A year after we entered the Covid-19 pandemic, the light at the end of the tunnel seems to be more distant.
According to data issued by the Covid-19 task force, it seems that we have reached the peak of the Covid-19 curve. However, after the global curve flattened drastically, it seems to be rising again slowly.
Data from the task force shows that the peak of the curve was reached on Jan. 30, 2021, when the number of new daily cases reached a high of 14,518. By March 13, the number of daily cases had dropped dramatically to 4,607. For comparison, at the same time, Brazil surpassed India to become the second-worst-hit country from Covid-19 pandemic. According to data from the Worldometers website from 19 March, the first place was still held by the United States with 30,357,255 cases, nearly 10 percent of the US population of 332 million.
Was this drastic decrease due to the mass vaccination that began on Jan. 13? In general, it can be said that the vaccination went smoothly, without significant obstacles. The use of the AstraZeneca vaccine has been postponed in several countries, but the overall Covid-19 vaccination drive is unimpeded. In the two months to 13 March, the number of people who have received the first dose of the vaccine in Indonesia reached 3,985,596 people, and those who have received the second dose reached 1,454,836 people.
Also read: Vaccine-induced and Natural Immunity
Medical personnel are the priority during the first stage of the vaccination, followed by the elderly and people with high exposure to the public in the second stage. Common sense says, although it is not the main factor, the vaccination has certainly contributed to the decrease in the daily case rate. Another factor that could play a bigger role in the decline in new cases is the strict application of social restrictions and health protocols, such as tracing, testing and treatment (3T) and wearing masks, washing hands regularly and social distancing (3M).
However, if you look at the drastic drop in the daily cases, it is rather surprising. It can lead to over-confidence, which could entice people to let down their guard. For example, there are regions that have started planning to end social restrictions and reopen recreation areas to allow mass travel during long weekends or public holidays, or to loosen control over mass gatherings, and so on. Sadly, there have been cases of crowds involving high-ranking officials or rich people who have not been touched by law enforcement.
The flattening of the Covid-19 curve should not cause us to act recklessly, especially by ignoring social restrictions and health protocol, such as by holding mass gatherings or allowing people to go on mudik (exodus) for holidays. It is quite risky. The curve that had started to flatten has since begun to rise again. Moreover, we are facing thousands of new variants resulting from SARS-CoV-2 mutations. New variants detected entering Indonesia include B-117 from the United Kingdom (UK), N349K and D614G.
The sloping curve has been globally affected, because, since Feb. 23, it has begun to rise again. The number of the new daily cases has increased from 300,000 to about 500,000 (March 19). The daily death toll has also increased from 6,000 to about 10,000. Daily cases in India, which had dropped to around 8,000, have since surged to about 36,000 (March 19), while deaths also increased. Indonesia's curve is also unstable. As of March 19, there were 6,570 new cases and 227 new deaths.
For comparison, on March 13, there were only 4,607 new cases and 100 deaths. Therefore, it is too early to ease social restrictions.
The "stealth" variant
Mutation is not a phenomenon that is unique to the coronavirus. Basically, all viruses try to continue to mutate into new variants. This is the basic law of the survival of the fittest and self-preservation through adaptation. Genetic change occurs when a virus creates new copies of itself to spread, resists the body's attack, modify and upgrade its power. The result is that there are several new variants that are more infectious or more virulent.
The mutation that occurred in South Africa created a new variant called 501.V2 or B.1.351. This variant initially entered the UK and spread quickly and caused concern because it accounted for 90 percent of new confirmed cases in the country. This variant entered the UK and then spread quickly to dozens of other countries, including Indonesia. The B-117 variant was announced to have entered Indonesia on March 2. Deputy Health Minister Dante Saksono said the new variant had infected six people in South Sumatra, North Sumatra, North Kalimantan and South Kalimantan. Two of them had just returned from Saudi Arabia. According to descriptions, this B-117 variant can transmit 50-74 percent faster than the parent virus.
Also read: Vaccination and Threat of Virus Mutation
The director of the Eijkman Institute of Molecular Biology, Amin Soebandrio, explained that there were no reports regarding the resistance of the B-117 variant to the vaccines used in Indonesia, such as Sinovac. So, for the time being, this vaccine is believed to be still effective to improve immunity against the new variant B-117. However, if a study later indicates that this new variant can reduce the efficacy of the vaccine that has been injected, the situation would be more complicated.
Another mutation that needs to be watched out for is the N349K variant, which has so far been detected in at least 30 countries. The Health Ministry's vaccination program spokesperson, Siti Nadia, said caution was needed, because, according to a report published in a journal, this variant adhered more strongly to receptor cells. Actually this N349 variant was detected earlier in Indonesia than the B-117. The ministry detected it at the end of November 2020 and immediately reported it to the Global Initiative on Sharing All Influenza Data (GISAID), and is now under the WHO’s review. However, the WHO has apparently recommended to pay more attention to the B-117 variant from the UK, B.1.351 from South Africa and B.1.1.248 from Brazil.
