India needs to move fast on infrastructure creation and vaccinations, given the small window of time it has
India is already bracing up to emerging variants. The delta variant of SARS-CoV-2 virus has raised concerns in Kerala, Maharashtra, Madhya Pradesh and Tamil Nadu
The All India Institute of Medical Sciences (AIIMS) in New Delhi has mostly been swift when it comes to planning and response measures. By 30 March 2020, for instance, when India had a seven-day average of 107 new covid-19 cases, the hospital’s ‘infection control committee’ had already put out a guidelines document, listing everything from “masks management" to “the rational use of personal protective equipment or PPE".
Fast forward to today. The hospital is planning and preparing again. This time, it is busy training the nursing staff to deal with paediatric cases of covid-19. Over 100 beds have been reserved for children who may require treatment post covid infection. Several other public and private hospitals are making similar arrangements. Nanavati-Max Super Speciality hospital in Mumbai, for instance, has also taken steps to ensure it has enough paediatric intensive care unit (ICU) beds. “We have trained nurses and adult intensivists who can manage paediatric cases. We are setting up a separate ward for children and pregnant women," Dr Deepak Patkar, medical director and head of Imaging at Nanavati-Max Super Speciality Hospital, said. The hospital is also trying to organize enough oxygen supply for critical patients.
Although there is not much scientific evidence as of now to show that children will be disproportionately infected in the next wave of the pandemic, the country’s hospitals don’t want to take a chance. Enough lessons have been learnt from the disastrous second wave of the pandemic when new cases touched as high as 4.5 lakh a day in April this year. Over 400,00 people have died of covid-19 in India so far, according to official estimates. The total number of cases recorded stand at 31.4 million. India’s healthcare system had collapsed with thousands of critical patients requiring tertiary hospital care and an acute shortage of hospital beds, oxygen facilities and medical manpower across the country during the second wave of covid-19.
The looming threat of a third wave and its “landfall" has been making rounds for some time. As things stand currently, India has not seen any significant reduction in new cases over the last one month. New cases are currently averaging between 38,000 and 42,000 per day. Public health experts have cautioned that when cases remain constant for this long, it usually signals the onset of a third wave. Over 400 million Indians continue to remain vulnerable to covid-19, according the fourth round of the national serological survey conducted by the Indian Council of Medical Research (ICMR). About 67.6% of India’s population was found to have antibodies against the SARS-CoV-2 virus, said the survey. Scientists charting mathematical models for the pandemic have indicated that the third wave may peak anytime between October and November if people don’t follow covid-appropriate behaviour.
Last year, the department of science and technology had formed a panel of scientists to forecast the surge of coronavirus cases using mathematical models. Professor Manindra Agarwal from the Indian Institute of Technology (IIT), Kanpur, a member of the panel, said that during the third wave, if a mutant and a more transmissible variant of SARS-CoV-2 emerges, the infections could spread faster.
India is already bracing up to emerging variants. The government had in June confirmed that it detected a mutation in the delta variant of the SARS-CoV-2 virus, which has emerged into an additional strain named delta plus. This variant has raised concerns in Kerala, Maharashtra, Madhya Pradesh and Tamil Nadu since it is highly transmissible and also binds stronger to the receptors existing in the lung cells.
India has a small window—at most two months—to prepare. Besides hospitals, the central and state governments appear to be using their time to build the necessary medical infrastructure and prepare medical workers for challenges that may emerge in the future.
The billion-dollar question: will all this be enough to save Indians from another nightmare?
Preparations need money. The central government’s financial response has been the ‘India covid-19 Emergency Response and Health System Preparedness Package’, first announced in April 2020. This month, the Union cabinet chaired by the Prime Minister Narendra Modi approved phase-II of the package with an allocation of ₹23,123 crore for 2021-22. The package has both a central share ( ₹15,000 crore) and a state share ( ₹8,123 crore). Like the name suggests, the scheme aims to “accelerate health system preparedness". More specifically, the package is expected to support central hospitals, AIIMS, and other institutions for repurposing as many as 6,688 beds for covid management. District and sub district capacity is also being boosted. Paediatric units are expected to come up in 736 districts along with a host of other infrastructure—the scheme, for instance, talks about installing 1,050 liquid medical oxygen storage tanks with a medical gas pipeline system to “support at least one such unit per district".
The package may be well-intentioned but its implementation remains crucial, say experts. “It will have to be implemented at the earliest because the third wave, if any, is due within a few months. The medical capacity will have to be built effectively," Arup Mitra, a professor of Economics at the Institute of Economic Growth, University of Delhi, said. “Steps need to be worked out meticulously for implementation. Second, the details need to be worked out in collaboration with the senior paediatricians," he added.
Setting up more paediatric units tops the agenda of some states, too. For instance, the Andhra Pradesh government is setting up paediatric care centres at Visakhapatnam, Tirupati and Krishna-Guntur regions. Similarly, Telangana’s state health department plans to increase the number of beds in government hospitals by 6,000, besides procuring medical equipment and medicines to treat children.
