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 Table of Contents  
EDITORIAL
Year : 2021  |  Volume : 2  |  Issue : 3  |  Page : 51-57

COVID-19 in India: Current status-prevalence, research area, public health, and primary care


Department of Pharmacology, Delhi Institute of Pharmaceutical Sciences and Research, Delhi, India

Date of Submission16-May-2021
Date of Decision19-Jun-2021
Date of Acceptance20-Jun-2021
Date of Web Publication28-Dec-2021

Correspondence Address:
Sweety Sharma
Department of Pharmacology, Delhi Institute of Pharmaceutical Sciences and Research, Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jphpc.jphpc_10_21

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  Abstract 


COVID-19 remains a serious global public health emergency. As of June 18, 2021, there had been 177,108,695 confirmed cases of COVID-19 worldwide, with 3,840,223 deaths. India is currently experiencing the world's worst outbreak, with the new emerging cases. This pandemic has a negative impact on India's public health, primary care, economic activity, and research. There are no proven treatments, and medicines have only been approved for emergency use or as an off-label drug. The growing number of COVID-19 cases causes a shortage of health-care resources such as medicines, testing, hospital beds, oxygen support, ventilators, and so on. The abrupt change in scenario has exacerbated mental health issues. Several clinical trials are underway, and many Indian companies are expected to begin supplying vaccine doses in July, with the hope that the crisis will be under control by the end of the year. This review focuses on the current state of COVID-19 in India in terms of research, public health, primary care, and prevalence.

Keywords: Coronavirus, COVID-19, health care, India, pandemic


How to cite this article:
Sharma S. COVID-19 in India: Current status-prevalence, research area, public health, and primary care. J Public Health Prim Care 2021;2:51-7

How to cite this URL:
Sharma S. COVID-19 in India: Current status-prevalence, research area, public health, and primary care. J Public Health Prim Care [serial online] 2021 [cited 2022 Jan 16];2:51-7. Available from: http://www.jphpc.com/text.asp?2021/2/3/51/333895




  Introduction Top


Coronavirus disease has posed a serious global public health emergency.[1] COVID-19 is now more widespread than Severe Acute Respiratory Syndrome (SARS).[2] Its first appearance was discovered in Wuhan (China) in December 2019, and its outbreak was declared a pandemic by the World Health Organization (WHO) on March 11, 2020. COVID-19 had been confirmed in 177,108,695 instances worldwide as of June 18, 2021, with 3,840,223 deaths.[3] Most infected people have mild-to-moderate respiratory illness and recover without any special treatment or hospitalization, but the elderly and those with underlying medical conditions such as cardiovascular disease, diabetes, chronic respiratory disease, and cancer are more likely to develop serious illness.[4] Coronaviruses are the most common group of viruses in the order Nidovirales and family Coronaviridae.[5] They have been linked to a variety of respiratory diseases, ranging from mild to severe, such as Middle East Respiratory Syndrome and SARS. This virus spreads primarily through droplets produced by infected people coughing or sneezing.[3] SARS CoV 2 has the potential to spread via the fecal-oral route.[6] Among the α, β, Υ and δ genus of coronavirus, α and β genus mainly affect the human population.[7] Unique features behind their effective binding with human angiotensin I-converting enzyme 2 receptors in comparison with the SARS-CoV includes mutations on the receptor-binding domain of S protein and the presence of O-linked glycans and polybasic furin cleavage site.[8] Drug repurposing techniques are being investigated to find prospective medications that disrupt critical components of the coronavirus life cycle pathway because no vaccinations or medicines are currently available for the prevention or treatment of COVID-19. In terms of public health, economic activity, and research, the pandemic's impact on India has been mostly disruptive. This review summarized the present state of COVID-19 in India in terms of research, public health, and prevalence.


