Report of the Indonesia Polio Outbreak

Response Assessment

May 2020
 ACKNOWLEDGEMENT

The OBRA team would like to acknowledge and express gratitude to the Government of
Indonesia for their excellent cooperation, support and active participation in the first ever
virtual polio outbreak response assessment. The Ministry of Health at the National level,
the Provincial teams in Papua and Papua Barat and the GPEI outbreak team in Indonesia
have made available data and documents to the OBRA team and responded to queries and
clarifications during the assessment without which the assessment could have been very
difficult. The OBAR team also would like to express true appreciation to the GPEI partners
and other development partners including USAID for their generous support for the
assessment. Thanks to the GPEI’s outbreak preparedness and response task team (OPRTT)
who provided the unique opportunity and corporation to conduct this first ever virtual
polio outbreak response assessment in Indonesia.

Indonesia cVDPV1 Outbreak Response Assessment 6 – 24 April 2020 2

 DISCLAIMER

The boundaries and names shown, and the designations used in the maps in this document
do not imply the expression of any opinion whatsoever on the part of the World Health
Organization concerning the legal status of any country, territory, city or area or of its
authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on
maps represent approximate border lines for which there may not yet be full agreement.

Indonesia cVDPV1 Outbreak Response Assessment 6 – 24 April 2020 3

 ACRONYMS

AFP Acute flaccid paralysis

bOPV bivalent oral polio vaccine
C4D Communication for development
COVID-19 Coronavirus disease 2019
cVDPV 1 circulating vaccine derived poliovirus type one
DHO District Health Office
ES Environmental surveillance
ES-CDC United States Centre for Disease Control and Prevention
EWARS Early warning, alert and response system
GPEI Global Polio Eradication Initiative
KPI Key performance indicator
MOH Ministry of Health
NCCPE National certification committee for polio eradication
NID National immunization days
NITAG National technical advisory group on Immunization
NPAFP Non polio AFP
NPEV Non-polio enterovirus
OBRA Outbreak response assessment
OPRTT Outbreak preparedness and response task team
PHEIC Public Emergency of International Concern
PHO Provincial Health Office
RI Routine immunization
SIA Supplementary immunization activities
tOPV Trivalent oral polio vaccine
UNICEF United Nations Children’s Fund
USAID United States Agency for International Development
VDPV vaccine derived poliovirus
WHO World Health Organization
WPV1 Wild poliovirus type one
WPV2 wild poliovirus type two
WPV3 wild poliovirus type three

Indonesia cVDPV1 Outbreak Response Assessment 6 – 24 April 2020 4

CONTENTS
ACKNOWLEDGEMENT .................................................................................................................................... 2
DISCLAIMER .................................................................................................................................................... 3
ACRONYMS ..................................................................................................................................................... 4
Executive Summary ........................................................................................................................................ 6
Introduction.................................................................................................................................................... 8
Objectives and Methodology ......................................................................................................................... 9
Limitation of the OBRA ................................................................................................................................. 10
Declaration of conflict of Interest ................................................................................................................ 10
OBRA Findings .............................................................................................................................................. 11
Management and coordination ............................................................................................................... 11
Advocacy, Communication and Social Mobilization ................................................................................ 13
Population Immunity ................................................................................................................................ 16
Supplementary Immunization activities................................................................................................... 16
Special SIA operations .............................................................................................................................. 18
Vaccination coverage ............................................................................................................................... 18
Rapid Convenience Assessment (RCA) ..................................................................................................... 20
Routine Immunization .............................................................................................................................. 21
Implementation of the EC-IHR Recommendations .................................................................................. 23
Vaccine, Cold Chain and Logistics Management ...................................................................................... 24
Enhanced Surveillance.............................................................................................................................. 25
Environmental Surveillance ...................................................................................................................... 27
Remaining risk of poliovirus transmission.................................................................................................... 29
Covid-19 Pandemic impact on outbreak response in Indonesia .................................................................. 29
Performance standards ................................................................................................................................ 30
OBRA CONCLUSIONS .................................................................................................................................... 31
OBRA RECOMMENDATIONS ......................................................................................................................... 32
Annex 1: OBRA team members ............................................................................................................ 33
Annex 2: Performance Standards ......................................................................................................... 34

Indonesia cVDPV1 Outbreak Response Assessment 6 – 24 April 2020 5

 Executive Summary

Context: In February 2019, the Indonesian Government notified WHO about an outbreak of Polio in
Papua Province which was associated with circulating vaccine derived poliovirus type one (cVDPV1).
This outbreak was not linked to the then ongoing polio outbreak in the neighboring country Papua New
Guinea. The Indonesia government in collaboration with Provincial government launched outbreak
response activities to stop the transmission within 120 days of the outbreak notification. Papua and
West Papua were identified as outbreak zone based on the risk assessment. The polio surveillance
activities were enhanced, and mass vaccination campaigns were conducted with bOPV targeting around
1.2 million children less than 15 years of age in Papua and West Papua. The number of polio cases
associated with cVDPV1 remains at one and in addition polio virus was detected from the stool
specimens of two healthy children from the local community. The first poliovirus was detected from the
AFP child who’s stool specimen was collected on 27 November 2018 and most recent cVDPV1 was
detected from one of the health children stool specimen which was collected 13 February 2019. These
isolated polioviruses had genetic divergence of 61nt and 58nt from the corresponding Sabin virus. An
outbreak response assessment was conducted from 6-14 April 2020 for the cVDPV1 outbreak in Papua
Province in Indonesia.

Objectives: The main objectives of the OBRA were, to assess polio outbreak response quality against
performance standards, and to determine the status of cVDPV1 transmission in Indonesia based on
evidence provided by the country team.

