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Why Indonesia is prioritizing the young, not the elderly, for coronavirus vaccines

Indonesian President Joko Widodo, 59, received the Sinovac coronavirus vaccine Jan. 13, as the government launched an ambitious vaccination campaign. (Video: Reuters)
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When Indonesia, home to some 270 million people, launched its mass coronavirus vaccination campaign Wednesday, President Joko Widodo was the first in line.

At 59, he just barely made the cutoff. The country’s vice president, Maruf Amin, 77, is considered too old for an early dose.

That’s because, according to the country’s initial vaccination guidelines, vaccines are to be reserved for adults under 60 — a move that runs contrary to many other countries’ plans to vaccinate their oldest residents first.

Indonesia, an archipelago nation that spans thousands of islands, has recorded more than 860,000 confirmed cases of the coronavirus and 25,000 deaths over the past year — one of the largest outbreaks in Asia. The government has cited two major lines of thought behind its divergent approach to vaccination.

Officials are concerned over what they described as a lack of adequate research into how the CoronaVac vaccine, developed by Chinese company Sinovac, will affect older recipients. The late-stage trial in Indonesia did not include participants over the age of 60. And officials have decided that vaccinating the young could be the best way to dampen widespread transmission of the virus.

Health Minister Budi Gunadi Sadikin has said the government wants to target “those who are likely to get it and spread it.”

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In Indonesia, that means prioritizing the working-age population, who have accounted for the majority of confirmed cases in the country. The rollout is “focusing on people who have to meet lots of people as part of their work; motorbike taxi, police, military,” Budi said, according to the BBC. “So, I don’t want people to think this is about just the economy. This is about protecting people.”

Indonesia approved the Chinese vaccine for emergency use Monday after announcing that a late-stage clinical trial showed it to be 65.3 percent effective, becoming the first country outside China to approve the shot. But a Brazilian analysis released this week put the effectiveness even lower, at just over 50 percent, raising concerns in the South American country that has seen one of the world’s worst outbreaks and planned to rely heavily on CoronaVac for its inoculation campaign. Like many countries, Indonesia has secured doses of several different vaccines, including those from Pfizer-BioNTech and AstraZeneca, which will be distributed at a later date.

The government plans to inoculate some 1.5 million health workers with the Sinovac vaccine by next month, Reuters reported. Police officers, members of the military, teachers and civil servants will also be prioritized before the vaccine is offered to the broader population of adults under 60.

Indonesia’s hope is that by slowing down community spread in younger residents, they will still protect older people from being infected by relatives or close contacts. Many families in Indonesia live in intergenerational households that make it nearly impossible for older relatives to isolate from younger family members.

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Other countries, including the United States, Britain and France, have pursued a different course, opting to prioritize older residents before younger ones because they are most likely to experience severe symptoms of disease and die. Outbreaks have ravaged long-term care facilities in Europe and North America, adding to the sense of urgency in protecting the elderly first.

But so long as there is a valid epidemiological rationale, there is not necessarily a right or wrong way to go about vaccinating a population, said Amesh Adalja, a senior scholar at the Johns Hopkins Center for Health Security.

“There’s an argument to be made about the drivers of spread in a given geographic area and having them get vaccinated to achieve herd immunity in the subpopulation faster,” he said. “People think about herd immunity, and they think about the population as being homogenous, but it really isn’t. We know certain individuals drive spread more than others.”

Jennifer Nuzzo, also a senior scholar at Johns Hopkins, said that opting to start by targeting the population understood to be spreading the virus “is a reasonable argument, and it’s one that some people have argued the U.S. should be doing,” she said.

The dilemma facing public health officials as they start to roll out vaccination plans, she said, is choosing whether to use the early doses of the vaccine to reduce transmission or “to prevent people from becoming seriously ill and dying.”

If Indonesia succeeds in vaccinating a large number of people deemed likely to spread the virus, “they would see a reduction in deaths,” Nuzzo said. But, she added, it “could take a tremendous amount of time” to see those results. Other countries are prioritizing the oldest populations first in large part to see a rapid reduction in the number of deaths linked to the virus.

And an effort to reduce transmission and deaths through targeted vaccinations of those spreading the virus relies strongly, Nuzzo said, on the hope that the vaccine protects people not just from developing severe disease but from passing the virus to others — a question that lingers as experts wait to see how case numbers change as a growing number of people receive vaccine doses globally.