Following an increase in international arrivals in summer 2021, new variants and outbreaks created new uncertainty.
Following the detection of the Omicron variant in November 2021, the US and other countries around the world rapidly instituted new travel restrictions, including bans from specific regions. In addition to blanket bans, many countries have been changing their testing and quarantine requirements for travelers - by December 2021 this was occurring on an almost daily basis.
The global tourism industry has been particularly hard-hit by the pandemic. International tourism has been almost entirely suspended at times, and nearly every country has implemented some type of travel restrictions. Global GDP contracted by 4.3% in 2020, according to the World Bank, and the impacts have been felt throughout supply chains and economies. In the US, for example, there were an estimated 200,000 more permanent business closures between March 2020 and February 2021 than would have been normal for the period.
In 2021, tourism began to rebound as some countries reopened, and global tourist arrivals rose sharply during the summer. However, the situation soon worsened.
International tourist arrivals declined by 84% between March and December 2020 compared with the period a year earlier, according to the World Tourism Organization, and parts of Asia, Oceania, and Africa saw the biggest downturns. This has been particularly concerning for the many small economies that rely heavily on international tourism and cruise ship arrivals (the G20 anticipates poorer nations will likely experience lasting health and economic damage due to COVID-19, more so than what they experienced after the global financial crisis of 2008).
The UK planned to allow for non-essential international travel in May 2021, by permitting fully-vaccinated travelers from countries with low infection rates to enter. During that month, US airports saw their busiest day of travel since February 2020. The emergence of new variants tends to prompt new travel restrictions, however. While grappling with the Delta variant in August 2021, Chinese officials vowed to restrict all non-urgent or unnecessary cross-border travel. US officials had also cited concerns about the Delta variant and resulting rises in cases.
The European Union also agreed to reopen its borders to fully-vaccinated travelers from countries with low infection rates the following month - as European countries devised their own quarantine and testing restrictions. The US did not allow fully-vaccinated foreign travelers to enter until November 2021.
Vaccine Distribution Rates and Mandates
Global distribution has been sluggish, and in many cases, mandates have been needed to boost coverage. A number of countries have implemented related publicity campaigns, and both governments and private companies have initiated mandates for at least some parts of the population.
The first mass vaccination program against COVID-19 started in Britain in December 2020, but global distribution has been sluggish. The COVAX program, which seeks to ensure global access to vaccines, delivered its first doses to Ghana in February 2021 and by December it had shipped more than 610 million vaccines.
The World Health Organization initially set a goal for all countries to vaccinate 10% of their populations by the end of September 2021, though 56 did not meet that goal - many in Africa. The WHO now aims for the vaccination of at least 40% of the global population by the end of 2021, and 70% by the mid-2022. By November 2021, more than 7 billion doses had been administered globally, and at least 14 different vaccines had been administered worldwide - with hundreds more in clinical development. However, vaccination rates vary by country (often due to access), and many places struggle to encourage uptake (which can lag due to hesitancy).
Governments can not only increase vaccination rates with mandates and strict rules, but also, according to experts, play important roles when it comes to increasing public trust in COVID-19 vaccines - through effective public health messaging, and creative, well-funded efforts to ensure inclusive access.
Indonesia and Micronesia, for example, have mandated vaccination for everyone eligible. In many instances, such mandates have increased prior vaccination rates significantly. Yet, several countries in the Asia Pacific region that initially had slower rollouts than the US and Europe have since achieved some of the highest vaccination rates in the world - even without mandates. France increased its overall vaccination rate by implementing a vaccine passport system, in which people had to demonstrate proof of a negative test, recovery from COVID-19, or full vaccination status to enter public places like restaurants. Several other European countries, including Austria, Germany, the Czech Republic, and Slovakia, announced in November 2021 that they would impose more stringent public health restrictions on the unvaccinated. Malaysia enlisted the Red Cross’s help to give shots to people living in the country illegally, and other hard-to-reach groups.
Testing and Surveillance of Covid-19
Misinformation of Covid-19
The World Health Organization recommends that comprehensive surveillance programs remain in place even in areas where COVID-19 has been suppressed - to detect new outbreaks at an early stage.
Many countries also have testing requirements for foreign travelers. In December 2021, the US began requiring that incoming, vaccinated travelers receive a negative test result within 24 hours of flying.
Some countries have employed population-wide surveillance testing programs (in October 2020 Slovakia became the first to test its entire populace). Surveillance testing involves a large subset of the population, regardless of whether people are symptomatic or have been exposed to the virus; it can help public health officials monitor infection rates, identify outbreaks, and better understand trends. Antigen tests may be less accurate than the PCR version, but they are fast and relatively reliable
Wastewater surveillance is another option, as it can contain detectable traces of RNA from the coronavirus. At the University of Arizona, for example, routine sewage testing enabled officials to promptly identify the presence of the virus in student housing. Efforts are also being made to detect variants through genetic sequencing, and keep public health measures, vaccines, and therapeutic interventions up to date. A genomic sequencing program in the United Kingdom helped identify the Delta variant, for example, and genetic sequencing helped identify the Omicron variant in South Africa. In both cases, scientists found mutations in spike protein that made it easier for the virus to infect human cells.
