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GS Paper: GS2-13.Issues relating to development and management of Social Sector/Services relating to Health, Education, Human Resources.

  • Antimicrobial resistance

    The article highlights the challenges posed by anti-microbial resistance (AMR) and suggests ways to deal with it.

    Understanding the severity of challenges posed by AMR

    • Antimicrobial resistance (AMR) is the phenomenon by which bacteria and fungi evolve and become resistant to presently available medical treatment.
    • AMR represents an existential threat to modern medicine.
    • Without functional antimicrobials to treat bacterial and fungal infections, even the most common surgical procedures, as well as cancer chemotherapy, will become fraught with risk from untreatable infections.
    • Neonatal and maternal mortality will increase.

    How AMR will affect low and middle-income countries

    • All these effects will be felt globally, but the scenario in the low- and middle-income countries (LMICs) of Asia and Africa is even more serious.
    • LMICs have significantly driven down mortality using cheap and easily available antimicrobials.
    • In the absence of new therapies, health systems in these countries are at severe risk of being overrun by untreatable infectious diseases.

    Factors contributing to AMR

    • Drug resistance in microbes emerges for several reasons.
    • These include the misuse of antimicrobials in medicine, inappropriate use in agriculture, and contamination around pharmaceutical manufacturing sites where untreated waste releases large amounts of active antimicrobials into the environment.

    Stagnant antibiotics discovery

    •  The Challenge of AMR is compounded by fact that no new classes of antibiotics have made it to the market in the last three decades.
    • This has happened on account of inadequate incentives for their development and production.
    • A recent report from the non-profit PEW Trusts found that over 95% of antibiotics in development today are from small companies, 75% of which have no products currently in the market.
    • Major pharmaceutical companies have largely abandoned innovation in this space.

    Measures to deal with the challenge of AMR

    •  In addition to developing new antimicrobials, infection-control measures can reduce antibiotic use.
    • A mix of incentives and sanctions would encourage appropriate clinical use.
    • To track the spread of resistance in microbes, surveillance measures to identify these organisms need to expand beyond hospitals and encompass livestock, wastewater and farm run-offs.
    • Finally, since microbes will inevitably continue to evolve and become resistant even to new antimicrobials, we need sustained investments and global coordination to detect and combat new resistant strains on an ongoing basis.

    Way forward

    •  A multi-sectoral $1 billion AMR Action Fund was launched in 2020 to support the development of new antibiotics.
    • The U.K. is trialling a subscription-based model for paying for new antimicrobials towards ensuring their commercial viability.
    • Other initiatives focused on the appropriate use of antibiotics include Peru’s efforts on patient education to reduce unnecessary antibiotic prescriptions.
    • Australian regulatory reforms to influence prescriber behaviour, and initiatives to increase the use of point-of-care diagnostics, such as the EU-supported VALUE-Dx programme.
    • Denmark’s reforms to prevent the use of antibiotics in livestock have led to a significant reduction in the prevalence of resistant microbes in animals and improved the efficiency of farming.
    • Finally, given the critical role of manufacturing and environmental contamination in spreading AMR there is a need to curb the amount of active antibiotics released in pharmaceutical waste.
    • Regulating clinician prescription of antimicrobials alone would do little in settings where patient demand is high and antimicrobials are freely available over-the-counter in practice, as is the case in many LMICs.
    • Efforts to control prescription through provider incentives should be accompanied by efforts to educate consumers to reduce inappropriate demand, issue standard treatment guidelines.
    • Solutions in clinical medicine must be integrated with improved surveillance of AMR in agriculture, animal health and the environment.
    • AMR must no longer be the remit solely of the health sector, but needs engagement from a wide range of stakeholders, representing agriculture, trade and the environment with solutions that balance their often-competing interests.
    •  International alignment and coordination are paramount in both policymaking and its implementation.

    Consider the question “Anti-microbial resistance (AMR) represents an existential threat to modern medicine. What are the factors contributing to AMR? Suggest the measures to deal with it.”

    Conclusion

    With viral diseases such as COVID-19, outbreaks and pandemics may be harder to predict; however, given what we know about the “silent pandemic” that is AMR, there is no excuse for delaying action.

