Conversations with an epidemiologist: On community transmission

(Over most of April and May, as the Covid-19 pandemic unfolded in India, growing from just a handful of cases to take region after region in its grasp, Dr T Jacob John, India’s foremost virologist, epidemiologist and researcher, spoke daily with Jagdish Rattanani, journalist and editor of Foundation of The Billion Press, to build what we call the COVID-19 diary.)

In the following extracts from the conversations, Dr John says it is puzzling why a lockdown has been announced and community transmission denied at the same time. Community transmission began in March itself, and its denial is costing the country dear, taking a heavy toll of the healthcare community. He makes a distinction between the public heatlh approach to testing, where the aim is to trace contacts and contain the disease, and the heatlhcare approach. Admitting community tranmission means the country can move to a healthcare approach, where the aim is to diagnose COVID in ill patients and save their lives, also protecting healthcare workers in the bargain. 

 

Jagdish Rattanani (JR): It is now seventeen days under the lockdown. What are you sensing?

Dr Jacob John (Dr John)- Technically, under lockdown, the spread must only be intra-family. So, if you are finding cases outside, the effect of the lockdown is not visible yet. You can argue that what we see today is what happened fourteen days ago, because if somebody got infected today, it will show up after fourteen days.

JR: Fourteen days is the outer limit, otherwise the symptoms would show in five to six days, isnt it?

JJ: Yes, anyway, fourteen days approximately. So, it is early to say whether our lockdown is successful for the objective of flattening the curve, because the curve doesn’t look anywhere near flattening. If you look at the simple numbers made into a graph, it is going upwards.

JR: Yes, it is. 

Dr John: It is disappointing, to say the least. It is commonsense that in a country like India, lockdown will work where people live in independent houses or independent flats, or where the distance between families is reasonably good. I had written a paper with my friend Dr M.S. Seshadri, (Retired Professor of Medicine, CMC) suggesting protection of grandparents and senior people by “cocooning” them.

But if you travel widely in India, say in my town of Vellore, you will see twenty-five or thirty places where you walk down the street and the houses are like packed matchboxes. And the women are chatting, the kids are playing, adults returning from work . . . also chatting. The street is the living room for innumerable families. The local administration should have been given enough time to plan physical distancing. That time was not given.

JR: So, more involvement and cooperation should have been sought from the local authorities to implement the lockdown and ensure social distancing?

Dr John: Yes. They should have been given time to plan, to make sure social distancing and physical distancing can happen, with responsibility and accountability.

JR: Yes.

Dr John: I still have not figured out what the deep strategy was for announcing this lockdown from 12 midnight three hours before? Or four hours?

JR: It was announced at 8 p.m.

Dr John: So, four hours of notice. There must have been a very strong logic or rationale behind it. I still have not figured it out. But even today the health minister says there is no community transmission. So, if there is no community transmission isn’t the lockdown too premature?

JR: One would think the earlier the better?

Dr John: Only when community transmission has begun will lockdown help to flatten the curve. The curve has to start before you can flatten it.

JR: But it can also work as preventive measure, can’t it? Because, then you don’t get the curve at all, isnt it?

Dr John: That is one way of thinking, but the day you remove the lockdown, you must realise this, you have created, for every infected person, five infected persons within the family. You will have five times the number of infected people at the end of lockdown as at the beginning. So the curve will take off, then you have to do a lockdown again. So the lockdown should have been when the curve started to go up. You cannot flatten a curve without a curve being alive.

JR: So, you think the lockdown was premature?                                                                         

Dr John: No, I don’t think it was premature (because I think there is community transmission), But to say that there is no community transmission and then announce a lockdown? On the part of those who believe there is no community transmission it is a premature move.

JR: OK.                     

Dr John: I believe that community transmission has started early March. So, therefore, the lockdown is very timely, but it hasn’t given time to local governments and administrations to take the responsibility, with accountability, for making this whole thing successful. For the international media, they (Indian government) have made a great and bold decision, but it is a bird’s-eye view. The worm’s-eye view from inside that is what I am talking about. These issues bother me.

JR: So, we come back to the point that our numbers are not reliable?

Dr John: As of April 12, there were 1,94,032 tests done, I was reading in The Hindu.  I would be interested to know how much of this belongs to healthcare COVID diagnosis, and how much to public health contact tracing for quarantine.

