Wawancara Covid-19: Dr Pande Januraga MD Phd

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http://ubudnowandthen.com/wawancara-covid-19-dr-pande-januraga-md-phd/

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Doctor Pande Jauraga is a doctor of Public Health (MD-PhD) who graduated from Flinders University in Australia with a medical doctor background. He is currently a lecturer at the Faculty of Medicine of the University of Udayana (Unud), unit head of the Center for Public Health Innovation and coordinator of the IKM S2 program (Master degree program for Public Health Sciences). Rio Helmi interviewed him 2 days ago. An Indonesian version of this article was published here yesterday

Rio Helmi:Doctor Januraga, recently social media and the public has been rife with theories about covid-19 immunity in Bali. There is also a theory that the real peak of the pandemic in Bali has passed, and so forth. As someone who is trained in public health, do you find any evidence or argument that this is likely?

Dr. Pande Januraga: The theory of immunity comes from the concept of herd immunity which in epidemiology equates to immunity against infectious diseases. This immunity is obtained by people living in certain places where the majority have gained immunity due either to vaccination or exposure to previous infections, and as a consequence this serves as a protection for the non-immune population. At least 60% of the population must be immune to be able to protect the members of the communities that are non-immune and an even higher percentage may be called for where infectious diseases are caused by germs whose transmission is very aggressive such as in the case of SARS-CoV2 that causes COVID-19. Well obviously, since there has been no available vaccination for COVID-19, this leaves the second option of exposure to previous infections, and so if this is the case is it reliable to suppose that 60% of Balinese have been previously infected? This is hard to believe. There is a blog that claims that in early January to February there were many hotels in Bali that dismissed employees who reported being ill. Wow! Where are these reports? What were the symptoms? Was this really COVID? How many hotel employees in Bali make up 60% of the entire population? This is difficult to accept. Also, if it is true that a large enough number of Balinese have suffered from COVID-19, then there must be available statistics allowing the calculation of approximately 10% of seriously ill patients as well as 5% needing ICU treatment, and allowing for at least 20% of those who entered the ICU to have died. You can try calculating the numbers yourself based on 60% of the population of Bali. If we have 4.5 million people, this means that 2.7 million have been infected, 270 thousand that were symptomatically ill, 135,000 needed ICU treatment and 20% of these 135,000 have died, amounting to at least 27 thousand deaths; this is hard to imagine, don’t you think?You can try lowering the count to half of the above percentage, but even then there have never been any reports of such incidents of morbidity and mass death over January and February in Bali. What if it is true that the Balinese really did get ill but only lightly? … Perhaps, but this still does not explain much; does this prove there is a genetic influence? There are still no answers.

OK, some could argue that the percentage of infected people need not be so high. If so, then what are we banking on? Ever heard of polio? Polio vaccination was campaigned 100% because it was so difficult to achieve herd immunity.

Then there is another aspect: how long does immunity to COVID-19 last? This is a new disease so as yet there are not many related studies. But think about it: up until today no vaccine has even been found for MERS and SARS, and these are both viruses of the same family as Corona. Why? Because it is very difficult to test for immunity to this particular type of virus). This is also why it is so repeatedly stated that it takes time to find a vaccine. Don’t forget influenza. If you have lived in a country where there are four seasons, you are up for an annual vaccine, which shows that the immunity offered by the vaccine does not last very long. So you can judge for yourself what kind of a claim promises you 30 years of immunity if you recover from a bout of Covid-19. You need 30 years to wait for such a claim to materialize hehehe.

For the second question: is Bali really over the peak? Let’s be sensible, this statement is not backed up by any data. Just take a look at the Bali Task Force report, is there any graphic image showing that the numbers of cases are continuing to fall? It is still fluctuating. I personally hope it is over the peak, but look at the data.

RH:From the perspective of your expertise, what is your response to the massive amount of similar theories circulating in the community? Do you see a need for public education, or intensive socialization from scientists / experts?

Dr PJ: At the moment our society is flooded with information. Everyone wants to play an active role in creating and sharing information, and this includes what we are doing now, this interview. But the thing is that information needs to be carefully digested and based on a progression of data that is properly backed. As long as reports keep coming in, it means the war is not over.

