A recent instance from a remote area in one of India’s hill states is illustrative. According to news reports, over 90% of vaccination slots meant for locals were booked by people from other areas.
Residents lost out because the area had no internet connectivity. To address the digital divide, local authorities had to appeal to the outsiders to cancel their bookings.
This access issue is just one of many ways India’s prioritisation strategy for COVID-19 vaccination has fallen short.
Who gets the shot first: what did experts agree on?
The World Health Organization (WHO) had foreseen vaccine shortages and consequently, inequitable distribution. In 2020, it advocated a nuanced approach to ensure those who most needed the vaccine got it.
The WHO’s Strategic Advisory Group of Experts on Immunization (SAGE) designed a document called the “Values Framework”. This document listed over 20 vulnerable groups such as homeless peoples, those living in informal settlements, and those in urban slums.
They underscored that countries ensure access to priority populations and take action to ensure equal access to everyone who qualifies under a priority group, particularly socially disadvantaged populations.
How did India prioritise vaccines?
The first phase of India’s rollout began in January, covering an estimated 30 million healthcare and front-line workers.
From May 1, it was decided all adults over 18 would be included.
Now, despite all adults being eligible, only 10% are fully protected with two doses. Despite the overall pace of vaccination increasing, the target of 135 million doses administered in July may be missed, and things look unlikely to improve in August.
With the threat of a third wave fuelled by variants, relaxing of lockdown restrictions, and the constant uptick in cases in two of the larger Indian states (Kerala and Maharashtra) as well as most of the North Eastern states, there’s an urgent need to increase vaccine coverage.
How should India prioritise vaccines?
India’s prioritisation strategy was limited to age, and to front-line workers specifically linked to COVID management — police and armed forces personnel, disaster management volunteers and municipal workers. It did not address the real-world diverse spectrum of vulnerabilities.
The Values Framework points to a range of vulnerabilities and priorities and includes people unable to physically distance such as those in geographically remote and clustered populations (detention facilities, dormitories, refugee camps and dense urban neighbourhoods).
Then there are those who are at high risk of transmitting infection such as youth who are mobile but largely asymptomatic, and school-going children. Vaccinating them early would minimise disruption of their education and socio-emotional development. The union health minister has announced vaccination of children is likely to begin in August.
Workers in non-essential but economically critical sectors, particularly in occupations that do not permit remote work such as construction and food services, should also be vaccinated early.
While only health workers were included in the category of essential workers, teachers, childcare providers, agriculture and food workers, and transport workers should have been added to this category.
Finally, to ensure equity, the needs of those who, at no fault of their own, are at risk of experiencing greater burdens from the COVID-19 pandemic, must be addressed.
This would include those living in extreme poverty, low-income migrant workers, nomadic populations, refugees or internally displaced persons, populations in conflict settings, those affected by humanitarian emergencies, and hard-to-reach groups.
At least one Indian state — Chhattisgarh — tried to reach out to its poorest, by proposing those under the state’s food scheme be vaccinated first in the 18–44 years category. However, after the intervention of the courts, the state had to reverse the order and allow vaccination for all adults.
What’s the fallout?
By late May, 114 of India’s least developed districts had administered just 23 million doses to its 176 million residents. India’s nine major cities received the same number of doses, despite having half as many people.
During the same period, 17% more men were immunised than women.
Equity groups need to be given priority access to vaccinations to ensure those already more vulnerable to death, disease and destitution, and least likely to be able to seek treatment due to poverty, distance, or other social disadvantages, are protected.
Rama V Baru, Jawaharlal Nehru University COVID-19 has exposed the inherent fault lines in India’s public health system. This year, as the pandemic’s deadly second wave began raging across the country, hospitals ran out of beds, oxygen cylinders, ventilators, and key drugs used in managing the disease.
Even as families of COVID-19 patients struggled to find decent hospital care, black marketeering of drugs and life-saving equipment such as oxygen concentrators and cylinders was reported across several cities.
Desperate to save their loved ones, citizens were forced to not only incur high costs of treatment at private hospitals, but also buy essential supplies, sometimes, at several times their original price.
