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.