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      The Risk and Prevention of Novel Coronavirus Pneumonia Infections Among Inpatients in Psychiatric Hospitals

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          Dear Editor, Since the middle of December 2019, human-to-human transmission of novel coronavirus pneumonia (NCP, also called COVID-19) has occurred among close contacts [1]. After the outbreak on January 21, 2020, it was swiftly included among the Class B infectious diseases stipulated in the Law of the People’s Republic of China on the Prevention and Control of Infectious Diseases, and measures for prevention and control of Class A infectious diseases were adopted. At 21:27 on February 12, 2020, the China News Network updated information to include epidemic data from the National Health Commission and official channels in Hong Kong, Macao, and Taiwan regions: the highest death rate was in Wuhan City (Table 1). Overload of inpatients at hospitals may play a negative role in the overall therapeutic effect and contribute to the death rate. Table 1 Outbreak status of novel coronavirus pneumonia from the National Health Commission (21:27 on Feb 12, 2020) Diagnosed Cured Dead Global 45204 5084 1117 (2.471%) Asia 45124 5075 1117 (2.475%) China 44763 5034 1116 (2.493%) Hubei 33366 2668 1068 (3.200%) Wuhan 19558 1379 820 (4.192%) At the same time, with the related law promulgated, Wuhan Mental Health Center (WMHC) announced the closed management of inpatients (visit prohibited), and this was followed by other psychiatric hospitals nationwide. Unfortunately, on February 8, China News Weekly exclusively reported that nosocomial infection had occurred in WMHC. Up to February 8, ~ 50 patients and 30 medical staff in WMHC were diagnosed with NCP, so WMHC became the first psychiatric hospital in China with clustered nosocomial infections. The official spokesman of WMHC revealed to the media that delay of information on infections increased the chance of infection in the early stage, such as unawareness of the infection and the mode of transmission, as well as the possibility of an asymptomatic incubation period, similar to the situation of other general hospitals in Wuhan. Related Risk Factors Three elements are responsible for the infection of hospitalized psychotic patients: source of infection (patients with NCP), transmission route (human-to-human droplet transmission), and susceptibility (patients without insight). A similar outbreak occurred in 2003 that has parallels with the emergence of NCP: the severe acute respiratory syndrome (SARS), which killed 349 of 5327 probable cases (6.6%) reported in mainland China [2]. Compared to the mean incubation period of 6.4 days of SARS [3], the 5.2 days of the 2019 new Coronavirus (SARS-CoV-2) means it is more infectious [1]. Although the death rate from NCP (2.5%) is lower than that of SARS, unfortunately, the number of deaths doubles that of SARS although the outbreak started less than two months ago. Thus, the Chinese government has realized the severity of the NCP outbreak. Staff working in psychiatric hospitals were not notified of factors that may increase the risk and outbreak, but these may include the following: The wards are often closed and crowded; As is common in psychiatric hospitals, the wards of WMHC were not designed to the standards for isolation against infectious respiratory disease, nor are they equipped with negative pressure devices; Now is the season of high incidence of respiratory diseases, which led to the initial underestimating of NCP as a common disease; The source of infection cannot be found in a timely manner because the patients are neither sensitive to nor concerned about the news after long-term social isolation; It is difficult for psychiatric patients to accept and cooperate with self-isolation measures for cutting off the NCP infection route in time; Medical staff in the psychiatric specialty lack knowledge in coping with infectious diseases; A practical clinical path has not yet been promulgated for preventing infectious diseases in such isolated groups; Patients with psychoses have slowed perception of changes to the external environment, and lack a sense of self-protection; More emphasis is placed on the “stability” of the patient’s condition and not causing trouble, resulting in insufficient subjectivity of medical staff in psychiatric hospitals. Clearly, even supported by the nearby Pulmonary Medicine Department, emergency facilities are far from sufficient. We know that the healthcare workload for NCP is extremely great, particularly under the condition of human-to-human transmission. Lessons to Learn Not only in China, any mistake in prevention and control can critically strike local health systems worldwide. It has been noted in the Diagnosis and Treatment of Pneumonia Caused by New Coronavirus Infection (Trial Version 5) that the incubation period is generally 3–7 days, and the longest is 24 days [4]. Fourteen days of observation have been announced by the authorities. We need to consider the absence of objective measures, subjective deficiencies, and points that need to be changed. In case of aggravation or recurrence in a psychotic patient, the physician should take precautions before receiving a patient for hospitalization. Psychiatrists ought to aware that psychiatric patients are a susceptible group, so they should be carefully treated and fully prepared for admission and hospitalization. Clearly, it is more difficult for these patients to go through the proper procedures than healthy persons. Especially for pre-hospital assessment and virus isolation, every necessary step must be followed and cannot be simplified at the current unusual time. During the hospital stay, the closure measures should be strictly enforced, because some family members have still been able to deliver materials to the hospital even when visits are prohibited. The first case of NCP