For many, these efforts failed, as hospitals ran out of oxygen supplies and lives were lost. The misery was compounded by high costs of firewood needed to cremate dead bodies. Unable to bear those costs, many were forced to bury the bodies on shallow riverbanks or dump them in rivers.
Rural India, particularly, has borne the brunt of the deadly virus, with several villages lacking even basic testing facilities and medical care.
None of this is surprising, though.
A study published in the medical journal The Lancet in 2018 compared South Asian countries on access to health services and health care quality. It ranked India the lowest, despite the fact countries such as Sri Lanka and Bangladesh have much lower GDPs.
The answer to India’s current health crisis lies in over four decades of under-investment in health at the federal and state levels, and rampant commercialisation.
Health is primarily a state responsibility in India, with some funding coming from the federal and local governments. Publicly funded schemes support the poor and government workers, and people who are privately employed pay for their own health insurance.
However there is great variation on spending between states. And most of that spending goes to hospitals in urban areas. This has meant that over the years, regional areas and services like general practice and paramedicine have been neglected.
Several government committees have acknowledged the need to increase spending to strengthen public systems. And the pandemic has provided an urgent case. But despite this, funding has not increased.
Private profits over public health
An underfunded public health system opened opportunities for private players. Since the late 1970s, private businesses have been flourishing in all aspects of health care in India.
Private players are now dominating medical research, medical and paramedical education, and drug and tech manufacturing and development.
In the 1990s, market principles were introduced into to the health system.
This included the introduction of fees for consultation, diagnostics and drugs; hiring doctors, nurses and paramedical workers on non-permanent contracts; and encouraging public-private partnerships for developing health infrastructure and diagnostic services.
This resulted in competition between the government-funded health sector, and an unregulated and aggressive private sector. Soon, a mixed economy of the health system with an increasingly large presence of the private sector became the norm. This worsened regional, class, caste and gender inequities in access and utilisation of health services.
Since the 2000s the government has also been investing in populist health insurance schemes for the poor.
The poor are a large voter base so you can see the appeal, but the schemes create demand for high-end medical services, mostly in the private sector. As a result, government subsidies have been flowing into strengthening private health-care.
Those who need health care the most, get the least
The consequences of these trends have been devastating, particularly for populations already marginalised because of their caste, class, gender, region or religion.
These marginalised groups bear the direct cost of treatment as well as the indirect costs: transport, loss of wages, and the prohibitive cost of drugs and diagnostics.
Government underfunding of public health causes the poor to suffer, and the middle class who don’t earn huge wages but have to pay for their own health insurance also bear a heavy burden.
These trends have only been amplified during the COVID-19 pandemic. The complete lack of state protection for its citizens in the midst of a humanitarian crisis reveals its lack of commitment to the basic values of democracy.
This news comes amid anger after the first repatriation flight from India following the controversial travel ban arrived in Darwin half empty on Saturday. Some 40 passengers tested positive for COVID-19 meaning neither they, nor their close contacts, were allowed to travel.
There’s no suggestion the Sydney man was due to board that flight, or any subsequent repatriation flight. But his case puts a spotlight on the current situation in India, where countless Australians are imploring the government to bring them home from a country in deep COVID crisis.
I would argue we can, and should, bring home at least some COVID-positive Australians — particularly those at highest risk of needing hospital-level care.
Weighing up the risks
Since Saturday’s repatriation flight, there’s also been controversy over the reliability of the tests which deemed so many passengers ineligible to travel. It’s critical the Australian government irons this out to ensure pre-flight testing is as accurate as possible.
Although, even if all passengers do test negative before flying, we still can’t guarantee a flight out of India, or any country, will have no positive cases on board. There’s a blind spot in testing between the time a person is exposed and when testing will reveal the infection. This gap could be up to ten days, but for most would be two to three days.
We know even with pre-flight screening requirements up to 1% of passengers are positive by the time they arrive in Australia.
At least if we know certain passengers are COVID positive at the time of boarding, we can manage the risk of transmission in transit.
Flying COVID-positive Australians home safely
Despite our best efforts, we can’t rule out the risk of transmission if there are COVID-positive travellers on a flight.
