COVID-19 pandemic in India and Most Affected Countries

ABSTRACT:

Understanding the dynamics of case-fatality and recovery rates of COVID-19 would enhance the
knowledge base on the current trends of the severity of the epidemic. This study presents the
trend analysis of mortality and recovery rate in the most affected countries and India. The data
for India were retrieved from the www.covid19india.org, a data-sharing portal and for other
countries from the Johns Hopkins University & Medicine webpage on Our World in Data, and
Worldometer.

The case-fatality ratio (CFR) has been increasing rapidly in the most affected countries during
the outbreak. The higher rate of mortality in most COVID-19 affected countries of the West may
be on account of the failure of the health system to cater to the large number of daily inflow of
patients. The pattern, however, also shows rapid increase in the cases in hotspot regions, and it
indicates the local transmission of COVID-19. The slow growth of the pandemic has contributed
to the lower CFR in the country. At the same time, the possibility of under-reporting of the
cases due to less number of testing and misreporting of other comorbidity are possible in the
India which needs to be monitored by health providers. Our results are based on real data with
reasonable assumptions and underlines the importance of age and social contact structures in
assessing the country specific impact of social distancing and LOCKDOWN.

INTRODUCTION:

In the book, The Great Leveler, Walter Scheidel, the Austrian economic historian, argues that
throughout human history, there have been four types of catastrophic events that have led to
greater economic equality: pandemic, war, revolution and state collapse. The past 20 years
have seen several epidemics like the acute respiratory syndrome coronavirus during 2002-2003
and H1N1 influenza during 2009 (Cascella et al., 2020).Currently, the world is going through one
of them: a massive COVID-19 pandemic. According to the World Health Organisation (WHO),
coronaviruses are the family of viruses which include Severe Acute Respiratory Syndrome
(SARS) and Middle Eastern respiratory syndrome (MERS) that is experienced in Saudi Arabia in
2012.

In December 2019, an outbreak of severe acute respiratory syndrome coronavirus 2 infection

occurred in Wuhan, Hubei Province, China, and spread across China and beyond. On February
12, 2020, the World Health Organization officially named the disease caused by the novel
coronavirus as coronavirus disease 2019 (COVID-19). The current novel coronavirus known as
COVID 19, is now pandemic and has never been encountered before. The COVID 19 cases are
increasing day by day with currently over 42.5M , 1.15M deaths and 28.7M recoveries.(as of
8:30 IST, October 24, 2020) (Worldometer). Though China which was the first to hit the most
cases, in the beginning, has presently flattened the curve by continuous testing and aggressive
quarantine measures. Outside China, South Korea being the country that had the most
significant initial outbreak has managed to slow down the spread and flatten the curve without
imposing lockdown in the country. Their only way of slowing and containing outbreak was mass
diagnostic testing and quarantining. South Korea and China have set an example of how the
battle is to be won against the virus. Nevertheless, scientists are at their best efforts to invent a
potent vaccine against the virus.

COVID-19 cases worldwide as of October 19, 2020, by country

Coronavirus (COVID-19) cases, recoveries, and deaths worldwide as of Oct. 19, 2020

50,000,000 40,281,74
1
40,000,000 30,116,67
6
30,000,000
20,000,000
10,000,000
1,118,328
0
Total cases Total recoveries Total deaths

Number of tests for COVID-19 in most impacted countries worldwide as of Oct. 19, 2020
Rate of coronavirus (COVID-19) tests performed in the most impacted countries
worldwide as of October 19, 2020 (per million population)

Taking a global view, India ranked at 57th positions in the list of 195 countries in terms of
preparedness of a pandemic, according to the Global Health Security (GHS) Index (GHS, 2019).
To tackle the pandemic situation in India, on 24th March 2020 Hon’ble Prime Minister of India
declared a 21-day lockdown till 14th April to break the chain of coronavirus transmission,
followed by, continuing nationwide lockdown till 3rd May 2020. In a nationwide address, PM
urged people to practice social distancing in order to combat this pandemic at an individual
level. Governments of each state are taking all measures to prevent the spread of coronavirus
and trying to follow the lockdown strictly.

