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Preparing for a syndemic

Innovations in population health surveillance are important as COVID-19 could become a syndemic

The World Health Organization has announced that COVID-19 will likely never go away. Experts warn that there will be a second wave of infections.

Meanwhile, some people have also raised the alarm about diseases like dengue and malaria emerging with the upcoming monsoon season in tropical South Asia. Therefore, going forward, could COVID-19 become even more problematic by becoming a syndemic? A syndemic is a situation when two or more epidemics interact synergistically to produce an increased burden of disease in a population, a situation first described by medical anthropologist Merrill Singer in the mid-1990s. Stephanie Shau and co-authors published a peer-reviewed journal article last month documenting this as a distinct possibility in people living with HIV.

Increased burden of disease

The 1957 Asian influenza pandemic, for example, showed that deaths then could be not only due to the primary viral infection, but also due to secondary bacterial infections among influenza patients; in short, they were caused by a viral/bacterial syndemic. Meanwhile, researchers have shown that in Kisumu, Kenya, 5% of HIV infections are due to higher HIV infectiousness of malaria-infected HIV patients.

Some also say that we need to watch out for secondary bacterial infection in those with weakened immunity due to COVID-19. Given that antibiotics resistance across the world is already a problem, the medical community needs to be aware of co-morbidities, especially if COVID-19 deepens as a syndemic in populations with antibiotic resistance.

If that happens, along with large-scale population testing, societies around the world will also have to consider innovations in population health surveillance technology and develop creative business models at a scale potentially unheard of in recent times. MIT alumnus Inder Singh’s startup, Kinsa, makes smart thermometers that are already making waves in the U.S. Many argue that Kinsa thermometers could be the key to constantly monitoring temperatures.

Another solution is to monitor oxygen levels in the brain daily through a pulse oximeter. It turns out that COVID-19 is causing happy hypoxia, where lack of oxygen in the brain is going undetected till things become too late. However, some say that this should not crowd out other important strategies like aggressive population-level PCR and antibody testing.

Overall, we can expect that this emerging market of technologies in population health surveillance will move towards similar discussions like global optimal pricing of Remdesivir, or faulty testing kits by Abbott or by Chinese firms. There will be the lure of speed of entry, quality concerns on the margin, and intellectual property battles.

But broadly, societies with resource-constrained settings, where even an economical pooled testing strategy might be difficult to enforce due to financial reasons, should evaluate innovative population health surveillance technologies to complement testing. This is especially important as there is a rising likelihood of COVID-19 becoming endemic and also probably syndemic.

New ways of thinking

With India’s ongoing migrant crisis, we cannot rule out COVID-19 becoming syndemic given large-scale urban-to-rural chaotic migration. Added to this is the complexity of the upcoming dengue and malaria season. Closing State borders, discriminating against migrants returning to their home States, and quarantining them in public locations may not be a viable option going forward if India is peaking on the COVID-19 curve. India recorded the largest single day spike just a few days ago. The time has come to look at testing/tracing/isolating as well as ideas to deploy population health surveillance technologies like smart thermometers and oximeters.

Are the policymakers listening?

Chirantan Chatterjee is a faculty member at IIM Ahmedabad and Visiting Fellow at Hoover Institution, Stanford University

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Printable version | Jun 1, 2020 2:22:29 PM | https://www.thehindu.com/opinion/op-ed/preparing-for-a-syndemic/article31617304.ece

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