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DOUBLE BURDEN OF COVID19 PANDEMIC TO PREGNANT WOMAN EARLY DETECTION WITH HBSAG IN INDONESIA
1Doni Lasut, 2Asep Hermawan
1,2Research Center of Public Health and Nutrition, National Research and Innovation Agency of Indonesia B.J.
Habibie Building, M.H. Thamrin Road No. 8, Central Jakarta, 10340 Email: doni.lasut@brin.go.id
ABSTRAK
Pandemi COVID-19 telah secara menyeluruh mempengaruhi penggunaan layanan kesehatan dasar di seluruh dunia, dengan gangguan di beberapa negara dimulai pada tahap awal keadaan darurat pada Maret 2020. Gangguan ini telah terjadi pada sisi ketersediaan dan kebutuhan perawatan kesehatan, dan sering kali dikaitkan dengan kekurangan sumber daya untuk memberikan perawatan dan menurunkan jumlah pasien yang terkait dengan pembatasan mobilitas dan ketakutan tertular COVID-19 di fasilitas.
Tujuan tulisan ini, bandingkan tes HBsAg sebelum dan sesudah pandemi COVID-19 pada deteksi dini ibu hamil dengan HBsAg untuk mencapai target minimal 80% pada tahun 2020. Metode menggunakan pendekatan pemodelan perhitungan matematika sederhana yang dikembangkan untuk memprediksi penggunaan layanan kesehatan hingga selama pandemi menggunakan data sistem informasi hepatitis yang dikumpulkan secara rutin (SIHEPI). Hasil penelitian menunjukkan HBsAg proporsi reaktif total ibu hamil di setiap provinsi sekitar 2,1% pada 47,91% ibu hamil di Indonesia, tertinggi di provinsi Indonesia timur (NTT, Papua dan Papua Barat). Dengan perhitungan pada 80% wanita hamil yang ditargetkan pada tahun 2020, proporsi reaktif diprediksi sekitar 4,4% di Indonesia, Papua Barat menjadi Provinsi tertinggi dengan 21,38%, Papua sekitar 12,63% dan NTT sekitar 11,31%. Kesimpulan perhitungan perbandingan senilai matematika jika cakupan mencapai 80% maka rata-rata nasional didapatkan sekitar 4,4%. Penundaan deteksi dini pada ibu hamil sebelum dan sesudah pandemi covid19 menjadi beban ganda di indonesia. Fenomena ini menjadi faktor risiko tinggi penularan dari bu ke anak.
Indonesia perlu tindakan serius untuk mencapai eliminasi Hepatitis B pada tahun 2030.
Kata Kunci : Hepatitis B, HBsAg, Covid19, Beban, Ibu Hamil
ABSTRACT
The COVID-19 pandemic has heterogeneously affected the use of essential health services worldwide, with disruptions in some countries beginning in the early stages of the emergency in March 2020. These disruptions have occurred on both the supply and demand sides of healthcare and have often been related to resource shortages to provide care and lower patient turnout associated with mobility restrictions and fear of contracting COVID-19 at facilities. The goal of this paper, compare the HBsAg test before and after the COVID-19 pandemic to a pregnant woman's early detection with HBsAg to achieve the target of at least 80% in 2020. Method using a simple mathematical calculation modeling approach developed to predict health service use until the pandemic using routinely collected health information systems data (SIHEPI). Results show HBsAg reactive Proportion of total pregnant women in each Province is about 2,1% on 47,91% of pregnant women in Indonesia, highest in eastern Indonesia province (NTT, Papua, and West Papua). With a calculation of 80% targeted a pregnant woman in 2020, reactive Proportion predicted about 4,4% in Indonesia, West Papua becomes the highest Province with 21,38%, Papua about 12,63%, and NTT about 11,31%. In conclusion, refered to comparison of mathematical calculation approach from 80% targeted average become 4,4% reactive HBsAg test. Delaying early detection in pregnant women before and after the covid19 pandemic becomes a double burden in Indonesia. These phenomena become a high-risk factor for maternal-to- child transmission. Indonesia needs serious action to achieve Hepatitis B elimination in 2030.
Keywords: Hepatitis B, HBsAg, Covid19, Burden, Pregnant Woman.
