Update on Omicron Variant & state of preparedness for fourth wave; with Deputy Minister

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Health

01 December 2021
Chairperson: Dr K Jacobs (ANC)
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Meeting Summary

Video

In this virtual meeting, the Committee was briefed by scientists at the KwaZulu-Natal Research and Innovation Sequencing Platform (KRISP) and the National Institute for Communicable Diseases (NICD) on the new COVID-19 variant, known as Omicron or B.1.1.529, whose detection in South Africa had been announced earlier that week. The national Department of Health was also present to answer questions. 

KRISP briefed the Committee on the genomic surveillance of COVID-19 and Omicron. It reported that South Africa was probably in the very early stages of a fourth wave of COVID-19 infections, which in turn would probably be driven by the Omicron variant. Current diagnostic tests appeared to be effective at detecting Omicron, but Omicron’s genetic code different significantly from that of the Delta and Beta variants, so further research was needed to ascertain its behaviour and likely impact. It was concerning that more than 30 of the Omicron mutations were concentrated in the spike protein. Initial study suggested that Omicron would increase the risk of reinfection and undermine the vaccine’s protections against infection. Importantly, however, the vaccine’s protections against severe disease were expected to remain effective against Omicron, meaning that vaccination remained the critical tool in preventing severe illness and death. KRISP also cautioned against relying too heavily on early anecdotal reports that Omicron caused only mild symptoms – more severe cases might be observed in coming weeks. 

Presenting an epidemiological update, NICD agreed that the fourth wave of COVID-19 infections appeared to be arriving sooner than expected, driven by the spread of the Omicron variant. On 1 December, 8 561 new cases had been reported, including 6 168 in Gauteng, for a national case positivity rate of 16.5%. Cases were currently most prevalent among people aged 25 to 29 and concentrated in Gauteng – the first clusters had been detected in Tshwane. However, they were beginning to spread to other age groups and provinces, though the coastal provinces appeared to be lagging slightly behind. Hospitalisations were also beginning to increase in Gauteng and the North West, and were expected to increase more markedly in a fortnight or so. NICD also agreed with KRISP that Omicron required the same public health response as prior variants: vaccination to reduce severe illness and death, and behavioural changes to reduce transmission. 

Among other things, Members asked KRISP and NICD how long the pandemic was expected to last, whether vaccination was the cause of mutations in the COVID-19 virus, and how the vaccines’ efficacy against Omicron would be tested. They sought further detail about the hospitalisations recorded thus far and about how PCR tests detected Omicron. They also wanted to know whether Omicron differed from previous variants in respect of its clinical profile, incubation period, and effects on children. Finally, KRISP and NICD were given a chance to raise the key points which they wanted to communicate to the public and which might have been miscommunicated to date, possibly fostering vaccine hesitancy. 

Most of Members’ questions to the Department were about national and provincial preparedness for the imminent fourth wave of COVID-19. They also asked about the Department’s current vaccine supply, its plans to acquire new therapeutic COVID-19 treatments, and its strategy for providing booster shots. Some Members were concerned about travel bans instituted in foreign countries, and, in the domestic arena, about the possibility of vaccination mandates, the possibility of more stringent lockdown regulations, and the effect of the COVID-19 pandemic on the Department’s primary healthcare programmes. 

Summarising the key messages of the meeting that should be communicated to the public, the Chairperson concluded that the pandemic would continue, and the virus would continue to mutate, until 70% to 80% of the population was vaccinated.


 

Meeting report

Apologies and opening remarks
The Chairperson said that the meeting had been called for a special purpose – to receive a briefing on the new Omicron variant of COVID-19, and related matters.

The Committee noted apologies from Ms N Chirwa (EFF) and Mr A Shaik Emam (NFP). 

Dr Sibongiseni Dhlomo, Deputy Minister of Health, conveyed an apology from the Minister of Health, who was driving back from a World Aids Day event in rural Limpopo.

He said that the delegation from the national Department of Health (NDOH) was led by Dr Sandile Buthelezi, Director-General, NDOH. Dr Buthelezi had been suspended pending an investigation, but he had been cleared and the Presidency had reinstated him on Sunday. He had returned to work that Monday.

The Chairperson read out the parliamentary rules for the meeting.

He said that the country had been quite shocked by the recent announcement of the new Omicron variant, which had 32 mutations, 30 of which, if he understood correctly, affected the spike protein of the virus. That meant that the variant presented certain challenges and a possible threat to public health outcomes. The purpose of the current meeting was to receive an update on the variant, as well as to alert the public that a fourth wave of COVID-19 infections was potentially imminent. It was therefore important that everybody should listen closely to the advice given in the current meeting.

Opening remarks by the Deputy Minister

Deputy Minister Dhlomo said that scientists would shortly brief the Committee on the Omicron variant, but he always liked to provide an explanation in simple terms for the public. In simple terms, the COVID-19 virus mutated in an effort to “escape” the measures that had been put in place to eliminate it. Indeed, NDOH and the scientific community had expected further mutations – they just had not known exactly when it would arrive. The Ministry commended the leadership of Mr Blade Nzimande, Minister of Higher Education, Science and Technology, who had installed a genomic surveillance team within his department. South African scientists were doing excellent work – they had detected the new variant and had rightfully reported it to the World Health Organisation (WHO). The Ministry was “greatly alarmed” by the response of various large foreign countries to South Africa’s announcement of the new variant. Omicron had since been detected in many countries other than South Africa.

He said that NDOH took comfort in the fact that scientists reported that the new variant was a “twin brother” to prior variants and therefore would “not completely escape” existing containment measures or the immunity provided by the existing vaccine. Ultimately, everybody should work together to increase vaccination uptake. According to the science, a vaccinated person might still be infected with COVID-19, but would not contract severe or fatal illness as a result. In terms of assessing how virulent or dangerous the new variant was, it was “still early days,” although the scientists might be able to report that they had learned slightly more about the variant since they last briefed the media.

