About 100 km from India’s national capital, Bharatpur district in Rajasthan has a population of more than 25 lakh people. The district hospital has 525 beds. Of these, only 18 beds are connected to piped oxygen, crucial to saving the lives of patients who develop acute respiratory distress because of the novel coronavirus infection.
As of May 2, the district had 111 coronavirus positive cases. But what if the number of cases were to rise?
Dr Navneet Saini, the principal medical officer of the district, said that in addition to the piped oxygen, the hospital had arranged for 90 oxygen cylinders and was procuring 200 more.
Across India, the coronavirus epidemic has sparked a rush to buy oxygen cylinders. In a letter dated April 4, the Union Ministry of Health directed all states and Union Territories to maintain adequate oxygen supplies.
In a press briefing on April 23, Dr Randeep Guleria, director of All India Institute of Medical Sciences, said that around 15% of all coronavirus cases in India could be treated with supportive care and oxygen therapy, while less than 5% would require ventilator support and critical care. This underlines the importance of oxygen availability – more vital than ventilators.
On May 1, in a press briefing, the ministry said India had capacity to manufacture 6,400 metric tonnes of oxygen daily of which 1,000 metric tonnes was used as medical oxygen. About 60,000 industrial oxygen cylinders had been ordered for conversion into medical oxygen, a spokesperson said. The country has 4.38 lakh medical oxygen cylinders and orders had been placed for more than 1 lakh cylinders, he added.
But health infrastructure varies across states and districts. States like Uttar Pradesh, Bihar and Assam have the most number of districts with shortages of isolation beds, intensive care units and ventilators, according to a presentation made by the Union cabinet secretary in a meeting attended by state health secretaries on April 26, The Indian Express reported.
As many as 143 of a total of 718 districts in the country did not have intensive care unit beds and 123 districts had no ventilator beds.
While there was no district-level data available publicly for beds connected to piped oxygen, Scroll.in spoke to district officials in seven districts across Rajasthan, Uttar Pradesh and Bihar.
Officials in four districts said that the district hospital did not have a medical gas pipeline connected to a central storage tanker to supply oxygen directly to beds. Some said they had just begun to construct the system in district hospitals. Others said it would be difficult to build infrastructure overnight and they had decided to stockpile oxygen cylinders to augment capacity.
Uttar Pradesh, India’s most populous state, has detected 2,328 coronavirus cases as of May 2.
In August 2017, more than 60 children had died in Gorakhpur’s Baba Raghav Das Medical College, the largest hospital in the state’s eastern region, because of an administrative crisis that failed to ensure supply of medical oxygen.
What has the state done to ensure lack of oxygen does not have lethal consequences during the current epidemic?
Muzaffarnagar district, which had reported 14 cases, did not have a piped oxygen supply system at the district hospital. “There is a proposal for now [to set up a central oxygen unit],” said Dr Praveen Chopra, the chief medical officer of the district. “We have got 100 cylinders.”
In Ballia district, which had not yet reported a single case of the coronavirus, the work to install a piped supply was still ongoing. “There is a lockdown that is why the work has stopped but for now we are making do with oxygen cylinders,” said Dr BP Singh, the chief medical superintendent of the district hospital. Singh said that the hospital had 43 cylinders for the 226-bedded hospital.
Kushinagar district has also not yet reported a single case. Chief Medical Officer Dr Narendra Kumar said that a central piped supply of oxygen was available for 100 beds in the district hospital and that an additional 40 cylinders had been ordered.
So far, Bihar has reported 471 cases of the virus. In Siwan district that has seven cases, only 25 beds – 12 beds in the intensive care unit and 13 in the emergency ward – had piped oxygen supply, said Dr MK Alam, the additional chief medical officer. “We have 186 cylinders in both small and large sizes and we have just ordered for the piped supply to reach 15 more beds which will take four more days,” he said.
There was no piped supply in Muzaffarpur’s district hospital where zero cases were reported, said Dr Harendra Kumar Alok, the chief medical officer. The hospital has 180 beds and had stockpiled 56 cylinders, he said.
