Nadyrov on COVID-19 in Almaty: Unloading hospitals, switching to telemedicine and forming drug warehouse

In order to stabilize the epidemiological situation in the republic, strict restrictive measures are in force. The main task is to stop the spread of coronavirus infection and achieve significant results in the treatment of patients. Also, special attention is paid to the availability and provision of medicines. In an interview with, Kamalzhan Nadyrov, head of the Almaty City Public Health Department, spoke about the measures taken to curb the growth of COVID-19 incidence in Almaty.

— Kamalzhan Talgatovich, how is the city fighting the coronavirus in general? Compared to previous months, what is the current epidemiological situation?

— Along with the change in the epidemiological situation in our country and in our city, the approaches to combating coronavirus infection have also changed. If earlier the main struggle was in the localization of foci, hospitalization of all arriving from abroad, today the epidemiological picture is different, both in the city and in the country as a whole. The main task is to learn how to manage change, learn how to manage the pandemic. Our task is to quickly manage logistics in providing assistance.

A lot of systematic work is being done in all areas, starting from emergency medical care, the work of clinics and hospitals. A large front of work is carried out by our epidemiologists in order to minimize the sites and contacts of the spread of infection. The city has built a systematic work on the organization of medical care. In particular, the provision of assistance at the PHC level has undergone a change, special mobile teams have been created that work only with patients who have CVI. Today, there are 72 mobile teams, the number of doctors and nurses has reached 400 people. Previously there were 200 people. The task of mobile teams is to keep patients at the PHC level as much as possible, that is, to prevent the development of complications and not get to the next level — inpatient.

We understand that the elderly and patients with chronic diseases need special care, so it was decided to establish a Monitoring Center. The Center's task is to monitor difficult patients around the clock and provide them with high-quality medical care.

We have also changed the approach to the work of ambulances. Today, an ambulance, arriving to patients, has a developed checklist on hand, by which it is possible to objectively assess the patient's current condition. Depending on the severity of the disease, the ambulance decides which of the clinics to hospitalize.

At the hospital level, we also changed our approach. If earlier clinics were divided into provisional and infectious diseases hospitals (this was relevant in previous months, when the number of cases was not at such a high level), today we divide clinics by the severity of patients. We divided them into three echelons. Clinics of the first echelon are clinics that have the best material and technical base, where the intensive care service is more prepared, there is the necessary set of specialists. Second-tier clinics also have specialists, but the number of intensive care beds is less. In third-tier clinics, we hospitalize patients with relatively mild and moderate severity of the disease. This separation by flows allowed us to systematically build the route of patients. We are already seeing positive results: the number of beds has increased, we have begun to discharge recovered patients more often. If earlier our percentage of bed occupancy at its peak reached almost 90%, now this figure is less than 50%. Every second bed is free today, but despite this, we are continuing to increase the bed reserve.

We understand that the autumn-winter period is ahead, a new wave of infections is possible. Therefore, we need to secure the supply of our resources. It is very important that today our city clinics have the required level of gas supply. This is medical oxygen. In this regard, a large program has been adopted, within the framework of which all clinics of the first echelon will be 100% provided with medical oxygen. This is very important because one of the symptoms of covid pneumonia is a lack of oxygen. The 7 largest hospitals in the city will be 100% supplied with oxygen.

— Please tell us what is the mechanism for calling a mobile team, taking materials for a PCR test. How many mobile teams are working today?

— The algorithm for applying for PHC is the same. The patient, if he has symptoms, should contact his local doctor. Further, the local doctor by phone asks the patient about the symptoms. If the local doctor understands that a visit to the patient is needed, a mobile team arrives at home to assess his condition. If the patient needs hospitalization, an ambulance is called and the patient is taken to the hospital. If the patient's condition allows treatment at home, then the necessary drugs are brought to him, and he receives treatment at home. If a local doctor encounters difficulties in prescribing treatment, he can contact the Patient Monitoring Center, where we have more than 50 leading medical professionals and experts who can consult patients remotely and, if necessary, adjust the treatment.

— In general, how many health workers involved in the fight against COVID-19 work in the city?

