Is India prepared for a coronavirus outbreak?

There are not more than 50,000 isolation beds across hospitals in the states to admit patients or suspected coronavirus cases in a country of 1.3 billion people, and most of them are in the capitals and major district hospitals.

From prohibitory orders banning public assemblies to finger-marking people under quarantine so as to identify them, disallowing social gatherings to closing educational institutions, state governments have spared no effort to prevent the spread of the novel coronavirus.

Even so, experts question the preparedness of the state machinery to cope with possible community transmission of the disease, which so far has been limited to travellers from other countries coming in contact with and infecting local residents, and Indian nationals getting infected during foreign tours and transmitting the virus to their close contacts upon return.

There are not more than 50,000 isolation beds across hospitals in the states to admit patients or suspected coronavirus cases in a country of 1.3 billion people, and most of them are in the capitals and major district hospitals. There are only 52 labs in the country to assay swab samples, which go for a final test and confirmation or otherwise of coronavirus to the National Institute of Virology in Pune. In Bihar, there is just one testing lab and Gujarat has two. These 52 labs have the capacity to conduct 1,000 tests in a day unlike a lab in Wuhan, China, constructed in 12 days, which can perform 10,000 tests in a day.
Health ministry officials said the government was ordering a million kitsfrom overseasfor increasing the testing capacity and private labs have been allowed to perform coronavirus tests on advice of a doctor.

Dr A S Anoop Kumar, head of the critical care unit at Baby Memorial Hospital in Kozhikkode, who played a key role in diagnosing the nipah virus in north Kerala two years ago, said, "We need to cut testing time in laboratories. We need more labs and isolation wards. We have to be equipped to treat a large number of patients and quarantine people at the local level."

Experts also question the training of medical staff to deal with the pandemic and say the governments need to enlist anganwadi staff and accredited social health activists to prepare a mitigation plan in which every house may require to be quarantined and every person scanned. And only a few states like Kerala have set up specialized centres to counsel people who tested positive for Covid-19. "Counselling of patients and family is important part of treatment of the coronavirus. We have asked states to set up specialized counselling centres," said Dr T Sundararaman, former director of the National Health Resource Centre.
Sundararaman said scaling up of laboratory tests for Covid-19 is possible because it is a polymerase chain reaction (PCR) test that is also done in case of other diseases such as dengue or HIV. "More testing will increase cases but it should not create a scare. It will help in implementing a mitigation plan," he said.

Government officials in several districts, especially in Hindi-speaking central and northern India, admitted to constraints in health infrastructure. "Our government hospitals are not fully equipped to handle patients (even) in normal days... if a large number of patients come. There will be chaos all over," said a health department official of the UP government. "The need of the hour is to decentralize and create facilities at the local level. We need separate isolation wards at taluka level and [need to] include private sector."

Maharashtra and Kerala

So far, only 137personsacross India have tested positive for coronavirus and 13 people, including two Italian tourists, have recovered. Three persons have died so far in India; the most number of cases were reported from Maharashtra, followed by Kerala.

The spread of the coronavirus has not been rapid so far in India, but data shows that in many European countries, the number of cases spiked once random community testing was scaled up. With the firstinfection in India reported in early March, the country is in its most vulnerable phase. Experts warned of a possible spike in cases once the government starts reinforcing the number of testing facilities.

In Maharashtra, all exams have been postponed and educational institutions closed. The state has also decided to put an indelible ink mark on the hands of people put under self-quarantine for easy identification.
"Next 15-20 days are most important for the state. We will have to take all the precautions. It has been observed that rise of the outbreak in second week and third week is very high and hence the state government doesn't want to take any chances," chief minister Uddhav Thackeray said.

Dr Behram Pardiwala, internal medicine expert from Wockhardt Hospital, said the state government is in a right direction. "I don't think that the government can do more than this... it is doing good job... we are still between stage 1 and 2. Any further restrictions would not be advisable."
Anant Bhan, researcher in Global Health and Policy, however, said, "We all are talking about isolation beds but we also need to check if all these beds are equipped with ventilators. Covid-19 leads to the development of pneumonia so patients need to be kept on ventilators. But in Mumbai, the number of ventilators is limited and mostly occupied."

Of the Indian states, it appeared that Kerala was best equipped. But, the second round of Covid-19 cases has busted this myth with 24 cases reported within a week. The number of cases in Kerala is 26 and 18,011 are under quarantine. The state has about 5,000 isolation beds and four testing labs. Health minister, K K Shailaja, blamed people coming from abroad for the spread saying they did not report symptoms. "Three Italy-returnees in Pathanamthitta had infected eight others. We expected some hike in cases but irresponsible behaviour of some returnees added to our woes," she said.

Dr Kumar said it appears that the state eased up after the three patients who tested positive in January recovered. The first Covid-19 patient of the country, a medical student who returned from Wuhan in China, was hospitalised on January 28. At least 100 persons she came in contact with were quarantined in their homes.

"Though Kerala is best equipped to deal Covid-19, there are still many gaps. There are no testing facilities at the district level. The state needs to make testing an effective mechanism."

Uttar Pradesh

In Uttar Pradesh, it was found that several district hospitals don't have dedicated desks to deal with suspected patients, especially in smaller districts like Barabanki.