Because the public is flooded with information, and there are even many free webinars, it has become difficult to develop media that can serve as a trusted source; there are too many channels. Serious efforts are needed to map public channels that can be used as reliable avenues of accurate information while also being well-liked by the community. This calls for mass communication experts, media, and people capable of having an effect, including influencers, to sit down together.

In my opinion it is not only the community that is overwhelmed by the floods of information but also politicians and policy makers. I would advise them to put their trust in science and technology!

RH:Until now, procurement of data in Bali seems beset by obstacles: lack of testing, stigmatization factors, and also the news of “false dengue” or covid-19 that is veiled by dengue. Is it actually true that these are significant obstructive factors? Or are there other issues that weigh more on the situation.

DrPJ: This is a complex question, but let me try to dissect it:

Lack of testing: this is almost certain if the benchmark is swab sampling and real time PCR (Polymerase chain reaction) testing; the outcome of a number of such tests has been considered worthwhile, and somewhat different from the rapid test. So far, only patients under surveillance (PDP/pasien dengan pengawasan) have been tested by PCR, while patients being monitored (ODP/orang dengan pemantauan) do not get a swab for PCR, just a rapid test. Not all migrant workers (PMI/pekerja migrant Indonesia) have been tested, only those who have tested positive by quick test receive a PCR swab. As I explained before, most infections are asymptomatic or mild, so if there is talk of ‘underdiagnosis’, I would agree. Does this mean the rapid test is inaccurate? Not exactly since the rapid test being circulated in Indonesia tests the presence or absence of an immune or antibody response due to a viral infection where the general response can appear anywhere from 1 week after infection to even 4 weeks; so timing or when the test is done is very important. Another issue is that the rapid test is not specific to SARS-CoV2, but only for infections due to the corona virus. I explained earlier that COVID-19 is caused by SARS-CoV2 and is only one type of corona virus. This implies a possibility of false negatives and on the other hand there may also be false positives. This is why our PMI friends are still asked to quarantine for 14 days despite having negative rapid test results. Stigma is caused by lack of appropriate information. There is a lot of information but people are left to search for themselves to fill in the gaps, to receive and filter the information on their own. The problem lies in the fact that they do not have enough background to be able to filter correctly. Also, on the one hand they neglect physical distancing and the use of masks, while on the other hand, they reject the corpses of patients who died of COVID-19. False dengue is a term that began to circulate after a scientific article reported that patients diagnosed with dengue turned out to suffer from COVID-19 and lately symptoms of COVID-19 have become more varied, with symptoms that liken to dengue being only one amongst others. I sought to verify this among doctor friends serving in several different hospitals in Bali, and found there was indeed a tendency for an increase in cases of dengue over the last two months. So far according to them the symptoms were still typical of dengue. The good thing is that the National Health Insurance Policy (BPJS/Badan Penyelenggara Jaminan Sosial Kesehatan) now allows NS1 and Dengue serology to help diagnose, which means that cases of Dengue can be verified. However, as someone who is looking at the data, it is difficult to use this as a measure if we do not know from the number of DB cases reported in Bali how many are actually confirmed to be dengue hemorrhagic fever (DHF), so ideally all doctors should do a patient history profile analysis, to check whether there is a risk of contact with COVID-19 cases, or if there were travels to red areas. And if possible, to at least carry out a quick test screening COVID-19. The results are then reported to the Department od Health for further analysis and intervention at the community level as well as health services. The prognosis on whether the burden on health services is heavier if there is a double infection is also unclear. That’s why data is very important and the key is analysis. We are also still weak in this area.

Please see more at http://ubudnowandthen.com/covid-19-interview-dr-pande-januraga-doctor-public-health/?fbclid=IwAR0Rp00XdLdJ9_Zm-IPlFVcqUBDaet_5AjNFTogNjm170whmPQcCmSYO54Y

In Balinese

In Indonesian

Rio Helmi: Doktor Januraga, belakangan ini di medsos dan kalangan publik sudah marak berbagai teori tentang immunitas Bali terhadap covid-19, ada juga teori bahwa sebenarnya puncak pandemi di Bali sudah lewat, dan sebagainya. Sebagai orang yang terlatih dalam ilmu kesehatan masyarakat (public health), apakah ada bukti atau argumen bahwa hal seperti itu mungkin?

