KUALA LUMPUR, April 3 — Not everyone who refuses vaccination for themselves or their children are “anti-vaxxers”, a doctor says. Vaccine hesitancy spans a spectrum, including those who can be persuaded to get their shots.
Post-Covid pandemic, it appears as if anti-vaccine sentiment is on the rise in not just Malaysia, but in many other countries as well.
What is of particular concern is hesitancy towards vaccines in general beyond Covid-19 vaccination.
Dr Megat Mohamad Amirul Amzar Megat Hashim – a family medicine specialist at the Department of Primary Care Medicine at Universiti Malaya Medical Centre (UMMC) and vice president of Medical Mythbusters Malaysia – explained to CodeBlue in an interview about the complexities of vaccine communication and how to address concerns.
Dr Amirul has 74,000 followers on his Facebook page.
Combating Misinformation: The Role Of Medical Mythbusters Malaysia
Medical Mythbusters Malaysia is a registered non-government organisation – consisting of various medical professionals – that works to eradicate medical misinformation among Malaysians.
“Initially, we started off with individuals doing myth busting in social media, but then we found that by creating a group, we can achieve more. So, that’s why in 2016, we registered this group called Medical Mythbusters Malaysia,” said Dr Amirul.
They work with various organisations, including the Ministry of Health (MOH), to increase the uptake and coverage of childhood immunisation, among others.
“Basically, our role is more on communication and countering misinformation.”
The Fundamentals Of Vaccination: Protecting Individuals And Communities
Vaccines play an important role in combating infections that could be dangerous and fatal for many.
“Basically, vaccines are a way for us to introduce immunity to our body because we fight off thousands of dangerous germs every day. And usually, when these germs infect us, we get immunity which lasts in our body to protect us from future infection from the same germs,” explained Dr Amirul.
“But some of the germs are so deadly that when they infect us, it can cause complications such as disabilities, paralysis, or even death. We want to build immunity from these germs. That’s how vaccines come into play.”
Beyond individual protection, vaccination achieves herd immunity. “So apart from protecting individuals, vaccines can also create what we call herd immunity to protect the whole community against particular infection. Because in a community, there are people who cannot get vaccinated due to medical reasons,” Dr Amirul said.
“For example, there are people who cannot receive measles vaccines because measles vaccines are live vaccines, and people who are immunocompromised or have low immune systems cannot receive the vaccine. So these are the people who are not individually protected against measles.
“But if the person is living in a community that has a high rate of vaccination, the germs cannot get to them because there is no transmission leak. And when this happens, this is what we call herd immunity.”
“When we see drops in herd immunity for measles vaccination, we will see a rise in cases. So this is the importance of vaccination, which is to protect the individuals and also to protect their community.”
Vaccine Hesitancy: A Wide Spectrum
The rise in anti-vaccine sentiment is complex. Vaccine acceptance and refusal is a spectrum, according to Dr Amirul, and people can vary in their attitude towards vaccinations.
“Vaccine hesitancy is actually a spectrum. It can be from those who really, really accept vaccines, to those who really, really refuse every vaccine. And interestingly, the vaccine hesitancy spectrum can be very dynamic even according to vaccines. For example, some people accept the influenza vaccine, but not the Covid-19 vaccines,” said Dr Amirul.
He advocated against using stigmatising language for vaccine hesitance. “When we say anti-vaccine, these are actually not the people who only refuse vaccines; they refuse vaccines, plus they also spread misinformation to make sure others also don’t take vaccines. These are the people who we call ‘anti-vaccine.’
“But sometimes we misunderstand. We call people who refuse vaccines ‘anti-vaccine’, which is stigmatising and actually pushes them away from us. We must understand that people have valid concerns. And sometimes people don’t have the proper knowledge and proper information about vaccines.
“For the connotation of ‘anti-vaccine’, I always advocate for it not to be used for those who only refuse vaccines.”
Dr Amirul said the World Health Organization (WHO) recommends using the term “vocal vaccine deniers” (VVD) to describe people who refuse vaccines and also propagate misinformation about vaccines.
The Five Cs Of Vaccine Hesitancy
Citing a 2018 study on the psychological factors of vaccination acceptance and refusal, Dr Amirul listed the 5Cs that either help to pull people to take or push them away from vaccination.
“The first C is Confidence, which can be divided into two parts. One is confidence towards the vaccine itself and the second is confidence towards the government and also the operator involved with the vaccine. That means the procurement, delivery and the administration of the vaccine itself. Confidence towards the vaccine is about the safety of the vaccine, whether it’s working or not.
“The second C is Complacency. Complacency means people are feeling ‘it’s okay, this (infection) is not so dangerous. Covid-19 can heal by itself. I got Covid already. I am already protected.’ They feel it’s okay not to get vaccinated.
“The third C is Calculation. This means when you are more engaged with information, you have tendencies to accept or to refuse vaccination.
“The fourth C is Collective responsibility, which is when you take the vaccine not only for yourself, but for others too.”
