Neglected Tropical Disease NTD2011

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Neglected Tropical Diseases

in Indonesia

An Integrated Plan of Action

Ministry of Health I ndonesia 2011-2015

An Integrated Plan of Acon to successfully achieve eliminaon and sustained control of 5 of the

mosmportant neglected tropical diseases in Indonesia: Lymphac Filariasis, Schistosomiasis,Leprosy,

Yaws and Soil-Transmied Helminths.

ltnWorld Hea hOrganization



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An Integrated Plan of Action to successfully achieve elimination and sustained control of 5 of the

most important neglected tropical diseases in Indonesia: Lymphatic Filariasis, Schistosomiasis,Leprosy, Yaws and Soil-Transmitted Helminths.

NEGLECTED TROPICAL DISEASES

IN INDONESIA

An Integrated Plan of Action

Ministry of Health Indonesia

2011 - 2015



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Foreword by WHO Representave 5

Foreword by Director General Disease Control & Environmental Health 7

Execuve Summary 11

Neglected diseases in Indonesia 11

Plan of Acon for NTD control/eliminaon 14

General objecves 14

Summary budget 17

Country Prole 18

Geography and demographics 18

Polical situaon and administrave structure 19

Health care system 19

School Health Programme (UKS) 21

School Immunizaon Month Programme (BIAS) 21

Background of NTDs & disease control iniaves in Indonesia 22

Leprosy 22

Lymphac lariasis 24

Schistosomiasis 28Soil-transmied Helminths 30

Yaws 32

Overlapping of NTDs endemicity 34

Health, hygiene & nutrion promoon 34

Integrated vector management 35

Integraon between disease control iniaves 36

Drug supply and logiscs 38

Development of Plan of Acon 40

Raonale 40

Benets 40

Challenges 40

Plan of Acon for NTD Control 41

General objecves 41

Expected results 42

ER I Updated strategies based on internaonal guidelines and best pracces 43

Contents


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ER II Accurate esmaon of the burden of the 5 NTDs 43

ER III Successful management of drug donaons 44

ER IV Strengthened capacity of health workers and volunteers 45

ER V Integrated social mobilizaon 46

ER VI Integrated and improved MDA for LF, schistosomiasis, and STH 47ER VII Integrated and intensied morbidity case detecon 49

ER VIII Integrated and intensied case management 49

ER IX Strengthened monitoring and evaluaon (M&E) system for the 5 NTDs 50

ER X Establishment of a surveillance system for leprosy, LF, schistosomiasis

and yaws aer their eliminaon as public-health problems 51

ER XI Establishment of a naonal NTD Taskforce 52

ER XII Increased visibility, advocacy and polical commitment for NTD control

and eliminaon 52

ER XIII Increased advocacy for comprehensive NTD control linking water,

sanitaon, hygiene educaon and chemotherapy 53

ER XIV Integrated health promoon 54

Milestones 56

A. Accelleraon Program of Filariasis Eliminaon, Drug Availability and

Distribuon 56

B. Program Management, Advocacy, Socializaon and Surveillance (MONEV) 57

A. Detailed acvies & Times 61


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Abbreviations

ALB - Albendazole

AusAID - Australian Agency for International Development

DC & EH - Disease Control & Environmental Health

DEC - Diethylcarbamazine

DG - Directorate General

DoE - Department of Education

DHO -District(orcity)HealthOfce

GSK - GlaxoSmithKline

IEC - Information, Education and Communication

LF - Lymphatic Filariasis

MB - Multi-bacillary

MDA - Mass Drug Administration

MDG - Millennium Development Goals

MF -MicrolariaeM&E - Monitoring and Evaluation

MOH - Ministry of Health

NTD - Neglected Tropical Diseases

PHC - Primary Health Centre

PHO -ProvincialHealthOfce

PoA - Plan of Action

SAE - Serious adverse events

UKS - School Health Programme

STH - Soil-transmitted Helminthiasis

UNICEF - United Nations Children Education Fund

USAID - United States Agency for International Development

WFP - World Food Program

WHO - World Health Organization


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Health is recognized as an essential component of human development. Incollaboration with Ministry of Health, World Health Organization and otherdevelopment partners created several opportunities for improving the healthof people, enhancing quality of life and ensuring a better future. In spite of

various constraints, tangible progress has been made by governments, communities andpartners towards improved health outcomes; nevertheless, many challenges lie ahead.These includes, weak health system, an increasing burden of communicable and non-communicable diseases, high child and maternal mortality, recurrent epidemics and

humanitariancrisesaggravatedbydisasterandlimitednancialresources.Inaccordancewith WHOs mandate, vision and collaboration and coordination with other partners, wehave pledged to continue to focus on partners role in the provision of normative and policyguidance; strengthening of partnerships and harmonization of support to the country,supporting health systems strengthening based on the primary health care approach;putting neglected tropical disease at top of the agenda and intensifying the preventionand control of communicable and non-communicable diseases; and accelerating responseto the determinants of health.

Indonesia is endemic for neglected tropical diseases (NTDs) for which chemotherapy

is available: lymphatic lariasis, soil-transmittedhelminthes andschistosomiasis, leprosyand yaws are among the major. Different studies have indicated that there are a numberof provinces and districts, where these diseases are co-endemic. Control programs forthesediseasesaremanaged vertically and the potential benets of integrationof the

programs have not been explored. The country is uniquely positioned to make majoradvances to reduce, and in some cases eliminate NTDs as public health problems giventhe demonstrated commitment and strong programmatic experience of the government,and a number of development partners working in NTD control. The NTDs form groupdiseases are strongly associated with poverty, and these disease agents thrive best intropical areas, where they have very favorable conditions for the breeding and further

development. These diseases are largely silent, as the people affected or at risk have littlerecognition in the communities and rarely have any political voice.

At present, the neglected tropical diseases have their breeding grounds in the placesleft furthest behind by socioeconomic progress, where substandard housing, lack of accessto safe drinkingwater and poor sanitation, lthy environments, and abundant insects

and othervectors contribute toefcient transmission of infection for thesediseases.

Close companions of poverty, these diseases also anchor large populations in poverty.IndevelopingcountrieslikeIndonesiatheleprosyandlymphaticlariasisdeforminways

that hinder economic productivity and cancel out chances for a normal social life. The

infectivity of soil transmitted helminthic infection disrupts school attendance, contributesto malnutrition and impairs the cognitive development of children.

Foreword


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The consequences are costly for societies and for health care such as rehabilitation forleprosyandlymphaticlariasis.Fortunately,inthecountrytheseproblemsarenowmuch

better documented and much more widely recognized. Good medicines are available formanyofthesediseases,andresearchcontinuestodocumenttheirsafetyandefcacywhen

administered individually or in combination. Generous drug donations by pharmaceuticalcompanieshavehelpedrelievesomeofthenancialbarriersandallowedprogrammesto

scale up coverage. A strategy of preventive chemotherapy, which mimics the advantagesof childhood immunization, is being used to protect entire at-risk populations and reducethe reservoir of infection. The fact that many of these diseases overlap geographically haspractical advantages preventive chemotherapy regimens are being integrated so that severaldiseases can be tackled together, thus streamlining operational demands and cutting costs.An integrated approach to vector management likewise maximizes the use of resourcesand tools for controlling vector-borne diseases are practical and feasible.

While the report highlights a number of remaining challenges, the overall message isoverwhelmingly positive. It is entirely possible to control neglected tropical diseases. Aiming

attheircompletecontrolandeveneliminationisfullyjustied,andthisintegratedactionplan sets out the solid evidence needed to achieve control.

Even though each Disease Control Sub-directorate at the MOH DG CDC & EH hasits own plan including some level of integrated activities for different diseases, this Plan ofAction was needed in light of recent announcement of enhanced drug donations for NTDby pharmaceutical companies globally, renewed donor interest in funding NTD activitiesfor accelerating elimination and control, review and evaluation of schistosomiasis programinCentralSulawesi(October-November2010),nalizationofLFplanfor2010-2014(May

2010), and need to revitalize MOH integrated disease control strategy developed in 2007

that integrates some activities in the LF, leprosy, yaws and STH program.This single document with key activities about a number of NTD in Indonesia is illuminate

synergies between NTD programs that enhance cost-effectiveness. This document canhelpreneactivitiesforacceleratedcontrolofNTDinlightofrecentinternationaland

national developments and could be used as a tool to promote funding at national levelin the country and external funding for activities implementation. I would like to expressmy sincere thanks to the Joint Mission Members from World Health Organization, USAID,and AusAID for the technical support and helping in the process of the development ofintegrated action plan on neglected tropical diseases to promote NTD Control in the

Republic of Indonesia

Khanchit Limpakarnjanarat

WHO RepresentativeIndonesia


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The neglected tropical diseases (NTDs) are a group of infectious diseases which

primarily affect the poorest sectors of society, especially the rural poor and themost disadvantaged urban populations. More than 1 billion people are affected withone or more neglected tropical diseases, yet these diseases remain neglected at

alllevels.AlthoughsomeofNTDsaffectIndonesia,overthepastveyearsthreeofthem

inparticularleprosy,lymphaticlariasis,andyawshavebeentargetedforelimination.

These diseases not only affecting large number of population also carry high mortality andmorbidity; they also affect peoples productive and social lives. Moreover, most of themare feared and are the source of strong social stigma and prejudice and as a result, thesediseases are often hidden- out of sight, poorly documented and unmentioned.

