Science’s COVID-19 reporting is supported by the Pulitzer Center and the Heising-Simons Foundation.
A new face at the helm of Indonesia’s Ministry of Health has raised scientists’ hopes that the country may take a more scientific approach to its increasingly desperate struggle with COVID-19. In a 22 December 2020 cabinet reshuffle, Indonesian President Joko Widodo named Budi Gunadi Sadikin, who has a degree in nuclear physics, as health minister. He took over from Terawan Agus Putranto, a military doctor known for pushing a controversial, unproven stroke therapy he had developed himself. His sluggish, secretive management of the pandemic was widely seen as a failure.
Sadikin, who has worked on the pandemic since March 2020 at the Ministry of State Owned Enterprises, “seems to understand the issue very well,” Zubairi Djoerban, head of the Indonesian Medical Association’s COVID-19 task force, wrote on Twitter after meeting Sadikin on 11 January. Indonesia lags in testing and data collection, and faces the gargantuan task of vaccinating its far-flung population of 270 million people. “Hopefully, a science-based approach will illuminate our way,” tweeted Ines Atmosukarto, an Indonesian molecular biologist who directs Lipotek, a biotech startup in Canberra, Australia.
Indonesia’s official pandemic toll is relatively low: The COVID-19 task force has reported only 850,000 cases and 25,000 deaths, a death toll per capita that’s less than one-tenth of that in the United States. But the situation on the ground tells a different story. Hospitals on Java, the country’s most populous island, are on the brink of collapse; some treat patients in chairs in the hallways instead of beds. Families drive from hospital to hospital with patients, trying to find one that will accept them. Infections are “uncontrolled,” says epidemiologist Henry Surendra of the Eijkman-Oxford Clinical Research Unit. (Surendra says he is speaking in a personal capacity, not on behalf of the research unit.)
The discrepancy stems in part from Indonesia’s very low test rates. The country currently performs about 0.12 tests per 1000 people per day, versus 3.9 in the United States and 8.1 in the United Kingdom, according to Our World in Data. Some regions have intentionally kept the number of tests low to avoid highlighting their infection rates, says Septian Hartono, a medical physicist at the Duke-NUS Medical School in Singapore and a volunteer at KawalCOVID19, a collaborative platform that analyzes Indonesian coronavirus data independently.
Without the right data, it’s very difficult for the government to produce the right policy.
Hartono has also found many discrepancies between the data reported by the provincial and national governments. On 10 January, for example, the national government reported 58% fewer deaths than the total reported by Indonesia’s provinces. Meanwhile, detailed demographic and clinical information about patients has been impossible to obtain from the Ministry of Health, Surendra says. “Without the right data, it’s very difficult for the government to produce the right policy,” Hartono says.
Hartono thinks Sadikin “really wants to fix this, but he is still in firefighting mode,” trying to bring down a surge in cases. Sadikin took over at the start of the holidays, when local and international tourists were flocking to Bali and mobility on Java was quite high. Sadikin imposed stricter lockdowns in both islands and issued a travel ban for foreigners effective 1 January. But daily infections have gone up by 30% to 40%, according to Ministry of Health data. Sadikin has asked hospitals to increase the number of beds for COVID-19 patients and enabled 10,000 unemployed nurses to work in hospitals temporarily.
One of Sadikin’s top priorities will be vaccination. On 11 January, the Indonesian Food and Drug Monitoring Agency (BPOM) issued an emergency use authorization for CoronaVac, produced by Chinese manufacturer Sinovac Biotech; 2 days later Widodo rolled up his sleeve for his first dose. Indonesia was the first country outside China to approve CoronaVac, and the decision is based on preliminary data.
A phase III trial in the city of Bandung, in West Java, showed the vaccine had 65.3% efficacy, according to BPOM—much lower than the rates of more than 90% seen in messenger RNA vaccines made by Western companies, but well above the 50% threshold the World Health Organization has recommended for widespread use of a vaccine. With only 1600 participants, the trial was much smaller than most, however, and it recorded just 25 infections. Researchers in Turkey in December reported that CoronaVac has 91.5% efficacy, based on another relatively small trial. One week ago, a team running a much larger study in Brazil announced an efficacy of 78%, but on Wednesday they said that based on stricter criteria, the efficacy was just 50%.
CoronaVac has cleared another important hurdle: On 11 January, the Indonesian Ulema Council issued a fatwa declaring the vaccine halal, or permissible under Islamic law. Many vaccines contain pork gelatin as a stabilizer, and in 2018, a new measles-rubella vaccine was declared haram, or forbidden, in Indonesia for that reason. It’s not clear whether CoronaVac contains elements of porcine origin as well, but Muslim scholars have decided the shots are halal in any case because the pandemic is an emergency. Sadikin has asked religious leaders in Muhammadiyah and Nahdlatul Ulama, the country’s two biggest Islamic organizations, for support for the new vaccine, and both have since said it is an obligation for every Muslim to get vaccinated.
Indonesia has ordered 125 million doses of CoronaVac. So far, 1.2 million have been distributed; another 15 million doses have arrived in Jakarta in bulk, to be processed by Bio Farma, Indonesia’s only vaccine manufacturing company. Sadikin says he has secured another 300 million doses of COVID-19 vaccine from Pfizer, AstraZeneca, and through the COVID-19 Vaccines Global Access Facility, a global mechanism to distribute vaccines equitably.
Detecting the spread of mutant variants of SARS-CoV-2 like one that emerged in the United Kingdom is another priority for Sadikin. Only 194 full viral genomes from the country have been posted in GISAID, an international virus genome database, suggesting more transmissible or dangerous variants could easily go unnoticed. On 9 January, Sadikin signed a memorandum of understanding with Bambang Brodjonegoro, minister of research and technology, aimed at increasing those numbers and strengthening collaboration between Indonesian universities. “I realize that we need to build a defense system against this virus,” Sadikin said at a press conference.