Indonesia's Progress Toward Measles and Rubella Elimination, 2013–2022

Indonesia cut reported measles by 95% and rubella by 89% between 2013 and 2021, but disruption to vaccination during the COVID-19 pandemic brought a large surge of both in 2022. In 2019 Indonesia and the other countries of the World Health Organization's South-East Asia Region adopted the goal of eliminating measles and rubella by 2023.

The programme

Indonesia's immunisation programme serves a birth cohort of about 4.4 million children a year.

• A first measles-containing vaccine dose (MCV1) at 9 months was introduced in 1982; a second (MCV2) for first-graders aged 7 in 2003, moved to 18–24 months in 2013 (first-graders still get a dose, recorded as the third).
• Rubella vaccine arrived in 2017, as two doses of a combined measles-rubella vaccine (MRCV) at 9 months and 18–24 months.
• The region's 2013 goal of eliminating measles and controlling rubella and congenital rubella syndrome (miscarriage, stillbirth or birth defects from rubella in pregnancy) by 2020 was widened in 2019 to eliminating both by 2023. Indonesia's 2021 National Strategic Plan for Measles-Rubella Elimination 2020–2024 aims at 95% or more coverage with both MRCV doses in every district, sensitive and timely surveillance, an accredited laboratory network covering all 38 provinces, rapid outbreak response, and stronger partnerships.

Vaccination

Figure 1: Reported measles cases, coverage with the first and second doses of measles-containing vaccine, and supplementary immunisation activities, Indonesia, 2013–2022. CDC.

• From 2013 to 2022, MCV1 coverage slipped from 87% to 84% and MCV2 from 76% to 67%. First-dose rubella coverage rose from 15% in 2017, when it was introduced, to 84% in 2022.
• The pandemic cut coverage: first-dose coverage fell from 88% in 2019 to 76% in 2020 and 72% in 2021, and second-dose from 71% to 60% and then 50%, as immunisation posts closed, movement was restricted and staff were moved to COVID-19 work.
• Campaigns: a 2016 follow-up measles campaign reached about 3.6 million children aged 9–59 months; in 2017–2018 the rubella introduction campaign reached about 58 million children and adolescents aged 9 months to under 15; and in 2022 National Children Immunization Month (Bulan Imunisasi Anak Nasional, BIAN) gave the combined vaccine to about 26 million children, an estimated 73% of the target, in 32 provinces. With other efforts, including seeking out unvaccinated children in remote and high-risk areas, coverage rebounded in 2022 to 84% (first dose) and 67% (second).

Disease and surveillance

Figure 2: Reported rubella cases, coverage with the first dose of rubella-containing vaccine, and supplementary immunisation activities, Indonesia, 2013–2022. CDC.

• Measles incidence fell from 33.2 cases per million in 2013 to a low of 1.4 in 2021, then jumped to 28.8 in 2022. In 2022, 88% of confirmed or linked patients had had no measles vaccine or an unknown history. Genotype D8 was found in 2018 and 2022, and B3 in 2022.
• Rubella incidence fell from 9.3 per million in 2013 to a low of 0.6 in 2020, then rose to 3.1 in 2022; 72% of patients were unvaccinated or of unknown status.
• Surveillance improved: WHO-accredited laboratories grew from four to seven by 2015; the rate of discarded non-measles, non-rubella cases, a sign of sensitivity, roughly tripled from 1.2 to 3.3 per 100,000 in 2018–2022; and investigations within 48 hours rose from 65% to 74%. But in 2022 only 43% of specimens were tested within 4 days of arriving at the lab, and 70% of results reached the programme within 4 days, which could delay action.
• Congenital rubella syndrome surveillance expanded from 13 hospitals in 2015 to 22 in 2022. Suspected cases rose from 275 in 2018 to 1,026 in 2022 as surveillance widened, but the confirmed share fell sharply, likely a real decline after rubella vaccine arrived.

What it means

Existing immunity gaps, widened by the pandemic, drove the 2022 surge, and an independent review in 2021 concluded Indonesia would not eliminate measles and rubella by 2023. The 2022 recovery brought coverage close to 2019 levels, but eliminating the diseases will need continued campaigns to close immunity gaps, especially in low-coverage districts, and better surveillance.

Limitations: administrative coverage may be inaccurate if doses or target populations are miscounted; surveillance likely undercounts cases; and few specimens were sequenced.

Sources

• Chacko S, Kamal M, Hastuti EB, et al. "Progress Toward Measles and Rubella Elimination — Indonesia, 2013–2022," MMWR (corrected; see the erratum). https://www.cdc.gov/mmwr/volumes/72/wr/mm7242a2.htm