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      The Coronavirus Disease (COVID-19) Challenge in Mexico: A Critical and Forced Reflection as Individuals and Society

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          Introduction Medically speaking we define a crisis as a sudden intensification of the symptoms of a disease (1). According to the Royal Spanish Academy, a crisis is defined as a profound change with important consequences in a process or situation or in the way in which these are appreciated (2). Historically, crisis are opportunities to question the status quo of entire societies; they are moments for reinventing ourselves and thus evolving toward, for example, a better system, a better organized, more tolerant, inclusive, and caring humanity. COVID-19: A Global Emergency Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) was identified as the cause of an outbreak of pneumonia of otherwise unknown cause in Wuhan City, Hubei Province, China, in December 2019 (3). Because of the rapid spread of SARS-CoV-2 globally, the World Health Organization declared infection by SARS-CoV-2 a global health emergency on January 20, 2020 (4). According to Johns Hopkins Center for Systems Science and Engineering data, as of June 20, 2020, COVID-19 cases are present in 188 countries. To date, worldwide 8,753,853 cases have been confirmed, of which 463,281 patients died (5). These pictures change daily. In Mexico on June 20, 2020 (phase 3), the statistics showed 175,202 confirmed cases and 20,781 deaths due to COVID-19 (6). Mexican Society in The Waiting Room Of SARS-Cov-2 The coronavirus pandemic has quickly become a public health problem and has revealed the deficiencies of our society, not only in Mexico but worldwide. When SARS-CoV-2 arrived in Mexico, it reached a country undergoing one of its most important political-economic transitions, where the economic and health systems were in the midst of reorganization, where it was not clear how the different government agencies would work. In a context where uncertainty and fear already reigned, with a population that, due to its socio-political background, is characterized by a distrust of its authorities, and which has abundant access to information that is sometimes unreliable (6–8), everything gives rise to new behaviors that limit the ability of the authorities and health personnel to deal with the pandemic (9). Health Personnel in Mexico Facing COVID-19 One of the first obstacles faced by health personnel and authorities was a society that did not trust the people taking care of it. Thousands of skeptical Mexicans even claimed that the pandemic would not reach Mexico, driven perhaps by a false a sense of security provided by the country's geographical remoteness from the epicenters of contagion up to that point: China and Italy (10). The first reported case in Mexico was on February 28, 2020 (11). Since its first reported case, the Mexican government gradually increased measures to avoid the increase in the number of cases. These measures included social distancing, closing schools, and the cancellation of sporting events and other gatherings. Almost in parallel (in early March), the Mexican newscasts were flooded with images of people buying scandalous amounts of toilet paper, antibacterial cleaning products, and gels, with the most sophisticated buying medical equipment (12–14). We had not yet entered the period of social distancing and there was already a shortage of supplies. Mexican health personnel throughout the country, from different institutions and levels of care, had to face the early stages of the pandemic without proper protective equipment. Despite this, health personnel continued to provide care to their patients knowing that they did not have the necessary safety provisions, that they were putting their own lives at risk (15, 16). Although this was common knowledge, citizens continued to buy protective medical supplies, even those citizens that were low-risk for the virus (14, 17). To a certain extent this situation was to be expected, due to lack of preparation for a pandemic, and lack of personal protective equipment (PPE) occurring early in the pandemic. This could have been avoided if government authorities did not underestimate the risk of COVID-19 across Mexico, and instituted adequate response plans early in the pandemic, or even before the virus arrived in Mexico. It is painful but necessary to say that the response and planning by all of the authorities has not been the best, because it seems that more than one governor or municipal president underestimated the situation. Even as healthcare workers protested the lack of PPE and medical equipment, there was no immediate response and healthcare workers continued to work under poor conditions to help those who had contracted COVID-19 (18–20). The health personnel who have worked overtime since the beginning, who have had to leave their families and friends are now falling ill. It is calculated that up to May 11, 2020, there were 8,544 Mexican health workers infected with SARS-CoV-2, and 111 dead, equivalent to 23.51% of total infections in our country. Of these, 37% are doctors, 41% nurses, 19% other health workers, 2% laboratory workers, and 1% dentist. The number of infected health professionals increased 341.77% in a period of 15 days (20). If we take into account that there are 2.4 doctors for every 1,000 inhabitants in Mexico (21), this means there are approximately 1,317,200 people without access to medical care. If we also take into account that, according to the Mexican First Minister