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From the central government to entrepreneurs, academics to automobile companies, a race is underway to build hundreds of thousands of ventilators. By pumping oxygen into the lungs of patients, the machines are critical for those in danger of lung failure, experienced by about a tenth of Covid-19 patients
. “It’s the last resort before a patient dies,” says Dr Ashok Mahashur, consultant chest physician at PD Hinduja Hospital, Mumbai.
There’s no official count of how many ventilators hospitals across the country have at present, but one manufacturer estimates there are 40,000. “Of these around 20 to 25 percent would be dysfunctional,” he says. That leaves around 30,000 to 32,000 ventilators. In normal times, hospitals need only a few dozen machines for critical cases. In these unprecedented times, though, demand will outstrip supply.
“It’s purely speculative to say how many ventilators we’ll need,” says one doctor associated with Mumbai’s Wockhardt Hospital. “But it’s safe to say we’ll need many times more [than what we have].”
According to a study by Brookings Institution, a US-based think tank, India will need 1.1 lakh to 2.2 lakh ventilators by mid-May in the worst-case scenario. It estimates India has a maximum of 57,000 ventilators at present. Another study by John Hopkins University in Baltimore, US, and the Washington and New Delhi-based Centre for Disease Dynamics, Economics and Policy (CDDEP), predicts that ventilator demand will be 10 lakh. The study estimates that the current availability of ventilators in India is between 30,000 and 50,000. To put this into perspective, the US has an estimated 1.6 lakh ventilators and is running short in most places. Andrew Cuomo, the governor of New York state, has said that the state alone will need 30,000 ventilators for critically ill coronavirus patients.
A young patient with a serious infection of coronavirus needs a ventilator for five to seven days, while an older patient might need it for 2 to 3 weeks, says Mahashur, adding that, “sometimes it may be more than three weeks because their lungs are weak.” This makes the ventilator shortage even more serious. In Italy, for instance, which has seen the highest number of deaths from the coronavirus, doctors have been prioritising patients with the highest chances of survival because of the lack of ventilators. “We don’t want a situation like that,” says the Wockhardt Hospitals doctor.
Manufacturers in India churned out 500 ventilators per month, or 6,000 units a year, before the coronavirus outbreak, says Vishwaprasad Alva, founder and managing director of Skanray Technologies, a Mysuru-based ventilator maker. In a press note dated March 31, the Association of Indian Medical Device Industry (AiMeD) said that it had reached out to seven of its 10 ventilator manufacturing members who confirmed that the total current production capacity was 5,500-5,750 units per month. “Every country across the globe is busy assessing the available stock of working ventilators. It is like assessing the military equipment before starting a war,” said Rajiv Nath, forum coordinator, AiMeD, in the press note. The aim, he added, was to produce 50,000 ventilators per month by May.
But is this realistic? To ensure that it is, the government has issued a clarion call to public sector units (PSUs) and automakers alike. “We have given an order to a PSU to provide 10,000 ventilators. Bharat Electronics Limited (BEL) has also been requested to purchase 30,000 additional ventilators in 1 or 2 months,” said Lav Aggarwal, joint secretary, Ministry of Health and Family Welfare, in his daily coronavirus briefing to the media on March 27.
Industry heavyweights including Maruti Suzuki, Mahindra & Mahindra, Tata Motors
, Kalyani Group, and Hyundai India have been asked to explore the possibility of reconfiguring their plants to produce ventilators. A number of them have stepped up to the challenge.
Maruti Suzuki, in a statement on March 28, announced a partnership with AgVa Healthcare, a Delhi-based manufacturer of ventilators. According to the agreement, AgVa will be responsible for the “technology, performance and related matters” of the ventilators, while Maruti Suzuki will reach out to its suppliers to produce the required components as well as “upgrade systems” for quality control and production of higher volumes.
AgVa sells ventilators for Rs 1.5 lakh to Rs 2 lakh, whereas imported machines cost between Rs 5 lakh and Rs 12 lakh. Prior to Maruti Suzuki’s announcement, when Forbes India spoke to Diwakar Vaish, co-founder and CEO of AgVa, he said they were looking to produce up to 20,000 ventilators in 30 days. But the nation-wide lockdown had affected production. “Our staff is unable to come in to work. We’re down from 350 employees to 150.” Also the flight ban had hit the supply of critical components such as sensors, chips and micro controllers sourced from China and Germany.
A day later, on March 27, Vaish took to Twitter to announce that shipments were now moving “with light speed”. Invest India, a national agency that looks into investment promotion and facilitation under the aegis of the central government, provided timely intervention and help, he tweeted. On the following day, the tie-up with Maruti Suzuki was announced. The partners plan to scale production from 400 units a month currently to 4,000 units in April, and finally, 10,000 units by May.
Similarly, SkanRay has tied up with Mahindra & Mahindra, Bharat Heavy Electronics Limited (BHEL) and BEL to ramp up production. “Very soon, Tata Motors could also join in,” says Alva. He too notes that supply chain breakages are an issue. “There are about 10 components that are currently difficult to procure… it’s difficult, but not impossible.” At present, Skanray makes hospital ICU and anesthesia ventilators. The version now being considered is a derivative of those, with more local components that will make it easier to scale.
“The government, via BEL, is making all efforts to source these components,” says Alva. It might take a few days to locate suppliers; BEL might also manufacture the components, if necessary. What works in favour of manufacturers is that ventilators already being made in India are localised to about 90 percent. Only 10 percent of the components, mostly various kinds of sensors and amplifiers, are imported, says Alva.
