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India must prepare for the manufacture of millions of low-cost ventilators

India is currently in the second stage of the Covid-19 crisis. The cases till now have been mostly related to travel abroad and transmission between family members and close contacts. But if the virus spreads into the general population, which is called “community transmission” and is labelled Stage-3 of the pandemic, there will be a very rapid increase of Covid-19 cases. Experts believe that it is an eventuality that must very rigorously be prepared for even while we are in this 21-day lock-down period to prevent the virus from spreading. Apart from India, the whole world faces the same threat and it is inevitable that many countries will be unable to control the virus in the second stage and it will progress into the general population. The 3rd stage is a period in which the number of infected people increase exponentially – their number doubling every few days until, if not stopped by some means, 60% to 80% of the population is infected – which would mean millions would be infected in any country where this happens, and in India it would mean hundreds of millions. While it is fervently to be hoped that our prompt actions would prevent that from happening, we must prepare for that possibility. Even if we ourselves are providentially spared, we must be prepared to help others in the world who may not be so fortunate.

The Covid-19 virus has a strangely varied effect on different people it infects. Some barely show symptoms and may not even realize that they are infected, while they still pass on the virus to others who may be more seriously affected. Others show symptoms after a few days even while in the interim they are passing on the infection to others. Of those infected, it is estimated that up to 85% will have mostly mild symptoms and will recover within two weeks. Of the remaining 15% who may need hospitalization, around one-third, i.e., 5% of the total infected persons, would pose the greatest challenge. They would develop respiratory difficulties for which ventilators for assisted breathing will become necessary. It is with regard to these ventilators that the rest of this article will focus. 

A Ventilator is a device designed to force breathable air into the lungs of patients who are unable to breathe for themselves. Modern ventilators are very expensive and sophisticated devices, which are generally found only in the ICUs of large hospitals. The most sophisticated ventilators, with computer controls, etc., cost around Rs. 40 lakhs, more modest foreign-made ones cost around Rs. 15 lakhs, Indian-made ones around Rs. 6 lakhs. There are around 40,000 ventilators in India right now, mostly in the private hospitals. The Indian industry has a manufacturing capacity of at most 6000 units per month, but even the Indian-made devices use a lot of foreign-made parts whose availability would now be uncertain, when every country would be maximizing their own ventilator production. 

Let us now consider the requirements in the case the Covid-19 crisis reaches Stage-3 in India. Assuming a low 6% infection rate, in case COVID-19 advancement in India continues, in the Indian population of 1.3 Billion, that would mean that around 80 million people would get affected. (Please note we are avoiding the more alarming 60-80% infection rate proposed by most models of a general Stage-3 epidemic. To get those figures just multiply our figures by ten). Of these 80 million, at least 5% would require ventilators, i.e., 4 million. Each of these 4 million patients would need the ventilators for around 21 days, thereby blocking that machine for at least that amount of time. Further, the machines are not portable and are found only in high-end hospitals in large cities, so patients from villages would need to be transported to these cities, which would be a logistics problem of unimaginable complexity. It is quite clear that even a mild 6% Stage-3 would overwhelm the country’s capacity to a devastating degree. Even if the Indian Industry was at peak production it could manufacture only another 60,000 machines in the next 10 months, at a cost of 3600 Crores. Therefore, the total number of ventilators would barely be 1 lakh devices – at a time when millions of machines may be needed. It is clear that we cannot depend of the conventional ventilators for a solution to this crisis.

Yet, even with these grim figures, there is hope. While the conventional ventilators are expensive, hard to produce, and not portable, there are small devices which are used to deliver breathing support in emergency situations that are inexpensive, easy to produce, and portable – which therefore have every quality that is required in this crisis. The most common of these devices is the bag valve mask, often called by the propriety name of Ambu Bag, that is used for resuscitation in emergency situations. Such devices are hand-powered and therefore not suitable for continuous use as a ventilator. However, it would be easy to design a similar device powered by an electrical source, which could be a car battery, say, apart from the conventional power supply.  It could be made portable, and therefore could be used in villages and areas without a power supply, and be inexpensive enough to manufacture in bulk. Our estimate of the cost is that it can be manufactured for less than Rs 5000, i.e., one-hundredth the cost of a conventional machine.  The cost of manufacturing 6 million of these devices will be probably less than that of the inadequate number of 60,000 conventional machines mentioned above. The cost is so low that it can be considered a single-use device that will be given over to single patient, and never used again. It needs to be manufactured, however, on an industrial scale, in millions, within a short time of a few months. 

It must be mentioned that this idea is not new. In the past few weeks, many countries have come up with this idea of manufacture of low-cost ventilators, and have even started competitions where the winning design would be declared open-source, i.e., not patented, and given free for anyone to copy if so inclined. Several designs are already available for 3-D printing, and so can be manufactured on a small scale on a 3-D printer. There have been several designs proposed within India itself, with IIT Hyderabad having at least one proposed design. While this is reassuring, we mention that there are some caveats involved – these designs are untested, and uncertified. Even if inexpensive, the designed devices should be capable of continuous and faultless 24×7 operation for at least one month – which requires very high performance both of the design and the manufactured components.   Also, while 3-D printing could be part of the manufacturing solution, conventional manufacturing may be much more effective for making the millions of devices in the most rapid and cost-effective way. It is on the steps required for this manufacture we will now focus.

We are proposing that the Government of India (through the DST/DRDO, or some other nodal organization) constitute a highly empowered task force which will carry out the tasks needed to start the production of these low-cost ventilators, within a maximum time-frame of 2 months. The production rate thereafter would need to be of several lakh units per week, so the preparation has to be done at a war-footing, under the direct scrutiny of the highest levels of Government.

We believe that such a plan is completely within the reach of our nation, but should be conducted with the utmost speed and efficiency to be useful at the time of the direst need. In the happy circumstance that the millions of devices so manufactured are not needed, i.e., if the virus is contained in Stage-2, say, India could then give these devices to other nations who may not be so fortunate. Even otherwise, due to the low costs involved, India can manufacture them beyond its own requirements for distribution to other nations. It is the least we can do for humanity in such dire circumstances.

By TIS Staffer
the authorBy TIS Staffer

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