Briefing: Genomic surveillance of Omicron variant

Dr Buthelezi introduced the NDOH delegation. He said that there would be two presentations: a genomics update led by the KwaZulu-Natal Research and Innovation Sequencing Platform (KRISP), and an epidemiological update led by the National Institute for Communicable Diseases (NICD).  

Dr Richard Lessells, Infectious Diseases Specialist, KRISP, presented on the genomic surveillance of the Omicron variant. He conveyed an apology from Prof Tulio de Oliveira, Director, KRISP, for his absence.

Detection of Omicron

He said that the new variant, known as Omicron or B.1.1.529, had been detected by the Network for Genomic Surveillance South Africa (NGS-SA). The Department of Science and Technology and the South African Medical Research Council had presciently invested in NGS-SA’s establishment. He outlined the composition of the network, which was very collaborative and included NICD, several academic laboratories, and several public and private testing laboratories. The discovery of the Omicron variant was due to Lancet Laboratories, one of the private laboratories. Lancet had noted an increase in S-gene dropout in the results of its polymerase chain reaction (PCR) tests, and that had led to the sequencing of Omicron.

The global public database now contained more than 300 Omicron genomes (an increase of 85 from the figure recorded in the presentation earlier that day), from samples collected since 8 November. The PCR testing suggested that Omicron was likely to be present and spreading in all provinces, and samples had already been collected from Gauteng, KwaZulu-Natal, the Western Cape, the Eastern Cape, and Mpumalanga.

Epidemiology

Dr Lessells said that South Africa was very likely in the very early stages of a fourth wave of COVID-19 infections. Currently, infections were most advanced in Gauteng, but a sustained increase in cases was beginning to become visible in most provinces. An increase in hospital admissions, mostly in Gauteng, was also beginning. Omicron was rapidly overtaking the Delta variant, which recently had been spreading at very low levels, to become the dominant COVID-19 variant in South Africa.

Genetic profile of Omicron

He highlighted the following about the genetic profile of the Omicron variant:
· The mutations (more than 30 of them) were concentrated in the spike protein, which was concerning;
· The genetic code differed significantly from that of the Delta and Beta variants, and Omicron therefore was not a direct descendent of those viruses; and
· Although some of the mutations were well known, many others had not been extensively studied before, so their full significance was uncertain.

Implications
Scientists could make some predictions about the properties of Omicron based on its genetic code and existing knowledge of the mutations, but more work was needed to fully understand its behaviour and likely impact. That work would involve both laboratory and field study. Pending confirmation, initial study suggested that Omicron probably:
· Presented a higher risk of reinfection among those previously infected;
· Would not significantly affect the recommended therapeutic interventions (since the primary therapeutic, Dexamethasone, did not act directly on the virus);
· Did not undermine the efficacy of existing diagnostic tests; and
· Undermined some of the vaccine’s immune protections against infection, though it was less likely to undermine the vaccine’s protections against severe disease and death.

Dr Lessells said that Omicron’s predicted effects on the reinfection rate and vaccine efficacy were related to the fact that the mutations seemed to affect neutralising antibodies, which might therefore become less effective at preventing infections. However, the mutations were much less likely to affect other arms of the immune system, particularly T cells, which protected against severe disease and death.

Thus vaccination remained the critical tool to prevent severe COVID-19-related disease and death. Indeed, the rollout of the vaccine meant that South Africa was better equipped to withstand the Omicron variant than it had been to withstand the Beta variant the same time last year. Non-pharmaceutical public health and social measures also remained critical to slowing the spread of COVID-19.

On disease severity, he said that there had been media reports claiming that the Omicron variant caused only mild cases. However, it was still early in the spread of Omicron, and so far Omicron cases had been concentrated among younger age groups, who were at much less risk of severe disease in the first place. Moreover, many of those infected with Omicron had previously been infected or vaccinated, and therefore might have some immune protection against severe disease. The concern – especially on the wider African continent, where vaccination rates were very low – was that if Omicron spread efficiently, it would ultimately infect vulnerable people who were unvaccinated and not protected against severe disease.

(See presentation.)

Briefing: COVID-19 epidemiology update
Dr Michelle Groome, Epidemiology Lead: Incident Management Team (IMT) and Head: Public Health, Surveillance and Response, NICD, presented an epidemiological update on COVID-19 in South Africa.

She reminded Members that there had been three waves of COVID-19 infections thus far, with a particularly protracted third wave. Before the emergence of Omicron, case numbers in South Africa had been very low. Based on past trends, a longer respite had been expected before the start of the fourth wave, but the emergence of Omicron had proved to be a “wild card.”

National incidence of COVID-19

Dr Groome presented national epidemiological data, the highlights of which included:
· 2.98 million confirmed COVID-19 cases in total;
· 8 561 new cases on 1 December, including 6 168 new cases in Gauteng;
· 8.3% case positivity rate in the previous week (and 15.9% in Gauteng), a substantial increase from an annual low of just over 1% in the first two weeks of November;
· 16.5% case positivity rate on 1 December; and
· Highest incidence in the last week among 25-29 year olds, although cases were beginning to spread to older age groups.

She said that the technical definition of a wave was not central to the public health response and should not be overemphasised. What was important was that epidemiological data showed an exponential increase in case numbers – indeed, a more rapid increase than that observed at the beginning of the previous waves. The positivity rate and seven-day moving average of new cases were both concerning. It should also be borne in mind that, although South Africa had the best testing facilities on the continent, the number of confirmed cases remained a considerable underestimate.

Hospitalisations and deaths

Although there had not yet been any indication that COVID-19-related deaths were increasing, hospitalisations were beginning to increase, especially in Gauteng and the North West. However, hospitalisations and deaths lagged behind case numbers, usually by two to three weeks, so severe illnesses probably would not be reflected for another fortnight or so. 