of Health Dr. Jorge Alcocer, there is a deficit of 200,000 doctors and 300,000 nurses to face the pandemic, it is evident that having health personnel sick due to lack of PPE is a situation that Mexico should not have allowed to occur. In several states of the Mexican Republic, the proportion of confirmed cases that occurred among health personnel was high. Indeed, outbreaks occurring in health institutions even caused their closure (22–24). Numerous doctors and nurses worked and still work in poor conditions, unable to see family and friends, because they are exposed daily to a high risk of suffering contagion, having to work even if they are sick, and in addition, having to bear the risk of bullying/harassment from the general public (9). It is important to consider how log shifts can impact the quality of care, as such multiple studies show extended-duration work shifts significantly increase fatigue and impair performance safety (25–27). This could have as a side effect the inappropriate use of PPE, increasing the risk of contagion. Another very important aspect was the use of poor quality PPE, which has been a constant throughout the evolution of the pandemic and which has reached such magnitudes that health personnel have seen the need to actively stop and mobilize in protests (28–31). In other countries, the health workers had a shortage of PPE and/or high exposure to SARS-CoV-2 in health care settings (32, 33). In United States 9,282 (19%) COVID-19 cases were identified as healthcare personnel, while in Spain until March 27, at least 9,444 (14.7%) healthcare workers had been infected with SARS-CoV-2 (34), and more than 6,000 (10%) Italian health workers got sick from COVID-19 (35). These numbers, in these countries, demonstrated that each nation has faced a variety of different obstacles but the common consequence has been a high percentage of healthcare personnel with COVID-19. Are Health Workers Heroes, Villains, or Martyrs? Modes of behavior that we believed to be well-defined have been erased and a social phenomenon has been born: discrimination against health personnel in a climate where everyone yearns to return to their lives in the way they used to be. There have been physical and verbal attacks both inside and outside hospital facilities (36), as well as while they carry out home visits to evaluate patients who, due to their basic diagnosis, had to stay at home. Have also been documented cases of nurses, resident doctors, and other health personnel who have been assaulted on their way home (9, 37), to the point where legal intervention by the authorities was necessary (38). María del Carmen Montenegro, professor at the Faculty of Psychology at the Autonomous University of Mexico, explains: “They (the medical staff) symbolically represent the disease itself and cure it, so the terror that this evil and stigma implies is uncontrollable, which generates the most interesting beliefs as a social process” (39). Who is Guilty? Nobody was prepared for this critical moment and we all could have done more as a population to protect our healthcare workers. We could have respected social distancing adequately, avoided crowded places at the first report of COVID-19, suspended non-essential activities, and complied with the instructions of the health authorities. Questions for the Mexican Government are: Could our authorities have acted more quickly? How effective were the measures and planning that began in January 2020? Should they have done more SARS-CoV-2 diagnostic tests? The answers to these questions may never be known, but we can do better than we are now to improve the working conditions for health personnel and thus help them to preserve the health of us all. We must face this challenge and overcome it in an organized manner with the understanding that our lives are at serious risk. Concluding Remarks We intend for this document to be the beginning point for discussion and for action to improve health institutions in both Mexico and the world and the conditions under which healthcare workers currently work. Above this is an invitation to a change of consciousness and to establish new priorities on the part of our governments. One of the questions on the table must be what will we do to give our health workers an adequate workplace protection? We must think of that we can do from this moment on to create an environment of respect, understanding, and solidarity for those who watch over our health. We must find ways to stop being a society that cares more about improbable wars than ensuring the dignity of life. We must become a society in which, in even in prosperous times, peace and that health are not only the focus of attention when people are dying. We must now ask ourselves what this pandemic means for humanity and how we should live once it ends. That SARS-CoV-2 should not be just another chapter in history, just one more pandemic that plagued humanity—it should become the reconversion point, where the health and lives of all becomes the priority of all nations. Author Contributions CC-V, IG-V, NM-A, ID-E, YO-C, GC-P, and MM-F: made significantly contributions to the conception of the work, to literature search, to writing the manuscript, revised it critically for important intellectual content, approved its final version, and agreed to its submission. All authors contributed to the article and approved the submitted version. Conflict of Interest The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. The reviewer VCK declared a shared affiliation with one of the authors, ID-E, to the handling editor at time of review.

