Controlling COVID has been a mammoth task for Africa’s public health agencies. Vaccine nationalism had previously been blamed for the continent’s low vaccine uptake, but public health leaders have now expressed concerns about the slow uptake of COVID-19 vaccines in many African countries.

Africa has the lowest share of the population fully vaccinated of any continent, at 7%, compared with 28% in lower middle income countries. Only 1 in 4 health workers in Africa have been fully vaccinated. But now that vaccines are arriving, local health authorities are concerned that improved vaccine availability is not being matched with enthusiasm for uptake.

Variable uptake

A total of 418 million doses of COVID-19 vaccines have now arrived in Africa, but fewer than 236 million doses have been administered, with almost half waiting to be used. The situation varies by country. South Africa has administered 82% of the doses it has received, Egypt has administered 52% of supplied doses, Nigeria has administered 48%, Cameroon 23%, and the Democratic Republic of Congo has administered fewer than 5% of the vaccine doses that they have received.

In early 2021, when doses of COVID-19 vaccines began to be available, Dr John Nkengasong, Director of the Africa Centres for Disease Control and Prevention, stressed the need for Africa to roll out the vaccines quickly and expressed confidence in the continent’s ability to do so. But after nine months, Nkengasong has admitted that the continent is now struggling and has convened a meeting of health ministers to come up with solutions.

“Vaccines are beginning to flow on the continent in a very predictable and steady manner. We are very concerned that countries are not picking up those vaccines. The uptake is not as we would love to see. We are on the drawing board, putting our heads together to see what can be done to galvanize that uptake,” Nkengasong told Nature Medicine.

“I think we're seeing a similar situation in many countries — the Democratic Republic of Congo, Ethiopia, South Sudan. In rural and remote areas, the vaccination drive has not picked up as one would like to see,” says Dr Richard Mihigo, coordinator of the Immunization and Vaccines Development Programme of the World Health Organization (WHO) Regional Office for Africa.

Problems in rural areas are perhaps expected, but low uptake in some of the continent’s most densely populated countries has also been seen, and is especially worrying.

Mihigo warns that the slow rollout of vaccines may increase the risk of new variants such as Omicron, although more data are needed on exactly where this variant emerged. “As much as you give the opportunity to the virus to continue to circulate in naive populations, you give the virus the opportunity to mutate and unfortunately, the occurrence of such a variant of concern is what we have seen today with Omicron,” says Mihigo.

Disinformation affects demand

Mihigo says that rumors and disinformation, spread throughout social media, have reduced the demand for COVID-19 vaccines, although supply issues remain.

“On the supply side, the main challenge now is how to deliver the vaccines. It is no longer that the vaccines are in short supply, it is the system to deliver the vaccine,” says Mihigo.

African countries are building on past experience with measles, polio and other immunization campaigns, but a myriad of issues are limiting the roll out of COVID-19 vaccines, including vaccine disinformation and logistical challenges, such as securing enough syringes.

“There is a looming threat that syringe supplies will dry up. UNICEF predicts, for example, a global shortage of around two billion of the auto-disposable syringes needed for COVID-19 vaccine and routine immunizations,” says Dr Matshidiso Moeti, WHO Regional Director for Africa.

The potential syringe shortage led to an agreement between COVAX, who are supplying vaccines to low- and middle-income countries, and syringe manufacturers, so that vaccine deliveries do not outpace the supply of syringes.

Another challenge is maintaining a cold chain, so that vaccines remain refrigerated or frozen. This is especially problematic when delivering vaccines to hard-to-reach rural areas where the electricity supply is not regularly available. Delivering vaccines to remote areas also requires support from local health workers, especially for the last mile of the journey.

Leveraging Omicron

The identification of Omicron by researchers in South Africa has led to travel restrictions. High-income countries will use the time gained to further vaccinate their population, says Dr Michael Marks, Associate Professor at the Department of Clinical Research at London School of Hygiene & Tropical Medicine.

“That might be good for those countries but triple vaccinating a small number of people in high-income countries when there is an overall inequitable global vaccine coverage, is likely a major player in the emergence of variants,” says Marks.

But African countries can also use Omicron to drive vaccine uptake on the continent. One of the reasons for vaccine hesitancy is a belief that previous infection would protect against future infections. The data do not bear this out, says Professor Anne von Gottberg, a clinical microbiologist at the South African National Institute for Communicable Disease (NICD) Centre for Respiratory Diseases and Meningitis. Several preprints or press releases, none of which has yet been peer-reviewed, show that the Omicron variant has extensive escape from antibodies against previous variants, although there is some evidence that natural infection plus vaccination boosts antibody responses, as does a booster dose of the vaccine.

“Previous infection used to protect against Beta and Delta variants but that doesn’t seem to be the case with Omicron,” von Gottberg says. “We should be vaccinating as many people as we can so that they can have vaccine-induced protection”

von Gottberg adds that available vaccines are likely to still protect against hospitalization and severe illnesses from infection with the Omicron variant. This should be an impetus to accelerate vaccine roll-out across Africa. Mihigo sees African countries increasing their vaccination rates as a response to Omicron.

“People are now seeing [Omicron] as a real threat and are now trying to get vaccinated. We are working with the countries and trying to use vaccine champions from within the community to educate, mobilize and advocate for vaccination,” Mihigo adds.

Beyond vaccines

African countries cannot afford to waste their COVID-19 vaccine stockpiles, says Professor Oyewale Tomori, a virologist and chairman of Nigeria’s Ministerial Expert Advisory Committee on COVID-19. Tomori warns that high-income countries are accelerating the roll out of booster doses, which could make even fewer doses available to African countries, who are at the back of the queue, relying on excess supply.

“In the face of variants of concern and the need for boosters, where is the excess?” Tomori asks.

When a new variant emerges, says Marks, governments around the world should address the underlying drivers of variants, such as a lack of vaccination in low-income countries, rather than introducing travel restrictions and rolling out boosters.

“This is just simple maths. If there are 100,000 infections, then there are more chances than if there are 100,” Marks says. “[But] I can guess that if another new variant emerges in 2022, we will just see the same response again.”

But vaccines alone are not sufficient to control the virus — public health measures are still needed, says Dr Ambrose Otau Talisuna, the WHO Regional Office for Africa’s regional advisor for International Health Regulations and Global Health Security.

Talisuna agrees: Africans still need the three Ws — “wearing your mask, washing your hands and watching your distance,”.

“Avoiding social mixing helps us to control COVID-19 whether it is the Delta or Omicron variant,” says Talisuna. “Vaccination is part of our armamentarium of interventions, but non-pharmacological interventions should continue.”