diagnosed in WMHC was a patient with Alzheimer’s disease. This patient might have been infected by outside goods brought by a family member. This phenomenon still occurs in the closed psychotic hospitals in China, with the most common reason being the tradition of reunion at Chinese New Year. Besides, experts have noted that if infected, the elderly and those with underlying diseases are more likely to develop severe pulmonary disease. Long-term hospitalized patients with mental disorders with comorbidity such as hypertension, diabetes, and other chronic diseases are more vulnerable than the general population [5]. Before the occurrence of this public health issue, such risks had not been fully discussed. Meanwhile, with the rapid development of information technology, far beyond that of the SARS period, such psychological influences spread more widely via the mainstream media and “We Media”. The long-term psychological implications of infectious diseases should not be ignored. These are likely to cause a secondary disaster due to stress and psychological distress even after the NCP is over [6]. These severe psychological stress factors could facilitate the onset of existing mental illness, for example, causing a serious delusion generalized by the epidemic situation. As a result, psychiatric hospitals will be burdened with extra pressure. The key conclusions from this section are: observation, threshold, isolation, and prevention. Possible Coping Strategies Once the novel coronavirus is imported into a public place, its speed of transmission is beyond control. To reduce the risk of infection at an early stage, all possible methods should be undertaken, such as to restrict hospitalization, expedite discharge, prohibit visits, provide physical supplies, and provide psychological assistance. A 14-day clinical observation period is indispensable before formal hospitalization procedures. It has been suggested that an observation room outside the routine ward should be set up for isolation and observation, so as to ensure the safety of patients with mental disorders during isolation. In particular, patients who cannot control their behavior should be more carefully assessed and stricter protective constraints than usual should be implemented. The intensive use of ward beds will increase the inconvenience of emergency deployment, the potential rate of cross infections, and the error rates due to fatigue of medical staff under high pressure. Therefore, remitted patients should be transferred to an outpatient clinic as soon as possible. Home quarantine has proved to be an effective way in these days [7], especially in less-affected provinces in China. The usual psychiatric ward is densely staffed and lacks sufficient space for activities and ventilation, which is conducive to the transmission of the novel coronavirus. Once exogenous infection occurs, transmission can be rapid and extremely hard to control. Therefore, the complete isolation of mental health centers has been recommended during the NCP epidemic. Specific measures to be considered are as follows: Fourteen days under observation in hospital is the key to reducing hospital infection; A pre-admission observation ward needs to be arranged immediately; A detailed understanding of the patient’s recent travel history in Hubei province, as well as the close contact history with suspected or confirmed patients; Based on the risk level of a latent infectious patient, the physician should make a firm decision on whether the patient should be transferred to the designated hospital for treatment set by the local government; Medical, nursing, logistics support, and canteen staff should limit their approaches to the hospital and have their temperature taken before entering and leaving the ward; Temporarily prohibit on-site visits, and replace them with video chat. In principle, only food and clothing from government-approved institutions are acceptable; More psychological services should be provided by community workers and family doctors to help the hospital to communicate about the restriction of visitors, so as to obtain consent on the necessity of these temporary arrangements; Ensure that family members know that the patients receive sufficient daily necessities from the hospital, so as to eliminate the worries and doubts of family members; The skills of medical staff in the psychiatric specialty needs to be improved in identifying and treating physical diseases. Panic is inevitable among patients and medical staff and timely mental health care for dealing with the novel coronavirus outbreak is urgently needed [8]. At present, it has been reported that many local hospital workers in Wuhan, especially nurses, have been confronting occupational exhaustion. Inevitably, the overloaded working conditions lead to mental health problems such as serious psychosomatic disorders and a decline in decision making and execution [9]. Psychological services and crisis interventions are needed at an early stage to reduce anxiety, depression, and post-traumatic stress disorder (PTSD) in almost all groups during such a stressful period. However, we should note that the premise of providing such services is to follow the advice in this paper, to isolate infected patients and cut off the transmission route to protect vulnerable people. Once a psychological consultation room is set up in a general hospital, the manager should pay attention to the redesign of the layout, formulate strict measures to prevent infection, and increase the protective equipment at work to ensure that consultations are conducted in a safe environment. Online psychotherapy is recommended. Where there is no sufficient preventative facility for the epidemic, psychiatrists and counselors are currently suggested to do more work over the phone, and via internet applications such as WeChat. The guiding principles divide the population affected by NCP into 6 categories and 4 