While the bell rang in the early morning in an elementary school and the pupils filled the classrooms, the anxious adults crowded the corridors outside. It was a day of vaccination, but many parents in this North Sumatra village did not want their children immunized with a new measles-rubella vaccine. Some told the teacher that their children were at home, they did not feel well. The others were there to make sure their children had not taken the shot. They whispered the reason in disgust: the vaccine "contains pig elements". When the vaccination team left, only six out of 38 students had been immunized.
Millions of parents in Indonesia have avoided the vaccine in recent months, after Islamic clerics have declared the vaccine against MR "haram"or prohibited by Islamic law because the components of the pig are used in its production.The vaccine coverage has precipitated as a result, alarming public health experts who fear that the largest country in the Muslim majority may see new waves of measles and more abortions and birth defects resulting from rubella infections during pregnancy.
Indonesia has long used a locally produced measles vaccine as part of its infant vaccination scheme, but coverage has been fragmented, and until recently, the country had one of the highest measles weights in the world. world, according to the World Health Organization (WHO). Last year, in the context of a WHO-led plan to eliminate measles and rubella globally by 2020, Indonesia switched to a combined MR vaccine, produced by the Serum Institute of India in Mumbai. The Ministry of Health has launched an ambitious collection campaign aimed at 67 million children aged 9 months to 15 years. The first phase, in 2017 on the island of Java, was a success; all six provinces reached the 95% coverage target and measles and rubella cases decreased by over 90%.
But the launch in the rest of the country, originally planned for August and September of this year, had problems. Shortly before it began, the Indonesian Council of Ulama (MUI) of the Riau Islands, a provincial Islamic institution, raised concerns that the new MR vaccine had not been certified "halal" or lawful by the Central MUI of Jakarta, the highest authority in these matters. The letter asked that the vaccinations be postponed. The news spread rapidly throughout the country, fueling the distrust between the parents.
To save the campaign, the health ministry in August put pressure on the central MUI to issue a fatwa – a sentence under Islamic law – which declared the halal vaccine. Instead, the council declared the MR vaccine haram, based on its ingredients and the production process. Like many vaccines, it is done using different pig components. Trypsin, an enzyme, helps to separate cells in which vaccine viruses have grown from their glass container. The gelatin derived from pigskin acts as a stabilizer, protecting the vaccine viruses since they are freeze-dried.
MUI has pledged not to block the vaccination campaign. He established that parents could still vaccinate their children, given the need to protect public health. "Trusted experts have explained the dangers of not being immunized," said MUI, a message reiterated in a public consultation with Health Minister Nila Moeloek on September 18.
But local clerics and confused parents drew their conclusions. In contrast to the success on Java, coverage of children on other islands has reached only 68% so far, according to the health ministry, which did not respond to requests for interviews. In some regions it is much worse: only 8% in Aceh, for example, a province governed by Sharia law.
A spokesperson for the WHO national office in Jakarta notes that Indonesia is not the only country where vaccination confidence has diminished and states that WHO remains optimistic about countryside. Although the fatwa "has caused some local confusion, it is clear in its directive and ultimately supportive" of the vaccination, wrote the spokesperson in an e-mail. The WHO is working with the Indonesian government, which extended the recovery campaign until December, to expand coverage.
Failure could be a serious stop to public health. Measles can cause deafness, blindness, convulsions, permanent brain damage and even death; the vaccination coverage must be 95% to reach the immunity of the herd, in which even the unvaccinated people are protected. This threshold is about 80% for rubella. At lower levels, a paradoxical effect may occur: some women who otherwise would have a harmless infection early in life now capture the virus during pregnancy, increasing the risk of miscarriage or giving birth to children with congenital rubella syndrome – whose symptoms include blindness, deafness, heart defects and mental disabilities. "We can not play" with the MR vaccine, says Elizabeth Jane Soepardi, an independent public health expert who until January was director of surveillance of the disease and quarantine at the health ministry. Low vaccination rates "could mean a boomerang for us," he says.
There is no ready alternative; no MR vaccine has been certified as halal anywhere. (The previous Indonesia anti-measles vaccine did not even have a halal certificate, which did not hinder its use.) Arifianto Apin, a Muslim pediatrician in Jakarta who supports vaccination within the Society Indonesian Pediatric, argues that education can be of help. Clerics in many Muslim countries have concluded that gelatin in the vaccines is halal because it has undergone hydrolysis, a chemical transformation that purifies it under an Islamic legal concept called istihalah. And in 2013, the Singapore Islamic Religious Council declared a vaccine against halal rotavirus despite the use of trypsin; established that the enzyme had been made pure by dilution and addition of other pure compounds, which is known as istihlak. If Muslim parents learn the different legal opinions within Islam, Apin says, "they will not hesitate to vaccinate their children".
If that does not happen, the only solution is to develop a halal vaccine as soon as possible, says Art Reingold, an epidemiologist at the University of California at Berkeley. Neni Nurainy, the chief scientist of the Indonesian state-owned vaccine company, Bio Farma, in Bandung, notes that non-dirty vaccine stabilizers exist, for example; the company plans to start studying bovine gelatine as a substitute. But development and clinical trials could take between 6 and 10 years, he says. "In the meantime, many will be ill and some may die avoidable deaths," says Reingold.
The WHO, however, is avoiding the religious debate and will not advise the development of a halal vaccine. "The WHO collaborates with regulatory authorities and manufacturers to ensure that vaccines have the highest safety and efficacy standards," says the spokesperson. "We do not evaluate vaccines on other criteria".