Doctor Pande Jauraga is a doctor of Public Health (MD-PhD) who graduated from Flinders University in Australia with a medical doctor background. He is currently a lecturer at the Faculty of Medicine of the University of Udayana (Unud), unit head of the Center for Public Health Innovation and coordinator of the IKM S2 program (Master degree program for Public Health Sciences). Rio Helmi interviewed him 2 days ago. An Indonesian version of this article was published here yesterday
Rio Helmi:Doctor Januraga, recently social media and the public has been rife with theories about covid-19 immunity in Bali. There is also a theory that the real peak of the pandemic in Bali has passed, and so forth. As someone who is trained in public health, do you find any evidence or argument that this is likely?
Dr. Pande Januraga: The theory of immunity comes from the concept of herd immunity which in epidemiology equates to immunity against infectious diseases. This immunity is obtained by people living in certain places where the majority have gained immunity due either to vaccination or exposure to previous infections, and as a consequence this serves as a protection for the non-immune population. At least 60% of the population must be immune to be able to protect the members of the communities that are non-immune and an even higher percentage may be called for where infectious diseases are caused by germs whose transmission is very aggressive such as in the case of SARS-CoV2 that causes COVID-19. Well obviously, since there has been no available vaccination for COVID-19, this leaves the second option of exposure to previous infections, and so if this is the case is it reliable to suppose that 60% of Balinese have been previously infected? This is hard to believe. There is a blog that claims that in early January to February there were many hotels in Bali that dismissed employees who reported being ill. Wow! Where are these reports? What were the symptoms? Was this really COVID? How many hotel employees in Bali make up 60% of the entire population? This is difficult to accept. Also, if it is true that a large enough number of Balinese have suffered from COVID-19, then there must be available statistics allowing the calculation of approximately 10% of seriously ill patients as well as 5% needing ICU treatment, and allowing for at least 20% of those who entered the ICU to have died. You can try calculating the numbers yourself based on 60% of the population of Bali. If we have 4.5 million people, this means that 2.7 million have been infected, 270 thousand that were symptomatically ill, 135,000 needed ICU treatment and 20% of these 135,000 have died, amounting to at least 27 thousand deaths; this is hard to imagine, don’t you think?You can try lowering the count to half of the above percentage, but even then there have never been any reports of such incidents of morbidity and mass death over January and February in Bali. What if it is true that the Balinese really did get ill but only lightly? … Perhaps, but this still does not explain much; does this prove there is a genetic influence? There are still no answers.
OK, some could argue that the percentage of infected people need not be so high. If so, then what are we banking on? Ever heard of polio? Polio vaccination was campaigned 100% because it was so difficult to achieve herd immunity.
Then there is another aspect: how long does immunity to COVID-19 last? This is a new disease so as yet there are not many related studies. But think about it: up until today no vaccine has even been found for MERS and SARS, and these are both viruses of the same family as Corona. Why? Because it is very difficult to test for immunity to this particular type of virus). This is also why it is so repeatedly stated that it takes time to find a vaccine. Don’t forget influenza. If you have lived in a country where there are four seasons, you are up for an annual vaccine, which shows that the immunity offered by the vaccine does not last very long. So you can judge for yourself what kind of a claim promises you 30 years of immunity if you recover from a bout of Covid-19. You need 30 years to wait for such a claim to materialize hehehe.
For the second question: is Bali really over the peak? Let’s be sensible, this statement is not backed up by any data. Just take a look at the Bali Task Force report, is there any graphic image showing that the numbers of cases are continuing to fall? It is still fluctuating. I personally hope it is over the peak, but look at the data.
Monkey Forest Road in Ubud, normally the site of traffic jams, now almost dead quiet.
RH:From the perspective of your expertise, what is your response to the massive amount of similar theories circulating in the community? Do you see a need for public education, or intensive socialization from scientists / experts?
Dr PJ: At the moment our society is flooded with information. Everyone wants to play an active role in creating and sharing information, and this includes what we are doing now, this interview. But the thing is that information needs to be carefully digested and based on a progression of data that is properly backed. As long as reports keep coming in, it means the war is not over.
Because the public is flooded with information, and there are even many free webinars, it has become difficult to develop media that can serve as a trusted source; there are too many channels. Serious efforts are needed to map public channels that can be used as reliable avenues of accurate information while also being well-liked by the community. This calls for mass communication experts, media, and people capable of having an effect, including influencers, to sit down together.
