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892 Indian Journal of Forensic Medicine & Toxicology, April-June 2021, Vol. 15, No. 2
A Review of India’s Preparedness to Tackle the Covid19
Crises?
Shreyasvi Sharma
Medical Intern, Jawahar Lal Nehru Medical College, Datta Meghe Institute of Medical Sciences
(Deemed to be University), Wardha, Maharashtra, India
Abstract
The novel Coronavirus, first appeared in Wuhan province of China in late December 2019, and gripped
the whole world in 2020, growing to be a full-blown pandemic and changed every individual’s life completely.
India recorded its first Novel Coronavirus case on 30th January 2020 in Kerala, a student from Wuhan,
China. In this article, the question about whether India is ready to tackle the crisis, i.e., Covid-19, was
answered. Three mathematical models were reviewed and then compared to the number of beds available
in the country. The third mathematical model seemed to model the country’s curve much closer than the
second one. The first one’s prediction actually came out to be true. Furthermore, the paper discusses the
health infrastructure in the country and the strategies adopted by states to prevent the spread. It talks about
two specific states Kerala and Maharashtra and how the country needs to deal with the crisis. It is important
to note that according to the models and numbers currently, India is geared, However, if precautions are not
taken the situation can get much worse. This paper also discusses the fatality rates currently in India and
where we stand for treatment. Currently, the treatment protocols keep changing from time to time.
Keywords: Covid-19, Mathematical Modelling, Health Infrastructure, Future of India
Introduction And, in case of COVID 19, it is found to be between 1.4
The novel Coronavirus, first appearing in Wuhan and 2.8 2. Community transmission being the worst-case
province of China in late December 2019, gripped scenario, where the source of the infection cannot be
the whole world in 2020, growing to be a full-blown traced, and if unchecked, can easily turn to an endemic
pandemic. As of 5th July, 11 million cases and about 5 in the region. While studies have been going on about
lakh deaths were recorded worldwide1. The virus spreads effective treatment and vaccines, behavioral intervention
primarily through droplets of saliva or discharge from is the preventive measure that can be taken by everyone,
the nose when an infected person coughs or sneezes or and screening and testing by the government. India
contact with contaminated surfaces, so it is important recorded its first Novel Coronavirus case on 30th
to maintain proper hygiene and respiratory etiquette. January 2020 in Kerala, a student from Wuhan, China.
However, A disease causing pathogen is transmitted A national lockdown was imposed on March 25th to
based on its infectibility, which depends on the R-naught curb the spread. However, starting from the first case,
value i.e., the number of persons who can possibly the country has recorded more than 6 lakh cases, placing
contract the virus from an infected person on an average. itself in the top ten worst affected countries.
The corona virus has affected everyone’s lives in a
Corresponding author: massive manner. With the case count growing everyday,
Shreyasvi Sharma it is important to answer questions like; Will we have
Medical Intern, Jawahar Lal Nehru Medical College, enough beds and ventilators for critical cases in the
Datta Meghe Institute of Medical Sciences (Deemed to future? Will some states be worse than the others? What
be University), Wardha, Maharashtra, India. precautions should each state take? When will all this be
Email – shreyasvisharma@gmail.com over? This paper sheds some light into these questions.
Indian Journal of Forensic Medicine & Toxicology, April-June 2021, Vol. 15, No. 2 893
It also looks at predictions of various mathematical India. Data from the second Fourier based model
models, extrapolates those peak numbers and compares was focused on. This model takes previous data for 14
them with the number of beds available in the country. days into account and predicts data for the future based
Furthermore, it discusses some of the strategies taken by on the previous data. Certain parameters were used for
various states. different countries in this model.
Materials and Method III. Regression Analysis - June 22nd, 2020 5
In this review article, a lot of mathematical modelling Finally, this paper also was based of covid
papers from various online publishing sources were 19’s exponential behaviour. For this study the
reviewed where the Covid-19 peak case count in India R-naught(reproduction) value was around 1.4 - 3.9.
was predicted. It is important to note that all of these This model was applied to two countries, China and
papers used different types of mathematical models and Korea, who are much further ahead as the coronavirus
also had different data available to them at the time of hit them earlier. The model seemed to fit both the
publishing. Different conditions and assumptions were countries and was adapted with specific constants for
taken into account for each model. Specifically, three India. It is important to note that this model was also a
papers and the mathematical models were chosen to be sort of compartmental model as paper I. However, it was
reviewed. After extrapolating data from these papers and written a lot after with a lot more data.
