The occupational and psychosocial impact of SARS on academic physicians in three affected hospitals

SARS-CoV-2 infection among physicians over time in Ontario, Canada: a population-based retrospective cohort study

AIM

To assess this risk of SARS-CoV-2 infection among Ontario physicians by specialty and in comparison with non-physician controls during the COVID-19 pandemic.

METHODS

In this retrospective cohort study, the primary outcome was incident SARS-CoV-2 infection confirmed by polymerase chain reaction (PCR). Secondary outcomes were hospitalization, use of critical care, and mortality.

RESULTS

From March 1, 2020 to December 31, 2022, 6172/30 617 (20%) active Ontario physicians tested positive for SARS-CoV-2. Infection was less likely if physicians were older (OR 0.78 [0.76-0.81] per 10 years), rural residents (OR 0.70 [0.59-0.83]), and lived in more marginalized neighborhoods (OR 0.74 [0.62-0.89]), but more likely if they were female (OR 1.14 [1.07-1.22]), worked in long-term care settings (OR 1.16 [1.02-1.32]), had higher patient volumes (OR 2.05 [1.82-2.30] for highest vs lowest), and were pediatricians (OR 1.25 [1.09-1.44]). Compared with community-matched controls (n=29 763), physicians had a higher risk of infection during the first two waves of the pandemic (OR 1.38 [1.20-1.59]) but by wave 3 the risk was no longer significantly different (OR 0.93 [0.83-1.05]). Physicians were less likely to be hospitalized within 14 days of their first positive PCR test than non-physicians (P<0.0001), but there was no difference in the use of critical care (P=0.48) or mortality (P=0.15).

CONCLUSION

Physicians had higher rates of infection than community-matched controls during the first two waves of the pandemic in Ontario, but not from wave 3 onward. Physicians practicing in long-term care facilities and pediatricians were more likely to test positive for SARS-CoV-2 than other physicians.

The effect of yoga on insomnia and quality of life among nursing professionals during COVID-19: A pre-post-test interventional study

Background

The coronavirus disease 2019 (COVID-19) pandemic has taken a toll on the well-being and quality of life (QoL) of healthcare professionals, especially nurses. Insomnia, a common consequence of the pandemic, adds to the physical and mental strain on healthcare workers.

Aim

This study aimed to assess the impact of workplace yoga intervention on insomnia severity and QoL among female nursing and healthcare professionals during the pandemic.

Methods

A pre-post-interventional study was conducted among 173 nursing professionals working in a hospital setting. Baseline assessments collected age, body mass index (BMI), insomnia severity using the Insomnia Severity Index (ISI), and QoL using the World Health Organization Quality-of-Life Brief Version (WHOQOL-BREF). A 6-week workplace yoga intervention was conducted by trained professionals, followed by posttest assessments.

Results

Among 173 participants, 57 had insomnia. Participants without significant insomnia had higher QoL scores (P < 0.001). Following the yoga intervention, both subthreshold and moderate clinical insomnia groups experienced reduced insomnia severity (P < 0.001). Quality-of-life scores in the physical, psychological, and environmental domains improved significantly (P < 0.05).

Conclusion

Workplace yoga intervention appears to be a promising approach to alleviate insomnia and enhance QoL among female nursing and healthcare professionals during the COVID-19 pandemic. Implementing tailored workplace yoga programs can play a crucial role in promoting the well-being and resilience of healthcare workers, contributing to a positive work environment and improved patient care outcomes.

Trends in U.S. self-reported health and self-care behaviors during the COVID-19 pandemic

IMPORTANCE

The COVID-19 pandemic represents a unique stressor in Americans' daily lives and access to health services. However, it remains unclear how the pandemic impacted perceived health status and engagement in health-related behaviors.

OBJECTIVE

To assess changes in self-reported health outcomes during the COVID-19 pandemic, and to explore trends in health-related behaviors that may underlie the observed health changes.

DESIGN

Interrupted time series stratified by age, gender, race/ethnicity, educational attainment, household income, and employment status.

SETTING

United States.

PARTICIPANTS

All adult respondents to the 2016-2020 Behavioral Risk Factor Surveillance System (N = 2,146,384).

EXPOSURE

Survey completion following the U.S. public health emergency declaration (March-December 2020). January 2019 to February 2020 served as our reference period.

MAIN OUTCOMES AND MEASURES

Self-reported health outcomes included the number of days per month that respondents spent in poor mental health, physical health, or when poor health prevented their usual activities of daily living. Self-reported health behaviors included the number of hours slept per day, number of days in the past month where alcohol was consumed, participation in any exercise, and current smoking status.

RESULTS

The national rate of days spent in poor physical health decreased overall (-1.00 days, 95% CI: -1.10 to -0.90) and for all analyzed subgroups. The rate of poor mental health days or days when poor health prevented usual activities did not change overall but exhibited substantial heterogeneity by subgroup. We also observed overall increases in mean sleep hours per day (+0.09, 95% CI 0.05 to 0.13), the percentage of adults who report any exercise activity (+3.28%, 95% CI 2.48 to 4.09), increased alcohol consumption days (0.27, 95% CI 0.18 to 0.37), and decreased smoking prevalence (-1.11%, 95% CI -1.39 to -0.83).

CONCLUSIONS AND RELEVANCE

The COVID-19 pandemic had deleterious but heterogeneous effects on mental health, days when poor health prevented usual activities, and alcohol consumption. In contrast, the pandemic's onset was associated with improvements in physical health, mean hours of sleep per day, exercise participation, and smoking status. These findings highlight the need for targeted outreach and interventions to improve mental health in individuals who may be disproportionately affected by the pandemic.

"Don't Just Study our Distress, Do Something": Implementing and Evaluating a Modified Stepped-Care Model for Health Care Worker Mental Health During the COVID-19 Pandemic

OBJECTIVE

Throughout the COVID-19 pandemic, there have been concerns about the mental health of health care workers (HCW). Although numerous studies have investigated the level of distress among HCW, few studies have explored programs to improve their mental well-being. In this paper, we describe the implementation and evaluation of a program to support the mental health of HCW at University Health Network (UHN), Canada's largest healthcare network.

METHODS

Using a quality improvement approach, we conducted a needs assessment and then created and evaluated a modified stepped-care model to address HCW mental health during the pandemic. This included: online resources focused on psychoeducation and self-management, access to online support and psychotherapeutic groups, and self-referral for individual care from a psychologist or psychiatrist. We used ongoing mixed-methods evaluation, combining quantitative and qualitative analysis, to improve program quality.

RESULTS

The program is ongoing, running continuously throughout the pandemic. We present data up to November 30, 2021. There were over 12,000 hits to the UHN's COVID mental health intranet web page, which included self-management resources and information on group support. One hundred and sixty-six people self-referred for individual psychological or psychiatric care. The mean wait time from referral to initial appointment was 5.4 days, with an average of seven appointments for each service user. The majority had moderate to severe symptoms of depression and anxiety at referral, with over 20% expressing thoughts of self-harm or suicide. Post-care user feedback, collected through self-report surveys and semistructured interviews, indicated that the program is effective and valued.

CONCLUSIONS

Development of a high-quality internal mental health support for HCW program is feasible, effective, and highly valued. By using early and frequent feedback from multiple perspectives and stakeholders to address demand and implement changes responsively, the program was adjusted to meet HCW mental health needs as the pandemic evolved.

The impact of the COVID-19 pandemic on palliative care practice: A survey of clinical oncologists

Background

Palliative care is an essential intervention to improve the quality of life for patients with cancer, whereas the ongoing COVID-19 pandemic poses a challenge to supportive and palliative care providers. This survey aims to explore the current status of palliative care practice for cancer and the influence of COVID-19, from the perspective of oncologists.

Methods

The semi-structure electronic questionnaire was designed. Mixed-mode surveys including electronic questionnaires, face-to-face interactions, and telephone interviews were adopted according to the willingness of respondents. Face-to-face and telephone interviews were based on same questions in the online questionnaire. Participants working in cancer-related departments with frontline palliative care experience during the COVID-19 outbreak were included. Surveys covered experiences and perspectives regarding the impact of COVID-19 on clinical work, personal lives, and palliative care practice. Suggestions on coping strategies were further proposed and qualitatively analyzed.

Results

Thirty-seven oncologists participated in this study from September 2021 to January 2022. The majority of them believed COVID-19 significantly and negatively affected their clinical work routines (75.7%), personal daily lives (67.6%), and palliative care practice (64.9%). Most specialists considered that currently the palliative care system remained underdeveloped (73.0%), and other factors besides COVID-19 were associated with this situation (78.4%). Seventeen participants further made suggestions on how to promote palliative care during COVID-19, and three themes emerged through the qualitative analysis: (1) Remote or online service (88.2%); (2) Publicity, education, or shared decision-making for patients (29.4%); (3) Guidelines, training, or programs for care providers (23.6%).

Conclusion

Oncologists consider that COVID-19 has an adverse impact on their palliative care practice and daily routine. In addition to COVID-19, other factors affecting palliative care should not be neglected. Corresponding measures are warranted to encourage palliative care practice during COVID-19.

Status of stigma on the health care workers related to COVID-19 at the first wave of the pandemic in Iran: A qualitative study

Background

Stigma can be seen as a mark of disgrace that can lead to the separation of one person from another. In this qualitative study, we assess the status of stigma among in front-line health care workers (HCWs) during the first wave of the COVID-19 pandemic in Iran.

