Maternal and Neonatal Tetanus Elimination Post-Validation ...

A post-validation assessment of maternal and neonatal tetanus elimination was

conducted in seven districts of Indonesia on 10–18 February 2020 in conjunction with a

national/international review of the Expanded Programme on Immunization and a

vaccine preventable surveillance review. This report presents the findings, conclusions

and recommendations of the assessment.

Combined with the joint national/international Expanded Programme on Immunization and

Vaccine Preventable Disease Surveillance review

Maternal and Neonatal Tetanus Elimination Post-Validation Assessment

Indonesia, 10–18 February 2020

SEA-IMMUN-120

SEA-IMMUN-120



Vaccine Preventable Disease Surveillance review Indonesia, 10–18 February 2020

Maternal and Neonatal Tetanus Elimination Post-Validation Assessment – Combined with the joint national/international Expanded Programme on Immunization and Vaccine Preventable Disease Surveillance review

SEA-IMMUN-120

© World Health Organization 2020

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Contents

List of tables ......................................................................................................................... iv

List of figures ........................................................................................................................ v

Acronyms ............................................................................................................................. vi

Executive summary ............................................................................................................. viii

1. Background ................................................................................................................... 1

MNTE in Indonesia ....................................................................................................... 2

MNTE post-validation assessment .............................................................................. 11

2. Methods ...................................................................................................................... 12

Planning ...................................................................................................................... 13

Implementation ........................................................................................................... 13

Analysis and reporting ................................................................................................ 14

District selection .......................................................................................................... 14

Field assessment ........................................................................................................ 17

3. Findings ...................................................................................................................... 18

NT incidence and NT surveillance ............................................................................... 18

ANC coverage and opportunities to vaccinate against tetanus .................................... 19

BIAS and TTCV delivery ............................................................................................. 21

SBA, clean delivery and cord care practices ............................................................... 21

Health system impact on MNTE sustainability ............................................................. 22

Human resources ........................................................................................................ 22

Data analysis and use for action ................................................................................. 22

Service delivery .......................................................................................................... 23

Demand generation and community engagement ....................................................... 23

4. Conclusions ................................................................................................................ 24

5. Recommendations ...................................................................................................... 24

6. Lessons learned ......................................................................................................... 27

Cost implications for the integration ............................................................................ 29

iv

List of tables

Table 1. Indonesia schedule for TTCV .............................................................................. 3

Table 2. MNTE core and surrogate indicators ................................................................. 11

Table 3. Summarizes the key findings from the rapid community convenience surveys .. 19

Table 4. Td2+ and SBA coverage provided at national and district level for MNTE PVA districts ........................................................................................... 20

Table 5. List of participants: MNTE Post-Validation Assessment ..................................... 29

v

List of figures

Figure 1. Trend of DTP3 coverage in Indonesia 2012–2018 ............................................... 4

Figure 2. TTCV booster dose coverage trend in Indonesia 2012–2018 .............................. 5

Figure 3. Coverage of >4 ANC visit in Indonesia ................................................................ 6

Figure 4. Td2+ coverage in Indonesia 2012–2018 .............................................................. 7

Figure 5. % of skilled birth attendance in Indonesia ............................................................ 8

Figure 6. Number of reported neonatal tetanus cases in Indonesia 1980–2018 .................. 9

Figure 7. Map of Indonesia showing regional grouping for MNTE validation ....................... 9

Figure 8. WHO algorithm for determining neonatal tetanus risk status of districts ............. 16

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Acronyms

ANC antenatal care ANC1 one visit of antenatal care BIAS Bulan Imunisasi Anak Sekolah

(Indonesia School-Based Immunization Programme) CDC Atlanta US Centers for Disease Control and Prevention, Atlanta cMYP comprehensive multiyear plan DHS demographic and health survey DQr data quality review DT diphtheria-tetanus (vaccine) DTP diphtheria-tetanus-pertussis (vaccine) DTP1 first dose of DTP DTP3 third dose of DTP EPI Expanded Programme on Immunization HepB hepatitis B vaccine HMIS Health Information System JRF joint reporting form LQA-CS lot quality assurance – cluster survey MCH maternal and child health MNT maternal and neonatal tetanus MNTE MNT elimination MoH Ministry of Health MR measles/rubella vaccine NIP national immunization programme NT neonatal tetanus PAB protection at birth Penta pentavalent vaccine (DTP-HepB-Haemophilus Influenzae type B) Penta 1 First dose penta vaccine PIE Post-introduction evaluation (of vaccines) PIRI periodic intensification of routine immunization PNC postnatal care PVA post validation assessment


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RMNCAH reproductive, maternal, newborn, child and adolescent health (programme) SAGE Strategic Advisory Group of Experts SBA skilled birth attendance SEARO South East Asia Regional Office (of WHO) SIAs supplementary immunization activities Td tetanus/diphtheria (toxoid) TT tetanus toxoid TT2+ two or more doses of TT TTCV tetanus toxoid containing vaccines VPDS Vaccine Preventable Disease Surveillance WHO World Health Organization WRA women of reproductive age WUENIC WHO-UNICEF estimate of national immunization coverage UNFPA United Nations Population Fund UNICEF United Nations Children’s Fund

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Executive summary Background Tetanus is an acute infectious disease caused by toxigenic strains of the bacterium Clostridium tetani (C. tetani) and has high case-fatality rate even where intensive care is available. The rates may approach 100% in the absence of medical intervention making it an important public health problem in many parts of the world. While tetanus may occur at any age, many cases are birth-associated and can occur among insufficiently vaccinated mothers and their newborn infants, following unhygienic deliveries and abortions, and poor postnatal hygiene and umbilical cord care practices.

To reduce the public health burden of tetanus, the Forty-second World Health Assembly called in 1992 for the elimination of neonatal tetanus in 57 countries (following their independence, East Timor (later Timor-Leste) and South Sudan were later included in this list to make it 59), which aims to reduce maternal and neonatal tetanus (MNT) cases to such low levels that the disease is no longer a major public health problem. Maternal and neonatal tetanus elimination (MNTE) is defined as less than one neonatal tetanus (NT) case per 1000 live births in every district per year.

In 2016, Indonesia became the last country in the World Health Organization’s (WHO) South-East Asia Region to be validated for MNTE through a WHO recommended process that was conducted in phases by grouping the provinces into regions: Region 1 (Java and Bali) and Region 2 (Sumatera) in 2010, in Region 3 (Kalimantan, Sulawesi, NTT and NTB) in 2011 and Region 4 (Papua and Maluku) in 2016. As per WHO recommendation, countries that have been validated for MNTE need to conduct yearly reviews of relevant core and surrogate MNTE indicators to evaluate their elimination status and implement corrective measures in at-risk districts.

Since Indonesia was validated for MNTE, it has not yet conducted the recommended yearly review. To review its MNTE status, the Indonesia National Immunization Programme (NIP), with technical guidance from partners, decided to combine an MNTE post-validation assessment (PVA) with the Expanded Programme on Immunization (EPI) and Vaccine Preventive Disease Surveillance (VPDS) review that was planned for February 2020.

Methods The MNTE PVA was combined with the EPI and VPDS review to save on costs, permit an understanding of the extent and nature of links between MNTE related issues and the broader EPI and VPDS systems nationally and possibly learn lessons on successful practices in such joined conduct.

The combined EPI/VPDS review and MNTE PVA, which was coordinated by the NIP and technical partners, was conducted through data desk reviews and field visits that also included rapid community convenience surveys in four high-risk NT districts.

Preparations for the combined review commenced about three months prior with regular teleconferences among WHO and UNICEF stakeholders at all levels, including two WHO recruited consultants to discuss critical aspects of the combined review such as the


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selection of districts, management of logistics and other resources and the modification of data collection tools.

Thirty districts (including four highest-risk NT districts for the PVA) in 15 of the 34 provinces in the country were selected for the EPI review based on criteria that included coverage of the third dose of diphtheria-tetanus-pertussis vaccine (DTP3), drop-out rates between first dose DTP vaccine (DTP1) and DTP3, urban/rural location, population size, and being at risk for diphtheria, polio or measles transmission. Papua province was excluded from this review for security reasons. The four NT highest-risk districts for the PVA focus were selected from the 30 districts after subjecting them to the WHO algorithm for NT risk analysis.

An in-depth MNTE PVA was conducted in the four high-risk districts by the two MNTE specific teams. A similar activity was conducted in three other randomly selected low NT risk districts by a team that was not MNTE specific. In addition to the immunization programme areas covered by all teams, the EPI and VPDS review also covered antenatal care (ANC) and clean deliveries/skilled birth attendance (SBA) and appropriate cord care services provided as well as the performance of NT surveillance.

Rapid community convenience surveys were implemented in the seven districts where in-depth MNTE PVA was conducted focusing on communities that are located >5 kilometres from the puskesmas. Ten mothers in each community who had delivered a child in the previous two years were interviewed to assess their level of tetanus protection, ANC attendance, the place and skills of person that assisted the delivery, and if any potentially harmful substance had been applied to the umbilical cord after delivery in the health facility or at home.

Findings Based on the desk review findings, none of the 30 districts had NT rate >1/1000 live births (LB), though there were evidences of gaps in NT surveillance with possible under-reporting of cases.

From desk reviews, ANC services were found to be available in all districts visited with coverage of one visit (ANC1) ranging from 60%–81%. Rapid convenience surveys showed even higher coverage: >90% ANC1 among the total of 171 mothers interviewed. However, coverage with two or more doses of tetanus/diphtheria toxoid (Td2+) among pregnant women through both desk review and rapid convenience surveys was less than 80% despite the high ANC coverage. This may possibly be due to several missed opportunities to vaccinate pregnant women during ANC visits as well as non-compliance by health workers with available policies and guidelines; amongst other factors.