The total number of COVID-19 patients, deaths and recovered persons are continuously
increasing in the Globe at varying pace. Understanding the dynamics of case-fatality and
recovery rate in the most affected countries and Indian states would enhance the knowledge
base. Therefore, this paper presents a review of case-fatality ratio, recovery rates in India in
comparison to the most affected countries and also across most affected states in India to date
and Impact of Lockdown on the COVID-19 epidemic in India. We also discussed the testing
pattern and treatment practices of COVID-19 with a special focus on India.

Data and methodology:

This paper compiled data on COVID-19 from different sources. For India, it was taken from the
covid19india.org(COVID-19India),GitHub,KAGGLE a data-sharing portal that provides the most
updated information on the daily and total confirmed cases, recovered cases, and deaths for
each affected states. This portal data matches with the data provided by the Ministry of Health
and Family Welfare, Government of India and also with ICMR on testing statistics. For other
countries, data was collected from Johns Hopkins University & Medicine (JHU, 2020), Our World
in Data (Roser et al., 2020) and Worldometer.
In epidemiology, the case-fatality rate/ratio is defined as the proportion of people who die due
to disease to total persons infected. We calculated the case-fatality ratio defined as the ratio of
the total number of deaths to the total number of confirmed cases. Similarly, the recovery rate
is defined as the ratio of the total number of recovered cases to the total number of confirmed
cases.

Analysis of COVID-19 Outbreak situation in India

8,000,000 7,429,233
7,000,000 6,520,011
6,000,000
Number of cases

5,000,000
4,000,000
3,000,000
2,000,000
795,026
1,000,000 113,002
0
Deceased Active Recovered Confirmed
Number of the coronavirus (COVID-19) cases across India as of October 16, 2020, by type
A key element of the pandemic control strategy everywhere has been to shut down economic and social
activity, and to impose social distancing with varying degrees of strictness. India accounts for almost
one-fifth of the world’s population and is second leading country in terms of population in the
world. India contributes heavily to the world’s GDP and is amongst the most prominent
developing country in the world with fairly strong economic growth percentages [0]. India’s
good camaraderie with majority of the nations in the world and its helpful nature makes it a
perfect ally for other countries.   India went into its first coronavirus-induced lockdown in the
last week of March 2020. India has been following a nationwide lockdown since 22-March-
2020, which was a one-day lockdown, followed by a 21-day lockdown after two days. Every
activity in India since then has been happening with permission from various administration
units and almost all the domestic and international travels have been either banned or
monitored closely. India is yet to get into the third phase of COVID-19 outbreak i.e. the
community outbreak as seen by various countries around the world, but the cases have been
rising continuously.
The first month of the severe lockdown, April 2020, witnessed a sharp rise in unemployment
which caused many problems to the migrant labourers. Within days of the lockdown
announcement, the migrant issue was looming large. The employers and the government let
them suffer without money or job for two months.  Because of the absolute lack of economic
and social security at their places of work and the inadequacy of support provided by the
state they started going back to their places as they didn’t had enough means to survive at
their place of work. Finally, they gave up, and the migrant labourers, a majority of whom
were by now infected, streamed out of urban red zones of the country,As they go back as
potential carrier of the infection, they face the threat of social ostracization. Hundreds of
them have died on their way and carried the infection into green rural India. Purulia and
Cooch Behar districts of West Bengal are classic examples.
These figures gives the cases count during pre-lockdown and after lockdown period in india and
across different countries. It may also assist to think whether lockdown would be a measure to
reduce social distancing among human beings and may reduce the spread of Coronavirus
disease from region to other region extensively. And 68 days, 1,73,763 positive cases and
4,971 deaths later, on May 31, the ministry of home affairs issued an order announcing a
phased reopening or ‘Unlock 1’ by dint of which almost all prohibitory orders were lifted,
except in containment zones.
India’s lockdown period has been impacted by two major events in the recent days which were
related to the mass from one state to other states (especially from Delhi to neighboring states)
and conduction of a religious event in Delhi which led to spike in the number of cases in various
states of India.
 Exodus of laborers and workers

