What India needs to do before exiting lockdown

Dr. T Jacob John talks to Jagdish Rattanani about unlocking the lockdown, which, he says, will be tricky and challenging and quite unlike the ease with which it was imposed. He also discusses at length the idea of a "social vaccine" and antibody testing versus testing for COVID

JR- So what can we talk about for today?

Today I had been discussing with my friends was about the how to unlock lockdown. Have been lots of conversation about that.

JR- And with the government also I think?

No; no government has to check with me. Nobody checks with me from that side. It is all media

JR- Okay.

Okay. It is easy to lock down. It is not… it is like in Mahabharata there is something called what chakravyuha

JR- correct, easy to enter

Something like, yes yes, old memory… So that's what we have done in the extraordinary hurry with which it was declared. And then the question of how to get out of it is very interesting scenario, if it was some other country we could criticise, but it's our own country. It t is a little, what shall I say, disconcerting.

JR-Okay, in what sense, what sense that

In a sense that, you know lockdown is the  very last resort in a way, because you're, you're disturbing. What's the right word? You're changing the whole human social interconnections….

JR- unsettling the whole rhythm                                                                    

Unsettling, yeah……that…if.. that is a solution for a calamity, like foreign country invading you, you know, there is some sense in it. This is just a virus and what are the options we have? I don't think people have looked at various options. I recall that schools were closed very early and its logic, nobody explained to anybody. It was the governmental action, probably imitating some other countries that they closed the school….it's not a well thought out response to anything. So the debate is very much like what we wrote on the Hindu, the social vaccine issue, the mitigating or flattening the curve through lockdown, or, letting herd immunity grow and then that will reduce the outbreak in due course. And if you allow herd immunity to grow naturally, the outbreak will be huge in a short time, peak will be high, health care will be overwhelmed so therefore you have to release the floodwaters little by little, don't open the whole shutter  immediately, you open it a little bit and so that is what we are doing through lockdown.

So, the more I think about mask wearing, I mean, the virus exit is through mouth and nose , the entry is through nose, eyes…..essentially nose and eyes. Mouth I don't think is a major entry point. If you swallow the virus, it'll get killed in the stomach and its acidity.  So, if you block these orifices with mask both the donor and the recipient, that is infected and the uninfected, that is also lockdown. That is the exact outcome of social distancing, what I call is physical distancing. The physical distancing is physically distanced enough so that the droplet will not reach the nostris, that’s the idea. So, here if both parties wear mask the droplets will not reach  nostrils. Universal mask wearing is equal to lockdown and the economic activity  could continue with the mask-wearing lockdown.

JR- correct, except that the while your universal mask wearing means people just put it and remove it and you will have to police it in a very different way given the way we are already seeing happening.   

yes, we have to teach people……..Hong Kong,  Chinese, Japanese, Koreans are all used to wearing masks all the time. You see them in the airport in Delhi, wearing masks. What for? Air is polluted maybe or they don't want get infected with influenza, maybe. The people with the kidney transplant and immunosuppression walk around wearing masks even in the streets. So, one has to be told, people have to be taught. And that is something that India failed miserably in. Unlike many other countries where their citizens were given essentially classes to inform them all the details that they need to know. That does not happen in India on the whole. Everything anybody knows is through social media, heresay; talk to each other or on WhatsApp. That…..I don't understand how a country likes India with so much of, anyway…..leadership, why it happens that way I do not know.                      

Anyway, so lifting up the lockdown is assuming that lockdown is the only method of flattening the curve. I'm saying equally good is the mask wearing so if everybody wears masks, I have no problem in lifting the lockdown any time. But with certain caveats

JR- like?

