Executive Summary Police Governance Index

In a country undergoing democratic transition such as Indonesia, rule of law becomes one of the most important factors for a successful transition

Randomized, Open-Label Trial of Primaquine against Vivax Malaria Relapse in Indonesia

Radical cure of Plasmodium vivax infection applies blood schizontocidal therapy against the acute attack and hypnozoitocidal therapy against later relapse. Chloroquine and primaquine have been used for 60 years in this manner. Resistance to chloroquine by the parasite now requires partnering other blood schizontocides with primaquine. However, the safety and efficacy of primaquine against relapse when combined with other drugs have not been demonstrated. This randomized, open-label, and relapse-controlled trial estimated the efficacy of primaquine against relapse when administered with quinine or dihydroartemisinin-piperaquine for treatment of the acute infection. Among 650 soldiers who had returned to their malaria-free base in Java, Indonesia, after 12 months in malarious Papua, Indonesia, 143 with acute P. vivax malaria were eligible for study. One hundred sixteen enrolled subjects were randomized to these treatments: artesunate (200-mg dose followed by 100 mg/day for 6 days), quinine (1.8 g/day for 7 days) plus concurrent primaquine (30 mg/day for 14 days), or dihydroartemisinin (120 mg) plus piperaquine (960 mg) daily for 3 days followed 25 days later by primaquine (30 mg/day for 14 days). Follow-up was for 12 months. One hundred thirteen subjects were analyzable. Relapse occurred in 32 of 41 (78%) subjects administered artesunate alone (2.71 attacks/person-year), 7 of 36 (19%) administered quinine plus primaquine (0.23 attack/person-year), and 2 of 36 (6%) administered dihydroartemisinin-piperaquine plus primaquine (0.06 attack/personyear). The efficacy of primaquine against relapse was 92% (95% confidence interval [CI]=81% to 96%) for quinine plus primaquine and 98% (95% Cl=91% to 99%) for dihydroartemisinin-piperaquine plus primaquine. Antirelapse therapy with primaquine begun a month after treatment of the acute attack with dihydroartemisinin-piperaquine proved safe and highly efficacious against relapse by P. vivax acquired in Papua, Indonesia

The language of malaria in Abui: An interdisciplinary investigation of healthcare practices in Alor, Eastern Indonesia

We report on an interdisciplinary collaboration between public health experts, linguists, and botanists which seeks to better understand indigenous perspectives on malaria among the Abui [abz] speaking communities of Alor Island, Eastern Indonesia. Malaria is endemic in Alor and is highly resistant to common conventional treatment regimens (Sutanto et al. 2009). There is a low rate of compliance with modern malaria treatments, and a correspondingly high reliance on traditional treatment methods (Krentel 2008). Our research attempts to understand traditional knowledge of malaria in Abui and its relevance to modern healthcare. We analyze a corpus of unstructured interviews concerning health-related problems in Abui in order to better understand the conceptualization of disease (Forster 1976). This includes the systematic study of metaphor (Author 2016), sequencing of symptom descriptions (Author 2016), symptom-based indigenous classification of malaria, an inventory of traditional health-protecting practices, and an inventory of medical plants. The plant terminology reveals a syncretism between terms referring to diseases and the plants which either treat or cause those diseases. For example, the term takaya denotes both the ti plant (Cordyline fruticosa) and a severe form of malaria (Plasmodium falciparum). The leaves of the ti plant takaya are tied onto valuable trees such as candlenut, areca palm, and jackfruit to create a protective spell which wards off theft of the fruits or nuts of that tree. Transgressing this protection by taking the fruits or nuts without permission will cause the transgressor to suffer the takaya disease. The existence of supernatural causes may go unnoticed when interviews are conducted in Indonesian, the national language closely associated with modernity. However, the pervasiveness of plant-disease syncretism within Abui belies the continuing significance of traditional beliefs regarding disease. The collaborative methodology described here shows great promise for improving our understanding of the conceptualization of malaria in Abui and thus increasing treatment efficacy for this disease. Moreover, this approach provides a platform for documentary linguistics which includes a high level of community engagement. The healthcare interviews yield a culturally significant corpus of spontaneous speech which also serves as an independent knowledge base to evaluate the reliability and accuracy of ethnobotanical research. Finally, we suggest several ways in which our approach can be applied to future healthcare research in other domains and with other communities. References Author. 2016. The Pragmatics Behind the Medical and Health Knowledge in Alor: An Understanding of how disease is conceptualized in the Abui language. Honors thesis. Nanyang Technological University, Singapore. Du Bois, Cora. 1944. The People of Alor: a social-psychological study of an East Indian island. Minnesota: The University of Minnesota Press Forster, George M. 1976. Disease Etiologies in Non-Western Medical Systems. American Anthropologist 78(4): 773-782. Krentel, Alison. 2008. Why do individuals comply with mass drug administration for lymphatic filariasis? A case study from Alor District, Indonesia. PhD dissertation. London School of Hygiene & Tropical Medicine. Sutanto, I. Nurhayati, S. S., Manoempil, P., Baird, J.K. 2009. Resistance to Choloroquine by Plasmodium vivax at Alor in the Lesser Sundas Archipelago in Eastern Indonesia. The American Society of Tropical Medicine and Hygiene, 81(2), 338-342. Author. 2016. The Semantics of Complex Sentences in the Discourse of Health and Diseases: A Case Study in Abui. Honors thesis. Nanyang Technological University, Singapore

