Older people are generally more vulnerable to any type of virus, compared to those from younger population groups.
Thus, it only makes sense that if the most vulnerable are vaccinated, the risk of other people passing the virus on to them is greatly reduced.
As we age, our immune system grows weaker and isn’t as good in reacting to and fighting off microorganisms it hasn’t encountered before.
Usually, the memory our immune system forms in response to infection or vaccination helps to protect us against future infections.
But like the brain, this immunity memory sort of decreases as we get older, which explains why older people are more prone to infections such as the flu and Covid-19.
While many of us might think vaccination is only for babies and children, there are actually many important and recommended immunisations for adults to prevent various diseases.
This is especially if they travel frequently, and therefore, are at higher risk of exposure to bugs and illnesses abroad.
Sadly, many adults here don’t know about the availability of such vaccines.
According to Universiti Malaya Medical Centre consultant geriatrician Professor Dr Tan Maw Pin, older people tend to have a lot of prejudice against healthcare, particularly prevention, and only seek it when they feel they need it.
“It’s the same scenario globally. The concept of prevention is just not there, and sometimes, it may be too late.
“Seventy percent of Malaysians access healthcare for free in our public healthcare facilities, so spending money is something they don’t want to do – to them, paying for vaccination is too much money, and therefore, there are consequences, when actually, the vaccination (e.g. flu) fee is so cost effective,” she says.
The consequences include the children of these elderly patients having to miss work (which can mean no income for those who work on a daily basis or who run their own business single-handedly) and divert their attention from other responsibilities (e.g. their own children) to care for them.
In addition, if these patients fall so ill as to need fulltime care afterwards, their children will have to fork out money to hire a caregiver or put them in a nursing home.
Prof Tan adds: “If they cannot afford care, the family member gives up her job to look after them fulltime, and might not be able to reenter the workforce again.
“The economic cost is phenomenal, but at the moment, nobody can see it.”
Different approaches needed
Vaccine hesitancy was listed as one of the World Health Organization’s (WHO) top 10 threats to global health in 2019.
Multiple surveys worldwide show that vaccine acceptance rates have dropped over time.
Locally, Perak tops the 2013-2019 ranking for vaccine refusal by state, followed by Kedah, Selangor, Terengganu, Pahang and Kelantan.
“The reasons were due to religion, vaccine content and use of alternative medicine,” says consultant paediatrician and paediatric cardiologist Datuk Dr Zulkifli Ismail.
“The numbers are small, but the anti-vaxxers make a loud noise and can influence the fence-sitters.
“It will be interesting to see how the Covid-19 vaccine refusal ranks according to state.
“There is also a knowledge gap between the government agencies and the public, so there is a trust deficit and this leads to a decrease in vaccine confidence.”
However, International Islamic University public health medicine specialist Assistant Prof Dr Mohammad Farhan Rusli notes that increased uptake of the Covid-19 vaccine in certain states does not necessarily mean that the residents there are more educated or urbanised.
“In Selangor, we saw that there was very poor uptake among the elderly, and when we went to the ground to investigate, we discovered that the majority did not have access to smartphones or didn’t know how to register even when we gave them laptops.
“So we have to strategise how to roll out the vaccines in different areas and different segments of society – we can’t use one approach for everyone.
“Perhaps with the orang asli community, we need to go to them,” says the Selangor Task Force Covid-19 director.
Hard to access
In terms of preventive healthcare in Malaysia, there aren’t many adult vaccinations available for free, unlike the Covid-19 vaccine that is being paid for by the government.
Says Prof Tan: “People have to pay for their own vaccines, although there are units of the Health Ministry that give budget allowances for certain groups, this reaches very few people.
“For the foreseeable future, people still have to pay for these vaccines out of their own pockets.
“In fact, our flu vaccination rates are so low that we are actually contributing to the world literature on what happens to an unvaccinated population.”
Many European countries already have a well-established adult vaccination programme targeting older people and vulnerable groups.
“They all get their influenza, pneumonia – and in some countries, shingles – shots.
“In Asia, some developing countries have implemented these, while others are funded by philanthropists.
“We are doing quite badly comparatively.
“We always blame the recipients for vaccine hesitancy, but it is actually a whole-system issue – even if people are aware, accessing the vaccine is a problem.
“For influenza, you need to know who stocks it, are the patients able to get to the centre to get jabbed, and are they able to afford it,” says Prof Tan.
Side effects, while generally mild, also need to be taken into consideration.