Like large crowds, , it's not yet time to allow large crowds even with masks because we don't want even . 5% chance of infection in spite of everybody wearing masks. So, we have to wait and see how things develop okay. So, so, assuming that the lockdown is the only way of flattening the curve, then you have to think in terms of lifting the lockdown in a staggered manner that is what is calibrated manner, staggered manner,f not all of a sudden, but even then. So, the district-by district  is not a bad idea. Some districts lift the lockdown, but other districts do not, based on,,,,, now it's based on some logic that is the number of infection within the district. They have already classified red, orange and green, the greens could be let out and the problem is when a green is adjacent to a hot green let out will seep into the hot and the hot will seep into the green. So, it's not like country borders that you can close; the district borders are not closable. So then you have to think in terms of what needs to be taken care of: schools, colleges you can make centralized decision. But state wise decision needs data bases, small industries, local industries, any local major industry, if it is a transport hub, all those kind of thing, district by district somebody must sit down and make a list and then see what should be done for each of those.                                

That is a district function. And so every district therefore should have a taskforce; medical officer, district collector should be the chief medical officer and a few others having a staff person they will go through all the rigmarole for the district lockdown withdrawal. If you do that, district by district withdrawal is not a bad idea. So, state by state is not as good as the district by the district it looks like. So there are ways of staggering it but you cannot go on lockdown for a long time because people are….this is very unnatural situation.

So originally….. First they locked down for three weeks originally 25th of March to 14th of April, it was three weeks. Now looking back I feel three weeks was the right time extension was not necessary. Mask wearing should have been necessary. So three weeks, universal mask wearing, and then gradual lifting of the lockdown in a staggered fashion. We haven't got IgG antibody test yet, if we get it then you can certify who are positive and you can release them wearing identity pass saying that they are free to go anywhere do anything they like, the police should not stop them because they have a badge…

JR- So they have got that and they will have antibodies                              

Yeah

JR- Yeah, but they can still infect or they cant?

No…. they… if they have IgG antibodies they are now ….they will not get infected and the virus will not grow in them and therefore, they cannot infect others. So, that is a possibility. So, we were thinking in terms of how to make districts unit of lockdown, rather than state as units of lockdown.  When it comes to Maharashtra, the units…..the units are different. Slums will be some unit and then Bombay itself maybe, certain wards maybe a unit but then that's very messy to have adjacent district one under lockdown and the other one free

JR- I guess Mumbai will have to continue under lockdown given the situation.

Yeah well, there is a price to pay for continued lockdown and we don't know what the price is because nobody seems to be actually keeping a tab on what's happening under the lockdown. I told you I look for pneumonia. There is no current data on pneumonia; by the same token we don’t know current data on death or people are dying of… or they are dying of preventable diseases that could have been prevented but lock down. Somebody wrote in the newspaper saying that impending stroke is a medical emergency, it must reach the hospital immediately, lockdown or no lockdown.                  

There may be a heart attack, chest pain; just being kept to lockdown is no good for a person with acute chest pain. We don't know if people are dying or not. So we have the issues that we were discussing today in terms of unlocking the lockdown, its feasibility and inadvisability of going beyond the 3rd May that is announced. It’s cruel on people to take it further. Wherever, it can be unlocked, we must unlock. Though the priority must be to see how unlocking and how to do it in the best way. Okay.                                                               

JR- Yep, is that your reflection for today?

yes, that is what we have been thinking about today.

JR- Yeah. I mean, that's good. Okay, you want to stop here or add something more.

Now, if you have any questions, go ahead

JR- Yeah. So I wanted to ask you one question only, which is at the back of my mind and not exactly related to what you're saying. So there was one view and one article that was published to us only that wrote that, right now the testing is only of those who are coming to you with problems or symptoms or contracting tracing through that you will never know the extent of the disease. So, while the lockdown continues the government could do a control kind of you know, proper statistical survey and get samples. So that you know how much it has really spread without that we cannot exist the lockdown because your readings are not capturing what the real extent in the community is.

Yes, that is… that is the real what shall I say public health approach, science based approach, know exactly the extent of the problem before you prescribe intervention, correct. However, the methodology has got to be doable and practical. Now, right now, what is happening is a real mess in the sense that the majority of testing is for no better reason than for no reason other than some contact with some likely infected person. And if the Tablighi Markaz was an example, the vast majority of the people who are found infected were totally asymptomatic.So, that number that is tested for only for because of contact should be separated from tested for somebody was ill and therefore tested, those two numbers should not be in the same box.

JR- Okay, why is that?

