(Focus - Malaysia)
Immunization is a cornerstone of public health, providing a powerful tool in disease prevention and global health security. Immunization Agenda 2030 (IA2030) by WHO targets to reduce 50% of zero-dose children by 2030. But during the COVID-19 pandemic, the world witnessed significant changes and events. How have lockdown measures and travel restrictions during the COVID-19 pandemic impacted IA2030 by WHO, and what steps has Malaysia taken to address this issue?
To learn more about this, we connected with Dr. Nurzarina Binti Abdul Rahman, a renowned General Practitioner from Malaysia who talked about how Malaysia addressed vaccination hesitancy during the COVID-19 pandemic. Dr. Nurzarina emphasized the importance of public engagement, advocating for the advantages of immunization, and seeking accurate information from healthcare professionals as vital strategies in addressing acceptance, or refusal, of vaccines.
Dr. Nurzarina Binti Abdul Rahman is a Medical Director, General Practitioner, and Lactation Consultant currently serving at Klinik Famili Gravidities and Gravidities Breastfeeding Center, Kuala Lumpur, Malaysia.
Each individual responds differently to vaccines. If you know about the varicella vaccine, certain people get the vaccine when they are smaller, but they actually get the varicella infection later on when they are bigger. So why does that happen? This is because our bodies are different. So, we can divide these factors into a few types; intrinsic, extrinsic, and environmental factors.
Although vaccines are available against more than 20 life-threatening diseases, low vaccination coverage is still a problem, especially in low and middle-income countries. Immunization Agenda 2030 (IA2030) by WHO targets to reduce 50% in the number of zero-dose children by 2030 [1]. How did COVID-19 impact this target?
Dr. Nurzarina - COVID-19 pandemic has a big impact on this. When it was first declared as a pandemic on the 11th of March 2020 by the World Health Organization,it has directly or indirectly affected the health and well-being of society globally. And definitely, there was a delay in routine childhood vaccinations all over the world since the enforcement of the mandatory lockdown and the travel restrictions in 2020 until it was lifted last year. So, of course, there are delays, and there will be expected delays for the years to come because of this vaccination hesitancy.
And many people are rethinking vaccinations for their babies, especially after the COVID-19 vaccines appeared to help us deal with COVID-19. So why does this delay happen? Because at that time, everyone was having lots of fear, lots of anxiety about the COVID-19 infection. And most parents will not want their children or their babies to be exposed to the disease, and they choose to defer, delay their routine vaccinations, and refuse to go to the health clinics. Apart from this, other factors that disrupted childhood vaccinations in Malaysia and other countries, which impacted the immunization agenda 2030 target:
Because of supply chain issues and transport limitations during the pandemic, especially in low and middle-income countries.
And also, healthcare centers will mostly prioritize COVID-19 patients over other healthcare services.
So, if a lockdown happens again in the near future, it will impact the target, and we'll never achieve the target by 2030.
Is there any program implemented by the Malaysian Government to improve vaccine coverage?
Dr. Nurzarina - Yes. In Malaysia, we have our National Immunization Program, called NIP. It was first introduced in 1950 by the government, aiming to reduce preventable communicable diseases. This Malaysian NIP was designed based on World Health Organization's expanded program on immunization. So, this expanded program recommends that all countries be immunized against six childhood diseases. However, the Malaysian NIP has expanded protection against 13 major childhood diseases in Malaysia. In the 1950s, we started with diphtheria, tetanus, and pertussis vaccine.
Then we introduced the BCG. Later, polio, measles, rubella, and HPV came in; the latest one in 2020 was pneumococcal. This vaccination is being given for free in all Malaysian government clinics, and they are also available at private clinics for a small fee. So, by 2019, I'm proud to say that Malaysia has an estimated childhood vaccination coverage of more than 90%, but in 2020 when the lockdown happened, some of the vaccination coverage came down, because of the restriction, because of the parents having fear. So, what did Malaysia do about this?
In 2020, Malaysia introduced the combined vaccine, the six-in-one combined vaccine, diphtheria, tetanus, pertussis, Haemophilus Influenza B, and Hepatitis B. When we had this combined vaccine, we reduced the number of injections and the number of visits of the babies and parents to care facilities. The visit at one month has been removed. And then, when we introduced the pneumococcal vaccine, it was included in the first six months of life of the baby. Now, babies are getting more vaccine coverage in the first six months of life. And apart from that, government health clinics have started to introduce appointment-based methods for parents to bring their babies and children for vaccination. This is to ensure that there will be a reduced waiting time and a reduced crowd of clinics. So, this is what I practice at my clinic as well. Giving the parents reminders and the slot to come will ensure they come to the clinic to complete the vaccination according to the schedule. Also, the health clinics have now extended the hours beyond their office hours to accommodate working parents. So that's why they can come and get their children vaccinated after office hours.
For any disease that an individual has, the immune system will respond to produce antibodies with the disease. And the function of the antibody is to protect the body from getting the disease again. In the case of COVID-19, the immune response increases with time. After somebody gets the infection, the immune response increases in the months after that. The antibody of COVID-19 undergoes maturation with time, which increases the body's ability to defend against COVID-19 infections even against the variant of concern.
People infected with any virus eventually develop immunity against that virus, but how long that immunity lasts varies. What factors are responsible for an individuals' immune response to vaccines?
