Context: Oxygen Crisis in India – Oxygen Shortage for Covid-19 patients treatment
There are serious calls to address the Oxygen Crisis in India due to shortage of Oxygen as infected patients of the second wave of Covid-19 are left gasping for breath as hospitals in some states are operating on the edge due to a shortage of medical oxygen.
Reporting more than 300,000 infections and almost 3,000 deaths every day, India has recorded the highest one-day tally of new Covid-19 cases anywhere in the world. Many breathless Covid-19 patients have died over the weeks of April 2020, due to the unavailability of medical oxygen in hospitals situated in Delhi, Uttar Pradesh, Maharashtra, Gujarat, and Madhya Pradesh.
The situation is only expected to get worse as apart from the Covid-19 cases increasing day by day, Maharashtra has already exceeded its production capacity and Madhya Pradesh does not have its own manufacturing plant and relies on Gujarat, Chhattisgarh, and Uttar Pradesh for oxygen supply.
The seriousness of the situation
- Around 3-5 % (over 50,000) of active Covid-19 cases in India have lung tissues damaged enough by the virus to require external oxygen support.
- Shortness of breath has emerged as a major concern among Covid-19 patients during the second wave, thus, the need for medical oxygen has increased exponentially – (Since March, medical oxygen demand has grown from 750-800 to over 2,500 metric tonnes).
- Although India has a daily production capacity of at least 7,100 tonnes of oxygen, including for industrial use, which appears to be enough to meet current demand, the present situation has arisen due to reasons other than just production capacity.
Learning from the past: This is not the first time that shortage of oxygen was an issue
- We need to act fast to prevent another incident like the Gorakhpur Hospital tragedy that occurred in 2017 from occurring. In 2017, more than 50 children of Uttar Pradesh’s state-run BRD Medical College hospital died because of encephalitis after the hospital’s piped oxygen supply ran out as the supply was cut due to long non-payment of dues.
- Already such incidents are occurring with the first example being the death of 22 Covid-19 patients in a hospital in April 2021, after they lost oxygen supply due to a leak while an oxygen tanker was refilling a storage tank at a hospital in Nashik city, Maharashtra.
The global scenario on shortage of Oxygen
- Despite oxygen’s critical role in treating patients and averting death, many people around the world don’t have reliable access to it. Nearly half of hospitals in low- and middle-income countries have inconsistent or no oxygen supply.
- The WHO estimates that more than half a million Covid-19 patients in low- and middle-income countries need oxygen treatment every day, however, Oxygen production facilities are much less common in low- and middle-income countries.
- According to a recent study, Oxygen in sub-Saharan Africa is “at least five times more expensive by volume than in Europe and North America”, and there are several other low-income countries facing issues with the cost of Oxygen.
- Many low- and middle-income countries won’t achieve widespread vaccination until 2023, unlike the wealthy countries where rapid vaccine rollouts have helped in controlling the spread. As Covid-19 continues to spread in these countries it is bound to put more pressure on the existing oxygen supply and further limit the amount of oxygen available to non-Covid patients as well.
What is Medical Oxygen?
- In simple words, ‘Medical Oxygen’ refers to high-purity oxygen that is used for medical treatments and is specifically developed for use in the human body.
- Medical Liquid Oxygen (or LMO Liquid Medical Oxygen) is supplied and stored as a liquid at very low temperatures, in vessels and storage tanks.
- LMO is converted to Medical Oxygen, a gas at normal temperatures, for breathing in when required. In hospitals, the converted Medical Oxygen is supplied via a medical gas pipeline system.
Medical Oxygen is used:
- during anaesthesia and for recovery following surgery
- to treat or prevent oxygen deficiency in the body in
- in many different situations leading to low blood oxygen levels, such as:
- surgery or major trauma such as a road traffic accident
- heart attacks
- severe blood loss
- carbon monoxide poisoning
- severe lung and heart conditions
- very high fevers
- for resuscitation of adults, children and babies
What is Industrial Oxygen and how it is different from LMO?
- Industrial Oxygen is used in industries for combustion, oxidation, cutting and chemical reactions.
- The difference between Oxygen used in Industries and LMO is that the purity levels of industrial oxygen are not appropriate for human use.
- There can be impurities in Industrial oxygen, which can make people ill.
- Apart from this, Medical oxygen cylinders should also be free of contaminants; hence, the cylinders need to be thoroughly cleaned before use.
Oxygen Sources in India
There are mainly three types of oxygen sources in India at present.
- Air Separation Units (ASU) that are used for commercial purposes,
- Pressure Swing Adsorption (PSAs) for producing on a medium scale and
- Oxygen Concentrator, which is used to produce 90-95% pure oxygen in homes and small rooms from atmospheric air.
How is Oxygen used to treat patients with breathing problems?