Limited skills among health workers to adequately and properly compute Td doses received by pregnant women (to include all previous tetanus toxoid containing vaccine/TTCV doses: primary infant series, booster doses and supplementary immunization activity/SIA doses) was also found to be a factor for the low Td2+ coverage observed through desk reviews.

Both desk review and rapid community convenience surveys show generally high (>90%) coverage for deliveries with SBA. Rapid community convenience surveys showed generally good cord care practices among mothers interviewed. Only in two districts did 15%


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and 17% of interviewed mothers, respectively, report applying substances to the umbilical cords of their babies.

Conclusions Based on the findings of the desk reviews, which indicate high coverage for core and surrogate MNTE indicators (except for Td2+) and field visits, including the rapid community convenience surveys, which also indicate high coverage for the same indicators, the MNTE PVA team concluded that Indonesia has maintained MNTE, however pockets of populations remain at risk and in need of protection with Td. This conclusion is, however, not valid for districts in Papua as the province was excluded from this review for security reasons.

Recommendations (1) To develop, implement and monitor a plan for sustaining MNTE. (2) To conduct NT risk assessment to assess the MNTE sustainability status in

Papua province and take necessary corrective actions. (3) To address the current gaps in adequately vaccinating pregnant women and

correctly documenting previously administered TTCV doses. (4) To provide information, during ANC visits, to communities about proper cord care

and the risks of using traditional substance application on the umbilical cord of newborns.

(5) To train health workers at all levels on programme areas in which they currently acknowledge gaps.

(6) To develop, implement and monitor micro plans in all health facilities, which include strategies and budget items for providing immunization services in remote communities and other hard-to-reach populations.

(7) To implement the recommendations of the recent DQR report1 on improving data completeness, availability and quality, including data on core and surrogate MNT indicators.

(8) To map surveillance sites in the districts for active search, investigation and reporting of vaccine preventable diseases, including NT.

(9) To implement human resources policies that allow staff retention and motivation, especially in remote areas.

(10) To strengthen the already existing platforms for delivering TTCV along the life-course2 (infant vaccination, booster doses during second year of life, school health programme, ANC, periodic intensification of routine immunization/PIRI).

(11) To consider introducing the monitoring of protection at birth (PAB) during DTP1 visits.

(12) To improve the coverage, quality and information sharing related to all MNTE services delivered through EPI, RMNCAH (Reproductive, Maternal, Newborn, Child and Adolescent Health) and school health programmes – Bulan Imunisasi Anak Sekolah (BIAS) – by improving the collaboration between the programmes.

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1 Data quality review of immunization monitoring and vaccine preventable disease surveillance system, September 2019 2 tetanus vaccine WHO position paper February 2017 https://www.who.int/health-topics/tetanus/#tab=tab_1

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1. Background Tetanus remains an important public health problem in many parts of the world, particularly in poor and remote rural areas as well as in poor periurban settings where access to essential health services is scarce. It is an acute infectious disease caused by toxigenic strains of the bacterium Clostridium tetani (C. tetani), whose spores are present in the environment irrespective of geographical location. 3 The spores enter the body through contaminated skin wounds or tissue injuries including puncture wounds.4 The disease may occur at any age and case-fatality rates are high even where intensive care is available. In the absence of medical intervention, the case-fatality rate approaches 100%.5

Many tetanus cases are birth-associated and can occur among insufficiently vaccinated mothers and their newborn infants, following unhygienic deliveries and abortions, and poor postnatal hygiene and umbilical cord-care practices.6 Neonatal tetanus (NT) can occur when non-sterile instruments are used to cut the umbilical cord or when contaminated material is used to cover the umbilical stump. Deliveries carried out by persons with unclean hands or on a contaminated surface are also tetanus risk factors for both mothers and newborn babies.7

In 1989, the Forty-second World Health Assembly called for the elimination of neonatal tetanus in 57 priority countries by 1995. The list of priority countries was later updated to 59 with the independence of East Timor (now Timor-Leste) and South Sudan, respectively, in 2002 and 2011. In 1990 the World Summit for Children listed neonatal tetanus elimination as one of its goals. In 1991, the Maternal and Neonatal Tetanus Elimination (MNTE) goal was endorsed by the Forty-fourth World Health Assembly, but due to slow implementation of the recommended strategies for NT elimination, the target date for the attainment of elimination by all countries was postponed to 2000.

In 1999, progress towards the attainment of the global elimination goal was reviewed by the United Nations Children’s Fund (UNICEF), the World Health Organization (WHO) and the United Nations Population Fund (UNFPA) and the initiative was reconstituted. Maternal tetanus elimination added to the goal with a 2005 target date, which was later shifted to 2015. However, by the end of this new elimination deadline, there were still 21 countries that had not yet attained elimination.8 Progress has since been made and as of December 2019, only 12 countries remained to eliminate maternal and neonatal tetanus (MNT).9

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3 WHO Tetanus Vaccine: Position paper February 2017. Weekly Epidemiological Record, 10 Feb. 2017, Vol 92, 6 (pp. 53-76) http://www.who.int/immunization/policy/position_papers/tetanus/en/ 4 WHO Tetanus Vaccine: Position paper February 2017. Weekly Epidemiological Record, 10 Feb. 2017, Vol 92, 6 (pp. 53-76) http://www.who.int/immunization/policy/position_papers/tetanus/en/ 5 WHO Tetanus Vaccine: Position paper February 2017. Weekly Epidemiological Record, 10 Feb. 2017, Vol 92, 6 (pp. 53-76) http://www.who.int/immunization/policy/position_papers/tetanus/en/ 6 WHO Tetanus Vaccine: Position paper February 2017. Weekly Epidemiological Record, 10 Feb. 2017, Vol 92, 6 (pp. 53-76) http://www.who.int/immunization/policy/position_papers/tetanus/en/ 7 https://www.who.int/immunization/monitoring_surveillance/burden/vpd/surveillance_type/passive/tetanus/en/ 8 https://www.who.int/health-topics/tetanus/#tab=tab_1, protecting all against tetanus, guide to sustaining maternal and neonatal tetanus elimination and broadening tetanus protection for all populations 9 https://www.who.int/immunization/diseases/MNTE_initiative/en/

https://www.who.int/health-topics/tetanus/#tab=tab_1


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The MNTE initiative aims to reduce MNT cases to such low levels that the disease is no longer a major public health problem. MNTE is defined as less than one NT case per 1000 live births (<1/1000 LB) in every district in every year. To attain and sustain MNTE, high access to clean delivery services, including appropriate umbilical cord care practices together with high coverage with tetanus toxoid containing vaccines (TTCV) 10 among pregnant women and in high-risk areas among all women of reproductive age (WRA) and strengthened NT surveillance, are the primary strategies for achieving this goal.11 Coverage of TTCV is routinely monitored by the TT2+ or Td2+12 method whereby the reported number of protective doses of tetanus and diphtheria vaccine (Td) (Td2, Td3, Td4 and Td5),13 given to pregnant women during a calendar year, is divided by the estimated number of LB during the year. Protection at birth (PAB) coverage on the other hand is the proportion of births in a given year that can be considered as having been protected against tetanus as a result of maternal immunization.14

Traditionally, PAB has been assessed and recorded at the first vaccination contact for the newborn baby/infant, usually at the visit for the first dose of diphtheria-tetanus-pertussis (DTP1) or pentavalent vaccine (DTP-Hepatitis B-Haemophilus influenzae type B/Hib). However, all postnatal care visits (currently recommended at 24 hours, day 3, and between 7–14 days and six weeks after delivery) present an opportunity to check PAB.15 Assessment of protection using the PAB monitoring method helps countries to overcome the underestimation of protection level when the TT+ (Td2+) method is used. PAB coverage is calculated as follows:

➢ For the numerator: Total number of infants who were protected against neonatal tetanus by their mother’s TTCV status.

➢ For the denominator: Total number of live births.16

Effective surveillance is critical for identifying areas or populations at high risk for MNT (see Figure 6 on “WHO algorithm for determining neonatal tetanus risk status of districts”) and for monitoring the impact of interventions. However, this can be very challenging in remote and hard-to-reach areas with limited health infrastructure and access to health services.

MNTE in Indonesia Prior to the introduction of measures to eliminate NT, Indonesia had one of the highest burdens of NT in Asia. Community-based NT mortality surveys conducted in the early 1980s ________________________

10 Tetanus toxoid containing vaccines (TTCV) include: diphtheria-tetanus-pertussis (DTP) (and its other various formulations) administered during infancy and as booster dose to children 12–23 months; diphtheria-tetanus (DT) (and its various formulations) given as booster to children 4–7 years, and tetanus-diphtheria (Td) as booster to children and adolescents aged 9–15 years 11 https://www.who.int/health-topics/tetanus/#tab=tab_1, protecting all against tetanus, guide to sustaining maternal and neonatal tetanus elimination and broadening tetanus protection for all populations 12 Since 1998 WHO has recommended that all countries replace tetanus toxoid (TT) with the combination tetanus-diphtheria (Td) vaccine, to sustain protection against diphtheria following waning immunity after the primary series 13 Td2, Td3, Td4 and Td5 represent the number of doses of Td respectively given to pregnant women 14 https://www.who.int/health-topics/tetanus/#tab=tab_1, protecting all against tetanus, guide to sustaining maternal and neonatal tetanus elimination and broadening tetanus protection for all populations 15 https://www.who.int/health-topics/tetanus/#tab=tab_1, protecting all against tetanus, guide to sustaining maternal and neonatal tetanus elimination and broadening tetanus protection for all populations 16 https://www.who.int/health-topics/tetanus/#tab=tab_1, protecting all against tetanus, guide to sustaining maternal and neonatal tetanus elimination and broadening tetanus protection for all populations






3

in Jakarta and more rural areas of the islands revealed mortality rates ranging from 6–23 NT deaths per 1000 LB. Based on these and other studies, the annual number of deaths from NT for Indonesia was estimated to be 71 000 during the early 1980s.17 Systematic efforts by Indonesia to eliminate NT began with TT immunization of pregnant women through the Expanded Programme on Immunization (EPI), which was introduced in 1977.18

The strategy for the elimination of MNT in Indonesia is mainly focused on administering TTCV to protect all against tetanus along life-course: from infancy through childhood and adolescent period to early adulthood. The strategy targets:19

➢ Infants with three adequately spaced doses of DTP/pentavalent (DTP-HepB-Hib) during the first year of life and a 1st booster at 18 months using the routine EPI platform, followed by a booster dose of DT to students in grade 1 of primary school, and Td booster doses for students of grades 2 and 3 (see Table 1).

