On Monday, India’s cumulative tally of Covid-19 cases crossed the 50 lakh-mark as the surge in daily cases continued unabated with an addition of another 90,123 new cases. The sustained and record surge in the number of cases over the last two weeks has put a strain on medical oxygen supply in some states. Although the situation has not spiralled out of control, the Centre this week took cognizance of the issue of medical oxygen shortage in some states and directed them to not impose any restrictions on inter-state movement of life-saving commodity.
The central government’s directive came amidst trouble between Madhya Pradesh and Maharashtra governments after the latter’s decision to restrict movement of medical oxygen in the wake of a spike in cases. In fact, the matter reached the Madhya Pradesh High Court, which ordered the Maharashtra government to ensure uninterrupted oxygen supply to Madhya Pradesh. There have also been similar instances of restrictions placed on the movement of oxygen between districts.
News18 explains the issues surrounding medical oxygen, its use, production capacities and procurement.
What is medical oxygen?
Medical oxygen is an essential medicine that is used to treat a range of ailments and in several medical procedures. It figures in India’s National List of Essential Medicines, 2015, and World Health Organization’s (WHO) list of essential medicines. Its medical uses primarily include, among others, treatment of respiratory illnesses, prevention of hypoxemia (low blood oxygen levels), neonatal care and emergency care. According to WHO, medical oxygen contains at least 82% pure oxygen and is free from contamination. Only medical grade oxygen is used as medicine.
Medical oxygen is produced using various methods, such as cryogenic distillation process for making liquid oxygen and in oxygen generation plants. Cryogenic distillation involves separating oxygen from nitrogen and argon after condensing atmospheric air using air separation.
Why is it crucial as a line of treatment against Covid-19?
Once the Covid-19 disease sets in, it affects the patient’s lungs and causes a dip in the blood oxygen level. This can adversely affect other vital organs, too. In the absence of any single effective line of treatment, drug or vaccine against Covid-19, oxygen therapy has proven to be the most efficient in treating moderately ill and severely ill patients. However, it is used more often in moderately-ill patients, according to doctors.
“Covid-19 poses serious trouble to the lungs and if the level of oxygen in the patient’s blood or oxygen saturation starts dropping below normal levels, we start oxygen therapy. It has been found to be effective, especially if the therapy is timely. In 10 patients, only two require oxygen therapy,” said Dr. Suresh Kumar, Director, Lok Nayak Jai Prakash Narayan Hospital. (LNJP). LNJP is Delhi’s biggest public hospital for Covid-19.
According to the health ministry, six per cent of patients in the country required oxygen support as on September 15. This included those in intensive care units, on ventilator support and in regular Covid-19 wards.
Who manufactures medical oxygen?
In India, oxygen is commercially produced largely for use in manufacturing industries such as steel plants, fabrication units, chemical industries, glass manufacturing and paper and pulp industries. In pre-Covid-19 times, industrial clients accounted for the lion’s share of oxygen use. However, in April this year, the central government permitted companies producing industrial oxygen to produce the its medical variant in order to meet the demand created by the Covid-19 crisis.
There are four to five large manufacturers in India which include Linde India, Inox Air Products and Goyal MG Gases. These companies make liquid oxygen. There are also other companies that run oxygen generation plants and many are based in Gujarat, Maharashtra and Tamil Nadu.
How do hospitals procure it?
Across large, medium and small hospitals and nursing homes, medical oxygen is procures in two or three different ways. Many hospitals have on-site oxygen generation plants which are connected by pipes to the wards, intensive care units and critical care units where it is administered to patients. This facility, however, requires uninterrupted power supply.
Hospitals that do not have their own oxygen generation plants source it from companies like Inox and Linde in liquefied form and store it in liquid oxygen tanks on the hospital premises. Even this system requires laying a central pipeline, which needs regular maintenance. Refillable cylinders, that can be filled at oxygen generation plants, are one of the most commonly used methods to procure medical oxygen. The oxygen is stored in the cylinder in compressed form and can be connected to a patient’s bed or a central pipeline.
Once cylinders are exhausted, they need to be refilled. In most cases, dealers who run oxygen cylinder businesses also refill them for the hospitals. Using cylinders though is heavily reliant on transportation.
Following issues in supplies and to meet high demand, some districts in Maharashtra are also setting up new oxygen generation plants.
Why is there a shortage?
As stated earlier, in April, the government allowed industrial oxygen producers to make medical oxygen as well. However, that was during a nation-wide lockdown and industries were shut. The surge in cases has coincided with the resumption of economic activities, including industrial activity. This has meant that industrial oxygen demand is slowly going back to normal, but state governments have ordered that medical oxygen should be priority and supply to industries should be kept low.
The relentless rise in the number of cases, although, has driven up the demand for medical oxygen manifold. With demand shooting up come issues of delay and hiccups in supply chains. Therein lies the main cause of shortage. There are delays in the supply chain, at the end of both liquid oxygen makers as well oxygen generation plants. These are compounded by limited availability of tankers to transport the commodity. In some cases, like is being seen in Marathwada, refilling of cylinders is taking time due to overwhelming demand.
Madhav Biradar runs an agency dealing in oxygen cylinders in Osmanabad city in Maharashtra’s Marathwada region. Biradar said the demand is so high that oxygen that was used over six days is now getting used up in a day or two. This has put a stress on generation plants too, he said.
“Two months back my clients needed 25-30 cylinders per day which have a capacity of 6,000 to 7,000 litres of oxygen. Now, the demand is almost 100 cylinders per day. When I go to refill the cylinder, sometimes I have to wait for half a day. Plants outside my district are asking me to not even try coming and this is the situation is only in the city. I also have no choice but to pass on transportation overheads and delays on to the buyers,” said Biradar.
What is the national production capacity and how much is being consumed?
Union health secretary Rajesh Bhushan said Tuesday that every day, India produces 6,000 metric tonnes oxygen. Of this, 2,800 MT is being used for medical purposes including for Covid-19 treatment, while 2,200 was being used in industries. “There is a head room of 1,000 MT and looking at the national level, there is no shortage of oxygen. As on Tuesday morning, we had a surplus of 1,900 MT.
Bhushan urged hospitals and other medical facilities to maintain an inventory management. “The problem arises when there is no oxygen inventory management and when there is a possible shortage of alert generation mechanism at the hospital level which needs to be monitored by states and UTs, so that replenishment can be done in a timely manner. Health Ministry has held detailed meetings with states, in which it has been advised to start a control room for monitoring oxygen supply and requirements on a daily basis,” the union health secretary said.