She says, “Older people may need to lie down or take other medicines – all this needs to be taken into account as this group needs to have a little bit more time to cushion the side effects.”
When it comes to getting the flu vaccine, it is a “no-brainer” and a “m-u-s-t” for the elderly, emphasises the consultant.
She cites a Malaysian study published a few years ago, which looked at 4,000 adults over a two-year period (400-odd participants were 65 years and above) presenting to primary care clinics with an upper respiratory tract infection.
Swabs were taken and researchers found that over 400 had influenza (one out of 10), and not the common cold.
There were no deaths in those aged below 65, but the death rate for those above 65 was 10% a year.
“I nearly fell off my chair when I saw the death rates!” exclaims Prof Tan.
She adds, “Very few people die of the flu per se, but of pneumonia complications following the flu.
“They get sarcopenia (loss of skeletal muscle mass) because of extended bed rest or a fall, which then leads to other problems.”
Hence, she asserts the importance of getting vaccinated yearly for the flu.
“We can get the flu every year, and you could be very unlucky and catch the flu three or four times a year as there are different variants and the vaccine only covers four strains.
“But scientists are getting better at predicting the strains and the vaccine will still offer some protection so that there is less strain on the healthcare system.”
Don’t test, don’t know
Most adults know when they get the flu because the symptoms include a sore throat, cough, runny nose and fever, but older persons often don’t have such typical symptoms.
Explains Prof Tan, “They may be a bit wobbly for a few days.
“The flu puts a strain on the heart and makes the blood extra thick, which then increases the risk of a heart attack and stroke.
“And because the immune system is weak, there is a risk of secondary complications such as pneumonia, which also strains the heart.”
There is often this belief that the flu only happens in cold countries because it usually strikes during winter, and thus, we are safe from it because we live in a warm country.
However, as tourists from such temperate nations like to get away to warmer climes like ours during their winter season, we are actually exposed the whole year round to flu viruses from both the Northern and Southern hemisphere.
She says: “If we don’t test, we don’t know it’s the flu.”
“We don’t have a widely available test for flu, and when it became a pandemic a few years ago (i.e. the H1N1 flu pandemic), there was no mandatory notifying mechanism.”
The test, which is the same as the PCR (polymerase chain reaction) test used to screen for the SARS-CoV-2 virus that causes Covid-19, is actually more expensive than the flu shot itself.
“So we’re riding on this Covid-19 wave to say that the flu has not gone away and we don’t want people to get the flu and Covid-19 together, creating a double pandemic.
“It’s looking more and more scary because people haven’t been going out much so they haven’t been catching the flu, and when the flu comes back, it will return with a vengeance,” cautions Prof Tan.
Her advice is for younger adults to sponsor the flu vaccine for the older generation as an act of love.
In fact, she presented her staff with a vaccine “ang pow” during Chinese New Year earlier this year.
She says: “If they’re not utilising it, they can pass it on to their elders.
“No one has done a study to see if it is okay to administer both the flu and Covid-19 vaccines together.
“There is no harm, but we don’t know whether it will affect the amount of antibodies you generate, so it’s best to take the vaccines at least two weeks apart.”
Not a panacea
As of May 4 (2021), only 9.8 million out of the eligible 24.3 million Malaysians have signed up for the Covid-19 vaccine.
This is far from the 80% target to achieve herd immunity.
Assist Prof Farhan says: “People now are getting smarter and doing ‘vaccine shopping’.
“Some will say they want Pfizer because it is more advanced, or AstraZeneca because it uses the adenovirus that they are familiar with, or Sinovac because the Chinese version will protect the Asian market.
“When politics comes into the picture, people are unable to understand what is beneficial.
“The best vaccine is whatever is available to you at that crucial moment in time.”
Hospital Putrajaya consultant physician and nephrologist Dr Rafidah Abdullah adds: “There is no head-to-head comparison at the moment – take any vaccine that is offered to keep us well.
“Instead of focusing on the side effects, focus on the bigger picture to protect everyone.
“The goal is not to get to zero infection, but to prevent serious disease, hospitalisation and death.”
Asst Prof Farhan says: “We are seeing a lot of vaccinated people feeling like they are superhumans.
“Vaccines were never marketed as a cure, but are aimed at preventing the public health system from collapsing.
“Vaccination only reduces the risk of getting severe forms of disease.
“If vaccines could cure, we would be celebrating, but this is not the case and this message needs to get across to the people.”