Special Issue: Coronavirus Disease 2019 (COVID-19) Pandemicand Responses

Handling by: Dewi Susanna, MS

Kesmas:JurnalKesehatan

MasyarakatNasional(NationalPublic

HealthJournal)

SpecialIssueVolum

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2020

Special Issue Volume 1, 2020

Kes as Jurnal Kesehatan Masyarakat Nasional(National Public Health Journal)

m

Nationally accredited and indexed in SINTA-S1 by Ministry of Education and Culture of the Republic of Indonesia, and indexed in SCOPUS

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

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 EvaluatingPublic 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 withInternational Model (pp. 93 - 98)

p-ISSN 1907-7505e-ISSN 2460-0601

Quarterly Journal

TABLE OF CONTENT

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

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

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

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

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

Acceleration of Telemedicine Use for Chronic Neurological Disease Patients during COVID-19Pandemic 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 .................................. 32-36Ririh Yudhastuti

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

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

Nationally accredited and indexed in SINTA-S1 by Ministry of Education and Culture of theRepublic of Indonesia, and indexed by SCOPUS since 2016

KesmasJurnal Kesehatan Masyarakat Nasional (National Public Health Journal)

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

TABLE OF CONTENT

The Impact of Large-scale Social Restrictions on the Incidence of COVID-19: A Case Study of FourProvinces in Indonesia ............................................................................................................................ 49-53Izza 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 ................................................................................................................................................. 54-59Dewi Rokhmah, Ricko Pratama Ridzkyanto, Khoiron

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

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

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

Annalysis of Epidemiological Surveillance Activity of the COVID-19 at Surabaya Airport Indonesiaon January 2020 ...................................................................................................................................... 77-84Rizma 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 .............. 93-98Stelvin Sebastian, Aby Paul, Jeeva Joseph, Joel Joby, Sanjo Saijan, Jobin Kunjumon Vilapurathu

Review of Trial Therapies and Treatment for COVID-19: Lessons for Indonesia ............................... 99-104Halma 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 theRepublic of Indonesia, and indexed by SCOPUS since 2016

KesmasJurnal Kesehatan Masyarakat Nasional (National Public Health Journal)

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

KesmasJurnal Kesehatan Masyarakat Nasional (National Public Health Journal)

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

Kesmas: Jurnal Kesehatan Masyarakat Nasional (National Public Health Journal) is a journal that containsboth research articles and invited review articles in the field of public health and published quarterly

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International Editorial BoardDumilah 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)

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AUTHOR GUIDELINES

Kesmas: Jurnal Kesehatan Masyarakat Nasional(National Public Health Journal)

Received : May 28, 2020Accepted : May 29, 2020Published: July 31, 2020

AbstractThe spread of coronavirus disease 2019 (COVID-19) has had a serious impact on public health. The speed and extent of its spread have demonstrated aglobal failure to cultivate awareness and cooperation in response to the threat. Therefore, in order to improve public awareness and the management of publichealth threats, we propose a strategy to initiate global civil society. Using Walt and Gilson's policy triangle framework for policy analysis, we reviewed andanalysed a series of articles and policies related to COVID-19, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the Global Health SecurityAgenda (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 publicpolicy strategy for handling COVID-19. One possible solution is to expand the GHSA commitments and bind all countries that have signed the agreement toa 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 so-ciety collaboratively oversee the Indonesia’s government’s implementation of its constitutional obligations. The government must make public health securitya 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

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

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

Correspondence*: Dumilah Ayuningtyas, Department of Health Administrationand Policy, Faculty of Public Health Universitas Indonesia, Lingkar KampusBaru Street, Depok City, West Java, Indonesia, E-mail:dumilah.ayuningtyas@gmail.com, Phone: +62-8161840446

1Department of Health Administration and Policy, Faculty of Public Health, Universitas Indonesia, Indonesia2Department of Business Law, Faculty of Law, Universitas Mataram, West Nusa Tenggara, Indonesia

Ayuningtyas et al. Kesmas: Jurnal Kesehatan Masyarakat Nasional (National PublicHealth Journal). 2020; Special Issue 1: 1-5DOI: 10.21109/kesmas.v15i2.3931

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

IntroductionThe outbreak of coronavirus disease 2019 (COVID-

19) has caused tremendous fear and has drawn substan-tial attention all over the world. The World HealthOrganization (WHO) has tracked the spread and in-crease in cases of COVID-19 throughout the world: as ofMay 15, 2020, there are 4,534,952 confirmed cases inmore than 200 countries and one cruise ship containingmore than 700 passengers. At least 307,159 deaths havebeen reported.1 Undoubtedly, COVID-19 has trans-formed into a serious threat to public health.

On February 28, 2020, the WHO raised the globalrisk status of COVID-19 to the highest level.2 Previously,the WHO had also classified COVID-19 under PublicHealth Emergencies of International Concern (PHEIC),which are defined by the International HealthRegulations, or IHR (2005), as extraordinary events thatcould threaten public health throughout the world dueto the threat of spreading diseases internationally, andthat need a coordinated international response. This res -ponse was prompted by the alarming spread of the dis-

ease throughout the world. Within 24 hours, the virushad successfully infected nine new countries, includingAzerbaijan, Mexico, and New Zealand.3 Italy is the mostaffected country in Europe ever since the number ofCOVID-19 cases and deaths in Italy jumped in one night.As the number cases has soared in Italy, Iran, and SouthKorea, it is has become indisputable that the virus hasswept the globe.

COVID-19 is a public health threat that knows no na-tional boundaries.4 Bill Clinton has characterized global-ization as a world without walls.5 Tony Blair has saidthat globalization is inevitable and irresistible.Theirclaims have now been validated in the context of health.The inability of countries to defend themselves againstthe threats of infectious diseases such as severe acute res-piratory syndrome (SARS), Avian Influenza, Swine Flu,and COVID-19 has demonstrated that the world we livein is indeed one without walls; the global transmission ofdangerous illnesses has become inevitable. The establish-ment of a “global village” has made it such that countriescan no longer effectively control the movement of people

2

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

across their borders. Kate Galbraith’s definition of glo -bal ization as “crossing borders”serves as a warning to us:when there are no more “international borders”,6 thenthe ability to deal with a variety of risks or potential ha -zards such as the transmission of infectious diseases isabsolutely a must-have.7

For this reason, it is crucial to find effective strategiesto manage the spread of COVID-19. With its high-riskstatus, anticipating and preventing the spread of COVID-19 will necessitate global cooperation, which can only beestablished by collective consciousness and a shared vi-sion among the world’s population. In light of the impor-tance of the global collective consciousness, in this study,we analyse the relationship between COVID-19 andglobalization. Moreover, we discuss the views that dis-eases such as COVID-19 are direct consequences ofglobal ization and that the Global Health Security Agenda(GHSA) must be central in the response to the outbreak.Finally, we consider the effectiveness of institutionalizingcollective awareness as a strategy for responding to glo -bal health threats.

MethodWe conducted a policy analysis using Walt and

Gilson's policy analysis triangle to incorporate context,actors, process, and content concepts in analysing thesepolicies. We reviewed and analysed a series of articlesand policies related to COVID-19, SARS-CoV-2, theGlobal Health Security Agenda (GHSA), national re-silience in the context of globalization, as well as othercountries’ experiences. We focused on collecting second-ary sources, data, and information by using keywordssuch as ”COVID-19”, “Coronavirus”, “SARS-CoV-2”,“GHSA”, “globalization”, “civil society”, and “publichealth”.

The framework also allows the analysis of the contex-tual factors: social, political, and international aspectsthat influenced the policy. The analysis of the process bywhich the policy was initiated, formulated, developed,implemented and evaluated, the objectives of the policyand the actors involved in the decision making as well asconstitutional obligations, public health legislation, col-laboration of civil society, and policies related to publichealth, as well as their implementation in the context ofCOVID-19 was also conducted. To ensure the validity,we included only the most current data, and we conduct-ed extensive literature reviews.

Result and DiscussionCoronavirus is a family of viruses that cause diseases

ranging from the common cold to more severe illnessessuch as Middle East respiratory syndrome-related coro -na virus (MERS-CoV) and severe acute respiratory syn-drome-related coronavirus (SARS-CoV). The SARS-

CoV-2 is a new strain that has been identified in humans.Common symptoms in infected individuals are fever,coughing, shortness of breath, and difficulty breathing.In more severe cases, an infection can cause pneumonia,severe acute respiratory syndrome, kidney failure, ordeath.8

On December 31, 2019, the WHO received the firstreport of SARS-CoV-2 in Wuhan City, the capital city ofHubei Province, People’s Republic of China,9 which isthe seventh largest port city in mainland China. The cityis known as one of the centres of the steel industry, amainstay of China’s national infrastructure, and isinhabit ed by 11 million people. The strategic significanceof Wuhan City to China’s (and perhaps even the world’s)economy made officials reluctant to make public the out-break of COVID-19. This may explain why COVID-19incubates and spreads quickly in cities and why it has be-come a deadly pandemic throughout the world.10,11

The increasing global movement of people hasbrought with it an increased risk of spreading infectiousdiseases. Indonesia has signed on to several internationaltrade agreements such as General Agreement on Tariffsand Trade (GATT), Trade-Related Investment Measures(TRIMs), Trade-Related Aspects of Intellectual PropertyRights (TRIPs), ASEAN Free Trade Area (AFTA), andFree Trade Agreements (FTAs). These agreements haveaccelerated the improvement and intensity of interactionamong people and institutions in various fields, such associo-economic, trade and investment, and socio-culturalactivities. This interaction has increased the dependencyof people, insti tutions, corporations, and nations on oneanother. Although the government enjoys the economicbenefits of such interrelations, it must also possess thecapacity to anticipate and overcome the negative impactsof these relationships, such as the transmission ofCOVID-19.

Undoubtedly, COVID-19 is a global public health is-sue that requires a coherent strategic response; that isprevention and treatment must occur not only at themacro level, globally, but also regionally, nationally, andeven locally. One option is to expand the GHSA commit-ments, which would oblige all countries that have signedthe agreement to develop procedures for preventing, de-tecting, and responding to public health threats.12 At aworld health meeting, Frenk J and Gómez-Dantés O,13

suggested that efforts to improve health are universalglobal activities. Therefore, the pursuance of internation-al initiatives must consider the welfare of all people andembody an ethos of “exchange, evidence, and empathy”.Regarding “exchange”, countries must be prepared to ex-change information on public health risks such asCOVID-19. Regarding “evidence”, public policy must beinformed by data and scientific evidence. Regarding “em-pathy”, interactions between people ought to take place

3

according to the principles of humanism. It is necessaryto convey priorities in Indonesia. One of them is the par-ticipation and empowerment of civil society in each coun-try.13

The COVID-19 has spread to more than 200 coun-tries, including Indonesia, and therefore global coopera-tion is imperative. This is the high price of globalization.The purpose of the GHSA is to respond to the increasingvulnerability of the global community to new diseasesand pandemics caused by the negative impacts of climatechange, increased trade, movement of humans and otheranimals across borders, as well as farming practices andindustries that are no longer considered acceptable. TheGHSA is made up of countries, international organiza-tions, non-governmental organizations, and people in theprivate sector that want to decrease the threat posed tothe world by infectious diseases. Under the leader ship ofthe GHSA, every signed country or party should haveastrong commitment to improve global health security andto make it a high priority for world leaders.12

The global trend toward a world without boundarieshas changed the landscape of interaction between coun-tries, which brings many opportunities and benefits, andhas also introduced global threats that should be ad-dressed by global strategies. This is because, regardlessof a country’s preparedness to face a pandemic, there isstill a potential risk to public health. Threats, due to theeffects of globalization, cannot be handled by individualcountries. It is concerning that the Indonesian govern-ment has left the responsibility for handling COVID-19to the governors, mayors, and heads of sub-districts, asthis has resulted in diametric decisions at different levelsof government. For example, Ganjar Pranowo, Governorof Central Java Province, and Rismaharini, Mayor ofSurabaya City, refused entry to several cruise ships suchas Viking Sun, Columbia, Viking Orion, and MSAlbatros, while I Wayan Koster, Governor of BaliProvince, and Zulkieflimansyah, Governor of NTBProvince, announced that they would permit the entry ofthose cruise ships.

After having reviewed the diametric responses of thecentral and local governments, we take a critical positionon the absence of coordination between them.Constitutionally, the government should be bound to res -pond consistently to outbreaks such as COVID-19. Somegovernments consider economic reasons while others un-derline the importance of public health and safety.Therefore, it is imperative that all governments maketheir public policies consistent at the local, national, re-gional, and global levels. It is crucial for the governmentto initiate and improve cooperation with other countriesin order to formulate a consistent global strategy for deal-ing with outbreaks like COVID-19. This can be embodi -ed by a global agreement that would regulate the proce-

dures pertaining to prevention of the spread of COVID-19, treatment of those infected with the disease, as wellas the preparation of testing and treatment facilities, suchas hospitals and clinics. Now is the time to determinewhether or not the GHSA can effectively prevent, detect,and respond to COVID-19.14

As members of the GHSA, Indonesia and other coun-tries can initiate the global consciousness needed to dealwith the threat of the COVID-19 outbreak. This con-sciousness is based on Articles 3 and 25 of the UniversalDeclaration of Human Rights (UDHR), which states“that the state guarantees the life of every human being,guarantees his safety, health and the environment.15 Inthe 1945 State Constitution of the Republic of Indonesia(UUD ’45), Article 28 also states that every person hasthe right to live in prosperity, physically and mentally,and to have a good and healthy environment.16 Article15-1 of the European Convention on Human Rights(ECHR) also confirms the same thing. This means thatevery country that has signed the UDHR, the ECHR, andother international conventions on health, has a respon-sibility to enforce policies that protect the health andsafety of their citizens.

The above normative foundation stipulates a consti-tutional obligation of the government in guaranteeingpublic health. In this respect, the government shouldmake any information that is relevant to citizens’ healthand safety available to them (Article 28, IndonesianConstitution 1945). Therefore, the government shouldbe informing the public transparently, objectively, ratio -nal ly and wisely. This would have been instrumental inanticipating public policy blunders in the early stages ofthe COVID-19 outbreaks, long before a positive case ofthe disease was found in Indonesia.

The WHO warned of the magnitude of the risk of thepandemic and advised countries not to be over -confident.17 Many foreign researchers cynically andcritical ly stated that the absence of COVID-19 inIndonesia was concluded based on 136 tests from 270million people.18,19 When the first COVID-19 case wasannounced in December 2019, Indonesia had had plentyof time to prepare for the negative impacts of COVID-19on various government sectors. The government repeat-edly claimed that there were no case of COVID-19 inIndonesia, even though the WHO had advised officialstopay careful attention to their handling of the spread ofthe disease. Despite the warnings, the result was confus -ion, the dissemination of unclear information, and incon-sistent public policy. Instead of urging vigilance, the gov-ernment tried to minimize the apparent scale of the prob-lem and called on the public to be calm in response tothe COVID-19 pandemic.20 According to the Indonesiancommunity, the government’s statement showed a lackof empathy and transparency. The Indonesia’s president

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

4

finally appointed a special spokesperson to talk aboutCOVID-19. This authority was left to the Secretary ofthe Directorate General of Disease Prevention andControl.21

Recently, the government introduced public policy in-tended to anticipate the negative economic impacts ofCOVID-19. It consists in reducing airplane ticket costsin order to maximize revenue, as well as promotingtourism activities. The Indonesian Minister of Financehas stated that the government has prepared incentivesof more than IDR 400 billion to reduce the price of air-plane tickets to tourist destinations. The government isalso preparing subsidies for local governments in theform of grants of more than IDR 3 trillion for hotel andrestaurant tax exemptions for entrepreneurs, includingIDR 72 billion for social media influencers promotingtourist destinations in Indonesia (familiarization trip).22

This policy is different from neighbouring countries’ poli-cies in Singapore, Korea, and Malaysia, which have putin place a series of policies for preventing the spread ofCOVID-19, such as informing the public about collectiveresponsibility and cancelling flights to and fromSingapore.

Unsurprisingly, the Indonesian government’s tourismpolicy has drawn heavy criticism from the public. Thepolicy has demonstrated that the government’s efforts todeal with COVID-19 are not serious enough to stop itsspread. Even though Indonesia announced two positivecases of COVID-19 on March 2, 2020, the governmentstated that it would not reconsider the tourism policy,based on its calculations. The government wants theCOVID-19 situation to be resolved without disruptingthe country’s economy.18 Finally, on March 3, 2020, theMinister of Tourism and Creative Economy of Indonesiastated that the provision of incentives for tourism wouldbe postponed indefinitely due to the presence of COVID-19 in Indonesia.23

ConclusionIn civil society, citizens cooperate voluntarily for mu-

tual benefit, which is crucial for personal development,establishing trust between groups, and making socialservices accessible. However, civil society remains boundby the rule of law. A social movement is a collective ac-tion undertaken by groups in civil society. In dealing withCOVID-19, civil society must play an active role.

The public needs to oversee the fulfillment of the gov-ernment’s constitutional obligations as the bearers of theconstitutional mandate, and also ensure that they can beheld constitutionally responsible. With a shared goal toprotect the world from various global health threats, civilsociety must be positioned as a subject, and not just as anobject. Well educated members of civil society can un-derstand what threatens their health and take the neces-

sary steps to deal with those threats. Society will be im-pacted by COVID-19.

The handling of the COVID-19 outbreak requires thecoordination of national governments, international or-ganizations, and civil society. The community will bemost impacted and thus needs to play an active role inhandling this situation. Collaboration between membersof civil society, particularly well educated citizens, canhelp oversee the government’s implementation of itscons titutional obligations. The Government of Indonesianeeds to make public health security a top priority inevery policy implementation. One way would be to im-plement the GHSA in every aspect of public health.Groups of educated people with a strong, shared visionmust harness the power of non-governmental advocacy.Protecting the health of the Indonesian people constitutesone aspect of the 1945 Constitution, which is the mostfundamental norm in Indonesia.

AbbreviationsCOVID-19: Coronavirus Diseases 2019; PHEIC: Public HealthEmergencies of International Concern; IHR: International HealthRegulations; SARS COV-2: Severe Acute Respiratory SyndromeCoronavirus 2; GHSA: Global Health Security Agenda; WHO: WorldHealth Organization; PPE: personal protective equipment; UNICEF:United Nations Children’s Fund; BPS: Badan Pusat Statistik; MERS-CoV: Middle East Respiratory Syndrome-related Coronavirus; GATT:General Agreement on Tariffs and Trade; TRIMs: Trade-RelatedInvestment Measures; TRIPs: Trade-Related Aspects of IntellectualProperty Rights; AFTA: ASEAN Free Trade Area; FTAs: Free TradeAgreements; UDHR: Universal Declaration of Human Rights; ECHR:European Convention on Human Rights.

Ethics Approval and Consent to ParticipateNot Applicable

Competing InterestAuthors declare that they have no competing interests to disclose.

Availability of Data and MaterialsNot Applicable

Authors’ ContributionDumilah Ayuningtyas conceived of the presented main idea and deve -loped the theory, and encouraged Hayyan Ul Haq and Raden RoroMega Utami to investigate and supervised the findings of the work. Allauthors discussed the results and contributed to the final manuscript.All authors agreed to be personally accountable for their own contribu-tions and ensured that questions related to the accuracy or integrity ofany part of the work are appropriately investigated, resolved, and theresolution documented in the literature.

AcknowledgmentNot Applicable

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12. Global Health Security Agenda. About the GHSA.

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tiknews; March 3, 2020.

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sawat. CNN Indonesia; 2020.

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termasuk untuk influencer. Liputan6; 2020.

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Hopkins University: Center for Systems Science and Engineering

(CSSE); 2020.

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inggi. CNBC Indonesia; 2020.

3. Berlinger J. Coronavirus has now spread to every continent except

Antarctica. CNN; 2020.

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ganization. 2020.

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Campus New; 2002.

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London: The Economist in association with Profile Books; 2007.

7. Ikatan Ahli Kesehatan Masyarakat Indonesia. Globalisasi dan transfer

risiko penyakit: tinjauan dan rekomendasi IAKMI terkait kasus penu-

monia akibat 2019-NCOV. Siaran Pers / Pernyataan Sikap PP IAKMI

Terkait 2019-NCOV. November 2014: 15–6.

8. World Health Organization. Coronavirus; 2020.

9. World Health Organization. Novel Coronavirus (2019-nCoV). WHO

Bulletin; 2020.

10. BBC News. Wuhan: the London-sized city where the virus began.

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11. World Health Organization. Report of the WHO-China joint mission

on coronavirus disease 2019 (COVID-19); February 16-24, 2020.

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

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

Correspondence*: Sang Gede Purnama, Doctoral Program in Public Health,Faculty of Public Health, Universitas Indonesia, Lingkar Kampus RayaUniversitas Indonesia Street, Depok, West Java, Indonesia, E-mail: sangpurna-ma@unud.ac.id, Phone: +62-877-3917-6777

Purnama et al. Kesmas: Kesmas: Jurnal Kesehatan Masyarakat Nasional (NationalPublic Health Journal). 2020; Special Issue 1: 6-13DOI: 10.21109/kesmas.v15i2.3932

AbstractThe 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 hygieneand sanitation approaches. The results show Indonesia's challenges namely urban area density, air pollution, and smokers, low hand washing habits, low ac-cess to clean water and drinking water, open defecation behavior, limited personal protective equipment. COVID-19 control policy with the hygiene sanitationapproach is carried out with 4 factors namely personal protect equipment, health education, personal hygiene, and sanitation.

Keywords: COVID-19, hygiene, sanitation, Indonesia

Hygiene and Sanitation Challenge for COVID-19 Prevention inIndonesia

Sang Gede Purnama1*, Dewi Susanna2

1Doctoral Program in Public Health, Faculty of Public Health, Universitas Indonesia, Indonesia2Department of Environmental Health, Faculty of Public Health, Universitas Indonesia, Indonesia

IntroductionCoronavirus infectious diseases 2019 (COVID-19)

caused by severe acute respiratory syndrome coronavirus2 (SARS COV-2) that initially occurred in Wuhan, Chinahave now spread to many countries.1,2 On March 11,2020 World Health Organization (WHO) has establishedCOVID-19 as a global pandemic.3,4 The COVID-19 inci-dent has spread to 213 countries including Indonesia. Asof April 20, 2020, the total number of COVID-19 caseswas 2,480,503 people with 170,397 deaths.5

Indonesia which has 34 provinces with a populationof 267 million in 2019 Chinese tourists visited 1.61 mil-lion visits (13.14%).6 Based on reports from the Ministryof Health and National Disaster Management Agency asof April 20, 2020, it was reported that COVID-19reached 6,760 people, 590 deaths, and 747 people reco -vered.7 Transmission that originally occurred to foreigncitizens has now become a local transmission betweenpeople.8 This incident is spreading quickly and the caseswill continue to grow. Indonesia is at risk of COVID-19transmission.

The COVID-19 transmission is reported to be directlyand indirectly, directly through droplets when coughing.9Transmission occurs from person to person, especially inthose who do not use personal protective equipment

(PPE) and contact with infected people.10-12 ThereforeWHO recommends doing physical distancing by keepinga distance and avoiding crowds and using masks.13

Indirectly, by touching the surface of objects that have avirus and then touching the mouth, nose, and eyes beforewashing hands. SARS COV-2 was even found in eye flu-id, this can be a source of infection.14 Therefore it is ad-visable to wash hands with soap and disinfecting the sur-face of objects that are often used.15 Handwashing withsoap in Indonesia is very low, so there is a risk of trans-mission through hygiene.16

There was evidence SARS COV-2 is detected in fecesand urine.17 This was also confirmed by the liquid wastein sewerage in the Netherlands, the United States, andSweden.18 This condition is an early warning forIndonesia which has a greater challenge, namely opendefecation behavior, which is still high, even the secondlargest in the world.19 Based on the United NationsChildren’s Fund (UNICEF) data, it is stated that thereare around 25 million people who still defecate inIndonesia.20

Stool contamination of clean water sources and com-munity drinking water is very vulnerable to contractingCOVID-19. In Indonesia, access to clean water anddrinking water is still lacking. Based on national socio -

Received : May 28, 2020Accepted : May 29, 2020Published : July 30, 2020

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economic survey data from Statistics Indonesia (BadanPusat Statistik/BPS), only 72.04% of households haveaccess to safe drinking water. The data indicated thatthere are around 80 million people who still do not haveaccess to adequate drinking water.21 Therefore, the exis-tence of the COVID-19 pandemic makes people very vul-nerable to be infected by the virus through contaminateddrinking water.

The low personal hygiene and poor sanitation indica-tors in Indonesia are a challenge in controlling COVID-19 in Indonesia. Hygiene and sanitation factors need toget the attention of policymakers in controlling COVID-19. For this reason, the purpose of this article is to des -cribe the mode of transmission, challenges, and policiesrelated to controlling COVID-19 with the hygiene andsanitation approach in Indonesia.

Mode of Transmission COVID-19Mode of transmission in COVID-19 with a journal

review related to transmission and hygiene and sanitationfactors that occur. Figure 1 explains how COVID-19transmission is direct and indirect, and the potential forcontamination of water sources. COVID-19 is transmit-ted directly through droplets when infected people coughand transmit it to others.22,23 Several studies haveshown, transmission from person to person throughdroplet splashing when people cough and sneeze withina distance of 1 meter or contact with an infected personwithout using PPE.24-27 Therefore, contact tracers areneeded in people who have been in contact with covidpatients before. This requires a policy of using masks andkeeping a distance from others.

Research shows SARS-CoV-2 is more stable in plas-tics and stainless steel than copper and cardboard, andviruses are detected up to 72 hours after application to

this surface.28 This causes indirect transmission becausethe persistance virus is on the surface of the object to in-fect someone because when touch their eyes, nose andmouth.29-31 SARS COV-2 is also found in eye fluid.14

However, the use of disinfectants such as 71% ethanol,0.5% hydrogen peroxide or 0.1% sodium hypochloritecan eliminate SARS COV-2 that contaminates the sur-face of the object.9

There is evidence that sputum, feces, and urine con-tain SARS COV-2.17,32 Although until now there hasbeen no evidence of transmission from fecal-oral this canbe an early warning. Researchers found in theNetherlands, the United States, and Sweden that fecalwaste discharged into sewerage was proven to be con-taminated with SARS COV-2.18,33 This needs serious at-tention, especially in Indonesia. Open defecation behav-iour is still high. This can pollute the surface water sup-ply. Furthermore, it can pollute community drinking wa-ter because access to our clean water is still low. This in-cident requires a special policy for the provision ofhealthy latrines and access to clean water. Medical wastetreatment systems also need attention, especially solidand liquid waste so as not to pollute the waters used bythe community for access to clean water.

The Challenges of Hygiene and Sanitation at COVID-19 in IndonesiaUrban area density

Indonesia which has a population of 268 million,most of the population lives in urban areas.21 High inter-island population mobility, if there is a case of COVID-19 without symptoms but carrier,34 then it can spreadquickly. Especially in public transportation modes suchas planes,35 trains, markets, religious events, and wed-dings. Activity in the crowd can transmit COVID-19

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

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quickly because droplets can spread and infect others.For this reason, social distancing is needed to reducecrowds, close schools, workplaces, terminals.36,37

The national socioeconomic survey reports thatIndonesia has a population living in urban areas (52.9%)and living in homes with a floor area of fewer than 8 m2

per capita (14.8%) and the population traveling last year(28.2%).38 Living in a crowded house and a large num-ber of residents and lack of air ventilation can interferewith health, especially airborne diseases.39 The use ofproper ventilation can help prevent airborne diseases thatgenerally occur in homes in urban areas.40 Increasing airventilation is effective to reduce the risk of long-rangeairborne transmission and help prevent droplet-borne.41

Air pollution and smokersAir pollution in big cities in Indonesia is very high,

making Indonesia 20 polluted countries in the world.42

High air pollution can be a driving factor in the occur-rence of respiratory disturbances.43-45 High levels of airpollution can cause cardiovascular disease and respirato-ry disease.46 According to WHO around 7.1 million peo-ple died due to the effects of air pollution and around94% live in low and middle-income countries.47

The BPJS reports in Indonesia that the incidence ofpneumonia is 1.3 per 1,000 population. Also, Indonesiaranks third in the world of tuberculosis with an estimatedcase of 845,000 people. The prevalence of acute respira-tory infections in Indonesia reaches 9.3%.48 This indi-cates that Indonesia already has a high respiratory diseaseburden. The symptoms of COVID-19, which is also pneu-monia, will increase the number of respiratory diseasesin Indonesia.

The Southeast Asia Tobacco Control Alliance (SEAT-CA) report mentions Indonesia as the country with themost smokers in Asia with 65.19 million people. Theybuy cigarettes installs, kiosks, minimarkets, and super-markets.49 The number of cases of tobacco-related dis-eases is 962,403 people. Chronic obstructive pulmonarydisease is the most common type of tobacco-related dis-ease, then severe low birth weight babies, coronary heartdisease, stroke and lung tumors, bronchus, and tra-chea.50 The WHO states smokers are at a higher risk ofbeing infected with COVID-19, firstly because the fingersused for smoking directly touch the lips. Second, smokersmay already have lung disease or not optimal lung capac-ity.51-53

Low handwashing habitsThe hand as a medium of transmission of COVID-19,

touches the surface of objects contaminated with SARSCOV-2 then touches the nose, mouth, and eyes.9,14 TheWHO recommends washing hands with soap andthrough running water to prevent COVID-19 because

washing hands not only prevents COVID-19 but also o -ther diseases such as diarrhea and pneumonia.54 Washhands with soap strategies to save costs to reduce theburden of global disease.55

Basic Health Research data mentioned that 50.2% ofimproper hand washing.16 The behavior of cleaninghands with soap and running water has been socializedthrough electronic media and print media. The SchoolHealth Unit program also promotes handwashing withsoap but is still not optimal. Studies in Indonesia foundthat handwashing behavior is influenced by the presenceand distance of handwashing facilities, interpersonal in-fluence, the desire to smell good, washing hands whenfeeling dirty.55 This behavior is closely related to COVID-19's control efforts.

Low access to clean water and drinking waterData from the central statistics agency states that ac-

cess to safe water in Indonesia reaches 72.55%, which isstill below the Sustainable Development Goals (SDGs)target of 100%.21 As many as 33.4 million people stilllack access to clean water. People who are difficult to getaccess to clean water will use water from polluted sourcesso that it can endanger their health. Polluted watersources are at risk of causing various types of digestiveand skin disorders.56

The results of the national socio-economic surveyfrom BPS show that households with access to decentdrinking water in Indonesia in 2012 amounted to65.05% of households. In 2014 it became 68.11% thenincreased in 2017 to 72.04%. This means that 80 millionpeople still do not have access to adequate drinking wa-ter.21 Utilization and management of drinking water thatis not according to the standard also risk causing diar-rhea, dysentery, cholera, and skin diseases. Especiallyconcerning COVID-19, potential water sources are con-taminated if drinking water is not treated properly.

Data from the Directorate General of PollutionControl and Environmental Damage stated that the quali -ty of the river began to decline, by 23.5% with mode -rately polluted status and 55.88% with severe pollu-tion.57 This river pollution is caused by the disposal ofhousehold waste, industrial waste, and also from the resi -dents' toilet. The heavy river pollution is not suitable forthe community to use because it contains heavy metalsand does not meet microbiological standards. The use ofriver water for bathing or drinking water is very danger-ous. COVID-19 could have polluted the river from fecesand stools that are directly discharged into the river.57

Open defecationThe WHO/UNICEF data states that Indonesia is the

second-largest country in the world where people stilldefecate openly.19 Based on UNICEF data in 2015, there

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are 32 million people who still defecate openly. Then in2018, there will be 25 million people. Around 150,000Indonesian children die each year from diarrhea and oth-er diseases caused by poor sanitation.20 Open defecation,such as in rivers, fields, forests, will pollute the soil andwater. Related to COVID-19 discarding feces carelesslycan contain SARS COV-2,58 which causes contaminationin the environment and surface water.

Based on World Bank data, it is known that of the60% of the urban population that is still open defecationas many as 14% and 62% have a septic tank but do nothave a sewage treatment system. Total losses due to poorsanitation reached USD 6.3 billion.59,60 Waste disposaldirectly into rivers, in the soil and waterways withoutproper waste treatment, can pollute the environment.Groundwater and surface water can be polluted by bac-teria and viruses.

A limited supply of personal protective equipment(PPE)

Since the COVID-19 pandemic, the need for personalprotective equipment such as face masks is very high.This makes it difficult for the public and health workersto get face masks. Limited personal protective equipmentsuch as face masks for the general public and specialequipment for health workers such as N95 masks, gloves,eye protection, dresses need to be addressed immediately.

The limitations of PPE can endanger health workers inhandling COVID-19 patients. Efforts to produce localPPE are needed to meet market needs. WHO recom-mends that the general public use cloth masks and healthworkers use standard clothing for handling patients withCOVID-19.61,62

COVID-19 Prevention Policy with Hygiene andSanitation Approach

COVID-19 transmission that is known directlythrough droplets from sufferers to others needs to be pre-vented by using PPE.10 Indirect transmission throughmeans and touch to the mouth, eyes, and nose requirespersonal hygiene. There is potential for environmentalpollution from feces that can pollute clean water andcommunity drinking water. Need to get attention to en-vironmental sanitation. Therefore, we need policies thatsupport prevention with aspects of environmental hy-giene and sanitation, namely personal protect equipment,health education, personal hygiene, and sanitation whichis described in Table 1. This policy is formulated inFigure 2.

Use of standard personal protective equipmentThe first step to reduce COVID-19 contamination

through direct transmission is the use of masks. WorldHealth 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

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use masks for everyone.24 This helps to reduce the risk ofexposure of COVID-19 sufferers to others and also therisk of transmitting COVID-19 to others. So in principle,we protect others and others protect us (see in Figure 3).

Availability of standard personal protective equip-ment (PPE) for medical staff treating patients withCOVID-19.13 The need for PPE medical standards hasincreased in the world since the pandemic occurred.Health workers are vulnerable to COVID-19 contamina-tion when treating COVID-19 patients. High intensitywith COVID-19 patients requires using PPE such as N-95 masks, glasses, hazard material clothing, shoe protec-tors as well as medical waste disposal containers andtheir sterile treatment.26 Without the proper PPE, trans-mission from patients to health care workers is vulnera-ble. There is also the possibility of patient-to-patienttransmission in hospitals.64

Physical distancingWorld Health Organization recommends keeping a

safe distance of more than 1 meter from other people(physical distancing). It aims to reduce direct contactwith other people who are symptomatic in COVID-19and those who are asymptomatic but have the potentialto transmit.13 This policy is effective in reducing the po-tential for virus transmission.37 This action was followedby a policy of reducing gatherings, closing schools, work-places, markets, public transportation, religious cere-monies, and marriages.38 This policy also encouragespeople to stay at home, work at home, study at home,worship at home.

Health education program with risk communicationSince March 17, 2020, Indonesia has formed a task

force for handling COVID-19 which is coordinated bythe National Disaster Management Agency (BNPB). Thetask force is expected to be able to accelerate efforts tohandle COVID-19 in various areas ranging from prepa-ration in handling, preventing, detecting, and responding.Structural task forces exist from the central to the villagelevel.65

Officers must provide education about hygiene andsanitation in the family, school, community, and work-place environment related to COVID-19.66 The role ofcommunity leaders, teachers, parents is needed in collab-oration to provide education in their respective environ-ments. A good understanding of transmission, control,and preventive actions can help the community in dealingwith the COVID-19 pandemic.

Risk communication on electronic media, print me-dia, and social media to provide information to the publicquickly and accurately through trusted sources. This is toavoid hoax information and create confusion in the com-munity. Incorrect and insistent information can causeanxiety and excessive fear in the community. For this rea-son, a centralized information and education system areneeded in each region and confirmation of hoax news.

The personal hygiene improvement programThe discovery of SARS COV-2 contamination that

causes COVID-19 in feces,67 and liquid waste requiresefforts to anticipate the occurrence of contamination incommunity sewage.18,33,68 Habits of people who defe-cate carelessly in Indonesia are still high. This behavior is

Figure 3. The Use of Masks to Protect Us and Others from COVID-19 Exposure64

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very dangerous because it can contaminate water sourcesso that the potential for transmission occurs throughdrinking water residents. This is an early warning to takeprecautionary measures by stopping open defecation.

Sanitation improvement programs in Indonesia so farhave been carried out through Community-based TotalSanitation & Hygiene (CLTS) Strategy with 5 main pil-lars namely Open Defecation Free communities,Handwashing with soap at critical moments, Householdwater treatment and safe storage of water and food, Solidwaste management and Liquid waste management. CLTSincreases toilet construction with community participa-tion,69,70 so that the CLTS program is more optimal, itrequires high-level political commitment, integration ofsanitation programs into health programs, improvementof community hygiene and coordination multi-sector.71

Multi-sector cooperation is needed for optimal programimplementation.

The handwashing with soap program is carried outsimultaneously to break the chain of transmission ofCOVID-19. Hands indirectly as a medium of transmis-sion of COVID-19 through touch on the eyes, nose, andmouth. Indonesian people's handwashing habits are stillvery low. There are 50.2% of people who do not washtheir hands properly.16 To prevent transmission ofCOVID-19, it is necessary to move the handwashing pro-gram using soap before touching the mouth, nose, andeyes.

Provision of environmental sanitation facilitiesProvision of handwashing facilities in public facilities.

To support the habits of the community who wash theirhands, hand washing facilities are needed in public facili -ties, namely markets, terminals, places of worship,schools, and others. This handwashing facility is usefulin supporting efforts to prevent COVID-19 transmissionin the community. The availability of handwashing facil-ities helps the community get used to washing hands withsoap in public places.

Disinfecting public facilities and items that are oftenused such as dining tables, cellphones, cabinets, algaedoors, elevator buttons, and others.12 Disinfectant actioncan kill the SARS COV-2 virus that is on the surface ofobjects, which are around us such as the surface of wood,plastic, metal, aluminum, copper, and cardboard. Thevirus can persist for up to 72 hours on these objects.Routine item sterilization needs to be done for objectsthat are frequently touched.9

Provision of clean water and proper drinking waterfacilities for the community. Access to clean water andproper drinking water is still low in Indonesia. Peoplewho do not get access to properly clean water, use watersources that are polluted and at risk of being contaminat-ed by COVID-19. Clean water sources should be provid-

ed through processing and piping facilities so that thequality is guaranteed. COVID-19 can pollute communitywater sources through contaminated faeces.17

Liquid waste treatment and waste management pro-gram. SARS COV-2 was found to be found in sewera -ge.33 Most households in Indonesia do not have a com-munal waste treatment system, most only have latrinesand septic tanks without further processing. Waste treat-ment systems need to be carried out before being dis-charged into the environment. For medical waste pro-duced including hazardous and toxic materials that needspecial treatment in handling so as not to pollute the en-vironment and contaminate humans. The solid wastegenerated from infectious hospitals must not be disposedof directly into the landfill, but can use an incinerator ora third party for disposal.

