By: Muhammad Zulfikar Biruni, Apt., MPH.
(Health Administrator at the Directorate of Pharmaceutical Production and Distribution – Master of Public Health graduate from the University of Melbourne, Australia)

In the implementation of the program, stakeholders must be able to understand the diverse experiences and perspectives that exist in the community and strive for the community to respond positively to the program so that they voluntarily carry out vaccination.

Novel Coronavirus Pandemic

In early 2020, the world was suddenly disrupted by a pandemic caused by a new (novel) strain of coronaviruses (CoV), SARS-CoV-2. The disease caused by SARS-CoV-2 infection is then referred to as coronavirus disease or COVID-19.⁽¹⁾ CoV itself is a family of RNA-viruses shaped like the corona of the sun that has caused many diseases ranging from influenza, Middle East Respiratory Syndrome (MERS) caused by MERS-CoV, to Severe Acute Respiratory Syndrome (SARS) caused by SARS-CoV.⁽²⁾ The speed of transmission of the SARS-CoV-2 virus is much higher than MERS-CoV or SARS-CoV so that on January 5, 2021, COVID-19 has become a global pandemic that infects around 84.5 million people with a death rate of 1.8 million.^(2,3) In Indonesia, as of January 6, 2021, positive cases of COVID-19 have reached around 780 thousand and caused 23 thousand deaths.⁽⁴⁾

Socioeconomic impact of COVID-19 and government intervention

The COVID-19 pandemic has certainly had a significant socio-economic impact. Since the World Health Organization (WHO) set the status of the COVID-19 outbreak on January 30, 2020, the implementation of the closure of borders/countries, travel restrictions, large-scale social restrictions (PSBB), and quarantine as an emergency response has stimulated the economic crisis in various parts of the world, including in Indonesia.^(5,6) Nicola et al. mentioned that most of the world's economic systems ranging from primary (raw material production), secondary (finished goods production), and tertiary (services) sectors were disrupted by this pandemic, including the healthcare sector and the pharmaceutical industry.⁽⁵⁾ Macroeconomically, Indonesia itself has been affected by experiencing a recession with a percentage of economic growth of -5.32% and -3.49% in the 2nd quarter and 3rd quarter of 2020.⁽⁷⁾ However, various strategies have been implemented by the Indonesian government to overcome the impact of the pandemic both through economic recovery strategies and increasing the capacity of the health system.^(8,9)

To overcome the impact of the COVID-19 pandemic, the government has implemented various health interventions. In addition to health protocols, health efforts to overcome the pandemic are by seeking COVID-19 vaccination for all Indonesians as stated by the President of the Republic of Indonesia on December 16, 2020.⁽¹⁰⁾ The vaccination program is one part of the health system to overcome health problems, especially in terms of diseases that can be prevented by immunization (PD3I). COVID-19 vaccination is carried out by administering vaccines to the human body in order to obtain specific immunity against the SARS-CoV-2 virus so as to break the chain of transmission.⁽¹¹⁾ From an economic perspective, COVID-19 vaccination will be more cost-effective than the treatment and care efforts that must be carried out in the event of infection.^(12,13) The broad positive impact on society, namely social and economic productivity, is expected to be restored through this vaccination program. However, to make the COVID-19 vaccination program a success, at least 3 key factors are needed, namely the COVID-19 vaccine, including its supply and access; health workers; and community participation. To achieve the success of the COVID-19 vaccination program, these three factors must be built and implemented holistically integrated with each other.

Keyfactor #1: COVID-19 vaccine (research, supply and distribution)

Novel coronavirus vaccine research is one of the stages of providing vaccines so that almost all countries are competing in this vaccine research. Research and discovery of the COVID-19 vaccine is one of the fastest in the world, not only because of its far-reaching impact but also because it is supported by very modern research technology and huge budget support that has never been done before in the world.^(14,15) Based on WHO data as of January 5, 2021, there have been 63 COVID-19 vaccine candidates that have entered clinical trials, of which 15 have entered the third phase.⁽¹⁶⁾ Although the entire third phase of the clinical trial has not yet been completed, several countries such as the United Kingdom and the United States have implemented COVID-19 vaccination through the Emergency Use Authorization (EUA) mechanism.^(17,18) The EUA mechanism is implemented to facilitate the provision and use of health products, including vaccines, during emergencies, including the COVID-19 pandemic.⁽¹⁹⁾ The EUA mechanism certainly does not replace the clinical trial system and protocol carried out in the vaccine research itself, so that the COVID-19 vaccine given to humans must still be tested for safety, quality and efficacy. In Indonesia, the Food and Drug Administration (BPOM), through a rolling submission mechanism or vaccine evaluation on the gradual submission of clinical trial data, ensures that the safety and immune response of the COVID-19 vaccine meet the requirements of efficacy and immunogenicity.⁽²⁰⁾

