A decision to take a vaccine is not a political feat, a civic duty, a moral imperative, or evidence of one’s intellectual capacity. It is fundamentally a medical decision. The choice of whether to receive a COVID-19 vaccine does not make one more or less intelligent, more or less patriotic, more or less worthy of constitutional rights, or more or less concerned about one’s fellow man. Already, narratives are being established that though vaccination is optional, constitutional rights via a state of emergency will remain suspended unless everyone submits to the jab. Implicitly, it is being dangerously suggested that those who choose not to make the personal medical decision to get vaccinated deserve to be denied services, promoting the misplaced idea that not taking the shot makes one more of a danger to society than he or she has been for the entire year of the COVID-19 pandemic. Wall to wall media focus on taking the jab has turned COVID-19 vaccinations into a celebrity and politics-driven campaign, couching vaccinations as a battle of statistics evidentiary of which country and political leader is doing the best job in a touted race to save humanity. When narratives such as these are attached to personal medical decisions, it blurs the lines between medicine and the need for informed consent, and external campaigns urging compliance irrespective of physician consultation and assessment of one’s personal circumstances. There is tremendous fear in the society over the prospect of taking experimental COVID-19 vaccines, though clinical trials suggest that serious adverse effects may be rare. But that fear should come as no surprise for a number of reasons. COVID-19 has been billed as the virus everyone should be afraid of, and world leaders, including those here at home, have used fear as a primary device in the quest to compel adherence to pandemic protocols. Once fear is embraced as a convenient tool to achieve objectives in a pandemic, it is a genie that you cannot simply order back into the bottle. Further, with so much yet unknown about the virus and the long-term effects of vaccines approved for emergency use, fear within the general population is an inevitability. Well before COVID-19, many Bahamians have been indifferent toward their illnesses and the need to be consistent with prescription regimens, which continues to pose challenges for healthcare providers. A large segment of the population trusts herbal and home remedies for maladies, and vaccine uptake for seasonal illnesses such as the flu, remains low each year. In short, resistance to a COVID-19 vaccine has cultural underpinnings in addition to new fears brought about by reports of adverse reactions, the pressure of a mass vaccination exercise being tied to economic restoration, and pervasive distrust of governments and of those who speak for them. Vaccine hesitancy should not be ignored, demonized, belittled or suppressed with threats of sanctions, restrictions and discrimination. It instead should be approached within the context of an unprecedented time that must be guided by science and medicine, and not by precipitousness or the politics of the day. As the British Medical Journal in its February 26 editorial asserts, tackling the reasons for vaccine hesitancy requires engagement, understanding, and trust. ‘It is okay to opt out’ Infectious disease specialist and Clinical Director of Infectious Disease at Doctors Hospital Dr. Charlyon Bonimy, told Perspective in an interview this past weekend that the decision to vaccinate should be patient-centered, with an understanding of what COVID-19 vaccination is observed to accomplish, which is to reduce the likelihood of hospitalizations and deaths. He explained, “Vaccination presents another arm by which to support the effort of decreasing severity of illness and hospitalizations. As a matter of fact, the primary measure of the vaccines was not to prevent transmission. “The primary measure in the vaccine research looked at hospitalizations and decreasing severity of illness and death.” Bonimy, who also manages COVID-19 cases in both the private and public sector, and is a consultant physician at Princess Margaret Hospital (PMH), painted the backdrop of the devastating global impact of COVID-19, its atypical complications such as stroke and heart attacks, its potential to worsen chronic illnesses, and its often mysterious long-term effects. He noted, “What unfortunately gets lost is the collateral damage that COVID has had that is not reported, of those people who don’t have COVID but they require medical care, and unfortunately that care is delayed or limited because resources are taken away like bed space or staff, due to the overwhelming attention and resources needed to care for COVID cases.” Bonimy affirmed that across the vaccine spectrum, research has shown a “significant reduction” in the risk of hospitalizations and deaths among the vaccinated, and that the side effect profile has been fairly consistent. He added, “The truth is, these vaccines have never been used or studied in this amount of people before, and despite the stringent protocols involved in their development, there still exists a huge amount of fear. “Even though right now we are hearing that numbers for [serious adverse reactions] are small and may not be related, it certainly should not be ignored. It calls for concern that in the midst of a pandemic, there are countries who feel that the risk of giving this vaccine outweighs its potential benefits.” Bonimy was referring to European countries that have temporarily suspended their rollouts of the AstraZeneca vaccine