Prepping Up Critical HealthCare Infra for 3rd wave of COVID19

“You are as good as the last fight. But you can’t beat the person who won’t give up.”

• Pandemics, like the 1918 Spanish Influenza and COVID-19, spread through regions of the World in subsequent waves. Here we discuss a consistent picture of the wave pattern based on the epidemic Renormalisation Group (eRG) framework, which is guided by the global symmetries of the system under time rescaling. We show that the rate of spreading of the disease can be interpreted as a time-dilation symmetry, while the final stage of an epidemic episode corresponds to reaching a time scale-invariant state. We find that the endemic period between two waves is a sign of instability in the system, associated to near-breaking of the time scale-invariance. This phenomenon can be described in terms of an eRG model featuring complex fixed points. Our results demonstrate that the key to control the arrival of the next wave of a pandemic is in the strolling period in between waves, i.e. when the number of infections grows linearly. Thus, limiting the virus diffusion in this period is the most effective way to prevent or delay the arrival of the next wave. In this work we establish a new guiding principle for the formulation of mid-term governmental strategies to curb pandemics and avoid recurrent waves of infections, deleterious in terms of human life loss and economic damage.
• Pandemics, like the 1918 Spanish Influenza1 and COVID-19, spread through regions of the World in subsequent waves. There is, however, no consensus on the origin of this pattern, which may originate from human behaviour rather than from the virus diffusion itself. Time-honoured models of the SIR type or others based on complex networks describe well the exponential spread of the disease, but cannot naturally accommodate the wave pattern. Nevertheless, understanding this time-structure is of paramount importance in designing effective prevention measures. Here we propose a consistent picture of the wave pattern based on the epidemic Renormalisation Group (eRG) framework, which is guided by the global symmetries of the system under time rescaling. We show that the rate of spreading of the disease can be interpreted as a time-dilation symmetry, while the final stage of an epidemic episode corresponds to reaching a time scale-invariant state. We find that the endemic period between two waves is a sign of instability in the system, associated to near-breaking of the time scale-invariance. This phenomenon can be described in terms of an eRG model featuring complex fixed points. Our results demonstrate that the key to control the arrival of the next wave of a pandemic is in the strolling period in between waves, i.e. when the number of infections grows linearly. Thus, limiting the virus diffusion in this period is the most effective way to prevent or delay the arrival of the next wave. In this work we establish a new guiding principle for the formulation of mid-term governmental strategies to curb pandemics and avoid recurrent waves of infections, deleterious in terms of human life loss and economic damage.
• As it emerged from the Spanish Influenza that hit the World in three consecutive waves between spring 1918 and the early months of 1919, virus-driven pandemics can feature a wave pattern, even though the origin of this behaviour is not understood. The very recent pandemic, caused by the coronavirus SARS-CoV-2, is showing a similar pattern, with a first wave hitting in the spring of 2020, and following ones still raging various regions of the World. Reliable algorithms were used at the beginning of the pandemic to predict the evolution of the number of cases affected by the COVID-19 disease, however it has proven difficult to predict the arrival of a second wave in the fall 2020. With the exception of a few countries like China, Vietnam and New Zealand, all regions of the World are suffering from multiple waves of COVID-19 infections.
• The diffusion of the virus can be described by various time-honoured models, like compartmental models of the SIR type and complex networks. These mathematical frameworks account for the exponential growth of the number of new infected cases, and the slowing down of the spreading once most of the susceptible individuals are infected. However, it is not a simple task to generate a wave pattern. For instance, in SIR models, one could induce a second wave either by injecting by hand new individuals in the susceptible sub-population, or by including a probability that the removed individuals may return to the state of susceptible. The latter case cannot apply to the COVID-19, as very few cases of recovered individuals being infected again have been recorded.
• Researchers successfully predicted the occurrence of a second wave in Europe starting in September–October. The analysis is based on the eRG framework, extended by interactions between various countries. The approach is based on the analysis of the time evolution of the total number of infected cases and the symmetries that this epidemic curve reveals, allowing to extract reliable information from the data independently on the specific conditions met in each country. In fact, all the elements that can influence the velocity of the disease spreading are included in a single parameter, which contains the effect of local conditions, non-pharmaceutical interventions and socio-demographical characteristics. The eRG, therefore, can provide complementary information to studies that analyse in detail the effect of various measures. As an example, the eRG framework has been used to study the effect of mobility reduction in Europe and the US during the first wave, highlighting a universal time-frame of 2–4 weeks before an observable effect can be detected in the virus diffusion. For comparison, detailed studies of the mobility in the US have been able to identify the locations and events that foster the infection of new individuals and ignite hotspots.
• In this work we focus on the total number of infected cases, as this is the most reliable tracker of the time-evolution of the pandemics. In fact, other data, like the number of deaths and of hospitalisations, depend on factors like the age distribution and medical pre-conditions of the infected individuals, which can influence the delay between the infection and the time-stamp in the data. The master multiwave equation for the time-evolution of the total number of infected cases 𝐼𝑗(𝑡)Ij(t) in a region j reads:

• where the first term on the right-hand side is a generalisation for 𝑤+1w+1 consecutive waves of the CeRG equations and the second term contains the interactions between regions. Here, we will always consider the number of cases per million inhabitants in order to compare different regions. In the master equation, most of the parameters are explicitly independent on the normalisation, as 𝐼𝑗(𝑡)Ij(t) always appears divided by the total number of cases at the end of the first wave, 𝐴𝑗Aj: the only exception is the interaction term, which also depends on the population of the regions (𝑛𝑚𝑗nmj measures the population of region-j in millions). The parameters 𝛾𝑗γj measure the effective velocity of the virus in each regions, and can be associated to an effective infection rate. This parameter can be eliminated from the equation by measuring the time in terms of a region-dependent scale, 𝜏𝑗=𝛾𝑗𝑡τj=γjt, once the couplings 𝑘𝑗𝑙kjl are also rescaled: 𝛾𝑗γj can therefore be interpreted as a local time-dilation, characteristic of each region and taking into account all the non-pharmaceutical measures and local conditions in each region. These parameters can be extracted from the data at the beginning of the epidemic diffusion in each region, independently on the normalisation of the number of cases, which is very sensitive to the testing strategies changing during the pandemic. More details on the equations, and on the meaning of other parameters can be found in the Supplementary Information.
• The master equation encodes the multiwave pattern in two ways: in the first term, the parameters 𝛿𝑗,𝜌δj,ρ destabilise the fixed points at 𝐼𝑗(𝜏∗𝜌)=𝐴𝑗/𝜁𝜌Ij(τρ∗)=Aj/ζρ; in the second term, the interactions with other regions, or with an external source, can also destabilise the system and drive a new growth of 𝐼𝑗Ij towards the next fixed point. In fact, for 𝛿𝑗,𝜌=0δj,ρ=0, the number of infected will grow until 𝐼𝑗(𝜏∗𝜌)=𝐴𝑗/𝜁𝜌Ij(τρ∗)=Aj/ζρ, where the growth stops because of the vanishing of the beta function. This is a steady-state, independent of time, which signals the end of the infection. For 𝛿𝑗,𝜌<0δj,ρ<0, the zero is moved on the complex plane and cannot be reached, thus driving an endemic state with linear growth, which we call strolling in honour to the application of this formalism in high energy physics. The second term has been used to predict the European second wave of September 2020, where 𝑘𝑗𝑙kjl was associated to an estimated number of travellers between each country. In general, both effects are expected to be present: as we will see, the instability due to 𝛿δ provides a maximal delay for the arrival of the next wave, which is directly related to the number of new cases recorded during the strolling period between waves. The presence of a large interaction can induce an early arrival of the new wave.
• Thus, effective measures to prevent and control the next wave of a pandemic like COVID-19 can only go via a strict control of the number of cases inside the country or region, combined to effective tracking of new infected individuals traveling in. This is precisely the strategy followed by China, Vietnam and New Zealand, leading to an early extinction of the disease and the absence of a second wave.

