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A tale of two cities


Today, I would like to highlight the increasingly divergent approaches of Singapore and Hong Kong to the COVID-19 pandemic. Singapore’s PM Lee Hsien Loong (李顯龍) made a speech on 31/5/2020 that laid out the city state’s strategy against the COVID-19 ‘New Normal’.

The transcript of this speech is linked here and I paraphrase some of his key points for brevity:

-COVID-19 is never going to disappear. We have to learn to live with the virus.

- Learning to live with the virus means getting vaccinated because vaccinations dramatically reduce risk of falling severely ill from COVID-19.

- Community spread of COVID-19 is eventually unavoidable. But high vaccination rates means that such outbreaks are NOT going to be disastrous or overwhelm healthcare.

This is an accurate and fact-based assessment. Singapore is undergoing a transition towards a phase where border restrictions and social distancing are gradually relaxed in step with ensuring most of the population is vaccinated. Singapore has already removed quarantine for arrivals from Hong Kong/Macau, which is a sensible and low-risk move. Singapore’s transition is challenging; there is no playbook on how to relax border restrictions in the current pandemic context, but there is no doubt that their basic strategy is sound and compatible with long-term economic viability.

Hong Kong will eventually have to walk Singapore’s path. There is no other realistic choice. However, HK is still unprepared to do so due to ONE factor: low vaccination rates in the elderly. In Singapore, > 80% of the elderly aged 70 & above are fully vaccinated. However, in HK, less than a third of elderly have received the vaccine. Old age is the strongest and most consistent predictor of COVID-19 mortality. If HK relaxes its border restrictions right now with its low elderly vaccination rates, there is no doubt that the resulting community COVID-19 outbreak will disproportionately affect the elderly with appalling loss of life. This, in turn, will inevitably cause major disruption of healthcare in the city. So, getting the elderly vaccination rates higher is an absolute priority for HK to develop any realistic plans for border relaxation.

In Singapore, over 80% of the elderly aged 70 & above are fully vaccinated. 

But, why is this rate so low among our elderly?

One reason is the lack of local cases leading to a false sense of security. I hope it is very clear from the above passage that HK cannot hide from COVID-19 forever. Getting vaccinated is an absolute prerequisite for the city to open up. COVID-19 vaccines remain extremely effective at preventing hospitalizations due to Delta variant even if they do not always prevent symptomatic disease (please refer to my recent post on herd immunity for a detailed discussion on this).

The other reason for low vaccination rates among elderly is an overwhelming perception among the general public that COVID-19 vaccines are dangerous for the elderly. This has been fuelled by miscommunication about vaccine side effects (especially the BioNTech vaccine) and regular news reports on adverse events following vaccination. Now, I commiserate with anyone who developed adverse events after vaccination; I fully understand that it can be a heart-breaking devastating experience just like any medical intervention that has unexpected outcomes. However, we must also acknowledge that there is a strong cognitive impulse to connect adverse events following vaccination to vaccination, even if this is not always the case.

I understand that people have very strong opinions about this, but I ask that we consider the facts rationally:

1.More than 80 – 90% of elderly in countries like the UK & Singapore have received COVID-19 vaccines. Would these countries have deployed vaccination in this scale for their elderly if there were serious questions on their safety? To those that say this mass-vaccination is only because they have high community COVID-19 rates unlike HK, I ask them to remember the simple fact that COVID-19 is here to stay. HK cannot remain in a bubble forever.

2. The US FDA has formally fully approved the BioNTech vaccine for anyone above age 16 a few days ago. Such regulatory approval comes after thorough assessment of the quality, safety, and effectiveness of the vaccine.

3. After more than an year of safety monitoring (including the phase 3 trials), we know that there are two potentially life-threatening side effects of the BioNTech mRNA vaccine: severe allergic reactions (anaphylaxis) and inflammation of the heart (myocarditis). Neither of these side effects is particularly more common in the elderly. In fact, myocarditis predominantly occurs in young vaccine recipients.

4. What about heart attacks & strokes? According to research in Israel by Barda N et al, NEJM, there is absolutely no evidence in a nationwide surveillance study that heart attacks/ strokes are more common in BioNTech vaccinated people compared to the unvaccinated population. So far, no signals that such side effects occur with Coronavac have been reported from countries like Chile that use it extensively. Please note that HK has a small population. It is highly unlikely that rare severe side effects due to vaccines are going to crop up in HK and not overseas.

So, in summary:

- HK is stuck with tight border restrictions for the foreseeable future due to low vaccination rates in a particularly vulnerable segment of the population;

- This situation is not sustainable as COVID-19 is likely going to be with us forever;

- Therefore, encouraging the elderly to get vaccinated is a top priority because vaccination against COVID-19 is the best way to reduce their risk of severe COVID-19 even if they get infected;

- COVID-19 vaccinations have an excellent safety record in the elderly population.

A litmus test for decision-making among doctors in medicine is ‘what would you recommend if the patient was your family member?’ I have unreservedly recommended COVID-19 vaccination to elderly in my family and I earnestly ask you all to join me in doing the same for your families.

Have a good Sunday.

(This article was originally published at the author’s Facebook.)


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