  • Undermining vaccination for all

    The article highlights the issues with the new vaccine strategy adopted by the government.

    Revamped vaccine strategy

    • With the second Covid-19 wave reaching catastrophic proportions, the Government of India has acted by unveiling a completely revamped vaccine strategy.
    • Two key elements are the hallmark of this new strategy, which will be implemented from May 1.
    • First, the vaccination drive has now been extended to the entire adult population, namely, to those above 18 years.
    • Second, vaccine manufacturers have been given the freedom to sell 50% of their vaccine production to State governments and private hospitals.
    •  A third element of the vaccine strategy, which was not announced formally, is a grant of ₹45 billion to the two vaccine manufacturers, the Serum Institute of India (SII) and Bharat Biotech, to boost their capacities.

    Issues with the new vaccine strategy

    1) Control over the market for vaccine

    • The central government has given up its control over the market for vaccines, a key feature of the vaccine roll-out plans thus far.
    • This issue assumes further significance since the Government of India is well aware about the significance of vaccinating every citizen in the country; “none of us will be safe until everyone is safe”.
    •  It is, therefore, vitally important that public health authorities in the country take an objective view of the realities of the country before adopting strategies for vaccine availability.

    2) Vaccine export

    • The phased roll-out of the government’s ambitious vaccination drive, beginning with health-care and frontline workers in January was in sync with the availability of vaccines in the country.
    •  But, given that India too saw a degree of “vaccine-scepticism”, the Government of India found itself in a situation where it could promise exports of vaccines to 95 countries, mostly in Africa and Asia.
    • As of April 26, these countries have received more than 66.4 million doses of vaccines from India.
    • Until now, nearly 142 million vaccine doses have been administered in the country, the third highest in the world.
    • However, in terms of population share, less than 2% has received both vaccine doses, while less than 9% has received one dose.
    • But there is one worrying facet, which is that a demand-supply mismatch has begun to appear as the coverage of the vaccine-eligible population expanded.
    • The largest supplier, SII, gave two explanations for its inability to meet its commitments.
    • The first was that the United States Government had restricted exports of vaccine culture and other essential materials.
    • Second, the company complained that it lacked the financial capacity to expand its production, requesting a grant of ₹30 billion from the government.

    3) Onus on the States

    • Central government have allowed vaccine producers to sell 50% of their production directly to State governments and private hospitals.
    • The central government would continue to support vaccination for people above 45 years, and health-care workers and frontline workers.
    • The new strategy shifts the onus onto the State governments, which have to take decisions regarding free vaccination for people above 18 years.
    • The government has not fixed the vaccine prices and has allowed the producers to pre-declare the prices they would charge from the State governments and private hospitals, a sharp departure from the extant strategy.
    • New policy fragments the market into three layers namely, central government procurement, State government procurement and the private hospitals.
    • This layering of the market would allow the producers to charge high prices from the State governments and private hospitals.
    • The new strategy would shift the burden of vaccination of the young population, namely, those between 18-44 years, entirely on the State governments.
    •  This implies that the vaccination of a significant section of the population depends on the financial health of each State government, resulting in inequitable access to vaccines across States. 

    4) Public money given for expanding production capacity

    • In view of the advance of ₹45 billion made by the Government of India to the two vaccine producers in India for expanding their production capacities decision to deregulate the vaccine market raises serious questions.
    • This question is more pertinent in India, where access to affordable vaccines is critical for ensuring “vaccination for all”.

    Way forward

    •  Rather than allowing duopoly in the vaccine market, the government should have ensured a competitive market for vaccines.
    • One positive step that the government has taken in this direction is to increase production of Bharat Biotech’s vaccine through the involvement of three public sector undertakings, including Haffkine Institute.
    • There is a need for more open licensing of this vaccine to scale up production.

    Conclusion

    There can be no alternative to vaccination for all if we want to overcome the Covid and to ensure that government needs to rethink its new strategy.

