As India reaches the cusp of a third lockdown only to prepare for Ver. 4.0, it is time to ask if the move has accomplished what it was meant to and laid the foundation for a future strategy for COVID-19. When Prime Minister Narendra Modi announced the lockdown on March 24, India had 564 Covid infections and 10 deaths. Worldwide, the global death toll had already crossed 10,000 and hospitals were fast running out of beds and ventilators. Italy was grappling with 69,176 cases, the US 42,164, and the UK 8,077. Going by their experience, India knew it had no choice but to go into lockdown. If the disease could overwhelm countries with healthcare systems far more sophisticated than ours, what chance did our fraught healthcare infrastructure have?
Eight weeks into the lockdown, set for further extension on May 18 with an entirely new set of rules, Dr V.K. Paul, member, NITI Aayog, and head of the empowered committee on medical emergency management, believes it has made a difference. “Eight weeks ago, our doubling time was 3.4 days; this week, it is 11-12 days. The lockdown was focused on slowing the rate of transmission, to push our curve on a trajectory low enough for our systems to cope with. It had a clear purpose, slow down the spread of infection and equip healthcare.”
If we have indeed achieved the target, why Lockdown 4.0? “To maintain the gains made in the past two months. We cannot let infections get out of hand,” says Dr Paul. It is almost certain that the Covid conventions of social distancing, hand hygiene and mask coverage will continue into the next phase of the lockdown even if restrictions on movement are gradually lifted. “We will continue to grow health infrastructure, the goal is to build good hospitals: more beds, more ventilators, treatment facilities, and push for diagnosis as well as containment in red zones,” adds Dr Paul. Geo-tagging Covid suspects through the Aarogya Setu app, drug and vaccine research and public awareness campaigns are likely to be the other areas of increased focus, according to a health ministry official.
“Our peak is expected in June or July; we must continue being responsible,” says Dr Randeep Guleria, director of the All-India Institute of Medical Sciences in Delhi and member of the empowered committee on hospitals and disease surveillance. With 70-80 per infections concentrated in metropolitan cities, he advocates micro-planning in the 130 national red zones, particularly the congested ones. “Tackling red zones will be a priority,” he says. While states can choose the restrictions they want lifted in Lockdown 4.0 (West Bengal, for example, plans to divide a red zone in three categories to allow public movement), the greatest fear public health officials have is that it is still too soon to reopen borders or allow public transport.
It is a valid enough fear. Ours remains an upward curve of infections. From May 10 to May 13, we saw around 3,500 cases a day. And even though the time taken for infections to double has come down, the infection rate, the number of those tested reporting positive, has gone up. On March 24, India had 564 infected people and an infection rate of 1.9 per cent, or roughly two out of 100 people tested were Covid-positive. By May 13, total cases were 74,280 and the infection rate 4 per cent. Hotspots like Mumbai have an infection rate as high as 15 per cent. India, thus, is still a long way off from Covid’s downward trajectory in South Korea, Italy or China.
Community transmission also continues to be a threat. An April 9 study by the health ministry and the Indian Council of Medical Research (ICMR) had already hinted at community transmission in 36 districts across 15 states, as 40 of the 105 Covid-positive SARI (Severe Acute Respiratory Infection) patients were found to have no travel or contact history. More than a month down the line, the ICMR has begun a surveillance of 75 districts to determine community transmission.
It is imperative, therefore, that Lockdown 4.0 continue with an aggressive containment strategy. “Are we sensitised and aware enough to be responsible without a lockdown?” asks noted virologist Dr Jacob John. “If we open restrictions, the public must not forget we are still at great risk. You cannot eradicate a virus so soon. What we can do is change behaviour and prepare for infections.”
Preparing for infections is precisely where the government has focused its energies till now. By May 13, the country had 1,025 dedicated Covid hospitals and 351 labs with the capacity to conduct 90,000 tests a day from one lab on March 1. From 105,890 isolation beds on March 12, two weeks before the lockdown, we had managed to add another 714,075 by May 13; around the same time, ICU beds went up by 23,343 from the existing 11,752 and ventilators by 9,368 from 6,324. Of the Rs 3,100 crore the government has allotted from the PM-CARES Fund to COVID-19, around Rs 2,000 crore has been earmarked for the purchase of ventilators and another Rs 100 crore toward supporting vaccine development. A hundred thousand PCR test kits and 200,000 personal protective equipment (PPE) kits will soon be produced per day in India.
These preparations by the central government have certainly offered some of the confidence needed to start lifting the lockdown in phases. “What we do with the resources is also an important consideration,” says Dr John. Certainly, there is wide discrepancy in facilities and tests across states. At this juncture, it may be worthwhile to assess where India stands in its fight against COVID-19 and its plans ahead.
