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Table of Contents
Year : 2022  |  Volume : 13  |  Issue : 1  |  Page : 1-3

Expecting pandemic to fatigue, before the pandemic fatigue sets in!

1 Department of Internal Medicine, Division of Infectious Diseases, Southern Illinois University School of Medicine, Springfield, Illinois, USA
2 Department of Medicine, Lady Hardinge Medical College, New Delhi, India

Date of Submission28-Jan-2022
Date of Acceptance28-Jan-2022
Date of Web Publication03-Feb-2022

Correspondence Address:
Dr. Anupam Prakash
Department of Medicine, Lady Hardinge Medical College, New Delhi
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/injms.injms_12_22

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How to cite this article:
Sundareshan V, Prakash A. Expecting pandemic to fatigue, before the pandemic fatigue sets in!. Indian J Med Spec 2022;13:1-3

How to cite this URL:
Sundareshan V, Prakash A. Expecting pandemic to fatigue, before the pandemic fatigue sets in!. Indian J Med Spec [serial online] 2022 [cited 2023 Jan 30];13:1-3. Available from: http://www.ijms.in/text.asp?2022/13/1/1/337217

COVID-19 pandemic will be completing 2 years in March 2022. India is witnessing the third wave of COVID-19; the first wave was caused by the alpha variant in 2020, a more lethal delta variant caused the second wave in 2021, and the seemingly milder omicron variant has been identified as the cause of the third wave at the end of 2021, heralding 2022. Many countries worldwide have already witnessed the fourth wave of COVID-19, while in certain countries, the wave never abated. Since the omicron variant is known to be much more infectious than the earlier variants, the number of cases has been rising very rapidly, like never before. However, the severity and hospital admissions, as well as the mortality rates, have been much lower with omicron. The fact that it is much more infectious than the delta variant implies that a larger number of persons would be affected in a short span of time. Some epidemiologists have predicted that because a large number of persons would be affected in a short span of time, this may actually herald an end to the pandemic. This may sound music to the ears, but there are several aspects to this idea.

The pandemic coming to an end does not mean that the disease will go away. For all practical purposes, COVID-19 will remain in the texts as another disease, as an endemic infection with potential for localized outbreaks and even future pandemics, such as influenza. Vaccinations effective against emerging variants are likely to become the order of the day, just like the present annual influenza vaccination protocol. Mass vaccination strategies coupled with the transient immunity provided by peaks such as the omicron may help the human race get some reprieve from the pandemic. High rates of vaccination are beneficial for two reasons. Vaccinations have been effective in preventing severe disease and death due to COVID, including due to omicron.

Although omicron seems to outcompete the existing variants, multiple variants may circulate at the same time. Many countries like the US continue to face the onslaught of a dual burden of delta as well as omicron variants at the same time, as seen in the last few months. Even in India, it is believed that the surge at certain places is contributed by the presence of both variants.

Two things have come up in the aforementioned discussion: the variants and immunizations and their interrelationship. It is now understood that variants can have immune escape mechanisms that render immunizations less effective. However, it is also now known that lack of vaccination can contribute to development of variants.

The major impetus world over has been on vaccination. We are seeing a disproportionate number of COVID cases in people who are unvaccinated, who also seem to have more severe disease and higher mortality. There is a school of thought that the pandemic is getting transformed into a pandemic of the unvaccinated. Such a transformation could be a nemesis for many as those who can afford the vaccine will get vaccinated, leaving the underprivileged without vaccination, making them predisposed to the virus and facing the brunt of the pandemic. This thought had come up repeatedly and recently brought to the forefront when the omicron wave started from South Africa, wherein the vaccination rates are not that high. In fact, more worrisome is that, by leaving the underdeveloped nations or the underprivileged sections of the society unvaccinated, they are highly susceptible to infection with SARS-CoV-2 and potentially can be the source of further mutations, resulting in new variants. The issue of vaccine equity has been raised by the World Health Organization (WHO) as well. The WHO had set a target of vaccinating 10% of each country's population by the end of September 2021, 40% by the end of 2021, and 70% by the middle of 2022.[1] 56 countries could not meet the September target, with most of these being in Africa. Even today in the 3rd week of January 2022, South Africa has administered only 2.93 crore doses with only 27.6% of the population that is fully vaccinated (1.64 crore). India, on the other hand, has 49.1% of the population fully vaccinated (67.7 crore), having administered 161 crore doses, while in the United States of America, 63.5% of its population is fully vaccinated (20.9 crores) and 50.3 crore doses administered.[2] One of the reasons for the origin of the omicron variant in the last week of November 2020 from South Africa is the low vaccination rates in South Africa. Further, it is perceived that countries like South Africa have been transparent in sharing information on the omicron variant, while high-income countries have not been forthcoming with regard to sharing the vaccine development and intellectual property of COVID-19 vaccines.[3]

