RO, R and the coming avalanche

In this longish conversation, Dr. T Jacob John talks to Jagdish Rattanani about R0, R and explains why he believes an avalanche is coming to hit us. This conversation was recorded on April 15, 2020.

I have not been particularly thinking about anything but I finished writing something and send it to The Hindu, and I can talk to you about it.

JR- yes

We have as of now no vaccine to prevent COVID 19 or an anti-viral to cure it. But an antiviral is right in front of our eyes: a virus neutralising antibody in convalescent serum and in the serum of people who have tested positive, and have the antibodies of COVID-19.

So, why are we not promoting or practising, popularising convalescent plasma therapy, I do not know.

JR- Okay

So, my suspicion is that there is no evidence that anybody has shown but plasma therapy is a conventional therapy for many conditions. All the major hospitals use plasma for many diseases. It’s called fresh frozen plasma, from a healthy donor.

So when a COVID patient, a senior citizen, or somebody with diabetes, has acute respiratory distress syndrome, is in the ICU, on a ventilator…one day, no improvement, two days, no improvement, three days, not doing well, that’s the time to give convalescent plasma.

JR- Okay                                                                                 

And if you gain enough experience from enough number of people…patients, by enough number of doctors, off the cuff, may be 20 patients, whom you do not expect to recover because you have tried your best for two to three days and they are not recovering. If they recover, if a majority of them recover, then it is working. If only one or two recover, then it’s probably not effective, but if the majority recover, that is evidence to try the therapy even earlier perhaps as early as when ventilator support is just started, .

JR: Okay

You understand that method?

So, why are we not promoting or practising, popularising convalescent plasma therapy, I do not know.

JR: I got it. My only point quickly would be if it was as seamless, then elsewhere in the world also they would have tried it. So obviously there are barriers that we do not know of, I suspect, I wouldn’t know, I am asking a question.

If they had tried and failed, that would have been news. The Chinese have put in two papers, one on ten patients and one with five patients, and all of them improved rapidly.

JR: Okay

So, if doctors are waiting for the “true” evidence, which is a randomised (placebo) controlled trial (the so-called RCT), then that’s not going to happen soon because nobody is going to do a study right now in the middle of fighting a war.

JR- Correct                                                                    

So, what I am saying is, just do it and gain experience.

JR – So I guess virologists around the world would have thought similarly obviously, isn’t it so?

I am one and I thought about it.

JR: Okay, okay

That’s why I am telling you…I do not know. I mean if people thought about it, then they didn’t see it as a good idea, then it would have been there in the all kinds of news that is coming out.                                                

JR: Yes.

But this has not come out. So, I want to put it out. This is an idea that belongs to a medical journal. No medical journal will in a hurry take this; it will take a month or more. But the need is today. We cannot wait for tomorrow.

JR: Correct                                                                    

So, how can I make this widely appreciated. You know, Mahatma Gandhi’s son, Gopalakrishnan Gandhi, lives in Bangalore. He just now called me and said, “Dr John, congratulations.” I said, “What for?”, and he said: “Two of your ideas, the Prime Minister mentioned the day-before-yesterday”. Number one, the idea of everyone being made to wear a mask. Number two, protecting the elderly.

Personally, he had asked me for some advice, and during conversation I told him both these things. He occasionally checks with me about how to handle, when somebody has delivered a packet or something home, how do you clean it etc. So he knows that I have been pushing both these initiatives for quite some time.

JR: Correct

The PM might have heard it from somebody else, who heard it from somebody else, or may be somebody read my papers, and then asked.. whatever, anyway. He was congratulating me for PM taking those two ideas.                                                        

So the thing is once you have an idea...

JR: You should put it out.

You have to put it out. If you have a candle, you don’t put it under your bed, you put it on candle stand, for others to see.                                              

JR: Correct. Very right. Very true. I want to ask…

What do you think?

JR: Yes, absolutely. I want to ask you one thing (on the plasma related line of treatment), is it correct or is it not correct that this would require a good study of people who have got COVID and recovered and have anti-bodies, isn’t it so?

Number one, yes, yes. They are all known, I mean COVID patients. They are all registered, you know whoever has been tested positive with COVID and have recovered all over the country, there will be three hundred four hundred people like that.

JR: So they should be called in?

Take the younger ones, test their blood for Hepatitis-B, HIV and Hepatitis-C. If they are clear, get their informed consent, and ask if they would be willing to donate their blood plasma. Every major hospital has a plasma extraction machine called Plasmapheresis Machine. It’s a routine process, every medical college will have it. They use plasma for so many other conditions.