ISOLATION AND ICU BEDS, VENTILATORS
A small percentage of the afflicted eventually require critical care. Yet, ICU beds, oxygen-supported beds and ventilators remain crucial because the care needed for patients with moderate and severe symptoms cannot be built up overnight. On May 10, concerns of Mumbai running out of ICU beds sent panic bells ringing. “Some central resources were not being used,” says Dr Paul. “These issues are being handled on an urgent basis. The severe stage of Covid can only be treated in an ICU.” According to Dr Richa Narang, an ICU anesthesiologist at the Lok Nayak Jai Prakash Narayan Hospital in Delhi, “We need ICU beds not just for oxygen support but for monitoring critically-ill patients.” The biggest change to ICU care since the start of the lockdown, she says, is “much more support for a holistic ICU. Earlier, we had to wheel patients to different rooms for different tests, now most of it can be done in the ICU.” As on May 13, India had 35,095 ICU beds, 60,000 oxygen beds (to be increased to 100,000 in the next few weeks) and 15,692 ventilators. We still have a long way to go, but given the time and cost needed to set up new critical care facilities, particularly with the country at a standstill, this is a welcome start.
The real test for the healthcare system, however, is ensuring even distribution of facilities. Health is a state subject, even during a biological emergency, and deficiencies in state bed capacities are an area of concern. Twelve states, Bihar, Jharkhand, Gujarat, Uttar Pradesh, Andhra Pradesh, Chhattisgarh, Madhya Pradesh, Haryana, Maharashtra, Odisha, Assam and Manipur, which account for 70 per cent of India’s population had beds less than the national average of 0.55 beds per 1,000 people. Bihar, India’s second most densely populated state after Maharashtra, has only 0.11 beds per 1,000. “For states already dismally lagging in hospital infrastructure, a few thousand extra beds won’t cover the shortfall,” says Prachi Singh, associate fellow at research firm Brookings India. While Rajasthan managed to add 3,000 ICU beds and 1,050 ventilators during the lockdown, Maharashtra could add only 1,500 ICU beds and 400 ventilators. In West Bengal, only 860 of the 5,677 ICU beds and 271 of the 2,838 ventilators are functional. “You cannot plug all the shortcomings of an ignored healthcare system in six or seven weeks,” says Dr John.
PERSONAL PROTECTION EQUIPMENT
With health workers being at the maximum risk of exposure to the disease, PPE has become critical to safeguard their health. “If you don’t protect your healthcare staff, your system will collapse, two hospitals had to be shut in Mumbai because its nurses were infected,” says Dr Avinash Bhondwe, president of the Maharashtra chapter of the Indian Medical Association. At the start of the lockdown, those working in the Covid wards of AIIMS in Delhi reported having just plastic sheets for protection. Already, 548 doctors and paramedics in the country have tested positive for Covid. In West Bengal, the shortfall in PPE led to 200 infections and quarantine for 600 healthcare workers.
Dr Narang says you need a minimum of three PPE per patient every day. With 71,865 cases on May 13, that is roughly 215,595 PPE daily. “The demand for PPE went up from 300,000 on March 18 to 2.2 million by March 24 to 100 million now,” says Sanjiiv Rehlan, chairman, Preventive Wear Manufacturers of India. After a shortfall in April, the situation has dramatically improved. From pre-lockdown production of 47,000 kits per year, the central government has now enabled manufacturers to produce 200,000 kits daily. And this is only expected to grow.
In the coming weeks, quality and supply of PPE will be pivotal. West Bengal claimed it had distributed 1.6 million PPE kits, 7.3 million masks and 3 million gloves, but block and peripheral health units complained of inadequate supply. “There are many complaints of inferior quality PPE,” says Manas Gumta, general secretary of the Association of Health Service Doctors. “They come in one size and don’t fit smaller-built workers.”
Home ministry guidelines mandate all PPE be liquid-proof, but, unlike ISO (International Organization of Standardizations) specifications, India is yet to prescribe any extensive guidelines for PPE quality. “PPE made today is liquid-proof, but it is also air-proof. Most manufacturers are using 90 GSM material and laminating it for liquid-proofing. As a result, the wearer feels suffocated within 50 minutes,” says Rehlan, who feels it is important to research for a multi-use solution. “Majority of PPE is being made from the same plastic material polythene bags are made of, which is banned. It is not a sustainable material.”
By contrast, states that regulated their PPE supply and training from the start are also the ones that are reporting low infections among health workers, Tamil Nadu, Kerala, Rajasthan, Chhattisgarh, for example. These states not only invested in protective gear but also taught staff how to use and dispose of PPE.