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          Outbreak of pneumonia of unknown etiology in Wuhan, China: The mystery and the miracle

          Since December 2019, a total of 41 cases of pneumonia of unknown etiology have been confirmed in Wuhan city, Hubei Province, China. Wuhan city is a major transportation hub with a population of more than 11 million people. Most of the patients visited a local fish and wild animal market last month. At a national press conference held today, Dr Jianguo Xu, an academician of the Chinese Academy of Engineering, who led a scientific team announced that a new‐type coronavirus, tentatively named by World Health Organization as the 2019‐new coronavirus (2019‐nCoV), had caused this outbreak. 1 The 2019‐nCoV has a different coronavirus‐specific nucleic acid sequence from known human coronavirus species, which are similar to some of the beta coronaviruses identified in bats. 2 , 3 The virus‐specific nucleic acid sequences were detected in lung fluid, blood and throat swab samples in 15 patients and the virus that was isolated showed a typical coronavirus appearance under electron microscopy. Further research will be conducted to better understand the new coronavirus to develop antiviral agents and vaccines. 4 We applauded the excellent job that has been done so far. The infection was first described in December. Within 9 days, a special team consisted of physicians, scientists and epidemiologists who ruled out several extremely contagious pathogens including SARS, which killed hundreds of people more than a decade ago, and MERS. This has surely alleviated environmental concerns as Hong Kong authorities had quickly stepped up the disinfection of trains and airplanes and checks of passengers due to this outbreak. Most of the patients visited the fish and wild animal market last month in Wuhan. This fish and wild animal market also sold live animals such as poultry, bats, marmots, and snakes. All patients received prompt supportive treatment in quarantine. Among them, seven patients were in serious condition and one patient died. All of the 42 patients so far confirmed were from China except one Thailand patient who was a traveler from Wuhan. Eight patients have been cured of the disease and were discharged from the hospital last week. The 2019‐nCoV now have been isolated from multiple patients and appears to be the culprit. But the mystery has not been completely solved yet. Until there is a formal published scientific manuscript, the facts can be argued, particularly regarding causality despite these facts having been officially announced. The data collected so far is not enough to confirm the causal relationship between the new‐type coronavirus and the respiratory disease based on classical Koch's postulates or modified ones as suggested by Fredricks and Relman. 5 The viral‐specific nucleic acids were only discovered in 15 patients, and successful virus culture was extremely limited to only a few patients. There remains considerable work to be done to differentiate between colonization, shedding, and infection. Additional strains of the 2019‐nCoV need to be isolated to study their homologies. It is expected that antigens and monoclonal antibodies will be developed so serology can be used to confirm previous and acute infection status. The episode demonstrates further the need for rapid and accurate detection and identification methods that can be used in the local hospitals and clinics bearing the burden of identifying and treating patients. Recently, the Clinical Laboratory Improvement Amendments (CLIA) of 1988 has waived highly sensitive and specific molecular devices known as CLIA‐waived devices so that these devices are gradually becoming available for point of care testing. Finally, the epidemiological similarity between this outbreak and that of SARS in 2002‐2003 6 is striking. SARS was then traced to animal markets 7 and eventually to palm civets. 8 Later bats were identified as animal reservoirs. 9 Could this novel coronavirus be originated from wild animals? The family Coronaviridae includes two subfamilies. 10 One, the subfamily Coronavirinae, contains a substantial number of pathogens of mammals that individually cause a remarkable variety of diseases, including pneumonia. In humans, coronaviruses are among the spectrum of viruses that cause the common cold as well as more severe respiratory disease—specifically SARS and MERS, which are both zoonoses. The second subfamily, Torovirinae, contains pathogens of both terrestrial and aquatic animals. The genus Torovirus includes the type species, equine torovirus (Berne virus), which was first isolated from a horse with diarrhea, and the Breda virus, which was first isolated from neonatal calves with diarrhea. White bream virus from fish is the type species of the genus Bafinivirus. However, there is no evidence so far that the seafood from the fish and animal market caused 2019‐nCoV‐associated pneumonia. This epidemiologic similarity clearly provides a starting point for the further investigation of this outbreak. In the meantime, this fish and animal market has been closed until the epidemiological work determines the animal host of this novel coronavirus. Only then will the miracle be complete.
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            Characteristics of Health Care Personnel with COVID-19 — United States, February 12–April 9, 2020

