FILE NAME : LA_Indonesia_22_2019.02.

01

DURATION : 0:44:39

Q : Question

A : Prof. Herini

T: Alright, thank you Prof. Herini, for the first time, may I ask for your demographic
profile Prof? I mean how old are you?

J: Oh, sure, do you ask for my age or my date of birth? I'm 60 years old. Yes.

Q: And for now your position in RSA or in FKKMK is as?

A: Here in RSA as director of medical and nursing services

Q: Then what about in FKKMK?

A: In FKKMK, I am a professor in department of pediatrics, especially pediatric

neurology division.

Q: And your position in the professional organization?

A: It's not an organization, that’s just ... I am as the chairman of the expert committee,
chairman of the measles elimination expert committee, measles elimination slash
Rubella control and CRS. CRS is Congenital Rubella Syndrome.

Q: Is this national, Mam?

J: It’s National. Yes, I often had a meeting with the Ministry of Health and WHO too.

Q: Next we wwant to know your experience in a profound polio eradication program

that has been going on until now, especially what happen during the implementation,
what activities that counted as successful or not successful, then if there are any
challenges, and also how to resolve these problems. for the first time, can you please
explain, doc, uhm.. sorry, I mean prof, about how did you get involved at the first
place?

A: I kind of forgot actually, but yes, obviously I was involved after I graduated from
here, there are many pediatrician who were involved. I graduated in 1997, but I don’t
exactly remember what year, uhm.. whether it was 2000s or something I became a
member of the..uhm.. AFP team, the AFP surveillance team in DIY. Then, a couple
of two or three times, I ..uhm., this team was actually has been established before the
the outbreak occurs in Cidahu. Then in 2005 the outbreak on Cidahu happened and
then after that I was asked by the Ministry of Health to follow the…uhm..what is it
called.. we were joined the international-national team which goes to the field. I
joined the international-national for about…if I did not forget was… one or three
times, but once I accompanied it to become an international national team, we both
jumped in. One international, whether from the CDC either from WHO members, we
accompanied them. So there were me as national team, and one of them as the
international teams. I was in charged in Lampung at that time, then in Jakarta. One
task might be around 10 days if I’m not mistaken. Within 10 days in Lampung for
example, we..uhm.. went to the health office (Dinas Kesehatan), then to the hospital
where AFP surveillance take place. Then go to the district or city health office, then
go to the puskesmas, from the puskesmas continued to the posyandu. Yes, we were
trained to take part some time after that we could jumped in, go to the field, the main
function was first, as the translator. Because they go straight to the field. I get a lot of
knowledge actually by following that like about how we do the searching, like..ukm..
what does it called…, oh, sorry, is it okay?

Q: uhm..ok, I will pause first

J: we pause it first, ok? The problem is in our (unclear) hello ...

(answering phone call)

So, yes, until that time, I joined in Jakarta and in Lampung. I got a lot of things to
learn, like… how was the international personnel doing…uhm..what is it.. the
searching, for example, oh.. they did that.. and do that.. like they actually take a good
look onour surveillans, does it good or bad, or how can we ‘missed’ the case, and so
on. This ‘missing’ could be like… uhm.. I will call you Ms Lutfi, alright.. ok, like
Ms lutfi has also interviewed a lot too, so you might has know about this thing too.
So I remembered that time at Cidahu, there are many people from RSCM who came
down too, we were wonder about Cidahu where it was not a very remote area, but
why did the immunization coverage were bad?, so when there once a people from
outside who had polio, the disease was quickly spreading to the child and many got
affected because there is no defense system. As if we are compared, it’s like a country
attacked by an enemy from outside and we are not ready, we lack of defense hence it
is so easy at that time for the virus spreading quickly, I don't know exactly how many
provinces, but quite a lot of provinces were affected. DIY, at that time we were afraid
to get affected but it didn’t. DIY did not effected, it’s shown that our defense is quite
strong, even though DIY is a tourist city, a student city where many people come
from local and international, but because our defense is strong enough so the outbreak
wasn’t happened here. That actually could shows how the benefits of immunization
were so great.

