- To eradicate measles, Indonesia undertook one of the largest vaccination campaigns in history. In parts of the country, the campaign faced huge hurdles related to misinformation and lack of understanding.
- Islamic religious authorities have provided different guidance but Islamic councils in Singapore and Malaysia both backed the use of vaccines as did the top authorities in Jakarta.
- Indonesia is laying the groundwork to manufacture a Chinese-developed vaccine in vast quantities but may have to overcome anti-vaxxer sentiments in some of the country’s more conservative areas.
Faced with constant and runaway measles outbreaks, Indonesia embarked on one of the largest vaccination campaigns in the world and had to overcome anti-vaxxer feelings and religious opposition to vaccines.
Now, faced with a runaway COVID-19 pandemic it is looking to repeat that feat and overcome the same challenges.
Before 2017, Indonesia’s measles problem was enormous with an average of 12,000 cases every year. The Muslim-majority country launched a massive vaccination campaign with a target of eliminating the disease by 2020.
Progress was fantastic until ignorance, confusion and misinformation led many parents to refuse to vaccinate their children.
In just two years, 68 million children under the age of 15 were vaccinated. In the island of Java, which includes the capital of Jakarta, the first phase of the campaign was a huge success and vaccination coverage rose from 75% to 95%.
The second phase of the campaign, through 2018, was supposed to reach 32 million children in 28 provinces but it was marred by challenges, according to a team led by Paul Pronyk, who now heads the Child Survival and Development program for Indonesia at Unicef.
One big stumbling block in parts of the country, particularly the island of Sumatra, was vaccine hesitancy, a problem exacerbated when some conservative Muslim groups withdrew their support for vaccination.
In late 2018, rumors began circulating around Indonesia’s Muslim-majority population that the vaccine for measles and rubella (MR) contained elements of pork, forbidden under Islamic law. Some conservative Islamic clerics declared the vaccine forbidden or haram and vaccine coverage rates fell sharply as a result.
The vaccine, made by the Serum Institute of India in Mumbai, had never been declared halal by the top Islamic clergy in the country, which first asked that vaccinations be postponed.
The vaccine does contain several porcine components including the enzyme trypsin, used to separate the cells used to grow viruses from glass containers, and gelatin, used as a stabilizer and a byproduct of the skin of pigs.
An earthquake in Lombok and a tsunami in Sulawesi in 2018 only added to the challenges.
“Vaccine hesitancy is on the rise globally and Indonesia’s experience is cautionary,” notes Pronyk’s paper. “More data are needed to understand the interplay between religion, politics, personal beliefs, and economics that influence individual and community decisions around vaccination.”
Eventually, Indonesia’s top religious authorities, the MUI, made it clear that immunization is needed but the message was muddled by the time it made its way to parents and local clerics. As a result, while almost all children in the island of Java were vaccinated against MR only two-thirds, on average, were vaccinated in other islands. In the conservative province of Aceh, governed by Sharia law, fewer than one in 10 children were vaccinated.
There is no MR vaccine that has been declared halal, or permitted, but there is some precedent for vaccines being designated as such.
The Islamic Religious Council of Singapore said in 2013 that a rotavirus vaccine was halal, even though it included a minuscule amount (0.0001%) of the enzyme trypsin and not in the end product itself while the “overwhelming percentage” of the elements in the vaccine are pure. The council noted that the “use of trypsin is limited to the inoculation, propagation and harvesting of the vero cells, which host the virus” and that “Islam highly advocates for its followers to seek treatment for all illnesses”.
The Singaporean Council made a point of saying that Islam encourages prevention and quoted the Hadith, a part of the Koran in support of the idea of prevention in health care: “Whoever consumes seven pieces of Ajwah dates every morning, s/he would be protected from poison and black magic on that day.”
Five years later, in Malaysia, the National Fatwa Council said government-issued diphteria vaccines are halal while Datuk Dr. Zulkifli Ismail, the chairman of the vaccine advocacy programme Immunise4Lfe, noted that there “is nothing in Islam or any other religion that says you cannot give vaccinations to children”.
Impressive progress towards vaccination
Still, the progress in Indonesia has been impressive and the country is on its way towards meeting its target of 95% coverage against MR but the delay in the progress and the occasional stumbles – there was one outbreak of 800 cases in 2018 that killed 72 children – highlight the dangers of vaccine hesitancy.
These dangers are particularly significant now that the COVID-19 pandemic continues to spread around the world.
As of August 5, Indonesia had recorded almost 117,000 cases and 5,452 deaths. If this count is accurate, Indonesia’s 270 million people have fared relatively well with fewer cases than much less populous countries like Canada with 40 million or Philippines with 105 million, according to Johns Hopkins University.
Indonesia is the world’s fourth most populous country and there are worries that there may not be enough COVID-19 vaccines to meet the demand of its huge population. Based on calculations from the Indonesian Coordinating Minister of Economic Affairs, the Southeast Asian country needs to secure a minimum of 340 million ampoules of a COVID-19 vaccine to treat around 170 million people, about two-thirds of the population, and achieve some kind of herd immunity.
The COVID-19 pandemic has given new urgency to the need to overcome this type of vaccine hesitancy in Indonesia and around the world.
A vaccine for Indonesia by Indonesia
Avoiding vaccine hesitancy will be an important chore for health authorities that are putting in place the capacity to manufacture and distribute a vaccine manufactured by PT Bio Farma. The state-owned vaccine manufacturer is now seeking volunteers to test out its vaccine candidate.
Padjajaran University in Bandung, West Java, and the Health Ministry will be assisting in the clinical trial of the vaccine, said Arya Sinulingga, an aide to State-Owned Enterprises Minister Erick Thohir.
Bio Farma is using a vaccine developed by China’s Sinovac Biotech, which provided the formulation, technology and active pharmaceutical ingredients (API). Sinovac is also testing out its vaccine in Brazil, Chile, Turkey and Bangladesh.
Bio Farma’s president director Honesti Basyir has outlined plans to distribute 40 million doses of the vaccine per year as soon as approval goes through. There is the possibility to expand distribution capacity to 250 million doses a year.
“Our production facility can handle up to 2 billion dosages, so we should be able to produce sufficient quantities of vaccine by ourselves,” said Basyir, during a presentation to the House of Representatives in April.
Sinovac is optimistic about the chances that its vaccine will be effectively. Sinovac’s CEO Yin Weidong believes it has “more than an 80% chance of success” based on data collected so far.
But Bio Farma is not putting all of its eggs in one basket.
It is also working on a novel vaccine with the Eijkman Institute for Molecular Biology based in Jakarta, but that will not be ready for distribution until the end of 2021 at the earliest.
The company has also applied to the Coalition for Epidemic Preparedness Innovations (CEPI) to hold trials and build capacity in the country of another possible vaccine.
South Korea’s Genexine Inc. is also keen to do a trial for its COVID-19 vaccine candidate in Indonesia. It will tap its Indonesian partner PT Kalbe Farma Tbk for the trials there, which will likely involve their joint venture company, PT Kalbe Genexine Biologic.