Dr. Paul N.

Harijanto, SpPD-KPTI, FINASIM

• Lulus Fak. Kedokeran Univ Gadjah Mada, Yogya 1973
• Spesialis Penyakit Dalam, FK UNSRAT, Manado 1995
• Konsultan Penyakit Tropik & Infeksi P.B. PAPDI, 2000

Riwayat Pendidikan
➢ Post Graduate Course of Medicine, Univ. Singapore 1979-1982
➢ Latihan Endoskopi dan Kolonoskopi, di Bagian Endoskopi RS
Schwaebisch Hall, Jerman Barat, 29 Maret 1988 - 21 Mei 1988.
➢ Course of Tropical Disease ( Up-date) , Atlanta 29 - 30 Oktober 1993
➢ The 9 th Postgraduate Course on Immunology, Surabaya 14-17, 1994
➢ WHO Training of the Trainers in Severe Malaria, Myanmar 1996
Jabatan Sekarang
1. Anggota Pengurus Besar (PB) Perhimpunan Konsultan Penyakit
Tropik & Infeksi Indonesia (PETRI)
2. Anggota Komisi ahli Malaria Nasional Depkes R.I
3. Ketua Perhimpunan Diabetisi Indonesia (PERSADIA ) Tomohon
4. Ketua PETRI, cabang Sulawesi Utara
5. Ketua PERDALIN cabang Sulawesi Utara
6. Kepala bagian Peny Dalam RSU Bethesda Tomohon
 MENEJEMEN COVID-19
DI BERBAGAI TINGKAT FASKES/
RUMAH SAKIT
DR. PAUL HARIJANTO, SP.PD-KPTI, FINASIM
KAMIS, 8 OKTOBER 2020
 FKTL
FKTP

PKM/
Pus-Pemb
Mobile Klinik
 MENEJEMEN COVID-19 PADA TINGKAT FASKES/ RS

• MENEJEMEN COVID-19 : • KEBUTUHAN :

1. DIAGNOSIS KASUS 1. ALAT & SDM
2. PENANGANAN KASUS : 2. SARANA & PRASARANA :
a. PENGOBATAN a. OBAT
b. PENCEGAHAN PENULARAN b. RUANG ISOLASI & APD
c. REHABILITASI c. SDM & ALAT
 MENEJEMEN COVID-19 DI FKTP/ PUSKESMAS

TRIASE AWAL : ANAMNESA ( GEJALA & KERT )

• PEMERIKSAAN FISIK : TEK DARAH, SUHU, RESP. , NADI, SATURASI, ORGAN
TUBUH
• LABORATORIUM : HEMATOLOGI, SAR-COV2, RADIOLOGI
TATALAKSANA :
• RUANGAN ISOLASI ( PEMERIKSAAN, R.TUNGGU, R. INAP )
• OBAT SIMPTOMATIK DAN SUPORTIF
• EDUKASI PASIEN, KELUARGA, MASYARAKAT
• TRACING / SURVAILENCE
 MENEJEMEN COVID-19 DI FKTL
RUMAH SAKIT RUJUKAN

