COVID second wave: Health sector in the north-eastern States put to the test

As the north-eastern States struggle to cope with the alarming rise in cases in the second wave of COVID-19, critical gaps in public health infrastructure in the region stand exposed.

A woman from the Reang tribe receives a COVID-19 vacccine dose at Gobindabari village in Tripura on May 12.

The second wave of COVID-19 has putthe resilience of the north-eastern States to the test. The mismatch between high positivity rates and the availability of oxygen beds, ventilators and critical care service has laid bare the gaps in public health infrastructure in the region. Even in the four States with the restrictive regime of Inner Line Permit (ILP)—Arunachal Pradesh, Nagaland, Manipur and Mizoram—infections are spiralling.

The cumulative death toll in the seven States of the region, excluding Assam, in the first and second waves has risen to 1,648. As of May 13, the State-wise break up of death toll was : 526 in Manipur, 423 in Tripura, 250 in Meghalaya, 192 in Sikkim, 165 in Nagaland, 69 in Arunachal Pradesh and 23 in Mizoram. The Ministry of Health and Family Welfare data show that test positivity rates in most districts in the region were above 10 per cent in the second week of May.

Although the population is lower than the other States, the pace of vaccination in the region has been slow. Vaccination for the 18-44 age group has been delayed, with Tripura launching it on May 13 and Meghalaya on May 14, while Nagaland and Arunachal Pradesh have scheduled it for May 17. Manipur and Mizoram had not rolled out vaccination for this age group as of the second week of May.

In Arunachal Pradesh, a total of 2,92,841 doses had been administered to the 45-plus age group until May 11—2,15,168 first doses and 77,673 second doses. On May 11, the State received 20,180 of the initial four lakh doses from the Serum Institute of India (SII). On an average, 5,000 doses are administered daily. The application of the 70:30 formula for 45-plus and 18-44 age groups would leave about 6,000 doses for the latter category.

According to the 2011 Census, Arunachal Pradesh has a population of 13.84 lakh. Some of its villages are located in remote areas close to the international border, with poor connectivity. Many places can be reached only after several days of trekking through jungle and mountain routes. Uncertainty in weather conditions often makes it difficult for helicopter sorties to deliver supplies of essential commodities and medical aid.

On May 13, Arunachal Pradesh Chief Minister Pema Khandu tweeted that by end May, the State would have 500 oxygen beds and seven oxygen generation plants functioning. At present, the State has only 66 ventilators, of which 60 are in government hospitals and six in private hospitals. There are 131 ICU beds (120 in government hospitals, 11 in private hospitals).

In Meghalaya, of the total 582 beds with oxygen support, 195 beds were occupied as of May 12. The State, which has a population of 29.67 lakh , has 55 ventilators. Only nine of the 22 COVID hospitals have ventilators, according to the National Health Mission (NHM), Meghalaya. The State has recorded 250 COVID deaths, while its active caseload has increased to 3,381. It reported over 400 cases daily for four consecutive days from May 9, indicating the rapid spread of infection. The East Khasi Hills district recorded the maximum number of 226 cases of the 406 fresh cases reported on May 12. The lockdown in this district has been extended until May 24.

Of the 692 beds earmarked for COVID patients, 298 beds were available as of May 14. The State Health Department has been trying to add 300 more beds to increase the number of beds for COVID patients to 892. Chief Minister Conrad Sangma tweeted: “Cluster or Community Quarantine Centres will be created in every District. The Centres will cater to positive cases that are asymptomatic and who do not need serious medical attention. This will be done to unburden our healthcare system/facilities in the State.” He also announced that oxygen generators would be installed at Tura, Jowai and Nongpoh and made functional by June.

Manipur reported an active caseload of 5,272 until May 13. In response to the demand for vaccination, the State government increased the number of beneficiaries to 150 from 100 in each of the designated vaccination centres in the 45-plus age group. The State government has placed orders for three lakh doses with the SII. On May 11, the State reported the highest single-day COVID-19 death toll of 20, as well as 592 fresh cases, the second highest single-day spike after 600 cases on May 7. Manipur has a population of 20.55 lakh, of which 20.21 lakh live in rural areas and 8.34 lakh live in urban areas.

Mizoram reported the highest single-day spike of 240 new cases on May 12. Aizawl district accounted for the highest number of 1,433 active cases. The State has a population of 10.99 lakhs. It has 830 villages, nine district hospitals, 57 primary health centres, 370 sub-centres with at least one ANM [auxiliary nurse midwife] staff in 321 and 157 sub-centres with two ANMs as of December 31, 2020. The State has set up 42 COVID care centres with 2,295 beds and 22 community COVID care centres with 670 beds. It has administered 2,81,548 vaccines doses, which include 2.30 lakh first doses. 51,455 beneficiaries have received both doses. The estimated number of people in the 18-44 age group in the State is five lakhs. The State government has announced free vaccination for all in this category.