Conclusion COVID-19 transmission can occur directly through

droplets to other people or indirectly through touchingthe surface of an infective object. Hygiene preventionsuch as using masks and washing hands is needed. Thisarticle also discusses Indonesia's challenges in controllingcovid is urban area density, air pollution and smoking,low hand washing habit, low access to clean water anddrinking water, open defecation. hygiene and sanitationapproach namely through personal protect equipment,health education, personal hygiene and sanitation.

AbbreviationsCOVID-19: Coronavirus infectious diseases 2019; SARS COV-2: se-vere acute respiratory syndrome coronavirus 2; WHO: World HealthOrganization; PPE: Personal Protective Equipment; UNICEF: UnitedNations Children’s Fund; BPS: Statistics Indonesia (Badan PusatStatistik); BPJS: ; SEATCA: Southeast Asia Tobacco Control Alliance;SDGs: Sustainable Development Goals; CLTS: Community-basedTotal Sanitation & Hygiene.

Ethics Approval and Consent to ParticipateNot Applicable

Competing InterestNo potential competing interest was reported by the authors.

Availability of Data and MaterialsAll data generated or analyzed during this study are included in thispublished article.

Authors’ ContributionSang Gede Purnama: Development and design of the models, creationand presentation of the published work, specifically writing the initialdraft (including substantive translation); Dewi Susanna: Analyze thereview, commentary and revision – including pre- or post-publicationstages.

Purnama et al, Hygiene and Sanitation Challenge for COVID-19 Prevention in Indonesia

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AcknowledgmentThe authors are grateful to Kesmas: Jurnal Kesehatan MasyarakatNasional (National Public Health Journal) for providing the editingEnglish services to this manuscript.

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Purnama et al, Hygiene and Sanitation Challenge for COVID-19 Prevention in Indonesia

IntroductionSome cases of pneumonia of unknown etiology de-

tected in Wuhan City, Hubei Province of China in theend of 2019. A total of 44 patients reported with pneu-monia of unknown cause in January 2020 that have beenreported to World Health Organization (WHO) by thenational authorities in China.1 The consensus statementthen established that the pneumonia of unknown etiolo-gy is coronavirus disease 2019 (COVID-19).2 As ofMarch 2020, COVID-19 cases have been found globally(spread out of China),3 that Centers for Disease Controland Prevention (CDC) then recognized that the COVID-19 is person-to-person spread.4,5 In March 11, 2020,based on the current situation that the COVID-19 haveaffected countries outside China tripled and the numberof cases has increased 13-fold outside China, then WHOidentified COVID-19 as pandemic.6

The COVID-19 pandemic has drained a lot of energy,whether in physical, mental, social and economic terms.7The calculations have continuously been made to deter-mine the latest situation of cases that have occurred.Indeed, it has truly felt that we are living in "one world"in which no place or country is free from "contamina-tion" of a problem that has afflicted certain regions.

The Case Fatality Rate (CFR) has especially becomean intriguing subject of discussion for many people.

People cannot avoid of talking the number of deathwhen they discuss COVID-19. In a way, this momenthas presented a new opportunity for the Indonesian com-munity to improve their knowledge on mortality meas-ures. As previously, the CFR was known only to those inthe health sector, but now more people are becoming fa-miliar with the measure. The CFR is a measure of mor-tality that is feared by human being for several reasonssuch as because death is the ultimate experience that allhuman being will surrender. Moreover, death is highlyimportance to each person including questions of whenand how death will occur and whether there is any wayto delay it.8-10

On social media, people have been debating the na-tional CFR and even compared it with CFR of othercountries such as China and Vietnam, which have nowhad lower CFR compared to other country. This com-parison is then followed by comparing the performanceof the Indonesian government in handling pandemicsunder the pretext why CFR in Indonesia is higher com-pared to other countries. Another thing that also hap-pens is the lots of people displaying CFR numbers inIndonesia on television or social media which then doesnot only make people understand but has the potentialto create excessive fear or anxiety. This is a mistake be-cause the community is more fixated on its CFR number

AbstractThe world is currently experiencing a COVID-19 pandemic. More than 5 million people have been infected with COVID-19 and more than 300 thousand havedied from this virus worldwide. In Indonesia, the number of infected people has reached more than twenty thousand people and more than one thousandpeople have died from this virus. During the COVID-19 pandemic, Case Fatality Rate (CFR) was a very important measure for many people because deathis 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 neededin 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

COVID-19 Case Fatality Rate and Detection Ability inIndonesia

Tiopan Sipahutar1*,Tris Eryando2

Correspondence*: Tiopan Sipahutar. Doctoral Program in Public Health, Facultyof Public Health, Universitas Indonesia, Lingkar Kampus Raya UniversitasIndonesia Street, Depok City, West Java, Indonesia, 16424, E-mail: tiopansi-pahutar@gmail.com, Phone: +62-812-1910-1192

1Doctoral Program in Public Health, Faculty of Public Health, Universitas Indonesia, Indonesia2Department of Health Informatic and Biostatistic, Faculty of Public Health, Universitas Indonesia, Indonesia

Sipahutar et al. Kesmas: Jurnal Kesehatan Masyarakat Nasional (National Public HealthJournal). 2020; Special Issue 1: 14-17DOI: 10.21109/kesmas.v15i2.3936

Received : May 29, 2020Accepted : May 30, 2020Published : 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)

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compared to other information behind the CFR.Therefore, it is very important to provide understandingto the public or community regarding what is meant bythe CFR and what are its weaknesses.

MethodThis is a literature review study. Authors submit that

it needs many considerations to interpret the CFR; andfor that authors present many expert’s views on how theCFR is calculated and its impact on the community.

DiscussionThe Case Fatality Rate (CFR) is a common measure

of the short-term severity of an acute disease; it could beused to measure any benefit of a new therapy or the ef-fectiveness of an intervention. The CFR is defined as theproportion of cases with certain diseases or conditionsthat die within a certain time. Generally, the CFR is pre-sented as a percentage.8-10 It is the proportion of peoplewith a given disease or condition who die from it in a giv-en period. In this pandemic context, the CFR is calculat-ed by dividing the number of COVID-19 patients whodied with the total number of patients with confirmed asCOVID-19 infection. The number of COVID-19 patientswho died is referred to as a numerator while the totalnumber of COVID-19 infected patients is referred to asthe denominator.8-10 In calculating CFR, it should useofficial data that has been confirmed by the party that is-sued the data. In Indonesia, official data is released bythe Ministry of Health which is published daily both di-rectly and on the official website.11

To April 27, 2020, the CFR in Indonesia was around8.4%.11 This figure was relatively high when compared

to other countries such as Singapore, Malaysia or evenChina. However, people must be careful in interpretingand comparing the CFR in Indonesia with other coun-tries. Let alone with other country, the CFR comparisonsbetween provinces in Indonesia also vary. This differenceis very reasonable, given the different characteristics ofthe regions in Indonesia.12-18

The calculation of CFR is particularly sensitive to thedenominator: the greater the denominator, the smallerthe CFR. The daily CFR figures can change according tothe denominator, which in this case is the number of peo-ple who have been confirmed as positive COVID-19based on real-time polymerase chain reaction (PCR)method. Several factors certainly affect the CFR figuresevery day. As we understand, COVID-19 is a new virusthat is still being researched. Much information regardingthe virus is still unknown. The capacity of health services;the availability of health workers, personal protectiveequipment, examination tools for diagnosis; and thereadiness of the central and local governments are severalfactors that also affect the CFR.14,15

One of the factors influencing the soaring figures ofthe CFR is the limited number of laboratories that can beused as referral sites for conducting real-time PCR testall over Indonesia. Initially, Indonesia only used one la -boratory to conduct the real-time PCR, and this assuredlyyielded a slow diagnosis, which, in effect, generated verylittle information (Figure 1). In March 16, 2020, it wasannounced that 12 laboratory networks were added, thenother additional 36 laboratories on April 3, and on April29 it was declared that the total number of laboratoriesready for PCR test was 89. This addition of laboratories,however, did not necessarily lead to the increase in the

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

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

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

16

number of test because Indonesia was constrained by thelimited availability of reagents and experts who were ableto carry out the test.11,19-21

With the addition of laboratories and the difficultiesencountered in the field, and when it compared to thevastness of Indonesia which consists of 514 districts, theoverall picture, of course, is still unfavourable. Such cir-cumstances have automatically slowed down the processof confirmation on people’s status – whether or not theyare infected; so the denominator would be small. In thiscase, the CFR tends to be over-estimated. We also under-stand that there were instances where patients under sur-veillance died but their results of real-time PCR test werenot yet known. If it was later discovered that the real-time PCR test results were confirmed to be positive, thenthe CFR calculation in the previous time was underesti-mated because it had not included the numerator.13,15,16

Both of such conditions, underestimation, and over-estimation of the CFR, have their respective impacts.Overestimation of the figures may induce fear and panicwhile underestimating it may lead to the lack of serious-ness in the community in preventing and overcoming thespread of the COVID-19. Thus, in presenting, interpret-ing and comparing the CFR for the public, caution andunderstanding of situations or contexts are indis -pensable.14

Responding to this situation, we must apply the na-tional standardization system in the context of laborato-ries for the equal distribution of the availability and quali -ty of examinations or diagnoses, so when one dayIndonesian is struck by a similar incident, we would nolonger hear a statement that “the data from Laboratory Ais unreliable” or “unconfirmed”. The minimum standardmust be prepared for each province, and if possible, beextended to the district or city level.7,11

Another thing of concern is the effort for modellingthe COVID-19 incident, which has been confusing to thepublic. Every academic and research institution has con-ducted modelling and each modelling has been developedwith an assumption. Different models were from differ-ent assumptions, and this is not even easily understoodby many people. Determining when transmission occursalso need to be assumed if the model is to be calculatedproperly. The determination of the initial transmissioncan be traced back from the first positive cases reported,where these cases are continuously traced until it be-comes possible to seize cases that have not been previ-ously diagnosed – but because of a proper symptomrecording – could show symptoms identical to the initial-ly diagnosed cases. Hence, we would be able to establisha diagnosis by running this method properly until the firsttransmission is assuredly discovered. Another option isto simply stop at the first confirmed case and pay atten-tion to the average transmission, hence an initial case can

be determined and a model with various assumptions bebuilt. The ability to trace back, known as disease epi-demiological research, is also important to be carried outby the health department in each district or city to assistin the discovery of new cases as well as to detect thesource of morbidity, which can help in handling a case ofillness.22-25

ConclusionFinally, this pandemic has inevitably demanded peo-

ple to understand the measures used in public healthproblems. However, displaying the size of public healthproblems without further explanation may cause infor-mation bias in the community, which can potentially cre-ate adverse interpretations and conclusions. Therefore,health information, especially about the size of publichealth problems, need to be displayed with explanationsof strengths and weaknesses. This is an opportunity toprovide more education to the public considering that50% of Indonesia's population has been connected tothe internet and almost all Indonesians can access televi-sion. Thus, this difficult pandemic would not just pass bybut also provide a learning effect for all Indonesians.

AbbreviationsCFR: Case Fatality Rate; WHO: World Health Organization; COVID-19: Coronavirus Diseases 2019; CDC: Centers for Disease Control andPrevention; PCR: Polymerase Chain Reaction.

Ethics Approval and Consent to ParticipateThe study was based on data available in public domain; therefore, noethical issue is involved.

Competing InterestThe author(s) stated that no potential conflicts of interest with respectto the research, authorship, and/or publication of this article.

Availability of Data and MaterialsAll material is publicly available in respective journals. The links areavailable in the reference list. All sources can be downloaded for free.

Authors’ ContributionAll authors have made substantial contribution to this research andhave approved the final manuscript.

AcknowledgmentNot Applicable

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

Correspondence*: Acim Heri Iswanto, Department of Public Health, Faculty ofHealth Science, Universitas Pembangunan Nasional Veteran Jakarta, Raya LimoStreet No. 1, Jakarta, Indonesia, E-mail: h.iswanto@upnvj.ac.id, Phone: +62-811-994-170

Iswanto. Kesmas: Jurnal Kesehatan Masyarakat Nasional (National Public HealthJournal). 2020; Special Issue 1: 18-23DOI: 10.21109/kesmas.v15i2.3949

Innovative Work Shift for Health Workers in the Health ServiceProviders in Handling COVID-19 Cases

Acim Heri Iswanto

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

AbstractWorking on shifts has the risk of being exposed to health problems, such as obesity and susceptibility to infections and hypertension. However, shift work isunavoidable for workers in sectors that require non-stop operations, such as health workers in the Health Service Providers. This article presented opinionabout 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 themorning 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 bytwo days off. This pattern has the potential to cause burnout and decrease reaction time. The article identifies a new work shift pattern that can accommodatethe risk of burnout while simultaneously assisting in the emergency of the corona outbreak. It emphasises the Morning-Evening-Night-Holiday work patternas an innovative work model that should replace the old work pattern. There are seven advantages of the new work pattern: biological balance, availability oftransportation, 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

IntroductionThe new coronavirus disease 2019 (COVID-19) ini-

tially appeared in Wuhan City, Hubei Province, China, inDecember 2019. Currently, the virus has spread to 213countries and territories with 5,743,245 infected victims,354,884 of whom died and 2,470,836 declared cured,resulting in a 13% fatality rate.1 World HealthOrganization (WHO) officially declared COVID-19 as aglobal pandemic on March 11, 2020. Meanwhile,Indonesia declared the corona outbreak as a national di-saster on April 13, 2020, through the Presidential DecreeNumber 12 of 2020 on the Stipulation of A Non-naturalDisaster of the Spread of COVID-19 as a NationalDisaster. In Indonesia, COVID-19 has spread to 33 pro-vinces and infected 23,851 people, of whom 1,473 died.2In line with this, there have been many local governmentsdeclaring the enactment of Large-Scale SocialRestrictions (Pembatasan Sosial Berskala Besar/PSBB)in their areas.

The coronavirus has also affected the health workerscaring for the patients. Psychologically, health workersmay experience post-traumatic and burnout disorders.3

In the United States, the country with the most casualtiesin the world, an estimated 54.4% of doctors experienceat least one burnout symptom due to the treatment of co-ronavirus.4 A Korean study on handling the Middle Eastrespiratory syndrome (MERS) outbreak found that theaverage nurse experienced burnout due to high workstress, low support from family and friends, and poorhospital resources.5

Burnout is an urgent problem that must be treatedbecause it has severe consequences including fatigue,stress, anxiety, depression, mood disorders, drug abuse,suicide, poor patient care, early retirement, andunexpect ed work stoppages.4 It may also have an impacton patient dissatisfaction, decreased patient outcomes,increased mortality, and failure to save patients.5

Burnout itself is a negative experience on employeeswho do not have the psychological and physical resourcesto meet work demands and expectations. The experienceis characterized by the presence of emotional exhaustion(the feeling of overwhelm), depersonalization (the feelingthat the self is not real or that one cannot be him/herself),as well as decreased personal achievement (lack of per-

Received : May 30, 2020Accepted : May 31, 2020Published : July 31, 2020

Kesmas: Jurnal Kesehatan Masyarakat Nasional(National Public Health Journal)

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

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sonal achievement).5Concerning the COVID-19 outbreak, burnout may

cause viral transmission, slow recovery, and even deathfor both patients and health workers due to the inabilityof health workers to protect themselves or because healthworkers give up or commit suicide. In Indonesia, as ofApril 16, 2020, 23 doctors (four of whom were profes-sors) died from direct contact or indirect transmissionfrom COVID-19.6 At least 12 nurses have also died dueto the virus.7

Many factors are understood to be the causes of bur-nout. These factors can be classified into work factors,personal factors, and organizational factors. Work factorsinclude prolonged stress from excessive workload andwork hours. Personal factors cover work-life imbalances,lack of sleep, and inadequate support. Meanwhile, orga-nizational factors comprise workload expectations, poorinterpersonal communication, insufficient rewards, andnegative leadership.4

Learning from the burnout experience of health work -ers in the previous outbreaks such as the MERS, SARS,and H1N1, researchers have suggested several measuresto anticipate burnout as follows: providing adequate re-sources and consistent and up-to-date work guidance;recruiting additional health workers, volunteers, and ad-ministrative staff; expediting bureaucracy and licensing;allocating more budget; leveraging information technolo-gy intensively; implementing leadership to communicateclearly and efficiently; reducing workload; ensuring thesafety and health of health workers and staff; trainingfrontline workers; as well as protecting and supportinghealth workers with operational action plans.4

Several ideas have emerged in regards to reducing theworkload of health workers and staff. Reducing theworkload can be undertaken by creating a rest schedule;limiting working hours (especially in emergency and in-tensive care units); and providing regular psychosocialsupport, basic needs, and spiritual sessions.4 One idea toreduce the workload that should be applied is to changethe work shift patterns of health workers and staff. Longwork shift is one of the factors causing burnout on healthworkers. Studies show that nurses who work in shifts of8-10 hours have lower burnout rates than nurses whocontinuously work for 12 hours.8 Conversely, workingcontinuously for 13 hours or more leads to patient dissa-tisfaction.9

It is possible that the work shifts prevailing so far inmany PPKs in Indonesia, especially those dealing withcorona patients, are a source of burnout for health wor-kers. Many media reports indicate that the shifts of healthworkers in dealing with the COVID-19 outbreak are ex-hausting. The Indonesian Doctors Association (IkatanDokter Indonesia/IDI), for example, claimed that therewere doctors who died from fatigue in handling patients

and issued recommendations for reducing shift work timefor health workers treating corona patients.10

Shift-based workShift-based work, which is work performed during

unnatural working hours, is a work commitment thatcannot be avoided by health workers or workers in sec-tors that require uninterrupted operations. Concerningthis, the natural working hours are those hours that fol-low the circadian rhythm, which suggests work at dayti-me (as opposed to at night time). Ideally, humans workat this natural time because they are diurnal creaturesthat have a biological rhythm adapted for daytime activi-ties and resting at night. Work shifts, however, requireemployees to work part-time at night.

Shift work leads to several health problems such asweight problems and susceptibility to infections or hy-pertension.11,12 These types of disorders can, in turn, le-ad to chronic diseases and infections in employees.However, the degree to which employees are affected bythese disorders depends on four groups of factors, namelypsychosocial factors, behavioral factors, physiologicalfactors, and modification factors. The link between shiftwork and these factors is shown in Figure 1.

Psychosocial factors cover factors such as work ten-sion, work satisfaction, work-life balance, and workstress. Behavioral factors include sleep behavior, physicalactivity, and eating patterns. Meanwhile, physiologicalfactors constitute immunological effects, light, and vita-min D. These three groups of factors can be modified byinterventions on three things: shift work characteristics,socio-demographic, and chronotypes. As for the latter,chronotypes are a variation on the circadian rhythms atthe individual level. Although humans are generally diur-nal and active during the day, some individuals may havea deviation from this pattern that they are categorized asthe "night types".

Night-typed individuals characterize nocturnal crea-tures more for having higher activity at night biologically.Chronotypes are partly determined by genetic factors.Individuals with a morning chronotype sleep at 11:00 pmand wake up at 06:00 am on workdays and at 07:00 amon holidays. Individuals with a night chronotype sleep at01:00 pm and wake up at 08:00 am on workdays andsleep at 03:00 pm and wake up at 12 noon on holidays.13

Shift work can take rotations with varying frequenciesbetween morning, evening, and night work. Low rotationwork is defined by a long rotation period, for example,one week's work in the morning, one week's work duringthe day, and one week's work at night; or two days’ workin the morning, two days’ work in the afternoon, and twodays’ work in at night, followed by a break of three days.High rotation work, on the other hand, is marked by a ra-pid rotation period, for example, one day’s work in the

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

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morning, one day’s work during the day, and one day’swork at night, and two days of rest.14

Research shows that workers with rapid shift rota-tions may have disorders in decreased sleep duration andsleepiness at work compared to workers who work per-manently (only day or only night).15 This is caused bythe disruption of brain activity when staying awake,which brings in concentration decline and inability tocommunicate well with clients.9 However, this patterncan be reversed if workers are given a break of two daysor more after working on the night shift.15

However, research in other contexts shows differentresults. A study on 315 nurses in Italy in 2015 comparedburnout incidents between two work cycles: a long cycle(n = 105 people) with two workdays in the morning, twoworkdays in the afternoon, and two workdays at night,followed by a rest of three days; and a short cycle (n = 59people) with one workday in the morning, one workdayin the afternoon, one workday at night, and two days ofrest.14 There was no significant difference (p-value =0.160) in the two groups in terms of sleep quality. Also,no notable differences were found in terms of task per-formance (p-value = 0.728) or contextual performance(p-value = 0.997). Meanwhile, there was a significant dif-ference (p-value = 0.040) between long shift nurses andshort shift nurses in terms of burnout. Nurses with shortshifts had lower burnout rates than nurses with longshifts. The researchers explained that this occurredbecause nurses with long shifts were more often exposedto patients and hospital environments than nurses with

short shifts.In addition to the evidence from the above research,

there are suppressive factors that allow for the restraintof the negative impacts of rapid shift patterns, at least inthe context of health workers who treat corona patients.A study in Wuhan reveals that burnout is greatest amonghealth workers who do not treat corona patients, as op-posed to those workers who are at the forefront.16

This unexpected finding puts several intriguing expla-nations. First, the health workers have felt that there hasbeen more control over the situation than before, that iswhen they only “stayed quiet” when the outbreak initiallyoccurred. Second, the treatment of corona patients hasbecome a priority, which causes non-corona patients toreceive less attention. Although this is unfortunate, inthe context of shifts, it makes the health workers with ra-pid shifts dealing with corona patients less stressed thanthe health workers treating non-corona patients. Third,the health workers who deal with corona patients are clo-ser to decision-makers that they have access to informa-tion more quickly and accurately. This leads to a highersense of achievement among them compared to those he-alth workers treating non-corona patients. This effect isgetting stronger, especially because their treatment re-sults can be directly seen through the health statistics ofcorona sufferers.

This explains why there is unclear impact of three-pe-riod shift work on nurse burnout in the case of the MERSoutbreak. Research in this context partially found thatshift work affected nurse burnout while some other stu-

Figure 1. Factors Linking Shift Work with Health Problems12

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dies did not find a significant relationship.17,18

Results and DiscussionBased on the author's observations on several health

service providers (HSPs), the applicable general shiftschedule has a 6-day time off cycle with a pattern of 7-hour morning work pattern, 7-hour evening work, and10-hour night work. The number of workers for eachduty cycle is usually three people, but this data is not thesame in all hospitals. Morning shift starts at 07:00 am.The following table illustrates the pattern of attendanceof four employees with this work schedule.

The pattern on Table 1 shows an eight-day work cyclebecause on the ninth day, all four employees will be inthe same combination again. A break of two days afterthe night shift is in accordance with previous research re-commendations to restore the pattern of early life for he-alth workers.15 However, this may still cause burnoutbecause employees who work at night work up to 10hours.8 Employees may experience fatigue and a decreasein psychomotor response time after working for long pe-riods.19 Ideally, the working time should be eight hours,divided into three shifts, starting at 08:00 am to maintainwork-life balance of employees.20

One way to reduce workload is to develop new shiftwork schedule patterns that have shorter time off cycles.For example, holiday can be given every three days, halfof the time off cycle in the usual work schedule. The du-ration of work is also balanced by eight hours on all shifts(morning, evening and night), because one day is 24

hours a day and divided by three shifts (eight hours pershift). The number of health workers per shift is reducedfrom three to two and the morning shift begins at 08:00am. The following table (Table 2) illustrates the atten-dance pattern of four employees with a work schedulethat has a four-day work cycle.

The advantages of this system lie in many aspects. Thefirst is the aspect of biological balance. Although there isan increase in one hour from seven hours to eight hoursin the morning and evening shifts, this increase is in linewith the human circadian rhythms and is at a maximumlimit of eight hours. Workers on the night shift also ex-perience a better balance because work time decreasesdramatically from eleven hours to eight hours. This redu-ces the negative effects of fatigue due to fighting the na-tural circadian rhythm. A study of 20 long night shiftworkers results in nine out of 20 workers sleeping duringthe day.21 Conversely, a schedule of rapid work shift pre-vents the emergence of sleep debt. A study on workerswith a work rotation of 12 hours of daytime work, 12hours of night work, and two days off, shows the preven-tion of sleep debt.22

Secondly, the new system allows for transportationavailability. With work coming in at 08:00 in the morningand 16:00 in the evening, transportation is still available.This is different from the old system in which morningservice starts at 07:00, evening service at 14:00, andnight service at 21:00. For workers in big cities likeJakarta, the difference in hours of coming to work betwe-

Table 1. Work Schedule (Old)

Employees Monday Tuesday Wednesday Thursday Friday Saturday Sunday

A I I II II III III IVB II II III III IV IV IC III III IV IV I I IID 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 IVB III IV I II III IV IC IV I II III IV I IID 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

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en 07:00 am and 08:00 am hours is huge. At 07:00 am,the road is very congested and congestion occurs at manypoints. Traffic monitoring data shows that in Jakarta, onaverage Monday - Friday, traffic jam at 05:00 am is 9-16% while at 06:00 am increased to 37% - 48%.23

Going early to work, as the sky is getting bright, canincrease one’s exposure to sunlight in the morning wit-hout having to be spoiled by air pollution. In fact, beingin a traffic jam would cause physical fatigue to those whopass through it.24 This makes employees want to sleepand rest more after experiencing a traffic jam.25

Third, more frequent time off allows for faster workrecovery before a buildup of fatigue befalls. Sleep depri-vation leads to heart disease, diabetes, depression, fain-ting, accidents, weak cognition, and low quality of life.26

Additionally, sleeping time under six hours per day maycause sleep debt that must be fulfilled immediately by thebody. If the sleep debt is not paid, there will be problemswith concentration and performance. Long cycle periodof six days may cause a buildup of sleep debt that ultima-tely reduces employee performance, especially in the finaldays before the holiday. Because the last day of work is atnight, the patient being treated might run the risk of me-dical errors. Moreover, employees may spend the firstday of their time off sleeping, disrupting their roles in thefamily such as being a mother or a father. If the cycle pe-riod is short, there would almost be no build up of sleepdebt and holidays can be treated as normal days withouthaving to sleep excessively. Furthermore, a study com-paring 24-hour and 72-hour break after a night shift doesnot highlight a significant difference, so the research con-cludes that one day's rest time is sufficient for employeework needs.22

Fourth, fewer workers are needed to work on theshift. The reduction of employees from three to twoemployees per shift allows for the use of less labor andmore efficient work because social interaction on thingsthat are not relevant to work is limited. Moreover, this isin line with the physical distancing instruction becausethere are only two, rather than three personnel. Shortwork hours make employees more often work at homeand not often come to health care centers.

Fifth, there would be an increase in patient satisfac-tion and a decrease in unwanted incidents. This is backedup by the fact that a short work cycle reduces the level ofburnout in health workers.14 This will be especially fa-vourable for patients who are treated at night as a pre-vention measure has been taken in regards to the risk oftreatment errors which might have been caused by ex-hausted health workers.

Sixth, although the rest period is one day less than re-commended for short shifts,14 this has been compensatedby the nature of the work. Work that deals with the CO-VID-19 outbreak have been found to have different cha-

racteristics from work that deals with "everyday pro-blems" in hospitals. In employees dealing the coronavi-rus, there is an increase in self-control, attention, andhigh support, all of which reduce the risk of burnout.16This should be able to compensate for one day removedfrom time off. In fact, if the time off is kept for two days,psychological problems may arise for health workers,such as feeling helpless because they are not participatingin critical tasks that require immediate actions.

Seventh, there is the possibility of improved perfor-mance. Although the study by Giorgi, et al.,14 find nosignificant differences between long shift workers andshort shift workers, other studies have shown an increasein performance in employees who work short shifts.21

This is attributed to increased melatonin secretion.Melatonin is a hormone produced by the pineal familythat runs in harmony with the circadian rhythms with itspeak level at night. Short shift work allows for an incre-ase in melatonin at night without interruption comparedto long shift work.

An alternative to the Morning-Evening-Evening-Holiday model with 8-hour working hours above can beconceptualized as well. For example, the cycle of oneday's work in the morning, one day's work in the evening,one day's work at night, and a two-day break from thestudy of Giorgi, et al.,14 can be applied while maintaininga long working time, though it may be less balanced whencompared with the emergence of the corona outbreak ca-se. Work shifts of three days in the morning, then timeoff, then three days’ work in the afternoon, followed bytime off, and then three days’ work at night, then time offagain, can also be considered as long as the workinghours per shift are no more than eight hours and time offis fast. The point is we need to modify working hours andshift patterns that have existed now so that it is more ba-lanced between the needs of health workers and theneeds of COVID-19 patients.

ConclusionThere is indeed societal pressures on physicans and

nurses engaged with Covid-19 cases to working as goodas they can. However, if the working shift can decreasinghealth professionals performance and their wellbeing,then this would constitute sufficiently compelling reasonsfor change the shift pattern to be lighter and shorter.Because of this reason, and also because demands fromphysicians and nurses themselves, we propose an innova-tive work shift scheduling. The new work shift schedulingcould solve some health problems experienced by physi-cians and nurses.

AbbreviationsWHO: World Health Organization; PSBB: Pembatasan Sosial BerskalaBesar (Large-Scale Social Restrictions); MERS: Middle East respiratory

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

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sindrome; IDI: Ikatan Dokter Indonesia (Indonesian DoctorsAssociation); HSP: Health Service Provider.

Ethics Approval and Consent to ParticipateNot Applicable

Competing InterestAuthor declares that there are no significant competing financial, pro-fessional, or personal interests that might have affected the perform-ance or presentation of the work described in this manuscript.

Availability of Data and MaterialsThe data and materials of this study were available upon request to thefirst author.

Authors’ ContributionAcim Heri Iswanto contributed substantially to the conception, writing,and revising of the manuscript.

AcknowledgmentMy sincere gratitude is addressed to Owner, Board of Directors, AllManagers and Staff of Ali Sibroh Malisi Hospital, Jakarta that grantedpermits to conduct implementation this idea in its working areas as pi-lot project.

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na, ini daftarnya. detikNews; Aprl 15, 2020 [cited 2020 Apr 16].

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corona. Katadata.com; April 12, 2020 [cited 2020 Apr 16].

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9. Nurumal MS, Makabe S, Ilyani F, Jamaludin C, Fahmi H, Yusof M.

Work-life balance among teaching hospital nurses in Malaysia. Global

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kerja melebihi beban. IDN Times; MArch 20, 2020 [cited 2020 May

28].

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sion and associated factors among healthcare workers: a cross-sectio-

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12. Loef B. Shift work: health, lifestyle, and immunological effects. Dutch

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16. Wu Y, Wang J, Luo C, Hu S, Lin X, Anderson AE, et al. A comparison

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

Correspondence*: Bunga Astria Paramashanti, Department of Nutrition, Facultyof Health Sciences, Universitas Alma Ata, Brawijaya Street No. 99, Yogyakarta,Indonesia 55183, E-mail: bunga@almaata.ac.id, Phone: +62 821-3193-1623

Paramashanti. Kesmas: Jurnal Kesehatan Masyarakat Nasional (National Public HealthJournal). 2020; Specia Issue 1: 24-27DOI: 10.21109/kesmas.v15i2.3934

Introduction Since the first case of severe acute respiratory

syndrome coronavirus 2 (SARS-CoV-2) was reported inDecember 2019 in Wuhan, Hubei Province, China,1 thecoronavirus disease 2019 (COVID-19) has spread to atleast 212 countries and territories worldwide. As of May4, 2020, when this manuscript was being written, therewere 11,587 people diagnosed with COVID-19 and 864deaths caused by the virus confirmed in Indonesia. Notonly the infected people, but a wider society has also beensocially and economically affected.

Indonesia’s economic growth was advancing rapidlyover the last decade with the gross domestic product(GDP) remained approximately at 5%. Nonetheless, thebenefits have not been equally distributed among theIndonesian population. The recent report revealed thatthe GDP in the first quarter of 2020 slowed to around3%. At this point, around 22 million Indonesians hadalready experienced hunger in 2016-2018.2 Things couldget worse before getting better.

To cut the virus transmission and lessen its impacts,the Indonesian Government has continuously called for“stay at home” to all the citizens. Moreover, some regionshave implemented large-scale social restriction whichrequires the closing of schools, offices, and public spaces,reduction in the public transport capacity, and restriction

Challenges for Indonesia Zero Hunger Agenda in the Contextof COVID-19 Pandemic

Bunga Astria Paramashanti

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

AbstractThe rapid spread of COVID-19 has not only threatened the lives of the infected people but also socially and economically affected a broader community. Thepandemic has also challenged the second goal of the 17 Sustainable Development Goals (SDGs) to eliminate all the forms of hunger by 2030. The mostdisadvantaged people may have a greater risk of having malnutrition and poor health as they cannot access a diet that is safe, nutritious, affordable, andsustainable. At this moment, saving lives by focusing on the health-care system should not be the only priority; the emphasis should be made in otheressential 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

in public activities, such as religious and cultural events.As one of the essential services, the food, and beveragesector is still allowed to run in the aftermath of theCOVID-19 pandemic.3 However, the IndonesianMinister of Agriculture, Syahrul Yasin Limpo, admittedthat the novel coronavirus pandemic has disrupted foodsupply chains, resulting in food price volatility anddecreased purchasing power at the national and theglobal levels.4 A distorting food environment means thatthere will be a change in dietary practices that may affectnutrition and health status.

The United Nations Development Programme(UNDP) has stated the global health and economic crisesraising as the impact of COVID-19 pandemic. The dualcrises may continue to overload policy and health-caresystems. For this issue, the political response will decidethe extent of the virus as well as the continuation ofachieving Sustainable Development Goals (SDGs).5Undoubtedly, the crisis demands a collective response.

Results and DiscussionThe second goal of SDGs aims to “end hunger,

achieve food security, and improve nutrition andpromote sustainable agriculture”. Working for ZeroHunger means ensuring that all people, particularlychildren, have adequate and nutritious food throughout

Received : May 29, 2020Accepted : May 30, 2020Published : 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)

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while the poor population was at 9.22%.13 TheIndonesian Minister of Finance, Sri Mulyani Indrawati,said that the pandemic may place the poverty rate intothe double-digit as in 2011.14 What could be worse thandying from the virus or starving to death?.

Secondly, hunger can happen when the community isfaced with severe food insecurity. In this state, foodcannot be obtained for a long period, either geo -graphically or financially. For those who still manage toaccess food, though perhaps not always, moderate foodinsecurity may cause them to risk food quality andadequacy. Worse still, we must not forget the mostaffected people already in food shortage, or childrenrelying on food supplementation programs, or the low-income informal workers.14 Too many people are notgetting access to safe, nutritious, affordable, andsustainable diets. Unfortunately, there are many datagaps to draw up a further conclusion on this pandemiceffect, however, we cannot ignore the rising risks ofmalnutrition and poor health.

Thirdly, children are the most vulnerable groupaffected by hunger.11 Of the Zero Hunger targets, it isglobally agreed to reduce wasting and stunting amongthe under-five.6 As a consequence of the COVID-19pandemic, recent food shortage may cause children atrisk of having acute malnutrition due to substantialweight loss or wasting. Given its chronic nature, the riskof stunting should not be left behind. Stunted growthmay also occur among children who are already in a stateof long-standing food scarcity.

One of three under-five children in Indonesia hasalready suffered from stunted growth in 2018,15

indicating chronic undernutrition. There was only a 1.3%annual decrease since 2013.16 The progress was not evenclose to the global and national targets which require3.9% and 2.8% yearly reduction, respectively. With thisemergency happening, we will be far further from thetarget.

Micronutrient deficiency may also arise. Hiddenhunger affects both children and women. The mostcommon form is iron deficiency anemia with itsprevalence around 39% among children and 49% amongmothers.15 In children, iron deficiency may reducelearning ability and school performance, whereas womenare at risk for mortality during or after delivery.17

Last but not least, the burden of malnutrition can beextended beyond hunger to overweight and obesity. Theway crop harvesting on the farm has been changed due toglobalization and urbanization which causes the highly-processed food displayed in the supermarket.18 Whilephysical distancing becomes common, consumersprioritize purchasing food which is durable, affordable,and easily accessed and prepared. This calling may invitean increased consumption of ultra-processed food with

the year for a healthy life. While undernutrition hasdeclined by nearly half in many countries due to rapideconomic growth and rising agricultural productivity, itis unfortunate that some still face malnutrition andstarvation.6 In this current situation, the question is, whatconsequences does the COVID-19 have on the SDGs?.

Firstly, the pandemic may affect food security byinterrupting the food system. We should look again atthe Indonesian Government’s responses to limittransnational and national movements to cut the growingtransmission of the COVID-19. The regulations sure havestruck economic activities heavily in several ways,including on food value chains. Similarly but differently,the pandemic crisis has affected food demand,production, distribution and storage, processing, andmarketing for both the low- and the high-incomepopulation.7 Even though there is no direct prohibitionon the food and beverage sector in Indonesia, there hasbeen a change on the way of food being produced andconsumed.

Indonesian agriculture is dominated by smallholderfarmers. Ironically, as food producers, farmers are highlyaffected by the threat of a food security crisis due topoverty. As a result, they are unable to buy seeds andrenew their crops.8 Yet, we should not worry about thestaple food supply in the next three to four months. Riceand corn stocks from March to May 2020 were 15.9million tons and 10.3 million tons, respectively,compared to the estimated need of the population, eachat 7.6 and 6.0 million tons.9 Then, what will happen afterMay?.

During the focus group discussion on “EffectivenessStrategies for Implementing Economic Stimulus Impactsof COVID-19”, the President Director of PT PerkebunanNusantara VIII said that grain production will fall by50%. Based on the field observation, rice productiondropped from 5-6 tons per hectare to 3 - 3.5 tons perhectare. Some regions have now increased the ricemarket price such as in Lembang with the rice price atIDR 12,000 per kg, exceeding the average price of IDR8,500 per kg.10 At the same time, Indonesia is still heavilyrelying on the imported source of animal protein, such asbeef and broiler. By the end of May, the estimatedcommodity of broiler is only 219,000 thousand tons,while beef is minus 19,000 thousand tons.9 A foodimport strategy may be an alternative to maintain pricestability. Still, other countries may also struggle with theirfood security and put restrictions on their exports.

Consumers’ demands for various food products hasbeen reduced due to human movement restriction, highprice volatility, and reduced purchasing power. If we lookback in 2019, the hunger level in Indonesia wascategorized as serious,11 and the food securityperformance ranked the 62nd among 113 countries,12

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high levels of sugar, fat, salt and energy, but low in fiber.Additionally, staying at home may also increase thesedentary lifestyle and reduce physical movement. Bothexcessive energy intake and low physical activity are themain drivers of overweight and obesity.19

There will be no healthy lives without healthy eating,and healthy eating cannot exist without sustainableagriculture.20,21 Nevertheless, health and agricultureagencies have little cooperation and are often steered bydistinctive and conflicting priorities.20 Also, the lack ofdata underlines the importance of effective monitoringand evaluation systems in each sector, followed by datasharing between sectors. The goal is early detection andimmediate response with emphasis on cost-effectivenessand cross-sector collaboration.

