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BRIEF RESEARCH ARTICLE
Year : 2022  |  Volume : 66  |  Issue : 2  |  Page : 187-189  

“Oxygen Pheriwala:” An innovative model for SARS-CoV-2 screening in resource-limited settings


1 Professor, Department of Neurology, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India
2 Assistant Professor, Department of Neurology, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India
3 Associate Professor, Department of Neurology, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India
4 Research Scholar, Department of Neurology, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India
5 Professor and Head, Department of Neurology, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India

Date of Submission18-Jul-2021
Date of Decision26-Sep-2021
Date of Acceptance17-Nov-2021
Date of Web Publication12-Jul-2022

Correspondence Address:
Rameshwar Nath Chaurasia
Department of Neurology, Institute of Medical Sciences, Banaras Hindu University, Varanasi - 221 005, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijph.ijph_1553_21

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   Abstract 


The second wave of SARS-CoV-2 infection came as a hypoxic emergency and situation became worse in rural India, where undiagnosed COVID-19 patients died without any diagnosis or intervention. The primary aim of this innovative model was the early diagnosis of suspected SARS-CoV-2 cases, providing empirical treatment and timely referral to appropriate COVID care facilities. Fever was measured with infrared thermometer and oxygen saturation level with pulse oximeter. A total of 8203 people were screened, of which 274 persons were febrile and 69 (25%) were hypoxic too. Sixty-four out of 69 (93%) patients turned COVID-19 positive on reverse transcription-polymerase chain reaction. At the end of 3 weeks, 48/64 (75%) patients were successfully discharged. This model can be easily implemented in resource-limited regions to identify and prioritize the patients not only in this pandemic but also in outbreak of other communicable diseases.

Keywords: COVID-19, infrared thermal sensor, pulse oximeter, rural awareness, SARS-CoV-2


How to cite this article:
Mishra VN, Singh VK, Pathak A, Kumari N, Kumar A, Chaurasia RN. “Oxygen Pheriwala:” An innovative model for SARS-CoV-2 screening in resource-limited settings. Indian J Public Health 2022;66:187-9

How to cite this URL:
Mishra VN, Singh VK, Pathak A, Kumari N, Kumar A, Chaurasia RN. “Oxygen Pheriwala:” An innovative model for SARS-CoV-2 screening in resource-limited settings. Indian J Public Health [serial online] 2022 [cited 2022 Aug 18];66:187-9. Available from: https://www.ijph.in/text.asp?2022/66/2/187/350647



The second wave of SARS-CoV-2 surges in India began in the 1st week of April 2021, reaching its peak on May 6, 2021, with 414,433 laboratory-confirmed cases on a single day all over the country. Health facilities were overwhelmed with thousands of patients presenting with COVID-19 pneumonia with hypoxia in several states, including Uttar Pradesh. Panic spread among people as hospitals and health facilities in metro cities and smaller cities ran out of oxygen. The rural areas in India, where bulk of the population lives, were more or less spared during the first wave of SARS-CoV-2 infection.[1] However, near the March end and beginning of April 2021, there was a surge in cases of SARS-CoV-2 infection in rural areas probably due to highly infectious mutant variant, lowering of guard against it by rural community, poor existing health-care facilities, and active migration from different parts of the country. In Uttar Pradesh, 32% of the total villages were found to be affected by COVID-19. It kept recording more than 7000 newer positive cases and over 280 deaths daily. Due to the poor connectivity of the villages and ignorance about the symptoms of the disease, many patients did not reach the center with COVID management facility.[2]

In this health crisis, we decided to initiate an innovative model, Oxygen Pheriwala (Pheriwala in Hindi means a street hawker), as an outreach program, intending to screen people for fever and oxygen level in rural areas and assist in early diagnosis and timely intervention for SARS-COV-2 infection.

Under this model, a team consisting of doctors, nursing staff, research scholars, and community volunteers visited 17 villages in 5 districts of Uttar Pradesh, India, from April 20, 2021, to May 21, 2021.