Methods: This is the first ever virtual OBRA in polio eradication. A team of 24 members comprising of
experts from GPEI partner agencies and ministry of health, Indonesia conducted this virtual OBRA using
standard tools and Global OBRA guidance. Due to the travel restrictions from the COVID-19 pandemic,
team members could not travel to Indonesia and provinces nor have opportunity to discuss face to face.
All the discussions, interviews were done through tele-video conference.

Findings: OBRA team noted and acknowledged that despite of the challenging operating environment
in the outbreak zone due the terrain, flooding, political and local security issues the Indonesian
government were able to implement the outbreak response operations in Papua and Papua Barat

Indonesia cVDPV1 Outbreak Response Assessment 6 – 24 April 2020 6

provinces. Government ownership and leadership was commendable and most of the outbreak
response budget was provided by the National and Provincial Government. However, a national public
health emergency was not declared by the National Authority resulted delayed release of emergency
funding for outbreak response implementation. Initial response was supported by local fund and GPEI
partners. GPEI and other development partners provided technical and financial resources, supported
high-level advocacy and extensive communication and social mobilization efforts at all levels. The
special operations in the high land districts of Papua province was one of the several major activities
through which thousands of children were vaccinated otherwise they could have been missed. UNICEF
supported the operations from planning to implementation including financial and logistics support in
the district of Yahukimo, which was a huge success. The special operations in other 13 districts were
fully financed and managed by MOH together with the province through a memorandum of
understanding with PHO Papua to implement the special operation. While the overall coverage in the
second SIA round was >90% in the outbreak zone, but coverage in the highland districts of Papua was
below the province average. There were special efforts to improve routine immunization coverage in
the highland areas, however, it was still very low in both provinces. Evidence was clear that polio
surveillance in Papua and Papua Barat was enhanced and NPAFP rate of ≥3 was achieved in 2019 in both
the provinces. However, the persistent low stool adequacy rate in Papua remain as a concern for
surveillance sensitivity and will continue to keep Papua province as high risk for PV transmission, unless
it is addressed urgently and effectively.

Conclusions: After a thorough review of the data, reports, documents provided by the National
programme and outbreak coordination team of Indonesia, the OBRA team concludes that the cVDPV1
transmission in Papua, Indonesia has been stopped within the globally expected time line of 120 days
and there is no evidence of ongoing cVDPV1 transmission in Indonesia.

Recommendations: WHO Regional Office for South-East Asia, based on the OBRA report and in
consultation with OPRTT, should decide on closure of the Indonesia polio outbreak associated with
cVDPV1 transmission.

Indonesia cVDPV1 Outbreak Response Assessment 6 – 24 April 2020 7

 Introduction

On 12 February 2019, the Indonesia government notified WHO regional office of the South East Asia
(WHO-SEARO) of a polio outbreak in Papua province. The outbreak of poliovirus was confirmed through
detection of circulating vaccine derived poliovirus type one (cVDPV1) in three individual children from
Dekai sub-district of Yahukimo district, Papua Province (figure 1). The index case was a 31-month-old
male child who was reported as an AFP case, had onset of paralysis on 27 November 2018 with no history
of polio vaccination in the past. The other two were healthy children from the local community. The
polioviruses from these three children had 61nt, 58nt and 58nt genetic divergence respectively from the
Sabin type 1 virus and genetically linked to each other but not linked to VDPV1 circulation in the
neighboring country Papua New Guinea which was ongoing since June 2018 1.

Figure 1, polio outbreak zone and spot map, Papua and Papua Barat

Both Papua and neighboring Papua Barat were considered as the outbreak zone in the development of
the comprehensive outbreak response plan. All provinces were put on alert. The Indonesian National
Technical Advisory Group on Immunization (NITAG) recommended to conduct two SIA rounds with
bOPV in Papua and Papua Barat Provinces targeting children less than 15 years of age. There has been
no further detection of cVDPV1 anywhere in Indonesia for more than 13 months at the time of this
OBRA. There was no evidence of any international spread from Indonesia during the outbreak response.

1
https://www.who.int/westernpacific/emergencies/papua-new-guinea-poliovirus-outbreak
Indonesia cVDPV1 Outbreak Response Assessment 6 – 24 April 2020 8
 Consequently, Indonesia is no longer considered as polio infected country according to the recent
statement of the emergency committee on polio under the International Health Regulations (2005). The
most recent cVDPV1 was isolated from a healthy child’s stool sample collected on 13 Feb 2019. Most
recent WPV1 case was reported in 2006 from Aceh, and Indonesia has never had a WPV2 laboratory
confirmed case and the last WPV3 case was reported in 1995 from East Java. Before the current
outbreak the last VDPV1 was reported in 2005 from East Java.

Indonesia has been assessing the situation and monitoring the outbreak response operations through a
well-coordinated mechanism involving partners and provincial teams. However, as per standard
protocols of the Global Polio Eradication Initiative (GPEI), Outbreak Response Assessment (OBRA) must
be conducted for all polio outbreaks. Due to the COVID-19 pandemic situation and travel restrictions,
the assessment was not possible to conduct through country visit and face to face interviews. However,
to maintain the polio programme continuity as per GPEI’s Covid-19 guidance, the GPEI’s outbreak
preparedness and response task team (OPRTT) and the Ministry of Health of Indonesia agreed to
undertake an OBRA in Indonesia from 6-14 April 2020. This is the first ever virtual OBRA in polio
eradication.

Objectives and Methodology

The main objectives of the virtual OBRA were:
• To assess polio outbreak response quality against performance standards2, and
• To determine the status of cVDPV1 transmission in Indonesia based on evidence provided by the
country team.

