As several states in India are facing acute shortage of medical oxygen in the second wave of the pandemic, Kerala has reported a surplus of medical oxygen stock. In the past week, Kerala sent medical oxygen tankers to Goa, Karnataka and Tamil Nadu, to meet the demands of their hospitals which are filling up with COVID-19 patients. “We have supplied 19 metric tonne of medical oxygen to Goa, 72 metric tonne to hospitals in Tamil Nadu and 36 metric tonne to hospitals in Karnataka in the past week. Currently we have a surplus of medical oxygen supply in the state,” says R Venugopal, deputy chief controller of explosives, Petroleum and Explosives Safety Organisation (PESO) and nodal officer for oxygen supply for Kerala and Lakshadweep.
A 123-year-old department formed by the Government of India, PESO is responsible for monitoring and ensuring the supply of medical oxygen to all states and Union Territories. PESO Kerala along with the State Health Department, has been monitoring the oxygen needs of the state since March 2020, i.e for the last 1 year and 1 month — or ever since the pandemic hit the country. They have been amping up the medical oxygen supply in the state accordingly.
“We have always had the capacity to produce oxygen in Kerala. But it was mostly being made for industries. Now it is rerouted to hospitals as everybody is frantically demanding oxygen,” Venugopal says.
In a single day, Kerala’s oxygen plants can produce up to 199 metric tonne of medical oxygen. An average of the past six days until April 18 shows that Kerala used 89.75 metric tonne of medical oxygen per day.
Most of this comes from INOX Air Products Private Limited, which is located in Kanjikode. Inox supplies medical oxygen to all the big hospitals in the state, including Medical College Hospitals.
Before 2020, 40% of the oxygen produced by Inox in Palakkad went to various industries. The rest (60%) was sold as liquid medical oxygen to hospitals in the state.
But from last year, Inox started keeping a tab on dealers to whom they were supplying medical oxygen, to ensure it was reaching hospitals. Inox in Kerala was primarily catering to hospitals, even before the pandemic, and from 2020, they stopped supplying to industries completely. This, according to an Inox official, was possible as the industrial demand was low. Most smaller private oxygen manufacturers in the state are also solely catering to hospitals whose tanks are emptying rapidly.
“Before the pandemic, none of these hospitals needed so much oxygen. I remember a public hospital in Kottayam where Inox used to fill a 1 Kilo Litre tank of medical oxygen. They only had to refill it once a week due to very less demand. Now, the same hospital gets its oxygen tank filled three times a week,” Venugopal says.
The 11 air separation units (ASU), out of 23 oxygen filling plants - in Kerala which bottle oxygen cylinders have reported doubling their sales during the pandemic. “There are no empty cylinders to fill,” says Venugopal.
There is also Praxair India private limited, a private manufacturing plant located in Eloor, Ernakulam, and KMML — a PSU — which produces 6 metric tonne of medical oxygen per day. The 11 ASUs mentioned can produce a total of 44 metric tonne of liquid oxygen per day.
“We have also identified a source at BPCL Cochin Refinery, which has a stock of 20 tonnes of medical oxygen. This will be set aside as part of our contingency measures,” Vengupal explains.
All of these plants together have the capacity to store 1,325 Metric Tonne of Liquid Oxygen, of which the Inox plant has the largest storage capacity at 1,000 metric tonne.
In addition, 32 big hospitals in the state have the licence and infrastructure to store liquid oxygen and a total storage capacity of 420 metric tonne.
As on April 17, Kerala had 586.77 metric tonne of medical oxygen stock in various storage units across the state.
When the pandemic started, the state re-routed gaseous industrial waste from the Kerala Metals and Minerals Ltd (KMML), and converted it to liquid medical oxygen to be used in hospitals. .
KMML is a Kollam based public sector undertaking which manufactures Titanium Dioxide. Thanks to the new 70 tonne per day oxygen plant inaugurated in October 2020, KMML too contributes to the state’s medical oxygen needs now.
The plant purifies, liquefies and separates air into industrial gases such as oxygen and nitrogen.
