Research & Policy Briefs From the World Bank Malaysia Hub No. 51 October 7, 2021 Managing Long COVID in East Asia and the Pacific Aneesa Arur, Ergys Islamaj, Young Eun Kim, Duong Trung Le, Aaditya Mattoo, and Aparnaa Somanathan The highly contagious Delta variant is fueling new outbreaks in East Asia and the Pacific (EAP). It is becoming evident that COVID-19 is not leaving any time soon and may be here to stay. Countries with high vaccination coverage show, however, that transition to a relatively benign phase of “managed endemicity” may be possible. At current trends, and given vaccine availability, many EAP countries are expected to vaccinate more than 60 percent of their populations by the first half of next year. Achieving and sustaining high coverage will require improving distribution capacity, overcoming vaccine hesitancy, and expanding regional production of vaccines to ensure reliable supplies for persistent COVID-19. Countries will also need to sustain the process of testing, tracing, and isolation, as well as precautions such as social distancing and wearing masks. Finally, countries need to strengthen their health systems to cope with long COVID. Key Messages transitioning to intensive testing-tracing-isolation. This approach proved very effective and was implemented with varying degrees of The process of testing, tracing, and isolation, which was a successful success in Cambodia, the Lao PDR, and Vietnam, and less so in strategy in 2020, has been less effective against the highly infectious Indonesia and the Philippines. Previous strategies were either not Delta variant in East Asia and the Pacific (EAP). Vaccination, which well-equipped or sufficiently intensive to cope with the highly would have helped reduce mortality and transmission, has been infectious Delta variant, and vaccination has been slow; therefore, slow. Despite the limited availability of vaccines in the near term, countries are being forced to impose longer restrictions on mobility many EAP countries are expected to vaccinate more than 60 (figure 1c). A cross-country econometric analysis reveals that percent of total populations by the first half of 2022, thereby delayed vaccination is hurting economic activity. A 10-percentage transitioning to a relatively benign phase of COVID-19. However, this point increase in a country’s vaccine coverage is associated with an cannot be taken for granted. Countries should improve vaccine approximately half a percentage point increase in quarterly GDP distribution capacity and overcome vaccine hesitancy, while (figure 1d). maintaining the process of testing, tracing, and isolation and continuing precautionary measures such as social distancing and Vaccination faces constraints that differ across countries in the wearing masks. Health systems must be strengthened to deal with region. A survey shows that vaccine availability is now the the lingering presence of COVID-19. And production of vaccines, binding constraint on vaccination in the larger EAP countries like including regionally, must expand to cope with sustained high Indonesia, the Philippines, and Vietnam (figure 2). Smaller, poorer demand and unreliable imported supply. countries such as Papua New Guinea and Fiji have benefited from vaccine donations but some, such as Papua New Guinea, are What is Happening? constrained by inadequacies in their distribution infrastructure. Several countries must still persuade a significant minority of East Asia and the Pacific region is suffering a reversal of fortune. citizens to be vaccinated. In 2020, many EAP countries successfully contained COVID-19 and economic activity swiftly revived as other regions struggled with the What can be Expected? pandemic and economic recession. Now the region is being hit hard by the COVID-19 Delta variant while many advanced economies are Countries with high vaccination coverage show that transition on the path to economic recovery. from the malignant phase of the disease to a relatively benign phase of “managed endemicity” may be possible. Like most other The Delta variant is fueling new and serious outbreaks in the countries, the United Kingdom (UK) initially suffered recurrent region. All major EAP economies, except China, are suffering from waves of the pandemic which were associated with high levels of the largest COVID-19 outbreaks of infection and fatalities since the infection and significant mortality. As vaccination coverage beginning of the pandemic. The Delta variant currently accounts for surpassed 60 percent, the UK relaxed social restrictions allowing over 97 percent of total new COVID-19 cases in Indonesia and for a resumption of economic activity (figure 3). The expectation Malaysia, and over 80 percent in Thailand – the three countries with was that a certain threshold level of immunity, due to a combination frequently reported genome sequencing. of vaccination and infection, would usher in a phase where we still The Delta variant is spreading because pre-vaccine containment see waves of infection but less severe illness and mortality. The strategies are proving