THE MAGIC BULLET: Will a vaccine be enough to stop Covid-19?

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IO – Since it was first reported in December 2020 in Wuhan, China, the Sars-Cov2 (or Covid-19 global pandemic) has entered its tenth month. Citing the data from Worldometers, as of Thursday, October 15, 2020, confirmed infections have reached 38,714,576, and 1,096,065 people worldwide infected with the virus have died. 

Below is the list of countries with the largest number of cases: 

As can be seen, America tops the list. Recently, even President Donald Trump himself caught the virus. This was alarming news as it added to the number of world leaders exposed to the virus, including those who were skeptical of Covid-19. The first world leader to test positive with coronavirus was British Prime Minister Boris Johnson, who was infected in late March, followed by Prime Minister of Russia Mikhail Mishustin who had to be hospitalized on 30 April 2020, due to the severity of his condition. The Prime Minister of Armenia Nikol Pashinyan, along with his wife and four children tested positive on June 1, 2020. The President of Honduras, Juan Orlando Hernandez said he had the virus, on June 16, 2020. And then the President of Brazil, Jair Bolsonaro, followed on July 7, 2020. 

Currently, the number of Covid-19 cases in Indonesia is still on the rise. According to Worldometers data, Indonesia ranks 17th of countries with the highest Covid-19 death toll in the world. In Asia, Indonesia ranks fifth. In Southeast Asia, the Philippines and Indonesia are still the worst-affected countries. Based on the latest data (October 15, 2020), total diagnosed coronavirus cases in Indonesia have reached 349,160. This means Indonesia has overtaken the Philippines for the second time, as the country with the highest number of Covid-19 cases in Southeast Asia, a repeat of its unenviable record set on April 17, 2020. 

Under the coordination of the Head of Covid-19 Task Force/ Head of the National Disaster Mitigation Agency (BNPB) Doni Monardo and the Coordinating Minister for Maritime Affairs and Investment Luhut Binsar Pandjaitan, the number of coronavirus cases in the ten worst-affected provinces hasn’t shown any sign of decreasing in the last month. Based on that data, the number of positive cases was still rising, while the number of recovered fluctuated and even decreased in the last two weeks; the number of deaths also decreased. The ten worst-affected provinces are Jakarta, West Java, Central Java, East Java, North Sumatra, South Kalimantan, South Sulawesi, Papua, Aceh and Bali. These are the designated “priority provinces” as they contribute to 75% of the total Covid-19 cases in the country. 

In terms of Covid-19 deaths, Indonesia also tops the list in Southeast Asia, with 12,268 inhabitants having died as of October 15, 2020. In second place is the Philippines with 6,497 deaths. Asia-wide, India is in first place with 7,307,097 cases and 111,266 deaths. Ranked second is Bangladesh, with 382,959 cases and 5,593 deaths, followed by Indonesia with 349,698 cases and 12,268 deaths. In fourth position is the Philippines, followed by Pakistan with 321,218 cases and 6,614 deaths. (FIGURE-1) 

The five provinces with the highest number of deaths in Indonesia are East Java (3,280), DKI Jakarta (1,755), Central Java (1,444), West Java (480) and North Sumatra (442). (FIGURE-2) 

There are three potential causes of coronavirus-related death, namely, among patients who are already in poor health when they are hospitalized. Furthermore, if the hospitals are full, it will become more difficult to treat patients. Secondly, most patients have pre-existing conditions, such as hypertension, diabetes and heart disease, which can significantly worsen their chances of survival. Lastly, the inadequacy of health care facilities and health workers in hospitals. Due to its large population, Indonesia is struggling to provide equitable access to decent health care. 

 Covid-19 handling in Indonesia 

President Jokowi has set the target for the top ten worst-affected provinces, to reduce their daily confirmed cases, increase the rate of recovery and suppress the death rate. There are several steps that Doni and Luhut must take. First, synchronizing data between central and local governments, in order to make prompter decisions. Second, enforce Covid-19 health protocols by imposing criminal charge against violators. Third, improve Covid-19 patient care management, to lower death toll and increase chances of recovery. Fourth, focus on the handling of emerging Covid-19 clusters in each province. 

According to the Director of the World Health Organization (WHO) Tedros Adhanom Ghebreyesus, the most effective way to control the spread of the virus and save lives is by interrupting the chain of transmission. And to achieve this, it is crucial that countries carry out testing, isolation and contact tracing, all of which have become the cornerstone of Covid-19 response . 

