Report of Integrated Measles, Polio & Vitamin A Campaign in Indonesia 2006 -2007
Report of ntegrated
Measles, Polio & Vitamin A
Campaign in Indonesia
2006 2007
Report of Integrated
Measles, Polio & Vitamin A
Campaign in Indonesia
2006 2007
I
-I
1
/"
/
.,
, -
.
( i
1 r..) I) (, -
\ ('
.......................
Expanded Programme on Immunization
Disease Control & Environment Health
Ministry of Health
Indonesia
Measles is a highly contagious disease and a major cause of childhood mortality in
developing countries like Indonesia. In 2003, WHOSEARO developed a strategic plan
focused on a 50% reduction in the measles death rate by 2005 as compared to 1999.
The main strategies included: accelerated outbreak investigation and response, effective
case management, high routine measles immunization (90% coverage in 100% of
districts) and a second opportunity for measles immunization.
Immunization data from Indonesia showed a significant accumulation of children who
did not receive measles vaccination. In addition to low coverage, the measles vaccine
effectiveness is generally 85%, leaving many children vulnerable to measles after
receiving one dose. These two factors result in periodic r:neasles outbreaks. In line with
the accelerated measles control strategies, Indonesia provided a second opportunity
for measles immunization to high risk age groups, implemented measles crash program
targeting children aged 659 months, and targeted measles catchup campaign for
elementary school children age 612 years old, regardless of previous immunization
status.
As per the recommendation of the International review of AFP surveillance, OPV was
added to the measles SIAs to ensure high immunity among children
OJ
L-
..0
..0
3.00
Per 10,000 population
Due this combination of conditions, measles surveillance information available at the
national level is not complete or reliable enough to understand measles epidemiology
in Indonesia. Despite these constraints, over 36,000 measles cases were reported as
aggregate data through the routine surveillance system in 2006. The distribution of
measles cases and incidence rate by province is given in figure 4. The highest number
of cases was reported from the densely populated island of Java, and the highest
incidence rates were reported from the sparsely populated provinces of Sumatera and
Kalimantan.
ｾ＠
OJ
•
(:
OJ
c
Ol
•
co
C.
E
co
u
7
2.1 Campaign Schedule
Phase I started in January 2005 targeting over 100,000 children among IDPs in the
tsunami affected provinces of NAD and North Sumatera and gradually expanded to
children in non-affected areas totaling 4.7 million. However, due to a variety of logistic
challenges, Phase I finished a year later in January 2006.
Figure 6. Phases of Measles SIA's in Indonesia 2005 2007
,
'\
-..,' , " ,
ｾＮＭ
ｾＢ＠
.....
Ｚ
ｾ
Legend:
. '... I
ｾＮ＠
ＢＮ＠
ｾ［Ｚｊ
_
Phase I
_
Phase II : Papua, West Irian Jaya, Maluku and North Maluku
Phase III : Sumatera and East Nusa Tenggara
Phase IV : Java
: Aceh and North Sumatera
_
Phase V : Kalimantan, Sulawesi, Bali and West,Nusa Tenggara
Phase II began in April 2006 covering the eastern provinces of Papua, West Irian Jaya,
Maluku and North Maluku. The campaign was planned for one month and was
synchronization with the fifth Polio NID. These four provinces are the least developed
in Indonesia with many inaccessible and remote areas, and consequently had low routine
immunization coverage at the beginning of the campaign. The provinces of Papua and
West Irian Jaya are sparsely populated over vast terrain. The provinces of Maluku and
North Maluku consist of hundreds of small islands. Due to these geographic obstacles
and poor infrastructure, Phase II took several months to finished.
