Future-Proofing Malaysia's Health: Data-Driven Immunisation Strategies

KUALA LUMPUR, Jan 20 — During the Covid-19 pandemic, Malaysia and other countries updated vaccination programmes to target new variants in a real-time data-driven approach that can be used for other infectious diseases. Experts speaking to CodeBlue say future-proofing disease interventions involves a two-part strategy: the first is a shift towards using the most current and real-time serology data to guide vaccination programmes. The second involves expanding Malaysia’s immunisation focus from a childhood-centric model to a comprehensive and lifelong approach that protects adults and senior citizens. A Dynamic Defence With Real-Time Data While some diseases like cancer take years to develop, giving the Ministry of Health (MOH) time to adapt with the necessary therapies, infectious diseases have much shorter turnaround times as viruses evolve much quicker. Experts are now advocating for a new, dynamic system that mirrors the adaptive response seen during the Covid-19 pandemic. According to former MOH disease control deputy director Dr Zainal Ariffin Omar, Malaysia should adopt a data-driven approach that integrates real-time surveillance and serology data. This means continuously monitoring disease trends by using tools like genomic sequencing to identify emerging variants and serosurveys to measure population immunity levels. ”Flexible vaccine policies would allow rapid updates to vaccination programmes based on evolving threats (e.g., variant-specific Covid-19 boosters, updated flu strains),” Dr Zainal told CodeBlue. The public health expert added that vaccination programmes should rely on the latest data. “For fast-mutating viruses like influenza and the coronavirus, frequent updates are critical. For more stable pathogens such as measles or human papillomavirus (HPV), updates are less urgent but still essential, as they can ensure new vaccines cover new oncogenic strains,” he explained. Dr Zainal said ultimately, these decisions should always be complemented with a thorough cost-benefit analysis. However, applying this “serotype approach” beyond pandemics is not without its challenges. Dr Zainal pointed out that factors such as regulatory delays for non-emergency approvals, the logistical complexities and costs of frequent programme changes, and the potential impact on public trust need to be carefully considered. It also requires strong surveillance systems to provide the robust evidence needed to justify updates. Despite these hurdles, the long-term benefits of an updated vaccination strategy are clear. “Using the latest data can reduce disease burden and health care costs,” he said. “Updated vaccines give better protection, and real-time data can guide targeted campaigns to prevent outbreaks, such as dengue serotype shifts.” Dr Zainal emphasised that the cost savings from fewer hospitalisations and long-term complications, such as HPV-related cancers, are significant. To achieve this, he says, Malaysia must strengthen its surveillance systems with tools like genomic sequencing and digital health reporting, and foster public-private partnerships for faster vaccine development and deployment. A 2023 study by Khoo et al showed that the effort to eliminate types 16 and 18 in HPV has given room to other high-risk cancer-causing serotypes (31, 33, 45, 52, and 58) to fill in the void. Not addressing the new serotypes will mean there will still be a likelihood of cervical cancer developing later in life. A similar pattern is emerging with pneumococcus. Serotype replacement is evident in countries that have implemented pneumococcal national immunization programs, such as Canada and Australia. Their national pneumococcal surveillance datasets show an increasing trend in certain serotypes such as serotype 3, an initially untargeted serotype, because of serotype replacement following the introduction of these programmes. Vaccine Immunogenicity: Better Value For Money Consultant paediatrician Dr Musa Mohd Nordin explained that a vaccine “trains” the immune system how to recognise and neutralise a pathogen (e.g. virus or bacteria) without causing the actual disease. “Immunogenicity is the measure of how well the vaccine ‘trains’ the body to produce an effective, robust and long lasting immune response. “This includes production of antibodies to neutralise the pathogen before it can cause an infection, activation of T-cells to search and destroy the infected cells to prevent replication, and generation of memory B and T cells to establish durable immune memory,” Dr Musa told CodeBlue. Thus, although vaccines may nominally provide protection against specific disease serotypes, it’s important to also evaluate how much of an effective immune response it provokes. Evidence from Hong Kong provides a clear case study. Although Hong Kong selected a pneumococcal conjugate vaccine that nominally covers serotype 3, the latest report from Hong Kong’s Centre for Health Protection on invasive pneumococcal diseases indicate that serotype 3 was dominant (with a prevalence range of 59 per cent to 82 per cent) in the pre-pandemic period (2015-2022) and remained so after (2023 onwards) at 43 per cent prevalence. Vaccines with lifelong or long-term protection were undoubtedly “better value for money” from a public health and economic perspective. “Health economists use specific metrics e.g. cost savings, to measure a vaccine’s ‘value for money’. The MMR and DTaP vaccines saved US$14 and US$27 for every US$1 invested respectively,” said Dr Musa. The paediatrician explained that two doses of the MMRV (measles, mumps, rubella, varicella) vaccine and five childhood doses of the DTaP (diphtheria, tetanus, pertussis) vaccine confer long-term protection