100,000 infections already?

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: 100,000 infections already?

16 April 2020                                                                                    

JR: Any thoughts for today?

Yes, I do have, and that is a simple calculation, 400 deaths…that’s the number, yes, so far, today.

JR: Cumulative number of deaths.

Yeah, rounded off. All numbers are cumulative; even the infected number when we talk of it is cumulative. So we keep to fatality here. If we take one per cent as the fatality, 400 multiplied by 100 is 40,000. Okay, be more conservative, and say 2 per cent fatality, so multiplied by 50, and we have 20,000 cases representing the 400 deaths, roughly. Now, every COVID case is one out of five infections. So, 20,000 multiplied by 5 is 100,000. So we had 100,000 infections of COVID-19 on a conservative estimate.       

If you don’t do diagnostic testing, (which is different from testing only for the sake of public health and safety), or testing anybody with COVID syndrome, you will not know how many COVID syndromes are getting confirmed. The priority given to that is lower than that given to public health testing.

We had 100,000 infections to result in 400 deaths, and we have just detected 10,000. Okay. So, we are under diagnosing by using test which is also in short supply and therefore very judiciously used where they want; the public health testing is given importance to catch the infected, to quarantine and prevent further transmission based on foreign travel, their contacts, their contact’s contact. Wherever you know there is a cluster, for example the Delhi cluster, and everybody who travels carries a virus, it is just like, a foreigner, foreigners coming in, so there they will start new outbreak wherever they settle down. So, the testing is done predominantly for these kinds of people and that will yield a certain proportion of positives. If you don’t do diagnostic testing, (which is different from testing only for the sake of public health and safety), or testing anybody with COVID syndrome, you will not know how many COVID syndromes are getting confirmed. The priority given to that is lower than that given to public health testing.

And that is what the BBC report that I saw today (https://www.youtube.com/watch?v=JIhNKZOHJ74) highlighted from two doctors; one saying 6 dead bodies arriving all of them sounded like acute respiratory death, COVID not tested. The lady doctor saying that we are seeing symptomatic COVID like patient but no testing. Now no testing in healthcare situation underestimates the total number of infection and puts health care staff at some risk.

JR: Correct

So the shortage of test kits and judicious applications of test predominantly for public health, gingerly for diagnostic tests, actually are skewing the data somewhat, we are under-diagnosing infection, because infections are not as much related to the tenuous travel connection as with COVID symptoms. Since we are not testing for COVID symptoms very much, then we are probably underestimating the whole scenario.

JR: Okay. And underestimating heavily, you think?                           

Yeah, the difference is, as we calculated, 100,000 infections vs. 10,000 tested.

JR: Correct

This is one order of magnitude. Another way to look at is, if you look at the speed of expansion, in the very early stage, the speed of expansion is proportional to the introductions into the country. If 1,000 fires were started in a forest, that will blaze much faster and much bigger than if only 10 were burning.   

So the shortage of test kits and judicious applications of test predominantly for public health, gingerly for diagnostic tests, actually are skewing the data somewhat, we are under-diagnosing infection, because infections are not as much related to the tenuous travel connection as with COVID symptoms. Since we are not testing for COVID symptoms very much, then we are probably underestimating the whole scenario.

Now, on February 2, the following countries had less than five cases; India, Italy, Spain, UK, Canada. On March 1, which is essentially introduction from China, India had cumulative three, Italy- 1,694, Italy was welcoming tourists from everywhere, Spain- 84, UK- 36, Canada- 24, India- 3.  During March, importation was not from China because everybody stopped people coming from China…… all importation was from Europe, Dubai, Middle-east. Okay.

So, March 01, India had three cases, and April 01, India had 1,998 cases, less than 2000. Italy had 1,10,574, Spain had 1,04,119, UK had 29,474, Canada had 9,731, Indian less than 2,000. So, then these things are growing at a slower…… now the introductions have come up to this level, then in 5 days, on April 06, that’s all the details that I have wrote down, India- 4,288 from 2,000, in five days it doubled; Italy- 4,288 Italy- 1,28,948, Spain- 1,31,646, UK- 47,806, Canada- 15,512, India- 4,288.   

So, India’s importations were far fewer than every other country and India first concentrated on Eastern side with the Asian countries and then concentrated on the Western countries…not travel restrictions that much but travel and contact, tracing and testing, fairly aggressively. They tested people when they came from Italy or from Dubai they came to Pune and tested the whole lot, like importation through cinema actress/singer Kanika Kapoor. She is the one who missed the testing net. So India has this testing net because of the low numbers we could do a better job, than if they were overwhelmed with high numbers.

So, the speed of spread has been very low. Now I said on April 05, 4,288 is our number and today it is 11,000, so more than double in ten days’ time.

Give time, it will grow, the slope of the curve is not flattening. It is still going fairly steeply, numbers are low but testing is low, the lowest testing rate in the world. So, slow beginning under-corrected by slow or low testing and the worrisome part is in in spite of the lockdown, the numbers are increasing, even beyond the two weeks of lockdown. Up to two weeks, you could say what happened is, what happened two weeks ago. So after 14 days of the lockdown, if we still see numbers going up, that means, there were lots of leaks in the lockdown.                      