237 INTRODUCTION
Chronic hepatitis B (HBV) infection is a global public health problem affecting approximately 240 million people. The most significant burden of the disease is Asians, who experience infection from perinatal or horizontal transmission during the first five years of life2,3. Cambodia is considered highly endemic for chronic HBV infection, with estimates by the World Health Organization (WHO) Regional Office for the Western Pacific of 9% hepatitis B surface antigen (HBsAg) seroprevalence in the general population, ranging from 7.7%-13% in various subpopulations. Adults based on convenience sample data(Mandel et al., 2022)(Ol et al., 2009).
The Action Plan (2016-2021) for addressing viral Hepatitis in the WHO South-East Asia Region has been developed in consultation with the Member States, community stakeholders, development partners, academia, and professional societies. Drawing upon the Global Health Sector Strategy for Viral Hepatitis (2016–2021) and using the framework of universal health coverage to ensure that no one is left behind, the Action Plan provides a roadmap for priority areas of focus and interventions within the health and related sectors that are needed at the national level to mount an effective and efficient response to prevention, diagnosis, management and care of viral hepatitis(Organization, 2017).
The Indonesian Ministry of Health, to deal with Hepatitis, issued a policy with the Minister of Health Regulation No. 53 of 2015. Thus, the targets mandated in this case, one of which is the early detection of hepatitis B risk groups, are contained and further translated in the 2014 - 2019 Ministry of Health strategic plan. (Kemenkes, 2015).
Because their same goal from other infectious diseases such as HIV, Syphilis, and Hepatitis B Indonesia MoH determined to solve together called with triple elimination are regular by Minister of Health Regulation No. 22 of 2017 needs to be accelerated and concrete efforts to be able to get to the elimination of Hepatitis in 2023. Therefore, one way is to conduct an in-depth study that needs to be carried out continuously so as to produce operational recommendations and as needed(Kemenkes, 2017). But other side impacts of this implementation have become a new problem, especially hepatitis B early detection with HBsAg ran slowly that indicated 90 % covered can't be achieved. On the roadmap and strategy, MoH to accelerate it still met some problems until the early covid19 pandemic.
A study from the National Institute of Health and Research Development Indonesia ever try to give some recommendations. Because some aspects between there were mindset early detection with HBsAg in the phc didn't work as a strategy developed, inadequate cold chain, ignorance pregnant woman, prioritize HIV screening than Hep B and Syphilis, Reporting form was too wide and complex in individual reporting called Form75 because contains next stage that will do in a hospital, minimum socialization as big trouble to do triple elimination as one burden in this program(Doni Lasut, 2018).
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The Indonesia election in 2019 has influenced the main problems in the central strategy, which were originally planned to be non-priority (Oliver, 2006; Pagliccia and Pérez, 2012; Østebø, Cogburn and Mandani, 2018). This condition, coupled with the COVID-19 pandemic, which began to occur in early April 2020, caused delays in early detection efforts carried out in Indonesia, domestically and globally (Muzakki, 2020; Qodir et al., 2020; Ayuningtyas et al., 2021).
METHOD
This writing method is based on puskesmas surveillance data in each Province which is reported through the Hepatitis information system (Sihepi).Sihepi was online application from Ministry of Health as data input on pregnant woman scrinning test with HBsAg.
The data is processed with the target set by the Ministry of Health of 80%. However, due to the Covid 19 virus pandemic at the end of March, the achievement of targets varied. For the predictive analysis of reactive HBsAg seroprevalence obtained in each Province, it was carried out as a comparison of mathematical worth each province. Where(Raharjanti, Nusantara and Mulyati, 2016);
Y0/Y1 = X0/XI ……… (1)
X0 = Proportion of pregnant women who joined HBsAg test in 2020 province i
Y.O. = Proportion of reactive pregnant women who joined HBsAg test 2020 province -i
X1 = Estimated Proportion of pregnant women who joined HBsAg test if coverage 80% province -i Y.I. = Estimated Proportion of reactive pregnant women who joined HBsAg test if coverage 80%
province i
RESULTS AND DISCUSSION
The condition of early detection of pregnant women with hbsag tests in Indonesia has experienced obstacles to its achievement, from what is targeted in 2020. This is due to the readiness of each health facility in this case which does not fully have adequate resources in carrying out the program, especially the readiness of the necessary tools and materials where the need for large quantities still has to be imported and must be distributed by the center to the regions. This condition was aggravated in line with the COVID-19 pandemic in early April that hit Indonesia.
