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REVIEW ARTICLE |
https://doi.org/10.5005/jp-journals-10085-9120
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A Dynamic Disease Model Portraying the Challenges and Management of COVID-19 in Puducherry, India: A Narrative Review
1–3Mahatma Gandhi Medical Advanced Research Institute, Sri Balaji Vidyapeeth (Deemed to-be University), Puducherry, India
4Research, Innovation and Development, Sri Balaji Vidyapeeth (Deemed to-be University), Puducherry, India
5Department of Biochemistry and Molecular Biology, Pondicherry University, Puducherry, India
Corresponding Author: Anitha TS, Department of Biochemistry and Molecular Biology, Pondicherry University, Puducherry, India, Phone: +91 9843576675, e-mail: tsanitha6@pondiuni.ac.in
How to cite this article: Precilla DS, Kuduvallli SS, Agiesh Kumar B, SR Rao, Anitha TS. A Dynamic Disease Model Portraying the Challenges and Management of COVID-19 in Puducherry, India: A Narrative Review. Ann SBV 2022;11(2):45–54.
Source of support: Nil
Conflict of interest: Dr Agiesh Kumar B is associated as the Associate Editor of this journal and this manuscript was subjected to this journal’s standard review procedures, with this peer review handled independently of the Editor-in-Chief and his/her research group.
Received on: 15 October 2022; Accepted on: 14 November 2022; Published on: 31 December 2022
ABSTRACT
Aim: To compile the epidemiological aspect of the coronavirus-2019 (COVID-19) pandemic in Puducherry, India, focusing on the infectivity, reasons for the increasing trend of COVID-19 cases, the measures undertaken by the governments to mitigate this disease, and the experiences of people of Puducherry.
Background: The COVID-19, a respiratory illness initially originated in Wuhan on December 2019, had exponentially spread across the globe since then. Nearly, 210 countries have been affected by this outbreak as of December 31, 2021. While the US, China, and Italy had high rates of infection initially, the disease gradually began threatening India as well, with the first case of this pandemic reported on 30 January 2020 in Kerala, India. As on 31 December 2021, 3.48 million affected cases have been reported in India, while in the Union Territory (UT) of Puducherry, India, 1.29 lakh affected cases have been reported. To date, the epidemiological aspect and the governance of this pandemic have not been documented.
Review results: Lessons learned in dealing with the pandemic, such as partial or full lockdowns, containment zone approach for focused management, problems in governance and geopolitical influences, immense vaccine drive, and zero COVID-19 campaign were important to promote rapid response to curb virus transmission.
Conclusion: Equally, the elucidation of pandemic preparedness and response in this article at the interface between the Government and the public points out to combat the increasing cases in the UT of Puducherry, India, in the second wave, understanding the current situation and tasks of compliance by the public and individuals is necessary through voluntary responsibility too.
Clinical significance: Documentation on pandemic management in Puducherry, India, is expected to provide a model to study disease dynamics, deployment of strategies for diagnostics, vaccination, and sensitization of the public, etc.
Keywords: Coronavirus-2019, Epidemiology, Vaccination.
BACKGROUND
The novel coronavirus (n-CoV) pandemic brought about a dramatic change worldwide within a quite short period.1 Emerging from the city of Wuhan, China, this deadly disease has transformed into an extraordinary disaster toward global health, economy, and geopolitical scenario.2 It is for the third time that the coronavirus family resulted in a pandemic, following Middle East respiratory syndrome (MERS) in 20123 and severe acute respiratory syndrome (SARS) in 2003.4 Initially declared as a “Public Health Emergency of International Concern” by World Health Organization (WHO) on 30 January 2020,5 this health disaster was later considered to be a “pandemic” on 11 March 2020.6 Though several viral respiratory infections have emerged in the recent past, the rapid global transmission, re-emerging potency, significant death rates, possibility of a community spread, and mortality among health providers are the major causes of concern for COVID-19.7 As of 31 December 2021, over 210 countries have been affected by this pandemic, with 273 million people being affected globally and a death toll of 5.3 million. Among the affected countries, the USA, India, and Brazil are severely affected by this pandemic with 31.4, 14.1, and 13.6 million COVID-19 cases, respectively.