— The number of medical organizations that are involved in the fight against COVID-19 is growing. If at the very beginning of our journey we started with two medical organizations: an adult and a children's hospital with a bed capacity not exceeding 500 beds, today there are about 6 thousand bed capacities in the city, in which 4,440 medical workers work. All working conditions are provided for them, including safe working conditions. They are provided with the necessary personal protective equipment. They are also placed in our hotels in order to minimize the spread of infection among family members. This is a very difficult job. Our colleagues have not seen their relatives and friends for several months. And in fact they have the same route — from the hotel to the hospital and back. Therefore, we are simultaneously working on the issue of mobilizing medical personnel, because we are faced with the task of increasing the number of beds to at least 7,700. Today, we have received about 1,500 doctors. A lot of preparatory work is also being done with them. They are trained in the issues of infectious safety, patient management, etc. In this regard, we have created a special educational and clinical center for the training of such specialists. We also connected our foreign colleagues who regularly give lectures and talk about the latest methods of fighting the coronavirus.

— Earlier, akim of the city Bakytzhan Sagintayev stated that a number of other facilities are being considered for the placement of hospitals, such as hotels and sanatoriums. How many additional beds need to be expanded and how many more hospitals will be deployed?

— We are working on all the options in order to increase the number of beds. For this, first of all, we began to study our medical organizations, which can be most easily re-profiled. Here you need to understand the moment that when deploying infectious beds, one should not get too carried away and re-profile the already operating medical organizations, because they continue to provide planned and emergency assistance to the population. A hospital has been opened in the city on the basis of the large ice palace "Halyk Arena", where 1,000 beds have already been placed. There are also plans to bring medical gases, oxygen there and deploy a full-fledged intensive care unit. In addition to medical organizations, we studied other objects, in particular, we stopped at one of the social facilities, which was originally built as a center for the treatment of neuropsychiatric diseases. We examined the entire infrastructure and realized that it is ideal for a medical facility and re-profiling. Corresponding work is already underway. It will be a full-fledged hospital with 500 beds, which we plan to put into operation in September. There, absolutely all the requirements of infectious safety will be met. The health of our colleagues is a priority for us today. And in this regard, the city will receive a full-fledged 500-bed hospital. It is important to note that all the investments that are now coming into the health care system in the post-covid period will work for the benefit of the population.

— In two days, 596 medical workers were employed in the Halyk Arena. How does the hospital work, what is the workload, are there enough medical workers at the moment and what difficulties did you face when opening the hospital?

— We very carefully studied international experience when we were looking for objects that could be converted into medical organizations. Our foreign colleagues often chose sports venues. After examining the infrastructure of the Halyk Arena, we were convinced that this is indeed a very rational approach, because there is an opportunity to separate flows. It is very important in any infectious diseases hospital to divide the territory into clean and dirty. The Halyk Arena around the perimeter has a lot of entrances and exits, which allows us to separate the streams. The ventilation system is very well built. We have improved it in terms of special disinfection, that is, the ventilation at the outlet will be completely disinfected. This is a very important point. The arena itself is already divided into sectors along the perimeter, these are impromptu offices. Today it is a full-fledged clinic that meets all the requirements of infectious safety.

— Also, the Akim of Almaty Bakytzhan Sagintayev set the task of 10 priority steps. Which ones have already been implemented? How should the population experience these changes?

— These are measures aimed at reducing the consequences of the coronavirus. The main task is to minimize deaths. In order to minimize the number of severe, extremely serious patients, deaths, we decided to organize a mobile group of resuscitators. This is a permanent mobile group that conducts round-the-clock rounds in all intensive care units of our city. It has two parts. The main part is those who physically make detours, enter the red zones, communicate with patients, look at their parameters and, through telemedicine, transmit all the data to the so-called headquarters. This headquarters is where our experienced specialists are concentrated — resuscitation specialists, anesthesiologists and department staff. Thus, we ensure constant monitoring of our difficult patients. This is very important when there is an opportunity and availability of consultations, and we can see the first results today. The number of deaths we have is decreasing. The number, we will say, of consultations around patients, if necessary, increases, transfers from the department to the intensive care unit or vice versa — this work has become more intense. Because already after holding these or those consultations, we begin to adjust the treatment. Not always local doctors can adequately and fully assess the patient's severity situation. And this is where our experienced colleagues come to the rescue. This experience has already proven itself quite well.