As BEL searches for components, Skanray’s team is simultaneously working on finding alternatives to those components. “The first step is to try and procure the parts. The next step is to work around alternative designs. The last resort is to see what designs can be put together with existing available components,” explains Alva. The consortium hopes to be prepared to manufacture as many as 1 lakh ventilators in a period of 8 to 12 weeks. “It’s a challenging task, but that is the target. We should start getting volumes from the third week onwards,” says Alva.
Meanwhile, Mahindra & Mahindra is working on an indigenous, low-cost device. In fact, it was the first industry major to step up to the challenge. On March 22, Anand Mahindra, chairman of the Mahindra Group
, took to Twitter to announce a series of measures the company is taking to help fight the pandemic, including the production of ventilators at the company’s manufacturing units.
On March 26, he tweeted out a demonstration video of a prototype his engineering team had developed. It was an automated version of a manual ventilator that would cost about Rs 7,500. “This could be a game changer in quickly providing large numbers of low-cost life-savers, particularly when ICU ventilators are still scarce,” he tweeted. The engineers in the video said that the team would be ready with three more “lighter and more compact” prototypes over the next 2 to 3 days.
Sure enough, on March 30 Pawan Goenka, managing director of Mahindra & Mahindra, tweeted that the device was “near fruition”. Testing had started, he claimed, while packaging was awaited. Once approved, Mahindra plans to make the design available to all manufacturers. The company declined to share additional information with Forbes India.
Biodesign Innovation Labs (Bild), a Bengaluru-based company established in 2017, also makes automated versions of manual ventilators. The devices don’t replace high-end mechanical ventilators, but serve as a “bridge” between mechanical and manual ventilators, says Gautham Pasupuleti, CEO and managing director. “We are talking about minimum capabilities, but those are really required for stabilising patients and saving their lives.” The device costs Rs 50,000 to Rs 70,000, and can be used at home, in an ambulance, or in a hospital.
Prior to the coronavirus outbreak, the ISO-certified and BIRAC-supported startup, which has also bagged a Qualcomm Design Innovation award, had been working on clinical trials at various hospitals. However, after receiving a surge of orders over the last couple of weeks, it started scouting for non-exclusive licensing partnerships to mass manufacture the device.
Bild has since tied up with Remidio, a Benguluru-based specialist maker of ophthalmology devices, to manufacture 15,000 ventilators over the next 1 to 2 months. Over the next 2 to 3 weeks, they hope to have 5,000 ventilators ready, says Pasupuleti. The startup is also in talks with Tata Motors, engineering solutions company Cyient, and construction machinery maker JCB India for licensing partnerships.
But how easy is it to repurpose factories that make cars or construction machinery to now make ventilators? “We will transfer all the technology and expertise to them, ensure that all precautions are taken to ensure the surroundings are clean and impurity-free and maintain all compliances,” explains Pasupuleti.
Even with the blueprint, it seems easier said than done. Forbes India spoke to Ramesh Singh, professor of mechanical engineering at Indian Institute of Technology Bombay to understand if this was the case. “Making a ventilator is much easier than making a car,” he says. Ventilators themselves are not complex devices, besides automobile manufacturing in India is of “very high quality and competency. So they can definitely do the ramping up process.”
The bigger challenge, Singh believes, is the sourcing of critical components like oxygen sensors and flow controllers, which are typically imported. “If you have these items, making a ventilator would not be a difficult task,” he says. But with the global supply chain disruptions and production only just picking up in China, companies will have to look at either locally making these parts or replacing them.
A team of engineers at the Indian Institute of Science (IISc) in Bengaluru, for instance, is working on a prototype of an electro-mechanical ventilator using an oxygen sensor that has been developed in-house. The device is expected to be ready in the next couple of weeks. But the challenge lies in scaling up production. “Making one oxygen sensor and making tens of thousands of them is a different ballgame,” notes Singh.
“My take is that they should be able to mass manufacture ventilators by May end. Supply chains will start opening up and these companies also keep making the parts that they import. Perhaps they could make do with the sensors that the automobile industry uses [pressure and flow sensors], to develop an oxygen sensor that might provide, say, a courser flow of oxygen. It can be done,” says Singh.
Regulatory hurdles also stand in the way. Ventilators can take up to two years to develop, test and obtain the necessary approvals for. So relaxed norms will be necessary, says Singh. Companies like AgVa and Bild have the necessary ISO-certifications to sell medical devices in India. However, in their most recent March tenders, the Maharastra and Rajasthan governments have mandated that US-FDA or European CE approvals are compulsory. “…[this is] an over reach and impractical and not really specifications which could [help in] making mass productions in tens of thousands of pieces that the government and the country is looking at. These have however been subsequently revised and still under review,” said AiMeD’s Nath in a press note.
Finally, even once the ventilators are ready, operating them is tricky business. “It takes 2 to 3 months of training to understand how to use a [sophisticated] ventilator,” says Mahashur of Hinduja hospital. All too aware of this critical bottleneck—given India’s already low levels of medical manpower—the Ministry of Health and Family Welfare recently announced online training sessions in ventilator management. It invited India’s top doctors to provide this e-training; additional details are awaited.
Meanwhile, hospitals are also preparing—and innovating—for tough times ahead. The team at Max Healthcare, for instance, drew on a 2012 article by Richard D Branson on how to split one ventilator between four patients, and has retooled its machines. “The best inventions in medicine happened during wars and pandemics,” says Chairman Abhay Soi
Indeed these are unprecedented times that call for unprecedented action.
(Additional inputs from Harichandan Arakali)