Indian migrant workers during the COVID-19 pandemic have faced multiple hardships. With
factories and workplaces shut down due to the lockdown imposed in the country, millions of
migrant workers had to deal with the loss of income, food shortages and uncertainty about
their future.[1][2] Following this, many of them and their families went hungry. [3] Thousands of
them then began walking back home, with no means of transport due to the lockdown. [4] In
response, the Central and State Governments took various measures to help them, [5][6][7] and
later arranged transport for them.[8][9] More than 300 migrant workers died due to the
lockdown, with reasons ranging from starvation, suicides, exhaustion, road and rail accidents,
police brutality and denial of timely medical care.
There are an estimated 139 million migrants in the country, according to the World Economic
Forum.[10] The International Labour Organization (ILO) predicted that due to the pandemic and
the lockdown, about 400 million workers would be poverty-stricken. [11]
As of 23 May 40 lakh migrants had travelled to their homes by buses. [12] Condition in the buses
is generally poor, with social distancing being impossible due to overcrowding. [13]As of 28 May
91 lakh migrants had travelled back home in government-arranged transport facilities. [14]As per
a report given by the Indian Railways on 23 May, migrant labourers from Bihar and Uttar
Pradesh comprised 80% of the train travellers. Additionally, it was expected that 36 lakh
migrants would be travelling in the ten days after the report. [15] 4,277 Shramik Special trains had
transported about 60 lakh people, as of 12 June.[16]
However, the numbers of infected cases were not impacted much by this mass movement as
majority of workers were not carrying any infection with them during their movements from
workplaces to their native places.
 Tablighi Jamaat
A Tablighi Jamaat religious congregation that took place in Delhi's Nizamuddin Markaz
Mosque in early March 2020 was a coronavirus super-spreader event,[1] with more than 4,000
confirmed cases[2] and at least 27 deaths linked to the event reported across the country. Over
9,000 missionaries may have attended the congregation, with the majority being from various
states of India,[3][4] and 960 attendees from 40 foreign countries.[5] On 18 April, 4,291 confirmed
cases of COVID-19 linked to this event by the Union Health Ministry represented a third of all
the confirmed cases of India. [6][7] Around 40,000 people, including Tablighi Jamaat attendees
and their contacts, were quarantined across the country.[6]
A cluster spread became apparent in the following days as cases traced back to the event were
reported in several states. In Telangana, five people who attended the event died on 30 March.
Dozens of people tested positive in other places such as Andhra Pradesh, Tamil Nadu, Uttar
Pradesh and Andaman and Nicobar Islands. State governments scrambled to trace the
whereabouts of the attendees.[35]
As of 3 April, more than 950 confirmed cases were detected across 14 states and union
territories in the country, including 97 percent of the total cases confirmed in the country on 2
and 3 April (647 out of 664 cases).[36][37] Tamil Nadu was the worst affected state, as 364 of the
411 people who tested positive had attended the event.[38] 259 of the 386 cases in Delhi[39] and
140 of the 161 cases in Andhra Pradesh were linked to the event. [40] All nine deaths reported in
Telangana until 2 April were of people who had returned from the congregation. [41]
The Srinagar man who died on 26 March was identified as a super-spreader as he travelled by
road, rail and air from Delhi to Srinagar via Uttar Pradesh, as officials feared that he may have
spread it to several people along the way.[42]
By 2 April, Maharashtra, Telangana and Karnataka traced down 1,325, 1,064 and 800 attendees
of the event respectively.[43][44][45] Tamil Nadu identified and quarantined 1,103 of the 1,500-odd
participants from the state.[46] Andhra Pradesh reportedly detected around 800 of the 1,085
people of the state who attended the congregation. [47] Gujarat Police identified 72 attendees
from the state who attended the event.[48] Uttar Pradesh managed to track and quarantine
1,205 people who participated in the congregation by 5 April. [49] On 4 April, it was reported that
the Delhi Police had found more than 500 foreign preachers "hiding in 16-17 places" in the city.
[50]

According to health authorities, until 2 April, among 2000 positive cases in India nearly 400
cases can be epidemiologically traced to the Tablighi Jamaat cluster. [51][52] By 3 April 647 cases
are reported which are related to this cluster. [53] By 4 April, 1,023 cases with links to this cluster
were reported which is about 30% of total cases in the country. [54] On 18 April, Union Health
Ministry said 4,291 out of 14,378 confirmed cases in 23 Indian states and union territories have
been linked to this event, around a third of all cases.[6][7]
Following are some of the positive cases from different states as reported in media .

