HEALTH CARE & IMMUNISATION

Medical Community VS Muslim Public PERSPECTIVES

Dato Dr Musa Mohd Nordin
FRCP (Edin) FRCPCH (UK) FAMM
Federation of Islamic Medical
Associations FIMA
Asian Strategic Alliance for
Pneumococcal Disease Prevention
ASAP
Malaysian Paediatric Association
MPA
www.immunise4life.my

DISCLOSURES
No research grants or honorarium from
GlaxoSmithKline, Sanofi Pasteur, Pfizer,
Merck, Novartis or other Vaccine
companies

OUTLINE
Brief history of Islamic Medicine
Maqasid Shariah
Early history of Vaccines

Concerns of Muslim public lay Muslims,

Muslim anti-vaccines, Muslim scholars
Conclusions

600AD - 1700AD
Modern
Industrial
Day
Revolution
Renaissance

Greek

BC

Romans

5th

17th 18th 20th

MEDICAL HERITAGE

622 - Hijrah
707 - 1st Hospital
766 - Med. School
920 - Doc. Exams
925 - Ar Razi
961 - Az Zahrawi
1037- Ibn Sina

1100 - 60 hospitals
1150 - Crusades
1162 - Ibn Zuhr
1276 - alMansour
1288 - Ibn anNafis
1331- Ibn alQayyim
1700 - Renaissance

Predating by centuries the modern

concept of air borne infection.
Clinical trial using control groups.
Monograph on small pox & measles

Had there been Nobel Prizes in 1000, they

would have gone almost exclusively to
Muslims.
Martin Kramer (American Historian)

VERSES OF SYIFAA
Al-Isra 17:82 And We send down of the Qur'an that which is
healing and mercy for the believers

As-Shuara 26:80
Yunus 10:57
An-Nahl 16:69
Taubah 9:14
Fussilat 41:44

PROPHETIC MEDICINE
And when I am ill. It is He who cures me.
(As-Shuara 26:80)

And Job, when he called to his Lord, "Indeed, adversity

has touched me, and you are the Most Merciful of the
merciful.
(Al-Anbiya 21:83)
And I cure the blind and the leper, and I give life to the
dead - by permission of Allah
(Al-Imran 3:49)

TIBB NABAWI
2 Blessings from Allah (Bukhari)
Setting Benchmarks:
Usul Fiqh - Principles of Jurisprudence

MAQASID SHARIAH
1. Religion
2. Life
3. Progeny
4. Intellect
5. Property
And whoever saves one life, it is as if he had saved all
mankind (Al-Maidah:32)

EARLY HISTORY OF VACCINES

429 BC: Greek historian
observed those who
survived SMALL POX
(VARIOLA) were not reinfected

900 AD: Chinese discovered

VARIOLATION. Prevent
smallpox by exposing
healthy people to smallpox
scabs.

1700s: VARIOLATION spreads around the world

Turkish doctors used variolation to immunise against
small pox.
Lady Mary W Montague brought idea back to England

Edward Jenner
Smallpox Vaccine
1796
Inoculation with
cowpox (vaccinia)
induced immunity to
smallpox

Before Vaccines - The Faces of Smallpox

Case Fatality Rates of Smallpox

1950-1971
Successfully Vaccinated

Case Fatality Rates

Never

52%

Only after the exposure

29%

0-10 years before exposure

1.4%

11-20 years before exposure

7%

> 20 years before exposure

11%

Fenner F et al. Smallpox and its Eradication, pp53

Last Cases of Smallpox**

Rahima Banu
16 Oct 1975, Bangladesh

Ali Maow Maalin

26 Oct 1977. Somalia

** Two laboratory acquired cases occurred in UK in 1978

1980

Anti-Vaccine Begins
Began around the first small pox vaccine
Arguments are basically the same as TODAY!
small pox isn't that bad
the vaccine won't provide life-long immunity
the vaccine will give you syphilis autism
it is against their religion

FEAR OF POLIO !