In my opinion it is not only the community that is overwhelmed by the floods of information but also politicians and policy makers. I would advise them to put their trust in science and technology!
RH:Until now, procurement of data in Bali seems beset by obstacles: lack of testing, stigmatization factors, and also the news of “false dengue” or covid-19 that is veiled by dengue. Is it actually true that these are significant obstructive factors? Or are there other issues that weigh more on the situation.
DrPJ: This is a complex question, but let me try to dissect it:
- Lack of testing: this is almost certain if the benchmark is swab sampling and real time PCR (Polymerase chain reaction) testing; the outcome of a number of such tests has been considered worthwhile, and somewhat different from the rapid test. So far, only patients under surveillance (PDP/pasien dengan pengawasan) have been tested by PCR, while patients being monitored (ODP/orang dengan pemantauan) do not get a swab for PCR, just a rapid test. Not all migrant workers (PMI/pekerja migrant Indonesia) have been tested, only those who have tested positive by quick test receive a PCR swab. As I explained before, most infections are asymptomatic or mild, so if there is talk of ‘underdiagnosis’, I would agree. Does this mean the rapid test is inaccurate? Not exactly since the rapid test being circulated in Indonesia tests the presence or absence of an immune or antibody response due to a viral infection where the general response can appear anywhere from 1 week after infection to even 4 weeks; so timing or when the test is done is very important. Another issue is that the rapid test is not specific to SARS-CoV2, but only for infections due to the corona virus. I explained earlier that COVID-19 is caused by SARS-CoV2 and is only one type of corona virus. This implies a possibility of false negatives and on the other hand there may also be false positives. This is why our PMI friends are still asked to quarantine for 14 days despite having negative rapid test results.
- Stigma is caused by lack of appropriate information. There is a lot of information but people are left to search for themselves to fill in the gaps, to receive and filter the information on their own. The problem lies in the fact that they do not have enough background to be able to filter correctly. Also, on the one hand they neglect physical distancing and the use of masks, while on the other hand, they reject the corpses of patients who died of COVID-19.
- False dengue is a term that began to circulate after a scientific article reported that patients diagnosed with dengue turned out to suffer from COVID-19 and lately symptoms of COVID-19 have become more varied, with symptoms that liken to dengue being only one amongst others. I sought to verify this among doctor friends serving in several different hospitals in Bali, and found there was indeed a tendency for an increase in cases of dengue over the last two months. So far according to them the symptoms were still typical of dengue. The good thing is that the National Health Insurance Policy (BPJS/Badan Penyelenggara Jaminan Sosial Kesehatan) now allows NS1 and Dengue serology to help diagnose, which means that cases of Dengue can be verified. However, as someone who is looking at the data, it is difficult to use this as a measure if we do not know from the number of DB cases reported in Bali how many are actually confirmed to be dengue hemorrhagic fever (DHF), so ideally all doctors should do a patient history profile analysis, to check whether there is a risk of contact with COVID-19 cases, or if there were travels to red areas. And if possible, to at least carry out a quick test screening COVID-19. The results are then reported to the Department od Health for further analysis and intervention at the community level as well as health services. The prognosis on whether the burden on health services is heavier if there is a double infection is also unclear. That’s why data is very important and the key is analysis. We are also still weak in this area.
Fogging in Banjar Waru, Tengkulak Kaja organnized and paid for by locals after two people came dwon with dengue.
RH: With these data constraints, what are the parameters for pandemic modeling / projection in Bali? What can you rely on to get a clearer picture of what is happening?
DrPJ: It must be remembered that none of the epidemic models or estimates is correct, all are wrong because they are only predictions, so even a slight miss in numbers and time can be misleading, right? hehehehe. It is only that having a model is very important for policy makers for developing a strategy going forward, and how to go about this. A good model depends on reliable data, especially on the onset or commencement of the epidemic, the time and numbers of positive cases, description of infection relating to severity, how many deaths, how many were PDP, how many ODP, and also demographic details of patients, details regarding availability of services. The more detailed the better the model.
What is confusing is the actual time when the Bali epidemic began. This is interesting because the illness must have occurred several days or perhaps the previous week before the announcement of the first case on March 11, 2020. Also is it true that this was the first case considering the ability of our lab even on the national level?This only surfaced at the beginning of March; before this time, we were as yet unable to carry out proper testing. This fact also contributed to triggering the claim that the peak of the epidemic has already passed and that we have been affected since January… but please remember, if you’re talking about it being past it’s peak, well we’ve only got to Bogor let alone Puncak. (ed: this is a play on words in Indonesian: puncak means peak, but it’s also a popluar resort in the mountains south of Jakarta, to get there you have tyo go through Bogor).