with fewer doses, resulting in cost savings. “Public health is also enhanced with improved population coverage due to better compliance and uptake,” said Dr Musa. “A higher population coverage would not only confer individual protection, but also community protection due to stronger herd immunity and fewer disease outbreaks. Persons who cannot be immunised due to various factors, e.g. too young, immunosuppressed, will be protected by this community immunity.” Life-Course Immunisation: A Lifelong Shield For All Dr Zulkifli Ismail, a consultant paediatrician and paediatric cardiologist who runs the Immunise4Life programme, is a strong advocate of expanding the very concept of immunisation to cover an individual’s entire lifespan, a strategy known as life-course immunisation. “It should protect the elderly especially since we will be an ageing population soon,” he told CodeBlue. “The elderly should be allowed to age healthily and vaccination is one of the ways. The others are proper nutrition, healthy lifestyle and prevention of falls.” Prof Dr Tan Maw Pin – consultant geriatrician who is president of the Malaysian Society of Geriatric Medicine (MSGM) and member of Malaysian Influenza Working Group (MIWG) – pointed out that many vaccines are now extremely effective in preventing severe disease and hospitalisation in older persons. “Vaccination is now the best option to address congestion in our hospital systems and to combat antibiotic resistance, since if people don’t get severe infection, they won’t be given antibiotics and they won’t be hospitalised. So yes, the government should consider a national immunisation programme for older adults,” Dr Tan told CodeBlue. “However, it will take time to revise the system to make it possible to effectively fund as well as deliver vaccines to older adults. While we all recognise that change takes time, we must make sure that the system is going in the right direction towards the necessary change.” Dr Tan highlighted the government’s extremely popular influenza vaccination programme for older adults with medical conditions, with only a small amount of vaccines left in public health clinics. “We would like to urge any older persons with at least one medical condition to book their appointment through MySejahtera for the vaccine immediately before the stocks run out,” she said. A 2023 study by Nur Syazana Mad Tahir et al estimated a total RM3.3 billion annual economic burden of influenza on older adults in Malaysia from direct health care costs, equivalent to 10.7 per cent of MOH’s budget for 2020. Another 2023 study by Syed Mohamed Aljunid et al estimated that the use of quadrivalent influenza vaccine in Malaysia’s elderly population would prevent more than 66,000 potential influenza cases and 888 potential deaths among the elderly. Influenza vaccination of senior citizens was also estimated to be able to save over US$4.4 million (RM18.6 million) currently spent on influenza-related hospitalisations and reduce productivity losses by approximately US$21.6 million (RM91.1 million). Experts’ Wish List Of Vaccines For Adults And Seniors In Routine Public Immunisation So, what vaccines should a routine public immunisation programme for adults and the elderly include? The experts have a wish list. For older adults, the consensus is strong. Dr Zulkifli recommended influenza and pneumococcal vaccines. “If the shingles vaccine is not so expensive, it should be included in our schedule for the elderly or for adults. The price of this vaccine is a deterrent,” said Dr Zulkifli. “For grandparents and pregnant mothers, the combination tetanus, diphtheria and acellular pertussis (Tdap) vaccine will help to prevent pertussis (whooping cough) in adults and also in newborns before their first Tdap vaccine at two months. In fact the MOH has already approved Tdap for pregnant women. “Lastly, the dengue vaccine. Dengue is common and contributes to loss of work days and high hospitalisation costs. The age of our patients getting dengue has moved from childhood to early adulthood, i.e. the most productive age group. Giving dengue vaccines to young adults will prevent this loss in the workforce.” Dr Tan’s list includes influenza, pneumococcal, respiratory syncytial virus (RSV), shingles, and Covid-19, as well as dengue in endemic areas, in addition to the existing list of vaccines which are either continuation (tetanus, mumps, diphtheria, hepatitis) or incomplete vaccinations for childhood vaccines. “The Malaysian Society of Geriatric Medicine has launched their Vaccine Preventable Diseases in Older Adults Position Statement to help highlight the need for vaccination in older adults as a health care priority,” said Dr Tan. “We are also working together with the Malaysian Society of Infectious Diseases and Chemotherapy which will be releasing the 4th Edition of their Malaysian Adult Immunisation Guidelines later this year. There will be new chapters in the guidelines to cover our new vaccines,” she added. Dr Zamberi concurred, emphasising the vulnerability of older adults to infectious diseases due to declining immunity and underlying chronic conditions. “⁠⁠For an effective and equitable adult immunisation strategy, vaccines should be prioritised based on disease burden, population vulnerability, and cost-effectiveness,” he said. “Older adults are more vulnerable to infectious diseases due to declining immunity and underlying chronic conditions. Recommended vaccines include influenza vaccine, pneumococcal vaccines, zoster vaccine, Covid-19 booster and RSV vaccine. “Individuals with diabetes, cardiovascular disease, chronic respiratory conditions (e.g. asthma, COPD), chronic kidney or liver disease, and immunocompromised persons are vaccinated based on their risk profiles.”