JR- Yes.

Okay, so, how to popularise this? That’s the question before me.

JR: So one patient can save how many? Plasma taken from one COVID-19 survivor who is now out of it can work with how many other patients?

That depends on the anti-body level. That means you have to measure antibody level.  If very high, then perhaps one plasma for two patients. Otherwise one plasma for one patient.

JR: And do we have the capacity at many places to measure the anti-body levels in India?

That is very important, I have been saying that we must have IgG anti-body testing, which is simpler  to create than the IgM antibody test otherwise called Rapid Test.

JR- Okay, okay.

Wherever you have virology labs with this BSL-4 facility, like NIV Pune, Bhopal, Gwalior. They should be asked to create the antigen to capture the anti-body.

JR: Which will take time, I guess?

It would take time…it may not be quick. Already they are doing IgM anti-body; that is called a rapid test.

JR: Correct

This is simpler than the rapid test.

JR: Okay. I got it.

Diagnostic test…you know, rapid test is diagnostic test for confirming ongoing infection, or current infection…but this IgG is testing for evidence of past infection.

JR: Hmmm.

Okay, if you cannot develop the anti-body, then this COVID positive, who have recovered, and cleared a particular period of time after full recovery, say, one month, because they could have virus lurking in the body for a few more days. So allow for full recovery and a one month margin; they are, say, below 50, healthy, then their convalescent serum is good enough.

JR: Okay                                                                                           

JJ: You can keep a sample and measure antibody eventually. One donor will donate for one or you can divide between two patients. No more than that.     

JR: But still it would fall short, I mean it would still be a difficult effort?

JJ- No. I mean...one person saved, is one person saved.

JR- Correct, correct, very true, very true, but I will ask you again...

I will tell you a story.

JR: Sorry, go on, go on please

There is an old story of a girl. When the tide was low, a lot of starfish were on the beach, dying in the sun, so she picked the starfish one by one and began throwing the starfish back in the sea. This big Professor was walking along and he said, “little girl, what are you doing, and what difference will it make. There are hundreds of them on the beach”, so she took one and showed it to him and said, “sir, it will make a difference to this one” and she threw that one starfish back into the sea.                                                              

JR: Correct, I agree with you, I agree with you. So the question that comes to my mind is again, how is it that nobody in Italy, in France, in Germany, in Iran, in America, has thought of this and tried it already? How is that possible? Surely somebody has tried it? I would be amazed if no one has.

To tell you the truth, I have thought about it. , I have been the first in the world or the only one in the world, with a few ideas, okay. The Chinese have thought about it. And Chinese have used it, the Chinese had reported one study of ten and one study of five patients, and whether they have pursued it, they have got positive results. I have no idea why would you not try it. It’s a very low hanging fruit, with no harm done. If, let’s say, that’s why I am saying people on treatment on the ventilator and you are now sure its patient is not going to recover, that’s the kind of patient whom you  choose and give this treatment.

JR: Correct                                                                                       

Okay, and that doesn’t do any harm and somebody recovers then you reduce your time period. First, give plasma the day a patient has to go on the ventilator. Once the results are good, and it gives confidence, then the treatment can be offered progressively earlier in the disease cycle. This is a very safe treatment. One in a million have some problem with plasma.

So this is what I have done today. Me and (Dr.) Sheshadri have written about this. We keep batting ideas back and forth and if the idea is mine and I write, I am the first author and if the idea is his and if I write it, then I give him the first authorship and vice versa.

JR: Got it, fair enough. That is very fair.

Today there was a BBC report

JR: Yes, very shocking. I am sure they spoke to you. or you saw that report elsewhere?

I refused to speak to the BBC. In general, I refuse to give my voice to BBC, because if I spoke, I will not speak anonymously like the two doctors who spoke had to speak anonymously because of…you know India is India.

JR: But they called you, did the BBC call you?

Yes. I said no voice recording. But then I saw this….

(phone disconnects)

JR: Sorry, we got disconnected. So, you said when you saw this…

I saw this I was…not surprised. What I said is coming true.

JR: No, but it is horrifying. I am shocked, I am in shock because one doctor has said without quoting himself, the six people who are brought in dead. You saw that report?

They will not be counted among COVID deaths.

JR: No that means people having brought in dead itself I never knew was happening, it was like this. I presume….

People go into respiratory distress and they can die within a few hours. You know, see if the brain doesn’t get enough oxygen for 10 minutes, the brain is dying, so the body will try to protect the brain as much as possible and then finally when it gives up, it gives up                

Now the thing is in India none of this will be reported as COVID deaths. We have no COVID death! The death will be recorded as something else.