Table 4. Campaign Schedule, Target Population and Age Group Targeted by
Different Phases of Measles SIAs, Indonesia
Target Population
Phase
Age Group
Campaign Period
6 Months - '5 Years
> 6 Years
Total
Targeted
4,809,164
6 Months 15 Years
146,344
913,760
6 Months - 12 Years
3,743,568
3,161,323
6,904,891
6 Months - 12 Years
February 2007
11,384,553
2,692,912
14,077,465
6 Months - 12 Years
August 2007
3,675,818
2,569,350
6,245,168
6 Months 12 Years
Phase I
Jan 2005 Jan 2006
Phase II
April 2006
767,416
Phase III
August 2006
Phase IV
Phase V
All Phases
32,950,448
Phase III began in August 2006 covering the rest of the eight provinces of Sumatera
(excluding NAD and North Sumatera) and province of NTI targeting nearly 7 million
children and was scheduled to be completed in one month . The provinces of Riau
Islands, NTI and Bangka Belitung also included in this phase consist of a large number
of small islands with a comparatively less dense population again leading logistic
challenges . Considering high endemic malaria in Sumatra island, learnt from malaria
control in Africa, during the measles campaign the long-lasting insecticide treated nets
(LLITNs) were distributed utilizing contacts with parents
.Phase IV began in February 2007 covering five out of six provinces on the island of
Java targeting 12 million children and was scheduled to be completed in one month.
The province of Yogyakarta (DIY) was not included in Phase IV because of an emergency
immunization campaign targeting 147,000 children that was conducted following an
earthquake in July 2006. Java Island is densely populated and constitute over 60%
of the total Indonesian population . It contains cities like Jakarta, Surabaya, Semarang,
and Bandung with considerable large population living in underserved, poor urban
settlements that provided its own logistic and implementation cha llenges.
Phase V began in August 2007 covering Kalimantan, Sulawesi, Bali and NTB Islands
targeting 6 million children and was again scheduled to be completed in one month.
With the exception of the provinces of Bali and NTB, which have the best-managed
healthcare in Indonesia, the remaining 10 provinces proved to be challenging to
implement due to the poorly developed health infrastructure and difficult terrain.
2.2 Campaign Strategy
The overall campaign strategy was to conduct rolling campaigns over a four weeks
period. The plan was to immunize children from the age of 6 months up to 5 years in
the community; and children in school from the age of 6 to 15 years in Phases I & II,
and children up to 12 years in Phases III, IV & V. In areas with low school enrollment,
children above age 6 years and not attending school were immunized at health posts
close to their homes.
Instructions were sent out to schools before the beginning of the campaigns to mobilize
the school aged children and were used as social mobilization launch points for parents
and community.
The community level health posts (posyandu) where most children receive their routine
immunizations were key vaccination points for the campaign. Additional posts were
created when the number of target children exceeded more than 200 children per health
post.
The health center level (puskesmas) routinely tasked with the overall responsibility for
public health programs including EPI was a key institution in the planning and
implementation of the campaigns. The micro plans under the supervision of the puskesmas
consisted of the campaign scheduling, staff allocation, logistics and IEC materials
distribution, and social mobilization.
At the community level, the cadre (health volunteers) attached to the posyandu made
lists of eligible children and provided families with vaccination dates and locations. This
activity helped to ensure that all children in the target area received informed about the
campaign.
On the day of vaccination, the health workers were responsible for administering the
measles vaccine and the cadres were responsible for the organization of immunization
post, registration, administration of OPV and vitamin A. The puskesmas staff together
with the educational authorities made separate micro plans for immunization of eligible
children at schools. The school age children who are not school enrolled should be
served by the health posts / Posyandu. Health workers were instructed to remain at
the immunization posts or at schools for at least one hour after vaccinating last child
in order to handle any Adverse Event Following Immunization (AEFI).
Additionally, health workers and caders visited areas where a number of children were
missed based on the up-dated registration lists prepared during the preparatory phase
of the campaign. These missed children were targeted for immunization during the mopup phases.
Throughout the campaign and mop-up, the immunization post at the puskesmas remained
open for any parent who missed the campaign dose at posyandu.
Based on the experience gained during the first three phases, the campaign schedule
for the last two phases consisted of two weeks for fixed-post immunization and two
weeks for mop-up activities, coverage data consolidation and report writing. Even though
a majority of the districts followed this plan, some districts continued to conduct fixedpost immunization for four weeks followed by mop-up activities.