JR: Correct.

There is no new importation that is happening. It’s all local fires catching up. So, my prediction, there is nothing to show that my prediction is likely to be wrong. I still expect a high peak, health care system may be overwhelmed, but health care people are in bad shape. So I am along with Dr. Sheshadri writing a piece on what exactly is a personal protective equipment for doctors. We are just writing one. It should be ready by tomorrow evening.

JR: Yes, that’s a very important one.          

Somebody has to tell the doctors and most doctors seem to think that if you don’t have COVID symptoms, patients are safe to handle, but that’s the result of undertesting and underreporting. People get a wrong impression that things are still not very serious, therefore people are not taking care. I am glad that the mask wearing has become a mandatory but it is not being enforced. Sorry, the police have to enforce it, the police have to be taught and police have to learn how to enforce. That will take little time but it must be done.

But people are going around almost as if it’s a holiday day. I see lot of people on the street outside my house...two wheelers with a pillion rider etc.

JR: In Vellore?                             

Give time, it will grow, the slope of the curve is not flattening. It is still going fairly steeply, numbers are low but testing is low, the lowest testing rate in the world. So, slow beginning under-corrected by slow or low testing and the worrisome part is in in spite of the lockdown, the numbers are increasing, even beyond the two weeks of lockdown. Up to two weeks, you could say what happened is, what happened two weeks ago. So after 14 days of the lockdown, if we still see numbers going up, that means, there were lots of leaks in the lockdown.

Yeah, in Vellore and in this small suburban area of Vellore that I live in. So, people have not, or it has not hit people between their eyes, you know that expression? Okay, and that is a result of people not been taken into confidence and told the technical side of the bio-medical problem. How is the virus spreading, how fast does it spread, how…and what exactly is the problem in India, where are the problem community, what should everybody do, why social distancing or physical distancing are necessary. When you say not more than five people to assemble, what I see is this: Four people sitting together and sharing tea from a tea shop. Sitting next to each other and no mask, chatting away. So, that scene has to change actually, people have to understand that physical distancing means actually physical distancing, mask means mask. Even now leaders are not wearing a mask when they come to the television camera, whereas you will not see a Japanese leader coming to television camera without a mask. So that is for today.  

JR: Correct. Good. I wanted a clarification; 20,000 why did you multiply by 5? Where does the 5 coming from? Is that a reasonable number?

Okay. For every COVID disease, there are four asymptomatic infected people, so one case equals 5 infected people.

JR: Says who? Where does the data come from?

Everybody knows that 80 per cent of the infections are asymptomatic

Take TB for example. India is the world capital of TB. We were never been able to get rid of malaria. So I wouldn’t count on any Indian advantage, except that the BCG vaccination given in India may have some dampening effect on a macro scale, so therefore we may have slightly less burden than a non-BCG country like Italy or Spain etc. But that is not worth counting on very much. However, that may be one factor. That will be seen only in retrospective analysis; after seeing the magnitude of the, height of the epidemic and the duration of the epidemic.

JR: So, this is been understood, tested, accepted as ……a medically proven kind of a number?    

Exactly

JR: That is not in doubt?

That’s not in doubt.

JR: What do they say about Indian inherent immunity? Some people talk about that, I know you will laugh at it, but I will still ask you. The Indian immunity been higher and the weather, those two factors. What do you say about that?

Weather is yet to come. See, Indian thing is age-old arrogance or the Indian superiority complex. Okay. Indians are somehow different. Genetically we are no different. The other theory people sometimes tend to say is all weak links have been killed off in the past, because we didn’t look after them, they died. Only the strongest one survived; so we are the children of the strongest among the species. Looking at the affect other diseases have had on us, there is absolutely no evidence to support that the Indian gene is different in that sense. Okay, we had small pox, we had influenza, we had all kinds of diseases that came in, we are as susceptible as NIPAH. No disease has shown we have an inherent superior gene.

Take TB for example. India is the world capital of TB. We were never been able to get rid of malaria. So I wouldn’t count on any Indian advantage, except that the BCG vaccination given in India may have some dampening effect on a macro scale, so therefore we may have slightly less burden than a non-BCG country like Italy or Spain etc. But that is not worth counting on very much. However, that may be one factor. That will be seen only in retrospective analysis; after seeing the magnitude of the, height of the epidemic and the duration of the epidemic.

JR: Got it. What about the weather? Last point.   

The weather, as an optimist, I would like to believe weather might make a difference; as a pessimist I would say, ‘no’, weather will not make a difference. As a public health person, I would say don’t count on weather; it is an unknown. So, assume it will have no effect. but if it has an effect, then thank your lucky stars.

This conversation was recorded on 16 April 2020 on a day a BBC report (which went into circulation and is available on YouTube at the link given in this diary) quoted unnamed doctors as saying six patients were brought dead to hospital with signs of COVID-19 but were not tested for the disease.