Quantifying the dynamics of COVID-19 burden and impact of interventions in Java, Indonesia
Authors: Djaafara Bimandra A , Whittaker Charles , Watson Oliver J , Verity Robert , Brazeau Nicholas F , Widyastuti Widyastuti , Oktavia Dwi , Adrian Verry , Salama Ngabila , Bhatia Sangeeta , Nouvellet Pierre , Sherrard-Smith Ellie , Churcher Thomas S , Surendra Henry , Lina Rosa N , Ekawati Lenny L , Lestari Karina D , Andrianto Adhi , Thwaites Guy , Baird J Kevin , Ghani Azra C , Elyazar Iqbal RF , Walker Patrick GT 
Published: October 2020

ABSTRACTBackgroundAs in many countries, quantifying COVID-19 spread in Indonesia remains challenging due to testing limitations. In Java, non-pharmaceutical interventions (NPIs) were implemented throughout 2020. However, as a vaccination campaign launches, cases and deaths are rising across the island.MethodsWe used modelling to explore the extent to which data on burials in Jakarta using strict COVID-19 protocols (C19P) provide additional insight into the transmissibility of the disease, epidemic trajectory, and the impact of NPIs. We assess how implementation of NPIs in early 2021 will shape the epidemic during the period of likely vaccine roll-out.ResultsC19P burial data in Jakarta suggest a death toll approximately 3.3 times higher than reported. Transmission estimates using these data suggest earlier, larger, and more sustained impact of NPIs. Measures to reduce sub-national spread, particularly during Ramadan, substantially mitigated spread to more vulnerable rural areas. Given current trajectory, daily cases and deaths are likely to increase in most regions as the vaccine is rolled-out. Transmission may peak in early 2021 in Jakarta if current levels of control are maintained. However, relaxation of control measures is likely to lead to a subsequent resurgence in the absence of an effective vaccination campaign.ConclusionSyndromic measures of mortality provide a more complete picture of COVID-19 severity upon which to base decision-making. The high potential impact of the vaccine in Java is attributable to reductions in transmission to date and dependent on these being maintained. Increases in control in the relatively short-term will likely yield large, synergistic increases in vaccine impact.Key questionsWhat is already known?In many settings, limited SARS-CoV-2 testing makes it difficult to estimate the true trajectory and associated burden of the virus.Non-pharmaceutical interventions (NPIs) are key tools to mitigate SARS-CoV-2 transmission.Vaccines show promise but effectiveness depends upon prioritization strategies, roll-out and uptake.What are the new findings?This study gives evidence of the value of syndrome-based mortality as a metric, which is less dependent upon testing capacity with which to estimate transmission trends and evaluate intervention impact.NPIs implemented in Java earlier in the pandemic have substantially slowed the course of the epidemic with movement restrictions during Ramadan preventing spread to more vulnerable rural populations.Population-level immunity remains below proposed herd-immunity thresholds for the virus, though it is likely substantially higher in Jakarta.What do the new findings imply?Given current levels of control, upwards trends in deaths are likely to continue in many provinces while the vaccine is scheduled to be rolled out. A key exception is Jakarta where population-level immunity may increase to a level where the epidemic begins to decline before the vaccine campaign has reached high coverage.Further relaxation of measures would lead to more rapidly progressing epidemics, depleting the eventual incremental effectiveness of the vaccine. Maintaining adherence to control measures in Jakarta may be particularly challenging if the epidemic enters a decline phase but will remain necessary to prevent a subsequent large wave. Elsewhere, higher levels of control with NPIs are likely to yield high synergistic vaccine impact.