Soroy Lardo

 BG (Ret), MD, Internist, Infectious Diseases Consultant (IDC), PhD

Executive Board of the Indonesian Medical Association (IDI)

                      Director of UPNVERI – UPN Veteran Health Research Institute

Veterans Development University- Jakarta-Indonesia

Emerging Infectious Covid-19 Team – Indonesia Army Central Hospital Gatot Soebroto

Jakarta, Indonesia


The transboundary disease, Covid-19, which has been ongoing since the year 2020, crosses borders and affects many parts of society. The ensuing health issues have weakened the nation’s economy, workforce, quality of life, and overall resiliency. Based on information from the Covid-19 Task Force and Emerging Infections of the Ministry of Health, the Cumulative Situation of Covid-19 in Indonesia as of July 18, 2022, shows 6,13,953 confirmed cases, 27,550 active cases, 156,849 deaths, and 5,950,554 recoveries from a total of 102,088,388 specimens tested. This cumulative mortality rate is 2.6% greater than the global average of 1.14%.

Current evidence from the fields of epidemiology and transmission demonstrates that Covid-19 has mutational traits that make it a community spreader, demonstrated by an uptick in asymptomatic positive cases, mobilization, and international migration. However, keeping an eye out for comorbid groups who have varying clinical signs and organ problems is still important.

The government has to re-encapsulate the upstream and downstream techniques into a single integration if it is to cope with the present situation. Hospital emergency plans and the notion of “High Vigilance” (also known as “High Alert”) are both included in this plan as a means of making the shift from a pandemic to an endemic.

High Vigilance’s strategy is to build organizational awareness and community participation by empowering Leadership, Best Practices, and Environmental Without Error as an integrated policy with measuring tools for the dynamic implementation of the rapid – detect- respond and prevention program. The High Vigilance strategy is expected to make a constructive contribution to the pandemic transition to the endemic.

The High Vigilance strategy is expected to make a constructive contribution to the pandemic transition to the endemic.

Keywords: High Vigilance Concept – Pandemic Transition to the Endemic


The World Health Organization (WHO) proclaimed a global pandemic of Covid-19, an infectious illness caused by the SARS-Cov 2 virus, on March 9, 2020. During the first year of the Covid pandemic, 225 million persons were diagnosed with Covid-19, and 4.6 million people died from the disease. As of now (2022), fewer people are being admitted to hospitals due to an endemic shift that is spreading across the population.1

The pathogenesis and pathophysiological investigation of the transmission and virulence of the Covid-19 virus were the first responses to the virus’s discovery. Spike proteins, which serve as grabbers in the nasopharynx, are a hallmark of virulence. Once they attach to the cell receptors in the lungs, they multiply rapidly, wreaking havoc on the respiratory system. In the subsequent pandemic stage, this procedure is repeated. Mutations may take many forms, and each one contributes to an elevated risk of illness and death. The lack of discipline in the community to take precautions like wearing masks, keeping a safe distance, and washing hands regularly contributes to the rise in severe cases in patients with comorbidities who are admitted to the emergency unit and the spread at the community level (super spreader).2-4

            Due to the severity of the Covid-19 epidemic, hospitals had to restructure their service delivery system from the ground up, shifting their focus from reactive to proactive measures. Hospital preparedness, as defined by the World Health Organization (WHO), is “a shift in the service paradigm toward infection risk stratification.” This shift includes, among other things, the identification and orientation of services, the allocation of human resources (doctors, nurses, care teams), the involvement of multidisciplinary specialties with professional culture, education, and training, the development of guidelines and treatment protocols, the collaboration of networks of hospitals, telemedicine consulting, and the preparation of research and evaluation studies.3

Given the dynamic interactions between government policy struggles to modify various regulations and implementations in the field, such as tracing, testing, and treatment in synergy with as early as possible through vaccination, the transition from pandemic to endemic is a natural process faced by every country. When vaccination rates are at their highest, they are most effective in preventing disease and limiting hospitalizations.

High vigilance is one technique that may be established at both the clinical and community levels in response to the following scenario.

Covid-19 as a Clinical Entity

   Given its tropical location, Indonesia faces a wide range of infectious disease challenges, including the transmission of dengue hemorrhagic fever and, in certain regions, the persistence of malaria. Because of the Covid-19 pandemic, we now know that education is like a virus: it spreads, infects its host, and undergoes constant change.

