The Covid-19 vaccination. A matter of trust and a race against time

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(Photo: Doc. Sekretariat Presiden RI)

IO – President Joko Widodo received the country’s first Sinovac- made Covid-19 inoculation at the State Palace on January 13, 2021. His inoculation was carried out by Prof. Dr. Abdul Muthalib, deputy head of the presidential medical team. Also present at this most anticipated moment was Health Minister Budi Gunadi Sadikin, Indonesian Medical Association (IDI) Chairman Daeng Mohammad Faqih, MUI Secretary General Amirsyah Tambunan, and Head of PBNU religious council Ahmad Ishomuddin. They all received the coronavirus shot, along with health workers, celebrities and street vendors. 

Prior to Jokowi, many other heads of state have received dose of Pfizer-BioNTech vaccine, including Saudi King Salman bin Abdulaziz al-Saud (January 7, 2021), US President-elect Joe Biden (December 21, 2020), US Vice President Mike Pence (December 18, 2020), Singaporean Prime Minister Lee Hsien Loong (January 8, 2021), Israeli Prime Minister Benjamin Netanyahu (December 9, 2020), Queen Elizabeth II and her husband Prince Philip (January 9, 2021). 

Vaccination is part of the drive to prevent disease. The protection given by any Covid-19 vaccine with an efficacy level above 50% is definitely much better than not being vaccinated at all. 

The Vaccine challenges in Indonesia 

Pros and cons of receiving the Covid-19 vaccine in the community grows due to misunderstanding and misinformation spread by the anti-vaccine groups who question its safety, post-immunization side effects, halal status, profiteering even to a conspiracy theory. Compounding this was the still-simmering post-presidential election resentment and stigmatization against China. 

Regarding the safety and efficacy of the Sinovac vaccine, the Indonesian Food and Drug Monitoring Agency (BPOM) issued an emergency use permit two days before the first injection, on January 11, 2021. The Sinovac-made CoronaVac vaccine officially received approval from BPOM for Emergency Use Authorization (EUA). The standards applied by the BPOM were no different from those set by WHO, as well as the US Food and Drug Administration (FDA), and European Medicines Agency (EMA). 

Based on an internal analysis, the clinical trial result in Bandung showed that the efficacy of the Sinovac vaccine was 65.3%. This figure means the Sinovac vaccine is capable of reducing the chance of being infected by Covid-19 by 65.3% and along with it the death rate. Meanwhile, the grand plan was to achieve herd immunity in the community, as well as for people to remain productive socially and economically. Herd immunity can only be achieved if the vaccination coverage is high and evenly distributed. 

The efficacy was lower than the clinical trials result in Turkey (91.25%) and Brazil (78%). However, recent findings suggest that, in average, efficacy in Brazil is lower, at 50.4%. This difference may be caused by many factors, as for differences in epidemiological conditions in each country. But most importantly, the efficacy figure was higher than WHO standard, which requires efficacy level above 50%. It is worth noting that efficacy is the percentage reduction in a disease in a group of people who received a vaccination in a clinical trial. It differs from effectiveness, which measures how well a vaccine works when given to people in the community outside of clinical trials. 

Besides the Sinovac vaccine efficacy, immunogenicity or the ability to form antibodies to kill and neutralize viruses was assessed in clinical trials Phase three. From the trials conducted in Bandung, antibody data up to three months after injection was at 99.23%. 

Vaccine Halal status 

One aspect of public concern is the Halal status of the Sinovac vaccine, triggered by a message circulating via WhatsApp saying that the vaccine to be used in the vaccination program was made from non-halal African green monkey tissue. This news was debunked by Senior Manager of PT Bio Farma Bambang Herianto, who is also the spokesperson for the Covid-19 vaccination. The Sinovac vaccine, he said, is made from the inactivated Covid-19 virus instead of a live or weakened virus, which means that its genetic material has been destroyed. 

To convince the public that the vaccine is halal, on January 8, 2021 the Indonesian Ulema Council (MUI) issued a fatwa (religious edict) for the Sinovac vaccine. Based on the decision from the fatwa commission meeting, MUI enacted Fatwa No. 02/2021 proclaiming the vaccine “holy and halal”, meaning it can be used by the Muslim community. 

In Indonesia, vaccines must fulfil the safety, efficacy, quality and halal aspects. Past experience showed that rubella vaccination in 2018 was not optimal because many questioned its halal status. President Director of Bio Farma Honesti Basyir said that besides its safety, the halal status is of significant importance as the majority of Indonesia population is Muslim, and thus it will determine whether or not a vaccination program will be successful. Deputy Religious Affairs Minister Zainut Tauhid Sa’adi also weighed in, stating that there is no reason to doubt the halal status of the Sinovac vaccine. The “holy and halal” statement is expected to wipe out public doubts, especially those who will be vaccinated in the first Phase in January. 