Then we also often discuss with the neurologist where neurologist of UKK directly
go to Cidahu, where the house of the citizens, the health center (puskesmas), were
located on side of the highway and were not a difficult place to reach but why the
immunization coverage is not good. This thing was often discussed later after this
polio in Indonesia suffered by around 350 people. So if there was one child affected,
there will be…uhm.. some people were infected too, I forgot whether it is 100 or
1000. So if there was one child is paralyzed, those children infected around him were
100 or is there anyone see this too? 100 or 1000 I forgot. So if there is one child
paralyzed, the other may be affected but not a heavy manifestation. Maybe he just
catch a cold, fever, or shown no symptoms at all. but it passed until 1000 or 100.. I
forget between those two numbers. Well it was last circulated on 2007 in Aceh, the
last stop was that. After 2007 were gone, I forgot, the PIN might be… Ms. Lutfi
might to know what pin it was after that. After that, the Indonesian, off the record,
may still be ‘confused’, maybe they don't have money and so on, so the response is
not fast, but the outsiders is the one who indeed feeling ‘nervous’, what if like this or
that, become a neighboring country, where CDC, WHO, they are the one who
actually ‘nervous’of how this big Indonesia got an outbreaks, less action, and so
finally there was an international national joint to really look down to the field.

About the story of looking down, I got a great thing about how to do good
surveillance, or not surveillance, but monitoring and evaluation and I learned
monitoring a lot there. So for example, because I was also work in puskesmas for
about 10 years, almost 10 years from year 84s to 92-93, My school was at
Gondomanan health center (Puskesmas) and Mergangsan health center so I knew
enough to go to the community on immunization issues, about how to go to
Posyandu, discuss with the community…, so I was invited to attend it, I was happy
too, even though I had to leave everything for like 10 days…or 2 weeks if I was not
mistaken, but I got a lot of very great experience from this, like…they tracked it
down sooo well, like going down to the hospital, we didn't just ask if there were cases
of paralysis which were reported or not, but we borrowed register book, so we would
like to see registers for a year, for example, and we open registers one by one, now I
apply here. because I am as the chairman of the expert committee and I also doing the
supervision

Q: and this one here, ma'am, MR

A: The MR, Maesles Rubella, is actually similar because we want to eliminate it in

2020. I have a lot of experience from there, isn’t it, by being invited by this
international people. They asked me to open the register book, and we see, for
example, if AFP, then we have to see if there are reports that there are patients who
admitted with paralyzed, or there are patients who do not move, or cannot move the
extremities, are they reported it or not, for example, there may 5 cases which can be
reported, but in reality they did not report at all. So, that it was to prove that the
health office of province, or district should be done lije that too when they are going
down to he field, where they aren’t usually done that, such as they didn’t take a really
good look when they go to the hospital, searching a valid data in hospital or
puskesmas, are they really reporting it or not.. that was all our weakness. And then
number two…

Q: Is this the HRR, Prof?

A: yes, yes it was the HRR, Hospital Record Review, HRR then came to the
puskesmas, hence, I asked then, is there anyone who have been trained for
surveillance. Then they pointed out the doctor. Oh, Mr. A, for example, we asked him
to move forward, we asked him, did you has been trained in surveillance and had
joined surveillance X, or Y or Z already? After that what do you do? Is there any
socialization? That's it. then maybe they will answer it with some yes and some no.
We often did this, including me, which also weak, I once joined a workshop before,
sometimes we are less aware or maybe too busy, forgetting that we have to spread the
knowledge to others. Then I asked him , ‘now you try, what if I am your friend now
and you told me or give me socialization about what you got' that was a real practice.
That's a good thing, like…Oh yeah, this reminding me first that I have to socialize…
oh yeah I have to convey this to others,… something like that. Then He showed us
what was he taught first, well, it was the thing I didn't know before, like. I know how
but the implementation wasn't like that. So now I know, including seeing vaccines.
Seeing the vaccine, it turns out that many expired vaccine that were still stored in the
refrigerator, so they were immediately removed
Q: So, that was the quality of the vaccine…

A: Quality of the vaccine is…, so for example, if the coverage of the vaccine is good,
is it true that the quality of the vaccine is good? The quality of vaccines is seen from
our center too, in our cases, if it’s in health office (dinas kesehatan), we see where
they stored vaccines, how to monitor the temperature and so on. That’s what we see.
Then continued to the second level office, to the posyandu and so on. they really are
extraordinary, right? We really checked it deeply. We were spread out to 10-15
provinces, and we were divided into so many teams. Then after we finished, we had a
meeting with the Ministry of Health and others, we conveyed the results and the
conclusion at that time was the achievement value in Indonesia was still 4. Score of
4means red, red is bad. So Indonesia was “punished” to carry out a PIN. Even though
PIN is very expensive. Every PIN was cost 120 billion or so. Hence, we just delayed
it maybe because we don't have money, right?

