Who Should Be Vaccinated First
The Health Ministry has determined that the first stage of vaccination is for 1.47 health workers, with the second stage targeting public officials (17.4 million) and the elderly (21.5 million).
"Alhamdulillah (praise be to God), I have been vaccinated!" A social media posting of a young man reads, with a picture of him giving a thumbs up.
On the other hand, in the ICU room of a hospital, an elderly man was battling the lethally threatening coronavirus. With the help of a ventilator, he was desperately inhaling oxygen that could no longer be obtained just by relying on his lungs, which have been "submerged".
He had been exposed to the virus while waiting for his turn for vaccination, which apparently now will never happen.
There have been no rules infringement in vaccinating the young man. Even though he is not a health worker or one in an essential field related to the Covid-19 mitigation program. He is just a government official.
Along with tourism workers and House of Representatives (DPR) members, government employees are the second priority for vaccination after health workers.
These two contrasting situations have garnered attention. Who exactly should be prioritized for vaccines when supply is limited: the elderly man who eventually died in the hospital or the government official who is not directly involved in handling Covid-19?
Also read: Pursuing Vaccination while Remaining Alert
The different level of risk posed by SARS-CoV-2, the virus that causes Covid-19, has different effects on the people infected with it.
World epidemiological data shows that out of 100 positive cases, about 81 had symptoms of minor illnesses such as mild flu, 14 suffered from severe symptoms such as pneumonia, and 5 were in critical condition triggered by the failure of respiratory function or the damage to various organs. Two of the five died.
Health Ministry data shows that among those who died, around 47 percent were elderly patients over 60 years (Kompas, 8/2/2021).
The results of data analysis on thousands of Covid-9 patients from hospitals in Jakarta show that Covid-19 patients over 70 had a 5-to-10-fold risk of death compared to Covid-19 patients under 50 (Surendra, Lancet Regional Health - Western Pacific 2021) . This is a gaping risk difference.
Data compiled by the Centers for Disease Controls (CDC) also shows that elderly patients aged 65-74 had a 24-time risk of death compared to patients aged 30-39. This is a very high difference of risk.
Apart from age, other factors that exacerbate the risk of serious illness and death are comorbidities, such as hypertension, diabetes and obesity.
Because, if they are exposed, the risk of death will be much higher than other members of the community.
Therefore, one of the public health policies taken by a number of countries is to prioritize shielding for the elderly and other vulnerable groups from virus exposure. Because, if they are exposed, the risk of death will be much higher than other members of the community.
Covid-19 Vaccine
Less than a year since Covid-19 was declared a pandemic, a vaccine, which was later proven to be effective, has been discovered. More than ten brands of vaccines have since been produced and used in several countries.
An engineer works in the general laboratory during a media tour of a new factory built to produce a COVID-19 coronavirus vaccine at Sinovac, one of 11 Chinese companies approved to carry out clinical trials of potential coronavirus vaccines, in Beijing on September 24, 2020.
In Indonesia, the CoronaVac or Sinovac vaccine from China, in collaboration with State-owned pharmaceutical holding company PT Bio Farma, obtained its emergency use permit from the Food and Drug Monitoring Agency (BPOM) on January 11.
Following it, was AstraZeneca on March 19 after the national vaccination rollout had begun on January 13, marked with an injection of President Joko Widodo.
Clinical tests reveal vaccines are quite effective in reducing the risk of getting ill with Covid-19. Vaccines are also very effective at bringing down the risk of severity and death. In Indonesia, Brazil and Turkey, the risk reduction impacted by Sinovac vaccine ranges from 50-83 percent. Turkey has even reported that Sinovac provides nearly 100 percent efficacy from the severity of Covid-19 disease (Reuters, 3/3/2021).
Also read: Keep up the Vaccination Momentum
However, there are no conclusive data yet to confirm vaccine efficacy in preventing transmission (Aschwanden, Nature 591, 2021).
Vaccine efficacy against transmission is indeed an important parameter to determine the minimum number of people that should be vaccinated to achieve herd immunity. Thus, prevention of transmission should not be the main objective of Covid-19 vaccination.
Vaccine Supply
Countries are struggling to procure vaccines. Only vaccine producing countries, such as the United States, have sufficient supply for the population, while importing countries must be patient to get access to it.
Indonesia is one of those importing countries that has already obtained the access to vaccines. However, the Health Minister has stated that from the initial plan of procuring 426 million doses, only 80 million doses will be available for use until June. With two doses for each person, the amount will only cater 40 million people (Kompas, 14/3/2021).
As of March 18, according to ourworldindata.org, more than 30 million people were vaccinated at least with one dose worldwide or 4 percent of the world\'s population.
Meanwhile in Indonesia, around seven million people were vaccinated as of March 17, or 2.7 percent of the total population, according to the Health Ministry.
World Vaccination Priority
With vaccine supply being short, the World Health Organization (WHO) provides guidance on who should be prioritized for vaccination.
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Elderly people wait in line outside the Health Ministry training center on Jl. Hang Jebat in Kebayoran Baru, South Jakarta, on Tuesday. They received a message broadcast on WhatsApp notifying recipients of free vaccinations for elderly people in the area. However, it turned out that the free vaccine was being offered only to elderly people with South Jakarta-registered ID cards and that the number was limited to 1,000 people per day.