manipulating them, they were compared to the number
of beds available in India and the main question whether Results
India is prepared to tackle the crises was answered. I. Stochastic Mathematical model - April 2nd,
2020
Study Design
Even though this model was written a while ago i.e.,
I. Stochastic Mathematical model - April 2nd,
there was not enough data at the time. It predicted that by
2020 3
25th May, 2020 if 50% of the people quarantined, there
This model uses a classic SEIR type model would be around 241,000 cumulative cases in India.
which divides the population into four compartments: That date has already passed and on 25th May, India
Susceptible, Exposed, Infectious, and Recovered. actually had a total of 144,000 cases6 which means that
Furthermore, the model then uses simple mathematical more than 50% of the people quarantined and helped us
differential functions on Matlab to predict the covid curve flatten the curve.
for India. This paper really focuses on the exponential
II. Gaussian Mixture model - June 16th, 2020
nature of the virus. It also compares the difference of
the impact of lockdown on the case count of covid 19. The fourier model in this predicts that, there will be
It gives the case counts based on the effectiveness of around 1.1 million cases at the peak
India’s lockdown.
of the curve. It seems like this model does not
II. Gaussian Mixture model - June 16th, 2020 4 accurately represent the current situation in India as we
are nearing 1 million cases and the case count is still
In this paper, the author uses two mathematical
increasing at a staggering rate everyday6.
methods to predict the curve for
894 Indian Journal of Forensic Medicine & Toxicology, April-June 2021, Vol. 15, No. 2
Figure 1 : Trend estimation using FDM4
III. Regression Analysis - June 22nd, 2020
Finally, the model that was derived from other countries and seemed to fit their data
estimated that the peak cases in India would be around 2.4 million cases. This makes a lot more sense
mathematically.
Figure 2: Forecast for India based on the third model5Indian Journal of Forensic Medicine & Toxicology, April-June 2021, Vol. 15, No. 2 895
Discussion about 1.1 million cases which seems a bit off now that
the cases are going up whereas the model predicts that
The predictions from the first test were pretty close
they should have already reached their peak and must be
to the numbers in the sense that we know that a lot more
going down by mid-July. Lastly, the third study is the
people quarantined at the start due to the restrictions set
value that needs to be compared to the number of beds
by the Government of India. The case count was a lot
available as it seems to make a lot more sense compared
lower than what was predicted. The second study predicts
to the current trend.
Table 1: Summarizing all the results
Study Peak Case Count Date written
241,000 - by 25th May if 50% people
Stochastic Mathematical model April 2nd, 2020
quarantined
Gaussian Mixture model 1.1 million June 16th, 2020
Regression Analysis 2.4 million June 22nd, 2020
According to recent Indian Government based The public health facilities used for COVID
covid-19 data, only 6-7% of the cases need hospitalization management were classified into 3 categories:
out of all the cases7. This implies that at the peak of 2.4
1. Dedicated COVID Hospital (DCH) - for the
million we would need about 2,00,000 beds rounded
clinically assessed severe cases
off. To get an actual comparison of how well prepared
the country is we need to understand India’s health 2. Dedicated COVID Health Centre - for the
infrastructure first. clinically assessed moderate cases
Health Infrastructure 3. Dedicated COVID Care Centre - for the mild or
suspect cases. These are mainly make-shift facilities set
For many poor households in India, public healthcare
up in hotels, hostels, stadiums etc.
is the only available option since private healthcare is
too expensive. And, isolation wards are required for the According to the National Health Profile 2019, there
confirmed positive patients and intensive care for the are a total of 7,13,986 government beds available in
critical patients. So, it is important to assess the medical India, i.e., 0.55 per 1000 population. As for the elderly
capacity to formulate how to go about handling the population, the availability of beds is 5.18 per 1000
situation. population 8.896 Indian Journal of Forensic Medicine & Toxicology, April-June 2021, Vol. 15, No. 2
Figure 3: Heat map of government beds in India 8
From the maps, many states lie below the national exports to make sure there was adequate supply for the
average of 0.55 per 1000 population. Bihar has a shortage country, however, the demand far exceeds the supply.
with just 0.11, whereas Sikkim, West Bengal and Delhi Shortage of PPE kits and other protective equipment is
seem to be better off with 2.34, 2.25 and 1.05 per 1000 a matter of growing concern as it puts all the healthcare
population, respectively. workers at great risk.