Results

• The CeRG multiwave model, corresponding to ( 1) without the interaction terms, can be used to effectively describe a pandemic episode in multiple subsequent waves. To illustrate the model, in the top panels of Fig. 1 we show some features of the solutions for an isolated region with only two waves, corresponding to \(w=1\) and \(\delta _1 = 0\). The latter condition ensures that the epidemic is extinguished after the second wave. All results are shown for number of cases normalised to the first wave, and expressed in the local time \(\tau = \gamma t\). Panel (a) shows three solutions (solid lines) together with the corresponding new cases (dashed lines), for three values of \(p_0\). We can clearly see the two-wave structure emerging in the solution, the fact that the second peak tends to be flatter than the first (for \(\zeta _1 = 1/2\)). Furthermore, larger values of the exponent \(p_0\) tend to delay the second peak and flatten it. An important factor in controlling the arrival of a future wave is the number of new cases during the intermediate strolling phase, which we encode in the parameter

• normalised to the total number of infected cases after the first wave, A, and expressed in terms of the local time. For the CeRG multiwave model in Eq. ( 1), the parameter \(S_t\) for each interwave period can be expressed as

• for the strolling phase after the kth wave. This is a crucial parameter in controlling the timing of the second wave, as illustrated in panel (b) of Fig. 1 where we show the peak delay \(\Delta \tau _\text{peak}\) (in local time) as a function of \(S_\text{t}\). For \(S_\text{t} \rightarrow 1\), the delay goes to zero as the two waves merge into a single one, while it grows for smaller values following a power law that depends on \(p_0\). The peak delays also depend strongly on \(\zeta _1\), which encodes the height of the second peak, being more delayed for decreasing \(\zeta _1\): for values above 0.8, however, the second wave becomes too small, thus the solution looses physical relevance.
• To connect the result in Fig. 1b to a specific country or region, it is enough to fit the values of A and \(\gamma\) from the current wave, and appropriately rescaling the values of \(S_t\) and \(\Delta \tau _\text{peak}\): the delay in real time is \(\Delta t_\text{peak} = \Delta \tau _\text{peak}/\gamma\) while the new daily number of cases during the strolling is \(A \gamma S_t\). In the left panel of Fig. 2 we provide a template for a country/region with \(A=50,000\) and \(\gamma = 0.1\) (inverse days). The band, which can be considered an error on the prediction, comes from varying \(p_0\). This plot shows that controlling the number of daily new cases during the endemic strolling phase below 10 could be enough to push the next wave peak beyond 40 weeks. In the right panel we show the same plot for 5 European countries, obtained by fitting the epidemiological data of the current wave.
• Comparing the predictions of the CeRG multiwave model to data is not an easy task: in fact, the number of detected infections, collected via the positivity of the tests done in each country, depends crucially on the number of tests done each day and on the specific testing policy adopted over time. For instance, during the first wave, many countries did fewer tests while focusing on hospitalised cases, while a more extensive testing campaign occurred starting in the summer months. As a consequence, quantities that depend on the number of cases, like the delay between peaks, cannot be computed accurately as a bias between two waves is present in the data. We, therefore, will apply the model to the second wave and following ones. As an example, in panel © of Fig. 1 we show the data for Japan compared to a scenario based on the CeRG multiwave model. Japan is an ideal candidate for this model since, being an island, the frontiers can be well-controlled, and one can consider the country as an isolated system. Furthermore, the second wave has already ended, followed by a two-month period of strolling with around 450 new infected cases detected each day. The CeRG model, shown in blue, provides a good quantitative and qualitative description of the data, and predicts that the third wave will peak at the beginning of December and be slightly higher than the second (\(\zeta _1 = 0.4\)). Between the first and second waves, instead, no significant strolling was observed. This scenario could be interpreted in the following way: after the first wave, the virus diffusion was strongly limited by the enacted measures. However, new infected cases may have entered the country from abroad and/or spontaneous emergence of local hotspots inside the country (parametrised by the k-interactions). After the second wave, the virus kept spreading geographically within the population triggering at a later stage the third wave. The latter phase can be described by the CeRG model, while the transition between the first and second wave is due to external interactions. We do not attempt to unify the three waves because of the bias in the counting.
• Testing the geographical diffusion of the virus in each country can provide useful indications on the mechanism behind each wave. For this purpose, we define a uniformity indicator, \(\chi ^2\), which encodes how far is the distribution of new cases in regions of the country from a completely flat one. Smaller values of \(\chi ^2\) indicate a more uniform distribution. For Japan, we considered the new cases in the various prefectures (where we exclude Okinawa for the geographical distance from the mainland) during the first and second waves, as shown in red in Fig. 1 d. The second wave has a larger \(\chi ^2\), which could be interpreted as more localised diffusion due to hotspots or travellers returning to their home cities. We also report the indicator for the month of November, which we would expect to be reduced if the strolling plays an important role in creating the third wave. The result is too preliminary, as Japan is still far from the peak of the third wave and the indicator is found to be minimised at the peak.
• Having validated the CeRG approach, we can now apply it to understand and predict the next wave in various regions of the World. As a caveat, we should recall that the interactions between regions and the presence of hotspots can also affect the results and anticipate the insurgence of the next wave.

