By Mary Hearty, Sharon Atieno and Tabitha Oeri

Since the arrival of the first batch of COVID-19 vaccines, Rwanda has been administering AstraZeneca-Oxford, Moderna and Pfizer vaccines to the priority risk groups, including health workers, the elderly, people with pre-existing health conditions and other frontline workers like hospitality personnel and teacher, among others.

“Aside from almost successfully completing the first roll out of the two vaccines, there have been reported cases of side effects of the vaccines including fever, headache, shortness of breath, spike in blood pressure, feeling weak, dizziness, some people are nauseated, and diarrhea among others,” Dr Menelas Nkeshimana, Leader of a Sub-Cell of COVID-19 Case Management and Infection Control at the Rwanda Joint Task for COVID-19 and Clinical Lecturer at the University of Rwanda said during an Africa Science Media Centre (AfriSMC) briefing.

The clinical health lecturer acknowledged that experiencing such side effects is expected and is a good sign that the vaccine is actually working.

“As a physician, when you vaccinate someone and they experience some fever, I am happy because it shows that the immune system has reacted. Unlike vaccinating someone and they do not experience any reaction. It is a difficult to know if they developed antibodies or not,” he said.

Dr. Menelas Nkeshimana

In terms of eligibility, the physician stated that vaccinating pregnant women and those breastfeeding is not advisable at the moment because studies are still ongoing. However, about 60 percent of those around them need to be vaccinated to help protect them against the virus.

Additionally, he advised that they should observe all measures put in place like wearing masks, staying at home and washing their hands.

Although Rwanda received a small amount of the Pfizer vaccine, it was not only delivered in the cities, and to the top government officials but also as far as in Rusizi area to different profiles of people through helicopters to avoid any kind of disruption and to reach such places as quick as possible.

On the other hand, AstraZeneca despite recent claims that people should not use it because it leads to clotting of blood, the physician said that recent analysis in Europe and other countries have found that there was no nexus between those claims and the vaccine.

“Therefore, we did not stop the vaccination campaign of the vaccine because the claims were not even observed among the people who had received it. But those who thought they had seen them realized it later that it was not associated. So we are going to continue using AstraZeneca vaccine and others that we might have as long as it is valid and authorized,” he said.

Furthermore, he added that unlike Pfizer vaccine, AstraZeneca is very easy to transport and demands less in terms of the cold chain. “Nevertheless, if we receive those with similar demands like Pfizer, we will still be able to handle them as well,” noted Dr. Nkeshimana.

For the second dose of the vaccines, he said that those that received the Moderna vaccine earlier have received their second dose. People who received Pfizer might have received or are receiving their second dose. Whereas for AstraZeneca, people can go as far as 3 months before receiving the second dose.

There has also been signing of a consent form among the people of Rwanda before taking the vaccine. “This form which is available online is part of a good clinical practice whereby you take your time explaining to the people why they need to be vaccinated and allow them to decide whether they want to be vaccinated or not,” he explained.

Vaccine hesitancy

Following media engagement with the people of Rwanda as part of vaccination plan, majority of the population accepted the vaccine. However, there has also been vaccine hesitancy in Rwanda since the roll out began.

“For instance, you find that when you try to talk to some people about the vaccine and the consenting, they refuse to sign or fail to show up for their vaccination appointment,” Dr. Nkeshimana said. “Some refuse but they are not sure if they should, others delay taking the vaccine, whereas there are people who take the vaccine but are not sure if they have made the right decision. This is due to their beliefs and other social circumstances.”

Therefore, the clinician recommended that in order to increase the level of acceptance by the population and the pace of vaccine roll-out and coverage, opinion leaders including ministers, religious leaders, doctors among others need to be engaged more to assure the population that they are also being vaccinated.

Also, he mentioned use of group work. In some districts of Rwanda, they are excused to remain by themselves so that they can calibrate their COVID-19 response plan through group discussions.

Dr Nkeshimana clarified that a vaccinated person can still get COVID-19 and transmit it. That is why they should continue observing all the measures put in place to prevent them from contacting the virus.

“Being vaccinated only give you the guarantee that you will not get the severe disease or die from it. So do not hug or jump at someone just because they have been vaccinated,” he noted.

Dr Nkeshimana with colleagues at the Emergency Medicine Department

The four Es of clinical practice
Early suspicion, early diagnosis, early treatment and early referral are keys to effective control and management of Covid-19.

Dr. Nkeshimana said adoption of the four Es of clinical practice has enabled Rwanda to stay ahead of the pandemic for the last one year.

He called on African countries to watch out for endemic diseases with common signs and symptoms such as malaria and COVID-19. “If one is being tested for malaria, they should also be tested for COVID-19, he said, adding that when measures are not taken on time and the virus is allowed to circulate longer such that there is no timely vaccination or quarantine, there is a risk of deadlier variants of the virus being precipitated.
Dr. Nkeshimana noted that the widespread of rapid diagnostic testing at the health centres is an opportunity to have early diagnosis so that treatment is initiated early and outcome is much better.

