Wuhan Coronavirus Resource Thread

[syam]

They tried... and nearly succeeded

yeah. I read about that report some time back. very suspicious of kejriwal to give the permission.

[DrRatnadip]

Paper yet to be published in NEJM about a clinical trial shows HCQ when given after severe Covid19 has set in worsens outcome.

Hydroxychloroquine administration to the hospitalized SARS-CoV-2 positive population was
associated with an increased need for escalation of respiratory support. There were no benefits of
hydroxychloroquine on mortality, lymphopenia, or neutrophil-to-lymphocyte ratio improvement.

Hcq has NO benefits in late course of disease.. It will help in decreasing number of patients getting serious if given in early course of disease..

[Sanju]

They tried... and nearly succeeded

yeah. I read about that report some time back. very suspicious of kejriwal to give the permission.

Post on 01-Apr

This is my summary of the source as we cannot copy the whole article due to copyright issues:

Mar 13: Delhi Govt gives the order that there should not be any religious/politcal/social gathering, despite which 3400 people approx., gather at Nizamuddin Markaz.

Mar 16: Cm Kejriwal further reduces the number to 50...Markaz continues regardless.

Mar 20: Indonesians (10) test positive in far away Telangana where they went after the event in Delhi. <snip>

I think it was planned in such a way by Kejri is able to vouch for his plausible deniability. TJ members were already at the Markaz by then, so his order was pretty much useless. The way TJ guys spread it and hid it, this points to something sinister rather than incompetence. In addition, the way Migrant workers were forced out of Delhi, this was truly a plan on a big scale to cause major mischief to GOI & in turn the people of India.

What has happened instead is that the GOI ably lead is getting plaudits and I am pretty sure major quid-pro-quo from many nations.

[DrRatnadip]

22 ys old female COVID patient died in MH..

https://lokmat.news18.com/maharashtra/c ... QlwHs4CoEw

[Gyan]

Paper yet to be published in NEJM about a clinical trial shows HCQ when given after severe Covid19 has set in worsens outcome.

Hcq has NO benefits in late course of disease.. It will help in decreasing number of patients getting serious if given in early course of disease..

It seems due to political maneuvering, Liberal politicians in USA & Europe are preventing use of HCQ early and are then claiming that it has failed. For instance, they are ignoring the study of Rauolt Didier wherein treating 1000-2000 patients with HCQ, the mortality rate was only 0.5% but emphasize another french study where HCQ failed in treatment of 11 patients all having serious multiple co-morbidities and were senior citizens.

Also Re Ratnadip Dr., Thx for taking trouble to write detailed & informative post/s on the issue of Zinc Supplements. Have we (in India) similarly examined the effect of high dosage of Vitamin C?

Incidentally, in India, Doctors are not thinking twice about prescribing HCQ while there is lot of hesitation in western world. Is it because of their lack of experience in Malaria drugs? They are (abroad) also recommending adding Potassium supplements to prevent QT prolongation and avoiding treating patients taking heart medicines with HCQ. What are your thoughts on the same?

[Gyan]

https://twitter.com/sidhant/status/1248572439883173888

Germany is the only real surprise. I did not hear them put in a request though it should have been expected. Italy, France & UK still not on the list is also a surprise. The others are mostly dependent on India for all their meds so was expected.

Expect a 2nd and a 3rd list soon.

It seems we have some special deal with Germany. Ventilators or testing kits deal etc

Some other names are also not there like Israel. Some Middle East Nations and what about Russia?

[DrRatnadip]

Hcq has NO benefits in late course of disease.. It will help in decreasing number of patients getting serious if given in early course of disease..

It seems due to political maneuvering, Liberal politicians in USA & Europe are preventing use of HCQ early and are then claiming that it has failed. For instance, they are ignoring the study of Rauolt Didier wherein treating 1000-2000 patients with HCQ, the mortality rate was only 0.5% but emphasize another french study where HCQ failed in treatment of 11 patients all having serious multiple co-morbidities and were senior citizens.

Also Re Ratnadip Dr., Thx for taking trouble to write detailed & informative post/s on the issue of Zinc Supplements. Have we (in India) similarly examined the effect of high dosage of Vitamin C?

