Eliminating schistosomiasis in Indonesia is no easy feat. There are several challenges hindering progress, including lack of commitment from non-health ministries and local government offices, limited community-based activities, inadequate surveillance and diagnostic methods, and scarce access to medication for animal treatment. In addition, limited financial resources hampers programme implementation and sustainability.
Schistosomiasis is a significant public health issue deeply rooted in specific communities in Indonesia. This disease is caused by a parasitic worm called Schistosoma japonicum, which lives in freshwater snails. The worms are endemic to only 28 villages in Central Sulawesi, specifically in Poso (Bada and Napu highlands) and Sigi districts (Lindu highland). Indonesia is the last country in the South-East Asia Region working towards eliminating schistosomiasis as a public health problem. Since 2019, no human schistosomiasis case has been found in six endemic villages in Bada highland, marking approximately three years of no indigenous cases. However, in 2022, Lindu reported a total of 11 cases, while Napu had the majority of cases with 205 individuals affected.
From 2017 to 2019, annual mass drug administration (MDA) programmes were implemented in the affected villages, providing weight-adjusted, single-dose praziquantel medications free of charge, courtesy of WHO. MDA coverage rates varied during this period, with rates of 79% in 2017, 92% in 2018, and 88% in 2019. The implementation of MDA led to a significant decrease in schistosomiasis prevalence among humans, reducing it to 0.1% in 2019. However, in 2021 and 2022, prevalence rates started to rise, reaching 1.45%. This increase was attributed to the shift in public health resources and focus towards the COVID-19 pandemic.
After conducting the last schistosomiasis monitoring mission in 2017, Indonesia organized a comprehensive joint review from 2 to 8 May 2023 in Central Sulawesi Province. It involved international and national experts, as well as relevant stakeholders at both national and subnational levels. This review encompassed various aspects of schistosomiasis control and elimination, including epidemiology and surveillance, health systems and service delivery, vector control, behaviour change communication, veterinary public health, and water, sanitation and hygiene (WASH). The review identified the programme's strengths and weaknesses and provided recommendations to enhance its effectiveness and guide its strategic direction towards achieving the goal of schistosomiasis elimination.
Warning sign near the foci area of schistosomiasis host snails in Puroo Village, Lindu Highland, Sigi District. It raises awareness about the disease and how to prevent its spread. Credits: WHO/Ajib Diptyanusa
The review found that the Ministry of Health (MoH) has shown strong commitment to eliminating schistosomiasis through implementation of the 2018 National Schistosomiasis Elimination Roadmap. Collaborating with various stakeholders and utilizing technical expertise, the MoH has successfully allocated resources and maintained low infection rates through MDA and snail control. However, challenges persist, including the lack of engagement from other sectors, misaligned priorities, limited knowledge and tools for animal interventions, and the absence of accurate diagnostic tools. Additionally, the coverage of treatment and compliance among farming and migrating populations remains inadequate. To address these issues, it is recommended to champion the elimination of schistosomiasis by advocating for inter-sectoral collaboration, allocating sufficient resources, conducting mass drug administration for both humans and animals, monitoring and modifying snail habitats, and ensuring sustained support for community engagement programmes.
“Eliminating schistosomiasis in Central Sulawesi demands a collaborative effort across various sectors, including animal health, agriculture, infrastructure, and human behaviour. Only through such multisectoral collaboration can we achieve the goal of eliminating schistosomiasis in the region,” said Ma’mun Amir, Deputy Governor of Central Sulawesi.
Meanwhile, according to Dr Aya Yajima, Regional Adviser for Neglected Tropical Diseases of WHO Regional Office for South-East Asia, “Indonesia will be the second country in the world after Japan to declare schistosomiasis elimination. It will also mark schistosomiasis elimination in the entire WHO South-East Asia Region.”
Dr Yajima added that the elimination will significantly contribute to the achievement of Sustainable Development Goal 3, which focuses on ensuring healthy lives and promoting well-being for all. This includes combating and preventing the spread of communicable diseases by 2030.
The assessment team of Joint Schistosomiasis Programme Review Mission with local stakeholders. Credit: WHO/Ajib Diptyanusa
This review mission is an essential step towards achieving schistosomiasis elimination in Indonesia by 2029, one year earlier than the 2030 target set by WHO South-East Asia Region. By addressing the challenges and implementing the recommended measures, Indonesia is moving closer to this goal.
Written by Dr Ajib Diptyanusa, National Consultant for Malaria, and Achmad Naufal Azhari, National Professional Officer for Neglected Tropical Diseases, WHO Indonesia