PDF Letter from Indonesia

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LETTER FROM ASIA-PACIFIC AND BEYOND

Letter from Indonesia

Key words:COVID-19, Indonesia, physician death.

The first coronavirus disease 2019 (COVID-19) cases reported by the Indonesian Government on 2 March 2020 came from Jakarta (population 11 million), the capital city of the Republic of Indonesia. The government appointed a COVID-19 Task Force under the National Disaster Management Authority to coordinate all aspects of the COVID-19 response.¹ At that time, three hospitals in Jakarta, namely the Persahabatan National Respiratory Referral Hospital, Sulianti Saroso Infection Center Hospital and Gatot Subroto Army Central Hospital were designated as referral hospitals for COVID-19 patients. These were referral hospitals at the time of the avian flu epidemic and are equipped with isolation rooms to handle cases of emerging infec- tious diseases such as multidrug-resistant tuberculosis (MDR-TB), avianflu and now COVID-19.

As COVID-19 cases in Jakarta increased, the Jakarta government imposed a large-scale social restriction (limited/partial lockdown) from 10 April 2020. With the implementation of this large-scale social restriction, the number of cases decreased until the level of transmis- sion became low. On 1 July 2020, the Jakarta government switched to a transitional period, namely by implementing health protocols consisting of compul- sory mask-wearing, social distancing and hand wash- ing. After a month of transition, the incidence of COVID-19 cases and deaths in Jakarta has increased again.²

Indonesia is the fourth most populous country in the world with a population of 270 million. This country is a vast archipelago, consisting of 17 000 islands and 34 provinces. Many places in Indonesia are still difficult to reach due to limited transportation. This situation makes it difficult to monitor and handle COVID-19 cases that occur in remote areas. We learned from the epidemic of avian influenza cases (2008) and MDR-TB, and rapidly implemented procedures for diagnosis, referral and management of COVID-19 cases.

All primary care facilities were equipped to do nasopharyngeal swabs, to be sent to 246 laboratories designated for COVID-19 diagnosis, linked with primary healthcare units for case tracing. After COVID-19 broke out in Jakarta, then one by one other provinces began reporting cases. In July 2020, there wereﬁve provinces that reported sharply increasing cases of COVID-19, namely East Java, Central Java, South Sulawesi, South Kalimantan and North Sumatra as shown in Figure 1.

Up to 31 August 2020, there were 172 053 conﬁrmed COVID-19 cases in Indonesia, with 40 525 people hospitalized and 7343 deaths (4.3%).

The Indonesian Society of Respirology (ISR) is col- laborating with the Ministry of Health and COVID-19

Task Force in developing guidelines and statements for COVID-19 in Indonesia.^3,4 The treatment guideline for mild cases is 14 days of self-isolation. Moderate, severe and critically ill patients were hospitalized either in an isolation room or intensive care unit (ICU). Routine treatment recommendations are antivirals (oseltamivir), azithromycin, anticoagulant (heparin or low-molecular weight heparin), dexamethasone and supportive therapy such as vitamin D, C, zinc, magne- sium supplementation and antibiotics. Other treatment regimens available for physician choice or clinical trial use included lopinavir-ritonavir, favirapir, remdesivir, hydroxychloroquine, chloroquine, intravenous immu- noglobulin (IVIg), tocilizumab or convalescent plasma.

All treatments (excluding IVIg and tocilizumab) were reimbursed under the Universal Health Coverage system.³

All pulmonologists were actively managing COVID- 19 cases, which is a high-risk environment. There was an appeal from the Indonesian Medical Associa- tion to doctors elder than 65 years not to engage with COVID-19 cases and limit their practice to reduce morbidity. In teaching hospitals, all pulmonary residents were in active service for COVID-19 including screening units, outpatient clinics, isolation wards, high-care unit and ICU wards; this practice was included in their modiﬁed curriculum and duty hours. Reduced visits of non-COVID-19 cases were impacting the educational schedule for pulmonary residents. There are only a few cases of bronchos- copy and other invasive procedures being done. All classes were replaced by virtual meetings, and all procedural training was taught using model systems.

National Board Examinations used both virtual and face-to-face meetings with physical distancing. This modiﬁcation continues with increasing cases of COVID-19.¹

Some problems that occurred in the management of COVID-19 cases in Indonesia are:

1. A small percentage of nasopharyngeal swab screening per 1000 population. There are disparities of testing in the capital Jakarta and wider Indonesia. As of 31 August 2020, the testing rate in Jakarta was 58 834 per million population (ﬁve times higher than the World Health Organization (WHO) target), but only 4732 tests per million population across all of Indonesia. The total positive rate across Indonesia was 13.4%.²

2. Lack of adequate facilities for treating COVID-19 cases, such as negative pressure wards, ICU rooms, high-ﬂow oxygen devices and mechanical ventila- tion, especially in small cities and outside Java island.

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3. Lack of availability of personal protective equipment for health workers such as coveralls, N95 masks and face shields, especially in rural areas.

4. Low compliance of people to health protocols such as social and physical distancing, not wearing masks and opening of ofﬁces, shopping malls and restaurants.

5. COVID-19 patients who passed away in health facilities were handled with special protocols for burial.

There have been several instances when the deceased patient’s family, especially those with low education levels, did not comply with protocols and carried out the burial themselves. There was a dis- pute between the hospital and the family of the deceased patient. Some COVID-19 patients refuse to be hospitalized.

6. Stigmatization of post COVID-19 patients, with some contacts reluctant to do testing.

The increasing number of COVID-19 cases has cre- ated a high burden to medical services all over the country, with high mortality among physicians treating COVID-19 patients. As of 31 August 2020, there are 100 physician deaths related to COVID-19, not including the numbers of physicians infected by COVID-19.⁵ Among them, our best three pulmonologists passed away. One is too much, it is a matter of utmost urgency to protect the safety and health of medical personnel.

Faisal Yunus, MD, PhD, FCCP, FISR and Sita Andarini, MD, PhD, FISR Department of Pulmonology and Respiratory Medicine, Faculty of Medicine, University of Indonesia- Persahabatan National Respiratory Referral Hospital, Jakarta, Indonesia

REFERENCES

1 Satuan Gugus Tugas Penanganan COVID-19. 2020. [Accessed 31 Aug 2020.] Available from URL: https://covid19.go.id/peta- sebaran

2 Pemerintah Daerah DKI Jakarta. Jakarta Tanggap COVID-19. 2020.

[Accessed 31 Aug 2020.] Available from URL: https://corona.jakarta.

go.id/en

3 Komite Penanganan COVID-19 dan Pemulihan Ekonomi Nasional:

Satuan Tugas Penanganan COVID-19. 2020. [Accessed 15 Sept 2020.] Available from URL: https://covid19.go.id/storage/app/

media/Protokol/Pedoman%20Tata%20Laksana%20COVID-19.pdf 4 Perhimpuan Dokter Paru Indonesia: Protokol Tatalaksana COVID-

19. 2020. [Accessed 15 Sept 2020.] Available from URL: https://

klikpdpi.com/bukupdpi/protokol-tatalaksana-covid-19/

5 Kompas. 100 Dokter Meninggal Akibat COVID-19, Apa Saja Dampaknya? 2020. [Accessed 1 Sept 2020.] Available from URL:

https://www.kompas.com/tren/read/2020/09/01/113000865/100- dokter-meninggal-akibat-covid-19-apa-saja-dampaknya-?page=all Figure 1 Total conﬁrmed coronavirus disease 2019 (COVID-19) cases and mortality inﬁve provinces with highest cases in Indonesia as of 31 August 2020.¹ , Total cases; , deaths.

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