To combat COVID-19, the mantra today has become, “No one is safe until everyone is safe.”[4] For this, vaccine equity is of paramount importance. Vaccination in low- and middle-income countries (LMICs) has to be ensured. In the LMICs, people live in proximity to densely populated homes and cities, predisposing them to infections. Practicing COVID-appropriate behavior (CAB) or implementing infection prevention and control measures can be more challenging in these regions. These inequities in vaccine availability and other resources are supposedly very detrimental to the course of the pandemic. The pandemic is unlikely to end until vaccination occurs equitably across all the countries of the world.

Next-generation sequencing has been used to determine the full-genome sequence of SARS-CoV-2 virus, which is approximately 30,000 letters in the form of A, T, C, and G, and helps identify its mutations responsible for the development of variants.[5] The SARS-CoV-2 Interagency Group of the USA classifies SARS-CoV-2 variants into four classes,[6] which are indicated in [Table 1]. The variant status can change over time and maybe upgraded or downgraded. To highlight, omicron was a variant of interest initially when it was recognized in South Africa; however, at present, it is upgraded to variant of concern. The classification can vary from region to region as well, depending upon the impact and prevailing dynamics in that region/country at that particular point in time.
Table 1: Classification of severe acute respiratory syndrome coronavirus 2 variants by the Centers for Disease Control and Prevention, USA

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As time elapses, scientists and practitioners are getting to know the virus much better, on the learning curve. Several publications on COVID-19 have been an eye-opener for the scientific community. The practicing physicians will need to embrace and become well versed with the evolving clinical features of COVID-19. The significance of persistent elevations of transaminases, amylase, D-dimer, and serum inflammatory markers (C-reactive protein, ferritin, and interleukin-6) and delayed return to normalcy will be known over a period of time. This issue also highlights the role of several investigative tools in COVID-19. Computed tomography (CT) thorax has been variably studied in COVID-19, and even in asymptomatic COVID-19 patients, CT thorax has been reported to pick up findings. A study by Najim published in this issue[7] has evaluated the chest CT severity score and reported its significance in the evaluation of COVID-19 pneumonia and assessment of its severity, demonstrating association with the varied spectrum of lesions seen in COVID-19 lungs. Serum presepsin levels were evaluated in COVID-19 patients[8] but did not appear to score over procalcitonin and C-reactive protein for prediction of COVID-19 disease severity. Elevated troponin levels have been reported to be associated with severity of COVID-19 and with worse outcomes in a study by Shukla and Munagekar.[9] Apart from the varied clinical spectrum and biomarkers which are being witnessed in COVID-19 illness, it is important to recognize the susceptibility of the vulnerable population groups viz. those with comorbidities, cancer patients and immunosuppressed patients including transplant recipients. Panigrahi et al. have highlighted the adverse outcomes in their series of kidney-transplant recipients who suffered from COVID-19, reporting high mortality of 17.1%.[10]

In COVID-19, teleconsultation as a tool has also become more common and is likely to continue. It can help preserving valuable resources, saving time in transit and waiting time in the consultation chamber, avoiding the need to take a leave of absence from work, and the convenience of accessing the modality from any suitable place, including the comfortable confines of one's home. For the organizations (hospitals/clinics) as well, it may reduce the resource burden in several ways, apart from the major advantage of reducing the chances of exposing the health-care worker to possible infection carried by the patient or attendant coming to its premises. The effectiveness of this tool and the barriers during the COVID-19 pandemic have been discussed in the review by Kalal.[11]

The general public, including the scientific professional communities, are waiting for the pandemic to fatigue but at the same time trying to keep pandemic fatigue at bay. Pandemic fatigue has been described in several populations across the world. It is defined as demotivation to follow recommended protective behaviors emerging gradually over time and affected by a number of emotions, experiences, and perceptions.[12] It is expected and is but natural. For those people, who considered infectious diseases to be easily controlled because of the plethora of antibiotics and preventive measures in place, it proved to be unusual and restrictive to adopt COVID-19 precautions to combat the pandemic. Witnessing lockdowns, remaining indoors, wearing face masks while venturing outdoors, maintaining social distancing, and working from home all took a toll on us in the long run. Socializing freely and travel has decreased significantly during the pandemic. Young and physically active individuals have particularly struggled with institution of these restrictions. Mental illness with anxiety and depression have sky-rocketed with social isolation, particularly in the elderly and children.

