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Lessons learned from the first and second wave of COVID-19 disease pandemic in India!

1 Department of Pulmonary Medicine, MIMSR Medical College, Latur, Maharashtra, India
2 Department of Pathology, MIMSR Medical College, Latur, Maharashtra, India

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Date of Submission24-Apr-2022
Date of Decision06-May-2022
Date of Acceptance28-May-2022
Date of Web Publication27-Oct-2022


Coronavirus disease-19 (COVID-19) pneumonia is a heterogeneous disease with variable effect on lung parenchyma, airways, and vasculature leading to long-term effects on lung functions. Although the lung is the primary target organ involvement in COVID-19, many patients were shown pulmonary and extrapulmonary manifestations of diseases variably during the first and second wave, which occurred as resultant pathophysiological effects of immune activation pathway and direct virus-induced lung damage.

Keywords: COVID-19, first wave, second wave

How to cite this URL:
Patil S, Acharya A, Narwade G. Lessons learned from the first and second wave of COVID-19 disease pandemic in India!. J Appl Sci Clin Pract [Epub ahead of print] [cited 2023 Feb 4]. Available from: http://www.jascp.org/preprintarticle.asp?id=358986

  Introduction Top

Coronavirus-related diseases such as coronavirus disease-19 (COVID-19), severe acute respiratory syndrome (SARS), and Middle East respiratory syndrome (MERS) are caused by SARS-CoV-2, SARS-CoV, and MERS-CoV, respectively. SARS and MERS are epidemics in localized geographical area and preparedness by health-care system has cut down its global spread. Although mortality of SARS was high as compared to MERS, no antiviral use has been reported during the management of these cases irrespective of the severity of illness. COVID-19 is the first coronavirus-related global pandemic, and rapid evolution of the pandemic has resulted in fast-track developments in antivirals and vaccination for use to prevent morbidity and mortality.

  Indian Perspective Top

Genetic makeup of coronavirus was determining factor for overall outcome in the first and second wave, i.e., the first wave was novel coronavirus strain as “Wuhan variant virus” and the second wave was mutant type “Delta variant” coronavirus. Due to multiple mutations in spike proteins in novel coronavirus strain resulted in “Delta variant” in the second wave which was associated with increased morbidity and mortality.[1],[2] In both the waves, COVID-19 pathophysiology was the same involving various pathways as immune activation, inflammatory, thrombogenic, and direct viral cytotoxic effects on pulmonary and extrapulmonary systems. During the first wave, predominant age groups affected were the geriatric population having epidemiological health impact in terms of morbidity and mortality, while in the second wave, younger age groups were most affected population. If we compare the duration of COVID-19 illness in both the waves from hospitalization to treatment initiation, was <1 week in the first wave to more than 1 week in the second wave and is the reason for delay and resulted in mortality in the second wave.[2],[3] The health system was unable to cope with increased emergency hospitalizations of critical cases with increased oxygen requirements and greater number of patients who required ventilatory support were more in the second wave as compared to the first wave. Although the health system has prepared with increased ventilators in intensive care facilities during the second wave, due to the rapidly growing pandemic and a greater number of cases in the second wave, the health system was facing shortage of oxygen and ventilator beds across the country.[1],[2],[3]