Health workers, who are at the frontline of handling Covid-19, is among the priority list, along with other groups who carry most risk of becoming seriously ill or dying if exposed to Covid-19.
WHO recommends that vaccination be carried out in several stages. The first stage includes health workers and elderly. The second stage is for the elderly who have not been vaccinated in the first stage, along with people having comorbidities, minority groups who have a high rate of death, such as persons with disabilities, poor people in densely populated slum areas, vaccinators and teachers who still have to teach face-to-face.
The third stage is done for teaching staff, pregnant women, and government’s employees, such as the police and civil servants.
Also read: Fulfilling the Pledge to Execute Vaccination
The vaccination stage is similar to the principle of saving lives and is being practiced in other countries, including the United States, UK and Australia.
Indonesia Vaccination Priority
What about the vaccination prioritization in the country? The Health Ministry has determined that the first stage of vaccination is for 1.47 health workers, with the second stage targeting public officials (17.4 million) and the elderly (21.5 million).
Public officials consist of state officials, House members, government employees, educators, tourism sector actors, journalists and media workers, security officials, transportation workers, religious leaders and market traders.
After the first and second priority groups is complete, the third stage of vaccination is for vulnerable communities or people in areas with high risk of transmission (63.9 million).
Other community groups that are not included in the first, second and third stages will have their turn in the fourth stage.
What is most striking difference is the shift in priority for the elderly and other vulnerable groups, such as people with comorbidities.
We can see the gap in vaccination priority in the country from that recommended by WHO. What is most striking difference is the shift in priority for the elderly and other vulnerable groups, such as people with comorbidities.
In the WHO guidelines, the elderly is the highest priority group (first stage), along with health workers, while the Health Ministry has place them in the second stage with public officials.
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This is a situation during Covid-19 vaccination at Istora Senayan, Jakarta, on Friday (26/2/2021). Athletes participated in the campaign on the importance of vaccination. The athletes have not experienced any negative effects after getting a vaccine shot. They are happy to receive the vaccine because it increases immunity and confidence for training and competition. They hope the vaccination marks a start for the recovery of sports in Indonesia, mainly for national competition.
It is true that vaccination priorities do not have to be exactly the same as those in the WHO guidelines and adopted by a number of countries. However, the principle of protecting the most vulnerable groups must be taken into consideration.
It is not the principle of preventing infection in the elite groups (vaccination of officials and representatives) or accelerating economic development (self-vaccination, vaccination of tourism sector workers).
The vaccination measures, which are not in line with WHO guidelines, have further been compounded by what has happened on the vaccination scene. Within two months of the program rollout, celebrities and families of House members were reported to have been vaccinated at the expense of the elderly.
Also read: Economics and Health Must Go Hand in Hand
Until March 28, as many as 1.43 million health workers or 98 percent of the total 1.47 million were vaccinated with 1.27 million of them having received second jabs, according to the Health Ministry. The high rate of vaccination for health workers is an achievement worthy of appreciation.
What has become a concern is the unequal vaccination coverage in the second stage between public servants and elderly.
Of the 39 million people targeted in the second stage, 4.4 million of 17.4 million public employees have been vaccinated with one dose and 1.9 million with two doses.
On the other hand, vaccination for the elderly has been administered only to 1.4 million people (6.6 percent of the total 21.5 million) and only around 100,000 have received the second dose (Health Ministry, 18/3/2021).
The government may have its own reasons, but the fact that the vaccination of the elderly has been four times slower than the public officials (1.5 million vs 6.3 million) is very worrying.
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People wait for their turns to get Covid-19 vaccine shots at the RSUD Kembangan hospital in West Jakarta, on Tuesday (23/2/2021). One hundred seventy-three elderly people had been registered to get their vaccine shots at that hospital on Tuesday (23/2/2021). The target for the second phase of the vaccination program is to inoculate more than 38 million people, which includes 17.4 million people working in public and essential services and 21.5 million elderly.
With sluggish progress of being vaccinated, more than 90 percent of the elderly people are remaining in the vulnerable zone, while public is already confident that the vaccination rollout will make the pandemic over soon.
What to Do?
With limited supply of vaccines, forget the long-term target of driving the economy or achieving herd immunity, because, due to various reasons, this could be a dilution. (Aschwanden, Nature 591, 2021).
The government should focus on using the available supply to vaccinate the elderly and other most vulnerable groups as quickly and expansively as possible.
Let’s refer back to the case raised at the beginning of this article in the context of who should be vaccinated first: a healthy man and government official who is not directly related to the handling of Covid-19, or an elderly man who has a multiple risk of dying if exposed to the virus.
Every citizen indeed is entitled to vaccines, but because of short supply of vaccines, it seems that there is only one option to take.
The choices taken show what the government\'s current priorities are.
Beben Benyamin
Beben Benyamin, Senior Lecturer in Biostatics, Epidemiology and Genetics, Australian Center for Precision Health, University of South Australia
(This article was translated by Musthofid).