Subjects and methods

The participants were selected from frontline HCWs related to COVID-19 in Imam Ali and Imam Hossein referral hospitals in Alborz province, Iran. Study was conducted between May and June 2020. The 32-item checklist Consolidated Criteria for Reporting Qualitative Research (COREQ) was used to report this qualitative study. Interview questions were prepared based on the grounded theory method. The thematic approach was used to analyze the data content. Data analysis was based on open and axial coding and after implementing the codes in MAXQDA software.

Results

The results of this study included 4 themes, 8 categories and 33 sub-categories. Themes included extrinsic and intrinsic elements of stigma, perplexity and stigma removal requirements. Extrinsic elements included "creating blame and shame" and "discrimination" categories. Intrinsic elements included "the desire to be avoidance," "feeling depressed and frustrated" and "feeling anxious and scared" categories. Perplexity included "feeling loss" category. Stigma removal requirements included "factors causing stigma" and "protective agents against stigma" categories.

Conclusion

Low public awareness on COVID-19 and inadequate public care, limited personal protective equipment and inadequate facilities for HCWs along with lack of appreciation for their efforts, lack of proper psychiatric/psychological counseling to identify and treat symptoms associated with mental health and the limitations of training to maintain mental health skills are considered to be factors in the formation of stigma among HCWs related to COVID-19. Health policymakers should implement coherent strategies related to increasing public awareness and providing personal protection needs and counseling care for HCWs in relation to COVID-19.

Psychological impact, coping behaviors, and traumatic stress among healthcare workers during COVID-19 in Taiwan: An early stage experience

OBJECTIVE

This study investigated the psychological impact on, coping behaviors of, and traumatic stress experienced by healthcare workers during the early stage of the COVID-19 pandemic and formulated effective support strategies that can be implemented by hospitals and government policymakers to help healthcare staff overcome the pandemic.

METHODS

This cross-sectional study recruited clinical healthcare workers at a regional hospital in Nantou County, Taiwan. The questionnaire collected personal characteristics, data on the impact and coping behaviors of the pandemic, and Impact of Event Scale-Revised (IES-R). A total of 354 valid questionnaires were collected. The statistical methods employed were univariate and multivariate stepwise regression, and logistic regression.

RESULTS

Perceived impact and coping behaviors were found to be moderate in degree, and traumatic stress was lower than that in other countries. However, our data identified the following subgroups that require special attention: those with young age, those living with minor children, nurses, those with self-rated poor mental health, and those with insufficient COVID-19-related training.

CONCLUSION

Managers should pay particular attention to helping healthcare workers in high-risk groups, strengthen COVID-19 training, provide adequate protective equipment and shelter, and offer psychological counseling.

Psychological impact of coronavirus disease on nurses exposed and non-exposed to disease

Introduction

Nurses who have direct contact with patients with coronavirus disease 19 (COVID-19) and are involved in diagnosis, treatment, and care are at risk for serious psychological health problems.

Purpose

To examine the psychological impact of COVID-19 on nurses who are in direct contact with COVID-19 patients and compared them with other nurses, not in direct contact with COVID-19 patients.

Methods

A descriptive comparative cross-sectional was conducted on a convenience sample of 364 nurses working at three hospitals in Jordan to collect their socio-demographic data and scores on the Depression, Anxiety Stress Scale, 22-item Impact of Event Scale-Revised, and Insomnia Severity Index via Google form questionnaires. Descriptive analysis, Kruskal-Wallis test, independent t-test, and multivariable logistic regression with a significance level of p-value < 0.05 were used to analyze the study data.

Results

Overall, the prevalence rates of depression, anxiety, stress, insomnia, and post-traumatic stress symptoms were 34.1%, 48.9%, 44%, 33.8%, and 67.3%, respectively. Depression, anxiety, stress, and insomnia were significantly more prevalent in the exposed group of nurses than in the non-exposed ones. However, no significant difference was found between the groups regarding post-traumatic stress symptoms. Exposure to COVID-19 and the existence of comorbidities were associated with an increased risk of anxiety, depression, insomnia, and stress.

Conclusion

Nurses who have direct contact with COVID-19 patients have a higher risk of psychological disorders than nurses who do not. Psychological interventions need to be implemented to enhance nurses' psychological well-being.

C, Boland P, Doherty A, Benedetto V, Gita BE, Clegg AJ. The prevalence of mental health conditions in healthcare workers during and after a pandemic: Systematic review and meta-analysis

AIMS

This review aims to explore the prevalence and incidence rates of mental health conditions in healthcare workers during and after a pandemic outbreak and which factors influence rates.

BACKGROUND

Pandemics place considerable burden on care services, impacting on workers' health and their ability to deliver services. We systematically reviewed the prevalence and incidence of mental health conditions in care workers during pandemics.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

Searches of MEDLINE, Embase, Cochrane Library and PsychINFO for cohort, cross-sectional and case-control studies were undertaken on the 31 March 2020 (from inception to 31 March 2020).

REVIEW METHODS

Only prevalence or incidence rates for mental health conditions from validated tools were included. Study selection, data extraction and quality assessment were carried out by two reviewers. Meta-analyses and subgroup analyses were produced for pandemic period (pre- and post), age, country income, country, clinical setting for major depression disorder (MDD), anxiety disorder and post-traumatic stress disorder (PTSD).

RESULTS

No studies of incidence were found. Prevalence estimates showed that the most common mental health condition was PTSD (21.7%) followed by anxiety disorder (16.1%), MDD (13.4%) and acute stress disorder (7.4%) (low risk of bias). For symptoms of these conditions there was substantial variation in the prevalence estimates for depression (95% confidence interval [CI]:31.8%; 60.5%), anxiety (95% CI:34.2%; 57.7%) and PTSD symptoms (95% CI,21.4%; 65.4%) (moderate risk of bias). Age, level of exposure and type of care professional were identified as important moderating factors.

CONCLUSION

Mental disorders affect healthcare workers during and after infectious disease pandemics, with higher proportions experiencing symptoms.

IMPACT

This review provides prevalence estimates of mental health conditions during and after a pandemic which could be used to inform service staffing impact and formulation of preventative strategies, by identifying clinical populations who may be at high risk of developing mental health symptoms and conditions.

Pandemics and the Impact on Physician Mental Health: A Systematic Review

Physician mental health is a major area of concern with physician burnout on the rise, while at the same time pandemics are becoming more frequent and serious in nature. This combination of physician burnout and pandemics has the potential for serious negative implications for physicians, patients, and health care organizations. Thus, we conduct a systematic review that examines the effect of pandemics on physician mental health using the burnout cascade as a framework. We identified 30 quantitative studies for inclusion. We find that Stages 4 and 5 of the burnout cascade are particularly troublesome with physicians experiencing high levels of anxiety and depression. Furthermore, we find in the degradation phase that physicians experience stigma which may intensify other negative effects. Physicians who are women, younger, and have less training are more susceptible to the negative effects of pandemics. We discuss overall implications and recommendations for future research.

Association Between Clinical Competencies and Mental Health Symptoms Among Frontline Medical Staff During the COVID-19 Outbreak: A Cross-Sectional Study

Background

In China, mental health of frontline medical staff might be influenced by clinicians' ability to handle the outbreak of coronavirus disease 2019 (COVID-19). Few studies to-date have addressed the association between clinicians' competencies and mental health in this context. This cross-sectional study was to examine the prevalence of mental health symptoms among frontline medical staff that fought against the COVID-19 outbreak, and explore the associations between their competencies, and separate and concurrent depressive and anxiety symptoms.

Methods

A total of 623 frontline medical staff was included in this study. Competencies, depressive symptoms, and anxiety symptoms were assessed using a self-reported short form of the Chinese clinical physicians' competency model, Patient Health Questionnaire-9, and Generalized Anxiety Disorder-7 questionnaire, respectively. Logistic regression models were used to evaluate the associations between one SD increase in competency scores and the prevalence of mental health problems.

Results

The prevalence of depressive, anxiety, and comorbid depressive and anxiety symptoms was 40.93, 31.78, and 26.00%, respectively. Among the medical staff with higher total competency scores, the prevalence of depressive [odds ratios (ORs) = 0.67, 95% confidence intervals (CIs): 0.55-0.81], anxiety (OR = 0.68, 95% CI: 0.56-0.83), and comorbid anxiety and depressive symptoms (OR = 0.69, 95% CI: 0.55-0.83) was lower than among their lower-scoring counterparts. Subgroup analyses stratified by core competency scores revealed similar associations as the main analyses.

Conclusion

The present findings highlight the association between high core competency scores and lower prevalence of depressive, anxiety, and comorbid anxiety and depressive symptoms.

Exploration of the occupational and personal dimensions impacted by the COVID-19 pandemic for nurses: A qualitative analysis of survey responses

Aim

To explore the occupational and personal life dimensions that have been impacted by the COVID‐19 pandemic for registered nurses (RN) and licensed practical nurses (LPN).

Design

Qualitative interpretive description approach.

Methods

Between July and September 2020, a web‐based cross‐sectional study was conducted among RNs and LPNs in Quebec, Canada. Included in this survey was an open‐ended question allowing nurses to describe the occupational and personal life dimensions that were impacted by the COVID‐19 pandemic. Thematic analysis was used to interpret the qualitative data from this open‐ended question. Reporting followed the Standards For Reporting Qualitative Research (SRQR).

