himpunan riset covid19

PERAN INFECTION PREVENTION CONTROL DALAM PERSPEKTIF
KEPERAWATAN MENGHADAPI PANDEMI COVID-19 : KAJIAN LITERATUR

Dewanti Widya Astari1*, Fransisca Sri Susilaningsih2, Iqbal Pramukti2

1PMN RS Mata Cicendo, Jl. Cicendo No.4, Babakan Ciamis, Kec. Sumur Bandung, Kota Bandung,
Jawa Barat, Indonesia 40117

2Fakultas Keperawatan, Universitas Padjadjaran, Gedung. L1 Lt. 2, Jl. Raya Bandung - Sumedang
No.KM. 21, Hegarmanah, Kec. Jatinangor, Kabupaten Sumedang, Jawa Barat, Indonesia 45363

*[email protected]

ABSTRAK
Penularan Covid-19 pada tenaga kesehatan hingga April 2020 mencapai 22.073 kasus di 52 negara
dengan Case Fatality Rate di Indonesia 8,13 %. Pelaporan infeksi Health Care Workers Covid-19
belum tersampaikan secara akurat kepada WHO, sehingga angka tersebut belum mewakili realita
secara global. Infection Prevention Control (IPC) menjadi esensial dimasa pandemi Covid-19 karena
perannya sebagai acuan pengendalian infeksi di rumah sakit. Pendekatan ilmiah dan solusi pada IPC
dirancang untuk mencegah risiko infeksi baik pada pasien maupun petugas kesehatan. Tujuan artikel
ini adalah telaah literature terkait peran IPC dalam menghadapi Covid-19. Penelusuran menggunakan
kata kunci (Infection Prevention Control) dan (Nurse) AND (Covid-19) pada 3 database yaitu PubMed,
EBSCO dan Google Scholar. Artikel yang digunakan menggunakan bahasa Inggris dan bahasa
Indonesia. Terdapat 10 artikel sesuai kriteria eligibilitas yang telah ditentukan oleh peneliti. 10 artikel
menyatakan IPC akan efektif apabila terdapat pelatihan dan pendidikan staf yang baik, kepemimpinan,
metode untuk mengdidentifikasi serta proaktif pada tempat berisiko infeksi, kebijakan dan prosedur
yang tepat serta koordinasi ke seluruh fasilitas pelayanan kesehatan. Manajemen IPC, Pemenuhan
APD dan IPC Surveillance merupakan peran terpenting dalam menghadapi Covid-19.

Kata kunci: covid-19; infection prevention control; perawat

ROLE INFECTION PREVENTION CONTROL IN PERSPECTIVE NURSING FOR
PANDEMIC COVID-19: LITERATURE REVIEW

ABSTRACT
Covid-19 transmission to health workers until April 2020 reached 22,073 cases in 52 countries with a
Case Fatality Rate in Indonesia of 8.13%. Reporting of Covid-19 Health Care Workers infection has not
been accurately conveyed to WHO, so this figure does not represent the reality globally. Infection
Prevention Control (IPC) became essential during the Covid-19 pandemic because of its role as a
reference for infection control in hospitals. The scientific approach and solutions to IPC are designed to
prevent the risk of infection for both patients and healthcare workers. The purpose of this article is to
examine the literature regarding the role of IPC in dealing with Covid-19. The search used keywords
(Infection Prevention Control) and (Nurse) AND (Covid-19) on 3 databases, namely PubMed, EBSCO
and Google Scholar. The articles used are in English and Indonesian. There were 10 articles according
to the eligibility criteria determined by the researcher. 10 articles stated that IPC will be effective if there
is good staff training and education, leadership, methods to identify and be proactive in places of risk of
infection, appropriate policies and procedures and coordination across health care facilities. IPC
Management, Compliance with PPE and IPC Surveillance are the most important roles in dealing with
Covid-19.

Keywords: covid-19; infection prevention control; nurse

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PENDAHULUAN akibat infeksi baik pada pasien maupun petugas
Covid-19 menjadi salah satu masalah kesehatan kesehatan. Konsep epidemiologi, penularan
dunia sejak bulan Januari 2020 dan ditetapkan penyakit, ilmu sosial dan penguatan sistem
sebagai pandemi oleh World Health kesehatan menjadi pondasi utama. IPC menjadi
Organization pada tanggal 11 Maret 2020. Pada perhatian khusus sehubungan dengan tingginya
10 September 2020 kasus Covid-19 tingkat penularan Covid-19 dan risiko terhadap
terkonfirmasi 27.738.179 kasus dan 899.916 perawat sebagai tenaga kesehatan dengan
angka kematian yang menimpa 215 negara jumlah terbanyak di Rumah Sakit. Tujuan dari
(WHO, 2020). Di Indonesia, kasus pertama artikel ini adalah telaah literature terkait peran
Covid-19 terkonfirmasi pada tanggal 2 Maret IPC dalam menghadapi Covid-19.
2020 dan terus bertambah hingga saat ini pada
tanggal 16 September terkonfirmasi 229.000 METODE
kasus dengan angka kematian 9100 kasus. Penelusuran literature dilakukan komprehensif
Case Fatality Rate (CFR) di Indonesia adalah menggunakan kata kunci (Infection Prevention
8,13 % dan Recovery Rate 13,18 % (Herlina J & Control) dan (Nurse) AND (Covid-19) pada 3
El- Matury, 2020) . database yaitu PubMed, EBSCO dan Google
Scholar. Artikel yang digunakan menggunakan
Perbandingan CFR dan RR merupakan bahasa Inggris dan bahasa Indonesia.
karakteristik sangat penting dari penyakit serta
sebagai indikator penting untuk penetapan HASIL
prioritas dan mengenali kinerja sistem Terdapat 10 artikel terpilih yang sesuai dengan
kesehatan. PPNI pada tanggal 7 Oktober 2020 kriteria eligibilitas yang telah ditentukan oleh
mencatat 115 dokter dan 96 perawat meninggal peneliti. 10 artikel menyatakan IPC akan efektif
akibat Covid-19 (Persatuan Perawat Nasional apabila terdapat pelatihan dan pendidikan staf
Indonesia, 2020). Perkembangan kasus di Jawa yang baik, kepemimpinan, metode untuk
Barat pada tanggal 7 Oktober 2020, mengdidentifikasi serta proaktif pada tempat
terkonfirmasi 24.910 kasus dan 511 kasus berisiko infeksi, kebijakan dan prosedur yang
kematian (pikobar.jabarprov.go.id, 2020). Sejak tepat serta koordinasi ke seluruh fasilitas
itu, angka kesakitan dan kematian terus pelayanan kesehatan.
bertambah dan berdampak pada tatanan
pelayanan kesehatan (WHO, 2020). Dampak Berdasarkan penelitian (Anita D et al., 2020)
pada tatanan pelayanan kesehatan diantaranya bahwa penggunaan APD dikaitkan dengan
dilakukan surveilans, pemeriksaan laboratorium, penurunan risiko infeksi dari virus corona.
manajemen klinis, pencegahan dan Laporan terbaru diperkirakan risiko terpajan
pengendalian infeksi, pencegahan penularan, kurang dari 5% terhadap tenaga kesehatan
komunikasi risiko, pemberdayaan masyarakat yang secara tidak sengaja terpajan pada pasien
dan pelayanan kesehatan esensial dalam yang tidak diketahui positif SARS-CoV-2.
menghadapi Covid-19 di semua fasilitas Kewaspadaan universal telah direkomendasikan
pelayanan kesehatan (Kementrian Kesehatan untuk mitigasi risiko yang optimal bagi tenaga
RI, 2020). kesehatan.

Pelaporan infeksi Health Care Workers Covid-19 Menurut (Chamboredon, Roman, & Colson,
belum tersampaikan secara akurat kepada 2020) bahwa implikasi untuk praktik
WHO, sehingga angka tersebut belum mewakili keperawatan: yaitu perawat diakui kegiatan
realita secara global. Infection Prevention sosialnya di Prancis. Namun, penting untuk
Control (IPC) menjadi bagian esensial dimasa mempertimbangkan efek jaminan krisis ini pada
pandemi Covid-19 karena perannya sebagai perawat dan keperawatan dan untuk
acuan pengendalian infeksi di rumah sakit. mengintegrasikan keterampilan keperawatan
Pendekatan ilmiah dan solusi pada IPC darurat kesehatan yang ditetapkan selama
dirancang dengan tujuan mencegah bahaya pandemi ke dalam bidang standar kompetensi

keperawatan. Implikasi untuk kebijakan Menurut Lei, Shulan,dan Caixia, 2020)
keperawatan: Profesi keperawatan memiliki menyatakan semua informasi yang diberikan
ekspektasi refleksi dan revisi keterampilan dalam review adalah untuk memperkuat praktek
keperawatan serta valorisasinya dalam sistem klinis dalam pengaturan perawatan kritis dan
perawatan kesehatan Prancis. Hasil dari lebih baik melindungi petugas kesehatan lini
penelitian ini menunjukan review studi lapangan depan dalam perawatan Pasien Covid-19.
bahwa Prancis mempunyai morbiditas dan Tingkat infeksi medis “zero” di pengalaman kami
mortalitas Covid-19 yang sangat tinggi. Terdapat sulit dimenangkan tetapi layak diperjuangkan.
dampak atau pengaruh terhadap masyarakat, Menurut Amrit (2020) menunjukkan hasil review
sistem dan profesional kesehatan, termasuk bahwa strategi mitigasi Covid-19 harus
diantaranya kepada perawat. Profesi melibatkan kelompok yang rentan untuk
keperawatan memiliki ekspektasi refleksi dan memastikan pemeliharaan hak asasi mereka
keterampilan keperawatan sangat berpengaruh dan mengurangi ketidakadilan, bukan
terhadap sistem perawatan kesehatan Prancis memperburuk kondisi mereka.
dalam menangani Covid-19.
Perawat, sebagai advokat, memainkan peranan
Menurut penelitian (Huang, Chen, Chen, & penting dalam proses ini. Investasi untuk
Wang, 2020) di Wuhan China, Pengalaman IPC meningkatkan pengetahuan dan keahlian
(Infection Prevention Control) merupakan bagian perawat tidak hanya akan memberikan hasil
yang penting dalam mengatasi Covid-19. Infeksi yang positif sekarang tetapi juga akan menjamin
Covid-19 diantara tenaga kesehatan merupakan kesiapan untuk menghadapi wabah di masa
hal yang sering terjadi dan fatal dalam sistem depan. Jika ada pelajaran yang dipetik dari
kesehatan. Berdasarkan temuan penelitian keadaan darurat ini, maka biaya dari
(Dewi Lelonowati, Tri Mustariningrum, & keterlambatan akan menjadi sangat besar.
Mulyatim Koeswo, 2015) menyatakan bahwa Dunia kemungkinan besar akan melihat
pelatihan berhubungan cukup kuat serta pandemi lain di masa depan. Upaya yang
berpengaruh signifikan, motivasi kerja IPCLN optimal harus dilakukan untuk memastikan
tidak berpengaruh signifikan terhadap Covid-19 teratasi dengan baik, seperti halnya
kinerjanya, supervisi berhubungan kuat serta kasus wabah Ebola 2014, dapat menjadi
berpengaruh signifikan terhadap kinerja IPCLN. pelajaran yang bisa diambil.
Pelatihan, motivasi kerja, dan supervisi
berhubungan kuat dan berpengaruh signifikan Menurut (Santosaningsih et al., 2017) Penelitian
terhadap kinerja IPCLN secara simultan. Kinerja dilakukan dari bulan Mei hingga Oktober 2014
IPCLN dapat dijelaskan sebesar 52,6% dari dan dibagi menjadi fase pra-intervensi,
variabel pelatihan, motivasi kerja dan supervisi intervensi, dan pasca-intervensi. Uji coba
secara simultan, dan supervisi yang terkontrol secara acak cluster ini
berpengaruh dominan. mengalokasikan implementasi tiga intervensi ke
departemen, termasuk pelatihan, presentasi ,
Menurut Mireille, Irene, dan Rosa (2019) kombinasi pelatihan dan presentasi, dan
menunjukan kurangnya bukti yang kuat tentang kelompok kontrol. Baik observasi langsung dan
efektivitas program ICLN (Infection Control Link survei persepsi pengetahuan tentang
Nurse). Faktor terkait yang mempengaruhi untuk kebersihan tangan dilakukan dengan
program ICLN mencakup deskripsi yang jelas menggunakan alat WHO.
tentang profil ICLN, pendidikan tentang
pencegahan dan pengendalian infeksi, Hasil penelitian ini menunjukan pengamatan
implementasi, dan dukungan dari manajemen di kepatuhan kebersihan tangan terhadap 2.766
bangsal dan rumah sakit. Penelitian di masa kesempatan membersihkan tangan, dan
depan diperlukan untuk mengevaluasi efek ICLN persepsi pengetahuan dinilai di antara 196
pada praktik klinis dan untuk pengembangan peserta pada pra-intervensi dan 88 pada
lebih lanjut untuk program ICLN yang maksimal. periode pasca-intervensi. Setelah intervensi,

tingkat kepatuhan kebersihan tangan meningkat harus memiliki akses ke mekanisme dukungan
secara signifikan pada pediatri (24,1% menjadi formal dan informal. Dalam pencegahan infeksi,
43,7%; P <0,001), penyakit dalam (5,2% hingga ini termasuk manajemen, rekan kerja, tim
18,5%; P <0,001), dan kebidanan-ginekologi pencegahan infeksi dan perawat penghubung
(10,1% hingga 20,5%; P <0,001). Penggunaan lainnya. Sama seperti akar yang sehat
hand rub yang salah oleh perawat saat memakai menentukan apakah bunga mekar atau layu,
sarung tangan juga meningkat (P <0,001). Skor dukungan kepemimpinan, budaya tempat kerja
pengetahuan rata-rata meningkat dari 5,6 (SD = yang mendukung, dan mempromosikan perawat
2,1) menjadi 6,2 (SD = 1,9) (P <0,05). Dalam penghubung untuk mengembangkan
survei persepsi, "bau alkohol yang menyengat" keterampilan kepemimpinan mereka sendiri
sebagai alasan ketidakpatuhan meningkat merupakan titik awal yang penting untuk
secara signifikan di departemen dengan keberhasilan implementasi program. Temuan ini
intervensi (10,1% menjadi 22,9%; P = 0,021). memberikan bukti lebih lanjut tentang
Program pendidikan peningkatan kepatuhan dan pentingnya faktor konteks, misalnya, gaya
pengetahuan kebersihan tangan di antara kepemimpinan pada keberhasilan atau program
petugas kesehatan pada dua dari tiga serupa (Saint et al., 2008). Kami berharap
departemen intervensi di rumah sakit sangat model ini dapat digunakan sebagai prinsip
dibutuhkan. Pelatihan memiliki pengaruh paling panduan untuk menetapkan program perawat
besar. Namun, penyesuaian strategi tetap tautan baru dalam pencegahan infeksi,
diperlukan untuk lebih meningkatkan kebersihan memaksimalkan peluang keberhasilan
tangan. implementasi dan keberlanjutan peran.

