E45: What's In A Number?

 
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What do Indonesia’s official Covid-19 statistics really mean, how are they derived and what can we expect going forward?

The Coronavirus Disease 19 or Covid-19, continues to spread across Indonesia despite early beliefs by many government officials that Indonesia somehow was immune to it or that because of their religiosity, they would be spared.

Instead, the virus has already begun to spread from its epicentre in the Jakarta metro area, to now nationwide. The virus is present in all 34 provinces.

Covid-19 Numbers

Although Indonesian news outlets continuously update viewers and readers with the latest Covid-19 statistics provided by the government, not much scrutiny has been placed on the numbers themselves.

Compared to the size of the population, Indonesia’s number of Covid-19 cases appear to be relatively low given its population of almost 270 million.

To date, the government says there are 10,551 positive cases with 801 deaths and 1591 “recovered” patients. Some health experts say the government’s numbers represent only a fraction of the actual cases and this is due to two key reasons: first, the lack of widespread testing since there have been less than 60,000 proper testing carried out for a population of 270 million. Second, those who are asymptomatic are not being tested.

Here is the first problem with the official numbers. On 16 April, the Covid Task Force chief finally admitted that localized data had yet to be compiled into the official tally. This means that until all the data is compiled from across the country, we won’t know the true scope of Covid-19 cases. For the first half of the pandemic, the ministry of health required all testing and data analysis to be conducted by their own single lab. The government has realized that it needs more labs and has authorized both public and private labs to take part in the testing process.

According to Dr Herawati, a human genome expert in Jakarta, Indonesia will likely have 100,000 “confirmed” Covid-19 cases by the end of June. A confirmed case is when an individual has gone through polymerase chain reaction testing (PCR) and has tested positive. So, the confirmed is a known positive case, not the actual number of people who may have contracted the virus. Since testing in Indonesia is extremely limited, this number would only represent a fraction of the total number of cases across the country.

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Why So Many Categories?

When looking at the government’s current official Covid-19 numbers, it can be quite confusing to understand, as the government breaks down cases into five different categories.

1. The first category includes those that have been tested with PCR and have died. Currently stands at 801 people.

2. Individuals that have been tested and confirmed to be infected after undergoing a PCR test. This currently stands at 10,551 people.

3. Patients under “supervision” or locally referred to as PDP. These are those who show clear Covid-19 symptoms, including respiratory issues, after basic health checks, but haven't actually gone through a PCR test. There are over 22,100 people in this category.

4. Those who have shown some mild Covid-19 symptoms such as fever. This is locally referred to ODP. This would be anyone that has come into contact with someone with the confirmed or probable Covid-19 cases. These people are asked to self-isolate at home. There are currently around 233.411 people in this category.

5. Those without any symptoms, but have had direct contact with a COVID-19 patient and thus have the risk of spreading the virus. They are locally referred to as OTG and asked to self-isolate in their home. The total number of those considered OTG is unclear.

All of the categories mentioned earlier are made public via a government website, but it’s very unusual to hear officials discussing the PDP, ODP, or OTG categories. Individuals in all of these categories are clearly at high risk and are a health risk to the general public. As a result, these numbers should not be side-lined in daily press conferences or by the media. Classifying both ODP and PDP categories as Covid-19 suspected cases would cause the official number to skyrocket to almost 300,000 cases based on the basic information that’s available.

Dr. Herwati told me that the international standard is to only have three categories, positive cases, deaths and suspected cases, not five. There are no “in between” categories similar to what Indonesia uses.

Some critics argue that dividing the cases into many categories allows the government’s official Covid-19 number to remain low. If you look closer into what accounts as Patients Under Supervision (PDP), those are patients who have clearly shown symptoms of the virus but simply have yet to undergo PCR testing.

Just recently, the Indonesian Doctors Association, urged the government to be more transparent with its numbers and called for the government to release the number of those who died while under the Patients Under Supervision category (PDP), not just those who have been confirmed to have the virus and died.

