1 Fighting community transmission
With the number of Novel Coronavirus cases climbing steadily and reports of local transmission emerging from across the country, India is on the brink of community transmission, or Stage 3, of COVID-19. On March 24, while announcing a three-week preventive lockdown of the entire country, Prime Minister Narendra Modi allocated Rs 15,000 crore to boost the health infrastructure. The funds will be used to create additional hospital beds, build on the stockpile of COVID-19 testing kits and train medical practitioners. The Centre is putting in place protocols, including the acquisition of medical equipment and protection gear needed in the special isolation wards and facilities. A training protocol for frontline health workers is also being prepared.
Dr Naresh Trehan
The funds announced are a beginning. We would need more, depending on how soon we can end this affliction. Earlier, states were only using National Health Mission (NHM) funds. Now, they have access to a central fund, says Dr V.K. Paul, public health expert and a member of NITI Aayog. The first thing to do with the funds is equip hospitals, with personal protective gear, ventilators, additional oxygen, drugs and train staff. While isolation wards are being created, Dr Paul says COVID-specific facilities also need to be looked at for Stage 3. In Geneva, they are out of ICU (intensive care unit) beds. Such is the virulence of the disease at its peak. We need good hospitals that is where the focus is now. To support hospitals, we must also have isolation facilities, a strict surveillance system and should even consider setting up call centres in medical colleges, he says. Dr Paul maintains that India is still at Stage 2 (local transmission), but testing is being done more widely now.
Kerala, which has both an enduring healthcare system and a strong network of Panchayati raj bodies, is stealing a march on other states with its preparedness. Chief Minister Pinarayi Vijayan says since a high number of people might need to be put under quarantine, local bodies have been instructed to identify hospitals, buildings, schools and auditoriums for the purpose. Even a minor lapse can prove disastrous, Vijayan cautioned office-bearers of local bodies during a video conference on March 19. If there is a spurt in cases, the existing facilities would not be enough to meet the requirements. Since the vast majority under observation would be home-quarantinedas people under special care’, Kerala’s strategy is to get the local bodies to take responsibility for local communities and ensure they do not face logistical problems while handling the situation.
Dr VK Paul
2 Dedicated COVID-19 hospitals and ICUs
With a hospital bed to population ratio of just 1:1,000 or around a million hospital beds in all, less than 100,000 ICU beds and only 40,000 ventilators at hand, India’s healthcare infrastructure is ill-equipped to face a sharp increase in COVID-19 cases. Ventilators will be particularly critical. The Indian Council of Medical Research (ICMR), in a report, said that about 5 per cent of COVID-19 patients may require intensive care, and half of those may need ventilator support.
COVID-19 impacts the lungs. In severe cases, the lungs fill up with fluid and it becomes hard to breathe. A ventilator ensures that the lungs do not collapse while the treatment is on, says Dr J.V. Divatia of the department of anaesthesiology, critical care and pain at Mumbai’s Tata Memorial Hospital. He warns of trouble if the patient numbers in India match those in China or Europe. There is no guideline on how many ventilators a hospital needs. In India, we keep about 20 per cent of beds for critical care, which is about enough in normal conditions, says Dr Divatia.
Dr Devi Prasad Shetty
Most high-end ventilators available in India are imported and cost Rs 5-12 lakh each. Hospitals say the quality of equipment made in the country isn’t as reliable. If orders are placed in advance, more ventilators can be bought and set up within a week. With little demand for their products at home, Indian manufacturers have been exporting ventilators. Ventilators manufactured by the Delhi-based Croyox Medical Service, costing Rs 4 lakh each, have been exported to Nepal, Thailand and Europe previously. Things changed on March 19 with the government’s ban on export of ventilators. It wants 100,000 simpler’ ventilators, customised for COVID-19 patients, installed across the country by April 30. Mysuru-based Skanray Technologies is being tasked to make 5,000 of these. Low-end ventilators could be an alternative if the COVID-19 symptoms are not very severe, says Dr Divatia.
