As the Delta variant is demonstrating, if the majority of the population is not vaccinated, Covid-19 will continue to spread and mutate into more dangerous forms that could overwhelm healthcare systems.
Within months of the first reported outbreak of the novel coronavirus disease (Covid-19) on December 31, 2019, in China, the virus had spread across much of the world. It continues to spread globally, resulting in almost 195 million confirmed cases and over four million deaths, across 220 countries and territories worldwide.
In Singapore, 62,000 Covid-19 cases, and over 30 Covid-19 deaths have been recorded since the disease first reached its shores on January 23, 2020. The country recently announced its return to Phase 2 Heightened Alert restrictions to control clusters of the new Delta variant.
Across the causeway the situation has been even direr, with Malaysia experiencing wave after wave of outbreaks, recording over one million cases and over 8,000 deaths since the first local infection was confirmed on January 25, 2020.
Vaccine hesitancy in Malaysia and Singapore
Yet despite rising infection rates, a worryingly high number of people remain vaccine-hesitant.
Surveys in Malaysia have reported vaccine hesitancy rates ranging from 16.7%, to as high as 33%, with vaccine acceptance being highest among tertiary-educated, working professionals under 50, and vaccine hesitancy being highest among the elderly, the less educated and those in rural communities.
While 16.7% might not seem high it could still be dangerous. Vaccine hesitancy was named one of the top 10 threats to global health by the World Health Organisation (WHO) even before the current pandemic. Back in 2019, the organisation reported a reduction in global immunisation rates for the measles, mumps and rubella vaccines, which slipped to 85% compared to the required target of 95%, leading to numerous measles outbreaks. A vaccine hesitancy rate as high as 33% for Covid-19 would make achieving population immunity practically impossible.
According to a recent survey of 1,400 Malaysian adults published in BMC Public Health, the leading causes for hesitancy were
fear of the side effects of the vaccine (95.8%),
concerns about safety (84.7%),
lack of information (80.9%), and
questions about the effectiveness of new vaccines (63.6%).
Although 72.3% of those surveyed were Muslim, religious beliefs (20.8%) and cultural factors (6.8%) were among the lowest causes of hesitancy.
Combating disinformation: Posters addressing concerns about vaccine safety by the Malaysian Special Committee for Ensuring Access to COVID-19 Vaccine Supply (Jawatankuasa Khas Jaminan Akses Bekalan Vaksin or JKJAV), and the Singapore Ministry of Health.
Citing a recent report by the United Nations Children’s Fund (UNICEF) and the United Nations Populations Fund, Professor Dr Moy Foong Ming, Professor of Epidemiology at the Department of Social & Preventive Medicine at University Malaya, says low-income households are another vaccine hesitant group;
“Vaccine hesitancy is high among the bottom 40% (B40) group, with four out of 10 people unwilling to get vaccinated. Unfortunately, low-income households are also less informed on the side effects, safety and efficacy of Covid-19 vaccines, and may not realise the importance of overcoming the pandemic for our country.”
Singapore’s National Vaccination Programme (NVP) has been gaining momentum in the last three months. According to key findings by the Institute of Policy Studies (IPS), one in three (33%) Singaporeans were unwilling to be vaccinated, while one in five were neutral. About half of the population, especially those aged 21 to 39 also expressed concerns over the safety, potential side effects and effectiveness of the vaccines.
Why does vaccine hesitancy occur?
According to Dr Khairil Erwan Khalid, Infectious Disease Physician at Hospital Kuala Lumpur (HKL), vaccine hesitancy is a global problem. He says most countries have two groups of people: one highly motivated to get vaccinated, the other hesitant for various reasons, particularly a fear of the unknown.
“Because Covid-19 is new, we don’t have long-term safety and efficacy data on its vaccines, with standard treatment still being debated among medical communities. These factors can contribute to vaccine hesitancy among the public,” he says.
