The Big Read: As COVID-19 becomes endemic, it’s a race against time to get more seniors vaccinated
Apart from concerns over the newness of mRNA technology, other factors include fear of the side effects, a belief that vaccines are not necessary. religious convictions and also a general lack of awareness of how to get vaccinated, interviews show.
SINGAPORE: Mr Paul Poh’s wife had been urging him to get vaccinated against COVID-19, even dangling the carrot of a safer environment for him to spend time with his grandchildren.
But the 72-year-old retiree would not be rushed; it was only after the authorities allowed some private clinics to administer China’s Sinovac vaccine last month — to overwhelming demand — that he decided to register for his doses. He is now waiting to receive his first jab.
His main reason for not participating in Singapore’s national vaccination programme — which only administers the Pfizer-BioNTech and Moderna shots — is because both vaccines use the messenger ribonucleic acid (mRNA) technology.
This is the first time that the mRNA technology has been approved by the World Health Organization and health authorities around the world for widespread use as vaccines, amid the battle against an unprecedented global health scourge that is COVID-19.
Mr Poh reiterated that his preference for Sinovac stems from the fact that it uses inactivated coronavirus to trigger an immune response — a more traditional vaccine technology that had been used to develop vaccines for other diseases such as polio.
Both the Pfizer-BioNTech and Moderna vaccines have shown efficacy rates of well over 90 per cent against symptomatic disease in clinical trials, compared with Sinovac's 51 per cent.
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Singapore’s expert committee on COVID-19 vaccination under the Ministry of Health (MOH) had previously come out to stress that current mRNA COVID-19 vaccines used here continue to be “safe and highly effective”, and “show protection against variants of concern”.
Separately, infectious diseases expert David Lye also said that the vaccines using mRNA technology are the most effective against the coronavirus, including its variants, while there is hardly any data on how the Sinovac vaccine performs against the variants.
Mr Poh is among a sizeable group of seniors aged 60 and above in Singapore who have yet to come onboard the national vaccination programme, which was started about six months ago with seniors as the first group eligible for the jabs. Vaccination is seen as key for a pandemic-weary nation to move to a “new normal”, where social distancing requirements and travel restrictions could be relaxed.
Apart from concerns over the newness of mRNA technology, other factors include fear of the side effects, especially among those who have pre-existing illnesses; a belief that vaccines are not necessary; religious convictions; and also a general lack of awareness of how to get vaccinated, interviews with those aged 60 and above showed.
Ms Patricia Lai, who is in her late 60s, is afraid that she would not be able to withstand the side effects, given that she is already riddled with several health problems, such as difficulty in walking due to her swollen legs.
“No vaccine is the best. Who likes vaccination?” she said.
Ms Lai added that she has always seen traditional Chinese medicine practitioners for any health ailments and does not want to be injected due to her overall distrust of Western medicine.
The Government has set a target of having two thirds of its population fully vaccinated by National Day on Aug 9.
Based on MOH’s latest figures, as of Jun 28, 76 per cent of seniors aged 60 and above have had at least one dose of the vaccine.
In April, it was revealed in Parliament that at the time, about 60 per cent of eligible seniors aged 70 and above had either been jabbed or booked their vaccination appointments. This was lower than the proportion (70 per cent) of those between 60 and 69 who had done so.
Throughout the pandemic, government leaders including Prime Minister Lee Hsien Loong himself have made impassioned pleas for seniors to get vaccinated.
READ: Commentary: Concerns over long-term side effects could hold back Singapore’s COVID-19 vaccination programme
Most recently, the three co-chairs of the multi-ministry COVID-19 task force — Trade and Industry Minister Gan Kim Yong, Finance Minister Lawrence Wong and Health Minister Ong Ye Kung — as well as MOH director of medical services Kenneth Mak all repeated the call last week.
The Government has left no stones unturned in its bid to encourage seniors to get jabbed. For example, it has been deploying doctors and nurses to homes to help those who are homebound or not mobile to receive their jabs. Those aged 60 and above can also walk into any vaccination centre and get vaccinated on the spot, without the need for prior registration.
In recent days, Cabinet Ministers have appeared in online videos with local celebrities and speaking in various vernacular languages about the importance of vaccination.
Infectious diseases specialists said vaccination is especially vital for the elderly — who are vulnerable to severe illness from COVID-19 — as it provides them with the needed protection when COVID-19 becomes endemic.
This is when people will get used to living with the coronavirus in their midst and where there may be occasional spikes in the infection rates — just like they have learnt to live with dengue and the common cold.
WHAT’S HOLDING SENIORS BACK
While the Sinovac vaccine offers recipients some form of protection against the COVID-19 virus, it is not part of Singapore's national vaccination regime. The Health Sciences Authority has yet to approve Sinovac because of the lack of some critical data from its manufacturer.