➢ Women engaged or recently married with a “bride-to-be” Td dose.

➢ Pregnant women with Td doses through routine EPI or antenatal care (ANC) services and

➢ WRA (15–39 years) with three rounds of Td supplementary immunization activities (SIAs) in areas where Td immunization and clean delivery coverage is low.

Table 1. Indonesia schedule for TTCV

TTCV schedule in Indonesia

TTCV Age administered Delivery platform

DTP-HepB-Hib (Pentavalent)20

2, 3, 4 & 18 months (2nd year of life) Routine EPI

DT Grade 1 primary school students) School Immunization Service

Td Grade 2 and 5 primary school students)* School Immunization Service

Td Pregnant women ANC visits, routine EPI

Td 15–39 years21 (women of reproductive age) SIAs

* in 2018, grade 3 schedule has been moved to grade 5

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17 Arnold RB, Soewarso TI, Karyadi A. Mortality from neonatal tetanus in Indonesia: results of two surveys. Bull WHO 1986; 64:259–262

18 Factsheet Indonesia Expanded Programme on Immunization 2019 https://www.who.int/docs/default source/searo/indonesia/indonesia-epi-factsheet-2019.pdf? sfvrsn=9ca1cf18_2 19 Maternal and Neonatal Tetanus Elimination in Java and Bali, Indonesia 2010 20 Pentavalent vaccine is composed of Diphtheria, Tetanus Pertussis (DTP), Hepatitis B and Haemophilus influenza type B (Hib) 21 Immunization Joint Reporting Form (JRF) 2012–2018 updated as of Dec 2019. While the women of reproductive age in Indonesia are within the 15–39 years, in most other countries, women of reproductive age fall between 15 and 49 years

https://www.who.int/docs/default


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Figure 1. Trend of DTP3 coverage in Indonesia 2012–2018

Source: JRF and WUENIC updated as of Dec. 2019

According to the administrative data from the WHO/UNICEF joint reporting forms (JRF), third dose DTP coverage (DTP3) in Indonesia has been >90% during the period 2012–2018. The WHO-UNICEF Estimates of National Immunization Coverage (WUENIC), however, estimates the DTP3 coverage to be <90% over the same period22 (see Figure 1). In order to address the waning of immunity associated with the infant series of TTCV, the country provides booster doses at the second year of life (at 18 months) and to grades 1, 2 and 3 students in primary schools through the school immunization programme23 (see Table 1).

From the JRF data, the coverage of 1st TTCV (penta) booster dose delivered at 18 months, which was introduced in 2014 has steadily improved from 32% in 2014 to 72% in 2018.24

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22 Immunization Joint Reporting Form (JRF) 2012–2018 updated as of Dec. 2019 23 Maternal and neonatal tetanus validation assessment in Region 4, Indonesia, May 2016 24 Immunization Joint Reporting Form (JRF) 2012–2018 updated as of Dec. 2019

96%99%

92% 91%94% 94% 93%

83%85%

78% 78% 79% 79% 79%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

2012 2013 2014 2015 2016 2017 2018

DTP3 Trend in Indonesia 2012–2018

JRF & WUENIC Data

DTP3 (JRF) DTP3 (WUENIC)


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Figure 2. TTCV booster dose coverage trend in Indonesia 2012–2018

Source: JRF updated as of Dec. 2019

The delivery of immunization through the school immunization programme (Bulan Imunisasi Anak Sekolah/BIAS) is well established in Indonesia and coverage data can readily be obtained through the JRF for at least the previous 5–10 years. The administrative coverage of the 2nd TTCV (DT) booster dose delivered at 6–7 years to grade 1 primary school students has been >90% during the period 2012 to 2017, except in 2015 when it dropped to 86%. However, in 2018 the coverage further dropped to 80%.

The coverage for the 3rd TTCV (Td) booster dose delivered to 2nd and 3rd grade students aged 7–8 years and 9–10 years respectively through the BIAS has been steadily >90% between 2012 and 2017 but dropped to 83% in 2018. It is worth noting that all TTCV booster doses delivered in Indonesia are delivered to both sexes helping to address the gender disparities in TTCV delivery that exist in other countries.25 The delivery of Td doses to pregnant women is one of the services provided during ANC visits in Indonesia. According to the Indonesia 2017 Demographic and Health Survey (DHS) report, almost all (98%) women aged 15–49 years who had a live birth in the 5 years preceding the survey went for at least one ANC visit, which was provided by a skilled provider for their most recent birth.

The WHO global database for maternal and newborn indicators 26 shows that the coverage for at least four ANC visits in Indonesia was respectively 88% and 84% in 2012 and 2013 (see Figure 3). Data for the period 2014 to 2018 through the same sources for the same indicator were not available.

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25 Immunization Joint Reporting Form (JRF) 2012–2018 updated as of Dec. 2019 26 https://www.who.int/data/maternal-newborn-child-adolescent/indicator-explorer-new/mca/antenatal-care-coverage

32%

36%

60%64%

72%

92% 94%91% 86% 92%

96%

80%

93% 95%93% 94%

92%

98%

83%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

2012 2013 2014 2015 2016 2017 2018

TTCV booster doses in Indonesia 2012–2018

Booster 1 Booster 2 Booster 3


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Figure 3. Coverage of >4 ANC visit in Indonesia25

Despite the high ANC coverage reported through the various data sources, the percentage of women who received two or more Td doses (Td2+) as reported through the JRF shows a declining trend between 2012 and 2018: 70.6% in 2012 to 52.0% in 2018 (see Figure 6). The same declining trend was reported through the 2017 DHS where between 2007 and 2017, the percentage of women who received two or more Td doses during their last pregnancy declined from 50% to 35%.

However, the 2017 DHS shows that the percentage of the most recent live births protected against NT remained steady between 2012 (60%) and 2017 (58%) These low Td2+ coverage figures reported through the JRF could be partly attributed to the suboptimal computation by health workers during ANC visits of TTCV doses received by pregnant women, which does not take into consideration doses received during previous pregnancies, mass Td immunization campaigns and TTCV booster doses delivered through the school immunization programme which is shown to be quite high in the country.27

The same factors could be attributed to the low Td2+ coverage reported through the DHS due to recall bias. As part of the MNTE immunization strategy, districts identified as high risk28 for neonatal tetanus, especially those with low coverage of Td and clean delivery, implement three rounds of Td targeting WRA, which in Indonesia is 15–39 years.

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27 Indonesia Demographic & Health Survey 2017 https://dhsprogram.com/pubs/pdf/FR342/FR342.pdf 28 Districts are considered high-risk if they have: NTR >1/1000 live births; Td2+ <80%; SBA rate <70% during a one-year period

55%61%

69%

81%

29%

82%88%

84%

0%

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30%

40%

50%

60%

70%

80%

90%

100%

1991 1994 1997 2003 2006 2007 2012 2013

% of four or more sntenatal care visits coverage trend in Indonesia


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Figure 4. Td2+ coverage in Indonesia 2012–2018

Source: JRF updated as of Dec. 2019

In parallel with TTCV immunization strategies, Indonesia has been implementing programmes and interventions to reduce maternal and neonatal mortality with the introduction of the Safe Motherhood programmes to strengthen maternal and child health (MCH) services, which have been implemented in Indonesia since 1988.29 In addition, the country launched in 2000 the Making Pregnancy Safer Initiative, which emphasizes skilled attendance during delivery, neonatal care visits through the postnatal care services (PNC) and other interventions to reduce maternal and neonatal mortality.

The proportion of clean deliveries has more than doubled during the two decades during which these programmes have been in effect.30 Efforts by the country to improve the provision of maternal health services to pregnant women by trained health personnel during antenatal, natal and postnatal periods are key to the survival and well-being of both mothers and their newborn babies. In Indonesia, there has been a steady increase in antenatal care, clean delivery and postnatal care coverage over the past decades. 31 Ensuring clean deliveries assisted by trained health personnel and the appropriate care of umbilical cords is instrumental to reducing neonatal death caused by infections, including tetanus. The 2017 DHS report indicates that 74% of live births in the 5 years preceding the survey were delivered in a health facility and nine in 10 (91%) live births were delivered with the assistance of a skilled health personnel. However, according to available information, the coverage of clean delivery and appropriate cord care practices remains low in hard-to-reach communities, especially those that lacked health training.

According to the 2017 DHS, only 69.5% of deliveries among rural dwellers were assisted by skilled birth attendants compared with 85.5% for their urban counterparts. The DHS findings on skilled birth attended delivery coverage align with the coverage reported ________________________

29 Maternal and neonatal tetanus validation assessment in Region 4, Indonesia, May 2016 30 Maternal and neonatal tetanus validation assessment in Region 4, Indonesia, May 2016 31 Maternal and neonatal tetanus validation assessment in Region 4, Indonesia, May 2016

70.6%66.2%

52.0%

63.2%65.0%

65.3%

52.0%

0.0%10.0%20.0%30.0%40.0%50.0%60.0%70.0%80.0%90.0%

100.0%

2012 2013 2014 2015 2016 2017 2018

Td2+ coverage trends in Indonesia 2012–2018


8

through the WHO global database, which shows >90% between 2016 and 2018 (see Figure 5).32 Regarding PNC, which provides an opportunity to check on appropriate care of the umbilical cords, the DHS survey found that 87% of women who had a live birth in the past five years received a postnatal check by a health provider within two days (48 hours) of delivery. It found that 79% of newborns received a postnatal check within two days of delivery. However, the survey has no information on the practice of applying potentially harmful substances to umbilical cords.

