Jakarta, Indonesia – In the UK, the first person to receive a COVID-19 vaccine outside trial conditions was a 90-year-old pensioner. In Canada, the first recipient was only marginally younger at 89. In Germany, a 101-year-old nursing home resident was first in line.
But in Indonesia, the country worst affected by the virus in Southeast Asia with 836,718 confirmed cases and 24,343 deaths, the government has chosen an unorthodox vaccination strategy.
In the first phase that begins on Wednesday and continues until the end of March, 1.3 million healthcare workers and a further 17.4 million workers from the public service – police, soldiers, teachers and bureaucrats – will receive free jabs of CoronaVac, the vaccine developed by Chinese firm Sinovac Biotech. After that, it will be working adults.
"Indonesia is targeting the productive age at 18 to 59 years instead of elderly people because we have not completed the stage three clinical trials for people this age range with the Sinovac vaccine," Ministry of Health spokesperson Dr Nadia Wikeko told Al Jazeera.
"We are still waiting for the BPOM (Indonesia's agency for drug and food control) review to see if the vaccine can be used safely for people over 60."
Many citizens support the strategy.
"Because older people in Indonesia mostly stay at home, the chance of being infected is lower than that of people of working age," said Putu, a 56-year-old Balinese woman who like many Indonesians goes by only one name. "So, if younger people get vaccinated first, they can visit older people safely."
But experts are sceptical.
"We know that older people who have already been vaccinated in China and the Middle East have responded as well to the vaccines as younger people," said Kim Mulholland, a professor of vaccinology at the London School of Hygiene and Tropical Medicine who is based at the University of Melbourne. "So the argument that older people should not be vaccinated because they have not been included in trials in Indonesia is not valid."
Indonesia's strategy is the reverse of the accepted wisdom on vaccination, with medical experts saying the first groups to be vaccinated should be front-line medical staff and then the elderly.
"Older adults, particularly those who are frail or living in long-term care facilities, have been disproportionately affected by the COVID-19 pandemic," found a recent study published in The Lancet, the world's leading medical journal. "Vaccines that are safe and effective in this population have been eagerly anticipated."
Mulholland puts it like this: "If you look at all the studies conducted in every country in the world, the evidence overwhelmingly shows the greatest risk factor for becoming gravely ill from COVID-19 is age. Even in Indonesia which has a young population, the most deaths are people over 60."
Data released by Indonesia's Ministry of Health corroborates the argument. People over 60 years of age represent only 10 percent of Indonesia's population but 39 percent of COVID-19 fatalities.
"So that makes me think about what my Indonesian colleagues have been telling me: that what the Indonesian government might really be trying to do is to achieve herd immunity by vaccinating young adults who are the most potent spreaders of the disease," Mulholland said.
"But the problem with this strategy is that there is no evidence to suggest that vaccinations prevent recipients from acquiring and transmitting the disease. Effective vaccines have only been shown to prevent recipients from getting sick."
The wrong vaccine?
Indonesia is one of six countries where Sinovac, a Chinese pharmaceutical firm, conducted phase three clinical trials for its CoronaVac experimental shot. Some 1,620 volunteers joined the trials which began in August, as the government secured 125 million doses of the vaccine and an option to secure an additional 100 million doses, 18 million of which have already been delivered.
In December, the country spread its bets by placing firm orders for hundreds of millions of more doses from vaccine makers AstraZeneca, Novavax and Pfizer. It has also announced plans to develop and produce its own COVID-19 vaccine by mid-2021.
But CoronaVac is the only vaccine that has received regulatory approval, and the only one already delivered in large numbers to Indonesia.
"I think Sinovac is a good vaccine for this country because Pfizer's has to be kept frozen at -70C and we do not have 'freeze chain' logistics across Indonesia," said Dr Panji Hadisoemarto, an epidemiologist at Padjadjaran University in Java. "But with the Sinovac vaccine, you can store it in a cold-chain, which we have in Indonesia."
"Another benefit from using Sinovac is that it's an 'inactivated' vaccine," Panji said, using the term to describe vaccines with virus particles that are dead instead of alive. "It's the type of vaccine we use all the time in Indonesia for immunisation campaigns. They do not take a lot of training to administer."
But Dr Dicky Budiman, an epidemiologist who helped lead the team that formulated Indonesia's strategic response to SARS, HIV, Avian Influenza, Swine Flu, tuberculosis and malaria, says Sinovac's is the last vaccine he would choose.
"I would choose AstraZeneca's first because it can also be stored in a refrigerator like Sinovac's and they have a great track record, whereas Chinese vaccine makers do not," he said.
Budiman's equal second choice – Pfizer's and Moderna's vaccines – are harder to transport, but contain messenger RNA technology that makes the vaccine flexible and able to deal with new mutations of the virus.
"Even a small mutation will have a significant impact on the effectiveness of a vaccine strategy and 40,000 mutations of COVID-19 have been found," he said. "But Sinovac's vaccine doesn't have any vac-flexibility so it would be the last one I would choose."
He added, "We have a proverb in Indonesia 'Tidak ada rotan, akar pun jadi'. It means 'make do with what you have – even if it's not good'. That's what happens with rapid antibody tests in Indonesia," he said, referring to the epidemiological tool that was improperly used to 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 use them."
It's the economy
Working-age adults will also be prioritised in the second phase of Indonesia's vaccination drive – a grand plan to inoculate 181.5 million people, or approximately 67 percent of the country's 273 million people, within 15 months.
This has fuelled speculation that Indonesia's vaccination strategy is based purely on economic considerations.
"It is clear the decision to target people of working age is related to the development of the economy," said Ajib Hamdani, chairman of the finance and banking division of the Indonesian Young Entrepreneurs Association.
"But the decision over vaccine allocation is also related to demographics," he explained. "In Indonesia, we have a much larger proportion of people who are of working age compared to developed countries. So, the government is right to make younger adults a priority because if it does not maintain the health of this age group, it will make much bigger problems for the country later on."
He added, "We acknowledge the first problem of the pandemic is health, not the economy. But with this vaccination policy, we have high hopes that it will fix both at the same time."
Fithra Faisal Hastiadi, an economist at the University of Indonesia and spokesperson for the Ministry of Trade, voiced similar sentiments.
"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 is no real difference between the two.
"Some say when 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. So, in this sense, the government is trying to do both."
Hastiadi believed the vaccination strategy would succeed in putting millions of Indonesians back to work.
"If you look at the sectors with the most unemployed, they are tourism, transport and logistics. These are also the sectors that have the greatest multiplier effect in terms of economic productivity. So, if people are vaccinated and can go back to work in these sectors, we can meet President Jokowi's target of a full economic recovery in 2021."
But a faster than expected economic recovery may provide little solace to the thousands of Indonesians who have lost elderly relatives to COVID-19, or to the tens of millions who live in intergenerational households.
There has been no confirmation of when over-60s will get their jabs. Health minister Budi Gunadi Sadikin said on Tuesday that they should wait for the Pfizer and AstraZeneca inoculations because they have been tested on older people, Rakyat Merdeka reported.
The first supplies are not due until April and Dr Budiman thinks the roll-out might not happen until the last quarter of 2021.
The London School of Tropical Medicine's Mulholland believes the lengthy wait will result in thousands more deaths among Indonesia's older people.
"It's quite plausible that young people who are vaccinated could still be acquiring the disease, not showing any symptoms and taking it home," Mulholland said. "If that is the case, vaccinating young adults will not slow down mortality rates."