due to concerns about blood clots and death in some vaccinated individuals. The specialist indicated, “It really and truly is a lot for the Bahamian people to consider in its totality. All of us must look at our own individual circumstances and be able to weigh out the risk versus benefits as we know them to be. “As a healthcare community, we have been able to identify those most at risk of being hospitalized and dying of COVID — and remember that is the underlying theme — and so our decision to vaccinate may be based on determining that the benefits outweigh the risks. “If you don’t fall within the high risk groups, or perhaps there isn’t enough medical data on people who have been vaccinated based on one’s age or unique medical circumstances, in the context of lack of evidence and supposed safety concerns, I think it is honestly fair to say it is okay to opt out, and that it is okay to defer vaccination. “But I think in doing so, whether vaccinated or not, we must always continue to be responsible and try to live a healthy lifestyle, try to get your underlying conditions under control, and continue to take precautions to protect others. “Don’t make the decision because Dr. Bonimy decided to get vaccinated or because some politician decided to get vaccinated, and at the same time, don’t decide not to take a vaccine because someone said not to take it. We all must make a decision that’s best for us and our own circumstances.” These decisions, Bonimy asserts, are best made between patient and physician. He stressed, “We must use our healthcare providers to help guide that decision making. Go over the benefits and the risks of this vaccination with them, and whenever possible, that decision to vaccinate or not should be patient-centered, and that way when we do make our decisions, we limit the amount of fear and regret that we have. “At the end of the day, you do have a certain population of people who might not benefit from a vaccine, and when I say might not benefit, I mean that the risk of them being hospitalized is lower than the potential side effects. “This is a medical decision because we are talking about putting something in somebody at the end of the day, it is a bit invasive, and so it certainly should come down to guidance from the medical community with the underlying premise being someone’s health. “I would not put a blanket statement out there and say ‘vaccinate everybody’. I do not think that makes sense. I think at the end of the day, we as physicians are to first do no harm, and in that, we have to make sure we weigh the risks and the benefits of all of our decisions.” Bonimy said in his discussions with patients, concerns and hesitation generally center around the length of time the vaccines have been studied, ideas about an underlying evil associated with the vaccines, and government distrust. He said there are also others who do want to be vaccinated and who recognize their risks, but who prefer to wait for now. Bonimy acknowledged, “People are scared, and they do not want to be critiqued or chastised because they decided not to take a vaccination.” In response to the narrative that opting not to be vaccinated inherently makes you a threat to your fellow man, Bonimy said, “You’re not. “Again, this goes back to what is the purpose of the vaccine. And the purpose of the vaccine is to complement the public health measures of wearing your mask, social distancing, et cetera. “And should you get COVID, [the purpose] is trying to prevent you from having some untoward effect from it.” Reports of serious adverse effects The Medical and Healthcare Products Regulatory Agency (MHRA) of the United Kingdom reports that as of February 28, 9.7 million doses of the AstraZeneca vaccine had been administered in the UK. To track and analyze reports of adverse reactions to drugs and vaccines, the MHRA employs a Yellow Card reporting system utilized by healthcare providers and the general public. The MHRA advises that a reported adverse reaction “does not necessarily mean that it was caused by the vaccine, only that the reporter has a suspicion it may have. Underlying or previously undiagnosed illness unrelated to vaccination can also be factors in such reports”. As of February 28, the MHRA received 194 reports of spontaneous anaphylaxis (severe allergic reaction) associated with the AstraZeneca vaccine. It also received 275 suspected adverse drug reaction (ADR) reports for the AstraZeneca vaccine wherein the patient died shortly after taking the vaccine. The agency indicated that most suspected deaths were of the elderly or of those with underlying medical conditions. MHRA said, “Usage of the AstraZeneca has increased rapidly and as such, so has reporting of fatal events with a temporal association with vaccination however, this does not indicate a link between vaccination and the fatalities reported. Review of individual reports and patterns of reporting does not suggest the vaccine played a role in the death. “A range of other isolated or series of reports of non-fatal, serious suspected ADRs have been reported. These all remain under continual review.” The United States Centers for Disease Control (CDC) tracks its ADRs via its Vaccine Adverse Event Reporting System (VAERS), also utilized by healthcare providers and the general public. The CDC notes in its disclaimer for the system that, “While very important in monitoring vaccine safety, VAERS reports alone cannot be used to determine if a vaccine caused or contributed to an adverse event or illness. The strengths of VAERS are that it is national in scope and can quickly provide an early warning