Vaccination Challenges In Rural Sabah & Sarawak

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By Research Analyst at EMIR Research, Amanda Yeo

Although Malaysia has a plan to inoculate more than 80 percent of the population (nearly 27 million out of 32 million Malaysians) against Covid-19 by March 2022, there is no clear indication on how the vaccines are going to be distributed throughout rural Sabah and Sarawak.

This is a valid concern, as in the rural areas of Sabah and Sarawak, more than a third of the population continue to live beyond five km of any kind of health facility. Due to the lack of specialists and medical equipment, patients seeking treatments or follow up treatments are often forced to refer to another public hospital that could cater to their respective medical needs.

Even in the case of medical emergencies, they have to travel across state borders, which includes driving through muddy, uneven roads besides having a boat ride at their own expense, which is relatively cost- and time- consuming.

As the official ratio of doctors to the population is 1:856 and 1:662 in Sabah and Sarawak respectively, which shows much fewer doctors per people in both East Malaysian states than the nationwide average of 1:454, this poses further challenges for the rural hospitals to reach rural populations in both states.

Science, Technology and Innovation (MOSTI) Minister Khairy Jamaluddin stated that rural Malaysians would most likely to receive the AstraZeneca Covid-19 vaccine but as this type of vaccine is only available in the second quarter of 2021, it is unclear whether the government will include frontliners, senior citizens and people with chronic diseases who are currently based in rural Sabah and Sarawak to have the first dose of the Pfizer vaccine.

Even if the government decides to deliver Pfizer doses to rural Sabah and Sarawak, the delivery process would be much more complicated.

After ensuring these vaccines are stored at a relatively low temperature, the inter-warehouse transfer will be conducted through flights where these ultra-cold vaccines can then be delivered from the Klang Valley to the distribution centres in Sarawak and Sabah. Thereafter, the vaccines will be repacked from these distribution centres and deliver to remote areas in both states via land transportation within 48 hours.

Due to the storage and delivery challenges, the Federation of Malaysian Freight Forwarders (FMFF) President Alvin Chua indicated that Pfizer and Moderna vaccines are not suitable for East Malaysian states – Pfizer-BioNTech’s Covid-19 vaccine requires storage at minus 70 degrees Celsius whereas Moderna Covid-19 vaccine is stored frozen between minus 25 to minus 15 degrees Celsius.

Under normal fridge temperature (2 to 8 degrees Celsius), Pfizer-BioNTech’s Covid-19 vaccine only can be stored for five days whilst Moderna Covid-19 vaccine can be stored for up to 30 days.

Given that most of the hospitals in Malaysia can only store a maximum of up to minus 20 degrees Celsius, frontliners who are based in rural Sabah and Sarawak might have to fly over to Klang Valley to receive their first Pfizer shot during this quarter as the Moderna Covid-19 vaccine that can be stored at such temperature level for up to six months is not available in Malaysia’s market yet.

It would also be too costly for the government to purchase cold storage freezer for each hospital in East Malaysia. Given the estimated cost per cold storage freezer is RM80,000, the total cost of having a cold storage freezer in 24 government hospitals in Sabah and 21 government hospitals in Sarawak would be about RM3.6 million.

To guarantee the safety of high-risk groups in rural Sabah and Sarawak, the Ministry of Health Malaysia (MOH) has to re-evaluate whether senior citizens and people with chronic diseases can receive Pfizer-BioNTech’s Covid-19 vaccines as there are 33 deaths among those aged 80 and above being recorded in Norway in mid-Jan after being vaccinated.

MOH also needs to be aware of the more transmissible variants from the UK, South Africa and Brazil as it might impact the current vaccines’ effectiveness.

A study published in late January 2021 shows that Pfizer-BioNTech vaccine offers good protection against the UK and South African variants. While AstraZeneca vaccine offers 75 percent effectiveness against the UK variant, a recent analysis on Feb 8 indicates that it only offers 22 percent effectiveness against the South African variant.

As there is no information on how effective both Pfizer-BioNTech and AstraZeneca vaccines are against the Brazilian variant, MOH needs to take extra precautions to avoid more transmissible variants entering the country.

Therefore, to ensure the effectiveness of the vaccine distribution during this year, EMIR Research has several policy recommendations for the government to look into:

  • The Covid-19 Vaccine Supply Access Guarantee Special Committee (JKJAV) should coordinate the joint-efforts between the federal government and state governments to ensure the vaccines are distributed based on the logistics requirement from the vaccine providers. For instance, Pfizer-BioNTech vaccine has to be stored in lower freezing temperature during the delivery process;
  • The federal government perhaps could allocate at least half of the AstraZeneca Covid-19 vaccines (6.4 million out of 12.8 million doses) to both Sabah and Sarawak when the first batch arrives in the second quarter of 2021. This type of vaccine can be distributed using existing logistics and stored in normal refrigerators, which is relatively easy-to-store and easy-to-deliver compared with Pfizer and Moderna vaccines;
  • As the federal government is going to hire 3,500 extra healthcare staff to deal with the country’s worsening pandemic, some of them can be allocated to Sabah and Sarawak, giving extra helping hands in vaccine injection for the benefits of Sabahans and Sarawakians;
  • Both state governments could prioritise in providing vaccines to the rural areas that were identified as red or orange zones. Red zones are the areas with more than 41 confirmed Covid-19 cases whereas orange zones are the areas that have between 21 to 40 cases; and
  • Both state governments should provide flying doctor services in the remote areas of both states to shorten the delivery time of vaccines and allow the rural citizens in both states to receive vaccines sooner.

In conclusion, vaccine distribution in rural Sabah and Sarawak poses a logistical challenge but at the end of the day, both federal and state governments should be well-poised to implement and execute a feasible delivery plan and according to schedule

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