In a village, the team went from house to house to screen the residents. They recorded brief demographic characteristics including name, age, sex, occupation, and history of recent travel. Apart from these, common symptoms of COVID-19 such as fever, cough, sore throat, body ache, and myalgia were also noted. Those who had a history of contact from suspected or confirmed COVID-19 cases and/or symptoms of COVID-19 were initially screened by infrared thermal sensors for fever and pulse oximeter for the presence of hypoxia [Figure 1]a. Persons with temperature >98.6°F were labeled as febrile and SpO2 <94% as hypoxic. Basic training was provided by doctors to the rest of the team members before initiating the process of screening. Patients with hypoxia were provided free oxygen instantly with the help of a mobile oxygen van and assisted further in getting admission at a proper health-care facility as per availability for further COVID-19 workup and management [Figure 1]b. The van was furnished with 16 oxygen cylinders, which, at a time, can supply oxygen to 32 patients for 30–60 min. All symptomatic patients were given empirical treatment as per guideline of the Ministry of Health and Family Welfare and ICMR immediately.[3]
Figure 1: (a) A member of oxygen Feriwala team measuring oxygen saturation of villagers with the help of pulse oximeter, (b) One of the female patients with fever and hypoxia identified at a village transported with oxygen support to the COVID care facility.

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The team screened 8203 people in 17 villages of five districts. Of these, 274 patients were febrile. Sixty-nine (25%) patients with fever had hypoxia also [Table 1]. Hypoxic patients (n = 69) were given oxygen through mobile oxygen van accompanying the team.
Table 1: The number of persons screened and detected to have fever and hypoxia in 17 villages of five districts of Uttar Pradesh, India

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Of 69 patients with fever and low oxygen saturation, 64 (93%) were given a single shot of 6 mg of injection dexamethasone intramuscularly and transported along with oxygen supply through face mask till they reached a hospital well equipped in COVID care management. All these 64 patients turned COVID-19 positive on reverse transcription-polymerase chain reaction (RT-PCR). At the end of 3 weeks, 48 (75%) patients got successfully discharged, whereas 16 (25%) patients succumbed to the illness.

Village chief (Gram Pradhan) was provided two pulse oximeters for monitoring and detection of newer suspected COVID-19 cases. A short session regarding importance of vaccination and encouragement to get vaccinated at the earliest was also conducted.

It was in mid-April 2021 when doctors observed that most of the hospital admissions because of COVID-19-related pneumonia led to hypoxemia and there was lack of oxygen due to overwhelming demand.[4] Unlike normal pneumonia where people feel chest pain and breathlessness, COVID-19 pneumonia does not cause shortness of breath during the initial stage. However, blood oxygen level keeps on decreasing which is difficult to identify as there are no symptoms other than fever and cough. This kind of situation where a low oxygen level does not manifest is referred to as “Silent” or Happy hypoxia.[5] The pathological pattern of disease may occur in stages such as epithelial (reactive epithelial changes), vascular (microvascular damage), and fibrotic (intestinal fibrosis) stages.[6] As the disease progresses, at high transpulmonary pressure, the airspace in the lungs does not inflate easily. This causes a sudden volume loss.[5],[7]

The key part in COVID-19 management is to detect hypoxemia at the correct time point with proper monitoring thereafter. One of the equipment to detect hypoxia in COVID-19 patients is a pulse oximeter. As per the World Health Organization and Ministry of Health and Family Welfare guidelines, a pulse oximeter is the most suitable device to monitor the blood oxygen level.[8] In rural areas, people did not have adequate knowledge about pulse oximeter and its use. The high demand for pulse oximeters in this pandemic deepened the crisis further.[9]

During the pandemic, there was a sense of fear among villagers of being taken away to hospital and getting quarantined. False local beliefs and rumors about COVID-19 contributed further in the non-declaration of their health issues. In addition, villagers usually were least informed about the COVID-19 symptoms and diagnostic protocols and hence hesitant to undergo costly investigations such as RT-PCR and computed tomography chest for diagnosis. All these factors created hindrance in early diagnosis and timely intervention. To screen such a population for fever and hypoxia with thermal sensors and pulse oximeter, respectively, proved effective in this model by saving the lives of many.