So, I traced back the COVID history of Kerala starting on 30^th January. There was another case on 2^nd February and the third on 3^rd Febraury. Now, in disease epidemiology, those three cases are definitely called imported cases, because they got infected in foreign soil. So they are not our cases. And all three were strictly quarantined. Good measures were taken, and not a single contact (of these three) got infected, because these three were received at the airport and straightaway taken into quarantine. This (first case) is on 30th January. Nobody had alerted anybody. This is Kerala’s own initiative. Thereafter, Kerala has gone into an aggressive accuracy, contact tracing, etc.  And that is a model that every other state is doing, no state has reinvented the wheel. They're all copying the Kerala model and looking at contact tracing and testing.

Now, the vast majority of testing is done on asymptomatic contacts of somebody who might have tested positive. We are testing the wrong people.

JR: Contacts do need to be tested, don’t they? Are you saying that we are not going beyond the testing of arrivals and their contacts?

Dr John: Yes, we are testing the right people for contact tracing for the sake of quarantining them. But we are not testing the sick people (in the community) to know how many COVID cases are out there in the community. So that's a big blind spot.

NITI Aayog has put up a graph somewhere showing that we have already reached the peak and the curve is now coming down, will come down and we'll hit bottom by end May. That is NITI Aayog’s prediction. So, our outbreak will end by end May, going by that graph.

The left side of the graph is bell-(shaped), not flattened. That is why they are saying, Oh, it is a bell-shaped curve. They don’t say it as much, but finding a bell-shaped curve, you mirror image it and have this curve on the other side. Then it will hit the bottom line by end of May. That's true (that there will be a curve on the other side). But you don't know when that mirror image is going to take place. Everybody is guessing, nobody is actually realistically projecting. There is another Singapore projection.

JR: The Singapore projection said that around May end Covid will come down or come to an end for India. And for many countries they're predicting this around May end.

Dr John: But the problem is, we do not have the right numbers. It's like leprosy. We (say that we) don’t have leprosy, we eliminated it. But there is a lot of leprosy. Then it is the absence of data that is making you say that there are very few COVID cases.

JR: That is worrying

Dr John: On the other side, the same government is taking precautions of red districts, orange, districts, green districts and wanting to keep them strictly colour coded, and that doesn’t gel with the optimistic view of NITI Aayog. So, yes, it is actually confusing to everybody.

Then there is the assertion made that the lockdown is working and that doubling time has increased from four days to seven days or something like that. Okay, great, then even better results are expected under the lockdown.

So, in justifying the lockdown with these kind of numbers (the authorities claiming India has low numbers and a low death rate), it looks as though they were not sure at the time of announcement of the lockdown that this (rise in cases) is going to happen. If they knew that this is the intention of the lockdown, then one wouldn’t make too much of it, as the intention would be working fine. But it's not working, that’s why they're trying to prove that it is working. That’s the way I feel.

JR: One does feel that the briefings from government are inadequate.  One does not know the logic behind many of their actions.

Dr John: I was sent an article from a foreign publication saying that the Modi government is fighting without a war room. The absence of a war room has been felt by foreign journals looking to India for response. (And we have people here) saying that the foreign journals want India to have a worse scenario (than it is already seen to have) and they're jealous or not appreciative of how well India has controlled the disease. The other gleeful explanation given for the increasing numbers is that it is only arithmetic expansion, not geometric exponential expansion.

JR: Well, the numbers are still relatively small, so perhaps they can get away with saying it.

Dr John: They are forgetting the fact that this is an increase under lockdown. Under lockdown, you cannot have geometric exponential increase. And again, the numbers game is terrible.  Currently (late April) the total death number is close to 700. Only COVID patients die, the asymptomatic infected don't die. So, 700 COVID patients mean 70,000 COVID patients, but the total detected as infected is only 21,000. That does not tally. Over 600 deaths from COVID means we have 60,000 infections. And we have detected only 21,000.

JR: What factor of deaths to COVID are you considering?

Dr John: If you take one per cent mortality of all COVID patients…. COVID can be mild, moderate, severe and life threatening, then 600 cases of COVID would mean 60,000 infections.

When you calculate fatality, nobody calculates the number of deaths per hundred infections because infections are mostly asymptomatic, so, we have to calculate fatality using COVID cases.  Case means disease. I have explained before that only 15 per cent to 20 per cent of those infected would have COVID disease and be COVID cases (with symptoms) and a small proportion would be severe COVID. (And we keep saying our fatality is very low)

To come back to the numbers, we have only detected 21,000 infections (as against what must be 60,000). The point I am making is, there is no division as to how many were detected through contact tracing. And how many were detected by testing for pneumonia.