The availability of government beds is extremely Finally, we extrapolated based on the third model
low and an epidemic can make the situation much that we need around 2,00,000 beds. It is
worse. Though measures are being taken to contain the
spread, and early detection and treatment is supposed important to note that this is based on the current
to prevent the cases from getting critical, the supply of statistic, that only 6-7% of the people get hospitalised.
beds and intensive care equipment like ventilators, ICU Once the cases rise, the demand will become much
and oxygen support need to be amped up. Also, the higher which puts our healthcare system under a lot of
government can coordinate with the private healthcare pressure. We need to ensure that this does not occur and
to meet the needs. keep, “flattening the curve,” so as to not put any pressure
on the Indian healthcare system.
Adding to the stress on health infrastructure is the
shortage of PPE kits for the healthcare workers. The Discussion II - Where is India at right now?
lockdown imposed by many countries interfered with Population, poverty, illiteracy and an overwhelmed
the imports and so, the government decided to stopIndian Journal of Forensic Medicine & Toxicology, April-June 2021, Vol. 15, No. 2 897
health care system are the main worries that prove to of workers returning home by foot or by train. This
be deciding factors in this battle against COVID 19. showed a steady rise of cases in countries like Assam,
The nationwide lockdown, a historic decision put into Chhattisgarh, Uttarakhand, Himachal Pradesh, with
action on March 24th 2020, was the first step taken by most of the new cases to be people who were travelling
the country to fight this, and thereby moving forward back from work places around the country. One
with a ‘cluster containment strategy’ to contain the important factor in deciding what will help our country
disease within a defined geographic area by early is how rapidly we test people around the nation. It will
detection of cases, breaking the chain of transmission help isolate breakouts and warn people that are affected
and thus preventing its spread. The 21 day lockdown by the virus to not spread it more.
was first extended to May 3rd and then to May 18th.
Testing
While there was still a steady rise in the number of cases
and fatalities, the growth rate was lower than the other India’s testing strategy changed multiple times
affected countries. Studies also show that the results of throughout the past 6 months. And in an attempt to
the lockdown can easily be negated if people go back ramp up the testing, ICMR approved a total of 1049
to normal activities post lockdown, showing the need laboratories, both public and private. However, the
for measures of suppression post lockdown.9 On June access to testing still remains a huge challenge in many
8th, the country took a tentative step out of a 75 day parts of the country. Approval of the use of point of
lockdown, opening up malls, restaurants, religious places care rapid antigen test, in containment zones as well
and offices with strict measures limiting the number of as hospitals is also aimed at increasing the outreach of
people, use of masks, social distancing and mandating testing, thereby reducing the spread since ‘test-track-
the sanitization of premises. treat’ is the key strategy to contain the pandemic.10 The
average testing rate as of June 15th was 4972 per million,
In a country like India with a population of 1.2
Ladakh having the highest number of testing, followed
billion, with a major sector being migrant workers and
by Goa, Jammu and Kashmir and Delhi.
daily wage earners, the lockdown resulted in millions
Figure 4: States with the greatest share of total COVID-19 cases in India as of June 15, 2020898 Indian Journal of Forensic Medicine & Toxicology, April-June 2021, Vol. 15, No. 2
Though Maharashtra seems to have the highest maintain social distancing and avoid public gatherings
number of cases, it’s testing rate stands at just 5445 per till July 2021, to cut the chain of transmission and to
million, indicating the need to test more and control the reduce the spread.
spread.11 The state recorded 6330 new cases as of July
Maharashtra
2nd , and also recorded its highest number of recovered
and discharged at a count of 8018 on the same day.12 Home to India’s largest city and financial capital,
Mumbai, the state recorded its first case on March 9th,
There is also the problem of cases not being added
and is now a red zone accounting for 32% of India’s
in the state database by considering they are not native
cases and 41% deaths.16 The state slashed the COVID
or residents of the area.13 This can grow to be an even
testing rates by private labs providing relief to people.
bigger problem and the authenticity of the numbers
The government also implemented an order in April,
published can be raised. These stray cases need to be
making it compulsory to wear a mask outside, and
identified, recorded and treated appropriately.
anyone violating the order would be fined or arrested.
