Baby with Rare Skin Disorder Gets Life-Changing Treatment

Baby with Rare Skin Disorder Gets Life-Changing Treatment

MADRID —Doctors in Spain have found a life-changing treatment for a 9-month-old baby suffering from a rare, incurable disease that caused her to have thick, dry skin.

The baby girl, whose name was not disclosed, was born earlier this year at Nino Jesus Hospital in Madrid weighing 4 kilograms (8.8 pounds), which is a slightly above average for a newborn.

The baby skin before the treatment. (H. Gregorio Maranon/Real Press)

However, over time, her weight dwindled to half of what is expected in babies her age, which meant she is considered severely malnourished with a risk of death, according to the World Health Organization.

The child suffers from ichthyosis,  a rare incurable skin disease that produces thick scaly skin, with varying degrees of symptoms or areas of the body affected, leading to serious discomfort and increasing the chance of infection.

The condition kept the baby from feeding or sleeping properly.

One of the doctors treating her, Rafael Correa, said in a press statement obtained by Zenger News, that the patient was missing an important protein in charge of maintaining her skin’s structure..

He added  her skin was “unstructured” and though the genetic mutation cannot be helped, the inflammation process caused by the disease could be treated to reduce the symptoms.

Doctors studied 150 different variables and used a mathematical algorithm to compare them with healthy children.

They found the patient had two cells linked to the inflammation. They applied a medicine used to treat psoriasis in adults, which is also directed at the altered cells causing the baby’s symptoms and subsequent malnourishment.

The patient has since gained enough weight to be considered average and her symptoms have almost disappeared, giving hope to others suffering from the illness.

However, she has not been cured and will require periodic injections of the treatment. Doctors hope her immune system will adapt to the medication over time.

“We should encourage doctors to take initiative and find solutions to give patients their daily routine back,” Jose Maria Soria de Francisco, president of the Spanish Association for Ichthyosis (SAI) told Zenger.

The members of the team participating in the project. (H. Gregorio Maranon/Real Press)

He explained  there are 36 types of ichthyosis, each with its own properties. Using the findings from this case, scientists could offer individual treatments to among the 300 people reportedly suffering from it in Spain. Statistics on how many such cases there are on a global scale were not immediately available.

Most patients suffering from ichthyosis need to spend about two hours daily applying cream-based skin treatments to relieve their symptoms. The medicine can cost 250-500 euros (roughly $300-$585) monthly, and it’s not covered by the Spanish health-care system.

“Ichthyosis knows no borders and can affect rich and poor families alike,” says SAI’s president.

(Edited by Matthew Hall and Fern Siegel)



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Stalled Life-Saving Transplant Ops Begin Again After COVID-19 Lockdown in India

Stalled Life-Saving Transplant Ops Begin Again After COVID-19 Lockdown in India

The coronavirus pandemic and the national lockdown that followed brought organ transplants in India to a complete standstill.

But as cities begin to unlock in phases and hospitals gradually steer the focus to other chronic ailments and lifesaving procedures undermined by Covid-19, organ donations and transplants are slowly resuming.

On Aug. 17, the family of a 31-year-old man from Kolkata in West Bengal consented to donate his organs after he was declared brain dead as a result of severe injuries he suffered in a road accident. The noble gesture marked Kolkata’s first organ donation  during the pandemic and third this year. The two others occurred in January.

In a similar gesture on Aug. 15, the family of a deceased 39-year-old woman from Pune saved the lives of five patients suffering from end-stage organ failure. The donor had suffered a brain hemorrhage and her family consented to donating her heart, liver, lungs, kidney and cornea after doctors declared her brain death. Two of her organs were flown to south India; the heart was sent to MGM Healthcare in Chennai; and the lungs were sent to KIMS Heart and Lung Transplant Institute in Hyderabad. The remaining organs were transplanted to patients in Pune.

“This was only the second heart transplant that we carried out in our center since the country went under lockdown,” said cardiac anesthesiologist and critical care specialist Dr. Suresh Rao.

 

Rao was part of the heart transplant team in Chennai’s MGM Healthcare. “Usually, we carry out anywhere between eight to 10 heart transplants in a month. But since the lockdown in mid-March, we have carried out only two,” he said.

Before Covid-19, the number of transplants done annually in India was about 5,ooo kidneys, 1,000 livers and 50 hearts, according to the Journal of the Practice of Cardiovascular Sciences.

