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SAMJ: South African Medical Journal

versão On-line ISSN 2078-5135
versão impressa ISSN 0256-9574

SAMJ, S. Afr. med. j. vol.111 no.7 Pretoria Jul. 2021 



COVID-19 mass vaccination campaign for healthcare workers in a low-resource setting: A clinician-driven initiative



D L ReddyI; Z DangorII; N LalaIII; J JohnstoneIV; L MaswabiV; J M L TsitsiVI

IMB ChB, MMed, FCP (SA), Cert ID (SA) Phys; Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
IIMB BCh, MMed, FC Paed (SA), Cert Pulmonology (SA) Paed, PhD; Department of Paediatrics, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
IIIMB BCh, MMed, FC Paed (SA), Cert Nephrology (SA) Paed; Department of Paediatrics, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
IVNational Certificate in Administration; Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
VBPharm Hons, MMENVC; Pharmaceutical Services, Chris Hani Baragwanath Academic Hospital, Johannesburg, South Africa
VIMB BCh, FCP (SA); Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa





COVID-19 vaccination has been globally accepted as a critical public health response measure to prevent severe disease and death, alleviate strain on healthcare systems, and prevent onward transmission of SARS-CoV-2. The South African Department of Health's plan to vaccinate 1.25 million healthcare workers through the Sisonke Early Access Vaccine Rollout for Healthcare Workers presented both opportunities and challenges in terms of designing and implementing a mass vaccination roll-out in the resource-limited state sector. We present our experiences and challenges from the largest hospital in Africa, and hope that this will assist other institutions with planning successful COVID-19 mass vaccination campaigns.



On 31 December 2019, the World Health Organization reported the emergence of an outbreak of pneumonia cases in Wuhan, China. The disease was later termed coronavirus disease 2019 (COVID-19) and the causative agent was identified as a novel coronavirus, SARS-CoV-2. [1] The first case of COVID-19 in South Africa (SA) was announced on 5 March 2020, and a cumulative total of ~1.5 million confirmed cases and 50 000 deaths had been recorded by 7 March 2021.[2,3] The COVID-19 vaccination roll-out for healthcare workers (phase 1) was planned for February 2021 using the Oxford AstraZeneca vaccine. [4,5] However, concerns arose about the efficacy of COVID-19 vaccine candidates in the context of dominance of the B.1.351 variant, as it contained mutations at the receptor-binding domain of the virus, the target site of many vaccines.[6,7] Further data analysis revealed that a two-dose regimen of the AstraZeneca ChAdOx1 nCoV-19 vaccine had an efficacy of 10.4% against mild to moderate COVID-19 caused by the B.1.351 variant.[8] In contrast, interim analysis of the single-dose Johnson & Johnson/Janssen Ad26.COV2.S vaccine (J&J) demonstrated 57% protection against the B.1.351 lineage of SARS-CoV-2 and complete protection against COVID-19 hospitalisation and death.[9] These findings led to a public announcement on 7 February 2021 that healthcare workers would be vaccinated through an implementation study using the J&J vaccine, under the name Sisonke Early Access Vaccine Rollout for Healthcare Workers.[10,11]

A core vaccine team was formed at Chris Hani Baragwanath Academic Hospital (CHBAH) on 13 January 2021. CHBAH is the largest hospital in the southern hemisphere and the third-largest in the world, with a bed capacity of 3 200 beds and a staff complement of ~7 400.[12] The facility is located in Soweto, a peri-urban town 27 km south-west of Johannesburg in the most populous province of the country, Gauteng.[12] The hospital serves a population of >1.3 million people, and offers a full range of generalised specialist and subspecialist services.[12]

The vaccine team planned for a 'mass vaccination' roll-out of staff on the launch date, 17 February 2021. Mass vaccination strategies are considered to be most useful in pandemic situations, as they allow for the fast and efficient vaccination of a large number of susceptible people, using a central vaccination site.[13] The benefits of mass vaccination of healthcare worker programmes over ward-to-ward-based vaccination programmes are: (i) a streamlined process for pharmacy vaccine delivery, preparation and secure storage, while also ensuring that the cold chain is maintained; (ii) easy access to an emergency care team that remains in the vaccination site in the event of adverse events following immunisation (AEFIs); and (iii) a centrally controlled data capture system. Disadvantages include the need for a large number of staff to support the mass vaccination process itself, requiring precision and careful planning.[14,15] There is a paucity of peer-reviewed literature on the implementation of mass vaccination programmes, particularly in low-resource, low-technology settings.[16-18]


Logistical concerns of the mass vaccination campaign

The core team began by meeting with various key stakeholders such as pharmacy management, the Sisonke study investigators, occupational health and safety (OHS) and labour unions. Major work streams and tasks were identified (Table 1). In addition, a large number of staff was required (Table 2). The majority of the staff who volunteered to support the vaccine roll-out were clinicians: doctors of all ranks, nurses of all ranks, psychologists, physiotherapists, and occupational and speech therapists.

