Myocarditis Cases amongst Applicants for Vaccine Injury Financial Assistance Programme

Dr Tan Wu Meng asked the Minister for Health whether there is updated information as of April 2023 on (i) the number of Vaccine Injury Financial Assistance Programme (VIFAP) applications that have been received for persons presenting with cardiac conditions after COVID-19 vaccination and (ii) the number of such VIFAP cases that have undergone further retrospective review in light of subsequent updated information on COVID-19 vaccination side effects including myocarditis.

My response will also cover the matters raised in the written question by Mr Shawn Huang, which is scheduled for a subsequent Sitting. I would invite the Member to seek clarifications, if need be. If the question has been addressed, it may not be necessary for him to proceed with the question for a future Sitting.

Let me, first, give an update on the current COVID-19 infection wave. By all indications, the wave peaked about two weeks ago, at an estimated 4,000 infection cases per day. It has since subsided to about 3,000 infections per day.

The key strains circulating are XBB.1.9, XBB.1.16 and XBB.2.3 – each accounting for about a quarter of all infections. The World Health Organization (WHO) has re-designated XBB.1.16 from being a Variant under Monitoring to a Variant of Interest. There is however no evidence, internationally or locally, that any of the variants have a clear growth advantage over the others or can lead to more cases of severe illnesses. The Ministry of Health (MOH) will continue to monitor the characteristics of the various strains.

There are now over 300 patients infected with COVID-19 in our hospitals. It is a fraction of the hospitalisations at the peak of the pandemic. For the Delta wave, it was about 1,800. Now, it is about 300-plus. Nevertheless, that added a significant workload to our hospitals. We should also see the number of COVID-19 hospitalisations falling in the coming week as the infection wave subsides.

This is the first infection wave we have encountered after transiting to Disease Outbreak Response System Condition (DORSCON) Green and treating COVID-19 as an endemic disease. We have weathered through it, without imposing any further public health measures. Many members of the public, in fact, are not even aware that we are undergoing a COVID-19 infection wave. This is what we have planned for when we transited to DORSCON Green and it is another important and noteworthy milestone.

However, we can maintain this public health posture, provided we continue to take our COVID-19 vaccinations. It is of critical importance that we understand that COVID-19 did not become a milder disease just because we transit to DORSCON Green. WHO no longer declares COVID-19 as a public health emergency of international concern, but it also added that it does not mean that COVID-19 is no longer a threat. In fact, it remains a dangerous disease. But our population resilience has strengthened due to vaccinations, boosters and safe recovery from infections. These are the reasons that enabled us to treat it as an endemic disease. So, it is of critical importance that we continue to take vaccinations, based on MOH's latest recommendations, to keep the level of our resilience high.

To illustrate what I just said, let me share some data collated over the first four months of 2023.

Seniors aged 60 and above continue to be more vulnerable to developing severe illnesses if infected with COVID-19. But amongst these seniors, the incidence of severe illnesses – that is, the infected persons need to be hospitalised or require oxygen supplementation – differs, depending on the vaccination status of the individuals. So, I am going to cite some incidence rates of severe illnesses, but please bear in mind what I am about to cite are over-estimates because, these days, cases are under-reported. So, these are over-estimates. But the point in the comparison is still the same.

For those seniors 60 and above who are unvaccinated, about 7.5% of them developed severe illnesses and have to be hospitalised. For those with minimum protection, that is, three doses of mRNA or Novavax, or four doses of Sinovac, the rate of severe illnesses was about 4%, half that of those who are unvaccinated. For those with minimum protection and kept their vaccination status up-to-date – that is, most of them got themselves boosted and their last shot was less than 12 months ago – the incidence rate of severe illnesses is even lower at 3.4%. So, it is 7.5%, 4% to 3.4%.

Hence, if you are aged 60 and above or are vulnerable due to underlying illnesses, please get your minimum protection of three shots of mRNA or Novavax, or four shots of Sinovac as soon as possible, if you have not already done so. And if you have minimum protection, please take a booster every year. This will enhance your protection against the Omicron variants and minimise the risk of being infected and developing severe illnesses.