JR: No, no, but tell me how do you feel after you read the doctor talking, what did…what went through your mind? The doctor saying six brought dead, what does it even mean?

I did not speak to anybody. I was speechless. I was devastated. I felt look, this is what I have been talking about. The avalanche I have been saying is coming.

Again, can I tell you a story?

JR: Yes

Do you have time?

JR: Yes, yes

I have never seen a COVID epidemic in my life in the past. Absolutely correct?

JR: Correct

Then how do I know it is going to be an avalanche? The name Tilly Smith, does it ring a bell? Tilly Smith was a 10-year-old girl in 2004, I think. She schooled in a place near Cambridge. A geography teacher was in class teaching the girl about a South Asian phenomenon called Tsunami, and so he graphically explained to them what a tsunami is…they teach so that the student understands and grasps  and he said the earliest signal of a tsunami is the sea withdrawing from the beach far into the ocean; it is a strange thing to happen that the sea recedes on its own and if that happens watch out in a few minutes there will be big wall of water, five meters, 10 meters high…it will overwhelm everybody.

Tilly Smith, a month later, reached Phuket in Thailand with parents for holiday. She was on the beach playing with other people, parents, children….Okay, Tilly Smith saw the sudden receding of the sea exactly like Andrew Kerney (that was the teacher’s name), had taught her. She immediately knew that a tsunami is coming. A 10-year-old girl, one geography lesson, and she persuaded her parents to immediately evacuate and there were about you know lots of people on the beach, not too many. They all ran back to the hotel, which was runnable distance, took all the hotel staff from the ground floor to the third floor, when they reached they saw a 10 meter water hitting their hotel, The first floor was completely submerged but not a single life was lost.

She saved the lives of as many as 100 people. She had not seen a tsunami before. She knew the initial signs of a tsunami. I have never seen a COVID epidemic before but the initial signs were sufficient for me to predict an avalanche. That’s my story.                                                                

JR: Correct. And can you quickly take me through to what are those initial red flags that you saw as signs? What are those initial signs that told you this is certainly an avalanche coming?

Okay. I detected the first (‘I’ means me and my team, my own colleague, junior colleagues) detected India’s first cases of HIV infection in 1986 in Vellore. Our team went to Chennai, Madurai, Salem, Trichy, Coimbatore, Vellore, and we did a survey. We found the first infected people. Nobody in India was ever worried about it; government was not, public health was not, nobody. Even if they were worried about it, they had no reagents to do the tests. Because of my overseas connections and friends, I got reagents and we… did this testing. Lo and behold, infections has already come here, it was spreading, and I have given at least 50-60 lectures on this in different institutions, particularly in colleges and high schools, medical colleges, medical groups and all that. Okay, so at that time I said to people, ‘thank God, it is a sexually transmitted disease, just imagine a HIV-like virus transmitting through social contact?’

This is the picture I saw in 1986-87, okay. When I see infection that is transmitting by social contact and mortality of whatever, whatever you believe….one per cent, two per cent, three per cent, five per cent, 10 per cent, 10 percent, in some people, 18 per cent, then I immediately knew there is a disaster, and then I know the R0 and R thing. I have discussed this…R0 and R…

JR: Explain R0 and R for the common person.

Okay, this is the contagious infection transmitting from person to person. Okay. And social contact is enough for transmission. And if one infected person does not infect at least one other fresh person, the infection will die out. So that is the effective reproduction number of an infection called R. On an average one case must result in one case. This is not one disease but one infection to another infection. Disease is the sub-set of the infection.

JR: Correct

So somewhere along the line the effective reproduction number, if it less than one, then the disease is disappearing; if it is more than one, the disease is in outbreak mode. All seasonal flu cycles or shifts between less than 1, more than 1, less than one, more than 1, and average is 1, that is the R, the effective reproductive number. Our infectious disease like this polio, measles, chicken-pox, mumps, all these are like this.                          

Okay. So there is a theoretical number, R0. The question is: if one person can infect another person, why is he not infecting more than one person? Because the others are all immune. Majority of the people are immune to measles or polio, mumps or influenza; a lot of people are immune. So the disease is knocking at the doors of several people, and only one door opens on an average. In winter time, it could be three doors for flu, in summer time if three people knock at three doors, only one opens and so three people succeeded in infecting one person only; in winter time one person succeeds in infecting three people

JR- Correct           

So the theoretical number is if everyone was non immune and susceptible, how many infection will one infection generate i.e. the infectiousness of that particular virus

JR: That is the R0                                                                              

Correct. So, a pandemic appears because everybody else is non-immune. So therefore R0 works for a time as R, until R becomes 1. R becomes 1 means it is endemic, R 1.5 it is epidemic. So, everybody says coronavirus’s R0 is 1.9 to between 2 and 3.