Covid-19 is a clinical entity with virulence features, binding to ACE receptors, cytokine storms, and atypical respiratory distress syndrome (ARDS), all of which are characterized by high-affinity receptors and large viral loads. If the patient also has comorbid conditions and an impaired immune system, the treatment path will be quite challenging. Cronn (2020) claims that the pathophysiology of the Covid-19 viral strain depends on the virus’s ability to enter the host through the ACE receptor and protein spikes that have gripping and cleaving activities. This virus uses many entry points, including ACE, TMPRSS2, DPP4, and GRP, in order to infect its host. Covid-19, at a later stage, eliminates p(protein) 53, a regulator that controls cell proliferation and immune cell activity. That begs the question, what are the repercussions? Immune cells multiply haphazardly and produce excessive cytokines (cytokine storms). In response to viruses, the body responds with inflammation in many organs, a phenomenon known as “cytokine storms,” which is characterized by excessive surges in immune proteins and attacks on healthy tissues. They may cause organs to fail, which can be fatal.5,6

Covid -19 as a Community Entity

Covid -19, as a community entity, spreads because of an increase in the number of cases in the community, and its distribution is as unexpected and rapid as that of superspreaders. The delay in diagnosis that resulted in a less-than-strict quarantine regime contributed to the rapid spread of the disease in numerous nations with poor trace rates. The emerging simple analysis is not yet in sync with the ideas of specialists, including government policies and attitudes concerned with public input. Covid-19 might be seen in a web of disorders with roots in people’s regular activities. Reemerging infectious and social illnesses need a disease perspective that is built around social cohesiveness, which affects the quality of life and how well a community works.

The environmental impact of this illness is reflected in the new nomenclature. Managing community health effectively calls for the participation of several community elements, including bureaucracy, the environment and culture, and the initiative of the community at large. Despite the fact that there may be disagreements and misunderstandings about how to best stop the spread of Covid-19, everyone in the community has to be on the same page about the need to take preventive measures.

ICRA is a policy and process that works to foster environmental health competencies to limit infection in the community. The ecological health control strategy includes a variety of field operations as well as monitoring the spread of Covid-19 via community control by enlisting different officials in ongoing education and training. Environmental health control is an important part of preventing disease. This includes the level of knowledge and skill of officers, the availability of facilities and facilities for the operation of healthy environment control, and support from bureaucratic management on the importance of reducing morbidity and improving community performance in terms of healthy living.

Covid -19 Risk Mitigation

Mitigation of Covid-19 during the pandemic has a global influence on public health, increasing awareness of the significance of suitable control tactics by combining demographic data, contact patterns, illness severity, capacity, and healthcare quality. Mitigation measures try to delay and interrupt the chain of transmission, particularly among low-income people with poor healthcare capability, leading to increased mortality and morbidity. The health system that becomes the standard is that the function of multi-sectoral economic and social sectors as support for involvement in community health strengthening is not yet fully realized.15

The transmission pattern revealed that viral alterations continued unabated, with severe delta variants and mild and moderate omicron variations. The reduction in transmission as a result of achieving vaccination coverage is reflected by an increase in population immunity. The phases of risk reduction consist of (1) minimizing the effect of the spread of disease; (2) preparedness and planning for potential catastrophes; (3) appropriate reaction to decrease risks when a disaster happens; and (4) recovery after a disaster. Preparing infrastructure, transportation routes, environmental cleanliness, and public education are the activities. In universities and schools, teaching and learning activities involve monitoring the individual hygiene and health condition of students who arrive at school; arranging coordination of educational institutions with health services in the event of cases; and monitoring daily activities.17

Post-Covid-19 Global Problems and Challenges

     Global problems and challenges in Covid-19 may be broken down into three categories: the intrinsic and extrinsic characteristics of infectious illnesses, the capabilities and constraints of human resources, and the empowerment of medical technology. The Intrinsic analysis seeks to comprehend Covid’s virulence as a microbe capable of causing mild, moderate, and severe infections and is linked to an endemic transition with a prolonged Covid-19 impact. The mental health effects of future uncertainty may be understood via the lens of the extrinsic approach, which considers the effects of the pandemic on health care. DSM-5 was provided on 123 symptom disorders in two articles from the University of Taiwan. Medical and psychological co-morbidity did not fully account for the intensity of physical discomfort and health anxiety.18

   The Economist Bulletin on August 22, 2020, disclosed that surveillance of post-Covid patients since March 2020 indicated periodic weariness after five months of recovery. This disease views comorbidities as a Covid susceptibility factor as a unique concern that must be adequately treated given that the adaptability of the host immune system is not as good as in immunocompetent individuals. The long-term consequences of Covid-19 include (1) brain, neurological diseases, and psychiatric symptoms; (2) liver, hepatocellular carcinoma, and hepatocellular carcinoma; (3) liver, hepatocellular carcinoma, and liver (2) Lung, lower tolerance owing to consolidation of ground glass opacity; (3) Liver, elevated liver enzymes due to direct viral or medication effects; (4) Gastrointestinal system, viral invasion of the gastrointestinal tract. (5) Muscle, malnutrition, sarcopenia, and disability owing to immobility, (6) Eyes, retinal vascular conditions, (7) Nose, nasal blockage, olfactory abnormalities, and dysgeusia, (8) Heart, inflammatory conditions, and congestive heart failure (9) Kidney, renal dysfunction, (10) Blood vessels, coagulation, and endothelial dysfunction (11) Inflammation/autoimmunity, heightened inflammation linked to cytokines and antibody production, (12) Chronic weariness, (13) Prolonged PCR+, (14) Prolonged post-viral infection syndrome and post-intensive care syndrome.19-20

