The following are key points to remember from this article about the coronavirus disease 2019 (COVID-19) pandemic in India:

1. India has a population of 1.35 billion and the largest concentration of COVID-19 cases has been in the metropolitan cities of New Delhi, Mumbai, Ahmedabad, and Chennai. According to Johns Hopkins Coronavirus Resource Center, on June 21, 2020, there were 410,451 cases to date in India with 13,254 deaths.
2. Government Response: The government response has included prolonged 8-week lockdown, public awareness campaign, and a series of innovations including a novel smartphone application called Aarogya Setu for contact tracing and aiding in quarantine and related containment measures.
3. Testing: As of May 10, 1.6 million tests have been conducted, with 64,558 positive individuals, yielding 4% positivity in the country. The debate continues on whether to expand the testing. The testing strategy has been revised many times, and tests have increased many fold. With indigenous enzyme-linked immunosorbent assay (ELISA) tests added as of May 10, the government is on the path towards defining what proportion of positivity for COVID-19 in severe community-acquired respiratory infections.
4. Community Transmission: The Ministry of Health has reiterated that India has not entered stage 3, and the World Health Organization has supported this assertion. Several other experts in the country argue that there is widespread community transmission. This discordance may be due to lack of a clear definition of what constitutes community transmission for countries such as India. While the assertion ‘absence of evidence is not evidence of absence’ holds good here too, there has also been no evident surge in manifest cases overwhelming the health system warranting any such suspicion.
5. Clinical Management: There are some differences in clinical management:
   • For example, the Indian Council of Medical Research task force recommended chemoprophylaxis with hydroxychloroquine, 400 mg twice a day, and 400 mg once a week thereafter. This is prescribed for asymptomatic health care workers who are treating patients with suspected or confirmed COVID-19, and also for asymptomatic household contacts of confirmed cases.
   • Empirical therapy includes neuraminidase inhibitors such as oseltamivir.
   • There are set protocols in terms of admission and discharges. Several hospitals have been designated as COVID hospitals, and also many hospitals triage these patients at registration to fever clinics or specialized areas within the hospitals. All confirmed patients with symptoms are admitted and managed based on their severity.
6. How are patients in India with cardiovascular disease (CVD) or risk factors coping?
   • There are currently 79 million individuals with diabetes and 200 million individuals with hypertension.
   • Anecdotal evidence suggests there has been a substantial reduction in patients with acute coronary syndrome (ACS) attending emergency departments. Whether this is real or artificial is unknown currently.
   • Previous registries indicate that patients largely use public or private transport to reach hospitals when they develop symptoms of ACS. Given the lack of public transportation and severe restriction of vehicles on the roads, it may be particularly difficult to reach hospitals from rural and far-flung areas.
   • Women and the elderly traditionally avoid hospitals—the impact of COVID-19 on CVD in this population needs to be assessed.
   • Given the economic difficulties as well as the additional efforts in obtaining drugs, the authors of this report speculate poor compliance with antidiabetic, antihypertensive, and lipid-lowering drugs.
7. Vaccine Development: The government aims to develop a vaccine through a public–private partnership, the National Institute of Virology. The Translational Health Science and Technology Institute, an autonomous institution of the Government of India, has announced that six companies are working towards developing a vaccine.
8. Pandemic Preparedness: India has proved its capability in terms of polio eradication and is emerging as a leader in helping other countries in managing a COVID-19 response. However, the greatest emphasis now is on gearing up the surveillance systems in India to prevent, address, and mitigate the effects related to any pandemic diseases in the future. While the pandemic has widened the gap between the rich and poor in India, health inequities can worsen in the immediate term.
9. India Case Study:
   • So far, the proactive measures taken by the Government of India have helped in delaying the surge in cases effectively. India had the advantage that it could prepare well based on the errors of other countries and acted in a timely manner in the early phase of the outbreak. It appears that India has flattened the curve, but the looming questions are: Will there be a surge with the lifting of lockdown? And, how do they prevent a second wave?
   • The COVID-19 pandemic reflects the classic Hamletian dilemma for the policymakers when lives and livelihood are competing with each other.
   • The real impact of the pandemic in India on all segments of the society will only be known when the lockdown is lifted, and a new ‘normalcy’ is established.

Clinical Topics: Acute Coronary Syndromes, COVID-19 Hub, Prevention, Novel Agents, Statins, Hypertension

Keywords: Acute Coronary Syndrome, Contact Tracing, Coronavirus, COVID-19, Diabetes Mellitus, Hydroxychloroquine, Hypertension, Neuraminidase, Oseltamivir, Patient Compliance, Primary Prevention, Public-Private Sector Partnerships, Quarantine, Risk Factors, Socioeconomic Factors

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