Unfortunately, despite the benefits of vaccinations, the proportion amongst seniors aged 60 and above who are updated with their vaccinations have been declining. From 58% at the beginning of this year, it has slowly declined to 50% currently. Because once they pass their 12-month mark, they are no longer updated. So, every day, every week, that number is dropping. Now, it is only 50%. So, if this trend continues, our resilience against COVID-19 will weaken over time, making ourselves vulnerable to the virus again. Falling vaccinations, even amongst the vulnerable segments of the population, is due to a few reasons.

First, there is a common thinking amongst seniors and amongst the public, "that I seldom go out of my home and hence, I do not have to take the vaccinations". This is not recommended. The current Omicron variants are highly infectious and we no longer impose social restrictions, which means that even if you do not go out of your home, it can find its way to your home through visiting family members or anyone you may come into contact with. So, it is much better to get the vaccinations and consider going out from time to time, meet friends, have coffee and join us for group exercises. It is, actually, good for your health.

Second, some seniors are also concerned about the risk of side effects if they take further vaccination shots. To date, hundreds of millions of vaccine doses have been administered globally. The incidence of severe adverse reactions is very low in Singapore, at about seven in 100,000 doses, and it is even lower at one in 100,000 doses with the latest bivalent mRNA formulations. These severe adverse reactions are mostly myocarditis, anaphylaxis, serious allergic reactions and most resolve after some treatment.

So, let me summarise what is the deal. If you belong to a vulnerable segment of the population and choose not to take vaccinations, there is a significant chance that you will get infected at some point by the Omicron variant, which can cause severe illnesses that require hospitalisation and oxygen supplementation.

If you attain minimum protection and keep your vaccination status updated through boosters, the chance of developing severe illnesses will be significantly reduced if you are infected. There is an added risk of developing a severe adverse reaction after vaccinations but that is very low, especially with the new bivalent formulations. In other words, the benefits of COVID-19 vaccines continue to far outweigh the risks and you should keep your vaccination updated. This is the recommendation of both the Expert Committee on COVID-19 Vaccination as well as Health Sciences Authority.

Specifically on myocarditis, this is a known illness associated with infections, including those by the COVID-19 virus. It can also occur, albeit at a lower probability, when taking COVID-19 vaccines, and it tends to affect young males aged 12 to 30 years old. The local incidence of vaccine-related myocarditis in this age group is low, at about one in 100,000 doses, and it is even lower at 0.1 in 100,000 doses with the latest bivalent mRNA formulations.

As of 27 April 2023, out of more than 17 million COVID-19 vaccine doses administered in Singapore, there were 160 reports of myocarditis and pericarditis linked to the vaccines. Of these cases, 32% had initial symptoms reported within one day of vaccination, another 20% reported within two days and another 24% reported within one week. The majority of cases of myocarditis from vaccination are generally mild and respond to treatment.

As of 27 April 2023, about 340 Vaccine Injury Financial Assistance Programme (VIFAP) applications are cardiology-related. Eighty-one of the applications were approved and financial assistance has been extended to the applicants. Myocarditis was picked up as a safety signal and reported in June 2021. A look-back at VIFAP applications from before June 2021 did not identify anyone with myocarditis. At present, COVID-19 vaccines are not known to be causally associated with any other cardiac conditions other than myocarditis.

I thank the Minister for his detailed answer and exposition. I declare that I am a medical doctor at a public hospital and I have seen first-hand how vaccinations has saved lives, when people are ill with COVID-19. I raise this Parliamentary Question in my capacity as a Member of Parliament.

Deputy Speaker, there are Clementi residents, fellow Singaporeans, who, early in the pandemic, underwent COVID-19 vaccination to protect themselves, their loved ones and the community. Some had applied for the VIFAP. Can I ask the Minister two supplementary questions?

Firstly, would Minister agree that if the policy intent of VIFAP is to provide goodwill financial assistance to persons whose serious side effects were assessed to be related to the vaccination, then the assessment must be based on the latest up-to-date scientific and medical understanding?

Secondly, would Minister consider that as the understanding continues to improve, older VIFAP cases should be subject to retrospective review closer to the three-year dates of limitation of claims, so that the latest up-to-date scientific and medical understanding can be applied to older cases as part of that review?

Thank you. The answer to both questions is yes. VIFAP applications have to be based on scientific and medical assessment. That is why we have an independent group of doctors who assess the VIFAP applications. And of course, if there are new understandings and/or new findings establishing the causal links of adverse reactions versus vaccines, old cases will be relooked at.