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 millionTotal school immunization target: 15 million

Central Indonesia

n Time

Western Indonesia

n Time

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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 95% (boys and girls)

4

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 MeaslesGrade 2 TT 1x TT 1xGrade 3 TT 1x TT 1xGrade 4 TT 1xGrade 5 TT 1xGrade 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) 8

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 (

010

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 12

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

o

v

e

r

a

g

e

0

10000

20000

30000

40000

50000

60000

70000

80000

90000

M

e

a

s

l

e

s

C

a

s

e

s

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)

Indonesias 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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