Understanding Vaccine Hesitancy On The Road To Vaccine-Nation

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As of writing, the world has seen over 205 million COVID-19 cases, out of which more than 4 million are estimated to have died. The world continues to grapple with the pandemic and its end is still nowhere in sight. In June this year, Singapore’s COVID-19 multi-ministry task force announced that the disease was likely to become endemic despite best efforts. Singaporeans would have to learn to live with COVID-19.

The key steps in the task force’s plan for endemic COVID-19 include vaccination, testing (with some shifts in focus and accessibility), treatment, and an emphasis on social responsibility.

A Powerful Vaccination Drive

Singapore was one of the first countries in Asia to kick-off an inoculation programme against COVID-19. Announcing this programme last December, PM Lee urged Singaporeans to get vaccinated even as vaccinations remained voluntary. National leaders led the way to demonstrate confidence in mRNA vaccines by being the first to get vaccinated with them. 

A central message of the vaccination drive is ‘Get vaccinated to protect yourself and your loved ones’. Singaporeans are repeatedly reminded to get vaccinated and abide by Safe Management Measures (SMMs) as part of their social responsibilities during the pandemic. 

Since 30 December 2020, Singapore has vaccinated close to 80% of its population with a full regimen of either mRNA vaccines, or others recognised by the WHO. With this, the task force is seeking to ease SMMs with some differentiation by vaccination status. 

Yet, some are choosing to remain unvaccinated in spite of the government’s best efforts, and some find differentiated measures unsettling, even among some who are vaccinated. These people may sometimes call themselves “vaccine (vax) hesitant”. Who are these hesitants, and why do they think this way?’

Are COVID-19 Vaccines Effective?

As the world continues to vaccinate more people, we are able to better understand infection and complication trends, as well as “suspected” side effects from vaccines. Here, we see different beliefs regarding vaccine efficacy emerge.

Some vaccine advocates may think that vaccinations are a ‘magic bullet’, suggesting that they are the best, or only way to end the pandemic. On the other hand, anti-vaxxers may believe that vaccines are completely useless, noting that the fully vaccinated continue to experience “breakthrough infections”. In fact, recent studies show that the fully vaxxed can be just as contagious with the Delta variant as the unvaxxed due to similar viral loads.

The possibility of newer variants of COVID-19 emerging looms large. Even more demoralising, is now observing the setbacks being suffered by countries that had previously re-opened activities following what they considered successful vaccination drives. As much as it pains us to admit it, Singapore should consider keeping some existing SMMs such as mask-wearing, the ring-fencing of suspected infection clusters and even pre-event testing. Current measures allow for events of up to 1000 vaccinated people, which may be too liberal. Hasty re-opening could ultimately set back the hard-earned stability and control over the pandemic in spite of high vaccination rates.

No vaccine is capable of giving 100% immunity against a COVID-19 infection, but the vaccines (including non-MRNA ones) do seem to prove useful in preventing complications following an infection. Vaccination is a useful measure to prevent the pandemic from getting out of hand and crippling the healthcare system, but should not be the only way to control it. Effective management even in an endemic world will require vaccination, calibrated SMMs, and, in the future, effective treatments that could provide a viable alternative for the vaccine-hesitant.

The “Experimental” Dilemma

Beyond concerns about efficacy, several other factors could contribute to vaccine hesitancy. 

Firstly, many vaccine-hesitants would say that the “experimental” nature of the vaccines, especially the mRNA ones, contributes to their attitudes. All but one (Pfizer BioNTech aka Comirnaty for individuals 16 years old and older) of the vaccines currently in use are not approved by the US Food and Drug Administration (FDA), which is widely recognised as a trustworthy regulatory body. In the US, the Kaiser Family Foundation found that ‘3 in 10 unvaccinated adults would be more likely to get the shots if one of the vaccines received FDA approval’. Singapore’s own Health Sciences Authority (HSA) has also granted all COVID-19 vaccines ‘Interim Authorisation’ under the ‘Pandemic Special Access Route’.