For example, Shelly Zeindia Putri, the young emergency ambulance worker for the Jakarta Public Health Office was admitted to the hospital on 17 April after suffering from severe Covid-19 symptoms. She died just two days later. As she was categorized as Patients Under Supervision category (PDP) and her death will not be added to the official Covid-19 death toll. Or Dr. Berkatnu Indrawan Janguk, a doctor serving Covid-19 patients in a Surabaya hospital, died last week from Covid-19 but his death likely won’t be added to the government’s official Covid-19 death count. The 28-year old doctor had undergone a swab test several weeks ago after showing symptoms of the virus and tested positive. He later underwent two additional PCR tests showed him as negative. As his final test appeared to show him as free from the virus and that he did have a history of suffering from asthma, it’s likely that that his death will not be attributed to the virus despite the fact that he had direct contact with Covid-19 patients and had shown symptoms.

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Rapid Tests

A key element in fighting the Covid-19 war is having good intelligence. That intelligence in this case, is widespread testing results. You need the data to know who is infected, who is recovering and if some are actually immune.

Covid-19 testing has increased in Indonesia, but only just recently. To date, less than 60,000 people have been tested across the country using the all-important PCR testing, the most reliable tests currently available in Indonesia.

The majority of the tests conducted in Indonesia however have been done using Rapid Antibody Test kits, commonly referred to as “Rapid Tests”, which uses a blood sample, are widely available and cost around US$16 prior to the pandemic. A special lab isn’t required to do the test and it can be done at home. Contrary to popular belief, this test does not check for Covid-19, but rather merely identifies if a person has an increased level of antibodies. This increase can be caused by any kind of virus whether that’s Covid-19, dengue, hepatitis, or another disease. Another issue with Rapid Test Kits is that the human body may not produce antibodies against Covid-19 for days or even weeks after an infection, so the test could result in a false negative. It should not be used to diagnose patients and the test cannot determine if a person is immune to Covid-19, as commonly believed. It’s very difficult to determine the significance of a Rapid Test result as there are too many questions left unanswered.

Dr. Herwati said that the tests are being abused by those who can buy them. “The just use them as if they are a pregnancy test and think that it can determine if they have the virus or not,” she said.

Dr. Aryati, a pathologist in Surabaya said that there needs to be more awareness about rapid tests. “Rapid tests are the lowest level of testing and need to followed by other tests. The government is purchasing a lot of these tests and many people think one test is enough but that’s not true. You need to have several PCR tests after,” she said.

Local governments are desperate to test and have procured Rapid Antibody Test kits to use in pop up locations or drive-thrus. There is a new concern about the quality of the tests, as a large number of them have yet to be certified in Indonesia or internationally. “There are many rapid tests coming into Indonesia and we don’t know if they are even certified in here. We need to start checking before we allow them in and to be used. This is a major problem now,” Dr Aryati explained.

Dr. Aryati went on to say that she is concerned about all the rapid test being done as it remains unclear if there is proper interagency coordination when it comes to compiling the data. She also said, “Some people who show an increased level of antibodies after the test are often panicked and try and see a doctor, but the doctor is not sure which test she took and if the results are accurate. This just adds to a lot of confusion.” She went on to say that the rapid tests also could miss those who are asymptomatic and continue to spread the virus while the person assumes they are virus-free. “There needs to be clear guidelines issued by the government to avoid all these problems,” she stated.

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Polymerase Chain Reaction (PCR) Tests

Another test that is being conducted in Indonesia, albeit in much smaller quantities is PCR or Polymerase Chain Reaction Test. This one is crucial for identifying Covid-19.

PCR uses a swab test and compares DNA samples from the suspected person with a DNA sample from the virus. So you need to make sure that you get enough DNA when taking sample to make the comparison. It can provide a far more accurate and detailed test result compared to Rapid Tests. It costs around USD$133 per test under normal situations.

Dr. Herwati said that Rapid Tests can be useful but only when they are followed up with a PCR test, but here lies the problem.

Obtaining PCR test results however can take around 2-3 days under normal conditions, but often takes up to 8 days to obtain test results in Indonesia. Crucial time lost to inform those who might have been in contact with the patient and have also become infected, there by spreading the virus.