ConclusionCOVID-19 pandemic could reverse Indonesia’s

progress towards the second goal of 17 SDGs by 2030.The unprecedented crisis may affect the Zero Hungeragenda in Indonesia which include food insecurity,hunger, and malnutrition – especially childhood stunting.The policymakers are urged to assist most vulnerablegroups that are not only the infected patients or theirfamily members, but also people who are food-deprivedand malnourished. Saving lives is a priority; however, at-tention and efforts must consider other aspects such asfood and agriculture, economy, social protection, and ed-ucation without adding the burden of another humani-tarian catastrophe.

AbbreviationsSDGs: Sustainable Development Goals; SARS-CoV-2: Severe AcuteRespiratory Syndrome Coronavirus 2; COVID-19: Coronavirus Disease2019; GDP: Gross Domestic Product; UNDP: United NationsDevelopment Programme.

Ethics Approval and Consent to ParticipateNot Applicable

Competing InterestNo potential conflict of interest was reported by the author.

Availability of Data and MaterialsNot Applicable

Authors’ ContributionBunga Astria Paramashanti contributed substantially to the conception,writing, and revising of the manuscript.

AcknowledgmentNot Applicable

References1. Wu F, Zhao S, Yu B, Chen Y-M, Wang W, Song Z-G, et al. A new

coronavirus associated with human respiratory disease in China.

Nature. 2020; 579 (7798): 265-9.

2. Asian Development Bank. Policies to support investment requirements

of Indonesia's food and agriculture development during 2020-2045.

Manila: Asian Development Bank, IFPRI and Kementerian PPN /

Bappenas; 2019.

3. Ministry of Health of Indonesia. Peraturan Menteri Kesehatan

Republik Indonesia Nomor 9 Tahun 2020 tentang Pedoman

Pembatasan Sosial Berskala Besar dalam Rangka Percepatan

Penanganan Corona Virus Disease 2019 (COVID-19); 2020.

4. Ministry of Agriculture of Indonesia. Pertemuan menteri G20,

Indonesia tekankan penguatan sistem pangan menghadapi COVID-19;

2020.

5. United Nations Development Programme. The social and economic

impact of COVID-19 in the Asia-Pacific region. Position note prepared

by UNDP Regional Bureau for Asia and The Pacific. Bangkok: United

Nations Development Programme; 2020.

6. United Nations Development Programme. Goal 2: zero hunger; 2020.

7. Haddad L, Fanzo J, Godfrey S, Hawkes C, Morris S, Neufeld LM. The

COVID-19 crisis and food systems: addressing threats, creating

opportunities. ed. 23 March 2020. London: Global Alliance for

Improved Nutrition (GAIN).

8. Pusat Penelitian Kependudukan LIPI. Ketahanan pangan dan ironi

petani di tengah pandemi COVID-19. Jakarta: Lembaga Ilmu

Pengetahuan Indonesia; 2020.

9. Hirawan FB, Verselita AA. Kebijakan pangan di masa pandemi

COVID-19. Jakarta: CSIS Indonesia; 2020.

10. Thomas VF. Pandemi corona: Indonesia bisa kekurangan beras dan

bahan pangan. tirto.id; 2020.

11. Global Hunger Index. Global hunger index 2019: Indonesia. ed.

October 2019; 2019.

12. Global Food Security Index. Global food security index: ranking and

trends; 2019.

13. Badan Pusat Statistik Indonesia. Persentase penduduk miskin

September 2019 turun menjadi 9,22 persen. Jakarta: Statistical Bureau

of Indonesia; 2020.

14. Food and Agriculture Organization. The state of food security and

nutrition in the world 2019. Safeguarding agaist economic slowdowns

and downturns. Rome: Food and Agriculture Organization (FAO);

2019.

15. National Institute of Health and Research Development. Laporan

nasional riskesdas 2018. Jakarta: National Institute of Health and

Research Development (Balitbangkes); 2019.

16. National Institute of Health and Research Development. Laporan

Nasional Riskesdas 2013. Jakarta: National Institute of Health and

Research Development (Balitbangkes); 2013.

17. United Nations Children’s Fund. Key asks for 2020 SDG voluntary

national reviews: zero hunger. New York: UNICEF; 2020.

18. United Nations Children’s Fund. The state of the world’s children

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

Kesmas: Jurnal Kesehatan Masyarakat Nasional (National Public Health Journal). 2020; Special Issue 1: 24-27

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21. Lartey A, Meerman J, Wijesinha-Bettoni R. Why food system

transformation is essential and how nutrition scientists can contribute.

Annals of Nutrition and Metabolism. 2018; 72 (3): 193-201.

M, et al. Energy balance and obesity: what are the main drivers?.

CCC-Cancer Causes & Control. 2017; 28 (3): 247-58.

20. Nugent R. Bringing agriculture to the table: how agriculture and food

can play a role in preventing chronic disease. Chicago, USA: The

Chicago Council on Global Affairs; 2012.

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

Correspondence*: Vincent Ongko Wijaya, School of Medicine, Duta WacanaUniversity, Wahidin Sudirohusodo Street 5-25, Yogyakarta, Indonesia, 55284, E-mail: vincent_wijaya007@yahoo.com, Phone: +62-813-9274-5050

Pinzon et al. Kesmas: Jurnal Kesehatan Masyarakat Nasional (National Public HealthJournal). 2020; Special Issue 1: 28-31DOI: 10.21109/kesmas.v15i2.3929

AbstractCOVID-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 Governmentand review 20 cases from Bethesda Hospital in Yogyakarta providing online consultation services. Perceptions of experience on telemedicine were collectedfrom neurological patients at the hospital who were asked about their impressions of consultations and pharmacy medication services, and their suggestionsabout the new system in outpatient consultations. The regulations for telemedicine use are relevant because of these patients’ risks related to comorbiditiesand 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 andhospital requirements for telemedicine services for neurological cases have been accelerated due to the pandemic. Telemedicine is a way to providehealthcare needed by patients at high risks for COVID-19 fatality related to comorbidities and treatments. Payment regulations, regulatory structures, state li-censing, and credentialing across hospitals for better telemedicine experience need to be enhanced.

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

Acceleration of Telemedicine Use for Chronic NeurologicalDisease 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, Indonesia2Faculty of Medicine, Duta Wacana University, Yogyakarta, Indonesia

Introduction In December 2019, a cluster of pneumonia cases

occurred on Wuhan, China. The World HealthOrganization (WHO) has officially named the disease ascoronavirus disease 2019 (COVID-19) and it has becomea major health problem worldwide.1,2 Data on May 2,2020, showed that there were 10,843 positive cases inIndonesia, with a mortality rate reaching 831 (7.7%)cases.3 A review study has estimated the basicreproduction number (R0) of SARS-CoV-2 to be around2.2.4

Social distancing and quarantine have cut off accessto routine medical care for many chronic neurologicaldisease patients. Patients with the chronic neurologicaldisease have some poor prognostic factors for COVID-19 fatality, for example, advanced age (alzheimer andparkinson) or vascular risk factors (stroke).5 Data fromIndonesia show that most of the fatal cases have beenrelated to these risks (hypertension, diabetes, andcardiovascular / stroke condition).3

The Indonesian Government has already launched the

Regulation on the Health Informatics and TelemedicineSystem in 2014.6 With the Indonesian Medical Council(IMC), or Komisi Kedokteran Indonesia (KKI), theyhave also launched another regulation dealing with theCOVID-19 crisis.7,8,9 This regulation states that patientswith high risks should avoid traditional outpatient visitsif possible, especially in crowded hospitals. The currentCOVID-19 crisis has accelerated the use of telemedicinefor caring for these patients, especially with manycomorbid and advanced age. This study aimed to reviewthe acceleration of telemedicine use catalyzed by thegovernment regulations, as well as to review 20 casesfrom Bethesda Hospital in Yogyakarta, Indonesia, whichprovides online consultation services.

MethodThis study was a cross-sectional study using a

questionnaire-based measurement to evaluate thesatisfaction of telemedicine use during the COVID-19pandemic. It collects the current regulations of theIndonesian Government and medical association on

Received : May 27, 2020Accepted : May 28, 2020Published : July XX, 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

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telemedicine and COVID-19 as shown in Table 1. It alsocollects case series from Bethesda Hospital in Yogyakartafrom neurological patients who used telemedicine (videocall by application for outpatient consultation). Thepatient survey was undertaken after consents wereobtained following video-call outpatient consultations.The subjects were asked about their perceptions of theconsultation, the service of medication on pharmacy, andtheir suggestions about the new system in outpatientconsultation.10 Their responses were noted in self-madequestionnaires designed for this study. The system andhospital requirements for telemedicine services forneurological cases were also reviewed in this study. Thisstudy has obtained ethical permission from the BethesdaHospital Research and Development Department. Oralinformed consent had been taken from the subjectsbefore the survey was conducted.

ResultsAs a response to the COVID-19 crisis in Indonesia,

the Indonesian Government has launched the Regulationof Ministry of Health on the use of telemedicine (Table1). The Indonesian Neurological Association (INA) alsoresponded to this situation.11

These regulations are very suitable for patients withneurological diseases because of these patients’conditions (advanced age), risk factors (hypertension anddiabetes), and treatments (immunosuppressive formultiple sclerosis or myasthenia gravis). Most of theseregulations require electronic prescribing and electronicmedical records for the use of telemedicine consultations.The prescriptions of controlled substances such asanalgesics or opioids require legitimate medical purposesin accordance with the law.

Outpatient visits for neurological disease during theCOVID-19 pandemic are inefficient and often unsafe.Individuals may require long travels to hospitals, whereinsparsely populated areas it may take hours for them.Following long commutes, patients often sit in crowdedwaiting rooms and pharmacies. This study reviews 20cases that have already used online consultation and the

demographic data is shown in Table 2. Most of thesubjects are male (70%), > 60 years old (90%) and havebeen diagnosed with stroke (60%). More than 75% ofthe subjects were satisfied with the use of telemedicinefor their chronic neurological consultation. In terms ofsuggestion, 80% of the subjects suggest the reimburse -ment services be evaluated during the COVID-19pandemic for their consultations.

DiscussionThe COVID-19 pandemic has resulted in

unprecedented disruptions in health care and hospitalservices. It has not only been affecting the COVID-19patients, but also patients with chronic neurologicalcases.12,13 The significant impact of the COVID-19pandemic on the healthcare system and the rapiddepletion of its resources, urgent steps should be takenwhile managing acute stroke patients to prevent thespread of the disease, to protect both patients and staff,and to minimize the uses of already strained resources.

The strict emphasis on self-isolation and socialdistancing has become the main factor that raises seriousconcerns about the well-being of patients with chronic

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 recordIndonesian 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

Table 2. The Characteristics of the 20 Patients Using Online Consultations at Bethesda Hospital Neurological Outpatient Clinics on April 2020

Characteristic Category Total %

Sex Male 14 70% Female 6 30%Age < 60 years old 2 10% > 60 years old 18 90%Diagnosis Stroke 12 60% Parkinson 2 10% Vertigo 2 10% Back pain 1 5% Other 3 15%Level of satisfaction Very satisfied 3 15%with the services Satisfied 15 75% Neither satisfied or not 2 10% Not satisfied 0 0 Very not satisfied 0 0Suggestions from patients Reimbursement 16 80% Medication 2 10% Services 2 10%

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

30

neurological diseases, given these patients require routinehospital visits for evaluation and medical adjustments.14

More than 75% of the subjects in our study weresatisfied with the use of telemedicine for their onlineconsultations. These results may become a reference forsome hospitals that some patients and caregivers cancope with the larger use of telemedicine for health careservices. A previous study has already shown thepotential for using telemedicine in disasters and publichealth emergencies.15

The rapid responses from the Indonesian Governmentand KKI on the potential use of telemedicine have beenresponded by professionals and specialty associations.The regulation cannot be responded to immediately byevery hospital because of the limitations on electronicmedical records and electronic prescribing system. Aprevious study has shown that there is great disparityamong health care facilities and hospitals in Indonesia.16

Our study on 20 cases with chronic neurologicaldisease patients was promising. Most respondentsshowed a positive response to the new outpatientconsultation method. Most of our patients are older than60 years old and disabled due to their illness (stroke).Therefore, the video calls online consultations wereestablished by the providers to avoid travel to in-personcare sites. This study only focused on doctor-patientconsultation. In stroke care, much additional care shouldbe in place. The majority of the important works done bydietary consultants, pharmacists, and stroke educationnurses could potentially be done without direct patientcontact in many cases. The challenges will be in thephysical therapy and rehabilitation aspects.13

Most of our subjects (80%) suggested the re -imbursement method be recalculated because of thedifferences between direct consultation and telemedicinein terms of physical examination and communication. Apast study of telemedicine and reimbursement forvascular surgery consultation was significant to thepatients. The use of telemedicine provided an increase inreimbursement from private payers and acceptance frompatients, which ranged from 0% to 67% of the totalcharges billed. However, telemedicine use has proven tobe effective to reach a broader population base, andwithout significant cost to the patients.17

The use of telemedicine, especially onlineconsultation, has been growing very slowly in Indonesia.Face to face consultations has become the main methodof outpatient visits. This study shows that the system,hospital system, and regulations have been accelerateddue to the COVID-19 pandemic. For the neurologicaldisease patients, these conditions are relevant because oftheir risks related to the comorbidities and treatments.

The American Academy of Neurology describes thelimitations of telemedicine especially in the terms of

neurological examination including comprehensive eyeexams, neuromuscular components, and vestibularexaminations.17 The main barriers to maintaining thistelemedicine are related to the reimbursement system.This approach can only be conducted in private patientsand limited for patients managed under the nationalhealth insurance program. The payers for the nationalhealth insurance system and other private insurancescompany should modify their payment policy in responseto COVID-19. The limitations of our study are that thereare no follow-ups for the long term and clinicaloutcomes, as well as the measurement methods of thesubjects’ satisfaction, which are based on self-madequestionnaires. Therefore, the validity and reliability ofthe instrument have yet to be tested.

ConclusionThe COVID-19 pandemic has presented unique

challenges to hospital and patients care. The significantimpact of the pandemic on the healthcare system inIndonesia has called for urgent steps for managingchronic neurological patients. The use of telemedicine isrequired to prevent the spread of the disease, protectboth patients and staff, and minimize the uses of alreadystrained resources. Payment and regulatory structures,state licensing, credentialing across hospitals should bemodified as the response to this.

AbbreviationsWHO: World Health Organization; COVID-19: Coronavirus Disease2019; IMC: Indonesian Medical Council; KKI: Komisi KedokteranIndonesia; INA: Indonesian Neurological Association.

Ethics Approval and Consent to ParticipateThis study has been approved by the Health Ethics Committee ofBethesda Hospital.

Competing InterestThe authors declare no conflict of interest to disclose.

Availability of Data and MaterialsThe data and materials of this study were available upon request to thefirst author.

Authors’ ContributionRizaldy Pinzon: Study concept and design, writing of the initial draft,supervision, data availability; Dessy Paramitha: Methodology, writingand revision of the manuscript; Vincent Ongko Wijaya: Data analysis,writing and revision of the manuscript.

AcknowledgmentNot Applicable

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References1. Lu R, Zhao X, Li J, Niu P, Yang B, Wu H, et al. Genomic

characterization and epidemiology of 2019 novel coronavirus:

implications for virus origins and receptor binding. Lancet. 2020; 395

(10224): 565–74.

2. World Health Organization. Coronavirus disease (COVID-2019)

situation reports; 2020.

3. Indonesian Task Force for COVID-19. Current situation reports of

COVID-19 in Indonesia; 2020.

4. Liu Y, Gayle AA, Wilder-Smith A, Rocklov J. The reproductive

number of COVID-19 is higher compared to SARS coronavirus.

Journal of Travel Medicine. 2020; 27 (2).

5. Peraturan Pemerintah Nomor 46 Tahun 2014 tentang Sistem

Informasi Kesehatan (Lembaran negara Republik Indonesia Tahun

2014 Nomor 126, Tambahan Lembaran Negara Republik Indonesia

Nomor 5542). Republik Indonesia.

6. Indonesian Ministry of Health regulation, 303/2020, Indonesian

Health Ministry regulation of the use of Information Technology and

Communication for Preventing the COVID-19, Indonesian Ministry

of Health.

7. Indonesian Medical Council Regulation, 74/2020, The Use of

Telemedicine and clinical appointment in the Era of COVID-19

Pandemic. Indonesian Medical Council.

8. Indonesia FDA regulation, 8/2020. Indonesia FDA regulation for

medicine and food online transaction, Indonesia FDA 2020.

9. Al-Abri R, Al-Balushi A. Patient satisfaction survey as a tool towards

quality improvement. Oman Medical Journal. 2014; 29 (1): 3‐7.

10. Indonesian Neurological Association. Technical information for the

use of telemedicine for neurological patients. Indonesia: Indonesian

Neurological Association; 2020.

11. Helmich RC, Bloem BR. The impact of the COVID-19 pandemic on

parkinson's disease: hidden sorrows and emerging opportunities.

Journal of Parkinsons Disease. 2020; 10 (2): 351-4.

12. Dafer RM, Osteraas ND, Biller J. Acute stroke care in the coronavirus

disease 2019 pandemic. Journal of Stroke and Cerebrovascular

Diseases. 2020; 29(7): 104881.

13. Bloem BR, Dorsey ER, Okun MS. The coronavirus disease 2019 crisis

as catalyst for telemedicine for chronic neurological disorders. JAMA

Neurol. Published online April 24, 2020.

doi:10.1001/jamaneurol.2020.1452

14. Lurie N, Carr BG. The role of telehealth in the medical response to

disasters. JAMA Intern Med 2018; 178: 745-6.

15. Mulyanto J, Kringos DS, Kunst AE. The evolution of income-related

inequalities in healthcare utilisation in Indonesia, 1993–2014. PLoS

ONE. 2019; 14(6): e0218519.

16. Lin JC, Kavousi Y, Sullivan B, Stevens C. Analysis of outpatient

telemedicine reimbursement in an integrated healthcare system.

Annals of Vascular Surgery. 2020; 65: 100‐6.

17. Evans DA, Benameur K, Busis N. Telemedicine and COVID-19.

American Academy of Neurology. 2020 [Accessed May 27, 2020].

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

AbstractThe 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 alternativepersonal 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 aWHO’s recommendation on April 6, 2020. Medical masks are categorized as medical waste, then the disposal must be appropriate to prevent COVID-19transmission 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 notenough to provide an adequate protection level. Other steps must be taken, such as washing hands with hand soap in running water, keeping a physical dis-tance of minimum one meter from people, especially from those showing respiratory tract symptoms (coughing, sneezing), cleaning items touched by handsof 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

The Use of Cloth Face Mask during the Pandemic Period inIndonesian People

Ririh Yudhastuti

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

IntroductionCoronavirus is a large family of viruses that cause dis-

eases, ranging from mild to severe symptoms.Coronavirus disease 2019 (COVID-19) is a new type ofdisease that has never been identified before in humans.In December 31, 2019, the World Health Organization(WHO) China Country Office reported a case of pneu-monia of unknown etiology in Wuhan City, HubeiProvince, China. On January 7, 2020, China identifiedpneumonia of unknown etiology as a new type of corona -virus (coronavirus disease, COVID-19). In January 30,2020, WHO has designated the Public Health Emergencyof International Concern (PHEIC). The increase in thenumber of COVID-19 cases took place quite quickly andthere has been a spread between countries.1

Common signs and symptoms of COVID-19 infectioninclude symptoms of acute respiratory disorders such asfever, coughing, and shortness of breath. The average in-cubation period is 5 - 6 days with the longest incubationperiod of 14 days. In severe cases, COVID-19 can causepneumonia, acute respiratory syndrome, kidney failure,and even death.1 As of May 18, 2020, a total of

4,628,903 confirmed cases were reported with a total of312,009 deaths where cases were reported in 216 coun-tries or regions.2 The total number of confirmed cases inIndonesia up to May 19, 2020, was 18,010 cases with amortality rate of 6.6%.3

Several behaviors have been recommended to limitthe spread of COVID-19 to be carried out, which is thesame as in the influenza pandemic, such as washinghands, limiting social distance and coughing, and sneez-ing.4 In addition, WHO has recommended the commu-nity to use face masks.5,6 Several studies also suggest theuse of face masks in public places.7,8

Medical masks must be provided for health workers.9The use of medical masks in the community will cause ashortage of masks for health workers.6 The impact of theCOVID-19 pandemic, such as people's fear of the dis-ease, causes people flock to buy face masks and someeven hoard them. This results in a mask vacuum and sky-rocketing mask prices.10

The Centers for Disease Control and Prevention(CDC) recommends the use of cloth face mask in publicsettings, especially in significant community-based trans-

Yudhastuti. Kesmas: Jurnal Kesehatan Masyarakat Nasional (National Public HealthJournal). 2020; Special Issue 1: 32-36DOI: 10.21109/kesmas.v15i2.3945

Kesmas: Jurnal Kesehatan Masyarakat Nasional(National Public Health Journal)

Correspondence*: Ririh Yudhastuti, Department of Environmental HealthFaculty of Public Health, Universitas Airlangga, Airlangga Street, Surabaya City,East Java, Indonesia, E-mail: ririh.unair@gmail.com, Phone: +62-878-5486-2677

Received : May 30, 2020Accepted : May 31, 2020Published : 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

33

mission areas. The CDC also recommends the use of asimple face-covering mask to slow the spread of the virusand help people who might have the virus, but not knowit from spreading it to others.11 The recommended clothface mask is not a surgical mask or an N-95 respirator.Surgical masks or N-95 respirators are critical suppliesthat must be continuously reserved for health workersand other first medi cal respondents.11

The use of face masks protects individuals from thespread of COVID-19 and control the source of transmis-sion through droplets of others, but with limited medicalmasks, a cloth face mask can be used as an alternativepersonal protection from COVID-19. This study aims todescribe the use of cloth face mask as an alternative per-sonal protection during the pandemic.

MethodIn a commentary, the authors sought to present new

views to researchers about certain topics. Commentarycan also draw attention to current progress and speculateon the direction of certain topics in the future. Therefore,the authors review scientific texts and messages pub-lished in the mass media and scientific articles as well associal life about the use of face masks during the COVID-19 pandemic. Also, the authors use prior knowledge andexperience, particularly regarding information on the useof cloth face masks during the COVID-19 pandemic inIndonesia. In this commentary, the author attempts toaccount for any information published during thecorona virus crisis.

Results and DiscussionSince the outbreak of the coronavirus (COVID-19),

there have been battles related to the use of face masksin the community. Sometime before, WHO is still incon-sistent in the use of masks in the community. On January2020, WHO did not recommend the use of face masks inhealthy individuals in the community (mass making) as away to prevent the transmission of COVID-19 in the in-terim guidelines dated on April 6, 2020.12,13 The UnitedKingdom Public Health has made similar recommenda-tions, however, the United States Centers for DiseaseControl and Prevention has recommended the use ofcloth face masks outside home or public places and theaction is followed by other countries, such as Canadaand South Korea. Initially, the purpose of using facemasks was to protect oneself, then for reasons of publichealth, the use of face masks is to protect each other be-tween people from asymptomatic COVID-19 transmis-sion sources.14,15 From a workshop organized by WHOin 2019, the workshop concluded that although therewas no evidence of trials of effectiveness in reducingcorona virus transmission, WHO recommended that theuse of a severe influenza pandemic mask wear in the

community should be considered.15,16 Concern about theinsufficient supply of masks in the community is becausea medical mask must be provided for health workers.While, to control the source of COVID-19 and protectyourself, the use of a cloth face mask (non-medical) issufficient for protection, especially if everyone uses it.Fabric masks are easily made at home and reused afterwashing.16 In Indonesia, the need for face masks in thecommunity is increasing, especially after the IndonesianGovernment recommends to always use masks while do-ing activities outside home.17 It is recommended to atleast use a cloth face mask to prevent the coronavirustransmission which is increasing and spreading acrossprovinces and districts in Indonesia.

A research on influenza, influenza-like illness, andcoronavirus in humans provides evidence that the use ofmedical masks can prevent the spread of sparks that cancause transmission from the infected people to other peo-ple and the air contamination due to the sparks. There isan evidence that the use of medical masks by healthy peo-ple at home or by people who come in contact with peo-ple infected with COVID-19, as well as in a crowd, facemasks can serve as limited prevention, although there iscurrently no evidence that using face masks (either med-ical masks or other types) by healthy people in the com-munity at large, including the use of face masks togetherin the wider community, can prevent people from respi-ratory tract infections, including COVID-19.18 TheIndonesian Government’s policies recommend that medi -cal masks should be provided for health workers. Theuse of medical masks by the public can create a falsesense of security, so that other health measures such asmaintaining hand hygiene and physical distance are ig-nored, and there is still a practice of touching the face be-hind the mask and under the eyes. Some suggestions suchas maintaining a physical distance of approximately onemeter, avoiding crowds of people (more than five people)and washing hands in running water with hand soap for30 seconds is a very helpful role in preventing the trans-mission of COVID-19.19,20

WHO and decision-makers can continue to advocatethe use of non-medical masks both outdoors andindoors.19 In such places, the following points related tonon-medical masks must be considered, such as 1) thenumber of layers of cloth / tissue, 2) the ease of breathinggiven to the user of the mask material 3) the waterproofor hydrophobic nature 4) the shape of the mask 5) con-formity to face shape and 6) mask size.

Several types of masks that are available in the com-munity:1. Cloth face mask,20,21

Cloth face masks can be used to prevent transmission,while anticipating the scarcity of masks that occur inmarkets such as pharmacies and health stores. Fabric

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

34

masks made need to have three layers, namely a water-proof non-woven layer (front), microfiber melt-blownnon-woven fabric (middle), and ordinary non-woven fab-ric (rear). Cloth masks need to be washed and can beworn many times. The material used for fabric masks iscotton, scarf, and so on. This type of mask can be usedin public places and other facilities while maintaining asafe distance of 1 - 2 meters. A three-layer fabric maskcan filter the air and ward off viruses by up to 70%.Ways and models of fabric masks can be adjusted to theface and not loose. Masks can be sewn manually or usingmachines, the use of these masks is important, consider-ing the spread of the virus through the nose, mouth, andeyes carried by human fingers. The use of cloth facemasks can be indoors or outdoors.22,23

Fabric mask treatments can be washed using deter-gents with less rubbing, so that the fabric pores do notwiden and should be used for four hours to prevent con-tamination by other microorganisms like bacteria suchas Escherichia coli, Enterobacter aeruginosa, Shigellasp., Staphylococcus aureus, and fungus / fungiAspergillus sp., Penicillium sp., and Candida sp. becausethe cloth face mask becomes moist. The average temper-ature of 27oC and 75% relative humidity are preferredby microorganisms including bacteria, viruses, or fungi /fungus.9 It is important to note that cotton cloth facemasks are not considered suitable for health workers.Regarding fabric masks as Personal ProtectiveEquipment (PPE), the production of cloth face masks foruse in health service facilities is proposed to be carriedout locally if the supplies are inadequate or run out.WHO stresses that medical masks and respirators mustbe prioritized for medical workers or health workers.24,25

2. N95 mask,26

N95 mask is one of the protective or filter particlesthat are harmful to the users. However, the N95 maskcan only function for dirt and dust, not for gas and steam.Even so, N95 mask can protect its users from droplets,particles which are 0.1 micron in size and have an effec-tiveness of up to 95%. Medical personnel use particulaterespirators with at least equivalent protection to N95 cer-tified by the US National Institute of Occupational Safetyand Health, code 95 means that it can filter out airborneparticles as much as 95%. In the N95 mask, there arethree levels of mask filtering which are divided into threelevels of filtering, namely FFP1, FFP2, and FFP3. FFP1means filtering out at least 80% of particles in the air,FFP2 means filtering out at least 94% of particles in theair, and FFP3 means filtering out at least 99% of particlesin the air. From this explanation, it can be interpretedthat FFP2 has almost the same standard with an N95mask, whereas FFP3 is the same as an N99 mask.26

Medical personnel use particulate respirators with pro-tection at least equivalent to N95 certified by the USNational Institute for Occupational Safety and Health,European Union standard FFP2, or equivalent, when car-rying out or working in the place of carrying out proce-dures that produce aerosols, such as tracheal intubation,ventilation noninvasive, tracheotomy, cardiac pulmonaryresuscitation, manual ventilation before intubation, andbronchoscopy.25,26

3. Surgical masks,21,22,26

This type is a mask easily found in the nearest store orpharmacy. Usually, surgical masks are green or blue.Surgical masks have a function for protecting the usersfrom drops of large particles or splashes of water from aperson's mouth. However, it has not been able to protectagainst airborne particles. Surgical masks have a filtra-tion effectiveness of 0.1 microns 10 to 95%.

4. Facepiece respirator,26

A facepiece respirator or gas mask serves to protectthemselves from harmful gases and vapors. This maskdoes not filter out airborne particles unless it is designedto have a filter to block it. Among others, masks that cov-er almost the entire surface of the face are usually de-signed to protect users from big and small splashes, with-out leakage and effectiveness of up to 99%. This maskcan be used repeatedly after disinfection according to rec-ommendations from WHO. Facepiece respirators arerarely encountered every day because they are usually on-ly used by workers in the gas field or jobs with high levelsof contamination. In addition to the masks above, thereare still N99, N100, and P95 masks.

Management of the use of mask,27,28

The use and disposal of masks regardless of the typeare important to be done properly to ensure they are ef-fective and to avoid increased transmission. The follow-ing information on the proper use of masks is taken frompractices in health care facilities,28:1. Place the mask carefully, and ensure the mask covers

the mouth and nose and attaches it firmly to minimizethe distance between the face and the mask

2. Avoid touching the mask while it is used3. Take the mask off with the correct technique: do not

touch the front of the mask, but remove the maskfrom the back

4. After removing or whenever you accidentally touchthe mask used, clean your hands with alcohol-basedantiseptic liquid or soap/detergent with running waterif hands look dirty

5. If the mask becomes moist, it must be replaced imme-diately with a new mask that is clean and dry

6. Disposable masks are not used anymore

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

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7. Take off and discard the disposable mask after useEducation on proper disposal of the masks must be

actively delivered to the community, and people mustlearn how to properly handle the masks. For this reason,the government urges the public to dispose the usedmasks to spray disinfectants first. Then you should re-member that, before removing the mask, please cut itfirst. The waste masks used by the people have been cate -gorized as potential medical waste in toxic and hazardouswaste. After that, wrap it in clear plastic as a marker ofmask waste. Trash have to be closed if necessary with aprominent logo, so that people can quickly find it. In ad-dition to not polluting the environment and disturbingpublic health, this is because the waste masks can containvarious microorganisms that cause disease in humans. Inaddition there are other microorganisms as secondary in-fections in mask waste, so that mask waste is categorizedas medical waste, so that the management of mask wasteis the same as the medical waste standard operating pro-cedure (SOP). It is hoped that by following the stages ofmanagement of used masks, the potential risk for trans-mission due to misuse of masks can be avoided. In addi-tion, the habit of washing hands before and after using amask will minimize the potential for transmission ofvirus, such as the SARS-CoV-2 virus which causesCOVID-19.29,30

ConclusionDuring a pandemic, the use of cloth face masks can

reduce the COVID-19 transmission and should be fol-lowed by washing hands with hand soap in running wa-ter, physical distancing and avoiding crowds of people.

AbbreviationsCOVID-19: Coronavirus Disease 2019; WHO: World HealthOrganization; PHEIC: Public Health Emergency of InternationalConcern; CDC: Centers for Disease Control and Prevention; PPE:Personal Protective Equipment; SOP: Standard Operating Procedure.

Ethics Approval and Consent to ParticipatePermission to use this data has been approved by the Ministry of Healthof the Republic of Indonesia through the COVID-19 Task Force.

Competing InterestThe author states that there are no competing interests to disclose.

Availability of Data and MaterialsData is available in the COVID-19 Task Force text of the Ministry ofHealth, Republic of Indonesia and existing literature related to the useof masks for literature review.

Authors’ ContributionThe study has been carried out independently by Ririh Yudhastuti, startfrom designing research, studying design, analysis and composing ma -

nuscripts

AcknowledgmentThe author thank the Ministry of Health of the Republic of Indonesiafor providing COVID-19’s data that being used in this manuscript.

References1. Kementerian Kesehatan Republik Indonesia. Pedoman Pencegahan

dan Pengendalian Coronavirus Disease (Covid-19); 2020.

2. World Health Organization. Coronavirus disease (COVID-19) pan-

demic; 2020.

3. Menteri Kesehatan Republik Indonesia. Keputusan Menteri Kesehatan

Republik Indonesia Nomor HK.01.07/MENKES/382/2020 Tentang

Protokol Kesehatan Bagi Masyarakat di Tempat dan Fasilitas Umum

dalm Rangka Pencegahan dan Pengendalian Corona Virus Disease

2019 (COVID-19); 2020.

4. Morrison L G, Yardley L. What infection control measures will people

carry out to reduce transmission of pandemic influenza? a focus group

study. BMC Public Health. 2009; 9(1): 258.

5. World Health Organization. Coronavirus disease (COVID-19) advice

for the public: when and how to use masks; 2020.

6. World Health Organization. Advice on the use of masks in the context

of COVID-19; 2020.

7. Greenhalgh T, Schmid MB, Czypionka T, Bassler D, Gruer L. Face

masks for the public during the covid-19 crisis. The BMJ. 2020; 369:

m1435.

8. Leung C C, Lam T H, Cheng K K. Mass masking in the COVID-19

epidemic: people need guidance. The Lancet. 2020; 395.

9. Setiati S, Azwar M K. COVID-19 and Indonesia. Acta Medica

Indonesiana. 2020; 52(1): 84-9.

10. Maria Inggita. Health department issues circular letter regarding pre-

cautions for COVID-19. Berita Jakarta; 2020.

11. Centers for Disease Control and Prevention (CDC). Use of cloth face

coverings to help slow the spread of COVID-19; 2020.

12. Feng S, Shen C, Xia N, Song W, Fan M, Cowling B J. Rational use of

face masks in the COVID-19 pandemic. The Lancet. 2020; 8(5): 434-

6.

13. World Health Organization. Advice on the use of masks in the com-

munity, during home care and in healthcare settings in the context of

the coronavirus (2019-nCoV) outbreak: interim guidance; 2020.

14. Yu P, Zhu J, Zhang Z, Han Y. A familial cluster of infection associat-

ed with the 2019 Coronavirus novel indicates possible person-person

transmission during the incubation period. The Journal of Infectious

Diseases. 2020; 221 (11): 1757-61.

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

– March 16, 2020. CDC: MMWR. 2020; 69(14): 411-5.

16. Aiello A E, Murray G F, Perez V, Coulborn R M, Davis B M, Uddin M,

et al. Mask use, hand hygiene, and seasonal influenza-like illness

among young adults: a randomized intervention trial. International

Journal of Infectious Diseases; 2010. 201(4): 491-8.

17. Gugus Tugas Percepatan Penanganan Corona Virus Disease 2019

(COVID-19). Menyembuhkan dunia saling kerja sama melawan

COVID-19; 2020.

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18. World Health Organization. Rational use of personal protective equip-

ment for coronavirus disease (COVID-19); 2020.

19. Centers for Disease Control and Prevention (CDC). Considerations for

wearing cloth face coverings: help slow the spread of COVID-19;

2020.

20. World Health Organization. Home care for patients with COVID-19

presenting with mild symptoms and management of their contacts: in-

terim guidance, 17 March 2020; 2020.

21. Tamtomo AB. Infografik: panduan protokol kesehatan pencegahan

Covid-19 untuk sambut new normal. Kompas.com; April 27, 2020.

22. Public Health England. Coronavirus (COVID-19) —what you need to

know; 2020.

23. World Health Organization. Infection prevention and control during

health care when COVID-19 is suspected: interim guidance, 19 March

2020; 2020.

24. World Health Organization. Q&A on infection prevention and control

for health care workers caring for patients with suspected or con-

firmed 2019-nCoV; 2020.

25. World Health Organization. Suggestions regarding the use of masks in

the context of COVID-19 provisional guide; 2020.

26. Novita M. 4 jenis masker untuk cegah penularan corona, mana yang

terbaik?. Tempo.co; April 4, 2020.

27. AKbar JB. Fighting Covid-19, BEM distributes masks and hand sanitiz-

ers to community. UNAIR News; 2020.

28. World Health Organization. Water, sanitation, hygiene, and waste

management for the COVID-19 virus: interim guidance; 2020.

29. Undang-Undang Republik Indonesia Nomor 18 Tahun 2008 Tentang

Pengelolaan Sampah; 2008.

30. World Health Organization. Safe management of wastes from health-

care activities: a summary. Geneva: World Health Organization; 2017.

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

Setyawan et al. Kesmas: Jurnal Kesehatan Masyarakat Nasional (National Public HealthJournal). 2020; Special Issue 1: 37-42DOI: 10.21109/kesmas.v15i2.3937

AbstractThe COVID-19 pandemic affects entire communities and causes a huge impact on all life aspects which include biological, psychological, social, and spiritualwell-being. Health systems and health policies are promising developments and opportunities to review progress and accelerate interventions in COVID-19control. Studies devoted to core holistic-comprehensive issues surrounding this pandemic are limited. Therefore, this article aimed to review several bestpractice studies that reflect holistic-comprehensive approaches to COVID-19. A comprehensive literature review was written based on 15 articles from thedata 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 andeffective strategies to improve all aspects of well-being before, during, and after the COVID-19 pandemic. Among these promising strategies, a holistic-com-prehensive approach could also be considered as a necessary action to improve health policy during the pandemic. A holistic-comprehensive approach in-volved providing bio-psycho-socio-spiritual care and offered a continuum of healthcare that provides promotive, preventive, curative, and rehabilitativeservices. A holistic-comprehensive approach to the COVID-19 pandemic requires a sustained commitment from entire communities, stakeholders, and poli-cymakers to achieve better health outcomes for all.

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

A Holistic-Comprehensive Approach: Best Practices to ImproveHealth 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

IntroductionThe current coronavirus disease 2019 (COVID-19)

pandemic in many countries is expected to diminish overthe coming months. This pandemic situation also affectsentire communities and causes a huge impact on all lifeaspects which include biological, psychological, social,and spiritual well-being. Health systems and health poli-cies are promising developments and opportunities to re-view progress and accelerate interventions in COVID-19control.