From just 22,440 samples (17 tests per million) on March 24 to 1,854,250 samples (1,404 tests per million) tested by May 13, India has certainly come a long way. We had no manufacturing and little laboratory infrastructure for PCR tests before the lockdown. Today, we have 72 approved suppliers for PCR kits, are poised to make 100,000 kits per day in India and are aiming to produce 500,000 kits per day by June.
“Despite a global shortage, our kit availability has improved. We are strategising testing to optimally use resources,” says Amita Jain, virologist and professor of microbiology at King George’s Medical College, Lucknow. Testing is now a crucial aspect of India’s gameplan. States like Tamil Nadu and Maharashtra, in fact, have a testing rate higher than the national average, 3,555 and 1,878 tests per million, respectively. The infection rate among those tested is lower than the national average in states that began aggressive testing in March itself. Kerala has a current infection rate of 2.6 per cent and Rajasthan 3.4 per cent. By contrast, states that did not prioritise diagnosis, such as Maharashtra, Gujarat, Delhi and West Bengal, are now reporting infection rates of 13.2 per cent, 10.6 per cent, 9.6 per cent and 5.7 per cent, respectively. Once Maharashtra improved its testing, the doubling rate slowed from three days in the first week of April to 12 days in the first week of May, claims state health minister Rajesh Tope. “But you cannot undo what has already spread,” says Dr Bhondwe.
A controversy over the quality and pricing of rapid test kits has forced many states, which were relying on them to improve diagnosis, to rethink testing strategy. States like Delhi, West Bengal and Maharashtra are also considering pooled PCR tests and using TB test machines to scale up diagnosis. Every district in West Bengal has two labs with CB-NAAT (cartridge-based nucleic acid amplification test) machines, which can also amplify the DNA required for PCR tests.
Pricing remains a major challenge for scaling up testing. PCR tests in private labs can cost from Rs 2,000 in Uttar Pradesh to Rs 6,400 at a private hospital in Mumbai (with the addition of ‘handling and consultation’ charges to the government capped price of Rs 4,500). A standardised price is crucial. “One must make costs affordable and reduce fear of social persecution, else no one will want to be diagnosed,” says Dr Amar Jesani, a public health and medical ethics analyst.
Our understanding of Covid has changed dramatically in the recent past. Though a vaccine still eludes us, the range of treatment to weather cytokine storms, thrombosis and organ inflammation has grown. “At 32 per cent, our recovery rate is among the highest in the world. This is because we’re treating multiple areas the virus might attack, lungs, heart, kidney, liver and blood oxygen,” says Dr Ajay Goenka, managing director of Chirayu Medical College, Bhopal.
India is also among the few countries to have begun human trials for plasma therapy. The results, if successful, will contribute immensely towards moderate and severe Covid infection. Five Indian hospitals are also a part of the WHO Global Solidarity Trials to test the efficacy of several drugs. Gilead, the company which holds a patent for one of the most promising Covid drugs, Remdesivir, has already partnered with Jubilant Life Sciences in India to produce and market the drug for domestic use. We are also the leading global producers of other Covid drugs like Paracetamol, Hydroxychloroquine and Lopinavir/ Ritonavir.
At 3.25 per cent, India’s death rate is far lower than of many western countries; it is nearly half of the US’s 5.57 per cent. However, as Dinesh Singh, statistician and former vice-chancellor of Delhi University, says, this could be because “disaggregated data is still missing from the public domain. As a nation, we are yet to know the value of predictive models, if we had reliable and accessible data, we could even predict the chances of you and me getting infected.” Public health analysts allege India is not recording comorbid deaths despite patients being Covid positive. Recently, when West Bengal added 39 comorbid deaths to its toll, its death rate shot up from 2 per cent to 7.6 per cent overnight.
As on May 13, India had 130 districts in the red zone and 284 in the orange zone, besides several thousand containment clusters within the red zones (Chennai alone has 690 clusters). Lockdown 4.0 will include combative strategies so that red and orange zones can become green, where no case has been reported for three weeks. The next few weeks are expected to give states the flexibility to narrow down high-risk areas even within the red zones (currently characterised by the Centre). Delhi, for example, has only 80 clusters where the infection is growing rapidly, yet the entire state is following red zone rules. Added surveillance and restricted movement can help isolate these clusters from areas of less concern, allowing economic and social activity to gradually resume even within a red zone.
“The uncertainty around Covid makes it difficult to evaluate specific action taken in response. Decisions have been made based on available information and the situation is rapidly changing,” says Jacquleen Joseph, chairperson, Centre for Disaster Management, Jamsetji Tata School of Disaster Studies. Using caution and restraint, states are preparing to come out of the lockdown. But we cannot let our guard down till a vaccine or treatment is found. Hygiene will be paramount, as will going to the doctor if you have Covid. In your safety lies the country’s well-being.
with Romita Datta, Rohit Parihar and Kiran D. Tare