POLIO IN MALAYSIA
5

No. of cases

4
4
3
3
2
1
1
0

0
1985
1997

1987

1989

1991

1993

1995

Year
Figure 1: Incidence of paralytic poliomyelitis in Malaysia (Ministry of Health)

INFLUENZA PANDEMIC 1918

1/5 world infected
I had a bird, Its name is ENZA, I opened the window & IN FLU ENZA

20-40 million deaths

Killed more than WW1
Influenza pandemic 2009 300K
deaths

CAUSES OF 8.8 MILLION UNDER 5 DEATHS

2008
1.6 MILLION PNEUMONIA DEATHS
in children < 5 years
Pneumonia
Pertussis
Measles
Meningitis
Malaria
Diarrhea
AIDS

MUSLIM COUNTRIES

40% UNDER 5 DEATHS

2.5mil deaths

2.5mil deaths averted

ANNUAL DEATHS & DEATHS AVERTED BY VACCINES

1,250,000

750,000

250,000

(250,000)

(750,000)

(1,250,000)

ARI
(Sp/Hib/NmAC)

Measles

Tetanus

Source: W. Orenstein, Gates Foundation; WHO, Burden of Disease 2004, released 2008

Pertussis

Rotavirus
Diarrhoea

Other (Polio,
Diptheria,
Yellow Fever,
J.E.)
30

POPULATION BENEFITS

HERD IMMUNITY

HERD IMMUNITY: IPD IN ADULTS > 65 YEARS

USA 1998-2004
Mass vaccination
recommended for infants
40

Cases per 100,000

35

33.6

32

30

73% reduction

24.6

25

17.6

20
15

11.9
9

10
5
0

1998/99

2000

2001

2002

2003

Lexau C et al JAMA 294:2043-51, 2005 and CDC unpublished data, presented by Dr Cynthia Whitney, IDSA 2005

2004

HERD IMMUNITY: IPD IN ADULTS > 65 YEARS

USA 1998-2004
Mass vaccination
recommended for infants
40

Cases per 100,000

35

33.6

32

30

24.6

25

73% reduction

17.6

20
15

11.9
9

10
5
0

1998/99

2000

2001

2002

2003

Lexau C et al JAMA 294:2043-51, 2005 and CDC unpublished data, presented by Dr Cynthia Whitney, IDSA 2005

2004

Health Impact of Vaccine Scale-Up

2011 -2020
6.4 Million Deaths Averted

426 million Cases Averted

Pneumonia
13%

Diarrhea
24%
Pertussis
7%

Measles
3%
Malaria
6%

Pneumonia
41%
Diarrhea
74%

Malaria
16%
Measles
6%

Meningitis
<1%

Meningitis
6%

63,000 Disabilities Averted

Due to meningitis prevention
72 GAVI Countries; 2011-2020 (inclusive)
Source: Stack ML, et al. Health Aff (Millwood). 2011;30(6):1021-1028.

Pertussis
4%

Immediate Economic Benefits

Preventing illness could save $6.2 billion ($4.8-9.1 b) in treatment
costs and $1.2 billion ($0.7-1.4 b) in lost output of caretakers

Millions

Annual Treatment Costs Saved

900
800
700
Malaria

600

Pertussis

500

Measles

400

Meningitis
Diarrhea

300

Pneumonia

200
100
2011

2012

2013

2014

2015

2016

2017

Source: Stack ML, et al. Health Aff (Millwood). 2011;30(6):1021-1028.

2018

2019

2020

Long-Term Economic Benefits

Totaling $151 billion ($131-176B) in immediate & longterm benefits

Billions

Cumulative Economic Benefits

Total Economic Benefits by Country

160
140
120

Cameroon
1%

100

Other
24%

India
33%

DRC
Bhutan 1%
2%

80

60
40
20
0
2011 2012 2013 2014 2015 2016 2017 2018 2019 2020
Immediate Benefits

Long-term Benefits

Immediate Benefits = Treatment costs + Caretaker Productivity

Long-term Benefits = Morbidity Productivity + Mortality Productivity

Afghanistan
2%
Sudan
Pakistan
3%
4%
Indonesia
7%

Nigeria
15%
Angola
8%

Source: Stack ML, et al. Health Aff (Millwood).