The best practices and guidelines shared throughoutthe world demonstrate that several interventions to con-trol this infectious disease are possible. There are manyevidence-based practices on safe and effective strategiesto improve all aspects of well-being before, during, andafter the COVID-19 pandemic. Among these promisingstrategies, a holistic-comprehensive approach could alsobe considered as a necessary action to improve healthpolicy during the pandemic. A holistic-comprehensiveapproach involved the provision of bio-psycho-socio-spi -

ritual care and offered a continuum of health care: pro-motive, preventive, curative, and rehabilitative servic-es.1,2

A holistic-comprehensive approach is intended to ad-dress the challenges of bringing healthcare services inmore direct and comprehensive care during the pande -mic. Assessment of all potential determinant factors thatinfluence health status in individuals, families, and com-munities should be addressed.3,4 Studies demonstratedfactors related to the outcomes of COVID-19, includingthe immune responses, age, sufficient treatment, and so-cioeconomic factors. Recent estimates suggest that socialand economic change contributed to the rapid spread ofCOVID-19 pandemic, for instance, social and demo-graphic characteristics, public health infrastructure,health statistics, economic development, and environ-mental quality.5-7 The culture of society also influencedthe psychological response to the pandemic and theirwillingness to manage mental health issues.8 Hence, it isimportant to understand the individual as a whole person

Correspondence*: Febri E B Setyawan, Department of Family, Industrial andIslamic Medical Sciences, Faculty of Medicine, University of MuhammadiyahMalang, Malang, Indonesia 65145, E-mail: febri@umm.ac.id, Phone: +62-341-552443

Received : May 29, 2020Accepted : May 31, 2020Published : 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)

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not just as a patient or diagnosis.A holistic perspective in health policy means that ad-

dressing health determinant factors at all levels is impor-tant to organize and develop goal-directed comprehen-sive interventions for COVID-19. There were five mainelements in holistic policy: (1) considering the whole in-dividuals and the interactions between the social systems,(2) comprehensive understanding of other risk factorsrelated to health, such as psychology, culture and socioe-conomic status, (3) developing community partnerships,creating reciprocal relationships and establishing opencommunication, (4) increasing collaborative practice forhealth promotion, and (5) improving sustainability inhealth systems and healthcare.9

A previous study investigated the benefits of using ho-listic health management during the Ebola outbreak inWest Africa. They found that health systems should in-clude efforts to incorporate cultural beliefs and practiceswhen determining strategies during an outbreak. Thefindings revealed that a holistic approach for comprehen-sive care is needed to address the challenges of emerginginfectious diseases.10 Studies devoted to core holistic-comprehensive issues surrounding this pandemic are lim-ited. Therefore, this article aim to review several bestpractice studies that reflect holistic-comprehensive ap-proaches to COVID-19.

MethodA comprehensive literature review was performed to

retrieve recent articles addressing holistic-comprehensiveapproaches related to COVID-19 treatment. Althoughthere is no standardized consensus on this type of litera-ture review, we have tried to critically evaluate articlesand provide suggestions for future research by using thePreferred Reporting Items for Systematic Reviews andMeta-Analyses (PRISMA) flow diagram. This study waswritten based on 15 articles from the data sources thatwere Google Scholar, Science Direct, ProQuest Health,and Medical Complete, and ProQuest Science Journalsfrom 2010 to 2020, searched terms related to holistic,comprehensive, outbreak, pandemic, epidemics, andCOVID-19. In addition to this, all articles were thenscreened to determine their relevance.

Articles meeting these criteria were included if articleswere peer-reviewed, using the English language between2010 and 2020, presented empirical studies related toCOVID-19 (quantitative and qualitative), and investigat-ed holistic-comprehensive approaches to pandemic, out-break, and epidemic.

A total of 50 articles were retrieved and then screenedbased on inclusionary criteria (Figure 1). Of this number,the study revealed 20 articles that met the inclusionaryand exclusionary criteria. The study which had incom-plete information was automatically excluded. Significant

articles were selected and only 15 articles obtained to bereviewed (Table 1). Relevant policy related to COVID-19 was identified by reviewing selected articles, and re-ports related to best practices to implement a holistic-comprehensive approach. Best practices research aimedto describe any practices as alternatives to improve themanagement by implementing strategies that are moresuccessful in the relevant fields.11

Any relevant articles presenting evidence (whetherprimary or secondary) on holistic-comprehensive ap-proaches were also included in the analysis. Additionally,this study was complemented by grey literature reviewsfrom newspapers’ reports, government websites with re-gards to rules and regulations, and current situation up-dates on COVID-19. We describe best practices studiesthat reflect holistic-comprehensive approaches toCOVID-19 based on the Centers for Disease Control andPrevention (CDC) before, during, and after the pande -mic.

ResultsTable 1 describe best practices studies that reflect ho-

listic-comprehensive approaches to COVID-19 based onCDC before, during, and after the pandemic. Any rele-

Figure 1. PRISMA Flow Diagram of the Articles Selection Process

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

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vant articles presenting evidence (whether primary orsecondary) on holistic-comprehensive approaches werealso included in the analysis. Additionally, this study wascomplemented by grey literature reviews from newspa-pers’ reports, government website with regards to rulesand regulations, and current situation updates onCOVID-19.

Discussion

A holistic-comprehensive of careCOVID-19 can be well managed through holistic

planning using a multi-sectoral and comprehensive ap-proach — “Detect, Develop, Deliver”. In China, re-searchers detected the genome sequence of COVID-19,and this investigation was then reported to the WHO, al-lowing all researchers in the world to develop the vac-cines. Developing COVID-19 treatment needs a multi-sectoral approach to help with financial budgeting.Additionally, the government should support social andeconomic changes as the impact of lockdown and work-from-home policy. In response to COVID-19, theGovernment of Singapore provided $ 55 million as finan -cial support for 40,000 drivers.12 In Indonesia, the go -vernment took immediate action to assist Indonesian civilsociety through Family Hope Program (IDR 37.4 tril-lion), Social Assistance for Staple Food (IDR 2.2 tril-lion), Village Fund (IDR 21 trillion), Cash Labor-Intensive Program (IDR 16.9 trillion), and Pre-Employment Card Program (IDR 360 billion).13

A comprehensive system of care delivery is needed,so people can have access to the continuum of care.

Engaging communities to support and comply with thehealth policy is needed to achieve sustainability of pro-gram.14 Strengthening public health infrastructure andsocial networks is essential during the pandemic. Learn -ing from Wuhan is important as they can build 27 hospi-tals and engage 2,000 workers to prepare for the othertwo hospitals for treating COVID-19 patients.12 InIndonesia, almost all the hospitals could deliver appro-priate treatment for COVID-19 patients, from conduct-ing a rapid test to comprehensive treatment for COVID-19.15

Best practices to implement a holistic-comprehensiveapproach

In this study, we described best practices based on acomprehensive literature review to describe and synthe-size with regards to holistic-comprehensive approachesrelated to COVID-19 treatment developed by researchersand clinicians. A holistic-comprehensive approach as bestpractices to improve health policy for the COVID-19pandemic was developed and modified according to theCDC, which designed best practices for health profes-sionals to properly respond before, during, and afterCOVID-19 state of emergency (Table 2). Non-pharma-cological approaches were recommended as key mes-sages and actions to address the COVID-19.16

As the COVID-19 response begins and ends at the lo-cal level, therefore, in the preparedness phase, compre-hensive community planning should focus on improvinghealth systems and services, including communicationsacross all levels: leaders, stakeholders, and wider com-munities. Six components should be taken before prepar-

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 out- break 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

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

40

ing emergency plans: (1) developing community re-silience and recovery after the outbreak, (2) improvingcoordination of care and connecting individuals withcommunity resources as a strategic transformation forbetter healthcare, (3) managing available resources tokeep people informed during the outbreak, (4) coordi-nating supply of essential medicines, (5) increasing emer-gency referral centers during the pandemic, and (6) eva -luating public health surveillance for emergingthreats.16,17 To achieve a holistic-comprehensive goal ofcommunity planning, thus discussions among the localgovernment and stakeholders are needed in the firstweeks of the pandemic.18

A holistic-comprehensive surveillance system helpshealth professionals and policymakers to better under-stand the pandemic disease and develop public healthpolicy for preventing the spread of infectious disease andpromoting health behaviors. Information on the COVID-19 collected should include sufficient information on thecurrent state of pandemic disease and the epidemiologyof the infectious disease. In a comprehensive surveillanceplan, it is also important to identify key populations atincreased risk of infectious disease, establish opportuni-ties to manage pandemic, and identify the allocation ofresources in the local community as low-income commu-nities were disproportionately affected by the dis-ease.19,20

Lesson learned from the cases of Ebola, they built in-tegrated surveillance health systems to strengthen theirpublic health infrastructure, improved early warning sys-tems, increased the capacity of health professionals, pro-

vided adequate support and feedback during and afterthe implementation of programs.21 The development ofcomprehensive planning presumably takes process, andit certainly needs support from whole societies for a suc-cessful program.

Before the COVID-19 crisis, there were six main com-ponents to consider while developing comprehensive ap-proach: (1) responsive key leaders, (2) multi-sector part-nerships and collaboration, (3) comprehensive healthsurveillance, (4) health education campaigns, (5) healthpolicy to support treatment, and (6) strategies to reduceharm and prevent further crisis.22 These key importantfactors can also be used to develop a holistic-comprehen-sive health policy to achieving sustainable developmentgoals.

Strengthening pandemic readiness and response toCOVID-19 is the key to successful health outcomes. Afast and effective response can delay a local outbreakfrom becoming a global threat. Before the pandemic,health professionals can work together and create colla -bo ration with the government, civil society, stakeholders,and policymakers to develop community resilience andrecovery after the outbreak. We can prepare a programthat could strengthen the community, how to respond toCOVID-19 issues, and build social networks to supportduring the crisis. We can improve the coordination ofcare and connect individuals with community resources.We can manage available resources, such as social media,the internet, and local newspapers to provide trusted in-formation and keep people informed during the out-break. Coordinating the supply of essential medicines andemergency referral centers is also important as this is thefundamental aspect of care. Public health surveillance foremerging threats is needed to inform disease transmis-sion and prepare for prevention and promotion interven-tions related to the COVID-19.23,24

Pandemic readiness enables the community to res -pond effectively to the disease and prepare for future dis-ease outbreak. Well-trained health professionals play acritical role in improving health management and opti-mizing coordination during the outbreak. Creating effect -ive communication plans was also the key to avoidingfalse information related to the disease. Further, compre-hensive planning in the readiness phase should includeresource mobilization, health facilities, and case manage-ment for controlling a disease outbreak.25

During the outbreak, effective communication isneeded between the local community, leaders, stakehold-ers, and policymakers. World Health Organization(WHO) and CDC have developed basic principles forrisk communication and the need to maintain public trustthroughout an outbreak. Therefore, health communica-tors and policymakers should understand the complexi-ties of the pandemic situation and make strategic re-

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

Table 2. Best Practices to Implement a Holistic-Comprehensive Approach during the COVID-19 Pandemic

Period of Pandemic Best Practices to Implement a Holistic-Comprehensive Approach

Before Develop community resilience and recovery after the outbreak. Improve coordination of care and connecting indivi duals with community resources. Manage available resources to keep people informed during the outbreak. Coordinate the supply of essential medicines. Increase emergency referral centers during the pandemic. Evaluate public health surveillance for emerging threats.During Ensure effective communication with the local commu- nity. Take appropriate measures to ensure immediate relief and support being given. Coordinate emergency resources to support bio-psycho- socio-spiritual needs. Develop health policy addressing stigma and mental health issues. After Evaluate the strategies used to control the outbreak. Facilitate healthy behavior change. Build partnerships with stakeholders to strengthen com- munity capacity and skills.

41

sponse plans to the affected populations.26 Also, the localcommunity can take appropriate measures to respond tosuch pandemic and ensure immediate relief and supportbeing given. They can also coordinate emergency re-sources to support bio-psycho-socio-spiritual needs at alocal level.

One of the medical treatments for COVID-19 patientsis patient isolation. Isolation precautions are commonlyused for patients who are either known or suspected tohave a COVID-19. However, a study on the Ebola out-break investigated that isolation was not always effectivein preventing the transmission of infectious disease.Comprehensive treatment was recognized as determiningfactors in controlling such disease.27

As the impact of the pandemic, people may experi-ence psychological symptoms such as fear, anxiety, andgrief leads to prejudices against people in the communityand stigma.28 The stigma associated with COVID-19 isalso known as xenophobia, the fears about COVID-19.Stigma was identified as a factor causing inequities inhealth services and creating a global burden of disease.The fears of COVID-19 are contagious, and it spreadsthrough daily conversations about the pandemic situa-tion. Public mental health systems can be improved ifpolicies to address these issues were put in place.29

Therefore, in developing health policy, stigma, and men-tal health issues as the impact of COVID-19 should bewell-addressed. Further, the culture of society affects thepsychological response to the pandemic and their will-ingness to comply with the health policy.8 Authorsstrongly encourage the entire society to support mentalhealth during the crisis. On the other hand, social, eco-nomic and cultural factors were determinants of healthstatus during pandemic.30-32 In addition to this, WHOprovided specific guidance for communities, leaders,health communicators, and mass media to address men-tal health issues including stigma related to COVID-19.33

After the current pandemic, it is crucial to evaluatestrategies used to control the outbreak through compre-hensive monitoring and evaluation system.34 Health pro-fessionals can facilitate changes for healthy behavior byproviding the most accurate information through all me-dia sources. The local community can also build partner-ships with stakeholders to strengthen the community’scapacity and skills for COVID-19. A study in Wuhanshowed an improvement when they combined pharma-cological treatment and community participation in re-sponding to COVID-19. This study provided a relevanttopic with regards to comprehensive approach whendealing with the COVID-19. Several public health strate-gies were used to combat the disease, even though therewas no proven drug or vaccine for COVID-19. It wasrecommended to improve health policy to influence deci-sion-makers to control the COVID-19 outbreak.35

Authors can learn from Wuhan and Ebola cases thatcomprehensive interventions require all health profes-sionals to collaborate and demonstrate their valuable ex-pertise in disease management.

ConclusionBeing physically and mentally healthy during the

COVID-19 pandemic is important as it helps us toachieve a state of good health. Strengthening pandemicreadiness and response to COVID-19, enhancing com-munication, recognizing and treating physical and psy-chological needs are keys to success when dealing withthe COVID-19. In conclusion, a holistic-comprehensiveapproach to the COVID-19 pandemic requires a sus-tained commitment from entire communities, stakehold-ers, and policymakers to develop programs and multi-stakeholder cooperation to achieve better health out-comes for all.

AbbreviationsCOVID-19: Coronavirus Disease 2019; PRISMA: Preferred ReportingItems for Systematic Reviews and Meta-Analyses; CDC: Centers forDisease Control and Prevention; WHO: World Health Organization.

Ethics Approval and Consent to ParticipateNot Applicable

Competing InterestThe authors declare that they have no conflict of interest to disclose.

Availability of Data and MaterialsThe authors confirm that the data supporting the findings of this studyare available within the article.

Authors’ ContributionAll authors contributed equally to the work presented in this paper.

AcknowledgmentAuthors special thanks are extended to the staff of Faculty of Medicine,University of Muhammadiyah Malang, Malang East Java for their valu-able support for this article.

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

AbstractCoronavirus disease 2019 (COVID-19) has become a public health concern. Preventive measures, such as wearing personal protective equipment, must bedone. 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. Journalsincluded were from databases such as Google Scholar, PubMed, search engines, and references from other studies. The MeSH keywords, such as "clothmask efficiency", "surgical mask", "COVID-19" and "filtration performance of common fabrics cloth mask" were used. Studies that used particle microorganismssized ≤ 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 surgicalmask. Results show that the efficacy of cloth face mask depends on its fabric, and that polyester provides the best filtration efficiency. However, the pressuredrop of polyester is unknown and more studies should be done.

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

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

IntroductionCoronavirus disease 2019 (COVID-19) is a disease

caused by the novel coronavirus SARS-CoV-2, which ini-tially spread in Wuhan, China. The World HealthOrganization (WHO) declared COVID-19 a publichealth emergency of international concern in January2020. The disease has now become a pandemic with5,406,282 COVID-19 confirmed cases globally and23,165 COVID-19 confirmed cases in Indonesia.1 Itscase fatality rate (CFR) has been dynamically changing,however as per May 2020, the CFR reported globally is6.35% and the CFR reported in Indonesia is as high as6.1%. The SARS-CoV-2’s infectiousness has become apublic health concern.1

WHO stated that SARS-CoV-2 is transmitted prima-rily through droplets. Direct contact with objects con-taminated by the virus and then touching the face mayalso be another mode of transmission. Airborne trans-mission of SARS-CoV-2 only occurs in clinical settings,where aerosol-generating procedures are done. Theseprocedures include endotracheal intubation, ma nual ven-tilation before performing intubation, performing car-diopulmonary resuscitation (CPR), and administering

treatment using a nebulizer.2 Recent studies showed thatCOVID-19 patients who appear asymptomatic or pre-symptomatic may be infectious.

This information raised the significance of using per-sonal protective equipment (PPE), such as face masks.Although research regarding the efficacy of public mask-wearing is scarce, some countries, such as Indonesia, theCzech Republic, Slovakia, and Germany proceed withpublic mask-wearing policies. A cross-sectional study inHongkong concluded the indirect efficacy of publicmask-wearing. This was shown by the reduction of in-fluenza cases in Hong Kong after public mask-wearingpolicy, which aimed to reduce COVID-19 transmission,was implemented.3

In April 3, 2020, the Centers for Disease Control andPrevention (CDC) recommended the use of cloth facemasks in public settings where physical distancing wasdifficult to conduct.4 This study aims to evaluate the ef-ficacy of cloth face mask in reducing COVID-19 trans-mission and to compare the efficacy of common fabrics.

MethodA literature search was conducted on April 5 - 20th,

Rizki et al. Kesmas: Jurnal Kesehatan Masyarakat Nasional (National Public HealthJournal). 2020; Special Issue 1: 43-48DOI: 10.21109/kesmas.v15i2.3893

Correspondence*: Andree Kurniawan, Department of Internal Medicine, Facultyof Medicine, Pelita Harapan University, Jend. Sudirman Street No.20, Tangerang,Banten, Indonesia, E-mail: andree.kurniawan@uph.edu, Phone: +62-21-54010130

Received : May 27, 2020Accepted : May 28, 2020Published : July 31, 2020

Kesmas: Jurnal Kesehatan Masyarakat Nasional(National Public Health Journal)

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

44

2020. A literature search process was continued usingthe limits of the literature research and then the titleswere selected from each database followed the PICOframework, using combined terms and Medical SubjectHeadings of the National Library of Medicine (MeSH).Journals included were from databases, such as GoogleScholar and PubMed, using a combination of keywordsMeSH “cloth mask efficiency”, “COVID-19”, “surgicalmask” and "filtration performance of common fabricscloth mask". Some journals were from search enginesand references from other journals. Studies evaluated theefficacy of cloth masks in the COVID-19 era were in-cluded. Other language articles besides English articleswere excluded.

Authors, as two independent reviewers, selected thearticles, extracted the data, and analyzed the data. Anydiscrepancies were resolved by consensus between thereviewers will be discussed. The reviewers evaluated thetitle for all studies that were identified through the searchstrategy. Irrelevant researches, opinions, recommenda-tions, commentaries, and researches using microorgan-isms with a size of more than 0.072 μm were excluded.

Full texts were evaluated when there was insufficientinformation in the title to make decisions about inclusionand exclusion or when the article title suggested the studywould match the inclusion criteria established.References in reviewed articles were examined to identifystudies that may not have been identified through the pri-mary search strategy. A total of 8 full-text articles werereviewed however one article was excluded as the studyonly evaluated the efficacy of surgical masks (Figure 1).

The performance of a mask is evaluated by themeasure ment of its filtration efficiency. The filtration ef-ficiency reflects the mask’s ability to filter particulates ormicroorganisms.5 Filtration efficiency is evaluated by ex-posing the convex side of the mask to aerosols generatedby a nebulizer. The detected colonies or particulates thatescape the mask is then counted. The filtration efficiencycan be calculated by the formula (Figure 2).5-7 The num-ber of the particulate count when a mask is not used issubtracted with the number of the particulate countwhen a mask is used, divided by the number of the par-ticulate count when a mask is not used and multiplied by100.7

Another aspect that can be evaluated is the mask’spressure drop (ΔP). The pressure drop reflects how com-fortable the mask is. The ΔP is inversely proportional tothe 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 arenon-randomized controlled studies thus ROBINS-IAssessment of Bias in Non-randomized Studies was used.Seven parameters were presence of confounding factors,selection bias, bias in classification of intervention, bias

due to deviations from intended interventions, presenceof missing data, measurement bias, and bias in selectionof the reported result. The study has a low risk of bias ifall parameters showed low risk of bias. The study has amoderate risk of bias if some parameters show low riskand some show moderate risk of bias. The study has a se-rious risk of bias if at least one parameter is judged tohave a serious risk of bias. The study has a critical risk ofbias if at least one parameter is judged to have criticalrisk. Authors, as two independent researchers, assessmethodological quality and standard of outcome report-ing in the included studies.

ResultsIn the end, 5 studies that studied the filtration effi-

ciency of cloth face mask in comparison to surgical maskagainst microorganisms or particles sized ≤ 0.072 μmwere included. The 2 journals which compared the filtra-tion efficiency of different fabrics were also included.Studies using microorganisms ≤ 0.072 μm were includedas researches using the actual SARS-CoV-2 virus is still

Figure 1. Systematic Flow of Literature Searching

Figure 2. Filtration Efficiency5-7

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

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scarce at the time being. A cut off of 0.072 μm was madedue to the size of SARS-CoV-2. The results of the includ-ed articles are summarized in Table 1.

ROBINS-I Assessment of Bias in Non-randomizedStudies was used to measure the risk of bias in this re-view. Two independent authors assessed methodologicalquality and standard of outcome report in the includedstudies. The results of the assessment of the studies werepresented in Table 2.

The filtration efficiency of cloth face masks differsfrom one another due to the different fabric materialsused. Table 3 summarizes filtration efficiency and pres-sure drop of common fabrics studied in research byDavies, et al.,8 Ma, et al.,10 and Rengasamy, et al.11

Davies, et al.,8 measured the filtration efficiency ofeach fabric by challenging the different types of fabricswith aerosols of Bacteriophage MS2 (0.023 μm) and B.

atrophecus (0.95-1.25 μm) generated by a Collison nebu -lizer. The filtration efficiency listed in table 3 is the fa -bric’s efficiency in filtering Bacteriophage MS2. Ma, etal.,10 challenged the cloth face mask using avian influen-za, whereas Rengasamy, et al.,11 (Table 4) challengedthe fabrics using aerosols of sodium chloride sized 20 -1,000 nm. Rengasamy, et al.,11 counted the penetrationpercentage of the fabrics instead of its filtration efficien-cy. Penetration percentage was determined as “the ratioof particle concentration downstream to upstream multi-plied by 100”.11

DiscussionIt can be concluded that most studies found that sur-

gical masks have higher filtration efficiency compared toa cloth face mask.6,8,10 Studies by Bae, et al.,9 andShakya, et al.,7 show that a cloth face mask can be more

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 maskMa, 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%

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

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effective compared to a surgical mask. The study by Bae,et al.,9 did not control confounding factors, such as maskleakage, and therefore may intervene with results.

A cloth face mask may be inferior to a surgical maskdue to the average size of its pores. Cloth face mask ge -nerally has larger pores compared to surgical masks,therefore allowing more particles and micro-organismsto pe netrate. However, the study by Neupane, et al.,6 on-ly studied the pore size of 20 different masks and thesemasks were chosen based on its fabric and material, andmay not represent cloth face masks entirely.

It must also be noted that the filtration efficiency ofeach cloth face masks differs from one mask to another.6,7 This depends on the mask’s fabric material.8,11

Filtration efficiency of both surgical mask and cloth facemask also decreases as the masks are challenged by small-er microorganisms as shown by studies by Davies, et al.,8and Shakya, et al..7 The study by Davies, et al.,8 involved21 volunteers who were asked to cough using no mask, asurgical mask and a homemade mask into a cough boxwhere an Andersen sampler and settle plates are placedinside. The study reported that the number of colony-forming units increased as the particle size decreased.

A homemade mask can also decrease the expulsion ofmicroorganisms compared to not using any mask. Thesedifferences were seen as protective for particles less than

3.3 micrometers. Several kinds of cloth face masks wereas good and as effective as surgical masks in the efficiencyof filtrating particles more than 1 micrometer.8

Although surgical masks are concluded to be more ef-fective than cloth face masks, it must be noted that nei-ther surgical masks nor cloth face masks have a filtrationefficiency that reaches 100%, especially for particles ormicroorganisms sized < 0.072 μm.6-10,12 It must also bekept in mind that although cloth face mask has lower fil-tration efficiency, it still aids in filtering particles andmicro organisms and is better than not wearing a mask atall.9,13 Therefore wearing a cloth face mask should notbe deemed as useless.

Judging from its filtration efficiency, polyester is con-cluded to be the best fabric that can be used as a mask.Ma, et al.,10 found that adding four layers of kitchen pa-per onto a polyester face mask results in a filtration effi-ciency as high as 95%. This is supported by the resultfound by Rengasamy, et al.,11 where scarf made of 100%polyester has a penetration percentage of 10%.Sweatshirts and shirts made of polyesters also have lower

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 LowBias 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

Study Fabric Used as Mask Filtration Efficiency (ΔP)

Davies, et al.,8 Tea towel 72.46% 7.23 Cotton blend 70.24% 6.18 Antimicrobial pillowcase 68.9% 6.11 Linen 61.67% 4.5 Pillowcase 57.13% 3.88 Silk 54.32% 4.57 100% cotton t-shirt 50.85% 4.29 Scarf 48.87% 4.36Ma, et al.,10 Polyester cloth with 4 layers of kitchen paper 95% N/A

Note: ΔP : pressure drop

Table 4. Penetration Level of Mask Type and Fabrics used as Masks,11

Penetration Against Mask Type and Fabric Used NACl Particles Size (ΔP) 20 nm ‘Respro’ Bandit mask (fiber composition N/A) 60% N/A‘Breathe health’ Cloth face mask (fiber composition N/A) 70% N/A Fleece mask (fiber composition N/A) 40% N/ASweatshirt 85% cotton and 15% polyester 48% N/A 70% cotton and 30% polyester ~30% N/A 60% cotton and 40% polyester 60% N/AT-shirt 99% Cotton and 1% polyester ~82% N/A 100% Cotton ~75% N/A 60% Cotton and 40% polyester ~58% N/AScarf 100% Cotton 70-75% N/A 100% Polyester 10% N/A

Note: ΔP : pressure drop

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

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penetration percentage. The concentration of polyesterseems to be inversely proportional to the penetration per-centage. However, none of the articles reviewed in thisarticle studied the pressure drop of masks made of poly-ester, therefore whether the mask is comfortable or not isunknown.

Although tea towels have the second-highest filtrationefficiency (72.46%), the high-pressure drop (7.23) indi-cates discomfort when using this as a mask. Discomfortmay cause users to be noncompliant and therefore re-duces the efficacy of the mask itself. As a comparison,surgical masks have a pressure drop of 5.23 and is con-sidered comfortable when being worn.8

Therefore, an alternative to polyester mask is using amask made of cotton blend. The cotton blend has a filtra-tion efficiency of 70.24% and a pressure drop of 6.18. Incomparison to surgical masks, this mask may be moreuncomfortable but it is still significantly lower than theamount of pressure drop tea towels have.8 It is speculatedthat the cotton blend provides decent filtration efficiencyin comparison to other fabrics as the combination of cot-ton and other materials provide mechanical filtration andelectrostatic-based filtration.14

ROBINS-I was used to evaluate the presence of biasin each journal (Table 1). Although bias is nearly impos-sible to avoid, unfortunately, most of the studies includedhad a high risk of bias. Out of six studies included in thisreview, one did not have enough information, two had aserious risk of bias, one had a critical risk of bias and twohad a low risk of bias that could affect the results. Morestudies regarding the efficacy of cloth face mask and thefiltration efficiency of each fabric should be made shortly.More reviews should also be made for better understand-ing.

In April 3, 2020, CDC recommended the use of clothface masks in public settings where physical distancing isdifficult to conduct. These settings include markets andpharmacies. The rationale behind this recommendationis possible virus transmission by COVID-19 positive pa-tients who are asymptomatic or pre-symptomatic andshortages of N95 respirator and surgical masks.

These recommendations intend to slow downCOVID-19 transmission, especially from people who areasymptomatic or pre-symptomatic as they may not beaware that they are infectious. These recommendationsalso intend to prevent further shortages of N95 respira-tors and surgical masks to allow these PPEs to be priori-tized for healthcare workers. Regardless of this new re -commendation, other measures, such as physical distanc-ing and practicing good hand hygiene, must also be prac-ticed.4

In April 6, 2020, WHO published its interim guidanceon the use of masks in the context of COVID-19. In thisinterim guidance, it could be highlighted that WHO re-

mains neutral in the context of public mask-wearing andthe use of cloth face mask.

This interim guidance stated that the efficacy of non-medical masks (e.g., cloth face masks) was not well eva -luated, therefore no recommendation for or against theuse of non-medical masks was made by WHO. The WHOsuggested certain things be taken into consideration if in-dividuals were to decide to use cloth face masks, such asthe number of layers of fabric or tissue, breathability, wa-ter repellence, the shape of the mask, and fit of themask.15

ConclusionAll of the previous studies reviewed in this research

showed the same result that cloth face masks remain in-ferior compared to surgical or medical masks. However,although in terms of efficacy it is inferior, it must be not-ed that cloth face masks still do filter viruses and couldnot be deemed as useless. Cloth face mask’s filtration e -fficiency depends on its material and this review con-cludes that mask made of polyester seems to be the mosteffective. Neither cloth face masks nor surgical masksprovide 100% filtration efficiency, thus other measures,such as physical distancing, practicing good hand hy-giene, and disinfecting, must also be done in combinationto reduce transmission.

AbbreviationsCOVID-19: Coronavirus Disease 2019; MeSH: Medical SubjectHeadings of the National Library of Medicine; CFR: Case Fatality Rate;CPR: Cardiopulmonary Resuscitation; WHO: World HealthOrganization; PPE: Personal Protective Equipment; CDC: Centers ofDisease Control; PSL: Polystyrene Latex; APS: Aerodynamic ParticulateSizer; LPM: Liters Per Minute, SMPS: Scanning Mobility Particle SizerSM: Simple Mask; CM: Cloth mask.

Ethics Approval and Consent to ParticipateNo ethics approval was requested/attached as this review article thatdid not involve any subjects.

Competing InterestThe authors declare that there are no competing interests.

Availability of Data and MaterialsData included in this article are openly available and may be accessedby accessing the links attached in the reference section.

Authors’ ContributionSaraswati Anindita Rizki contributed to the collection of studies, as-sessing the qualities of studies included in this article using theROBINS-I assessment and drafted the article. Andre Kurniawan con-tributed to the collection of studies, assessing the qualities of studies in-cluded using ROBINS-I and critically reviewed the draft of this article.The final version was approved by all authors.

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AcknowledgmentThe authors would like to thank everyone who helped us in this review.

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cloth facemasks in reducing particulate matter exposure. Journal of

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W22-3.

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Ming C. Potential utilities of mask-wearing and instant hand hygiene

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al. A cluster-randomized trial of cloth masks compared with medical

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

AbstractThe Indonesian government has chosen to implement large-scale social restrictions (Pembatasan Sosial Berskala Besar/PSBB) to minimize the spread ofCOVID-19. Large-scale social restrictions is a government policy aimed at restricting the internal movement of people in a bid to reduce the spreading ofSARS-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 ofIndonesia. 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 beforeand during PSBB implementation. The trend of COVID-19 cases in the provinces of West Java, East Java, Banten, and Jakarta continued to fluctuate. Thesefour provinces continue to experience a significant increase in COVID-19 incidence rate ratio after the first and second PSBB period implementation comparedto the time of before PSBB implementation. Lack of proper implementation of the large-scale social restriction led to the PSBB’s ineffectiveness in reducingthe number of COVID19 cases in each of the provinces.

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

The Impact of Large-scale Social Restrictions on the Incidenceof 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, Indonesia3Department of Hospital Administration, Vocational Education Program, Universitas Indonesia4Institute of Science, Istanbul University, Turkey

IntroductionDespite the flattening of the coronavirus disease 2019

(COVID-19) curve by some countries, the number of cas-es in Indonesia conti nue to increase on a daily basis.1 ByMay 11, 2020, the number of confirmed cases hadreached 14,265, with 991 deaths.2 Although the numberof cases is not as high as in other countries, theIndonesian fatality rate from COVID-19 is, unfortunate-ly, the worst among Southeast Asian countries.3 Themain transmission routes of COVID-19 are throughdroplets, contact and aerosols; maintaining an appropri-ate distance from other people is among the preventivemeasures.4 Given the current si tuation, with the absenceof vaccines and lack of proper treatment for COVID-19cases, non-pharmaceutical interventions (NPIs) are theonly methods to reduce transmission of the virus.5 Suchmeasures range from standard precautions such as hand,respiratory and environmental hygiene; in the form ofpersonal protective action taken by individuals, to actionsrequiring the engagement of communities and the in-volvement of local, regional or national authorities (e.g.,social distancing and travel-related measures).6 These in-

terventions were important and necessary to minimizethe spread of this epidemic and to reduce on the burdenplaced on the healthcare service.7

Governments’ decisions to restrict the mobility ofpeople in order to reduce the risk of spreading the virushave been very diverse; ranging from shutting downschools, workplaces, and transportation; restricting pub-lic gatherings; and imposing a ‘stay at home’ policy.8 Asa response to the increase in the number of COVID-19cases, the Indonesian government declared a nationalpublic health emergency on March 31, 2020. However,it declined putting the country under total lockdown ow-ing to economic considerations.9 Later, the governmentchose to implement large-scale social restrictions(Pembatasan Sosial Berskala Besar/PSBB) as one of thepolicies aimed at restricting the internal movement ofpeople in a bid to reduce the spread of SARS-CoV-2.10

PSBB measures included limiting certain activities, themobility of people and goods within a certain area.11

The scope of PSBB restrictions include: 1) the closureof schools and the workplaces, apart from central gov-ernment offices, and businesses and transportation com-

Correspondence*: Mochamad Iqbal Nurmansyah, Faculty of Health Science,Universitas Islam Negeri Syarif Hidayatullah Jakarta, Kertamukti Road, SouthTangerang 15412, Indonesia, E-mail: iqbalnurmansyah@uinjkt.ac.id, Phone:+62- 823-1618-8190

Received : June 19, 2020Accepted : June 20, 2020Published : July 31, 2020

Suraya et al. Kesmas: Jurnal Kesehatan Masyarakat Nasional (National Public HealthJournal). 2020; Special Issue 1: 49-53DOI: 10.21109/kesmas.v15i2.3990

Kesmas: Jurnal Kesehatan Masyarakat Nasional(National Public Health Journal)

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

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panies that serve essential public needs, 2) restrictionson religious activities that involve mass gatherings, 3)limitations on activities in public places or facilities, 4)limitations on social-cultural activities, 5) limitations onmodes of transportation, and 6) restrictions on other act -iv ities related explicitly to defense and security, but withmilitary and police operation activities allowed. the PSBBin all regions of Indonesia, but only in a few, with the cri-teria for doing so based on the number of cases and/ ordeaths due to a significant increase and spread of thevirus in those specific regions. A province or city can im-pose PSBB after obtaining approval from the IndonesianMinister of Health. Its implementation for 14 days, basedon the longest incubation period, and if there are newcases of COVID-19, this will be extended for an extra 14days from the date of the last observed infected case.12

In May 11, 2020, four provinces and 22 cities werestill implementing PSBB whereas one city had completedthe process. The beginning of PSBB implementationamong the different regions in Indonesia has been differ-ent. Jakarta Province was the first region to implement it,with the first PSBB period implemented be April 10-23,2020, followed by a second period from April 24, 2020until May 22, 2020. Even though some areas in Indonesiaare still implementing PSBB, with many others requestingapproval from the minister to do so, evidence of its effect -iveness in flattening the COVID-19 curve remains un-clear. The study aims to evaluate the effectiveness of PS-BB measures on reducing incidence of COVID-19 in va -rious areas of Indonesia.

MethodThe study assessed COVID-19 cases of four provinces

in Indonesia before and during PSBB implementation.We selected the four provinces with the highest numberof confirmed cases in Indonesia, namely Jakarta (5,375cases), East Java (1,669 cases), West Java (1,545 cases),and Banten (559 cases).13 The daily data of confirmedcases in each province in Indonesia was obtained fromthe Ministry of Health of Indonesia between March 19,2020 and May 12, 2020. The PSBB period in eachprovince was different, since ratification and implemen-tation depended on the development of the specific num-ber of cases in the region. Besides, PSBB also allows forthe option to not implement it in all the cities in the sameprovince, but only in a few, since not all cities in aprovince have the same incidence rates. Therefore, in thisstudy West Java, East Java, and Banten ProvincialGovernments implemented PSBB only in regions that hadmet the criteria for doing so. The period of PSBB for eachprovince and its city scopes can be seen in Table 1.

The data were analyzed using statistical software.Data analysis was performed using time-series analysisto observe the trends of COVID-19 cases in each

province. Descriptive statistics were used to calculate theaverage and standard deviation of confirmed COVID-19cases before and during PSBB implementation. In addi-tion, quasi-Poisson regression with an interaction modelwas performed to estimate the incidence rate ratio(IRR).The ratio was calculated to compare the incidencerate before and during PSBB implementation.

ResultsFigure 1 shows the trend of COVID-19 cases in the

provinces of West Java, East Java, Banten, and Jakarta,which continues to fluctuate. Table 2 shows the averagenumber of cases in each province before and during thefirst and second PSBB periods. The average number inWest Java continued to increase before, and during thefirst and second PSBB periods (19.62 ± 23.32; 29.93 ±24.48; 41.14 ± 35.15). In Banten Province, cases beforePSBB and during the first period decreased, but increasedduring the second period. In Jakarta, the average numberof cases during the first PSBB period experienced an in-crease from the average before implementation, but laterexperienced a decline during the second PSBB period.

Table 3 shows the incidence rate ratio before and du -ring the first and second periods of PSBB in the fourprovinces. We found most of the areas to have experi-enced a significant increase in the COVID-19 incidencerate ratio in the first and second periods of PSBB com-pared to the period before its implementation. In the firstround of PSBB, the provinces of West Java, East Java,and Jakarta experienced increased incidences of COVID-19 compared to the pre-PSBB period. East Java showedthe highest incidence rate ratio compared to the two o -ther provinces, with IRR = 2.62 (95% CI = 2.37 - 2.90).In the provinces of West Java and East Java, after theadoption of the second round of PSBB, the incidence rateratio was higher than in the first period. In Jakarta, theincidence rate ratio of COVID-19 decreased after the sec-ond PSBB period, compared to that in the first period.