Q: Sorry, Mam, this was happened in the year of?

A: Uhm… I forgot a little, it wasn’t clear, whether it’s around PIN 2010, 2008 or
2009. I remembered I was going to the field on 2005-2007. I remember exactly that
the first on Cidahu in 2005 then ended in Aceh on 2007. I remember that because
actually we already had 10 years without polio at that time. Because the last time was
on 1995 in East Java. then 10 years after, it present. If it was 2007, so it has been 12
years. Uhm..12 years, but also with out the record. Oh god I was anxious and really
stressed right now even though it's not that big, huh. And then…

T: The PIN, we asked to held the PIN, right prof?

A: Yes, PIN, there are two rounds of PIN if I’m not mistaken. I kind of forgot. But it
is true that with that PIN, when I came to Lampung who were having PIN that time,
the citizens are refusing it. Refusing, and ran into the forest. Then there is one group,
one group in Lampung that is almost inaccessible until the governor also intervenes,
where they say that there are ‘elder’ people there who has a large family and has
many children, this one group that refuse to get immunization. It was at Lampung at
that time, where the governor all intervened. And at that time, all the provincial health
offices in Jakarta were invited. So this is to show the bad value of Indonesian report,
so all provincial health offices are invited to realize it and there are something to be
done. Initially theMinistry of Health went to the President's office. I forget who the
president was. SBY, yes, if I'm not wrong.

T: It was 2007 and above, right, Prof

J: Yes, SBY. if I was not mistaken. At the time, SBY, initialy did not budge, he did
not have the funds, then just stay quiet. After that, it was only after Who and ministry
of health insisted, thenhe say okay. I don't know where the money come from, but
finally the PIN has been running for two rounds if I’m not wrong. Well that's the
story about PIN. Then the quotation marks “improved”, was the surveillance. AFP
surveillance was targeted at children under 15 years old, suspect AFP. The experience
for surveillance is also such a great experience for me. There are many things that can
be told because at that time it is not easy for people to report the AFP because it is
fearful that, for example, if there is an AFP, so it must be polio, and it means that
immunization is bad, so there were many people who do not want to report it or fear
to report it. Well, we are continually socializing that this surveillance is not looking
for something as wrong or right, but what is important is that we report that there is a
case of paralysis but not count as polio case.

Now our hope is, we have to take one per one hundred thousand children, under the
age of 15 years. except for those who over 15 years that really leads to polio because
there was an outbreak when there was a 25 year old who got polio and was treated in
Jakarta. Then there are some children who are over the age and got affected because
they don't have immunity. Then in 2006 and 2009, oh yeah, I remembered that in
2005, then to 2006, I was traveling around in 2006 because yesterday I was cleaning
the house and I found a photo. This is 2006, I happened to be just a fad and sent to a
friend who worked in WHO Jakarta, "Mrs. Nip, this is a picture of yours, when we
were young". Just like that

Q: Ehm…bu Niprida?

A: Yes Niprida. There is a picture of her stay close with me. That means we have
long cooperation. Because I always go along with Mrs. Nip up to now. We got that
picture from 2006, then the next photo was 2009, if I’m not wrong. I have that photo,
how come I found it, even though I wanted to throw it away, but ah, I love it, I want
to keep it. Yes, so back in the surveillance, I did it in Yogyakarta, because I did not
join the AFP team at the center, I did not participate. Those who came along at that
time were just some people. Then after that surveillance in several regions. I often
giving lecture especially in DIY area, sometimes I was asked, at that time the expert
was actually Prof. Ismoe, Ismoedianto Surabaya. I once replaced him because he
couldn't giving lecture in Sorong, Papua. So all the pediatricians in Papua gathered,
then we share about this surveillance. I also got a very valuable experience because
such a remote access in Papua, there some many people stilI don't know what AFP
surveillance is, not all puskesmas have their chairman and if there any, not all of them
were doctors, many of them were nurses, and yes, they also afraid to report any cases.
But with socialization, there are some stories told that even to took the feces sample
we have to take a helicopter because the terrain was difficult but it was reported that
there were AFP surveillance cases so they had to rent helicopters, which, at that time,
were very expensive, it was 14 million or something. So there were a high price of
taking feces sample at that time.

