Indonesia is emerging from a new wave of Covid-19 infections. Since the first case of Omicron was confirmed in early December 2021, Indonesia has registered more than 1.5 million new cases and 7,400 deaths.
These data are much less discouraging compared to Indonesia’s experience with the delta wave in 2021, when more than 2.5 million Indonesians were infected and more than 112,000 deaths were recorded. The healthcare system has also held up better this time around. Bed occupancy remained stable at around 60% during Omicron’s peak – a stark contrast to the situation in July and August 2021, when hospitals were unable to cope with the surge in Delta and high mortality rates have been recorded among health workers.
There are several reasons for the seemingly better results of this push. The first is the less severe clinical presentation of the Omicron variant compared to Delta. Second, more Indonesians have now been vaccinated. At the time of writing, more than 90% of the population had received at least one dose and more than 70% were fully vaccinated. Vaccination coverage is even higher in Java and Bali, where boosters have been rolled out for the general population since late January.
Additionally, widespread previous infection appears to have provided some degree of immunity to the Omicron push. A serological survey conducted in November and December 2021 revealed that 86% of Indonesians already had antibodies against Covid-19 (this was at a time when the average vaccination coverage was only 59% for the first dose and 42% for both doses).
The Indonesian healthcare system has also learned from previous waves. The Ministry of Health implemented a more effective monitoring system and ensured higher testing capacity before Omicron reached its peak. Local health centers (puskesmas) were ready to lead case registration and local tracing and testing, there were almost no stockouts of rapid tests, and PCR testing capacity kept pace with demand. There was also better preparedness at the health facility level in terms of anticipating an increase in cases. Similarly, the government acted quickly to adjust travel restrictions and quarantine requirements.
The government was clearly buoyed by its ability to handle the Omicron wave. From the second week of March, despite a record number of daily new cases at 26,000, Indonesia began to ease social restrictions. Quarantine for international travelers has been reduced from three days to one (and on March 21 completely dropped). The mandatory PCR test or rapid swab antigen test requirement for domestic flights and train travel has been waived for passengers with at least two vaccine injections. Confusingly, however, the Interior Ministry at the same time encouraged a reintroduction of social restrictions in many districts of Java and Bali. Although the government is still promoting its “5M” health protocols (hand washing, masks, social distancing, avoiding crowds, reducing mobility), the public has started wondering when Indonesians will follow in the footsteps of other European countries and begin to take off their masks.
But there are many reasons for caution. The first is that Omicron is still around and still 3.2 times more transmissible than Delta. During Omicron’s peak, there were about 63,000 new cases per day, compared to 56,000 during the Delta wave. Indonesia was lucky the spike wasn’t more severe and its health systems weren’t overwhelmed. Omicron’s BA.2 subvariant has led to record high spikes in UK cases and has already identified in Indonesia. The WHO has stated that while disease severity appears similar to the BA.1 subvariant, BA.2 is much more transmissible. Its full impact has yet to be felt in Indonesia.
Second, geographic disparity in vaccination coverage is a serious problem. At the end of January 2022, there were 19 provinces where less than 50% of the population had received two doses of the vaccine. Meanwhile, provinces prioritized by disease burden or economic importance have achieved near universal coverage. Same in mid-March 2022, in eastern provinces such as Papua, West Papua, Moluccas and North Moluccas, the proportion of the population who received two doses of the vaccine ranged from only 27 to 46%. This is significantly lower than the national average (73%) and well below provinces like Jakarta (124%) and Bali (104%).
Immunity levels, whether acquired through vaccination or infection, decline over time. If vaccination inequity is not addressed quickly, areas with low vaccination coverage could see a much higher case load and death rates if another wave hits.
Another cause for concern is fatigue with public health measures like mask-wearing, social distancing and social isolation. Pandu Riono, eminent epidemiologist from Universitas Indonesia said that social restrictions known as PPKM may no longer be as effective, as Indonesians are fed up with intermittent restrictions on activities.
Like many people around the world, Indonesians yearn for some normality, including in their daily social interactions and travels. More lax mask-wearing and social distancing measures could lead to much higher cases and mortality if another wave hits.
How can Indonesia strike the right balance?
Indonesia must first ensure that it implements a strong risk communication strategy. The easing of travel restrictions and quarantine requirements should not be interpreted as giving the green light to a complete easing of public health measures. People who have been fully vaccinated should continue to wear masks in public, limit their mobility and avoid gathering in crowds. The arrival of the BA.2 variant in Indonesia suggests the government needs to start emphasizing the importance of restricting mobility ahead of the Eid holiday in early May.
Consistent public health messaging is needed, and not just from government. The media should resist the temptation to use sensational headlines and framing that could deceive the public.
Second, the government must remain vigilant and responsive to any new spikes in Covid-19 overseas. International travel restrictions should be tightened as soon as new variants are suspected to emerge in other countries. Strict quarantine requirements in November and December 2021 (which required international travelers to undergo a mandatory 10-day quarantine) seemed to have been somewhat effective in delaying the arrival of the Omicron wave and allowed Indonesia to save precious time to increase its vaccination coverage.
Finally, and most importantly, the resilience of the health system is central to mitigating pandemic risks in the future and ensuring that other essential health services remain accessible to those who need them. The Covid-19 pandemic in Indonesia has caused significant disruptions to other vital health services, including for pregnant women, newborn babies and people with chronic conditions such as heart disease and cancer. Some puskesmas have closed or reduced their opening hours, while some hospitals have been converted to Covid-19 facilities. Mobility restrictions have prevented some sick people from accessing health facilities.
Building a more resilient health system will require more intensive collaboration with health education institutions to address future increases in human resource needs. The past two years have shown that students in the health sector can play a vital role in filling labor shortages and rapidly scaling up vaccination, testing and tracing.
Strengthening service delivery is also essential, including working with the private sector and community initiatives to anticipate future peaks. This could involve ensuring that quality telemedicine is provided by the public and private sectors and that public and private hospitals continue to receive Covid-19 patients during peak periods. Better coordination with community initiatives could help patients self-isolate and promote compliance with social restrictions at the community level.
Finally, leaders at the village level are uniquely placed to respond to the needs of the community. They have access to village funds (dana desa) and are often well connected to their local communities. Local governments must redouble their efforts to empower and support village leaders so that village funds are directed towards supporting community responses to the pandemic.
Indonesia has done much better in running Omicron than it did with Delta, but that’s no reason to be complacent. Indonesians are weary of the restrictions, but in a country with patchy vaccination coverage and an overburdened health system, it’s too early to abandon masks and social distancing.