DiscussionIt is shown that the large-scale social restriction policy

(partial lockdown) did not have a significant effect on re-ducing the number of COVID-19 cases in the fourprovinces studied. These results are different to those ofa previous study conducted in Italy and Spain, whichshowed that the lockdown had an effect by decreasing

Table 1. Pembatasan Sosial Berskala Besar Period for Each Province

Province Number of Cities PSBB First Period PSBB Second Period

Jakarta All city 10 April – 23 April 24 April – 22 MayWest Java 5 cities 15 April – 28 April 29 April – 22 MayEast Java 3 cities 28 April – 11 May 12 May – 25 MayBanten 3 cities 18 April – 1 May 2 May – 17 May

Note: PSBB: Pembatasan Sosial Berskala Besar

Kesmas: Jurnal Kesehatan Masyarakat Nasional (National Public Health Journal). 2020; Special Issue 1: 49-53

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diagnosed cases by 42.1% in Italy and 69.1% in Spain.14

Another study using the modelling method in India foundthat preventive measures such as social isolation andlockdown had an impact on the reduction of the spreadof the virus.15 School and workplace closures and socialdistancing strategies are not new in response to influenzapandemics. A study by Jackson revealed that school clo-sures reduced influenza transmission,16 while anotherstudy indicated that workplace measures could reduceincidence rates and slow the transmission of influenza.17

This study did not overlook the ineffectiveness ofmini mized physical contact measures in reducing thenumber of cases, but instead claims that the lack of com-munity compliance was the real factor why interventionwas not significant in suppressing COVID-19 incidentsin Indonesia. This is supported by a study which foundthat PSBB policy was not effective in reducing the entryof human traffic from outside the Jakarta region. The

movement of people from Bekasi (West Java) to Jakartaand from Banten to Jakarta after the Jakarta’s PSBB poli -cy had been implemented changed little compared to themovements before enactment. Daily mobility analysis hasshown that a significant decrease in community mobilityonly occurred at weekends.18 A report from theDepartment of Transportation of Jakarta Province alsoshows that the number of vehicles entering Jakarta fromWest Java and Banten during the second period of PSBBwas still high.19 A different report from the Jakarta Metropolice states that after 16 days of PSBB, there werearound 36,000 violations by motorcyclists and car driversrelated to PSBB policy, such as not wearing masks andgloves.20 Moreover, the report states that during PSBBmany non-essential workplaces were still ignoring thepolicies and requiring their workers to go to work amidstthe physical distancing requirements.21

The underlying conditions to explain people’s lack of

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 and Period

Mean + SDProvince Before PSBB First PSBB Second PSBB

West Java 19.62 ± 23.32 29.93 ± 24. 48 41.14 ± 35.15East Java* 20.18 ± 23.89 52.86 ± 37.05 - Banten 9.52 ± 9.05 7.64 ± 6.52 12.82 ± 6.75Jakarta 75.52 ± 59.58 129. 36 ± 42.73 97.79 ± 24.76

Notes: PSBB: Pembatasan Sosial Berskala Besar; SD: Standar Deviation; * Thesecond PSBB period had already started in East Java on 12 May 2020

Table 3. Incidence Rate Ratio of Confirmed COVID-19 Cases Before and During the Pembatasan Sosial Berskala Besar Periods

Incidence Rate RatioProvince Before PSBB First PSBB Second PSBB

West Java 1 1.53 (1.34 – 1.73)* 2.10 (1.86 -2.36)*East Java 1 2.62 (2.37 – 2.90)* 6.52 (5.48 – 7.92)*Banten 1 0.80 (0.64 – 1.00)*** 1.35 (1.10 – 1.65)**Jakarta 1 1.78 (1.67 – 1.91)* 1.35 (1.26 -1.44)*

Notes: PSBB: Pembatasan Sosial Berskala Besar; *p-value < 0.001; **p-value =0.004; *** p-value = 0.054

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

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implementation of PSBB protocol are complicated.Restricted social and business processes impose shortand possibly medium-term financial burdens.7 People,particularly those working in the informal sector, need tocontinue to work or open their businesses to obtain in-come. However, adherence to public health protocolmight be affected by the existence of financial compensa-tion for losses incurred.22 Research in the United Statesrevealed that 39.8% of respondents reported not com-plying with social distancing recommendations.23 Someof the reasons for this were work requirements for non-essential industries; engagement in social, physical orroutine activities; and the belief that social distancing wasnot needed if other preventive measures were in place.23

ConclusionThe study reveals the failure of PSBB policy to reduce

the incidence of COVID-19 in Indonesia. We suggest thatimplementation of the policy is improved so that itachieves its objectives. Timely implementation with highcompliance from the community could be a factor in thesuccessful implementation of non-pharmaceutical inter-ventions.24 Therefore, the government needs to bestricter with certain communities and companies to e -ffectively encourage them to adhere to large-scale socialrestrictions during the pandemic. On the other hand, thecommunity should be more intensively engaged to enablethem to manage the epidemic through the implementa-tion of preventive measures at individual, family, andcommunity levels.

AbbreviationsPSBB: Pembatasan Sosial Berskala Besar (Large-scale SocialRestrictions); COVID-19: Coronavirus Disease 2019; NPIs: Non-Pharmaceutical Interventions; IRR: Incidence Rate Ratio.

Ethics Approval and Consent to ParticipateNo ethical approval was required for this study, which relied solely onopen-access public data.

Competing InterestThe authors declare that there are no competing interests to disclose.

Availability of Data and MaterialsThe data that support the findings of this study are available, upon rea-sonable request.

Authors’ ContributionIzza Suraya and Mochamad Iqbal Nurmansyah participated in the de-sign of the study; Izza Suraya and Mochamad Iqbal Nurmansyah par-ticipated in data collection; Izza Suraya participated in analysed the da-ta; Izza Suraya, Mochamad Iqbal Nurmansyah, Emma Rachmawati,Badra Al Aufa and Ibrahim Isa Koire helped to draft the manuscript.All authors revised the manuscript critically and approved the final ver-

sion of manuscript.

AcknowledgmentThe authors thank Ministry of Health of Indonesia for providing accessto the COVID-19 cases data we used and also thank research assistantswho helped with data processing.

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Indonesia; 2020 [cited 2020 Mar 16].

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

AbstractThe 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 reached7,775 positive cases of COVID-19. East Java Province ranks the third in Indonesia with 662 cases. COVID-19 requires a health financing system aimed forCOVID-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 theRegional 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 theprovince 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 IDR877,301,513,766 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 IDR691,158, Promotive Preventive IDR 92,262, Social Safety Net IDR 833,299 and Recovery IDR 380,421. According to districts, the highest budgeting is JemberDistrict, 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

Analysis of Government Budgeting for Health: Case Study ofCOVID-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, Indonesia3Department of Environmental Health, Faculty of Public Health, University of Jember, Indonesia

IntroductionIn December 31, 2019, information began to spread

about coronavirus caused by Coronavirus Disease 2019(COVID-19). COVID-19 has been declared by WHO asthe World Public Anxiety Emergency/Public HealthEmergency of Pandemic, where transmission is very fastin humans with a quite high level of mortality rate. TheLaw Number 4 of 1984 concerning CommunicableDisease Outbreaks stated that outbreaks means out-breaks of infectious diseases in a society where the num-ber of patients significantly increases beyond normal con-ditions at certain times and regions and may cause a ha -voc. The Minister of Health determines certain types ofdiseases that can cause epidemics. The head of theNational Agency for Disaster Management has decidedthe status of certain conditions in the CoronavirusDisease in Indonesia due to Coronavirus in Indonesia andthen through the Decree of the Head of the NationalDisaster Management Agency No. 13 of 2020 concerningthe Extension of the Status of Certain Conditions in theDisaster of the Corona Virus Disease in Indonesia,whereas the status of specific conditions is extended for

91 days dated on February 29, 2020.1The COVID-19 disease in Indonesia was first report-

ed on March 2, 2020 in two cases and has increased eachday until April 23, 2020 and reached 7,775 positive casesof COVID-19 consisting of 647 death cases, 960 reco -very cases, and 6,168 active cases of treatment. East JavaProvince ranks the third in Indonesia with a total of 662cases per April 23, 2020, consisting of 66 death cases,127 recovery cases, and 469 active cases of treatment.Of the 469 active cases, 168 cases were treated at home,31 cases were treated in the building, and 270 cases weretreated in hospital.2

The COVID-19 financing aims to facilitate the pay-ment of treated COVID-19 patients. It can be a referencefor hospitals that provide services for COVID-19 tomaintain the quality, efficient cost, and sustainability ofhealth care services for COVID-19 patients.3 Accordingto the Regulation of the President of the Republic ofIndonesia Number 72 of 2012 Concerning the NationalHealth System, the sources of health financing are thegovernment, local government, the private sector, com-munity organizations, and the community itself.

Rokhmah. Kesmas: Jurnal Kesehatan Masyarakat Nasional (National Public HealthJournal). 2020; Special Issue 1: 54-59DOI: 10.21109/kesmas.v15i2.3986

Kesmas: Jurnal Kesehatan Masyarakat Nasional(National Public Health Journal)

Correspondence*: Dewi Rokhmah, Health Promotion and Behavior Science,Faculty of Public Health, University of Jember, Kalimantan Street No. I / 9368121 Jember, East Java, Indonesia, E-mail: dewirokhmah@unej.ac.id, Phone:+62 812-1540-0530

Received : May 28, 2020Accepted : May 29, 2020Published : 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

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Investment of public health care services are a publicgood, which is the responsibility of the government. Incontrast, for individual health care services, the financingis private, except for the poor and the government's in-ability to be responsible. Adequate, integra ted, stable,and sustainable health financing plays a vital role in thedelivery of health care services to achieve health deve -lopment goals. Health financing is provide to producethe availability of health budget with sufficient amount,be fairly allocated and utilized effectively and efficientlyfor the implementation of health efforts that are equi-table, affordable, and quality for the whole community.4

Based on the explanation of the problem above andthe theory presented, the study objective was to find adescription of the COVID-19 fund and the use of fundsfor COVID-19 in East Java Province, Indonesia.

MethodThis study was a descriptive-analytic study which

aimed to determine the amount of COVID-19 funds andthe use of COVID-19 funds in East Java Province,Indonesia. Secondary data analysis used COVID-19 funddata of 31 districts/cities in the East Java Province fromthe Regional Development Agency of East Java Provincein period of March 23 - April 23, 2020. The analyticaltest used was a descriptive analysis using tables and nar-

ratives reinforced with theoretical studies and related lite -rature.

ResultsHealth financing comes from various sources, namely

the government, local government, private sector, com-munity organizations, and the community itself.Adequate, integrated, stable, and sustainable health fi-nancing plays a vital role in the delivery of health careservices to achieve health development goals.11 Thisstudy discussed the government budget for COVID-19as follows in Table 1 and Figure 1.

The study results showed at Table 1 that of 31 dis-

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

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tricts/cities in the East Java Province, the top highestTotal Budget for COVID-19 by districts/cities wereJember District with IDR 400 billion, Surabaya City withIDR 196 billion, and Gresik District with IDR 150 bil-lion. Total Budget worth IDR 400 billion in JemberDistrict was allocated for Curative IDR138,429,540,671, Promotive-Preventive IDR18,478,853,395, Social Safety Net IDR166,898,414,109, and Recovery IDR 76,193,191,825. Atotal fund of IDR 196 billion in Surabaya City was allo-cated for Curative IDR 67,830,474,928, PromotivePreventive IDR 9,054,638,164, Social Safety Net IDR81,780,222,914, and Recovery IDR 37,334,663,994.Funds in the amount of IDR 150 billion in Gresik Districtwere allocated for Curative IDR 51,911,077,752,Promotive Preventive IDR 6,929,570,023, Social SafetyNet IDR 62,586,905,291 and Recovery IDR28,572,446,934.

The results of the study on Table 2 showed that of the31 districts/cities in East Java Province, the highest Fundper Capita by districts/cities were Batu City with IDR487,747, Jember District with IDR 162,609, andTrenggalek District with IDR 143,349. Based on Table3, Total Fund per Capita worth IDR 487,747 in BatuCity were allocated for Curative IDR 168,796, Promotive

Preventive IDR 22,532, Social Safety Net IDR 203,510,and Recovery IDR 92,907. Fund per capita worth IDR162,609 in Jember District were allocated for CurativeIDR 56,275, Promotive Preventive IDR 7,512, SocialSafety Net IDR 67,848 and Recovery IDR 30,974. The Per-capita funds worth IDR 143,349 in TrenggalekDistrict were allocated for Curative IDR 49,609,Promotive Preventive IDR 6,622, Social Safety Net IDR59,812, and Recovery IDR 27,305.

Figure 2. Distribution of the Use of COVID-19 Mitigation Funds per Capitain East Java Province, Indonesia

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

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DiscussionThe COVID-19 outbreak has designated under the

National Agency for Disaster Management Authority.1The Ministry of Finance framework needs to understandthe nature and scale of these impacts and their relevanceto financial, economic, and fiscal management strategiesand policies for which the government has primary res -ponsibility.5 Based on the Law Number 24 of 2007Concerning Disaster Management, one of the govern-ment's tasks is to grant the rights of people affected bythe disaster. The Law stated that one of reasons for peo-ple affected by an emergency is to get health care servic-es.6 The health care service process cannot separate fromhealth financing. Health costs are a large number of fundsrequired to organize and utilize various health effortsneeded by individuals, families, groups, and communi-ties.7 The purpose of implementing the health financingsubsystem is the availability of adequate health funds, al-located relatively, evenly, and utilized effectively and ef-ficiently, channeled according to its designation to ensurethe implementation of health development to improvethe highest degree of public health.3 Planning and ar-ranging adequate health care financing can help the gov-ernment be able to mobilize sources of health financing,allocate it rationally, and use it efficiently and effectively.

Health financing in each region is different.7 Healthbudgeting is due to several factors, such as the ability ofregional planning, regional commitment, advocacy abili-ty, when prioritizing local health problems, and programinterventions.8 The distribution of the use of COVID-19Prevention Funds consisted of curative funds for treat-ment, promotive-preventive for promotional and preven-tion activities, social safety net funds to protect informaland daily workers during the COVID-19 pandemic, andrecovery funds to restore the condition of the communityand the environment affected by the disaster. Based onthe Ministry of Social Affairs' understanding, the socialsafety net as the form of support from the Ministry ofSocial Affairs reduces the burden on the poor and vul-nerable families.9 The Social Safety Net has previouslybeen conducted in several countries and is effective.10

Therefore, Social Safety Net occupies the highest budgetfrom the distribution of COVID-19 funds. The Curativesector ranked the second and followed by Recovery sec-tor. Promotive-Preventive is at the lowest order of financ-ing. Based on data from the Ministry of Health regardingthe growing number of COVID-19 patients, this causesCurative funds to be higher than funds for Promotive-Preventive. Patients that can make claims are those withPeople-in-Monitoring (PIM) status, both the PIM aged

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

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over 60 years with or without comorbidities and the PIMaged less than 60 years with comorbidities; Patient underSupervision (PUS), those with COVID-19 confirmation;valid for Indonesian citizens and foreign citizens treatedat hospitals in the territory of the Republic of Indonesia.Service areas include outpatient and inpatient care at re-ferral hospitals for handling certain emerging infectiousdiseases and other hospitals that provide services forCOVID-19 patients.4 Services that can be funded followthe service standards in the patient-handling guidelinesbased on the patient's medical needs as well as financingfor outpatient and inpatient services including adminis-tration of facilities, accommodation (rooms and assis-tance in emergency rooms, inpatients, intensive carerooms, and room isolation), doctor's services, actions inthe place, the use of ventilators, medical consumables,diagnostic support examinations (laboratory and radiol-ogy following medical indications), drugs, medical de-vices including the use of personal protective equipmentin the room, referral, corpse screening, and other healthcare services according to medical indications.4

Payment methods are based on services provided anda maximum length of treatment is determinedusingIndonesian Case-Based Groups (INA-CBG) ratesand top-up procedures calculated as an effective and ef-ficient cost per day. The amount of the INA-CBG tarifffor COVID-19-related outpatient services uses regionalclass A hospital rate 1. The amount of INA-CBG fare forCOVID-19-related inpatient services uses local A class 1hospital rates and class 3 Nursing Classes. Make a referralto COVID-19 to other hospitals (referral hospitals andother hospitals that provide COVID-19 services). Theprice of the INA-CBG tariff follows the payment norm,e.g., caring for 6 hours, paying INA-CBG outpatientrates, caring for > 6 hours-2 today, 70% of the fare paidclaims, caring for > 2-5 days, 80% of the menu paidclaims, caring for > 5 days, paid 100% of the claimsrates.4 Top up per day (cost per day) includes compo-nents of services administration, accommodation in in-patient rooms, doctor services, outpatient and inpatientservices, diagnostic supporting examinations (laboratoryand radiological according to medical indications), me -dicines, medical devices, and consumable restorative ma-terials such as personal protective equipment (PPE), am-bulance reference, and corpse screening. For hospitalsthat receive PPE assistance and medicines from the go -vernment, deductions made from claims received. ThePPE and medicines purchased by the hospital must attacha purchase invoice and assistance from other sources.The COVID-19 patients who get recovered (return sta-tus) with evidence of laboratory examinations (by theCOVID-19 prevention and control manual), for concomi-tant diseases that still require treatment, the benefits ofthe next service are changed to the National Health

Insurance (NHI) service and general services.

ConclusionThe total budget for COVID-19 in East Java Province

is IDR 2,102,600,000,000 allocated for Curative IDR727,654,880,535, Promotive-Preventive IDR97,134,092,873, Social Safety Net IDR877,301,513,766, and Recovery IDR 727,654,880,535,Promotive Preventive IDR 97,134,092,873, Social SafetyNet IDR 877,301,513,766, and Recovery IDR727,654,880,535, Promotional-Preventive IDR97,134,092,873, Social Safety Net IDR877,301,513,766, and Recovery IDR 727,654,880,535IDR 400,509,512,826. The highest total of coping fundsby districts/cities are Jember with IDR 400 billion,Surabaya City with IDR 196 billion, and Gresik Districtwith IDR 150 billion.

The total per-capita funds for COVID-19 in East JavaProvince is IDR 1,997,139 allocated for Curative IDR691,158, Promotive-Preventive IDR 92,262, SocialSafety Net IDR 833,299 and Recovery IDR 380,421. Thehighest total per-capita funds by districts/cities are BatuCity with IDR 487,747, Jember District with IDR162,609 and Trenggalek District with IDR 143,349.

AbbreviationsCOVID-19: Coronavirus Disease 2019; PIM: People-in-Monitoring;PUS: People Under Supervision; PPE: Personal Protective Equipment,INA-CBG: Indonesian Case-Based Groups; NHI: National HealthInsurance.

Ethics Approval and Consent to ParticipateNot Applicable

Competing InterestAuthors declare that they have no competing interests to disclose.

Availability of Data and MaterialsThe authors have full access to all the data in the study and take respon-sibility for the data integrity.

Authors’ ContributionDewi Rokhmah, Ricko Pratama Ridzkyanto, Khoiron designed and con-ceptualized the study. Dewi Rokhmah and Khoiron collected data.Ricko Pratama Ridzkyanto analyzed data. Dewi Rokhmah, RickoPratama Ridzkyanto, Khoiron discussed and interpreted the final re-sults. Ricko Pratama Ridzkyanto wrote the first draft of the manuscript.Dewi Rokhmah, Ricko Pratama Ridzkyanto, Khoiron revised and con-tributed to the final manuscript.

AcknowledgmentThe researcher would like to thank the Regional Development Agencyof East Java Province for granting a permission to carry out this study.

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Tentang Penganggulangan Bencana; [updated 2007 April 26; cited

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Indonesia Nomor Hk.01.07/Menkes/238/2020 Tentang Petunjuk

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Pelayanan Coronavirus Disease 2019; 2020.

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lenges. OECD Publishing: Paris; 2015.

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Tentang Penganggulangan Bencana; [updated 2007 April 26; cited

2020 May 10].

7. Setyawan FEB. Sistem Pembiayaan Kesehatan. Saintika Medika. 2017;

11 (2): 119.

8. Harmana WA. Faktor-faktor yang mempengaruhi pembiayaan kese-

hatan daerah bersumber anggaran pendapatan dan belanja daerah

tahun 2006. Jurnal Manajemen Pelayanan Kesehatan. 2006; 9(3).

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pencegahan COVID-19; 2020 [cited 2020 April 20].

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

AbstractThe 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 beprevented by implementing social restrictions, also known as social distancing. The World Health Organization (WHO) has issued several methods for theprevention 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 beenchallenging.

Keywords: COVID-19, physical distance, social distance

From Social Distancing to Physical Distancing: A Challenge forEvaluating Public Health Intervention against COVID-19

Hadi Pratomo

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

The ongoing coronavirus disease 2019 (COVID-19)pandemic has become closely associated with the intro-duction of the popular term “social distancing”, followedshortly by the emergence of the new jargon “physical dis-tancing”. These two terms are very closely related to thepublic health emergency and quarantine protocols.

A public health emergency is an extraordinary situa-tion, during which a communicable disease rapidly dis-seminates across different regions and even countries.Based on the Indonesian Law, No 06, 2018, quarantinewas defined as the isolation of a person or group of per-sons who have been exposed to a communicable disease,regardless of the presentation of symptoms.1

The History of Social DistancingOver the past 35 years, I have taught public health

students in a course on Health Communications. One ofthe required readings that we discussed was HealthCommunication: A Handbook for Health Professionals.This textbook includes a section, titled, NonverbalCommunication in Health Care Setting (Chapter 4).2This book was written by health communication expertPeter Guy Northouse, Ph.D and his wife Laurel LindhoutNorthouse, RN, MSN (a nurse) from western MichiganUniversity in the United States of America.

Nonverbal communication refers to communicationwithout words and encompasses messages developed bybody motions, the use of space, and the use of soundsand touch. One dimension of nonverbal communicationis kinesics, which refers to the study of body motions asa form of communication.2 The other dimension is prox-emics, a term proposed by the anthropologist Edward T.Hall, which refers to how individuals use and interpretspace. One area of proxemics that is relevant to the cur-rent pandemic issue is distance. Both space and distanceplay significant roles in how individuals interact.3

Hall (1966) in Martinez et al.,3 defined that individu-als in a social situation used four distance zones namelyintimate, personal, social, and public. The intimate dis-tance represents an area in which persons can touch oneanother, representing approximately 1.5 feet (45 cm) ofseparation. Personal distance is defined as between 1.5and 2.5 feet (45 – 75 cm) of separation, equivalent to ap-proximately an arm’s length. When individuals are sepa-rated by 4 – 12 feet (120–360 cm), they are practicingsocial distancing. Finally, when two individuals are sepa-rated by 12–25 feet (360–750 cm), this distance is re-ferred to as public distance.3

Social distance is currently being endorsed by WorldHealth Organization (WHO) as one practice that can pre-

Pratomo. Kesmas: Jurnal Kesehatan Masyarakat Nasional (National Public HealthJournal). 2020; Special Issue 1: 60-63DOI: 10.21109/kesmas.v15i2.4010

Kesmas: Jurnal Kesehatan Masyarakat Nasional(National Public Health Journal)

Correspondence*: Hadi Pratomo, Department of Health Education & HealthPromotion, Faculty of Public Health, Universitas Indonesia, Depok, West Java,Indonesia, E-mail: hadi.pratomo@ui.ac.id, Phone: +62217863475

Received : June 29, 2020Accepted : July 20, 2020Published : 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

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vent the transmission of COVID-19. This term originatedin the field of health communication. Putting a social dis-tance between two people indicates that an individual is6 feet (1 foot= 30.48 cm or 0.305 m) away from anotherindividual, which can prevent the spread of droplets froma patient suffering from COVID-19. In Indonesia, we areunfami liar with measurement in feet; therefore, I wouldsuggest that a distance of 6 feet is equivalent to approxi-mately 2 meters of separation.

From Social Distancing toward Physical DistancingThe Canadian Agency for Public Health,4 indicated

that physical distancing refers to making changes in one'severyday routines, to minimize close contact with others,including avoiding crowded places and non-essentialgatherings, avoiding common greetings, such as hand-shakes, and limiting contact with people at higher risk(e.g., older adults and those in poor health). In addition,maintaining a distance of least 2 arm lengths from otherindividuals, as much as possible, is an important compo-nent of physical distancing.

The John Hopkins University,5 defined social distanc-ing as a public health practice that aims to prevent sickpeople from coming into close contact with healthy peo-ple, to reduce opportunities for disease transmission.While, the US Centers for Disease Control andPrevention (CDC),6 defines social distancing as remain-ing out of congregate settings, avoiding mass gatherings,and maintaining distance (approximately 6 feet) fromothers when possible. Social life is a part of human tosurvive. We could not live in an isolated world. Mariavan Kerkhove, an epidemiologist from WHO urged that,“We're changing to say physical distance from social dis-tance and that's on purpose because we want people tostill remain connected”.7 Physical distancing representsthe maintenance of physical distance from other people,to prevent the spread of COVID-19 while remaining so-cially connected to others, through the internet or socialmedia. Therefore, currently, the term physical distancingis preferable to social distancing.7

Physical Distancing as an Applied Public HealthPractice against COVID-19

Since COVID-19 is a relatively new disease, to assessthe effectiveness of physical distancing, I attempted toidentify literature examining the impacts of physical dis-tancing for the spread of another, similar disease, namelysevere acute respiratory syndrome (SARS). I found astudy report by Ahmed, et al.,8 using certain criteria, asystematic review was conducted to look for publicationwithin 2000–2017, then it found 13 research models andtwo epidemiology studies. The research model indicatedthat physical distance could only reduce approximatelyone-fourth (23%) of the attack rate and could reduce the

peak attack rate of SARS.8 This reduction would be evenmore effective faster if physical distancing was combinedwith other non-pharmacological interventions, such asthe use of masks, washing hands with soap, or usinghand-sanitizer, according to the WHO recommendations.Epidemiology research has shown that phy sical distancehas a strong association with the reduction of influenza-like illnesses and the serum conversion of flu A (H1N1).8However, careful interpretations of these data should bemade, as there was potential for bias.

In the United Stated of America (USA), the stay-at-home orders were not coordinated at the national level.Fowler, et al.,9 analyzed publicly available data sourcesregarding the timing of stay-at-home orders and con-firmed the reported daily COVID-19 cases, at the countylevel, for the USA. The results indicated that a coordinat-ed, nationwide, stay-at-home order may have significantlyreduced the numbers of both infections and deathscaused by COVID-19. In this case, stay-at-home ordersreduced the infection growth rate and are the most ben-eficial when the infection counts are still low.9 In con-trast, in the United Kingdom (UK), the implementationof physical distance measures was widely adopted by theUK public, which substantially reduced COVID-19 trans-mission. However, this decrease is projected, and will notoccur immediately due to delays in the onset of sympto-matic disease and hospitalization, in addition to delays inthese events being reported. Tracking behavioral changescan provide a more rapid assessment of the impacts ofphysical distancing measures compared with routine epi-demiological surveillance.10

The absence of evidence regarding the effectivenessof mask use from clinical trials should not be regarded asbeing equivalent to evidence of ineffectiveness. Xiao, etal.,11 argued that cough etiquette (proper behavior whencoughing and sneezing, such as covering your nose andmouth with a tissue or inner sleeve) is based on this con-sideration, and not on evidence provided by clinical trials.Cheng, et al.,12 stated that mass masking to control theviral source represents a useful and low-cost complementto social distancing and hand washing (with soap or 70%alcohol hand sanitizer) during the COVID-19 pandemic.These measures shift the focus from self-protection to al-truism and actively involve every citizen. In addition,these actions are considered symbols of social solidarityduring the response to the global COVID-19 pandemic.

Various studies have examined the use of masks.Surgical masks are known to prevent the inhalation oflarge droplets and sprays but are limited in their abilityto filter submicron-sized airborne particles.13 BecauseSARS-CoV-2, the virus responsible for COVID-19, canalso be embedded in aerosols < 5 μm in diameter, evi-dence remains necessary regarding whether surgicalmasks are effective for preventing transmission. In one

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study, conducted in Hong Kong, surgical mask use wasfound to significantly prevent the transmission of corona -viruses and influenza viruses from asymptomatic peo-ple.14 Based on reports by Esposito, et al.,15 more studyremains necessary regarding the effectiveness of maskuse.

The impacts of physical distance on the spread ofCOVID-19, in combination with other non-pharmaceuti-cal interventions, including staying and working at home,frequent handwashing with disinfectants, wearing masksin the community (mass masking), and practicing cough-ing etiquette, remain poorly understood. A study con-ducted by Singh A, et al.,16 reported a mathematicalmodel showing that the implementation of non-pharma-cological interventions could potentially reduce viralspread. Study conducted in Hong Kong and theNetherlands revealed similar results.17-19 Study byKucharski AJ, et al.,20 found that the application of self-isolation, testing, and physical distancing would increasethe likelihood of controlling COVID-19 transmission.However, these studies all have limitations, includinglarge uncertainties regarding estimates and the durationof infectiousness; therefore, further study must be per-formed, which should be carefully evaluated by publichealth researchers, especially epidemiologists, who havea keen interest in this field of study.

AbbreviationsCOVID-19: Coronavirus Disease 2019; WHO: World HealthOrganization; CDC: Centers for Disease Control and Preventions;SARS: Severe Acute Respiratory Syndrome.

Ethics Approval and Consent to ParticipateNot Applicable

Competing InterestThere is no competing interest.

Availability of Data and MaterialsNot Applicable

Authors’ ContributionHadi Pratomo as an author inisiated the paper with ideas and finallywrote the manuscript.

AcknowledgmentThe author would like to thank Ms. Paskalinda M. Y. Bandur STr.Keb., MKM, who provided support for literature review.

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4. The Canadian Agency for Public Health. Physical distancing: actions

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3].

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Working Group, Klepac P, et al. Quantifying the impact of physical

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et al. Respiratory virus shedding in exhaled breath and efficacy of face

masks. Nature Medicine. 2020 [cited 2020 May 14]; 26: 676–80.

15. Esposito S, Principi N, Leung CC, Migliori GB. Universal use of face

mask for success against COVID-19: evidence and implications for

prevention policies. European Respiratory Journal. 2020; 55:

2001260.

16. Singh A, Chandra SK and Bajpai MK. Study of non-pharmacological

interventions on COVID-19 spread. medRxiv. 2020 [cited 2020 May

14].

17. Cowling BJ, Ali ST, Ng TWY,Tsang TK, Li JCM, Fong MW, et al.

Impact assessment of non-pharmaceutical interventions against coro -

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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 -

res against covid-19 transmission on contacts and mixing patterns in

the Netherlands: repeated cross-sectional surveys. medRxiv. Posted

May 20, 2020.

19. Prem K, Liu Y, Russell TW, Kucharski AJ, Eggo RM, Davies N. The

effect of control strategies to reduce social mixing on outcomes of the

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Covid-19 epidemic in Wuhan, China: a modelling study. The Lancet.

2020; 5 (5): E261-70.

20. Kucharski AJ, Klepac P, Conlan AJK, Kissler SM, Tang ML, Fry H, et

al. Effectiveness of isolation, testing, contact tracing, and physical dis-

tancing on reducing transmission of SARS-CoV-2 in different settings:

a mathematical modelling study. The Lancet Infectious Disease.

Published online June 16, 2020.

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

AbstractCoronavirus 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 thespread 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 atthe destination, individual health, and inadequate prevention and control measures. The virus is thought to be transmitted through respiratory droplets, gen-erated by coughing or sneezing and spread through close contact with infected persons or contaminated surfaces. Diagnostic strategies include detection ofantiviral antibodies, multiplex nucleic acid amplification, and microarray-based assays. Currently, no approved antiviral therapy or vaccine exists to treat orprevent the infection. Public health measures have been enforced, to slow spread of the virus, by governments. The World Health Organization (WHO) haverecommended screening be performed at airports, for all travelers, before traveling to endemic countries and the restriction of travel to countries more thanone 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

Traveler’s Infections: Understanding SARS-CoV-2 as aPotential 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

IntroductionSevere acute respiratory syndrome coronavirus 2

(SARS-CoV-2) is an enveloped, single-stranded, positive-sense, ribonucleic acid (RNA) virus that causes corona -virus disease 2019 (COVID-19), a zoonotic infectiousdisease that has been declared a global, public healthemergency of international concern (PHEIC).1,2 The in-fection was reported to originate from Wuhan, HubeiProvince, China, in 2019, and has been linked toWuhan's Huanan Seafood Wholesale Market. Bats arereportedly the major natural reservoir of the virus, and a5-year study indicated the coexistence of highly diverseSARS-CoVs in bat populations found in caves in YunnanProvince, China.3 A recombination event may have facili -ta ted the ‘spillover’ from the virus’s original host to anew host, humans. The viral agent may have been dis-seminated, from bats to an unknown intermediate host,followed by the infection of human beings.4,5 The viralinfection has since spread to virtually all parts of theglobe, due to travel and the global migration of infectedand exposed individuals.6 On March 11, 2020, theWorld Health Organization (WHO) declared COVID-

19 to be a pandemic, due to its spread to almost all sixWHO regions.7 A reported 1,051,635 (and counting)confirmed cases have been identified, worldwide, andboth local and international travelers represent popula-tions at high risk of acquiring the infection.7,8

Coronaviruses usually cause mild respiratory infections;however, the symptoms of SARS-CoV-2 infections canrange from mild, including fever, cough, and difficultybreathing, to severe, causing pneumonia and multi-organfailure. Elderly individuals and individuals with pre-ex-isting medical conditions are at high risk of progressingspeedily and swiftly into acute respiratory distress syn-drome, septic shock, and coagulation dysfunction, whichcan result in death.1 This review examines SARS-CoV-2infect ions and COVID-19 as a potential traveler’s dis-ease.

The Structure of Severe Acute Respiratory SyndromeCoronavirus 2 (SARS-CoV-2)

SARS-CoV-2 also known as 2019-nCoV,2 is an en-veloped, single-stranded, positive-sense RNA virus, witha 3’-poly-A tail and a 5′-cap structure. The name corona -

Correspondence*: Victor Baba Oti, Department of Microbiology, Nasarawa StateUniversity, PMB 1002, Keffi, Nigeria, E-mail: obabavictor1@gmail.com, Phone:+23 470 6965 7739

Received : June 18, 2020Accepted : June 20, 2020Published : 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. Kesmas: Jurnal Kesehatan Masyarakat Nasional (National Public HealthJournal). 2020; Special Issue 1: 64-69DOI: 10.21109/kesmas.v15i2.3974

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virus derives from the crown-like characteristic appear-ance under electron microscopy (corona is the Latin termfor crown), due to the presence of spike glycoproteins onthe envelope 9 (Figure1).

SARS-CoV-2 is a strain of SARS-related coronavirus-es, from the taxonomic perspective. SARS-CoV-2 be-longs to the family Coronaviridae, in the genusBetacoronavirus.11 The genetic material found in SARS-CoV-2 is approximately 30 kb in length, which makes itthe largest known genome that has been identified in anRNA virus. The SARS-CoV-2 virus is one of sevenCoronaviridae capable of infecting human beings, in ad-dition to NL63, HKU1, 229E, OC43, MERS-CoV, andSARS-CoV.12,13 The genome of a typical coronaviruscontains a minimum of six open-reading frames (ORFs).Approximately 70% of the viral genome encodes thepolyprotein pp1ab, which is further cleaved into 16 non-structural proteins, which play roles in genome replica-tion and transcription through the viral-encoded chy-motrypsin-like protease (3CLpro), in synergy with oneor two papain-like proteases.14,15 The other 30% of thegenome encodes four structural proteins, including spike(S), envelope (E), membrane (M), and nucleocapsid (N),and additional helper proteins. The S protein plays a sig-nificant role, mediating membrane fusion and receptorbinding, which, in turn, determines the host tropism ofthe virus.16,17

Transmission Routes and Diagnosis of COVID-19Epidemiological studies in Wuhan were the first out-

break was reported, associated the virus with a sea foodmarket where live animals were sold, with many patientshaving worked in, or visited the market.4,5 Sub sequently,secondary cases begun to appear approximately ten dayslater.18 Although the new patients had no direct contactwith the seafood market, contact tracing showed thatthey had contacts with inhabitants near the market.19

Advanced genetic and virologic studies have found thatbats represent natural reservoirs of this viral agent.4,20

Studies have demonstrated that most bat CoVs have simi -lar genomes as those found in beta-CoVs and alpha-CoVs.19,21

The virus can be identified through different labora-tory methods, including the rapid testing ofImmunoglobulin G (IgG) and Immunoglobulin M (IgM)levels, electron microscopy, cell-culturing, and nucleicacid detection reverse transcriptase-polymerase chain re-action (RT-PCR), which is currently the gold standardfor SARS-CoV-2 testing and is performed on a nasopha-ryngeal sample. When an individual is confirmed to beinfected, contact tracing is performed, during which a de-tailed history of all persons in contact with a confirmedpatient is examined, using precise laboratory testing.1,22

SARS-CoV-2 infections can also be determined by a myr-

iad of clinical features, predictors, a chest computed to-mography (CT) scans showing pneumonia characteristicsand others.23,24 As of March 19, 2020, no antibody-based techniques have been developed, although seriousongoing studies are attempting to develop these tech-niques.22

Clinical Features of SARS-CoV-2 InfectionThe viral agent gains entry into the respiratory tract

and infects the cells of the respiratory system,25,26 caus-ing acute respiratory disease, with a high prevalenceamong travelers.27 The incubation period for the viralinfection is approximately 2–14 days, with an average in-cubation period of 5 days.19 The infection is usuallyasymptomatic among those with a travel history to en-demic countries, but can also present with symptomssimilar to those observed during flu infections, includingfever, dry cough, and difficulty breathing.14,28 Whenthese symptoms are present, the difficulty breathing andassociated chest pain and pressure persists, resulting inwalking difficulties, confusion, and a bluish tint to thelips and face. These symptoms indicate a critical situationthat requires immediate medical attention.14,29 Zhang,et al.,22 reported the presence of the virus in fecal andblood samples, suggesting the possibility of multipletransmission routes. The identification of the viral recep-tor, angiotensin-converting enzyme 2 (ACE2), which isoften present in large quantities on enterocytes in thesmall intestines and epithelial cells in the lung alveoli, islikely to assist researchers in understanding infectionroutes and the pathogenesis of the viral agent.30

Figure 1. SARS-CoV-2 Morphology with the Minimal Set of Structural

Proteins 9-10

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Aspects of COVID-19 Epidemiology as a Traveler’sInfection

In December 31, 2019, the novel SARS-CoV-2 out-break was first reported in Wuhan City, Hubei Province,China,31 as pneumonia outbreak without a known causalagent. The WHO announced that the etiology was a newcoronavirus, which was temporarily referred to as2019-nCoV, and was posited to be the causal agent for the in-fection on January 12, 2020.32 Similar to SARS, theCOVID-19 outbreak is thought to have initiated at a localseafood market, the Huanan Seafood Wholesale Market,and 2/3 of the first 41 confirmed cases were linked to themarket. Within a few weeks, the virus had spread to oth-er countries, including those in Europe. Most SARS-CoV-2 cases reported during the first 6 days (January 23–28, 2020) were associated with direct contact with some-one who traveled to or from Wuhan.33 In Germany, a33-year-old man (patient 1) became ill with cold and flusymptoms, on January 24, 2020, after attending a meet-ing in Munich with a Chinese business partner, onJanuary 20, 2020.21 The business partner was visitingfrom Shanghai and she did not experience any signs orsymptoms of illness. In Italy, a Bayesian phylogenetic re-construction suggested that the virus found in Italy wasimported by Chinese travelers, who were infected beforethey arrived in Italy.34 Japan identified its first case of vi-ral infection on January 16, 2020, associated with aChinese traveler from Wuhan.35 Australia’s first case wasidentified on January 25, 2020, associated from a manwho traveled to Wuhan.36 On January 20, 2020, the USAidentified its index case, a traveler who returned fromWuhan, China.37 On January 24, 2020, France identifiedits first confirmed case of the novel coronavirus, whichwas also connected with a travel history to China.38 Atraveler from Wuhan and Qom imported the first case ofthe infection from China to Iran on January 19, 2020.39

The index case for Pakistan was identified on February26, 2020, when a young man with travel history toKarachi tested positive for the virus.40 On March 10,2020, Turkey reported its index case, in a Turkish malewho traveled to Europe.41 The initial report of viral in-fection in South Africa was March 5, 2020, in a patientwho had traveled to Italy with his wife.42 The WHO hasreported that the median age of people testing positivefor the virus was approximately 45 years and that overtwo-thirds of those infected were males.18 The mortalityrate among confirmed positive cases was 4.5%, as ofMarch 25, 2020, and appears to range from 0.2%–15%,depending on age group and other health-relatedfactors.18 The fatality rates differ among countries andover time, based on differences in the rate of diagnosisand due to differences in access to adequate healthcareworkers and facilities.

