Dr Krishna Reddy
The world has been seeing frequent outbreaks of epidemics and pandemics over the past few years. SARS-1, MERS, H1N1, Avian Flu, Zika, Ebola, SARS-2 are some of the recent ones. Globalization, along with increased population mobility across borders, rapid urbanization with crowded living, and increasing interaction between humans and wildlife are some of the reasons behind the growing frequency. The Covid pandemic has laid bare the poor preparedness of health systems across most countries. Planning for the ongoing wave andlikely future waves of Covid and for other future pandemics will be critical in improving the response of health systems as a whole.
Strengthening disease surveillance systems
Disease control is one of the fundamental functions of public health systems. Robust disease surveillance is foundational to disease control. Apart from traditional epidemiological systems, rapidly advancing digital and molecular technologies offer additional tools in improving surveillance. Mobility data is being extensively used in evaluating containment measures during the ongoing Covid-19 pandemic. Genomic surveillance is being shared globally and is guiding many public health responses. Standardized and interoperable health record systems will enable live monitoring of disease trends across every geography. It will enable monitoring changing clinical presentations with new variants. Data from laboratory and pharmacy chains can be triangulated with other data to further strengthen surveillance. Artificial Intelligence and deep machine learning can come up with faster and more accurate analysis of emerging trends to guide public health professionals in their rapid responses.
Rapid data sharing
A remarkable feature of the current pandemic is the amount of data that is being shared across the globe through open sharing systems. The rapid pace of diagnostic tests release, repurposing of drugs, and vaccine development within one year of the onset of the pandemic reflects the power of data sharing. Data is useful only when it is authentic, accurate, and trustworthy. Certain governments are either fudging data or not sharing data to owing to the rising criticism in the face of the loss of lives and livelihoods. These actions will not help in scientific planning to mount an effective response. Preprint online publications have sped up the sharing of scientific data. While they bypass the rigors of peer review meant for authenticity, they are helping in accessing data in time. A simple tool to validate unauthenticated data is to triangulate it other relevant data. Official data of the plateauing surge can be corroborated by on ground observations of the number tests being done in labs and the demand for beds. Reported mortality figures can be revised based on computation of excess number of deaths in a year compared to the previous year.
Epidemiological modelling has been the cornerstone of public health response to an emerging epidemic or pandemic. The predictive ability of these models depends on the accuracy of the data and the underlying assumptions. While the models work well for known organisms, they tend to fail for novel or new organisms, as the model depends on many assumptions and unknowns. Standard error increases as the number of assumptions increase. Dynamic big data analytics might offer better predictive models as is demonstrated during the current pandemic. Public health measures, people’s response to those measures, ongoing mutations and emergence of new variants, use of proven and unproven drugs etc., will influence the predictive ability of the models. Models that depend on limited but more accurate data with provision for adding more variables as the data on these becomes available will be better placed than the conventional models. Decision makers will turn sceptics if the models fail in prediction and will be forced to move away from informed decision making towards ad hoc decisions.
Planning for the worst-case scenarios
Professionally managed organizations always insist on risk analysis and risk mitigation strategies. Defense preparedness is based on worst case scenario analysis. Governments and health systems should have these strategies in-built into their governance systems. The second wave in India is a perfect example of not planning for the worst-case scenario. Last serological survey undertaken by ICMR indicated a sero-positivity rate of <30% for the country as a whole. That means >70% of the population (~900 million people!) was vulnerable to infection towards the end of the first wave. The duration of immune protection following natural infection, especially in asymptomatic and mildly symptomatic cases is still not clear for SARS-CoV 2. Reports on emergence of new variants with increased virulence and immune evading properties started appearing in latter part of 2020. Hence, there was sufficient information to expect a second wave.
Maharashtra, followed by Punjab became the epicenters of the second wave that began in mid February. The exponential growth was clearly evident in the first few weeks itself. Compared to the first wave, epidemiologists had better knowledge about the virus to make more reliable district-wise and state-wise predictions on the case load in different scenarios in terms of containment measures and people’s adherence to Covid appropriate behaviour.The above information was either not available or not communicated or not sought in planning for the health systems response.
Health systems are highly complex. All actors – governments, public and private providers, public and private insurers, public health professionals, and people – are responsible to plan their responses based on accurate information. Governments are responsible to plan public health response, disseminate information to various health system stakeholders, prepare public healthcare provider systems to meet the needs of affected people in general and of poor, marginalized, and rural people in particular, take policy decisions to enable the supply of adequate human, material, and financial resources, and enforce laws in response to the crisis. Providers are responsible for puttingCovid care systems in place, plan for full occupancy of their capacities, train their personnel, develop strategies to handle human resource shortages and stock adequate critical equipment and drugs. Payers (public and private) were required to inform their beneficiaries, design Covid-specific products, engage and assist their empaneled providers, and even advance amounts adjustable against future claims. People are responsible for their own behavior, especially if it can endanger others. They are responsible for planning ahead to meet expected hardships, not to spread false or unverified information, and not to hoard essential drugs and items. Hence, planning is a response of the whole system, and not just that of the government alone. However, governments should steward the this response as they have the power and means to do so.