JR: Which is a pandemic?

People did not worry about it very much. Yeah…the R0 is low. I am saying R0 anything more than 1 for a contagious disease is scary. It will spread like wildfire, it will reach every nook and corner of the world, because it is a social contact infection. If it is sexual contact infection, I am not worried. If it is social contact infection, I am worried. That is why I predicted in a community in which no one has antibody, this R0 will continue until 70 per cent are infected. So, all this is predicted, and that’s why I predicted an avalanche saying that, it would begin very small, it will take time to catch up and influenza multiplies every two days or three days, so its generation time is fast. One becomes two intwo days, two becomes four in 4 days, four becomes eight in six days and eight becomes sixteen in 8 days, sixteen will become thirty-two in ten days. The COVID infection, one becomes two in ten days, two becomes four in twenty days, four becomes eight in thirty days, eight becomes sixteen in forty days, sixteen becomes thirty-two in fifty days. Influenza has already reached in ten days, this takes fifty days. You see this slow take off of this, that’s why I said it is an avalanche.

JR: I got it. And you are still convinced that it is an avalanche coming, right?

You don’t believe me…you believe the BBC thing.

JR: No, no, no, I believe, I am just trying to…

Absolutely, I still believe an avalanche is going to hit us, and mask wearing and lockdown will help, like Shiva blocked a huge river coming to flood by putting his head there to block it. Okay. So, we are blocking the avalanche, by universalisation of mask use and a lockdown. And what you are seeing here there in the Bombay and in all these news are the slip-throughs. So just imagine if the lockdown were not there, what could have happened? The avalanche would have hit us in… I had predicted avalanche would have hit us in April, now I am saying because of this slow down, Shiva’s head is protecting us and you give, a month after avalanche will still show up again. So, May, May-June, if heat protects us a little bit, June-July, something like that…again…I have never seen an epidemic like this, just that I am Tilly Smith, with the knowledge of how tsunami shows up.

JR- Correct, correct, I got it.                                                                        

I know how this…because I know the behaviour of viruses, and I know the transmission dynamics of virusest, transmission potential, generation time, that is the Tilly Smith’s geography lesson, so I have not seen this before. See, everybody in different countries, I don’t think put together, all this knowledge that I am talking about and predicted what is going to happen. So being one in the world, speaking about this, it’s okay at least one person thought about this.

JR: Sure, sure, of course

Another person who thought about it will say: who am I?, nobody will listen to me.

JR: Correct, correct, very true very true

Okay. One has to be like me to have published more than 500 papers, scientific papers. So, I am bold enough to say what I am convinced about. Once I am convinced, then nobody can stop me from saying it.

JR- I get you.  What should…is there anything the government or the nation can do to avoid the avalanche today?

Absolutely nothing, except a long term, six-month-long lockdown.             

JR: oh, okay.

But that means people will not die of COVID for sure. They will die of starvation, other causes.

JR: So, we are in a bind

So you are in a bind, you are in an absolute bind. And we could have been the world leaders if in February we had taken action.

JR: Okay what action? Action like a lockdown?                                

We should have acted in February. On February 2, we had two cases, on March 1, we had three cases, what does that mean? That means importation from China was extremely rare in India. March 1, three cases; March end, I think more than a thousand.

JR: Correct

Where did it all come from. They all came from Europe, Dubai. India had it that the risk is only from countries East of India, and the west of India is clean. So India targeted China, Hong Kong, South Korea, Japan, Taiwan then eventually Malaysia, Thailand, Singapore. They were, okay, people coming from there will be carrying the virus, people coming from the Western front are safe. Big mistake. We got far more viruses coming from the Western side than from the Eastern side.

In February, what we should have done is to watch out which other countries have it. Six other countries had it, including UK, USA, Italy,.I think.. Germany. We should have said okay, anybody coming from there also to be screened. On February 3, we should have done it. On February 4, we should have done it. We would have converted the avalanche into a flood, and then what Kerala did, the whole of India could have done. Because numbers were very small in the beginning. But then this is not for a transcription…

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JR: I understand, we could have done it then, is what you are saying…     

We could have shown the world how smart India was

JR: And today there is nothing we can do

I don’t know what the Prime Minister is going to do when the avalanche hits us. He will find umpteen scapegoats. Okay. I can’t imagine how the Muslim group in Delhi, they were allowed to meet between 8 and 15 March, when the avalanche was sure to come. So, they were victims of lack of public health? And the victims of course, the infected person can only infect someone else. So why blame the victim, blame the system that made the victim the victim.

