Safe Practice of Flexible Bronchoscopy for Non-COVID-19 Indications during the SARS-CoV-2 Pandemic.

Background: Flexible bronchoscopy is an aerosol-generating procedure (AGP), which increases the risk of transmission of SARS-CoV-2 infection. We aimed to find COVID-19 symptoms among healthcare workers (HCWs) involved in flexible bronchoscopies for non-COVID-19 indications during the SARS-CoV-2 pandemic. Materials and Methods: The participants of this hospital-based single-center descriptive study were HCWs of our hospital involved in flexible bronchoscopies of patients with non-COVID-19 indications. These patients had no clinical features of COVID-19 and were tested negative for SARS-CoV-2 by the real-time polymerase chain reaction of nasopharyngeal and throat swabs before the procedure. The study outcome was the occurrence of COVID-19 in study participants after exposure to bronchoscopies. Results: Thirteen HCWs performed 81 bronchoscopies on 62 patients. Indications for bronchoscopies included malignancy (61.30%), suspected infections (19.35%), non-resolving pneumonia (6.45%), mucus plug removal (6.45%), central airway obstruction (4.84%), and hemoptysis (1.61%). The mean age of patients was 50.44 ± 15.00 years, and the majority was males (72.58%). Bronchoscopic procedures included 51 bronchoalveolar lavages, 32 endobronchial ultrasound- transbronchial needle aspiration (EBUS-TBNA), 26 endobronchial biopsies, 10 transbronchial lung biopsy (TBLB), 3 mucus plug removals, 2 conventional TBNA, and 2 radial EBUS-TBLB. Except for two HCWs who complained of transient throat irritation of non-infectious cause, none of the cases developed any clinical features suggestive of COVID-19. Conclusion: A dedicated bronchoscopy protocol helps in minimizing the risk of transmission of SARS-CoV-2 infection among HCWs involved in flexible bronchoscopies for non-COVID-19 indications during the SARS-CoV-2 pandemic.

Perinatal Transmission and Outcomes of SARS-CoV-2 Infection.

Maternal SARS-CoV-2 infection can adversely affect the birth and neonatal outcomes. The authors prospectively enrolled 196 neonates born to 193 SARS-CoV-2-positive mothers to determine the rate of mother-to-baby transmission of SARS-CoV-2 and its effect on short-term neonatal outcomes in Indian population. Nineteen babies turned out to be RT-PCR-positive for SARS-CoV-2, carrying a perinatal transmission rate of 9.8%. Rates of prematurity and low birth weight were 12.8% and 18.9% in the neonatal group, respectively. On comparing SARS-CoV-2-positive (n = 19) and negative (n = 177) neonatal groups, rate of prematurity, hospital admission rate, and death rate were higher in the former group. The placental positivity rate for SARS-CoV-2 was 8.1%, but no relation was found between placental and neonatal infection.

Large Vessel Occlusions By Free Floating Thrombi in Strokes During the COVID-19 pandemic- A Single Center Observational Study.

Background: An increased incidence of systemic macrothrombotic phenomena such as strokes has been observed in moderate and severe COVID. However, strokes have also been increasingly observed in mild COVID, post COVID, or without obvious COVID illness. Objective: To share our experience with a specific stroke type noted during the COVID pandemic period. Materials and Methods: A single-center observational study was conducted in Western India from January to December 2020, and data regarding stroke patients admitted under Neurology services were noted. Clinical, laboratory, and radiological characteristics of strokes and subtypes were documented. Results: A total of 238 stroke patients were admitted in 2020, 76.5% during the COVID pandemic period. Among 153 ischemic strokes, 16.3% and 56.2% had large vessel occlusion (LVO) in pre-COVID and COVID pandemic period, respectively. Of all ischemic strokes, 20.9% (18 patients) and 12% (3 patients) had free floating thrombus (FFT) in the COVID versus pre-COVID period, respectively. Only 44.4% of all FFT patients could be proven SARS-CoV-2 RT-PCR positive while 50% were COVID suspect with surrogate markers of heightened inflammation at time of stroke. All patients were given anticoagulation and average mRS at discharge was 3.1 (range: 1-6) and 1.84 (range: 0-4) at 3-month follow-up in survivors. Conclusions: This study highlights the presence of FFT causing LVO as a new stroke subtype during the COVID-19 pandemic. With renewed and steeper spike in COVID-19 cases, especially new variants, the resurgence of this stroke subtype needs to be actively explored early in the course of illness to reduce morbidity and mortality.

