Implementation and Efficacy of COVID-19 Infection Prevention and Controls Measures Among Indonesia’s Health Care Workers

Introduction

The global coronavirus disease 2019 (COVID-19) pandemic has had a profound impact on the occupational health of health care professionals. Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) has been identified as the causative agent of this pandemic. The virus initially triggered an outbreak in Wuhan, Hubei, China on December 31, 2019.^1,2 Primary healthcare workers face immense pressure throughout the ongoing COVID-19 crisis, a situation expected to persist until a significant reduction in cases is achieved.³ Notably, the risk of nosocomial infection and transmission poses a considerable threat to the control of COVID-19, particularly among primary healthcare workers.⁴ According to the World Health Organization (WHO), the prevalence of infections among health workers has exhibited significantly, ranging from 2%-35%.⁵ Healthcare workers are susceptible to infection through prolonged exposure to COVID-19 patients, with certain healthcare activities, such as endotracheal intubation, noninvasive ventilation, tracheotomy, and manual ventilation before intubation, potentially leading to the virus becoming airborne. These procedures increase the risk to healthcare workers.⁶

In Indonesia, the Ministry of Health established two pivotal regulations aimed at guiding and safeguarding healthcare workers in the face of the COVID-19 pandemic. These regulations are Ministry of Health Regulation No. 413 of the year 2020, outlining guidelines for COVID-19 prevention and control, and Ministry of Health Regulation No. 327 designating COVID-19 as a work-related disease for specific occupations. The latter regulation serves the purpose of protecting healthcare workers from the risk of contracting COVID-19.^7,8 According to WHO data on May 14, 2021, there have been 160,813,869 confirmed COVID-19 cases worldwide, with 3,339,002 reported deaths.⁹ Additionally, WHO reported that as of May 11, 2021, 1,264,164,553 vaccine doses have been administered globally.⁹ The initial cases of COVID-19 in Indonesia were documented on March 2, 2020, with two confirmed positive cases.¹⁰ Recognizing the severity of the situation, Presidential Decree No. 12 of 2020, issued on April 13, 2020, declared the spread of COVID-19 as a non-natural disaster, designating it an Indonesian national disaster.¹⁰

As of May 14, 2021, Indonesia had reported 1,734,285 confirmed COVID-19 cases, with 1,592,886 individuals having successfully recovered and 47,823 reported deaths. These cases are distributed across 34 provinces in the country.¹¹

Puskesmas, or primary healthcare (PHC) in Indonesia, play a vital role in executing preventive and promotive programs within local communities. This encompasses activities such as providing early warning for endemic or pandemic diseases; executing public health infectious or disease prevention measures; conducting education and promoting a healthy lifestyle; and actively participating in COVID-19 contact tracing, testing, and early treatment of COVID-19 patients. The expansive network comprises 10,134 primary healthcare centers across Indonesia.^12–14 To ensure the effective execution of COVID-19 prevention and control measures within these Primary Health Care settings, the Ministry of Health, Republic of Indonesia, under the coordination of the Occupational Health and Sports Directorate, collaborated with the Indonesian Occupational Health Association and Universitas Indonesia to conduct this research. The primary objective of this research was to analyze the implementation of COVID-19 prevention and control measures among primary health care workers in Indonesia.

Methods

Results

Regulation compliance of COVID-19 prevention and control implementation in primary health care (PHC)

Figure 1 illustrates the compliance of OHC facilities in six provinces with the regulations for COVID-prevention and control, as stipulated by the Indonesian Ministry of Health.^7,8 The observed compliance and the specified requirements outlined by the Ministry were compared. Figure 3 further represents the compliance levels in three distinct ranges: greater than 80%, between 60% and 80%, and less than 60.

Figure 1. Regulation compliance of COVID-19 prevention and control in PHC.

The evaluation of each element of COVID-19 prevention and control in PHC, as presented in Table 2, indicates notable strengths in certain areas. The strongest element across all regions was infection prevention and control, consistently achieving a compliance rate of above 80%. Additionally, elements focusing on leadership and incident management systems show strength in several areas, including East Java, West Kalimantan, and West Java. The ranking of achievements for the implementation of COVID-19 prevention and control in PHC, listed from the highest to the lowest, was as follows: East Java, West Java, West Sumatera, West Kalimantan, South Kalimantan, and Central Java.

Table 2. Evaluation on each element of COVID-19 prevention and control in PHC.