Provincial incidence of COVID-19

Dr Groome outlined the epidemiological trends in each province. The current increase in cases was concentrated in Gauteng – it had first been detected in Tshwane, but was now affecting all districts of Gauteng. There were also increases in Limpopo, in Mpumalanga, and in the North West, where case clusters had first been picked up in districts bordering Tshwane. Case numbers in the other provinces were also increasing, but seemed to be lagging slightly behind in the coastal provinces.

Implications

As Dr Lessells had said, there were anecdotal reports that Omicron caused milder symptoms, but cases had thus far been reported mostly among younger age groups, and any widespread severe illness was not expected to present for another few weeks. The rapid increase in cases, and particularly the rapid spread of the Omicron variant, was concerning. As Dr Lessells had also said, the same public health measures remained critical, especially promoting vaccination and, to reduce transmission, promoting mask-wearing, adhering to social distancing, and limiting large gatherings. 

(See presentation.)

Discussion

Questions for KRISP and NICD

Ms A Gela (ANC) asked how many individuals were in the intensive care unit (ICU) with illness related to the Omicron variant.

She asked whether children and other young people were particularly affected by the Omicron variant. She had heard of children under the age of 12 being infected with Omicron, and she knew that the vaccination programme had now been opened to children aged 12 to 17.

Mr P Van Staden (FF+) asked how PCR tests detected the Omicron variant. What was South Africa doing to obtain and use those tests?

He agreed with Dr Lessells that more work had to be done to understand the new variant fully. There had been local elections on 1 November, but that did not seem to have led to any uptick in COVID-19 cases in mid-November. An uptick was now being observed in early December. How was that possible?

He said that he had personally been fully vaccinated. However, how effective was the vaccine against the Omicron variant? He thought that many South Africans wanted to know.

He asked how long scientists expected COVID-19 to remain prevalent. When would COVID-19 be completely “destroyed”? 

Mr M Sokatsha (ANC) said that he applauded researchers for their outstanding work and for detecting the Omicron variant at a very early stage. South Africa, and especially its knowledge systems, had been “colonised” for too long, and this showed that South Africans could also “take initiative.” He condemned the way that the United States and other countries were treating South Africa after its discovery of the variant. South Africa had moved away from colonisation – it needed to decolonise and develop its own knowledge systems and research.

He said that many of his questions had already been asked by other Members or answered. However, did the Omicron variant have the same symptoms as earlier variants? Did it have new symptoms by which it could be distinguished?

Ms E Wilson (DA) asked whether scientists had any idea of the incubation period of the Omicron variant. She knew that was a difficult question to answer, but it was often asked by members of the public, for example if they had come into contact with people who were infected with COVID-19.

She said that earlier that day she had read an article which had basically said that vaccinations caused the virus to mutate. She was not sure how to respond to that, because it was not her sphere of expertise – could the scientists explain?

She said that the graphs in the NICD presentation showed marked increases in the number of cases among children. She knew that the Omicron variant was being observed in teenagers and young adults, especially at higher education facilities, but there also seemed to be a marked increase in cases among children under the age of nine. Had something changed in that regard? She did not recall that children had been particularly affected by COVID-19 in the past.

On behalf of Dr S Thembekwayo (EFF), the Chairperson asked whether the Omicron variant caused the same level of illness as other variants.

Ms M Sukers (ACDP) asked whether KRISP could expand on natural immunity, and on how durable natural immunity was expected to be against the Omicron variant.

She asked how the vaccines’ efficacy against Omicron would be assessed. 

Ms H Ismail (DA) asked whether existing vaccines would protect against Omicron. Would Omicron possibly necessitate a completely different vaccine, especially since it was affecting young people more than it was affecting older people?

She asked how many deaths the Omicron variant had caused.

She asked whether children had been adversely affected by the Omicron variant because they had not been prioritised for vaccination. Did the children who had contracted COVID-19 have comorbidities?

She said that members of the public had asked whether it was not strange that vaccinated people were those most affected by COVID-19.

Ms S Gwarube (DA) said that many of her questions would relate to the vaccination rollout, because, although the vaccine’s efficacy against Omicron had not yet been determined, vaccines probably remained the best way to protect people from COVID-19. What was the process for determining the efficacy of vaccines against various variants, and how advanced was that process in respect of Omicron? The outcome of that evaluation would determine what the next step in the response should be – the situation would be completely different if there were concerns that existing vaccines were not effective against Omicron.

The Chairperson said that, for some time, the Committee had wanted to meet with scientists in order to receive explanations on several COVID-19-related matters. He had been asking himself, what was it that members of the public misunderstood about COVID-19? What was it that caused vaccine hesitancy? What were the government and the scientific community explaining poorly? The current meeting was being broadcast on television and elsewhere, and it was an opportunity for participants to tell the public what they should be doing and why. Other Members had raised questions about vaccine mandates and the vaccination of children, and, throughout the pandemic, there had been such questions about and challenges to the vaccination programme and its rationale. This was a major challenge, and he thought that some part of the government’s message was not being communicated clearly.

He said that, at first, it appeared confusing that the vaccine did not protect against infection but did protect against severe illness and death. Dr Lessells had explained this point, but he would reiterate, because it was critical for the public to understand the importance of vaccinations and of non-pharmaceutical interventions. As Dr Lessells had said, the new variant could probably sidestep neutralising antibodies, but fortunately probably had less of an effect on the other arms of the immune response, particularly on T cells. These were two different responses the body had to a virus: an antibody response, and then a T cell response. The T cell response was not triggered until the person had already contracted an infection – only antibodies, and not T cells, could prevent someone from contracting an infection following exposure.

He asked KRISP and NICD what their key message the public was. What were their key reasons for urging people to get vaccinated?

He also asked about the clinical profile of the Omicron variant. Was it the same as that of the Beta and Delta variants? He was not sure how much was known at this stage, but the clinical profile of the virus would determine patients’ health outcomes.