  Coronavirus Structure Top


This coronavirus consists of five different protein types, namely the Spike Protein (S), Envelope Protein (E), membrane protein (M), hemagglutinin-esterase dimer protein (HE) and the Nucleocapsid Protein (N). The first four proteins are present on the surface while the N protein is linked to the nucleocapsid RNA genome. The genome has a length of approximately 26,000–32,000 base pairs.[9] The N protein, located in the endoplasmic reticulum-Golgi region, involved in viral replication cycle processing and host cellular responses.[10] The S protein comprises two subunits-S1 and S2. S1 and S2 subunits are responsible for virus attachment to the host cell receptor and fusion of the viral and cellular membranes.[8]


  Mechanism of Viral Entry Top


The coronavirus enters the host cell through endocytosis by attaching spike (S) protein to angiotensin converting enzyme 2 receptors. This coupling causes S protein to change conformation, which is followed by cathepsin L proteolysis and the activation of membrane fusion mechanisms within endosomes. Endosomes then open and release virus into the cytoplasm, followed by nucleocapsid uncoating via proteasomes. Finally, the ssRNA is released into the cytoplasm, where it begins replication and transcription.[11] The positive strand viral RNA is transcribed into negative RNA, which serves as a template for the synthesis of viral mRNA. Then viral proteins are produced, which are then assembled with genome RNA into virions in the ER-Golgi region, followed by budding and exocytosis.[12]


  Prevalence in India Top


On January 30, 2021, the first case of COVID-19 in India was reported in the state of Kerala.[13] India currently has the world's second highest number of confirmed cases. With 62,480 new infections, India's COVID case count will be close to 3 crores on May 18, 2021. The death toll has risen to 3.83 lakh, with 1587 people succumbing to the infection.[14] In terms of both COVID instances and mortality, India is currently the world's worst-affected country.[15] The active cases decreased below 8 lakh after 73 days and the national COVID-19 recovery rate had surpassed 96%.[16] On May 18, 2021, the COVID-19 caseload has decreased by a net of 38,692 cases in the last 24 h. The daily positivity rate was calculated to be 3.48%. It has been <5% for 10 days in a row.[17] Various types of COVID-19 variants were reported in India including B.1.1.28 variant (Brazil variant), B.1.351 variant (South Africa variant), B.1.1.7 variant (UK variant), N440K variant, and E484Q variant.[18] The B.1.617.2 coronavirus variant, also known as the Delta variant, is classified as a Variant of Concern (VoC) and is thought to have originated in India.[19] Aside from these variants, the Coronavirus has several mutations in the country. Double Mutant Strain and Triple Mutant Strain are two known mutations that are thought to be responsible for the deadlier second COVID wave in India.[18] In the midst of India's recovery from the second wave of the COVID-19 pandemic, Maharashtra has issued a warning for the third wave.[20]


  Research Area Top


Treatment in India

No proven treatments are available; most of them are still undergoing clinical trials. Medicines have been approved only for emergency use or as an off-label drug.

For mild cases: Symptomatic management, hydroxychloroquine, ivermectin, and inhaled Budesonide are used for treating mild cases.

Symptomatic management

Antipyretics, anti-tussive, and multi-vitamins are used for the management of symptoms.[21],[22]

Hydroxychloroquine

HCQ was discovered to be effective in inhibiting SARS CoV 2 entry and postentry stages. It was also discovered to have anti-inflammatory activity, as it reduces the production of cytokines found in the plasma of SARS CoV 2-infected patients. According to the research, it is less toxic and less potent than CQ.[23] It is approved on the basis of evidence with a low degree of certainty. It should only be used when absolutely necessary, and should be avoided if the QTc is >500 msonds. On the 1st day, 400 mg BD is administered as a tablet, followed by 400 mg daily for the next 4 days (unless contraindicated).[21],[22]