State or UT Positive Cases Deaths Ref(s)

[55]
Andaman and Nicobar Islands 9 –
[56][57][58]
Andhra Pradesh 280 1
[59]
Arunachal Pradesh 1 –
[55][60]
Assam 33 1
Bihar – 1
[61][better  source  needed]
Delhi 1080 5
[62]
Gujarat 12 1
[63][64]
Haryana 106 –
[65][66][67]
Himachal Pradesh 21 –
[55]
Jammu and Kashmir 22 2
[68]
Jharkhand – –
[56][69][70][71]
Karnataka 107 1
[72]
Kerala 15 –
[73][74]
Madhya Pradesh 71 –
[75][better  source  needed]
Maharashtra 23 2
 State or UT Positive Cases Deaths Ref(s)
Odisha – –
[55]
Puducherry 2 –
[76][better  source  needed]
Punjab 26 –
[77][better  source  needed]
Rajasthan 43 –
[78]
Tamil Nadu 1113 2
[65][79][80]
Telangana 388 11
[81][82]
Uttar Pradesh 1138 –
[68][83][84]
Uttarakhand 24 –

Total 4,514* 27*

*These numbers are not complete as some States do not report hotspot sources for cases

March

 On 18 March, Eight Indonesians of Tablighi Jamaat were tested positive in Karimnagar in

Telangana.[85][86] They had arrived from Hazrat Nizammudin, Delhi on 14 March. [87] Security
agencies had traced the link of these cases to Nizamuddin Markaz. [88]
 On 21 March, two Thai Nationals in Erode, Tamil Nadu were reported as positive case
number 5 and 6. They had attended this congregation in Delhi in early March. [89][90]
 On 26 March, Jammu and Kashmir reported first death to the pandemic, a 65-year-old
who had attended this congregation. [91] At that time, more than 40 of 48 cases in the region
was tracked back to this patient.[citation needed]
 On 31 March 57 new cases were reported in Tamil Nadu. 80 out of total 124 cases in the
state are linked to Tablighi Jamaat cluster.[92]
April

 First positive case from Dharavi in Mumbai who eventually died on 1 April, has hosted

10 Tablighi Jamaat members between 22 and 25 March.[93][94]
 On 1 and 2 April Tamil Nadu reported 110 and 74 positive cases respectively, all of them
had related to this cluster.[95]
 On 3 April 100 cases in Tamil Nadu and 42 in Uttar Pradesh are related to this cluster. [96]
[97]

 On 4 April, in Tamil Nadu 73 people who had taken part in congregation are tested
positive.[98] In Assam, 25 out of 26 cases reported until this date had taken part in this event.
[99]

 On 5 April, Tamil Nadu positive cases reached 571 in which 522 are related to this
hotspot.[100] In Uttar Pradesh, out of 139 out of 283 cases reported until this date has linkage
to this cluster and in Delhi it is 320 out of 503 total cases.[101][102][better  source  needed]
 On 9 April 97 new cases, all linked to the Tablighi Jamaat event, were reported in Delhi,
bringing the total number linked to this cluster to 430 in Delhi, out Of 669 for all cases. [103]
 Graph showing the average number of days for the infected cases to double with or without cluster events

The average number of days to double the infected cases from corona virus without any cluster
event was estimated to be 7.1 as per the health ministry, while it is 4.1 after Delhi’s religious
event took place [104]. This event resulted in formation of clusters in the whole country as
people who attended this event went to different parts of the country without following any
rules of getting quarantine. Some of them even came from out of India to attend this event and
no rules were followed by them regarding COVID-19 protection. This resulted in a sharp spike in
the number of infected cases after 31st March 2020.

Distribution of Infected Cases due to religious event in Delhi out of the total infected cases as per the data released by Ministry of Health

At least 36% of the total infected cases reported on 6th April 2020 were linked to the religious
event in Delhi [105]. Out of over 4000 cases reported, a minimum of 1445 cases were
suspected to be due to the religious event in Delhi. This event took the graph sky high in a
week’s time with growth slowly moving towards exponential path and India entering into the
third phase of community transmission for COVID-19 virus. Many regions of India which were
totally isolated with the infection of Corona Virus, also reported their first case in the first 3-4
days of the conduction of the event. Therefore, it can be said that religious event that
happened in Delhi has really pushed the bars higher for infected cases from coronavirus in
India. It has far more serious consequences than it seems right now and authorities needs to be
really alert as people linked to this event have gone back to different parts of the nation.