“It produced 7 tonnes of ‘waste’ oxygen per day as a by-product of producing 63 tonnes of industrial oxygen (in gaseous form) and 70 tonne of nitrogen. We decided to liquify this wasted oxygen to use them for medical purposes,” Venugopal says.
While oxygen supply was never an issue, some medical colleges in the state suffered from a lack of infrastructure to offer uninterrupted oxygen to patients.
“We didn’t have the copper pipeline to connect and supply oxygen. Only our ICU beds and Operation Theatres had pipeline connection for oxygen. For the rest of the beds, we used cylinders,” the former COVID-19 nodal officer from Thrissur MCH explained.
In September 2020, as COVID-19 cases peaked, the Thrissur MCH struggled to continuously supply oxygen to its patients.
“We had to keep replacing cylinders for patients. It takes two people to replace one cylinder and is a laborious task. There was also a shortage of empty cylinders,” he adds.
This is when the Medical College came up with a crowdfunding campaign to install pipeline oxygen supply in the hospitals. The Prana Air for Care crowdfunding campaign was launched on September 16, 2020 and the hospital was able to crowdsource pipeline connections for 600 beds, costing Rs 12,000 per bed.
Apart from infrastructure, the hospital also had to frequently purchase medical oxygen from private players.
“We have one huge tank of 13 kilo litres capacity inside the hospital. Before the pandemic the tank used to last us for 10 days after one filling. But by September 2020, it was only lasting five days and our spending on oxygen increased,” the former nodal officer explains.
By October 2020, it looked like the Union government had found a solution to this problem. A procurement agency under the Ministry of Health — the Central Medical Services Society — floated tenders for 150 PSA oxygen generation plants to be set up in hospitals across India.
A PSA or Pressure Swing Adsorption generator plant is a unit designed to concentrate oxygen from ambient air at scale. Once the PSA plants are set up, these hospitals can produce their own liquid oxygen and would not need to buy from private players.
In October, five of these tenders were won by Medical College hospitals in Kerala, namely the Thiruvananthapuram, Pariyaram, Kottayam, Thrissur and Ernakulam MCHs
Seven months after winning tenders, only three PSA plants have been set up in the state — in the Thrissur, Ernakulam and Kottayam MCH. None of these plants have begun functioning.
“We are nearly done and expect it to be functioning by May. The last part is the electrification process which is being done now. The pandemic made it very difficult for us to get workers to complete the plant. Hence the delay,” a former nodal officer from the Thrissur MCH explains to TNM.
Once functional, the three PSA units can generate 1,250 litres per minute of liquid oxygen.
As on April 7, 2021, the total medical oxygen requirement of Kerala’s COVID-19 patients was 20.6 metric tonne per day. For non-COVID-19 patients, this was 42.35 metric tonne per day. But in less than a fortnight, this demand rose to 31.60 metric tonne per day as COVID-19 cases increased. For non-COVID-19 cases, this demand only rose marginally to 42.65 metric tonnes. But the state tackled this spike by calculating the individual oxygen requirement of each patient in the state.
According to PESO’s calculations, ICU patients on ventilator support need 24 litres per minute of medical oxygen, while non-ventilator patients in ICUs and wards need 10 litres per minute.
With the number of patient admissions in the state’s hospital, an expert committee under the Directorate General of Health Services (DGHS) projected the oxygen requirement of the state.
By April 30, the state is expected to have 103.51 metric tonne of medical oxygen requirement.
For the smaller hospitals in Kerala, oxygen goes out in the form of cylinders from the 23 cylinder filling plants in the state. Totally, these bottling plants have a storage capacity of 225 metric tonnes.
A cylinder can be filled in 30 minutes and totally, these bottling units can fill and push out 10,772 cylinders per day.
“Cylinders come in two sizes - 7 metre cube and 1.5 metre cube. Totally we have 2213 medical oxygen cylinders (of both sizes) currently (as on April 18) which is over 17 metric tonnes.,” Venugopal says.