Have you ever seen any numbers that show how many pneumonia cases we have?

JR: No.                                                                                  

Dr John: At one point, they said 2 per cent of severe pneumonia (in India) tested in a study by Indian Council of Medical Researcj, were positive for COVID. But routine testing is not happening.

JR: What exactly do you mean by contact testing and routine testing?

Dr John: The objectives are different. I call it public heath testing and healthcare testing. So, the denominator of 21,000 infections today is a mixture of public testing and healthcare testing. The 600 deaths could not have come from public health testing because public testing mostly yields 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 cases did these 600 die, we don't know. If you assume 2 per cent case (COVID disease, not just infection) fatality, then the COVID cases alone would be 30,000.

My guess will be that 90 per cent of the 21,000 infections detected is from public health testing. 18,000 will be from public health testing only 2,000 may be from 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 the data for lockdown. And this is very dangerous for the healthcare system.

JR: Yes, when healthcare professionals fall ill, where do we go?

Dr John: Yes. The other place where the virus will grow, from the Italian experience, is hospitals. Hospitals are outside the lockdown areas. Anybody who goes hospital with any symptoms today in my mind should be suspected for coronavirus because they are surprising doctors in different places. And unrecognized infection at the entry point in a hospital will make the hospital a reservoir of virus.

JR: OK                                                                                                                      

Dr John: That was exactly what happened in Italy. That I am afraid might happen in India because there is a lot of similarities between Italy and India.  People are happy-go-lucky, not very discriplined, a little lackadaisical. Such cultural traits are likely to allow the virus to break through the crack and crevices of the lockdown system and the mask system, hand-washing hygiene . . .

I am afraid that if hospitals became hotch-potch (affected), the healthcare system 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 healthcare staff get infected, other doctors will be very reluctant and demoralised. So, that is something we have to watch out for.

JR: So, what should hospital do to avoid this?

Dr John: Has anybody given a clear indication to hospitals, as to what to do and what not to do? I voluntarily sent 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.

Hospitals have to be clearly told about the Do’s/Dont’s, the protocol, PPE . . . ? Let me tell you, today every doctor who sees a patient must have the full gear for preventing respiratory transmitted infection. What does that mean? Masks must be changed periodically. Certainly, the doctors must have goggles and a white sour. In Kerala, the cottage industry is making white sours. Tiny droplets from the patient fly to the ground within one metre of the patient. This can hit the eye of the doctor, and that is a sure way to get infected. All doctors above sixty should be kept in reserve only for proven non-COVID disease. I am saying that there are things that we expect the government system to convert into protocol that everybody can use.

JR: True.

Dr John: If you think that a patient is infectious to healthcare workers only after COVID develops, we are grossly mistaken.

JR: So you are saying, a patient could infect without showing symptoms.

Dr John: Yes. The matter hangs on one issue – community transmission. It is so obvious that there is community transmission, and if the government denies it, I don’t understand the implication of both of these (having a lockdown while also saying there is no community transmission) in the same country. How will doctors protect themselves… because I believe commuity transmission is widespread. COVID is not only in the hotspots. If I am wrong, I will be happy, but if I am right, I will be unhappy that things are not being done properly.

And we had community tranmission in March itself. There was this 22-year-old man who travelled from Delhi to Chennai by train. He had no contact with anybody, any foreign traveller, no other risk factor of travel-related contact. He came to Chennai, he was sick, tested, and he was found positive on 18 March. That is the first recognized community transmission; we already knew thereafter that umpteen community transmissions have been taking place. This was the second case in Tamil Nadu. The first case in Tamil Nadu was somebody who had come back from the Middle East, that was an imported case, directly imported into Tamil Nadu.

So, India has been denying it. So, that is what I have written about in the Hindu, on my definition of community transmission.

JR: The only argument against that is by now we should have had many patients, in that case.

Dr John: We are getting many patients. Where is the surveillance? Where is the testing? You know, I refused to speak to the BBC. In general, I refuse to give my voice to BBC, because if I spoke, it would not be anonymously, like the two doctors who had to speak anonymously because of…you know, India is India.

JR: This is the story about a doctor saying six people were brought in dead. They will not be counted among COVID deaths.

Dr John: People go into respiratory distress, and they can die within a few hours. See, if the brain doesn’t get enough oxygen for ten 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. The deaths will be recorded as something else.

JR: How do you feel after you read about this doctor … what went through your mind? The doctor saying six brought dead, what does it even mean?

