Context: As per official data, we now have over three lakh cases and 3,000 deaths every day.
- In most cities across India there is great demand for ICUs and critical care beds, a shortage of oxygen and hoarding of key medicines.
- Our top scientists and bureaucrats have claimed that the second wave was indeed expected and we were prepared.
Reasons behind the surge
- A more infectious mutation of the virus: The ‘double mutant’ virus that scientists say is responsible for the spread of the pandemic in India, has a formal scientific classification: B.1.617.
- It has one key mutation in the spike protein similar to one found in the Brazilian and South African variants, and another already found in the B.1.427 and B.1.429 California variants.
- The people not following COVID discipline.
- Routine failure of our centralised scientific and administrative bureaucracy
- Non availability of data: US gives us several important facts, state-wise, about the epidemic there, diligently collected by many university researchers.
- None of these clinical facts are known for India. They are crucial for managing the epidemic.
- Lack of research: Our scientific agencies have not come up with any quantitative norm for preparedness or guidelines for states to follow, more sophisticated lifesaving services such as bed allocations or ambulance dispatch software.
- Scarcity of hospital beds: As tier I hospital capacity is exhausted, anxiety rises as only poorer quality tier II hospitals are available.
- The supply chains of these hospitals are weak leading to shortages of oxygen and drugs.
- Hoarding of services becomes endemic and mortality rises.
- Oxygen crisis: Assuming a critical care consumption of 15 kg per patient per day, the current India-wide demand of 4,000 MT indicates that about 2,60,000 patients are under critical care.
- A peak rate of five deaths per million per day should be adopted as a planning objective in our National Disaster Management Plan.
- The national capacity of 7,000 MT was not adequate and urgent measures were required.
- Robust oxygen systems, that would support a pandemic, take time to put in place.
- The basics are the oxygen source and the options include gas cylinders, oxygen concentrators and oxygen generators.
- The neglect of oxygen systems has been partly market failure, partly lack of knowledge and anticipation, partly inertia.
- No National Plan for the epidemic: The Supreme Court has asked the Centre for a national plan on oxygen and vaccinations and the states for an affidavit stating their health infrastructure.
- Vaccine Demand-supply gap: According to recent estimates, existing producers in India will be unable to meet the country’s vaccine requirements.
- In terms of population share, less than 2% has received both vaccine doses, while less than 9% has received one dose.
- A demand-supply mismatch has begun to appear as the coverage of the vaccine-eligible population expanded.
- The United States Government had used a Cold War piece of legislation, the Defense Production Act, to restrict exports of vaccine culture and other essential materials.
- There is a lack of the financial capacity to expand its production and companies are requesting a grant of ₹30 billion from the government.
- The government has not fixed the vaccine prices and has allowed the producers to pre-declare the prices they would charge from the State governments and private hospitals.
- The new strategy fragments the market into three layers namely, central government procurement, State government procurement and the private hospitals.
- This layering of the market would allow the producers to charge high prices from the State governments and private hospitals.
- The new strategy would shift the burden of vaccination of the young population, namely, those between 18-44 years, entirely on the State governments.
- Moreover, given their poor state of finances, most State governments may not be able to procure the required number of vaccine doses to meet the demands of the targeted population.
There was poor design of empirical and scientific systems, excessive centralisation and a failure of execution.
- Deciding parameter of preparedness for pandemic
- Hospital beds: COVID-19 care is broadly organised as tier I consisting of large private hospitals, and well-equipped public hospitals in main cities.
- Tier II of smaller private and public hospitals dotted across the state, and tier III of community or home care. Tier III is essentially a denial of service for a severe COVID patient.
- Critical care is provided by tier I hospitals, and to some extent, tier II hospitals.
- Anticipating mortality: We should expect roughly one death per day from a 250-bed tier I critical care hospital, but three deaths from a 250-bed tier II hospital.
- For any hospital, computing the basic quality-of-care multiplier, that is, recording the mortality and duration of care is basic statistics.
- In fact, this, along with the number of beds in each tier, defines the preparedness of the district or the city.
- Given the daily death rate (DDR), it is now easy to estimate hospital utilisation and classify the stress level in a district.
- Plan for oxygen:
- For an oxygen system to be developed there must be a good understanding of the local context.
- This includes the
- systems that are already in use,
- the local providers,
- biomedical technician capacity,
- reliability of power supplies (often power supplies are erratic and
- power surges can damage concentrators, solar power is more stable) and
- the size of local populations and projected oxygen needs.
- For now, governments and health services should invest in bedside oxygen concentrators and generators to supply whole hospital or district needs.
- Global agencies should support this in a similar way that vaccines are being scaled up through global partnerships like COVAX.
- Health services and their partners should conduct training programmes for health care workers in the use of oxygen technology.
- More open licensing for vaccines: There is a need for more open licensing of this vaccine to scale up production. This would enhance competition in the market, enabling the vaccines to reach every citizen in the country.
- Tackling duopoly in the vaccine market: The government should have urgently addressed the serious doubts over affordability of vaccines by ensuring a competitive market for vaccines.
- India needs more vaccine manufacturers to ensure uninterrupted supply.
- One positive step that the government has taken in this direction is to increase production of Bharat Biotech’s vaccine through the involvement of three public sector undertakings, including Haffkine Institute.
COVID-19 is a long-game; the best time to start implementing effective plans may have been several years ago, but the next best time is now.
- The SARS-CoV-2 virus causes COVID-19 pneumonia and hypoxaemia.
- Hypoxaemia is a lack of oxygen in the blood. It is the most important complication of COVID-19 pneumonia and a major cause of death.
- In severe pneumonia, oxygen relieves hypoxaemia. It can allow time for the infection to clear and the lungs to heal.
An oxygen system
- It involves the equipment needed to detect hypoxaemia and give oxygen.
- This includes;
- a small device called a pulse oximeter which is essential to detect hypoxaemia,
- the source of oxygen (of which there are several options),
- other technical equipment to give oxygen (such as flow meters and oxygen tubing), a small device called an oxygen analyser (which assesses the purity of oxygen from the source) and a power supply.
- trained health workers, biomedical technicians and equipment maintenance are vital.
Ways to supply oxygen
- A single oxygen cylinder, which would supply one person, may last for between 24 to 72 hours depending on the severity of hypoxaemia and how much oxygen they need.
- Oxygen concentrators can provide oxygen to up to five children, or one or two sick adults, at a time.
- These are devices that concentrate the oxygen from ambient air.
- An oxygen concentrator is recommended by doctors to fulfil the shortage of oxygen in a person's body.
- The atmosphere has 78 per cent nitrogen, 21 per cent oxygen and 1 per cent other gases.
- An oxygen concentrator takes the ambient air and filters the oxygen from nitrogen.
- Then the device releases the nitrogen back into the air and collects the oxygen, dispensing it to the patient through the pressure valve.
- The oxygen that is concentrated in an oxygen concentrator holds 90 to 95 per cent purity.
- It is not recommended for ICU patients as they are required to use liquid medical oxygen (LMO).
- Oxygen generators: They are large machines which generate oxygen from the air (about 5,000 litres per hour) and can fill between 30 to 50 cylinders per day
- A key benefit of oxygen generators and concentrators is that they can supply a whole region or health service in a way that can be independent of private gas companies.