He noted that there had been an increase in hospitalisations. Where had those patients been admitted – the COVID-19 wards, the high care units, or the ICU? How many were in the ICU?

Responses from KRISP and NICD

To Mr Van Staden’s question about the detection of Omicron, Dr Lessells replied that the variants were usually picked up through genome sequencing. Genome sequencing was the complicated process by which specialist laboratories used specialist machines to ascertain the virus’s whole genetic code. However, Omicron was flagged by one variety of PCR test. Many different kinds of PCR tests were in use in South Africa, and they targeted or detected different areas of the genetic code. The kind of PCR test in question was used in about 20% of testing by the National Health Laboratory Service, and it was used frequently by some private laboratories, especially Lancet. Omicron was flagged on this kind of test because of the location of one of its mutations. When virologists looked at the test results in the laboratory, they could see that the PCR test was detecting only two of the genetic targets – one target, the S-gene, was missing. That test result profile acted as a proxy marker for the Omicron variant. However, it was inconclusive, because the same profile could be observed with other variants, especially the Alpha variant, which had never been a big problem in South Africa but had been a problem in the United Kingdom and elsewhere. Because the PCR test could not conclusively identify the Omicron variant, it was still necessary to use genome sequencing to confirm. However, the PCR test did provide a proxy marker, by which the spread of Omicron could be roughly measured, without doing genome sequencing for all samples.

On the Omicron variant’s clinical profile, Dr Lessells said that he knew that there had been reports in the media about doctors’ anecdotal observations. However, the severity and type of the illness depended on the host’s immune system as well as on the virus itself. Although the virus was changing, the population’s immune response was also changing. Much of the population had built up some immunity from previous infections or from vaccination, and that would modify the symptoms experienced by such individuals, including upon infection with the new variant. That was why scientists were cautious in interpreting recent reports of mild illness due to Omicron: younger people were more likely to have mild illness; people who had immunity were more likely to have mild illness; and most COVID-19 cases were mild anyway.

However, he said that, overall, the symptoms of the new variant were not likely to be significantly different from the symptoms of previous variants, though there might be some slight variations. COVID-19 was still a respiratory virus with the corresponding respiratory symptoms: fever, sore throat, headache, running nose, and, if the disease progressed, cough and shortness of breath. The overall clinical picture would not change significantly, despite the changes in the virus’s genetic code.

To Ms Wilson’s question about the incubation period, he replied that scientists did not know whether Omicron’s incubation period differed from that of other variants. However, it was very unlikely to be significantly different. The incubation period for COVID-19 usually ranged from two or three days to about 14 days, and was five or six days on average.

To Ms Wilson’s question about whether vaccination caused mutations, he replied that the exact opposite was true. Unfortunately, variants would continue to emerge for as long as COVID-19 was allowed to continue infecting people. The virus evolved in order to survive and continue spreading. That was why the mutations did not really change the clinical profile of the disease: the mutations were solely designed to enable the virus to keep spreading, and COVID-19 was mostly transmitted just before or around the time that symptoms appeared in its host, so the virus’s survival did not depend on the symptoms experienced by its host. Currently, it seemed that COVID-19 had evolved to more effectively infect people who had some immunity to previous variants. The Omicron variant had a survival advantage because it was able to get around some immune defences – it could spread more efficiently because it could infect people who had some immune protection as well as people who were unprotected. 

On the Chairperson’s point about vaccine hesitancy, Dr Lessells said that he thought that all scientists and doctors took some blame for what might have been poor communication about the COVID-19 vaccine. It was critical to understand the different layers of protection offered by the virus, and to understand that the vaccines were primarily designed to prevent severe disease of the kind that resulted in hospitalisation or death. Early on, the results of the first vaccine trials had supported the optimistic view that the vaccines were also good at preventing milder and moderate illness, so the scientific community had initially hoped that vaccines would help prevent infections and slow the spread of COVID-19. Over time, with the emergence of variants, that optimism had dissipated, as it became clear that the virus had found ways to get around the vaccine’s protection against infection. The virus was clearly getting better at that. However, so far, there was no sign that the virus could get around the vaccine’s other, more important layer of protection, the protection against severe disease. That was critical, and that was what had to be communicated to the public. The vaccines were designed to prevent their recipients from being hospitalised or dying, and they did that well even in the face of the virus’s evolution. He thought that most people did not want to get very sick, be hospitalised, or die – and, currently, the only way to give oneself that kind of protection against the virus was to get vaccinated.

Dr Groome said that the age distribution of new COVID-19 cases had been covered in her presentation, but the presentation had contained a lot of information that might have been difficult for Members to parse. Very little severe COVID-19-related disease was observed among the very young – it affected only a small proportion of children under the age of ten. More affected among younger age groups were those over the age of ten, especially high schoolers, who, clinically, tended to behave similarly to adults. In previous waves, there had been some infection among younger children, but only a small proportion, and those who became severely ill usually had underlying conditions. The case numbers always reflected the testing that was done in the population. Thus, for example, some of the cases among children were likely asymptomatic or very mild, and had only been detected because the child had taken a test when an adult in his household had symptomatic illness. Sometimes there was a small increase in hospitalisations among very young children, those under the age of two. She thought that was mostly a result of paediatricians being cautious and having a very low threshold for hospital admission. NICD regularly reported on the paediatric population specifically. Much of the information was available in its daily and weekly reports, which were published publicly on the NICD website.

On recent hospitalisations, Dr Groome said that there had been a small increase in the number of hospitalisations, but hospitalisations remained at very low levels. Some COVID-19 patients were in the ICU, but there had not been a significant increase in ICU occupation yet. She thought the situation would change in the coming weeks, and NICD would continue to monitor it. If Members were interested, NICD put out regular reports using Daily Hospital Surveillance (DATCOV) data, which recorded the number of admissions, ICU admissions, ventilations, and so on. 

