The Jakarta Post
Breaking the chain of transmission is key to containing the COVID-19 outbreak, but in Indonesia, contact tracing remains weak due to problems ranging from an insufficient number of tracers to people's reluctance to open up to these workers.
Six months into the epidemic, COVID-19 task force spokesperson Wiku Adisasmito said earlier this month that the country's contact-tracing ability was still poor. He said the government was working on tracing a minimum of 30 contacts per confirmed case.
Contact tracing means identifying the contact history of confirmed, probable or suspected cases by interviewing the patients in order to test and quarantine those having been in contact with them as soon as possible.
To roll out contact tracing, Indonesia has been relying on community health center (Puskesmas) workers, sometimes with the help of volunteers and village leaders.
There are 9,993 Puskesmas in the country, according to 2018 health ministry data, with some of their workers now juggling between serving patients and monitoring the condition of confirmed and suspected cases in self-imposed isolation in their respective areas.
The Jakarta Health Agency’s head of disease control and prevention, Lies Dwi, said obstacles they were facing included an unwillingness of some COVID-19 patients to provide a contact history due to a lack of trust. Others told the health workers they had trouble recalling their activities over the preceding 14 days, especially given the high mobility of urbanites, Lies said.
There was also stigma surrounding COVID-19 that could possibly prompt fears of expulsion from their communities, Lies said, in addition to instances of incomplete or incorrect contact data.
Jakarta tested an average of six contacts per confirmed case in July, even though, according to Lies, the number of contacts traced was higher.
"COVID-19 is not replacing other illnesses. [...] The burden [on Puskesmas] has become bigger. To break transmission chains as soon as possible, we need more workers to trace contacts, and it's not enough just to rely on Puskesmas workers,” Lies told The Jakarta Post on Saturday. “Volunteers have indeed been very helpful.”
Jakarta has deployed between 40 and 60 workers from each of its 44 district-level Puskesmas to conduct COVID-19 tests, trace contacts and analyze data, she said, adding that it had also recruited between two and three community helpers for each Puskesmas.
She said that not all contacts would have to be tested or go into quarantine for 14 days. The decision, she said, was rather based on a priority scale in regard to the risk borne by the contacts -- whether they were close contacts or had higher risks.
The Health Ministry's latest COVID-19 protocol, issued following the World Health Organization's newest guidelines, define close contacts as people having a contact history with confirmed or probable cases and those having face-to-face interaction with these cases within at least 15 minutes or with physical touch.
The protocols deem contact-tracing capacity adequate when more than 80 percent of new cases' close contacts are identified and quarantined within 72 hours of the cases being confirmed, and for them to be monitored for 14 days since their last contact.
Reuters reported last week that unpublished data from the COVID-19 task force it had reviewed showed only 53.7 percent of people identified as confirmed or suspected carriers of the disease were subjected to contact tracing by June 6.
Two university students recruited as community helpers to trace contacts from late July to mid-August in Surabaya, East Java, another COVID-19 epicenter in the country, told the Post recently that they had faced similar obstacles.
Out of economic concerns and stigma many also refused to be tested and to go into self-imposed quarantine even as the Surabaya administration promised them free meals. The absence of enforcement left tracers with no option but to let them go, the volunteer said.
"For tracing, we'd need very detailed data, but there were people who had doubts [...] They're afraid that I'd misuse the data," said Anggara Widyartanto, one of the community helpers assigned to a Puskesmas in one of the city's hardest-hit areas.
Anggara said he managed to trace an average of three contacts per case. Another volunteer assigned to a different Puskesmas, who requested anonymity, said the target in his Puskesmas at that time was 14 contacts per case, but the reality was that he, most of the time, could only reach the closest contacts -- family members and their neighbors.
They said that, at the time, for contacts to be swab-tested or go into quarantine, some would first be tested using the rapid antibody tests, which experts have strongly opposed for diagnostic purposes.
East Java Governor Khofifah Indar Parawansa previously said in June that the tracing ratio in Surabaya was 2.8. The province's COVID-19 task force tracing team head Kohar Hari Santoso did not immediately respond to the Post's request for updated data.
"There were also times in which the Health Agency only notified us a week, or even nine days, after the cases were confirmed positive. We then had to rush to trace and isolate them, because there were only several days left before their isolation period was up,” one of the volunteers said. “I'm talking about cases tested by companies or by people on their own.”
The volunteers also highlighted the need for the city administration to continue recruiting community helpers, as Puskesmas workers had also been overwhelmed, with some workers themselves testing positive and going into self-imposed quarantine.
Masdalina Pane of the Indonesian Epidemiologists Association (PAEI) said regional leaders had not paid much attention to Puskesmas and contact-tracing efforts, when massive tracing and isolation should have been the ultimate means of epidemic control.
With only around 30 percent of cases hospitalized and the remaining in self-imposed isolation, more resources should have been given to Puskesmas to contain sources of transmission.
The monitoring of people in self-imposed quarantine remained weak, she said, adding that, given people's mobility, especially in Greater Jakarta, tracing would necessitate cooperation across regions.
"One of the indicators of good contact tracing is when more than 80 percent of the cases have their sources known, who are then contained," she said.