Indonesian Medical Association (IDI) chairman Daeng M Faqih emphasized the importance of being aware of the N349K variant. In addition to its ability to bind more strongly to the ACE2 receptor cells in human cells, this variant is also good at hiding. As a result, these mutant viruses cannot be recognized by polyclonal antibodies (collections of immune globulin molecules that react to specific antigens) that form in previously infected persons. In theory, a person who has been infected with the virus and survives has a natural immunity in his body, which records data about the virus. If one day they are infected again by the same virus, their immune system's memory will quickly recognize it and immediately eradicate it.
However, the N349K has "stealth" properties so that it is not detected by the immune system. This is like a F35 stealth fighter jet that uses metal with a certain coating to make it undetectable by the enemy's radar system, so that it can attack the target without being noticed.
With the risk of the curve rising again and the spread of new Covid-19 variants, it is clear that we are still under threat. The biggest concern is that new variants of the virus may not be prevented by existing vaccines. That means the existing vaccines are only effective against early-generation viruses, so that engineering or modification is needed to update the vaccines. However, vaccine development takes a long time, and it normally takes 10 to 15 years.
Ending the pandemic is so urgent that the vaccine development process should be accelerated, including through the issuance of emergency use authorization (EUA). Moreover, the vaccine has an “age”. As reported, one of the vaccines that have obtained a license for use is able to provide immunity for just six months. This is shorter than the flu vaccine, which can provide immunity for a year. Therefore, if the Covid-19 pandemic continues, vaccination should be repeated.
Fair, mutual cooperation
Given the gravity of the above risks, all parties must work together to try to overcome and anticipate new developments. This mutual cooperation must be fair.
All parties, both ordinary people and authorities, should participate in self-restraint and share in pandemic relief. The vaccination can definitely help halt the spread of the disease, but it is not the ultimate weapon. The conventional methods, namely (contact tracing and specimen testing, must be maximized, so that the number of the tests can be further increased, and the published data should be closer to the actual facts and less data remains hidden or is deliberately hidden. All parties, including those in power, must consistently adhere to health protocols, and the rule of law must reflect justice without favoritism.
We are not sure when this pandemic will end. It looks like the light at the end of the tunnel is more distant now than a few months ago. In April 2020, there was a political surveyor, who suddenly acted like an epidemiologist and made an unreasonable prediction that the Covid-19 pandemic would end by June 2020. There should be no place for such misleading predictions. We should be smarter and more experienced, beyond the "intelligence" of Covid-19. For that, let competent scientists do the talking.
We can be jealous if we see the success of New Zealand or Taiwan in suppressing Covid-19 case numbers. Now, there are no new cases there. Based on the success of these countries, the main factors to halt the spread of the disease are the culture and behavior of the people, as well as the consistency of the attitude of the government in enforcing health protocol.
This is why it differs from us. Our society, on average, is relatively easy to manage with the threat of sanctions. Unfortunately, people in power often invite cynicism, because they seem free to violate the rules against crowd-drawing events. In such a difficult situation, there are some people who dare to act immorally by “stealing” the social funds meant for those severely affected by the pandemic.
The personal behavior, societal (cultural) behavior, and state behavior are proven to be more effective than the implementation of strict lockdown policies. A survey conducted by Imperial College London in June 2020 indicated that 53 countries that had consistently implemented strict social restrictions and health protocols saw no significant increase in infections as earlier estimated.
The countries that have been quite successful in adhering to the health protocols have now begun to ease their social restrictions.
The application of community-based social restrictions, such as the micro-scale public activity restrictions (PPKM) implemented in Indonesia, is also starting to show encouraging results. There has been a decrease in new cases since the PPKM were implemented in February, because isolation has been carried out selectively in residential areas, such as in neighborhood units (RT) and community units (RW) or event at homes where the positive cases are located. The isolation is also carried out selectively. Infected people with moderate and severe symptoms are taken to a hospital, while those who have no symptoms or mild symptoms are isolated at home. The implementation of the PPKM, plus vaccination, and the implementation of the health protocols are considered to be more effective in suppressing the transmission.
Such an endeavor is supported by the mathematical formula of Osmar Pinto Neto in the form of a gradual reduction of social distancing strategies and the application of strict health protocols. Neto explained that, if 50-65 percent of people are disciplined in adhering to health protocols such as wearing masks and washing their hands often, this can sufficiently replace the social distancing requirement. At the same time, it can help prevent further waves of infection from spreading over the next two years, and the outbreak will decrease.
So, facing the threat of a new viral variant, we inevitably have to repeat the clichéd appeal: Multiply the tracing and specimen testing efforts and obey health protocols. More importantly, the government must enforce such obligations indiscriminately.
Djoko Santoso, Professor of the School of Medicine, Airlangga University, and Chairman of the Health Division of the Indonesian Ulema Council (MUI) of East Java, and a Covid-19 survivor.
This article was translated by Hendarsyah Tarmizi.