Unlike with Rapid Tests, a special lab is required to conduct PCR tests and requires trained professionals. The labs are available in different provinces across the country with Jakarta having five such labs, East java with four and there are less labs available as you move outside of Java. The lack of labs has led to a backlog of PCR swabs waiting to be tested. “We didn’t expect to be required to conduct so many tests. Since we are manually doing the extraction of the RNA and DNA, it takes a longer time. If we have automated machine we could speed things up and we expect to resolve this soon,” said Dr Herawati.

Dr. Aryati added, “There are many instances where it is very helpful when the Rapid Tests are conducted first while awaiting for a PCR test in the special isolation rooms. So patients are at times asked to get the Rapid Test first since there is still a long queue for PCR testing.”

To cope with the nationwide PCR bottleneck, the Ministry of State-Owned Enterprises has procured new PCR machines in mid-April from Europe that can do thousands of tests a day, up to 300,000 a month, in ideal conditions according to the machine’s manual. The government says it will ramp up tests, but has yet to elaborate how that will be done quickly with a lack of Level II labs and trained staff.

When Dr. Herwati was asked to estimate the maximum number of PCR tests that could be done nationwide, she said, “Automated high throughput machines can detect 1,000 virus a day at full capacity, running 24 hours a day, so it depends on how it’s used. We are able to conduct 360 a day with our machine. All labs have their own capacity so I can’t provide an estimate on the total number of tests that can be done nationwide.”

Professor Aryati said that the new machines are desperately needed and welcomed, but that it’s important to ensure that the staff downstream in the process are trained properly so these machines can produce accurate test results. “If the whole testing process is done accurately, from obtained a sample properly, using biosafety lab and proper safety precautions and equipment, I think there can be 2,000 tests conducted. But, then you have to do the extraction which is done manually and this has a higher probability of false negatives if it’s not done properly. We hope that the government takes this matter seriously. Therefore, not only getting more PCR machines, but they must also think about the swab process, reagents, safety suits, extraction and then the PCR itself,” she said.

A third method to accurately test for Covid-19 is through rapid molecular testing which uses the same machine used for Tuberculosis testing. Over 900 of these machines exist in Indonesia and each test costs around USD$26 normally. This sounds like a decent solution to ramp up testing. The problem is that these machines have a disposable cartridge with Covid-19 testing. These cartridges are in short supply as only Sweden and the US manufacture them. The US has banned exports of the cartridges during the pandemic and Sweden can’t keep up with the demand.

Reagent Shortage

As if Indonesia wasn't facing enough difficulties with mass testing, a new problem is emerging. Labs conducting PCR tests are having difficulties obtaining reagents. A reagent is a substance or compound used to cause a chemical reaction and used in the PCR Covid-19 tests. The test cannot be done without it.

“Reagents are very important for testing. You can buy a machine but without reagents, you can’t do anything with it. They are now difficult to get due to the low supply and now because it’s hard to ship it here,” said Dr. Herawati.

The government has been scrambling to procure reagents from other countries as Indonesia’s current stock of reagents are in short supply. Dr. Aryati said that her hospital in Surabaya is ready to do more tests but are still waiting for reagents.

She added, “ It seems as if there is no single chain command for getting reagents. It also seems that the institutions that are supposed to be involved in providing these reagents are not doing that. Or maybe perhaps that the global demand is so high in every country due to the outbreak.”

Forecast

The majority of health experts believe that without drastic intervention by the government, experts say that confirmed positive cases could reach 100,000 with peak sometime in May to July. Again, that’s the number of cases that have been tested and shown positive for infection, not the total number of suspected cases.

When Dr. Aryati was asked if she agrees with that estimate, she said it would depend on if the labs are able to enough reagents. “If the reagents have already arrived in early May and we can detect up to around 10,000 tests in a day nationwide, for instance, surely we can have up to 100,000 cases. That’s my assumption.”