Ivermectin

It is an FDA-approved anti-parasitic medicine that belongs to the avermectin class of macrocyclic lactone compounds with 16 members. Its method of action against SARS-CoV 2 is likely to be through the inhibition of viral IMP/1-mediated nuclear import, which results in a decrease in viral replication and as a result, a decrease in viral load.[24] It is also approved on the basis of evidence with a low degree of certainty. It is a safe medicine, with no serious negative effects observed to yet. Lactating and pregnant ladies should stay away from it. It is given in the form of a 200 mcg/kg tablet once a day for 3 days.[21],[22]

Inhaled budesonide

It is given at a dose of 800 mcg BD for 5 days via metered dose inhaler/dry powder inhaler if symptoms like fever or cough last longer than 5 days after the onset of the sickness.[21],[22]

For moderate and severe cases

Methylprednisolone and dexamethasone

Methylprednisolone and dexamethasone should be avoided during the first 4–5 days of the disease. Methylprednisolone or dexamethasone in two divided doses of 0.5–1 mg/kg for 5–10 days (can switch to oral route).[21],[22],[25],[26]

Unfractionated heparin or low-molecular-weight heparin

They are avoided when contraindicated or when there is a high risk of bleeding and are administered as Enoxaparin 0.5 mg/kg per dose subcutaneously BD (in severe cases) and OD (in moderate cases).[21],[22],[25],[26]

Remdesivir (emergency use authorization)

It's an analogue of adenosine triphosphate.[27] It is recommended for persons who require oxygen. It is avoided when AST/ALT levels are > 5 times the upper limit of normal, or in renal failure when eGFR is < 30 ml/min/m2 or when haemodialysis is required, or in pregnancy or lactating females, or in children under the age of 12. It is administered intravenously at a dose of 200 mg on day one, followed by 100 mg IV daily for the next 4 days.[21],[22],[25],[26]

Itolizumab

It is an anti-CD6 IgG1 monoclonal antibody that is given as an injection of 25 mg/5 mL.[21],[22],[25],[26]

Favipiravir

It is a prodrug (T-705) having a molecular weight of 157.1 g/mol.[28] Its approval is based on clinical evidence that showed clinical improvement of up to 88% in people with mild-to-moderate COVID-19. A dose of 1800 mg orally Bd is used on the 1st day, followed by 800 mg orally Bd for a maximum of 14 days.[21],[22],[25],[26]

For severe cases

Tocilizumab (off label)

It is used when a patient's condition does not improve despite the usage of steroids and when inflammatory indicators are elevated. Before using, active infections and tuberculosis should be ruled out. It is given in 100 ml of normal saline at a rate of 4–6 mg/kg (400 mg in a 60 kg adult) over 1 h.[21],[22]

Moderate disease

Convalescent plasma (off label)

It is not used after 7 days of symptom onset and is only used when patients are not improving despite steroid treatment. Donor plasma should have a neutralizing titer over the particular threshold, and it should be avoided in patients with IgA deficiency or immunoglobulin allergy.[21],[22]

Recently approved drugs in India

Virafin (Restricted, emergency use)

It is a pegylated interferon alpha-2b which was approved on April 23, 2021. It has shown to reduce the need for oxygen support among moderate cases of COVID-19, along with improving recovery time.[29]

2-deoxy-d-glucose (emergency use authorization)

It is a glucose molecule that has been modified. Based on the scant data, it was approved on May 8, 2021. Defence Research and Development Organization created it, and Dr. Reddys Laboratories Ltd manufactures it. It has been shown to be effective against all COVID-19 variants. Clinical studies showed that hospitalized patients are recovering faster and additional oxygen dependence is decreased.[30]

Vaccines

Covishield and Covaxin were formally approved by the Central Drugs and Standards Committee onJanuary 3, 2021. They are initially available to healthcare and frontline employees, and then to anybody over 45. On May 1, 2021, persons aged 18–44 began receiving vaccinations. The country had vaccinated a total of 26,89,60,399 persons as of June 18, 2021.[31] In India, Sputnik V has been approved on April 12, 2021. In India, almost 260 million doses of three authorized vaccines have been administered.[32]