Strategic steps taken by the international community have contributed to such progress:the World Health Assembly passed resolutions for the global elimination of leprosy andlymphatic lariasis in 1991 and 1997, respectively. In 2006, theWHOSouth-EastAsia

Regional Committee passed a resolution calling all Member States to intensify effortstowards achieving the goals of eliminating selected NTDs including yaws.

The Ministry of Health has targeted to decrease the diseases transmission, to preventdiseasesrelateddisability,especiallyforleprosyandlymphaticlariasisandtodiminishthe

social stigma toward the diseases. Early case detection and early treatment with MDT (MultiDrug Therapy) are the important strategy to be carried out to reduce leprosy burden.

Yaws elimination programme has been started out in hyper-endemic provinces and hascompletedactivecasendingandtreatmentwithbenzathinpenicillin,whiletheeliminationstrategyforlymphaticlariasisreliesonthemassadministrationofdiethylcarbamazineand

albendazole to all individuals living in endemic areas.

Minimizing public stigmatizationon leprosyand lymphatic lariasispatientsarealso

an important role to be conducted. We should push for integrating these programmeswith other sectors by implementing this developed integrated national action plan. Weshould act rightly and promptly, working in teams which have high integrity, transparentand accountable. NTD control requires an integrated approach with chemotherapy beingbacked up by a range of supplementary interventions, along with inter-sectoral cooperationby Ministry of Health, education, agriculture and other development related ministries.

Foreword


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I would like to make it clear that to make people healthy, there are four main strategies

that should become the guideline of every health worker, as follow:

1. Mobilize and empower people to live clean and healthy

2. Improvetheaccessibilityofpeopletothequaliedhealthservices

3. Improve the surveillance system, monitoring, and information of health4. Toensureimplementationoftheactivitiesoutlinedinthisintegratedplanofaction,

additional funding need to be allocated from the government of Indonesia at central,and district levels, as well as external funds from international donors.

Prof. dr. Tjandra Yoga Aditama

Director General DC and EH


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WHO/USAID/AusAID Joint Mission for the Promotion of NTD Control

in the Republic of Indonesia

15-19 November, 2010

Aim of the mission is to promote the development of a National PoA for the integrated control

of NTD.

PARTICIPANTS

International Participants

A Montresor, Scientist, Control of Neglected Tropical Diseases, World Health Organization,Geneva, Switzerland

M. Brady, Advisor, Control of Neglected Tropical Diseases, World Health Organization,Geneva, Switzerland

M. Pacque, GHFP Technical Advisor, USAID/Washington DC

M. Linehan, Infectious Diseases Team Leader, USAID Indonesia

K. Kopoc, Director or CWW (Children without Worms)

M Rebollo, Consultant, World Health Organization, Geneva, Switzerland

Ministry of Health Indonesia

Tjandra Yoga Aditama, Director General of DC & EHRita Kusriastuti, Director of Vector Borne Disease Control

H. Mohammad Subuh, MPPM, Director Direct Transmitted Diseases

Trihono, Director General National Institute of Health Research & Development

Saktiyono, Programme Manager. LF, Schistosomiasis and STH

Christina Widaningrum, Programme Manager, Leprosy and Yaws

Taniawati Supali - Indonesia University

World Health Organization: Regional Ofce

A.P. Dash, Regional Advisor for NTD, WHO/SEARO, India

World Health Organization: Country Ofce

Khanchit Limpakarnjanarat, WHO Representative, Indonesia

Anand B. Joshi, Program Manager for NTD, WHO- Indonesia

USAID Indonesia

IreneKoek,Director,OfceofHealth

Kendra Chittenden, Senior Infection Disease Advisor

Artha Camelia, Emerging Infections Diseases Specialist


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AUSAID

Gerard Cheong, First Secretary Health Australian Embassy

Gina Samaan, Consultant AusAID, Jakarta

JICA Indonesia

Yurico Egami

WHO Indonesia - Neglected Tropical Diseas Working Group

KhanchitLimpakarnjanarat,WHORepresentative-Advisorandoverallguidance

M.RKanaga,Administration/Management

AnandBJoshi,Member:NTDfocalpoint

GrahamTallis,Member:CommunicableDiseasesExpert

SharadP.Adhikary,Member:EnvironmentalHealthExpert

MSudomo,Member:SchistososomiasisandLFexpert

BenyaminSihombing:,Member:Leprosy,YawsandotherNTDspecialist

NursilaDewi,Member:Information/Communication

RepresentativefromUSAID,Indonesia

RepresentativefromAUSAID-Indonesia

RepresentativefromJICA-Indonesia


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Executive Summary

1 Working to overcome the global impact of neglected tropical diseases. WHO 2010

T

he Government of Indonesia has demonstrated awareness of the important

burden of neglected tropical diseases (NTDs). National plans and policies havebeen developed to ght leprosy, lymphatic lariasis (LF), schistosomiasis, soil-

transmitted helminths (STH) and yaws. Successful experiences have demonstrated

the political commitment both at the central and district levels. Community compliance and

participation are an important part of the NTD programs, as shown by the example of LF,

where mass drug administration (MDA) is carried out with help of community volunteers

or school deworming where children receive the drug during immunization days, achieving

coverageofalmost90%ofschool-agechildren(SAC)intheareaswheretheprogramis

implemented. However Indonesia faces many challenges to achieve the goal of control of

STH and elimination of leprosy, LF, schistosomiasis, and yaws. Lack of coordination between

different programs and stakeholders, insufcient and irregular political commitment at

thedistrictlevel,andlimitedfundingtofullyimplementstrategiesandachievesufcient

coverage,makesitdifcultforIndonesiatosucceedinachievingthetargetssetbyWHO

for sustainable control and elimination of NTDs.

This Integrated Plan of Action (PoA) confronts many of those obstacles and proposes a

roadmap for integrated control of 5 of the main NTDs in Indonesia: leprosy, LF, schistosomiasis,

STH and yaws. Under the leadership of a national NTD Taskforce, integration will focus on

advocacy and social mobilization, use of a common pathway to distribute drugs and detect

disease cases, capacity building of health workers, and health promotion at community

level. This integrated NTD Program will facilitate cost savings and optimal use of human

resources,aswellasspeedup implementationtondtheshortestroutetoachievethe

goals on time.

To ensure implementation of the activities outlined in this PoA, additional funding will

need to be allocated from Indonesian government at central and district levels, as well as

external funds from international donors. Drug donations will continue to play a key role

in the success of the plan.

Neglected diseases in IndonesiaNeglected tropical diseases (NTDs) blight the lives of a billion people worldwide

and threaten the health of millions more. These ancient companions of poverty weaken

impoverished populations, frustrate the achievement of health in the Millennium

Development Goals and impede global development outcomes1.

Indonesia has one of the heaviest burdens of NTDs globally, with one of the largest

populationsatrisk.ThecountryisendemicforveoftheNTDsforwhichchemotherapy

is available: leprosy, LF, schistosomiasis, STH, and yaws.


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Leprosy

In 2000, Indonesia eliminated leprosy at the national level, with a prevalence rate of

less than 1 case per 10,000 populations. However, the number of new leprosy cases,

approximately20,000peryear,hasremainedstablefortenyears.In2009,14provincesand

160districts,mostlyintheeastandcentralandwestJava,stillreportedaprevalencerateof

>1 per 10,000 population. Epidemic indicators such as the proportion of grade-2 disability(10.5%),theproportionofchildcases(12.01%)andtheproportionofmulti-bacillary(MB)

cases(82.43%)indicatethatongoingsupportisneededtoreducetheleprosyburden.

Theleprosyprogramaimstoreducedisabilityfrom10%to5%by2015,throughrapid

index-casendinginhighendemicareas.TheNationalProgrammeforLeprosysstrategy

consists of fourmain activities i.e., case nding, case detection, casemanagement and

mitigationoftheimpactofleprosy.Comprehensivecasendinganddetectioneffortsare

important initial activities to identify and detect cases in a leprosy service area unit. Case

management emphasizes accurate diagnosis and treatment. Counseling is an integral activityin case management to ensure treatment compliance and to overcome stigma. Mitigation

of the impact of leprosy includes improving the quality of life of for people affected by

leprosy through disability care and rehabilitation and psychosocial and economic support.

Theleprosyprogramestimatesacostof$60,000perdistrictforactivecasending,for

a total of $3 million for 50 districts. The Novartis Foundation supplies free drugs through

WHO. The Netherlands Leprosy Relief and Sasakawa Foundation provide operational and

technical assistance to the MOH program.

Lymphatic Filariasis (LF)

LF is one of the major public health problems in Indonesia. All three types of lymphatic

parasites namely Wuchereria bancrofti, Brugia malayi and Brugia timori are prevalent in

Indonesia, but B. malayi is the most dominant. Twenty-three species of mosquitoes are

vectorsforLFinIndonesiaasof2009,anestimated125millionpeopleareatriskoflariasis

infection, in 337 endemic districts, which function as the LF programs implementation units.

The highest prevalence rates were in Maluku, Papua, West Irian Jaya, East Nusa Tenggara and

NorthMalukuprovinces(allineastIndonesia).Atotalof11,914chroniccaseshavebeen

reportednationallybetween2000and2009.

