Evolutionary Nature of the COVID-19 Pandemic: An Impending Endemicity?

It is 2022, that is, two years into the COVID-19 pandemic. The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus’s deadly effects appear to be waning globally. Based on the factors such as global case rate, positivity rate, daily death count, virus reproduction rate, susceptibility of the population, social behavior changes (masking, vaccinations, among others), pathogen transitionality, etc., COVID-19 is slowly starting to plummet globally with some nations still experiencing high caseloads due to the much transmissible (compared to the Delta variant) Omicron variant. Currently, the nature of next phase of the pandemic is what is being hotly debated in the scientific community and outside. Is the pandemic about to get over? Are we in the process of transitioning from a pandemic phase to an endemic phase? What would endemicity phase entail? What are other probable future scenarios that could affect public health response to the pandemic? These are some of the questions that would constitute the deliberations in this article.

Defining Endemicity

What does endemicity actually mean? Epidemic means ‘upon the people’ (epi+demos) and endemic means ‘within the people’ (en+demos). An endemic disease is one that becomes potentially stabilized within a population – not vanishing completely but present with symptoms that could be categorized as mild or harmless or even with low transmissibility. This does not mean that global COVID outbreaks would not occur. That said, it is difficult to predict for sure regarding the next phase of the pandemic. After a global Omicron variant surge registering elevated level of COVID-19 cases, the evolving coronavirus seems to be finally transitioning from a pandemic to an endemic phase. An endemic phase could observe lifting of country-specific COVID-19 pandemic-related travel restrictions, mask and testing mandates, among other restrictions. This does not mean that public should confuse COVID-19 with influenza. Thus, the global community needs to be cautious as ever – aware that we might be entering an endemic phase, however, cognizant of the fact that we need to be well prepared of the difficult days ahead! In other words, we need to be extra vigilant during this crucial juncture wherein the world is at the crossroads of overturning this hopefully once-in-a-century global public health crisis. The evolutionary and transitional nature of the coronavirus is what makes it inherently unpredictable to counter completely worldwide. Different national healthcare system approaches and capacities, seasonality, and unfavorable geographic location/distribution would allow more variants to spread successfully. This in turn could lead to prolonged emergency situation with new waves of epidemics cropping up in distinct parts of the world. One risky factor that is emerging is the spread of Omicron subvariant – BA.2. Thus, it might be useful to start thinking about a global endemic resolution strategy for the purposes of COVID-19 pandemic preparedness rather than becoming a casualty of an ‘endemic delusion‘.

Evolution of COVID-19 – A ‘new normal‘

As discussed above, one likely evolutionary scenario for the future of SARS-CoV-2 is endemicity. Humans currently coexist with four known endemic coronaviruses. Their scientific designations, that is, 229E (llama coronavirus), OC43 (bovine coronavirus), NL63 (NetherLand 63), and HKU1 (Hong Kong University 1) are known as common cold coronaviruses. The immunity to these coronaviruses’ wanes with time. Thus, infections can recur throughout the human lifespan. This is the most likely scenario for COVID-19 pandemic within the realm of possibilities. Additionally, some non-mutually exclusive evolutionary scenarios are contemplated in the next sections of this article.

Modified diseases and symptoms

A likely scenario could be a mutant virus producing an altogether different (altered) disease and symptoms. In this scenario, the SARS-CoV-2 could infect new cells in the human body. That is, the coronavirus could infect and affect other organ systems rather than predominantly infecting and affecting the respiratory system only. The ultimate effect on the human body is difficult to predict as it depends on the severity of organ(s) damaged – intestine, kidney, and the central nervous system.

Recombinant coronavirus

Current evidence suggests that there is a likelihood that SARS-CoV-2 evolves into a novel hybrid – combination of genetic material of the human SARS-CoV-2 and the genetic material of an existing animal coronavirus. Given the huge caseloads of SARS-CoV-2 infected humans, there is a good probability that someone somewhere on this planet might be simultaneously infected with SARS-CoV-2 and an animal coronavirus. SARS-CoV-2-infected humans who have close contact with coronavirus-infected animals could serve as hosts for the novel recombinant viruses. Regardless of where and how novel hybrid variations of coronavirus might arise, the recombinant virus could easily diminish SARS-CoV-2 immunity and could even have different disease genetics than what has been observed in context of COVID-19 and its variants.

