As the first people in South Africa prepare to receive COVID-19 vaccinations outside of clinical trials, government recently released information on which groups of people will receive the vaccine first. While local experts welcome most of the prioritisation choices, some practical nuances remain unclear.
The Department of Health published its Vaccine Rollout Strategy on the third of January, based on an advisory from the Ministerial Advisory Committee (MAC) on COVID-19 Vaccines. The framework for allocation explains that since vaccine amounts are limited, prioritisation is needed and based on both evidence-based practicalities and ethical considerations, including African indigenous values.
The rollout plan has three phases, starting with a target population of 1.25 million frontline healthcare workers (HCWs).
The second phase includes essential workers such as police officers, miners, teachers, various government officials and those working in the food, retail, security, funeral, and banking sectors. People in congregate settings, such as care homes, prisons, and shelters, as well as workers in the hospitality, tourism, and educational sectors are also included. Another phase two population group is people over the age of 60 and adults over 18 who have comorbidities such as chronic lung disease, poorly controlled cardiovascular disease, HIV, tuberculosis, and obesity. The combined target population of phase 2 is around 16.6 million.
Lastly, all others over 18 years old make up phase 3, which has a target population of over 22 million people.
Professor Landon Myer, Head of the School of Public Health and Family Medicine at the University of Cape Town, calls the plan "well thought out and sensible - a considered balance of priorities to protect vulnerable populations, protecting ongoing government functions, and ensuring ongoing economic activity".
Professor Leslie London, a steering committee member of the People's Health Movement South Africa (PHM) explains that it is also not radically different to international norms, such as guidelines from the World Health Organisation. "It's not a big surprise, because it's more or less following what other countries have done and what other guidelines have said, but in South Africa, I think there are quite a few specificities which might apply differently."
Starting with medical and health personnel makes intuitive sense, given their importance and vulnerability during the pandemic. "With a sharply limited number of doses available in the first phase, the focus on HCWs is strategic on several fronts - and sends a valuable signal at a critical time," says Myer.
However, with it being unclear just how many doses of which vaccine will ultimately be used and when, rationing and prioritisation across this group may also take place. Keymanthri Moodley, a medical ethics expert speaking in her personal capacity, says "the challenge arises when vaccine demand exceeds supply and there needs to be a choice amongst [HCWs]". Those at highest risk from occupational exposure and personal health risk ought to be prioritised for the first rollout of vaccines," she says.
From a civil society perspective, London adds that there needs to be equity among the frontline health workers, such as for community healthcare workers. London says that this group was particularly affected during the first and second wave of the pandemic, even though they are critical to the healthcare service. He refers specifically to difficulties some community healthcare workers faced in accessing personal protective equipment and hopes that the vaccine rollout will not reflect this imbalance again.
"We don't want to see community health workers rationed out, because they are high risk, and they should be protected because they are kind of the arms and feet of the health service and community."
Some experts speaking to Spotlight emphasised that other workers in the healthcare community, such as traditional healers and medical students, should be included in phase one. Now that the electronic vaccination registration portal has been launched, it is clear that these groups are indeed included.
"The devil however, as in almost all countries whose vaccination policies I am following, is in the details of Phase 2," says Professor Gesine Meyer-Rath, from the Boston University School of Public Health and the Health Economics and Epidemiology Research Office at the University of the Witwatersrand. She says how the sequencing of this phase will go is important and will reflect what the government most wants to achieve, for instance in prioritising between workers helping society function and those at high health risk.
Myer says that the exact list of essential jobs and sectors is somewhat debatable, for instance, whether mining and retail workers should be included. However, the list is overall acceptable. The prioritisation of people with pre-existing conditions is fairly understandable, although he questions the notion of 'uncontrolled' chronic diseases such as diabetes as a helpful and constant qualifier.
Including people in congregate settings, particularly prisoners, has drawn some public criticism. Public health lawyer Safura Abdool Karim says this is a smart move because of the overcrowded and poorly sanitised nature of many prisons and the turnover of people. "Thinking about prisons as something that's isolated from us is a mistake," she says.
"There are very strong human rights and constitutional imperatives for the [government] to prioritise access to prisoners, because those people are wards of the state, so the [government] has a level of responsibility. Above and beyond that, we know that prisons were a massive hotspot for infections in the first wave," says Abdool Karim.
"I think the categories are fine in and of themselves, the whole issue is context," says London. "I think there's too much preoccupation with whether the government has made the right prioritisation. I find it quite distracting. The real issue is being able to implement it in a way that is equitable."
For instance, he is concerned about people in rural areas accessing the vaccines. "Rural areas have been relatively spared of our epidemic, which means that a lot of vulnerable people in rural areas don't have natural immunity following infection, to the extent that it [confers] you with immunity." There is also concern about equity between different provinces.
Abdool Karim explains that there is also concern about equity given South Africa's tiered medical system. "It's not tenable, in terms of our constitutional democracy to, for example, have preferential access given to people who have medical aid or access to private facilities, but we know that there's a lot more healthcare capacity in the private sector." She says that while the rollout plan may be enough, for now, information about this more granular allocation in the second and third phases will need to be clarified.
Louis Reynolds, also on the PHM steering committee, is a retired paediatrician and particularly noticed the age restriction. "I think certainly that the 18 year age limit seems a bit hard and arbitrary, given the fact that children younger than 18 are also susceptible." He explains that children younger than ten seem to be less susceptible to COVID-19 and don't pick up more severe forms of the disease, but that from around 12 years old, children seem to react more like adults and perhaps should be considered for the vaccines.
Meyer-Rath explains that the prioritisation may also be influenced by the practicality of which populations are easiest to reach and not only most vulnerable. "Speed seems to be of the essence, lest we end up in a situation where sub-optimal levels of population immunity give rise to additional mutations increasing the virus' transmissibility."
Clarity on process
The vaccine rollout plan has been long-awaited and now gives some clarity on the order of who will get the jab, but experts say that it is unclear how the government came up with this order and whether enough perspectives were involved. Abdool Karim says that while the vaccine MAC membership itself was clear, she would have wanted to understand the further layers of consultation and partnership that informed the rollout.
"Public consultation ought to have been initiated by the Vaccine MAC when it was established," says Moodley. She says that data should have been collected from healthcare workers to inform the decision-making process for phase one. In particular, HCW's should be surveyed to understand levels of willingness to accept the vaccine and personal and occupational risk levels. She says that this could have been the basis of a scoring system to determine who to prioritise with the vaccine.
"The process of determining a schedule of rationing any scarce health resource is highly controversial at the best of times, but perhaps becomes less controversial in an emergency setting such as this," says Myer. He adds that while public participation is critical, it is not fully feasible given the time pressure of the pandemic.