The Government of Indonesia has decreed lariasis elimination as one of national

priorities to combat communicable diseases in line with Presidential decree number 7,

2005, and agreed to participate in the international goal launched by WHO to eliminate LF

as a public health problem by 2020. The LF programs objectives are to reduce and eliminate

transmissionofLFbyMDA,andtoreduceandpreventmorbidityinaffectedpersons.In2009,

MDAwithdiethylcarbamazine(DEC)+albendazolecoveredmorethan19millionpeople

in30%oftheendemicdistricts,withanaverageprogramdrugcoveragerateof66.5%of

the at-risk population in those districts. Albendazole is donated by GlaxoSmithKline (GSK)

throughWHOandDECispurchasedlocally.Accordingtothe2011-2014NationalPlanfor

LF, the central government is responsible to ensure the procurement of drugs and provide


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routine budget, while the local government is expected to contribute the operational and

maintenance budget. External funding is required to achieve the goal of elimination by

2020. The cost of distribution per person calculated in the National Plan is US $0.23.

Schistosomiasis

Schistosomiasis, due to Schistosoma japonicum, is endemic in the Lindu, Napu and Badavalleys in Central Sulawasi province, with an at-risk population of 25,000 to 50,000. Although

control activities ended in 2005, 2010 surveys showed a resurgence of transmission with

anaverageprevalenceofinfectionof9.6%among5villagesinNapuValley.Theseareas

have restricted access to potable water and sanitation, with few families having latrines.

The program has limited resources for control operations and praziquantel for treatment

ofthoseinfectedhasnotbeenreadilyavailable.Adetailedandbudgetedplan(2011-2014)

for schistosomiasis elimination was developed by the Vector-Borne Disease Control

Directorate (VBDCD) within MOH. The total cost of the programme in the draft plan is

US$4,838,760fortheperiod.Theunfundedgapisequivalentto65%ofthetotalamount.

Soil-transmitted helminths (STH)

In the last 15 years, hundreds of districts have been surveyed in Indonesia to assess the

STHprevalence.Over40,000 individuals (mostlychildren)were involved.Results show

that STH infection is widespread in the country and, according to WHO guidelines, most

of the areas surveyed need at least one treatment/year. Preliminary predictive mapping for

areas for which data are not available suggests that STH are intensively transmitted through

the entire country.

In2009,morethan19millionindividualsweretreatedwithdonatedalbendazolethroughLFMDA;thistreatmentresultedindewormingof1millionpreschoolchildrenand3.6million

school-age children. An additional number of children were dewormed through the school

system by local authorities and international partners such as the World Food Programme

(WFP);howeverexacttreatmentguresarenotknownatnationallevel.Twenty-oneand

ahalfmillionchildrenliveindistrictswhereLFisnotendemicandthereforedonotbenet

from the impact of albendazole distribution through LF MDA. As some of these districts are

highlyendemicforSTH,theywouldbenetfromadonationofmebendazole.

Yaws

Currently18ofthe33provincesarebelievedtobeaffectedwithyaws,withveclassied

ashighburden.In2009,8,309caseswerereported(mostlyfrom6districtsinNusaTenggara

Timur province), and numbers have been increasing steadily since 2001 (when 2,112 cases

were reported). From the remaining provinces, no information is available. The MOH

strategy is designed to eradicate the disease by 2013. The strategy includes active case-

ndingofcasesandtheircontacts,mobilizationof communitysupport,capacitybuilding

of health staff for detection and management of cases, and establishment of partnerships

withotherdiseasecontrolprogramsandexternalpartners.Activecasending,orannual

search and treat missions, is planned to scale up from 10 districts in 2010 to 18 districtsin 2011, using an island-by-island approach. Technical assistance, monitoring, supervision and

2WHO.Preventivechemotherapyinhumanhelminthiasis.Geneva,WorldHealthOrganization,2006.


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training are integrated with the leprosy programme. The program estimates a budget of

$80,000 per district, not including technical assistance and monitoring, for a total cost of

$9millionover5years.

Plan of Action for NTD control/elimination

The Government of Indonesia is committed to intensify its efforts to control andeliminateveofthemostimportantNTDsaffectingthecountryandcausingsufferingand

impoverishing millions of people. This Plan of Action (PoA) was developed to improve the

managementofeachdiseaseandmaketheprogramsmoreefcientbyintegratingsome

of the activities in a way that will save human resources, time and money. This integrated

approachshouldobtainbetterhealthresultsandhelpachievethenalgoalofsustained

control of STH and elimination of leprosy, LF, schistosomiasis, and yaws from Indonesia.

General objectives

i) to strengthen the Indonesian health system through improved training, advocacyand coordination at all levels of the health system,

ii) to strengthen multi-sectoral collaboration within the MOH, Ministry of Education,

Ministry of Internal Affairs and Ministry of Religious Affairs among others, and

iii) to strengthen the national capacity for successful management of international

cooperation funding (USAID, AusAID, WHO and other international agencies)

and drugs donations (DEC, albendazole, mebendazole, benzathine penicillin,

praziquantel, leprosy multidrug combination).

The main expected results of this PoA are:

i) Updated strategies based on international guidelines and best practices

ii) Accurate estimates of the burden of these 5 NTDs to improve macro and

micro planning, monitoring and evaluation.

iii) Successful management of drug donations. Lack of timely access to drugs

constitutes a barrier for success of most of the programs. However, there are

companies willing to donate their drugs to countries which can demonstrate their

capacity to forecast and distribute the drugs to those in need.iv) Strengthened capacity of health workers and volunteers through integrated

training at all levels. Activities which strengthen the knowledge, abilities, skills and

behavior of individuals (MoH, health workers, school teachers and communities)

and improve institutional structures and processes help the program more

efcientlymeetitsmissionandgoalsinasustainableway.

v) Integrated social mobilization activities, key for the success and sustainability

of the plan.

vi) Integrated and improved MDA for LF, schistosomiasis, and STH includingscaling up and increasing coverage to achieve the individual program goals.


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vii) Integrated and intensied morbidity case detection for leprosy, LF and

yaws through MDA campaigns and eld visits of health care workers (index

casecontactsstudy). Intensiedcase-ndingduringLFMDAcampaignsandIEC

activities is a unique opportunity for leprosy and yaws elimination efforts to screen

communities.

viii) Integrated and intensied case management for leprosy, LF and yawsthrougheldvisitsofhealthworkersandsupporttoself-caregroups.Improving

casemanagement isoneofthebestwaystoghtstigmaanddiscriminationof

chronic patients, win the trust of the community, and increase self declaration by

suspected patients.

ix) Strengthened monitoring and evaluation system for the 5 NTDs.

x) Establishment of a surveillance system for leprosy, LF, schistosomiasis and yaws

after the elimination of these diseases as public health problems.

Supporting expected results are:

xi) Establishment of a national NTD Taskforce. By joining all national and international

stakeholders in a single network, the program will improve coordination among

the different programs, integrate of activities, share results, facilitate solutions, and

maximize impact.

xii) Increased visibility, advocacy and political commitment for NTD control

and elimination. Having one PoA for 5 different NTDs will increase their visibility

andwillfacilitatepoliticalandnancialcommitmentbymaximizingresultswith

minimum cost.

xiii) Increased advocacy for comprehensive NTD control which links water,

sanitation,hygieneeducationandchemotherapy.Along-termsolutiontoghtand

eliminatediseasesrelatedtopovertyistoghtpovertyitself,byimprovingliving

conditions and enabling people to change their behavior by having access to water,

sanitation and hygiene education.

xiv) Integrated health promotion and hygiene education. Every opportunity will

be used to promote health and hygiene in the community. Social mobilization

campaigns, MDA, school deworming days, self-care groups as well as every contactwith the health system will be use to promote hygiene and health habits.


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an integrated actions


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SummaryBudget:IntegratedNeglectedTropicalDiseaseBu

dgetEstimationinUS

D

Description

2011

2012

2013

2014

2015

Estimated

government

commitment

Operational

gaps

(

External

funds

r

equired)

Estimated

government

commitment

Operational

gaps

(External

funds

required)

Estimated

government

commitment

Operational

gaps

(External

funds

required)

Estimated

government

commitment

Operational

gaps

(External

funds

required)

Estim

ated

government

commitment

Operational

gaps

(External

funds

required)

Lym

phaticfilariasis

10,

000,

000

5,

000,

000

10,

000,

000

5,

000,

000

10,

000,

000

5,

000,0

00

10,0

00,

000

5,

000,

000

10,0

00,

000

5,

000,

000

SoilTransmitted

HelminthicInfection

(STH)

500,

000

200,

000

500,

000

200,

000

500,

000

200,

000

500,

000

200,

000

5

00,

000

200,

000

Lep

rosyandYaws

1,0

00,

000

700,

000

1,

000,

000

700,

000

1,

000,

000

700,

000

1,0

00,

000

700,

000

1,0

00,

000

700,

000

Sch

istosomiasis

150,

000

100,

000

150,

000

100,

000

150,

000

100,

000

150,

000

100,

000

1

50,

000

100,

000

G

randTotal

11,650,000

6,000,000

11,650,000

6,000,

000

11,650,000

6,000,000

11,650,000

6,000,000

11,6

50,000

6,000,000


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Geography and Demographics

Indonesia is the largest archipelago country in the world with 17,508 islands of which6,000areinhabited3 . It is located in Southeast Asia between the Indian Ocean andthePacicOcean,andspansatotalareaof1,919,440sqkm(land1,826,440sqkm&

water93,000sqkm).Indonesiahasanumberofnaturalresourcesincludingpetroleum,

tin, natural gas, nickel, timber, bauxite, copper, fertile soils, coal, gold, silver. Various islandsperiodicallyfacenaturaldisasterssuchasoods,severedroughts,tsunamis,earthquakes,

volcanoesandforestres4.