At the same time when compared to the testing rates
However, the battle seemed to be not just against
of 20 other countries most affected by the virus, India
the virus but also other deep seated issues which were
ranks in the bottom quartile with 5.63 tests per 1000
blunting the government’s efforts. The health care system
people till June 26th.14 However, the testing rate has
was found to be overwhelmed and burdened with having
increased during the course of the pandemic, and if the
to choose between patients to save due to the shortage of
trend keeps up, India could move up on the list, but the
beds and ventilators, and also there seemed to be piling
testing needs to be ramped up extensively to keep up
up of cases that died due to COVID, with families not
with the surge in cases per day to contain the disease.
willing to take them being afraid of the infection.
Strategies Adopted by Different States Kerala
The state also houses one of the largest slums of
The state which first detected the virus in the country Asia, Dharavi, where 80% of the population depends on
in late January, declared a health emergency after 2 community toilets and 8-10 people live in a house all in
more cases were recorded on February 2nd and 3rd. narrow lanes with 2-3 storied houses, social distancing
Surveillance and screening of all incoming passengers can only be considered a luxury with no possibility of
from China and people who were in close contact with effective home quarantine. The first case was confirmed
the travelers was the first response. With the increase in the beginning of April and by the end of the month,
in cases, the state ramped up the testing, contact tracing there were about 491 cases with a doubling period of
and strengthened the surveillance and control measures 18 days. The BMC was quick into action to contain
against the disease. The state also built thousands of the spread, and the main components were effective
shelters for the migrant workers stranded due to the containment strategy, conducting comprehensive testing
nationwide shutdown, and established COVID care and ensuring uninterrupted supply of essentials to
centers in all districts to accommodate the non-residents. the community. Also, quarantine facilities were set in
Some of the key strategic interventions that helped colleges and nature parks and 90% of the patients were
keep the disease in control are the strong community treated in Dharavi and only the critically ill were moved
engagement and addressing the psychosocial needs of out. The proactive measures taken successfully reduced
the vulnerable population. As of June 30th, the state the growth rate to 4.3% in May and 1.02% June.17
had sent 171,846 samples for testing, and in addition
Case Fatality Rates
samples were collected from health care workers as
a part of sentinel surveillance, to assess community Case fatality rate, ratio of confirmed deaths to
transmission.15 The experience and learnings of the state confirmed cases. It is usually used as a measure of the
from the past Kerala floods of 2018 and the NIPAH severity of a disease, and also to predict its prognosis,
outbreak in 2019 proved to be useful to prepare in where high rates indicate that a high fraction of COVID
the fight against COVID. Furthermore, the state also affected patients are succumbing to the disease. CFR has
extended the COVID regulations – to wear masks,Indian Journal of Forensic Medicine & Toxicology, April-June 2021, Vol. 15, No. 2 899
seen to be increasing in most of the affected countries throughout the course of the pandemic. The rates in India
went up from 1.9 in February, to 3.6 in March and then declined to 3.2% in April.18 However, when compared to
other South Asian countries, India has a significantly high CFR, which highlights the limitations of the healthcare
strategies like care of critical patients, early detection of cases, proper triage etc.
Another concept, Lag case fatality rate which takes into consideration a 14 day delay in reporting COVID 19
deaths, is being looked into since CFR data only includes deaths till a particular date and there is usually some delay
in reporting.
Figure 5: Risk of death due to COVID-19 in the five worst hit states
The disease wise fatality rate of COVID 19 with underlying health conditions.19
calculated based on any comorbid disorders present,
indicated that diabetes, cardiovascular ailments, Treatment20
hypertension, respiratory ailments and kidney diseases The treatment protocol keeps changing from time to
were the highest cause of COVID related death, in the time based on new evidence. The various drugs Indian
order mentioned. And around 31.8% deaths without any Council of Medical Research (ICMR) approved are:
underlying health condition, indicating how everyone
needs to be vigilant and not just the elderly or the ones900 Indian Journal of Forensic Medicine & Toxicology, April-June 2021, Vol. 15, No. 2
1. The use of Hydroxychloroquine for Conclusion
chemoprophylaxis in asymptomatic health care workers
In conclusion, the first study showed that more than
treating confirmed cases of COVID 19 and also
50% of the people quarantined and India managed to
asymptomatic household contacts of confirmed cases.