In an effort to capitalize on the programmatic and logistic efforts, three interventions
were targeted for integration with the measles SIAs: OPV, Vitamin A, Insecticide Treated
Nets (ITNs) and micronutrients. In keeping with the recommendations of the 2006
International review of AFP Surveillance, the Indonesian government decided to use the
measles SIAs as an opportunity to deliver OPV to children less than 5 years of age. This
intervention was planned to start with the second phase of the measles SIAs. The
government funded all of
the program and operational costs associated with integrating OPV with the measles
SIAs. This decision saved millions of dollars in operational costs as well as the time of
staff and parents had the intervention been conducted separately.
In th e mid - 1980s, Indonesia was one of the first countries to develop a national
supplemental vitamin A program for preschool children . Currently, vitamin A capsules
are distributed twice a year (February and August) free of charge to children 6-59
months old.
Out of a total of 440 districts in Indonesia, thirty-one high malaria endemic districts
on the Island of Sumatera were selected for integrated distribution of Insecticide Treated
Nets (ITNs) during the measles SIAs. Over 2 million ITNs were distributed to households
with a child under the age of five .
Table 5. ITNs Distribution
Province
Bangka Belitung
Districts
Number Nets (Total)
Bangka Selatan
37,440
Bangka
61, 560
Pangkalpinang
40,960
Belitung
35,700
Belitung Timur
SubTotal
Kepulauan Riau
Kab. Lingga
21,300
Natuna
2],300
Bintan
30,898
Karimun
52, 550
128,048
Bengkulu Utara
91,100
Kota
82,100
Seluma
46,900
Muko-muko
34, 200
Kab. Kaur
Sub Total
Jambi
Merangin
74,400
Batang Hari
54,800
Kota Jambi
112,400
Sub Total
Rokan Hilir
130,]60
Indragiri Hilir
164,800
295,160
Kab. Kep. Mentawai
Sub Total
Sumalera Selatan
78,600
320,200
SubTotal
Sumatera Barat
31,480
285, 780
Muara Jambi
Riau
23,480
238,940
SubTotal
Bengkulu
39,BOO
Bangka Barat
19, 200
19,200
Muara Enim
Muba
SubTotal
TOTAL
165,560
128,200
293,760
1,581,088
The result of this integrated EPI-Malaria activity shown as follows:
• % HH who has 1 or more ITNs, increased from 2.2% (2/91) before the campaign
to 94.5% (86/91) after the campaign.
• But the % ITNs that was used/hanged = 44.8% (64/143)
• % children under five years of age who slept using ITN before the campaign =
1.9% (2/106). After the campaign, 51 % (54/106) children U5 slept under the ITN.
1
Figure 7. Net Coverage Before &. After The Campaign, and Net Usage Post Campaign
120
100
80
60
40
20
0
Ｎｾ＠
ｾ＠ OJ
::;:
＠ｾ "
a>
c:
al
ｾ＠
2
ｾ＠
c:
2
ro
11
a>
c:
OIl
ｾ＠IJl
5
a>
[
c;:
c:
ｾ＠
ｾ＠
E
;::
a>
ｾ＠
c:
e
ro
'"
ｾ＠
'"
ｾ＠
'"
11
a>
1ii
'"
ｾ＠
:0
E
0
U
tl
Ｎ ｾ＠
is
Legend:
Families that owned l/more ITN's before campaign
_
Families that received at least 1 LLITN during campaign
_
ITN's distributed that are seen to be hanging on day of interview
During the measles SIAs in the Central Lombok district of NTB province, a pilot project
for the distribution of micronutrient sachets was conducted in seven health centers
reaching more than 27,000 children. This was the first time this type of intervention
was attempted in Indonesia as well as the region.
