Who First, And How Many, Should Get Covid-19 Vaccine In Malaysia?

The government should inform the public on whether it plans to make Covid-19 vaccination mandatory, says a health expert.

KUALA LUMPUR, Oct 6 — As countries race to procure a Covid-19 vaccine, health experts have urged the government to strategise and decide on Malaysia’s target vaccination rate.

Former Health deputy director-general (public health) Dr Lokman Hakim Sulaiman said that if the government’s strategy is to achieve herd immunity, then 80 per cent of the population should be immune to the infection.

He explained that some people would have also acquired immunity through natural infection.

“So, if we know the percentage of the population already immune, then you vaccinate the remaining to achieve 80 per cent,” Dr Lokman told CodeBlue.

As of October 5, MOH reported a total of 10,340 recoveries from the Covid-19 infection, an estimate of only 0.03 per cent of Malaysia’s 32 million-strong population.

According to Dr Awang Bulgiba, an epidemiologist and public health expert, herd immunity is not likely to be achieved quickly through a vaccine, unless a large number of vaccine doses is obtained in a short period of time.

The Ministry of Health’s (MOH) target vaccination rate for most vaccines is 95 per cent as it ensures a large coverage so that herd immunity is more or less assured, even if the efficacy of a vaccine is only moderate.

“Of course, 95 per cent coverage is not really realistic in such a short term,” the professor from the Department of Social and Preventive Medicine University Malaya said.

However, he said that some epidemiologists proposed a vaccination rate of at least 60 per cent for the coronavirus, which he says does not guarantee very high levels of herd immunity.

Herd immunity occurs when a huge portion of a community becomes immune to a disease which makes it unlikely for the disease to spread from person to person so as a whole, the whole community becomes protected. Herd immunity can be achieved through natural infection (where sufficient numbers of people in the population get infected and build immunity) or through a vaccine.

“If we factor in uncertainties about overall vaccine efficacy in the population, as well as how long antibodies are likely to persist in the body, new Covid-19 cases can still be expected to occur even if 60 per cent of the population are vaccinated.”

Dr Awang Bulgiba, professor from the Department of Social and Preventive Medicine University Malaya

He also said that even a 60 per cent coverage may be difficult to achieve, as the demand for vaccines is worldwide and it will be difficult to assure that production can be ramped up in such a short time to cater for a huge amount.

Who Should Get The Vaccine First?

When asked about who should be vaccinated first, Dr Awang said that it would depend on who is considered to be at highest risk and has the greatest need to be protected from Covid-19.

The United States’ National Academies of Sciences, Engineering and Medicine has proposed a tiered approach, five-phase plan to fairly allocate a coronavirus vaccine to US residents.

  • Phase One: Health care workers and first responders
  • Phase Two: People with underlying conditions that put them at high risk of severe Covid-19 disease or death, and older adults in densely populated settings
  • Phase Three: Essential service workers at high risk of exposure, teachers, and school staff, people in homeless shelters, and prisons, older adults who have not already been treated, and people with underlying conditions that put them at moderate risk.
  • Phase Four: Young adults, children, and essential service workers at increased risk of exposure.
  • Phase Five: All remaining residents

It was interestingly pointed out by Dr Awang that if the vaccines were to be administered to medical frontliners simultaneously on a large scale, then, there may be a risk of exposing these health care workers to unexpected adverse side-effects.

“Is there a risk of making too many frontliners ill from unexpected adverse side effects, that they are unable to care for other sick people?”

Dr Awang Bulgiba, professor from the Department of Social and Preventive Medicine University Malaya

China’s pharmaceutical company Sinopharm’s interim results from their Phase One/Two clinical trial of its coronavirus experimental vaccine showed low rates of adverse effects among those who received the vaccine, while US pharmaceutical company Moderna’s Phase One trial of its Covid-19 vaccine candidate showed that there was strong immune response elicited in older adults with no serious adverse effects.

On the other hand, Oxford-AstraZeneca’s Phase 3 trial was halted when one of their participants who received the experimental Covid-19 vaccine suffered from serious adverse effects. Researchers in the study later said the “unexplained neurological symptoms” suffered by the participant were unlikely to be caused by the vaccine, or there was insufficient evidence for any link between the vaccine and the participant’s illness.

