New Delhi: In the 934-bed Kasturba Hospital in Wardha, Maharashtra, medical superintendent S.P. Kalantri is worried about whether hospitals will have the capacity to provide enough oxygen to patients with COVID-19, he told IndiaSpend. The local administration has asked him to create 200 oxygen-beds by May, up from the 100 they had earlier requested, Kalantri said.
“All our preparations are going haywire… The problem is, everything is closed due to the lockdown. We cannot get skilled labour to lay down the copper piping needed for the oxygen,” he said, adding that the hospital has not been able to procure enough raw material such as pipes and tubes.
Maharashtra, the state in which Kalantri’s hospital is situated, is the worst hit state by COVID-19 in India, with 8,068 confirmed cases--29% of the country’s total--as of April 27, 2020, according to HealthCheck’s Coronavirus Monitor.
Oxygen is vital for patients of COVID-19--a respiratory disease that mainly attacks the lungs and leads to dangerously low levels of oxygen in the body.
“Many of the patients can be saved by giving just one treatment, that is by giving them oxygen,” said Randeep Guleria, director of the All India Institute of Medical Sciences, at a government press conference on April 23, 2020. “Therefore a strategy of having more oxygen-beds is based on this,” he said, adding that when oxygen levels in blood fall, it can trigger cardiac and neurological problems.
About 15% of all COVID-19 patients with “severe infection” will require oxygen while 5% with “critical infection” will need a ventilator, the World Health Organization (WHO) has said. The rest of the 80% will be asymptomatic or mildly ill and will not need oxygen.
Oxygen is listed as an essential medicine and is regulated under India’s National List of Essential Medicines. It is also on the WHO’s model list of essential medicines. States are still trying to ramp up capacity to provide oxygen and ventilators to COVID-19 patients. The pandemic presents an uncertain time, for both demand and supply of oxygen in India.
For instance, of 123 districts in the country that did not have any ventilator beds, 39 had a COVID-19 case, The Indian Express reported on April 27, 2020. As many as 191 of 266 officials who responded to a government survey in March 2020 on COVID-19 preparedness said they disagreed or strongly disagreed that they had sufficient ventilator machines.
There is no official data on India’s overall oxygen requirement and hospitals might find it challenging to estimate future demand for oxygen for COVID-19 patients.
In 2017, the critical role of oxygen made headlines when, at the Baba Raghav Das Medical College in Uttar Pradesh’s Gorakhpur, at least 24 children died because the hospital ran out of oxygen. Investigations revealed the fatal consequences of supply chain issues and human error in tracking levels of oxygen, as The Wire reported in August 2018.
A 200-bed hospital needs at least 180 oxygen cylinders a day
Despite seeing 3,000 patients daily, on average, Kasturba Hospital does not have an oxygen tank on campus with piped liquid oxygen. Their regular supply of large oxygen cylinders comes by truck from a vendor about 50 km away. The cylinders are docked in an “oxygen bank” on their campus. The oxygen reaches wards and the intensive care unit (ICU) via copper pipes.
“We have been given just about two weeks to get the oxygen-beds ready. Thankfully the local administration has recently offered to help us on this,” Kalantri said.
Usually, the hospital gets about 200 or 250 cylinders a day, and they have not had a shortage, said Kalantri. At present, due to the lockdown, they have fewer patients than usual. A 200-bed medical facility, which depends on oxygen cylinders, like Kasturba Hospital, would need 90 jumbo cylinders per day and another 90 cylinders as backup, according to a recent health ministry assessment. Each cylinder has about 7.25 cubic metres of oxygen.
Hospitals would have to prepare their oxygen inventory well to ensure that they do not run out of oxygen. At any given point, hospitals should have three times the cylinders consumed daily--one in use, one as a backup and one in the refilling station, according to the same assessment.
Oxygen cylinders are “labour intensive, logistically challenging, unsafe, unhygienic and expensive” while piped supply to hospitals is “far better, cheaper, safer”, according to this document. Still, for a “short term and emergency situation”, the ministry has recommended using oxygen cylinders as they are the “most adaptable”.
