“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

13

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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