click here for pdf English

Weekly Update on COVID19 situation

JAN SWASTHYA ABHIYAN (JSA) AND ALL INDIA PEOPLE’S SCIENCE NETWORK (AIPSN)

Dated 2nd April, 2020

1. Making Sense of the numbers:: Where are we in the epidemic curve
2. The lock-down and its sheer brutality
3. Do lock-downs work?
4. Health system preparedness
5. The peoples movement response

Part I. Making Sense of the Numbers

In India the COVID19 epidemic has reached the 64th day since the first case was reported on January 29th. The number of cases crossed the 100 cases mark three weeks back, on March 14th. At the start of the lockdown India was at 648 cases, which doubled (close to 1251 cases) within six days. .

As of 1st April the total COVID 19 positive cases are 2012. The growth rate since 24rd March is 252% and the daily growth rate from 31st Mar to 1st Apr is 23% (see chart below).

Globally there are now 801,064 cases which translates into an average of 102 COVID positive cases per million population. The total deaths reported are 37,815, which works out to a mortality rate of 5 per million population.

India in contrast has a case rate of only 0.9 million per million population and a death rate of 0.02 per million. Does this mean that we are doing well for this stage of the epidemic, or is it too early to tell? To analyze this, our weekly update looks at cross country comparisons, our testing protocol and case definitions and the entire narrative on ‘stages of the epidemic’.

Table : Cross-Country Comparisons

Sources:

1. Data for USA testing rates is from https://covidtracking.com
2. Data for testing rates for India, Bangladesh and Pakistan is from Wikipedia
3. Data for testing rates for all other countries is from https://ourworldindata.org/covidtesting
4. Data for dates of 100th case and number of cases since lockdown is from https://coronavirus.jhu.edu/map.html

1. Cross Country Comparisons:

 While the first case in most nations occurred at about the same time,- but as the table above shows, there has since been a big divergence between the experience of the high income countries (HIC) and a selection of relatively high population low or middle income emerging economies (LMICs) (https://www.worldometers.info/coronavirus/#countries)

Between these two groups, the divergence in both incidence and mortality is huge. High-income nations appear to have a much higher infection rate and even a much higher mortality rate. Iran and Thailand are outliers in the middle-income countries group since they have relatively higher infection rates. But they are also known to have more universalized health care systems.

Within the high-income nations too the experience can be very different. But on the whole they have much higher infection rates than the LMICs irrespective of the date of first infection or the date of lock-down. One probable reason is the testing protocol followed (whether mild and moderate cases or all asymptomatic cases are tested) and the capacity to deliver these services, both in terms of test kit availability and access to testing. The more one tests, the more one uncovers positive cases. The alternative to such an explanation is to believe that LMICs on the whole have a higher resistance to the spread of infection. But that does not seem to protect nations like Thailand and Iran who are known for both better health systems and better health sovereignty.

Absolute Mortality rates is a true reflection of the health burden imposed by the disease and here there is a clear difference between the different nations. Case Fatality rates are important, but at this point of time could be misleading. We need to adjust for testing rates and protocols. They could be appearing high in Italy and Spain, and certainly in UK because tests were not offered to many of those with mild or moderate symptoms, whereas in South Korea it may appear low since more persons were tested. We will know for sure only later, when studies measure the total proportion of those who were infected- and calculate the proportion that were asymptomatic, mild or moderately symptomatic, and the proportion with severe symptoms, and fatality.

That being said- after adjusting for testing rates we find that some countries such as US, UK and Belgium have a much higher proportion of positive cases and others like South Korea and Australia have lower positivity rates.

Moreover, even for a certain level of incidence- certain countries like Germany, Scandinavian countries, Japan and South Korea had much less mortality. What we can conclude: One can comment on true incidence of COVID 19 only when testing rates conform to a protocol where ideally a) all symptomatic cases are tested and b) all asymptomatic contacts of COVID 19 positive cases are tested. If the testing protocol fails to test the above, the incidence rates must be adjusted accordingly by modeling or computation, assuming that the proportion between asymptomatic, mild, moderate and severe is the same universally. Similar adjustment is required for commenting on mortality too. However, in nations where accurate cause of death reporting is universal, such as in most HICs and countries like Thailand, absolute mortality rates would also be indicative. However this is not the case in India and the increment mortality that COVID19 may cause, may not be readily visible.

2. Comparisons between states:

The following charts show the number of COVID-19 infections and related deaths across 15 States with the highest numbers (See charts below). Maharashtra has the highest number of infections and deaths.

3. Testing Protocols in India:

          The current testing protocol in India could seriously under-estimate the number of COVID 19 positive patients in India by about 80%. India has allowed testing only for severe acute respiratory infections where a) the age is over 15 years there is fever and one respiratory symptom- cough and shortness of breath AND requires hospitalization; b) OR has traveled abroad c) OR been in contact with a confirmed case of COVID-19 positive case in last 14 days, d) OR any health worker admitted with severe acute respiratory infections (SARI).

Further, it also stipulates that if the history of travel and contact is not there, then only half of those admitted patients would be tested. While this may be good enough for a research study, the hospitalized half not tested actually has an equal chance of having COVID 19 and therefore could infect the entire staff and patient attendees. Further, if there is no increased number of cases- and there is just the same number of cases as was already there in the previous 15 days, no one however serious and typical of COVID19 infection, needs to be tested.

Informally and anecdotally, reports from across the states indicate difficulties in getting it tested even where ICU mortalities have occurred. There is almost an unwritten order within the system to keep the numbers low.

4. Case Definitions in India:

            Current case definitions in use for mild or moderate case of COVID 19 need to be examined. The WHO case definition of a mild case is: “Patients with uncomplicated upper respiratory tract viral infection, who may have non-specific symptoms such as fever, fatigue, cough (with or without sputum production), anorexia, malaise, muscle pain, sore throat, dyspnea, nasal congestion, or headache. Rarely, patients may also present with diarrhoea, nausea and vomiting (3, 11-13)”. The Public Health England definition is even wider. In India however, the case definition emphasizes fever AND cough AND shortness of breath. If there was only fever with sore throat and limited cough or nasal congestion this would not even be considered as suspect.

When by definition all mild and moderate cases are excluded from testing, – we should then assume that prima facie over 80% of all COVID 19 cases will not be picked up and interpret our figures with that important caveat. Our numbers are therefore well designed under-estimates.

5. ‘Stages’ of the Epidemic in India- an ICMR innovation?

In India, ICMR has created a narrative built around epidemic stages, which is widely adopted by the media and now also by very many reputed clinicians who are briefing the media. Indeed, this was first announced in a well-attended media briefing.