Availability and access to vaccines is one of the determining factors for the success of the COVID-19 vaccination program. Based on a statement delivered by the Minister of Health on December 29, 2020, the Government of Indonesia has sought to fulfill the need for vaccines, which is around 426 million doses for the allocation of national vaccination recipients based on inclusive criteria (over 18 years old, no comorbidities, never been infected with COVID-19, not pregnant women, etc.) and 15% buffer stock according to WHO regulations.⁽²¹⁾ All of these targets are expected to create herd immunity or indirect group protection against infection through the vaccination process of a large number of populations. Vaccination that will take place in Indonesia is expected to reach at least 70% of the total population.⁽²²⁾ In terms of supply, the government has planned several alternatives for vaccine procurement, including through the purchase of Sinovac, Novavax, AstraZeneca, Pfizer vaccines, as well as procurement through COVAX/GAVI which is legally stated in the Decree of the Minister of Health Number HK.01.07 / Menkes/12758/2020 dated December 28, 2020. Domestic vaccine manufacturer Biofarma has also been working on research and production of the COVID-19 vaccine through short-term and long-term collaboration strategies with a number of pharmaceutical industries, research institutions, domestic universities, and related Ministries/Institutions. Based on the vaccination roadmap that has been prepared, Biofarma's vaccine will be available at the end of February or early March 2021 (first semester of 2021), while the importation of Novavax, AstraZeneca, Pfizer, and COVAX vaccines is targeted to arrive before mid-2021. All of these vaccines will be used immediately after receiving an EUA from BPOM. Meanwhile, as of December 31, 2020, two batches with a total of 3 million doses of COVID-19 vaccine from Sinovac have been imported, which are currently being distributed to 34 provinces in Indonesia to reach health workers who were targeted in the first phase.⁽²³⁾

Furthermore, a strong and robust vaccine distribution and delivery system is one of the supporters of achieving COVID-19 vaccination targets in Indonesia, given the large vaccination coverage and geographical challenges to remote areas and islands. In addition, technical factors in handling and handling methods of vaccines are indeed a challenge, for example, distribution and storage temperature and sensitivity to light are very crucial so that the quality of the vaccine is maintained until it is given to the patient. Sinovac vaccines, for example, which are inactivated virus vaccines, must be stored at 2-8 Celsius and Moderna vaccines must be stored at -20 Celsius, so that the transportation and storage of these vaccines must be carried out following cold-chain distribution system procedures, and specifically for Pfizer vaccines which must be stored at -70 Celsius, ultra-cold-chain equipment is required in handling.^(24,25) WHO has also provided guidelines for maintaining vaccine quality where temperature monitoring must be carried out and recorded during transportation and storage, including in vaccine carriers.⁽²⁵⁾ The handling techniques in this cold-chain system must of course be fully known and implemented by health workers and all personnel involved in COVID-19 vaccination so that the vaccines given can provide immunity to vaccine recipients while avoiding possible side effects due to vaccines that do not meet predetermined standards.

Keyfactor #2: Health workers as the frontline

Health workers are a crucial supporting factor in the implementation of COVID-19 vaccination. Referring to the WHO Strategic Advisory Group of Experts (SAGE) Roadmap on Immunization as well as the results of the study of the National Immunization Expert Advisory Committee (Indonesian Technical Advisory Group on Immunization, ITAGI), health workers are one of the priorities for receiving the COVID-19 vaccine.^(26-28) Also referring to the CDC Framework for Equitable Allocation of COVID-19 Vaccine, this vaccination priority has been implemented based on ethical principles so as to achieve the highest degree of benefit in such a way as to achieve equity and mitigate the possibility of inequality of access to vaccines.⁽²⁹⁾ By placing health workers as a priority, it is hoped that in the implementation of mass vaccination for a wider community, health workers themselves can be protected from the possibility of COVID-19 infection so that the risk of obstructing vaccination and other health services due to illness can be avoided. In implementing the vaccination program, WHO has provided direction that health workers must be able to carry out infection prevention and control through self-protection, patient protection, and family and community protection.⁽³⁰⁾ Infection prevention and control is carried out not only during vaccine administration sessions, but also at health facilities, during the implementation of education and advocacy to the community.