We identified a large, well-ventilated hall as the most suitable vaccination site, and formed a venue operation centre team to assist with the set-up and infrastructure of the vaccination site. Additional needs were a large outdoor tent to serve as a waiting area; procuring furniture and equipment for the vaccination site; demarcating spaces for parking, assembly, a waiting area, a vaccination area and an observation area; the provision of computers and connectivity for data capturing; and a reliable power supply with a back-up generator (Fig. 1).


The vaccine roll-out process

Our preparation for mass vaccination at CHBAH involved creation of a staff database from human resources, line managers, and self-completed electronic registration forms. Using this database, vaccination appointments were scheduled by email or text messages. Staff had the opportunity to reschedule their appointments based on availability. The preregistration booking system was intended to minimise time spent away from the staff working areas and the impact on service delivery, and to allow for social distancing.

Our vaccinators were drawn from a pool of nurses who were trained and accredited using the national COVID-19 Vaccination Training for Healthcare Workers online course by the nursing education team at CHBAH. The training included infection prevention and control measures on appropriate personal protective equipment to be worn, and sanitisation of their individual vaccination stations. To allow for social distancing while optimising efficiency, the vaccinator stations were arranged into four rows (A, B, C, D), each comprising six vaccinator stations (A1 - 6, B1 - 6, C1 - 6, D1 - 6), which allowed for 24 vaccinator stations in total (Fig. 2). Distribution of vaccine doses to the vaccinators was co-ordinated by pharmacy teams and OHS nurses prior to the vaccinees entering the vaccination hall. The pharmacy and OHS teams were also responsible for the reconciliation of all vaccine doses dispensed after each round of 24 vaccinees.

The vaccination process, as depicted in Fig. 2, involved:

Scheduled vaccinees arrived at the vaccination site with a form of identification and proof of booking.

Vaccinees were directed to the registration tent, where they were screened for COVID symptoms, and gave consent for vaccination.

Vaccinees were then asked to seat themselves in the waiting area.

Any extra paperwork was completed and information on the process was provided to the vaccinees by a co-ordinator.

Vaccinees were directed into the vaccination hall in groups of 24 at a time (24 vaccination stations accommodated by 24 vaccinees in each round).

Vaccinees were asked to leave the hall after vaccination, to be observed for 15 minutes in the observation area.

Any vaccinee who was unwell was immediately taken to the emergency medicine team, who were stationed behind screens on the side of the vaccination hall (Fig. 2).

This process continued throughout the day, with tea and lunch breaks for vaccinators and co-ordinators coinciding with times needed for the pharmacy to replenish vaccine stock. Multiple co-ordinators (n=14) were required in our mass vaccination roll-out, and this contributed to the overall organisation, precision and teamwork that led to a successful campaign (Table 2). Our process emphasised the importance of piloting the programme on day 1, troubleshooting and adapting at the end of each day. We were able to vaccinate 5 659 staff by the end of our 8-day vaccination campaign, with 32 vaccinated on day 1, and gradually upscaling to 1 160 vaccinated on day 8 (Table 3).


Pitfalls and unique challenges

Initial pitfalls identified in our mass vaccination planning included:

An objective method for categorisation of staff according to their risk of acquiring severe COVID-19 disease was lacking: we couldn't guarantee that all staff at highest risk would be vaccinated first.

An effective booking system taking into account staff availability was lacking, owing to the scale of administrative support needed.

Reliance on clinicians to staff the vaccination site without providing back-up clinical support or de-escalation of clinical services during the roll-out period. Clinician-led services are widely lauded for their success; however, when this process is employed, it should be a dedicated responsibility and should not compromise patient care.[19]

The urgency of the roll-out and the change from the AstraZeneca to the J&J vaccine. This process resulted in new stakeholders, the need to implement a national electronic booking system, and a limited daily supply of vaccine doses.

Our team was additionally tasked with assisting other frontline private and public sector healthcare workers, which was not initially planned for.

External factors such as visits by dignitaries and media to the vaccine site.


Lessons learned from a mass vaccination campaign

Choose a vaccination site on the basis of good ventilation, space, lighting, toilets and shelter for poor weather conditions. Ensure unidirectional flow of vaccinees through the site, with adequate space in an observation area.

Find a team of passionate, motivated individuals. Ensure that vaccinators are trained, supported and rested. Donations of refreshments went a long way to boost morale.