Dr Ling Li Min, Infectious Disease Specialist at the Rophi Clinic and Prof Dr. Moy add that the 'infodemic' (a portmanteau of information and epidemic, defined by a rapid and far-reaching spread of accurate and inaccurate information about something), and religious, cultural and personal beliefs, may also promote vaccine anxiety among vulnerable groups.
“People may be less accepting of vaccines if they don’t trust or understand official information, while those who have less access to mainstream media or official information may only listen to their friends and other people’s experiences with vaccines,” says Dr Ling.
“There are also groups who are influenced by religious or cultural beliefs that sickness is fated and to therefore accept whatever misfortune that befalls them,” adds Prof Dr Moy.
An article in The Atlantic suggests vaccine refusal is not an individual problem, but a social one. Pandemics need communities in which to spread, so addressing pandemics requires an understanding of the interpersonal dynamics that determine a community’s attitudes towards vaccines.
The article describes how in the largely vaccine-hesitant Missouri — one of the worst-hit states in the US — negative local attitudes have either resulted in groups rejecting the vaccine or worse, preventing pro-vaccine individuals from getting inoculated for fear of being ostracised by their communities.
Other factors that contribute to vaccine hesitancy
While some individuals choose to avoid vaccines, others want to get vaccinated but simply do not have access to them due to impatience, lack of technology or logistical problems.
“Malaysia’s National Covid-19 Immunisation Programme (NIP) has three phases, in which healthcare frontliners and the elderly are vaccinated first. If young people are forced to wait their turn, this can potentially promote vaccine hesitancy simply because they get tired of waiting,” Dr Khairil explains.
“Rural communities are also at risk because they are located far away from vaccination centres. Plus, they may not have access to a computer to register and book their shots online, which potentially increases the risk of infection among these groups, as they also have less access to official Covid-19 information, such as the importance of practising standard operation procedures (SOPs) when in public, including sanitising or washing the hands frequently, and wearing a mask at all times.”
The drive for more vaccinations
As the pandemic continues to ravage healthcare systems and economies, governments across the world have been scrambling to vaccinate their populations.
Malaysia, experiencing one of Southeast Asia’s worst infection rates, has ramped up its NIP since its initiation on February 26, 2021, by setting up mega vaccination centres and recruiting private clinics and hospitals to administer inoculations. The government is also enabling registration through district health clinics, local politicians and NGOs, as well as providing outreach vaccination services in remote communities.
In Singapore, the NVP was implemented on December 30, 2020. The government has set up community vaccination centres in most HDB towns, while polyclinics and some GP clinics have also been recruited to administer vaccines under the NVP.
Singapore and Malaysia are leading the world in the vaccine race, having recently been ranked first and second in the world respectively for average daily vaccinations per capita.
Data collected demonstrated a rate of 1.3 vaccinations for every 100 Singaporeans, reaching up to 70,000 daily inoculations in Singapore. Fast forward to July 26 2021, about 3.1 million people, or 55% of Singapore's population have been fully vaccinated, with 77% of seniors, aged 60 and above having completed their vaccinations. This puts Singapore roughly on track to achieve its goal of having two-thirds (around 67%) of the population fully vaccinated by its National Day on August 9, 2021.
In Malaysia, the country achieved a record high of daily vaccinations administered at 521,923 on July 26, 2021. According to an August 1 article in The Edge, in the same month, Malaysia gave out a total of 12.47 million doses of Covid-19 vaccines, more than double the 5.08 million doses given out in June. About 42.3% of the total population or 13.82 million people have received at least their first dose, while 20.6% of the total population or 6.72 million people have received the total two doses.
Singapore and Malaysia hope to be the first countries in Southeast Asia to be fully protected against Covid-19, but to do so they will have to overcome the vaccine hesitancy that still affects a significant percentage of their populations.
How does vaccine hesitancy impact public health and national healthcare systems?
Until population immunity is reached there will continue to be new daily Covid-19 cases, more hospitalisations, and more deaths. The more uninoculated people there are, and the longer it takes to reach population immunity, the more opportunities there are for the virus to mutate and become more dangerous; potentially crippling healthcare systems and economies around the world.