In this context, this review aims to address the epidemiological aspect of the COVID-19 pandemic in Puducherry, India focusing on its geographical vulnerability, infectivity, reasons for the increasing trend of COVID-19 cases, the measures undertaken by the governments to mitigate this disease and the implementation of various drugs and vaccines to mitigate the viral outbreak.
Such detailed documentation on pandemic management in Puducherry, India, would provide a model to understand the disease dynamics, deployment of strategies for diagnostics, vaccination, and sensitization of the public, etc. Lessons learned in dealing with the pandemic, such as partial or full lockdowns, containment zone approach for focused management, problems in governance and geopolitical influences, immense vaccine drive, and zero COVID-19 campaign are important to promote rapid response to curb virus transmission.
REVIEW METHOD
The literature review for the assessment of pandemic infectivity across India and Puducherry was collected and pooled from electronic databases such as ScienceDirect, PubMed, Google Scholar, ProQuest, and manual searching. Articles published from 2015 to 2021 were considered for data collection. The keywords employed in the search were COVID-19, pandemic impact in India, pandemic impact in Puducherry, India, measures taken by the Government of Puducherry to curb the coronavirus (CoV) outbreak, and the vaccines and drugs that were recommended to curtail COVID-19. Literature works collected were about 200, among which about 140 articles were subsequently pooled based on the inclusion and exclusion criteria. The inclusion criteria were to include studies focusing on COVID-19 impact nationally and, in the UT of Puducherry, India, measures undertaken by the UT of Puducherry, India, and COVID-19 vaccines under clinical evaluation. The exclusion criteria were studies published before 2015 and those without quantitative research. Considering these, a total of 50 literature sources corresponding to the subject area of research were streamlined and compiled in this review.
Limitations of the Review
This review includes literature that focuses on the pandemic infectivity in Puducherry, India, and the measures taken to curb the viral outbreak. This review is a formal quality assessment of the trend of COVID-19 infectivity and a compilation of the vaccines that were used against the disease. Some sources, that depict design bias were also included in this review as they provide valuable insights into dilemmas among people and how the government had to face the situation to improvise human wellbeing.
REVIEW RESULTS
Spread of the COVID-19 Pandemic in India
In India, following the first confirmed case of COVID-19, which was reported at Thrissur, district of Kerala State on 30 January 2020, as of 31st December 2021, 3.48 million affected cases and 4.7 lakh deaths have been reported which includes 28 states and 7 union territories (36 entities) within the country8 (Fig. 1). Being the world’s second-largest populated country with 1.34 billion people, it would be quite challenging for India to control the transmission of severe acute respiratory syndrome coronavirus 2 (SARS-Cov-2).9
Figs 1A and B: The cumulative impact of reported and death cases of COVID-19 in 28 states and 7 UTs
As a strategic plan to control the transmission of COVID-19 in India, the Government of India announced the first lockdown, wherein people were advocated at the national level to observe a voluntary curfew with the Hindi phrase, “Janta Curfew” (“Janta” means people) on 22 March 2020 after which, a sharp decrease in the number of people visiting public places and workplaces was noted,10 In this pandemic, the state and the UT governments collaborated with Ministry of Home Affairs (MHA) of Government of India in jointly executing various preventive measures like travel restrictions, diplomatic gathering, and several wartime protocols such as countrywide lockdown in five phases (from 25 March 2020 to 30 June 2020).11 In order to build resilience against this disease, the Government of India has enforced the Epidemic Disease Act, 1897 along with the provisions of the Disaster Management Act, 2005.12 The systems of social distancing, self-quarantine, restriction of physical contact, use of personal protective equipment (PPE) while traveling are sole tactics prioritized to regulate this outbreak13 Both government and private healthcare hospitals are putting in constant efforts to curb the outbreak by arranging separate isolation ward, ventilators, testing kits, and continuous monitoring of the home quarantines to execute essential diagnosis and control the viral spread.14
Every state and UT in India is not equally equipped with sufficient public health infrastructure such as isolation wards, ventilators, and quantitative real-time polymerase chain reaction (qRT-PCR) testing laboratories to provide necessary medical services to the patients. The initial scarcity of ventilators, low sample testing rate, and hospitals denying to admit patients h significantly contributed to the surge in the country’s gross number of COVID-19 patients.15 Thus, interstate disparities and socioeconomic vulnerabilities resulted in a spiked rate of the viral outbreak.
