In Reply to “Letter to the Editor Regarding Neurosurgery Services in Dr. Sardjito General Hospital, Yogyakarta, Indonesia, During the COVID-19 Pandemic: Experience from a Developing Country”

We appreciate the commentary written by Dr. Goyal and colleagues in their “Letter to the Editor Regarding Neurosurgery Services in Dr. Sardjito General Hospital, Yogyakarta, Indonesia, During the COVID-19 Pandemic: Experience from a Developing Country” regarding our latest published writing. It is pleasant for us to respond to some main points in the letter and revise the information regarding management of neurosurgical patients during the COVID-19 pandemic in our center.

As of November 17, 2020, the national number of cumulative cases was 470,648, and there were 15,296 mortalities (1734.6 deaths in 1 million population).¹ In Yogyakarta, the number of cumulative confirmed cases were 4828.² September 2020 had the highest newly confirmed cases, with 691 new cases in a month.² In our last article, we divided the pandemic into 4 phases and Indonesia was in phase 2 then.³ Until the end of October 2020, it appeared that Indonesia had passed the peak of the pandemic (i.e., phase 3) in the third week of September 2020.^{3 , 4} However, since November 2020, there was a significant change in the number of confirmed cases. This phenomenon might be associated with the long weekend holiday in the last week of October 2020.^{4 , 5} During this event, there was tremendous tourist mobility.^{6 , 7} Following the holiday, the number of national confirmed cases increased sharply. November 6, 2020, was even recorded as the day with the highest number of new cases in a day, with 7843 confirmed cases.⁴ Therefore as of the second week of November 2020, Indonesia was still in phase 2 of the pandemic.

Since our last article, there had been several notable dynamics in terms of COVID-19 management in Indonesia. On May 27, 2020, a new regulation about the relaxation of the previous social restriction was released.⁸ The region that satisfied all the criteria (such as a decrease in the number of positive cases and deaths) could be exempt from social restriction.⁸ Besides, each regency in Indonesia was grouped into 3 risk zones (i.e., high-, moderate-, and low-risk zones) or no-risk zone. There was no high-risk zone in the Special Region of Yogyakarta, and as of November 17, 2020, four of five regencies were included in the moderate-risk zone.⁹ Nevertheless, to maintain public awareness of the pandemic, the governor of the Special Region of Yogyakarta released a new regulation (Decree of Governor No. 318/KEP/2020) on October 27, 2020, that extended the disaster response period in Yogyakarta.¹⁰ The decree emphasized implementation of the health care protocol in all public places as a measure to confine the disease.

Furthermore, the number of COVID-19 testing rates skyrocketed. As of November 18, 2020, the government had tested 5,129,899 people.¹¹ This was a massive increase in terms of tests per 1 million population, from 130 tests per 1 million population in our last article to 18,680 tests per 1 million population. However, this test rate was still relatively modest if compared with other countries in the Association of Southeast Asian Nation region, where Indonesia was in fifth place in terms of test rate. Therefore, there is still some room for improvement.

As of the management of neurosurgical cases during the COVID-19 pandemic in Dr. Sardjito General Hospital (DSGH), there had also been some significant changes. Since the beginning of the pandemic, we have decided to perform both elective and emergency procedures. The reason behind this policy had already been discussed in our last article.³ Therefore a sufficient amount of personnel protective equipment (PPE) was a necessity. In the last week of April 2020, the number of PPE in DSGH increased significantly. Our center could even donate a package of PPE to another network hospital with a low amount of PPE supply. The positive development was associated with the effort by the government and other private sectors to increase the supply of PPE.

Despite these changes, the number of neurosurgical procedures in the early phase of the pandemic was still low. In May 2020, there were 22 elective procedures and 12 emergency cases (Figure 1 ). Those figures reflected that the availability of PPE was not the only determinant in COVID-19 management. At that point, our department was still in the stage of the "wait-and-see” period. The elective procedure was deliberately planned and would consider the availability of PPE and medical personnel. Also, the coordinator of the intensive care unit had decided to reduce the spots for postoperative neurosurgical patients in the intensive care unit. This policy also played an important role in the reduction of neurosurgical procedures. When the policy was loosened in the next month, the number of procedures recovered in June and July 2020. Unfortunately, 1 of our staff was infected with the SARS-CoV2 virus in August 2020. In addition, 1 resident from the Division of Cardiothoracic Surgery also contracted COVID-19. Following these 2 events, COVID-19 contact-tracing procedures were performed. All health care personnel who were included in the tracing were ordered to go into self-isolation and underwent 2 polymerase chain reaction (PCR) tests, the diagnostic gold standard for COVID-19. At the time of the hospital's outbreak, our center did not have any neurosurgical patient with COVID-19. In addition, the PCR test result revealed that no other health care provider was infected with the disease. Nevertheless, those 2 unfortunate events reduced the number of available personnel and ultimately led to the decline of the neurosurgical procedures in August 2020.

Figure 1.

Number of neurosurgical procedures in Dr. Sardjito General Hospital between February 2020 and October 2020.

As of the preoperative preparation, all neurosurgical patients had a rapid test using the SARS-CoV2-antibody kit. These patients were also referred to a COVID-19 medical team (i.e., a team of doctors consisting of infection specialists from the Department of Internal Medicine) to be screened for COVID-19. The team then assessed all patients by using 2 types of scoring systems.^{12 , 13} All new, nonemergency patients with positive rapid tests or high scores on both scoring systems were hospitalized in the isolation ward. The team would then perform 2 PCR tests and, if necessary, order a thorax computed tomography scan for each patient with a positive rapid test. All confirmed cases would receive appropriate medical management, and their neurosurgical plan was delayed until they were categorized as “discarded COVID-19 patient” (i.e., got 2 negative PCR results on 2 successive tests that were 24 hours apart). These discarded COVID-19 patients were then relocated to a nonisolation ward. As for the emergency cases, all patients will be operated on in a specialized operating room, and the operating team had to wear level III PPE.¹⁴ Between March and October 2020, we managed to detect 2 neurosurgical patients with positive COVID-19 test results. Both patients were then treated with the protocol mentioned earlier.

Moreover, we realized that our hospital relied heavily on the use of rapid tests to detect antibody for SARS-CoV-2 virus. Such a test would detect the availability of IgM and IgG in the serum, which were detectable between 7 and 14 days after the onset of symptoms.¹⁵ Therefore, since the last week of June 2020, our division has actively advocated the use of rapid antigen testing in DSGH to replace the rapid antibody testing. This rapid test detects the antigen of the virus, so we did not have to wait for almost a week to know the patient's state of infection.¹⁶ In late September 2020, the World Health Organization had approved the use of a rapid antigen test to be used in a country with a low number of PCR tests.¹⁷ We expected that the number of rapid antigen test kits would be increasing in the next few months.

In summary, there were significant changes in the way we handled neurosurgical patients between the early phase of the outbreak and the current situation. The number of neurosurgical procedures has waxed and waned over the past 7 months, and this has been a reflection of our actual condition during this pandemic. Collaboration among various stakeholders is really needed to maintain patient safety during each surgical procedure.