Almost five months after the Covid-19 pandemic began, Maharashtra has recorded over 3 lakh cases, of them over a lakh are active infections. As focus of cases shifts from Mumbai to Mumbai Metropolitan Region and Pune, Health Secretary Dr Pradeep Vyas says the state has become wiser and is better equipped to control fatality. Excerpts from an interview with The Indian Express.
Maharashtra continues to have the maximum number of cases in India. Although it does not have the largest population, it continues to drive the country’s curve. Why is that?
We need not be concerned by rise in positive cases. If cases are detected in time, fatality can be as low as 1-2 per cent. To pick people early, we need to test more and that’s why we have high numbers. Maharashtra is testing 13,848 people per million population, Uttar Pradesh is only testing 7,113 per million, Bihar is testing 3,423 per million. These states have less cases because they are testing less. There were no cases in Telangana, Tamil Nadu and Andhra Pradesh at the beginning. It was pointed out that they were not testing enough. Now you see that case growth is at the rate of 5-7 per cent in Telangana and Andhra Pradesh is high. Tamil Nadu did a lot of testing in the beginning, and now the state has the second highest cases in the country.
But Maharashtra’s death rate is also second highest after Gujarat.
We have followed a transparent policy, in case of any death, if at the time of death the Covid status of the concerned patient was positive, then the death has been declared as Covid death, irrespective of underlying cause. Do not look at absolute numbers. The fatality rate must be ascertained once the pandemic is over, to make comparisons. Once the pandemic is over, we will find that death rate across all states is uniform. Yes, there were problems when we were overwhelmed with a sudden deluge. March and April were a bad period for us, June onwards we improved. Now we are wiser, we know how to prevent deaths. We also have to look at virulence. Then virus from US and Europe had a different virulence, Gujarat and some pockets of Maharashtra had virus with severe virulence. That is also why deaths in these two states were high in the initial phase.
Maharashtra announced a lockdown overnight, not giving a chance to migrant labourers to return home. In Mumbai, they were contained in a high population density for a month before they could return home in congested trains, trucks, buses. Do you think the implementation could have been handled better?
This infection has a positive point and a negative point. There is no vector involved, like a mosquito in malaria or dengue. It transmits from person to person, and the simplest method to control the virus is to stop movement of people to stop the virus from jumping from person to person. The negative point is that it is highly infectious. A lockdown for a 14-day period could have cut the viral chain. How we could have implemented the lockdown is debatable. We had to take care of the economy, essential needs. When it should have been done, I do not want to get into a debate. In cities where a lockdown was implemented strictly, we could contain the virus, in cities where it could not be controlled due to various factors the virus grew. Lockdown also bought us time. When our first case came on March 9, we had only two isolation hospitals. We had less than 2,000 PPEs, we had some overalls from HIV programme and some N-95 masks under TB programme. There was an acute shortage of these items. There were hardly any suppliers of PPE. Lockdown gave us a window to arrange for logistics, scale up bed capacity. This far outweighs any ill effects that it may have caused, like keeping people within Mumbai.
The World Health Organisation notified the first Covid-19 case on December 31, 2019. So we did have two months in hand to prepare before the first case.
To prepare we need some knowledge. WHO declared it a pandemic in mid-January. We began screening from January 18, every day 16,000-18000 people were screened. It was an unknown enemy. What could we have prepared for in those two months?
Do we have learning lessons from H1N1 pandemic to use now?
Pune in Maharashtra was the first in India to record H1N1. Back then we led from the front and devised our own treatment protocol in the country. For Covid-19 too there was no protocol until April by GoI. Maharashtra devised its own protocol before waiting for GoI to frame one. We learnt from H1N1 that early identification is important, invasive ventilation has to be avoided as much as possible. These learnings we are implementing even now.
New studies have found that antibodies level in cured Covid patients falls after a few weeks, indicating a possibility of reinfection. If this infection becomes recurring, how does Maharashtra plan to deal with it for the next few years?
If it is a recurring infection, by next year we will know better how to deal with it. Take the example of H1N1, we now know how to treat it. There is a proposal for infectious diseases hospital that Government of India discussed last month with states. Maharashtra has suggested a 100-bed infectious wing in hospitals of 26 districts with population of more than 10 lakh. In eight districts with population less than 10 lakh we can have a 50-bed infectious unit. We will provide some beds for dialysis, since we realised dialysis was a missing resource in this pandemic. For a 100-bed wing, there will be 20 ICUs, and half for 50-bed ones. For Mumbai there is a separate proposal for an infectious hospital. All upcoming infectious diseases are urban in nature, so we need to improve urban infrastructure. Urban pockets with less than 50,000 population will have field level health workers and health posts. GoI will roll out a national plan on all this. We also have a long standing proposal for infectious hospital at Pune. At state level too, we will take this up.