Results

Of the 1860 survey respondents, 774 RNs and 43 LPNs responded to the open‐ended question (total n = 819). For the occupational dimension, six themes were identified: impacts of infection control on work, change in daily work tasks, offloading and reorganization of care, deterioration of working conditions, increased stress at work and issues related to the profession. For the personal dimension, four themes were found: impacts on the family, dealing with changes about leisure and personal life, impacts on physical and psychological health.

Conclusion

Knowing the dimensions affected by the COVID‐19 pandemic could help to identifying appropriate interventions to support RNs and LPNs.

Impact

The COVID‐19 pandemic has significantly impacted the occupational and personal lives RNs and LPNs working in the Quebec healthcare system. More specifically, Quebec's nurses experienced a major reorganization of care generated by important government decisions. Knowing how the pandemic affected different life dimensions will help in the development of support adapted to nurses' realities. Even in a pandemic context, improvements in the work environment or appropriate support could lead to an improved psychological health for nurses.

Impact of COVID-19 pandemic on psychological health of a sample of the health care workers in the western region of Kingdom of Saudi Arabia

Background

The coronavirus disease 2019 pandemic has shown a significant impact on the psychological well-being of health care workers. The aim of the study was to evaluate the impact of the COVID-19 pandemic on the psychological health of health care workers in the Kingdom of Saudi Arabia. During the months of November and December, 283 health care workers completed a survey containing measures of depression, anxiety and stress (using Depression Anxiety and Stress-21 scale [DASS-21]) and questions regarding potential predictors such as the role of COVID-19 perception, availability of mental health support and work-related factors. Pearson X² test revealed factors associated with the presence of significant psychiatric symptoms.

Result

Among the participants, 17.3% screened positive for depression, 26.2% for anxiety and 17.3% for stress. Nurses reported significantly more depression, anxiety and stress than doctors. Those who received mental health support reported significantly lesser depression, anxiety and stress. Those who felt that quality of life was heavily impacted due to COVID-19 reported significantly high depression, anxiety and stress.

Conclusions

Poor psychological well-being was prevalent in health care workers; however, mental health measures have been shown to significantly reduce the mental health burden in health care workers.

A systematic review and meta-analysis on the prevalence of stigma in infectious diseases, including COVID-19: a call to action

Infectious diseases, including COVID-19, are crucial public health issues and may lead to considerable fear among the general public and stigmatization of, and discrimination against, specific populations. This meta-analysis aimed to estimate the pooled prevalence of stigma in infectious disease epidemics. We systematically searched PubMed, PsycINFO, Embase, MEDLINE, Web of Science, and Cochrane databases since inception to June 08, 2021, and reported the prevalence of stigma towards people with infectious diseases including SARS, H1N1, MERS, Zika, Ebola, and COVID-19. A total of 50 eligible articles were included that contributed 51 estimates of prevalence in 92722 participants. The overall pooled prevalence of stigma across all populations was 34% [95% CI: 28-40%], including enacted stigma (36% [95% CI: 28-44%]) and perceived stigma (31% [95% CI: 22-40%]). The prevalence of stigma in patients, community population, and health care workers, was 38% [95% CI: 12- 65%], 36% [95% CI: 28-45%], and 30% [95% CI: 20-40%], respectively. The prevalence of stigma in participants from low- and middle-income countries was 37% [95% CI: 29-45%], which is higher than that from high-income countries (27% [95% CI: 18-36%]) though this difference was not statistically significant. A similar trend of prevalence of stigma was also observed in individuals with lower education (47% [95% CI: 23-71%]) compared to higher education level (33% [95% CI: 23-4%]). These findings indicate that stigma is a significant public health concern, and effective and comprehensive interventions are needed to counteract the damaging effects of the infodemics during infectious disease epidemics, including COVID-19, and reduce infectious disease-related stigma.

A mental health survey among young front-line clinicians in high-risk areas during the COVID-19 sporadic epidemic in China

BACKGROUND

The sporadic coronavirus disease (COVID-19) epidemic has placed enormous psychological stress on people, especially clinicians. The objective of this study was to examine depression, anxiety, quality of life (QOL), and related social psychological factors among young front-line clinicians in high-risk areas during the COVID-19 sporadic epidemic in China and to provide a reference for formulating reasonable countermeasures.

METHODS

In this cross-sectional study, demographic information, COVID-19-related questions, anxiety (Generalized Anxiety Disorder-7, GAD-7), depression (Patient Health Questionnaire-9, PHQ-9), insomnia (Insomnia Severity Index, ISI), stress (Perceived Stress Scale-10, PSS-10), and QOL (World Health Organization Quality of Life-brief version, WHOQOL-BREF) were collected. Binary logistic regression analysis was used to test the relationships between anxiety and/or depression and other related problems. Multiple linear regression analysis was used to test the relationships among factors influencing QOL.

RESULTS

A total of 146 young front-line clinicians were included. The prevalence rates of depression, anxiety, and anxiety-depression comorbidity were 37.7% (95% CI = 29.7-45.6%), 26.0% (95% CI = 18.8-33.2%), and 24.0% (95% CI = 17.0-31.0%), respectively. Severe stress (OR = 1.258, 95% CI = 1.098-1.442, P < 0.01) and insomnia (OR = 1.282, 95% CI = 1.135-1.447, P < 0.01) were positively correlated with depression. Severe stress (OR = 1.487, 95% CI = 1.213-1.823, P < 0.01) and insomnia (OR = 1.131, 95% CI = 1.003-1.274, P < 0.05) were positively correlated with anxiety. Severe stress (OR = 1.532, 95% CI = 1.228-1.912, P < 0.01) was positively correlated with anxiety-depression comorbidity. However, insomnia (OR = 1.081, 95% CI = 0.963-1.214, P > 0.05) was not correlated with anxiety-depression comorbidity. The belief that the vaccine will stop the COVID-19 pandemic (OR = 0.099, 95% CI = 0.014-0.715, P < 0.05) was negatively correlated with anxiety and anxiety-depression comorbidity (OR = 0.101, 95% CI = 0.014-0.744, P < 0.05). Severe stress (B = -0.068, 95% CI = -0.129 to -0.007, P < 0.05) and insomnia (B = -0.127, 95% CI = -0.188 to -0.067, P < 0.01) were negatively correlated with QOL. The belief that the vaccine could provide protection (B = 1.442, 95% CI = 0.253-2.631, P < 0.05) was positively correlated with QOL.

CONCLUSIONS

The prevalence of depression, anxiety, and even anxiety-depression comorbidity was high among young front-line clinicians in high-risk areas during the COVID-19 sporadic epidemic in China. Various biological and psychological factors as well as COVID-19-related factors were associated with mental health issues and QOL. Psychological intervention should evaluate these related factors and formulate measures for these high-risk groups.

The dynamic changes of cellular immunity among frontline medical workers who supported Wuhan for fighting against the COVID-19

The outbreak of novel coronavirus disease 2019 (COVID-19) poses a great stress to frontline medical workers. Our previous study indicated that immune cells in the peripheral blood of frontline medical workers changed significantly. However, the dynamic changes of immune cells of frontline medical workers remain unclear. Here, we reported the dynamic changes of lymphocyte subsets in the peripheral blood of 51 frontline medical worker. The frontline medical workers struggling with COVID-19 from February 8 to March 31, 2020. Demographic and clinical data, including routine blood test data were extracted from the electronic health examination record and retrospectively analyzed. The lymphocyte (LYM) count and LYM ratio increased while the monocyte (MONO) ratio, neutrophil to lymphocyte ratio (NLR), monocyte to lymphocyte ratio (MLR) and neutrophil (NEUT) ratio in the peripheral blood of frontline medical workers decreased 10 days after struggling with COVID-19. Interestingly, the differences of LYM count, LYM ratio, MONO ratio, NLR, NEUT ratio were more significantly in nurse than doctor. The differences of LYM ratio, NLR and NEUT ratio were more significantly in female than male. However, the changes of LYM count, LYM ratio, MONO ratio, NLR, MLR, NEUT ratio returned to the baseline 10 months after struggling with COVID-19. Together, these data indicated that immune cells in the peripheral blood changed significantly 10 days after struggling with COVID-19, but returned to normal after 10 months. Those maybe caused by psychological stress and we recommend to pay more attention to mental health and immune response of frontline medical workers.

Predictors of Psychological Distress in Health Care Staff in Qatar during COVID-19 Pandemic

Background & Objective

The Coronavirus disease 2019 (COVID-19) pandemic has caused widespread psychological distress. The aims of the study were a) to assess mental health symptoms experienced by expatriate hospital staff and b) to determine the impact of staff wellbeing interventions specific to pandemic related stress.

Methods

The study was conducted from June 2020 until August 2020. A 16-question survey was disseminated online via Survey Monkey to assess the mental health needs of hospital staff during the pandemic. Based on results, a virtual, tiered mental health support model was developed, and staff feedback was collected.

Results

Almost 46.2% of respondents (N: 1001) reported at least one mental health symptom in the initial survey. The most common symptoms were anxiety, low mood and feelings of isolation. Being single and in poor health status were predictors of developing mental health symptoms (P <0.01). Female gender was a predictor for experiencing fear of getting infected. Time constraints at work was the most common reason for not accessing mental health support.

Conclusions

As in other parts of the world, hospital staff in Qatar experienced mental health symptoms and significant fear related to the COVID-19 Pandemic. Being single and in poor health status were risk factors. Mental health interventions at work must take into account time constraints experienced by staff.

