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Dr. T Jacob John, India’s foremost virologist, epidemiologist and researcher in a daily conversation with Jagdish Rattanani, journalist and editor of Foundation of The Billion Press, to build what we call the COVID-19 diary
COVID diary: "All doctors must have PPE and visors"
12 April 2020
The major step forward was announcing universal use to mask.
JR: Which you have been asking for…
Yes, I have been asking for it for some time now, and I got the inspiration from the Czech Republic, Taiwan, Hong Kong, where that was the main stay of the country to slow down the transmission or flatten the curve.
And they were quite successful. So, India with universal mask use, if it is accepted by people and if people do really stick with the stipulation, I expect a real slowing down of the growth curve of the infection. That, plus the lockdown, should make things much better. In other words, flatten the curve, so that the health care system network is not suddenly overwhelmed with a flood of infected people needing specialised care. That’s just one side.
On the other side, this disease is contagious, respiratory transmitted In spite of all this precautions, we must expect that there will be flip flop and increase in numbers and we will have a peak coming, somewhat delayed, so June and July is a realistic expectation for the peak. April May is too soon. You know it’s a realistic expectation for the peak. May and June would have been expected surge and peak, but then interventions like mask and lockdown would have made a difference. We will have increases in those kinds of places where none of these works; like very overcrowded bastis, slums etc
And in other place where the virus will grow, given the Italian experience, is hospitals. Hospitals are outside the lockdown area, lockdown territory. Anybody who would go to hospital with any symptoms today, in my mind, should be suspected of coronavirus infection because they are surprising doctors in different places. And the unrecognised infection at the entry point in the hospital will make the hospital a reservoir of virus. That’s exactly what happened in Italy, That I am afraid might happen in India because there is lot of similarities between Italy and India.
What are the similarities?
Similarities are like people are happy-go-lucky, not very disciplined, little lackadaisical, not well informed. Such cultural traits are likely to allow the virus to break through the cracks and crevices of the lockdown system and the mask system, hand washing, hand hygiene… somewhere along the lines this will get broken.
But I am afraid that if hospitals became hot spot, the health care system would, well, not exactly paralysed but will weaken, because then some hospitals will have to close. If there is a cluster of infection among the staff, if more and more hospital staff and health care staff get infected, other doctors will be very afraid, reluctant and demoralised. So, that we will have to watch out.
So these two are my main concerns
JR: Yes, I got it. So what should hospitals do to avoid this?
This is important: has anybody given clear indication to hospitals, what to do and what not to do? You saw what I sent voluntarily, a guideline/protocol to smaller hospitals. We are saying that COVID disease can be diagnosed clinically with specified criteria. There is no mystery about it.
There was a news item today, there was a case report in which a person complained of loss of smell. So hospitals have to be clearly told how to suspect COVD and the dos and the don’ts, the protocols. Take PPE, what is recommended? Let me tell you, today every doctor who sees outpatients must have the full gear for preventing respiratory transmitted infection. What does that mean?
A decent mask that is changed periodically, I don’t know in how many hours, that is what the experts have to say. My guess would be every four hours, he should throw the mask away and different mask should be worn. If it is recyclable, recycle it, if disposable, dispose it.
Secondly, the doctors must have goggles, preferably, plus a visor. In Kerala, cottage industry is making visors that is to prevent infection getting through the eye. When…people talk, they expel saliva droplets. Large droplets fall to the ground. The tiny droplets won’t fall to the ground, they float in the air and float around a meter or more and they will hit the eye of the doctor. That is a sure way to get infected. Goggle/Visors prevent that and they should be provided immediately.
What I think should be done immediately: All doctors above 60 should be kept in reserve only for proven non-COVID disease treatment. Only doctors at or below 40 should be assigned to COVID hospitals, There are such things that we expect the government system to convert into protocols that everybody can use.
If you think that only after COVID develops in some patients that they are infectious to the healthcare workers, we are grossly mistaken.
JR: So you are saying, he could be infected without showing symptoms. Of course.
The whole matter hangs on one issue: community transmission. It is so obvious that there is community transmission by one definition and if the government denies it using another definition, there are implications for both, the observation of and the denial of, community transmission. I can’t make a meaningful interpretation of both of these assertions in the same country.
I am saying how the doctors should protect themselves because I believe community transmission is fairly widespread. It is not only in hotspots, and if I am wrong, I will be happy and but If I am right, I will be very unhappy that things are not done properly.
JR: The argument against that is by now we should have had many patients by now in that case.
We are getting many more patients. Where is the surveillance? Where is the testing? Okay...if we test 100 Acute Severe Respiratory Illness but if there are one million cases, how good is the sample of 100 to inform us the reality?
We need true surveillance of all cases that all hospitals see, all pooled together, through the public health system, on a daily basis. We don’t have that system, so we will never know. That is the worry that I have today.
How many cases are out there? We don’t have data. We don’t have a surveillance system that tells you how many acute respiratory infection cases are happening today. If the number is known, then an, ICMR study can be extrapolated to the whole. If not, you will never know if the sample was large enough.
The frequency of coronavirus infection in severe acute respiratory illness (SARI) cases (for instance) was one per cent last week but three per cent this week, and if the number of SARI cases are known, then immediately we could calculate. If the total was say,25,000 cases in a particular day, you can easily say 250 COVID cases (for 1%), 500 (for 2%), 750 cases (for 3%) today. Tomorrow, the number may change. We need true surveillance of all cases that all hospitals see, all pooled together, through the public health system, on a daily basis. We don’t have that system, so we will never know. That is the worry that I have today.
This interview was recorded on Easter Sunday, April 12, 2020