The first case of Covid-19 was reported in India on Jan. 30. A nationwide lockdown was announced by Prime Minister Narendra Modi from March 24 as the number of cases began to soar. The country has now crossed 2.7 million cases and recorded more than 50000 deaths.

“The state governments advised to stop the transplant procedures due to the concern about the outcome if patients get infected with Covid-19,” said Rao. “The Tamil Nadu government lifted this clause last month and allowed hospitals to restart transplants if organs were available within their centers. Now the government has allowed inter-city transplants too, thus enabling us to fly the organs from other states.”

However, the process remains challenging due to the low number of domestic commercial flights operating in the country.

“We had to arrange a chartered flight with help from a charitable trust to bring the heart from Pune to Chennai,” Rao said, referring to the organ donation on Aug. 15.

In Western India, the State of Maharashtra recorded 160 organ donations in 2019. So far this year, the state has recorded 50. Maharashtra currently has over 5,500 patients waiting for kidney transplants, nearly 1,100 waiting for liver transplants, 74 waiting for heart transplants, and 16 in line for lung transplants. While patients with kidney failure are sustained on dialysis, those in need of other organs have little interventions other than transplants.

The living donor organ transplants, where a close relative is allowed to donate the organ, also took a back seat during the pandemic. In some cases, organ donors and recipients feared contracting the infection and delayed the procedure, while in other cases hospitals they had registered with had halted the program.

“It is logical to presume that patients on the waiting list who did not get transplants in time may have succumbed. But we currently don’t have any data on this,” said Dr. Vasanthi Ramesh, director of the National Organ and Tissue Transplant Organisation. “Hospitals are still busy with Covid-19 and the health systems are stretched. We will collate the data from centers in the coming days”.

Some transplant centers have calculated the mortality based on their own waiting list. Chennai’s MGM Healthcare has lost nearly 30 percent of its patients on the waiting list for heart transplants.

“Patients in need of heart transplants have to wait anywhere between one to three months to get the organ. However, this year, the waiting period had crossed six months for most patients,” said Rao.

Doctors say that ensuring a COVID-free pathway before and after the transplant is most challenging. This fear is probably keeping most hospitals away from restarting their transplant programs, even as it is not economically viable for them to sustain.

“In Mumbai, we have 39 recognized transplant centers but only one-third have agreed to restart the procedures,” said Dr. SK Mathur, president of the Zonal Transplant Coordination Centre, Mumbai. A similar trend in reduction in the number of transplant procedures has been recorded in the United States and France.

Gradually though, states have devised standard operating procedures to minimize the risk of infection. Tamil Nadu government, for instance, has insisted that not just the donor and the recipient, but also close family members of the recipient be tested for Covid-19. In Maharashtra, patients and healthcare workers must be screened and followed up for up to 28 days.

Doctors believe the number of transplants will increase in coming days after speedier test results for Covid-19 tests and increased public awareness of safety measures to control spread of the virus.

(Edited by Siddharthya Roy and Judy Isacoff.)



The post Stalled Life-Saving Transplant Ops Begin Again After COVID-19 Lockdown in India appeared first on Zenger News.

Burning Fuse on India’s Devastating Smoking Cancer Time Bomb

Burning Fuse on India’s Devastating Smoking Cancer Time Bomb

With tobacco consumption contributing significantly to the rising number of cancer cases in India, doctors and others are urging the government to step up its tobacco control measures.

Cancer cases in the country are likely to jump from 1.39 million in 2020 to 1.57 million, or 12.9 percent, in 2025, according to a recent report released by the Indian Council of Medical Research.

The report was based on information collated from 28 population-based and 58 hospital-based cancer registries across the country. It states that nearly 370,000 cancer cases this year alone will be caused by tobacco consumption, including cancer of the lip, tongue, mouth, pharynx, esophagus, larynx, lungs and  bladder.

While India is reported to have a very high level of tobacco use in both smokeless and smoking forms, it also has measures in place to help curb use, according to the World Health Organization.

“The MPOWER measure that India is implementing at the highest level of achievement is conducting national mass-media campaigns to warn people about the dangers of tobacco use,” the WHO report states. MPOWER is the organization’s tobacco-free initiative.

 

Still the numbers continue to rise.