In2008,thepopulationwasestimatedat228.8million,ofwhich168.3millionare15

years old. The gross income per capita was estimated at USD 3,310 (Box 1). The major

religioninIndonesiaisIslamwith88%ofthepopulation,followedbyProtestant5%,RomanCatholic3%,Hindu2%,Buddhist1%,other1%(1998data)4. Infant mortality rate (IMR)nationallyis26.8,rangingfrom8.2inDKIJakartaprovinceto43.2inWestNusaTenggara

province3.

Box 1: Demographic statistics in Indonesia5

Based on Bureau of Statistics 2008 data,3 mean years of schooling is higher for males than

females (8 years vs. 7.1 years) nationally. The National Socio-economic Survey (SUSENAS),ahouseholdsurveyconductedbytheIndonesiaBureauofStatistics(BPS),foundthat96.1%

ofchildren7-12yearsoldwereenrolledinschool,comparedto79.2%forchildren13-15

yearsold,and49.8%forchildren16-18yearsold.Schoolenrollmentvariesfrom99.52%in

Jogjakartaprovinceto83.38%inPapuaprovince.

The percentage of households using an improved drinking water source, such as a pump/well/springwater(thatareatleast10mawayfromaseptictank),was52.72%nationally.This

variedwidelyfrom69.21%inJogjakartaprovinceto34.86%inWestPapua.Importantly,the

regional variation did not necessary correlate with urbanization since city provinces such

asJakartaalsohadlowrates(44.33%).

Country Profle

Statistics:

Totalpopulation:228,864,000

Gross national income per capita (PPP international $): 3,310

Lifeexpectancyatbirthm/f(years):66/69

Healthylifeexpectancyatbirthm/f(years,2003):57/59

Probabilityofdyingunderve(per1000livebirths):34

Probabilityofdyingbetween15and60yearsm/f(per1000population):231/192

Totalexpenditureonhealthpercapita(Intl$,2006):87

Totalexpenditureonhealthas%ofGDP(2006):2.2

3BureauofStatistics:www.dds.bps.go.id/eng/download_le/booklet_leaet/booklet_okt2009.pdf4AsianCenterfortheProgressofPeoples2007:www.acpp.org/uappeals/cprole/Indo%20Country%20Prole.pdf5 World Health Statistics: http://www.who.int/healthinfo/statistics/en/


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Political situation and administrative structure

Indonesiaisademocraticrepublicwith33provincesencompassing397districtsand98

cities3. Indonesias governance was decentralized to the level of district/city on 1 January2001.The495districtsandcitieshavebecomethekeyadministrativeunitsresponsiblefor

providing most government services including health but excluding defense and national

security,foreignaffairs,scalpolicyandreligion.Since2001thesituationhasevolvedandcurrently decentralization in Indonesia has entered a new phase of consolidation; howeverlocalinstitutionsinmanydistrictsandcitiesstilllackthecapacitytofullltheirnewmandates

effectively.Further,developmentindices,povertyrates,andpronenesstocrisis(conictor

natural disasters) vary across different provinces. Coupled with the diversity in culture,terrain and population, these have made implementation of interventions a challengingtask6 . The Ministry of Interior Affairs (Dalam Negeri) is the key ministry responsible fordecentralization and the funding of regional governments.

Health care systemThe overall health nancing situation in Indonesia is complex and incompletely

documented7.In2003,around34%oftotalhealthexpenditurewasundertakenbypublicsectoragencies,while66%wasprivate.Byfarthelargestsinglesourceofprivateexpenditure

was direct out-of-pocket payments by households, accounting for nearly half of the totalexpenditure. Insurance coverage has been increasing since the advent of the new socialinsurance scheme for the poor7.

The general decentralization process implemented in 2001 has had many impacts onthehealthsystem,eventhoughitwasnotdesignedspecicallywiththehealthsector

inmind.Inparticular,healthnancing,healthinformationsystem,humanresourcesforhealth and service provision have been affected. Under decentralization, responsibilityfor health care provision is largely in the hands of district/city governments. Despitethis, the central government continues to set the national agenda, targets for health andalong with the provincial governments, provides a supervisory, support and monitoringrole for district/city governments.

The Ministry of Health (MOH) in Indonesia, situated in the capital Jakarta, has 4

Directorate-Generals, 2 Institutes, an Inspectorate-General and a Secretariat-Generalunderwhichthereare14CentersandBureaus(Figure1).Anumberofthesestructuresare

critical for the control of NTDS under consideration in this PoA. Primarily, the Directorate-GeneralofDiseaseControl&EnvironmentalHealth(DGDC&EH)hasvedirectorates,where the Directorate of Vector-Borne Disease Control oversees LF, schistosomiasis & STHcontrol and the Directorate of Directly-Transmitted Diseases oversees leprosy and yawscontrol.UndertheDGDC&EH,thereisaplanningunit,nanceunitandaregulationunit

that are involved in the overall management of the business of the Directorate-General.

6 GovernmentofIndonesiaandUNDPCountryProgrammeActionPlan,2006-10www.undp.or.id/pubs/docs/CPAP%202006-2010.pdf7 WorldHealthOrganizationIndonesiaCountryOfcewww.searo.who.int/indonesia


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For NTD control, the DG DC & EH also coordinates with the Centre for HealthPromotion, the Bureau of Planning & Budgeting (under the Secretary-General), as well asthe Directorate-General for Pharmacy & Medical Services and the National Institute forHealth Research & Development. In addition to lateral coordination, the DG DC & EHalso coordinates with the provincial and district health authorities. Structures for diseasecontrol such as vector-borne diseases and directly-transmitted diseases are replicated on asmaller scale in provincial governments. The general division of mandate between national,

provincial and district/city governments can be seen below: CentralMOH:preparenationalstrategy,guidelines&regulationsfordiseasecontrol

and provide a supervision, monitoring and support role to provincial and district/cityauthorities

Provincial Health Ofce (PHO): adopt national strategies to develop provincial

strategy based on local situation, provide training, funding support, supervision &monitoringfordistrict/citylevelhealthofces

District/CityHealthOfce(DHO):developdistrict/citylevelplans,directlyimplement

disease control activities, supervise lower health structures such as primary health

care centers.

INSPEKTORAT JENDERAL

STAF AHLI MENTERI

SEKRETARIAT JENDERALINSPEKTORAT JENDERAL

INSPEKTORAT

DIREKTORAT DIREKTORAT DIREKTORATDIREKTORAT

DIREKTORAT JENDERAL

BINA KESEHATAN

MASYARAKAT

DIREKTORAT JENDERAL

BINA PELAYANAN

MEDIK

BADAN

PENELITIAN DAN

PENGEMBANGAN KESEHATAN

PUSAT

DATA SURVEILANS

EPIDEMOLOGI

PUSAT

KESEHATAN HAJI

PUSAT

PROMOSI

KESEHATAN

PUSAT

PENANGGULANGAN

KRISIS

PUSAT

PEMBIAYAAN DAN

JAMINAN KESEHATAN

PUSAT

KOMUNIKASI

PUBLIK

PUSAT

KERJASAMA LUAR

NEGERI

PUSAT PEMELIHARAAN

PENINGKATAN, DAN

PENANGGULANGAN

INTELEGENSIA KESEHATAN

PUSAT

SARANA, PRASARANA DAN

PERALATAN KESEHATAN

BADAN

PENGEMBANGAN DAN

PEMBERDAYAAN SDM KESEHATAN

DIREKTORAT JENDERAL

BINA KEFARMASIAN DAN ALAT

KESEHATAN

DIREKTORAT JENDERAL

PENGENDALIAN

PENYAKIT DAN PENYEHATAN

LINGKUNGAN

SET

SET SET SET SET

SET

PUSAT PUSAT

SET

BIROPERENCANAAN

DAN ANGGARAN

BIROKEPEGAWAIAN

BIROKEUANGAN DANPERLENGKAPAN

BIROHUKUM DANORGANISASI

BIROUMUM

*Menteri kesehatan = Minister of Health, Direcktorat Jendral Pengendalian Penyakit dan Penyehatan lingkungan

= DG DC & EH, Direktorat Jendral Bina Kefarmasian dan Alat Kesehatan = DG Pharmacy and Health

Supplies, Pusat Promosi Kesehatan = Centre for Health Promotion, Pusat Kerja Sama Luar Negeri = Centrefor International Collaboration, Direktorat Jendral Bina Pelayanan Medik = DG General Medical Services,

Direktorat Jendral Bina Kesehatan Masyarakat = DG Community Health.

STRUKTUR ORGANISASI DEPARTEMEN KESEHATAN

Figure 1: Organizational structure of Ministry of Health, Indonesia*


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School Health Programme (UKS)

There are about 175,000 public, religious and private schools in Indonesia, all of which areeligible to participate in the School Health Programme (UKS - Upaya Kesehatan Sekolah).There are about 27 million students in primary school, about one quarter of whom arein religious schools (Madrasah Ibtidaiyah). Education is compulsory and provided free of

chargeinpublicschoolsforchildrenfrom7to15/16yearsofage,correspondingtoall6classesofprimaryschooland3classesofsecondaryschool.Thenumberofteachers

working in primary schools is 1.38 million.

The three major UKS programmes include health education, health service deliverythrough schools, and a healthy school environment. In addition to immunization, the healthservices delivered include health and nutrition screening for new students; height and weightmonitoring; health education, dental care; iron and iodine supplementation; and de-wormingin some areas. Booklets and materials have been developed for UKS, which provide theobjectives of the program, health information, how to conduct health promotion in schools

and monitoring/evaluation procedures. Content includes information about good nutritionand how to build latrines and water pipes.

