Halal Concerns Complicate Measles Vaccination as Madura Outbreak Kills at Least 20

More than 2,600 children infected in nine months

A measles outbreak on Indonesia's Madura Island has infected more than 2,600 children and killed at least 20 during 2025, sending health workers through Sumenep with vaccine supplies and lists of children who still need protection. By September 27, the outbreak had stretched through nine months.

Every day, teams of three travel by motorbike through the coastal city, carrying blue cold boxes containing measles or measles rubella vaccines. Their visits bring a difficult decision to the doorstep of families concerned about whether vaccine ingredients are permissible under Islamic law.

Between May and July, isolation wards in regional hospitals filled quickly, with staff treating well over 100 measles cases a day. Health centers are now trying to close gaps in protection before the next school term and the rainy season.

The regional government has made more than 78,000 doses available, opened clinic days, sent teams into schools and organized visits to homes. Health workers cannot force hesitant parents to consent. Their task involves both delivering vaccines and answering religious questions in communities where faith strongly shapes daily decisions.

Some measles and measles rubella vaccines use gelatin made from pigs to keep their weakened live viruses stable during transport and storage. Many families in this predominantly Muslim district regard substances derived from pigs as unclean. Others agree to vaccination after speaking with a nurse or local cleric.

Indonesia's highest Islamic authority, the Indonesian Ulema Council, known as MUI, permits use of the vaccine while no halal alternative is available. For some parents, however, the permission has not resolved their discomfort about its ingredients.

Why a stabilizer has become a question of faith

Halal means permissible under Islamic law. Pork and substances derived from it are haram, or forbidden. Gelatin made from pigs is widely used in food and medicines because it protects delicate ingredients from heat and helps products keep their shape during transport.

In vaccines containing weakened live viruses, gelatin serves as a stabilizer. It reduces the chance that the vaccine will lose potency, meaning its ability to provide protection, as vials pass through long supply chains and warmer climates.

Indonesia's geography makes that function especially relevant. Vaccines must reach communities across thousands of islands, and interruptions to the cold chain can happen. The cold chain is the system of refrigerated storage and transport used to keep vaccines at suitable temperatures.

MUI issued an opinion in 2016 permitting vaccination and encouraging halal certification. In 2018, it declared the measles rubella vaccine then in use haram because of porcine gelatin and elements of production for the rubella component involving human cell lines. The same ruling allowed its use until a halal alternative became available, giving priority to protecting life.

Some districts paused vaccination campaigns in schools after the 2018 ruling. Others continued with counseling and parental consent. The combination of a prohibition in principle and permission under medical necessity still leaves some families uncertain whenever another outbreak or vaccination day arrives.

Musthafa, general secretary of MUI in Sumenep, said the longer term answer should come through government procurement that meets religious requirements:

We have high hopes for Muslims in Indonesia, who are the ones consuming it. Let us ask the government, in this case the Health Office and the Ministry of Health, to find a halal vaccine.

How religious guidance allows treatment in an emergency

Islamic scholars across the Muslim world often apply principles of necessity and public benefit when considering medicines that would normally be prohibited. Preserving life can take priority when no lawful alternative is available.

Some scholars also refer to transformation, the idea that processing can change a substance into something else. Others disagree with that argument. Parents can therefore hear different points stressed by different preachers or in different provinces.

Pujiati Wahyuni, a Muslim nurse and mother in Sumenep, encounters these differences while counseling families. She described resistance that can extend beyond the current outbreak:

"Yes, there are some. Islam is a big religion. Maybe some Muslim people just do not want to get vaccinated, and it is not just now, but since they were born," she said.

Local clerics describe parents who want their children vaccinated but feel torn. For many households, reassurance from a trusted ustadz or ustadzah, a male or female religious teacher, that protecting a child takes precedence during an outbreak can be decisive. Public health officials say open discussion with religious leaders often helps secure consent, particularly after families have seen measles nearby.

Why small gaps in vaccination allow rapid spread

Measles is one of the most contagious viruses known. An infected person can spread it to nine out of ten unvaccinated people nearby. The virus travels through the air and can linger in a room long after a cough.

