Jurnal Kesehatan Masyarakat Nasional

Special Issue Volume 1, 2020 p-ISSN 1907-7505 e-ISSN 2460-0601 m Jurnal Kesehatan Masyarakat Nasional ems unlKshtnMsaaa ainl(ainlPbi elhJournal) Health Public (National Nasional Masyarakat Kesehatan Jurnal Kesmas: Kes as (National Public Health Journal)

Quarterly Journal

Special Issue: Coronavirus Disease 2019 (COVID-19) Pandemic and Responses Handling by: Dewi Susanna, MS

Initiating Global Civil Society as a Strategy for Handling the COVID-19 Public Health Threat: A Policy (pp. 1 - 5)

pca su oue12020 1 Volume Issue Special Hygiene and Sanitation Challenge for COVID-19 Prevention in Indonesia (pp. 6 - 13)

COVID-19 Case Fatality Rate and Detection Ability in Indonesia (pp. 14 - 17) From Social Distancing to Physical Distancing: A Challenge for Evaluating Public Health Intervention against COVID-19 (pp. 60 - 63)

Traveler’s Infections: Understanding SARS-CoV-2 as a Potential Agent (pp. 64 - 69) Impact of Lockdown in India: A Case Study Comparing Kanataka with International Model (pp. 93 - 98)

Nationally accredited and indexed in SINTA-S1 by Ministry of Education and Culture of the Republic of Indonesia, and indexed in SCOPUS JurnalKesmas Kesehatan Masyarakat Nasional (National Public Health Journal)

Special Issue Volume 1, 2020 p-ISSN 1907-7505 e-ISSN 2460-0601

TABLE OF CONTENT

Initiating Global Civil Society as a Strategy for Handling the COVID-19 Public Health Threat: A Policy ...... 1-5 Dumilah Ayuningtyas, Hayyan Ul Haq, Raden Roro Mega Utami

Hygiene and Sanitation Challenge for COVID-19 Prevention in Indonesia ...... 6-13 Sang Gede Purnama, Dewi Susanna

COVID-19 Case Fatality Rate and Detection Ability in Indonesia ...... 14-17 Tiopan Sipahutar, Tris Eryando

Innovative Work Shift for Health Workers in the Health Service Providers in Handling COVID-19 Cases ...... 18-23 Acim Heri Iswanto

Challenges for Indonesia Zero Hunger Agenda in the Context of COVID-19 Pandemic ...... 24-27 Bunga Astria Paramashanti

Acceleration of Telemedicine Use for Chronic Neurological Disease Patients during COVID-19 Pandemic in Yogyakarta, Indonesia: A Case Series Study ...... 28-31 Rizaldy Pinzon, Dessy Paramitha, Vincent Ongko Wijaya

The Use of Cloth Face Mask during the Pandemic Period in Indonesian People ...... 32-36 Ririh Yudhastuti

A Holistic-Comprehensive Approach: Best Practices to Improve Health Policy for COVID-19 Pandemic ...... 37-42 Febri E B Setyawan, Retno Lestari

Efficacy of Cloth Face Mask in Reducing COVID-19 Transmission: A Literature Review ...... 43-48 Saraswati Anindita Rizki, Andree Kurniawan

Nationally accredited and indexed in SINTA-S1 by Ministry of Education and Culture of the Republic of Indonesia, and indexed by SCOPUS since 2016 JurnalKesmas Kesehatan Masyarakat Nasional (National Public Health Journal)

Special Issue Volume 1, 2020 p-ISSN 1907-7505 e-ISSN 2460-0601

TABLE OF CONTENT

The Impact of Large-scale Social Restrictions on the Incidence of COVID-19: A Case Study of Four Provinces in Indonesia ...... 49-53 Izza Suraya, Mochamad Iqbal Nurmansyah, Emma Rachmawati, Badra Al Aufa, Ibrahim Isa Koire

Analysis of Government Budgeting for Health: Case Study of COVID-19 in East Java Province, Indonesia ...... 54-59 Dewi Rokhmah, Ricko Pratama Ridzkyanto, Khoiron

From Social Distancing to Physical Distancing: A Challenge for Evaluating Public Health Intervention against COVID-19 ...... 60-63 Hadi Pratomo

Traveler’s Infections: Understanding SARS-CoV-2 as a Potential Agent ...... 64-69 Victor Baba Oti, Marina Ioannou

Handling of Public Stigma on COVID-19 in Indonesian Society ...... 70-76 Wahyu Sulistiadi, Sri Rahayu, Nanny Harmani

Annalysis of Epidemiological Surveillance Activity of the COVID-19 at Surabaya Airport Indonesia on January 2020 ...... 77-84 Rizma Dwi Nastiti, Kurnia Dwi Artanti, Achmad Faridy Faqih

Pre-testing of the WHO’s Educational Video: “How to Protect Yourself Against COVID-19” ...... 85-92 Hilyatul Fadliyah, Manendra Muhtar, Munih, Sylviasari Risgiantini, Weny Wulandary, Hadi Praomo

Impact of Lockdown in India: A Case Study Comparing Kanataka with International Model ...... 93-98 Stelvin Sebastian, Aby Paul, Jeeva Joseph, Joel Joby, Sanjo Saijan, Jobin Kunjumon Vilapurathu

Review of Trial Therapies and Treatment for COVID-19: Lessons for Indonesia ...... 99-104 Halma Zahro Mukhlida, Hilma Hasro Maulida, Gunanti Khairunnisa, Margaretha Josephine Mantrono, Risky Kusuma Hartono, Rindu, Eka R W Purnamasari, Rizky Fajar Meirawan

Nationally accredited and indexed in SINTA-S1 by Ministry of Education and Culture of the Republic of Indonesia, and indexed by SCOPUS since 2016 Kesmas Jurnal Kesehatan Masyarakat Nasional (National Public Health Journal)

Special Issue Volume 1, 2020 p-ISSN 1907-7505 e-ISSN 2460-0601 Kesmas: Jurnal Kesehatan Masyarakat Nasional (National Public Health Journal) is a journal that contains both research articles and invited review articles in the field of public health and published quarterly

Editor in Chief Dewi Susanna

International Editorial Board Dumilah Ayuningtyas (Faculty of Public Health Universitas Indonesia, Indonesia) Ahmad Syafiq (Faculty of Public Health Universitas Indonesia, Indonesia) Zarfiel Tafal (Faculty of Public Health Universitas Indonesia, Indonesia) Doni Hikmat Ramdhan (Faculty of Public Health Universitas Indonesia, Indonesia) Ahmad Sulaeman (Faculty of Human Ecology Bogor Agricultural University, Indonesia) Tris Eryando (Faculty of Public Health Universitas Indonesia, Indonesia) Tri Yunis Miko Wahyono (Faculty of Public Health Universitas Indonesia, Indonesia) Upik Kusumawati Hadi (Faculty of Veterinary Medicine Bogor Agricultural University, Indonesia) Yodi Mahendradhata (Faculty of Medicine Gadjah Mada University, Indonesia) Rajendra Prasad (Merit India Consultant Pvt Ltd, India) Peter D Sly (Faculty of Medicine and Biomedical Science, University of Queensland, Australia) Budi Haryanto (Faculty of Public Health, Universitas Indonesia, Indonesia) Prathurng Hongsranagon (University of Chulalongkorn, Thailand) Hidayatulfathi Othman (Faculty of Health Sciences, National University of Malaysia, Malaysia) Don Eliseo Lucero-Prisno III (Xi’an Jiatong-Liverpool University, China) Orawan Kaewboonchoo (Mahidol University, Thailand) Dian Kusuma (Imperial College London, the United Kingdom) Mellissa Withers (University of Southern California, the United State of America) Jalaludin Bin Badrudin (University of New South Wales, Australia)

Managing Editor Ella Ayu Septia Mustika

Web Programmer Eddy Afriansyah Nico Kurnia Pratama

Language Editor Ayu Lestari Purborini

Editorial Secretary Ninez Dwiandra Sekarsari

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Initiating Global Civil Society as a Strategy for Handling the COVID-19 Public Health Threat: A Policy Review

Dumilah Ayuningtyas1*, Hayyan Ul Haq2, Raden Roro Mega Utami1

1Department of Health Administration and Policy, Faculty of Public Health, Universitas Indonesia, Indonesia 2Department of Business Law, Faculty of Law, Universitas Mataram, West Nusa Tenggara, Indonesia

Abstract The spread of coronavirus disease 2019 (COVID-19) has had a serious impact on public health. The speed and extent of its spread have demonstrated a global failure to cultivate awareness and cooperation in response to the threat. Therefore, in order to improve public awareness and the management of public health threats, we propose a strategy to initiate global civil society. Using Walt and Gilson's policy triangle framework for policy analysis, we reviewed and analysed a series of articles and policies related to COVID-19, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the Global Health Security Agenda (GHSA), health resilience in the context of globalization, as well as other countries’ experiences. The study also explored constitutional obligations, public health legislation, collaboration of civil society, and policies related to public health, as well as their implementation. Every country has its own public policy strategy for handling COVID-19. One possible solution is to expand the GHSA commitments and bind all countries that have signed the agreement to a single public policy strategy for the handling of COVID-19. The poor handling of the COVID-19 outbreak has demonstrated the need for Indonesia’s civil society collaboratively oversee the Indonesia’s government’s implementation of its constitutional obligations. The government must make public health security a top priority, and collectives of educated individuals with a strong, shared vision must harness the power of non-governmental advocacy.

Keywords: constitutional mandatory, COVID-19, global civil society, global health security, state responsibility

Introduction ease throughout the world. Within 24 hours, the virus The outbreak of coronavirus disease 2019 (COVID- had successfully infected nine new countries, including 19) has caused tremendous fear and has drawn substan- Azerbaijan, Mexico, and New Zealand.3 Italy is the most tial attention all over the world. The World Health affected country in Europe ever since the number of Organization (WHO) has tracked the spread and in- COVID-19 cases and deaths in Italy jumped in one night. crease in cases of COVID-19 throughout the world: as of As the number cases has soared in Italy, Iran, and South May 15, 2020, there are 4,534,952 confirmed cases in Korea, it is has become indisputable that the virus has more than 200 countries and one cruise ship containing swept the globe. more than 700 passengers. At least 307,159 deaths have COVID-19 is a public health threat that knows no na- been reported.1 Undoubtedly, COVID-19 has trans- tional boundaries.4 Bill Clinton has characterized global- formed into a serious threat to public health. ization as a world without walls.5 Tony Blair has said On February 28, 2020, the WHO raised the global that globalization is inevitable and irresistible.Their risk status of COVID-19 to the highest level.2 Previously, claims have now been validated in the context of health. the WHO had also classified COVID-19 under Public The inability of countries to defend themselves against Health Emergencies of International Concern (PHEIC), the threats of infectious diseases such as severe acute res- which are defined by the International Health piratory syndrome (SARS), Avian Influenza, Swine Flu, Regulations, or IHR (2005), as extraordinary events that and COVID-19 has demonstrated that the world we live could threaten public health throughout the world due in is indeed one without walls; the global transmission of to the threat of spreading diseases internationally, and dangerous illnesses has become inevitable. The establish- that need a coordinated international response. This res- ment of a “global village” has made it such that countries ponse was prompted by the alarming spread of the dis- can no longer effectively control the movement of people

Correspondence*: Dumilah Ayuningtyas, Department of Health Administration Received : May 28, 2020 and Policy, Faculty of Public Health Universitas Indonesia, Lingkar Kampus Accepted : May 29, 2020 Baru Street, Depok City, West Java, Indonesia, E-mail: Published: July 31, 2020 [email protected], Phone: +62-8161840446

Copyright @ 2020, Kesmas: Jurnal Kesehatan Masyarakat Nasional (National Public Health Journal), p-ISSN: 1907-7505, e-ISSN: 2460-0601, SINTA-S1 accredited, http://journal.fkm.ui.ac.id/kesmas, Licensed under Creative Commons Attribution-ShareAlike 4.0 International Kesmas: Jurnal Kesehatan Masyarakat Nasional (National Public Health Journal). 2020; Special Issue 1: 1-5 across their borders. Kate Galbraith’s definition of glo - CoV-2 is a new strain that has been identified in humans. bal ization as “crossing borders”serves as a warning to us: Common symptoms in infected individuals are fever, when there are no more “international borders”,6 then coughing, shortness of breath, and difficulty breathing. the ability to deal with a variety of risks or potential ha - In more severe cases, an infection can cause pneumonia, zards such as the transmission of infectious diseases is severe acute respiratory syndrome, kidney failure, or absolutely a must-have.7 death.8 For this reason, it is crucial to find effective strategies On December 31, 2019, the WHO received the first to manage the spread of COVID-19. With its high-risk report of SARS-CoV-2 in Wuhan City, the capital city of status, anticipating and preventing the spread of COVID- Hubei Province, People’s Republic of China,9 which is 19 will necessitate global cooperation, which can only be the seventh largest port city in mainland China. The city established by collective consciousness and a shared vi- is known as one of the centres of the steel industry, a sion among the world’s population. In light of the impor- mainstay of China’s national infrastructure, and is tance of the global collective consciousness, in this study, inhabit ed by 11 million people. The strategic significance we analyse the relationship between COVID-19 and of Wuhan City to China’s (and perhaps even the world’s) globalization. Moreover, we discuss the views that dis- economy made officials reluctant to make public the out- eases such as COVID-19 are direct consequences of break of COVID-19. This may explain why COVID-19 globalization and that the Global Health Security Agenda incubates and spreads quickly in cities and why it has be- (GHSA) must be central in the response to the outbreak. come a deadly pandemic throughout the world.10,11 Finally, we consider the effectiveness of institutionalizing The increasing global movement of people has collective awareness as a strategy for responding to glo - brought with it an increased risk of spreading infectious bal health threats. diseases. Indonesia has signed on to several international trade agreements such as General Agreement on Tariffs Method and Trade (GATT), Trade-Related Investment Measures We conducted a policy analysis using Walt and (TRIMs), Trade-Related Aspects of Intellectual Property Gilson's policy analysis triangle to incorporate context, Rights (TRIPs), ASEAN Free Trade Area (AFTA), and actors, process, and content concepts in analysing these Free Trade Agreements (FTAs). These agreements have policies. We reviewed and analysed a series of articles accelerated the improvement and intensity of interaction and policies related to COVID-19, SARS-CoV-2, the among people and institutions in various fields, such as Global Health Security Agenda (GHSA), national re- socio-economic, trade and investment, and socio-cultural silience in the context of globalization, as well as other activities. This interaction has increased the dependency countries’ experiences. We focused on collecting second- of people, institutions, corporations, and nations on one ary sources, data, and information by using keywords another. Although the government enjoys the economic such as ”COVID-19”, “Coronavirus”, “SARS-CoV-2”, benefits of such interrelations, it must also possess the “GHSA”, “globalization”, “civil society”, and “public capacity to anticipate and overcome the negative impacts health”. of these relationships, such as the transmission of The framework also allows the analysis of the contex- COVID-19. tual factors: social, political, and international aspects Undoubtedly, COVID-19 is a global public health is- that influenced the policy. The analysis of the process by sue that requires a coherent strategic response; that is which the policy was initiated, formulated, developed, prevention and treatment must occur not only at the implemented and evaluated, the objectives of the policy macro level, globally, but also regionally, nationally, and and the actors involved in the decision making as well as even locally. One option is to expand the GHSA commit- constitutional obligations, public health legislation, col- ments, which would oblige all countries that have signed laboration of civil society, and policies related to public the agreement to develop procedures for preventing, de- health, as well as their implementation in the context of tecting, and responding to public health threats.12 At a COVID-19 was also conducted. To ensure the validity, world health meeting, Frenk J and Gómez-Dantés O,13 we included only the most current data, and we conduct- suggested that efforts to improve health are universal ed extensive literature reviews. global activities. Therefore, the pursuance of international initiatives must consider the welfare of all people and Result and Discussion embody an ethos of “exchange, evidence, and empathy”. Coronavirus is a family of viruses that cause diseases Regarding “exchange”, countries must be prepared to ex- ranging from the common cold to more severe illnesses change information on public health risks such as such as Middle East respiratory syndrome-related coro - COVID-19. Regarding “evidence”, public policy must be na virus (MERS-CoV) and severe acute respiratory syn- informed by data and scientific evidence. Regarding “em- drome-related coronavirus (SARS-CoV). The SARS- pathy”, interactions between people ought to take place

2 Ayuningtyas et al, Initiating Global Civil Society as a Strategy for Handling the COVID-19 Public Health Threat according to the principles of humanism. It is necessary dures pertaining to prevention of the spread of COVID- to convey priorities in Indonesia. One of them is the par- 19, treatment of those infected with the disease, as well ticipation and empowerment of civil society in each coun- as the preparation of testing and treatment facilities, such try.13 as hospitals and clinics. Now is the time to determine The COVID-19 has spread to more than 200 coun- whether or not the GHSA can effectively prevent, detect, tries, including Indonesia, and therefore global coopera- and respond to COVID-19.14 tion is imperative. This is the high price of globalization. As members of the GHSA, Indonesia and other coun- The purpose of the GHSA is to respond to the increasing tries can initiate the global consciousness needed to deal vulnerability of the global community to new diseases with the threat of the COVID-19 outbreak. This con- and pandemics caused by the negative impacts of climate sciousness is based on Articles 3 and 25 of the Universal change, increased trade, movement of humans and other Declaration of Human Rights (UDHR), which states animals across borders, as well as farming practices and “that the state guarantees the life of every human being, industries that are no longer considered acceptable. The guarantees his safety, health and the environment.15 In GHSA is made up of countries, international organiza- the 1945 State Constitution of the Republic of Indonesia tions, non-governmental organizations, and people in the (UUD ’45), Article 28 also states that every person has private sector that want to decrease the threat posed to the right to live in prosperity, physically and mentally, the world by infectious diseases. Under the leadership of and to have a good and healthy environment.16 Article the GHSA, every signed country or party should havea 15-1 of the European Convention on Human Rights strong commitment to improve global health security and (ECHR) also confirms the same thing. This means that to make it a high priority for world leaders.12 every country that has signed the UDHR, the ECHR, and The global trend toward a world without boundaries other international conventions on health, has a respon- has changed the landscape of interaction between coun- sibility to enforce policies that protect the health and tries, which brings many opportunities and benefits, and safety of their citizens. has also introduced global threats that should be ad- The above normative foundation stipulates a consti- dressed by global strategies. This is because, regardless tutional obligation of the government in guaranteeing of a country’s preparedness to face a pandemic, there is public health. In this respect, the government should still a potential risk to public health. Threats, due to the make any information that is relevant to citizens’ health effects of globalization, cannot be handled by individual and safety available to them (Article 28, Indonesian countries. It is concerning that the Indonesian govern- Constitution 1945). Therefore, the government should ment has left the responsibility for handling COVID-19 be informing the public transparently, objectively, ratio - to the governors, mayors, and heads of sub-districts, as nal ly and wisely. This would have been instrumental in this has resulted in diametric decisions at different levels anticipating public policy blunders in the early stages of of government. For example, Ganjar Pranowo, Governor the COVID-19 outbreaks, long before a positive case of of Central Java Province, and Rismaharini, Mayor of the disease was found in Indonesia. Surabaya City, refused entry to several cruise ships such The WHO warned of the magnitude of the risk of the as Viking Sun, Columbia, Viking Orion, and MS pandemic and advised countries not to be over- Albatros, while I Wayan Koster, Governor of Bali confident.17 Many foreign researchers cynically and Province, and Zulkieflimansyah, Governor of NTB critically stated that the absence of COVID-19 in Province, announced that they would permit the entry of Indonesia was concluded based on 136 tests from 270 those cruise ships. million people.18,19 When the first COVID-19 case was After having reviewed the diametric responses of the announced in December 2019, Indonesia had had plenty central and local governments, we take a critical position of time to prepare for the negative impacts of COVID-19 on the absence of coordination between them. on various government sectors. The government repeat- Constitutionally, the government should be bound to res- edly claimed that there were no case of COVID-19 in pond consistently to outbreaks such as COVID-19. Some Indonesia, even though the WHO had advised official governments consider economic reasons while others un- stopay careful attention to their handling of the spread of derline the importance of public health and safety. the disease. Despite the warnings, the result was confus - Therefore, it is imperative that all governments make ion, the dissemination of unclear information, and incon- their public policies consistent at the local, national, re- sistent public policy. Instead of urging vigilance, the gov- gional, and global levels. It is crucial for the government ernment tried to minimize the apparent scale of the prob- to initiate and improve cooperation with other countries lem and called on the public to be calm in response to in order to formulate a consistent global strategy for deal- the COVID-19 pandemic.20 According to the Indonesian ing with outbreaks like COVID-19. This can be embodi- community, the government’s statement showed a lack ed by a global agreement that would regulate the proce- of empathy and transparency. The Indonesia’s president

3 Kesmas: Jurnal Kesehatan Masyarakat Nasional (National Public Health Journal). 2020; Special Issue 1: 1-5

finally appointed a special spokesperson to talk about sary steps to deal with those threats. Society will be im- COVID-19. This authority was left to the Secretary of pacted by COVID-19. the Directorate General of Disease Prevention and The handling of the COVID-19 outbreak requires the Control.21 coordination of national governments, international or- Recently, the government introduced public policy in- ganizations, and civil society. The community will be tended to anticipate the negative economic impacts of most impacted and thus needs to play an active role in COVID-19. It consists in reducing airplane ticket costs handling this situation. Collaboration between members in order to maximize revenue, as well as promoting of civil society, particularly well educated citizens, can tourism activities. The Indonesian Minister of Finance help oversee the government’s implementation of its has stated that the government has prepared incentives cons titutional obligations. The Government of Indonesia of more than IDR 400 billion to reduce the price of air- needs to make public health security a top priority in plane tickets to tourist destinations. The government is every policy implementation. One way would be to im- also preparing subsidies for local governments in the plement the GHSA in every aspect of public health. form of grants of more than IDR 3 trillion for hotel and Groups of educated people with a strong, shared vision restaurant tax exemptions for entrepreneurs, including must harness the power of non-governmental advocacy. IDR 72 billion for social media influencers promoting Protecting the health of the Indonesian people constitutes tourist destinations in Indonesia (familiarization trip).22 one aspect of the 1945 Constitution, which is the most This policy is different from neighbouring countries’ poli- fundamental norm in Indonesia. cies in Singapore, Korea, and Malaysia, which have put in place a series of policies for preventing the spread of Abbreviations COVID-19, such as informing the public about collective COVID-19: Coronavirus Diseases 2019; PHEIC: Public Health responsibility and cancelling flights to and from Emergencies of International Concern; IHR: International Health Singapore. Regulations; SARS COV-2: Severe Acute Respiratory Syndrome Unsurprisingly, the Indonesian government’s tourism Coronavirus 2; GHSA: Global Health Security Agenda; WHO: World policy has drawn heavy criticism from the public. The Health Organization; PPE: personal protective equipment; UNICEF: policy has demonstrated that the government’s efforts to United Nations Children’s Fund; BPS: Badan Pusat Statistik; MERS- deal with COVID-19 are not serious enough to stop its CoV: Middle East Respiratory Syndrome-related Coronavirus; GATT: spread. Even though Indonesia announced two positive General Agreement on Tariffs and Trade; TRIMs: Trade-Related cases of COVID-19 on March 2, 2020, the government Investment Measures; TRIPs: Trade-Related Aspects of Intellectual stated that it would not reconsider the tourism policy, Property Rights; AFTA: ASEAN Free Trade Area; FTAs: Free Trade based on its calculations. The government wants the Agreements; UDHR: Universal Declaration of Human Rights; ECHR: COVID-19 situation to be resolved without disrupting European Convention on Human Rights. the country’s economy.18 Finally, on March 3, 2020, the Minister of Tourism and Creative Economy of Indonesia Ethics Approval and Consent to Participate stated that the provision of incentives for tourism would Not Applicable be postponed indefinitely due to the presence of COVID- 19 in Indonesia.23 Competing Interest Authors declare that they have no competing interests to disclose. Conclusion In civil society, citizens cooperate voluntarily for mu- Availability of Data and Materials tual benefit, which is crucial for personal development, Not Applicable establishing trust between groups, and making social services accessible. However, civil society remains bound Authors’ Contribution by the rule of law. A social movement is a collective ac- Dumilah Ayuningtyas conceived of the presented main idea and deve - tion undertaken by groups in civil society. In dealing with loped the theory, and encouraged Hayyan Ul Haq and Raden Roro COVID-19, civil society must play an active role. Mega Utami to investigate and supervised the findings of the work. All The public needs to oversee the fulfillment of the gov- authors discussed the results and contributed to the final manuscript. ernment’s constitutional obligations as the bearers of the All authors agreed to be personally accountable for their own contribu- constitutional mandate, and also ensure that they can be tions and ensured that questions related to the accuracy or integrity of held constitutionally responsible. With a shared goal to any part of the work are appropriately investigated, resolved, and the protect the world from various global health threats, civil resolution documented in the literature. society must be positioned as a subject, and not just as an object. Well educated members of civil society can un- Acknowledgment derstand what threatens their health and take the neces- Not Applicable

4 Ayuningtyas et al, Initiating Global Civil Society as a Strategy for Handling the COVID-19 Public Health Threat

12. Global Health Security Agenda. About the GHSA. References 13. Frenk J, Gómez-Dantés O. Globalisation and the challenges to health 1. COVID-19 dashboard: Coronavirus COVID-19 global case. Johns systems. British Medical Journal. 2002; 325 (7355): 95–7. Hopkins University: Center for Systems Science and Engineering 14. Chattu VK, Kevany S. The need for health diplomacy in health securi- (CSSE); 2020. ty operations. Health Promotion Perspectives. 2019; 9 (3): 161–3. 2. Sembiring LJ. Gawat! WHO naikkan status risiko corona ke level tert- 15. Zandy J. Universal declaration of human rights. Radical Teacher. inggi. CNBC Indonesia; 2020. 2019; 113: 54–5. 3. Berlinger J. Coronavirus has now spread to every continent except 16. Presiden Republik Indonesia. Perubahan kedua Undang-Undang Antarctica. CNN; 2020. Dasar Negara Republik Indonesia Tahun 1945. 2000; 3: 1–6. 4. Bloomberg. The coronavirus knows no borders, says world health or- 17. Lovelace B. WHO warns failure to prepare for coronavirus now ‘could ganization. 2020. be a fatal mistake. CNBC; 2020. 5. Clinton WJ. Transcript of Bill Clinton at UC Berkley January 29, 2002. 18. McVeigh K and Harrison EG. Academic stands by research querying Campus New; 2002. Indonesia’s claim to be coronavirus-free. The Guardian; 2020. 6. Galbraith J K. Globalisation: making sense of an integrating world. 19. Bevege A. Is Bali really safe from coronavirus? why Indonesia’s claim London: The Economist in association with Proﬁle Books; 2007. that no one there has caught the deadly virus could be a complete lie. 7. Ikatan Ahli Kesehatan Masyarakat Indonesia. Globalisasi dan transfer Daily Mail Australia; 2020. risiko penyakit: tinjauan dan rekomendasi IAKMI terkait kasus penu- 20. Satria JN. Minta masyarakat Tak panik soal penyebaran virus corona, monia akibat 2019-NCOV. Siaran Pers / Pernyataan Sikap PP IAKMI menkes: enjoy saja. detiknews; 2020. Terkait 2019-NCOV. November 2014: 15–6. 21. Tim detikcom. Saat Menkes Terawan tak lagi bicara virus corona. de- 8. World Health Organization. Coronavirus; 2020. tiknews; March 3, 2020. 9. World Health Organization. Novel Coronavirus (2019-nCoV). WHO 22. Ananda A. Jurus Jokowi lawan virus corona dengan diskon tiket pe- Bulletin; 2020. sawat. CNN Indonesia; 2020. 10. BBC News. Wuhan: the London-sized city where the virus began. 23. Egeham L. Menteri Wishnutama tunda pemberian insentif pariwisata, BBC; 2020. termasuk untuk inﬂuencer. Liputan6; 2020. 11. World Health Organization. Report of the WHO-China joint mission on coronavirus disease 2019 (COVID-19); February 16-24, 2020.

5 Purnama et al. Kesmas: Kesmas: Jurnal Kesehatan Masyarakat Nasional (National Kesmas: Jurnal Kesehatan Masyarakat Nasional Public Health Journal). 2020; Special Issue 1: 6-13 DOI: 10.21109/kesmas.v15i2.3932 (National Public Health Journal) Hygiene and Sanitation Challenge for COVID-19 Prevention in Indonesia

Sang Gede Purnama1*, Dewi Susanna2

1Doctoral Program in Public Health, Faculty of Public Health, Universitas Indonesia, Indonesia 2Department of Environmental Health, Faculty of Public Health, Universitas Indonesia, Indonesia

Abstract The case of COVID-19 in Indonesia continues to increase, transmitted directly and indirectly. Hygiene and sanitation approaches are needed for prevention. The purpose of this review is to review how the transmission COVID-19, the challenges of Indonesia, and the policy of COVID-19 prevention with hygiene and sanitation approaches. The results show Indonesia's challenges namely urban area density, air pollution, and smokers, low hand washing habits, low access to clean water and drinking water, open defecation behavior, limited personal protective equipment. COVID-19 control policy with the hygiene sanitation approach is carried out with 4 factors namely personal protect equipment, health education, personal hygiene, and sanitation.

Keywords: COVID-19, hygiene, sanitation, Indonesia

Introduction (PPE) and contact with infected people.10-12 Therefore Coronavirus infectious diseases 2019 (COVID-19) WHO recommends doing physical distancing by keeping caused by severe acute respiratory syndrome coronavirus a distance and avoiding crowds and using masks.13 2 (SARS COV-2) that initially occurred in Wuhan, China Indirectly, by touching the surface of objects that have a have now spread to many countries.1,2 On March 11, virus and then touching the mouth, nose, and eyes before 2020 World Health Organization (WHO) has established washing hands. SARS COV-2 was even found in eye ﬂu- COVID-19 as a global pandemic.3,4 The COVID-19 inci- id, this can be a source of infection.14 Therefore it is ad- dent has spread to 213 countries including Indonesia. As visable to wash hands with soap and disinfecting the sur- of April 20, 2020, the total number of COVID-19 cases face of objects that are often used.15 Handwashing with was 2,480,503 people with 170,397 deaths.5 soap in Indonesia is very low, so there is a risk of trans- Indonesia which has 34 provinces with a population mission through hygiene.16 of 267 million in 2019 Chinese tourists visited 1.61 mil- There was evidence SARS COV-2 is detected in feces lion visits (13.14%).6 Based on reports from the Ministry and urine.17 This was also conﬁrmed by the liquid waste of Health and National Disaster Management Agency as in sewerage in the Netherlands, the United States, and of April 20, 2020, it was reported that COVID-19 Sweden.18 This condition is an early warning for reached 6,760 people, 590 deaths, and 747 people reco- Indonesia which has a greater challenge, namely open vered.7 Transmission that originally occurred to foreign defecation behavior, which is still high, even the second citizens has now become a local transmission between largest in the world.19 Based on the United Nations people.8 This incident is spreading quickly and the cases Children’s Fund (UNICEF) data, it is stated that there will continue to grow. Indonesia is at risk of COVID-19 are around 25 million people who still defecate in transmission. Indonesia.20 The COVID-19 transmission is reported to be directly Stool contamination of clean water sources and com- and indirectly, directly through droplets when coughing.9 munity drinking water is very vulnerable to contracting Transmission occurs from person to person, especially in COVID-19. In Indonesia, access to clean water and those who do not use personal protective equipment drinking water is still lacking. Based on national socio -

Correspondence*: Sang Gede Purnama, Doctoral Program in Public Health, Received : May 28, 2020 Faculty of Public Health, Universitas Indonesia, Lingkar Kampus Raya Accepted : May 29, 2020 Universitas Indonesia Street, Depok, West Java, Indonesia, E-mail: sangpurna- Published: July 30, 2020 [email protected], Phone: +62-877-3917-6777

Figure 1. COVID-19 Transmission Patterns Related to Hygiene and Sanitation

7 Kesmas: Jurnal Kesehatan Masyarakat Nasional (National Public Health Journal). 2020; Special Issue 1: 6-13 quickly because droplets can spread and infect others. washing hands not only prevents COVID-19 but also o - For this reason, social distancing is needed to reduce ther diseases such as diarrhea and pneumonia.54 Wash crowds, close schools, workplaces, terminals.36,37 hands with soap strategies to save costs to reduce the The national socioeconomic survey reports that burden of global disease.55 Indonesia has a population living in urban areas (52.9%) Basic Health Research data mentioned that 50.2% of and living in homes with a floor area of fewer than 8 m2 improper hand washing.16 The behavior of cleaning per capita (14.8%) and the population traveling last year hands with soap and running water has been socialized (28.2%).38 Living in a crowded house and a large num- through electronic media and print media. The School ber of residents and lack of air ventilation can interfere Health Unit program also promotes handwashing with with health, especially airborne diseases.39 The use of soap but is still not optimal. Studies in Indonesia found proper ventilation can help prevent airborne diseases that that handwashing behavior is influenced by the presence generally occur in homes in urban areas.40 Increasing air and distance of handwashing facilities, interpersonal in- ventilation is effective to reduce the risk of long-range fluence, the desire to smell good, washing hands when airborne transmission and help prevent droplet-borne.41 feeling dirty.55 This behavior is closely related to COVID- 19's control efforts. Air pollution and smokers Air pollution in big cities in Indonesia is very high, Low access to clean water and drinking water making Indonesia 20 polluted countries in the world.42 Data from the central statistics agency states that ac- High air pollution can be a driving factor in the occur- cess to safe water in Indonesia reaches 72.55%, which is rence of respiratory disturbances.43-45 High levels of air still below the Sustainable Development Goals (SDGs) pollution can cause cardiovascular disease and respirato- target of 100%.21 As many as 33.4 million people still ry disease.46 According to WHO around 7.1 million peo- lack access to clean water. People who are difficult to get ple died due to the effects of air pollution and around access to clean water will use water from polluted sources 94% live in low and middle-income countries.47 so that it can endanger their health. Polluted water The BPJS reports in Indonesia that the incidence of sources are at risk of causing various types of digestive pneumonia is 1.3 per 1,000 population. Also, Indonesia and skin disorders.56 ranks third in the world of tuberculosis with an estimated The results of the national socio-economic survey case of 845,000 people. The prevalence of acute respira- from BPS show that households with access to decent tory infections in Indonesia reaches 9.3%.48 This indi- drinking water in Indonesia in 2012 amounted to cates that Indonesia already has a high respiratory disease 65.05% of households. In 2014 it became 68.11% then burden. The symptoms of COVID-19, which is also pneu- increased in 2017 to 72.04%. This means that 80 million monia, will increase the number of respiratory diseases people still do not have access to adequate drinking wa- in Indonesia. ter.21 Utilization and management of drinking water that The Southeast Asia Tobacco Control Alliance (SEAT- is not according to the standard also risk causing diar- CA) report mentions Indonesia as the country with the rhea, dysentery, cholera, and skin diseases. Especially most smokers in Asia with 65.19 million people. They concerning COVID-19, potential water sources are con- buy cigarettes installs, kiosks, minimarkets, and super- taminated if drinking water is not treated properly. markets.49 The number of cases of tobacco-related dis- Data from the Directorate General of Pollution eases is 962,403 people. Chronic obstructive pulmonary Control and Environmental Damage stated that the quali - disease is the most common type of tobacco-related dis- ty of the river began to decline, by 23.5% with mode- ease, then severe low birth weight babies, coronary heart rately polluted status and 55.88% with severe pollu- disease, stroke and lung tumors, bronchus, and tration.57 This river pollution is caused by the disposal of chea.50 The WHO states smokers are at a higher risk of household waste, industrial waste, and also from the resi - being infected with COVID-19, firstly because the fingers dents' toilet. The heavy river pollution is not suitable for used for smoking directly touch the lips. Second, smokers the community to use because it contains heavy metals may already have lung disease or not optimal lung capac- and does not meet microbiological standards. The use of ity.51-53 river water for bathing or drinking water is very dangerous. COVID-19 could have polluted the river from feces Low handwashing habits and stools that are directly discharged into the river.57 The hand as a medium of transmission of COVID-19, touches the surface of objects contaminated with SARS Open defecation COV-2 then touches the nose, mouth, and eyes.9,14 The The WHO/UNICEF data states that Indonesia is the WHO recommends washing hands with soap and second-largest country in the world where people still through running water to prevent COVID-19 because defecate openly.19 Based on UNICEF data in 2015, there

8 Purnama et al, Hygiene and Sanitation Challenge for COVID-19 Prevention in Indonesia are 32 million people who still defecate openly. Then in The limitations of PPE can endanger health workers in 2018, there will be 25 million people. Around 150,000 handling COVID-19 patients. Efforts to produce local Indonesian children die each year from diarrhea and oth- PPE are needed to meet market needs. WHO recom- er diseases caused by poor sanitation.20 Open defecation, mends that the general public use cloth masks and health such as in rivers, fields, forests, will pollute the soil and workers use standard clothing for handling patients with water. Related to COVID-19 discarding feces carelessly COVID-19.61,62 can contain SARS COV-2,58 which causes contamination in the environment and surface water. COVID-19 Prevention Policy with Hygiene and Based on World Bank data, it is known that of the Sanitation Approach 60% of the urban population that is still open defecation COVID-19 transmission that is known directly as many as 14% and 62% have a septic tank but do not through droplets from sufferers to others needs to be pre- have a sewage treatment system. Total losses due to poor vented by using PPE.10 Indirect transmission through sanitation reached USD 6.3 billion.59,60 Waste disposal means and touch to the mouth, eyes, and nose requires directly into rivers, in the soil and waterways without personal hygiene. There is potential for environmental proper waste treatment, can pollute the environment. pollution from feces that can pollute clean water and Groundwater and surface water can be polluted by bac- community drinking water. Need to get attention to en- teria and viruses. vironmental sanitation. Therefore, we need policies that support prevention with aspects of environmental hy- A limited supply of personal protective equipment giene and sanitation, namely personal protect equipment, (PPE) health education, personal hygiene, and sanitation which Since the COVID-19 pandemic, the need for personal is described in Table 1. This policy is formulated in protective equipment such as face masks is very high. Figure 2. This makes it difficult for the public and health workers to get face masks. Limited personal protective equipment Use of standard personal protective equipment such as face masks for the general public and special The first step to reduce COVID-19 contamination equipment for health workers such as N95 masks, gloves, through direct transmission is the use of masks. World eye protection, dresses need to be addressed immediately. Health Organization recommends that it is required to

Table 1. Hygiene and Sanitation Factors for COVID-19

Personal Protect Equipment (PPE) Health Education Personal Hygiene Sanitation

• Use a face mask for everyone • Formation of a task force team • Washing hands with soap and water • Provision of handwashing facilities in public facilities • Provision of standard PPE to • Education about hygiene and • Do not touch the face before washing • Routinely disinfecting objects that are medical staff sanitation in the family, school, hands frequently touched community and workplace environment • Physical distancing • Risk communication on electronic • Come home, take a shower before • Provision of clean and safe water media, print media and social media touching objects facilities • Stop open defecation • Wastewater management

Figure 2. Prevent COVID-19 Use Hygiene and Sanitation Approach

9 Kesmas: Jurnal Kesehatan Masyarakat Nasional (National Public Health Journal). 2020; Special Issue 1: 6-13

Figure 3. The Use of Masks to Protect Us and Others from COVID-19 Exposure64 use masks for everyone.24 This helps to reduce the risk of Health education program with risk communication exposure of COVID-19 sufferers to others and also the Since March 17, 2020, Indonesia has formed a task risk of transmitting COVID-19 to others. So in principle, force for handling COVID-19 which is coordinated by we protect others and others protect us (see in Figure 3). the National Disaster Management Agency (BNPB). The Availability of standard personal protective equip- task force is expected to be able to accelerate efforts to ment (PPE) for medical staff treating patients with handle COVID-19 in various areas ranging from prepa- COVID-19.13 The need for PPE medical standards has ration in handling, preventing, detecting, and responding. increased in the world since the pandemic occurred. Structural task forces exist from the central to the village Health workers are vulnerable to COVID-19 contamina- level.65 tion when treating COVID-19 patients. High intensity Ofﬁcers must provide education about hygiene and with COVID-19 patients requires using PPE such as N- sanitation in the family, school, community, and work- 95 masks, glasses, hazard material clothing, shoe protec- place environment related to COVID-19.66 The role of tors as well as medical waste disposal containers and community leaders, teachers, parents is needed in collab- their sterile treatment.26 Without the proper PPE, trans- oration to provide education in their respective environ- mission from patients to health care workers is vulnera- ments. A good understanding of transmission, control, ble. There is also the possibility of patient-to-patient and preventive actions can help the community in dealing transmission in hospitals.64 with the COVID-19 pandemic. Risk communication on electronic media, print me- Physical distancing dia, and social media to provide information to the public World Health Organization recommends keeping a quickly and accurately through trusted sources. This is to safe distance of more than 1 meter from other people avoid hoax information and create confusion in the com- (physical distancing). It aims to reduce direct contact munity. Incorrect and insistent information can cause with other people who are symptomatic in COVID-19 anxiety and excessive fear in the community. For this rea- and those who are asymptomatic but have the potential son, a centralized information and education system are to transmit.13 This policy is effective in reducing the po- needed in each region and conﬁrmation of hoax news. tential for virus transmission.37 This action was followed by a policy of reducing gatherings, closing schools, work- The personal hygiene improvement program places, markets, public transportation, religious cere- The discovery of SARS COV-2 contamination that monies, and marriages.38 This policy also encourages causes COVID-19 in feces,67 and liquid waste requires people to stay at home, work at home, study at home, efforts to anticipate the occurrence of contamination in worship at home. community sewage.18,33,68 Habits of people who defecate carelessly in Indonesia are still high. This behavior is

10 Purnama et al, Hygiene and Sanitation Challenge for COVID-19 Prevention in Indonesia very dangerous because it can contaminate water sources ed through processing and piping facilities so that the so that the potential for transmission occurs through quality is guaranteed. COVID-19 can pollute community drinking water residents. This is an early warning to take water sources through contaminated faeces.17 precautionary measures by stopping open defecation. Liquid waste treatment and waste management pro- Sanitation improvement programs in Indonesia so far gram. SARS COV-2 was found to be found in sewera- have been carried out through Community-based Total ge.33 Most households in Indonesia do not have a com- Sanitation & Hygiene (CLTS) Strategy with 5 main pil- munal waste treatment system, most only have latrines lars namely Open Defecation Free communities, and septic tanks without further processing. Waste treat- Handwashing with soap at critical moments, Household ment systems need to be carried out before being dis- water treatment and safe storage of water and food, Solid charged into the environment. For medical waste pro- waste management and Liquid waste management. CLTS duced including hazardous and toxic materials that need increases toilet construction with community participa- special treatment in handling so as not to pollute the en- tion,69,70 so that the CLTS program is more optimal, it vironment and contaminate humans. The solid waste requires high-level political commitment, integration of generated from infectious hospitals must not be disposed sanitation programs into health programs, improvement of directly into the landﬁll, but can use an incinerator or of community hygiene and coordination multi-sector.71 a third party for disposal. Multi-sector cooperation is needed for optimal program implementation. Conclusion The handwashing with soap program is carried out COVID-19 transmission can occur directly through simultaneously to break the chain of transmission of droplets to other people or indirectly through touching COVID-19. Hands indirectly as a medium of transmis- the surface of an infective object. Hygiene prevention sion of COVID-19 through touch on the eyes, nose, and such as using masks and washing hands is needed. This mouth. Indonesian people's handwashing habits are still article also discusses Indonesia's challenges in controlling very low. There are 50.2% of people who do not wash covid is urban area density, air pollution and smoking, their hands properly.16 To prevent transmission of low hand washing habit, low access to clean water and COVID-19, it is necessary to move the handwashing pro- drinking water, open defecation. hygiene and sanitation gram using soap before touching the mouth, nose, and approach namely through personal protect equipment, eyes. health education, personal hygiene and sanitation.

Provision of environmental sanitation facilities Abbreviations Provision of handwashing facilities in public facilities. COVID-19: Coronavirus infectious diseases 2019; SARS COV-2: se- To support the habits of the community who wash their vere acute respiratory syndrome coronavirus 2; WHO: World Health hands, hand washing facilities are needed in public facili- Organization; PPE: Personal Protective Equipment; UNICEF: United ties, namely markets, terminals, places of worship, Nations Children’s Fund; BPS: Statistics Indonesia (Badan Pusat schools, and others. This handwashing facility is useful Statistik); BPJS: ; SEATCA: Southeast Asia Tobacco Control Alliance; in supporting efforts to prevent COVID-19 transmission SDGs: Sustainable Development Goals; CLTS: Community-based in the community. The availability of handwashing facil- Total Sanitation & Hygiene. ities helps the community get used to washing hands with soap in public places. Ethics Approval and Consent to Participate Disinfecting public facilities and items that are often Not Applicable used such as dining tables, cellphones, cabinets, algae doors, elevator buttons, and others.12 Disinfectant action Competing Interest can kill the SARS COV-2 virus that is on the surface of No potential competing interest was reported by the authors. objects, which are around us such as the surface of wood, plastic, metal, aluminum, copper, and cardboard. The Availability of Data and Materials virus can persist for up to 72 hours on these objects. All data generated or analyzed during this study are included in this Routine item sterilization needs to be done for objects published article. that are frequently touched.9 Provision of clean water and proper drinking water Authors’ Contribution facilities for the community. Access to clean water and Sang Gede Purnama: Development and design of the models, creation proper drinking water is still low in Indonesia. People and presentation of the published work, speciﬁcally writing the initial who do not get access to properly clean water, use water draft (including substantive translation); Dewi Susanna: Analyze the sources that are polluted and at risk of being contaminat- review, commentary and revision – including pre- or post-publication ed by COVID-19. Clean water sources should be provid- stages.

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International Journal of Biological Sciences. 2020; 16 (10): 1753–66. 42. Greenstone M, Fan Q. Indonesia’s worsening air quality and its impact 63. Huang S. COVID-19: why we should all wear mask— there is new sci- on life expectancy. Air Quality Life Index; 2019. entific rationale. Medium. 2020; 43. Conticini E, Frediani B, Caro D. Can atmospheric pollution be consi- 64. Wang D, Hu B, Hu C, Zhu F, Liu X, Zhang J, et al. Clinical character- dered a co-factor in extremely high level of SARS-CoV-2 lethality in istics of 138 hospitalized patients with 2019 novel coronavirus-infect- Northern Italy?. Environmental Pollution. June 2020; 261: 114465. ed pneumonia in Wuhan, China. JAMA. 2020; 323 (11): 1061–9. 44. Sun Z, Zhu D. Exposure to outdoor air pollution and its human-relat- 65. Gugus Tugas Percepatan Penanganan COVID-19. Pedoman penangan ed health outcomes: an evidence gap map. BMJ Open 2019; 9: cepat medis dan kesehatan masyarakat COVID-19 di Indonesia. e031312. Jakarta; Maret 2020: pp.1-38. 45. Sweileh WM, Al-Jabi SW, Zyoud SH, Sawalha AF. Outdoor air pollu- 66. Roy D, Tripathy S, Kar SK, Sharma N, Verma SK, Kaushal V. Study tion and respiratory health: a bibliometric analysis of publications in of knowledge, attitude, anxiety & perceived mental healthcare need in peer-reviewed journals (1900 - 2017). Multidisciplinary Respiratory Indian population during COVID-19 pandemic. Asian Journal of Medicine. 2018; 13: 15 (1-12). Psychiatry. 2020; 51: 102083. 46. Ghorani-Azam A, Riahi-Zanjani B, Balali-Mood M. Effects of air pol- 67. Yuen KS, Ye ZW, Fung SY, Chan CP, Jin DY. SARS-CoV-2 and lution on human health and practical measures for prevention in Iran. COVID-19: the most important research questions. Cell & Bioscience. Journal of Research in Medical Sciences. 2016; 21: 65. 2020; 10 (40). 47. World Health Organization. Burden of disease from the joint effects of 68. Gormley M, Aspray TJ, Kelly DA. COVID-19: mitigating transmission household and ambient air pollution for 2016: summary of results; via wastewater plumbing systems. The Lancet Global Health. 2020; 8 2018. (5): e643. 48. Kementerian Kesehatan Republik Indonesia. Diseases report; 2018. 69. Cameron L, Olivia S, Shah M. Scaling up sanitation: evidence from an 49. Mark Drajem, Lorraine Woellert. Clove cigarettes may prompt U.S., RCT in Indonesia. Journal of Development Economics. 2019; 138: 1– Indonesia dispute. Southeast Asia Tobacco Control Alliance. 2018; 16. pp. 1–144. 70. Venkataramanan V, Crocker J, Karon A, Bartram J. Community-led to- 50. Infodatin. Situasi umum konsumsi tembakau di Indonesia. Jakarta: tal sanitation: a mixed-methods systematic review of evidence and its Kementerian Kesehatan Republik Indonesia; 2019. quality. Environmental Health Perspectives. 2018; 126 (2): 026001. 51. World Health Organization. Tobacco free initiative: tobacco and wa- 71. Zuin V, Delaire C, Peletz R, Cock-Esteb A, Khush R, Albert J. Policy terpipe use increases the risk of suffering from COVID-19; 2020. diffusion in the rural sanitation sector: lessons from community-led to- 52. Terzikhan N, Verhamme KMC, Hofman A, Stricker BH, Brusselle tal sanitation (CLTS). World Development. 2019; 124: 104643. GG, Lahousse L. Prevalence and incidence of COPD in smokers and non-smokers: the Rotterdam study. European Journal of Sipahutar et al. Kesmas: Jurnal Kesehatan Masyarakat Nasional (National Public Health Kesmas: Jurnal Kesehatan Masyarakat Nasional Journal). 2020; Special Issue 1: 14-17 DOI: 10.21109/kesmas.v15i2.3936 (National Public Health Journal) COVID-19 Case Fatality Rate and Detection Ability in Indonesia

Tiopan Sipahutar1*,Tris Eryando2

1Doctoral Program in Public Health, Faculty of Public Health, Universitas Indonesia, Indonesia 2Department of Health Informatic and Biostatistic, Faculty of Public Health, Universitas Indonesia, Indonesia

Abstract The world is currently experiencing a COVID-19 pandemic. More than 5 million people have been infected with COVID-19 and more than 300 thousand have died from this virus worldwide. In Indonesia, the number of infected people has reached more than twenty thousand people and more than one thousand people have died from this virus. During the COVID-19 pandemic, Case Fatality Rate (CFR) was a very important measure for many people because death is very important to each person, including questions of when and how death will occur and whether there is any way to delay it. However, caution is needed in calculating and displaying CFR. This paper will present the uses and the weaknesses of CFR in the context of the COVID-19 pandemic in Indonesia.