Case-Fatality Ratio and Recovery Rate of COVID-19 , and Testing in different countries
and India
Coronavirus cases in India increased by 54,044 new infections in last 24 hours, taking the
total covid tally to 7.6 million, informed the health ministry. India recorded 717 new deaths, toll
death count mounted to 1,15,914.Despite rising COVID-19 cases, the country continues to
 maintain one of the lowest case fatality rates (CFR) when compared to several nations, said the
Union Health Ministry in a release issued on 3rd October 2020. While the global CFR stood at
2.97% as on date, the comparative figure for India was 1.56%. India's COVID-19 tally had
crossed the 20-lakh mark on August 7, 30 lakh on August 23 and 40 lakh on September 5. It
went past 50 lakh on September 16, 60 lakh on September 28 and crossed 70 lakh on October
11.
India's total active cases are at 7,40,090 after a decrease of 8,448 in last 24 hours. There are
7,40,090 active cases of coronavirus infection in the country which comprises 9.67 per cent of
the total caseload, the data stated. Total cured/migrated cases are 67,95,103 with 61,775 new
discharges in last 24 hours.India has tested total 9,72,00,379 samples tested for coronavirus till
20th October. Of these, 10,83,608 samples were tested yesterday, reflected data on Indian
Council of Medical Research (ICMR) portal.The active cases of coronavirus infection remained
below 8 lakh for the fifth consecutive day.According to the ICMR, a cumulative total of
9,72,00,379 samples have been tested up to October 20 with 10,83,608 samples being tested
on Tuesday.
The deaths per million population in India is among the lowest in the world. While the global average is
130 deaths /million population, India is reporting 73 deaths /million population. India is doing better
that Russia, South Africa, United States, Brazil, Spain, France and United Kingdom. The overall case
fatality rate of people with co-morbidities like diabetes, hypertension, renal and heart diseases
and cancer is 17.9%, while it is 1.2% for those without co-morbidities, according to health
ministry data. Overall deaths due to the infection in India remain at 1.5% of total confirmed
cases.With the second highest number of cases in the world after the US, India is trying to
increase testing, but there've been issues around the reliability of some types of test.
The latest testing technique gives fast results, like a pregnancy test, and is called Feluda.It uses
a technique known as Crispr - short for Clustered Regularly Interspaced Short Palindromic
Repeats - which is a gene editing technology.

 The DNA tool that could correct most genetic defects

Gene editing works in a way similar to word processing, and can scan DNA to make microscopic
changes to the genetic code.It's been used to treat ailments like sickle cell disease.
 New paper Covid-19 test could be a ‘game changer’
The one that's been most commonly used globally is a PCR (polymerase chain reaction) test,
which isolates genetic material from a swab sample.It's regarded as the gold standard of
testing Chemicals are used to remove proteins and fats from the genetic material, and the
sample is put through machine analysis.But they're the most expensive and take up to eight
hours to process the samples. To produce a result may take up to a day, depending on the time
taken to transport samples to labs.
In order to increase testing capacity, the Indian authorities have been switching over to a
cheaper and quicker method called a rapid antigen test, also known as diagnostic or rapid
tests. These isolate proteins called antigens that are unique to the virus, and can give a result in
15 to 20 minutes.But these tests are less reliable, with an accuracy rate in some cases as low as
50%, and were originally meant to be used in virus hotspots and healthcare settings
only. Antigen tests produce faster results than PCR tests but are less reliable.
India's top medical research body, the Indian Council of Medical Research (ICMR), has approved
the use of three antigen tests developed in South Korea, India and Belgium. But one of these
was independently evaluated by the ICMR and the All Indian Institute of Medical Sciences
(AIIMS), which found that their accuracy in giving a true negative result ranged between 50%
and 84%.  The ICMR issued guidelines saying those with negative results from an antigen test
should also get a PCR test if they show symptoms, to rule out a false negative. The World
Health Organization (WHO) and the US Food and Drugs administration have also advised getting
a PCR test if you test negative in a rapid antigen test.

Delhi was the first state to begin antigen-based testing in June, and many other states followed
suit. It began using them on 18 June, although there is no data publicly available until 29 June. 