13
Table 5. Result of Vitamin A Micronu trient supplem ent (Tabur G,'z,')
distribution
Month
Disrtrict
Province
No
I
Puskesmas
(HC)
August-October 2007
Lombok Tengah
NTB
VIHage
Ba tunyala
Batunyala
Lajut
PSJangglk
Ke!ebuh
5esake
100
463
Measles, Polio & Vitamin A
Campaign in Indonesia
2006 2007
Report of Integrated
Measles, Polio & Vitamin A
Campaign in Indonesia
2006 2007
I
-I
1
/"
/
.,
, -
.
( i
1 r..) I) (, -
\ ('
.......................
Expanded Programme on Immunization
Disease Control & Environment Health
Ministry of Health
Indonesia
Measles is a highly contagious disease and a major cause of childhood mortality in
developing countries like Indonesia. In 2003, WHOSEARO developed a strategic plan
focused on a 50% reduction in the measles death rate by 2005 as compared to 1999.
The main strategies included: accelerated outbreak investigation and response, effective
case management, high routine measles immunization (90% coverage in 100% of
districts) and a second opportunity for measles immunization.
Immunization data from Indonesia showed a significant accumulation of children who
did not receive measles vaccination. In addition to low coverage, the measles vaccine
effectiveness is generally 85%, leaving many children vulnerable to measles after
receiving one dose. These two factors result in periodic r:neasles outbreaks. In line with
the accelerated measles control strategies, Indonesia provided a second opportunity
for measles immunization to high risk age groups, implemented measles crash program
targeting children aged 659 months, and targeted measles catchup campaign for
elementary school children age 612 years old, regardless of previous immunization
status.
As per the recommendation of the International review of AFP surveillance, OPV was
added to the measles SIAs to ensure high immunity among children
OJ
L-
..0
..0
3.00
Per 10,000 population
Due this combination of conditions, measles surveillance information available at the
national level is not complete or reliable enough to understand measles epidemiology
in Indonesia. Despite these constraints, over 36,000 measles cases were reported as
aggregate data through the routine surveillance system in 2006. The distribution of
measles cases and incidence rate by province is given in figure 4. The highest number
of cases was reported from the densely populated island of Java, and the highest
incidence rates were reported from the sparsely populated provinces of Sumatera and
Kalimantan.
ｾ＠
OJ
•
(:
OJ
c
Ol
•
co
C.
E
co
u
7
2.1 Campaign Schedule
Phase I started in January 2005 targeting over 100,000 children among IDPs in the
tsunami affected provinces of NAD and North Sumatera and gradually expanded to
children in non-affected areas totaling 4.7 million. However, due to a variety of logistic
challenges, Phase I finished a year later in January 2006.
Figure 6. Phases of Measles SIA's in Indonesia 2005 2007
,
'\
-..,' , " ,
ｾＮＭ
ｾＢ＠
.....
Ｚ
ｾ
Legend:
. '... I
ｾＮ＠
ＢＮ＠
ｾ［Ｚｊ
_
Phase I
_
Phase II : Papua, West Irian Jaya, Maluku and North Maluku
Phase III : Sumatera and East Nusa Tenggara
Phase IV : Java
: Aceh and North Sumatera
_
Phase V : Kalimantan, Sulawesi, Bali and West,Nusa Tenggara
Phase II began in April 2006 covering the eastern provinces of Papua, West Irian Jaya,
Maluku and North Maluku. The campaign was planned for one month and was
synchronization with the fifth Polio NID. These four provinces are the least developed
in Indonesia with many inaccessible and remote areas, and consequently had low routine
immunization coverage at the beginning of the campaign. The provinces of Papua and
West Irian Jaya are sparsely populated over vast terrain. The provinces of Maluku and
North Maluku consist of hundreds of small islands. Due to these geographic obstacles
and poor infrastructure, Phase II took several months to finished.
