This article first appeared in The Edge Malaysia Weekly on June 7, 2021 - June 13, 2021

BE it luck or desperation for normalcy, Malaysia’s race to attain herd immunity against Covid-19 by year end was surprisingly boosted by the government’s decision in late April to exclude the AstraZeneca-Oxford vaccine from the National Covid-19 Immunisation Programme when some countries in the EU had halted its usage while experts investigated reports of rare but potentially fatal blood clots.

We know now that just one month on, the AstraZeneca vaccine is back in the national immunisation programme following overwhelming demand in both rounds of the voluntary registration that offered a total of 1.53 million doses — significant, given the fact that only 2.1 million people in Malaysia had received at least one dose of vaccine as at June 2. Only 1.11 million people had completed two doses as at June 2, bringing the total vaccine doses administered to 3.21 million.

The first round of opt-in registration for 268,800 slots of the AstraZeneca vaccine were snapped up in a little over three hours on May 2. The remaining 956,609 slots, not taken up by those above age 60 given priority on May 23 to 25, were snapped up within 90 minutes when registration opened to those aged 18 to 59 on May 26. A total of 1.26 million slots were given out under Round 2 of the opt-in drive, including 29,183 slots given to those on the waiting list from Round 1.

While national registration for vaccines had improved from 9.89 million or 40.8% of the adult population on May 6 to 12.58 million or 51.9% of the adult population on June 2, the government knows it needs to shore up registration fast to attain the desired herd immunity by inoculating 25 million people or 80% of the adult population by year end.

While there are those who reckon that having more opt-in rounds for AstraZeneca vaccine could help boost inoculation numbers among people who want to be vaccinated fast, others say that alone would not be enough to shore up what looks like a stubbornly low vaccine registration rate.

Not only does Malaysia need at least another 12 million people — double the current number of people who have registered for vaccination — to sign up in the coming months for the country to have a fighting chance of attaining herd immunity against Covid-19 by end-2021, it also needs to get the people who have registered to actually turn up for their jab when their turn comes.

The attendance rate among those who have registered is about 80% on average, Khairy Jamaluddin, who heads the National Covid-19 Immunisation Programme, told reporters on May 31.

While there is a waiting list to make sure the vaccines do not go to waste, both the registration and average attendance rate indicate that vaccine hesitancy remains an issue more than three months after the government began accepting registrations for vaccination.

Health Minister Datuk Seri Adham Baba said on May 27 that the government may start imposing fines or even make vaccination compulsory to make sure that Malaysians do not skip their vaccination appointments, following reports of no shows by at least 52,000 people from seven states.

Prime Minister Tan Sri Muhyiddin Yassin had reportedly directed the Covid-19 Vaccine Supply Access Guarantee Special Committee (JKJAV) to prepare a contingency plan should the registration rate for vaccination continue to fall short of the 80% needed to attain herd immunity. He told Bernama on June 4 that the government is studying the possibility of taking legal action against anyone who dissuades Malaysians from getting vaccinated against Covid-19.

According to Khairy, Malaysia is looking at providing incentives to significantly shore up registrations for Covid-19 vaccination from the current 50% level. “We are looking at some incentives. [We are] discussing with the Treasury,” he told The Edge on June 4, without providing any specifics or a timeline.

Khairy also said he is in favour of providing “carrots” before wielding a “stick” at those who have yet to register themselves to support the national vaccination drive towards achieving herd immunity against Covid-19. This could mean that mandatory vaccination, which some parties reckon may be necessary to attain herd immunity by year end, is not on the cards yet.

While vaccination is necessary to protect the people and herd immunity is required for some semblance of normalcy to return post-Covid-19, no government has chosen to make vaccination mandatory thus far.

One reason may be the fact that “top-down imposition of vaccination can be seen as a failure of governments to adequately communicate, educate, convince or persuade their citizens about the safety and effectiveness of vaccines”.

“More broadly, it can also be a failure to inspire trust in institutions of health and to inspire civic responsibilities and public-spiritedness,” Dr Khor Swee Kheng and Nurul Ezzaty Hasbullah wrote in a policy brief headlined “Should Covid-19 vaccines be mandatory?”, published in December 2020 by the Institute of Strategic and International Studies (ISIS) Malaysia.

Yet, the authors concluded that mandatory vaccination “is a useful public health tool” in a pandemic, “though it is not a silver bullet and should not be viewed as such”.

“Mandatory vaccination is a nuclear option that should only be deployed if all other measures have failed, and not the first policy instrument that governments reach for,” they wrote, flagging the need for policymakers to address the threat of vaccine hesitancy, which stems from “reasonable fears of safety to absurd claims of government conspiracies”. Unintended consequences could ensue should proper communication not be done to soften any perceived harshness of regulation, they add.

