Tag Archives: covid-19

Going beyond access to health information: a pandemic call to action

About a decade earlier we brought to attention that the lack of access to health information is ‘a social injustice that the global health community cannot afford to ignore’. We argued that governments are morally and legally obliged to ensure access to health information. In the backdrop of the COVID-19 pandemic, we have seen significant investments from multinational agencies, governments, non-profits and private actors to disseminate health information. However, a narrow focus on providing access to health information alone, without any investment or thought on how information can be translated by people to meaningful health outcomes, is proving to be counterproductive.

Read the Editorial by Dr Soumyadeep Bhaumik and Dr Pranab Chatterjee in BMJ Global Health (Open access)

From trials to the bedside: convalescent plasma during the COVID-19 pandemic [Seminar]

Convalescent plasma has a long history in treatment of infectious diseases – being used  when other therapies are available .The use of plasma from patients who have recovered from COVID-19   was  used similarly as it can neutralize  viral particles and hence help patient care.   But many randomized controlled trials have now been completed and it is time now for using evidence to inform not only clinical care but also future research.

The International Severe Acute Respiratory and emerging Infection Consortium is organizing a seminar titled “Use of convalescent plasma in patients hospitalised with COVID-19” as a part of the Oxford University Tropical Medicine Seminar . The seminar is on Jun 10, 2021, 13:30 -14:30 hours Indian Standard Time.

The talk will have presentation’s from Dr Aparna Mukherjee (ICMR) and Professor Peter Horby ( Oxford University) and Dr Soumyadeep Bhaumik (The George Institute for Global Health, India). The seminar is moderated by Bharath Kumar Tirupakuzhi Vijayaraghavan (Apollo Hospitals, India)

Dr Soumyadeep Bhaumik will talk about ” From trials to the bedside: convalescent plasma during the COVID-19 pandemic”

Abstract of talk

The use of convalescent plasma in hospitalized COVID-19 patients has started from the beginning of the pandemic. However, during the second wave of the COVID-19 pandemic – with a failing health system , with exhausted doctors and desperate patients – this meant  widespread irrational use . Patient and care-givers had to run pillar-to-post to secure plasma from COVID-survivors. The national guidelines remained unchanged and many doctors were confident about its utility . I will discuss the sum-total of evidence (from a systematic review), discuss about how confident we are about the results (through GRADE), and put it in the evidence-to-decision framework in the Indian context. I will also touch on problems in our current guidelines which exist in form of mere flowcharts.

Event is free to attend but requires pre-registration: Click

COVID-19 vaccination in India: we need equity

Just a few days after starting its own COVID-19 vaccination program , India provided vaccines as grant- in-aid to other countries1 . This was in sharp contrast to some high-income countries which stockpile vaccines,  and block proposals to suspend intellectual property rights in World Trade Organisation2. India now is in the midst of a humanitarian crisis 3 but its vaccination rates continue to fall. While it is not possible to go back in time and make amends to ensure availability for all, revising the current vaccination strategy (which is riddled with equity issues) can save lives ,  prevent health systems burdening and ensuring a functioning ecosystem during the pandemic .

Equity enables maximizing benefits from scarce resources

India’s original vaccination strategy was to sequentially vaccinate priority groups healthcare workers, frontline workers, people more than 50 years. of age and younger people with associated comorbid conditions (diabetes, hypertension, cancer, lung diseases) 4. In principle this invoked equity – prioritising those at highest risk. However, the Indian government continually changed its strategy – announcing more inclusive eligibility criteria for vaccination every month. The last of these came suddenly in the last week of April 2021, when the Indian government announced a new “liberal policy” for vaccination5.In midst of the current crisis, while already being riddled with shortages the new policy announced that everyone above 18 years will be eligible, and effectively removed any distribution or price controls for manufacturers. This is unparalleled – no other federal democracy is making citizens pay for COVID-19 vaccines or have states competing to secure supplies. The huge demand amid all the death and despair in th current wave meant that the two Indian vaccine manufactures resorted to differential and predatory pricing. They fixed prices for state governments which are almost twice of the price paid by the union government ; it is four times for private hospital 6. An immediate consequence of this was that most state governments were not able to offer vaccines for high-risk groups , while even richer people(who can pay ₹ 1600-2400 , £ 15 to £ 25)  in non-priority 18-45 years age group are able to access vaccines from private hospitals 7. The “liberal policy” also perpetuates regional inequities, wherein richer state governments will be able to buy more doses for non-priority groups while poorer states (with weaker health system) will have to wait for revenues to accrue for buying vaccines for priority groups.

The realities of vaccine shortage need to first publicly acknowledged, and a pragmatic and equity-based strategy needs to be adopted. As per media reports, only 37% of frontline and health workers had been fully vaccinated by mid-April 8 .