Does COVID-19 Clinical Status Associate with Outcome Severity? An Unsupervised Machine Learning Approach for Knowledge Extraction

Since the beginning of the COVID-19 pandemic, 195 million people have been infected and 4.2 million have died from the disease or its side effects. Physicians, healthcare scientists and medical staff continuously try to deal with overloaded hospital admissions, while in parallel, they try to identify meaningful correlations between the severity of infected patients with their symptoms, comorbidities and biomarkers. Artificial intelligence (AI) and machine learning (ML) have been used recently in many areas related to COVID-19 healthcare. The main goal is to manage effectively the wide variety of issues related to COVID-19 and its consequences. The existing applications of ML to COVID-19 healthcare are based on supervised classifications which require a labeled training dataset, serving as reference point for learning, as well as predefined classes. However, the existing knowledge about COVID-19 and its consequences is still not solid and the points of common agreement among different scientific communities are still unclear. Therefore, this study aimed to follow an unsupervised clustering approach, where prior knowledge is not required (tabula rasa). More specifically, 268 hospitalized patients at the First Propaedeutic Department of Internal Medicine of AHEPA University Hospital of Thessaloniki were assessed in terms of 40 clinical variables (numerical and categorical), leading to a high-dimensionality dataset. Dimensionality reduction was performed by applying a principal component analysis (PCA) on the numerical part of the dataset and a multiple correspondence analysis (MCA) on the categorical part of the dataset. Then, the Bayesian information criterion (BIC) was applied to Gaussian mixture models (GMM) in order to identify the optimal number of clusters under which the best grouping of patients occurs. The proposed methodology identified four clusters of patients with similar clinical characteristics. The analysis revealed a cluster of asymptomatic patients that resulted in death at a rate of 23.8%. This striking result forces us to reconsider the relationship between the severity of COVID-19 clinical symptoms and the patient's mortality.

Psychosocial support for providers working high-risk exposure settings during a pandemic: A critical discussion

Psychological first aid is a form of support designed to lessen disaster-related distress. In a pandemic, providers may need such support but with the high risk of exposure, such a program is offered only virtually. The research is scant for traditional post-disaster support and non-existent for virtual; therefore, by using related research this discussion considers the likelihood of providers accessing and benefiting from this program. The virtual platform is heralded as the responsible way to provide support in a pandemic but this standard may be ineffective and is inherently inequitable. As a global event, pandemics require containment strategies applicable on an international level; therefore, psychosocial support should also be developed with an international audience in mind. Online psychosocial support falls short of being such a strategy as it incorrectly assumes global internet access. Many low-income areas such as Sub-Saharan Africa will need support strategies which compliment local frontline staff and fit with community-driven initiatives, whereas wealthier countries may use a combination of onsite and online support. Provider psychosocial support needs in a pandemic, if articulated, are globally similar but how this support is offered requires contextually sensitive considerations not yet found in the literature.

COVID-19: anxiety among hospital staff and associated factors

BACKGROUND

During the COVID-19 pandemic, hospital staff have experienced a variety of mental health challenges. European research on anxiety and stress among hospital workers during the pandemic is limited. This study aimed to describe the anxiety levels of Finnish hospital workers during the COVID-19 pandemic.

METHODS

The multidimensional, cross-sectional survey was distributed to all hospital staff working at two Finnish specialized medical care centres in the spring of 2020 (n = 1,995). The Generalized Anxiety Disorder 7-item (GAD-7) scale was used to measure the workers' anxiety.

RESULTS

The total mean GAD-7 score was 4.88, indicating normal anxiety levels. However, 30% (n =  1,079) of the respondents had mild, 10% (n = 194) moderate and 5% (n = 88) severe anxiety. Key risk factors were young age, working in a university hospital, problems in cooperation between co-workers, difficulty concentrating at work, a health-threatening physical and psychological workload, and a fear of being infected at work.

CONCLUSION

Hospital staff experienced a variety of work-related stress and anxiety issues that should be visible to hospital administrators and policymakers alike. The anxiety is independent of whether the worker is directly involved in caring for or in any way coming into contact with COVID-19 patients. Key message Fifty-five percent of hospital staff have normal anxiety levels. The remaining workers may need targeted support interventions, and a smaller proportion (15%) are in danger of developing longer-term problems affecting their well-being. The anxiety experienced by hospital workers during the COVID-19 pandemic is more severe than that of the population on average. If the pandemic continues, the well-being of hospital staff may be widely threatened. Despite the different geographical locations and COVID-19 situations, hospital workers in Finland and China had similar anxiety levels. The anxiety is independent of whether staff are working in the front line of managing the COVID-19 pandemic or of the number of covid-19 patients admitted to the hospital. The hospital workers felt anxiety because they were facing a new situation which causes changes in their work and daily routine. Health care employers should engage in long-term follow-up as regards the personnel's recovery from the burden caused by the pandemic and from work in general. It is necessary to make easily attainable, flexibly delivered and cost-effective treatment interventions for anxiety available to hospital staff.

Psychosocial experiences of frontline nurses working in hospital-based settings during the COVID-19 pandemic - A qualitative systematic review

BACKGROUND

Frontline nurses have been directly exposed to the SARS-CoV-2 virus and come in close contact with patients during the COVID-19 pandemic. Nurses execute tasks related to disease control and face multiple psychosocial challenges in their frontline work, potentially affecting their mental well-being and ability to satisfyingly perform their tasks.

OBJECTIVES

To explore the psychosocial experiences of frontline nurses working in hospital-based settings during the COVID-19 pandemic.

DESIGN

The qualitative systematic review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) recommendations. Registered in PROSPERO (CRD42021259111).

DATA SOURCES

Literature searches were performed through PubMed, CINAHL, and the WHO COVID-19 database. Inclusion criteria were: All types of nurses having direct contact with or taking care of patients; Primary, secondary, and tertiary health-care services admitting and treating COVID-19 patients; Experiences, perceptions, feelings, views in psychosocial aspects from the identified population group; Qualitative studies; Mixed methods studies; Language in English; Published date 2019-2021. Exclusion criteria were: Commentaries; Reviews; Discussion papers; Quantitative studies; Language other than English; Published in 2018 or earlier; Studies without an ethical approval and ethical statement.

REVIEW METHODS

The studies were screened and selected based on the inclusion and exclusion criteria. Quality appraisal was conducted according to the Critical Appraisal Skills Program qualitative study checklist. Data was extracted from included studies and a thematic synthesis was made.

RESULTS

A total of 28 studies were included in the review. The experiences of 1141 nurses from 12 countries were synthesised. Three themes were constructed: 'Nurses' emotional, mental and physical reactions to COVID-19', 'Internally and externally supported coping strategies', and 'A call for future help and support'.

CONCLUSION

Nurses working frontline during the COVID-19 pandemic have experienced psychological, social, and emotional distress in coping with work demands, social relationships, and their personal life. The results pointed to a need for increased psychological and social support for frontline nurses to cope with stress and maintain mental well-being, which may subsequently affect nursing care outcomes.

Anxiety and sleep quality in a sample of Lebanese healthcare workers during the COVID-19 outbreak

A cross-sectional, survey based study was conducted in order to assess mental health outcomes among healthcare workers in a private university hospital involved in the COVID-19 response in Lebanon. The main objective was to quantify symptoms of anxiety and sleep quality using self-rating scales (the State-Trait Anxiety Inventory (STAI) and Pittsburgh Sleep Quality Index (PSQI) respectively), while identifying factors that might affect those symptoms. A total of 628 healthcare workers completed the survey; 409 (66.2%) were younger than 40 years, and 441 (71.4%) were women. Of all participants, 503 (81.4%) were nurses, 52 (8.4%) were physicians and 63 (10.2%) were residents. Registered nurses, residents, women, and younger participants presented higher scores on both scales than other categories of participants. Among factors related with COVID-19, those associated with higher scores were having relatives affected by the virus (22.2%), being excessively exposed to media (12.9%), and increasing the consumption of substances/alcohol (31.2%) during this period. Factors associated with higher risk of anxiety symptoms after multivariable logistic regression analysis were: female sex, young age, poor sleep quality, and living with elderly. Our findings contribute to the understanding of the psychological wellbeing of health care workers involved in the acute COVID-19 outbreak in Lebanon.

Mental Health Status of Healthcare Workers During the COVID-19 Outbreak

Abstract. Background: The COVID-19 pandemic is a massive health crisis that has exerted enormous physical and psychological pressure. Mental healthcare for healthcare workers (HCWs) should receive serious consideration. This study served to determine the mental-health outcomes of 1,556 HCWs from 45 countries who participated in the COVID-19 IMPACT project, and to examine the predictors of the outcomes during the first pandemic wave. Methods: Outcomes assessed were self-reported perceived stress, depression symptom, and sleep changes. The predictors examined included sociodemographic factors and perceived social support. Results: The results demonstrated that half of the HCWs had moderate levels of perceived stress and symptoms of depression. Half of the HCWs ( n = 800, 51.4%) had similar sleeping patterns since the pandemic started, and one in four slept more or slept less. HCWs reported less perceived stress and depression symptoms and higher levels of perceived social support than the general population who participated in the same project. Predictors associated with higher perceived stress and symptoms of depression among HCWs included female sex, not having children, living with parents, lower educational level, and lower social support. Discussion: The need for establishing ways to mitigate mental-health risks and adjusting psychological interventions and support for HCWs seems to be significant as the pandemic continues.