Yes, but it shows that the effort was extraordinary even though we got to rent a
helicopter. Yes, it was my experience. All Papuan pediatricians were gathered. Then
another interesting case is in Central Java. In the banjarnegara there was the first case,
according to them it was actually reported by AFP. The Pediatrician were come from
UGM alumnee. At that time we were happy with the findings and tell the sub-district
PKK that we found the AFP case . Then when it was clarified with the pediatrician,
his said that this was not AFP because it was not acute, not flacid, this was the
spasticc case. Then we just like don’t believe it, like, really? We just got exciting, the
government itself will gave us reward if there are any AFP case findings..and… uhm,
sorry, I pause it a bit…

(Receiving phone call)

Q: WLl, back to the statement where in Central Java, if anyone found a case and get a
reward…

A: So after that they asked us because the pediatrician was a graduate of UGM, so we
consulted with those who came from UGM, at that time Prof. Nartini invite me to
look at Banjarnegara and we saw that when the children came out, and he was carried
by his mother, his legs looked so soft. But once we examine, the physiological
reflexes increace,so it does not flacid. So we conclude that it is not AFP. But after we
take a history taking , there is a history of trauma. AFP is actually what we reported if
it wasn't caused by trauma. It's just that sometimes we do not know whether the
trauma caused him to fall before, or the fall due to other weaknesses, such as trauma,
this is what really needs to be studied. But anyhow, we should still reported it while
clarifying that this is AFP case or not.

Well, yeah. The target was one per a hundred thousand. Then it was raised after that,
because of that case, there was an increase of two per a hundred thousand. Yes, so
now, especially for DIY, we increase is to three per a hundred thousand. Then what
what was the question? For now we just continue it, we routinely have a meeting
between Sardjito Hospital and the provincial health office. In neurology division we
have CRS surveillance, AFP surveillance, and Japanese Encephalitis surveillance so
we had a meeting to read, and discussing these three cases together. so it is not only
AFP because the funds are also limited, there is hardly AFP surveillance now. There
used to be fund for one patient, 25 thousand rupiah or something.. I forgot. It was
from the Ministry of Health. There used to be this fund.

Q: What is the difference from the WHO that has SO itself?

J: oh this…, actually it was established by the Ministry of Health but the support
came from WHO, at that time, SO who got a good big paid a large like they got 4 or 5
million a month, so they work hard and diligently. But when it’s stop, they keep
going down even though we, who were in the Sarjito area, we will still report it
regularly. In Sardjito there are quite a lot, but not only in DIY, whether fot the health
office, DIY is counted. If I were them, I will think nationally even though case will be
come from anywhere, it will be national scope, so suppose that the case was from
Central Java, DIY will call to Central Java, that here the AFP case is found. either
from banjarnegara either from kebumen, sometimes east java, cilacap, wonogiri, and
so on. It was almost fifty fifty for us in Sardjito avout the case might be from DIY
and from outside DIY. Now they were not fully controlled because there were no
funds, it was considered a routine activity, right? But for me at thebeginning, I also
not directly can see thatthis is AFP, or this is not AFP. No Iwasn’t that type at the
beginning. But now I already has. but, for others, sometimes we forget, there was
JE,but why we didn't report it? Yes, it is sometimes too late,. Moreover, other
hospitalshave no teaching hospital. Even though we already giving lecture in S1
degree, for Erapo…

Q: Oh S1 degree are include prof?

A: Yes, already.

Q: Does this fill out.., uhm,…what does it say that giving Erapo program is in the
curriculum?

A: Yes, it id. It was me or Mrs. Nartini who giving the lecture

Q: Has it been a long time ago at S1 degree? Has it been a long time or just recently?

A: It have been in the block system for a long time, included in S1 program, but I did
not remember when, but it was quite a long time it was in the S1 program

Q: Yesterday other participants also mentioned that in erapo and other programs it
could also be included in the curriculum because the new doctor didn't understand
such AFP surveillance programs

A: Yes, yes, UGM included it. But you haven't got it yet?

