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As part of its new national immunisation strategy, South Africa is adopting a life-course vaccination approach. This shift will protect people of all ages from vaccine preventable diseases while also strengthening preparedness for future pandemics.

Since early 2024, a diphtheria outbreak across five South African provinces has resulted in 61 infections and claimed 12 lives. Of note is, that 70 percent of the confirmed cases have occurred among people over the age of 18.

Diphtheria is a vaccine preventable disease which is included in South Africa’s essential immunisation programme for children, so the unusually high proportion of cases among adults points to a worrying ‘immunity gap’ in pockets of the population. However, in responding to the outbreak, public health officials have no easy way to identify, reach and protect adults who could be at risk of infection. At present, there are no systems for tracking people’s vaccination status and contacting individuals who have missed doses, or who might need a booster shot because their immunity has waned.

In South Africa, as in most countries, children are at the heart of the national immunisation programme. But health experts increasingly see the need to have systems for reaching adults with vaccinations, too. This is why South Africa’s National Department of Health, in line with the World Health Organization’s Immunization Agenda 2030, is moving towards the adoption of a life-course vaccination approach which will ensure that vaccines are available to people of all ages as part of routine health services.

Germany supports South African partners to navigate a changing immunisation landscape

Immunisation, one of the pillars of public health, is facing both incredible opportunities and stiff headwinds. The COVID-19 pandemic demonstrated the feasibility to develop and deploy a safe and effective vaccine against a novel virus, but at the same time threw a harsh spotlight on inequalities within and between countries in terms of access to life-saving jabs and vaccine manufacturing capacity. While vaccines have proven to be an effective first line of defense against a host of deadly diseases, the number of people questioning their safety and effectiveness is on the rise in many countries, including South Africa. In addition, resources for vaccine procurement and distribution are coming under intense pressure at the very time that evidence about the socio-economic benefits of adult immunisation is increasingly persuasive.

As part of its long-standing partnership with the health sector in South Africa, German development cooperation is working with the National Department of Health, and with provincial health departments in Gauteng and Mpumalanga, to navigate this rapidly changing terrain. The Vaccines for Africa: Roll-out and Production in South Africa (SAVax) programme aims to improve access to high quality vaccines for all people in South Africa by strengthening the entire vaccine value chain, from disease surveillance to research and development, local vaccine manufacturing, regulatory systems, procurement, demand, and delivery. SAVax is financed by the German Ministry for Economic Cooperation and Development (BMZ) and the Team Europe Initiative on Manufacturing and Access to Vaccines, Medicines and Health Technologies (‘MAV+’), and implemented by the Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ).

Support for the introduction of a life-course vaccination approach is a key pillar of this larger strategy. The SAVax programme is cooperating with partners at the national level to revise the National Immunisation Strategy, which will serve as the local roadmap for implementing Immunization Agenda 2030. This includes exploring suitable institutional arrangements for managing immunisation services across the life course. SAVax is also collaborating with the provincial departments of health in Gauteng and Mpumalanga to pilot an adult vaccination programme.

‘An adult vaccination programme can help to create demand for vaccines which are produced locally and can also ensure that this demand is met by making vaccines easily available to people as an opt-in service during routine health consultations,’ says Kirstin Walker, who leads the work on vaccine distribution, regulation and pandemic preparedness for the SAVax programme.

Health benefits for an ageing population, and an investment in pandemic preparedness

South Africa’s new National Immunisation Strategy is attuned to the country’s changing demographics: people over the age of 60 already comprise more than 10 per cent of the population and are on track to make up more than 16 per cent by 2050. As the proportion of older persons grows, investments in preventing diseases such as influenza, respiratory syncytial virus (RSV), herpes zoster (shingles) and pneumococcal disease can help to reduce pressures on the healthcare system. The revised strategy also acknowledges the likelihood that new vaccines, including for tuberculosis and possibly even HIV, will become available in the foreseeable future – and that it will be essential to have systems and processes in place to deliver these to eligible individuals.

An adult vaccination programme will not only offer health benefits to an ageing population, but will also provide a platform for responding quickly in the event of a public health emergency. South Africa’s experience during the COVID-19 pandemic showed the limits of trying to roll out a nationwide vaccination programme for adults using ad hoc systems. The country was ultimately successful in reaching 70 per cent of the population over the age of 60 with at least one dose of COVID vaccine, thanks in part to innovative measures like pop-up vaccination sites at pension offices, where older people queue to collect their payments. But among healthy younger adults, particularly men, there was significant hesitancy to come forward and be vaccinated.

‘We saw that other countries with better medical records and the ability to contact individuals for vaccination had much better uptake,’ says Dr Lesley Bamford, the acting Chief Director for Maternal, Child and Women’s Health at the National Department of Health. ‘Everyone takes their children to be vaccinated, but the notion of being vaccinated as an adult was new.’ She continues:

The best way we can prepare ourselves for a future pandemic is to have an adult vaccination programme rooted in the primary health system. The stronger the systems we have, and the more people are used to immunisation, the more prepared we’ll be for the next time.