Nurses' experiences of caring for people with COVID-19 in Hong Kong: a qualitative enquiry

OBJECTIVES

Nurses are the largest group of healthcare workers on the front line of efforts to control the COVID-19 pandemic. An understanding of their nursing experiences, the challenges they encountered and the strategies they used to address them may inform efforts to better prepare and support nurses and public health measures when facing a resurgence of COVID-19 or new pandemics. This study aimed to explore the experiences of nurses caring for people with suspected or diagnosed COVID-19 in Hong Kong.

DESIGN

A qualitative study was conducted using individual, semistructured interviews. All interviews were audio-recorded and transcribed verbatim for thematic analysis.

SETTING

Participants were recruited from acute hospitals and a public health department in Hong Kong from June 2020 to August 2020.

PARTICIPANTS

A purposive sample of registered nurses (N=39) caring for people with COVID-19 in Hong Kong were recruited.

RESULTS

Two-thirds of the nurses had a master's degree and over a third had 6-10 years of nursing experience. Around 40% of the nurses cared for people with COVID-19 in isolation wards and a quarter performed COVID-19-related work for 31-40 hours/week. Most (90%) had training in COVID-19 and three-quarters had experience of working in infection control teams. Six key themes emerged: confronting resource shortages; changes in usual nursing responsibilities and care modes; maintaining physical and mental health; need for effective and timely responses from relevant local authorities; role of the community in public health protection and management; and advanced pandemic preparedness.

CONCLUSIONS

Our study found that nurses possessed resilience, self-care and adaptability when confronting resource shortages, changing nursing protocols, and physical and mental health threats during the COVID-19 pandemic. However, coordinated support from the clinical environment, local authorities and community, and advanced preparedness would likely improve nursing responses to future pandemics.

Perceived stress and post-traumatic stress disorder symptoms among intensive care unit staff caring for severely ill coronavirus disease 2019 patients during the pandemic: a national study

BACKGROUND

Intensive care unit (ICU) staff have faced unprecedented challenges during the coronavirus disease 2019 (COVID-19) pandemic, which could significantly affect their mental health and well-being. The present study aimed to investigate perceived stress and post-traumatic stress disorder (PTSD) symptoms reported by ICU staff working directly with COVID-19 patients.

METHODS

The Perceived Stress Scale was used to assess perceived stress, the PTSD Diagnostic Scale for the Diagnostic and Statistical Manual of Mental Disorders (5th edition) was used to determine PTSD symptoms, and a sociodemographic questionnaire was used to record different sociodemographic variables.

RESULTS

Altogether, 124 participants (57.2% of whom were men) were included in the analysis. The majority of participants perceived working in the ICU with COVID-19 patients as moderately to severely stressful. Moreover, 71.4% of doctors and 74.4% of nurses experienced moderate-to-severe perceived stress. The staff with previous ICU experience were less likely to have a probable diagnosis of PTSD than those without previous ICU experience.

CONCLUSIONS

Assessing perceived stress levels and PTSD among ICU staff may enhance our understanding of COVID-19-induced mental health challenges. Specific strategies to enhance ICU staff's mental well-being during the COVID-19 pandemic should be employed and monitored regularly. Interventions aimed at alleviating sources of anxiety in a high-stress environment may reduce the likelihood of developing PTSD.

Dynamic monitor on psychological problems of medical aid teams in the context of corona virus disease 2019: a multi-stage and multi-factor quantitative study

Background

To explore the psychological status and vulnerability characteristics of medical staff with the progress of the epidemic.

Methods

This study investigated the prevalence of mental problems of 2748 medical staff in four stages. The PHQ-9 (Patient Health Questionnaire), GAD-7 (Generalized Anxiety Disorder questionnaire), SSS (Somatization Symptom Checklist), Pittsburgh sleep quality index, and PCL-C (Self-rating scale for post-traumatic stress disorder) were used for the psychological evaluation, and univariate logistic standardised analysis, and multivariate logistic regression for data analysis.

Results

The prevalence of mental problems showed a statistically significant difference. In Stage 1, mild anxiety and mild depression reached the highest value of 41.4 and 40.72% respectively. Between 4 and 17 March that of mild depression rose from 16.07 to 26.7%, and between 17 and 26 March the prevalence of mild anxiety increased from 17.28 to 20.02%. Female, unmarried, and working in Wuhan are the risk factors of mental health of medical staff (P < 0.05).

Conclusion

The psychological status of the medical staff has changed dynamically. Stage 1 and the latter period of Stages 2 and 3 are the high-risk stages. Female and unmarried are the dangerous characteristics of psychological vulnerability.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-11479-0.

Risk Factors of Psychological Responses of Chinese University Students During the COVID-19 Outbreak: Cross-sectional Web-Based Survey Study

BACKGROUND

COVID-19 is a highly contagious and highly pathogenic disease caused by a novel coronavirus, SARS-CoV-2, and it has become a pandemic. As a vulnerable population, university students are at high risk during the epidemic, as they have high mobility and often overlook the severity of the disease because they receive incomplete information about the epidemic. In addition to the risk of death from infection, the epidemic has placed substantial psychological pressure on the public. In this respect, university students are more prone to psychological problems induced by the epidemic compared to the general population because for most students, university life is their first time outside the structure of the family, and their mental development is still immature. Internal and external expectations and academic stress lead to excessive pressure on students, and unhealthy lifestyles also deteriorate their mental health. The outbreak of COVID-19 was a significant social event, and it could potentially have a great impact on the life and the mental health of university students. Therefore, it is of importance to investigate university students' mental health status during the outbreak of COVID-19.

OBJECTIVE

The principal objective of this study was to investigate the influencing factors of the psychological responses of Chinese university students during the COVID-19 outbreak.

METHODS

This study used data from a survey conducted in China between February 21 and 24, 2020, and the data set contains demographic information and psychological measures including the Self-Rating Anxiety Scale, the Self-Rating Depression Scale, and the compulsive behaviors portion of the Yale-Brown Obsessive-Compulsive Scale. A total of 2284 questionnaires were returned, and 2270 of them were valid and were used for analysis. The Mann-Whitney U test for two independent samples and binary logistic regression models were used for statistical analysis.

RESULTS

Our study surveyed 563 medical students and 1707 nonmedical students. Among them, 251/2270 students (11.06%) had mental health issues. The results showed that contact history of similar infectious disease (odds ratio [OR] 3.363, P=.02), past medical history (OR 3.282, P<.001), and compulsive behaviors (OR 3.525, P<.001) contributed to the risk of mental health issues. Older students (OR 0.928, P=.02), regular daily life during the epidemic outbreak (OR 0.410, P<.001), exercise during the epidemic outbreak (OR 0.456, P<.001), and concern related to COVID-19 (OR 0.638, P=.002) were protective factors for mental health issues.

CONCLUSIONS

According to the study results, mental health issues have seriously affected university students, and our results are beneficial for identifying groups of university students who are at risk for possible mental health issues so that universities and families can prevent or intervene in the development of potential mental health issues at the early stage of their development.

Immediate impact of the COVID-19 pandemic on the work and personal lives of Australian hospital clinical staff

ObjectiveThis study investigated the short-term psychosocial effects of the COVID-19 pandemic on hospital clinical staff, specifically their self-reported concerns and perceived impact on their work and personal lives.MethodsNurses, midwives, doctors and allied health staff at a large metropolitan tertiary health service in Melbourne, Australia, completed an anonymous online cross-sectional survey between 15 May and 10 June 2020. The survey assessed respondents' COVID-19 contact status, concerns related to COVID-19 and other effects of COVID-19. Space was provided for free-text comments.ResultsRespondents were mostly concerned about contracting COVID-19, infecting family members and caring for patients with COVID-19. Concerns about accessing and using personal protective equipment, redeployment and their ability to provide high-quality patient care during the pandemic were also reported. Pregnant staff expressed uncertainty about the possible impact of COVID-19 on their pregnancy. Despite their concerns, few staff had considered resigning, and positive aspects of the pandemic were also described.ConclusionThe COVID-19 pandemic has had a considerable impact on the work and personal lives of hospital clinical staff. Staff, particularly those who are pregnant, would benefit from targeted well-being and support initiatives that address their concerns and help them manage their work and personal lives.What is known about the topic?The COVID-19 pandemic is having an impact on healthcare workers' psychological well-being. Little is known about their COVID-19-related concerns and the perceived impact of the pandemic on their work and personal lives, particularly hospital clinical staff during the 'first wave' of the pandemic in Australia.What does this paper add?This paper contributes to a small but emerging evidence base about the impact of the COVID-19 pandemic on the work and personal lives of hospital clinical staff. Most staff were concerned about their own health and the risk to their families, friends and colleagues. Despite their concerns, few had considered resigning. Uncertainty about the possible impact of COVID-19 on pregnancy was also reported.What are the implications for practitioners?During the current and future pandemics, staff, especially those who are pregnant, would benefit from targeted well-being and support initiatives that address their concerns and help them manage the impact on their health, work and personal lives.

The experiences of cooperation among healthcare workers who participated in COVID-19 aid mission in China: A qualitative study

Aims and objectives

To assist future offsite planning for pandemics, we documented lived experiences of cooperation among healthcare workers (HCWs) during the coronavirus disease (COVID‐19) pandemic.

Background

The COVID‐19 pandemic poses a global health crisis. Most recent studies on the COVID‐19 focus on frontline HCWs' physio‐psychological experiences, with few studies examining their experiences of cooperation.

Design

A descriptive phenomenological design reported based on COREQ checklist.

Methods

25 HCWs (17 nurses and eight physicians) were interviewed, selected through convenience and purposive sampling, who participated in a medical aid mission in China during the COVID‐19 pandemic. Data were collected via semi‐structured online video interviews, and the transcripts were analysed using Colaizzi's phenomenological method.