In Rajasthan’s Alwar district that has recorded seven cases, the district hospital does not have a piped supply facility either, said Dr OP Meena, the chief medical and health officer.
“We only have cylinder supply only in specific wards,” he said, adding that the supply reached 84 beds out of 200 beds. “There is zero requirement [for oxygen] right now,” he said. Meena said that they had 80 cylinders and that they had begun the process of setting up the piped system. “We have spoken to the contractor. It could take around 15 to 20 days,” he said.
As district hospitals across India order more oxygen cylinders, demand for the metal cylinders itself has risen manifold, said manufacturers. But firms supplying medical-grade oxygen say demand for the gas has dropped as elective surgeries have been deferred around the country during the lockdown.
“The demand for the gas has gone down by 20-25%,” said Rajeev Gupta of Vinayak Air Products that supplies medical grade oxygen across North India. Gupta is the general secretary of All India Industrial Gases Manufacturers Association. He anticipates the demand could rise in the future – once the lockdown is lifted, and if there is a rise in coronavirus cases. “In case the number of Covid patients goes up, then in that scenario also we are equipped,” he said.
Meanwhile, firms making cylinders that can store oxygen have already started beefing up capacity.
Ravi Kaul of Luxfer Uttam India, a cylinder manufacturer based in Faridabad, Haryana, said that their manufacturing units had started to focus solely on making cylinders for medical oxygen. “We are not manufacturing anything else,” he said.
Another manufacturer explained why firms were only producing cylinders for medical grade oxygen. “We have only got the licence for this [under the lockdown] so there is no use producing for any other gas,” said Puneet Khurana of Everest Kanto Cylinders, that manufactures cylinders from Kutch, Gujarat and Boisar, a suburb located outside Mumbai, Maharashtra.
Khurana said that the firm manufactured around six lakh cylinders annually and supplied across the country to oxygen plants that would fill up the gas.
“All the small hospitals and quarantine facilities cannot go on the pipeline system immediately,” he said. “Cylinders provide a temporary solution.”
Both Kaul and Khurana said their firms faced difficulties in working with a minimal workforce under the lockdown. Kaul’s firm can produce around 2,000 cylinders a month but he said the unit was underproducing.
“We are having issues mobilising manpower for production,” he said. “There are problems in some pockets. The workers are unable to come.”
Another manufacturer in Gandhidham, Gujarat, cited the same reason for being unable to meet their capacity of producing around 8,000 cylinders per month. “We are getting many calls everyday and we are only making 30% of our capacity,” said Pravin Nandu of Euro India.
To add to this, there was also difficulty in procuring raw materials for other parts that go into a cylinder such as flow meters, valves and regulators among other accessories. “We have to supply the complete kit,” he said. “But there is a problem in procuring this material. Some of these shops selling the parts may not be open.”
Producing more oxygen
At present, the industry produces around 900 metric tonnes of medical oxygen per day but the capacity could go up to 6,400 metric tonnes, said Gupta. The maximum retail price of the gas is fixed at Rs 17.5 per cubic metre, he said.
To fast track the process of increasing oxygen supply in the country, the Central Drugs Standard Control Organisation on April 7 issued an order to state drug controllers stating that industrial gas manufacturers would get a licence within 24 hours to start manufacturing medical oxygen.
On April 22, the Petroleum and Explosives Safety Organisation issued a circular stating the standard operating procedure of converting industrial gas cylinders to medical oxygen cylinders.
“Now we have an option, if the need arises for the stock of industrial oxygen to be converted into medical oxygen,” said Saket Tiku, president of the All India Industrial Gases Manufacturers’ Association.
Tiku is a member of a committee set up to ensure oxygen supply in the country under the Department of Promotion of Industry and Internal Trade of the Ministry of Commerce and Industry. The committee had made the proposal before the ministry.
“This can reach far flung areas where there is no medical oxygen plant nearby but there is an industrial gas plant available,” he said. “We have to keep the [oxygen] impurity level in mind since we are not exempt from the [Drugs and Cosmetics] Act.”