Kerala and Telangana have admitted to local community transmission. In Maharashtra, most cases now have no index case to trace back to. Why is Maharashtra silent on community transmission?
I cannot comment yes or no. We had an academic discussion with GoI team. They made an observation, we have still not reached a point where any random person picked comes positive for Covid-19. Until that happens, we cannot say there is community transmission. The positivity rate in testing is only 20 per cent, so how can this be called community transmission? In tracing a case, a person has to recall and give entire information. Initially we had very few cases, we were able to get day-wise history of positive cases. As cases increased, extracting detailed history became difficult. This does not mean positive cases cannot be traced. ICMR has to take a call on community transmission, it is their purview. As a health administrator there will be no difference in my work if community transmission is there or not. Our work will remain the same.
But we have more than 3 lakh Covid-19 cases, and over a lakh active infections. And still no community transmission?
It is not under our domain to decide this. Every state is following ICMR protocol.
Are you in favour of continuing the lockdown beyond July 31?
Local corporations have to decide based on level of transmission and local resources available. If local corporations have to break the chain of the virus, then 2-3 days lockdown serves no purpose. We will require minimum 10-14 days of lockdown, which is double the incubation period, and corporations have to strictly implement it.
Will Maharashtra continue 80 per cent bed reservation in private hospitals after August?
Yes, it seems we will still require reservation in private hospitals. A final decision is yet to be taken. Depending on the situation in August, we may reserve beds in only areas with high cases.
Do you think Mumbai could have fared better in controlling cases? It has the best resources in state. Several people who returned from Mumbai to regions like Beed, Osmanabad, where there were zero cases, took the virus home.
There could be analysis done later about what could have been done better or differently. I do not want to comment on it. But understand, it was like a war-like situation here. It is the commander on the ground, the resources he has, the situation he faces at that point which drive decisions.
Dharavi model was hailed as a success, but we are seeing rise in cases again.
The Dharavi concept is simple. We took out high risk people from that area to break the viral chain and avoid physical proximity. The model has worked and is replicable. We have asked congested areas in Mumbai Metropolitan Region and Pune to replicate Dharavi model in slums. Family members and high risk contacts of positive cases have to be brought to institutional quarantine. New cases in Dharavi are due to incoming people returning from other states. I am told 15,000 people are travelling back to Mumbai daily.
When it comes to drugs to treat Covid-19, there is a continued issue of dearth in supply of Remdesivir and Tocilizumab. What is the government doing to bring this under control?
There is a demand-supply mismatch. Only three companies are producing Remdesivir, one is producing Tocilizumab and one Favipiravir. The state government has floated tenders and got competitive rates. Tocilizumab can be bought by government hospitals for Rs 30,870, Remdesivir for Rs 3,392 per vial and a strip of 34 Favipiravir tablets for Rs 1,999. While we have made these drugs available at cheaper price, we are also cautioning doctors. This is not a panacea. We came across a few examples where use of these drugs rather deteriorated a person. Tocilizumab can only be used if Covid-19 patient has no other infection else he can lapse into sepsis. We have given standard protocol to doctors, we have done video conferences to sensitise doctors and task force have been formed in districts to monitor this. We have explained to doctors that these drugs do not reduce mortality.
What about convalescent plasma therapy?
For plasma therapy we have written to Government of India to fix the rate of therapy and to allow component separation facility for plasma extraction instead of just plasma apheresis technique. Aphaeresis cost is Rs 8,000-10,000. All district blood banks have component separation facility and it’s cheaper. Till July 20, 241 plasma units have been collected and 91 units have been transfused into Covid-19 patients.
Has this pandemic shown we invest poorly in health?
Everybody, in policy making and in finance department, has realised that now, and maybe we will get better funds in the budget for health now.
Which major health programmes have been hit in the last four months when attention was focused on Covid-19?
Immunisation has fallen by 10 per cent. Government of India came out with immunisation policy late, in which they asked not to hold immunisation camps in containment zones. Our Tuberculosis notification has definitely taken a toll, it has dropped by 30-35 per cent. Several private clinics that reported cases have shut. A lot of our hospitals converted into Covid facility. That affected dialysis services, ante-natal care, sick new born care units. We are in process of bringing this work back on track.
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