Vaccines are among the most effective public health tools,[footnote]1|1. Shattock, A. J., Johnson, H. C., Sim, S. Y., Carter, A., Lambach, P., Hutubessy, R. C. W., Thompson, K. M., Badizadegan, K., Lambert, B., Ferrari, M. J., Jit, M., Fu, H., Silal, S. P., Hounsell, R. A., White, R. G., Mosser, J. F., Gaythorpe, K. A. M., Trotter, C. L., Lindstrand, A., O'Brien, K. L., … Bar-Zeev, N. (2024). Contribution of vaccination to improved survival and health: modelling 50 years of the Expanded Programme on Immunization. Lancet (London, England), 403(10441), 2307–2316.[/footnote] but like any medical intervention, they come with rare risks. In Singapore, the Bacillus Calmette-Guérin (BCG) vaccine has been a mainstay in preventing tuberculosis since the 1950s.[footnote]2|2. Ministry of Health Singapore. “Update on Tuberculosis Situation in Singapore, 2024.” Accessed December 22, 2024. https://www.moh.gov.sg/newsroom/update-on-tuberculosis-situation-in-singapore-2024.[/footnote] While overwhelmingly safe, very rare but severe complications such as disseminated BCG infection — or BCGosis — can occur, and they result in life-threatening illness, long-term disabilities, and heavy financial costs for families. How might policymakers in Singapore address gaps in its vaccine injury compensation or protection programmes?
Rare but severe complications
While the BCG vaccine is generally well-tolerated by the majority of infants, local complications such as abscesses or lymphadenitis (lymph node swellings) occasionally occur. In extremely rare instances, the vaccine can lead to widespread complications, including BCGosis, with an incidence estimated at 1 to 3.4 per million doses.[footnote]3|3. Lee, P. P. “Disseminated Bacillus Calmette-Guérin and Susceptibility to Mycobacterial Infections: Implications on Bacillus Calmette-Guérin Vaccinations.” Annals of the Academy of Medicine, Singapore 44, no. 8 (2015): 297–301.[/footnote] A 15-year retrospective review conducted by the KK Women’s and Children’s Hospital identified 10 cases of severe outcomes of BCG vaccination, including BCGosis and other adverse reactions requiring long-term treatment or hospitalisation.[footnote]4|4. Ong, R. Y. L., Y. A. Chong, K. Y. Lee, S. H. Chan, and B. T. Khor. “Disseminated Bacillus-Calmette-Guérin Infections and Primary Immunodeficiency Disorders in Singapore: A Single Center 15-Year Retrospective Review.” International Journal of Infectious Diseases 97 (2020): 117–125.[/footnote]
At present, no formal recourse is available for vaccine-related injuries involving routine childhood immunisations. This raises questions about where families affected by rare but serious vaccine-related outcomes can turn to for financial and emotional support.
Why vaccine injury protection matters
Globally, the ethical and policy rationale for vaccine injury protection lies in the understanding that individuals bear a small personal risk for a public good. When such risks result in serious harm, the state arguably has a moral and social obligation to provide fair and timely redress.
During the Coronavirus Disease 2019 (COVID-19) pandemic, the Singapore government rolled out a comprehensive National Vaccination Programme (NVP) for COVID-19, and the Ministry of Health (MOH) introduced the Vaccine Injury Financial Assistance Programme (VIFAP).[footnote]5|5. Ministry of Health Singapore. "COVID-19 Vaccine Injury Financial Assistance Programme." Accessed December 22, 2024. https://www.moh.gov.sg/seeking-healthcare/overview-of-diseases/communicable-diseases/covid19/covid19-vaccine-injury-financial-assistance-programme.[/footnote] The VIFAP provides financial assistance to Singapore citizens, permanent residents and long-term pass holders who experience serious side effects related to the COVID-19 vaccines received under the NVP. Notably, no equivalent system exists for injuries arising from the 14 vaccines in the National Childhood Immunisation Schedule (NCIS),[footnote]6|6. Ministry of Health Singapore. “Nationally Recommended Vaccines.” Accessed December 22, 2024. https://www.moh.gov.sg/seeking-healthcare/overview-of-diseases/communicable-diseases/nationally-recommended-vaccines.[/footnote] despite some (measles and diphtheria) being legally mandated under the Infectious Diseases Act.
Without a comprehensive compensation system:
Affected families may face high out-of-pocket costs or have to resort to protracted and complicated legal processes.
Public trust in vaccination programmes may erode, especially in a global climate of rising vaccine hesitancy.[footnote]7|7. Soveri, A., L. C. Karlsson, J. Antfolk, O. Mäki, L. Karlsson, H. Karlsson, S. Nolvi, M. Karukivi, M. Lindfelt, and S. Lewandowsky. "Spillover Effects of the COVID-19 Pandemic on Attitudes to Influenza and Childhood Vaccines." BMC Public Health 23, no. 1 (2023): 764.[/footnote]
Questions of equity arise, particularly for low-income households with limited means to absorb medical and caregiving costs.
