Just 54% of people in South Africa over the age of 50 have received at least one COVID-19 jab, with significant variation between provinces, as experts warn of the possibility of another wave of COVID-19 in future.
Since older persons are at greatest risk of serious illness or death because of COVID-19, they are particularly vulnerable to a fourth wave.
Accordingly, various local experts interviewed by Spotlight, including Acting Director-General of Health Dr Nicholas Crisp, agree that accelerating the vaccination programme is paramount.
Professor Debbie Bradshaw, Chief Specialist Scientist at the South African Medical Research Council (SAMRC) says, "Vaccine coverage of older folk is pretty important in terms of loss of life via COVID. Every vaccination counts in slowing down the pandemic, especially those into older arms which will reduce the overall loss of life."
Meanwhile, vaccinologist and Dean of the Faculty of Health Sciences at Wits, Professor Shabir Madhi has called for the vaccination campaign to focus almost exclusively on people above 50 to avoid the possible overwhelming of hospitals around Christmas and to mitigate another wave.
A total of 49% of those between the ages of 50 and 59 in South Africa have received at least one dose of a COVID-19 vaccine. For people aged 60 and older, this figure is currently at 59%.
Preparing as if a fourth wave is certain
Crisp concedes that the (two-jab) coverage of older people is still too low.
"We can't avoid a fourth wave if there is another mutation. What we can do is minimise the destruction and clogging of hospitals with people who could have been protected," he says.
However, he has a caveat. "From a clinical perspective, Prof Madhi is correct - and that's our (vaccination) focus. But from a public perspective, we need to maintain the 'everyone' message. We've seen child infections in this (Delta) wave, which we did not see before and we've seen many children die this time. We can't cherry-pick a handful of comorbidities, so we need people to be able to come for vaccination if they feel at risk. We can't avoid the fourth wave if there's another mutation," he says.
Best and worst-performing provinces
Department of Health statistics shows that by 22 September Mpumalanga was the worst-performing province when it comes to vaccinating the 50 to 59-year-old age group. The number for this age group (all percentages at least one jab) stood at 39.6%.
Also in this age band is North West as second worst-performing province at 40.43%, but arguably even more concerning, the third worst-performing province is the far more densely populated Gauteng, at 45.3%.
For the over 60s, the Northern Cape, (SA's least-populated province), has 45.8% jabbed, followed by Mpumalanga at 49.1% and the North West at 49.4%. Limpopo comes out top in vaccinating the over-60's at 71.7%, followed by the Western Cape at 65.66%.
In the 50 to 59-year-old age band, the Eastern Cape has 59% of people jabbed, followed by the Western Cape at 53.3%.
Crisp says that while district-level health data is available, it is not very helpful because people tend to move to the most accessible vaccination station, which is often in another district, and are thus incorrectly counted geographically.
Real jab percentages lower
Emeritus Professor Rob Dorrington of the University of Cape Town's Centre for Actuarial Research points out that very few of the 60-plus group were fully vaccinated in time for South Africa's third wave of COVID-19.
He warns that vaccination figures for those fully vaccinated (either one dose J&J or two doses Pfizer/BioNTech) in this group will be at least 10% or more lower than the single-dose figures to the end of September.
"The difference will be even bigger for the 50-59 age group (where vaccination rollout began later)," he adds.
Of Limpopo's success with the most vulnerable over 60s age group, Bradshaw says, "Right in the beginning they went from village to village and were strong on community outreach. I don't think we've tried that in all areas."
Literacy and access biggest barriers
Bradshaw doubts that vaccine hesitancy or anti-vaccination sentiment was behind the overall low older age vaccination figures.
"I think it's all about vaccination literacy and access. The government's literacy campaign virtually coincided with the start of vaccination. They've been late with the entire program. In December last year, scientists like Shabir and Glenda (Gray, CEO of the SAMRC) had to rattle the cage just to get them to think about vaccination. This duo wrote a paper for the SA Medical Journal where they literally had to say, this is what you have to do to get a vaccination program... here are the 10 essential steps," says Bradshaw.
Asked if she knew of any specific sub-groups and geographic districts where vaccine uptake was particularly low, Bradshaw says there was a paucity of data, "but it seems to me that uptake in the white areas is greater than in other areas and I think vaccine literacy probably plays a big part in that. It's been left to government across the country and it's very uneven, with several areas where not nearly enough is being done."
She expresses concern about the townships but cautioned that her knowledge centred on the Cape Metropole townships.
"Khayelitsha (Cape Town's biggest township with an estimated 1.2 million inhabitants), had a very bad first wave with a much lower second wave, (some consensus around acquired immunity), but the third (Delta) wave hit them hard again. Nobody's reached out to townships like this to make sure they get full access," she says.
Waves hard to predict
Bradshaw parts company somewhat with Madhi on the likelihood of a fourth wave by Christmas.
"I'm not convinced there's going to be a fourth wave - it all depends on the variants and it's so random. I honestly don't know that you can predict it from our data. I think the nature of viruses is they mutate. So yes, it's going to happen sometime. There seems to be a lot of certainty about it when I think there aren't really grounds for it. You have to see it against a backdrop of [a] heck of a lot of people infected, so the level of immunity when combined with vaccination, is growing. A fourth wave is not a given, but I would expect one by next winter," she says.
"She's right," Crisp agrees. "If Delta remains dominant and there is no new variant, there will be protection via both vaccination and from the natural immunity in people who've been infected and recovered. But this virus mutates and we need to be on our guard."
Asked if South Africa was "sort of OK until next winter?" Crisp's answer was an unequivocal "no".
"From where I sit, we need to be prepared for anything. We cannot make rapid plans if things change - we need to be ready now. As much as I pray for a reprieve for our colleagues at the coalface, I am afraid that now is the time to fortify defences, not slack off and hope for the best. Better to be pleasantly surprised than caught off-guard," he says.
"The message must be clear- vaccinate to save the health system and to save lives. And maintain the non-pharmaceutical interventions throughout. This is everyone's responsibility, not something government or the Department of Health can or should attempt to do alone," says Crisp.
Hard to quantify
While there is wide agreement that vaccination has and will continue to save lives, the exact impact is hard to quantify.
Dorrington says he had tried to tease out the impact of vaccines on excess deaths, using the numbers of people testing positive and comparing the trend over time of the 60-plus excess deaths with that of the under 60s deaths. "Neither produced results that I had much confidence in or made much sense provincially," he says.
He said the reasons for this probably included 'significant uncertainty' around the estimates of confirmed cases and the very different pattern of confirmed cases, by age, between the second and third waves.
More teens getting infected
Meanwhile, Dorrington says that the highest current percentage of COVID-19 positive people is in the 10 to 19-year-old age band.
South Africa's Minister of Health, Joe Phaahla recently acknowledged a decision by the health products regulator to approve Pfizer's COVID-19 vaccine for use in children over the age of 12. He said that depending on the number of adults vaccinated by the end of October, the government would then review its policy on vaccinating people under 18.
"Even though we know the Pfizer vaccine has been approved (for children), we want to remain focused on the high-risk people as of now. If we can reach 70% of the 50 and older age group, (fully vaccinated), when the next wave comes, our hospitals will not be as overwhelmed as they have been," he said.
Phaahla said that government was aware of pressure from schools to have children vaccinated. Other factors that would be considered were the local government elections on 1 November, which could result in a high number of transmissions, and an excess vaccine supply that would allow the under 18 age group to be targeted.
"We think it will be very risky to be all over and start just vaccinating people everywhere. Let's manage the schools and keep on pushing the elderly to get vaccinated," he said.