By Faraz Honarvar, University of Toronto
Haemophilus influenzae type b (Hib) disease is a dangerous communicable disease that has the potential to propagate many life-threatening illnesses such as meningitis and pneumonia, mainly amongst children 3 months to 3 years of age. The disease has been a significant threat to infants in Indonesia for many years, but with new vaccination programs being implemented and significant collaboration between organizations such as the Indonesian government, UNICEF, The GAVI and the WHO, promising results have been achieved. This paper focuses on challenges Indonesia – as the fourth largest populated country in the world – has had in attempting to mitigate the effects of Hib and also provides an in depth explanation of the newly implemented plans to provide vaccines for all infants in the country.
The disease causes, transmission, and symptoms
Haemophilus influenzae type b (Hib) disease is one of the main causes of meningitis, pneumonia, epiglottitis, arthritis, and blood stream infections and most often targets children 3 months to 3 years of age.1 Hib is considered a communicable disease and is usually transmitted through the mucus of an infected person’s mouth or nose. There is a possibility for an individual to be a carrier and a threat to surrounding individuals without manifesting any signs of the disease.1
The main symptom of the Hib disease is fever.1 If the disease develops into meningitis, symptoms include stiff neck, vomiting, and headache. If it causes pneumonia, symptoms include rapid breathing and mucus-containing coughs. If it causes epiglottitis, the symptoms are sore throats and noisy breathing.1
Burden of disease
In a study conducted in 1998 in Lombok, Indonesia, scientists were able to document the burden of Hib disease for the first time in Indonesian history.2 Before this study, there was no data suggesting the burden of Hib disease in the fourth most populated country in the world. Scientists discovered that more than 4.6% of the population carried the disease and one-third to one-fifth of the natal deaths, occurring at a prevalence of 90 in 100,000 infants, were associated with pneumonia caused by Hib disease.2 Less than a decade later, another study estimated that more than 84,100 infants develop Hib infection and 7,846 die each year. The burden of disease was also suggested to be approximately 300,000 disability-adjusted life years (DALYs).3 This clearly highlights the severe consequences of Hib disease in Indonesia and the urgent need for an effective vaccination to mitigate the disease’s pernicious effects.
The Indonesian government has been performing Hib vaccination in Lombok since 2000.4 The government implemented the vaccination program against Hib disease and analyzed the efficacy of this vaccination on two different types of pneumonia: the clinical pneumonia and pneumonia with radiographic consolidation. The results indicated a 3.8% prevention of clinical pneumonia due to Hib disease; however there was no sign of prevention of pneumonia with radiographic consolidation. The inefficacy of the latter attempted prevention in Indonesia was more evident when compared to that of other countries such as the Gambia, Bangladesh, or Chile, which all had significant success in preventing pneumonia with radiographic consolidation. 4 Taking those results into account, the Indonesian government realized a more effective vaccination method needed to be implemented.
The Indonesian government’s plan in collaboration with The Global Alliance for Vaccines and Immunizations (GAVI), The United Nations Children’s Fund (UNICEF), and the World Health Organization (WHO) to mitigate the effects of Hib disease on the country started in 2012 when pentavalent vaccinations protecting against diphtheria-tetanus-pertussis (DTP), hepatitis B and Hib were licensed and bought from the Indonesian manufacturer Bio Farma.5 As an Indonesian company, Bio Farma was considered an attractive investment for the government due to the money spent strengthening the country’s economy instead of leaving the country. By the end of 2013 the government hoped to have vaccinated 20% of the infant population located in the West Java, Bali, West Nusa Tenggara and DIY provinces. By the end of 2014, it is predicted that more than half the infant population in Java, South Sulawesi, Bangka, Belitung, North and South Sumatera, Jumbi and Lampung will be vaccinated. Finally, if everything is conducted as planned, by the end of 2015 the government hopes to have vaccinated 100% of the infant population.6 The vaccination program is gradually covering the large Indonesian infant population spread across the country’s many islands.6
Without vaccination, every year more than US $9.06 million is spent treating Hib disease worldwide.3 On the other hand, the UNICEF pricing for the cost of implementing the Hib vaccination program alongside the existing DTP-Hep B vaccination and Hib disease treatment is around US $28.5 million. This costs more than three times the cost associated with treating Hib disease without vaccination. However, The GAVI’s pricing for the cost of Hib vaccination program and Hib disease treatment is only $5.39 million, which is significantly cheaper than the UNICEF pricing and would save more than US $3.7 million instead of tripling the costs.3 The latter pricing significantly strengthens the practicality of implementing the five-in-one vaccination plan.
This plan is predicted to avert approximately 76,700 cases of infection, 7,150 deaths and 273,000 DALYs. These numbers were calculated by subtracting the predicted cases of infection (7460) and DALYs (26600) after the national availability of five-in-one vaccine (with herd immunity taken into account) from the total infants expected to have Hib infection in one year without vaccination (84100 cases of infection with a burden of 300000 DALYs).3
The prevention of Hib disease in Indonesia, despite proving to be a very difficult and laborious task due to the high population, sets yet another example for developing countries that through global cooperation great results can be achieved and many lives can be saved. Patience and careful planning also play major roles in achieving this goal. If performed properly, the five-in-one vaccination has been shown to be an incredibly effective method for reducing DALYs and mortality in Indonesia and with this model can now be implemented in other developing countries facing the same problem.
- Haemophilus Influenzae Type B (Hib) Disease. 2013. http://healthvermont.gov/prevent/hib_disease/hibdisease.aspx.
- Gessner, B. et al. 1998. A population-based survey of Haemophilus influenzae type b nasopharyngeal carriage prevalence in Lombok Island, Indonesia. Pediatric Infectious Disease Journal 17, S179-S182
- Broughton, E.I. 2007. Economic evaluation of Haemophilus influenzae type B vaccination in Indonesia: a cost-effectiveness analysis. J Public Health 29, 441-448.
- Watt, J.P. et al. 2009. Burden of disease caused by Haemophilus influenzae type b in children younger than 5 years: global estimates. The Lancet 374, 903-911.
- Indonesia introduces five-in-one vaccine for children. 2013. http://www.who.int/immunization/newsroom/indonesia_five_in_one_20130822/en/index.html
- Comprehensive multi year plan national immunization program Indonesia 2010-2014. 2010. http://www.gavialliance.org/country/indonesia/documents/cmyps/comprehensive-multi-year-plan-for–2010-2014/