• DITETAPKAN OLEH PERMENKES ATAU DITETAPKAN OLEH PEMDA

• TERGANTUNG SARANA & PRASARANA, SDM
• RUANG ISOLASI PENDERITA COVID-19/ INFEKSIUS
• UNIT PELAYANAN INTENSIF ( ICU ) / INFEKSIUS
• VENTILATOR & SARANA LAINNYA.
• HEMODIALISA
• REHABILITASI MEDIK
 / KRITIS
❑Tanda pneumonia:
❑ frekuensi napas >30 x/menit,
❑ distress pernapasan berat, atau
❑ saturasi oksigen (SpO2) <90% pada udara kamar
❑ Kritis : ARDS / SYOK SEPTIC/ MOD :
❑ KRITERIA ARDS PADA DEWASA:
❑ ARDS ringan: 200 mmHg <PaO2/FiO2 ≤ 300
mmHg (dengan PEEP atau continuous positive
airway pressure (CPAP) ≥5 cmH2O, atau yang
tidak diventilasi)
❑ ARDS sedang: 100 mmHg <PaO2 / FiO2 ≤200
mmHg dengan PEEP ≥5 cmH2O, atau yang tidak
diventilasi)
❑ ARDS berat: PaO2 / FiO2 ≤ 100 mmHg dengan
PEEP ≥5 cmH2O, atau yang tidak diventilasi)
❑ Ketika PaO2 tidak tersedia, SpO2/FiO2 ≤315
mengindikasikan ARDS (termasuk pasien yang
tidak diventilasi)
 TERAPI FARMAKOLOGIK COVID-19
• BELUM ADA / TIDAK ADA SAAT INI
• OBAT SEDANG DALAM PENELITIAN/ TRIAL :
• CHLOROQUIN/ HYDROXY-
CHLOROQUINE + AZITHROMYCIN
• LOPINAVIR-RITONAVIR
• IVERMECTIN
• REMDESIVIR
• CONVALESCENT PLASMA
• IMMUNOGLOBULIN
• MESENCHYMAL STEM CELLS
• VIT C, D
• ZINC
• IMMUNO-MODULATOR
• DEXAMETHASONE
• IL-1 INHIBITOR ( ANAKINRA )
• INTERFERON ALFA & BETA
• ANTI IL-6 ANTIBODIES (SARILUMAB,
TOLICIZUMAB, SILTUXIMAB)
• BRUTON’S TYROSINE KINASE INHIBITORS
(ACALABRUTINIB, IBRUTINIB,
ZANUBRUTINIB)
• JANUS KINASE INHIBITORS (BARICITINIB,
RUXOLITINIB, TOFACITINIB).
 ISDA GUIDELINES, 25 SEPTEMBER
• REKOM 1, 2 : IDSA GUIDELINE PANEL RECOMMENDS AGAINST HYDROXYCHLOROQUINE, AGAINST
HYDROXYCHLOROQUINE PLUS AZITHROMYCIN. (STRONG, MODERATE/ LOW EVIDENCE)
• REKOM 3.: RECOMMENDS THE COMBINATION OF LOPINAVIR/RITONAVIR ONLY IN THE CONTEXT OF A
CLINICAL TRIAL. (KNOWLEDGE GAP)
• REKOM 4: RECOMMENDS DEXAMETHASONE RATHER THAN NO DEXAMETHASONE. (STRONG , MODE)
• REKOM 5 : NON-CRITICAL, SUGGESTS DEXAMETHASONE RATHER THAN NO DEXAMETHASONE.
(CONDITIONAL, MODERATE CERTAINTY OF EVIDENCE)
• REKOM 6 : NON-SEVERE, WITHOUT HYPOXEMIA REQUIRING SUPPLEMENTAL OXYGEN, SUGGESTS AGAINST
THE USE OF GLUCOCORTICOIDS. (CONDITIONAL, LOW EV)
• REKOM 7. : AGAINST THE ROUTINE USE OF TOCILIZUMAB. (CONDITIONAL , LOW EVIDENCE )
• REKOM 8 : RECOMMENDS CONVALESCENT PLASMA ONLY IN A CLINICAL TRIAL. (KNOWLEDGE GAP)
• REKOM 9 : SUGGESTS REMDESIVIR OVER NO ANTIVIRAL TREATMENT. (CONDITIONAL, MODERATE EVID.)
• REKOM 10, 11 : NOT ON VENTILATION/ ECMO, SUGGESTS TREATMENT WITH 5 DAYS OF REMDESIVIR
RATHER THAN 10 DAYS OF REMDESIVIR. (CONDITIONAL , LOW EVIDENCE)
• REKOM 12 : AGAINST FAMOTIDINE USE FOR TREATING COVID-19 OUTSIDE OF THE CONTEXT OF A CLINICAL
TRIAL. (CONDITIONAL RECOMMENDATION, VERY LOW CERTAINTY OF EVIDENCE)
CHLOROQUINE/ HYDROXYCHLOROQUINE + AZITHROMYCINE

