As part of the response efforts, Indonesia has introduced an innovative tool known as novel oral polio vaccine type 2 (nOPV2) to address the evolving risk of c-VDVP2. This novel vaccine, designated for outbreak response, has met rigorous requirements. Special approval from the Director General of WHO after meeting 16 emergency use listing (EUL) requirements is required for a country to access the vaccine. Remarkably, Indonesia completed all these requirements within a record-breaking 12 days. The rollout programme for this vaccine includes facilitation briefing, virtual daily meetings, thorough reviews to meet the requirements and detailed implementation planning. The programme has been a success with more than 12 million vaccines administered in three provinces, effectively reducing the transmission of the poliovirus. To ensure continued effectiveness, it is required to further analysis the outbreak response.
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A discussion between the head of the Puskesmas and the OBRA assessor during a field visit at Puskesmas Tanah Jambo Aye, North Aceh. Credits: WHO/ Mindo Nainggolan.
Recognizing the WHA Resolution 59.1 recommendations on additional measures necessary to reduce the spread of poliovirus following outbreaks in polio-free areas, an independent review of the outbreak response was conducted by an external team six months after outbreak confirmation and will continue periodically thereafter until the outbreak is concluded. These assessments aim to review progress in controlling outbreaks, track progress, and make recommendations on actions to close remaining gaps.
The OBRA was conducted to evaluate whether the outbreak has likely concluded. This assessment took place from 10 to 20 July 2023, involving briefings, field visits, desk reviews, and a debriefing. Throughout the process, WHO Indonesia played a crucial role in supporting the implementation of OBRA by providing both financial resources and technical assistance.
The technical support included preparations for OBRA implementation, coordination with international assessors and partners, raising awareness among key stakeholders such as the PHO, DHO, and Puskesmas, document collection, facilitation for technical briefings, assessments, and evaluation. An initial preparation meeting was held with the MoH team and partners in Indonesia to establish a comprehensive understanding of planned activities. WHO led the assessment process, coordinating the activities with all assessor teams, managing the content, providing administrative support, and facilitating the activities at both the national and provincial levels.
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OBRA team assessors (Dr Naveed-left and John McCrary-right) with Dr Olivi Silalahi (middle) check the completeness of immunization of children living in a plantation area by using the Maternal and Child Health Book. Credits: WHO/ Novi Anggraeni
Throughout the implementation, the assessors examined supporting documents and cross-checked statements through interviews. WHO assisted in clarifying questions and collecting responses from interviewees. Field assessments included visits to hospitals, Posyandus and communities to supplement findings on the outbreak response. Upon completing the field interviews, all findings were thoroughly analysed by the assessor team to formulate recommendations. These findings and recommendations were then submitted to the subnational and national-level health authorities for further action.
For example, the assessment carried out in North Sumatera involved visits to two districts – Karo and Labuhan Batu Selatan. These visits encompassed various locations, including district health offices, health facilities (hospitals and primary health centres), and households. During household interviews, assessors captured insights into community perspectives, experiences, and challenges related to the polio response efforts, including the quality of the Polio SIA and routine immunization services.
From these visits, the team concluded that most of the targeted children had received nOPV2 vaccine during the Polio SIA campaign. However, the assessment also revealed that some children had not received age-appropriate doses of routine immunization, raising concern about incomplete vaccination schedules and potential gaps in routine immunization coverage.
In summary, there are several key findings. Firstly, the polio SIAs are no longer recommended, since the vaccination coverage in three provinces now exceeds 95%. In addition, it was recommended to establish an improvement plan for AFP surveillance and enhance monitoring efforts. A robust surveillance system is essential for local health authorities to early detect and promptly respond to potential outbreaks.
Dr Iman, the head of CDC unit in Aceh PHO, stated, “OBRA should also capture high-performing districts when documenting OBRA findings in Aceh province. The two low-performing districts are not sufficiently representative to capture findings in Aceh province.”
OBRA results concluded that the risk of continued circulation is declining. Nevertheless, the OBRA team recommends increasing the sensitivity and quality of AFP surveillance over the next 3 to 6 months to ensure the complete cessation of transmission. Moreover, several follow-up actions are recommended, including ensuring every child receives polio vaccines (bOPV and IPV), actively engaging local key stakeholders (the head of regional government) in strengthening routine immunization and VPD surveillance, identifying high-risk populations, implementing a specific transit strategy, expanding and conducting RCAs systematically, and strengthening the quality of AFP surveillance.
As part of the follow-up, there is a strong emphasis on the proper management of waste generated by nOPV2 doses to maintain a safe environment. Moreover, WHO encourages the three provinces to establish improvement plans for AFP surveillance and to monitor their achievements. Enhancing the quality of AFP surveillance and polio immunization are crucial steps to stop the transmission of the poliovirus and provide adequate protection against polio for children.
This outbreak response assessment was supported by the Government of United States through USAID.
Written by: Olivi Silalahi, NPO routine immunization; Mindo Nainggolan, National polio coordinator; Novi Anggraeni, Vaccination Technical Officer; WHO Indonesia.