No.	Evaluation elements	East Java	Central Java	West Kalimantan	South Kalimantan	West Sumatera	West Java	Average score
1	Leadership and incident management system	100%	71%	93%	75%	58%	89%	81%
2	Coordination and communication	83%	67%	69%	83%	79%	75%	76%
3	Surveillance and information management	88%	71%	72%	75%	69%	67%	74%
4	Risk communication and community engagement	69%	50%	50%	63%	44%	69%	57%
5	Administration, finance and business continuity	75%	38%	61%	50%	58%	67%	58%
6	Human resources	44%	39%	56%	58%	57%	44%	50%
7	Continuity of essential support services	79%	58%	67%	75%	93%	58%	72%
8	Patient management	92%	100%	61%	50%	81%	100%	81%
9	Occupational health, mental health and psychosocial support	50%	40%	27%	35%	45%	50%	41%
10	Rapid identification and diagnosis	85%	70%	70%	50%	80%	95%	75%
11	Infection prevention and control	88%	93%	97%	89%	96%	96%	93%
	Mean	78%	63%	66%	64%	69%	74%

The average score results clearly show that the strongest elements are infection prevention and control (93%), leadership and incident management systems (81%), and patient management (81%). The weakest elements were occupational health, mental health, psychosocial support, and human resources.

Figure 2 presenting a radar plot analysis of the evaluation scores for COVID-19 prevention and control in Primary Health Care (PHC), illustrates several notable patterns. There are several elements are the strongest which include infection prevention and control, leadership and incident management system, and patient management. However, there are several elements which are the weakest including occupational health, mental health and psychosocial support and human resources. Result from radar plot analysis align with mean score evaluation results.

Figure 2. Radar plot on evaluation score of COVID 19 prevention and control in PHC.

Figure 3 shows the Box-Whisker plot analysis used to analyze the tendencies and distributions of compliance among all locations. The highest and smallest tendencies and distributions show that the element of infection prevention and control is best implemented in most locations. The locations of the boxes show how well the element is implemented, and it is clear that occupational health, mental health, and psychosocial support are the lowest for most of the locations.

Figure 3. Box-whisker plot analysis for compliance tendencies and distributions.

Discussion

The comprehensive findings of this study suggest that the most robust elements in the realm of COVID-19 prevention and control within primary healthcare (PHC) are COVID-19 infection prevention and control, leadership and incident management, and patient management ( Figure 3). The majority of the selected PHC locations have demonstrated exemplary implementation of COVID-19 prevention and control measures, with an impressive compliance rate of 93%. Several critical factors contribute to the success of COVID-19 prevention and control in these PHC. This includes the effective reinforcement of the role of health and safety officers, ensuring the meticulous implementation of COVID-19 infection prevention and control measures among healthcare workers. There is also a strong emphasis on ensuring the availability of appropriate personal protective equipment (masks, respirators, gloves, gowns, and goggles). Moreover, careful attention is given to ensuring that the Personal Protective Equipment (PPE) is both adequate and acceptable based on the specific requirements within facility zones and the tasks performed by workers. Other noteworthy aspects contributing to success include the availability of standard operating procedures for working with COVID-19 patients, a systematic approach to conducting investigations in the event of confirmed cases among workers, and a well-established mechanism for reporting and recording COVID-19 cases. The commendable implementation of COVID-19 infection prevention and control measures across the majority of the 17 PHC locations is attributed to proactive measures taken by the Indonesian government, particularly through the Ministry of Health. The release of regulations on COVID-19 infection prevention and control since July 13, 2020, has played a pivotal role in guiding and facilitating successful implementation in these locations.

The second aspect demonstrating commendable implementation is leadership and incident management, which is notably well-executed in the majority of the 17 PHC locations ( Figures 2 and 3). The leadership and incident management elements encompass various critical components, including the establishment of an emergency response plan; formation of a COVID-19 task force; issuance of a formal decree delineating assigned responsibilities for coordinators and task force teams; ensuring the execution of incident management for COVID-19; utilizing evidence-based data for decision-making; conducting simulations; implementing COVID-19 incident management; defining mechanisms for coordinated responses with local and national governments; addressing community prevention, preparedness, response, and recovery from COVID-19; and ensuring that all related documents for COVID-19 risk management are established and readily available to all PHC staff and workers. The importance of leadership and incident management during a pandemic is well known.¹⁵ This is a well-known incident management approach and response framework that has been used in many organizations in disasters or complex event management and has proven to be effective.^16,17 These findings align with the WHO report from the field assessment of Pandemic Preparedness and response capacity in Indonesia that most health facilities have had command and control structures for pandemic management.¹⁸