• REKOM 1, 2 : IDSA GUIDELINE PANEL RECOMMENDS AGAINST HYDROXYCHLOROQUINE,

AGAINST HYDROXYCHLOROQUINE PLUS AZITHROMYCIN. (STRONG, MODERATE/ LOW
EVIDENCE)
• 9 RCT AND 6 OBSERVATIONAL STUDIES
• OUTCOME : MORTALITY, CLINICAL ASSESSMENT, PROGRESSION ON VENTILATION, ADVERSE
EVENT, QT PROLONGATION, ARRYTHMIAS, SEVERE ADVERSE EVENTS.
• BIAS : SERIOUS/ NOT SERIOUS
• INCONSISTENCY, ETC
 LOPINAVIR-RITONAVIR
• LOPINAVIR-RITONAVIR IS A COMBINATION OF PROTEASE INHIBITORS FOR THE TREATMENT OF HIV
INFECTION
• IN VITRO ANTIVIRAL ACTIVITY AGAINST BETA- CORONAVIRUSES SUCH AS SARS-COV, AND MERS-COV
• LOPINAVIR-RITONAVIR ALONE MAY NOT DEMONSTRATE A DIFFERENCE FROM PLACEBO IN REDUCING
VIRAL LOAD
• ASSOCIATED WITH MORE RAPID VIRAL CLEARANCE (MEDIAN, 21 DAYS VS. 28 DAYS) THAN HCQ IN 65
MILD TO MODERATE COVID-19 PATIENTS IN SOUTH KOREA, BUT THERE WAS NO DIFFERENCE IN TIME
TO CLINICAL IMPROVEMENT
• FOUND TO BE INFERIOR TO ARBIDOL IN TERMS OF VIRAL CLEARANCE ON DAY 14 AFTER ADMISSION.
• 3 RCT, SERIOUS BIAS
• DOSE : LPV 400 MG/RTV 100 MG PO TWICE DAILY FOR 10–14 DAYS
FAVIPIRAVIR (‘ AVIGAN “ )
• A PURINE ANALOGUE THAT INHIBITS THE RNA DEPENDENT RNA POLYMERASE OF INFLUENZA
AND OTHER RNA VIRUSES
• APPROVED IN JAPAN FOR TREATMENT OF INFLUENZA.
• TERATOGENICITY RISK, FAVIPIRAVIR SHOULD NOT BE GIVEN DURING PREGNANCY
• NON-RANDOMIZED, OPEN-LABEL STUDY IN CHINA, ORAL FAVIPIRAVIR WAS ASSOCIATED WITH
SHORTER TIME TO VIRAL CLEARANCE AND GREATER IMPROVEMENT IN CHEST IMAGING THAN
LOPINAVIR/RITONAVIR
• RCT : NO APPARENT EFFECT OF FAVIPIRAVIR (OR BALOXIVIR) ON VIRAL CLEARANCE
 REMDESIVIR (RDV)
• INTRAVENOUS (IV), NUCLEOTIDE PRODRUG OF AN ADENOSINE ANALOG.
• BINDS TO THE VIRAL RNA-DEPENDENT RNA POLYMERASE, INHIBITING VIRAL REPLICATION THROUGH
PREMATURE TERMINATION OF RNA TRANSCRIPTION.
• RECOMMENDS FOR USE IN HOSPITALIZED PATIENTS COVID-19 WHO REQUIRE OXYGEN, USING
REMDESIVIR FOR 5 DAYS
• NOT FOR MILD OR MODERATE COVID-19
• GLOMERULAR FILTRATION RATE (EGFR) OF <50 ML/MIN ARE EXCLUDED RDV
• DOSE : FOR PATIENTS WITH SEVERE COVID-19 WHO ARE NOT INTUBATED: RDV 200 MG IV OVER
30–120 MINUTES FOR 1 DOSE, FOLLOWED BY RDV 100 MG IV ON DAY 2 THROUGH DAY 5 (AI).
• 12 RCT: BIAS, 6 NOT SERIOUS, 3 SERIOUS, 3 VERY SERIOUS
 DEXAMETHASONE

