Why that shot in the arm isn't just another jab

VACCINATION is a personal choice, but what if you couldn't board an aeroplane because you decided not to take the jab, or have to cut down on business travel in keeping with your company's policy, or have to serve the usual 14-day stay-home notice (SHN) long after it has been cut short for others who have taken the vaccine? Worse, what if your job role has to change from front-end to back-end so that you interface less with clients, or you have to work from home more frequently as a result of your decision not to take the jab? Consultants note the need to not discriminate against those who have exercised their choice not to take the vaccine, be it for personal, medical or religious reasons.

But questions like these remain up in the air. The consensus appears to be that going forward, it will be easier to take the vaccination than to be part of the minority that doesn't.

Dale Fisher, a senior infectious diseases expert at the National University Hospital, who also chairs the Global Outbreak Alert and Response Network at the World Health Organization (WHO), says that eventually not being vaccinated will become quite inconvenient for people, whether when they travel or have to do nasal swabs before entering any conference. "I believe - and this is not an announcement - that there will be a time when you can show your antibody or vaccine status and people will say: 'Fine, you are allowed through'. So I do believe that even those that are slightly vaccine-hesitant will just eventually say it's too inconvenient to toe this line and would rather just have it and be like everyone else."

It is already happening. Qantas Airways has said it will require passengers to provide proof that they have taken the Covid-19 vaccination before they fly. Some companies overseas are already applying a "no jab, no job" policy for staff. In the United States, the Equal Employment Opportunity Commission last December issued guidance that employers can legally require most workers to be vaccinated, barring those with legitimate reasons for not being able to.

Meanwhile, the International Air Transport Association is also developing a digital Covid-19 vaccine passport for travellers as a way to certify their vaccination status and Covid-19 test results and share the information with airlines and border authorities. Malaysian Prime Minister Muhyiddin Yassin has said that although the government has not made it mandatory for the people to get vaccinated, those who refuse inoculation could face restraints in moving around or engaging in businesses in the future.

In Singapore, Education Minister Lawrence Wong, who co-chairs the multi-ministry task force on Covid-19, has also spoken of the "tangible benefits" for those who choose to get their vaccine shots. They may not have to serve SHN, or will at least be allowed to serve a shorter one.

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Business incentives

Some retail and F&B (food and beverage) operators in the US are already incentivising their employees to get inoculated to allay customers' concerns about health safety. In Singapore, OCBC last month said it would engage medical experts to educate its 10,000-strong workforce about the vaccine to address their concerns, and introduce practical benefits such as enabling employees to take a day off on the day of each vaccination, and offering them private taxi reimbursement to and from the vaccination clinics.

There is added pressure for healthcare workers to be vaccinated, given the liability involved if they unknowingly transmit the disease to a patient, especially since the virus lends itself to asymptomatic transmission. Several hospitals The Business Times spoke to declined comment on whether job roles will change for those who decide not to take the vaccine.

A spokesperson for the Agency for Integrated Care (AIC), when asked if nursing homes will mandate vaccination or move healthcare workers that refuse vaccination to a different role not involving patient care, replied it continues to encourage all community care staff to get vaccinated, if they are medically eligible to ensure their safety and health, as well as that of the vulnerable seniors. But for those not vaccinated, AIC will provide them appropriate personal protective equipment, hand sanitisers, and regular surveillance testing for Covid-19, as well as give them prompt medical attention if they feel unwell.

Low Kiang Wei, medical director at health and security services firm International SOS says: "Particularly for industries that have a lot of interaction with consumers, it will be beneficial for them to ensure that they have all the policies in place and that their employees are vaccinated. This sends a message to the general public that it is safe to do business with them." (see amendment note)

But he warned that business leaders and human resource managers need to handle situations sensitively where employees refuse to take the vaccine shot, to ensure that they are not discriminated for their choice. "We should never assume that they are anti-vaxxers, and we have to speak to them to understand the reasons. There are plenty of personal, medical or even religious reasons that one is uncomfortable taking the shot, so the company should see if anything can be done to alleviate their fears, or to facilitate their vaccination process."

In a situation where the employer is insistent on not getting vaccinated, the company may need to see if the job scope of the employee has to be altered in a non-discriminatory way, such as by taking a more back-end function such as training, at least until herd immunity has been achieved.

But an inevitable reality for this group of people may be that they will be accorded slightly different treatment. For instance, they may face different corporate risk tolerance for travel and more stringent quarantine processes when they return, Dr Low notes.

Some have asked if employers can pay employees to get vaccinated. The consensus appears to be that this will introduce potential ground for discrimination, especially for employees who cannot get vaccinated for legitimate reasons such as severe allergies or pregnancy, and so will miss out on the monetary reward, he adds.

More importantly, paying people to do something inevitably increases the public's suspicion that there is profiteering to be made by the pharmaceutical industry.

Vaccine hesitancy

Government efforts to urge vaccination have met with some resistance from a growing minority who are urging people not to take it. While not as prevalent in Singapore, it is spreading in the US, the United Kingdom, Japan and India.

On the extreme end, some of these anti-vaxxers believe Covid-19 to be a conspiracy, and vaccines to be a big capitalist lie. Their accusation stems from a lost trust in the government, further fuelled by misinformation.

More commonly, people worry about the rushed vaccine development process and side effects that it may cause. Even in Singapore, shortly after the government announced that it has approved the Pfizer-BioNTech vaccine, word started spreading on social media that mRNA vaccines like the Pfizer-BioNTech one might alter the DNA genome of those vaccinated.

Another common myth for vaccination goes that it is better to get "natural immunisation" by getting infected than to get a vaccine shot. Prof Fisher says people are forgetting the severity of Covid-19. It is also easier to treat an adverse event from vaccination than from the disease itself.

