Vaccine hesitancy in Indonesia
Authors: Paul Pronyk, Anung Sugihantono, Vensya Sitohang, Thomas Moran, Sowmya Kadandale, Sam Muller, Charlie Whetham, Robert Kezaala
Journal: The Lancet Planetary Health (2019)

Indonesia is currently undertaking the world's largest vaccination campaign against measles and rubella (MR). Between 2017 and 2018, over 68 million children aged 9 months to 15 years were targeted for MR immunisation, with the country committed to eliminating measles and controlling rubella and congenital rubella syndrome (CRS) by 2020.1WHOStrategic plan for measles elimination and rubella and congenital rubella syndrome control in the South-East Asia region 2014–2020. WHO, 2015http://www.searo.who.int/immunization/documents/sear_mr_strategic_plan_2014_2020.pdfDate accessed: November 13, 2018Google Scholar Measles and rubella are serious public health challenges. Indonesia's coverage with the first dose of measles has plateaued at 75%,2WHOUNICEFIndonesia: WHO and UNICEF estimates of national immunization coverage. WHO, 2018http://www.who.int/immunization/monitoring_surveillance/data/idn.pdfDate accessed: November 13, 2018Google Scholar and there were over 12 000 reported measles cases annually in the 5 years leading up to the campaign.3WHODistribution of measles cases by country and by month, 2011–2018.http://www.who.int/immunization/monitoring_surveillance/burden/vpd/surveillance_type/active/measles_monthlydata/en/Date accessed: November 13, 2018Google Scholar An outbreak of 800 cases in a single district earlier this year resulted in 72 child deaths.4Indonesia declares end to deadly Papua measles outbreak.The Straits Times. 2018; https://www.straitstimes.com/asia/se-asia/indonesia-declares-end-to-deadly-papua-measles-outbreakDate accessed: November 13, 2018Google Scholar Rubella remains endemic as the vaccine has not yet been introduced, with an estimated 15–20% of pregnancies being susceptible to CRS.5Basic health research survey (Riskesdas). Research and Development Board (Balitbangkes), Ministry of Health, Government of Indonesia, 2007http://labdata.litbang.depkes.go.id/riset-badan-litbangkes/menu-riskesnas/menu-riskesdas/147-rkd-2007Date accessed: November 13, 2018Google Scholar Indonesia has invested nearly US$100 million in the campaign with the aim of achieving 95% coverage. The first phase in 2017 was a major success, with over 35 million children vaccinated on the main island of Java. With coverage nearing 100%, measles cases dropped sharply.3WHODistribution of measles cases by country and by month, 2011–2018.http://www.who.int/immunization/monitoring_surveillance/burden/vpd/surveillance_type/active/measles_monthlydata/en/Date accessed: November 13, 2018Google Scholar Targeting 32 million children across 28 provinces, the second phase of the campaign, which launched in August, 2018, has been marred by challenges. A recent outbreak of vaccine-derived polio in Papua New Guinea has required the bundling of oral polio vaccine with MR in adjoining Papua, posing added logistical challenges in Indonesia's most remote province. An earthquake in Lombok in August, 2018, and a tsunami in Sulawesi in September, 2018, contributed to local interruptions. And in the initial weeks of the 2018 campaign, some important Muslim groups withdrew support, leading to suspensions in dozens of districts. The campaign, originally planned for 2 months, has twice been extended to a 5-month horizon to reach the 95% target. Resumption has been particularly slow on the conservative and highly populated island of Sumatra, home to two-thirds of unvaccinated children, with coverage as low as 10% in one province. As the campaign ends, nearly 10 million children remain unimmunised. Concerns exist regarding the potential fallout for routine immunisation, which would confound Indonesia's impressive reductions in child mortality. Indonesia has not turned away from its investment. The government and partners are working to ensure parents are informed by influencers, including religious leaders, that childhood vaccination is their duty and the right of every child. Videos featuring Indonesia's Muslim leaders have been recorded to persuade parents of the importance immunisation. However, addressing concerns requires careful, nuanced, and sustained communication from the right influencers before trust can be regained. Vaccine hesitancy is on the rise globally6Coombes R Europe steps up action against vaccine hesitancy as measles outbreaks continue.BMJ. 2017; 359: j4803Crossref PubMed Scopus (21) Google Scholar and Indonesia's experience is cautionary. Political leaders and health ministries must continue dialogue with religious scholars and communities to generate both a common understanding and unambiguous messaging regarding the benefits of immunisation. Leadership from the Organisation of Islamic Cooperation is important. More data are needed to understand the interplay between religion, politics, personal beliefs, and economics that influence individual and community decisions around vaccination. Additional resources and capacity are needed to ensure that the best practice from behavioural science underpin local engagement strategies. The health and survival of Indonesia's children depend on it. This online publication has been corrected. The corrected version first appeared at thelancet.com/planetary-health on April 9, 2019 This online publication has been corrected. The corrected version first appeared at thelancet.com/planetary-health on April 9, 2019 We declare no competing interests. Correction to Lancet Planetary Health 2019; 3: e114–15Pronyk P, Sugihantono A, Sitohang V, et al. Vaccine hesitancy in Indonesia. Lancet Planet Health 2019; 3: e114–15—In this Comment corrections have been made to remove discussion of vaccine manufacturing. One reference has also been removed. These corrections have been made as of April 9, 2019. Full-Text PDF Open Access