Following the emergence of the Omicron variant in South Africa big business has made a major push for the implementation of vaccine passes and mandates. Martin Kingston, Chair of B4SA, has called for a rapid move “to a situation where only vaccinated individuals should be allowed to travel in buses, taxis and airplanes, or to eat and drink in indoor establishments such as restaurants and taverns. This is in line with global restrictions and based on the science regarding airborne disease.”

The organisation also called for employers to consider, where necessary, “restricting access to vaccinated individuals and implementing vaccine mandates wherever possible”. This proposal has now been pushed through Nedlac and has been endorsed by Minister of Employment and Labour, Thulas Nxesi.

The case made for the mandate is essentially as follows. According to data presented by Discovery, for a person without pre-existing immunity to the disease, two doses of the Pfizer vaccine reduced the chance of death by 94%, during the Delta-driven Third Wave. They were also less far likely to become infected at all, or transmit the disease onwards, even if they were.

Although there is an ample supply of vaccinations the government’s vaccination drive had stalled, with only 38% of the adult population fully vaccinated. A vaccine mandate at places of work, and the requirement for a vaccine pass to enter certain public spaces, would, business argues, both be protective and push up vaccination rates. It is also a way of avoiding another hard lockdown, something which is of huge importance to big business.

Introducing a national vaccine mandate/pass system is a big step and it is far from clear that those pushing for it have fully thought through the implications and issues. There is a notable scientific void in big business’ case which seriously undermines its credibility and also puts their proposal at odds with European best practice.

I

Many of the policies adopted by governments through the course of the epidemic have essentially been “social placebos”. They enjoy a short-term surge of popular support as they make a frightened population feel “secure” - with political leaders believing that they are “doing something” decisive - but the difference they have ultimately made to the outcomes of the epidemic has been nominal. The costs to children’s education, the economy, and basic civil liberties, meanwhile have in many cases been catastrophic.

This experience should have taught us that only the most clearly necessary measures should be implemented by government, with the benefits always weighed against potential harms. If there are two paths to achieving a certain outcome, then one should choose the least coercive and damaging. This has the additional benefit of maintaining a high degree of consent and compliance among the population over the medium term.

For example, it makes sense, in a first world context, to require people to wear medical or preferably FFP2/N95/KN95 masks when crowded together with strangers in closed and confined places (such as on public transport). If you extend a mask requirement to situations where compliance is both onerous and largely pointless, such as in outdoor settings or to children in nursery and primary schools, you start seriously eroding public acceptance and trust. Eventually resistance will grow, and compliance will decline across the board, even in situations where mask-wearing may be highly beneficial at limiting super-spreader events.

Equally, ordinary people depend on the authorities for public health advice and information. In a situation where one is dealing with a novel coronavirus, some of the early advice could only be provisional to begin with, but it needed to be updated as soon as it is shown to be inaccurate.

The World Health Organisation’s initial advice about Covid-19 was that it was transmitted by droplets and fomites (touch) but not aerosols. This was wrong and it now is accepted that aerosols but not fomites are a significant source of infection. The advice though has not been properly updated and communicated in SA; emphasis still first placed on endless hand sanitising rather than on ensuring proper ventilation and encouraging people to meet in outdoor settings or in rooms with open windows or, in very cold weather, air filtration systems.

It is critical then that the advice conveyed by the authorities (and the media) is honest, up-to-date, and accurate, with errors acknowledged and corrected as quickly as possible. People depend on that information for determining how best to protect themselves, and others, from risk. Bad advice suggesting that cloth masks protect one from infection or that the Pfizer vaccine is protective immediately after the first dose (rather than some two weeks later) can get at-risk people who rely on it killed.

Even so-called ‘noble lies’ – untruths aimed at ensuring the best overall public health outcome – should be avoided at all costs. The moment people realise they have been deliberately misled, trust in the authorities evaporates and people will look for and find alternative (and often wildly unreliable) sources of information on the internet. This is particularly deadly if people lose trust in the authorities to convey accurate information about the efficacy and safety of vaccinations for them and their children, as it massively increases vaccine hesitancy.

Essentially then, combatting the epidemic effectively requires a strong consensus built up from the centre which must be rationally grounded. It is important to avoid pushing extreme and scientifically unsupported measures of no real benefit – even if enjoying majority support - as, apart from infringing on people’s rights and livelihoods for no good reason, this polarises the population and the political debate.