Exploitation of human immune response

There is likelihood that the future scenario could entail a variant that exploits human immune response. The major variants of SARS-CoV-2 virus such as Alpha through Omicron (and now reportedly Deltacron) led to virus evolution that helped evade the human immune system. Further, there is a possibility of exploitation of the immune system. For instance, when humans are infected with dengue (not a coronavirus), the immune system produces an immune response entailing illness with high fever and muscle and joint pain. The initial immune response to dengue makes the individual immune to future exposures with that same type of dengue virus. However, if the person gets a reinfection from dengue-type virus, the initial infection increases the severity of disease(s) instead of providing protection against it. This is due to an effect called ‘antibody-dependent enhancement‘ (ADE) of virus infection and disease. This is worrisome because SARS-CoV-2 may evolve to use ADE to increase virus growth and transmission, and a new or hybrid variant could explosively spread through immune populations across the globe.

Conclusion

All of the above listed future scenarios are equally likely, however, my hunch is that SARS-CoV-2 will enter a phase of endemicity in the months to come. That said, other scenarios discussed in this article are within the realm of possibility – altered disease, recombinant viruses, and/or exploitation of immune response. Some other scenarios (not discussed in this article) that might take place is infection transmission from humans to animals and spillover effects of reinfection from animals back to humans. Further, there could be a situation where there is an uptick of transmissibility from chronically infected people with ‘long Covid‘ to immune populations. All these scenarios could decide how the COVID-19 pandemic end game will play out. A new coronavirus variant could emerge anywhere in the world and spread like wildfire in a matter of few weeks as has been the case with successive variations of the evolving coronavirus. The hope is that COVID-19 would recede rather than intensify from the current scenario.

In closing, we are about to reach there but we are not quite there yet. This translates to public health policy measures to be centered around masks and vaccines (including booster shots to counter variants). Therefore, the pandemic end game still seems like a waiting game! It remains to be seen which way the wind blows.

COVID-19 Pandemic and Strained Global Medical Waste Management Systems: An Environmental Health Issue

Hello Blog Readers and Podcast Listeners!

In today’s topic, I am going to discuss about a grave issue related to COVID-19 pandemic, that is, the issue of medical waste management and climate crisis. A clear negative externality of the pandemic is the medical waste produced since the inception of the pandemic. Healthcare waste including masks, gloves, gowns, testing kits, personal protective equipment (PPE), vials, syringes, and needles – in millions of tons of medical waste!

The World Health Organization recently released a report conducting global analysis of healthcare waste in the context of COVID-19 pandemic. Globally, the latest data indicates that one-third global healthcare facilities do not safely manage medical waste. This number goes up to 60% for least developed settings. The pressure of medical waste was observed to be more in least developing countries, especially due to lack of safe and proper waste management services in those countries. The COVID-19 pandemic has led to huge spikes in medical waste, straining under-resourced healthcare facilities, and exacerbating negative environmental impacts from solid medical waste on public health. According to the report, the COVID-19 pandemic waste from healthcare facilities includes 144,000 tons of syringes, needles, and safety boxes from 8 billion doses of vaccine; 2,600 tons of mostly plastic waste and 731,000 liters of chemical waste from at least 140 million test kits. This also includes 87,000 tons of PPE shipped via a United Nations emergency initiative alone.

However, the report captures only medical waste volumes generated from PPE, COVID-19 testing, and vaccinations from March 2020 to November 2021. The data is sourced from the United Nations COVID-19 Supply Portal, which represents only a small fraction of global procurement. The global analyses encapsulates neither the substantial amounts of pandemic commodities that have been procured outside the United Nations system, nor COVID-19-related waste generated by the general public, including surgical masks. Thus, the actual medical waste would surmount to a much larger size and impact.

So, how did the medical waste problem start?; what are the consequences?; India’s case; future solutions for low- and middle-income countries (LMICs), and recommendations targeted at global, national, and facility (local) level. Let’s discuss!