WHO has particularly highlighted the relatively low number of tests in Indonesia. The health body has urged Indonesia to increase its laboratory capacity, so that all suspected cases can be tested immediately. Ideally, positive case numbers can be representative of actual conditions if surveillance is carried out comprehensively and testing is implemented at the rate of 1 per 1,000 population per week. The problem is that only a few regions are able to meet this minimum requirement to detect new cases, such as Jakarta, West Sumatra and West Papua in the last three weeks, and Yogyakarta in the last two weeks. Although West Papua has met the number of required tests, it has seen a very high rate of positive cases which in the period of September 14-20 was above 40%, higher than the WHO threshold of below 5%. On the other hand, South Sumatra and Central Kalimantan have an average positivity rate of 15%-25%. 

In Indonesia, public health experts say that the lack of testing also means that many infected people will slip through the net, thus complicating quarantine measures and exacerbating the spread of the virus. Instead of using a more reliable PCR test through analysis of saliva or nasal swab specimen, Indonesia still widely employs rapid tests whose accuracy is questioned by many health experts. The number of Covid-19 tests in Indonesia in the first week of October was still below the target set by the WHO, which is 267,000 people per week. In the first week of October, the test rate in Indonesia was still recorded at 70.13%. The government said it will continue to increase the test rate to meet the WHO target. As stated by President Joko Widodo, the daily test rate can be boosted to up to 30,000 tests. It’s just that, in fact, almost every day, the Covid-19 test rate is still far below that number. On average, only 20 thousand specimens. Even on weekends and early weekends, the test specimens dropped below 20 thousand due to a lack of human resources and many laboratories taking holidays. 

The number of Covid-19 tests in Indonesia is still low, even when compared to lower-middle-income countries. There is almost no reason why Indonesia’s testing performance is so poor. The budget for handling COVID-19 is quite large. The difficulty in obtaining equipment and reagents is illogical. Poorer countries than Indonesia, such as Bangladesh, Pakistan and the Philippines, are able to perform more tests. Among countries with cases over 10,000, the number of tests in Indonesia is only higher than the 10 low-income and lower-middle-income countries in Africa and one low-income country in Asia, namely, Afghanistan. The low number of tests does not reflect Indonesia’s status as an upper-middle-income country. (FIGURE-3) 

WHO also urges Indonesia to develop a nationwide electronic system to improve contact tracing throughout the country. WHO found that 86% of testing and recording were still done manually using paper and pen, 9% used locally made applications, and the remaining 5% did not reveal their testing procedures. Nationally, contact tracing is very low, at around 3 people. WHO recommends tracking between 10-30 close contacts per one confirmed case. Even in Jakarta, the epicenter of the country’s Covid-19 outbreak, the isolation and tracking ratio (RLI) actually fell, from around 4 in June to less than 2 in September. 

Can vaccine be ready by November 2020? 

Vaccines to treat infectious diseases often take years to develop, involving multiple stages of clinical trials until they are ready for distribution. Even then, the success of a vaccine cannot be guaranteed. To date, only one human infectious disease that is confirmed to have been completely eliminated through mass vaccination, namely, smallpox. However, this success took 200 years in the making, while for the others, we have to learn to live with diseases such as polio, tetanus, measles, mumps and tuberculosis. Our health depends on the vaccine designed to prevent those diseases. 

Clinical trials of Covid-19 vaccines involving thousands of people are now under way. The goal is to see if those vaccine candidates can protect us from the new coronavirus. The trials, which normally would take 5-10 years, from research to implementation, have now been fast-tracked into just a matter of months. At the same time, production volume is doubled. Investors and companies are betting billions of US dollars in search of a potent vaccine. But concerns have been raised about the accelerated process. 

Several countries are now hoping their vaccines will receive a green light for distribution later this year. This, despite WHO’s doubts about the coronavirus vaccine being ready before mid-2021. US infectious diseases expert Dr Anthony Fauci also estimated that Covid-19 vaccine in the US will not be ready before April 2021. In November or December, researchers must determine whether the clinical trials of a number of vaccine candidates are completely safe. If any candidate is proven safe, initial production may only amount to a few million doses. This means that even the Covid-19 vaccine development is successful, there is bound to be scarcity and a black-market price will skyrocket. 

