Global status of Covid-19 infection





Currently, there are confirmed 29,018,702 cases of novel coronavirus infection worldwide, with a total tally of 925,619 deaths and it has affected 213 countries and territories across the globe. The top three countries affected by Covid-19 infection are USA (6,683,812 cases), followed by India with 4,788,593 cases and Brazil at number 3rd position with total 4,315,858 cases. Globally, 20,891,496 cases have recovered or been discharged. It is important to note that out of currently infected patients, 80% patients are in mild condition while rest are in serious or critical condition.





More than 99% of the cases are now outside China where it all started, however China seems to have controlled the infection.





Current status in India









Symptoms of Coronavirus infection





Most common symptoms include:





• Fever

• Tiredness

• Dry cough





Less common symptoms are:





• Sore throat

• Aches and pains

• Diarrhea

• Loss of taste

• Loss of smell

• Conjunctivitis

• Headache

• A rash on skin, or discolouration of fingers or toes





About 80 of patients recover from coronavirus without the need of hospitalization. It has been observed that around 1 out of every 5 people who gets infected becomes seriously ill and develops difficulty breathing.





Serious symptoms include:





• Difficulty breathing or shortness of breath

• Chest pain or pressure

• Loss of speech or movement





Other symptoms may include runny nose or congestion, and nausea or vomiting. In severe cases, it can cause pneumonia and respiratory failure sometimes leading to death.













Testing for Coronavirus





Two types of tests are available:





1. Viral test: It indicates the presence of current infection





If you test result is positive for Covid-19, you should take protective steps if you are sick.

Majority people have mild Covid-19 and can recover at home without medical care.

However, contact your healthcare provider if your symptoms are getting worse.





If you test negative for Covid-19, you were not infected at the time of testing or that your sample was collected too early in your infection. Nevertheless, it does not guarantee that you will not get sick. You can be exposed to it even after the test and then get infected and spread the virus to others.





2. Antibody test: It suggests whether a person had a past infection.





A positive test result shows that you may have antibodies from an infection with the virus causing Covid-19. However, there can be a possibility that a positive result means you have antibodies from an infection with a different virus from the same family of viruses.





If you test negative, you may not have or ever had Covid-19. It an also suggest that you could have a current infection. However, test may be negative because it typically takes 1–3 weeks after infection for your body to make antibodies.





What is the latest treatment update of coronavirus?





Hydroxychloroquine





On June 15, 2020,FDA has discontinued the use of hydroxychloroquine and chloroquine for treating hospitalized patients with COVID-19. Several studies have determined that hydroxychloroquine is unlikely to be efficacious in treating COVID-19, and its potential benefits are masked by serious cardiac adverse events and other potential serious side effects.





Anti-HIV drugs





Earlier ICMR suggested that anti-HIV drugs like lopinavir and ritonavir can be utilized to treat Covid-19 patients in extreme cases. However, currently WHO and NIH panel has advised against its use due to adverse pharmacodynamics and no significant clinical benefit in these patients.





Anticoagulants





Latest research shows high incidence of thrombotic disease in patients affected by COVID-19. Therefore, it warrants the need to use therapeutic anticoagulants in high-risk individuals.





Furthermore, delayed hypoxia may occur on Day 15-17 with sudden deterioration. All high risk patients should be administered anti-thrombotic treatment, DVT prophylaxis in order to prevent it.

If at the onset of pneumonia, dexamethasone 6 mg is given for 10 days, along with statin and oral anticoagulant (rivoraxaban) for 40 days and antiviral, it may help in reducing mortality.









Dexamethasone





Corticosteroid can be lifesaving for patients who are critically ill with Covid-19. For patients on ventilators, the treatment has shown to reduce mortality by about 1/3rd, and for those who require only oxygen, mortality was cut by about 1/5th.

IDSA guidelines suggest low-dose dexamethasone (6 mg orally or intravenously daily for 10 days) in patients requiring respiratory support.

If dexamethasone is not available, the panel recommends using alternative glucocorticoids such as prednisone, methylprednisolone, or hydrocortisone.









Approach to treatment







Covid-19 has no recommended specific antiviral treatment, and vaccine is currently under development. The treatment is usually symptomatic, and oxygen therapy is the first step for managing respiratory impairment.