The MOH Child Health Directorate coordinates activities relevant to the UKS. Fourministries (MOH, Ministry of Education, Ministry of Internal Affairs and Ministry of Religion)are involved in UKS. The implementation is mandated by teachers and supported by primaryhealth care staff in all schools, including religious schools. There is also a ministerial decreeaboutminimumstandardsinschoolsforensuringhealth(KepMenKes1429/MENKES/SK/

XH/2006).

School Immunization Month Programme (BIAS)

In1998,theMinistriesofHealth,Education(MoE),ReligiousAffairs(MRA),andInternal

Affairs launched Bulan Imunisasi Anak Sekolah (BIAS), School Immunization MonthProgramme. BIAS was designed to be a sustainable routine activity to eliminate tetanus andprovidediphtheriaboosters.In2000,measlescampaignsfor6-12yearoldswereincluded

in provinces that had funding. Since 2003, reported vaccination coverage in schools throughBIAShasbeenabout95%eachyear.

The MOH has the responsibility for policy, service delivery and evaluation, while theMoE and MRA handle social mobilization. The Ministry of Internal Affairs, through its localgovernmentandmunicipalityofces, is responsible forcoveringoperational costs. The

UKS team leader at each level coordinates and monitors implementation of the overallintegrated school health programme, including BIAS. Within the MOH, the staff in charge ofhealth promotion at each level looks after UKS overall; however, the Expanded Programmeon Immunization (EPI) is given responsibility at each level to implement BIAS. The UKSguru(s) oversees BIAS within the school.

BIASismanaged,suppliedandimplementedwithoutthetechnicalornancialinvolvement

of multilateral or bilateral partner agencies. While BIAS was integrated within the existingUKS structure, most respondents at lower levels indicated that the existence of the UKSstructure was helpful but not in fact required for the adoption of BIAS, since the health

workers felt they were able to forge good relations with local schools on their own.


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Leprosy

Leprosy is a disease caused by Mycobacterium leprae, a bacterium which primarily affectsthe skin and peripheral nerves. The main mode of transmission is considered to be air-borne,

through droplets discharged from the respiratory tract of untreated infectious cases, who form10 per 100,000 population. 2007 data fromtheMOHshowthatprevalenceremainsabove theeliminationlevel in160(35%)outof

460districts.Furtherstraticationofnewcasedetectionratesfrom2007suggeststhatthe

heaviestdiseaseburdenisin125(27%)outofthe460districts.

Figure 2: Indicates the burden of disease by province in Indonesia

Since2000,17,000-18,000newcaseshavebeenreportedeachyear,ofwhich10%have

grade-2disabilityandofwhich10%arechildren.Morethan70%ofthenewcasesareof

the multi-bacillary type (MB). MB cases carry two major risks: they are at higher risk ofdeveloping disabilities and they are primarily responsible for disease transmission. Eachyearabout1,500newcaseswithgrade-2disabilitiesareaddedtothepoolofabout26,000

accumulated cases with grade-2 disabilities thus increasing the burden of socio-economicrehabilitation on the national, local governments and communities (Figure 3).

High burden

(CDR>10/100000)

Or new case>1000

Low burden

CDR


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supervision/monitoring. MOH has produced ample IEC material of excellent quality readyfor dissemination, which is also available in CD format so that local governments canduplicate/print the standard materials.

The Leprosy Programme conducts 21-day annual training of province and districtleprosy workers at the National Leprosy Training in Makassar, South Sulawesi. Health center

workers take part in 5 day trainings, other health workers are trained for 1 day, and cadresaretrainedforhalfaday.However,insub-districtswithintensiedcasendingwithIEC

campaigns, the programme conducts an additional 1-day annual training that focuses onthe an overview of leprosy and yaws, a description of the local epidemiology, and how toidentify suspect cases. The morning session is for health care workers and cadres, as wellas other sectors (religious, social welfare, education and local government). The afternoonsession is for health center works only and focuses on more technical aspects of diseaserecognition and treatment.

The Programme receives drug donations via WHO yearly for case management. The

drugs are imported into the country by WHO and are then distributed to district levelfrom MOH budget. The budget is reliable but has been delayed in previous years. The totalcost is approximatelyUSD 66,000 toenable distribution ofdrugs four timesper year

to district level, handling a total of 25 ton (25,000 kg). The cost per kilogram averagesRp24,000(2.65USD).Furtherdisseminationistheresponsibilityofthelocalgovernment,

which is problematic since it relies on the assurance that the budget line is maintained bythe local level planning system.

Another aspect of the control program is the recent establishment of PerMaTa groupsfor people affected by leprosy. PerMaTa is now present in parts of East Java, South Sulawesi,East Nusa Tenggara and Jakarta.

Partners

The Netherlands Leprosy Relief (NLR), an international non-governmental organization(NGO), is supporting the MOH in leprosy case detection and disability management. NLRhasanofceinJakartabutalsohasstaffinsomeofthehigh-burdenprovinces.Amongthe

activities conducted by NLR include monitoring and evaluation meetings in high-prevalencedistrictswhichprovideanopportunitytore-traineldstaff,andsupporttosomeofthe13

leprosyhospitalsaroundthecountryincludingvehospitalsforprosthesis.

In addition, the Sasakawa Foundation provides support to manage the disabilitiesarising from leprosy. Further information regarding the Sasakawa support will be availableonce the workplan is completed. The WHO also provides limited funds to the MOH forleprosycontrol,whichinthepasthavebeenusedtofundcasendingmissionsandnational

meetings.

Lymphatic lariasis

Lymphatic Filariasis (LF) is caused by helminthic worms inhabiting the lymphatics. Thediseasepredominantlyafictspoorpeopleinbothurbanandruralareasaswellasmarginalized

and neglected populations. It is usually acquired in early childhood and is responsible for

considerable morbidity, causing social stigma among men, women and children. LF is one theonly six infectious diseases considered eradicable by WHO with the available tools9.

9LymphaticFilariasis:thediseaseanditstreatment(WHO,2006).www.searo.who.int/en/Section10/Section2096_10583.htm


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Epidemiology

LF is one of the major public health problems in Indonesia. All three types of lymphaticparasites namely Wuchereria bancrofti, Brugia malayi and Brugia timori are prevalent inIndonesia(Figure4),butB.malayiisthemostdominant.Twenty-threespeciesofmosquitoes

are vectors for LF in Indonesia.

Figure 4: Distribution of larial parasite in Indonesia

Since 2005, districts or cities have been used as the implementation unit (IU) todetermine endemicity and implement MDA. The MOH nished mapping endemicity

throughoutthecountryin2009,albeitsomedistrictsweremappedusingepidemiological

surveys (proximity of district to endemic districts, presence of chronic cases and MF ratessurrounding chronic cases) rather than MF surveys using Lot Quality Assurance Sampling(LQAS),asrecommendedforconrmationofendemicityinWHOguidelines. 10

Asof2009, anestimated125millionpeople areatriskoflariasis infection, in337

endemicdistricts,i.e.wheremicrolaremia(MF)>1%(Figure5).Basedonbloodsurveys

forMFinIndonesia,provincelevelprevalencevariedfrom0-38.57%.Thehighestrateswerein Maluku, Papua, West Irian Jaya, East Nusa Tenggara and North Maluku provinces (all ineastIndonesia).Atotalof11,914chroniccaseshavebeenreportednationallybetween

2000and2009,althoughthisismostlikelyanunderestimategiventhatitonlyincludes

cases that sought care through the national health system.

10WHO.Preparingandimplementinganationalplantoeliminatelymphaticlariasis(inareaswhereonchocerciasisisnotco-endemic).

WHO/CDS/CPE/CEE/2000.15.


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Strategy and Activities

The LF Program sits within the Sub-directorate for Filariasis and Schistosomiasis. Atcentral level, there are 11 staff members working on LF, schistosomiasis and STH. At provincialanddistricthealthofces,therearenospecicstaffmembersforLF,schistosomiasis,and/or

STH. Instead the Head of Health, the Head of Division, the Chief of Section and functionalstaff are responsible for communicable diseases. At primary health centre level, the Headof Health Centre and functional staff also are responsible for control of all communicable

diseases.

Since 2002, the LF Program has implemented MDA campaigns, scaling up to cover moredistrictseachyear. However,duetonancialandhumanresourceconstraints,districts

often provide only partial coverage of the at-risk population within the district.

The LF Program conducts 5-days annual training of central and province LF workersAt central levels. The training focuses on epidemiology, management program, laboratorydiagnostic, treatment and case management of LF. In province level training conduct 3 daysannual training of district LF worker. The training focuses on epidemiology, managementprogram, treatment and case management of LF. In district level LF training conduct 2 daysannual training of health center that focuses on management program, treatment and case

management. Whereas in health center level conduct one day training that focuses on thean overview of LF and mass treatment.

Figure 5: LF endemicity in Indonesia based on surveys up to September 2009, by district

Table 1. MDA coverage 2006-2009

MDA2 (DEC+ALB) 2006 2007 2008 2009Population Targeted 7,075,000 11,116,000 16,799,000 28,719,000

Population Treated 5,325,000 8,411,000 12,310,000 19,160,000

Geographical Coverage 26,5% 25,3% 30,7% 29,7%Programme Coverage 75.3% 75,7% 73,3% 66,7%

National coverage 5.4% 7.5% 10.4% 15.4%


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Further, the University of Indonesia, with support from the Bill & Melinda Gates Foundation,is comparing the impact of twice-yearly MDA campaigns for three years versus once-yearlyMDAcampaignsforveyears.