Based on the above concepts, we discuss in detail the various facets of epidemiology, policy, and enforcement issues of the UT of Puducherry as an example to assess the preparedness and response planning, when compared to the rest of the country. We would also like to speculate that unlike other states of India, which have respective governments, these UTs with a kind of administrative division in the Indian Republic, are governed either in parts or in whole, by the Government of India.
Spread of COVID-19 Pandemic in Puducherry, India
Puducherry, a UT of India, with a seaside promenade running along the Bay of Bengal has a population of 1.65 million which includes the Yanam, Mahe, and Karaikal regions.16 Yanam is situated on the eastern side of India, near the district Vijayawada, Andhra Pradesh while Mahe is on the western part adjoining Kerala. Irrespective of their location, all of these regions have been affected by COVID-19. The first confirmed case of COVID-19 in Puducherry was reported in a 68-year-old woman on 17 March 2020 at Mahe who returned from Saudi Arabia.17 Later, in the UT, the pandemic began to spread slowly and had a spike in this UT with 4.5 thousand affected cases as on 19 September 2020.18 Being a UT with the total area19 of 483 km2 and with a population density of Puducherry with 3,231 people/m2 when compared to the national average of 382 people/km2, this life-threatening disease had dragged Puducherry toward a crisis, where in case of public non-compliance to the basic norms such as wearing masks, practicing social distancing brought the whole region of Puducherry under containment zone (Fig. 2).
Figs 2A and B: Extent of COVID-19 outbreak in Puducherry
Various possibilities behind this shift in the COVID-19 trend from “its only orange and green zones in Puducherry” to getting enlisted as a “red zone,” and subsequent management strategies that could uplift vibrant India’s Little France to speedy retrieval from the menace of this pandemic is discussed below.
Shift of the COVID-19 Trend from Orange to Red in Puducherry, India
To classify the areas as red, orange, or green based on the incidence of cases, the extent of testing, and the doubling rate, the Government of India has adopted a strategy. The areas with high cases were denoted as red zones, whereas areas with limited cases or those areas with no surge in positive cases recently were designated as orange zones, and those areas with no confirmed cases in the past 21 days were known as green zones.
In Puducherry, following the identification of the first COVID-19 case in the UT on 17 March 2020 and taking into consideration of virus outbreak in other states, the government of Puducherry decided to enforce a complete lockdown till 31 March 2020 to curb the viral spread.20 In this case, a multipronged approach involving intensive screening of tourists entering the UT through air or roadways, and enforcement to close schools, colleges, gymnasiums, and cinemas were brought into play to keep the viral outbreak at the bay.21 Interestingly, this single case was cured on 30 March 2020 crediting the UT as one of the safest places in the nation without any reported cases of COVID-19. Within a day’s gap, two more patients, who returned from New Delhi having attended the religious conference at Nizamuddin in New Delhi tested positive although they were asymptomatic,22 raising the total number of cases to three. Although the whole globe was gripped with COVID-19 cases between 3 April 2020 to 7 May 2020, Puducherry held its cases in one-digit numbers only. However, this number began to double at such a rate that by the end of May 2020, about 70 positive cases were reported with the sharpest spike on 23 May 2020, the date on which six new cases were reported for the first time.23
Alarmingly, by the end of 1 week of June, while India reported 2.5 lakh cases with 7,200 deaths,8 Puducherry was packed with 119 total COVID-19 cases and not a single death was reported.18 However, by the 2 weeks of June 2020, 57 new cases and 3 deaths were reported, thereby increasing the affected tally to 176. Since then, a mild increase in the affected rate was observed day by day. Notably, by the end of June 2020, when the total number of affected cases in India was 5.85 lakh, Puducherry reported 714 cases with 12 deaths.18 An interesting fact amid this chaos was that, out of 714 cases, 272 patients have already recovered.