Source:-Delhi Government
Data from 29 June to 28 July showed that of all tests done in Delhi, 63% were antigen
tests. Between 8 and 15 September, less than a quarter of tests carried out were PCR tests - the
rest were done using the antigen test.But a right to information reply showed that less than 1%
of over 700,000 who underwent antigen tests between June 18 and August 27 were re-tested
with the more reliable PCR test.Of these, 11% tested positive in the follow-up test.Delhi
increased PCR testing in October, and as a result, the proportion of positive tests went up to
6.2% against the previous week's figure of 5.6% because they are less likely to miss positive
cases.

The southern state of Karnataka started using antigen tests in July, aiming for 35,000 a day
across 30 districts. 
 Source:Karnataka State Government

In the beginning of August, the state ramped up antigen testing and reduced PCR testing. But it
has increased PCR tests again - now 60% of all tests - after concerns about accuracy.Figures give
out at the end of August showed that 17% of those who tested negative in an antigen test got a
positive result in a PCR test later on.
In Telangana state, the government also ramped up antigen testing in July.There are currently
only 61 government and private labs equipped to do PCR tests, as against more than a
thousand government facilities for antigen tests.India's worst affected state, Maharashtra, first
began antigen tests in Mumbai in July.The city's municipal corporation reported at the time that
65% of those who had symptoms of Covid-19 tested negative in the antigen test, but went on
to be positive in a PCR test. 
There are some advantages to the rapid tests. It allows a faster detection process and means
you can quickly detect highly infectious individuals with a high viral load.But these rapid tests,
can potentially miss many infections

 Impact of age on COVID-19

In COVID19, all age ranges are susceptible.But it is found in case studies that middleage groups 
and older age groups are the most frequently affected age groups. The majority of hospitals wit
h COVID19 confirmed cases have a median age range of 49 to 56 years of age.
In Indian scenario, the total population (Census-2011) was divided in similar age-group and it
was found that 15.92% persons belong to the age group of elderly people (with age 50 years
and greater), 25.58% and 58.5% related to the age group of 30–49 years and 0–29 years
respectively.

% elderly % elderly
State/UT population Elderly population State/UT population Elderly population
Andhra Pradesh 9.8 8,288,916 Lakshadweep 8.2 5287
 A and N Islands 6.7 25,499 Madhya Pradesh 7.9 5,737,518
Arunachal Pradesh 4.6 63,651 Maharashtra 9.9 11,125,059
 Assam 6.7 2,090,774 Manipur 7 199,906
 Bihar 7.4 7,703,359 Meghalaya 4.7 139,444
Chandigarh 6.4 67,549 Mizoram 6.3 69,124
Chhattisgarh 7.8 1,992,525 Nagaland 5.2 102,882
Dadra and Nagar 4 13,748 Odisha 9.5 3,987,551
Haveli
 Daman and Diu 4.7 11,433 Puducherry 9.7 121,051
 Delhi 6.8 1,141,580 Punjab 10.3 2,857,564
 Goa 11.2 163,357 Rajasthan 7.5 5,141,133
 Gujarat 7.9 4,774,736 Sikkim 6.7 40,909
 Haryana 8.7 2,205,577 Tamil Nadu 10.4 7,503,291
 Himachal Pradesh 10.2 700,189 Tripura 7.9 290,239
Jammu and Kashmir 7.4 928,056 Uttar Pradesh 7.7 15,385,550
Jharkhand 7.1 2,342,158 Uttarakhand 8.9 897,680
Karnataka 7.7 4,704,338 West Bengal 8.5 7,758,470
 Kerala 12.6 4,209,164

As per publication by the Ministry of Statistics and Programme Implementation of India

regarding elderly in India, 8.6% population (104,133,528 people) belonged to elderly people
were present in Census-2011 and this was projected to be around 10% (135,389,042 people) in
the projected population of 2019. The large portion of the population could be more prone to
COVID-19 virus infection and death. Within this age group, most deaths (71%) are among those
in 45-74 age group, health ministry data showed. But the data also showed that people
between 30-44 years and 45-59 years – comprising 37% of the population – registered 43% of
COVID deaths. A majority of the coronavirus (COVID-19) cases in India affected people between
ages 45 and 74 years as of July 9, 2020. Of these, the age group between 60 and 74 years had
the highest share of deaths during the measured time period. 