Figure 5. % of skilled birth attendance in Indonesia

The simultaneous implementation of the various MNTE strategies in Indonesia over the past decades has resulted in significant decline in the number of annually reported NT cases from 1506 cases in 1981 to only 14 cases in 2018 (99% decline), according to the WHO/IVB database on neonatal tetanus cases (see Figure 6). However, one needs to take into consideration the general under-reporting of NT cases, which may have contributed to the significantly low number of annually reported NT cases in recent years, especially after the country was validated for MNTE.

________________________

32 https://www.who.int/data/maternal-newborn-child-adolescent/indicator-explorer-new/mca/proportion-of-births-attended-by-skilled-health-personnel

32%

37%

43%

87%

93% 93% 94%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

1991 1994 1997 2013 2016 2017 2018


9

Figure 6. Number of reported neonatal tetanus cases in Indonesia 1980–2018

Source: WHO/IVB database as of Dec. 2019

Figure 7. Map of Indonesia showing regional grouping for MNTE validation

MNTE validation in Indonesia

In 2016, Indonesia became the last country in the WHO Southeast Asia Region to be validated for MNTE. In view of Indonesia’s large population and the diversity of cultures and levels of health service development, the MNTE validation process was conducted in phases like the state-wise validation process that took place in India.33 The government, in consultation with technical partners, also opted for the regional approach in view of the cost both in terms of time and financial requirements that a single survey covering the entire country will

________________________

33 Maternal and Neonatal Tetanus Elimination in Java and Bali, Indonesia 2010


10

entail.34 The country was divided into four regions to allow for sequential validation: 1–Java and Bali; 2–Sumatera; 3–Kalimantan, Sulawesi, Nusa Tenggara Barat and Nusa Tenggara Timur; 4–Papua, West Papua, Maluku and North Maluku (see Figure 5). It is important to note that regions 1, 2 and 3 account for 88.7% of the cities or districts of Indonesia and 97.4% of the Indonesian population, while region 4 makes up 2.6%.35 The MNTE validation took place by regions as follows: Region 1 – July/August 2010; Region 2 – November 2010; Region 3 – July 2011 and finally, Region 4 and by extension, the entire country in May 2016. MNTE in Indonesia represented an important public health success and contributed towards South-East Asia Regional MNTE in 2016.36

The MNTE validation survey method in Indonesia was adapted from a WHO protocol that combines the principles of lot quality assurance and cluster sampling (LQA-CS).37,38 The survey evaluates whether mortality rates from NT were <1/1000 live births during a 12-month period ending at least four weeks prior to the start of the survey. Each neonatal death identified in the survey is investigated by a physician who uses validated verbal autopsy questions to determine if the death was due to NT.

The survey also assesses maternal TTCV history, clean delivery coverage and use of traditional substances on the umbilical stump for a sub-sample of infants included in the survey. The sub-sample for this aspect of the LQA-CS survey is usually a sub-sample of 250 mothers selected from the first three eligible infants39 in each survey cluster. Preceding each regional validation survey was a pre-validation assessment by WHO and UNICEF at the request of the Ministry of Health (MoH).

These assessments were used to verify claims by the MoH that each region had eliminated MNT based on NT risk analyses conducted after the completion of planned TTCV SIAs. For each regional pre-validation assessment, the WHO team conducted desk review of core and surrogate MNTE indicators (see Table 2) and visited three to four districts that included both poor and well performing ones, to assess MNTE performance indicators at the district and health facility levels, as well as conduct rapid community convenience surveys among women of reproductive age for their TTCV2+ status, skilled birth attended deliveries and cord care practices.

For each regional pre-validation assessment, the WHO team once satisfied that the findings from the desk review and field assessments were in line with the criteria for MNTE, recommended an LQA-CS survey, to ascertain that the region had eliminated MNT. In the case of Indonesia, the regional pre-validation assessments showed that the regions had met MNTE criteria, and were therefore, ready for the recommended LQA-CS surveys.

The validation survey in each region was conducted in the worst performing district identified through the NT risk analysis conducted after the pre-validation assessment. The lot quality assurance-cluster sampling surveys, which sampled clusters of live births delivered

________________________

34 Maternal and Neonatal Tetanus Elimination in Java and Bali, Indonesia 2010 35 Maternal and Neonatal Tetanus Elimination in Java and Bali, Indonesia 2010 36 Maternal and Neonatal Tetanus Elimination in Java and Bali, Indonesia 2010 37 Stroh G, Birmingham M. Protocol for assessing neonatal tetanus mortality in the community using a combination of cluster

and lot quality assurance sampling: field test version. Geneva, World Health Organization, 2002 (WHO/V&B/02.05) 38 WHO-recommended surveillance standard of neonatal tetanus. Geneva, World Health Organization, 2010

(http://www.who.int/immunization_monitoring/diseases/NT_surveillance/en/index.html, accessed October 2010) 39 Eligible infants for the LQA-CS surveys are children born during the previous 12-month period prior to the survey

http://www.who.int/immunization_monitoring/diseases/NT_surveillance/en/index.html


11

during a one-year period prior to the survey concluded in each region, that the worst performing district in the region has MNTE indicators that met elimination criteria. Each validation survey made recommendations to improve coverage for TTCV2+, skilled birth attendance, improve cord care practices and strengthen NT surveillance.

Table 2. MNTE core and surrogate indicators40

Core indicators Surrogate indicators Additional indicators of interest (examples)

Reported number of NT cases

ANC1 coverage) Urban versus infants

Reported NT rate/1000 LB per district

ANC 4 coverage Geographic accessibility

Skilled birth attendance (SBA) coverage

DTP1/Penta1 coverage District health infrastructure

District-level data for coverage TTCV2+ and PAB

DTP3/Penta 3 coverage Other human development indicators

TTCV2+ coverage: for pregnant women and WRA by TTCV SIAs and year of implementation

TTCV booster coverage Rural percentage, absolute number and clustering of un- or under- vaccinated MCV1 coverage

Survey based coverage estimates (EPI-CES/MICS/DHS) for comparison with reported data (health management information systems/HMIS or EPI or WUENIC data)

% pregnant women never attending ANC1, and/or delivering in absence of a SBA

WHO recommends that once a country has been validated for MNTE, a yearly review of core and surrogate indicators should be conducted to evaluate if MNTE remains maintained. The core indicators include: 1) NT incidence, which should be <1/1000 live births in all district each year; 2) SBA delivery coverage which should be >70% and/or 3) Td2+ coverage, which should be >80% in all districts. The surrogate indicators include DTP3 coverage, coverage with measles rubella vaccine, DTP1/DTP3 dropout rate and general information on the district in terms of rural or urban populations.

MNTE post-validation assessment Since Indonesia was validated for MNTE in 2016, it has not conducted a formal MNTE

post validation assessment (PVA) to assess if the country is maintaining the elimination status as recommended by the WHO Strategic Advisory Group of Experts (SAGE).41 It was therefore decided by the MoH together with WHO and UNICEF to combine the planned EPI and Vaccine Preventable Disease Surveillance review with the MNTE PVA assessment.

PVA is conducted in countries that have been validated for MNTE with the objective of finding out if the countries are sustaining their elimination status. It requires intensive desk ________________________

40 https://www.who.int/health-topics/tetanus/#tab=tab_1, protecting all against tetanus, guide to sustaining maternal and neonatal tetanus elimination and broadening tetanus protection for all populations 41 WHO Tetanus Vaccine: Position paper February 2017. Weekly Epidemiological Record, 10 Feb. 2017, Vol 92, 6 (pp. 53–76) http://www.who.int/immunization/policy/position_papers/tetanus/en/



12

review of technical materials across several programmes which include: EPI, RMNCAH, health systems and disease surveillance at national, provincial, district and health facility levels. Data for the assessment are obtained from various sources that include administrative vaccine coverage data, household Surveys and qualitative data (reports, plans, policies, norms, guidelines). The assessment also requires a component of rapid community surveys to collect data from the WRA group on their use of services related to maternal immunization, ANC, PNC, institutional/skilled birth attended deliveries and newborn care, including cord care.42

Options for MNTE PVAs include:43

➢ Including MNTE sustainability in annual desk reviews of data.

➢ Integrating MNTE sustainability into a national immunization programme review.

➢ Conducting a standalone PVA.

➢ Using sero-surveys to assess MNTE sustainability.

2. Methods The MNTE PVA in Indonesia was combined with the review of the EPI and VPDS system in the country with the aim of saving on time, human, logistic and financial resources. It also aimed to raise the profile of the MNT PVA, permit an understanding of the extent to which issues related to poorly performing districts in terms of MNTE are cross cutting and relate to the EPI and VPDS systems nationally. The EPI review framework would also give opportunity to learn about MNTE in districts supposedly not at high risk, with validation conducted a long time ago. It will also possibly allow for lessons to be learned on successful practices in combining the activities.

The overall integration of the PVA into the EPI review was coordinated by a WHO-HQ recruited MNTE consultant who worked closely with the consultant recruited by the WHO South-East Asia Regional Office (SEARO) as team lead for the EPI and VPDS review; both receiving support from the WHO headquarters, WHO-SEARO, WHO Indonesia, UNICEF headquarters, UNICEF Regional Office, UNICEF Country Office and a national consultant recruited by the UNICEF Country Office.

