Jakarta, Indonesia – In the UK, the first person to receive a COVID-19 vaccine outside of trial conditions was a 90-year-old retiree. In Canada, the first beneficiary was only slightly younger, at 89 years old. In Germany, a 101-year-old nursing home resident was in the lead.
But in Indonesia, the country most affected by the virus in Southeast Asia with 836,718 confirmed cases and 24,343 deaths, the government has chosen an unorthodox vaccination strategy that does not take the elderly into account at all.
In the first phase, which begins Wednesday and continues through to the end of March, 1.3 million health care workers and an additional 17.4 million public service workers – police, soldiers, teachers and bureaucrats – will receive injections free of CoronaVac, the vaccine developed by Chinese company Sinovac Biotech. After that, it will be working adults.
“Indonesia is targeting the productive age of 18 to 59 instead of the elderly because we have not completed phase three clinical trials for people in this age group with the Sinovac vaccine,” said to Al Jazeera, spokesperson for the Ministry of Health, Dr Nadia Wikeko. “We are still awaiting a review from the BPOM (the Indonesian Food and Drugs Control Agency) to see if the vaccine can be used safely for people over the age of 60.”
Many citizens support the strategy.
“Because older people in Indonesia mostly stay at home, the risk of getting infected is lower than that of people of working age,” said Putu, a 56-year-old Balinese woman who, like many Indonesians, has only one name. “So if young people get vaccinated first, it is safe for them to visit the elderly.”
But experts are skeptical.
“We know that older people who have already been vaccinated in China and the Middle East have responded to vaccines as well as younger ones,” said Kim Mulholland, professor of vaccinology at the London School of Hygiene and Tropical Medicine based in the University of Melbourne. “The argument that the elderly should not be vaccinated because they were not included in the trials in Indonesia is not valid.”
Indonesia’s strategy is the reverse of accepted wisdom on vaccination, with medical experts saying the first groups to be vaccinated should be frontline health workers, then the elderly.
“Seniors, especially those who are frail or living in long-term care facilities, have been disproportionately affected by the COVID-19 pandemic,” a recent study published in The Lancet, the leading medical journal in the world. “Safe and effective vaccines are eagerly awaited in this population.”
Mulholland puts it this way: “If you look at all the studies done in every country in the world, the evidence overwhelmingly shows that the biggest risk factor for becoming seriously ill from COVID-19 is age. Even in Indonesia, which has a young population, the largest number of deaths are people over the age of 60. “
Data released by the Indonesian Ministry of Health supports this argument. People over 60 make up only 10% of Indonesia’s population but 39% of deaths from COVID-19.
“So it makes me think about what my Indonesian colleagues told me: that what the Indonesian government could really try to do is achieve herd immunity by vaccinating young adults who are the most powerful spreaders of the disease. Mulholland said.
“But the problem with this strategy is that there is no evidence to suggest that vaccinations prevent recipients from acquiring and transmitting the disease. Effective vaccines have only been shown to prevent recipients from getting sick. “
The wrong vaccine?
Indonesia is one of six countries where Sinovac, a Chinese pharmaceutical company, has conducted phase three clinical trials for its experimental injection CoronaVac. Some 1,620 volunteers have joined trials which began in August, with the government securing 125 million doses of the vaccine and an option to get 100 million more doses, of which 18 million have already been delivered.
In December, the country extended its bets by placing firm orders for hundreds of millions of additional doses from vaccine makers AstraZeneca, Novavax and Pfizer. It also announced its intention to develop and produce its own COVID-19 vaccine by mid-2021.
But CoronaVac is the only vaccine that has received regulatory approval, and the only one already shipped in large numbers to Indonesia.
“I think Sinovac is a good vaccine for this country because the one from Pfizer has to be frozen at -70 ° C and we don’t have ‘freeze chain’ logistics across Indonesia,” said the Dr Panji Hadisoemarto, epidemiologist at the University of Padjadjaran in Java. “But with the Sinovac vaccine, you can store it in a cold chain, which we have in Indonesia.”