She said that the efficacy of the COVID-19 vaccines was measured through clinical trials, some of which had been conducted in South Africa. Once the vaccines were introduced into the larger population, their efficacy in that context could be assessed, too. To assess the vaccines’ efficacy against the Omicron variant would require scientific studies of a specific design. NICD and other institutions were planning such studies – there was a working group of scientists who were experienced in conducting similar studies, and the WHO and others were also involved. Those studies would definitely be able to measure how the efficacy of the vaccine against Omicron differed from its efficacy against other variants like Delta.  

To Mr Van Staden’s question about when the pandemic would end, she said that COVID-19 was a very new virus and there was still a lot to learn. As Dr Lessells had said, the scientific community had initially been very optimistic that a highly effective vaccine could be developed and the virus eliminated. That optimism should probably have been tempered by the knowledge that, although smallpox had been eradicated and polio nearly eradicated, no respiratory viruses had ever been eradicated. It was probably unlikely that COVID-19 would disappear entirely. As the emergence of new variants had shown, initial ambitions for herd immunity would not be easily achievable.

However, as more people were vaccinated or acquired natural immunity, there would be less transmission of COVID-19 and less development of new variants which helped the virus to spread. South Africa was definitely in a better position now that it had been at the start of the pandemic – more was known about the virus, and many more people had some immune protection. Many people were vaccinated, and the level of natural immunity in the population was good – a large proportion of people in South Africa had been exposed, whether or not they had had symptoms or been tested. Studies showed that natural immunity lasted for at least six months, probably longer.

She said that, hopefully, the vaccine would be rolled out to younger children. She thought that the rollout had prioritised those who were at highest risk of severe disease, which was why it had started with older age groups. In the United States, the vaccine had been used for children under the age of 12. However, she thought that the vaccination programme would be driven by the clinical pictures observed, and currently those under 12 experienced a lot of asymptomatic disease.

To the Chairperson’s point about vaccine hesitancy, Dr Groome said that what had been different about the COVID-19 pandemic was the extent of the public’s access to information and to misinformation. On the one hand, scientists tried to ensure that data was freely available, but, on the other hand, the data might be difficult to interpret or open to misinterpretation. She thought that it was ultimately up to every individual to try to assess the available evidence to the best of his ability, and to counter misinformation by directing queries to the relevant health professionals. She thought that only a small proportion of the population was truly vaccine hesitant – the rest were fearful of the vaccines, perhaps due to what they had heard anecdotally or due to difficulties interpreting the data correctly.

She thought that another factor was that there had never been a vaccine roll-out on this scale before. Thousands of people were being vaccinated against COVID-19 daily, and that was different to the Expanded Programme on Immunisation schedules and other vaccination programmes that targeted diseases that were already controlled. She thought that people had forgotten the critical role of vaccines – probably only the older generations remembered the time before there had been vaccines for polio and other deadly diseases. There seemed to be a public perception that natural immunity was superior to immunity acquired by vaccination, and maybe also some disregard for the implications of attempting to control the disease through natural immunity alone. Providing the right information to the public was critical.

Questions for NDOH and Ministry

Ms Gela asked how prepared NDOH was for the fourth wave of COVID-19. Were all the provinces prepared? In the past, there had been oxygen shortages in some of the provinces – would that be a problem in the current wave? Had the provinces submitted reports on their readiness in respect of bed availability and staff numbers?  

Mr Van Staden said that he thought that the country was entering a difficult period, so it was good to receive the information presented in the briefings. However, he was “disappointed” that the Minister was not present – he thought it important that the Minister should be available for such meetings.

Mr Van Staden said that upon the announcement that the Omicron variant had been discovered, he thought that there had been a lot of concern among the public that the government would “overreact” and institute another hard lockdown. In his view, there were no grounds for a lockdown – the previous night, it had been reported that South Africa currently had 28 000 cases and a recovery rate of 96%. Last Friday, he had cautioned against the government creating “unnecessary panic” among members of the public. There was still not enough scientific information about Omicron available to justify a lockdown. The public was tired of lockdowns, and the government had to guard against making political decisions at the expense of the economy and the public’s wellbeing. Otherwise, there would be “severe protests.” He was glad that the Minister had issued a state condemning other countries for overreacting by instituting travel bans against South Africa – but, for the last twenty months, the South African government had been treating its own people in the same way that other countries were now treating South Africa. He welcomed the fact that the President had not announced a tightening of lockdown regulations during his speech on Sunday night. Because of the severe economic damage caused by previous lockdowns, South Africa simply could not afford a harsher lockdown. People had to accept that COVID-19 was “here to stay,” and the country had to find a way to “live with it.”

He said that COVID-19 vaccination mandates would not achieve the desired effects – they would only encounter “opposition” from members of the public. The choice to get vaccinated was the free choice of every individual. The government could not, under any circumstances, attempt to force or compel anybody to get vaccinated. As he had said at a Committee meeting in August, neither public nor private services could be denied to anybody on the basis that they had not or would not get vaccinated. It would be unconstitutional and could not be allowed. He referred attendees to Section 12 and 27 of the Constitution, and read out the entirety of Section 36, which required that limitations on constitutional rights had to be reasonable and justifiable, and listed factors which had to be considered prior to effecting such a limitation.  He also quoted from the speech the President had made on 1 February, in which the President had said that, “Nobody will be forced to take this vaccine. Nobody will be forbidden from travelling, from enrolling at school, or from taking part in any public activity if they have not been vaccinated.” The President’s announcement on Sunday – that a task team would be launched to investigate the option of mandatory vaccination – was concerning and indicated that he was “backtracking” on promises he had made in February. The Committee ought to serve on that task team, on the inter-ministerial committee, and on the National Coronavirus Command Council. Members had to be allowed to exercise oversight as Members of Parliament and as Committee Members.