Europe:

• Most of the European countries are being hit by a second wave of the COVID-19. A general trend we observe is that the infection rate during the second wave is smaller than the one of the first wave, as shown by the values of \(\gamma _\text{eRG}\) in Supplementary Table T1 in the Supplementary Information. The comparison is done by fitting the two waves independently by use of the eRG model. Moreover, the expected cumulative number of infected cases during the second wave is much larger than that for the first wave, even taking into account the higher number of tests performed during the second wave. The emergence of the second wave was explained as arising from the interactions between countries13, nevertheless the presence of strolling between the two waves indicates that both effects participated. The decrease of the geographical uniformity indicator, shown in Fig. 1 d, indicates that the strolling had an important role in diffusing the virus across the countries (for England, the uniformity was present since the first wave). The geographical diffusion may also be the reason behind the fact that the second wave has infected a larger portion of the population.
• The CeRG model cannot be applied straightforwardly to the first two waves, due to the uncertainty in their relative normalisation, while it can be used to estimate when a third wave will hit starting from the data of the current (second) wave. The result is shown in Table 1, and in Fig. 3 and the top row of Fig. 4 . The timing of the next wave peak depends crucially on the time-dilation parameter \(\gamma\), and on the amount of strolling in the intermediate endemic phase: in the projections, we fitted \(\gamma\) to reproduce the second wave and fixed \(S_\text{t} = 0.01\), with the corresponding total number of new cases, expected during the strolling, reported in the figures. The last column of Table 1 shows that a wide range of peak timings are expected, ranging from March to November 2021, where we associated an error of 1 week to the projection due to a variation of 10% in the infection rate. These results show clearly that controlling the infection rates and reducing the level of strolling after the end of the second wave are keys to delaying the next wave. Another element that should be included is the number of travellers across various countries, which can help propagate the wave from country to country, thus affecting the ones with pronounced delayed projections.
• In the right panel of Fig. 2 we show the delay between the current and next waves (in weeks) for 5 European countries, as a function of the daily number of new cases during the strolling. Thus, to delay the next wave peak beyond 40 weeks from the current one, it would suffice to keep the number of new cases below 10 per day. Delays beyond 20 weeks can be obtained with 100 new cases per day per million inhabitants. France has comparatively larger delays due to the smaller \(\gamma\) obtained from the data.

The US:

• The US has already seen two waves in April and July-August, and is undergoing a third. However, the first two waves are geographically distinct, with the episode in April mainly involving New York and New England, and the second spreading all over the remaining states. This is well illustrated by the geographical uniformity indicator in Fig. 1d, which sharply drops between the two episodes. The third point, based on the data of November, is still preliminary and will decrease as the third wave approaches its peak. To analyse the evolution of the COVID-19 epidemic in the US, a dedicated study which takes into account sub-regions is required. The uniformity analysis suggests that the first two episodes should be described in terms of interactions between states, while the third one may be originated by the strolling. Results of this analysis and projections for the future waves in the US will be presented in a separated article.

Other countries:

• We included in our analysis a selection of countries for other regions of the World, selected in order to represent all continents. Note that we retained only countries for which the multiwave analysis is best explained in terms of the CeRG model, i.e. where diffusion of the virus in sub-regions do not produce features that would require a multi-region analysis. The latter situation can be tackled within coupled CeRG equations, but this analysis goes beyond the scope of the present work.
• In Table 1 we show the results for the selected countries, also illustrated in the bottom row of Fig. 4 for South Africa and Saudi Arabia. In most selected cases, the country is in the strolling regime, following the end of the first or second wave, thus allowing us to tune the CeRG parameters to reproduce the strolling and give a more reliable forecast for the following wave. In some cases, like South Africa, the high level of strolling indicates that a new wave is imminent. As we are not trying to perform a fit, due to the many uncertainties in the social distancing and testing policies, the scenario we present should be considered as a probable one. Yet, it should be noted that the model does not leave much room to modify the expected number of total infected cases during the future wave nor change the timing substantially, without drastic pharmaceutical or non-pharmaceutical interventions.

Discussion

• We provide a mathematical understanding of the wave pattern for pandemics, like the COVID-19 one. The approach is employed to forecast the timing of a future wave based on the number of new infections during the intermediate endemic phase. The timing of the new wave is related to a newly introduced parameter, \(S_t\), that can be easily deduced from the cumulative number of infected cases. We studied several countries in different regions of the World and, in absence of any pharmaceutical interventions, we estimate the timing of the next wave of infections. We found countries where a new wave will start in December 2020, like South Africa, and countries where it could start as late as October 2021, like in France. Our predictions will be affected by the border control regulations with the generic effect of inducing an early increase in the number of infections.
• Our understanding of the wave structure of the COVID-19 pandemic draws the attention to the inter-wave strolling period. We discover that controlling the number of new infections during the strolling period is necessary to delay the beginning of a future wave. This amounts to imposing social distancing measures and break potential chains of infections after the end of the wave in order to keep \(S_t\) as low as possible. Delaying the next wave is crucial in order to have enough time to realise an effective vaccine campaign.
• Our results can effectively guide policymakers to time (non)pharmaceutical interventions to delay or reduce the impact of future COVID-19 waves. Until now, most measures are taken when the number of new infected cases has already grown substantially. At this point in time one can only contain the wave, not avoid it, with serious impact for the loss of human lives as well as the economy. We prove that intervening during the strolling period of endemic diffusion is essential to delay or avoid a new wave while buying time for pharmaceutical interventions, like an effective vaccine campaign. More specifically, to maximise the delay, the strolling parameter must be kept small, \(S_t \approx 10^{-5}\) for an optimal use of the enacted measures. In most countries, this implies that the number of new cases at the end of the wave should be kept at the level of 10 cases per million inhabitants per day. This effect can be achieved by keeping or introducing new measures after the end of the wave, in the form that is more appropriate for the local conditions.

INDIA — Prepping Up Critical HealthCare Infra for 3rd wave of COVID19

What India’s healthcare system needs to effectively battle a likely third wave

As India continues to reel under the impact of the second wave, the burning question is, what comes next? What can we do to better manage the next wave to ensure it won’t be equally fatal?