Incidentally, in India, Doctors are not thinking twice about prescribing HCQ while there is lot of hesitation in western world. Is it because of their lack of experience in Malaria drugs? They are (abroad) also recommending adding Potassium supplements to prevent QT prolongation and avoiding treating patients taking heart medicines with HCQ. What are your thoughts on the same?

I dont understand why there is so much hesitation in giving chloroquine.. I dont think it is commonly used in US..It is quite safe drug.. I remember paramedical staff dispensing it for every fever / chills patient without even confirmed diagnosis of malaria.. HCQ is also commonly used in India for other viral fevers like dengue and chickengunya..

[Gyan]

For the record, the total HCQ approval based on the first list

https://twitter.com/ANI/status/1248654354984259585

ANI @ANI

India has cleared first list of 13 countries for Hydroxychloroquine: USA, Spain, Germany, Bahrain, Brazil, Nepal, Bhutan, Afghanistan, Maldives, Bangladesh, Seychelles, Mauritius & Dominican Republic - total 14 million tablets, API 13.5 MT ton: Sources

13.5 MT API = 13.5 x 5 Million = 67.5 Million tablets of 200 mg each

Therefore, India has effectively approved exports of = 81.5 million tablets of 200 mg each (Standard dosage it seems).

Added later:

1. US got most of its supplies as API (9 MT = 45 million tablets of 200 mg each)
2. Looks like API production ramp up is on track for GOI to sanction such a quantity in the first list.

I think API is slightly more generic term and may not refer only to pure HCQ. Some News Reports were equating 1 MT = 1 Million tablets rather than 5 Million. But then it may be DDM.

[saip]

If each tablet has 200 mg of active ingredient then there will 5 million tablets in 1 Metric tonne of API. Is it not? Besides the active ingredient there will be fillers too.

[M_Joshi]

[sanjaykumar]

What is most interesting is that the Chinese have still not published their hydroxychloroquine trial results.

I suspect it is because there may be evidence that it is beneficial perhaps if given early. I can believe they will sit on the data and let people die.

Anyway, there are several trials underway elsewhere.

[JayS]

The lack of deliveries for AntiBody kits is worrisome. We are wasting precious lock-down time. The delivery for the 0.5M test kits (presumably import order) is taking forever. The request for quotation went on 23rd March or so IIRC. Earlier ICMR said, they should come by Wednesday, 8 April. Today, ICMR said 2-3 more days. Then add 2-3 more days for deploment of those kits. Meanwhile we have 4-5 Desi kits approved, only one of which, HLL, is known to be producing at an abysmal rate of 2L kits in 10days. I see no news about other companies. One of them, Pune based company, claimed, as per one article, they can make 1Cr kits per month. But Still no delivery from any of the companies, despite two of they having validated the kits in March last week. I hope they are not stuck in approval process red tapism at CDSCO.

We are sending HCQ to everyone, but we are not getting AB kits. The way things are happening in Mumbai in many areas, if we do not start mass scale testing ASAP, the infection may spread too much before we can detect them with our targeted testing protocol. With 3 desi RT-PCR and 4-5 desi AN fast kits, we have little to worry about kit availability, we should have been doing much more testing in the hotspots by now than what we are doing now. SARI surveillance indicates "localized" community transmission. We have no idea about the scale of infection and scale of asymptomatic patients. The nature of disease is such that out current protocol will only see current situation 2-3 weeks down the line.

[pankajs]

Post by a senior beaurocrat with GOI. Must be some truth in this in which case it a good news.

https://twitter.com/drajaykumar_ias/sta ... 5072619521

Ajay Kumar @drajaykumar_ias

A silver lining of #COVID2019india is the eruption in related innovation across our vibrant startup ecosystem.
One such case is devpt of Rs 50K ventilator by #NoccaRobotics Catching eye of the world & of @MoHFW_INDIA @ICMRDELHI

https://bbc.com/news/world-asia-india-52106565

However, there are 2 worrying sign with this news.
1. Why is such news picked up by BBC before our channels/papers?
2. Out babus still consider BBC as gold standard. Unless the attitude changes at the top it is a slog for India to defeat the BBC.

[sudeepj]

Usually, the more deadly a virus or bacteria is, the more the pressures of natural selection and evolution against it! Most viruses are much more potent when they first emerge, pressures of natural selection ensure that they become less of a threat with time. Its not in the viruses self interest (if a virus can have a self interest!) to kill the host! This can be seen in all viruses throughout history. Even HIV used to be much more deadly early on but now the virus is not as deadly.