flatten the curve. The second study seemed to miss the
2. Remdesivir – for patients in a moderate stage mark however showed good early data. The third was
(on oxygen) used to compare the number of beds and serious cases
predicted and see how geared India is. Furthermore the
3. Tocilizumab – for moderate cases with strategies from a couple different states were analyzed
increasing oxygen demands, and also for mechanically to discuss what measures we are taking currently to
ventilated patients showing no improvement with flatten the curve. This review article shows that India’s
steroids. healthcare is prepared but that is just based on theoretical
numbers. People need to be cautious and take preventive
4. Dexamethasone – as an alternative to
measures otherwise, the situation could get out of hand.
methylprednisolone in moderate to severe cases. The
drug was shown to have benefits in critically ill patients Conflict of Interest: Nil
and also reduced mortality by one third for patients
on ventilators and one fifth for patients maintained on Funding: DMIMS (DU), Wardha
oxygen therapy.
Ethical Approval: From Institutional Ethical
5. Convalescent Plasma Therapy – is used as a Committee, DMIMS.
post exposure prophylaxis where plasma containing
neutralizing antibodies collected from a previously References
infected and cured patient is transfused into infected 1. Coronavirus Cases: [Internet]. Worldometer.
patients. It is considered in moderate cases not improving Available from: https://www.worldometers.info/
despite the use of steroids. To ease access to plasma, coronavirus/
India got its first plasma bank set up in Delhi on July 4th. 2. Schumaker E. What is R-naught for the COVID-19
virus and why it’s a key metric for re-opening plans
Ayurveda is a medicine system originating [Internet]. ABC News. ABC News Network; 2020.
from India. This type of system believes that prevention Available from: https://abcnews.go.com/Health/
is better than cure. It includes eating a healthy diet r0-covid-19-virus-key-metric-opening-plans/
with various herbs and doing specific exercises related story?id=70868997
to our respiratory system to build immunity against 3. Chatterjee K, Chatterjee K, Kumar A, Shankar
COVID-19.21 Prevention is definitely better than the S. Healthcare impact of COVID-19 epidemic in
cure and one of the only ways to fight against covid India: A stochastic mathematical model [Internet].
until the vaccine is made.22 Additionally, the role media Medical journal, Armed Forces India. Elsevier;
plays is very important in keeping us connected in times 2020. Available from: https://www.ncbi.nlm.nih.
like this. However, there is a lot of misinformation gov/pmc/articles/PMC7126697/
going around on social media that hinders people from 4. Singhal A, Singh P, Lall B, Joshi SD. Modeling
preventing covid correctly. It is important to ensure and prediction of COVID-19 pandemic using
the information we get about preventive measures Gaussian mixture model [Internet]. Chaos, solitons,
from trustworthy sources with a proper scientific and fractals. Elsevier Ltd.; 2020. Available from:
background.23 Furthermore, we need to ensure no other https://www.ncbi.nlm.nih.gov/pmc/articles/
diseases originate like obesity during quarantine due to PMC7296328/
lack of exercise. So it is important to maintain a healthy 5. R. Bhardwaj AA, Renshaw E, K. Verma Mahendra
diet with a specific caloric intake. The diet will also help AA. A Predictive Model for the Evolution of
in building immunity against Covid 19. 24 COVID-19 [Internet]. Transactions of the Indian
National Academy of Engineering. Springer
Singapore; 1970. Available from: https://link.Indian Journal of Forensic Medicine & Toxicology, April-June 2021, Vol. 15, No. 2 901
springer.com/article/10.1007/s41403-020-00130- testing-for-coronavirus-11593418452366.html
w#Fig8 15. https://www.who.int/india/news/detail/02-07-
6. Coronavirus Cases: [Internet]. Worldometer. 2020-responding-to-COVID-19---learnings-from-
Available from: https://www.worldometers.info/ kerala
coronavirus/country/india 16. Shelar J. COVID-19 situation in Maharashtra a
7. Only 6% cases need hospitalisation, over 40,000 ‘tragedy of errors’: experts [Internet]. The Hindu.
have recovered: Govt [Internet]. Hindustan The Hindu; 2020. Available from: https://www.