The narrative goes like this: India is at stage 2 of the epidemic and this is a manageable stage. A lock-down is meant to prevent it from going to stage 3, which is a terrible stage to be in, where we lose all control and an irreversible and terrible situation has set in. Thanks to our lock-down we are remaining in stage 2 and have been saved from stage 3. Stage 2 is characterized by the fact that we can trace back every case to a case of international travel. This is therefore called local transmission. Whereas in stage 3 we cannot do so- and therefore will be called community transmission.

There are many problems with this narrative. Firstly, WHO does not use such stages nor are we aware of such stages in any major public health texts. WHO does talk of four phases- the third being amplification and fourth reduced transmission- but containment, control and mitigation are overlapping concepts.

Secondly, though local transmission traceable back to an international travel contact is important and may be the exclusive form of case identification in an early stage of the epidemic, it has no relevance at this level of disease incidence. We know that a large number of travelers have entered in whom symptoms develop late, or they were from nations, which were then not known to have transmission. Further there are very many asymptomatic carriers of the disease who will never even know they have it and therefore transmission without a known contact is happening. Indeed such transmission is widely reported, but the government is not willing to give up its narrative, and ad hoc explanations appear- “oh this is only a small minority of patients”, or “we are still tracing the contacts”. That is not the meaning of the term “community transmission”. Further, whether a contact is identifiable or not is also dependent on subjective factors like patient recall, or skill in contact tracing. And then most importantly, we do not allow for testing anyone without contact history- therefore creating by design an absence of evidence to detect community transmission and then touting such data as the evidence for its absence.

Finally there is no big break-point between these two stages. Stage 3 is just as reversible as stage 2 and stage 2 just as likely to continue to generate cases. What matters is the rate of increase of incidence of infection, and if it is increasing exponentially, the action that is required. At this moment we cannot predict in whom the fresh cases are likely to occur, and instead we are tracing back to find out from where they got it. Whereas, we have already reached the stage where the main strategy should be identify all likely cases, isolate, test, treat and trace their contacts for further testing and isolation.

The probable reasons why the narrative of ‘stages’ is being maintained could be the sense of triumph in the declaration of still being in stage 2 and the sense of horror created by the threat of entering stage 3 are necessary to justify and manufacture the consent that is required for this brutal lockdown in India. We could live with this, except for the fact, that maintenance of this false, misleading and irrelevant epidemic stages, leads us to justifying the exclusion of mild and moderate cases from testing and well planned isolation. This is also leading to a huge amount of victim blaming when each instance of the disease can be traced back to some transgressor- where the accountability of the government is only in not being authoritarian enough. Recently this has also taken a communal turn. Governments filing FIRs or taking other action against such offenders follow this, with a large section of media applauding it. On closer examination most such charges are without merit.

Further, these mild and moderate cases are being handled in our regular outpatients as non-COVID ARIs and even 50% or more of our severe and hospitalized COVID 90 patients are being examined and treated by healthcare providers without any personal protective equipment (PPE) whatsoever. Recognizing this, the government has made all symptomatic healthcare workers eligible for testing and further allowed an as yet under-investigation drug Hydroxychloroquine for chemo-prophylaxis- but this is not quite the way to go.

            The call from people’s movements to the government is to drop this narrative of stage 2 and stage 3, and instead talk of immediately initiating the isolate, test, treat and trace- as the main strategy in readiness for the lifting of lock-down on April 14th. The lockdown has bought the system valuable time to prepare for the epidemic and was to some extent inevitable due to the weight of scientific opinion as was available then to the government, but now that we have the experience, and also understand the collateral damage it causes we could review this strategy and learn the lessons so that we do not have to repeat this in the future. We should also stop misleading comparisons we make with European nations which have different contexts and note that our figures are more comparable to much of Africa and the more economically and socially disadvantaged countries of every region.

Part 2. The Lock-Down and its brutality

The other major feature of this week was the lock-down. In sheer scale and scope few nations have seen anything like this. The program theory that justifies lock-down is that the measure of the contagiousness of a disease is dependent, not only on the virulence of the organism which we can do nothing about, but also to the number of contacts between an infected person and a non-infected person. It is an extreme and enforced form of physical distancing.

The lock-down was anticipated to cause economic slow-down, and personal hardships and some curbs on individual rights, but the rationale was that this was the price the country and its people had to pay for safeguarding us from losing anywhere from an estimated 0.5 % to 3 % of our population which could be many millions and if we go by the lower estimates it would still be thousands of deaths.

As expected, the lock-down did cause hardships to all- but very disproportionately. When the lockdown was introduced the hardships presented in the media either related to corporate concerns like economic slowdown, or middle class concerns like inability to buy groceries, boredom, managing with maid-servants etc. In hindsight it appears that there was absolutely no recognition or consideration in policy circles of who the majority of the country were and the conditions of their life. There was neither planning nor messaging related to problems like farmers having standing crops ready for harvest, or fishermen who could not go to sea, or the millions of daily waged migrant labour who live on the brink with no social security whatsoever. The immense tragedy that has followed, in terms of mass migration and hunger, was clearly unanticipated by government. It made clear the real social distance between the ruling elite and the majority of the people. It also made a mockery of the efforts at physical distancing. The large movement of people after the lockdown means that the key objective of the lockdown failed and has in effect rendered it as ineffective. The lockdown has created conditions suitable to transmission of COVID-19 infection. Moreover, the number of deaths due to such distress, hunger, lack of transportation and lack of access to healthcare for other diseases, may in fact be many times more than the deaths due to Covid-19 infections.

The social, economic and human cost being paid by the poor is enormous. Relief measures were not announced in parallel with the lockdown announcement. Two days later the government announced a very incomplete and inadequate package of measures that could not win the confidence of the people or stem the huge surge of migration all across the country, as fearful working people made a desperate bid to get home. Instead of responding with utmost sympathy to this distress migration, and strengthening relief measures, the government response was brutal, insensitive and at the end of the day- ineffective as well.