   In developing nations, a lack of human resources and medical technology is an issue. During the pandemic caused by the delta variety, the identification and verification of individuals requiring treatment based on weight and mortality pushed every service element to work tirelessly to satisfy those demands. This course increases understanding of human resources as a component that must be prepared for the pandemic-to-endemic transition. Global climate change and infectious illnesses with the ability to spread are inextricably linked to endemic transition concerns in global health. Changes in humidity, the biology of mosquitoes, and rising vector densities High rates of non-communicable diseases, including mental health, are caused by illnesses mediated by vector-borne diseases, water-borne diseases, and diseases connected to environmental changes, including pollution and hazardous chemicals.21-22

High Vigilance Concept: Transition from Pandemic to Endemic

Because of its transboundary nature, Covid-19 affects people on a personal, national, and global scale, with consequences for policy and infection management in a variety of areas. Due to the unpredictability of the pandemic, each nation does its own experimentation on the transboundary transmission of Covid in order to better understand the factors that contribute to its emergence and spread. The community-wide epidemic has led to a rise in the use of quarantine and isolation techniques aimed at lowering the disease’s rate of spread, while the epidemic among hospitalized patients has led to an increase in the number of patients admitted with severe symptoms. Every government tactics boil down to socially canceling a wide range of activities and events that occur between lockdowns and when they are lifted. Delta cases, which lead to death and long-term effects on socioeconomic conditions, are just one example of how this pattern epidemiologically stimulates infection experts to study the virus’s characteristics in depth in relation to virulence, immunology, host adaptation, and transmission variant patterns.25

    The effects of Covid-19’s transition from pandemic to endemic on society, technology, and the area of education; how universities might adapt to the difficulties and possibilities of hybrid education in the wake of the pandemic. Changes in COVID-19 determination have emerged as a prominent feature in several European and Asian countries, especially with the occurrence of delta variant events during the shift from pandemic to endemic, and this is largely due to the ability of Covid mutations, both local and national variants. This circumstance inspires fresh thinking on how to implement community-level Covid-19 control measures.25

      Understanding the progression of this disease from pandemic to endemic can be the first step in implementing the Pandemic Transition to Endemic approach based on the High Vigilance concept. These four processes are 1) Covid as a Battle Transformation, 2) Covid as a Determinant Analysis, 3) Covid as a New Endemic Adaptation Culture, and 4) Covid as a Preventive Strategy.

       Covid-19, also known as Battle Transformation, is a contagious disease that results from the interplay of systems, namely those of the body and the outside world. The internal system is the part of the body that may undergo cell degeneration, affecting structural alterations and the immune system’s response to microbial invasion. The covid-19 infection has additional potential to produce serious illness conditions in the population because of the increased risk of degeneration due to comorbid disorders, including diabetes, hypertension, and old age. At the same time, the infectious disease’s behavior is influenced by the external system, including global environmental conditions (pandemic to endemic) with dynamic variants of mutations. This disease has an asymmetric relationship with the reality it causes, with respect to the possibility of both outbreaks and endemicity.27

     Covid-19’s recent outbreak has sparked fresh debate about the link between infectious diseases and climate change as a global health crisis. There is a rise in respiratory illnesses and early mortality from lung and heart disease as a result of natural disasters, including floods, forest fires, and droughts. A change in the mosquito vector’s biology will have an indirect effect on the community’s susceptibility to disease. Mosquitoes will become more sexually active as temperatures and humidity rise, their life cycles will shorten, leading to a higher mosquito population, and their operational range will expand.27

     Recognizing the aforementioned issues, developing novel scientific understandings in the field of Covid-19 infectious disease as a process of transforming battles involving multiple countries, providing a lesson in denying war as a basic human right despite superficial differences, and utilizing geographical areas to foster a sense of national identity that can coexist without resorting to outright war are all illustrated as follows:

The community’s duty to construct health empowerment networks as a connection to synergize diverse components of the country as the center of the dynamic movement in society is a vital aspect of health security initiatives. In order to protect the community from the discipline of health restrictions in the face of changing Covid-19 transmission variables and to generate new policy innovations, the implementation of large-scale social restrictions (PSBB) calls for the collaboration of a group of thinkers with multidisciplinary scientific competence and a national spirit.28

The following graphic depicts the model of policy coherence and community network engagement in the investigation of Covid-19 determinants.