Sinovac is provided here only under the Special Access Route framework. Vaccines under this framework are not covered under the Vaccine Injury Financial Assistance Programme, which supports people who suffer adverse effects from their COVID-19 jabs.
MOH has said that residents who choose Sinovac have to pay for consultation fees and the 7 per cent goods and services tax, but they would not be charged for the vaccine itself, since it is being provided at no cost to these private clinics.
Still, some seniors remain apprehensive of the mRNA technology. “We are being treated like guinea pigs,” said a relief kindergarten teacher, who wanted to be known only as Ms Yap, about her fears in relation to mRNA vaccines.
The 63-year-old was speaking while registering her interest for the Sinovac vaccine at the HeartlandHealth clinic at Bedok South, one of 24 private clinics selected to administer the Government’s stock of Sinovac vaccines.
Mr S Teo, who declined to give his full name, said he also prefers Sinovac as it is made using the same technology as the flu vaccine he takes every year.
“I know you may say there are no side effects now, but maybe in five to 10 years, you don’t know what are the effects that are going to come out,” said the 64-year-old.
Mr Poh and Mr Teo also cited reports from Israel on how young men who had taken the Pfizer-BioNTech vaccine appeared to have a higher risk of developing heart muscle inflammation.
On this, the expert committee said the benefits of getting vaccinated still outweigh the risk. Nevertheless, it has advised “adolescents and younger men” to avoid strenuous physical activity for a week after their second dose as a precaution against a “small risk” of heart inflammation.
Mr Poh said he has doctor-friends who send him reports of potential negative effects of mRNA vaccines, and he is confused as to which reports he should trust.
Ultimately, he opted for Sinovac on the basis that it is developed with an older and therefore proven technology.
Some seniors said that they do not want to be vaccinated due to religious convictions.
“If you are so strong in your faith and believe that God is in control, you don’t need that kind of vaccination. That’s my take,” said Mr Simon Wee, a 62-year-old Christian.
Mr Eric Tan, 72, said that he will only take the vaccine if it is made mandatory or if he needs to go overseas.
Mr Tan, who works in the courier service, said while he does not fear contracting COVID-19, he still takes precautions such as wearing a mask and washing his hands when he goes out.
“I will not allow fear to come upon me … and I pray for God’s protection,” he added.
‘I’M SO OLD ANYWAY’
Some other seniors said that they do not believe that vaccination is necessary for them since they rarely leave their homes and do not interact with many people.
An 83-year-old, who wanted to be known only as Madam Ong, said that she finds it too troublesome to get vaccinated.
“I’m so old anyway, so why should I get vaccinated?” she said. “Only if the Government makes vaccination compulsory, then I will get vaccinated.”
Similarly, Madam Fatmah Hakimdin, 77, said that she has not been vaccinated as she only goes out once a week to buy groceries from the market.
“I’m mostly at home … I’m not worried about getting COVID-19 and falling sick,” she added.
Mdm Fatmah is also fearful of the possible side effects from taking the vaccine as she had suffered allergic reactions after taking muscle relaxant pills.
But she has not ruled out getting vaccinated, adding that she will take the next one to two weeks to make a decision. “When I’m ready and more relaxed, maybe I’ll take the vaccine.”
For Mr Ang Heng Soon, 70, he does not want to trouble his sons and grandchildren in case he suffers from any side effects from the vaccination, given that he is already beset with health issues.
“My body is deteriorating quite badly. I don’t want to live so long. I’m retired, I just live life peacefully and quietly ... Why should I get jabbed and feel uncomfortable?,” he said in Mandarin.
He believes that exercising daily, eating well and not going out too often are good enough.
“If I get it (COVID-19), then I will think of what to do … We cannot be scared of everything as human beings,” said the retiree.
Other unvaccinated seniors, such as an 82-year-old retiree, who wanted to be known only as Mr Chew, said he is “waiting to see how things go” by monitoring the side effects of others who had taken the vaccine first.
“I’m a bit selfish, I would like for more people to get vaccinated so we can get herd immunity. But I might only get vaccinated when I know for certain that (the vaccines are) safe,” he said.
Mr Chew said that while he goes out every day to run errands and exercise, he takes precautions such as keeping his distance from people and driving to his destinations instead of taking public transport.
Dissuaded by her daughter and son-in-law, Madam Koh Kah Mooi has delayed getting vaccinated as she is concerned that she may develop health problems later.
“My family members are all busy, who will take care of me?” said the 75-year-old, who works as a part-time consultant.
Despite her reservations, Mdm Koh is now considering getting jabbed in the next one to two months after observing that most of her vaccinated friends have not experienced side effects.
Encouragement from her eldest grandson and the fact she goes out daily are other factors that have led her to reconsider.
There are also seniors, such as Madam Teo Ah Eng, who want to be vaccinated but do not know how to go about it.