Keywords: case fatality rate, COVID-19 pandemic, Indonesia

Introduction People cannot avoid of talking the number of death Some cases of pneumonia of unknown etiology de- when they discuss COVID-19. In a way, this moment tected in Wuhan City, Hubei Province of China in the has presented a new opportunity for the Indonesian com- end of 2019. A total of 44 patients reported with pneu- munity to improve their knowledge on mortality meas- monia of unknown cause in January 2020 that have been ures. As previously, the CFR was known only to those in reported to World Health Organization (WHO) by the the health sector, but now more people are becoming fa- national authorities in China.1 The consensus statement miliar with the measure. The CFR is a measure of mor- then established that the pneumonia of unknown etiolo- tality that is feared by human being for several reasons gy is coronavirus disease 2019 (COVID-19).2 As of such as because death is the ultimate experience that all March 2020, COVID-19 cases have been found globally human being will surrender. Moreover, death is highly (spread out of China),3 that Centers for Disease Control importance to each person including questions of when and Prevention (CDC) then recognized that the COVID- and how death will occur and whether there is any way 19 is person-to-person spread.4,5 In March 11, 2020, to delay it.8-10 based on the current situation that the COVID-19 have On social media, people have been debating the na- affected countries outside China tripled and the number tional CFR and even compared it with CFR of other of cases has increased 13-fold outside China, then WHO countries such as China and Vietnam, which have now identified COVID-19 as pandemic.6 had lower CFR compared to other country. This com- The COVID-19 pandemic has drained a lot of energy, parison is then followed by comparing the performance whether in physical, mental, social and economic terms.7 of the Indonesian government in handling pandemics The calculations have continuously been made to deter- under the pretext why CFR in Indonesia is higher com- mine the latest situation of cases that have occurred. pared to other countries. Another thing that also hap- Indeed, it has truly felt that we are living in "one world" pens is the lots of people displaying CFR numbers in in which no place or country is free from "contamina- Indonesia on television or social media which then does tion" of a problem that has afflicted certain regions. not only make people understand but has the potential The Case Fatality Rate (CFR) has especially become to create excessive fear or anxiety. This is a mistake be- an intriguing subject of discussion for many people. cause the community is more fixated on its CFR number

Correspondence*: Tiopan Sipahutar. Doctoral Program in Public Health, Faculty Received : May 29, 2020 of Public Health, Universitas Indonesia, Lingkar Kampus Raya Universitas Accepted : May 30, 2020 Indonesia Street, Depok City, West Java, Indonesia, 16424, E-mail: tiopansi- Published: July 31, 2020 [email protected], Phone: +62-812-1910-1192

Source: https://covid19.go.id/peta-sebaran

Figure 1. The Trend of Number of Cases Confirmed Along with the Addition of Laboratory in Indonesia

15 Kesmas: Jurnal Kesehatan Masyarakat Nasional (National Public Health Journal). 2020; Special Issue 1: 14-17 number of test because Indonesia was constrained by the be determined and a model with various assumptions be limited availability of reagents and experts who were able built. The ability to trace back, known as disease epi- to carry out the test.11,19-21 demiological research, is also important to be carried out With the addition of laboratories and the difficulties by the health department in each district or city to assist encountered in the field, and when it compared to the in the discovery of new cases as well as to detect the vastness of Indonesia which consists of 514 districts, the source of morbidity, which can help in handling a case of overall picture, of course, is still unfavourable. Such cir- illness.22-25 cumstances have automatically slowed down the process of confirmation on people’s status – whether or not they Conclusion are infected; so the denominator would be small. In this Finally, this pandemic has inevitably demanded peo- case, the CFR tends to be over-estimated. We also under- ple to understand the measures used in public health stand that there were instances where patients under sur- problems. However, displaying the size of public health veillance died but their results of real-time PCR test were problems without further explanation may cause infor- not yet known. If it was later discovered that the real- mation bias in the community, which can potentially cre- time PCR test results were confirmed to be positive, then ate adverse interpretations and conclusions. Therefore, the CFR calculation in the previous time was underesti- health information, especially about the size of public mated because it had not included the numerator.13,15,16 health problems, need to be displayed with explanations Both of such conditions, underestimation, and over- of strengths and weaknesses. This is an opportunity to estimation of the CFR, have their respective impacts. provide more education to the public considering that Overestimation of the figures may induce fear and panic 50% of Indonesia's population has been connected to while underestimating it may lead to the lack of serious- the internet and almost all Indonesians can access televi- ness in the community in preventing and overcoming the sion. Thus, this difficult pandemic would not just pass by spread of the COVID-19. Thus, in presenting, interpret- but also provide a learning effect for all Indonesians. ing and comparing the CFR for the public, caution and understanding of situations or contexts are indis- Abbreviations pensable.14 CFR: Case Fatality Rate; WHO: World Health Organization; COVID- Responding to this situation, we must apply the na- 19: Coronavirus Diseases 2019; CDC: Centers for Disease Control and tional standardization system in the context of laborato- Prevention; PCR: Polymerase Chain Reaction. ries for the equal distribution of the availability and quality of examinations or diagnoses, so when one day Ethics Approval and Consent to Participate Indonesian is struck by a similar incident, we would no The study was based on data available in public domain; therefore, no longer hear a statement that “the data from Laboratory A ethical issue is involved. is unreliable” or “unconfirmed”. The minimum standard must be prepared for each province, and if possible, be Competing Interest extended to the district or city level.7,11 The author(s) stated that no potential conflicts of interest with respect Another thing of concern is the effort for modelling to the research, authorship, and/or publication of this article. the COVID-19 incident, which has been confusing to the public. Every academic and research institution has con- Availability of Data and Materials ducted modelling and each modelling has been developed All material is publicly available in respective journals. The links are with an assumption. Different models were from differ- available in the reference list. All sources can be downloaded for free. ent assumptions, and this is not even easily understood by many people. Determining when transmission occurs Authors’ Contribution also need to be assumed if the model is to be calculated All authors have made substantial contribution to this research and properly. The determination of the initial transmission have approved the final manuscript. can be traced back from the first positive cases reported, where these cases are continuously traced until it be- Acknowledgment comes possible to seize cases that have not been previ- Not Applicable ously diagnosed – but because of a proper symptom recording – could show symptoms identical to the initial- References ly diagnosed cases. Hence, we would be able to establish 1. World Health Organization. Emergencies preparedness, response: a diagnosis by running this method properly until the first pneumonia of unknown cause – China; 20 May 2020. transmission is assuredly discovered. Another option is 2. Gorbalenya AE, Baker SC, Baric RS, et al. The species severe acute to simply stop at the first confirmed case and pay atten- respiratory syndrome-related coronavirus: classifying 2019-nCoV and tion to the average transmission, hence an initial case can naming it SARS-CoV-2. Nature Microbiology. 2020; 5: 536–44.

16 Sipahutar et al, COVID-19 Case Fatality Rate and Detection Ability in Indonesia

3. Jogalekar MP, Veerabathini A, Gangadaran P. Novel 2019 coron- Infectious Disease. 2020; 20 (7): 773-4. avirus: genome structure, clinical trials, and outstanding questions. 15. Rajgor DD, Lee MH, Archuleta S, et al. The many estimates of the Experimental Biology and Medicine (Maywood). 2020; 245 (11): 964- COVID-19 case fatality rate. Lancet Infectious Disease 2020; 20 (7): 9. 776-7. 4. Centers for Disease and Control and Prevention. CDC conﬁrms per- 16. Baud D, Qi X, Nielsen-Saines K, et al. Real estimates of mortality fol- son-to-person spread of new coronavirus in the United States; January lowing COVID-19 infection. Lancet Infectious Disease. 2020; 20 (7): 30, 2020. 773. 5. World Health Organization. Modes of transmission of virus causing 17. Xu S, Li Y. Beware of the second wave of COVID-19. Lancet. 2020; COVID-19: implications for IPC precaution recommendations; 2020. 395 (10233): 1321-2. 6. World Health Organization. WHO Director-General’s opening re- 18. Santesmasses D, Castro JP, Zenin AA, Shindyapina AV, marks at the media brieﬁng on COVID-19 - 11 March 2020; 2020. Gerashchenko MV, Bohang Z, et al. COVID-19 is an emergent disease 7. Djalante R, Lassa J, Setiamarga D, Sudjatma A, Indrawan M, of aging. medRxiv. Posted April 15, 2020. Haryanto B, et al. Review and analysis of current responses to 19. Kementerian Kesehatan Republik Indonesia. Pedoman pencegahan COVID-19 in Indonesia: period of January to March 2020. Progress in dan pengendalian coronavirus disease (COVID-19); July 2020: pp. 1– Disaster Science. 2020; 6: 100091. 115. 8. Gordis L. Epidemiology. 5th Edition. Elsevier Saunders. 20. Maharani T. Pemerintah tetapkan 12 jejaring laboratorium pemerik- 9. Webb P, Brain C. Essential epidemiology: an introduction for students saan Covid-19. kompas.com; March 16, 2020. and health professionals. 2nd Edition. Cambridge, UK: Cambridge 21. CNN Indonesia. Kemenkes: tes PCR corona massal terkendala alat University Press; 2011. dan SDM; April 22, 2020. 10. Bonita, Beaglehole, Kjellstrom. Basic epidemiology. 2nd Edition. 22. Gleick PH. No COVID-19 models are perfect, but some are useful. Geneva: World Health Organization; 2006. Time; May 19, 2020. 11. Kementerian Kesehatan Republik Indonesia. Peta sebaran COVID-19. 23. Brookmeyer R. Op-Ed: predictions about where the coronavirus pan- www.covid19.go.id; 2020. demic is going vary widely. Can models be trusted?. Los Angeles 12. Onder G, Rezza G, Brusaferro S. Case fatality rate and characteristics Time; April 22, 2020. of patients dying in relation to COVID-19 in Italy. JAMA. 2020; 323 24. Jewell NP, Lewnard JA, Jewell BL. Predictive mathematical models of (18): 1775-6. the COVID-19 pande mic: underlying principles and value of projec- 13. Spychalski P, Błażyńska-Spychalska A, Kobiela J. Estimating case fa- tions. JAMA. 2020; 323 (19): 1893–4. tality rates of COVID-19. Lancet Infectious Disease. 2020; 20 25. Wynants L, Calster BV, Collins GS, Riley RD, Heinze G, Schuit E, et (7):774-5. al. Prediction models for diagnosis and prognosis of covid-19: syste- 14. Kim DD, Goel A. Estimating case fatality rates of COVID-19. Lancet ma tic review and critical appraisal. BMJ. 2020; 369: m1328.

17 Iswanto. Kesmas: Jurnal Kesehatan Masyarakat Nasional (National Public Health Kesmas: Jurnal Kesehatan Masyarakat Nasional Journal). 2020; Special Issue 1: 18-23 DOI: 10.21109/kesmas.v15i2.3949 (National Public Health Journal) Innovative Work Shift for Health Workers in the Health Service Providers in Handling COVID-19 Cases

Acim Heri Iswanto

Department of Public Health, Faculty of Health Science, Universitas Pembangunan Nasional Veteran Jakarta, Indonesia

Abstract Working on shifts has the risk of being exposed to health problems, such as obesity and susceptibility to infections and hypertension. However, shift work is unavoidable for workers in sectors that require non-stop operations, such as health workers in the Health Service Providers. This article presented opinion about an optimal shift rotation pattern in reducing the health risks of shift health workers while increasing the effectiveness of the treatment of coronavirus (COVID-19) cases. In general, today’s pattern of shift work for health workers is schemed in the eight-day cycle, in which employees work two days in the morning service for seven hours, two days in the evening service for seven hours, and another two days in the night service for ten hours, then followed by two days off. This pattern has the potential to cause burnout and decrease reaction time. The article identifies a new work shift pattern that can accommodate the risk of burnout while simultaneously assisting in the emergency of the corona outbreak. It emphasises the Morning-Evening-Night-Holiday work pattern as an innovative work model that should replace the old work pattern. There are seven advantages of the new work pattern: biological balance, availability of transportation, rapid recovery, reduced risk of COVID-19 transmission, increased patient satisfaction, increased self-control, and improved performance.

Keywords: burnout, corona outbreak, health workers, work risk, work shift

Introduction In the United States, the country with the most casualties The new coronavirus disease 2019 (COVID-19) ini- in the world, an estimated 54.4% of doctors experience tially appeared in Wuhan City, Hubei Province, China, in at least one burnout symptom due to the treatment of co- December 2019. Currently, the virus has spread to 213 ronavirus.4 A Korean study on handling the Middle East countries and territories with 5,743,245 infected victims, respiratory syndrome (MERS) outbreak found that the 354,884 of whom died and 2,470,836 declared cured, average nurse experienced burnout due to high work resulting in a 13% fatality rate.1 World Health stress, low support from family and friends, and poor Organization (WHO) officially declared COVID-19 as a hospital resources.5 global pandemic on March 11, 2020. Meanwhile, Burnout is an urgent problem that must be treated Indonesia declared the corona outbreak as a national di- because it has severe consequences including fatigue, saster on April 13, 2020, through the Presidential Decree stress, anxiety, depression, mood disorders, drug abuse, Number 12 of 2020 on the Stipulation of A Non-natural suicide, poor patient care, early retirement, and Disaster of the Spread of COVID-19 as a National unexpect ed work stoppages.4 It may also have an impact Disaster. In Indonesia, COVID-19 has spread to 33 pro- on patient dissatisfaction, decreased patient outcomes, vinces and infected 23,851 people, of whom 1,473 died.2 increased mortality, and failure to save patients.5 In line with this, there have been many local governments Burnout itself is a negative experience on employees declaring the enactment of Large-Scale Social who do not have the psychological and physical resources Restrictions (Pembatasan Sosial Berskala Besar/PSBB) to meet work demands and expectations. The experience in their areas. is characterized by the presence of emotional exhaustion The coronavirus has also affected the health workers (the feeling of overwhelm), depersonalization (the feeling caring for the patients. Psychologically, health workers that the self is not real or that one cannot be him/herself), may experience post-traumatic and burnout disorders.3 as well as decreased personal achievement (lack of per-

Correspondence*: Acim Heri Iswanto, Department of Public Health, Faculty of Received : May 30, 2020 Health Science, Universitas Pembangunan Nasional Veteran Jakarta, Raya Limo Accepted : May 31, 2020 Street No. 1, Jakarta, Indonesia, E-mail: [email protected], Phone: +62- Published: July 31, 2020 811-994-170

Copyright @ 2020, Kesmas: Jurnal Kesehatan Masyarakat Nasional (National Public Health Journal), p-ISSN: 1907-7505, e-ISSN: 2460-0601, SINTA-S1 accredited, http://journal.fkm.ui.ac.id/kesmas, Licensed under Creative Commons Attribution-ShareAlike 4.0 International Iswanto, Innovative Work Shift for Health Workers in the Health Service Providers in Handling COVID-19 Case sonal achievement).5 and issued recommendations for reducing shift work time Concerning the COVID-19 outbreak, burnout may for health workers treating corona patients.10 cause viral transmission, slow recovery, and even death for both patients and health workers due to the inability Shift-based work of health workers to protect themselves or because health Shift-based work, which is work performed during workers give up or commit suicide. In Indonesia, as of unnatural working hours, is a work commitment that April 16, 2020, 23 doctors (four of whom were profes- cannot be avoided by health workers or workers in sec- sors) died from direct contact or indirect transmission tors that require uninterrupted operations. Concerning from COVID-19.6 At least 12 nurses have also died due this, the natural working hours are those hours that fol- to the virus.7 low the circadian rhythm, which suggests work at dayti- Many factors are understood to be the causes of bur- me (as opposed to at night time). Ideally, humans work nout. These factors can be classified into work factors, at this natural time because they are diurnal creatures personal factors, and organizational factors. Work factors that have a biological rhythm adapted for daytime activi- include prolonged stress from excessive workload and ties and resting at night. Work shifts, however, require work hours. Personal factors cover work-life imbalances, employees to work part-time at night. lack of sleep, and inadequate support. Meanwhile, orga- Shift work leads to several health problems such as nizational factors comprise workload expectations, poor weight problems and susceptibility to infections or hy- interpersonal communication, insufficient rewards, and pertension.11,12 These types of disorders can, in turn, le- negative leadership.4 ad to chronic diseases and infections in employees. Learning from the burnout experience of health work- However, the degree to which employees are affected by ers in the previous outbreaks such as the MERS, SARS, these disorders depends on four groups of factors, namely and H1N1, researchers have suggested several measures psychosocial factors, behavioral factors, physiological to anticipate burnout as follows: providing adequate re- factors, and modification factors. The link between shift sources and consistent and up-to-date work guidance; work and these factors is shown in Figure 1. recruiting additional health workers, volunteers, and ad- Psychosocial factors cover factors such as work ten- ministrative staff; expediting bureaucracy and licensing; sion, work satisfaction, work-life balance, and work allocating more budget; leveraging information technolo- stress. Behavioral factors include sleep behavior, physical gy intensively; implementing leadership to communicate activity, and eating patterns. Meanwhile, physiological clearly and efficiently; reducing workload; ensuring the factors constitute immunological effects, light, and vita- safety and health of health workers and staff; training min D. These three groups of factors can be modified by frontline workers; as well as protecting and supporting interventions on three things: shift work characteristics, health workers with operational action plans.4 socio-demographic, and chronotypes. As for the latter, Several ideas have emerged in regards to reducing the chronotypes are a variation on the circadian rhythms at workload of health workers and staff. Reducing the the individual level. Although humans are generally diur- workload can be undertaken by creating a rest schedule; nal and active during the day, some individuals may have limiting working hours (especially in emergency and in- a deviation from this pattern that they are categorized as tensive care units); and providing regular psychosocial the "night types". support, basic needs, and spiritual sessions.4 One idea to Night-typed individuals characterize nocturnal crea- reduce the workload that should be applied is to change tures more for having higher activity at night biologically. the work shift patterns of health workers and staff. Long Chronotypes are partly determined by genetic factors. work shift is one of the factors causing burnout on health Individuals with a morning chronotype sleep at 11:00 pm workers. Studies show that nurses who work in shifts of and wake up at 06:00 am on workdays and at 07:00 am 8-10 hours have lower burnout rates than nurses who on holidays. Individuals with a night chronotype sleep at continuously work for 12 hours.8 Conversely, working 01:00 pm and wake up at 08:00 am on workdays and continuously for 13 hours or more leads to patient dissa- sleep at 03:00 pm and wake up at 12 noon on holidays.13 tisfaction.9 Shift work can take rotations with varying frequencies It is possible that the work shifts prevailing so far in between morning, evening, and night work. Low rotation many PPKs in Indonesia, especially those dealing with work is defined by a long rotation period, for example, corona patients, are a source of burnout for health wor- one week's work in the morning, one week's work during kers. Many media reports indicate that the shifts of health the day, and one week's work at night; or two days’ work workers in dealing with the COVID-19 outbreak are ex- in the morning, two days’ work in the afternoon, and two hausting. The Indonesian Doctors Association (Ikatan days’ work in at night, followed by a break of three days. Dokter Indonesia/IDI), for example, claimed that there High rotation work, on the other hand, is marked by a ra- were doctors who died from fatigue in handling patients pid rotation period, for example, one day’s work in the

19 Kesmas: Jurnal Kesehatan Masyarakat Nasional (National Public Health Journal). 2020; Special Issue 1: 18-23

Figure 1. Factors Linking Shift Work with Health Problems12 morning, one day’s work during the day, and one day’s short shifts. work at night, and two days of rest.14 In addition to the evidence from the above research, Research shows that workers with rapid shift rota- there are suppressive factors that allow for the restraint tions may have disorders in decreased sleep duration and of the negative impacts of rapid shift patterns, at least in sleepiness at work compared to workers who work per- the context of health workers who treat corona patients. manently (only day or only night).15 This is caused by A study in Wuhan reveals that burnout is greatest among the disruption of brain activity when staying awake, health workers who do not treat corona patients, as op- which brings in concentration decline and inability to posed to those workers who are at the forefront.16 communicate well with clients.9 However, this pattern This unexpected finding puts several intriguing expla- can be reversed if workers are given a break of two days nations. First, the health workers have felt that there has or more after working on the night shift.15 been more control over the situation than before, that is However, research in other contexts shows different when they only “stayed quiet” when the outbreak initially results. A study on 315 nurses in Italy in 2015 compared occurred. Second, the treatment of corona patients has burnout incidents between two work cycles: a long cycle become a priority, which causes non-corona patients to (n = 105 people) with two workdays in the morning, two receive less attention. Although this is unfortunate, in workdays in the afternoon, and two workdays at night, the context of shifts, it makes the health workers with ra- followed by a rest of three days; and a short cycle (n = 59 pid shifts dealing with corona patients less stressed than people) with one workday in the morning, one workday the health workers treating non-corona patients. Third, in the afternoon, one workday at night, and two days of the health workers who deal with corona patients are clo- rest.14 There was no significant difference (p-value = ser to decision-makers that they have access to informa- 0.160) in the two groups in terms of sleep quality. Also, tion more quickly and accurately. This leads to a higher no notable differences were found in terms of task per- sense of achievement among them compared to those he- formance (p-value = 0.728) or contextual performance alth workers treating non-corona patients. This effect is (p-value = 0.997). Meanwhile, there was a significant dif- getting stronger, especially because their treatment reference (p-value = 0.040) between long shift nurses and sults can be directly seen through the health statistics of short shift nurses in terms of burnout. Nurses with short corona sufferers. shifts had lower burnout rates than nurses with long This explains why there is unclear impact of three-pe- shifts. The researchers explained that this occurred riod shift work on nurse burnout in the case of the MERS because nurses with long shifts were more often exposed outbreak. Research in this context partially found that to patients and hospital environments than nurses with shift work affected nurse burnout while some other stu-

20 Iswanto, Innovative Work Shift for Health Workers in the Health Service Providers in Handling COVID-19 Case

Table 1. Work Schedule (Old)

Employees Monday Tuesday Wednesday Thursday Friday Saturday Sunday

A I I II II III III IV B II II III III IV IV I C III III IV IV I I II D IV IV I I II II III

Notes: I. Morning shift : 07:00 am - 02:00 pm (7 hours) II. Afternoon shift : 02:00 am - 09:00 pm (7 hours) III. Night shift : 09:00 pm - 07:00 am (10 hours) IV. Holiday

Table 2. Example of Modified Work Schedule

Employees Monday Tuesday Wednesday Thursday Friday Saturday Sunday

A II III IV I II III IV B III IV I II III IV I C IV I II III IV I II D I II III IV I II III

Notes: I. Morning shift : 08:00 am - 04:00 pm (8 hours) II. Evening shift : 04:00 pm - 12:00 pm (8 hours) III. Night shift : 12:00 pm - 08:00 am (8 hours) IV. Holiday dies did not find a significant relationship.17,18 hours a day and divided by three shifts (eight hours per Results and Discussion shift). The number of health workers per shift is reduced Based on the author's observations on several health from three to two and the morning shift begins at 08:00 service providers (HSPs), the applicable general shift am. The following table (Table 2) illustrates the atten- schedule has a 6-day time off cycle with a pattern of 7- dance pattern of four employees with a work schedule hour morning work pattern, 7-hour evening work, and that has a four-day work cycle. 10-hour night work. The number of workers for each The advantages of this system lie in many aspects. The duty cycle is usually three people, but this data is not the first is the aspect of biological balance. Although there is same in all hospitals. Morning shift starts at 07:00 am. an increase in one hour from seven hours to eight hours The following table illustrates the pattern of attendance in the morning and evening shifts, this increase is in line of four employees with this work schedule. with the human circadian rhythms and is at a maximum The pattern on Table 1 shows an eight-day work cycle limit of eight hours. Workers on the night shift also ex- because on the ninth day, all four employees will be in perience a better balance because work time decreases the same combination again. A break of two days after dramatically from eleven hours to eight hours. This redu- the night shift is in accordance with previous research re- ces the negative effects of fatigue due to fighting the na- commendations to restore the pattern of early life for he- tural circadian rhythm. A study of 20 long night shift alth workers.15 However, this may still cause burnout workers results in nine out of 20 workers sleeping during because employees who work at night work up to 10 the day.21 Conversely, a schedule of rapid work shift pre- hours.8 Employees may experience fatigue and a decrease vents the emergence of sleep debt. A study on workers in psychomotor response time after working for long pe- with a work rotation of 12 hours of daytime work, 12 riods.19 Ideally, the working time should be eight hours, hours of night work, and two days off, shows the preven- divided into three shifts, starting at 08:00 am to maintain tion of sleep debt.22 work-life balance of employees.20 Secondly, the new system allows for transportation One way to reduce workload is to develop new shift availability. With work coming in at 08:00 in the morning work schedule patterns that have shorter time off cycles. and 16:00 in the evening, transportation is still available. For example, holiday can be given every three days, half This is different from the old system in which morning of the time off cycle in the usual work schedule. The du- service starts at 07:00, evening service at 14:00, and ration of work is also balanced by eight hours on all shifts night service at 21:00. For workers in big cities like (morning, evening and night), because one day is 24 Jakarta, the difference in hours of coming to work betwe-

21 Kesmas: Jurnal Kesehatan Masyarakat Nasional (National Public Health Journal). 2020; Special Issue 1: 18-23 en 07:00 am and 08:00 am hours is huge. At 07:00 am, racteristics from work that deals with "everyday pro- the road is very congested and congestion occurs at many blems" in hospitals. In employees dealing the coronavi- points. Traffic monitoring data shows that in Jakarta, on rus, there is an increase in self-control, attention, and average Monday - Friday, traffic jam at 05:00 am is 9- high support, all of which reduce the risk of burnout.16 16% while at 06:00 am increased to 37% - 48%.23 This should be able to compensate for one day removed Going early to work, as the sky is getting bright, can from time off. In fact, if the time off is kept for two days, increase one’s exposure to sunlight in the morning wit- psychological problems may arise for health workers, hout having to be spoiled by air pollution. In fact, being such as feeling helpless because they are not participating in a traffic jam would cause physical fatigue to those who in critical tasks that require immediate actions. pass through it.24 This makes employees want to sleep Seventh, there is the possibility of improved perfor- and rest more after experiencing a traffic jam.25 mance. Although the study by Giorgi, et al.,14 find no Third, more frequent time off allows for faster work significant differences between long shift workers and recovery before a buildup of fatigue befalls. Sleep depri- short shift workers, other studies have shown an increase vation leads to heart disease, diabetes, depression, fain- in performance in employees who work short shifts.21 ting, accidents, weak cognition, and low quality of life.26 This is attributed to increased melatonin secretion. Additionally, sleeping time under six hours per day may Melatonin is a hormone produced by the pineal family cause sleep debt that must be fulfilled immediately by the that runs in harmony with the circadian rhythms with its body. If the sleep debt is not paid, there will be problems peak level at night. Short shift work allows for an incre- with concentration and performance. Long cycle period ase in melatonin at night without interruption compared of six days may cause a buildup of sleep debt that ultima- to long shift work. tely reduces employee performance, especially in the final An alternative to the Morning-Evening-Evening- days before the holiday. Because the last day of work is at Holiday model with 8-hour working hours above can be night, the patient being treated might run the risk of me- conceptualized as well. For example, the cycle of one dical errors. Moreover, employees may spend the first day's work in the morning, one day's work in the evening, day of their time off sleeping, disrupting their roles in the one day's work at night, and a two-day break from the family such as being a mother or a father. If the cycle pe- study of Giorgi, et al.,14 can be applied while maintaining riod is short, there would almost be no build up of sleep a long working time, though it may be less balanced when debt and holidays can be treated as normal days without compared with the emergence of the corona outbreak ca- having to sleep excessively. Furthermore, a study com- se. Work shifts of three days in the morning, then time paring 24-hour and 72-hour break after a night shift does off, then three days’ work in the afternoon, followed by not highlight a significant difference, so the research con- time off, and then three days’ work at night, then time off cludes that one day's rest time is sufficient for employee again, can also be considered as long as the working work needs.22 hours per shift are no more than eight hours and time off Fourth, fewer workers are needed to work on the is fast. The point is we need to modify working hours and shift. The reduction of employees from three to two shift patterns that have existed now so that it is more ba- employees per shift allows for the use of less labor and lanced between the needs of health workers and the more efficient work because social interaction on things needs of COVID-19 patients. that are not relevant to work is limited. Moreover, this is in line with the physical distancing instruction because Conclusion there are only two, rather than three personnel. Short There is indeed societal pressures on physicans and work hours make employees more often work at home nurses engaged with Covid-19 cases to working as good and not often come to health care centers. as they can. However, if the working shift can decreasing Fifth, there would be an increase in patient satisfac- health professionals performance and their wellbeing, tion and a decrease in unwanted incidents. This is backed then this would constitute sufficiently compelling reasons up by the fact that a short work cycle reduces the level of for change the shift pattern to be lighter and shorter. burnout in health workers.14 This will be especially fa- Because of this reason, and also because demands from vourable for patients who are treated at night as a pre- physicians and nurses themselves, we propose an innova- vention measure has been taken in regards to the risk of tive work shift scheduling. The new work shift scheduling treatment errors which might have been caused by ex- could solve some health problems experienced by physi- hausted health workers. cians and nurses. Sixth, although the rest period is one day less than recommended for short shifts,14 this has been compensated Abbreviations by the nature of the work. Work that deals with the CO- WHO: World Health Organization; PSBB: Pembatasan Sosial Berskala VID-19 outbreak have been found to have different cha- Besar (Large-Scale Social Restrictions); MERS: Middle East respiratory

22 Iswanto, Innovative Work Shift for Health Workers in the Health Service Providers in Handling COVID-19 Case sindrome; IDI: Ikatan Dokter Indonesia (Indonesian Doctors 12. Loef B. Shift work: health, lifestyle, and immunological effects. Dutch Association); HSP: Health Service Provider. National Institute for Public Health and the Environment (RIVM); 2020. Ethics Approval and Consent to Participate 13. Roenneberg T, Wirz-Justice A, Merrow M. Life between clocks: daily Not Applicable temporal patterns of human chronotypes. Journal of Biological Rhythms. 2003; 18 (1): 80–90. Competing Interest 14. Giorgi F, Mattei A, Notarnicola I, Petrucci C, Lancia L. Can sleep qua- Author declares that there are no significant competing financial, pro- lity and burnout affect the job performance of shift-work nurses ? a fessional, or personal interests that might have affected the perform- hospital cross-sectional study. Journal of Advance Nursing. 2018; 74 ance or presentation of the work described in this manuscript. (3): 698–708. 15. Dibas M, Hashan MR. The difference in the timings of healthcare pro- Availability of Data and Materials fessionals ’ shifts and sleep disturbances. MedPharmRes. 2018; 2 (6): The data and materials of this study were available upon request to the 32–4. ﬁrst author. 16. Wu Y, Wang J, Luo C, Hu S, Lin X, Anderson AE, et al. A comparison of burnout frequency among oncology physicians and nurses working Authors’ Contribution on the front lines and usual wards during the COVID-19 epidemic in Acim Heri Iswanto contributed substantially to the conception, writing, Wuhan, China. Journal of Pain and Symptom Management. 2020; 60 and revising of the manuscript. (1): e60-5. 17. Kim JS, Choi JS. Factors influencing emergency nurses’ burnout during Acknowledgment an outbreak of Middle East Respiratory Syndrome Coronavirus in My sincere gratitude is addressed to Owner, Board of Directors, All Korea. Asian Nursing Research (Korean Soc Nurs Sci). 2016; 10 (4): Managers and Staff of Ali Sibroh Malisi Hospital, Jakarta that granted 295–9. permits to conduct implementation this idea in its working areas as pi- 18. Mirfat ME-K, Mageda A. Shift work pattern and menstrual characte- lot project. ristics among nurses in Egypt. Biomedicine and Nursing. 2016; 2 (4): 104–15. References 19. Thompson B. Does work-induced fatigue accumulate across three 1. Worldometer. Coronavirus; 2020. compressed 12 hour shifts in hospital nurses and aides?. PLoS One. 2. Worldometer. Coronavirus: Indonesia; 2020 [cited 2020 May 28]. 2019; 14 (2): e0211715. 3. Sood S. Perspective Psychological effects of the Coronavirus. RHiME. 20. Williams C. Work-life balance of shift workers. Perspectives on 2020; 7: 23–6. Labour and Income. 2008; 9: 5–16. 4. Shah K, Chaudhari G, Kamrai D, Lail A, Patel RS. How essential is to 21. Quera-Salva MA, Claustrat B, Defrance R, Gajdos P, Mccann CC, de focus on physician’s health and burnout in coronavirus ( COVID-19) Lattre J. Rapid shift in peak melatonin secretion associated with im- pandemic?. Cureus. 2020; 12 (4): e7538. proved performance in short shift work schedule. Sleep. 1997; 20 5. Kim Y, Seo E, Seo Y, Dee V, Hong E. Effects of Middle East respira- (12): 1145–50. tory syndrome coronavirus on post-traumatic stress disorder and bur- 22. Fischer D, Vetter C, Oberlinner C, Wegener S, Roenneberg T. A uni- nout among registered nurses in South Korea. International Journal of que, fast-forwards rotating schedule with 12- h long shifts prevents Healthcare. 2018; 4 (2): 27–33. chronic sleep debt. Chronobioogyl International. 2016; 33 (1): 98– 6. Medistiara Y. Total 23 dokter meninggal dunia selama pandemi coro- 107. na, ini daftarnya. detikNews; Aprl 15, 2020 [cited 2020 Apr 16]. 23. Tom Tom Traffic Index. Weekly traffic congestion by time of day in 7. Setyowati D. 44 dokter dan perawat RI meninggal dunia akibat virus Jakarta. Tom Tom Traffic Index; 2020. corona. Katadata.com; April 12, 2020 [cited 2020 Apr 16]. 24. Sadeek S, Rifaat S, Mahamud H, Saif A, Rimol A, Tahmid A. Effect of 8. Hunsaker S, Chen H, Maughan D, Heaston S. Factors that influence fatigue on traffic law violation of bus drivers in context of developing the development of compassion fatigue, burnout, and compassion sa- countries. In: Proceedings of the Eastern Asia Society for tisfaction in emergency department nurses. Journal of Nursing Transportation Studies. 2019; 12. Scholarship. 2015; 47 (2): 186–94. 25. Zuraida R, Iridiastadi H, Sutalaksana I. Fatigue from driving – a com- 9. Nurumal MS, Makabe S, Ilyani F, Jamaludin C, Fahmi H, Yusof M. parison between morning and afternoon tasks. In: Proceedings of the Work-life balance among teaching hospital nurses in Malaysia. Global 2016 International Conference on Industrial Engineering and Journal of Health Science. 2017; 9 (8): 81–9. Operations Management. Kuala Lumpur; 2016. p. 714–20. 10. Suciatiningrum D. Dokter meninggal kelelahan, IDI: tenaga medis 26. Smyth C MSN, APRN, BC, ANP/GNP, Montefiore Medical Center. kerja melebihi beban. IDN Times; MArch 20, 2020 [cited 2020 May The Pittsburgh Sleep Quality Index (PSQI). try this: Best Practice in 28]. Nursing Care to Older Adults. 2012; 29 (6): 1–2. 11. Sirinara P, Hanprathet N, Jiamjarasrangsi W. Prevalence of hypertension and associated factors among healthcare workers: a cross-sectional study. Chula Med J. 2019; 63 (3): 193–9.

23 Paramashanti. Kesmas: Jurnal Kesehatan Masyarakat Nasional (National Public Health Kesmas: Jurnal Kesehatan Masyarakat Nasional Journal). 2020; Specia Issue 1: 24-27 DOI: 10.21109/kesmas.v15i2.3934 (National Public Health Journal) Challenges for Indonesia Zero Hunger Agenda in the Context of COVID-19 Pandemic

Bunga Astria Paramashanti

Department of Nutrition, Faculty of Health Sciences, Universitas Alma Ata, Yogyakarta, Indonesia

Abstract The rapid spread of COVID-19 has not only threatened the lives of the infected people but also socially and economically affected a broader community. The pandemic has also challenged the second goal of the 17 Sustainable Development Goals (SDGs) to eliminate all the forms of hunger by 2030. The most disadvantaged people may have a greater risk of having malnutrition and poor health as they cannot access a diet that is safe, nutritious, affordable, and sustainable. At this moment, saving lives by focusing on the health-care system should not be the only priority; the emphasis should be made in other essential aspects, including agri-food sector, in order not to cause any additional burden of hunger, malnutrition, and overall health.

Keywords: COVID-19, Indonesia, novel coronavirus, Sustainable Development Goals, Zero Hunger

Introduction in public activities, such as religious and cultural events. Since the first case of severe acute respiratory As one of the essential services, the food, and beverage syndrome coronavirus 2 (SARS-CoV-2) was reported in sector is still allowed to run in the aftermath of the December 2019 in Wuhan, Hubei Province, China,1 the COVID-19 pandemic.3 However, the Indonesian coronavirus disease 2019 (COVID-19) has spread to at Minister of Agriculture, Syahrul Yasin Limpo, admitted least 212 countries and territories worldwide. As of May that the novel coronavirus pandemic has disrupted food 4, 2020, when this manuscript was being written, there supply chains, resulting in food price volatility and were 11,587 people diagnosed with COVID-19 and 864 decreased purchasing power at the national and the deaths caused by the virus confirmed in Indonesia. Not global levels.4 A distorting food environment means that only the infected people, but a wider society has also been there will be a change in dietary practices that may affect socially and economically affected. nutrition and health status. Indonesia’s economic growth was advancing rapidly The United Nations Development Programme over the last decade with the gross domestic product (UNDP) has stated the global health and economic crises (GDP) remained approximately at 5%. Nonetheless, the raising as the impact of COVID-19 pandemic. The dual benefits have not been equally distributed among the crises may continue to overload policy and health-care Indonesian population. The recent report revealed that systems. For this issue, the political response will decide the GDP in the first quarter of 2020 slowed to around the extent of the virus as well as the continuation of 3%. At this point, around 22 million Indonesians had achieving Sustainable Development Goals (SDGs).5 already experienced hunger in 2016-2018.2 Things could Undoubtedly, the crisis demands a collective response. get worse before getting better. To cut the virus transmission and lessen its impacts, Results and Discussion the Indonesian Government has continuously called for The second goal of SDGs aims to “end hunger, “stay at home” to all the citizens. Moreover, some regions achieve food security, and improve nutrition and have implemented large-scale social restriction which promote sustainable agriculture”. Working for Zero requires the closing of schools, offices, and public spaces, Hunger means ensuring that all people, particularly reduction in the public transport capacity, and restriction children, have adequate and nutritious food throughout

Correspondence*: Bunga Astria Paramashanti, Department of Nutrition, Faculty Received : May 29, 2020 of Health Sciences, Universitas Alma Ata, Brawijaya Street No. 99, Yogyakarta, Accepted : May 30, 2020 Indonesia 55183, E-mail: [email protected], Phone: +62 821-3193-1623 Published: July 31, 2020

Copyright @ 2020, Kesmas: Jurnal Kesehatan Masyarakat Nasional (National Public Health Journal), p-ISSN: 1907-7505, e-ISSN: 2460-0601, SINTA-S1 accredited, http://journal.fkm.ui.ac.id/kesmas, Licensed under Creative Commons Attribution-ShareAlike 4.0 International Paramashanti, Challenge for Indonesia Zero Hunger Agenda in the Context of COVID-19 Pandemic the year for a healthy life. While undernutrition has while the poor population was at 9.22%.13 The declined by nearly half in many countries due to rapid Indonesian Minister of Finance, Sri Mulyani Indrawati, economic growth and rising agricultural productivity, it said that the pandemic may place the poverty rate into is unfortunate that some still face malnutrition and the double-digit as in 2011.14 What could be worse than starvation.6 In this current situation, the question is, what dying from the virus or starving to death?. consequences does the COVID-19 have on the SDGs?. Secondly, hunger can happen when the community is Firstly, the pandemic may affect food security by faced with severe food insecurity. In this state, food interrupting the food system. We should look again at cannot be obtained for a long period, either geo- the Indonesian Government’s responses to limit graphically or financially. For those who still manage to transnational and national movements to cut the growing access food, though perhaps not always, moderate food transmission of the COVID-19. The regulations sure have insecurity may cause them to risk food quality and struck economic activities heavily in several ways, adequacy. Worse still, we must not forget the most including on food value chains. Similarly but differently, affected people already in food shortage, or children the pandemic crisis has affected food demand, relying on food supplementation programs, or the low- production, distribution and storage, processing, and income informal workers.14 Too many people are not marketing for both the low- and the high-income getting access to safe, nutritious, affordable, and population.7 Even though there is no direct prohibition sustainable diets. Unfortunately, there are many data on the food and beverage sector in Indonesia, there has gaps to draw up a further conclusion on this pandemic been a change on the way of food being produced and effect, however, we cannot ignore the rising risks of consumed. malnutrition and poor health. Indonesian agriculture is dominated by smallholder Thirdly, children are the most vulnerable group farmers. Ironically, as food producers, farmers are highly affected by hunger.11 Of the Zero Hunger targets, it is affected by the threat of a food security crisis due to globally agreed to reduce wasting and stunting among poverty. As a result, they are unable to buy seeds and the under-five.6 As a consequence of the COVID-19 renew their crops.8 Yet, we should not worry about the pandemic, recent food shortage may cause children at staple food supply in the next three to four months. Rice risk of having acute malnutrition due to substantial and corn stocks from March to May 2020 were 15.9 weight loss or wasting. Given its chronic nature, the risk million tons and 10.3 million tons, respectively, of stunting should not be left behind. Stunted growth compared to the estimated need of the population, each may also occur among children who are already in a state at 7.6 and 6.0 million tons.9 Then, what will happen after of long-standing food scarcity. May?. One of three under-five children in Indonesia has During the focus group discussion on “Effectiveness already suffered from stunted growth in 2018,15 Strategies for Implementing Economic Stimulus Impacts indicating chronic undernutrition. There was only a 1.3% of COVID-19”, the President Director of PT Perkebunan annual decrease since 2013.16 The progress was not even Nusantara VIII said that grain production will fall by close to the global and national targets which require 50%. Based on the field observation, rice production 3.9% and 2.8% yearly reduction, respectively. With this dropped from 5-6 tons per hectare to 3 - 3.5 tons per emergency happening, we will be far further from the hectare. Some regions have now increased the rice target. market price such as in Lembang with the rice price at Micronutrient deficiency may also arise. Hidden IDR 12,000 per kg, exceeding the average price of IDR hunger affects both children and women. The most 8,500 per kg.10 At the same time, Indonesia is still heavily common form is iron deficiency anemia with its relying on the imported source of animal protein, such as prevalence around 39% among children and 49% among beef and broiler. By the end of May, the estimated mothers.15 In children, iron deficiency may reduce commodity of broiler is only 219,000 thousand tons, learning ability and school performance, whereas women while beef is minus 19,000 thousand tons.9 A food are at risk for mortality during or after delivery.17 import strategy may be an alternative to maintain price Last but not least, the burden of malnutrition can be stability. Still, other countries may also struggle with their extended beyond hunger to overweight and obesity. The food security and put restrictions on their exports. way crop harvesting on the farm has been changed due to Consumers’ demands for various food products has globalization and urbanization which causes the highly- been reduced due to human movement restriction, high processed food displayed in the supermarket.18 While price volatility, and reduced purchasing power. If we look physical distancing becomes common, consumers back in 2019, the hunger level in Indonesia was prioritize purchasing food which is durable, affordable, categorized as serious,11 and the food security and easily accessed and prepared. This calling may invite performance ranked the 62nd among 113 countries,12 an increased consumption of ultra-processed food with

25 Kesmas: Jurnal Kesehatan Masyarakat Nasional (National Public Health Journal). 2020; Special Issue 1: 24-27 high levels of sugar, fat, salt and energy, but low in fiber. References Additionally, staying at home may also increase the 1. Wu F, Zhao S, Yu B, Chen Y-M, Wang W, Song Z-G, et al. A new sedentary lifestyle and reduce physical movement. Both coronavirus associated with human respiratory disease in China. excessive energy intake and low physical activity are the Nature. 2020; 579 (7798): 265-9. main drivers of overweight and obesity.19 2. Asian Development Bank. Policies to support investment requirements There will be no healthy lives without healthy eating, of Indonesia's food and agriculture development during 2020-2045. and healthy eating cannot exist without sustainable Manila: Asian Development Bank, IFPRI and Kementerian PPN / agriculture.20,21 Nevertheless, health and agriculture Bappenas; 2019. agencies have little cooperation and are often steered by 3. Ministry of Health of Indonesia. Peraturan Menteri Kesehatan distinctive and conflicting priorities.20 Also, the lack of Republik Indonesia Nomor 9 Tahun 2020 tentang Pedoman data underlines the importance of effective monitoring Pembatasan Sosial Berskala Besar dalam Rangka Percepatan and evaluation systems in each sector, followed by data Penanganan Corona Virus Disease 2019 (COVID-19); 2020. sharing between sectors. The goal is early detection and 4. Ministry of Agriculture of Indonesia. Pertemuan menteri G20, immediate response with emphasis on cost-effectiveness Indonesia tekankan penguatan sistem pangan menghadapi COVID-19; and cross-sector collaboration. 2020. 5. United Nations Development Programme. The social and economic Conclusion impact of COVID-19 in the Asia-Pacific region. Position note prepared COVID-19 pandemic could reverse Indonesia’s by UNDP Regional Bureau for Asia and The Pacific. Bangkok: United progress towards the second goal of 17 SDGs by 2030. Nations Development Programme; 2020. The unprecedented crisis may affect the Zero Hunger 6. United Nations Development Programme. Goal 2: zero hunger; 2020. agenda in Indonesia which include food insecurity, 7. Haddad L, Fanzo J, Godfrey S, Hawkes C, Morris S, Neufeld LM. The hunger, and malnutrition – especially childhood stunting. COVID-19 crisis and food systems: addressing threats, creating The policymakers are urged to assist most vulnerable opportunities. ed. 23 March 2020. London: Global Alliance for groups that are not only the infected patients or their Improved Nutrition (GAIN). family members, but also people who are food-deprived 8. Pusat Penelitian Kependudukan LIPI. Ketahanan pangan dan ironi and malnourished. Saving lives is a priority; however, at- petani di tengah pandemi COVID-19. Jakarta: Lembaga Ilmu tention and efforts must consider other aspects such as Pengetahuan Indonesia; 2020. food and agriculture, economy, social protection, and ed- 9. Hirawan FB, Verselita AA. Kebijakan pangan di masa pandemi ucation without adding the burden of another humani- COVID-19. Jakarta: CSIS Indonesia; 2020. tarian catastrophe. 10. Thomas VF. Pandemi corona: Indonesia bisa kekurangan beras dan bahan pangan. tirto.id; 2020. Abbreviations 11. Global Hunger Index. Global hunger index 2019: Indonesia. ed. SDGs: Sustainable Development Goals; SARS-CoV-2: Severe Acute October 2019; 2019. Respiratory Syndrome Coronavirus 2; COVID-19: Coronavirus Disease 12. Global Food Security Index. Global food security index: ranking and 2019; GDP: Gross Domestic Product; UNDP: United Nations trends; 2019. Development Programme. 13. Badan Pusat Statistik Indonesia. Persentase penduduk miskin September 2019 turun menjadi 9,22 persen. Jakarta: Statistical Bureau Ethics Approval and Consent to Participate of Indonesia; 2020. Not Applicable 14. Food and Agriculture Organization. The state of food security and nutrition in the world 2019. Safeguarding agaist economic slowdowns Competing Interest and downturns. Rome: Food and Agriculture Organization (FAO); No potential conflict of interest was reported by the author. 2019. 15. National Institute of Health and Research Development. Laporan Availability of Data and Materials nasional riskesdas 2018. Jakarta: National Institute of Health and Not Applicable Research Development (Balitbangkes); 2019. 16. National Institute of Health and Research Development. Laporan Authors’ Contribution Nasional Riskesdas 2013. Jakarta: National Institute of Health and Bunga Astria Paramashanti contributed substantially to the conception, Research Development (Balitbangkes); 2013. writing, and revising of the manuscript. 17. United Nations Children’s Fund. Key asks for 2020 SDG voluntary national reviews: zero hunger. New York: UNICEF; 2020. Acknowledgment 18. United Nations Children’s Fund. The state of the world’s children Not Applicable 2019: children, food and nutrition: growing well in a changing world. New York: UNICEF; 2019. 19. Romieu I, Dossus L, Barquera S, Blottière HM, Franks PW, Gunter

26 Paramashanti, Challenge for Indonesia Zero Hunger Agenda in the Context of COVID-19 Pandemic

M, et al. Energy balance and obesity: what are the main drivers?. 21. Lartey A, Meerman J, Wijesinha-Bettoni R. Why food system CCC-Cancer Causes & Control. 2017; 28 (3): 247-58. transformation is essential and how nutrition scientists can contribute. 20. Nugent R. Bringing agriculture to the table: how agriculture and food Annals of Nutrition and Metabolism. 2018; 72 (3): 193-201. can play a role in preventing chronic disease. Chicago, USA: The Chicago Council on Global Affairs; 2012.