Covishield

Based on the Oxford AstraZeneca vaccine, it was produced by the Serum Institute of India for limited usage in emergency situations. Two dosages are given 4 to 12 weeks apart.[33] It is a single-vector vaccine made up of a recombinant, replication-deficient chimp adenovirus (ChAdOx1) vector that encodes SARS-S CoV-2's glycoprotein. SARS-CoV-2 S glycoprotein is expressed locally after injection, eliciting neutralizing antibody and cellular immunological responses.[34] It has an overall efficacy of about 70%, but when given as a half dose followed by a full dose a month later, the efficacy can be as high as 90%.[35]

Covaxin

This was developed by Bharat Biotech for limited usage in emergency conditions, and the business now has the exclusive manufacturing licence for Covaxin.[36],[37] COVAXIN is an inactivated vaccine derived from the SARS-CoV-2 strain isolated at the National Institute of Virology, a virology research institute in Pune, India. The vaccine is combined with immune stimulants known as vaccine adjuvants to improve immune response and provide longer-lasting immunity (Alhydroxiquim-II). The vaccine candidate is made by combining inactivated virus with ViroVax's Alhydroxiquim-II adjuvant. Its two doses are separated by 4 weeks. Preliminary data from its phase 3 trial show an efficacy rate of 81%.[38]

Sputnik V

It will be India's third vaccination to receive approval.[39] This vaccine was created by the Gamaleya National Research Institute of Epidemiology and Microbiology in Moscow. Gam-COVID-Vac, commonly known as Sputnik V, is a hybrid of two adenoviruses (Ad26 and Ad5). The adenoviruses (viruses that produce the common cold) are coupled with the SARS-CoV-2 spike protein (virus that causes COVID-19), which activates the immune system. The two shots are separated by 21 days.[40] It has a 91.6% effectiveness rate.[39] Sputnik V was launched in India by Dr. Reddy's Laboratories.[41] For Sputnik V, five other Indian companies have joined forces with RDIF (Russian Direct Investment Fund). Gland Pharma, Hetero Biopharma, Virchow Biotech, Panacea Biotec, and Stelis Biopharma, the biopharmaceutical arm of Bengaluru-based Strides Pharma Science, are among the others.[42] This is currently the second most expensive COVID-19 jab in the country.[41]

Clinical trials

As of the May 18, 2021, 83 studies were registered on clinicaltrials.gov to evaluate the effect of various interventions in the management of COVID-19 in India (Recruitment status: 20 completed, 43 recruiting, 14-active, not recruiting).[43] [Table 1] shows a list of several active clinical studies in India. 38% of the total interventions evaluated in the clinical trials were different types of drugs followed by 13% of biologicals, [Table 2]. List of some vaccines which are under trials in India are given in [Table 3].
Table 1: List of some ongoing clinical trials in India

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Table 2: Number of clinical trials registered for evaluating different types of interventions for management of COVID-19 in India

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Table 3: List of some vaccines which are under trials in India

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  Public Health Top


In the second wave, India experienced the world's fastest-growing number of COVID-19 cases, resulting in shortages of medicines, testing, hospital beds, oxygen support, ventilators, and other supplies. Anxiety, depression, insomnia, and stress have all increased as a result of the abrupt change in scenario, deaths, and isolation. Patients requiring transplants and those suffering from end-stage organ failure are particularly vulnerable because the healthcare facilities that treat them are also affected by the pandemic.[44] Long-term care for chronic conditions, as well as rehabilitation, are severely disrupted, affecting older people and people with disabilities.[45] As a result of caring for COVID-19 patients, frontline healthcare professionals are at risk for physical and mental harm. A study found that using a PPE kit for an extended period of time resulted in cutaneous manifestations and skin damage (97% of the time), with the nasal bridge being the most affected (83%).[46] This pandemic had a negative impact on children's diet, sleep routines, and physical activity, increasing the risk of obesity. During the lockdown, physical activity decreased by nearly 2 h per week, while sugary and processed food consumption increased.[47]