And there are so many other directions as well. In particular, we are currently working on a model. We call it the disease management model. In order to completely eliminate the incidence of the population, you need to come to a complete quarantine, the so-called full-fledged lockdown, to close everyone at home. And it minimizes the spread of the infection. But since we understand that this greatly influences from the point of view of the economy, load on business and so on, we cannot completely close the city. Our task is to find the very necessary balance, what measures of restriction we should set and in what period. It is very important. In this regard, we are working on a special algorithm, where it will be clearly understood both for the population and for business, when the level of morbidity is reached, certain levers to curb the spread of infection should be included. Because if the infection is not contained through restrictive measures, the growth of incoming patients may at some point lead to the collapse of the healthcare system. By collapse, we mean that all beds will be 100% full, that treatment will continue, and doctors may need to choose whom to hospitalize and whom to treat at home. Of course, this is the most undesirable scenario for us. We will do our best to avoid this scenario. It is very important here that the system of checks and balances works. We have practically worked out this system. It will be presented in the near future. Thus, we will regulate the flow of morbidity and, in general, the spread of infection in society.

— How is drug supply implemented in the city? Is there an adequate supply of drugs to treat patients in hospitals?

— I will say right away that now in our hospitals and at the outpatient level, the whole range of necessary drugs is available. Yes, I will not deny that there were certain failures. They are associated with a number of reasons. The main supplier of drugs to combat COVID-19 at the inpatient and outpatient levels is the single distributor SK-Pharmacy. Due to various reasons, certain failures were observed at different times. It has something to do with logistics issues: some drugs are imported from abroad. Now, in the pandemic, it is very difficult to build logistics routes. What have we done in order to minimize the negative impact of certain failures? Patients continue to be admitted, they must take treatment continuously. The city decided to form a stabilization fund for drugs. About 10 billion tenge has been allocated for this. This money is used to ensure that all the necessary drugs are available in private pharmacies and hospitals on a permanent basis. This fund will work both for private pharmacies in order to meet the demand from our patients, and at the inpatient level, so that in the event of an interruption on the part of SK-Pharmacy it will always be possible to print out our warehouse and deliver drugs to one or more another hospital. This will ensure continuity. This is already yielding positive results. Now we have all the necessary drugs.

— The minister of healthcare assured that in July-August this year, ventilators will be purchased for the entire country. What is the provision of mechanical ventilation today in Almaty hospitals, how many devices were purchased during the state of emergency, are there enough ventilators today?

— Today there are enough devices. For various scenarios for the development of the epidemic, we are preparing, including in terms of material and technical equipment. About 100 ventilators have already been purchased. They are on their way. We are now working on the issue of additional purchase of ventilators so that, along with oxygen supply, medical organizations have ventilators. The patient must have physical access to invasive and non-invasive ventilation. This is a very important issue and it is always under our control.

— On July 6, a team of Russian specialists arrived in Almaty. What is their assessment of the work of our hospitals, where patients with COVID-19 are treated. With health workers from which countries do you still exchange experience?

— In general, the pandemic has rallied the medical community around the world. From the first days of the outbreak of the pandemic, both the World Health Organization and other international organizations organized various seminars and trainings so that those countries that have already begun to deal with this new infection for all broadcast their experience to other countries ... Practically from the first days of the start of the pandemic, the Ministry of Health has carried out colossal work to provide information support to our colleagues. Clinical protocols were regularly reviewed. Of course, this is inconvenient, perhaps for doctors, when clinical protocols are often revised, but on the other hand, one must understand that it is important to keep up with the times and treat according to the latest standards and protocols that have already established themselves in society.

If we talk about our Moscow colleagues, then, as you know, Russia faced a high wave of infection a little earlier. In principle, this crisis was successfully dealt with, of course, certain conclusions were made. They shared this experience with us. Their visit was very useful for us. We have worked out a lot of issues. Including the creation of monitoring centers, mobile teams, and so on. It was a useful exchange of information. There are times when we shared information and experience with them. Now we continue to consult online with various experts from different countries.

