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January 11, 2021

Asia

INDONESIA: Vaccination program will have to overcome three hurdles

BY Bob Herrera-Lim

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( 5 mins)
  • The Sinovac vaccine has received the needed regulatory approvals, paving the way for the formal start of the vaccination program this week.
  • The first vaccine supply will go to 2.6 million recipients.
  • Although the initial distribution to provincial-level governments seems to have been uneventful, three challenges face the vaccination effort: the “last mile” of the cold chain, registration of recipients and overcoming vaccine hesitancy.

 

The CoronaVac vaccine of Sinovac Biotech Ltd. obtained emergency use authorization on Monday and halal certification last Friday, paving the way for the planned start of the country’s vaccination campaign on January 13. Although Singapore was the first in the region to start vaccinations, Indonesia is the first country in Southeast Asia to approve CoronaVac, which may also be used by the Philippines, Thailand and Malaysia in volume.

Indonesia has about 3mn doses of the vaccine on hand, a substantial portion of which has already been distributed to the country’s 34 provincial health departments in the last two weeks. In most cases, they have been held in provincial storage units, but with the EUA having been issued, will now be distributed to the district level. President Joko Widodo will be the first to be symbolically vaccinated on Wednesday. The government’s goal is to vaccinate around 19 million priority recipients from January to April. This includes about 1.3 million healthcare personnel, using the current supplies, and then 17.4 million security personnel and teachers, with vaccines to be locally manufactured under license from Sinovac.

Three challenges to the vaccination effort

There will be three challenges to meeting this goal. The first is in establishing the “last mile” of the distribution process. CoronaVac requires storage at 2 – 8 degrees Celsius, and refrigeration facilities appear to have been sufficiently established at the provincial level, as well as in the larger cities, with local officials over the past week emphasizing their preparations in receiving their allocated supplies from Jakarta. However, the central government only started sending out the vaccines on 3 January, and how robust the cold chain is beyond the provincial government, whether in terms of transportation or storage, has not yet been fully established. This will likely be a challenge as distribution spreads out from the larger cities and towns. Nonetheless, the relatively forgiving temperature requirement of CoronaVac is sustaining expectations among public officials that any initial problems are manageable and that resources to address cold chain problems can be reallocated or acquired domestically within a reasonable time, unlike with the vaccines requiring substantially lower temperatures.

The second is in ensuring that the vaccine recipients are registered and can be directed to the correct health facility. Over the past two weeks, the Health Ministry had sent text messages to the first intended recipients, asking them to fill out a form using their resident identity number (NIK), which would then inform them if they had been registered or not for the program. The system will also presumably match them with the correct healthcare facility. Since 2011, Indonesians have had electronic IDs, which should facilitate this process. However, the government had also used the NIK system to deliver aid and handouts during the peak of the pandemic, but encountered problems of delays and incomplete databases.

Vaccine hesitancy could be the main challenge

The third and arguably the most difficult to forecast is vaccine hesitancy. Various surveys have been conducted, with public and non-governmental organizations reporting different numbers, sometimes depending on context. For instance, the Ministry of Health had one survey in September where 65% of Indonesians said they were willing to be vaccinated, with only 27% saying no. However, of the percentage willing to be vaccinated, only one third would do so if they were asked to shoulder the vaccination cost. Initially, former Health Minister Terawan Agus Putranto had stated that only 32 million out of the 107 million targeted for vaccination over the next 12-18 months would receive the vaccine for free, but Widodo subsequently said that no one would have to pay to be vaccinated to overcome the resistance due to cost. A private research organization, Saiful Mujani Research, reported volatile and lower numbers in December, with only 37% of Indonesians willing to receive the vaccine, 40% uncertain and 17% saying that they would not participate. These latter numbers are more consistent with perceptions in the Phillippines. Most surveys are conducted online, which increases their margin of error.

Less established is whether the government’s response to the social and health concerns about the vaccine have been sufficiently communicated to the public, and how these are affecting hesitancy. The Indonesian Ulema Council has already certified the vaccine as halal, but rumors of pork gelatin used as vaccine stabilizer have abounded. In 2018, the measles’ vaccine rate plummeted and varied greatly across the islands after reports spread that pork products were used. Other safety concerns, from fears about side effects to its efficacy, may also cause Indonesians to hold off on receiving the vaccine for weeks while they wait for anecdotal reports from the field.

Beyond these challenges with the initial campaign, the next major obstacle will be in ramping up to reach the 70 million that the government believes it may realistically be able to serve through 2022, and where many of these issues may be magnified. The succeeding capacity will be a mix of imported and domestically manufactured vaccines. According to State Enterprises Minister Erick Thohir, the raw materials for the production of CoronaVac will be delivered starting the second week of January to the locally licensed manufacturer, state-owned PT Bio Farma. This will be enough for 15 million doses although Bio Farma can currently produce 100 million doses annually, according to Thohir, and there are plans to increase the capacity to 250 million doses per year. But how the vaccination program goes in the next few weeks will reveal the mix of technical and social issues that will ultimately affect the broader vaccine rollout.