To manage this situation, the local government of Puducherry identified 163 containment zones (the entire UT) for focused and integrated efforts to convert these from orange zones to green ones.24 Despite continuous efforts taken up by the Puducherry government, the COVID-19 tally increased gradually in the month of July 2020 with 3,200 affected cases and 48 deaths in Puducherry. Within a short period of 15 days, the death tally in UT crossed 100, with 7,300 reported cases (as on 15 August 2020). Surprisingly, this range doubled with 228 deaths and 14,400 affected cases by the end of 31 August 2020.18 Significantly, among the 14.4 thousand affected cases, 9,300 patients were discharged after recovery.25
A seroprevalence study carried out around this time by the experts from the Department of Preventive and Social Medicine and Microbiology, Jawaharlal Institute of Postgraduate Medical Education & Research (JIPMER), Puducherry, has depicted that one in twenty people showed evidence of COVID-19 infection by the end of July 2020. This study, indeed, provided novel insights into the fact that the proportion of patients with circulating antibodies in their blood was 26-fold higher than that of the cases diagnosed by qRT-PCR.25 At this stage, the Director of JIPMER, Puducherry gave an alarming note stating that “Puducherry tops the nation in COVID-19 cases per million, with a doubling time of just 14 days”.26 The above-stated facts reveal a sharp spike in the outbreak of the disease, which warranted priority-based essential actions to curb the viral spread.
Measures Taken by the Government of Puducherry, India
The COVID-19 cases in this UT have shown an exponentially increasing trend every 4–6 days.18 To reduce the sharp spike in cases, the Government of UT of Puducherry, enforced continuous lockdowns (Lockdowns 1.0–4.0), which severely impacted the lives of common mankind. During the initial phases of lockdown (lockdown 1.0 to unlock 1.0), UT sealed its borders with the neighboring state of Tamil Nadu with high incidence, thereby completely halting interstate travel (Fig. 3). This had a very good impact on the reduction of viral spread, which was evident from the data provided on COVID-19 outbreak in Puducherry COVID-19 Dashboard.18Although Puducherry sealed its borders with Tamil Nadu, around 120 uncontrolled entry and exit points were not taken care of, which ultimately paved way for people from a neighboring city, Chennai and other states to enter the UT. A strict enforcement of e-pass to enter Puducherry for a medical emergency was, indeed, a good initiative.
Figs 3A and B: Restrictions and relaxations implemented in Puducherry during lockdown and unlock phases
Puducherry, being a popular tourist destination in India has given a lot of employment opportunities to the local people. The lockdown has completely hampered the economic growth and tourism industry of UT. Taking this into consideration, Puducherry liberalized the Interstate travel restrictions, and extended working hours in shops and commercial establishments from 6.00 am to 8.00 pm in the month of August 2020.27 It was at that point the viral spread began to double every 4–6 days with an accelerated surge on the COVID-19 tally, whereby 521 deaths and 27,500 affected cases were stated by the end of 30 September 2020.
Meantime, to reduce the infectivity and viral spread, the government implemented a microplan wherein officials were appointed for COVID-19 management activities such as surveillance, isolation, contact tracing, bed availability, and data management. Yet, the surge of viral outbreaks continued alarmingly, with 35.1 thousand affected cases and 591 deaths reported as of October 2020. Considering the sustainability of the public, the Government of Puducherry on 1 November 2020 announced a few more relaxations such as permission to operate inter and intrastate movement of persons and goods without e-approval or permission. In addition, international travelers were also allowed to enter the UT with a negative RT-PCR test report, 72 hours before the journey. By imposing several guidelines and following precautionary aids, the UT began to keep the viral spread under control, as only 1,500 new COVID-19 cases and 19 cases were reported by the end of November 2020. This trend was maintained at the same level till December 2020, wherein the total number of cases reported was found to be 38,100 while the death toll was 633 at the end of 2020.