  • Complexities of herd immunity

    What is herd immunity

    • The herd immunity concept is based on lowering the number of susceptible individuals.
    • If sufficient individuals in the population are immune either through vaccination or a prior exposure, then the number of susceptible individuals drops.
    • For example, if the immune population is 70%, then the susceptible population is 30%.

    Does herd immunity really protect from subsequent waves?

    • The number of daily cases depends on three factors: The number of infectious people in the population, the number of susceptible individuals, and the rate of transmission of the virus.
    • The rate of transmission is dependent on the nature of the virus and the extent of contact between individuals.
    • So, if the rate of transmission increases due to change in social behaviour and increased contact then even with a large percentage of the immune population, a significant number of daily cases can result.
    • The “herd immunity” number is not a static number but it changes depending on the rate of transmission of the virus and the extent of virus present.

    Estimating exposures in metro cities

    • Serosurveys indicated that Covid had touched 56% of population in Delhi by January; 75% in some slums Mumbai in November, and about 30% in Bengaluru in November.
    • The population touched by Covid can also be estimated by the Infection Fatality Rate (IFR).
    • This is the total number of deaths divided by the total people infected. In India, the estimate is 0.08%.
    • So this number can be used to back-calculate the number of infections based on the number of deaths in the different cities.
    • The table given below shows the number of people exposed to Covid in some metros until January 31 using the method above.

    What are the reasons behind the recent surge

    • The reasons behind the recent surge are not fully understood.
    • The one factor that is not in doubt, however, is that interaction and contact with the population has increased since February.
    • Such increased contact increased the virus in circulation and led to increased cases in the susceptible population.

  • Centre uses Disaster Management Act to restrict liquid oxygen use for non-medical purposes

    Order under Disaster Management Act 2015

    • Invoking the Disaster Management Act, the Centre ordered States that all liquid oxygen shall be made available to the government and will be used for medical purposes only.
    • The order said that under section 10(2)(I) and section 65 of the DM Act, States had to ensure that “liquid oxygen is not allowed for any non medical purpose”
    • The order was passed after the review of oxygen supply situation in the country.

    Dealing with the shortage

    • On April 22, Centre issued order under the DM Act, making the district magistrates and senior superintendent of police personally liable to allow unhindered inter-State movement of vehicles carrying medical oxygen.
    • Despite MHA’s orders and letters, States continued to flag shortage of oxygen supply.
    • Medical oxygen to States are being provided as per daily quota decided by an empowered group of officers in central ministries.

  • Understanding infections after Covid-19 vaccination

    Breakthrough infections

    • There have been several cases of Covid-19 vaccinated people, even those who have received both doses, testing positive for the virus.
    • Such cases are referred to as “breakthrough” infections, indicating that the virus has been able to break through the defences created by the vaccine.
    • Such cases have led to some doubts being expressed about the effectiveness of the vaccine, and contributed to the already prevailing vaccine hesitancy. 
    • However, vaccines protect not against the infection, but against moderate or severe disease and hospitalisation.
    •  It typically takes about two weeks for the body to build immunity after being vaccinated.
    • So, the chances of a person falling sick during this period are as high — or as low — as the chances for any person who has not been vaccinated.
    •  Also, those in the priority list of vaccination, such as healthcare workers and frontline workers, have been prone to getting infected due to prolonged occupational exposure to the virus

    Full protection not possible

    • It is very well understood that no vaccine offers 100% protection from any disease.
    • However, according to the Centers for Disease Prevention and Control (CDC) in the United States, vaccinated people are much less likely to get sick, but it is never entirely ruled out.
    • Then there is the emergence of new variants of the virus.
    • Some variants of the virus are able to evade the human immune response, and therefore have a greater chance to break through the defences created through the vaccine.

    Breakthrough cases in India

    • Among 10.03 crore people who had taken only the first dose of Covishield vaccina, 17,145 had got infected.
    • That translates into a 0.02% prevalence.
    • Among the 1.57 crore people who received the second dose as well, 5,014, or about 0.03%, had got infected later.
    • About 1.1 crore doses of Covaxin have been administered until now.
    • Of the 93.56 lakh who took only the first dose, so far 4,208 have got the infection.
    • That is about 0.04% of the total.
    • Among the 17.37 lakh who have taken the second shot, only 695 had been infected, again 0.04%.