Schistosomiasis

Schistosomiasis in Indonesia is caused by a parasite, Schitosoma japonicum, which infectsa number of mammals, including humans. The intermediate host is Oncomelania hupensislindoensis,anamphibioussnail.Thesnaillivesinabandonedriceelds,alongditches,known

as disturbed habitat, under dense wild canes, along creeks or seepage waters. In humans,the disease has toxic and dysenteric symptoms as well as loss of appetite and weight,emaciation, retarded growth, in young patients. Hepato-splenomegaly and ascities arecharacteristic, progressing to death. Currently, single dose treatment with praziquantel isthe treatment of choice since it is highly effective, easy-to-administer, and with minimumside effects. WHO provides donations of praziquantel to affected countries, however, globalsupplies of the drug are limited.

Epidemiology

In Indonesia, schistosomiasis is known to occur in three very isolated areas in twodistricts in Central Sulawesi province: the Bada, Napu and LinduValleys (Figure 6).A

comprehensivecontrolprogramwasinitiatedinLinduandNapuvalleysin1973.Control

strategies included chemotherapy, hygiene & sanitation improvements and agro-engineering.However,duetodiminishingfundingaftertheterminationofa speciccontrolprogram

in 2005 and the absence of post-elimination campaign activities, infection rates started torisein2006.By2009,prevalenceintheNapuvalleyreached3.8%.Inthesameperiod,the

infectionrateamongsnailsincreasedfrom0to13.4%and0to9.09%inNapuandLinduvalleys, respectively.


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The Schistosomiasis Program sits within the Sub-directorate for Filariasis and

Schistosomiasis. At central level, there are 11 staff members working on LF, schistosomiasisandSTH.Atprovincialanddistricthealthofces,therearenospecicstaffmembersforLF,schistosomiasis, and/or STH. Instead the Head of Health, the Head of Division, the Chief ofSection and functional staff are responsible for communicable diseases. At primary healthcentre level, the Head of Health Centre and functional staff also are responsible for controlof all communicable diseases.

Based on an Oct-Nov 2010 evaluation mission by WHO, a number of challenges wereidentiedforthediseasecontrolprogram.Sincediseaselevelswerebroughttolowlevelsin

previousyears,therehavebeendifcultiesinsustainingpolicymakersinterestandallocation

of budgets for disease control activities. Further, there has been a lack of coordinationbetween the MOH and others departments involved in the environmental and agriculturalaspects of the overall strategy. Based on the evaluation mission, resumption of the controlprogram would be critical to eliminate the disease where the at-risk population is up to50,000people,withmappingdonetoclearlydeneifthereareotherendemicareasin

the highlands of Central Sulawesi. At the core of the strategy is yearly MDA to reducedisease incidence in humans. This would slowly reduce environmental contamination andthus snail infection, curbing the disease cycle over time. The core strategy of MDA can becoupled with education to the local community, rat and snail surveillance, and support tothe environmental management programs including introduction of latrines and suitable

water sources.

Figure 6: Schistosomiasis endemicity in Indonesia


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Soil-transmitted Helminths

Soil Transmitted Helminthiasis is the infection with one or more intestinal parasiticworms: roundworms (Ascaris lumbricoides), whipworms (Trichuris trichiura), or hookworms(Necator americanus and Ancylostoma duodenale). Infected people excrete helminth eggsin their feces, which then contaminate the soil in areas with inadequate sanitation. Other

people can then be infected by ingesting eggs or larvae in contaminated food, or throughpenetration of the skin by infective larvae in the soil (hookworms). Infestation can causemorbidity and, in rare instances, death, by compromising nutritional status, affecting cognitiveprocesses, inducing tissue reactions, such as granuloma, and provoking intestinal obstructionor rectal prolapse. Control of helminthiasis is based on drug treatment, improved sanitationand health education.

Epidemiology

Soil-transmitted helminth (STH) infections are considered to be an enduring public

health problem in Indonesia, although national-level data are not complete.Available national data consist of those collected during periodic school surveys

(conducted in 8 provinces per year), the historical data collected during surveys conductedin the last 10 years and available in literature and a complete review of the literatureconducted by the London School of Hygiene and Tropical Medicine (LSHTM) for UNICEFin 2002. 11

Dr S. Brooker and Dr. R. Pullan from LSHTM updated the 2002 revision with more recentdata12,13 and produced the following map providing a visual localization of the available dataand their level of endemicity (Figure 7a).

Based on this epidemiological data and on climatic and population information the samegroup in LSHTM extrapolated a map in which the areas that have a strong possibility tohaveaprevalenceofSTHover20%aremarkedinpurple(Figure7b).

11 Brooker S.(2002) Human helminth infections in Indonesia, East Timor and the Philippines. UNICEF

12AlbrightJW,HidayatiNR,Basaric-KeysJ.Behavioralandhygieniccharacteristicsofprimaryschoolchildrenwhichcanbemodiedtoreduce

theprevalenceofgeohelminthinfections:astudyincentralJava,Indonesia.SoutheastAsianJTropMedPublicHealth.2005May;36(3):629-

40.

13AlbrightJW,Basaric-KeysJ.Instructioninbehaviormodicationcansignicantlyaltersoil-transmittedhelminth(STH)re-infectionfollowing

therapeuticde-worming.SoutheastAsianJTropMedPublicHealth.2006Jan;37(1):48-57.

Figure 7a. Maps of STH prevalence in Indonesia: a. Data-based


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Table 2 Population living in STH endemic areas

Total Population (2010 Census) 237 million

Total population living in STH endemic areas 195 million

31 provincesPre-school children living in STH endemic areas 13 million

School-age children living in STH endemic areas 37 million

Pre-school children living in STH endemic areas not

endemic for LF

4.6 million

7 provincesSchool-age children living in STH endemic areas not

endemic for LF

13.5 million

According this extrapolation, the population in need to be treated is presented inthe following table: (details based on the province positives for LF and STH and provincepopulation according the 2010 census data are available in the annex


The responsibility of STH sits under the Diarrhea Sub-directorate in DG DC& EH butwill relocate to Sub-directorate LF & Schistosomiasis in 2011. At central level, there are11 staff members working on LF, schistosomiasis and STH. At provincial and district healthofces, thereare nospecicstaffmembers forLF, schistosomiasis, and/orSTH. Instead

the Head of Health, the Head of Division, the Chief of Section and functional staff areresponsible for communicable diseases. At primary health centre level, the Head of Health

Centre and functional staff also are responsible for control of all communicable diseases.

To date, the activities conducted by the Diarrhea Sub-directorate include:

Periodicschoolsurveys(usuallyin4schoolseachin8provincesperyear)

ProvisionofMDAorselectivetreatmentofpositivecases(dependingonavailability

of resources and drugs nationally and at local level)

Healthpromotionandhygieneeducation

Promotingimprovementinsanitationespeciallylatrinecoverage

Trainingofhealthcareworkersandcommunity

Intersectoralandinter-programcoordination Monitoringandevaluationofactivities

Figure 7b. Maps of STH prevalence in Indonesia: b. Predicted


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On average less than 2 000 school age children were treated every year.

TheSTHProgramconducts4-daysannualtrainingofcentralandprovinceSTHworkers

central and province STH workers central and province STH workers. The training focuseson epidemiology, management program, laboratory diagnostic and treatment. In districtlevel training conduct 2 days annual training of district STH worker and health center.The training focuses on epidemiology, management program, laboratory diagnostic andtreatment of STH. Whereas in health center level conduct one day training of cadres(school teachers) that focuses on the an overview of LF and mass treatment .

Partners

In addition to the activities conducted by the DG DC & EH, other stakeholders such asthe Child Health Directorate (under the DG Community Health at MOH) have undertakenMDA activities for STH. The Child Health Directorate encourages provincial authoritiesto adopt MDA twice per year and coordinates with the Ministry of Education. Due to the

decentralization process, provinces and districts need to self-purchase drugs for the MDAwhich has reduced compliance with the national program since the budget is not routinelyavailable.

Other STH partners include the World Food Program (WFP)s school feeding programwith which de-worming activities are paired. WFP highlighted two major challenges in thedeworming aspect of their campaigns: parents need to be educated before the dewormingcampaign otherwise there is reluctance to participate, and, transportation of the WFP drugsfrom the district to the schools has proved challenging. WFP operates in three provincesNTT (Kupang, TTS and Belu districts), NTB (Central Lombok, West Lombock and East

Lombock districts) and East Java (Sampang). WFP conducted systematic deworming inall schools in thesedistricts during the period 2007-2009.After that dewormingwas

interrupted. Only Sampang and TTS districts continue deworming with local resources.

Yaws

Yaws (Framboesia tropica) is a chronic, contagious, non-venereal infection caused by thespirochete Treponema pertenue. The disease is most prevalent in children


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i i

i

i i il l

.

Fig .1 Trend in Yaws case reporti ng Ind onesia 2001-2009

2112

4987

3283 3489

5099

6464

8907

6083

7751

0

2000

4000

6000

8000

10000

2001 2002 2003 2004 2005 2006 2007 2008 2009

Case

The Yaws Eradication Program has been reporting a steady increase in number of newcasessince2001.Theprogramreported7,751newcasesfromveprovincesattheendof

2009(Figure9).Ofthese,7,400caseswerereportedfromactivesurveyscarriedoutin6

highly endemic districts in East Nusa Tenggara (NTT) province.


The Sub-directorate for Leprosy and Yaws, in which the Yaws Eradication Program isbased, has 12 staff at national level. At provincial and district level, there is 1 staff who isresponsible to the program. In most province, leprosy control program and yaws eradicationprogram are held by one staff, except in Papua, East Java and Central Sulawesi provinces.

