India and COVID-19 (Med Journals)


The following is a Medical Journal search using the query (India AND (COVID-19 OR coronavirus OR SARS-CoV-2))

This list will be updated every Monday  

Rapid chromatographic immunoassay-based evaluation of COVID-19: A cross-sectional, diagnostic test accuracy study & its implications for COVID-19 management in India – PubMed

Rapid chromatographic immunoassay-based evaluation of COVID-19: A cross-sectional, diagnostic test accuracy study & its implications for COVID-19 management in India.

Methods: A cross-sectional, single-blinded study was conducted at a tertiary care teaching hospital in north India. Paired samples were taken for RDT and rRT-PCR (reference standard) from consecutive participants screened for COVID-19 to calculate the sensitivity and specificity of the RDT. Further subgroup analysis was done based on the duration of illness and cycle threshold values. Cohen’s kappa coefficient was used to measure the level of agreement between the two tests.

Convalescent plasma: A possible treatment of COVID-19 in India

Copyright © 2020 Director General, Armed Forces Medical Services. Published by Elsevier, a division of RELX India Pvt. Ltd.

Lessons learned thus far from the largest outbreaks of this pandemic in China, the US, Italy, and Spain reveal that there is still no cure, although several possible drugs and novel agents, which have not been clinically tested, are available through compassionate use, or as repurposed antiviral and immune-modulating pharmacotherapies. 4 India is likely to also be testing such repurposed drugs, but these can carry risks. A search on PubMed for the term “COVID-19” reveals close to 3900 studies published on this disease, with countless others on preprint servers such as bioRxiv or medRxiv. The wealth of data and the speed at which information related to all aspects of COVID-19 is astonishing, and historical.

Globally, there is currently no effective postinfection prophylaxis for the treatment of COVID-19, although some drugs are being repurposed. There are also no antibodies for the prevention of COVID-19, and it will likely be months before antibodies emerge from clinical trials. CP, a postinfection treatment, has shown limited and moderate success, previously for SARS-1 and MERS, and for COVID-19 in China, and could serve as a short-term solution to suppress mortality rates in India. As the number of infections increases, the CP of infected patients could be donated or harvested for simultaneous treatment or future use until an effective antibody is discovered.

On March 24, 2020, the US Food and Drug Administration (FDA) approved the use of CP therapy for patients with severe COVID-19 infections. 8 The Indian Council of Medical Research (ICMR) has approved a trial for CR therapy, to be conducted by the Sree Chitra Tirunal Institute for Medical Sciences and Technology (SCTIMST), although approval is still required from the Drug Controller General of India (DCGI). 9

2. Ministry of Health and Family Welfare. Government of India [Internet]. COVID-19 INDIA [cited 2020 April 22] Available from: .

3. Chatterjee K., Chatterjee K., Kumar A., Shankar S. Healthcare impact of COVID-19 epidemic in India: a stochastic mathematical model. Med J Armed Forces India. 2020;76:147–155. doi: 10.1016/j.mjafi.2020.03.022. [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]

9. India Today [Internet]. Coronavirus: India in final stages of framing protocols for clinical trial of plasma therapy, says ICMR [cited 2020 April 22] Available from:

Healthcare impact of COVID-19 epidemic in India: A stochastic mathematical model – ScienceDirect

In India, the SARS-CoV-2 COVID-19 epidemic has grown to 1251 cases and 32 deaths as on 30 Mar 2020. The healthcare impact of the epidemic in India was studied using a stochastic mathematical model.

Uninterrupted epidemic in India would have resulted in more than 364 million cases and 1.56 million deaths with peak by mid-July. As per the model, at current growth rate of 1.15, India is likely to reach approximately 3 million cases by 25 May, implying 125,455 (±18,034) hospitalizations, 26,130 (±3298) ICU admissions, and 13,447 (±1819) deaths. This would overwhelm India‘s healthcare system. The model shows that with immediate institution of NPIs, the epidemic might still be checked by mid-April 2020. It would then result in 241,974 (±33,735) total infections, 10,214 (±1649) hospitalizations, 2121 (±334) ICU admissions, and 1081 (±169) deaths.

© 2020 Director General, Armed Forces Medical Services. Published by Elsevier, a division of RELX India Pvt. Ltd.

Safety of hydroxychloroquine in healthcare workers for COVID-19 prophylaxis – PubMed

2 Department of Pharmacology & Therapeutics, Seth Gordhandas Sunderdas Medical College & King Edwards Medical Hospital, Mumbai, Maharashtra, India.

What’s Causing India’s Second Coronavirus Wave?

Dispatch: What’s Behind India’s Second Coronavirus Wave? What’s Behind India’s Second Coronavirus W…

Waning immunity, new virus variants—India’s sharp surge could be caused by any number of alarming factors.

CHENNAI, India—If there’s one thing that’s sure about the COVID-19 pandemic, it’s new waves can always be just around the corner. But even with that knowledge, India’s second wave is unique and challenges established narratives. Just one month ago, the global consensus was India had emerged as an unlikely success story of the pandemic. From a peak of close to 100,000 new lab-confirmed cases each day by the middle of September 2020, its decline had been swift and sharp, even as developed nations were struggling. “India has successfully contained the pandemic,” Health Minister Harsh Vardhan said at the end of January. Some were quick to declare that mask compliance was responsible for India’s low numbers. Other health officials said the decline showed that India’s strict lockdown had been effective.

But if it wasn’t evident earlier, it is now abundantly clear to local and national administrations, doctors, and citizens that the second wave is here. India reported more than 100,000 new cases on April 4, a new record for the country, a level not seen in its first wave. This places it at the top of the list of countries worldwide in terms of new cases being reported each day. The western state of Maharashtra alone reported more than 40,000 new cases on March 28, making it one of the worst-hit regions in the world. Moreover, the second wave has gathered momentum much quicker than the first. Although it took 61 days between June and August 2020 to go from almost 8,000 to almost 55,000 daily cases, it took just 41 days to go from 10,000 to 60,000 this time around.

India has reported relatively fewer fatalities than many other countries—although questions over the country’s ability to accurately count all deaths from COVID-19 remain, on account of historic under-registration in health systems—but there is no evidence yet that the second wave will be less deadly than India’s first wave. On the contrary, daily reported deaths are growing faster in India than they have since May 2020. In some regions, including the northern state of Punjab, the recent surge was associated with a sharp increase in fatalities relative to cases through February of this year, according to Murad Banaji, a lecturer of mathematics at Middlesex University, who has been studying India’s COVID-19 numbers.

For most of the world, a second—or even third—wave was anticipated; after all, that is the logic of a pandemic. In India, the story is a bit more complicated. The recent surge is less of a mystery in the country’s rural areas; fewer citizens had already been exposed to the virus there. India’s most recent nationwide serosurvey, conducted over December 2020 and January 2021, indicated that more than 1 in 5 Indians had been exposed to the virus, but the proportion of those with antibodies in urban slums was more than 12 percent higher than in rural areas. “From the serosurveys, we know that there is still a high uninfected population in rural areas,” said Manoj Murhekar, director of India’s National Institute of Epidemiology and lead author of national serosurveys. “This population remains vulnerable.” Coronavirus cases first emerged in big cities or from return migration to villages, but cases are now being detected in small hamlets and villages too, said SP Kalantri, a leading doctor who lives and works in Maharashtra’s impoverished, rural Wardha region.

But the recent rise in cases in big cities has defied some accepted assumptions about the nature of India’s pandemic and called into question whether the September 2020 decline can really be attributed to successful government containment.

Last year, astonishingly high levels of exposure to the virus indicated that herd immunity was imminent, experts, including Murhekar, believed. Serosurveys conducted in India have shown the virus rampaged through parts of the country, particularly its big cities, toward the middle of 2020. By July and August 2020, a serosurvey conducted in five high-incidence areas in the western city of Pune showed that more than half of the people sampled had been exposed to the virus. Two serosurveys conducted in Mumbai showed seropositivity of around 40 percent in the city’s slums, and similar surveys in smaller neighborhoods showed up to 75 percent prevalence of antibodies later in the year. The most recent serosurvey, conducted in Delhi, showed a seroprevalence of 56 percent .

Moreover, it’s becoming increasingly clear that visualizing herd immunity as a single threshold or moment of time in the future will not work for this pandemic. “When we walked into this pandemic, we learned a lot from epidemiologists about … this concept called herd immunity. We took it a bit far,” said Anup Malani, a professor at the University of Chicago Law School and Pritzker School of Medicine who has led multiple serosurveys in India. “Now the difficulty was that when we started seeing these really high rates of seroprevalence, say Mumbai slums with 55 percent, immediately people said, ‘oh, we’re close to herd immunity. We can relax.’ The problem with that is we don’t actually know what the level of herd immunity is; it’s a belief that we have, but it’s something to be estimated. And the second thing is that herd immunity is not an absolute level. It depends on human behavior.”

Other parts of the world are learning similar lessons. In October 2020, 76 percent of a sample of blood donors in Manaus, Brazil, tested positive for antibodies against the coronavirus. Yet when Brazil experienced a new surge in January, Manaus saw a resurgence. Some of the investigators of the original study wrote in the Lancet medical journal that the 76 percent could have been an overestimate—serosurveys can suffer from erroneous mathematical and epidemiological assumptions. But Manaus carries other potentially important lessons for India. Immunity against infection in Manaus might have already begun to wane by December 2020. Investigators found there could have been new, more transmissible variants circulating, and reinfections, in which immunity acquired from the first wave might not guard against infection from new variants, may have had an impact.

All of these are possible explanations for the current surge in India, but a delayed and yet incomplete research program has meant that the answers are still inconclusive. Mumbai’s serosurveys demonstrated waning antibody levels between the first round conducted in July 2020 and the second round conducted in late August 2020, but there is little research yet in India to show whether this means immunity wanes too. Reinfections have been poorly studied, despite some high-profile anecdotal evidence: At least one minister in Maharashtra’s government announced he had tested positive for the second time. The national serosurveys return to the same regions but not to the same individuals in subsequent rounds, meaning the possibility of reinfection remains untested. In one badly hit region of Maharashtra, some of the samples sent for genomic sequencing were from people who had tested positive twice, Prashant Thakare, the head of the district’s molecular lab said , but the lab no longer had the blood samples from the first time they tested positive—they were destroyed for lack of storage capacity.

India has similarly fallen short when it comes to genomic surveillance for the detection of variants.

India has similarly fallen short when it comes to genomic surveillance for the detection of variants. There is huge genome sequencing capacity in India, said Gagandeep Kang, virologist and professor of microbiology at Christian Medical College, Vellore, but it has been underutilized. “There was initially a huge pitch to sequence, but it turns out we have virtually no strains sequenced after July 2020. Now they have started sequencing again,” she said. It was only at the end of December 2020 that the government launched the Indian SARS-CoV-2 Genomic Consortium (INSACOG), comprising 10 laboratories charged with monitoring genomic variations on a regular basis.

This delay is not one India can afford. On March 24, the Indian government announced that INSACOG had detected 771 variants of concerns (VOC) in a total of 10,787 positive samples from across the country. These included 736 positive samples for viruses of the United Kingdom (B.1.1.7) variant, 34 positive samples for viruses of the South African (B.1.351) variant, and one positive sample for viruses of the Brazilian (P.1) variant. Two previously identified mutations, which could confer the ability to evade immune system defenses and increase infectivity, were also more common in the sample. In the state of Punjab, more than 80 percent of recent samples were found positive for the U.K. variant, which could be both more transmissible and more likely to cause fatalities.

India also reported having found a unique “double mutant” coronavirus variant with a combination of mutations not seen anywhere else in the world. This was reported to the global database as a potential VOC. While officially the government said “these have not been detected in numbers sufficient to either establish a direct relationship or explain the rapid increase in cases in some States,” researchers looking at spread trends believe the speed of increase in states like Maharashtra, which were already hit hard in the first wave, indicates variants are playing a role this time around. Yet, it’s been reported that in the three months since India launched its sequencing consortium, it has sequenced less than 1 percent of total COVID-19 samples, citing a lack of funds . “It was likely that the U.K. variant was circulating in India soon after it was sequenced and identified in the U.K. But we lost precious time by not sequencing enough,” Kang said.