The 85-year-old said in Mandarin that she is waiting for her son to take her to the vaccination centre when he is free.
“I think it’s important but I don’t dare to go myself. I don’t know the direction, and I don’t know how to get back,” said Mdm Teo, who was not even aware that the vaccine has to be taken in two doses.
EFFORTS TO GET SENIORS VACCINATED
From house visits to dialogue sessions, Members of Parliament (MPs) said they have deployed various outreach methods to encourage elderly residents in their constituencies to get vaccinated.
A common problem is that many elders have mobility issues, and find it difficult to travel to vaccination centres.
Ms Tin Pei Ling, MP for MacPherson Single Member Constituency (SMC), said her team appealed to MOH to have a mobile vaccination team at MacPherson Community Centre so that elderly residents in the area would not have to travel to Geylang Serai to get vaccinated, as that was the closest vaccination centre for them then.
She and her team then went door-to-door to inform residents.
Other MPs made special arrangements for those with mobility issues by helping to arrange transport to vaccination centres and back, or to have them vaccinated at their own homes.
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Several MPs also said that they, along with grassroot activists and volunteers from the Silver Generation Office, conduct home visits to correct misconceptions the elderly may have about getting vaccinated.
Mr Wan Rizal, MP for Jalan Besar Group Representation Constituency (GRC), said that he would approach each elderly person differently based on the reasons why they do not want to be vaccinated.
For those who have been misinformed, he said it is important to prepare facts beforehand.
“For example, last year there was talk that in a particular foreign country the residents in the old folks’ home died after vaccination. So we had to show them the proof that it wasn't so,” he said.
Ms Joan Pereira, MP for Tanjong Pagar GRC, said that she and her team would try to allay the senior citizens’ fears and suspicions about the vaccine by explaining to them using simple terms in the language or dialect that they understand.
Yio Chu Kang MP, Yip Hon Weng, said that his team analysed data on the characteristics of unvaccinated seniors, such as whether there are language barriers, to understand various reasons among different groups of residents for not getting the vaccine.
“Specific population segments may have varying reasons for this, for example, age group, where they live in the estate, living arrangements (alone/with family members), etc. Following on, we could then take a targeted approach in addressing each of these groups’ concerns, and come up with more focused communications and outreach to tackle the issue,” he said.
MPs such as Mr Yip, Mr Wan Rizal, Ms Denise Phua (Jalan Besar GRC) and Mr Melvin Yong (Radin Mas SMC), have also held various forums and dialogues, both in-person and online, with a medical doctor to explain how mRNA vaccines work.
Mr Yong said some seniors even brought their medication along to ask the doctor whether it was safe for them to be vaccinated.
“These sessions, facilitated by our numerous Senior Activity Centres, have been useful in dispelling the misinformation they receive via social media and forwarded messages on various chat apps,” he said.
Given that some elderly are not so tech-savvy, Mr Wan Rizal said he would use the iPad and show such residents the videos featuring the Cabinet Ministers talking in dialects about the importance of vaccination, when conducting door-to-door visits.
However, he added that more seniors these days are using messaging services such as WhatsApp, which can help circulate these videos.
Nonetheless, the MPs agreed that such online videos need to be complemented with home visits to reach out to more of the elderly and address their concerns about vaccinations.
Workers’ Party’s Hougang MP Dennis Tan said a small number of his residents who are above 60 had told him that they could not take the jabs due to their medical conditions.
“A few wanted to wait for the Sinovac vaccination. MOH should continue to reach out to those who still do not understand why Sinovac is not available generally in the same manner as (the Pfizer and Moderna vaccines) are,” he said. “It would be desirable if everyone understands the correct rationale for vaccination and chooses to vaccinate for the right reasons.”
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WHY SENIORS NEED TO BE VACCINATED
While the concerns and fears that the elderly have about COVID-19 vaccines are valid, it is of paramount importance that they are persuaded to get vaccinated as soon as possible, infectious disease specialists said.
Professor Leo Yee Sin, executive director of the National Centre for Infectious Diseases, pointed out that over a third (35.5 per cent) of COVID-19 cases during the recent surge between Jun 12 and 24 involved those aged 60 and above.
While she said that there is no set target for the vaccination rate of the elderly, Singapore should aim to have as many people vaccinated as it reduces the risk of infection and severe illness, helps to protect others and reduces the viral load in the community.
“Based on our observations thus far, no vaccinated individual was required to be mechanically ventilated. This is a stark contrast to those who were unvaccinated,” she said.
If vaccine coverage for the oldest age groups can go up from 60 per cent to 90 per cent, the number of deaths due to COVID-19 can be reduced by 75 per cent, said Associate Professor Alex Cook, vice-dean of research from the Saw Swee Hock School of Public Health at the National University of Singapore (NUS).