Menurut (Lee, Lee, Lee, & Park, 2020) Sejalan dengan penelitian (Asemahagn, 2020)
menunjukan, sebanyak 37 studi dimasukkan yang menunjukkan sebagian besar health care
dalam sintesis kualitatif. Patogen tunggal yang workers memiliki pengetahuan yang baik tetapi
paling sering dilaporkan adalah virus influenza, memiliki kemampuan praktik pencegahan Covid-
diikuti oleh streptokokus grup A (GAS). Dari 19 yang lebih rendah. Sosio-demografi dan
studi yang mengidentifikasi penyebabnya, akses sumber informasi menjadi faktor
sekitar setengah dari mereka mencatat wabah pengetahuan tentang Covid-19. Demikian pula,
yang ditularkan melalui person to person. tempat tinggal, kekurangan APD, beban kerja
Praktik pengendalian infeksi yang kurang yang tinggi, penyakit penyerta, pengetahuan,
optimal termasuk dekontaminasi yang tidak dan akses ke pelatihan dan pedoman Infection
memadai dan kebersihan tangan yang buruk Prevention merupakan faktor yang membatasi
adalah masalah yang paling sering diangkat praktik pencegahan. Oleh karena itu, pasokan
yang menyebarkan penularan. Terutama, APD yang konsisten dan peningkatan
penyimpangan dalam prosedur perawatan pengetahuan petugas kesehatan, membuat
tertentu dikaitkan dengan wabah GAS dan virus pedoman Infection Prevention dan sumber
hepatitis B dan C. Sekitar 60% dari studi yang informasi tersedia, serta mengelola penyakit
disertakan melaporkan kasus yang terkena kronis sangat penting untuk mencegah Covid-19
dampak di antara staf, tetapi hanya sedikit studi di antara Health care workers.
yang menerapkan pembatasan kerja selama
wabah. PEMBAHASAN
Infeksi antara sesama tenaga kesehatan dapat
Menurut (Williams et al., 2019) menunjukkan mengakibatkan penyebaran transmisi dan
bahwa menilai pengetahuan dan keterampilan, kolapsnya seluruh sistem kesehatan. Jadi IPC
dan mempertimbangkan titik awal, kepercayaan merupakan bagian terpenting dalam
diri dan motivasi perawat tautan potensial menghadapi pandemi Covid-19, sebagaimana
merupakan faktor penting untuk diperhatikan dapat terlihat dari tujuan IPC yaitu
selama proses seleksi. Setelah ditetapkan mengidentifikasi dan menurunkan risiko infeksi
dalam peran tersebut, perawat penghubung yang didapat serta ditularkan di antara pasien,

staf, tenaga profesional kesehatan, tenaga WHO, 2) Pengaturan Zona Perawatan : Area
kontrak, tenaga sukarela, mahasiswa, dan fasilitas pelayanan kesehatan dibagi menjadi
pengunjung. Risiko infeksi dan kegiatan beberapa zona area kerja, 3) Surveillans :
program dapat berbeda dari satu rumah sakit ke Diperlukan seorang pemimpin yang bertugas
rumah sakit lainnya bergantung pada kegiatan mengawasi pemakaian dan pelepasan APD,
klinis dan pelayanan rumah sakit, populasi mengidentifikasi langkah-langkah perbaikan,
pasien yang dilayani, lokasi geografi, jumlah pengaturan limbah medis dan non medis, 4)
pasien, serta jumlah pegawai. Program IPC Manajemen dalam non-occupational setting :
akan efektif apabila mempunyai pimpinan yang memfasilitasi komunikasi dengan menggunakan
ditetapkan, pelatihan dan pendidikan staf yang ponsel, membatasi pertemuan dan kontak antar
baik, metode untuk mengdidentifikasi serta tenaga kesehatan, desinfeksi rutin terhadap
proaktif pada tempat berisiko infeksi, kebijakan permukaan diantaranya pada telepon genggam,
dan prosedur yang memadai, juga melakukan gagang pintu, dll. 5) Pelatihan IPC.
koordinasi ke seluruh rumah sakit. (Komisi
Akreditasi Rumah Sakit, 2019). Delapan pilar tanggapan kesehatan masyarakat
menurut (WHO, 2020): 1)Koordinasi,
Tim IPC di dalam suatu rumah sakit terdiri dari, perencanaan dan pemantauan tingkat nasional,
IPCD (Infection Prevention and Control Doctor) , 2)Komunikasi risiko dan pelibatan masyarakat,
IPCN (Infection Prevention and Control Nurse) 3)Surveilans, penyelidikan epidemiologis,
dan IPCLN (Infection Prevention and Control tanggapan cepat dan penyelidikan kasus, 4)Titik
Linked Nurse) (Kementrian Kesehatan RI, masuk, 5)Laboratorium nasional, 6)Pencegahan
2017). IPCLN sebagai perawat pelaksana harian dan pengendalian infeksi 7)Manajemen kasus,
atau penghubung bertugas dari tiap unit rawat 8)Dukungan dan logistic operasi, termasuk
inap atau unit pelayanan di rumah sakit. Seluruh rencana kontinjensi dan mekanisme pendanaan.
pelayanan kesehatan saat ini merujuk kepada Pemahaman terkait risiko pandemi Covid-19
Pedoman Pencegahan Pengendalian pada tenaga kesehatan sangatlah penting.
Coronavirus Disease (Covid-19). IPCLN sebagai Prediksi risiko dapat menginformasikan
pelaksana program PPI di Rumah Sakit bagaimana cara melindungi tenaga kesehatan
diharapkan menjadi “ëxecutor” untuk memotivasi seperti rekomendasi penggunaan alat pelindung
seluruh karyawan, pasien dan pengunjung diri (APD) di tempat kerja atau di masyarakat.
dalam pencegahan dan pengendalian infeksi.
Pencegahan dan Pengendalian Infeksi adalah
Strategi-strategi IPC menurut (WHO, 2020) upaya untuk mencegah dan meminimalkan
diantaranya adalah untuk mencegah atau terjadinya infeksi pada pasien, petugas,
membatasi transmisi, triase, pengenalan awal, pengunjung, dan masyarakat sekitar fasilitas
dan pengendalian sumber, Kewaspadaan pelayanan kesehatan (Kementrian Kesehatan
standar (mencuci tangan, penilaian risiko, APD, RI, 2017). Sementara menurut World Health
etiket bersin dan batuk, pencegahan luka jarum Organization (WHO) Pencegahan dan
suntik, pembersihan lingkungan, pengelolaan pengendalian infeksi adalah pendekatan ilmiah
linen, pembuangan limbah, peralatan perawatan yang disertai solusi praktis untuk mencegah
pasien), kewaspadaan empiris tambahan bahaya dari infeksi atas pasien dan tenaga
(kontak, droplet, dan jika sesuai kewaspadaan kesehatan didasarkan pada prinsip-prinsip
airborne) untuk kasus Covid-19 suspek, penyakit menular, epidemiologi, ilmu social dan
Rekayasa administratif; sosialisasi kepada penguatan system kesehatan, dan berakar
tenaga kesehatan, kebijakan, dll. Rekayasa dalam kualitas layanan keselamatan dan
lingkungan dan mekanis: ventilasi, pembersihan. kesehatan pasien (World Health Organization,
2020). Dari definisi yang telah dikemukakan
Peran IPC diantaranya adalah 1) Penerapan diatas, peneliti menyimpulkan bahwa IPC adalah
APD yang tepat : Semua tenaga kesehatan suatu usaha untuk pencegahan dan
harus menerapkan APD sesuai rekomendasi pengendalian sumber infeksi bagi pasien,

pengunjung dan tenaga kesehatan berdasarkan diperlukan pada kasus tertentu yangterjadi di
evidence based, epidemiologi dan ilmu sosial. fasyankes. 7)Melakukan audit IPC di seluruh
wilayah fasyankes dengan menggunakan daftar
Standar pencegahan IPC diantaranya adalah; 1) tilik. 8)Memonitor pelaksanaan pedoman
Kebersihan tangan (hand hygiene): dengan antibiotika bersama Komite/Tim Program
prinsip 6 Langkah 5 Momen‟ sesuai panduan Pengendalian Resistensi Mikroba (PPRA).
WHO, 2) Alat pelindung diri (APD): mulai dari 9)Mendesain, melaksanakan, memonitor,
masker (surgical atau N95), sarung tangan mengevaluasi dan melaporkan surveilans infeksi
karet, kacamata pelindung (googles), hingga yang terjadi di fasilitas pelayanan kesehatan
pakaian/jubah pelindung infeksi sekali pakai, 3) bersama Komite / Tim IPC. 10)Memberikan
Pencegahan tertusuk jarum atau benda tajam: motivasi kepatuhan pelaksanaan program IPC.
terutama pada staff kesehatan dan pasien, 11)Memberikan saran desain ruangan rumah
diperlukan alur tatalaksana jika terjadi sakit agar sesuai dengan prinsip IPC.
kecelakaan seperti ini, 4) 12)Meningkatkan kesadaran pasien dan
Pembersihan/perawatan lingkungan rumah pengunjung rumah sakit tentang IPC.
sakit: untuk memastikan kondisi selalu bersih 13)Memprakarsai penyuluhan bagi petugas
terutama pada ruangan yang digunakan untuk kesehatan, pasien, keluarga dan pengunjung
penangan pasien infeksius. 5) Pencucian dan tentang topik infeksi yang sedang berkembang
disenfektan peralatan medis: sebagain sarana emerging) atau infeksi dengan insiden tinggi.
pencegahan berpindahnya patogen dari alat 14)Sebagai coordinator antar departemen/unit
kesehatan yang sudah digunakan dan 6) dalam mendeteksi, mencegah dan
Manajemen pembuangan limbah medis: mengendalikan infeksi dirumah sakit.
sampah medis infeksius dibuang pada tempat 15)Memonitoring dan evaluasi peralatan medis
sampah berwarna kuning dan diberi label single use yang di reuse.
„limbah infeksius‟, sementara sampah biasa
(non-infeksius) dibuang pada tempat sampah SIMPULAN
dengan warna gelap dan diberi label „sampah Semua informasi di dalam literature review ini
non-infeksius‟ (Morfi, 2020). memperkuat peran IPC yaitu diantaranya
Manajemen IPC, Pemenuhan APD dan IPC
Hal ini sejalan dengan peran perawat dalam IPC Surveillance sebagai bagian terpenting dalam
di fasilitas pelayanan kesehatan yang terdiri dari pencegahan pengendalian infeksi dalam
Infection Prevention Control Nurse (IPCN) dan menghadapi Covid-19. Perlindungan terhadap
Infection Prevention Control Link Nurse (IPCLN). tenaga kesehatan haruslah diperjuangkan.
Tugas IPCN diantaranya 1) Melakukan Penelitian dan studi lebih lanjut terkait
kunjungan kepada pasien yang berisiko di manajemen IPC dalam mengatasi tantangan
ruangan setiap hari untuk mengidentifikasi pencegahan pengendalian Covid-19 perlu
kejadian infeksi pada pasien di baik rumah sakit dilakukan.
dan fasilitas pelayanan kesehatan lainnya.
2)Memonitor pelaksanaaan program IPC, DAFTAR PUSTAKA
kepatuhan penerapan SPO dan memberikan Amrit Kaur Purba. (2020). How should the role
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doi:10.1371/journal.pone.0229911

KEPUASAN PASIEN TERHADAP MUTU PELAYANAN KEPERAWATAN DI ERA
PANDEMI COVID-19 DI RUMAH SAKIT MATA CICENDO

DEWANTI WIDYA ASTARI1, AFNI NOVIANTANI1, ROSDIANA SIMANJUNTAK2

1Pavviliun Rumah Sakit Mata Cicendo
2Rawat Inap Rumah Sakit Mata Cicendo
Email korespondensi: [email protected]
Dikirimkan 30 Agustus 2020, Diterima 27 Desember 2020

ABSTRAK
Latar Belakang: Semenjak diberlakukannya physical distancing dan Pembatasan Sosial Berskala
Besar (PSBB) pada 20 Maret 2020, terjadi penurunan pasien di Rumah Sakit Mata Cicendo sebanyak
67,9 % dari bulan Maret sampai dengan April 2020. Dorongan kepada masyarakat untuk menjaga jaga
jarak, menghindari kerumunan, dan anjuran untuk tetap diam di rumah mengakibatkan alur proses
pelayanan kesehatan selama pandemi Covid-19 berubah, seperti penerapan langkah pencegahan
standar untuk semua pasien serta memastikan identifikasi awal dan pengendalian sumber. Adanya
kebijakan Covid-19 berupa screening, prosedur pelayanan, serta alur proses pelayanan yang berubah
diduga juga berpengaruh terhadap kepuasan pasien dan mutu pelayanan keperawatan.
Tujuan: Menganalisis mutu pelayanan keperawatan selama pandemi Covid-19 di Rumah Sakit Mata
Cicendo.
Metode: Menggunakan metode Importance Performance Analysis (IPA). Pengambilan data dilakukan
di rawat jalan dan rawat inap Rumah Sakit Mata Cicendo. Sumber data berupa data primer melalui
kuesioner Responsiveness, Assurance, Tangible, Empathy dan Reliability (RATER) dan data sekunder
berupa data kepuasan pasien dan mutu pelayanan tahun 2019. Responden terdiri dari 143 pasien
rawat inap dan rawat jalan. Penelitian dilakukan bulan Mei-Juni di Rumah Sakit Mata Cicendo.
Hasil: Kualitas mutu pelayanan keperawatan puas pada dimensi tangibles sebesar 57,90%, realibility
58,04%, responsiveness 62,65%, assurance 58,18% dan empathy 58,74%. Namun berdasarkan
analisis gap IPA, didapatkan empat nilai negatif yang harus dilakukan peningkatan yaitu dimensi
tangibles, realibility, responsiveness dan assurance.
Kesimpulan: Mutu pelayanan keperawatan selama masa pandemi Covid-19 dinilai sudah baik, akan
tetapi perlu dioptimalkan pada dimensi tangibles dan reliability.