Mr Van Staden said that mandatory vaccination would clearly create problems – if it was instituted, large-scale violence and protests would erupt. The day before, even the President of the United States had said that Omicron was no different from other variants, and that harsher regulations therefore would not be implemented in the United States. The Financial Times had reported that week that, according to the Chief Executive Officer of Moderna, Mr Stéphane Bancel, existing vaccines would be much less effective against the Omicron variant, and it would take months for pharmaceutical companies to develop a new vaccine that would be effective. COVID-19 was real and had to be “destroyed,” but the government could not institute any more lockdowns and could not violate anybody’s constitutional right to choose not to be vaccinated. People could not be denied access to health services, shops, and educational facilities on the grounds that they refused to get vaccinated. Employees could not be dismissed for refusing to get vaccinated – instead, employers had to take “reasonable steps” to accommodate those employees. A “balance” had to be found to resolve the issue for all South Africans. People’s constitutional rights had to be respected, and the government had to “be careful not to start a fight or unrest” between the vaccinated and the unvaccinated.

Mr Van Staden asked about the public health system’s state of readiness for the fourth wave of COVID-19 infections. Was the situation the same as it had been during the level-five lockdown, or had it improved?

The Chairperson said that he had been wondering whether Mr Van Staden was going to leave time for other Members to raise their questions and concerns.

Mr Sokatsha said that the Committee’s role was to serve as an oversight body and to keep government accountable. It had to be careful to retain its proper role, and therefore should not try to participate in structures of the executive arm of government.

On behalf of Dr Thembekwayo, the Chairperson asked whether the Omicron variant was expected to damage the South African economy further.

Also on behalf of Dr Thembekwayo, he said that governments around the world had moved quickly to warn the public about Omicron and to isolate travellers who might have been exposed to it. That response differed significantly from the response to previous variants, including the ultimately devastating Delta variant. Why had Omicron elicited a different response?  

Ms Sukers said that South Africa’s therapeutic response to COVID-19 appeared to be very limited. What plans did NDOH have to acquire supplies of molnupiravir and Paxlovid, and what other therapeutics was it considering?

She asked what proportion of the population had contracted COVID-19 so far. There had recently been a study by Discovery which suggested that 80% of the population had probably contracted COVID-19 in the past. Was there a level of herd immunity that might affect the severity of COVID-19-related illness?

She asked about disease control and disease management, particularly at the primary healthcare level. What was NDOH doing to ensure that patients sought early treatment, to arrest the progression of the disease? What was NDOH doing to promote disease control among people who had comorbidities? The ACDP was concerned that, contrary to what Deputy Minister Dhlomo had said in response to her parliamentary question in the House, other healthcare programmes, such as HIV/Aids programmes, had been neglected during the pandemic. She had read an article earlier that day which said that South Africa was at the forefront of HIV research and response, but was losing the battle to eradicate HIV/Aids and arrest its spread. The ACDP had raised these concerns before, and the country was now entering a fourth wave of COVID-19 infections. What was NDOH doing differently to ensure that more people did not die because they had underlying conditions, like diabetes, which were not under control?

Ms Ismail asked how prepared hospitals and communities were for the fourth wave of infections. Were there any programmes or workshops conducted in communities, so that communities were aware of what to expect, what to look out for, and how to react when their family members fell ill?

She said that citizens’ constitutional rights always had to be respected, including their right to choose whether or not to take the vaccine.

She asked whether there was any logic to travel bans.

She said that the government was promoting vaccines in order to reach herd immunity and in order to mitigate COVID-19’s effects on those who contracted it. It seemed that booster shots would probably be offered more widely, because the existing vaccines did not protect anyone from infection with COVID-19, regardless of the variant. In the long term, did NDOH envisage a situation similar to that with flu shots, where vaccines were administered annually?

Ms Gwarube asked about the readiness of the health system. The second wave had been particularly devastating partly because it had occurred during the festive season – the healthcare system had been severely overstretched. The health sector’s readiness remained an important question, even if, as Dr Lessells had said, it was not yet possible to determine exactly how the Omicron variant would behave.

She asked about the supply of the COVID-19 vaccine. How many doses were currently available in South Africa?

She noted that NDOH had announced that additional shots of the vaccine would be made available to immunocompromised people. In general, what was NDOH’s strategy and stance in respect of booster shots, especially for healthcare workers? A long time had now passed since the vaccination of healthcare workers under the Sisonke programme.

She said that other Members had expressed a lot of concern about mandatory vaccination. Could the Ministry provide an update on what conversations were happening as the government considered the feasibility of instating mandatory vaccination? This would not be an easy issue, and other countries, especially in the European Union, were dealing with the same problems.

The Chairperson said that vaccine nationalism, vaccine hoarding by certain countries, and the unavailability of vaccines in poorer countries had a major impact on South Africa and on the African continent. Moreover, insofar as it affected health outcomes in Africa, it would also affect health outcomes in other countries. This interdependency should be apparent to foreign governments from both a long-term and a short-term perspective.

The Chairperson said that, for many people, herd immunity was a central objective of vaccination. It was necessary to reach a point where people no longer became infected, so that the virus would die out. Once the virus’s hosts were immune to it, it would cease to mutate.

Responses from NDOH and Ministry

Deputy Minister Dhlomo said that Ms Gwarube might have missed NDOH’s announcement about booster shots for healthcare workers. NDOH had already decided, even before scientists confirmed that immunity was waning among healthcare workers, to err on the side of caution and give booster shots to healthcare workers. NDOH officials would confirm, but he thought that the booster shot programme had been ongoing for about three weeks. Healthcare workers had been the first to be vaccinated, so they should be the first to receive booster shots. Moreover, they had to care for patients, including COVID-19 patients, so it was morally correct to minimise the risks they faced. A significant number of healthcare workers had received the first shot and were expected to go for the booster shot. In terms of improving vaccine uptake generally, there was another Vuma vaccination campaign that weekend, during which NDOH would take the vaccine closer to where people lived.