The OBRA started on 06 April 2020 with a virtual briefing session participated by a total 24 OBRA team
members (annex 1) including representatives from MoH, members from Indonesia polio committees,
provincial health offices of Papua and Papua Barat provinces, US-CDC Indonesia and representatives from
all three levels of WHO and UNICEF. The assessment was focused on the outbreak zone, Papua and Papua
Barat. The Indonesia MOH, in coordination with Provincial health offices (PHOs) of Papua and Papua
Barat, provided all documents, data, and reports to the OBRA team as requested. OBRA team members

2
http://polioeradication.org/wp-content/uploads/2016/07/Polio-Outbreak-Response-Assessment-English-Version-2-December-2019-201912.pdf
Indonesia cVDPV1 Outbreak Response Assessment 6 – 24 April 2020 9
 divided into six sub-groups to work on specific key programme area and conducted assessments.
Standard tools and check lists were used to capture evidence of programme performance. The OBRA was
conducted entirely through desk review, meetings, discussions with National and Provincial teams
through Webinar, TC, Email, group WhatsApp messaging, Skype call, etc. Planning communication with
country, WHO-UNICEF Regional offices and GPEI was done in the month of March 2020 before starting
the assessment. Data collection, analysis and composition of findings were conducted during 6 to14 April,
followed by report compilation and preparation from 15 to 22 April. GPEI OBRA guidance3 and decision
tree was consulted to formulate conclusions. The OBRA report was presented to the Government of
Indonesia and partners on 24 March 2020 through Webinar meeting where a total 51 persons
participated including members from the GPEI partner agencies.

Limitation of the OBRA

Normally, the final OBRA can draw upon one or two earlier OBRAs taking place during the outbreak.
However, this was both the first and final external OBRA in Indonesia and unusually new issues were
identified. As already mentioned, this is the first OBRA ever conducted remotely by the GPEI as on-site
verification was not possible due to travel restrictions for COVID-19 Pandemic. Face to face discussions,
interviews, were not possible to conduct but were achieved through several tele and video conferences.
Hence it took longer time to complete.

Declaration of conflict of Interest

Several OBRA team members were involved in different stages of the outbreak response in Indonesia and
provided technical support in planning, implementation and monitoring of the response activities.

3
http://polioeradication.org/wp-content/uploads/2020/04/POL-SOP-V3.1-20200424.pdf
Indonesia cVDPV1 Outbreak Response Assessment 6 – 24 April 2020 10
 OBRA Findings

Management and coordination

On 12 February 2019, the MoH notified WHO, provinces and all stakeholders in Indonesia about the
detection cVDPV1 in Dekai, Yahukimo district. The Yahukimo district authority declared outbreak of
polio that was followed by MOH circular and decree to the affected provinces and across the country,
outlining essential response activities. National and provincial emergency operation centres (EOCs)
were functional and led the response operation and coordination. The national outbreak response plan
was developed timely. Reports were provided regularly to the Polio Emergency Committee convened
under the IHR.

On 7 March 2019, WHO graded the cVDPV1 outbreak as emergency grade-1 according to the WHO
Emergency Framework. Indonesian Government demonstrated sound political leadership and
commitment by deploying senior officials and led a collaborative effort involving multiple sectors within
the government and together with partner agencies to respond to the outbreak. The WHO
Representative to Indonesia, the UNICEF Representative and Deputy Representative to Indonesia,
several senior officials and polio experts from US-CDC, WHO and UNICEF Regional offices and
Headquarters made visits to Papua including Dekai village of Yahukimo district during different stages
of the outbreak response. These visits helped in advocacy to strengthen local government political
commitment, mobilize resources and provide technical support to the provincial and district teams. The
political and administrative leaders of Papua and Papua Barat were very engaged in leading the
outbreak response and put all possible efforts into stopping the outbreak of polio in the provinces
(figure 2).

Indonesia cVDPV1 Outbreak Response Assessment 6 – 24 April 2020 11

 Figure 2: Launching of polio vaccination campaign by the District Commissioners, Papua Province

GPEI assigned an outbreak coordinator in Indonesia to ensure coordinated support to Government-led

response activities. Regular partner meetings, briefings were conducted at provincial, national and
global levels. The MoH, province and districts provided most of the financial resources that were
necessary for outbreak response. In addition, GPEI funding and resources that were mobilized by
development partners were available to support outbreak response situation reports (SITREPs) that
were regularly shared globally. A plan of action to sustain the gains and continuity of intensified efforts
for polio eradication has been approved by the Government.

The outbreak response activities were implemented under several challenges and constraints. As
national public health emergency was not declared and there was a delayed release of funds from
central level to provinces and districts causing delayed implementation of some activities. Decentralized
governance structure was another challenge for accountability and coordination between central and
local government on outbreak response. Papua province has certain unique challenges such as difficult
geography in the highland districts, and poor travel infrastructure which results in travel being very
difficult and expensive. Local security issues challenged travel and work in high land districts of Papua.
Over one hundred people were killed and around a hundred were missing during flooding in Papua in
March 2019 which coincided with the outbreak response and was challenging for both the National and
Provincial governments.

Indonesia cVDPV1 Outbreak Response Assessment 6 – 24 April 2020 12

Recommendation

The Indonesian government is encouraged to find a suitable mechanism to improve timely

release of funds at both national and local level for any future polio outbreak response
activities.

