Implementation of ‘PPKM Darurat’
PPKM Darurat are stricter than the previous micro PPKM regulations. Of course, with these tighter restrictions, it is hoped that virus transmission can be reduced and the rise in cases controlled.
Emergency public activity restrictions have been implemented in several areas in Java and Bali, from 3 to 20 July 2021.
On the first day of the emergency public activity restrictions (PPKM Darurat) on 3 July 2021, the number of daily new cases of Covid-19 reached a record high for that time, which was 27,914, and reportedly it would be lowered to less than 10,000 per day.
PPKM Darurat are stricter than the previous micro PPKM regulations. Of course, with these tighter restrictions, it is hoped that virus transmission can be reduced and the rise in cases controlled. It is also hoped that hospital capacity will be reduced so that those who need services do not have to queue for the emergency ward (IGD) as they do now. Also, health worker casualties can be decreased.
Indeed, there are those who still question that these social restrictions are not yet strict enough, partly because the essential sector can still go to the office with a maximum office capacity of 50 percent, and the critical sector even 100 percent.
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The concern is not only the mobility of employees in the essential and critical sectors, but also those in other related sectors, either directly or indirectly, which are quite large in number. However, of course we need to hope that these PPKM Darurat will play an important role in controlling Covid-19 in our country, of course if its implementation goes well and firmly.
Monitoring and targets
What now needs to be done is to monitor the existing situation to determine the next policy steps and get the best impact. In this case, the World Health Organization (WHO) often uses the term public health and social measure (PHSM) to describe social distancing efforts.
On 23 June 2021, WHO Indonesia in the "Situation Report" mentioned two characteristics of PHSM that can be associated with monitoring the situation during PPKM Darurat implementation.
The current decision to implement PPKM Darurat in certain regencies/cities in Java-Bali until 20 July 2021 is in line with this principle.
First, very strict social restrictions are indeed imposed in a certain area and at a certain time, so do not extend it for a long time because it will certainly greatly affect the socioeconomic community. The current decision to implement PPKM Darurat in certain regencies/cities in Java-Bali until 20 July 2021 is in line with this principle.
The second characteristic of PHSM is that social restrictions can be further tightened when the situation worsens, something we do not expect of course. The experience of other countries shows that their social restrictions have been extended from the original plan because the target has not been achieved.
Commuters leave the Woodlands Causeway across to Singapore from Johor, hours before Malaysia imposes a lockdown on travel due to the coronavirus outbreak, in Singapore March 17, 2020.
Malaysia, for example, started a total lockdown, which they call a movement control order (MCO), on 1 June 2021, when there were 7,105 new cases of Covid-19 and 8,209 cases on 3 June 2021. After the lockdown, this figure continued to decline to the lowest on 21 June with 4,611 new cases, but then it rose again to 6,982 on 2 July 2021.
With these fluctuations, within one month of lockdown (whose enforcement is indeed stricter than our PPKM Darurat), several areas in the country were imposed with a lockdown, even tighter in the first days of July 2021, but on the other hand restriction is eased in several states that have met the pandemic response indicators. This means that the decision is truly situational based on local data.
Another example is India. New Delhi, the capital city of India, began implementing a total lockdown (again, admittedly more stringent than our PPKM Darurat) on 19 April 2021, originally planned for only a week, but later turned out to be extended.
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India\'s cases still increased and it was only on 6 May 2021 that it peaked with 414,188 cases a day. That was almost three weeks after the lockdown in New Delhi. After that, the cases continued to decline and it was only on 31 May 2021 that a gradual easing in the form of the unlocking process began, meaning a total lockdown for almost 1.5 months.
Several other major cities in India have also implemented social restrictions to varying degrees, and quite a number of large cities (such as Mumbai) have also implemented total lockdowns. Cases in India have now fallen considerably from 400,000 a day to 44,111 on 2 July 2021, a nearly tenfold drop in less than two months. An amazing achievement.
To determine which areas and how long the PPKM Darurat will run, and whether they will be tightened or relaxed, as in the examples in Malaysia and New Delhi above, of course, requires a monitoring system that is good, accurate and based on scientific data.
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A public order officer is on guard to ensure people wear masks at Rawa Terate, Cakung, East Jakarta, on Thursday (21/1/2021). The operation was held in response to a lack of discipline among residents in adhering to health rules. The relatively low discipline of residents is complying with community restrictions has been identified as one reason for rising Covid-19 infection numbers.
Good monitoring is one of the main keys to the success of the PPKM Darurat that we are currently implementing. One way is to use digital technology in the form of movement restriction and mobility change, which analyzes the pattern of population movement during social restrictions, which then results in a decrease in population mobility and is associated with a decrease in the number of cases from day to day.
