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Confidence Commentary: Blog archive

Another vaccine confidence breaker in Asia: Indonesia

Heidi Larson | 28 Jul, 2016

with Ruoran Li , PhD  student, Department of Epidemiology, Harvard T.H. Chan School of Public Health.  Xiong-Fei Pan , PhD student,Epidemiology, Sichuan University, and Chinese Evidence-based Medicine Center at West China Hospital.

Last month another vaccine scandal story broke in Asia, just when the news on China’s multi-million dollar, multi-year vaccine scandal was starting to wane. This time, an illegal vaccine operation was uncovered in Indonesia well over a decade after it opened for business and continued unchecked. The two four-month apart scandals attracted global attention to the risks of inadequate regulatory systems and their consequences for public trust.

In China the vaccines being illegally sold after their expiry date had been legitimately manufactured. In Indonesia, the vaccines were counterfeit all the way from their content – found to include antibiotics and saline solution – to their labels, which imitated known international vaccine brands. The similarity is that in both countries officials tasked with ensuring the safety of vaccines were aware of the criminal activity well before it became public, angering the public even more than action was not taken earlier. Parents in both countries became anxious that their children were not protected against the diseases the vaccines were meant to prevent, and also worried that their children’s health may have been otherwise compromised by the illicit vaccines. In both China and Indonesia, the headline message to calm the parents was that the illegal vaccines were not dangerous, just ineffective. This stance alone, however, provided little comfort for the parents’ broken trust.

These are instances where the demand for vaccines was not the issue. Most people wanted the vaccines and counted on them to protect their child’s health and life. In both China and Indonesia, there are other underlying issues of distrust in the health system more broadly. As one of the media reports on the Indonesia scandal pointed out, this incident became more of a last straw in their already waning trust in the system, resulting in at least one aggressive attack on a doctor.

The public distrust in the healthcare system led ringleaders in Indonesia to intentionally promote the counterfeit vaccines as imported with international brand names. They were fully aware that those who could afford imported vaccines would prefer them to locally produced ones. What’s more, well-off Indonesians wanting to search for other vaccines are likely to turn to Singapore or Malaysia, as implied by earlier reports. But Malaysia has its own vaccine confidence challenges, with growing anti-vaccine sentiment around the most basic childhood vaccines, which has led to recent cases, and even deaths, of totally vaccine-preventable diphtheria. With wavering trust following the vaccine safety fears, Indonesian parents and caretakers are likely to be more vulnerable to the influences of others who are questioning vaccines for a myriad of other reasons.

Episodes like these in China and Indonesia drive people to the internet searching for information on vaccines. There they find an often confusing and complex mix of information and misinformation, propaganda from both the pro-vaccine as well as anti-vaccine lobbies, and conversations and debates among those who are undecided, but share their questions and concerns publicly.

Ensuring a reliable supply of safe vaccines is foundational for any immunization programme. It is also foundational for sustaining public trust. It is much more difficult, if not impossible, to change philosophical or other beliefs about vaccines that drive vaccine hesitancy and refusal, than to make sure that the systems are in place to ensure safe delivery of one of the most basic of all health interventions. From a trust perspective, it’s a deal breaker.

Literature Literature archive

Peprah D, Palmer J, Rubin GJ, Abubakar A, Costad A, Martin S, Perea W, Larson HJ Vaccine 34( 33):3823–3827
Carlsen B., Glenton C. 2016. BMC Health Services Research. Volume 16:203
J. Patrick Woolley, Michelle L. McGowan, Harriet J. A. Teare, Victoria Coathup, Jennifer R. Fishman, Richard A. Settersten, Sigrid Sterckx, Jane Kaye and Eric T. Juengst 2016 BMC Medical Ethics 2016 17:33

Videos Video archive

Drs. Larson and Paterson join a discussion on vaccine confidence at Hong Kong University.  September, 2015.

Dr. Larson’s address to the CSIS conference on “The Global Experience in Addressing Cervical Cancer”.

Dr. Larson discusses the VCP’s 2015 report on the State of Vaccine Confidence worldwide.

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