Ventilator parts such as valves and sensors, though, are expected to remain in short supply. We will share the knowhow with others ready to make these customised ventilators so that the demand can be met as soon as possible, says Vishwaprasad Alva, managing director, Skanray Technologies. Experts also underscore the need to ensure adequate oxygen supplies in hospitals; many hospitals in Europe struggled to save COVID-19 patients as oxygen supplies ran out.
Across states, properties are being identified to transform them into dedicated COVID-19 hospitals. These could be defunct or upcoming hospitals or even hostels of educational institutions that can be converted into 250-300-bed facilities. The first such facility is a 100-bed centre set up by the Sir H.N. Reliance Foundation Hospital, Mumbai, at the 700-bed SevenHills Hospital in Andheri. Anand Mahindra, chairman of the Mahindra Group, has pledged his Club Mahindra Resorts to serve as care centres for COVID-19 patients. He also said the group’s manufacturing units will see if they can manufacture ventilators. Hyderabad’s Owaisi Hospital and Research Centre is setting up an exclusive 100-bed centre.
The All India Institute of Medical Sciences (AIIMS), New Delhi, which has about 1,300 doctors and 1,800 nurses on its rolls, has set up an isolation ward for COVID-19 cases. The institute has also freed up some 150 beds at its facilities in Jhajjar, Haryana. Regular meetings are being held to assess the situation and, on March 23, AIIMS suspended OPD (out-patient department) services as a precautionary measure.
Plans for more isolation wards are being fine-tuned and will be reviewed by the ICMR in terms of protocol. This is among the steps being taken just in case the need arises, says Dr Indu Bhushan, CEO, National Health Authority (NHA). We are preparing ourselves should there be a [community-level] spread. That includes ensuring that private sector facilities support the treatment of COVID-19 cases. The NHA is assessing the capacity and readiness of private hospitals on this.
Dr CS Pramesh
3 Stimulus for domestic pharma
The abrupt stoppage in the flow of active pharmaceutical ingredients (APIs), mostly from China, is impacting the Indian pharmaceutical sector, with fears now of a potential shortage of bulk drugs and intermediates. A corpus fund to incentivise Indian pharma companies is one way to encourage domestic production of APIs. The central department of pharmaceuticals has asked the Union ministry for environment, forest and climate change to waive the environmental impact assessment reports for projects by some categories of pharma firms. This, it is felt, will help reduce the time required to manufacture bulk drugs and APIs locally. The Centre has also pledged Rs 10,000 crore towards the production of critical drugs and another Rs 4,000 crore to promote manufacturing of medical equipment in the country.
The ICMR’s announcement on March 23 that the antimalarial hydroxychloroquine could be used as a preventive drug by COVID-19 high-risk groups (health workers or household members of patients) has led to a scramble, with chemists reporting that stocks are running out. In Mumbai, most shops are out of stock. Doctors have been trying a combination of drugs, which worked for other infections, to treat COVID-19 symptoms. If this drug is proven to work, we would have a need for it, says Dr C.S. Pramesh, director, Tata Memorial Hospital, Mumbai.
Following US president Donald Trump’s endorsement of hydroxychloroquine, Indian pharma companies Ipca and Zydus Cadila received bulk orders of the drug from the US. Even though India has a strong foothold in the production of hydroxychloroquine and pharma experts say production can be ramped up any time, there is already a noticeable shortage because of hoarding. While the government is planning to stockpile about 2 million doses of hydroxychloroquine, ensuring smooth supplies will also require a ban on its export, like the UK has done, as well as on over-the-counter sale.
4 Reliable testing kits
As of 10 am, March 25, India had tested 22,928 samples for COVID-19, according to ICMR. This includes more than 500 random sample tests. The governing body for testing in India had come under fire for limiting the testing criteria in the initial days of the outbreak to those who had travelled to countries affected by the virus or had come in close contact with a COVID-19 patient. While about 300,000 test kits were available, only about 9,000 samples had been tested in the first week of March. Without data, it is hard to gauge the extent of the spread or make projections on the course the disease will take. Testing can slow down the disease, says K. Sujatha Rao, former Union health secretary.