Irrespective of the precautions and regulations enforced by the government, it was public’s insensitivity to the situation and the ramifications of this disease were also one of the reasons. There was negligence and gross non-compliance of the rules imposed by the government to practice social distancing, wearing masks, using sanitizers regularly, avoiding direct contact with either suspected or affected patients, and avoiding mass gatherings even during the days of lockdown.
Path of Vaccines in COVID-19 Pandemic
Never before in history, during the period from October 2020 to December 2020, had the general public witnessed a global and national debate on the immediate need for vaccines, their safety, and efficacy including delivery strategy was discussed. By the end of the year 2020, COVID-19 vaccines were in various stages of clinical phases 1–3. In India, New Drugs and Clinical Trials Rules, 2019 laid the provisions for the approval of clinical trials of new medicines and vaccines (www.cdesco.gov.in). The Emergency-use Authorization (EUA) as new to India’s drug regulations, at least three applications were filed in January 2021 for their consideration under the Central Drugs Standard Control Organization (CDSCO). Pune-based Serum Institute of India was conducting late-stage bridging clinical trials of Oxford-AstraZeneca’s AZD1222 vaccine under the name of Covishield. In its application, the Serum Institute of India has quoted Phases 1 and 2 safety data and efficacy rates from Phase 3 human trials conducted in the UK and Brazil. Meanwhile, Hyderabad-based Bharat Biotech started the Phase 3 human trial of Covaxin, wherein Bharat Biotech has cited its safety data recorded during phases 1 and 2 clinical trials. Pfizer – BioNTech’s vaccine – was the first in the world to receive EUA as it has been approved by UK and Canada; however, it is yet to conduct any level of human trials in India. On detailed examination data submitted and risk/benefit assessment, the Central drug Licensing Authority of India granted permission for the sale or distribution of Covaxin and Covishield for restricted use in an emergency in public to prevent Coronavirus Disease 2019 by the end of January 2021. While vaccine availability was foreseen in near future, as a new hope, in Puducherry, the number of COVID-19 active cases gradually began to decline in the month of January, steadily with only 41 newly reported, 21 cured, and 2 deaths. Since then, a similar trend in the viral spread was observed till the end of February with an overall total of 39,700 cases (Fig. 4).
Fig. 4: The timeline of COVID-19 outbreaks in the UT of Puducherry
The Second Wave in Puducherry, India
As the saying, “Calm before a storm” goes by, the first wave had a calm departure from the UT after having taken 668 lives, leaving the public clueless about its second entry. Nonetheless, due to the availability of vaccines, the government kept insisting the public get vaccinated (Covishield and Covaxin), maintain proper social distancing, and wear face masks, and other precautionary aids. While the COVID-19 cases were in single digits, the government launched a “Zero COVID-19” campaign on February 28, 2021. Schools began to function as usual and people were about to lead a normal life by the mid of March 2021. It was that time when the second wave stepped in as a storm in different States of India including Puducherry. The mutant strain, B.1.1.7 (501Y.V1) which was of UK origin, was reported to be more severe, and the number of new COVID-19 cases began to increase sharply with 81 new cases on 18 March 2021. Meanwhile, UT of Puducherry UT reported the highest number of single-day COVID-19 cases on 8 April 2021, wherein 293 patients tested positive for the virus. In response to the “Vaccine Utsav” meaning “Vaccine Festival,” a call given by the Prime Minister of India to curtail the viral spread; a 5-day camp was hosted by the UT, wherein each vaccinating site was given a target of vaccinating 500 persons daily. Despite the efforts taken to vaccinate the public, the infected trend was surging continuously with 1.29 lakh COVID-19 cases and 1,800 deaths as on 31 December 2021 (Fig. 4).
