On Wednesday, the Indonesian health authorities still banned the sale of all medicinal syrup. In total, Indonesia recorded 241 cases of acute kidney injury, of which 133 were fatal. Health Minister Budi Gunadi Sadikin said this at a press conference.
According to epidemiologist Dicky Budiman, there are many more victims. “I think there are three or maybe five times as many cases.” That’s because three-quarters of Indonesians prefer to treat themselves, he explains. They do not have the financial means to go to the hospital. “That starts with islanders who can’t afford the boat to the mainland for hospital visits, let alone the hospital itself.”
Registration falls short
For example, Budiman spoke to a colleague from Sulawesi who said that children who had already died had the same symptoms as the registered children. They vomited, urinated less, had diarrhea and had to cough and sneeze. “They never reached the hospital and that is why they are not registered.” The registration of the number of victims is therefore far from precise.
According to the epidemiologist, it also explains why most cases are registered in Jakarta. In the city people do have the means to go to the hospital.
Previously in The Gambia
The ban on the 102 syrups followed the discovery that some of the syrups contained ethylene glycol and diethylene glycol. Those substances were found in cough syrups that some victims had at home, according to the health minister. They are two ingredients that have also previously been linked to infant deaths from kidney failure in The Gambia.
Two weeks ago, The Gambia reported that 70 children had died as a result of acute kidney injury after ingesting a syrup containing too high a dose of these substances. Most victims were younger than five, just like in Indonesia. In The Gambia, the cough syrups from the Indian manufacturer Maiden Pharmaceuticals seem to be responsible for the kidney failure in the children.
But this syrup is not available in Indonesia, so the country itself started an investigation. As long as that continues, it is not possible to say with one hundred percent certainty whether the syrups are the direct cause of the kidney failure. For example, Zullies Ikawati, professor of pharmacology and clinical pharmacy at UGM University, emphasizes that a link has not yet been proven and the cause remains a mystery.
Epidemiologist Budiman also says that nothing can be said with certainty yet, but the fact that Indonesia is one of the largest importers of raw materials for medicines from India does raise questions. “So the syrups are produced in Indonesia, but they contain raw materials from India, among others.”
Antidote
The health minister said yesterday that the condition of some patients improved after receiving an antidote imported from Singapore. He therefore promised to buy more of it.
According to Budiman, this is a ‘perfect choice’. The antidote appears to be effective against the toxic substance found in the syrups. “The fact that patients respond well to that means that they must be poisoned with that substance.”
But there is a ‘but’, explains the epidemiologist. “Not all patients respond well to the antidote.” That means that not all patients have acute renal failure thanks to the syrups. It can also be caused by infections, such as corona.
To gain more insight into the causes, Budiman therefore argues in favor of declaring an official outbreak. “Then we can better record the cases,” he explains. Because in the event of an official outbreak, the government can financially support people to go to hospital.
“That even means that for island residents the crossing to a hospital on the mainland is reimbursed.” The extra information that more registrations entail can then be used to investigate the exact causes of the outbreak.
But the information provision also has to change, says Budiman, who specializes in crisis communication. There are now too many sources spreading different types of information and that confuses people.
According to him, it would therefore be a good idea to plan joint press conferences where the Ministry of Health and the Indonesian Food and Medicine Authority simultaneously share their findings and answer questions.
Sale of all liquid medicines stopped
Because the syrups did not cause any problems in recent years, it is now being investigated which components have gone so wrong, says Southeast Asia correspondent Thom Schelstraete. “According to a medicine expert who spoke to Indonesian media, there is a good chance that the composition of those syrups has recently changed.”
The Indonesian Ministry of Health is now conducting research into those precise ingredients, says Schelstraete. “Yesterday they already came with the first results, they said they could say with ’75 percent certainty’ that the poor production quality of a substance commonly used in syrups was the cause of the fatal kidney injuries.”
Indonesians immediately thought of a link with the Indian syrups used in The Gambia. “But according to the responsible ministry, those syrups are not registered in Indonesia. The government does not say which syrups are now suspected. 102 are being investigated, as a precaution Indonesia has stopped the sale of all liquid medicines.”