‘No Quarantine’ Policy Program

Another interesting news story came out. The government plans to do a trial of the no-quarantine policy in Bali starting March 14.

Visitors from abroad, both foreigners and Indonesian citizens, no longer need to undergo quarantine as long as their vaccination shots are complete and the PCR test results are negative. If this trial is successful, as of April 1, this quarantine-free policy will be implemented throughout Indonesia.

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This news was met with mixed reactions. For foreign tourists and the diaspora, this news is definitely encouraging. With this program, they no longer need to undergo quarantine, which drains time and money. Until now, all arrivals from abroad have had to undergo quarantine, which varied between three and 10 days. For some experts, this news is troubling.

Why does the government dare to open the door wide when the outbreak of Omicron has not yet subsided?

Multifactor rationality

Compared to a number of other countries, Indonesia has recently relaxed its restrictions. Currently, dozens of countries have relaxed their restrictions, including ending quarantine policies. The United Kingdom, India and France are examples of countries where relaxation is now very loose. As long as they have complete vaccinations, there is no need for a PCR test to enter these countries.

In Southeast Asia, Thailand, the Philippines and Malaysia have stopped quarantine policies for some time. Some are for its citizens only and some are for all visitors. Each country has its own justification for ending the quarantine policy. There are multiple justifications. In addition to considering internal and external epidemiological profiles, economic, social and political factors also have an influence. The justification of the Indonesian government is the same.

Mortality increased 20-fold, from 0.03 to 1.61 per 1 million head of population.

At the national level, the epidemiological profile of the pandemic shows an improving trend. Two months after the outbreak of the pandemic, the case rate has indeed increased 300-fold, from 0.67 cases to 201.5 cases per 1 million head of population. The death rate has also increased, the increase must not be linear in proportion to the rate of cases. Mortality increased 20-fold, from 0.03 to 1.61 per 1 million head of population.

Interestingly, the fatality rate of infected people (case fatality rate or CFR) decreased drastically from 3.4 percent to 0.5 percent. This epidemiological profile gives a clear message that although

Omicron transmits sporadically and massively, the fatality rate is relatively low (widespread but mild).

At the same time, Indonesia's vaccination coverage is already high. As of March 1, 2022, the proportion of the population who have received the first, second and third vaccines are 70 percent, 54 percent and 3.7 percent, respectively. This is a brilliant figure and has met the standards of the World Health Organization (WHO). The combination of improved epidemiology and high vaccine coverage is an important justification for the quarantine-free policy plan.

At the global level, the pandemic situation is also improving. In the midst of the Omicron outbreak that is sweeping through the world, the case rate has dropped from a peak of 435 cases to 193 cases per 1 million head of population. This rate is expected to continue lower due to the Omicron factor, which is widespread but has a minimal effect.

Although it increased during the early Omicron outbreak, the death rate has now fallen back to 1.1 per million inhabitants. At last year's peak and this year's Omicron peak, the death rate ranged between 1.85 and 1.39 per 1 million inhabitants. This means that there is a significant decrease.

The world's CFR profile is also a relief: dropping from 7.8 percent at its peak in 2020 to 0.4 percent today. Some experts even predict this CFR will lower to below 0.1 percent. Global vaccination coverage is also stunning: 63 percent of the world's population has received one dose and 55 percent two doses. Improvements in the global profile have made many countries feel confident that the pandemic will end and are competing to soften their restrictions.

Only a few countries continue to adopt a zero-Covid policy with strict restriction programs, including lock-down. This global improvement is one of the bases for the WHO to say that the pandemic status will become endemic this year and the Covid-19 emergency status will be lifted.

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Non-health factors, such as economic and political, also influence the decision to loosen quarantine. Several countries around Indonesia have relaxed their restrictions and made it easier for foreign travelers to visit. Since a few weeks ago, Singapore has been implementing a vaccinated travel lane (VTL) program that allows travelers from certain countries to enter with no quarantine.

This program will be extended to all countries in the near future. As of 1 March, the Malaysian government stopped the quarantine program and allowed visitors to enter the country as long as they had been vaccinated and the PCR results were negative. Thailand is even faster, since 1 February they have scrapped the quarantine program for visitors who have been vaccinated. With this program, they are targeting to welcome 5 million-9 million tourists this year.

In fact, the tourism sector is an important commodity that accounts for 4.8 percent of gross domestic product (GDP).

