The Matka of the Covid Elite

There is an interesting side-story to the football World Cup, which was held in France in 1998. When Puducherry (then Pondicherry) was finally handed over to India by the French in 1954, the citizens had the option to choose between French and Indian citizenship. Most of the privileged Pudducherians opted for Indian citizenship, while many of the under-privileged and low-income groups saw a way out and took up French citizenship, quite a few migrating to France as well. During the 1998 World Cup, these “under-privileged (originally from India)” immigrants  played host to the “privileged (traveling from India)”and invited them into their homes for the duration of the World Cup - chances are in Puducherry these same privileged people would never even have dreamt of entering the homes of the under-privileged. The “elite” are defined as “a select group that is superior in terms of ability or qualities to the rest of a group or society”. The French Pudducherians thus became the new Elite for the Indian Pudducherians who had come to see the World Cup, upturning class and caste based rules.

I was reminded of this after reading the SIREN (SARS-CoV-2 Immunity and Reinfection Evaluation Study) study paper[1] that was published on 09 April in the Lancet, which said that depending on the definition of re-infection, between 84-90% of people, who had been previously infected, were protected from reinfection for at least 7 months (the duration of the study), irrespective of the type of SARS-CoV-2 strain. There is no mention of severity if re-infected, but from their study it appears that those who had re-infection had mild symptoms.

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While direct extrapolation of such results to other environments is always a bit of an issue, a small observational study from India by Aparna Mukherjee and her colleagues from ICMR, recently showed a 4.5% re-infection rate [2], though many of these patients reported more severe symptoms than during the first episode. In both studies it is unclear whether those re-infected continued to wear masks or had dropped safety practices.

Essentially therefore, those infected last year in India are by and large protected from re-infection and even if re-infected are likely to have minimal to mild symptoms, a norm we are seeing at the ground level during this second wave as well…and this is based on the observations of multiple intensivists and physicians actively involved in Covid-19 patient management in Mumbai.

Last year, the infection ripped through the low income localities including the slums and chawls and infected most of our household help and other helpers and workers. At that time, during the first nation-wide lockdown, we shunned our help, because we were afraid of contracting the infection from them. Today,  when the second Covid wave is affecting predominantly the  middle and high income groups, ironically, we are not only not shunning them, we are inviting them into our homes and offices with open arms.

If they were a shade better organized and understood all of this, they could actually negotiate a substantial salary hike and better terms as the new “Elite” given that they are significantly protected during this wave.

If only social justice followed direct logic.

While the vast majority of those infected get away with minimal to mild symptoms and a full recovery, there is a small percentage of people who have long-Covid with problems that persist for weeks or months. I doubt they see themselves as part of the Elite…and yet, without trivializing their suffering and/or the loss of near and dear ones, it is now quite clear that prior infection protects from re-infection or severe disease, if re-infected.

The other Covid Elite is the group of  “The Fully Vaccinated”.

A large real-world vaccine efficacy study was published on 15th April [3] in the New England Journal Medicine on the Pfizer vaccine in Israel. It included 596,618 vaccinated and an equal number of non-vaccinated patients and found that 7 or more days after the 2nd dose, the efficacy was 92% for preventing infection, 94% for being mildly symptomatic if infected, 87% for preventing hospitalisation and 92% for preventing severe disease. There was no inference made about the death rate efficacy, though it was 72% protective from death, 14-20 days after the first dose. It is not that those fully vaccinated are completely immune, but the chance of infection and if infected, the chance that the infection will be severe, drops drastically, though it would not be zero as we have seen from a few news reports of post-vaccine deaths in India. Smaller studies out of the United States have also shown similar real-word efficacy [4,5] as has a further analysis of the trial data by Pfizer, which now shows protection for up to six months after vaccination.

So just like those previously infected, the fully vaccinated can be a bit less stressed about contracting Covid-19 and can be a little more relaxed when going to work or interacting with people…as long as they continue to wear masks and not become Covidiot cowboys believing themselves to be super-immune, as has been the case with many of these so-called Elites. And theoretically, the Covid Elite can intermingle with each other, provided they are aware of each others’ status in advance…and maintain safe boundaries.

