Family members of a COVID-19 victim mourn during a funeral in Jakarta, Indonesia on Mar 31, 2020. (Photo: AFP/Bay Ismoyo)

JAKARTA - CNA
Why Indonesia has the highest COVID-19 fatality rate in Asia

Multiple factors contribute to Indonesia's high COVID-19 fatality rate, including poor general health and gaps in the healthcare system, said experts interviewed by CNA. 

It is widely believed that old age and pre-existing medical conditions play a significant part in the fatality rate. In the case of Indonesia, which has the highest fatality rate in Asia, other factors such as a high incidence of smoking and what is said to be an inadequate early response by the authorities are also key.

Indonesian epidemiologist Pandu Riono said there are many factors which could lead to a COVID-19 death, from the patient's age to the underlying conditions the person had.

"Many Indonesians are generally less fit and this made them more susceptible.

“Most people in Indonesia don’t take care of their lungs well, because most of them are smokers," he noted.

Indonesia has the highest rate of male smokers in the world at about 75 per cent, according to 2015 World Health Organization data.

He added that this is also the reason why many people suffer from cardiac disease, hypertension, and diabetes.

Since Indonesia reported its first COVID-19 death in the middle of March, just less than 10 days after President Joko Widodo announced the country’s first two COVID-19 cases, the fatality rate in the country has been consistently high between 8 per cent and 9 per cent.

This figure, calculated by dividing the number of deaths by the number of cases, is the highest in Asia.

The Philippines' fatality rate is around 6.5 per cent, while the figures for Singapore and Malaysia are around 0.1 per cent and around 1.7 per cent respectively.

The fatality rate in China is around 5.6 per cent, while the numbers for Japan and South Korea are between 2 per cent and 3 per cent.  


GAPS IN HEALTHCARE SYSTEM, INADEQUATE RESPONSE BY AUTHORITIES

Other factors in the equation include the slow response of authorities in the initial stages of the outbreak, Dr Riono added. 

In early March, there was only one laboratory in the entire country which was capable of conducting COVID-19 tests.

Swab test results could not be known quickly, which prevented medical workers from treating patients accordingly. This resulted in a backlog of patients waiting to be treated at hospitals.

The hospitals quickly became overwhelmed. “There were just too many cases all at once,” Dr Riono opined.

Many doctors were also overworked and this, as well as the lack of personal protective equipment (PPE), may have led to the fact that many doctors and medical workers were infected with the disease.

“If authorities had acted quickly and designated many hospitals to specialise in just handling COVID-19 cases, then the human resources, equipment and medications could have been fully optimised in certain hospitals.

“All the beds could be used, thus the fatality rate could have been lower because it would have focused on COVID-19 instead of only treating a certain number of COVID-19 patients limited in the hospitals' isolation rooms,” he said.

Dr Lia Partakusuma, secretary-general of the Association of Hospitals in Indonesia concurred with Dr Riono.

“It could be that a patient was initially mildly ill but then failed to receive proper healthcare while the person became weaker," she said.

Current data shows about half of the country's COVID-19 cases were reported in Jakarta, making it the epicentre of the outbreak in Indonesia. As the health services in Jakarta scrambled to cope, Dr Partakusuma said it is not immediately known if other regions are overwhelmed as well because they do not have as many cases yet. 

However, she is concerned that the other provinces would fare worse than the capital.

“The facilities at regional hospitals are not yet fully adequate. But it is an ongoing process,” she said.

According to data from the World Bank, Indonesia has 1.2 hospital beds for every 1,000 people. In comparison, Malaysia and Singapore have 1.9 and 2.4 respectively.

Dr Partakusuma also noted that the number of tests conducted in Indonesia is considered to be on the low end as compared to other countries in Asia, especially given that it has a population of 260 million. As of Wednesday, Indonesia has conducted about 55,000 tests. 

In comparison, Malaysia has conducted over 115,000 tests, in a population of 32.6 million. Singapore has conducted over 80,000 tests. Its population is 5.7 million.

There are now more than 7,700 COVID-19 cases in Indonesia, with more than 640 reported deaths.



MASSIVE TESTING, MORE RELIABLE DATA NEEDED

Experts broadly agree that there is a need for more COVID-19 tests as well as reliable data, so that a more accurate picture of the pandemic can be seen.

Dr John MacArthur, the Centers for Disease Control and Prevention’s Country Director in Thailand pointed out: “The testing in Indonesia is conducted in a limited manner and usually among those patients who are much sicker”.

“This can result in a higher mortality rate because the denominator is lower, without the large number of asymptomatic or mildly symptomatic cases.”

Professor Zubairi Djoerban, head of the COVID-19 task force at the Indonesian Medical Association added: “We’re now at the tip of an iceberg where the number of reported cases is not equal to the reality where the number of real cases is most likely higher."

“The peak will be between May to June when we have diagnosed about 106,000 people, then the mortality rate would be closer to reality,” Prof Djoerban said.

Already, President Joko Widodo has called for more testing to be carried out, as well as data transparency. The government reportedly said it has increased capacity to conduct 12,000 tests a day.

Those interviewed also pointed out that the data collection process should be improved.

Dr Hasbullah Thabrany, a health expert from think tank ThinkWell Global believes that those who were treated at hospitals were already critically ill, as they were not detected earlier due to lack of testing in the community.

Therefore, it is important that there is data available which shows the number of days COVID-19 patients pass away on average, after testing positive. There should also be more information on what conditions patients were in when they were admitted, he said.

“This will then explain whether the death was caused by the quality of the (health) service or whether the patients were admitted too late.

“If it is the latter, it could be due to a lack of discipline on their side or because they didn’t have access to healthcare,” Dr Thabrany told CNA.

He also said there should be data released on how many people were rejected at hospitals due to overcapacity.

In a press briefing on Thursday, Dr Wiku Adisasmito, the head of the expert team on the national COVID-19 task force explained: “The high mortality rate of COVID-19 for Indonesia at this moment, is due to the limitation of early detection and late diagnosis.”

With efforts to increase laboratory capacity, more human resources and improvements in the quality of data, the mortality data in Indonesia will become more reliable going forward, he predicted.

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