The MNTE PVA was conducted mostly through desk review of available documents relevant to MNTE (reports on routine immunization coverage, previous EPI review reports, NT risk analysis reports, JRF and WUENIC data, DHS reports) and field visits to interview EPI officers at provincial, district and health facility levels. These were complemented with data collected in four districts determined to be at high risk for NT, using rapid community convenience surveys among mothers that delivered during the two-year period preceding the assessment.

About three months prior to the planned dates of the EPI and VPDS review, SEARO formally informed WHO Headquarters of the plan by the MoH of Indonesia to combine the

________________________

42 https://www.who.int/health-topics/tetanus/#tab=tab_1, protecting all against tetanus, guide to sustaining maternal and neonatal tetanus elimination and broadening tetanus protection for all populations 43 https://www.who.int/health-topics/tetanus/#tab=tab_1, protecting all against tetanus, guide to sustaining maternal and neonatal tetanus elimination and broadening tetanus protection for all populations




13

review with an MNTE PVA. The WHO Regional Office organized a series of teleconferences between WHO and UNICEF headquarters, regional offices and Indonesia country offices, with the participation of the two recruited consultants, to discuss and agree on the feasibility to combine the assessments, agree on the critical aspects of the integration, including the selection of districts, the deployment of teams, modification of data collection tools and the overall coordination of the combined assessment. The MNTE PVA was included among the objectives of the EPI and VPDS review with the aim to assess the current status of MNTE and make recommendations for maintaining the elimination status.

Some modifications were made to the planning, implementation and data analysis of the EPI and VPDS review to accommodate the integration of the MNTE PVA. The key modifications are as outlined below:

Planning (1) The provincial, district and health facility level EPI and VPDS review

questionnaires, including exit interview questionnaires were revised to include questions related to core and surrogate MNTE indicators such as: ➢ NT specific surveillance, including community surveillance and neonatal

death investigation

➢ Health facility and SBA and appropriate cord care practices

➢ Td2+ coverage

➢ Td booster dose coverage through the school immunization programme

➢ ANC visits.

(2) Additionally, a separate standard questionnaire for conducting MNTE household rapid community convenience surveys was provided to the teams that visited four MNTE specific districts (the selection of these districts is described below).

(3) Teams that visited the four MNTE specific districts were oriented on the method and tools for conducting MNTE household rapid convenience surveys.

Implementation (1) In each of the four MNTE focus districts, in addition to interviewing staff at

provincial and district health departments and at health facilities as part of the EPI and VPDS review, the MNTE teams conducted rapid community convenience surveys in four villages in each district targeting those villages that are at least 5-10km from the health centres, to interview 10 WRA in randomly selected households in each village that delivered during the two-year period prior to the survey. The mothers were questioned about their TTCV doses during their last and previous pregnancies and at school, places of delivery of their last baby (health facility or home) and their cord care practices (application or not, of substances to the umbilical stumps).


14

Analysis and reporting (2) Separate from the EPI and VPDS review data analysis, the MNTE teams

analysed: (a) data and information collected from all 15 provinces (30 districts) to assess

the impact of immunization and health systems barriers on MNTE sustainability, and

(b) data for core and surrogate MNTE indicators (NT incidence, Td2+ coverage, SBA deliveries, ANC visits and cord care practices) using data collected through the rapid community convenience surveys.

(3) Conclusions on MNTE sustainability status in the country were based on the combined MNTE related immunization systems findings from the EPI and VPDS review questionnaires and the findings through the community household rapid convenience surveys and exit interviews.

(4) The MNTE team made a separate debriefing presentation to stakeholders about the outcomes of the MNTE PVA.

(5) An abridged version of the MNTE PVA narrative report that highlights the lessons learned from the integration process was included in the EPI and VPDS review report.

(6) This detailed narrative report of the MNTE PVA will be disseminated among stakeholders.

District selection Available district performance data for the previous three years (2016, 2017 and 2018) were collected to select the districts for the EPI and VPDS review and the MNTE PVA with a total of 30 districts in 15 provinces out of the total of 34 in the country, representing Indonesia’s four regions,44 selected. Four of these 30 districts were selected for an in-depth MNTE assessment as part of the PVA because they were high-risk for MNT. For the EPI and VPDS review, one team stayed at national level to meet with national level committee members, the national laboratory, and relevant figures in the national government.

The selection of provinces and districts was done following discussion and consensus among staff from MoH, WHO headquarters, WHO-SEARO, WHO Indonesia, UNICEF headquarters, UNICEF Regional Office and UNICEF Indonesia, with technical inputs from PVA experts.

Selection criteria for the provinces for both, the EPI and VPDS and MNTE PVA review, were:

➢ population size, with preference for larger population;

➢ administrative coverage (DTP3 2018 JRF) <80%;

➢ drop-out rates DTP1 – DTP3 (2018 JRF) >5%;

➢ occurrence of cases of VPDs, in particular cases of diphtheria and measles;

________________________

44 Region 1: Java and Bali; Region 2: Sumatera; Region 3: Kalimantan, Sulawesi, East and West Nusa Tenggara; Region 4: Papua, West Papua, Maluku and North Maluku


15

➢ transport connections/geographical vicinity to the 2019–2020 polio outbreak-affected areas in Philippines and Malaysia; and

➢ representation of all four regions of the country.

The 30 districts to be visited for the EPI and VPDS review were selected in the following manner:

➢ Districts that were not accessible to international reviewers due to security concerns were excluded, with the exception of Aceh (the team that visited Aceh was led by an international staff based in Indonesia).

➢ Districts too geographically remote for teams to visit (given the need to visit two districts per team) were excluded.

➢ The remaining districts were stratified as “well-performing” (DTP3 >80%) and “less well performing” (DTP3 <80%).

➢ Within each group, rural and urban districts were identified.

➢ Districts were ranked by population size.

➢ For each district, information was sought on diphtheria transmission, reported measles cases, and polio reintroduction risk.

➢ Within each province, a well-performing and a less-well performing district were identified to be visited by the same team; both districts needed to be accessible to the field team within the allotted field visit period. Hospitals and private immunization clinics were also to visited.

A separate assessment was done to identify districts at high-risk for MNT, from which four could be selected for the PVA. The selection process for the PVA was as follows:

➢ Four districts with the highest risk for MNT were selected among all districts in the country with district selection based on the WHO algorithm for NT risk analysis as outlined in Figure 8.

➢ A district is considered “at risk for MNT”45 based on the algorithm presented:

If the surveillance system is reliable and the NT rate is below 1/1000 live births, NT is considered eliminated in the district.

If the surveillance system is not reliable, a district is considered at low risk if the SBA delivery rate is above 60% or if the coverage for two or more doses of tetanus toxoid vaccines (Td2+) is above 70%.

The under-one-year population sizes of the districts were also considered and districts with <4000 under-one-year population were excluded from the selection.

________________________

45 https://www.who.int/health-topics/tetanus/#tab=tab_1, protecting all against tetanus, guide to sustaining maternal and neonatal tetanus elimination and broadening tetanus protection for all populations



16

If the assessment concludes that MNTE is maintained in these districts, we assume that, that is likely the case in the other districts as well. The conclusions of the assessment team do not extend to districts in Papua province, which were excluded from the PVA due to insecurity.

Figure 8. WHO algorithm for determining neonatal tetanus risk status of districts43

From the NT risk analysis conducted, none of the districts in the country have an NT incidence above 1/1000 live births. However, we factored in the district NT surveillance reliability46 in interpreting the NT rates, hence we conducted further analysis using the other core NT indicators (Td2+ and SBA). The MNT “at highest risk” districts of the country were identified based on an average SBA delivery rate of less than 60% over the last 3 years (2016, 2017 and 2018).

Since Td2+ was generally low in most districts, (most districts had a Td2+ coverage below 70%,) the districts with the lowest Td2+ coverage (below 30%47) were selected among the districts with less than 60% SBA.48 Out of this group, districts with DTP3 coverage below 60% and with an under-one-year-of-age population of more than 4000 were selected. A total

________________________

46 District NT surveillance was considered reliable if zero reporting >80% 47 Many districts reported very low Td2+ coverage during 2016–2018 with coverage as low as 0% 48 All data for the MNT risk analysis were obtained from the risk analysis spreadsheet shared by the Indonesia country programme

5

Algorithm–todetermineNTriskstatus

1. ReliableNTsurveillance:a)zeroreportinginoperation,b)completenessofdistricthealthfacilitysurveillancereporting≥80%,c)adequatedistributionofreportingsites(subjective),d)reviewofhospitalrecordsatleastonceayear.

2. Deliverybyahealthstafforasdefinedbythenationalpolicy.


17

of 14 districts were in this way identified as being at highest risk for MNT in the country. These districts are located in Riau (2), North Sumatera (3), Nusa Tenggara Timur (6), West Kalimantan (1), South Kalimantan (1) and Papua (1).49

None of these 14 highest-risk districts was already among the 30 selected districts for the EPI review. Four districts from the initial EPI review list could be exchanged for MNT highest-risk districts because these districts were located near the districts in the initial EPI review list and met the selection criteria for the EPI review list districts.

Based on the above selection criteria and processes, the four districts that were finally selected for MNTE PVA were Kupang and Manggarai-Barat, both in Nusa Tenggara Timur province and Humbang Hasundutan and Tapanuli Utara, both in North Sumatera province.

The four districts were assigned to two MNTE specific teams that visited two districts each, who in addition to completing the questionnaires for the EPI and VPDS review, conducted a more in-depth MNTE PVA by means of rapid community convenience surveys in these four districts. These surveys were also implemented in three well-performing districts for comparison, in Siak and Dumai in Riau province and in Halmahera Tengah district in Maluku province. After adjusting the list of districts to include the four PVA districts, the list resulted in a final distribution of 13 urban and 17 rural districts for the combined EPI and VPDS review and MNTE PVA.