levels and require the first-level population to be the focus of psychological crisis intervention. Then the intervention shall be gradually expanded to the second, third, and fourth levels, and finally, involve all populations. Common psychological and behavioral issues that have emerged from the outbreak, as well as psychological crisis interventions and principles have been explained in detail [10]. In order to alleviate the current acute stress responses of individuals and patients and reduce the incidence of psychological distress or PTSD, we should take appropriate measures for the support of public mental health. Probable practices are as follows: Disseminating knowledge on mental health to the public; Setting up psychological counseling hotlines nationwide; Launching individualized psychological support by psychiatrists and psychologists; Encouraging public and private physicians to provide psychological assistance; Encouraging voluntary support by infected survivors; Developing mental health insurance for special periods. Last but not least, we should identify high-risk individuals in a timely manner, and avoid the occurrence of extreme events such as suicide, impulsive behavior, and group psychological crisis [10]. We know that, to prevent and control nosocomial infections, it is essential to take measures to monitor patients outside the hospital. Probable practices for psychotic patients are: Lengthening the duration of prescriptions for stable outpatients; Ensuring remote monitoring for unstable outpatients; Early warning of the risk for patients needing hospitalization and rapid precaution planning. Further Perspectives Generally, a psychiatric hospital is required to provide mental health services to millions of local residents while hospital administrators have many difficulties in cutting off exogenous infections completely without higher administrative direction. The management system for psychiatric hospitals in China is still incomplete for responding well to public emergencies. We expect that the Government of China will promulgate targeted and operable laws and regulations as soon as possible to ensure the organization and personnel deployment for medical staff after this epidemic. A precise policy is essential for orderly treatment in psychiatric hospitals nationwide.

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          Timely mental health care for the 2019 novel coronavirus outbreak is urgently needed

          The 2019 novel coronavirus (2019-nCoV) pneumonia, believed to have originated in a wet market in Wuhan, Hubei province, China at the end of 2019, has gained intense attention nationwide and globally. To lower the risk of further disease transmission, the authority in Wuhan suspended public transport indefinitely from Jan 23, 2020; similar measures were adopted soon in many other cities in China. As of Jan 25, 2020, 30 Chinese provinces, municipalities, and autonomous regions covering over 1·3 billion people have initiated first-level responses to major public health emergencies. A range of measures has been urgently adopted,1, 2 such as early identification and isolation of suspected and diagnosed cases, contact tracing and monitoring, collection of clinical data and biological samples from patients, dissemination of regional and national diagnostic criteria and expert treatment consensus, establishment of isolation units and hospitals, and prompt provision of medical supplies and external expert teams to Hubei province. The emergence of the 2019-nCoV pneumonia has parallels with the 2003 outbreak of severe acute respiratory syndrome (SARS), which was caused by another coronavirus that killed 349 of 5327 patients with confirmed infection in China. 3 Although the diseases have different clinical presentations,1, 4 the infectious cause, epidemiological features, fast transmission pattern, and insufficient preparedness of health authorities to address the outbreaks are similar. So far, mental health care for the patients and health professionals directly affected by the 2019-nCoV epidemic has been under-addressed, although the National Health Commission of China released the notification of basic principles for emergency psychological crisis interventions for the 2019-nCoV pneumonia on Jan 26, 2020. 5 This notification contained a reference to mental health problems and interventions that occurred during the 2003 SARS outbreak, and mentioned that mental health care should be provided for patients with 2019-nCoV pneumonitis, close contacts, suspected cases who are isolated at home, patients in fever clinics, families and friends of affected people, health professionals caring for infected patients, and the public who are in need. To date, epidemiological data on the mental health problems and psychiatric morbidity of those suspected or diagnosed with the 2019-nCoV and their treating health professionals have not been available; therefore how best to respond to challenges during the outbreak is unknown. The observations of mental health consequences and measures taken during the 2003 SARS outbreak could help inform health authorities and the public to provide mental health interventions to those who are in need. Patients with confirmed or suspected 2019-nCoV may experience fear of the consequences of infection with a potentially fatal new virus, and those in quarantine might experience boredom, loneliness, and anger. Furthermore, symptoms of the infection, such as fever, hypoxia, and cough, as well as adverse effects of treatment, such as insomnia caused by corticosteroids, could lead to worsening anxiety and mental distress. 