In the next two weeks, distribution of millions of doses of the Oxford/AstraZeneca SARS-COV2 to health workers across Africa will get underway, said the director of the Africa Centers for Disease Control in a joint press briefing with the WHO Regional Office for Africa on Thursday. 

CDC Director John Nkengasong told Health Policy Watch that at least 20 African countries have so far ordered for over 200 million doses of COVID-19 vaccines, including AstraZeneca’s,  through the African Union’s African Vaccine Acquisition Task Team (AVATT)  – the first such vaccine pre-order arrangement by the AU, similar to ones brokered by the European Union. 

The AU purchasing channel comes in addition to the rollout of some 90 million doses of the AstraZeneca vaccine, which are set to be distributed to countries on the continent through the WHO co-sponsored global COVAX facility, beginning this month.   

However, striking a different note from WHO recommendations issued only yesterday, Nkengasong said that Africa CDC was not recommending use of the AstraZeneca vaccine, at this stage, in countries where the B-1351 variant, first identified in South Africa, has become dominant.

“We should encourage countries actually to use that [AstraZeneca] vaccine, where they do not have evidence of that South African variant,” said Nkengasong, adding, “having reported one or two cases in the country doesn’t mean that the variant has dominated; we only have to be cautious in areas that have an extensive takeover of the pandemic by the variant. 

“So, our recommendation for the use of the AstraZeneca vaccine is very clear – if you have evidence that the variant is predominant in your country, then we recommend that the [AstraZeneca] vaccine should not be issued for the obvious reason that it will have reduced activity in neutralizing antibodies,” Nkengasong said.

On Sunday, South Africa announced that it was pausing a massive public rollout of the AstraZeneca vaccine, pending more research – after a small local trial showed that it performed poorly in controlling mild and moderate cases of the virus caused by the B-1351 variant of the SARS CoV2 virus that has become dominant there.  

However, in a press briefing on Wednesday, WHO’s Strategic Advisory Group of Experts (SAGE) said it was still recommending that African countries begin immunizing with the AstraZeneca vaccine – even if the variant is present – because it’s still likely to be effective against more serious COVID cases. 

South Africa has, meanwhile, decided to roll out to its public a one-shot Johnson and Johnson vaccine – while undertaking a larger controlled trial among health workers to examine the performance of  AstraZeneca – particularly for controlling severe COVID cases. 

African CDC Statement Recommends Targeted AstraZeneca Use 

In the formal Africa CDC statement, the recommendation was two-fold stating:

1. For countries that have NOT reported the circulation of the SARS-CoV-2 N501Y.V2 (or B.1.351), we recommend proceeding with the rollout of the AstraZeneca vaccine.
2. For countries that HAVE reported the circulation of the SARS-CoV-2 N501Y.V2 (or B.1.351), we recommend the acceleration of their preparedness to introduce all COVID-19 vaccines that have received emergency use authorization or approval by regulatory authorities. Consideration should be given to the effectiveness of the vaccine against SARS-CoV-2 N501Y.V2 or any other circulating SARS-CoV-2 variant in the country.

The CDC also called on countries to expand their genomics testing capacity – so that it could identify and track the expansion of new virus variants.

Here’s the @AfricaCDC statement on the @AstraZeneca #COVID19 #vaccine in the context of known variants. We remain focused in Securing Africa’s Health. https://t.co/4xzUFwNuPK

— 𝔻𝕣. 𝔸𝕙𝕞𝕖𝕕 𝕆𝕘𝕨𝕖𝕝l – FAPH (@laktarr001) February 11, 2021

Vaccines Can’t Come Too Soon 

Altogether, the vaccines cannot arrive fast enough as African health facilities have been overwhelmed by the pandemic’s second wave, said WHO’s Regional Director Matshidiso Moeti, also speaking at the joint briefing.  

According to a recent WHO survey of 21 countries,  66% reported inadequate critical care capacity; 71% were reporting shortages of vital oxygen supplies, and 24% reported health worker burnout, she said.  

According to WHO, the B-1351 variant has now spread to eight African countries including not only South Africa but — Botswana, Ghana, Kenya, Comoros, Mozambique, Zambia and Tanzania. The Tanzanian variant cases, identified among travelers arriving in the United Kingdom, are significant as it suggests the steady creep of the variant northward.  

The report about Tanzania also is significant insofar as the country is widely believed to be underreporting its COVID case numbers – with doctors and health workers under government pressure to avoid COVID diagnoses whenever possible. Only 509 COVID cases have been reported in the country, to date, as compared to 102,000 cases in Kenya, which lie on Tanzania’s northern border,  and 65,000 in Zambia, to the south.  In light of the weak overall surveillance of the disease – new variants that migrate in are likely to escape notice as well.

South Africa, meanwhile, continues to lead in the number of cases on the continent, with more than 14 million cases and over 45,000 deaths, Africa CDC said.