Early treatment aims at reducing the viral load and preventing inflammation. This can be achieved by using off label drugs like hydroxychloroquine with azithromycin; ivermectin, remdesivir; Tocilizumab; convalescent plasma therapy, anti-HIV drugs like lopinavir-ritonavir and favipiravir.





If patient comes within first 4 days of symptoms, antibiotics with anti-viral response (doxycycline or azithromycin x 5 days) can be given.

Initially, steroids were administered only in serious cases. However, now their indication has shifted to moderately severe cases. It is likely that in coming days, use of steroids may become mandatory in all patients from day 3.





If a patient develops exertional hypoxia or pneumonia (day 4-7), tocilizumab IV 8 mg/kg as a single dose or IV remdesivir or methylprednisolone alone or in combination can be given.

Latest update regarding Favipiravir suggests the dosage of 1600 or 1800 mg twice daily on

day 1, then a total daily dosage of 1200–2000 mg in 2, 3, or 4 divided doses for 4–13 days for treatment of high risk cases of COVID-19 in adults.





Although efficacy and safety of convalescent plasma is yet not established, it is effective if given within first 7 days of illness. Plasma should be donated between 28 and 40 days.





In patients who experience loss of smell/taste, recovery is the rule (disease is salvageable at every step but it does not mean that mortality is zero) within 4 weeks and mortality is an exception.

Inj Clexane 0.6 Ml OD or BID should be given in all above the age of 58 years, patients with heart problems, hypertension, diabetes, heart failure, asthma, COPD, sudden drop of oxygen on rest or exertion, post cancer patients, and those on oxygen.





If the patient presents with post-Covid sequelae, he should be given high doses of vitamin C, D and zinc x 3 days OR colchicine or hydroxychloroquine twice daily.





A delayed inflammatory response between Day 14 and 18, has been seen in Mumbai. Due to this, a 6-minute walk test has become mandatory at the time of discharge to find out whether there is any drop in oxygen saturation. In such cases, low molecular weight heparin (LMWH)/oral anticoagulant and small dose of statin should be prescribed for 5-10 days at the time of discharge, especially to patients who have been in hospital for more than 28 days and are above 55 years of age. This can help in reducing mortality.





Isolate the patient for 9 days, quarantine for 5 days and then monitor with rest for next 2 weeks. Monitoring means that the person is not contagious, but is likely to get secondary complications.





Delayed recovery (symptoms of fatigue, cough, and shortness of breath) has been seen in nearly a quarter of 18- to 34-year-old patients and in 1/3rd of 35- to 49-year-olds who were not sick enough to need hospitalization.





In Uttar Pradesh, government has decided to replace hydroxychloroquine with ivermectin for the treatment of Covid-19 patients. In addition, it is also recommended for the prevention of large scale infection among frontline health workers.





In Kerala, quarantine-stress management-symptomatic treatment with drugs like paracetamol and antivirals is the approach followed for the management of patients of Covid-19.





In Jaipur, innovative combination of drugs used for malaria and swine, lopinavir and ritonavir with oseltamivir and chloroquine, are being used used to treat patients with Covid-19





In Delhi, patient suffering from this disease is treated on the basis of symptoms and supportive treatment is done like dengue. In addition, formulation of oseltamivir, drug given for swine flu is given to patients of Covid-19.









Latest Update on Corona virus Vaccine





According to the U.S. FDA, for a coronavirus vaccine to be effective it would have to prevent or decrease the severity of the disease in at least 50% of people who are vaccinated.





Various parts of the virus are being utilized to manufacture the vaccine. There are different ways to produce vaccine such as killed virus, live attenuated virus (India, phase 1 trial), conjugate vaccine, mRNA vaccine (Moderna), spike protein (Oxford), VLP platform, membrane and envelope vaccine. Of these, which one will be successful remains unknown., According to the World Health Organisation, a total of 26 vaccine candidates are being developed all around the world.





Currently, India has three vaccine candidates for COVID-19 and all of them are in different stages of clinical trial. A total of 19 vaccines around the world have completed phase 1, are in or have completed phase 2 or have entered phase 3.