COVID-19 First Wave vs Second Wave in India
While the whole country was almost ready to recover from the first wave by the end of September 2020, within 6 months, the second wave of the pandemic struck the country, whereby there was an exponential rise in cases every day. In this scenario, Indian Council for Medical Research (ICMR) analyzed the effect of the COVID-19 pandemic in 2020 and 2021, wherein there was not much difference in the infection ratio among various age groups. As in the case of the first wave, older people seemed to be more vulnerable to the virus, while only a marginally higher proportion of younger age groups were prone to this second wave. Interestingly, it has been documented that more than 70% of the patients (in both waves) are more than 40 years of age. The difference in the percentage of affected cases between waves reported in the age group of 0–19 years was 5.8% vs 4.2% while in the age group of 20–40 years was reported to be 25% vs 23%. Besides, a large number of asymptomatic cases have been recorded in the second wave, with the majority of the patients admitted showing breathlessness; in contrast, in the first wave, most of the people had symptoms of sore throat, joint pain, headache, and dry cough. However, no significant difference in the mortality rate between the first and second waves was observed. To add on, the oxygen demand was higher in the second wave (54.4%) while the first wave required only 41.5% oxygen demand. Amid being in the surge of infections, a severe shortage of vaccines was observed due to the lack of improper preparedness for the equal distribution of vaccines in India. As on 31 December 2021, only 1.4 billion people in the nation have received COVID-19 vaccines and this lack of shortage of vaccines made India’s “100% vaccinated” an unmet goal.
Preventive Measures to Curb Viral Outbreak
The WHO has framed several recommendations for minimizing exposure to viral infections.28 These precautions have been classified at both personal and environmental levels and they must be strictly emphasized to limit the viral spread. First and foremost, preventive measures such as the proper use of PPE must be followed. Patients who tested positive must be isolated into a separate room and those who were in direct contact with them have to be motivated to report the fever or any other risk factors and quarantine themselves as well; direct unprotected contact with animals and consumption of raw or undercooked animal products has to be avoided. At the level of precaution for Healthcare Workers (HCWs), a separate and specialized team must be appointed to deal with COVID-19 patients alone. At the environmental level, patients must cover their mouth and nose every time they sneeze and sanitize once they come across any respiratory secretions. To avoid virus exposure, people should restrict themselves from traveling to various other countries that are highly affected by this pandemic.29 In this regard, a travel advisory has been released by India for intra- and interaircraft regulations.
The Puducherry regional airport has been operationalized in August 2017, wherein the airport has handled around 40,000 arrivals and 38,000 departures between the cities of Bengaluru and Hyderabad, which has several international air connections. Following the government regulations, flights to Puducherry were canceled and continued to do so, limiting the spread and leading to the second wave. Based on the WHO, Centers for Disease Control (CDC), USA, and ICMR recommendations, Puducherry has formulated several strategies to seize the viral spread and overcome the socioeconomic loss encountered due to this pandemic. Also, Puducherry Disaster Management Authority has strictly enforced people to intimate about the arrival of any person from other states in the neighborhood.30 Full lockdown on every Tuesday under Section 144 was implemented to bid the curfew from 15 August 2020 to 31 August 2020.31
In terms of population density, as reported by the National Institution for Transforming India (NITI) Aayog (2017) the premier policy “Think Tank” of the Government of India (providing both directional and policy inputs), Puducherry is the country’s third largest UT (2,598 persons/km2), with Delhi (11,297 persons/ km2) being the first and Chandigarh (9,252 persons/km2) at the second place.32 This high population density might be a conductive factor in enhancing the clustered transmission of the virus as well. Also, Puducherry is reported to have a considerable slum population (35,070 in total), as per the 2011 Census of India which might increase the vulnerability of the people to COVID-19 residing in these areas as they have to step out of their premises routine amenities such as drinking water and sanitary purposes.33
To accommodate COVID-19-positive patients, Puducherry has categorized the medical services into three groups based on the severity of the viral infection such as COVID-19 care center (mild), COVID-19 health center (moderate), and dedicated COVID-19 hospital (severe cases). Also, to cautiously monitor the pandemic-stricken people and identify the spike in new infections, Puducherry has launched a door-to-door platform to test the samples from 5 September 2020 onward. As of 20 April 2021, the testing rates in Puducherry have been scaled up from 200/day to 1,000/day.34 The ICMR has recognized a list of laboratories eligible for RT-PCR testing of COVID-19 swabs-based samples throughout the country. As on February 2021, there were a total of 2,394 laboratories consisting of 1,220 government and 1,174 private sectors in the country recognized by ICMR (www.icmr.gov.in). New Delhi with a population density of 11,297 persons/km2 accounted for 98 RT-PCR labs (government, 29; private, 69) for a total estimated metro–population of 31,181,376. Whereas Puducherry had 14 ICMR-approved COVID-19 (government, 6; private, 8) testing laboratories for a density of 2,598 persons/km2 with a metro population of 856,000 at the rate of one laboratory for every 60,000 populations compared to 3,00,000 population in Delhi. In the surge of the second wave all over the country, probably, Puducherry has a healthy ratio of labs per population as there is chaotic atmosphere on this account. It appears such a ratio would have prevented current delays in tests results in Delhi and unrest and queues outside labs by people demanding RT-PCR tests.