The study found that East Khasi Hills in the northeastern state of Meghalaya had the highest relative proportion of cancers associated with the use of tobacco — 70.4 percent in males and 46.5 percent in females.  Among men, lung cancer was most common in eastern India, while cancer of the mouth was highest in the central part of the country.

In women, mouth cancer was high in central states, while esophageal cancer was common in northern India.

“Nearly half of the cancers in men are tobacco-related,” said Dr. Pankaj Chaturvedi, head and neck cancer surgeon at Tata Memorial Centre hospital in Mumbai, India’s largest cancer center.

Chaturvedi, one of the most prominent anti-tobacco crusaders in the country, said, “The government has initiated many measures over the past several years, including pictorial warnings on cigarette packets, display of warnings in films and television serials, advertisements in cinemas, starting a quit-line for people who want to fight the habit, and most recently banning e-cigarettes. All of these measures tackle the demand side. But what is being ignored is the supply side of the massive tobacco industry.”

A 2019 study by Thought Arbitrage, an independent think tank,  and ASSOCHAM, an organization affiliated with chambers of commerce, said nearly 45.7 million people in India depend on the tobacco sector for their livelihood. This includes 6 million farmers; 20 million farm laborers; 4 million leaf-pluckers; 8.5 million working in processing, manufacturing and exports; and 7.2 million workings in retailing and trading.

“There is enough data that India is a leading tobacco exporter with exports of leaf tobacco and tobacco products contributing around INR 6,000 crore ($808 million) annually in terms of foreign exchange to the government,” the study said.  “Of the total net exports, the un-manufactured tobacco has a significant share amounting to INR 4,173 crore ($562 million). The rest includes tobacco products such as cigars, cheroots, cigarillos and cigarettes.”

The report also said India produces tobaccos of different grades and types for various users, providing a one-stop-shop for different styles, qualities and price ranges. Flue-Cured Virginia tobacco is the main exportable tobacco produced in India, with around 70 percent of that crop being exported.

“India has a 5 percent value share of the $12 billion global tobacco leaf export trade.  The diversity of Indian tobacco has enabled the country to export tobacco to over 100 countries across the globe,” the study said.

“To deal with this supply of tobacco, the Indian government has to show commitment by stopping tobacco cultivation and offering alternative crops and income sources to the farmers and other workers deeply rooted in the industry,” said Chaturvedi. “The government should also withdraw its share from the country’s leading cigarette company. Controlling tobacco is the responsibility of multiple ministries such as Home, Health, Education, Labor, Finance, Women and Child, Agriculture, Environment, Commerce and Industry, etc., and it has been a challenge to get them all on the same table. It is crucial for these ministries to work together.”

The Global Adult Tobacco Survey shows that consumption of tobacco in India dropped from 34 percent to 28 percent between 2010 and 2016. However, experts said the growth in population during that period has not been accounted for.

“The recent projections made by the Indian Council of Medical Research are alarming,” said Dr. A C Kataki, director of the Dr. B Borooah Cancer Institute in Guwahati, in the northeastern state of Assam. “The government has to give a strong push to tobacco control if it intends to reduce the cancer burden in the country. It is also the responsibility of the society and citizens to demand such laws and ensure that they are stringently implemented.”

Experts said that the smokeless form of tobacco is more common in rural India.

“The raw, chewable form of tobacco is easily available and culturally accepted in rural India,” said Rajashree Kadam, vice-president of the nonprofit Salaam Bombay Foundation that works in this sector. “There is little awareness of its harmful effects.

“Tobacco companies typically target youth with surrogate advertisements. Their lobby is very strong in the country and it is time the government stands up against it.”

(Edited by Siddharthya Roy and Judy Isacoff.)



The post Burning Fuse on India’s Devastating Smoking Cancer Time Bomb appeared first on Zenger News.

Stalled by Pandemic, Organ Transplants Slowly Resume in India

Stalled by Pandemic, Organ Transplants Slowly Resume in India

The coronavirus pandemic and the national lockdown that followed brought organ transplants in India to a complete standstill.

But as cities begin to unlock in phases and hospitals gradually steer the focus to other chronic ailments and lifesaving procedures undermined by Covid-19, organ donations and transplants are slowly resuming.