27 Pinzon et al. Kesmas: Jurnal Kesehatan Masyarakat Nasional (National Public Health Kesmas: Jurnal Kesehatan Masyarakat Nasional Journal). 2020; Special Issue 1: 28-31 DOI: 10.21109/kesmas.v15i2.3929 (National Public Health Journal) Acceleration of Telemedicine Use for Chronic Neurological Disease Patients during COVID-19 Pandemic in Yogyakarta, Indonesia: A Case Series Study

Rizaldy Pinzon1,2, Dessy Paramitha1,2, Vincent Ongko Wijaya1,2*

1Neurology Department, Bethesda Hospital, Yogyakarta, Indonesia 2Faculty of Medicine, Duta Wacana University, Yogyakarta, Indonesia

Abstract COVID-19 preventions have cut access to routine medical care, especially for many chronic neurological disease patients. This condition has especially pro- moted telemedicine use in providing healthcare. This study aimed to review telemedicine use catalyzed by several regulations of the Indonesian Government and review 20 cases from Bethesda Hospital in Yogyakarta providing online consultation services. Perceptions of experience on telemedicine were collected from neurological patients at the hospital who were asked about their impressions of consultations and pharmacy medication services, and their suggestions about the new system in outpatient consultations. The regulations for telemedicine use are relevant because of these patients’ risks related to comorbidities and treatments. Of the 20 respondents involved in this study, 15 (75%) were satisfied with the service, 3 (15%) very satisfied, and 2 (10%) others neutral. Most respondents suggest improvement of reimbursement (80%) and others suggest improvement on medications (10%) and services (10%). System and hospital requirements for telemedicine services for neurological cases have been accelerated due to the pandemic. Telemedicine is a way to provide healthcare needed by patients at high risks for COVID-19 fatality related to comorbidities and treatments. Payment regulations, regulatory structures, state licensing, and credentialing across hospitals for better telemedicine experience need to be enhanced.

Keywords: COVID-19, Indonesia, neurologic disorder, telemedicine

Introduction Regulation on the Health Informatics and Telemedicine In December 2019, a cluster of pneumonia cases System in 2014.6 With the Indonesian Medical Council occurred on Wuhan, China. The World Health (IMC), or Komisi Kedokteran Indonesia (KKI), they Organization (WHO) has ofﬁcially named the disease as have also launched another regulation dealing with the coronavirus disease 2019 (COVID-19) and it has become COVID-19 crisis.7,8,9 This regulation states that patients a major health problem worldwide.1,2 Data on May 2, with high risks should avoid traditional outpatient visits 2020, showed that there were 10,843 positive cases in if possible, especially in crowded hospitals. The current Indonesia, with a mortality rate reaching 831 (7.7%) COVID-19 crisis has accelerated the use of telemedicine cases.3 A review study has estimated the basic for caring for these patients, especially with many reproduction number (R0) of SARS-CoV-2 to be around comorbid and advanced age. This study aimed to review 2.2.4 the acceleration of telemedicine use catalyzed by the Social distancing and quarantine have cut off access government regulations, as well as to review 20 cases to routine medical care for many chronic neurological from Bethesda Hospital in Yogyakarta, Indonesia, which disease patients. Patients with the chronic neurological provides online consultation services. disease have some poor prognostic factors for COVID- 19 fatality, for example, advanced age (alzheimer and Method parkinson) or vascular risk factors (stroke).5 Data from This study was a cross-sectional study using a Indonesia show that most of the fatal cases have been questionnaire-based measurement to evaluate the related to these risks (hypertension, diabetes, and satisfaction of telemedicine use during the COVID-19 cardiovascular / stroke condition).3 pandemic. It collects the current regulations of the The Indonesian Government has already launched the Indonesian Government and medical association on

Correspondence*: Vincent Ongko Wijaya, School of Medicine, Duta Wacana Received : May 27, 2020 University, Wahidin Sudirohusodo Street 5-25, Yogyakarta, Indonesia, 55284, E- Accepted : May 28, 2020 mail: [email protected], Phone: +62-813-9274-5050 Published: July XX, 2020

Table 1. Regulations from the Indonesian Government and Medical Associations

Regulation Date Scope Requirement

The Ministry of Health (303/2020) April 29, 2020 Inpatient and outpatients setting Electronic prescribing and electronic medical record Indonesian Medical Council (IMC), or April 29, 2020 Non-emergency cases should use Electronic prescribing and electronic Komisi Kedokteran Indonesia (KKI), telemedicine medical record (74/2020) Outpatients setting The Indonesian Food and Drug Authority April 2020 Medicine, food supplement, and tradi- Electronic prescribing and electronic (FDA) (8/2020) tional medicine medical record Exception: opioid analgesic, tranquilizer The Indonesian Neurological Association April 2020 Mild cases, over the counter medication, None (INA) (032/2020) symptomatic treatment telemedicine and COVID-19 as shown in Table 1. It also Table 2. The Characteristics of the 20 Patients Using Online Consultations at collects case series from Bethesda Hospital in Yogyakarta Bethesda Hospital Neurological Outpatient Clinics on April 2020 from neurological patients who used telemedicine (video Characteristic Category Total % call by application for outpatient consultation). The patient survey was undertaken after consents were Sex Male 14 70% Female 6 30% obtained following video-call outpatient consultations. Age < 60 years old 2 10% The subjects were asked about their perceptions of the > 60 years old 18 90% consultation, the service of medication on pharmacy, and Diagnosis Stroke 12 60% Parkinson 2 10% their suggestions about the new system in outpatient Vertigo 2 10% consultation.10 Their responses were noted in self-made Back pain 1 5% questionnaires designed for this study. The system and Other 3 15% Level of satisfaction Very satisfied 3 15% hospital requirements for telemedicine services for with the services Satisfied 15 75% neurological cases were also reviewed in this study. This Neither satisfied or not 2 10% study has obtained ethical permission from the Bethesda Not satisfied 0 0 Very not satisfied 0 0 Hospital Research and Development Department. Oral Suggestions from patients Reimbursement 16 80% informed consent had been taken from the subjects Medication 2 10% before the survey was conducted. Services 2 10%

Results demographic data is shown in Table 2. Most of the As a response to the COVID-19 crisis in Indonesia, subjects are male (70%), > 60 years old (90%) and have the Indonesian Government has launched the Regulation been diagnosed with stroke (60%). More than 75% of of Ministry of Health on the use of telemedicine (Table the subjects were satisfied with the use of telemedicine 1). The Indonesian Neurological Association (INA) also for their chronic neurological consultation. In terms of responded to this situation.11 suggestion, 80% of the subjects suggest the reimburse- These regulations are very suitable for patients with ment services be evaluated during the COVID-19 neurological diseases because of these patients’ pandemic for their consultations. conditions (advanced age), risk factors (hypertension and diabetes), and treatments (immunosuppressive for Discussion multiple sclerosis or myasthenia gravis). Most of these The COVID-19 pandemic has resulted in regulations require electronic prescribing and electronic unprecedented disruptions in health care and hospital medical records for the use of telemedicine consultations. services. It has not only been affecting the COVID-19 The prescriptions of controlled substances such as patients, but also patients with chronic neurological analgesics or opioids require legitimate medical purposes cases.12,13 The significant impact of the COVID-19 in accordance with the law. pandemic on the healthcare system and the rapid Outpatient visits for neurological disease during the depletion of its resources, urgent steps should be taken COVID-19 pandemic are inefficient and often unsafe. while managing acute stroke patients to prevent the Individuals may require long travels to hospitals, wherein spread of the disease, to protect both patients and staff, sparsely populated areas it may take hours for them. and to minimize the uses of already strained resources. Following long commutes, patients often sit in crowded The strict emphasis on self-isolation and social waiting rooms and pharmacies. This study reviews 20 distancing has become the main factor that raises serious cases that have already used online consultation and the concerns about the well-being of patients with chronic

29 Kesmas: Jurnal Kesehatan Masyarakat Nasional (National Public Health Journal). 2020; Special Issue 1: 28-31 neurological diseases, given these patients require routine neurological examination including comprehensive eye hospital visits for evaluation and medical adjustments.14 exams, neuromuscular components, and vestibular More than 75% of the subjects in our study were examinations.17 The main barriers to maintaining this satisfied with the use of telemedicine for their online telemedicine are related to the reimbursement system. consultations. These results may become a reference for This approach can only be conducted in private patients some hospitals that some patients and caregivers can and limited for patients managed under the national cope with the larger use of telemedicine for health care health insurance program. The payers for the national services. A previous study has already shown the health insurance system and other private insurances potential for using telemedicine in disasters and public company should modify their payment policy in response health emergencies.15 to COVID-19. The limitations of our study are that there The rapid responses from the Indonesian Government are no follow-ups for the long term and clinical and KKI on the potential use of telemedicine have been outcomes, as well as the measurement methods of the responded by professionals and specialty associations. subjects’ satisfaction, which are based on self-made The regulation cannot be responded to immediately by questionnaires. Therefore, the validity and reliability of every hospital because of the limitations on electronic the instrument have yet to be tested. medical records and electronic prescribing system. A previous study has shown that there is great disparity Conclusion among health care facilities and hospitals in Indonesia.16 The COVID-19 pandemic has presented unique Our study on 20 cases with chronic neurological challenges to hospital and patients care. The significant disease patients was promising. Most respondents impact of the pandemic on the healthcare system in showed a positive response to the new outpatient Indonesia has called for urgent steps for managing consultation method. Most of our patients are older than chronic neurological patients. The use of telemedicine is 60 years old and disabled due to their illness (stroke). required to prevent the spread of the disease, protect Therefore, the video calls online consultations were both patients and staff, and minimize the uses of already established by the providers to avoid travel to in-person strained resources. Payment and regulatory structures, care sites. This study only focused on doctor-patient state licensing, credentialing across hospitals should be consultation. In stroke care, much additional care should modified as the response to this. be in place. The majority of the important works done by dietary consultants, pharmacists, and stroke education Abbreviations nurses could potentially be done without direct patient WHO: World Health Organization; COVID-19: Coronavirus Disease contact in many cases. The challenges will be in the 2019; IMC: Indonesian Medical Council; KKI: Komisi Kedokteran physical therapy and rehabilitation aspects.13 Indonesia; INA: Indonesian Neurological Association. Most of our subjects (80%) suggested the reimbursement method be recalculated because of the Ethics Approval and Consent to Participate differences between direct consultation and telemedicine This study has been approved by the Health Ethics Committee of in terms of physical examination and communication. A Bethesda Hospital. past study of telemedicine and reimbursement for vascular surgery consultation was significant to the Competing Interest patients. The use of telemedicine provided an increase in The authors declare no conflict of interest to disclose. reimbursement from private payers and acceptance from patients, which ranged from 0% to 67% of the total Availability of Data and Materials charges billed. However, telemedicine use has proven to The data and materials of this study were available upon request to the be effective to reach a broader population base, and first author. without significant cost to the patients.17 The use of telemedicine, especially online Authors’ Contribution consultation, has been growing very slowly in Indonesia. Rizaldy Pinzon: Study concept and design, writing of the initial draft, Face to face consultations has become the main method supervision, data availability; Dessy Paramitha: Methodology, writing of outpatient visits. This study shows that the system, and revision of the manuscript; Vincent Ongko Wijaya: Data analysis, hospital system, and regulations have been accelerated writing and revision of the manuscript. due to the COVID-19 pandemic. For the neurological disease patients, these conditions are relevant because of Acknowledgment their risks related to the comorbidities and treatments. Not Applicable The American Academy of Neurology describes the limitations of telemedicine especially in the terms of

30 Pinzon et al, Acceleration of Telemedicine Use for Chronic Neurological Disease Patients during COVID-19 Pandemic in Yogyakarta, Indonesia

References 9. Al-Abri R, Al-Balushi A. Patient satisfaction survey as a tool towards 1. Lu R, Zhao X, Li J, Niu P, Yang B, Wu H, et al. Genomic quality improvement. Oman Medical Journal. 2014; 29 (1): 3‐7. characterization and epidemiology of 2019 novel coronavirus: 10. Indonesian Neurological Association. Technical information for the implications for virus origins and receptor binding. Lancet. 2020; 395 use of telemedicine for neurological patients. Indonesia: Indonesian (10224): 565–74. Neurological Association; 2020. 2. World Health Organization. Coronavirus disease (COVID-2019) 11. Helmich RC, Bloem BR. The impact of the COVID-19 pandemic on situation reports; 2020. parkinson's disease: hidden sorrows and emerging opportunities. 3. Indonesian Task Force for COVID-19. Current situation reports of Journal of Parkinsons Disease. 2020; 10 (2): 351-4. COVID-19 in Indonesia; 2020. 12. Dafer RM, Osteraas ND, Biller J. Acute stroke care in the coronavirus 4. Liu Y, Gayle AA, Wilder-Smith A, Rocklov J. The reproductive disease 2019 pandemic. Journal of Stroke and Cerebrovascular number of COVID-19 is higher compared to SARS coronavirus. Diseases. 2020; 29(7): 104881. Journal of Travel Medicine. 2020; 27 (2). 13. Bloem BR, Dorsey ER, Okun MS. The coronavirus disease 2019 crisis 5. Peraturan Pemerintah Nomor 46 Tahun 2014 tentang Sistem as catalyst for telemedicine for chronic neurological disorders. JAMA Informasi Kesehatan (Lembaran negara Republik Indonesia Tahun Neurol. Published online April 24, 2020. 2014 Nomor 126, Tambahan Lembaran Negara Republik Indonesia doi:10.1001/jamaneurol.2020.1452 Nomor 5542). Republik Indonesia. 14. Lurie N, Carr BG. The role of telehealth in the medical response to 6. Indonesian Ministry of Health regulation, 303/2020, Indonesian disasters. JAMA Intern Med 2018; 178: 745-6. Health Ministry regulation of the use of Information Technology and 15. Mulyanto J, Kringos DS, Kunst AE. The evolution of income-related Communication for Preventing the COVID-19, Indonesian Ministry inequalities in healthcare utilisation in Indonesia, 1993–2014. PLoS of Health. ONE. 2019; 14(6): e0218519. 7. Indonesian Medical Council Regulation, 74/2020, The Use of 16. Lin JC, Kavousi Y, Sullivan B, Stevens C. Analysis of outpatient Telemedicine and clinical appointment in the Era of COVID-19 telemedicine reimbursement in an integrated healthcare system. Pandemic. Indonesian Medical Council. Annals of Vascular Surgery. 2020; 65: 100‐6. 8. Indonesia FDA regulation, 8/2020. Indonesia FDA regulation for 17. Evans DA, Benameur K, Busis N. Telemedicine and COVID-19. medicine and food online transaction, Indonesia FDA 2020. American Academy of Neurology. 2020 [Accessed May 27, 2020].

31 Yudhastuti. Kesmas: Jurnal Kesehatan Masyarakat Nasional (National Public Health Kesmas: Jurnal Kesehatan Masyarakat Nasional Journal). 2020; Special Issue 1: 32-36 DOI: 10.21109/kesmas.v15i2.3945 (National Public Health Journal) The Use of Cloth Face Mask during the Pandemic Period in Indonesian People

Ririh Yudhastuti

Department of Environmental Health, Faculty of Public Health, Universitas Airlangga, Indonesia

Abstract The use of masks protects individuals from the spread of COVID-19 and control the source of transmission through droplets, but with limited medical masks, a cloth face mask can be used as an alternative personal protection from COVID-19. This study aimed to describe the use of cloth face mask as an alternative personal protection during the pandemic. WHO recommends the use of non-medical masks both at home and in public places. The use of face masks is a WHO’s recommendation on April 6, 2020. Medical masks are categorized as medical waste, then the disposal must be appropriate to prevent COVID-19 transmission in community. Cloth face mask can be used repeatedly and washed, its use can be adjusted to face. However, using a face mask alone is not enough to provide an adequate protection level. Other steps must be taken, such as washing hands with hand soap in running water, keeping a physical distance of minimum one meter from people, especially from those showing respiratory tract symptoms (coughing, sneezing), cleaning items touched by hands of people such as door handles and handles stairs. Therefore, the use of cloth face mask must be carried out together with clean and healthy living behaviors.

Keywords: cloth face mask, COVID-19, Indonesia, mask crisis, pandemic

Introduction 4,628,903 confirmed cases were reported with a total of Coronavirus is a large family of viruses that cause dis- 312,009 deaths where cases were reported in 216 coun- eases, ranging from mild to severe symptoms. tries or regions.2 The total number of confirmed cases in Coronavirus disease 2019 (COVID-19) is a new type of Indonesia up to May 19, 2020, was 18,010 cases with a disease that has never been identified before in humans. mortality rate of 6.6%.3 In December 31, 2019, the World Health Organization Several behaviors have been recommended to limit (WHO) China Country Office reported a case of pneu- the spread of COVID-19 to be carried out, which is the monia of unknown etiology in Wuhan City, Hubei same as in the influenza pandemic, such as washing Province, China. On January 7, 2020, China identified hands, limiting social distance and coughing, and sneez- pneumonia of unknown etiology as a new type of corona - ing.4 In addition, WHO has recommended the commu- virus (coronavirus disease, COVID-19). In January 30, nity to use face masks.5,6 Several studies also suggest the 2020, WHO has designated the Public Health Emergency use of face masks in public places.7,8 of International Concern (PHEIC). The increase in the Medical masks must be provided for health workers.9 number of COVID-19 cases took place quite quickly and The use of medical masks in the community will cause a there has been a spread between countries.1 shortage of masks for health workers.6 The impact of the Common signs and symptoms of COVID-19 infection COVID-19 pandemic, such as people's fear of the dis- include symptoms of acute respiratory disorders such as ease, causes people flock to buy face masks and some fever, coughing, and shortness of breath. The average in- even hoard them. This results in a mask vacuum and sky- cubation period is 5 - 6 days with the longest incubation rocketing mask prices.10 period of 14 days. In severe cases, COVID-19 can cause The Centers for Disease Control and Prevention pneumonia, acute respiratory syndrome, kidney failure, (CDC) recommends the use of cloth face mask in public and even death.1 As of May 18, 2020, a total of settings, especially in significant community-based trans-

Correspondence*: Ririh Yudhastuti, Department of Environmental Health Received : May 30, 2020 Faculty of Public Health, Universitas Airlangga, Airlangga Street, Surabaya City, Accepted : May 31, 2020 East Java, Indonesia, E-mail: [email protected], Phone: +62-878-5486-2677 Published: July 31, 2020

Copyright @ 2020, Kesmas: Jurnal Kesehatan Masyarakat Nasional (National Public Health Journal), p-ISSN: 1907-7505, e-ISSN: 2460-0601, SINTA-S1 accredited, http://journal.fkm.ui.ac.id/kesmas, Licensed under Creative Commons Attribution-ShareAlike 4.0 International Yudhastuti, The Use of Cloth Face Mask during the Pandemic Period in Indonesian People mission areas. The CDC also recommends the use of a community should be considered.15,16 Concern about the simple face-covering mask to slow the spread of the virus insufficient supply of masks in the community is because and help people who might have the virus, but not know a medical mask must be provided for health workers. it from spreading it to others.11 The recommended cloth While, to control the source of COVID-19 and protect face mask is not a surgical mask or an N-95 respirator. yourself, the use of a cloth face mask (non-medical) is Surgical masks or N-95 respirators are critical supplies sufficient for protection, especially if everyone uses it. that must be continuously reserved for health workers Fabric masks are easily made at home and reused after and other first medical respondents.11 washing.16 In Indonesia, the need for face masks in the The use of face masks protects individuals from the community is increasing, especially after the Indonesian spread of COVID-19 and control the source of transmis- Government recommends to always use masks while do- sion through droplets of others, but with limited medical ing activities outside home.17 It is recommended to at masks, a cloth face mask can be used as an alternative least use a cloth face mask to prevent the coronavirus personal protection from COVID-19. This study aims to transmission which is increasing and spreading across describe the use of cloth face mask as an alternative per- provinces and districts in Indonesia. sonal protection during the pandemic. A research on influenza, influenza-like illness, and coronavirus in humans provides evidence that the use of Method medical masks can prevent the spread of sparks that can In a commentary, the authors sought to present new cause transmission from the infected people to other peo- views to researchers about certain topics. Commentary ple and the air contamination due to the sparks. There is can also draw attention to current progress and speculate an evidence that the use of medical masks by healthy peo- on the direction of certain topics in the future. Therefore, ple at home or by people who come in contact with peo- the authors review scientific texts and messages pub- ple infected with COVID-19, as well as in a crowd, face lished in the mass media and scientific articles as well as masks can serve as limited prevention, although there is social life about the use of face masks during the COVID- currently no evidence that using face masks (either med- 19 pandemic. Also, the authors use prior knowledge and ical masks or other types) by healthy people in the com- experience, particularly regarding information on the use munity at large, including the use of face masks together of cloth face masks during the COVID-19 pandemic in in the wider community, can prevent people from respi- Indonesia. In this commentary, the author attempts to ratory tract infections, including COVID-19.18 The account for any information published during the Indonesian Government’s policies recommend that medi- corona virus crisis. cal masks should be provided for health workers. The use of medical masks by the public can create a false Results and Discussion sense of security, so that other health measures such as Since the outbreak of the coronavirus (COVID-19), maintaining hand hygiene and physical distance are ig- there have been battles related to the use of face masks nored, and there is still a practice of touching the face be- in the community. Sometime before, WHO is still incon- hind the mask and under the eyes. Some suggestions such sistent in the use of masks in the community. On January as maintaining a physical distance of approximately one 2020, WHO did not recommend the use of face masks in meter, avoiding crowds of people (more than five people) healthy individuals in the community (mass making) as a and washing hands in running water with hand soap for way to prevent the transmission of COVID-19 in the in- 30 seconds is a very helpful role in preventing the trans- terim guidelines dated on April 6, 2020.12,13 The United mission of COVID-19.19,20 Kingdom Public Health has made similar recommenda- WHO and decision-makers can continue to advocate tions, however, the United States Centers for Disease the use of non-medical masks both outdoors and Control and Prevention has recommended the use of indoors.19 In such places, the following points related to cloth face masks outside home or public places and the non-medical masks must be considered, such as 1) the action is followed by other countries, such as Canada number of layers of cloth / tissue, 2) the ease of breathing and South Korea. Initially, the purpose of using face given to the user of the mask material 3) the waterproof masks was to protect oneself, then for reasons of public or hydrophobic nature 4) the shape of the mask 5) con- health, the use of face masks is to protect each other be- formity to face shape and 6) mask size. tween people from asymptomatic COVID-19 transmis- Several types of masks that are available in the com- sion sources.14,15 From a workshop organized by WHO munity: in 2019, the workshop concluded that although there 1. Cloth face mask,20,21 was no evidence of trials of effectiveness in reducing Cloth face masks can be used to prevent transmission, corona virus transmission, WHO recommended that the while anticipating the scarcity of masks that occur in use of a severe influenza pandemic mask wear in the markets such as pharmacies and health stores. Fabric

33 Kesmas: Jurnal Kesehatan Masyarakat Nasional (National Public Health Journal). 2020; Special Issue 1: 32-36 masks made need to have three layers, namely a water- Medical personnel use particulate respirators with pro- proof non-woven layer (front), microfiber melt-blown tection at least equivalent to N95 certified by the US non-woven fabric (middle), and ordinary non-woven fab- National Institute for Occupational Safety and Health, ric (rear). Cloth masks need to be washed and can be European Union standard FFP2, or equivalent, when car- worn many times. The material used for fabric masks is rying out or working in the place of carrying out proce- cotton, scarf, and so on. This type of mask can be used dures that produce aerosols, such as tracheal intubation, in public places and other facilities while maintaining a ventilation noninvasive, tracheotomy, cardiac pulmonary safe distance of 1 - 2 meters. A three-layer fabric mask resuscitation, manual ventilation before intubation, and can filter the air and ward off viruses by up to 70%. bronchoscopy.25,26 Ways and models of fabric masks can be adjusted to the face and not loose. Masks can be sewn manually or using 3. Surgical masks,21,22,26 machines, the use of these masks is important, consider- This type is a mask easily found in the nearest store or ing the spread of the virus through the nose, mouth, and pharmacy. Usually, surgical masks are green or blue. eyes carried by human fingers. The use of cloth face Surgical masks have a function for protecting the users masks can be indoors or outdoors.22,23 from drops of large particles or splashes of water from a Fabric mask treatments can be washed using deter- person's mouth. However, it has not been able to protect gents with less rubbing, so that the fabric pores do not against airborne particles. Surgical masks have a filtra- widen and should be used for four hours to prevent con- tion effectiveness of 0.1 microns 10 to 95%. tamination by other microorganisms like bacteria such as Escherichia coli, Enterobacter aeruginosa, Shigella 4. Facepiece respirator,26 sp., Staphylococcus aureus, and fungus / fungi A facepiece respirator or gas mask serves to protect Aspergillus sp., Penicillium sp., and Candida sp. because themselves from harmful gases and vapors. This mask the cloth face mask becomes moist. The average temper- does not filter out airborne particles unless it is designed ature of 27oC and 75% relative humidity are preferred to have a filter to block it. Among others, masks that cov- by microorganisms including bacteria, viruses, or fungi / er almost the entire surface of the face are usually de- fungus.9 It is important to note that cotton cloth face signed to protect users from big and small splashes, with- masks are not considered suitable for health workers. out leakage and effectiveness of up to 99%. This mask Regarding fabric masks as Personal Protective can be used repeatedly after disinfection according to rec- Equipment (PPE), the production of cloth face masks for ommendations from WHO. Facepiece respirators are use in health service facilities is proposed to be carried rarely encountered every day because they are usually on- out locally if the supplies are inadequate or run out. ly used by workers in the gas field or jobs with high levels WHO stresses that medical masks and respirators must of contamination. In addition to the masks above, there be prioritized for medical workers or health workers. are still N99, N100, and P95 masks. 24,25 Management of the use of mask,27,28 2. N95 mask,26 The use and disposal of masks regardless of the type N95 mask is one of the protective or filter particles are important to be done properly to ensure they are ef- that are harmful to the users. However, the N95 mask fective and to avoid increased transmission. The follow- can only function for dirt and dust, not for gas and steam. ing information on the proper use of masks is taken from Even so, N95 mask can protect its users from droplets, practices in health care facilities,28: particles which are 0.1 micron in size and have an effec- 1. Place the mask carefully, and ensure the mask covers tiveness of up to 95%. Medical personnel use particulate the mouth and nose and attaches it firmly to minimize respirators with at least equivalent protection to N95 cer- the distance between the face and the mask tified by the US National Institute of Occupational Safety 2. Avoid touching the mask while it is used and Health, code 95 means that it can filter out airborne 3. Take the mask off with the correct technique: do not particles as much as 95%. In the N95 mask, there are touch the front of the mask, but remove the mask three levels of mask filtering which are divided into three from the back levels of filtering, namely FFP1, FFP2, and FFP3. FFP1 4. After removing or whenever you accidentally touch means filtering out at least 80% of particles in the air, the mask used, clean your hands with alcohol-based FFP2 means filtering out at least 94% of particles in the antiseptic liquid or soap/detergent with running water air, and FFP3 means filtering out at least 99% of particles if hands look dirty in the air. From this explanation, it can be interpreted 5. If the mask becomes moist, it must be replaced imme- that FFP2 has almost the same standard with an N95 diately with a new mask that is clean and dry mask, whereas FFP3 is the same as an N99 mask.26 6. Disposable masks are not used anymore

34 Yudhastuti, The Use of Cloth Face Mask during the Pandemic Period in Indonesian People

7. Take off and discard the disposable mask after use nuscripts Education on proper disposal of the masks must be actively delivered to the community, and people must Acknowledgment learn how to properly handle the masks. For this reason, The author thank the Ministry of Health of the Republic of Indonesia the government urges the public to dispose the used for providing COVID-19’s data that being used in this manuscript. masks to spray disinfectants first. Then you should remember that, before removing the mask, please cut it References first. The waste masks used by the people have been cate- 1. Kementerian Kesehatan Republik Indonesia. Pedoman Pencegahan gorized as potential medical waste in toxic and hazardous dan Pengendalian Coronavirus Disease (Covid-19); 2020. waste. After that, wrap it in clear plastic as a marker of 2. World Health Organization. Coronavirus disease (COVID-19) pan- mask waste. Trash have to be closed if necessary with a demic; 2020. prominent logo, so that people can quickly find it. In ad- 3. Menteri Kesehatan Republik Indonesia. Keputusan Menteri Kesehatan dition to not polluting the environment and disturbing Republik Indonesia Nomor HK.01.07/MENKES/382/2020 Tentang public health, this is because the waste masks can contain Protokol Kesehatan Bagi Masyarakat di Tempat dan Fasilitas Umum various microorganisms that cause disease in humans. In dalm Rangka Pencegahan dan Pengendalian Corona Virus Disease addition there are other microorganisms as secondary in- 2019 (COVID-19); 2020. fections in mask waste, so that mask waste is categorized 4. Morrison L G, Yardley L. What infection control measures will people as medical waste, so that the management of mask waste carry out to reduce transmission of pandemic influenza? a focus group is the same as the medical waste standard operating pro- study. BMC Public Health. 2009; 9(1): 258. cedure (SOP). It is hoped that by following the stages of 5. World Health Organization. Coronavirus disease (COVID-19) advice management of used masks, the potential risk for trans- for the public: when and how to use masks; 2020. mission due to misuse of masks can be avoided. In addi- 6. World Health Organization. Advice on the use of masks in the context tion, the habit of washing hands before and after using a of COVID-19; 2020. mask will minimize the potential for transmission of 7. Greenhalgh T, Schmid MB, Czypionka T, Bassler D, Gruer L. Face virus, such as the SARS-CoV-2 virus which causes masks for the public during the covid-19 crisis. The BMJ. 2020; 369: COVID-19.29,30 m1435. 8. Leung C C, Lam T H, Cheng K K. Mass masking in the COVID-19 Conclusion epidemic: people need guidance. The Lancet. 2020; 395. During a pandemic, the use of cloth face masks can 9. Setiati S, Azwar M K. COVID-19 and Indonesia. Acta Medica reduce the COVID-19 transmission and should be fol- Indonesiana. 2020; 52(1): 84-9. lowed by washing hands with hand soap in running wa- 10. Maria Inggita. Health department issues circular letter regarding pre- ter, physical distancing and avoiding crowds of people. cautions for COVID-19. Berita Jakarta; 2020. 11. Centers for Disease Control and Prevention (CDC). Use of cloth face Abbreviations coverings to help slow the spread of COVID-19; 2020. COVID-19: Coronavirus Disease 2019; WHO: World Health 12. Feng S, Shen C, Xia N, Song W, Fan M, Cowling B J. Rational use of Organization; PHEIC: Public Health Emergency of International face masks in the COVID-19 pandemic. The Lancet. 2020; 8(5): 434- Concern; CDC: Centers for Disease Control and Prevention; PPE: 6. Personal Protective Equipment; SOP: Standard Operating Procedure. 13. World Health Organization. Advice on the use of masks in the community, during home care and in healthcare settings in the context of Ethics Approval and Consent to Participate the coronavirus (2019-nCoV) outbreak: interim guidance; 2020. Permission to use this data has been approved by the Ministry of Health 14. Yu P, Zhu J, Zhang Z, Han Y. A familial cluster of infection associat- of the Republic of Indonesia through the COVID-19 Task Force. ed with the 2019 Coronavirus novel indicates possible person-person transmission during the incubation period. The Journal of Infectious Competing Interest Diseases. 2020; 221 (11): 1757-61. The author states that there are no competing interests to disclose. 15. Wycliffe E W, Zongbin L, Calvin J C, Sarah E Y, Toh P, Vernon J L . Presymptomatic transmission of SARS-CoV2 - Singapore, January 23 Availability of Data and Materials – March 16, 2020. CDC: MMWR. 2020; 69(14): 411-5. Data is available in the COVID-19 Task Force text of the Ministry of 16. Aiello A E, Murray G F, Perez V, Coulborn R M, Davis B M, Uddin M, Health, Republic of Indonesia and existing literature related to the use et al. Mask use, hand hygiene, and seasonal influenza-like illness of masks for literature review. among young adults: a randomized intervention trial. International Journal of Infectious Diseases; 2010. 201(4): 491-8. Authors’ Contribution 17. Gugus Tugas Percepatan Penanganan Corona Virus Disease 2019 The study has been carried out independently by Ririh Yudhastuti, start (COVID-19). Menyembuhkan dunia saling kerja sama melawan from designing research, studying design, analysis and composing ma - COVID-19; 2020.

35 Kesmas: Jurnal Kesehatan Masyarakat Nasional (National Public Health Journal). 2020; Special Issue 1: 32-36

18. World Health Organization. Rational use of personal protective equip- for health care workers caring for patients with suspected or con- ment for coronavirus disease (COVID-19); 2020. ﬁrmed 2019-nCoV; 2020. 19. Centers for Disease Control and Prevention (CDC). Considerations for 25. World Health Organization. Suggestions regarding the use of masks in wearing cloth face coverings: help slow the spread of COVID-19; the context of COVID-19 provisional guide; 2020. 2020. 26. Novita M. 4 jenis masker untuk cegah penularan corona, mana yang 20. World Health Organization. Home care for patients with COVID-19 terbaik?. Tempo.co; April 4, 2020. presenting with mild symptoms and management of their contacts: in- 27. AKbar JB. Fighting Covid-19, BEM distributes masks and hand sanitiz- terim guidance, 17 March 2020; 2020. ers to community. UNAIR News; 2020. 21. Tamtomo AB. Infograﬁk: panduan protokol kesehatan pencegahan 28. World Health Organization. Water, sanitation, hygiene, and waste Covid-19 untuk sambut new normal. Kompas.com; April 27, 2020. management for the COVID-19 virus: interim guidance; 2020. 22. Public Health England. Coronavirus (COVID-19) —what you need to 29. Undang-Undang Republik Indonesia Nomor 18 Tahun 2008 Tentang know; 2020. Pengelolaan Sampah; 2008. 23. World Health Organization. Infection prevention and control during 30. World Health Organization. Safe management of wastes from health- health care when COVID-19 is suspected: interim guidance, 19 March care activities: a summary. Geneva: World Health Organization; 2017. 2020; 2020. 24. World Health Organization. Q&A on infection prevention and control

36 Setyawan et al. Kesmas: Jurnal Kesehatan Masyarakat Nasional (National Public Health Kesmas: Jurnal Kesehatan Masyarakat Nasional Journal). 2020; Special Issue 1: 37-42 DOI: 10.21109/kesmas.v15i2.3937 (National Public Health Journal) A Holistic-Comprehensive Approach: Best Practices to Improve Health Policy for COVID-19 Pandemic

Febri E B Setyawan1*, Retno Lestari2

1Department of Family, Industrial and Islamic Medical Sciences, Faculty of Medicine, University of Muhammadiyah Malang, Indonesia 2Department of Mental Health Nursing, Faculty of Medicine, University of Brawijaya, Malang, Indonesia

Abstract The COVID-19 pandemic affects entire communities and causes a huge impact on all life aspects which include biological, psychological, social, and spiritual well-being. Health systems and health policies are promising developments and opportunities to review progress and accelerate interventions in COVID-19 control. Studies devoted to core holistic-comprehensive issues surrounding this pandemic are limited. Therefore, this article aimed to review several best practice studies that reflect holistic-comprehensive approaches to COVID-19. A comprehensive literature review was written based on 15 articles from the data sources which are Google Scholar, Science Direct, ProQuest Health, and Medical Complete, and ProQuest Science Journals from 2010 to 2020, searched terms related to holistic, comprehensive, outbreak, pandemic, epidemics, and COVID-19. There are many evidence-based practices on safe and effective strategies to improve all aspects of well-being before, during, and after the COVID-19 pandemic. Among these promising strategies, a holistic-comprehensive approach could also be considered as a necessary action to improve health policy during the pandemic. A holistic-comprehensive approach involved providing bio-psycho-socio-spiritual care and offered a continuum of healthcare that provides promotive, preventive, curative, and rehabilitative services. A holistic-comprehensive approach to the COVID-19 pandemic requires a sustained commitment from entire communities, stakeholders, and policymakers to achieve better health outcomes for all.

Keywords: Coronavirus, health policy, holistic-comprehensive, pandemic

Introduction ritual care and offered a continuum of health care: pro- The current coronavirus disease 2019 (COVID-19) motive, preventive, curative, and rehabilitative servic- pandemic in many countries is expected to diminish over es.1,2 the coming months. This pandemic situation also affects A holistic-comprehensive approach is intended to ad- entire communities and causes a huge impact on all life dress the challenges of bringing healthcare services in aspects which include biological, psychological, social, more direct and comprehensive care during the pande - and spiritual well-being. Health systems and health poli- mic. Assessment of all potential determinant factors that cies are promising developments and opportunities to re- influence health status in individuals, families, and com- view progress and accelerate interventions in COVID-19 munities should be addressed.3,4 Studies demonstrated control. factors related to the outcomes of COVID-19, including The best practices and guidelines shared throughout the immune responses, age, sufficient treatment, and so- the world demonstrate that several interventions to con- cioeconomic factors. Recent estimates suggest that social trol this infectious disease are possible. There are many and economic change contributed to the rapid spread of evidence-based practices on safe and effective strategies COVID-19 pandemic, for instance, social and demo- to improve all aspects of well-being before, during, and graphic characteristics, public health infrastructure, after the COVID-19 pandemic. Among these promising health statistics, economic development, and environ- strategies, a holistic-comprehensive approach could also mental quality.5-7 The culture of society also influenced be considered as a necessary action to improve health the psychological response to the pandemic and their policy during the pandemic. A holistic-comprehensive willingness to manage mental health issues.8 Hence, it is approach involved the provision of bio-psycho-socio-spi - important to understand the individual as a whole person

Correspondence*: Febri E B Setyawan, Department of Family, Industrial and Received : May 29, 2020 Islamic Medical Sciences, Faculty of Medicine, University of Muhammadiyah Accepted : May 31, 2020 Malang, Malang, Indonesia 65145, E-mail: [email protected], Phone: +62-341- Published: July 31, 2020 552443

Method A comprehensive literature review was performed to retrieve recent articles addressing holistic-comprehensive approaches related to COVID-19 treatment. Although there is no standardized consensus on this type of literature review, we have tried to critically evaluate articles and provide suggestions for future research by using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) ﬂow diagram. This study was written based on 15 articles from the data sources that were Google Scholar, Science Direct, ProQuest Health, and Medical Complete, and ProQuest Science Journals from 2010 to 2020, searched terms related to holistic, comprehensive, outbreak, pandemic, epidemics, and COVID-19. In addition to this, all articles were then screened to determine their relevance. Articles meeting these criteria were included if articles were peer-reviewed, using the English language between 2010 and 2020, presented empirical studies related to COVID-19 (quantitative and qualitative), and investigated holistic-comprehensive approaches to pandemic, outbreak, and epidemic. A total of 50 articles were retrieved and then screened based on inclusionary criteria (Figure 1). Of this number, the study revealed 20 articles that met the inclusionary and exclusionary criteria. The study which had incomplete information was automatically excluded. Signiﬁcant Figure 1. PRISMA Flow Diagram of the Articles Selection Process

38 Setyawan et al, A Holistic-comprehensive Approach: Best Practices to Improve Health Policy for COVID-19 Pandemic

Table 1. Literature Review

Study Reference (Year) Study Design Result

1 Saha, et al.,19 (2018) Retrospective surveillance Epidemiology characteristics may affect the interpretation of disease burden 2 Shen, et al.,27 (2015) Mathematical model Patient isolation may not always have a contribution in controlling disease transmission 3 Pan, et al.,35 (2020) Cohort study Public health strategies improved COVID-19 management 4 Njuguna, et al.,21 (2019) Surveillance An integrated surveillance system to help recover from Ebola crisis 5 Arslantas, et al.,31 (2019) Modeling a holistic framework Hazard exposure, vulnerability, poor coping skills, socio- economic factors increased disease risk 6 Abdulkareem, et al.,32 (2020) Modeling intelligent learning Social learning was affected by social and cultural norms 7 Kinsman, et al.,23 (2018) Case study Preparedness and response plans during an epidemic 8 Afayo, et al.,24 (2019) Cross-sectional study The gap between preparedness and response to the outbreak 9 Craig, et al.,20 (2018) Surveillance The surveillance system is a priority during the outbreak 10 Sepers, et al.,34 (2018) Participatory study Needs a comprehensive monitoring and evaluation system 11 Alonge, et al.,18 (2019) Interviews with stakeholders Leadership, social bonding, trusted information, social trust affected community resilience during the outbreak 12 Rabelo, et al.,28 (2016) Focus group discussions Feeling worried, lack of respect, motivation, hope, isolated 13 Siu, et al.,30 (2016) Phenomenology Sociocultural factors using personal protective equipment 14 Respati, et al.,14 (2018) Focus group discussion Eco-health model: prevention, community engagement, environment, and climate 15 Loignon, et al.,17 (2018) In-depth semi-structured Barriers in supportive care: lack of resources, restricted to interviews deliver supportive care, poor coordination vant articles presenting evidence (whether primary or Engaging communities to support and comply with the secondary) on holistic-comprehensive approaches were health policy is needed to achieve sustainability of pro- also included in the analysis. Additionally, this study was gram.14 Strengthening public health infrastructure and complemented by grey literature reviews from newspa- social networks is essential during the pandemic. Learn - pers’ reports, government website with regards to rules ing from Wuhan is important as they can build 27 hospi- and regulations, and current situation updates on tals and engage 2,000 workers to prepare for the other COVID-19. two hospitals for treating COVID-19 patients.12 In Indonesia, almost all the hospitals could deliver appro- Discussion priate treatment for COVID-19 patients, from conducting a rapid test to comprehensive treatment for COVID- A holistic-comprehensive of care 19.15 COVID-19 can be well managed through holistic planning using a multi-sectoral and comprehensive ap- Best practices to implement a holistic-comprehensive proach — “Detect, Develop, Deliver”. In China, re- approach searchers detected the genome sequence of COVID-19, In this study, we described best practices based on a and this investigation was then reported to the WHO, al- comprehensive literature review to describe and synthe- lowing all researchers in the world to develop the vac- size with regards to holistic-comprehensive approaches cines. Developing COVID-19 treatment needs a multi- related to COVID-19 treatment developed by researchers sectoral approach to help with financial budgeting. and clinicians. A holistic-comprehensive approach as best Additionally, the government should support social and practices to improve health policy for the COVID-19 economic changes as the impact of lockdown and work- pandemic was developed and modified according to the from-home policy. In response to COVID-19, the CDC, which designed best practices for health profes- Government of Singapore provided $ 55 million as finan - sionals to properly respond before, during, and after cial support for 40,000 drivers.12 In Indonesia, the go- COVID-19 state of emergency (Table 2). Non-pharma- vernment took immediate action to assist Indonesian civil cological approaches were recommended as key mes- society through Family Hope Program (IDR 37.4 tril- sages and actions to address the COVID-19.16 lion), Social Assistance for Staple Food (IDR 2.2 tril- As the COVID-19 response begins and ends at the lo- lion), Village Fund (IDR 21 trillion), Cash Labor- cal level, therefore, in the preparedness phase, compre- Intensive Program (IDR 16.9 trillion), and Pre- hensive community planning should focus on improving Employment Card Program (IDR 360 billion).13 health systems and services, including communications A comprehensive system of care delivery is needed, across all levels: leaders, stakeholders, and wider com- so people can have access to the continuum of care. munities. Six components should be taken before prepar-

39 Kesmas: Jurnal Kesehatan Masyarakat Nasional (National Public Health Journal). 2020; Special Issue 1: 37-42

vided adequate support and feedback during and after Table 2. Best Practices to Implement a Holistic-Comprehensive Approach the implementation of programs.21 The development of during the COVID-19 Pandemic comprehensive planning presumably takes process, and

Period of Pandemic Best Practices to Implement a Holistic-Comprehensive it certainly needs support from whole societies for a suc- Approach cessful program. Before the COVID-19 crisis, there were six main com- Before Develop community resilience and recovery after the outbreak. ponents to consider while developing comprehensive ap- Improve coordination of care and connecting indivi duals proach: (1) responsive key leaders, (2) multi-sector part- with community resources. nerships and collaboration, (3) comprehensive health Manage available resources to keep people informed during the outbreak. surveillance, (4) health education campaigns, (5) health Coordinate the supply of essential medicines. policy to support treatment, and (6) strategies to reduce Increase emergency referral centers during the pandemic. harm and prevent further crisis.22 These key important Evaluate public health surveillance for emerging threats. During Ensure effective communication with the local commu- factors can also be used to develop a holistic-comprehen- nity. sive health policy to achieving sustainable development Take appropriate measures to ensure immediate relief goals. and support being given. Coordinate emergency resources to support bio-psycho- Strengthening pandemic readiness and response to socio-spiritual needs. COVID-19 is the key to successful health outcomes. A Develop health policy addressing stigma and mental fast and effective response can delay a local outbreak health issues. After Evaluate the strategies used to control the outbreak. from becoming a global threat. Before the pandemic, Facilitate healthy behavior change. health professionals can work together and create colla - Build partnerships with stakeholders to strengthen com- bo ration with the government, civil society, stakeholders, munity capacity and skills. and policymakers to develop community resilience and recovery after the outbreak. We can prepare a program ing emergency plans: (1) developing community re- that could strengthen the community, how to respond to silience and recovery after the outbreak, (2) improving COVID-19 issues, and build social networks to support coordination of care and connecting individuals with during the crisis. We can improve the coordination of community resources as a strategic transformation for care and connect individuals with community resources. better healthcare, (3) managing available resources to We can manage available resources, such as social media, keep people informed during the outbreak, (4) coordi- the internet, and local newspapers to provide trusted in- nating supply of essential medicines, (5) increasing emer- formation and keep people informed during the out- gency referral centers during the pandemic, and (6) eva- break. Coordinating the supply of essential medicines and luating public health surveillance for emerging emergency referral centers is also important as this is the threats.16,17 To achieve a holistic-comprehensive goal of fundamental aspect of care. Public health surveillance for community planning, thus discussions among the local emerging threats is needed to inform disease transmis- government and stakeholders are needed in the ﬁrst sion and prepare for prevention and promotion interven- weeks of the pandemic.18 tions related to the COVID-19.23,24 A holistic-comprehensive surveillance system helps Pandemic readiness enables the community to res - health professionals and policymakers to better under- pond effectively to the disease and prepare for future dis- stand the pandemic disease and develop public health ease outbreak. Well-trained health professionals play a policy for preventing the spread of infectious disease and critical role in improving health management and opti- promoting health behaviors. Information on the COVID- mizing coordination during the outbreak. Creating effect - 19 collected should include sufﬁcient information on the ive communication plans was also the key to avoiding current state of pandemic disease and the epidemiology false information related to the disease. Further, compre- of the infectious disease. In a comprehensive surveillance hensive planning in the readiness phase should include plan, it is also important to identify key populations at resource mobilization, health facilities, and case manage- increased risk of infectious disease, establish opportuni- ment for controlling a disease outbreak.25 ties to manage pandemic, and identify the allocation of During the outbreak, effective communication is resources in the local community as low-income commu- needed between the local community, leaders, stakehold- nities were disproportionately affected by the dis- ers, and policymakers. World Health Organization ease.19,20 (WHO) and CDC have developed basic principles for Lesson learned from the cases of Ebola, they built in- risk communication and the need to maintain public trust tegrated surveillance health systems to strengthen their throughout an outbreak. Therefore, health communica- public health infrastructure, improved early warning sys- tors and policymakers should understand the complexi- tems, increased the capacity of health professionals, pro- ties of the pandemic situation and make strategic re-

40 Setyawan et al, A Holistic-comprehensive Approach: Best Practices to Improve Health Policy for COVID-19 Pandemic sponse plans to the affected populations.26 Also, the local Authors can learn from Wuhan and Ebola cases that community can take appropriate measures to respond to comprehensive interventions require all health profes- such pandemic and ensure immediate relief and support sionals to collaborate and demonstrate their valuable ex- being given. They can also coordinate emergency re- pertise in disease management. sources to support bio-psycho-socio-spiritual needs at a local level. Conclusion One of the medical treatments for COVID-19 patients Being physically and mentally healthy during the is patient isolation. Isolation precautions are commonly COVID-19 pandemic is important as it helps us to used for patients who are either known or suspected to achieve a state of good health. Strengthening pandemic have a COVID-19. However, a study on the Ebola out- readiness and response to COVID-19, enhancing com- break investigated that isolation was not always effective munication, recognizing and treating physical and psy- in preventing the transmission of infectious disease. chological needs are keys to success when dealing with Comprehensive treatment was recognized as determining the COVID-19. In conclusion, a holistic-comprehensive factors in controlling such disease.27 approach to the COVID-19 pandemic requires a sus- As the impact of the pandemic, people may experi- tained commitment from entire communities, stakehold- ence psychological symptoms such as fear, anxiety, and ers, and policymakers to develop programs and multi- grief leads to prejudices against people in the community stakeholder cooperation to achieve better health out- and stigma.28 The stigma associated with COVID-19 is comes for all. also known as xenophobia, the fears about COVID-19. Stigma was identified as a factor causing inequities in Abbreviations health services and creating a global burden of disease. COVID-19: Coronavirus Disease 2019; PRISMA: Preferred Reporting The fears of COVID-19 are contagious, and it spreads Items for Systematic Reviews and Meta-Analyses; CDC: Centers for through daily conversations about the pandemic situa- Disease Control and Prevention; WHO: World Health Organization. tion. Public mental health systems can be improved if policies to address these issues were put in place.29 Ethics Approval and Consent to Participate Therefore, in developing health policy, stigma, and men- Not Applicable tal health issues as the impact of COVID-19 should be well-addressed. Further, the culture of society affects the Competing Interest psychological response to the pandemic and their will- The authors declare that they have no conflict of interest to disclose. ingness to comply with the health policy.8 Authors strongly encourage the entire society to support mental Availability of Data and Materials health during the crisis. On the other hand, social, eco- The authors confirm that the data supporting the findings of this study nomic and cultural factors were determinants of health are available within the article. status during pandemic.30-32 In addition to this, WHO provided specific guidance for communities, leaders, Authors’ Contribution health communicators, and mass media to address men- All authors contributed equally to the work presented in this paper. tal health issues including stigma related to COVID-19.33 After the current pandemic, it is crucial to evaluate Acknowledgment strategies used to control the outbreak through compre- Authors special thanks are extended to the staff of Faculty of Medicine, hensive monitoring and evaluation system.34 Health pro- University of Muhammadiyah Malang, Malang East Java for their valu- fessionals can facilitate changes for healthy behavior by able support for this article. providing the most accurate information through all media sources. The local community can also build partner- References ships with stakeholders to strengthen the community’s 1. Supriyanto S, Ernawaty E, Setyawan FEB, Lestari R. Enhancing family capacity and skills for COVID-19. A study in Wuhan medicine practice in developing countries through a holistic-compre- showed an improvement when they combined pharma- hensive model: a review. Indian Journal of Public Health Research & cological treatment and community participation in re- Development. 2019; 10(10): 774-8. sponding to COVID-19. This study provided a relevant 2. Setyawan FEB. Pendekatan pelayanan kesehatan dokter keluarga (pen- topic with regards to comprehensive approach when dekatan holistik komprehensif). Sidoarjo: Zifatama Jawara; 2019. dealing with the COVID-19. Several public health strate- 3. Pritasari K. Public health and political commitment: learning toward gies were used to combat the disease, even though there comprehensive public health effort. 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42 Rizki et al. Kesmas: Jurnal Kesehatan Masyarakat Nasional (National Public Health Kesmas: Jurnal Kesehatan Masyarakat Nasional Journal). 2020; Special Issue 1: 43-48 DOI: 10.21109/kesmas.v15i2.3893 (National Public Health Journal) Efficacy of Cloth Face Mask in Reducing COVID-19 Trans- mis s ion: A Literature Review

Saraswati Anindita Rizki1, Andree Kurniawan2*

1Faculty of Medicine, Pelita Harapan University, Indonesia 2Department of Internal Medicine, Faculty of Medicine, Pelita Harapan University, Indonesia

Abstract Coronavirus disease 2019 (COVID-19) has become a public health concern. Preventive measures, such as wearing personal protective equipment, must be done. On April 2020, the Center for Disease Control stated cloth face mask was recommended to be used by the public. This systematic review aimed to eva - luate the efficacy of cloth face masks in reducing COVID-19 transmission and to compare the fabric material that suits best for a cloth face mask. Journals included were from databases such as Google Scholar, PubMed, search engines, and references from other studies. The MeSH keywords, such as "cloth mask efficiency", "surgical mask", "COVID-19" and "filtration performance of common fabrics cloth mask" were used. Studies that used particle microorganisms sized ≤ 0.072 μm were included in this study. Studies showed that cloth face mask still can filter to a certain extent, however, it is inferior compared to surgical mask. Results show that the efficacy of cloth face mask depends on its fabric, and that polyester provides the best filtration efficiency. However, the pressure drop of polyester is unknown and more studies should be done.