Q: I wasn’t from UGM, prof, I am UNS alumnee

A: oh well, it seems that UGM is the only one who included the program, as far I
know. But I also often convey to WHO if they supervise here, so we put it in the
program, in S1degree, uhm.. in block….uhm.

Q: On a pediatric blog?

H: yes pediatric. This was in other block before pediatric, but I forgot it. Neurology
used to be one topics, but now it's in pediatric, isn’t it? Prof Nartini is the only one
who teach. But if she can't, I do. I happened to get subject of meningitis or febrile
seizures. In residency we also teach them too. And then… this program was still
running until now, it has been running as a routine.

Q: What about the way for AFP surveillance compared to now and then?

A: Actually, if we are in Sardjito, is still the same, especially now we had this WA
group, it became more active, back then, we had to contact one by one, now in WA
the group, we can just posted it there. And when I had to visit with our resident, and
report this and that.. oh we can posted it real time, and we survey it. The resident who
doing the survey included to the from, the one who has done that were expelled from
group. SO we keep it updated. WE could know if there any case, the resident has
shared it here, like this, for example (showing WA) we have WA for CRS. Here we
have DIY AFP CRS surveillance. And so on.

Q: Does that mean hospitals, and puskesmas are all included?

H: oh no, no, this is just us, sarjito, the health office, and other related ones. No
Puskesmas included, this is for case who were found at Sardjito, whe most case are
found in here.

T: So is there Mr. Andri too? He is a Surveyor

J: Yes, There is. Mr.Andri, Mrs. Amalia BPTK are joining JE, Japanese Encephalitis.
For example, "are the Specimen of children in the name of riska with SP ready?", So
we can discuss. "Oh, I just took the stool one, it already is". Then on Sunday, when I
was on a week's visit, "how about if there is no pot to put the poo? the pot is taken by
Mbak Puri". We can share here, and Mr. Andri can add, "you can use the usual pot,
Mam." So it was all real time. we are getiing better with this. In the past, we had to
contact here and there. This is what the WA group for. if I supervise it to another
place, I say and example like, in CRS why we achieve the highest target in DIY
compared to other sentinel provinces, like what I see yesterday when I supervised on
medan, they only reported one case in a year. Then, CRS in …uhm, not Bringhadi
'foundation, the other one, uhm.. yes, adam malik, thay report one. It was in
sSUrabaya. A supervision is should be like that, so with this, the surveillance is
running well until now. Is there more?

Q: What is the biggest obstacle faced by prof during erapo?

A: If the obstacle is that,.. just like what I told you before, And then we also often
asked by the province to socialize to general practitioners, to midwives, nurses. Now,
the one who got most called is Mr. Agung, because I already enough. dr. Agung are
often asked by the province to go around for AFP, JE, for the socializations. That's a
routine. So with minimal budget, we still had socialization for once or twice a year.
Q: did you have training too, prof?

A: Yes, the socialization invited whether general practitioner or others. The problem
is when we have no socialization, they will forget. There may be cases that are not
reported. It was the main obstacle. There are no other big problem. I ever heard one
of complained about the province, when I was left going somewhere, they said,
"Wow, if Herini wasn’t here, there is no AFP report,". For example, when I went to
Japan for 3 months, or when I studied at RSCM for 6 months. I can’t really involved
with this surveillance, right? So I mean, wherever the hospital is, as long as the doctor
is aware of that, it won’t be a problem. The problem is we did not used to think
about… oh this is AFP case or not, it is not always automatic. I used to often missed,
like, oh the feces is not adequate, oh I forgot, and another obstacle, even though it is
in Sarjito, for example in Hematoonchology cases, or other divisions in PICU, the
report is somewhat delayed. Ut was the weakness of the division. The patient itself
eventuallu admitted when they already flaccid for a month, and so the feces is not
already valid. It was really difficult, to set the community more aware. Or the fist
person who acknowledge the case is not aware that it should be a reported case. It
was some of obstacle about why AFP case is not fully targeted. In national scope, I
think this is also the same problems.

Q: Then about the learning process, what matters in this erapo that we can apply to
other programs according to prof. Herini?

