Editorial 1 : ‘We need to stop the fear mongering on vaccines’
Introduction
The COVID-19 pandemic has exacerbated a fringe anti-vaccine movement, and it is not surprising that recently, a rare life-threatening post-vaccination complication named ‘thrombosis with thrombocytopenia syndrome’ (TTS), was the topic of well-circulated disinformation on social media.
Risk vs benefit
- In some nations, with other available highly effective options, recombinant DNA vaccines were paused.
- In India and other nations, a risk-benefit analysis, and consideration of alternatives, favoured continuation.
- Nothing could be further from the truth, as illustrated by objectively considering the risk, benefit, and alternatives that guided India’s vaccine policy during the pandemic.
- First, risk. TTS was found to occur most commonly in fit, healthy, young women around thirty years of age at a very low frequency of around one to two per lakh (100,000).
- At a general population level, it was estimated to occur at only about two to three cases per million people vaccinated.
- To put these numbers in perspective, the Ministry of Road Transport and Highways estimates annual deaths in road accidents at about ten per lakh. Thus, the highest estimated risk of TTS is still much lower than the annual risk of dying in a road accident.
- Second, benefit. Covishield was associated with over 80% protection against severe COVID-19 and over 90% protection against death in multiple studies, including during the severe Delta wave.
- For a 50% chance of contracting COVID-19 and 0.1% risk of death, this corresponds to a mortality benefit of around 40 in 100,000 - that outweighs the risk by far.
- Reducing disease severity is important for minimising immediate suffering and stress on healthcare systems, as well as minimising long-term disability and risk of premature heart attacks and strokes.
- This risk was observed very early in the pandemic, even before vaccines were developed, and was found to be reduced by vaccination. The current disinformation about vaccines and young heart attacks ignores this important data from large studies.
The vaccine and TTS
- It seems that this is a rare side effect of the current recombinant DNA platform technology, since a similar vaccine used in America, developed by Johnson and Johnson, also increased TTS risk.
- Antibodies to platelet activating factor (PF4) are seen in most patients, similar to another drug-induced TTS – heparin-induced thrombosis and thrombocytopenia.
- Overall, it seems that the same powerful induction of immune response that makes DNA vaccines effective also carries a small risk of inducing auto-immune responses that lead to side effects.
- People who benefit the most from vaccines – older people and those with diabetes – seem to also be least likely to develop such aberrant responses.
- A similar pattern has been seen with mRNA vaccines and autoimmune myocarditis, where young healthy males were most at risk.
- Killed virus vaccines appear to be safer but induce lower levels of immune response, conferring lower levels of protection against severe disease and death. This was importantly seen in elderly deaths during the 2022 Omicron wave in Hong Kong.
No perfect choice
- As in much of medicine, there is no perfect choice. Further research is essential to maximise benefits, minimise risks, and increase alternative options.
- However, at any given point of time, a decision must ultimately be made within available options, given available knowledge.
- Despite having given nearly a billion doses of Covishield, almost all our knowledge of critical side effects like TTS comes from outside India.
- Second, while it is acceptable to choose an imperfect best option, we need to be nimbler in creating alternatives. For example, protein-subunit vaccines like Covovax (also made by Serum Institute) could have replaced Covishield for boosters.
- SARS-CoV2 never quite left. It keeps circulating and evolving to escape immunity, periodically giving rise to infection surges that are mostly ignored due to milder symptoms in a partially immune population.
- For example, based on viral load in sewage and sequencing of wastewater, we had a silent surge of undiagnosed JN.1 SARS-CoV2 infections in January this year.
Conclusion
- To conclude, vaccines are some of the most effective public health interventions against infectious diseases. We need to stop the fear-mongering and celebrate the great Indian COVID-19 vaccination drive that saved innumerable lives.
Editorial 2 : Reservation within Constitutional bound
Context
A political slugfest has emerged over the reservation issues.
Constitution and affirmative action
- The Constitution aims to secure social justice while guaranteeing equality as a fundamental right.
- Articles 15 and 16 guarantee equality to all citizens in any action by the state (including admissions to educational institutions) and public employment respectively.
- To achieve social justice, they also enable the state to make special provisions for the advancement of OBC, SC and ST. OBC is a collective term to classify socially and educationally backward castes.
- Many States also classify certain castes as the Most Backward Classes (MBC). The reservation percentages vary from State to State.
- In the Indra Sawhney case (1992), the Supreme Court upheld the 27% reservation for OBC. It opined that caste is a determinant of class in the Indian context and backwardness cannot be determined solely on economic criteria.
- However, to uphold the basic structure of equality, it fixed a cap of 50% for reservations unless there were exceptional circumstances.
- The reservation of OBC (27%), SC (15%) and ST (7.5%) resulted in a total reservation of 49.5%.
- The court also provided for excluding the creamy layer from OBC with an income limit currently at ₹8 lakhs per annum.
- Children of parents, either of whom entered the government service (Centre or State) as Group A/Class I officers and children of parents, both of whom entered as Group B/Class II officers are also excluded.
- In the Janhit Abhiyan case (2022), the court by a majority of 3:2 upheld the constitutional validity of the EWS reservation. It held that economic criteria could be a basis for reservation.
Current debate
- The Constituent assembly that framed our Constitution was against reservation solely based on religion.
- The Constitution guarantees the prohibition of discrimination only based on religion under Articles 15 and 16.
- The inclusion of all Muslim communities within the OBC quota in Karnataka forms the basis for the BJP’s campaign at present. However, it is pertinent to note that sub-categorisation for Muslims within the OBC quota has been present in Karnataka since 1995.
- The four per cent sub-categorisation for Muslims introduced in 1995 by the H. D. Deve Gowda-led government was removed by the previous government led by Basavaraj Bommai.
- This was redistributed amongst the OBC in the Hindu community. However, after observation by the court in the case challenging this order, the status quo continues.
- Muslim and Christian communities who are socially and educationally backward are provided reservations under the OBC/MBC category.
- There is also sub-categorisation within the OBC/MBC quota for Muslim communities in States like Kerala, Tamil Nadu and Andhra Pradesh.
- All This is because the term used in the Constitution is ‘socially and educationally backward classes’ and could encompass backward communities from all religions.
- It is only for being a member of a SC, ‘The Constitution (Scheduled Castes) order, 1950’ specifies that the person should profess only Hinduism, Sikhism or Buddhism. There is no such requirement for being a member of a ST.
The way forward
- Reservation is affirmative action meant to balance the historical discrimination faced by OBC, SC and ST communities.
- Rohini Commission was set up to provide recommendations on sub-categorisation amongst OBC castes. Though the findings of the report are yet to be made public.
- There must be effort nevertheless to deliberate on these matters and frame suitable policies such that the benefits of reservation progressively reach the extremely marginalised sections.
- The aim should be towards the continuous pursuit of social justice while maintaining a harmonious balance with equality guaranteed in the Constitution.