Kata kunci: Covid-19, kepuasan pasien, mutu pelayanan keperawatan

LATAR BELAKANG menggunakan instrumen baku berdasarkan
Covid-19 menjadi salah satu masalah kesehatan indikator kinerja rumah sakit Departemen
dunia sejak bulan Januari 2020. Pada 3 Mei Kesehatan Republik Indonesia tahun 2005
2020 kasus Covid-19 terkonfirmasi 3.272.202 (Nursalam, 2014). Di Rumah Sakit Mata
kasus dan 230.104 angka kematian yang Cicendo, hasil survei kepuasan pasien yang
menimpa 215 negara (WHO, 2020). Kasus dilaksanakan sebelum pandemi Covid-19 yaitu
Covid-19 pertama kali terkonfirmasi di di bulan Desember 2019 menunjukan bahwa di
Indonesia pada tanggal 2 Maret 2020 dan instalasi rawat jalan reguler 78,27 dengan
hingga kini terus bertambah. Sejak itu, angka mutu pelayanan B, rawat jalan paviliun 75,09
kesakitan dan kematian terus bertambah dan dengan mutu pelayanan B, dan rawat inap
berdampak pada tatanan pelayanan kesehatan 84,76 dengan mutu pelayanan B (RS Mata
(WHO, 2020). Selain kesakitan dan kematian, Cicendo, 2020). Data kepuasan pasien saat
Covid-19 juga mengharuskan physical pandemi Covid-19 di bulan Maret 81,43 dan di
distancing dan PSBB pada 20 Maret 2020, Bulan April 81,52. Standar kepuasan
semenjak itu terjadi penurunan pasien di berdasarkan indeks kepuasan masyarakat
Rumah Sakit Mata Cicendo sebanyak 67,9 adalah 80%. Dengan diterapkannya alur
% dari bulan Maret sampai dengan April 2020. pelayanan triage Covid-19 di semua unit
Penurunan kunjungan pasien pada bulan April pelayanan, diduga terjadi penurunan mutu
terjadi di semua instalasi, seperti di instalasi pelayanan keperawatan. Tujuan penelitian ini
paviliun, IGD, lasik, rawat inap, dan rawat jalan. menganalisis mutu pelayanan keperawatan
selama pandemi Covid-19 di Rumah Sakit
Pandemi Covid-19 menyebabkan penurunan Mata Cicendo karena selama masa pandemi
angka kunjungan pasien, hal ini terjadi belum pernah dilakukan pengukuran mutu.
karena terdapat alur proses pelayanan
kesehatan yang berubah, pembatasan jumlah METODE
pasien sebagai upaya menghindari kerumunan, Jenis penelitian yang digunakan adalah
serta diterapkannya langkah pencegahan kuantitatif. Penelitian ini dilakukan di ruang
standar, identifikasi awal dan pengendalian rawat inap dan rawat jalan Rumah Sakit Mata
sumber virus (Indonesia. Kementerian Cicendo Bandung. Populasi dalam penelitian ini
Kesehatan, 2020). Pembatasan jumlah pasien adalah pasien rawat jalan dan rawat inap
setiap harinya mengakibatkan pasien diduga Rumah Sakit Mata Cicendo bulan Mei sampai
berobat ke rumah sakit lain sehingga bulan Juni tahun 2020. Sampel penelitian
mengakibatkan penurunan jumlah pasien. berdasarkan rumus Slovin sebanyak 143
Semua tenaga kesehatan belum mempunyai responden yang masuk dalam kriteria inklusi
pengalaman menangani Covid-19. Tenaga (Notoatmodjo, 2010). Kriteria inklusi dalam
kesehatan harus menyesuaikan diri dengan penelitian ini adalah pasien di ruang rawat inap
perubahan kondisi, mulai dari implementasi dan rawat jalan Rumah Sakit Mata
panduan penatalaksanaan Covid-19, panduan- Cicendo, pasien dalam keadaan sadar, dan
panduan baru yang harus diimplementasikan, pasien bersedia menjadi responden. Kriteria
perubahan interaksi pasien-perawat, eksklusi adalah pasien dengan penyakit
penggunaan Alat Pelindung Diri (APD), berat (terminal). Penelitian dilakukan dari bulan
kecemasan tertular Covid-19 ataupun Mei sampai dengan Juni 2020 dan sudah
menularkan kepada keluarga. Kebiasaan baru mendapatkan kaji laik etik dari Komite Etik
ini diduga dapat berimbas kepada mutu Penelitian Kesehatan RS Mata Cicendo
pelayanan keperawatan. Kepuasan pasien Bandung. Data yang digunakan adalah data
berkorelasi dengan mutu pelayanan di rumah primer dan data sekunder. Data primer
sakit. Dengan memahami tingkat kepuasan menggunakan kuesioner RATER (Nursalam,
pasien, manajemen rumah sakit dapat 2014). Kuesioner dalam bentuk manual dan
mempelajari dan melakukan peningkatan mutu diisi oleh pasien yang menjadi responden.
pelayanan. Penentuan kepuasan pasien diukur Proses pengisian kuesioner didampingi oleh

peneliti, kuesioner diberikan sebelum dan penggambaran kinerja sebuah objek
sesudah pelayanan keperawatan yang dibuat dibandingkan dengan harapan pasien akan
menggunakan skala Likert. Sementara data kinerja yang seharusnya ada, menggunakan
sekunder didapatkan dari data kepuasan pasien diagram Cartesius (Riyanto, 2012). Analisis data
dan mutu pelayanan tahun 2019. Analisis data univariat digunakan untuk menunjukkan
secara statistik deskriptif menggunakan program distribusi frekuensi dan persentase dari
Microsoft Excel dengan metode IPA yaitu karakteristik responden.

HASIL
Karakteristik responden penelitian lebih banyak berjenis kelamin perempuan, paling banyak memiliki
tingkat pendidikan SLTA dan dengan pekerjaan lebih banyak sebagai lainnya/Ibu Rumah Tangga
(IRT) (Tabel 1).
Tabel 1. Distribusi Jenis kelamin, Umur, Pendidikan dan Pekerjaan Responden (n = 143 responden)

Karakteristik Rawat Rawat n %

Responden Inap Jalan

Jenis Kelamin

Laki-laki 25 42 67 46,9

Perempuan 20 56 76 53,1

Tingkat Pendidikan

SD 3 8 11 7,7

SLTP 8 4 12 10,5

SLTA 22 32 54 37,8

D1/D3/D4 8 10 18 12,6

S1 12 28 40 28,0

S2 0 5 5 3,5

Pekerjaan

PNS/TNI/POLRI 11 10 21 14,7

Pegawai Swasta 13 15 28 19,6

Wiraswasta 11 20 31 21,7

Pelajar/Mahasiswa 1 4 5 3,5

IRT/Lainnya 23 35 5 40,6

Harapan responden tertinggi pada dimensi dimensi assurance dan emphaty yaitu 3,34,
reliability yaitu 3,41 sedangkan terendah pada sedangkan terendah pada dimensi
dimensi responsiveness 3,32 (Tabel 2). Aspek responsiveness 3,26 (Tabel 2).
reliability meliputi perawat mampu menangani Empathy yakni pasien mendapatkan perhatian
masalah perawatan dengan tepat dan dari perawat secara individual. Dimensi empathy
professional, perawat mampu memberikan dapat diaplikasikan dalam bentuk memberikan
informasi tentang fasilitas yang tersedia, cara perhatian khusus kepada setiap pasien.
penggunaannya dan tata tertib yang berlaku di Sementara assurance berarti perawat
RS, perawat mampu memberitahu dengan jelas menanggapi setiap keluhan dan memberi
tentang hal-hal yang harus dipatuhi dalam perhatian, perawat dapat menjawab pertanyaan
perawatan, perawat mampu memberitahu tentang tindakan perawatan yang diberikan
dengan jelas tentang hal-hal yang dilarang kepada responden, perawat jujur dalam
dalam perawatan dan ketepatan waktu perawat memberikan informasi tentang keadaan,
tiba di ruangan ketika pasien atau responden perawat selalu memberi salam dan senyum
membutuhkan. Persepsi atau kenyataan yang ketika bertemu dengan responden dan perawat
dirasakan oleh responden tertinggi pada teliti dan terampil dalam melaksanakan tindakan

keperawatan kepada responden. tangibles (-0,09), realiability (-0,11),
Prosedur teknik IPA dilakukan dengan cara responsiveness (- 0,6) dan assurance (-0,03).
responden diminta untuk mengukur tingkat Pengukuran kepuasan pasien didapatkan nilai
kepentingan dan kinerja, lalu nilai rata-rata harapan di dimensi tangibles 3,39 dengannilai
tingkat kepentingan dan kinerja tersebut kenyataan 3,30, nilai harapan di dimensi
dianalisis pada Importance Performance Matrix, reliability 3,41 dengan nilai kenyataan 3,30,
yang mana sumbu X mewakili persepsi nilai harapan di dimensi responsiveness 3,32
sedangkan sumbu Y mewakili harapan. Maka dengan nilai kenyataan 3,26, nilai harapan di
nanti akan didapat hasil berupa empat kuadran dimensi assurance 3,37 dengan nilai kenyataan
sesuai gambar 1. Gambar 1 menunjukan bahwa 3,34, dan nilai harapan di dimensi emphaty 3,34
berdasarkan gap analisis terdapat 4 dimensi dengan nilai kenyataan 3,34.
dengan hasil gap negative yaitu dimensi

Kepuasan Pasien

3.42

3.41 Reliability
3.40

Harapan 3.39 Tangibles Assurance
3.38

3.37

3.36

3.35 Responsiveness Empathy
3.34

3.33

3.32

3.31
3.25 3.26 3.27 3.28 3.29 3.30 3.31 3.32 3.33 3.34

Kenyataan

Gambar 1 Diagram Kartesius Pengukuran Kepuasan Pasien

Tabel 2. Analisis Kesenjangan antara Harapan dan Kenyataan Atau Persepsi Responden pada
Dimensi Mutu Pelayanan (n = 143 r)

Pernyataan Mutu Rerata Rerata Kesenjangan Makna
Pelayanan Harapan Kenyataan/Persepsi
-0,09 Tidak puas
Tangibles 3,39 3,30 -0,11 Tidak puas
Reliability 3,41 3,30 -0,06 Tidak puas
Responsiveness 3,32 3,26 -0,03 Tidak puas
Assurance 3,37 3,34 0,00
Emphaty 3,34 3,34 Puas

Persepsi sangat tidak puas yang tertinggi terdapat pada dimensi tangibles (1,96%) dan terendah
pada dimensi assurance (0,98%) (Tabel 3). Proporsi tidak puas yang tertinggi terdapat pada dimensi
responsiveness (3,78%) dan terendah pada dimensi empathy (1,96%). Sedangkan skala puas tertinggi
pada dimensi responsiveness (62,52%) dan terendah pada dimensi tangibles (57,90%), serta skala
sangat puas terdapat pada dimensi assurance (38,18%) dan terendah pada dimensi responsiveness
(32,45%)

Tabel 3. Analisis Kualitas Mutu Pelayanan Keperawatan (n = 143 responden)

Dimensi Sangat Tidak Puas (%) Tidak Puas (%) Puas (%) Sangat Puas (%)

Tangibles 1,96 2,94 57,90 37.20
3,36 58,04 36,78
Reliability 1,82 3,78 62,52 32,45
2,66 58,18 38,18
Responsiveness 1,26 1,96 58,74 38,04

Assurance 0,98

Empathy 1,26

PEMBAHASAN pelayanan kepada pasien dapat membuat
Berdasarkan analisis IPA didapatkan kualitas pasien merasa tidak nyaman.
mutu pelayanan keperawatan sudah baik, akan Berdasarkan analisis kesenjangan diperlukan
tetapi ditemukan 4 nilai kesenjangan negatif adanya peningkatan di 4 dimensi yang
yang harus dioptimalkan. Pandemi Covid-19 menunjukkan kesenjangan yang negatif yaitu
mengubah kualitas mutu pelayanan dimensi tangibles (-0,09), realiability (-0,11),
keperawatan di rumah sakit yang sebelumnya responsiveness (-0,6) dan assurance (-0,03).
bergantung pada keterampilan, kecepatan, Hal ini sejalan dengan penelitian Fitria (2019)
kemudahan dan ketepatan dalam melakukan yang menunjukkan terdapat perbedaan dari
tindakan praktek keperawatan (Muhith & ketiga rumah sakit dilihat dari lima dimensi
Nursalam, 2012). Kemudian tingginya harapan Rumah sakit R dan I (inisial rumah sakit) pasien
pasien bahwa mutu pelayanan yang dianggap merasakan tidak puas rerata pada dimensi
baik dan memuaskan apabila jasa yang diterima keandalan. Pasien merasa pemberian
sesuai atau melebihi dari yang diharapkan dan pelayanan keperawatan dirasa kurang tepat
sebaliknya mutu pelayanan yang diasumsikan waktu dan informasi yang diberikan kepada
tidak memuaskan jika yang diterima lebih pasien dirasa kurang jelas. Peristiwa ini bisa
rendah dari yang diharapkan. Kualitas terjadi karena adanya perubahan pola interaksi
pelayanan kesehatan dan kepuasan pasien antara perawat dan pasien sesuai dengan
merupakan elemen penting dalam memberikan protokol kesehatan yang berlaku dalam pandemi
pelayanan kesehatan. Menilai dan Covid-19 (Fitria, 2019).
mengevaluasi suatu pelayanan kesehatan
berdasarkan persepsi pengguna penting untuk Eksperimen yang dilakukan oleh Rahayu & Sahli
perbaikan pelayanan kesehatan yang (2020) menyiratkan bahwa bila pengendalian
berkelanjutan. Kepuasan pasien diyakini administratif yang dilakukan dengan tepat,
berkorelasi dengan kualitas pelayanan dan seperti pola penatalaksanaan penerimaan
merupakan kunci dari hasil perawatan (Ong & pasien saat pandemi Covid-19, dapat menjamin
Pambudi, 2014). kenyamanan dan keamanan pelayanan
kesehatan yang diberikan kepada masyarakat
Pelayanan kesehatan saat ini mengikuti tanpa penularan. Hal ini bisa dijadikan pedoman
Pedoman Pencegahan Corona Virus Disease- bahwa pengelolaan pelayanan yang baik dapat
19 edisi pertama menurut Kementerian tetap dilakukan walaupun dalam masa pandemi
Kesehatan Indonesia (Kementrian Kesehatan, Covid-19. Implementasi regulasi yang telah
2020). Kepuasan pasien dapat dipengaruhi oleh ditetapkan oleh pemerintah, pengelolaan
adanya protokol kesehatan dan alur pelayanan penerimaan pasien, pemberian pendidikan
triage Covid-19 (Gambar 2). Dorongan kepada kesehatan kepada pasien tentang perubahan
masyarakat agar tetap menjaga jarak pada saat prosedur pelayanan, serta terjaminnya
berkunjung ke rumahsakit, aturan untuk keamanan dan kenyamanan pasien menjadi
memakai masker selama di rumah sakit, serta bagian yang krusial. Menurut Pujiyanto,
adanya identifikasi awal serta pengendalian Syaifudin, & Susi (2020), diperlukan suatu tata
sumber infeksi berdampak pada perubahan alur kelola asuhan keperawatan yang berkualitas di

era pandemi Covid-19. Semua belum ada diharapkan pasien sebanding dengan
pengalaman, panduan maupun tatakelola yang ekspektasinya. Berdasarkan penelitian
baku yang sudah teruji dan dapat Wittayapairoch, Punchai, Jenwitheesuk,
diimplementasikan. Profesi keperawatan Chotmongkol, Sawanyawisuth, & Jenwitheesuk
mendapat tantangan untuk belajar, inovatif dan (2019), kondisi fisik seperti sakit kepala tidak
kreatif dalam meberikan asuhan keperawatan berkorelasi dengan kepuasan pasien, akan
yang berkualitas kepada pasien, secara khusus tetapi yang berpengaruh secara signifikan
pasien Covid-19. Pendidikan tata kelola asuhan adalah usia responden.
keperawatan berkualitas dari perspektif
pengalaman pandemi Covid-19 harus diberikan Sementara penelitian Wulandari, Ridho,
di fasilitas pelayanan kesehatan primer dan Supriyanto, Qomarrudin, Damayanti, Laksono, &
sekunder, dan pendidikan tinggi keperawatan Rassa (2018) mengemukakan pentingnya
bagi para dosen dan mahasiswa keperawatan. pengaruh akreditasi terhadap kepuasan pasien
di Puskesmas sehingga terjadinya perbaikan
Penelitian yang dilakukan oleh Ryandini & sistem pelayanan. Pelayanan yang diterima oleh
Hakim (2019) memperlihatkan hasil yang pasien berasal dari stimulus yang dihasilkan
berbeda, yaitu kepuasan terendah pada dimensi oleh panca indera akan dipersepsikan sehingga
responsiveness, berbanding terbalik dengan nantinya akan dapat menilai mutu pelayanan,
hasil di Rumah Sakit Mata Cicendo. Hal ini jika apa yang mereka harapkan sesuai dengan
terjadi bisa terjadi karena pengalaman pasien kenyataan yang mereka dapatkan, maka akan
yang pernah berobat sebelumnya, atau karena dapat memberikan kepuasan kepada pasien
daya tanggap pelayanan keperawatan yang (Sukarni & Saputra, 2018).