insufficient, populations have low reason is that vaccines do not offer sterilizing immunity, critical for immunity, and vaccination has been slow (figure 1a, 1b). In the preventing transmission, and different vaccine types differ in their pre-COVID-19 vaccine era, many countries in the region were able efficacy as far as infection and mild illness are concerned, but most to contain the disease by imposing short periods of stringent offer high levels of protection against hospitalization and death and restrictions on domestic and international mobility and then differ much less in this respect. The current situation is in line with Affiliations: Ergys Islamaj, Duong Trung Le, and Aaditya Mattoo, EAP Chief Economist Office, World Bank; Young Eun Kim, EAP Chief Economist Research Center, World Bank; Aneesa Arur and Aparnaa Somanathan, Health, Nutrition and Population EAP, World Bank. Acknowledgements: Valuable comments, insights, and suggestions were provided from Daniel Dulitzky, Manuela V. Ferro, Son Nam Nguyen, Ekaterine T. Vashakmadze, and David Wilson. Bob Flanagan, Pagma Genden, Wei Han, Pandu Harimurti, Wayne Irava, Edith Kariko, Christophe Lemiere, Nareth Ly, Kate Mandeville, Emi Masaki, Mike Michael, Jose Mousaco, Somil Nagpal, Mesulame Namedre, Anh Thuy Nguyen, Dayo Obure, Sutayut Osornprasop, Eko Pambudi, Anne Provo, Jake Robyn, Hui Sin Teo, Anna Wielogorska, and Shuo Zhang provided survey responses and helpful comments. Nancy Morrison provided editorial assistance. Objective and disclaimer: Research & Policy Briefs synthetize existing research and data to shed light on a useful and interesting question for policy debate. Research & Policy Briefs carry the names of the authors and should be cited accordingly. The findings, interpretations, and conclusions are entirely those of the authors. They do not necessarily represent the views of the World Bank Group, its Executive Directors, or the governments they represent. Managing Long COVID in East Asia and the Pacific Figure 1. The relatively low level of vaccination and high levels of susceptibility are necessitating stringent lockdowns and hurting growth in many EAP countries a. Global vaccine coverage b. Vaccinated, recovered, and susceptible Fully vaccinated Recovered, Infected and Deaths Susceptible Percent 100 80 Fully vaccinated Partially vaccinated World average 80 (at least one dose) 60 60 40 40 20 20 0 Mongolia China Malaysia Cambodia Fiji Lao PDR Samoa Timor-Leste Myanmar Indonesia Vietnam Philippines Thailand Solomon Is. Vanuatu Papua New 0 Guinea NA ECA EAP LAC MENA SA SSA c. Stringency of lockdowns d. COVID-19 vaccinations and GDP growth 6 World Average (percent change since last quarter) 100 4 GDP growth, Q2-2021 EAP Average 80 2 Indonesia China 60 Thailand Index 0 40 Philippines -2 Malaysia 20 y = 0.0429x - 0.7935 -4 R = 0.06923 0 -6 Jan-20 Mar-20 May-20 Jul-20 Sep-20 Nov-20 Jan-21 Mar-21 May-21 Jul-21 Sep-21 0 10 20 30 40 50 60 70 80 COVID-19 vaccinations (% of people with at least one dose) Source: Oxford Covid-19 Government Response Tracker (OxCGRT), Global Economic Prospects June 2021. Note: Panel a and b are based on vaccination observations as of August 31, 2021. In panel b, fully vaccinated and recovered, infected, and deaths populations are assumed to be non-overlapped. Panel c is based on latest observations as of September 21, 2021. EAP=East Asia and the Pacific; ECA=Europe and Central Asia; LAC=Latin America and the Caribbean; MENA=Middle East and North Africa; NA=North America; SA=South Asia; SSA=Sub-Saharan Africa. Figure 2. Delivery delays drive slow vaccination and are perceived as the major problem for larger EAP countries; distribution capacity perceived to be the major constraint for smaller and poorer countries a. Delivered vaccines versus administered b. Delivery delay versus distribution (perception) 100 Distribution capacity, importance Least % of eligible population 7 Thailand Fiji 80 Fully vaccinated, Cambodia Indonesia 6 60 Vietnam Cambodia 5 Indonesia 40 Philippines Lao PDR 4 Thailand Fiji Philippines Samoa Solomon Vietnam Timor-Leste 3 20 Myanmar Lao PDR Islands 2 Samoa Myanmar Kiribati Timor-Leste Most 0 PNG Kiribati 1 Marshall PNG Vanuatu Solomon Isl Islands 0 0 20 40 60 80 100 0 1 2 3 4 5 6 7 Vaccines delivered to country, % of eligible population Most Least Delivery delay, importance Delivered vaccines: <40% 40%-80% ≥80% Delivered vaccines: <40% 40%-80% ≥80% Source: Data on those fully vaccinated from Our World in Data (https://ourworldindata.org/covid-vaccinations, September 2, 2021) (Ritchie et al. 2021); data on delivered vaccines from Multilateral Leaders Task Force on COVID-19 (https://data.covid19taskforce.com, September 2, 2021) and survey responses from World Bank staff; perceptions on constraints from survey responses from World Bank staff. Note: The size of circles represents relative population size. Importance of the constraint (ranging from 1, the most important, to 7, the least) was assessed among potential constraints (delivery delays, financing, procurement process, domestic production, distribution capacity, regulation, hesitancy). The