As a result, table 1 shows us there was some trouble in the early detection of pregnant women with HBsAg in Indonesia. Only 47,91% and 80% were targeted. Some provinces could achieve more than 50% of their pregnant woman in their Province. Of 34 provinces, only 15 provinces can achieve more than 50%, the others lower than it even though it is still lower than the target.
Following the strategy, normally, it must be 90% in 2020. Even though it has decreased related to the impact of covid19 pandemic to 80%, it still can not be achieved by 2020. The highest Province in North Kalimantan is about 76,40%, and the lowest Province is North Sumatera, at about 9,80%.
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Reactive HBsAg test results show lower Province not always lowest reactive HBsAg, NTT is the highest Province from 34,66% pregnant woman who joined about 4,9% reactive HBsAg test results, West Papua from 17,51% about 4,68% and Papua from 24,77% about 3,91%. DIY Province is the lowest Province with 44,45% pregnant women who joined about 0,69% of reactive HBsAg test results, followed by South Sumatera from 41,32% about 0,72%, and North Sumatera from 9,8% about 1,1%.
Then we assumed that each Province could achieve the target of about 80% of pregnant women who joined HBsAg test results using simple equation mathematics as a prediction. The Province with the highest prediction is West Papua, with about 21,38% reactive HBsAg test, followed by Papua at about 12,63% and NTT at about 11,31%, and on average, in Indonesia, about 4,4% predicted reactive HBsAg test results.
Table 1. HBsAg Test in Indonesia since 2017 and in 2020
No Provinsi Coverage
2017
Coverage 2020
Reactive 2020
Prediction in 80% Cov.
Projection of pregnant women
1 North Kalimantan 59.89 76.40 2.07 2.17 13,361
2 DKI Jakarta 58.12 58.98 1.39 1.89 179,462
3 Central Sulawesi 50.24 50.42 2.48 3.93 68,716
4 Kepulauan Riau 37.91 38.38 1.55 3.23 44,625
5 East Java 42.65 68.60 1.87 2.18 618,207
6 South Sulawesi 41.73 68.15 2.13 2.50 183,791
7 Gorontalo 40.04 56.49 3.27 4.63 26,283
8 Lampung 36.62 66.37 1.35 1.63 162,463
9 Jambi 32.32 48.62 1.25 2.06 71,970
10 Central Java 32.15 72.21 1.28 1.42 575,082
11 North Maluku 30.20 48.67 3.90 6.41 32,210
12 Aceh 29.76 65.98 1.01 1.22 126,085
13 South Kalimantan 29.54 54.66 2.14 3.13 87,583
14 East Kalimantan 24.91 55.93 1.92 2.75 82,512
15 NTB 24.34 59.08 3.00 4.06 112,725
16 Bangka Belitung 23.95 70.98 2.15 2.42 30,224
17 Bengkulu 23.20 38.98 1.78 3.65 40,609
18 NTT 22.77 34.66 4.90 11.31 154,663
19 South Sumatera 22.66 41.32 0.72 1.39 174,076
20 DIY 20.75 44.45 0.69 1.24 59,442
21 Bali 19.15 56.05 1.23 1.76 70,859
22 Maluku 17.25 39.87 1.85 3.71 49,283
23 Banten 16.35 52.20 1.53 2.34 261,628
24 West Java 13.13 48.24 1.25 2.07 955,411
25 West Sulawesi 13.04 47.92 2.20 3.67 36,337
26 West Sumatera 12.68 44.68 1.22 2.18 119,518
27 Southeast Sulawesi 11.94 29.95 3.46 9.24 69,018
28 Papua 11.94 24.77 3.91 12.63 78,487
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No Provinsi Coverage
2017
Coverage 2020
Reactive 2020
Prediction in 80% Cov.