• 14 months into the pandemic, the scale of death and destruction to families and livelihoods that we are witnessing in the country today is far beyond anything we imagined. Amongst healthcare professionals, there is a collective sense of despair and exhaustion felt by the medical fraternity even as we trudge along to do the best we can, in these trying circumstances.
• The pandemic has shown that India’s healthcare system is lacking on multiple fronts and calls for a rework by all stakeholders. Government expenditure on health, demand-supply mismatch, and chronic shortages are just some of the problems.
• In 2020–21, India spent 1.8% of its gross domestic product (GDP) on healthcare. With ‘health and well-being’ one of the six pillars of the Union Budget 2021–22, the government has committed approximately 2.5–3% of GDP now. Data shows that India has 1.4 beds per 1,000 people, 1 doctor per 1,445 people, and 1.7 nurses per 1,000 people. According to the World Health Organization (WHO), India ranks 184 out of 191 countries in health spending. The US spends over 16% of its total GDP on healthcare, while Japan, Canada, Germany etc. spend over 10% of their GDP on healthcare.
• India has a total of 43,486 private hospitals, 1.18 million beds, 59,264 ICUs, and 29,631 ventilators. On the other hand, there are 25,778 public hospitals, 713,986 beds, 35,700 ICUs, and 17,850 ventilators. Total private infrastructure accounts for nearly 62% of all of India’s health infrastructure. The capacity of most public hospitals and private hospitals is the same in the states (measured by beds to hospitals ratio, ICU to hospitals ratio, and ventilator to hospitals ratio), besides Chandigarh and Puducherry, where private hospitals have more capacity than public hospitals.
• Out of 35 Indian states and Union Territories — Daman & Diu, Dadra & N Haveli are counted together, Ladakh is excluded due to missing data — (“States”), 15 states (Andhra Pradesh, Bihar, Dadra & N Haveli Daman & Diu, Gujarat, Haryana, Jharkhand, Karnataka, Kerala, Madhya Pradesh, Maharashtra, Punjab, Tamil Nadu, Telangana, Uttar Pradesh, Uttarakhand) have more private hospitals, beds, ICUs, and ventilators (“Infrastructure”), than government Infrastructure. These 15 states account for approximately 74.25% of India’s projected population for 2020 (including Ladakh’s population). Private Infrastructure forms 69–70% of all health infrastructure in these 15 states. Private infrastructure in other states (where government infrastructure exceeds or equals private infrastructure) forms nearly 35–36% of all health infrastructure.
• Uttar Pradesh, Karnataka, and Maharashtra are the top three states with the highest gap between private and public health infrastructure. These three states account for 31% of India’s population. In Uttar Pradesh and Maharashtra, private infrastructure exceeds public infrastructure by nearly 128,000 beds, 6,400 ICUs and 3,200 ventilators. In Karnataka, private infrastructure exceeds public infrastructure by 122,667 beds, 6,133 ICUs and 3,067 ventilators.

How do states rank on the health index?

• The Health Index for States developed by Niti Aayog in consultation with the health ministry and the World Bank has rankings for large states, smaller states and Union territories. It is based on 23 health parameters ranging from mortality rate and sex ratio to functioning cardiac care units. In 2019, Kerala was the top performer followed by Andhra Pradesh and Maharashtra. The best incremental change was seen in Haryana, Rajasthan, Jharkhand, Andhra Pradesh and Assam. The index results indicated that states even with a lower economic output are performing better on health and well-being.

How have facilities coped with the pandemic?

• Badly. The capacity of the healthcare system has been stretched to its limits with critical shortages of hospital beds, oxygen concentrators, life-saving drugs, medical supplies, disease surveillance etc. With urban India struggling to counter the onslaught of the second wave of covid-19, rural India’s threadbare healthcare system stands even more stressed.

Does poor healthcare impact the economy?

• At a micro level, increased expenditure adversely impacts savings and consumption levels. Reduced consumption leads to reduced demand, disincentivising producers to invest more in capital formation. In case of firms, poor health conditions impact physical and mental ability, worker turnover, and attendance, leading to lower productivity. At a macro level, lower economic efficiency results in lower production relative to inputs employed, leading to lower economic growth and reduced income generation.

What is needed to improve healthcare?

• India is in desperate need of an all-encompassing public healthcare system. The need of the hour is to have a regulator who can work with states and ensure that the focus shifts to affordable health-care, availability of more health-care professionals, well-equipped facilities, and disease prevention instead of disease management. Inequity among states in terms of facilities needs to be minimized. The Centre needs to aim for 100% health insurance coverage.
• The huge, ever-widening urban-rural chasm in healthcare services, which was obvious to any interested observer, has found its denouement with Covid. Over the last many decades, besides the puny investment in rural healthcare services, the availability too has been largely non-existent. Public sector investment in healthcare service is poor in both quantity and quality, while the private sector provides 75% of its services to 25% of the urban population. That leaves the rural population as well as the urban poor exposed. Investments by governments in primary health centres (PHC), community healthcare centres and district-level general hospitals have awning gaps: shortage of doctors, para medical staff, ambulances and basic medical equipment, including oxygen plants.
• Medical staff do not want to live or work in rural areas. The more backward the district, the lesser the chance that it will have staff in the government facilities. These gaps and problems have been ignored as politicians have rarely won elections because of good health facilities. But the pandemic is showing they almost certainly risk losing an election because of poor healthcare facilities.
• The biggest fear was always: what would happen if the Covid virus reached rural India? Now that it has got into the rural areas, what do we do?
• Different governments are reacting to this challenge in different ways. Healthcare infrastructure cannot be built overnight and doctors or trained staff cannot be motivated to go to Covid-infested rural areas.
• Haryana has formed 8,000 teams to visit villages and carry out testing, tracking and tracing of the Sars-CoV-2 virus that causes Covid-19. Punjab has also formed teams for rural services. States are trying to marshal all the manpower that can be diverted to rural areas.
• To allay the fears of medical personnel, they all have to be vaccinated before being sent to rural areas. Second, their life and health insurances have to be increased by the state government. Third, they have to be given a hardship allowance for their rural service. These three steps are absolutely necessary for any rural anti-Covid drive to succeed.