The third aspect demonstrating exemplary implementation is patient management, with an achievement rate of 81% in compliance with the requirements set by the local Indonesian government, as presented in Table 2, Figure 2, and Figure 3.⁸ Several aspects covered under this patient management element include updating standard operating procedures (SOP) according to the Indonesian Ministry of Health 413,⁸ and the SOP that has been made readily available to workers and relevant stakeholders, patient administration, patient referral, patient therapy, diagnostics, COVID-19 infection prevention and control, network with other PHC, and safe patient transport before and after referral including from homecare. The Indonesian Ministry of Health guidelines on COVID-19 prevention and control have provided clear guidance for health services, and the majority of PHC have implemented this in their routine patient management before the pandemic. PHC only need to update and adjust the requirement and compliance to the guidance, and most PHC have fully functioning patient management according to the guidelines.⁸

On the contrary, the elements exhibiting the weakest implementation in COVID-19 prevention and control are occupational health, mental health and psychosocial support (41% compliance), human resources (50% compliance), risk communication and community engagement (57% compliance), and administration, finance, and business continuity (58% compliance). Both the World Health Organization (WHO) and the International Labour Organization (ILO) issued guidance for occupational health, with a revised version of the initial guidance released in March 2020.^19–21 The guidance provides information for the primary prevention of COVID-19 among health workers, which was based on risk assessment and introduction of appropriate measures; several risks to healthcare workers, including worker protection from workplace violence, harassment, negative stigma, discrimination, heavy workload, and prolonged use of personal protective equipment (PPE), which should be managed. Indeed, WHO and ILO stated that all healthcare workers should acquire occupational health services, mental health and psychosocial support, adequate hygiene, sanitation, and rest services, and healthcare services should have an occupational health program in conjunction with programs for infection prevention and control. Moreover, Universitas Indonesia has taken proactive steps by launching educational materials on COVID-19 through a massive open online course (MOOC) for health workers. This initiative is facilitated through the “EDURISK” platform, covering essential topics such as mental health management and mindfulness techniques.^20–23 Recognizing the critical role of healthcare workers, prioritizing their protection is imperative to ensure continuous and effective functioning of the health sector.^24,25

The lack of human resources during the pandemic COVID-19 is also an area of concern and improvement.^26,27 Other studies and reports have indicated a lack of human resources during the pandemic COVID-19, including the availability of competent human resources, adequate number of human resources, and distribution of appropriate human resources.^18,28 The majority of the 17 locations had inadequate human resources, ranging from 39% to 58% compliance with the Indonesian Ministry of Health guidance, as presented in Table 2 and Figures 2 and 3. These results suggest that several measures can be taken to increase human resources during the COVID-19 pandemic. These measures include conducting workplace risk assessments, making changes to work procedures, recruiting volunteers, understanding health workers’ challenges and needs, and providing capacity-building initiatives.^19,27,29

With regard to risk communication and community engagement, the results suggest that it is also an area that needs improvement. The results from this study suggested that the average compliance with regard to risk communication and community engagement was 57%, as presented in Table 2 and Figures 2 and 3. Aspects evaluated under risk communication and community engagement, including SOPs for risk communication, and all workers, patients, visitors, relevant stakeholders, and the community have been informed and educated. The majority of PHC achieved compliance between 44-69%, which means that it needs to be improved further. The WHO, in conjunction with UNICEF, IFRC, and GOARN, has released guidance related to the Global Risk Communication and Community Engagement (RCCE) strategy to guide how to better communicate COVID-19 and empower community involvement.³⁰

In assessing the elements of administration, finance, and business continuity, the study revealed an average compliance percentage of 58%, as detailed in Table 2, Figure 2, and Figure 3. The evaluation encompasses several critical aspects, including the availability of necessary SOPs related to administration and finance for effective COVID-19 control, and encompassing areas such as purchasing, supply chain, and essential services. Additionally, the study examined the provision of guidance and policies pertaining to COVID-19 pandemic control for all staff and health workers. It further explored the implementation of systems to manage COVID-19-related measures, encompassing testing and case management. The study also assessed the presence and execution of systems governing working hours and procedures to mitigate fatigue and work overload, ensuring the sustained business continuity of Primary Health Care (PHC). Furthermore, the evaluation considers the implementation of individual care strategies, including independent non-critical care, such as home care, and innovative approaches, such as telemedicine. Despite these measures, this study highlights a notable gap in the establishment of business continuity plans (BCP) within the health sector. The research papers provided offer insights into the strategies and technologies that can enhance the resilience of healthcare systems, emphasizing the importance of robust BCP in maintaining service continuity to ensure the uninterrupted delivery of services even in the face of disasters.