Advocacy, Communication and Social Mobilization

There was a high-level political commitment from Government of Indonesia. The Chief of Staff of the
President Office was directly involved in advocacy and supervision of the polio outbreak response. A
Senior Advisor to MOH was appointed to lead the polio outbreak response at national and provincial
levels. Several advocacy engagements with media, community leaders, and religious leaders were
conducted in Papua province. Partnership with the six biggest church denominations in Papua, Indonesian
Red Cross and local NGOs helped expand penetration of communication into hard-to-reach highlands of
Papua province. Church volunteers proved instrumental in social mobilization and vaccination activities.
With respect to communication research and post-campaign monitoring, for example, findings of Measles
- Rubella post-campaign monitoring, including a drop-out study and social investigation/social mapping,
were used to guide the development of the communication strategy and plan. RapidPro tool was utilized
to track the implementation of social mobilization activities and RCA data was used to understand and
address social mobilization gaps. Cultural diversity required a specially tailored communication strategy.
Advocacy, Communication and social mobilization interventions were evidence- and context-based,
including high level advocacy, interpersonal communications, community motivational social
mobilization, production and dissemination of culturally-appropriate informational, educational and
communication (IEC) materials, such as social mobilization flip guides for frontline workers, street
projections, etc. (figure 3).

Indonesia cVDPV1 Outbreak Response Assessment 6 – 24 April 2020 13

Figure 3: ACSM activities, Papua

By end of Dec 2019, over 1,870 social mobilization activities were implemented that reached over 73,000
caregivers with key information on polio campaigns. Media monitoring was established to ensure accurate
and adequate information was provided. Microplanning included social mobilization aspects, costs and
mapping high-risk and hard-to-reach communities and strategies to reach them were developed and
implemented. Partners’ presence in Papua and Papua Barat was mapped, and roles and responsibilities
identified based on each comparative advantage. As a part of the Health Advisory Group, the Dewan Adat
Papua (Papuan Customary Council - an organization representing indigenous people) played an important
role in informing and influencing members of Dewan Adat Papua at all districts of Papua province to
support polio immunization (figure 4).

Figure 4: Polio outbreak response support in outbreak zone by partners and C4D activities in Yahukimo district

The technical assistance provided for ACSM: The Development partners particularly the UNICEF team in
coordination with National and Provincial teams brought in several other local partners and conducted
situation analysis, designed local level advocacy, communication and social mobilization products and
provided technical assistance to the government for implementation and monitoring of the activities.

Indonesia cVDPV1 Outbreak Response Assessment 6 – 24 April 2020 14

Challenges: At the beginning, the provincial level political support for the polio planned activities was
found to be sub-optimal due to several local issues including flooding and security issues. The funds
allocated for social mobilization activities in the Papua highlands were insufficient because budgets were
based on fixed government rate (SBM) with no adjustment for higher actual costs. The communication
response in Papua highlands required greater time and resources because it had to be done by
interpersonal communication, due to lack of access to television, radio and mobile communication. Clear
delineation between C4D and external communication was not evident in the National Polio Preparedness
and Response Plan. Social investigation in Dekai revealed vaccine hesitancy due to rumors and a lack of
knowledge about immunization. The investigation also alluded to the public confidence issue of
government services.

Recommendations
• Leverage the partnerships with local NGOs, religious organizations (churches, Mosques, etc.)
and stakeholders that were mapped during the outbreak response for all future community-
based partner supported PEI/EPI activities;
• Consider implementing context-based communication and social mobilization plan at Papua
and Papua Barat provinces for further enhancing community mobilization efforts for future
SIAs, RI-SOS and catch up campaign strategies at least for the next 6-12 months;
• Ensure that National Polio Preparedness and Response Plan includes C4D and Advocacy
Communication plan based on lessons learned;
• A clear delineation between external communication and C4D activities should be made in
the National polio outbreak preparedness and response plan.

Indonesia cVDPV1 Outbreak Response Assessment 6 – 24 April 2020 15

Population Immunity

Indonesia took certain actions to improve population immunity before the cVDPV1 outbreak was
confirmed. Following the cVDPV1 outbreak in neighboring Papua New Guinea, as a preventive strategy
measures were taken to improve population immunity by administering the polio vaccine together with
the measles-rubella (MR) vaccine during a campaign held in September to December 2018. Subsequently,
on detection of VDPV1 a round zero with bivalent OPV campaign was started immediately in the affected
community in January-February 2019, while detailed investigation of the poliovirus event was being
conducted. In response to the outbreak of cVDPV1, Indonesia further strengthened its vaccination
activities through conducting SIAs and as well as strengthening RI activities.

Supplementary Immunization activities

Based on epidemiological analysis done by the Government, NITAG, Polio Eradication Expert Committee,
WHO, UNICEF and CDC, two larger and wide age range (0 months -15 years) SNIDs, with bOPV, covering
Papua and Papua Barat province were planned. Papua Barat province was considered as high risk, as this
province shares land borders with Papua. All districts of Papua and Papua Barat provinces were covered
with a target of 1.2 million children. SIAs were not conducted anywhere else in Indonesia in 2019.
However, Indonesia had conducted an NID in March 2016 with tOPV before the switch.

bOPV was delivered to the children through combination of several strategies such as vaccination at the
health centre, at village post and at schools and followed by sweeping activities through house to house
strategy. Vaccination was also offered at important markets, bus terminals, churches, mosques, IDP
camps, etc. (figure 5).

Indonesia cVDPV1 Outbreak Response Assessment 6 – 24 April 2020 16

Figure 5: Vaccination through various strategies

The implementation of two rounds of bOPV SIA took extraordinary time and effort to implement because
of steep terrain, sparsely populated populations, weak infrastructure, challenging access, and additional
time to arrange workforce and to mobilize financial resources and community, particularly in 14 highland
districts in Papua.

The programme managers regularly monitored the campaign performance through a web-based data
platform, RapidPro (figure 6), discusses it in the daily review meeting at the PHO and take necessary
measures accordingly for better performance.