Times. 2020. Available from: https://www. thehindu.com/news/cities/mumbai/COVID-19-
hindustantimes.com/india-news/only-6-cases- situation-in-state-a-tragedy-of-errors-experts/
need-hospitalisation-over-40-000-have-recovered- article31837383.ece
govt/story-4jTOt7S5TNhKpPzaBZ0YQI.html 17. Correspondent S. Coronavirus: Dharavi turns
8. Singh P, Ravi S, Chakraborty S. COVID-19: Is the corner with steep decline in COVID-19 cases
India’s health infrastructure equipped to handle [Internet]. The Hindu. The Hindu; 2020. Available
an epidemic? [Internet]. Brookings. Brookings; from: https://www.thehindu.com/news/national/
2020. Available from: https://www.brookings. other-states/steep-decline-of-daily-COVID-19-
edu/blog/up-front/2020/03/24/is-indias-health- cases-in-dharavi-says-union-health-ministry/
infrastructure-equipped-to-handle-an-epidemic/ article31883369.ece
9. Ray, D., Salvatore, M., Bhattacharyya, R., Wang, 18. Dhillon, Preeti & Kundu, Sampurna & Shekhar,
L., Du, J., Mohammed, S., … Mukherjee, B. (2020). Chander & Ram, Usha & Dwivedi, Laxmi &
Predictions, Role of Interventions and Effects of a Dwivedi, Suryakant & Yadav, Sayeed & Unisa,.
Historic National Lockdown in India’s Response (2020). Case-Fatality Ratio and Recovery Rate of
to the COVID-19 Pandemic: Data Science Call to COVID-19: Scenario of Most Affected Countries
Arms. Harvard Data Science Review. and Indian States. 10.13140/RG.2.2.25447.68000.
10. Sudan P., (July 01, 2020) Joint Letter Test Track. 19. Dey JK, Dey SK (2020). SARS-CoV-2 Pandemic,
Available from: https://www.icmr.gov.in/pdf/ COVID-19 Case Fatality Rates and Deaths per
covid/strategy/Joint_Letter_Test_Track_Treat.pdf Million Population in India. J Bioinf Com Sys Bio
11. Bharali I, Kumar P, Selvaraj S. How well is 2(1): 110.
India responding to COVID-19? [Internet]. 20. https://www.pib.gov.in/PressReleasePage.
Brookings. Brookings; 2020. Available from: aspx?PRID=1634725
https://www.brookings.edu/blog/future- 21. Rajput DS. Evolution, Ayurveda, immunity, and
development/2020/07/02/how-well-is-india- preventive aspects for emerging infectious diseases
responding-to-covid-19/ such as COVID-19. ijrps [Internet]. 2020May13
12. Maharashtra: State crosses 1 million tests, one lakh [cited 2020Sep.28];11(SPL1):86-3. Available from:
recoveries [Internet]. The Indian Express. 2020. https://pharmascope.org/ijrps/article/view/2227
Available from: https://indianexpress.com/article/ 22. Samrudhi Khatod, Anuja Ikhar, Pradnya Nikhade,
india/maharashtra-coronavirus-news-update- Kaustubh Khatod. Preventive measures for Dental
maharashtra-state-crosses-1-million-tests-one- Professionals during worldwide emergency
lakh-recoveries-6487665/ COVID-19. ijrps [Internet]. 2020Jun.22 [cited
13. Sinha A. India coronavirus numbers explained: 2020Sep.28];11(SPL1):150-3. Available from:
Fewer cases in some states, but faster growth rate https://pharmascope.org/ijrps/article/view/2294
[Internet]. The Indian Express. 2020. Available 23. Tarare Toshida, Chaple Jagruti. Covid-19 – rumours
from: https://indianexpress.com/article/explained/ and facts in media. ijrps [Internet]. 2020Jul.2 [cited
india-coronavirus-numbers-explained-6429296/ 2020Sep.28];11(SPL1):171-4. Available from:
14. Jain BN. Opinion: How does India compare https://pharmascope.org/ijrps/article/view/2344
with other countries on testing for coronavirus? 24. Ayushi Sunil Lohi, Gaurav Sawarkar. Management
[Internet]. Livemint. 2020. Available from: https:// Of Diet During Covid-19 Pandemic. ijrps [Internet].
www.livemint.com/opinion/online-views/opinion- 2020Jun.22 [cited 2020Sep.28];11(SPL1):154-7.
how-does-india-compare-with-other-countries-on- Available from: https://pharmascope.org/ijrps/
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