Gambar 2. Alur Pelayanan Triage Covid-19 di RS Cicendo (Sumber: Satgas Covid Rumah Sakit
Cicendo, 2020)

KESIMPULAN berdasarkan analisis kesenjangan diperlukan
Pada pandemi Covid-19, secara keseluruhan peningkatan pada empat dimensi dengan
mutu pelayanan keperawatan di Rumah Sakit kesenjangan negatif, yaitu dimensi tangibles,
Mata Cicendo baik, ditunjang dengan hasil yang realiability, responsiveness dan assurance.
paling tinggi pada dimensi responsiveness dan Berdasarkan analisis IPA, maka terdapat
diikuti dengan assurance. Akan tetapi sepuluh hal yang perlu ditingkatkan dari dimensi

tangibles dan reliability (Kuadran A). Sepuluh Peningkatan Mutu Asuhan Keperawatan
hal tersebut adalah perawat memberikan Berbasis Patient Safety; Perspective
informasi, menjaga kebersihan dan kerapihan Experience Pandemi Covid-19, Sekolah
ruangan, menjaga kebersihan dan kesiapan Tinggi Ilmu Kesehatan Karya Husada
alat-alat kesehatan yang akan digunakan, Semarang.
menjaga kebersihan dan kelengkapan fasilitas, 9. Rahayu, C. D., & Sahli, M. (2020). Patient
menjaga kerapihan dan penampilannya, Service Management in the Community
menangani masalah perawatan pasien dengan Health Centers During the Covid-19
tepat dan professional, memberikan informasi Pandemic. Jurnal Keperawatan, 12(4), 935-
tentang fasilitas yang tersedia, cara 942.
penggunaannya dan tata tertib yang berlaku di 10.Riyanto, A. (2012). Penerapan Analisis
RS, memberitahu dengan jelas tentang hal-hal Multivariat dalam Penelitian Kesehatan.
yang harus dipatuhi dalam perawatan, Yogyakarta: Nuha Medika.
memberitahu dengan jelas tentang hal-hal yang 11.Rumah Sakit Mata Cicendo. (2020).
dilarang dalam perawatan pasien serta Pedoman Pelayanan Kesehatan Mata dalam
ketepatan waktu perawat tiba di ruangan ketika Menghadapi Pandemi Covid-19. Bandung.
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ICAM-1 LEVELS IN PATIENTS WITH COVID-19 WITH DIABETIC FOOT ULCERS: A
PROSPECTIVE STUDY IN SOUTHEAST ASIA

Mendy Hatibie Oley a, b, c,*, Maximillian Christian Oley c, d, e, Billy Johnson Kepel f, Djony E. Tjandra c, g, h,
Fima Lanra Fredrik G. Langi i, Herwen j, k, Deanette Michelle R. Aling c, Angelica Maurene Joicetine
Wagiu j, k, Muhammad Faruk l

aPlastic Reconstructive and Aesthetic Surgery Division, Department of Surgery, Faculty of Medicine, Sam Ratulangi University, Manado, Indonesia
bPlastic Reconstructive and Aesthetic Surgery Division, Department of Surgery, R. D. Kandou Hospital, Manado, Indonesia
cHyperbaric Centre Siloam Hospital, Manado, Indonesia
dNeurosurgery Division, Department of Surgery, Faculty of Medicine, Sam Ratulangi University, Manado, Indonesia
eNeurosurgery Division, Department of Surgery, R. D. Kandou Hospital, Manado, Indonesia
fDepartment of Chemistry, Faculty of Medicine, Sam Ratulangi University, Manado, Indonesia
gVascular Surgery Division, Department of Surgery, Faculty of Medicine, Sam Ratulangi University, Manado, Indonesia
hVascular Surgery Division, Department of Surgery, R. D. Kandou Hospital, Manado, Indonesia
iDepartment Epidemiology and Biostatistics, Public Health Faculty, Sam Ratulangi University, Manado, Indonesia
jDepartment of Surgery, Faculty of Medicine, Sam Ratulangi University, Manado, Indonesia
kDepartment of Surgery, R. D. Kandou Hospital, Manado, Indonesia
lDepartment of Surgery, Faculty of Medicine, Hasanuddin University, Makassar, Indonesia

ABSTRACT
Background: Viral infection can compound the severity of pre-existing inflammation caused by
underlying dis- eases. For those with a chronic, immune-related condition such as diabetic foot ulcers
(DFUs), the coronavirus disease (COVID-19) serves to exacerbate the inflammatory burden. Serum
levels of intracellular adhesion molecule-1 (ICAM-1), a primary mediator of cell adhesion express in the
inflammatory process, are often used to indicate the gravity of all inflammatory conditions. Therefore,
the purpose of this study was to investigate serum ICAM-1 levels before and after debridement in
patients with DFUs who were also diagnosed as COVID-19 pos- itive compared with those who were
COVID-19 negative.
Methods: 20 patients with DFUs were screened for COVID-19 and then divided into COVID-19 positive
and negative groups according to the results. Before debridement, chest x-rays and blood analysis,
including ICAM-1 serum levels, were performed in both groups. Only ICAM-1 serum levels were
measured after debridement.
Results: Of the 20 patients included in this study, 55% were male (n = 11) and 45% were female (n =
9). The mean age was 52.9 ± 1.9 years. ICAM-1 levels in patients with DFU in the COVID-19-positive
group were significantly higher than those in the COVID-19-negative group (median 317.2 vs 149.2,
respectively; p < 0.001). Serum levels of ICAM-1 reduced significantly in patients with DFU in the
COVID-19-positive group were significantly higher than those in the COVID-19-negative group after
debridement (median 312.5 vs 130.3; p < 0.001).
Conclusion: ICAM-1 serum levels represent an additional, initial screening marker for COVID-19.

1. INTRODUCTION in patients with diabetes compared with non-
Pre-existing inflammation caused by diabetics. Approximately 70–80% of all non-
underlying diseases worsens in the presence traumatic amputations are caused by
of a viral infection. Coronavirus disease 2019 diabetes.
(COVID-19) is caused by infection with the
severe acute respiratory syndrome Patients with DFUs, therefore, undergo
coronavirus 2 (SARS-CoV-2). The common debridement for infection control to prevent
symptoms are fever, cough, dyspnea that amputation [13,14]. Patients with DFUs are
can progress to pneumonia, acute respiratory exposed to prolonged, low-grade
distress syndrome, multiple organ failure, inflammation and infection. Triggered by
and death [1–3]. The first case of a inflammation, endothelial adhesion
‘pneumonia of unknown etiology’ was molecules such as ICAM-1 are produced in
reported on December 31, 2019, in Wuhan, excessive amounts as a component of the
Hubei Province, China by the World Health immune response. Adding weight to the load,
Organization (WHO) country office in China. patients with DFUs who are also diagnosed
The second case of coronavirus pneu- monia with COVID-19 experience an acute
was detected on January 7, 2020, and by inflammatory response on top of their pre-
March 11, 2020, the WHO declared COVID- existing chronic inflamma- tion. We
19 a global pandemic. As of September 30, hypothesize that ICAM-1 levels are elevated
2020, global COVID-19 cases reached in these patients even after debridement.
33,249,563 with a mortality of 1,000, 040 Therefore, this study aims to investigate the
people. Indonesia reported 278,722 COVID- levels of ICAM-1 before and after
19 cases, with 10,473 deaths [4,5]. debridement in patients with DFUs who are
also diagnosed as COVID-19 positive
Diabetes is one of the known comorbidity compared with those who are COVID-19
factors for COVID-19 [6, 7]. The prevalence negative.
of diabetes mellitus increased from 108
million in 1980 to 422 million in 2014 2. METHODS
according to the WHO. In Southeast Asia, This cohort prospective study was conducted
the prevalence was 71.4 million in 2011 and at the Surgery Department of Prof. Dr. R.D.
this is predicted to increase to 120 million Kandou Hospital Manado from March to
people in 2030 [8,9]. Diabetes mellitus is a June 2020. This study was approved by the
syndrome that includes metabolic and ethics commission for research at Prof. Dr.
vascular aspects in which fasting, R.D. Kandou Hospital Manado (license no.
postprandial, or random blood glucose levels 039/EC- KEPK/V/2020) and has been
increase. It can be classified into two types, registered with the Research Registry (no.
type 1 diabetes mellitus (insulin-dependent) 6341). This study is reported in line with the
and type 2 diabetes mellitus (non-insulin- Strengthening the Reporting of Cohort
dependent). Complications from type 2 Studies in Surgery (STROCSS) guidelines
diabetes mellitus are grouped into two [15].
categories, microvascular (e.g., diabetic
retinopathy, diabetic nephropathy, and 2.1 Population and Sampling
diabetic neuropathy) and mac- rovascular The population included in this study were
(e.g., coronary vascular disease, peripheral patients with type 2 diabetes mellitus and
vascular disease, brain vascular disease) DFUs with asymptomatic COVID-19 either
[10–12]. Diabetic foot ulcers (DFUs) occur in posi- tive or negative COVID-19 by RT-
more than 25% of patients with diabetes. It PCR of nasopharyngeal swab results. The
causes infection in 50% and amputation in inclusion criteria were: type 2 diabetes
20% of patients. The number of lower mellitus (random blood glucose > 200
extremity ampu- tations is 10-20-fold higher mg/dL and HbA1c > 6.0%) with DFUs

currently or pre- viously receiving holistic blood counts and NLR were determined at
therapy for diabetes mellitus, an our institution’s clinical laboratory using a
ankle- brachial index over 0.9, HbA1c Sysmex XP-300™ (Sysmex; Kobe, Japan)
levels below 8%, and hemoglobin levels according to the manufacturer’s
above 7.5 g/dL%. Individuals with a type instructions. Serum electrolytes, liver
1 diabetes mellitus, traumatic ulcer, function, renal function, and albumin were
malignancy, coagulopathy, or any measured at our institution’s laboratory
peripheral vascular disease were excluded using the Cobas® 8000 (Roche
from this study. The 20 remaining patients Diagnostics, Indianapolis, IN, USA)
were screened for COVID-19 according to according to the manufacturer’s
the hospital’s COVID-19 protocol and instructions.
Indonesian health protocols. The COVID- Nasopharyngeal swabs were sent in a
19 IgG/IgM Rapid Diag- nostic Test protected container directly to the
identified 10 people as reactive and 10 laboratory for COVID-19 RT-PCR tests with
as non-reactive for SARS-CoV2 Abbott RealTime SARS- CoV-2 Assay from
antibodies. The 10 reactive patients were Abbott Molecular Inc, (Salt Lake City, IL,
tested for COVID-19 by RT-PCR of USA) ac- cording to the manufacturer’s
nasopharyngeal swab samples and 8 of instructions [16–18]. ICAM-1 serum levels
these patients tested positive. The patients were measured 1-week before and after
were then divided into two groups, 8 in the debridement according to the protocol in
COVID-19 group and 12 in the non-COVID- the Human sICAM-1 ELISA Kit (Merck
19 group. Patients provided their written Millipore, cat. no. ECM335, Burlington,
informed consent after receiving Massachusetts, USA) [9,19,20]. All patients
information about the advan- tages and were then treated with a protocol for DFUs
risks of participating in the study. that included debridement. Blood samples
were stored at 2-5 ◦C before being
2.2 Procedure centrifuged (1000 rpm) for 60 min until
Before debridement, patients with DFUs coagulation occurred. The resulting
were screened for COVID-19 using the samples were stored at—80 ◦C until further
IgG/IgM Rapid Diagnostic Test followed by analysis.
an RT-PCR swab test if the former was The typical range for leucocytes is 4.0–10.0
reactive. Other tests included a chest x-ray
(pneumonia), blood test [complete blood 10/μL, erythrocytes 4.70 to 6.10
count, neutrophil to lympho- cyte ratio 103/μL, hemoglobin 13.0–16.5 g/dL,
(NLR)], liver function test (SGOT, SGPT), natrium 135 to 153 mEq/L, kalium 3.50 to
renal function test (urea, serum creatinine), 5.30 mEq/L, chloride 98.0 to 109.0 mEq/L,
and serum electrolyte (natrium, kalium, SGOT <33 U/L, SGPT <43 U/L, urea 10–40
chloride), albumin, and ICAM-1 levels. mg/dL, serum creatinine 0.5–1.5 mg/dL,
All patients underwent baseline digital and albumin 3.50–5.70 g/dL.
anteroposterior chest radi- ography at full
inspiration using a chest radiographic 2.3 Statistical analysis
instrument (RADspeed Pro style edition Results from this study were presented as
MC, Shimadzu Corporation, Kyoto, Japan). descriptive and analytical data. The
Blood was drawn from the peripheral vein descriptive tabulation of the patients’
before and after debridement. The COVID- characteristics was carried out according to
19 IgG/IgM Rapid Diagnostic Test was the type of variable. Normally distributed
applied immediately with the SARS-CoV-2 data are presented as a mean and
Antibody Test (Lateral Flow Method) from standard deviation. If the distribution was
Guangzhou Wondfo Biotech Co Ltd not normal, median and interquartile range
(Guangzhou, China); while the complete (IQR) were used for nu- merical variables
and proportions for categorical variables.