In the resultant noise people don’t know what to believe or whom to trust, people will become entrenched in their respective positions, however irrational they may be, and many others will default to a ‘wait and see’ mode.

II

In February this year, South Africa got rid of the one million COVID-19 Astra Zeneca vaccine doses it had received from the Serum Institute of India due to its perceived inadequacy at preventing infection by the Beta-variant. This was a decision which would go on to cost an estimated twenty thousand at-risk South Africans their lives in the subsequent Delta-driven Third Wave. It also turbo-charged vaccine hesitancy more generally in the population.

Towards the end of the Third Wave, Discovery Health estimated, from an analysis of its client database, that recent vaccination was between 50% to 80% effective in reducing infections, and over 90% effective at reducing the chance of death. Without a vaccine the infection fatality rate of Covid-19 was between eight to ten times higher than with influenza. After vaccination it dropped to lower than that from the flu.

The Johnson & Johnson and Pfizer vaccines arrived too late however to save the close to a quarter-of a-million people who died from Covid-19 through the first three waves, though their belated arrival would save 55 000 others. On the basis of an infection fatality rate of between of 0,39% and 0,5% - and 215 000 excess deaths caused by Covid-19 - Emile Stipp of Discovery suggested in August that between 70% and 80% of the population had been infected and recovered.

In addition, over the past several months 43,5% of the adult population has now received at least one vaccine dose; a figure rising to 60,7% for those between 50 and 59 and 65,1% of over sixties, the most at-risk age groups.

Source: NICD, 9 December 2021

A great proportion of the population has now acquired a significant level of immunity to Covid-19 either through vaccination or prior-infection or both. The 38% figure is thus highly misleading, with the real figure for acquired immunity potentially closer to 90%.

The current research suggests that immunity acquired the hard and dangerous way, from infection, is as good, possibly better, and certainly more enduring than that acquired from vaccination. An analysis by Discovery Health in early November found that for a person who had “recovered from COVID-19, their odds of a future bout of COVID-19 are reduced by 75% (compared to people who have not had a prior COVID-19 infection). We also note a relative risk decrease of 85% for COVID-19 admission, for people who have recovered from COVID-19, relative to individuals with no documented prior infection.” For those with such infection-acquired immunity vaccination works as a form of booster shot.

The key figure to look at then, when evaluating the need for vaccine mandates/passes, is the percentage of the population who either have already had the disease or been vaccinated. In a country which has largely kept out the disease up until now, trying to vaccinate as much of the immunologically naïve population as possible is an imperative, if massive fatalities are to be avoided, once it is reopened to the world.

However, the cost-benefit calculation in a country like South Africa, where high levels of immunity have already been acquired, at great human cost, is obviously very different. It is redundant and unnecessary to implement vaccine passes in a situation where almost the entire adult population has already acquired a significant level of immunity, one way or another.

III

One of the most bemusing aspects of the debate in South Africa though is that it completely discounts immunity acquired from infection both in evaluating the need for, and implementation of, vaccine mandates/passes.

Indeed, those pushing for this measure seem to regard immunity acquired from natural infection of being of no account at all. For instance, the Financial Mail editor Rob Rose described the “59% of South Africans who haven’t got vaccinated” as posing a “direct threat to society”, given the rise of the Omicron variant. In addition, there appears to be no suggestion that any such system account for immunity acquired from infection.

This is in contrast to the situation that pertains in the European Union which accommodates to a certain degree prior infection in their vaccination certificates.

Germany has what is called the “3G” rule for its “impfpass” system by which persons who wish to access certain facilities must be either “geimpft” (vaccinated), “genesen” (recovered) or “getestet” (recently tested.)

The testing referred to here is antigen rather than PCR testing, which is provided for free. Rapid antigen self-tests are also cheap and readily available and are also distributed by government for free as one means of checking the spread of Covid-19 in institutions such as schools and kindergartens.

Due to a surge of cases this has recently been tightened in many places to “2G”, whereby “persons who recovered from COVID or fully vaccinated persons are admitted” and “2G plus” whereby “persons who recovered from COVID or fully vaccinated persons are admitted if they can also present a negative test result.”

A "2G Plus" entry notice in Lower Saxony, Germany. A person must either be vaccinated or recovered, must have recently taken a rapid antigen test, and must wear an FFP2 mask. 