What’s also only partly known is how well vaccines will hold up against the variants already identified in India as well as the potential new “double mutant.” India began vaccinating health care and frontline workers on Jan. 16, and those over age 60—including Prime Minister Narendra Modi—on March 1. An estimated 60 million people had received at least one dose by March 28. From April 1, vaccinations will open up to those over age 45 to help India meet its goal of vaccinating 300 million people —around a quarter of its population—by the end of July 2021. Government health officials have said that both vaccines currently being deployed in India—the Oxford-AstraZeneca vaccine manufactured by the Serum Institute of India as Covishield and the Bharat Biotech-Indian Council for Medical Research vaccine sold in India as Covaxin—are effective against the U.K. and Brazilian variants while research is ongoing against the South African variant. The Indian double mutant has not yet been studied.

Time and time again in the pandemic, India has demonstrated it has the ability to punch above its weight. It scaled up testing at an impressive rate and demonstrated its vaccine manufacturing abilities are world-class and its genome sequencing capabilities are substantial for a middle-income country. But to deploy these capabilities with the foresight, speed, and transparency needed has been another matter—and India’s ongoing second wave will test them all.

The SARS‐CoV‐2/COVID‐19 pandemic and challenges in stroke care in India

1 Department of Neurology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram Kerala, India,

7 Department of Pharmacology and Toxicology, National Institute of Pharmaceutical Education and Research (NIPER), Ahmedabad, Gandhinagar Gujarat, India,

*Address for correspondence: Pallab Bhattacharya, Ph.D., Associate Professor, Department of Pharmacology and Toxicology, National Institute of Pharmaceutical Education and Research (NIPER), Ahmedabad (NIPER‐A), Opposite Air Force Station, Palaj, Gandhinagar‐382355, Gujarat, India. moc.liamg@uhb.ballap , ,

Stroke care in India has evolved rapidly in the last decade with a focus on stroke awareness, prevention, rapid triage, treatment, and rehabilitation. But acute stroke care and poststroke rehabilitation in the country have limitations owing to the economic constraints and poor access to health care. The SARS‐CoV‐2/COVID‐19 pandemic has made stroke care even more challenging. We outline the unfavorable circumstances in stroke care induced by the pandemic; propose mitigating measures; crisis management; and provide a comparative evaluation of stroke care between India and the United States during the pandemic. There is a need for public health systems in both developed and developing countries to improve awareness, implement proper strategies of triage, acute treatment, well‐defined rehabilitation plans, telemedicine services, and virtual check‐ins.

We outline the unfavorable circumstances in stroke care induced by the SARS‐CoV‐2/COVID‐19 pandemic, propose mitigating measures, crisis management, and provide a comparative evaluation of stroke care between India and United States during the pandemic.

Systems of stroke care in India have been evolving at a rapid pace in recent years to meet the stroke burden, with remarkable advances made in stroke awareness, prevention, rapid triage, treatment, and rehabilitation. Yet, acute stroke care and poststroke rehabilitation in the country have limitations owing to the economic constraints and poor access to healthcare, burdening a large section of the population. 1 It is not surprising that the health impact of the SARS‐CoV‐2/COVID‐19 pandemic sweeping the world has created challenges for stroke care in India, which are distinct from those faced by the developed world.

We conducted a survey of stroke experts from 13 established stroke centers in India using a brief questionnaire aimed at capturing the impact of the COVID‐19 pandemic and the nationwide lockdown on acute stroke care services. We compare our data with that from a developed country, the United States of America, and attempt to understand and substantiate the observed similarities and differences. In this report here, we, stroke neurologists from high‐volume stroke centers in India, identify the weak links in acute stroke care, poststroke rehabilitation, and care of stroke survivors during the COVID‐19 outbreak, and suggest remedial measures with a special focus on telemedicine.

India is home to 1.37 billion people, nearly one fifth of the world’s population. 2 The first case of COVID‐19 in India was reported on January 30, 2020 and rapid escalation of cases was noted in mid‐March, with confirmed cases crossing 70,756 as of May 12, 2020. A nationwide lockdown in India was imposed on March 25, 2020, which brought to a standstill nearly all travel and commercial human activities across the country. 3 The swift and strict restrictive measures adopted have at least temporarily halted the flooding of the health services with COVID‐19 cases, though current epidemiological models project the peak of the curve for hospital admissions to be in June or July 2020. 3 , 4

The stroke “chain of survival” and care pathways in India have likely been affected in one way or the other because of the pandemic and lockdown. The shortfall of health insurance coverage and rehabilitative care centers ensures that most of the burden of illness is borne by out‐of‐pocket payment by patients and families. 5 A large percentage of specialized health services, such as advanced stroke care, is provided by corporate hospitals. 5 However, many of these centers are currently unable to extend care for stroke in persons suspected of having COVID‐19, as COVID‐19 care in India is mostly confined to designated hospitals under the state and central governments. The few exceptions are in regions with a high COVID‐19 caseload, where some of the larger private hospitals have been identified for care. Individuals from poorer sections of society and daily‐wage workers are the worst affected owing to their already limited access to a healthcare facility. 5 The priority has shifted from health to daily sustenance for economically weaker populations. Lower educational levels and traditional cultural beliefs contribute to poor understanding of the need for quarantine and distancing measures. 6 These factors may eventually lead to a rise in COVID‐19–related as well as –nonrelated diseases—including stroke‐related mortality and morbidity—across the country in the coming days. An additional concern is the high risk of infection among healthcare workers from the shortage of personal protective equipment (PPE), which can lead to a reduced workforce available for stroke services.

Impact of the SARS‐CoV‐2/COVID‐19 pandemic in acute stroke services in India: survey report

Changes in acute stroke care in selected high‐volume stroke centers in India during the COVID‐19 outbreak

1 All India Institute of Medical Sciences, New Delhi 28 8 6–7 1 1–3 1 No COVID‐19 positive and negative No Yes Yes

9 All India Institute of Medical Sciences, Jodhpur 6–8 2–5 2–3 < 1 < 1 0 No COVID‐19 negative only No No No

(A) Map of India showing the location of apex medical centers where the questionnaire‐based survey was conducted (Map of India adapted from Bhuvan, ISRO). (B) Graph representing the percentage reduction of total reporting of stroke cases post‐COVID‐19, along with percentage reduction in IV thrombolysis and thrombectomies in apex medical centers across India.

A comparison of the impact of COVID‐19 on stroke care in India and the United States

The extreme measures adopted to contain the spread of SARS‐CoV‐2 have resulted in a dramatic fall in the number of stroke patients reaching hospitals in India. A similar change in the pattern of stroke patients was noted in Italy, with more severe patients reaching hospitals and at longer times after onset. 9 This may be mostly owing to patients with minor stroke and transient ischemic attack not seeking care because of unavailability of transport, fear of contracting infection, and financial liabilities. The lockdown has also created difficulty in timely consultation with caregivers, leading minor stroke cases to remain undiagnosed.

Acute stroke care in individuals suspected of having COVID‐19 is of special concern. According to the Ministry of Health and Family Welfare (MoHFW) Government of India guidelines, these cases are supposed to go to designated COVID‐care government hospitals—several of them are in smaller districts and are state hospitals. Many of the COVID‐19–designated hospitals either may not have facilities for acute stroke care or are not stroke ready. The consequent disruption of hyperacute stroke treatment requiring mechanical thrombectomy is particularly acute because resources are particularly strained: the bulk of endovascular therapy in India is provided by corporate hospitals, 1 which are currently excluded from caring for stroke patients suspected of having COVID‐19. Those patients who reach a healthcare facility having no stroke expertise are undertreated and need referral to higher‐level centers, often after a considerable delay with unavoidable complications. 14 As noted in many severely affected countries, the onset‐to‐door and door‐to‐treatment times are prolonged in the SARS‐CoV‐2 epidemic, compromising acute care. 9

Recovery from a disabling stroke greatly depends on early and easy access to tailored, comprehensive rehabilitative measures, including physical, speech, and occupational therapies, especially in the initial 3–6 months poststroke. 18 India has few rehabilitation centers, and most of the patients with mild‐to‐moderate strokes receive postacute rehabilitation at home or through outpatient clinics of large hospitals. 19 The stroke recovery curves are likely to turn suboptimal, as patients will have even less access and availability to comprehensive rehabilitation facilities poststroke. The sudden interruption in rehabilitation may lead to other acute difficulties, including worsening of ambulation that patients may assume to be stroke recurrence, causing panic.

Developing a caregiver‐driven stroke rehabilitation program has been attractive in India to address the scarcity of rehabilitation centers and trained therapists. Implementing such programs will be crucial in (and perhaps after) COVID‐19 in order to avoid preventable disabilities. As one example, video‐ and app‐based programs developed in the local language can facilitate home therapy. 20

Poor accessibility to testing facilities for risk factor monitoring has rendered risk factor control challenging in the remote areas of the country. India has a higher burden of rheumatic heart diseases compared with developed countries; afflicted patients require vitamin K antagonists for anticoagulation and secondary stroke prevention. 10 , 21 Hence, the proportion of anticoagulated patients using warfarin, acenocoumarol, or related drugs is likely to be comparable to those using nonvitamin K–antagonist or –anticoagulation. 10 , 21 Patients generally have poor knowledge of the optimal use of anticoagulation and monitoring, which is likely to worsen further with decreased interaction with physicians. 22 With both laboratory and hospital access hampered, adverse events related to both poor physical therapy maintenance and suboptimal vascular risk–factor control are likely to surface. Mental health issues have also come more to the fore, with depression and anxiety associated with separation from loved ones and fear for well‐being, lack of money, and inability to work because of COVID‐19 implications and consequences. 23

With India under lockdown, the availability of essential medications is also hampered. There are increased chances of stroke recurrence if patients fail to take their medications due to unavailability, limitations in venturing out to buy medications, and inability to reach public hospitals for prescriptions and refilling from free shops. The high demand for medicines, in turn, increases prices, making it difficult for some patients to attain essential medicines. This makes patients highly susceptible to availing medicines from unauthorized sources or even receiving incorrect medications.

Teleconsultation facilities are being set up in tertiary care facilities to ensure that patients receive timely medical advice and, more importantly, motivation and counseling to endure the crisis. Such stroke teleconsultation facilities should use the opportunity to reinforce the need to also continue preventive measures for NCDs and to see that timely treatment of life‐threatening diseases like myocardial infarction and stroke is not compromised. 24 Government drug suppliers in India and defense personnel are reaching out to ensure that available drugs reach the difficult‐to‐access locations in the country, 25 whereas political action is required to ensure the resumption of drug manufacturing. In many parts of the country, local administrations have established counseling centers to tackle depression and stress. 26 Interestingly, popular media are attributing the decrease in reporting of acute myocardial infarction and strokes to an actual reduction in incidence of both related to the improvement of certain risk factors: reduced consumption of fast food, more sleep, decreased environmental pollution, and lower work‐related stress are touted as possible positive influencers. 27

One of the major concerns about telemedicine, especially in the West, has been to ensure privacy the Health Insurance Portability and Accountability Act of 1996 (HIPAA). In the United States, HIPAA noncompliant platforms have generally not been allowed. However, the U.S. Department of Health and Human Services recently waived potential penalties for HIPAA violations and declared that it would not enforce compliance rules during the COVID‐19. 31 Policymakers in India have also opened the route of telemedicine by a fast track issuing of telemedicine guidelines. 32 These guidelines provide authorization to use various telemedicine platforms by registered medical practitioners and hospitals. It, however, prohibits any technology platforms based on artificial intelligence or machine learning to counsel or prescribe medicines to patients.

Stroke management using telestroke platforms can be utilized in India to provide high‐quality care for triaging patients, as well as the entire stroke care pathway, even in resource‐poor settings. 33 As the number of COVID‐19 patients continues to increase, there may be a greater resource crunch in the routine outpatient care of stroke patients, which may be avoided to a significant extent if telemedicine platforms could be integrated early on into health systems within the framework of the guidelines of the MoHFW, Government of India.