Early in the pandemic, COVID-19 incidence was highest among older adults. Nationwide, the median age
of COVID-19 cases declined from 46 years in May to 37 years in July and 38 in August. During June–
August, COVID-19 incidence was highest in persons aged 20–29 years, who accounted for >20% of all
confirmed cases. The southern United States experienced regional outbreaks of COVID-19 in June. In
these regions, increases in the percentage of positive SARS-CoV-2 test results among adults aged 20–39
years preceded increases among adults aged ≥60 years by an average of 8.7 days (range  = 4–15 days),
suggesting that younger adults likely contributed to community transmission of COVID-19. 

A similar age shift occurred in Europe, where the median age of COVID-19 cases declined from 54 years
during January–May to 39 years during June–July, during which time persons aged 20–29 years
constituted the largest proportion of cases (19.5%) .

 Sex differences in COVID-19

A large proportion of males are found in the confirmed cases. It is expected in the country
where male work participation, mobility and migration is predominately higher than that of
females. According to the Economic Survey of India (2020), labour-force participation among
women is only 25%, and 60 percent of (15-59) women are involved in household work. The
mobility among men is quite high as compared to females, which increases the chances of
getting the infection. Men have shown markedly increased risk of developing complications in
comparison to women. Also, in a meta-analysis, it was found that there is increased severity
and fatality rate among males. It might be due to sex-differentials in cellular compositions and
immunological microenvironment of lungs (Wei et al., 2020). However, the present study
observed a little gender gap in CFR. Males reported slightly over CFR than that of females.
Women’s roles as caregivers—both within the health system and at home—may place them at
increased risk of infection. Approximately 70% of health and social care workforce worldwide
are women [101], including frontline healthcare workers. Women are also more likely to care
for children or other relatives who are ill [15].

 Sex differences in COVID-19 treatment approaches

The original clinical reports from China suggested that the COVID-19 virus infected both men
and women equally; further studies suggested that sex differences exist in both mortality and
infection susceptibility for SARS-CoV-2 [12, 13].Females and males differ in their susceptibility
and response to viral infections, leading to sex differences in incidence and disease severity
[65]. For infectious diseases caused by viruses, there are numerous and diverse ways in which
sex and gender can impact differential susceptibility between males and females.The innate
recognition and response to viruses as well as downstream adaptive immune responses during
viral infections differ between females and males. The number and activity of innate immune
cells, including monocytes, macrophages, and dendritic cells (DCs) as well as inflammatory
immune responses in general are higher in females than in males [71–73]. 
 Immune responses to viruses can vary with changes in sex hormone concentrations naturally
observed over the menstrual cycle, following contraception, after menopause and during
hormone replacement therapy (HRT) as well as during pregnancy [79].With regard to adaptive
immune responses, females generally exhibit greater humoral and cell-mediated immune
responses to antigenic stimulation, vaccination, and infection than do males [80]. Both basal
levels of immunoglobulin [81] as well as antibody responses are consistently higher in females
than in males [82].
Sex and gender impact vaccine acceptance, responses, and outcomes. Females are often less
likely to accept vaccines, but once vaccinated, develop higher antibody responses (i.e., primary
correlate of protection) and report more adverse reactions to vaccines than males (Table  
(Table1)1) [80].

Table 1
Sex differences in adverse reactions, immune responses, and efficacy of vaccines and antiviral
drugs in humans

Virus Antiviral Sex-specific Comments References

drug/vaccine features

HIV HAART M<F CD4+ T cell count, adverse reactions, fat [102–108]
accumulation, drug concentration, virus
clearance, hepatitis

HAART M>F Fat loss, survival [103, 109]

HSV-2 HSV-2 gD vaccine M<F Humoral immune responses, cell-mediated [110–112]

immune responses, vaccine efficacy

Acyclovir M<F Frequency of prescription, adverse [113, 114]

reaction

Acyclovir M>F Reduction of virus shedding [114]

 Virus Antiviral Sex-specific Comments References
drug/vaccine features

HBV HBV vaccine M<F Humoral immune responses [115–118]

HCV Pegylated interferon M<F Adverse reaction, sustained virologic [119–121]

alpha/ribavirin response1

Seasonal TIV vaccine M<F Humoral immune responses, adverse [122–125]

influenza reactions
viruses

Oseltamivir M<F Drug clearance and metabolism2 [126]

