Indonesia's province of Aceh has started to vaccinate about 1.2 million children, after four were infected with polio.
Children in school uniforms and toddlers with their parents lined up on Monday for vaccine shots in Sigli town of Pidie regency, Aceh.
On the first day of vaccine rollout, the health authorities in Pidie regency said more than 14,000 children aged 0–12 months, or 15 per cent of the target, had received the immunisation.
The push comes after the virus was detected in October in a 7-year-old boy suffering from partial paralysis near Sigli.
Three more cases were found in the regency on November 19, leading to the Indonesian government declaring polio as an "extraordinary event" and promoting the mass immunisation campaign.
Maxi Rein Rondonuwu, the health ministry's director general for disease control and prevention said none of the three children had their basic vaccinations.
"It has to be reported as an outbreak, because it had been declared eradicated in Indonesia, but it turns out that there is still wild polio virus,” he said.
Indonesia and ten other South-East Asian countries were declared polio free in 2014 by the World Health Organization (WHO).
Mr Rondonuwu said his ministry was doing door-to-door screening to ensure there were no infections that have not been reported.
"There is no cure for polio, the only treatment is prevention and the tool for prevention is vaccination," Mr Rondonuwu said.
Last week, Indonesia's Health Minister Budi Gunadi Sadikin said there were parents in the regency who were still reluctant to vaccinate their kids.
Mr Sadikin said the reluctance occurred after the outbreak of measles-rubella several years ago.
A "lack of clean and healthy living behaviour" was also mentioned as a cause of the new polio cases, Mr Sadikin was reported as saying by CNN Indonesia.
There was still a number of residents who practice open defecation in rivers where children sometimes swim.
The polio virus is transmitted person-to-person, generally through the "fecal-oral" route, according to the WHO.
Reluctant to be immunised
Officials said polio immunisation rates in the conservative province are behind the rest of the country.
For a comparison, only 50.9 per cent of the infants born in Aceh in 2021 received a polio vaccination.
It was the second lowest on a national scale after West Papua, where only 43.4 per cent of babies were vaccinated.
The efforts to eradicate the disease were also hampered by widespread disinformation the vaccine is incompatible with religious beliefs.
Aceh is particularly conservative, and is Indonesia's only province allowed to practice Sharia, which was a concession made by the national government in 2006 to end a war with separatists.
False rumours that the polio vaccine contains pork or alcohol, prohibited according to Muslim beliefs, have proliferated, especially in rural areas, complicating vaccination efforts, said the head of the Aceh Health Office, Hanif, who only goes by one name like many Indonesians.
“We can't work alone, we need support from all parties, including religious leaders, so that people understand the importance of immunisation," said Hanif.
In 2019, the Indonesian Ulema Council released a fatwa stating the polio vaccine was permissible for consumption, especially for children who are immunocompromised.
But Azhar, the father of the 7-year-old who contracted polio, said he had opted not to immunise his son after other villagers told him vaccines may contain harmful chemicals or non-halal substances.
"My neighbours said that my son doesn’t need to be immunised and I didn’t want my son get sick because of harmful chemicals that are against Islam," the 45-year-old said.
Dewi Safitri, a mother of three who was getting her children vaccinated on Monday, said it was simply a matter of not knowing it was necessary.
She said she was convinced after health workers spelled out the risks of paralysis or death if her children were to go unvaccinated.
“I didn’t even know about immunisation,” she said.
Australians shouldn't be complacent
Polio primarily affects children under the age of 5, according to the WHO, but unvaccinated people of any ages can contract the disease and sporadic cases continue to crop up.
In September, New York stepped up its polio-fighting efforts after the disease was detected in wastewater.
Officials began checking for signs of the virus there after the first case of polio in the United States was identified in July in Rockland County, which is north of the city.
It was confirmed in a young adult who was unvaccinated.
The statewide polio vaccination rate is 79 per cent but Rockland's rate was lower, and New York health officials urged all unvaccinated residents, including children of at least 2-months-old, to get vaccinated immediately.
Dicky Budiman, an Indonesian epidemiologist from Australia's Griffith University, said the discovery of polio in Aceh must be responded to seriously because "the threat is real for Indonesia".
Basic immunisation coverage was still low, putting the country in a high-risk category, he said.
"This is what the government really has to pursue, because it’s dangerous if we don't," Dr Budiman said.
Last September, New South Wales and Victoria started testing sewage for polio, as cases of polio re-emerged overseas.
Professor Michael Toole, associate principal research fellow at the Burnet Institute, told ABC News Daily Podcast in September that polio outbreak in Australia is "a moderate, yet plausible risk".
Professor Toole said vaccination rates today in Australia were "pretty high, 90-95 per cent, but of course, there are pockets of low coverage".
Despite generally high immunisation, he said Australians shouldn't be complacent about the risk, particularly since the strain that paralysed the patient in New York has been genetically linked to sewage samples taken in both London and Israel.
Last week, new polio cases were found in Afghanistan, Algeria, Chad, Democratic Republic of Congo, Ethiopia and Nigeria, according to the WHO's Global Polio Eradication Initiative.
Polio is considered endemic in Afghanistan and Pakistan.
ABC/AP