Secondly, there is no way to guarantee that COVID-19 vaccines, especially mRNA ones, will have no long-term side effects, or that other side effects will be recognised as vaccine injuries by governments. This holds regardless of regulatory approval. Indeed, new severe side effects have in recent months been discovered to be linked to the vaccine, or are beginning to be studied.

It is difficult, if not impossible for governments to fully address these concerns. Faced with a novel virus, all vaccines and treatments are by definition experimental. Even Ivermectin, which some vaccine-hesitants tout as a potentially safe treatment, is experimental with respect to its ability to treat COVID-19. Long-term side effects of Ivermectin on COVID-19 patients are also unknown. Use of Ivermectin has been strongly disputed. The FDA repeatedly discouraged off-label use of  Ivermectin while reminding people that there’s an important difference between Ivermectin for animals and Ivermectin for humans (animal drugs are often highly concentrated and thus can result in a toxic overdose in humans). Some vaccine-hesitant people in the US have taken Ivermectin without prescription (including veterinary products) and ended up severely ill due to overdose.

According to the US National Institutes of Health, studies for safe use of Ivermectin for the purpose of treating patients with COVID-19 are still ongoing and recommended the following: “There is insufficient evidence for the COVID-19 Treatment Guidelines Panel (the Panel) to recommend either for or against the use of ivermectin for the treatment of COVID-19. Results from adequately powered, well-designed, and well-conducted clinical trials are needed to provide more specific, evidence-based guidance on the role of ivermectin in the treatment of COVID-19.

As Ivermectin is yet to be an authorised for emergency use or become an approved drug for the treatment of COVID-19 except in clinical trials, governments can only continue with SSMs and promoting vaccination to manage the pandemic. 

Forcing people to be vaccinated may however backfire as people can become increasingly suspicious of governmental overreach and further vaccine resistant following public disparaging of the vaccine-hesitant. On this point, governments may have to simply bank on the trust of their populations, while signalling that long-term or newly-recognised side effects of vaccines will be handled well by setting an example for the short-term and already-recognised ones in order to encourage vaccination. 

Issues with Reporting Suspected Adverse Reactions

This brings us to the third reason for vaccine hesitancy.

Globally, there is perceived difficulty in having adverse reactions recognised and compensated by governments. In Singapore, any adverse reaction experienced following a dose of mRNA vaccines is labelled as a ‘suspected adverse event/reaction’ until a link can be established. There are two ways by which an adverse reaction can be reported to the authorities:

1.The government has offered a ‘vaccine injury financial assistance programme’ (VIFAP) for all Singapore citizens, permanent residents and long-term pass holders vaccinated under the national vaccination programme who had experienced serious side effects that are assessed to be related to COVID-19 vaccines. 

While VIFAP is a commendable initiative, which many other countries lack, to qualify one has to experience side effects that are ‘potentially life-threatening or fatal’,  ‘require inpatient hospitalisation’ or lead to ‘persistent incapacity or disability’. 

Under this definition, it is expected that most experienced side effects do not qualify for VIFAP given that side effects of such level of severity are (thankfully) rare. However, there could be less threatening yet chronic and normal activity-impairing medical issues that could be expensive to treat which currently do not qualify for VIFAP.

As of 25 June, 292 completed VIFAP applications were submitted, of which 159 did not meet the eligibility criteria, and 31 were waiting to be reviewed or pending more medical information from the applicant’s doctor. 102 applications have been processed, amounting to $451,000 worth of financial aid for those whose serious side effects have been assessed to be related to the mRNA vaccines.  

In an update on 17 August, MOH announced that two individuals had received the maximum possible payout of $225,000 each under VIFAP meant for individuals who ‘die or suffer permanent severe disability as a result of the COVID-19 vaccination’, and another $332,000 worth of financial aid given to 142 people who experienced medically significant serious side effects related to the COVID-19 mRNA vaccines.