    Challenges

    • “Given the scope of the pandemic, there’s a huge amount of virus in the world right now, meaning a huge opportunity for mutations to develop and spread.
    • That is going to be a challenge for the developers of vaccines.

  • Emergency use nod for Virafin

    About the drug

    • It is used in treating people with chronic hepatitis B and C. 
    • The Drug Controller General of India (DCGI) granted emergency use approval for pharma major Zydus Cadila’s antiviral drug ‘Virafin’, to treat moderate COVID-19 disease in adults.
    • When administered early on during COVID, Virafin will help patients recover faster and avoid much of the complications.
    • It significantly reduces viral load when given early on and can help in better disease management.

    Findings of the clinical trials

    • A single dose subcutaneous regimen of the antiviral Virafin [a pegylated interferon alpha-2b (PegIFN)] will make the treatment more convenient for the patients.
    • When administered early on during COVID, Virafin will help patients recover faster and avoid much of the complications.
    • In the phase-3 trials, the drug was able to achieve “better clinical improvement in the patients suffering from COVID-19”.
    • A “higher proportion (91.15%) of patients administered the drug were RT-PCR negative by day seven as it ensures faster viral clearance”.
    • The drug reduced the duration for supplemental oxygen to 56 hours from 84 hours in moderate COVID-19 patients.

    How the drug works

    • Type I interferons are the body’s first line of defence against many viral infections.
    • In old people, the ability to produce interferon alpha in response to viral infections gets reduced, which might be the reason for higher mortality.
    • The drug when administered early during the disease can replace this deficiency and help in the recovery process.

  • Very few post-vaccine infections

    Breakthrough infection

    • ICMR said that a small fraction of those vaccinated with either Covaxin or Covishield have tested positive (i.e. breakthrough” infections).
    • However, these instances do not undermine the efficacy of the vaccines.
    • The immune response begins to develop usually two weeks after every dose and there are variations within individuals, too.
    • Of the 9.3 million who received the first dose of Covaxin, 4,208 tested positive; and of the 1.7 million who received the second dose, 695 tested positive.
    • For Covishield, of the 100.3 million who received the first dose, 17,145 tested positive; and of the 15 million who got the second dose, 5,014 tested postive.

    What explains infections after vaccination

    • Healthcare and frontline workers, who were among the first to be vaccinated, were as a population far more exposed to the virus and therefore more susceptible.
    • Secondly, the emergence of “the highly transmissible second wave (newer variants) ” may have contributed to instances of infection among those vaccinated.
    • Several variants, which have mutations that have been shown to avoid detection by the immune system, and in some cases reduce the efficacy of vaccines, have been reported globally, including in India.

  • Tackling second Covid wave

    The article suggests ways to deal with the second wave of Covid in India.

    What explains the bigger second wave

    • The size of any epidemic is a function of three things:
    • 1) The size of the pool of the susceptible population.
    • 2) The pattern of contact between the members of the population (frequency, mix, closeness and duration).
    • 3) Probability of spread during that contact (infectiousness of the agent).

    Let us have a look at these 3 factors in the current context

    • As many people have already been infected in the first wave, the pool of susceptibles should be smaller.
    • Serosurveys also support this as they found that about 25 per cent of people had already been infected nationally.
    • However, this is an average and hides significant variations by state, age and place of residence.
    • Populations with lower seroprevalence become the potential pool for the second wave.
    • Given India’s large population base, the actual number of people are sufficiently large to enable multiple waves till we achieve a more even spread of protected people.
    • The persistence of protectiveness of antibodies of those already infected and their cross-protectiveness to newer strains is not well established.
    • Vaccination would reduce the pool of susceptibles.
    • However, the current level of vaccination coverage is not sufficient to make a significant difference to this wave, given the fact that we are already riding it.
    • It is a good strategy to prevent the next wave, if we can achieve substantial coverage with it.
    • Vaccination also prevents severe disease, and hence reduces the death toll.
    • With the removal of most restrictions, the probability of contact between individuals has risen sharply.