            As of April 9, 2020, the coronavirus disease 2019 (COVID-19) pandemic had resulted in 1,521,252 cases and 92,798 deaths worldwide, including 459,165 cases and 16,570 deaths in the United States ( 1 , 2 ). Health care personnel (HCP) are essential workers defined as paid and unpaid persons serving in health care settings who have the potential for direct or indirect exposure to patients or infectious materials ( 3 ). During February 12–April 9, among 315,531 COVID-19 cases reported to CDC using a standardized form, 49,370 (16%) included data on whether the patient was a health care worker in the United States; including 9,282 (19%) who were identified as HCP. Among HCP patients with data available, the median age was 42 years (interquartile range [IQR] = 32–54 years), 6,603 (73%) were female, and 1,779 (38%) reported at least one underlying health condition. Among HCP patients with data on health care, household, and community exposures, 780 (55%) reported contact with a COVID-19 patient only in health care settings. Although 4,336 (92%) HCP patients reported having at least one symptom among fever, cough, or shortness of breath, the remaining 8% did not report any of these symptoms. Most HCP with COVID-19 (6,760, 90%) were not hospitalized; however, severe outcomes, including 27 deaths, occurred across all age groups; deaths most frequently occurred in HCP aged ≥65 years. These preliminary findings highlight that whether HCP acquire infection at work or in the community, it is necessary to protect the health and safety of this essential national workforce. Data from laboratory-confirmed COVID-19 cases voluntarily reported to CDC from 50 states, four U.S. territories and affiliated islands, and the District of Columbia, during February 12–April 9 were analyzed. Cases among persons repatriated to the United States from Wuhan, China, and the Diamond Princess cruise ship during January and February were excluded. Public health departments report COVID-19 cases to CDC using a standardized case report form* that collects information on patient demographics, whether the patient is a U.S. health care worker, symptom onset date, specimen collection dates, history of exposures in the 14 days preceding illness onset, COVID-19 symptomology, preexisting medical conditions, and patient outcomes, including hospitalization, intensive care unit (ICU) admission, and death. HCP patient health outcomes, overall and stratified by age, were classified as hospitalized, hospitalized with ICU admission, and deaths. The lower bound of these percentages was estimated by including all cases within each age group in the denominators. Upper bounds were estimated by including only those cases with known information on each outcome as denominators. Data reported to CDC are preliminary and can be updated by health departments over time. The upper quartile of the lag between onset date and reporting to CDC was 10 days. Because submitted forms might have missing or unknown information at the time of report, all analyses are descriptive, and no statistical comparisons were performed. Stata (version 15.1; StataCorp) and SAS (version 9.4; SAS Institute) were used to conduct all analyses. Among 315,531 U.S. COVID-19 cases reported to CDC during February 12–April 9, data on HCP occupational status were available for 49,370 (16%), among whom 9,282 (19%) were identified as HCP (Figure). Data completeness for HCP status varied by reporting jurisdiction; among 12 states that included HCP status on >80% of all reported cases and reported at least one HCP patient, HCP accounted for 11% (1,689 of 15,194) of all reported cases. FIGURE Daily number of COVID-19 cases, by date of symptom onset, among health care personnel and non-health care personnel (N = 43,986)* , † — United States, February 12–April 9, 2020 Abbreviation: COVID-19 = coronavirus disease 2019. * Onset date was calculated for 5,892 (13%) cases where onset date was missing. This was done by subtracting 4 days (median interval from symptom onset to specimen collection date) from the date of earliest specimen collection. Cases with unknown onset and specimen collection dates were excluded. † Ten-day window is used to reflect the upper quartile in lag between the date of symptom onset and date reported to CDC. The figure is a bar chart showing the number of reported COVID-19 cases among health care personnel and non-health care personnel (N = 