A Vaccine Won’t End Indonesia’s Dengue Problem

The world's first dengue vaccine is now available in Indonesia, but for many of the more than 100,000 people infected in the country annually, the landmark vaccine is still years away.

Dengue is one of the world's deadliest viruses, infecting as many as 100 million people worldwide a year, according to the World Health Organization. Nearly half the world's population lives in areas endemic with the virus and the Aedes aegypti mosquito responsible for most infections. It's one of a half-dozen diseases and maladies—including malaria, diarrhea, and tuberculosis—that kill far more people in the developing world than Ebola or MERS, but typically receive far less attention.

"Dengue cases are an annual problem all over Indonesia," Andi Khomeini Takdir Haruni of Indonesian Doctor Association told VICE. "We can actually help prevent this, but we haven't given the problem maximal effort yet."

In Indonesia, the dengue virus infected nearly 129,000 people and killed 1,071 last year. The country has the second-highest instances of dengue transmissions, behind Brazil.

The vaccine, called Dengxavia, was developed by the international pharmaceutical company Sanofi Pasteur after 20 years of research and testing. It's proven effective in reducing hospitalizations by as much as 30 percent in regions with high instances of dengue transmission, according to a recent study published in the peer-reviewed journal Science.

But the high cost of the vaccine—Rp. 900,000 for each of a three-shot sequence—could prevent a large percentage of the population most in-need from ever accessing this potentially life-saving vaccine. On average, nearly half of Indonesia's 250 million people hover around the poverty line, living off around $2 USD per day. Low-income areas are more prone to dengue virus outbreaks, with communities in poorer East Jakarta reporting higher rates of transmission than wealthier sections of the capital.

A nationwide vaccination program is currently underway in the Philippines, but a similar program is still years away in Indonesia, according to local health officials. The Indonesian government needs to conduct a large-scale test of the vaccine before it can be incorporated into a national vaccination program. That trial is expected to begin in August of 2017, with the first results available for review by early 2018, Elizabeth Jane Soepardi, the Ministry of Health's surveillance and quarantine director told VICE Indonesia.

"We still need to conduct a demonstration project, where we have to test the vaccine in a certain group of people living in regions with a high rate of dengue cases," Elizabeth said. "Then we can analyze the impact, the operational strategy, and the budget.

"Once we found out that it's useful and important, then we may talk to the House of Representatives and the Ministry of Finance to fund a [national] roll out of the vaccine program."

Initial small-scale tests in Indonesia show that the vaccine could reduce new infections by as much as 65 percent, hospitalizations by 80 percent, and instances of dengue hemorrhagic fever by 92 percent.

But recent research questions whether a national vaccination program should be implemented in the first place. The vaccine works by immunizing the patient with a strain of dengue that allows people to build up an immunity. It's effective in populations previously infected with the virus. But in populations with less exposure to the dengue virus, the vaccine could create a situation where first infections are significantly worse.

This is because of how the virus works. There are four strains of dengue, and the first infection, while painful, is rarely life-threatening. But subsequent infections are significantly more dangerous. In areas with high-instances of dengue transmissions, the vaccine basically acts as a secondary infection without the illness—providing patients with a higher degree of immunity.

But in populations with low-transmission rates, the vaccine acts as a primary infection, meaning that when a person is eventually infected with a different strain of the virus it immediately jumps to a worse secondary infection. This, according to the study, could actually increase the number of hospitalizations in certain environments.

Indonesian health experts point out that any vaccine, while important, is not as vital as preventive measures. Mosquito fogging, the elimination of standing water, and barriers like mosquito nets are effective, and cheap, ways to reduce transmission rates.

"In medical sciences, the use of vaccines is classified as one of the curative measures," said Marius Widjajarta, the chairman of the Indonesian Health Consumers Empowerment Foundation (YPKKI). "I'm worried that the government will now focus merely on curative measures instead of preventive measures."