The t-test (or Mann-Whitney U test) and had a median over 3.13 with no significant
chi-square test (or Fisher’s exact test) were difference observed between the two
used to correlate patient characteristics groups, although the value from the non-
with their RT-PCR test results. Univariable COVID-19 group was higher (Table 1). The
distribution was presented using charts same was found for serum electrolyte
(histogram, boXplot, and Q-Q plot) for levels, such as so- dium, potassium, and
numerical data and a bar chart for chloride. There was no significant
categorical data. The Shapiro-Wilk test was difference in the random blood sugar levels
used to determine the normality of the dis- between the COVID-19 and non-COVID-
tribution of numerical variables. Serum 19 groups (p 0.323). Liver function
ICAM-1 levels were analyzed based on parameters (SGPT and SGOT) were within
their relationship with the RT-PCR swab the normal limits for both groups. Renal
test results for pre- dicting accuracy in function tests (urea and serum creatinine) in
COVID-19 infection. The non-parametric the COVID-19 group appeared higher than
Mann- Whitney U test was used to the non-COVID-19 group (55.5 mg/dL and
differentiate serum ICAM-1 levels from the 1.9 mg/dL vs 33.5 mg/dL and 1.1 mg/dL).
COVID-19 and non-COVID-19 groups. In contrast, serum albumin levels in the non-
Repeated measure analysis of variance COVID-19 group indicated hypoalbuminemia
(ANOVA) was used to determine the effect (mean albumin serum 2.5 0.7 g/ dL) and
of time and the interaction between groups were lower than the COVID-19 group (mean
and time. All data were processed and albumin serum 3.2 ± 0.5 g/dL; p 0.027).
analyzed using R version 4.0.1 software. Table 2 compares the relationship between
Descriptive tabulation, graphing, and serum ICAM-1 levels in the COVID-19 and
regression modeling were performed using non-COVID-19 groups before and after
the software’s packages. Data were debridement and with other COVID-19
prepared using Microsoft EXcel 2017. criteria, such as high NLR value, pneumonia,
leukopenia or leucocytosis, and
3. RESULTS lymphocytopenia. Regardless of the time of
The 20 patients with DFUs who participated examination (before or after debridement),
in this study underwent the RT-PCR swab serum ICAM-1 levels differed between
test and were categorized into two groups, patients in the swab-positive and negative
those with COVID-19 and those without. groups. There were notable differences in
The RT-PCR swab test identified 12 pos- ICAM-1 levels between the COVID-19 and
itive and 8 negative samples. The mean non-COVID-19 groups at baseline and even
age was 53 years and there was no after debridement (p< 0.001). However, the
difference in terms of age between the two differences in ICAM-1 levels before and
groups. The sex ratio was almost equal, with after debridement in each group were non-
slightly more men diagnosed with COVID- significant. Remarkable differ- ences were
19 than women and no significant also seen in the NLR values (p 0.001) and
differences among those in the non-COVID- leukocyte counts (p 0.042). The results in
19 group. Anemia was seen in both groups, Fig. 1 mirror those presented in Table 2,
with a mean hemoglobin level of 10.01 g/dL. where ICAM-1 levels were significantly
Leukocyte counts for both groups indicated elevated in the COVID-19 group relative to
leucocytosis, with the median value from the non-COVID-19 group, before and after
the COVID-19 group being slightly lower debridement. The other criteria in Table 2
than from the non-COVID-19 group; did not correlate significantly, except for
however, this difference was not the association between pneumonia and the
statistically significant (12.9 vs 16.3; p results of the RT-PCR COVID-19 swab test.
0.280). The median platelet counts for both However, some patients with negative
groups were within normal limits. The NLR swab tests were also diagnosed with

pneumonia during the treatment. As such, elevated levels of ICAM-1 mark a
pre-existing inflammation process. Moreover,
4. DISCUSSION a retrospective study in China of 39 patients
A novel finding from our study is that ICAM-1 with COVID-19 and 32 controls showed that
levels were signifi- cantly elevated in patients the former had significantly increased levels
with COVID-19 with DFUs compared with of ICAM-1 and other endothelial adhesion
patients without COVID-19 (Table 2 & Fig. 1). molecules, which may contribute to
This suggests that ICAM-1 could be used as coagulopathy [22]. COVID-19-associated
an additional biomarker of COVID-19 since coagulopathy seems to happen due to
inflam- mation plays a crucial role in the excessive levels of von Willebrand factor,
pathogenesis of the disease. Induced by platelet activation, and hypercoagulability
inflammation, ICAM-1 facilitates leukocyte- [23]. Therefore, an acute inflammatory
endothelial binding and the migration of process followed by a hypercoagulable state
leukocytes across the endothelial barrier [21]. can contribute to the severity of COVID-19.

TABEL 1
Patient characteristics.

TABEL 2
The relationship between serum ICAM-1 levels and screening criteria for COVID-19 and RT-PCR
swab test results

Fig. 1. The relationship between serum ICAM-1 level both the innate and adaptive immune
and RT-PCR COVID-19 swab test results based on responses to become dysregulated; the
time of examination, pre- (1) and post- (2) ulcer resulting impairment contributes to the
debridement. P-value for repeated-measure ANOVA systemic tissue damage, respi- ratory and
for swab test result group <0.001, time <0.001, and multiorgan failure, and inability to defend
interaction = 0.721. against invading pathogens characteristic of
the disease. A harmful cytokine storm de-
Diabetes is one of many comorbidity risk velops more readily when patients with
factors for COVID-19. The pathological diabetes are presented with an immune insult
mechanism underlying diabetes, including due to their preexistent, chronic low-grade
chronic inflammation and coagulopathy, hyper-- inflammatory state. Moreover,
encourages COVID-19 progression. particularly in cases with a high viral load, the
Inflammatory biomarkers such as IL-6, C- capacity to mount an effective acute immune
reactive protein, serum ferritin, coagulation response against SARS-CoV-2 might be
index, and D-dimer are increased in patients compromised in these patients, thereby
with diabetes compared with those without rendering them more susceptible to the
diabetes [24]. Other studies also found severe adverse effects associated with
higher levels of serum ICAM-1 in patients COVID-19 [24].
with diabetes compared with controls [25]. In
patients with diabetes, hyperglycemia causes

Moreover, hyperglycemia stimulates the parameters associated with COVID-19 that
production of coagulation factors such as von enable early diagnosis and, ideally, accurate
Willebrand factor, factor VII, factor VIII, factor prognosis.
IX, factor XII, the extrinsic pathway, and
thrombin factor, which leads to excessive 5. CONCLUSIONS
thrombus formation in the arteries, veins, and The statistically significant increase in ICAM-
microvascular circulation [26]. 1 serum levels among patients with COVID-
19 compared with their non-COVID-19
A complication associated with diabetes is counter- parts supports the inclusion of this
metric as a preliminary screening method for
DFUs caused by periph- eral neuropathy, SARS-CoV-2 infection particularly for
asymptomatic patients prior to surgery or
reduced peripheral blood flow, and peripheral other medical procedures to enable
healthcare workers to take the proper
artery disease [27–30]. DFU management precautions when providing care for these
patients.
requires a multidisciplinary approach
DECLARATION OF COMPETING INTEREST
including blood glucose control, proper The authors declare that they have no conflict of
interests.
wound treatment, and eliminating risk factors
ACKNOWLEDGEMENTS
that may hinder or delay the wound healing We would like to thank all doctors and patients
at the Faculty of Medicine, Sam Ratulangi
process. However, patients with COVID-19 University and Prof. Dr. R. D. Kandou Hospital
Manado, Indonesia, who contributed to this
are subjected to a severe systemic study.

inflammatory response and APPENDIX A. SUPPLEMENTARY DATA
Supplementary data related to this article can be
hypercoagulability that further compromises found at https://do
i.org/10.1016/j.amsu.2021.02.017.
the blood supply to the ulcer and adds
PROVENANCE AND PEER REVIEW
additional burden to the ongoing infection by Not commissioned, externally peer-reviewed.

prolonging the inflammation, hence wors- ETHICAL APPROVAL
All procedure for human experiment has been
ening the DFU outcome [27]. approved by Ethics Commission of Kandou
Hospital Manado, Number: 039/EC-KEPK/V/
Albumin is an essential protein in the wound 2020.
healing process [31]. Low albumin levels are
associated with inflammation and are often SOURCES OF FUNDING
found in difficult-to-heal diabetes-associated No funding or sponsorship.
wounds [32,33]. Our findings support this
theory as low albumin levels were found in AUTHOR CONTRIBUTION
both patient groups (Table 1). In addition, an MHO, MCO, BJK, DET, FGL, HW, DMA, AMJ,
observational study of patients with COVID- and MF wrote the manuscript and participated in
19 in Italy found that severe the study design. MHO, MCO, BJK, DET, FGL,
hypoalbuminemia is positively correlated with HW, DMA, and AMJ drafted the manuscript.
COVID-19 mortality (HR: 2.48, 95% CI: 1.44–
4.26; p=0.001) and is also associated with
old age (R 0.367; p < 0.001) [34]. In their
historical prospective study, Akirov et al.
also correlated with hypoalbuminemia with
mortality among hospitalized patients diag-
nosed with several comorbidities including
malignancy, ischemic heart disease, and
diabetes mellitus [35]. Unfortunately, the
correlation be- tween COVID-19 severity and
low albumin levels were not analyzed in this
study due to its small sample size and limited
data collection period, which are the
limitations of this study. Therefore, further
research is needed to identify other

MHO, MCO, BJK, DET, FGL, HW, DMA, AMJ, Dalam Indones. 7 (2020) 45,
and MF checked the manuscript and made https://doi.org/10.7454/jpdi.v7i1.415.
corrections. MHO, FGL, HW, DMA, AMJ, and 5. D. Cucinotta, M. Vanelli, WHO declares
MF performed bioinfor- matics analyses and COVID-19 a pandemic, Acta Biomed. 91
revised the manuscript. MHO, MCO, BJK, DET, (2020)157–160,
and FGL provided the overall guidance and https://doi.org/10.23750/abm.v91i1.9397.
support. All authors read and approved the final 6. M. Zhang, W. Gao, COVID-19 and diabetes
manuscript. cutaneous comorbidity, Metab. Open 7
(2020)100055,
REGISTRATION OF RESEARCH STUDIES https://doi.org/10.1016/j.metop.2020.10005
This study has been registered with the 5.
Research Registry no. 6341. 7. S. Das, K.R. Anu, S.R. Birangal, A.N.
https://www.researchregistry.com/register- Nikam, A. Pandey, S. Mutalik, A. Joseph,
now#home/registrat Role of comorbidities like diabetes on
iondetails/5fcce2e1748734001c96ba4c/ severe acute respiratory syndrome
coronavirus-2: a review, Life Sci. 258
GUARANTOR (2020)118202,
Mendy Hatibie Oley. https://doi.org/10.1016/j.lfs.2020.118202.
8. V. Mohan, Y.K. Seedat, R. Pradeepa, The
CONSENT rising burden of diabetes and hypertension
The research was conducted ethically in in Southeast Asian and African regions:
accordance with the World Medical Association need for effective strategies for prevention
Declaration of Helsinki. The patients have given and control in primary health care settings,
their written informed consent on admission to Int. J. Hypertens. 2013 (2013) 409083,
use their prospective data base and files for https://doi.org/10.1155/2013/409083.
research work. 9. M.H. Oley, M.C. Oley, D.E. Tjandra, S.W.
Sedu, E.R.N. Sumarauw, D.M.R. Aling, J.
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LIVER TRANSAMINASE LEVELS AND NEUTROPHIL TO LYMPHOCYTE RATIO AS
PROGNOSTIC AND PREDICTOR IN CORONAVIRUS DISEASE 2019

Jonathan Arifputra1*, Bradley Jimmy Waleleng2, Fandy Gosal2, Nelly Tendean Wenas2, Luciana Rotty2, Jeanne Winarta2,
Andrew Waleleng2

1Department of Internal Medicine, Faculty of Medicine, Sam Ratulangi University, Prof. Dr. R. D. Kandou Hospital, Manado,
Indonesia; 2Division of Gastroenterology-Hepatology, Department of Internal Medicine, Faculty of Medicine, Sam Ratulangi
University, Prof. Dr. R. D. Kandou Hospital, Manado, Indonesia

ABSTRACT
BACKGROUND: Coronavirus disease 2019 (COVID-19) was a disease caused by the severe acute
respiratory syndrome coronavirus-2 (SARS-CoV-2) virus with severe respiratory distress syndrome.
SARS-CoV-2 can attack the gastrointestinal and liver system. In several studies, elevated levels of
alanine aminotransferase (ALT) and aspartate aminotransferase (AST) were reported, ranging from
14% to 53%. The increase of neutrophil to lymphocyte ratio (NLR) also increases the risk of mortality in
COVID-19.
AIM: This research wants to study ALT, AST, and NLR as prognostic and predictor in COVID-19.
METHODS: A cross-sectional retrospective study was conducted on COVID-19 patients. The
diagnostic criteria are based on the recommendations of the Indonesian Ministry of Health. The
patient’s blood was examined in a central laboratory at the hospital. Data analysis was done using
SPSS version 22.
RESULTS: A total of 126 patients with COVID-19 were included in this study. There are 57 (45.2%)
patients having abnormal liver test. There was a significant difference in the mean AST and NLR
between non-survival and survival outcome in COVID-19 patients (82.91 ± 103.82 vs. 40.54 ± 33.59
U/L; p = 0.0001 and 7.42 ± 3.65 vs. 3.47 ± 2.41;p = 0.0001). High AST (≥34.5 U/L) and NLR (≥4.7)
independently associated with non-survival outcome in COVID-19 patient with odds ratio 5.31 and 9.49
(1.89–14.95, 95% confidence interval [CI]; p = 0.002 and 3.57–25.22, 95% CI;p = 0.0001).
CONCLUSION: This study revealed that high AST and NLR at hospital admission were associated with
high mortality risk in COVID-19 patients. Therefore, AST and NLR can be a significant prognostic of
outcome in COVID-19 patients.

INTRODUCTION laboratory test alterations are associated with a
At the end of 2019, it was discoveredpneumonia worse prognosis. This research wants to study
caused by the severe acute respiratory ALT, AST, and NLR’s comparison of patient
syndrome coronavirus-2 (SARS-CoV-2) virus in outcome and their best cut point for outcome
Wuhan, China, which was named coronavirus prediction in COVID-19 patients.
disease 2019 (COVID-19). COVID-19 was
declared a pandemic in the world by the World METHODS
Health Organization (WHO) at the end of March A. Patient Selection
2020. SARS- CoV-2 has an almost identical This study was a cross-sectional retrospective
genome sequence with SARS-CoV. SARS- study conducted on COVID-19 patients who had
CoV-2 can be transmitted between humans been confirmed at Prof. Dr. R.D. Kandou
through close contact and airdroplets inhalation. hospital. Inclusion criteria are stated as follows:
So far, COVID-19 has spread in 215 countries Male or female aged ≥18 years old, patients
around the world [1], [2]. were diagnosed with COVID-19. From March 1,
Viral pneumonia is the primary manifestation of to June 30, 2020, 145 patients were diagnosed
COVID-19, which has symptoms such as fever, with COVID-19 based on the guideline for
fatigue, dry cough, anosmia, and headache. diagnosis and prevention coronavirus 2019 in
Lately, several studies show that COVID-19 can Indonesia. This study was approved by the Local
also attack other organs besides the respiratory Ethics Committee.
system, such as the gastrointestinal and liver
system. This is due tothe spread of main viral B. Confirmation Of Covid-19
entry, angiotensin-converting enzyme 2 (ACE2), The presence of SARS-CoV-2 was detected by
which is abundant in other organs such as the real-time reverse transcription PCR. Two
upper esophagus, enterocytes of the ileum and pairs of primers targeting the open reading
colon, liver, and bile duct cells [3], [4].The frame 1ab (ORF1ab) and the nucleocapsid
neutrophil to lymphocyte ratio (NLR) is an easy protein (N) were amplified and examined. The
test to do, by dividing the absolute count of corresponding sequences for ORF1ab were 5’-
neutrophils by the absolute count of lymphocytes. CCCTGTGGGTTTTACACTTAA-3’ (F), 5’-
NLR was reported to indicate the inflammatory ACGATTGTGCATCAGCTGA-3’ (R), and 5’-
status of patients. IncreasedNLR was a factor in CY3-
the risk of mortality from various diseases such CCGTCTGCGGTATGTGGAAAGGTTATGG-
as cancer, acute coronary syndrome, andcerebral BHQ1-3’ (probe), and those for were 5 ’ -
hemorrhage. Recent research has also revealed GGGGAACTTCTCCTGCTAGAAT-
that increasing the NLR value also increases the 3 ’ ( F ) , 5’-CAGACATTTTGCTCTCAAGCTG-
risk ofmortality in COVID-19 [5], [6], [7]. 3’(R), and 5’-FAM-
Liver impairment has also been reportedas a TTGCTGCTGCTTGACAGATT-TAMRA-
common manifestation, although it is not a 3’(probe). These diagnostic criteria are based on
prominent feature of the illness. Several the recommendations of the Indonesian Ministry
studies have shown different degrees of of Health.
elevated serum liver biochemistries in COVID-19
patients, mainly indicated by abnormal alanine C. Data Collection
aminotransferase (ALT) and aspartate Medical records from 145 patients werecollected
aminotransferase (AST) levels. Recent studies and examined by researchers. Identity,
have found that SARS-CoV-2 can bind to ACE2 laboratory, and outcome data from patients were
in cholangiocytes, which triggers cholangiocyte obtained from the hospital information system.
dysfunction and triggers a systemic Patient outcomes are categorized as survival and
inflammatory response that ends with liver non-survival. NLR, ALT, and AST
injury. In several studies, elevated levels of ALT The patient serum and peripheral venous blood
and AST were reported, ranging from 14% to were taken from all COVID-19 patients who were
53% [8], [9]. It remains unclear whether these