The MOH strategy is designed to eradicate the disease by 2013. WHO guidelinesrecommendthatwhereprevalenceislessthan5%,asisthecaseinIndonesia,allactive

cases, household members and obvious contacts should be treated with a single injectionof long-acting benzathine penicillin.

Figure 8: Geographic distribution of provinces reporting cases on yaws, Indonesia

Figure 9: Yaws case reporting in Indonesia, 2001-2009


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TheMOHstrategyincludesactivecasendingandtreatmentofcasesandtheircontacts,

mobilization of community support, capacity building of health staff for detection andmanagement of cases, and establishment of partnerships. The main operational activity is toundertake search and treat missions at least once annually in the districts still reportingcases.This would then be followed by sero-surveillance for eradication certication,

monitoring and evaluation.

The Yaws Eradication Program conducts 2 days training of district and health center staff.However this program is not regularly conducted, it depends on the budget availability. Thetraining focuses on case diagnostic, case management and reporting-recording system.

Benzathine penicillin is ordered by the Program, which takes responsibility for distributingit to the district level. However, the Indonesian supplier is not currently making the drug;therefore, the Yaws Program will have to procure it elsewhere.

Despite the clear strategy for yaws eradication in Indonesia and its alignment withglobal recommendations14, low commitment and funding of the operational activities have

delayed implementation of the eradication program. Recognizing this limitation, the Sub-directorate of Yaws and Leprosy at the MOH has piloted integrated activities with otherdisease control programs including leprosy and LF. The integrated strategy and activities aredescribed further in latter sections of this document.

Overlapping of NTDs endemicity

A complete listing of all districts with LF, leprosy, yaws and schistosomiasis was obtainedfrom the different Sub-directorates at the MOH. It is assumed that STH is endemicthroughout the country but that prevalence varies. A summary of the population at risk for

LF and STH can be seen in Table 3.

Health, hygiene & nutrition promotion

The MOHs Centre for Health Promotion is responsible for promoting Living a cleanand healthy life, otherwise, known as PHBS in Indonesia. The activities for PHBS are variedand extend to activities in the primary health care centers in all districts across Indonesia,including staff visiting schools and communities for hygiene education and outreach. Forexample, each primary health care center is mandated to conduct PHBS activities seventimes per year for each school under their geographic purview.

According to the 2007 Health Indicator Survey (Riskesdas), the percentage of householdsthatmeetthecriteriaforgoodapplicationofPHBSis38.7%.Provincesthatperformbetter

Table 3: At-risk population for diseases that need mass drug distribution (LF, SCH and STH)

Population 5-12 years

(school-aged children)

Total population 237.3 million 45.1 million

LF endemic/ STH endemic/SCH endemic 50 000 (9 500)

LF endemic/ STH endemic 124.9 million 23.7 million

LF not endemic/ STH endemic ( 70.6 million) 13.4 million

Total in need of treatment 124.9 million 37.1 million

LF not endemic/ STH not endemic 41.8 million 7.9 million

14YawsGoals,Objectives&Strategy(WHO,2006).www.searo.who.int/en/Section10/Section2134_10840.htm


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than38.7%areJogjakarta(58.2%),Bali(51.7%),EastKalimantan(49.8%),CentralJava(47%)

andNorthSulawesi(46.9%).ProvinceswithlowperformancescoresarePapua(24.4%),

EastNusaTenggara(26.8%),Gorontalo(27.8%),Riau(28.1%)andWestSumatera(28.2%).

The Riskesdas 2007 also assessed hygienic behavior, measured by appropriateness ofdefecation practices (at minimum, use of latrine) and appropriateness of hand-washing

practices (wash hands with soap before eating, before handling food, after defecation, aftercleaningchildrensdefecationandafterhandinganimals).Thesurveyfoundthat71.1%of

population10yearssurveyedpracticedappropriatedefecationpractices,butthatonly

23.2%hadgoodhandhygiene.TheprovincewithbesthygienepracticeswasJakarta:98.6%

fordefecationpracticesand44.7%forhandhygiene.Provinceswithlowperformancefor

defecationpracticeswereWestSulawesi(57.4%),Gorontalo(59.2%)andWestSumatera

(59.3%).Provincesfoundtohavelowhand-hygienepracticeswereWestSumatera(8.4%),

NorthSumatera(14.5%)andRiau(14.6%).

Recent activities by the MOH Child Health Directorate and supported by WHO included

developing a teaching guide for teachers in primary schools about child health, development,hygieneandnutrition.Thebookwasnalizedin2010andisawaitingtheendorsementofthe Ministry of Education before it can be circulated to schools nationwide. This will soonbe followed by a similar book for high school students.

Integrated vector management

InIndonesiathereare23speciesofmosquitoesfrom5generafoundaslariasisvectors.

These are Mansonia, Anopheles, Culex, Aedes and Armigeres.

Figure 10


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Species of Anopheles are the main vectors of nocturnal periodic W. bancrofti in rural areas.The main vector of nocturnal periodic W. Bancorfti in urban areas is Culex quinquefasciatus,a highly anthropophilic species which feeds readily both indoors and outdoors and has itspeak biting period between midnight and 3 am. The main vector of diurnal subperiodic W.Bancrofti is the day-biting, exophilic Ae. Polynensiensis. It breeds in small water containersand has a peak of feeding just before sunset. Mansonia uniformis is one of the main vectorsof nocturnal periodic Bancroftian and Brugian Filariasis.

Malaria is another mosquito-borne disease that plagues much of the population inlymphaticlariasisendemicareasandisspreadbyAnophelesmosquitoes.InIndonesia,itis

concentrated on the outer islands of Papua, Maluku, Nusa Tenggara, Sulawesi, Kalimantan,and Sumatra. A primary control strategy is the use of long-lasting impregnated nets (LLINs)to reduce the number of indoor-resting mosquitoes and shift mosquito feeding fromhumans to animals.

With funding from the Global Fund for AIDS, Tuberculosis, and Malaria, UNICEF and the

International Red Cross, the National Program for Malaria Control in Indonesia deliversLLINs through either:

Routinedistributionsinwhicheverypregnantwomenreceives1LLINintheprenatal

services (immunization and maternal and child health program, midwifes, malaria post).From2007to2009,over2.2millionLLINsweredeliveredaccordingtotheMalaria

World Report 2010. CampaignswhichdistributetwoLLINsperfamilyinareasatrisk.Thenumberofbed

nets distributed under this strategy is unknown.

MalariaprogrameducationalmaterialsinIndonesiaincludemessagesaboutthebenets

of using LLINs for decreasing both malaria and LF transmission. During LLIN distributionand MDA campaigns the use of LLINs should be encouraged, as advocacy for bednet usewillbenetmalariaandLFcontrol.MalariaandLFprogramsshouldstrengthentheirlinks

and send integrated messages related to vector control and protection during the routineand campaign distribution of LLINs and during MDA campaigns.

Integration between disease control initiatives

Disease control integration has taken place between the various programs within theMOH structure, as well as through integration with various partner agencies such as World

Food Program, Ministry of Education and Ministry of Religious Affairs.Within the MOH structure, NTD integrated control received some attention in the last

few years. In 2007, the MOH prepared Integration Guideline for the Control of LF, leprosy,yaws and STH. The basic concept is demonstrated diagrammatically, where the various Sub-directorates under DG DC & EH work with other units of the MOH and jointly enable theintegration of activities at the provincial and district level (including monitoring, supervision,case detection, case management etc) (Figure 10). Schistosomiasis is not included in thelist of the diseases in this guideline since the public health problem is limited to a smallgeographical area and population.

The integrated guideline outlines the principles of integration, the objectives, the strategy,the structural organization, and the roles and responsibilities of different levels of the health


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system. Importantly, the guideline recognizes that there are some activities that have thepotential for integration but that there are those that have to stand alone. The guidelinedescribes the mechanisms for integrating rapid mapping, endemicity surveys, health careworker training, health volunteer training, MDA campaigns, self-care groups for casemanagement, health promotion activities, documentation and reporting, and monitoringand evaluation. The guideline includes the forms that can be used by health care workersat each level (PHO, DHO, PHC and cadres), but it does not provide scripts (step-by-stepinstructions) for how each activity such as the integration of LF MDA registration withleprosysuspectcasendingwillbeconducted.Suchoperationalguidelinesareneededto

simplify the concepts, enable rapid training of health care workers and assist in standardizingprocesses and activities.

Since 2007, there has been limited uptake by provinces and districts of the integratedguidelines. This is likely a consequence of limited opportunity to disseminate and help in

the planning process for integration, especially due to the vertical budget lines allocatedto each disease control program. Nevertheless, the MOH undertook a pilot project in2007 in two locations: Subang in West Java to integrate leprosy and LF, and Buton in EastSulawesi to integrate leprosy, LF and yaws. The reasons for selecting these two areas for thepilot were the high endemicity of NTDs in these areas, availability of highly motivated staffandcommitteddecisionmakers.Thetrialsshowedthatintegrationforself-carebeneted

patients of all diseases and that there was commitment to the activities of the self-caregroups.