JR: Correct

You saw my cocoon idea, the cocoon idea is from me for myself. So, I am cocooning myself.

JR: What do you do? You don’t meet anybody outside or what?                

No. I don’t. Tomorrow there is an important meeting in CMC, I refused to go. I am cocooning. You have the meeting, go ahead, but everybody must wear a mask at the meeting.

JR: But you have to go out for groceries or something, what do you do?

I had to go out this morning to buy milk, I went about 0730 when very few people are around the street, went straight to the milk vendor; he is not wearing a mask. I am wearing a mask. I open my bag, and he dropped two milk bags into it. I brought it home, I opened it and dropped the milk bags into soapy water that my wife has already prepared. Then I put the bag away and I wash my hands. I went upstairs, change my clothes and had a shower.

JR- All this, for…milk

Exactly, all that for buying two bags of milk

JR: Why if you are wearing a mask, and you wash your hands, the bottle of milk is washed, if you have not touched anybody, then how can it transmit?

My clothes would have been contaminated, my shoes. I mean, I have no idea how many people are infected; it is too late to know if somebody, is infected. So this is what I did, I came back home, got the milk bags, dumped into the soapy water, I did that, my wife had prepared the water, and then she washed her hand, I washed my hand, I went and had a shower.               

JR – You will do this every day when you go to get milk?

I have to. We don’t go every day for milk. Once in three days or four days is enough for milk.

JR: Okay, okay, just the two of you?

Yes, two of us. A gardener lady comes and does the watering and all outside. She is such a sweet lady that she wears a mask; if my wife goes anywhere near her, she will say, ‘stay away, stay away’. She keeps eight feet away. And when my wife makes tea for her, she says, ‘leave the tea there, I will go and pick it up’. That’s her, you know, attitude.

JR: I understand

She is the only one whom we allow. Our maid came and said, ‘shall I come and cook?’, I said, ‘no, please go away’.                                                               

JR: Not to take a chance. I must tell you these are very important conversations we have, and I collect every day and putting it on our website. I am not publishing it in a newspaper, but over a period of month, they will tell us, a lot, on what has happened. They are my daily question and your daily reflections.

Ya. Today when I saw the BBC news…                 

JR: I am shocked. I am feeling very uncomfortable.               

Ya, and you can imagine, me, all these days, feeling the same thing, without seeing the evidence, but predicting and hoping that my prediction is wrong, something is wrong, my guess is wrong, my this thing is wrong, my knowledge is wrong, and all this I was hoping against hope, but this BBC news, completely devastated me.         

JR: Ya, that means it’s happening, already six brought in dead means, it’s a very major thing, I mean, you just don’t have people.. it is almost like people falling down on the road.

This is the old plague story and yet officially India has no community transmission! All transmission is from Martians coming in, infecting somebody and flying away. It is not community transmission!

JR: It is amazing.

India has no leprosy, it has eradicated. So, that’s the same thing. You don’t look, you don’t see, you say it doesn’t exist. So, you don’t, you don’t, we do test a lot, that’s why today the number is something like, todays number is 10,000, is it? I think it has crossed 10,000.

JR- So we are testing, it’s not that we are not testing.                               

Ya, we are testing, we are finding and those testing and findings are based on epidemiological risk – travel, contact. That’s how they are testing. What I want is healthcare testing, anybody with upper respiratory symptom. Fever, fever is a must because 90% to 95% of people start with a fever. So that’s good enough. Fever and cough, two major criteria.

JR: Correct

And there are other criteria like loss of sense of smell, taste, these are all major criteria. That’s enough to make COVID diagnosis. So, I think, my definition of community transmission is the original travel contact’s primary source, their contacts, the contact’s contact is called community transmission. Because the contact is a non-traveller, he is a member of the community and the moment he infects, the next generation is already a community transmission. If you want to define community transmission by some other weird way, then you can pretend as though community transmission is not happening. But why are you pretending? Public health doesn’t allow you to pretend, public health doesn’t allow you to underestimate. Public health wants you to overestimate, take action and if you are wrong, be thankful because you are lucky. Okay?

JR: Thank you so much

This conversation was recorded on April 15       

Editor's note: Soon after this conversation, reports came in that the Kerala government as well as the Mumbai municipal corporation were working on offering plasma therapy in their fight agianst Covid-19.