confirmed when the patient entered the hospital. data. Of the total, 126 patients consisted of 60
The patient’s blood was examined in the central men (47.6%) and 66 women (52.4%). A total of
laboratory at Prof Dr. R.D. Kandou Hospital 32 (25.4%) patients died during hospitalization.
following the hospital’s standard operative The mean age of the patients was 48.81 ± 15.70
procedures. Liver test abnormalitieswere defined years. There are 57 (45.2%) patients with an
as the elevation of AST >40 U/L and ALT >40 abnormal liver test consisted of increasing AST
U/L [9]. (38.1%) and ALT (31%). The baseline
characteristics of the patients are shown in Table
D. Statistical Analysis 1. NLR, AST, and ALT were higher in non-
Data analysis was performed through univariate survival than survival outcomes in COVID-19
and bivariate analyses using the SPSS 22nd patients (Table 1).There was a significant
version (SPSS Inc., Chicago) with a 95% difference in the mean AST levels between non-
confidence interval (CI). Bivariate analysis was survival and survival outcomes in COVID-19
performed using Mann–Whitney. Multivariate patients. Patients in the non-survival group had
analysis was performed using logistic higher AST levels than the survival group (82.91 ±
regression. Data were also analyzed using 103.82vs. 40.54 ± 33.59 U/L; p = 0.0001) (Table 1).
receiver operating characteristic (ROC) curve and There was no significant difference in the mean
Youden’s index, p < 0.05 was considered ALT levels between non-survival and survival
statistically significant. outcomes in COVID-19 patients (56.72 ± 71.71
vs. 34.57 ± 32.28 U/L; p = 0.136) (Table 1).
RESULTS There was a significant difference in the mean
In this study, 145 confirmed COVID-19 patients NLR between non-survival and survival
were found, but only 126 patients had complete outcomes

Table 1: Basic characteristics of the study population

Characteristics Outcome p

Non-survival Survival

n Min Max Median Mean SD n Min Max Median Mean SD

Age (years) 32 32.00 80.00 58.50 57.31 12.14 94 19.00 82.00 44.00 45.91 15.78 0.0001

NLR 32 1.71 15.17 7.04 7.42 3.65 94 0.70 13.00 2.58 3.47 2.41 0.0001

AST (U/L) 32 21.00 544.00 50.00 82.91 103.82 94 15.00 207.00 30.00 40.54 33.59 0.0001

ALT (U/L) 32 10.00 358.00 30.00 56.72 71.71 94 3.00 198.00 25.00 34.57 32.28 0.136

Min: Minimal; Max: Maximal; SD: Standard deviation; n: Count. NLR: Neutrophil to lymphocyte

ratio, AST: Aspartate aminotransferase, ALT: Alanine aminotransferase.

in COVID-19 patients. Patients in the non- best AST and NLR cut off point to give better
survival had NLR significantly higher than the sensitivity dan specificity to predict COVID-19
survival group (7.42 ± 3.65 vs. 3.47 ± 2.41; p = patients’ outcome. For AST, the best cutoff point
0.0001) (Table 1). Analysis using the ROC test was 34.5 U/L to get 78.12% sensitivity and
showed that ASThad an area under the ROC of 61.70% specificity, and for NLR, the best cutoff
0.739 (p = 0.0001), andNLR had an area under point was 4.7 to get 75% sensitivity and 79.78%
the ROC of 0.830 (p = 0.0001) (Figure 1). specificity.
Youden’s index was calculated to determine the

Figure 1: ROC curve of AST and NLR

After logistic regression analysis was performed, high AST (≥34.5 U/L) and NLR (≥4.7) remained
independently associated with non-survival outcome in COVID-19 patient with odds ratio 5.31 (1.89–
14.95, 95% CI; p = 0.002) and 9.49 (3.57-25.22, 95% CI; p = 0.0001), respectively (Table 2).

Table 2. Logistic regression analysis of predictors of COVID-19patients’ mortality

Variablea OR (95% CI) p
AST (≥34.5 U/L) 5.31 (1.89–14.95) 0.002
NLR (≥4.7) 9.45 (3.57–25.22) 0.0001

CI: Confidence interval; OR: Odds ratio; aadjusted for gender. NLR: Neutrophil to lymphocyte ratio, AST:
Aspartate aminotransferase

DISCUSSION Several studies have shown that SARS-CoV-2
In this study, 45.2% of COVID-19 patients had requires ACE2 as a receptor to enter cells,
abnormal liver tests, where there was an where ACE2 is mainly expressed in the heart,
increase in AST by 38.1% and ALT by 31%. Fan lungs, and kidneys. In addition, ACE2 is also
et al. also found that there were abnormal liver slightly expressed in the colon and liver. The
tests in 37.1% of patients with COVID-19 [10]. previous studies have shown that ACE2
This result is almost the same as the study expression is present in cholangiocytes,
conducted by Chen et al., where the increase in suggesting that cholangiocyte is the direct target
AST was 35%, and ALT was 28% [11]. of SARS-CoV-2 to attack the liver. The increase
Liver impairment is closely related to mortality in in AST and ALT is an indicator of liver cell
COVID-19 patients. In this study, it was found damage. However, pathological analysis of the
that AST and ALT values were higher in COVID- liver tissue of COVID-19 patients failed to prove
19 patients with the non-survival group, where that cholangiocyte damage and viral infiltration
statistically, AST levels had a significant in liver tissue occurred. The specific cause of
difference between COVID-19 patients with non- liver damage and elevated liver transaminase
survival and survival outcome (p < 0.05). enzymes is not clear and needs further study [8],
Several studies also found that AST increases [9], [14], [15], [16], [17], [18], [19].
more frequently than ALT in severe COVID-19 In this study, it was found that there was an
patients [12], [13]. A study conducted by Lei et al. increase in NLR in COVID-19 patients with the
gave similar results, in which patients with non- survival outcome, which was statistically
elevated AST had a high risk of mortality [14]. significant when compared with COVID-19

patients with survival outcome (p < 0.05). Liu et mortality risk in COVID-19 patients. Therefore,
al. also obtained the same results, where a AST and NLR can be a significant prognostic of
higher increase in NLR was associated with an outcome in COVID-19 patients. However, a
increased risk of mortality in COVID-19 patients scoring system is needed to have a more
[7] Research conducted by Yan et al. also found accurate prediction of prognosis.
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SENSITIVITAS PEMERIKSAAN CT-SCAN PADA PASIEN DENGAN CORONAVIRUS
DISEASE2019 (COVID-19)

Muhammad F. H. Putra,1 Vonny N. Tubagus,2 Yovana P. M. Mamesah2

1Program Studi Pendidikan Dokter Fakultas Kedokteran Universitas Sam Ratulangi, Manado, Sulawesi
Utara, Indonesia
2Bagian Radiologi Fakultas Kedokteran Universitas Sam Ratulangi/RSUP Prof. Dr. R. D. Kandou
Manado, Sulawesi Utara, Indonesia
Email: [email protected]

Abstract: COVID-19 is an infectious disease caused by SARS-CoV-2 virus that has become ahealth
problem worldwide, including Indonesia. The SARS-CoV-2 was identified in the early 2020. For current
diagnostic procedures, RT-PCR is considered as the gold standard in COVID- 19 detection. However,
there is another alternative method which is the chest CT-scan that can supports the diagnosis of
COVID-19 faster. This study was aimed to determine the sensitivity ofthe CT scan in COVID-19 patients.
This was a literature review study using three databases, as follows: Pubmed, ClinicalKey, and Google
Scholar. The keywords used were sensitivity AND CTscan AND COVID-19. After being selected based
on inclusion and exclusion criteria, 10 literatures would be discussed. The results showed that the
sensitivity of the CT scan among COVID-19 patients was quite good and had a sensitivity percentage
ranging 70-90%. In comparison with the RT-PCR examination, the CT scan results are quite good. CT
scan has a highsensitivity to COVID-19 and has a better result compared to the RT-PCR test.

Keywords: sensitivity of test, CT scan, COVID-19

Abstrak: COVID-19 merupakan penyakit infeksi yang disebabkan oleh SARS-CoV-2 yang telah menjadi
masalah kesehatan di dunia, termasuk di Indonesia. SARS-CoV-2 baru teridentifikasi pada awal tahun
2020. Untuk prosedur diagnostik saat ini, RT-PCR dianggap sebagai standar baku emas dalam deteksi
COVID-19. Namun terdapat metode lain yaitu pemeriksaan CT scan toraksyang merupakan tes alternatif
cepat untuk dilakukan dan dapat membantu menegakkan diagnosis COVID-19. Penelitian ini bertujuan
untuk mengetahui sensitivitas dari pemeriksaan CT scan padaCOVID-19. Jenis penelitian ialah literature
review dengan pencarian data menggunakan tiga database yaitu Pubmed, ClinicalKey, dan Google
Scholar. Kata kunci yang digunakan yaitu sensitivity AND CT scan AND COVID-19. Setelah diseleksi
berdasarkan kriteria inklusi dan eksklusi, didapatkan 10 literatur yang dibahas dalam penelitian ini. Hasil
penelitian menunjukkan bahwa sensitivitas pemeriksaan CT scan pada COVID-19 cukup baik dan
memiliki rentang persentase sensitivitas 70-90%. Pada perbandingan dengan pemeriksaan RT-PCR
didapatkan hasil yang cukup baik untuk pemeriksaan CT scan. Pemeriksaan CT Scan memiliki nilai
sensitivitasyang cukup tinggi pada COVID-19 dan lebih baik dibandingkan RT-PCR.

Kata kunci: sensitivitas tes, CT scan toraks, COVID-19

PENDAHULUAN terdapat lima dari 167 pasien (3%) pernah
Coronavirus disease 2019 (COVID-19) teridentifikasi RT-PCR negatif untuk COVID-19
merupakan penyakit infeksi oleh virus yangtelah pada presentasi awal meskipun terdapat temuan
menjadi masalah kesehatan di dunia, termasuk khas dari pneumonia virus pada pemeriksaan
di Indonesia. Penyakit yang disebabkan oleh CT scan toraks.5,6 COVID-19 telah ditetapkan
Severe Acute Respiratory Syndrome oleh WHO sebagai pandemi yang memerlukan
Coronavirus 2 (SARS-CoV-2) baru teridentifikasi kete- patan penenegakan diagnosis segera; hal
pada awal tahun 2020.1 Berdasarkan website ini yang mendorong penulis untuk menelusuri
WHO, data terkini per tanggal 16 Desember sensitivitas pemeriksaan CT scan toraks pada
didapatkan total jumlah kasus COVID-19 di COVID-19 serta membandingkannya dengan
seluruh dunia ialah sekitar 71,919,725 kasus pemeriksaan RT-PCR.
positif yang terkonfirmasi dan 1,623,064 kasus
kematian yang terkonfirmasi penyebab COVID- METODE PENELITIAN
19 yang diperoleh dari 216 negara yang Penelitian ini dilaksanakan dalam bentuk suatu
terindikasi pandemik COVID-19.2 Tercatat pada literature review mengenai sensiti- vitas
tanggal 16 Desember 2020, Indonesia pemeriksaan CT scan pada COVID-19. Data
melaporkan kasus terkonfirmasi COVID-19 yang diperoleh dalam penelitian ini merupakan
pertama hingga data terbaru yangmenunjukkan berbagai hasil penelitian, artikel atau jurnal
kasus telah mencapai angka 629,429 dengan nasional dan internasional yang diterbitkan
kasus kematian akibat COVID-19 sebanyak selama tahun 2020. Pencarian data di internet
19,111 kasus.3 Untuk prosedur diagnostik saat menggunakan database dari ClinicalKey,
ini, reverse-transcription ion polymerase chain Google Scholar, PubMed, dan berbagai sumber
reaction (RT-PCR) dianggap sebagai standar literatur lainnya. Kata kunci yang digunakan
baku emas dalam deteksi COVID-19. yaitu COVID-19 AND CT Scan AND sensitivity.
Mengingat keadaan darurat global saat ini, Pencarian data juga dilakuikan berdasarkan
sensitivitas variabel RT-PCR dan waktu tunggu tersedia- nya abstrak dan fulltext dari sebuah
yang lama untuk hasil menyiratkan bahwa literatur.Setelah melakukan seleksi berdasarkan
banyak pasien yang terjangkit COVID-19 kriteria inklusi dan eksklusi didapatkan 10 artikel
mungkin tidak dapat diiden- tifikasi, sehingga penelitian yang dibahas.
mempertaruhkan perpa-rahan infeksi yang lebih
lebih lanjut pada populasi sehat. Chest HASIL PENELITIAN
computed tomography (Chest CT) atau Berdasarkan 10 artikel penelitian yang telah
pemeriksaan CT scan toraks merupakan tes diperoleh, didapatkan data persentase nilai
alternatif cepat untuk dilakukan dan dapat sensitivitas CT scan pada pasien yang
membantu dalam diagnosis COVID-19, terindikasi positif COVID-19. Tabel 1
terutama dalamsituasi laboratorium yang sangat memperlihatkan persentase nilai sensitivitas CT
dibanjiri oleh pemeriksaan RT-PCR saat ini.4 scan masing-masing literatur yang dikaji dalam
Penelitian oleh Xie et al5 melaporkan bahwa penelitian ini.

Tabel 1. Data persentase nilai sensitivitas CT scan masing-masing literatur.

Nomor literatur Penulis Asal Negara Sensitivitas
CT scan toraks

1 He et al7 China 79%

2 Ai et al8 China 97%

3 Long et al9 China 97,2%

4 Fang et al10 China 98%

5 Wang et al11 China 96,5%

6 Dangis et al12 Belgium 86,7%

7 Falaschi et al13 Italia 90,7%

8 Fu et al14 China 85,9%

9 Himoto et al15 Jepang 100%

10 Wen et al16 China 93%

Hasil penelitian dari literatur ke-1 oleh He et al, 84,6%.
20207 di China mendapatkan bahwa dari 34
pasien saat melakukan pemeriksaan awal RT- Hasil penelitian dari literatur ke-4 oleh Fang et
PCR sebanyak 27 orang memiliki hasil positif al, 202010 di China mendapatkan perbedaan
COVID-19 sedangkan hasil pemeriksaan dari hasil positif COVID-19 yaitu dari 51 pasien pada
CT scan toraks mendapatkan hasil positif awal pemeriksaan, 36 memiliki hasil positif pada
COVID-19 pada 26 pasien. Dengan demikian pemeriksaan RT- PCR sedangkan pada
nilai sensitivitas RT-PCR berada di persentase pemeriksaan CT scan toraks didapatkan 50
79% sedangkan CT scan toraks memiliki nilai pasien memiliki hasil abnormal, 36 pasien (72%)
persentase 77%. Nilai spesifitas RT-PCR yaitu memiliki gam- baran manifestasi tipikal
100% dan CT scan toraks 96% sedangkan sedangkan 14 pasien (28%) memiliki gambaran
untuk nilai akurasi PCR yaitu 92%dan CT scan manifes- tasi atipikal sehingga untuk nilai
toraks 88%. sensitivitaspemeriksaan CT scan sekitar 98%.