2011;30(6):1021-1028.

COST BENEFIT ANALYSIS

$ saved per $ invested

25

20

$ medical savings
Societal $ saved*

15

10

DTPa

IPV

MMR

Varicella

Hepatitis
B**

Haemophilus
influenzae b

*Includes work loss, deaths and disability

**Perinatal/infant

Centres for Disease Control and Prevention 2002

Cost-Benefit Analysis of Hib

Immunisation Study in Malaysia
COST OF VACCINATION
PROGRAMME
RM 32.5 M
(US $8.6 M)

BENEFITS:
Saved premature death cost
Saved hospitalization cost
Indirect cost to family saved
Saved long term care cost

RM 47.1M
RM 4.3 M
RM1.4 M
RM 21.1 M

NET BENEFIT : RM 41.4 M (US$ 10.9 M)

BENEFIT TO COST RATIO : 2.3

SENSITIVITY ANALYSIS

cost (25%)

detection rate

BENEFIT TO COST RATIO : 3.5

MAQASID SHARIAH
1. Religion
2. Life
3. Progeny
4. Intellect
5. Property
And whoever saves one life, it is as if he had saved all
mankind (Al-Maidah:32)

OPERATIONALISING MAQASID
Visionary



Virtuous virtues, values & morality

Vocal engaged in scientific discourse

Visual new vocabulary of the global age
Virtual rise of the network scientific society

IMMUNISATION: JUSTICE & EQUITY

Cases/100,000 Population

250
200
150

Black

PCV7

100
50

White

0
1998

1999

2000

Flannery B, et al. JAMA 2004;291(18):2197-203

2001

2002

2003

Say: This is my Way: I call on Allah

with sure knowledge, I and
whosoever follows me. Glory be to
Allah! And I am not of the idolaters.

BIGGEST MYTH OF THEM ALL

ARE VACCINES SAFE ?

Bath 350 die/year

Breakfast 200 choke & die/year
Play in rain 100/year struck by lightning
Benefit/Risk favours vaccines
Small risk to enjoy huge benefits

MEASLES IN USA 1994 - 2014

MEASLES EPIDEMIC IN WALES UK

MEASLES CASES - MALAYSIA 20082012 1

350

Number of measles cases

300

250

200

150

100

50

Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec

2008 (N=332)
Lab & Epi=110
Clinically=222

2009 (N=56)
Lab & Epi=55
Clinically=1

Lab-confirmed
Source: National measles and rubella monthly country reports
1 Reports received for January toDecember 2012

2010 (N=74)
Lab & Epi=70
Clinically=4

Epi-linked

2011 (N=1573)
Lab & Epi=1530
Clinically=43

Clinically confirmed

2012 (N=2112)
Lab & Epi=1720
Clinically=392

Vaccine Safety Information

Parents Level Of Trust
100

75

A lot

Some

Not at all

Do not use

50

25

Freed et al Pediatr 2011;127:S107

http://www.immunise4life.my

European Council for Fatwa & Research

Use of Porcine Trypsin in OPV
Professor Yusuf Al-Qaradawi
President of ECFR
Judge Sheikh Faisal Maulawi
Vice-President
Sheikh Hussein Mohammad Halawa General Secretary

(Egypt, Qatar)
(Lebanon)
(Ireland)