There are many contenders for the most shameful of the orders passed or measures enacted to prevent this migration and to enforce the lock-down. One example that shocked the nation was that of a group of migrant workers being sprayed with chemicals. Another is the Haryana government order creating temporary jails and calling for the arrest of migrant families walking on the road with luggage and young children as “jaywalkers.” In a series of press releases and public statements the peoples health movements have protested such brutalities and unethical behavior of the state and of communities. (See JSA-AIPSN statement on state obligations during the lock down (http://phmindia.org/2020/03/29/government-responsibilities-during-lockdown/ ) and JSA-AIPSN press release protesting criminalization and use of coercion and violence against the movement of migrants (http://phmindia.org/2020/03/31/press-release-retract-notifications-that-criminalize-use-coercion-against-the-movement-of-migrants/) )

The fear and victim-blaming that was rampant in all official messaging on the epidemic has also led to a huge degree of stigmatization and hatred within communities. One form, which it took, was doctors and nurses engaged in the struggle being thrown out of homes and refused entry into residential areas, as fearful residential colonies locked-down. Another was the hostility shown to those on whose houses quarantine notices had been stuck. Such public naming and implicit shaming and measures like public circulation of names of those who had been on international travel and of COVID patients- all in sheer violation of all ethics related to privacy and confidentiality- did not help the cause of physical distancing (See JSA_AIPSN statement protesting breach of confidentiality and privacy (http://phmindia.org/2020/03/23/jsa-statement-on-breach-of-confidentiality-around-coronavirus-cases/   ) and JSA-AIPSN statement regarding concerns on isolation and quarantines (http://phmindia.org/2020/03/24/jsa-statement-on-concerns-with-regard-to-isolation-and-quarantine-covid-19/  ) ). Clearly the perpetrating authorities were unaware of centuries of public health experience in epidemic management that teaches us how fear and stigmatization lead to families hiding the episodes or illness and circumventing rather than following the requirements of quarantine and physical distancing.

It was not only the migrant workers who were affected but all working people- especially farmers, agricultural labour, fisher folk, tribals, construction workers, sex workers and other unorganized sector workers. The relief measures were often a re-packaging of items already on the budget or very small tokens of relief. The JSA-AIPSN has brought out a statement explaining the inadequacy of the proposed measures at economic mitigation and articulating people’s demands for relief and mitigation (See JSA_AIPSN statement on the economic package announced by FM with respect to COVID19 pandemic and the lockdown (http://phmindia.org/2020/04/02/statement-on-the-economic-package-announced-by-fm-with-respect-to-covid19-pandemic-and-the-lockdown/ ) ).

One important component of this litigation is the urgency to prevent hunger and starvation. The Right to Food Coalition has issued a statement in this regard (Right to Food Campaign- statement on urgent Steps for Mitigation of Impact of Covid-19 on the Poor and Vulnerable during the lock down and coronavirus pandemic (http://phmindia.org/2020/03/20/letter-to-the-pm-demanding-for-urgent-steps-for-mitigation-of-impact-of-covid-19-on-the-poor-and-vulnerable/  ) ). Another important component was the way the lock-down hurt access to essential healthcare services. Partly this was due to lack of transport, but in part because essential health services were shut down or diverted to make way for services to address the epidemic.

The JSA has documented the crisis in access to essential health services due to the lockdown and written to the government demanding that such services must be continued through this period, with special arrangements made for the sick to access services during this period (See JSA-AIPSN statement on lockdown and suspension of essential healthcare services (http://phmindia.org/2020/03/27/statement-against-closing-essential-health-services-during-lockdown/) ).

We also note that among working people themselves and in civil society there are also outstanding individuals and organizations who have come out, sometimes at great risk to themselves to help those in such great distress. These have to be built on- but cannot substitute for the obligations of the government under a lock-down. Individuals have obligations which most follow to the extent it is feasible for them- but the big question we ask is whether the government is able to fulfill its obligations. The JSA and AIPSN have released a number of statements that highlight the consequences of the lock-down and immediate action that government must take to ameliorate this crisis.

Part 3. Do lock-downs work?

One of the big questions that have arisen is whether lock-downs work. Firstly it must be noted that much of the scientific justification for lock-downs lies in a combination of mathematical modeling and the assumptions it makes as well as expert opinion. There is very little hard evidence. The problems with the models are many.

Most models never factored in the social costs and collateral economic damage and reduced access to health care. None of the models even attempted to model for equity and the differential impact that a lock-down would have on different sections of society in different nations. The working people in a nation where most of the workforce is in the organized sector, where universal healthcare is a reality and where social security covers all sections like the North European and Scandinavian nations, is clearly less likely to suffer such damage as compared to a nation like India, where most of the workforce is in the unorganized sector progress towards universal health care is minimal and where for the vast majority there is no social security. It is not only economic outcomes one is worried about- it is also health outcomes. Of course most of the increased mortality that would result from the lock-down will be on the poor, whereas at this stage of the epidemic, arising as it is from international travel and their contacts a major part of the morbidity would be on the more affluent. Had all of this been factored in, the least the experts could have done, was to give a week time for people to get home and better arrangements to be made. The logic of announcement of demonetization or an enemy strike is one thing, but the logic of shutting down all of people’s social and economic life is quite another.

Models also never factored in how the epidemic plays out in different context of immunity, vulnerability and virulence. They also did not factor in what would have happened in scenarios where the lock-down was more focused on hotspots and vulnerable sub-sections like age, and the identification of these hotspots guided by testing. Finally, the reasoning for the lock-downs has not quite figured out what happens after a lock down is lifted, the number of days the infection will take to reach back to the same level of spread as now.

On the other hand there is clearly one major benefit of the lock-down that there is a consensus on- that it flattens the curve- i.e. delays the peak of the epidemic and prevents a huge surge of cases giving time for health systems to prepare themselves. Even on this, we need to keep an open mind- since in practice the level of physical distancing achieved may be negligible because of the problems of implementation and because preparation in such short times is really not feasible. If South Korea and Japan and Germany have done better, these were precisely the three nations who had the technological capacity to scale up testing based on indigenous capacity plus also had the highest bed to population ratios and ICU bed to population ratios even within the developed world.

The best time to have started preparation was actually at least 15 years back- but failing that, the next best time would be now.

Given these very many uncertainties about the benefits of a lock-down and the very certain ill-effects the least we can do is to measure its effectiveness and in a gradual and phased manner, starting now, lift the lock-down and make arrangements so that it is not needed again after 14th April.

Part 4. Health system preparedness:

Irrespective of its narrative on stage of the disease or the effectiveness, health system preparedness to meet this pandemic is essential.