Oseltamivir M>F Alleviation of symptoms, reduction of [127]

viral load

Zanamivir M=F Alleviation of symptoms, reduction of [127]

viral load

HAART highly active antiretroviral therapy, HBV hepatitis B virus, HCV hepatitis C virus, HIV human

immunodeficiency virus, HSV herpes simplex virus, TIV trivalent inactivated influenza virus. 1premenopausal
females only, 2tested in neonates only

Reports from countries have pointed to a sex imbalance with regard to detected cases and case
fatality rate of COVID-19.  The sex-disaggregated data are still not provided by all countries, the
interaction of sex is usually not visible in the public databases, and number of cases and case
fatality vary significantly by region.
 Table of Sex-disaggregated data of confirmed COVID-19 cases and deaths provided by Global Health
50%50 data tracker as of April 2, 2020 is given below:

Despite some studies showing gender differences in the incidence and case fatality rate in
COVID-19 patients, a growing number of studies show no gender differences in SARS-CoV-2
infections. A study in Jiangsu Province, China, examined 80 patients with COVID-19 who found
that men (49%) and women (51%) were equally affected. The authors of the study noted that
the lack of gender differences could be related to the small sample size or the mode of
transmission during the early stages of the pandemic. A similar study involving 135 patients, an
equal distribution between men (53%) and women (47%) were noted with an average age of 47
years.
A study involving patients on a Japanese cruise ship found that among the 634 people who
tested positive for COVID-19, 49% of cases were female and 51% male. The cases were from a
total of 28 countries, including Japan (270 cases), the United States (88 cases), China (58 cases;
including 30 from Hong Kong), Philippines (54 cases), Canada (51 cases), and Australia (49
cases). Given the assortment of different ethnic groups in close proximity, this study suggests
that COVID-19 infection rates may not depend on gender but may be reflective of underlying
health status, comorbidities, and social factors within a given population.
In fact, reports from Switzerland and Germany have recently reported incidence rates (cases
per 100,000 inhabitants by age and sex), which confirm an increased disease incidence in men >
60 years. In detail, the disease incidence in men per 100,000 Swiss inhabitants in the age groups
of 60–69 years, 70–79 years, and 80+ years was 267, 281, and 477, respectively, as of March 30.
The numbers reported in men exceeded the ones reported in women by 74, 87, and 108 per
100,000 Swiss inhabitants, respectively. In Germany, relative differences between men and
women were similar to Switzerland, but at a lower level, with the incidence in Germany being
one-third of that in Switzerland. It is notable, however, that the number of confirmed cases and
therefore also the incidence depends largely on testing strategy in countries and regions.

The latest age-wise analysis of Covid-19 mortality by the health ministry showed that those in
the younger age band were more vulnerable to the disease, though the fatality rate continues
to be higher at 53% among people over 60 years of age.
About 47% of Covid-19 deaths have been recorded among hose aged below 60 years and
patients aged 45-60 accounted for a substantial 35% of total deaths.About 70% Covid-19 deaths
have been of male patients while 30% was reported in females.

In conclusion, governments in all countries should disaggregate and analyze data for sex and age
differences and tailor treatment according to sex and age differences. Overall, more research is
needed to understand how sex and gender, and the intersection of sex and gender, is causing
differential outcomes and effects related to COVID-19 among and between men and women. In
particular, there is a need to evaluate the influence of such gender variables on disease
manifestation and outcomes.
The decision to impose a lockdown was always going to be tricky because of its impact on
the Indian economy. The lockdown gave the country some time to ramp up its public health
infrastructure. It was a trade-off between loss of lives and loss of income.

The ideal thing to do for the migrant workers was to cater to their needs wherever they
were. Setting up camps and arranging basic provision and some cash in hand. It doesn’t take
much efforts to organise these camps. This basic administrative input was missing since
there was zero consultation. After that, a relatively small number of labourers would have
wanted to go home. That could have been arranged without much hassle. There should be
adequate social security for the migrant labourers at their workplace itself. Unfortunately,
there was no considerable effort and the health crisis predictably led to an economic crisis.
The sudden shutting down of production and distribution led to a total collapse of the
economy rendering millions jobless.The global evidence suggests that job losses associated
with COVID-19 are much more concentrated among individuals with low levels of
education and those with vulnerable jobs with no tenure or security.