Q&A with Professor Shabir Madhi

Shabir Madhi is Professor of Vaccinology at the University of the Witwatersrand, Johannesburg, South Africa; and co-founder and co-Director of the African Leadership Initiative for Vaccinology Expertise (ALIVE).

Q: What is the likelihood that South Africa will experience a third wave?

A: It is very likely we will experience a third wave. At least four of the nine provinces are seeing the start of it and in the next two to three weeks we will probably see a substantial uptick in number of new cases that will probably worsen for a period of another six to eight weeks after that. The third wave will most likely be at its worst in June and then subsiding by the middle of July.

One of the difficulties in predicting the severity of the third wave is how stable the virus remains. If the virus undergoes further mutation, as it did in the second wave, we could end up with an epidemic similar to what we experienced in the first and second wave. If the virus remains stable, we can expect the next wave to be less severe at least in relation to hospitalisation and death. This is because a large percentage of the South African population would have developed some level of immunity, enough to protect them against severe disease and death.

Q: Would other variants like the one discovered in India be a concern?

A: The critical element of the variant discovered in India (B.1.617.2) is a mutation that makes the virus relatively resistant to the immune responses by past infection and vaccines. The variant found in South Africa (B1.351) shares this trait with B.1.617. The only difference in the B.1.617 variant is a mutation that makes it more transmissible. It’s unlikely that the B.1.617 variant will significantly affect South Africa as the B1.351 variant will confer some similar protection to the B.1.617 variant. The variant discovered in the United Kingdom (B.1.1.7) is a much greater concern due to its heightened transmissibility and virulence. Fortunately, it remains relatively sensitive to antibodies induced by infection by ancestry virus and the current first generation COVID-19  vaccines, unlike the B1.351, P1 (in Latine America) and B.1.617 variants.

Q: Why is the variant discovered in South Africa (B1.351) getting much more publicity if the variant discovered in the United Kingdom (B.1.1.7) is more transmissible and virulent?

A: The B1.351 variant is relatively resistant to antibody induced by COVID-19 vaccines and past infection due to the ancestry virus, while the B.1.1.7 variant remains susceptible to both vaccine and antibody responses.

Q: How has the South African Government handled the vaccine rollout?

A: The most significant challenge facing South Africa is facing is not getting large enough quantities of vaccines in the shortest period of time. South Africa needs to vaccinate 150,000 individuals a day to meet the phase two target. Currently, South Africa is not even receiving 350,000 vaccines per week. Therefore, unfortunately, the targets previously set will not be met. Only the high-risk individuals are likely to be vaccinated in the next three months. The vaccine that is currently being secured by government, in terms of availability extends right into 2022.  

But at the end of the day, the reality is that we actually wouldn’t derive too much benefit by vaccinating 40 million people either, because many of the first generation COVID-19 vaccines, is not going to perform that well in protecting against mild infection due to the B1.351 variant.

From a public health perspective, the most important reason we are wanting to vaccinate people is to prevent hospitalisation to avoid overwhelming of our healthcare facilities and minimise the number of deaths from COVID-19.

Q: Would vaccinated travellers be safe visiting South Africa?

For vaccinated travellers, their risk of infection would probably not be too different from someone who was traveling to South Africa in June and July 2019 when an influenza virus was circulating, as an example. They would still have been infected with influenza virus but because many people have some sort of immunity against the virus, they don’t end up in hospital if they were infected with the virus.

Irrespective of whether someone is vaccinated with AstraZeneca vaccine or any of the other COVIID-19 vaccines, they would still have reasonably good protection against severe disease and death even though they might still get infected with the B.1351 variant.

Q: Is it possible to introduce a zero-risk environment?

A: The government will need to recalibrate their expectations about the elimination of the virus. That was probably never going to be an option when one considers that variants with mutations conferring relative resistance to immunity induced by past infection and most of the current 1st generation COVID-19 vaccines are circulating. Rather, we should be focussing our efforts on protecting against severe disease and death. The sooner the government acknowledges that elimination is not the correct path, we can recalibrate our expectations of the vaccine and with that how we plan for the endgame to get back to a normalised situation.

Q: What is the effectiveness of travel bans?

A: Travel bans work in a country that has successfully contained the virus at a very early stage, such as island nations like New Zealand, Australia or Iceland. This is where a travel ban makes sense, allowing a country to avoid new cases entering, until their populations are vacinnated.  In South Africa, a travel ban is likely to be of nominal consequence in terms of the trajectory of the pandemic because the virus is already widely spread. If cases are imported from India of the United Kingdom, there will be an insignificant difference in the trajectory of the spread. After the first wave, South Africa initiated a travel ban on a whole range of countries, and it pretty much had zero effect as evident from the B.1351 variant evolving in South Africa and the magnitude of the second wave.

Once 70% to 80% of the population of South Africa’s source markets are vaccinated, it is likely these governments will open their borders much more readily. There may still be some requirements in terms of people needing negative PCR test within 48 hours of arrival and show proof of vaccination status, but they would not ask people to quarantine for 14 days.

Q: Is the data produced by South Africa credible?

A: The data that South Africa provides on infections is reasonable, considering that most individuals are either asymptomatic or have a mild infection. No country can fully quantify its number of infected persons accurately. South Africa’s hospitalisation data is reasonably robust however we may be under-reporting the number of deaths. We are using the Medical Research Council’s to access mortality data which is as good as you will get anywhere else in the world. We may not be doing as well as high-income countries because they do much more testing but what we are doing is certainly the best across Africa. In terms of accurate data collection, we are probably comparable to places such as Thailand and Indonesia.

Q: Is the quality of South African healthcare sufficient for international travellers?

A: International travellers will likely make use of private sector healthcare. There is more than adequate capacity in the private sector, which is well equipped, especially when we are not at a peak in infections.

Q: Has South Africa handled the pandemic well?

A: There are positives and negatives to how South Africa has handled the pandemic. The positives are that we have vaccinated some healthcare workers, the healthcare system has been upgraded, and we developed good regulations. The negatives are that, as a whole, the vaccine rollout has failed and we have been mediocre at enforcing the regulations, which is perhaps more of a societal issue.

Q: What would you have done differently if you were in charge?

A: There are two things that I would have done differently. Firstly, I would have started negotiations for the vaccine last year and not at the beginning of this year. Secondly, I argued that level 5 lockdown was never going to achieve anything except delay the inevitable in a country like South Africa. While this may have bought some time, even that was nominal.

Q: Should we be discouraging travel?

A: Travel is inconsequential in terms of what happens next in South Africa. Regardless of whether individuals carrying Covid-19 variants enter the country it is unlikely to influence the trajectory of the pandemic in South Africa. What happens locally will determine the trajectory of infections. What is important is for us to vaccinate our population.

Q: What would you say to a traveller coming into South Africa?

A: It is recommended that they are vaccinated and ensure that they avoid overcrowded or poorly ventilated indoor spaces as this is where travellers’ (and others) risk of being infected is greatest.