Dr Lesley Bamford, National Department of Health

What will it take to operationalise an adult vaccination programme?

Guided by the priorities of the National Immunisation Strategy and the recommended immunisation schedule for adults, provincial departments will be responsible for making vaccination routinely available to adults alongside other primary health care services. Dr Cheryl Nelson, the Chief Director for Primary Healthcare Services at the Mpumalanga Department of Health, sees this as an important opportunity: ‘We have a lot of adults who live with co-morbidities, including HIV and tuberculosis. We believe that introducing a life-course vaccination approach will assist over time in building a healthy, more resilient population.’

The immunisation platform in Mpumalanga is currently based on the expanded programme on immunisation (EPI) for infants and children, with additional programmes targeting adolescent girls (HPV), pregnant women (tetanus/pertussis), and identified high-risk groups (influenza). A new adult vaccination programme will be able to leverage the systems and ‘know-how’ which underpin these existing programmes, from the established cold chain infrastructure to the skilled personnel trained to administer vaccines.

However, provincial officials are aware that a new adult vaccination programme will need to be planned and introduced carefully to avoid overwhelming the existing routine health services. ‘As a province we face competing health priorities and limited resources,’ explains Dr Cheryl Nelson. ‘There is also the challenge of ensuring equitable access to vaccines in hard-to-reach areas.’

Vaccine hesitancy is another major challenge to surmount. ‘During the COVID-19 pandemic addressing the myths and misinformation around vaccines was one of our biggest problems,’ adds Dr Cheryl Nelson. ‘If a new adult vaccination programme is to be accepted, our messaging needs to be very clear, tailored to specific age cohorts and risks groups, and consistent across provinces.’

To capitalise on provincial-level insights and experience about what works in the delivery of vaccination services, the SAVax programme has established a ‘community of practice’ for provincial health officials and practitioners from across South Africa. This provides a platform for joint discussion about the shape of the future programme, and will offer a place for regular exchange and sharing of good practice once the programme is rolled out.

A chance to streamline institutional arrangements  

The introduction of an adult vaccination programme offers an opportunity to strengthen the way immunisation services are managed in South Africa. At present, responsibility for immunisation services is spread across four different programmatic directorates within the national and provincial health departments – child and youth health, school health, maternal health, and communicable diseases – with each targeting specific population groups. This fragmentation in management and implementation arrangements can lead to inefficiencies, duplication, and missed vaccination opportunities – and ultimately to immunity gaps such as the one the diphtheria outbreak has exposed.

As immunisation services become more complex with the addition of an adult vaccination programme, a more cross-cutting approach will be needed. ‘Immunisation touches upon so many different aspects, from supply chain management to health communication and service delivery. It’s therefore very difficult to have a siloed vertical programme that does only immunisation. We see the need to move towards a more dynamic way of working,’ says Dr Lesley Bamford, of the National Department of Health. The SAVax programme is supporting the department to map out alternative structures in which, for example, a core unit responsible for immunisation can draw upon expertise from other teams as needed.

Reconsidering institutional arrangements so that they are fit for this broader mandate may help to address some of the limitations of the current immunisation programme. These include vaccine stock-outs, gaps in surveillance of vaccine preventable diseases, and a lack of social mobilisation campaigns to generate demand for vaccines. ‘With support from external partners, many innovative things were tried out and learned during the COVID-19 response,’ says Kirstin Walker of the SAVax programme. ‘This is the right moment to see which of these can be integrated into existing processes so that the vaccination system as a whole works even better.’

A strategic partnership at a critical time

All of these deliberations are taking place against a backdrop of mounting resource constraints in the health sector. ‘While vaccines for diseases like measles and polio are cheap and extremely effective, the new vaccines coming to market are expensive investments for a middle-income country like ours,’ explains Dr Lesley Bamford. ‘We know how to introduce vaccines from a technical perspective, but not necessarily from a financing perspective.’

With an eye to the complex decisions awaiting the government in the coming years, SAVax is working with the National Department of Health to strengthen expertise in the development of vaccine ‘investment cases’ which weigh anticipated public health benefits of new vaccines against their costs. It is also providing guidance on emergency procurement procedures for vaccines, so that the Department is prepared to react quickly in the event of future disease outbreaks. To ensure that procured vaccines ultimately reach the people they are intended to protect, the programme is supporting a study into factors underpinning vaccine hesitancy in South Africa.

At this difficult moment for global health, these strategic contributions are furthering South Africa’s efforts to retool the country’s immunisation programme to better meet existing challenges – and emerging ones.  Working across the vaccine value chain, the SAVax programme is helping to realise the vision of bringing the benefits of immunisation to everyone in South Africa, from birth to old age.

Karen Birdsall
August 2025