Meanwhile, the central government, in June, had also announced a loan guarantee scheme for pandemic-hit sectors that included healthcare—the programme allows companies to access funds at a reasonable interest rate for ramping up hospital capacity in non-metropolitan cities with the government acting as a guarantor. A sum of ₹50,000 crore was dedicated as part of this scheme, a move that industry experts said would perhaps aid struggling hospitals in tier-2 and tier-3 cities.
According to heath experts, however, everything may fall flat because of two factors: inappropriate behaviour on the part of citizens and a slow pace of vaccination.
VP Singh, professor of Economics at the Great Lakes Institute of Management, Gurgaon, held that countering the real threat requires sound co-ordination across central government, state governments and the country’s citizens. All efforts in creating the medical infrastructure, ensuring the supply of medicines, doctors, nurses and logistics will be outstripped by the demand if people fail to behave responsibly. “No amount of infrastructure is adequate to contain inappropriate mass behaviour. Medical oxygen demand saw a meteoric rise from 700 million tonnes (MT) per day to 7,000MT per day during the second wave. Centre-state acrimony added to the agony," he pointed out. Singh was referring to the “vaccine politics" that involved some state governments alleging that they weren’t getting an adequate supply of jabs.
Rush the jabs
India has already administered over 430 million covid-19 doses and around 4% of the total population is fully vaccinated. That makes India second only to China in the pecking order of citizens vaccinated in each country. This feat may deserve a pat but certainly not a party, experts said.
While timelines for all nations are the same, the target to achieve for India is much higher given its huge population and the rise of new variants. After alpha, beta, gamma and delta (originated in India), the delta plus is emerging as a new threat across the globe. Nirmal Kumar Ganguly, president, Jawaharlal Institute of Post Graduate Medical Education and Research and the former director general of the Indian Council of Medical Research, argued that many of the densely vaccinated countries are showing a new surge with the emergence of delta variant, which has reached 90 countries, and the delta plus variant, which has reached 19 countries including Israel, UAE, Russia, USA and UK. “This could have been prevented if global molecular/genomic surveillance modelling and forecasting were in place, supported by enhanced diagnostics, tracking and containment," he said. “The strategy to prevent a third wave will be to vaccinate all the eligible population within the country, keeping ethics and equity in mind, masking and enhancing the diagnostic and genomic surveillance," he added.
The problem is that the pace of vaccinations has slowed down. Almost all states jabbed fewer people in the last seven days than they did in the week before, with the average daily pace dipping below 3,000 doses per million population. Vaccine doses given averaged 3,012 per million population per day between 11-17 July. Between 18-25 July, the number dropped to 2,941 per million population per day.
Dr Merlin Moni, associate professor, Division of Infectious Diseases at Amrita Hospital in Kochi, Kerala, says that India’s preparedness for a the third wave depends on how the authorities gauge readiness. “The readiness depends on several factors including total vaccinated individuals, total population at risk; adherence to infection control measures, policies on public events and planned public health response. In the aftermath of the second wave, these challenges remain unsolved. With the looming threat of a third wave, India is lagging in devising tailored strategies for the at-risk group," she said.
The emergence of the highly transmissible variants of concern have the potential to outpace the current vaccination rollouts in the country since a huge chunk of India’s population still remains at risk, she added. Moni held that major stakeholders in the Indian healthcare system, including the private sector, are yet to be actively involved in vaccine deployment at the required scale. India probably paid a heavy price because of this during the second wave. “The government has to maximize the vaccine roll out programme for robust coverage of the population before the third wave. This strategy should not only limit to government settings but focus on involving the private sector, non-governmental organizations (NGOs) and deployment measures that include door to door delivery," Moni said.
So, how is the private sector preparing? Besides more beds, hospitals are working on oxygen supplies and the testing infrastructure. Fortis Healthcare Ltd, which runs a chain of private hospitals, is planning to step up its own oxygen generation plants. This would be a significant step towards achieving oxygen self-sufficiency and mitigation of supply side constraints, Dr Bishnu Panigrahi, group head, Medical Strategy and Operations at Fortis Healthcare said.
However, there remains a critical gap in testing. While India has so far totalled over 450 million in cumulative tests, a majority of them were concentrated in urban India. Lack of testing may translate into a sudden burst of infection in rural India, experts held. State governments have set up RT-PCR labs across major districts and the capacities of these labs are decided by the state health department. Overall, India has about 1,292 government laboratories and 1,479 private laboratories for covid-19 testing but that’s hardly enough.
Anand K., chief executive officer at SRL Diagnostics, said that the vast and diverse geographical terrain of India makes it difficult to reach every corner of the country. Generating awareness and encouraging people to take the test will be another challenge. “The government and private bodies need to work cohesively to collect and test the samples. Diagnostics players can provide the infrastructure and human resources required in the laboratories while the government should take the responsibility of collection. At this point, surveillance and screening are vital components to tackle growing cases in rural India," he said.
A public-private partnership approach is a tried and tested solution, he added. While that may be true, India needs to move fast on the twin fronts of infrastructure creation and vaccinations, given the small window of time it has.
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