Figure 6: Example of monitoring of daily trend of SIA coverage, Papua

Indonesia cVDPV1 Outbreak Response Assessment 6 – 24 April 2020 17

Special SIA operations
The special operation in Yahukimo district as an epicenter of the outbreak through intensified micro-
planning and logistic air support with chartered helicopters and small fixed planes supported by UNICEF
during the piloting phase showed that the model can work and substantial increase in coverage was
achieved. Coverage has increased from 14.57% in first round to 91.75% in round two (local target data).
The national authorities considered it as an efficient approach to replicate in the hard-to-reach areas in
other 13 highland districts of Papua which constitute 10-15% of population in Papua. Later, the Government
of Indonesia allocated special budget to conduct special operations in all the other 13 high-land districts of
Papua which was continued till mid -December 2019 and vaccinated large number of missed children (figure
7).

Figure 7: Special operations team ready to travel to remote areas for vaccination, Papua

Vaccination coverage
Around 1.2 million children less than 15 years of age were targeted for the vaccination campaign in Papua
and Papua Barat province, while the estimated number of <5y children in both provinces were only
436,051. The overall administrative coverage in Papua Barat province was ≥95% in both the rounds while
in Papua province the coverage was around 70% in round one and around 90% in round two (figure 7 &
8)

Indonesia cVDPV1 Outbreak Response Assessment 6 – 24 April 2020 18

Figure 7: SIAs coverage, Papua province

In Papua province 285,471 children were missed in round one and after the second round a total of
119,723 children (14% of the target children) <15y of age (estimated around 40,000 of them are <5y
children) remain unvaccinated despite the attempts through various special strategies (figure 8). The
OBRA team has been informed that the provincial team with support from national level will continue
their efforts to reach these missed children through various special efforts during the coming months.

Figure 8. campaign coverage and missed children analysis

Indonesia cVDPV1 Outbreak Response Assessment 6 – 24 April 2020 19

 Rapid Convenience Assessment (RCA)
As endorsed by MoH, the Rapid Convenient Assessment (RCA) have been conducted by relevant partners
and stakeholders for two rounds in both provinces. A total of 342 RCAs were completed in Papua and 106
RCAs in West Papua. RapidPro which has already been used and tested by UNICEF CO during the 2018 MR
SIA has been leveraged again during the polio outbreak response to facilitate timely collection and
reporting of RCA data and this was proven to be very useful platform in providing feedback to national
and provincial EOCs (figure 9). Based on the RCA data, the main reasons for children missing vaccination
in West Papua and Papua were traveling (parents), lack of information on the campaign and children being
sick. In October and November 2019, an additional 141 RCAs using the new modified form were
conducted in 21 districts in Papua. The RCA data showed that more than 52% of children were vaccinated
at health facilities and outreach sites (Puskesmas and Posyandu) and 38% at school; and 95% children
who were assessed found to be vaccinated with Polio vaccine, though only 84% received two doses of
OPV during 1st and 2nd Polio Sub NID.

Figure 9. Example of RCAs

Challenges: The overall administrative coverage in the two provinces combined did not meet the
target coverage of ≥95% in either Round 1 or Round 2. However, it can be clearly seen that this is
largely due to sub optimal coverage in Round 1 in the highland districts and improved but still below
the expected coverage in Round 2 (Figure 10).

Indonesia cVDPV1 Outbreak Response Assessment 6 – 24 April 2020 20

Figure 10: SIA coverage in Papua and Papua Barat province

Routine Immunization
Routine immunization services continued during the SIAs. Strong collaboration with different sectors,
including religious organizations/leaders, local NGOs, and volunteers, that was built during outbreak
response SIA also proved useful for strengthening routine immunization. Overall capacity of the health
workers, as well as staff in the PHO and DHO, has improved, especially in terms of development of micro-
plans and social mobilization activities. Cold chain inventory was updated, together with SIA
microplanning development. High risk populations, like those who live in highland areas and internally
displaced persons (IDP), that were identified during SIA and reached for RI services. Nduga district
allocated funds from their local budget to deliver vaccines and conduct outreach sessions in hard to
reach communities. EPI review conducted in early 2020 with the support from different development
partners. Although the OPV3 and IPV coverage increased significantly in 2019 in both the provinces,
however, it is still below the standards (figure 11).

Indonesia cVDPV1 Outbreak Response Assessment 6 – 24 April 2020 21

Figure 11: OPV & IPV coverage in Papua and Papua Barat

Challenges: There was shortage of human resources in highland districts and shortage of IPV since the
last quarter of 2019 led to compromised routine immunization services across in Papua and West Papua.
Reflection of the low OPV coverage was evident on OPV doses among AFP cases which was below 50%
with three doses of OPV in 2019 in both Papua and Papua Barat.

The MoH has recommended Papua and Papua Barat to strengthen routine immunization through
efforts as follows:
▪ Conduct defaulter tracking to identify drop out and left out children and complete their
immunization status specifically OPV and IPV.
▪ Conduct Backlog Fighting, targeting children under 3 years old who have not completed
their immunization status and complete them accordingly.
▪ Improve access of immunization service for targets in remote areas, using SOS approach.
▪ Optimize the inter-sectoral collaboration between the programmes and with other and
stakeholders.

Indonesia cVDPV1 Outbreak Response Assessment 6 – 24 April 2020 22

Recommendations

• Conduct at least one bOPV SIAs in 2020 in Papua and other high-risk provinces to improve
population immunity;

• Strengthen RI and take measures to improve OPV and IPV coverage to build population
immunity against all types of polioviruses everywhere;

• Strengthen implementation of all special operations such as integrated health service

delivery through SOS strategies, defaulter tracking, drop out follow up, BLF strategies;

• Consider allocating adequate resources and capacity building for RI programme.