She added that a stigma is growing against those who have tested positive for the virus and those who may have come in contact with them and said that this is slowing testing. Some people have been thrown out of their neighbourhoods after being identified as possibly having contact with a patient. “If there is still a stigma in society that prevents people from admitting that they have been in contact with [Covid-19] patients, they won’t inform the community. If that is the case, then in my opinion, I don’t think we can increase testing because even though the PCR machines are available, if no one wants to come and test then there is nothing we could do.”

Mortality rate

Indonesia has a mortality rate surpassing 9%. This is considered quite high compared to many other countries. While Indonesia’s rate is high, there are several factors which may explain why. The lack of capacity to do widespread testing means that only those with severe symptoms tend to receive proper testing, and as a result, are already in poor health. Dr. Aryati explained, “If the confirmed positive cases are higher, then the fatality rate will be reduced. Currently, it seems really high because we only have a small number of confirmed cases. “If we treat not only severe symptoms in the hospital but can treat the others as well, then people can be treated earlier. The death rate won't be as high as it is now. Since the fatality rate it’s so high, which means that those that are confirmed are still low.”

Dr. Herwati also stated that since there has been very low testing capacity in the country, only symptomatic and critical ill patients have been tested which increases the mortality rate. “If we can do mass PCR testing, the number might decline.”

Mudik

We are closely approaching Eid al-Fitr or Idul Fitri as it is known in Indonesia, the end of the Holy month of Ramadan where people traditionally return to their hometowns for the holiday, or Mudik, as it’s known. Initially the government had been very reluctant to ban people from Mudik and only suggested that people avoid traveling to reduce the spread of the virus.

On 7 April, the Widodo administration then changed its mind and issued a partial ban of Mudik, preventing civil servants, police, military and employees of state-owned enterprises from visiting their hometowns for Idul Fitri, but not the general public.

Finally after weeks of cabinet meetings, the government announced on 21 April that Mudik will be banned and the holiday will be postponed until the end of the year.

This policy was very much welcomed as many health experts have been warning against allowing Mudik, as pandemic models predicted that over 14 million people would travel this year. This is something that would clearly lead to the virus spreading to every part of the country and infect one million people as a result, according to Pandu Riono, an epidemiology expert at the University of Indonesia.

Both Dr. Herwati and Dr. Aryati cautioned against allowing the Mudik. “The Mudik will be a source of widespread disease. If we study how the virus spread from Wuhan globally, it was from people travelling. This is not different than people travelling locally in Indonesia. The Chinese New Year holiday and traveling with it made things worse in China. You don’t need any more explanations, it has happened with MERS, SARS and now Covid-19. It has been proven what will happen. People will bring the virus with them, especially the ones without clinical manifestation,” said Dr. Herawati.

Just one day after the Mudik ban was announced, President Widodo made a statement that puzzled many when he signalled that some travel was allowed which is called pulang kampung or “returning to your hometown”, even though both Mudik and pulang kampung are essentially the same activity, which is the transportation of people from one place to another. From the public health perspective, whatever motivation is and what you want to call it, it poses the same danger of spreading the virus at a high rate.

Dr. Herwati ended our conversation by saying, “In the time of a pandemic, what we should have is transparency, facts and need to act fast. Transparency meaning, we have to have good public communications, risk communications and in my opinion, we are lacking these. Singapore for example, gives very clear information regarding the situation when there is a positive case. They are open about announcing who may have come in contact instead of stigmatize them. They are open so people know if they have come in contact and this is important. In the beginning, people wanted to know if Indonesia had cases of the virus, but people weren’t told. Singapore, Australia and Wuhan had flights to Indonesia and these places had Covid-19 cases. The lack of information to the public just allowed for hoaxes to grow and things to become chaotic. If the information is open in the beginning, people may be more prepared, maybe not completely, but at least some will have an understanding of the disease and that can help mitigation.”

Shawn Corrigan is the host and producer of Indonesia In-depth, Indonesia’s leading business, political and culture podcast based in Jakarta. He has spent more than a decade in Indonesia working as a political risk consultant and established Indonesia In-depth in 2017. He speaks English and Indonesian. In addition to the podcast, Indonesia In-depth provides professionals with content services, from podcasts, audio documentaries to social media content.

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