Anti-SARS-CoV-2 IgG status among frontline health workers involved in COVID-19 survey at Jodhpur, Rajasthan, India.

Background: Asymptomatic carriers are responsible for the consistent spread of coronavirus disease 2019 (COVID-19) in the community. The Government of India has deputed house-to-house survey teams to aid in identifying asymptomatic individuals and their susceptible contacts. We selected door-to-door survey teams of a COVID-19 red zone in western India and determined their infectioncontrol practices and anti-severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) immunoglobin G (IgG) status. Materials and Methods: This single-day prospective cross-sectional study was conducted by the Department of Microbiology of a tertiary care hospital of Jodhpur, in collaboration with the Rajasthan State Health Services. Participants were asked to fill out a questionnaire regarding personal protective equipment (PPE) use after written informed consent. Venous blood samples were collected and Kavach enzyme-linked immunosorbent assay (ELISA) (J Mitra and Co.) was performed to determine anti-SARS-CoV-2 IgG status. Results: Out of the total 39 participants, IgG antibody was detected in four. Of them, three reported mild symptoms in the past. Out of two previously real-time polymerase chain reaction (RT-PCR) SARS-CoV-2-positive participants, only one had detectable IgG antibodies (Ab) in serum. Cloth mask was used by 24, N95 mask by 11, and surgical masks by four. Conclusion: Anti-SARS-CoV-2 IgG Abs were detected among four members of house-to-house COVID-19 survey teams in Jodhpur. Most of the team members used cloth masks, whereas the Government of India guidelines has recommended triple-layered surgical masks as minimum essential PPE for healthcare workers in India. More such studies should be conducted to ascertain infection prevention and control practices among such vulnerable frontline workers in our country.

Oral Manifestations of COVID-19 Infection: An Analytical Cross-Sectional Study.

OBJECTIVES: The current COVID-19 pandemic has created a huge impact across the globe. Recent literature has reported the occurrence of varied oral lesions in COVID-19 patients in the form of sporadic case reports. This analytical cross-sectional study was carried out to gauge and understand the pattern of oral lesions in qualitative RT-PCR-confirmed COVID-19 patients. METHODS: A cross-sectional study involves a total of 500 qualitative RT-PCR confirmed, hospitalized COVID-19 patients who were meticulously scanned for any hard and soft tissue lesions developing concomitantly with the disease occurrence. RESULTS: This study included a total of 367 (73.4%) males and 133 (26.6%) female patients with a mean age of 53.46 ± 17.50 years. Almost 51.2% of patients presented with gustatory disturbance, 28% with xerostomia and 15.4% of patients were found to have oral findings like erythema, ulcers, depapillation of tongue. There was a statistically significant correlation between oral manifestations and disease severity (p ≤ 0.001). CONCLUSION: COVID-19 is found to effect oral health with greater probability in patients with severe diseases (SARI) which may be due to disease itself, immune response and lack of motivation for personal hygiene measures. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1007/s12663-021-01679-x.

Catastrophic Presentation of COVID-19 with Solitary Large Denovo Tumefactive Demyelination.

BACKGROUND: The ongoing Coronavirus disease-19 (COVID-19) pandemic has revealed a plethora of extrapulmonary manifestations including neurological presentations. To date, nervous system demyelination has been relatively infrequently reported in this setting. Also, while most data point toward immune activation as a causative process, few studies propound a direct effect. CASE DESCRIPTION: A 35-year-old man presented with severe new-onset headache, hemiparesis, and focal seizures culminating in deeply altered sensorium. Radiological evaluation showed a large expansile demyelinating lesion in the right cerebral hemisphere. Nasopharyngeal swab COVID reverse transcription-polymerase chain reaction (RT-PCR) was positive. After initial non-response to steroids, the patient responded well to plasma exchange leading to complete recovery. CONCLUSIONS: This report highlights a case of active severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection presenting with tumefactive demyelination and subsequent response to therapy. It is important to recognize atypical presentations at this juncture as it may be crucial for planning treatment strategies.

COVID-19 seropositivity among non-medical frontline office staff from two cities in Rajasthan, India.