We note that there are several major very welcome developments in this area- and we list these below:

1. The finance minister announced a fund of Rs 15,000 crore to strengthen the health systems to meet this challenge. This was much needed. Such an amount should anyways have been part of the annual budget, in fulfillment of the government’s own policy commitments to the health sector. But given the fact, that this is coming after years of under-financing, it would be inadequate to close the gaps. Further, much of the strengthening of health services- whether it is by hiring more human resources or by increasing ICU beds and ventilators cannot and should not be seen as a transient measure. What would have helped and could still help the state governments in utilizing this amount effectively, is a clear commitment by MOHFW to retain this amount in future budgets as well.
2. The government has sanctioned three companies last week for production of test kits for COVID2. These three promise to reach a capacity of about 30,000 kits per day. Another 11 companies were in the queue for approval, and by now are probably approved. But some of these are importers and importing now may be impossible. The government aim is to reach a testing capacity of 60,000 per week, which may seem a big target now, but in practice is still too low. The way forward would be for the government to support private companies with both financial resources and imported technical support (perhaps from the South Koreans) to accelerate indigenous production to close to 1 lakh per day, and bring the costs down to Rs 300 per kit or less. With the availability of kits, hopefully the protocols for testing would be changed. However by the time of the lockdown we may reach only about 30,000 kits per day. As we go to release this we have disturbing news of a crisis in the availability of reagents. Though the government action on this has been very delayed, it is welcome, There are many concerns regarding the impending severe shortage of APIs for essential drugs, issues of Intellectual Property Rights related to new drugs , medical kits and vaccines and on the government’s approach that the JSA, AIPSN and AIDAN have written to the government about (See JSA-AIDAN_AIPSN letter to prime minister on scaling up access to free testing and treatment for COVID 19 (http://phmindia.org/2020/03/25/letter-to-the-pm-addressing-issues-of-scaling-up-access-to-free-testing-and-treatment-for-covid19/ ))
3. The government has passed an order stopping the export of ventilators in the second week of March. Further it has placed an order for 10,000 ventilators to become available before mid-April and another 30,000 to become available in one more month. The government has taken note of some private hospitals to buy and hoard ventilators and of private companies to sell at higher prices to them. Ventilators must be now declared an essential commodity, and government should ensure proper allocation and deployment of these as and when they become ready. We note that 40,000 ventilators in a month is optimistic, especially when the orders are yet to be finalized, but here the government is on right track.
4. The government has identified a number of sites in larger cities; largely student hostels, guest houses, and sports facilities, which it can use for quarantine and potentially for isolation of COVID 19 patients who do not need hospitalization. We have no clear information about how many such student hostels and sports facilities have been so requisitioned.
5. The government has also identified one or two hospitals for each cluster of districts that can be brought under a public authority for exclusive use in management of COVID 19 severe cases and critical care. In some large hospitals it has identified wards and/or sections of the hospital for such use.

6. The government passed an order stopping export of personal protective equipment (PPE) in early February. Since then it has placed an order, including emergency imports for PPE through the government owned company HLL Lifecare limited. It is also in the process of giving sanction to Indian manufacturers of the same. Though these are steps in the right direction, we have concerns about the adequacy of these arrangements, on which we have written to the government. This could be another major bottle-neck. This could also be contributing to the pressures to identify less number of cases. The JSA-AIPSN will be writing to the government in this regard.
7. There are many areas where many states are not making enough efforts. Only one or two states have made moves to address the gaps in ambulances and patient transport systems that would be needed. Many states have large gaps in human resources and in supply chain management systems that they are not addressing. Training is also behind schedule in most states. Most states have also not begun efforts to prevent hospital acquired COVID19 infections. The JSA-AIPSN has written to the government on many of these gaps in health system strengthening and what corrective actions that states must undertake as a priority (See JSA-AIPSN letter to government on health system preparedness (http://phmindia.org/2020/04/03/letter-to-secretary-health-which-encloses-our-statement-on-health-systems-preparedness/ )). We are also monitoring the efforts to rapidly build up health systems and collecting more details on ongoing health system preparedness as happening in the states.
8. In conclusion, though in denial of the extent of spread and very delayed and inadequate in scale in preparedness, this last week has seen a series of policy initiatives that address most requirements for health systems preparedness, backed by the funds needed to achieve this. There is also rise in seriousness across states though some states are still slow to begin, or focused on only one or two dimensions of preparedness. An useful collation of orders by state governments (including state Health Departments) is being updated and made available here covid-india.in
9. One priority area where the plans of the government are not clear or consistent is the strategy for mild and moderate case who could be as much as 20 to 30% of the entire population. Even if we assume that these patients are in homes due to the lock-down, as soon as lock-down lifts, those they have infected would be moving freely in the population- and their family members and primary healthcare givers would be unaware and unprotected. This would be a major source for spread of the infection. Our suggestion is that there must be an intensive effort, with help of community and voluntary team to identify all those with mild and moderate symptoms, test them for the disease, and if positive offer institutional isolation to them. Only if they are in a position to practice home isolation effectively or if in that district it is not possible to arrange institutional isolation should home isolation be preferred. For such a strategy there is are two requirements- (a) expand access to testing, and where possible try to organize sample collection from home in response to a call to a help-line call (with all necessary safety precautions) or for patient transport to designated sample collection centre. And (b) identify a large number of spaces that could be considered for institutional isolation and plan the systems required to set these up and manage them when the need arises. If the government is not ready to undertake this, we must understand that the government is opting for a strategy where the majority get infected and recover, giving rise to herd immunity, while government only takes care of the very sick. But if that is the plan then such a huge all out lock-down should not be resorted to.
10. We are also concerned about some recent reports of strategies of containment that have no basis in evidence or the science of public health. One such innovation is to define a 5 km radius around a COVID-19 hotspot as a danger zone and a further 3 km as buffer zone and lock down everyone within these zones as well as universal masks etc. This appears like another whacko modeling effort gone wrong, where physical distance is being interpreted literally and not along the lines of a social distance defined by the economic activity and production and social relationships in that area. When efforts are made at modeling, there is an urgent need to see that there are social scientists and public health expertise as part of the team.
11. One area where innovation would help is point of care diagnostics to identify those who are immune to the disease and no longer infective- for these would make much more effective volunteers, requiring less protection and be able to serve in the different frontlines. If the epidemic plays out as per current projections the government is going to require a large number of volunteers.

Part 5. The Response from Peoples Movements and Communities:

1. This week has also seen the build-up on a major response across people’s health movements, people’s science movements, women’s organizations, trade unions and associations of working people, civil society organizations and community based organizations. These organizations have also sought and got support from a number of progressive intellectuals and scientists and public health experts.
2. The JSA and the AIPSN have been holding consultation on Skype and have tried to understand the developments, critically review and in consultation with domain experts brought out a number of papers and statements that can inform their own membership and the general public. They have also articulated demands for better COVID 19 control and for better mitigation of the social and economic costs of the lock down through a charter of demands and a number of press releases and petitions to the government.
3. In addition to these statement, the JSA and AIPSN have launched campaigns to inform its own members and the general public of the dangers from this epidemic, how to keep the community, themselves and the public safe and to counter fake news, stigmatization and victim blaming messages that emanate both from sections of the government and communities. (See PHM Advisory for Families and Communities, and PHM FAQs on the COVID 19 pandemic (http://phmindia.org/2020/03/28/advisory-for-workers-cleaning-hands-in-low-resource-settings-and-protection-in-crowded-places/ ). There are also short videos and WhatsApp posters that are available.)
4. Because of the lock down, extensive field level mobilization and community support action has not been possible, though in many states, organization who are part of this network are engaged in organizing community kitchens. Once the lockdown lifts, a major effort at social bonding and mobilization to counter hate campaigns, and provide support to affected families and communities, is being planned.
5. We would be sending this weekly update along with a special press release that would  a) demand a review of the lockdown and an phased withdrawal of the same; b) an acceleration of work in preparing the health systems for the epidemic through a more comprehensive approach and c) a call for much more participatory and less authoritarian approach to controlling and mitigating this pandemic.

