Breathless

 Yesterday was a day of desperate messages on our neighbourhood e-group:

13:50: "Does anybody know where oxygen cylinders can be purchased right now? "

19:02: "Mr. B needs a ventilator immediately...his hospital does not have one to spare.."

01:14: "Very, very sorry to inform you that Mr. B is no more..."

The same tragic sequence of events is being played out in thousands of places across the country now. As the "Second Wave" of Covid-19 infections sweeps across India a major crisis of medical supply-chain inefficiencies has hit India. There has been such a sharp spike in Covid cases that 54.5% of patients during second wave required supplemental oxygen during treatment - a 13.4% increase from the peak during September and November 2020.

The irony of the situation is that there is no shortage of O2 production in the country - India has a total production capacity of more than 100,000 tons/day (7,100 tpd of medical O2 as per HT), of which over 80% goes for steel-making. According to HL Meghnani, an industry veteran, industrial O2 has to be 99.5% pure while medical O2 needs to be only 93% pure, and less than 1% of O2 produced is used for medical purposes. Yet the scale of crisis currently unfolding is mind-boggling.

India's clinical management protocol recommends oxygen therapy as the primary form of treatment: the target is to achieve 92-96% SpO2, or 88-92% in patients with COPD. While proportion of those requiring oxygen beds is still hovering around under 10%, this number is at an all time high with India's active caseload crossing 26 lakh (2.6 million). The demand for medical oxygen has increased by 18% over the last 6 days across 12 states which account for 83% of India's active cases.

Where did we go wrong? What will it take to bring this situation under control? 

One of the points made by Meghnani brings out the nature of the complexities involved rather nicely - "The current crisis arises because of a shortage of road tankers, storage tanks and cylinders... each tanker costs INR 4.5 million and a cylinder costs INR 10,000 in which you sell O2 worth just INR 300" (!) Add to this the location of the O2 plants -  mostly in Western  and Eastern India -  and the decision taken by major hospitals to outsource O2 supply instead of having captive plants, and you begin to understand why the supply-chains collapsed last week.

We are now in the process of rushing in extra cryogenic O2 tankers from abroad, and penalising those who have been profiteering during this crisis by hoarding O2, and driving up the prices.

What remains unclear is a more granular picture of O2 demand and consumption in our hospitals. How many O2 tankers are needed every day to service all the hospitals in our cities and towns? Can some of the shortage be handled by portable O2 concentrators? 

------------------------------------------------------------

REFERENCES & LINKS

* 28Apr21 - Gurumurthy S, New Indian Express - Missing Facts, Misdirected Course - https://www.hindustantimes.com/india-news/why-india-is-facing-an-oxygen-crisis-as-covid-19-cases-mount-101619268862048.html

* 25Apr21 IEexplained - What changed in the second wave? - https://indianexpress.com/article/explained/explained-whats-changed-in-second-wave-7289002/

* 25Apr21 IESunday - Falling Short O2 - https://indianexpress.com/article/opinion/editorials/nirmala-sitharaman-economic-package-migrant-workers-one-nation-one-ration-card-coronavirus-6410303/

* 24Apr21 - HT - Why India is facing an oxygen crisis - https://www.hindustantimes.com/india-news/why-india-is-facing-an-oxygen-crisis-as-covid-19-cases-mount-101619268862048.html

Covid Shielded

The lady who helps us with the housework is from a remote coastal village in West Bengal. Yesterday she got a call from her parents and the news was that they were both suffering from fever. A few thousand kilometres away, near the capital city, we too were afflicted by the same symptoms - the expected after-effects of a vaccination national drive against Covid-19. 

We were among the four million+ people who got vaccinated in India today. While the fever and the dull pain of an intramuscular injection abates, it is quite amazing to think of superlative effort that has gone into creating, testing and delivering these vaccines all over the world.

The vaccination program started its rollout in India couple of months ago. First for those over 65 years of age, and for those who were vulnerable due to 'co-morbidities'. At first people were wary, and senior citizens had to be coaxed and cajoled to the vaccination centres. This changed on 1 April 2021 when the government decided to expand the coverage to those over 45 years of age.

The sheer scale of this effort does not hit you until you participate in it. It is a four step process is driven by information technology in which each dose can be traced back to a specific vial at a specific vaccination centre:

(1) Registration at CoWIN site - a single phone can be used to make four bookings at either government 

(2) Selecting a vaccination centre - Based on your postal PIN code you can opt for either the nearest government centres (free of charge) or private hospitals / clinics (fixed at INR 250) 

(3) Vaccination - At the hospitals a queuing system ensures that people maintain social distance. Each vaccine station has three staff  - two for writing out the registration details, one  for preparing the vaccination card, one for checking the CoWIN id, uploading the confirmations online, and a nurse who administers the vaccine. The whole process takes about 8 minutes. After the jabs people are expected to wait for 30 minutes of observation before returning home. 

