One of the challenges of rolling out a national vaccination programme in the middle of a pandemic is that some people die within days of getting the jab. Not from the vaccine, but from the virus which had been insidiously incubating at the time of vaccination, resulting in death before the body could mount an adequate immune response.

The South African Health Products Regulatory Authority (Sahpra) has investigated 86 deaths that occurred soon after vaccination up to the end of August 2021, and of the 40 fully investigated by mid-September, 13 had been as a result of Covid-19 infection, while the rest were unrelated to Covid.

We should remember that people continue to die of other natural causes at the rate of about three deaths to every one Covid-death. Nevertheless, my voice of reason becomes a little reedy when a grieving woman tells me that her sister died from the vaccination. Reedy not because I doubt the science, but because the rawness of death confers on the bereaved a certain immunity from contradiction.

Unfiltered, that news will spread rapidly through physical and digital villages, landing in the homes of those who don’t have a major issue with vaccines, but are just a bit scared of the unknown; scared enough to wait “until tomorrow” before being vaccinated. In their minds, and in the absence of reassuring information to the contrary, the bad news reinforces the stream of misinformation bombarding their cellphones.

For many in South Africa, these falsehoods are clasped not so much as immutable beliefs steeped in ideology as psychological handholds in the face of uncertainty. Factoids may be false, but they are transmitted with 100% conviction – unlike the guarded language of science which expects the layperson to find comfort in lower statistical probabilities of infection, disease and death.

Which is why direct rebuttal of anti-vaxxer positions may prove counterproductive. It makes people feel more embattled in the face of so many intersecting stresses of life. They retreat into their networks of trust, buttressed against the cold incursions of science. While we may obsess over Covid-19, it is simply one of the many risks faced by ordinary people in the course of their daily lives, who are concerned with their safety on the streets, coping with domestic violence, or living with hunger and other health conditions like HIV.

This is probably why we see such a big gap between the high percentage of adults in South Africa who tell interviewers that they will accept the vaccine if they are offered one, and the lower numbers of people who actually come forward for vaccination.

Strategies for beating the fourth wave

With a fourth wave likely before the end of the year, our national target is to vaccinate 70% of adults – with at least one dose – by Christmas. By mid-October we’ll be halfway there, which means the pace of vaccination must be massively escalated to avert the 20,000 to 30,000 deaths predicted in this wave.

Working with leadership both inside and outside of government, the Department of Health has identified five key strategies to build “demand”. They include:

  1. Intensifying public leadership across all sectors;
  2. Making communications simpler and clearer;
  3. Ramping up media and marketing strategies;
  4. Energising networks of civil society, labour and business; and
  5. Encouraging incentives that enhance the value and offset the opportunity costs of vaccination.

Over the past two months, a more systematic and grounded process of demand acceleration has been put in place, which we hope will provide new impetus to the roll-out process.

One such activity is the Vooma Vaccination Weekends, recently announced by President Cyril Ramaphosa. The first one was held over three days at the beginning of October, where provincial premiers and municipal mayors were requested to convene events in support of the programme.

At least 43 of the 52 metros and districts did so, staging 88 community events, and close to 1,400 vaccination sites remained open for the entire Saturday. On Sunday, 506 sites were open for business. Over three days, 360,000 people were vaccinated – well below target, but still a substantial increase on normal weekend traffic.

The number of doses administered on the Saturday and Sunday was two and a half times the usual number, and in the subsequent week, the number of first-dose vaccines administered was about 25% higher than the average for the prior fortnight. This suggests that some of the “Vooma vibe” spilled over into the following week.

These events also provided an opportunity to recognise and appreciate the immense effort of health workers, health service managers and support staff across both public and private services. More than 1,000 health workers were nominated for special recognition and next week they will receive certificates signed by the President.

Eastern Cape comes first

It was especially encouraging to see the Eastern Cape ranked first in a comparison of provincial performance. This composite score rated the overall coverage (percentage of adults 18 years and older vaccinated), the impact on risk reduction (coverage of older people and men so as to substantially reduce hospital admissions and deaths), and considerations of equity (the ratio of vaccinations among those with medical insurance compared with those without).