AIMS: The indigenously developed Indian Council of Medical Research (ICMR)-NIV COVID Kavach IgG enzyme linked immunosorbent assay (ELISA) has been recommended for seroprevalence among vulnerable populations in India, which provided essential services throughout the lockdown. The staff working in the High Court was one such group. We compared anti-SARS-CoV-2 IgG seropositivity among the staff of Jodhpur and Jaipur High Courts, Rajasthan, India. METHODS: Asymptomatic judiciary staff of Jodhpur and Jaipur benches of High Courts were enrolled after informed written consent. A questionnaire was filled and 3-5 ml venous blood was collected from participants. The ICMR-NIV COVID Kavach IgG ELISA and EUROIMMUN IgG ELISA were used for detection of Anti-SARS-CoV-2 IgG antibodies. RESULTS: A total of 63 samples (41 from Jodhpur and 22 from Jaipur) were collected between 28th July to 4th August 2020. The overall anti-SARS-CoV-2 IgG seroprevalence was found to be 6.35%. Seropositivity was higher among the staff from Jaipur (13.64%) as compared to Jodhpur (2.44%). The Kavach ELISA results were in complete agreement with EUROIMMUN ELISA. The infection control measures were deemed effective. CONCLUSION: Seroprevalence among the staff of Jodhpur High Court was found to be lower than Jaipur, reflecting higher susceptibility to COVID-19 in the former. Many offices worldwide are closed till mid 2020 but need to come up with pre-emptive policies eventually. This study may help to anticipate the possible challenges when other government/private offices start functioning. The infection control practices of one workplace may help formulate guidelines for other offices.

Evaluation of Pathological Findings of COVID-19 by Minimally Invasive Autopsies: A Single Tertiary Care Center Experience from India.

Objectives The 2019 novel coronavirus (2019-nCoV) has spread across the globe with more than 6 lakh deaths. Clinical autopsies are important to understand the pathobiology of the disease. Materials and Methods Autopsy techniques have been modified to be minimally invasive autopsies in all COVID-19 positive cases, and tissue biopsies were sampled from lungs, liver, and bone marrow within an hour after death. Detailed histological analysis was performed in the sampled tissues, along with immunohistochemistry. Patients' clinical records were collected. Statistical Analysis Descriptive statistics were used to summarize data. Results Of the 21 cases studied, 76.2% patients were ≥ 60 years of age, 80.9% were males, and 85.7% had co-morbidities. Histopathological analysis revealed diffuse alveolar damage (including exudative and organizing phase) in 88.9% cases. Microthrombi were seen in 44.4% cases. Additional findings include viral cytopathic changes, metaplastic change in the epithelium, intra-alveolar hemorrhage, and pulmonary edema. Liver showed centrizonal congestion with hepatocytic loss, lobular inflammation, steatosis, Kupffer cell hypertrophy, and sinusoidal neutrophilic infiltration, while significant portal infiltrate and cholestasis were absent to minimal. Bone marrow revealed hemophagocytosis in 60% cases. Conclusion Incorporation of minimally invasive autopsies provides an effective method to study the pathological findings in COVID-19 deaths in resource-constrained settings. Presence of pulmonary microthrombi in a significant number of cases supports the vascular events, apart from the characteristic diffuse alveolar damage, as an important pathogenic mechanism for lung injury in COVID-19 infections. Histopathological findings in the liver and bone marrow suggest indirect insult to these organs, related to circulatory and/or hyperinflammatory response to viral infections.

Predictors of Clinical Outcomes in Adult COVID-19 Patients Admitted to a Tertiary Care Hospital in India: an analytical cross-sectional study.