Doctors in Singapore have come out to correct falsehoods and reassure the community that no corners were cut in the vaccine development process. Instead, the ramped-up process was made possible by the right conditions happening at the same time, coupled with immense government support.

Shawn Vasoo, clinical director at the National Centre for Infectious Diseases, says that large sample sizes were involved in the clinical trials, which allows for representative populations and a better study of the rarer side effects. For example, the Pfizer-BioNTech Phase III trial had more than 43,000 participants, and the Moderna vaccine Phase III trial had over 30,000 participants. Both showed excellent safety with minimal side effects. Many more doses of vaccine have also been administered by now outside of clinical trials, with very few cases reporting severe allergic reaction.

Associate Professor Jenny Low, senior consultant from the Department of Infectious Diseases at the Singapore General Hospital, adds that there is post-marketing surveillance as well, where a newly licensed vaccine continues to be tracked for rare side effects, and action can be taken to pull a product from the market or to make further recommendation on the usage if anything happens. Regardless, negative headlines warning of dangers have a way of drawing more eyeballs than doctors' rebuttals, as the medical fraternity continues to fight against people's morbid inclination towards vaccine horror stories and bad news.

Dispelling hesitancy

To make a level-headed decision, people need to have transparency and clarity about not just the benefits of taking the jab but also the risks posed, Associate Professor Richard Sugrue from the School of Biological Sciences at NTU Singapore, says.

The source matters, too. "It is probably best that such messages are provided by experienced domain experts in the field of vaccines and vaccine delivery such as vaccinologists," he adds.

The opposite of honest, consistent messages is mixed messaging, which, as an example, has thrown Americans into confusion about the most basic of facts such as whether masks are helpful in reducing transmission.

There needs to be a trust built and community leaders can all play a part in this, Prof Fisher says. Ultimately, this goes towards making vaccination normative. "What's been shown in science is that if the general practitioner says: 'It's time for your vaccine', then people are much more likely to be accepting, as opposed to if you ask: 'Are you sure you want the vaccine?' Like school vaccination, yes you can opt out, but it is more normal to have the vaccine."

Right now, there is no way to measure vaccine hesitancy in Singapore as it is still early days. As at Feb 14, close to 250,000 people have received their first dose, of which about 55,000 have also received their second dose. Vaccine centres are still busy vaccinating the elderly and frontline healthcare workers, and a clearer pattern will only emerge when the vaccine programme has been rolled out to the wider population.

There have been polls of vaccine take-up intentions globally. One by consulting firm Kantar last November showed two-thirds of Singaporean respondents agreeing that it would seriously affect their health if they were to catch Covid-19, which was a higher percentage than Australia, UK, US and other European countries.

While it might seem like a no-brainer, this statement is meaningful because people must believe there is a problem before they will agree to the solution, Prof Fisher says. This is why it is a challenge to convince those who think Covid-19 is a big conspiracy theory to take the jab.

The Kantar poll also showed that 28 per cent of respondents in Singapore saying that they would

"definitely" get a vaccine when it is available, with 45 per cent saying they "probably" would.

But Dr Low from International SOS says that, as with political polls, polling of vaccine intentions can never be fully reflective as sentiments change over time with unfolding events. "For example, if the situation worsens in Singapore, you will see a lot more people keen to take it because the threat is right in your face, whereas if we are doing very well, more people may adopt a wait-and-see approach because the threat is further away."

Besides traditional and online media, the corporate arena is also a way to reach large populations because there is a certain level of trust with employers and among co-workers. International SOS works with multinational corporations that have global assets to help them manage their employees' vaccination progress and travel arrangements, given that the different countries they operate in are progressing at different paces with their respective vaccination programmes.

Dr Low believes that the next step in Singapore could be to perform vaccinations in the workplace, similar to how staff vaccination is done at healthcare institutions here.

Only part of the solution

With the efficacies of vaccines ranging between 50 and 95 per cent, it should be clear that the vaccine was never meant to be the 100-per-cent solution to the virus.

In fact, assuming the efficacy of a Covid-19 vaccine is 90 per cent, vaccinating 80 per cent of the population - which is what Singapore's Health Ministry recommends - would mean that about 72 per cent of the population would become protected, helping to achieve herd immunity.

"This is a tool. This is not the solitary answer. This will help bring numbers down, this will save lives. But at the end of the day, it's only part of the solution," Prof Fisher says. To complement vaccinations, masks will still have to be worn and safe distancing practised.

What's more, the pace of manufacturing the vaccines cannot meet the world's demand in 2021. There are 7.8 billion people in the world. At last count, the manufacturers of the three vaccines with widespread distribution - AstraZeneca, Moderna and Pfizer - have estimated a total production capacity of six billion doses in 2021. AstraZeneca has reported delivery delays, so the number could be lower.

Considering each person would require two doses of any one vaccine, this will cater for less than half the world's population. Most are going to the developed world for now, but Covax, led by WHO and two vaccine advocacy groups, are helping to deliver 1.3 billion doses to 92 poorer countries to cover about one-fifth of their populations.

It is an uphill task, and it is becoming clearer that a vaccine will not be the clear-cut solution that so many hoped for, to end the virus outbreak quickly this year.

Herd immunity requires a substantial percentage of a population to take the shot. Government and corporate initiatives can go some way to hasten decision-making, but not everyone can be swayed with carrots and sticks.

The final ingredient could lie in helping people understand how the individual rights they exert can impinge on the community good. It worked with masks, lockdowns and other precautionary measures; it could work with vaccines too.

Amendment note: The organisation name of International SOS has been amended.