Almost the same method has also been used to see the increase in population mobility during long holidays in our country with an increase in cases that has occurred several times.
Another way is to use the PHSM severity index approach, which is also used by the WHO, which assesses six main indicators of the success or failure of a social restriction activity. This can also be applied to PPKM Darurat if needed, of course it can be modified as needed. The six indicators are discipline in wearing face masks; school closures; closing/restricting the operation of offices, businesses and other institutions; prohibition of gathering crowds of people; restrictions on population movement; and international flight restrictions.
Currently what seems to be used is the number of cases and the number of beds available in the form of the hospital bed occupancy rate.
These various approaches can also be combined in the form of an analysis of risk indicators that matrixes the magnitude of the pattern of transmission in the community with the available response capacity. The parameters to be targeted can be a combination of several things. Currently what seems to be used is the number of cases and the number of beds available in the form of the hospital bed occupancy rate.
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What is also a very appropriate target is the positivity rate, because it describes how big the pattern of transmission in the community is. The positivity rate on 3 July 2021 on the first day of the PPKM Darurat was 25.2 percent, which was divided into the positivity rate based on the PCR test (which is the gold standard) that was 36.7 percent and based on the antigen rapid test that was 7.8 percent.
It would be good to analyze why there is an almost fivefold difference in positivity rate between these two tests, and the results of the analysis can be used as a basis for making sound decisions. According to the WHO benchmark, which has also been written in the Health Ministry document, the benchmark for the targeted positivity rate for easing social restrictions is 5 percent, of course if the number of tests has been carried out with an adequate number, namely at least one test per 1,000 population per week.
Another parameter that can be targeted is the case reproduction rate, both in the form of the basic reproduction number (Ro) and the effective reproduction number (Re/Rt), a figure that should also be announced periodically to the public. Monitoring of these targeted parameters certainly needs to be done locally, say in every regency/city, or maybe even in a smaller area than that.
Commuters take the Woodlands Causeway to Singapore from Johor a day before Malaysia imposes a lockdown on travel due to the coronavirus outbreak in Singapore March 17, 2020.
Various approaches to monitoring and calculating the targets to be achieved during PPKM Darurat must indeed be carried out in a valid scientific way so that further policymaking truly meets the principles of evidence-based decision-making process and provides maximum impact.
Tests, traces and vaccinations
In addition to social restrictions in the form of PPKM Darurat, we welcome the government\'s decision to increase testing and tracing and vaccination. On the first day of the PPKM Darurat, tests were carried out on 110,983 people, the initial figure was quite encouraging because previously it was always below 100,000 per day. The decision to increase the number of people tested to several hundred thousand people must be realized because only then can we truly know the magnitude of the problem. Cases in the community will also be found, handled and isolated/quarantined so as to break the chain of transmission.
If India has succeeded in conducting tests on about 2 million people per day, then with our population which is about a quarter of India\'s population, the target of testing up to 500,000 a day seems worth pursuing.
If one of them turns out to be positive for Covid-19, another 15-30 contacts must be traced, and so on.
Of course, after testing is carried out, it must be followed with massive tracing activities for every case found, and it has also been determined how many targets to look for and find from each positive case, say 15-30 contacts that must be found. If one of them turns out to be positive for Covid-19, another 15-30 contacts must be traced, and so on.
Regarding vaccination, we are grateful that the number of 1 million a day has been exceeded. Many have discussed the various targets to be achieved. If we take India again as one of the benchmarks, then that country has succeeded in vaccinating 8 million people a day. Accordingly, achieving 2 million vaccinations a day in our country is a viable target.
In conclusion, there are three things that can be said. First, it is well said that field implementation is the key, followed by monitoring and evaluation of the situation based on appropriate scientific evidence. Second, PPKM Darurat must be implemented jointly with the community.
Tjandra Yoga Aditama
All of us are an active part in the implementation and success of PPKM Darurat, and there is no need to "blame each other".
The third thing, for us individually, let\'s always implement strict health protocols, according to the hashtag “Pesan Ibu [Mother\'s Message]”, wear masks, wash hands and maintain distance, while still limiting unnecessary mobility and avoiding crowds. Hopefully, we as a nation can control Covid-19, and all of us can give our respective positive roles.
Tjandra Yoga Aditama, Director of Postgraduate Studies at Yarsi University; professor at the Medical Faculty of the University of Indonesia (FKUI); former director of the WHO for Southeast Asia and former director general of P2P and head of Balitbangkes.
(This article was translated by Kurniawan Siswoko).
