Jakarta, Indonesia – In the UK, the first person to receive a COVID-19 vaccine outside of the experimental conditions was a 90-year-old retiree. In Canada, the first recipient was only slightly younger at 89 years of age. In Germany, a 101-year-old nursing home resident came first.

In Indonesia, the country hardest hit by the virus in Southeast Asia with 836,718 confirmed cases and 24,343 deaths, the government has adopted an unorthodox vaccination strategy that ignores the elderly at all.

In the first phase, which starts on Wednesday and lasts until the end of March, 1.3 million healthcare workers and a further 17.4 million public sector workers – police, soldiers, teachers and bureaucrats – will receive free vaccinations with CoronaVac, which is made by Chinese Sinovac Biotech company. After that, they will be working adults.

“Indonesia is aiming for a productive age of 18 to 59 years instead of the elderly as we have not yet completed the third stage clinical trials for people in that age group with the Sinovac vaccine,” said Health Ministry spokeswoman Dr. Nadia Wikeko, across from Al Jazeera. “We’re still waiting for the BPOM (Indonesia’s Drug and Food Control Agency) review to see if the vaccine is safe for people over 60 to use.”

Many citizens support the strategy.

“As the elderly in Indonesia mostly stay at home, they are less likely to get infected than people of working age,” said Putu, a 56-year-old Balinese woman who, like many Indonesians, has only one name. “So if younger people are vaccinated first, they can safely visit older people.”

However, experts are skeptical.

“We know that older people who have been vaccinated in China and the Middle East have responded to the vaccines as much as younger people,” said Kim Mulholland, professor of vaccination science at the university-based London School of Hygiene and Tropical Medicine from Melbourne. “So the argument that older people shouldn’t be vaccinated because they haven’t been included in studies in Indonesia is not valid.”

A veteran who died of COVID-19 is buried in a cemetery in North Sumatra. People over the age of 60 make up only 10 percent of the Indonesian population but account for 39 percent of coronavirus deaths [Dedi Sinuhaji/EPA]Indonesia’s strategy is to reverse accepted wisdom regarding vaccinations. Medical experts say the first groups to be vaccinated should be frontline medical staff, and then the elderly.

“Older adults, especially those who are frail or who live in long-term care facilities, are disproportionately affected by the COVID-19 pandemic,” according to a study recently published in The Lancet, the world’s leading medical journal. “Vaccines that are safe and effective in this population have been eagerly awaited.”

As Mulholland puts it, “If you look at all of the studies that have been done in every country in the world, the evidence overwhelmingly shows that the greatest risk factor for developing serious COVID-19 is age. Even in Indonesia with a young population, most of the deaths are people over the age of 60. “

The data published by the Indonesian Ministry of Health confirm the argument. People over the age of 60 make up only 10 percent of the Indonesian population, but 39 percent of COVID-19 deaths.

“That makes me think about what my Indonesian colleagues have told me: what the Indonesian government could really try is herd immunity by vaccinating young adults, who are the strongest spreaders of the disease,” Mulholland said.

“The problem with this strategy, however, is that there is no evidence that vaccinations prevent recipients from acquiring and transmitting the disease. Effective vaccines only prevent recipients from getting sick. “

The Wrong Vaccine?

Indonesia is one of six countries where Sinovac, a Chinese pharmaceutical company, has conducted phase 3 clinical trials for its experimental CoronaVac shot. Around 1,620 volunteers took part in the trials, which began in August when the government gave 125 million doses of the vaccine and the option to secure an additional 100 million doses, of which 18 million have already been dispensed.

In December, the country spread its bets by placing firm orders for hundreds of millions more doses from vaccine makers AstraZeneca, Novavax and Pfizer. It has also announced plans to develop and manufacture its own COVID-19 vaccine by mid-2021.

Deliveries of the Sinovac COVID-19 vaccine arrive in Banda Aceh in northern Sumatra [Hotli Simanjuntak/EPA]However, CoronaVac is the only vaccine to have received regulatory approval and the only one that has already been shipped to Indonesia in large numbers.

“I think Sinovac is a good vaccine for this country as Pfizer needs to be frozen at -70 ° C and we don’t have freeze chain logistics across Indonesia,” said Dr. Panji Hadisoemarto, epidemiologist at Padjadjaran University in Java. “But with the Sinovac vaccine, you can store it in a cold chain that we have in Indonesia.”