Prevention and Control of SARS-CoV-2 InfectionPreventive measures that have been implemented

against the spread of the novel coronavirus include stay-ing at home, practicing social distancing (avoidingcrowded places), washing hands with soap and runningwater, regularly, for at least 20 seconds, good personalhygiene practices and the avoidance of picking or touch-ing the nose, eyes, mouth, and other parts of the facewith unwashed hands.43-45 Recommendations by theCenters for Disease Control and Prevention (CDC) in-cluded covering the nose and mouth with tissues whensneezing or coughing or using the inside of the elbowwhen tissue availability is scarce.46 Social distancing,which refers to people remaining at least 6 feet apartfrom one another, was introduced to reduce contact be-tween people carrying the virus and uninfected popula-tions. Workplaces and schools were closed, travelrestrict ions were implemented, and mass gatherings ofmore than 50 individuals were canceled.47 According tothe WHO and CDC, surgical masks should only be usedwhen an individual is symptomatic or is administeringcare to infected or suspected-infected persons, such ashealth workers.43,44

Measures that benefit the community, such as the can-cellation of mass gatherings, social distancing, the closingof schools, and the creation of plans that allow employeesto work from home can help mitigate the disseminationof SARS-CoV-2 infections, and these types of preventivemeasures have been recommended by different CDCagencies, worldwide.46,47 Public health experts shouldprovide travelers with information and guidelines regard-ing how they can mitigate their overall risks of viral in-fections and other respiratory complications, which canbe disseminated through travel agencies, conveyance o -perators, travel health clinics, and at points of entry.46

Possible Treatments and Vaccine Candidates forCOVID-19 Infection

A variety of treatment methods and antiviral agentsare being explored for the potential treatment of SARS-CoV-2 infections, and some are progressing to the clini-cal trial stage.48 WHO has launched “Solidarity”, whichis a multi-country trial including 10 countries, in res -ponse to the COVID-19 pandemic, on March 2020.44

The following drugs are being studied: chloroquine andhydroxychloroquine, ritonavir / lopinavir and remdesivirin synergy with beta interferon.45,49 Scientific reports e -xist showing that remdesivir can be used to treat the viralinfection,50 because it inhibits SARS-CoV-2 RNA tran-scription, in vitro.

Chloroquine, a drug that is currently used to treatmalaria, is another potential drug that is currently beingtested in China, with positive preliminary evidence.4,51

Chloroquine and hydroxychloroquine can effectively stop

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the effects of the viral agent, in vitro, and hydroxychloro-quine has been shown to be more potent than chloro-quine, with a more tolerable safety profile.47 Chloroquineand hydroxychloroquine have been listed as drugs withgood preliminary outcomes for COVID-19 therapy, bythe Italian Pharmaceutical Agency (IPA) in March 17,2020.46,52

Currently, no vaccines are available for SARS-CoV-2infections; however, vaccine development is crucial forinducing herd immunity and the possible eradication ofthis disease.43 Various ongoing studies are examiningmRNA, epitope, and S protein-RBD structure-based vac-cine candidates. Models of the human ACE2 protein intransgenic mice and rhesus monkeys have been well-mapped for the creation of a vaccine, and some SARS-CoV-2 vaccines candidates are already entering the clini -cal trial stage.53 In Seattle, USA, the first human trialsfor a vaccine candidate began on March 16, 2020, withjust four volunteers.54 The vaccine candidate contains aharmless genetic code, copied from the SARS-CoV-2virus that causes disease. Recombinant interleukin-7 (IL-7) therapy is also being investigated, as this protein playsa significant function in the reproduction and maturationof lymphoid cells.55

ConclusionGlobal migration, changes in climate, and evolving

human-animal interactions are possible factors that mayenhance the COVID-19 pandemic. Travelers are at highrisk of acquiring the infection, and most countries withhigh numbers of cases have placed travel bans on foreigntravel. We have provided a summarized review of theCOVID-19 pandemic as a potential agent for traveler’sinfections, worldwide.

AbbreviationsCOVID-19: Coronavirus disease 2019; SARS-CoV-2: Severe AcuteRespiratory Syndrome Coronavirus 2; RNA: Ribonucleic Acid; PHEIC:Public Health Emergency of International Concern; WHO: WorldHealth Organization; ORFs: Open-reading Frames; S: Spike; E:Envelope; M: Membrane; N: Nucleocapsid; IgG: Immunoglobulin G;IgM: Immunoglobulin M; RT-PCR: Reverse Transcriptase-PolymeraseChain Reaction; ACE2: Angiotensin-Converting Enzyme 2; CDC:Centers for Disease Control and Prevention.

Ethics Approval and Consent to ParticipateNot Applicable

Competing InterestAuthors declares that there is no significant competing financial, pro-fessional, or personal interests that might have affected the performanceor presentation of the work described in this manuscript.

Availability of Data and MaterialsThe datasets used and/or analysed during the current study are avail-able from the corresponding author on reasonable request.

Authors’ ContributionVictor B. Oti conceptualized and designed the study. Victor B. Oti andMarina Ioannou searched the literature and prepared the manuscript.All authors reviewed the manuscript and approved the final manuscript.

AcknowledgmentWe appreciate the financial support of Mrs. Augustina C. Oti. The au-thors dedicate this review to the blessed memory of P. B. Oti, PhD andthose who lost their lives due to COVID-19.

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Kesmas: Jurnal Kesehatan Masyarakat Nasional(National Public Health Journal)

AbstractCoronavirus disease 2019 (COVID-19) patients, their families, health workers, and cemetery officials are not only haunted by tragedies of the new coronavirusbut are also stigmatized by the community. Stigma can be very detrimental to social life because it can be long-lasting without proper social measures. Thisqualitative 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 ofpeople. 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 gov-ernment has not acted in a sufficiently prompt mannerto prevent the spread of imported infectious diseases, resulting in local transmission and creatingvarious stigmasamong local communities. Although the infection has already begun to spread, the government must continue toensure the correct under-standing and clear mechanismsfor how to prevent COVID-19 among the public.

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

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, Indonesia3Program Study of Public Health, Faculty of Health Sciences, Universitas Muhammadiyah University Prof. Dr. Hamka, Indonesia

IntroductionAvailable information regarding the global corona -

virus disease 2019 (COVID-19) pandemic was has beenmet with diverse responses among Indonesian society, re-sulting in the development of various public stigmas.Disinformation resulted in excessive caution, worries,and fear that were not balanced with empathy and sym-pathy for the victims.1 One nurse, who treated COVID-19 patients and had isolated herself from her family, wasnot welcomed into her neighborhood because her neigh-bors feared she would spread the virus, despite her appli-cation of the COVID-19 personal protective equipment(PPE) protocol. In another case, some nurses were evict-ed from their rented house because the owner feared thatthey would infect him.2 The first patient in Indonesia wasdiscovered and announced by the President of theRepublic of Indonesia, on March 2, 2020, which raisedpublic concern and worries associated with the surge invirus transmission.3 By April 2020, one month after thefirst case of COVID-19 was detected, more than 8,000COVID-19-positive cases were confirmed in Indonesia.Incorrect understanding, incomplete knowledge regard-

ing COVID-19, and confusing guidance regarding social-ization provided by pubic officials resulted in adverse re-actions towards health workers, COVID-19 patients, andpatients’ families.

The government attempted to reduce public turmoilwith certain policies but did not provide sufficient infor-mation to increase public understanding. In some areas,stigma cases developed surrounding COVID-19 patients,patients’ families, and health workers. Almost fivemonths have passed since the first case was detected, butthe COVID-19 pandemic has not yet subsided. COVID-19 cases have been increasing since the disease was firstdiscovered, in Wuhan, China, in December 2019, andwas declared a pandemic by the World HealthOrganization (WHO) on March 11, 2020.4 By April 11,2020, more than 1.69 million people, from 203 coun-tries, had been infected, resulting in 102,000 deaths and376,000 recovered patients.5

Over time, the concerns and stigma associated withthe COVID-19 pandemic have become more terrible thanthe virus itself. As stated by the WHO’s Director-General, Tedros Adhanom Ghebreyesus, stigma is a

Correspondence*: Sri Rahayu, Postgraduate in Public Health Science,Universitas Muhammadiyah Prof. Dr. Hamka, Warung Buncit Raya Street No.17,Pancoran, South Jakarta, Indonesia, Indonesia, E-mail: ayutuguibu@gmail.com,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

Received : May 17, 2020Accepted : June 28, 2020Published : July 31, 2020

71

frightening enemy and is more dangerous than the coro-navirus.4 The stigma associated with the coronavirus thatemerged in local communities, threatening those whohave tested positive for COVID-19 and the health work-ers who have been at the forefront, handling the out-break. As a result, news stories reporting the refusal ofmedical personnel to treat COVID-19 patients in theirhomes, the public rejection of the dead bodies of healthcare workers, and individuals throwing stones at ambu-lances carrying COVID-19 patients are not uncommon.6

On one hand, these cases indicate public awarenessand vigilance regarding the dangers associated withCOVID-19, and the public is beginning to understandnot to underestimate COVID-19. On the other hand, thefear of coronavirus and the efforts to maintain distancehave been detrimental to humanity. Social distancing andphysical distancing, should not result in the exclusion ofpeople or the rejection of dead bodies. The coronavirusoutbreak is predicted to continue for an extended period.Although some people would prefer to view themselvesas safe and protected, we cannot predict whether this dis-ease will eventually affect ourselves or the people weknow. Therefore, negative labeling caused by excessivefear will only result in the loss of our sense of solidarity.

Many studies have demonstrated that stigma canworsen a disease,which has also been reported for the so-cial stigma associated with COVID-19. Stigma is a majorcause of discrimination and exclusion, affecting individ-uals’self-esteem, disrupting family relationships, and lim-iting their abilities to socialize and obtain housing andjobs.7 Stigma can take the form of social rejection, gossip,physical violence, and denial of service. Naturally, we at-tempt to distance ourselves from people who can infectus. This disease avoidance reaction can result in peopledistance themselves physically from someone they believeto be suffering from an infectious disease.8 Stigma alsoarises from the belief that terrible circumstances befallpeople who make mistakes. This logical fallacy cancausepeople to believe that those who have become in-fected with a disease have done something wrong. Peoplethink that perhaps individuals who become infected withCOVID-19 do not wash their hands properly, touch theirfaces too often, or do not maintain social distancing.These beliefs are especially common among individualswho believe they control their own destinies and that ifone does everything properly, one will not get infected.However, we do not live in such a world. Although wecan attempt to avoid COVID-19 by washing our handsfor 60 seconds, instead of 20 seconds, the risk of infect -ion remains the same.

Some individuals, such as ambulance drivers, musthandle COVID-19 corpses daily, and these individualsare required to utilize PPE when delivering dozens ofbodies to graves from several hospitals in Jakarta. These

individuals work late into the night and are not allowedto return home fortwo tofive days due to the enactmentof the Large Scale Social Restrictions that require a five-day isolation period for COVID-19-exposed individuals.However, COVID-19 cases continue to spread, indicatingthat means the community has not obeyed governmentregulations. The very empathetic driver may ask the pub-lic to stay at home so that he will not be required to con-tinue delivering the bodies of COVID-19 patients. Theburial regulations regarding COVID-19 patients inIndonesia mandates respect for the body, by avoiding theuse of mass graves. The government protocol requiresbodies to be buried, without the presence of family andvisitors. Bodies can be buried in their family villages,butthe remaining protocols must be followed.

Because of some of the described stigma cases, the re-searcher attempted to determine and analyze how publicstigma associated withvarious groups affects health work-ers and other support staff who treat COVID-19 patients,the patients and their families, mass media exposure, andthe understanding of COVID-19 in Indonesia.

MethodThis study utilized a qualitative approach to some case

studies in Indonesia, by gathering information from in-terviews that were broadcast live and online by one pri-vate television station, on April 15, 2020. These inter-views were supplemented with information from reliablenews sources and various mass media, including web-sites, such as kawalcovid19.id, galamedianews.com, jog-ja.tribunnews.com, nationalgeographic.grid.id, palu.tri-bunnews.com, jateng.tribunnews.com, and aceh.tribun-news.com; online media platforms, such as liputan6.comand kompas.com; and live discussions presented by ‘MataNajwa’ on Trans7 TV.

This study was conducted during the COVID-19 pan-demic, so the researcher could not perform face-to-faceinterviews. Primary information was obtained through in-terviews, moderated by virtually by a television channel.

The data were collected and analyzed, to exploreproblems associated with COVID-19 and to evaluate theperceptions and experiences of COVID-19 patients andcaregivers, and the environment surrounding them untilthe patients have passed away.

The researcher framed the results of the interview tocoincide with the concept of this study and performed atriangulation of the information provided during inter-views with information obtained from reputable onlinemedia sources. The primary informants were professionaland public figures, including the governor, mayor, thehead of the Indonesian Medical Association, the head ofthe Indonesian Nursing Organization, sociology experts,psychologists, police, and village leaders.

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ResultsThe information in this study was obtained from vari -

ous informants,with different backgrounds and charac-teristics, as shown in the Table 1.

The informants’ perceptions of the COVID-19 factorsthat cause stigma associated with excessive fear and wor-ry, the factors that result in the emergence of stigma, andthe efforts being made to eliminate stigma were evaluat-ed. a. Public perceptions ofthe health workers who serve

COVID-19 patients and their families;“Patients experience heavy days and must undergotreatment alone in the hospital. So, he was very sorrywhen there are people who push people suffering fromCOVID-19 away socially. There are even residents whorefuse the COVID-19 corpse.”9 (Informant-1)

“Because of the wrong perceptions and excessive fearfrom the community in her village in Ungaran, CentralJava, which was also triggered by village leaders, causedthe village members to reject the nurses’ bodies in theirhometown, the nurse who was a fighter on the frontbattle against COVID 19. The community refused be-cause they were afraid of being infected by a bodyburied in the area. The village’s head provoked the com-munity to reject the body due to fear the virus mightspread through the water under the ground. The com-munity also refused the body because the deceased’s res-idence was not initially in their village.”10 (Informant-2)

“The residents fear the exposure to the corona -virus.”11(Informant-3)

b. Factors causing stigma against health workers who serve COVID-19 patients and their families;“The influencing factors are the low level of knowledgeabout medical facts related to COVID-19, the low levelof education, and the differences in perceptions betweenone person and another.”10 (Informant-2)

“Education regarding the handling of COVID-19 corpsein the community is still lacking. Currently, health

workers only use standards PPE in isolation and ICUrooms.”12 (Informant-4)

“The residents fear the exposure to the coronavirus.”11

(Informant-3)

c. Efforts to eliminate the stigma of health workers, COVID-19 patients, and their families;“There should be more support from the people aroundthe patient. Not only moral support, but also motiva-tion, prayer, and positive energy are needed for the pa-tient to go through various healing stages and meet theirneeds for at least 14 days so that patients can isolatethemselves optimally. A patient who is positive withoutsevere symptoms must inform the community to be alertand anticipated.” Informant-1 suggested “living healthywith balanced nutrition, frequent hand-washing, wear-ing masks when outside of the house, and keeping adistance from others”.9 (Informant-1)

“Efforts can be done with educating the public by rolemodels, delivering positive charged news such as peoplewho have recovered, the government should convey ap-propriate information and applying coping strategies(individual efforts to cope with pressure or problems)that are adaptive to the community.”10 (Informant-2)

“There should be systematic handling of regional heads,religious leaders, TNI-Polri, and other parties in movingtogether." He continued "all health workers use PPEaccording to standards not only those in isolation andICU.”12 (Informant-4)

“[We] have coordinated with various parties so thatnurses, doctors, and medical personnel who died fromCOVID-19 are buried in the Heroes’ Cemetery inCentral Java, anticipating a repeat rejection of the bodyincluding readiness for place and administration.”13

(Informant-5)

“[To] increase the sense of humanity and togetherness,the officials, together with security forces, should ensurethat the government has handled it according to proce-

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 PractitionerInformant-3 Community leader Male Website Head of a villageInformant-4 Indonesian Nursing Profession Organization Male Website ChairpersonInformant-5 Governor Central Java Male TV, Website GovernorInformant-6 Policeman Male TV, Web Head of an office Informant-7 Sociologist Male TV LecturerInformant-8 Indonesian Medical Association Male TV Chairperson

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dures so that it does not endanger the community, andthe village administration allocates village funds to helpthe family’s basic needs because they undergo an inde-pendent quarantine.”11 (Informant-6)

“The community perceives that people who died fromCOVID-19 would still transmit the coronavirus; there-fore, community leaders and local officials are neededto provide material and spiritual support to the deceasedpatient’s families or confirmed positive patient’s fami-lies.” (Informant-7)

“All COVID-19 corpse has followed the protocol of theburial screening that guarantee to not spread the virusbecause starting from the corpse wrapping until the bu -rial, disinfectant is used several times and tightlyclosed.” (Informant-8)

According to Kompas media, on April 11, 2020, anurse died from COVID-19 in a government hospital inCentral Java while struggling to help her patients. Thenurse’s body was intended to be buried in her village, inUngaran, beside her father’s grave. Because of the wrongperceptions and excessive fear among the community inher village, in Ungaran, Central Java, which was also trig-gered by the village leaders, the village members rejectedthe nurse’s body. The community refused the corpse be-cause they were afraid of being infected by a body buriedin the area. The village’s head provoked the communityto reject the body because of fear that the virus mightspread through the water, underground. The communityalso refused the body because the deceased did not live intheir village. The issues and opinions that arise withoutproper understanding can lead to excessive fear. Anothernurse, from Dr. Kariadi General Hospital, Semarang whodied while treating COVID-19 patients, was rejectedfrom Sewakul Public Graves; thus, the body was eventu-ally buried in a family funeral atDr. Kariadi Hospital inSemarang. One informant, a psychologist at the Facultyof Education at the University of Persatuan GuruRepublik Indonesia (PGRI) Semarang, stated that “thegrowing trend in the COVID-19 case has made the publicworried, plenty of inaccurate information and reporting,community misunderstanding creates a negative stigmato Orang Dalam Pemantauan/ODP (Person UnderSurveillance), Pasien Dalam Pemantauan/PDP (PatientUnder Supervision), and COVID-19 positive patients andtheir families.” Learning that the nurse died fromCOVID-19 resulted in rejection from the public becauseof the stigma that the virus might spread if the corpsewas buried in their hometown.

Furthermore, “stigma in the form of rejection, exclu-sion, ridicule, and harassment still exists, even thoughthe socialization has been carried out by several regional

heads, religious leaders, and Indonesian MedicalAssociation.” Informing the public is not easy, even-though when information is delivered by competent indi-viduals.

Another interesting case was reported in Banyumas,Central Java. A positive attitude was identified inBanyumas, and the Regent participated in burying thebody of a COVID-19 patient because of the previous re-fusal from the community. The governor intervened,apologizing to the families of the health worker, engagingindirect socialization, and asking epidemiologists andvirus experts from well-known campuses, fatwas from re-ligious leaders, village heads, and village officials to pro-vide information and education to the public. The gover-nor sent a proposal to the president of Indonesia suggest-ing that the country pay respects and show appreciationto health workers who have died while fighting againstCOVID-19 by burying them in the Heroes Cemetery. Inaddition, six professional health organizations inIndonesia released a joint statement, asking for the era-sure of the stigma and discrimination displayed againsthealth workers who fight COVID-19. The COVID-19 pa-tients’ homes have also been stigmatized as presenting atransmission risk to surrounding communities. The gov-ernor’s effort to show appreciation to medical staff thathave died while dedicating themselves to COVID-19 pa-tients included the suggestion of presenting these indi-viduals with a Hero Award by the President.

In Lampung, COVID-19 patientsare rejected in onearea but accepted in another area. The local communityleaders in Lampung (‘RT’/neighborhood and ‘RW’/sub-village) would not help the first individual who died fromCOVID-19. Residents rejected the body, so his funeralwas delayed for more than 24 hours. However, for thesecond case of death due to COVID-19 in Lampung, theresidents worked together to prepare the funeral in theSekicau Village, Sekicau District, West LampungRegency, in April 4, 2020, and the body was buried inthe Sri Galuh Environment Public Graves in April 5,2020. Solidarity was essential in the face of the COVID-19 pandemic.

DiscussionStigma in society can bediverse, differing case by case;

however, the sources of stigma tend to be similar, includ-ing a lack of information and the social environment.Stigma refers to the negative labeling of a person due toan environmental influence, which can be reduced oreliminated by implementing an effective strategy. The le -vel of stigma associated with COVID-19 is based on threemain factors: 1) the disease is new and many factors re-main unknown; 2) we are often afraid of the unknown;and 3) the fear of the unknown can easily be associatedwith ‘others’. Understandably, confusion, anxiety, and

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fear regarding COVID-19 exist among the public.Unfortunately, these factors canalso fuel harmful stereo-types.14 An effective strategy, such as strong interven-tions from the central/regional government, religiousleaders, and security forces, is necessary to eliminate thenegative stigma associated with COVID-19, reduce com-munity anxiety, improve the status of victims, andopti-mize the resources ofthe community.15 Therefore, the pa-tient’s families and the health workers who surviveshould not be isolated from the community because ofstigma. Even if one does not want to help these indivi -duals, patients and their families should not experienceadditional stress associated with stigma, judgments, andeven insults.

1. Stigma eliminationStigma can damage mental health and worsens the

condition of someone suffering from an illness. Beingviewed wrongly by people can cause anxiety, stress, andeven depression. Both stigmatized individuals and thosewho attempt to protect people from stigma can experi-ence anxiety and stress.

Stigma affects people who are sick, people who haverelationships with sufferers, and people who directly in-teract with the disease, daily. Family members and healthcare providers who treat patients with high-risk diseasesexperience stigma during pandemics. During theCOVID-19 outbreak, stigma was also directed at peoplewho have traveled from areas affected by the pandemic.

Stigmatizing anyone during a pandemic poses a threatto everyone. Study on HIV, Ebola, Hansen’s Disease, andother infectious disease epidemics have shown that stig-ma can be an obstacle to disease treatment. People whoworry that they will be socially ostracized if they are sicktend to be reluctant to undergotesting for an illness or toseek treatment if they experience symptoms.

Not surprisingly, some patients being monitored(PDP) escaped from the hospital for fear of being positivefor COVID-19. Logical fallacies may lead these individu-als to believe that they cannotbe infected with the diseasebecause they have not made mistakes and have taken pre-cautions to avoid disease.

Education is one of the most effective ways to stopthe stigma. Regional leaders in centers with positiveCOVID-19 cases must be open regardingtheir diagnoses,to help normalize the disease. Similarly, celebrities andfamous individuals who suffer from COVID-19 shouldalso educate the public through social media. Posts onsocial media from celebrities who suffer from illness tendto help lift taboos. Their fans will be more intrigued ifthey discover that people they admire can also suffer fromCOVID-19.The trust that develops fromthis open sharingof information should not be broken, as the res ponse tofuture outbreaks could be at stake. Another characteristic

of this response is that the community has made use ofsocial media to communicate and discuss ideas in real-time, enabling any interested member of the public tofollow the data analysis and commentary provided by ex-perts regardingoutbreak control, genomic epidemiology,virus evolution, and coronavirus pathogenesis. Providingappropriate information, truth-telling, and transparentactions can augment the sense of civic res ponsibility andthe willingness to volunteer among the public.16

Information that reflects real conditions demonstratesthe trust in society to judge situations fairly.

2. It is not social isolationSocial distancing is a term that is used to restrict pub-

lic activities in an area. Social distancing aims to preventthe spread of coronaviruses, which can be transmittedthrough small droplets formed by coughing or sneezing.Maintaining physical distance does not mean that oneshould cut off social contacts with others; thus, the WHOhas changed the phrase social distancing to physical dis-tancing, to encourage global society to maintain socialcontacts with family and others while maintaining a phy -sical distance. Although we should maintain distancefrom COVID-19 patients or those who are still beingmonitored, we can continue to communicate with themthrough other media,without being physically close. Wecan call or text our friends, relatives, or neighbors, espe-cially those who are sick. We can also share the anxietywe experience with people we trust or with experts,through cyber space. Although stigma is a reaction de-signed to avoid illness, stigma is not sustainable. Stigmamakes us scattered, but the COVID-19 pandemic re-minds us that we are all connected. We are all susceptibleto this virus, which should make us more united. Wemust remember that our enemy is COVID-19, not thesufferer. Prevent and fight the disease, not the person.17

3. Clear education and informationThe government should massively and comprehen-

sively disseminate proper information, education, andcommunication regarding COVID-19. Informing thepublic regarding the identities of those who are affectedand those who are handling COVID-19 is not neces-sary.18 The provision of education to the right target sus-ing appropriate cultural mechanisms for the local com-munity can increase knowledge and eliminate negativestigma.19 For example, for People Living With HIV-AIDS (PLWHA), reducing negative stigma against themrequires an increase in the available knowledge regardingHIV/AIDS.20

4. CommunicationCommunication is the process of transmitting infor-

mation and common understanding, from one person to

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another.21 Therefore, the recipient of the information canmake strategic decisions by considering the conditionsand situations (space and time) being faced into account,which can affect change in the public audience.

Establishing a communication strategy should consi -der several components. ‘Who delivers the message?’ noteveryone is free to convey negative stigma. ‘What mes-sage should be conveyed?’ health workers and other sup-porting staff on the front line serve wholeheartedly, andvictims who have died cannot transmit the COVID-19virus because the host is not alive. The communicatorsshould always ask the community to live according toHealthy Clean-Living Behavior. ‘What media does issue -s?’ by utilizing media and mass media networks and hold-ing webinar forums, the direct delivery of informationcan be performed by experts or ordinary people. ‘Who isthe communicant?’ this message should be targeted toall e lements of society. ‘What effect is expected?’ the ex-pected effect is that the community implements HealthyClean-Living Behaviors, creates a positive stigma, andprovides motivation and empathy for health workers, de-ceased victims, and their families.22

5. Assistance from the government and security appara-tusRaising local champions in the community would sup-

port health workers. Creativity, led by community leadersand government officials,can increase empathy and im-prove understanding. Anxiety and fear can overcome em-pathy and sympathy when the public is presented withmisinformation. Without empathy, the attitude thatemerges in response to COVID-19 patientsis likely to beavoidance and stigmatization of patients, their families,and health workers. The sympathy deficit results in nega -tive stigma and can be discriminatory.

6. Best practice campaignIn Cimahi, a COVID-19-positive patient was assisted

by his neighbors and his surrounding community througha majlis ta’lim (women’s association). They providedfood to patients and their families, who were isolated intheir homes. This support makes the patient and familyfeel content, which speeds the healing process. To sup-porting the patient to perform tests himself, the commu-nity supported him with an N95 mask, even though thesewere difficult to find at the time. The patient’s other fami -ly members had different religions and beliefs, indicatingthat tolerance is crucial for public health. The communi-ty’s participation, led by the head of the RT, demonstrat-ed empathy, and providing correct information to thecommunity can move the heart and soul of the commu-nity to generate humanitarians who will fight for the sakeof public health.

ConclusionIn general, people in Indonesia did not clearly under-

stand the COVID-19 epidemic, including transmission,management, and how to avoid it. This misunderstandingcan extend the pandemic and the length of large-scale so-cial restrictions. The central or regional government, to-gether with local leaders/religious leaders and the localsecurity apparatus, have the responsibility of deliveringeducation, precise information, and accurate and appro-priate communication strategies that align with the cul-ture of the community, to increase community empathyand sympathy. The government and community must de-velop strategic, concrete, and decisive policies that arenot confusing to the public and learn from the success ofother countries’ experiences with the control of COVID-19 transmission.

AbbreviationsCOVID-19: coronavirus Disease 2019; WHO: World HealthOrganization; PPE: Personal Protective Equipment; ODP: OrangDalam Pemantauan (Person Under Surveillance); PDP: Pasien DalamPemantauan (Patient Under Supervision); ICU: Intensive Care Unit;TNI: Tentara Nasional Indonesia (Indonesian National Army); Polri:Kepolisian Negara Republik Indonesia (National Police of Republic ofIndonesia); PGRI: Persatuan Guru Republik Indonesia (TeachersAssociation of the Republic of Indonesia)

Ethics Approval and Consent to ParticipateNot Applicable

Competing InterestThe author declares that they have no competing financial interests orpersonal relationships that might have affected the performance of thework reported in this manuscript.

Availability of Data and MaterialsData and information supporting this writing are available from directinterviews broadcast directly tothe public that can be viewed and con-firmed.

Authors’ ContributionWahyu Sulistiadi and Sri Rahayu conceptualized and designed the studyand prepared the manuscript. Sri Rahayu and Nanny Harmani searchedthe literature and analyzed the data. All authors reviewed the manu-script and approved the final manuscript.

AcknowledgmentWe would like to thank the Center for Education and CommunityServices, Faculty of Public Health, Universitas Indonesia for supportingthis research until the completion of this manuscript.

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Nastiti et al. Kesmas: Jurnal Kesehatan Masyarakat Nasional (National Public HealthJournal). 2020; Special Issue 1: 77-84DOI: 10.21109/kesmas.v15i2.3953

Kesmas: Jurnal Kesehatan Masyarakat Nasional(National Public Health Journal)

AbstractThe Surabaya Port Health Office (PHO) Class I is tasked with the disease prevention by detection, response and protection at entrance gates for the sea andairports and over the state cross-border posts regarding the situation of COVID-19 pandemic. This analysis aimed to assess activities of early warning alertand 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 in-formation variables. Activities in the early warning alert and response system of COVID-19 are in accordance with the Preparedness Guidelines by theIndonesian 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

Analysis of Epidemiological Surveillance Activity of theCOVID-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

IntroductionIn December 31, 2019, the World Health

Organization (WHO) China Country Office reported acase of pneumonia of unknown etiology in Wuhan City,Hubei Province, China. In January 7, 2020, China identi-fied this pneumonia as a new type of coronavirus (novelcoronavirus, 2019-nCoV). In February 12, 2020, theWHO changed the disease name from 2019-nCoV toCoronavirus Disease 2019 (COVID-19).

The SARS-CoV-2 coronavirus is a new type of virusthat has never been identified before in humans.Transmission of COVID-19 has been classified as inter-human transmission but is still limited to the patient'sfamily, health care workers who treat patients, and thosewho have had close contact with confirmed cases.COVID-19 is less severe than SARS and MERS.However, a rapid increase in the number of people withCOVID-19 disease and evidence of human-to-humantransmission means that COVID-19 is more easily trans-mitted than SARS and MERS.1

Since it appeared in December 31, 2019 until the endof February 2020, the increasing number of cases of

COVID-19 patients has been quite rapid and has spreadboth nationally and internationally. In January 30, 2020,WHO announced the Public Health Emergency ofInternational Concern (PHEIC) status regarding COVID-19. PHEIC is declared when there is an outbreak of dis-ease that is a public health risk, that can spread acrosscountries and that potentially requires a coordinated in-ternational response.

COVID-19 has since spread to other countries in theworld. As of March 2, 2020, WHO reported that therewere 88,948 patients with confirmed cases of COVID-19. 80,174 of them came from the epicenter in China,and 8,774 people were spread over 64 other countries.Chinese deaths were put at 2,915, with a further 128deaths outside of China; the crude fatality rate (CFR)was 3.4%.2 Indonesia announced its cases of COVID-19on March 2, 2020.

Indonesia has numerous entrances to the territory asthe in and out access of risk factors for the spread of dis-ease and health problems. Anticipating the threat of glo -bal disease, especially in terms of public health, is one ofinternational concern. The International Health

Correspondence*: Kurnia Dwi Artanti, Department of Epidemiology, Faculty ofPublic Health, Universitas Airlangga, Dr. Ir. H. Soekarno Street, Surabaya,Indonesia, E-mail: kurnia-d-a@fkm.unair.ac.id, Phone: +62-857-3029-9854

Received : June 1, 2020Accepted : June 20, 2020Published : 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

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Regulations (IHR) of 2005 are the guideline forIndonesia to increase its capacity and capability in healthsurveillance and response and in health quarantine in theregion and at the entrances at both ports, airports, andthe State Cross-border Post.

Health Surveillance at the State Entrance is one of theresponsibilities of the Port Health Office (PHO). ThePHO has the task of carrying out prevention of entry andexit of diseases, potential outbreaks, epidemiological sur-veillance, quarantine, environmental health impact con-trol, health services, drug, food, beverages, cosmetics,medical devices, and addictive substances control as wellas averting new diseases and those that are reemerging,or linked to bioterrorism, biological, chemical, or radia-tion protection in the working area of airports, ports andnational land borders.

One of the PHOs in Indonesia is PHO Class I inSurabaya, East Java, which has five working areas, name-ly Tanjung Perak Sea Port, Juanda Airport, Gresik SeaPort, Kalianget Sea Port and Tuban Sea Port.Epidemiological surveillance is conducted by theSurabaya Port Health Office Class I, and one of its rou-tine surveillances is of transit via sea and air. The surveil-lance is carried out through supervising the traffic of peo-ple, goods, and transportation equipment.

Implementation of IHR (2005) at the state entranceis the responsibility of the PHO along with all agencies atthe state entrance. In maintaining the state entrance,PHO implements surveillance in routine conditions andsurveillance of events under certain conditions, such asthe PHEIC declaration. Activities at the state entranceinclude efforts to detect, prevent, and respond toCOVID-19 at ports, airports, and the State Cross-borderPost. These efforts are carried out through the supervi-sion of transportation equipment, people, goods, and theenvironment coming from regions and countries affectedby COVID-19 and are carried out by PHO in coordina-tion with related sectors. This study aimed to analyze theactivities of early warning alert and response system tothe PHEIC of COVID-19 at Juanda International Airporton January 2020.

MethodThis study applied a descriptive evaluative research

using an input-process-output (IPO) system approach toobtain in-depth information from data and sources aboutthe activities that occurred. With the input subsystem,the 4M method (man, material, method, machine) is usedwith modification by adding time, technology, and infor-mation variables. It is a reliable, intermediate tool forproblem analysis.3

ResultsAnalysis of COVID-19 early awareness activities

through monitoring the arrival of transport vehicles, peo-ple and goods in Surabaya PHO Class I was completedthrough a system approach (input, process, output). Hereis the description of the subsystem:1. Input

Those included in the input section are man, method,material, machine, time, technology, and information.1) Man

Data collection in the early detection and alert systemof COVID-19 at Juanda International Airport involved24 Surabaya PHO Class I employees in the working areaof the Airport. This consisted of a team in each workshift with a total of four people, involving a doctor, anurse, an environmental risk management expert, and aquarantine control and epidemiological surveillance ex-pert at the quarantine post at Terminal 2, which servesinternational arrivals. Due to increased awareness andefforts to prevent the entry of the COVID-19 virus by thearrival of people from abroad, there are additional staffand training in the implementation of activities with de-tails as follows:a. Adding a further three people from other health sec

tors as Human Resources assistance.b. Improving the quality of human resources by brief

ing by the duty officer.c. Briefing on the use of Personal Protective Equipment

(PPE) and early detection devices for negative pressure transport capsule (evacuation capsules).

2) Materiala. Health Alert Card (HAC)

Since the PHEIC status of COVID-19 was applied onJanuary 2020, every crew or passenger coming fromabroad will be given a Health Alert Card (HAC). TheHAC is a form used as an information tool that containsthe identity, travel history, and symptoms of a traveler. Ifduring the incubation period of 14 days after traveling,the person experiences symptoms of COVID-19 diseaseand visits the health service and also brings their com-pleted HAC, the health worker can see the history oftraveling of the person and whether there is a probabilityof COVID-19 infection, thereby enabling risk communi-cation, prevention, and alertness. The HAC used bySurabaya PHO Class I is a procurement from theMinistry of Health of the Republic of Indonesia. The newprocurement per January 2020 was 94,500 pieces fromfunds from the Surabaya PHO Class I BudgetImplementation List (Dana Isian Pelaksanaan Anggaran/ DIPA) in 2020. This procurement amount has been ad-justed to the estimated needs for a month based on thenumber of travelers arriving each month, which is ap-proximately 90,000 people. This amount is sufficient tomeet the needs of HAC distribution to all internationalarrivals at Juanda International Airport, Surabaya.

Based on appearance, HAC consists of one sheet of

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yellow paper that includes two parts (Figure 1). Thesmaller part contains the identity that must be filled bythe traveler, such as name, age, gender, address, tele-phone number, flight number, and seat number. Oncefilled, this piece will be collected to PHO officers for dataentry and recapitulation, while the large part is given totravelers. The contents of the large part are the identitiesof the traveler that can be shown to health facilitator ifthere is manifestation of disease. On the back side of thepersonal data form contained brief information about thedisease including COVID-19. The HAC form is writtenin two languages, Indonesian and English, making it eas-ier for Indonesian citizens and foreigners to fill in.b. Personal Protective Equipment

Personal protective equipment (PPE) is an officersafety tool needed for supervision of people and goodstraffic in accordance with the Decree of the Minister ofhealth of the Republic of Indonesia No. 425 of 2007 con-cerning Guidelines for the Implementation of HealthQuarantine at the Port Health Office, and includes dress,N95 mask, and gloves. Based on interviews with programimplementers, the availability of PPE on January has beensufficient, and in accordance with existing regulations, aminimum of 200 PPE is available.c. Communication Tool

The tools used for communication on the field aresmartphones and handy talky. For fast reporting, smart-phones are more often used due to a wider range and fastmessage delivery. In dealing with the PHEIC COVID-19condition, Surabaya PHO Class I coordinates with manycross-sectors. The WhatsApp group is used as a mediafor rapid information exchange such as sharing informa-tion, current updates and other purposes aimed at earlywarning alert activities towards COVID-19.d. Communication, Information, Education Media

There are communication, information, and educationmedia in the form of banners and leaflets. The media islocated in front of the Terminal 2 quarantine room forinternational arrivals and next to the thermal scannerroom located at the international arrival gate of JuandaInternational Airport, which contains information onsymptoms, transmission, and prevention of COVID-19.3) Method

Guidance procedures in early warning alert and re-sponse activities refer to the Preparedness Guidelines of2019-nCoV (COVID-19) which consists of guidance 1and revision 2 issued by the Indonesian Ministry ofHealth on January and February 20204. Activities at theentrance of the state include efforts to detect, prevent,and respond to COVID-19. These efforts are carried outthrough supervising the arrival of conveyances, people,goods, and the environment coming from regions andcountries affected by COVID-19. This activity also refersto Law No. 6 of 2018 concerning Health Quarantine es-

pecially in Chapter IV on Health Quarantine at theAirport as the Entrance of the State.