of a safety problem with a vaccine.” VAERS reports are thought by some to represent just a fraction of all suspected incidences in the population. Over 100 million vaccine doses have been administered in the US thus far. As of March 13, VAERS received 684 reports of suspected deaths from the Pfizer/BioNTech vaccine, and 704 suspected death reports from the Moderna vaccine. The majority of suspected deaths for both vaccines were of those aged 65 and older, and many reports were of individuals in all age groups who died shortly after taking the vaccine. For the Pfizer/BioNTech vaccine, there were 170 reports of severe allergic reactions and 46 reports of thrombosis (blood clots). There were 84 reports of severe allergic reactions for the Moderna vaccine, and 22 reports of thrombosis. Reports of serious adverse reactions to the newly introduced Johnson and Johnson vaccine were not listed as of Saturday. The MHRA said it received 227 UK reports of fatal ADRs to the Pfizer/BioNTech vaccine, and 194 reports of anaphylaxis or anaphylactoid reactions, an incidence it described as “very rare”. Chairperson of the COVID-19 vaccine consultative committee Dr. Merceline Dahl-Regis, in a February 4 address, said that the monitoring of adverse effects would be among four steps in the country’s vaccination process, but further details have not been provided. Such a system is key to enabling The Bahamas to develop its mechanisms, as exists in other countries, to determine when or if a vaccination program should be halted if concerns arise about suspected serious adverse effects. In its February 26 guidance to healthcare practitioners, Public Health England (PHE) gave advice on vaccination for individuals including those on blood thinners, and immunocompromised individuals including those with HIV, and those who have scheduled immunosuppressive therapies. Director of the National HIV/AIDS and Infectious Disease Program Dr. Nikkiah Forbes told us that protocols do exist for such patients, as well as for the monitoring of vaccine recipients for a period immediately after inoculation, in the event of a severe allergic reaction. PHE advised, “It is not yet known whether vaccination will stop people from catching and passing on the virus and as no vaccine is completely effective, some people may still become infected with COVID-19 despite having been vaccinated, although this should be less severe.” Mixed views on vaccination In recent interviews with Perspective, residents who are battling with long-term effects of COVID-19, including a nurse and physician, offered mixed views on receiving a COVID-19 vaccination. Camille Smith, 59, said she plans to take the vaccine when it becomes available to her and was also advised to do so by her physician, since a childhood accident left her without a gallbladder, an organ that is thought to play an important role in the body’s immune system. Royal Bahamas Defence Force marine Orentress Smith, 38, said he “absolutely” plans to take the vaccine as soon as it becomes available to him. The healthcare professionals we spoke to registered doubts and concerns. A nurse at PMH for 19 years, Judyann Johnson, 56, suffered severe illness due to COVID-19, has diabetes as an underlying condition, and has suffered significant “long hauler” effects. She said back in January, “It is your personal choice. The nurses nor the doctors know the long-term effects of COVID nor of the vaccine. “I am not comfortable taking the vaccine. I would have to see someone first who had [COVID] and who is experiencing my [long-term] issues because you don’t want to take something and you are going from being almost out of the woods, to being back in the woods.” Speaking prior to the announcement that the viral vector AstraZeneca vaccine would be provided to The Bahamas, Dr. Cara Dorsette-Pena, a senior health officer in the Rand Memorial Hospital’s internal medicine department on Grand Bahama, also expressed concerns. Continuing to work through her long hauler complications, Pena said of marketed vaccines, “I believe more testing could have been done in terms of the long-term side effects of it. “I haven’t seen any data that says persons who had COVID also got the vaccines, so I am a little hesitant. I would rather my body mount a response naturally before I get a vaccine not knowing how it could affect me, especially after having all these complications now with COVID. “I would hope that the governing bodies do the necessary research, if they could hold off longer until more trials can be done, to see what the effects are, especially in persons who have other comorbidities. “Our population is so special in terms of the way we deal with things. We believe in bush medicines as a cure-all for instance. And if persons were to get vaccinated and have any effects, what do you tell them to prepare for, because most vaccine [manufacturers] are not necessarily claiming the reports of deaths. “There is not enough evidence to say these vaccines cannot elicit such a response in persons with uncontrolled hypertension for example, or uncontrolled diabetes, heart failure, patients with all three of these, or persons with cancer. Our population is so special that we cannot just say, ‘here, we are going to give you this vaccine and this should work for you because it worked in [other population groups]. “I would hope the governing bodies pay particular attention to our population, our needs, the fact that there is no rush in it, especially since our cases have been more controlled. “I just pray that we do the right thing.”


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