Projection of pregnant women
29 Riau 11.32 26.36 1.51 4.58 170,854
30 North Sulawesi 9.77 18.68 1.54 6.60 44,546
31 West Kalimantan 7.01 41.76 2.41 4.62 109,316
32 West Papua 3.42 17.51 4.68 21.38 24,189
33 North Sumatera 2.58 9.80 1.10 8.98 329,118
34 Central Kalimantan 1.40 51.78 2.51 3.88 59,161
Indonesia 24.55 47.91 2.10 4.44 5,221,814
The calculation of pregnant women as dynamic data as an approach using projection from existing coverage in 2020 that varies in each Province. This calculation results in one approach to determining the projection if coverage is about 80%. The results show highest Province is West Papua 80% of pregnant women that joined the HBsAg test, about 21,38%, followed by Papua, from 80% to about 12,63%, and NTT, from 80% to about 11,31%.
Figure 1. Early Detection with HBsAg in 2017 and 2020 3,42
11,94 22,77
11,94 2,589,77
30,20 40,04
7,01 11,32
24,34 50,24
1,40 17,25
13,04 23,20
37,91 29,54
24,91 41,73
23,95 16,35
12,68 42,65
59,89
13,13 32,32
58,12
19,15 36,62
32,15 22,66
20,75 29,76
17,51 24,77
34,66 29,95
9,80 18,68
48,67 56,49
41,76
26,36 59,08
50,4251,78 39,87
47,92 38,9838,38
54,6655,93 68,1570,98
52,20 44,68
68,60 76,40
48,2448,62 58,98
56,05 66,37
72,21
41,3244,45 65,98
0,00 10,00 20,00 30,00 40,00 50,00 60,00 70,00 80,00 90,00
Papua Barat Papua NTT Sulawesi Tenggara Sumatera Utara Sulawesi Utara Maluku Utara Gorontalo Kalimantan Barat Riau NTB Sulawesi Tengah Kalimantan Tengah Maluku Sulawesi Barat Bengkulu Kepulauan Riau Kalimantan Selatan Kalimantan Timur Sulawesi Selatan Bangka Belitung Banten Sumatera Barat Jawa Timur Kalimantan Utara Jawa Barat Jambi DKI Jakarta Bali Lampung Jawa Tengah Sumatera Selatan DIY Aceh
Early Detection With HBsAg Test
2017 2020
241
Figure 2. Early Detection Pregnant Woman with HBsAg Test in 2020 and Reactive Results
There were some problems with the management of hepatitis B early detection with HBsAg in Indonesia. It could be influenced by many factors, such as many targets to achieve at the same time.
Although ideal, following the regulation but too hard on grass root to do it. Some PHC in the first study showed this condition, but engagement at that time could not pursue better. Stagnant progress in some provinces caused prioritize islands outside the java island. Indonesia, as the archipelago, has become a high challenge to mobilize the need for HBsAg kit until the phc location also influenced it.
0,00 10,00 20,00 30,00 40,00 50,00 60,00 70,00 80,00 90,00 Papua Barat
Papua NTT Sulawesi Tenggara Sumatera Utara Sulawesi Utara Maluku Utara Gorontalo Kalimantan Barat Riau NTB Sulawesi Tengah Kalimantan Tengah Maluku Sulawesi Barat Bengkulu Kepulauan Riau Kalimantan Selatan Kalimantan Timur Sulawesi Selatan Bangka Belitung Banten Sumatera Barat Jawa Timur Kalimantan Utara Jawa Barat Jambi DKI Jakarta Bali Lampung Jawa Tengah Sumatera Selatan DIY Aceh Indonesia
Coverage and Reactive HBsAg Test in 2020
2020 Reaktif_2020
242
Figure 3. Calculation HBsAg Test in Coverage 80% and Prediction of Reactive HBsAg Test
It explained eastern Indonesia has lower coverage HBsAg kit, but there some anomalies could not be explained, such as DKI Jakarta, North Sumatera, and Kepulauan Riau might cause other factors near they didn't run the early detection. According to Health Facility Research (Rifaskes), in 2019, from 514 Districts in Indonesia who joined with early detection with HBsAg, about 306 (59,53%) although the indicator joined built and measured if at least one phc joined was defined as eligible(Badan Penelitian dan Pengembangan Kesehatan Kementerian Kesehatan RI, 2019). This lack of preparedness in the program can be identified and calculated if the program will not achieve 90% in 2020.