The devastating forest fire in Lunglei district in April exposed the vulnerability of the region to the simultaneous occurrence of multiple disasters. The State cannot afford to lower its guard against forest fire even during the pandemic, but its health system is ill-equipped to handle twin disasters.

On May 13, Nagaland (which has a population of 19.88 lakh) recorded its highest single-day spike of 366 cases and its active caseload increased to 3,297. The number of active cases had declined to nine in the last week of February. On May 1, the State had reported 1,353 active cases—1,189 asymptomatic, 113 with mild symptoms, 24 with moderate symptoms and on oxygen, and three with severe symptoms, including two on ventilator support and one on oxygen in ICU.

Dimapur district accounted for 164 active cases and Kohima district reported 124 active cases on May 13. On this day, the number of COVID patients with severe symptoms increased to 104, with 15 in ICU (10 on ventilator support) and 88 on oxygen support. The number of patients with moderate symptoms requiring oxygen support was 47. Thus, the demand for oxygen increased in less than two weeks, with the number of patients requiring oxygen support increasing from 25 on May 1 to 135 on May 13. Data uploaded on the website of the NHM, Nagaland, show that the State had only 50 ICU beds with 24 ventilators in 12 notified and dedicated COVID hospitals as of December 2020. In January, the number of ventilators was increased to 68.

The Nagaland government has decided to carry out vaccination in the 18-44 age group on Mondays and Tuesdays while vaccination for the 45-plus age group is to be carried out on the remaining days of the week. The State received a supply of 36,580 Covishield doses to roll out vaccination for the 18-44 age group. Nagaland has estimated the population in this category at eight lakhs.

On April 24, Chief Minister Neiphiu Rio wrote to Uday Kotak, president of the Confederation of Indian Industry urging him to request member companies to contribute generously to Nagaland’s endeavour to procure vaccines and provide them free of cost to its residents. The letter, uploaded on Rio’s Twitter account, says that the cost of the vaccine alone at Covishield’s stated price is Rs.64 crore and “this would be a burden on the already stretched state finances of our small State”.

Logistical challenges

He requested Defence Minister Rajnath Singh on April 28 for help with airlifting equipment for three oxygen plants as it would take 10 days for the consignment to reach Nagaland from Delhi by road. On April 30, the Indian Air Force airlifted the 13-tonne equipment meant for installing three oxygen plants at Kohima, Dimapur and Mokokchung district hospitals. The area of Nagaland is 16,527 square kilometres and its population density 120 per square kilometre. This presents a logistical challenge of maintaining the vaccine cold chain all the way to remote villages.

Tripura reported 128 COVID-19 deaths over 13 days from May 1 to May 13. The sharp increase in the death toll in May, compared to six deaths recorded in April, is indicative of the ferocity of the second wave in the State. Data on daily status released by the State government show that the cumulative death toll on April 30 increased to 395 from 389 on April 1 and active cases rose to 3,482 on May 13. Tripurahas a population of 36.79 lakh. It has so far administered 14.42 lakh doses; about five lakh people have received both the doses. The State conducted 6,234 tests, including 1,168 RT-PCR tests on May 13, of which 480 samples tested positive.

In Sikkim, the rate of COVID-19 testing has been abysmally low. The active caseload in the State increased to 2,946. In all 641 tests (rapid antigen test, RT-PCR, TrueNat/CBNAAT) were carried out on May 12, of which 231 cases were positive, with a TPR of 36 per cent. The total number of tests done in the State since February 28, 2020 is 1,02,413, including 74,696 RT-PCR and 21,763 RAT, according to the government on COVID-19. The State has received 310 oxygen concentrators while the second oxygen plant is expected to come up by the end of May. Sikkim, has a total population of 6.10 lakh. The State has administered 2.23 lakh doses, which include 1.64 lakh first doses and 59,026 second doses.

The north-eastern States are struggling to prevent the spread of COVID through the adoption of State-specific containment strategies that include the imposition of lockdown, curfew, restricting entry of people and enforcing strict surveillance and testing at entry points. However, the second wave of COVID-19 has revealed that the health sector received the least priority in the region, which New Delhi boasts of being at the centre of India’s Act East and Neighbourhood First policies.