43,986), by date of illness onset, in the United States during February 12–April 9, 2020. Among the 8,945 (96%) HCP patients reporting age, the median was 42 years (IQR = 32–54 years); 6,603 (73%) were female (Table 1). Among the 3,801 (41%) HCP patients with available data on race, a total of 2,743 (72%) were white, 801 (21%) were black, 199 (5%) were Asian, and 58 (2%) were other or multiple races. Among 3,624 (39%) with ethnicity specified, 3,252 (90%) were reported as non-Hispanic/Latino and 372 (10%) as Hispanic/Latino. At least one underlying health condition † was reported by 1,779 (38%) HCP patients with available information. TABLE 1 Demographic characteristics, exposures, symptoms, and underlying health conditions among health care personnel with COVID-19 (N = 9,282) — United States, February 12–April 9, 2020 Characteristic (no. with available information) No. (%) Age group (yrs) (8,945) 16–44 4,898 (55) 45–54 1,919 (21) 55–64 1,620 (18) ≥65 508 (6) Sex (9,067) Female 6,603 (73) Male 2,464 (27) Race (3,801) Asian 199 (5) Black 801 (21) White 2,743 (72) Other* 58 (2) Ethnicity (3,624) Hispanic/Latino 372 (10) Non-Hispanic/Latino 3,252 (90) Exposures†,§ (1,423) Only health care exposure 780 (55) Only household exposure 384 (27) Only community exposure 187(13) Multiple exposure settings¶ 72 (5) Symptoms reported§,** (4,707) Fever, cough, or shortness of breath†† 4,336 (92) Cough 3,694 (78) Fever§§ 3,196 (68) Muscle aches 3,122 (66) Headache 3,048 (65) Shortness of breath 1,930 (41) Sore throat 1,790 (38) Diarrhea 1,507 (32) Nausea or vomiting 923 (20) Loss of smell or taste¶¶ 750 (16) Abdominal pain 612 (13) Runny nose 583 (12) Any underlying health condition§,*** (4,733) 1,779 (38) Abbreviation: COVID-19 = coronavirus disease 2019. * “Other” includes patients who were identified as American Indian or Alaska Native (16), Native Hawaiian or Other Pacific Islander (22), or two or more races (20). † Cases were included in the denominator if the patient reported a known contact with a laboratory-confirmed COVID-19 patient within the 14 days before illness onset in a health care, household, or community setting. § Responses include data from standardized fields supplemented with data from free-text fields. ¶ Includes all patients with contact reported in more than one of these settings: health care, household, and community. ** Cases were included in the denominator if the patient had a known symptom status for fever, cough, shortness of breath, nausea or vomiting, and diarrhea. HCP with mild or asymptomatic infections might have been less likely to be tested, thus less likely to be reported. †† Includes all patients with at least one of these symptoms. §§ Patients were included if they had information for either measured or subjective fever variables and were considered to have a fever if “yes” was indicated for either variable. ¶¶ Symptom data on loss of smell or taste was extracted only from free-text symptom fields, thus the proportion with this symptom is likely an underestimate. *** Preexisting medical conditions and other risk factors (yes, no, or unknown) included the following: chronic lung disease (inclusive of asthma, chronic obstructive pulmonary disease, and emphysema); diabetes mellitus; cardiovascular disease; chronic renal disease; chronic liver disease; immunocompromised condition; neurologic disorder, neurodevelopmental or intellectual disability; pregnancy; current smoking status; former smoking status; or other chronic disease. Among 1,423 HCP patients who reported contact with a laboratory-confirmed COVID-19 patient in either health care, household, or community settings, 780 (55%) reported having such contact only in a health care setting within the 14 days before their illness onset; 384 (27%) reported contact only in a household setting; 187 (13%) reported contact only in a community setting; 72 (5%) reported contact in more than one of these settings. Among HCP patients with data available on a core set of signs and symptoms, § a total of 4,336 (92%) reported having at least one of fever, cough, shortness of breath. Two thirds (3,122, 66%) reported muscle aches, and 3,048 (65%) reported headache. Loss of smell or taste was written in for 750 (16%) HCP patients as an “other” symptom. Among HCP patients with data available on age and health outcomes, 6,760 (90%) were not hospitalized, 723 (8%–10%) were hospitalized, 184 (2%–5%) were admitted to