bias rumah sakit
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BIAS
Indonesia School Based
Immunization Program
Dr Andi Muhadir, MPH
Director, Surveillance Epidemiology and Immunization, Ministry of Health,
Republic of Indonesia
Global Immunization Meeting
New York
17-19 Feb 2009 1
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Eastern Indonesia
n Time
INDONESIA
Total infant (0-11 month): 4,8 millionTotal school immunization target: 15 million
Central Indonesia
n Time
Western Indonesia
n Time
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School Immunization Program (BIAS)
School Immunization Month is immunization services conducted at all primary schools nation wide in the months of August and November
This was introduced as collaboration of four Ministries
Target: children in grades 1, 2 & 3
Vaccines: DT, Measles & TT
Started since 1984 and evolved gradually in 1997 and in 2002.
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Why Indonesia Implemented BIAS
DT/TT Basic immunization (DPT 3x) produces immunity
up to 95% (boys and girls)
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Why Indonesia Implement BIAS for
Measles control
NIHRD serological study among primary school children in 1997 at Yogyakarta, Ambon & Palu showed only 72% of children were protected against measles
Surveillance data showed high proportion (52-79%) of Measles cases in East Java in 1996 among school going children (5-14 years old)
In 1998-2000 surveillance data showed 40% of measles cases nationally were in children above 5 years of age
As a measles control strategy: 2nd dose of Measles vaccine
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Objectives of
School Based Immunization
To provide life-long immunity
against tetanus to all primary
school graduates
To provide a booster dose for
Diphtheria
To reduce measles mortality
and morbidity
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School Immunization Schedule
Dynamic and Evolving
1984-1997 2001/2 onwards 1998-2000
Grade 1 DT 2x DT 1x DT 1x MeaslesGrade 2 TT 1x TT 1xGrade 3 TT 1x TT 1xGrade 4 TT 1xGrade 5 TT 1xGrade 6 TT 2x TT 1x
ELIGIBLE TARGET 9 MILLION 29 MILLION 15 MILLION
2002 onwards: inclusion of routine second dose measles in class 1 on rolling basis province by province 7
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BIAS Strategies
Effective inter-sector collaboration (involving four Ministries: Health, Education, Religion Affair, Internal Affair)
Sound policy and guidelines for both health workers and other stake holders in place
Trained health workers in all 8,000 primary health centers across the country
Central government provides vaccines and logistics (includes cold-chain) 8
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BIAS Strategies (cont..)
15 million children studying in 175,000 primary schools (public, private and religious) targeted across the country
Strong commitment with regular contribution by provincial and district governments is provided
Monitoring and supervision done by inter-sectoral teams
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Roles and Responsibilities
Micro planning done by teachers & health workers
Schools inform parents and this is considered as public informed consent s when children come to school for vaccination
Vaccination conducted in school by local health center staff
School immunization coverage is reported by health centers on same channels as for routine EPI
Monitoring and supervision is undertaken by joint interdepartmental school health program supervisory team 10
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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 (
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010
20
30
40
50
60
70
80
90
100
1998 1999 2000 2001 2002 2003 2004 2005 2006 2007
Percentage of DT Coverage
Grade I (age 6-7 years), 1998 - 2007
Source: Sub Dir EPI, CDC, MoH 2008 12
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Percentage of TT Coverage
Grade II and III (age 7-10 years), 1998 - 2007
0
10
20
30
40
50
60
70
80
90
100
1998 1999 2000 2001 2002 2003 2004 2005 2006 2007
Source: Sub Dir EPI, CDC, MoH 2008 13
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Percentage of Measles Coverage
Grade- I (6-7 years of age), 2003 - 2007
0
10
20
30
40
50
60
70
80
90
100
2003 2004 2005 2006 2007
Source: Sub Dir EPI, CDC, MoH 2008
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Measles Immunization Coverage and Measles Cases*
Indonesia, 1983-2008
0
20
40
60
80
100
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
%
C
o
v
e
r
a
g
e
0
10000
20000
30000
40000
50000
60000
70000
80000
90000
M
e
a
s
l
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s
C
a
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Measles Cases Reported doses administered (%) School measles dose
: SIAs*Source: Surveillance Unit, MOH
**
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Key Factors Which Make BIAS Successful
Compulsory education, free of charge in public schools
High enrollment of girls and boys in early primary schools (97%)
Sufficient number of health centers and staff
Regular budget: vaccines and logistics provided by MOH
Inter ministerial coordination exits through BIAS
Clear roles and responsibilities through guidelines for health provider and teachers and periodic training for providers
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Absenteeism is around 5 10% on vaccination day
Non compliance to the public consent by some schools
Mechanism to reach for out of school children still not developed
Limited sources for monitoring and evaluation
Competing priorities at local level specifically in decentralization context, need for regular advocacy with local governments
ChallengesChallenges
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Conclusion (1)
Indonesias school immunization program is well-established
Key elements for a successful program exist
official policy
operational guidelines for health workers and teachers
High immunization coverage for all antigens
Not a heavy burden on health center staff
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Conclusion (2)
Unit cost per student vaccinated is cost effective in comparison with routine vaccination $0,70 for TT , $0,80 for Measles
Strengthen tetanus elimination strategy in a sustainable fashion and contribute significantly in measles control
Builds infrastructure for future vaccine preventable disease control programs
BIAS inline with GIVS to reach immunization beyond the traditional target groups
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