Bringing Down the Death Rate
It is quite difficult to increase the capacity of beds, not easy to find oxygen, difficult to get new sophisticated drugs, but recruiting some hundreds or thousands health workers is really a major challenge to mount.
Didie SW
The July 26 Kompas editorial entitled “Daya Lenting Bangsa Indonesia Diuji [the resilience of the Indonesian nation is tested]” discussed the death rate resulting from COVID-19 with the hope that the declining number of deaths to 1,266 people on July 25 was a signal that the fatality curve was going down further.
However, the data on the following days showed a reversal. On July, 1,487 people died, and on July 27, deaths exceeded the "psychological limit" of 2,000, to be exact, 2,069 of our fellow citizens died of the disease in a day.
The editorial mentioned that the highest daily death toll in India was 5,015 on May 23. India\'s population is about four times the population of Indonesia. So by analogy, the highest death toll in India is equivalent to 5,015 divided by four – about 1,250 in Indonesia, while in reality we have had more than 2,000 people die in one day.
This is, of course, appalling because death numbers are not just statistics. Our family members and relatives who have died will never come back again. And the number is already very high. Maximum efforts must be made to analyze the situation, contain the transmission and reduce the number of deaths from the pandemic. There are at least four aspects worthy of serious attention.
Transmission and new variants
The first aspect to note is that it is clear that the high mortality rate is partially caused by the large number of cases. If community transmission remains high, cases will continue to grow, and severe cases and deaths will also continue to increase proportionately.
The first aspect to note is that it is clear that the high mortality rate is partially caused by the large number of cases.
Transmissibility in the community is marked by the positivity rate, which in Indonesia has reached 25 percent. If based on PCR testing, the figure would be more than 40 percent.
The positivity rate of 25 percent (even up to 30 percent in the past few days) is evidently very high. Neighboring Malaysia, which is also facing a spike in its caseload, has a positivity rate of only around 9 percent. India, which once showed a sharp escalation, is now at only about 2 percent.
The high positivity rate indicates highly expansive transmission in the community. This means that the number of the infected and ailing people will continue to pick up, and some of them will experience serious illness, possibly leading to death.
It is evident that to reduce the death rate, efforts at the upstream should be the main priority by suppressing the transmission rate in the community in order to prevent new cases.
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The emergency public activity restrictions (PPKM Darurat), which are part of social distancing measures to reduce the transmission rate, must be supervised strictly and in a measured way, based on scientific evidence.
Stepping up swab testing and contact tracing is also imperative. Only with massive testing and extensive tracing can we track new cases in the community, followed immediately by providing treatment to people thought to have the illness before it is too late. Admit to self-isolation those who are found positive so that the transmission chain can be cut. In this context, vaccination should also roll on consistently and extensively to realize the target of 1 million to 2 million vaccinated citizens per day.
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There was an addition to the first stage on Thursday (28/2/2021) at the health center for those who had not been vaccinated. A total of 3,700 doses of Covid-19 vaccines have been prepared to be distributed to nine hospitals in Setiabudi district. Problems with vaccine data collection and distribution, which caused the first phase of the Covid-19 vaccination program to be prioritized for health workers, persist.
The second aspect of the death rate is related to the fact that we are coping with new variants of the COVID-19 virus. In his speech on July 25, President Joko “Jokowi” Widodo warned that we had to be vigilant against the highly contagious Delta variant. The President even reminded Indonesians that there was a possibility that the world would face other more contagious variants.
The second aspect of the death rate is related to the fact that we are coping with new variants of the COVID-19 virus.
On July 12, World Health Organization (WHO) director general Tedros blamed the escalating cases and deaths on the global reach of the fast-spreading Delta variant, which is reported to have been found in more than 104 countries. And it is not unlikely that the variant will dominate the world’s concerned situations in the future.
WHO COVID-19 emergency committee chairman Didier Houssain stated on July 12 that it was likely that additional variants that were more dangerous and more difficult to control would appear in the future. This means that we are indeed up against new variants, which are likely to be cause increases in transmission and death.
For this, the whole genome sequencing (WGS) examinations in our country should be enhanced to enable us to detect existing variants and get well prepared with anticipatory measures.
Self-isolation and hospitalization
The third aspect is the handling of those who are undergoing self-isolation. Before talking about self-isolation, it would be of significance if there were an analysis of the thousands of daily deaths – how many died at the hospital, how many died at home, how many had been taken to the hospital but couldn\'t be taken in and so on.
With an in-depth public health analysis like this, we\'d know where the problem was and what needed to be done to address it more precisely.
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Preparing food for covid-19 self isolation patients in Semarang, Central Java, Saturday (31/7/2021).