The critical point Indonesia still has some trouble with next time, although vaccination is well.
But the target is for newborns under five years. As a characteristic of Hepatitis is silent infection without detection, we don't know a pregnant woman in a clean condition, which means they have no hepatitis virus in their body. In developed and committed countries, mandatory premarital screening does have
4,68 3,91
4,90 3,46 1,10
1,54 3,90 3,27 2,41 1,51
3,00 2,48 2,51 1,85
2,20 1,78 1,55
2,14 1,92
2,13 2,15 1,53 1,22
1,87 2,07 1,25 1,25 1,39 1,23
1,35 1,28 0,72 0,69 1,01
2,10
21,4 12,6
11,3 9,2 9,0 6,6 6,4 4,6 4,6 4,6 4,1 3,9 3,9 3,7 3,7 3,7 3,2 3,1 2,7 2,5 2,4 2,3 2,2 2,2 2,2 2,1 2,1 1,9 1,8 1,6 1,4 1,4 1,2 1,2
4,4
0,00 5,00 10,00 15,00 20,00 25,00
Papua Barat Papua NTT Sulawesi Tenggara Sumatera Utara Sulawesi Utara Maluku Utara Gorontalo Kalimantan Barat Riau NTB Sulawesi Tengah Kalimantan Tengah Maluku Sulawesi Barat Bengkulu Kepulauan Riau Kalimantan Selatan Kalimantan Timur Sulawesi Selatan Bangka Belitung Banten Sumatera Barat Jawa Timur Kalimantan Utara Jawa Barat Jambi DKI Jakarta Bali Lampung Jawa Tengah Sumatera Selatan DIY Aceh Indonesia
Existing Coverage and Target 80%
Prediction80% Reaktif_2020
243
the potential to succeed as long as the target population is clearly identified and all ethical issues (including confidentiality of the results), religious, cultural, and human rights, and concerns about proper post-diagnostic management are fully addressed(Alswaidi and O’brien, 2009). In contrast to HIV, action in hepatitis testing and treatment has been fragmented and limited to a few countries, and there remains a large burden of undiagnosed cases globally. We summarize key challenges in the hepatitis testing response, including lack of simple, reliable, and low-cost diagnostic tests, laboratory capacity, and testing facilities; inadequate data to guide country-specific hepatitis testing approaches and who to screen; stigmatization and social marginalization of those with or at risk of viral Hepatitis;
and lack of international or national guidelines on hepatitis testing for resource-limited settings. We highlight some of the key lessons applicable to Hepatitis from the experience of expansion and diversification of HIV testing approaches over the last 30 years of the HIV response(Easterbrook et al., 2016).
The unknown of this global and national strategy of Hepatitis Screening also could have a big influence on the success of the awareness among pregnant women to join the programs. Some contradictive found at the phc along this program has started to need fast evaluation. Some findings in the field without a fast response by the ministry of health as the first burden for this program. Actually, when the program started for the first time in 2017, Indonesia by MoH had achieved almost 30 %.
Normally in 2020 could achieve 90% of the target.
