If you’d asked Dani a few months ago which COVID-19 vaccine she was getting, she probably would have said the same as most other Filipinos: Sinovac. Until as recently as May, the Chinese-made vaccine—which has since become the most widely used vaccine in the world—was touted as the most preferred option among adults in the Philippines, outranking Pfizer and AstraZeneca in a nationwide survey.
Then the stories started circulating.
“I heard a lot of situations when people were vaccinated with Sinovac who became COVID-19 patients a few days after they got their jabs—not to mention people who passed away afterwards,” Dani, a 28-year-old entrepreneur from Manila who asked to remain anonymous for fear of community backlash, told VICE World News. “As someone who is not high-risk and not in the priority list for the vaccine, I’d rather wait it out and continue practicing COVID-19 safety protocols rather than get a jab from a brand I don’t trust.”
The Philippines is one of several Southeast Asian countries that, due to socioeconomic barriers and limited supply of Western products, has had to rely heavily on Chinese vaccines throughout the pandemic. Cambodia, Indonesia, Malaysia, and Thailand have all received millions of doses of Sinovac from China since December, many donated as part of a COVID-19 Vaccines Global Access (COVAX) initiative that aims to help developing countries inoculate their populations against the virus, and many others purchased using loans offered by Beijing.
China has, in turn, become the single biggest global exporter of COVID-19 vaccines, delivering over 943 million doses worldwide. But with a number of those recipient countries now being overrun by fresh and devastating outbreaks, and as hundreds of fully vaccinated citizens become infected with virulent new strains, faith in Sinovac has started to spiral.
Many experts maintain that one shot of Sinovac, which has an observed efficacy rate of 51 percent against symptomatic SARS-CoV-2 infection and 100 percent against severe COVID-19 and hospitalization, is better than no vaccine at all. But in some of the world’s most vulnerable countries, the message isn’t getting through.
People are reluctant to put their faith in what they’ve come to view as an inferior product. And in a region where vaccine hesitancy is already rife—due to a range of factors including religious propaganda, distrust in governments and poor public health messaging—such endemic skepticism poses a number of problems for public health.
Last month, just weeks after the World Health Organisation (WHO) approved Sinovac for emergency use, Indonesian officials reported that more than 350 doctors and medical workers who’d been inoculated with Sinovac had since contracted COVID-19. At least 10 died.
Weeks later, Thailand’s health ministry announced that more than 600 medical workers who’d received two doses of Sinovac had been infected with COVID-19, amid a surging outbreak fuelled by the highly contagious Delta variant. A groundswell of doctors and Thai citizens called for front-line medical workers to be given a booster shot of an mRNA vaccine, like Pfizer, to protect them against more-contagious variants of the virus, while a leaked Thai ministry memo revealed that an unnamed official was discouraging authorities from doing so because such a move would be “admitting that the Sinovac vaccine is not effective.”
Eventually the ministry changed its advice to suggest that Sinovac be used only as a first vaccine dose, and that an AstraZeneca shot be administered as the second—the first publicly announced mix-and-match of a Chinese vaccine and a Western-developed shot. Cambodia followed suit. Weeks later, amid a surge of infections, the government announced that it would start offering AstraZeneca booster shots to citizens already vaccinated with Sinovac.
Much of the criticism directed at Sinovac hinges on the fact that it is an “inactivated vaccine,” developed from dead virus particles, whereas an mRNA vaccine uses proteins to trigger an immune response. The mRNA vaccines for COVID-19 have been found to provide better protection than their inactivated counterparts.
All this has contributed to changing sentiment toward Sinovac. Over the past few weeks, the tide has continued to turn away from Chinese-made vaccines in Southeast Asia and more toward Western alternatives. Malaysia’s health ministry said the country will stop administering Sinovac once its current supply runs out, after it secured about 45 million doses of Pfizer. Singapore announced that only people who’ve had Pfizer or Moderna shots would be counted in the city state’s vaccine tally, while those who’ve received Sinovac would be excluded. And according to sources who spoke to Caixin magazine, even China is planning to offer free jabs of Pfizer as a booster for those who have already received locally-made vaccines.