an ICU, and 27 (0.3%–0.6%) died (Table 2). Although only 6% of HCP patients were aged ≥65 years, 10 (37%) deaths occurred among persons in this age group. TABLE 2 Hospitalizations,* intensive care unit (ICU) admissions, † and deaths, § by age group among health care personnel with COVID-19 — United States, February 12–April 9, 2020 Age group¶ (yrs) (no. of cases) Outcome, no. (%)** Hospitalization†† ICU admission Death 16–44 (4,898) 260 (5.3–6.4) 44 (0.9–2.2) 6 (0.1–0.3) 45–54 (1,919) 178 (9.3–11.1) 51 (2.7–6.3) 3 (0.2–0.3) 55–64 (1,620) 188 (11.6–13.8) 54 (3.3–7.5) 8 (0.5–1.0) ≥65 (508) 97 (19.1–22.3) 35 (6.9–16.0) 10 (2.0–4.2) Total (8,945) 723 (8.1–9.7) 184 (2.1–4.9) 27 (0.3–0.6) Abbreviation: COVID-19 = coronavirus disease 2019. * Hospitalization status known for 7,483 (84%) patients. † ICU status known for 3,739 (42%) patients. § Death outcomes known for 4,407 (49%) patients. ¶ Age status known for 8,945 (96%) patients. ** Lower bound of range = number of persons hospitalized, admitted to ICU, or who died among total in age group; upper bound of range = number of persons hospitalized, admitted to ICU, or who died among total in age group with known hospitalization status, ICU admission status, or death. †† Hospitalization status includes hospitalization with or without ICU admission. Discussion As of April 9, 2020, a total of 9,282 U.S. HCP with confirmed COVID-19 had been reported to CDC. This is likely an underestimation because HCP status was available for only 16% of reported cases nationwide. HCP with mild or asymptomatic infections might also have been less likely to be tested, thus less likely to be reported. Overall, only 3% (9,282 of 315,531) of reported cases were among HCP; however, among states with more complete reporting of HCP status, HCP accounted for 11% (1,689 of 15,194) of reported cases. The total number of COVID-19 cases among HCP is expected to rise as more U.S. communities experience widespread transmission. Compared with reports of COVID-19 patients in the overall populations of China and Italy ( 4 , 5 ), reports of HCP patients in the United States during February 12–April 9 were slightly younger, and a higher proportion were women; this likely reflects the age and sex distributions among the U.S. HCP workforce. Race and ethnicity distributions among HCP patients reported to CDC are different from those in the overall U.S. population but are more similar to those in the HCP workforce. ¶ , ** Among HCP patients who reported having contact with a laboratory-confirmed COVID-19 patient in health care, household, or community settings, the majority reported contact that occurred in health care settings. However, there were also known exposures in households and in the community, highlighting the potential for exposure in multiple settings, especially as community transmission increases. Further, transmission might come from unrecognized sources, including presymptomatic or asymptomatic persons ( 6 , 7 ). Together, these exposure possibilities underscore several important considerations for prevention. Done alone, contact tracing after recognized occupational exposures likely will fail to identify many HCP at risk for developing COVID-19. Additional measures that will likely reduce the risk for infected HCP transmitting the virus to colleagues and patients include screening all HCP for fever and respiratory symptoms at the beginning of their shifts, prioritizing HCP for testing, and ensuring options to discourage working while ill (e.g., flexible and nonpunitive medical leave policies). Given the evidence for presymptomatic and asymptomatic transmission ( 7 ), covering the nose and mouth (i.e., source control) is recommended in community settings where other social distancing measures are difficult to maintain. †† Assuring source control among all HCP, patients, and visitors in health care settings is another promising strategy for further reducing transmission. Even if everyone in a health care setting is covering their nose and mouth to contain their respiratory secretions, it is still critical that, when caring for patients, HCP continue to wear recommended personal protective equipment (PPE) (e.g., gown, N95 respirator [or facemask if N95 is not available], eye protection, and gloves for COVID-19 patient care). Training of HCP on preventive measures, including hand hygiene and PPE use, is another important safeguard against transmission in