Oxygen supply is a challenge in rural India
In a “worst-case scenario”, if all patients in a 10-bed ICU need a ventilator, that medical facility would need 40 cylinders of 6,000 litres of oxygen each per day, according to a website on medical inventory, facilitated by India’s scientific adviser. This facility will also need a reserve backup of 10 cylinders of 1,246 liters.
“Only one ventilator is available,” said an official from Panna district in Madhya Pradesh, in the March 2020 government survey. The shortage of oxygen cylinders and ventilators was exacerbated by the lockdown, which had resulted in inter-state borders being sealed, making it hard for vehicles to transport these items, some officials had said.
There were other related problems too, such as staff to administer a ventilator. “We don't have an anaesthetic in Dumka. Hence, we can't run the ventilators,” said the district official from Dumka in Jharkhand in the same survey.
Given that so far COVID-19 has not spread widely in rural India, and as long as it is concentrated in urban India, patients would likely have access to piped oxygen supply in big hospitals, said Vinod Singh, the business head for north India at Mumbai-based oxygen manufacturer INOX.
There is also the new “challenge of ensuring oxygen supply in the various new COVID-19 centres being set up, as many of them are makeshift”, said Saket Tiku, president of the All India Industrial Gases Manufacturers Association (AIIGMA).
If COVID-19 spreads to rural India, where pipelines for liquid oxygen cannot be quickly laid and a reliable supply of oxygen cylinders might not be available, it could impact COVID-19 fatality rates.
India’s capacity to supply oxygen
Oxygen is artificially produced via oxygen concentrators or generators at gas plants around the country. It is then transported by road to medical establishments.
Medical oxygen is supplied through several modes. In well established set-ups, liquid oxygen is filled into large tanks built into the ground, then supplied via a network of pipelines which reach an output point on a wall near a patient’s bed. Patients can be directly connected to the oxygen supply as and when required. Piped oxygen networks are more automated, reducing the chances of human error in tracking and controlling the levels of oxygen.
But many medical establishments in India, especially those in smaller cities and towns, depend on cylinders. Some use jumbo cylinders, which are bought in bulk and stored in an oxygen-bank, technically known as a “manifold” from where a network of pipes goes to an output by the patient’s bed. Other hospitals depend on smaller cylinders which are placed by the patient’s bedside. These are moved as needed and also used when a patient is being transported.
Steps taken by the government
India detected its first COVID-19 patient on January 30, 2020, but many key government circulars and press statements on oxygen were published only in April 2020.
It was on April 4, 2020, that the government announced that it had created guidelines for the management of oxygen as the COVID-19 pandemic had led to “particular challenges of not only ensuring the adequate supply of oxygen but also protocols related with handling the major source of supplies”. The circular cautioned hospitals to ensure that they requisition and pay for oxygen in time so that there is no disruption. A committee for this was also set up on April 4.
The home ministry wrote to states about the “critical need to maintain adequate supply of medical oxygen in the country” on April 6, 2020. The supply-chain of medical oxygen was exempted from the lockdown and states were asked to ensure that hospitals are able to procure oxygen, the letter said.
Finally, by April 18, 2020, the Indian government put out a tender, inviting expressions of interest and bids for the procurement of medical oxygen cylinders.
Using industrial oxygen capacity for medical oxygen
According to the AIIGMA, only about 15%-20% of oxygen made in India is for the medical sector, and the rest is for industrial purposes such as for the production of steel. “India has enough capacity to make medical oxygen, since this is actually a small proportion of the oxygen made in the country. So our capacity to make industrial oxygen can be diverted for medical purposes,” said Tiku.
The AIIGMA has been working on this issue with the government and on April 7, 2020, India’s drug controller issued a circular permitting this.
But unlike with personal protective equipment, for which several new players such as regular garment manufacturers were able to quickly adapt and begin production, the oxygen sector will not be able to immediately adapt to a surge in demand. “This [oxygen] industry is capital intensive, highly technical and it takes time to set up a new plant. Hence we should be prepared in advance,” said Tiku.
(Bhuyan is a special correspondent at IndiaSpend.)