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
Eastern Indonesian Time
Central Indonesian Time
Western 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 lt5 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 gt95 (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
2001/2 onwards ?
1998-2000
Grade 1 DT 2x DT 1x DT 1x Measles Grade
2 TT 1x TT 1x Grade 3 TT 1x TT
1x Grade 4 TT 1x Grade 5 TT
1x Grade 6 TT 2x TT 1x ELIGIBLE
TARGET 9 MILLION 29
MILLION 15 MILLION
2002 onwards inclusion of routine second dose
measles in class 1 on rolling basis province by
province
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 (lt20)
• 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)

• 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

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