  Primary Care Top


Primary care in India

Primary care is critical in the COVID-19 response because it can meet more than 80% of people's health needs. It is critical in identifying and triaging potential COVID-19 cases, ensuring early diagnosis, assisting vulnerable people in coping with psychological conditions (anxiety and depression), and reducing hospital service demand. In India, all six principles of Primary Care for COVID Response mentioned in the WHO guiding document have been incorporated into the strategies that most state governments have implemented. Several guidelines have been issued from time to time with these specific principles in mind.[48] Primary health care in India is provided through a complex network of government and private sector pharmacies and clinics.[49] Several states' health-care systems are currently struggling due to a lack of skilled human resources, infrastructure (hospital beds, equipment), and testing facilities.[48] Large health-care organizations are currently struggling to keep up with the system's demand. The WHO is providing technical assistance to three districts in Chhattisgarh's Bastar region to support and strengthen the Health and Wellness Centre program.[50] People are continuously advised to visit hospitals only in unavoidable circumstances to prevent overcrowding of health facilities and reduce the burden on emergency services.[51] Some states are maintaining regular communication with the public about the hazards and risks of this novel disease, disseminating precautionary messages through official channels to dispel fake news.[52] Primary care apparatus has also played one of the most significant roles in provisioning COVID-19 vaccination services in India.[48]

Primary care physician's role during COVID-19

COVID-19 vaccines will be administered to all people above the age of 18 years over the following few months. For an effective vaccination campaign, people must be taught about the necessity of vaccines, the safety and efficacy of vaccines must be presented in a comprehensible manner, and a culture of confidence in the COVID-19 vaccines must be fostered. In order to identify, prioritise and inform patients based on age, health risk, and their location, it is also necessary to have reliable mechanisms. Primary care physicians are the best resources available for achieving this goal. The public trusts primary care physicians, and given the inconsistent messaging from social media, it is critical that vaccine information and education come from highly trusted sources.[53] Primary care physicians can help the COVID-19 response by distinguishing patients with respiratory symptoms from those with COVID-19, making an early diagnosis, assisting vulnerable people with their fear of the virus, and reducing the demand for hospital services.[54] Primary care physicians are an important component of surveillance systems because they are responsible for notifying public health when communicable diseases of significance are identified.[55] This paper will help in assisting physicians in the management of COVID-19 by providing status of currently available treatment options.

Challenges

India is currently confronting numerous challenges. The following are some of the challenges in controlling COVID-19 in India:

  • India is the world's second most populous country, with a current population of approximately 1,391,753,322. One of the most difficult challenges is vaccinating everyone
  • Lack of medical supplies
  • Lack of disease awareness in some segments of the population
  • Limited access to health-care systems in underdeveloped areas.



  Conclusion Top


COVID-19 is still wreaking havoc around the world. A number of advances in the field of research have been made, but new variants, including B.1.1.28, B.1.351-are still emerging. India now has the worst outbreak in the world. This transmission chain seemed like the development of vaccines and medicines to manage COVID-19. The lack of medical facilities, however, further aggravates the crisis. A number of clinical trials are still going on. The soft launch of the third vaccine in India gives reason for optimism. From July onwards, more Indian companies are scheduled to begin supplying vaccine doses, giving hope that this crisis will be under control by the end of the year.

Key points

  • The impart of COVID-19 in India is largely disruptive
  • The health system in a few states of India is currently struggling
  • No proven treatments are available for the management of COVID-19
  • Virafin and 2-deoxy-d-glucose (2-DG) are the recently approved drug in India.


Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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Abstract
Introduction
Coronavirus Stru...
Mechanism of Vir...
Prevalence in India
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