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Immunomodulatory agents. SARS-CoV-2 triggers a strong immune response which may cause cytokine storn1 syndron1e⁶⁰.<->1. Thus, immunomodulatory agents that inhibit the excessive inflammatory response may be a potential adjunctive therapy for COVID-19. Dexamethasone is a corticosteroid often used in a wide range of conditions to relieve inflan1n1ation through its anti-inflammatory and immunosuppressant effects. Recently, the RECOVERY trial found dexan1ethasone reduced mortality by about one third in hospitalized patients with COVID-19 who received invasive mechan­ ical ventilation and by one fifth in patients receiving oxygen. By contrast, no benefit was found in patients without respiratory support¹+('.
Tocilizun1ab and sarilumab, two types of interleukin-6 (IL-6) receptor-specific antibodies previously used to treat various types of arthritis, including rheumatoid arthritis, and cytokine release syndron1e, showed effec­ tiveness in the treatment of severe COVID-19 by atten­ uating the cytokine storm in a sn1all uncontrolled trial¹·F. Bevacizun1ab is an anti-vascular endothelial growth factor (VEGF) medication that could potentially reduce pulmonary oeden1a in patients with severe COVID-19. Eculizumab is a specific n1onoclonal antibody that inhibits the proinflan1n1atory complen1ent protein CS. Preliminary results showed that it induced a drop of inflammatory n1arkers and C-reactive protein levels, suggesting its potential to be an option for the treatment of severe COVID-19 (REF¹⁴⁸).



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COVID-19 was found to be 3.28, vvhich is significantly higher than the initial WHO esti1nate of
1.4 to 2.5 (77). It is too early to obtain the exact Ro
value, since there is a possibility of bias due to insufficient data. The higher R₀ value is indicative of the 1nore significant potential of SARS-CoV-2 trans1nission in a susceptible population. This is not the first tin1e where the culinary practices of China have been blamed for the origin of novel coronavirus infection in hu1nans. Previously, the ani1nals present in the live-animal 111arket were identified to be the intermediate hosts of the SARS outbreak in China
(78). Several wildlife species were found to harbor potentially evolving coronavirus strains that can overco1ne the species barrier (79). One of the 1nai n principles of Chinese food culture is that 1ive­ slaughtered ani1nals are considered 1nore nutritious (5).
After 4 months of struggle that lasted from December 2019 to March 2020, the COVID-19 situation now seems under control in China. The wet animal markets have reopened, and people have started buying bats, dogs, cats, birds, scorpions, badgers, rabbits, pangolins (scaly anteaters), 1ninks, soup fro1n pahn civet, ostriches, ha1nsters, snapping turtles, ducks, fish, Sia1nese crocodiles, and other
, ...
been used based on the experience with SARS and MERS. In a historical control study in patients with SARS, patients treated with lopinavir­ ritonavir with ribavirin had better outcomes as compared to those given ribavirin alone [15].
In the case series of 99 hospitalized patients with COVID-19 infection from Wuhan, oxygen was given to 76%, non­ invasive ventilation in 13%, mechanical ventilation in 4%, extracorporeal membrane oxygenation (ECMO) in 3%, continuous renal replacement therapy (CRRT) in 9%, antibiotics in 71%, antifungals in 15%, glucocorticoids in 19% and intravenous immunoglobulin therapy in 27% [15].
Antiviral therapy consisting of oseltamivir, ganciclovir and lopinavir­ ritonavir was given to 75% of the patients. The duration of non-invasive ventilation was 4-22 d [median 9 d]
had >95% homology with the bat coronavirus and> 70% similarity with the SARS- CoV. Environmental samples from the Huanan sea food market also tested positive, signifying that the virus originated from there [7]. The number of cases started increasing exponentially, some of which did not have exposure to the live animal market, suggestive of the fact that human-to-human transmission was occurring [8]. The first fatal case was reported on 11th Jan 2020. The massive migration of Chinese during the Chinese New Year fuelled the epidemic. Cases in other provinces of China, other countries (Thailand, Japan and South Korea in quick succession) were reported in people vvho were returning from Wuhan. Transmission to healthcare workers caring for patients was described on 20th Jan, 2020. By 23rd January, the 11 million population of Wuhan was placed under lock down
exrenaea i:o 01:ner c1nes or 11uoe1 province. Cases of COVID-19 in countries outside China were reported in those with no history of travel to China suggesting that local human-to­ human transmission was occurring in these countries [9]. Airports in different countries including India put in screening mechanisms to detect symptomatic people returning from China and placed them in isolation and testing them for COVID-19. Soon it was apparent that the infection could be transmitted from asymptomatic people and also before onset of symptoms.
Therefore, countries including India
who evacuated their citizens from Wuhan through special flights or had travellers returning from China, placed all people symptomatic or otherwise in isolation for 14 d and tested them for the virus.
Cases continued to increase exponentially and modelling studies

must be on the look-out for the possible occurrence of atypical clinical manifestations to avoid the possibility of missed diagnosis. The early trans1nission ability of SARS-CoV-2 was found to be si1nilar to or slightly higher than that of SARS-CoV, reflecting that it could be controlled despite 1noderate to high trans1nissibility (84).

Increasing repo11s of SARS-CoV-2 in sewage and wastewater warrants the need for further investigation due to the possibility of fecal-oral trans1nission. SARS-CoV-2 present in enviromnental co1npart1nents such as soil and water will finally end up in the wastewater and sewage sludge of treatment plants (328). Therefore, we have to reevaluate the current wastewater and sewage sludge treatment procedures and introduce advanced techniques that are specific and effective against SARS-CoV-2. Since there is active shedding of SARS-CoV-2 in the stool, the prevalence of infections in a large population can be studied using wastewater-based epide1niology. Recently, reverse transcnptlon­ quantitative PCR (RT-qPCR) was used to enumerate the copies of SARS-CoV-2 RNA concentrated from wastewater collected from a wastewater treat1nent plant (327). The calculated viral RNA copy nu1nbers detennine the nu1nber of infected individuals. The