“BIAS” Indonesia School Based Immunization Program

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

2. INDONESIA Western Indonesian Time Central Indonesian Time Eastern Indonesian Time Total infant (0-11 month): 4,8 million Total school immunization target: 15 million

3. 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.

4. 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)

5. 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

6. 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

7. School Immunization Schedule Dynamic and Evolving 1984-1997 1998-2000 2001/2 onwards  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 TARGET9 MILLION 29 MILLION 15 MILLION 2002 onwards: inclusion of routine second dose measles in class 1 on rolling basis province by province

8. “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)

9. “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

10. 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

11. 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

12. Percentage of DT Coverage Grade I (age 6-7 years), 1998 - 2007 Source: Sub Dir EPI, CDC, MoH 2008

13. Percentage of TT Coverage Grade II and III (age 7-10 years), 1998 - 2007 Source: Sub Dir EPI, CDC, MoH 2008

14. Percentage of Measles CoverageGrade- I (6-7 years of age), 2003 - 2007 Source: Sub Dir EPI, CDC, MoH 2008

15. Measles Immunization Coverage and Measles Cases* Indonesia, 1983-2008 ** : SIAs *Source: Surveillance Unit, MOH

16. 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

17. Challenges • 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

18. 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

19. 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

20. THANK YOU