    Way forward

    • What can and should be avoided are super-spreader events like a crowded park, the Kumbh mela, election rallies, etc.
    • A much stronger community engagement with a robust communication strategy and lesser emphasis on “criminalising” inappropriate behaviour is required.
    • A nuanced communication campaign is the need of the hour and is conspicuous by its complete absence.
    • What is urgently needed is a robust evidence-based communication campaign.
    • Such a campaign would involve proactive serial assessment of the community perceptions and concerns, testing and refining messages through an evolving campaign.
    •  A district-specific strategy of “test, trace, treat” along with containment measures (isolation and quarantine) is still the best way to deal with the situation.
    • We also need to put a stop to political bickering; it erodes public trust and confidence.

    Conclusion

    Dealing with the second wave should be based on the experience drawn from dealing with the first wave and complemented by a better communication strategy.

  • [pib] MANAS Platform

    The MANAS App to promote wellbeing across age groups was recently launched.

    Name, acronym and the purpose; thats all. The rest of the theory is of less importance.

    MANAS Platform

    • MANAS is an acronym for Mental Health and Normalcy Augmentation System.
    • It is a comprehensive, scalable, and national digital wellbeing platform and an app developed to augment the mental well-being of Indian citizens.
    • MANAS was initiated by the Office of the Principal Scientific Adviser to the Government of India and jointly executed by NIMHANS Bengaluru, AFMC Pune and C-DAC Bengaluru.
    • It was endorsed as a national program by the Prime Minister’s Science, Technology, and Innovation Advisory Council (PM-STIAC).
    • It integrates the health and wellness efforts of various government ministries, scientifically validated indigenous tools with gamified interfaces developed/researched by various national bodies and research institutions.

  • NCAHP Bill 2020

    The article highlights the key aspects of NCAHP Bill 2020 which recognises the allied healthcare professionals and seeks to regulate and set the standards of education.

    Regulating allied health professions

    • The National Commission for Allied and Healthcare Professions Bill, 2020 (NCAHP) was passed by Parliament in March.
    • Global evidence demonstrates the vital role of allied professionals in the delivery of healthcare services.
    • They are the first to recognise the problems of the patients and serve as safety nets.
    • Their awareness of patient care accountability adds tremendous value to the healthcare team in both the public and private sectors.
    • The passage of this Bill has the potential to overhaul the entire allied health workforce by establishing institutes of excellence and regulating the scope of practice by focusing on task shifting and task-re distribution.

    What the Bill provides for

    • This legislation provides for regulation and maintenance of standards of education and services by allied and healthcare professionals and the maintenance of a central register of such professionals.
    • It recognises over 50 professions such as physiotherapists, optometrists, nutritionists, medical laboratory professionals, radiotherapy technology professionals, which had hitherto lacked a comprehensive regulatory mechanism.
    • This Bill classifies allied professionals using the International System of Classification of Occupations (ISCO code).
    • This facilitates global mobility and enables better opportunities for such professionals.
    • The Act aims to establish a central statutory body as a National Commission for Allied and Healthcare Professions.
    • The Bill has the provision for state councils to execute major functions through autonomous boards.

    Shift in perception and policy in healthcare delivery

    • There has been a paradigm shift in perception, policy, and programmatic interventions in healthcare delivery in India since 2017.
    • In the past, curative healthcare received substantially greater attention than preventive and promotive aspects.
    • Ayushman Bharat as a programmatic intervention, with its two pillars of Health and Wellness Centres (HWCs) and Pradhan Mantri Jan Arogya Yojana (PMJAY), operationalised certain critical recommendations of the National Health Policy, 2017, emphasising wellness in healthcare.
    • With PMJAY, the neediest are protected from catastrophic expenditure and India took the first step towards delivering comprehensive primary healthcare with HWCs.

    Conclusion

    Caring for patients with mental conditions, the elderly, those in need of palliative services, and enabling professional services for lifestyle change related to physical activity and diets, all require a trained, allied health workforce. The NCAHP is not only timely but critical to this changing paradigm.