On March 20, ICMR expanded the testing criteria to include even those who showed flu-like symptoms but had not travelled to countries reporting an outbreak of the disease. Two days later, it was announced that private labs would be granted licences for testing and orders would be placed with Indian companies to produce COVID-19 test kits. Private labs, however, say it is too early to comment on whether they can start testing since quality-compliant kits are not freely available. Also, the countrywide lockdown has crippled public transport, affecting staff strength in the labs.
Dr Navin Dang, founder of Dr Dang’s Labs (one of the private facilities approved for testing), favours widespread testing. A few kits might be lost, but lives are also saved, he says. An ideal situation would be one like South Korea where mass testing is possible, where anyone with symptoms can be tested and isolated if needed. Dr Dang, however, discourages home tests. Self-assessment is not advisable as it is not reliable. The COVID-19 test has highly specific guidelines, nose and throat swabs are collected in protective packing and tested in labs with a biosafety level of 2 and above and a real-time PCR (polymerase chain reaction) system. Trained personnel are needed for it, he says.
The Centre has capped the pricing of the test at Rs 4,500 and urged private labs to conduct the test free of cost, if possible. It has also mandated that only US Food and Drug Administration and European CE certified test kits be used. Pune-based Mylab Discovery Solutions, the first home company to get commercial approval for manufacturing the test kits, has produced indigenous kits that give results faster (in 2.5 hours as opposed to the standard 7 hours) and are cheaper (the company wants to price it around Rs 1,500). While ICMR has ordered about 200,000 kits from Germany, MyLab claims it can produce that many in a week. Its test kits, though, are yet to acquire international certifications. For me, quality is everything and I will not start testing till the time I am able to procure high-quality test kits. We cannot afford misdiagnosis at this stage, says Dr Dang.
5. Lessons from home-quarantine
From a COVID-19 positive man in Telangana, who hosted 1,000 guests at his wedding, to a London-returnee in Kolkata who repeatedly evaded testing, to the wife of a COVID-19 patient who escaped from quarantine and boarded a train to Agra, India’s fight against coronavirus is being thwarted by cases of individuals fleeing isolation. Who says COVID-19 cannot affect young people? It can. There have been severe symptoms in the youth too. Fewer, but it cannot be ruled out, says Dr Naresh Trehan, chairman and managing director, Medanta Hospital, Gurugram. Those who are old or immunocompromised are high-risk. Recovery is also slower for them. The lungs get damaged a bit in severe cases, and this can impact long-term cardiovascular health, though we don’t know exactly how yet. Dr Trehan says that COVID-19 being a new disease, it is hard to predict who will get sick and in what manner. Those breaking quarantine because they feel they are going to get only mild symptoms and will be fine are wrong. They are putting everyone at risk.
While states like Maharashtra are hand-stamping quarantined patients, to allow easy detection in case they step out in public, Kerala has adopted a home-quarantine model that relies more on community support than coercive measures. It is very difficult to convince people to stay at home for two weeks. We had been constantly contemplating how people could be dissuaded from breaking the rules of quarantine without having to punish’ them, says Dr Amar Fettle, nodal officer for public health emergencies in Kerala’s health department. The state has close to 53,000 people under home quarantine. Dr Fettle credits this to community outreach. We have 30,000 Accredited Social Health Activists and 15,000 field workers, who visit homes and educate people on the importance of isolation and social distancing, he says.
Dr Amar Fettle
The state health department also makes surprise calls twice daily to check in on those in quarantine. The calls make note of the medical and other supplies they may be in need of, which are then arranged for through the primary health centres or panchayats. We realised that when you let people know that you are working with them, and not merely enforcing rules, they are more willing to listen, adds Dr Fettle. There are the odd defaulters in Kerala as well, but few.
6. Defeating fake news
Another challenge is to curb the fake news circulating on COVID-19 and counter it with a credible information source. Telangana is rolling out one such digital solution to fight the misinformation. We are planning a WhatsApp number, on which people can get [COVID-19-related] messages verified, a website as well as an archive of fact-checked information, says Dileep Konatham, director, digital media, Telangana government. There have also been instances of misreporting by local electronic media, such as quarantined individuals undergoing tests being reported as new COVID-19 cases, only to retract the news within a few hours without even a hint of an apology. Determined to come down hard on such misinformation, Telangana has invoked Section 54 of the Disaster Management Act, 2005, which stipulates imprisonment and fine for circulating false alarms/warnings’ related to disasters.
