Hot Topics: Kuala Lumpur Malaysia

That shot at prevention


While some parents think vaccination is not important, doctors insist that it is vital as a health investment because diseases, even if they no longer exist, are not completely eradicated, write Kasmiah Mustapha and Syida Lizta Amirul Ihsan

WHEN it comes to babies, vaccination is almost always a passe topic among parents, most of whom think that other than those provided in the country’s National Immunisation Programme, other recommended vaccines are not necessary for their newborn or toddler. Some urban parents have also been influenced by the Internet and other sources and are now opting not to vaccinate their children.

This worries paediatricians. “This (not vaccinating kids) is at the cost of protection of these children and of others who may be too young to be vaccinated. Since these parents have not seen the diseases concerned, they are not aware of the consequences of their decision — unless their child is unfortunate enough to get infected,” paediatrician Datuk Dr Zulkifli Ismail says.

Dr Zulkifli is also past president of the Malaysian Paediatric Association and chairman of the Asian Strategic Alliance for Pneumococcal disease prevention.

Owing to herd immunity, with large enough coverage, children who are not vaccinated will still be protected, benefiting from those who have been vaccinated. For herd protection to have an effect, there must be at least 80 to 90 per cent of the population at risk who have been vaccinated. “With more parents not vaccinating their children, this herd effect will subside,” he says.

“The Health Ministry is concerned and so are we paediatricians. The trend is not so large and not that worrying now, but we need to put in some effort to inform the public about vaccines especially since it is no more like what it used to be in the past. There are many more antigens in the vaccines and there are also convenient combination vaccines,”


“Vaccination is prevention and it is an investment in health. If we are to practice what we preach about prevention being better than cure, then we should be advocating vaccination. It is not new and it has been shown to be safe and effective in reducing serious diseases,” Dr Zulkifli says.

He says for vaccines under the NIP, those who reject them are mainly urban parents, perhaps since the population has access to worldwide information and a fair amount is by anti-vaccine lobbyists. Some parental groups — especially in the United States and United Kingdom — believe that vaccination is unnecessary. They had questioned the need to vaccinate children especially as some of the diseases are no longer around.

They also say some of the vaccines have side effects, claiming that these shots can cause other issues such as autism. “In the 1980s when there was widespread rejection of the DTP (diphtheria, tetanus and pertussis) vaccine in the UK, many babies succumbed to pertussis. When the article on MMR (measles, mumps, rubella) and autism was published, MMR vaccination in the UK dropped the subsequent year resulting in an increase in measles cases, including many deaths. The article in the Lancet has since been withdrawn and the authors proven to be fraudulent. Possibly the last local case of diphtheria occurred in the mid-80s among a religious cult group that refused vaccination for its members,” he says.

The rural population, he says, will send their children for the vaccines in the NIP because of their contact with the community nurses who are their neighbours. “The problem is getting information on other recommended vaccines to them, especially with the relatively high price of these vaccines.”


Prince Court Medical Centre consultant paediatrician Dr Anthony James Mansul says an important point to remember is that preventable diseases have not been completely eradicated. As movement of people increases, there is a chance that the virus will be carried from one country to another.

“We live in a time when there are large movement of peoples from different countries. In some of these countries, the diseases are still present. If our vaccine uptake is reduced below a critical level, we will again see outbreaks of vaccine preventable diseases.

He says vaccines are victims of their own success. “The incidence of vaccine preventable diseases, which has almost vanished due to aggressive vaccination programmes over the decades, has unfortunately, resulted in younger generations of parents questioning the need for the vaccination schedule because their children are healthy.”


“Some parents had also questioned the number of vaccines the child has to take, because the view is that children’s bodies cannot handle too many vaccines. But it has been estimated that theoretically, the number of vaccines an infant can take is around 10,000. So we have a long way to go.” Dr Mansul says.

Here, vaccinations under the NIP began in the 1960s. The schedule is compulsory although it is not strictly enforced or enforceable policy. Dr Mansul says there are two other vaccines which should be included in the NIP — for pneumococcal disease and rotavirus.