Four key strategies have been proposed in a WHO document[12] to combat pandemic fatigue: (i) understand people, (ii) engage people as part of the solution, (iii) allow people to live their lives, but reduce risk, and (iv) acknowledge and address the hardship people experience. The response of the government and the administrative authorities needs to align with these strategies. The intense lockdown witnessed in 2020 was not enforced to the same extent in 2021, and now, during the omicron threat, lockdowns have been only synonymous with transitory weekend and night curfews, with minimal flight restrictions. The emphasis has been more on enforcing CABs such as compliance with wearing masks, social distancing, hand hygiene/infection prevention measures, as well as optimal ventilation.

While the general public experience pandemic fatigue, the health-care workers are at the other end of the spectrum. They get exposed to patients with COVID-19 at work (a professional hazard, one may say), and make sacrifices as front-liners, putting their own family members at risk in the unlikely event of carrying the virus home during the incubation period or asymptomatic phase of the illness. The health-care workers have continued to offer services with immense dedication during the unabated pandemic phase of 2 years. Burnout among health-care workers and its characteristics have been reported by Sosa and Sosa in this issue.[13]

These are truly testing times for the human race. This brings to mind the quote by Robert H Schuller, “Tough times never last, but tough people do!” Hence, one needs to get vaccinated and keep practicing CAB, ensuring not to develop pandemic fatigue but to patiently wait for the pandemic to fatigue out.

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Conflicts of interest

There are no conflicts of interest.

  References Top

World Health Organization. Vaccine Equity. Available from: https://www.who.int/campaigns/vaccine-equity. [Last accessed on 2022 Jan 23].  Back to cited text no. 1
Coronavirus (COVID-19) Vaccinations-Our World in Data. Available from: https://ourworldindata.org/covid-vaccinations?country=OWID_WRL. [Last accessed on 2022 Jan 23].  Back to cited text no. 2
Bansal A. Vaccine equity: There is no time to waste. Bull World Health Organ 2022;100:2-2A.  Back to cited text no. 3
The Lancet Infectious Diseases. COVID-19 vaccine equity and booster doses. Lancet Infect Dis 2021;21:1193.  Back to cited text no. 4
Hawaii Department of Health. State of Hawaii Sequencing and Variant Report of SARS-CoV-2. Published on 15-12-2021. Available from: https://health.hawaii.gov/coronavirusdisease2019/files/2021/12/variant_report_20211215.pdf. [Last accessed on 2022 Jan 23].  Back to cited text no. 5
Centers for Disease Control and Prevention, USA. SARS-CoV-2 Variant Classifications and Definitions. Available from: https://www.cdc.gov/coronavirus/2019-ncov/variants/variant-classifications.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fcoronavirus%2F2019-ncov%2Fvariants%2Fvariant-info.html#anchor_1632158924994. [Last accessed on 2022 Jan 23].  Back to cited text no. 6
Najim RS, Abdulwahab AD, Tawfeeq DN. Significance of chest computed tomography scan findings at time of diagnosis in patients with COVID-19 pneumonia. Indian J Med Spec 2022;13:9-16.  Back to cited text no. 7
  [Full text]  
Caglar FN, Yildiz C, Korkusuz R, Yasar KK, Isiksacan N. Serum presepsin levels among COVID-19 patients. Indian J Med Spec 2022;13:17-22.  Back to cited text no. 8
Shukla V, Munagekar A. Troponin levels in COVID-19 patients and its correlation with the severity of disease and its clinical outcomes. Indian J Med Spec 2022;13:41-4.  Back to cited text no. 9
  [Full text]  
Panigrahi DK, Bagai S, Singh KN, Gandhi KR, Prasad P, Chhabra GD, et al. Clinical profile and outcomes of coronavirus disease-2019 in kidney transplant recipients admitted to a tertiary care centre: A retrospective study. Indian J Med Spec 2022;13:45-50.  Back to cited text no. 10
  [Full text]  
Kalal N, Vel NS, Mundel S, Daiyya S, Dhayal S, Bishnoi S, et al. Effectiveness and barriers of telehealth during the COVID-19 pandemic: A narrative review. Indian J Med Spec 2022;13:4-8.  Back to cited text no. 11
  [Full text]  
World Health Organization Regional Office for Europe. Pandemic Fatigue. Reinvigorating the Public to Prevent COVID-19. Policy Framework for Supporting Pandemic Prevention and Management. Available from: https://apps.who.int/iris/bitstream/handle/10665/335820/WHO-EURO-2020-1160-40906-55390-eng.pdf. [Last accessed on 2022 Jan 23].  Back to cited text no. 12
Sosa FK, Sosa KF. Burnout syndrome in doctors in the context of COVID-19 pandemic. Indian J Med Spec 2022;13:69-70.  Back to cited text no. 13


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