During the first wave, the majority of affected COVID-19 cases were having extrapulmonary involvement as compared to pulmonary, while in the second wave, the predominant pattern was pulmonary. Cardiovascular involvement was seen more often in the first wave as compared to the second wave, and the rational for the same was not known, and medical experts believed as “Wuhan variant virus has more thrombogenic activation syndrome” as compared to Delta variant coronavirus.[4] In the first wave, extrapulmonary manifestations as pseudoacute coronary syndrome, pulmonary thromboembolism, and stroke were documented in a greater number of cases as compared to the second wave. Rapidly evolving pneumonia or “accelerated acute respiratory distress syndrome” (ARDS) was more commonly documented in the second wave, i.e., the larger number of cases were presented with rapidly deteriorating radiological and clinical laboratory parameters as increased computed tomography severity score, worsened oxygenation, increased inflammatory markers such as C-reactive protein, interleukin 6 (IL-6), ferritin, lactate dehydrogenase, and D-dimer, and decreased leukocyte and platelet counts and that to occur in shorter interval from onset to deterioration. Cytokine storm which is natural trends of pathophysiology in COVID-19 were documented in both the first and second waves, but the duration of manifestation of cytokine storm was variable and it was delayed till 2nd week in the first wave due to earlier hospitalizations, and in the second wave, it was documented in 1st week of hospitalization due to delay form patients to reach the health centers, they presented in advanced stage and cytokine storm in the first 3 days to 1st week in the second wave.[4],[5],[6]

During the first wave, many patients were presented with mild symptoms, and many advanced cases were showing excellent response to medical treatment due to earlier hospitalizations and relatively less cases required intensive care unit hospitalizations and ventilator requirements. In the second wave, many patients were in advanced stage till they access treatment in indoor units and required intensive care unit treatment including ventilatory support. Overall mortality is “no significantly different” in the first and second wave or slightly more in the second wave, as we are dealing with the Wuhan variant virus in the first wave and mutant Delta variant coronavirus in the second wave.[7],[8] Shortage of oxygen and shortage of ventilators were big concern in the second wave as compared to the first wave in spite of increase in oxygen beds and increase in ventilator beds across the country, and this might have faced due to “exuberant caseload” due to rapidly spreading nature of Delta variant coronavirus as compared to less mutant first wave Wuhan variant coronavirus. Although the health system has prepared to tackle a greater number of COVID cases till the evolution of the second wave, rapid resurgence of cases and rapidly evolving ARDS were determining factors for relatively more mortality and health-care crisis in the second wave as compared to the first wave.[3],[7],[8]

If we compare the response to different treatment options available to treat COVID-19 pneumonia in both the waves, treatment response to steroids and anticoagulation were similar in both the waves, ventilator response was quite satisfactory in the first wave as compared to the second wave due to milder version of Wuhan variant virus as compared to deadly mutant Delta variant virus, and many cases were required longer ventilatory support in the second wave, resulted in shortage of these machines in majority of the intensive care units.[8] Remdesivir was used in both the waves and documented benefit in terms of decrease in overall duration of hospitalization, with negligible mortality benefit in both the waves. Remdesivir has shown some mortality benefit in the second wave as compared to the first wave, and rational for relative more benefit due to its earlier use in course of COVID-19 illness along with steroids as many cases were presented in rapidly evolving pneumonia.[9] Similarly, tocilizumab has used in both the waves in condition with “cytokine storm with hypoxemia” and significantly raised IL-6, and documented benefit in the majority of these cases without any significant mortality benefit. Few reports from country documented some mortality benefit in the first wave as compared to the second wave, and proposed rational for this benefit was timing of its use in course of evolution of COVID-19 disease.[10]

Post-COVID lung fibrosis and mucormycosis were two deadlier complications documented during the evolution of COVID-19 pneumonia, predominantly in the second wave as compared to the first wave across the country. Rational for the occurrence of both the complications was not clear, post-COVID fibrosis was documented more commonly in the second wave and related to more virulent nature of mutant Delta variant virus as compared to Wuhan variant of the first wave.[11] Mucormycosis, both pulmonary and extrapulmonary types (eyes, nose, sinuses, cerebral) were documented in the second wave with no reports documented during the first wave, and pathway for same was unclear, thought to be related to more steroid use in the second wave as compared to the first wave, coronavirus-mucor fungus symbiosis to gain access through mucosal inflammation in airways, humidifier chamber contamination of oxygen supplementation system, but the exact reason for concurrent occurrence was unknown till today.[12]