Results

The HCWs experienced stressed and anxious, but rated their overall cooperation experience as positive. We categorised the reported experiences in five themes: (1) a multi‐level management structure; (2) nurse managers as internal and external team coordinators; (3) high morale and a mutual supportive context; (4) a continuous streamlined workflow; and (5) the value of multidisciplinary collaboration in care. Reasonable management structure and division of work were the basis for successful aid mission. High morale and a mutual supportive context were foundational for growth and stress mitigation. The HCWs continuously streamlined workflow through communication and met patients' individual need through multidisciplinary collaboration.

Conclusions

Planning for a pandemic aid mission is challenging, given the unpredictable nature of the working circumstances. Our results underline the importance of supportive strategies for COVID‐19 aid mission.

Relevance to clinical practice

Recommendations for future pandemic planning: (1) positive morale and supportive working text should be paid prioritised attention; (2) sufficient experienced and ancillary staff should be recruited; (3) multiple communication channels such as regular handover meetings, online chat applications and electronic recording devices are essential, and (4) multidisciplinary cooperation are is necessary in COVID‐19 wards.

The COVID-19 Pandemic from the Health Workers’ Perspective: Between Health Emergency and Personal Crisis

Different scholars have emphasised the psychological distress experienced by health workers during the COVID-19 pandemic; however, there are almost no qualitative studies and we know very little about the everyday experience of this group. The present study’s goal was to explore how health workers interpreted the meaning of the pandemic crisis in their life. An online survey was available during the Italian lockdown. Respondents were asked to write a passage about the meaning of living in the time of COVID-19. A total number of 130 questionnaires (M = 42.35; DS = 10.52; women: 56.2%) were collected. The Automated Method for Content Analysis (ACASM) procedure was applied to the collected texts to detect the factorial dimensions underpinning (dis)similarities in the respondents’ narratives. Such factors were interpreted as the markers of latent dimensions of meanings (DS). The two main DS that emerged were characterised by the pertinentisation of two extremely basic issues: what the pandemic represents (health emergency versus personal crisis) and its impact (powerlessness versus discovery of new meanings). On the whole, health workers’ narratives help to highlight the risk of normalising the feelings of fear and impotence experienced when facing the health emergency and the need to recognise that such feelings are strictly intertwined with the limited resources received to “face the battle”; the need to recognize the human vulnerability of the women and men “inside the lab coat” and the human effort to maintain or reconstruct a sense of self and purpose in the face of troubled circumstances.

The Impact of Epidemics and Pandemics on the Mental Health of Healthcare Workers: A Systematic Review

BACKGROUND

There is increasing evidence that healthcare workers (HCWs) experience significant psychological distress during an epidemic or pandemic. Considering the increase in emerging infectious diseases and the ongoing COVID-19 pandemic, it is timely to review and synthesize the available evidence on the psychological impact of disease outbreaks on HCWs. Thus, we conducted a systematic review to examine the impact of epidemics and pandemics on the mental health of HCWs.

METHOD

PubMed, PsycInfo, and PsycArticles databases were systematically searched from inception to June-end 2020 for studies reporting the impact of a pandemic/epidemic on the mental health of HCWs.

RESULTS

Seventy-six studies were included in this review. Of these, 34 (45%) focused on SARS, 28 (37%) on COVID-19, seven (9%) on MERS, four (5%) on Ebola, two (3%) on H1N1, and one (1%) on H7N9. Most studies were cross-sectional (93%) and were conducted in a hospital setting (95%). Common mental health symptoms identified by this review were acute stress disorder, depression, anxiety, insomnia, burnout, and post-traumatic stress disorder. The associated risk factors were working in high-risk environments (frontline), being female, being a nurse, lack of adequate personal protective equipment, longer shifts, lack of knowledge of the virus, inadequate training, less years of experience in healthcare, lack of social support, and a history of quarantine.

CONCLUSION

HCWs working in the frontline during epidemics and pandemics experience a wide range of mental health symptoms. It is imperative that adequate psychological support be provided to HCWs during and after these extraordinary distressful events.

A preliminary study on the anxiety and depression situation and psychological intervention of the first-line medical staff in our hospital during the COVID-19 epidemic

To assess the anxiety and depression situation and psychological intervention effect of the first-line medical staff in our hospital during the COVID-19 epidemic. A total of 384 front-line medical staff in our hospital from January 25 to March 8, 2020 were selected as subjects, which were divided into group A and group B respectively. PHQ-9 depression scale and GAD-7 self-rating anxiety scale questionnaire were used to investigate their anxiety and depression. After 1 month, all subjects were re-self-assessed for anxiety and depression, which were named as A1 and B1 group respectively. The GAD-7 anxiety scale had mild, moderate, and severe anxiety scores before group A, which were significantly higher than those in group B (P < 0.05); after psychological intervention, group A1 had significantly reduced anxiety scores (P < 0.05). And there were no markedly difference of PHQ-9 scale scores before and after psychological intervention between groups A and B, A and A1, and B and B1 (P > 0.05). The first-line medical staff in our hospital have different degree of anxiety and depression during COVID-19. Early positive psychological intervention has an effect on ameliorating the anxiety.

Drawing Parallels Among Past Public Health Crises and COVID-19

In the early stages of the coronavirus disease 2019 (COVID-19) pandemic, there were shortages of personal protective equipment (PPE) and health-care personnel across severely affected regions. Along with a lack of testing, these shortages delayed surveillance, and possible containment of the virus. The pandemic also took unprecedented tolls on the mental health of many health-care workers who treated and witnessed the deaths of critically ill patients. To address these effects and prepare for a potential second wave, a literature review was performed on the response of health-care systems during the influenza pandemics of 1918, 1957, 2009, and the epidemics of Ebola, severe acute respiratory syndrome (SARS), and Middle East respiratory syndrome (MERS). We can use lessons identified to develop a competent and effective response to the current and future pandemics. The public must continue to engage in proper health mitigation strategies, including use of face coverings, physical distancing, and hand washing. The impact the pandemic has had on the mental health of frontline health-care workers cannot be disregarded as it is essential in ensuring effective patient care and mitigating psychological comorbidities. The lessons identified from past public health crises can help contain and limit morbidity and mortality with the ongoing COVID-19 pandemic.

Impacts of the COVID-19 Pandemic on Cardiac Rehabilitation Delivery around the World

Background

We investigated impacts of COVID-19 on cardiac rehabilitation (CR) delivery around the globe, including virtual delivery, as well as effects on providers and patients.

Methods

In this cross-sectional study, a piloted survey was administered to CR programs globally via REDCap from April to June 2020. The 50 members of the International Council of Cardiovascular Prevention and Rehabilitation (ICCPR) and personal contacts facilitated program identification.

Results

Overall, 1062 (18.3% program response rate) responses were received from 70/111 (63.1% country response rate) countries in the world with existent CR programs. Of these, 367 (49.1%) programs reported they had stopped CR delivery, and 203 (27.1%) stopped temporarily (mean = 8.3 ± 2.8 weeks). Alternative models were delivered in 322 (39.7%) programs, primarily through low-tech modes (n = 226,19.3%). Furthermore, 353 (30.2%) respondents were re-deployed, and 276 (37.3%) felt the need to work due to fear of losing their job, despite the perceived risk of contracting COVID-19 (mean = 30.0% ± 27.4/100). Also, 266 (22.5%) reported anxiety, 241(20.4%) were concerned about exposing their family, 113 (9.7%) reported increased workload to transition to remote delivery, and 105 (9.0%) were juggling caregiving responsibilities during business hours. Patients were often contacting staff regarding grocery shopping for heart-healthy foods (n = 333, 28.4%), how to use technology to interact with the program (n = 329, 27.9%), having to stop their exercise because they have no place to exercise (n = 303, 25.7%), and their risk of death from COVID-19 due to pre-existing cardiovascular disease (n = 249, 21.2%). Respondents perceived staff (n = 488, 41.3%) and patient (n = 453, 38.6%) personal protective equipment, as well as COVID-19 screening (n = 414, 35.2%), and testing (n = 411, 35.0%) as paramount to in-person service resumption.

Conclusion

Given the estimated number of CR programs globally, these results suggest approximately 4400 CR programs globally have ceased or temporarily stopped service delivery. Those that remain open are implementing new technologies to ensure their patients receive CR safely, despite the challenges.

Highlights

- COVID-19 has impacted cardiac rehabilitation (CR) delivery around the globe.- In this cross-sectional study, a survey was completed by 1062 (18.3%) CR programs from 70 (63.1%) countries.- The pandemic has resulted in at least temporary cessation of ~75% of CR programs, with others ceasing initiation of new patients, reducing components delivered, and/or changing of mode delivery with little opportunity for planning and training.- There is also significant psychosocial and economic impact on CR providers.- Alternative CR model (e.g., home-based, virtual) reimbursement advocacy is needed, to ensure safe, accessible secondary prevention delivery.

