Cough, runny nose, fever and a spreading, blotchy rash: the symptoms of measles are all too familiar, even though the illness should have been consigned to history by now.

A vaccine to inoculate children against this nasty disease has been available for more than 50 years, yet immunisation rates have remained stubbornly inconsistent and outbreaks, serious illnesses and deaths continue to occur around the world.

Indonesia, which had the third highest number of measles cases in the world last year, is the latest Asian country to undertake a comprehensive campaign to protect children against the infection. By the end of September, health workers hope to have treated a total of 32 million infants and children with the measles-rubella (MR) vaccine, which prevents the two diseases.

But religious objections, superstition and mistrust are threatening to neutralise this ambitious project before it is even completed. With one month to go, only 30 per cent of eligible children, aged 9 months to 14 years, have been given the free vaccine according to the Indonesian Ministry of Health – against an official target of 95 per cent.

Dr Aman Pulangan, president of the Indonesian Paediatric Society which is backing the 881 billion rupiah (US$60 million) campaign, described it as an “emergency situation”.

To be effective, more than 90 per cent of the country’s children need to receive the MR vaccine, so their immune systems will collectively recognise and fight off infections, he said. But as the deadline nears, only 30 per cent of eligible children have done so. Take-up rates have varied widely, from 60 per cent in Hindu-oriented Bali to just 7 per cent in Muslim-dominated Aceh, North Sumatra.

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“If the coverage of this immunisation is less than 90 per cent anywhere, outbreaks can happen. In Indonesia, fewer than 15 provinces have coverage of 90 per cent or more. In towns and districts, it varies considerably. Some parents just do not understand that the community needs herd immunity.”

Unlike the recent scandal involving substandard vaccines in China, there appear to be no issues with quality control in Indonesia. The jab chosen for the MR campaign is manufactured in India, approved by the World Health Organisation (WHO) and conforms to rigorous safety standards.

But the vaccine does contain negligible traces of pork gelatin – used to stabilise the medicine against the effects of temperature – and this has generated a fierce backlash in some parts of Muslim-majority Indonesia.

The use of vaccines containing traces of pork gelatin had been controversial for Muslim and Jewish communities in other countries in the past. However, religious consensus on their use had previously been achieved, such as during a 2003 conference of Islamic scholars convened by the WHO.

Last week, the Indonesian Ulama Council (MUI), which judges whether food, medicines, cosmetics and other consumer products are halal (permitted) for Muslims, declared the MR vaccine mubah (permitted for use by Muslims) but only because a halal alternative was not available.

Despite the influence of the MUI – its leader, Ma’ruf Amin, is running for vice-president alongside President Joko Widodo in next year’s election – the long-delayed decision came too late for regional community leaders and some parents, who had already rejected the vaccine as haram (forbidden).

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Dr Pulangan blamed Indonesia’s decentralised system of local politics, which allows mayors, schools and parents to refuse to participate in the vaccination programme, with no consequences.

“Right now, immunisation depends on local communities so if the head of district or town does not want it, it does not happen,” he said. “When I started practising medicine in 1998 it wasn’t like this, everything was controlled from Jakarta and policies could be carried out across the country. Now, if the head of a district knows nothing about health or immunisation and objects to the vaccine, then his community is at risk. It feels like we are going backwards.”

In some areas, suspicions of the central government, international aid agencies or hoaxes based on false side-effects of the vaccine have also acted as a deterrent to parents, echoing similar controversies in the West. But resistance on religious grounds has been particularly strong in Sumatra and the Riau Islands, where conservative Muslim clerics issued their own decrees outlawing the vaccine – and vaccination rates among students have stagnated at around 28 per cent.

It’s impossible to wait [for a halal vaccine], we cannot afford to
Dr Aman Pulangan

“Now that it is clear [the vaccine contains] elements that are forbidden for Muslims, the MUI asks Muslims in Riau Islands province to reject the vaccine,” said Riau Islands MUI secretary Ustadz Santoso. “We don’t find any sense of urgency in using the vaccine, as measles and rubella do not plague the area. If the MR vaccine is really so important, then we call on the government to quickly make one that is halal and safe for Muslims.”

But Dr Pulangan said if vaccination rates remained low, it was only a matter of time before Indonesia suffered another outbreak, given that more than 7,700 measles and 3,000 rubella cases occurred in the country annually.

A halal MR vaccine is not available currently, and would take many years to develop, he said: “It’s impossible to wait, we cannot afford to.”

“If something goes wrong, and there’s another outbreak, who will be responsible? If there are children sick, who do they blame? No one will speak up for the children. We all have a responsibility to improve vaccination [rates] and provide immunity”.