I personally pray that the Indonesian model that shows the culmination of the case to be May and to be over by June is correct, I sincerely pray for this. It is already much too heavy on our communities to bear the economic burden brought on by this COVID-19. So I pray that whatever modeling predicts June as the end date turns out to be correct. However, judging from the data that is still being updated today, the number of cases is still increasing quite a lot.
RH:I heard (on the 24th) from a source among medical staff in Bali who are handling covid-19 that there were 5 medical staff (3 doctors, a nurse, and other personnel) who tested positive, and 15 other medical staff who were being quarantined while waiting for the results of testing. Maybe the results are there now. Can the number of medical staff be used as indicators of the speed of the pandemic?
DrPJ: I cannot confirm whether the above information is correct. But the casualties of health workers reflect more on the unpreparedness of services, especially in relation to the safety of officers and patients. As far as I know many occurred early in the epidemic when we are still trying hard to catch up with the speed of the epidemic in the midst of a lack of infrastructure such as isolation rooms, personal protective equipment (PPE) and even knowledge of medical personnel and procedures. It must be admitted that although we already heard of COVID-19 since early January, preparations were only made after COVID-19 entered Indonesia, including Bali.
“You can’t point at one thing, all these factors are linked to each other”
RH: In your opinion, what factors make the pandemic in Bali appear to be slower than Jakarta or other big cities in Java? Or is it just an ‘impression’ because of less aggressive testing, surveys and tracking?
DrPJ: This is another difficult question. The slow development of cases in Bali and Bali as a main tourist destination has also triggered the immune theory that we discussed earlier. Factors are interrelated so none of them can be singled out separately. If I may make a guess based on my knowledge of disease and also public health, there are a number of factors beyond the test:
- The weather in Bali has been hot and humid since December and there is scientific evidence that shows heat and humidity not to be very supportive towards the virus holding out over long periods of time either in the air or on the surface of objects. Jakarta was actually raining and wet at the beginning of this year. Weather is of course influential, but it’s only one factor, and the extent of its contribution is undetermined.
- Bali hardly has any public transportation, including for tourists Private vehicles with separate passenger seating from drivers are more common in Bali.
- Bali tourist attractions are also more often in open spaces.
- Hotels in Bali also have quite specific architecture; many are styled as exclusive resort models and private villas. Guests from China also have different hotel preferences from guests from other countries and local visitors.
- The culture of hugging and kissing is also less prevalent in Bali.
- Settlement in Bali is also not as dense as in Jakarta, especially relating to the type of residence.
- The Balinese government’s positive response since case 1 and even before case 1 was publicly announced. I see for example that the Bali Health Office deliberated readiness of services and prevention efforts from the time the first case in Jakarta was made known.
- And perhaps it may indeed be just luck!
You can’t point your finger at just one thing, all these factors are linked.
But …. what I have just described are only factors that could have a reducing effect, it does not deny the fact that we have been affected and cases are still on the increase. If we look at the data provided by the Covid Task Force between the 12th and 26thof April, reported cases of local transmission amounting to a total of 10% has risen to 22% within two weeks. This is a warning to us all.
Above: One of the first communities to put up a check point at their entrance was Nyuhkuning, all those who enter need to state their purpose and must have their hands sanitized, and Below: an unmmanned checkpoint in Umbalan at 7:30 in the morning. Not all things are equal.
Below: a sticker at a gas station are asking people to keep a distance from each other.
RH:When passing through Bali these days, especially on village roads, there are some villagers who spray the vehicle at the entrance of the village with disinfectants; others only ask that we clean our hands with sanitizers. Different villages have different stories. What measures can be advised for all villages / banjars to help them effectively reduce the rate of infection?
DrPJ: What is currently being carried out by traditional villages is already good, so keep going and be even more conscientious!Keep wearing a mask, avoid crowds and wash your hands before entering any place as well your home when you return from any outside activity. Do not touch your face area before washing your hands. If this is only practiced locally it will have less impact; it must equally be practiced throughout the whole island. Why? Because among the Balinese there is very high mobility between villages and regions; just look at Jalan Bypass Mantra: Gianyar residents are moving to and fro Denpasar or Badung, morning and evening.