Health agencies therefore set a demanding target: at least 95 percent of children need two doses to block outbreaks. Global estimates for 2024 put first dose coverage at 84 percent and second dose coverage at 76 percent, leaving many children without the recommended protection.

Indonesia also fell below its vaccination targets. Measles rubella vaccinations reached 86.6 percent of the goal in 2023 and 82.3 percent in 2024, a decline of 4.3 percentage points. These figures describe achievement against the vaccination goal; the outbreak prevention benchmark calls for at least 95 percent of children to receive two doses.

Madura's gaps include families who delayed vaccination for religious reasons, children who missed clinic days while traveling, and households facing transport difficulties or work commitments. Where unvaccinated children are concentrated, measles can spread quickly.

Closing those gaps requires fuel for outreach teams, cold boxes, staff for school clinics and community voices parents trust. The same effort must keep vaccines in good condition while making appointments accessible to families whose difficulties are practical as well as religious.

The decisions unfolding in Sumenep classrooms

At an Islamic kindergarten in Pamolokan village, the head of the community health center met mothers in a small classroom before opening any vaccine vials. She explained how measles spreads, why children need two doses and which side effects parents might expect.

The discussions took place after the outbreak's peak months, when local hospitals treated more than 100 cases daily and some parents saw neighbors rushing feverish children for care. For families who had postponed vaccination, illness close to home made the danger immediate.

Ayu Resa Etika, a mother aged 28 from Kebunan village, delayed her son's second dose before changing her mind after seeing nearby families struggle. She explained her decision:

"There is a little doubt because it is not halal. But despite all that, this is for the sake of the child's health. The effects are quite extraordinary; it can cause death. I am afraid that if my son is not vaccinated against measles, that is the risk. So it is OK, as long as the effects are good," she said.

Health workers describe similar decisions among other parents. Some who hesitate initially return after talking with a midwife, cleric or teacher. Familiar settings give mothers room to ask questions and see neighbors making the same choice.

How clinics and religious leaders can coordinate

MUI sets guidance nationally, while provincial and district branches help bring it into local discussions. Imams, leaders of pesantren, or Islamic boarding schools, and women's study circles also shape how families understand that guidance.

Joint planning between health offices and religious leaders can reduce confusion and conflicting messages between neighborhoods. Health teams explain ingredients and side effects in plain language, while clerics explain the current permission to vaccinate when no halal alternative exists.

Outreach works best as a conversation. Parents can ask about both health and religious concerns without feeling pressured. Approaches used in other provinces include:

• Regular forums where health officials and ulama review vaccine contents, cold chain procedures and the exact wording of religious rulings.
• Friday sermons and village gatherings explaining why vaccination is permitted during an outbreak when no halal option exists.
• Vaccination days at pesantren and mosques, with private spaces and female health workers available for mothers' questions.
• Sessions where nurses show vial labels and explain each ingredient in simple terms.
• Consent forms referring to religious guidance and identifying local clerics available for consultation.

What a halal alternative would require

Most licensed measles or measles rubella vaccines in wide use include gelatin from pigs as a stabilizer. Researchers and manufacturers have explored alternatives, including fish gelatin, polymers made from plants and ingredients based on sugars.

Replacing a stabilizer requires more than exchanging one ingredient for another. Manufacturers would need new batches and stability testing, followed by regulatory review, to confirm that heat tolerance and effectiveness remain unchanged. Reduced protection would be especially concerning in rural areas where reliable refrigeration can be harder to maintain.

Indonesia is seeking options, but no date has been given for a halal alternative to become available. Supply contracts, licensing and staff training would take time even after a halal product received approval.

Halal certification would trace ingredients from raw materials to the finished vial. It would also examine cleaning agents, packaging and labeling. Technology transfer to a regional producer, or contract manufacturing with a clear record for halal audits, could support that process.

Cooperation among countries with Muslim majorities could create a larger market for one product, encouraging manufacturers to invest in a formula that meets halal requirements. For Sumenep's current response, the practical religious guidance remains permission to use the vaccine while no halal alternative exists.

What parents need to know about the vaccine

The measles vaccine contains a weakened form of the virus that trains the immune system to fight the disease. The measles virus used in production is grown in chick embryo cells. In the combined measles rubella vaccine, the rubella component is produced using a human cell line developed decades ago.

