‘Mutations in virus not specific to India’
as we were entirely dependent on imported PPES in the prepandemic period. We have also scaled up the availability of hospital beds, and oxygen supply linked beds, to enable supportive treatment of Covid-19 patients. While there are sufficient ventilators, our goal is to prevent patients from going on ventilators because the global experience shows that once patients go on ventilators, the mortality rate is very high.
Overall, we are focusing on preparedness in the community (physical distancing, phased relaxation of lockdown), augmenting healthcare facilities (more beds, oxygen support, ICU) and public health management measures (surveillance, testing) to ensure that a holistic plan is in place to combat the threat of resurgent infections once the lockdown is lifted in a phased manner at varying levels in different districts. are being sequenced by the Council of Scientific & Industrial Research (CSIR).
The key mutations in SARSCOV-2 virus have been found in spike glycoprotein (D614G, G1124V), nucleocapsid (R203K, G204R), RNA dependent RNA Polymerase (P323L) . The circulating viruses in India belong to three major strains. The majority of our samples belong to A2a and about 15% to A3 genotypes. There are a few samples belonging to genotypes B, B1, B4, and A1a. They do not have any mutation that has been reported to be associated with any disease progression or acquisition so far. So, despite the fact that no key mutation specific to India has been found in the virus and it still continues to be an imported virus strain, we cannot afford to be complacent. We have to remain vigilant and continue tracking the virus to identify emerging quasi-species or strains. while some belong to A3 and B1 clades. It is too early to detect major differences. We are trying for a systematic study of viral RNA sequence from different zones of India and correlate with disease severity.
The focus is on self-reliance. We have ramped up our capacity for developing indigenous testing kits. From being completely dependent on imports, we now have over 20 indigenous manufacturers with a diagnostic kit production capacity of nearly 50 lakh kits per month getting ready by the end of May. This includes indigenous components and reagents.
The government’s role has been very proactive in supporting innovation for vaccine development, development of cost-effective diagnostic equipment , as well as drug discovery and repurposing. The Covid Consortium, under DBT-BIRAC (Biotechnology Industry Research Assistance Council), has supported 70 projects. Support has been also given to medical devices such as ventilators and equipment such as PPES, N-95 masks etc, and for drugs and vaccine development. Funding start-ups that offer immediate solutions has been fast-tracked.
The recent study from New York which failed to find any mortality benefits associated with the use of hydroxychloroquine is a retrospective cohort study. There are several caveats in the study which need to be accounted for. First, the design of the study precludes attribution of the causal effect of the use of hydroxychloroquine on the disease outcomes. Second, the recipients of the drug were already suffering from severe disease, thus making the comparative sample groups unfair. Third, the best effect of hydroxychloroquine based strategy is seen when initiated in the mild to moderate disease stage. Several clinical trials are underway, and once their results are declared, we shall have definite evidence of the effectiveness of hydroxychloroquine.
Several studies are also underway in India, and as the results emerge, we shall be able to provide more insights into the experiences. However, early reports from the pharmacovigilance programme indicate that there are no unexpected spikes of adverse reactions from the use.
In India, we plan to randomise at least 1,500 Covid-19 patients over five to six months. The trial has been initiated with 46 randomised Covid-19 patients, symptomatic adults who have been recently hospitalized and have not yet received hydroxychloroquine. The nature of care proposed as part of the randomized trial include providing only local standard of care, administering Remdesivir, hydroxychloroquine, Lopinavir / Ritonavir or Lopinavir / Ritonavir with Interferon Beta-1a. So far, around 2,500 people have been randomized globally. Being a five-arm study, large numbers (> 10,000) are required, although there is no cap on sample size. It’s not possible to give timeframe for outcomes as the analysis resulting from these trials is global.
BCG vaccination has been found to be an immunomodulator in malignancies and also protects against certain infectious diseases. Several high-income countries, which do not have routine BCG vaccination in childhood, have initiated clinical trials of BCG in highrisk groups, especially in health care workers. Currently, there are two ongoing clinical trials in India. Serum Institute of India (in Pune) is conducting a trial of VPM1002 and Cadila is conducting a trial using mycobacterium indicus pranii. However, we have to keep in mind the fact that India has very high rates of BCG vaccination at birth, and this could be an effect modifier or confounder in the results.