PANCHAYATS AND BLOCKS

• There is enormous testing and vaccination hesitancy in rural areas. People do not want to accept that they are suffering from Covid, lulling themselves into believing that their ailments are anything else but Covid. Concerns are aplenty about the safety of the vaccine. Fear, combined with ignorance and misinformation, is creating testing hesitancy; besides, when rural citizens do summon the courage, it is difficult to get tested in the villages. State governments are making efforts to reach rural areas but these will never be sufficient. Hence, it is important that a parallel and lateral approach be adopted for rural areas.
• It is important for rural citizens to have oximeters and thermometers available as well. They should be taught about the three levels of Covid: mild, moderate and severe. Asha workers and the anganwadi workers are closer to the frontlines. They will be able to learn quickly about these three levels. If equipped with basic kits and knowledge they will save more lives than any district-level hospital.
• The testing labs are mostly in the cities; transporting samples from the rural areas to the lab for testing is going to be a long haul. Already, in cities, it is taking 48–72 hours to process the test samples. This is too long for severely ill Covid patients as the deterioration is very rapid in such cases. These are the cases that need urgent hospitalisation, oxygen and ventilators.
• Moderate cases have to be prevented from turning into severe, and mild cases need quarantine to control the spread.
• These are problems that do not solve well at scale as they are wicked, distributed problems with multiple critical factors involving logistics, people and training. Therefore, it is also important that freedom and support to decentralisation be provided right down to the panchayat level.
• If a panchayat wants to take a decision to lock down a village, it should be allowed to do so as long as it follows the standard operating procedure, and does not disrupt essential supply chains.
• Recognising what decisions can be taken at the ground level and what cannot be taken is a crucial element. Wide variance is seen in how each state is organising itself in preparing for the imminent rural Covid wave.
• Punjab has a better ratio of hospitals and beds than Haryana; its health minister Balbir Singh Sidhu is also well aware of the need for healthcare services. Even before the second wave began, he had started investing in building large hospitals in the state, each with more than 1,000 beds. Punjab also has several other large hospitals in Jalandhar, Amritsar and Ludhiana thanks to the influx of NRI populations coming for treatment to the state. Haryana does not have many large hospitals, except for one in Gurgaon and an AIIMS in Rohtak.
• The lack of large hospitals in the private sector is due to several factors, including the high risk-low return perception that prevents entrepreneurs from investing at scale in a single location. This severely restricts their ability to meet the needs of the country during a pandemic.

• Public sector investment in healthcare care services has been anaemic for decades; only the AIIMS has any scale. Most general hospitals at district levels do not possess top quality infrastructure or personnel, and face low investment in critical infrastructure such as on-premise oxygen generating plants. But, more importantly, it is the lack of doctors, para-medical or lab technicians in public sector hospitals. While the exact figures are not easily available for each and every state, the overall number of doctors per thousand combined shows the poor capacity of trained staff.
• Populous states such as Uttar Pradesh are particularly low down the scale and fare worst, as is showing up in the death numbers in the state. Hence, while the second wave might ebb in cities, the jumbo Covid centres that are being created there should service the rural population. An ambulance-based logistics chain needs to be set up between rural and urban hospitals.

• More important is the difference between the rural and urban areas in terms of the distribution of doctors. The paucity of doctors and healthcare services in rural areas is well known.
• Dividing doctors’ numbers on a simple 80:20 division in rural and urban areas shows the wide variance in Chart 3 below.
• There are anecdotal reports of the lack of doctors, nurses and anaesthesiologists across small town India. Ventilators cannot be used without anaesthesia and are useless as a life-saving equipment in an ICU without a trained anaesthesiologist. Now, the skill of injecting an anaesthesia, or the quantity that needs to be injected, can be taught, but the medical-legal requirements insist that an anaesthesiologist can only do it.

• The multi-pronged approach for rural areas involves devolution of resource depots at block level. These resource depots have to be critical equipment, with oxygen cylinders being the primary. Portable oxygenators are crucial for controlling level 2 moderate patients from deteriorating to level 3. Logistics for transporting level 3 patients to nearby hospitals from the village will be the most important part of saving lives because of the distance between hospitals and the shortage of the number of beds in rural hospitals. Finally, these patients will have to be brought to cities, especially the new Covid centres being created. Even though the Covid wave may be ebbing away in the cities, we should not stop creating additional beds with oxygen — these will be needed very soon.
• The country’s rural healthcare is not adequate or prepared to contain Covid-19 transmission, especially in densely populated northern states, because of the shortage of doctors, hospital beds and equipment. Even the facilities for vaccination are scanty in the villages. The villagers often have to travel long distances to receive specialised treatment in the cities.
• A planned, strategic approach to healthcare management at the national level is both alien to us and difficult. The healthcare system has also been challenged by the limited time we have had to scale, the rate of infection spread, pressure on resources, infrastructure, equipment and medicine supply. As India continues to reel under the impact of the second wave, the burning question is, what comes next? What can we do to better manage the next wave to ensure it won’t be equally fatal?
• All experts believe that the third wave is likely to impact children and rural India. Both of these are extremely tricky and difficult segments to deal with. The need of the hour is to think differently and start preparing early. Reputed healthcare professionals are already weighing in on how to supplement healthcare staffing and caregiving concerns, alongside various vaccination ramp-up strategies for young parents.
• Here are important strategies on what else should be doing now to better prepare for the next wave and save ourselves from free-falling into the abyss of long-term disaster.

Tactical vs long-term strategy

• The need of the hour is a two-pronged strategy, as Covid-19 is here to stay for a while. Hospitals, healthcare professionals and the governments at the central and state levels must identify and mobilize resources who will work on strategizing and planning for subsequent waves, separate from the team that’s fighting the fire on the streets now.

Involve the experts

• The planning committee must have adequate representation from leading healthcare practitioners in relevant fields — pulmonologists, virologists, epidemiologists etc., and senior management from India’s largest hospitals treating Covid patients. Involving institutions like the ICMR including the National Institute of Virology, NCDC, Institute of Hygiene and Public Health, IMA, The Center for Cellular and Molecular Biology and others is also critical to planning a robust strategy. For instance, are we holistically evaluating inputs from The Indian Medical Association (IMA) and other institutions who have expressed concern about their suggestions being ignored? Representation from research professionals, policy makers, management experts and healthcare providers is key to ensuring we have a comprehensive, workable strategy while bearing in mind reality on the ground. An objective analysis of the systemic advantages and inefficiencies we have, and stock taking of what is required to address the limitations and meet the need gap will help us prepare better.

Focus on Tier III towns and rural India

• Approximately 60% of our population continues to live in rural India — where people lack healthcare awareness and amenities. Supporting rural India with our limited resources and poorly equipped health care centers can become an insurmountable, herculean task, as the NCDC has warned. Apart from stepping up vaccination efforts, we need to focus on awareness campaigns on Covid-19 appropriate behavior and symptoms early on. Involving local leaders, gram panchayats, village priests, regional movie stars and other influencers in rural areas will help in spreading awareness. Likewise, we can rope in regional NGOs early on to disseminate information, free cloth masks, soaps, sanitizers etc. We also need to identify zonal head-quarters where we can ramp up basic healthcare infrastructure and medical equipment for cases that require hospitalization, monitored by the regional committees. Investing in mobile medical facilities will be key to managing Covid cases in rural areas.