Keywords: cloth face mask, COVID-19, efficacy, face mask, surgical mask

Introduction treatment using a nebulizer.2 Recent studies showed that Coronavirus disease 2019 (COVID-19) is a disease COVID-19 patients who appear asymptomatic or pre- caused by the novel coronavirus SARS-CoV-2, which ini- symptomatic may be infectious. tially spread in Wuhan, China. The World Health This information raised the significance of using per- Organization (WHO) declared COVID-19 a public sonal protective equipment (PPE), such as face masks. health emergency of international concern in January Although research regarding the efficacy of public mask- 2020. The disease has now become a pandemic with wearing is scarce, some countries, such as Indonesia, the 5,406,282 COVID-19 confirmed cases globally and Czech Republic, Slovakia, and Germany proceed with 23,165 COVID-19 confirmed cases in Indonesia.1 Its public mask-wearing policies. A cross-sectional study in case fatality rate (CFR) has been dynamically changing, Hongkong concluded the indirect efficacy of public however as per May 2020, the CFR reported globally is mask-wearing. This was shown by the reduction of in- 6.35% and the CFR reported in Indonesia is as high as fluenza cases in Hong Kong after public mask-wearing 6.1%. The SARS-CoV-2’s infectiousness has become a policy, which aimed to reduce COVID-19 transmission, public health concern.1 was implemented.3 WHO stated that SARS-CoV-2 is transmitted prima- In April 3, 2020, the Centers for Disease Control and rily through droplets. Direct contact with objects con- Prevention (CDC) recommended the use of cloth face taminated by the virus and then touching the face may masks in public settings where physical distancing was also be another mode of transmission. Airborne trans- difficult to conduct.4 This study aims to evaluate the ef- mission of SARS-CoV-2 only occurs in clinical settings, ficacy of cloth face mask in reducing COVID-19 trans- where aerosol-generating procedures are done. These mission and to compare the efficacy of common fabrics. procedures include endotracheal intubation, manual ventilation before performing intubation, performing car- Method diopulmonary resuscitation (CPR), and administering A literature search was conducted on April 5 - 20th,

Correspondence*: Andree Kurniawan, Department of Internal Medicine, Faculty Received : May 27, 2020 of Medicine, Pelita Harapan University, Jend. Sudirman Street No.20, Tangerang, Accepted : May 28, 2020 Banten, Indonesia, E-mail: [email protected], Phone: +62-21- Published: July 31, 2020 54010130

2020. A literature search process was continued using due to deviations from intended interventions, presence the limits of the literature research and then the titles of missing data, measurement bias, and bias in selection were selected from each database followed the PICO of the reported result. The study has a low risk of bias if framework, using combined terms and Medical Subject all parameters showed low risk of bias. The study has a Headings of the National Library of Medicine (MeSH). moderate risk of bias if some parameters show low risk Journals included were from databases, such as Google and some show moderate risk of bias. The study has a se- Scholar and PubMed, using a combination of keywords rious risk of bias if at least one parameter is judged to MeSH “cloth mask efficiency”, “COVID-19”, “surgical have a serious risk of bias. The study has a critical risk of mask” and "filtration performance of common fabrics bias if at least one parameter is judged to have critical cloth mask". Some journals were from search engines risk. Authors, as two independent researchers, assess and references from other journals. Studies evaluated the methodological quality and standard of outcome report- efficacy of cloth masks in the COVID-19 era were in- ing in the included studies. cluded. Other language articles besides English articles were excluded. Results Authors, as two independent reviewers, selected the In the end, 5 studies that studied the filtration effi- articles, extracted the data, and analyzed the data. Any ciency of cloth face mask in comparison to surgical mask discrepancies were resolved by consensus between the against microorganisms or particles sized ≤ 0.072 μm reviewers will be discussed. The reviewers evaluated the were included. The 2 journals which compared the filtra- title for all studies that were identified through the search tion efficiency of different fabrics were also included. strategy. Irrelevant researches, opinions, recommenda- Studies using microorganisms ≤ 0.072 μm were included tions, commentaries, and researches using microorgan- as researches using the actual SARS-CoV-2 virus is still isms with a size of more than 0.072 μm were excluded. Full texts were evaluated when there was insufficient information in the title to make decisions about inclusion and exclusion or when the article title suggested the study would match the inclusion criteria established. References in reviewed articles were examined to identify studies that may not have been identified through the primary search strategy. A total of 8 full-text articles were reviewed however one article was excluded as the study only evaluated the efficacy of surgical masks (Figure 1). The performance of a mask is evaluated by the measure ment of its filtration efficiency. The filtration efficiency reflects the mask’s ability to filter particulates or microorganisms.5 Filtration efficiency is evaluated by ex- posing the convex side of the mask to aerosols generated by a nebulizer. The detected colonies or particulates that escape the mask is then counted. The filtration efficiency can be calculated by the formula (Figure 2).5-7 The number of the particulate count when a mask is not used is subtracted with the number of the particulate count when a mask is used, divided by the number of the particulate count when a mask is not used and multiplied by 100.7 Another aspect that can be evaluated is the mask’s pressure drop (ΔP). The pressure drop reflects how comfortable the mask is. The ΔP is inversely proportional to the level of comfort-the the higher the pressure drop is, the more uncomfortable the mask is to be worn.5 Most of the studies involved in this review article are Figure 1. Systematic Flow of Literature Searching non-randomized controlled studies thus ROBINS-I Assessment of Bias in Non-randomized Studies was used. Seven parameters were presence of confounding factors, selection bias, bias in classification of intervention, bias Figure 2. Filtration Efficiency5-7

44 Rizki et al, Efficacy of Cloth Face Mask in Reducing COVID-19 Transmission: A Literature Review

Table 1. The List of Characteristic Studies

Author (Years) Population Method Intervention vs Control Result (Filtration Efficiency) Comments

Davies, et al.,8 8 different fabrics and Filtration efficiency was evaluated Intervention: tea towel, Against Bacteriophage MS2: - (2013) a surgical mask were with aerosols of Bacteriophage cotton blend, antimicrobial ● Surgical mask: 89.52% used MS2 (0.023 μm) and B. atrophecus pillowcase, linen, pillow- ● Cloth face masks: ≤ 72.46% (0.95-1.25 μm) generated by a case, silk, 100% cotton Collison nebulizer. t-shirt, scarf. Against B. atrophecus: Control: surgical mask ● Surgical mask: 96.35% ● Cloth face masks: ≤83.24% Bae, et al.,9 4 COVID-19 positive Patients were asked to cough into Intervention: cloth face Both masks were ineffective. The confounding (2020) patients a petri dish without a mask while mask and a surgical mask However, cloth face masks factor was not using a surgical mask and a cloth Control: no mask filtered SARS-CoV-2 better controlled cface mask. than surgical masks. Nasopharyngeal and saliva samples were obtained before patients were instructed to cough. Neupane, et al.,6 Petri dishes with a The apparatus was kept 20 feet Intervention: petri dish Against particles sized ≤10 μm Selection bias (2019) microscope overslips above ground in central Kathmandu covered by cloth face Cloth face mask: 63-84% may occur contained inside were for 30 minutes. mask and a surgical mask Surgical mask: 94% covered with four Microscope magnification of 100x Control: Petri dish without different cloth face was used to evaluate the number of a mask masks, one surgical particles deposited. mask, and no mask Ma, et al.,10 A surgical mask, an N95 Avian influenza was incorporated Intervention: surgical mask Medical mask: 97.14% Low risk of bias (2020) mask, and a polyester into a Type 403 nebulizer and and polyester mask with Polyester mask with four layers mask with four layers of aerosols were produced to four layers of kitchen paper of kitchen paper: 95.15% kitchen paper added to challenge masks involved. Control: N95 mask N95 Mask: 99.98% it were involved. Shakya, et al.,7 3 cloth face masks, Polystyrene latex (PSL) was used Intervention: cloth face Against particles 30-100 nm, Low risk of bias (2017) 1 surgical mask, and to generate aerosols with a flow masks, surgical masks 8 Liter per minute (LPM) 2 N95 masks were rate of 8 and 19 Liter per minute Control: N95 Mask ● Simple Mask (SM): ~86-93% involved in this study (LPM) to challenge masks involved. ● Cloth Mask (CM)1: ~82-90% Masks were placed on a mannequin ● Cloth Mask (CM)2: ~63-65% and attached to an aerodynamic ● Cloth Mask (CM)3: ~50-55% particulate sizer (APS) and scanning ● N95 1: ~85-97% mobility particle sizer (SMPS) which ● N95 2: ~65-85% accurately count the amount and Against particles 30-100 nm, sizes of particles that penetrate the 19 LPM mask. ● Simple Mask (SM): ~60-65% ● Cloth Mask (CM)1: ~75-82% ● Cloth Mask (CM)2: ~10-30% ● Cloth Mask (CM)3: ~22-28% ● N95 1: ~80-90% ● N95 2: ~75-85% scarce at the time being. A cut off of 0.072 μm was made atrophecus (0.95-1.25 μm) generated by a Collison nebu- due to the size of SARS-CoV-2. The results of the includ- lizer. The filtration efficiency listed in table 3 is the fa- ed articles are summarized in Table 1. bric’s efficiency in filtering Bacteriophage MS2. Ma, et ROBINS-I Assessment of Bias in Non-randomized al.,10 challenged the cloth face mask using avian influen- Studies was used to measure the risk of bias in this re- za, whereas Rengasamy, et al.,11 (Table 4) challenged view. Two independent authors assessed methodological the fabrics using aerosols of sodium chloride sized 20 - quality and standard of outcome report in the included 1,000 nm. Rengasamy, et al.,11 counted the penetration studies. The results of the assessment of the studies were percentage of the fabrics instead of its filtration efficien- presented in Table 2. cy. Penetration percentage was determined as “the ratio The filtration efficiency of cloth face masks differs of particle concentration downstream to upstream multi- from one another due to the different fabric materials plied by 100”.11 used. Table 3 summarizes filtration efficiency and pressure drop of common fabrics studied in research by Discussion Davies, et al.,8 Ma, et al.,10 and Rengasamy, et al.11 It can be concluded that most studies found that sur- Davies, et al.,8 measured the filtration efficiency of gical masks have higher filtration efficiency compared to each fabric by challenging the different types of fabrics a cloth face mask.6,8,10 Studies by Bae, et al.,9 and with aerosols of Bacteriophage MS2 (0.023 μm) and B. Shakya, et al.,7 show that a cloth face mask can be more

45 Kesmas: Jurnal Kesehatan Masyarakat Nasional (National Public Health Journal). 2020; Special Issue 1: 43-48

Table 2. ROBINS-I Assessment of Bias in Non-Randomized Studies

Bae, et al.,9 Davies, et al.,8 Ma, et al.,10 Neupane, et al.,6 Shakya, et al.,7 Rengasamy, et al.,11

Bias due to: Confounding Serious Low Low Serious Low Serious Selection of participants in the study Low No information Low Critical Low Low Deviations from intended interventions Low Low Low Low Low Low Missing data Low Low Low Low Low Low Bias in: Measurement outcomes Low Low Low Low Low Low Selection of the reported result Low Low Low Low Low Low Overall judgement Serious risk of bias No information Low risk of bias Critical risk of bias Low risk of bias Serious risk of bias

Table 3. Filtration Efficiency of Common Fabrics used as Masks Table 4. Penetration Level of Mask Type and Fabrics used as Masks,11

Study Fabric Used as Mask Filtration Efficiency (ΔP) Penetration Against Mask Type and Fabric Used NACl Particles Size (ΔP) Davies, et al.,8 Tea towel 72.46% 7.23 20 nm Cotton blend 70.24% 6.18 Antimicrobial pillowcase 68.9% 6.11 ‘Respro’ Linen 61.67% 4.5 Bandit mask (fiber composition N/A) 60% N/A Pillowcase 57.13% 3.88 ‘Breathe health’ Silk 54.32% 4.57 Cloth face mask (fiber composition N/A) 70% N/A 100% cotton t-shirt 50.85% 4.29 Fleece mask (fiber composition N/A) 40% N/A Scarf 48.87% 4.36 Sweatshirt Ma, et al.,10 Polyester cloth with 4 layers 85% cotton and 15% polyester 48% N/A of kitchen paper 95% N/A 70% cotton and 30% polyester ~30% N/A 60% cotton and 40% polyester 60% N/A Note: ΔP : pressure drop T-shirt 99% Cotton and 1% polyester ~82% N/A 100% Cotton ~75% N/A 60% Cotton and 40% polyester ~58% N/A effective compared to a surgical mask. The study by Bae, Scarf et al.,9 did not control confounding factors, such as mask 100% Cotton 70-75% N/A leakage, and therefore may intervene with results. 100% Polyester 10% N/A A cloth face mask may be inferior to a surgical mask Note: ΔP : pressure drop due to the average size of its pores. Cloth face mask ge - nerally has larger pores compared to surgical masks, 3.3 micrometers. Several kinds of cloth face masks were therefore allowing more particles and micro-organisms as good and as effective as surgical masks in the efficiency to penetrate. However, the study by Neupane, et al.,6 on- of filtrating particles more than 1 micrometer.8 ly studied the pore size of 20 different masks and these Although surgical masks are concluded to be more ef- masks were chosen based on its fabric and material, and fective than cloth face masks, it must be noted that nei- may not represent cloth face masks entirely. ther surgical masks nor cloth face masks have a filtration It must also be noted that the filtration efficiency of efficiency that reaches 100%, especially for particles or each cloth face masks differs from one mask to another. microorganisms sized < 0.072 μm.6-10,12 It must also be 6,7 This depends on the mask’s fabric material.8,11 kept in mind that although cloth face mask has lower fil- Filtration efficiency of both surgical mask and cloth face tration efficiency, it still aids in filtering particles and mask also decreases as the masks are challenged by small- micro organisms and is better than not wearing a mask at er microorganisms as shown by studies by Davies, et al.,8 all.9,13 Therefore wearing a cloth face mask should not and Shakya, et al..7 The study by Davies, et al.,8 involved be deemed as useless. 21 volunteers who were asked to cough using no mask, a Judging from its filtration efficiency, polyester is con- surgical mask and a homemade mask into a cough box cluded to be the best fabric that can be used as a mask. where an Andersen sampler and settle plates are placed Ma, et al.,10 found that adding four layers of kitchen pa- inside. The study reported that the number of colony- per onto a polyester face mask results in a filtration effi- forming units increased as the particle size decreased. ciency as high as 95%. This is supported by the result A homemade mask can also decrease the expulsion of found by Rengasamy, et al.,11 where scarf made of 100% microorganisms compared to not using any mask. These polyester has a penetration percentage of 10%. differences were seen as protective for particles less than Sweatshirts and shirts made of polyesters also have lower

46 Rizki et al, Efficacy of Cloth Face Mask in Reducing COVID-19 Transmission: A Literature Review penetration percentage. The concentration of polyester mains neutral in the context of public mask-wearing and seems to be inversely proportional to the penetration per- the use of cloth face mask. centage. However, none of the articles reviewed in this This interim guidance stated that the efficacy of non- article studied the pressure drop of masks made of poly- medical masks (e.g., cloth face masks) was not well eva- ester, therefore whether the mask is comfortable or not is luated, therefore no recommendation for or against the unknown. use of non-medical masks was made by WHO. The WHO Although tea towels have the second-highest filtration suggested certain things be taken into consideration if in- efficiency (72.46%), the high-pressure drop (7.23) indi- dividuals were to decide to use cloth face masks, such as cates discomfort when using this as a mask. Discomfort the number of layers of fabric or tissue, breathability, wa- may cause users to be noncompliant and therefore re- ter repellence, the shape of the mask, and fit of the duces the efficacy of the mask itself. As a comparison, mask.15 surgical masks have a pressure drop of 5.23 and is considered comfortable when being worn.8 Conclusion Therefore, an alternative to polyester mask is using a All of the previous studies reviewed in this research mask made of cotton blend. The cotton blend has a filtra- showed the same result that cloth face masks remain in- tion efficiency of 70.24% and a pressure drop of 6.18. In ferior compared to surgical or medical masks. However, comparison to surgical masks, this mask may be more although in terms of efficacy it is inferior, it must be not- uncomfortable but it is still significantly lower than the ed that cloth face masks still do filter viruses and could amount of pressure drop tea towels have.8 It is speculated not be deemed as useless. Cloth face mask’s filtration e - that the cotton blend provides decent filtration efficiency fficiency depends on its material and this review con- in comparison to other fabrics as the combination of cot- cludes that mask made of polyester seems to be the most ton and other materials provide mechanical filtration and effective. Neither cloth face masks nor surgical masks electrostatic-based filtration.14 provide 100% filtration efficiency, thus other measures, ROBINS-I was used to evaluate the presence of bias such as physical distancing, practicing good hand hy- in each journal (Table 1). Although bias is nearly impos- giene, and disinfecting, must also be done in combination sible to avoid, unfortunately, most of the studies included to reduce transmission. had a high risk of bias. Out of six studies included in this review, one did not have enough information, two had a Abbreviations serious risk of bias, one had a critical risk of bias and two COVID-19: Coronavirus Disease 2019; MeSH: Medical Subject had a low risk of bias that could affect the results. More Headings of the National Library of Medicine; CFR: Case Fatality Rate; studies regarding the efficacy of cloth face mask and the CPR: Cardiopulmonary Resuscitation; WHO: World Health filtration efficiency of each fabric should be made shortly. Organization; PPE: Personal Protective Equipment; CDC: Centers of More reviews should also be made for better understand- Disease Control; PSL: Polystyrene Latex; APS: Aerodynamic Particulate ing. Sizer; LPM: Liters Per Minute, SMPS: Scanning Mobility Particle Sizer In April 3, 2020, CDC recommended the use of cloth SM: Simple Mask; CM: Cloth mask. face masks in public settings where physical distancing is difficult to conduct. These settings include markets and Ethics Approval and Consent to Participate pharmacies. The rationale behind this recommendation No ethics approval was requested/attached as this review article that is possible virus transmission by COVID-19 positive pa- did not involve any subjects. tients who are asymptomatic or pre-symptomatic and shortages of N95 respirator and surgical masks. Competing Interest These recommendations intend to slow down The authors declare that there are no competing interests. COVID-19 transmission, especially from people who are asymptomatic or pre-symptomatic as they may not be Availability of Data and Materials aware that they are infectious. These recommendations Data included in this article are openly available and may be accessed also intend to prevent further shortages of N95 respira- by accessing the links attached in the reference section. tors and surgical masks to allow these PPEs to be prioritized for healthcare workers. Regardless of this new re- Authors’ Contribution commendation, other measures, such as physical distanc- Saraswati Anindita Rizki contributed to the collection of studies, as- ing and practicing good hand hygiene, must also be prac- sessing the qualities of studies included in this article using the ticed.4 ROBINS-I assessment and drafted the article. Andre Kurniawan con- In April 6, 2020, WHO published its interim guidance tributed to the collection of studies, assessing the qualities of studies in- on the use of masks in the context of COVID-19. In this cluded using ROBINS-I and critically reviewed the draft of this article. interim guidance, it could be highlighted that WHO re- The final version was approved by all authors.

47 Kesmas: Jurnal Kesehatan Masyarakat Nasional (National Public Health Journal). 2020; Special Issue 1: 43-48

Testing the efficacy of homemade masks: would they protect in an in- Acknowledgment fluenza pandemic?. Disaster Medicine and Public Health Preparedness. The authors would like to thank everyone who helped us in this review. 2013; 7 (4): 413–8. 9. Bae S, Kim M-C, Kim JY, Cha H-H, Lim JS, Jung J, et al. Effectiveness References of surgical and cotton masks in blocking SARS-CoV-2: a controlled 1. World Health Organization. WHO coronavirus disease (COVID-19) comparison in 4 patients. Annals of Internal Medicine. 2020; 173 (1): dashboard; 2020 [updated 2020 May 26; cited 2020 May 27]. W22-3. 2. World Health Organization. Modes of transmission of virus causing 10. Qing-Xia M, Hu Shan, Hong-Liang Z, Gui-Mei L, Rui-Mei Y, Ji- COVID-19: implications for IPC precaution recommendations; 2020 Ming C. Potential utilities of mask-wearing and instant hand hygiene [updated 2020 Mar 29; cited 2020 Apr 4]. for fighting SARS-COV-2. Journal of Medical Virology. 2020; 1–5. 3. Cowling BJ, Ali ST, Ng TWY, Tsang TK, Li JCM, Fong MW, et al. 11. Rengasamy S, Eimer B, Shaffer RE. Simple respiratory protection - Impact assessment of non-pharmaceutical interventions against coron- evaluation of the filtration performance of cloth masks and common avirus disease 2019 and influenza in hong kong: an observational fabric materials against 20-1000 nm size particles. The Annals of study. Lancet Public Health. 2020; 5 (5): e279–88. Occupational Hygiene. 2010; 54 (7): 789–98. 4. Centers for Disease Control and Prevention. Considerations for wear- 12. MacIntyre CR, Seale H, Dung TC, Hien NT, Nga PT, Chughtai AA, et ing cloth face coverings: help slow the spread of COVID-19. 2020 [up- al. A cluster-randomized trial of cloth masks compared with medical dated 2020 Apr 3; cited 2020 Apr 10]. masks in healthcare workers. BMJ Open. 2015; 5 (4): 1–10. 5. Shokri A, Golbabaei F, Zadeh AS, Baneshi MR, Asgarkashani N, 13. Clase CM, Fu EL, Joseph M, Beale RCL. Cloth masks may prevent Zarandi AF. Evaluation of physical characteristics and particulate fil- transmission of COVID-19: an evidence-based, risk-based approach. tration efficiency of surgical masks used in Iran’s hospitals. Annals of Internal Medicine. 2020; M20-2567. International Journal of Occupational Hygiene. 2015; 7 (1): 10–6. 14. Konda A, Prakash A, Moss GA, Schmoldt M, Grant GD, Guha S. 6. Neupane BB, Mainali S, Sharma A, Giri B. Optical microscopic study Aerosol filtration efficiency of common fabrics used in respiratory of surface morphology and filtering efficiency of face masks. PeerJ-Life cloth masks. ACS Nano. 2020; 14: 6339–47. & Environmental. 2019; 7: e7142. 15. World Health Organization. Advice on the use of masks in the com- 7. Shakya KM, Noyes A, Kallin R, Peltier RE. Evaluating the efficacy of munity, during home care, and in health care settings in the context of cloth facemasks in reducing particulate matter exposure. Journal of the novel coronavirus (2019-nCov) outbreak: interim guidance, 29 Exposure Science & Environmental Epidemiology. 2017; 27: 352–7. January 2020; 2020 [updated 2020 Apr 6; cited 2020 Apr 8]. 8. Davies A, Thompson KA, Giri K, Kafatos G, Walker J, Bennett A.

48 Suraya et al. Kesmas: Jurnal Kesehatan Masyarakat Nasional (National Public Health Kesmas: Jurnal Kesehatan Masyarakat Nasional Journal). 2020; Special Issue 1: 49-53 DOI: 10.21109/kesmas.v15i2.3990 (National Public Health Journal) The Impact of Large-scale Social Restrictions on the Incidence of COVID-19 : A Case Study of Four Provinces in Indonesia

Izza Suraya1, Mochamad Iqbal Nurmansyah2*, Emma Rachmawati1, Badra Al Aufa3, Ibrahim Isa Koire4

1Faculty of Health Sciences, Universitas Muhammadiyah Prof. Dr. Hamka, Indonesia 2Faculty of Health Science, Universitas Islam Negeri Syarif Hidayatullah Jakarta, Indonesia 3Department of Hospital Administration, Vocational Education Program, Universitas Indonesia 4Institute of Science, Istanbul University, Turkey

Abstract The Indonesian government has chosen to implement large-scale social restrictions (Pembatasan Sosial Berskala Besar/PSBB) to minimize the spread of COVID-19. Large-scale social restrictions is a government policy aimed at restricting the internal movement of people in a bid to reduce the spreading of SARS-CoV-2. This study aims at assessing the impact of large-scale social restriction measures on the incidence of COVID-19 cases in the four provinces of Indonesia. Time series analysis was used to describe the trends of COVID-19 case by using surveillance data from the Ministry of Health of Indonesia. Quasi- Poisson regression with an interaction model was used to estimate the incidence rate ratio (IRR). IRR was calculated to compare an incidence rate before and during PSBB implementation. The trend of COVID-19 cases in the provinces of West Java, East Java, Banten, and Jakarta continued to fluctuate. These four provinces continue to experience a significant increase in COVID-19 incidence rate ratio after the first and second PSBB period implementation compared to the time of before PSBB implementation. Lack of proper implementation of the large-scale social restriction led to the PSBB’s ineffectiveness in reducing the number of COVID19 cases in each of the provinces.

Keywords: COVID-19, incidence rate ratio, social restriction, time series analysis

Introduction terventions were important and necessary to minimize Despite the flattening of the coronavirus disease 2019 the spread of this epidemic and to reduce on the burden (COVID-19) curve by some countries, the number of cas- placed on the healthcare service.7 es in Indonesia conti nue to increase on a daily basis.1 By Governments’ decisions to restrict the mobility of May 11, 2020, the number of confirmed cases had people in order to reduce the risk of spreading the virus reached 14,265, with 991 deaths.2 Although the number have been very diverse; ranging from shutting down of cases is not as high as in other countries, the schools, workplaces, and transportation; restricting pub- Indonesian fatality rate from COVID-19 is, unfortunate- lic gatherings; and imposing a ‘stay at home’ policy.8 As ly, the worst among Southeast Asian countries.3 The a response to the increase in the number of COVID-19 main transmission routes of COVID-19 are through cases, the Indonesian government declared a national droplets, contact and aerosols; maintaining an appropri- public health emergency on March 31, 2020. However, ate distance from other people is among the preventive it declined putting the country under total lockdown ow- measures.4 Given the current si tuation, with the absence ing to economic considerations.9 Later, the government of vaccines and lack of proper treatment for COVID-19 chose to implement large-scale social restrictions cases, non-pharmaceutical interventions (NPIs) are the (Pembatasan Sosial Berskala Besar/PSBB) as one of the only methods to reduce transmission of the virus.5 Such policies aimed at restricting the internal movement of measures range from standard precautions such as hand, people in a bid to reduce the spread of SARS-CoV-2.10 respiratory and environmental hygiene; in the form of PSBB measures included limiting certain activities, the personal protective action taken by individuals, to actions mobility of people and goods within a certain area.11 requiring the engagement of communities and the in- The scope of PSBB restrictions include: 1) the closure volvement of local, regional or national authorities (e.g., of schools and the workplaces, apart from central gov- social distancing and travel-related measures).6 These in- ernment offices, and businesses and transportation com-

Correspondence*: Mochamad Iqbal Nurmansyah, Faculty of Health Science, Received : June 19, 2020 Universitas Islam Negeri Syarif Hidayatullah Jakarta, Kertamukti Road, South Accepted : June 20, 2020 Tangerang 15412, Indonesia, E-mail: [email protected], Phone: Published: July 31, 2020 +62- 823-1618-8190

Copyright @ 2020, Kesmas: Jurnal Kesehatan Masyarakat Nasional (National Public Health Journal), p-ISSN: 1907-7505, e-ISSN: 2460-0601, SINTA-S1 accredited, http://journal.fkm.ui.ac.id/kesmas, Licensed under Creative Commons Attribution-ShareAlike 4.0 International Kesmas: Jurnal Kesehatan Masyarakat Nasional (National Public Health Journal). 2020; Special Issue 1: 49-53 panies that serve essential public needs, 2) restrictions province. Descriptive statistics were used to calculate the on religious activities that involve mass gatherings, 3) average and standard deviation of confirmed COVID-19 limitations on activities in public places or facilities, 4) cases before and during PSBB implementation. In addi- limitations on social-cultural activities, 5) limitations on tion, quasi-Poisson regression with an interaction model modes of transportation, and 6) restrictions on other act - was performed to estimate the incidence rate ratio iv ities related explicitly to defense and security, but with (IRR).The ratio was calculated to compare the incidence military and police operation activities allowed. the PSBB rate before and during PSBB implementation. in all regions of Indonesia, but only in a few, with the criteria for doing so based on the number of cases and/ or Results deaths due to a significant increase and spread of the Figure 1 shows the trend of COVID-19 cases in the virus in those specific regions. A province or city can im- provinces of West Java, East Java, Banten, and Jakarta, pose PSBB after obtaining approval from the Indonesian which continues to fluctuate. Table 2 shows the average Minister of Health. Its implementation for 14 days, based number of cases in each province before and during the on the longest incubation period, and if there are new first and second PSBB periods. The average number in cases of COVID-19, this will be extended for an extra 14 West Java continued to increase before, and during the days from the date of the last observed infected case.12 first and second PSBB periods (19.62 ± 23.32; 29.93 ± In May 11, 2020, four provinces and 22 cities were 24.48; 41.14 ± 35.15). In Banten Province, cases before still implementing PSBB whereas one city had completed PSBB and during the first period decreased, but increased the process. The beginning of PSBB implementation during the second period. In Jakarta, the average number among the different regions in Indonesia has been differ- of cases during the first PSBB period experienced an in- ent. Jakarta Province was the first region to implement it, crease from the average before implementation, but later with the first PSBB period implemented be April 10-23, experienced a decline during the second PSBB period. 2020, followed by a second period from April 24, 2020 Table 3 shows the incidence rate ratio before and du - until May 22, 2020. Even though some areas in Indonesia ring the first and second periods of PSBB in the four are still implementing PSBB, with many others requesting provinces. We found most of the areas to have experi- approval from the minister to do so, evidence of its effect - enced a significant increase in the COVID-19 incidence iveness in flattening the COVID-19 curve remains un- rate ratio in the first and second periods of PSBB com- clear. The study aims to evaluate the effectiveness of PS- pared to the period before its implementation. In the first BB measures on reducing incidence of COVID-19 in va- round of PSBB, the provinces of West Java, East Java, rious areas of Indonesia. and Jakarta experienced increased incidences of COVID- 19 compared to the pre-PSBB period. East Java showed Method the highest incidence rate ratio compared to the two o - The study assessed COVID-19 cases of four provinces ther provinces, with IRR = 2.62 (95% CI = 2.37 - 2.90). in Indonesia before and during PSBB implementation. In the provinces of West Java and East Java, after the We selected the four provinces with the highest number adoption of the second round of PSBB, the incidence rate of confirmed cases in Indonesia, namely Jakarta (5,375 ratio was higher than in the first period. In Jakarta, the cases), East Java (1,669 cases), West Java (1,545 cases), incidence rate ratio of COVID-19 decreased after the sec- and Banten (559 cases).13 The daily data of confirmed ond PSBB period, compared to that in the first period. cases in each province in Indonesia was obtained from the Ministry of Health of Indonesia between March 19, Discussion 2020 and May 12, 2020. The PSBB period in each It is shown that the large-scale social restriction policy province was different, since ratification and implemen- (partial lockdown) did not have a significant effect on re- tation depended on the development of the specific num- ducing the number of COVID-19 cases in the four ber of cases in the region. Besides, PSBB also allows for provinces studied. These results are different to those of the option to not implement it in all the cities in the same a previous study conducted in Italy and Spain, which province, but only in a few, since not all cities in a showed that the lockdown had an effect by decreasing province have the same incidence rates. Therefore, in this Table 1. Pembatasan Sosial Berskala Besar Period for Each Province study West Java, East Java, and Banten Provincial Governments implemented PSBB only in regions that had Province Number of Cities PSBB First Period PSBB Second Period met the criteria for doing so. The period of PSBB for each Jakarta All city 10 April – 23 April 24 April – 22 May province and its city scopes can be seen in Table 1. West Java 5 cities 15 April – 28 April 29 April – 22 May The data were analyzed using statistical software. East Java 3 cities 28 April – 11 May 12 May – 25 May Data analysis was performed using time-series analysis Banten 3 cities 18 April – 1 May 2 May – 17 May to observe the trends of COVID-19 cases in each Note: PSBB: Pembatasan Sosial Berskala Besar

50 Suraya et al, The Impact of Large-scale Social Restrictions on the Incidence of COVID-19

Figure 1. Daily Case of Covid-19 in West Java, East Java, Banten, and Jakarta Province

Table 2. Average Number of Confirmed COVID-19 Cases in Each Province Table 3. Incidence Rate Ratio of Confirmed COVID-19 Cases Before and and Period During the Pembatasan Sosial Berskala Besar Periods

Mean + SD Incidence Rate Ratio Province Province Before PSBB First PSBB Second PSBB Before PSBB First PSBB Second PSBB

West Java 19.62 ± 23.32 29.93 ± 24. 48 41.14 ± 35.15 West Java 1 1.53 (1.34 – 1.73)* 2.10 (1.86 -2.36)* East Java* 20.18 ± 23.89 52.86 ± 37.05 - East Java 1 2.62 (2.37 – 2.90)* 6.52 (5.48 – 7.92)* Banten 9.52 ± 9.05 7.64 ± 6.52 12.82 ± 6.75 Banten 1 0.80 (0.64 – 1.00)*** 1.35 (1.10 – 1.65)** Jakarta 75.52 ± 59.58 129. 36 ± 42.73 97.79 ± 24.76 Jakarta 1 1.78 (1.67 – 1.91)* 1.35 (1.26 -1.44)*

Notes: PSBB: Pembatasan Sosial Berskala Besar; SD: Standar Deviation; * The Notes: PSBB: Pembatasan Sosial Berskala Besar; *p-value < 0.001; **p-value = second PSBB period had already started in East Java on 12 May 2020 0.004; *** p-value = 0.054 diagnosed cases by 42.1% in Italy and 69.1% in Spain.14 movement of people from Bekasi (West Java) to Jakarta Another study using the modelling method in India found and from Banten to Jakarta after the Jakarta’s PSBB poli- that preventive measures such as social isolation and cy had been implemented changed little compared to the lockdown had an impact on the reduction of the spread movements before enactment. Daily mobility analysis has of the virus.15 School and workplace closures and social shown that a significant decrease in community mobility distancing strategies are not new in response to influenza only occurred at weekends.18 A report from the pandemics. A study by Jackson revealed that school clo- Department of Transportation of Jakarta Province also sures reduced influenza transmission,16 while another shows that the number of vehicles entering Jakarta from study indicated that workplace measures could reduce West Java and Banten during the second period of PSBB incidence rates and slow the transmission of influenza.17 was still high.19 A different report from the Jakarta Metro This study did not overlook the ineffectiveness of police states that after 16 days of PSBB, there were minimized physical contact measures in reducing the around 36,000 violations by motorcyclists and car drivers number of cases, but instead claims that the lack of com- related to PSBB policy, such as not wearing masks and munity compliance was the real factor why intervention gloves.20 Moreover, the report states that during PSBB was not significant in suppressing COVID-19 incidents many non-essential workplaces were still ignoring the in Indonesia. This is supported by a study which found policies and requiring their workers to go to work amidst that PSBB policy was not effective in reducing the entry the physical distancing requirements.21 of human traffic from outside the Jakarta region. The The underlying conditions to explain people’s lack of

51 Kesmas: Jurnal Kesehatan Masyarakat Nasional (National Public Health Journal). 2020; Special Issue 1: 49-53 implementation of PSBB protocol are complicated. sion of manuscript. Restricted social and business processes impose short and possibly medium-term financial burdens.7 People, Acknowledgment particularly those working in the informal sector, need to The authors thank Ministry of Health of Indonesia for providing access continue to work or open their businesses to obtain in- to the COVID-19 cases data we used and also thank research assistants come. However, adherence to public health protocol who helped with data processing. might be affected by the existence of financial compensa- tion for losses incurred.22 Research in the United States References revealed that 39.8% of respondents reported not com- 1. New England Complex Systems Institute. Which countries do best in plying with social distancing recommendations.23 Some beating covid-19?. EndCoronavirus.org; 2020 [cited 2020 May 16]. of the reasons for this were work requirements for non- 2. Gugus Tugas Percepatan Penanganan COVID-19. Data sebaran; 2020 essential industries; engagement in social, physical or [cited 2020 May 2]. routine activities; and the belief that social distancing was 3. ASEAN Biodiaspora Virtual Center (ABVC). Risk assessment for in- not needed if other preventive measures were in place.23 ternational dissemination of COVID-19 to the ASEAN Region; 2020. 4. Adhikari SP, Meng S, Wu YJ, Mao YP, Ye RX, Wang QZ, et al. Conclusion Epidemiology, causes, clinical manifestation and diagnosis, prevention The study reveals the failure of PSBB policy to reduce and control of coronavirus disease (COVID-19) during the early out- the incidence of COVID-19 in Indonesia. We suggest that break period: a scoping review. Infectious Disease of Poverty. 2020; 9 implementation of the policy is improved so that it (1): 29. achieves its objectives. Timely implementation with high 5. Ferguson NM, Laydon D, Nedjati-Gilani G, Imai N, Ainslie K, compliance from the community could be a factor in the Baguelin M, et al. Report 9: impact of non-pharmaceutical interven- successful implementation of non-pharmaceutical inter- tions (NPIs) to reduce COVID-19 mortality and healthcare demand. ventions.24 Therefore, the government needs to be Imperial College London; 2020. stricter with certain communities and companies to e- 6. European Center for Disease Prevention and Control. Guidelines for ffectively encourage them to adhere to large-scale social the use of non-pharmaceutical measures to delay and mitigate the im- restrictions during the pandemic. On the other hand, the pact of 2019-nCoV. ECDC: Stockholm; 2020. community should be more intensively engaged to enable 7. Anderson RM, Heesterbeek H, Klinkenberg D, Hollingsworth TD. them to manage the epidemic through the implementa- How will country-based mitigation measures influence the course of tion of preventive measures at individual, family, and the COVID-19 epidemic?. Lancet. 2020; 395 (10228): 931–4. community levels. 8. Hale T, Petherick A, Phillips T, Webster S, Beatriz K, Angrist N. Variation in government responses to COVID-19. Version 5.0; 2020. Abbreviations 9. Pasley J. Here’s how Indonesia — where “ghosts” representing trapped PSBB: Pembatasan Sosial Berskala Besar (Large-scale Social souls are scaring people into maintaining lockdown — went from no Restrictions); COVID-19: Coronavirus Disease 2019; NPIs: Non- cases in early March to having the second highest death rate in Asia. Pharmaceutical Interventions; IRR: Incidence Rate Ratio. Insider; 2020 [cited 2020 May 16]. 10. The Ministry of Tourism Republic of Indonesia. Large scale social res - Ethics Approval and Consent to Participate triction implementation; 2020 [cited 2020 May 16]. No ethical approval was required for this study, which relied solely on 11. Sekretariat Kabinet Republik Indonesia. Inilah PP pembatasan sosial open-access public data. berskala besar untuk percepatan penanganan Covid-19; April 1, 2020. 12. Menteri Kesehatan Republik Indonesia. Peraturan Menteri Kesehatan Competing Interest Republik Indonesia Nomor 9 Tahun 2020 Tentang Pedoman The authors declare that there are no competing interests to disclose. Pembatasan Berskala Besar dalam Rangka Percepatan Penanganan Corona Virus Disease 2019 (COVID-19); 2020. Availability of Data and Materials 13. Ministry of Health of Indonesia. Dashboard data kasus COVID-19 di The data that support the findings of this study are available, upon rea- Indonesia; 2020 [cited 2020 Mar 16]. sonable request. 14. Tobías A. Evaluation of the lockdowns for the SARS-CoV-2 epidemic in Italy and Spain after one month follow up. Science of The Total Authors’ Contribution Environment. 2020; 725: 138539. Izza Suraya and Mochamad Iqbal Nurmansyah participated in the de- 15. Tomar A, Gupta N. Prediction for the spread of COVID-19 in India sign of the study; Izza Suraya and Mochamad Iqbal Nurmansyah par- and effectiveness of preventive measures. Science of The Total ticipated in data collection; Izza Suraya participated in analysed the da- Environment. 2020; 728: 138762. ta; Izza Suraya, Mochamad Iqbal Nurmansyah, Emma Rachmawati, 16. Jackson C, Vynnycky E, Hawker J, Olowokure B, Mangtani P. School Badra Al Aufa and Ibrahim Isa Koire helped to draft the manuscript. closures and influenza: systematic review of epidemiological studies. All authors revised the manuscript critically and approved the final ver- BMJ Open. 2013; 3 (2): e002149.

52 Suraya et al, The Impact of Large-scale Social Restrictions on the Incidence of COVID-19

17. Ahmed F, Zviedrite N, Uzicanin A. Effectiveness of workplace social haan pelanggar PSBB. katadata.co.id. 2020 [cited 2020 May 15]. distancing measures in reducing inﬂuenza transmission: a systematic 22. European Centre for Disease Prevention and Control. Community and review. BMC Public Health. 2018; 18 (518). institutional public health emergency preparedness synergies — en- 18. Suryahudaya EG, Wicaksono TY. Mobilitas, migrasi dan kebijakan PS- ablers and barriers. ECDC: Stockholm; 2019. BB COVID-19: gambaran terkini dari data Facebook disease preven- 23. Moore RC, Lee A, Hancock JT, Halley M, Linos E. Experience with so- tion map. Indonesia: CSIS Commentaries; 2020. cial distancing early in the COVID-19 pandemic in the United States: 19. Rahmawati F. PSBB, kendaraan masuk Jakarta masih tinggi. implications for public health messaging. medRxiv. 2020; 04.08.2005. Ayojakarta.com. 2020 [cited 2020 May 18]. 24. Fong MW, Gao H, Wong JY, Xiao J, Shiu EYC, Ryu S, et al. Non- 20. Nasution AD. Sejak 13 April, Polda Metro temukan 36 ribu pelanggar pharmaceutical measures for pandemic inﬂuenza in nonhealthcare set- PSBB Jadetabek. katadata.co.id. 2020 [cited 2020 May 13]. tings-social distancing measures. Emerging Infectious Disease. 2020; 21. Nasution AD. Pemprov Jakarta tutup sementara hampir 200 perusa- 26 (5).

