Indonesian Screening May Be Missing Virus Carriers

The popular tourist destination has had no coronavirus cases. Is that good luck—or bad testing?

A student shows a letter from the Indonesian health ministry
A student shows a letter from the Indonesian health ministry as he arrives at Sultan Iskandar Muda International Airport in Blang Bintang, Aceh province, on Feb. 17. Chaideer Mahyuddin/AFP via Getty Images

A tourist from mainland China who visited Bali, Indonesia, in late January tested positive for the novel coronavirus disease, formally known as COVID-19, upon her return from China. That has sparked a hectic round of discussion in an Indonesian media obsessed with the virus—was the patient sick before arrival?

It’s an unsurprising obsession in a country where the virus is the dog that didn’t bark in the nighttime. Indonesia has no cases yet—but many Indonesians are convinced it’s only a matter of time and that undetected virus-carriers are walking among them.

After the World Health Organization announced a global emergency, Indonesians snatched up respirator face masks from the supermarkets, tripling prices. Indonesia’s statistics bureau noted that 1.2 million tourists from mainland China traveled to Bali—which has a direct flight from Wuhan—the epicenter of the outbreak, in 2019 alone.

As of Monday, most of Southeast Asia had detected some cases of the coronavirus—75 in Singapore, 19 in Malaysia, 34 in Thailand. Meanwhile, Indonesia has observed 64  samples collected from the throat swab of suspected patients in 30 hospitals in 30 provinces, but there’s not a single confirmed case.

But has Indonesia been preternaturally lucky? Or is its health service simply missing cases?

The head of the Health Crisis Center of the Ministry of Health, Achmad Yurianto, denies that Indonesia’s detection system is weak. He told Foreign Policy that Indonesian officials have applied multiple layers of detection and said that they meet the international standard.

The current system applies two checks: temperature checks at arrival gates, followed by self-reporting from passengers, who are given what are known as “control cards” and told to report to a hospital if they feel unwell.  If a potential carrier reports any symptoms, the doctor contacts the national health care system and takes a sample. It’s then sent to laboratories designated by the Ministry of Health and will produce a result within about two days.

Yurianto added that Indonesia has been working with other countries to prevent sick passengers from traveling inside and outside the country. Vivi Setyawati, the head of the research and development center at the Ministry of Health, has guaranteed that WHO has certified the laboratory and the staff.

The team in Jakarta who receive the specimens use a double test—polymerase chain reaction and DNA sequencing—to confirm the case. The system has been applied since the Middle East respiratory syndrome-related coronavirus outbreak in 2011.

But the Sydney Morning Herald recently revealed that Indonesia had no “specific detection kit” for DNA sequencing to confirm the new type of coronavirus. Amin Soebandrio, a fellow at the Jakarta-based Eijkman Institute for Molecular Biology, argued that even without the specific sequencing primer necessary, the identification could be made. Indonesia eventually received the primer on Feb. 4, allowing for an easier detection process.

The claim itself has already sparked a scientific debate. Marc Lipsitch, the director of the Center for Communicable Disease Dynamics at Harvard University, who has just published research on the new coronavirus, told Foreign Policy that tests conducted without the primer would be lacking.

Soetjipto, an expert in biochemistry and biomolecular studies from Airlangga University who, like many Indonesians, only goes by one name, agreed, adding that the team could use a common coronavirus primer beforehand, and the results would be close, but not 100 percent accurate.

Lipsitch’s modeling at Harvard, meanwhile, argues that cases are very likely to have gone undetected in Indonesia and Cambodia. “They may go undetected for some weeks, as the individuals may not seek care or may not be suspected and tested for coronavirus,” he said.

Indonesia should have confirmed at least five cases by now. Another obvious hole in the system, acknowledged by Yurianto, is that temperature checks alone have proved an unreliable detector for the coronavirus, which has an incubation period of potentially as long as 24 days. Self-reporting also often fails to catch cases, especially in carriers with weaker symptoms.

The researchers recommended that outbreak surveillance and control capacity should be rapidly strengthened in both countries.

The Indonesian government slammed the Harvard modeling, with Minister of Health Terawan Agus Putranto calling it “insulting.” But Lipsitch says his data holds up, given the experiences of other countries. The evidence shows that at least 98,700 passengers from Wuhan traveled to Indonesia between December 2018 and November 2019, making it one of the top 10 destinations for Wuhan travelers.

Lipsitch also emphasized that many countries, not only Indonesia, probably face the same issue of detection at the border. “It’s not 100 percent effective, even with excellent levels of testing,” he said.

As questions remain unanswered, Indonesians have taken to social media for fierce arguments. Some of them argue the virus cannot survive Indonesia’s tropical temperatures. “But there is no [scientific] evidence yet,” Soetjipto from Airlangga University clarified.

John  Nicholls, a clinical professor in pathology at the University of Hong Kong and an expert on coronaviruses, has commented on the possibility of higher temperature variables. Nicholls emphasized that the SARS outbreak managed to be stopped in 2003 with good hygiene practices as well as seasonal high temperature and humidity.

Indonesia is in a poor position if the virus does strike. Although the country has set aside 100 hospitals for potential cases, Indonesia’s massive size and relatively underequipped health care system would leave it struggling to cope with an outbreak. At one hospital checked by Foreign Policy, only four out of 28 rooms were properly equipped with negative pressure systems required for proper isolation. The nation’s scientific budgets are also small—the research budget was only 0.3 percent of Indonesia’s GDP in 2018, one of the lowest in Asia.

Meanwhile, the Indonesian government seems more determined to fight critics than the virus – and some officials have been spreading conspiracy theories online. Agus Wibowo, the spokesperson for the Indonesian National Disaster Management Authority,  retweeted fake claims that the virus is a biological weapon, but later deleted them after criticism.

Febriana Firdaus is a journalist in Jakarta, Indonesia.

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