Towards harmonization of microscopy methods for malaria clinical research studies

Microscopy performed on stained films of peripheral blood for detection, identification and quantification of malaria parasites is an essential reference standard for clinical trials of drugs, vaccines and diagnostic tests for malaria. The value of data from such research is greatly enhanced if this reference standard is consistent across time and geography. Adherence to common standards and practices is a prerequisite to achieve this. The rationale for proposed research standards and procedures for the preparation, staining and microscopic examination of blood films for malaria parasites is presented here with the aim of improving the consistency and reliability of malaria microscopy performed in such studies. These standards constitute the core of a quality management system for clinical research studies employing microscopy as a reference standard. They can be used as the basis for the design of training and proficiency testing programmes as well as for procedures and quality assurance of malaria microscopy in clinical research.Publisher PDFPeer reviewe

Mortality among healthcare workers in Indonesia during 18 months of COVID-19

The impact of SARS-CoV-2 infections upon Indonesian health care workers (HCWs) is unknown due to the lack of systematic collection and analysis of mortality data specific to HCWs in this setting. This report details the results of a systematic compilation, abstraction and analysis of HCW fatalities in Indonesia during the first 18 months of COVID-19. HCW who passed away between March 2020 and July 2021 were identified using Pusara Digital, a community-based digital cemetery database dedicated to HCW. We calculated the mortality rates and death risk ratio of HCWs versus the general population. The analysis indicates that at least 1,545 HCWs died during the study period. Death rates among males and females HCWs were nearly equivalent (51% vs. 49%). The majority were physicians and specialists (535, 35%), nurses (428, 28%), and midwives (359, 23%). Most deaths occurred between the ages of 40 to 59 years old, with the median age being 50 years (IQR: 39–59). At least 322 deaths (21%) occurred with pre-existing conditions, including 45 pregnant women. During the first 18 months of COVID-19 in Indonesia, we estimated a minimum HCW mortality rate of 1.707 deaths per 1,000 HCWs. The provincial rates of HCW mortality ranged from 0.136 (West Sulawesi) to 5.32 HCW deaths per 1,000 HCWs (East Java). The HCW mortality rate was significantly higher than that of the general population (RR = 4.92, 95% CI 4.67–5.17). The COVID-19 pandemic in Indonesia resulted in the loss of many hundreds of HCWs, the majority of whom were senior healthcare workers. The HCW mortality rate is five times that of the general population. A national systematic surveillance of occupational mortality is urgently needed in this setting

Weekly primaquine for radical cure of patients with Plasmodium vivax malaria and glucose-6-phosphate dehydrogenase deficiency