However, transmission on planes appears to have been relatively infrequent. Recent reports of high positive rates on arrival and in quarantine may signal high rates of pre-flight exposure and transmission in transit — it’s hard to assess to what degree on-board transmission is a factor.
Although we know being in an enclosed space with someone with COVID-19 for a long time is high risk, the air in the cabin is filtered and turned over very regularly and therefore protects against viral spread. This could be why transmission on flights is not as common as we might expect.
That said, if we do knowingly put COVID-positive people on a flight with other passengers and crew, it would be important to take extra precautions.
All crew on repatriation flights should be vaccinated regardless. To minimise the risk further, all crew dealing directly with COVID-positive passengers should be wearing full personal protective equipment (PPE).
COVID-positive passengers should be seated in a separate section of the plane to those who have tested COVID negative. An analysis of possible on-board transmission during a flight from London to Hanoi demonstrated most infection risk was restricted to the business class section, with attack rates dropping when people were two or more seats apart.
Commissioning large planes with more space to spread passengers out and group them according to risk would help in this regard.
It’s already a requirement that everyone on board must wear a mask unless eating or drinking. Of course, none of this eliminates the risk completely, just as negative tests might still allow someone incubating the virus on board.
It would also be important to consider end-to-end safety including using separate buses from the airport for COVID-positive patients.
Another option would be dedicated flights for COVID-positive passengers.
Either way, it’s essential to have medical staff on board to provide care for travellers, if needed, and oversee infection control.
Accommodating COVID-positive returned travellers in quarantine
At present, Howard Springs, the Darwin quarantine facility housing returned Australians from India, is aiming to keep the number of COVID-positive residents at 50 or below.
Over time, COVID cases are increasingly likely to be asymptomatic or have mild disease if more people are vaccinated, and therefore shouldn’t need high levels of medical care. If most can stay in normal quarantine accommodation, maybe this could see the number of positive cases Howard Springs can accommodate increased.
If there’s a sound reason for this cap to remain as is, we should still use this capacity to enable evacuation of known cases at high risk of needing hospital care in India.
Sticking to a cap of 50 would likely mean we couldn’t accommodate every COVID-positive Australian who wanted to return home. But we could prioritise those at greatest risk of serious COVID disease, such as older people and those with underlying illnesses. Medical professionals would be on the ground to decide who qualifies as the highest priority.
We need to shift our mindset
Would we feel we had balanced the risks well if our thorough off-shore screening were to result in only a few positive cases in Howard Springs this month, while some people left in India were to die as a result of the virus and inadequate hospital care?
We pat ourselves on the back for what we achieved in containing the first wave by moving hard and fast, and rightly so. But as we’ve learnt more about the virus, we have become more determined to simply keep it out rather than use our knowledge and increased public health response capacity to control it.
We are now vulnerable and are resorting to inhumane steps to protect ourselves. Given the devastating situation in India, I believe it’s time to step back and weight up the true costs of the “zero tolerance” strategy underpinning our approach to repatriation.
Monica Slavin, Peter MacCallum Cancer Centre and Karin Thursky, The Peter Doherty Institute for Infection and ImmunityThis week we’ve seen reports of an infection called mucormycosis, often termed “black fungus”, in patients with COVID, or who are recovering from COVID, in India.
Fungal infections can be devastating. And in this case mucormycosis is adding to the burden of suffering in a country already in a deep COVID crisis.
As of March this year 41 cases of COVID-19-associated mucormycosis had been documented around the world, with 70% in India. Reports suggest the number of cases is now much higher, which is unsurprising given the current wave of COVID infections in India.
But what is mucormycosis, and how is it linked with COVID-19?
What is mucormycosis?
Mucormycosis, formerly known as zygomycosis, is the disease caused by the many fungi that belong to the fungal family “Mucorales”.
Fungi in this family are usually found in the environment (for example, in soil) and often associated with decaying organic material such as fruit and vegetables.
The member of this family which most often causes infection in humans is called Rhizopus oryzae. In India though, another family member called Apophysomyces, found in tropical and subtropical climates, is also common.
In the lab, these fungi grow rapidly and have a black/brown fuzzy appearance.