COVID-19 surveillance in the field consists of check-ing aircraft conditions, checking aircraft crew health doc-uments, and screening crew and passengers through ther-mal scanners and filling and summarizing of GeneralDeclaration (GENDEC) or aircraft health documents. Ifa traveler detected by the thermal scanner has a bodytemperature of more than 38oC, the device will sound asa warning. The traveler is given further inspection, riskcommunication, and a warning alert.

Based on the COVID-19 Preparedness Guidelines bythe Indonesian Ministry of Health (revision-2), there arefour terms that are used as operational definitions ofCOVID-19 infection cases, which are Person inMonitoring (PIM), Patient Under Supervision (PUS),probable cases and confirmed cases. Whereas the casedefinition by WHO consists of suspected cases, probablecases, and confirmed cases 5 (Tabel 1).4) Machine

Surabaya PHO Class I has three thermal scannersfrom the supply in 2016 with condition two functioningand 1 broken as well as adding one thermal scanner wassupplied in 2019. The supply of body thermal scanners isfrom the Indonesian Ministry of Health, sub. TheDirectorate General of Port Health Quarantine, and ifthere is damage and requires maintenance, it can only befixed by central technicians, therefore it takes a long timeto repair. The body thermal scanner functions as a tem-perature observation screening tool to detect the travel-er’s body temperature passes through the arrival gate. Ifperson is detected with a body temperature of more thanor equal to 38oC, the device will take pictures, show ared display and sound a warning.

The body thermal scanner is installed at the Terminal1 and Terminal 2 arrival gates at Juanda InternationalAirport. In addition to the body thermal scanner, the of-ficers also use an infrared thermometer, to confirm the

Figure 1. Health Alert Card

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temperature and double check the result. The machinesand supporting equipment are stored in the SurabayaPHO Class I room at Juanda International Airport, whichconsists of a thermal scanner room, an interview room, anegative pressure observation room, and a negative pres-sure transport capsule or a temporary isolation room.5) Time

Supervision of arrivals for early detection and re-sponse to COVID-19 takes place each day for 24 hourson international arrivals at Juanda International Airport,Surabaya. Data collection and data summarizing of air-craft health documents takes approximately five minutesboth online and offline per flight arrival. Whereas dataentry and summarizing of HACs takes one minute perHAC sheet. The estimated data entry and summarizingof HACs for one aircraft arrival is around one to twohours.6) Technology

Coordination uses technology such as electronic toolsand the internet through online groups, both internallyand across sectors, while manual data summarization u -ses software that can be found on computers in general.7) Information

Information regarding aircraft arrivals from abroad isobtained through notification from the airline by givingthe GENDEC or aircraft health documents to SurabayaPHO Class I officer on duty. In addition, information isalso obtained through the Flight Radar application, viasmartphone. Information sourced from the HAC is theidentity, health conditions, and travel history of the crewor passenger. The data is useful as a precautionary meas-ure if the COVID-19 case is found among travelers. Thewhole process has been progressing well. The officer canprepare and carry out tasks in the field in every arrivalfrom abroad on time.

2. ProcessThe stages and methods of implementation have been

regulated in the Standard Operating Procedures for AirTraffic Control, in addition to the PreparednessGuidelines of COVID-19 issued by the IndonesianMinistry of Health.1) Data Collection

Data collection by Surabaya PHO Class I officers inthe context of early warning alert and response ofCOVID-19 was carried out by direct observation and su-pervision of the arrival of aircraft entering Indonesiathrough Juanda International Airport.

Passenger health is observed by checking body tem-perature through a thermal scanner by PHO’s officer onduty, and checking the HAC completed by the traveler.The HAC is summarized to obtain early information onany COVID-19 infection. Flight arrival data collection isby collecting GENDEC data by the airline to the PHO’sofficer on duty and using the Flight Radar application.The GENDEC summary results consist of data: aircraftname, flight number, aircraft registration number, air-craft origin, total flight crew, total airplane passengers,total number of sick passengers, as well as body temper-ature screening results. The HAC summary consist of da-ta on the identity of the travelers such as name, age, gen-der, address, flight, seat number, travel history and symp-toms of the disease. PHO’s officer on duty also observedthe flight schedule by monitoring the Flight Radar appli-cation.2) Data processing

PHO's officers use software that can be found oncomputers in general to process monitoring data on thearrival of conveyances, people, and goods. This softwareis a form created to enter, summarize, and process datafrom GENDEC and HAC.3) Data Compilation

In the early alert activities of COVID-19 by KKP Class

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 VCough/runny nose/throat pain V V V VMild to severe pneumonia based on clinical symptoms and/orradiological features V Risk Factors:

Travel history to China or the affected region/country within14 days before symptoms develop V VHistory 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 orcountry

• 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 havea history of travel to Wuhan (there are epidemiological links) V

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1 Surabaya at Juanda International Airport, aircraft ar-rivals are grouped according to the area of origin of thearrivals based on a WHO’s circular letter forwarded bythe Ministry of Health about countries infected or en-demic of an infectious disease.

However, there is no data regarding the area, region,or address after the arrival of passengers from an area orregion affected by COVID-19 as there is no question col-umn about this. There is an address column in the HACform, but based on the results of the HAC summary,many passengers misunderstand the requirements and donot fill in the HAC correctly resulting in incomplete data.This results in difficulties in monitoring the risk of trav-elers spreading disease, since the incubation period ofCOVID-19 is 14 days. Therefore, it is a possibility thatnew disease cases could occur during this incubation pe-riod while the travelers have been in their respective des-tinations.4) Data Presentation

Presentation of data on the analysis of COVID-19 ear-ly warning alert and response activities in the form ofgraphs, tables, images, and narratives. The examples ofdata presentation are below for aircraft arrivals (Figure2) and crew and passenger arrivals (Figure 3).

On January 2020, there were 583 aircraft arrivalsfrom abroad at Terminal 2 of Juanda InternationalAirport. The country of origin with the highest numberof landings during January 2020 is Malaysia with a totalof 284 arrivals. There were eight flights from China ori -ginating from Haikou Airport, Hainan Province, 1,497.9km from Wuhan City, Hubei Province, the epicenter re-gion of COVID-19.

There were 4,773 crew members and 97,154 passeng -ers in Terminal 2 of the International Arrival of JuandaInternational Airport on January 2020. The highest num-ber of crew and passengers was from Singapore, with1,720 crew members and 36,092 passengers.

On January 2020, it was recorded that two travelerswho were identified with thermal scanners had a bodytemperature of ≥ 38oC. Both of them had fever, coughand runny nose symptoms. The flight origin country wereSingapore and Saudi Arabia. However, these two peoplewere not included in the COVID-19’s PIM because theywere not included in the PIM criteria.5) Data Analysis and Interpretation

Data analysis is a simple analysis of risk factors bycomparing findings with existing indicators. Data hasbeen processed based on risk factors and are analyzeddescriptively to ensure that conveyances, people andgoods are in a healthy condition and not carrying diseasefrom other countries. Whereas if there is a potentialCOVID-19 case found, a comparison is made with thecriteria for PIM cases, PUS cases, probable cases andconfirmation cases determined by the Ministry of Health.

3. Output The output results in three data sets:

1) Epidemiological InformationOne of the outputs obtained is epidemiological infor-

mation based on the results of daily reports and report ofepidemiological investigations if a case of COVID-19 isfound.

Daily reports from all COVID-19 early warning alertand response activities on aircraft arrivals from abroadare forwarded to the relevant sectors (Figure 5). Thesereports are likely to be the same as daily reports on nor-mal condition, but also include the reporting of detailsabout PPE stock and HAC stock every day.2) Notification

One notification was issued on January 30, 2020, de-tailing 18 people who had just travelled from China, 12from Hangzhou, two from Jinhua, one from Dongyangand three from Yiwu. Of the 18 people, 12 people wereIndonesian students from China and six people were oth-er passengers on flights that landed at JuandaInternational Airport.

Notification contains information about the name,age, gender, passport number, origin, destination, occu-pation, symptoms, and information of the traveler. Thenotification is useful as a warning to the Provincial HealthOffice and relevant agencies to conduct early warning

Figure 2. The Number of Aircraft Arriving from Abroad Based on theCountry of Origin on January 2020

Figure 3. Number of Crew and Passengers Arriving from Abroad Based onthe Country of Origin on January 2020

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alert of COVID-19 in their respective regions.3) Information Dissemination

Information dissemination is being held after the re-port or notification is complete. The daily report dissem-ination process is carried out by the officer on duty totheir higher officer every day before 07:00 am on the fol-lowing day via the WhatsApp application. Notification isgiven by the Surabaya PHO Class I to the ProvincialHealth Office and the others at PHO according to theoriginal address of the PIO or POM, which is forwardedto the Directorate General of P2P, the IndonesianMinistry of Health. Quick report notifications are viaWhatsApp, while official reports are delivered via email.Whereas if a COVID-19 case is found, the report will besubmitted to the PHEIC of the Directorate General ofP2P, the Indonesian Ministry of Health through an offi-cial report via email.

Problems foundThe data format of HAC has only written “address”,

therefore many interpretations in the way of filling thatpart. A few passengers write their address abroad, in-stead of the destination address in Indonesia.

Discussion1. Input1) Man

The number of epidemiological surveillance officersat the Surabaya PHO Class I is sufficient and has receivedadditional human resource assistance during the initialalert of COVID-19. The number of officers is in accor-dance with the standards in the Decree of HealthMinister of the Republic of Indonesia Number425/Menkes/SK/IV/2007.

Officers have also been given training and perform-ance capacity building. However, the number of officerson duty is not sufficient compared to the number of pas-sengers on one flight arrival, causing the communicationof HAC checking methods to be less effective. This isshown by the results of the HAC summary that containeda large amount of blank spaces, data incorrectly filled in,or other matters relating to the passenger misunderstand-ing the form.

Whether or not an organization's goals are achievedis basically determined by the person carrying out the ac-tivity. Therefore, to balance this requires officers who areadept and trained in communicating directions for fillingout the HAC. Proper training and development leads tocondition of workers accomplish their task at full poten-tial on their work.62) Material

The facilities and equipment available in the activitiesare largely sufficient for the implementation of earlyawareness activities for COVID-19. Facilities and equip-

ment, especially PPE are the main supporting activitiesthat are important as protection for officers in carryingout work. In order to prevent the transmission of diseasein health services, PPE must be used consistently and inthe right way by health workers to prevent exposure topathogens that could cause infection.7 The use of PPE re-duces of disease transmission and protects health workerespecially in COVID-19 treatment.83) Machine

Body thermal scanners function well as the main de-tection tool; however, if damaged, these require mainte-nance that can only be done by specialized technicians,which causes a long delay in repair. If this happens, itcan disrupt surveillance activities at the airport.Machines as a means of supporting activities require careand maintenance so that their working functions are op-timal. The thermal scanner can operate between 18 to 24hours continuously. Hence, in operating thermographicdevice, health worker should be trained and the toolneeds to be maintained to avoid any possibility of ma-chine error.9 With the maintenance and care of the ma-chine, in this case the body thermal scanner, then the in-terference or damage to the tool can be minimized andavoided to enable continuous surveillance.

Body temperature screening using a body thermalscanner or other similar device such as infrared thermo -graphy has several limitations. For example, travelerswho take anti-pyretic drugs to briefly modify body tem-perature can affect the scanning efficiency.10 In addition,the scanner cannot detect symptoms if an infected personis still in the 14 days incubation period. Therefore, it isnecessary to improve the detection accuracy and furtherdevelop the system, for example, by using multisensorydetection of heart rate and breathing.10

4) MethodThe method of implementing early detection, warning

alert, and response of COVID-19 is in accordance withthe Preparedness Guidelines of COVID-19 (revision-2).This activity is also in accordance with Law No. 6 of2018 of the Republic of Indonesia concerning HealthOutcome especially in chapter IV on Health Outreach atthe Airport as the State Entrance.5) Time

The activity continues 24 hours a day so that all ar-rivals from abroad can be monitored regularly. However,the summarizing of the HAC requires a longer time.While a large number of HACs are being completed, theguard must also continue to supervise, so this can resultin an increased workload for officers. Excessive workloadcan cause work-related stress on workers.11 This can af-fect the performance of traveler supervision by the officeron duty, so that job control is needed to enable an officerto specifically handle the HAC, while traffic surveillanceactivities continue to run optimally. Sufficient job control

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does not pose major concerns on high workload.12

6) TechnologyInternet and social media have been implemented to

coordinate and disseminate information on activities tofacilitate the data collection and administration of theCOVID-19 vigilance system. The role of technology, es-pecially in the field of communication today is very im-portant due to the many demands for rapid and accurateinformation exchange.13 Therefore, technology is veryhelpful in the early detection, warning alert, and responseto COVID-19 by rapid reporting using information dis-semination for both internal and cross-sectoral users. 7) Information

Aircraft arrivals from abroad can be monitoredthrough Flight Radar and GENDEC collection. The tra -veler’s data is obtained through the summarizing theHAC. The whole process has been progressed well, sothat for every arrival from abroad at Juanda InternationalAirport, the officer can prepare and carry out tasks in thefield optimally. Data and information quality become animportant requirement in making decisions for an organ-ization so that it can achieve sustainable performance.14

Information is only high quality if what is received by therecipient is in accordance with the intent of the sender.15

The COVID-19 outbreak is a reminder of the need forconstant surveillance and strong research to understandthe basic biology of the new COVID-19 virus and also todevelop effective treatments for this disease.16 Therefore,high quality sources of information are critical in the im-plementation of COVID-19 surveillance, especially at theentrances to the country.

2. ProcessData collection through supervising of aircraft ar-

rivals at Juanda International Airport is based on temper-ature observations and HAC to obtain information for anearly alert to COVID-19 infection. In the summarizingprocess, this may take between one to two hours as theprocess must be carried out by many officers. This hasbeen helped by the existence of additional officers fromagencies outside the KKP Class I Surabaya.

In the data compilation, there was no data on the area,region, or address for passengers after their arrival inIndonesia from a region affected by COVID-19 as therewas no question column for this in the HAC. Many for-eigners give their original addresses in the country of ori-gin instead of the destination place in Indonesia.

Overall, the process subsystem in the analysis ofCOVID-19 early vigilance activities at JuandaInternational Airport by KKP Class 1 Surabaya has beenrunning in accordance with existing guidelines and SOPs.Processes and components must be aligned with the ob-jectives of the surveillance system so that it can producevalid information, improve operational efficiency, and

not violate applicable regulations.17 The important thingto do is to strengthen public health surveillance to pro-vide early warning and to develop appropriate actions orresponses, which are the main focus of public health.18

3. OutputThe outputs of PHO activities are the effort to prevent

disease at the entrance point of the country. This is par-ticularly relevant when dealing with the status of PHEICCOVID-19 through administrative actions, as evidencedby daily reports, notifications to the Provincial HealthOffice, local PHO and other related sectors, and reportsto PHEIC Directorate General of P2P of any potentialcases. These three things have been implemented andhave been forwarded to the relevant agencies. Reportingis done vertically to superiors and also horizontally tocross-sectoral agencies so that the results of the data fromearly vigilance activities can be utilized by sector pro-grams or other agencies.

Alternative Troubleshooting1. Add questions to the HAC form regarding the desti-

nation or area to be visited by passengers after landing at Terminal 2 of Juanda International Airport.

2. Add media examples of correctly completed HAC forms at the HAC post.

3. Advise guard officers to give instructions and warnings when distributing HAC forms, so that passengers fill the HAC correctly, honestly, and completely.

ConclusionThere was an increase in the vigilance of health sur-

veillance in the Juanda International Airport by SurabayaPHO Class 1 regarding the COVID-19 entry toIndonesia. Problems and weaknesses were found in in-formation sources such as HAC. There are no examplesof travelers checking media such as the completed exam-ple forms in the HAC charging post. The results of HACfilling by the travel agents are still incomplete becausesome people do not understand the HAC form sufficient-ly.

The format of the HAC is still unclear regarding thedestination area, region, or address for arriving passen-gers from an area or region affected by COVID-19. Theaddress column on the HAC is still often misinterpretedas the original address, even though not all travelers willgo directly back to the original address after landing atthe airport. In addition, many foreigners still write theorigin address from their respective countries. The HACis a vital source of data to obtain high quality informationfor taking early precautions against COVID-19.

Activities in the early warning alert and response sys-tem of COVID-19 are in accordance with thePreparedness Guidelines established by the Indonesian

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Ministry of Health. The outputs or activities both verti-cally and horizontally have been classified as appropriate.Reporting has been done routinely to the DirectorateGeneral of P2P and there is no delay. It is necessary toeducate travelers about completing HAC forms throughthe addition of media, such as, a completed form as anexample, and communication and direction fromSurabaya Class I officers so that the effectiveness of HACcan be maximized.

AbbreviationsPHO: Port Health Office; HAC: Health Alert Card; WHO: WorldHealth Organization; COVID-19: Coronavirus Disease 2019; PHEIC:Public Health Emergency of International Concern; CFR: Case FatalityRate; IHR: International Health Regulation; IPO: Input Process Output;DIPA: Dana Isian Pelaksanaan Anggaran; PPE: Personal ProtectiveEquipment; GENDEC: General Declaration; PIM: Person inMonitoring; PUS : Patient Under Supervision.

Ethics Approval and Consent to ParticipateNot Applicable

Competing InterestAuthor declares that there are no significant competing financial, pro-fessional, or personal interests that might have affected the performanceor presentation of the work described in this manuscript.

Availability of Data and MaterialsData collected without constraints.

Authors’ ContributionRizma Dwi Nastiti did the research, analyzes the data and writes the ar-ticle. Kurnia Dwi Artanti gave supervision and monitores the research.Achmad Faridy Faqih gave supervision and monitors the study.

AcknowledgmentWe would like to thank all staff Surabaya Port Health Office Class I,Juanda Area Working, Surabaya, Indonesia. We also thank UniversitasAirlangga and all the investigators who collected and analyzed the da-ta.

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AbstractThe coronavirus disease 2019 (COVID-19) pandemic, caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) was declared a publichealth emergency in many countries, including Indonesia. The World Health Organization (WHO) released an educational video, entitled "How to ProtectYourself 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, basedon the Information, Education, Communication (IEC) theory, by analyzing teenagers’ perceptions of the video. The design used was a Rapid AssessmentProcedure (RAP), and the data were collected by conducting in-depth interviews with participants, through virtual meetings. The data were analyzed using aqualitative data matrix and thematic analysis. The results showed that all participants found the video regarding the prevention of COVID-19 spread to be at-tractive and comprehensible. In addition, the participants felt that the contents of the video were not contradictory to their personal values and that themessage was targeted to everyone, including themselves. The video was also perceived to be persuasive. Overall, the participants held a generally positiveperception of the video.

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

Pre-testing of the WHO’s Educational Video: “How to ProtectYourself 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

IntroductionThe coronavirus disease 2019 (COVID-19) pandem-

ic, caused by the severe acute respiratory syndrome coro-navirus 2 (SARS-CoV-2) virus has been declared a publichealth emergency in several countries, includingIndonesia. The virus is spread through human-to-humantransmission, primarily through droplets that are releasedwhen an individual coughs or sneezes.1 Under the cur-rent COVID-19 conditions, health-related organizations,such as the World Health Organization (WHO), havecontinuously attempted to disseminate accurate andcredible information, worldwide, via social media plat-forms.2 The WHO released an educational video on thesocial media platform YouTube explaining how to pre-vent the spread of COVID-19 by regularly washing handswith soap and running water, maintaining a minimumdistance of 1 meter between people, and coughing andsneezing properly. Videos represent one type of mass me-dia that allows information to be spread quickly, reachinga wide audience.3 The dissemination of accurate infor-mation regarding self-protection efforts during a pan-demic, such as COVID-19, has been shown to encourage

positive health behaviors in individuals, which could helpcontrol the spread of the pandemic.2,4 Behaviors are in-fluenced by each individual’s knowledge and perceptionof the pandemic conditions.5

Information, Education, Communication (IEC) is anapproach that can be used to promote a sustainable be-havioral change in individuals. The IEC approach can beapplied through the use of mass media. The WHO recog-nizes the important role of IEC methods for the achieve-ment of health goals and recommends the use of IECmethods in health programs, to obtain better and moresustainable results.6 In our study, we performed a pre-test analysis of the WHO’s educational video, which is atype of communication or IEC material. We analyzed fivecomponents of communication material (IEC) effective-ness, which included (1) attractiveness, the elements thatmake people want to see and listen to the material; (2)comprehension, the clarity of the content and its presen-tation; (3) acceptability, whether the audience feels thatthey can accept, believe, and not be offended by the ma-terial; (4) self-involvement, whether the audience canidentify the materials and recognize the messages that

Fadliyah et al. Kesmas: Jurnal Kesehatan Masyarakat Nasional (National Public HealthJournal). 2020; Special Issue 1: 85-92DOI: 10.21109/kesmas.v15i2.3950

Kesmas: Jurnal Kesehatan Masyarakat Nasional(National Public Health Journal)

Correspondence*: Hadi Pratomo, Department of Health Education & HealthPromotion, Faculty of Public Health, Universitas Indonesia, Depok, West Java,Indonesia, E-mail: hadi.pratomo@ui.ac.id, Phone: +62217863475

Received : May 31, 2020Accepted : July 2, 2020Published : July 31, 2020

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are meant for them; and (5) persuasiveness/tendency toact, whether the audience is motivated or persuaded toperform a particular action.7-10

The present study was specifically performed amongteenagers (high school students, aged 15–18 years).Despite having a lower risk of developing severe compli-cations associated with COVID-19, teenagers remain aslikely as older people to become infected andcontagious.11,12 Furthermore, teenagers represent an agegroup that interacts with technology, media, and the in-ternet more frequently than any other age group.Therefore, teenagers can play a critical role in the dis-semination of accurate information regarding COVID-19, through the media and internet that they accessdaily.11

MethodThe design of the study was a Rapid Assessment

Procedure (RAP), and a qualitative approach was usedto collect the data. RAP is a data collection method forobtaining and analyzing in-depth information regardingpublic health behaviors, during a relatively short periodof time,13,14 and can be used for IEC materials.15 Thisstudy was performed by only five researchers, who had ashort time to execute the project, as well as limited funds;therefore, we used the RAP method.

In present study, participants were selected through apurposive, snowball sampling technique, which utilizedthe networks of one or several informants. There were atotal of 10 teenagers, who attended senior high school,five of whom lived in an urban area (East Jakarta) andfive who lived in a rural area (Karawang, West Java).Data were collected by performing in-depth interviewswith participants, and the results of the interview wereinterpreted by analyzing the contents of the participants'answers regarding their perceptions of the effectivenessof the WHO’s educational video, which is a type of IECmaterial.

The instrument used was an in-depth, interviewguideline, which was assembled based on the compo-nents of the IEC material, including effectiveness, per-ceived attractiveness, comprehension, acceptability, self-involvement, and persuasiveness/tendency to act. Priorto the use of the instrument, a trial field interview wasconducted, to determine whether the interview guidelineswere clear, to determine the order of the interview guide-lines, and to determine how long the interviews wouldtake. Two participants (one rural and one urban) werechosen for the trial interview. The results of the trial in-terview showed that, in both rural and urban areas, all ofthe questions included in the instrument could be under-stood well by the trial participants. After the trial, the re-searchers added two new questions to the instrument.Regarding the aspect of “acceptability”, a question was

asked regarding the participants’ knowledge regardingthe institution that published the video was added. Thisquestion was deemed to be necessary because it was as-sociated with the informants’ belief in the message beingconveyed in the WHO video. Regarding the aspect of“persuasiveness/tendency to act”, a question was addedto ask whether the video requires translation into variouslanguages. This question was considered to be importantbecause it was associated with the interest of the infor -mants to “act”, by spreading the video; the language usedin the video was English, and not everyone understandsEnglish. In both rural and urban areas, the interviewprocess took approximately 30 minutes, for each partici -pant.

Data were collected by public health graduate stu-dents, who have been trained in qualitative research tech-niques. Before each interview, the informants were in-structed to watch the video, "How to protect yourselfagainst COVID-19", produced by WHO, which lasted 1minute and 30 seconds. The presented video was target-ed towards a general audience and was not aimed to-wards a specific gender; therefore, our selection of par-ticipants did not consider gender diversity. After watch-ing the video, semi-structured, in-depth interviews wereconducted through teleconference services, includingtelephone lines and video conference services, includingZoom, Google Meet, and WhatsApp, between April 20and April 28, 2020. After revising the instrument, inter-views were conducted with the remaining 8 informants(four rural and four urban). During the interviews,recordings and field notes were taken by the researchteam members. Data were transcribed, and matrices ofqualitative data were prepared. Thematic analysis wasused to present the results. We performed the six stepsof thematic analysis, as suggested by Braun and Clarke,16

which are as follows: (1) familiarization with the data;(2) generating initial codes; (3) searching for themes; (4)reviewing the themes; (5) defining and naming thethemes; (6) and, finally, producing the report.

To ensure both trustworthiness and data objectivity,after the completion of each in-depth interview, the re-search team members summarized the results of the in-terview and confirmed the completeness of the informa-tion. In addition, the research team members also deter-mined the willingness of the participants to be re-inter-viewed, if more information was determined to be neces-sary.

There is no ethical clearance. Therefore, informedconsent collected from each participant to comply withthe Helsinki Declaration, which states that participationby individuals who are capable of providing informedconsent must be voluntary and without compulsion. Theparticipants should agree voluntarily and are allowed tocontinue or halt their participation in the study, without

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facing penalties.17

ResultsThe participants in this study were eight senior high

school students (grades 10 and 12), four of each fromurban (code: U) and rural (code: R) regions. Their agesranged between 15–18 years. The participants consistedof three males and five females. A summary of the partici -pants whose data were used in our analysis can be foundin Table 1.

Five aspects of communication material (IEC) effec-tiveness were evaluated, and representative statementsprovided during the interviews regarding each aspect canbe observed in Table 2.a. Perceived attractiveness of the video

Most of the participants believed that the animationwas good, interesting, and easy to understand. However,participants U3, U4, and R3 found that the animationwas not colorful enough, as it was only portrayed in blackand white. According to these participants, the animationshould have been more colorful, to make the video moreinteresting. All participants, both rural and urban, statedthat the text could be read clearly. Participant U4 sug-gested adding a different color besides black, to highlightthe most important text.

All participants stated that the sound could be heardclearly, although some participants described the speechas being too fast. The participants felt that the video waseffective, not too long, and straight to the point.Participant U4 felt that the duration was ideal, but wouldnot mind additional information that would prolong thevideo, such as if contents describing the use of alcohol towash hands effectively were to be added. b. Perceived comprehension of the video

For some participants (four rural participants and oneurban participant), the use of English in the video madecomprehension of the information and messages con-veyed in the video more difficult. However, in general,the participants were able to grasp the message regardingthe prevention of COVID-19 transmission. Some partici -pants (R2 and R3) were able to mention all of the mainpoints regarding the prevention of COVID-19 mentionedin the video, whereas others only mentioned some of the

points. All of the participants stated that the function andpurpose of this video were to inform people how to pre-vent the transmission of COVID-19.c. Perceived acceptability of the video

According to all participants, nothing in the video wascontradictory to their personal values. Although partici-pant R1 stated that she did not fully agree with the im-plementation of social distancing, as it prevented herfrom meeting up with her friends, overall, she was okaywith the implementation for the greater good. She alsosuggested adding the recommendation of using masks tothe video.

Participant R1 did not identify the institution that re-leased the video. Participants R2 and R4 identified thatthe WHO released the video but claimed little knowledgeabout the WHO. All other participants were able to iden-tify the institution that released the video as the WHOand knew that the WHO is a global health organization.

All participants, from both rural and urban areas, stat-ed that they believed in the contents of the video.However, the participants provided different reasons forwhy they believed the video. All of the urban participantsand participant R3 stated that their belief was based onthe fact that the video was published by the WHO, aworldwide credible organization. In contrast, most ruralparticipants stated that they believed in the video’s con-tent because it contained a positive message.d. Perceived self-involvement of the video

All participants felt that they were part of the targetaudience for the video and that the video was beneficialfor them. They found the message to be useful because itexplained the spread and prevention of the virus, encou -raged them to maintain cleanliness, added informationthat the virus could be spread at a distance of 1 meter,and, overall, found the message to be positive. ParticipantU4 learned why social distancing rules are implementedafter watching the video because the video states that thevirus could spread if people do not maintain a distance of1 meter. e. Perceived persuasiveness of the video

All participants were interested in implementing thevarious messages that were conveyed in the video, suchas 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 JavaE (R2) Rural 18 (grade 12) Female Karawang, West JavaMAA (R3) Rural 18 (grade 12) Male Karawang, West JavaBBM (R4) Rural 17 (grade 12) Female Karawang, West JavaNDP (U1) Urban 18 (grade 12) Male Pondok Gede, East JakartaANZ (U2) Urban 16 (grade 10) Male Duren Sawit, East JakartaALF (U3) Urban 16 (grade 10) Female Jati Bening, East JakartaDSGP (U4) Urban 15 (grade 10) Female Jati Bening, East Jakarta

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reas, enacting social distancing, washing hands with soapand running water or hand sanitizers, and maintainingthe cleanliness of objects by spraying them with disinfec-tants.

All participants, both rural and urban, felt thatspreading the video was important. The informants

planned to spread the video to their families and friends,via social media, such as WhatsApp (through WhatsAppstatus posts or WhatsApp groups) and Instagram(through Instagram feed posts or Instagram story posts).Participant R4 believed that spreading the video by post-ing it to her Instagram feed would be more effective be-

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 infor- mation and explanations are needed.” (U4) Overall opinions of the video Overall, the video is good / clear “The video provides good and informative information. The anima- tion 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 co- lorful 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 under- stand.” (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)

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cause more people will see it and the post can be viewedat any time. Similarly, participant U4 believed thatspreading the video via Instagram stories would be moreeffective because she felt that more people would watchthe video if it is posted on Instagram stories.

All participants felt that the video should be translat-ed into various languages. Participant R1 expressed thenecessity for translations into Indonesian, the primarylanguage used in Indonesia, but stated that the video doesnot need to be translated into local languages, such asSundanese or Javanese. According to participant U1, thevideo should be supplemented with Indonesian subtitlesand also dubbed into Indonesian because sometimes peo-ple in Indonesian are lazy to read.

DiscussionIn this study, authors explored the participants’ per-

ceptions regarding the attractiveness of a video, pub-lished by the WHO, and examined the participants’ com-prehension, acceptability, self-involvement, and persua-siveness/tendency to act towards the video contents.Videos, as IEC media, should attract the audience’s at-tention through animation, text, and sound. Moreover,videos should also have an ideal duration. Most of ourparticipants expressed interest in the video’s animation.Animations can help informants to better understand theinformation being conveyed, as described by Johari, etal.18 Similarly, text and sounds can make the message

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 distanc- ing 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 pre- vent 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 informa- tion 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)

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being conveyed easier to understand, by listening to thenarrator's voice and reading the text contained in thevideo. The length of the video, 1 minute and 30 seconds,was also considered quite effective by participants be-cause the information was conveyed clearly and com-pletely in a relatively short period of time.

This study revealed that participants’ overall under-standing of the video contents were considered good be-cause they knew the function and purpose of the video,which was to provide information and education to thepublic regarding the transmission and preventionCOVID-19 spread. An individual’s understanding of in-formation or messages can be interrupted by semanticinterference, especially communication disorders causedby errors in the language used.19 Authors identified dif-ferences in the English language comprehension levelsbetween rural and urban participants, with four ruralparticipants stating that they had difficulty understandingthe English used in the video, whereas only one urbanparticipant stated that they had difficulty with Englishcomprehension. However, this obstacle can easily beovercome. Because the video is equipped with anima-tions, the inclusion of text or subtitles in English that canenhance their comprehension.

The COVID-19 educational video published by theWHO contains five important messages: (1) the virus’transmission distance of 1 meter; (2) cleaning the sur-faces of objects regularly; (3) the prohibition of touchingeyes, nose, and mouth with dirty hands; (4) covering thenose and mouth when coughing or sneezing, using el-bows or tissues; and (5) washing hands with soap andwater, as the most effective way to prevent virusspread.12 Out of these five messages, only a few partici-pants were able to mention all of them completely. Thecontents that all the participants were able to identifywere (1) to maintain a distance of 1 meter, and (2) towash hands. Authors assumed that this occurred becausethese two points have previously been reported or havebeen frequently heard by all participants. Both rural andurban participants generally displayed a satisfactory levelof comprehension for the contents of the video.

As a communication medium, messages from videosmust be acceptable to the target population. Messagesthat can be received well are usually messages that arenot offensive, do not cause distrust, do not cause disap-proval, and do not cause the audience to reject the mes-sage and, ultimately, not act according to the message.20

A similar pattern was observed among the participants’answers. Among the urban participants, who were ge -nerally aware of the WHO, trusted and believed the con-tents in the video because they felt that the institutionthat published the video was credible. Those participants,including most of the rural participants, who answeredthat they trusted the contents of the video but did not

know what the WHO is, implied that they trusted thevideo because the message delivered was a positive one.

Furthermore, one of the parameters for determiningthe effectiveness of communication materials is “self-in-volvement”, which determines the perceptions of the re-cipients based on whether the message is believed to bedirected and intended for them or others.8,9 The partici-pants agreed that the information regarding the spreadand prevention of COVID-19 was useful and targets thewhole community, in general. Moreover, one urban par-ticipant was able to link the message conveyed in thevideo with the reasons for the implementation of socialdistancing regulations, despite the video not explicitly in-cluding any messages regarding social distancing regula-tions.21 This result indicated that the video successfullyengaged the participant.

One result of effective communication is persuasive-ness or the tendency to act.22 Authors believe that thevideo was able to persuade the participants to implementand spread the messages conveyed in the video. The par-ticipants expressed a preference for the use of various so-cial media platforms to spread and share the video, indi-cating that one of the most important advantages of usingsocial media is the ability to share knowledge and infor-mation online, between various groups of people.23 Forvideo distribution, the participants believed the videoshould be translated into the Indonesian language,through both subtitles and dubbing, because not every-one who watches the video can understand English. Formost Indonesians, English is not their mother tongue;therefore, the English language used in the video couldpotentially obstruct their understanding of the messagesbeing conveyed.

ConclusionThe information authors collected from both rural

and urban participants suggested that all of them havesimilar perceptions of the video. Overall, the video wasconsidered to provide clear information, and the inclu-sion of images made the video easier to comprehend. Thepartici pants also found the video to be attractive andwere able to perceive that the function of the video is toinform viewers regarding how to prevent the spread ofCOVID-19. The participants believed that the content ofthe video contains trustworthy information because itwas published by the WHO, an organization they consid-ered to be credible, or because of the messages in thevideo itself. The participants also felt that the contents ofthe video did not contradict their personal values and be-liefs. The participants considered everyone, includingthemselves, to be the target audience of the video. Theinformants were also interested in sharing the video withpeople. Additionally, the participants indicated theirhope that the video could be translated into Indonesian

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because not everyone, especially in Indonesia, that canunderstand the English used in the video.

AbbreviationsCOVID-19: Coronavirus disease 2019; SARS-CoV-2: Severe AcuteRespiratory Syndrome Coronavirus 2; WHO: World HealthOrganization; IEC: Information, Education and Communication; RAP:Rapid Assessment Procedure.

Ethics Approval and Consent to ParticipateThere is no ethical clearance. Therefore, informed consent was collect-ed from each participant to comply with the Helsinki Declaration,which states that participation by individuals who are capable of pro-viding informed consent must be voluntary and without compulsion.The participants should agree voluntarily and are allowed to continueor halt their participation in the study, without facing penalties.

Competing InterestAuthors declare that they have no competing intereset in this study.

Availability of Data and MaterialsData and materials are available on request.

Authors’ ContributionAll authors contributed equally to this work. Hilyatul Fadliyah con-ceived the idea and planned the research. Munih and SylviasariRisgiantini contributed to the recruitment of the informants. HilyatulFadliyah, Manendra Muhtar, Munih, Sylviasari Risgiantini, WenyWulandary carried out research, generated and discussed theresults.Munih with support from Weny Wulandary took lead in writinga draft of the manuscript. Hadi Pratomo directed and supervised thisstudy right from the begining, overviewed and gave final approval tothe manu script.

AcknowledgmentWe would like to acknowledge all our informants for their willingnessto take part in this study. In addition, we would like to extend our ap-preciation to the Director of the Health Promotion and CommunityEmpowerment, Indonesia’s Ministry of Health and WHO representa-tives for their support of this study.This study was self-funded. We received no financial support from anyorganization.

Additional InformationHilyatul Fadliyah1, Manendra Muhtar1, Munih1, Sylviasari Risgiantini1,Weny Wulandary1, Hadi Pratomo2*

1Graduate Student of Public Health, Faculty of Public Health,Universitas Indonesia; 2Department of Health Education & BehavioralSciences, Faculty of Public Health, Universitas Indonesia.

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Herikurniawan H, et al. Coronavirus Disease 2019: tinjauan literatur

terkini. Indonesian Jurnal Penyakit Dalam Indonesia. 2020; 7 (1): 45-

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Information or misinformation about COVID-19: a phenomenological

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education, and communication campaign on a community-based

health insurance scheme in Burkina Faso. Global health action. 2013;

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tion: a guide for AIDS programme managers. WHO Regional Office

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communication materials; 2015 [Last accessed 26 June 2020].

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Interim Technical Brief; 2020 [Last Accessed 23 June 2020].

12. Heng Li, Shang-Ming Liu, Xiao-Hua Yu, Shi-Lin Tang, Chao-Ke Tang,

Coronavirus disease 2019 (COVID-19): current status and future per-

spective, International Journal of Antimicrobial Agents. 2020; 55(5):

105951.

13. Scrimshaw NS, Gleason GR, editors. RAP: Rapid assessment proce-

dures; qualitative methodologies for planning and evaluation of health

related programmes. Boston: International Nutrition Foundation for

Developing Countries; 1992.

