Preventing the Resurgence of Covid-19 Cases
In future, it is better not to wait until there is a tenfold increase in the daily caseload, maybe only a fivefold increase as enough of a reason to retighten the social restrictions.
We should certainly be grateful that the implementation of the public activity restrictions (PPKM) since 3 July 2021 has triggered a reduction in new Covid-19 cases and a clear declining trend from day to day.
The record high in new daily cases to date is around 50,000, which occurred in mid-July. The figure then dropped to around 5,000 cases by the end of August. It means a tenfold decrease over a period of 1.5 months. The positivity rate has also dropped, as has the death rate, although of course we expect the number of those who died from Covid-19 also to continue on a sharp decline.
On the other hand, upon the improving epidemiological situation, and also prompted by the socioeconomic drive, the government has begun to relax the PPKM. The restrictions that had been tight all this time are now being eased. Moreover, quite a number of regions have been downgraded in their epidemiological status from level 4 to level 3, and similar.
Since we all agree that the decline in cases is due to the strict PPKM implementation, of course people will ask, what will be the impacts of easing the PPKM in stages so far? If the number of cases decreased because the PPKM was tight, what should be done so that cases will not rise uncontrollably again once the PPKM is relaxed?
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To answer this, we need to realize that there are three elements that make a surge in cases possible. First, there are people to transmit the virus. Second, the availability of modes or ways of transmission. And third, transmission occurs between healthy people.
Improve 3T, tighten 3M
In connection with the three elements above, at least five steps must be taken to prevent cases from rising again when the PPKM is relaxed.
The first step is to maximally reduce the number of people transmitting the virus. There are two ways this can and must be done. First is to find people in the community who have Covid-19, including those who are asymptomatic. For this, the 3T (testing, tracing and treatment) activities as well as maximum isolation must be carried out.
We know that the government has targeted a daily testing rate of 400,000 tests. However, less than 100,000 people were tested in the last few days of August. In addition, around 15 close contacts must be tested for every confirmed case of Covid-19 to determine whether they were infected or not.
If people are found to test positive for Covid-19 during testing and tracing, of course they can be a source of community transmission. If this is not managed, the caseload will increase again. Therefore, those who test positive for Covid-19 must be found, their health given proper treatment and isolated or quarantined to break the chain of transmission.
Another way to minimize transmission by people who have Covid-19 but have not been detected and are still active in the community is to apply the 3M (mask wearing, handwashing, keeping distance). If a person has Covid-19 and they wear a face mask and keep their distance, the chances of transmitting the disease are somewhat smaller. Yet, they should still be isolated or quarantined.
For the second step, namely limiting the transmission mode, there are two ways to do this. First to maintaining strict 3M. Applying 3M is very important to reduce the potential for contracting Covid-19, so its strict enforcement must be continued, and it appears that we must do so for the long term.
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The second way to limit the transmission mode is to ease the PPKM very gradually and carefully by prioritizing public health and safety. It must be arranged so that people di not gather in crowds.
In India, where the caseload has dropped, a recent increase in the number of cases has occurred in Kerala, partly because of festivals and large crowds.
Maximize vaccination
The third step in preventing the resurgence of cases amid the current declining trend is to increase protection for people who are vulnerable to infection. There are two important ways to increase protection, namely through vaccination and general efforts to boost their immune system, such as following a nutritious diet, exercising, getting adequate rest and managing stress.
Especially regarding vaccination, now is the time to maximize coverage. As of the end of August, data show that only 20 percent of our people have received the second vaccine dose. This means that around 80 percent of the population still have not been fully vaccinated. Indeed, what needs assessing is the number of fully vaccinated people, or people who have received both doses, because the vaccines currently used in Indonesia requires two doses to gain the expected immunity.
The Kompas daily highlighted on 28 Aug. 2021 the low vaccination rate for the elderly, which still remains below 20 percent even though the elderly have a high risk of contracting the virus and becoming ill. Even the cartoon character Mang Usil quipped, “The distribution of the Covid-19 vaccines is neglecting the elderly. They are our parents, you know."
A systematic program is needed in the coming months to maximize vaccination. We know that there is a problem with vaccine availability across the globe. The supply from vaccine manufacturers is lower than the demand for inoculating entire populations in countries around the world.