The authors acknowledge Dr. Samhita Panda (Department of Neurology, All India Institute of Medical Sciences, Jodhpur), Dr. Keyur Patel and Dr. Devashish Vyas (Neuro1 Stroke and Critical Care Institute, Ahmedabad), Dr. Sudheer Ambekar (Jaslok Hospital, Mumbai), Dr. Jayanta Roy (Director and Head, Department of Neuromedicine, AMRI Hospitals, Mukundapur), Dr. Anand Alurkar (KEM Hospital, Pune), Dr. Thomas Iype (Department of Neurology, Government Medical College, Thiruvananthapuram), and Dr. Srijithesh Rajendran (National Institute of Mental Health and Neurosciences, Bengaluru) for their kind help in completing the survey for the study.

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4. Chatterjee, K. , Chatterjee K., Kumar A., et al 2020. Healthcare impact of covid‐19 epidemic in India: a stochastic mathematical model. Med. J. Armed Forces India 10.1016/j.mjafi.2020.03.022. [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]

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Covid-19: India sees new spike in cases despite vaccine rollout

India is experiencing a sharp spike in covid-19 cases after months of numbers dropping. The rise comes as India celebrates festivals like Holi, religious functions like the Kumbh Mela, and with five states currently involved in elections.

The country’s pandemic curve had been flattening by January and February this year but has taken a sharp upward turn since March. On 27 March, India’s confirmed active cases on the day were 62 632, the highest seen since October 2020.

Globally, India has had the third highest number of confirmed cases and deaths from covid-19 after Brazil and the US. As of 29 March, India had 12 million cases and 162 000 deaths from the disease.1

Srinath Reddy, president of the Public Health Foundation of India, said there has been a “perfect storm” of reasons for the spike. “The recent rapid upswing in cases is from a confluence of careless crowd behaviours, slackening of governmental vigil, and mutations of the virus.” He said that the decline in deaths between October 2020 and January 2021, “gave rise to a popular belief that the danger has fully passed, reinforced by overly confident assertions by some experts and politicians that we have attained herd immunity.”

India’s ability to control the spread of covid-19 and its demand for and supply of vaccines will impact global supply. According to government data,4 74 countries are currently using vaccines made in India. In total, India has supplied 60 million doses to the world—8.1 million have been grants to counties including Bangladesh, Bhutan, Myanmar, and Nepal.4 Some 34 million have been commercial sales, and 18 million have been given to Covax.

India began its covid-19 vaccination programme on 16 January. Initially, it was only for health and

India began its genomic sequencing project for covid-19 last year but, according to a paper6 published by Indian government scientists involved in the sequencing, its pace and volume has been insufficient when compared with India’s high number of cases.

A recent press statement7 from the government said that even though variants of concern have been found in India, they have not been detected in high enough numbers to either establish a direct relationship or explain the rapid surge in cases.

7 Ministry of Health and Family Welfare. Genome sequencing by INSACOG shows variants of concern and a novel variant in India. 24 March 2021. px?PRID=1707177.

9 Lockdown not a solution, learn to live with covid”: Delhi health minister.– news/coronavirus-delhi-lockdown-not-a-solution-learn-to-live-with-covid-delhi-health-minister- satyendar-jain-2400081. doing-to-fight-the-second-wave-11616888630767.html. rise-in-coronavirus-cases-2397485.

12 Indian Express. Watch: covid rules go for a toss as thousands converge at UP’s Banke Bihari Temple to celebrate Holi. as-thousands-converge-at-ups-banke-bihari-temple-to-celebrate-holi-7250013/

Indian Publications on SARS-CoV-2: A bibliometric study of WHO COVID-19 database

The first case of the COVID-19 pandemic in India was reported on January 30, 2020. As on May 17, 2020, the Ministry of Health and Family Welfare, Government of India has reported 90927 confirmed cases from 33 states with 2872 deaths [ 3 ]. Though India is in complete lockdown since March 24, over the weekend there is a rapid increase in COVID-19 cases in some states in India notably from Maharashtra, Gujarat, Tamil Nadu, Delhi, Madhya Pradesh and few other states. The rapid increase over the weekend in the month of May has created some kind of panic in India. The government and other civil bodies are making efforts to mitigate the spread of this virus.

WHO has made its COVID-19 database searchable freely and data can be exported to. CSV or RIS format. The search terms used for retrieving the data were “COVID-19” and “India”. The “title, abstract and subject” option available on the database website was used to retrieve the documents. The search results retrieved 107 results for the search term. The database was search on May 12, 2020. The data was exported from. CSV format to excel sheet for further refinement of data and analysis. After thoroughly reviewing the data, it was found that there were few repeatable titles and titles not associated with Indian author or authors and articles other than English language were excluded from the study. Only articles written in English were included in the study. In all 89 articles were considered for the final analysis.

Fig. 1 indicates the date-wise daily publication pattern of Indian authors on COVID-19. All the publications that have been included in the study were curated from March 03, 2020 to May 08, 2020 in WHO COVID-19 database. As it can be seen from Table- 1 that after mid-April there is a considerable and constant increase in number of publications published from Indian authors on the subject. Given the gravity of the problem and the virus infectivity scale, it is obvious that medical researchers have been looking for potential treatment or vaccines for this virus and this has increased the output of research in India and in other parts of the globe as well. Clinical trials for identifying vaccine or potential drug for COVID-19 is in full swing. The database has listed 1510 studies on COVID-19. This indicates the increasing interest and rapidity in which research studies have been carried out on this virus.

Gupta, Nivedita Division of Epidemiology & Communicable Diseases, Indian Council of Medical Research, New Delhi, India 06 6.74

Gangakhedkar, Raman R. Division of Epidemiology & Communicable Diseases, Indian Council of Medical Research, New Delhi, India 04 4.49

Giri, Sidhartha Division of Epidemiology & Communicable Diseases, Indian Council of Medical Research, New Delhi, India 04 4.49

Misra, Anoop Fortis CDOC Hospital for Diabetes and Allied Sciences, New Delhi, India 04 4.49

Basu, Atanu Maximum Containment Laboratory, ICMR-National Institute of Virology, Pune, Maharashtra, India. 03 3.37

Choudhary, Manohar Lal Bioinformatics & Data Management Group, ICMR-National Institute of Virology, Pune, Maharashtra, India. 03 3.37

Nyayanit, Dimpal A. Maximum Containment Laboratory, ICMR-National Institute of Virology, Pune, Maharashtra, India. 03 3.37

Shete-Aich, Anita Maximum Containment Laboratory, ICMR-National Institute of Virology, Pune, Maharashtra, India. 03 3.37

The hierarchical tree map ( Fig. 5 ) indicates the frequency of author assigned keywords to the documents that they have published on COVID-19. Keywords are helpful in identifying key domains of research and its growth. The keyword corpus contained 415 words with 208 unique words, same have been used to identify the frequency of keyword occurrences on COVID-19. It is found that the keywords “covid” (34 times), “coronavirus” (23 times), “India” (14 times), “pandemic” (12 times), “sars” (8 times) etc., have the highest frequency of occurrences.

Eighty Nine articles have received 186 citations in all with an average citations of 2.18 per documents. The article entitled “Chloroquine and hydroxychloroquine in the treatment of COVID-19 with or without diabetes: A systematic search and a narrative review with a special reference to India and other developing countries” authored by Awadhesh Kumar Singh et al. and “Prudent public health intervention strategies to control the coronavirus disease 2019 transmission in India: A mathematical model-based approach” authored by Sandip Mandal et al., and “Fear of COVID 2019: First suicidal case in India!” by Kapil Goyal and others have received 28 citations each and topped the Table, followed by the article “Full-genome sequences of the first two SARS-CoV-2 viruses from India” authored by Pragya Yadav with 18 citations. Other highly cited articles can be seen in Table 3 .

1.→ Chloroquine and hydroxychloroquine in the treatment of COVID-19 with or without diabetes: A systematic search and a narrative review with a special reference to India and other developing countries. Singh, Awadhesh Kumar; Singh, Akriti; Shaikh, Altamash; Singh, Ritu; Misra, Anoop Diabetes & Metabolic Syndrome: Clinical Research & Reviews 28 25

2.→ Prudent public health intervention strategies to control the coronavirus disease 2019 transmission in India: A mathematical model-based approach. Mandal, Sandip; Bhatnagar, Tarun; Arinaminpathy, Nimalan; Agarwal, Anup; Chowdhury, Amartya; Murhekar, Manoj; Gangakhedkar, Raman R; Sarkar, Swarup India Journal of Medical Research 28 75

3.→ Fear of COVID 2019: First suicidal case in India! Goyal, Kapil; Chauhan, Poonam; Chhikara, Komal; Gupta, Parakriti; Singh, Mini P. Asian Journal of Psychiatry 28 24

4.→ Full-genome sequences of the first two SARS-CoV-2 viruses from India. Yadav, Pragya D; Potdar, Varsha A; Choudhary, Manohar Lal; Nyayanit, Dimpal A; Agrawal, Megha; Jadhav, Santosh M; Majumdar, Triparna D; Shete-Aich, Anita; Basu, Atanu; Abraham, Priya; Cherian, Sarah S Indian Journal of Medical Research 18 75

5.→ Telemedicine for diabetes care in India during COVID19 pandemic and national lockdown period: Guidelines for physicians. Ghosh, Amerta; Gupta, Ritesh; Misra, Anoop Diabetes & Metabolic Syndrome: Clinical Research & Reviews 09 25

6.→ Lopinavir/ritonavir combination therapy amongst symptomatic coronavirus disease 2019 patients in India: Protocol for restricted public health emergency use. Bhatnagar, Tarun; Murhekar, Manoj V; Soneja, Manish; Gupta, Nivedita; Giri, Sidhartha; Wig, Naveet; Gangakhedkar, Raman Indian Journal of Medical Research 09 75

8.→ Healthcare impact of COVID-19 epidemic in India: A stochastic mathematical model. Chatterjee, Kaustuv; Chatterjee, Kaushik; Kumar, Arun; Shankar, Subramanian Medical Journal Armed Forces India 05 16

The results of the study reflects the current Indian scholarly publications on COVID-19 or SARS-CoV-2. Result of this study found some significant insights. The authors who have published more number of publications have all come from either AIIMS or ICMR institutions. Most of these authors have collaborated each other in publishing research papers on COVID-19 and have come from same institutions. This emphasizes that there is need to collaborate with other medical research institutions outside the intra-institute collaborations. It is interesting to note that more than eighty five percent of the articles on coronavirus were collaborative publications. Since COVID-19 is a global pandemic, collaborative research is the need of the hour to mitigate this infectious disease. The state-wise publication pattern indicates that except smaller states like Delhi, Chandigarh, Punjab and Haryana there are no significant publications from North India’s largest states like Uttar Pradesh, Madhya Pradesh and Bihar. This can be attributed for lack of medical or health science education and research institutions in this part. This is high time that the Government of India establishes medical research institutes and strengthen healthcare facilities across India. The study found no publication from North Eastern Region states. This emphasizes need of robust medical infrastructure in this region.

Indian research is largely done in the area of epidemiology and its impact on diabetes, cardio patients, environmental impact and pandemic outbreak, less studies on clinical prognosis, pharmaceutical interventions, and laboratory based studies or virology related studies on SARS-CoV-2. The highly cited publications were of evidence based studies, for instance “Chloroquine and hydroxychloroquine in the treatment of COVID-19 with or without diabetes: A systematic search and a narrative review with a special reference to India and other developing countries” or “Prudent public health intervention strategies to control the coronavirus disease 2019 transmission in India: A mathematical model-based approach” which have been cited by 28 times and other studies as well. As this pandemic is no way to go early, the research is shifting from basic to experimental studies across the globe [ 6 ], if we see the top highly cited documents in India also gradually studies are shifting more towards evidence based medical research for finding drugs or vaccine at the earliest for this highly infectious disease.

3. Ministry of Health and Family Welfare, Government of India COVID-19 India dashboard. 2020. Retrieved from.

Microsoft Word – Bula vacina covid-19 recombinante_vp_002_27.01.2021

Serum Institute of India Pvt. Ltd

212/2, Hadapsar, Pune 411 028 Índia

Seroprevalence of IgG against SARS-CoV-2 and its determinants among healthcare workers of a COVID-19 dedicated hospital of India – PubMed

Seroprevalence of IgG against SARS-CoV-2 and its determinants among healthcare workers of a COVID-19 dedicated hospital of India

2 Department of Community and Family Medicine, All India Institute of Medical Sciences Patna, Bihar, India.

3 Department of Anaesthesiology and Critical Care, Director, All India Institute of Medical Sciences Patna, Bihar, India.