The COVID-19 pandemic struck in December 2019/January 2020, and accelerated globally through March 2020. Sudden chaos resulted in severe and mounting disruptions to the global supply of PPE. Initially, due to rising aggregate demand for PPE (including hoarding), there was a global shortage of PPE. This also resulted in rising deaths of healthcare workers (including needle-stick injuries, burns, and exposure to pathogenic microorganisms). Thus, the immediate focus of global efforts was to increase availability of PPE. Since, the United Nations and its Member States grappled with the urgent task of securing supplies and assuring their quality, less attention and resources were devoted to the pandemic-related safe medical waste management. resulting in poor solid waste management services, especially in LMICs.

Globally, countries lacked the capacity to manage existing medical waste loads, let alone increases in waste volumes during pandemic. Further, this has weakened our fight against climate crisis and accelerated environmental degradation. The pandemic tested the resilience of health systems globally, with dire consequences for least developed settings with poor waste management, lack of proper water and sanitation, and poor quality of healthcare.

So, where does India stand?

In India, recycling of plastics from medical waste reduces healthcare waste volumes that need to be treated. That said, India generated approximately 100 tonnes of daily COVID-19-related medical waste during the first wave of the pandemic. This is in addition to the 609 tonnes of waste generated daily from routine health services. This makes it a total of at least 700 tonnes of waste generated per day. Albeit the total available capacity for incineration of pandemic waste in the country is 840 tonnes, the capital city of New Delhi accounts for about 10% of India’s daily COVID-19 waste generation but has only two incinerators. During the first wave, 70% of this capacity was being used, and measures were needed to ensure that capacity was not exceeded by sending waste to industrial incinerators and centralized waste treatment centers. Thus, in order to address the pressing issue of increased pandemic medical waste, the Central Pollution Control Board, under the Ministry of Environment, produced a set of waste guidelines in 2020. The guidelines emphasized the importance of waste segregation. The ministry regularly amended the guidelines in an effort to further reduce the amount of waste incineration and placed a greater focus on non-burn and environmentally sustainable technologies and practices, such as autoclaving, microwaving and recycling by state-approved facilities. Training in local languages on COVID-19-appropriate waste disposal and hygiene practices was conducted, and mass media communication was used to educate the general public on management of COVID-19 waste generated at home. Simultaneously, the ministry launched a COVID-19 medical waste mobile application to track generated waste amounts, as well as transport and reception at the treatment centers. This includes tracking of waste vehicles to prevent theft of waste and unauthorized recycling of waste.

Whilst conducting a case study on India, the report noted a number of indigenous solutions that were trialed during the pandemic. These included conversion of COVID-19 waste into clean energy (hydrogen fuel) using sunlight, and conversion of PPE waste into eco-friendly construction materials, including construction bricks, bituminous road surfaces and partial replacement of cement in concrete. However, evaluation of their impact was out of scope. The report further noted that waste management proved to be very challenging in rural areas where there are limited waste treatment and disposal facilities.

Furthermore, there is an urgent need to increase the number of authorized, trained waste recyclers to respond to the increase in waste generated. Overall, the emphasis on waste segregation by the Central Pollution Control Board resulted in less waste being incinerated, reducing the environmental impact.

Lastly, the report suggested the need for implementing a waste management system that allows waste generators and authorities to identify the current waste streams and determine how much waste is generated, and what waste can be recycled or reused to reduce the climate footprint. This information will help with planning adequate infrastructure such as storage, and required waste treatment capacities. Moreover, it can support healthcare facilities to monitor adequate segregation and evaluate performance of the waste tracking system.

Drawn from various global health system experiences, some of the innovative and scalable solutions for improving environmental sustainability of safe medical waste management that were noted by the World Health Organization are: a) reducing the amount of unnecessary PPE through safe and rational use; b) using sustainable packaging; c) development of reusable masks and gloves; d) use of recyclable PPE; e) implementation of reverse logistics and centralized treatment of waste using non-burn technologies; and f) investment in local and regional production of medical equipment.

At a global level, following recommendations were suggested in the report:

a) Strengthening coordination among global health donors, logistics, infection and control, medical waste, and environmental actors;

b) Promoting and investing in more sustainable PPE and solid waste management systems; and

c) Supporting behavior change away from single use and overuse of PPE.