On Aug. 17, the family of a 31-year-old man from Kolkata in West Bengal consented to donate his organs after he was declared brain dead as a result of severe injuries he suffered in a road accident. The noble gesture marked Kolkata’s first organ donation  during the pandemic and third this year. The two others occurred in January.

In a similar gesture on Aug. 15, the family of a deceased 39-year-old woman from Pune saved the lives of five patients suffering from end-stage organ failure. The donor had suffered a brain hemorrhage and her family consented to donating her heart, liver, lungs, kidney and cornea after doctors declared her brain death. Two of her organs were flown to south India; the heart was sent to MGM Healthcare in Chennai; and the lungs were sent to KIMS Heart and Lung Transplant Institute in Hyderabad. The remaining organs were transplanted to patients in Pune.

“This was only the second heart transplant that we carried out in our center since the country went under lockdown,” said cardiac anesthesiologist and critical care specialist Dr. Suresh Rao.

 

Rao was part of the heart transplant team in Chennai’s MGM Healthcare. “Usually, we carry out anywhere between eight to 10 heart transplants in a month. But since the lockdown in mid-March, we have carried out only two,” he said.

Before Covid-19, the number of transplants done annually in India was about 5,ooo kidneys, 1,000 livers and 50 hearts, according to the Journal of the Practice of Cardiovascular Sciences.

The first case of Covid-19 was reported in India on Jan. 30. A nationwide lockdown was announced by Prime Minister Narendra Modi from March 24 as the number of cases began to soar. The country has now crossed 2.7 million cases and recorded more than 50000 deaths.

“The state governments advised to stop the transplant procedures due to the concern about the outcome if patients get infected with Covid-19,” said Rao. “The Tamil Nadu government lifted this clause last month and allowed hospitals to restart transplants if organs were available within their centers. Now the government has allowed inter-city transplants too, thus enabling us to fly the organs from other states.”

However, the process remains challenging due to the low number of domestic commercial flights operating in the country.

“We had to arrange a chartered flight with help from a charitable trust to bring the heart from Pune to Chennai,” Rao said, referring to the organ donation on Aug. 15.

In Western India, the State of Maharashtra recorded 160 organ donations in 2019. So far this year, the state has recorded 50. Maharashtra currently has over 5,500 patients waiting for kidney transplants, nearly 1,100 waiting for liver transplants, 74 waiting for heart transplants, and 16 in line for lung transplants. While patients with kidney failure are sustained on dialysis, those in need of other organs have little interventions other than transplants.

The living donor organ transplants, where a close relative is allowed to donate the organ, also took a back seat during the pandemic. In some cases, organ donors and recipients feared contracting the infection and delayed the procedure, while in other cases hospitals they had registered with had halted the program.

“It is logical to presume that patients on the waiting list who did not get transplants in time may have succumbed. But we currently don’t have any data on this,” said Dr. Vasanthi Ramesh, director of the National Organ and Tissue Transplant Organisation. “Hospitals are still busy with Covid-19 and the health systems are stretched. We will collate the data from centers in the coming days”.

Some transplant centers have calculated the mortality based on their own waiting list. Chennai’s MGM Healthcare has lost nearly 30 percent of its patients on the waiting list for heart transplants.

“Patients in need of heart transplants have to wait anywhere between one to three months to get the organ. However, this year, the waiting period had crossed six months for most patients,” said Rao.

Doctors say that ensuring a COVID-free pathway before and after the transplant is most challenging. This fear is probably keeping most hospitals away from restarting their transplant programs, even as it is not economically viable for them to sustain.

“In Mumbai, we have 39 recognized transplant centers but only one-third have agreed to restart the procedures,” said Dr. SK Mathur, president of the Zonal Transplant Coordination Centre, Mumbai. A similar trend in reduction in the number of transplant procedures has been recorded in the United States and France.

Gradually though, states have devised standard operating procedures to minimize the risk of infection. Tamil Nadu government, for instance, has insisted that not just the donor and the recipient, but also close family members of the recipient be tested for Covid-19. In Maharashtra, patients and healthcare workers must be screened and followed up for up to 28 days.

Doctors believe the number of transplants will increase in coming days after speedier test results for Covid-19 tests and increased public awareness of safety measures to control spread of the virus.

(Edited by Siddharthya Roy and Judy Isacoff.)



The post Stalled by Pandemic, Organ Transplants Slowly Resume in India appeared first on Zenger News.