ICMR has received Tamil Nadu governments’ approval to assess the effectiveness of Bacillus Calmette-Guerin (BCG) vaccine in senior citizens in the fight against Covid-19, at its National Institute for Research in Tuberculosis (NIRT).





One vaccine known as Covaxin is being developed by the India's Bharat Biotech with the ICMR, and has received approval for Phase 1 and Phase 2 clinical trials.It already completed phase 1 human trials in just one month and has initiated Phase 2 human trials. Human trials of Covaxin are going on in 12 sites across India.





Another, Indian drug maker Zydus Cadila has secured regulatory approval to start human trials on its own Covid-19 vaccine contender. It has launched Phase II clinical trials of its vaccine, ZyCoV-D, which was found to be safe and well tolerated in healthy participants in a Phase I study.





One of the three front-runners vaccine in India is by Serum Institute of India, Pune, which is manufacturing the vaccine developed by Oxford University, currently in phase 3 human trials. A report suggested that the phase 3 trials of the Oxford vaccine or covidshield or ChAdOx1 nCoV-19 will begin in India in August, as vaccine candidate entering the third phase has provided encouraging results in the initial phases of its trial. However, currently the trial has been halted and will be progressed after the the permission from theDrugs Controller General of India(DCGI).

First people who are going to get this vaccine are those who have not been infected by the virus. However, it will not be administered to patients who have tested positive for the virus and others who have developed antibodies against the virus. Latest update by chief executive of Serum Institute's suggests that there may not be enough Covid vaccine for all Indians until 2024.





Besides, Gennova Pharmaceuticals, India is also developing‘first-of-its-kind’ mRNA vaccine and have almost finished preclinical studies. It is similar to US based biotech company Moderna’s covid vaccine whose initial trials resulted in a robust immune response.Phase III trials of Us vaccine has begin in collaboration with the NIH and BARDA.





The vaccines by Oxford and Moderna are using either an adenovirus platform or a messenger RNA platform which may not be able to prevent all known complications and presentations of Covid-19. However, ICMR and Bharat Biotech are using a live attenuated virus platform and if successful, this will be the best bet as far as the vaccine is concerned as it contains the Indian strains of the virus.





Russia is the first nation to launch first Covid-19 vaccine. The results have proven the medication’s effectiveness and safety. However, there is no further information on when this vaccine would enter commercial production stage. Recently, Russian scientists have published the first report on their coronavirus vaccine, saying early tests showed signs of an immune response.





Sinovac inactivated whole virus vaccine from China has also entered its human trial. It is alum adjuvanted and formaldehyde is used to activate the virus.





A Covid-19 vaccine developed by German biotech firm BioNTech and U.S. pharmaceutical giant Pfizer has shown potential and reported to be well tolerated in early-stage human trials.





However, no Covid-19 vaccine has yet been approved for commercial use.





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References:



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5. Treatment of Coronavirus Disease 2019 (COVID-19): Investigational Drugs and Other Therapies. Available at:https://emedicine.medscape.com/article/2500116-overview#a11. Accessed on:12-09-2020.

6. COVIDIndia.org-Treatment. Available at: https://covidindia.org/treatment/#:~:text=How%20is%20India%20Treating%20COVID,and%20other%20considerations%2C%20click%20here.&text=Remdesivir%20has%20been%20approved%20under,19%20(those%20on%20oxygen). Accessed on:12-09-2020.

7. Covid-19 latest updates: 3 Indian vaccines under trial, Russia to allow civilian use this week.Available at: https://www.hindustantimes.com/india-news/covid-19-latest-updates-3-indian-vaccines-under-trial-russia-to-allow-civilian-use-this-week/story-eUNncepriH354QPlOjXflK.html. Accessed on:12-09-2020.

8. Coronavirus vaccine news live updates. Available at: https://www.deccanherald.com/science-and-environment/coronavirus-vaccine-live-updates-covaxin-clinical-trials-human-trials-coronavirus-vaccine%20tracker-india-russia-us-china-oxford-moderna-bharat-biotech-866148.html#1. Accessed on:12-09-2020.

9. Coronavirus: Russian vaccine shows signs of immune response. Available at: https://www.bbc.com/news/world-europe-54036221. Accessed on:12-09-2020.



