Indonesia’s big gamble: Covid-19 Vaccination strategy

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(Illustration: Agung Wahyudi/IO)

IO – President  Jokowi’s  first Covid-19 inoculation on January 13, 2021 was the start of a new strategy against the coronavirus pandemic in Indonesia, a very crucial move in overcoming the public health disaster that has been ongoing for almost a year now. The Vaccines are expected to become new ammunition that can help Indonesia, and all countries around the world, emerge from the prolonged multidimensional crisis.

With this big hope comes big questions. Can vaccines really be the weapon and life saver for the people of Indonesia? Up until now, it’s anybody’s guess.

Vaccination, on the local and global level, is aimed at achieving herd immunity — the indirect protection that happens when a population is immune either through previous infection or vaccines. In theory, herd immunity can be achieved when 70% of the total population has become immune. To achieve herd immunity on a global level, 5.5 billion people (out of a total of 7.8 billion world population) will need to be vaccinated. That means that 11 billion doses of Covid-19 vaccines would thus be needed. Consider, due to limited capacity, global vaccine production capacity can only deliver a total of 6.2 billion doses per year. This doesn’t even take into account the need for other vaccines such as those for rubella, polio, HPV, and tuberculosis and the time it takes to ramp up production. If we assume that the global capacity for Covid-19 vaccine production is only at half the capacity, vaccinating 5.5 billion people will take 3.5 years.

Amid such limitations, the hunt for a Covid-19 vaccine has become an issue in itself. Inequality may bedevil the process, as the procurement and distribution of Covid-19 vaccine is dominated by high-income countries. Low-and middle-income countries often find it difficult to purchase the vaccines to meet their domestic needs if there is no consensus on fair distribution at the global level. As a matter of fact, political tensions can even occur among the high-income countries themselves. The limited production of Astra-Zeneca vaccines for the EU has caused political tensions between EU, UK and the vaccine manufacturers. Conflicts like this might recur in the coming years if there is no mutual understanding at regional and global levels, either between countries or between countries and the manufacturers. The world places great hopes on vaccines, but it must also recognize all the current limitations. It is difficult to be realistic amid the high demand for vaccines, limited production, and complex distribution.

Target and achievement

As is the case with Indonesia. The challenge of vaccination doesn’t end with the efficacy results and the decision to issue an Emergency Use Authorization (EUA), even halal certification. Vaccination involves a much more complex process, starting from production capacity, distribution and storage, training of medical staff, systematic reporting of adverse effects, and acceptance of vaccines in the community.

To achieve the herd immunity by vaccinating 70% of its population, and judging from the rapid rate at which the infection spreads throughout the community, as well as the efficacy of the vaccine used, Indonesia is setting a target for 181 million vaccine recipients. Assuming a wastage rate of 15%, the country needs at least 426 million doses of vaccine.

Health Minister Budi Gunadi Sadikin provided assurance that the need can be met. “To date, we have secured a delivery commitment for around 600 million doses of vaccine,” he said on January 21, 2021. “This has covered 150 per cent of the target.” Currently there are four manufacturers that have collaborated with Indonesia, namely, Sinovac, AstraZeneca, Pfizer-BioNTech, and Novavac.

With such an ambitious target, and under an optimal scenario, it will take Indonesia 15 months to vaccinate 181 million of its population. This assuming that the supply of raw vaccine material from Sinovac will arrive in timely manner, the vaccine production capacity at BioFarma is at an optimal level, there is no delay in delivery from other vaccine manufacturers, and distribution to inoculation runs according to plan. It also means that, on an average, Indonesia will need to vaccinate 2 million of its population every month.

In early January, President Jokowi set a more ambitious target. “It means we have to inject 364 million doses. Hopefully it can be done within a year,” he asserted. With such lofty target, the Covid-19 vaccination program must be able to cover around 15 million people per month. Is this figure realistic?

In the initial effort to vaccinate its health workers, Indonesia still encountered significant hurdles. Of the 1.53 million health workers slated to get vaccinated, 1.5 million (98%) have been registered. However, by the end of January, only 493,000 (32.8%) health workers had received their first dose. (Figure 1)

Health Minister Budi Gunadi hopes the remaining one million health workers will have been vaccinated by the end of February. “We expect to vaccinate 500,000 health workers by the end of this month so that our target of 1.5 million health workers can be achieved by the end of February,” he said on January 30, 2021. To reach this target, extra effort is needed to administer an average of 35,714 inoculation per day. And for a second dose, 71,428 health workers will need to be inoculated daily, starting mid-February.

