. “By doing the roll-out in the form of an implementation study, additional information can be gathered to confirm the findings of the phase three study that this vaccine protected against hospitalisation and death.”

Although there is existing trial data showing the vaccines’ safety, certain groups like pregnant women are not able to participate in clinical trials. Groups like these that were previously excluded from trials can now participate in the implementation study and provide information on how the vaccine performs and to continue monitoring the jabs’ safety in a wider roll-out.

Bekker concludes: “Additionally, this approach to roll-out can provide insight into vaccine uptake among the population.”

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