2.There’s another lesser-known online reporting form by the HSA titled ‘COVID-19 Vaccine Side Effect Self-Reporting Form’. It is from this form that we get the official figures from the HSA 9,403 ‘suspected adverse event reports’ as of 16 August.

Three options exist on this form.

  • No side effect;
  • Side effects which are manageable;
  • Side effects which are severe, persistent or worsening.

Should an applicant select ‘side effects which are manageable’, they will be required to fill up more information about themselves, the vaccine they had taken, check off a list of side effects which are common to vaccines, and provide brief information about their medical status and treatment received for the experienced side effect.

Should an applicant select ‘side effects which are severe, persistent or worsening’, the form ends with a paragraph that reads,

“If you are experiencing side effects which are severe, persistent or getting worse, please see a doctor. Your doctor will be able to advise you and report the side effects to HSA. The vaccine may cause a severe allergic reaction in very rare instances. If you experience a severe allergic reaction, seek immediate medical attention by calling 995 or going to the nearest A&E.”

This form is only for the purposes of reporting suspected side effects following COVID-19 vaccination. It does not seem to lead to any form of financial support.

Given that these are self-reporting mechanisms, under-reporting could happen should individuals who suffered a suspected adverse reaction be unaware of the reporting process or choose not to report due to personal reasons. Assuming that all VIFAP applications are automatically included in the 9,403 reports of suspected adverse reactions as of 16 August, only about 1.5% of these reports have received financial support/payout. 

Several other claims of death or heart issues have also made the news, but most of them were not concluded to be related to the vaccine. Explanations include ‘coincidence’’possible link to strenuous activity and health supplements’ and/or ‘pre-existing conditions’ without a note about whether the vaccines could have also played a role in triggering these pre-existing conditions. 

Some may worry that their own pre-existing conditions or those of loved ones could act up following the vaccine. Coupled with a perceived lack of support should one experience an adverse reaction following vaccination, such people may find it hard to trust the government’s call to ‘protect yourself and your loved ones’. This group may also be prone to online “radicalisation” by anti-vax arguments and personalities. 

While pro-vaxxers may wonder why vaccine-hesitants are even worried when officially reported figures show that risks of severe adverse reactions are low, it might be good to see this concern through lenses of empathy. It may be merely ‘facts and figures’ to a pro-vaxxer, but to the vaccine-hesitant, loved ones who have to suffer chronically or even passed on shortly after vaccination are at the top of their mind. A single anecdotal story of a severe adverse reaction happening to a loved one could be extremely unbearable or frightening for people.

It is important to persuade rather to coerce this group of people into vaccination. One possible way is to compare the risks of severe complications from being infected with COVID-19 while unvaccinated with the risk of suspected severe complications from a COVID-19 vaccine (mRNA and non-mRNA). Raising awareness about VIFAP and HSA’s reporting form, as well as strengthening injury reporting processes could also help reduce vaccine hesitancy.

Keeping the Narrative on Differentiated Measures Clear

Many countries, including Singapore, have implemented differentiated restrictions ‘measures’ according to vaccination status. On 6 August, MOH announced updates to SMMs which include differences in limit on social gathering sizes, ability to dine-in, event size caps and operating capacities of attractions, cruises, museums, public libraries, shopping malls and showrooms. Notably, hawker centres and coffeeshops remain open to all, with a group size cap of 2. In addition, those who have recovered from COVID-19 are considered vaxxed for SMM purposes. The same applies for the unvaxxed who clear a COVID-19 test. 

Singapore’s narrative is that the unvaxxed stand a higher chance of serious injury or death from contracting COVID-19, all else being equal, and that differentiated measures can help to keep our healthcare system from reaching its limits. In addition, differentiated measures can help Singapore to escape economically crippling lockdowns. One side effect, which the government likely finds useful, is that the measures may ”encourage” some unvaccinated to get their shots. However, there are signs that further unintended consequences may be in play.