Hasil penelitian dari literatur ke-2 oleh Ai et al, Hasil penelitian dari literatur ke-5 oleh Wang et
20208 di China mendapatkan hasil dari 1014 al, 202011 di Jepang mendapatkan hasil dari
pasien terdapat 601 yang positif COVID-19 114 orang, hanya 3 orang saja yang tidak
dengan pemeriksaan RT-PCR dan 580 dari 601 memperlihatkan hasil abnormal pada
tersebut mendapatkan hasil CT scan toraks pemeriksaan CT scan toraks dan 1pasien yang
positif. Untuk hasil negatif didapatkan sejumlah memperlihatkan adanya dilatasi pada bagian
413 dari hasil pemeriksaan RT-PCR; 308 dari tengah kanan dan bawah paru namun tak
413 tersebut mendapatkan hasil positif pada menunjukkan abnormalitas lain- nya. Semua
pemeriksaanCT scan toraks. pasien lainnya menunjukkan abnormalitas pada
hasil pemeriksaannya. Dari hasil tersebut
Hasil penelitian dari literatur ke-3 oleh Long et didapatkan sensitivitas pemeriksaan CT scan
al, 20209 di China mendapatkan hasil dari 36 toraks sekitar 96,5%.
kasus COVID-19 disertai pneumonia dan pada
pemeriksaan CT scan toraks didapatkan 35 Hasil penelitian dari literatur ke-6 oleh Dangis et
pasien memiliki hasil CT scan abnormal. Hasil al, 202012 di Belgia mendapatkandari 192 pasien
pemeriksaan RT- PCR mendapatkan 30 pasien yang dilakukan pemeriksaan CT scan dosis
positif COVID-19 sehingga hal tersebut mengha- rendah (Low Dose Sub Millisievert CT scan)
silkan nilai sensitivitas pemeriksaan CT scan didapatkan nilai sensitivitas 86,7%, spesifitas
toraks sekitar 97,2% dan RT-PCR sekitar 93,6%, dan akurasi 90,2% yang telah

dibandingkan dengan RT-PCR. Hasil penelitian dari literatur ke-9 oleh Himoto et
al, 202015 mendapatkan hasil dari21 pasien yang
Hasil penelitian dari literatur ke-7 oleh Falaschi sudah terkonfirmasi positif COVID-19,
et al, 202013 yang melakukan pene- litian pada semuanya memiliki gambaran hasil CT scan
masa epidemi di Italia pada 773 pasien dengan toraks yang abnormal (GGO bilateral,
pemeriksaan CT scan toraks dan telah limfadenopati mediastinal, efusi pleura, dll)
dilakukan beberapa prosedur lainnya sehingga sehingga didapatkan hasil persentase
mendapatkan data hasil sensitivitas dari sensitivitas CT scan toraks sebesar 100%.
pemeriksaan CT scan toraks itu sendiri sekitar
90,7%, spesifitas 78,8%, dan akurasi 85,9%. Hasil penelitian dari literatur ke-10 olehWen et al,
202016 mendapatkan hasil dari 103 pasien yang
Hasil penelitian dari literatur ke-8 oleh Fu et al, dalam pengawasan, dida- patkan 86 pasien
202014 di China mendapatkan hasil dari 64 (85%) pasien positifCOVID-19, sedangkan untuk
pasien, 58 diantaranya memiliki temuan hasil pemerik- saan CT scan toraks dari 88
abnormal pada pemeriksaan CT scan toraks. CT pasien yang positif hasil RT-PCR didapatkan 82
scan pertama (dalam 2 hari)memiliki sensitivitas orang memiliki hasil abnormal sehingga nilai
yang lebih tinggi dari RT-PCR dalam sensitivitas dari pemeriksaan CT scan toraks
mendeteksi COVID-19 yaitu sekitar 85,9% untuk sekitar 93%.
CT scan toraks dan 56,3% untuk RT-PCR. mendapatkan dari 51 pasien diperoleh 15
pasien yang mendapat- kan hasil negatif untuk
BAHASAN pemeriksaan RT-PCR namun hasil positif untuk
Berdasarkan hasil kajian literatur- literatur pemeriksaan CT scan toraks. Ketika ditotalkan
penelitian yang telah dijelaskan, didapatkan jumlahnya dengan pasien yang positif untuk
bahwa pemeriksaan CT scan toraks pada kedua pemeriksaan tersebut didapatkan bahwa
COVID-19 memiliki sensiti- vitas yang baik dan CT scan memiliki sensitivitas yang lebih tinggi
bahkan pada beberapa penelitian, persentase yaitu sekitar 50 orang atau 98% diban- dingkan
nilai sensitivitas mencapai nilai 98-100%.10,15.Hal RT-PCR yang hanya dapat mendeteksi 36 orang
ini bisa menjadi tolak ukur bahwa pemeriksaan saja.10
CT scan bisa dijadikan salah satu metode dalam
menilai kondisi seseorang yang telah terinfeksi Angka ini malah menunjukkan terdapat
COVID-19. Pada penelitian oleh He et al7 perbedaan bermakna antara CT scan dan RT-
dilakukan proses pembandingan hasil PCR dibandingkan penelitian sebelumnya.
pemeriksaan RT-PCR dan CT scan toraks Menurut Fang,10 alasan yang menyebabkan
dalam men- diagnosis COVID-19 pada 82 hasil deteksi asam nukleat virus memiliki
pasien yang dirawat. Setelah melakukan efektifitas rendah yaitu perkembangan teknologi
pemeriksaan RT-PCR didapatkan 34 positif dan pendeteksian asam nukleat yang belum matang;
48 negatif COVID-19. Pada pemeriksaan awal variasi dalam tingkat deteksi dari produsen yang
RT-PCR didapatkan sebanyak 27 pasien positif berbeda; viral load pasien yang rendah, atau
dan 7 pasien dalam pengawasan dari total 34 pengambilan sampel klinis yang tidak tepat.
pasien yang diatas. Pemeriksaan RT-PCR dan CT scan toraks
efektif dalam skrining cepat COVID-19.
Hasil pemeriksaan CT scan toraks dari 34 Kombinasi pemeriksaan RT-PCR dan CT scan
pasien yang telah dirawat tersebut sebelumnya toraks dapat dilakukan jika salah satu
telah menunjukkan sebanyak 26 pasien memiliki pemeriksaan negatif.7 Keuntungan CT scan
hasil CT scan positif untuk COVID-19 dan 6 toraks untuk mendeteksi COVID-19 pada pasien
pasien memiliki normal sehingga tidak bergejala dengan sensitivitas yang lebih tinggi
didapatkan perbedaan hasil secara statistik dan pada periode waktu awal infeksi ini cukup
pada kedua pemeriksaan tersebut.7 Berbeda penting dan harus dijelaskan lebih lanjut dalam
halnya dengan penelitian oleh Fang et al10 yang studi prospektif.10,12

F, Liu J, et al. Chest CT for typical 2019-

SIMPULAN nCoV pneumonia: relationship to nega- tive
Tingkat sensitivitas dari pemeriksaan CT scan
toraks pada COVID-19 baik dalam menentukan RT-PCR testing. Radiology. 2020;296:E41–
diagnosis dan tingkat keparah- an dari COVID-
19. Tingkat sensitivitas dari CT scan toraks E45.
dibandingkan dengan RT- PCR pada beberapa
penelitian mendapatkan hasil yang lebih baik 6. Young D, Tatarian L, Mujtaba G, Chow P,
namun CT scan toraks masih belum disarankan
sebagai modalitas utama pada COVID- Ibrahim S, Joshi G, et al. Chest CT versus
19.Disarankan bahwa terkait dengan topik ini,
perlu dilakukan penelitian lebih mendalam juga RT-PCR for diagnostic accuracyof COVID-19
untuk kasus-kasus COVID-19 yang terjadi di
Indonesia mengingat masih sangat kurang detection: a meta-analysis search results. J
penelitian mengenai topik inidi Indonesia. Selain
itu, perlu dilakukan penelitian dan Vasc Med Surg. 2020; 8(3):3-4.
pengembangan mengenai topik ini lebih lanjut
dikarenakan topik ini masih terbilang cukup baru doi.org/10.35248/2329-
dan masih banyak penelitian selanjutnya yang
akan dilakukan di masa depan sehingga tidak 6925.20.8.392.Copyright
menutup kemungkinan hasil dan simpulan
penelitian ini akan berbeda dengan hasil 7. He J, Luo L, Luo Z, Liu J, Ng M, Shen X et al.
terbaru.
Diagnostic performance between CT and
KONFLIK KEPENTINGAN
Penulis menyatakan tidak terdapat konflik initial real-time RT-PCR for clinically
kepentingan dalam studi ini.
suspected 2019 coronavirus disease
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3.doi:10.1016/j.ajem.2020.04.051

POTENTIAL OF FECAL-ORAL TRANSMISSION AND
GASTROINTESTINAL MANIFESTATION OF COVID-19

Randy Adiwinata*, Visakha Revana Irawan*, Jonathan Arifputra*, Bradley Jimmy Waleleng**, Fandy
Gosal**, Luciana Rotty**, Jeanne Winarta**, Andrew Waleleng**, Marcellus Simadibrata***

*Department of Internal Medicine, Faculty of Medicine,
Universitas Sam Ratulangi/Prof. dr. R. D. Kandou Hospital, Manado
**Division of Gastroenterology-Hepatology, Department of Internal Medicine, Faculty of Medicine,
Universitas Sam Ratulangi/Prof. dr. R. D. Kandou Hospital, Manado
***Division of Gastroenterology, Department of Internal Medicine, Faculty of Medicine,
Universitas Indonesia/Dr. Cipto Mangunkusumo General National Hospital, Jakarta

Corresponding author:
Randy Adiwinata. Department of Internal Medicine, Faculty of Medicine, Universitas Sam Ratulangi/Prof. dr. R. D. Kandou
Hospital Manado Indonesia. Phone: +62-431-7283949. Email: [email protected]

ABSTRACT
The World Health Organization have declared COVID-19 as a pandemic. The COVID-19, caused by SARS-CoV-2,
is spreading at an alarming rate and creates a significant worldwide burden to the economy while increasing
morbidity and mortality. While COVID-19 was primarily considered as a respiratory-infection disease,several reports
have shown that many COVID-19 infected patients have presented or developed some digestivesymptoms. Many
studies also demonstrated, using reverse transcriptase-polymerase chain reaction method, that SARS-CoV-2 are
present in stools or other gastrointestinal tract secretions. All these reports raised the possibility of COVID-19
transmission via the fecal-oral route and the involvement of the gastrointestinal-liver system. Until further studies are
available, physicians should be aware of the digestive manifestation of COVID-19 and useuniversal precautions
to avoid the transmission of COVID-19 via the fecal-oral route.

Keywords: COVID-19, Coronavirus, gastrointestinal, liver, pandemic, infection

ABSTRAK
Badan Kesehatan dunia (World Health Organization/WHO) telah menyatakan COVID-19 sebagai suatu keadaan
pandemi. COVID-19, disebabkan oleh SARS-CoV-2, menyebar dengan cepat dan memberikan dampak beban
ekonomi akibat tingginya angka kesakitan dan kematian. COVID-19 diketahui sebagai penyakit pernafasan,akan tetapi
beberapa laporan menunjukkan bahwa pasien COVID-19 juga mempunyai gejala gangguan pencernaan.
Beberapa studi menunjukkan bahwa dengan penggunaan metode reverse transcriptase-polymerasechain reaction,
SARS-CoV-2 juga ditemukan pada faeces atau sekret saluran cerna lainnya. Laporan tersebut menimbulkan
hipotesa terkait kemungkinan penularan COVID-19 melalui jalur fecal-oral dan keterlibatan sistempencernaan dalam
patogenesisya. Hingga dibuktikan dengan penelitian lebih lanjut, para praktisi kesehatan hendaknya waspada
mengenai kemungkinan manifestasi pencernaan pada pasien penderita COVID-19 dan menegakkan
kewaspadaan universal selalu untuk menghindari kemungkinan transmisi COVID-19 melalui fecal-oral.

Kata kunci: COVID-19, Virus Corona, Pencernaan, Hati, Pandemi, Infeksi

INTRODUCTION CoV-2 RNA remained present in both stool
The novel Coronavirus (COVID-19) has been specimens and anorectal swabs of COVID-19
declared as a world pandemic. It is caused by patients, even after the swab result from upper
the severe acute respiratory syndrome respiratory tract was already negative. These
Coronavirus 2 (SARS- CoV-2), genus ß findings may indicate that the COVID-19 virus
Coronavirus. COVID-19 was first identified in was persistent in shedding on the
Wuhan, China, at the end of 2019.1,2 By the gastrointestinal tract even after viral clearance in
end of March 2020, COVID-19 had spread to the respiratory tract.6 Both the first COVID-19
202 countries and had infected 634,835 people cases reported in the United States and Europe
and caused 29,891 deaths worldwide.1 Fever turned up positive for the detection of SARS-
and respiratory symptoms are the major CoV-2 in their stools.7,8 The first COVID-19
symptoms of COVID-19 infection, but digestive patient in the United States was tested positive
symptoms are also present in some of the for SARS-CoV-2 in his stool using the reverse
patients.Based on recent studies, SARS-CoV-2 transcriptase polymerase-chain- reaction (RT-
ribonucleic acid can be found in fecal PCR) on the seventh day of illness.7 Two of the
specimens, which leads to the idea that SARS- first five cases in Europe had positive stool
CoV-2 can infect the gastrointestinal tract and detection in the first few days of illness, while
transmit via the fecal-oral pathways.3 This they did not have any digestive symptoms.8
review article will discuss the manifestations and Zhang et al conducted a retrospective analysis
infection of COVID-19 in the digestive tract. of 14 laboratory-confirmed cases of COVID-19
pneumonia. They found that 35.7% of the
EVIDENCE OF SARS-COV-2 TRACES IN SALIVA patients had positive stool samples for SARS-
AND FECES CoV-2 nucleic acid. They demonstrated that the
Several studies have shown the detection of accuracy of detection using either the stool or
SARS- CoV-2 in the gastrointestinal secretion the oropharyngeal swab was similar.9 Xu et al
products, mainly saliva and stool. Detection of presented other evidence that further raised the
SARS-CoV-2 in the saliva has raised the possibility of virus shedding in the
possibility of virus transmission and awareness gastrointestinal tract and the possibility of fecal-
among dentists when performing dental oral transmission. They found that 8 among ten
procedures. A study has shown that selected pediatric COVID-19 patients aged 2 months to
strains of SARS-CoV-2 have remain detected in 15 years old were positive for COVID-19 based
saliva for 29 days after infection. SARS-CoV-2 on RT-PCR results from rectal swabs. After
may be present in saliva, through (1) the liquid follow-up, those patients remained positive,
droplets frequently exchanged between the even after the nasopharyngeal swab turned
upper and lower respiratory tract; (2) SARS- negative.10 Xiao et al observed 73 COVID-19
CoV-2 accessed the oral cavity through the patients. About 39 (53.4%) patients were found
crevicular fluid; (3) SARS-CoV-2 directly infects to be positive for COVID-19 in their stool, with
major-minor salivary gland.4 To et al. have the duration ranging from one to twelve days.
discovered that SARS-CoV-2 could be detected Moreover, 17 (23.3%) patients remained positive
in salivary specimens from 20 of 23 subjects for COVID-19 in stool after being negative in
included in their study. The highest salivary viral their respiratory samples.11 All those evidence
load was detected during the first week when have demonstrated that COVID-19 can be
the symptoms occurred. The SARS-CoV-2 present in the stools of some COVID-19
detected viral load declines gradually after the confirmed cases, and that viral shedding on the
first-week onset.5 Further studies are still gastrointestinal tract may last longer compared
required to both characterize the SARS-CoV-2 to the respiratory tract. There is also a lack of
viral load in the saliva and to validate the correlation between the presence of digestive
diagnosis of COVID-19 using salivary samples. symptoms and the presence of positive tests
Previous studies have concluded that the SARS- from stool samples.3,8-11