Explore the P3 model

• India Inc has the strategic expertise, manufacturing and operational prowess, technological capabilities and most importantly unmatched reach across the length and breadth of the country, with multiple internal and external interdependencies across the value chain. This knowledge, reach and execution expertise can be extremely beneficial to India’s understaffed and underprepared healthcare system in effectively dealing with the next wave across rural India. Consider how the BBMP in Bangalore roped in Mr. Nandan Nilekani to help rehaul the bed booking system for improved hospital bed allocation for Covid-19 patients. We must be ideating with India Inc at this stage, ahead of the third wave, on portable, low-cost ventilators, medical oxygen units, mobile care units, make-shift triaging centers near their facilities across urban and rural India, and other out-of-the-box solutions that will help us beef up caregiving across PHCs and government hospitals. They can also be very instrumental in aiding efficient and timely distribution of medical equipment, medicines and other essentials, given their reach. We must work in tandem with them early on in planning to effectively tackle the next wave instead of knee-jerk, post-facto measures that lead to staccato resolutions. This will free up precious bandwidth for both the hospital administrations and medical experts, helping them focus on what they need to — patient care.
• Also, urban hospitals can be roped in to remotely train rural healthcare practitioners and medical students in their region on appropriately diagnosing Covid-19 symptoms, testing for it, triaging and treating diagnosed cases. This is key, with information trickling in on many Covid-19 cases being misdiagnosed as Typhoid in rural areas. Helplines and reviews for rural doctors can be set up with experts in the city and zonal authorities for periodic guidance and consultation. Bridging the rural urban divide is critical in conquering the spread of the pandemic.
• India has far fewer pediatricians than the standard norm — roughly around 30,000 as against the required 2,30,000. Their representation across the country is also very skewed. Pediatrics is a specialized subject, and should children be impacted, there will be an acute shortage of doctors who can care for children. It is important to train general physicians and other specialists now in pediatric caregiving, so they can help attend to children under the guidance of expert pediatricians, if more children are impacted.

Data is oil, Leverage it now

• There is valuable information to be garnered across all stages of infection. Pre-infection stages, symptoms and signs leading up to the infected stage, various treatment plans and outcomes, post infection recovery rates and death rates. Demographical data by region — identifying urban and rural patterns. And so much more. From medicines that work on typical age groups to likely symptoms in specific geographic pockets, data can tell us the whole story, the finer details and the larger picture all at once. We must leverage and integrate technology and analytics to harness this data from across hospitals and care centers now, and establish effective backward and forward linkages in data collection and analysis. This will help our experts draw insights and appropriately strategize our approach to the next wave(s).

Build a robust, fool proof triaging system

• Should children and the rural populace be affected, health professionals and hospitals will have a mammoth, nightmarish task on their hands. The solution might lie in building an effective and efficient multi-channel triaging system. An ideal solution is a three-stage triaging system — initial telephonic triaging across multiple languages, introduce online video triaging, and third — offline triage centers across the country that provide primary healthcare facilities for less severe cases. Key areas include building more lines to reduce wait times on telephonic triaging to less than 30 seconds to avoid drop-offs, and introducing triaging call backs and follow ups to support the rural populace as they are unlikely to wait long durations on calls for guidance. Crisp and clear and guided communication through symptoms and next steps with SMS and WhatsApp messaging integration will be helpful given that parents will panic when it comes to their children.
• More importantly, the triaging system needs to be unified at the backend, providing a single pane of view to authorities, integrating and feeding data backwards and forwards to ensure operational scale and efficacy. Hospital support staff must be able to ascertain patient status with a simplified, unique ref ID or two, ensuring smooth flow of data and patient information across channels to reduce wait times, bed booking and critical care support.
• What does this mean? As a patient moves through the triaging stages from home isolation and care to offline triaging to critical care, all patient history available on the patient thus far must seamlessly move with him, available at the doctor’s fingertips, cutting down systemic and procedural delays and complications currently existing in the system. A simplified Covid-19 specific EHR system of sorts. Pandemic policy makers, healthcare experts and local regulatory authorities must be able to have access to the triaging data to view progress, highlights, risk markers and more that will help the policy makers intervene to remediate as required. This data must be fed back to the integrated data analytics systems for a comprehensive view of the situation.

Integrate mental healthcare

• A major area of growing concern is how Covid will impact children’s mental and emotional health. We need to start integrating mental health support in basic Covid-19 care plans and hospitalization programs to help children cope with the highly altered, difficult and disconnected lifestyle they are living in the post-Covid world.

Communicate ahead, communicate better

• The government’s mass media and social campaigns on the pandemic have been informative, but very reactive. The think tanks and media houses need to come together to effectively work a large-scale awareness and information dissemination programs on curtailing the next wave. Detailed and regular informative sessions on Covid-19 appropriate behavior and home care of patients that is devoid of panic, focusing on children and rural population, can be aired during prime time on regional television and radio channels. A detailed and intensive information dissemination and communication strategy, similar to what the national channels did two decades ago on Polio eradication, is key.
• If the pandemic has driven home two key learnings, they are this. Prevention is much better than cure. And health is truly wealth. We are a large and complex country, mildly put. No single government body or think tank can manage to control this wrath of nature alone. And our healthcare system is overburdened with the numbers. While we do not know what lies ahead and how the pandemic will pan out, to err on the side of caution is better than to be underprepared, as the second wave has proven. The secret to successfully curbing further devastation lies in integrating all our resources with clear cut objectives, planning ahead and executing well. And in order to do this, we must step up, think strategically, and aggregate all forces and expertise required. Starting NOW.
• As states continue to grapple with the severity of the second wave of Covid, the spectre of a potential third wave has been haunting the country and many states have begun planning and even putting in place infrastructure. The focus is on children this time, with apprehension that they could be the worst affected. From ramping up paediatric beds to prioritising vaccination for parents of kids below 12 years and formulating children-specific protocol, states are concentrating hard on paediatric Covid care along with other measures like setting up oxygen plants and establishing more testing labs. The Uttar Pradesh government recently announced that priority would be given to parents of children below 12 years in vaccination. Goa wants to prioritise vaccination for lactating mothers with children below two years.

• Most states are either adding or earmarking beds for paediatric Covid care, including paediatric intensive care units (PICU), neonatal intensive care units (NICU) and sick newborn care units (SNCU). Sample this: Maharashtra, where the second wave took a heavy toll, has planned to increase paediatric Covid beds from the present 600 to 2,300. BMC commissioner Suresh Kakani said 500 beds will be added in Mumbai alone.
• In Uttarakhand, DRDO, which is setting up two hospitals, has planned a facility to house mothers of Covid affected kids in paediatric sections. Odisha too has decided to allow one of the parents to accompany the child in hospital. Focused paediatric treatment protocols have been drawn up by states like West Bengal and Tamil Nadu. Many states are setting up expert panel and task force to protect children. Delhi government is forming a special task force consisting of paediatricians, experts and senior IAS officers. Maharashtra, Uttarakhand, Himachal Pradesh and Goa too have formed task force for paediatric cases. Jharkhand government recently reached out to experts in Delhi and Bengaluru to seek suggestions in fighting Covid among stunted and anaemic children in the state, which has 43% of its population in the below 18 years category. While a large part of the efforts to counter the possible third wave is centred around children, states are also ramping up health infrastructure.