Over 200 Million Vaccine Orders Through African Union Platform – Long-Term Local Manufacturing Capacity Needed 

There have been worries that the slow spread of the South African variant, which is more effective than others in evading antibody immune responses,, has dampened some of the enthusiasm over the use of AstraZeneca’s vaccine in Africa.   

But despite the concerns about variant creep, no country so far has requested that its AstraZeneca vaccine order be swapped for other vaccines on the platform, Nkengasong said at the briefing. 

And the vaccine is still available for preorder by African countries until February 15 on the Africa Medical Supplies Platform (AMSP) that was created by the African Union , to facilitate countries’ vaccine purchases after the AU negotiated a series of bilateral pre-order deals with pharma manufacturers to ensure higher volumes than the WHO’s COVAX facility could provide.   

While the AU arrangements, supported by Africa CDC, have been a milestone, going forward, Nkengasong stressed that Africa CDC supports a long-term plan to enable the manufacturing of COVID-19 vaccines in more countries on the continent – particularly in light of the fact that periodic vaccine boosters will likely be needed. 

 CDC is thereby backing calls by African heads of governments for more effective transfer of COVID health technologies, especially in the area of vaccine production.

“We truly are dealing with a new virus, we don’t know for how long, when people receive vaccines, their protection will last,” Nkengasong said.

“And if, it so happens….that we do periodic vaccinations, we also require that Africa is well-positioned and equipped to be able to manufacture vaccines locally so that the continent can at least meet the demand for 1.2 billion people.” 

The ‘Predominant’ Variant Criteria

In contrast to Nkengasong’s recommendation that countries where the B1351 virus variant is ‘predominant’ should try to procure other vaccines, Moeti’s comments adhered more closely to the WHO global guidance advising use of the AstraZeneca vaccine irregardless. 

That guidance, issued by WHO’s SAGE expert group on Wednesday, holds that the AstraZeneca vaccine is still likely to reduce more serious COVID disease – despite the findings of the small South African study in which it failed to reduce mild and moderate cases.  

Although a vaccine that protects against all forms of COVID-19 illness is the aspiration, preventing severe cases and hospitalizations which overwhelm hospitals and health systems is the first priority, Moeti stressed. And the AstraZeneca vaccine can still perform that task, she affirmed. 

“If cases remain mostly mild and moderate, and don’t require critical care, then we can save many lives,” she said. 

She encouraged Africans to go out and get vaccinated whenever a vaccine becomes available in their country, adding that ensuring equitable access to COVID-19 vaccines and sustaining other preventive public health measures, such as masking, hygeine and social distancing, are all critical priorities to overcome the pandemic.  

According to the AMSP site, the AstraZeneca vaccine uses “a replication-deficient chimpanzee viral vector based on a weakened version of a common cold virus (adenovirus) that causes infections in chimpanzees and contains the genetic material of the SARS-CoV-2 virus spike protein. 

“After vaccination, the surface spike protein is produced, priming the immune system to attack the SARS-CoV-2 virus if it later infects the body”.

While the SARS-CoV2 virus has spawned multiple variants, the B-1351 virus variant is particularly significant because of a spike protein mutation (called 501Y-V2), which has been better at eluding some of the vaccines that target the virus spike, in particular, to prime immunity. 

According to the recent study of the AstraZeneca vaccine, conducted by a team of researchers at the South African University of Wits in collaboration with Oxford University and involved nearly 2000 study participants, the vaccine’s displayed only a 21.9% efficacy, in terms of prevent mild and moderate disease. This was well below the levels demonstrated in the company’s Phase 3 trials, which yielded an average vaccine efficacy of 66.7% among volunteers aged 18-55.  

More Genomic Tracking In Africa Critical To Successful Vaccine Rollout

Increasing genomic tracking of virus variants on the continent is also critical, Nkengasong stressed – if the challenges posed by virus variants are to be met. So far, only South Africa has adequate genomic surveillance data on variants to identify not only which variants are present but also those that are predominant.

Developing such data will require countries to begin sequencing many more COVID test samples – and yet many countries lack any genomic sequencing capacity at all. Through the Africa CDC Pathogen Genomic Initiative,  CDC is leveraging its network of laboratories to support countries to build their capacity to conduct genomic sequencing for the purposes of widespread tracking and surveillance. 

“Our target is to generate about 50,000 genomic sequences in the next coming months, so that we better understand the layout with respect to the new variant,” Nkengasong said.

In addition, as African countries begin to roll out vaccines, health authorities need to do so in a way that they can also generate data on the safety and efficacy of vaccine candidates, particularly in regions where variants may be present.  

“It is important that we generate, very quickly, data that will inform us on the rollout,” he said.

Image Credits: GovernmentZA/Flickr, Paul Adepoju, Johns Hopkins University & Medicine, Flickr: IMF Photo/James Oatway.