- There are many illnesses and other conditions that can cause a condition known as hypoxemia (the oxygen level in the blood dips to dangerously low levels) and most life-threatening situations including premature birth, sepsis, and malaria can be avoided with oxygen treatment.
- For example: Even though pneumonia is treatable with simple interventions like antibiotics and oxygen, it is still the leading cause of death in children under five, killing more than 800,000 a year. This number could have been drastically reduced with the help of medical oxygen.
- The use of medical oxygen restores tissue oxygen tension by improving oxygen availability and this is used for a wide range of conditions such as shock, severe haemorrhage, carbon monoxide poisoning, major trauma, cardiac/respiratory arrest.
- LMO is used to provide life support for artificially ventilated patients and to aid the cardiovascular stability of patients.
Specifically, for Covid-19 patients: As mentioned earlier, shortness of breath due to severe damage of the lungs and subsequent drop in the oxygen level in the blood is the most serious concern with the advent of the second wave. Intervention with LMO is crucial to prevent the loss of life in Covid-19 patients with low blood oxygen levels.
Reasons for Oxygen Crisis: Why is there a shortage of Oxygen?
Location of plants
- The Eastern industrial states are where most of India’s Oxygen plants are located and since they are far from urban areas in Delhi or Maharashtra where LMO is required – this also leads to long transportation hauls and a turnaround time of at least 6-7 days for each tanker supplying Oxygen. Even in an ideal scenario, it takes 3-5 days for oxygen to journey from a manufacturer to a patient’s bed.
Time required to manufacture Oxygen
- India’s big oxygen manufacturers, such as Inox Air Products, Linde India, Goyal MG Gases, National oxygen, use cryogenic distillation technique to compress air, feed it into distillation columns and get liquid oxygen with 99.5% purity. This process, an official from Inox Air Products said, can take more than 2 days.
- Special cryogenic transport tankers that maintain a temperature of -180° C, are required to transport LMO to smaller plants where liquid oxygen is converted into gaseous form and fed into cylinders to be sent to the final destination – hospitals.
- Before the second wave of the pandemic, the 1,200-1,500 tankers in India were enough, but as demand surges, logistics are falling short and now tankers are difficult to hire and cost more (Cryogenic tankers cost around Rs. 50 lakh each). Companies are not buying these tankers because once this wave is over, that investment will turn into losses.
- A significant delay in inter-state transportation of oxygen from manufacturers to hospitals is due to the shortage of such oxygen tankers. It may be noted that medical facilities and healthcare centres located in remote areas face a bigger oxygen shortage crisis due to longer transportation time.
Time required to set up plants
- It is not feasible to set up new oxygen manufacturing plants or expanding existing plants within a short span of time, like a month. For example, A private company that started to install a new oxygen-producing facility in the past took almost 24 months to properly install one manufacturing plant.
The rapid surge in Prices
- An Oxygen cylinder that would earlier cost Rs 100-150 in normal situations now costs Rs 500-700 for refilling. Due to this along with increasing panic, hoarding of Oxygen cylinders has begun. Fearful of not getting a Covid bed in hospital, people are keeping oxygen cylinders at home.
- Several private hospitals charge patients Rs 1,500-3,000 for oxygen per day.
Heavy reliance on private players
- Nearly 60% of the total medical oxygen supply in India is manufactured by one private firm alone.
Usage related issues
- In the past, the Health Ministry repeatedly demanded hospitals to reduce wastage and unnecessary oxygen use in Hospitals. Industrial experts also raised concerns over possible leakages in hospital pipelines that supply oxygen.
Are Oxygen exports to blame for the current oxygen shortage?
- Oxygen export data from the Department of Commerce showed that the country exported twice as much oxygen to the world during the first 10 months of FY21 in comparison to the previous financial year. However, the demand for oxygen in India was not as high during that period.
- During the first wave, the demand for liquid medical oxygen (LMO) increased from 700 metric tonnes per day (MTPD) to 2,800 MTPD and to make it worse, during the second wave, it has skyrocketed to 5,000 MTPD.
- It was only in the second week of April 2021 when demand for medical oxygen in India witnessed a five-fold jump, according to Crisil.
- The fact that the country produces over 7,000 metric tonnes of liquid oxygen per day (which, as mentioned earlier is apparently sufficient to meet the existing demands) indicates that the problem lies somewhere else.
An Alternative: What is an Oxygen Concentrator?
- An Oxygen Concentrator is a medical device that concentrates oxygen from ambient air.
- The oxygen concentrator takes in atmospheric air (Composition of Atmospheric Air is: 78% Nitrogen and 21% Oxygen, with other gases making up the remaining 1%) and filters it releasing the nitrogen back into the air and works on the remaining oxygen.
- The remaining Oxygen from the atmospheric air is 90-95% pure and this is compressed and dispensed through a cannula.