53 Rokhmah. Kesmas: Jurnal Kesehatan Masyarakat Nasional (National Public Health Kesmas: Jurnal Kesehatan Masyarakat Nasional Journal). 2020; Special Issue 1: 54-59 DOI: 10.21109/kesmas.v15i2.3986 (National Public Health Journal) Analysis of Government Budgeting for Health: Case Study of COVID-19 in East Java Province, Indonesia

Dewi Rokhmah1*, Ricko Pratama Ridzkyanto2, Khoiron3

1Department of Health Promotion and Behavior Science, Faculty of Public Health, University of Jember, Indonesia 2Department of Health Administration and Policy, Faculty of Public Health University of Jember, Indonesia 3Department of Environmental Health, Faculty of Public Health, University of Jember, Indonesia

Abstract The COVID-19 in Indonesia was first reported in March 2, 2020 with two cases, and the number has increased each day until April 23, 2020 and reached 7,775 positive cases of COVID-19. East Java Province ranks the third in Indonesia with 662 cases. COVID-19 requires a health financing system aimed for COVID-19 patients and hospital services. The study aimed to describe the amount of COVID-19 and the use of funds for COVID-19 in East Java Province. This study applied descriptive analytic method. Secondary data analysis used the COVID-19 fund data of 31 districts/cities in East Java Province from the Regional Development Agency of East Java Province in period of March 23 - April 23, 2020. The results showed that the total budget for COVID-19 in the province was worth IDR 2,102,600,000,000 divided for Curative IDR 727,654,880,535, Promotive Preventive IDR 97,134,092,873, Social Safety Net IDR 877,301,513,766 and Recovery IDR 400,50,512,826. The total fund for COVID-19 per capita in the province was IDR1,997,139 divided for Curative IDR 691,158, Promotive Preventive IDR 92,262, Social Safety Net IDR 833,299 and Recovery IDR 380,421. According to districts, the highest budgeting is Jember District, Surabaya City, and Gresik District. The highest per-capita funds, according to districts/cities, are Batu City, Jember District, and Trenggalek District.

Keywords: COVID-19 pandemic, fund management, health financing

Introduction 91 days dated on February 29, 2020.1 In December 31, 2019, information began to spread The COVID-19 disease in Indonesia was first report- about coronavirus caused by Coronavirus Disease 2019 ed on March 2, 2020 in two cases and has increased each (COVID-19). COVID-19 has been declared by WHO as day until April 23, 2020 and reached 7,775 positive cases the World Public Anxiety Emergency/Public Health of COVID-19 consisting of 647 death cases, 960 reco - Emergency of Pandemic, where transmission is very fast very cases, and 6,168 active cases of treatment. East Java in humans with a quite high level of mortality rate. The Province ranks the third in Indonesia with a total of 662 Law Number 4 of 1984 concerning Communicable cases per April 23, 2020, consisting of 66 death cases, Disease Outbreaks stated that outbreaks means out- 127 recovery cases, and 469 active cases of treatment. breaks of infectious diseases in a society where the num- Of the 469 active cases, 168 cases were treated at home, ber of patients significantly increases beyond normal con- 31 cases were treated in the building, and 270 cases were ditions at certain times and regions and may cause a ha- treated in hospital.2 voc. The Minister of Health determines certain types of The COVID-19 financing aims to facilitate the pay- diseases that can cause epidemics. The head of the ment of treated COVID-19 patients. It can be a reference National Agency for Disaster Management has decided for hospitals that provide services for COVID-19 to the status of certain conditions in the Coronavirus maintain the quality, efficient cost, and sustainability of Disease in Indonesia due to Coronavirus in Indonesia and health care services for COVID-19 patients.3 According then through the Decree of the Head of the National to the Regulation of the President of the Republic of Disaster Management Agency No. 13 of 2020 concerning Indonesia Number 72 of 2012 Concerning the National the Extension of the Status of Certain Conditions in the Health System, the sources of health financing are the Disaster of the Corona Virus Disease in Indonesia, government, local government, the private sector, com- whereas the status of specific conditions is extended for munity organizations, and the community itself.

Correspondence*: Dewi Rokhmah, Health Promotion and Behavior Science, Received : May 28, 2020 Faculty of Public Health, University of Jember, Kalimantan Street No. I / 93 Accepted : May 29, 2020 68121 Jember, East Java, Indonesia, E-mail: [email protected], Phone: Published: July 31, 2020 +62 812-1540-0530

Investment of public health care services are a public ratives reinforced with theoretical studies and related lite - good, which is the responsibility of the government. In rature. contrast, for individual health care services, the financing is private, except for the poor and the government's in- Results ability to be responsible. Adequate, integra ted, stable, Health financing comes from various sources, namely and sustainable health financing plays a vital role in the the government, local government, private sector, com- delivery of health care services to achieve health deve- munity organizations, and the community itself. lopment goals. Health financing is provide to produce Adequate, integrated, stable, and sustainable health fi- the availability of health budget with sufficient amount, nancing plays a vital role in the delivery of health care be fairly allocated and utilized effectively and efficiently services to achieve health development goals.11 This for the implementation of health efforts that are equi- study discussed the government budget for COVID-19 table, affordable, and quality for the whole community.4 as follows in Table 1 and Figure 1. Based on the explanation of the problem above and The study results showed at Table 1 that of 31 dis- the theory presented, the study objective was to find a description of the COVID-19 fund and the use of funds for COVID-19 in East Java Province, Indonesia.

Method This study was a descriptive-analytic study which aimed to determine the amount of COVID-19 funds and the use of COVID-19 funds in East Java Province, Indonesia. Secondary data analysis used COVID-19 fund data of 31 districts/cities in the East Java Province from the Regional Development Agency of East Java Province in period of March 23 - April 23, 2020. The analytical Figure 1. Allocation of Budget for COVID-19 in East Java Province, test used was a descriptive analysis using tables and nar- Indonesia

Table 1. Allocation of Budget for COVID-19 in East Java Province, Indonesia

District/City Curative (IDR) Preventive-Promotive (IDR) Social Safety Net (IDR) Recovery (IDR) Total Budget (IDR)

Surabaya 67,830,474,928 9,054,638,164 81,780,222,914 37,334,663,994 196,000,000,000 Malang 12,908,554,667 1,723,153,079 15,563,277,116 7,105,015,138 37,300,000,000 Jember 138,429,540,671 18,478,853,395 166,898,414,109 76,193,191,825 400,000,000,000 Sidoarjo 39,452,419,091 5,266,473,218 47,566,048,021 21,715,059,670 114,000,000,000 Pasuruan 26,647,686,579 3,557,179,279 32,127,944,716 14,667,189,426 77,000,000,000 Banyuwangi 7,267,550,885 970,139,803 8,762,166,741 4,000,142,571 21,000,000,000 Kediri 7,025,299,189 937,801,810 8,470,094,516 3,866,804,485 20,300,000,000 Gresik 51,911,077,752 6,929,570,023 62,586,905,291 28,572,446,934 150,000,000,000 Jombang 26,993,760,431 3,603,376,412 32,545,190,751 14,857,672,406 78,000,000,000 Bojonegoro 26,647,686,579 3,557,179,279 32,127,944,716 14,667,189,426 77,000,000,000 Lamongan 12,458,658,660 1,663,096,806 15,020,857,270 6,857,387,264 36,000,000,000 Tuban 20,764,431,101 2,771,828,009 25,034,762,116 11,428,978,774 60,000,000,000 Probolinggo 42,221,009,904 5,636,050,286 50,904,016,303 23,238,923,507 122,000,000,000 Blitar 35,991,680,575 4,804,501,883 43,393,587,668 19,810,229,874 104,000,000,000 Mojokerto 7,267,550,885 970,139,803 8,762,166,741 4,000,142,571 21,000,000,000 Sumenep 8,651,846,292 1,154,928,337 10,431,150,882 4,762,074,489 25,000,000,000 Nganjuk 6,679,225,337 891,604,676 8,052,848,481 3,676,321,506 19,300,000,000 Lumajang 4,568,174,842 609,802,162 5,507,647,666 2,514,375,330 13,200,000,000 Tulungagung 622,932,934 83,154,840 751,042,863 342,869,363 1,800,000,000 Bangkalan 17,303,692,584 2,309,856,674 20,862,301,764 9,524,148,978 50,000,000,000 Bondowoso 15,919,397,177 2,125,068,140 19,193,317,623 8,762,217,060 46,000,000,000 Madiun 13,842,954,067 1,847,885,340 16,689,841,411 7,619,319,182 40,000,000,000 Magetan 12,458,658,660 1,663,096,806 15,020,857,270 6,857,387,264 36,000,000,000 Ngawi 1,626,547,103 217,126,527 1,961,056,366 895,270,004 4,700,000,000 Pacitan 3,460,738,516 461,971,335 4,172,460,353 1,904,829,796 10,000,000,000 Pamekasan 21,456,578,804 2,864,222,276 25,869,254,187 11,809,944,733 62,000,000,000 Ponorogo 10,728,289,403 1,432,111,138 12,934,627,093 5,904,972,366 31,000,000,000 Sampang 7,613,624,737 1,016,336,937 9,179,412,776 4,190,625,550 22,000,000,000 Situbondo 8,997,920,143 1,201,125,471 10,848,396,917 4,952,557,469 26,000,000,000 Trenggalek 34,607,385,168 4,619,713,349 41,724,603,527 19,048,297,956 100,000,000,000 Batu 35,299,532,871 4,712,107,616 42,559,095,598 19,429,263,915 102,000,000,000 Total 727,654,880,535 97,134,092,873 877,301,513,766 400,509,512,826 2,102,600,000,000

55 Rokhmah et al, Analysis of Government Budgeting for Health: Case Study of COVID-19 in East Java Province, Indonesia

Kesmas: Jurnal Kesehatan Masyarakat Nasional (National Public Health Journal). 2020; Special Issue 1: 54-59

Table 2. Distribution of COVID-19 Mitigation Funds per Capita in East Java Province, Indonesia

District/City Total of Population (People) Fund (IDR) Fund per Capita (IDR)

Surabaya 2,904,751 196,000,000,000 67,476 Malang 2,619,975 37,300,000,000 14,237 Jember 2,459,890 400,000,000,000 162,609 Sidoarjo 2,282,215 114,000,000,000 49,951 Pasuruan 1,637,682 77,000,000,000 47,018 Banyuwangi 1,617,814 21,000,000,000 12,980 Kediri 1,580,092 20,300,000,000 12,847 Gresik 1,326,420 150,000,000,000 113,086 Jombang 1,268,504 78,000,000,000 61,490 Bojonegoro 1,252,020 7,000,000,000 61,501 Lamongan 1,189,380 36,000,000,000 30,268 Tuban 1,177,016 60,000,000,000 50,976 Probolinggo 1,174,890 122,000,000,000 103,840 Blitar 1,163,789 104,000,000,000 89,363 Mojokerto 1,126,392 21,000,000,000 18,644 Sumenep 1,092,387 25,000,000,000 22,886 Nganjuk 1,057,011 19,300,000,000 18,259 Lumajang 1,044,718 13,200,000,000 12,635 Tulungagung 1,043,182 1,800,000,000 1,725 Bangkalan 994,212 50,000,000,000 50,291 Bondowoso 778,789 46,000,000,000 59,066 Madiun 683,784 40,000,000,000 58,498 Magetan 629,020 36,000,000,000 57,232 Ngawi 830,134 4,700,000,000 5,662 Pacitan 555,984 10,000,000,000 17,986 Pamekasan 888,214 62,000,000,000 69,803 Ponorogo 871,825 31,000,000,000 35,558 Sampang 989,001 22,000,000,000 22,245 Situbondo 685,776 26,000,000,000 37,913 Trenggalek 697,600 100,000,000,000 143,349 Batu 209,125 102,000,000,000 487,747 Total 37,831,592 2,102,600,000,000 1,997,139 tricts/cities in the East Java Province, the top highest Total Budget for COVID-19 by districts/cities were Jember District with IDR 400 billion, Surabaya City with IDR 196 billion, and Gresik District with IDR 150 billion. Total Budget worth IDR 400 billion in Jember District was allocated for Curative IDR 138,429,540,671, Promotive-Preventive IDR 18,478,853,395, Social Safety Net IDR 166,898,414,109, and Recovery IDR 76,193,191,825. A total fund of IDR 196 billion in Surabaya City was allocated for Curative IDR 67,830,474,928, Promotive Preventive IDR 9,054,638,164, Social Safety Net IDR 81,780,222,914, and Recovery IDR 37,334,663,994. Figure 2. Distribution of the Use of COVID-19 Mitigation Funds per Capita Funds in the amount of IDR 150 billion in Gresik District in East Java Province, Indonesia were allocated for Curative IDR 51,911,077,752, Promotive Preventive IDR 6,929,570,023, Social Safety Preventive IDR 22,532, Social Safety Net IDR 203,510, Net IDR 62,586,905,291 and Recovery IDR and Recovery IDR 92,907. Fund per capita worth IDR 28,572,446,934. 162,609 in Jember District were allocated for Curative The results of the study on Table 2 showed that of the IDR 56,275, Promotive Preventive IDR 7,512, Social 31 districts/cities in East Java Province, the highest Fund Safety Net IDR 67,848 and Recovery IDR 30,974. The per Capita by districts/cities were Batu City with IDR Per-capita funds worth IDR 143,349 in Trenggalek 487,747, Jember District with IDR 162,609, and District were allocated for Curative IDR 49,609, Trenggalek District with IDR 143,349. Based on Table Promotive Preventive IDR 6,622, Social Safety Net IDR 3, Total Fund per Capita worth IDR 487,747 in Batu 59,812, and Recovery IDR 27,305. City were allocated for Curative IDR 168,796, Promotive

56 Rokhmah et al, Analysis of Government Budgeting for Health: Case Study of COVID-19 in East Java Province, Indonesia

Table 3. Distribution of Utilization of Covid 19 Mitigation Funds per Capita in East Java Province, Indonesia

District/City Curative (IDR) Preventive-Promotive (IDR) Social Safety Net (IDR) Recovery (IDR) Total of Funds per Capita (IDR)

Surabaya 23,352 3,117 28,154 12,853 67,476 Malang 4,927 658 5,940 2,712 14,237 Jember 56,275 7,512 67,848 30,974 162,609 Sidoarjo 17,287 2,308 20,842 9,515 49,951 Pasuruan 16,272 2,172 19,618 8,956 47,018 Banyuwangi 4,492 600 5,416 2,473 12,980 Kediri 4,446 594 5,361 2,447 12,847 Gresik 39,136 5,224 47,185 21,541 113,086 Jombang 21,280 2,841 25,656 11,713 61,490 Bojonegoro 21,284 2,841 25,661 11,715 61,501 Lamongan 10,475 1,398 12,629 5,766 30,268 Tuban 17,642 2,355 21,270 9,710 50,976 Probolinggo 35,936 4,797 43,327 19,780 103,840 Blitar 30,926 4,128 37,286 17,022 89,363 Mojokerto 6,452 861 7,779 3,551 18,644 Sumenep 7,920 1,057 9,549 4,359 22,886 Nganjuk 6,319 844 7,619 3,478 18,259 Lumajang 4,373 584 5,272 2,407 12,635 Tulungagung 597 80 720 329 1,725 Bangkalan 17,404 2,323 20,984 9,580 50,291 Bondowoso 20,441 2,729 24,645 11,251 59,066 Madiun 20,245 2,702 24,408 11,143 58,498 Magetan 19,806 2,644 23,880 10,902 57,232 Ngawi 1,959 262 2,362 1,078 5,662 Pacitan 6,225 831 7,505 3,426 17,986 Pamekasan 24,157 3,225 29,125 13,296 69,803 Ponorogo 12,306 1,643 14,836 6,773 35,558 Sampang 7,698 1,028 9,281 4,237 22,245 Situbondo 13,121 1,751 15,819 7,222 37,913 Trenggalek 49,609 6,622 59,812 27,305 143,349 Batu 168,796 22,532 203,510 92,907 487,747 Total 691,158 92,262 833,299 380,421 1,997,139

Discussion Health financing in each region is different.7 Health The COVID-19 outbreak has designated under the budgeting is due to several factors, such as the ability of National Agency for Disaster Management Authority.1 regional planning, regional commitment, advocacy abili- The Ministry of Finance framework needs to understand ty, when prioritizing local health problems, and program the nature and scale of these impacts and their relevance interventions.8 The distribution of the use of COVID-19 to financial, economic, and fiscal management strategies Prevention Funds consisted of curative funds for treat- and policies for which the government has primary res - ment, promotive-preventive for promotional and preven- ponsibility.5 Based on the Law Number 24 of 2007 tion activities, social safety net funds to protect informal Concerning Disaster Management, one of the govern- and daily workers during the COVID-19 pandemic, and ment's tasks is to grant the rights of people affected by recovery funds to restore the condition of the community the disaster. The Law stated that one of reasons for peo- and the environment affected by the disaster. Based on ple affected by an emergency is to get health care servic- the Ministry of Social Affairs' understanding, the social es.6 The health care service process cannot separate from safety net as the form of support from the Ministry of health financing. Health costs are a large number of funds Social Affairs reduces the burden on the poor and vul- required to organize and utilize various health efforts nerable families.9 The Social Safety Net has previously needed by individuals, families, groups, and communi- been conducted in several countries and is effective.10 ties.7 The purpose of implementing the health financing Therefore, Social Safety Net occupies the highest budget subsystem is the availability of adequate health funds, al- from the distribution of COVID-19 funds. The Curative located relatively, evenly, and utilized effectively and ef- sector ranked the second and followed by Recovery sec- ficiently, channeled according to its designation to ensure tor. Promotive-Preventive is at the lowest order of financ- the implementation of health development to improve ing. Based on data from the Ministry of Health regarding the highest degree of public health.3 Planning and ar- the growing number of COVID-19 patients, this causes ranging adequate health care financing can help the gov- Curative funds to be higher than funds for Promotive- ernment be able to mobilize sources of health financing, Preventive. Patients that can make claims are those with allocate it rationally, and use it efficiently and effectively. People-in-Monitoring (PIM) status, both the PIM aged

57 Kesmas: Jurnal Kesehatan Masyarakat Nasional (National Public Health Journal). 2020; Special Issue 1: 54-59 over 60 years with or without comorbidities and the PIM Insurance (NHI) service and general services. aged less than 60 years with comorbidities; Patient under Supervision (PUS), those with COVID-19 confirmation; Conclusion valid for Indonesian citizens and foreign citizens treated The total budget for COVID-19 in East Java Province at hospitals in the territory of the Republic of Indonesia. is IDR 2,102,600,000,000 allocated for Curative IDR Service areas include outpatient and inpatient care at re- 727,654,880,535, Promotive-Preventive IDR ferral hospitals for handling certain emerging infectious 97,134,092,873, Social Safety Net IDR diseases and other hospitals that provide services for 877,301,513,766, and Recovery IDR 727,654,880,535, COVID-19 patients.4 Services that can be funded follow Promotive Preventive IDR 97,134,092,873, Social Safety the service standards in the patient-handling guidelines Net IDR 877,301,513,766, and Recovery IDR based on the patient's medical needs as well as financing 727,654,880,535, Promotional-Preventive IDR for outpatient and inpatient services including adminis- 97,134,092,873, Social Safety Net IDR tration of facilities, accommodation (rooms and assis- 877,301,513,766, and Recovery IDR 727,654,880,535 tance in emergency rooms, inpatients, intensive care IDR 400,509,512,826. The highest total of coping funds rooms, and room isolation), doctor's services, actions in by districts/cities are Jember with IDR 400 billion, the place, the use of ventilators, medical consumables, Surabaya City with IDR 196 billion, and Gresik District diagnostic support examinations (laboratory and radiol- with IDR 150 billion. ogy following medical indications), drugs, medical de- The total per-capita funds for COVID-19 in East Java vices including the use of personal protective equipment Province is IDR 1,997,139 allocated for Curative IDR in the room, referral, corpse screening, and other health 691,158, Promotive-Preventive IDR 92,262, Social care services according to medical indications.4 Safety Net IDR 833,299 and Recovery IDR 380,421. The Payment methods are based on services provided and highest total per-capita funds by districts/cities are Batu a maximum length of treatment is determined City with IDR 487,747, Jember District with IDR usingIndonesian Case-Based Groups (INA-CBG) rates 162,609 and Trenggalek District with IDR 143,349. and top-up procedures calculated as an effective and efficient cost per day. The amount of the INA-CBG tariff Abbreviations for COVID-19-related outpatient services uses regional COVID-19: Coronavirus Disease 2019; PIM: People-in-Monitoring; class A hospital rate 1. The amount of INA-CBG fare for PUS: People Under Supervision; PPE: Personal Protective Equipment, COVID-19-related inpatient services uses local A class 1 INA-CBG: Indonesian Case-Based Groups; NHI: National Health hospital rates and class 3 Nursing Classes. Make a referral Insurance. to COVID-19 to other hospitals (referral hospitals and other hospitals that provide COVID-19 services). The Ethics Approval and Consent to Participate price of the INA-CBG tariff follows the payment norm, Not Applicable e.g., caring for 6 hours, paying INA-CBG outpatient rates, caring for > 6 hours-2 today, 70% of the fare paid Competing Interest claims, caring for > 2-5 days, 80% of the menu paid Authors declare that they have no competing interests to disclose. claims, caring for > 5 days, paid 100% of the claims rates.4 Top up per day (cost per day) includes compo- Availability of Data and Materials nents of services administration, accommodation in in- The authors have full access to all the data in the study and take respon- patient rooms, doctor services, outpatient and inpatient sibility for the data integrity. services, diagnostic supporting examinations (laboratory and radiological according to medical indications), me- Authors’ Contribution dicines, medical devices, and consumable restorative ma- Dewi Rokhmah, Ricko Pratama Ridzkyanto, Khoiron designed and con- terials such as personal protective equipment (PPE), am- ceptualized the study. Dewi Rokhmah and Khoiron collected data. bulance reference, and corpse screening. For hospitals Ricko Pratama Ridzkyanto analyzed data. Dewi Rokhmah, Ricko that receive PPE assistance and medicines from the go - Pratama Ridzkyanto, Khoiron discussed and interpreted the final re- vernment, deductions made from claims received. The sults. Ricko Pratama Ridzkyanto wrote the first draft of the manuscript. PPE and medicines purchased by the hospital must attach Dewi Rokhmah, Ricko Pratama Ridzkyanto, Khoiron revised and con- a purchase invoice and assistance from other sources. tributed to the final manuscript. The COVID-19 patients who get recovered (return status) with evidence of laboratory examinations (by the Acknowledgment COVID-19 prevention and control manual), for concomi- The researcher would like to thank the Regional Development Agency tant diseases that still require treatment, the benefits of of East Java Province for granting a permission to carry out this study. the next service are changed to the National Health

58 Rokhmah et al, Analysis of Government Budgeting for Health: Case Study of COVID-19 in East Java Province, Indonesia

References 6. Presiden Republik Indonesia. Undang-undang Nomor 24 tahun 2007 1. Ariﬁn D. Presiden tetapkan COVID-19 sebagai bencana nasional; Tentang Penganggulangan Bencana; [updated 2007 April 26; cited 2020 [cited 2020 April 20]. 2020 May 10]. 2. Gugus Tugas Pusat covid19.go.id. Peta sebaran COVID-19 JATIM; 7. Setyawan FEB. Sistem Pembiayaan Kesehatan. Saintika Medika. 2017; 2020 [cited 2020 April 22]. 11 (2): 119. 3. Presiden Republik Indonesia. Undang-undang Nomor 24 tahun 2007 8. Harmana WA. Faktor-faktor yang mempengaruhi pembiayaan kese- Tentang Penganggulangan Bencana; [updated 2007 April 26; cited hatan daerah bersumber anggaran pendapatan dan belanja daerah 2020 May 10]. tahun 2006. Jurnal Manajemen Pelayanan Kesehatan. 2006; 9(3). 4. Kementerian Kesehatan. Keputusan Menteri Kesehatan Republik 9. Kementerian Sosial Republik Indonesia. Upaya Kemensos terkait Indonesia Nomor Hk.01.07/Menkes/238/2020 Tentang Petunjuk pencegahan COVID-19; 2020 [cited 2020 April 20]. Teknis Klaim Penggantian Biaya Perawatan Pasien Penyakit Infeksi 10. Alam MA, Hossain SA. Effectiveness of social safety net programs for Emerging Tertentu Bagi Rumah Sakit Yang Menyelenggarakan poor people in the government level of Bangladesh. International Pelayanan Coronavirus Disease 2019; 2020. Journal of Social Sciences and Management. 2016; 3 (3): 153-8. 5. OECD. Disaster risk ﬁnancing: a global survey of practices and chal- 11. Presiden Republik Indonesia. Peraturan Presiden 72 tahun 2012 ten- lenges. OECD Publishing: Paris; 2015. tang Sistem Kesehatan Nasional; 2012.

59 Pratomo. Kesmas: Jurnal Kesehatan Masyarakat Nasional (National Public Health Kesmas: Jurnal Kesehatan Masyarakat Nasional Journal). 2020; Special Issue 1: 60-63 DOI: 10.21109/kesmas.v15i2.4010 (National Public Health Journal) From Social Distancing to Physical Distancing: A Challenge for Evaluating Public Health Intervention against COVID-19

Hadi Pratomo

Department of Health Education and Health Promotion, Faculty of Public Health, Universitas Indonesia, Indonesia

Abstract The coronavirus disease 2019 (COVID-19) pandemic has affected every country. Currently, no suitable vaccine or treatment has been identified; therefore, each country has attempted to issue appropriate policies, designed to reduce and prevent increases in the numbers of extreme cases. Transmission can be prevented by implementing social restrictions, also known as social distancing. The World Health Organization (WHO) has issued several methods for the prevention of transmission, including social distancing, washing hands with soap (or using hand sanitizer containing at least 70% alcohol), and using masks. Over time, the term social distance has changed to physical distance. Evaluating the impacts of different types of non-pharmacological interventions has been challenging.

Keywords: COVID-19, physical distance, social distance

The ongoing coronavirus disease 2019 (COVID-19) Nonverbal communication refers to communication pandemic has become closely associated with the intro- without words and encompasses messages developed by duction of the popular term “social distancing”, followed body motions, the use of space, and the use of sounds shortly by the emergence of the new jargon “physical dis- and touch. One dimension of nonverbal communication tancing”. These two terms are very closely related to the is kinesics, which refers to the study of body motions as public health emergency and quarantine protocols. a form of communication.2 The other dimension is prox- A public health emergency is an extraordinary situa- emics, a term proposed by the anthropologist Edward T. tion, during which a communicable disease rapidly dis- Hall, which refers to how individuals use and interpret seminates across different regions and even countries. space. One area of proxemics that is relevant to the cur- Based on the Indonesian Law, No 06, 2018, quarantine rent pandemic issue is distance. Both space and distance was defined as the isolation of a person or group of per- play significant roles in how individuals interact.3 sons who have been exposed to a communicable disease, Hall (1966) in Martinez et al.,3 defined that individu- regardless of the presentation of symptoms.1 als in a social situation used four distance zones namely intimate, personal, social, and public. The intimate dis- The History of Social Distancing tance represents an area in which persons can touch one Over the past 35 years, I have taught public health another, representing approximately 1.5 feet (45 cm) of students in a course on Health Communications. One of separation. Personal distance is defined as between 1.5 the required readings that we discussed was Health and 2.5 feet (45 – 75 cm) of separation, equivalent to ap- Communication: A Handbook for Health Professionals. proximately an arm’s length. When individuals are sepa- This textbook includes a section, titled, Nonverbal rated by 4 – 12 feet (120–360 cm), they are practicing Communication in Health Care Setting (Chapter 4).2 social distancing. Finally, when two individuals are sepa- This book was written by health communication expert rated by 12–25 feet (360–750 cm), this distance is re- Peter Guy Northouse, Ph.D and his wife Laurel Lindhout ferred to as public distance.3 Northouse, RN, MSN (a nurse) from western Michigan Social distance is currently being endorsed by World University in the United States of America. Health Organization (WHO) as one practice that can pre-

Correspondence*: Hadi Pratomo, Department of Health Education & Health Received : June 29, 2020 Promotion, Faculty of Public Health, Universitas Indonesia, Depok, West Java, Accepted : July 20, 2020 Indonesia, E-mail: [email protected], Phone: +62217863475 Published: July 31, 2020

Copyright @ 2020, Kesmas: Jurnal Kesehatan Masyarakat Nasional (National Public Health Journal), p-ISSN: 1907-7505, e-ISSN: 2460-0601, SINTA-S1 accredited, http://journal.fkm.ui.ac.id/kesmas, Licensed under Creative Commons Attribution-ShareAlike 4.0 International Pratomo, From Social Distance to Physical Distance: A Challenge for Evaluating Public Health Intervention against COVID-19 vent the transmission of COVID-19. This term originated peak attack rate of SARS.8 This reduction would be even in the field of health communication. Putting a social dis- more effective faster if physical distancing was combined tance between two people indicates that an individual is with other non-pharmacological interventions, such as 6 feet (1 foot= 30.48 cm or 0.305 m) away from another the use of masks, washing hands with soap, or using individual, which can prevent the spread of droplets from hand-sanitizer, according to the WHO recommendations. a patient suffering from COVID-19. In Indonesia, we are Epidemiology research has shown that physical distance unfamiliar with measurement in feet; therefore, I would has a strong association with the reduction of influenza- suggest that a distance of 6 feet is equivalent to approxi- like illnesses and the serum conversion of flu A (H1N1).8 mately 2 meters of separation. However, careful interpretations of these data should be made, as there was potential for bias. From Social Distancing toward Physical Distancing In the United Stated of America (USA), the stay-at- The Canadian Agency for Public Health,4 indicated home orders were not coordinated at the national level. that physical distancing refers to making changes in one's Fowler, et al.,9 analyzed publicly available data sources everyday routines, to minimize close contact with others, regarding the timing of stay-at-home orders and con- including avoiding crowded places and non-essential firmed the reported daily COVID-19 cases, at the county gatherings, avoiding common greetings, such as hand- level, for the USA. The results indicated that a coordinat- shakes, and limiting contact with people at higher risk ed, nationwide, stay-at-home order may have significantly (e.g., older adults and those in poor health). In addition, reduced the numbers of both infections and deaths maintaining a distance of least 2 arm lengths from other caused by COVID-19. In this case, stay-at-home orders individuals, as much as possible, is an important compo- reduced the infection growth rate and are the most ben- nent of physical distancing. eficial when the infection counts are still low.9 In con- The John Hopkins University,5 defined social distanc- trast, in the United Kingdom (UK), the implementation ing as a public health practice that aims to prevent sick of physical distance measures was widely adopted by the people from coming into close contact with healthy peo- UK public, which substantially reduced COVID-19 trans- ple, to reduce opportunities for disease transmission. mission. However, this decrease is projected, and will not While, the US Centers for Disease Control and occur immediately due to delays in the onset of sympto- Prevention (CDC),6 defines social distancing as remain- matic disease and hospitalization, in addition to delays in ing out of congregate settings, avoiding mass gatherings, these events being reported. Tracking behavioral changes and maintaining distance (approximately 6 feet) from can provide a more rapid assessment of the impacts of others when possible. Social life is a part of human to physical distancing measures compared with routine epi- survive. We could not live in an isolated world. Maria demiological surveillance.10 van Kerkhove, an epidemiologist from WHO urged that, The absence of evidence regarding the effectiveness “We're changing to say physical distance from social dis- of mask use from clinical trials should not be regarded as tance and that's on purpose because we want people to being equivalent to evidence of ineffectiveness. Xiao, et still remain connected”.7 Physical distancing represents al.,11 argued that cough etiquette (proper behavior when the maintenance of physical distance from other people, coughing and sneezing, such as covering your nose and to prevent the spread of COVID-19 while remaining so- mouth with a tissue or inner sleeve) is based on this con- cially connected to others, through the internet or social sideration, and not on evidence provided by clinical trials. media. Therefore, currently, the term physical distancing Cheng, et al.,12 stated that mass masking to control the is preferable to social distancing.7 viral source represents a useful and low-cost complement to social distancing and hand washing (with soap or 70% Physical Distancing as an Applied Public Health alcohol hand sanitizer) during the COVID-19 pandemic. Practice against COVID-19 These measures shift the focus from self-protection to al- Since COVID-19 is a relatively new disease, to assess truism and actively involve every citizen. In addition, the effectiveness of physical distancing, I attempted to these actions are considered symbols of social solidarity identify literature examining the impacts of physical dis- during the response to the global COVID-19 pandemic. tancing for the spread of another, similar disease, namely Various studies have examined the use of masks. severe acute respiratory syndrome (SARS). I found a Surgical masks are known to prevent the inhalation of study report by Ahmed, et al.,8 using certain criteria, a large droplets and sprays but are limited in their ability systematic review was conducted to look for publication to filter submicron-sized airborne particles.13 Because within 2000–2017, then it found 13 research models and SARS-CoV-2, the virus responsible for COVID-19, can two epidemiology studies. The research model indicated also be embedded in aerosols < 5 μm in diameter, evi- that physical distance could only reduce approximately dence remains necessary regarding whether surgical one-fourth (23%) of the attack rate and could reduce the masks are effective for preventing transmission. In one

61 Kesmas: Jurnal Kesehatan Masyarakat Nasional (National Public Health Journal). 2020; Special Issue 1: 60-63 study, conducted in Hong Kong, surgical mask use was 3. Rios-Martinez J, Spalanzani A, Laugier C. From proxemics theory to found to significantly prevent the transmission of corona- socially –aware navigation: a survey. International Journal of Social viruses and influenza viruses from asymptomatic peo- Robotics. 2015; 7: 137-53. ple.14 Based on reports by Esposito, et al.,15 more study 4. The Canadian Agency for Public Health. Physical distancing: actions remains necessary regarding the effectiveness of mask for reducing the spread of Covid-19; April 15, 2020 [cited 2020 May use. 3]. The impacts of physical distance on the spread of 5. John Hopkins University. What is social distancing and how can it COVID-19, in combination with other non-pharmaceuti- slow the spread of Covid-19; 2020 [cited 2020 May 3]. cal interventions, including staying and working at home, 6. Center for Disease Control and Prevention (CDC). Social distancing: frequent handwashing with disinfectants, wearing masks what is social distancing ?; July 15, 2020 [cited 2020 May 3]. in the community (mass masking), and practicing cough- 7. World Health Organization. Physical distancing; 2020 [cited 2020 ing etiquette, remain poorly understood. A study con- May 3]. ducted by Singh A, et al.,16 reported a mathematical 8. Ahmed F, Zviedrite N, and Uzicanin A. Effectiveness of workplace so- model showing that the implementation of non-pharma- cial distancing measures in reducing influenza transmission: a systema - cological interventions could potentially reduce viral tic review. BMC Public Health. 2018 [cited 2020 May 3]; 18: 518. spread. Study conducted in Hong Kong and the 9. Fowler JH, Hill SJ, and Levin, Obradovich N, Levin R. The effect of Netherlands revealed similar results.17-19 Study by stay-at-home orders on COVID-19 infections in the United States. Kucharski AJ, et al.,20 found that the application of self- medRxiv; Posted May 12, 2020. isolation, testing, and physical distancing would increase 10. Jarvis CI, Zandvoort KV, Gimma A, Prem K, CMMID Covid-19 the likelihood of controlling COVID-19 transmission. Working Group, Klepac P, et al. Quantifying the impact of physical However, these studies all have limitations, including distance measures on the transmission of Covid-19 in the UK. BMC large uncertainties regarding estimates and the duration Medicine. 2020; 18: 124. of infectiousness; therefore, further study must be per- 11. Xiao J, Shiu EYC, Gao H, Wong JW, Fong MW, Ryu S, et al. formed, which should be carefully evaluated by public Nonpharmaceutical measures for pandemic influenza in nonhealthcare health researchers, especially epidemiologists, who have settings-personal protective and environmental measures. Emerging a keen interest in this field of study. Infectious Disease. 2020; 26 (5): 967-75. 12. Kar KC, Tai HL, Chi CL.Wearing face masks in the community during Abbreviations the COVID-19 pandemic: altruism and solidarity. Lancet. Published COVID-19: Coronavirus Disease 2019; WHO: World Health online April 26, 2020. Organization; CDC: Centers for Disease Control and Preventions; 13. Migliori GB, Nardell E, and Yedilbayev A. Reducing tuberculosis SARS: Severe Acute Respiratory Syndrome. transmission: a consensus document from the World Health Organization regional for Europe. European Respiratory Journal. 2019 Ethics Approval and Consent to Participate [cited 2020 May 14]. Not Applicable 14. Leung NHL, Chu DKW, Shiu EYC, Chan KH, McDevitt JJ, Hau BJP, et al. Respiratory virus shedding in exhaled breath and efficacy of face Competing Interest masks. Nature Medicine. 2020 [cited 2020 May 14]; 26: 676–80. There is no competing interest. 15. Esposito S, Principi N, Leung CC, Migliori GB. Universal use of face mask for success against COVID-19: evidence and implications for Availability of Data and Materials prevention policies. European Respiratory Journal. 2020; 55: Not Applicable 2001260. 16. Singh A, Chandra SK and Bajpai MK. Study of non-pharmacological Authors’ Contribution interventions on COVID-19 spread. medRxiv. 2020 [cited 2020 May Hadi Pratomo as an author inisiated the paper with ideas and finally 14]. wrote the manuscript. 17. Cowling BJ, Ali ST, Ng TWY,Tsang TK, Li JCM, Fong MW, et al. Impact assessment of non-pharmaceutical interventions against coro - Acknowledgment navirus disease 2019 and influenza in Hong Kong: an observational The author would like to thank Ms. Paskalinda M. Y. Bandur STr. study. Lancet Public Health. 2020; 5 (5): E279-88. Keb., MKM, who provided support for literature review. 18. Backer JA, Mollema L, Klinkenberg D, de Melker HE, Van der Klis FRM, Van den Hof S, et al. The impact of physical distancing measu - References res against covid-19 transmission on contacts and mixing patterns in 1. Undang-Undang Republik Indonesia No. 06 Tahun 2018 Tentang the Netherlands: repeated cross-sectional surveys. medRxiv. Posted Kekarantinaan; 2018. May 20, 2020. 2. Northouse PG, Laurel L. Health communication: a handbook for 19. Prem K, Liu Y, Russell TW, Kucharski AJ, Eggo RM, Davies N. The health professionals. USA: Prentice Hall; 1985. effect of control strategies to reduce social mixing on outcomes of the

62 Pratomo, From Social Distance to Physical Distance: A Challenge for Evaluating Public Health Intervention against COVID-19

Covid-19 epidemic in Wuhan, China: a modelling study. The Lancet. tancing on reducing transmission of SARS-CoV-2 in different settings: 2020; 5 (5): E261-70. a mathematical modelling study. The Lancet Infectious Disease. 20. Kucharski AJ, Klepac P, Conlan AJK, Kissler SM, Tang ML, Fry H, et Published online June 16, 2020. al. Effectiveness of isolation, testing, contact tracing, and physical dis-

63 Oti et al. Kesmas: Jurnal Kesehatan Masyarakat Nasional (National Public Health Kesmas: Jurnal Kesehatan Masyarakat Nasional Journal). 2020; Special Issue 1: 64-69 DOI: 10.21109/kesmas.v15i2.3974 (National Public Health Journal) Traveler’s Infections: Understanding SARS-CoV-2 as a Potential Agent

Victor Baba Oti1*, Marina Ioannou2

1Department of Microbiology, Nasarawa State University, Keffi, Nigeria 2School of Life Sciences, University of Essex, Cholchester, the United Kingdom

Abstract Coronavirus disease 2019 (COVID-19) has become a major, global, public health challenge. Over 1,051,635 confirmed cases have been reported worldwide, and both local and international travelers are considered to represent populations at high risk of acquiring the infection. Many factors are involved in the spread of this viral agent, including travel to and from endemic areas, a history of contact with a traveler from an endemic country, the virus infection rate at the destination, individual health, and inadequate prevention and control measures. The virus is thought to be transmitted through respiratory droplets, generated by coughing or sneezing and spread through close contact with infected persons or contaminated surfaces. Diagnostic strategies include detection of antiviral antibodies, multiplex nucleic acid amplification, and microarray-based assays. Currently, no approved antiviral therapy or vaccine exists to treat or prevent the infection. Public health measures have been enforced, to slow spread of the virus, by governments. The World Health Organization (WHO) have recommended screening be performed at airports, for all travelers, before traveling to endemic countries and the restriction of travel to countries more than one thousand cases of infection. In response to the global outbreak, this review examines COVID-19 as a potential traveler’s infection.

Keywords: COVID-19, incidence rate ratio, social restriction, time series analysis

Introduction 19 to be a pandemic, due to its spread to almost all six Severe acute respiratory syndrome coronavirus 2 WHO regions.7 A reported 1,051,635 (and counting) (SARS-CoV-2) is an enveloped, single-stranded, positive- confirmed cases have been identified, worldwide, and sense, ribonucleic acid (RNA) virus that causes corona - both local and international travelers represent popula- virus disease 2019 (COVID-19), a zoonotic infectious tions at high risk of acquiring the infection.7,8 disease that has been declared a global, public health Coronaviruses usually cause mild respiratory infections; emergency of international concern (PHEIC).1,2 The in- however, the symptoms of SARS-CoV-2 infections can fection was reported to originate from Wuhan, Hubei range from mild, including fever, cough, and difficulty Province, China, in 2019, and has been linked to breathing, to severe, causing pneumonia and multi-organ Wuhan's Huanan Seafood Wholesale Market. Bats are failure. Elderly individuals and individuals with pre-ex- reportedly the major natural reservoir of the virus, and a isting medical conditions are at high risk of progressing 5-year study indicated the coexistence of highly diverse speedily and swiftly into acute respiratory distress syn- SARS-CoVs in bat populations found in caves in Yunnan drome, septic shock, and coagulation dysfunction, which Province, China.3 A recombination event may have facili - can result in death.1 This review examines SARS-CoV-2 ta ted the ‘spillover’ from the virus’s original host to a infect ions and COVID-19 as a potential traveler’s dis- new host, humans. The viral agent may have been disease. seminated, from bats to an unknown intermediate host, followed by the infection of human beings.4,5 The viral The Structure of Severe Acute Respiratory Syndrome infection has since spread to virtually all parts of the Coronavirus 2 (SARS-CoV-2) globe, due to travel and the global migration of infected SARS-CoV-2 also known as 2019-nCoV,2 is an en- and exposed individuals.6 On March 11, 2020, the veloped, single-stranded, positive-sense RNA virus, with World Health Organization (WHO) declared COVID- a 3’-poly-A tail and a 5′-cap structure. The name corona -

Correspondence*: Victor Baba Oti, Department of Microbiology, Nasarawa State Received : June 18, 2020 University, PMB 1002, Keffi, Nigeria, E-mail: [email protected], Phone: Accepted : June 20, 2020 +23 470 6965 7739 Published: July 31, 2020

Copyright @ 2020, Kesmas: Jurnal Kesehatan Masyarakat Nasional (National Public Health Journal), p-ISSN: 1907-7505, e-ISSN: 2460-0601, SINTA-S1 accredited, http://journal.fkm.ui.ac.id/kesmas, Licensed under Creative Commons Attribution-ShareAlike 4.0 International Oti et al, Traveler’s Infection: Understanding SARS-CoV-2 as a Potential Agent virus derives from the crown-like characteristic appearance under electron microscopy (corona is the Latin term for crown), due to the presence of spike glycoproteins on the envelope 9 (Figure1). SARS-CoV-2 is a strain of SARS-related coronaviruses, from the taxonomic perspective. SARS-CoV-2 be- longs to the family Coronaviridae, in the genus Betacoronavirus.11 The genetic material found in SARS- CoV-2 is approximately 30 kb in length, which makes it the largest known genome that has been identified in an RNA virus. The SARS-CoV-2 virus is one of seven Coronaviridae capable of infecting human beings, in addition to NL63, HKU1, 229E, OC43, MERS-CoV, and SARS-CoV.12,13 The genome of a typical coronavirus contains a minimum of six open-reading frames (ORFs). Approximately 70% of the viral genome encodes the polyprotein pp1ab, which is further cleaved into 16 non- structural proteins, which play roles in genome replica- tion and transcription through the viral-encoded chy- Figure 1. SARS-CoV-2 Morphology with the Minimal Set of Structural motrypsin-like protease (3CLpro), in synergy with one Proteins 9-10 or two papain-like proteases.14,15 The other 30% of the genome encodes four structural proteins, including spike (S), envelope (E), membrane (M), and nucleocapsid (N), iad of clinical features, predictors, a chest computed to- and additional helper proteins. The S protein plays a sig- mography (CT) scans showing pneumonia characteristics nificant role, mediating membrane fusion and receptor and others.23,24 As of March 19, 2020, no antibody- binding, which, in turn, determines the host tropism of based techniques have been developed, although serious the virus.16,17 ongoing studies are attempting to develop these techniques.22 Transmission Routes and Diagnosis of COVID-19 Epidemiological studies in Wuhan were the first out- Clinical Features of SARS-CoV-2 Infection break was reported, associated the virus with a sea food The viral agent gains entry into the respiratory tract market where live animals were sold, with many patients and infects the cells of the respiratory system,25,26 caus- having worked in, or visited the market.4,5 Subsequently, ing acute respiratory disease, with a high prevalence secondary cases begun to appear approximately ten days among travelers.27 The incubation period for the viral later.18 Although the new patients had no direct contact infection is approximately 2–14 days, with an average in- with the seafood market, contact tracing showed that cubation period of 5 days.19 The infection is usually they had contacts with inhabitants near the market.19 asymptomatic among those with a travel history to en- Advanced genetic and virologic studies have found that demic countries, but can also present with symptoms bats represent natural reservoirs of this viral agent.4,20 similar to those observed during flu infections, including Studies have demonstrated that most bat CoVs have simi - fever, dry cough, and difficulty breathing.14,28 When lar genomes as those found in beta-CoVs and alpha- these symptoms are present, the difficulty breathing and CoVs.19,21 associated chest pain and pressure persists, resulting in The virus can be identified through different labora- walking difficulties, confusion, and a bluish tint to the tory methods, including the rapid testing of lips and face. These symptoms indicate a critical situation Immunoglobulin G (IgG) and Immunoglobulin M (IgM) that requires immediate medical attention.14,29 Zhang, levels, electron microscopy, cell-culturing, and nucleic et al.,22 reported the presence of the virus in fecal and acid detection reverse transcriptase-polymerase chain re- blood samples, suggesting the possibility of multiple action (RT-PCR), which is currently the gold standard transmission routes. The identification of the viral recep- for SARS-CoV-2 testing and is performed on a nasopha- tor, angiotensin-converting enzyme 2 (ACE2), which is ryngeal sample. When an individual is confirmed to be often present in large quantities on enterocytes in the infected, contact tracing is performed, during which a de- small intestines and epithelial cells in the lung alveoli, is tailed history of all persons in contact with a confirmed likely to assist researchers in understanding infection patient is examined, using precise laboratory testing.1,22 routes and the pathogenesis of the viral agent.30 SARS-CoV-2 infections can also be determined by a myr-

65 Kesmas: Jurnal Kesehatan Masyarakat Nasional (National Public Health Journal). 2020; Special Issue 1: 64-69

Aspects of COVID-19 Epidemiology as a Traveler’s Prevention and Control of SARS-CoV-2 Infection Infection Preventive measures that have been implemented In December 31, 2019, the novel SARS-CoV-2 out- against the spread of the novel coronavirus include stay- break was first reported in Wuhan City, Hubei Province, ing at home, practicing social distancing (avoiding China,31 as pneumonia outbreak without a known causal crowded places), washing hands with soap and running agent. The WHO announced that the etiology was a new water, regularly, for at least 20 seconds, good personal coronavirus, which was temporarily referred to as2019- hygiene practices and the avoidance of picking or touch- nCoV, and was posited to be the causal agent for the in- ing the nose, eyes, mouth, and other parts of the face fection on January 12, 2020.32 Similar to SARS, the with unwashed hands.43-45 Recommendations by the COVID-19 outbreak is thought to have initiated at a local Centers for Disease Control and Prevention (CDC) in- seafood market, the Huanan Seafood Wholesale Market, cluded covering the nose and mouth with tissues when and 2/3 of the first 41 confirmed cases were linked to the sneezing or coughing or using the inside of the elbow market. Within a few weeks, the virus had spread to oth- when tissue availability is scarce.46 Social distancing, er countries, including those in Europe. Most SARS- which refers to people remaining at least 6 feet apart CoV-2 cases reported during the first 6 days (January 23– from one another, was introduced to reduce contact be- 28, 2020) were associated with direct contact with some- tween people carrying the virus and uninfected popula- one who traveled to or from Wuhan.33 In Germany, a tions. Workplaces and schools were closed, travel 33-year-old man (patient 1) became ill with cold and flu restrict ions were implemented, and mass gatherings of symptoms, on January 24, 2020, after attending a meet- more than 50 individuals were canceled.47 According to ing in Munich with a Chinese business partner, on the WHO and CDC, surgical masks should only be used January 20, 2020.21 The business partner was visiting when an individual is symptomatic or is administering from Shanghai and she did not experience any signs or care to infected or suspected-infected persons, such as symptoms of illness. In Italy, a Bayesian phylogenetic re- health workers.43,44 construction suggested that the virus found in Italy was Measures that benefit the community, such as the can- imported by Chinese travelers, who were infected before cellation of mass gatherings, social distancing, the closing they arrived in Italy.34 Japan identified its first case of vi- of schools, and the creation of plans that allow employees ral infection on January 16, 2020, associated with a to work from home can help mitigate the dissemination Chinese traveler from Wuhan.35 Australia’s first case was of SARS-CoV-2 infections, and these types of preventive identified on January 25, 2020, associated from a man measures have been recommended by different CDC who traveled to Wuhan.36 On January 20, 2020, the USA agencies, worldwide.46,47 Public health experts should identified its index case, a traveler who returned from provide travelers with information and guidelines regard- Wuhan, China.37 On January 24, 2020, France identified ing how they can mitigate their overall risks of viral in- its first confirmed case of the novel coronavirus, which fections and other respiratory complications, which can was also connected with a travel history to China.38 A be disseminated through travel agencies, conveyance o- traveler from Wuhan and Qom imported the first case of perators, travel health clinics, and at points of entry.46 the infection from China to Iran on January 19, 2020.39 The index case for Pakistan was identified on February Possible Treatments and Vaccine Candidates for 26, 2020, when a young man with travel history to COVID-19 Infection Karachi tested positive for the virus.40 On March 10, A variety of treatment methods and antiviral agents 2020, Turkey reported its index case, in a Turkish male are being explored for the potential treatment of SARS- who traveled to Europe.41 The initial report of viral in- CoV-2 infections, and some are progressing to the clini- fection in South Africa was March 5, 2020, in a patient cal trial stage.48 WHO has launched “Solidarity”, which who had traveled to Italy with his wife.42 The WHO has is a multi-country trial including 10 countries, in res - reported that the median age of people testing positive ponse to the COVID-19 pandemic, on March 2020.44 for the virus was approximately 45 years and that over The following drugs are being studied: chloroquine and two-thirds of those infected were males.18 The mortality hydroxychloroquine, ritonavir / lopinavir and remdesivir rate among confirmed positive cases was 4.5%, as of in synergy with beta interferon.45,49 Scientific reports e - March 25, 2020, and appears to range from 0.2%–15%, xist showing that remdesivir can be used to treat the viral depending on age group and other health-related infection,50 because it inhibits SARS-CoV-2 RNA tran- factors.18 The fatality rates differ among countries and scription, in vitro. over time, based on differences in the rate of diagnosis Chloroquine, a drug that is currently used to treat and due to differences in access to adequate healthcare malaria, is another potential drug that is currently being workers and facilities. tested in China, with positive preliminary evidence.4,51 Chloroquine and hydroxychloroquine can effectively stop

66 Oti et al, Traveler’s Infection: Understanding SARS-CoV-2 as a Potential Agent the effects of the viral agent, in vitro, and hydroxychloro- Availability of Data and Materials quine has been shown to be more potent than chloro- The datasets used and/or analysed during the current study are avail- quine, with a more tolerable safety profile.47 Chloroquine able from the corresponding author on reasonable request. and hydroxychloroquine have been listed as drugs with good preliminary outcomes for COVID-19 therapy, by Authors’ Contribution the Italian Pharmaceutical Agency (IPA) in March 17, Victor B. Oti conceptualized and designed the study. Victor B. Oti and 2020.46,52 Marina Ioannou searched the literature and prepared the manuscript. Currently, no vaccines are available for SARS-CoV-2 All authors reviewed the manuscript and approved the final manuscript. infections; however, vaccine development is crucial for inducing herd immunity and the possible eradication of Acknowledgment this disease.43 Various ongoing studies are examining We appreciate the financial support of Mrs. Augustina C. Oti. The au- mRNA, epitope, and S protein-RBD structure-based vac- thors dedicate this review to the blessed memory of P. B. Oti, PhD and cine candidates. Models of the human ACE2 protein in those who lost their lives due to COVID-19. transgenic mice and rhesus monkeys have been well- mapped for the creation of a vaccine, and some SARS- References CoV-2 vaccines candidates are already entering the clini- 1. Adhikari SP, Meng S, Wu Y, Mao Y, Ye R, Wang Q, et al. cal trial stage.53 In Seattle, USA, the first human trials Epidemiology, causes, clinical manifestation and diagnosis, prevention for a vaccine candidate began on March 16, 2020, with and control of coronavirus disease (COVID-19) during the early out- just four volunteers.54 The vaccine candidate contains a break period: a scoping review. Infectious Diseases of Poverty. 2020; harmless genetic code, copied from the SARS-CoV-2 9: 29. virus that causes disease. Recombinant interleukin-7 (IL- 2. World Health Organization. Emergencies preparedness, response: 7) therapy is also being investigated, as this protein plays novel coronavirus - China; January 12, 2020. a significant function in the reproduction and maturation 3. Cui J, Li F, Shi ZL. Origin and evolution of pathogenic coronaviruses. of lymphoid cells.55 Nature Reviews Microbiology. 2019; 17: 181-92. 4. Lu R, Zhao X, Li J, Niu P, Yang B, Wu H, et al. 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Functional assessment of cell entry and Ethics Approval and Consent to Participate receptor usage for SARS-CoV-2 and other lineage B betacoronavirus- Not Applicable es. Nature Microbiology. 2020; 5: 562–9. 12. Wu F, Zhao S, Yu B, Chen Y M, Wang W, Hu Y, et al. Complete Competing Interest genome characterisation of a novel coronavirus associated with severe Authors declares that there is no significant competing financial, pro- human respiratory disease in Wuhan, China. bioRxiv; 2020. fessional, or personal interests that might have affected the performance 13. Lai CC, Shih TP, Ko WC, Tang HJ, Hsueh PR. Severe acute respirato- or presentation of the work described in this manuscript. ry syndrome coronavirus 2 (SARS-CoV-2) and coronavirus disease- 2019 (COVID-19): the epidemic and the challenges. International Journal of Antimicrobial Agents. 2020; 55 (3): 105924.

