By Dr Khor Swee Kheng / Nur Izzaty bt Badrol Hisham
In the past week, the COVID-19 vaccine was approved by the United Kingdom regulator and was delivered to the first patient. Soon, Malaysia may begin vaccinating our population with the COVID-19 vaccine too. Achieving the stated objective of 70% population coverage will require public confidence in the vaccine’s safety and effectiveness. But what is vaccine confidence, and how can we increase it in Malaysia?
"Vaccine confidence" is defined as the willingness to accept a vaccine, when supply, access and information are available. This term is coined by The Vaccine Confidence Project (VCP), based in the London School of Hygiene and Tropical Medicine (LSHTM). In layperson terms, vaccine confidence is high when the population that should receive a vaccine considers it safe and effective, and will turn out to receive it.
According to the VCP, Malaysia ranks high in the Vaccine Confidence Index with 91% of the population being confident in vaccines. One of the drivers of high vaccine confidence in Malaysia is public acceptance and trust in public healthcare services and providers. This is evident in the success of the vaccination programs conducted by the Ministry of Health (MOH) Malaysia. Other contributing factors include high vaccine risk-awareness and understanding vaccine information, and high health-seeking behavior, according to Universiti Putra Malaysia (UPM) researchers.
Unfortunately, vaccine hesitancy is a growing movement globally, with anti-vaxxers being the more vocal minority. Data from the Wellcome Trust Global Monitor shows that while 79% of people believe in the use of vaccines, 14% are unsure and 7% somewhat or strongly disagree with vaccines. The 21% of the population must be won over to increase vaccine confidence.
Lessons from other nations
In strategizing against COVID-19, Malaysia can learn from Bangladesh and Rwanda, two nations that have overcome large hurdles to improve their vaccination levels. Bangladesh overcame systemic and cultural limiters by reinventing its Expanded Program on Immunization (EPI) in the mid-1980s. This was accompanied by an increase in public engagement to educate the unvaccinated population. One of the prominent features of EPI is the implementation takes place via various outreach centers and clinic-based activities. Education on immunization and engagement occurs during household visits by health workers, which improves trust in services. Today, Bangladesh has the highest immunization coverage in contrast to neighboring countries with roughly similar characteristics.
Similarly, Rwanda has dramatically improved its childhood immunization levels from less than 30% in 1995 (after their civil war ended) to 98% of its population in 2015. Some critical success factors are to encourage international partnerships such as UNICEF and its local government, local community health workers, and localizing technology solutions. There is also a strong political will for health. Rwanda’s vaccination campaign is integrated with the health management information system which also guides vaccine procurement and distribution. Rwandan's leaders at all levels of government also commit to performance contracts tied to vaccination targets, promoting accountability and ownership of an important national priority. These contracts are called Imihigo, a Kinyarwanda word meaning "vow to deliver". Does Malaysia need our own version, perhaps called the "Tekad"?
Policy recommendations for Malaysia
We provide the following recommendations to increase COVID-19 vaccine confidence in Malaysia. While they are described in sequence, all are equally important. Work must start now because confidence is a fragile commodity that requires patient and long-term work, well before the first Malaysian is vaccinated.
Allow space for National Pharmaceutical Regulatory Agency (NPRA)
As a regulatory body, the NPRA plays a vital role to review and approve vaccines to ensure safety and efficacy. This role is critical to increase vaccine confidence. However, the recent and rapid global vaccine progress may put NPRA under a lot of pressure to approve a vaccine quickly. It is important to note that the Priority Review process for NPRA is untested for vaccines, and certainly also for the mRNA vaccines.
Although the response to a pandemic should be treated with the highest urgency, we must give NPRA adequate space to be vigilant. Any undue pressure on NPRA will impair its credibility and decrease vaccine confidence. Therefore, we welcome the repeated reassurances by the Director-General of Health that NPRA will remain independent in its approval process.
Zero tolerance towards fake news
The COVID-19 pandemic offers a new set of challenges alongside the virus itself - rampant misinformation or fake news. Even the World Health Organization coined the term "infodemic" to describe it.
The government can consider stronger campaigns for "zero-tolerance for fake news" not only locally, but also at the international stage. Local campaigns such as the news verification website www.sebenarnya.my have gained traction throughout this year. More local public figures can be trained to provide better communications regarding the vaccine on their social media. Therefore, entrusting vaccine confidence to a broader audience.
Internationally, the Malaysian government must either engage platforms like Facebook and Twitter either alone or with other countries. As these platforms are global in nature, this may require a global solution. The public can play a role, by reporting irresponsible anti-vaccine groups on social media. Complaint mechanisms on platforms like Facebook (such as "Report Page") can be exercised to prevent falsehood super-spreaders in the community.
Empowering communities through strong communications
One of the limiting factors of vaccine confidence is fear and a genuine lack of information. This should be addressed through adequate and effective risk communications.
Vaccine risk communications should take a more inclusive approach by decentralizing the communication efforts between rural and urban areas. Communicating the risk to the urban population can be done via online platforms. For the rural population, communicating in-person such as house-to-house visits by health professionals could be more effective.
For most companies, it is important for their employees to be vaccinated before working in an office is safe again. Private sectors too can take the initiative to arrange risk communication privately or separately to educate their workforce on vaccination. Peer-to-peer encouragement and education can help in building confidence within the workforce.
The social element to vaccine confidence such as lead-by-example strategy is arguably one of the more effective ways to empower the community. Malaysia can learn from Rwanda's success story, whereby leaders at all levels of government commit to vaccination rates as a Key Performance Indicator (KPI). Similarly, three former presidents of United States (Barack Obama, Bill Clinton and George W Bush) have declared their willingness to be vaccinated publicly. In 1956, Elvis Presley was vaccinated against polio on live television, raising teenage vaccination rates from 0.6% to 80% in six months. These examples show that strong public figures can persuade people to have confidence in vaccines.
Although vaccine confidence level in Malaysia is high, we cannot take this for granted. The most important vaccination program in Malaysia’s history depends on high vaccine confidence levels and this requires an all-of-society efforts that must begin now.