— The pandemic has made adjustments to the plans of the Almaty Public Health Department. How is the health care system of Almaty city developing in general today?

— Of course, there is coronavirus, there are other nosologies and diseases that have not been canceled. In this regard, the city continues to live its own life. Maternity hospitals are operating, we continue to deliver childbirth, provide high-tech medical care for heart attacks, strokes, etc. For this, we have our emergency clinics on duty, which are ready to receive our patients in an emergency format. There is a state program for the development of health care, which defines the causes and indicators. Nobody removed this responsibility from us. Therefore, it is very important to note the moment that all our services, be it an ambulance or primary care, are operating in a regular mode and we are doing everything to ensure that our patients do not feel the burden associated with this pandemic. All patients who have some kind of chronic disease, are today 100% receiving drugs at home. We have minimized contacts and visits of our patients to polyclinics. For this we have a register of dispensary patients, it is a special electronic platform where we see all our chronic patients, know their diagnoses and know what drugs they need. And in this regard, our district services work so that these patients are not left unattended and receive all the necessary therapy at home.

— The akim of the city spoke earlier about the planned introduction of telemedicine. Please tell us how remote consultations will be carried out? Which doctors will consult? What will be the coverage, i.e. the show will be only in the city of Almaty?

— The pandemic is making its own adjustments in the overall provision of medical services. Our task is to cover the largest number of patients in a remote format as much as possible. Patients should not think that they have been left unattended or neglected by medical professionals. The Patient Monitoring Center, which we have created, today focuses on critical patients, patients at risk. And in general, the task is for this Patient Monitoring Center to deal not only with patients at risk, but in general to scale up its work and our patients have the opportunity to remotely, without leaving home, receive certain services through telemedicine. We are currently working on a large program in this direction. I think it will be presented in the near future. This is a very convenient format, which, in principle, has proven itself long ago. There is a certain technical component that we will need to refine. The point is that the doctor, without leaving his home or being somewhere in the headquarters, consulting the patient, could see the entire medical history of the patient. And without asking unnecessary questions, we see what he was sick with, what his last tests were, fortunately, we have electronic health passports of our patients. Our task today is to integrate all these systems and provide the highest quality medical care in a remote format.

— Kamalzhan Talgatovich, earlier you said that there is an increase in the incidence of patients diagnosed with ARVI and pneumonia in the city. Can you tell us how many cases were detected in July in the city of Almaty and in comparison with previous months, what is the current epidemiological situation?

— From the end of June and in the first decade of July, we had a peak in the incidence, when the number of calls to the ambulance reached 3,000-3,200. At the moment, we note a certain stabilization: the number of calls to an ambulance has almost halved. At the peak, we hospitalized up to 300 pneumonia patients per day, now — no more than 100-120. This is due to the fact that the restrictions that we have introduced are producing certain positive results.

If we generally talk about the increase in pneumonia, we see a clear relationship between the decrease in the abolition of quarantine measures, which were in late May-early June, and when we removed checkpoints along the perimeter of the city, the displacement of our population was restored, it was during that period that we note a sharp increase pneumonia disease. By the end of June and the beginning of July, it was increasing, now it is already wavy in decline.

— And finally. At the moment, some health experts are inclined to believe that the coronavirus will intensify in the fall and winter. Could you give any advice to Kazakhstanis on how to protect themselves from the virus or transfer it in a milder form.

— The recommendations are the same, in fact, they are not difficult: it is to maintain social distance, wear masks and frequent hand treatment. Here, of course, I would like to say that we see the experience of various countries in the fight against the pandemic and the most successful experience in those countries where the population heeded the advice and recommendations of experts and changed their way of behavior, approached these issues in a more disciplined manner. I am now talking about Japan, South Korea and Vietnam, which have shown good results and got out of this crisis as soon as possible.

We, as a healthcare system, can increase our capacity as much as we like, increase beds, purchase equipment, train personnel, etc. But you need to understand that this is not the point, we are already facing the consequences. Success is so that each of us can understand the importance and criticality of the situation and change our behavior. Not going out into society and not visiting crowded places unnecessarily is actually simple actions that give colossal results, and how quickly we get out of this crisis will depend on how disciplined we approach this issue. It is very important.

— Thanks for the interview!

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