So far, there are four vaccine sources. First is to buy the vaccines in the international market, pending their availability and a sufficient budget. Second, get it through bilateral cooperation. According to media reports, Indonesia has received vaccines from China, the United States, Japan, and France, possibly other countries as well.
The third way to obtain Covid-19 vaccines is through the Covax multilateral cooperation scheme, an initiative managed by the World Health Organization (WHO), Unicef, Gavi and CEPI, under which I am one of 12 members in the Independent Allocation of Vaccines Group (IAVG). Covax has distributed vaccines to Indonesia and other countries in the world several times and will continue to do so.
The fourth way to get the vaccines, of course, is by producing it, if a country has the capacity. In this case, we are waiting for the mass production of the Merah Putih vaccine, which is currently being trialed according to scientific methods to ensure safety and effectiveness.
If the vaccines are available, four things must be done. The first is to guarantee a good national distribution system to reach all corners of the country. Of course, in this case, a cold chain must be guaranteed because the vaccines will deteriorate if the appropriate temperature is not maintained. The availability of pharmaceutical warehouses in each province, regency and city must also be ensured, as well as accurate distribution management.
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The second is to ensure the availability of health workers for administering the vaccines. This should not be too complicated because after all, we are used to vaccinating children and infnats. It just needs
adjusting because the country now has a few Covid-19 vaccine brands and each has its own specifications that vaccinators must know.
The third and very important this is easy public access to the vaccines. Vaccination centers are now being provided in various public places, such as schools, stadiums and other meeting spaces. Indeed, many people can be inoculate at one time this way, but there is a risk that people will form crowds or queues, which is uncomfortable.
It would be better if the Covid-19 vaccination program was conducted only at puskesmas (community health centers) and hospitals, which total 10,000 units nationwide. All puskesmas and hospitals already have health workers and decades of experience in administering vaccines, and they are spread evenly across the archipelago.
People can thus easily and conveniently be vaccinated close to their homes or workplaces. Also, it would be easier to control any adverse effects following immunization (AEFI), because all people need do is to contact the puskesmas or the hospital where they were vaccinated.
Fourth, if the vaccine supply is still limited, those who need the vaccine first should be prioritized. There are three considerations for selecting the recipients. First, based on the individual’s risk level for contracting the virus, for example by prioritizing health workers, the elderly, and those with comorbidities, because all are vulnerable to contracting Covid-19.
The second consideration is the local epidemiological situation, such as controlling the currently high occurrence of community transmission.
The third consideration is targeted coverage, for example vaccinating teachers, educators and students because limited face-to-face learning (PTM) will start at school, or vaccinating certain areas to increase tourism or ahead of large national events like sports events and the like.
After that, organizers of national and regional Covid-19 vaccination programs must also consider five community groups, each of which needs proper management. First, of course, are the high-risk groups, such as health workers and others that are first priority by international agreement. The second is community groups that need special protection, such as strategic industrial workers, field officers directly serving the public, teachers, and others.
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The third is ordinary people. Public enthusiasm to be vaccinated shows that our vaccination programs are still running for the general public.
Furthermore, we need to pay special attention to two other community groups, namely people who live in remote areas with difficult access (hard-to-reach populations) and members of the public who, for various reasons, still do not want to be vaccinated (vaccine hesitancy). We know that there is a special approach to reaching these last two groups so that vaccination coverage can be maximized.
Strict monitoring
The fourth step that must be made to prevent another explosion of cases is to observe very closely and carefully the developments of regional data. The monitored data must at least include the positivity rate, reproductive number, the number of new cases, the number of deaths, the testing rate and the number of cases that are followed up.
Based on the results of this strict observation of data, a fifth step may be needed, namely retightening the PPKM if necessary. Past experience has shown that we were below 3,000 new cases and then it increased tenfold to 27,000 new cases, so the emergency PPKM was implemented on 3 July.
Tjandra Yoga Aditama
In future, it is better not to wait until there is a tenfold increase in the daily caseload, maybe only a fivefold increase as enough of a reason to retighten the social restrictions.
Hopefully, the current declining trend in confirmed Covid-19 cases can be maintained. And by implementing the five measures above, hopefully the situation will not worsen again.
Tjandra Yoga Aditama, Director of postgraduate program at Yarsi University, professor at University of Indonesia medical school (FKUI), former Southeast Asia director of the WHO, former P2P director general and Balitbangkes head
This article was translated by Kurniawan Siswoko.