Table 4. Campaign Schedule, Target Population and Age Group Targeted by
Different Phases of Measles SIAs, Indonesia
Target Population
Phase
Age Group
Campaign Period
6 Months - '5 Years
> 6 Years
Total
Targeted
4,809,164
6 Months 15 Years
146,344
913,760
6 Months - 12 Years
3,743,568
3,161,323
6,904,891
6 Months - 12 Years
February 2007
11,384,553
2,692,912
14,077,465
6 Months - 12 Years
August 2007
3,675,818
2,569,350
6,245,168
6 Months 12 Years
Phase I
Jan 2005 Jan 2006
Phase II
April 2006
767,416
Phase III
August 2006
Phase IV
Phase V
All Phases
32,950,448
Phase III began in August 2006 covering the rest of the eight provinces of Sumatera
(excluding NAD and North Sumatera) and province of NTI targeting nearly 7 million
children and was scheduled to be completed in one month . The provinces of Riau
Islands, NTI and Bangka Belitung also included in this phase consist of a large number
of small islands with a comparatively less dense population again leading logistic
challenges . Considering high endemic malaria in Sumatra island, learnt from malaria
control in Africa, during the measles campaign the long-lasting insecticide treated nets
(LLITNs) were distributed utilizing contacts with parents
.Phase IV began in February 2007 covering five out of six provinces on the island of
Java targeting 12 million children and was scheduled to be completed in one month.
The province of Yogyakarta (DIY) was not included in Phase IV because of an emergency
immunization campaign targeting 147,000 children that was conducted following an
earthquake in July 2006. Java Island is densely populated and constitute over 60%
of the total Indonesian population . It contains cities like Jakarta, Surabaya, Semarang,
and Bandung with considerable large population living in underserved, poor urban
settlements that provided its own logistic and implementation cha llenges.
Phase V began in August 2007 covering Kalimantan, Sulawesi, Bali and NTB Islands
targeting 6 million children and was again scheduled to be completed in one month.
With the exception of the provinces of Bali and NTB, which have the best-managed
healthcare in Indonesia, the remaining 10 provinces proved to be challenging to
implement due to the poorly developed health infrastructure and difficult terrain.
2.2 Campaign Strategy
The overall campaign strategy was to conduct rolling campaigns over a four weeks
period. The plan was to immunize children from the age of 6 months up to 5 years in
the community; and children in school from the age of 6 to 15 years in Phases I & II,
and children up to 12 years in Phases III, IV & V. In areas with low school enrollment,
children above age 6 years and not attending school were immunized at health posts
close to their homes.
Instructions were sent out to schools before the beginning of the campaigns to mobilize
the school aged children and were used as social mobilization launch points for parents
and community.
The community level health posts (posyandu) where most children receive their routine
immunizations were key vaccination points for the campaign. Additional posts were
created when the number of target children exceeded more than 200 children per health
post.
The health center level (puskesmas) routinely tasked with the overall responsibility for
public health programs including EPI was a key institution in the planning and
implementation of the campaigns. The micro plans under the supervision of the puskesmas
consisted of the campaign scheduling, staff allocation, logistics and IEC materials
distribution, and social mobilization.
At the community level, the cadre (health volunteers) attached to the posyandu made
lists of eligible children and provided families with vaccination dates and locations. This
activity helped to ensure that all children in the target area received informed about the
campaign.
On the day of vaccination, the health workers were responsible for administering the
measles vaccine and the cadres were responsible for the organization of immunization
post, registration, administration of OPV and vitamin A. The puskesmas staff together
with the educational authorities made separate micro plans for immunization of eligible
children at schools. The school age children who are not school enrolled should be
served by the health posts / Posyandu. Health workers were instructed to remain at
the immunization posts or at schools for at least one hour after vaccinating last child
in order to handle any Adverse Event Following Immunization (AEFI).
Additionally, health workers and caders visited areas where a number of children were
missed based on the up-dated registration lists prepared during the preparatory phase
of the campaign. These missed children were targeted for immunization during the mopup phases.
Throughout the campaign and mop-up, the immunization post at the puskesmas remained
open for any parent who missed the campaign dose at posyandu.
Based on the experience gained during the first three phases, the campaign schedule
for the last two phases consisted of two weeks for fixed-post immunization and two
weeks for mop-up activities, coverage data consolidation and report writing. Even though
a majority of the districts followed this plan, some districts continued to conduct fixedpost immunization for four weeks followed by mop-up activities.