India needs to prioritise people “who matter and are in need” over the “rich and elite”. Vaccination of non-priority people in 18-45 years of age, should be stopped until adequate coverage of priority groups is acquired. A moral, social, and human rights lens is essential for the purpose. Younger people with mental health conditions, informal sanitation and cremation workers, families of frontline workers and healthcare workers, hawkers,  home-delivery workers, prisoners , homeless people, people living in slums and field journalists who are at higher risk 9 10 11 need to be under priority groups. Some of the re-defining of priority groups has been done by states like West Bengal and Delhi – but this is not uniform across the country.

Adopting a “One Nation – One Price – One Vaccine Buyer” policy such that the Government of India buys and makes it free for all citizens of India is the need for the hour. To overcome shortage, it can issue compulsory licenses (under Section 92 of the Indian Patent Act for public health emergencies) for all COVID-19 vaccines. A single buyer and a fixed price of ₹ 150 (£ 1.5 ;  current price paid by the Union government) for the entire nation would prevent pandemic profiteering.

Putting equity in the heart and soul of COVID-19 vaccination policy in India
Digital health driven inequity

Vaccination in India require pre-registration through a centralized online digital system called Co-WIN. With only 20% of Indians using internet12 the implementation strategy is not in touch with ground realities. The “digital divide” is even greater in rural areas, particularly in women, tribal/Adivasi people, and the urban poor13 who remain clueless about the system. Urban youth are travelling to rural areas to get vaccines14 –potentially transmitting COVID-19 to villages. Micro-planning 15 and participatory community engagement16 is crucial for successful implementation. India has in the past used them successfully without any digital tools. The Co-WIN based registration and tracking system needs to be stop and time-tested walk-in and community outreach (for disabled, homeless, very old people and other equity groups) needs to be adopted.

Instead of investing in digital health, government needs to invest in employing more vaccinators and vaccination officers. The current strategy of drawing into existing human resources has led to disruptions in routine service delivery 17 18 .

The way forward

Mahatma Gandhi’s maxim that a “nation’s greatness is measured by how it treats its weakest members” should  guide the overhauling of the COVID-19 vaccination policy. Getting the vaccination program right in India is crucial for the pandemic endgame too. There is not a moment to waste.

About the Author

Dr Soumyadeep Bhaumik is a medical doctor and international public health specialist working in The George Institute for Global Health India. He is also associate editor of BMJ Global Health. Views are personal and not necessarily reflective of employer or the BMJ Global Health. He tweets at @DrSoumyadeepB

Competing interests: I have read the BMJ Group Conflict of Interests and declare no competing interests.

Funding : None

Acknowledgment : Dr Sambit Dash from Melaka Manipal Medical College, India with whom author had a discussion.

Provenance : The article is not peer-reviewed.

The article was originally published in BMJ GH Blogs and is published here under CC-BY-NC-SA