Throughout the pandemic, public health officials have sought to identify and isolate people with COVID-19 before they can spread the disease. Within two weeks of the publication of the reference genome of SARS-CoV-2, the first diagnostic test to detect it was issued. The RNA genome of SARS-CoV-2 can be directly identified by highly-accurate PCR tests. Antigen tests detect viral proteins, and while they are less accurate than PCR tests, they do deliver fast and relatively reliable results.
The sensitivity of a COVID-19 test can depend on the timespan following initial infection - viral load typically declines after someone develops symptoms, and many people are infectious up to five days before developing those symptoms. Still, tests are a critical public health tool. After identifying a COVID-19 case, contact tracing can be used to identify and isolate secondary contacts; in South Korea, authorities used interviews and credit card transaction records to identify thousands of people linked to an outbreak at a nightclub, for example.
Misinformation has also contributed significantly to vaccine hesitancy - widely-spread fabrications have included suggestions that COVID-19 vaccines can alter DNA, that they contain microchips to track people, or that they cause infertility.
False and harmful information about COVID-19 continues to proliferate as the disease spreads. The World Health Organization has used the term “infodemic” to describe the overabundance of information regularly accompanying novel disease outbreaks, much of which is misleading or fabricated.
Now, this misleading and false information can be shared with unprecedented efficiency. One survey conducted in November 2021 found that at least three-quarters of US adults believed or were unsure about at least one false statement related to the pandemic, and in Iran hundreds of people died after drinking toxic methanol that had been touted on social media as a cure for COVID-19. Many millions of false messages have been removed from popular social media platforms, but they continue to spread
One study published in Nature in early 2021 quantified the amounts that people exposed to online misinformation about vaccines were less likely to take one - with a decline of 6.2 percentage points for someone in the UK recently exposed to misinformation, even after they had previously stated they would definitely accept one.
Governments at the international, national, and local levels have meanwhile implemented messaging campaigns meant to combat pandemic-related misinformation. For example, the WHO partnered with the UK government in 2020 to produce a series of websites and apps meant to raise awareness about COVID-19 misinformation. One such campaign showed members of the public how to report false or misleading information on popular social media platforms.
Several organizations have launched efforts to combat misinformation about the pandemic. Major news publishers, including the Atlantic, The New York Times, and The Wall Street Journal have made coronavirus-related material available to non-subscribers during the pandemic to help blunt the use of fake news, for example. Meanwhile companies like Meta, the parent of Facebook and Instagram, have come under immense pressure to remove false information from their platforms - including denials of the existence of COVID-19, claims that certain groups of people are immune to the virus, or misrepresentations of the efficacy of COVID-19 vaccines. Meta says it had removed about 20 million such false claims as of August 2021. Similarly, Twitter and Google have been pressed to reduce and flag potentially harmful misinformation.
Behavior that Reduces Transmission
The risk of infection decreases in relation to distance and time following the exhalation of infectious particles by a person with the disease. Public health officials have recommended maintaining six feet (two metres) of distance from others, though if an infectious person has been indoors for more than 15 minutes the virus concentration in the air may be enough to transmit to people more than 6 feet away. This is even more likely if the infected person is raising their voice or breathing heavily, or if the indoor space is not adequately ventilated. Studies have found that reducing the occupancy of crowded indoor spaces particularly where people are unmasked to eat or drink can help reduce the spread of the disease.
Evidence suggests that masks reduce the odds of catching COVID-19, and the make and fit of the mask matter.
In the first part of 2020, experts suspected that the coronavirus that causes COVID-19 was spreading via contaminated surfaces. However, we now know that the virus primarily spreads through respiratory droplets - and that the most effective mitigation measures target airborne spread. Transmission can largely be avoided through physical distancing, adequate ventilation, limiting indoor gatherings, and the use of well-fitting masks.
In April 2021, the US CDC said that contact with a contaminated surface had less than a 1 in 10,000 chance of causing infection. Other early COVID-19 prevention measures are no longer supported by scientific consensus as well - temperature checks at entrances have been dismissed as inaccurate, and the US Restaurant Association actually recommends against their use.
Transmission of the virus is far less likely outdoors, and evidence suggests that masks reduce the chances of both transmitting and catching COVID-19 - although efficacy varies according to the make and fit of the mask. A well-fitted N95 mask filters out approximately 90% of incoming aerosols, while surgical and cloth masks are closer to 67% effective in terms of protecting the wearer but can still prevent virus transmission.
