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

INDONESIA

Western
Indonesia
n Time

Central
Indonesia
n Time

Total infant (0-11 month): 4,8 million

Total school immunization target: 15 million

Eastern
Indonesia
n Time
2

School Immunization Program (BIAS)

School Immunization Month is

immunization services conducted
at all primary schools nation wide
in the months of August and
November

This was introduced as

collaboration of four Ministries
Target: children in grades 1, 2 & 3
Vaccines: DT, Measles & TT
Started since 1984 and evolved
gradually in 1997 and in 2002.

Why Indonesia Implemented BIAS

DT/TT

Basic immunization (DPT 3x) produces immunity

up to <5 years old children

National Institute of Health and Research

Development (NIHRD) conducted serological
studies among 4-5 yrs old in 1996 in Papua &
Central Kalimantan, it revealed declining
immunity levels against Diphtheria (74-77%)

Need of booster dose for Diphtheria

Low TT2+ coverage among CBAW

As part of School Health Program (UKS) which is

existing since 1956

School enrollment rate >95% (boys and girls)

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 (5279%) 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
5

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
6

School Immunization Schedule

Dynamic and Evolving
1984-1997

Grade 1
Grade 2
Grade 3
Grade 4
Grade 5
Grade 6
ELIGIBLE TARGET

DT 2x

1998-2000

TT 2x

DT
TT
TT
TT
TT
TT

1x
1x
1x
1x
1x
1x

9 MILLION

29 MILLION

2001/2 onwards

DT 1x Measles
TT 1x
TT 1x

15 MILLION

2002 onwards: inclusion of routine second dose measles in class 1 on

rolling basis province by province

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 coldchain)

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
9

Roles and Responsibilities

Micro planning done by teachers & health
workers
Schools inform parents and this is considered as
public informed consent s when children come
to school for vaccination
Vaccination conducted in school by local health
center staff
School immunization coverage is reported by
health centers on same channels as for routine
EPI
Monitoring and supervision is undertaken by
joint interdepartmental school health program
supervisory team

10

Result of BIAS
High coverage achieved for all antigens
NIHRD serological studies showed high
protection level against Diphtheria (98%)
and against TT (100%) among 10-14 yrs
old after BIAS
Low vaccine wastage rates (<20%)
Declining trends of measles incidences
High acceptance of BIAS by parents

11

Percentage of DT Coverage
Grade I (age 6-7 years), 1998 - 2007
100
90
80
70
60
50
40
30
20
10
0
1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

12
Source: Sub Dir EPI, CDC, MoH 2008

Percentage of TT Coverage
Grade II and III (age 7-10 years), 1998 - 2007
100
90
80
70
60
50
40
30
20
10
0
1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

13
Source: Sub Dir EPI, CDC, MoH 2008

Percentage of Measles Coverage

Grade- I (6-7 years of age), 2003 - 2007
100
90
80
70
60
50
40
30
20
10
0
2003

2004

2005

2006

2007

14
Source: Sub Dir EPI, CDC, MoH 2008

Measles Immunization Coverage and Measles Cases*

Indonesia, 1983-2008
100

90000

80000

80

70000

60
50000
40000

40

Measles Cases

% Coverage

60000

30000

20000

20

10000

0
19
83
19
84
19
85
19
86
19
87
19
88
19
89
19
90
19
91
19
92
19
93
19
94
19
95
19
96
19
97
19
98
19
99
20
00
20
01
20
02
20
03
20
04
20
05
20
06
20
07
20
08

Measles Cases

*Source: Surveillance Unit, MOH

Reported doses administered (%)

**

School measles dose

: SIAs

15

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
16

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

17

Conclusion (1)
Indonesias school immunization program is wellestablished
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
18

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
19

20