References

  1. Ministry of External Affairs. Made-in-India COVID19 vaccine supplies so far (In lakhs): Ministry of External Affairs, Government of India; 2021 [Available from: https://www.mea.gov.in/vaccine-supply.htm accessed 02 May 2021.
  2. Sachs JD, Karim SA, Aknin L, et al. Priorities for the COVID-19 pandemic at the start of 2021: statement of the Lancet COVID-19 Commission. The Lancet 2021
  3. Thiagarajan K. Why is India having a covid-19 surge? BMJ 2021;373:n1124. doi: 10.1136/bmj.n1124
  4. MOHFW-GOI. COVID-19 vaccines : operational guidelines New Delhi: Ministry of Health & Family Welfare, Government of India; 2020 [Available from: https://www.mohfw.gov.in/pdf/COVID19VaccineOG111Chapter16.pdf.
  5. Sahu P. New ‘liberal’ policy: States to spend a tidy sum for vaccination drive: Financial Express; 2021 [Available from: https://www.financialexpress.com/economy/new-liberal-policy-states-to-spend-a-tidy-sum-for-vaccination-drive/2237743/ accessed 17th May 2021.
  6. Mahal J. ‘Don’t Leave Vaccine Pricing And Distribution To Manufactures’: Supreme Court Questions Centre’s COVID Vaccination Policy 2021 [cited 2021 03 May]. Available from: https://www.livelaw.in/top-stories/supreme-court-questions-centres-vaccine-policy-vaccine-pricing-and-distributionto-manufactures-173389.
  7. FE Online. COVID-19: Amid vaccine shortages across India, big private hospitals start vaccination for 18-44 years: Financial Express; 2021 [cited 2021 03 May]. Available from: https://www.financialexpress.com/lifestyle/health/covid-19-amid-vaccine-shortages-across-india-big-private-hospitals-start-vaccination-for-18-44-years/2243577/.
  8. Dey S. Only 37% of 3 crore health, frontline workers fully vaccinated New Delhi: Times of India; 2021 [Available from: https://timesofindia.indiatimes.com/india/only-37-of-3-crore-health-frontline-workers-fully-vaccinated/articleshow/82135322.cms accessed 19 April 2021.
  9. Nemani K, Li C, Olfson M, et al. Association of Psychiatric Disorders With Mortality Among Patients With COVID-19. JAMA Psychiatry 2021;78(4):380-86. doi: 10.1001/jamapsychiatry.2020.4442 [published Online First: 2021/01/28]
  10. Akiyama MJ, Spaulding AC, Rich JD. Flattening the Curve for Incarcerated Populations – Covid-19 in Jails and Prisons. N Engl J Med 2020;382(22):2075-77. doi: 10.1056/NEJMp2005687 [published Online First: 2020/04/03]
  11. Tan LF, Chua JW. Protecting the Homeless During the COVID-19 Pandemic. Chest 2020;158(4):1341-42. doi: 10.1016/j.chest.2020.05.577 [published Online First: 2020/06/13]
  12. World Bank. Individuals using the internet ( % of population) – India Washington: World Bank; 2021 [Available from: https://data.worldbank.org/indicator/IT.NET.USER.ZS?locations=IN accessed 03 May 2021.
  13. Bose A. Explained: Why Delhi’s Slum Dwellers Are Struggling To Get Vaccinated Delhi: Boom Live; 2021 [Available from: https://www.boomlive.in/explainers/why-delhis-slum-dwellers-are-struggling-to-get-vaccinated-13164 accessed 18 May 2021.
  14. Lalwani V. Tech savvy Indians drive to villages for Covid-19 vaccinations. Those without smartphones lose out: Scroll 2021 [Available from: https://scroll.in/article/994871/tech-savvy-indians-drive-to-villages-for-covid-19-vaccinations-those-without-smartphones-lose-out accessed 18 May 2021.
  15. Mallik S, Mandal PK, Ghosh P, et al. Mass Measles Vaccination Campaign in Aila Cyclone-Affected Areas of West Bengal, India: An In-depth Analysis and Experiences. Iran J Med Sci 2011;36(4):300-5. [published Online First: 2012/11/02]
  16. Burgess RA, Osborne RH, Yongabi KA, et al. The COVID-19 vaccines rush: participatory community engagement matters more than ever. Lancet 2021;397(10268):8-10. doi: 10.1016/s0140-6736(20)32642-8 [published Online First: 2020/12/15]
  17. Chatterjee P. India’s child malnutrition story worsens. The Lancet Child & Adolescent Health 2021;5(5):319-20. doi: https://doi.org/10.1016/S2352-4642(21)00064-X
  18. Shet A, Dhaliwal B, Banerjee P, et al. COVID-19-related disruptions to routine vaccination services in India: perspectives from pediatricians. MedXRiv 2021; [pre-print]

Evidence informed standardised prescription: home care for mild COVID

A vast majority of those with COVID have mild to moderate symptoms- and can appropriately be managed at home. In most cases people seek care from registered medical practitioners . But many clinicians and consultants are prescribing a cocktail of drugs which are known to have little or no value in improvement of patients. On the other hand it adds unnecessarily to costs, causes anxiety and makes diagnosis of progressive symptoms difficult ( progression of disease, complication or drug reactions) . To help clinicians tide over and have a tool which is backed by evidence, the evidence-informed standardised prescription has been developed for modern medicine doctors treating mild or moderate COVID cases at home (in-person or telemedicine).

Access is free but restricted to only modern medicine doctors (anywhere in the world) and organisations on a peer-to-peer basis and is available here . Apart from the prescription it provides an inventory of external resources to enable better clinical decision making. The standardised prescription is licensed under CC BY-NC-SA 4.0 license . This means it is free to use, adapt and mix provided the original source is cited/attributed appropriately, the use is for non-commercial use and further derivates are also licensed similarly.

Access, can be requested through an email to : work [at the rate of] soumyadeepbhaumik [dot] in

For individual modern medicine doctors please send either of the following:

  1. link to institutional webpage which demonstrated your medical degree
  2. information on medical council registration

Organizations working in providing modern medicine might write a mail to the same address providing link to their website and mention the specific potential use of the prescription.

The standardised evidence-informed telemedicine prescription has already been used by more than 30 doctors in India and a more stable Version 2.0 is now available. The passcode changes when a new version is available and requests can be made in a similar fashion as above. Link to access remains same.

Requests from practitioners of other forms of medicine will not be responded to.