• “ (RECOVERY) TRIAL “, THE COVID-19 TREATMENT GUIDELINES PANEL (THE PANEL)

RECOMMENDS USING DEXAMETHASONE 6 MG PER DAY FOR UP TO 10 DAYS OR UNTIL
HOSPITAL DISCHARGE, FOR :
• WHO ARE MECHANICALLY VENTILATED (AI)
• WHO REQUIRE SUPPLEMENTAL OXYGEN BUT WHO ARE NOT MECHANICALLY VENTILATED (BI).
• AGAINST USING DEXAMETHASONE FOR THE TREATMENT OF COVID-19 IN PATIENTS WHO DO
NOT REQUIRE SUPPLEMENTAL OXYGEN (AI).
• RECOMMENDS USING ALTERNATIVE GLUCOCORTICOIDS SUCH AS PREDNISONE 40 MG,
METHYLPREDNISOLONE 32MG, OR HYDROCORTISONE 160MG
• 7 RCT : BIAS 5 NOT SERIOUS, 2 SERIOUS
 CONVALESCENT PLASMA
CONVALESCENT PLASMA ONLY IN THE CONTEXT OF A CLINICAL TRIAL. (KNOWLEDGE GAP)
• PASSIVE IMMUNOTHERAPY FOR PREVENTION AND TREATMENT OF INFECTIONS FOR OVER 100 YEARS
• CP HAS BEEN USED IN OVER 75,000 PATIENTS WITH MODERATE TO SEVERE INFECTION AS PART OF AN
EXPANDED ACCESS PROGRAM
• MULTIPLE PROSPECTIVE CLINICAL TRIALS ARE IN PROGRESS UTILIZING PLASMA WITH AN IGG ELISA TITER
CUTOFF OF ≥1:320.
• EFFICACY IS EXPECTED TO BE BEST WHEN CP IS GIVEN AT EARLIER STAGES OF THE DISEASE AND PARTICULARLY
PRIOR TO WHEN PATIENTS BECOME CRITICALLY ILL
• EXPANDED ACCESS PROGRAM SUGGESTS THE MOST BENEFIT IS SEEN WHEN CP IS GIVEN IN THE FIRST THREE
DAYS FROM DIAGNOSIS
• CONVALESCENT PLASMA TRANSFUSION FAILED TO SHOW OR TO EXCLUDE A BENEFICIAL OR DETRIMENTAL
EFFECT ON MORTALITY BASED ON THE BODY OF EVIDENCE FROM RCTS
• STUDY FROM 1 RCT AND 5 OBSERVATION
 KEY MESSAGES :
1. MENEJEMEN COVID-19 HARUS DIMULAI DENGAN MENEMUKAN KASUS SEDINI
MUNGKIN DENGAN DIAGNOSE YANG TEPAT
2. TATALAKSANA DAPAT DIMULAI DARI FASKES PERTAMA (FKTP) SAMPAI FKTL
TERGANTUNG SARANA, PRASARANA DAN SDM
3. PENGOBATAN COVID-19 : SYMPTOMATIC, SUPPORTIVE ; TERAPI CAUSAL MASIH
BELUM ADA
4. PEMBERIAN OBAT SAAT INI HANYA BERSIFAT PENELITIAN, DENGAN MEMPERHATIKAN
KAIDAH PENELITIAN, KEAMANAN, MANFAAT DAN PENYELAMATAN
5. YANG LEBIH UTAMA IALAH PENCEGAHAN UNTUK MENGHINDARKAN DARI INFEKSI,
USAHA MENURUNKAN JUMLAH KASUS DAN TATALAKSANA KASUS YG CEPAT DAN
AKURAT
6. UNTUK KALANGAN PROFESSIONAL UNTUK DAPAT SEGERA MENG-UPDATE DAN
MEMBUAT PEDOMAN YANG PRAKTIS BERDASAR KAIDAH ILMIAH YANG AKURAT
PAKATUAN WO PAKALAWIREN
Sampai Baku Dapa !
Dr. Paul Harijanto, Sp.PD-KPTI
Div. Penyakit Tropik & Infeksi
SMF/ Bag. Penyakit Dalam
FK UNSRAT/ RSUP Manado
RSU Bethesda -Tomohon