Seroprevalence of antibodies to SARS-CoV-2 in healthcare workers & implications of infection control practice in India.

Dr. Jalal Baig: With Covid variant raging, U.S. puts restrictions on travel from India. How this happened.

Dr. Jalal Baig With Covid variant raging, U.S. puts restrictions on travel from India. How this happened.

Prime Minister Narendra Modi’s hubris, lax restrictions, the new variant and a misguided vaccine policy have plunged India into crisis. The world could be next.

Men wearing protective equipment perform the last rites for a deceased relative in a granite quarry repurposed to cremate the dead on Friday in Bengaluru, India. Abhishek Chinnappa / Getty Images

India’s second Covid-19 wave has left much of the populace literally gasping for air. More daily infections — almost 390,000 — are now being logged there than in any other country since the start of the pandemic. Yet the true numbers likely dwarf these official figures as many cases and deaths are going uncounted . The spike led the U.S. to announce it would restrict travel from India starting on Tuesday.

The Indian double mutant is shrouded in mystery. And though it’s premature to say anything with certitude about B1617, the devastation on offer in India’s second wave is a troubling sign.

To handle the overwhelming number of cases, makeshift funeral pyres are being built in parking lots as crematories are overflowing with bodies. Hospitals have been overrun by infections, with sick patients being turned away and lifesaving medicines and oxygen supplies woefully low. As journalist Rana Ayyub wrote in Time, “If the apocalypse had an image, it would be the hospitals of India.”

This horror show is a stunning development for a country that registered less than 10,000 cases in mid-February and declared victory against the contagion. But the combination of Prime Minister Narendra Modi’s hubris, lax restrictions, the emergence of an insidious new variant and a misguided vaccine policy of national self-reliance have conspired to plunge India into its current Covid abyss.

Though the culpability of Modi’s Hindu nationalist regime in this public health carnage must be recognized, the greater concern still is how India’s galactic infection burden may further the spread and development of vaccine-resistant Covid-19 variants inside the country and out.

A jarring example of how quickly foreign variants can become domestic problems is on offer right now in the form of B.1.1.7., a coronavirus strain that arose in the U.K. and has become dominant in the U.S. just months since it was first identified. Even in India, B.1.1.7. has caused an uptick in cases, most notably in the state of Punjab.

As the world starts to answer India’s distress call and begins to help its suffering masses breathe again via shipments of medical supplies and vaccines, this situation is a reminder of how our collective fates are bound to one another. An uncontrolled Covid-19 wave anywhere is a threat to human life everywhere. Though the U.K. variant is currently ascendant in the U.S., from initial impressions, the Indian strain — B. — may be more problematic for an American population that remains suboptimally vaccinated.

While other known variants carry one mutation in the all-important spike protein that enables SARS-CoV-2, the virus that causes Covid-19, to infect unsuspecting cells, the Indian variant carries two of these. Multiple mutations such as these threaten to create a virus that is not only more contagious and potentially deadlier, but one that can also evade a vaccinated body’s immune system. While existing vaccines promise efficacy against better studied variants, such as those from the U.K. and South Africa, the Indian double mutant is shrouded in mystery. And though it’s premature to say anything with certitude about B., the devastation on offer in India’s second wave is a troubling sign.

While a second Covid wave was long overdue in India, the current scale was never envisaged. Cases had been dropping since last September, and the country had several inherent advantages that seemed like it could curb any coming viral onslaught: youthful demographics, natural immunity from prior exposure to other coronavirus strains and high prevalence of Covid-19 antibodies — suggesting past infection — in the population.

The government pounced on these trends and declared an early victory. India’s health minister, Harsh Vardhan, stated that the country was “in the endgame” of the pandemic on March 7. In February, Modi’s Bharatiya Janata Party (BJP) hailed its premier “for introducing India to the world as a proud and victorious nation in the fight against Covid.”

At the same time, India’s vaccine supply has fallen far short of demand. Despite anointing itself the “pharmacy of the world” for its prodigious vaccine production, only 1.9 percent of the nation’s citizens are fully inoculated, in part due to Modi’s initial desire to export vaccines as part of a diplomacy effort to “save humanity with two ‘Made in India’ coronavirus vaccines.” The country’s national pride in its two domestically manufactured vaccines (Covishield and Covaxin) also contributed to it spurning foreign vaccines early on. These shortages have been compounded by the United States’ export ban on vaccine supplies .

All of this is superimposed on a first wave that saw the Indian government scapegoat Muslims for Covid-19 outbreaks and unilaterally institute a snap “lockdown and scatter” policy that left tens of millions of migrants jobless while shuttling coronavirus to all parts of India. Now the Indian government has been accused of censoring social media criticism of its Covid-19 policies.

The uncontrolled virus transmission that has resulted from these manifold failures has created the potential for India to serve as a variant factory. As the virus hurries to replicate its genome, it can make “mistakes” that produce a more virulent and potent form of the virus. The more unvaccinated bodies it can replicate in, the greater the potential for these errant mutations to occur. In India’s large, dense and vulnerable population, the virus has been able to infect the cells of millions.

The uncontrolled virus transmission that has resulted from these manifold failures has created the potential for India to serve as a variant factory.

In a globalized world, the consequences of India’s unchecked infections won’t stop at the country’s borders. Already, the shockwaves are being felt in more than 20 other countries .

While Donald Trump’s pandemic failures toppled his presidency, Modi will not face the electorate again until 2024 — though the sheer scale of India’s suffering coupled with international accountability may not insulate him. And whatever Modi’s political fate, his missteps have already helped unleash a variant whose consequences may well be felt globally.

Isolation and characterization of the new SARS-CoV-2 variant in travellers from the United Kingdom to India: VUI-202012/01 of the B.1.1.7 lineage

Isolation and characterization of the new SARS-CoV-2 variant in travellers from the United Kingdom to India: VUI-202012/01 of the B.1.1.7 lineage

Maximum Containment Facility, Indian Council of Medical Research-National Institute of Virology, Pune, Maharashtra 411 021, India

Influenza Department, Indian Council of Medical Research-National Institute of Virology, Pune, Maharashtra 411 001, India

Pragya D Yadav, Maximum Containment Facility, Indian Council of Medical Research-National Institute of Virology, Pune, Maharashtra 411 021, India.

We have isolated the new severe acute respiratory syndrome coronavirus-2 variant of concern 202 012/01 from the positive coronavirus disease 2019 cases that travelled from the UK to India in the month of December 2020. This emphasizes the need for the strengthened surveillance system to limit the local transmission of this new variant.

The rapid spread of the new variants has alerted the public health system of all the countries and necessitates the active molecular and genomic surveillance of the SARS-CoV-2 with respect to the disease transmission and pathogenicity. As per Ministry of Health and Family Welfare, Government of India, advisory all the international travellers/passengers were screened at the point of entry and at community level that had travelled through UK in the past 4 weeks (from 25th November 2020). Indian SARS-CoV-2 Genomics Consortium was also established to understand the evolution and spread of new variant. 4

Five cases with recent travel history from UK to India on 22 December 2020 were tested positive by real-time Reverse Transcriptase – Polymerase Chain Reaction. 5 They were kept in an isolation facility of respective state health authorities. Four cases (aged: 39, 32, 50 and 35 years) had low-grade fever with mild headache from 2 days before testing of samples; while one case was asymptomatic (aged: 25 years). All the cases were followed for 14 days and no new symptoms developed in any of the cases and all had recovered completely. Here, we report the (VOC) 202012/01 isolation and its molecular characterization from these human cases.

In conclusion, the isolation of the SARS-CoV-2 Variant Under Investigation (VUI)-202012/01 variant was confirmed using the sequencing method. The isolation of these variants may shed light on vaccine efficacy of the currently Restricted Emergency-approved coronavirus disease 2019 vaccine in India. Further the efficacy of different SARS-CoV-2 vaccine candidates need timely evaluation against this new variant.

Authors gratefully acknowledge the encouragement and support extended by Prof. (Dr) Balram Bhargava, Secretary to the Government of India Department of Health Research, Ministry of Health & Family Welfare & Director-General, ICMR; and Prof. (Dr) Priya Abraham, Director, ICMR-NIV, Pune. We thank the team member of Maximum Containment Facility, ICMR-NIV, Pune including Ms Pranita Gawande, Mrs Ashwini Waghmare, Ms Kaumudi Kalele and Mr Ratandeep More for providing excellent technical support.

Dimpal A Nyayanit, Maximum Containment Facility, Indian Council of Medical Research-National Institute of Virology, Pune, Maharashtra 411 021, India.

Rima R Sahay, Maximum Containment Facility, Indian Council of Medical Research-National Institute of Virology, Pune, Maharashtra 411 021, India.

Prasad Sarkale, Maximum Containment Facility, Indian Council of Medical Research-National Institute of Virology, Pune, Maharashtra 411 021, India.

Jayshri Pethani, Department of Microbiology, Smt. Nathiba Hargovandas Lakhmichand, Municipal Medical College (NHLMMC), Ahmedabad, Gujarat, 380006, India.

Savita Patil, Maximum Containment Facility, Indian Council of Medical Research-National Institute of Virology, Pune, Maharashtra 411 021, India.

Shreekant Baradkar, Maximum Containment Facility, Indian Council of Medical Research-National Institute of Virology, Pune, Maharashtra 411 021, India.

Varsha Potdar, Influenza Department, Indian Council of Medical Research-National Institute of Virology, Pune, Maharashtra 411 001, India.

Deepak Y Patil, Maximum Containment Facility, Indian Council of Medical Research-National Institute of Virology, Pune, Maharashtra 411 021, India.

4. Ministry of Health and Family Welfare, Government of India . Genomic Surveillance for SARS-CoV-2 in India Indian SARS-CoV-2 Genomics Consortium (INSACOG). (6 January 2021, date last accessed)

6. Sarkale P, Patil S, Yadav PD et al. First isolation of SARS-CoV-2 from clinical samples in India. Indian J Med Res 2020; 151:244. [ PMC free article ] [ PubMed ] [ Google Scholar ]

7. Yadav PD, Nyayanit DA, Shete AM et al. Complete genome sequencing of Kaisodi virus isolated from ticks in India belonging to Phlebovirus genus, family Phenuiviridae. Ticks Tick Borne Dis 2019; 10:23–33. [ PubMed ] [ Google Scholar ] of Novel Coronavirus Disease COVID19 in India on Available Database-51867.pdf

Address for correspondence: Deepti Yadav, MD. Department of Zoology, Indira Gandhi University, Rewari, Haryana, India Phone: +91 8708353583 E-mail:

Novel coronavirus also known as severe acute respiratory syndrome human coronavirus 2 (SARS-CoV-2) was emerged from Wuhan, China and have taken catastrophic form globally. India being a dense populated country is also in sec- ond stage of virus transmission. Bats were considered as its primary host but COVID-19 disease became pandemic via human to human transmission by droplet nuclei. The incubation period ranges upto 14 days and main symptoms of disease were noticed as atypical pneumonia, fever, difficult breathing, decreased SPO2 level and ultimately death due to respiratory failure depending upon immune status of the patients. India has witnessed 229 deaths so far while more than 6500 cases have been confirmed for COVID-19. Presently India has 21days complete lockdown and taken all im- mediate preventive measures for control of the disease. We aimed collection and compilation of scattered information about COVID-19 in India and so that this could be used in a suitable manner to combat the disease.

Cite This Article: Yadav D, Yadav R. Review of Novel Coronavirus Disease (COVID-19) in India on Available Database. EJMI 2020;4(3):284–288.