(4) Certificate - within a few minutes of getting vaccinated an SMS message leads you to an online certificate (PDF) which can be used as proof while travelling.

(4) Follow-up - each vaccinated person is given a card which specifies the vaccine type (Covidshield / Covaxin), the date for the second dose (min. 28 days), emergency helpline numbers and a list of five possible after effects (mild fever, pain and swelling, etc.,)

One thing I have learnt along the way is that the government machinery seems to be far more efficient than the private sector. In my immediate neighbourhood all the hospitals were booked until 14 April, so I expanded the generic Noida PIN code and booked two slots on 1 April at Metro Hospital from a list of about 10 hospitals. 

However my experience at Metro Hospital left me quite disappointed. It is a large hospital in Sector-11 Noida. When I found my way to the entrance the staff seemed paralysed by chaos - there were over a 100 angry, impatient people already crowding inside, with the guards telling the newcomers that they would need to wait for three hours!

I went back to the CoWIN site and got my appointment rescheduled to the  next day at the District Combined Hospital, a government facility in Sector 30. Over here the whole process was a breeze. There was ample parking outside; masks, hand sanitisers and social distancing was compulsory; tokens were being distributed at the main gate and security guards were systematically guiding people through waiting halls while giving priority to the elderly and infirm.

Millions of tiny vials from Oxford-AstraZeneca / Serum Institute of India, Sputnik and J&J have now set out to deal with a virus from China that had the world paralysed for more than a year. Hope is in the air, and in our blood streams.

-----------------------------------------------------

LINKS & REFERENCES:

https://www.livemint.com/news/india/covid19-vaccination-over-36-lakh-people-get-the-jab-on-april-1-the-highest-so-far-11617335903675.html

https://www.bbc.com/news/world-asia-india-55748124 - Covishield and Covaxin: What we know about India's Covid-19 vaccines

On the remarkable role being played by Co-WIN and its developers (19 April 2020, Indian Express) - https://indianexpress.com/article/india/co-win-platform-coromnavirus-vaccine-india-modi-govt-7279432/

Container Ships and Indian Ports

A fwd from DM on the Emma Maersk set me wondering – If ships carry 90% of India’s export-import volume, how much do the containers carry? How do our ports compare internationally?

According to IPA data (2005-6), Indian ports carried 4.7 million TEUs last year, of which nearly 60% went through JNPT-Mumbai (2.6 m TEU). This port has a draft of 12.5m and so the largest ships that can get here hold up to 5,000 TEUs (panamax).

To put things in perspective, here are the numbers for China – just the port of Hong Kong handles more than 22m TEUs annually. Four of the top ten container ports are Chinese.

Two critical factors affect the economies of ship operations – operation costs and time. On both counts Indian ports lag far behind the international benchmarks. In Hong Kong it takes eight hours to unload and load a ship; Indian ports take an average of 3.4 days (78 hours!).

Increasingly, global shipping lines are going for ships that can carry more than 7500 TEUs. A BRS-Alphaliner report says that 150 such ships have already been ordered, in addition to the 40 already in operation. By 2015 vessels with 12,000 TEUs (Suezmax) and 18,000 TEUs (Malaccamax) will become common. And India, with its strategic location and 7600km coastline will get only “feeder” ships and higher costs per container :(

And here are the vital stats of the lady from Denmark who is rewriting the rules:

• Length - 1,302 ft (397m)
• Width - 207 ft (56m)
• Net cargo - 123,200 tons
• Engine - 14 in-line cylinders diesel engine (110,000 BHP)
• Cruise Speed - 31 mi/h (50kmph) – special silicon paint reduces drag and saves 317,000 gallons (1.4 million liters) of diesel per year!
• Cargo capacity - 15,000 TEU (stated capacity is only 11,000 TEUs)
• Crew - 13 people
• First Trip - Sept. 08, 2006
• Construction cost - US $145,000,000+

Ports capable of hosting Emma - Suez Canal (Egypt), Gothenburg, Aarhus, Bremerhaven, Rotterdam, Algeciras, Singapore, Kobe, Nagoya, Yokohama, Yantian, Hong Kong, Tanjung Pelepas and Felixstowe.

--------------------------------------------------------------------------------

Note:

50 Largest Container Ports, 2004: Four ports handled more than 10m TEUs annually – all in the Far East

Top 20 Container ports, 2002