Wednesday, 18 March 2020

Basic mistakes in India's response to Covid-19

It's been more than 2 months since the global spread of the new Coronavirus which originated in Wuhan, China. The extensive lock down implemented by China seems to have help slowed down the spread of the Covid-19 disease with in China and outside. While the numbers reported by China are not reliable it is unquestionable that they have a fairly developed hospital infrastructure and production capability which has played a role in bringing the epidemic in control in China.

India had a two month advance warning and there were certain basic capability gaps that India had compared to China which it had to make and attempt to bridge in these two months.

1) Personal protection of medical staff and training for treatment of infectious disease.
2) Hospital capacity increase for critical care including procurement of required equipment.
3) Diagnostic Kits for Covid-19 disease detection in the numbers needed.

These are obvious gaps that are public knowledge, yet we have not seen the effort required at the scale needed to fill these gaps. We had two months to do this but only yesterday have we seen some communication from ICMR on a plan to increase the testing capacity. They have said that we have only two rapid diagnostic labs with capacity of 1400 tests per day. Total of 121 labs will be brought online by week ending 20/Mar/2020 most of them have the capacity of 90 tests per day. ICMR has mentioned that there is limit on how many tests can be conducted which is limited by number of probes available which are to be imported. India has ordered 1 million probes and has requested WHO for another 1 million probes. They have also now started to tie up with private labs for testing to increase capacity.

But the testing guidelines that India follows assumes that there is no community transmission of this disease in India. It involves testing only travel cases and their contacts. WHO guideline includes all atypical pneumonia cases for Covid-19. But India has not included that in its guideline. India is doing a surveillance testing which involves sample of 20 per lab in 52 government medical college hospital labs for severe acute respiratory illness patients to check for Covid-19 disease. This testing is seems can only reveal if there is a widespread Covid-19 epidemic in the country but it does not appear such a sampling method will catch the disease spread in its initial stages. The best way to catch that is to perform a more aggressive testing of GP doctors, respiratory ICU medical staff, atypical pneumonia cases and the like as per WHO guidelines.

There hasn't been any effort spent on increasing the hospital ICU capacity in the last 2 months. This is something which could have been started on a war footing immediately in mid January once the pattern of the disease in China had become clear. It was known that this disease is unstoppable because of asymptomatic transmission and has a high percentage of sever illness requiring ICU care. Hence this step of mass procurement of ICU equipment for hospitals should have been started immediately. But till date we have not heard of any effort by central or state governments to bridge the gap. Recently GOI has declared Covid-19 as a national disaster allowing states to utilize State Disaster Response Funds for procurement of medical equipment but there has been a cap of 10% put on the state spending for ICU equipment, PPE and training. Its inexplicable why there should be this cap of 10% put on these funds.

Finally on the front of personal protection equipment again the scale at which this equipment is needed has not been addressed. You can gauge the availability of this equipment with India on this figure the number of N95 masks which India could spare to send to China for Covid-19 relief sent by India in February was a total of 4,000.  We need millions of N95 masks and other high quality personal protection equipment for our medical staff in hospitals but it is not clear how much India is prepared on this front. The news reports coming out of several states on their handling of the first cases which were sent to isolation wards is not encouraging. The medical staff did not have correct equipment, they were not trained, no drills had been conducted, isolation wards were not proper negative pressure rooms, ICU beds were not available in isolation wards.

No doubt India has put a lot of effort in airport screening, contact tracing of confirmed cases and travel restrictions. India has also started implementing the so called social distancing measures slowly. But most of the testing that India has done has been a result of voluntary disclosures. There have been several cases where the patients have hidden their travel history before first approaching a medical professional or seeking medical care in hospitals. We can only conclude that there would be several silent chains of transmission of this disease and it is only prudent to assume that community transmission of the disease is taking place already. It is important to start testing for it and that required relaxing the test criterion and increasing the testing capacity asap.

Friday, 31 January 2020

India's response to Wuhan Coronavirus lacking

In one word the Indian response so far to Wuhan Coronavirus seems 'casual'. There have been some news reports of a shortage of N95 respirators and surgical masks in India due to demand in China.  But the public concern as well as more importantly the response from GOI on a threat of nCoV epidemic has been lacking any real urgency. We have seen the action which has been taken in terms of body temperature screening of inbound passengers from China on airports and some reports of certain states monitoring the returnees. But the effectiveness of such a screening is suspect. Given the studies emerging that this virus is infectious even in asymptomatic patients. China's health minister has also said the same. A study in Germany has shown that the virus is infectious both before the onset of symptoms and after the symptoms have disappeared. This makes is very difficult to contain the spread of this virus in populations since there is no existing immunity to it yet in any population cluster.