The Impact of COVID-19 on nurses working in a University Health System in Singapore: A qualitative descriptive study

Given Singapore's high population density and extensive geographical interconnections, it is unsurprising that the country reported one of the highest numbers of COVID-19 cases in Asia. Past pandemic studies have suggested that nurses working in such crises might experience a deterioration of mental health, which could persist for years beyond the initial outbreak. This study used a qualitative descriptive design to explore nurses' experiences of working in tertiary hospitals during the COVID-19 pandemic. A total of 17 registered nurses who had worked for at least one year prior to the start of the COVID-19 pandemic were recruited from a University Health System in Singapore from March to June 2020. Data were collected through semi-structured interviews lasting at least an hour conducted over an online platform by the principal investigator. The data were analysed through Braun and Clarke's six-step thematic analysis independently by two researchers. Three main themes emerged: (i) challenging moments of COVID-19, during which the participants reported physical and psychological challenges relating to working conditions of the hospital in the initial months of the pandemic; (ii) the professional role as nurses, in where the participants dispelled their worries and demonstrated commitment to their role as nurses; and (iii) support for nurses, which originated from their family, friends and leaders from their organizations for them to persevere and overcome the unprecedented challenges of COVID-19. The nurses in this study demonstrated resilience and professionalism despite the challenges of COVID-19. The findings highlighted the importance of a robust support system for healthcare professionals.

Rapid Evidence Assessment of Mental Health Outcomes of Pandemics for Health Care Workers: Implications for the Covid-19 Pandemic

Background: Little is known about the long-term mental health (MH) impact of the Covid-19 pandemic on health care workers (HCWs). However, synthesizing knowledge from past pandemics can help to anticipate this, along with identifying interventions required, when, and target populations most in need. This paper provides a balanced evaluation of what is currently known about short- and long-term MH impacts of pandemics on HCWs and effect of methodological limitations on knowledge claims. Method: A rapid evidence assessment (REA) was conducted on 41 studies published in the past two decades that examined MH outcomes for HCWs in relation to pandemics. Results: Findings of literary synthesis highlight common MH outcomes across pandemics, including increased stress, distress, burnout, and anxiety in the short-term, and post-traumatic stress and depression in the long-term. Findings also show the key role that organizations and public health bodies play in promoting adaptive coping and reducing health worries and the emotional and psychological distress caused by this. Evidence highlights particular groups at risk of developing MH issues (contact with patients that are infected, having children), and time points where risk may increase (initial response phase, when quarantined). However, inconsistencies in measures, analysis, and reporting all create limitations for pooling data. Conclusions: Findings can be used by researchers to provide a knowledge framework to inform future research that will assist HCWs in responding to pandemics, and by policy makers and service planners to provide an evidence-led brief about direction and evidence base for related policy initiatives, interventions or service programmes.

Burnout among Portuguese radiographers during the COVID-19 pandemic

INTRODUCTION

The COVID-19 pandemic has had a global impact, including in health services, placing health professionals under enormous tension, pressure, and stress. Professionals involved in the care, diagnosis, and treatment of COVID-19-infected patients have been subject to emotional and physical distress that can potentially enhance the development of occupational diseases. The aim of this study was to assess the impact of the COVID-19 pandemic on the incidence of burnout among Portuguese radiographers.

METHODS

This was a cross-sectional, quantitative study. Burnout levels were estimated using the Maslach Burnout Inventory-Human Services Survey, composed of 22 questions. Specific questions were developed to characterize the socio-demographic situation and the impact of the pandemic on the radiographers. Data were descriptively analyzed and Mann-Whitney and Kruskal-Wallis tests were used for correlation analysis.

RESULTS

The study sample comprised 386 radiographers, 68.7% of whom where female and 31.3% male. The mean sample age was 36.3 (±9.1) years. A total of 43.5% and 45.5% of subjects had a high level of emotional exhaustion and depersonalization, respectively, and 59.8% experienced low personal accomplishment. Altogether, 23.3% of study participants were at high risk of burnout in the three dimensions assessed and 77.2% in at least one.

CONCLUSION

Study results showed that radiographers were at high risk of developing burnout in the COVID-19 pandemic setting. Health institutions should actively monitor these professional's mental health and develop restorative strategies that enable their emotional wellbeing, preventing absenteeism and increasing patients' quality of care.

IMPLICATIONS FOR PRACTICE

Burnout of health professionals has a strong impact on health services organization, resulting in increased absenteeism and error probability, frequent work delays, low productivity and job satisfaction, inter- and intra-professional conflicts, high job turnover, high job quit, and decreased quality of care perceived by users.

Psychological Distress Reported by Primary Care Physicians in China During the COVID-19 Pandemic

OBJECTIVE

Primary care physicians (PCPs) play a key role in responding to the COVID-19 epidemic. The objective of this study was to explore the influencing factors associated with self-reported psychological distress among a sample of PCPs in China in relation to COVID-19.

METHODS

An online survey was distributed to a sample of PCPs in Chengdu city between February 10 and February 13, 2020. The survey consisted of three sections: demographic characteristics, COVID-19-related questions, and the General Health Questionnaire-12 (GHQ-12). After 5 months, a follow-up survey investigating the change of the GHQ-12 was conducted.

RESULTS

A total of 712 PCPs completed the baseline survey (11.8% of those invited), 55.6% were female and 74.4% were aged between 30 and 49 years. High levels of psychological distress (GHQ-12 ≥3) were observed in 29.2% and were associated with low preparedness, high work impact, working with infected residents, personal life impact, and concerns, as well as older age and being married (p values < .05). Logistic regression analysis showed that psychological distress was associated with low preparedness (odds ratio [OR] = 0.91, 95% confidence interval [CI] = 0.87-0.96), high work impact (OR = 1.11, 95% CI = 1.03-1.20), personal life impact (OR = 1.12, 95% CI = 1.07-1.17), and safety-related concerns (OR = 1.09, 95% CI = 1.02-1.16). At the 5-month assessment point, high psychological distress was less frequent (21.8%).

CONCLUSIONS

COVID-19 has resulted in high levels of distress in approximately 30% of PCPs in China. Factors associated with high psychological distress levels include low preparedness and high levels of work impact, personal life impact, and concerns. These findings highlight the importance of enhancing psychological health throughout the course of infectious pandemics.

Immune response of frontline medical workers providing medical support for Wuhan COVID-19 patients, China

The outbreak of novel coronavirus disease 2019 (COVID-19) posed a great challenge and stress to frontline medical workers in China. Stress is closely related to immunity. However, the immune response of frontline medical workers providing medical support for COVID-19 patients is unclear. Here, we reported the immune response of 76 frontline medical workers and 152 controls from the Second Affiliated Hospital of Xi'an Jiaotong University. The frontline medical workers were involved in the care for Wuhan COVID-19 patients from February 8 to March 31, 2020 in Tongji Hospital of Huazhong University of Science and Technology. The controls were medical workers of our hospital who had not been in contact with COVID-19 patients during the same period. Demographic and clinical data, including routine blood test data were extracted from the electronic health examination record and retrospectively analyzed. The post-stress frontline medical workers had higher lymphocyte (LYM) count compared with controls or pre-stress. However, the post-stress frontline medical workers had lower monocyte (MONO) count, neutrophil to lymphocyte ratio (NLR), monocyte to lymphocyte ratio (MLR) and neutrophil (NEUT) ratio than controls or pre-stress. Interestingly, we found the differences were more significantly in female subgroup and nurse subgroup. Together, these data indicated that changes of immune response were found in frontline medical workers providing medical support for Wuhan COVID-19 patients, especially in females and nurses. Those maybe caused by psychological stress and we recommend to pay more attention to mental health of frontline medical workers, and provide appropriate psychological interventions for them.

Determinants of burnout and other aspects of psychological well-being in healthcare workers during the Covid-19 pandemic: A multinational cross-sectional study

The Covid-19 pandemic has placed unprecedented pressure on healthcare systems and workers around the world. Such pressures may impact on working conditions, psychological wellbeing and perception of safety. In spite of this, no study has assessed the relationship between safety attitudes and psychological outcomes. Moreover, only limited studies have examined the relationship between personal characteristics and psychological outcomes during Covid-19. From 22nd March 2020 to 18th June 2020, healthcare workers from the United Kingdom, Poland, and Singapore were invited to participate using a self-administered questionnaire comprising the Safety Attitudes Questionnaire (SAQ), Oldenburg Burnout Inventory (OLBI) and Hospital Anxiety and Depression Scale (HADS) to evaluate safety culture, burnout and anxiety/depression. Multivariate logistic regression was used to determine predictors of burnout, anxiety and depression. Of 3,537 healthcare workers who participated in the study, 2,364 (67%) screened positive for burnout, 701 (20%) for anxiety, and 389 (11%) for depression. Significant predictors of burnout included patient-facing roles: doctor (OR 2.10; 95% CI 1.49-2.95), nurse (OR 1.38; 95% CI 1.04-1.84), and 'other clinical' (OR 2.02; 95% CI 1.45-2.82); being redeployed (OR 1.27; 95% CI 1.02-1.58), bottom quartile SAQ score (OR 2.43; 95% CI 1.98-2.99), anxiety (OR 4.87; 95% CI 3.92-6.06) and depression (OR 4.06; 95% CI 3.04-5.42). Significant factors inversely correlated with burnout included being tested for SARS-CoV-2 (OR 0.64; 95% CI 0.51-0.82) and top quartile SAQ score (OR 0.30; 95% CI 0.22-0.40). Significant factors associated with anxiety and depression, included burnout, gender, safety attitudes and job role. Our findings demonstrate a significant burden of burnout, anxiety, and depression amongst healthcare workers. A strong association was seen between SARS-CoV-2 testing, safety attitudes, gender, job role, redeployment and psychological state. These findings highlight the importance of targeted support services for at risk groups and proactive SARS-CoV-2 testing of healthcare workers.

