The Indus Health Network’s
response to COVID-19
The Indus Health Network has been and continues to be, at the forefront of the battle against coronavirus in Pakistan. This can be gauged from the swift response of the organization to the pandemic, the brisk rate of increase of COVID-19 handling capacity of the Network, as well as the multi-faceted response of the organization to the pandemic. The dynamics of the Indus Health Network were rapidly transformed to adjust to the demands placed on the system by the pandemic, including a revision of the scope of services, expansion of the infrastructure, as well as the initiation of diagnosis and treatment of COVID-19 in line with internationally recommended guidelines
IHN’s comprehensive response to the COVID-19 pandemic can be grouped in the following
Policy Engagement and Collaboration with provincial governments
Indus Health Network is supporting the provincial Governments right from the onset of
COVID-19 in Pakistan.
Contribution in Policymaking Decisions
The honorable Chief Minister of Sindh, Syed Murad Ali Shah included The Indus Hospital (Indus Health Network) in the anti-coronavirus campaign. Dr. Abdul Bari Khan, Chief Executive Officer was selected as a member of Chief Minister of Sindh’s Corona Task Force. Dr. Bari’s contributions were based on the insights derived from the massive COVID-19 workload that The Indus Hospital was catering to and were instrumental in the formulation of province-wide policies for pandemic control.
Support to Government for COVID-19 Testing and Screening
IHN through its’ public-private partnership initiatives, is a major testing center for samples collected at government-run hospitals. Currently, TIH is receiving samples from districts Thatta, Badin, South Karachi, West Karachi, Korangi, Central Karachi, Lasbela, and Baluchistan.
Support to Establish Government-run Facilities
The Indus Health Network helped the Government of Sindh in setting up a 100-bed quarantine center in Dumba Goth. As well as a 120-bed COVID-19 hospital in Gadap Town, and a 20-bed COVID-19 unit in Badin.
Coordination with Other Hospitals Dealing with COVID-19
A weekly meeting was held among the managing directors of seven public sector hospitals to create a central dashboard to oversee the progress.
RTEH Designated as Referral Center for South Punjab
The 175-bed facility at the Recep Tayyip Erdogan Hospital (RTEH), Muzaffargarh was dedicated as a major referral center for COVID-19 in South Punjab with a mutual understanding of IHN and the Government of Punjab.
Governance Framework and Foundation Activities
Formation of COVID-19 Lead Group
To govern and manage all pandemic-related activities in a streamline manner several committees were formed as a part of the lead group which includes members of the Emergency Response Committee, Disaster Management team, and Infection Control Committee
CSM as Operations Lead for COVID-19 Activities
As a response to the rapidly evolving international guidelines on COVID-19 management, a Clinical Services Management (CSM) was established, and assigned the role of COVID-19 operations lead. This was also endorsed by hospital operations, thus enabling uniformity of command and quick execution of decisions relating to COVID-19 management. CSM was also the focal department dealing with COVID-19 related internal and external affairs, including engagement with the respective government departments and agencies, as well as private donors and other stakeholders.
Mobilization of Human Resource
With the increase of COVID-19 dedicated beds in the in-patient settings, physicians, nursing, and ancillary staff number was increased by re-allocating them to the COVID-19 unit.
Arrangement of Equipment
Equipment, including ventilators and monitors, was ensured in close collaboration with other hospitals as well as Indus’ Supply Chain and Biomedical departments.
Availability of Medications
All specialized medicines were made available in TIH and RTEH by the pharmacy department.
It was ensured by limiting the number of attendants and a ‘No Visitor’ policy.
Personal Protective Equipment (PPE)
A centralized PPE counter was established to control the consumption of PPE at TIH. A protocol was designed for not only providing the front line operators with appropriate PPE but also to ensure its availability.
COVID-19 PCR Testing
COVID-19 testing capacity by Polymer Chain reaction (PCR) was increased at TIH from 0 to 2500 per day in just 14 weeks. The first SARS-CoV-2 RT-PCR testing was initiated within three weeks of the onset of the pandemic. The first batches of PCR testing was done using manual methods. However, as workloads increased, automation was also introduced enabling the lab to continue to respond effectively to the ever-increasing demands placed on its services.
Testing with Automated Extraction
During March 30 – April 6, fully automated RNA extraction was initiated, enhancing the lab’s capacity to conduct 7,000 tests a week.
