Prof Julie Leask, Prof Amin Soebandrio and Sr Afu Tei on Vaccine Uptake

Welcome to episode 20 of Contain This, brought to you by the Indo-Pacific Centre for Health Security. This episode is hosted by Camilla Burkot, a senior adviser with the Department of Foreign Affairs and Trade’s Vaccine Access Taskforce, which will oversee the Australian Government’s recently announced Regional Vaccine Access and Health Security Initiative. 

This initiative will help to ensure that people across the Pacific and Southeast Asia are able to access safe, effective and affordable COVID-19 vaccines when they become available by supporting both procurement of vaccine doses and strengthening immunization policy and delivery pathways in our region. On today’s show, we will discuss the issue of vaccine uptake in the Indo-Pacific region with two experts in the fields of vaccine development and delivery from Australia and Indonesia. We'll also hear from the field with the story of a senior immunisation nurse from Tonga.

Camilla will begin by talking to Professor Julie Leask from the Susan Wakil School of Nursing and Midwifery at the University of Sydney. She's a member of the Australian Regional Immunisation Alliance, visiting professorial fellow at the National Centre for Immunization Research and Surveillance and holds a range of advisory roles with the World Health Organization. In addition, Julie has recently been appointed to the Expert Advisory Group that will guide the new Regional Vaccine Access and Health Security Initiative.

You will then hear from Sister Afu Tei about her experience as an immunisation nurse in Tonga. Sister Afu Tei is the Supervising Public Health Sister, Reproductive Health Project Co-ordinator and National EPI Co-ordinator in Tonga. 

Lastly, Camilla speaks with Professor Amin Soebandrio is a lecturer in clinical microbiology at University’s Indonesia and chairman of the Eijkman Institute for Molecular Biology, a nonprofit research body under the Ministry of Research and Technology and National Agency for Research and Innovation located in Jakarta. He is also honorary professor at the University of Sydney Medical School has played a key role in building strong relationships between the Indonesian and Australian medical research communities. At the beginning of the pandemic, Professor Amin oversaw the laboratory that analyzed samples from the earliest COVID-19 cases in Indonesia. Now, the institute’s work has turned towards vaccine development.

For more information about the Indo-Pacific Centre for Health Security, visit our website https://indopacifichealthsecurity.dfat.gov.au.

Connect with us on Twitter via @CentreHealthSec and @AusAmbRHS

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Enjoy,
Contain This Team

Transcript

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The views presented in this podcast are the views of the host and guests. They do not necessarily represent the views or the official position of the Australian Government.

Camilla Burkot  00:01

Welcome to Contain This. I'm Camilla Burkot, a senior adviser with the Department of Foreign Affairs and Trade’s Vaccine Access Taskforce, which will oversee the Australian Government's recently announced Regional Vaccine Access and Health Security Initiative. This initiative will help to ensure that people across the Pacific and Southeast Asia are able to access safe, effective and affordable COVID-19 vaccines when they become available by supporting both procurement of vaccine doses and strengthening immunization policy and delivery pathways in our region. On today's show, we will discuss the issue of vaccine uptake in the Indo-Pacific region with two experts in the fields of vaccine development and delivery from Australia and Indonesia. We'll also hear from the field with the story of a senior immunisation nurse from Tonga. I will begin by talking to Professor Julie Leask from the Susan Wakil School of Nursing and Midwifery at the University of Sydney. She's a member of the Australian Regional Immunisation Alliance, visiting professorial fellow at the National Centre for Immunization Research and Surveillance and holds a range of advisory roles with the World Health Organization. In addition, Julie has recently been appointed to the Expert Advisory Group that will guide the new Regional Vaccine Access and Health Security Initiative. Julie, welcome to Contain This. To begin, can you tell us about yourself and your interest in vaccination in our region?