At the national level, following recommendations were suggested in the report:

a) Updating, implementing, and regulating medical waste standards and practices;

b) Investing in safe medical waste management services and infection prevention and control; and

c) Monitoring and reporting medical waste practices.

At the facility level, following recommendations were suggested in the report:

a) Improving training, mentoring, and investments for safe and sustainable waste management services;

b) Supporting hand hygiene and good water and sanitation practices; and

c) Improving environmental sustainability of waste treatment technologies.

In closing, a more holistic approach is required to address the global issue of increasing medical waste. The solutions and recommendations enlisted above do not compromise on safety issues, suggesting that a win-win outcome can be achieved. As the pandemic response transitions into the next phase of endemicity, there is both a need and opportunity to invest in resilient health systems. This includes investing in underlying systems supporting a strong health workforce and waste management system. Implementing the WHO solutions and recommendations will help ensure proactive global responses to effectively counter climate crisis and future public health emergencies. This in turn will lead to promotion of health of individuals, communities, and populations, and ensuring resilient environmental health systems are in place to tackle future waste management shocks.

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The Ugly Effect of COVID-19: ‘Pandemic Pets’

Hi Readers!

This blog post is an emotional appeal rather than an opinion piece. As you must have guessed from the headline of this post that this blog is going to be more about Animal Rights. It is also about reflecting on the ‘ugly trend‘ of pet abandonment emerging as people are surrendering ‘pandemic pets’ to shelters, now that restrictions are slowly getting lifted and people are heading back to their ‘new normal’ lives.

Let’s first understand what I mean by ‘pandemic pets‘. So, what essentially was a byproduct of pandemic is that there was a rise in pet adoption/purchasing during the pandemic. However, as COVID-19 restrictions are being eased and people head back to offices for their jobs, the pets being adopted during the pandemic (the so-called ‘pandemic pets’) are being returned to shelters. Here, we need to acknowledge the fact that the pandemic still looms large, thus, the actual pet returns number would be much higher once the pandemic approaches its end and in the post-pandemic phase.

Separately, as an animal lover, past pet owner, and promoter of animal rights, this makes me feel anguished! So, what really happened in the pet adoption space since the advent of the pandemic? Let’s discuss!

Based on various research studies and news reports, there was an increase in pet adoption. Pandemic did actually enhance public interest in pet adoption. According to a study conducted in May 2021, there was an increase of global interest in pet adoption immediately after the World Health Organization declaration of the pandemic. The study conducted a Google Trends search using keywords related to pet adoption. Relative search volume (RSV) was scored between 0 and 100 for the lowest and the highest, respectively. Top countries contributing to the data set included Australia, the United States, Canada, New Zealand, the United Kingdom, Singapore, the Philippines, and Malaysia.

From 2015 through 2020, the observed global RSV for the categories of pet, dog and cat adoption peaked between April and May 2020 (the early epidemic phase of the pandemic). Interestingly, the interest in cat adoption remained sustainably high (somewhere 8 months on in the pandemic), possibly reflecting the feline acclimation to indoor living. The study concluded that the global interest in pet adoptions surged in the early phase of the pandemic but not sustainably.

Now that we might be approaching the end of the pandemic, or most importantly transitioning towards an equally deadly ‘endemic’ phase, global concern would be on more or less transmissible variants countered through vaccine trials targeting various variants as time progresses. However, that’s a separate topic for another blog!

Some news reports suggested that there was an increase in pet returns due to misjudgement on the part of pet owners regarding pet ownership costs. This data is specific to Ontario, Canada. So, what really increased pet adoption application rates? During the beginning of pandemic, people were self-isolating and working from home, the pandemic provided a window and presumably the best time to get a new pet and, for many, it was their first time doing so. The pet adoption applications have soared since the pandemic hit. Toronto Humane Society received over 11,000 applications during the first few months following the initial pandemic lock down. Similar spikes in pet adoption interest was noted by Action Volunteers for Animals, etc.