In the Philippines, the health department recently announced that the public would not be told in advance which vaccine brands would be available at inoculation centres, after people queued from 2AM at a site they believed was offering Pfizer. Anecdotes, stories, and news reports from across the region have cast a spectre of fear around Chinese shots. And many, it seems, aren’t willing to take the risk.
“I was about to get my jab around a month ago, I was already in line, but when I heard it was Sinovac, I stepped out of the line,” Dani told VICE World News. Hours after sending that message, she received her first dose of Russia’s Sputnik V vaccine, which has not been approved by WHO but was found to have a 91.6 percent efficacy rate. Explaining her choice, Dani said, “I’d rather be on the safe side.”
In certain other parts of the world, this skepticism is nothing new. Yuen, a 48-year-old resident of Hong Kong, told VICE World News that his aversion to Chinese-made vaccines has been informed by a lifetime of experience.
“There is a saying in Hong Kong: Never trust anything made in China to go inside your body,” he said. “That means food, it means cookware, and it absolutely means a highly sophisticated vaccine that I am depending on to protect me from death.”
Yuen, who asked to remain anonymous for fear of being punished for criticizing China, elected to receive a dose of Pfizer, the only other vaccine available in Hong Kong. It is by far the more popular option. Professor Lau Yu-lung from the WHO’s Technical Advisory Group for Immunisation and Vaccine Preventable Diseases told the South China Morning Post last month that demand for Pfizer shots in Hong Kong had outstripped that of Sinovac by a rate of four to one. A recent study conducted in the city showed the former produced 10 times more antibodies after two doses.
Experts have raised similar questions around how well Sinovac fares in the vaccine arms race, particularly against the Delta variant. Chinese state media, meanwhile, has stridently defended the country’s domestic vaccines in the face of negative press.
Following reports of 350 Indonesian medical workers testing positive for COVID-19, Wei Sheng, a professor at the School of Public Health of Tongji Medical College of Huazhong University of Sciences and Technology, told China's state broadcaster CCTV that according to the results of the latest trials, Sinovac was still effective against the Delta variant. State-run outlet the Global Times further suggested that insufficient public health management and an overrun medical system may have contributed to Indonesia’s infections, and that some of the medical workers might have even contracted the virus before getting a Sinovac shot but did not show symptoms until the inactivated virus in the vaccine attacked their immune system.
The damage to public faith in China’s vaccine has already been done, though. Questions about data deficits, the vaccine’s relative inefficacy and a sharp uptick in worrying anecdotes and news reports have created a perfect storm for Sinovac skepticism.
It’s a “complicated issue,” according to Dr. Jin Dong-Yan, a virologist at the University of Hong Kong's department of biochemistry. Dr. Jin noted that while there is also some skepticism toward the Pfizer and Moderna vaccines, it’s less common. And this, he told VICE World News, could be put down to a number of contributing factors.
“[It] might come from mistrust of China and Chinese products, lack of transparency, lack of strong phase 3 trial data or real-world data, relatively low efficacy, relatively high incidence of breakthrough infection, or just misinformation,” he said. In some cases, he added, anti-China sentiment, or “Sinophobia,” plays a role. “If you don't like China, neither will you use Sinovac. This happens in Vietnam, Hong Kong, and elsewhere.”
Yuen, for his part, claimed his position was not so much from a political stance as a general mistrust of “anything designed and made in China.”
“We have seen too many shoddy goods and poorly built structures from China that have failed, sometimes catastrophically,” he said. “So, given that I had a choice, I opted out of the ‘Brand China’ vaccine.”