Professor Julie Leask  01:24

Yes, so I'm basically a social scientist who specializes in vaccination. So I look at what people think feel and do about vaccination. And our research looks at supporting vaccination programs in practice. I have a nursing and midwifery background and I've been in public health since 1996, when I did my Masters of Public Health. So I've been privileged to become more involved in immunization in the region just in the last couple of years really, through the establishment of the Australian Regional Immunization Alliance, which brings together people who have high level expertise in vaccination around Australia to continue existing work they do with countries in the region, or to establish new work. And we've been fortunate to receive a grant from the Pacific Island development program to support countries in their vaccination programs, and also to support surveillance of vaccine preventable diseases. And that work extends to Timor-Leste, it extends to Papua New Guinea, and of course, the Pacific Island countries as well. So I and Fiona Russell are leading the work in the Pacific Island countries. Professor Russell has a huge amount of experience in vaccination programs in the region. So it's a real privilege to be learning from my colleagues. And I also had the opportunity to assist the WHO office in Fiji and Samoa in January as part of the Samoan measles outbreak recovery effort.

Camilla Burkot  03:15

How can we assure high uptake of the COVID-19 vaccine if one proves successful?

Professor Julie Leask  03:19

So we've got to do a lot of things. And, you know, governments right now are looking at how they can ensure, first of all, that they get the vaccine, that they have access to it in their country through facilities like you know, the COVAX facility and other efforts, multi-agency efforts at a global level to ensure that there's equitable access to vaccines in all countries, not just wealthy countries. So that's number one. The second is making sure that the vaccine is safely distributed, and the cold chain is maintained. And of course, that could present a new challenge with some of these vaccine candidates that require extremely low temperatures for storage. So there's the distribution, the cold chain, making sure that the services that are actually giving the vaccine have enough vaccine, and you don't have too much going to another area. So having that balance right in the distribution. They're all major challenges. 

And then you've got the sort of programmatic strategy such as you know, do you have... Have you been able to set up services that are capable, have existing capabilities in delivering vaccines like these to the community, and that the services are very accessible for the community? Do you have very good systems in place for the whole vaccination procedure and how the vaccine is explained to people? How side effects are explained what to look out for, do we have good systems for monitoring adverse events following immunization? So there's all those sort of system and programmatic issues. And of course, it's very important to support and make sure that providers of the vaccines are sufficiently trained, and upskilling young people who, A, may not be familiar with vaccination, or B, might not be familiar with giving a COVID-19 vaccine to an adult, which, of course will be everybody initially. And then, and then you've got things that are issues around access for people to get to the clinic as well, and making sure that the clinics are convenient, have convenient opening hours, so that people can easily reach. And so you know, of course, there's the challenge in getting vaccines to people in outer islands in many Pacific island nations. 

And if you've got a vaccine that requires a pretty strict cold chain, how are you going to manage that practically. So all of those things need to be thought through. And then of course, there's the communication side of things where you're making sure that people are aware that they are recommended to have a vaccine and where they can go to get it. And then there's the sort of more community engagement. And that's that more two-way communication that I was talking about earlier. And that's extremely important. You know, have you got your community leaders feeling informed and knowledgeable enough? Based on the limited knowledge you might have at the time? Have you engaged with religious leaders, provider organizations? Have you had an opportunity to hear what their concerns and perspectives are? And, and just making sure that there's that early frequent communication, and it's communication that's two way not just one way. So all of those things are multi-component strategies of what work to improve vaccination rates, and no one thing is going to get as high vaccination rates. So if you have even the most perfect ways of dealing with misinformation, that's not going to cure all vaccine uptake problems.

Camilla Burkot  07:30

There has been an example of a serious vaccine safety event in the Pacific in recent years. In July 2018, two infants and someone died after receiving the measles, mumps and rubella vaccine. Following that event, the Samoan government suspended the measles vaccination program for about 10 months. It was later established that the deaths were due to an administration error where the nurses prepared the vaccine using an expired muscle relaxant instead of water. What lessons can we learn from that suspension of vaccination and the subsequent measles outbreak?

Professor Julie Leask  07:58

There’s is a tendency to think, look, if we just get our messaging, right, people act. And of course, it's much more than that. I mean, of course, in Samoa there had to restore trust in the vaccine, which ended up of course, being possible and it was certainly motivated by having a lot of measles around. But it is still possible to restore trust in vaccines without having major outbreaks. I think it showed that communication needs to be two way. And it starts with understanding the perspectives of communities and how they see things and what their information needs are. So in that period, when the vaccine had been suspended, I would imagine there was a huge amount of hesitancy among parents in Samoa, and many certainly wouldn't want their children vaccinated even when they started to half-heartedly return, restore the vaccination recommendation, because there probably needed to be more frequent communication. 