The long haul. A suspected COVID 19 patient arrives bat RML hospital, New Delhi. Photo: Qamar Sibtain
The AIIMS staff has been among the victims of misinformation. On March 24, a circular from the hospital mentioned how members of its staff living on rent were being harassed or evicted by home-owners over fears that they would pass on the infection. Myths help COVID-19 spread. Doctors must be supported, not stigmatised, says Dr Randeep Guleria, director, AIIMS, adding that the pandemic is a daily evolving scenario. COVID-19 is a serious threat. Hospitals are taking steps to cope with the high numbers. The public needs to play a part too. If we are responsible today, it could stop the spread.
Dr Randeep Guleria
7. Strengthening the healthcare force
With an estimated 0.62 doctors per thousand people, as opposed to the WHO ideal of 1 per thousand, India’s healthcare sector looks acutely under-staffed in the fight against coronavirus. According to Dr Devi Prasad Shetty, founder of the Narayana Health chain of hospitals, round-the-clock treatment of 2,000 patients in an ICU would require an estimated 2,800 nurses, 800 resident doctors and 400 anaesthetists. At the time of community transmission in China’s Wuhan (a city of 11 million), 9,689 patients were severe and needed to be admitted to an ICU. Going by Dr Shetty’s estimate, attending to, say, 9,600 patients in Delhi (a city of 18 million) will require the services of 13,440 nurses and 3,840 doctors. Last year, it was reported that Delhi has 4,644 sanctioned (not necessarily filled) posts for doctors while the Delhi Nursing Council puts the number of registered nurses in the city at about 7,000.
To bridge the shortfall, Dr Shetty recommends that postgraduate students of medicine be given the option by their institutions to serve at COVID-19 ICUs and wards as part of their training. He also suggests that the Indian Nursing Council permit final-year nursing students to take care of stable’ patients while young doctors trained overseas be given temporary licences to work under senior doctors in India. The government also needs to ensure the safety of healthcare workers. Doctors should be given personal protective equipment for practice runs and COVID-19 ICU simulations should be set up to teach them the safe practices, says Dr Shetty.
8. A protocol for safe funerals
In Italy, mounting fatalities prompted the authorities to call in the army for safe disposal of bodies. As with other contagious diseases, there is a strict protocol in place for cremation/ burial of COVID-19 patients to minimise the risk of spreading infection. In India, in the absence of guidelines, there have been reports of crematoriums refusing to handle bodies of COVID-19 victims. In Delhi, the family of a woman who succumbed to the disease had to run from pillar to post for hours before the city’s largest crematorium let in her body for the last rites. According to officials at Chennai’s Kalyan Hospital, the role of the hospital ends with cleaning and securing a COVID-19 victim’s body in a body bag, and the local administration needs to take over from thereon. A protocol that ensures the timely, hassle-free and respectful funeral of COVID-19 victims is urgently required.
9. Ensuring the sick know what to do
The protocol for treatment in Germany bans hospital walk-ins. Those who feel they have symptoms are forced to stay at home, dial a number, which can take 40-50 minutes to connect, and wait for a doctor to call back to see whether or not their condition is serious enough to be treated. This has led to severe psychological stress for patients, many of whom have gone on social media to share their stories. To avoid such a situation in India, a clear guideline needs to be designed so that individuals with COVID-19 symptoms know what to do. Examples from Italy point to the fact that the infection spread a lot more through people-to-people contact in hospitals. Italian doctors have emphasised that COVID-19 should be treated at home as much as possible.
Goa is creating an app that guides a person on the next steps to take based on a self-assessment of symptoms. But as cases rise, this may not be enough. Some projections point to 300,000 cases soon. If that happens, India would collapse, as would any country, says Rao. She is, however, hopeful that the situation will remain manageable. We are already one of the five countries to have isolated the virus strain. We should be coming up with a standardised procedure or guidelines soon. At this point, meticulous planning will save the day. Those who are sick should be assisted with the least amount of waiting period, says Rao.