In an effort to capitalize on the programmatic and logistic efforts, three interventions
were targeted for integration with the measles SIAs: OPV, Vitamin A, Insecticide Treated
Nets (ITNs) and micronutrients. In keeping with the recommendations of the 2006
International review of AFP Surveillance, the Indonesian government decided to use the
measles SIAs as an opportunity to deliver OPV to children less than 5 years of age. This
intervention was planned to start with the second phase of the measles SIAs. The
government funded all of
the program and operational costs associated with integrating OPV with the measles
SIAs. This decision saved millions of dollars in operational costs as well as the time of
staff and parents had the intervention been conducted separately.
In th e mid - 1980s, Indonesia was one of the first countries to develop a national
supplemental vitamin A program for preschool children . Currently, vitamin A capsules
are distributed twice a year (February and August) free of charge to children 6-59
months old.
Out of a total of 440 districts in Indonesia, thirty-one high malaria endemic districts
on the Island of Sumatera were selected for integrated distribution of Insecticide Treated
Nets (ITNs) during the measles SIAs. Over 2 million ITNs were distributed to households
with a child under the age of five .
Table 5. ITNs Distribution
Province
Bangka Belitung
Districts
Number Nets (Total)
Bangka Selatan
37,440
Bangka
61, 560
Pangkalpinang
40,960
Belitung
35,700
Belitung Timur
SubTotal
Kepulauan Riau
Kab. Lingga
21,300
Natuna
2],300
Bintan
30,898
Karimun
52, 550
128,048
Bengkulu Utara
91,100
Kota
82,100
Seluma
46,900
Muko-muko
34, 200
Kab. Kaur
Sub Total
Jambi
Merangin
74,400
Batang Hari
54,800
Kota Jambi
112,400
Sub Total
Rokan Hilir
130,]60
Indragiri Hilir
164,800
295,160
Kab. Kep. Mentawai
Sub Total
Sumalera Selatan
78,600
320,200
SubTotal
Sumatera Barat
31,480
285, 780
Muara Jambi
Riau
23,480
238,940
SubTotal
Bengkulu
39,BOO
Bangka Barat
19, 200
19,200
Muara Enim
Muba
SubTotal
TOTAL
165,560
128,200
293,760
1,581,088
The result of this integrated EPI-Malaria activity shown as follows:
• % HH who has 1 or more ITNs, increased from 2.2% (2/91) before the campaign
to 94.5% (86/91) after the campaign.
• But the % ITNs that was used/hanged = 44.8% (64/143)
• % children under five years of age who slept using ITN before the campaign =
1.9% (2/106). After the campaign, 51 % (54/106) children U5 slept under the ITN.
1
Figure 7. Net Coverage Before &. After The Campaign, and Net Usage Post Campaign
120
100
80
60
40
20
0
Ｎｾ＠
ｾ＠ OJ
::;:
＠ｾ "
a>
c:
al
ｾ＠
2
ｾ＠
c:
2
ro
11
a>
c:
OIl
ｾ＠IJl
5
a>
[
c;:
c:
ｾ＠
ｾ＠
E
;::
a>
ｾ＠
c:
e
ro
'"
ｾ＠
'"
ｾ＠
'"
11
a>
1ii
'"
ｾ＠
:0
E
0
U
tl
Ｎ ｾ＠
is
Legend:
Families that owned l/more ITN's before campaign
_
Families that received at least 1 LLITN during campaign
_
ITN's distributed that are seen to be hanging on day of interview
During the measles SIAs in the Central Lombok district of NTB province, a pilot project
for the distribution of micronutrient sachets was conducted in seven health centers
reaching more than 27,000 children. This was the first time this type of intervention
was attempted in Indonesia as well as the region.
13
Table 5. Result of Vitamin A Micronu trient supplem ent (Tabur G,'z,')
distribution
Month
Disrtrict
Province
No
I
Puskesmas
(HC)
August-October 2007
Lombok Tengah
NTB
VIHage
Ba tunyala
Batunyala
Lajut
PSJangglk
Ke!ebuh
5esake
100
463