Please digest the posts that raise new information before comment. HIV is now a chronic infection not because of attenuation of the virus but because patients are on life long antiretroviral drugs.

Why dont you take your own advise?
Perhaps someone may have read something else beyond 'the posts' here?

There were many HIV strains.. and the current prevalent strains are less deadly than the earliest 1980s strains. Here is just one paper that describes the fall in HIV 'virulence'.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5115872/
A transmission-virulence evolutionary trade-off explains attenuation of HIV-1 in Uganda
"Evolutionary theory hypothesizes that intermediate virulence maximizes pathogen fitness as a result of a trade-off between virulence and transmission, but empirical evidence remains scarce. We bridge this gap using data from a large and long-standing HIV-1 prospective cohort, in Uganda. We use an epidemiological-evolutionary model parameterised with this data to derive evolutionary predictions based on analysis and detailed individual-based simulations. We robustly predict stabilising selection towards a low level of virulence, and rapid attenuation of the virus. Accordingly, set-point viral load, the most common measure of virulence, has declined in the last 20 years. Our model also predicts that subtype A is slowly outcompeting subtype D, with both subtypes becoming less virulent, as observed in the data. Reduction of set-point viral loads should have resulted in a 20% reduction in incidence, and a three years extension of untreated asymptomatic infection, increasing opportunities for timely treatment of infected individuals."

[Raja]

Most of the countries that are doing well have all done large scale testing (sooner, rather than later). I feel like our testing rates and testing protocol needs to be far more aggressive. Think of on a war footing. Ignore the naysayers who think that India is too large and too poor to test on a large scale. Any company that is able to produce kits should be given unlimited resources to scale up their production. Every single rupee we spend on this will have a massive return in health of people and the economy.

I hope all of your loved ones are safe and sound and stay that way.

[vijayk]

My SIL works in Central Govt. Hospital in Charminar. 2-3 weeks ago, she was complaining that they did not have masks. We spoke to her yday. Amazingly in 2 weeks , everything has been ramped up. They got complete kits. More are coming. Even nurses and workers got suits. They trained patients to wear masks. Cases are going up.

[Cyrano]

Curious that Israel doesn't figure in the HCQ export list. Their PM tweeted thanking Modi & India couple of days ago.

Sanofi produces HCQ under the brand name Plaquenil in one of its 18 factories in France, using API hydroxychloroquine sulfate imported from India (Ipca, Cadila Laurus Labs), China (Chongqing), US (AMRI), Taiwan (SCI Pharmtech) and three other European co.s.

[saip]

Israel is also a leading producer of generic drugs. Being a small country they may not need that many and they may be producing it themselves.
Israel appears to be donating to USA.

Teva

[yensoy]

One question for the medical and other gurus here:

Typically when the incidence of an issue is small, tests can be done on pooled samples collected from a batch of say 10 individuals, and the batch analyzed for incidence. If the test is positive, then each member is tested again till the victim(s) are identified. If the test is negative, then all 10 are cleared in one go. I did the math and for an incidence rate of around 5% we can have pretty large batches.

Same technique is used in airport bomb material detection in some places where a batch is checked together with the sample gathering material rubbed against each of their luggage pieces and then analyzed once in the machine.

Further, in these days of lockdown, it's likely that if one person in a family is a candidate for testing, then there is a higher likelihood that others are infected too. So these batches can be naturally formed for each family or group of neighbouring families to clear them quickly. The negative test can be repeated with a different test methodology to make it even more foolproof.

This can help save huge amounts of testing resources because if a batch of say 10 people clears (an event with 60% probability in the random case) then we just saved 8 test kits (accounting for one test kit wasted if we lose the bet).

Some downsides I can think of are (i) inaccuracy due to dilution of samples, (ii) difficulty in mixing the samples (blood can be mixed but mucus swabs?), (iii) delays. Still, it may be worthwhile to pursue this line of thinking. Your opinions Gurus?

My SIL works in Central Govt. Hospital in Charminar. 2-3 weeks ago, she was complaining that they did not have masks. We spoke to her yday. Amazingly in 2 weeks , everything has been ramped up...Cases are going up.