Among reasons confidence in vaccines may be low is the perception that corners had been cut for the Covid-19 vaccines to be developed, approved and manufactured so quickly. “Public health officials and the media may not have offered [enough] explanations for how science, economics and politics enabled such speed without compromising on quality or safety,” Khor wrote in a journal published by the University of Hong Kong’s Asia Global Institute in April.

Apart from the need to communicate well, governments can impose restrictions to shore up vaccination rates, especially if rewards and incentives alone do not yield the desired numbers, say observers. These include not allowing those who are not vaccinated to travel, even interstate.

If herd immunity remains far out of reach by the third quarter of this year, a harsher stance may need to be taken, including not allowing those who are unvaccinated to be part of the crowd in cinemas, concert halls, supermarkets and dine-in restaurants or even on public transport.

Rather than impose penalties on the people, the government may choose to penalise companies whose employees are slow to be vaccinated, reckons one observer. It is likely, however, that the carrots will come first — at least for now.

Companies that are losing money as a result of the movement restrictions may not need much push from the government to get their employees vaccinated.

Datuk Dr Syed Hussain Syed Husman, president of the Malaysian Employers Federation (MEF), tells The Edge that it strongly encourages employees to be vaccinated because having herd immunity will help reduce the public’s fear of infection, which adds to the economic stress faced by many small and medium enterprises and entrepreneurs.

“There have been many companies that have sought to source vaccines at their own expense to vaccinate employees. However, this has not made much progress as vaccine supply is controlled by the government,” he says.

The MEF, which represents 6,000 member companies and 25 associations covering 2.82 million employees, is of the view that all stakeholders must play a role in reaching out to the public, including private hospitals, public health clinics and district hospitals, and mobilise all medical vehicles including the armed forces medical units. “In rural areas, we propose a more comprehensive execution team through FELDA, Felcra, Risda and UDA, which are able to reach the mass settlers in estates and rural areas,” says Syed Hussain.

While fully supportive of the mass vaccination drive, he did not, however, take a stance on mandatory programmes. “Whether vaccination should be mandatory or not is for the government to decide,” he says.

Our channel checks indicate that a number of companies here are encouraging vaccination by giving paid leave to employees in support of the government’s national vaccination drive.

It is understood that some companies have taken an even tougher stance by making vaccination a health and safety requirement for employment. The Hong Kong Football Club that offered cash payments to vaccinated staff, for instance, reportedly said there would be no pay rise, bonuses and promotions for those who are unvaccinated.

While Malaysia has procured enough vaccine doses to inoculate the entire population, the delivery timeline had not been confirmed for a significant portion at the time of writing due to a global supply shortage. That may explain, in part, the rush for the opt-in AstraZeneca vaccine.

On May 3, Khairy said Malaysia had received 1,938,660 doses of Pfizer, Sinovac and AstraZeneca vaccines, of which 1,453,382 doses had been administered — indicating a utilisation rate of 75%. The current vaccine stock and utilisation rate are not immediately known.

Still, according to the government, vaccine supply is set to increase within two months, so much so that there is a fear that not enough people will line up for vaccination if the number of registrations do not rise quickly.

Some 2.22 million doses of the Pfizer vaccine and 610,000 doses of the AstraZeneca vaccine are due to arrive in June. By end-July, all 12 million doses of the Sinovac vaccine procured will have arrived. Barring further delays, another 25.68 million doses of Pfizer are due to arrive in the third quarter. That’s on top of the 410,000 doses of the AstraZeneca vaccine in July and 1.2 million doses between August and September.

Khairy told reporters that arrangements are already underway to ramp up vaccination capacity to 150,000 doses a day, which works out to 4.5 million doses a month. That would mean at least eight million or one-third of Malaysia’s adult population may receive at least one dose of vaccine by end-August compared with 2.1 million or about 8% to 9% of the adult population (and 6.4% of the total population) currently, our back-of-the-envelope calculations show. The experience in the US and the UK indicates that the number of infections decline once 25% of the population gets at least one dose of the vaccine.

To be sure, the government needs to ensure that the procured vaccines are delivered and distributed in a timely and efficient manner. Good communication is part of the job.

Just as the government needs to do whatever it takes to save lives and livelihoods threatened by Covid-19, all Malaysians have a part to play in achieving the herd immunity required for normalcy to return. Getting vaccinated is one way everyone can be part of the solution to Covid-19.

#ifyourenotpartofthesolutionyouwillbepartoftheproblem

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