The motive behind this innovative model was to increase awareness among the villagers about COVID-19 and provide measures for the early diagnosis and timely referral of suspected COVID-19 cases. We chose a local name “Pheriwala” to make the residents of the village more friendly with the management team.

However, this concept of Pheriwala was a makeshift arrangement of a well-equipped ambulance and a type of task shifting. It was just a system equipped to provide oxygen to buy time till they got hospitalized. This short experimental model has also given an example to the policymakers in the country of how small innovations can cause significant changes in the existent health system.

After success of this “Oxygen Pheriwala,” similar model was adopted by multiple villages in nine more states and our team was connected with them through digital means to guide them. Not to reiterate that fully equipped ambulance facilities were well short of meeting the need of the patients due to humongous requirement in a short period. When many of the health facilities were engaged in battling the challenge imposed by COVID-19 in the urban areas, resources were scarce to mitigate the SARS-CoV-2 threat looming over the rural belt. Hence this unique experiment could be a humble example of screening and treatment strategies in a low- and middle-income country, especially dealing with a pandemic like COVID-19.

Acknowledgment

We acknowledge the patients' relatives for giving their informed consent.

Financial support and sponsorship

The study has been funded by Village Health Mission (Reg. No: S/896/Distt. South/2012).

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Large Number of COVID Cases Being Reported from Rural Areas: Lok Sabha Speaker Om Birla. Economic Times. Available from: https://economictimes.indiatimes.com/news/india/large-number-of-covid-cases-being-reported-from-rural-areas-ls-speaker-om-birla/articleshow/82629146.cms. [Last updated on 2021 May 14].  Back to cited text no. 1
    
2.
Omar R. COVID-19 Cases Found in Nearly a Third of U.P. Villages, Says Official Co. Available from: https://www.thehindu.com/news/national/other-states/covid-19-cases-in-nearly-a-third-of-up-villages-according-to-official/article34594247.ece. [Last updated on 2021 May 20].  Back to cited text no. 2
    
3.
AIIMS/ICMR-COVID-19 National Task Force/Joint Monitoring Group (Dte.GHS) Ministry of Health & Family Welfare, Government of India. Clinical Guidance for Management of Adult Covid-19 Patients; 2021.  Back to cited text no. 3
    
4.
Teo J. Early detection of silent hypoxia in covid-19 pneumonia using smartphone pulse oximetry. J Med Syst 2020;44:134.  Back to cited text no. 4
    
5.
Dhont S, Derom E, Van Braeckel E, Depuydt P, Lambrecht BN. The pathophysiology of 'happy' hypoxemia in COVID-19. Respir Res 2020;21:198.  Back to cited text no. 5
    
6.
Polak SB, Van Gool IC, Cohen D, von der Thüsen JH, van Paassen J. A systematic review of pathological findings in COVID-19: A pathophysiological timeline and possible mechanisms of disease progression. Mod Pathol 2020;33:2128-38.  Back to cited text no. 6
    
7.
Light RB. Pulmonary pathophysiology of pneumococcal pneumonia. Semin Respir Infect 1999;14:218-26.  Back to cited text no. 7
    
8.
World Health Organization. Pulse Oximetry: Training Material. Geneva: WHO; 2011. Available from: https://www.who.int/patientsafety/safesurgery/pulse_oximetry/tr_material/en/. [Last updated on 2021 Jun 01].  Back to cited text no. 8
    
9.
Praveen M. Pulse Oximeters in Short Supply as Pandemic Rages. Available from: https://www.thehindu.com/news/cities/Kochi/pulse-oximeters-in-short-supplyas-pandemic-rages/article34415960.ece. [Last updated on 2021 May 31].  Back to cited text no. 9
    


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