Religious and Community Leaders' Acceptance of Rotavirus Vaccine Introduction in Yogyakarta, Indonesia: A Qualitative Study

"Given their influence in the community, religious leaders play an important role in providing the bridge between immunization programs and the community, particularly during the introduction of a new vaccine."

Community acceptance of any new vaccine programme is contingent on the involvement of key stakeholders. In Indonesia, oral rotavirus vaccines to prevent severe diarrhoea especially among children under age 5 are available but not funded on the National Immunization Program (NIP). Uptake is considered to be low. Religious and community leaders and the Majelis Ulama Indonesia (MUI) are important resources for many religiously observant Muslims in decisions regarding the use of medicines, including vaccines. In an attempt to inform policy, this study aimed to explore the acceptance by religious and community leaders to the introduction of rotavirus vaccines in Yogyakarta, Indonesia, and their perceptions of the acceptability of the rotavirus vaccine to the communities they represent.

At issue is the public's acceptance of vaccines that contain animal-derived products and their permissibility under Islamic law. The current oral rotavirus vaccines use porcine trypsin in the manufacturing process. While certification that the vaccine is halal (permissible under Islamic Shariah Law) has been issued in other countries, a certification has not been issued by MUI. To date, the MUI have issued halal certifications for the 2 meningococcal vaccines required for the Hajj and a fatwa (religious-legal response) to permit the use of inactivated polio vaccine (IPV). For other vaccines, including those on the NIP, no specific halal certifications or fatwas by the MUI exist.

In all, 20 informants participated in semi-structured in-depth interviews, including 4 religious leaders and 7 leaders or staff members of Islamic organisations. Of the community leaders, 4 volunteer cadres and 4 formal community leaders or staff members of sub-district, district, and provincial level offices were interviewed. Key results, which are shared in part through quotations from interviewees, include:

• Most participants were knowledgeable of the vaccines listed on the current Indonesian NIP and of the consequences to both the individual and the community of not vaccinating. One religious leader said of vaccination, "in Islam it is permitted...because it has 'kemaslahatan' or for the collective good."
• There was an overarching belief that mild diarrhoea was common in children under 5 and very easy to treat. Only 4 participants said a virus could cause diarrhoea, and only 3 mentioned (unprompted) that it could be prevented by vaccination. The majority of participants had never heard of rotavirus as a cause of diarrhoea, and only 3 respondents were aware of the rotavirus vaccine.
• After receiving information on the rotavirus vaccine, all participants perceived it as being important for children in their community and anticipated community acceptance of a vaccine preventing diarrhoea. However, all agreed that in the absence of NIP funding, the current cost of the vaccine on the private market was beyond the reach of most parents. Almost all community and religious leaders opined that rotavirus vaccine should be included in the NIP to communicate to the community the message that the disease is severe, especially for children, and that the government is committed to the prevention of the disease.
• Participants perceived that the community would be divided in their decision to accept or reject the vaccine due to the association with porcine. According to the religious leaders, such decisions for fatwa could be decided with ijtihad (independent reasoning) based on the agreement by all ulamas (religious scholars) about the product. Religious leaders predicted the vaccine being interpreted as haram (prohibited) but still permitted for use because of the potential for saving children's lives in the absence of other equivalent halal products.
• Religious leaders felt they could assist with providing evidence to the development of a fatwa and in advocating to the MUI to endorse the vaccine. Community and religious leaders described their additional role in announcing the fatwa during congregation meetings and in discussions with other religious and community leaders. However, they acknowledged a need for information from the health authority or healthcare providers to assist them in the promotion of the vaccine. Religious and community leaders considered the importance of a communication plan with tools to inform and educate them, including information about the manufacturing process, along with assurances that the final product has been "washed" more than 7 times to remove any trace of porcine, as well as information on the burden of rotavirus diarrhoea.

In short, amongst the religious and community leaders interviewed, there was broad acceptance of the rotavirus vaccine. In addition, there was unanimous agreement that, in order to successfully promote the rotavirus vaccine in Indonesia, it must be appropriately labeled as halal and included in the NIP. They believed that such a statement on the permissibility of the vaccine would have a significant impact on community acceptance. Religious and community leaders are willing to provide support in the introduction of new vaccines and felt their role should include advocacy for immunisation prior to the introduction of a new vaccine, during implementation, and as part of the ongoing programme. As such, they should be equipped with adequate information and engaged at different stages of new vaccine rollout.