In addition to integration within the MOH, activities have been integrated with otherprograms at local level. One example is the combination of deworming campaigns withimmunization for children in primary school classes 1-3. This activity is conducted by

MOH/PHO/DHO

Sec. GenCommunityHealth

MedService

DC & EH

Surv-Epid

D-DTDC

Env Health

Water Sanitation

Leprosy & Yaws

PHO/DHO/HC

Health Promotion

Integrated

Control

MCH, Schoolhealth & Nutrition

focus

D-VBDC LF, Schisto & STH

Health Promotion

PHO/DHO/HC

Focus

MCH, School

health & Nutrition

Water Sanitation

LF, Schisto & STH

Leprosy & Yaws

Figure 11: Coordination between different units in MOH to enable integration of NTD

control activities at local level


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primary health care workers who are also in charge of the UKS at sub-district level. Inaddition, in the seven districts in east Indonesia where WFP provides supplemental feeding,deworming activities including MDA twice per year, latrine provision and water provisionhave been integrated. The WFP no longer supports the STH control campaign but has seensustainable local government continuation of the program in two of the seven districts.

Drug supply and logistics

Adequate and timely supplies of drugs constitute a barrier to success for most of the NTDprograms. However, drug donation programs now exist for all 5 of the NTDs in the PoA,as follows:

In 2010, Johnson & Johnson announced the donation of 200 million tablets of

mebendazole for countries heavily burdened by STH. This donation program ismanaged by the NGO Children Without Worms (CWW).

In2010,EisaiCo.,Ltd.announcedadonationofDECforLFendemiccountries.Thisis

still in the negotiation phases, but WHO will facilitate the donation starting in 2012. GlaxoSmithKlineprovidesalbendazolefreeofchargeforLFeliminationprograms.This

program is managed through WHO.

MerckdonatespraziquantelforschistosomiasiscontrolinAfricaandotherselected

countries. This program is managed by WHO.

Multidrug therapy for leprosyisdonatedbyNovartis.Thisprogramismanagedby

WHO.

WHO supports the procurement of benzathine penicillin for some endemic

countries.

Albendazole and multidrug therapy for leprosy have previously been donated to Indonesia.Both drugs are fully registered in the country. DEC is produced and procured locally.Mebendazole is registered as Vermox produced by Janssen Cilag, which is a division of

Johnson & Johnson in Indonesia. Benzathine penicillin was produced locally but productionhas been discontinued in 2010.

Within Indonesia, the MOHs DG for Pharmacy & Health Supplies procures a range ofdrugs for the NTD programs. For 2010, the drug quantities procured through the MOHsystemcanbeseeninTable4.

Table 4: Number of tablets procured by MOH for distribution to district level, 2010

NTD Drug Tablet/box Total tablets

procured

LF DEC 100/box 1,285,493

Albendazole 30/box (400mg) 749,021

Schistosomiasis Praziquantal 100/box (600mg) 5,000

STH Albendazole - 125,673

Leprosy Blister pack combinations 3000/bottle 2,399,712

Yaws Benzathine penicillin 10 vials @ 20mL 1,500


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Table 5: Drug price adjustment based on regions

Region Provinces Price Adjustment

Region 1 Jakarta, West Java, Central Java, Jogjakarta, East

Java, Bali, Lampung, Banten

nil

Region 2 North Sumatera, West Sumatera, Riau, Jambi,

South Sumatera, Bengkulu, Riau Islands, Bangka

Belitung, NTB

5%

Region 3 NAD, West Kalimantan, Central Kalimantan,

South Kalimantan, East Kalimantan, North

Sulawesi, Central Sulawesi, South-East Sulawesi,

South Sulawesi, West Sulawesi, Gorontalo

10%

Region 4 NTT, Maluku, North Maluku, Papua, West Papua 20%

The ministerial decree is then circulated to each disease control program so that they canmake requests for drug purchase based on their available budget and needs. These requestsare submitted by April of each year. Following this, the MOH DG Pharmacy & HealthSupplies commences the tender process. The companies that are allocated the tender arethen responsible to deliver the drugs to district level. Delivery of drugs commences after

April and may take until the end of the year.

Most drugs are purchased from the three state-owned companies producing genericproducts:

PTPhapros(ceasedbutmayinfutureyearsrecommenceproductionofbenzathine

penicillin)

PTKimiaFarma

PTIndoFarma(producesmebendazole)

AseparatesystemisavailablefordrugdonationstoMOH.Therstoptionistoestablisha Special Access Scheme (SAS). The SAS is an agreement between MOH and the donatingagency that is valid for one year to enable drug importation. This is especially useful fordrugs that are not registered in the country. Another option is to register the drug inIndonesia;aprocessthattakes6-12months.Theregistrationisvalidforveyears.

The process of procurement commences each year in January, where the DG Pharmacy& Health Supplies compiles and agrees with pharmaceutical companies on the list of genericdrugs & prices for purchase. A ministerial decree is then signed listing the drugs and theagreed MOH purchase price. The price of the drug is adjusted for four regions in Indonesiabased on the geographic distance from Jakarta. Regions and the price adjustment can beseen in Table 5.


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Development o Plano Action

Rationale

Even though each Disease Control Sub-directorate at the MOH DG CDC & EH hasits own plan including some level of integrated activities for different diseases, this

Plan of Action was needed in light of:

RecentannouncementofenhanceddrugdonationsforNTDbypharmaceutical

companies globally. ReneweddonorinterestinfundingNTDactivitiesforacceleratingeliminationand

control ReviewandevaluationofschistosomiasisprograminCentralSulawesi(October-

November 2010) FinalizationofLFplanfor2010-2014(May2010)

NeedtorevitalizeMOH2007integrateddiseasecontrolstrategythatintegrates

some activities in the LF, leprosy, yaws and STH program. NeedtoleverageresourcesalreadymadeavailabletocertainNTDforthepurpose

of supporting and enriching other NTD programs receiving little attention. AchievementofMDGgoals

Decentralizationofhealthservices

Benefts

SingledocumentwithkeyactivitiesaboutanumberofNTDsinIndonesia

IlluminatesynergiesbetweenNTDprogramsthatenhancecost-effectiveness

ReneactivitiesforacceleratedcontrolofNTDsinlightofrecentinternational

and national developments Promoteexternalfundingforactivities

Challenges

WiderconsultationindevelopingPlanofAction:limitedtocurrentpartnersbut

little involvement from other sectors of government (Dalam Negeri, Bappenas). Thelargesizeofthecountryandtheconsiderablepopulationatriskwillrequirea

progressive scaling up of the control activities, but the entiere area endemic fore LFshould be covered by 2015 in order to get the target of LF elimination by 2020

Theeastpartofthecountryincludeveryremoteareaswithmajorlogistic

difcultiesforcoveringthepopulationatrisk


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Plan o Action orNTD Control

General objectivesi) to strengthen the Indonesian health system through improved training, advocacy and

coordination at all levels of the health system,

ii) to strengthen multi-sectorial collaboration within the MOH, Ministry of EducationMinistry of Internal Affairs and Ministry of Religious Affairs among others, and

iii) to strengthen the national capacity for successful management of internationalcooperation funding (USAID, AusAID, WHO and other international agencies) and

drugs donations (DEC, albendazole, mebendazole, benzathine penicillin, praziquantel,leprosy multidrug combination).

Table 6: Main goals and targets by disease

Goal Disease Objectives Drugs InterventionFrequency of

Intervention

Intervention

Population

Unit of

Implementation

Elimination

LEP - To decrease

leprosy

prevalence in

hyperendemic

areas below 1

per 1000

population

- To reduce

disability due to

leprosy below

35%

Multidrug

combination

therapy

Active case

finding and

treatment

Not

applicable

Not

applicable

District

LF - To interrupt

transmission

and achieve

elimination of

the public-

health

problem by

2020

- To cover at

least 65% of at-

risk population

with MDA by

2016

DEC + ALB MDA Once a year Entire

population

(excluding

4 yrs

Village

Yaws To eliminate yaws

by 2013

Benzathine

Penicillin

Active case

finding andtreatment

Once a year All cases and

contacts

Villages


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MDA=mass drug administration PZQ=praziquantel

ALB=albendazole SAC=school-age children

MEB=mebendazole

Expected results

To establish an integrated strategy towards control of STH and elimination of leprosy, LF,schistosomiasis and yaws in Indonesia, the PoA will achieve the following expected results(ER):

ER I Updated strategies based on international guidelines and best practices

ER II Accurate estimation of the burden of these 5 NTDs

ER III Successful management of drug donations

ER IV Strengthened capacity of health workers and volunteers

ER V Integrated social mobilizationER VI Integrated and improved MDA for LF, schistosomiasis, and STH including scaling up

and increasing coverage

ERVII Integrated and intensied morbidity case detection for leprosy, LF, and yaws

throughMDAcampaigns and eld visits ofhealth careworkers (contactcase

detection)

ERVIII Integratedandintensiedcasemanagementforleprosy,LF,andyawsthrougheld

visits of the health workers and self-care groups

ER IX Strengthened monitoring and evaluation system for the 5 NTDs

ER X Establishment of a surveillance system for leprosy, LF, schistosomiasis, and yaws

after their elimination as public health problems

Supporting expected results

ER XI Creation of a National NTD Taskforce joining all stakeholders including national

and international actors

ER XII Increased visibility, advocacy and political commitment for NTD control and

elimination

ER XIII Increased advocacy for comprehensive NTD control linking water, sanitation,

hygiene education and chemotherapy

ER XIV Integrated health promotion

Goal Disease Objectives Drugs InterventionFrequency of

Intervention

Intervention

Population

Unit of

Implementation

Con

trol

STH - To achieve a

coverage of at

least 75% of at-

risk SAC by

2012 where

STH prevalence

is 20% or

higher.

- To

Neglected Tropical Disease NTD2011

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