BACKGROUND: The outbreak ofsevere acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic has resulted inexponential rise in the number of patients getting hospitalised with corona virus disease 2019 (COVID-19). There is a paucity of data from South East Asian Region related to the predictors of clinical outcomes in these patients. This formed the basis of conducting our study. METHODS: This was an analytical cross-sectional study. Demographic, clinical, radiological and laboratory data of 125 patients was collected on admission. The study outcome was death or discharge after recovery. For univariate analysis, unpaired t-test, Chi-square and Fisher's Exact test were used. Receiver operating characteristic (ROC) curves were plotted for Sequential Organ Failure Assessment (SOFA) score and few laboratory parameters. Logistic regression was applied for multivariate analysis. RESULTS: Elderly age, ischemic heart disease and smoking were significantly associated with mortality. Elevated levels of D-dimer and lactate dehydrogenase (LDH) and reduced lymphocyte counts were the predictors of mortality. The ROCs for SOFA score curve showed a cut-off value ≥ 3.5 (sensitivity- 91.7% and specificity- 87.5%), for IL-6 the cut-off value was ≥ 37.9 (sensitivity- 96% and specificity- 78%) and for lymphocyte counts, a cut off was calculated to be less than and equal to 1.46 x 109per litre (sensitivity-75.2%and specificity- 83.3%). CONCLUSION: Old age, smoking history, ischemic heart disease and laboratory parameters including elevated D-dimer, raised LDH and low lymphocyte counts at baseline are associated with COVID-19 mortality. A higher SOFA score at admission is a poor prognosticator in COVID-19 patients.

Chest-X-ray-Based Scoring, Total Leukocyte Count, and Neutrophil-to-Lymphocyte Ratio for Prediction of COVID-19 in Patients with Severe Acute Respiratory Illness.

OBJECTIVE: This study aimed to use chest-X-ray (CXR)-based scores along with total leukocyte count (TLC) and neutrophil-to-lymphocyte ratio (NLR) in the prediction of coronavirus disease 2019 (COVID-19) in patients presenting with clinical features of severe acute respiratory illness (SARI). MATERIAL AND METHODS: This is a retrospective study involving all patients who presented with clinical features of SARI and who had undergone bedside chest X-ray (CXR), hemograms with TLC, NLR, and reverse transcriptase-polymerase chain reaction (RT-PCR) at our institute from May 1 to June 30, 2020. RESULTS: Of 204 patients, 115 tested RT-PCR-positive and 89 tested negative. The patients who presented with SARI, using CXR-based score of 4 or more, TLC of less than 8,700 cells/µL, and NLR of <7 had a statistically significant area under the curve (p<0.001) for diagnosing COVID-19. The sensitivity and specificity of the CXR score was 80.8% and 73.0%, of TLC was 70.1% and 74.7%, and of NLR was 70.1% and 59.0%, respectively, in diagnosing COVID-19 alone. The specificity further increased to 90.4% when we used the CXR score with NLR and to 92.8% when we used the CXR score with TLC. The post-test odds ("rule in" disease) of a positive test for having the disease were 3, 2.77, and 1.71 times with the use of either CXR score, TLC, or NLR criteria, respectively; whereas, combined use of CXR score and NLR increased the post-test odds by 5.53 times, and combination of CXR score with TLC increased the post-test odds by 7.5 times. CONCLUSION: CXR score with TLC and NLR can predict COVID-19 infection among those who presented with features of SARI. This may help in the early isolation of the patient until the RT-PCR report becomes available.

Rational use of PPE and preventing PPE related skin damage.

On 31st December, 2019, an outbreak of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) was declared in Wuhan, China. On 24 March 2020, there was a nationwide lockdown for 21 days, followed by Janata curfew on 22nd March. As the pandemic has developed and spread across continents, everyone including policy makers have realized shortage of personal protective equipment (PPE) such as N95 respirators, coverall, and face shields. This is one of the major factors putting healthcare workers not only at risk of infection but also to various side effects of prolonged use of PPE. Based on international experiences, new ideas in procuring and mass manufacturing, rational use of PPE equipment is the need of hour, especially for developing nations which lack adequate resources and infrastructure for manufacturing PPEs.

Suraksha Chakra: A new scoring system to protect the healthcare workers from COVID.

Doctors, nurses, house cleaning staff and hospital ward attendants are at increased risk of acquiring coronavirus disease 2019 (COVID-19) if there is a breach in the personal protection equipment. A new simple, easy to implement scoring system has been developed by our Suraksha Chakra team which can be used by the policy makers and hospital administrators. The scoring system is not to discourage anyone but constantly reinforce the healthcare workers for safe practices during patient care.

Preparing for a COVID-19 pandemic: Redefining roles of multidisciplinary team in a large tertiary hospital in Rajasthan.

Through this manuscript, we would like to share our experience with building a COVID hospital, allocating duties, planning and managing supplies during COVID-19 pandemic. This manuscript is prepared by the Doctors of various specialties with vast experience involved in actual planning of the infrastructure and resources. This comprehensive manuscript will help teams to prepare and train, stockpile necessary equipment and prepare their staff to deal with current crisis if there is a surge in infected cases.