The public’s level of trust toward vaccine 

Vaccine rejection is taking place in almost all countries in the world. They are known as anti-vaxxers. This group spreads false information via the internet, university seminars. The world leader who refuses to be vaccinated is President of Brazil Jair Bolsonaro. Bolsonaro said the coronavirus vaccine could have side effects, he said could turn humans into crocodiles or make women grow beards. He made the baseless claim during the launch of the country’s vaccination program on December 16, 2020. 

In a new study published by Nature Medicine, researchers in Spain, US and UK surveyed 13,400 people in 19 countries who have been hit by Covid-19. They found that 72% of respondents said they agreed to vaccination, 14% refused and 14% were undecided. When measured against the total population, the number of those who reject vaccine can reach tens of millions of people. Scientists say these findings should be a call to action for the international health community. According to Jeffrey Lazarus, research coordinator of the Barcelona Institute for Global Health, vaccine doubts point to a lack of trust in the government. 

As there are various types of Covid-19 vaccines being developed, the misinformation and disinformation surrounding the vaccine is also greater. Claire Wardle, executive director of First Draft, a nonprofit organization dedicated to educating journalists in a post-truth era, described her research team’s findings from 14 million posts on Twitter, Facebook and Instagram containing the keywords “vaccine” or “vaccination” between June-September 2020. Millions of posts in English, Spanish, and French across 41 countries were analyzed and condensed into around 1,200 posts with the highest user interactions based on the number of likes, shares, comments, and retweets. The research team found social media posts containing lies and distortion of truth designed to trigger emotional responses, such as fear or anger. 

Rachel O’Brien, head of the WHO immunization division, also expressed concern that misinformation being spread publicly including by the anti- vaccine movement could lead to reduced public participation. European Parliament Member Deirdre Clune also said that disinformation is a serious threat to democracy. But, in the midst of a pandemic, disinformation can even cost lives. 

Anti-vaccine movement in Indonesia 

Since President Joko Widodo announced that the government will make Covid-19 vaccines free for all, fake news about the Covid-19 vaccine started to emerge. To make things worse, these hoaxes continue to flood social media timelines. For example, after President Joko Widodo became the first person in Indonesia to be vaccinated, fake news started spreading that the vaccine used by the President was made in Europe. This news, which includes misleading content, was disseminated in a Facebook group and it became widespread on the internet. Misleading content like this can be used by certain groups of people to reject the government’s Covid-19 vaccination program. It is not unlikely that the misinformation, if not countered, can further sow doubt and lead to wider vaccine rejection by the community. 

Further complicating the problem, on January 12, 2021, a day before the first Covid-19 vaccination event at the State Palace, a member of the House from Indonesian Democratic Party of Struggle (PDI-P) Ribka Tjiptaning openly rejected the Covid-19 vaccine during the Committee IX hearing with the Health Ministry, where she made a number of controversial statements regarding the vaccine. Previously, a prominent Muslim cleric Nuril Arifin Husein, popularly known as Gus Nuril, also said that he did not prohibit the vaccine, but also did not recommend it. 

As for vaccination, it can be said that the community is split into three groups. First, the one that welcomes and is ready to be vaccinated. This group has felt the fatigue and severity of Covid-19 pandemic which has claimed thousands of lives and destroyed all aspects of life, both economically and socially, so they are hoping that vaccination is the way out. Second, the group that has not decided yet. This wait-and-see group wants to see whether the first batch of vaccination is safe and effective. Third, the group that doesn’t want to be vaccinated for whatever reason, even though it is proven safe and halal. This last group is very vocal on social media and can freely produce and share fake news and misleading information about vaccinations to the public. When the public is bombarded by hoaxes on social media, over time it can be ultimately considered a truth especially by uninformed lay people. 

The Health Ministry and the Indonesian Technical Advisory Group on Immunization (ITAGI), with the support of UNICEF and WHO, conducted a survey on the public’s acceptance of the Covid-19 vaccine to understand their perceptions and concerns. It involved more than 115,000 people across 34 provinces and 508 regencies/municipalities, concluding that three quarters of respondents said they had heard of the COVID-19 vaccine, and two third said they were willing to be vaccinated. However, the level of acceptance varies from province to province, driven by economic status, religious beliefs, education levels and region. [FIGURE-1] 

The most common reasons for refusal are concern about its safety (30%), effectiveness (22%), trustworthiness (13%), side effects (12%) and halal status (8%). Doubts were expressed by respondents who are afraid of needles and who had previously experienced side effects after being immunized. Respondents also hoped that political leaders would become role models, for example, by being the first to be vaccinated before mass vaccination program is to be carried out. Many respondents did not believe that Covid-19 is real or that it is highly contagious and can threaten public health. Several respondents stated that the pandemic was the product of propaganda, conspiracy, hoaxes, and/or deliberate attempts to spread fear for profit. [FIGURE-2] 