GASTROINTESTINAL - RELATED COVID-19 claw-like ACE2-PD in complex with the RBD or
PATHOPHYSIOLOGY the S protein of SARS-CoV is a crucial
Coronaviruses are a family of single-stranded molecular detail. Esophageal epithelium is
enveloped DNA viruses that consists of four composed mostly of squamous epithelial cells,
major genera. SARS-CoV-2 have an almost which express less ACE-2 than glandular
identical genome sequence with SARS-CoV. epithelial cells. Thus, ACE-2 staining in the
Structurally, the SARS- CoV has a well-defined esophageal mucosa is very unlikely to bear
composition comprising 14 binding residues with desired results. After SARS-COV-2 binds to
human angiotensin-converting enzyme 2 (ACE- ACE2 receptors via glycoprotein S, the
2). It was reported that the coronavirus S protein endocytosis process begins. Then, virus-specific
is a significant determinant of virus entry into RNA and proteins are synthesized in the
host cells. In the case of SARS-CoV-2, the spike cytoplasm to assembly new virions, which can
glycoprotein (S protein) on the virion surface be released to the gastrointestinal tract. When a
mediates receptor recognition and membrane virus infects, enterocyte cells increases the
fusion. The cleavage of the SARS-CoV S protein gastrointestinal wall permeability to foreign
is facilitated by cathepsin L in endosomes, pathogens, producing enteric symptoms such as
indicating a mechanism of receptor-mediated diarrhea.3,13,14
endocytosis. During viral infection, the trimeric S
protein is cleaved into S1 and S2 subunits. S1 REPORTED GASTROINTESTINAL
subunits contain the receptor-binding domain MANIFESTATION OF COVID
(RBD), which directly binds to the peptidase COVID-19 infection is mainly regarded as a
domain (PD) of ACE-2, whereas the S2 is respiratory infection, which affects the
responsible for membrane fusion and viral respiratory tract with common manifestations
infectivity.3,11-14 Aside from membrane fusion, such as dry cough, running nose, shortness of
the clathrin-dependent and independent breath, and fever.12 However, several published
endocytosis also mediated SARS-CoV entry. case reports have shown that many COVID-19
After the virus enters the cells, the viral RNA patients had gastrointestinal manifestations
genome is released into the cytoplasm and is (Table 1) and signs of liver injury. Holshue et al.
translated into two polyproteins and structural reported the first case of COVID-19 in the United
proteins, after which the viral genome begins to States of which the patient came with a
replicate. The newly formed envelope complaint of persistent dry cough and a 2-day
glycoproteins are then inserted into the history of nausea and vomiting, followed by
membrane of the endoplasmic reticulum or abdominal discomfort and diarrhea during
Golgi, and the nucleocapsid is formed by admission. His stool was tested positive for
combining the genomic RNA and nucleocapsid COVID-19 using RT-PCR.7 Pan et al have
protein. Then, viral particles germinate into the released a report regarding the characteristics of
endoplasmic reticulum- Golgi intermediate COVID-19 patients in Hubei with digestive
compartment. Finally, the vesicles containing the symptoms. This study has revealed that among
virus particles then fuse with the plasma 204 COVID-19 patients, there are 103 patients
membrane to release the virus. 3,11-14 The (50.5%) with digestive symptoms of which a lack
mechanism for gastrointestinal tract infection of of appetite was most common (78.6%), followed
SARS-CoV-2 is proposed to be related to the by diarrhea (34%), vomiting (3.9%), and
ACE-2 cell receptor. The binding affinity of ACE- abdominal pain (1.9%). There were 6 patients
2 receptors is one of the most important with only gastrointestinal symptoms without
determinants of infectivity. Some cells in the respiratory symptoms. They also found that
human body have ACE 2 receptors such as AT2 COVID-19 patients with digestive symptoms
lung cells, upper esophagus, glandular cells of have demonstrated a higher level of liver
gastric, stratified epithelial cells and enterocytes enzymes and a worse clinical course.15 Another
of the ileum and colon. The interaction of the descriptive study was conducted by Zhang et al.,

which found that up to 39.6% of 140 COVID-19 symptoms.10 Qiu et al. also found that 6%
patients in Wuhan had GI symptoms. Nausea among 36 COVID-19 infected children in
was the most common GI symptom (17.3%), Zhenjiang had either a diarrhea or vomiting
followed by diarrhea (12.9%), anorexia (12.2%), symptom.17 Contrast findings was reported by
abdominal pain (5.8%), belching (5.0%), and Guan et al., who analyzed 1099 positive COVID-
vomiting (5.0%).16 Yu et al. found that among 19 hospitalized patients. They found that
10 COVID-19 pediatric patients, three patients diarrhea (3.8%) and nausea or vomiting (5.0%)
had symptoms of diarrhea without other GI were uncommon manifestations.12

Table 1. Presentation of gastrointestinal symptoms in Coronavirus infection10-12,15-20

Study Subject (n) Age (years old) Male (%) Lack of appetite Nausea Vomiting Diarrhea (%) Abdominal pain

Xu et al 10 0-15* 60 NA NA NA 30 NA

Xiao et al 73 0-78* 56.2 NA NA NA 35.6 NA

Guan et al 1099 47 (35-58)** 58.1 NA 5% 5% 3.8 NA

Pan et al 204 52,9±16*** 52.5 78,6% NA 3.9% 34 1.9%

Zhang et al 140 25-87* 50.7 NA 17,3% 5% 12.9 5.8%

Qiu et al 36 1-16* 63.9 NA NA 6% 6 NA

Luo et al 183 53,8*** 55.7 98% 73% 65% 37 25%

Zhou et al 254 15-87* 45.3 NA 8.3% 5.9% 18.1 1.2%

Jin et al 74 46,1±14,2*** 50 NA 13.5% 14.7% 71.6 NA

NA: Data not available, *Presented as range, ** Presented as Median (Interquartile range), ***

Presented as Mean ± Standard Deviation

A recently published review article by Wong et al. COVID-19. Mild bilirubin levels elevation and
has described several published studies decreased albumin levels can also be present.
regarding the digestive manifestation of COVID- 3,21-23 The exact mechanism of liver injury in
19, of which they found that diarrhea was a many COVID-19 patients was still unclear. Liver
complaint among 2.0-10.1%, while nausea and injury may be caused by several mechanisms
vomiting were found in 1.0-10.1% COVID- such as possible direct liver injury by COVID-19
patients. The variable-frequency number of or related to COVID-19 management. The use of
reported GI symptoms between the studies is an high-level positive end-expiratory pressure during
indication for the need for further study to identify mechanical ventilation may lead to hepatic
theexact cause of said variations and determine congestion. Ischemic hepatitis due to the hypoxic
whether digestive symptoms are specific for condition in the acute respiratory distresscondition
COVID-19 or not.3 may also serve as a possible explanation.21-23
The use of several drugs during COVID-19,
Elevated Liver Enzymes among COVID-19 such as: chloroquines; macrolides; quinolones;
Patients and lopinavir/ ritonavir may also lead to drug-
Several studies have shown that the liver induced liver injury. However, all those probable
may be affected by COVID-19 infection. While mechanisms require further study, as many
jaundice or ascites is not commonly reported as elevated liver enzymes were present without any
a clinical manifestation of COVID-19, laboratory previous treatment, nor are they severely
result has commonly shown elevations of liver hypoxic.22 Other explanation may be related to
enzymes. Pan et al. reported that patients with the dysregulated innate immune response,
digestive symptoms had significantly higher which leads to liver injury. The role of cytotoxic T
elevated AST and AST compared to those without cell in response to COVID-19 infection should be
digestive symptoms.15 Wong et al. havefound that further evaluated. Dysregulated immune system
elevated liver enzyme levels were reported14.8- in response to SARS-CoV-2 infection may lead
53.1% among COVID-19 patients based on to the cytokine- storm and multiple organ
several published reports.3 Severe liver injury is damage. Interleukin-2, interleukin-6, interleukin-
more commonly found in a severe condition of 7, tumor necrosis factor-a, Th17, macrophage

inflammatory protein 1-a were some significantly hospital than COVID-19patients with GI symptoms
elevated pro-inflammatory cytokines in severe (60% vs. 34.3%). This maybe caused by a more
COVID-19 patients. Based on the common severe disease course, as patientswho initially do
sepsis model, hypoxic liver injury affects the bile not have typical respiratory symptomsmay suffer
metabolism leading to cholestasis. That, and the from later stages of the disease down the line or
cytokine-storm condition altogether may play a may suffer from viral replication in the digestive
part in liver injury.3,21-23 Nowadays, it is postulated tract, which causes more severe illness.26
that the ACE-2 serves as the entry point of Higher body temperature (more than 38.50C)
COVID-19. Direct liver injury may be explained indicates a higher severity in COVID-19 patients
by the detection of ACE-2 receptor in bile duct with GI symptoms when compared with those
cells and epithelial cell of the liver, which is without GI symptoms. GI symptoms may cause
minimal in hepatocytes. During the acute phase of COVID-19 patients to be more susceptible to
liver injury, the proliferation of hepatocytes may electrolyte disturbances, such as decreased in
increase to restore liver function. This serum sodium levels significantly (p = 0.016).
compensatory mechanism may lead to an Symptoms of fatigue, shortness of breath, and
upregulated ACE-2 expression in the liver.23Xu headaches are also significantly higher in
et al. have conducted pathologicalexaminations COVID-19patients with GI symptoms. It was due
of the liver of deceased COVID-19 patients, to higher fever and increased electrolyte
demonstrating moderate microvesicular imbalance.20
steatosis and mild lobular activity.24 Other As outlined before that, liver injury in COVID-19
autopsy reports by Liu et al have shown lobular patients may be caused due to the sepsis
focal necrosis with infiltration of neutrophils, condition. Cai et al have reported that, at
hepatic sinusescongestion with microthrombosis, admission, severe COVID-19 patients In
and monocytes and lymphocytes in the portal Zhenzhen had significantly higher level of ALT,
area.25 AST, total bilirubin, and gamma GT level
compared to non-severe patients. Liver injuries
The Implication of Gastrointestinal and Liver also more commonly found among severe
Involvement related to COVID-19 Prognosis COVID-19 patients compared to non-severe
Regarding infection-related markers for COVID-19 patients (36.2% vs. 9.6%).27 A cohort study
patients, there were no significant differences in involving 1099 COVID-19 patients by Guan et al
both procalcitonin and C-reactive protein (CRP) have shown that livery injury has more
between patients with and without GI-related commonly occurred in severe and critical
symptoms. Of COVID-19 patients with GI cases.12 Wang et al have discovered that ALT,
symptoms, acute respiratory distress syndrome AST, and total bilirubin levels are significantly
(ARDS), liver injury, and shock occurred as a higher among COVID-19 patients that require
complication in 6.76%, 17.57%, and 1.35% of ICU admission.28 Several other reports with similar
cases, respectively. ARDS occurs significantly findings had also been published.29,30 All this
more common in COVID-19 patient groups with evidence may point out the possible relationship
GI symptom compared to the non-GI symptoms of liver injury with the severity of the COVID-19
(6.76% vs. 2.08%, p = 0.034). The liver injury condition.
also significantly occurs more commonly among
COVID-19 patients with GI symptom (17.57% vs. Current and Future Direction with
8.84%, p = 0.035).20 GastrointestinalIssue Related with COVID-19
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symptoms were transferred to and managed released recommendations regarding
with mechanical ventilation in the ICU, which endoscopy and outpatient GI services regarding
was significantly higher than 2.08% in COVID-19 the COVID-19 pandemic. They recognized that
patients without GI symptoms (p = 0.034).20 the virus may be present in stools and that a
COVID-19 patients without GI symptoms were potential fecal-oral transmission must be
more likely to be cured and discharged from the considered. Liver injuries, which are marked by

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TRAKEOSTOMI DINI PADA PASIEN KRITIS CORONAVIRUS DISEASE(COVID-19)

DIS BIMA PURWAAMIDJAJA1*, MAYANG INDAH LESTARI2

1. Departemen Anestesiologi dan Terapi Intensif RSPAD. Gatot Soebroto, Jakarta
2. Bagian Anestesiologi dan Terapi Intensif Fakultas Kedokteran Universitas Sriwijaya–RSUP. Dr. Moh. Hoesin,

Palembang
*penulis korespondensi

ABSTRAK
Alasan utama pasien kritis coronavirus disease (COVID-19) dirawat di unit perawatan intensif ialah
gagal napas yang memerlukan bantuan ventilasi mekanis invasif. Durasi pemakaian ventilasi mekanis
cenderung lama sehingga berisiko menimbulkan komplikasi seperti meningkatnya mortalitas, kesulitan
penyapihan, ventilator associated pneumonia (VAP), kebutuhan sedasi, dan stenosis trakea. Kondisi
COVID–19 diperparah dengan produksi sekret kental yang banyak dan berpotensi menyumbat
endotracheal tube (ETT) sehingga terjadi gangguan oksigenasi dan ventilasi. Trakeostomidapat menjadi
salah satu alternatif jalan napas pada pasien kritis COVID–19. Teknik ini memberikanmanfaat antara lain
mengurangi ruang rugi dan resistensi jalan napas, work of breathing, kebutuhan obat sedasi, serta lesi
orofaring dan laring. Teknik ini aman, mempermudah perawatan dan drainase sekret, meningkatkan
nutrisi oral, memberikan kenyamanan pasien, serta komunikasi menjadi lebih baik. Percutaneous
dilatational tracheostomy merupakan prosedur trakeostomi yang aman dan dapat dilakukan secara
bedside. Pasien yang akan dilakukan trakeostomi sebaiknya memiliki prognosis baik sehingga
mendapatkan manfaat yang lebih banyak mengingat trakeostomi juga termasuk proseduryang berisiko
menimbulkan aerosol dan dapat menyebabkan transmisi ke tenaga kesehatan. Telaahpustaka ini akan
membahas hal-hal berkaitan dengan implikasi COVID-19, pilihan trakeostomi dan manfaat trakeostomi
dini pada pasien kritis.

Kata Kunci: COVID–19; pasien kritis; percutaneous dilatational tracheostomy; trakeostomi dini