God bless her and her colleagues! If it took the lockdown to get the safety equipment in place, then the lockdown was worth it. Otherwise we are just giving death sentences to the best of our people, the medical fraternity.

[pankajs]

https://twitter.com/kiranshaw/status/12 ... 4245776384

Kiran Mazumdar Shaw @kiranshaw

A team from @iitbombay is working to develop a nasal gel using a new technology that can capture and inactivate the #coronavirus inside human beings. The team hopes that the nasal gel will be ready for use in about 9 months.

https://twitter.com/rahulkanwal/status/ ... 9618707457

Rahul Kanwal @rahulkanwal

This is of concern. Herd wisdom so far was that if a person gets #CoronaVirus once he develops immunity for life. But South Korean officials on Friday reported 91 patients thought cleared of the new coronavirus had tested positive again. https://in.reuters.com/article/us-healt ... NKCN21S15X
Virus reactivated

This is concerning ..

[vijayk]

James Todaro, MD

@JamesTodaroMD
·
5h


Washington (Kirkland) nursing home: No hydroxychloroquine, 35 deaths out of 120 residents

Texas nursing home: Treatment WITH hydroxychloroquine, 1 death out of 135 residents

#COVIDー19 #coronavirus

https://www.npr.org/2020/04/10/83034883 ... -criticism

COVID-19 Patients Given Unproven Drug In Texas Nursing Home In 'Disconcerting' Move

[sudeepj]

Most of the countries that are doing well have all done large scale testing (sooner, rather than later). I feel like our testing rates and testing protocol needs to be far more aggressive. Think of on a war footing. Ignore the naysayers who think that India is too large and too poor to test on a large scale. Any company that is able to produce kits should be given unlimited resources to scale up their production. Every single rupee we spend on this will have a massive return in health of people and the economy.

I hope all of your loved ones are safe and sound and stay that way.

I am in a US metropolitan area that has about the same number of cov infections as all of India. Even we do not have very aggressive testing right now. If you look at the percentage of people who are turning up positive in the tests in India, its still a very low single digit number. Around 2 - 3%. This number will likely drop as the number of tests are doubled/tripled etc.

Right now, the Indian approach seems to be focusing on contact tracing. If you came in contact with a person who is cov+ or if you are coming from a region that is known to have a cov outbreak, you are treated as if you were positive and are quarantined. Basically, this renders the question of testing moot. What different would you have done had this quarantined person tested negative? or positive? The Indian approach is actually more stringent than would be dictated by the 'more testing' protocol. And so far.. it appears to be working somewhat.

[sanjaykumar]

Please digest the posts that raise new information before comment. HIV is now a chronic infection not because of attenuation of the virus but because patients are on life long antiretroviral drugs.

Why dont you take your own advise?
Perhaps someone may have read something else beyond 'the posts' here?

There were many HIV strains.. and the current prevalent strains are less deadly than the earliest 1980s strains. Here is just one paper that describes the fall in HIV 'virulence'.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5115872/
A transmission-virulence evolutionary trade-off explains attenuation of HIV-1 in Uganda
"Evolutionary theory hypothesizes that intermediate virulence maximizes pathogen fitness as a result of a trade-off between virulence and transmission, but empirical evidence remains scarce. We bridge this gap using data from a large and long-standing HIV-1 prospective cohort, in Uganda. We use an epidemiological-evolutionary model parameterised with this data to derive evolutionary predictions based on analysis and detailed individual-based simulations. We robustly predict stabilising selection towards a low level of virulence, and rapid attenuation of the virus. Accordingly, set-point viral load, the most common measure of virulence, has declined in the last 20 years. Our model also predicts that subtype A is slowly outcompeting subtype D, with both subtypes becoming less virulent, as observed in the data. Reduction of set-point viral loads should have resulted in a 20% reduction in incidence, and a three years extension of untreated asymptomatic infection, increasing opportunities for timely treatment of infected individuals."

Do you see the epistemological problem with this paper?

[Rahul M]

The only addition I would do is 100% testing for all SARI patients.

[shaun]

https://twitter.com/kiranshaw/status/12 ... 4245776384

Rahul Kanwal @rahulkanwal

This is of concern. Herd wisdom so far was that if a person gets #CoronaVirus once he develops immunity for life. But South Korean officials on Friday reported 91 patients thought cleared of the new coronavirus had tested positive again. https://in.reuters.com/article/us-healt ... NKCN21S15X
Virus reactivated

This is concerning ..

