“BIAS” Indonesia School Based Immunization Program Dr Andi Muhadir, MPH Director, Surveillance Epidemiology and Immunization, Ministry of Health, Republic of Indonesia Global Immunization Meeting New York 17-19 Feb 2009 1
“BIAS”
Indonesia School Based
Immunization Program
Dr Andi Muhadir, MPH
Director, Surveillance Epidemiology and Immunization, Ministry of Health,
Republic of Indonesia
Global Immunization Meeting
New York
17-19 Feb 2009 1
Eastern
Indonesia
n Time
INDONESIA
Total infant (0-11 month): 4,8 million
Total school immunization target: 15 million
Central
Indonesia
n Time
Western
Indonesia
n Time
2
School Immunization Program (“BIAS”)
• School Immunization Month is immunization services conducted at all primary schools nation wide in the months of August and November
• This was introduced as collaboration of four Ministries
• Target: children in grades 1, 2 & 3
• Vaccines: DT, Measles & TT
• Started since 1984 and evolved gradually in 1997 and in 2002.
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Why Indonesia Implemented “BIAS”
DT/TT• Basic immunization (DPT 3x) produces immunity
up to <5 years old children
• National Institute of Health and Research Development (NIHRD) conducted serological studies among 4-5 yrs old in 1996 in Papua & Central Kalimantan, it revealed declining immunity levels against Diphtheria (74-77%)
• Need of booster dose for Diphtheria
• Low TT2+ coverage among CBAW
• As part of School Health Program (UKS) which is existing since 1956
• School enrollment rate >95% (boys and girls)
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Why Indonesia Implement “BIAS” for
Measles control
• NIHRD serological study among primary school children in 1997 at Yogyakarta, Ambon & Palu showed only 72% of children were protected against measles
• Surveillance data showed high proportion (52-79%) of Measles cases in East Java in 1996 among school going children (5-14 years old)
• In 1998-2000 surveillance data showed 40% of measles cases nationally were in children above 5 years of age
• As a measles control strategy: 2nd dose of Measles vaccine
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Objectives of
School Based Immunization
• To provide life-long immunity
against tetanus to all primary
school graduates
• To provide a booster dose for
Diphtheria
• To reduce measles mortality
and morbidity
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School Immunization Schedule
Dynamic and Evolving
1984-1997 2001/2 onwards ����1998-2000
Grade 1 DT 2x DT 1x DT 1x Measles
Grade 2 TT 1x TT 1x
Grade 3 TT 1x TT 1x
Grade 4 TT 1x
Grade 5 TT 1x
Grade 6 TT 2x TT 1x
ELIGIBLE TARGET 9 MILLION 29 MILLION 15 MILLION
2002 onwards: inclusion of routine second dose measles in class 1 on rolling basis province by province 7
“BIAS” Strategies
• Effective inter-sector collaboration (involving four Ministries: Health, Education, Religion Affair, Internal Affair)
• Sound policy and guidelines for both health workers and other stake holders in place
• Trained health workers in all 8,000 primary health centers across the country
• Central government provides vaccines and logistics (includes cold-chain)
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“BIAS” Strategies (cont..)
• 15 million children studying in 175,000 primary schools (public, private and religious) targeted across the country
• Strong commitment with regular contribution by provincial and district governments is provided
• Monitoring and supervision done by inter-sectoral teams
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Roles and Responsibilities
• Micro planning done by teachers & health workers
• Schools inform parents and this is considered as public informed consent s when children come to school for vaccination
• Vaccination conducted in school by local health center staff
• School immunization coverage is reported by health centers on same channels as for routine EPI
• Monitoring and supervision is undertaken by joint interdepartmental school health program supervisory team 10
Result of “BIAS”
• High coverage achieved for all antigens
• NIHRD serological studies showed high protection level against Diphtheria (98%) and against TT (100%) among 10-14 yrs old after “BIAS”
• Low vaccine wastage rates (<20%)
• Declining trends of measles incidences
• High acceptance of BIAS by parents
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0
10
20
30
40
50
60
70
80
90
100
1998 1999 2000 2001 2002 2003 2004 2005 2006 2007
Percentage of DT Coverage
Grade I (age 6-7 years), 1998 - 2007
Source: Sub Dir EPI, CDC, MoH 2008
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Percentage of TT Coverage
Grade II and III (age 7-10 years), 1998 - 2007
0
10
20
30
40
50
60
70
80
90
100
1998 1999 2000 2001 2002 2003 2004 2005 2006 2007
Source: Sub Dir EPI, CDC, MoH 2008
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Percentage of Measles Coverage
Grade- I (6-7 years of age), 2003 - 2007
0
10
20
30
40
50
60
70
80
90
100
2003 2004 2005 2006 2007
Source: Sub Dir EPI, CDC, MoH 2008
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Measles Immunization Coverage and Measles Cases*
Indonesia, 1983-2008
0
20
40
60
80
100
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
% C
overa
ge
0
10000
20000
30000
40000
50000
60000
70000
80000
90000
Measle
s C
ases
Measles Cases Reported doses administered (%) School measles dose
: SIAs*Source: Surveillance Unit, MOH
**
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Key Factors Which Make “BIAS” Successful
� Compulsory education, free of charge in public schools
� High enrollment of girls and boys in early primary schools (97%)
� Sufficient number of health centers and staff
� Regular budget: vaccines and logistics provided by MOH
� Inter ministerial coordination exits through BIAS
� Clear roles and responsibilities through guidelines for health provider and teachers and periodic training for providers
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• Absenteeism is around 5 – 10% on vaccination day
• Non compliance to the public consent by some schools
• Mechanism to reach for out of school children still not developed
• Limited sources for monitoring and evaluation
• Competing priorities at local level specifically in decentralization context, need for regular advocacy with local governments
ChallengesChallenges
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Conclusion (1)
• Indonesia’s school immunization program is well-established
• Key elements for a successful program exist
– official policy
– operational guidelines for health workers and teachers
• High immunization coverage for all antigens
• Not a heavy burden on health center staff
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Conclusion (2)
• Unit cost per student vaccinated is cost effective in comparison with routine vaccination – $0,70 for TT , $0,80 for Measles
• Strengthen tetanus elimination strategy in a sustainable fashion and contribute significantly in measles control
• Builds infrastructure for future vaccine preventable disease control programs
• BIAS inline with GIVS to reach immunization beyond the traditional target groups
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