Photo by Karolina Grabowska on Pexels.com

Why the AIIMS/ICMR 2021 COVID guideline is wrong about hydroxychloroquine ?

On 22nd April 2021 in the midst of a crumbling health system the AIIMS/ ICMR-COVID-19 National Task Force/Joint Monitoring Group , Ministry of Health & Family Welfare has finally issued a revised “Clinical Guidance for Management of Adult COVID-19 patients” (* see post-publication note in end). In essence, it is not much of a guideline but a flowchart (much like the previous one). It does not adhering to any standards of a guideline, does not present any evidence (not even citations!), nor does it communicate anything around risk-benefits for any of the drugs. As such, it is impossible to understand how the guideline was developed and why some drugs were chosen and why it was not.

The article however focusses only on one aspect of the guidelines- the recommendation for hydroxychloroquine being recommended as a “may do” . However, this recommendation for hydroxychloroquine is contrary to data from randomized controlled trial. Between July 2020 (when the last guideline was issued) and now, there is a lot of trials that has been completed and we now have reasonable evidence to inform decision making. Evidence from randomized controlled trial shows that hydroxychloroquine does do not have any effect on mortality (based on data from 10859 patients ; 29 studies) in COVID=19 patients . In fact patients given hydroxychloroquine may have significantly more diarrhea , nausea and vomiting compared to those not given so.  Diarrhoea and vomiting are known to increase the risk of hypovolaemia, hypotension and acute kidney injury, additional health systems burdens which one should avoided at all costs in this phase of the pandemic.

Hydroxychloroquine for COVID19 clinically meaningful outcomes https://app.magicapp.org/#/guideline/5058/section/67027

Even if we look at health systems relevant outcomes (which are of course equally important to patients) which are of significance in the currently crumbling health system recommending the use of hydroxychloroquine does not make any sense – it increases the number of people who need mechanical ventilation(based on data from 6379 patients ;5 studies).

Hydroxychloroquine for COVID 19 on outcomes of health systems significance https://app.magicapp.org/#/guideline/5058/section/67027

It is high time that issues in the guideline development process that has been already identified are resolved such that lives of patients can be saved through evidence informed therapies .

*As of 10th May 2021 – another version of the AIIMS/ICMR guideline is being circulated in social media without hydroxychloroquine . I could not verify the veracity of this version of guideline being genuine considering the ICMR website https://www.icmr.gov.in/ still hosts the 22nd April 2021 version

Moral philosophy, pragmatism, and the larger cause: why “war” metaphors are needed during pandemics

Coronavirus disease (Covid-19), which originated in China, is now a full-blown pandemic which has thrown governments and societies off-track in an unprecedented manner. War metaphors have been used widely to describe the scenario, but many critics decry them as harmful narratives. In this piece, we discuss the utility of the war metaphor to build solidarity and fraternity, which will be essential to get through the crisis. We also explain how concerns regarding increased authoritarianism and state excesses due to the use of these narratives are misplaced. We then tease out the colonial era concept of war that guides the arguments against the use of war metaphors in pandemics. We argue that in the post-modern world and in South Asian and African philosophies, wars are seen through the prism of the larger cause of dharma or ubuntu and that individual losses or gains in these contexts are part of a larger cause. The use of war metaphors reflects the need to get together for a societal cause. These metaphors are largely understood across societies while other alternatives are exclusionary, poetic and tangential in nature.

Read the full article in Indian Journal of Medical Ethics here (open access)

Photo by Miguel u00c1. Padriu00f1u00e1n on Pexels.com

Community health workers for pandemic response

The COVID-19 outbreak that originated in Wuhan City, China, in December 2019 now affects 213 countries or territories across the globe. Better health workforce utilisation and support are key pillars to enhance health systems capacity. Community health workers (CHWs) constitute a significant proportion of frontline health workforce in many countries and play an important role in control and prevention of pandemics like COVID-19.

A rapid evidence synthesis was conducted to understand what role CHWs can play in pandemics. The study found that in previous pandemics, CHWs have played several roles including for generating community awareness countering stigma and contact tracing. CHW engagement in contact tracing might hamper routine primary service delivery. Policies, guidance and training for these had to be developed. Disruption in supply chain, logistics and supportive supervision for CHWs have been common in pandemic scenarios. CHWs have been at increased risk for contracting disease. In the course of pandemics, CHWs have experienced stigmatisation, isolation and socially ostracisation. Improved remuneration, additional incentives, public recognition countering societal stigma, provision of psychosocial support and personal protective equipment were reported to be enablers. There is not much evidence about initialisation of new CHW programmes during pandemics. Considering the complexity of barriers faced even in contexts with well-integrated programmes, ambitious programmes need to be considered with caution.

Read the full study in BMJ Global Health here (open access)

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