Well lightning fast testing for large number of populations have its pitfalls ,what was their testing protocol , is it similar to us when using rapid anti body tests ?? percentage of their population went through rapid antibody type blood test
for example ours below

https://icmr.nic.in/sites/default/files ... 042020.pdf

[DrRatnadip]

https://twitter.com/kiranshaw/status/12 ... 4245776384

Kiran Mazumdar Shaw @kiranshaw

A team from @iitbombay is working to develop a nasal gel using a new technology that can capture and inactivate the #coronavirus inside human beings. The team hopes that the nasal gel will be ready for use in about 9 months.

https://twitter.com/rahulkanwal/status/ ... 9618707457

Rahul Kanwal @rahulkanwal

This is of concern. Herd wisdom so far was that if a person gets #CoronaVirus once he develops immunity for life. But South Korean officials on Friday reported 91 patients thought cleared of the new coronavirus had tested positive again. https://in.reuters.com/article/us-healt ... NKCN21S15X
Virus reactivated

This is concerning ..

- A person can develop "natural immunity" against a disease only when its pathogen has "protective antigen".

-Protective antigen is one that can ( but not necessarily will ) stimulate an immune response either cellular (T cell mediated) or humoral ( antibody mediated ) and prevent important clinical consequences of infection.

- pathogens who dont have protective antigens do not lead to natural immunity after primary infection ex. HIV , Hep C virus..

- Covid infected patients can get re infected.. If they are exposed to sufficient viral load.. But they are less likely to land in severe disease as their bodies are capable of mounting rapid antibody response..

[Primus]

It seems due to political maneuvering, Liberal politicians in USA & Europe are preventing use of HCQ early and are then claiming that it has failed. For instance, they are ignoring the study of Rauolt Didier wherein treating 1000-2000 patients with HCQ, the mortality rate was only 0.5% but emphasize another french study where HCQ failed in treatment of 11 patients all having serious multiple co-morbidities and were senior citizens.

Also Re Ratnadip Dr., Thx for taking trouble to write detailed & informative post/s on the issue of Zinc Supplements. Have we (in India) similarly examined the effect of high dosage of Vitamin C?

Incidentally, in India, Doctors are not thinking twice about prescribing HCQ while there is lot of hesitation in western world. Is it because of their lack of experience in Malaria drugs? They are (abroad) also recommending adding Potassium supplements to prevent QT prolongation and avoiding treating patients taking heart medicines with HCQ. What are your thoughts on the same?

I dont understand why there is so much hesitation in giving chloroquine.. I dont think it is commonly used in US..It is quite safe drug.. I remember paramedical staff dispensing it for every fever / chills patient without even confirmed diagnosis of malaria.. HCQ is also commonly used in India for other viral fevers like dengue and chickengunya..

My class group has been having a zoom hangout meeting once a week for several weeks now. We are distributed all over the world, from the US to NZ and Tasmania. This morning one of my friends who is a cardiologist and in the front lines in a major US metro hospital said he has been taking HCQ for several weeks now, in the same prophylactic dose and manner that he used to take when visiting India as prophylaxis against malaria. He advised double dose to 'load up' on day one then one dose once a week. That alone is significantly effective in prevention.

He says N95 in their hospital are only for ICU workers, everyone else is simply using regular surgical masks which are quite effective. Meanwhile, our local hospital has a simple mask sanitizing machine using UV radiation that clears a used mask of any virus in 8 seconds, limitation being a mask can only be sanitized three times before you have to throw it away, but still, allows for repeated use.

On a more sobering note, a friend reported another physician in India dying of probably TdP from combination of HCQ and Azithro, so main point to be noted is that if you put yourself on this combination, the QTc must be checked prior to initiation, but this does not seem to be a problem with HCQ alone. BTW, chloroquine alone is just as effective as HCQ as per my classmate.

[sanjaykumar]

Please check QTc after intitiation of hydroxychloroquine as well. Just picked up prolonged QTc in a lupus patient after starting the drug. Reverted to normal after discontinuance.

[nam]

Anyone knows why it takes 5-7 days for the body to react (become symptomatic with fever) to the virus?