Dr Pande Januraga: Teori imunitas berasal dari konsep herd immunity yang dalam ilmu epidemiologi berarti kekebalan terhadap penyakit menular yang diperoleh masyarakat di tempat tertentu karena sebagian besar masyarakat telah kebal karena vaksinasi atau paparan infeksi sebelumnya, akibatnya masyarakat yang tidak kebal akan terlindungi. Untuk bisa melindungi masyarakat yang tidak kebal paling tidak 60% dari masyarakat harus kebal, bahkan mungkin perlu angka yang lebih tinggi jika penyakit menular disebabkan oleh kuman yang penularannya lebih mudah seperti SARS-CoV2 penyebab COVID-19 ini. Nah jelas vaksinasi belum pernah ada untuk COVID-19 kemudian jika sudah pernah terinfeksi apakah benar 60% orang Bali sudah pernah terinfeksi sebelumnya? Sangat sulit untuk yakin. Ada blog yang menulis bahwa pada awal Januari sampai Februari ada banyak hotel yang meliburkan karyawan karena mereka melaporkan sakit, wah dimana laporannya? Sakitnya apa? Apakah benar karena COVID? Berapa banyak karyawan hotel di Bali, apakah 60% dari penduduk Bali? Sulit diterima. Hal lain adalah jika benar telah cukup banyak orang Bali yang pernah menderita COVID-19 maka statistik dari tempat lain bisa digunakan untuk menghitung bahwa akan ada kurang lebih 10% yang sakit berat dan 5% perlu perawatan di ICU dan anggap saja paling sedikit 20% dari yang masuk ICU meninggal, coba hitung sendiri angkanya dari 60% penduduk Bali. Jika kita memiliki 4,5 juta jiwa maka, 2,7 juta terinfeksi, 270 ribu sakit bergejala berat, 135 ribu perlu ICU dan 20% dari 135 ribu ini meninggal maka ada minimal 27 ribu kematian, jumlah yang sulit dibayangkan kan? Silahkan diturunkan setengah persentase di atas, maka tetap saja belum pernah ada laporan bahwa ada kejadian kesakitan dan kematian masal di Januari dan Februari di Bali. Bagaimana jika memang orang Bali, sakitnya tidak berat…mungkin saja, tetapi ini tidak ada dasarnya, apakah ada pengaruh genetik? Belum ada jawabannya.

OK, mungkin akan ada yang membantah, tidak perlu sebanyak itu yang terinfeksi. Kalau begitu apa dasarnya? Pernah dengar polio, vaksinasi polio malah dikampanyekan 100% karena memang sulit mencapai herd immunity.

Hal lain adalah seberapa lama kekebalan pada COVID-19 bertahan? Ini penyakit baru, penelitian terkait belum banyak, tetapi coba pikirkan, sampai sekarang MERS dan SARS yang virusnya setipe yaitu Corona belum ditemukan vaksinnya, mengapa karena sulit menguji kekebalan spesifik untuk jenis virus ini. Itu sebabnya ada banyak informasi yang mengatakan perlu waktu untuk vaksin berhasil ditemukan. Plus, ingat saja influenza, jika anda pernah tinggal di negara 4 musim, maka wajib vaksin tiap tahun, yang artinya kekebalannya tidak bertahan lama, nah silahkan nilai sendiri bagaimana mungkin ada klaim bahwa anda akan kebal 30 tahun setelah sembuh dari COVID-19, butuh 30 tahun menunggu untuk klaim ini hehehe.

Untuk pertanyaan kedua, Bali sudah lewat puncak, sudahlah ini pernyataan tanpa basis data, lihat saja laporan Satgas Bali, apakah ada gambar grafik temuan kasus turun terus? Masih fluktuatif. Saya pribadi berharap ya, tapi itu lihat data-nya.

di lanjutkan di sini: http://ubudnowandthen.com/wawancara-covid-19-dr-pande-januraga-md-phd/