Hospitals Need To Be Differently Prepped For Children With Covid: Experts

• What is the best way to deal with the spread of Covid-19 among children? Ensure child-friendly facilities and approach at treatment centres, say experts.
• The medical expertise, equipment and approach needed to treat children with Covid-19 is unique and this is a challenge in India where the health infrastructure has been hit by decades of underfunding and neglect, say experts. Vaccination against the virus too is necessary for children but a host of complex issues need to be resolved first, they say.
• The Centre and state governments are increasingly stressing on preparedness to deal with paediatric Covid care: Prime Minister Narendra Modi, in a meeting with local government officials on May 20, 2021, urged them to collect data on how Covid-19 is affecting children. Maharashtra has set up a state task force focussed on the infection among children and Delhi government is planning one as well.
• So far, there is no science nor are there data to back widespread fears that children will be hit more severely in the anticipated third wave of the pandemic. Infections among children have been mild, and even severe cases among them tend to be treatable, researchers reported on May 23, 2021. It is also likely that the number of cases among children in the second surge is linked to the sheer number of cases in a short span, said doctors.
• What can be done to make paediatric care for Covid-19 more efficient? Experts from the fields of paediatrics and immunology pointed out that children are vulnerable to Covid-19 in unique ways and need special and different attention when they are infected. This means child-friendly care facilities, infrastructure and treatment approaches, as we explain later.
• Experts also believe that with about 40% of India’s population aged under 19, children have to be seriously considered for Covid-19 vaccination. The Indian government has announced that Bharat Biotech, the company manufacturing the Covaxin vaccine, will be beginning phase 2 and phase 3 clinical trials among children aged 2–18 years in the next two weeks. In the United States of America and Canada, the Pfizer-BioNTech vaccine has been approved for children aged 12 to 15. This vaccine is not approved in India for children or adults.
• While Covid is milder in children, the treatment options for them are also fewer: The government issued and updated its clinical management protocol for adults with Covid-19 on May 19, 2021. On April 29, 2021, it issued a protocol for children. Many of the Covid-19 drugs tested for efficacy in adults have not been tested enough for their use in children. For example, the paediatric protocol notes that there are “limited data’’ on the use of drugs such as remdesivir on children.

Focus on children: Courts, governments

• Over the last month, there has been increased focus on ways in which the pandemic is affecting children. Early in May, Justice S. Ravindra Bhat took cognisance of the vulnerability of children at a meeting of the Supreme Court’s Juvenile Justice Committee with United Nations Children’s Emergency Fund (UNICEF). The committee discussed issues such as children being orphaned when both parents die of Covid-19 or not having access to healthcare and supervision when their parents are hospitalised with the disease. Justice Bhat also sought that parents of young children or those who work with children be vaccinated on priority basis.
• Also at a hearing in the Supreme Court this month, Justice D.Y. Chandrachud said that the central government needs to prepare for the third wave of Covid-19 and keep a special focus on the needs of children, including vaccinating them.
• The Maharashtra government set up a paediatric task force for Covid-19 and is looking to set up more specialised units for the treatment of sick and newborn infants, install ventilators better suited for children and draft a treatment protocol for the young. The task force has submitted its report to the state government.
• To gear up paediatricians for any Covid-19 challenges, and also to calm the anxieties of parents and school administrations, the Maharashtra government and the Indian Academy of Paediatrics will be developing special guidelines, Samir Dalwai, a paediatrician and a member of the task force.
• “We have been organising training and orientation sessions online for thousands of paediatricians around the country. Even the chief minister, Uddhav Thackeray, has attended some of these, to give the message that this is serious and that the government as well as the medical community should take it seriously,” said Dalwai.
• The paediatric task force set up by the state government will be looking into finalising guidelines for the clinical management of children, training paediatricians and analysing the existing infrastructure for treating kids and what may be needed, said Dalwai.
• In Delhi too, the state government has decided to set up a special task force to focus on Covid among children and the government-run Lok Nayak Jai Prakash hospital has added six paediatric ventilators to the existing 15.

Nothing to show children at greater risk’

• Up to 80–90% of children who are infected with SARS-CoV-2 will be asymptomatic, and only about 1–3% of those who are symptomatic will need intensive care treatment, according to the Indian government’s clinical protocol for management of Covid-19 in children. These numbers are far smaller than those seen adults, according to the Indian Academy of Paediatrics.
• Some of the fears about the susceptibility of children to SARS-CoV-2 stems from the discovery of the newly identified variant, B.1.1.7. But these fears may be premature, shows existing evidence. A February 2021 paper in The Lancetanalysing this variant’s effects said that while more children had been admitted to hospitals in the United Kingdom between November 2020 and January 2021 compared to March 2020 and May 2020, this could be due to a higher overall caseload. It said that there was “no evidence of more severe disease having occurred in children and young people”.
• A lot more research needs to be done on this variant but investigations so far do not indicate that children are particularly vulnerable to it, said Maria Van Kerkhove, an official at the World Health Organization (WHO).
• But public comments — that children may be more affected in future waves of Covid-19 — have stoked anxiety. For instance, Delhi chief minister Arvind Kejriwal tweeted this week that India’s third wave would be very dangerous for children.
• While some medical experts warn of rising Covid cases among children, others say there is no evidence to establish this. “The current evidence indicates that severe illness in infected children remains much less common than among the elderly this year, just as it was last year. I do not think there is any evidence so far that children are being affected more or worse this year,” said Satyajit Rath, immunologist and former scientist at the National Institute of Immunology, New Delhi.
• There are questions too about the warnings about the third wave and its impact on children. “People have been making very loose comments about a third wave affecting children more. There is no epidemiological basis for this so far, and it is just conjecture,” said Tanu Singhal, a paediatrician and infectious disease specialist at the Kokilaben Ambani Hospital in Mumbai. “Yes, there might be a third wave. And by that time, a wide section of the adult population may be vaccinated. Hence it may seem like more children are being affected, but this may only be in relation to people affected in the third wave, and not an overall indication that children are at a greater risk.”