The final product is purified. Small amounts of gelatin, sugar and other salts help keep it stable during transport. Questions about these ingredients and production methods are central to MUI's ruling and its permission to use the vaccine in the absence of a halal alternative.

Measles vaccines have been used for decades and have a strong safety record. Side effects are usually mild, such as a sore arm, a brief fever or a rash. Serious allergic reactions are very rare.

Measles itself carries much greater risks. It can cause pneumonia, swelling of the brain and death, particularly among very young children and those who are malnourished.

Children need two doses for strong protection. Clinics can provide catch up vaccinations when a dose has been missed, and health workers in Sumenep are offering appointments in schools and homes to help families complete the schedule.

Most people who recover from measles have lasting immunity to that virus. The combined vaccine also protects against rubella, which can cause serious birth defects if a pregnant woman becomes infected. Local clinics can advise on the appropriate vaccination schedule for each child.

What research in Aceh reveals about hesitation

A recent survey of 1,689 Muslim parents in Aceh, where sharia is enforced locally, found that only 34 percent of children were fully vaccinated. Twenty nine percent of parents expressed vaccine hesitancy, while 32 percent had specific concerns that vaccine ingredients were not halal.

Parents who were hesitant were far less likely to have a fully vaccinated child. The findings connect religious concerns with completion of childhood vaccination, while national research also identifies differences linked to wealth, education and access.

Analyses covering 1991 to 2017 found that measles vaccination increased among both Muslims and people of other religions, with the gap between the groups narrowing. Coverage among Muslims stagnated in the years that followed, as debates about vaccine ingredients became more prominent.

Large differences remain between provinces, with Aceh historically among those with the lowest coverage. Madura's response brings several of these issues together: families need reliable information about religious permission and ingredients, as well as services they can reach.

Practical steps include building partnerships with local ulama, publishing clear ingredient lists in Bahasa Indonesia, and inviting mothers and fathers to observe vaccination days and ask questions. Consistent messages across clinics, schools and mosques can accompany services brought to the places where children live and learn.

How the outbreak fits the longer timeline

Indonesia's present vaccination effort follows years of religious guidance, uneven coverage and previous outbreaks. In 2018, a large measles outbreak in the eastern province of Papua caused dozens of deaths, illustrating the consequences when the virus reaches communities with gaps in protection.

The main developments leading to the current response are:

• 1991 to 2017: Measles vaccination increased among Muslims and people of other religions, and the gap between the groups narrowed.
• 2016: MUI permitted vaccination and encouraged halal certification.
• 2018: MUI declared the measles rubella vaccine then in use haram, while allowing its use until a halal alternative became available. Some districts paused school campaigns, while others continued with counseling and consent. A large outbreak in Papua caused dozens of deaths.
• 2023: Indonesia's measles rubella vaccinations reached 86.6 percent of the goal.
• 2024: Achievement fell to 82.3 percent. Global estimates put first dose measles coverage at 84 percent and second dose coverage at 76 percent.
• May to July 2025: Hospitals treating Madura's outbreak faced their busiest period, with more than 100 measles cases daily.
• September 27, 2025: The outbreak had lasted nine months, infecting more than 2,600 children and causing at least 20 deaths. Teams continued vaccination visits, with more than 78,000 doses made available.

Sumenep's immediate task is to help children complete two doses before the next school term and rainy season. That means keeping vaccines cold, reaching families at home and school, and making space for parents to discuss religious concerns with people they trust.

Key Points

• Madura's measles outbreak has infected more than 2,600 children and killed at least 20 during 2025.
• Teams of three are delivering vaccines by motorbike in Sumenep, alongside clinic and school sessions.
• Concerns focus on gelatin from pigs and aspects of vaccine production addressed by MUI's 2018 ruling.
• MUI permits use of the vaccine while no halal alternative is available, prioritizing protection of life.
• Indonesia's measles rubella vaccinations fell from 86.6 percent of the goal in 2023 to 82.3 percent in 2024.
• At least 95 percent of children need two measles doses to block outbreaks.
• The Aceh survey found halal concerns among 32 percent of parents and full vaccination among only 34 percent of children.
• Religious dialogue, clear ingredient information and accessible vaccination services are central to closing protection gaps.