Indonesia’s low testing rate has persisted seven months into the COVID-19 pandemic, as laboratories throughout the archipelago face problems ranging from limited testing kits to delays in reported results.
According to Oct. 16 data compiled by Oxford University’s Our World in Data, Indonesia had tested 0.12 people per 1,000 daily on a 7-day average. The figure was lower than the Philippines’ 0.3 per 1,000 and India’s 0.79 per 1,000.
The latest World Health Organization situation report on Indonesia highlighted the need for the country to increase its lab capacity to ensure all suspected cases were tested. WHO data showed a widening gap between suspected cases and the number of people tested. The country's COVID-19 positivity rate is also hovering in the teens.
Lab managers and doctors from eight regions in Indonesia told The Jakarta Post that government procurement of reagents, the chemicals used to detect the presence of the coronavirus in samples, had improved. But they said there was more to testing than reagents.
Testing kit procurement, adjustment
“Sometimes we run out of consumables [...] such as methanol, which can’t be transported by plane because it is flammable, and filter [pipette] tips," said Hessyani Raranta, who is in charge of Dr. Kandou General Hospital’s laboratory in Manado, North Sulawesi, last week.
"They aren’t sold in Manado. We have to look for them ourselves and transport them by sea – or by land from Makassar."
Ichsan, the infectious diseases lab manager at Syiah Kuala University in Aceh, said that beyond the difficulty of collecting the funds to purchase consumables and transporting them to the province, the goods had become scarce and could take up to two months to arrive at the lab.
Ichsan said the government should make sure its own reagents would work well when used by labs.
“We have had to return some reagents to the central government because other labs in the country complained about the reliability of their results. We returned some others because the reagents required devices that we didn’t have,” he said.
The varying reagents, experts noted, had made it harder to draw information from test results, specifically through the CT value, a number that signals a patient’s viral load and, potentially, their infectiousness – which could be useful for hospital discharge decisions.
Timely reporting of results
Doctors and managers said their labs could provide test results one to three days after receiving samples from health facilities or local health agencies.
Health agencies, however, did not always send samples immediately after swabbing patients, said Sri Ratna Dewi of Warmadewa University’s COVID-19 lab in Denpasar, Bali.
“For example, they may take samples today and only send them to labs the following day because of distance constraints […] It’s not a problem as long as they store samples at the correct temperature – 2 to 8 degrees Celsius – for a maximum of five days,” Ratna said on Monday.
As the number of cases reported daily was not the same as number of people who had contracted COVID-19 that day, the WHO cautioned against interpreting the figures and epidemiological curves for further analysis, noting that the reporting of lab-confirmed results could take up to a week after the time of testing.
Ryan Bayusantika of the West Java regional health lab acknowledged that data entry was a problem. Workers had to input data twice – once for the central government and once for the provincial administration. He said the databases needed to be integrated.
“It’s not an issue for labs with a small number of samples, but it is certainly a problem for those processing more than 1,000 samples per day,” he said. “Inputting one result of a sample, along with the patient’s identity, takes about 7 minutes. And if there’s a problem with the central server, it takes much more time.”
Hessyani said the absence of a standardized data-input method made it difficult for labs to report test results. Even if just one letter or number was missing, labs would be unable to input the data into the system and would have to report the data directly to the health agency.
“Even if there are 1,000 patients [whose samples have been tested], if they are not recorded in the system, it will seem as if there are no cases,” Hessyani said.
Yetty Fauza of the East Kalimantan provincial health lab in Samarinda said her lab was able to report test results on time only after the central government provided additional workers.
Endra Muryanto, head of Jakarta’s regional lab, said a dozen health agency workers had been helping his lab input data.
Labs cannot improve testing alone
Almost all the doctors and health managers interviewed by the Post said that testing had to be improved but that it was not solely up to the labs.
While some labs have more samples than they can handle, others are operating below capacity. But the allocation of samples to particular labs relies on testing and tracing data obtained by health agencies and health facilities.
Dewi Indah Sari Siregar of North Sumatra University’s hospital lab in Medan said aggressive contact tracing would allow samples to be sent to labs more efficiently.
The government is providing free tests mainly for people with symptoms and who have had contact with confirmed patients. Others have to pay for their own tests.
Earlier this month, the government set a Rp 900,000 (US$61.09) price ceiling on polymerase chain reaction (PCR) tests, between a third and a quarter of the minimum monthly wages in the country, in a bid to encourage people to get tested. Prior to the cap, tests cost millions of rupiah.
While labs have adhered to the price cap, many doctors and managers said the price was too low and would not cover the price of the expensive reagents, consumables and personal protective equipment.
Ichsan said his lab could no longer test samples paid for by individuals under the price ceiling because the lab would have to purchase test kits of questionable quality to break even.
Yetty said her lab in Samarinda had temporarily suspended testing for individuals as a result of the price ceiling but eventually resumed the service after adjusting spending on test kits.
COVID-19 task force spokesperson Wiku Adisasmito said the price cap had taken the financial condition of health facilities into consideration, as well as the Development Finance Comptroller’s (BPKP) suggestions.
Riat El Khair of Dr. Sardjito General Hospital in Yogyakarta said labs’ testing expenses did not end with the purchase of test kits; they also had operational costs.
Yetty, for instance, said her lab spent around Rp 1.75 million per week on waste management, which she said was not covered by the government.
Many said well-trained health workers were the most important factor in improving testing.
“I’m not sure how long [the current number of] medical workers can last [effectively] because we’re seeing a rising trend of cases and severe cases, which is not commonly talked about,” Riat said.