Shortage of paediatricians, ICUs for children

• Experts pointed out to that all health infrastructure in India needs to be ramped up given the system’s chronic under-funding and neglect. However, the medical expertise needed to treat children as well as the equipment in intensive care units (ICUs) need to be different for children, they added.
• “The equipment for children in hospitals has to be paediatric-friendly. The sizes are very different for children — an adult may come in an average size range, but as paediatricians we may be treating a newborn infant weighing just 600 gm, or a child weighing up to 100 kg,” said Jesal Sheth, paediatrician at Fortis Hospital, Mulund. For example, someone trained in dealing only with adults will find it hard to intubate a child, she said. “Furthermore, children may also be non-verbal and won’t be able to describe their illness. So only a trained paediatrician can recognise from non-verbal communication, what the child may need.”
• So far, the health infrastructure for children has not been overwhelmed in either the first or second wave, said Sheth. But the country will have to keep preparing for any future situation where this could happen, she said.
• “Paediatric ICUs would be useful, especially because severe COVID-19 in children can take somewhat special different forms than in adults,” said Rath. There is already a “sad and glaring lack of public health facilities in India, both for adults and children. So this will also become a major problem in effective treatment of the children who will become severely affected”, he said.
• There is an 82% shortage of paediatricians in India’s primary health centres, according to a parliamentary standing committee report in 2015. Up to 62.8% of positions for paediatricians in community health centres were vacant, according to the same report. This shortage fits into a larger context of an overall shortage of doctors in India — while the WHO’s recommendation is a doctor-population ratio of 1:1,000, India reports 1:1,674.
• There should be emergency-rehearsals for crisis management, said Sheth, where work-flows can be set and practised to deal with any emergency in the future. “These rehearsals should look into issues like, what do health workers need to do when a child is brought to a hospital for Covid-19 treatment, what preliminary treatment can be started, how to monitor them and when to refer them to further treatment,” she explained.

‘Long path’ to vaccinations for children

• Up to 40% of India’s population is aged under 19 years, according to the 2011 census. This is projected to fall to 34.6% by 2021. Currently the government’s COVID-19 vaccination drive is limited to those over 18 years of age. This implies that about half the country is eligible and trying to get vaccinated, and another half is not yet old enough for immunisation.
• “Yes I would recommend vaccination for children at the earliest, once its safety profile is established. About 40% of India is aged under 18 and we cannot leave them unvaccinated,” said Dalwai, adding that vaccinations of children will need to happen at some point so that schools can be safely re-opened.
• Rath welcomed the announcement of clinical trials of Covaxin for children. “We should definitely start trials for children and should have started it earlier. Given the evidence that has already come in all over the world on adult Covid-19 vaccination, starting formal trials in children is safe and the right thing to do,” he said. However, the path ahead will not be short — trials have to be completed, regulatory approval has to be given and the overall vaccine shortage has to be addressed, he said.
• Taking note of projections of a third wave of Covid-19 infections in the country which is projected to impact children adversely, the National Commission for Protection of Child Rights (NCPCR) has sounded the alarm for the government to put in place the necessary medical infrastructure and equipment, so that the cases and fatalities may be limited.
• Over the past week, NCPCR has written to the Union Ministry of Health and Welfare (MoHFW) as well as the Indian Council Medical Research (ICMR) asking them to start preparing keeping in mind the projections.
• On Thursday, the commission also sent directions to all states to supply information on facilities available in their districts to treat children for Covid-19.
• Officials said the commission aims at getting paediatric infrastructure in place by July, so as to minimise the damage that may be caused by the third wave.
• On May 15, the NCPCR wrote to Union Health Secretary Rajesh Bhushan pointing out an urgent need for changes in the country’s medical infrastructure. “The ongoing Covid-19 pandemic is impacting several children and adolescents as India grapples with escalating virus cases in the second wave of this pandemic situation. Doctors have confirmed that even newborns and infants are testing Covid-19 positive, though their condition remains under control and rarely turns fatal. Further, a third wave of Covid-19 is projected to hit the country and according to experts, it may affect children in large numbers. There are guidelines on the management of the new born in a maternity ward and in the Neonatal Intensive Care Unit (NICU), but there is an urgent need to reorganize a Neonatal/children Emergency Transport Service (NETS) to prepare specifically for neonatal [cases] and children for third wave of Covid-19,” said the letter to Bhushan, adding that “necessary directions for emergency transport services/ambulances suitable for children and neonatal” be issued by the Centre.
• Sources in NCPCR say there are particular specifications for ambulances for children, to be equipped with ventilators and incubators, but there are hardly any manufacturers of such ambulances in the country. “But if specifications are to be issued right now and the MSME sector, or other sectors, could be brought in and start manufacturing as soon as possible, then we will be able to avoid untoward incidents involving children when the third wave hits,” said an official.
• NCPCR chairperson Priyank Kanoongo said that from the commission’s own past experience, they have felt a need to verify medical equipment and machinery in neonatal and paediatric hospitals and wards in the country.
• “In 2019, the Commission investigated the deaths of 100 children in Kota’s JK Lon Mother and Child Hospital in December in Rajasthan. What we found was that a lot of the equipment and machinery at the hospital were not functioning. Very often, across states, this is the case. Annual maintenance contracts are not renewed by hospitals, and equipment lies in disrepair. Very often, these hospitals also do not have enough trained paramedical staff that can operate the machinery. These things, if rectified, can save the lives of a large number of children,” said Kanoongo.
• In its letter to states on Thursday, NCPCR directed them to furnish details of the total number of Sick new-born Care Units, paediatric intensive care units and neonatal intensive care units in each district, the number of beds and incubators in each of these units, the total number of functional beds and incubators, number of dedicated beds for high dependency care, number of resident paediatricians, on call paediatricians, nurses, paramedical staff and support staff.
• The NCPCR has further asked states to furnish details of medical equipment including Radiant warmers, basinets, Phototherapy, Irradiance meter, Self-inflating reservoir bag, Laryngoscope, oxygen cylinders and concentrators, pulse oximeters, ECG units, transport incubators, Bilirubinometer, Nebulizer (Electric) etc. The states are to submit this information to the Commission within a week.
• A third letter has been sent to ICMR director general Balram Bhargava asking him to share protocols and guidelines developed by ICMR for treatment and clinical management of children with Covid-19.
• “This is so that we can begin an awareness campaign as soon as possible. If there are additional guidelines specific to the treatment of children suffering from Covid that the ICMR has drawn up, or will draw up, we want to be able to disseminate this as well — not just to medical practitioners but also to parents, so that they have information, such as when to take a child to the hospital and what kind of treatment needs to be done at home. Our aim is to monitor all infrastructure and make sure that we are ready for the third wave by July this year, so that children can be saved,” says Kanoongo.
• ICMR protocols are to be further shared by NCPCR with the State Commissions for Protection of Child Rights (SCPCRs) for dissemination.