Things to consider while moving forward with Covid-19 booster shots

US President Joe Biden receives a booster shot of the Pfizer/BioNTech Covid-19 vaccine last Monday. Vaccination should be prioritised in those who haven’t even gotten a single shot yet, rather than booster shots. — Bloomberg

Malaysia announced a Covid-19 vaccine booster strategy to be implemented in Sarawak beginning this month (October 2021).

This decision is aligned with other countries like France, Germany, the United Kingdom and the United States, who announced booster strategies mostly last month (September 2021).

The first country to offer such vaccine boosters was Israel, which has been providing these shots to citizens above 60 years old since July.

Real-world data from Israel now shows reductions in cases, hospitalisations and deaths in that age group.

This writer supports Covid-19 vaccine boosters for scientific, immunological and public health reasons.

However, the details of the booster strategy for Malaysia are crucial to determine whether we have effective, safe and equitable outcomes.

It is helpful to look at the short history of Covid-19 vaccines in Malaysia in order to look to the future.

Therefore, this column examines some timeless lessons from the National Covid-19 Immunisation Program (PICK) so far.

Vaccine equity

The first timeless lesson is that vaccine equity is important.

There is a clear need to provide booster shots to those whose immune responses were high, but have dropped over time, or third doses to those whose immune responses were never high in the first instance. (There is a subtle difference between “booster” and “third dose”, which this column does not discuss).

Although we must protect high-risk groups with boosters or third doses, it is equally important to allocate scarce vaccine doses to those who have not even completed their primary vaccine shots.

For example, only 59% of adults in Sabah were fully vaccinated at the time of writing, while the comparable number is 89% in Sarawak and 110% in the Klang Valley.

In other words, booster doses to one state must not compromise vaccine doses in other states who have not yet completed their primary vaccine shots.

We must equally prioritise vaccination in those who have not yet received even one vaccine dose, because “no one is safe unless everyone is safe”.

That is the basic scenario of vaccine inequity between states in Malaysia.

This basic scenario is also playing out globally, as rich countries complete their primary vaccine doses and start using their vaccine supply as boosters.

Globally, Covid-19 vaccination programmes are only 10 months old, with the first dose delivered on Dec 8, 2020, in the UK.

In that 10-month journey so far, over six billion doses have been administered, covering 45% of the world’s population.

But only 2% of the 650 million people in 24 low-income countries have received even one dose, while high-income countries are projected to have 1.2 billion doses of surplus vaccines by the end of this year (2021).

You read that number correctly.

Rich countries are hoarding 1.2 billion unused Covid-19 vaccines, and are not donating or sharing them with other countries.

If we are upset with rich countries hoarding vaccine doses from poor countries, we must be equally upset with rich Malaysian states getting more vaccine doses than poorer Malaysian states, even if it’s for an understandable reason like booster shots.

Risk communication

Part of our risk communications strategy should be continued vigilance against fake news and weaponised disinformation about Covid-19 vaccines. — FilepicPart of our risk communications strategy should be continued vigilance against fake news and weaponised disinformation about Covid-19 vaccines. — Filepic

PICK and the Special Committee for Ensuring Access to Covid-19 Vaccine Supply (JKJAV) have done well in communicating the science and importance of vaccines, as proven by the high demand for vaccines and high vaccination coverage rates.

They should be congratulated.

But successful science, health and risk communications is a moving target that must continually evolve.

In other words, the Health Ministry, JKJAV and PICK must continue their high tempo of operations and add several new elements.

The first element is strategic, which is to shift the messaging around vaccinations from “campaign mode” to “routine mode”.

Many people either believe or desperately want to believe that Covid-19 is temporary and will disappear.

This desire to return to the “old normal” is understandable, but unrealistic.

A communications strategy which signals that Covid-19 vaccinations are a short-term campaign will not change behaviours.

Instead, we need a strategy which signals that Covid-19 and vaccinations will be part of our long-term routine.

The second element is tactical, which is to persuade populations that boosters are necessary because our immune systems naturally work this way.

One possible risk is that populations perceive that boosters are needed because the vaccines have failed, science is weak or pharmaceutical companies want to profit.

Therefore, risk communications must shift to educate on the long-term need for boosters or multiple rounds of vaccinations for an endemic Covid-19.

The third element is to remain vigilant in the fight against fake news and weaponised disinformation.

Some are difficult to predict, like the isolated incident of a soldier suing the Malaysian Armed Forces because he was dishonourably discharged for refusing to take the Covid-19 vaccine.

Others are easier to predict and manage, like Facebook groups that spread lies about vaccines or religious groups that are anti-vaccine (despite Malaysia’s fatwa that Covid-19 vaccines are “permissible [harus] and obligatory [wajib]”).

While Malaysia does not need a blanket vaccine mandate for all citizens, the government must actively fight disinformation as boosters are rolled out.

Transparency is the underlying principle.

The data on criteria for booster decisions, adequacy of vaccine supplies, vaccine effectiveness, vaccine procurements and other important data will anchor all communication efforts.

Our own vaccines

Malaysia is an upper-middle- income country with a peculiar problem: we’re too rich to obtain subsidies, vaccine donations or Covax priorities, but not rich enough to endlessly purchase expensive vaccines.

This means that Malaysia must quickly implement ways to build our own vaccines as soon as possible.

This will not be easy, of course.

But there are several policies that can act as leverage points.

One, the government should clearly and explicitly state that they will create a friendly regulatory environment for private sector investment and innovation, instead of trying to own vaccine factories (whether directly or indirectly).

Around the world, only the South African government owns a direct stake in pharmaceutical producers, and Malaysia should follow the global trend of government-as- regulator.

Two, the government can provide tax incentives for foreign vaccine producers to set up factories in Malaysia.

These vaccine producers will bring their technologies, know-how, capital and networks with them, benefiting from our favourable tax regime, relatively well-educated population, and export links to South-East Asia and the Muslim world.

However, it is crucial that the technologies and know-how remain in Malaysia for the long term, so any tax incentives must be ultra-long-term – perhaps 10 to 20 years.

And three, we need to identify short-term vaccine technologies to manufacture and long-term technologies to invest in.

For example, inactivated vaccines are generally easier to process and manufacture compared to mRNA (messenger ribonucleic acid) or DNA (deoxyribonucleic acid) vaccines, so they can be covered in the 12th Malaysia Plan (12MP).

The 12MP (2021-2025) also needs to lay down the infrastructure so that we are ready for mRNA or DNA vaccines during the 13MP (2026-2030).

Being neither rich enough to be able to afford endless supplies of expensive vaccines nor poor enough to qualify for subsidies, we need to start producing our own vaccines to fill the gap. — PharmaniagaBeing neither rich enough to be able to afford endless supplies of expensive vaccines nor poor enough to qualify for subsidies, we need to start producing our own vaccines to fill the gap. — Pharmaniaga

Only one part

PICK has been a success for Malaysia and is an important part of the universe of pandemic responses.

However, it is not the only part and must be integrated with other parts like surge healthcare, adequate testing, rapid tracing, targeted lockdowns, and adequate social protections.

Booster shots are inevitable for an endemic Covid-19 and they will help protect us, but we cannot place all our bets on vaccines alone.

Dr Khor Swee Kheng is a physician specialising in health policies and global health. He tweets as @DrKhorSK. The views expressed here are entirely his own. For more information, email The information provided is for educational and communication purposes only. The Star does not give any warranty on accuracy, completeness, functionality, usefulness or other assurances as to the content appearing in this column. 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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