While the NT risk analysis indicates that almost all districts in Papua province are at risk based on the SBA rate <60% and Td2+ <70%, these districts except one, have relatively small under-one-year-of-age population size (<4000) and were therefore, not selected. Due to insecurity in Papua province, the only district with >4000 under-one-year-of-age population size, which is also NT high-risk was excluded from the list of selected districts for the MNTE PVA.

Field assessment All the teams, including those designated for the four MNTE PVA specific districts visited 15 provincial health departments, 30 district health departments and 60 health facilities, including referral hospitals, a well performing and a poor performing puskesmas (equivalent of a health centre) and several posyandus (sites where outreach sessions for health and nutritional services, including immunization are conducted) in each of the 30 districts. Travel distance and geographic access were also taken into account for the selection of the puskesmas and posyandus.

All teams (EPI, VPDS review and MNTE PVA) assessed performance on: i) planning, monitoring and data use; ii) human resources and capacity; iii) immunization service delivery; iv) vaccine, supply stock and cold chain management; v) ANC and clean delivery (SBA, cord care practices); and vi) NT surveillance performance. All teams also assessed the performance of disease specific eradication/elimination/accelerated control initiatives in the country, including for polio, measles/rubella/congenital rubella syndrome, diphtheria, hepatitis B and Japanese encephalitis. In addition, the teams to the four MNTE-specific districts and the teams to three non-MNTE-specific districts conducted a total of 17 rapid

________________________

49 Almost all districts in Papua province are at risk based on SBA rate <60% and Td2+ <70%, but due to the relatively small population size of most districts, only one district has more than 4000 under-one-year-of-age population. While this district satisfied the selection criteria for both assessments, it was excluded for security reasons


18

community convenience surveys as part of the MNTE post-validation assessment in 17 villages (eight in Nusa Tenggara Timur, four in North Sumatera, four in Riau and one in North Maluku) located at more than 5 km from nine puskesmas (four in Nusa Tenggara Timur, two in North Sumatera, two in Riau and one in North Maluku) in seven districts (four high-risk and three low-risk districts).

Ten mothers from randomly selected houses in each village who had delivered a child in the previous two years, were interviewed to assess their level of tetanus protection based on health cards and/or history of all TTCV doses during last pregnancy as well as those administered during past pregnancies, or during mass immunization campaigns or through the BIAS. They were also interviewed on whether they had or had not attended ANC, if they delivered at home or in a health facility, by whom, and if any potentially harmful substances had been applied to the umbilical cord after delivery in the health facility or at home.

Forty mothers were interviewed in each high-risk district in NTT. Due to time constraints only twenty mothers were interviewed in each of the two high-risk districts in North Sumatera province. Additionally, 20 mothers were interviewed in each of the two low NT risk districts in Riau province and 10 mothers in the low NT risk Halmahera Tengah district in North Maluku province.

Detailed findings from the EPI and VPDS review were compiled, and analysed to draw conclusion and for appropriate recommendations to address the health and immunization systems barriers towards improving routine immunization coverage, including Td2+ coverage. These are described in the separate more comprehensive EPI and VPDS review report, which contains a short summary of the MNTE PVA.

This report describes the findings from the MNTE PVA in detail and the recommendations for sustaining MNTE in the country. The report incorporates aspects of the EPI and VPDS review that impact on MNTE sustainability and made recommendations for addressing the broader immunization and health systems barriers to MNTE sustainability in Indonesia.

3. Findings NT incidence and NT surveillance Desk reviews of MNTE related data and information at the provincial and district levels indicate that none of the 30 districts visited by all teams (EPI/VPDS and MNTE specific) had a NT rate greater than one per 1000 live births. However, the MNTE team interpreted this core MNTE indicator finding in the context a NT surveillance, which we found to be mostly passive in most of the health facilities visited and may be incapable of detecting all NT cases that may occur.

For example, the MNTE teams did not find evidence that active search in health facility registers and in communities for possible NT cases take place. We also found no evidence that the cadres (community/village volunteers) in the villages who are well positioned to identify and report NT cases in the community have been trained or that they form part of the NT surveillance network. Neonatal death reporting and investigation is not yet well developed, only very few neonatal cases were reported to the provinces in 2019 (for example, only 3 neonatal cases were reported to Nusa Tenggara Timur province in 2019).


19

Table 3. Summarizes the key findings from the rapid community convenience surveys

Indicator Kupang

Manggarai

Barat

Humbang-

Hasundutan

Tapanuli

utara Siak Dumai

Halmahera

Tengah

(n=41) (n=40) n=20 n=20 n=20 n=20 n=10

% Td2+* 37% 70% 90% 80% 35% 10% 80%

% of births

delivered in HFs or

by SBA

49% 90% 100% 95% 100% 100% 90%

% of women who

put traditional

substances on

cord*

17% 15% 0% 0% 0% 0% 0%

% of women

attending at least 1

ANC visit

90% 100% 98% 98% 100% 95% ND

% of women

attending >4 ANC

visits

68% 95% 65% 65% 85% 65% ND

% of women

neither protected

against tetanus by

TT nor SBA

delivery

10% 3% 0% 5% 0% 0% ND

*Td2+ included TT received from BIAS programme/premarital (TT Calon Pengantin or before marriage)/during pregnancy either by history or card. Most of the respondents could not show the proof of receiving TT from the BIAS programme

ANC coverage and opportunities to vaccinate against tetanus From the interview of health workers and review of documents at district and health facility levels, review teams observed that ANC services are widely available with sufficient staff to provide the services. From health facility immunization registers in the MNTE districts visited, ANC1 coverage was found to range from 60%–81%. From the rapid convenience survey, >90% of the total 171 mothers interviewed in the communities had at least one ANC visit (ANC1) during their last pregnancies.

However, the number of interviewed mothers that received more than four ANC visits during their last pregnancies varied from 65% in Humbang-Hasundutan, Tapanuli Utara and Dumai to 95% in Manggarai Barat. The rapid community convenience survey findings are nearly similar to those reported in WHO data50 on ANC coverage in Indonesia that indicates that 88% and 83% of pregnant women received at least four ANC care visits in 2012 and 2013 respectively. There were, however, no similar data through the same source for the period beyond 2013.

________________________

50 https://www.who.int/data/maternal-newborn-child-adolescent/indicator-explorer-new/mca/antenatal-care-coverage


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The more than 90% ANC1 coverage through the rapid community convenience surveys aligns with the Indonesia DHS 2017 reported 98% coverage for ANC1. Despite the high ANC coverage reported through desk review and rapid convenience surveys, Td2+ and PAB coverage figures among pregnant women were found to be <80%. Interview of health workers at the district and health facility levels by the MNTE teams revealed several missed opportunities to vaccinate pregnant women during ANC visits.

For example, in one puskesmas (Camplong, Nusa Tenggara Timur), the assessment team found that an incorrect orientation was provided to health workers requesting them to only vaccinate pregnant women at the 27th and 36th week, leading to missed opportunities when mothers presented during other period of their pregnancies. In another puskesmas (Benteng, Nusa Tenggara Timur), there was lack of awareness about TT/Td replacement,51 leading to missed opportunity to vaccinate with Td as health workers were not aware that Td replaces TT and, therefore, should be administered to pregnant women and women of reproductive age. It was not clear how widespread these problems are.

Table 4. Td2+ and SBA coverage provided at national and district level for MNTE PVA districts

2018 NTT

Kupang

NTT Manggarai

Barat

North Sumatera Humbang-

Hasundutan

North Sumatera Tapanuli

Utara

Riau Dumai

Riau Siak

Maluku Halmahera

Tengah

SBA coverage provided in national spreadsheet

41% 20% 66% 67% 107% NA 67%

SBA coverage provided by the district

59% 64% 77% 67% 93% 65% 70–89%

Td2+ coverage provided in national spreadsheet

0% 6% 0% 4% 39% 12% 61%

Td2+ coverage provided by the district

8% 13% 52% 73% 45% 25% NA

Besides incorrect information that leads to missed opportunities to vaccinate, the MNTE teams also found gaps in the health workers’ understanding of some immunization policies/guidelines that lead to missed opportunities. For example, not all posyandus in Nusa Tenggara Timur, North Sumatera and Riau provide immunization services leading to missed opportunities to vaccinate children and pregnant women. In other posyandus in these districts, children are vaccinated while opportunities are missed to vaccinate pregnant mothers/caregivers as ANC service may not take place during the outreach sessions.

________________________

51 In line with WHO recommendation, Indonesia replaced TT with Td in 2016


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In some puskesmas and hospitals in North Sumatera and Riau, ANC services are provided but opportunities are missed to vaccinate the pregnant women as they are expected to go to posyandus (outreach sites) for immunization. In one puskesmas (Kerinci Kanan in Riau) pregnant women are referred for Td vaccine at the immunization site for the children, which is in another building beside the main building of the puskesmas with no guarantee that the mothers will actually visit the vaccination sites. While the assessment teams could not verify how widespread the missed opportunities to vaccinate pregnant women exemplified above are, the examples seem to align with the declining Td2+ coverage reported in the country in recent time.

BIAS and TTCV delivery From desk review and field visits, the MNTE teams observed the existence of a strong school immunization programme in the visited districts, through which booster doses of vaccines, including TTCV and/or opportunities used to vaccinate children who may have missed certain vaccine doses in their schedules. According to the desk review, the reported BIAS vaccination coverage data at national level, including for TTCV are above 80%. In most districts where this EPI and VPDS review/PVA took place, desk review shows that TTCV coverage through the school immunization programme was >80% except for Nagan Raya (DT 61%, MR 64%, and Td 62% in 2019) and Banda Aceh districts (DT 18%, MR 19% and Td 23%) both in Aceh province.