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69 Sulistiadi et al. Kesmas: Jurnal Kesehatan Masyarakat Nasional (National Public Health Kesmas: Jurnal Kesehatan Masyarakat Nasional Journal). 2020; Special Issue 1: 70-76 DOI: 10.21109/kesmas.v15i2.3909 (National Public Health Journal) Handling of Public Stigma on COVID-19 in Indonesian Society

Wahyu Sulistiadi1, Sri Rahayu2*, Nanny Harmani3

1Department of Health Policy and Administration, Faculty of Public Health, Universitas Indonesia 2Postgraduate in Public Health Science, Universitas Muhammadiyah Prof. Dr. Hamka, Indonesia 3Program Study of Public Health, Faculty of Health Sciences, Universitas Muhammadiyah University Prof. Dr. Hamka, Indonesia

Abstract Coronavirus disease 2019 (COVID-19) patients, their families, health workers, and cemetery officials are not only haunted by tragedies of the new coronavirus but are also stigmatized by the community. Stigma can be very detrimental to social life because it can be long-lasting without proper social measures. This qualitative study examined some cases of stigma in Indonesia. The interview was broadcast both live and online by a private television station, in April 15, 2020, and supplementary informationwas obtained from reliable news stories published by various mass media and from interviews with various groups of people. We identified the limited availability of personal protective equipment among health workers, a public lack of clear understanding regarding COVID- 19, the distortion of news by various media, and a lack of clarity among those responsible for providing education, information, and communication. The government has not acted in a sufficiently prompt mannerto prevent the spread of imported infectious diseases, resulting in local transmission and creating various stigmasamong local communities. Although the infection has already begun to spread, the government must continue toensure the correct understanding and clear mechanismsfor how to prevent COVID-19 among the public.

Keywords: communication, COVID-19, education, information, public stigma

Introduction ing COVID-19, and confusing guidance regarding social- Available information regarding the global corona - ization provided by pubic officials resulted in adverse re- virus disease 2019 (COVID-19) pandemic was has been actions towards health workers, COVID-19 patients, and met with diverse responses among Indonesian society, re- patients’ families. sulting in the development of various public stigmas. The government attempted to reduce public turmoil Disinformation resulted in excessive caution, worries, with certain policies but did not provide sufficient infor- and fear that were not balanced with empathy and sym- mation to increase public understanding. In some areas, pathy for the victims.1 One nurse, who treated COVID- stigma cases developed surrounding COVID-19 patients, 19 patients and had isolated herself from her family, was patients’ families, and health workers. Almost five not welcomed into her neighborhood because her neigh- months have passed since the first case was detected, but bors feared she would spread the virus, despite her appli- the COVID-19 pandemic has not yet subsided. COVID- cation of the COVID-19 personal protective equipment 19 cases have been increasing since the disease was first (PPE) protocol. In another case, some nurses were evict- discovered, in Wuhan, China, in December 2019, and ed from their rented house because the owner feared that was declared a pandemic by the World Health they would infect him.2 The first patient in Indonesia was Organization (WHO) on March 11, 2020.4 By April 11, discovered and announced by the President of the 2020, more than 1.69 million people, from 203 coun- Republic of Indonesia, on March 2, 2020, which raised tries, had been infected, resulting in 102,000 deaths and public concern and worries associated with the surge in 376,000 recovered patients.5 virus transmission.3 By April 2020, one month after the Over time, the concerns and stigma associated with first case of COVID-19 was detected, more than 8,000 the COVID-19 pandemic have become more terrible than COVID-19-positive cases were confirmed in Indonesia. the virus itself. As stated by the WHO’s Director- Incorrect understanding, incomplete knowledge regard- General, Tedros Adhanom Ghebreyesus, stigma is a

Correspondence*: Sri Rahayu, Postgraduate in Public Health Science, Received : May 17, 2020 Universitas Muhammadiyah Prof. Dr. Hamka, Warung Buncit Raya Street No.17, Accepted : June 28, 2020 Pancoran, South Jakarta, Indonesia, Indonesia, E-mail: [email protected], Published: July 31, 2020 Phone: +62- 878-8779-1985

Copyright @ 2020, Kesmas: Jurnal Kesehatan Masyarakat Nasional (National Public Health Journal), p-ISSN: 1907-7505, e-ISSN: 2460-0601, SINTA-S1 accredited, http://journal.fkm.ui.ac.id/kesmas, Licensed under Creative Commons Attribution-ShareAlike 4.0 International Sulistiadi et al, Handling of Public Stigma on COVID-19 in Indonesian Society frightening enemy and is more dangerous than the coro- individuals work late into the night and are not allowed navirus.4 The stigma associated with the coronavirus that to return home fortwo tofive days due to the enactment emerged in local communities, threatening those who of the Large Scale Social Restrictions that require a five- have tested positive for COVID-19 and the health workday isolation period for COVID-19-exposed individuals. ers who have been at the forefront, handling the out- However, COVID-19 cases continue to spread, indicating break. As a result, news stories reporting the refusal of that means the community has not obeyed government medical personnel to treat COVID-19 patients in their regulations. The very empathetic driver may ask the pub- homes, the public rejection of the dead bodies of health lic to stay at home so that he will not be required to con- care workers, and individuals throwing stones at ambu- tinue delivering the bodies of COVID-19 patients. The lances carrying COVID-19 patients are not uncommon.6 burial regulations regarding COVID-19 patients in On one hand, these cases indicate public awareness Indonesia mandates respect for the body, by avoiding the and vigilance regarding the dangers associated with use of mass graves. The government protocol requires COVID-19, and the public is beginning to understand bodies to be buried, without the presence of family and not to underestimate COVID-19. On the other hand, the visitors. Bodies can be buried in their family villages,but fear of coronavirus and the efforts to maintain distance the remaining protocols must be followed. have been detrimental to humanity. Social distancing and Because of some of the described stigma cases, the re- physical distancing, should not result in the exclusion of searcher attempted to determine and analyze how public people or the rejection of dead bodies. The coronavirus stigma associated withvarious groups affects health work- outbreak is predicted to continue for an extended period. ers and other support staff who treat COVID-19 patients, Although some people would prefer to view themselves the patients and their families, mass media exposure, and as safe and protected, we cannot predict whether this dis- the understanding of COVID-19 in Indonesia. ease will eventually affect ourselves or the people we know. Therefore, negative labeling caused by excessive Method fear will only result in the loss of our sense of solidarity. This study utilized a qualitative approach to some case Many studies have demonstrated that stigma can studies in Indonesia, by gathering information from in- worsen a disease,which has also been reported for the so- terviews that were broadcast live and online by one pri- cial stigma associated with COVID-19. Stigma is a major vate television station, on April 15, 2020. These inter- cause of discrimination and exclusion, affecting individ- views were supplemented with information from reliable uals’self-esteem, disrupting family relationships, and lim- news sources and various mass media, including web- iting their abilities to socialize and obtain housing and sites, such as kawalcovid19.id, galamedianews.com, jog- jobs.7 Stigma can take the form of social rejection, gossip, ja.tribunnews.com, nationalgeographic.grid.id, palu.tri- physical violence, and denial of service. Naturally, we at- bunnews.com, jateng.tribunnews.com, and aceh.tribun- tempt to distance ourselves from people who can infect news.com; online media platforms, such as liputan6.com us. This disease avoidance reaction can result in people and kompas.com; and live discussions presented by ‘Mata distance themselves physically from someone they believe Najwa’ on Trans7 TV. to be suffering from an infectious disease.8 Stigma also This study was conducted during the COVID-19 pan- arises from the belief that terrible circumstances befall demic, so the researcher could not perform face-to-face people who make mistakes. This logical fallacy can interviews. Primary information was obtained through in- causepeople to believe that those who have become interviews, moderated by virtually by a television channel. fected with a disease have done something wrong. People The data were collected and analyzed, to explore think that perhaps individuals who become infected with problems associated with COVID-19 and to evaluate the COVID-19 do not wash their hands properly, touch their perceptions and experiences of COVID-19 patients and faces too often, or do not maintain social distancing. caregivers, and the environment surrounding them until These beliefs are especially common among individuals the patients have passed away. who believe they control their own destinies and that if The researcher framed the results of the interview to one does everything properly, one will not get infected. coincide with the concept of this study and performed a However, we do not live in such a world. Although we triangulation of the information provided during inter- can attempt to avoid COVID-19 by washing our hands views with information obtained from reputable online for 60 seconds, instead of 20 seconds, the risk of infect- media sources. The primary informants were professional ion remains the same. and public figures, including the governor, mayor, the Some individuals, such as ambulance drivers, must head of the Indonesian Medical Association, the head of handle COVID-19 corpses daily, and these individuals the Indonesian Nursing Organization, sociology experts, are required to utilize PPE when delivering dozens of psychologists, police, and village leaders. bodies to graves from several hospitals in Jakarta. These

71 Kesmas: Jurnal Kesehatan Masyarakat Nasional (National Public Health Journal). 2020; Special Issue 1: 70-76

Table 1. Characteristics of the Informants

Informant Representative from Sex Media Position

Informant-1 Bandung City Male Website City regent Informant-2 Psychologist Male Website Practitioner Informant-3 Community leader Male Website Head of a village Informant-4 Indonesian Nursing Profession Organization Male Website Chairperson Informant-5 Governor Central Java Male TV, Website Governor Informant-6 Policeman Male TV, Web Head of an office Informant-7 Sociologist Male TV Lecturer Informant-8 Indonesian Medical Association Male TV Chairperson

Results workers only use standards PPE in isolation and ICU The information in this study was obtained from vari - rooms.”12 (Informant-4) ous informants,with different backgrounds and characteristics, as shown in the Table 1. “The residents fear the exposure to the coronavirus.”11 The informants’ perceptions of the COVID-19 factors (Informant-3) that cause stigma associated with excessive fear and worry, the factors that result in the emergence of stigma, and c. Efforts to eliminate the stigma of health workers, the efforts being made to eliminate stigma were evaluat- COVID-19 patients, and their families; ed. “There should be more support from the people around a. Public perceptions ofthe health workers who serve the patient. Not only moral support, but also motiva- COVID-19 patients and their families; tion, prayer, and positive energy are needed for the pa- “Patients experience heavy days and must undergo tient to go through various healing stages and meet their treatment alone in the hospital. So, he was very sorry needs for at least 14 days so that patients can isolate when there are people who push people suffering from themselves optimally. A patient who is positive without COVID-19 away socially. There are even residents who severe symptoms must inform the community to be alert refuse the COVID-19 corpse.”9 (Informant-1) and anticipated.” Informant-1 suggested “living healthy with balanced nutrition, frequent hand-washing, wear- “Because of the wrong perceptions and excessive fear ing masks when outside of the house, and keeping a from the community in her village in Ungaran, Central distance from others”.9 (Informant-1) Java, which was also triggered by village leaders, caused the village members to reject the nurses’ bodies in their “Efforts can be done with educating the public by role hometown, the nurse who was a fighter on the front models, delivering positive charged news such as people battle against COVID 19. The community refused be- who have recovered, the government should convey ap- cause they were afraid of being infected by a body propriate information and applying coping strategies buried in the area. The village’s head provoked the com- (individual efforts to cope with pressure or problems) munity to reject the body due to fear the virus might that are adaptive to the community.”10 (Informant-2) spread through the water under the ground. The community also refused the body because the deceased’s res- “There should be systematic handling of regional heads, idence was not initially in their village.”10 (Informant- religious leaders, TNI-Polri, and other parties in moving 2) together." He continued "all health workers use PPE according to standards not only those in isolation and “The residents fear the exposure to the corona - ICU.”12 (Informant-4) virus.”11(Informant-3) “[We] have coordinated with various parties so that b. Factors causing stigma against health workers who nurses, doctors, and medical personnel who died from serve COVID-19 patients and their families; COVID-19 are buried in the Heroes’ Cemetery in “The influencing factors are the low level of knowledge Central Java, anticipating a repeat rejection of the body about medical facts related to COVID-19, the low level including readiness for place and administration.”13 of education, and the differences in perceptions between (Informant-5) one person and another.”10 (Informant-2) “[To] increase the sense of humanity and togetherness, “Education regarding the handling of COVID-19 corpse the officials, together with security forces, should ensure in the community is still lacking. Currently, health that the government has handled it according to proce-

72 Sulistiadi et al, Handling of Public Stigma on COVID-19 in Indonesian Society

dures so that it does not endanger the community, and heads, religious leaders, and Indonesian Medical the village administration allocates village funds to help Association.” Informing the public is not easy, even- the family’s basic needs because they undergo an inde- though when information is delivered by competent indi- pendent quarantine.”11 (Informant-6) viduals. Another interesting case was reported in Banyumas, “The community perceives that people who died from Central Java. A positive attitude was identified in COVID-19 would still transmit the coronavirus; there- Banyumas, and the Regent participated in burying the fore, community leaders and local officials are needed body of a COVID-19 patient because of the previous re- to provide material and spiritual support to the deceased fusal from the community. The governor intervened, patient’s families or confirmed positive patient’s fami- apologizing to the families of the health worker, engaging lies.” (Informant-7) indirect socialization, and asking epidemiologists and virus experts from well-known campuses, fatwas from re- “All COVID-19 corpse has followed the protocol of the ligious leaders, village heads, and village officials to pro- burial screening that guarantee to not spread the virus vide information and education to the public. The gover- because starting from the corpse wrapping until the bu - nor sent a proposal to the president of Indonesia suggest- rial, disinfectant is used several times and tightly ing that the country pay respects and show appreciation closed.” (Informant-8) to health workers who have died while fighting against COVID-19 by burying them in the Heroes Cemetery. In According to Kompas media, on April 11, 2020, a addition, six professional health organizations in nurse died from COVID-19 in a government hospital in Indonesia released a joint statement, asking for the era- Central Java while struggling to help her patients. The sure of the stigma and discrimination displayed against nurse’s body was intended to be buried in her village, in health workers who fight COVID-19. The COVID-19 pa- Ungaran, beside her father’s grave. Because of the wrong tients’ homes have also been stigmatized as presenting a perceptions and excessive fear among the community in transmission risk to surrounding communities. The gov- her village, in Ungaran, Central Java, which was also trig- ernor’s effort to show appreciation to medical staff that gered by the village leaders, the village members rejected have died while dedicating themselves to COVID-19 pa- the nurse’s body. The community refused the corpse be- tients included the suggestion of presenting these indi- cause they were afraid of being infected by a body buried viduals with a Hero Award by the President. in the area. The village’s head provoked the community In Lampung, COVID-19 patientsare rejected in one to reject the body because of fear that the virus might area but accepted in another area. The local community spread through the water, underground. The community leaders in Lampung (‘RT’/neighborhood and ‘RW’/sub- also refused the body because the deceased did not live in village) would not help the first individual who died from their village. The issues and opinions that arise without COVID-19. Residents rejected the body, so his funeral proper understanding can lead to excessive fear. Another was delayed for more than 24 hours. However, for the nurse, from Dr. Kariadi General Hospital, Semarang who second case of death due to COVID-19 in Lampung, the died while treating COVID-19 patients, was rejected residents worked together to prepare the funeral in the from Sewakul Public Graves; thus, the body was eventu- Sekicau Village, Sekicau District, West Lampung ally buried in a family funeral atDr. Kariadi Hospital in Regency, in April 4, 2020, and the body was buried in Semarang. One informant, a psychologist at the Faculty the Sri Galuh Environment Public Graves in April 5, of Education at the University of Persatuan Guru 2020. Solidarity was essential in the face of the COVID- Republik Indonesia (PGRI) Semarang, stated that “the 19 pandemic. growing trend in the COVID-19 case has made the public worried, plenty of inaccurate information and reporting, Discussion community misunderstanding creates a negative stigma Stigma in society can bediverse, differing case by case; to Orang Dalam Pemantauan/ODP (Person Under however, the sources of stigma tend to be similar, includ- Surveillance), Pasien Dalam Pemantauan/PDP (Patient ing a lack of information and the social environment. Under Supervision), and COVID-19 positive patients and Stigma refers to the negative labeling of a person due to their families.” Learning that the nurse died from an environmental influence, which can be reduced or COVID-19 resulted in rejection from the public because eliminated by implementing an effective strategy. The le- of the stigma that the virus might spread if the corpse vel of stigma associated with COVID-19 is based on three was buried in their hometown. main factors: 1) the disease is new and many factors re- Furthermore, “stigma in the form of rejection, exclu- main unknown; 2) we are often afraid of the unknown; sion, ridicule, and harassment still exists, even though and 3) the fear of the unknown can easily be associated the socialization has been carried out by several regional with ‘others’. Understandably, confusion, anxiety, and

73 Kesmas: Jurnal Kesehatan Masyarakat Nasional (National Public Health Journal). 2020; Special Issue 1: 70-76 fear regarding COVID-19 exist among the public. of this response is that the community has made use of Unfortunately, these factors canalso fuel harmful stereo- social media to communicate and discuss ideas in real- types.14 An effective strategy, such as strong interven- time, enabling any interested member of the public to tions from the central/regional government, religious follow the data analysis and commentary provided by ex- leaders, and security forces, is necessary to eliminate the perts regardingoutbreak control, genomic epidemiology, negative stigma associated with COVID-19, reduce com- virus evolution, and coronavirus pathogenesis. Providing munity anxiety, improve the status of victims, andopti- appropriate information, truth-telling, and transparent mize the resources ofthe community.15 Therefore, the pa- actions can augment the sense of civic responsibility and tient’s families and the health workers who survive the willingness to volunteer among the public.16 should not be isolated from the community because of Information that reﬂects real conditions demonstrates stigma. Even if one does not want to help these indivi - the trust in society to judge situations fairly. duals, patients and their families should not experience additional stress associated with stigma, judgments, and 2. It is not social isolation even insults. Social distancing is a term that is used to restrict public activities in an area. Social distancing aims to prevent 1. Stigma elimination the spread of coronaviruses, which can be transmitted Stigma can damage mental health and worsens the through small droplets formed by coughing or sneezing. condition of someone suffering from an illness. Being Maintaining physical distance does not mean that one viewed wrongly by people can cause anxiety, stress, and should cut off social contacts with others; thus, the WHO even depression. Both stigmatized individuals and those has changed the phrase social distancing to physical dis- who attempt to protect people from stigma can experi- tancing, to encourage global society to maintain social ence anxiety and stress. contacts with family and others while maintaining a phy- Stigma affects people who are sick, people who have sical distance. Although we should maintain distance relationships with sufferers, and people who directly in- from COVID-19 patients or those who are still being teract with the disease, daily. Family members and health monitored, we can continue to communicate with them care providers who treat patients with high-risk diseases through other media,without being physically close. We experience stigma during pandemics. During the can call or text our friends, relatives, or neighbors, espe- COVID-19 outbreak, stigma was also directed at people cially those who are sick. We can also share the anxiety who have traveled from areas affected by the pandemic. we experience with people we trust or with experts, Stigmatizing anyone during a pandemic poses a threat through cyber space. Although stigma is a reaction de- to everyone. Study on HIV, Ebola, Hansen’s Disease, and signed to avoid illness, stigma is not sustainable. Stigma other infectious disease epidemics have shown that stig- makes us scattered, but the COVID-19 pandemic re- ma can be an obstacle to disease treatment. People who minds us that we are all connected. We are all susceptible worry that they will be socially ostracized if they are sick to this virus, which should make us more united. We tend to be reluctant to undergotesting for an illness or to must remember that our enemy is COVID-19, not the seek treatment if they experience symptoms. sufferer. Prevent and ﬁght the disease, not the person.17 Not surprisingly, some patients being monitored (PDP) escaped from the hospital for fear of being positive 3. Clear education and information for COVID-19. Logical fallacies may lead these individu- The government should massively and comprehen- als to believe that they cannotbe infected with the disease sively disseminate proper information, education, and because they have not made mistakes and have taken pre- communication regarding COVID-19. Informing the cautions to avoid disease. public regarding the identities of those who are affected Education is one of the most effective ways to stop and those who are handling COVID-19 is not neces- the stigma. Regional leaders in centers with positive sary.18 The provision of education to the right target sus- COVID-19 cases must be open regardingtheir diagnoses, ing appropriate cultural mechanisms for the local com- to help normalize the disease. Similarly, celebrities and munity can increase knowledge and eliminate negative famous individuals who suffer from COVID-19 should stigma.19 For example, for People Living With HIV- also educate the public through social media. Posts on AIDS (PLWHA), reducing negative stigma against them social media from celebrities who suffer from illness tend requires an increase in the available knowledge regarding to help lift taboos. Their fans will be more intrigued if HIV/AIDS.20 they discover that people they admire can also suffer from COVID-19.The trust that develops fromthis open sharing 4. Communication of information should not be broken, as the response to Communication is the process of transmitting infor- future outbreaks could be at stake. Another characteristic mation and common understanding, from one person to

74 Sulistiadi et al, Handling of Public Stigma on COVID-19 in Indonesian Society another.21 Therefore, the recipient of the information can Conclusion make strategic decisions by considering the conditions In general, people in Indonesia did not clearly under- and situations (space and time) being faced into account, stand the COVID-19 epidemic, including transmission, which can affect change in the public audience. management, and how to avoid it. This misunderstanding Establishing a communication strategy should consi - can extend the pandemic and the length of large-scale so- der several components. ‘Who delivers the message?’ not cial restrictions. The central or regional government, to- everyone is free to convey negative stigma. ‘What mes- gether with local leaders/religious leaders and the local sage should be conveyed?’ health workers and other sup- security apparatus, have the responsibility of delivering porting staff on the front line serve wholeheartedly, and education, precise information, and accurate and appro- victims who have died cannot transmit the COVID-19 priate communication strategies that align with the cul- virus because the host is not alive. The communicators ture of the community, to increase community empathy should always ask the community to live according to and sympathy. The government and community must de- Healthy Clean-Living Behavior. ‘What media does issue- velop strategic, concrete, and decisive policies that are s?’ by utilizing media and mass media networks and hold- not confusing to the public and learn from the success of ing webinar forums, the direct delivery of information other countries’ experiences with the control of COVID- can be performed by experts or ordinary people. ‘Who is 19 transmission. the communicant?’ this message should be targeted to all elements of society. ‘What effect is expected?’ the ex- Abbreviations pected effect is that the community implements Healthy COVID-19: coronavirus Disease 2019; WHO: World Health Clean-Living Behaviors, creates a positive stigma, and Organization; PPE: Personal Protective Equipment; ODP: Orang provides motivation and empathy for health workers, de- Dalam Pemantauan (Person Under Surveillance); PDP: Pasien Dalam ceased victims, and their families.22 Pemantauan (Patient Under Supervision); ICU: Intensive Care Unit; TNI: Tentara Nasional Indonesia (Indonesian National Army); Polri: 5. Assistance from the government and security appara- Kepolisian Negara Republik Indonesia (National Police of Republic of tus Indonesia); PGRI: Persatuan Guru Republik Indonesia (Teachers Raising local champions in the community would sup- Association of the Republic of Indonesia) port health workers. Creativity, led by community leaders and government officials,can increase empathy and im- Ethics Approval and Consent to Participate prove understanding. Anxiety and fear can overcome em- Not Applicable pathy and sympathy when the public is presented with misinformation. Without empathy, the attitude that Competing Interest emerges in response to COVID-19 patientsis likely to be The author declares that they have no competing financial interests or avoidance and stigmatization of patients, their families, personal relationships that might have affected the performance of the and health workers. The sympathy deficit results in nega - work reported in this manuscript. tive stigma and can be discriminatory. Availability of Data and Materials 6. Best practice campaign Data and information supporting this writing are available from direct In Cimahi, a COVID-19-positive patient was assisted interviews broadcast directly tothe public that can be viewed and con- by his neighbors and his surrounding community through firmed. a majlis ta’lim (women’s association). They provided food to patients and their families, who were isolated in Authors’ Contribution their homes. This support makes the patient and family Wahyu Sulistiadi and Sri Rahayu conceptualized and designed the study feel content, which speeds the healing process. To sup- and prepared the manuscript. Sri Rahayu and Nanny Harmani searched porting the patient to perform tests himself, the commu- the literature and analyzed the data. All authors reviewed the manu- nity supported him with an N95 mask, even though these script and approved the final manuscript. were difficult to find at the time. The patient’s other fami - ly members had different religions and beliefs, indicating Acknowledgment that tolerance is crucial for public health. The communi- We would like to thank the Center for Education and Community ty’s participation, led by the head of the RT, demonstrat- Services, Faculty of Public Health, Universitas Indonesia for supporting ed empathy, and providing correct information to the this research until the completion of this manuscript. community can move the heart and soul of the community to generate humanitarians who will fight for the sake References of public health. 1. Prayitno P. Hoaks menyebar di tengah wabah corona Covid-19, apa

75 Kesmas: Jurnal Kesehatan Masyarakat Nasional (National Public Health Journal). 2020; Special Issue 1: 70-76

solusinya?. liputan6.com; March 28, 2020. 14. World Health Organization. Social stigma associated with Covid-19; 2. Mantalean V. Rawat pasien Covid-19, tenaga medis diusir dari kos 2020. hingga harus menginap. KOMPAS.com; March 25, 2020. 15. Ferrie J, Miller H, C.Hunter S. Psychosocial outcomes of mental illness 3. Al Khasni I. Kisah pasien pertama COVID-19 Indonesia yang diu- stigma in children and adolescents: a mixed-methods systematic re- mumkan Presiden Jokowi, sembuh berbekal ini. TribunJogja.com; Mei view. Children and Youth Services Review. 2020; 113: 104961. 14, 2020. 16. Editorial. Rapid outbreak response requires trust. Nature 4. Widyaningrum GL. WHO tetapkan COVID-19 sebagai pandemi glob- Microbiology. 2020; 5: 227–8. al, apa maksudnya?. Nationalgeographic.co.id; March 12, 2020. 17. Fathriani L. Melawan stigma Covid-19. Serambinews.com; April 16, 5. Saputro I. Update corona di dunia 11 April 2020: 210 negara terinfek- 2020. si, ada 1,6 juta kasus, Amerika terbanyak. Tribunnews.com; April 11, 18. Dewan Perwakilan Rakyat Republik Indonesia. Komisi IX minta pe- 2020. merintah penuhi kekurangan APD bagi pejuang Covid-19. dpr.go.id; 6. Adelia L. Viral petugas pemakaman jenazah pasien corona dilempari April 3, 2020. batu oleh warga. TribunJateng.com; April 3, 2020. 19. Yang F, Yang BX, Stone TE, QinWang X, Zhou Y, Zhang J, et al. 7. World Health Organization Regional Ofﬁce for Europe. Stigma and Stigma towards depression in a community-based sample in China. discrimination; 2020. Comprehensive Psychiatry. 2020; 97: 152152. 8. Michaels PJ, López M, Rüsch N, Corrigan PW. Constructs and con- 20. Situmeang B, Syarif S, Mahkota R. Hubungan pengetahuan HIV/AIDS cepts comprising the stigma of mental illness. Psychology, Society, & dengan stigma terhadap orang dengan HIV/AIDS di kalangan remaja Education. 2012; 4 (2): 183–94. 15-19 tahun di Indonesia (analisis data SDKI tahun 2012). Jurnal 9. Awal B. Jangan ada stigma penderita dan keluarga Covid-19. galame- Epidemiologi Kesehatan Indonesia. 2017; 1 (2): 35–43. dianews.com; April 16, 2020. 21. Lunenburg FC. Communication: the proess, barrers, and improving ef- 10. Kompas.com T. #Update-Virus-Corona-11-April-2020. Kompas.com; fectiveness. Schooling. 2010; 1 (1): 1–11. April 11, 2020. 22. Agung Suciono. Strategi komunikasi manajemen Persebaya dalam upa- 11. Penolakan pemakaman jenazah Covid-19. kawalcovid19.id; 2020. ya menghilangkan stigma negatif “Bonek”. Repository Stikosa AWS. 12. Azanella LA. Penolakan jenazah pasien Covid-19, mengapa bisa terja- 2017. di?. Kompas.com; April 13, 2020. 13. Agriesta D. 11 Pasien positif corona meninggal di Jateng pada 3 April, ini penjelasan Ganjar. kompas.com; April 4, 2020.

76 Nastiti et al. Kesmas: Jurnal Kesehatan Masyarakat Nasional (National Public Health Kesmas: Jurnal Kesehatan Masyarakat Nasional Journal). 2020; Special Issue 1: 77-84 DOI: 10.21109/kesmas.v15i2.3953 (National Public Health Journal) Analysis of Epidemiological Surveillance Activity of the COVID-19 at Surabaya Airport Indonesia on January 2020

Rizma Dwi Nastiti1, Kurnia Dwi Artanti1*, Achmad Faridy Faqih2

1Department of Epidemiology, Faculty of Public Health, Universitas Airlangga, Surabaya, Indonesia 2Surabaya Port Health Office Class I, Juanda International Airport, Surabaya, Indonesia

Abstract The Surabaya Port Health Office (PHO) Class I is tasked with the disease prevention by detection, response and protection at entrance gates for the sea and airports and over the state cross-border posts regarding the situation of COVID-19 pandemic. This analysis aimed to assess activities of early warning alert and response system to COVID-19 at Juanda International Airport on January 2020. The method used includes interviewing four informants, studying of docu - ments and directing field-observation by following activities of PHO, who supervise, inspect General Declarations, distribute, and collect the Health Alert Card (HAC) and monitor body temperature of travelers. The analysis uses a system approach and 4M model with modification by adding time, technology and information variables. Activities in the early warning alert and response system of COVID-19 are in accordance with the Preparedness Guidelines by the Indonesian Goverment. The outputs of reported activities have been classified as appropriate. The HAC form is lacking as a source of COVID-19 surveillance, address information part is often being misinterpreted by travelers. It is necessary to add additional questions regarding the destination address of travelers, and to educate on how to fill HAC correctly so that the effectiveness of HAC can be maximized.

Keywords: airport, COVID-19, epidemiology, surveillance, screening

Introduction COVID-19 patients has been quite rapid and has spread In December 31, 2019, the World Health both nationally and internationally. In January 30, 2020, Organization (WHO) China Country Office reported a WHO announced the Public Health Emergency of case of pneumonia of unknown etiology in Wuhan City, International Concern (PHEIC) status regarding COVID- Hubei Province, China. In January 7, 2020, China identi- 19. PHEIC is declared when there is an outbreak of dis- fied this pneumonia as a new type of coronavirus (novel ease that is a public health risk, that can spread across coronavirus, 2019-nCoV). In February 12, 2020, the countries and that potentially requires a coordinated in- WHO changed the disease name from 2019-nCoV to ternational response. Coronavirus Disease 2019 (COVID-19). COVID-19 has since spread to other countries in the The SARS-CoV-2 coronavirus is a new type of virus world. As of March 2, 2020, WHO reported that there that has never been identified before in humans. were 88,948 patients with confirmed cases of COVID- Transmission of COVID-19 has been classified as inter- 19. 80,174 of them came from the epicenter in China, human transmission but is still limited to the patient's and 8,774 people were spread over 64 other countries. family, health care workers who treat patients, and those Chinese deaths were put at 2,915, with a further 128 who have had close contact with confirmed cases. deaths outside of China; the crude fatality rate (CFR) COVID-19 is less severe than SARS and MERS. was 3.4%.2 Indonesia announced its cases of COVID-19 However, a rapid increase in the number of people with on March 2, 2020. COVID-19 disease and evidence of human-to-human Indonesia has numerous entrances to the territory as transmission means that COVID-19 is more easily trans- the in and out access of risk factors for the spread of dis- mitted than SARS and MERS.1 ease and health problems. Anticipating the threat of glo - Since it appeared in December 31, 2019 until the end bal disease, especially in terms of public health, is one of of February 2020, the increasing number of cases of international concern. The International Health

Correspondence*: Kurnia Dwi Artanti, Department of Epidemiology, Faculty of Received : June 1, 2020 Public Health, Universitas Airlangga, Dr. Ir. H. Soekarno Street, Surabaya, Accepted : June 20, 2020 Indonesia, E-mail: [email protected], Phone: +62-857-3029-9854 Published: July 31, 2020

Regulations (IHR) of 2005 are the guideline for through monitoring the arrival of transport vehicles, peo- Indonesia to increase its capacity and capability in health ple and goods in Surabaya PHO Class I was completed surveillance and response and in health quarantine in the through a system approach (input, process, output). Here region and at the entrances at both ports, airports, and is the description of the subsystem: the State Cross-border Post. 1. Input Health Surveillance at the State Entrance is one of the Those included in the input section are man, method, responsibilities of the Port Health Office (PHO). The material, machine, time, technology, and information. PHO has the task of carrying out prevention of entry and 1) Man exit of diseases, potential outbreaks, epidemiological sur- Data collection in the early detection and alert system veillance, quarantine, environmental health impact con- of COVID-19 at Juanda International Airport involved trol, health services, drug, food, beverages, cosmetics, 24 Surabaya PHO Class I employees in the working area medical devices, and addictive substances control as well of the Airport. This consisted of a team in each work as averting new diseases and those that are reemerging, shift with a total of four people, involving a doctor, a or linked to bioterrorism, biological, chemical, or radia- nurse, an environmental risk management expert, and a tion protection in the working area of airports, ports and quarantine control and epidemiological surveillance ex- national land borders. pert at the quarantine post at Terminal 2, which serves One of the PHOs in Indonesia is PHO Class I in international arrivals. Due to increased awareness and Surabaya, East Java, which has five working areas, name- efforts to prevent the entry of the COVID-19 virus by the ly Tanjung Perak Sea Port, Juanda Airport, Gresik Sea arrival of people from abroad, there are additional staff Port, Kalianget Sea Port and Tuban Sea Port. and training in the implementation of activities with de- Epidemiological surveillance is conducted by the tails as follows: Surabaya Port Health Office Class I, and one of its rou- a. Adding a further three people from other health sec tine surveillances is of transit via sea and air. The surveil- tors as Human Resources assistance. lance is carried out through supervising the traffic of peo- b. Improving the quality of human resources by brief ple, goods, and transportation equipment. ing by the duty officer. Implementation of IHR (2005) at the state entrance c. Briefing on the use of Personal Protective Equipment is the responsibility of the PHO along with all agencies at (PPE) and early detection devices for negative pres the state entrance. In maintaining the state entrance, sure transport capsule (evacuation capsules). PHO implements surveillance in routine conditions and 2) Material surveillance of events under certain conditions, such as a. Health Alert Card (HAC) the PHEIC declaration. Activities at the state entrance Since the PHEIC status of COVID-19 was applied on include efforts to detect, prevent, and respond to January 2020, every crew or passenger coming from COVID-19 at ports, airports, and the State Cross-border abroad will be given a Health Alert Card (HAC). The Post. These efforts are carried out through the supervi- HAC is a form used as an information tool that contains sion of transportation equipment, people, goods, and the the identity, travel history, and symptoms of a traveler. If environment coming from regions and countries affected during the incubation period of 14 days after traveling, by COVID-19 and are carried out by PHO in coordina- the person experiences symptoms of COVID-19 disease tion with related sectors. This study aimed to analyze the and visits the health service and also brings their com- activities of early warning alert and response system to pleted HAC, the health worker can see the history of the PHEIC of COVID-19 at Juanda International Airport traveling of the person and whether there is a probability on January 2020. of COVID-19 infection, thereby enabling risk communication, prevention, and alertness. The HAC used by Method Surabaya PHO Class I is a procurement from the This study applied a descriptive evaluative research Ministry of Health of the Republic of Indonesia. The new using an input-process-output (IPO) system approach to procurement per January 2020 was 94,500 pieces from obtain in-depth information from data and sources about funds from the Surabaya PHO Class I Budget the activities that occurred. With the input subsystem, Implementation List (Dana Isian Pelaksanaan Anggaran the 4M method (man, material, method, machine) is used / DIPA) in 2020. This procurement amount has been ad- with modification by adding time, technology, and infor- justed to the estimated needs for a month based on the mation variables. It is a reliable, intermediate tool for number of travelers arriving each month, which is ap- problem analysis.3 proximately 90,000 people. This amount is sufficient to meet the needs of HAC distribution to all international Results arrivals at Juanda International Airport, Surabaya. Analysis of COVID-19 early awareness activities Based on appearance, HAC consists of one sheet of

78 Nastiti et al, Analysis of Epidemiological Surveillance Activity of the COVID-19 at Surabaya Airport Indonesia on January 2020 yellow paper that includes two parts (Figure 1). The smaller part contains the identity that must be filled by the traveler, such as name, age, gender, address, telephone number, flight number, and seat number. Once filled, this piece will be collected to PHO officers for data entry and recapitulation, while the large part is given to travelers. The contents of the large part are the identities of the traveler that can be shown to health facilitator if there is manifestation of disease. On the back side of the personal data form contained brief information about the disease including COVID-19. The HAC form is written in two languages, Indonesian and English, making it easier for Indonesian citizens and foreigners to fill in. b. Personal Protective Equipment Personal protective equipment (PPE) is an officer Figure 1. Health Alert Card safety tool needed for supervision of people and goods traffic in accordance with the Decree of the Minister of pecially in Chapter IV on Health Quarantine at the health of the Republic of Indonesia No. 425 of 2007 con- Airport as the Entrance of the State. cerning Guidelines for the Implementation of Health COVID-19 surveillance in the field consists of check- Quarantine at the Port Health Office, and includes dress, ing aircraft conditions, checking aircraft crew health doc- N95 mask, and gloves. Based on interviews with program uments, and screening crew and passengers through ther- implementers, the availability of PPE on January has been mal scanners and filling and summarizing of General sufficient, and in accordance with existing regulations, a Declaration (GENDEC) or aircraft health documents. If minimum of 200 PPE is available. a traveler detected by the thermal scanner has a body c. Communication Tool temperature of more than 38oC, the device will sound as The tools used for communication on the field are a warning. The traveler is given further inspection, risk smartphones and handy talky. For fast reporting, smart- communication, and a warning alert. phones are more often used due to a wider range and fast Based on the COVID-19 Preparedness Guidelines by message delivery. In dealing with the PHEIC COVID-19 the Indonesian Ministry of Health (revision-2), there are condition, Surabaya PHO Class I coordinates with many four terms that are used as operational definitions of cross-sectors. The WhatsApp group is used as a media COVID-19 infection cases, which are Person in for rapid information exchange such as sharing informa- Monitoring (PIM), Patient Under Supervision (PUS), tion, current updates and other purposes aimed at early probable cases and confirmed cases. Whereas the case warning alert activities towards COVID-19. definition by WHO consists of suspected cases, probable d. Communication, Information, Education Media cases, and confirmed cases 5 (Tabel 1). There are communication, information, and education 4) Machine media in the form of banners and leaflets. The media is Surabaya PHO Class I has three thermal scanners located in front of the Terminal 2 quarantine room for from the supply in 2016 with condition two functioning international arrivals and next to the thermal scanner and 1 broken as well as adding one thermal scanner was room located at the international arrival gate of Juanda supplied in 2019. The supply of body thermal scanners is International Airport, which contains information on from the Indonesian Ministry of Health, sub. The symptoms, transmission, and prevention of COVID-19. Directorate General of Port Health Quarantine, and if 3) Method there is damage and requires maintenance, it can only be Guidance procedures in early warning alert and re- fixed by central technicians, therefore it takes a long time sponse activities refer to the Preparedness Guidelines of to repair. The body thermal scanner functions as a tem- 2019-nCoV (COVID-19) which consists of guidance 1 perature observation screening tool to detect the travel- and revision 2 issued by the Indonesian Ministry of er’s body temperature passes through the arrival gate. If Health on January and February 20204. Activities at the person is detected with a body temperature of more than entrance of the state include efforts to detect, prevent, or equal to 38oC, the device will take pictures, show a and respond to COVID-19. These efforts are carried out red display and sound a warning. through supervising the arrival of conveyances, people, The body thermal scanner is installed at the Terminal goods, and the environment coming from regions and 1 and Terminal 2 arrival gates at Juanda International countries affected by COVID-19. This activity also refers Airport. In addition to the body thermal scanner, the of- to Law No. 6 of 2018 concerning Health Quarantine es- ficers also use an infrared thermometer, to confirm the

79 Kesmas: Jurnal Kesehatan Masyarakat Nasional (National Public Health Journal). 2020; Special Issue 1: 77-84

Table 1. Operational Definition of Infection Case of COVID-19

Symptomp Patient Under Supervision Person in Monitoring Probable Cases Confirmed Cases

Fever/history of fever V V V V Cough/runny nose/throat pain V V V V Mild to severe pneumonia based on clinical symptoms and/or radiological features V Risk Factors: Travel history to China or the affected region/country within 14 days before symptoms develop V V History of exposure to one or more: • A history of close contact with COVID-19 confirmed cases • Work or visit health facilities associated with COVID-19 confirmed patients in China or in the affected region or country • History of contact with infectious animals (if identified) V Have a fever (≥38oC) or have a history of fever, have a history of travel to Wuhan or contact with those who have a history of travel to Wuhan (there are epidemiological links) V temperature and double check the result. The machines 2. Process and supporting equipment are stored in the Surabaya The stages and methods of implementation have been PHO Class I room at Juanda International Airport, which regulated in the Standard Operating Procedures for Air consists of a thermal scanner room, an interview room, a Traffic Control, in addition to the Preparedness negative pressure observation room, and a negative pres- Guidelines of COVID-19 issued by the Indonesian sure transport capsule or a temporary isolation room. Ministry of Health. 5) Time 1) Data Collection Supervision of arrivals for early detection and re- Data collection by Surabaya PHO Class I officers in sponse to COVID-19 takes place each day for 24 hours the context of early warning alert and response of on international arrivals at Juanda International Airport, COVID-19 was carried out by direct observation and su- Surabaya. Data collection and data summarizing of air- pervision of the arrival of aircraft entering Indonesia craft health documents takes approximately five minutes through Juanda International Airport. both online and offline per flight arrival. Whereas data Passenger health is observed by checking body tem- entry and summarizing of HACs takes one minute per perature through a thermal scanner by PHO’s officer on HAC sheet. The estimated data entry and summarizing duty, and checking the HAC completed by the traveler. of HACs for one aircraft arrival is around one to two The HAC is summarized to obtain early information on hours. any COVID-19 infection. Flight arrival data collection is 6) Technology by collecting GENDEC data by the airline to the PHO’s Coordination uses technology such as electronic tools officer on duty and using the Flight Radar application. and the internet through online groups, both internally The GENDEC summary results consist of data: aircraft and across sectors, while manual data summarization u- name, flight number, aircraft registration number, air- ses software that can be found on computers in general. craft origin, total flight crew, total airplane passengers, 7) Information total number of sick passengers, as well as body temper- Information regarding aircraft arrivals from abroad is ature screening results. The HAC summary consist of da- obtained through notification from the airline by giving ta on the identity of the travelers such as name, age, gen- the GENDEC or aircraft health documents to Surabaya der, address, flight, seat number, travel history and symp- PHO Class I officer on duty. In addition, information is toms of the disease. PHO’s officer on duty also observed also obtained through the Flight Radar application, via the flight schedule by monitoring the Flight Radar appli- smartphone. Information sourced from the HAC is the cation. identity, health conditions, and travel history of the crew 2) Data processing or passenger. The data is useful as a precautionary meas- PHO's officers use software that can be found on ure if the COVID-19 case is found among travelers. The computers in general to process monitoring data on the whole process has been progressing well. The officer can arrival of conveyances, people, and goods. This software prepare and carry out tasks in the field in every arrival is a form created to enter, summarize, and process data from abroad on time. from GENDEC and HAC. 3) Data Compilation In the early alert activities of COVID-19 by KKP Class