“Pneumoccocal vaccine should be included in the NIP or at least subsidised. Rotavirus vaccine would prevent diarrhoea and vomiting. Unfortunately for developing countries like Malaysia, both vaccines — although they are very good — may not be cost-effective to be included in the NIP at their current price level.

“However if I were to prioritise, I would pick pneumococcal to be the next on the list of our NIP due to the simple fact that unvaccinated, all of us will be getting this particular infection for the rest of our life.”


Pfizer Inc senior director of scientific affairs, vaccines, Dr Ralf Rene Reinert says unless there is a global eradication of the disease, there is a need to continue with vaccination. “People are travelling now more than previously. If you do not see polio in Europe, it does not mean the possibility of an outbreak is not there. If someone comes from a country where polio is still around, he could carry the virus when he travels.

“It is difficult to stop diseases from spreading due to humans being the hosts. So it is easier to vaccinate people against the diseases. In the ideal world everyone should be vaccinated. The concept of eradicating disease rather than vaccination is a good idea but it is very difficult to do because of the borderless world.”

As for the “anti-vaccine” groups, Dr Reinert says he always asks for studies or data when it is that vaccines cause serious health issues on children. “I have not seen any cases of combination of various vaccines causing problems. If people question why vaccines are expensive, it is because we have to test one vaccine in combination with other vaccines.”


Dr Reinert says the cost of treatment for such diseases would also decrease through vaccinations. Citing an example, in Germany he says, if a person spends 1 Euro (RM4) for a vaccine, the return is 1.30 Euro in saving for treatment costs.

“Vaccine doesn’t increase the cost of health, it reduces it. So either you pay for treatment of disease or you pay for the vaccines. If you make the decision not to pay for the vaccine, then pay for the treatment. But I believe it is better for you to pay for the vaccines rather than the treatment.”

Dr Reinert, who is based in Collegeville, Pennsylvania was responsible for providing scientific and strategic support for the Pneumococcal Conjugate Vaccine European Medicines Agency filing. He was in Kuala Lumpur recently to talk about pneumoccocal diseases vaccination.

He says a World Health Organisation paper released in 2007 has stated that penumoccocal diseases vaccines should become a priority in every country.
“I think when it comes to overall burden of all diseases, preventing pneumoccocal disease has become a huge issue. Our problem is that this is a complex disease — it has invasive and non-invasive. A child’s immune system is highly susceptible to these diseases.

“So every country should have the vaccine in their immunisation programmes. You will get the full benefit of the vaccination. The downside of not being vaccinated is that the people will be susceptible to suffer from the diseases.”
Dr Zulkifli says other vaccines are works in progress. “The dengue vaccine is much anticipated and is expected to be in the market in two or three years, new meningococcal conjugate vaccines will replace the polysaccharide ones for those going for hajj as these conjugate vaccines can be given to younger children and the immunity lasts longer.

“Vaccination should be seen by governments as an investment rather than an expense in tabling the budget. It is an investment in health to ensure that the future generation will be healthy and contribute to the workforce.”

Vaccine victory
Dr Zulkifli says vaccination has:
•    Eliminated smallpox.
•    Made the region polio-free.
•    Taken us towards measles elimination.
•    Reduced the incidence of congenital rubella syndrome (congenital abnormalities in babies born to mothers who get rubella or German measles during early pregnancy).
•    Saved many lives during the last influenza pandemic.

Aside from those in the NIP, parents also should consider:
• Pneumococcal conjugate vaccines
• Rotavirus vaccine
• Hepatitis A vaccine
• Influenza vaccine
• Chickenpox vaccine
• Tdap (tetanus, diphtheria and acellular pertussis) vaccine for adolescents and adults


Dr Reinert says the concept of eradicating disease rather than vaccination is a good idea but it is very difficult to do because of the borderless world

Vaccines don’t increase the cost of health but reduce it in the long run


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