COVID-19 protective vaccination was not available in the first wave, and the national COVID-19 protective vaccination policy has been started just 8 weeks before evolution of the second wave. Vaccines used in our country were Covishield and Covaxin and very few people were vaccinated before peak of the second wave. Significant difference was documented in terms of the severity of illness and response to treatment and mortality in vaccinated cases as compared to virgin or unvaccinated cases.[3]

The point to remember is that, coronavirus-related COVID-19 is a respiratory virus with propensity of mutations, having very short host immunity and immune memory, i.e., immune escape mechanisms to evade immune response in previously vaccinated or exposed individuals, virus having capability of minor and major antigenic variations as of influenza virus type leading to antigenic shift-drift related “endemic-epidemic” and deadly pandemics, and importantly a very short-lasting immunity after vaccination requiring frequent boosters as of influenza.

Coronavirus is less studied respiratory virus to date as of other respiratory viruses. Vaccination is a key step and that too with most updated genetic makeup vaccine which is prepared by analyzing “global viral genomic data” as in influenza is the only option to protect humankind from these smarter virions, and they will live with us and we should make adjustments according to them because they were present before we on this plant. Important learning point to tackle this pandemic is “COVID-appropriate behavior” using masks, and social distancing to break the “chain of transmission” and these are key steps for at least coming few years…show must go on!!

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Conflicts of interest

There are no conflicts of interest

  References Top

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Jain VK, Iyengar KP, Vaishya R. Differences between First wave and Second wave of COVID-19 in India. Diabetes Metab Syndr 2021;15:1047-8.  Back to cited text no. 2
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Madjid M, Safavi-Naeini P, Solomon SD, Vardeny O. Potential effects of coronaviruses on the cardiovascular system: A review. JAMA Cardiol 2020;5:831-40.  Back to cited text no. 4
Ramos-Casals M, Brito-Zerón P, Mariette X. Systemic and organ-specific immune-related manifestations of COVID-19. Nat Rev Rheumatol 2021;17:315-32.  Back to cited text no. 5
Shang Y, Pan C, Yang X, Zhong M, Shang X, Wu Z, et al. Management of critically ill patients with COVID-19 in ICU: Statement from front-line intensive care experts in Wuhan, China. Ann Intensive Care 2020;10:73.  Back to cited text no. 6
A Nightmare on Repeat – India is Running out of Oxygen Again. Available from: https://www.bbc.com/news/uk-56841381. [Last accessed on 2021 Dec 12].  Back to cited text no. 7
COVID-19 Second Wave: Why are Hospitals Falling Short of Ventilators, Again? Available from: https://www.forbesindia.com/article/take-one-big-story-of-the-day/covid19-second-wave-why-arehospitals-falling-short-of-ventilators-again/67381/1. [Last accessed on 2021 Dec 12].  Back to cited text no. 8
Beigel JH, Tomashek KM, Dodd LE, Mehta AK, Zingman BS, Kalil AC, et al. Remdesivir for the treatment of COVID-19 – Final report. N Engl J Med 2020;383:1813-26.  Back to cited text no. 9
Salvarani C, Dolci G, Massari M, Merlo DF, Cavuto S, Savoldi L, et al. Effect of tocilizumab vs. standard care on clinical worsening in patients hospitalized with COVID-19 pneumonia: A randomized clinical trial. JAMA Intern Med 2021;181:24-31.  Back to cited text no. 10
Ahmad Alhiyari M, Ata F, Islam Alghizzawi M, Bilal AB, Salih Abdulhadi A, Yousaf Z. Post COVID-19 fibrosis, an emerging complication of SARS-CoV-2 infection. IDCases 2020;23:e01041.  Back to cited text no. 11
Rao VU, Arakeri G, Madikeri G, Shah A, Oeppen RS, Brennan PA. COVID-19 associated mucormycosis (CAM) in India: A formidable challenge. Br J Oral Maxillofac Surg 2021;59:1095-8.  Back to cited text no. 12

Correspondence Address:
Shital Patil,
Pulmonary Medicine, MIMSR Medical College, Latur, Maharashtra
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jascp.jascp_24_22


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