He said that he did not know how to assist Mr Van Staden with his disappointment about the Minister’s absence, which had been unavoidable. The Ministry had been invited to meet with the Committee today, which happened to be World Aids Day and the date scheduled for a government event in Limpopo. It would have been “unfair” for the Deputy President to attend that event but not the Minister. Deputy Minister Dhlomo and others were present on behalf of the Ministry.

Deputy Minister Dhlomo said that the President’s address of 28 November dealt with many of the points raised by Mr Van Staden. He quoted at length from the address, in which the President said, “As individuals, as companies and as government, we have a responsibility to ensure that all people in this country can work, travel and socialise safely. We have therefore been undertaking engagements with social partners and other stakeholders on introducing measures that make vaccination a condition for access to workplaces, public events, public transport and public establishments. This includes discussions that have been taking place at NEDLAC between government, labour, business and the community constituency, where there is broad agreement on the need for such measures.” He emphasised the “broad agreement” emphasised by the President – the government could not ignore the fact that others might, and did, strongly hold the opposite of Mr Van Staden’s own position. For example, church leaders were ready to have their congregations return, but first had to ensure that all members of the congregation were protected and therefore that they were vaccinated.

Quoting the President further, he said that there was a task team, which “will report to the Inter-Ministerial Committee on Vaccination chaired by the Deputy President, which will make recommendations to Cabinet on a fair and sustainable approach to vaccine mandates.” Mr Van Staden seemed to be implying that his individual rights trumped collective rights, yet the government had been advised that the opposite was often true. The government would not deny people the freedom to remain at home if they wished to remain unvaccinated, but it would be “foolhardy” for unvaccinated people to insist on riding in taxis full of vaccinated people. A person could insist on his individual right not to get vaccinated, but he also had to be prepared to respect the rights of other people in society, whom his choices affected.

Deputy Minister Dhlomo said that the President had been clear about the policy stance on lockdowns. He had said in his address, “In taking the decision not to impose further restrictions at this stage, we considered the fact that when we encountered previous waves of infection, vaccines were not widely available and far fewer people were vaccinated. That is no longer the case. Vaccines are available to anyone aged 12 and above, free of charge, at thousands of sites across the country.” South Africa was not the only country which had instated lockdowns at the start of the pandemic – all the world had shared the same fears about COVID-19. However, as the President had explained, lockdowns were no longer necessary, because vaccines had been developed and the circumstances had therefore changed. Thus the government encouraged everybody to get vaccinated. According to scientists, the vaccine might not prevent transmission of COVID-19, but it would reduce hospitalisations and deaths.

On the readiness of the health system for the fourth wave, Mr Raveen Naidoo, Lead: IMT and Director: Emergency Medical Services (EMS), NDOH, said that NDOH had started planning and preparing as soon as the third wave ended. Scientists had anticipated a fourth wave. NDOH had revised key areas of its readiness plan on the basis of lessons learned in previous waves. The plan encompassed contract tracing and testing, communications, hospital readiness, case management, Port Health Services, EMS, and epi-surveillance. The results of the active work being done in epi-surveillance had been demonstrated to the Committee in the current meeting. Once the national plan was completed, it had cascaded down to each province. Each province had reviewed its fourth wave plans, including continuous and daily monitoring of case numbers, using data, and so on. There were also provincial IMTs. The results were visible, for example, in KwaZulu-Natal – NDOH had been notified of an outbreak in KwaZulu-Natal the day before, and had worked with the provincial department to ensure that Ballito Rage was cancelled.

He said that there was an oxygen plan in place, which incorporated lessons NDOH had learned in the past, especially during the second wave, when there had been an oxygen “crisis” particularly affecting the Western Cape. Under the plan, the hospital readiness team closely monitored the status of oxygen supplies. There were live dashboards which NDOH shared with Afrox and other oxygen suppliers, and which recorded the oxygen levels in all oxygen tanks across the country. The moment that a tank dropped below half of its capacity, trucks were actively diverted to refill it. Ensuring the supply of oxygen depended on many factors – manufacturing, storage, and trucking. During the third wave, no facilities in the country had experienced a critical oxygen shortage, and the successful practices would be taken into the fourth wave. 

He said that hospital readiness preparations were ongoing, including the preparation and monitoring of beds. During the third wave, the health system had been under pressure, but it had not exhausted its resources – if one hospital was under strain, NDOH had used EMS to transfer patients to facilities which had more available capacity. He thought that the country was ready and prepared for the fourth wave. Bed occupancy had increased in Gauteng already, but the province was ready and had the capacity to respond to patients’ clinical needs. 

On the vaccination of 12 to 17 year olds, Dr Nicholas Crisp, Deputy Director-General: National Health Insurance, NDOH, said that NDOH had vaccinated 447 000 adolescents to date. They had all received the Pfizer vaccine, which was the only of South Africa’s vaccines approved for use in that age group.

To Mr Van Staden’s earlier question about the duration of the pandemic, Dr Crisp replied that nobody knew how long the pandemic would last. It depended on what people did – not only as individuals, but on the community level, the national level, and globally – and how they responded to measures put in place to control the spread of COVID-19. NDOH suspected that COVID-19 would be “with us” for years.

On travel bans, he said that it did not really help for a community to “close the door” once a virus had already spread inside that area and in many other areas. It was better for the communities to work together – that was the approach that NDOH was trying to promote in the scientific community.

To Ms Sukers’s question about therapeutics, he replied that NDOH was working on it. It was in discussion with the manufacturers of molnupiravir and Paxlovid, and it was possible that one of the manufacturers might manufacture the medicine inside South Africa. NDOH was discussing those and other medicines with suppliers so that it understood what each product was and what it did. The medicines, and their economic value, were being assessed by the National Essential Medicines List Committee. And NDOH had worked with provincial departments to estimate the volumes of molnupiravir and Paxlovid for which the health system would have use.