There may well be spikes or surges in confirmed COVID-19 cases when large groups of people head indoors for holiday gatherings, or due to cold weather, and do not wear masks or ensure adequate ventilation. In contrast to social distancing and masking measures, simply disinfecting high-touch surfaces does little to stop the spread of COVID-19.
The evolution of covid-19
The Virus and The Disease
At roughly the same time the Delta variant was accounting for most sequenced cases, the Omicron variant was identified
SARS-CoV2, the virus that causes COVID-19, was first identified in early 2020. While little was known at the time, our understanding of both the virus and the disease has expanded considerably. Experts initially believed the virus was primarily respiratory, as its symptoms included a shortness of breath and coughing.
However, there is growing evidence that it can impact other parts of the body - including the heart, kidneys, and brain - in ways we are still trying to understand. Many people experience lingering symptoms or health problems up to a year after infection; this “long COVID” may involve a loss of taste or smell, an inability to concentrate, heart and kidney conditions, excessive fatigue, or difficulty breathing.
While this appears to impact people in their 30s, 40s, or 50s, young people may also experience lingering impacts - multisystem inflammatory syndrome (MIS-C) is a rare, treatable condition that can develop in school-aged children between two and six weeks after COVID-19 infection. In addition, we now know fully vaccinated people can become infected in “breakthrough cases.” These are often mild; as of August 2021, fewer than 0.01% of such cases documented in the US had resulted in hospitalization or death.
As our understanding of the disease has evolved, so has the virus. SARS-CoV-2, like other RNA viruses, is prone to making errors in its genetic code during replication, which results in roughly two mutations per month during a large-scale outbreak. These mutations cause variants; by the week of 21 November 2021, the Delta variant accounted for nearly 99% of all sequenced cases worldwide. Delta was first identified in India in October 2020, and designated as a Variant of Concern (VOC) by the World Health Organization in May 2021.
In November 2021 the Omicron variant was identified, leading to new travel restrictions and other more concerted efforts to contain the spread. The WHO defines VOCs as relatively more transmissible, virulent, or vaccine resistant. Early indications suggest the majority of vaccines in use retain significant efficacy against the majority of variants - and the most common difference in each new strain has been, to date, transmissibility. However, medical tools and public health responses must continually be updated as new variants are identified. It is now assumed that we will need vaccine boosters to maintain population-level immunity amid the inevitable waning of efficacy and more infectious variants.
SARS-CoV-2 was detected in late 2019, and the spread of COVID-19 soon followed. COVID-19 causes clinical symptoms including shortness of breath or difficulty breathing, fatigue, fever, malaise, and loss of sense of taste or smell. Symptoms of the disease typically begin within a week of exposure, but may take up to 14 days to appear.
The virus can be transmitted before people know they are infected; evidence suggests that at least 30% of infected people will not experience symptoms but may still be able to transmit the virus to others (one study put this as high as 81%).
Quarantine and isolation guidance continue to evolve, and Instructions for what to do following close contact may vary based on vaccination and infection history. The US CDC recommends that vaccinated people test five to seven days after an exposure, and wear a mask around others for 14 days after that exposure. For the unvaccinated, the CDC recommends isolation from others for at least 14 days following close contact with an infected person. A person is typically no longer able to transmit to others 10 days after their symptoms resolve, but some may have persistent issues (“long COVID”) including organ damage (particularly the lungs), loss of taste and smell, and severe fatigue.
Not long after it was first detected in late 2019, the coronavirus SARS-CoV-2 spread rapidly around the world. Coronaviruses had previously caused diseases ranging from the common cold, to Severe Acute Respiratory Syndrome (SARS), and Middle East Respiratory Syndrome (MERS).
Humans are primarily infected by exposure to SARS-CoV-2 in respiratory liquid particles spread when an infected person coughs, sneezes, sings, speaks, or even just breathes heavily. Airborne transmission, in which the virus spreads via smaller, airborne droplets, is also possible.
The original virus is highly contagious - on average, each infection may infect between two and three additional people. Newer variants have even higher transmission rates - someone with the Delta variant may infect between six to seven additional people. This rate depends heavily on behavior. Super-spreading events, where an infected person transmits to many more others than is average have been particularly problematic. Vaccination, mask-wearing, and physical distancing can significantly slow the spread, however, and adults are more at risk than children to severe infections that require hospitalization.
In each case, spreading occurs most easily in crowded and confined settings with inadequate ventilation, especially those where people remain for extended periods.