For further information, please contact:

T.Sundararaman – 9987438253

D.Raghunandan – 9810098621

Sarojini N. – 9818664634

Sulakshana Nandi – 9406090595

Follow for regular updates:

Website www.phmindia.org  www.aipsn.net

Twitter @jsa_india

Facebook @janswasthyaabhiyan

11-JSA-AIPSN statement on PPE_v1

On the Personal Protection Equipment (PPEs) for Healthcare Workers in the Light of Increasing Numbers of COVID-19 Patients

Joint Statement by Jan Swasthya Abhiyan and All India Peoples Science Network

The JSA and AIPSN draw the attention of the public and the media to the major crisis that has developed in health worker safety due to the lack of PPEs. Not only will the healthcare staff be at higher risk of getting the infection, widespread infection in healthstaff would sharply decrease the capacity of the country to delivery health care services in both the public and private sector. 

The greatly increased need for PPE: 

 COVID-19 cases are growing in India with every passing day. It falls on the frontline healthcare workers to treat and care for them. However, the lack of proper protection in the form of Personal Protective Equipment (PPE) is preventing health workers to make effective interventions in the containment of COVID-19. It is putting lakhs of health workers including sanitation and other frontline personnel tasked to treat patients and clean premises of health facilities and other public spaces at the risk of contracting the virus.  

Healthcare workers across the spectrum have been hit by the lack of masks, gloves and gowns. Four thousand Community Health Volunteers (CHVs) in Mumbai have been directed to search for suspected COVID-19 affected patients without being given enough protective gear and sanitisers. We have learnt about instances in private hospitals where the nurses are working in Intensive Care Units (ICUs) without masks and where the private hospital is treating Severe Acute Respiratory Illness Patients who have not been tested for COVID-19.  

We are also privy to many reports that any doctor or nurse managing any general out-patient  unit anywhere in the nation is now at increased risk of getting exposed to COVID 19 patients and developing the disease- since mild and moderate cases are not identified and isolated in India’s approach to managing the epidemic. Indeed the past week has seen an alarming increase in healthcare providers who are so effected

 The doctors across India have been demanding PPE to go ahead with their work uninterrupted. The fact of their higher risk for infection, instead of bringing support has often exposed them to violence and hostility as sources of infection into the community. On 21st March, Doctors Association Kashmir sent a letter to the advisor to lieutenant governor of the UT of Jammu and Kashmir citing acute shortages of personnel protection gear especially N95 Masks, PVC coated gowns and goggles. There are similar reports from all states. 

As the spread of COVID-19 increases, providing PPE at all levels of care – community as well as hospitals , to those seeing COVID patients and those managing general patients– is of paramount importance.   And to rationalize the use, those at higher risk like those collecting samples or those in the frontline of care provision have far more extensive and stringent requirements of PPE as compared to others. 

Unpreparedness of Indian Hospitals for Infection Control: 

The Indian healthcare system has long neglected infection control in its health facilities. Studies show that not more than 20-30% of hospitals have Infection Control and Prevention (IPC) guidelines in place. Fewer follow them diligently. After SARS epidemic and then due to the increased focus on antibiotic resistance and drug-resistant tuberculosis, IPC started to gain currency in policymaking circles with ICMR and NCDC revising their guidelines for hospital acquired infections. 

Despite the guidelines, hospitals have never invested in procuring PPE for their staff, letting them suffer on the way. COVID-19 has brought this historical neglect to the fore. Had the Indian health system been investing in protective gear for its staff from before, we would not be facing the crisis to the extent that we do today. 

Delays, and inadequacy of government efforts on  procure PPE : 

The role of the government over the past two months is also baffling.. The first case of COVOD-19 was registered on 30th January in India. Taking cognisance of the seriousness of the issue, the government issued an order prohibiting export of all PPE. But it was amended on 8th February allowing export of surgical masks and all gloves except NBR gloves. The restrictions were further relaxed to include more items on 25th February. 

TheWHO issued an interim guidance regarding PPE on 27th February noting that there is going to be a global shortage of PPE and hence came up with a document on its rational use. Taking cue from this, the government should have moved fast to prohibit export of domestically produced PPE and raw material so as to ensure its availability in the country. But that order came only on 19th March. 

Current government efforts at procurement are far too little, and very late, making it unlikely that we would have adequate PPE anytime soon. The government has placed the order of 7.5 lakhs body overalls to be supplied by May. However, the need could be upto 5 lakhs of body overalls a day. Similarly the order of 60 lakh N95 masks and one crore three ply masks will be grossly inadequate in the current scenario. 

Barriers to scaling up production: 

We also understand that there are many constraints to scaling up of production  to desired levels. A few of the PPE components are not manufactured in India and there is an import dependency. Also, there is shortage of the required raw material in the country making increased manufacturing a problem. Further there is is disruption of supply chains, making  the availability of these equipment from import markets difficult. Now when the orders are placed, many manufacturers find that due to the lock down immediate procurement of raw material or hiring and deployment of labour are both very difficult. 

Part of the barriers are in the past and relate to our economic liberalisation program, which  has eroded the manufacturing base of even low technology content products and created import dependency. Though our potential capacity in required technology, in our hour of need, we find that our past policies have compromised our self reliance in this secor, and therefore oour health security. Considering the huge demand from many countries for PPE India cannot depend on the import to meet its demands. Therefore the government has to scale up the production and maintain this in the future also

Recent Welcome Moves to address the crisis: 

We welcome the letter of NPPA to all states to find out the inventories and available production capacity. During the initial days there was no mechanism to find out the inventory and manufacturing capacities existing in the country. 

We also appreciate the government’s effort to place PPE components like mask and hygiene product like hand sanitisers and the raw materials for their production as essential commodity and imposing price control over them. However, it  is important to ensure uninterrupted supply. While the export restrictions are an important step to ensure the domestic supply, it is also important to enhance the production capacity to also supply to many countries who are in need of these products. However, such export should be at the government-to-government level to avoid profiteering at the cost of public health and also to ensure domestic supply.  

