Who is Unsuitable for Vaccination? Actions to Curb Transnational Discrepancies
Henry Kwan
Fellow, Royal Society for Public Health
Member, Asian Academy of International Law
16 August 2021 | #21.19 | The views expressed in this post are those of the author and may not reflect those of UNU-CRIS.
Different governments have implemented their own guidelines for the suitability for Covid-19 vaccination. However, upon comparisons, they offer conflicting advice, especially regarding certain groups such as those who are pregnant or are diabetic. Furthermore, some jurisdictions offer multiple and inconsistent guidelines. With transnational access to information, these discrepancies are confusing for the public. This article raises this potent issue and its potential consequences while emphasising that governments should clarify that citizens should refer to local guidance in case of any discrepancies.
United States, World Health Organization and United Kingdom
These three groups are grouped together, because their guidelines are in conformity.
The United States (US) Government (including the US Food and Drug Administration and the Centers for Disease Control and Prevention) lists mainly one category of unsuitable persons: those who are allergic to the ingredients of Covid-19 vaccines. The US Government confirms that pregnant persons can receive vaccination. Other groups such as diabetics should also be vaccinated.
Similarly, the World Health Organization (WHO) excludes those with allergic reactions to Covid-19 vaccines. It affirms the suitability of the Covid-19 vaccine for pregnant and diabetic persons.
The United Kingdom adopts the same arrangement. Persons with diabetes are prioritised to receive vaccination due to higher risk of death after infection. The vaccine is confirmed to be suitable for pregnant persons.
China
The National Health Commission of the People’s Republic of China (PRC) issued the ‘Technical guideline for the inoculation of Covid-19 vaccines (First Edition)’ on 29 March 2021. It is an important document has been relied upon by the Hong Kong SAR Government in its formulation of its vaccination policy dated 7 May 2021.
The official English version was reported by the press, which later quoted that there are five categories for whom the vaccine could be unsuitable:
“(6) Groups not suitable for vaccination
a. Those who are allergic to the ingredients of the vaccine or who have history of allergy to the same type of vaccine;
b. History of serious allergy to vaccines (such as acute allergic reactions, angioedema, breathing difficulty);
c. People with uncontrolled epilepsy and other serious neurological diseases;
d. Patients with fever, or acute diseases, or during acute attacks of chronic diseases, or patients with uncontrolled severe chronic diseases;
Singapore
The Singaporean Government affirms that persons with chronic diseases such as diabetes are recommended to receive the vaccine. However, there are two categories that should not do so, namely (1) individuals with a severely weakened immune system (recent transplant in the past 3 months; aggressive immunotherapy for non-cancer conditions; HIV with CD4 count < 200 cells/mm3) and (2) individuals below 12 years of age for the Pfizer-BioNTech / Comirnaty vaccine, and individuals below 18 years of age for the Moderna vaccine.
There is room for better clarity to avoid the internal confusion, as the form itself indicates that those allergic to vaccination is a third unsuitable category. Another separate guideline lists the fourth unsuitable category without listing the third in the same document. One document says pregnant women are not encouraged to receive such; whilst another says there is “no evidence” of harm without explicitly saying whether they can receive.
Hong Kong
Compared to other countries discussed, Hong Kong has the broadest categories of persons who should not be vaccinated. This guide was updated in June 2021, and provides the follows:
“Contraindications
- People with history of allergic reaction to any component (active or inactive ingredients, or any materials used in the manufacturing process) of the vaccine or similar vaccines (please refer to the component as listed in the package insert (Annex II)).
- People with previous severe allergic reactions to vaccine (e.g. acute anaphylaxis, angioedema, dyspnea, etc.).
- People with severe neurological conditions (e.g. transverse myelitis, Guillain-Barré syndrome, demyelinating diseases, etc.).
- Patients with uncontrolled severe chronic diseases.
- Pregnant and lactating women”
Specifically, the third and fourth grounds are not present in many other countries. In relation to the fourth category, many other countries suggest, or even prioritise, that persons with chronic illness such as diabetes should be vaccinated. By striking contrast, the Hong Kong Government advises that “[v]accines should be used with caution” in those circumstances. It emphasises that those groups of people are suitable only if their medical condition are controlled or stable.
The guidance for the fifth category is rather confusing. Whilst the Government Guideline in June 2021 says no, the Hong Kong Government refers citizens to the suggestion of Hong Kong College of Obstetricians and Gynaecologists issued in May 2021 that “[p]regnant women should be offered” and “are advised to be vaccinated at the earliest opportunity”. This internal confusion is undesirable.
Consequences of the Discrepancies and Confusion
With transnational access to information via the Internet, the guideline provided in a specific country is not only referred to by its local community but may also be considered by the citizens in another country as reference.
The discrepancies and confusion can fuel the spread of disinformation. It causes misunderstanding among the public, which may undesirably lead to vaccination delay or hesitation. The discrepancies may be used as an excuse or dissuasion by anti-vaxxers to undermine the universal goal of achieving herd immunity by increasing vaccination. Apart from causing doubts on the correctness of the guidelines, the unexplained discrepancies may also negatively affect the trust and confidence in the governments. It also makes explanation more difficult for frontline health practitioners.
Furthermore, the discrepancies provide room for the public to debate on whether to get vaccinated. This may create social disagreement and disrupt harmony between those who are vaccinated and those who are not.
Moreover, the confusion undermines the citizens’ right to health, which is articulated in the WHO Constitution and Article 12 of the International Covenant on Economic, Social and Cultural Rights. The right to health is understood broadly to ensure the public have access to proper information. The WHO Constitution emphasises that:
“The extension to all peoples of the benefits of medical…knowledge is essential to the fullest attainment of health…
Informed opinion and active co-operation on the part of the public are of the utmost importance in the improvement of the health of the people.”
The UN Committee on Economic Social and Cultural Rights and the World Health Organization both stress upon the importance of information accessibility. Arguably, the inconsistency is indirectly undermining proper access to information. This confuses not just the public, but also frontline health practitioners.
Achievable Suggestions
The lack of a uniform approach is highly problematic. The confusion is a potential obstacle to achieving global herd immunity. However, it may be practically very difficult for governments to act in concert in issuing a uniform guidance.
To ameliorate such, the governments should explain the cause of the discrepancies as far as possible – i.e., in terms of why they choose to set a guideline different than other countries. The medical explanation vitally helps clarify to and assure the public.
In addition, it is important for governments to curb the transnational influence of the inconsistent guidance on vaccination. It is suggested that the governments take a strong and affirmative stance and that local citizens refer to local guidance in case of any discrepancies. This assures the public, and avoids unnecessary confusion.