Figure 1. Graphical representation of No. of confirmed cases, No. of recovered cases and No. of deaths due to COVID-19 in India (Graph generated on the base of data retrieved from https://www.covid19in-[14]

SARS-CoV-2 replicates poorly in dogs, pigs, chickens, and ducks, but ferrets and cats are permissive to infection.[30] US confirmed death of a 4-year-old Malayan tiger tested posi- tive for novel coronavirus SARS-CoV-2 virus at Bronx Zoo in New York City. The tiger was infected by close contact of COVID-19 positive tiger attendant.[31] However, no human to animal transmission has been reported till date. Epidemi- ological data showed that SARS-CoV-2 infected cases were doubled in number in every week. The basic reproduction number or infection rate (R0- R naught) is 2.2 world-wide. [7] This R0 value denotes that each patient can infect an ad- ditional 2.2 individuals. The SARS-CoV epidemic in 2002- 2003 as more severe as R0 value of that was 3.[32] In general, the larger the value of R0 signifies harder it to control the epidemic. The infection rate of SARS-CoV-2 or COVID-19 in India is reported to be 1.7, which is significantly lower than worst affected countries.[33]

There is no specific antiviral treatment has been proven effectively to treat SARS-CoV-2 or COVID-19 patients. Still there is no vaccine yet. Some countries have did in vitro drug trials for COVID-19 based on SARS-CoV and MERS- CoV trials and proposed several possible drugs such as lopinavir/ritonavir (400/100 mg every 12 hours), chloro- quine (500 mg every 12 hours), and hydroxychloroquine (200 mg every 12 hours). India being prone to malaria has high number hydroxychloroquine manufacturing. Many of the developed and developing countries have given demands for hydroxychloroquine. But none of the drug molecule has been approved by WHO for COVID-19 treat- ment yet.[7] Proper protective measures are the only op- tion for inhibition of disease spread. The WHO and other organizations have issued general guidance to follow for all counties. This includes social distancing, proper hy- gienic measures, surface disinfection, proper hand wash or sanitization, avoiding social gathering, use of face masks etc.[12] Government officials of India had begun the battle with announcement of Janta Curfeu on 22nd March 2020 followed by 21 days complete lockdown in the country from 24th March to 14 April 2020.[35,36] Over 1 lakh samples have been tested across the country and more authorized government and private laboratories were in- cluded for achieving the target of testing 1 lac tests per day in upcoming months.[37,38] The Indian Council of Medi- cal Research has approved rapid antibody test kits for screening new emerging hotspots of SARS-CoV-2 virus in the country. The RT-PCR using for genotypic detection of SARS-CoV-2 is little time consuming (4-5 hrs) and required skilled professionals. So the Rapid antibiotic kits will en- hance traceability of hidden infection.[38]

India is in second stage of virus transmission and may enter into community transmission stage like other countries i.e Europe, US and China. So the upcoming few weeks of April 2020 are very crucial for prevention and control of pan- demic COVID-19 in. There is paucity of current information regarding epidemiology, duration of human transmission, and clinical spectrum of disease, therapeutic investigation, vaccine development etc. which could be fulfilled by more experimentation. Along with research, preventive mea- sure could be very important for inhibiting the rate of virus transmission. Tracing infected persons rapidly by testing and isolating them, could practically suppress virus trans- mission. Proper quarantine of confirmed as well as doubt- ful cases should be done very efficiently.

15.Available online at news/2020-02-14-kerala-defeats-coronavirus-indias-three- covid-19-patients-successfully

16.Available online at coronavirus-in-india-tracking-country-s-first-50-covid- 19-cases-what-numbers-tell-1654468-2020-03-12

19.Available online at story/covid-19-india-records-biggest-single-day-spike- as-cases-reach-1300-nizamuddin-gathering-leaves- 6-dead-1661561-2020-03-31

33. Available online at: One COVID-19 positive infects 1.7 in India lower than in hot zones The Indian Express 19 March 2020. 34. MacIntyre CR. Wuhan novel coronavirus 2019nCoV – Update

38. Available online at navirus-outbreak/india-aims-to-scale-up-covid-19-testing- to-one-lakh-daily.

Frontiers | Kerala, India’s Front Runner in Novel Coronavirus Disease (COVID-19) | Medicine

Figure 1. Timeline of epidemic outbreak in India in 21st century. Data Source from WHO website ( ).

After the initial case reports during late January and early February, the Kerala government took numerous steps to strengthen the guidelines, emergency preparedness, diagnostics, and categorization of risk involved in reducing the transmission of the virus in any outbreak. Notably, this state had previously experienced endemics, which helped to deliver a more rigorous action plan during the COVID-19 epidemic as compared to other states in India. Due to its previous epidemic experience, the state immediately declared a health emergency in the first week of February. With no new case reports, the health emergency was withdrawn on February 12, 2020. During this period, all travelers, including student returnees from Wuhan, China, were quarantined, and registrations were initiated to keep a record of travelers entering the state from SARS-CoV-2 affected countries. In mid-February 2020, the number of positive cases gradually increased as many Kerala natives returned from the affected countries. With the recurrence of cases, in mid-March 2020, the state implemented additional precautionary measures, including the immediate shutdown of non-medical educational institutes, surveillance at airports, and the use of sanitizers in public places such as salons, malls, and shopping centers. Further, an immediate fund was released from the State Disaster Response Fund (SDRF) to tackle the outbreak after the identification of COVID-19 as a notified disaster. These precautionary and state lockdowns were more advanced than the national curfew, which was declared 1 week later (March 25, 2020). Despite the severe measures, the entire state was declared to be COVID affected on March 25, 2020. The number of active cases in the state peaked at 266 on April 6 2020. Subsequently, the number of active cases has gradually decreased to date. During the period of lockdown, rigorous testing was performed for symptomatic COVID-19 cases, and contact tracing was carried out for infected people. To date (May 1, 2020), 27,150 samples were tested, out of which 26,225 were found to be negative (data available at ). This was followed by geographical tracking and mapping of confirmed cases, which helped to enable contacts of positive cases to report to the health system and seek advice regarding quarantine. In addition, nearly 82 hotspot regions in Kerala were spotted, and these containment zones are referred to as “LSG Needing Special Attention” ( 12 ). The successful containment in this state was due to the effective coordination between the inter-departments at rural and urban levels. In addition, the daily address of the state’s Chief Minister helped to instill confidence among the residents. Moreover, the state had deployed many officers from various departments to monitor activities related to containing COVID-19, such as household surveys during the quarantine period. This surveillance at a grassroots level was conducted by local self-government and primary health care workers. As of May 1, 2020, the details of people under surveillance have been provided by the Kerala government. Of these, 21,894, 21,484, and 410 were kept under observation and kept under home isolation, respectively, and 410 symptomatic persons were hospitalized ( 13 ). If domestic flights resumed, it is mandatory for travelers to use the Covid19 Jagratha portal ( ) to register their information and agree to the quarantine norms ( 14 ). After medical examination for any COVID-19 symptoms, asymptomatic travelers were requested to follow home quarantine while those with symptoms are referred to either a hospital or a COVID care center.

1. Singh S (2003). SARS in India. Available online at: ; (accessed April 16, 2020).

3. Khaiboullina S, Uppal T, Martynova E, Rizvanov A, Baranwal M, Verma SC. History of ZIKV infections in India and management of disease outbreaks. Front Microbiol. (2018) 9:2126. doi: 10.3389/fmicb.2018.02126

4. Arunkumar G, Chandni R, Mourya DT, Singh SK, Sadanandan R, Sudan P, et al. Outbreak investigation of nipah virus disease in Kerala, India, 2018. J Infect Dis. (2019) 219:1867–78. doi: 10.1093/infdis/jiy612

5. Thomas B, Chandran P, Lilabi MP, George B, Sivakumar CP, Jayadev VK, et al. Nipah virus infection in Kozhikode, Kerala, South India, in 2018: epidemiology of an outbreak of an emerging disease. Ind J Commun Med. (2019) 44:383–7. doi: 10.4103/ijcm.IJCM_198_19

8. Yergolkar PN, Tandale BV, Arankalle VA, Sathe PS, Gandhe SS, Gokhle MD, et al. Chikungunya outbreaks caused by African genotype, India. Emerg Infect Dis. (2006) 12:1580–3. doi: 10.3201/eid1210.060529

9. Kumar NP, Joseph R, Kamaraj T, Jambulingam P. A226V mutation in the virus during the 2007 chikungunya outbreak in Kerala, India. J Gen Virol. (2008) 89:1945–8. doi: 10.1099/vir.0.83628-0

11. COVID-19 update (2020). COVID-19 INDIA, Ministry of Health and Family Welfare. MOHFW. Available online at: (accessed May 9, 2020).

Citation: Udhaya Kumar S, Thirumal Kumar D, Siva R and George Priya Doss C (2020) Kerala, India‘s Front Runner in Novel Coronavirus Disease (COVID-19). Front. Med. 7:355. doi: 10.3389/fmed.2020.00355

K Srinath Reddy, President, Public Health Foundation of India; Commissioner, Lancet COVID- 19 Commission, New Delhi

3. Urgently approve and deploy a broader mix of vaccines: At this moment India deploys the use of 2 vaccines: Covishield and Covaxin. As of April 13, 2021, the Government of India has given emergency approval for other vaccines that have met safety and efficacy standards and received regulatory approvals in other markets. These include: Janssen (Johnson and Johnson), Novavax, Sputnik V, and mRNA vaccines (Pfizer-BioNTech, Moderna). We applaud this decision for three reasons: first, as a risk mitigation strategy beyond relying on two relatively new vaccines; second, to utilize domestic manufacturing capabilities to enable India to meet its COVAX obligations as well as domestic demand; and third, to focus on vaccines that have been proven safe and effective and are and can be produced locally within the country.14,15 We urge that immediate steps are taken to expand the supply of all vaccines available for domestic use in India.

6. Monitor, collate, and transparently report on Adverse Events Following Inoculation (AEFIs): Given the new, expanded pool of vaccines being made available within India, and given the global AEFI related concerns with specific vaccines such as Covishield and Janssen, we strongly urge the government to update AEFI guidelines to report regularly on a) the frequency of AEFIs related to each vaccine; and b) the severity and nature of AEFIs. We also urge appropriate training of healthcare workers to recognize and treat AEFIs from vaccines, and to update vaccine related advisories based on the incidence of AEFIs associated with specific vaccines for the Indian population. Finally, we recommend that the 30-40 minutes observation time be used for basic health screening (checks for hypertension and diabetes, for example) which can inform links between comorbidities and AEFIs.

7. Public advocacy campaign on mask wearing and safe behaviour: The Government of India, led by its political leadership carried out an exemplary campaign at the start of the pandemic, encouraging citizens to wear masks outdoors, buttressed by mandatory fines for non- compliance. Given the relative return to normal economic and social activity one year on, we believe it is time to relaunch a massive public advocacy campaign on mask wearing, this time shifting the message onto the importance of wearing masks in closed spaces outside one’s own home, along with in the open, as currently advised. This would cover public transportation, office and work spaces, shops, religious sites, and visits to friends and family. A high profile campaign will focus attention on a) the benefits of masks indoors and outdoors in preventing air borne infections, b) the value of double masking in high risk settings such as hospitals or close, confined spaces, c) the importance of air ventilation; and d) the need to wear masks and practise safe behaviour even after receiving the vaccination. The susceptibility to infections appears to be particularly high immediately after vaccination (either due to lower immunity or due to unsafe behaviour), and an advocacy campaign on the need to remain vigilant will help mitigate this risk. Other elements of safe behaviours (physical distancing, hand washing) need continual emphasizing as well.

potential events are scheduled in parts of India for the months of April and May. These include religious events, political events (state elections), and social gatherings (resurgence of weddings, sporting events). We strongly recommend a temporary ban on gatherings of groups larger than 10 for the next two months. We recognize the impact of such events in that past. These experiences should be used to formulate future strategies. Such restrictions will be disruptive, but believe that public health concerns need to override any other considerations, given the risk of infection, morbidity, and mortality. Where such events have already taken place, we urge greater vigilance to monitor for surges in infections, especially in districts to which people will return from such events. Further, we strongly recommend, in districts with increasing infections and load on health facilities, closures of all movie theatres, sports arenas and stadia, and indoor halls where groups of more than 50 can gather, for the months of April and May 2021.