As reported, Italy, Germany, the Netherlands and France have agreed to down-pay an initial deposit of €750 million or US$843.2 million (equivalent to Rp12 trillion at Rp14,000/ US dollar exchange rate) for 300 million doses of candidate vaccines produced by the British pharmaceutical giant As traZeneca Plc. Those countries were also offered the option to purchase 100 million doses of boosters. An Italian news agency also reported that the county is willing to shell out €185 million (equivalent to Rp3 trillion at Rp16,100/ Euro exchange rate) for 75 million doses of a vaccine currently being developed by Oxford University. The Indonesian government has also allocated a budget of up to Rp3.8 trillion to acquire a coronavirus vaccine. This budget is to be used for registration with the Global Alliance for Vaccine and Immunization (GAVI) and Covid-19 vaccine advances. 

The Indonesian government is working on deals with several vaccine companies, from Sinovac, Sinopharm, Cansino to AstraZeneca. A Covid-19 vaccination program to commence in November 2020 will use a Chinese-made vaccine. State-Owned Enterprises Minister Erick Thohir has confirmed that the vaccine will be produced by PT Bio Farma and will be certified “Halal” by the Indonesian Ulema Council (MUI) to ensure that it can be given to a broad cross-section of society. Spokesperson for the Covid-19 Task Force Wiku Adisasmito also added that government will work to ensure the safety of the vaccines. The government is also preparing a road map for a mass vaccination program that will be carried out based on associated risk factors in Indonesian society. The government will also adhere to the principle of “just and equal” when implementing its mass vaccination program. 

The vaccine will be initially prioritized for those who are at the forefront battling Covid-19, as well as several provinces in Indonesia with highest risk of a Covid-19 outbreak. One of the provinces to be prioritized in November is East Java. Bogor Regency is also reported to be on the list of priority locations because it is considered an area of special concern. 

Three Chinese vaccine companies have expressed their commitment and ability to provide Indonesia with millions of Covid-19 vaccine doses. They are known to have entered the final stage of clinical trial phase 3 and are in the process of obtaining Emergency Use Authorization (EUA) license in a number of countries. 

Some epidemiologists have warned the government not to focus too much on pursuing a vaccine while ignoring the public health system. Dicky Budiman, a medical doctor currently pursuing his doctoral degree at the Griffith University, Queensland and Dr Pandu Riono, a University of Indonesia epidemiologist, raised their concerns about the government’s vaccination strategy. The focus should be on strengthening surveillance and promotion of an ongoing “3M” campaign (in reference to mask wearing, hand washing and social distancing) which is still weak, as the number of cases increases. 

Dicky Budiman has stated that no vaccine has been declared effective in preventing Covid-19. The government must be careful in starting its coronavirus vaccination program in November 2020, because until now no vaccine has yet to pass quality, safety and efficacy norms and standards. The government should also not rely on one country to supply the Covid-19 vaccine. No one, so far, can expressly guarantee that the vaccination will work. 

Drawing a lesson from past swine flu outbreak, he reminded all of the risks when many countries ignore the danger of vaccines that had yet to complete their research and clinical trial process which had led to disastrous effects, such as narcolepsy, a chronic neurological disorder caused by the brain losing its function to regulate the wake/ sleep cycle. The most important lesson from history is that no pandemic can be ended by a vaccine. A vaccine is not a “magic bullet” solution to every pandemic, especially considering the characteristics of Covid-19. 

Pandu Riono said that in the long term the vaccine can help end the pandemic but, in the short term, what we have to do is bolster the public health system, improving surveillance and changing people’s behavior. 

The solution to curbing the spread of coronavirus should not rely solely on vaccines. The best thing that society can do is to enforce health protocols in preventing further transmission. Discipline and consistency in implementing health protocols will be a long-term investment in health. Vaccines can’t guarantee that the pandemic will be beaten in Indonesia. 

A more effective strategy is to educate the public to follow “3M” health protocols and encourage health workers to do “3T” strategy (in reference to testing, tracing and treatment). Health workers should carry out aggressive mass testing, to find positive cases, instead of testing people when suspected or requested. People with confirmed infection must be swiftly quarantined to prevent wider community transmission. 

Additionally, it is necessary to involve the entire community, religious leaders and all elements of society to enforce discipline in following health protocols. We should be able to bring the Covid-19 pandemic under control with, or without, vaccines. (Drg. Tince Arniati Jovina, MKM.)

 Drg. Tince Arniati Jovina, MKM. Policy analyst of the Research and DeA policy analyst of the Research and Development Agency of the Indonesian Health Ministry. She graduated from the Faculty of Dentistry, Univeritas Prof.Dr.Moestopo, and obtained a Master’s degree in Public Health from the Faculty of Public Health, Universitas Indonesia.