According to Dr Ling, the danger from new mutations has been proven by the Delta variant, which has caused a surge in new cases and lockdowns in some countries, due to its 40% to 60% higher transmission rate than the Alpha variant.
In countries like Malaysia where new infections have exceeded 10,000 daily cases recently, healthcare facilities and systems have become inundated, even close to collapse, says Prof Dr Moy.
The scene on the ground (Malaysia): Congestion in front of the emergency department at a Covid-19 treatment centre; while at a Kuala Lumpur hospital staff set up canvas beds in one of the emergency department zones as wards and ICUs are full.
“Malaysia hit a new ceiling of 17,045 new cases, 199 deaths, and 972 patients in intensive care units (of which 456 patients needed ventilators to breathe) on July 25, July 21, and July 13, respectively. The number of patients with serious stage 4 and 5 disease have also increased, with many non-Covid wards converted to Covid-19 wards, depriving other patients of the care they need.”
As a doctor working on the ground at HKL, Dr Khairil admits Malaysian Covid-19 treatment centres are overwhelmed as hospital beds, medical supplies and staff have been stretched thin in recent months.
“With so many new critical patients daily, and limited bed capacity, more wards need to be opened which require additional manpower to operate. When hospitals operate at overcapacity, medical staff must work multiple shifts, resulting in physical and emotional burnout.”
Overrun with patients: Crowded Covid-19 wards with patients who require oxygen tanks (Malaysia)
“A lack of ventilators has also resulted in doctors having to play God and choosing who deserves breathing assistance the most. This is why I urge the public to get vaccinated as soon as possible, because vaccinations reduce the risk of severe disease, easing the burden on healthcare facilities, frontliners and the overall healthcare system.”
How are vaccines approved in Singapore and Malaysia?
All the vaccines available in Malaysia and Singapore have been approved by the WHO as well as Malaysia’s National Pharmaceutical Regulatory Agency (NPRA) and Singapore’s Health Sciences Authority (HSA) respectively.
Worldwide, hundreds of millions of doses of these vaccines have been administered with minimum side effects.
Globally, millions of people take a daily dose of aspirin to prevent stroke and heart attack, yet statistically one in 10,000 of them might die each year from side effects of the aspirin. In comparison, more than 187 million people in the US have been vaccinated as of July 19, 2021, with only three confirmed deaths from vaccine side effects.
What can governments do to improve vaccination rates?
Dr Ling says that creating a pro-vaccination culture that appeals to various segments of the population, establishing more avenues for vaccine registration such as landline dial-ins or walk-ins, and setting up vaccination centres would be helpful.
“Offering financial support for medical care should an adverse reaction occur and implementing a vaccine passport, to enable more leisure and business travel, might also incentivise people to get vaccinated,” she adds.
Prof Dr Moy also urges political and religious leaders do their part to promote vaccinations by tailoring messages to their constituencies and congregations, affirming that vaccines are not only halal (for the Muslims) and safe, but are also key to protecting themselves and their loved ones.
How can the public do their part in reducing the spread of Covid-19?
Getting vaccinated has never been a personal choice, but a social obligation as it protects everyone. If certain individuals, or groups, refuse to get vaccinated, this can lead to a vicious cycle of Covid-19 mutations and more dangerous variants of the disease.
For this reason, Prof Dr Moy, Dr Ling and Dr Khairil believe that vaccinating ourselves out of the pandemic and achieving herd immunity is the only way countries can resume any sense of normalcy.
Prof Dr Moy encourages everyone to do their part in reducing the spread of Covid-19 by getting vaccinated, not being picky about vaccine brands, continuing to practise SOPs once fully inoculated, and avoiding circulating uncertified claims on vaccines or the disease.
Ultimately, everyone must do their part in keeping their countries and loved ones safe. As the Malaysian government likes to say: ‘Kita Jaga Kita’, (we look out for each other), so let’s get vaccinated, stay safe and stay healthy.
Disclaimer: All figures are correct at the time of publishing.
For full video of panel discussion click here