Barely 29 kilometres from capital Lucknow, at the district hospital in Barabanki, scant information is being provided about the disease. "Sahab batayenge (sir will tell)," was the almost common reply from all doctors. Chief medical superintendent (CMS), Barabanki, SK Singh, said, his team was prepared.

In the Bahraich hospital, there was no separate queue for patients having symptoms similar to that exhibited by Covid-19. A patient asked, "What happens if an infected patient stands in the queue? Many would get infected."

Chief medical officer Dr DK Singh said there was no reason to worry as the hospital had a trained team and added a ward was stacked with the N95 masks, thermal scanners, body protection suits and medication.

In a recent meeting, chief minister Yogi Adityanath directed his ministers to visit districts to review measures taken by the state. In all 75 districts, a total 1,268 beds have been reserved for isolation wards, officials said.

West Bengal, Jharkhand, Bihar

In West Bengal, even though chief minister Mamata Banerjee on Monday invoked the Epidemic Act, 1897 and announced a Rs 200 crore fund to create medical infrastructure to deal with the pandemic, there aren't enough isolation beds in the border districts of Malda, Murshidabad, North Dinajpur and Birbhum, home to workers who migrate to other states every year.

The state has about 163 isolation beds for a population of 90.2 million. There is only one testing facility even though officials said more facilities will be created in consultation with Indian Council of Medical Research. "Government has strengthened the surveillance and control measures against the disease. We have a 24x7 helpline number," said Ajay Chakraborty, director of state health services.

Banerjee said the state has special problems because of its high population density and it shares international borders with Bhutan, Nepal and Bangladesh.

Neighbouring Sikkim has announced a ban on the entry of people, including tourists and migrant labourers, from other states and sealed three out of five entry points.

In the two densely populated eastern states of Jharkhand and Bihar, there are only four testing labs and just over 4,000 isolation beds. The population of the two states is 130 million.

Both states have created special funds to fight coronavirus and invoked the Epidemic Act. "That no positive case of coronavirus has been reported from Bihar is a testimony to this fact," said Dr Ajay Kumar, former national president of the Indian Medical Association (IMA). "There are, however, some gaps at the Patna airport, where I did not find anyone either to distribute forms or screen passengers when I returned from Goa via Mumbai on Sunday (March 15). Otherwise, the arrangements seem sufficient," he said.

Director of the Rajendra Memorial Research Institute of Medical Sciences Dr Pradeep Das, said the only lab in the state has capacity to test 700 samples per day. "We have so far tested 40 samples and all are negative."

J&K, Ladakh, Punjab

In Jammu and Kashmir and Ladakh, officials have maintained vigil over 100 persons who have returned from abroad in the past one month. "Of 52testing labs in the country, J&K has three — 2 in Kashmir and 1 in Jammu. We activated them in the shortest time," said Bhupinder Kumar,director of the National Health Mission and nodal officer for the Covid-19 campaign in J&K.

The sarpanch of Samba's Kaily Mandi Halqa, Ravinder Singh Sambyal, which has seven wards for a population of 1,600 people, said, "There is no fumigation, no awareness, no preparedness in primary health centres."

Darshan Bharti, a resident of the border town of Poonch, said, "The administration has issued prohibitory orders under section 144 Cr PC [Code of Criminal Procedure], which are not being taken seriously by anyone. However, a few posters and hoardings have been put for awareness."

Suresh Sharma of Bishnah, a rural belt of Jammu, said, "In Bishnah, Deoli and Makhanpur, a few people, who returned from abroad, have been quarantined and every day health teams visit them to see their symptoms."

In Punjab, which sees a vast number of non-resident Indian visitors in April, tracking foreigners is a tough task. Punjab has entrusted 3,000 auxillary nurse midwives and 15,000 accredited social health activists with the task of tracking more than 60,000 passengers with a history of travel abroad.

It was found that ventilators were not available at civil hospitals, including in Sangrur, Barnala and Mansa. "We are fully prepared to tackle any outbreak and as far as availability of ventilators is concerned, the number is enough. Still we are increasing its availability daily," state nodal officer Dr Gagandeep Singh said

Haryana, Uttarakhand, Northeast

In neighbouring Haryana, there is only one positive case of coronavirus and the health authorities claim to be fully prepared to handle the virus. "Elaborate arrangements pertaining to manpower and with isolation wards are in place to handle the virus in case there are any positive case," said director, integrated diseases surveillance programme, Dr Usha Gupta.

Officials said awareness of the disease in smaller towns and villages was rudimentary.

In Uttarakhand, two days after one positive case of Covid-19 was confirmed in Dehradun on Sunday, the Uttarakhand government has quarantined the whole campus of the Forest Research Institute and Indira Gandhi National Forest Academy, where the first infected patient is staying.

Over 600 people have been quarantined by the state government, said a state health department official. JC Pandey, public relations officer the Uttarakhand health department, said the state had around 2,000 doctors, of whom around 1,700 are directly involved in dealing with the coronavirus outbreak.

Most other north-eastern states have ordered the closure of all schools until April 15 and created isolation wards to accommodate up to 100 patients each. "We can increase the number if needed," said Meghalaya chief minister Conrad Sangma.