Indonesian vaccine "fatwa" lowers measles immunization rates | Science

When the bell rang recently in an elementary school and students filled clbadrooms, worried adults invaded the corridors at the school. 39; outside. It was the day of the vaccination, but many parents in this village in northern Sumatra did not want their children to be vaccinated with a new measles, rubella and rubella vaccine. Some told the teacher that their children were at home and did not feel well. Others were there to make sure their children would not get the sting. They murmured reason with disgust: The vaccine "contains pork meat". At the time of the departure of the vaccination team, only six out of 38 students had been vaccinated.

Millions of parents in Indonesia have avoided being vaccinated in recent months after Islamic clerics declared the MR haram vaccine . "or prohibited under Islamic law because pork components are used in its manufacture.As a result, vaccine coverage has dropped, alarming public health experts who worry that the largest country in the world World, with a Muslim majority, could see new waves of measles and more miscarriages and conbad malformations resulting from rubella infections during pregnancy.According to the World Health Organization (WHO), the country was producing measles vaccine as part of its childhood immunization program, but the coverage was uneven and until recently, the country was one of the most affected by measles in the world.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 World Health Organization (WHO). by the Institutional Serum Te of India in Mumbai The Ministry of Health has launched an ambitious catch-up campaign targeting 67 million children aged 9 months to 15 years. The first phase, in 2017 on the island of Java, was a success. The goal of coverage was 95% and cases of measles and rubella dropped by more than 90%.

But the deployment to the rest of the country, originally scheduled for August and September of this year, has been difficult. Just before beginning, the Indonesian Council of Scholars (MIU) of the Riau Islands, a provincial Islamic body, said it was concerned that the new MR vaccine had not been certified "halal" or by the central MUI of Jakarta, the highest in the United States. authority in the matter. The letter requested that vaccinations be postponed. The news spread quickly throughout the country, raising the mistrust of parents.

To save the campaign, the Ministry of Health lobbied in August on the central MUI for it to promulgate a fatwa (Islamic law ruling) declaring the halal vaccine. Instead, the board declared the MR haram vaccine based on its ingredients and its manufacturing process. Like many vaccines, it is made from several porcine components. Trypsin, an enzyme, helps to separate cells in which vaccine viruses develop from their glbad containers. The gelatin obtained from pig skin serves as a stabilizer, protecting the vaccine viruses when they are lyophilized.

MUI has given the trouble not to block the vaccination campaign. He decided that parents could still vaccinate their children, given the need to protect public health. "Trusted experts have explained the dangers of not being vaccinated," said MUI, in a message he repeated at a public consultation on 18 September with the minister of health. Health, Nila Moeloek.

But local clerics and confused parents drew their own conclusions. In contrast to the success experienced in Java, the coverage of children from other islands has only reached 68% so far, according to the Ministry of Health, which has not responded to requests for medical care. ; interviews. In some areas, the situation is much worse: in Aceh, for example, a province governed by sharia (barely 8%).

A spokesman for the WHO country office in Jakarta said that Indonesia was not the only country to have lost confidence in vaccination says that the WHO remains optimistic about the campaign. Although the fatwa "has created some confusion at the local level, it is actually clear in its directive and ultimately favorable" to vaccination, the spokesman said in an email. WHO is collaborating with the Indonesian government, which extended the catch-up campaign until December, in order to extend coverage.

Failure could be a serious setback for public health. Measles can cause deafness, blindness, convulsions, irreversible brain damage and even death; Immunization coverage must be 95% to achieve group immunity, in which even unvaccinated people are protected. This threshold is about 80% for rubella. At lower levels, a paradoxical effect may occur: some women who would otherwise have a harmless infection early in life now catch the virus during pregnancy, increasing their risk of miscarriage or giving birth to babies with conbad rubella syndrome. – whose symptoms include blindness, deafness, cardiac malformations and mental disabilities. "We can not play" with the MR vaccine, says Elizabeth Jane Soepardi, independent expert in public health, who until January was director of disease surveillance and quarantine at the Ministry of Health. A low vaccination rate "could mean a boomerang for us," she says.

There is no alternative ready. no MR vaccine has been halal certified anywhere. (The previous Indonesian measles vaccine also did not have a halal certificate, which did not prevent its use.) Arifianto Apin, a Muslim pediatrician in Jakarta, who advocates immunization in the Indonesian Pediatric Society, believes that education can help. Religious in many Muslim countries have concluded that the gelatin in the vaccines is halal because it has undergone hydrolysis, a chemical transformation that purifies it according to an Islamic legal concept called istihalah. And in 2013, the Islamic Religious Council of Singapore declared a halal rotavirus vaccine despite the use of trypsin; he ruled that the enzyme had been purified by dilution and addition of other pure compounds, known as istihlak. If Muslim parents discover the various legal points of view within Islam, Apin adds, "they will not hesitate to vaccinate their children"

. If this does not happen, the only solution is to develop a halal vaccine as soon as possible. Says Art Reingold, an epidemiologist at the University of California at Berkeley. Neni Nurainy, chief scientist of the Indonesian vaccine company Bio Farma in Bandung, notes that there are, for example, anti-swine vaccine stabilizers; the company plans to start studying bovine gelatin instead. But development and clinical trials could take 6 to 10 years, she says. "In the meantime, many people will get sick and some may die in a preventable way," says Reingold.

However, the WHO stands apart from the religious debate and will not recommend the development of a halal vaccine. "WHO is working with regulators and manufacturers to ensure that vaccines meet the highest safety and efficacy standards," said the spokesman. "We do not evaluate vaccines on any other criteria."