As the bell rang on a recent morning at an elementary school here and pupils filled the classrooms, anxious adults crowded the corridors outside. It was vaccination day, but many parents in this North Sumatra village did not want their children immunized with a new measles-rubella (MR) vaccine. Some told the teacher their children were at home, not feeling well. Others were there to make sure their kids didn't get the jab. They whispered the reason with disgust: The vaccine "contains elements of pork." By the time the vaccination team left, only six out of 38 students had been immunized.
Millions of parents around Indonesia have eschewed the vaccine in recent months, after Islamic clerics declared the MR vaccine "haram," or forbidden under Islamic law because pig components are used in its manufacturing. Vaccine coverage has plummeted as a result, alarming public health experts who worry that the world's largest Muslim-majority country could see new waves of measles and more miscarriages and birth defects resulting from rubella infections during pregnancy.
Indonesia has long used a locally produced measles vaccine as part of its childhood vaccination scheme, but coverage has been patchy, and until recently, the country had one of the highest measles burdens in the world, according to the World Health Organization (WHO). Last year, as part 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 launched an ambitious catchup campaign targeting 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 dropped by more than 90%.
But the rollout to the rest of the country, originally scheduled for August and September of this year, ran into trouble. Just before it began, the Indonesian Ulama Council (MUI) of the Riau Islands, a provincial Islamic body, raised concerns that the new MR vaccine had not been certified as "halal," or lawful, by the central MUI in Jakarta, the highest authority in such matters. The letter asked for vaccinations to be postponed. The news quickly spread throughout the country, stoking distrust among parents.
To salvage the campaign, the health ministry in August lobbied the central MUI to issue a fatwa—a ruling under Islamic law—declaring the vaccine halal. Instead, the council declared the MR vaccine haram, based on its ingredients and manufacturing process. Like many vaccines, it is made using several porcine components. Trypsin, an enzyme, helps separate the cells in which the vaccine viruses are grown from their glass container. Gelatin derived from pigs' skin serves as a stabilizer, protecting vaccine viruses as they are freeze-dried.
MUI took pains not to block the vaccination campaign. It ruled that parents could still have their children vaccinated, given the need to protect public health. "Trusted experts have explained the dangers posed by not being immunized," MUI said, a message it reiterated at a public consultation with Health Minister Nila Moeloek on 18 September.
But local clerics and confused parents have drawn their own 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 interview requests. In some regions it is far worse—just 8% in Aceh, for example, a province ruled by sharia law.
A spokesperson for WHO's country office in Jakarta notes that Indonesia is hardly the only country where trust in vaccination has eroded and says WHO remains optimistic about the campaign. Although the fatwa "has caused some confusion at local levels, it is in fact clear in its directive and ultimately supportive" of vaccination, the spokesperson wrote in an email. WHO is working with the Indonesian government, which has extended the catch-up campaign until December, to expand the coverage.
Failure could be a major setback for public health. Measles can cause deafness, blindness, seizures, permanent brain damage, and even death; vaccination coverage needs to be at 95% to reach herd immunity, in which even nonvaccinated people are protected. That threshold is about 80% for rubella. At lower levels, a paradoxical effect can occur: Some women who would otherwise have an innocuous infection early in life now catch the virus while pregnant, raising their risk of miscarriage or giving birth to babies with congenital rubella syndrome—whose symptoms include blindness, deafness, heart defects, and mental disabilities. "We can't play" with the MR vaccine, says Elizabeth Jane Soepardi, an independent public health expert who until January was director of disease surveillance and quarantine at the health ministry. Low vaccination rates "could mean a boomerang for us," she says.
There is no ready alternative; no MR vaccines have been certified as halal anywhere. (Indonesia's previous measles vaccine didn't have a halal certificate either, which has not hampered its use.) Arifianto Apin, a Muslim pediatrician in Jakarta who advocates for vaccination within the Indonesian Pediatric Society, says education may help. Clerics in many Muslim countries have concluded that gelatin in 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 Islamic Religious Council of Singapore declared a rotavirus vaccine halal despite the use of trypsin; it ruled that the enzyme had been made pure by dilution and the addition of other pure compounds, which is known as istihlak. If Muslim parents learn about the diverse legal views within Islam, Apin says, "they won't hesitate to vaccinate their children."
If that doesn't happen, the only solution is to develop a halal vaccine as soon as possible, says Art Reingold, an epidemiologist at the University of California, Berkeley. Neni Nurainy, the lead scientist at Indonesia's state-owned vaccine company, Bio Farma, in Bandung notes that nonporcine vaccine stabilizers exist, for instance; the company plans to start to investigate bovine gelatin as a replacement. But development and clinical trials could take 6 to 10 years, she says. "In the meantime, many will be made ill and some may die avoidable deaths," Reingold says.
WHO, however, is steering clear of the religious debate and won't recommend the development of a halal vaccine. "WHO works with regulatory authorities and manufacturers to ensure vaccines have the highest standards of safety and efficacy," the spokesperson says. "We don't assess vaccines on other criteria."