Figure: The vaccinated and previously infected have much lower risk of infection compared to the non-vaccinated and non-previously-infected. Wearing masks further reduces risk for both groups, while not wearing masks increases the risk for both groups.

The ones who however, fully deserve our utmost sympathy, are those who have had the ability to get vaccinated fully (health care workers, senior citizens, those with co-morbidities, etc), but have chosen not to, because…God only knows why…and I mean…seriously?

Not only does being fully vaccinated matter within the country but globally as well. Depending on which country gets vaccinated when and how quickly, we will have Elite and non-Elite countries, and this inequality will have its own impact on economies, economics and population dynamics. As Angus Deaton, the noted Harvard economist wrote recently [6], population weighted income inequality among countries widened during the pandemic, especially because of declining Indian incomes…this inequality is likely to further widen after the current wave abates in India.

So for the near to medium term, the previously infected and the fully vaccinated are our new Elites, at least till such a time that everyone is either vaccinated or infected, or new strains develop that negate the protective effects of prior infection or vaccines. It is also very likely that we may need annual vaccination or some form of continuous protection for quite a few years to come.

To enter the Covid Elite club though, vaccination is a far far better route than being infected. And however Elite the club may be, it does not take away the need to wear masks, especially in India and definitely at this particular point in time, masks plus vaccines being the best protection there is currently is, as I had written on 07th Feb 2021.

Footnotes

1. Hall VJ, Foulkes S, Charlett A, Atti A, Monk EJ, Simmons R, Wellington E, Cole MJ, Saei A, Oguti B, Munro K, Wallace S, Kirwan PD, Shrotri M, Vusirikala A, Rokadiya S, Kall M, Zambon M, Ramsay M, Brooks T, Brown CS, Chand MA, Hopkins S; SIREN Study Group. SARS-CoV-2 infection rates of antibody-positive compared with antibody-negative health-care workers in England: a large, multicentre, prospective cohort study (SIREN). Lancet. 2021 Apr 9:S0140-6736(21)00675-9. doi: 10.1016/S0140-6736(21)00675-9. Epub ahead of print. PMID: 33844963; PMCID: PMC8040523.

2. Mukherjee A, Anand T, Agarwal A, Singh H, Chatterjee P, Narayan J, Rana S, Gupta N, Bhargava B, Panda S. SARS-CoV-2 re-infection: development of an epidemiological definition from India. Epidemiol Infect. 2021 Mar 26;149:e82. doi: 10.1017/S0950268821000662. PMID: 33766185; PMCID: PMC8027559.

3. Dagan N, Barda N, Kepten E, Miron O, Perchik S, Katz MA, Hernán MA, Lipsitch M, Reis B, Balicer RD. BNT162b2 mRNA Covid-19 Vaccine in a Nationwide Mass Vaccination Setting. N Engl J Med. 2021 Apr 15;384(15):1412-1423. doi: 10.1056/NEJMoa2101765. Epub 2021 Feb 24. PMID: 33626250; PMCID: PMC7944975.

4. Daniel W, Nivet M, Warner J, Podolsky DK. Early Evidence of the Effect of SARS-CoV-2 Vaccine at One Medical Center. N Engl J Med. 2021 Mar 23:NEJMc2102153. doi: 10.1056/NEJMc2102153. Epub ahead of print. PMID: 33755374; PMCID: PMC8008752.

5. Keehner J, Horton LE, Pfeffer MA, Longhurst CA, Schooley RT, Currier JS, Abeles SR, Torriani FJ. SARS-CoV-2 Infection after Vaccination in Health Care Workers in California. N Engl J Med. 2021 Mar 23:NEJMc2101927. doi: 10.1056/NEJMc2101927. Epub ahead of print. PMID: 33755376; PMCID: PMC8008750.

6. Deaton A. Covid-19 and Global Income Inequality. NBER 2021, February