Lessons from Asia: Japan, Taiwan, and Thailand
To identify possible solutions, we look to the vaccine injury compensation frameworks in place in Japan, Taiwan, and Thailand. Each of them offers insights into causality assessment, funding mechanisms and administrative models for Singapore.
Japan: Flexibility and shared responsibility
Japan’s Health Damage Relief System, governed by the Immunisation Act since 1976, provides wide-ranging compensation for injuries resulting from routine and special vaccinations.[footnote]8|8. Enami, Takeshi, and Hiroko Otsubo. “The Current State of Immunization Administration in Japan.” Japan Medical Association Journal 53, no. 2 (2010): 111–117.[/footnote] In particular, its review board uses a flexible causality standard — compensating even if injuries are only “probably related” or “indeterminate.” Long-term support — such as pensions and rehabilitation — is available for severe cases. Funding is shared between the government and pharmaceutical companies, reflecting a model of co-responsibility.[footnote]9|9. Kang, C. R., Y. J. Choe, and S. J. Yoon. "COVID-19 Vaccine Injury Compensation Program: Lessons Learned from a Review of 10 Implementing Countries." Journal of Korean Medical Science 39, no. 13 (April 8, 2024): e121.[/footnote]
Taiwan: Vaccine premium and broad coverage
Taiwan’s Vaccine Injury Compensation Programme (VICP) includes a wide range of vaccines — from routine and imported to self-paid and off-label.[footnote]10|10. Taiwan Centers for Disease Control. Vaccine Injury Compensation Program Overview. Accessed December 22, 2024. https://www.cdc.gov.tw/Uploads/archives/81f39836-ca2f-433c-8a72-b7d6d3e2cd81.pdf.[/footnote] Funded via a small per-dose premium, the programme is both financially sustainable and transparent.[footnote]11|11. Chen, C. S., and T. C. Liu. "The Taiwan National Health Insurance Program and Full Infant Immunization Coverage." American Journal of Public Health 95, no. 2 (2005): 305–311.[/footnote] It uses a multidisciplinary review board and allows appeals, balancing fairness with administrative efficiency. Compensation is available even for cases deemed indeterminate, with built-in appeals processes.
Thailand: Expedited no-fault support
Thailand offers a broader no-fault compensation scheme under its National Health Security Office, which was extended to include vaccine injuries during COVID-19. Compensation is tiered and can be paid as preliminary support before final adjudication, which ensures timely support for affected individuals.[footnote]12|12. National Health Security Office. No-Fault Compensation for Medical Injuries (Article 41): Understanding Thailand's Approach. Bangkok: NHSO, 2021. Accessed December 20, 2024. https://stream.nhso.go.th/assets/portals/1/files/64-6_NoFaultCompensation%28Article41%29_Book%28Eng%29.pdf.[/footnote] Although its payouts are more modest, its speed and simplicity foster trust and accessibility.
Potential directions for Singapore
Singapore may not need to replicate any one system but could consider several feasible policy adaptations. These might include a tiered framework, differentiated by severity of harm and supported by sustainable financing.
Minor reactions: For mild, self-limiting reactions (e.g. fever, rashes), compensation is likely unnecessary. Instead, public education and post-vaccination counselling remain key.
Moderate injuries: For reactions requiring hospitalisation or specialist care (e.g. severe allergic responses), a lump-sum payment system could help offset immediate costs. Causality assessments could follow WHO’s “balance of probabilities” framework, with a multidisciplinary panel making determinations based on available evidence.[footnote]13|13. World Health Organization. “Adverse Events Following Immunization (AEFI).” Accessed December 22, 2024. https://www.who.int/groups/global-advisory-committee-on-vaccine-safety/topics/aefi/aefi.[/footnote]
Severe/Long-term disabilities: For permanent disabilities or chronic treatment needs, a two-pronged model could be considered: (1) One-time compensation to cover acute care, surgeries or home modifications; and (2) Ongoing government support integrated with disability assistance programmes, including access to allied health services, long-term rehabilitation and caregiver subsidies.
This approach mirrors Japan and Taiwan’s systems, where long-term needs are addressed within existing social safety nets.
Opportunity to strengthen public confidence
Singapore currently lacks a dedicated compensation framework for non-COVID-19 vaccine injuries. As immunisation programmes expand and vaccine awareness grows, this policy gap becomes increasingly significant. By studying regional and international models and assessing what might work in the local context, Singapore has the opportunity to strengthen both equity and public confidence in vaccination. The question of how to design such a framework (balancing fairness, sustainability, and administrative simplicity) remains open to policy dialogue, interdisciplinary analysis and ethical reflection. We need to ensure that those who accept the societal good of vaccination are not left unprotected when rare adverse events occur.
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