Background The World Health Organization recommends that primaquine should be given once weekly for 8-weeks to patients with Plasmodium vivax malaria and glucose-6-phosphate dehydrogenase (G6PD) deficiency, but data on its antirelapse efficacy and safety are limited. Methods Within the context of a multicentre, randomised clinical trial of two primaquine regimens in P. vivax malaria, patients with G6PD deficiency were excluded and enrolled into a separate 12-month observational study. They were treated with a weekly dose of 0.75 mg/kg primaquine for 8 weeks (PQ8W) plus dihydroartemisinin piperaquine (Indonesia) or chloroquine (Afghanistan, Ethiopia, Vietnam). G6PD status was diagnosed using the fluorescent spot test and confirmed by genotyping for locally prevalent G6PD variants. The risk of P. vivax recurrence following PQ8W and the consequent haematological recovery were characterized in all patients and in patients with genotypically confirmed G6PD variants, and compared with the patients enrolled in the main randomised control trial. Results Between July 2014 and November 2017, 42 male and 8 female patients were enrolled in Afghanistan (6), Ethiopia (5), Indonesia (19), and Vietnam (20). G6PD deficiency was confirmed by genotyping in 31 patients: Viangchan (14), Mediterranean (4), 357A-G (3), Canton (2), Kaiping (2), and one each for A-, Chatham, Gaohe, Ludhiana, Orissa, and Vanua Lava. Two patients had recurrent P. vivax parasitaemia (days 68 and 207). The overall 12-month cumulative risk of recurrent P. vivax malaria was 5.1% (95% CI: 1.3–18.9) and the incidence rate of recurrence was 46.8 per 1000 person-years (95% CI: 11.7–187.1). The risk of P. vivax recurrence was lower in G6PD deficient patients treated with PQ8W compared to G6PD normal patients in all treatment arms of the randomised controlled trial. Two of the 26 confirmed hemizygous males had a significant fall in haemoglobin (>5g/dl) after the first dose but were able to complete their 8 week regimen. Conclusions PQ8W was highly effective in preventing P. vivax recurrences. Whilst PQ8W was well tolerated in most patients across a range of different G6PD variants, significant falls in haemoglobin may occur after the first dose and require clinical monitoring. Trial registration This trial is registered at ClinicalTrials.gov (NCT01814683)

Pandemic inequity in a megacity: a multilevel analysis of individual, community and healthcare vulnerability risks for COVID-19 mortality in Jakarta, Indonesia

Introduction Worldwide, the 33 recognised megacities comprise approximately 7% of the global population, yet account for 20% COVID-19 deaths. The specific inequities and other factors within megacities that affect vulnerability to COVID-19 mortality remain poorly defined. We assessed individual, community-level and healthcare factors associated with COVID-19-related mortality in a megacity of Jakarta, Indonesia, during two epidemic waves spanning 2 March 2020 to 31 August 2021. Methods This retrospective cohort included residents of Jakarta, Indonesia, with PCR-confirmed COVID-19. We extracted demographic, clinical, outcome (recovered or died), vaccine coverage data and disease prevalence from Jakarta Health Office surveillance records, and collected subdistrict level sociodemographics data from various official sources. We used multilevel logistic regression to examine individual, community and subdistrict-level healthcare factors and their associations with COVID-19 mortality. Results Of 705 503 cases with a definitive outcome by 31 August 2021, 694 706 (98.5%) recovered and 10 797 (1.5%) died. The median age was 36 years (IQR 24–50), 13.2% (93 459) were <18 years and 51.6% were female. The subdistrict level accounted for 1.5% of variance in mortality (p<0.0001). Mortality ranged from 0.9 to 1.8% by subdistrict. Individual-level factors associated with death were older age, male sex, comorbidities and age <5 years during the first wave (adjusted OR (aOR)) 1.56, 95% CI 1.04 to 2.35; reference: age 20–29 years). Community-level factors associated with death were poverty (aOR for the poorer quarter 1.35, 95% CI 1.17 to 1.55; reference: wealthiest quarter) and high population density (aOR for the highest density 1.34, 95% CI 1.14 to 2.58; reference: the lowest). Healthcare factor associated with death was low vaccine coverage (aOR for the lowest coverage 1.25, 95% CI 1.13 to 1.38; reference: the highest). Conclusion In addition to individual risk factors, living in areas with high poverty and density, and low healthcare performance further increase the vulnerability of communities to COVID-19-associated death in urban low-resource settings