New normal: homework for the government and the people

Indonesian government introduced the term 'new normal' in May, and this period officially began in early June. Malls, offices, public spaces, and flights are resuming with the hygiene and health protocols.

As the 'new normal' commences, we see a growing number of COVID-19 cases in Indonesia instead. Since mid-June, the daily number of confirmed cases has fluctuated around a thousand per day, setting a new trend in our country. This increasing rate raises the alarm about how Indonesia handle the pandemic.

Actually, how is the management of COVID-19 case in Indonesia?
Once diagnosed, person under monitoring (ODP), patient under supervision (PDP), or close-contact without symptom (OTG) will continue the evaluation and contact tracing guided by national epidemiological surveillance form.

The next step varies between regions based on their testing capacity and isolation facility.

For instance, in the satellite city where I work, most patients with mild symptoms receive medications and begin isolation at home while waiting for the test schedule from regional Dinas Kesehatan. Once confirmed with COVID-19, they resume self-isolation at home. In this situation, staff from nearby Puskesmas monitor them virtually every day until their cases finish. Only a few isolation facilities are available for suspected or confirmed mild cases.

On the other hand, patients with old age, chronic health problems, moderate or severe symptoms can receive treatment in COVID-19 hospital.

In most facilities, SARS-CoV-2 antibody or antigen rapid test is the way to screen COVID-19. People tested positive with the rapid test need to confirm the result with the swab test, a more accurate tool. Subsequently, many of them have to wait for around a week or more to know their swab test results.

From this story, we can still see delays in diagnosis and isolation facility limitations, even in the satellite city near Jakarta. 

The system will be different for patients who can pay. If they can spend about 200-500 thousand rupiah for rapid test and around 1-2 million rupiah for a swab test, they can readily be tested and receive the results.

In addition, some areas and institutions have held free COVID-19 rapid tests or swab tests, but we can find this mostly in major cities.

The issues to be solved
Until now, Indonesia is still among Asian countries with the lowest testing rate. Indonesia's daily testing rate started at only 0.001 per thousand in late March. This figure has increased gradually and peaked at 0.04 per thousand after three months.

As a result, experts warn that we should carefully interpret Indonesia's curve because it is not accurate enough to picture the population. Exaggerating this problem, the limited test kit slows the surveillance process for most people that they have to wait until up to a week or more until knowing their COVID-19 status. New cases we identify today could be the reflection of cases diagnosed days or weeks before.

The other issue comes from the isolation and quarantine facility. As seen in the national guideline, protocol for patients with mild or without symptoms is home-isolation. However, this method has some drawbacks, according to studies.

A model estimated that institutional-based isolation is better in reducing COVID-19 transmission than the home-based isolation because isolation at home requires sufficient knowledge and proper measures. An ideal self-isolation is hard to meet for low educated people and those who live in tiny and crowded houses. Another study found secondary transmission occurred in thirty percent of household contacts. 

Besides the limited healthcare capacity, stigma problems regarding COVID-19 arise in society. Some people, along with their close contacts, do not want to be tested because they will be ashamed if the result turns out to be positive.

Moreover, many people believe that COVID-19 is just a conspiracy or false news, so they think people should resume their usual activities without aware of the importance of testing and isolation. These problems further obstruct the epidemic control of COVID-19 in our country.

Homework for the government
As learned from other countries, a combination of social distancing, large-scale diagnostic capacity, and centralized isolation or quarantine facilities has resulted in slowing COVID-19 transmission; thus, they can begin easing restrictions step by step.

The first thing to do is to ensure adequate and reliable testing kits in healthcare facilities. These modalities would help physicians, experts, and country to visualize individuals' and populations' immunity.

Behind the examination desk, physicians need reliable diagnostic modalities to confirm whether a case is a COVID-19 or not. COVID-19 diagnosis has been challenging because it mimics many diseases.

Not only to test patients, but the kits also be used to test the close contacts. Plenty of point-of-care testing would help catching and tracking the virus immediately from individuals.

From the public health perspective, extensive testing represents a larger sample that can estimate the population immunity more closely. This data should be the basis for the government before easing restrictions.

Secondly, following testing and contact tracing, isolation and quarantine are crucial to support prompt treatment and focused monitoring.

Isolation separates sick people with healthy ones, while quarantine separates people who were exposed to contagious diseases to see if they become ill. Testing without these strategies means letting people go back to their community despite the likelihood of infecting others.

Some regionals already took the initiative to provide isolation or quarantine facilities for confirmed or suspected patients with any severity status. Each area should follow this step to strengthen the national mitigation efforts.

We need to keep our guards up
Although the government allowed activities to resume, we should keep our guards up because the pandemic is not over yet. Even the experts predict that COVID-19 remains spreading until up to the end of 2021.

We should continue obeying preventive measures, such as frequent hand washing, minding cough etiquette, keeping a safe distance, wearing masks, and avoiding crowds.

Furthermore, we can help to control the circulation of false information and to reduce the stigma, starting from ourselves by checking the accuracy of a particular topic before sharing it with the others. 

To sum up
Although the government has decided to allow the new normal, we have to keep our guards up. Of course, our government has some homework in handling this pandemic; however, we should work hand in hand with the government to control the virus transmission.