[Primus]

Please check QTc after intitiation of hydroxychloroquine as well. Just picked up prolonged QTc in a lupus patient after starting the drug. Reverted to normal after discontinuance.

You are probably correct, however, millions of people take it (or chloroquine) without getting an EKG. Still, does not hurt to check the QTc. Anecdotal experience is probably not a good indicator - either way. The other issue of course is the large list of 'common' medications that can prolong the QTc and often the patient may not volunteer what else they are taking. I find that a frequent problem even in the US where everything is checked three times

[Primus]

Another thing I am told is that although terribly expensive, anti-IL6 and anti-IL 1 agents have shown very promising results in an ICU setting, patient's improving overnight. The anti-GM-CSF agent Gimsilumab is also very good I believe, and may be what was given to BoJo. These things are still investigational but are being used in high risk cases (and perhaps high-profile patients) with very encouraging results.

[IndraD]

Bojo was treated keeping ICS recommendations and established treatment on SARS 2 aside. His intubation was delayed for as long as possible (kindly look at ICS recommendations > it asks for short burst of CPAP if at all followed by early intubation, after which patients fall apart!!) and he was given IL6 blocker & plasma from a patient recovered from Covid19.

[IndraD]

NHS likely to run out of ITU drugs pretty soon https://www.independent.co.uk/news/worl ... 58511.html

[mappunni]

James Todaro, MD

@JamesTodaroMD
·
5h


Washington (Kirkland) nursing home: No hydroxychloroquine, 35 deaths out of 120 residents

Texas nursing home: Treatment WITH hydroxychloroquine, 1 death out of 135 residents

#COVIDー19 #coronavirus

https://www.npr.org/2020/04/10/83034883 ... -criticism

COVID-19 Patients Given Unproven Drug In Texas Nursing Home In 'Disconcerting' Move

This is why I stopped contributing to Jihadi loving NPR and encourage others to STOP giving money to NPR!

[IndraD]

PPE shortage in NHS is really grim! Quality of ppe terrible https://www.theguardian.com/world/2020/ ... 9-patients

One hospital doctor told the BMA: “The quality of our eye protection and apron is useless. Some of the PPE provided feels like a tick-box exercise just for psychological reassurance.

[srai]

mappunni
^^^
Stop politicizing the issue. I don’t see how the twitter, NPR report melds with Jihadi support. That’s a big leap my friend.

[Suresh S]

One of the surprising early finding from the intensive care deaths is that the commonest underlying condition in the patients who are dying is hypertension in almost upto 50% of cases. One would have thought on common sense grounds that you are going to find smoking as the commonest condition, it is present in about 30% of cases. That is why they say common sense and science do not always go together. Early days, will wait for more data as time goes by.Other common underlying condition are diabetes, cancer and patients on hemodialysis and chronic obstructive pulmonary disease

[Karan M]

mappunni
^^^
Stop politicizing the issue. I don’t see how the twitter, NPR report melds with Jihadi support. That’s a big leap my friend.

In India, their correspondent frayer is definitely anti-H. She got that bigot Furkan as well, and is currently RTing articles claiming Indians are Islamophobic.

[Mort Walker]

mappunni
^^^
Stop politicizing the issue. I don’t see how the twitter, NPR report melds with Jihadi support. That’s a big leap my friend.

Have you even bothered to read what NPR has been saying about India? They are no different than NYT or WaPo. NPR is deceit with dignity. Chablis sipping liberals. Mike Pompeo was right to blast their reporter. See what NPR is reporting and what their reporters in India are re-tweeting? The GoI is too nice and needs to tell NPR that their reporters are engaged in hate speech within India and their visa is going to be cancelled. Send other reporters. NPR doesn't deserve a single penny of US taxpayer money. Let the left support them.

[Deans]

Post by a senior beaurocrat with GOI. Must be some truth in this in which case it a good news.
However, there are 2 worrying sign with this news.
1. Why is such news picked up by BBC before our channels/papers?
2. Out babus still consider BBC as gold standard. Unless the attitude changes at the top it is a slog for India to defeat the BBC.

There is a significant difference between designing a ventilator (which is something any good Univ can do), manufacturing it, and then scaling it up to meet volume and quality standards. There are, AFAIK, 2 groups which are actually going to make a significant number of ventilators at a low cost - the DRDO/BEL/Mahindra group and AgVa health + Maruti.