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Ventilators to determine the fatality rate

As India continues to battle against COVID-19, ventilators will play a large part in determining what the fatality rate will be, at least until there is a vaccine to help save lives.

As COVID-19 infections increase globally, the concern on shortage of life-saving equipment and other essential supplies to prevent the spread of the virus and care for the sick also broadens. There is an urgent need for rapid escalation in the manufacturing of a full range of test kits, gloves, and masks. Of these, the ventilator is perhaps the most critical, and the one in maximum shortage.

In particular, until a pharmacological treatment can be developed, ventilators are the vital treatment option for the minority of COVID-19 patients who require critical care. Ventilators help coronavirus patients breathe as their lungs begin to fail, they have quickly become one of the most sought-after medical devices on the planet. Amid shortages, governments are turning to help from the military, enlisting other manufacturers and even looking to 3D printing in the hopes of ramping up production of the potentially life-saving breathing machines. They are calling on industry to increase production of ventilators, and coordinating with other firms to maximize the use of existing facilities and the building of new capacity may well be the most efficient way to respond to this challenge. Although competition-enforcement authorities generally recognize the importance of collaborative efforts to develop crises responses, antitrust risk surrounding discussions between parties operating in the same market, however well intentioned, remains. In particular, for the existing vendors, sharing competitively sensitive information, using discussions as an opportunity to set prices, restrict output, divide customers and markets, and coordinate on commercial strategy remains high risk.

Getting the parts that go in it will be difficult at a time when some countries are shutting borders or taking steps to safeguard stocks of medical supplies. If the imported materials cannot be supplied in time, the production capacity will be severely affected. For instance, Beijing Aeonmed relies on imports from countries including Switzerland, the United States, and The Netherlands for key components such as valves and turbines to make ventilators. However, the company’s international suppliers have had trouble during the global outbreak in sourcing some basic parts to produce the components it needs. The company has even tried to help its international suppliers to replace those previously foreign-made supportive components with China-made alternatives. But if the imported materials cannot be supplied in time, the production capacity of some ventilator models at the Aeonmed factory will be severely affected.

Global scenario
As the coronavirus spread, the nightmare scenario quickly sounded alarm bells in most countries that they would need more ventilators to prevent mass casualties. Governments even blocked companies from selling them abroad.

As Italy’s medical system became overwhelmed with coronavirus patients in recent weeks, doctors soon realized they did not have enough ventilators to save them all and were forced to choose which patients lived and which died. A team of doctors has developed a way to provide oxygen to two people from one ventilator, therefore doubling capacity.

In Germany, where hospitals had about 20,000 ventilators before the outbreak, the government has placed an order for 10,000 machines from Draegerwerk, the equivalent to a year’s normal production at the company.

Demand in France, which is usually for about 1000 to 1500 ventilators annually, has increased to hundreds per week.

The British government is trying to get as many ventilators as they can get their hands on. It has increased its stock to about 8000 ventilators.

At least 950,000 coronavirus patients in the US could need ventilators, according to the Society of Critical Care Medicine, but hospitals have just 160,000. The hospitals are considering re-deploying older ventilators, which still work but had been abandoned because they did not connect to modern electronic records systems. They are also looking into re-purposing the machines that administer anaesthesia to be used as ventilators.

Russia appears to be in a better starting position than other countries. Russia has a total of around 42,000–43,000 ventilators in its state hospitals around the country, and Russia only had 253 reported coronavirus cases on March 21. But medical experts are concerned that 25 percent of the country’s ventilators are located in the plush areas as Moscow, the Moscow region, and St. Petersburg. And going one step further, Russia’s rich are setting up makeshift clinics in their own homes to ensure they can have better care than the masses, if they get infected. And in what may have severe ramifications down the road for Russia’s battle against the coronavirus, they are buying up and hoarding the ventilators that have proven essential in saving lives in severe cases.

Non-MedTech companies to supply ventilators
Some countries, including Italy, Britain, and the United States, are drafting automakers and aerospace manufacturers to ramp up ventilator production. Authorities are seeking that big manufacturers repurpose some factories and use digital design expertise, including 3D printing, to make up the expected shortfall in vital medical hardware.

McLaren Group Ltd., a conglomerate that includes a sports-car maker, is looking at how to design a simple version of a ventilator. Nissan Motor Co. is working with others to support existing ventilator producers. Ford Motors is also weighing plans to do so. General Motors is collaborating with Ventec Life Systems to help the company increase output of its respiratory care products, including by providing logistics, purchasing, and manufacturing resources. Elon Musk promised to use the supply chains that support Tesla Inc. and SpaceX for help in assembling ventilators. SpaceX has been in a long engineering discussion with ventilator manufacturer Medtronic, which has operational headquarters in Fridley, Minn. ResMed has reallocated resources away from producing other devices to meet demand that is more than four times normal levels.

However, it is not easy to ramp up production. It could take about three months for manufacturers to increase their capacity, and even longer for companies without prior experience making ventilators. That means companies that have offered to build ventilators could expect even longer lead times.

For one, there is a difference between the ventilators used in ICUs and the ones used at home for patients with severe chronic respiratory failure, or in ambulances. Medtronic, for instance, uses more than 1500 parts to make high-performance ventilators, and currently partners with more than 100 suppliers from around the globe. The company manufactures high-performance ventilators in Galway, Ireland.

Indian scenario
India has about 40,000 ventilators in running condition. It is expected, as of now, that 20 percent to 60 percent of the 1.3 billion Indian population may get infected with coronavirus, translating to 260 to 780 million people, depending on the severity of the epidemic. Of that only about 2 percent are expected to be severe cases, and they will definitely need ventilators. Thus, as a conservative estimate, India will need at least 5 million ventilators to treat its infected, expected to be mostly over the 65-year age bracket. India neither has the financial muscle, nor suppliers who can export this quantity, while their own country is in the midst of an acute shortage. This calculation is supported by Ramanan Laxminarayan, Affiliate Professor, Global Health; and Director and Senior Fellow, The Centre for Disease Dynamics, Economics and Policy, Washington DC. Since 1995, Laxminarayan has worked to improve the understanding of antibiotic resistance as a problem of managing a shared global resource.

The vaccine is at least 12–18 months away, and over the next three months the cases will increase exponentially. The Indian government will need to invest large amounts of moneys into ventilators to succeed in its fight against this virus. India will need to bank on indigenous sources as Mahindra Group, Tatas and Maruti, who have announced plans to repurpose their facilities to manufacture ventilators, and on indigenous manufacturers as Skanray and AgVa to ramp up production, and encourage manufacturers as stent manufacturers, SMT for 3D manufacturing of ventilators. Arming up with 70,000 units, a requirement the Indian experts are agreeing on, at an investment of Rs 5000 crore may be a good beginning!

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