Adolescent Immunization in

Developing Countries:
Obstacles and Opportunities

Hartono Gunardi
Department of Child Health
Faculty of Medicine University of Indonesia
 2

| Outline
Adolescent immunization schedules in developed
countries and developing countries

Obstacles related to optimal implementation of

vaccines

Identify opportunities to address these obstacles

2017 Adolescent (7-18 years old) recommended immunization
Developing countries adolescent immunization schedule
Vaccines : Tetanus toxoid / Tetanus diphtheria toxoid
Measles Rubella (campaign)
Influenzae
HPV (demonstration projects/NIP)
Meningococcal (certain countries)

J. Vandelaer, et al. Vaccine 33 (2015) 719–725.

WHO vaccine-preventable diseases: monitoring system. 2017 global summary
 Obstacles of implementation 5

Social marketing (Benefit & safety)

Population Web-based education
level Antivax & Halal issues

Enhance access
Practice level School based immunization
Health facility based

Patient level Vaccine hesitancy

Reminders
Modified from Dempsey AF, Zimet GD. Vaccine. 2015;33 Suppl 4:D106-13.
Berenstein HH. Pediatrics 2017;139(3):e20164186
 Obstacles of implementation 6

Social marketing (Benefit & safety)

Population Web-based education
level Antivax & Halal issues

Enhance access
Practice level School based immunization
Health facility based

Patient level Vaccine hesitancy

Reminders
Modified from Dempsey AF, Zimet GD. Vaccine. 2015;33 Suppl 4:D106-13.
Berenstein HH. Pediatrics 2017;139(3):e20164186
 Population 7

TV, Radio, Newspapers, Social

Social media : benefit & safety
marketing Ministry of Health & Professional
org

Web-based Created by MoH or professional

education organization or NGOs

Ministry of Health (HPV)

Antivax Fatwa Muslim Council
Professional organization
Modified from Dempsey AF, Zimet GD. Vaccine. 2015;33 Suppl 4:D106-13.
 9

The fatwa went on to add that "there is nothing wrong in

giving medicines to ward off the feared disease'. The fatwa
committee Saudi that quoted Ibn Baz added that the side
effects of vaccination can be overlooked 'when compared
to the great harm that is warded off, namely the diseases
that may kill or cause great harm to a person's health.'
 Indonesia Diphtheria Outbreak 2017

Pocket unimmunized children due to antivax &/ vaccine hesitancy

2017 : diphtheria cases 954  adolescent cases 239 (25%)

 Obstacles of implementation 11

Social marketing (benefit & safety)

Population Web-based education
level Antivax & Halal issues

Enhance access
Practice level School based immunization
Health facility based

Patient level Vaccine hesitancy

Reminders
Modified from Dempsey AF, Zimet GD. Vaccine. 2015;33 Suppl 4:D106-13.
Berenstein HH. Pediatrics 2017;139(3):e20164186
Practice level 12

Enhance More working hour for

access adolescents

Second opportunity for missed

School base first attempt
Combined with other health
intervention
Health facility Lowering number of adolescent
per vaccine vial
based Low access to immunization
Modified from Dempsey AF, Zimet GD. Vaccine. 2015 Nov
27;33 Suppl 4:D106-13.
record
 School based
• Delivery platform for vaccinating large numbers of
adolescents
• May not be successful due to suboptimal school
attendance rates  geographical location, socio-
economic status and gender
• Strategies such as mass immunization campaigns can be
used to complement school-based vaccination
programmes
Barry D. Increasing knowledge about HPV and the HPV vaccine amongst adolescents and adults through a schoolbased setting: a Capstone project. Doctor of Nursing
Practice (DNP) Capstone Projects. Paper 31. (http://scholarworks.umass.edu/nursing˙dnp˙capstone/31) 2013.
Clements C, et al. Vaccine 2004;22:2822-6.
 Potential adolescent school-based health interventions
Intervention Possible complimentary intervention
category
Screening Vision screening (if referral/glasses available & affordable)
/ psychosocial screening
Provision of Reproductive and sexual health education; HIV prevention,
information Life skill

Commodity delivery Anti-helminthic treatment / Insecticide treated bed nets

for malaria prevention / Iron and folic acid
supplementation
Vaccines Td booster / hepatitis B
N. Broutet, et al. Effective health interventions for adolescents that could be integrated with human papillomavirus vaccination programmes, J. Adolesc. Health 53 (2013) 6–13.
World Health Organization, Options for Linking Health Interventions for Adolescents with HPV Vaccination, WHO, 2014.
Impact of strategies on vaccination coverage
Vaccination requirement in schools

Das JK, et al. J Adolesc Health. 2016 Oct;59(4S):S40-S48

Coverage achievements across delivery experiences
of HPV vaccination in 45 LMIC

Coverage of a 2 or 3 dose regimen (only 10 experiences had coverage data on 2-dose

regimen)
Gallagher KE, et al. Lessons learnt from human papillomavirus (HPV) vaccination in 45 low-and-middle-income countries.
PLoS One. 2017 Jun 2;12(6):e0177773.
 Outreach Programmes

• To reach out-of-school
Mobile unit adolescents
• Geographical obstacles

Vaccine •Lowering number of

availability adolescent per vaccine vial
Out-of-school children and adolescent globally

Important to reduce immunization inequality

Unesco Institute for statistics. http://uis.unesco.org/en/news/263-million-children-and-youth-are-out-school
Mobile unit
 Immunization to reach out-of-school
adolescents
(1)Identify and quantify out-ofschool adolescents eligible
for HPV vaccination,
(2)Understand barriers to vaccine access and acceptance,
(3)Communicate effectively with communities and eligible
adolescent about vaccine,
(4)Increase vaccine access by creating opportunities for
follow-up, outreach, and integrated health services.
Bonner K, et al. Vaccine 2018;36:191-3.
 Obstacles of implementation 21

Social marketing (Benefit & safety)

Population Web-based education
level Antivax & Halal issues

Enhance access
Practice level School based immunization
Health facility based

Patient level Vaccine hesitancy

Reminders
Modified from Dempsey AF, Zimet GD. Vaccine. 2015;33 Suppl 4:D106-13.
Berenstein HH. Pediatrics 2017;139(3):e20164186
Patient level

Vaccine • Education by professional

organization/healthcare
hesitancy provider

• Text message
• Postcard
Reminders • Email
• Phone call

Modified from Dempsey AF, Zimet GD. Vaccine. 2015 Nov 27;33 Suppl 4:D106-13.
.
 Vaccine Hesitant

Definition : has significant

concerns about the risk of
vaccination
Strategy  establish rapport and trust, provide
informations and answer questions, use the
guiding style
Bernstein HH, Bocchini JA. Practical Approaches to Optimize Adolescent Immunization. Pediatrics Volume 139 , number 3. 2017.
Vaccination reminders
Impact of strategies on vaccination coverage

Das JK, et al. J Adolesc Health. 2016 Oct;59(4S):S40-S48

 Conclusion

High adolescent immunization coverage may be achieved by

taking the opportunities to overcome obstacles in
population, practice, and patient level through good
colaboration from all level of stakeholder.
Thank you