“Once COVID-19 becomes endemic, it will be circulating at levels higher than Singaporeans have become accustomed to over the last year, and the key modifiable determinant in how many deaths occur will be how many of our elders have been vaccinated,” he said.
He added: “The lower the vaccine coverage in the elderly, the more cautious will be our reopening, and the longer we’ll have to live with the damage to livelihoods and well-being caused by the control measures in place.”
About a week ago, the three co-chairs of the multi-ministry COVID-19 task force wrote in an opinion piece published in the newspapers that the coronavirus may never go away and will likely become endemic.
“The evidence is clear: Vaccines are highly effective in reducing the risk of infection as well as transmission. Even if you are infected, vaccines will help prevent severe COVID-19 symptoms,” they wrote, adding that a road map is being drawn to help Singapore to transit to a “new normal”.
The “new normal” would refer to a situation where Singapore would register a few COVID-19 infections every now and then but with the elderly and vulnerable protected, said Associate Professor Paul Tambyah, President of the Asia Pacific Society of Clinical Microbiology and Infection.
He added that major pandemics, such as the “Spanish flu” in 1918 to 1919 and the H1N1 influenza in 2009, which was circulating up to May last year, have become endemic.
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“The focus of vaccination for endemic diseases is preventing sickness and death,” said Assoc Prof Tambyah. This is why seniors are encouraged to take the flu vaccine every year. Healthcare workers are also urged to be vaccinated against the flu to protect the vulnerable.
If not enough seniors are being vaccinated, Assoc Prof Cook said that there is a “substantial risk” that Singapore would not be able to reach herd immunity through vaccination.
“In that case, we can expect that whenever we finally relax our control measures, we’ll see a wave of infections.”
If herd immunity is not achieved when safe-distancing measures to curb the spread of the disease have ceased, an epidemic will ensue, noted Assoc Prof Cook.
“Our models say that the most important factor determining how many people will die in that epidemic is the vaccination rate of the elderly, since their risk of dying from COVID if unvaccinated is so much higher than younger ages,” he said.
DOING MORE TO NUDGE SENIORS
To boost vaccination rates, jurisdictions such as Hong Kong and the United States have resorted to giving prizes for vaccinated citizens.
They include a brand new HK$10.8 million flat in Hong Kong or a lottery cash prize of US$1 million in the American state of North Carolina.
In Singapore, private companies have also started to offer their own incentives, although on a much smaller scale.
While some MPs applaud these efforts by the private sector and view them as fulfilling their corporate social responsibility, most are cautious about such an approach if it were to be taken up by the public sector.
Mr Lim Biow Chuan, MP for Mountbatten, said that such incentives may be unfair for residents who had stepped forward earlier to get vaccinated.
Mr Yip added that citizens may also expect future government programmes to offer incentives.
Some MPs felt that such inducements may not be enough to persuade seniors who have strong convictions that the vaccine is not safe for them.
Mr Wan Rizal said a better long-term solution would be to establish befriender programmes or networks with the elderly where they can be informed about the benefits of vaccination.
Mr Yip also suggested allowing residents in their 30s or 40s to book for their appointment and be vaccinated with their parents at the same time, especially those staying in the same household.
Infectious disease experts said that an important step is to incorporate vaccination in Singapore’s primary healthcare system, which refers to the general practitioner (GP) clinics and polyclinics which most Singaporeans go to as part of their routine medical care.
Based on his team’s research on promoting influenza vaccines before the pandemic, Assoc Prof Cook said that the most effective way to encourage vaccination is for doctors at GP clinics or polyclinics check on the vaccination status of seniors when they consult them, and offer their unvaccinated patients a jab on the spot.
By offering vaccination through primary care, Assoc Prof Tambyah said this would integrate vaccination into routine care and would not involve complicated electronic booking systems, which can be a challenge for many seniors.
Ms Ng Ling Ling, deputy chairperson for the Government Parliamentary Committee for Health, said that such an approach has merit as primary care family doctors are often the first line of medical advice that seniors seek out.
However, Ms Ng, who is also an MP for Ang Mo Kio GRC, said there may be practical and operational constraints, especially for smaller standalone GP clinics to administer the vaccination.
“The logistical and storage requirements of the vaccination can be difficult to manage for smaller GP clinics and they will need support to be part of the vaccination programme,” she said.
MPs also stressed the importance of having friends and family members in encouraging their elderly loved ones to get vaccinated.
While there is a lot of scientific information available and one can go into the technical details of how mRNA vaccines work, Ms Tin said the personal touch is the most important.
“Knowing that their friends or friends who may have similar symptoms or conditions themselves went through (the vaccination process) and are okay, I think these would all be helpful.
“The fear always comes from ‘what if’ or ‘I don’t know enough, this is so new’... But when they see that their peers are okay, that would be more encouraging,” Ms Tin said.