Compared to the other states, the COVID-19 infectivity curve flattened during the period between January 2021 and February 2021 in Puducherry, because of the increased testing rate, isolation of patients, and increased testing laboratories. Also, with increasing COVID-19 cases, the per capita ventilated-hospital beds in India is only 0.55 per 1,000 population, which is lower than other countries like South Korea (11.4), France (6.5), China, and Italy (4.2 and 3.4, respectively).15 The isolated bed is an elementary requirement for COVID-19 care and Puducherry is underprivileged in this scenario. The worsening part is that without sufficient beds, people were kept in wheelchairs and stretchers at one point.35 Shortage in the number of HCWs to sustain proper sanitation practices in healthcare centers was pointed out by the Puducherry Health Ministry himself during a visit public sector general hospital.36 Despite the scarcity of medical necessities such as qRT-PCR kits, HCWs, and accommodation, Puducherry has recorded one of the highest testing rates in the country.37 However, during the first wave, delay in the declaration of results to an extent of five days indeed, resulted in panic and stress among patients, thereby rendering them in a confused state.
Rapid test kits were not available for a long-time to announce test results within a few hours. Governance and rapid decision making by policymakers in Puducherry quite often depended on the geopolitical scenario of UT even during the peak of the pandemic. This was mainly because some areas of the Puducherry and Karaikal districts are bound by the state of Tamil Nadu, while Yanam and Mahe districts are enclosed by the states of Andhra Pradesh and Kerala, respectively. Decisions by the neighboring states have made an enormous impact on the transboundary movement of people and trade. It can be observed that COVID-19 incidence in Mahe was much lower than those at Karaikal and Puducherry which was mainly attributed to the strict policies enforced by the neighboring state government, the Government of Kerala.
Further, being a UT of India, Puducherry directly comes under the federal authority for its governance and administration. One among the three Indian Union Territories (Jammu and Kashmir, Delhi, and Puducherry) in India, Puducherry also is enfranchised by a special constitutional amendment to have an elected legislative assembly and a cabinet of Ministers, thereby imposing a partial statehood; wherein the whole constituency is represented the Lieutenant Governor. The Government of India is more directly involved in the territory’s financial wellbeing, unlike the other states which have a central grant that they oversee. According to the Treaty of Cession of 1956, the four territories of the former French India territorial administration are permitted to make laws with respect to specific matters. In many cases, such legislation may require ratification from the federal government or the assent of the President of India. Therefore, opinion to formulate rules and execute preventive measures, even during pandemic situations vested with the Government of India which made it very hard for the Government of UT of Puducherry to implement any decision promptly. For instance, the then Chief Minister (CM) had decided to provide rice and wheat for the affected people during the pandemic, however, the then Governor, in accordance with the Government of India, opposed the CM’s idea and insisted on providing financial support instead of supplying cereals to the public.
