Are India’s Hospitals Ready To Tackle COVID Among Children?
Even as COVID-19 cases have begun to decline across the country, the Central and State governments have stepped up their efforts to prepare for a possible third wave during which children could be the next vulnerable group.
The first wave impacted the elderly the most. The second wave affected people aged 18 to 45.
Dr Rakesh Mishra, the former director of CSIR-Centre for Cellular and Molecular Biology in Hyderabad, earlier told FIT that we haven't seen anything in the virus that indicates it prefers certain age-groups.
All India Institute of Medical Sciences Delhi chief Dr Randeep Guleria also recently said that there is no data to show that children will be seriously infected in the next wave of COVID-19.
But the concern is not Covid among children per se, but the complications that occur after the infection, doctors told FIT. Several cases of multi-system inflammatory syndrome or MIS-C have been found among children, days after recovering from Covid across India.
MIS-C is a condition in which a patient develops fever and inflammation in multiple organs such as the heart, lungs and brain. It usually affects those aged 5-18 and can cause serious complications and even death if not recognised early.
Yes, MIS-C is a rare condition. But when 40 percent of India's population is below 18 years, and there's a sudden spike in the number of infections, the absolute number is bound to be huge, posing a number of challenges to the stuttering healthcare system.
How Equipped Is Our Health Infrastructure?
Supposing the third Covid wave does affect children, is our healthcare infrastructure equipped to deal with the surge? Do we have preparedness in terms of beds, healthcare professionals and capacity building?
The paediatric infrastructure in the country is "very poor" and concentrated in few states and metropolitan cities, said Dr GV Basavaraja, Paediatrician and Chairperson of the Indian Academy of Pediatrics (IAP) - Intensive Care Chapter - 2020.
Dr Dhiren Gupta, a paediatric intensivist at Ganga Ram Hospital in Delhi, said there are only few centres where good intensive care, especially paediatric intensive care is available.
"Suppose a number of patients have MIS-C...50-80 percent do require ICU, then the system is not equipped," Dr Gupta said.
"Even with adult intensive care, it is concentrated in private hospitals...The problem is with a government setup. Except premier institutions like AIIMS, PGI, the government institutions are in very bad shape. They cannot tackle the adult population well also, let alone pediatric population,” Dr Gupta said.
There are over 31,000 paediatricians in the country, according to the Indian Academy of Pediatrics. While this does not include all of them, the paediatrician-to-children ratio is still bad. Is this enough to treat the number of children who might be affected due to Covid?
Dr Gupta thinks there are enough paediatricians in the country. What we don't have is specialists like anaesthetists, intensivists to cater to paediatric sick patients, he said.
A Lot Needs To Be Ramped up, But...
The infrastructure has been augmented for the adult population in the first two waves. Now is the time to do the same for the paediatric population, doctors said.
But to prepare for the impending wave, we need data on this particular population to know what needs to be ramped-up. There is no data on the paediatric hospitals, beds available and the paediatric intensive care units (PICU) in the country.
According to a research conducted last year, it is estimated that there are approximately 1.9 million hospital beds, 95,000 ICU beds, and 48,000 ventilators. However, there is no data on the number of paediatric ICU beds, which the doctors say is "miniscule".
Meanwhile, Dr Asha Benakappa, leading paediatrician and former director of Karnataka's Indira Gandhi Institute of Child Health, stressed on the need for segregated data.
“Why can’t the government give us the data? How many of them are below 18 years? How many are 0-6 years, 6-15 and 15-18 year-olds? If we don’t get the data, how can we take action?”
How Do We Boost Paediatric Infrastructure?
The next wave could be problematic if a lot of pediatric patients turn up in serious condition and require intensive care, especially in small towns and villages, doctors said. From equipment to manpower, the paediatric infrastructure needs a different kind of scaling-up.
“More than pediatricians, you have to train other people. Pediatricians are trained, but we need to train even our paramedical workers and other doctors who can take care of the children,” Dr Suneela Garg, Professor of Excellence, Community Medicine at Maulana Azad Medical College in Delhi and Member of Lancet Commission Covid India Task Force, said.
Dr Gupta thinks the whole system should be revamped in such a way that it benefits the society. “We should prepare the entire healthcare staff to take care of pediatric population.”
There is also difference in equipments used like ventilators, saturation probes, ICUs, among other things. All these should be augmented, doctors said.
“Taluk headquarters should have ECGs for paediartic age groups…saturation probes for them…In the district headquarters they should be backed up with entire facility for ICUs,” Dr Dhananjaya Sarji, a leading paediatrician in Karnataka said.
Capacity-building of the families is also important. "We need to make provision for the mothers too because the child will not be accepting of anybody and everybody," Dr Garg said.
‘Prevent, Protect, Prepare’: What Are States Doing?
Several states including Maharashtra, Delhi, Karnataka and Andhra Pradesh have set up paediatric task force to prepare for the possible wave.
“We don’t want to be caught the way we were caught with the second wave...Even if it doesn’t affect children, at least we’ll be ramping up our healthcare infrastructure, which will help children in the future,” Dr Samir Dalwai, who is a member of the task force in Maharashtra, said.
The taskforce has prepared an entire assessment of what could be the problem in children. This is been stratified or triaged into three levels -- mild infection, moderate infection, severe infection and laid down guidelines on what needs to be done.
In Karnataka, the government is strengthening the district hospitals and ordering sufficient number of ventilators, monitors, syringe pumps, and medications. Protocols are being prepared and disseminated among the healthcare professionals, including the ASHA workers.
Delhi is setting up of a paediatric task force and two genome sequencing labs, and plans to ramp up oxygen capacity to prepare for a possible third Covid wave that could peak at 37,000 cases a day. The government will also create a buffer stock of important medicines, Chief Minister Arvind Kejriwal said.
While all these efforts are necessary, doctors said, it’s not a question of third wave. The paediatric infrastructure in India needs to be ramped up given years of neglect, the doctors pointed out.
“We need to be prepared for Holistic Management of children that has got nothing to do with Covid,” Dr Garg said.
“The government should wake up. What they haven’t done the last 10 to 20 years, in the next 7 months they should completely revamp the system,” Dr Basavaraja said.
"Believe me, children are already coming in with moderate infection. MIS-C is happening. Deaths are happening." Dr Benakappa said, sounding an alarm.
“It's time we prevent, protect and prepare.”
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