14. There are several theories, but few definitive explanations for the new surge of infections in India. We urge a focused effort to identify the root causes of the surge, including an expansion of genome sequencing of the coronavirus to understand if mutants or variants are responsible for the current surge, and if so, the nature and type of such variants. This will require a much broader effort at genome sequencing. We recognize the Government of India effort to launch the Indian SARS-COV-2 Genomics Consortium (INSACOG), led by the National Centre for Disease Control (NCDC)

15.The health system in India has been under tremendous strain for the past year, and is likely to continue to stretch to deliver the care needed for rising COVID-19 cases, as well as the backlog of non-COVID medical cases. In addition, health workers are responsible for the scaled up vaccination drives, leading to enormous pressure on their time and capacity. We urge the government to take the following steps urgently: a) address bottlenecks in the pharmaceutical supply chain to end shortages of essential drugs (steroids) and equipment; b) invest in medical facilities infrastructure including enhanced ability to transport patients, and overall preparedness especially in tier 2 and 3 cities to cope with high levels of hospitalization; c) initiate refresher training programs and support for health care workers to equip them to handle COVID cases (including optimal deployment through task shifting); d) strengthen ongoing programs to support the mental, emotional, and physical needs of health care workers, through access to resources, counselling, and care as needed. In areas with a surge of COVID-19 cases, we recommend temporary postponement of elective surgeries, and restricted OPD hours. In all cases we recommend strengthening of virtual health consultations, and management of mild COVID cases remotely (through home based care).

most disruptive to the poorest sections of society. In urban areas, daily wage earners, informal sector workers, and low-skill workers are the most likely to be impoverished from disruptions in economic activities. Yet, experience from other countries has shown that lockdowns do assist in bringing down transmission rates.27,28,29 A middle ground approach will be needed in India. We recommend that in areas of high infection rates, the focus is on breaking the chain of transmission through local actions. We recommend that advisories be issued that strongly encourage anyone that can to remain at home (white collar workers, for example, who can work from home) to do so. We also recommend that venues that host large congregations should be closed, as described above, and activities that encourage large gatherings should be banned. But restrictions on the movement, or work of the working urban and rural poor should be minimized and locally determined through the creation of micro-containment zones in high case-load areas. Decisions on local lockdowns or curfews are best left to local authorities, and must be based on localised trends in epidemiological data (transmission, test positivity rates, hospitalization, and mortality rates). These decisions should be made after in-depth consultations with local businesses, community leaders, and workers associations. More importantly, extra care needs to be taken in terms of testing and vaccinations to ensure that workers are protected and safe during this current phase of the pandemic.

India is at a critical stage in the COVID-19 pandemic. In the first instance, all efforts need to be made to break the transmission chain and reduce the rate of new infections, with minimum disruption to the economy and to the livelihood of its people. Simultaneously, accelerated vaccinations will help contain the pandemic in the medium run. The past year has shown us, both within India and in other countries, that strong political will, together with building preparedness in the health system, and individual and community behaviour change can yield powerful results. We hope that strong, decisive actions taken now will spare India a long second wave and set in place actions to prevent further waves of COVID-19 infections.

3. Ministry of Health and Family Welfare, Government of India. “COVID-19 India“. https://www. (accessed 13 April 2021.)

11. Kaul R. Widen network, say experts as India aims to boost Covid vaccination drive. 2021. https://www. experts-as-india-aims-to-boost- drive-101614983519071.html (accessed 14 April 2021).

15. Ng A. India is set to become a vital Covid vaccine maker — perhaps second only to the U.S. 2021. play-an-important-role-in-producing-vaccines.html

producers meet demand? 2021. com/news/world-asia-india-55571793 (accessed 13 April 2021).

18. Kapur K. Availability of vaccine supplies in India. 2021. availability-of-vaccine-supplies-in-india/?amp (accessed 13 April 2021).

19. BioSpectrum. Panacea Biotec to produce 100 M doses of Sputnik V vaccine in India per year. 2021. panacea-biotec-to-produce-100-m-doses-of-sputnik- v-vaccine-in-india-per-year.html (accessed 13 April 2021).

20. Mint. India’s Biological E aims to produce 60 crore doses of Johnson & Johnson covid vaccine a year. 2021. indias-biologial-e-aims-to-produce-60-crore-doses- of-j-j-s-covid-vaccine-a-year-11612936996025.html (accessed 13 April 2021).

23. WHO. Responding to COVID-19 – Learnings from Kerala. 2020. feature-stories/detail/responding-to-covid- 19—learnings-from-kerala (accessed 13 April 2021).

24. Court E. How India is using a digital track and trace system to ensure COVID-19 vaccines reach everyone. 2021. how-india-using-digital-track-and-trace-system- ensure-people-dont-miss-out-covid-19 (accessed 13 April 2021).

Impact of COVID-19 pandemic on patients with SLE: results of a large multicentric survey from India | Annals of the Rheumatic Diseases

Impact of COVID-19 pandemic on patients with SLE: results of a large multicentric survey from India

23 Department of Clinical Immunology and Rheumatology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India

Correspondence to Dr Mohit Goyal, Rheumatology, CARE Pain & Arthritis Centre, Udaipur 313002, India; dr.mohitgoyal{at}

Response to: ‘Impact of COVID-19 pandemic on patients with SLE: results of a large multicentric survey from India’ by Goyal et al

Improved air quality and associated mortalities in India under COVID-19 lockdown

The year 2020 commenced with the incidence of a highly contagious SARS-CoV-2 that rapidly spread worldwide and declared a pandemic by the World Health Organization (WHO) ( Huang et al., 2020 ; Cucinatta and Venelli, 2020 ). The first cases of pneumonia-associated with coronavirus (COVID-19) were reported at the end of 2019 in Wuhan, China ( Huang et al., 2020 ), and became a worldwide public health concern ( Chen et al., 2020a ; Gilbert et al., 2020 ). In India, the first case of SARS-CoV-2 was reported in Kerala State in January 2020 ( Gautam and Hens, 2020 ). India is a densely populated country, and owing to the fear of spreading SARS-CoV-2 infection, a nationwide lockdown was imposed on March 24, 2020 for three weeks up to April 14, and was later extended until the end of June.

Qin et al. (2020) examined a correlation between high mortality and atmospheric pollution and they showed that communities living in polluted areas are more susceptible to COVID-19 due to inhalation of toxic pollutants for a prolonged time. Another study found that long-term exposure to poor air quality increases vulnerability to the incidence of more severe outcomes from COVID-19 ( Wu et al., 2020 ). Poor air quality generally suppresses the immune system, which may exacerbate virus replication and diminish virus clearance by the host ( Viehmann et al., 2015 ; Schraufnagel et al., 2019 ). AP can aggravate symptoms in individuals with respiratory infections, which can lead to the risk of hospitalization and death ( Urrutia-Pereira et al., 2020 ). The present research demonstrated the post-lockdown improvement in air quality, associated mortalities through spatial mapping, and the relationship between AP and COVID-19 cases and mortalities in India.

We employed various datasets to examine the immediate environmental impact of the COVID-19 lockdown and associated mortalities in India. Air quality index (AQI) data from 194 ground-monitoring stations ( Fig. 1 ) and satellite data for tropospheric pollutants were used to assess the spatiotemporal variation in India.

Study area. Spatial locations of Air Quality Index (AQI) ground monitoring stations in the different states of India.

Remote sensing data were analyzed on Google Earth Engine, which allows geospatial analysis ( Gorelick et al., 2017 ). NO2 and O3 data were collected from the Copernicus Sentinel-5 Precursor Tropospheric Monitoring Instrument, which is widely used for air quality-based applications ( Veefkind et al., 2012 ) to monitor the daily changes in tropospheric NO2 column number density ( Tobias et al., 2020 ). The in situ sensor used for the overall AQI data (including ambient PM10, PM2.5, NO2, SO2, CO, O3, and NH3) was procured for pre-lockdown (February 25, 2020 and March 20, 2020) and post-lockdown (March 25, 2020 and April 25, 2020) from the Central Pollution Control Board (CPCB) website ( Air Pollution Monitoring Data of India. Central Pollution Control Board ) under the Ministry of Environment , Forests and Climate Change. To ascertain that the changes in air quality in 2020 were related to the COVID-19 lockdown, we compared different parameters for the corresponding period in 2019. We chose to perform a single year comparison based on the previously published literature, where only 2019 was used as a control period ( Singh et al., 2020 ; Mesas-Carrascosa et al., 2020 ). The spatial distribution and variation in AQI data were interpolated using the inverse distance weighted (IDW) method. The IDW estimate is equal to the spatial mean of all sampled points and is one of the most widely used interpolation methods for generating real-time AQI spatial predictions ( Eberly et al., 2004 ). To examine the impact of the COVID-19 lockdown on tropospheric air quality, we procured 5 d mean data of tropospheric NO2 and O3 column number densities (mol/m2) before the lockdown (February 25–29, 2020), immediately after the lockdown (March 25–30, 2020), and almost one month after the lockdown (April 20–25, 2020) for India. For land surface temperature (LST) analysis and spatial variation, MOD11A1.006 Terra Land Surface Temperature and Emissivity Daily Global 1 km data products ( Wan et al., 2015 ) were procured for March 25–30 and April 25–30 of 2019 and 2020 (during lockdown).

Statewide data for PM-related and household air pollution (HAP)-related deaths were procured from Balakrishnan et al. (2018) , with yearly rates converted to monthly estimates. Monthly road accident (RA) deaths for each state were estimated using data from the Ministry of Road Transport & Highway Transport Research Wing ( MoRTHTRW, 2019 ) and projected on a map. All the estimated datasets for PM, HAP, and RA were obtained for one month to include the COVID-19 lockdown period (March 25 to April 25, 2020) to estimate the monthly mortalities, and were represented using the graduated color map method using ArcMap software (version 10.3). For the same period, COVID-19 cases and deaths were obtained from different portals handled by the Ministry of Health & Family Welfare ( COVID-19 Data of India. Ministry of Health & Family Welfare ; COVID-19 Data of India ). Regression and correlation analyses (Pearson correlation) were performed for a few sampled metropolitan cities (based on data availability up to May 5, 2020) with high and low air quality concentrations using ambient NO2 (μg/m3) and AQI (mainly dominated by SPM) pollution data. A schematic of the data collection sources and methodology adopted for the study is shown in Fig. 2 .

Improvement in air quality index (AQI) concentrations following the COVID-19 lockdown in India. Spatial variations in AQI a. one month pre-lockdown, b. 2 d before the Janata/People’s Curfew, c. 1 d post-lockdown, and d. one month post-lockdown. e. Histogram showing the percent change in mean AQI concentrations for March (1 d post-lockdown) and April (one month post-lockdown) relative to those in February (one month pre-lockdown). A similar analysis for the corresponding period in 2019 was also performed to compare the direct impact of the lockdown on air quality.

Restoration of NO2, O3, and land surface temperature (LST) post-COVID-19 lockdown. Spatial distribution and deviations in tropospheric a–c. NO2 and e–g. O3 concentrations over India derived from Sentinel-5 satellite data for the indicated period. Histograms showing improvement in tropospheric d. NO2 density and h. O3 density (5 d mean) one month post-lockdown compared with one month pre-lockdown or immediately post-lockdown. For comparison, the tropospheric densities of NO2 and O3 are included for the same period in 2019. i–l. Spatial distribution of LST (°C) immediately after lockdown and one month post-lockdown compared with that in the corresponding period in 2019.

Having established an association between the COVID-19 lockdown and superior air quality, we next examined its beneficial impact on mortality. The number of deaths attributed to COVID-19 ( COVID-19 Data of India. Ministry of Health & Family Welfare ), PM, HAP from Balakrishnan et al. (2018) , and RA records ( MoRTHTRW, 2019 ) were procured. The number of reported COVID-19 deaths (until May 5, 2020) was 1152, which was considerably lower compared with PM-, HAP-, or RA-related mortalities ( Fig. 5 a; Table S2 ). The mean monthly PM, HAP, and RA concentrations accounted for 56094, 40144, and 12610 deaths, respectively. The spatial distribution of the estimated monthly PM, HAP, and RA mortalities is shown in Fig. 5 b–d. Overall, Uttar Pradesh, Maharashtra, Haryana, and Rajasthan were the leading states among all the aforementioned mortality categories. In the case of RAs, Uttar Pradesh, Maharashtra, Tamil Nadu, and Rajasthan led the mortality charts. The monthly incident rate (per 100,000) of RAs during the lockdown was 0.04, compared with 2.90 for 2018, which amounted to a reduction of approximately 72-folds.