Regarding those who are self-isolating at home, there are four very important things to do. First and foremost is a routine evaluation on their condition at least twice a day to check their temperature with a thermometer, oxygen saturation with an oximeter and changes in symptoms, as well as changes in the inhibiting comorbidities.
It would be helpful if all those undergoing self-isolation were provided with thermometers and oximeters. If they are living with diabetes, for example, their sugar levels must be monitored periodically with a rapid test. If the patient has a history of hypertension, their blood pressure should be checked at least twice a day.
So, in addition to COVID-19 infection, an examination must be carried out on the existing diseases, because aggravating comorbidities will exacerbate the impact of COVID-19 and likely lead to critical condition or even death.
The second thing about self-isolation is that there should be communication with health workers on a regular basis, advisably every day. This can be done by telephone or WhatsApp messages to hospitals or health centers or via telemedical services provided by the government or with a doctor or another health worker the patient is already familiar with. With this regular communication, a worsening condition can be detected early and treated immediately.
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The third thing is the provision of drugs – both for COVID-19 and for comorbidities. Drug taking, apart from the consumption of vitamins and other unprescribed drugs, should be consulted with a doctor.
The fourth thing is that those in self-isolation should maintain hygienic and healthy lifestyles, eat nutritient-rich foods, do physical exercise, get enough rest and manage stress well.
Death ‘audit’
The fourth aspect in controlling the death rate is the handling of critical patients in hospitals. This aspect is indeed very important, but it is equally urgent to address the root of the problem by suppressing community transmission to reduce the number of cases.
The fourth aspect in controlling the death rate is the handling of critical patients in hospitals.
Regarding deaths in hospitals, there needs to be a mortality audit, a procedure that has been routinely carried out at a number of hospitals. When the data from the audit is collected and compiled, a national pattern will be obtained showing what factors are associated with deaths.
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A woman who tested positive for Covid-19 at community health center (Puskesmas) in Duren Sawit, East Jakarta, awaits a car that will take her to the Covid-19 hospital in Kemayoran on Tuesday (26/1/2021). The total number of Covid-19 cases in Indonesia per 26 January 2021 at 3:53 p.m. was recorded at 1,012,350, with total deaths of 28,468. The daily addition of cases and deaths in Indonesia was quite high compared to other countries. With a positive test ratio of 27.8 percent in the past week and the low number of people being tested, it is almost certain that the real number of cases is higher than that being reported.
The trend of patients arriving late to the hospital is certainly related to the health service referral system. This means that efforts to reduce mortality must also involve primary health services and the national health system as a whole.
Regarding oxygen, it has been discussed considerably, and hopefully over time it will be resolved.
Regarding the availability of emergency unit (IGD) and hospital beds, many of the problems have also been dealt with. Intensive care unit (ICU) beds and their support equipment need serious attention, although health workers certainly need attention as well.
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The WHO includes the number of skilled ICU personnel as an additional indicator to determine the social restriction level from level 1 to 4. The availability of sophisticated drugs, such as tocilizumab, intravenous immunoglobulin and monoclonal antibodies, should also be pursued.
We need to use drugs that are recommended by international organizations such as the WHO and national bodies such as the Health Ministry, the Food and Drug Monitoring Agency (BPOM) and medical professional organizations. These authorized health bodies and organizations administer the medication that is proven to be scientifically effective and safe.
A motorist drives past street art on Thursday (2/4/2020) beneath the Jl. Latuharhari overpass in Central Jakarta. Graffiti artists and talented locals have responded to the public health emergency by painting murals and graffiti to raise awareness and urge togetherness, as well as to cheer on medical workers on the front lines of the outbreak in Indonesia.
In the health treatment service for COVID-19, we need to emphasize once again the central role of health workers. It is quite difficult to increase the capacity of beds, not easy to find oxygen, difficult to get new sophisticated drugs, but recruiting some hundreds or thousands health workers is really a major challenge to mount.
In the health treatment service for COVID-19, we need to emphasize once again the central role of health workers.
Meanwhile, health workers must also get ample protection in their duties, decent working hours, proper personal protective equipment (PPE), and the fulfillment of their rights in carrying out their duties.
We must suppress and control the deaths due to COVID-19. The way to overcome the pandemic must be based on an analysis of the situation, and must be carried out from upstream to downstream as a whole. Everything needs to be prioritized. We have to do it all.
Tjandra Yoga Aditama, Director of postgraduate studies at YARSI University, professor at the University of Indonesia Medical School, former director of WHO Southeast Asia, former Health Ministry director general of disease prevention and control (P2P) and head of the Health Research and Development Agency (Balitbangkes)
(This article was translated by Musthofid)