Testing by GeneXpert
Using the funds provided by Global Fund for TB, the Global Health Directorate (GHD) team was able to mobilize savings to help get GeneXpert SARS-CoV2 cartridges to the laboratory services. This expanded testing options by utilizing GeneXpert machines (originally used for TB) with a turnaround testing time of two hours.
Electronic Data Entry for Community Collection
The laboratory along with the GHD team developed an electronic data entry for community collection. This employed an end-to-end electronic system which further improved efficiency. To date, the laboratory at Indus Hospital has conducted more than 170,000 SARS-CoV-2 PCR tests.
To match the rapidly increasing capacity of the lab, training was conducted for the staff of PNS Shifa Hospital, Abbasi Shaheed Hospital, Faisal Base Hospital, and Recep Tayyip Erdogan Hospital. Initially, The Indus Hospital had three technical staff trained to do PCRs but by week 14, a total of 58 staff were working in three shifts. After week 14, the staff requirement was reduced by 40% as efficiencies were improved through staff training, updating of the laboratory Management Information System and more automation in testing.
Diagnostic Facility at RTEH
A new diagnostic facility for COVID-19 was established at RTEH with the help of the Government of Punjab.
Indus Hospital Research Center (IHRC) in collaboration with the Infectious Diseases and IT department, developed the first Pakistan-specific self-screener for COVID-19 based on Infectious Diseases guidelines. http://covid19.tih.org.pk/
Respiratory Emergency Room
To ensure staff and patient safety, it was necessary to control the spread of COVID-19 within the Emergency Room. Appropriate ventilation mechanisms to handle airborne infections were designed and installed, modifying the Emergency Room into a Respiratory ER and a non-Respiratory ER, each having 11 beds
Initially, a 20-bed COVID-19 unit with an ICU facility was established which was later expanded to 55 beds. The unit managed COVID -19 patients of all severity, including critically ill patients needing ventilation.
Modifications at Sheikh Saeed Memorial Campus
Obstetric Labor Room, Neonatal ICU, and Operating Room were modified at SSMC to continue maternal and neonatal care without compromising on safety and volume. A COVID-19 labor room and operating theater was established to deliver coronavirus positive mothers in a safe environment.
COVID-19 Unit in Badin
The District Headquarter Hospital, Badin, is one of the government-funded hospitals managed by IHN, operating under a public-private partnership. The hospital established a 20-bed COVID-19 Unit which served as the major referral point for Northern Sindh.
The Indus Hospital started COVID-19 clinics for hospital staff and rehabilitation of recovered COVID-19 patients. It also has a dedicated acute and maintenance dialysis facility for positive patients.
Follow up of Stable COVID-19 Patients at Home
Patients on home isolation were guided throughout the isolation period whenever required.
The COVID-19 pandemic has adversely affected all areas of healthcare delivery, blood transfusion services being one of them. Social distancing, reduced mobility, and the lockdown have resulted in reduced blood donor mobilization and blood collections. To overcome the hurdle, the Indus Hospital Blood Center contacted potential donors through social media. It was a mid-scale campaign to connect with donors to organize small-scale blood drives at their residences. The Indus Blood Center managed to conduct 97 blood drives, 42 home collections and drew 1,858 units of blood in March 2020.
Physiotherapy Management for Post-COVID Patients
216 coronavirus patients received physiotherapy support. These patients were the ones who were hospitalized and treated with a ventilator. They received post-COVID rehabilitation helps for Post Intensive Care Syndrome and Intensive Care Unit Acquired Weakness.
Development of Guidelines
COVID-19 guidelines were developed to bring uniformity in treatment and management. These included COVID-19 treatment guidelines for adults; COVID-19 treatment guidelines for children; COVID-19 home care guidelines; Ethical guidelines for doctors and staff; Burial guidelines (English and Urdu); Policy for exposed healthcare workers; Donning and doffing.
Courses and Webinars
The hospital conducted several webinars and lectures for clinical and paramedical staff.
Data Management and Research
Data management modules and structures were developed to maintain uniformity. The Electronic Medical Record (EMR) data was shared with the government daily.
The psychosocial team has been playing an active role in providing psychological counseling, morale-boosting activities, and mental health support to patients and caregivers.
