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A woman wearing a face mask waits for a commuter train in Jakarta, Indonesia. Scientists worry Indonesia may already have a “silent epidemic” of COVID-19.

REUTERS/Willy Kurniawan

Indonesia finally reports two coronavirus cases. Scientists worry it has many more

Indonesia finally reported its first two COVID-19 cases on Monday. At a press conference in Jakarta, President Joko Widodo announced that two women aged 31 and 64 from Depok had contracted the virus. But some scientists believe the country, which has close ties to China, almost certainly has a “silent epidemic” within its borders and should urgently boost its surveillance efforts.

Scientists at the Eijkman Institute for Molecular Biology tell Science they have offered to the Indonesian Ministry of Health to help test more people, but have been snubbed so far.

The detection of the first two cases, along with measures to prevent the spread of the disease, demonstrate Indonesia’s seriousness and capability to deal with the COVID-19 epidemic, Widodo said yesterday. “Since the beginning, we have been serious in strictly following WHO [World Health Organization] guidelines regarding the coronavirus issue,” he said.

But epidemiologists have long said COVID-19’s absence in the world’s fourth most populous nation was implausible, given the large number of visitors—both for tourism and business—from nearby China. A modeling study based on the number of travelers from Wuhan, published by a team at the Harvard T.H. Chan School of Public Health on bioRxiv on 11 February, concluded that even then, it was unlikely that Indonesia did not have a single COVID-19 case. (Indonesian Minister of Health Terawan Agus Putranto called the study insulting and later said the lack of cases was the result of prayer.)

Today, “It’s statistically impossible that we only have two cases,” says Ahmad Utomo of the Stem Cell and Cancer Research Institute.

So far, all testing for COVID-19 has taken place at the health ministry’s National Institute of Health Research and Development (Balitbangkes). The lab can handle 1000 samples per day, says Ahmad Yurianto of the health ministry’s Disease Control and Prevention Directorate. Since the start of the epidemic, Balitbangkes has only tested 333 people, however.

Utomo says the ministry’s testing criteria are unclear and nontransparent. So far, its COVID-19 guidelines only called for testing those who show symptoms and have traveled to affected countries. The ministry did not test 238 symptomless Indonesians who were evacuated from Wuhan—and were kept in quarantine for 2 weeks—but it did perform tests on 188 Indonesian crew members returning from the World Dream, a cruise ship that was quarantined in Hong Kong, China, for 4 days in February. (All tested negative.) The ministry’s website does not provide information about the location and travel history of the remaining 143 people who were tested. Scientists have also pointed out that having just one lab for the vast archipelago is a source of delays.

In response to the criticism, Yurianto today said in an interview with BBC that Indonesia would loosen the criteria by also testing people who have symptoms but no travel history. And he has promised that the ministry will make testing capability available to 10 provinces.

Utomo says Balitbangkes should communicate its findings in a research paper, or at least make test results available on the ministry’s website. Testing should also include people with a relevant travel history who don’t have symptoms, he says, and those who have been in contact with COVID-19 patients—especially 76 hospital staff in Depok who were in close proximity to the two confirmed cases.

Amin Soebandrio, head the Eijkman Institute, says he offered Indonesia’s Ministry of Research (BRIN) help detecting COVID-19 cases in mid-January. The institute has an Emerging Virus Research Unit that has studied human coronaviruses and is equipped with a biosafety level-3 laboratory and advanced sequencing equipment. Soebandrio says BRIN contacted him the next day to say Terawan would come to Eijkman the same week to discuss the offer. “But that was canceled,” Soebandrio says.

The institute did receive a green light from BRIN to start active surveillance for coronavirus cases in five major cities with big airports, Soebandrio says, but that program has yet to start.

Balitbangkes uses test kits provided by the U.S. Centers for Disease Control and Prevention (CDC) that were recalled from many U.S. labs because they had a faulty reagent. Last week, in response to an urgent shortage of tests in the United States, the U.S. Food and Drug Administration said the CDC tests could still be used.