Greater Tobacco Controls Urged as Cancer Cases Spike in India

Greater Tobacco Controls Urged as Cancer Cases Spike in India

With tobacco consumption contributing significantly to the rising number of cancer cases in India, doctors and others are urging the government to step up its tobacco control measures.

Cancer cases in the country are likely to jump from 1.39 million in 2020 to 1.57 million, or 12.9 percent, in 2025, according to a recent report released by the Indian Council of Medical Research.

The report was based on information collated from 28 population-based and 58 hospital-based cancer registries across the country. It states that nearly 370,000 cancer cases this year alone will be caused by tobacco consumption, including cancer of the lip, tongue, mouth, pharynx, esophagus, larynx, lungs and  bladder.

While India is reported to have a very high level of tobacco use in both smokeless and smoking forms, it also has measures in place to help curb use, according to the World Health Organization.

“The MPOWER measure that India is implementing at the highest level of achievement is conducting national mass-media campaigns to warn people about the dangers of tobacco use,” the WHO report states. MPOWER is the organization’s tobacco-free initiative.

 

Still the numbers continue to rise.

The study found that East Khasi Hills in the northeastern state of Meghalaya had the highest relative proportion of cancers associated with the use of tobacco — 70.4 percent in males and 46.5 percent in females.  Among men, lung cancer was most common in eastern India, while cancer of the mouth was highest in the central part of the country.

In women, mouth cancer was high in central states, while esophageal cancer was common in northern India.

“Nearly half of the cancers in men are tobacco-related,” said Dr. Pankaj Chaturvedi, head and neck cancer surgeon at Tata Memorial Centre hospital in Mumbai, India’s largest cancer center.

Chaturvedi, one of the most prominent anti-tobacco crusaders in the country, said, “The government has initiated many measures over the past several years, including pictorial warnings on cigarette packets, display of warnings in films and television serials, advertisements in cinemas, starting a quit-line for people who want to fight the habit, and most recently banning e-cigarettes. All of these measures tackle the demand side. But what is being ignored is the supply side of the massive tobacco industry.”

A 2019 study by Thought Arbitrage, an independent think tank,  and ASSOCHAM, an organization affiliated with chambers of commerce, said nearly 45.7 million people in India depend on the tobacco sector for their livelihood. This includes 6 million farmers; 20 million farm laborers; 4 million leaf-pluckers; 8.5 million working in processing, manufacturing and exports; and 7.2 million workings in retailing and trading.

“There is enough data that India is a leading tobacco exporter with exports of leaf tobacco and tobacco products contributing around INR 6,000 crore ($808 million) annually in terms of foreign exchange to the government,” the study said.  “Of the total net exports, the un-manufactured tobacco has a significant share amounting to INR 4,173 crore ($562 million). The rest includes tobacco products such as cigars, cheroots, cigarillos and cigarettes.”

The report also said India produces tobaccos of different grades and types for various users, providing a one-stop-shop for different styles, qualities and price ranges. Flue-Cured Virginia tobacco is the main exportable tobacco produced in India, with around 70 percent of that crop being exported.

“India has a 5 percent value share of the $12 billion global tobacco leaf export trade.  The diversity of Indian tobacco has enabled the country to export tobacco to over 100 countries across the globe,” the study said.

“To deal with this supply of tobacco, the Indian government has to show commitment by stopping tobacco cultivation and offering alternative crops and income sources to the farmers and other workers deeply rooted in the industry,” said Chaturvedi. “The government should also withdraw its share from the country’s leading cigarette company. Controlling tobacco is the responsibility of multiple ministries such as Home, Health, Education, Labor, Finance, Women and Child, Agriculture, Environment, Commerce and Industry, etc., and it has been a challenge to get them all on the same table. It is crucial for these ministries to work together.”

The Global Adult Tobacco Survey shows that consumption of tobacco in India dropped from 34 percent to 28 percent between 2010 and 2016. However, experts said the growth in population during that period has not been accounted for.

“The recent projections made by the Indian Council of Medical Research are alarming,” said Dr. A C Kataki, director of the Dr. B Borooah Cancer Institute in Guwahati, in the northeastern state of Assam. “The government has to give a strong push to tobacco control if it intends to reduce the cancer burden in the country. It is also the responsibility of the society and citizens to demand such laws and ensure that they are stringently implemented.”