Learning from second wane to prepare for future waves.
Many data points are available to us, such as daily new cases, existing case load, daily recoveries, weekly moving averages, percentage of positive cases that need hospitalization, ICU care, and ventilation. We are also getting accurate information on the amount of oxygen needed per patient per day based on actual consumption in hospitals. If and when cases start to rise again, based on these variables, an assessment can be made in the early days as to the number of Covid care oxygen beds, ICU beds, ventilator beds, general nurses, nurses with experience in ICU care and ventilator care, general doctors and critical care specialists needed, essential drugs and disposables needed to manage an assumed peak load in a given geography. This assessment can be done at national, state, and district levels for planning the response. The projected Covid care demand should be evaluated in the context of available supplyin a given geography.
Assuming a peak active case load of ~ 5 million cases in the future waves, we will need 500,000 Covid care hospital beds assuming a hospitalization rate of 10 percent. Around 15 percent of hospitalized patients needed ICU care during the second wave. Thus, there will be a need for 75,000 ICU beds. Of these, about one fourth may need invasive ventilation.As per publicly available information, there are ~470,000 Covid care beds in the country. In addition to the projected shortfall, these beds are not distributed uniformly. We also have to keep in mind that we need to care for non-Covid patients’ emergency needs. Hence, this information will not be useful unless similar information is available for each city and district. Unless the planning is decentralized to a district level, the response will more likely be inadequate. A planned national register on each provider is ideal in order to have accurate information on the operational capacity and present occupancy in all geographic regions.
While planning for infrastructure is fundamental, planning for human and material resources is equally critical. On ground experience during the first and second waves shows that the true Covid care bed capacity is determined more by available competent and willing manpower than the infrastructural capacity. It is further impacted by higher rates of infections in frontline health workers necessitating their isolation. Amongst drugs, steroids, oxygen, and anticoagulants are the most essential for treating Covid patients. No other drugs that are in current common usage, including Remedesivir, Tocilizumab etc., are as essential as the above three. Since the consumption of oxygen per patient per day is far higher (almost by a factor of 10 times) in Covid patients compared to regular consumption, advanced planning should be done for enhanced oxygen demand. While most of the planning focuses on quantities, it should also focus on the entire supply chain process cycle of raw materials to finished products to quality checks to transport to storage to distribution. It should take into consideration the disruptions in global supply chains and the exponential demand for limited supplies across the world.
Social security net
While health systems should have a robustreponse system in place for pandemic preparedness, social systems should also have plans to provide food, employment, and financial security during crises. Covid-19 has taught us that the lack of a robust social security system hampers the required public health response especially with regards to stringent containment measures. Many lost livelihoods during the first wave due to the most stringent lockdown and now we are losing lives during the second wave as we are hesitant to reinforce the same lockdown measures, given the images of mass movement of migrants during the first nation-wide lockdown. While formal labor has a reasonable security net, the dominant informal labor haveneither social security nor health financial security. Policies and strategies to bring informal labor into the formal labor pool will secure peoples’ lives and livelihoods.
Take home messages
To secure the health of its people, India should have the following things in place
- A robust surveillance system leveraged by digital and molecular technologies, anchored by theNational Digital Health Mission (NDHM)
- Reliable predictive dynamic models based on big data analytics, AI, and machine learning
- Periodic stress testing (akin to simulated war games) to assess preparedness of the health systems and other social systems
- National registers to provide accurate information on healthcare providers, payers, professionals and products
- Redundancy in critical resources to build resilience while driving efficiency in operations
- Federated National Health Data Exchanges to unlock the power of data to enable dynamic surveillance, build rapid response systems, and to inform policy at national, state, and district levels
- Reaching the goal of Universal Health Coverage at the earliest to secure people from catastrophic and impoverishing health expenses
- A robust social security net during times of, crises arising from pandemics, climate change, and mass displacements due to war and strife.
We will be paying a fitting tribute to those who have lost their lives during the current pandemic if we, as a nation, learn from the ongoing disaster and put resilience systems in place to secure our people’s health in the future. We rather join our hands and work together, than blame each other.
Dr Krishna Reddy
Country Director, ACCESS Health International