Implementation of the EC-IHR Recommendations

In line with IHR recommendations, and to prevent spread of disease to other provinces as well as to
other countries, MoH performed screening and administration of bOPV to all travelers departing to and
leaving from Papua and West Papua and established vaccination posts at Papua New Guinea borders,
vaccinating all age groups during the almost entire period of the outbreak response in 2019. A total of
1,434 individuals in Papua and 16,388 individuals in West Papua were given OPV by the port health
(figure 12) and cross border vaccination posts.

Figure 12: Vaccination by port health team

Indonesia cVDPV1 Outbreak Response Assessment 6 – 24 April 2020 23

Vaccine, Cold Chain and Logistics Management
All required doses of bOPV for the SIAs were funded by the Government of Indonesia and self-procured
by the national authority from Biopharma, which delivered vaccines to the Provincial level as planned.
The PHOs then managed the transportation of vaccine and logistics to the districts. West Papua
received, 1,190,000 doses of bOPV, Papua received, 4,074,000 doses of bOPV for both rounds.

402,100 bOPV doses were surplus at the end of two rounds in Papua. Delivering vaccines through special
operations in the remote high lands of Yahukimo and other high land district was extraordinary and
commendable but expensive and hard to reproduce elsewhere.

No major cold chain failure was reported during the outbreak response operations; Various means of
transportation were used based on the local situation such as, boat, small airplane, helicopter, human
laborer, etc. to reach children in remote places with vaccine. Both Provinces used different strategies to
understand the cold chain storage capacity and supply chain management system’s functionality before
SIA. For example, Papua PHO applied data from the local area monitoring tool, and vaccine request
forms; and West Papua used available cold chain equipment inventory data from the 2018 MR
campaign. Cold chain capacity was assessed by National and Province team (Table 1).

Table 1: Cold chain assessment findings

Provincial Data West Papua Papua

Cold Chain Equipment functionality- 95% (241 out of 78.5% (361 out
No. of refrigerators were functional 254) of 460)

Ministry of Health Data

Cold Chain Equipment availability- 86% (137 out of 83% (340 out of
No. of Puskesmas have standard and 160) 408)
functional refrigerators

Indonesia cVDPV1 Outbreak Response Assessment 6 – 24 April 2020 24

Recommendations

• Continue to deliver vaccines through special operations and ensure additional

funding allocation for the hard to reach high land districts of Papua;

• Explore innovative solutions in delivering vaccines to the remote and hard to

reach areas;

• Continue supportive supervision system for further strengthening vaccine

and cold chain logistics management everywhere and especially in the high
land areas of Papua.

Enhanced Surveillance
All provinces in Indonesia were alerted and requested to intensify surveillance activities through a MOH
decree. Following deployment of ten Surveillance Officers by WHO, in various districts of Papua and
Papua Barat, the active surveillance and AFP case reporting increased in both provinces compared to
previous years.

Formal hospital record reviews were conducted in 12 high risk provinces including in Papua (35
hospitals) and Papua Barat (19 hospitals). Many missed AFP cases were found (Papua-28, Papua Barat-
6 cases). A re-sensitization training workshop was conducted for doctors, clinicians, nurses, other care
givers and provincial and district surveillance teams, sample collectors, etc.. To strengthen surveillance,
supportive supervision was conducted by national and provincial teams. Weekly surveillance analysis
was conducted at MOH sub-directorate surveillance and shared with PHO and other partners.

The National Certification Committee for Polio Eradication (NCCPE) is functional and provides oversight
to the programme. Polio expert review committee is responsible for classifying inadequate cases, its
meetings were held in July and December 2019. Surveillance was supported by three WHO accredited
NPLs.

Indonesia cVDPV1 Outbreak Response Assessment 6 – 24 April 2020 25

There is a mechanism of weekly reporting through EWARS which exists in Indonesia. In 2019, the
completeness of weekly reports was 85.5% and timeliness of weekly reports was 83.4%. It was observed
that timeliness and completeness of weekly reporting was less than 80% in five districts of West Papua
and in 14 districts of Papua.

In 2019, both standard AFP surveillance indicators were met at the National level. The non-polio AFP
rate was 2.27 with a stool specimen adequacy rate of 81% (as of 09 April 2020). Papua province has an
annualized NPAFP rate of 6.55/100,000 U15 children, stool specimen adequacy rate was at 59.4% while
West Papua has an annualized NPAFP rate of 7.71/100,000 U15 children, stool specimen adequacy rate
was at 54.6%. Therefore, the non-polio AFP rate of ≥3 per 100,000 U15 children (outbreak indicator)
was met in both Papua and Papua Barat in 2019. The surveillance index ≥2.4 was also met. NPEV
isolation rate from the AFP stool specimens and AFP contact specimens were ≥10% in 2019 in both
Papua and Papua Barat. (figure 13 & 14)

Figure 13: AFP surveillance Indicator, Papua and West Papua Province

Figure 14: AFP contact specimens analysis, Papua and West Papua Province

Indonesia cVDPV1 Outbreak Response Assessment 6 – 24 April 2020 26

Challenges: In 2019, adequate stool rate of ≥80% was not met in 2019 in Papua (59.4%) and West Papua
(52.2%). The inadequate stool collection was mostly due to late collection (54%, 82%), arrival at
laboratory in poor condition (33%, 9%) and collection of only one specimen (13%, 9%). While contact
samples were collected for 70% of AFP cases in Papua Barat and 57% of cases in Papua. The key reasons
for not collecting specimens from contacts of all AFP cases and for inadequate stool specimens from
AFP cases were, cases being reported more than 60 days after onset of illness, no stool specimen was
available from the child, no contacts of the AFP case was available due to isolated community, no houses
were there around the case or no houses were there having <5 children who can be fit to the eligibility
criteria of contact specimen. In some cases, the surveillance staff were not motivated to collect contact
specimens and there were instances of refusals from parents and communities for contact sampling as
they suspected the purpose of contact sampling.