Another strategic role of health workers in the COVID-19 vaccination program is to build public trust and convey the benefits of vaccines so as to create confidence in the community to support program implementation. Health workers should be a communication bridge in the context of community engagement so that vaccination coverage can reach the target and herd immunity outcomes are formed.⁽²⁶⁾ In addition, with the current situation where hoax information can be easily obtained and disseminated, which often leads to disinformation and doubts in the community, health workers must be able to become one of the “primary sources” of health information in the community. This is important because several studies have shown that directions and information conveyed by health workers, including cadres, are more easily accepted and implemented by the community.^(31,32) Health workers, through empathy, can implement a counter to doubts about vaccines and vaccinations in the community, so that people who feel unsure or refuse can switch to accepting vaccines and vaccinations.⁽³³⁾

Illustration: Health worker (Doc. Shutterstock)

Another crucial thing, where health workers play a very important role, is in the event of adverse events following immunization (AEFI) or post-vaccination adverse events (KIPI), both in prevention, handling and reporting.⁽³⁰⁾ As we know, vaccine effectiveness will indeed be measured after the vaccine is widely used in the community, therefore data on the incidence of AEFI will be very helpful in evaluating vaccines. KIPI data and information, as an integral part of pharmacovigilance, is important because it certainly serves as a control of the robustness of the health service and vaccination system.⁽³⁴⁾ This is because the occurrence of adverse events is not necessarily due to the administration of vaccine products, but can occur due to other factors such as inappropriate vaccine quality due to handling errors, immunization technique errors, psychological stress related to vaccination, or other conditions.⁽³⁵⁾ In this case, health workers must also be able to detect and investigate the causes of KIPI, for example, whether there are deviations from the cold-chain system, vaccine administration procedures, waste handling, and so forth.⁽³⁴⁾ Due to the importance of this, the KIPI reporting system for COVID-19 vaccination can be integrated between health workers, the pharmaceutical industry, and the government (Health Office and Ministry of Health) and implemented based on clear procedures and by using a user-friendly reporting system.⁽³⁶⁾ Thus, all roles and functions of health workers are expected to support the optimization of vaccination so that program outcomes can be achieved according to the set targets.

Keyfactor #3: Community participation

Another key factor affecting the success of the COVID-19 vaccination program is community participation. Empowering the community to accept vaccines and support the COVID-19 vaccination program itself requires the participation of many parties, where good communication between the government, health workers, families, and communities is one of the factors that must be built.⁽³³⁾ In the implementation of the program, stakeholders must be able to understand the diverse experiences and perspectives that exist in the community and strive for the community to respond positively to the program so that they voluntarily carry out vaccination.^(31,33) On the other hand, the community also needs to actively understand the COVID-19 vaccination program including how the scheme and prerequisite conditions, target outcomes, access to vaccines, and risks that may be faced if they do not get vaccinated.⁽²⁸⁾ In terms of building a positive perspective, the participation of community leaders, such as religious leaders, traditional elders, and public figures, is needed so that the community is interested and accepts the program to jointly succeed COVID-19 vaccination. This is important because several things such as religious factors and beliefs including concerns about the halalness of vaccines, negative news related to vaccination, superstitions, certain cultural norms, and anti-vaccine propaganda can hinder the success of vaccination.⁽³⁶⁾

In addition to vaccination, the important role of the community is in implementing health protocols, including sanitation and hygiene during a pandemic, including when vaccinated, because it will certainly help the complete eradication of COVID-19. Key behaviors to prevent COVID-19 include wearing masks, washing hands using soap and running water, and maintaining a safe distance, as well as aspects of knowledge and positive beliefs about handling a pandemic are part of an integral part of community participation.^{(28,31,37,38)} In the future, community behavior in terms of healthy living must continue to be carried out as a new-normal so that in addition to reducing the possibility of spreading infectious diseases, it can also holistically reduce health costs because preventive health efforts are proven to be more cost-effective than curative and rehabilitative health efforts.^(39,40)

Thus, vaccination intervention is one of the health efforts that must be implemented holistically by involving various parties. In the short term, the success of the program will certainly greatly impact the national economic recovery, while in the long term, the outcome of increasing the capacity of the health system as a whole is expected to be achieved so that it is better prepared if Indonesia has to face a pandemic in the future.

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