To fulfil its needs the government has placed a number of orders and is is now supervising the manufactures, 

More steps  required to achieve required production capacity. 

However the number and output would be very low compared to the demand.. To close this gap, government should instruct select large scale manufacturing companies to start production of the important elements of PPEs. Further, though specificiations are provided, government would also need to transfer designs and other blue prints to new actors to initiate manufacturing. Further, government should directly procure these specified raw materials and supply to the end-product manufactures who are supplying the government. These steps  would be urgently required to enhance the efficiency in the supply and production of PPE. 

Re-examine specifications:

Another important issue we noticed is that the Indian PPE requirement specifications as well as guidelines for use are higher than the WHO prescribed standards. We are afraid that such higher standards would create scarcity of prescribed PPE and result in the failure of the real purpose. Another important issue is the guidelines to be framed for the reuse of Hazmat Suits after autoclaving. At the moment the supply is limited to disposable PPE kits which are in limited supply. The government should set up an expert committee to arrive at these specifications and guidelines which are more conducive to the Indian context and to meet our immediate needs. The expert committee should be tasked with constantly revising the decisions as new and better data arrive. We have done some preliminary exercise in this regard that we can share on request. 

To increase production of PPE and ensure safety of healthcare workers, we make the following demands from the government: 

1. Urgently ensure availability and free supply of PPE to all health workers. directly or indirectly providing care for COVID 19 patients at per their level of risk.  Towards this end government should revisit its specification and guidelines for use. 
2. Private hospitals should be directed to follow the guidelines and not put their staff at risk.
3. Include all health workers seeing general outpatients as also at higher risk due to unidentified mild and moderate and even asymptomatic cases in circulation and develop recommendations on PPE for them.
4. Scale-up the production of PPEs within the country. Government should identify the products that are not currently manufactured in India and within a short deadline seek proposals and technically and financially support the manufacturing of those components in a decentralised manner so all states have at least one manufacturing unit. 
5. In order to enhance the number of manufactures, government should publish the designs and blue prints along with the specifications and  convert largescale apparel production firms to start the immediate production of PPE components. 
6. In order to expedite the procurement and supply of PPE equipment, government should involve more public sector establishments.  Currently, the government has given HLL Lifecare Limited, a government-owned company, rights for procurement of PPE. Approval for more public sector institutions in the procurement would speed up the procurement and supply. 
7. Issue guideline for the appropriate disposal of PPEs used by health workers as well as face masks that public use 
8. Ensure transparency with regard to the procurement prices and suppliers and the number of procurement.  
9. Set up an Expert Committee to establish PPE requirement specifications as well as guideline for use in the Indian context. Its role should include constant revision in light of new and emerging data.

08 JSA advisory on health systems preparedness Apr 2 v1

From Jan Swasthya Abhiyan (JSA)                                                                 April 2, 2020

&

All India Peoples Science Network(AIPSN):

To

Secretary,

Department of Health & Family Welfare,

Govt of India, Nirman Bhavan,

Dear Sir/Madam:

Subject: Advisory to State and Central Governments

On strengthening health systems to manage the COVID 19 pandemic

Please find enclosed a detailed note prepared in a participatory and consultative manner by a number of organizations and concerned citizens who are part of our network of civil society organizations and peoples movements

We note that the country is going through a lock-down which has brought immense hardships to the majority of the people. The only justification for such suffering is to give time to the health systems to prepare for the oncoming epidemic.  We have noted the significant number of measures that government has announced to step up the supply of testing kits, and PPE and ventilators, but we are worried that it would be little and late.

From our interaction at state level, we are deeply concerned that the preparations are patchy, slow, and selective. In our enclosed advisory, we have put together the very many aspects on which all state governments and the state governments needs to take immediate action. We demand that urgent action be taken on each and every one of these suggestions. We also call on you to include representatives of our organizations in monitoring the pace and comprehensiveness and quality of preparation.

We are also releasing this statement to the media so that they can also be informed on what, in our view, requires to be done. This would promote early identification of gaps and this would strengthen the effort at preparation.

We are also issuing an advisory to people and communities on what they require to do to protect themselves and to be of assistance to frontline staff of the department and all others who are working in partnership to help combat this epidemic. We would also be working to ensure social solidarity in this time of crisis.

T.Sundararaman

Sulakshana Nandi

N. Sarojini

D. Raghunandan

On behalf of  JSA and AIPSN

Advisory to State and Central Governments

On strengthening health systems to manage the COVID 19 pandemic

INTRODUCTION:

The lockdown implemented across the country only buys the government time to prepare the health systems for the coming epidemic.  As, informal workers and poor people are paying an immense price in terms of suffering and even deaths; the urgency and moral obligation to prepare each state’s health system is even more.

We in people’s health movements, people’s science movements and in all movements of working people are seriously concerned by the lack of clarity on what is required in terms of preparation. Different state governments are prioritizing one or another aspects, failing to address the rest. We therefore call on governments to take immediate note of all the elements of preparing health systems that we list below:

These are based on the March 25th, 2020, briefing of the Director General of World Health Organization:

“ We call on all countries who have introduced so-called “lockdown” measures to use this time to attack the virus. You have created a second window of opportunity. The question is, how will you use it?»

The six key actions that we recommend are:

1. First, expand, train and deploy health care and public health workforce;
2. Second, implement a system to find every suspected case at community level
3. Third, ramp up the production, capacity and availability of testing;
4. Fourth, identify, adapt and equip facilities to manage risk, treat and isolate patients;
5. Fifth, develop a clear plan and process to quarantine contacts;
6. And sixth, refocus the whole of government on suppressing and controlling COVID-19.