80 Nastiti et al, Analysis of Epidemiological Surveillance Activity of the COVID-19 at Surabaya Airport Indonesia on January 2020

1 Surabaya at Juanda International Airport, aircraft arrivals are grouped according to the area of origin of the arrivals based on a WHO’s circular letter forwarded by the Ministry of Health about countries infected or endemic of an infectious disease. However, there is no data regarding the area, region, or address after the arrival of passengers from an area or region affected by COVID-19 as there is no question column about this. There is an address column in the HAC form, but based on the results of the HAC summary, many passengers misunderstand the requirements and do not fill in the HAC correctly resulting in incomplete data. Figure 2. The Number of Aircraft Arriving from Abroad Based on the This results in difficulties in monitoring the risk of trav- Country of Origin on January 2020 elers spreading disease, since the incubation period of COVID-19 is 14 days. Therefore, it is a possibility that new disease cases could occur during this incubation period while the travelers have been in their respective destinations. 4) Data Presentation Presentation of data on the analysis of COVID-19 early warning alert and response activities in the form of graphs, tables, images, and narratives. The examples of data presentation are below for aircraft arrivals (Figure 2) and crew and passenger arrivals (Figure 3). On January 2020, there were 583 aircraft arrivals from abroad at Terminal 2 of Juanda International Figure 3. Number of Crew and Passengers Arriving from Abroad Based on Airport. The country of origin with the highest number the Country of Origin on January 2020 of landings during January 2020 is Malaysia with a total of 284 arrivals. There were eight flights from China ori - 3. Output ginating from Haikou Airport, Hainan Province, 1,497.9 The output results in three data sets: km from Wuhan City, Hubei Province, the epicenter re- 1) Epidemiological Information gion of COVID-19. One of the outputs obtained is epidemiological infor- There were 4,773 crew members and 97,154 passeng - mation based on the results of daily reports and report of ers in Terminal 2 of the International Arrival of Juanda epidemiological investigations if a case of COVID-19 is International Airport on January 2020. The highest num- found. ber of crew and passengers was from Singapore, with Daily reports from all COVID-19 early warning alert 1,720 crew members and 36,092 passengers. and response activities on aircraft arrivals from abroad On January 2020, it was recorded that two travelers are forwarded to the relevant sectors (Figure 5). These who were identified with thermal scanners had a body reports are likely to be the same as daily reports on nor- temperature of ≥ 38oC. Both of them had fever, cough mal condition, but also include the reporting of details and runny nose symptoms. The flight origin country were about PPE stock and HAC stock every day. Singapore and Saudi Arabia. However, these two people 2) Notification were not included in the COVID-19’s PIM because they One notification was issued on January 30, 2020, de- were not included in the PIM criteria. tailing 18 people who had just travelled from China, 12 5) Data Analysis and Interpretation from Hangzhou, two from Jinhua, one from Dongyang Data analysis is a simple analysis of risk factors by and three from Yiwu. Of the 18 people, 12 people were comparing findings with existing indicators. Data has Indonesian students from China and six people were oth- been processed based on risk factors and are analyzed er passengers on flights that landed at Juanda descriptively to ensure that conveyances, people and International Airport. goods are in a healthy condition and not carrying disease Notification contains information about the name, from other countries. Whereas if there is a potential age, gender, passport number, origin, destination, occu- COVID-19 case found, a comparison is made with the pation, symptoms, and information of the traveler. The criteria for PIM cases, PUS cases, probable cases and notification is useful as a warning to the Provincial Health confirmation cases determined by the Ministry of Health. Office and relevant agencies to conduct early warning

81 Kesmas: Jurnal Kesehatan Masyarakat Nasional (National Public Health Journal). 2020; Special Issue 1: 77-84 alert of COVID-19 in their respective regions. ment, especially PPE are the main supporting activities 3) Information Dissemination that are important as protection for officers in carrying Information dissemination is being held after the re- out work. In order to prevent the transmission of disease port or notification is complete. The daily report dissem- in health services, PPE must be used consistently and in ination process is carried out by the officer on duty to the right way by health workers to prevent exposure to their higher officer every day before 07:00 am on the fol- pathogens that could cause infection.7 The use of PPE re- lowing day via the WhatsApp application. Notification is duces of disease transmission and protects health worker given by the Surabaya PHO Class I to the Provincial especially in COVID-19 treatment.8 Health Office and the others at PHO according to the 3) Machine original address of the PIO or POM, which is forwarded Body thermal scanners function well as the main de- to the Directorate General of P2P, the Indonesian tection tool; however, if damaged, these require mainte- Ministry of Health. Quick report notifications are via nance that can only be done by specialized technicians, WhatsApp, while official reports are delivered via email. which causes a long delay in repair. If this happens, it Whereas if a COVID-19 case is found, the report will be can disrupt surveillance activities at the airport. submitted to the PHEIC of the Directorate General of Machines as a means of supporting activities require care P2P, the Indonesian Ministry of Health through an offi- and maintenance so that their working functions are op- cial report via email. timal. The thermal scanner can operate between 18 to 24 hours continuously. Hence, in operating thermographic Problems found device, health worker should be trained and the tool The data format of HAC has only written “address”, needs to be maintained to avoid any possibility of ma- therefore many interpretations in the way of filling that chine error.9 With the maintenance and care of the ma- part. A few passengers write their address abroad, in- chine, in this case the body thermal scanner, then the instead of the destination address in Indonesia. terference or damage to the tool can be minimized and avoided to enable continuous surveillance. Discussion Body temperature screening using a body thermal 1. Input scanner or other similar device such as infrared thermo - 1) Man graphy has several limitations. For example, travelers The number of epidemiological surveillance officers who take anti-pyretic drugs to briefly modify body tem- at the Surabaya PHO Class I is sufficient and has received perature can affect the scanning efficiency.10 In addition, additional human resource assistance during the initial the scanner cannot detect symptoms if an infected person alert of COVID-19. The number of officers is in accor- is still in the 14 days incubation period. Therefore, it is dance with the standards in the Decree of Health necessary to improve the detection accuracy and further Minister of the Republic of Indonesia Number develop the system, for example, by using multisensory 425/Menkes/SK/IV/2007. detection of heart rate and breathing.10 Officers have also been given training and perform- 4) Method ance capacity building. However, the number of officers The method of implementing early detection, warning on duty is not sufficient compared to the number of pas- alert, and response of COVID-19 is in accordance with sengers on one flight arrival, causing the communication the Preparedness Guidelines of COVID-19 (revision-2). of HAC checking methods to be less effective. This is This activity is also in accordance with Law No. 6 of shown by the results of the HAC summary that contained 2018 of the Republic of Indonesia concerning Health a large amount of blank spaces, data incorrectly filled in, Outcome especially in chapter IV on Health Outreach at or other matters relating to the passenger misunderstand- the Airport as the State Entrance. ing the form. 5) Time Whether or not an organization's goals are achieved The activity continues 24 hours a day so that all ar- is basically determined by the person carrying out the ac- rivals from abroad can be monitored regularly. However, tivity. Therefore, to balance this requires officers who are the summarizing of the HAC requires a longer time. adept and trained in communicating directions for filling While a large number of HACs are being completed, the out the HAC. Proper training and development leads to guard must also continue to supervise, so this can result condition of workers accomplish their task at full poten- in an increased workload for officers. Excessive workload tial on their work.6 can cause work-related stress on workers.11 This can af- 2) Material fect the performance of traveler supervision by the officer The facilities and equipment available in the activities on duty, so that job control is needed to enable an officer are largely sufficient for the implementation of early to specifically handle the HAC, while traffic surveillance awareness activities for COVID-19. Facilities and equip- activities continue to run optimally. Sufficient job control

82 Nastiti et al, Analysis of Epidemiological Surveillance Activity of the COVID-19 at Surabaya Airport Indonesia on January 2020 does not pose major concerns on high workload.12 not violate applicable regulations.17 The important thing 6) Technology to do is to strengthen public health surveillance to pro- Internet and social media have been implemented to vide early warning and to develop appropriate actions or coordinate and disseminate information on activities to responses, which are the main focus of public health.18 facilitate the data collection and administration of the COVID-19 vigilance system. The role of technology, es- 3. Output pecially in the field of communication today is very im- The outputs of PHO activities are the effort to prevent portant due to the many demands for rapid and accurate disease at the entrance point of the country. This is par- information exchange.13 Therefore, technology is very ticularly relevant when dealing with the status of PHEIC helpful in the early detection, warning alert, and response COVID-19 through administrative actions, as evidenced to COVID-19 by rapid reporting using information dis- by daily reports, notifications to the Provincial Health semination for both internal and cross-sectoral users. Office, local PHO and other related sectors, and reports 7) Information to PHEIC Directorate General of P2P of any potential Aircraft arrivals from abroad can be monitored cases. These three things have been implemented and through Flight Radar and GENDEC collection. The tra- have been forwarded to the relevant agencies. Reporting veler’s data is obtained through the summarizing the is done vertically to superiors and also horizontally to HAC. The whole process has been progressed well, so cross-sectoral agencies so that the results of the data from that for every arrival from abroad at Juanda International early vigilance activities can be utilized by sector pro- Airport, the officer can prepare and carry out tasks in the grams or other agencies. field optimally. Data and information quality become an important requirement in making decisions for an organ- Alternative Troubleshooting ization so that it can achieve sustainable performance.14 1. Add questions to the HAC form regarding the desti- Information is only high quality if what is received by the nation or area to be visited by passengers after landing recipient is in accordance with the intent of the sender.15 at Terminal 2 of Juanda International Airport. The COVID-19 outbreak is a reminder of the need for 2. Add media examples of correctly completed HAC constant surveillance and strong research to understand forms at the HAC post. the basic biology of the new COVID-19 virus and also to 3. Advise guard officers to give instructions and warnings develop effective treatments for this disease.16 Therefore, when distributing HAC forms, so that passengers fill high quality sources of information are critical in the im- the HAC correctly, honestly, and completely. plementation of COVID-19 surveillance, especially at the entrances to the country. Conclusion There was an increase in the vigilance of health sur- 2. Process veillance in the Juanda International Airport by Surabaya Data collection through supervising of aircraft ar- PHO Class 1 regarding the COVID-19 entry to rivals at Juanda International Airport is based on temper- Indonesia. Problems and weaknesses were found in in- ature observations and HAC to obtain information for an formation sources such as HAC. There are no examples early alert to COVID-19 infection. In the summarizing of travelers checking media such as the completed exam- process, this may take between one to two hours as the ple forms in the HAC charging post. The results of HAC process must be carried out by many officers. This has filling by the travel agents are still incomplete because been helped by the existence of additional officers from some people do not understand the HAC form sufficient- agencies outside the KKP Class I Surabaya. ly. In the data compilation, there was no data on the area, The format of the HAC is still unclear regarding the region, or address for passengers after their arrival in destination area, region, or address for arriving passen- Indonesia from a region affected by COVID-19 as there gers from an area or region affected by COVID-19. The was no question column for this in the HAC. Many for- address column on the HAC is still often misinterpreted eigners give their original addresses in the country of ori- as the original address, even though not all travelers will gin instead of the destination place in Indonesia. go directly back to the original address after landing at Overall, the process subsystem in the analysis of the airport. In addition, many foreigners still write the COVID-19 early vigilance activities at Juanda origin address from their respective countries. The HAC International Airport by KKP Class 1 Surabaya has been is a vital source of data to obtain high quality information running in accordance with existing guidelines and SOPs. for taking early precautions against COVID-19. Processes and components must be aligned with the ob- Activities in the early warning alert and response sys- jectives of the surveillance system so that it can produce tem of COVID-19 are in accordance with the valid information, improve operational efficiency, and Preparedness Guidelines established by the Indonesian

83 Kesmas: Jurnal Kesehatan Masyarakat Nasional (National Public Health Journal). 2020; Special Issue 1: 77-84

Ministry of Health. The outputs or activities both verti- 3. Knop K, Mielczarek K. Using 5W-1H and 4M methods to analyse and cally and horizontally have been classified as appropriate. solve the problem with the visual inspection process – case study. Reporting has been done routinely to the Directorate MATEC Web of Conferences. 2018; 183 (5-6): 03006. General of P2P and there is no delay. It is necessary to 4. Kementerian Kesehatan Republik Indonesia. Pedoman Kesiapsiagaan educate travelers about completing HAC forms through Menghadapi Coronavirus Disease (COVID-19). 2020; 1–88. the addition of media, such as, a completed form as an 5. World Health Organization. The first few X (FFX) cases and contact example, and communication and direction from investigation protocol for 2019-novel coronavirus (2019-nCoV) infect - Surabaya Class I officers so that the effectiveness of HAC ion, 2020. can be maximized. 6. Walters K, Rodriguez J. The importance of training and development in employee performance and evaluation. World Wide Journal of Abbreviations Multidisciplinary Research Development. 2017; 10 (3): 206–12. PHO: Port Health Office; HAC: Health Alert Card; WHO: World 7. Phan LT, Maita D, Mortiz DC, Weber R, Fritzen-Pedicini C, Bleasdale Health Organization; COVID-19: Coronavirus Disease 2019; PHEIC: SC, et al. Personal protective equipment doffing practices of health- Public Health Emergency of International Concern; CFR: Case Fatality care workers. J Occup Environ Hyg. 2019; 16 (8): 575–81. Rate; IHR: International Health Regulation; IPO: Input Process Output; 8. Cook TM. Personal protective equipment during the coronavirus dis- DIPA: Dana Isian Pelaksanaan Anggaran; PPE: Personal Protective ease (COVID) 2019 pandemic – a narrative review. Anaesthesia. Equipment; GENDEC: General Declaration; PIM: Person in 2020; 75 (7): 920-7. Monitoring; PUS : Patient Under Supervision. 9. Sathyamoorthy D, Yunus ARM. Thermographic mass blind fever screening: a review of the effectiveness of correlation tests and opera- Ethics Approval and Consent to Participate tions. Def S T Tech Bull. 2011; 4 (2): 105–18. Not Applicable 10. Sun G, Matsui T, Kirimoto T, Yao Y, Abe S. Applications of infrared thermography for noncontact and noninvasive mass screening of Competing Interest febrile international travelers at airport quarantine stations. In: Ng EY, Author declares that there are no significant competing financial, pro- Etehadtavakol M, editors. Springer Singapore. 2017; pp. 347–58. fessional, or personal interests that might have affected the performance 11. HSE. Work-related stress, anxiety or depression statistics in Great or presentation of the work described in this manuscript. Britain, 2019. Annual Statistic. 2019; 1–9. 12. Portoghese I, Galletta M, Coppola RC, Finco G, Campagna M. Availability of Data and Materials Burnout and workload among health care workers: the moderating Data collected without constraints. role of job control. Safety and Health Work. 2014; 5 (3): 152–7. 13. Daeng ITM, Mewengkang NN, Kalesaran ER. Penggunaan smartphone Authors’ Contribution dalam menunjang aktivitas perkuliahan oleh mahasiswa Fispol Unsrat Rizma Dwi Nastiti did the research, analyzes the data and writes the ar- Manado. E-Journal Acta Diurna Komunikasi. 2017; 6 (1): 1–15. ticle. Kurnia Dwi Artanti gave supervision and monitores the research. 14. Alshikhi OA, Abdullah BM. Information quality: definitions, measure- Achmad Faridy Faqih gave supervision and monitors the study. ment, dimensions, and relationship with decision making. European Journal of Bussiness and Innovation Research. 2018; 6 (5): 36–42. Acknowledgment 15. Azemi NA, Zaidi H, Hussin N. Information quality in organization for We would like to thank all staff Surabaya Port Health Office Class I, abetter decision-making. International Journal of Academic Research Juanda Area Working, Surabaya, Indonesia. We also thank Universitas in Business and Social Sciences. 2017; 7 (12): 429–37. Airlangga and all the investigators who collected and analyzed the da- 16. Fauci AS, Lane HC, Redfield RR. Covid-19 - navigating the uncharted. ta. New England Journal of Medicine. 2020; 382: 1268-9. 17. Groseclose SL, Buckeridge DL. Public health surveillance systems: re- References cent advances in their use and evaluation. Annu Rev Public Health. 1. Yanping Zhang. The Epidemiological Characteristics of an Outbreak 2017; 38 (1): 57–79. of 2019 Novel Coronavirus Diseases (COVID-19) — China, 2020. 18. Choi BCK. The past, present, and future of public health surveillance. Web. 2020; 2 (8): 113–22. Scientifica (Cairo). 2012; 2012: 875253. 2. World Health Organization. Coronavirus disease 2019; 2020.

84 Fadliyah et al. Kesmas: Jurnal Kesehatan Masyarakat Nasional (National Public Health Kesmas: Jurnal Kesehatan Masyarakat Nasional Journal). 2020; Special Issue 1: 85-92 DOI: 10.21109/kesmas.v15i2.3950 (National Public Health Journal) Pre-testing of the WHO’s Educational Video: “How to Protect Yourself against COVID-19”

Hilyatul Fadliyah1, Manendra Muhtar1, ..., Hadi Pratomo2*

1Graduate Student of Public Health, Faculty of Public Health, Universitas Indonesia 2Department of Health Education & Behavioral Sciences, Faculty of Public Health, Universitas Indonesia

Abstract The coronavirus disease 2019 (COVID-19) pandemic, caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) was declared a public health emergency in many countries, including Indonesia. The World Health Organization (WHO) released an educational video, entitled "How to Protect Yourself Against COVID-19", which explained how to prevent the spread of COVID-19. This study is a qualitative study that aims to pre-test this video, based on the Information, Education, Communication (IEC) theory, by analyzing teenagers’ perceptions of the video. The design used was a Rapid Assessment Procedure (RAP), and the data were collected by conducting in-depth interviews with participants, through virtual meetings. The data were analyzed using a qualitative data matrix and thematic analysis. The results showed that all participants found the video regarding the prevention of COVID-19 spread to be attractive and comprehensible. In addition, the participants felt that the contents of the video were not contradictory to their personal values and that the message was targeted to everyone, including themselves. The video was also perceived to be persuasive. Overall, the participants held a generally positive perception of the video.

Keywords: COVID-19, educational video, teenagers, World Health Organization

Introduction positive health behaviors in individuals, which could help The coronavirus disease 2019 (COVID-19) pandem- control the spread of the pandemic.2,4 Behaviors are in- ic, caused by the severe acute respiratory syndrome coro- ﬂuenced by each individual’s knowledge and perception navirus 2 (SARS-CoV-2) virus has been declared a public of the pandemic conditions.5 health emergency in several countries, including Information, Education, Communication (IEC) is an Indonesia. The virus is spread through human-to-human approach that can be used to promote a sustainable be- transmission, primarily through droplets that are released havioral change in individuals. The IEC approach can be when an individual coughs or sneezes.1 Under the cur- applied through the use of mass media. The WHO recog- rent COVID-19 conditions, health-related organizations, nizes the important role of IEC methods for the achieve- such as the World Health Organization (WHO), have ment of health goals and recommends the use of IEC continuously attempted to disseminate accurate and methods in health programs, to obtain better and more credible information, worldwide, via social media plat- sustainable results.6 In our study, we performed a pre- forms.2 The WHO released an educational video on the test analysis of the WHO’s educational video, which is a social media platform YouTube explaining how to pre- type of communication or IEC material. We analyzed ﬁve vent the spread of COVID-19 by regularly washing hands components of communication material (IEC) effective- with soap and running water, maintaining a minimum ness, which included (1) attractiveness, the elements that distance of 1 meter between people, and coughing and make people want to see and listen to the material; (2) sneezing properly. Videos represent one type of mass me- comprehension, the clarity of the content and its presen- dia that allows information to be spread quickly, reaching tation; (3) acceptability, whether the audience feels that a wide audience.3 The dissemination of accurate infor- they can accept, believe, and not be offended by the ma- mation regarding self-protection efforts during a pan- terial; (4) self-involvement, whether the audience can demic, such as COVID-19, has been shown to encourage identify the materials and recognize the messages that

Correspondence*: Hadi Pratomo, Department of Health Education & Health Received : May 31, 2020 Promotion, Faculty of Public Health, Universitas Indonesia, Depok, West Java, Accepted : July 2, 2020 Indonesia, E-mail: [email protected], Phone: +62217863475 Published: July 31, 2020

Copyright @ 2020, Kesmas: Jurnal Kesehatan Masyarakat Nasional (National Public Health Journal), p-ISSN: 1907-7505, e-ISSN: 2460-0601, SINTA-S1 accredited, http://journal.fkm.ui.ac.id/kesmas, Licensed under Creative Commons Attribution-ShareAlike 4.0 International Kesmas: Jurnal Kesehatan Masyarakat Nasional (National Public Health Journal). 2020; Special Issue 1: 85-92 are meant for them; and (5) persuasiveness/tendency to asked regarding the participants’ knowledge regarding act, whether the audience is motivated or persuaded to the institution that published the video was added. This perform a particular action.7-10 question was deemed to be necessary because it was as- The present study was specifically performed among sociated with the informants’ belief in the message being teenagers (high school students, aged 15–18 years). conveyed in the WHO video. Regarding the aspect of Despite having a lower risk of developing severe compli- “persuasiveness/tendency to act”, a question was added cations associated with COVID-19, teenagers remain as to ask whether the video requires translation into various likely as older people to become infected and languages. This question was considered to be important contagious.11,12 Furthermore, teenagers represent an age because it was associated with the interest of the infor- group that interacts with technology, media, and the in- mants to “act”, by spreading the video; the language used ternet more frequently than any other age group. in the video was English, and not everyone understands Therefore, teenagers can play a critical role in the dis- English. In both rural and urban areas, the interview semination of accurate information regarding COVID- process took approximately 30 minutes, for each partici - 19, through the media and internet that they access pant. daily.11 Data were collected by public health graduate students, who have been trained in qualitative research tech- Method niques. Before each interview, the informants were in- The design of the study was a Rapid Assessment structed to watch the video, "How to protect yourself Procedure (RAP), and a qualitative approach was used against COVID-19", produced by WHO, which lasted 1 to collect the data. RAP is a data collection method for minute and 30 seconds. The presented video was target- obtaining and analyzing in-depth information regarding ed towards a general audience and was not aimed to- public health behaviors, during a relatively short period wards a specific gender; therefore, our selection of par- of time,13,14 and can be used for IEC materials.15 This ticipants did not consider gender diversity. After watch- study was performed by only five researchers, who had a ing the video, semi-structured, in-depth interviews were short time to execute the project, as well as limited funds; conducted through teleconference services, including therefore, we used the RAP method. telephone lines and video conference services, including In present study, participants were selected through a Zoom, Google Meet, and WhatsApp, between April 20 purposive, snowball sampling technique, which utilized and April 28, 2020. After revising the instrument, inter- the networks of one or several informants. There were a views were conducted with the remaining 8 informants total of 10 teenagers, who attended senior high school, (four rural and four urban). During the interviews, five of whom lived in an urban area (East Jakarta) and recordings and field notes were taken by the research five who lived in a rural area (Karawang, West Java). team members. Data were transcribed, and matrices of Data were collected by performing in-depth interviews qualitative data were prepared. Thematic analysis was with participants, and the results of the interview were used to present the results. We performed the six steps interpreted by analyzing the contents of the participants' of thematic analysis, as suggested by Braun and Clarke,16 answers regarding their perceptions of the effectiveness which are as follows: (1) familiarization with the data; of the WHO’s educational video, which is a type of IEC (2) generating initial codes; (3) searching for themes; (4) material. reviewing the themes; (5) defining and naming the The instrument used was an in-depth, interview themes; (6) and, finally, producing the report. guideline, which was assembled based on the compo- To ensure both trustworthiness and data objectivity, nents of the IEC material, including effectiveness, per- after the completion of each in-depth interview, the received attractiveness, comprehension, acceptability, self- search team members summarized the results of the in- involvement, and persuasiveness/tendency to act. Prior terview and confirmed the completeness of the informa- to the use of the instrument, a trial field interview was tion. In addition, the research team members also deter- conducted, to determine whether the interview guidelines mined the willingness of the participants to be re-inter- were clear, to determine the order of the interview guide- viewed, if more information was determined to be neces- lines, and to determine how long the interviews would sary. take. Two participants (one rural and one urban) were There is no ethical clearance. Therefore, informed chosen for the trial interview. The results of the trial in- consent collected from each participant to comply with terview showed that, in both rural and urban areas, all of the Helsinki Declaration, which states that participation the questions included in the instrument could be under- by individuals who are capable of providing informed stood well by the trial participants. After the trial, the re- consent must be voluntary and without compulsion. The searchers added two new questions to the instrument. participants should agree voluntarily and are allowed to Regarding the aspect of “acceptability”, a question was continue or halt their participation in the study, without

86 Fadliyah et al, Pre-testing of the WHO’s Educational Video: “How to Protect Yourself against COVID-19” facing penalties.17 points. All of the participants stated that the function and purpose of this video were to inform people how to pre- Results vent the transmission of COVID-19. The participants in this study were eight senior high c. Perceived acceptability of the video school students (grades 10 and 12), four of each from According to all participants, nothing in the video was urban (code: U) and rural (code: R) regions. Their ages contradictory to their personal values. Although partici- ranged between 15–18 years. The participants consisted pant R1 stated that she did not fully agree with the im- of three males and five females. A summary of the partici- plementation of social distancing, as it prevented her pants whose data were used in our analysis can be found from meeting up with her friends, overall, she was okay in Table 1. with the implementation for the greater good. She also Five aspects of communication material (IEC) effec- suggested adding the recommendation of using masks to tiveness were evaluated, and representative statements the video. provided during the interviews regarding each aspect can Participant R1 did not identify the institution that re- be observed in Table 2. leased the video. Participants R2 and R4 identified that a. Perceived attractiveness of the video the WHO released the video but claimed little knowledge Most of the participants believed that the animation about the WHO. All other participants were able to iden- was good, interesting, and easy to understand. However, tify the institution that released the video as the WHO participants U3, U4, and R3 found that the animation and knew that the WHO is a global health organization. was not colorful enough, as it was only portrayed in black All participants, from both rural and urban areas, stat- and white. According to these participants, the animation ed that they believed in the contents of the video. should have been more colorful, to make the video more However, the participants provided different reasons for interesting. All participants, both rural and urban, stated why they believed the video. All of the urban participants that the text could be read clearly. Participant U4 sug- and participant R3 stated that their belief was based on gested adding a different color besides black, to highlight the fact that the video was published by the WHO, a the most important text. worldwide credible organization. In contrast, most rural All participants stated that the sound could be heard participants stated that they believed in the video’s con- clearly, although some participants described the speech tent because it contained a positive message. as being too fast. The participants felt that the video was d. Perceived self-involvement of the video effective, not too long, and straight to the point. All participants felt that they were part of the target Participant U4 felt that the duration was ideal, but would audience for the video and that the video was beneficial not mind additional information that would prolong the for them. They found the message to be useful because it video, such as if contents describing the use of alcohol to explained the spread and prevention of the virus, encou - wash hands effectively were to be added. raged them to maintain cleanliness, added information b. Perceived comprehension of the video that the virus could be spread at a distance of 1 meter, For some participants (four rural participants and one and, overall, found the message to be positive. Participant urban participant), the use of English in the video made U4 learned why social distancing rules are implemented comprehension of the information and messages con- after watching the video because the video states that the veyed in the video more difficult. However, in general, virus could spread if people do not maintain a distance of the participants were able to grasp the message regarding 1 meter. the prevention of COVID-19 transmission. Some partici- e. Perceived persuasiveness of the video pants (R2 and R3) were able to mention all of the main All participants were interested in implementing the points regarding the prevention of COVID-19 mentioned various messages that were conveyed in the video, such in the video, whereas others only mentioned some of the as maintaining personal hygiene, not touching facial a-

Table 1. Participants’ Characteristics

Initials (Code) Region Age Sex Domicile

OAM (R1) Rural 18 (grade 12) Female Karawang, West Java E (R2) Rural 18 (grade 12) Female Karawang, West Java MAA (R3) Rural 18 (grade 12) Male Karawang, West Java BBM (R4) Rural 17 (grade 12) Female Karawang, West Java NDP (U1) Urban 18 (grade 12) Male Pondok Gede, East Jakarta ANZ (U2) Urban 16 (grade 10) Male Duren Sawit, East Jakarta ALF (U3) Urban 16 (grade 10) Female Jati Bening, East Jakarta DSGP (U4) Urban 15 (grade 10) Female Jati Bening, East Jakarta

87 Kesmas: Jurnal Kesehatan Masyarakat Nasional (National Public Health Journal). 2020; Special Issue 1: 85-92

Table 2.1 Pre-testing Aspects, Themes, and Sub-themes Regarding the Participants’ Perceptions of the COVID-19 Educational Video Released by the WHO

Pre-testing Aspect Theme Sub-theme Participants’ Statement

Attractiveness Opinions of the animation The animation is good/attractive “The video has a good animation.” (U1) in the video “The animation is attractive.” (R2) The animation is not attractive enough “The animation is not attractive enough, as it should’ve been more colorful.” (U3) Opinions of the sound in Sound is clear and understandable “The sound is clear and understandable.” (U1) the video Sound is spoken too fast “The sound is clear, but spoken too fast.” (R4) Opinions of the text in the Text can be read clearly “The text can be read clearly.” (R1) video Different colored texts could have “The text is clear, but different colored texts could have been added been added to highlight the more important parts.” (U4) Opinions on the duration The duration is sufficient “The video is not too long and not too short, the video is straight to of the video the point.” (R2) “I think that sufficient general information is provided. But I think it’s okay to have additional time added to the video, if further information and explanations are needed.” (U4) Overall opinions of the video Overall, the video is good / clear “The video provides good and informative information. The animation provides a clear depiction of the messages being conveyed, I can understand the message just by watching the animation and without having to read the text. The subtitles are good, not confusing and in sync with the sound. The sound and pronunciation are also clear, making the message easy to understand.” (U1) “The video is very clear, the illustration is clear, which allows us to understand the meaning of the video, but the illustrations are not colorful enough.” (U3) Comprehension Comprehension of the English Quite difficult “I don't fully understand the English, so I looked at the animation to language used in the video help me better understand the meaning.” (R3) “It’s quite difficult to understand.” (R4) Somewhat easy to understand “The English is somewhat easy to understand, but there are some terms that are not understood.” (U4) Easy to understand “The English words used were common, so it was easy to understand.” (U1) “I understand the English being used.” (U2) Comprehension of the infor- The virus’ transmission distance “To prevent the virus, we need to implement social distancing measu- mation regarding COVID-19 of 1 meter res, by keeping a 1-meter distance.” (R1) prevention steps obtained “The transmission can occur within an approximate distance of 1 from the video meter.” (U4) Cleaning the surface of objects “Clean objects around us by spraying disinfectants or other liquids regularly that can kill the viruses.” (R2) “Objects around us need to be sprayed with disinfectants so that the microbes die.” (U3) Prohibition of touching eyes, nose, “Do not touch the eyes, nose, or mouth or around any part of the and mouth with dirty hands face.” (R3) “Avoid touching the eye, nose, and mouth areas.” (U2) Covering the nose and mouth when “If we are having a cough, we must cover it with a tissue and imme- coughing, or sneezing, using elbows diately remove the tissue.” (R2) or tissues “When we cough/sneeze it must be covered with our elbows.” (U1) Washing hands with soap and water “Wash hands with soap, or use hand sanitizers.” (R4) as the most effective method to prevent “Handwashing is done with soap and water or alcohol.” (U1) spreading Comprehension of the purpose To inform/to educate the public “To inform people about how to prevent the transmission of corona- of the video virus.” (R2) “To educate the public so they know more about COVID-19, espcial- ly how to prevent it.” (U2) To persuade the public “To invite all people in the world to do actions such as keeping their distance and spraying disinfectants.” (R3) “To remind the public to be more aware of the prevention of COVID-19.” (R4) reas, enacting social distancing, washing hands with soap planned to spread the video to their families and friends, and running water or hand sanitizers, and maintaining via social media, such as WhatsApp (through WhatsApp the cleanliness of objects by spraying them with disinfec- status posts or WhatsApp groups) and Instagram tants. (through Instagram feed posts or Instagram story posts). All participants, both rural and urban, felt that Participant R4 believed that spreading the video by post- spreading the video was important. The informants ing it to her Instagram feed would be more effective be-

88 Fadliyah et al, Pre-testing of the WHO’s Educational Video: “How to Protect Yourself against COVID-19”

Table 2.2 Pre-testing Aspects, Themes, and Sub-themes Regarding the Participants’ Perceptions of the COVID-19 Educational Video Released by the WHO

Pre-testing Aspect Theme Sub-theme Participants’ Statement

Acceptability The existence of content which No content is contradictory to the “I found nothing offensive, but social distancing advice makes me a is contradictory to the partici- participants’ feelings, values, and little upset because they prevent me from meeting up with my friends, pants’ feelings, values, and beliefs but it’s okay, as it is for the greater good.” (R1) beliefs “In accordance with my values and beliefs.” (U2) “There are no offensive messages.” (U3) Knowledge about the institution Knows about the institution “It was published by WHO, the World Health Organization.” (U3) that published the video “It was published by WHO (World Health Organization). WHO is an international organization that takes care of everything related to health.” (R3) Does not know about the institution “I do not know about the institution that published the video.” (R1) “The video was published by WHO, but I first heard about ‘WHO’ when I was invited to this interview by my friend. I don't really know much about WHO.” (R2) Trust/belief towards the infor- Believes the information because the “I believe it, because the video spreads a positive message regarding mation message of the video is positive/ the prevention of the virus’ spread.” (R4) beneficial “Can be trusted because the video has a lot of beneficial messages.” (R2) Believes the information because the “I believe it, because the information was released by a worldwide video was published by the WHO organization, so the information is accurate.” (U4) Self-involvement The opinion of the participants Targeted for all groups/everyone “It is targeted for all groups, from children to the elderly.” (U2) regarding whom the video is “For all people in the world. Even though the elderly are the more targeted for vulnerable group, but perhaps this video is meant for everyone: young people, young children, and the elderly.” (R3) The benefits of the video for the Beneficial for preventing COVID-19 “Very helpful in explaining the spread and prevention of the virus.” participants transmission (R1) “The video is useful, and I feel more optimistic that this virus can be prevented by washing our hands. And now I know why social distancing rules are implemented, if we don’t keep a distance of 1 meter, the virus can spread easily. So, the benefit is, we can help prevent the transmission of the virus.” (U4) “Very useful because the video persuades us to do positive actions.” (R3) Persuasiveness/ How the participants will act Implement the messages that were “I’m interested to implement the various messages.” (R2) Tendency to Act regarding the messages convey- conveyed in the video “I want to implement the things that were explained in the video ed in the video because my mindset immediately said ‘oh these are the ways to prevent transmission of the virus.’” (U4) Spread the video through social media, “It is important to spread the video, I want to share it to my groups, spreading the messages in the video my contacts, my relatives and through my WhatsApp story.” (R3) “It is very important for people to know this, as it is official information from the WHO. I want to share this video to my family, friends, and social media, like Instagram.” (U3) Feels the need for a translation of the “There needs to be a translation to Indonesian, but it doesn't need to video into the Indonesian language be translated into local languages such as Sundanese or Javanese.” (R1) “Indonesian subtitles need to be added, and the video also needs to be dubbed in Indonesian because sometimes Indonesian people are lazy to read.” (U1) cause more people will see it and the post can be viewed at any time. Similarly, participant U4 believed that Discussion spreading the video via Instagram stories would be more In this study, authors explored the participants’ per- effective because she felt that more people would watch ceptions regarding the attractiveness of a video, pub- the video if it is posted on Instagram stories. lished by the WHO, and examined the participants’ com- All participants felt that the video should be translat- prehension, acceptability, self-involvement, and persua- ed into various languages. Participant R1 expressed the siveness/tendency to act towards the video contents. necessity for translations into Indonesian, the primary Videos, as IEC media, should attract the audience’s at- language used in Indonesia, but stated that the video does tention through animation, text, and sound. Moreover, not need to be translated into local languages, such as videos should also have an ideal duration. Most of our Sundanese or Javanese. According to participant U1, the participants expressed interest in the video’s animation. video should be supplemented with Indonesian subtitles Animations can help informants to better understand the and also dubbed into Indonesian because sometimes peo- information being conveyed, as described by Johari, et ple in Indonesian are lazy to read. al.18 Similarly, text and sounds can make the message

89 Kesmas: Jurnal Kesehatan Masyarakat Nasional (National Public Health Journal). 2020; Special Issue 1: 85-92 being conveyed easier to understand, by listening to the know what the WHO is, implied that they trusted the narrator's voice and reading the text contained in the video because the message delivered was a positive one. video. The length of the video, 1 minute and 30 seconds, Furthermore, one of the parameters for determining was also considered quite effective by participants be- the effectiveness of communication materials is “self-in- cause the information was conveyed clearly and com- volvement”, which determines the perceptions of the re- pletely in a relatively short period of time. cipients based on whether the message is believed to be This study revealed that participants’ overall under- directed and intended for them or others.8,9 The partici- standing of the video contents were considered good be- pants agreed that the information regarding the spread cause they knew the function and purpose of the video, and prevention of COVID-19 was useful and targets the which was to provide information and education to the whole community, in general. Moreover, one urban par- public regarding the transmission and prevention ticipant was able to link the message conveyed in the COVID-19 spread. An individual’s understanding of in- video with the reasons for the implementation of social formation or messages can be interrupted by semantic distancing regulations, despite the video not explicitly in- interference, especially communication disorders caused cluding any messages regarding social distancing regula- by errors in the language used.19 Authors identified dif- tions.21 This result indicated that the video successfully ferences in the English language comprehension levels engaged the participant. between rural and urban participants, with four rural One result of effective communication is persuasive- participants stating that they had difficulty understanding ness or the tendency to act.22 Authors believe that the the English used in the video, whereas only one urban video was able to persuade the participants to implement participant stated that they had difficulty with English and spread the messages conveyed in the video. The par- comprehension. However, this obstacle can easily be ticipants expressed a preference for the use of various so- overcome. Because the video is equipped with anima- cial media platforms to spread and share the video, indi- tions, the inclusion of text or subtitles in English that can cating that one of the most important advantages of using enhance their comprehension. social media is the ability to share knowledge and infor- The COVID-19 educational video published by the mation online, between various groups of people.23 For WHO contains five important messages: (1) the virus’ video distribution, the participants believed the video transmission distance of 1 meter; (2) cleaning the sur- should be translated into the Indonesian language, faces of objects regularly; (3) the prohibition of touching through both subtitles and dubbing, because not every- eyes, nose, and mouth with dirty hands; (4) covering the one who watches the video can understand English. For nose and mouth when coughing or sneezing, using el- most Indonesians, English is not their mother tongue; bows or tissues; and (5) washing hands with soap and therefore, the English language used in the video could water, as the most effective way to prevent virus potentially obstruct their understanding of the messages spread.12 Out of these five messages, only a few partici- being conveyed. pants were able to mention all of them completely. The contents that all the participants were able to identify Conclusion were (1) to maintain a distance of 1 meter, and (2) to The information authors collected from both rural wash hands. Authors assumed that this occurred because and urban participants suggested that all of them have these two points have previously been reported or have similar perceptions of the video. Overall, the video was been frequently heard by all participants. Both rural and considered to provide clear information, and the inclu- urban participants generally displayed a satisfactory level sion of images made the video easier to comprehend. The of comprehension for the contents of the video. partici pants also found the video to be attractive and As a communication medium, messages from videos were able to perceive that the function of the video is to must be acceptable to the target population. Messages inform viewers regarding how to prevent the spread of that can be received well are usually messages that are COVID-19. The participants believed that the content of not offensive, do not cause distrust, do not cause disap- the video contains trustworthy information because it proval, and do not cause the audience to reject the mes- was published by the WHO, an organization they consid- sage and, ultimately, not act according to the message.20 ered to be credible, or because of the messages in the A similar pattern was observed among the participants’ video itself. The participants also felt that the contents of answers. Among the urban participants, who were ge- the video did not contradict their personal values and be- nerally aware of the WHO, trusted and believed the con- liefs. The participants considered everyone, including tents in the video because they felt that the institution themselves, to be the target audience of the video. The that published the video was credible. Those participants, informants were also interested in sharing the video with including most of the rural participants, who answered people. Additionally, the participants indicated their that they trusted the contents of the video but did not hope that the video could be translated into Indonesian

90 Fadliyah et al, Pre-testing of the WHO’s Educational Video: “How to Protect Yourself against COVID-19” because not everyone, especially in Indonesia, that can terkini. Indonesian Jurnal Penyakit Dalam Indonesia. 2020; 7 (1): 45- understand the English used in the video. 67. 2. Jayaseelan R, D Brindha, Waran K. Social media reigned by Abbreviations Information or misinformation about COVID-19: a phenomenological COVID-19: Coronavirus disease 2019; SARS-CoV-2: Severe Acute study. Social Sciences & Humanities Open; Posted May 12, 2020. Respiratory Syndrome Coronavirus 2; WHO: World Health 3. Arguin PM, Navin AW, Steele SF, Weld LH, Kozarsky PE. Health Organization; IEC: Information, Education and Communication; RAP: communication during SARS. Emerging infectious diseases. 2004; 10 Rapid Assessment Procedure. (2): 377-80. 4. Collinson S, Khan K, Heffernan JM. The effects of media reports on Ethics Approval and Consent to Participate disease spread and important public health measurements. PloSone. There is no ethical clearance. Therefore, informed consent was collect- 2015; 10 (11). ed from each participant to comply with the Helsinki Declaration, 5. Tsai, A. G., & Bessesen, D. H. Integrating obesity treatment into rou- which states that participation by individuals who are capable of pro- tine primary care. Annals of Internal Medicine. 2019; 170 (5). viding informed consent must be voluntary and without compulsion. 6. Cofie P, De Allegri M, Kouyate B, Sauerborn R. Effects of information, The participants should agree voluntarily and are allowed to continue education, and communication campaign on a community-based or halt their participation in the study, without facing penalties. health insurance scheme in Burkina Faso. Global health action. 2013; 6 (1): 20791. Competing Interest 7. World Health Organization. Information, education and communica- Authors declare that they have no competing intereset in this study. tion: a guide for AIDS programme managers. WHO Regional Office for South-East Asia; 2000. Availability of Data and Materials 8. Bertrand JT. Communications pretesting. Univ of Chicago Community Data and materials are available on request. & Family; 1978. 9. Escalada, M.M. Pretesting and evaluation of communication materials. Authors’ Contribution November. 2007; p.2008. All authors contributed equally to this work. Hilyatul Fadliyah con- 10. Zambia Ministry of Health. Guidelines for pretesting and evaluating ceived the idea and planned the research. Munih and Sylviasari communication materials; 2015 [Last accessed 26 June 2020]. Risgiantini contributed to the recruitment of the informants. Hilyatul 11. Coronavirus Disease (COVID-19) Preparedness and Response UNFPA Fadliyah, Manendra Muhtar, Munih, Sylviasari Risgiantini, Weny Interim Technical Brief; 2020 [Last Accessed 23 June 2020]. Wulandary carried out research, generated and discussed the 12. Heng Li, Shang-Ming Liu, Xiao-Hua Yu, Shi-Lin Tang, Chao-Ke Tang, results.Munih with support from Weny Wulandary took lead in writing Coronavirus disease 2019 (COVID-19): current status and future per- a draft of the manuscript. Hadi Pratomo directed and supervised this spective, International Journal of Antimicrobial Agents. 2020; 55(5): study right from the begining, overviewed and gave final approval to 105951. the manu script. 13. Scrimshaw NS, Gleason GR, editors. RAP: Rapid assessment procedures; qualitative methodologies for planning and evaluation of health Acknowledgment related programmes. 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92 Sebastian et al. Kesmas: Jurnal Kesehatan Masyarakat Nasional (National Public Health Kesmas: Jurnal Kesehatan Masyarakat Nasional Journal). 2020; Special Issue 1: 93-98 DOI: 10.21109/kesmas.v15i2.3978 (National Public Health Journal) Impact of Lockdown in India: A Case Study Comparing Karnataka with an International Model

Stelvin Sebastian1*, Aby Paul1, ... , Jobin Kunjumon Vilapurathu2

1Pharm D Interns of Nirmala College of Pharmacy, India 2Department of Pharmacy Practice, Nirmala College of Pharmacy, India

Abstract The COVID-19 was declared a pandemic and a global health emergency by WHO, prompting various countries to implement early and stringent social distancing protocols through lockdown, to flatten the epidemic curve. The objective of the present study was to assess the impacts and effectiveness of the lockdown protocol in Karnataka and Punjab, compared with the implementation of this method in Australia and the UK. This study involved the collection of data from different authorized databases, in two phases. The first phase included the time starting with the first-reported index case through the 14th day after the declaration of lockdown, for each country. The second phase involved the data collected between the 15th day through the 28th day of the lockdown. The highest doubling rate for cases was observed in Australia, followed by Karnataka and Punjab, whereas the lowest was observed in the UK. Comparisons of the numbers of the samples tested, the mortality rate, and the recovery rate between Karnataka and Punjab, after the implementation of lockdown, revealed a better recovery rate and lower mortality rate in Karnataka than in Punjab. This study revealed that the implementation of social distancing and lockdown reduced the transmission of the coronavirus and the number of cases reported. However, the effectiveness of lockdown varied among locations, due to demographic and physiological differences.