To Ms Sukers’s question about herd immunity, he replied that it had been known for some time that herd immunity was “elusive.” The reason for that, as explained by KRISP and NICD in the current meeting and by others in previous meetings, was that the variants “changed the ballgame entirely.” To reach herd immunity, one had to get “ahead of the game” very quickly – by vaccinating between 70% and 90% of the population – to prevent new variants from emerging. Once a new variant emerged, the progress made in the interim was lost. It was a bit like playing snakes and ladders.

To Ms Sukers’s concern about non-COVID-19 healthcare programmes, he replied that other programmes had been neglected to some extent. The Minister, Deputy Minister, senior officials, and provinces had been working very hard to “play catch-up” in that regard. NDOH had not caught up on all its programmes, but it was very pleased to see an improvement, especially in HIV and tuberculosis programmes and in some other services that had been slightly neglected during the first year of the COVID-19 pandemic.

To questions about the efficacy of the COVID-19 vaccine, he said emphatically that the vaccine did provide protection against COVID-19. He hoped that Members and all other attendees were convinced on this point. The vaccine certainly protected people against severe illness, even if it did not totally protect against all COVID-19-related illness.

To questions about the strategy behind the vaccine rollout going forward, Dr Crisp said that new vaccines and better vaccines would probably be developed – scientists and laboratories were working on it all the time. Right now, the vaccine had been rolled out to everybody aged 12 and above, and NDOH was especially prioritising the vaccination of the elderly. NDOH had been informed that it would not get an application for vaccinations for children under 12 until the new year. Once that application was received and approved, NDOH would be able to roll out to children under 12.

He said that comorbidities had not been the most significant factor in the severity of COVID-19 illness, neither in children nor in adults. He had been following up with a lot of hospitals and practitioners that week. Age seemed to be much more significant than comorbidities. However, one specific category of comorbidities, those that resulted in immunosuppression, did make people vulnerable. That was why NDOH had implemented a specific programme to give immunosuppressed people an additional vaccine dose. That programme had been running for a few days. The additional dose was given shortly after the end of what was called the primary vaccination schedule. The primary schedule for the Johnson & Johnson vaccine was one dose, and for Pfizer two doses. The additional dose was given 21 days after the end of the primary schedule. The programme was targeted at people whose immune response was suppressed, such that regular dosing generated less immunity for them than it did for others.

Answering Ms Gwarube’s question about booster shots, he said that an additional shot differed from a booster shot – a booster shot was given six months after the end of the primary schedule, to give the recipient’s immune system a “reminder” about the earlier exposure to the COVID-19 protein. Healthcare workers had been receiving booster shots since 8 November. As of that evening, 164 904 healthcare workers had received booster shots, all Johnson & Johnson.

To Ms Gwarube’s question about current vaccine supply, Dr Crisp said that NDOH had thus far dispensed 25.78 million doses of the vaccine to 16.6 million individuals – about 42% of adults had received at least one dose of the vaccine. There were currently 19.2 million doses of the vaccine available in South Africa, of which 15 million were held centrally, about half-and-half Johnson & Johnson and Pfizer. Generally, less than 150 000 doses were being used each day, although on that particular day well over 150 000 had been used. At that rate of utilisation, South Africa’s current stock of vaccines would last a very long time. Thus NDOH had been delaying the delivery of further vaccines. It did not want to stockpile and hoard vaccine doses when other countries needed them. Moreover, it did not want to hold a stockpile of vaccines inside the country, because it would incur the risks associated with their expiry. If it accepted delivery later, the vaccines delivered would have later expiry dates. None of South Africa’s vaccines held centrally were under immediate threat of expiry, but there were some doses in the provinces that had been thawed for some time and therefore would expire if not used quickly. NDOH was trying to use up those doses, so it encouraged people to come forward for vaccination now.

Closing remarks

Ms Gwarube said that the Committee obviously had to exercise oversight over the executive, an important role which it fulfilled on behalf of the public. Sometimes in the “hurly-burly” of its meetings, the Committee did not make clear how much it appreciated South Africa’s world-class scientists. She thought it was important for Members to express their gratitude and well wishes to those who did this work, often “behind the scenes” but often of world-renowned quality. It made Members proud that there were South African scientists capable of doing the necessary work.

Deputy Minister Dhlomo replied that, now that he was working closely with NDOH, he was aware that many scientists took on their COVID-19-related research as an addition to the specific responsibilities that they already had at universities and in research institutions. NDOH offered them no remuneration – they did it to serve the country. The Ministry was very appreciative and grateful, and Members’ recognition helped encourage those scientists to continue to do their best in supporting the country.  

Ms Sukers said that she did not want to moderate the “sweet atmosphere” of the meeting, and she was also very proud of South Africa’s scientific community. She thought that the lesson was that experts should be left to do their work – politicians should not be allowed to “drive the message” when it came to public health.

She said that the Ministry had not answered Mr Van Staden’s question about the status of the mandatory vaccination task team announced by the President. She did not expect the question to receive an answer now, because the Chairperson intended to adjourn the meeting, but she wanted to note that it had not been answered. Mr Van Staden had not raised a point of debate – the vaccination mandate issue would have to be debated in the House. Instead, Mr Van Staden had raised a direct question about the current status of the task team.

The Chairperson said that he would draw on participants’ remarks to summarise the “bottom line” of the meeting, as a message to the public. The bottom line was that the COVID-19 virus evolved in order to survive and spread – that was in the nature of a virus. The pandemic would end only when the virus “burn[ed] itself out” or when society was able to stop the virus from infecting people. People’s behaviour would determine how long the pandemic lasted. And the way to stop the virus from infecting people was to “get ahead of the game” and vaccinate 70% to 80% of the population.

The meeting was adjourned.

 

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