Dr. Nurzarina - Each individual responds differently to vaccines. If you know about the varicella vaccine, certain people get the vaccine when they are smaller, but they actually get the varicella infection later on when they are bigger. So why does that happen? This is because our bodies are different. So, we can divide these factors into a few types; intrinsic, extrinsic, and environmental factors.
Intrinsic factors include age, sex, genetics, existing diseases in the body, whether they've gotten their mother's antibodies while in the uterus, the birth weight, and the feeding method, whether they are breastfed or formula fed.
Extrinsic factors include pre-existing immunity, microbiota, infections, and the usage of antibiotics by these individuals.
Environmental factors include family size, toxins, geographical location, and behavior like smoking, alcohol consumption, sleep, stress, exercise, BMI, and dietary intake.
These are the various factors we need to understand each individual's differences. Whether babies or elderly, everybody will respond differently towards the vaccine. The type of vaccine they receive also plays a role, whether it is a live vaccine or attenuated vaccine, whether they are given any other vaccines simultaneously with that particular vaccine, or whether they are taking any drugs.
In the case of COVID-19 infection, WHO is also looking into whether the strength and length of immune response depend on the severity of infection a patient has, like asymptomatic, mild or severe [2]. What are your thoughts?
Dr. Nurzarina - I believe this is true because, for any disease that an individual has, the immune system will respond to produce antibodies with the disease. And the function of this antibody is to protect the body from getting the disease again. In the case of COVID-19, the immune response increases with time. After somebody gets the infection, the immune response increases in the months after that. The antibody of COVID-19 undergoes maturation with time, which increases the body's ability to defend against COVID-19 infections even against the variant of concern. One paper recently published in August 2022 found that antibodies last longer in patients with severe cases of COVID-19. Generally, these patients with severe COVID-19 have an antibody lasting more than six months. But if their disease is mild, antibody levels may come down within two to four months after the viral clearance.
We have seen physicians suggesting to stop smoking after receiving the COVID vaccination. How do smoking and other activities like alcohol consumption affect the immunological response to vaccines?
Dr. Nurzarina - Actually, it is known that smoking and heavy alcohol drinking can interfere with the activation of innate and acquired immunity, and it may suppress vaccine-induced antibody production. So, in Japan, they did one study in August 2022, published in the paper. They researched on 3433 healthcare workers who received two vaccine doses. And then, they tested the antibodies two months after the vaccinations. Those who smoke cigarettes have significantly lower COVID-19 antibody titers than those who never smoke. For those who drink alcohol, they also see a decreasing trend of antibody titers, even at a modest amount of alcohol. Cigarette smoking induces chronic inflammation and downregulates the CD4 and CD4+T, and B cells. These cells are responsible for producing antigen-specific antibodies, and they found out that in this cigarette smokers, immunoglobulin A, immunoglobulin G, and immunoglobulin M is reduced. For those who drink alcohol, even in a low dose, the alcohol inhibits the antigen-stimulated B cells proliferation and their antibody production towards the COVID-19 antibodies. So, it has a big impact, and that's why most doctors will ask the patients to stop smoking and even drink alcohol after the COVID vaccinations so that it will not interfere with the immune response.
Are there any unmet needs to be addressed in developing and delivering any life-saving vaccines in Malaysia?
Dr. Nurzarina - I would say that vaccinations are for all. But vaccinations in Malaysia have never been an issue, unlike other lower developing countries, whereby they don't have the resources to get their vaccines. In Malaysia, developing vaccines are still very far, and we have yet to have more experts on developing our own vaccines. However, we deliver life-saving vaccines. This involves many stakeholders, policymakers, and collaboration between the government and private healthcare facilities. In Malaysia, more public and private partnerships in vaccination health screening have started since the beginning of 2020. We hope that delivering the life-saving vaccines to the community will go far. It's not just the work of the government but also the work of the private doctors. The unmet needs are actually collaboration and reducing the hesitancy of the community in receiving the vaccine, education, and awareness. These are the things that we need to work on.
As you mentioned, increase in vaccine hesitancy has a negative impact on achieving herd immunity. So, what would be your message to the public to reduce vaccination hesitancy?
Dr. Nurzarina - Number one, I advise everyone to get well informed. It's not simply just putting the vaccination aside. You must read, discuss with the right people, and ask the right questions to address the concern about vaccinations from doctors, not simply from any website. You can attend the public forum or webinars that are being done all over Malaysia or even internationally regarding vaccinations so that hesitancy will be reduced when you are well informed.
Number two,let's say working parents are busy bringing their children, which is the number one problem that reduces the routine vaccinations for their children. Find the clinic or doctor that may suit your time so you can bring your children after office hours for their routine vaccinations. And please note that by vaccinating your children, you are also helping to protect the other children. In the world we live in, we need to think about other people around us, and we have to work together to protect other people. We must know that there are people who cannot or are not eligible for vaccinations due to their health status. These people need to be protected as well. By vaccinations, we provide herd immunity. Hence, why not we take vaccinations while we are still healthy, while our children and our family members are still healthy? After all, immunization is never about treatment. Immunization is all about prevention, staying healthy and well for a better future in Malaysia and globally.
Thank you for your valuable input, doctor!
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