We acknowledge the limitations of this study, including the short study period, low cases of infection and mortality, and spatial uncertainty of IDW predictions. The objective of this study was to examine the immediate early impact of the COVID-19 lockdown on AP in the Indian subcontinent. These observations provide scientific evidence of the rapid environmental impact of the national pandemic response. In India, COVID-19 spread slowly until May 5, 2020 and began to exponentially increase after May 2020. Low cases of COVID-19 infection and mortality reported during the study period could also skew the correlation analysis. However, we specifically selected metropolitan cities with ≥1000 cases. We focused on the early spread in metropolitan cities with severe and low–moderate AP. Another limitation is the sparse spatial locations of the monitoring stations. This is primarily attributed to the limited number of air quality monitoring stations provided by the CPCB. In addition, some of the stations lacked complete AQI datasets; therefore, they were not included.

Our results showed that the COVID-19 lockdown was highly beneficial in reducing AP in India, one of the most polluted nations, in a relatively short period. The AQI was markedly improved post-lockdown compared with that pre-lockdown or in the corresponding month in 2019. In addition to ambient air quality, positive outcomes in the tropospheric NO2, O3, and LST values were observed. Our results provide strong evidence for a correlation between the COVID-19 lockdown and improvement in AQI parameters in India, except for the coal mining regions. This heterogeneity could be attributed to the incessant natural production of NO2 (and other greenhouse gases) from the coal mines; these areas showed no improvement post-lockdown, while anthropogenic-induced emissions in other regions showed a marked reduction following the COVID-19 lockdown. The COVID-19 lockdown reduced the mortalities associated with environmental pollutants and may additionally have a beneficial impact by curtailing RAs and numerous life-threatening chronic diseases attributed to these air pollutants. In addition to statistical correlation, our tropospheric NO2 and AQI spatial distribution also support a strong relationship between air pollutant concentration and COVID-19 cases/mortality. Our findings corroborate a recent study showing a possible correlation between AP (especially NO2) and COVID-19 mortality ( Wu et al., 2020 ; Chen et al., 2020 ). We acknowledge that this analysis requires further investigation owing to the lack of data availability for all metropolitan cities in India. If this lockdown continues for a longer period, the beneficial impact in India maybe overshadowed by other emerging factors such as household pollution, increasing incidences of domestic violence, suicides, mental health concerns in adults and children, and rising food insecurity among the unemployed.

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Probiotics in Prevention and Treatment of COVID-19: Current Perspective and Future Prospects – PubMed

1 Department of Pharmacy Practice, Manipal College of Pharmaceutical Sciences, Manipal Academy of Higher Education, Manipal, Karnataka, India-576104; Manipal Center for Infectious Diseases, Prasanna School of Public Health, Manipal Academy of Higher Education, Manipal, Karnataka, India-576104.

3 Department of Pharmacy Practice, Manipal College of Pharmaceutical Sciences, Manipal Academy of Higher Education, Manipal, Karnataka, India-576104; Manipal Center for Infectious Diseases, Prasanna School of Public Health, Manipal Academy of Higher Education, Manipal, Karnataka, India-576104. Electronic address:

6 Department of Pharmacy Practice, Manipal College of Pharmaceutical Sciences, Manipal Academy of Higher Education, Manipal, Karnataka, India-576104.

7 Department of Surgery, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, India-576104.

8 Manipal Center for Infectious Diseases, Prasanna School of Public Health, Manipal Academy of Higher Education, Manipal, Karnataka, India-576104; Department of Respiratory Medicine, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, India-576104.

9 Manipal Center for Infectious Diseases, Prasanna School of Public Health, Manipal Academy of Higher Education, Manipal, Karnataka, India-576104; Department of Infectious Diseases, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, India-576104.

10 Department of Microbiology & Center for Emerging and Tropical Diseases, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, India-576104.

Phylogenetic classification of the whole-genome sequences of SARS-CoV-2 from India & evolutionary trends – PubMed

4 Department of Microbiology, Topiwala National Medical College & B.Y.L. Nair Charitable Hospital, Mumbai, Maharashtra, India.

Background & objectives: Several phylogenetic classification systems have been devised to trace the viral lineages of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). However, inconsistency in the nomenclature limits uniformity in its epidemiological understanding. This study provides an integration of existing classifications and describes evolutionary trends of the SARS-CoV-2 strains circulating in India.

Interpretation & conclusions: This study interpreted the geographical and temporal dominance of SARS-CoV-2 strains in India over a period of nine months based on the GISAID classification. An integration of the GISAID, Nextstrain and Pangolin classifications is also provided. The emergence of new lineages B.1.1.8 and B.1.113 was indicative of host-specific evolution of the SARS-CoV-2 strains in India. The hotspot mutations such as those driven by positive selection need to be further characterized.

The Novel Coronavirus Enigma: Phylogeny and Analyses of Coevolving Mutations Among the SARS-CoV-2 Viruses Circulating in India.

Comprehensive analysis of genomic diversity of SARS-CoV-2 in different geographic regions of India: an endeavour to classify Indian SARS-CoV-2 strains on the basis of co-existing mutations.

Chinese and European variants of Sars-Cov-2 most prevalent in India | Hindustan Times

An Indian family dressed in personnel protective suits walk towards security gates after checking in their baggage at Kempegowda International Airport in Bengaluru, India.(AP)

The researchers have contended there are 198 variants of the coronavirus prevalent in India, with the most being found in Delhi, followed by Gujarat, Telangana, Maharashtra and Karnataka.

Two variants of the coronavirus disease (Covid-19) virus from China and Europe are most prevalent, according to researchers from the Zoological Survey of India (ZSI), who identified 198 variants of the Sars-CoV-2 virus in India.

“Scientists and scholars from ZSI have analysed nearly 400 genomes found in India and found at least 198 variants of the virus, which means the virus had mutated at least 198 times in India or before entering the country,” said Kailash Chandra, director, ZSI, Kolkata.

Also Watch | Covid-19: India crosses 2 lakh case mark, multiple layer masks better than single

The study was conducted by a team of seven scientists from the Centre for DNA Taxonomy of ZSI, India’s apex organisation on animal taxonomy under the Union ministry of environment and forests.

The researchers analysed genomes from India in the GISAID global database between early March and the last week of May. On June 2, the database showed more than 37,000 genomes, of which at least 550 were from India.

India’s first Covid-19 case was a medical student evacuated from Wuhan, who tested positive on January 30, which reported the country’s first three cases. On March 2, two more cases of travellers back from Italy and Dubai were reported by the Union health ministry, following which the number of cases steadily increased.

“Of the nearly 200 variants we have spotted, one mutation was the most common. It has been named D614G. It was not the most prevalent mutation in India, but found in large numbers in Europe and the US. How the mutation has helped the virus, and whether its transmission modes have changed, need to be further studied,” said Abhishek Singh, another team member.

First isolation of SARS-CoV-2 from clinical samples in India

The outbreak of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has, as on March 31, 2020, spread to over 207 countries around the world 1 , 2 , with a total of 896,475 confirmed cases and 45,525 deaths 2 . The number of reported SARS-CoV-2 cases in India is also on an increase with 1,636 cases and 38 deaths 2 . In the current pandemic situation, the isolation of SARS-CoV-2 is important for developing and evaluating diagnostic reagents, for antiviral studies and for screening of vaccine candidates. Earlier studies showed that SARS-CoV-2 could not replicate in several cell lines, which are routinely used for isolation of respiratory viruses 3 . Human and animal cell lines that were found to support SARS-CoV-1 replication during the first outbreak of SARS in China, 2002 4 , are currently being studied. The virus was first isolated in the human airway epithelial cells from clinical specimens as part of early attempts to identify the aetiologic agent of infection 5 . We describe here the successful isolation and characterization of SARS-CoV-2 from clinical samples in India using Vero CCL-81 cells by observing cytopathic effects (CPEs) and cycle threshold (Ct) values in real-time reverse transcription-polymerase chain reaction (RT-PCR), electron microscopy and next-generation sequencing (NGS).

The first three SARS-CoV-2 cases were reported from Kerala during January 27-31, 2020. Later during March 2020, cases were also reported from a group of Italian tourists (n=15) and their contacts in New Delhi, India. Simultaneously, cases were reported in Agra, Uttar Pradesh, which was the outcome of close contact of an infected Delhi-based individual who returned from Italy. The designated COVID-19 testing laboratories of Virus Research Diagnostic Laboratory network (All India Institute of Medical Sciences, New Delhi; Sawai Man Singh Medical College, Jaipur; and King George’s Medical University, Lucknow) referred the specimens (throat swab/nasal swab, oropharyngeal swab/sputum) to the Indian Council of Medical Research-National Institute of Virology (ICMR-NIV), Pune, after screening for envelope (E) gene by real-time RT-PCR was done 6 . A total of 12 SARS-CoV-2 positive specimens having a Ct <30 for the E gene were included in the study. Of these, eight samples were from positive cases of Italian tourists and their contacts in New Delhi. The rest of the specimens were from four positive cases at Agra, Uttar Pradesh, and the close contact cases of an infected Delhi-based individual who returned from Italy.

Serial numbers 1-7: Italian tourists who arrived in Delhi, India and an Indian contact of the cohort; Serial numbers 8-9: Close contacts in Agra, Uttar Pradesh, of an infected Delhi-based person who returned from Italy. qRT-PCR, quantitative RT-PCR

MEGA software version 7.0.11 16 was used for the multiple alignments of the sequences retrieved in this study and the sequences from the Global Initiative on Sharing All Influenza Data (GISAID) database ( ) ( Supplementary Table (available from )). A neighbour-joining tree was generated using the best substitution model (Kimura 2-parameter model) with a bootstrap of 1000 replicates. As per Tang et al 17 , the circulating SARS-CoV-2 can be grouped into two types (S and L type) based on the two different single-nucleotide polymorphisms (SNPs) at positions 8782 and 28144 in the genome. The S type possesses TC SNPs while the L type possesses CT SNPs at positions 8782 and 28144, respectively. In the present study, it was observed that two sequences from clinical samples (nCoV-763 and nCoV-770) had TT SNPs, while the other sequences had CT as the SNP (L type) ( Table II ). The TT SNPs have been observed in few of the GISAID sequences, including one of the Kerala genome sequences (nCoV-19/India/31 January 2020) submitted by us earlier. All the isolates of the clinical samples were of L type. Specific amino acid mutations in the nsp3 region, spike protein and ORF8, in general, lead to the formation of V, G and S genetic variants/clades, respectively, as per the recent classification followed by GISAID. It was observed that the clinical samples, as well as the isolates, had the mutation D614G in the spike protein, classifying the study samples and isolates into the G clade ( Table II and Fig. 4 ). No specific substitutions were observed in any of the isolate sequences with respect to the corresponding clinical sample sequences, as these were sequences from a low passage. The sequences of the clinical samples and the isolate from the contact of the infected Delhi-based individual, who returned from Italy, further showed two mutations, R203K and G204R in the nucleocapsid protein (N). Although all strains demonstrated 99.6 per cent identity with the original Wuhan Hu-1 sequence, the role of unique SNPs and mutations in identifying the source of infection needs to be explored.

After the first isolation of the virus in the human airway epithelial cells reported by China 5 , countries such as Australia 18 , Korea 19 , Germany 20 and the USA 21 have also isolated the SARS-CoV-2 strain. In India, initial attempts to isolate the virus from the first three cases did not succeed due to low titres in the clinical specimens. This is the first successful virus isolation of SARS-CoV-2 in the Vero CCL-81 cells in India from nasal and throat swabs of persons with a travel history from Italy and their contacts. Isolation of SARS-CoV-2 from clinical samples will be helpful to address key questions of correlating the differential cell line susceptibility and viral replication efficiency, especially important for clinical samples with low viral titres. Isolation of the virus in such a pandemic situation would help to develop indigenously designed reagents such as positive controls, virus antigen and antibodies, which could lead to the indigenous development of sero-diagnostic assays. These assays would be critical for conducting population-based serosurveys. Propagation in culture will also facilitate antiviral susceptibility studies and vaccine efforts in India.