These measures are the best way to suppress and stop transmission, so that when restrictions are lifted, the virus doesn’t resurge. The last thing any country needs is to open schools and businesses, only to be forced to close them again because of a resurgence. Aggressive measures to find, isolate, test, treat and trace are not only the best and fastest way out of extreme social and economic restrictions – they’re also the best way to prevent them

The eight measures we set out before are what state governments must do in the immediate to achieve the above objectives:

• Arrangements for Testing
• Arrangements for Isolation and Treatment of Mild and Moderate cases
• Arrangements for Treatment of Severe Patients and for Critical Care
• Addressing Human Resource Requirements
• Addressing Human Resource Rights and Safety
• Ensuring Supply Chain Management
• Ensuring Ambulance and Patient Transport
• Engaging community Volunteers

• Arrangements for Testing:

1. Expand testing protocols to include all patients where the health care provider thinks it to be a clinically suspect case of Covid-19, based on clear, scientific standard protocols. This is required for both public health planning and because everyone who tests positive must be isolated. This is central to control of the epidemic – now and in the future. Denying testing to those with mild symptoms is a failure to isolate the main sources of infection and any amount of physical distancing will not make up for this. We note that he rate of testing in India is very low at around 20 tests per million compared to about 7000 tests per million in South Korea[1]. Though India has much less resources, there is clear need for very rapid increase in the number of tests being done.  The main reason for this is restricting testing to contacts, foreign travel, which means that by protocol we are excluding the majority of COVID-19 patients who are mild and asymptomatic. This is leading to a false complacency as well as many clusters of infection growing unnoticed. It is also leading to all healthcare providers, even those not addressing COVID19 specifically getting infected. It is also required to guide areas where case searches and preventive measures have to be intensified.
2. To achieve the above, hospitals need to ensure designated collection centres of samples in every district or preferably in every block. Immediately identify and train the concerned personnel in using PPE and collecting samples properly.
3. Consider small mobile teams with adequate training and appropriate PPE collecting test samples from home in symptomatic patients in response to a phone call to a designated number. This will reduce infection when they come by public transport to the facility, and reduce infection at the facility when they wait to be tested. One possibility that the government can explore with due precautions is to use a number of volunteers who have recovered from the disease and therefore immune. To be safe they should have been tested to ensure that they are positive for antibodies and negative for the virus. Where distances are very big, and public transport very crowded this may be the only option.
4. All testing must be free. All test results should be uploaded to an open repository with due care taken for privacy considerations. This will ensure that the test results can be checked publicly. A number that is linked to them could identify patients. So repeat testing can be followed up. Charges are to be considered only if the patient has come out of own accord with a doctor’s prescription for the test. Even that can be allowed only when the availability of test kits becomes much better than it is now.
5. The testing protocol should ensure that all suspect mild moderate and severe cases are tested, and the necessary testing kits, equipment and reagents for this should be available. Asymptomatic contacts of COVID19 patients should also be tested on the 5^th and the 14^th day of the contact- but this could be included only when necessary test kits to test the symptomatic patients are in place..
6. For the purposes of surveillance all these testing results should be anonymized, aggregated and reported to a central and state authority. In addition carefully selected surveillance sites should test a well drawn sample of the entire population to monitor true infection and case fatality rates, as well as the development of immunity. Antibody tests which are available would also be essential to test for asymptomatic infection and herd immunity.

2) Preparing for the Management of Mild and Moderate Cases

1. In many nations there is an effort to hospitalize all mild and moderate cases so as to ensure good quality of isolation. Considering the large numbers that will be involved, private nursing homes, hostels and hotels will require to the requisitioned to serve as isolation hospitals. These are «hospitals» from the perspective that their occupants are sick persons, requiring a basic level of care that nurses and paramedics could provide. However some supervision by medical staff is required to identify those turning severe and referring them early.
2. District administration should therefore earmark and prioritize the order in which beds would be requisitioned and deployed – for the first 100 patients, and then in further increments of 100. We note that there are plans to convert railway passenger trains into isolation center. Though as a desperate measure this may be a good idea, the average period of isolation would be anywhere from 10 to 14 days- and a railway compartment would be very restrictive. The recruitment of sports facilities and hostels and guest homes and hotels would be preferable.
3. In districts where the public and private sector capacity to do this is weak, some of these centers could be managed by civil society organizations or local community based organizations or local self-government institutions- like municipalities and panchayat. These are then community managed institutional isolation sites with largely supportive care- food, water, symptomatic medicines, being organized and isolation being enforced.
4. In all the above situations the working staff, should have adequate PPE.
5. In many nations in the world even this has not been possible and home isolation has been resorted to. This is easier in middle class and privileged populations where housing has the necessary space. But in all circumstances it would require to be backed by good outreach services and monitoring.
6. There should be a helpline in every state where people with symptoms can approach and be guided for whether to test, where to test, and transport for testing and/or isolation.
7. The current approach of de facto denying the very existence of mild and moderate cases through a calculated strategy of non-testing and inaction will drive the epidemic forward.

3)            Management of Severe Cases and those requiring Critical care and ventilatory assistance:

1. For severe cases with signs of pneumonia confirmed by X-rays, hospitalisation should be ensured. Dedicated wards in existing health facilities should be utilised for this. In all such wards oxygen should be available, isolation should be possible and working staff should have PPE. Oxygen concentrators and pulse oximeters and consumables as required for acute respiratory illness with respiratory distress would also be needed in adequate numbers. Managing oxygen supplies is often a critical bottle-neck and this must be attended to.
2. For critical cases, given the high requirement in skills, equipment, PPE and isolation it would be preferable to centralize management of severe and critical care patients in a dedicated COVID-19 hospital. Either requisitioning or recruiting a private sector hospital, or using a public hospital should achieve this. The existing caseload in that hospital should not be left without alternative. This is a reason why, in many states, a large under-utilized private hospital would be best commandeered. In many nations, entire hospitals have been built at short notice. This is may be required in some of the northern states where both public and private infrastructure is most inadequate.
3. When planning for critical care and ventilators, we suggest a norm of one such bed and ventilator for about 30,000 population. However the requirement may increase if there is a surge (the curve did not get flattened) or where a big cluster of cases got established. It would decrease if there is higher mortality rate (about 90% of those on ventilators dying within two or three days) and increase if survival is better (patients may need 10 to 20 days of ventilator support). Sharing of such ventilators is possible to a limited extent. Efforts should be made to prevent the spreading out of ventilators across multiple hospitals. Ventilation in this disease requires a much more sophisticated equipment and a higher level of training. Ventilators should be pooled in one or two hospitals identified as nodal hospitals to treat COVID 19 patients. In cases where ventilation is required, we caution that any ventilator will not do.

1. For the overall management of all COVID 19 patients in a district or a cluster of small districts, there should be one medical command centre for ensuring the preparation and allocation of resources, creating the necessary beds at different levels of care and allocation of patients accordingly. Proper guidelines should be set in place to prevent nosocomial or hospital-acquired infections. Care should be taken to ensure the separation of COVID-19 cases from routine patients in all health facilities.
2. The orders required for requisition of private hospitals and nursing homes for isolation and treatment when the need arises should be issued now. Clear guidelines on costing, administration and treatment protocols should be laid out and finalized as soon as possible and before a crisis situation emerges.
3. All treatment should be free. A few private hospitals that are undertaking COVID-19 care on their own, can be permitted to do so but treatment fees should be capped.