“Another benefit of using Sinovac is that it is an ‘inactivated’ vaccine,” Panji said, describing vaccines with virus particles that are dead rather than alive. “It’s the type of vaccine that we in Indonesia use all the time for vaccination campaigns. It doesn’t require much training to manage. “

Dr. Dicky Budiman, an epidemiologist who led the team that formulated Indonesia’s strategic response to SARS, HIV, avian flu, swine flu, tuberculosis and malaria, says Sinovacs will be the last vaccine he would choose.

“I would choose AstraZeneca first because it can also be kept in a refrigerator like Sinovac’s and they have a great track record while Chinese vaccine manufacturers don’t,” he said.

Budiman’s equivalent second choice – Pfizer and Moderna vaccines – are harder to transport but contain messenger RNA technology that makes the vaccine flexible and able to deal with new mutations in the virus.

“Even a small mutation will have a significant impact on the effectiveness of a vaccination strategy, and 40,000 mutations of COVID-19 have been found,” he said. “But Sinovac’s vaccine doesn’t have vacuum flexibility, so it would be the last one I would choose.”

He added: “We have a saying in Indonesia: Tidak ada rotan, akar pun jadi. It means “do with what you have – even if it is not good”. That is what happens with rapid antibody tests in Indonesia, ”he said, referring to the epidemiological tool that was not used to properly screen domestic passengers at Indonesian airports last year. “Now they’re doing it again with the vaccine. They already have millions of Sinovac vaccines so they’re going to be using them. “

It’s the economy

Working-age adults will also have priority in the second phase of Indonesia’s vaccination drive – a great plan to vaccinate 181.5 million people, or about 67 percent of the country’s 273 million people, within 15 months.

Indonesia conducted “vaccination exercises” prior to the start of the mass vaccination program this week [Made Nagi/EPA]This has led to speculation that Indonesia’s vaccination strategy is based entirely on economic considerations.

“It is clear that the decision to target people of working age is related to the development of the economy,” said Ajib Hamdani, chairman of finance and banking for the Indonesian Young Entrepreneurs Association.

“The decision about the allocation of vaccines also depends on demographics,” he said. “In Indonesia we have a much larger proportion of people of working age than in developed countries. So the government is right to make younger adults a priority because if they don’t maintain the health of that age group, it will cause much bigger problems for the country later. “

He added, “We recognize that the first problem facing the pandemic is health, not the economy. However, we sincerely hope that this vaccination guideline will fix both at the same time. “

Fithra Faisal Hastiadi, an economist at the University of Indonesia and spokeswoman for the Ministry of Commerce, expressed similar feelings.

“When you talk about public health, you are also talking about the economy because public health is a function of the economy,” he said. “There’s really no difference between the two.

“Some say if you push more on public health, the economy will suffer and vice versa. But we cannot restore public health if we do not restart the economy. With that in mind, the government is trying to do both. “

Hastiadi believed the vaccination strategy would succeed in getting millions of Indonesians back to work.

“If you look at the sectors with the highest number of unemployed, it is tourism, transportation and logistics. These are also the sectors that have the greatest multiplier effect in terms of economic productivity. If people are vaccinated and can get back to work in these sectors, we can achieve President Jokowi’s goal of full economic recovery in 2021. “

However, a faster than expected economic recovery may bring little comfort to the thousands of Indonesians who have lost elderly relatives to COVID-19 or the tens of millions who live in intergenerational households.

There is no confirmation of when those over 60 will get their bumps. Health Minister Budi Gunadi Sadikin said Tuesday to wait for the Pfizer and AstraZeneca vaccinations as they were tested on the elderly, Rakyat Merdeka reported.

Experts fear vaccinating people of working age in Indonesia will only lead to more deaths from COVID-19 [File: Dedi Sinuhaji/EPA]The first deliveries are not due until April, and Dr. Budiman expects the launch may not happen until the last quarter of 2021.

Mulholland, of the London School of Tropical Medicine, believes the long wait will result in thousands more deaths among the elderly in Indonesia.

“It is entirely plausible that young people who are vaccinated will still get the disease, show no symptoms and take it home,” Mulholland said. “If so, vaccinating young adults is not going to slow the death rate.”