Pharmacy teams need training on storage and preparation of the vaccine.

Strengthen the OHS team, as they are needed to drive the vaccination process and 'mop up' afterwards. OHS must prepare for AEFIs at a dedicated OHS vaccination clinic.

Communication between all stakeholders is essential, especially on vaccination days: have clear channels of communication between the site vaccination team and the pharmacy.

Ensure fast and reliable internet connectivity, as well as electricity and a back-up generator. Ideally have a pre-registration booking system and a back-up list for each day to avoid wastage of vaccine doses. Generate 'batches' of vaccinees as per risk categorisation, and provide vaccine appointments timeously.

Encourage visible involvement from hospital management - this adds credibility and confidence to the vaccine campaign.

Conduct a 'dry-run' or simulation of the vaccination process before starting the roll-out.

Pilot the process on day 1 before scaling up: prepare to change the plan as it unfolds, taking into account the demands and pressure from other stakeholders.



The mass vaccination strategy developed and implemented at CHBAH was targeted at healthcare workers. Since the launch, our strategy has been adapted for use by other public and private institutions in SA. With a committed core lead team, including pharmacists and clinicians, support from managers and a suitable venue, mass vaccination campaigns can be successfully rolled out in resource-limited settings. Innovation, adaptability and teamwork are critical.

Declaration. None.

Acknowledgements. The authors wish to acknowledge members of the CHBAH COVID-19 Vaccine Committee. Management: Dr Nkele Lesia, Dr Nita Soma; Human resources/admin: Mr Vollie Adoons, Mr Nkosiyethu Mazibuko and team; Occupational health: Ms Chama Jere, Ms Patience Seletela, Ms Refilwe Legoale, Ms Mariam Nephawe, Ms Prisca Ngwenya, Dr Tumelo Makamu; Pharmacy: Mr Saul Dikgang, Mrs Azraa Paruk, Mrs Tshilidzi Shabangu, Ms Courtney Jacobs; Nursing: Mr Baldwin Mulaudzi, Mrs Tshidi Tlhapi, Mrs Ralinala, Mrs Ngeno, Mrs Ntikane, Mrs Sarah Magodielo and the team of vaccinators; Infection prevention and control: Dr Hermenegilda Madeira, Mrs Letta Mafoko, Mrs Kefilwe Tladi; Environmental health: Mrs Nangani Ramulongo and team; Allied medical disciplines: Mrs Premila Naik, Dr Sadna Balton and team; Logistics: Mr Kgadimane, Mr Leon van der Westhuizen and team; Equipment: Mrs Tlale and team; Security: Mr Lucky Mnisi, Mr Ngubane and team; Risks24 ThreeSixtyFive Security: Mr Hoosein Loonat; Clinicians: Dr Kavita Makan, Dr Denishan Govender, Prof. Michelle Wong, Dr Waunita Naidoo, Dr Palesa Mogane, Dr Anisah Mamoojee, Prof. Martin Smith, Dr Zafar Khan, Prof. Sithembiso Velaphi, Prof. David Moore, Dr Nosisa Sipambo, Dr Charl Verwey, Prof. Yasmin Adam, Dr Jayshree Jeebodh, Dr Mary Adam, Dr Vuyelwa Baba, Prof. Rudo Mativha, Dr Kuban Naidoo, Dr Jacqui Brown, Dr Tristan Pillay, Dr Roland Hollhumer, Dr Hassan Alli, Dr Tamarin Nell, Dr Foriwah Obeng-Adjei, Prof. Yasmien Jeenah, Dr Sanushka Moodley, Dr Alex Maisto, Dr Faeeza Nawab, Dr Wendy Friedlander, Dr Nathalie de Klerk, Dr Lisa Galvin, Dr Yumna Minty, Dr Sibu Zuma, Dr Sheila Lutaaya, Mrs Jasmin Kooverjee, Ms Ashleigh Craig, Ms Tasneem Bulbulia, Mr Ahmed Mayet; Ms Tatiana Campbell; Sisonke working team: Prof. Glenda Gray, Prof. Ameena Goga, Ms Fatima Mayat, Dr Erica Lazarus, Ms Anusha Nana, Mr Nazim Akoojee and the pharmacy team.

Author contributions. DLR and ZD compiled the manuscript. NL, JJ, LM and JMLT contributed to the final manuscript. ZD, NL and DLR contributed to the planning and set-up of the infrastructure. LM co-ordinated the pharmaceutical response, and JJ was responsible for administration. JMLT provided oversight and guidance throughout the process.

Funding. None.

Conflicts of interest. None.



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Z Dangor

Accepted 31 March 2021

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