“And the last C is Constraint. Constraint means the capabilities of a person to get the vaccine, whether it is having a barrier due to logistical reasons, vaccine stocks, or the price of the vaccine.”
Dr Amirul believes that a rise in vaccine hesitancy post-Covid is a case of trust deficit, i.e. the Confidence and Calculation factors.
“Confidence is reducing, not only towards the vaccine, but also towards the government that is procuring the vaccines and delivering the vaccines. People are associating a lot of side effects with vaccines. Most of the time, these are actually not related to vaccines. Also, sometimes we are not communicating the risk properly and the proper effect of vaccines itself. This creates a trust deficit,” he said.
“Number two, because of the rise of the internet, people are getting more calculative. People can search for information here and there, and this increases their calculation. This may push people away from vaccination.”
Respect Patient Autonomy In Persuading Vaccination
Dr Amirul, a family medicine specialist, encounters vaccine hesitancy daily in his line of work as a primary care doctor.
“Vaccination is one of our preventive strategies. We offer vaccination to everyone. MOH also is starting the influenza vaccination programme for free for elderly with comorbidities. We also advocate for that.
“A lot of people accept it, but there are people who are reluctant. We hear that people are scared because they think this influenza vaccine is similar to the Covid vaccine. So we explore, we address their concern, and we try to explain. There are people who understand and accept.
“There are people who need more time to think and to contact other doctors and to basically, to have more time to think. And there are people who actually don’t even want to listen to our facts.
“The way we deal with them also needs to be precise. Those who accept – we congratulate them, and we ask them to continue the vaccination. But at the same time, we also warn about potential side effects despite it being very, very low.”
He added that respecting patient autonomy is crucial.
“As for those who really don’t want to listen to us, we cannot force them. We can just give our strong recommendation that ‘look, I have taken my vaccination, and I think it works for me. That’s why I take the influenza vaccine every year .But if you don’t want to, it’s your choice. But whenever you change your mind, you can come to us.’”
Dr Amirul urged doctors to explore the concerns and barriers preventing “fence-sitters” from taking their shots.
The Double-Edged Sword Of Increased Knowledge Post-Covid
Dr Amirul attributed the rise of vaccine hesitancy after the Covid-19 pandemic to increased awareness about vaccines, particularly on social media. Before mass vaccinations during the pandemic, although there were VVDs, people did not know much about vaccines in general and hence, tended to follow medical consensus.
“But now, after the Covid-19 pandemic, people have started to search more about vaccines. You can do one simple experiment by yourself. When you search ‘vaccine’ on the internet, most of the time, you will find unverified information. But if you search ‘immunisation’, you will be directed to credible sources most of the time,” he said.
“We cannot dictate how people search for information and how they perceive the information. Many times, they have wrong information and these are not from authorities. So, the increase in knowledge, but not credible sources, increases resistance and hesitancy towards vaccines.”
Dr Amirul shared tips for those who want to get good and credible vaccination information from the internet, simplified to four Cs: Credible, Current, Commercial, Consultation.
“Number one, please make sure that the ones giving the information are Credible. ‘Credible’ means they must be a practising doctor.
“Number two, please make sure that the information that you are getting is Current because scientific evidence changes day by day. We frequently conduct studies, hence information changes.
“Number three is to avoid Commercial sites. Commercial sites tend to have a hidden agenda. They tend to gain something by spreading misinformation.
“Number four, whatever you listen, watch, or read on the internet cannot replace your own Consultation with doctors. You need to check with your doctors or check with experts.”
Dr Amirul stressed that it is unlikely that a solo opinion on the internet is credible compared to scientific consensus.
“We can see that there are some doctors who propagate different opinions on the internet. In science, usually, the consensus is what is right because the highest level of evidence is reviewed by a consensus of experts. Then we make recommendations based on them.
“If, let’s say, someone is going against the recommendation, that means someone is going against not only the evidence, but the experts who discussed the evidence. So it’s very unlikely for that particular solo person to be true.”
Balancing Free Speech And Public Health
Addressing anti-vaccine content requires a balance of strict regulation and education.
“I think both ways need to be done. Number one, we need to educate people on how to get correct information. But we also need to acknowledge that VVDs are using methods that are unbecoming. Sometimes they resort to personal attacks and use smearing tactics on vaccine advocates,” said Dr Amirul.
He added that Malaysia regulates advertising for medications under the Medicines (Advertisement & Sale) Act 1956 that prohibits the advertisement of medicines for 20 chronic diseases.
However, Dr Amirul said enforcement isn’t easy. “There’s simply too many of them. There’s not enough enforcement manpower to curb this.”
Dr Amirul reiterated that vaccinations are safe because of the amount of work that goes into producing a vaccine.
“One thing never changes – vaccines really work and they are really safe because before we roll out any vaccination, there’s a lot of process. There’s a lot of studies being done. That includes the Covid-19 vaccine as well.
“So, please make sure that the information that you are getting is the current information.”