- According to a 2015 report by the WHO, concentrators are designed for continuous operation and can produce oxygen 24 hours a day, 7 days a week, for up to 5 years or more.
- Experts say that 90-95% purity is good enough for mild and moderately affected Covid-19 patients with oxygen saturation levels of 85% or above. It is, however, NOT advisable for ICU patients.
How is the oxygen from the concentrator different from LMO?
- Oxygen concentrators can only supply 5-10 litres of oxygen per minute (critical patients may need 40-50 litres per minute) and are best suited for moderately ill patients, yet, they are the easiest alternatives to cylinders.
- Unlike LMO that needs to be stored and transported in cryogenic tankers, Concentrators are portable and need no special temperature.
- Concentrators only need a power source to draw in ambient air and do not need refilling like cylinders of LMO.
- Oxygen Concentrators cost Rs 40,000-90,000 and are more expensive than cylinders which cost Rs 8,000-20,000. However, Oxygen concentrators are a one-time investment and apart from electricity and routine maintenance, there’s little by way of operational cost, unlike cylinders that involve refilling costs and transportation.
The Government’s steps to manage the Oxygen crisis
- Under the Disaster Management Act, 2005, the Ministry of Health & Family Welfare (MOHFW) delegated its powers to the NPPA to take all necessary steps to regulate the availability and pricing of liquid medical oxygen (LMO) and oxygen cylinders. Subsequently, the NPPA capped the price of medical oxygen cylinders and LMO during the starting stages of oxygen crisis in September 2020 for six months in order to control the prices due to shortage of oxygen supply.
- The Centre appointed Empowered Group-2 to map the medical oxygen requirement and production/procurement capacity in the 12 States having extreme burden.
- The Ministry of Health and Family Welfare (MoHFW) recently sanctioned the installation of 162 Pressure Swing Adsorption plants at hospitals to augment oxygen capacity by over 154 Metric Tonnes.
- The Indian railways have been activated by the government to move tankers from refilling plants to where it is most needed – this use of trains to supply oxygen is likely to ease the shortage that some states are facing.
- The government’s decision to let suppliers use argon and nitrogen tanks for oxygen supply will also help ease the shortage in some states.
- Indian Air Force (IAF) is airlifting empty oxygen tankers and taking them to industrial units that have switched to producing medical grade oxygen to speed up transportation.
- The government’s decision to import 50,000 metric tonnes of oxygen is also likely to help mitigate the demand crisis in the next few days as operations have already started.
- The armed forces are also importing 23 mobile oxygen generation plants from Germany.
Who controls Medical Oxygen Prices in India?
- Medical oxygen is placed under the National List of Essential Medicines (NLEM) according to the Drug Prices Control Order, 2013.
- Since the National Pharmaceutical Pricing Authority (NPPA) monitors and controls the prices of the National List of Essential Medicines (NLEM) – the NPPA controls and monitors the Medical Oxygen prices in India.
Innovation: Oxygen Enrichment Unit (OEU)
- The Central Mechanical Engineering Research Institute (CMERI) developed an Oxygen Enrichment Unit (OEU) that could provide crucial support to COVID-19 patients.
- An Oxygen Enrichment Unit (OEU) is a device that concentrates the oxygen from the surrounding atmospheric air (somewhat similar to Oxygen Concentrators).
- OEUs will help reduce the dependence and requirement of ventilators and oxygen cylinders in homecare, villages and remote places.
Steps that were taken at a Global level
- As of February 2021, the WHO and its partners – the UNICEF, and the Bill and Melinda Gates Foundation had distributed more than 30,000 oxygen concentrators and 40,000 pulse oximeters to 121 countries with the Oxygen Therapy Project that was launched in 2017.
- Recently, the WHO, along with other global health agencies, including the Wellcome Trust, Unitaid, and many more, announced a Covid-19 Oxygen Emergency Taskforce to secure funding, identify oxygen needs, and provide oxygen supplies and technical support in the hardest-hit countries.
- India has got a commitment of assistance from Europe, the Gulf region and even further parts of the world, Australia, New Zealand and countries like Guyana which are located geographically further away to deal with the Oxygen crisis in the country.
- Capacity-boosting supplies are expected to arrive in the coming days of May 2021 from Egypt, Uzbekistan, Bangladesh, apart from the big powers like Russia, the U.S. and Saudi Arabia.
- The Ministry of Foreign Affairs of Bangladesh has announced 10,000 anti-viral vials, 30,000 PPE kits, and several thousand zinc, calcium, vitamin C and other necessary tablets that will be sent to India in the coming days.
- From Egypt, Gilead Sciences has committed 4,50,000 doses of Remdesivir to India.
- A special cargo for medical aid including more than 150 ventilators and other medical supplies arrived from the UAE recently in April 2021 as well.
- Three oxygen generation units will be sent from surplus stocks in Northern Ireland.