14. Holdsworth L M, Safaeinili N, Winget M, Lorenz K A, Lough M,

Aschet S, et al. Adapting rapid assessment procedures for implementa-

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L. Long, A. T. Panter, D. Rindskopf, & K. J. Sher (Eds.), APA hand-

books in psychology®. APA handbook of research methods in psychol-

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in both vacuuming and filling refrigerant towards result of students

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Rosdakarya; 2005.

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

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

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

Impact of Lockdown in India: A Case Study ComparingKarnataka with an International Model

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

1Pharm D Interns of Nirmala College of Pharmacy, India2Department of Pharmacy Practice, Nirmala College of Pharmacy, India

IntroductionInfections associated with the novel coronavirus se-

vere acute respiratory syndrome coronavirus 2 (SARS-CoV-2), causing coronavirus disease 2019 (COVID-19),emerged in Wuhan, China, at the end of 2019, and rap-idly spread to the United States, France, Italy, Spain,Iran, South Korea, India, Singapore, Japan, and othercountries. Although the highest death rates were initiallyreported by China, this trend later shifted to Europeancountries and the United States, forcing the WorldHealth Organization (WHO) to declare the COVID-19pandemic a global health emergency.1 India implementedstrict restrictions on the movement of citizens, in accor-dance with the epidemic disease act, on March 25, 2020,after a spike in COVID-19 cases was identified. BecauseIndia is the second-most populous nation in the world,the risk for a pandemic outbreak was thought to be espe-cially high, due to undeveloped slum areas, unhygieniclifestyles, and the lack of health facilities.2 Non-pharma-ceutical forms of infection prevention, such as "socialdistancing", intended to prevent direct contacts with in-

fected individuals, were proposed, resulting in the clo-sure of all educational institutions, the restriction of non-essential travel, increased encouragement to work fromhome, and the complete cessation of all public trans-portation.3 The initial plan for 21 days of national lock-down was followed by another phase of lockdown, last-ing through May 3, 2020, which helped to flatten thecurve and hold the mortality rate to 0.25% - 0.5% of to-tal positive cases, compared to other developed coun-tries.4

The negative impacts of the lockdown were reflectedin the Indian economy, leading to the greatest economicemergency since the declaration of Indian independence.The International Monetary Fund has estimated thatIndia’s Gross Domestic Product (GDP) is likely toshrink, from 4.5% to 1.9%, due to the economic crisesin the fields of marketing, industry, and networking.5Although India received a helpful contribution of approx-imately US $ 1 billion from the World Bank, to combatCOVID-19, the impending financial crisis is inevitable.6However, the complete lockdown of India also had pos-

Sebastian et al. Kesmas: Jurnal Kesehatan Masyarakat Nasional (National Public HealthJournal). 2020; Special Issue 1: 93-98DOI: 10.21109/kesmas.v15i2.3978

Kesmas: Jurnal Kesehatan Masyarakat Nasional(National Public Health Journal)

Correspondence*: Stelvin Sebastian, Pharm D Intern of Nirmala College ofPharmacy, Nirmala College Road, Kizhakkekara, Muvattupuzha, Kerala 686661,India, Email: stelvinsebastian@gmail.com

Received : July 2, 2020Accepted : July 3, 2020Published : 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

94

itive effects, especially those associated with the environ-ment, as an overall reduction in pollution has been ob-served in metropolitan cities. Additionally, during thespring and summer seasons, the rate of progression forthe coronavirus is expected to be slower.7

The state Karnataka, in India, has achieved worldwiderecognition for its efforts to prevent the spread ofCOVID-19, starting at the beginning of the pandemic, aspart of the restrictions enacted by the government.8 AsKarnataka has continued its long and sustained battle toblunt the impacts of coronavirus, one-third of its districtshave managed to keep the pandemic at bay. Although 18deaths have been reported through April 25, 2020, thestrict enforcement of lockdown appears to have helped,as 10 of 30 districts that have not reported a singleCOVID-19 case, thus far.9 Another state in India,Punjab, followed strict curfew strategies and showed areduction in mortality rate, up to 0.5%, and has con-trolled the number of new cases reported. When com-pared with other states in India, both of these states havebeen exceptional in addressing this pandemic, utilizingdigital technologies for contact tracing and communitysurveillance. Thus, this study aimed to assess the impactsand effectiveness of the lockdown procedures implement-ed in Karnataka and Punjab, compared with the methodsimplemented in Australia and the United Kingdom (UK).

MethodA prospective, observational study was performed, to

assess and compare the impacts of lockdown implemen-tations between Karnataka, Punjab, Australia, and theUnited Kingdom (UK). The study involved the collectionof data from authorized databases, performed in twophases. The first phase included the time from the first-reported index case through the 14th day after the decla-ration of lockdown, in each. The second phase involvedthe data collected between the 15th day and the 28th dayof lockdown. This division was based on the incubationperiod for the virus, which can be as long as 14 days;therefore, cases reported during the first 14 days of lock-down may have been acquired prior to the commence-ment of lockdown. The authors collected data for cumu-lative cases, active cases, recovery rate, death rate, andthe number of tests performed, for each of these time in-tervals. The ratio between positive case numbers and thenumber of tests performed was also assessed, to analyzethe preparedness and testing strategies of the differentregions.

The effects of lockdown were evaluated by comparingthe doubling time for each region. The doubling time ofan infectious disease or epidemic, in a population that isexhibiting exponential growth, refers to the time neces-sary for the infected population to double. Implicit in thisdefinition is the fact that no matter when you start meas-

uring, the population will always take the same amountof time to double.10

The exponential solution for a linear equation used todescribe the relationship between cumulative case num-bers and time is as follows:

PT = P0 * bT

where PT is the cumulative number of cases, reported asa function of time (T), P0 is the initial case reported, andb >1 indicates exponential growth.

We fit a linear, discrete, dynamical system model tothe cumulative increase in reported cases, to determinethe doubling time, as follows:

Doubling time, Tdouble = log (2) / log (b) [where b > 1]

The doubling rates of the various regions were usedto compare the effectiveness of the lockdown protocol ineach region. The doubling rate from the first-reported in-dex case through the 14th day of lockdown and the dou-bling rate between the 15th and 28th days of lockdownwere analyzed. Higher doubling rates indicate a reducedrate of spread and a more effective lockdown protocol.Increases in the doubling rates were analyzed forKarnataka, Punjab, Australia, and the UK. Moreover, thepercentage reduction in the cases was assessed, relativeto the number of cases that were predicted without theimplementation of lockdown, to determine the effective-ness of the lockdown protocol for each region.

The daily reported data for the number of new cases,the number of recovered patients, the mortality rate, thenumber of samples tested, and total cases reported ob-tained before and after lockdown, through the 28th day,from WHO sites and official medical bulletins.

Statistical analysis was performed using software forstatistical analysis. Demographic variables, including theage and gender of COVID-19 patients in Karnataka, wereassessed and presented as percentages. The ages of pa-tients who tested positive for COVID-19 during bothphases of lockdown were also assessed. The percentagesof active and recovered cases were analyzed. The growthrates in the numbers of reported cases were measuredduring pre- and post-lockdown phases.

The testing strategies for Karnataka and Punjab wereanalyzed. The total populations of both states and the to-tal number of samples tested, before April 1, 2020, andbetween April 1 and April 25, 2020, were assessed. Theratio between the total number of tests performed andthe total population was determined for both periods.The number of tests required to detect a positive casewas also assessed, as the ratio between total cumulativeCOVID-19 cases and the number of tests performed.

The comparisons of the death rate and recovery rate

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were expressed in percentages and represented as bardia grams.

The doubling rates and the predictions of the totalnumbers of cases were calculated by assuming that casegrowth represented an exponential model. The equationof the line was used to assess the doubling rates and pre-dictions, and R2 values were assessed to evaluate themodel fitness.

The doubling rate and case projections were analyzedin two phases, to analyze the efficiency of the lockdownin each assessed region.

Improvements in the doubling rates between pre- andpost-lockdown conditions were assessed, and the impactsof the lockdown were assessed as the percentage reduc-tion in the occurrence of actual cases relative to the num-ber of predicted cases.

ResultsIn Karnataka, between January 25, 2020, and April

25, 2020, 500 cases of COVID-19 were identified, in-cluding the index case, among which 158 (32%) reco -vered, 324 (64%) remained active cases, and 18 (4%)died. Of these 500 cases, 356 were men and 144 werewomen (Table 1).

The average daily growth rate in positive COVID-19cases, which was 13.52% from March 8 until the imple-mentation of lockdown, was reduced to 4.15% after theimplementation of lockdown. The cumulative growthrate for positive COVID-19 cases in Karnataka declined,compared with the cumulative growth rate in COVID-19cases for all of India (Figure 1).

Examining the number of samples tested for suspect-ed COVID-19-positive cases showed that Punjab had

tested a larger proportion of its population thanKarnataka. Based on the population, more tests were nec-essary to identify a case in the suspected population aftera lockdown in Punjab (Table 2).

Comparisons of the recovery rates, death rates, andtotal cases between Karnataka and Punjab showed an in-creased recovery rate and a reduced mortality rate forKarnataka compared with Punjab after April 1, 2020,whereas Punjab showed a higher recovery rate and re-duced mortality rate than Karnataka before April 1, 2020

Table 1. COVID-19-Positive Cases in Karnataka, India, Distributed by Age

COVID-19-PositiveAge (years) Before April 1, 2020 April 1–April 25, 2020

0–5 0 75–10 4 1410–20 16 4220–30 21 12230–40 27 12540–50 14 6750–60 8 52> 60 20 71

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

Table 2. Numbers of COVID-19 Tests for the Total Population

State Karnataka Punjab

Total population 6,6834,193 3,073,507No. of samples tested before April 1, 2020 3,254 1,260Total test / population before April 1, 2020 20,539.09 24,392.91No. of samples tested till April 25, 2020 35,378 13,270Total test / population through April 25, 2020 2,325.153 2,316.132Tests required to identify a positive case inthe suspected population before April 1, 2020 285.2651 27.08696

Tests required to identify a positive case inthe suspected population through April 25, 2020 5.432 7.4955

Sebastian et al, Impact of Lockdown in India

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(Figure 2). To determine the impact of lockdown, we divided the

examined period into two phases. The first phase includ-ed the time from the first-reported index case through 14days after the declaration of lockdown. We assumed thatcases reported during the first 14 days of lockdown mayhave been acquired before the lockdown declaration, dueto the incubation period of COVID-19. During the se -cond phase, we included the period starting 14 days afterthe declaration of lockdown.

Karnataka reported its first COVID-19 case on March9, 2020. Then, a complete lockdown was initiated onMarch 25, 2020. During the lockdown period, approxi-mately 428 cases were reported. The doubling time be-fore lockdown for Karnataka was calculated to be 6.35days (R2 = 0.89). The overall doubling time during thelockdown phase was found to be 2.46 days (R2 = 0.96),and the doubling rate for cumulative cases decreased af-ter the initiation of lockdown.

In Punjab, 332 cases were reported, with 17 deaths.Their first index case was reported on March 5, 2020,and they declared complete lockdown on March 25,2020. During the lockdown period, Punjab reported ap-proximately 309 cases. The doubling time for Punjab, be-fore the lockdown was determined to be 4.85 days (R2 =0.87). The doubling time for Punjab after the lockdownwas found to be 3.35 days (R2 = 0.87).

In Australia, 6,675 total COVID-19 cases and 78deaths were reported through April 25, 2020. They an-nounced a lockdown on March 23, 2020, which was 58days after the diagnosis of the index case, on Jan 25,2020. By the time lockdown was implemented, approxi-mately 5,285 cases were reported. The doubling timelockdown in Australia was found to be 8.13 days (R2 =0.95). During the second phase, we examined the periodafter the 14th day of the declaration of lockdown, andthe overall doubling time for this period in Australia was7.2 days (R2 = 0.97)

In the UK, 119,908 positive cases and 15,464 deathswere reported through April 25, 2020. They announceda lockdown on March 23, 2020, which was 53 days afterthe first-reported index case, on January 31, 2020.During this lockdown period, the UK reported approxi-mately 114,221 COVID-19-positive cases. The doublingtime before the lockdown in the UK was found to be 4.32

days (R2 = 0.97). The doubling time after the lockdownin the UK was found to be 4.06 days (R2 = 0.959).Although the UK improved the overall doubling rate be-cause of lockdown, an extension of lockdown is necessaryto increase the doubling time.

The efficiency or the impact of lockdown for reducingthe infection spread can be determined by assessing therise in the doubling rate from the first phase to the secondphase. The largest observed increase in the doubling rateoccurred in Karnataka (2.41 days), followed by Punjab(1.49 days). The doubling rate in Australia increased by0.92 days, whereas the lowest increase was observed forthe UK, which was 0.26 days illustrating the necessity ofprolonging the lockdown rate and implementing strictermeasures for disease control in the UK.

The percentage in case reduction attributed to lock-down was determined relative to the predicted cases andwas found to be highest for Punjab (95%) and the lowestfor the UK (74%) (Table 3).

DiscussionThe COVID-19 epidemic caused a unique and alarm-

ing situation, requiring the implementation of new strate-gies to control the transmission of infection. In this study,we assessed the impacts of lockdown in four regions, in-clude Karnataka, Punjab, Australia, and the UK, to pro-vide a comprehensive analysis of the COVID-19 out-break. We analyzed the estimated epidemic size when so-cial distancing was activated in different regions, on dif-

Figure 2. Comparisons of the Death Rates, Recovery Rates, and Total Casesbetween Punjab and Karnataka

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

Total CasesPlace 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%

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ferent dates, by determining the doubling time. An in-crease in the doubling time implies a slowdown in trans-mission.11 The highest doubling rate was identified forAustralia, followed by Karnataka and Punjab, whereasthe lowest was identified for the UK. However, as a resultof the lockdown, the rise in the doubling rate was thehighest for Karnataka and the lowest for the UK.Compared with the number of predicted cases if lock-down had not been implemented, the number of cases re-ported after the implementation of lockdown was signifi-cantly lower than the number that was predicted withoutlockdown. Thus, the lockdown implementation likelylowered the epidemic spread in all 4 regions. Rodriguez,et al.,12 observed an increasing trend in the doubling timefor the coronavirus among the Chinese population duringFebruary 2020.

When comparing the numbers of samples tested, themortality rates, and the recovery rates between Karnatakaand Punjab, after the implementation of lockdown, anincreased recovery rate and a reduced mortality rate wereobserved for Karnataka compared with those in Punjab,and Karnataka also displayed a high rate of sample test-ing compared with that in Punjab. A similar study sug-gested that to control the epidemic size and death rate,earlier social distancing rules should be followed, withoutlockdown.13 As Karnataka continues its long and sus-tained battle to blunt the impacts of COVID-19, throughthe use of a functional disease surveillance system, one-third of its districts have managed to keep the pandemicat bay.

When the demographic features of Karnataka werecompared with those of other countries, age and genderwere found to be significant factors for determining theimpacts of lockdown. Similar to the observations report-ed globally, the majority of COVID-19 patients identifiedin the state of Karnataka are between 30 and 40 years ofage. Almost 500 total cases were reported, of which 32%of them recovered and more than 64% of cases remainedactive. The death rate was maintained under 4%, as partof Karnataka's contingency action plan for the control ofthe epidemic. The plan included a strategy consisting ofcommunity surveillance, quarantine, fever clinics,COVID-19-specific hospitals, multiple testing centers,personal protective equipment, and a rapid responseteam for COVID-19 disaster management.14 After theoutbreak of the coronavirus, the government ofKarnataka executed a strict protocol, including the clo-sure of educational establishments, the prevention ofnon-essential travel, the maintenance of hygiene andphysical distancing, and screening, at all airports, railwaystations, and state borders. In Punjab, the first case wasreported on March 5, 2020, and through April 25, 2020,approximately 309 confirmed COVID-19 cases were re-ported, with a 5% mortality rate. They also implemented

a lockdown strategy, maintaining a fine balance betweenallowing normal economic activities and controllingCOVID-19. Punjab's COVID-19 action plan, which con-sisted of a task force to contain the spread of the corona -virus, required changes in human behavior, includingmaintaining physical distances, limiting mobility, andperforming rigorous personal hygiene.15

Australia’s COVID-19 plans were also highly success-ful in flattening the curve of the new COVID-19 casesthrough April 25, 2020, with 6,675 total cases and 78deaths reported. The emergency response plan of theAustralian health sector was successfully implementedby the government, to allow the population to continueliving and working in a COVID-19-safe manner. Theyare now capable of keeping the number of cases lowwhile taking steps to relax restrictions.16 As a part of thedrastic lockdown, they closed their borders to non-resi-dents, enacted stringent social distancing protocols, andwere able to mitigate the rapid spread of thecoronavirus.17

The UK government was well-prepared for diseaseoutbreak, as they learned during the outbreak of an in-fluenza pandemic, over a decade ago.18 The overall phas-es of the UK COVID-19 action plan included the con-tainment, delay, and mitigation of any outbreak, usingresearch to inform policy development. Based on theavailable scientific evidence, they were focused primarilyon the continuity of public, the stability of the economy,and the provision of critical services in the fight againstCOVID-19.19 The other preventive measures includedsocial distancing, information campaigns regarding per-sonal hygiene, and rapid testing. Thus, the UK continuesto respond robustly to various pandemic outbreaks, tomaximize the effectiveness of their public health and caresystem.20

Our study is subject to some inherent limitations, in-cluding the under-reporting of cases due to under-diag-nosis, the unavailability of data regarding mortality, test-ed cases and confirmed cases from different countries.

ConclusionOur study reveals that the implementation of social

distancing and lockdown impacted the transmission ofcoronavirus and the number of cases reported. However,the effectiveness of lockdown varied among regions, de-pending on multiple factors, including demographic vari-ables, population density, and social gathering.Therefore, lockdown appears to represent an effectivemethod for flattening the exponential curve associatedwith the COVID-19 pandemic.

AbbreviationsSARS-CoV-2: Severe Acute Respiratory Syndrome Coronavirus 2;COVID-19: Coronavirus disease 2019; WHO: World Health

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Organization; GDP: Gross Domestic Product; UK: United Kingdom.

Ethics Approval and Consent to ParticipateNot Applicable

Competing InterestThere are no conflicts of interest.

Availability of Data and MaterialsThe datas used and/or analysed during the current study are availablefrom the author on reasonable request.

Authors’ ContributionStelvin Sebastian and Aby Paul conceived the study and drafted the re-search protocol. Stelvin Sebastian, Aby Paul, Jeeva Joseph and Joel Jobyprovided critical review of and approved the study design. Sanjo Saijanconducted the database searches. Aby Paul made the primary selectionof eligible papers including data extraction. Jeeva Joseph, Aby Paul andJobin Kunjumon Vilapurathu supervised and checked the study selec-tion process and data extraction. Sanjo Saijan analysed the data. All au-thors contributed to interpretation of the analysis. Stelvin Sebastianand Aby Paul wrote the manuscript. All authors provided critical reviewand approved the final manuscript.

AcknowledgmentSincere gratitude to our beloved researchers, friends, and family.

Additional InformationStelvin Sebastian1*, Aby Paul1, Jeeva Joseph1, Joel Joby1, Sanjo Saijan1,Jobin Kunjumon Vilapurathu2

1Pharm D Interns of Nirmala College of Pharmacy, India; 2Departmentof Pharmacy Practice, Nirmala College of Pharmacy, India.

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11. Lau H, Khosrawipour V, Kocbach P, Mikolajczyk A, Schubert J,

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the COVID 19 outbreak in China. Journal of Travel Medicine. 2020;

27 (3): taaa037.

12. Rodriguez M K, Chowell G, Cheung C, Jia D, Lai P Y, Yiseul L, et al.

Doubling time of the COVID-19 epidemic by Chinese Province.

MedRxiv; 2020.

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-

ta-driven SEIQR study; 2020.

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2019 (COVID-19); 2020.

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COVID-19 crisis: perspectives on public policy centre for Aboriginal

Economic Policy Research. Australian National University; 2020

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to what you can expect across the UK; 2020.

19. Sun K, Chen J, Viboud C. Early epidemiological analysis of the coron-

avirus disease 2019 outbreak based on crowdsourced data: a popula-

tion-level observational study. Lancet Digital Health 2020; 2: e201-8.

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

Mukhlida et al. Kesmas: Jurnal Kesehatan Masyarakat Nasional (National Public HealthJournal). 2020; Special Issue 1: 99-104DOI: 10.21109/kesmas.v15i2.3958

Kesmas: Jurnal Kesehatan Masyarakat Nasional(National Public Health Journal)

AbstractThe infectious disease from Coronavirus Disease 2019, or COVID-19, has quickly spread world-wide since 2019. Therapies for managing COVID-19 haveyet 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 trialtherapy and treatment to the patients in the hospital with COVID-19. Using PRISMA guidelines as a method for conducting a systematic literature review, atotal of 67 articles were collected from several online journal databases. Various therapies were found that are effective in the treatment and management ofCOVID-19. In accordance with the inclusion and exclusion criteria of this study, a total of 8 articles were selected. The study showed that several therapiesare effective in managing the severe illness, can be used as COVID-19 treatment. Combination of medicine have shown the effectiveness of clinical improve-ments and recovery rate in a short time compared to single medicine. Nevertheless, further study into effective therapies for COVID-19 must be continued tofind the best therapy and treatment.

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

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 Maju3Department of Public Health, Sekolah Tinggi Ilmu Kesehatan Indonesia Maju

IntroductionThe emergence of the infectious disease known as

Coronavirus Disease 2019 (COVID-19) began in Wuhanat the end of 2019.1 The causative agent of COVID-19 isthe same as the virus from severe acute respiratory syn-drome (SARS) disease. The first infection of SARS wasfound in the South China last month in 2002.2

The virus has spread rapidly worldwide, and was re-ported by the World Health Organization (WHO) inJanuary 30, 2020.3 Thus far, as of June 2020 the corona -virus has affected 215 countries and territories, with over6,190 confirmed cases, and over 376,300 deaths.4 InIndonesia, cases confirmed by the Ministry of Health areover 28,200 and confirmed deaths over 1,600 cases.5

COVID-19 is a respiratory disease which can causefatigue, fever, dry muscle aches, coughs, shortness ofbreath and in some instances lead to pneumonia.6,7 Themost common means of transmission occurs person toperson, including amongst family members, and alsofrom healthcare workers.8,9 There is no agreed medica-tion to help recovery from COVID-19; the managementof medication is based on each patient’s sign and symp-toms. The WHO advises to apply empiric antimicrobial

thera py and to implement mechanical ventilation basedon the clinical diagnosis of patients.10-12 The purpose ofthis study was to review the previous research of the ef-ficacy of trial therapy and treatment to the patients withCOVID-19. The study emphasizes that effective therapyfor COVID-19 to the patients should be able to accele -rate the recovery of patients and the symptoms ofCOVID-19 suffered by patients are not getting worse inIndonesia.

MethodThe research used Preferred Reporting Items for

Systematic Reviews and Meta-Analyses (PRISMA) guide-lines for conducting a systematic literature review.13,14

Authors chose relevant study published from January2020 to March 2020, by searching Pubmed, ScienceDirect and Google Scholar, with a total of 67 articlesfound.

The search terms used were "Coronavirus Disease2019", "Novel Corona Virus 2019", "The Therapy forCoronavirus Disease", "The Treatments for Severe Acuteof COVID-19”. Only articles written in English were con-sidered. The study was focused on the treatment of

Correspondence*: Halma Zahro Mukhlida, Departemen Keperawatan, SekolahTinggi Ilmu Kesehatan Indonesia Maju. Jl. Harapan No.50 Lenteng Agung,Jakarta,12610, Indonesia. Email: zahromukhlidahalma@gmail.com, Phone:+62-877-8076-7822

Received : June 4, 2020Accepted : June 19, 2020Published : 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

100

SARS, virus MERS-Cov and SARS-CoV. Inclusion crite-ria for this study are only articles on therapy and treat-ment of COVID-19 given to patients in hospitals orhealth servi ces. While the exclusion criteria of this studyare articles on COVID-19 prevention treatments in thecommunity. The screening was conducted by reading thetitle, abstract, and full text of the articles.

Eligible studies on therapies and treatment for mana -ging COVID-19 to the patients were perfomed in a sys-tematic review table. This table showed the author andyear; country of publication of the trial therapy or treat-ment; population/data source; efficacy measure; adverseevents; and lessons learned. Interpretation of the data isdone by using qualitative and quantitative approach. Thequalitative approach involved interpreting tables andlearning the lessons, while the quantitative approach in-cluded assessing the efficiency rate of the therapy andtreatment reviewed.

ResultsA total of 67 articles were obtained from three sources

(Figure 1); 16 articles from Google Scholar, 24 articlesfrom Pubmed, and 27 articles from Science Direct. Threearticles from these sources were copied articles. Afterscreening by reading 64 abstracts, 28 articles were ex-cluded since they discussed preventive thera py in thecommunity, such as physical distancing, use of facemasks, or the symptoms of COVID-19. After screeningby reading the whole 36 articles, 28 articles were exclud-ed since they only discussed the contain of medicines re -commended for therapeutic use or treatment for COVID-19. Therefore, the included articles according to the in-clusion and exclusion criteria of this study were eightquantitative studies.

Table 1 shows the systematic literature review of theefficacy of therapy for managing COVID-19, while Table2 shows the review of the efficacy of treatment for ma -naging COVID-19. A total of eight studies were selectedfor the review, showing that various therapies and inter-ventions were effective in handling COVID-19.

Based on Table 1, a combination of medicines wasbetter than one type of medicine. The level of clinical pa-tient improvement on day 14 was higher in the Lopinavir(LPV) - Ritonavir (RTV) group than in the standard caregroup (45.5% vs 30.0%). In the study of Arbidol com-bined with LPV/r (Lopinavir/Ritonavir), after 14 days in15 (94%) out of 16 patients, COVID-19 could not be de-tected at p-value of less than 0.05. After six days of treat-ment, all the six patients (100%) at the group ofHydroxychloroquine combined with Azithromycin weretested negative of COVID-19.

Table 1 also shows the evaluation of the adverseevents of the reviewed studies. Study Cai, et al.,17

Favipiravir (FPV) patients had two cases of diarrhea, one

liver injury case, and one poor diet case), while studyChen, et al.,20 found that FPV increased serum uric acid(16 /116), with OR = 5.52 at p-value of less than 0.005).LPV/RTV patients had five cases of diarrhea, five vo -miting cases, six nausea cases, four rash cases, three liverinjury cases, and two cases of chest tightness and palpi-tation. Two patients in the group of Arbidol was diag-nosed with leukopenia (white blood cell count < 4 x109/L). In one study which combined Arbidol withLPV/r, 68.7% of patients demonstrated elevated levelsof bilirubin, with a top mean of 25.26 μmol/L (10.61μmol/L).

Not only the use of drugs, but also treatment by pro-gressive muscle relaxation and sunbathing can also in-crease healing (Table 2). Progressive muscle relaxation isuseful in reducing stress for COVID-19 patients, espe-cially in hospitals.

DiscussionBased on the results of this study, it appears that there

are drugs that can be used to cure patients of COVID-19;for example, antiviral and antimalarial medicines, suchas Lopinavir/ Ritonavir, Fapiviravir, Arbidol, andHydroxy chloroquine. The study results of Zhu, et al.,16

show that the side effects that need to be considered in-

Figure 1. PRISMA Diagram Flow of the Efficacy of Therapy and Treatmentfor Managing COVID-19

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

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clude two patients who had leucopenia when usingArbidol. Another effect found in the study by Cai, etal.,17 was that using FPV that can cause diarrhea and li -

ver injury. The advice to medical personnel in Indonesiais that they should also pay attention to these side effectsif some of these therapies will be prescribed to patients

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 infect- ion common in theZhu, 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 pa- tients (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.

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

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of COVID-19.The results of this study show that a combination of

drugs works better. In the research conducted by Deng,et al.,19 it was shown that the combination of Arbidoland Lopinavir/Ritonavir could accelerate healing for pa-tients of COVID-19. On the 14th day of treatment, 94%of patients receiving combination therapy showed nega-tive signs of the SARS COV 2 virus. In research Gautret,et al.,18 also combined Hydroxychloroquine withAzithromycin in their study. On day 6 post-inclusion, thenumber of negative patients was 6/6, 100%. The studyby Cao, et al.,15 which combi ned Lopinavir and Ritonavirshowed an improvement in the patient's health conditionat 45.5% on day 14. The effects that need attention areserious gastrointestinal adverse events with Lopinavirand Ritonavir, elevated levels of bilirubin, and digestiveupsets, such as mild diarrhea and nausea in combinedArbidol with Lopinavir/Ritonavir therapy.

Apparently, progressive muscle relaxation can helpreduce stress for COVID-19 patients. Based on medicaldiagnosis, some coronavirus disease patients have sleepdisturbance and anxiety after isolation therapy. Anxietydue to psychological stress could become a trigger of de-creased immunity and physiological disorders.23

Progressive muscle relaxation (PMR) training reducedthe effect of anxiety on the patients, which might happendue to the ba lance between the hypothalamic nucleus andanterior. By reducing the activity of the sympathetic ner -vous system, stress and anxiety can be prevented, andphysical and mental relaxation can be increased.24

Sunlight can also be applied to increase healing in pa-tients COVID-19 as triggers the production of vitaminD, which strengthens the immune system.25

Recently, to help progress in the study of the effect -iveness of several therapies, WHO developed the solida -rity clinical trial project for COVID-19 treatments.26 Theproject aims to obtain strong and valid clinical evidence

for four potential therapies that have been tried. InMarch 2020, the government of Indonesia joined the tri-al.

In Indonesia, there is some development of pharma-ceutical drug research in herbal trials. UniversitasIndonesia and the IPB University (Institut PertanianBogor) research teams are also developing this line ofstudy with regard to antibodies and antivirals accessedfrom guava, moringa leaves, and orange peel. These com-positions include hesperidin, rhamnetin, kaempferol,quercetin, and myricetin from the mixture of guava (pinkfruit skin), orange peel, and moringa leaves.27 The studydiscusses research against the protein, and gatheringherbs related to the work of the virus, obtained severalrelated groups to prevent the SARS-CoV-2 virus (corona -virus).27

The limitation of this study is to limit studies that havebeen reviewed because there are still many trial therapystudies that are being conducted in several other coun-tries. This study also did not involve an additional popu-lation variation, such as pregnant mothers and children,so the efficacy and occurrence of adverse events for preg-nant women and children could not have been exploredmore in this study.

ConclusionSeveral studies have shown the effectiveness of seve -

ral trial therapies and treatment for COVID-19. Theseused a single drug or a combination of drugs, mostly fromthe antiviral class. Progressive muscle relaxation and sun-bathing treatment can also improve the healing process.Medical personnel is expected to implement the resultsof this study to COVID-19 patients in Indonesia.Nevertheless, research about the effective therapies forCOVID-19 must be continued to find the best therapyand treatment. Future studies on the treatment ofCOVID-19 could be related to varying ages and condi-

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

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

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tions, such as pregnant women and children.

AbbreviationsCOVID-19: Coronavirus disease 2019; SARS: Severe AcuteRespiratory Syndrome; WHO: World Health Organization; PRISMA:Preferred Reporting Items for Systematic Reviews and Meta-Analyses;LPV: Lopinavir; RTV: Ritonavir; LPV/r: Lopinavir/Ritonavir; FPV:Favipiravir; ZNWU: Zhongnan Hospital of Wuhan University; LSS:Leishenshan Hospital; HBTH: The Third People's Hospital of HubeiProvince; STAI: The Spielberger State-Trait Anxiety Scale; SRSS: SleepState Self-Rating Scale; PMR: Progressive Muscle Relaxation.

Ethics Approval and Consent to ParticipateNot Applicable

Competing InterestThe authors declare that they have no competing financial interest.

Availability of Data and MaterialsThe authors confirm that the data supporting the findings of this studyare available within the article.

Authors’ ContributionHalma Zahro Mukhlida, Hilma Hasro Maulida, Gunanti Khairunnisa,Margaretha Josephine Mantrono, Rindu, Eka R W Purnamasari, andRizky Fajar Meirawan created the manuscript. Halma Zahro Mukhlida,Hilma Hasro Maulida, Gunanti Khairunnisa, and Margaretha JosephineMantrono collected the literature data. Rindu, Eka R W Purnamasari,and Rizky Fajar Meirawan review and revised the Manuscript. RiskyKusuma Hartono supervised and discussed the final result.

AcknowledgmentWe would like to thanks to Indonesian Government authorities forCOVID-19, as well as to Directorate of Laboratorium Riset of SekolahTinggi Ilmu Kesehatan Indonesia Maju (STIKIM) that made the avail-ability of data, The Head of STIKIM, and all parties and staff that sup-ported to this study.

Additional InformationHalma Zahro Mukhlida1*, Hilma Hasro Maulida1, GunantiKhairunnisa2, Margaretha Josephine Mantrono2, Risky KusumaHartono2, Rindu3, Eka R W Purnamasari1, Rizky Fajar Meirawan3.

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

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Reviewer Acknowledgment

Al AsyaryAria KusumaBesralDefriman DjafriDumilah AyuningtyasEde Surya DarmawanFridawati RivaiGita Miranda WarsitoOnny Setyani

Rahayu LubisRahmadewiRirih YudhastutiSetyowatiSoedjajadi KemanSuriahUmar Fahmi AchmadiYodi Mahendradhata

Reviewer AcknowledgmentKesmas: 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 appreciateDewi Susanna, MS as Handling Editor and really thank all Reviewers for kind assistance in Special Issue Volume 1,2020:

Aby Paul ........................................................................... 93-98Achmad Faridy Faqih ....................................................... 77-84Acim Heri Iswanto ........................................................... 18-23Andree Kurniawan ........................................................... 43-48Badra Al Aufa ................................................................... 49-53Bunga Astria Paramashanti .............................................. 24-27Dessy Paramitha ............................................................... 28-31Dewi Rokhmah ................................................................. 54-59Dewi Susanna ................................................................... 6-13Dumilah Ayuningtyas ....................................................... 1-5Eka Rokhmiati Wahyu Purnamasari ................................ 99-104Emma Rachmawati ........................................................... 49-53Febri Endra Budi Setyawan .............................................. 37-42Gunanti Khairunnisa ........................................................ 99-104Hadi Pratomo .................................................................... 60-63; 85-92Halma Zahro Mukhlida .................................................... 99-104Hayyan Ul Haq ................................................................. 1-5Hilma Hasro Maulida ....................................................... 99-104Hilyatul Fadliyah .............................................................. 85-92Ibrahim Isa Koire ............................................................. 49-53Izza Suraya ....................................................................... 49-53Jeeva Joseph ...................................................................... 93-98Jobin Kunjumon ................................................................ 93-98Joel Joby ............................................................................ 93-98Khoiron ............................................................................. 54-59Kurnia Dwi Artanti ........................................................... 77-84Manendra Muhtar .............................................................. 85-92

Margaretha Josephine Mantrono ....................................... 99-104Marina Ioannou ................................................................. 64-69Mochamad Iqbal Nurmansyah ........................................... 49-53Munih ................................................................................ 85-92Nanny Harmani ................................................................. 70-76Raden Roro Mega Utami ................................................... 1-5Retno Lestari ..................................................................... 37-42Ricko Pratama Ridzkyanto ................................................ 54-59Rindu ................................................................................. 99-104Ririh Yudhastuti ................................................................ 32-36Risky Kusuma Hartono ..................................................... 99-104Rizaldy Pinzon ................................................................... 28-31Rizky Fajar Meirawan ....................................................... 99-104Rizma Dwi Nastiti ............................................................. 77-84Sang Gede Purnama .......................................................... 6-13Sanjo Saijan ....................................................................... 93-98Saraswati Anindita Rizki ................................................... 43-48Sri Rahayu Slamet ............................................................. 70-76Stelvin Sebastian ............................................................... 93-98Sylviasari Risgiantini ......................................................... 85-92Tiopan Sipahutar ............................................................... 14-17Tris Eryando ...................................................................... 14-17Victor B. Oti ...................................................................... 64-69Vincent Ongko Wijaya ...................................................... 28-31Wahyu Sulistiadi ............................................................... 70-76Weny Wulandary ............................................................... 85-92

Author IndexKesmas: Jurnal Kesehatan Masyarakat Nasional (National Public Health Journal)

Special Issue Volume 1, 2020

Author Index

Airport ....................................................... 77-84Burnout ...................................................... 18-23Case Fatality Rate ...................................... 14-17Clinical improvement ................................ 99-104Cloth face mask ......................................... 32-36Cloth mask ................................................ 43-48Communication ......................................... 70-76Constitutional mandatory .......................... 1-5Corona outbreak ........................................ 18-23Coronavirus ................................................ 37-42COVID-19 .................................................. 1-5; 6-13; 24-27; 28-31; 32-36; 49-53; 54-59; 60-63; 64-69; 70-76; 77-84; 85-92; 93-98; 99-104COVID-19 Indonesia ................................. 14-17COVID-19 pandemic ................................. 14-17Education ................................................... 70-76Educational video ...................................... 85-92Effective therapy ........................................ 99-104Efficacy ...................................................... 43-48Epidemic .................................................... 93-98Epidemiology ............................................. 77-84Face mask .................................................. 43-48Fund management ..................................... 54-59Global civil society .................................... 1-5Global Health Security ............................. 1-5Health financing ........................................ 54-59Health policy ............................................. 37-42Health workers .......................................... 18-23Holistic-comprehensive ............................. 37-42Hygiene ..................................................... 6-13Incidence Rate Ratio ................................. 49-53

Indonesia .................................................... 6-13; 24-27; 28-31; 32-36Indonesia Case Fatality Rate ...................... 14-17Information ................................................ 70-76Lockdown .................................................. 93-98Management treatment .............................. 99-104Mask crisis ................................................. 32-36Neurologic disorder ................................... 28-31Novel coronavirus ...................................... 24-27Outbreak .................................................... 93-98Pandemic .................................................... 32-36; 37-42; 64-69Physical distance ........................................ 60-63Pre-testing of IEC material ........................ 85-92Public stigma ............................................. 70-76Sanitation ................................................... 6-13SARS-COV-2 ............................................. 64-69Screening ................................................... 77-84Social distance ........................................... 60-63Social distancing ........................................ 93-98Social restriction ........................................ 49-53State responsibility ..................................... 1-5Surgical mask ............................................. 43-48Surveillance ................................................ 77-84Sustainable Development Goals ................ 24-27Teenagers ................................................... 85-92Telemedicine .............................................. 28-31Time series analysis ................................... 49-53Travelers .................................................... 64-69Viral agent ................................................. 64-69Work risk ................................................... 18-23Work shift .................................................. 18-23World Health Organization ....................... 85-92Zero hunger ............................................... 24-27

Subject Index

Subject IndexKesmas: Jurnal Kesehatan Masyarakat Nasional (National Public Health Journal)

Special Issue Volume 1, 2020

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