The pediatric complex of the Indus Hospital has an exclusive play area for pediatric patients. During COVID-19, the play area was designated as the Worry-Free Zone for TIH staff. The staff used it for relaxation during the COVID-19 breakout.
Research Proposals and Studies
The Indus Hospital Research Center (IHRC) has conducted multiple researches on COVID-19. To date there are nearly 37 research studies at various stages; seven of which are sponsored studies. The sponsored studies are as follows:
- Solidarity Trial [WHO]
- Efficacy and Safety of Favipiravir on mild COVID-19 patients [Martin Dow]
- Efficacy and Safety of JHQ granules for treatment of mild COVID-19 patients [International Center for Chemical and Biological Science (ICCBS, Karachi University), and Beijing Institute of Biological Products Co.]
- Phase III placebo control AD-5 vaccine trial – efficacy, safety, immunogenicity [NIH (Pakistan) and CanSino Biologics (China)]
- Phase I placebo control inactivated vaccine trial – safety, immunogenicity [Int’l Center for Chemical and Biological Science (ICCBS, Karachi University), and Beijing Institute of Biological Products Co.]
- Efficacy of the Alnno-Ventura CPAP System in patients requiring continuous positive airways pressure to reduce respiratory distress [Alsons Group]
Point of Care Test
- Proof of Concept for the Panbio™ COVID-19 Ag Antigen Test in Symptomatic Subjects (POC) [Abbott, USA]
As part of the research support, the IHRC team has helped faculty develop proposals, analyzed data; helped with grant applications and budgets.
Pilot Antibody Testing
GHD along with IHRC collaborated with the Government of Sindh, and Aga Khan University to plan and conduct a pilot antibody testing survey to help influence lockdown decisions. The Indus team was responsible for all epidemiological aspects including sampling and design of the survey.
COVID-19 Research Oversight Committee
The Committee was established to ensure standards and inclusiveness of pertinent stakeholders in all COVID-19 research.
Public Health Initiatives
Training and Learning at GHD
During the pandemic, GHD’s training and learning department conducted training on awareness, screening, sampling, sample handling, and the use of PPEs. 333 healthcare professionals from IHN and other partner institutes were trained.
Screening of All Employees, Patients and Attendants
Screening desks were set up at every significant point of the campus across all IHN health facilities to minimize the spread of disease among staff, patients and attendants. People with wymptoms were directed towards the isolation area or ER for further evaluation and testing. Throgh integration of these services, over 10,000 individuals have been screened and over 7,000 patients have been tested to-date.
Drive-through Screening and Testing
In March 2020, a public-private partnership between Karachi’s District South administration and GHD was initiated to screen and/or test individuals for COVID-19. The district administration set up the country’s first drive-thru COVID-19 screening and testing facility. Citizens can make a phone call to the helpline 1166 to get an appointment for PCR testing after answering a few basic risk-assessment questions. Due to the low coronavirus numbers and decreased demand, it is currently functioning as a walk-in clinic. The on-ground operations of the facility includes verbal symptom screening, assessment by a medical officer, chest X-ray, and nasopharyngeal swab collection — are all managed by the GHD team. The goal of this testing facility is to screen and test masses while minimizing physical contact by limiting individuals to their vehicles. Through this initiative, more than 1,800 people have been screened and tested and more than 1,100 cases have been identified.
Active Screening COVID-19 Clusters
In collaboration with the district governments, GHD provided screening, triage, and swab collection facilities in sub-sets of different districts in Karachi that had been identified as high-burden areas for COVID-19.
In districts Malir and West, GHD teams have been working alongside the deputy commissioner and district health office teams in high-burden areas identified based on case detection. The mobile X-Ray vans were mobilized on a need basis near hotspots where they would set up a screening and testing camp. As District West was identified as a high-burden vicinity, a fixed screening, and testing facility was set up at Qatar Hospital, Orangi Town by The Indus Hospital, District West administration, and GHD. It facilitated walk-in patients, six days a week without prior appointments. GHD made its screening and testing services available for public and private sector organizations — people at Baldia Police Training Center, SITE police station, Binoria University hostel, and several factories and offices were screened and tested for COVID-19 through this facility.