There have been some people returning from Wuhan who have been found with flu likes symptoms and have been isolated in certain hospitals across India out of which one person has so far tested positive in Kerala. Other tests have either come negative or are still awaiting results. From the news reports about the diagnostics which have come out till now it appears that the turn around time of PCR testing result from National Institute of Virology, Pune is upwards of 2 days. NIV itself takes 3-6 hours to test and total of 12-18 hours to prepare and upload a report. So far it remains the only centre for testing this virus. A report suggested that NIV was awaiting fast diagnostic test kits from abroad. One report even suggested that for a certain patient in Kolkata NIV determined not to conduct an nCoV test based on description of symptoms and other report of the patient. All this points to the expected current scenario that testing infrastructure is not adequate yet. Also it is not clear if  proper contact tracing is being done to ensure that all potentially infected people are being tested. This is a clear case where media should be asking questions to GOI and union health ministry should be addressing this seriously.

There are a number of Indian medical students studying in China and the infected person is also one of them. Indian government is also airlifting some 600 odd students from Hubei province and plans to house them in a military establishment in Haryana for a duration of 14 days. Now that may be fine but here are some lax deficiencies which are visible already. The Wuhan returnees will be housed in dormitories. With such a large number of 600 people I suppose India lacks infrastructure to be able to provide them all with isolated accommodation. The is a huge risk factor and shows how this epidemic can cause devastation in India which lacks woefully in terms of infrastructure. China which has a much better infrastructure than India is struggling to control this epidemic, for India this will be 10 times tougher.

It appears that nCoV is much more contagious than a normal flu and the severity of infection in some patients and percentage of complications including death rate is much higher. Though the severity is lower than SARS or MERS but is much more contagious with exponential growth rate so far. Clearly given the risk of an epidemic in India a lot more needs to be done and to avoid any panic among the people a transparent communication is needed regularly from the health ministries in state and centre both. I find that the updates from government about what action they are taking are very low especially when compared to what is being done across the world. This needs to change fast. In a media briefing today the Ministry of External affairs has mentioned that while preparations are on way to get the stranded Indians from Wuhan back to India there have been no moves to restrict any travel to and from China. Only the ministry of health has issued an advisory to avoid travel to China but no VISA restrictions have been placed on Chinese nationals visiting India nor has there been any action by the civil aviation ministry to issue any instructions to airlines to stop flying to China/ Hong Kong.

Given the kind of disease we are dealing with and the severity of contagion in China, one would expect that GOI will do more than a mere airport screening, which they keep repeating as a reply to every question, as if its going to solve the issue. It is clearly not effective in preventing this disease from spreading in India. GOI ministers seems to be acting this was to avoid panic when in fact they should be erring in favour of caution here and take a leaf from what other countries are doing. Russia and Mongolia have stopped land border with China. US has issue strong warning to its citizens against travel to whole of China. Several foreign airlines have already stopped all to and fro flights to China or have curtailed the number of flights. So far Indian airliners like Air India and Indigo have curtailed the number of flights and destinations in China and Hong Kong but there is no blanket ban yet.

While World Health Organisation has declared this a world wide health emergency, but it has cautioned countries against taking any travel or trade restrictions on China. In its press conference on 30/Jan/2020 it even suggested that it would be questioning countries which declare a unilateral trade or travel restriction on China. This seems puzzling to say the least. On the one hand WHO commends China for its quarantine efforts, while the spread of the disease in China and around the world looks quite extensive including the disease spreading from person to person outside of China, including cases of asymptomatic spread and yet WHO is favouring economic reasons over health reasons in its advisory. So far it seems GOI is not going to do anything to restrict movement of people to and from China and other affected counties. One hopes the truth dawns on GOI soon and these travel and VISA restrictions are put in place. Israel has decided to suspend all flight to China and quarantine all travellers from China. Singapore has decided to not issue VISA to any Chinese passport holder nor to anyone who has been to China in last 14 days. I hope India too takes some drastic steps now when there may still be time.