A: Yes, it is clearly that it should be applied in this MR. For elimination of Maesles
Rubella is the same as this journey. The trip was the same, Maesles Rubella, and
polio had gone too many rough ways, delayed, it should have been certified in 2008,
if I’m not wrong.

Q: uhm.. it was targeted in 2010

A: It used to be 2008, buat because of Cidahu outbreak, dit delayed to 2010, then it
continued to delayed until 2014 if I am not mistaken

Q: In 2014, which I know is that we get free, free certifivcate of polio, but it haven't
yet implemented right, prof?

A: not yet, it's still long way to eradicate

Q: There were a case too in Papua nugini

A: Yes but that only one, and actually it was VDVP, not polio. But VDVP, and their
children have not been immunized at all. We used to think that from Papua Nugini.
But the thing is, we can take a lesson to applied it to another programs

Q: Which can be applied prof? In What subject?

A: yea..about the process of the trip, the surveillance, so we are used to do such AFP
surveillance, so we can go on to another surveillance like Maesles Rubella. What is
clear is that we are familiar with surveillance. For those who don’t know, we often
think that.. this case isn’t measles, it should not be reported, and so on,. This knid of
mindset should be corrected. Surveillance should be spreadwide and done to prove
that oh, it’s a measles case, or, oh, this is not the case. Sometimes, this kind of insight
is still lacking. Like, how come this case should get surveillance. We need to
understand it. It takes a long journey to understand

Q: the concept of surveillance itself, right?

A: yes the concept of surveillance

Q: The last one is, After in SEARO got free polio status in 2014, what is the
difference between before they got the status?

A: it actually need more hard work. It works to maintain that free status, it mean
strong surveillance, that's just the difference, we have to strengthen it and increase
immunization coverage, that’s the only thing we can do. Just like the current MR, I
was the one reporting the results, and Prof. Ismoe is the one who reports the results of
both immunization coverage and AFP surveillance, while when reporting to SEARO,
my coverage of MR immunization and rubella measles surveillance and CRS are still
need a lot of work. So last year I reported in New Delhi, previously Sri Lanka, this
year I still didn't know yet, but yesterday there was already an invitation to discuss
this MR in New Delhi to change about how it might be, because Indonesia is still
quite heavy with “the foult of measles campaign” in outside Java. In Java, we have
already 100% coverage,while outside of Java, only about 60 to 70, it was 69% even if
we map it, a very low area is like Aceh, North Sumatra, Riau. Aceh is not up to 10%
of the campaign coverage. This is so terrible, huh. Yes, we keep having a meeting to
one another, and make new strategies and so on. Well, this is actually the same
process with this erapo, the erapo is quite heavy. Prof. Ismoe always tells us that it is
hard for us if P2 emerge, while there is almost no vaccine for P2. So if P2 appears,
the PIN must be P2. Where do we look for that ….

Q: The biofarma isn't out yet, prof?

A: The biofarma was asked to save it, but I didn't know it was finally a deal or not, I
didn't follow it up

Q: The mOPV prof, the single one?

J: Yes, single, IPV has started already. IPV and DIY have started, but to save it is
stated that there is none, I do not know, first it requires the terms of the conditions, it
is not yet deal because the Ministry of Health has not obtained it.

Q: I overlooked this prof, about the refusal of rejection. what strategies have been
taken?

A: what rejection?
Q: from immunization, polio. What kind of strategy that you used?

A: About polio..now is.. oh, wait, it is clear not in DIY, It is in some provinces that
still argued about haram-halal problems which is illegal, and so on, it's always an
issue, this is also the problem in Lampung. But I don't know that now are they have
succeeded or not, I did not follow it up because I did not participate in ITAGI, but
one thing for sure is that the coverage in DIY is good already. It is uncear for other
province, I didn’t know. There still chance for a hole bag if there any outbreakanother
day.

Q: DIY is indeed special, right, Prof.

A: Yes, DIY has not too many people, the level of education is also good, people can
easily be educated, that’s why DIYis firstly moved to IPV. People used to prefer
polio drop because they prefer not to be injected, but if we educate more benefits by
IPV because it is more complete and fulfilled, well people will convert to IPV and
they wouldn’t take it as a problem.. so for the population it doesn't matter either. yes,
have I answered everything?

Q: Yes, Prof. Well, if there is something that I want to clarify, may I email or call
you?

J: Yes, please, my pleasure.