Covid-19 and Supply Chains
The United Kingdom became the first country to give a green light to an oral antiviral pill for the treatment of COVID-19 in November 2021, when it authorized molnupiravir to treat mild to moderate COVID-19 in adults at risk for severe illness. That same month, the pharmaceutical firm Pfizer released results demonstrating the effectiveness of its Paxlovid pill. Study participants who received it within three days of symptom onset had an 89% reduced risk of COVID-19-related hospitalization or death compared with those who received a placebo. While promising, however, these antiviral treatments are not a substitute for getting vaccinated.
Some antiviral treatments have shown great promise, but none are a substitute for vaccination. Two oral antiviral drugs for the prevention of severe COVID-19 that are in development, molnupiravir and Paxlovid, have performed particularly well - and unlike other treatments they could potentially be taken at home. In October 2021 the pharmaceutical company Merck released study results demonstrating that molnupiravir significantly reduced the risk of hospitalization and death in high-risk patients with mild or moderate COVID-19. This randomized, placebo-controlled, and double-blind study found that patients taking the drug were half as likely to be hospitalized or die from COVID-19 compared with those taking a placebo.
Oral antiviral drugs are a major focus, and there is hope that they may dramatically reduce fatality rates. By February 2021, both the European Medicines Agency and the US Food and Drug Administration had approved the use of the intravenous antiviral drug remdesivir for those hospitalized with COVID-19.
There have been marked improvements in the treatment of COVID-19 that have helped mitigate severe cases. A large, randomized evaluation run by the World Health Organization observed that the anti-inflammatory drug dexamethasone reduced deaths by a third among ventilated COVID-19 patients, and by a fifth among other patients only receiving oxygen.
Dexamethasone has been strongly recommended by the US National Institutes of Health for patients requiring supplemental oxygen, and particularly for those requiring mechanical ventilation. In November 2020, the FDA granted emergency use authorization for two monoclonal antibody treatments for COVID-19.
Monoclonal antibodies are laboratory-made molecules that mimic natural antibodies; they can help a patient’s immune system recognize and respond more effectively to the virus that causes COVID-19, and can be used in combination with anti-inflammatory drugs like dexamethasone to dampen exaggerated (and harmful) immune responses in COVID-19 patients.
In the early part of the pandemic, lockdowns in China shuttered factories and delayed the shipment of goods. In response, some US companies shifted manufacturing out of China to other countries - even as the US suffered its own domestic disruptions as the coronavirus spread among workers in meat processing plants, warehouses, and grocery stores, impeding food production and distribution (in April 2020, for example, a meat processing plant producing 5% of the country’s pork closed after 230 workers contracted COVID-19). In August 2021, an outbreak of the Delta variant shut down factories in Viet Nam - the second-largest supplier of shoes and apparel to the US after China. As of that month, only 3% of Viet Nam’s population had been vaccinated against COVID-19. Increased demand for goods has also contributed to shortages - particularly after the economic downturns caused by the health crisis caused shipping companies to anticipate a drop in demand.
COVID-19 triggered widespread supply chain disruptions, as factories and ports shut down amid outbreaks, and companies found themselves at the mercy of shipping container shortages, delays, power supply issues, and labor shortages. The pandemic’s impacts on trade and supply chain logistics have caused shortages and frustration
The cost of shipping a container of goods from Asia to the US rose from about as low as $2,000 pre-pandemic to as much as $30,000 by September 2021. It is unclear when supply chain disruptions and shortages will end; experts suspect they will continue well into 2022. In response, some policy-makers in the US and Europe have proposed re-localizing production. The Organization for Economic Co-operation and Development has warned against this, however - and has said major economies will return to pre-pandemic growth by 2025.
While demand for in-person services certainly declined, Canadians, Americans, and Europeans in particular actually began to spend more on consumer goods to be used at home - like exercise equipment, game consoles, and kitchen appliances. In Asia, factories attempted to meet this increased demand. But they struggled to transport goods amid a shipping container shortage that was amplified as China re-directed the use of containers to deliver COVID-19 protective gear to countries struggling to respond to the pandemic. Large numbers of incoming ships began overwhelming ports, as containers could not be promptly unloaded from them, transported, and used again.
How can the world reach herd immunity against COVID-19 before the second anniversary of the pandemic?
By March 2022 there were more than 440 million confirmed cases globally, and about 6 million recorded deaths - though the actual death toll may be significantly higher. However, we have the knowledge and tools necessary to contain it.
COVID-19 has had an increasingly devastating impact since the World Health Organization first identified a new coronavirus as the cause of a mysterious pneumonia in early 2020.
Rules for the use of masks and vaccines have been deployed broadly, and numerous additional vaccines are in development. In addition, new treatments have been shown to successfully reduce the risk of severe COVID-19. The challenge now is to protect vulnerable populations, while limiting additional economic damage and continuing to monitor a constantly evolving viral threat.
This research paper - How to End the COVID-19 Pandemic by March 2022 - by the World Bank is part of a larger effort to provide open access to its research and make a contribution to development policy discussions around the world.