“Another advantage of using Sinovac is that it is an ‘inactivated’ vaccine,” said Panji, using the term to describe vaccines that contain dead virus particles instead of living ones. “This is the type of vaccine that we use all the time in Indonesia for vaccination campaigns. They don’t require a lot of training to be administered.
But Dr Dicky Budiman, an epidemiologist who helped lead the team that formulated Indonesia’s strategic response to SARS, HIV, avian flu, swine flu, tuberculosis and malaria, says that Sinovac is the last vaccine he would choose.
“I would choose the first AstraZeneca because it can also be stored in a refrigerator like the one in Sinovac and they have a great track record unlike Chinese vaccine makers,” he said.
Budiman’s second choice – vaccines from Pfizer and Moderna – are more difficult to transport, but contain messenger RNA technology that makes the vaccine flexible and able to cope with new mutations in the virus.
“Even a small mutation will have a significant impact on the effectiveness of a vaccine strategy and 40,000 COVID-19 mutations have been discovered,” he said. “But Sinovac’s vaccine doesn’t have vacuum flexibility, so it would be the last one I would choose.”
He added, “We have a proverb in Indonesia ‘Tidak ada rotan, akar pun jadi’. It means “make do with what you have – even if it isn’t good”. This is what is happening with the rapid antibody tests in Indonesia, ”he said, referring to the epidemiological tool that was misused to screen domestic passengers at Indonesian airports last year. . “Now they are starting over with the vaccine. They already have millions of Sinovac vaccines, so they’re going to use them. “
It’s the economy
Working-age adults will also be a priority in the second phase of Indonesia’s immunization campaign – a grand plan to immunize 181.5 million people, or about 67% of the country’s 273 million people, within a timeframe. 15 months.
This has fueled speculation that Indonesia’s vaccination strategy is based purely on economic considerations.
“It is clear that the decision to target people of working age is linked to the development of the economy,” said Ajib Hamdani, president of the financial and banking division of the Indonesian Association of Young Entrepreneurs.
“But the decision on the allocation of vaccines is also linked to demographics,” he explained. “In Indonesia, we have a much larger proportion of people of working age than in developed countries. The government is therefore right to make young adults a priority, because if it does not maintain the health of this age group, it will later create much more serious problems for the country.
He added: “We recognize that the number one problem with the pandemic is health, not the economy. But with this vaccination policy, we have high hopes that it will solve both at the same time. “
Fithra Faisal Hastiadi, an economist at the University of Indonesia and spokesperson for the Ministry of Commerce, expressed similar sentiments.
“When you talk about public health, you also talk about economics because public health is a function of the economy,” he said. “There is no real difference between the two.
“Some say that when you put more emphasis on public health, the economy will suffer and vice versa. But we cannot restore public health if we do not restart the economy. So in that sense the government is trying to do both.
Hastiadi believed the vaccination strategy would get millions of Indonesians back to work.
“If you look at the most unemployed sectors, they are tourism, transport and logistics. These are also the sectors that have the greatest multiplier effect in terms of economic productivity. So if people are vaccinated and can return to work in these sectors, we can achieve President Jokowi’s goal of a full economic recovery in 2021. ”
But a faster-than-expected economic recovery may provide little comfort to the thousands of Indonesians who have lost elderly parents to COVID-19, or the tens of millions of people who live in intergenerational households.
There has been no confirmation of when the over 60s will receive their blows. Health Minister Budi Gunadi Sadikin said on Tuesday that they should wait for the Pfizer and AstraZeneca inoculations as they have been tested on elderly people, Rakyat Merdeka reported.
The first supplies are not due until April and Dr Budiman believes the deployment may not take place until the last quarter of 2021.
Mulholland of the London School of Tropical Medicine believes the long wait will result in thousands more deaths among older people in Indonesia.
“It is quite plausible that young people who are vaccinated could still contract the disease, have no symptoms and bring it home,” Mulholland said. “If this is the case, vaccinating young adults will not slow death rates.”