For him, it’s not a matter of being “pro-democracy and therefore anti–Chinese vaccines,” and he’s not of the opinion that information coming out of China should automatically be discounted as fabricated or false. But he does believe that the government’s claims deserve some scrutiny.
“I don’t deny that good medical advice and good science can be done in China; I am less certain that it is always done,” he said. “And in something as high-stakes as the international vaccine race, there would be too much political pressure on it to say [the vaccine] was perfect regardless of the reality.”
In short, Yuen suggests that China could have a geopolitical agenda when it comes to Sinovac and its global vaccine rollout. And he isn’t the only one who’s suspicious of the country’s motivations.
It’s in the Asia-Pacific that Sinovac has found its biggest foothold. More than half of the vaccine doses donated by Beijing globally have been distributed to countries across the region—many of which, notably, are now battling severe outbreaks of the Delta strain. But the long arm of China’s vaccination program has extended to low- and middle-income countries all over the world.
A far-reaching global vaccine rollout that Chinese President Xi Jinping labelled the “Health Silk Road” has already delivered hundreds of millions doses of vaccines to the international community—including five countries in South Asia, 12 in Western and Central Asia, 27 in Africa, and 15 in Latin America. Nations like Brazil, Mexico, Pakistan, South Africa, and Turkey have all received large shipments of Sinovac, in a gesture that many have viewed through the prism of vaccine diplomacy: an attempt by China to curry favour and cast itself as a responsible global health leader.
“If you don't like China, neither will you use Sinovac. This happens in Vietnam, Hong Kong and elsewhere.”
An additional benefit for China, some have suggested, is that the donated and loan-purchased vaccines may further cement recipients’ allegiances to Beijing—a projection of soft power dressed up as public health altruism. And the proof may be in the pudding. A recent report by the Think Global Health organisation found that of the 72 countries to which China has pledged doses, all but two are participants in its Belt and Road Initiative.
“China is using vaccine donations to further elevate the Belt and Road Initiative in bilateral relations,” the report stated. “Preceding or immediately following many donation announcements, Chinese ambassadors and high-ranking officials including President Xi Jinping have met with counterparts in recipient countries to discuss deepening or expanding bilateral cooperation.”
That report also suggested that a potential motivation for Chinese vaccine donations could be to solidify or incentivise support for Beijing’s contentious positions on Hong Kong, Taiwan, Tibet, and Xinjiang. The authors pointed out that Caribbean countries like Guyana and Dominica reaffirmed their commitments to the “One China Policy” after receiving donations.
If the Delta and other variants continue to rattle faith in Sinovac, however, it could do serious damage to China’s vaccine diplomacy strategy—particularly as many governments turn to Western vaccine manufacturers.
“It's up to the governments to decide whether they will still use Sinovac,” said Dr. Jin, “[but] the Chinese do have the responsibility to improve their existing products and to develop better next-generation vaccines. This is the only way that they can accomplish their diplomacy goals and contribute more substantially to bringing the end to the pandemic.”
There’s another, more troubling consequence of Sinovac skepticism and anti-China sentiments, though: namely, that they’re fanning the flames of anti-vaxxer propaganda and disinformation, and dissuading people from getting the jab at all, particularly in countries with low vaccine uptake.
A recent report by Yatun Sastramidjaja and Amirul Adli Rosli at the ISEAS-Yusof Ishak Institute, in Singapore, found a “worrying” amount of anti-vaccine propaganda on social media platforms like TikTok, specifically in Indonesia. And according to the Anti-Slander Society (MAFINDO), a body working to fight misinformation in the country, one of the most influential groups of anti-vaxxers are those with an anti-Chinese bias.
“Bolstering the anti-vaccine claims of religious micro-influencers is the fact that Indonesia’s vaccination programme has relied predominantly on the Sinovac vaccine from China,” the ISEAS report states. “This allows anti-vaccine propagandists to exploit the anti-Chinese bias sentiments traditionally nurtured among Indonesia’s conservative Muslims, embellish fears about the ‘foreign threat’ posed by China to Indonesia’s geopolitical and economic interests, and question the quality of ‘second-rate’ products made in China.”
