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Indonesia's "vaccine fatwa" reduces measles vaccination coverage

Children are vaccinated against measles and rubella in a school in Aceh, Indonesia, where the coverage is only 8%.


From Dyna Rochmyaningsih

When the bell in a primary school rang recently and the students filled the classrooms, anxious adults crowded the corridors. It was vaccine day, but many parents in this northern Sumatra village did not want their children immunized with a new measles-rubella (MR) vaccine. Some told the teacher that their children were at home and did not feel well. Others were there to make sure their children did not get jab. They whispered the reason with disgust: The vaccine "contains pork". At the time of the termination of the vaccination team, only six out of 38 students had been immunized.

Millions of parents across Indonesia have avoided the vaccine in recent months after Islamic clerics declared MR vaccineHaramIt has banned vaccine coverage and has alarmed public health experts who fear that the world's largest Muslim country could see new measles waves and more miscarriages and birth defects as a result of rubella infections during pregnancy.

Indonesia has long used a locally produced measles vaccine as part of its childhood vaccination program, but coverage was incomplete and, until recently, the country had one of the world's highest measles levels, according to the World Health Organization (WHO). As part of a WHO-led plan to eradicate measles and rubella worldwide by 2020, Indonesia switched to a combined MR vaccine last year from the Serum Institute of India in Mumbai. The Ministry of Health launched an ambitious catch-up campaign for 67 million children aged 9 months to 15 years. The first phase of 2017 on the island of Java was a success. All six provinces reached the coverage target of 95% and cases of measles and rubella fell by more than 90%.

However, the rollout for the rest of the country, which was originally planned for August and September this year, got into trouble. Just before it began, the Riau Islands' Islamic Ulama Council (MUI), an Islamic provincial authority, expressed concern that the new MRI vaccine from the central MUI in Jakarta, the highest MUI in Jakarta, was not considered "halal" or was lawfully authorized authority in such matters. The vaccinations were postponed in the letter. The news quickly spread throughout the country, causing distrust among the parents.

To save the campaign, the Ministry of Health in August called on the central MUI to issue a fatwa – a ruling under Islamic law – halalizing the vaccine. Instead, the council declared the MR vaccine Harambased on the ingredients and the manufacturing process. Like many vaccines, it is made from several components of the pig. Trypsin, an enzyme, helps to remove the cells in which the vaccine viruses are grown from their glass container. Pigskin gelatin acts as a stabilizer and protects the vaccine viruses when they are freeze-dried.

MUI tried not to block the vaccination campaign. It decided that parents can still have their children vaccinated because public health needs to be protected. "Trusted experts have explained the dangers of non-vaccination," MUI said on September 18 in a public consultation with Health Minister Nila Moeloek.

But even local clerics and confused parents have come to their own conclusions. In contrast to the success in Java, the coverage of children on other islands has reached only 68% so far, according to the Ministry of Health, which did not respond to interview requests. In some regions it is far worse – only 8% in Aceh, a province governed by Sharia law.

A spokesman for the WHO Regional Office in Jakarta points out that Indonesia is hardly the only country in which confidence in vaccination has waned, and that WHO remains optimistic about the campaign. Although the fatwa has "caused some confusion at the local level, it is indeed clear in its policy and ultimately supports vaccination," the spokesperson wrote in an e-mail. WHO is working with the Indonesian government, which has extended the catch-up until December to expand coverage.

Failure could be a major setback for public health. Measles can cause deafness, blindness, seizures, permanent brain damage and even death. The vaccination quota must be 95% to achieve herd immunity, which also protects unvaccinated people. This threshold is about 80% for rubella. At a lower level, a paradoxical effect may occur: some women, who otherwise would have had a harmless infection early in life, catch the virus during pregnancy, increase the risk of miscarriage or give birth to babies with congenital rubella syndrome – the symptoms include blindness and deafness, heart defects and mental disabilities. "We can not play with the MR vaccine," says Elizabeth Jane Soepardi, an independent health expert who served as director of disease surveillance and quarantine at the Department of Health until January. Low vaccination rates "could be a boomerang for us," she says.

There is no ready alternative; No MR vaccines have been certified Halal anywhere (Indonesia's earlier measles vaccine also did not have Halal certification, which did not hinder its use.) Arifianto Apin, a Muslim pediatrician in Jakarta who is vaccinating within the Indonesian Pediatric Society, says Education can help. Clerics in many Muslim countries have come to the conclusion that gelatin in vaccines is halal because it has undergone hydrolysis, a chemical transformation that purifies it under the name of Islamic legal concept Istihalah And in 2013, despite the use of trypsin, the Singapore Islamic Religious Council declared a halal vaccine against rotavirus. it decided that the enzyme was made pure by dilution and the addition of other pure compounds known to be istihlak. When Muslim parents learn more about the different legal views in Islam, Apin says, "they will not hesitate to vaccinate their children."

If this is not the case, the only solution is to develop a halal vaccine as soon as possible, says Art Reingold, epidemiologist at the University of California, Berkeley. Neni Nurainy, chief scientist at the Indonesian state vaccine company Bio Farma in Bandung, points out that vaccine stabilizers for nonporins, for example, exist. The company plans to investigate bovine gelatin as a replacement. However, development and clinical trials could take 6 to 10 years, she says. "In the meantime, many will get sick, and some die from preventable deaths," says Reingold.

However, the WHO refrains from religious debate and will not recommend the development of a halal vaccine. "WHO works with regulators and manufacturers to ensure that vaccines meet the highest safety and efficacy standards," said the spokesperson. "We do not rate vaccines according to other criteria."


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