This component functioned when the district would alert the GHD team for the cases that had been detected through the PCR testing and had close contacts that fell under the criteria of high-risk populations. The District Health Office would manage to bring in all such people to a nearby health facility where the GHD team would set up a contact screening and testing facility with a mobile X-Ray van. In all such instances, the X-ray image was also read for TB indication.
Primary Care Community Health Centers
The Community Health Centers remained open while most public health programs operations were impacted. Tuberculosis, HIV, Maternal and Neonatal Child Health, Malaria, and Hepatitis-C teams came up with solutions to ensure the continuation of medication supply for those under treatment to prevent treatment failures. These solutions included: provisions of medicine for a longer period; delivery of TB medicine at the patients’ homes; active follow-up, etc. Teleconsultation was provided to those patients that suffered from chronic conditions.
Community Health Workers (CHW) were integrated into COVID-19 response. They were initially involved in delivering COVID-19 awareness sessions in the community before lockdown. CHWs conducted 186 sessions in communities across Karachi, interior Sindh, and Punjab, having engaged 1,753 participants.
CHWs are now involved in COVID-19 screening, testing, data collection, and management across all the Primary Care Program sites in which Community Engagement Center is operational. These operations have reached thousands of individuals seeking care for COVID-19. They also conducted follow-up phone calls and voice note engagements with community members during this time to understand their experiences of COVID-19 and link them to help where possible. CHWs have also, with the help of community engagement center (CEC) teams, identified 4,250 vulnerable families in need of immediate support during the pandemic. Through funds from external donors, CEC was able to provide 3,226 families with ration support.
In partnership with IRD’s ‘Pursukoon Zindagi’ program a comprehensive mental health response to the pandemic was developed that catered to various populations, such as COVID-19 patients, caregivers, employees, parents with children who are differently-abled, and the general public. Psychosocial support for patients tested for COVID-19 was provided during their isolation or quarantine period to provide mental health support as well as check-ins regarding physical health, contact tracing, and referrals to facilities. Between April and June 2020, over 6,000 patients were reached out to provide integrated support. Mental health support to frontline service-providers was provided through webinars, support groups and check-in calls for clinicians in isolation. Between April and June 2020, 144 healthcare providers were provided mental health check-ins.
A reactive helpline was launched for community members to call in and avail free-of-cost crisis counseling
Counselling for Partners
Additionally, collaborations were initiated with organizations including Karachi Down Syndrome Program, Loreal, JS Bank, and Daraz to engage employees and beneficiaries with mental health and coping strategies. Between April and June 2020, 471 people were provided psychosocial support through the helpline.
Psychosocial Support Intervention
The COVID-19 pandemic called upon an immediate psychosocial response to the emerging public health emergency at both facility and community levels; this was done by responding to the needs and supporting healthcare staff and daily wage earners. The staff contributed to the sample collection of 4300+ individuals at the facility in Karachi.
Mobilization of TB vans
GHD runs 55 TB mobile vans across the country that are mobilized in the community as well as private and public hospitals to screen for tuberculosis. 28 of those vans were used to help battle the COVID-19 along with screening for tuberculosis. The mobile X-ray vans aided with artificial intelligence-based software that detect pulmonary infiltrates and other abnormalities providing real-time screening for communicable diseases such as TB and COVID-19. The vans are being used in several different facilities and community settings to help with the COVID-19 response.
In areas of Sindh, specifically Karachi, the vans are being used by teams of trained healthcare workers to screen and triage for COVID-19 in the Emergency Department at The Indus Hospital, Civil Hospital, Karachi, and Qatar Hospital, Orangi Town to help lessen the overwhelming burden in the ERs. To ensure thorough screening, all individuals were also provided a chest X-ray in the van. Between March-June, 2020 more than 27,000 individuals were screened and redirected to testing areas ensuring that presumptive cases were separated to control further transmission. From this, more than 1,100 COVID cases were identified.
The Indus Hospital and Indus Health Network have played an important role in supporting the COVID-19 frontline teams by providing multifaceted services: communication; resource generation; creating public awareness; establishing partnerships with corporate organizations; receiving in-kind, and monetary donations; collaboration with donors, volunteers, and other stakeholders; writing stories and articles of faculty members and COVID-19 survivors, and running social and digital media campaigns to secure blood donations. The Indus Health Network’s faculty appeared on print, electronic, and digital media to provide expert opinions. Multiple partnerships were made to facilitate the clinical teams.