Council Members
Sheikh Muhammed Ali Saleh Al-Mansour (UAE)
Sheikh Muhammed Siddique (Germany)
Sheikh Dr. Ahmad Jaballah (France)
Sheikh Dr. Muhammed Al-Hawari (Germany)
Sheikh Dr. Ahmed Ali Al-Iman (Sudan)
Sheikh Mahumoud Mujahed (Belgium)
Sheikh Mufti Ismail Kashoulfi (UK)
Sheikh Dr. Mustafa Ciric (Bosnia)
Ustadh Ahmed Kadhem Al-Rawi (UK)
Sheikh Nihad Abdul Quddous Ciftci (Germany)
Sheikh Ounis Qurqah (France)
Sheikh Dr. Naser Ibn Abdullah Al-Mayman (Saudi Arabia)
Sheikh Rashild Al-Ghanouchi (UK)
Sheikh Abdullah Ibn Sulayman Al-Manee (Saudi Arabia)
Sheikh Dr. Abdullah Ibn Bayya (Saudi Arabia)
Sheikh Dr. Abdul Sattar Abu Ghudda (Saudi Arabia)
Sheikh Abdul Raheem Al-Taweel (Spain)
Sheikh Yusf Ibram (Switzerland)
Judge Sheikh Abdullah Ibn Ali Salem (Mauritania)
Sheikh Salem Shekhi (UK)
Sheikh Abdullah Ibn Yusuf Al-Judai (UK)
Sheikh Elbakali Elkhammar (Holland)
Sheikh Dr. Ajell Al-Nashmi (Kuwait)
Sheikh Salem Shekhi (UK)
Sheikh Al-Arabi Al-Bichri (France)
Sheikh Elbakali Elkhammar (Holland)
Sheikh Dr. Issam Al-Bashir (Sudan)
Sheikh Mustafa Mollaoglo (Germany)
Sheikh Tahir Mahdi (France)
Sheikh Dr. Salah Soltan (USA)
Sheik Mahboub-ul-Rahman (Norway)
Sheikh Dr. Gamal Badawi (Canada)
Sheikh Muhammed Taqi Othmani (Pakistan)
Sheikh Ali Qaradaghi (Qatar)
Sheikh Dr. Hussien Hamed (Egypt)
Federation of Islamic Organisations in Europe: European Council for Fatwa & Research.
Last accessed on 2 September 2012 at http://euro-muslim.com/en_u_foundation_details.aspx?news_id=343

Experience from Oral

Poliovirus Vaccine

FATWA from
ECFR on use of
PORCINE
TRYPSIN IN
ORAL POLIO
VACCINE

Manufacturing process
Add virus stock seed

Harvest and
diluted with
solution

Incubation

Virus grow and replicate in

cultured cells (growth
medium)

HVF

TRYPSIN to
dissociate
virus from
cultured
cells

Trace amount of
TRYPSIN to activate
virus through cleavage

Micro-filtration

Sterile filtration
through 0.2 m
membrane

FVF

Ultrafiltration

Removal of
TRYPSIN and
other medium
components

HVF: Harvested virus fluids

FVF: Filtered virus fluids

Fatwa from the European Council of Fatwa

and Research on Oral Polio Vaccine

FIQH TAYSIR
MEMUDAHKAN BUKAN MENYUSAHKAN




And strive for Allah with the striving due to Him. He has
chosen you and has not placed upon you in the religion
any difficulty (Al-Hajj 22:78)

Given a choice, the Prophet will opt for the less

burdensome, provided it was permissible (Bukhari &
Muslim)

81st Conference Fatwa Committee National

Council of Islamic Religious Affairs, Malaysia
March 31, 2006
The usage of the ROTAVIRUS VACCINE (RV) is NOT
PERMITTED based on the following three reasons:
1. There is no urgent need at the moment
2. There are alternative substances or medicines
besides using pig sources in the production of the
said vaccines
3. There is no concrete proof that people in the
country are in dire need of such vaccine.

1. NO URGENT NEED?
CAUSES OF 8.8 MILLION UNDER 5 DEATHS 2008
1.3 MILLION DIARRHEAL
DEATHS in children < 5 years
Pneumonia
Pertussis
Measles
Meningitis
Malaria
Diarrhea
AIDS

3. There is no concrete proof

that people in the country are
in dire need of RV vaccine.

STUDIES TO RATIONALISE RV
INCLUSION IN NIP
RV
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.