Telp.:
0431-351024/046 ( RSU Bethesda)
0812-430-2869 ( HP)
0431-351187 (Res)
E-mail : paulharijanto@gmail.com
PUBLIC HEALTH SURVEILLANCE FOR COVID-19,7 AGUSTUS 2020,
SUSPECTED COVID-19 CASE (TWO SUSPECTED CASE DEFINITIONS A OR B):

A. A person who meets the clinical AND epidemiological criteria:

Clinical criteria:
1. Acute onset of fever AND cough; OR
2. Acute onset of ANY THREE OR MORE of the following signs or symptoms: fever, cough,
general weakness/fatigue1, headache, myalgia, sore throat, coryza, dyspnoea,
anorexia/nausea/vomiting, diarrhoea, altered mental status. AND
Epidemiological criteria:
• Residing or working in an area with high risk of transmission of the virus: for example,
closed residential settings and humanitarian settings, such as camp and camp-like settings
for displaced persons, any time within the 14 days prior to symptom onset; OR
• Residing in or travel to an area with community transmission2 anytime within the 14 days
prior to symptom onset; OR
• Working in health setting, including within health facilities and within households, anytime
within the 14 days prior to symptom onset.
B. A patient with severe acute respiratory illness (SARI: acute respiratory infection with
history of fever or measured fever of ≥ 38 C°; and cough; with onset within the last
10 days; and who requires hospitalization).
PROBABLE COVID-19 CASE: (WHO 7 AUGUST )
A. A PATIENT WHO MEETS CLINICAL CRITERIA ABOVE AND IS A CONTACT OF A
PROBABLE OR CONFIRMED CASE, OR EPIDEMIOLOGICALLY LINKED TO A
CLUSTER OF CASES WHICH HAS HAD AT LEAST ONE CONFIRMED CASE
IDENTIFIED WITHIN THAT CLUSTER.
B. A SUSPECTED CASE (DESCRIBED ABOVE) WITH CHEST IMAGING SHOWING
FINDINGS SUGGESTIVE OF COVID-19 DISEASE* * TYPICAL CHEST IMAGING
FINDINGS SUGGESTIVE OF COVID-19 INCLUDE THE FOLLOWING (MANNA 2020):
1. CHEST RADIOGRAPHY: HAZY OPACITIES, OFTEN ROUNDED IN MORPHOLOGY, WITH
PERIPHERAL AND LOWER LUNG DISTRIBUTION
2. CHEST CT: MULTIPLE BILATERAL GROUND GLASS OPACITIES, OFTEN ROUNDED IN
MORPHOLOGY, WITH PERIPHERAL AND LOWER LUNG DISTRIBUTION
3. LUNG ULTRASOUND: THICKENED PLEURAL LINES, B LINES (MULTIFOCAL, DISCRETE, OR
CONFLUENT), CONSOLIDATIVE PATTERNS WITH OR WITHOUT AIR BRONCHOGRAMS.

C. A PERSON WITH RECENT ONSET OF ANOSMIA (LOSS OF SMELL) OR AGEUSIA

(LOSS OF TASTE) IN THE ABSENCE OF ANY OTHER IDENTIFIED CAUSE.
D. DEATH, NOT OTHERWISE EXPLAINED, IN AN ADULT WITH RESPIRATORY DISTRESS
PRECEDING DEATH AND WHO WAS A CONTACT OF A PROBABLE OR CONFIRMED
CASE OR EPIDEMIOLOGICALLY LINKED TO A CLUSTER WHICH HAS HAD AT LEAST
ONE CONFIRMED CASE IDENTIFIED WITHIN THAT CLUSTER.