Indonesia's Weakness With Covid-19 Testing

source: kompas

The Widodo administration has pledged to ramp up PCR testing for Covid-19, but an imported key ingredient remains in short supply, slowing the testing process.

Indonesia continues to lag behind many countries in the region when it comes to conducting proper mass testing for Covid-19, however the government has finally begun to move away from serology tests or “Rapid Test kits”, the lowest tier of testing, and instead ramp up Polymerase Chain Reaction Testing or commonly known as PCR. As I’ve mention in previous articles, rapid tests cannot determine if an individual has Covid-19, but rather only checks for elevated antibodies in the blood, a sign that some type of virus is found in the body without identifying which one. These tests should be used as part of first phase screening process rather for diagnosis. PCR tests on the other hand are more costly but provide far greater detailed result and uses a swab test to compare the RNA of the patient with a RNA sample from the Covid-19 virus to determine if the person is infected. 

Just as the Indonesian government moves to ramp up the all-important PCR tests by bringing more certified labs online across the country and purchasing new automatic PCR machines from Europe that potentially can test 300,000 tests a month in ideal conditions, a major obstacle has emerged.

As swab samples have begun to flow in, some labs are finding themselves unable to conduct the tests due to a lack of crucial ingredients in the testing process, the reagents. Reagents are substances or compounds used to cause a chemical reaction to extract RNA from swab samples during the testing process. It’s used to identify if the virus’ genetic code is present in a patient’s body. Reagents are used in multiple stages of testing process such as extraction, amplification and for detection. A PCR test cannot be done without it. 

Dr. Aryati, a pathologist at Airlangga University in Surabaya, tells me that having new automated PCR machines are very much needed and could help reduce false negative results but added, “We are still waiting for the reagents at our hospital in Surabaya. We are ready to do tests but we have to wait for the molecular reagents, especially for the extraction. I hope that we can start doing an automatic extraction soon.”  

Until recently, the majority of PCR tests in Indonesia were done manually particularly when it comes to extraction of genetic material. This requires skilled personnel and has a higher risk for errors compared to using machines. The machines can also run the tests much faster and run 24 hours a day if needed.

Dr. Herawati, a DNA expert at the Eijkman Institute in Jakarta, one of the labs conducting PCR testing, stated in my recent interview, “Reagents are very important for testing. You can buy a machine but without reagents, you can’t do anything with it. They are now difficult to get due to the low supply and now because it’s hard to ship it here commercially.”

The government has been scrambling to procure reagents from other countries as Indonesia’s current stock of reagents are in short supply. Dr. Aryati said, “It seems as if there is no single chain command for getting reagents [in Indonesia]. It also seems that the institutions that are supposed to be involved in providing these reagents are not doing that. Or maybe perhaps that the global demand is so high in every country due to the outbreak.” At the end of April, almost half of the newly authorized labs conducting PCR tests experienced either drastic slowdowns or halted testing due to the lack of reagents. Other labs were running on a less than a week’s supply.

Help From South Korea

Last week, the government was able to procure around 525,000 reagents from South Korea, but much more will be needed to meet the president’s testing targets. The recent shipment of over 500,000 reagents may sound like a lot, however at least four different reagents are required to process a single test and each Covid-19 patient is required to be tested for more than once.

Currently suppliers in South Korea and China appear to be the only ones with the capacity to export reagents. China had ramped up production during the peak of its Covid-19 outbreak and now is seeing supplies increase. South Korea understood the importance of moving quickly to stockpile reagents when the first signs of the virus emerged late last year. The country has experience viral epidemics from the Corona family, such as SARS and MERS a few years ago and had the supply chain in place ready for a future outbreak.

Indonesia is not alone when it comes to reagent difficulties as there is a lack of supply globally. Typically, companies only needed to supply large orders of reagents to one or two countries at a time while Covid-19 has become a global pandemic. The situation has been made worse with some countries imposing export bans on reagents, companies have limited production capacity, and the fact that only a handful of companies dominate the reagent market to begin with. To make matters worse, not all reagents can be used in all brands or specific models of automated PCR machines. Each brand has their own protected secret formula customized to work in their machine.

Why Doesn’t Indonesia Make their Own Reagents?

All the reagents used for PCR testing in Indonesia are imported, as both the private and public sector have yet to develop their own production capabilities. The government’s spokesperson on Covid-19, Ahmad Yurianto, has previously said that Indonesia will move to produce reagents domestically and rely less on imported supplies. However, changing that would require far too much time to have an impact to current pandemic.

Not only would new special laboratories have to be built and the reagents would later have to be tested and verified, but it’s also likely that the new reagents could only be used in manual PCR testing and not with imported automatic PCR machines unless developed alongside the machine manufacturers to ensure that they are compatible with their machines. Manufactures have clearly warned against using outside reagents in their units as their machines are calibrated for specific mix of reagents.

Some governments have rushed to develop their PCR test kits using their own reagents, such as the American Center for Disease Control (CDC), but have failed to produce them in mass quantities due to contamination issues.

Supply Chain As National Security

The Covid-19 pandemic has shown that Indonesia, along with many other countries, are very vulnerable when it comes to supply chain management for healthcare, particularly when it comes to viruses.

The Indonesian government needs to see the virus testing supply chain as a national security issue and a strategic asset so it can take necessary steps to prepare when an epidemic or pandemic is on the horizon in the future. For example, the government could have begun negotiating or begun pre-ordering reagents from the manufacturers back in January once China published the initial genome and in anticipation that the virus would spread from China.

Finally, calling for an increase in testing is not just about test kits and taking swab samples, but about making sure that the labs are staffed by trained personnel along with ensuring that crucial supplies such as reagents are available to fuel the testing process.

President Widodo’s target to conduct 10,000 PCR tests a day will be difficult to accomplish without a steady supply of reagents and that may not happen until other countries have tested enough and gotten the virus under control and thereby reducing the demand for reagents.   

This article was partially based on the latest episode of Indonesia In-depth titled, “What’s In A Number?” Listen to the full episode here: http://hyperurl.co/whatsinanumber

Shawn Corrigan is the host and producer of Indonesia In-depth, Indonesia’s leading business, political and culture podcast based in Jakarta. He has spent more than a decade in Indonesia working as a political risk consultant and established Indonesia In-depth in 2017. He speaks English and Indonesian. In addition to the podcast, Indonesia In-depth provides professionals with content services, from podcasts, audio documentaries to social media content.