The high TTCV booster dose coverage through school immunization programme observed in most of the districts visited aligns well with similar high coverage reported through the 2017 DHS. A review of the BIAS is planned for this year and will provide recommendations to increase immunization coverage though the programme. There is currently no systematic approach to collecting and documenting TTCV doses provided through the BIAS, as the existing MCH card does not have section on school health vaccination. The MoH recently commenced providing health report cards to students, but with only 20% coverage nationally so far. It is important that the planned review of the BIAS addresses the current gaps in the collection and documentation of TTCV doses administered through the programme.

While Indonesia has a high school enrolment rate that ensures that most school age children benefit from the BIAS, there is currently no strategy for reaching out- of- school children with vaccines provided to their counterparts in schools, including TTCV. Though the absolute number of this group might be small, however there is the need to respect the rights of those children to be protected against tetanus and diphtheria as well as the other antigens provided to school children.

SBA, clean delivery and cord care practices

Findings from the rapid community convenience surveys show very high (>90%) coverage for SBA deliveries among mothers during their last pregnancies except in one district where it was 49%. The reported high coverage of SBA deliveries aligns with the WHO maternal and newborn data for Indonesia that shows >90% coverage between 2016 and 2018 (see Figure 4). The 2017 Indonesia DHS also reported SBA coverage of >90%.

From the rapid community convenience surveys, in two districts, 15% and 17% of mothers respectively reported applying substances to the umbilical cords of their babies. In


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the remaining districts, interviewed mothers reported not applying substances to the umbilical cords of their babies in line with the WHO guidelines52 on cord care practices.

Health system impact on MNTE sustainability The EPI and VPDS review and PVA indicate several health system issues that currently impact or could impact on MNTE sustainability in the country. In this report, we however, limit the findings to those that are specific and relevant to MNTE, while readers are referred to the general EPI and VPDS report for detailed findings.53

Human resources Human resources for immunization provide support for the programme across antigens and initiatives, including the MNTE initiative with the main objective of attaining the coverage targets and goals, respectively for the antigens and initiatives.

Desk review shows that in provincial and district health departments as well as at the health facility level, trained nurses and midwives are charged with the responsibility for planning, implementing and monitoring MNTE activities, such as NT surveillance, TTCV delivery to pregnant women during ANC visits and outreach sessions in posyandus and mass immunization campaigns targeting WRA in high-risk districts. These nurses and midwives are also charged with coordinating the interface between the immunization programme and other maternal, newborn and child health programmes for ANC, clean delivery and appropriate cord care practices.

However, the MNTE teams observed during the assessment that immunization and surveillance staff in the visited districts and health facilities have limited skills to adequately, plan, implement and monitor the MNTE initiative. There was limited understanding among the interviewed health workers of the key strategies of the initiative and the monitoring indicators

Data analysis and use for action Routine immunization data collection tools, including home-based records were found to be readily available at provincial and district health offices as well as health facilities visited with established clear guide for monthly transmitting data from lower to higher level. Tools for collecting data on VPDs, including case investigation forms were also found to be readily available. The data collection tools have components for monitoring TTCV administered to pregnant women.

For MNTE related data, health workers interviewed in most of the health facilities visited were found to lack the skills and knowledge to correctly compute and record in data collection tools, Td doses administered to pregnant women, which take into account doses provided during previous pregnancies. The understanding of the health workers is that pregnant women should receive two doses of TTCV during each pregnancy, regardless of the doses received during previous pregnancies. The MNTE team also observed that TTCV

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52 https://www.healthynewbornnetwork.org/hnn-content/uploads/Final-for-translation_CWG-Country-Guidance_Jan-19-2018_EN.pdf 53 Indonesia EPI & VPDS review report, 2020


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doses provided to WRA during TTCV SIAs are not taken into account during the computation of TTCV doses for pregnant women.

The teams observed that the provision of immunization services and RMNCAH interventions such as ANC is by the same health workers both at service delivery levels (puskesmas and posyandu), helping to solve the problems of constrained exchange of data between the two programmes observed in other countries. However, field teams did not see obvious and routine communication and dialogue, especially at the district and provincial levels between MCH and EPI teams in terms of data sharing and programme planning.

Service delivery Desk review of the national immunization policy, strategies and guidelines indicates that most communities have access to vaccination points, though there were reports of communities in remote areas for which vaccination is only possible through outreach or mobile sessions. Immunization services delivered through the various platforms (fixed and outreach/mobile) include TTCV.

In addition to the provision of immunization through public health facilities, private facilities that receive vaccine from the EPI also provide immunization, including Td, free of charge. However, private facilities charge clients for vaccines they procure outside of the EPI vaccination schedules. The MNTE team did not find evidence that private facilities charge pregnant women for Td. The MNTE teams found that despite the ready availability of ANC services, there were several missed opportunities to vaccinate pregnant women who attend ANC clinics with Td.

Demand generation and community engagement Visits to provincial and district health departments as well as health centres revealed the existence of social mobilization and communication materials and guidelines, including those developed for the introduction of new vaccines and for mass immunization campaigns. These materials include those for social mobilization and community awareness about the vaccination of pregnant women.

Community engagement in immunization services delivery was evidenced by the observed roles of female village volunteers (cadres) in supporting the planning and implementation of outreach sessions that include the vaccination of pregnant women held at posyandus, through mobilizing the communities. Awareness sessions that include pregnancy and newborn related information by health promotion officers before outreach sessions were observed in some of the health posts visited.

The MNTE teams, however, observed limitation in the ability of the health workers to provide, through Interpersonal communication, essential messages on immunization to caregivers, pregnant women and WRA. Health workers at provincial, district and health facility levels expressed concerns about the non-remuneration of the female community volunteers who provide selfless services during outreach sessions and the negative impact this could create on their motivation on the long run.


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4. Conclusions Based on the findings from desk review and rapid convenience surveys, the PVA team concludes that core and surrogate indicators show that MNTE is most likely sustained in the four highest-risk districts and by extension, in all other districts in Indonesia except for the districts in Papua province. Given security and travel logistics constraints, the review teams were unable to visit districts in Papua province.

The above conclusion is based on the following findings:

➢ NT incidence is below 1/1000 live births in the four MNT high-risk districts (none reported any NT case over the previous 2-3 years), a finding that is further supported by the low number of annually reported NT cases for Indonesia through the WHO global database. This finding, however, needs to be interpreted in the context of an NT surveillance system that is not as sensitive as it should be, as well as low reporting sensitivity for tetanus cases and uncertainty about the true disease incidence.54

➢ SBA coverage of >60% in the four highest-risk districts, further supported by the >90% coverage reported for Indonesia through both the WHO global database and the 2017 Indonesia DHS report.

➢ Despite the low Td2+ coverage reported in some of MNTE districts through the rapid convenience surveys, overall, we estimate that at least 70% of the mothers in these four districts is protected through TTCV received through infant series and childhood booster doses. The coverage figures for TTCV administered during childhood (infant series and booster doses) have been high in Indonesia since the late 90s. Furthermore, 60% to 80% of the mothers in the four highest risk districts attended at least one antenatal care clinic with an opportunity to receive a Td booster dose.

➢ Findings from the four high-risk districts showed that unhygienic cord care practices (application of potentially harmful substances to umbilical cords) is quite rare with only a small proportion (15%–17%) of interviewed mothers reported that they applied substance to the umbilical cord of their babies delivered during the previous two years.

➢ Moreover, Indonesia has over the years used the life-course approach for the delivery of TTCV that aims to protect everyone against tetanus.

5. Recommendations Short-term

(1) As Indonesia has not developed an MNTE sustainability plan, since the country was validated for elimination in 2016, the NIP in collaboration with the RMNCAH programme and with the support of relevant stakeholders should develop, implement and monitor a plan for sustaining MNTE. The plan should be based on the recently

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54 WHO Tetanus Vaccine: Position paper February 2017. Weekly Epidemiological Record, 10 Feb. 2017, Vol 92, 6 (pp. 53–76) http://www.who.int/immunization/policy/position_papers/tetanus/en/


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disseminated WHO global guide on Protecting all against tetanus: Guide to sustaining maternal and neonatal tetanus elimination (MNTE) and broadening tetanus protection for all populations. The plan should also take into consideration key recommendations related to increasing Td coverage from the planned BIAS review. The key aspects of the MNTE sustainability plan should be integrated into the country comprehensive multi-year plan (cMYP) currently being developed.

(2) Critical findings and recommendations from this MNTE PVA should be incorporated into the 2020–2024 cMYP currently being developed to maintain MNTE during the period covered.

(3) The EPI in Papua province with the support of the NIP should conduct NT risk analysis, desk review of MNTE related documents and field visits to three high-risk districts to assess the MNTE sustainability status in the province and recommend necessary actions.

(4) District health departments with the support of their provincial counterparts should take measures to address the current gaps in correctly vaccinating pregnant women during ANC visits and correctly documenting previously administered TTCV doses through: (a) Training health workers to regularly screen pregnant women at ANC visits to

ensure they receive the appropriate Td doses, which take into consideration doses received during previous pregnancies and through the BIAS.

(b) Developing and implementing a clear guideline for documenting all Td doses provided during ANC visits and include in the numerator for Td2+ pregnant women not vaccinated as their records show that they have received 5 doses of TTCV previously.

(c) Implementing existing guidelines to ensure all opportunities to vaccinate pregnant women with Td are used, to avoid the current missed opportunities, especially in high-risk areas.

(d) The planned BIAS programme review should identify strategies to improve individual records of TTCV doses provided through the programme. Such strategies could include the revision of the existing maternal and child health (MCH) book to include a page for capturing through a life course vaccination approach, vaccine doses administered through the BIAS programme and to WRA, which can include a card with record of their TTCV vaccination history to be kept by each related individual.

(e) Appropriate strategies should be developed to target out-of-school children with antigens, including TTCV which are provided to school age children. Strategies could include special outreach sessions in locations where these children may be found.