The emergence of quarantine-free programs in a number of neighboring countries has sparked economic and geopolitical issues. If Indonesia does not participate in softening its quarantine, tourists will most likely flee to neighboring countries that have freed quarantine. Income potential is lost. In fact, the tourism sector is an important commodity that accounts for 4.8 percent of gross domestic product (GDP).

Due to the lack of tourist visits, in 2020 alone, Indonesia lost more than Rp 10 trillion. In 2021, foreign tourist arrivals declined by 62 percent. Greater losses will occur if this issue is not addressed.

At the same time, geopolitical considerations are also a factor. There would be a negative perception when countries around Indonesia have scrapped their quarantine policy and Indonesia still keeps it. There will be an impression that the pandemic has not been controlled or that Indonesia's health system is inadequate.

This excuse sounds cliché, but the effects can be serious. There are still subjective views of the global community that link quarantine with controlling the pandemic. Countries that have ended the quarantine program are considered successful in controlling the pandemic and vice versa. It’s a cliché excuse, but real.

Not a cowboy program

Each country takes a different stance on relaxation programs. Some countries implement full relaxation. They allow visitors to enter their country without restrictions or only with minimal restrictions. They do not care about the status of the country of origin, vaccines and PCR results of the visitors. They don't even require visitors to wear masks and keep their distance.

Some call this stance cowboy style. Some other countries are still vigilant, allowing relaxation, but with restrictions. They apply the principle of risk stratification by looking into the country of origin, vaccination status and PCR test of the visitors.

In Indonesia, the government cites some requirements for implementing no-quarantine policy. Among other things, visitors must have got a complete dose of vaccine and underwent PCR twice, namely on arrival and on the third day. This means that the government does not adopt a full relaxation model. This step is very correct. Visitor risk stratification is indeed necessary. Two important criteria, namely vaccination status and PCR results, became the criteria for consideration of the quarantine-free policy.

The criterion that is not used is the status of origin of the immigrant country. In fact, the status of country of origin is important because the quality of management and the risk of transmission differ from country to country. Some countries have succeeded in controlling the pandemic and reducing the risk of transmission; other countries struggle with high cases and deaths and high risk of transmission.

Hong Kong, for example, is currently experiencing its fifth wave with a high number of cases and deaths. The daily number of cases once exceeded 16,000; the highest number in the country during the pandemic. Singapore is also experiencing the same, daily cases are currently 18,000. In both countries, the case rate ranges from 250-350 cases per 100,000 head of population.

The United States Center for Disease Control (CDC) categorizes these two countries as level 3-4 (high and very high risk) and advises their citizens to avoid traveling to these countries.

The government should include country of origin as one of the criteria for this quarantine-free policy. Different treatment needs to be applied for visitors from high-risk countries and travelers

from low-risk countries. The risk of transmission of visitors from high-risk countries is certainly greater and therefore additional requirements are needed to minimize the possibility of transmission.

For example, they must perform a PCR test in their home country 48 hours before leaving. Or after the first PCR test in Indonesia they can only carry out activities in hotels. In essence, the quarantine-free requirements cannot be applied equally to all travelers from high-risk and low-risk countries. In addition, when the policy is implemented, it is necessary to closely monitor a number of epidemiological indicators. This is important because the influx of migrants can increase cases and deaths.

A study shows that for every 1 percent increase in visitors from abroad, there will be a 1.2 percent increase in positive cases and 1.4 percent in deaths. The case rate, mortality rate, positivity rate, reproduction number, hospital bed occupancy and vaccination coverage need to be continuously monitored.

The emergence of 100-500 cases per 100,000 population is one of the CDC's red lines. If this limit is exceeded, a change in management will need to be made.

There must be a red line for each parameter. If the red line is exceeded, adjustments must be made to the rules and management immediately. The emergence of 100-500 cases per 100,000 population is one of the CDC's red lines. If this limit is exceeded, a change in management will need to be made.

Although the quarantine-free policy program in Indonesia is based on rational considerations, it is very important not to be rash with this program. The WHO reminds that although relaxation policy cannot be separated from economic, social and political interests, it is very important to meet three factors for relaxation: high immunization coverage, a strong health system and improving epidemiological trends.

Failure to consider these three aspects can lead to an increase in transmission, spread of disease and death. Therefore, the quarantine-free policy program should be based on rational, realistic and correct considerations and not only based on short-term interests. The quarantine free program is not a “cowboy” program.

Iqbal Mochtar,Physician and doctor in health and medicine. Observer on health issues

(This article was translated by Kurniawan Siswo)