The Jakarta Post
Indonesia has been carrying out rapid testing that has resulted in the discovery of hundreds of potentially positive COVID-19 cases, but a backlog in further tests to confirm these findings has raised questions about the system’s efficacy.
The government has distributed some 400,000 rapid testing kits to the regions, mainly focusing on the hardest-hit areas such as Greater Jakarta. However, even those who have tested positive for the disease still need to take the more reliable but limited polymerase chain reaction (PCR) tests, given the high possibility of false positives among rapid test results.
Aryati, a professor of clinical pathology at Airlangga University, in Surabaya, East Java, said that as rapid testing was used to detect antibodies in blood samples, there was always the possibility of a false positive, due to the cross-reaction of antibodies with similar viruses, such as dengue, as well as a patient’s history of past infections with other coronavirus strains.
"Don't be too happy about a negative result either, as it might also turn out to be a false negative, because antibodies may not already be formed at the time of testing or if the person suffers from an impaired immune system," Aryati said on Thursday.
“That's why they should be tested again within 10 days.”
This might explain why people who have tested positive through the rapid testing kits are not included in the government’s official daily tally of confirmed COVID-19 cases, which only includes those samples that are confirmed using the PCR tests.
"The gold standard is still PCR testing [...] while the confidence level in rapid antibody testing is the lowest among all other forms of tests,” said Herawati Supolo Sudoyo, the Eijkman Institute of Molecular Biology’s deputy for fundamental research, on Thursday.
Indonesia, the world's fourth-most populous nation has run PCR tests on fewer than 8,000 people, in stark contrast with neighboring countries' testing figures. As of Friday, Indonesia had the second-highest death toll in Asia after China, with 1,986 confirmed cases and 181 deaths.
The official figure, however, does not include fatalities recorded among patients under surveillance (PDP) and persons under general observation (ODP), who have not yet been tested or who have died while waiting for their lab test results to come back.
While the central government has recorded only 90 fatalities in the capital city, Jakarta Governor Anies Baswedan said on Thursday that between March 6 and April 1, some 401 corpses had been buried using protocols designed for people who died from the contagious COVID-19 disease.
Experts have called for people who have tested positive for the disease though the rapid test kits to be immediately tested with the PCR method while isolating and having their contacts traced, but the lack of preparedness among laboratories and insufficient testing kit provisions have contributed to a nationwide PCR testing backlog. As of Friday, 720 people in Jakarta alone were still waiting for their lab test results to come back, according to the provincial health agency.
West Java Health Agency head Berli Hamdani has said that swab testing kits and the viral transfer mediums (VTMs) to carry out PCR tests following rapid testing in the province's health laboratory are limited.
Ryan B. Ristandi, who is in charge of West Java’s health laboratory, said previously that the laboratory had the capacity to test 96 samples a day but it was experiencing bottlenecks because of the extraction process being used. The laboratory has three manual PCR machines.
Meanwhile, West Java Governor Ridwan Kamil said that the administration had used about 15,000 rapid testing kits, resulting in 677 people having tested positive for the disease.
Ridwan said during an online video conference with Vice President Ma’ruf Amin on Friday that he feared the tests were not carried out rapidly enough, as he believed the real number of confirmed cases in West Java, currently at 225 with 25 deaths, was "many times higher".
Experts warn that carrying out rapid testing alone, while helpful for contact-tracing and further studies of the virus, cannot be regarded as mass testing. Rapid PCR testing on a massive scale should rather be prioritized to prevent wider transmission by isolating confirmed cases and detecting cases as early as possible to set hospitals' priorities straight and suppress death rates.
The country's "weakness" is that it does "not have the tools to carry out rapid testing on a massive scale", said Doni Monardo, the head of the National Disaster Mitigation Agency and the COVID-19 rapid-response team, during a virtual working meeting with the House of Representatives on Thursday.
"We've consulted with the Health Ministry, [there are] 44 Health Ministry labs spread [across the country]. Their facilities and equipment are not yet adequate, so only 13 labs are effective," he said, adding that the government was trying to import as many PCR testing kits as it could so that tests could be conducted in and outside of Java.
Data compiled by The Jakarta Post from the Health Ministry's daily COVID-19 reports, also provided on its website, show that up until the first confirmed case was announced in March, the ministry had tested 339 people.
Since then, the government has reported its daily cumulative number of tests, which the Post has used to calculate the number of tests that are carried out daily. The Post's analysis shows that the number of tests varies daily, but the figure is usually in the hundreds, with the highest number being 1,439 tests on March 27. There were two days in which the number of tests and confirmed cases were recorded as being the same: once on March 30 with 124 new cases and tests, respectively, and March 31 with 114 new cases and tests, respectively.
The government, up until mid-March, had insisted on carrying out PCR tests solely through the Health Ministry's Research and Development Agency lab in Jakarta, before eventually extending this to other laboratories across the country. It then allowed 12 labs to carry out tests before the Health Ministry's lab on March 31 tweeted that it would be expanding its COVID-19 lab network to 48.
Also in mid-March, the Health Ministry said it had acquired 10,000 PCR testing kits but the government's spokesperson for COVID-19 affairs, Achmad Yurianto, told the Post on Tuesday that the country already had tens of thousands of PCR testing kits, and that it would import more.
He did not provide any figures on the country's daily testing capacity, arguing that each lab had different testing capacities, although he stood by his earlier claim that the central lab could conduct up to 1,700 tests a day.
"It's like we've just woken up from a long, comfortable sleep only to find that we have so many shortcomings. We might have been ready in the past for the avian flu influenza, but the game today is different; the labs and the ways of handling specimens are different with this new virus," Herawati of the Eijkman Institute said.
Aryati of Airlangga University said the country could still pin its hopes on the government's plan to use modified diagnostic test kits for tuberculosis, urging the government to widen its lab network by welcoming private sector labs to carry out the PCR testing.
She said there were at least 196 labs across the country with compatible machines to run the tests as long as the government helped supply their reagents, VTMs and protective equipment.
— Arya Dipa and Karina M. Tehusijarana contributed to this story