With 593 cases and 32 fatalities reported since early November in 20 provinces, the Health Ministry recently declared the country is in the midst of a diphtheria outbreak. Of those affected, 66 percent were recognized as failing to be vaccinated against diphtheria, while 31 percent had only been partially vaccinated over their life course.
In 2010 the government had classified diphtheria as one out of 17 communicable diseases with high possibility of an outbreak. Thus, the outbreak should not have been a surprise to authorities.
Yet, the outbreak took place not only in area with restricted resources, like isolated islands or rural areas, whose limited access to diphtheria-pertussis-tetanus (DPT) vaccination, but in urban settings like Jakarta with Java as the most affected island.
As a response, the government is carrying out a free vaccination program in the 20 provinces affected in three of the most populated and affected provinces: East Java, West Java, and Banten. Will this be enough?
Diphtheria is a heavily contagious bacterial infection in the nose and throat that could be deadly if not prevented or treated in time. The “throat distemper” causes hide-like membrane on the tonsils and “bullneck”. Worldwide, the first recorded diphtheria epidemic was the Spanish outbreak of 1613, known as the “Year of Strangulations”, a reference to the severe sore throat and breathing difficulties that diphtheria causes. It was frequently perceived as disease of the poor in the 19th century. In Indonesia, this ancient disease reappears after its inexistence since 1986, in a totally different stage of development.
Immunization, which should be easily accessible at the local clinic, is the best protection against the possibility of contracting diphtheria. The World Health Organization (WHO) has reiterated that all children worldwide should be immunized against diphtheria.
Populations of every country are expected to achieve timely vaccination with a complete primary series plus booster doses which Sustainable Development Goals (SDG) platform emphasizes in its 3.8 target. However, considering current immunization coverage, this is hard to imagine in the near future.
Data from 2015 reveals “only” 4,500 cases of diphtheria found worldwide, but Indonesia ranks third following sub-Saharan African countries and India. The diphtheria immunization coverage among infants rates at 50-79 percent while the ideal should be above 90%. Province like Aceh, Maluku and Papua are reported to be of lowest performing area when it comes to immunization coverage. (explanations in wide gap in percentage). Ironically, while Indonesia’s population living in cities (new paraphrase) has better access to healthcare service and information, it is concerning that the recent outbreak cost most death toll in Java with three most affected provinces included East Java, West Java and Banten.
The issue of immunization coverage in Java is beyond biomedicine and health administrative dimensions. Signs of resistance against the vaccine reveal strong as anti-vaxxers in the country have echoed ignorance of particular groups who undervalue the benefit of vaccine and emphasize its rare adverse effect while accusing it as haram (forbidden).
In many other developing countries, anti-vaxxers played a crucial part in the spread of diseases requiring vaccine. For instance, in Afghanistan, Nigeria and Pakistan where antivaccine campaigns against polio vaccine were strong, which cost hundreds of lives.
In Afghanistan, 1,625 children contracted acute flaccid paralysis in 2008, represented a 150% increase over the number of cases in 2007. In Nigeria, attempts by Islamic extremists to ban a United Nations immunization campaign have resulted in the infection returning to eight previously polio-free countries in Africa. In Indonesia, faith-based antivaxxers including popular clerics are now working in accordance with like-minded celebrities.
Promoting vaccine is not an easy task for health authority in developing countries like Indonesia. A former health minister, the late professor Sujudi, used to say, “I’m a professor, a doctor, and a minister but nobody listens to me; when it comes to polio vaccine, yet everybody would listen to Mandra and Si Doel!”. He was referring to two popular figures of a TV drama who, at that time, successfully helped Ministry of Health to over-achieve National Immunization Week (Pekan Imunisasi Nasional) coverage target. (new paraphrase) His statement on government incapacity to implement health campaign was no exaggeration.
One might think the victory should be replicated. Let alone today, where more and more people tend to adopt celebrities conduct as they often speak personally and persuasively to the public. Indeed, celebrities might convey a short-term boost to campaigns. But today, when it comes to implement nation-wide health campaign, celebrities should be treat cautiously as the celebrity tend to be the story, not the campaign (new paraphrase). A counterproductive effect might reveal as celebrity commits to personal decision which eventually might risk the sustainability of public health program in the future. The pervasive existence of contemporary communication channels today may also put the effectiveness of employing celebrities effect into question.
In urban area where every community has the benefit of social media connectedness, faith-based religious groups are of major players to work with who potentially offer more sustenance as their attitude toward issues tend to remain the same for long if not forever. Building on the extensive experience, strengths, and capacities of faith-based organisations; in terms of geographical coverage, influence, and infrastructure; offers a unique opportunity to improve health campaign outcomes.
How can we win?
Indonesia’s public health community and authority should do more to engage faith-based religious groups to provide a much needed complement to public health campaign on healthy behaviours. Indeed, religious group broad reach and influence have for centuries played critical roles in delivering education, health, and social services even in resources-limited area.
As the 2018 Asian Games approach, Indonesia could not afford to let the diphtheria outbreak out of control while not anticipating for other threat to emerge. As ORI implemented, existing infrastructure and community partnerships need a boost to improve health outcomes especially in responding to antivaccine movement. It is time for public health community to recognise the magnitude of services offered and partner or support to provide long-standing health campaign in the society.
Besides, authorities must stand firm against the antivaccine groups. They must be given a warning, including some public figures sharing their stance for risking their children in not taking up vaccines. After all, to win this hard-to-win-but-possible battle, collaborative public health efforts and increased public health education are imperative in containing this outbreak diphtheria and possibly future outbreak or epidemics.
By : Fadjar Wibowo
The writer, who graduated from Karolinska Institute’s Global Health Master, is a former Chief Editor of Klikdokter.com and current Outreach & Partnership Coordinator at Center for Indonesia’s Strategic Development Initiatives (CISDI). The opinion is personal.