Prevalence of poor psychiatric status and sleep quality among frontline healthcare workers during and after the COVID-19 outbreak: a longitudinal study

Poor psychiatric status and sleep quality were common among frontline healthcare workers (FHWs) during the outbreak of the 2019 novel coronavirus disease (COVID-19), but the change in these mental health outcomes overtime remained unknown. This study compared the psychiatric status and sleep quality of FHWs during and after the COVID-19 outbreak in China. FHWs who volunteered to work in Hubei province (the COVID-19 epicenter) were assessed at baseline during the COVID-19 outbreak and re-assessed when they returned to their place of origin (Liaoning province) after the COVID-19 outbreak. Participants' psychiatric status and sleep quality were measured with the Symptom CheckList-90 (SCL-90) and the Pittsburgh Sleep Quality Index (PSQI), respectively. A total of 494 FHWs was assessed at baseline and 462 at follow-up assessments. The prevalence of poor psychiatric status was 10.5% at baseline and increased to 14.9% at the follow-up assessment (P = 0.04). The corresponding figures of poor sleep quality at baseline and follow-up assessment were 16.4% and 27.9%, respectively (P < 0.001). Multiple logistic regression analysis found that severe fatigue (p = 0.003, OR = 1.266, 95% CI = 1.081-1.483), poor sleep quality (p < 0.001, OR = 1.283, 95% CI = 1.171-1.405), and history of pre-existing psychiatric disorders (p < 0.001, OR = 5.085, 95% CI = 2.144-12.06) were independently associated with higher odds of poor psychiatric status among the FHWs. Poor psychiatric status and sleep quality were common among FHWs during the COVID-19 outbreak, and the prevalence increased following their volunteer experiences. This suggests a critical need for longer-term psychological support for this subpopulation.

The Impact of COVID-19 on Dual-Physician Couples: A Disproportionate Burden on Women Physicians

Background: Currently, physicians face an unprecedented crisis with the novel coronavirus disease 2019 (COVID-19) pandemic. The impact of the pandemic on dual-physician households remains unknown. In this survey study, we examined the impact of the COVID-19 pandemic on dual-physician families and described gendered differences related to the impact of the pandemic. Methods: This was a cross-sectional survey distributed via e-mail and social media, with results collected from April 30, 2020 until May 26, 2020. Respondents were members of a dual-physician couple. Respondents provided information on demographic characteristics and the impact of the pandemic on their professional lives, personal lives, and well-being. Categorical variables were compared using chi-squared or Fisher's exact test. Ordinal variables were compared between genders using Cochran-Armitage trend test. Feeling emotionally and physically drained compared to pre-pandemic was analyzed as a binary outcome in a multivariable logistic model. Results: Of the 1799 physicians who completed the survey, 52% were between 30 and 39 years old, 81% self-identified as women, and 62% were white. Women were more likely to report increased worry about their job security, finances, personal health, partner's health, and children's health (p = 0.02, p = 0.01, p < 0.001, p < 0.001, and p < 0.001, respectively). Seventy-eight percent of respondents reported feeling more drained during the pandemic. Multivariable analysis revealed that female gender (odds ratio [OR] 2.4, 95% confidence interval [CI] 1.7-3.3, p < 0.001), and having children younger than 5 years of age (OR 1.43, 95% CI 1.05-1.95, p = 0.02) were associated with an increased risk of feeling more drained. Conclusions: Women were more likely to report increased worry about job security, finances, and health and had an increased risk of feeling more drained during the pandemic. While the COVID-19 pandemic is a significant stress for all physicians, women in dual-physician families were disproportionately affected, demonstrating the need for increased support from hospital administrations.

Assessing COVID19-related anxiety in an Egyptian sample and correlating it to knowledge and stigma about the virus

Background

COVID19 public health crisis has led to extensive anxiety regarding spread of virus. Aim of study is to assess COVID19-related anxiety in Egypt and correlate it to knowledge and stigma.

Results

Online questionnaire, 17–20 April 2020, had 218 Egyptian respondents to a socio-demographic questionnaire and Generalized Anxiety Disorder Scale (GAD-7). The present study revealed that 21.2% of the respondents were experiencing severe anxiety, 34.8% moderately severe anxiety, 25.2% moderate anxiety, and 18.8% mild anxiety. Women have more rates of severe anxiety. People who get online knowledge about COVID19 have least rates of severe anxiety. 51.8% think having the virus is stigmatizing. Knowledge and stigma are insignificantly inversely correlated to anxiety scores

Conclusion

Online scientific health education is necessary to reduce anxiety.

Impact of COVID-19 on paramedicine students: A mixed methods study

Background

Viral epidemics have negative and sometimes extreme impacts on psychological well-being, particularly in health care workers. Studies have reported higher levels of depression, anxiety, insomnia, stress, distress, fear, burnout, and post-traumatic symptoms.

Objective

This research aimed to explore the psychological impacts of COVID 19 on paramedicine students.

Methods

A convergent mixed method design study was undertaken using self-reporting instruments and qualitative interviews.

Results

Responses were received from 151 students (38.3% responses rate). Most students experienced some level of anxiety (62%), although severe levels were only reported by 6% of respondents. Students had significantly greater odds (OR = 2.05, p = 0.045, 95% CI: 1.02, 4.12) of higher anxiety levels if they were female. Thematic analysis of the interviews largely supported these results, with themes focused on changing approaches to study, financial situation, social support, University adaptation, acceptance and career pathway choice.

Conclusions

This study identified and explored the anxiety and coping strategies in an undergraduate paramedicine cohort when faced with a viral epidemic. Although most of the responding paramedic students reported above normal levels of anxiety in the initial stages of the COVID-19 outbreak, many students, with the help of learning, financial and social support, and a range of positive coping strategies, have adapted well to the impact of the pandemic and associated lockdown period.

Prevalence and Determinants of Immediate and Long-Term PTSD Consequences of Coronavirus-Related (CoV-1 and CoV-2) Pandemics among Healthcare Professionals: A Systematic Review and Meta-Analysis

Background: The COVID-19 pandemic continues to rise. In order to control the COVID-19 pandemic, healthcare professionals have been subjected to increased exposure to work stress. In this systematic review, we aimed at investigating the prevalence and determinants of immediate and long-term post-traumatic stress disorder (PTSD) effects on healthcare professionals by the COVID-19 (SARS CoV-2) and SARS-2003 (SARS CoV-1) pandemics. Methods: This systematic review was conducted according to the recommendations of the Protocols for Systemic Review and Meta-Analysis (PRISMA) statement. Only studies reporting the prevalence of PTSD (frequency, percentage) and related risk factors (adjusted odds ratio (OR)) in healthcare professionals (HCPs) during the SARS CoV-2 and SARS CoV-1 pandemics were included. The following databases were screened: Medline, Embase, PsychINFO, and Health Psychosocial Instrument (HaPI). Results: Six of eight studies reported PTSD symptoms among healthcare professionals during the COVID-19 pandemic in China (three), Singapore (one), India (one), and the United States of America (USA) (two), while two studies reported symptoms during the SARS-2003 pandemic in China (one) and Singapore (one). Sample sizes ranged from 263 to 5062 with a combined total of 10,074 participants. All of the studies self-reported the level of exposure to coronaviruses (CoV-1 and CoV-2) and severity of PTSD. Seven studies reported the prevalence of immediate PTSD and determinants, while one study reported delayed-onset PTSD (3 years after CoV-1 pandemic). Determinants of immediate PTSD were reported for the CoV-2 pandemic, while those for long-term PTSD were reported for the CoV-1 pandemic. Conclusions: A comprehensive understanding of the prevalence and determinants of immediate or long-term pandemic PTSD for healthcare workers can improve prevention, diagnosis, and management. Rigorous research measuring the prevalence of PTSD and its associated risk factors (adjusted OR) for the CoV-2 pandemic are envisaged. Although strategies to resolve immediate PTSD are key, long-term PTSD must not be overlooked.

Experiences and management of physician psychological symptoms during infectious disease outbreaks: a rapid review

BACKGROUND

Prior to the COVID-19 pandemic, physicians experienced unprecedented levels of burnout. The uncertainty of the ongoing COVID-19 pandemic along with increased workload and difficult medical triage decisions may lead to a further decline in physician psychological health.

METHODS

We searched Medline, EMBASE, and PsycINFO for primary research from database inception (Medline [1946], EMBASE [1974], PsycINFO [1806]) to November 17, 2020. Titles and abstracts were screened by one of three reviewers and full-text article screening and data abstraction were conducted independently, and in duplicate, by three reviewers.

RESULTS

From 6223 unique citations, 480 articles were reviewed in full-text, with 193 studies (of 90,499 physicians) included in the final review. Studies reported on physician psychological symptoms and management during seven infectious disease outbreaks (severe acute respiratory syndrome [SARS], three strains of Influenza A virus [H1N1, H5N1, H7N9], Ebola, Middle East respiratory syndrome [MERS], and COVID-19) in 57 countries. Psychological symptoms of anxiety (14.3-92.3%), stress (11.9-93.7%), depression (17-80.5%), post-traumatic stress disorder (13.2-75.2%) and burnout (14.7-76%) were commonly reported among physicians, regardless of infectious disease outbreak or country. Younger, female (vs. male), single (vs. married), early career physicians, and those providing direct care to infected patients were associated with worse psychological symptoms.

INTERPRETATION

Physicians should be aware that psychological symptoms of anxiety, depression, fear and distress are common, manifest differently and self-management strategies to improve psychological well-being exist. Health systems should implement short and long-term psychological supports for physicians caring for patients with COVID-19.