The Approach to Preventive Strategy and New Adaptations Culture is social control as a societal movement (community movement). The created policies and management comprise activities that may constitute a social chain, consisting of a number of health-improving initiatives. Infection control at the hospital level, backed by ongoing resources, and management of the transition from pandemic to endemic comprise the sequence of programs. Prioritizing quality and patient safety, the objective is to return the hospital to its former function, which was hospital readiness, in everyday practice. The second part is limiting community infection (social and illness), which entails maintaining an environment and work system based on compassion for life and concentrating on community-level health safety connected to the transmission. The strategy covers environmental health control, including actions on the ground to monitor and encourage environmental management. This is done by involving different health professionals in ongoing training and education to prevent illness as much as possible and help people live healthier lives.29

The Infection Control Risk Assessment (ICRA) tool is used in one program to analyze risks and implement preventative measures against the spread and consequences of illness. In the event of a resurgence of the virus or bacterium, there is a risk that it may have undergone a transmissible mutation. This might lead to an epidemic that would disrupt community life. The promotion of healthy social interactions and relationships is an important part of risk assessment, prevention, and control programs. The SCAC (Social Care Associate Community)  is a social diversification that encourages the organic growth of society’s distinguishing traits. Correcting socioeconomic inequalities is an essential part of every social intervention. In the context of disease prevention and control, SCAC refers to social monitoring that may be measured. The Integrated Service Post (Posyandu) in Indonesia is one example of a non-governmental organization (NGO) that operates at the village level to do this kind of monitoring.29

   The High Vigilance idea centers on the new endemic adaptation culture, which is particularly important for prevention in the workplace and the classroom. The idea of High Vigilance is an updated version of PHBS (Clean and Healthy Living Behavior) that emphasizes a healthy immune system. Awareness of one’s own body’s strengths and weaknesses in relation to vulnerabilities that make it easier to become infected is central to PHBS, which is the fundamental notion of disease prevention. Although PHBS has been around for some time, it has not yet been fully adopted into daily life, particularly in underdeveloped nations. One of the PHBS procedures to stop the spread of Covid-19 is washing your hands with soap and water. According to studies conducted in Indonesia between 2013 and 2018, just 47% and 49.8% of household members displayed appropriate hand-washing behavior. This means that the correct hand-washing behavior of Indonesians only increased by 1.8% during the course of the 5 years this program was in effect.30-33

        High vigilance is a notion that, in practice, requires a fighting attitude in order to sustainably practice good habits. The first area of healthy behavior, according to Becker, is knowledge about health, which encompasses what an individual understands to enhance and preserve health. Second, a mentality that encourages one to take measures to improve or maintain one’s health, whether that be via the application of knowledge or the use of one’s own evaluations. Finally, consistent practice is a direct step toward a better quality of life. According to Lawrence W. Green, there are three essential components for PHBS to be successfully implemented: (1) exemplary leadership and healthcare provider behavior (such as wearing masks and keeping a safe distance when examining patients); (2) the existence of a forum for information, consultation, and participation between healthcare providers and the community in dealing with Covid 19; and (3) the establishment of a continuous process with various existing health inequalities.30,34

      The availability of facilities and infrastructure, such as hand washing stations with soap and running water, obstacles to enforcing social distancing, tissues and trash cans for convenience, and other amenities, are two crucial enabling aspects in adopting PHBS in order to maintain respiratory health. The next element to consider is the reinforcing factor. The outward appearance of health professionals, religious leaders, and community leaders serves as an example to the public and inspires them to get involved in their communities.33

         High vigilance demands not just clean and healthy lifestyle choices but also a social network that reinforces them, specifically the execution of Rapid-Detect-Respond-Prevent. Rapid is a swift and dynamic progression toward circumstances with transmission potential in the new average period. Detect is the capability and process for unraveling the nodes of transmission, including three aspects: (1) documenting the possible danger of an epidemic, (2) identifying new species, and (3) incorporating information into management choices. Respond is a kind of authority mechanism that involves planning, coordination, identification of species and sites in danger, monitoring of particular regions for prevention, and oversight of the host-agent system’s relationship with the environment. Prevent is a disease prevention strategy and hard effort based on monitoring systems to prevent the spread of COVID-19 by fostering individual and community biosafety and successful immunization programs for vulnerable people. This is a proposed implementation plan for Rapid Detection, Respond, and Prevent.30,33


The concept of High Vigilance, which covers the new normal covid adaptation, clean and healthy behavior based on individuals and communities, and infection control engineering in the fields of education and the work environment, is a paradigm shift towards a pandemic and endemic transitional health civilization by strengthening the combined role of hospitals in the area of preparedness and daily practices, and empowering Rapid – Detect – Respond and Prevent as the primary measuring tool for the sustainability of the community infection control ecosystem running a measurable manner to achieve health and resilience of every nation.


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