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Why is India having a covid-19 surge? | The BMJ

India’s infections set new pandemic records in April, with more than 300 000 positive tests each day for a week. Kamala Thiagarajan looks at the many unanswered questions

On 26 April India saw the highest daily tally of new SARS-CoV-2 infections ever recorded in the world, 360 960, taking its pandemic total to 16 million cases, second only to the US, and more than 200 000 deaths.

What is causing India’s second wave, and why is it so much worse than the first?

After the first wave people dropped their guard, said Chandrakant Lahariya, an epidemiologist who helped write India’s national covid vaccine policy. “In some of the most badly hit states, like Delhi and Maharashtra, community transmission was so rampant that there have been several localised waves,” he said. Media reports have blamed lax social distancing and mask wearing, alongside mass political rallies for recent elections and religious events such as the Kumbh Mela, in which hundreds of thousands of Hindus gather at the Ganges river.

“The government was easing restrictions by what seemed to be the end of the first wave,” said V Raman Kutty, an epidemiologist and honorary chairman of the non-profit organisation Health Action by People in Thrissur, Kerala. “Malls and theatres opened; there were sporting events, elections, and religious events. Politicians even made the unsupported claim that India had beaten the pandemic.”

A report published in the International Journal of Infectious Diseases in December 2020 concluded that the transmission rate fell significantly during the first lockdown but warned that lockdown was only a temporary measure to quell outbreaks. 2 The authors recommended ramping up testing and self-isolation to prevent secondary infections, yet India’s testing rate remains among the lowest in the world. Comparisons are difficult, as India doesn’t release daily test numbers for the country as a whole, but the health ministry said that a total of 1.75 million samples had been PCR tested by 27 April. The UK performs 500 000 PCR tests a day. 3

In the latest crisis, medical supplies and oxygen are being shipped in from 15 countries and international aid organisations such as Unicef. Devi Prakash Shetty, a cardiac surgeon and chairman and founder of the Narayana Health chain of medical centres, has estimated that India would need about 500 000 ICU beds and 350 000 medical staff in the next few weeks. At present it has only 90 000 ICU beds, almost fully occupied. 5

India is also struggling to vaccinate its population of 1.36 billion, despite boasting one of the largest pharmaceutical manufacturing capacities in the world. 6

But the testing numbers themselves may not tell the whole story. “Official statistics in India are often doctored to suit the political bosses, and there was tremendous pressure to report less,” Kutty told The BMJ, adding that there is a lack of transparency in the figures for infections and mortality too. “One hardly knows who is responsible for them. It is definitely dependent on the number of tests done, and in many states it could be argued that not enough tests were done. However, the numbers of deaths are a more robust indicator, and in the first wave deaths seem to have been less compared with other countries. The second wave is a totally different story.”

With a reported 16 million deaths, the official figures in India are likely to be much lower than the actual numbers, Lahariya says. “Testing was limited, and so many who weren’t tested were admitted [to hospitals]. When these patients die, their deaths are not recorded as covid-19 deaths,” he said, adding that death can also occur much later after discharge. 7

Variants first identified in South Africa (known as 20H/501Y or B.1.351), Brazil (P.1), and the UK (B.1.1.7) are circulating in India, alongside a newly identified distinct Indian variant (B.1.617) first identified in October. All are likely to be a factor, but the extent of involvement of each is as yet unknown.

“The B.1.617 variant has spread rapidly in parts of India, apparently dominating over previously circulating viruses in some parts of the country,” said Ravi Gupta, professor of clinical microbiology at the University of Cambridge, who is studying these variants. “B.1.1.7 is dominating in some parts, and B.1.617 has become dominant in others, suggesting both may have an advantage over pre-existing strains.”

Public Health England has identified several cases of B.1.617 in the UK, 12 mostly linked to travel. This led the UK government to add India to its travel red list and the prime minister to cancel a high profile diplomatic visit to the country.

India launched its vaccine drive on 16 January 2021, mostly relying on Covishield, a version of the Oxford-AstraZeneca vaccine produced by the Serum Institute of India. A smaller number of people get India’s domestically developed Covaxin, manufactured by Bharat Biotech. 13 The government had set a target of vaccinating 250 million people by July. So far India has vaccinated about 117 million people, according to Oxford University’s Our World in Data, and around 17 million have received the full two doses of a vaccine.

As infections have risen, hospitals in hotspots have been running out of vaccines. 16 Kutty said that shortages were one thing; another is how fast India is able to vaccinate. “I think our [health] infrastructure at present may not be able to do it fast enough even if there were enough supplies of vaccines. The government has to plan a real campaign to cover as much of the population in as short a time as possible.”

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SARS-CoV-2 pandemic in India: what might we expect? | SpringerLink

As of April 07, 2020, 1,348,628 cases of, including 74,834 deaths attributed to, novel Covid-19 (coronavirus disease 2019) had been informed worldwide (WHO 2019 ; Gautam and Trivedi 2020 ; 7 April, 2020). The incidence of known cases of novel coronavirus originated from Wuhan City of China has now been decreased by using prevention measures including strict social distancing; however, the pandemic SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2) is continued transmitting in the developing countries including India.

In India, as of April 07, 2020, 4421 cases of, including 114 deaths attributed to, novel Covid-19 (coronavirus disease 2019) were reported ( 7 April, 2020). The variation of number of affected persons can easily observed in India, where the highest and lowest cases have been reported from Maharashtra and Mizoram, respectively (Fig. 1 ).

On March 22, 2020, The Lt. Governor of Delhi has notified the “Delhi Epidemic Diseases, Covid-19, Regulations, 2020” in New Delhi, where all hospitals to have flu corners to test for suspect cases, history of travelling to be recorded, and right to impose home or institution are the important silent features. On the other hand, all the states of India, applied the notification in which academic institutes will be closed until the next notification. Similarly, the government and private companies have asked their employees to work from home due to novel pandemic issue. The Prime Minister of India “Narendra Modi” announced a 21-day nationwide “Curfew/Lockdown”, to minimize the impact of novel coronavirus, as he requested to Indian citizens with folded hands to practise strict social distancing.

To reduce the impact of novel coronavirus and its transmission, lockdown activities launched in whole country with restriction of human mobility and economic activities. However, to observe comprehensive air quality data in different places of India, it can be seen that these novel coronavirus disease countermeasures led to remarkable improvement in the concentration of air pollutants ( ). According to WHO ( 2018 ), 4.2 million premature deaths were reported in the year of 2016 due to ambient air pollution. So, as per the air quality index is concerned, the enhancement in air quality of India now would significantly avert premature deaths due to air pollution on monthly/annually basis.

In India, many studies indicated that the transportation and movement of respiratory diseases depend on seasonal variation (Humbal et al. 2018 , 2019 , 2020 ). In this regard, we might expect that the effects of novel coronavirus will be decreased with higher temperature in summer, due to reduction in intrinsic transmissibility of the novel virus (Gautam and Trivedi 2020 ; Jung et al. 2009 ). Moreover, Ma et al. ( 2020 ) conducted the first study to identify the significant effects of meteorological parameters (i.e., temperature and relative humidity) on daily mortality due to Covid-19 in China. This study clearly mentioned that the daily mortality of Covid-19 is positively and negatively associated with temperature and relative humidity, respectively. It can be concluded that the warmer season (higher temperature during next few months) and lockdown activities will be key to reduce the exposure to novel coronavirus on humans. Close monitoring and real time data will be benefitted to predict and make sound public health decisions.

Humbal, C., Gautam, S., et al. (2019). Evaluating the colonization and distribution of fungal and bacterial bioaerosol in Rajkot, western India using multi-proxy approach. Air Quality Atmosphere and Health, 12(6), 693–704.

Humbal, C., Gautam, S., Joshi, S. K., & Rajput, M. S. (2020). Spatial variation of airborne allergenic fungal spores in the ambient PM2.5—A study in Rajkot City, Western Part of India. In T. Gupta, et al. (Eds.), Measurement, analysis and remediation of environmental pollutants (pp. 199–209). Singapore: Springer. .

Gautam, S., Hens, L. SARS-CoV-2 pandemic in India: what might we expect?. Environ Dev Sustain 22, 3867–3869 (2020).

3. Kumar, P., Pandey, R., Sharma, P., et al. (2020). Integrated genomic view of SARS-CoV- 2 in India. bioRxiv preprint doi: Published online 4 June 2020.

1Department of Instrumentation & Control Engineering, Dr B. R. Ambedkar National Institute of Technology, Jalandhar, Punjab, India

As 2019 ended, news arrived of an epidemic of pneumonia, with a few cases in a seafood wholesale market in Wuhan, China. Initially, a few cases were detected around December 8, and a cluster was revealed on approximately December 31, 2019, when the WHO office in China was given the information. The market was shut down on January 1, 2020, and the Chinese authority announced the viral threat. All active and suspected cases were tested. At that time, ~300 cases were positive and 4 people had died. Initially, few reports verified human-to-human transmission, and reports of super-spreading patients included 15 healthcare workers and viral spread to different Chinese cities. Various other countries also con- firmed human-to-human transmission. After China, SARS-CoV-2 spread to Europe, across Asia, and throughout the rest of the world. On January 31, 2020, first case of COVID-19 was confirmed in Kerala, India, where a student tested positive as she returned from Wuhan, China.3,4 Presently, SARS-CoV-2 is still spreading through- out the world and has affected nearly 132,758 persons globally in 167

Cite this article: Sharma P and Veer K. (2020). Action and problems related to the COVID-19 outbreak in India. Infection Control & Hospital Epidemiology, 41: 1478–1479,

COVID-19 has been declared a national disaster by the Indian government.6,7 The scientists at the Indian Council of Medical Research (ICMR) are continually obtaining global information related to the pandemic. They suggest the use of retroviral drugs. The ICMR is providing free and reliable testing and diagnosis to all individuals with symptoms of COVID-19. The government is trying to expand laboratory testing using Ministry of Health and Family Welfare (MOHFW) and non-ICMR laboratories in many facilities and organizations, such as the Council of Scientific & Industrial Research (CSIR), the Department of Biotechnology (DBT), Defence Research, and the Development Organization (DRDO), and government medical colleges. Thus far, 15 laborato- ries in India are testing for SARS-CoV-2, and 19 will soon be added.8 The agencies in India conducting COVID-19 testing include the National Institute of Virology (NIV) in Pune, the Indian Council of Medical Research (ICMR) in Hyderabad, and the National Center for Disease Control (NCDC) in Delhi. All of these agencies work under the NIV. A fund named the COVID Fund for South Asian Association for Regional Cooperation (SAARC) Countries has been started by SAARC countries to fight COVID-19. In addition, the Indian government has appealed to its citizens to follow social distancing procedures, which is the most effective way to stop the community transmission of SARS-CoV-2.

The current COVID-19 situation has affected the whole world and has had a dramatic impact on India. In India, the death rate is comparatively good, but the recovery rate of infected persons is not, which is leading to a difficult situation in India. Infections are increasing day by day in India, even though community transmission began only recently. The Indian govern- ment has taken a few necessary steps to control the situation, such as making masks and sanitizer available and providing free testing and diagnosis. Public awareness and programs of “do’s and don’ts” for COVID-19 are run at public places. Environmental conditions may also support controlling SARS-CoV-2; across Asia spring tem- peratures are increasing, which may decrease viral spread somewhat. Early prediction methods and a specific vaccine are not yet available, although government has been able to control the pandemic thus far. The World Health Organization (WHO) helps developing countries by providing funding, medical kits for testing, and proper guidance

for treatment and safety. In India, the death rate and the recovery rate indicate that the pandemic is being controlled, largely because of the preparation done by government before COVID-19 reached more advanced stages. The numbers of laboratories, test kits, and medical facilities have been enhanced appropriately. The Indian gov- ernment is collaborating with SAARC countries to fight this pan- demic. Because the Indian government has taken the appropriate actions outlined here, the COVID-19 pandemic, although tragic, will have the best possible outcome in India.