On the one hand, Credit Canada (a federal agency providing credit counseling) reported an increase in clients with debt issues who are new pet owners. Major cost heads for owning a pet is the fixed or rather sunk costs involving purchase or adoption fees for a pet. Then there are variable costs such as veterinary visits, training, grooming, pet sitting, dog-walking, and monthly food bills. Some pet owners may also choose to purchase pet insurance (30 dollars per month for cats and 40 dollars per month for dogs). This is an overhead cost but very much recommended as you never know when that unexpected emergency visit to veterinary center comes up!

On the other hand, for pets, sudden changes in lifestyle of the owner and separation resulted in higher rates of separation anxiety.

On the contrast, not every news is negative. There’s mixed news coming from the United States. On the one hand, new data survey released by the The American Society for the Prevention of Cruelty to Animals suggested that overwhelming majority of pets (90 percent dogs and 85 percent cats) acquired during the pandemic remain in their homes and people are not returning pandemic pets in large quantities. That said, there are reports that US dog shelters are struggling with pet returns after pandemic adoption boom.

In Canada, the picture looks very grim. Although the pandemic pets emerged as a lifesaver to many Canadians during COVID-19 isolation, the shelter numbers i.e. pet returns are also increasing exponentially. The shelters are now reporting overcrowding.

In closing, pet owners (first time or second time or whatever time) need to be more aware of the important elements involved in buying pets such as pet budgeting, monthly cost estimation, for approximately 10 years on average, etc. Thus, having more time at home does not make everyone pet-ready! Doing detailed research before pet-adoption or buying is required to reduce pet abandonment. Pet owners need to deeply think about post-pandemic pet care and educate themselves about the different breeds, dog exercise requirements, dog size, pet temperament, and sociability, to name a few. In simple words, pet ownership is a big responsibility and should not be taken lightly. We all collectively must be more vigilant and responsible for our actions. We must safeguard animal rights and genuinely take interest in pet adoption and care. Perhaps, the way forward is provision of enhanced education and support to the pet owner(s). This will be key to minimizing the ugly trend of pet abandonment and rising separation anxieties reported among pets.

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COVID-19 Pandemic Effect: An Increased Public Health Literacy?

In these unprecedented times of COVID-19 pandemic, an infodemic of misinformation has enveloped the social media. On the one end, it has very serious consequences with negative externalities such as misinformation and disinformation eroding trust in public health authorities and news media. However, in this piece I wonder if it has led to positive externalities in the form of enhanced public health literacy? What COVID-19 has done is that it has embedded features of public health promotion at the foundational level of human development. The salient health elements of hygiene, sanitation, handwashing, masking, and vaccines, among others became vital techniques to counter the deadly global waves of the pandemic. So, has the pandemic increased scientific knowledge absorption? Let’s discuss!

In my personal opinion, I have experienced an average increase in scientific vocabularies. People are becoming more aware of concepts taught in biology, immunology, and public health. Some of the common household words (in the online and offline world) were ‘herd immunity’, ‘reproduction rate’, ‘positivity rate’, the word ‘pandemic’ itself, among others. Further, people are somewhat more aware that vaccines have an approval process and an authorization process.

On the educational and professional front, people are becoming more aware of healthcare programs (epidemiology, virology, etc.) and roles (sanitarians, epidemiologists, etc.). The pandemic has shown the non-scientific world how scientific world works through trial and error approach. That’s positive news! This further helps increase acceptance rates of community health measures and strengthens the overall coalition supporting public health, both as a discipline and profession.

COVID-19 has definitely increased knowledge about cutting-edge science. For example, I recently graduated in public health with a MPH degree. However, I still didn’t know what mRNA vaccines are? It was not part of the curriculum. However, because of the pandemic and also with so much focus on public health in recent times via news media, social media, and podcasts, knowledge democratization has become possible. Suddenly, people without any background in health sciences, knew important scientific concepts. People finally know what public health is!

Lastly, what remains to be seen is that this scientific knowledge will stay among public for long or not. It is still early days to answer this question as the pandemic looms large. There are growing concerns over the end of the pandemic and protests related to increased COVID-19 restrictions since the advent of more transmissible Delta and Omicron variants. Perhaps, resilience is the key word. Community resilience in the form of general resilience, resilience of trust in health institutions, and the resilience of hard facts in this crisis. This would prove to be a boon for both the scientific research world and the non-scientific world alike.