Because there's two different testing…..

JR- indicators…..?!

Indicators, the objective is different when you get testing…..I used to call it public heath testing and healthcare testing. So, the denominator of 20,000 today is a mixture of public testing and healthcare testing. The 600 deaths  could not have come from the public health thing because they're just infected people. They don't drop dead; they have to go through COVID before they die. So the denominator of the 600 is unknown. Out of how many COVID, these 600 die, we don't know. If you assume 2% case fatality, 600 is: two out of 100.

So 600 multiply by 50 that is 3000, is it? No, 30,000, there have been 30,000 cases already. In addition to the public health testing, which has, we don't know, out of 20,000 how many public health testing? My guess will be that 90% of that is public health testing. 18,000 will be public health testing only 2000 may be disease testing or healthcare testing.  And we have missed these 30,000 COVID cases out of which 600 died. 600 cannot die without a base of 30,000.

Where are they? So we are actually flying blind. We don't have data. We didn’t have data to lock down. We don't have to unlock the lockdown. So, what do you call it, discretionary decision, not a judgement, common sense judgment decision. That is worrying me. Does it answer your question, more or less?

JR- Yes, I think so. I think yes. Now one last question. I'm sorry. Antibody testing versus testing for COVID. What are the two different purposes they serve and which one should we prioritize?                                                                                           

No, I wouldn't prioritize that. They're both necessary. Okay. There is no...because we need as much information as we can get we need because of the crisis okay. Okay, we need as much information as we can get. Okay. So, antibody test we are talking about which antibodies IgM or IgG?

JR- I wouldn't know the difference you would know the difference you said you're preparing some getting bio to do something?

That is IgG. IgM is a surrogate for PCR. That is to test if somebody is infected now or ; not, that is what PCR is. The PCR will be positive from day one through day lets say day 21. Incubation period positive, illness period it'll be positive recovery time it may become negative, but you have to assume three weeks it should be positive. The IgM antibody will be positive only after the symptoms develop.  In the Incubation period IgM antibody will be negative.

So IgGM antibody as a diagnostic test can only be applied for a person who has had fever coughing, breathlessness for at least, I am just pulling a number from my hat, at least three days. Before that we cannot expect the rapid IgM test to be positive. It's not a good test to know the infection load but it's a good test if you have somebody with fever for three four days and you don't know what it is. So a quick test is this idea of antibody test.

It has a role but the IgG is not necessarily to identify the COVID recovered people. COVID recovered people say you know you had COVID and you are recovered, so you are COVID recovered. You don't need any more intervention. This is to essentially for who can bewithout risk to themselves and to others….

JR- go around?!

Go out and do economic activities                                                

JR- the one who will carry a pass and move around according to your plan

Exactly, exactly.

JR- You can't test anybody with that….

Why not? It's a finger stick it just like a testing glucose. You need not test everybody, you don't need to test old people for that. You need to have the productive age-group who are now stuck because of inability to move out of lockdown. So who are the crucial people they should all be tested. And that thing testing should be very well designed by statistical experts.

So you start in one place. You say which age group you will test. You select that age group and you test and then come back and test those who were negative two weeks later orthree weeks later so that you can add on more and more people who are allowed economic activities.

Let's say the test costs 30 rupees, that 30 rupees is well worth because if a person is positive, he is going back to economic activity.

JR- So that’s positive….the purpose of the two will be different. I got it.

Exactly. The purposes of two are entirely different.

JR- both are needed

Yes, they're both rapid tests. It only takes 10 minutes to show up the antibody according to the…. if you're doing it as a rapid test method… okay, but you can do it in a voluntary based method called the ELISA; enzyme-linked immunosorbent assay which is a standard technique, which is more probably more reliable. That requires, blood samples collected, taken to a lab and tested and somebody has to work out if both these techniques are of equal reliability, then the one with their finger stick is satisfactory…very simple to do.

You can see right in front of your eyes a line forming. So then you are satisfied. You are given a badge and you are exempted from anymore…you can look up your grandparent or you can do your shop or you can whatever….   

This conversation was recorded on April 22