This optimal scenario demands both extraordinary and realistic effort amidst limited technical capabilities. Administering vaccines to 35,000 people in one day is not impossible, but it definitely requires strategic planning. Jakarta, as the area with the best infrastructure, is planning a mass Covid-19 inoculation at five locations with a capacity of 500-1,000 people per location per day. That means there are a maximum of 5,000 injections per day. Thus, in order to achieve the target of 1 million inoculations for health workers there needs to be at least seven regions with similar capacities that can carry out mass inoculations.

After February, the vaccination program will be expanded to include public servants and members of the armed force/police with an equally ambitious target within 1.5 months. And, at the end of April 2021, the inoculation will be given to all Indonesian citizens aged 19-59 years without comorbidity.

Alternative strategy

Judging from the obstacles encountered in the first month, Indonesia needs to come up with alternative strategies to make the vaccination more systematic and measurable, while addressing technical realities in the field.

First, it is difficult to have a centralized database, given the limitations of the current information system. Many complaints have been raised during the registration process for health workers  vaccination’,  directed  via WhatsApp, email and website. Apart from registration failure, many health workers were directed to vaccination sites far from where they work and with significant delay in response. This information system failure caused frustration – which may lead to chaos if it is to be scaled-up to include a larger population.

Spokesperson for Covid-19 vaccination Siti Nadia Tarmizi announced the change from online registration to manual. “No more SMS blasts,” she said, referring to the initial strategy and directing health workers to reregister for vaccinations. Data collection is now carried out through the PCare system synchronization and the PeduliLindungi application, as well as manual registration, through the Health Human Capital Information System (SISDMK). The manual data collection process seems to be the most reliable strategy for the implementation of group vaccination of public servants. As the state civil apparatus (ASN) is widely dispersed, forced centralized data collection and registration processes will only complicate implementation, especially if there is no clear definition of the public service workforce: who, in what sector, and at what level.

According to the National Civil Service Agency (BKN) data, there are 4.12 million ASN across Indonesia, dominated by ASN at the regional level (77%) and certain functional positions (51%). This indicates that the vaccination strategy for public servants would be better conducted locally, as opposed to be centralized. With almost 70% of functional ASN being teachers, a teacher database should be improved from early on, by identifying suitable locations for vaccination drive in each region. In addition, it is necessary to include honorary teachers, for the sake of fairness. However, this will require additional doses, identification of targets, and wider inclusion criteria. Second, improving the general population database. Health Minister Budi Gunadi considers General Elections Commission (KPU) data to be the most valid and accurate currently available, and could be used as the basis for estimating intended vaccine recipients. However, KPU data cannot identify targets with comorbid risks. Such data can be obtained from the Healthcare and Social Security Agency (BPJS Kesehatan) database, which covers 80% of the Indonesian population. However, such wide coverage doesn’t necessarily indicate that all health conditions are recorded in the database and there is no integration between the population database and the health database. This has implications for data filtering in the field, which must be well synchronized: who is eligible, who has the authority, and when comorbidity screening is carried out.

Third, improving local cold chain capacity. Even though Indonesia is experienced in vaccine distribution, and the Sinovac-made vaccine is compatible with the existing cold chain system, Covid-19 vaccination remains a challenge in itself due to the larger number of recipients and very tight completion deadlines. This situation is compounded by a surplus of nonCovid-19 vaccines resulting from distribution difficulty during the pandemic.

Fourth, increase public acceptance of vaccines. National survey found that only 64.8% of 112,888 respondents are willing to be vaccinated. The proportion of the population that has yet to decide whether they want to be vaccinated or not is around 27.6%. If projected on youth population, that means there are 52 million-strong young people who still need convincing. A significant hurdle that the government must tackle.

The survey data for vaccine acceptance certainly needs to be updated, to assess the extent to which the acceptance rate changes after the vaccine has received EUA and halal certification from the Indonesia Ulema Council (MUI). They should erase public doubts about vaccine safety, effectiveness and religious permissibility, which account for 60% of the reasons for vaccine rejection.

