Mid-March saw a sudden spike in positive coronavirus cases in Kerala’s Kannur.
As the isolation wards in the district’s Pariyaram Medical College Hospital filled up with COVID-19 patients, its frontline health workers fought not just the virus, but a fast depleting stockpile of Personal Protective Equipment (PPE) kits.
The shortage was like a ticking time bomb which could expose the hospital’s 400 odd frontline workers to the virus, if cases exploded in Kannur. Realising this, the Medical College’s doctors formed a COVID-19 committee to troubleshoot the crisis. And the solution they arrived at has since ensured a steady supply of PPE kits to the hospital, even amid a global scarcity of protective gear for healthcare workers battling the pandemic.
“We custom designed our PPE gowns and got hundreds of them made to order,” a doctor from the hospital, who wished to remain anonymous, shared with TNM.
A simple idea on the face of it, the hospital’s doctors had to look outside of the state’s supply of protective gear and identify a manufacturing unit which was willing to stitch and deliver gowns to them.
“We tried options in Delhi and Coimbatore - but all those factories had run out of PPE material. We also tried to source raw material from abroad, but then came the lockdown. And then by a stroke of luck, we found a local manufacturer,” the doctor added.
The PPE crisis
A 26-year-old healthcare institution in Pariyaram, the Kannur hospital is among the handful of institutions equipped with resources and personnel to fight COVID-19 in North Malabar, which has been marked out as a virus hotspot.
As cases began multiplying in Kasaragod in early March, several patients from the northern district were admitted here. Doctors soon began to feel the pinch of fewer kits.
So far, the Medical College hospital has treated 33 coronavirus patients, out of which 19 cases have made a full recovery and 11 cases are under treatment as on Friday. One patient, from Mahe, succumbed to the virus while under treatment. The hospital has also treated six pregnant coronavirus patients, and even delivered a baby from a COVID-19 positive mother, becoming the first in Kerala to do so.
However, the doctors here say that this would have been impossible if they had stuck to their depleting stock of PPE kits.
“Every day, we need 100-120 kits for our frontline health workers and we were facing a shortage of 50% while treating patients,” the doctor said.
“It wasn’t just the health workers. There are about 30 security staff appointed in the isolation wards and 3 ambulance drivers who transported patients and swab samples. Then there were those who performed burials. They too need PPE kits. If one of them gets infected by a positive patient’s droplets, the whole medical team would be forced to quarantine themselves, triggering a healthcare crisis,” Shereen*, a senior medical officer who was part of the COVID-19 team, told TNM.
Through their multiple brainstorming sessions, the hospital’s COVID-19 team identified a small scale surgical equipment manufacturer which stitched coveralls locally. The firm was contacted and orders were placed for 50-75 PPE suits per day - just enough to tide over the shortage they faced.
“It wasn’t easy. The firm made surgical gowns and the material had to be tweaked to turn it into a PPE gown,” the doctor added. Design specifications were despatched from the hospital and when the first batch of gowns arrived, further changes were recommended.
“We added a laminate coating to enforce the fluid resistance properties of the gown material. And then a few changes like increasing the length of the shoe covers up to the knees were given,” the doctor said. A typical surgical isolation PPE gown has to meet GSM thickness standards - about 50-60 GSM - to be used by frontline workers, and the custommade coveralls for the hospital were tweaked to meet these specifications.
“We even added an extra feature called a face shield. This is a thick transparent plastic face cover which could be disinfected and reused by healthcare workers in isolation wards,” the doctor added. According to the hospital, the face shield acts as an effective droplet barrier, especially when patients cough or sneeze in close proximity to a doctor or nurse, or while being intubated.
Coupled with the N95 masks, the PPE kits stitched by the hospital worked out to be a feasible alternative, costing Rs 550 - 600 as against the open market price of Rs 1200, hospital authorities say.
Quality checks impossible during crisis
The hospital sourced these PPE kits using funds collected from donations, OutPatient treatment charges and contributions of local political representatives.
These funds go to the bank account of the Hospital Management Committee affiliated with the institution. At the Pariyaram Medical College Hospital, the management committee is chaired by the district collector with several senior authorities including the superintendent, Medical College Principal and panchayat, Public Works Department (PWD) members inducted as the committee’s stakeholders.
A March 2007 Government Order released by Kerala empowers Hospital Management Committees to use their funds to procure essential medical equipment for the institute’s functioning. The Pariyaram MCH exercised this bylaw to procure adequate PPE sets using their funds.
But while autonomy aids these institutions to tide over a pandemic, quality checks become difficult in the face of decentralised procurements.
“There are mandatory standards to be maintained while buying kits. This is to prevent viral fluid exposure of frontline workers battling the pandemic. For instance, PPE gown material has to be SITRA certified (South Indian Textile Research Association) - which is tested by a Coimbatore based laboratory - and the N95 masks and goggles have to match IS standards. When hospitals place orders privately, we cannot assure the quality of the procurements,” says Dileepkumar SR, General Manager of Kerala Medical Services Corporation Ltd.(KMSCL)
KMSCL is the appellate authority and government appointed distributor of PPE kits and N95 respirators in the state. It is the KMSCL which also supplies these kits to all 28 centres treating COVID-19 cases in Kerala’s 14 districts.
However, in mid-March, a global shortage of protective equipment coupled with a lockdown in PPE supplier countries such as China and Hong Kong, led to a shortage. At this point, multiple hospitals resorted to alternatives to resolve the crisis amid increasing case counts, as some protection was better than no protection.
As the Centre mandated SITRA certification for all PPE kits used in hospitals, several experts have, in the face of scarcity, urged the government to allow manufacturers to self attest quality of PPE kits or authorise more laboratories to certify kits. This as the SITRA certificate requirement (only done by the Coimbatore laboratory) was affecting the supply of PPE kits required to fight the pandemic in India.
Speaking to TNM, Dr Dileepkumar added that KMSCL now faces no dearth of PPE kits, with stocks being regularly replenished, as per utilisation, at warehouses in every district. With factories in China resuming operations, orders for raw material are now in the pipeline, he adds.
“We had buffer stocks of about 4,000 PPE kits from the 2018 Nipah virus outbreak which we used for this pandemic. We will now ensure 3-4 fold PPE kit reserves for every district depending upon their utilisation. This should last us about 10-15 days after the state has reached a zero case stage,” Dr Dileep added.
However, hospitals continued to face a pinch until late March. Earlier reports by TNM have highlighted that private hospitals while equipped with isolation wards and ventilators as a contingency measure, did not have any stock of PPE kits. Previously, a medical officer treating COVID-19 patients, in an interview to TNM, revealed that nurses had been wearing N90 respirators (pollution masks) instead of the recommended N95 masks in COVID-19 isolation wards. At the same time, hospitals also received donations of kits and N95 masks from local political leaders, banks and well-wishers, to tide over the shortage.
In several districts, Members of Parliaments too are using their MPLAD (Member of Parliament Local Area Development) funds to purchase PPE kits for hospitals.
“Bengaluru based voluntary organisations have promised us about 6,000 PPE kits, but we are yet to receive them. Another doctor in our hospital donated N95 masks to the tune of Rs 1 lakh as her birthday donation. Help is coming in various ways to protect our healthcare workers and we are taking it,” the doctors say.