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Jakarta Post

Experts press for consistency, honesty in applying new COVID-19 protocols

  • Ardila Syakriah
    Ardila Syakriah

    The Jakarta Post

Jakarta   /   Fri, July 17, 2020   /   09:17 am
Experts press for consistency, honesty in applying new COVID-19 protocols A health worker checks a rapid test kit on June 21, 2020 during a testing program sponsored by the National Police in Jakarta. (AFP/Adek Berry)

The Health Ministry has recently issued a set of new protocols on COVID-19 management and mitigation based on the recommendations of the World Health Organization (WHO), but experts have questioned whether the government would translate them into better containment policies.

The fifth version of COVID-19 health protocols notably scraps the local terms “person under observation” (ODP) and “patient under surveillance” (PDP) in favor of the international designations “suspect” and “probable”. It also expands the definition of COVID-19 deaths to include deaths among probable cases for the purpose of epidemiological surveillance.

Health Minister Terawan Agus Putranto claimed that Indonesia was the "most obedient" country as regards the WHO guidelines, and that it had changed its terminology to fit the agency's recommendations.

"That way, our data will be acknowledged [as] good data. The trust of the international community [in Indonesia] will also grow," he said on Tuesday, as quoted by Tempo.co.

The two terms introduced in the latest revision to Indonesia's health protocols were in common use internationally, said Indonesian Epidemiologists Association (PAEI) chairman Hariadi Wibisono.

The WHO updated its case definitions for global surveillance purposes in the March 20 situation report , and expanded its definition of "COVID-19 deaths" in the April 11 report to include deaths among probable cases.

The current definitions of suspect case are:

  1. A patient with acute respiratory illness with no other etiology that fully explains the clinical presentation and a history of travel to or residence in a location reporting community transmission during the 14 days prior to symptom onset; or
  2. A patient with any acute respiratory illness who has been in contact with a confirmed or probable case in the last 14 days prior to symptom onset; or
  3. A patient with severe acute respiratory illness requiring hospitalization with no alternative diagnosis that fully explains the clinical presentation.

A probable case, meanwhile, is defined as a suspect case "for whom testing for the COVID-19 virus":

  1. is inconclusive; or
  2. could not be performed for any reason.

Hariadi believes, however, that simply updating the jargon will not automatically lead to an improvement in surveillance.

"The principle is to do as many tests as possible, because we don't want suspect and probable cases swinging between yes and no. We want immediate certainty and that means improving our testing [capacity]," he said.

On Thursday, Indonesia recorded 81,668 confirmed cases, of which 41,323 are currently active. The official COVID-19 dashboard now lists 47,859 suspect cases. The country reported 76 deaths, bringing the total to 3,873 fatalities – which still only accounts for deaths among confirmed cases, in accordance with older guidelines.

Biostatistician Iwan Ariawan of the University of Indonesia public health school urged the government to revise its previous data for recorded deaths to include the toll among probable cases.

Meanwhile, the data compiled by volunteer group KawalCOVID-19 showed that more than 8,000 deaths in the country were attributable to the former government classifications ODP and PDP.

Iwan said that comparing the two datasets would help calculate the disparity between current and past data on recorded deaths, as the government's updated definition was expected to result in a higher figure for COVID-19 deaths.

Other areas that have previously revised their death toll include Wuhan in China and New York City in the United States.

Iwan also urged the government to be consistent in applying the new guidelines to its COVID-19 management strategy, including the criteria for determining whether a region has brought the local transmission under control.

The criteria emphasizes keeping a region's effective reproduction number (Rt) below 1 for a duration of 14 days. 

Other supporting criteria in the case of inadequate data to estimate the local Rt includes achieving a minimum 50 percent decline in new cases for three weeks since the last recorded surge. The region must have also maintained a below 5 percent positivity rate (percentage of positive results from all tests) for two weeks, which requires optimal surveillance and a weekly testing capacity of 1 test per 1,000 population.

WHO Indonesia's situation report dated July 15 states that Jakarta is the only province in Java to have achieved this "minimum case detection benchmark" for "comprehensive surveillance and testing of suspected cases".

"This means that the government must be honest [when] telling the public that there are regions where the epidemic hasn't been brought under control yet, but that we have to [ease restrictions] for economic and other reasons," Iwan said.

“That [also] means telling the public that the risk [of infection] is still high, that they must be cautious, wear their masks and not step out of their homes unless necessary – and certainly not out of euphoria,” he stressed.

PAEI's Hariadi insisted that a region “must retreat” from a decision to ease restrictions once it notices a negative trend as per the WHO’s recommendations, such as a daily increase in new cases. Regions should reimpose restrictions when this happens, he said.

Critics have acknowledged persisting issues with Indonesia’s testing capacity, but have pressed their stance that ensuring adequate testing before relaxing restrictions was nonnegotiable.

Iwan said the government should start considering the pool testing method – as West Sumatra had been doing, followed by other regions – to overcome insufficient testing, instead of relying on rapid diagnostic tests for antibodies.

The pool testing method tests samples collected from multiple individuals as a single batch. If the batch test returns a positive result, each person in the pool must then be tested individually. If the batch test produces a negative, however, the entire group can be cleared of infection.

The changes made to the criteria for discharging patients in accordance with WHO guidelines issued in May are expected to also help narrow the gap between the number of specimens and suspected cases tested.

The new rules stipulate that follow-up PCR tests are no longer necessary in asymptomatic patients and in cases with mild to moderate symptoms, although there is a required period of isolation to account for the onset of symptoms. Previously, confirmed cases had to test negative twice before the patient is cleared for discharge.

The WHO noted on July 10 that only 58.8 percent of all PCR tests Indonesia conducted had been used on people who had not been tested, based on the previous criteria for discharging patients.