Dr John: 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. I mean, 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: We are testing, it’s not that we are not testing.                                               

Dr John: Yes, we are testing, and those tests 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 symptoms. Fever . . .  fever is a must, because 90 per cent to 95 per cent of people start with a fever. So that’s good enough. Fever and cough, two major criteria. And there are other criteria like loss of sense of smell, taste, these are all major criteria. That’s enough to make a COVID diagnosis.

Let me explain what I see as community transmission. There is the primary source in the country who is the original travel contact (the person who brings it from overseas). He gives the disease to his contact. Now if this contact passes on the disease, it is community transmission. Because he is a non-traveller and he is a member of the community, so the next-generation transmission is already 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?

Dr John: So, the numbers are low. I think personally, predominantly because our testing strategy is based on the risk factors of contacts and travel. But today if you test all the symptomatic people with criteria of COVID 19 –  cardinal criteria of fever, cough, loss of smell or loss of taste, that are highly specific for this disease and breathlessness, and the minor symptoms are body ache, exhaustion – if you select those symptomatic people who come to hospitals and test them all, immediately you get a different number. And that will tell you whether transmission is traceable or untraceable. Untraceable equals community transmission. And then you protect the environment of the hospital. The doctors and nurses have to be protected . . .

What is happening now is, a patient comes to hospital, he tests positive, the hospital is closed down… there is an old saying in Malayalam, ‘the Namboodri burned his home because he couldn’t chase the rat out..’ I mean, that is a drastic way of closing down hospitals,

JR: Hospitals closing at such a time will cost our people dear.

Dr John: And doctors have not been given a very clear picture of what to expect, what to do, what precautions they should take. . . what they should do in this bio-medical field in this pandemic.

I believe that the surgery department in Madras Medical College was shut down because a doctor got infected from a patient. The whole unit had to be shut down. That is evidence-based reaction. We found a positive that is evidence. And you shut down. The proactive thing would have been for all patients to be screened, and for all doctors to be wearing complete protective wear before any surgery.

JR: So, it has to be a healthcare approach from now, as opposed to a public health approach.

Dr John: Once the numbers grow into large number, you’re thinking that should shift to the healthcare approach. There is a time when the core concept of containment was valuable. That time is long passed. Now, this is a respiratory transmitted agent. And you cannot stop it in its tracks except when the people who are infected are extremely few in number.

There is of course the Wuhan-like approach of blocking an entire area, to let the infection evolve inside.  But then you must remember that there are vulnerable people and older people, and you have to protect them. You can't simply let them just die because you want to protect the people outside the containment area. That is inhuman, inhuman. So, you have to balance with whatever you do with human rights.

JR: How would you manage in a place like Mumbai without a strict lockdown?

Dr John:  Mumbai will have to go through some very careful strategy planning, and that is where universal mask wearing will make a difference. And antibody testing with IGG will make a difference. So, it is a multi-prong strategy of containment. There should be dedicated hospitals for COVID, and the patients cannot stay with family, so you have to take extra care for their welfare, safety, psychological support, physical support and food. At the same time, all senior citizens and people with diabetes, etc., have to be able to consult their own doctors. Or, arrangements should be made for their medical requirements.

It's a labour-intensive programme, if you want to go the whole hog.  Expecting that the blocking will somehow kill the virus within that blocked area . . . the price will be heavy, the senior citizens and the vulnerable people will have to be taken care of, and many of them may die. That should not be allowed. A judicious mix of public health and healthcare has to be defined . . . again I am telling you . . .  we had enough and more time to go through this in our minds.

JR- But, tell me, what is your gut feeling on Mumbai? What are you feeling?

Dr John: The rich people will have to stay home, they stay put, but the lower-income people . . . physical distancing is only theoretical for them. They have to live, and livelihood requires social interaction. That is why I don't like the term social distancing. I always say social connectedness, physical distancing So, social connectedness is a psychological requirement for everybody. Physical distancing is a biomedical requirement for everybody.

With Mumbai too, there is this evidence-based approach . . .  and one has not acknowledged community transmission. And these people who are getting infected, where are they getting infected from? (In India) Denying community transmission and posturing that we are different and that we have many advantages is all theoretical. The BCG advantage appeared one tangible advantage, but BCG people themselves say don’t count on it. One microbiologist pointed out that BCG does not protect from TB itself.

So, while the lockdown continues, the government could do a control kind of proper statistical survey and get samples. So that you know how much COVID has really spread, and without that we cannot proceed, because your readings are not capturing what the real extent of spread in the community is.

