Responding to the polio outbreak in three provinces—Aceh, North Sumatera, and West Java—linked to circulating vaccine-derived poliovirus type two (cVDPV2), the Ministry of Health (MoH) and WHO conducted various efforts to mitigate the impact and prevent further transmission. These efforts included local advocacy for outbreak response, raising awareness of the society, strengthening surveillance efforts, the roll-out of the vaccination strategy, outbreak assessment, and monitoring and evaluation of the outbreak response. These comprehensive efforts were undertaken to ensure sustainability and enhance effectiveness.
To combat the outbreak, polio supplementary immunization activities (SIAs) with the novel oral polio vaccine type 2 (nOPV2) were delivered across these provinces, aiming for a uniform coverage of at least 90%. Health care workers administered over 12 million vaccine doses across three provinces. Given the brief window for countering polio virus transmission during SIAs, a robust strategy was imperative, involving daily monitoring and feedback mechanisms during implementation to capture best practices, identify challenges, track the progress of children vaccinated and establish necessary action plans.
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The health worker records nOPV2 vaccinations in children’s immunization card and form in Tunas Karya Posyandu Cirebon District. Credit: WHO/Endang Sri Utami
Despite the success in the vaccination rollout, the polio outbreak has not yet been fully contained. Based on the outbreak assessment findings, efforts will focus on several key areas. These include strengthening acute flaccid paralysis (AFP) surveillance, reducing risk by building population immunity through strengthening routine immunization programmes, and refining the management of the nOPV2 vaccine.
It is essential to establish daily monitoring and robust feedback mechanisms from the field, particularly for the SIA evaluation, to ensure the quality of immunization interventions. WHO and MoH have taken various steps in this regard, encompassing providing technical assistance and training, conducting rapid convenience assessments (RCAs), offering support for the electronic registry tool, and collecting and analysing data.
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An immunization officer and midwifes in Pidie, Aceh, review vaccination numbers and nOPV2 usage before reporting to the district level. Credit: WHO/Hermansyah.
These combined efforts have improved the response to the polio outbreak, reflected in nOPV2 coverage exceeding 90% in these provinces for both rounds of vaccination. Throughout the SIA implementation, WHO and MoH ensured several interventions to ensure success. These included sub-national advocacy efforts, providing microplanning support, facilitating reporting, conducting awareness-raising activities, as well as ensuring monitoring and evaluation.
- Advocacy efforts at national and subnational levels
To ensure smooth SIA implementation, WHO and MoH organized advocacy activities at the subnational level in Aceh, North Sumatera, and West Java. These activities received technical and financial support from WHO and included a sharing session on the global polio situation and the strategy to achieve high and equitable coverage. Aceh province served as a good example of obtaining support from both government and health units.
To reinforce commitment generated from this advocacy, particularly in community mobilization, the MoH, WHO, and UNICEF collaborated to develop communication and educational materials tailored to the local context. These resources effectively conveyed information about polio SIA implementation. Moreover, WHO actively assisted the district health offices and community health centres in monitoring the sustainability of polio campaign awareness.
Once the local government established the outbreak response plan, WHO provided assistance in adopting guidelines and developed microplanning tools for polio outbreak response using the nOPV2 vaccine. This microplanning process underwent multiple reviews and resulted in a comprehensive plan to assist health care workers in administering nOPV2 immunization.
During the nOPV2 training in North Sumatera, WHO demonstrated the business process of the microplanning forms. Throughout the orientation, WHO also provided support in revising microplanning for several locations. Additionally, WHO staff were deployed to several districts/cities and conducted hands-on training for immunization officers at health centres. The initial assistance aimed to equip health care workers with the necessary data, facilitating their efforts in implementing the microplanning.
- Raising community awareness and assistance for ASIK recording
Prior to the campaign, MoH, WHO, UNICEF and UNDP developed training material for orientation meetings with health workers in Aceh, North Sumatra and West Java, including recording and reporting. Health workers were strongly encouraged to utilize the electronic immunization registry tool, called Aplikasi Sehat IndonesiaKu (ASIK), to record vaccinations, while maintaining manual backup reports.
Prior to SIA implementation, WHO, in collaboration with other partners, conducted awareness-raising activities to improve acceptability of the polio vaccine. This was particularly crucial as the nOPV2 vaccine is not part of the routine vaccination schedule, and there were parental concerns about adverse events following immunization (AEFI). Therefore, there might be some hesitancy in receiving the vaccines.
As of June 2023, a total of 12,416,088 doses of nOPV2 have been administered during the polio SIA in these provinces. The SIAs were a success, achieving coverage rates of over 95% in the 1st round, with specific rates of 96.9%, 96.1%, and 96.2% in Aceh, North Sumatera, and West Java, respectively. In the 2nd round, coverage remained high, exceeding 90%, with rates of 94.7%, 94.8%, and 92.3% in Aceh, North Sumatera, and West Java, respectively. However, based on ASIK, there was a gap of 27.4% between manual report and ASIK. This underscores the importance of prioritizing improvements in reporting accurately to ASIK.
- Monitoring and evaluation
WHO field personnel assisted the monitoring of nOPV2 SIA in these provinces. WHO tracked immunization coverage, provided corrective action, and discussed the feedback with PHO and DHO. WHO also helped MoH to develop a supervisory tool, available at
https://link.kemkes.go.id/SupervisiORIKLB, visualized through an internal online dashboard, to facilitate supervision and follow-up actions.
Daily monitoring and feedback mechanisms were crucial to address obstacles and action points, as well as ensure timely and accurate data reporting. This effort aimed to reach all targeted children for immunization. WHO provided support throughout the monitoring process, including logistics, vaccination administration, and investigation of those who opted not to receive vaccines. These processes helped districts and villages with low coverage to improve their roll-out strategy.
This effort aimed to rapidly evaluate the coverage data of SIAs through the use of the RCA tool. This tool served to verify reported SIA coverage, identify missing targets, and uncover reasons for non-vaccination, along with addressing other significant aspects like the sources of information for the immunization campaign. Monitoring polio SIA and providing feedback was vital to address the obstacles occurred, ensure the timeliness, completeness, and accuracy of data reporting.
Recognizing the outbreak is not yet fully contained, these collaborative and concerted efforts are indispensable to improve the response to the polio outbreak. These led to positive impact on immunization coverage, a key indicator of success in containing the outbreak. It is important that Indonesia remains vigilant and prepared for potential future outbreaks.
These activities were supported by the government of United States through USAID.
Written by Olivi Silalahi, NPO routine immunization; Mindo Nainggolan, National polio coordinator; and Endang Sri Utami, Immunization data assistant; WHO Indonesia