The family members causing human disease grow well at body temperature and in an acidic environment (seen when tissue is dead or dying or with uncontrolled diabetes).
How do you get mucormycosis?
Mucorales are considered opportunistic fungi, meaning they usually infect people with an impaired immune system, or with damaged tissue. Use of drugs which suppress the immune system such as corticosteroids can lead to impaired immune function, as can a range of other immunocompromising conditions, like cancer or transplants. Damaged tissue can occur after trauma or surgery.
There are three ways humans can contract mucormycosis — by inhaling spores, by swallowing spores in food or medicines, or when spores contaminate wounds.
Inhalation is most common. We actually breathe in the spores of many fungi every day. But our immune system and healthy lungs generally prevent them from causing an infection.
When the lungs are damaged and the immune system is suppressed, such as is the case in patients with severe COVID, these spores can grow in our airways or sinuses and invade our bodies’ tissue.
Mucormycosis can manifest in the lungs, but the nose and sinuses are the most common site of mucormycosis infection. From there it can spread to the eyes, potentially causing blindness, or the brain, causing headache or seizures.
It can also affect the skin. Life-threatening wound infections have been seen after injuries sustained during natural disasters or on battle fields where wounds have been contaminated by soil and water.
In the environment
We haven’t seen mucormycosis infections associated with COVID in Australia, and there have been very few in other countries. So why is the situation in India so different?
Before the pandemic, mucormycosis was already far more common in India than in any other country. It affects an estimated 14 per 100,000 people in India compared to 0.06 per 100,000 in Australia, for example.
Globally, outbreaks of mucormycosis have occurred due to contaminated products such as hospital linens, medications and packaged foods. But the widespread nature of the reports of mucormycosis in India suggests it’s not coming from a single contaminated source.
Mucorales can be found in soil, rotting food, bird and animal excretions, water and air around construction sites, and moist environments.
Although never compared, it may be that in Australia we have a lower environmental burden of Mucorales than in India.
Mucormycosis and diabetes
When diabetes is poorly controlled, blood sugar is high and the tissues relatively acidic — a good environment for Mucorales fungi to grow.
Of all mucormycosis cases published in scientific journals globally between 2000-2017, diabetes was seen in 40% of cases.
A recent summary of COVID-19-associated mucormycosis showed 94% of patients had diabetes, and it was poorly controlled in 67% of cases.
A perfect storm
People with diabetes and obesity tend to develop more severe COVID infections. This means they’re more likely to receive corticosteroids, which are frequently used to treat COVID-19. But the corticosteroids — along with their diabetes — increase the risk of mucormycosis.
Meanwhile, COVID itself can damage airway tissue and blood vessels, which could also increase susceptibility to fungal infection.
So damage to tissue and blood vessels from COVID infection, treatment with corticosteroids, high background rates of diabetes in the population most severely affected by COVID, and, importantly, more widespread exposure to the fungus in the environment are all likely to be playing a part in the situation we’re seeing with mucormycosis in India.
In Australia, as in many other Western countries, we’ve seen increased cases of another fungal infection, Aspergillosis, in patients who had severe COVID infections, needed intensive care management and received corticosteroids. This fungus is found in the environment but belongs to a different family.
As Aspergillosis is the most common opportunistic fungus globally, we have tests to rapidly diagnose this infection. But this is not the case with mucormycosis.
For the many patients affected with mucormyosis, the outcome is poor. About half of patients affected will die and many will sustain permanent damage.
Diagnosis and intervention as early as possible is important. This includes control of blood sugar, urgent removal of dead tissue, and antifungal drug treatment.
But unfortunately many infections will be diagnosed late and access to treatment limited. This was the case in India prior to COVID and the current demands on the health system will only make things worse.
Controlling these fungal infections will require increased awareness, better tests to diagnose them early, a focus on controlling diabetes and using corticosteroids wisely, access to timely surgery and antifungal treatment, and more research into prevention.
Monica Slavin, Head, Department Infectious Diseases, Peter MacCallum Cancer Centre, Peter MacCallum Cancer Centre and Karin Thursky, Professor, The Peter Doherty Institute for Infection and Immunity