So, we do need a public-health approach, a science-based approach, to know exactly the extent of the problem before you prescribe intervention. However, the methodology has got to be doable and practical. Tight now, what is happening is a real mess, in the sense that the majority of testing is for no better reason than that someone came into contact with some infected person. And if the Tablighi episode was an example, the vast majority of the people who are found infected are totally asymptomatic.

So, the number that is tested only because of contact with infected persons should be separated from those tested because they are ill. And those two numbers should not be in the same box.

You may have a major extension of the epidemic and lots more of infections. And an inkling of that is already being seen in Delhi and Mumbai, in hospitals particularly. Doctors are getting infected; the doctors and nurses are getting infected from patients who came for something else, not for COVID. And they don't even know which patients could have been infected. That, by definition, is community transmission.

JR: It is a very serious matter if the healthcare system collapses.

Dr John: What I hear from Delhi, Kolkata and Mumbai is very scary. Healthcare workers are getting infected in fairly large numbers. And that means wherever sick people assemble, they bring in COVID with them. They don't have COVID symptoms; they're not coming for COVID disease. They're not coming with fever, cough and just breathlessness.

They are coming with so many other things. In Kolkata, one doctor who died was an orthopaedic surgeon, the other one was a government medical officer, the one in Chennai was a neurosurgeon. Healthcare professionals who never expected COVID in their clientele are getting infected, partly because their guard is down.

JJ: Denial of community transmission really is a costly mistake.

It's a costly mistake because many doctors and nurses have got infected because they did not have their guard up. They were letting their guard down because they believed there was no community transmission, so they were not taking precautions. They were treating patients and they got hit by asymptomatic people coming to their clinics. If community transmission had been announced earlier, somebody would have told them they have to expect COVID infected visiting their clinics and they have to use protective paraphernalia.

And we know of a series of have doctors who have died from the infection, probably from their clinics, from unknown sources. Is this not community transmission? The same parallel one sees in the WHO delay in declaring it as a pandemic. Countries did not believe there is a pandemic. Here, the government denies community transmission.

JR- How many health workers have we lost? Is there a break-up? Officially? 

Dr John: There is no official website, no official count or official platform on which you can find this. There is only media news. There is no agency of a person who keeps giving the people the progress report on a day-to-day basis or even a weekly basis.

JR: I am talking about the main website of the Government of India. Ministry of Health would have it, certainly?

Dr John: Do they give the number of doctors or number of nurses?

JR: No.

Dr John: In a Malayalam newspaper I read that some hundred nurses from Kerala have been infected in Mumbai.

JR-  About community transmission, I would like to ask you, at what stage do we then say that tracing of contacts has no meaning because it goes way beyond one’s ability to trace every interaction of infected persons.                                                                                                           

Dr John- Good question. That will depend upon when you get exhausted by tracing. Until then you go on tracing contacts and quarantining them, so that you maximize the protection of the uninfected. That is what Kerala has done

JR: But at what stage will that end?

Dr John:  That you cannot predict. If the state exhausts itself or the infection load increases out of hand, out of control, then you have to give it up and then concentrate on the other side, which is healthcare. That is, the COVID hospitals and diagnostic tests and all those. Now, Australia and New Zealand are taking the first approach, aggressively pursuing all transmission and trying to contain it and hoping that they will get rid of the infection from the whole population, their island populations.

We are not doing things right. We may desire to look good in front of the world. Everybody accused China of lack of transparency. Are we going to be non-transparent? Will somebody come and do research and say all our data is non-representative and non-comprehensive? I don't know. So, the prospects of people like me remaining in reverse quarantine is going to be for a longer time than the lockdown time.

JR- What is the formal position today (late April), is community transmission admitted or not admitted?

Dr John- No one has admitted community transmission in the last four or five days. So, the position is still no community transmission.

JR: And what is the interest of the government to do that?

Dr John: It could be a semantic misunderstanding. Community transmission for the epidemiologist is what I described to you earlier, but government advisors are not necessarily epidemiologists. They might have said community transmission means widespread transmission in a community. If that was the definition made, that would explain why the government saying no community transmission.

JR- I understand . . .

Dr John: Another interpretation could be that we have created an aura of India doing very well. Other countries are thinking that our intervention was super; we believe that we have some hidden protection. okay. So, therefore we have to defend that image. So, one way is to say we don't have community transmission, but the costly mistake is the number of healthcare workers we have lost because of that. And the number of infections that have developed because of that.