Rare RV strains 2011

Circulating GpA RV 2010
Burden of RV in Sabah 2009
Out of pocket cost 2009
Estimated economic burden of RV 2007
Epidemiology of RV 2006
RV & other entero-pathogens 2006
Admission with childhood AGE 2007
Estimates of RV burden in Malaysia 2005
Hospitalisation of RVGE in KL 2003

RV
11. Serotypes of RV 1993
12. Deaths following AGE 1999
13. HUSM study on RV 2003
14. Pre-admission management of AGE 99
15. Pre-admission treatment for AGE 2009
16. Study on under 5 deaths in Malaysia 2006
17. RV RNA electrophenotype 2004
18. Molecular characterisation and
epidemiology of RV 2009
19. RV genotypes in Malaysia 2012
20. PLOS One sudy 2015

Malaysia: Estimated Burden of RV Disease

Among Children < 5 Years of Age
Annual Cases of Disease (n)a

Burden

Acute
Gastroenteritis
Related

Rotavirus
Related

Cumulative Risk
of Rotavirus-Related
Disease by 5 Years of Age

Deaths

69

34

1 in 15,000

Hospitalizations

13,937

8,571

1 in 61

Outpatient clinic visits

60,342

14,482

1 in 37

aFrom

discharge records from government hospitals, 19992000.

Adapted from: Hsu VP, et al. J Infect Dis. 2005;192(S1):S80S86.

Rotavirus Diarrhoea Deaths in 2012

Out of pocket cost for RV hospitalization

RM 677 (RM 318 RM 2397)

28%
Household monthly income

*Mean parental work day loss for

RV admission = 4.8 days

Rotavirus Vaccination Recommended

Globally by WHO

In 2009, the Strategic Advisory

Group of Experts (SAGE)
recommended the global inclusion of
RV vaccination into ALL National
Immunisation Programmes (NIP) for
1
all infants
1. WHO. Weekly Epidemiol Rec 2009; 84: 21336

Potential Projected Global Impact of

RV Vaccination
Between 2007 and 2025 vaccination of 716 million infants could:

70
60
50
40
30
20
10
0

250
200
150
100
50
2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025

Infants vaccinated

Lives saved

Accelerating the Introduction of Rotavirus Vaccines into GAVI-Eligible Countries: Investment

Case for GAVI Secretariat Submitted by PATHs Rotavirus Vaccine Program in Collaboration with
WHO and the US CDC, October 2006.

Lives saved (thousands)

Infants vaccinated
(millions)

save 2.4 million lives

prevent 93 million hospital admissions and outpatient visits
save nearly US$500 million in direct medical costs

2. There are alternative substances or

medicines besides using pig sources in the
production of RV vaccines
At present there are no other medicines or
substances which can act as an alternative to
the present two oral RV vaccines.
These have been studied in virtually all regions
of the world and proved to be effective, safe,
cost-effective and are life saving.

FATWA Imunisasi Campak, TB, Batuk Kokol,

Dipteria, Tetanus & POLIO (5-6 Jun 1989)
HARUS dari segi syarak kerana berdasarkan kaedah

dalam perundangan Islam.
VAKSIN tersebut hendaklah diambil daripada bahan
yang SUCI.
Sekiranya VAKSIN daripada bahan suci TIDAK
DIPEROLEHI atau SUKAR DIPEROLEHI, maka
penggunaan VAKSIN YANG SEDIA ADA adalah
DIHARUSKAN.
felofatwa@gmail.com

fatwa Malaysia

Year

NIP - Vaccine Introduction

2000
IPV/aP
2008

1990

MMR & Hib

2002

1980
Measles

1970

Rubella
1986

Hepatitis B
1989

1982

Polio
1972

1960
DTP
1960

1950

Smallpox

BCG
1961

RV
PCV

1950

Vaccine Type

HPV
2010

CONCLUSIONS
Vaccination save lives of children & prevent
disabilities.
Vaccines are safe, effective, permissible and cost
savings.
The vaccine concerns of some are unfounded,
not evidence based & not shariah driven
Wider usage of vaccines would help meet our
MDG4 target of reducing Under-5 mortality by
2/3.

IN LOVING
MEMORY