RH:Recently the chairman of the Bali Covid-19 HandlingTask Force, Dewa Made Indra, said that the local transmission rate continued to increase due to “disorderly SOP”. Do you think the local transmission rate will bring Bali to the peak of the pandemic in the near future? What are your projections if the state of society remains the same as it is now?
DrPJ: The rate of every epidemic has a peak. In terms of epidemiology there are what are called vulnerable populations. In the case of COVID-19 transmission, the entire population is vulnerable. If there is still a vulnerable population, the threat of infection will remain. The way to reduce vulnerability is to implement health protocols such as physical distancing and hand washing. There is another way to reduce the risk of infection that relates to the way those who are infected or may be infected are taken care of. Try to do as much testing as possible so that the infected person immediately receives proper treatment and in the case of those who may be infected but do not know, campaign and force everyone to wear a mask.
We should consider everyone to be vulnerable and perhaps be infected even while remaining healthy. Wear a mask to protect others. In this way and other measurable ways, we can reach the peak faster. The term that is used is flattening the curve or bending the curve; the epidemic curve or peak is reached faster in this way, or the slopes become gentler, and the number of cases in the peak is lower.The service burden is then lighter and there is more time available to decrease the impact of the disease on social and economic hardship.
RH:Was there local transmission in Bali even before the issue of migrant workers, considering that during January, February, and even March, there were still tourists from China in Bali?
DrPJ: Wow, this goes back to my previous answer; this is always a possibility. Before the beginning of March, no serious attempt was made to seek out COVID-19, finding means of conducting tests on those suspected of suffering from it. At the time, our procedure was not as flexible as it is now where many people can be tested using PCR and rapid tests. You should perhaps take another look at my previous explanations.
RH: International epidemiologists have now begun to talk about the dangers of infection / local transmission within the lockdown, among family members in their own homes – either because one of the family members had been exposed before the lockdown or because of a “leak”. Do you think this has become a new threat?
DrPJ: Of course, when the Chinese government operated a lockdown they also developed a screening system that could be used by the public to find out if there were family members who might be suffering from COVID-19. That is why even during the lockdown there was an increase of cases to begin with, before there was a substantial drop. From this we understand that lockdown is not just any old lockdown but also a monitoring system on the family level with a ready service to ‘pick up the ball’ if the need is reported. Careless lockdown only causes chaos.
RH:How do you respond to the death rate in Bali of only 4 people so far, even though the that percentage compared to other places is very low?
DrPJ: Yes, this is a question that is not only posed within our own society but also by foreign observers. Only yesterday a doctor colleague and public health activist from the UK sent a What’sApp asking if there were really only 4 people who have died so far in Bali. We must look at various factors. First, statistics in many places show that the rate of loss varies from 0.6%, for example in Iceland, to a fairly high 13% in Italy. The world average so far is 7%. For Indonesia as of the 27th there were 765 deaths from among 9096 reported cases, or 8.4%.
To make sense of these numbers, we can also take a look at trends in mortality by age group. A lot of data suggests that the mortality rate is higher within an age bracket above 50 years, and highest when the age bracket is above 60 years. Unfortunately the report in Indonesia has not been developed as far. Now in Italy, a high percentage of deaths occurred because many who were impacted were within an age bracket beginning with 40 years of age.Meanwhile, the US is different again, with a 5-6% mortality rate affecting black-Americans who already have a weak health profile due to non-communicable diseases such as chronic airway infections, diabetes, heart disease, hypertension, and kidney problems. This has proven to worsen the prognosis or future of those among them who are infected by COVID-19.
Again there is no such data for Indonesia as yet, eh it has yet to be disclosed hehehe. For Bali, if we look at the 194 confirmed cases with only 4 deaths, and if not mistaken, 3 were foreigners and there was one Indonesian national who was a migrant worker. With only 20% of local transmissions reported from among the 194 it is difficult to assess the mortality rate in Bali. We know that most COVID positive migrants workers are indeed young, and as far as I know, have an average age of 30-40 years, which is indeed the age with the lowest mortality rate this year. There will probably be speculation of other deaths beyond what is known; but in the time being this is just speculation, we don’t have the data! That is why it’s important to expand the scope of testing, of accurate tests. Back to my previous statement about tests.
RH: Doctor Januraga thank you very much for sharing your knowledge and your precious time!
correction: of the 4 deaths mentioned in the last answer, 2 were foreigners and 2 were indonesian nationals
all photos with the exception of Dr Januraga’s portrait ©Rio Helmi
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