Several non-functional health centers in highland districts lead to challenges in timely reporting and
investigation of cases. Active surveillance visits by district surveillance officers are not documented.
There is limited role of private sector in surveillance both in Papua (2%) and West Papua (4%). Low rate
of 60 days follow-up investigation has been observed across the country, the most common reasons
being deaths or due to movement to other location or lost to follow up.

Environmental Surveillance
In 2018-19, environmental surveillance expansion was carried out in outbreak zone with additional
sampling sites were identified in Papua and West Papua. The samples were tested in Jakarta laboratory.
However, the capacity of Surabaya laboratory has been enhanced to test ES samples. A private shipping
company (PT Citra Air) was hired under a long-term agreement until December 2019 to ensure all
samples from PHOs of Papua and West Papua reach laboratory within 24 hours of shipment.

In 2019, an Environmental Surveillance assessment was carried out in Indonesia, which showed that
only 40% sample collection sites, among a total 20 sites in 12 Provinces, were meeting quality standards.
All specimens from Papua and West Papua were negative for poliovirus or any enterovirus. Moreover,
no sample was collected from Papua and Papua Barat after June 2019 due to stock out of laboratory
reagents.

Indonesia cVDPV1 Outbreak Response Assessment 6 – 24 April 2020 27

Challenges: Papua, Papua Barat and several other provinces do not have a sewage system and thus it is
difficult to establish a well-functioning environmental surveillance network. Moreover, collection and
shipment of these samples from provinces is expensive and time taking efforts.

Recommendations

• Continue to implement enhanced surveillance activities at least for the next 12 months
in Papua and West Papua and expand to other high-risk provinces;
• Consider urgent measures so that AFP stool specimens are collected ≤14 days of onset of
paralysis and arrive at the laboratory in good conditions
• Continue contact sampling from all AFP cases including inadequate cases and community
sampling from selected priority areas in Papua and West Papua until timely stool
collection and transportation to laboratory in good condition are achieved;
• Monitoring of reverse cold chain by using temperature log tag can be considered;
• Maintain npAFP rate of ≥3/100,000 U15 children for the next 12 months at least in
Papua and West Papua;
• Consider urgent measures for resuming environment sample collection from Papua and
West Papua and expand ES to other high-risk provinces where AFP surveillance
sensitivity is persistently insufficient.

Indonesia cVDPV1 Outbreak Response Assessment 6 – 24 April 2020 28

 Remaining risk of poliovirus transmission
Afghanistan and Pakistan remain as polio endemic due to continued WPV1 circulation, over 20 countries
in four WHO regions are affected by VDPV outbreaks (Africa, Eastern Mediterranean, South-east Asia
and Western Pacific Regions). In January 2020, the Polio Emergency Committee under IHR stated that
the risk of international spread of poliovirus remains a Public Health Emergency of International Concern
(PHEIC). Recent risk assessment shows >50% provinces of Indonesia with around 23 million <15y
population are at risk of poliovirus transmission (figure 15)4. The ongoing cVDPV1 and cVDPV2 outbreaks
in Malaysia and Philippines poses a greater risk to Indonesia for poliovirus importation.

Figure 14: Risk of poliovirus transmission, RA 2020

Covid-19 Pandemic impact on outbreak

response in Indonesia
COVID-19 has had a negative impact on immunization and surveillance activities in Indonesia. AFP case
detection and reporting has decreased; while Indonesia reported 160 AFP cases in March 2019 only
seven were reported in March 2020. Surveillance Officers and some laboratory staff have been assigned
to COVID-19 work as additional tasks. AFP specimens and Environmental sample shipment have been
postponed because flights were cancelled from Papua and West Papua. Specimen storage capacity at
the laboratories might be overwhelmed by COVID-19 samples if the COVID-19 situation continues and
increases.

4
Surveillance and Immunization bulletin, Indonesia, March 2020
Indonesia cVDPV1 Outbreak Response Assessment 6 – 24 April 2020 29
 Performance standards
Most of the key performance standards of the outbreak response were met. The KPI on management
and coordination is mentioned here below (table 2) and other programme areas performance
standards can be found as annex 2.

Table 2: KPI on Management and coordination

Indonesia cVDPV1 Outbreak Response Assessment 6 – 24 April 2020 30

 OBRA CONCLUSIONS

OBRA team noted and acknowledged that the operating environment for this outbreak response was
very challenging, due to the difficult terrain, geographically isolated populations, difficult and expensive
transportation system in the highland districts, very complex and expensive operations, security
challenges and political unrest and flooding in some areas of Papua at the same time of the outbreak of
cVDPV1. The OBRA team commends the efforts of the Ministry of Health and its partners for the
outbreak response to find solutions to these challenges in Papua and Papua Barat provinces. The special
SIA operations in the highland districts and vaccination efforts continued for longer period to reach
every child. Broadening the target age group up to 15 years was a good decision by the Indonesia team
which has contributed to strengthening polio immunity in a wider proportion of the population.

While the overall coverage in the second SIA round was >90% in the outbreak zone, coverage in the
highland districts of Papua was still insufficient. The SIA opportunity was used to identify pockets of low
immunization coverage where the RI services were delivered in those areas.

Evidence was clear that polio surveillance in Papua and Papua Barat was enhanced and NPAFP rate of
≥3 was achieved in 2019 in both the provinces. However, the persistent low stool adequacy rate in Papua
is a concern for surveillance sensitivity and will continue to keep Papua province at high risk for
poliovirus transmission, unless it is addressed urgently and effectively. The AFP contact specimens from
Papua and Papua Barat that were tested for poliovirus, NPEV and Sabin viruses were isolated from a
good proportion of those specimens (≥10%), but no poliovirus was detected.