Clinical outcome, viral response and safety profile of chloroquine in COVID-19 patients - initial experience.

INTRODUCTION: Chloroquine and its analogues are currently being investigated for the treatment and post exposure prophylaxis of COVID-19 due to its antiviral activity and immunomodulatory activity. MATERIAL AND METHODS: Confirmed symptomatic cases of COVID-19 were included in the study. Patients were supposed to receive chloroquine (CQ) 500 mg twice daily for 7 days. Due to a change in institutional protocol, initial patients received chloroquine and subsequent patients who did not receive chloroquine served as negative controls. Clinical effectiveness was determined in terms of timing of symptom resolution and conversion rate of reverse transcriptase polymerase chain reaction (RT-PCR) on day 14 and day 15 of admission. RESULTS: Twelve COVID-19 patients formed the treatment arm and 17 patients were included in the control arm. The duration of symptoms among the CQ treated group (6.3 ± 2.7 days) was significantly (p-value = 0.009) lower than that of the control group (8.9 ± 2.2 days). There was no significant difference in the rate of RT-PCR negativity in both groups. 2 patients out of 12 developed diarrhea in the CQ therapy arm. CONCLUSION: The duration of symptoms among the treated group (with chloroquine) was significantly lower than that of the control group. RT-PCR conversion was not significantly different between the 2 groups.

Viral Ribonucleic Acid Shedding and Transmission Potential of Asymptomatic and Paucisymptomatic Coronavirus Disease 2019 Patients.

We studied the pattern and duration of viral ribonucleic acid (RNA) shedding in 32 asymptomatic and 11 paucisymptomatic coronavirus disease 2019 cases. Viral RNA shedding in exhaled breath progressively diminished and became negative after 6 days of a positive reverse-transcription polymerase chain reaction test. Therefore, the duration of isolation can be minimized to 6 days.

Tobacco, alcohol use and other risk factors for developing symptomatic COVID-19 vs asymptomatic SARS-CoV-2 infection: a case-control study from western Rajasthan, India.

BACKGROUND: Understanding risk factors of symptomatic coronavirus disease 2019 (COVID-19) vis-à-vis asymptomatic severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, severe disease and death is important. METHODS: An unmatched case-control study was conducted through telephonic interviews among individuals who tested positive for SARS-CoV-2 in Jodhpur, India from 23 March to 20 July 2020. Contact history, comorbidities and tobacco and alcohol use were elicited using standard tools. RESULTS: Among 911 SARS-CoV-2-infected individuals, 47.5% were symptomatic, 14.1% had severe COVID-19 and 41 (4.5%) died. Older age, working outside the home, cardiac and respiratory comorbidity and alcohol use were found to increase the risk of symptomatic disease as compared with asymptomatic infection. Current tobacco smoking (odds ratio [OR] 0.46 [95% confidence interval {CI} 0.26 to 0.78]) but not smokeless tobacco use (OR 0.81 [95% CI 0.55 to 1.19]) appeared to reduce the risk of symptomatic disease. Age ≥60 y and renal comorbidity were significantly associated with severe COVID-19. Age ≥60 y and respiratory and cardiac comorbidity were found to predispose to mortality. CONCLUSIONS: The apparent reduced risk of symptomatic COVID-19 among tobacco smokers could be due to residual confounding owing to unknown factors, while acknowledging the limitation of recall bias. Cross-protection afforded by frequent upper respiratory tract infection among tobacco smokers could explain why a similar association was not found for smokeless tobacco use, thereby being more plausible than the 'nicotinic hypothesis'. Those with comorbidities and age ≥60 y should be prioritized for hospital admission.

Dynamics of SARS-CoV-2 Transmission Among Indian Nationals Evacuated From Iran.

