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Indonesia plans to vaccinate its young working-age population against the coronavirus before the elderly, in contrast to much of the world that’s planning on putting its vulnerable older people first in line.

Southeast Asia’s first country to receive delivery of Covid-19 vaccines will focus on inoculating those between 18 to 59 years of age, starting with those working on the front lines of the pandemic such as health workers, the police, and the military. The U.K. started the Western world’s earliest vaccination program with a 91-year-old woman last week, in line with most other countries.

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The U.S. too started its vaccination program with the elderly this week, following its Centers for Disease Control and Prevention advice that healthcare workers and nursing-home residents should get shots first followed by those with pre-existing medical conditions.

As the death toll from the pandemic continues to climb, governments are grappling with the question of who should first get the many vaccines that companies are rushing through approvals. While Indonesia’s strategy currently stands apart, it may signal how other developing nations could consider their own roll-out given their struggle to procure enough doses to cover their population.

“Our aim is herd immunity," said Amin Soebandrio, director at the Eijkman Institute for Molecular Biology in Jakarta. “With the most active and exposed group of population -- those 18 to 59 -- vaccinated, then they form a fortress to protect the other groups. It’s less effective when we use our limited number of vaccines on the elderly when they’re less exposed."

Immunizing Workers

Indonesia is targeting the people who are most mobile due to their jobs, as well as regions with the highest number of coronavirus cases as it focuses on using the vaccine as a tool to curb the spread of infections.

Health workers on the islands of Java and Bali, which account for more than 60% of confirmed cases, will receive the 1.2 million doses of China’s Sinovac Biotech Ltd. vaccine that arrived on Dec. 6. That will be followed by front line workers in the rest of the country.

A roll-out date will be set when the country’s drug regulator gives the go-ahead.

The government has set a target of 246 million doses to reach its calculation of herd immunity -- the number of vaccines they need to immunize 107 million people, or 67% of their target 18-59 group and just 40% of the whole population. This is considerably lower than the generally accepted definition of mass immunity, which includes 60%-72% of a country’s entire population.

That government target will be met with 155.5 million doses ordered from Sinovac and Novavax Inc., with another 116 million potential orders from Pfizer Inc., AstraZeneca Plc, and the Covax facility. It’s also looking to develop its own shots, called Merah Putih after the colors of the nation’s flag, in a bid to supplement its supply.

Other experts view Jakarta’s vaccination plan with caution.

“Indonesia has a young population, so this may have influenced their thinking, but I think vaccinating older people makes sense," said Raina MacIntyre, professor of global biosecurity at the University of New South Wales. “In the end, however, with a limited vaccine supply, the difference between age-based strategies is not great."

Tough Choices

The country that’s home to the world’s fourth-largest population is placing the elderly, those with existing health problems, and pregnant women at the back of the line because it doesn’t have the data to ensure the safety of Covid-19 vaccines for those groups, Health Minister Terawan Agus Putranto said on Dec. 10. The Sinovac shots were tested on those who are 18 to 59 years old, which is why the government is wary of inoculating those in different age groups.

One day after the U.K. started distributing the Pfizer vaccine, its National Health Service had to issue a warning that people with a significant history of allergies shouldn’t receive the shots after two people experienced reactions.

“The question is a matter of suffering," said Djohansjah Marzoeki, president of the Indonesia Bioethics Forum. “Who develops severe symptoms or dies from the virus and who only gets minor effects and recovers on their own, it’s by this question that we should decide who should be vaccinated first."

As in other countries, the elderly account for most of the deaths from Covid-19 in Indonesia. Those who are 60 years old and above accounted for 39% of the country’s 19,111 fatalities, while 36% were 46 to 59 years old.

Finally, the decision on who to vaccinate comes down to how many shots a country can procure quickly.

“Developed nations may start with the elderly knowing that they have enough doses to cover the entire population, where that may not be the case for us," said C.B. Kusmaryanto, a member of Indonesia’s bioethics commission. “Our choices are extremely minus malum; There are no good choices, there is only the least-bad choice. When Indonesia only has enough to vaccinate those most likely to infect others then that’s who it should go to first."

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