Health systems and policies specialist Dr Khor Swee Kheng said the World Health Organization’s (WHO) recommendation — for health care and social care workers; adults more than 65 years old; and high-risk adults to get Covid-19 vaccination priority — would be a good starting point for a discussion in Malaysia on who should be vaccinated first.

“The government must start this public discussion, so that the rakyat will help decide on the criteria in ways that are transparent, inclusive, and fair,” Dr Khor said.

Should Pregnant Women Be Vaccinated?

It was noted that Covid-19 vaccine manufacturers have not included pregnant or breastfeeding women in their clinical trials. Most women working in health care or who are first responders are in the reproductive age group.

The Lancet reported that pregnant women, who are at increased risk of adverse outcomes from Covid-19, would be additionally harmed if they were unable to access evidence-based chemoprophylaxis (the use of drugs to prevent disease) from vaccine trials.

Dr Awang said that an introduction of a new drug or a vaccine, especially when the safety is not established, is always risky for pregnant mothers in their first trimester.

However, he stressed that pregnant women are also at risk of getting infected with the coronavirus, hence they should be protected.

The professor from University Malaya also said that a decision to include pregnant women in any vaccination programme needs to consider factors, such as — does the benefit of the vaccine outweigh the risk? Are pregnant women at higher risk of contracting more severe Covid-19 infection? Has the vaccine been tested on pregnant women or considered to be safe for them because the delivery method has been shown to be safe in previous trials?

Dr Lokman said that the safety profile and the type of the vaccine should be understood first.

“If it is based on a killed or inactivated vaccine, (it) generally is safe for pregnant women, just like our flu vaccine which is safe for pregnant mothers.”

Dr Lokman Hakim Sulaiman, former Health deputy director-general (public health)

An inactivated vaccine uses a killed version of the germ that causes a disease but does not usually provide as strong immunity like the live vaccine. Hence, it requires booster shots for one to get ongoing immunity against the disease.

Addressing Vaccine Hesitancy

Dr Khor Swee Kheng, a physician and specialist in health systems and policy. Picture by Boo Su-Lyn.

Health systems and policies specialist Dr Khor said that the government should now inform the public on whether it plans to make Covid-19 vaccination mandatory.

In 2019, WHO listed vaccine hesitancy as one of the top 10 global health threats. Vaccine hesitancy is the reluctance or refusal to get vaccinated despite the availability of vaccines.

Dr Khor said that education, engagement with social media platforms, appropriate legal penalties for misinformation and disinformation, and engagement with religious authorities and civil societies are several measures that can be taken to reduce vaccine hesitancy in Malaysia.

“Increasing vaccine confidence requires a basket of solutions, as there is no one magic solution.”

Dr Khor Swee Kheng, health systems and policies specialist

Dr Khor also tweeted that vaccines are controversial if made compulsory. He said some believe that the government should let people choose, while others believe the government should compel people to protect public health.

“Both sides have a point. The solution? Focus on increasing vaccination rates, not ideology,” he tweeted.

A survey titled ‘Global Attitudes on a Covid-19 Vaccine’ by Ipsos showed that 85 per cent of Malaysians expressed their interest in getting a Covid-19 vaccine when one becomes available.

Among those who were unwilling to get the Covid-19 vaccine, 48 per cent of them said that they worry about side effects, 36 per cent felt that there were not sufficiently at risk of contracting the coronavirus, 33 per cent doubted its effectiveness, 8 per cent said they wouldn’t have the time, 7 per cent of them were against vaccines in general, while 11 per cent had other reasons.

Dr Awang stressed that health education covering the minority and marginalised population groups, which is easy to understand and continuous, is one of the most important ways to reduce vaccine hesitancy.

While also saying health education alone is not enough, Dr Awang said any vaccine that is administered to the public needs to be studied carefully.

“(This) is to reduce the likelihood of adverse side effects, which will give anti-vaxxers the ammunition they are looking for to dissuade people from getting vaccinated.”

You may also like