After the gover nment has mapped intended vaccine recipients, the next crucial step is how

to formulate a more targeted communication strategy for each of these groups. The current vaccine campaign is still heavy on ways to remind people about the importance of vaccines, encourage participation and provide appropriate incentives to groups who are still doubtful but show a positive attitude. In fact, the communication strategy in the group that refused to be vaccinated should be different from the one that was still in doubt. Do not use a judgmental approach against vaccine rebels but instead build a narrative that can change their mind without embarrassing them. Thus, for those who reject vaccine, a general campaign strategy should be complemented by continuous storytelling, involving opinion leaders in the group, and stirring up their emotion. (Figure 2)

Is herd immunity rational?

One million Covid-19 confirmed cases may look like a lot, but is still small (0.37%) relative to Indonesia’s total population. If it is assumed that at least 70% of the population has to be vaccinated to achieve herd immunity, with a basic reproduction number (R0) of 3 and a vaccine efficacy of 65%, achieving herd immunity is almost impossible, theory-wise. Under these assumptions, Indonesia needs to vaccinate almost its entire population, not just 181 million people.

Vaccine priority for the youth population also leaves older adults – the age group with the most at risk from coronavirus infection and death – even more vulnerable. With limited healthcare capacity and the higher risk of infection among the elderly population, healthcare facilities can be easily overwhelmed by a surge of Covid-19 patients.

Given the current situation and constraints, Indonesia needs to rethink its vaccination strategy. Instead of trying to distribute vaccines evenly, vaccination in the early phase needs to focus on the areas most affected by the pandemic while taking into account the capacity of healthcare facilities in each region. Thus, the main objective of current vaccination drive must be laid out rationally. The main goal is no longer on how to achieve herd immunity, but on how to be as efficient as possible in alleviating the burden of existing healthcare facilities.

This strategy is important because there is no single piece of evidence confirming how long the protection provided by the vaccine can last. Several scientific reports have shown that patients infected by Covid-19 can form memory B cells – immune cells that can “remember” viral proteins and trigger antibody production when exposed to the virus for the second time. Natural protection acquired in this manner can only last for eight months.

Using this assumption, a much more progressive vaccination drive is needed, because the government must be able to achieve the target within a period of vaccine-induced immunity. If it persists, herd immunity will not be achieved. For example, if it turns out that the vaccine only provides temporary protection for 10 months, and within this period the vaccination program has only covered 50% of the intended recipients, then herd immunity will be much more difficult to achieve. There will be a double target: one group gets the first dose and the other group gets the second dose – the strategy on how to do this is still unclear.

If herd immunity is a crazy idea that proves nearly impossible, the government should not rely on vaccines as the only ammunition against the pandemic. Indonesia needs non-pharmaceutical intervention, which must be carried out simultaneously, among others through social restrictions and mobility controls. This strategy, which was recently renamed Public Activity Restrictions Enforcement (PPKM), must be evaluated continuously. President Jokowi even admitted in a statement on January 31 that it is not effective. Data on people’s mobility in Java did decline, but not significantly so to make a dent on the number of confirmed cases, patients under treatment, and deaths.

The problem lies in indecisiveness and inconsistency. Concerns about economic fallout should not be a hindrance in implementing mobility restrictions. What President Jokowi said – that there is no standard formula in dealing with this pandemic – is true. “There is no ‘right strategy’. Even those who chose lockdown still see an exponential rise in cases,” he said. If we want to be consistent, vaccination to reduce the burden of healthcare facilities and mortality rate needs to be accompanied by extended mobility restrictions with more consistent implementation in the field. Loosening restrictions to allow the economy to keep staggering along, despite the devastating toll, is also not a wise option.

Vaccination is indeed very complex. The problem goes beyond negotiating and securing a vaccine supply, but also the accuracy of targeting, compliance with implementation, public acceptance, and consistency with other non-pharmaceutical strategies. Without these, we will continue to wallow in an endless pool of suffering from the pandemic. (Ahmad Fuady, MD,PhD.)

Ahmad Fuady, MD,PhD. Researcher and faculty me the Department of Community Medicine, University of Indonesia’s School of Medicine. He received his doctorate in public health from the Erasmus Univer- sity Rotterdam and is currently a guest researcher with the Department of Pub- lic Health, Era Center, the Netherlands.