OBJECTIVE: During the coronavirus disease (COVID-19) pandemic, Indian nationals evacuated from Iran were quarantined at Jaisalmer, Rajasthan. We wished to study the transmission of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in this closed population. METHODS: A basic susceptible, exposed, infected, and removed (SEIR) compartmental model was developed using the daily stepwise approach in Microsoft Excel. An advanced model using standard differential equations in Python software version 3.6 was used to estimate R0 based on model fit to actual data. RESULTS: Forty-eight SARS-CoV-2 infections were found among the 474 quarantined individuals. Out of these, 44 (92%) were asymptomatic. R0 for the overall duration was found to be 2.29 (95% CI: 1.84-2.78). Male gender and age ≥ 60 years were associated with SARS-CoV-2 infection (RR = 4.33, 95% CI: 2.07-9.05 and 5.32, 95% CI: 3.13-9.04, respectively). Isolation of infected individuals and stricter quarantine of remaining individuals reduced the R0 from 2.41 initially to 1.17 subsequently. CONCLUSION: R0 value was found comparable to the earlier studies indicating similar transmission dynamics among quarantined individuals in India. Universal testing and prompt isolation of infected individuals reduced the transmission of SARS-CoV-2. Smaller group sizes should be preferred to large groups during facility-based quarantine in evacuation situations. The role of asymptomatic individuals appears to be strong in SARS-CoV-2 transmission within closed populations.

Pathophysiology and Potential Therapeutic Candidates for COVID-19: A Poorly Understood Arena.

Coronavirus disease 2019 (COVID-19), an acute onset pneumonia caused by a novel Betacoronavirus, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), emerged in the Wuhan City of China in December 2019 and evolved into a global pandemic. To date, there are no proven drugs or vaccines against this virus. Hence, the situation demands an urgent need to explore all potential therapeutic strategies that can be made available to prevent the disease progression and improve patient outcomes. In absence of clinically proven treatment guidelines, several repurposed drugs and investigational agents are currently being evaluated in clinical trials for their probable benefits in the treatment of COVID-19. These include antivirals (remdesivir, lopinavir/ritonavir, umifenovir, and favipiravir), interferon, antimalarials (chloroquine/hydroxychloroquine), antiparasitic drugs (ivermectin and nitazoxanide), biologics (monoclonal antibodies and interleukin receptor antagonist), cellular therapies (mesenchymal stem cells and natural killer cells), convalescent plasma, and cytokine adsorber. Though several observational studies have claimed many of these agents to be effective based on their in vitro activities and extrapolated evidence from SARS and Middle East respiratory syndrome (MERS) epidemics, the currently available data remains inconclusive because of ill-defined patient selection criteria, small sample size, lack of concurrent controls, and use of intermediary outcomes instead of patient-relevant outcomes. Moreover, there is a need to clearly define the patient populations who warrant therapy and also the timing of initiation of treatment. Understanding the disease pathology responsible for the clinical manifestations of COVID-19 is imperative to identify the potential targets for drug development. This review explains the pathophysiology of COVID-19 and summarizes the potential treatment candidates, which can provide guidance in developing effective therapeutic strategies.

The Enigma of Low COVID-19 Fatality Rate in India.

Coronavirus disease 2019 (COVID-19), an acute onset pneumonia caused by a novel Betacoronavirus Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) has rapidly evolved into a pandemic. Though its origin has been linked to the Wuhan City of China's Hubei Province in December 2019, recent reports claim that the original animal-to-human transmission of the virus probably happened sometime between September and October 2019 in Guangdong Province, rather than Hubei. As of July 3, 2020, India has reported a case positivity rate of 6.5% and a fatality rate of 2.8%, which are among the lowest in the world. Also, the severity of the disease is much less among Indians as evidenced by the low rate of ICU admission (15.3%) and the need for mechanical ventilation (4.16%). As per the World Health Organization (WHO) situation report 165 on July 3, 2020, India has one of the lowest deaths per 100,000 population (1.32 deaths against a global average of 6.04). Several factors related to the pathogen, host and environment might have some role in reducing the susceptibility of Indians to COVID-19. These include some ongoing mutations that can alter the virulence of the circulating SARS-CoV-2 strains, host factors like innate immunity, genetic diversity in immune responses, epigenetic factors, genetic polymorphisms of ACE2 receptors, micro RNAs and universal BCG vaccination, and environmental factors like high temperature and humidity which may alter the viability and transmissibility of the strain. This perspective -highlights the potential factors that might be responsible for the observed low COVID-19 fatality rate in Indian population. It puts forward several hypotheses which can be a ground for future studies determining individual and population susceptibility to COVID-19 and thus, may offer a new dimension to our current understanding of the disease.