Geographically, Papua province reports the highest acceptance rate (75%), followed by provinces in Java and Kalimantan. Aceh province was the lowest (46%), along with other provinces in Sumatra, Sulawesi and Maluku.[FIGURE-3] 

The purpose of vaccination in a time of pandemic 

Health experts encourage the public not to hesitate or fear being vaccinated. Vaccination is the administration of a vaccine into the body, either through injection or drops to help the body build an immune system by producing antibodies that can protect against Covid-19 virus infection. The aim of the vaccine itself is to reduce Covid-19 morbidity and mortality, maintain productivity and minimize socio-economic impacts and bolster the general health system. The ultimate goal of Covid-19 vaccination is to create herd immunity in the Indonesian population. To realize this, the government must achieve a vaccination target of 70%. This will be an uphill battle if many people refuse vaccination. 

Herd immunity is a form of indirect protection from a disease that occurs when a large part of the population becomes immune to infection, either through vaccinations or previous infections. As a result, people who are not immune to the disease will also be protected. Herd immunity can only occur only if 70 % of the Indonesian people are vaccinated, so that it can protect the other 30 % of the people who cannot be vaccinated or are vulnerable. [FIGURE-4] 

WHO warns that herd immunity in the case of Covid-19 is highly unlikely to be achieved this year even though a vaccine is available. In general, to achieve herd immunity, vaccination coverage is needed for about 70% of the population but considering the highly contagious nature of Covid-19 and its rapid mutation, it is necessary to have a higher threshold above 90%. 

Another problem is that there is a gap in vaccination rates between rich and poor countries. Presently, poor and developing countries still find it difficult to get access to vaccines, even though WHO has established Covax as guarantor. [FIGURE-5] 

Vaccination: Between a right and responsibility 

The Jakarta provincial government has outlined provisions relating to Covid-19 prevention through Regional Regulation (Perda) No. 2/2020. It stipulates, among others, sanctions for people who refuse to be vaccinated. Article 30 states that every person who refuses a vaccination program or other Covid-19 treatment will be subject to a fine of Rp5 million. The regulation has generated controversy in the community because it was seen as too forceful without accounting for the socio-economic conditions of the community. Prof. Eddy Hiariej, Deputy Minister of Law and Human Rights said in a legal review webinar that when a person refuses to be vaccinated for rational reasons, that is his/her right, but if he/she incites others to follow suit, that is a criminal offence according to Article 160 of the Criminal Code on incitement, which also applies when a person spreads a hoax about the vaccines. 

Article 93 of Law No. 6/2018 on regional quarantines also states that every person who does not comply with the administration of a health quarantine and/or obstructs the implementation of health quarantine so as to cause a public health emergency shall be sentenced to imprisonment of maximum of one year and/or a maximum fine of IDR100,000,000. 

When we talk about human rights, there are issues of both rights and obligations of an individual toward others. This is stated in the Article 69 Paragraph 2 of Law No. 39/1999 on Human Rights, that “every human right gives rise to the basic obligation and responsibility to uphold the human rights of others, and it is the duty of government to respect, protect uphold and promote these rights and obligations”. So in the context of vaccination, it is also the obligation of every citizen to participate in maintaining public health. 

Is there a strategic solution? 

Vaccination is, by all means, not the ultimate weapon to break the chain of Covid-19 transmission, but belief in Covid-19 vaccine among global citizens will be a key factor in global efforts to curb infection rates during the pandemic. Immunization not only protects oneself, but also other people, families, all Indonesians, and even the whole world. So, vaccination is very humanistic, as opposed to individualistic. In addition, people’s perceptions of health and disease prevention are also important factors. Rational rejection needs to be handled with a rational approach. The actions of political and public leaders in getting vaccinated first deserve appreciation, but of course this is not enough to quell people’s doubts. The government and relevant agencies, including public figures and non-governmental organizations, need to be more proactive in familiarizing and disclosing information related to vaccine clinical trials, as well as spreading truthful comment through mass media and social media more frequently, focusing on specific issues. Educational content needs to be ramped up to fight massive disinformation on various platforms. At the same time, implementing health protocols remains mandatory, before and even after receiving the Covid-19 vaccine. 

The recommendation for the government is to bolster testing, tracing, and isolation, while the community has to continue practicing the 4M health protocols – mask wearing, hand washing, social distancing, and crowd avoidance. (Drg. Tince Arniati Jovina)

Drg. Tince Arniati Jovina, MKM Policy analyst of the Health Ministry Research and Development Agency. She holds a Master’s Degree in Public Health from the University of Indonesia’s Faculty of Public Health.