Who should get the Covid-19 vaccine first?

GPs are at constant risk of being exposed to Covid-19 patients, as many of its symptoms resemble that of other respiratory diseases like the cold or flu. — 123rf.com

Interpol issued new guidelines for law enforcement on Nov 17, 2020, when the approval and roll-out of Covid-19 vaccines was imminent.

The Interpol statement said: “High demand, combined with a limited supply, will make Covid-19 vaccines the equivalent of liquid gold to organised crime networks as soon as one is available.”

In a notice to global law enforcement agencies on Dec 20, 2020, Interpol warned of potential criminal activity in relation to the falsification, theft and illegal advertising of Covid-19 vaccines, including examples of crimes where individuals have been advertising, selling and administering fake vaccines.

Within days of the commencement of the Covid-19 vaccination programme in Malaysia on Feb 25, media reports of queue-jumping by political aides and senior civil servants were brought to the attention of the Science, Technology and Innovation Minister, who announced that he will personally look into the matter.

The Covid-19 vaccines are in the custody of the Health Ministry, whose employees are the sole vaccinators to date.

No one else has access to these vaccines.

The question arises on how anyone can jump the queue without the involvement of the custodians of the vaccines.

The government had stated that those who jump the queue can be fined, but there was no mention of punishment for the vaccinators who have to be complicit in the alleged queue-jumping.

Proper priorities?

The government has repeatedly stated that healthcare staff will be the first priority in its vaccination programme.

The National Covid-19 Immunisation Programme is divided into three phases.

Phase 1 includes two priority groups, with the first group consisting of both public and private healthcare frontliners.

The second group consists of frontliners from essential services, defence and security personnel.

However, not all in this second group are expected to receive their vaccinations during the Phase 1, with the remainder being slated to receive their vaccinations as part of the first priority group for Phase 2.

According to the Guidelines for the Determination of Frontliners for the National Covid-19 Immunisation Programme (Garis Panduan Penetapan Senarai Barisan Petugas Hadapan Bagi Program Imunisasi Covid-19 Kebangsaan), frontliners are defined as those at high risk of contracting and spreading Covid-19 infection.

This consists of those who are exposed directly to infected individuals, individuals at high risk of being infected, infected patient samples or an environment where there is high risk of infection.

These frontliners are further put into two categories.

The first category consists of both public and private healthcare workers.

The second category includes:

  • General practitioners (GPs)
  • Private dentists
  • Traditional and complementary medicine practitioners
  • Registered medical laboratory staff
  • Members of various security forces
  • Social services workers
  • Customs Department staff
  • Health Ministry contractors
  • Haemodialysis operators
  • Teachers with comorbidities
  • Cabinet ministers and state executive council (exco) members
  • Members of Parliament and state legislative assemblies, and
  • Government officials involved in the overseas trips of Cabinet ministers.

GP clinics provide the majority of primary care to the population.

These clinics are usually the first point of care for the majority of the population whenever they have respiratory symptoms, which could well be due to Covid-19.

In fact, a number of GPs and their staff have been reported to be infected with Covid-19 following exposure to patients who were later found to be positive.

The exposure risks are increased for GPs involved in community and mass screening, and dentists who are exposed daily to respiratory droplets from patients who could be Covid-19 positive.

The Health Minister has stated that there was no risk stratification of healthcare staff for vaccination.

If that were so, how come GPs and dentists are not included in the first category for frontliners?

Although the Health Minister has said that GPs will be included in Phase 1, the ministry’s guidelines clearly state that GPs come under Category 2 for frontliners.

When it comes down to the ground at the state and district levels, it is more likely that ministry staff will refer to the official guidelines to determine who should or should not be prioritised for vaccinations, rather than media statements, and even the National Covid-19 Immunisation Programme, which has not been distributed to the state and district health offices.

Needless to say, the Health Minister, a trained doctor, would surely appreciate that sick healthcare staff will decrease the numbers of those who are society’s last line of defence against Covid-19.

Dentists are exposed daily to respiratory droplets from patients who could potentially be Covid-19 positive. — FilepicDentists are exposed daily to respiratory droplets from patients who could potentially be Covid-19 positive. — Filepic

More information needed

People with comorbidities are at increased risk of severe disease and death.

Yet, there is limited information provided to them by the Health Ministry with regard to Covid-19 vaccination.

The Academy of Medicine has asked the government to clarify where the various high-risk groups fall on the priority list.

It also said in its statement on March 3 (2021) that: “The vaccine registration process in the MySejahtera app does little to inform pregnant women and immunosuppressed patients of their risk status.

“It also falls short of providing resources for educating those with comorbidities on the Covid-19 vaccine as it relates to their condition.

“We urge the government to provide necessary updates to the app that will allow patients to empower themselves with the information and resources to get vaccinated according to their risk group.”

Instilling confidence or taking advantage?

There are many groups who seem to think that they qualify for Phase 1.

They are neither healthcare staff nor those whose work setting poses a higher risk of SARS-CoV-2 viral transmission.

Some heads of governments and dignitaries have been vaccinated to instil public confidence in vaccination – at least that was the stated motivation for some.

Whether such public demonstrations will promote and generate support for vaccination is uncertain.

When government officials, politicians, their aides or family members jump the queue, it suggests that they are more important that members of the public who are at increased risk of contracting the SARS-CoV-2 virus and that the rules do not apply to them.

It also runs counter to the principles of health equity – vaccine equity in this instance.

Unlike many healthcare staff and essential workers, such individuals are more likely to have rapid access to high quality healthcare should they develop Covid-19, and hence, have lower risk of progression to severe disease.

Can such diversion of vaccines from members of the public who are at increased risk be justified?

Vaccine tourism

Tourism has suffered a big blow in the pandemic.Cuba is one of the countries aiming to attract tourists with the promise of a Covid-19 vaccination once its homegrown vaccines pass their clinical trials. — AFPCuba is one of the countries aiming to attract tourists with the promise of a Covid-19 vaccination once its homegrown vaccines pass their clinical trials. — AFP

With the availability of vaccines, some countries and travel agencies are looking to promote vaccine tourism, i.e. to visit some place(s) with Covid-19 vaccination included as part of the tour package.

While Malaysia is not one of these countries, our authorities should take steps to ensure that this does not happen here.

The authorities have a duty to take all necessary measures to ensure that vaccines intended for our population get to the target recipients and are not diverted for vaccine tourism.

Fairness and transparency

Fairness should be a guiding principle in the formulation of the allocation criteria for the limited number of vaccines available.

It should also guide the implementation of the vaccination programme, which should be impartial and balanced without arbitrary exceptions and opportunities for gaming the programme.

The criteria for the various phases should be based on science, clearly articulated in advance and implemented transparently.

Public explanations on who will and will not be prioritised, and the basis for the decisions, are necessary.

Special prioritisation for certain individuals in positions of influence would be inappropriate.

The flouting of guidelines or treatment of certain individuals as more important than the general public, will only lead to mistrust in the government and hamper its future public health responses.

Dr Milton Lum is a past president of the Federation of Private Medical Practitioners Associations and the Malaysian Medical Association. For more information, email starhealth@thestar.com.my. The views expressed do not represent that of organisations that the writer is associated with. The information provided is for educational and communication purposes only and it should not be construed as personal medical advice. Information published in this article is not intended to replace, supplant or augment a consultation with a health professional regarding the reader’s own medical care. The Star disclaims all responsibility for any losses, damage to property or personal injury suffered directly or indirectly from reliance on such information.

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