number of delivered vaccines as the percentage of eligible population (aged 15 and above) was adjusted for the required doses per person; if a vaccine brand was not available, two doses per person was assumed. Eligible population was defined as population aged 15 and above; this measure may differ across countries and may change as countries consider vaccinating people younger than 15 years old. 2 Research & Policy Brief No.51 Figure 3. Increases in the vaccination coverage reduce mortality but not necessarily infections, and vaccination above certain thresholds is associated with increased mobility and economic activity a. United Kingdom B. Germany 1000 100 400 80 800 80 300 60 Percent, Index Percent, Index Cases, Deaths Cases, Deaths 600 60 200 40 400 40 100 20 200 20 0 0 0 0 -200 -20 -100 -20 Mar-20 Jun-20 Sep-20 Dec-20 Mar-21 Jun-21 Sep-21 Mar-20 Jun-20 Sep-20 Dec-20 Mar-21 Jun-21 Sep-21 Cases per million Deaths per hundred thousand Cases per million Deaths per hundred thousand Vaccination coverage (right scale) Mobility reduction (right scale) Vaccination coverage (right scale) Mobility reduction (right scale) Manufacturing PMI (right scale) Services PMI (right scale) Manufacturing PMI (right scale) Services PMI (right scale) Source: Haver Analytics; Oxford Covid-19 Government Response Tracker (Hale et al 2021). Note: The figures are based on latest available data as of September 21, 2021. PMI = Purchasing Managers’ Index expectations except that high levels of transmission have led to after a certain period and may require booster shots to sustain it; significant deaths even though case fatality is low – mortality in the and (ii) absent other measures to suppress transmission, new UK is higher than a year ago when nobody was vaccinated but less variants can lead to increased levels of infection and hence infectious variants prevailed. The country has found the mortality putting pressure on health systems even though case sustainability of this benign phase is conditional on vaccination fatality rates are low. staying a step ahead of the disease, in terms of immunity offered Despite the limited availability of vaccines in the near term, many across people and over time against old and new variants. The East Asia and the Pacific countries could vaccinate more than 60 recent upturn in mortality in the UK suggests: (i) immunity wanes percent of total population by June 2022 (figure 4). Coverage is Figure 4. Many EAP countries will fully vaccinate more than 60 percent of their populations by June 2022 Partially vaccinated (one dose) 100 Fully vaccinated (two doses) 60% population threshold Expected availability at end-2021 (IMF estimates) Percent of population 80 60 40 20 0 China Mongolia Fiji Cambodia Malaysia Tuvalu Samoa Tonga Lao PDR Timor-Leste Papua New Guinea Thailand Vietnam Kiribati Indonesia Philippines Vanuatu Myanmar Solomon Is. 2021 Q1-2022 Q2-2022 Q3-2022 or beyond Estimated timing of achieving 60% population coverage based on current pace of vaccination and expected availability of vaccines Source: World Bank staff calculations. Oxford Covid-19 Government Response Tracker (OxCGRT) (Hale et al. 2021) and Agarwal and Gopinath 2021. Note: Latest available vaccination data as of 31 August 2021 from OxCGRT. Expected availability at end-2021 refers to provisional estimates from Agarwal and Gopinath (2021) (or “IMF estimates”). It is defined as vaccine doses expected to be delivered by end-2021 per 100 people, divided by 2, and corresponds to a notional concept of the effective share of the population that is fully vaccinated. Estimated timing of 60 percent effective population coverage is calculated based on current vaccine coverage, IMF’s estimates of expected vaccine availability, and the average daily vaccines administered in August 2021, assuming non-binding constraints on vaccine availability and administration. IMF= International Monetary Fund. 3 Managing Long COVID in East Asia and the Pacific still low in several EAP countries, like Indonesia, Philippines, and Testing coverage has increased to a lesser extent in Indonesia, Vietnam, and vaccine availability still an issue because of limited Thailand, and Philippines since the second quarter of 2021, and is global production capacity and the decision to provide booster plateauing. vaccines in industrial countries. However, at current pace of vaccine administration, and given estimates of availability, several EAP Since zero COVID-19 may not be an affordable option for most economies could reach 60 percent of total population that is fully East Asia and the Pacific countries, they must adapt their health vaccinated over the next 9 months, with China and Mongolia systems to live with long COVID. When COVID-19 first struck, already there and Indonesia and the Philippines likely to get there in several countries, like Australia, China, and New Zealand, sought to the first half of next year. eliminate it completely. The highly infectious Delta variant significantly raised the economic cost of elimination because of the What Needs to be Done? stringency and duration