4) Human Resources for Combatting the Epidemic:

1. To close the gap in human resources – the first and most immediate measure is to immediately fill existing vacancies by employing those who have applied for employment and are waiting at different stages of recruitment. Online interviews and video conferencing, as done in Kerala, is a feasible option. Those employed on short-term contracts and contracted through third party agencies are at risk of discrimination with regard to access to personal protective equipment, leave and other safeguards. Additional care has to be taken to ensure that they are involved and/or covered by all the necessary procedures.
2. Put in place on-line training programs on COVID 19 for the entire medical workforce in the country, facility based training for the entire workforce in the each facility, including ASHA and community-based health workers attached to different health posts.
3. The medical professional at the nodal hospitals should be given training to manage ventilators in case of Acute Respiratory Distress Syndrome (ARDS) arising out of COVID 19 infection. Web-based training is a start- but on the job mentoring by experienced domain expertise would be required.
4. The entire staff in all COVID-19 earmarked hospitals, ICU units and isolation centers should have proper training and this should include both guidelines and protocols for COVID-19 care, as all as personal safety, infection risk management and the use of personal protective equipment. The government should provide guidelines for these procedures to be followed in private facilities.
5. For work such as contact tracing, outreach support to those in home quarantine or isolation, develop a policy of health care auxiliary workers- not only ASHAs, but also including volunteers.
6. States should ensure that the logistics to supply equipment and material for hospitals and health centres is not hampered due to the lockdown.

5) Ensure health workers rights and safety

1. The rights of all health workers should be protected. Wages should be provided as per existing government norms, and extra hours remunerated as per the law. Considering that health workforce in private facilities will also be involved in responding to the epidemic, and facing higher risks that what health workers face in their usual settings, state governments should ensure compliance with the Supreme Court Recommendation related to wages in private healthcare facilities In many situations a special risk allowance could be considered. Special paid leave in case of Covid-19 related sickness and quarantine should be provided, including to workers on short-term contracts and employed through a third party.
2. Health workers undergo considerable stress during this period. Therefore counseling and mental health support should be made available. Breaks and time-off should be maintained, as healthcare workers’ burnout aids spread of virus. Health workers displaying Covid-19 like symptoms should not be asked to continue attending to work. Health workers’ right to opt out of work when they are not provided with a safe working environment and adequate protective equipment should be respected. Health workers working in high risk areas, such as isolation wards, have to be provided the option of adequate hostel accommodation so that they can avoid going home where there are old relatives or young children whose health they are concerned about.
3. For health worker safety adequate availability and training to use the necessary Personal Protective Equipment (PPE) is essential. These guidelines should be clearly displayed and followed. Those who refuse to work because of violation of these guidelines should not be penalized. These guidelines should apply and their implementation monitored in private health facilities too A monitoring system should be put in place so that health workers can raise concerns about violation of guidelines and action taken accordingly by the relevant government.
4. Maintenance of and adequate supply chain for PPEs and safety equipment for health workers is one of the key challenges before governments and they should be held accountable for this. Government of India should examine the feasibility of its rigid criteria for PPEs and adopt the more practical, yet adequate, WHO guidance on the same. The inability to follow unnecessarily
   demanding guidelines should not become an excuse to avoid strict implementation of the WHO guidance (see PHM Advisory in this regard).
5. Training should be given on infection risk management and on how to use PPEs. All health workers should be provided with communication materials on the use of PPEs. Guidelines should clearly mention as to who are at what level of risk and the adequate PPE requirement for different workers. The government should engage with trade unions of health workers to ensure that the guidelines effectively reach = all concerned health workers. Facility management should facilitate an active role of health workers’ representatives in determining safety measures and safeguards of their health.
6. Free access to health care for health workers dealing with the Covid-19 outbreak, even in events that do not lead to hospitalization, has to be ensured for all health workers, including those working in facilities under the central and state government, but also municipal and local bodies, in the private sector, and health workers with informal employment conditions.

6) Supply Chain Management:

• The pandemic management is going to require a very high degree of efficiency and time-lines and quality controls to ensure that the necessary testing kits, medicines, and PPE are available where they are needed, when they are needed, and in adequate quantity and quality.
• States like Tamil Nadu, Rajasthan and Kerala have already robust systems in place for doing this, but even they would find it difficult. States, which have not established such systems, must immediately put together a state level authority, which can manage this using the guidelines from the exemplar states. In consultation with center, where the funds are from the center, procurement procedures must be simplified to meet the situation.
• Given that manufacturing capacity is the key bottleneck, both states and center should set up task forces which will look at the choice between manufacturing within the state and/or purchasing from outside, make forecasts of the requirement, identify and address potential barriers and then place orders well ahead of the peak of the epidemic. The center has to ensure that patent and trade barriers do not come in the way.
• Ambulances and Patient Transport:
  1. There would be the need to designate some ambulances with advanced life support for shifting patients in need of ventilation and many other patient transport vehicles for shifting patients suspected of COVID 19 for testing, or of confirmed cases for hospitalization, isolation etc.

1. The number of ALS ambulances and patient transport vehicles required would vary with the surge and clustering of cases. Norms can be developed. In states where the number of public ambulances under the 108 and related services is well below requirements, order for more ambulances should be placed NOW.
2. Mechanisms for sterilization of the ambulances, training and low risk PPE for drivers and training with high risk PPE for accompanying emergency technicians, should also be put in place.

8)            Community Volunteers and Community Participation.

1. Ensuring community participation is essential. We will need volunteers to do surveillance and tracing. These volunteers can be enrolled from within the community or through community based organizations.
2. People who are discharged after COVID-19 treatment can be a useful resource and they should be encouraged to volunteer. They will be able to help in home isolation and their experience of encountering the disease will help in changing the perspective around it. They would also help in tasks like institutional isolation, home and institutional quarantine, contact tracing. Some of them, especially if from within the health workforce could be useful for testing.
3. The availability of antibody testing for past infection and immune status is expected to become available. Given the way we have managed mild and moderate cases, this “individuals who have recovered from infection” may be useful asset as community volunteers.
4. Community Organizations would need to be deployed widely for many tasks including relief and welfare measures to reach most the vulnerable sections, management of home and institutional quarantine, monitoring of human rights issues, campaigns against stigmatization of the disease and public education, as required.

In conclusion:

The State and district level units of peoples health movements and peoples science movements and of a wide variety of civil society organizations and trade unions and workers associations stand ready to help the government and communities in combatting this pandemic and the humanitarian crisis that both the pandemic and measures to contain it have led to. The government must make use of this resource.

[1]
                        ^[1] https://www.icmr.nic.in/