COVID-19 variants

“The variants come with different behaviours from the first original virus. They might come as more frequent or prone to evade the immune system,” Dr. Nkeshimana said.

He said that the COVID-19 variants can be classified into three main categories: variant of interest, variant of concern, variants of high consequences.

“A variant of interest is a variant that has been cited or mentioned that it could lead to problems. Whenever you compute it and you put the scientific data around it, you find it associated with problems,” he notes.

He adds that the variant is associated with high infectability, severity of the illness and affected with the ability to produce symptoms in children for example, which was different from the original virus.

There are three variants in this category, Dr. Nkeshimana states, two had been identified in New York and one in Brazil.

According to the Vice president of the Rwanda Medical Association, with the variant of concern there is evidence that if effort is not put to manage them, they are going to create problems. He notes that this variant is highly infectious, highly transmissible, leading to severe cases and death.

He lists five variants in this group, including: the UK strain, the strain identified first in Japan and Brazil, the South African strain and two strains identified in US California.

Dr. Nkeshimana said that the variant of high consequence is not about association only or the evidence, “we know that they are leading to disaster.”

The Sub-cell lead, Rwanda Joint Task force for COVID-19 Case management said: “They are evading the immune system. They cannot be covered with all the available vaccine. They are leading to high mortality and morbidity but there is no variant in this category yet.”

“But we could easily have them if we don’t manage well the variants of concern,” he cautioned. “We don’t have and we shouldn’t have the variant of great consequences because the cost is going to be much higher and the consequences difficult to manage.”

Dr. Nkeshimana notes that a country with this variant will be struggling massively with the third wave characterized by high morbidity, cases and deaths despite the on-going quarantine, isolation measures and vaccination.

He emphasized the need to control cases of people with variants of concern to ensure that there is limited contact with general population so as to avoid community transmission of such cases that could lead the virus mutating into a deadlier virus of high consequences.

The 4S Strategy for Vaccination Rollout

Dr. Nkeshimana during a public briefing

To share the life-saving Covid-19 vaccines equitably across the globe, keen consideration needs to be on appropriate strategies to enhance effective rollout.

Dr. Nkeshimana noted that a nation-wide vaccine rollout has a fairly complex logistics that must be considered.

He gave an example of the use of the highly successful 4S strategy involving staff, stuff, space and systems being employed in Rwanda in the vaccine roll-out.

“You will need staff like doctors, nurses, security organs, people to volunteer, pharmacists, administrators, journalists to explain more on the vaccine to curb misinformation, pilots and drivers for timely delivery to avoid wastage due to the vaccine measures that need to be followed keenly,” Dr Manelas elaborated.

Dr Nkeshimana emphasized the need for collaborations among various multi-sectoral departments such as transportation, media engagement and opinion leaders to be able to mobilize the rollout.

He emphasized the need to ensure adequate supply of stuff like needles, swabs, ambulances, personal protective equipment (PPEs), helicopters and transport vehicles. Space for storage (ultra-cold chain for some types of vaccines such as Pfizer), registration, waiting rooms, observation rooms and systems also need to be in place to facilitate the rollout.

Rwanda is one of the few African countries with capacity to receive, store and administer Moderna and Pfizer vaccines that the country is administering in addition to the AstraZeneca vaccine, which is rocked with safety concerns.

In a recent press release (datelined March 25, 2021), AstraZeneca underscored the safety of its product when it noted that in a study involving 190 cases with symptoms of the disease the vaccine showed 76% vaccine efficacy against symptomatic COVID-19; 100% efficacy against severe or critical disease and hospitalization and 85% efficacy against symptomatic COVID-19 in participants aged 65 years and over.

Dr Nkeshimana also highlighted an emerging global health threat to population causing vaccine hesitancy that might slow down the process. He, therefore, called on opinion-leaders (ministers, mayors, religious leaders, doctors etc.) to facilitate rapid vaccination to move ahead of the pandemic without delays, noting: “A successful vaccination campaign depends on the level of acceptance by the population and the pace of vaccine roll-out and coverage.”

He reiterated Peter Piot’s saying that, “Epidemics on the other side of the world are a threat to us all. No Epidemic is just local.”

Therefore, no one is safe, until all of us are safe thus highlighting that the Covid-19 pandemic does not respect borders, it moves from a country to country along with population movements and transportation of goods.

He gave the example of Rwanda which experienced a sharp spike of infections due to relaxation of border controls that allowed many Tanzanians to enter the country without strict screening for the virus. Thus, there is need for neighboring countries to collaborate if the East African region is to beat the deadly pandemic, Dr Nkeshimana said.

“Vaccinating only one part of the world or one country/continent is very dangerous and could lead to the forgotten side being a breeding ground for variants that would eventually circulate globally. There is a pressing need for the timely re-establishment of global health security,” he said.