There was no evidence of ongoing poliovirus transmission in the outbreak zone and no detection of any
VDPV1 linked to Papua cVDPV1outside the outbreak zone, either in Indonesia or internationally. The
last cVDPV1 was isolated from a healthy child’s stool specimen collected on 13 February 2019 (>13
months at April 2020).

After a thorough review of the data, reports, documents provided by the National programme and
outbreak coordination team of Indonesia, the OBRA team concluded that the circulating vaccine
derived poliovirus type 1 (cVDPV1) transmission in Papua, Indonesia has been stopped within the
globally expected time line of 120 days and there is no evidence of ongoing cVDPV1 transmission in
Indonesia.

Indonesia cVDPV1 Outbreak Response Assessment 6 – 24 April 2020 31

 OBRA RECOMMENDATIONS

• WHO Regional Office for South-East Asia, based on the OBRA report and in consultation with
OPRTT, should decide on closure of the Indonesia polio outbreak associated with cVDPV1
transmission;

• Indonesia programme should maintain high quality polio eradication activities in all provinces in
Indonesia but particularly in Papua, Papua Barat and other high-risk provinces until at least global
polio eradication is achieved and OPV use is ceased globally.

Indonesia cVDPV1 Outbreak Response Assessment 6 – 24 April 2020 32

Annex 1: OBRA team members

Ministry of Health, Indonesia

Muammar, M. Epid, Surveillance unit MOH, Jakarta, Indonesia

Cornelia K, Surveillance unit MOH, Jakarta, Indonesia
Gertrudis Tandy, Chief of Section of Secondary Immunization and Immunization in Certain Situation, MOH,
Jakarta, Indonesia
Lulu Ariyantheny Dewi, EPI unit MOH, Jakarta, Indonesia
Sherli Karolina, EPI unit MOH, Jakarta, Indonesia
Yusneri, EPI unit MOH, Jakarta, Indonesia
Reza Isfan, EPI unit MOH, Jakarta, Indonesia

Polio Committee

Hariadi Wibisono, Chairperson NCPPE, Jakarta, Indonesia

Ismoedijanto Moedjito, Chairman of Surveillance Expert Committee, Former member of SEARCCPE, Jakarta,
Indonesia

UNICEF

Sugiarto, Immunization Consultant, UNICEF, Jakarta, Indonesia

Haditya Mukri, Data Officer, UNICEF, Jakarta, Indonesia
Ruhul Amin, Immunization Specialist, UNICEF, Jakarta, Indonesia
Abu Obeida Eltayeb, Immunization Specialist, UNICEF RO EAPRO, Bangkok, Thailand
Farhad Imambakiev, C4D specialist, UNICEF HQ, Geneva, Switzerland
Adinda Silitonga, Communication specialist, UNICEF, Jakarta, Indonesia

US-CDC

Jane Soepardi, Senior CDC Immunization Staff, US-CDC, Jakarta, Indonesia

Fetty Wijayanti, VPD CDC Staff, US-CDC, Jakarta, Indonesia

WHO

Olivi Silalahi, National Professional officer, Polio eradication, WHO, Jakarta, Indonesia
Fina Tams, National Professional officer, Immunization, WHO, Jakarta, Indonesia
Dewantara Riza, Data assistant, VPD, WHO, Jakarta, Indonesia
Winda Hutami, Data assistant, VPD, WHO, Jakarta, Indonesia
Vinod Bura, GPEI OB coordinator and WHO Team Lead Immunization, Jakarta, Indonesia
Sudhir Joshi, Technical officer, Polio endgame, WHO SEARO, New Delhi, India
Graham Tallis, Senior Advisor to DAI Coordinator, WHO HQ, Geneva, Switzerland
Zainul Abedin Khan, Technical officer, Polio Eradication, WHO HQ, Geneva, Switzerland (OBRA team leader)

Indonesia cVDPV1 Outbreak Response Assessment 6 – 24 April 2020 33

Annex 2: Performance Standards

Key performance indicators Status (Papua and Papua Barat)

Advocacy, communication and social
mobilization Adequately done in Papua Barat and low land
High level Advocacy meeting /activities of Papua province including several activities
in the highland districts of Papua Province.
Print and electronic media communication
C4D activities /community engagement
Routine Immunization
Strategies of RI for hard to reach populations Defaulter tracking and special outreach
and population under conflicts sessions conducted in priority areas
OPV and IPV routine coverage Both coverage have improved in 2019
Formal immunization performance /EPI External EPI review conducted in Feb 2020
review conducted
Supplementary Immunization activities
R0 + R1 + R2 implemented in the outbreak Implemented both in Papua and Papua Barat
zone 448 RCAs were conducted
SIA quality assessed by monitoring
Vaccination for travellers as per IHR Implemented
recommendations
Vaccine, cold chain logistics management
Adequacy of vaccine No vaccine shortage
Cold chain management No cold chain failure
Methods used for vaccine and logistics Various means of transportations were used
transportation to the remote and hard to including through special operations
reach areas
Surveillance
Enhanced surveillance Both provinces achieved NPAFP rate above
>3 /100,000 U15 children, however low stool
rate
Contact sampling was implemented
ES ad hoc sites expansion was done, sampling
was done until June 2019

Indonesia cVDPV1 Outbreak Response Assessment 6 – 24 April 2020 34

 End of report

Indonesia cVDPV1 Outbreak Response Assessment 6 – 24 April 2020 35

Correspondence: Zainul Abedin Khan, Technical Officer, Polio Eradication, WHO HQ, Geneva. khanzai@who.int

Report from the Seventeenth Meeting of the GCC, Geneva, Switzerland, 26-27 February 2018