health care settings. Among HCP with COVID-19 whose age status was known, 8%–10% were reported to be hospitalized. This is lower than the 21%–31% of U.S. COVID-19 cases with known hospitalization status described in a recent report ( 8 ) and might reflect the younger median age (42 years) of HCP patients compared with that of reported COVID-19 patients overall, as well as prioritization of HCP for testing, which might identify less severe illness. Similar to earlier findings ( 8 ), increasing age was associated with a higher prevalence of severe outcomes, although severe outcomes, including death, were observed in all age groups. Preliminary estimates of the prevalence of underlying health conditions among all patients with COVID-19 reported to CDC through March 2020 ( 9 ) suggested that 38% had at least one underlying condition, the same percentage found in this HCP patient population. Older HCP or those with underlying health conditions ( 8 , 9 ) should consider consulting with their health care provider and employee health program to better understand and manage their risks regarding COVID-19. The increased prevalence of severe outcomes in older HCP should be considered when mobilizing retired HCP to increase surge capacity, especially in the face of limited PPE availability §§ ; one consideration is preferential assignment of retired HCP to lower-risk settings (e.g., telemedicine, administrative assignments, or clinics for non–COVID-19 patients). The findings in this report are subject to at least five limitations. First, approximately 84% of patients were missing data on HCP status. Thus, the number of cases in HCP reported here must be considered a lower bound because additional cases likely have gone unidentified or unreported. Second, among cases reported in HCP, the amount of missing data varied across demographic groups, exposures, symptoms, underlying conditions, and health outcomes; cases with available information might differ systematically from those without available information. Therefore, additional data are needed to confirm findings about the impact of potentially important factors (e.g., disparities in race and ethnicity or underlying health conditions among HCP). Third, additional time will be necessary for full ascertainment of outcomes, such as hospitalization status or death. Fourth, details of occupation and health care setting were not routinely collected through case-based surveillance and, therefore, were unavailable for this analysis. Finally, among HCP patients who reported contact with a confirmed COVID-19 patient in a health care setting, the nature of this contact, including whether it was with a patient, visitor, or other HCP, and the details of potential occupational exposures, including whether HCP were unprotected (i.e., without recommended PPE) or were present during high risk procedures (e.g., aerosol-generating procedures) are unknown ( 10 ). It is critical to make every effort to ensure the health and safety of this essential national workforce of approximately 18 million HCP, both at work and in the community. Surveillance is necessary for monitoring the impact of COVID-19-associated illness and better informing the implementation of infection prevention and control measures. Improving surveillance through routine reporting of occupation and industry not only benefits HCP, but all workers during the COVID-19 pandemic. Summary What is already known about this topic? Limited information is available about COVID-19 infections among U.S. health care personnel (HCP). What is added by this report? Of 9,282 U.S. COVID-19 cases reported among HCP, median age was 42 years, and 73% were female, reflecting these distributions among the HCP workforce. HCP patients reported contact with COVID-19 patients in health care, household, and community settings. Most HCP patients were not hospitalized; however, severe outcomes, including death, were reported among all age groups. What are the implications for public health practice? It is critical to ensure the health and safety of HCP, both at work and in the community. Improving surveillance through routine reporting of occupation and industry not only benefits HCP, but all workers during the COVID-19 pandemic.
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              Sleep deprivation and fatigue in residency training: results of a national survey of first- and second-year residents.