So we learn from any vaccine safety event, whether it be Samoa’s or the one that we had in Australia with a certain type of influenza vaccine for children, where there was a high rate of febrile convulsions after that vaccine was given and that particular vaccine had to be suspended in children. What we learn is that people will certainly get scared off a vaccine, but governments also get scared off communicating about the vaccine afterwards. And they actually need to do what's not intuitive, which is to communicate early and often, acknowledge uncertainty and communicate amidst uncertainty. Use trusted spokespeople, be empathic and also respect cultural ways. And, and, you know, country constraints and those sorts of issues. So I think I think for me Samoa, other vaccine issues, health emergencies, the pandemic, again and again illustrates the importance of good risk communication. And at the heart of good risk communication is accepting and involving the public, which in a practical sense means having an ear to the ground, having social listening, community consultation to find out the perspectives of the communities, and then tailoring the information that's given according to what people need to know.

Camilla Burkot  10:44

Thank you, Professor Julie Leask, for your insights. We'll now hear from Sister Afu Tei about her experience as an immunization nurse in Tonga.

Sister Afu Tei 11:00

Immunisation programming in Tonga started in 1958 by introducing BCG Vaccine. The immunisation coverage for Tonga is 99%. For coverage, we keep it in high maintaining the coverage since the last two to three decades. Immunisation program in Tonga was started, like I said, in 1958. We are so thankful for the donors, the partners. They were funding the vaccines. But since 2000, the government fully funded the vaccines. We have a policy in the handbook that for workers to follow and we still have our vaccines procured by UNICEF. We do the same as with the other Pacific Island countries. And our vaccine is recommended by the WHO. I think this is our immunisation in Tonga. 

In the meantime, we have about 76 vaccinators in Tonga that's allocated to different stations, including the Outer Islands. I think this issue is I think it's became a proper issue - the misconception on vaccines. There are some people that are against the immunization program, because they have something from internet talking about vaccine can cause what in what you know, cause problems to the kids. But even with the efforts of our nurses and their experience, they can convince them, you know, only a few who refuse immunization in Tonga. It's mainly, really those with the religious belief. But even that, like I said, it's about 99% of our immunization coverage, it is only a few they refuse to have the immunization. 

I think with our immunization program, we really need the help of the people. The strong partnership with the people, I know this from my experience in working with immunization program. It's very successful when we when we give us from partnership with the community. Mass media campaign is very helpful. Community outreach, just to raise the awareness of the of the people is very helpful with making it clear to the community and make sure that vaccines very safe. It's tested. It's recommended from the WHO to use. But I think mass media campaign in the community outreach is needed just to raise that community awareness.

Camilla Burkot  14:34

You've been listening to Sister Afu Tei, a supervising public health sister and national EPI coordinator in the Ministry of Health in Tonga. At this time, most South Pacific countries have reported very few or zero COVID-19 cases. However, the situation is very different in some parts of Southeast Asia. The Philippines and Indonesia have reported high numbers of COVID-19 cases starting from around March this year. Professor Amin Soebandrio is a lecturer in clinical microbiology at Universitas Indonesia and chairman of the Eijkman Institute for Molecular Biology, a nonprofit research body under the Ministry of Research and Technology and National Agency for Research and Innovation located in Jakarta. He is also honorary professor at the University of Sydney Medical School has played a key role in building strong relationships between the Indonesian and Australian medical research communities. At the beginning of the pandemic, Professor Amin oversaw the laboratory that analyzed samples from the earliest COVID-19 cases in Indonesia. Now, the institute's work has turned towards vaccine development. Professor Amin, welcome to Contain This.

Professor Amin Soebandrio  15:37

Thank you. Thank you very much.

Camilla Burkot  15:38

In terms of COVID-19 I understand there's a relatively recent partnership with CSIRO, could you tell us a bit about that partnership and the work that's going on under that project?