On the contrary, one of the private tertiary care teaching hospitals in Puducherry, the Mahatma Gandhi Medical College and Research Institute (MGMCRI), a unit of Sri Balaji Vidyapeeth (Deemed to be University) has been exemplary in the region by continuously striving from day one to prevent the pandemic spread and create awareness among people. Owing to the increase in the number of COVID-19-positive cases in and around Puducherry, MGMCRI has introduced a compact, economically viable Home Care Management package to avoid stress and minimizing panic among patients, who are asymptomatic or mildly symptomatic of COVID-19.38
DISCUSSION
“Adversity introduces a man to himself,” although attributed to Albert Einstein saying so, this pandemic situation has given us a better understanding of who we are, what should we do, and how it has to be done. The impact of COVID-19 on the economy, revenue, and personal and sociopolitical lives of people is unpredictable.39 After having faced certain financial constraints following the implementation of uniform Goods and Service Tax (GST) and demonetization by the federal government, people were getting back on track to normal life and soon the COVID-19 pandemic struck.40 This pandemic has adversely affected the socioeconomic fabric of small and medium businesses, migrant labor, and the overall economy of the UT like in many parts of the world, with no relief so far. Amid this pandemic, scientists have teased out the field of the molecular biology of this devastating disease and have successfully launched vaccines for immunization against the virus.41
India is well-known for its traditional herbs in the form of Ayurveda, Yoga, Unani, Siddha, and Homeopathy (AYUSH).42 The Ministry of AYUSH has unconfined a press release on medications that can improve immunity against the virus.43 Also, Siddha’s research has shed light on the efficacy of the herbal concoction, “Kabasura kudineer,” in managing COVID-19 cases.44 Healthcare centers at the UT of Puducherry are providing a balanced healthy diet that develops immunity in COVID-19 patients.45 The quality of food for COVID-19 patients is being enhanced in Puducherry. At present, the government is providing food at the rate of ₹230 per patient to serve nutritious food to them.46 Further, a combination of Lopinavir and Ritonavir has been recommended by ICMR for severe cases, and hydroxychloroquine as prophylaxis for SARS-CoV-2.47 Recently, Remdesivir, an anti-malarial agent has emerged as a drug of hope following the second wave of COVID-19. The comparison between the effect of the two waves of COVID-19 in Puducherry and the proposed therapeutic options to curtail viral entry are shown in (Fig. 5).
Figs 5A and B: Comparison between the first and second wave of COVID-19 in the UT of Puducherry and the proposed therapeutic options to curtail COVID-19 viral entry
Rapid antigen testing kits have been tested at the National Institute of Virology, Pune, India, and eight kits were found to be satisfactory.48 Convalescent plasma therapy, which was once employed with moderate success for SARS and MERS proved to be beneficial in SARS-CoV-2 and 20 health centers have already rolled in executing this therapy.49
While the second wave started on 16 April 2021, about 15.5 lakh people have been vaccinated all over India, while in the UT, the vaccine has been applied to 1.06 lakh people. Interestingly, about 64 million doses of vaccines have been shipped from India to 86 countries to protect against the severity of this disease.50
Clinical Significance
The current pandemic COVID-19 caused by SARS-Cov-2 is a serious global threat. This has imposed a great challenge to the political, economic, and public health infrastructure of India. The results from the current study provide a clear picture of the aggressiveness of COVID-19 impact in Puducherry. The detailed account of the impact, measures, and experiences of Puducherry with a small population size could serve as a model to study disease dynamics deployment strategies for diagnostics, vaccination, and sensitization of the public, etc. Lessons learned in dealing with first and second-wave, such as partial or full lockdowns, containment zone approach for focused management, and problems in governance and geopolitical influences, immense vaccine drive, and zero-COVID-19 campaign are important to promote rapid response to curb virus transmission. Equally, the elucidation of pandemic preparedness and response in this article at the interface between the Government and the public points out to combat the increasing cases in the UT in the second wave, understanding of the current situation and tasks of compliance by the public and individuals is necessary through voluntary responsibility too.
ACKNOWLEDGMENTS
The authors thank the Faculty of Mahatma Gandhi Medical Advanced Research Institute (MGMARI), Sri Balaji Vidyapeeth (Deemed to be University), Puducherry, India, for giving constant support in drafting this review article.
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