Indonesia, the current epicentre of the pandemic in Asia, is one of the biggest buyers of Sinovac vaccines in the world, with almost 90 percent of vaccine doses offered in the country made by the Chinese manufacturer. Yet according to an online tracker from the University of Oxford, just 6.5 percent of the country’s population are fully vaccinated against COVID-19.
Other high-risk countries reflect similar trends. In Thailand, where more than 60 percent of vaccine doses received so far have been made by either Sinovac or Sinopharm, just 5.2 percent of the population is fully vaccinated. That country is currently being ravaged by its worst COVID-19 outbreak to date, and last month large throngs of protesters took to the streets to condemn the government’s slow vaccine rollout while demanding that they buy mRNA vaccines to replace Sinovac. It is also the most vaccine-hesitant nation in Southeast Asia.
Last month, an online article published by the Center for Strategic and International Studies observed that “vaccine hesitancy [in Thailand] has increased rapidly in the lead-up to the government’s nationwide vaccine rollout, with willingness to receive vaccinations decreasing from 83 percent to 63 percent between January and May.
“Public distrust of the Thai government has exacerbated this vaccine hesitancy,” the article noted, “especially with regards to government-procured vaccines from China.”
Dr. Jin said that this accelerating shift away from Chinese-made vaccines, particularly in countries with low vaccine uptake, is worrisome.
“They are saving lives [in those countries]; the benefits outweigh the harms or risks,” he said. “Just like AstraZeneca or Johnson & Johnson, they [Chinese vaccines] are effective but imperfect. In places where people have no other options than Sinovac, they should still be vaccinated with Sinovac first.”
While clinical trials indicate that Sinovac is an inferior vaccine—a large phase three trial in Brazil showed that two doses had an efficacy of 51 percent against symptomatic SARS-CoV-2 infection, compared to as much as 95 percent from Pfizer—it’s safe, it’s cheap, and in poorer countries that are less able to access Western equivalents, it’s better than nothing.
There is also some fortifying real-world evidence that Sinovac is more effective than some of its detractors have suggested. Dr. Sophon Iamsirithavorn, deputy director-general of Thailand’s Disease Control Department, said that of about 700,000 medics who were mostly fully inoculated with Sinovac vaccine, only 880 were infected with COVID-19, according to the Bangkok Post. Of the seven who died, five were not vaccinated, one had received just one dose of the vaccine, and one was fully inoculated.
“In places where people have no other options than Sinovac, they should still be vaccinated with Sinovac first.”
It’s also worth noting that an efficacy of 51 percent, while relatively low, is not as fickle as it might sound.
“Sinovac is very safe,” said Dr. Jin. “It is sufficiently effective to earn the validation from WHO for emergency use. However, it is less effective than the mRNA vaccines on the market.”
His advice is that if people can get Pfizer, they should. But if they have no other option, they should be vaccinated with Sinovac.
Some are better-positioned than others, of course. Unlike in the Philippines, where Dani says “citizens are not given much choice,” Hong Kongers like Yuen have the luxury to pick and choose. And unless China upgrades its vaccines to combat the more contagious COVID-19 variants that are currently taking the world by storm, Sinovac’s popularity in such places is sure to slide.
“Sinovac is very safe … It is sufficiently effective to earn the validation from WHO for emergency use. However, it is less effective than the mRNA vaccines on the market.”
In other countries, though—particularly poorer countries—the effective but imperfect vaccine remains an important weapon in the fight against coronavirus. And even Yuen concedes that if he had no other option, he’d roll up his sleeve for a Sinovac jab.
“I am less concerned that it will damage me and more concerned that it would not be effective, thus ruining my chances of getting an effective shot,” he said. “If it were Sinovac or nothing, I would choose the former.”
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