While the differentiated measures officially announced by the government seem targeted to avoid excluding the unvaxxed from essential goods and services, there needs to be safeguards against abuse and calls for unjustified restrictions by individuals and businesses. This will help assuage concerns by some (both vaxxed and unvaxxed) that these measures are wrongfully discriminatory. Much is also uncertain about the duration of these measures, if they will continue to be necessary to protect the unvaxxed as their population shrinks, and whether the government is willing to consider alternative measures once Singapore reaches a very high level of vaccination.

Some have suggested implementing more drastic measures, such as keeping the unvaxxed out of markets/supermarkets/public transportremoving subsidised treatment or insurance coverage for those who ‘can but refuse to get vaccinated’ should they become infected with COVID-19, or a state-backed firing of unvaccinated employees. The fact that a couple of high-profile Singaporeans have strongly expressed the need to go further drives some resistance to the relatively reasonable government SMMs. Their proposals would effectively exclude the unvaxxed from essential services, making vaccination de-facto mandatory. Rice Media interviewed a bioethicist who expressed concerns over such overreach.

Given Singapore’s remarkably high vaccination rate, such “mission creep” is unnecessary and will likely facilitate the conversion of many exasperated vaccine-hesitants into outright anti-vaxxers.

Regardless, Risks Will Be Taken

A pandemic is at hand, and something must be done as the world adjusts to endemic COVID-19. The odds of someone getting infected with COVID-19 will be high, especially when most of the world resumes travel and eases restrictions on social activities. We already see this in several countries in the West.

The vaccine-hesitant are left with a difficult decision: to risk vaccination or to risk COVID-19 infection without vaccine protection.

Experts continue to reassure the public, releasing data to show that when ‘viewed in the right context’, the risks from COVID-19 vaccines currently don’t outweigh benefits. While concerns about the mRNA vaccine remains, the mRNA vaccine-hesitant can look forward to non-mRNA alternatives such as Novavax and Sinovac which have recently received recognition by the Ministry of Health

Vaccine-hesitant people who remain unvaccinated may also be advocates for treatment in place of vaccines. As mentioned, they are still taking risks, given that studies for the efficacy of suggested treatment methods remain inconclusive and little is known about the safety of off-label use of drugs like Ivermectin and Hydroxychloroquine. Those hoping to acquire natural immunity (which 1 study shows it to be more effective) instead of receiving vaccinations  must also be mindful of the risk they are taking – which is having to first endure a COVID-19 infection without risks of complications mitigated by prior vaccination.

It is clear that either way, a choice must be made – a choice that should be made with the help of proper disclosure of information about the risks involved, support measures and freedom from unjustified compulsion. 

While it may be tempting to handwave away those who have chosen to remain unvaccinated, their reasons for vaccine hesitancy are real and should not be disregarded. Further pushes to impose more restrictions are unlikely to help the unvaccinated feel safer and more willing to be vaccinated. Instead, it might alienate them further by making them easier targets for social discrimination.

The most effective way of encouraging the remaining unvaccinated individuals to get vaccinated will therefore require addressing their concerns. It looks like helping those who have fallen through the cracks in their experience of less than life-threatening side effects, and crafting and truly sticking to a finely-honed narrative about how Singapore can emerge into endemic COVID-19 stronger (and more united) than before.

Seeking Help For Suspected Vaccine Injuries

If you have personally experienced any suspected side effects following a COVID-19 vaccination or knows someone that did, do (encourage them to) see a doctor and report the case to HSA via this form.

If your condition is severe, you should also seek advice from your doctor and apply for VIFAP via this MOH form.

Editor’s Note: This piece was edited as of 28 Aug to reflect the latest developments regarding vaccines, and to strengthen the section discussing Ivermectin.

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