Professor Amin Soebandrio  15:54

Yeah. Yeah, we have been discussing this CSIRO several times and currently we are in the process of finalizing the kind of implementation agreement. The first idea was we will establish this advisory board for vaccine research consisting of some Australian researchers and Eijkman researchers and also we propose to invite vaccine researchers from other countries like from European institutions, from the US, probably from Japan to build a very strong advisory board that is limited to the vaccine development. And we are still in the process now. And just to be clear, we will start to discuss, to receive advice from CSIRO on improvement of our animal facilities for example. And also improvement of one facility located a little bit outside Jakarta. The facility was designed as pilot production facilities for biological substance. So the facilities already prepared today has been constructed three or four years ago. It has two main facilities. One is for GMP facilities, good manufacturing facilities and also the other side as a good laboratory practice facility. So probably in the near future, we will start our discussion with CSIRO to improve that facility and make it used in pilot production. As you know, before we start the first phase or clinical trial, we need only limited minor vaccine. Not mass production. That's why we need the pilot production facilities.

Camilla Burkot  19:00

I see yes. So you have enough to undertake the trials and then develop evidence before mass production. I'd like to turn now to talk a little bit about the Indonesian vaccine for COVID-19 that's been developed. And perhaps for listeners who may not be very familiar you could give a bit of an introduction about this vaccine and why it's so important.

Professor Amin Soebandrio  19:27

Based on several justifications, we finally realize that herd immunity is very important. But the herd immunity should be achieved by vaccination. And that's why we need to have the facilities, we need to have good access to a vaccine. And then when we come to the number of vaccines required in Indonesia, we have to consider the number of population in Indonesia, we have 260 million population. And if we have to reach herd immunity, minimally, we have to vaccinate about 175 million people. Right. And if we consider every subject have to be vaccinated twice that means we would need to see 350 million doses. So, again, if we refer to the international schemes like COVAX or CEPI they promise to provide Indonesia with some amount of vaccine, but only probably limited to 20 or 30% of population. Yeah, you could, you could imagine that the other 70% of target population still need vaccinations. So, in that case, we decide that Indonesia should not be dependent to other countries, we have to have our own sovereignty, and so, we need to have our own facilities in developing and producing vaccines. That's why around the end of March, the Minister of Research and Technology, assigned the Eijkman Institute to lead a consortium of some institutions in Indonesia to start research and development and production of our own vaccine.

Camilla Burkot  22:24

So how is it going so far? Where are you now? Where's the vaccine candidate up to?

Professor Amin Soebandrio  22:32

You know that there are two main steps in developing vaccines. One is the first one, the first step is laboratory scale, and then followed by industrial scale. So Eijkman actually was assigned a decision to develop the laboratory scale of vaccine. And we were given only 12 months to develop the seed vaccine. And currently, we can see that we are in the year about 55% of the task. And we are targeting that in February or March next year, we could deliver the seed vaccine to the industry. So it could be processed for a clinical trial Phase One, Two and Three.

Camilla Burkot  23:34

Okay. So it's coming along, but maybe some time yet before it's able to enter into clinical trials and, and into regulation and approval. I wondered if we could, as we're looking forward a little bit, to actually talk a little bit about the process and how it is that vaccines go from research and development to approval in Indonesia. And if there's any particular requirements that the Indonesian regulators have to approve vaccines, for example, I know in some countries, the regulators require that the Phase Three trials must take place in that country, and there has to be data in that country for a vaccine to be approved.

Professor Amin Soebandrio  24:30

Yes, we received a strong message from the president, that the vaccine, the so called Red and White vaccine should be safe, yet effective for Indonesian people. So that's why we are doing our research and development process very, very carefully. We are not in a very great hurry, although we know that people are expecting the vaccine very badly. Yeah, but we do it very carefully, all the procedure we follow. And also we have already invited the Indonesian MDA [annual vaccination campaign administration body]. As well as you understand that this is very sensitive, is the halal vaccine. So we need to receive also have a certification later. So that's why those two main government bodies. So we're already informed from very, very beginning. So we have to carefully select all the ingredients or the reagents, all the processes and to make sure that it fulfills all the requirements for safety, efficacy as well as for Halal. And that's the key point because we have to make sure that the vaccine will be accepted by most of people in Indonesia.

Camilla Burkot  26:21

That's absolutely, that's very important. And that's a great segue to what I wanted to talk about next, which was a little bit more about vaccine uptake and delivery. Once the vaccine is approved, do you think do you think it will make a difference for people in Indonesia, do you think there will be more acceptance or people will be more likely ready to receive a vaccine knowing that there's a vaccine that has been developed by Indonesia for Indonesia?