By excluding the concept of infection-acquired immunity from consideration, business and government in South Africa are contemplating a measure which clearly infringes on people’s rights, in a situation where there is no clear need to do so; and requiring people to get vaccinated who already have immunity, and for whom the benefits are on the margins.

IV

Current indications are that Omricon is highly infectious and can overcome, to a significant degree, pre-existing immunity against infection, hence the massive spike in recorded cases. Discovery recently released research that found that “Protection as a result of prior infection appears to have declined from 77% to 48% as a result of Omicron variant”. The same seems to have happened though with vaccine-induced protection from infection. In one super-spreader event in Norway 60 out of 120 people attending a Christmas party at a restaurant tested positive, all of whom had been vaccinated and recently tested.

More hopefully though are early indications that the Omicron variant is not causing the severe disease that characterised the Beta and Delta waves in South Africa, either because it is less virulent, or because of high levels of underlying immunity, or both. It is unvaccinated people, without pre-existing immunity, and those with compromised immune systems, who are generally the ones getting seriously ill.

If these two trends hold then vaccine mandates/passes are of little point, as they will not seriously stem infections. In such a context those who prefer to acquire initial immunity through infection rather than vaccination are a threat mainly to themselves. In any event, by the time a vaccine mandate/pass system would be in place, the Omicron-driven fourth wave would be over, and an even smaller percentage of the population would remain immunologically naive.

The necessity for a vaccine mandate/passport system is thus far less compelling than business has made out. As with the hard lockdown in South Africa, which was initially very popular, one should remember that implementation will be in the hands of incapable, unfeeling and unthinking state machinery.

People who have been vaccinated may believe that a vaccine pass system would not affect them, only the “anti-vaxxers”. This is not true. Even if you are vaccinated you will still have to show your pass on entering certain places and you will be denied entry if you have left it at home, lost it, it has been stolen, or expired, or – if it is on your smartphone – your device has run out of battery.

The onerous cost and responsibility for implementation will fall on businesses themselves, who will likely lose custom if they do so diligently. Enforcement then means giving SA’s inept and often brutish police force the power to go into establishments and require that customers produce their papers on demand and penalise customers and owners who are not compliant. Once sacrificed, basic rights - such as the right to informed consent- are not readily recovered.

V

In Europe, the countries and regions which achieved the highest level of vaccination achieved this quietly, and without drama, threats or bullying. This was a product of high levels of trust and organisational drive and competence. The resort to coercive measures is, in a sense, an indication not of “best practice”, but rather of government failure.

There are, in other words, other means of reaching the same or better public health outcomes without resorting to such coercive measures – and which big business should rather press for. State imposed vaccine mandates/passes will provoke a highly divisive political debate, court action, popular resistance, and will lose popularity as soon as theory becomes practice and enforcement passes over to the SAPS, or vaccine-refuseniks start being thrown out of their jobs.

State and business' efforts would be far better directed towards trying to reach and persuade the vaccine hesitant. This is often simply a matter of better organisation and systematic problem-solving, rather than forceably overcoming perceived resistance. 

There are other sensible measures which should be implemented in response to Omicron, and which in no way intrude on people’s rights. These include making booster shots immediately available to the already vaccinated but at-risk, approving mix-and-match vaccines, ensuring those with HIV are on ARVs, and making inexpensive rapid antigen tests available to the public and institutions for self-testing.

The first good treatment for the disease – Pfizer’s Paxlovid – is likely soon to be approved in America, after which the imperative for South Africa will be securing adequate supplies of the drug. In public messaging there should be a shift towards emphasising ventilation, rather than hand sanitising, and encouraging the at-risk to wear well-fitting FFP2 masks in closed and confined public spaces.

Businesses should certainly encourage as many of their staff as possible to get vaccinated, though immunity from prior infection should be recognised, as it is in Europe. They should also accept that many people have a deep-rooted aversion to getting the jab – whether on emotional, moral, religious grounds, or their personal perceptions of the risks versus the benefits – and such people should be left alone, and not hounded in or out of their jobs.

One possible solution to the question of the merely vaccine hesitant is to remove doing nothing as the default option. Just as a patient should be told the benefits versus the risks before they are given the vaccine, those who are hesitant or unsure should be explained the benefits versus the risks of not getting vaccinated before they are able to then opt out.