of lockdowns. Vaccination helps soften the tradeoff by reducing transmission and the adverse consequences of Widespread vaccination with safe and effective vaccines is a infection. However, the economic costs of elimination are expected necessary condition for a sustainable economic recovery. China, to remain steep for EAP countries because vaccines available in the Malaysia, Mongolia, Nauru, and Palau have already fully vaccinated region is not likely to be sufficient to prevent transmission, and more than 60 percent of their people. Most countries in the region, thereby vaccination coverage and the duration of immunity will be including Indonesia and the Philippines, are expected to vaccinate limited. For most countries in the region, therefore, living with the more than 60 percent of their populations by the first half of 2022 disease may be more acceptable than striving for zero COVID-19 (figure 4). But as vaccination coverage increases, distribution to using economically debilitating measures. In these circumstances, remote areas is likely to vary and vaccine hesitancy to become a the priority will be to strengthen health systems. Monitoring binding constraint, as has been the case even in industrial countries. hospitalizations and deaths as well as infection cases will be Therefore, the attainment of these goals cannot be taken for important to guide policy responses. Vaccinating (and eventually granted and will continue to require a special effort to acquire re-vaccinating) high-risk groups is critical, but so is managing vaccines, distribute them, and persuade people to get vaccinated. underlying health conditions that exacerbate vulnerability to the The experience of high vaccination countries like the UK reveals that disease. Countries may also invest in improving diagnostics to while currently available vaccines significantly reduce detect cases that are more likely to progress to severe illnesses. hospitalization and mortality among the infected, they do not eliminate infections. High infections can lead to higher In parallel, production of vaccines, including regionally, needs to hospitalization and mortality, prompting limits on mobility that hurt be accelerated because global supply remains unreliable and economic activity. Therefore, the region will need to make a serious regional demand will remain high. To reach and sustain the state of effort to enhance testing, tracing, and isolation, encourage “managed endemicity,” a large and predictable supply of vaccines is precautionary behavior, and strengthen health systems. needed. Relying on suppliers in industrial countries would be naïve, International assistance is needed to support national efforts in all because the political imperative to vaccinate and revaccinate their these areas, especially in countries with limited capacity. populations is stronger than the political incentive to share. Greater efforts must therefore be made to expand regional production by Most importantly, East Asia and the Pacific countries must sustain acquiring technology, repurposing production lines, and facilitating emphasis on non-pharmaceutical interventions, especially operation of supply chains. While the scope for expanding testing, tracing, and isolation. In many EAP countries, vaccination production of mRNA vaccines may be limited in the near term coverage is low, and a high share of population are susceptible because of the difficulty in transferring technology, there is a (figure 1a, 1b). Precautionary measures, such as some levels of greater scope for the expansion of vector vaccines, like social distancing and wearing masks in crowded spaces, will need to Oxford-AstraZeneca, and protein adjuvant vaccines, like Novavax. continue. In the EAP region, a group of high vaccination/high testing Production of the Astra Zeneca has already been initiated in China, countries is emerging, of which China, Chinese Taipei, New Zealand, the Republic of Korea, and Thailand. Through an agreement signed and Singapore are the best examples. Unfortunately, COVID-19 by COVAX co-lead, Gavi, China-based Clover is set to make over 400 testing coverage and pace are uneven in the region. Among the million doses of its protein-based vaccine available for procurement Association of Southeast Asian Nations (ASEAN) countries, Malaysia in 2021 and 2022, pending Emergency Use Listing (EUL) from the and Vietnam have been ramping up COVID-19 mass testing in the World Health Organization. Other initiatives are underway; for effort to control the growing number of COVID-19 cases in the example, Thailand is also considering domestic production for both community but the levels are still low compared to Singapore. mRNA and sub-unit protein vaccines. References Agarwal R and Gopinath G. 2021. “A Proposal to End the COVID-19 pandemic.” IMF Staff Islamaj E, Le DT, Mattoo A. 2021. “Lives versus Livelihoods during the COVID-19 Pandemic: Discussion Notes No. 2021/004. Page 53. May 19, 2021. How Testing Softens the Trade-off.” Policy Research Working Paper; No. 9696. 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