Professor Amin Soebandrio  26:53

Yes. There was a survey ... and this survey shows that currently we are doing Phase Three clinical trial for Sinovac vaccine. And then the survey was conducted by an independent body. And it was, to my surprise, actually, what was the result. First, the acceptance of the Sinovac vaccine is about 44%. So about 56% of the respondents were not sure about side effects. But then what surprised me is when they asked about the acceptance to the Red and White Vaccine. In the response is sorry, Sinovac was accepted by 36% and that Red and White vaccine was actually accepted by about 44%. Actually, we have not made any promotion to the public about what happened. But the most impressive, at least 44% of the population are already prepared to accept the Red and White vaccine, although the other 56% has been challenging, but that even before any publication on Red and White vaccine 44% of population has already have already accepted. Excellent. Yeah, hopefully as the completed preclinical trial and also already start the first clinical trial the acceptance rate increased significantly.

Camilla Burkot  29:33

And in that in that survey, did they ask any questions of people about why they responded that they would accept or not accept? Do you have a sense of what people's thinking, the public's thinking is behind that?

Professor Amin Soebandrio  29:48

The same question actually has two or three factors. One is the safety and efficacy and halal, whether the vaccine is halal or not.

Camilla Burkot  30:03

So that's a very important consideration. Yes, I wanted to ask you because we know Indonesia is a very diverse and very, as you said, a very large country, but also a very, very diverse country. And in thinking about communications and how communities can be engaged in order to accept the vaccine, a vaccine, once it's ready, I wonder if you had any reflections on whether there are particular strategies that will need to be used in order to reach what is a very wide range of people?

Professor Amin Soebandrio  30:37

Actually vaccine hesitancy and also refusal, has, has been experienced, since several years by the vaccine program of the Ministry of Health. I belong to going to the so called Indonesian Technical Advisory Group for Immunisation. And we realized that, too, for some populations it is this still difficult to accept the vaccine. It happened in polio vaccine in the history of vaccine. Yeah, in the past. So that's why only one or two years ago there were some outbreaks of diphtheria for example, in some part of Malaysia. And then if we look back, then we realize that actually that area were not vaccinated well during the vaccination program, a couple of years before. So, we anticipate to face a similar situation. So, what we have to do is, and decide on information by the government, by the Minister of Health, we should use informal channels. I mean, we should involve people who could influence population. For example, a person from the religion sector, not only Muslim, but some of the Christian population also they refuse to be vaccinated. So that's why we have to consider religious leaders to be involved in the vaccination campaign.

Camilla Burkot  33:02

Yes, I think that's been experienced in in similar experiences in many countries, both with vaccine hesitancy, but also using those channels, social channels, religious channels and voices to speak through. Another sort of a related question I was just thinking, as you were talking about using informal channels is also the impact or the use of social media and popular media to spread messages. Is there much practice in Indonesia of using social media or these kinds of digital channels to get out public health messaging and whether that might be used as well?

Professor Amin Soebandrio  33:49

Oh, yes, of course. Media, in particular electronic mediums are very powerful. Of course, the mainstream media, like television, is most certainly, they help us. Then even currently, some of the television program they have already included promotion and publication for vaccination. And but now, we have also to mobilize the social media, yeah, because hundreds of social media platform were there and not hundred percent supporting. So we have to be very careful and to some extent, that the informal or informal social media is they have better access to the public. So people probably just open their cell phone and receive the message directly rather than watching the television. That's why we have to work hard with the channel.

Camilla Burkot  35:41

Yes, it's a channel that comes with advantages and disadvantages, as you say it's very accessible. But there's also many the potential for much misinformation to travel. I think we covered a lot of ground in a short time, but it was very, it was very interesting. So thank you again, Professor Amin.

Professor Amin Soebandrio  36:02

Thank you. Thank you very much.

Camilla Burkot  36:04

You have been listening to Professor Amin Soebandrio, chairman of the Eijkman Institute of Molecular Biology. I'm Camilla Burkot from the Indo-Pacific Centre for Health Security. Thank you for joining us for this podcast, the first in a series of Contain This episodes focusing on issues surrounding COVID-19 vaccines in the Pacific and Southeast Asia. Please subscribe to our podcast channel to hear future episodes discussing vaccine financing, priority groups, efficacy, stories of community initiatives launched to support vaccine uptake and much more.