Experts said that the smokeless form of tobacco is more common in rural India.

“The raw, chewable form of tobacco is easily available and culturally accepted in rural India,” said Rajashree Kadam, vice-president of the nonprofit Salaam Bombay Foundation that works in this sector. “There is little awareness of its harmful effects.

“Tobacco companies typically target youth with surrogate advertisements. Their lobby is very strong in the country and it is time the government stands up against it.”

(Edited by Siddharthya Roy and Judy Isacoff.)



The post Greater Tobacco Controls Urged as Cancer Cases Spike in India appeared first on Zenger News.

India Gauges Herd Immunity

India Gauges Herd Immunity

More than half of the slum population in Mumbai, India’s financial capital, is infected with coronavirus. These findings, culled from a serological prevalence study undertaken in three wards of the city in July, signal the possible presence of herd immunity.

To drill down into results, researchers have undertaken a second round of serosurvey in the same wards. They hope to better gauge the prevalence of the virus and analyze how long immunity lasts.

Initial findings provide some hope for the future.

“Prevalence in India is dependent on population density, with non-slums being low and slums being high. It will be important to know which shows the maximum change in the repeat study and what are the reasons,” said Professor Ullas S. Kolthur of the Tata Institute of Fundamental Research.

The first round of serosurvey in Mumbai covered nearly 7,000 people. The findings revealed that 57% of the slum population and 16% of the non-slum population were infected with the virus. In the repeat survey, Kolthur will study 6,000 more people.

Seroprevalence surveys identify people in the community who have developed antibodies against the disease. Blood samples of the participants are collected and tested for the presence of the Immunoglobulin G antibody.

“We don’t know how long the immunity lasts,” said Kolthur. “Based on the second survey results, we will select a cohort and study this aspect.”

In the city of Pune, a Covid-19 hotspot 150 miles east of Mumbai, the recently released serosurvey data showed 51% of people have antibodies. In Delhi, the country’s capital, the second round of serosurvey concluded recently and results are expected soon.

The first round, carried out in July, showed 23% of people had antibodies. It is estimated that India would need 60% to 70% of the population to have antibodies to achieve herd immunity. But this may vary, given the vast differences in the country’s urban and rural populations and their living conditions.

“Herd immunity cannot be a fixed number for the whole country,” said Dr. Jayaprakash Muliyil, a leading epidemiologist in India. “Each section of the country will have herd immunity coming in its own time. In certain slum clusters, it has already set in.” He cited Dharavi, one of the world’s densest slums, that managed to bend the curve and even garner praise from the World Health Organization.

The slum is home to 900,000 people crammed into a mere 2.5 sq km area. One toilet seat is used by 200 people daily in Dharavi, which recorded nearly 2,300 cases and more than 200 deaths at the height of infections but has seen numbers drop, reporting daily positive cases in a single digit.

“Clusters like Dharavi, which were containment areas once, have stopped recording cases — that means the prediction there will be herd immunity is correct,” said Muliyil. “By the time 45% to 50% of people have antibodies, new cases stop emerging. The virus can’t find a susceptible person easily in a crowd of immune people.”

“Dharavi also saw aggressive testing and efforts to isolate the infected patients, which helped to a very large extent,” said Kiran Dighavkar, assistant municipal commissioner of the G-North ward in Mumbai, which covers the slum pocket. “Concentrated actions were initiated to break the chain of infection.”

As India crosses 2.7 million cases and more than 50,000 deaths, what does it mean to have such a large population carry antibodies?

“It tells you that many people are now resistant to Covid,” said Muliyil. “By all our knowledge of science so far, a viral infection like this should give lasting immunity. Once you get the infection, you will not get the disease again.”

However, there is a concern that people who have recovered can become transient carriers of the infection.

“We don’t know that,” said Muliyil. “What we know is they can’t get the disease again. We say this based on the knowledge that they have demonstrated an excellent cell-mediated response. In people who were infected during the previous outbreak of SARS, it was found their bodies could remember the virus and mounted immunity even after 18 years.”

The serological studies have economic implications. Experts say that limited economic activity, with proper precautionary health measures, given crowding conditions, could be permitted.

“Section by section,” Muliyil said, “India will go low in the number of cases.”

(Edited by Siddharthya Roy and Fern Siegel.)



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