Keywords: COVID-19, lockdown, outbreak, pandemic, social distancing

Introduction fected individuals, were proposed, resulting in the clo- Infections associated with the novel coronavirus se- sure of all educational institutions, the restriction of non- vere acute respiratory syndrome coronavirus 2 (SARS- essential travel, increased encouragement to work from CoV-2), causing coronavirus disease 2019 (COVID-19), home, and the complete cessation of all public trans- emerged in Wuhan, China, at the end of 2019, and rap- portation.3 The initial plan for 21 days of national lock- idly spread to the United States, France, Italy, Spain, down was followed by another phase of lockdown, last- Iran, South Korea, India, Singapore, Japan, and other ing through May 3, 2020, which helped to flatten the countries. Although the highest death rates were initially curve and hold the mortality rate to 0.25% - 0.5% of to- reported by China, this trend later shifted to European tal positive cases, compared to other developed coun- countries and the United States, forcing the World tries.4 Health Organization (WHO) to declare the COVID-19 The negative impacts of the lockdown were reflected pandemic a global health emergency.1 India implemented in the Indian economy, leading to the greatest economic strict restrictions on the movement of citizens, in accor- emergency since the declaration of Indian independence. dance with the epidemic disease act, on March 25, 2020, The International Monetary Fund has estimated that after a spike in COVID-19 cases was identified. Because India’s Gross Domestic Product (GDP) is likely to India is the second-most populous nation in the world, shrink, from 4.5% to 1.9%, due to the economic crises the risk for a pandemic outbreak was thought to be espe- in the fields of marketing, industry, and networking.5 cially high, due to undeveloped slum areas, unhygienic Although India received a helpful contribution of approx- lifestyles, and the lack of health facilities.2 Non-pharma- imately US $ 1 billion from the World Bank, to combat ceutical forms of infection prevention, such as "social COVID-19, the impending financial crisis is inevitable.6 distancing", intended to prevent direct contacts with in- However, the complete lockdown of India also had pos-

Correspondence*: Stelvin Sebastian, Pharm D Intern of Nirmala College of Received : July 2, 2020 Pharmacy, Nirmala College Road, Kizhakkekara, Muvattupuzha, Kerala 686661, Accepted : July 3, 2020 India, Email: [email protected] Published: July 31, 2020

Copyright @ 2020, Kesmas: Jurnal Kesehatan Masyarakat Nasional (National Public Health Journal), p-ISSN: 1907-7505, e-ISSN: 2460-0601, SINTA-S1 accredited, http://journal.fkm.ui.ac.id/kesmas, Licensed under Creative Commons Attribution-ShareAlike 4.0 International Kesmas: Jurnal Kesehatan Masyarakat Nasional (National Public Health Journal). 2020; Special Issue 1: 93-98 itive effects, especially those associated with the environ- uring, the population will always take the same amount ment, as an overall reduction in pollution has been ob- of time to double.10 served in metropolitan cities. Additionally, during the The exponential solution for a linear equation used to spring and summer seasons, the rate of progression for describe the relationship between cumulative case num- the coronavirus is expected to be slower.7 bers and time is as follows: The state Karnataka, in India, has achieved worldwide recognition for its efforts to prevent the spread of PT = P0 * bT COVID-19, starting at the beginning of the pandemic, as part of the restrictions enacted by the government.8 As where PT is the cumulative number of cases, reported as Karnataka has continued its long and sustained battle to a function of time (T), P0 is the initial case reported, and blunt the impacts of coronavirus, one-third of its districts b >1 indicates exponential growth. have managed to keep the pandemic at bay. Although 18 We fit a linear, discrete, dynamical system model to deaths have been reported through April 25, 2020, the the cumulative increase in reported cases, to determine strict enforcement of lockdown appears to have helped, the doubling time, as follows: as 10 of 30 districts that have not reported a single 9 COVID-19 case, thus far. Another state in India, Doubling time, Tdouble = log (2) / log (b) [where b > 1] Punjab, followed strict curfew strategies and showed a reduction in mortality rate, up to 0.5%, and has con- The doubling rates of the various regions were used trolled the number of new cases reported. When com- to compare the effectiveness of the lockdown protocol in pared with other states in India, both of these states have each region. The doubling rate from the first-reported in- been exceptional in addressing this pandemic, utilizing dex case through the 14th day of lockdown and the dou- digital technologies for contact tracing and community bling rate between the 15th and 28th days of lockdown surveillance. Thus, this study aimed to assess the impacts were analyzed. Higher doubling rates indicate a reduced and effectiveness of the lockdown procedures implement- rate of spread and a more effective lockdown protocol. ed in Karnataka and Punjab, compared with the methods Increases in the doubling rates were analyzed for implemented in Australia and the United Kingdom (UK). Karnataka, Punjab, Australia, and the UK. Moreover, the percentage reduction in the cases was assessed, relative Method to the number of cases that were predicted without the A prospective, observational study was performed, to implementation of lockdown, to determine the effective- assess and compare the impacts of lockdown implemen- ness of the lockdown protocol for each region. tations between Karnataka, Punjab, Australia, and the The daily reported data for the number of new cases, United Kingdom (UK). The study involved the collection the number of recovered patients, the mortality rate, the of data from authorized databases, performed in two number of samples tested, and total cases reported ob- phases. The first phase included the time from the first- tained before and after lockdown, through the 28th day, reported index case through the 14th day after the decla- from WHO sites and official medical bulletins. ration of lockdown, in each. The second phase involved Statistical analysis was performed using software for the data collected between the 15th day and the 28th day statistical analysis. Demographic variables, including the of lockdown. This division was based on the incubation age and gender of COVID-19 patients in Karnataka, were period for the virus, which can be as long as 14 days; assessed and presented as percentages. The ages of pa- therefore, cases reported during the first 14 days of lock- tients who tested positive for COVID-19 during both down may have been acquired prior to the commence- phases of lockdown were also assessed. The percentages ment of lockdown. The authors collected data for cumu- of active and recovered cases were analyzed. The growth lative cases, active cases, recovery rate, death rate, and rates in the numbers of reported cases were measured the number of tests performed, for each of these time in- during pre- and post-lockdown phases. tervals. The ratio between positive case numbers and the The testing strategies for Karnataka and Punjab were number of tests performed was also assessed, to analyze analyzed. The total populations of both states and the to- the preparedness and testing strategies of the different tal number of samples tested, before April 1, 2020, and regions. between April 1 and April 25, 2020, were assessed. The The effects of lockdown were evaluated by comparing ratio between the total number of tests performed and the doubling time for each region. The doubling time of the total population was determined for both periods. an infectious disease or epidemic, in a population that is The number of tests required to detect a positive case exhibiting exponential growth, refers to the time neces- was also assessed, as the ratio between total cumulative sary for the infected population to double. Implicit in this COVID-19 cases and the number of tests performed. definition is the fact that no matter when you start meas- The comparisons of the death rate and recovery rate

94 Sebastian et al, Impact of Lockdown in India were expressed in percentages and represented as bar tested a larger proportion of its population than dia grams. Karnataka. Based on the population, more tests were nec- The doubling rates and the predictions of the total essary to identify a case in the suspected population after numbers of cases were calculated by assuming that case a lockdown in Punjab (Table 2). growth represented an exponential model. The equation Comparisons of the recovery rates, death rates, and of the line was used to assess the doubling rates and pre- total cases between Karnataka and Punjab showed an in- dictions, and R2 values were assessed to evaluate the creased recovery rate and a reduced mortality rate for model fitness. Karnataka compared with Punjab after April 1, 2020, The doubling rate and case projections were analyzed whereas Punjab showed a higher recovery rate and re- in two phases, to analyze the efficiency of the lockdown duced mortality rate than Karnataka before April 1, 2020 in each assessed region. Improvements in the doubling rates between pre- and Table 1. COVID-19-Positive Cases in Karnataka, India, Distributed by Age post-lockdown conditions were assessed, and the impacts COVID-19-Positive of the lockdown were assessed as the percentage reduc- Age (years) tion in the occurrence of actual cases relative to the num- Before April 1, 2020 April 1–April 25, 2020 ber of predicted cases. 0–5 0 7 5–10 4 14 Results 10–20 16 42 In Karnataka, between January 25, 2020, and April 20–30 21 122 30–40 27 125 25, 2020, 500 cases of COVID-19 were identified, in- 40–50 14 67 cluding the index case, among which 158 (32%) reco - 50–60 8 52 vered, 324 (64%) remained active cases, and 18 (4%) > 60 20 71 died. Of these 500 cases, 356 were men and 144 were women (Table 1). Table 2. Numbers of COVID-19 Tests for the Total Population The average daily growth rate in positive COVID-19 State Karnataka Punjab cases, which was 13.52% from March 8 until the implementation of lockdown, was reduced to 4.15% after the Total population 6,6834,193 3,073,507 implementation of lockdown. The cumulative growth No. of samples tested before April 1, 2020 3,254 1,260 Total test / population before April 1, 2020 20,539.09 24,392.91 rate for positive COVID-19 cases in Karnataka declined, No. of samples tested till April 25, 2020 35,378 13,270 compared with the cumulative growth rate in COVID-19 Total test / population through April 25, 2020 2,325.153 2,316.132 cases for all of India (Figure 1). Tests required to identify a positive case in the suspected population before April 1, 2020 285.2651 27.08696 Examining the number of samples tested for suspect- Tests required to identify a positive case in ed COVID-19-positive cases showed that Punjab had the suspected population through April 25, 2020 5.432 7.4955

Figure 1 – Total Positive COVID-19 Total Cases in India, Karnataka, and Bengaluru

95 Kesmas: Jurnal Kesehatan Masyarakat Nasional (National Public Health Journal). 2020; Special Issue 1: 93-98

(Figure 2). days (R2 = 0.97). The doubling time after the lockdown To determine the impact of lockdown, we divided the in the UK was found to be 4.06 days (R2 = 0.959). examined period into two phases. The first phase includ- Although the UK improved the overall doubling rate be- ed the time from the first-reported index case through 14 cause of lockdown, an extension of lockdown is necessary days after the declaration of lockdown. We assumed that to increase the doubling time. cases reported during the first 14 days of lockdown may The efficiency or the impact of lockdown for reducing have been acquired before the lockdown declaration, due the infection spread can be determined by assessing the to the incubation period of COVID-19. During the se - rise in the doubling rate from the first phase to the second cond phase, we included the period starting 14 days after phase. The largest observed increase in the doubling rate the declaration of lockdown. occurred in Karnataka (2.41 days), followed by Punjab Karnataka reported its first COVID-19 case on March (1.49 days). The doubling rate in Australia increased by 9, 2020. Then, a complete lockdown was initiated on 0.92 days, whereas the lowest increase was observed for March 25, 2020. During the lockdown period, approxi- the UK, which was 0.26 days illustrating the necessity of mately 428 cases were reported. The doubling time be- prolonging the lockdown rate and implementing stricter fore lockdown for Karnataka was calculated to be 6.35 measures for disease control in the UK. days (R2 = 0.89). The overall doubling time during the The percentage in case reduction attributed to lock- lockdown phase was found to be 2.46 days (R2 = 0.96), down was determined relative to the predicted cases and and the doubling rate for cumulative cases decreased af- was found to be highest for Punjab (95%) and the lowest ter the initiation of lockdown. for the UK (74%) (Table 3). In Punjab, 332 cases were reported, with 17 deaths. Their first index case was reported on March 5, 2020, Discussion and they declared complete lockdown on March 25, The COVID-19 epidemic caused a unique and alarm- 2020. During the lockdown period, Punjab reported ap- ing situation, requiring the implementation of new strate- proximately 309 cases. The doubling time for Punjab, be- gies to control the transmission of infection. In this study, fore the lockdown was determined to be 4.85 days (R2 = we assessed the impacts of lockdown in four regions, in- 0.87). The doubling time for Punjab after the lockdown clude Karnataka, Punjab, Australia, and the UK, to pro- was found to be 3.35 days (R2 = 0.87). vide a comprehensive analysis of the COVID-19 out- In Australia, 6,675 total COVID-19 cases and 78 break. We analyzed the estimated epidemic size when so- deaths were reported through April 25, 2020. They an- cial distancing was activated in different regions, on dif- nounced a lockdown on March 23, 2020, which was 58 days after the diagnosis of the index case, on Jan 25, 2020. By the time lockdown was implemented, approximately 5,285 cases were reported. The doubling time lockdown in Australia was found to be 8.13 days (R2 = 0.95). During the second phase, we examined the period after the 14th day of the declaration of lockdown, and the overall doubling time for this period in Australia was 7.2 days (R2 = 0.97) In the UK, 119,908 positive cases and 15,464 deaths were reported through April 25, 2020. They announced a lockdown on March 23, 2020, which was 53 days after the first-reported index case, on January 31, 2020. During this lockdown period, the UK reported approximately 114,221 COVID-19-positive cases. The doubling Figure 2. Comparisons of the Death Rates, Recovery Rates, and Total Cases time before the lockdown in the UK was found to be 4.32 between Punjab and Karnataka

Table 3. COVID-19-Positive Projections, with and without Lockdown

Total Cases Place Percentage Reduction from Predicted Cases Reported with Lockdown Predicted without Lockdown

UK 114,221 436,665.6 73.85% Australia 5,285 23,830 77.83% Karnataka 428 4,953.561 91.35% Punjab 309 6,697.687 95.33%

96 Sebastian et al, Impact of Lockdown in India ferent dates, by determining the doubling time. An in- a lockdown strategy, maintaining a fine balance between crease in the doubling time implies a slowdown in trans- allowing normal economic activities and controlling mission.11 The highest doubling rate was identified for COVID-19. Punjab's COVID-19 action plan, which con- Australia, followed by Karnataka and Punjab, whereas sisted of a task force to contain the spread of the corona- the lowest was identified for the UK. However, as a result virus, required changes in human behavior, including of the lockdown, the rise in the doubling rate was the maintaining physical distances, limiting mobility, and highest for Karnataka and the lowest for the UK. performing rigorous personal hygiene.15 Compared with the number of predicted cases if lock- Australia’s COVID-19 plans were also highly success- down had not been implemented, the number of cases re- ful in flattening the curve of the new COVID-19 cases ported after the implementation of lockdown was signifi- through April 25, 2020, with 6,675 total cases and 78 cantly lower than the number that was predicted without deaths reported. The emergency response plan of the lockdown. Thus, the lockdown implementation likely Australian health sector was successfully implemented lowered the epidemic spread in all 4 regions. Rodriguez, by the government, to allow the population to continue et al.,12 observed an increasing trend in the doubling time living and working in a COVID-19-safe manner. They for the coronavirus among the Chinese population during are now capable of keeping the number of cases low February 2020. while taking steps to relax restrictions.16 As a part of the When comparing the numbers of samples tested, the drastic lockdown, they closed their borders to non-resi- mortality rates, and the recovery rates between Karnataka dents, enacted stringent social distancing protocols, and and Punjab, after the implementation of lockdown, an were able to mitigate the rapid spread of the increased recovery rate and a reduced mortality rate were coronavirus.17 observed for Karnataka compared with those in Punjab, The UK government was well-prepared for disease and Karnataka also displayed a high rate of sample test- outbreak, as they learned during the outbreak of an in- ing compared with that in Punjab. A similar study sug- fluenza pandemic, over a decade ago.18 The overall phas- gested that to control the epidemic size and death rate, es of the UK COVID-19 action plan included the con- earlier social distancing rules should be followed, without tainment, delay, and mitigation of any outbreak, using lockdown.13 As Karnataka continues its long and sus- research to inform policy development. Based on the tained battle to blunt the impacts of COVID-19, through available scientific evidence, they were focused primarily the use of a functional disease surveillance system, one- on the continuity of public, the stability of the economy, third of its districts have managed to keep the pandemic and the provision of critical services in the fight against at bay. COVID-19.19 The other preventive measures included When the demographic features of Karnataka were social distancing, information campaigns regarding per- compared with those of other countries, age and gender sonal hygiene, and rapid testing. Thus, the UK continues were found to be significant factors for determining the to respond robustly to various pandemic outbreaks, to impacts of lockdown. Similar to the observations report- maximize the effectiveness of their public health and care ed globally, the majority of COVID-19 patients identified system.20 in the state of Karnataka are between 30 and 40 years of Our study is subject to some inherent limitations, in- age. Almost 500 total cases were reported, of which 32% cluding the under-reporting of cases due to under-diag- of them recovered and more than 64% of cases remained nosis, the unavailability of data regarding mortality, test- active. The death rate was maintained under 4%, as part ed cases and confirmed cases from different countries. of Karnataka's contingency action plan for the control of the epidemic. The plan included a strategy consisting of Conclusion community surveillance, quarantine, fever clinics, Our study reveals that the implementation of social COVID-19-specific hospitals, multiple testing centers, distancing and lockdown impacted the transmission of personal protective equipment, and a rapid response coronavirus and the number of cases reported. However, team for COVID-19 disaster management.14 After the the effectiveness of lockdown varied among regions, de- outbreak of the coronavirus, the government of pending on multiple factors, including demographic vari- Karnataka executed a strict protocol, including the clo- ables, population density, and social gathering. sure of educational establishments, the prevention of Therefore, lockdown appears to represent an effective non-essential travel, the maintenance of hygiene and method for flattening the exponential curve associated physical distancing, and screening, at all airports, railway with the COVID-19 pandemic. stations, and state borders. In Punjab, the first case was reported on March 5, 2020, and through April 25, 2020, Abbreviations approximately 309 confirmed COVID-19 cases were re- SARS-CoV-2: Severe Acute Respiratory Syndrome Coronavirus 2; ported, with a 5% mortality rate. They also implemented COVID-19: Coronavirus disease 2019; WHO: World Health

97 Kesmas: Jurnal Kesehatan Masyarakat Nasional (National Public Health Journal). 2020; Special Issue 1: 93-98

Organization; GDP: Gross Domestic Product; UK: United Kingdom. 5. Paital B, Das K, Parida K S. Inter nation social lockdown versus medic al care against COVID 19, a mild environmental insight with Ethics Approval and Consent to Participate special reference to India. Science of the total environment. 2020: 20; Not Applicable 31 6. Chaudhury DR. USA announces a $2.9 million package to help India Competing Interest combat COVID-19; 2020. There are no conﬂicts of interest. 7. Oliveiros B, Caramelo L, Ferreira N C, Caramelo F. Role of temperature and humidity in the modulation of the doubling time of Covid19 Availability of Data and Materials cases. medRxiv; 2020. The datas used and/or analysed during the current study are available 8. COVID-19 India; 2020 [Retrieved: 2020-04-03]. from the author on reasonable request. 9. Yediyurappa B S. Health department bulletin. COVID-19 Information Portal of Government of Karnataka; 2020. Authors’ Contribution 10. Cornette JL, Ackerman RA, and Nykamp DQ. Doubling time and half- Stelvin Sebastian and Aby Paul conceived the study and drafted the re- life of exponential growth and decay. Math Insight; Accessed May 16, search protocol. Stelvin Sebastian, Aby Paul, Jeeva Joseph and Joel Joby 2020. provided critical review of and approved the study design. Sanjo Saijan 11. Lau H, Khosrawipour V, Kocbach P, Mikolajczyk A, Schubert J, conducted the database searches. Aby Paul made the primary selection Bania J, et al. The positive impact of lockdown in Wuhan containing of eligible papers including data extraction. Jeeva Joseph, Aby Paul and the COVID 19 outbreak in China. Journal of Travel Medicine. 2020; Jobin Kunjumon Vilapurathu supervised and checked the study selec- 27 (3): taaa037. tion process and data extraction. Sanjo Saijan analysed the data. All au- 12. Rodriguez M K, Chowell G, Cheung C, Jia D, Lai P Y, Yiseul L, et al. thors contributed to interpretation of the analysis. Stelvin Sebastian Doubling time of the COVID-19 epidemic by Chinese Province. and Aby Paul wrote the manuscript. All authors provided critical review MedRxiv; 2020. and approved the ﬁnal manuscript. 13. Zhang Y, Jiang B, Yuan J, Tao Y. The impact of social distancing and epicenter lockdown on the Covid-19 epidemic in mainland china: a da- Acknowledgment ta-driven SEIQR study; 2020. Sincere gratitude to our beloved researchers, friends, and family. 14. Ministry of Health and Family Welfare Government of India. Containment plan for the large outbreak novel coronavirus disease Additional Information 2019 (COVID-19); 2020. Stelvin Sebastian1*, Aby Paul1, Jeeva Joseph1, Joel Joby1, Sanjo Saijan1, 15. Lockdown Exit Strategy-Punjab; 2020. Jobin Kunjumon Vilapurathu2 16. Prime Minister of Australia. Update on coronavirus – Australia; 2020. 17. Markham F, Smith D, Morphy F. Indigenous Australians and the 1Pharm D Interns of Nirmala College of Pharmacy, India; 2Department COVID-19 crisis: perspectives on public policy centre for Aboriginal of Pharmacy Practice, Nirmala College of Pharmacy, India. Economic Policy Research. Australian National University; 2020 18. Department of Health & Social Care. Coronavirus action plan: a guide References to what you can expect across the UK; 2020. 1. Suresh V. The 2019 novel coronavirus outbreak- An institutional 19. Sun K, Chen J, Viboud C. Early epidemiological analysis of the coron- guidelines. Indian Journal of Anesthesia 2020; 64 (3): 242-3. avirus disease 2019 outbreak based on crowdsourced data: a popula- 2. Levush R. FALQs: India's government response to COVID-19. Library tion-level observational study. Lancet Digital Health 2020; 2: e201-8. of congress; 2020. 20. Kobie N. This is how the UK is strengthening its coronavirus defenses. 3. Chandrashekhar V.1.3 billion people. A 21day lockdown. Can India Wired.co.uk; 2020 [archived from the original on 2 March 2020, re- curb the coronavirus. ScienceMag.org; 2020. trieved 2 March 2020] 4. Daniyal S. India is enforcing the harshest and most extensive COVID- 19 lockdown in the world; 2020.

98 Mukhlida et al. Kesmas: Jurnal Kesehatan Masyarakat Nasional (National Public Health Kesmas: Jurnal Kesehatan Masyarakat Nasional Journal). 2020; Special Issue 1: 99-104 DOI: 10.21109/kesmas.v15i2.3958 (National Public Health Journal) Review of Trial Therapies and Treatment for COVID-19: Lessons for Indonesia

Halma Zahro Mukhlida1*, Gunanti Khairunnisa2, Rindu3,...

1Department of Nursing, Sekolah Tinggi Ilmu Kesehatan Indonesia Maju 2Department of Vocational (Health Insurance), Sekolah Tinggi Ilmu Kesehatan Indonesia Maju 3Department of Public Health, Sekolah Tinggi Ilmu Kesehatan Indonesia Maju

Abstract The infectious disease from Coronavirus Disease 2019, or COVID-19, has quickly spread world-wide since 2019. Therapies for managing COVID-19 have yet to be confirmed as medication for the severe sickness that the disease may cause. This study aimed to review the previous research of the efficacy of trial therapy and treatment to the patients in the hospital with COVID-19. Using PRISMA guidelines as a method for conducting a systematic literature review, a total of 67 articles were collected from several online journal databases. Various therapies were found that are effective in the treatment and management of COVID-19. In accordance with the inclusion and exclusion criteria of this study, a total of 8 articles were selected. The study showed that several therapies are effective in managing the severe illness, can be used as COVID-19 treatment. Combination of medicine have shown the effectiveness of clinical improvements and recovery rate in a short time compared to single medicine. Nevertheless, further study into effective therapies for COVID-19 must be continued to find the best therapy and treatment.

Keywords: Clinical improvement, COVID-19, effective therapy, management treatment

Introduction thera py and to implement mechanical ventilation based The emergence of the infectious disease known as on the clinical diagnosis of patients.10-12 The purpose of Coronavirus Disease 2019 (COVID-19) began in Wuhan this study was to review the previous research of the ef- at the end of 2019.1 The causative agent of COVID-19 is ficacy of trial therapy and treatment to the patients with the same as the virus from severe acute respiratory syn- COVID-19. The study emphasizes that effective therapy drome (SARS) disease. The first infection of SARS was for COVID-19 to the patients should be able to accele - found in the South China last month in 2002.2 rate the recovery of patients and the symptoms of The virus has spread rapidly worldwide, and was re- COVID-19 suffered by patients are not getting worse in ported by the World Health Organization (WHO) in Indonesia. January 30, 2020.3 Thus far, as of June 2020 the corona - virus has affected 215 countries and territories, with over Method 6,190 confirmed cases, and over 376,300 deaths.4 In The research used Preferred Reporting Items for Indonesia, cases confirmed by the Ministry of Health are Systematic Reviews and Meta-Analyses (PRISMA) guide- over 28,200 and confirmed deaths over 1,600 cases.5 lines for conducting a systematic literature review.13,14 COVID-19 is a respiratory disease which can cause Authors chose relevant study published from January fatigue, fever, dry muscle aches, coughs, shortness of 2020 to March 2020, by searching Pubmed, Science breath and in some instances lead to pneumonia.6,7 The Direct and Google Scholar, with a total of 67 articles most common means of transmission occurs person to found. person, including amongst family members, and also The search terms used were "Coronavirus Disease from healthcare workers.8,9 There is no agreed medica- 2019", "Novel Corona Virus 2019", "The Therapy for tion to help recovery from COVID-19; the management Coronavirus Disease", "The Treatments for Severe Acute of medication is based on each patient’s sign and symp- of COVID-19”. Only articles written in English were con- toms. The WHO advises to apply empiric antimicrobial sidered. The study was focused on the treatment of

Correspondence*: Halma Zahro Mukhlida, Departemen Keperawatan, Sekolah Received : June 4, 2020 Tinggi Ilmu Kesehatan Indonesia Maju. Jl. Harapan No.50 Lenteng Agung, Accepted : June 19, 2020 Jakarta,12610, Indonesia. Email: [email protected], Phone: Published: July 31, 2020 +62-877-8076-7822

SARS, virus MERS-Cov and SARS-CoV. Inclusion crite- liver injury case, and one poor diet case), while study ria for this study are only articles on therapy and treat- Chen, et al.,20 found that FPV increased serum uric acid ment of COVID-19 given to patients in hospitals or (16 /116), with OR = 5.52 at p-value of less than 0.005). health services. While the exclusion criteria of this study LPV/RTV patients had five cases of diarrhea, five vo- are articles on COVID-19 prevention treatments in the miting cases, six nausea cases, four rash cases, three liver community. The screening was conducted by reading the injury cases, and two cases of chest tightness and palpi- title, abstract, and full text of the articles. tation. Two patients in the group of Arbidol was diag- Eligible studies on therapies and treatment for mana - nosed with leukopenia (white blood cell count < 4 x ging COVID-19 to the patients were perfomed in a sys- 109/L). In one study which combined Arbidol with tematic review table. This table showed the author and LPV/r, 68.7% of patients demonstrated elevated levels year; country of publication of the trial therapy or treat- of bilirubin, with a top mean of 25.26 μmol/L (10.61 ment; population/data source; efficacy measure; adverse μmol/L). events; and lessons learned. Interpretation of the data is Not only the use of drugs, but also treatment by pro- done by using qualitative and quantitative approach. The gressive muscle relaxation and sunbathing can also in- qualitative approach involved interpreting tables and crease healing (Table 2). Progressive muscle relaxation is learning the lessons, while the quantitative approach in- useful in reducing stress for COVID-19 patients, espe- cluded assessing the efficiency rate of the therapy and cially in hospitals. treatment reviewed. Discussion Results Based on the results of this study, it appears that there A total of 67 articles were obtained from three sources are drugs that can be used to cure patients of COVID-19; (Figure 1); 16 articles from Google Scholar, 24 articles for example, antiviral and antimalarial medicines, such from Pubmed, and 27 articles from Science Direct. Three as Lopinavir/ Ritonavir, Fapiviravir, Arbidol, and articles from these sources were copied articles. After Hydroxy chloroquine. The study results of Zhu, et al.,16 screening by reading 64 abstracts, 28 articles were ex- show that the side effects that need to be considered included since they discussed preventive thera py in the community, such as physical distancing, use of face masks, or the symptoms of COVID-19. After screening by reading the whole 36 articles, 28 articles were excluded since they only discussed the contain of medicines recommended for therapeutic use or treatment for COVID- 19. Therefore, the included articles according to the inclusion and exclusion criteria of this study were eight quantitative studies. Table 1 shows the systematic literature review of the efficacy of therapy for managing COVID-19, while Table 2 shows the review of the efficacy of treatment for managing COVID-19. A total of eight studies were selected for the review, showing that various therapies and interventions were effective in handling COVID-19. Based on Table 1, a combination of medicines was better than one type of medicine. The level of clinical patient improvement on day 14 was higher in the Lopinavir (LPV) - Ritonavir (RTV) group than in the standard care group (45.5% vs 30.0%). In the study of Arbidol combined with LPV/r (Lopinavir/Ritonavir), after 14 days in 15 (94%) out of 16 patients, COVID-19 could not be detected at p-value of less than 0.05. After six days of treatment, all the six patients (100%) at the group of Hydroxychloroquine combined with Azithromycin were tested negative of COVID-19. Table 1 also shows the evaluation of the adverse 17 events of the reviewed studies. Study Cai, et al., Figure 1. PRISMA Diagram Flow of the Efficacy of Therapy and Treatment Favipiravir (FPV) patients had two cases of diarrhea, one for Managing COVID-19

100 Mukhlida et al, Review of Trial Therapies and Treatment for COVID-19

Table 1. Systematic Literature Review the Efficacy Therapy for Managing COVID-19

Author Year Country Population / Data Source Therapy Efficacy Measure Adverse Event Lesson Learn

Cao et al.,15 2020 China When adult patients have un- Lopinavir (LPV) – Clinical improvement Lopinavir/Ritonavir: Lopinavir-Ritonavir der treatment of COVID-19. Ritonavir (RTV) at day 14: four serious gastro- treatment more effective RTV and LPV with standard versus standard care The LPV and RTV are intestinal. beyond standard care care group 99 patients. Only 45,5 % and standard Standard care: only. standard care 100 patients. care only are 30%. respiratory failure, acute kidney injury, and secondary infection common in the Zhu, et al.,16 2020 China After laboratory checked, 50 Arbidol monothera- On day 14, viral Diagnosed with leuko- Arbidol monotherapy patients conﬁrmed with py versus Lopinavir/ load Arbidol group penia: more effective than COVID-19. They are divided Ritonavir was detectable in Lopinavir/Ritonavir Lopinavir-Ritonavir into two groups: including all the patient. group: 1 patient; Arbi- lopinavir/ritonavir group Lopinavir / Ritonavir dol group: 2 patients (34 cases) and Arbidol group was found in 44.1% (16 cases). Cai, et al.,17 2020 China Patients of COVID-19 were Favipiravir (FPV), Viral clearance and FPV patients had (2 FPV more effective screened in The Third versus Lopinavir chest imaging rate: diarrhea, 1 liver injury, treatment for SARS- People’s Hospital on (LPV)-Ritonavir FPV (4 day, 91.43 %), 1 poor diet). Cov-2 patients during Shenzhen. FPV (35 Patients), (RTV) LPV/RTV (11 day, LPV/RTV patients had the growth and settle- LPV/RTV (45 patients) 62.22%) (5 diarrhea, 5 vomiting, ment of viral virus. 6 nausea, 4 rashes, 3 liver injury, 2 chest tightness and palpita- tion). Gautret, et al.,18 2020 France The population located in Hydroxychloroquine After 6 day of inclu- Potential risk has not Hydroxychloroquine Marseille at the University only versus combined sions, a number of been established yet treatment is significant- Hospital. with Azithromycin negative patients: ly associated with the Hydroxychloroquine group Hydroxychloroquine reduction of the virus (14 patients), with Azithromycin disappearance and Azi- Hydroxychloroquine with (6/6 patients, 100%) thromycin reinforced its Azithromycin (6 patients), Hydroxychloroquine effect. control patients (16). only (3 /13 patients, 57.1%), control patients (2/16 patients, 12.5%). Deng, et al.,19 2020 China Included adults (age ≥18 Arbidol combined After 14 days, the The proportion of pa- The apparent favorable years old) with laboratory- with LPV/r versus SARS-Cov-2 was not tients who demonstrat- clinical response with conﬁrmed COVID-19 LPV/r alone detected in therapy ed elevated levels of bi- Arbidol and LPV/r sup- without invasive ventilation using Arbidol combin- lirubin were 68.7%, ports further LPV/r and patient were given oral ed with LPV/r in with a top mean biliru- only. Arbidol and LPV/r in the more than 94% pa- bin was 25.26 μmol/L; combination group and oral tients. While Arbidol 43.7% of patients de- LPV/r only in the monothe- monotherapy only monstrated digestive up- rapy group. worked in 52.9% sets, such as mild diar- patients. Improving rhea and nausea, but all the chest CT scans. patients had no prema- 11(69%) of 16 pa- ture discontinuation se- tients in the combinat- condary to adverse ion group after seven effects. days, compared with 5 (29%) of 17 in the Monotherapy group. Chen, et al.,20 2020 China An entire data of 240 pa- FVP against Arbidol After 7 days of the cli- The highest frequently Favipiravir equaled to tients with COVID-19 pneu- nical recovery rate of observed Favipiravir - Arbidol, did not impor- monia were hired from the Favipiravir group 71 coalition adverse event tantly to improve the three hospitals (120 from from 116 patients, the was elevated serum uric medical recovery rate Zhongnan Hospital of Wuhan Arbidol group only 62 acid (16/116). on day 7. University (ZNWU), 88 from from 120. Favipiravir importantly Leishenshan Hospital (LSS), Favipiravir controlled recover the latency to and 32 from The Third People's to petite latencies to respite for pyrexia and Hospital of Hubei Province relief for two of pyrexia cough. (HBTH) and cough. clude two patients who had leucopenia when using ver injury. The advice to medical personnel in Indonesia Arbidol. Another effect found in the study by Cai, et is that they should also pay attention to these side effects al.,17 was that using FPV that can cause diarrhea and li- if some of these therapies will be prescribed to patients

101 Kesmas: Jurnal Kesehatan Masyarakat Nasional (National Public Health Journal). 2020; Special Issue 1: 99-104

Table 2. Systematic Literature Review the Efficacy Treatment for Managing COVID-19

Author Year Country Population / Data Source Therapy Efficacy Measure Adverse Event Lesson Learn

Liu, et al.,21 2020 China 51 patients from Hainan Progressive muscle The anxiety (STAI) No adverse event was Progressive muscle General Hospital, China relaxation score after a 5-day in- found in this study. relaxation can reduce tervention was signifi- anxiety and improve cant (p-value < 0.001). sleep quality in patients The sleep quality score with COVID-19. (SRSS) after the 5-day treatment was meaning- ful (p-value < 0.001). Asyary, et al.,22 2020 Indonesia Only 8% of hospitals are Exposed directly to After daily sunlight ex- No adverse event was Direct exposure to sun- available to care for sunlight posure for a minimum found in this study. light was connected sig COVID-19 patients, being of 3 hours, deaths due niﬁcantly to recovery emergency hospitals in to COVID-19 decreased. from COVID-19 among Jakarta. patients in Jakarta, Indonesia.

Notes: STAI: The Spielberger State-Trait Anxiety Scale; SRSS: Sleep State Self-Rating Scale of COVID-19. for four potential therapies that have been tried. In The results of this study show that a combination of March 2020, the government of Indonesia joined the tri- drugs works better. In the research conducted by Deng, al. et al.,19 it was shown that the combination of Arbidol In Indonesia, there is some development of pharma- and Lopinavir/Ritonavir could accelerate healing for pa- ceutical drug research in herbal trials. Universitas tients of COVID-19. On the 14th day of treatment, 94% Indonesia and the IPB University (Institut Pertanian of patients receiving combination therapy showed nega- Bogor) research teams are also developing this line of tive signs of the SARS COV 2 virus. In research Gautret, study with regard to antibodies and antivirals accessed et al.,18 also combined Hydroxychloroquine with from guava, moringa leaves, and orange peel. These com- Azithromycin in their study. On day 6 post-inclusion, the positions include hesperidin, rhamnetin, kaempferol, number of negative patients was 6/6, 100%. The study quercetin, and myricetin from the mixture of guava (pink by Cao, et al.,15 which combined Lopinavir and Ritonavir fruit skin), orange peel, and moringa leaves.27 The study showed an improvement in the patient's health condition discusses research against the protein, and gathering at 45.5% on day 14. The effects that need attention are herbs related to the work of the virus, obtained several serious gastrointestinal adverse events with Lopinavir related groups to prevent the SARS-CoV-2 virus (corona - and Ritonavir, elevated levels of bilirubin, and digestive virus).27 upsets, such as mild diarrhea and nausea in combined The limitation of this study is to limit studies that have Arbidol with Lopinavir/Ritonavir therapy. been reviewed because there are still many trial therapy Apparently, progressive muscle relaxation can help studies that are being conducted in several other coun- reduce stress for COVID-19 patients. Based on medical tries. This study also did not involve an additional popu- diagnosis, some coronavirus disease patients have sleep lation variation, such as pregnant mothers and children, disturbance and anxiety after isolation therapy. Anxiety so the efﬁcacy and occurrence of adverse events for preg- due to psychological stress could become a trigger of de- nant women and children could not have been explored creased immunity and physiological disorders.23 more in this study. Progressive muscle relaxation (PMR) training reduced the effect of anxiety on the patients, which might happen Conclusion due to the ba lance between the hypothalamic nucleus and Several studies have shown the effectiveness of seve - anterior. By reducing the activity of the sympathetic ner- ral trial therapies and treatment for COVID-19. These vous system, stress and anxiety can be prevented, and used a single drug or a combination of drugs, mostly from physical and mental relaxation can be increased.24 the antiviral class. Progressive muscle relaxation and sun- Sunlight can also be applied to increase healing in pa- bathing treatment can also improve the healing process. tients COVID-19 as triggers the production of vitamin Medical personnel is expected to implement the results D, which strengthens the immune system.25 of this study to COVID-19 patients in Indonesia. Recently, to help progress in the study of the effect- Nevertheless, research about the effective therapies for iveness of several therapies, WHO developed the solida - COVID-19 must be continued to ﬁnd the best therapy rity clinical trial project for COVID-19 treatments.26 The and treatment. Future studies on the treatment of project aims to obtain strong and valid clinical evidence COVID-19 could be related to varying ages and condi-

102 Mukhlida et al, Review of Trial Therapies and Treatment for COVID-19 tions, such as pregnant women and children. (10): 1337–48. 3. Wang L, Wang Y, Ye D, Liu Q. Review of the 2019 novel coronavirus Abbreviations (SARS-CoV-2) based on current evidence. International Journal of COVID-19: Coronavirus disease 2019; SARS: Severe Acute Antimicrobial Agents. 2020; 155 (6): 105948. Respiratory Syndrome; WHO: World Health Organization; PRISMA: 4. World Health Organization. Coronavirus Disease (COVID-19): situa- Preferred Reporting Items for Systematic Reviews and Meta-Analyses; tion reports; 2020. LPV: Lopinavir; RTV: Ritonavir; LPV/r: Lopinavir/Ritonavir; FPV: 5. Kementrian Kesehatan Indonesia. Situasi terkini perkembangan coro - Favipiravir; ZNWU: Zhongnan Hospital of Wuhan University; LSS: navirus disease (COVID-19) 3 Juni 2020. covid-19.kemkes.go.id; May Leishenshan Hospital; HBTH: The Third People's Hospital of Hubei 2020 . Province; STAI: The Spielberger State-Trait Anxiety Scale; SRSS: Sleep 6. Rothan HA, Byrareddy SN. The epidemiology and pathogenesis of State Self-Rating Scale; PMR: Progressive Muscle Relaxation. coronavirus disease (COVID-19) outbreak. Journal of Autoimmunity. 2020; 109: 102433. Ethics Approval and Consent to Participate 7. Liu C, Zhou Q, Li Y, Garner L V, Watkins SP, Carter LJ, et al. Not Applicable Research and development on therapeutic agents and Vaccines for COVID-19 and related human coronavirus diseases. ACS Central Competing Interest Science. 2020; 6 (3): 315–31. The authors declare that they have no competing financial interest. 8. Chan JFW, Yuan S, Kok KH, To KKW, Chu H, Yang J, et al. A fami - lial cluster of pneumonia associated with the 2019 novel coronavirus Availability of Data and Materials indicating person-to-person transmission: a study of a family cluster. The authors confirm that the data supporting the findings of this study Lancet. 2020; 395 (10223): 514–23. are available within the article. 9. Wang D, Hu B, Hu C, Zhu F, Liu X, Zhang J, et al. Clinical characteristics of 138 hospitalized patients with 2019 novel coronavirus-infect- Authors’ Contribution ed pneumonia in Wuhan, China. JAMA. 2020; 323 (11): 1061–9. Halma Zahro Mukhlida, Hilma Hasro Maulida, Gunanti Khairunnisa, 10. Chen C, Qi F, Shi K, Li Y, Li J, Chen Y, et al. Thalidomide combined Margaretha Josephine Mantrono, Rindu, Eka R W Purnamasari, and with low-dose glucocorticoid in the treatment of COVID-19 Rizky Fajar Meirawan created the manuscript. Halma Zahro Mukhlida, Pneumonia; Preprints 2020 (February):1–6. Hilma Hasro Maulida, Gunanti Khairunnisa, and Margaretha Josephine 11. Tobaiqy M, Qashqary M, Al-Dahery S, Mujallad A, Hershan AA, Mantrono collected the literature data. Rindu, Eka R W Purnamasari, Kamal MA, et al. Therapeutic management of patients with COVID- and Rizky Fajar Meirawan review and revised the Manuscript. Risky 19: a systematic review. Infectio Prevention Practice. 2020; 2 (3): Kusuma Hartono supervised and discussed the final result. 100061. 12. Beauchet O, Dubost V, Herrmann FR, Kressig RW. Stride-to-stride Acknowledgment variability while backward counting among healthy young adults. We would like to thanks to Indonesian Government authorities for Journal of Neuroengineering and Rehabilitation. 2005; 2 (1): 26. COVID-19, as well as to Directorate of Laboratorium Riset of Sekolah 13. Tekelab T, Akibu M, Tagesse N, Tilhaun T, Yohanes Y. Neonatal mor- Tinggi Ilmu Kesehatan Indonesia Maju (STIKIM) that made the avail- tality in Ethiopia: a protocol for systematic review and meta-analysis. ability of data, The Head of STIKIM, and all parties and staff that sup- Systematic Reviews. 2019; 8: 103. ported to this study. 14. Fakultas Kesehatan Masyarakat Universitas Indonesia. Writing a protocol (background and objective); 2018. Additional Information 15. Cao B, Wang Y, Wen D, Liu W, Wang J, Fan G, et al. A trial of Halma Zahro Mukhlida1*, Hilma Hasro Maulida1, Gunanti lopinavir-ritonavir in adults hospitalized with severe Covid-19. New Khairunnisa2, Margaretha Josephine Mantrono2, Risky Kusuma England Journal of Medicine. 2020; 382: 1787-99. Hartono2, Rindu3, Eka R W Purnamasari1, Rizky Fajar Meirawan3. 16. Zhu Z, Lu Z, Xu T, Chen C, Yang G, Zha T, et al. Arbidol monotherapy is superior to lopinavir/ritonavir in treating COVID-19. J Infect. 1Department of Nursing, Sekolah Tinggi Ilmu Kesehatan Indonesia 2020; 81 (1): e21-3. Maju; 2Department of Vocational (Health Insurance), Sekolah Tinggi 17. Cai Q, Yang M, Liu D, Chen J, Shu D, Xia J, et al. Experimental treat- Ilmu Kesehatan Indonesia Maju; 3Department of Public Health, Sekolah Tinggi Ilmu Kesehatan Indonesia Maju. ment with favipiravir for COVID-19: an open-label control study. Engineering. Available online March 18, 2020. References 18. Gautret P, Lagier J-C, Parola P, Hoang VT, Meddeb L, Mailhe M, et 1. Lai CC, Shih TP, Ko WC, Tang HJ, Hsueh PR. Severe acute respirato- al. Hydroxychloroquine and azithromycin as a treatment of COVID- ry syndrome coronavirus 2 (SARS-CoV-2) and coronavirus disease- 19: results of an open-label non-randomized clinical trial. International 2019 (COVID-19): the epidemic and the challenges. International Journal of Antimicrobial Agents. 2020; 56 (1): 105949. Journal of Antimicrobial Agents. 2020; 55 (3): 105924. 19. Deng L, Li C, Zeng Q, Liu X, Li X, Zhang H, et al. Arbidol combined 2. Kumar V, Jung YS, Liang PH. Anti-SARS coronavirus agents: a patent with LPV/r versus LPV/r alone against corona virus Disease 2019: a review (2008-present). Expert Opinion Therapeutic Patents. 2013; 23 retrospective cohort study. Journal of Infect. 2020; 81 (1): e1-5.

103 Kesmas: Jurnal Kesehatan Masyarakat Nasional (National Public Health Journal). 2020; Special Issue 1: 99-104

20. Chen C, Huang J, Cheng Z, Wu J, Chen S, Zhang Y, et al. Favipiravir 24. Ferendiuk E, Biegańska JM, Kazana P, Pihut M. Progressive muscle re- versus Arbidol for COVID-19: a randomized clinical trial. medRxiv; laxation according to Jacobson in treatment of the patients with tem- 2020. poromandibular joint disorders. Folia Medica Cracoviensia. 2019; 59 21. Liu K, Chen Y, Wu D, Lin R, Wang Z, Pan L. Effects of progressive (3): 113-22. muscle relaxation on anxiety and sleep quality in patients with 25. Slusky DJG, Zeckhauser RJ. Sunlight and protection against inﬂuenza. COVID-19. Complement Theraphies in Clinical Practice. 2020; 39: National Bureu Of Economic Research: NBER Working Paper Series. 101132. 2018; 1–34. 22. Asyary A, Veruswati M. Sunlight exposure increased Covid-19 recov- 26. World Health Organization. Off-label use of medicines for COVID-19; ery rates: a study in the central pandemic area of Indonesia. Science of March 2020. The Total Environment; 2020: 729: 139016. 27. Universitas Indonesia. Tim FIK UI dan IPB temukan kandidat pence- 23. Rajeswari S and Reddy NS. Efﬁcacy of progressive muscle relaxation gahan virus corona. www.ui.ac.id; 2020. on pregnancy outcome among anxious Indian primi mothers. Iran Journal of Nursing and Midwifery Research. 2020; 25 (1): 23-30.

104 Reviewer Acknowledgment

Reviewer Acknowledgment Kesmas: Jurnal Kesehatan Masyarakat Nasional (National Public Health Journal) Special Issue Volume 1, 2020

Editorial Team of Kesmas: Jurnal Kesehatan Masyarakat Nasional (National Public Health Journal) highly appreciate Dewi Susanna, MS as Handling Editor and really thank all Reviewers for kind assistance in Special Issue Volume 1, 2020:

Al Asyary Rahayu Lubis Aria Kusuma Rahmadewi Besral Ririh Yudhastuti Defriman Djafri Setyowati Dumilah Ayuningtyas Soedjajadi Keman Ede Surya Darmawan Suriah Fridawati Rivai Umar Fahmi Achmadi Gita Miranda Warsito Yodi Mahendradhata Onny Setyani Author Index

Author Index Kesmas: Jurnal Kesehatan Masyarakat Nasional (National Public Health Journal) Special Issue Volume 1, 2020

Aby Paul ...... 93-98 Margaretha Josephine Mantrono ...... 99-104 Achmad Faridy Faqih ...... 77-84 Marina Ioannou ...... 64-69 Acim Heri Iswanto ...... 18-23 Mochamad Iqbal Nurmansyah ...... 49-53 Andree Kurniawan ...... 43-48 Munih ...... 85-92 Badra Al Aufa ...... 49-53 Nanny Harmani ...... 70-76 Bunga Astria Paramashanti ...... 24-27 Raden Roro Mega Utami ...... 1-5 Dessy Paramitha ...... 28-31 Retno Lestari ...... 37-42 Dewi Rokhmah ...... 54-59 Ricko Pratama Ridzkyanto ...... 54-59 Dewi Susanna ...... 6-13 Rindu ...... 99-104 Dumilah Ayuningtyas ...... 1-5 Ririh Yudhastuti ...... 32-36 Eka Rokhmiati Wahyu Purnamasari ...... 99-104 Risky Kusuma Hartono ...... 99-104 Emma Rachmawati ...... 49-53 Rizaldy Pinzon ...... 28-31 Febri Endra Budi Setyawan ...... 37-42 Rizky Fajar Meirawan ...... 99-104 Gunanti Khairunnisa ...... 99-104 Rizma Dwi Nastiti ...... 77-84 Hadi Pratomo ...... 60-63; 85-92 Sang Gede Purnama ...... 6-13 Halma Zahro Mukhlida ...... 99-104 Sanjo Saijan ...... 93-98 Hayyan Ul Haq ...... 1-5 Saraswati Anindita Rizki ...... 43-48 Hilma Hasro Maulida ...... 99-104 Sri Rahayu Slamet ...... 70-76 Hilyatul Fadliyah ...... 85-92 Stelvin Sebastian ...... 93-98 Ibrahim Isa Koire ...... 49-53 Sylviasari Risgiantini ...... 85-92 Izza Suraya ...... 49-53 Tiopan Sipahutar ...... 14-17 Jeeva Joseph ...... 93-98 Tris Eryando ...... 14-17 Jobin Kunjumon ...... 93-98 Victor B. Oti ...... 64-69 Joel Joby ...... 93-98 Vincent Ongko Wijaya ...... 28-31 Khoiron ...... 54-59 Wahyu Sulistiadi ...... 70-76 Kurnia Dwi Artanti ...... 77-84 Weny Wulandary ...... 85-92 Manendra Muhtar ...... 85-92 Subject Index

Subject Index Kesmas: Jurnal Kesehatan Masyarakat Nasional (National Public Health Journal) Special Issue Volume 1, 2020

Airport ...... 77-84 Indonesia ...... 6-13; 24-27; 28-31; 32-36 Burnout ...... 18-23 Indonesia Case Fatality Rate ...... 14-17 Case Fatality Rate ...... 14-17 Information ...... 70-76 Clinical improvement ...... 99-104 Lockdown ...... 93-98 Cloth face mask ...... 32-36 Management treatment ...... 99-104 Cloth mask ...... 43-48 Mask crisis ...... 32-36 Communication ...... 70-76 Neurologic disorder ...... 28-31 Constitutional mandatory ...... 1-5 Novel coronavirus ...... 24-27 Corona outbreak ...... 18-23 Outbreak ...... 93-98 Coronavirus ...... 37-42 Pandemic ...... 32-36; 37-42; 64-69 COVID-19 ...... 1-5; 6-13; 24-27; 28-31; Physical distance ...... 60-63 32-36; 49-53; 54-59; 60-63; Pre-testing of IEC material ...... 85-92 64-69; 70-76; 77-84; 85-92; Public stigma ...... 70-76 93-98; 99-104 Sanitation ...... 6-13 COVID-19 Indonesia ...... 14-17 SARS-COV-2 ...... 64-69 COVID-19 pandemic ...... 14-17 Screening ...... 77-84 Education ...... 70-76 Social distance ...... 60-63 Educational video ...... 85-92 Social distancing ...... 93-98 Effective therapy ...... 99-104 Social restriction ...... 49-53 Efficacy ...... 43-48 State responsibility ...... 1-5 Epidemic ...... 93-98 Surgical mask ...... 43-48 Epidemiology ...... 77-84 Surveillance ...... 77-84 Face mask ...... 43-48 Sustainable Development Goals ...... 24-27 Fund management ...... 54-59 Teenagers ...... 85-92 Global civil society ...... 1-5 Telemedicine ...... 28-31 Global Health Security ...... 1-5 Time series analysis ...... 49-53 Health financing ...... 54-59 Travelers ...... 64-69 Health policy ...... 37-42 Viral agent ...... 64-69 Health workers ...... 18-23 Work risk ...... 18-23 Holistic-comprehensive ...... 37-42 Work shift ...... 18-23 Hygiene ...... 6-13 World Health Organization ...... 85-92 Incidence Rate Ratio ...... 49-53 Zero hunger ...... 24-27 SUBSCRIPTION FORM

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