Limpopo came second, while the Western Cape (top-ranked in terms of total coverage) came third. These ratings point to the relative success of these three provinces in achieving the right mix of service provision and stimulation of demand.

Across the country, the Vooma Vaccination Weekend helped build momentum for the broader demand acceleration strategy, driving an unprecedented level of political and social mobilisation in almost every district. The “Vooma” name stuck, and the mining industry will soon hold its own Vooma weekend, aiming to achieve 80% coverage of its workforce.

Nationally, two more Vooma weekends are planned before the end of the year.

Notwithstanding the relative success, the weekend also served up its own dose of realism. An admittedly ambitious target of half a million vaccinations over a weekend was not achieved. We plan to retain that target number, because nothing less will make a massive dent in the numbers of hospital admissions and deaths projected for the fourth wave. Nothing less over the Vooma weekends – and at least a quarter of a million first-dose vaccinations every weekday between now and mid-December.

A more modest target would imply that we accept a higher predicted mortality, which we don’t.

The increase in vaccinations over the Vooma weekend was driven largely by keeping sites open that are typically closed over weekends. The biggest challenge was the availability of staff, who also need time off, and in consequence only about two-thirds of the total number of vaccination venues were made available. Provinces have now been encouraged to review their daily vaccination patterns to ensure that hours of opening are most efficient in order to free up staff willing to work more over weekends.

One of the challenges in rolling out a national vaccination programme in the middle of a pandemic is that some people die within days of getting the jab. Not from the vaccine, but from the virus which had been insidiously incubating at the time of vaccination, resulting in death before the body could mount an adequate immune response. (Photo: Felix Dlangamandla)

However, higher public participation was not only due to the availability of sites, but also to the intense public communication and social mobilisation that accompanied it.

Regression analysis of the weekend data suggests that the “Vooma effect” created by publicity and active enlistment was about 34% above the numbers that could have been expected simply by keeping vaccination sites open. We hope to enhance this premium over time as both media and community-based initiatives continue to expand.

Incentivising vaccination

But even a 50% increase on current first-dose vaccination numbers would still leave us five million adults short of the end-of-year target. Of these, more than two million will be among people older than 50, who must be included because they account for 80% of the Covid-19 mortality.

That is why we must now consider incentivising vaccination among older people.

While the vaccine itself is free, current levels of food insecurity mean that for many, when gogo catches the minibus taxi to get vaccinated, her family goes a lot hungrier that day. A R100 grocery voucher could tip the scales in favour of vaccination by offsetting that fare and other transactional costs. If one million unvaccinated people aged 60 or older responded favourably to the incentive, the outlay of R100-million would result in net savings of R525-million in terms of hospital admissions averted. The broader social and economic returns would be even greater.

Perhaps a million is over-optimistic, but even a third of that number would return five times the amount spent incentivising participation in this age group. The gains from incentivising younger people is less a direct impact on morbidity and mortality and more in achieving the critical thresholds of coverage needed to prevent future waves of infection.

It would still be worth it.

When the first national round of Covid-19 vaccinations draws to a close – hopefully by March or April 2022 – we will have spent close to R10-billion of public funding on the procurement, distribution and delivery of vaccines. While the state of our public coffers constrains commensurate investment in demand-side strategies, it is in our common interest to secure the resources to continue to both expand societal mobilisation and those individual incentives likely to yield substantial rates of return.

The fewer people dying, the lower our shared anxiety and the easier it will be for Covid-19 vaccinations to become a normal part of life. Our aim is to achieve that epidemiological and psychological tipping point before the end of this year. Ultimately, there are only two ways to drive demand. Either we can make vaccinations mean more to people or we can make it easier for them to get vaccinated. If we are to get anywhere near our target, we will need to do both. DM/MC

David Harrison is the CEO of the DG Murray Trust. He has been seconded to the National Department of Health to lead a Demand Acceleration Task Team.

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