Finally, the HBsAg test since early March 2020 has stopped after Covid19 Pandemic spread and attacked Indonesia. The impact of mandatory Global health sector strategy and targets on Hepatitis 2016-2021(Organization, 2016) has decreased the target from 90% to 80%. The COVID-19 pandemic has heterogeneously affected the use of basic health services worldwide, with disruptions in some countries beginning in the early stages of the emergency in March 2020. These disruptions have occurred on both the supply and demand sides of healthcare and have often been related to resource shortages to provide care and lower patient turnout associated with mobility restrictions and fear of contracting COVID-19 at facilities. The COVID-19 pandemic caused by the SARS-CoV-2 virus has resulted in a myriad of interventions with the urgent aim of reducing the public health impact of this virus. However, a wealth of evidence, both from high-income and low-income countries, is accruing on the broader consequences of such interventions on economic and public health inequalities, as well as on pre-existing programs targeting endemic pathogens. We provide an overview of the impact of the ongoing COVID-19 pandemic on hepatitis B virus (HBV) programs globally, focusing on the possible consequences for prevention, diagnosis, and treatment. Ongoing disruptions to infrastructure, supply chains, services, and interventions for HBV are likely to contribute disproportionately to the short-term incidence of chronic hepatitis B, providing a long-term source of onward transmission to future generations that threaten progress towards the 2030 elimination goals(Pley et al., 2021). Civil society
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has a central role to play in the pandemic response. Even if the numbers of deaths and new infections decrease, the fear of attending a traditional healthcare setting might persist. The decentralization of services will become a crucial method of service delivery. In November 2019, the leading liver societies made a joint call for action to explore the ways in which hepatitis prevention, testing, and treatment services can be decentralised. This pandemic is an opportunity to accelerate this call to action. However, many civil society organizations face an uncertain future. In the WHA survey, one participant from the USA expressed concern over their organization's funding situation and uncertainty over what services will look like in the future(Wingrove et al., 2020). The detection of pregnant women is to get further management, especially preventing vertical transmission from mother to child so cases of hepatitis B prevalence can be prevented before transmitting to the baby who is born. As research in Magelang Regency, the incidence of HBV infection in infants aged more than 9 months who were born to mothers with positive HbsAg in Magelang Regency in 2014-2016 showed no transmission or 0%(Ahmad and Kusnanto, 2017). This was obtained from the history of administering the HBO vaccine <12 hours by 100% and the administration of HBIg 65 <12 hours by 68.85%.
The estimation to show the description with linear assumption and as a tool described the burden of reactive HBsAg. So, we can determine the total pregnant woman seroprevalence based on the data from SIhepi (information system hepatitis B) as a target. The disparity of catchment in each Province in Indonesia gives us some information that needs an appropriate strategy to handle it. We can't deny there was some challenge in Indonesia country, and the central government needs to take into consideration the growing interregional disparities in terms of resources, services, and health outcomes and develop a comprehensive strategy to address these disparities. The objective of equity in the achievement of health indicators across districts has not yet been addressed properly in the decentralization policy. With a large, wide area and population and with the commencement of a universal health coverage system, the need for a reliable and integrated information system to support the planning and decision-making process is becoming even more urgent(Mahendradhata et al., 2017).
One major implementation challenge currently being addressed is to establish the institutions, systems, and procedures necessary for the effective and efficient operation of the national health insurance program (JKN). In general, the supply side is still largely lagging behind the demand side, particularly in poorer and more distant regions, and the central government needs to ensure a better investment in the health workforce, facilities, and equipment in less developed regions to ensure equity in access to services. Other necessary elements to support an effective and efficient JKN also present challenges. For example, HTAs, cost containment strategies, and health information systems have become more crucial in JKN, and yet progress on these elements remains slow.
245 CONCLUSIONS AND SUGGESTIONS
Handling hepatitis B in the at-risk group, namely pregnant women, is still a serious problem, therefore if it is not found soon, it will transmit it to the baby they are carrying. Screening pregnant women with HBsAg is an effort to cut off vertical transmission, which is 90% based on some research will transmit to the baby they are born with. However, the government's efforts have basically been very good with the vaccine program since the baby was born with HB0, HB1 at the age of 3 months, HB2 at the age of 6 months and HB3 at the age of 9 months.
There are some challenges, such as disparity in each Province, and covid-19 pandemic will hinder pregnant women's HBsAg test achievement target in 2030. Both become a double burden to achieve the actual target. It is estimated that the high prevalence in Indonesia based on the HBsAg test in pregnant women is around 4.4%, with the highest Province being West Papua, at around 22.4%.
As a suggestion in this writing:
1. The coverage rate was still low, especially in 18 provinces in Indonesia, and needs to be addressed and prioritized again
2. The high risk in East Nusa Tenggara, Papua, and West Papua based on Sihepi 2020 data at coverage of 34.66% seroprevalence 4.9%, 24.77% seroprevalence 3.91%, 17.51% seroprevalence 4, 68%, the need pursue to increase coverage immediately so the risk of vertical transmission can be prevented.
3. Further research is needed regarding the seroprevalence of antibody titers in bumil as an effort to map antibodies owned by pregnant women in Indonesia.
ACKNOWLEDGEMENT
A writer would like to acknowledge Subdit PISP- Indonesia Ministry of Health for providing the information and report clearly. Also, DR Hapsari Tjandarinini, SKM, MKes gave support to join in this seminar.
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