              To examine the relationship between residents' self-reported sleep hours, work hours, and other empirical correlates. Using the American Medical Association's Graduate Medical Education database, a national, random sample of PGY (postgraduate year) 1 and PGY2 residents in the 1998-1999 training year was surveyed by mail. Residents completed a 5-page survey with 44 questions requiring 144 separate responses about their residency experience. Completed surveys were received from 3,604 of 5,616 residents contacted, a 64.2% response rate. Although work hours and sleep hours were significantly correlated (r = -.39), this relationship was less robust than is generally assumed. Total average sleep hours varied across specialties but also within specialties. Just over 20% of all residents reported sleeping an average of 5 hours or less per night, with 66% averaging 6 hours or less per night. Residents averaging 5 or fewer hours of sleep per night were more likely to report serious accidents or injuries, conflict with other professional staff, use of alcohol, use of medications to stay awake, noticeable weight change, working in an "impaired condition," and having made significant medical errors. Reduced sleep hours were significantly related to a number of work-related, learning, and personal health variables. Capping residents' work hours is unlikely to fully address the sleep deficits and resulting impairments reported by residents.
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                Author and article information

                Contributors
                Journal
                Front Public Health
                Front Public Health
                Front. Public Health
                Frontiers in Public Health
                Frontiers Media S.A.
                2296-2565
                26 June 2020
                2020
                26 June 2020
                : 8
                : 337
                Affiliations
                [1] 1Molecular Medicine Laboratory, Academic Unit of Human Medicine and Health Sciences, Universidad Autonoma de Zacatecas , Zacatecas, Mexico
                [2] 2School of Medicine, University of Colima , Colima, Mexico
                Author notes

                Edited by: Marissa G. Baker, University of Washington, United States

                Reviewed by: Victor Cervantes Kardasch, University of Colima, Mexico; Laura Cristina Hernández Ramírez, Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), United States

                *Correspondence: Margarita L. Martinez-Fierro margaritamf@ 123456uaz.edu.mx

                This article was submitted to Occupational Health and Safety, a section of the journal Frontiers in Public Health

                Article
                10.3389/fpubh.2020.00337
                7332544
                32671012
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                Copyright © 2020 Caldera-Villalobos, Garza-Veloz, Martínez-Avila, Delgado-Enciso, Ortiz-Castro, Cabral-Pacheco and Martinez-Fierro.

                This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

                History
                : 01 May 2020
                : 16 June 2020
                Page count
                Figures: 0, Tables: 0, Equations: 0, References: 39, Pages: 4, Words: 3164
                Funding
                Funded by: Universidad Autónoma de Zacatecas 10.13039/501100007506
                Categories
                Public Health
                Opinion

                covid-19,sars-cov-2,pandemic,health workers,méxico,coronavirus
                covid-19, sars-cov-2, pandemic, health workers, méxico, coronavirus

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