(5) The RMNCAH programme with the support of relevant stakeholders should identify strategies to improve the coverage of clean delivery and appropriate cord care practices that could include: (a) Improving the provision information and awareness to pregnant women

during ANC visits, about proper cord care and the risks of applying traditional substances on the umbilical cord.


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(b) In hard-to-reach communities with limited (or lack) health workers, identify innovative strategies that will improve their access to clean delivery and appropriate cord care practices as well as improve community/family knowledge and awareness.

(c) Formulate and implement policies that ensure the availability of health workers in hard-to-reach communities.

(6) The NIP with the support of relevant stakeholders and in collaboration with provincial and district health departments should use appropriate training modules/platforms/methods (WHO training modules for mid-level managers and Immunization in Practise, on the job training, online courses, mentorship, supportive supervision) to train health workers at all level on programme areas (programme planning, monitoring, data quality, demand generation, service delivery, immunization supply chain management) in which they currently acknowledge gaps.

(7) Provincial and district health departments should support health facilities to develop, implement and monitor microplans with budgets that include strategies and budget items for providing immunization services in remote communities and other hard-to-reach populations.

(8) The NIP should support provincial, district and health facility levels to implement the recommendations of the recent data quality review report on improving data completeness, availability and quality, including data on core and surrogate MNT indicators.

(9) The provincial and district surveillance units with the support of relevant stakeholders should map surveillance sites in the districts for active search, investigation and reporting of vaccine preventable diseases, including NT.

(10) NT surveillance should be fully integrated into active VPD surveillance, including the revision of case investigation forms and protocols. NT surveillance should include community assessment and zero case reporting.

(11) All reported NT cases should be investigated, and immunization response implemented as per WHO guidelines,55 especially in areas with generally low coverage.

Medium- to long-term

(12) The NIP should support provincial and district health departments in advocating with provincial and district health authorities/governments to implement human resources policies that allow staff retention and motivation especially in remote areas.

(13) The NIP, with support from stakeholders, should review and strengthen the already existing platforms for delivering TTCV along the life-course56 (infant vaccination, booster doses during second year of life, booster doses through school health programme, ANC, PIRI), special outreach sessions that target special populations including out-of-school children.

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55 https://www.who.int/immunization/documents/MLM_module8.pdf?ua=1 56 tetanus vaccine WHO position paper February 2017 https://www.who.int/health-topics/tetanus/#tab=tab_1


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(14) As part of efforts to address the current underestimation of Td2+ the NIP should consider introducing PAB monitoring during DTP1 visits, which should be preceded by training of health workers on the method for obtaining information from care-givers and monitoring of PAB coverage.

(15) The NIP should strengthen its collaboration with the RMNCAH and BIAS programmes at all levels, to improve the coverage and quality as well as information sharing related to all MNTE services delivered through platforms under these programmes. Such collaboration could include, among others, quarterly data sharing and review meetings to identify areas of weakness and monitor the implementation of corrective actions.

(16) The NIP should incorporate VPDS information into all training of trainers, refresher, pre-service and in-service trainings (including training on an accountability framework).

(17) Epidemiological data analysis for acute flaccid paralysis, measles and rubella, diphtheria, tetanus and other VPD cases should be conducted and shared across the districts, health facilities and partners by the respective national teams.

6. Lessons learned In the face of dwindling financial resources, the option of integrating MNTE PVAs into already planned reviews and surveys seems the most viable and cost-effective option. Currently, several of the 47 countries that have been validated for elimination are scheduled to conduct EPI reviews or post-introduction evaluations (PIE) over the coming six months, and it will be a good opportunity to integrate MNTE PVAs into these, where feasible. Moreover, the integration of MNTE PVAs into planned EPI and VPDS and other programmes reviews is highly recommended by WHO and the other technical partners

The lessons learned from combining the MNTE PVA with the EPI and VPDS review in Indonesia can be categorized into two:

(1) Enabling factors, advantages and critical requirements

(a) The decision to combine the assessments was taken by the MPH with technical guidance by WHO and UNICEF regional offices.

(b) Use of common resources helping to reduce costs that would have accrued from a standalone PVA.

(c) An approach to MNTE sustainability in the broader RMNCAH and life-course in the WHO South-East Asia Region.

(d) Maintaining MNTE is one of the eight SEARO Regional Vaccine Action Plan goals under which life-course approach is particularly being emphasized with coordination approach by the immunization, reproductive health and child and adolescent health teams.

(e) The regional focal point for EPI reviews is also the focal person for MNTE in the region.

(f) MNTE sustainability is part of the disease eradication, elimination and accelerated control goal in the country, making it logical to combine the PVA with the EPI and VPDS review, which already included the other diseases


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such as polio, measles/rubella, diphtheria, hepatitis B and Japanese encephalitis.

(g) Opportunity to incorporate key PVA findings and recommendations into the draft Indonesia cMYP 2020–2024.

(h) Early (three months ahead of the review) engagement through regular teleconferences, phone calls, email exchanges between WHO and UNICEF offices at all levels to discuss and plan critical aspects of the integration.

(i) Involvement of country MCH programme in the planning and implementation of the combined review.

(j) Recruitment by WHO Geneva of an external MNTE expert to coordinate and provide technical guidance for the MNTE PVA integration.

(k) Decision to incorporate questions on core and surrogate MNTE indicators into the questionnaires for the EPI and VPDS review at all levels, thus avoid the use of separate questionnaires for the PVA.

(l) Deployment of international MNTE experts to four NT high-risk districts to conduct rapid convenience community surveys in addition to the EPI and VPDS review activities.

(m) Teams deployed to the four MNTE specific high-risk districts given orientation on conducting rapid convenience community surveys as well as the use of the data collection tool.

(n) Experience from the field indicates that the inclusion of PVA would have benefited from additional days to the review especially, given the long travel distance within the provinces and districts.

(2) Barriers and disadvantages

(a) Limited prior orientation and sensitization of provincial, district and health facility teams about the rapid community convenience survey ahead of time, so they are better prepared for the required engagement with the communities that could further improve the quality and scope of the rapid community convenience surveys.

(b) Incorporating the PVA into the EPI and VPDS Review may have led to less in-depth exploration and, therefore, less robust conclusions than if we had been able to focus more on the PVA. This is specifically, so in the case of the EPI and VPDS review in Indonesia to which multitude of topics (polio, Measles/rubella, congenital rubella syndrome, diphtheria, hepatitis B, Japanese encephalitis) were targeted. EPI reviews in most countries do not have so many topics added. This also reduced the emphasis on the collection of MNTE related data by teams that visited non MNTE specific districts, which limited the available information on MNTE from these districts.

(c) Inability of the PVA team to participate in the meeting between the EPI and VPDS review team and officers of relevant programmes at the central, which denied the PVA team of the opportunity to gain insight into the perception of the MNTE initiative and collaboration between EPI and the RMNCAH programme at the central level.


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Cost implications for the integration The integration of MNTE PVA into the planned EPI and VPDS review helped to cut down on the costs that the programme would have incurred if a standalone PVA was conducted. However, there was a marginal additional cost as a result of combining the PVA with the EPI and VPDS review. The main cost driver of the PVA for the country team was the operational cost for the rapid community convenience survey in 17 villages in seven districts (four NT high-risk districts and three low-risk NT districts). Other budget items for the PVA included travel costs, including daily subsistence allowance for international and national officers that specifically supported the MNTE-specific high-risk districts.

Table 5. List of participants: MNTE Post-Validation Assessment

S/N Names Affiliation

1 Dr Hilde Sleurs Consultant, MNTE PVA, WHO Headquarter

2 Dr Lucy Breakwell Epidemiologist, Accelerated Disease Control and Vaccine Preventable Disease Surveillance Branch, US CDC, Atlanta

3 Dr Bilal Ahmed Planning & Monitoring Specialist – MNTE, Programme Division, Maternal, Newborn & Adolescent Health, UNICEF Headquarters

4 Dr Nasir Yusuf (Mission Coordinator)

Expanded Programme on Immunization Plus, WHO Headquarter

5 Mr Rubiyo Wahyuriadi Staff, Surveillance – MoH, Indonesia

6 Ms Widyawati Family Health, MoH, Indonesia

7 Dr Fina Tams (National Coordinator)

National Professional Officer – Immunization, WHO Indonesia

8 Dr Alfrida Silitonga National Professional Officer - Reproductive, Maternal, Newborn, Child and Adolescent Health, WHO Indonesia

9 Ms Vivi Voronika Staff, Surveillance – MoH, Indonesia

10 Ms Rabiatul Adawiyah Nusa Tenggara Barat Provincial Health Office, Indonesia

11 Ms Adinda Silitonga Communication Specialist UNICEF Indonesia

12 Mr Hakimi Staff, EPI – MoH, Indonesia

13 Ms Defi Amalia MoH, Indonesia

14 Dr Ike Silviana CDC Manager Jambi Provincial Health Office, Indonesia

15 Dr Sartini Saman National Consultant UNICEF Indonesia

16 Ms Sekar Astrika Staff, EPI – MoH, Indonesia

17 Mr Abuchori Public Health Emergency Operating Centre (PHEOC), MoH, Indonesia

18 Mr Welly Wamear Head of Surveillance and EPI Division, Papua Barat Provincial Health Office, Indonesia

A post-validation assessment of maternal and neonatal tetanus elimination was

conducted in seven districts of Indonesia on 10–18 February 2020 in conjunction with a

national/international review of the Expanded Programme on Immunization and a

vaccine preventable surveillance review. This report presents the findings, conclusions

and recommendations of the assessment.


Vaccine Preventable Disease Surveillance review


Indonesia, 10–18 February 2020

SEA-IMMUN-120

Maternal and Neonatal Tetanus Elimination Post-Validation ...

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