2019-nCoV has been repeatedly described as a killer virus, for example on WeChat, which has perpetuated the sense of danger and uncertainty among health workers and the public. In the early phase of the SARS outbreak, a range of psychiatric morbidities, including persistent depression, anxiety, panic attacks, psychomotor excitement, psychotic symptoms, delirium, and even suicidality, were reported.6, 7 Mandatory contact tracing and 14 days quarantine, which form part of the public health responses to the 2019-nCoV pneumonia outbreak, could increase patients' anxiety and guilt about the effects of contagion, quarantine, and stigma on their families and friends. Health professionals, especially those working in hospitals caring for people with confirmed or suspected 2019-nCoV pneumonia, are vulnerable to both high risk of infection and mental health problems. They may also experience fear of contagion and spreading the virus to their families, friends, or colleagues. Health workers in a Beijing hospital who were quarantined, worked in high-risk clinical settings such as SARS units, or had family or friends who were infected with SARS, had substantially more post-traumatic stress symptoms than those without these experiences. 8 Health professionals who worked in SARS units and hospitals during the SARS outbreak also reported depression, anxiety, fear, and frustration.6, 9 Despite the common mental health problems and disorders found among patients and health workers in such settings, most health professionals working in isolation units and hospitals do not receive any training in providing mental health care. Timely mental health care needs to be developed urgently. Some methods used in the SARS outbreak could be helpful for the response to the 2019-nCoV outbreak. First, multidisciplinary mental health teams established by health authorities at regional and national levels (including psychiatrists, psychiatric nurses, clinical psychologists, and other mental health workers) should deliver mental health support to patients and health workers. Specialised psychiatric treatments and appropriate mental health services and facilities should be provided for patients with comorbid mental disorders. Second, clear communication with regular and accurate updates about the 2019-nCoV outbreak should be provided to both health workers and patients in order to address their sense of uncertainty and fear. Treatment plans, progress reports, and health status updates should be given to both patients and their families. Third, secure services should be set up to provide psychological counselling using electronic devices and applications (such as smartphones and WeChat) for affected patients, as well as their families and members of the public. Using safe communication channels between patients and families, such as smartphone communication and WeChat, should be encouraged to decrease isolation. Fourth, suspected and diagnosed patients with 2019-nCoV pneumonia as well as health professionals working in hospitals caring for infected patients should receive regular clinical screening for depression, anxiety, and suicidality by mental health workers. Timely psychiatric treatments should be provided for those presenting with more severe mental health problems. For most patients and health workers, emotional and behavioural responses are part of an adaptive response to extraordinary stress, and psychotherapy techniques such as those based on the stress-adaptation model might be helpful.7, 10 If psychotropic medications are used, such as those prescribed by psychiatrists for severe psychiatric comorbidities, 6 basic pharmacological treatment principles of ensuring minimum harm should be followed to reduce harmful effects of any interactions with 2019-nCoV and its treatments. In any biological disaster, themes of fear, uncertainty, and stigmatisation are common and may act as barriers to appropriate medical and mental health interventions. Based on experience from past serious novel pneumonia outbreaks globally and the psychosocial impact of viral epidemics, the development and implementation of mental health assessment, support, treatment, and services are crucial and pressing goals for the health response to the 2019-nCoV outbreak. © 2020 VW Pics/Science Photo Library 2020 Since January 2020 Elsevier has created a COVID-19 resource centre with free information in English and Mandarin on the novel coronavirus COVID-19. The COVID-19 resource centre is hosted on Elsevier Connect, the company's public news and information website. Elsevier hereby grants permission to make all its COVID-19-related research that is available on the COVID-19 resource centre - including this research content - immediately available in PubMed Central and other publicly funded repositories, such as the WHO COVID database with rights for unrestricted research re-use and analyses in any form or by any means with acknowledgement of the original source. These permissions are granted for free by Elsevier for as long as the COVID-19 resource centre remains active.
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            The mental health of medical workers in Wuhan, China dealing with the 2019 novel coronavirus

            In December, 2019, a novel coronavirus outbreak of pneumonia emerged in Wuhan, Hubei province, China, 1 and has subsequently garnered attention around the world. 2 In the fight against the 2019 novel coronavirus (2019-nCoV), medical workers in Wuhan have been facing enormous pressure, including a high risk of infection and inadequate protection from contamination, overwork, frustration, discrimination, isolation, patients with negative emotions, a lack of contact with their families, and exhaustion. The severe situation is causing mental health problems such as stress, anxiety, depressive symptoms, insomnia, denial, anger, and fear. These mental health problems not only affect the medical workers' attention, understanding, and decision making ability, which might hinder the fight against 2019-nCoV, but could also have a lasting effect on their overall wellbeing. Protecting the mental health of these medical workers is thus important for control of the epidemic and their own long-term health. The local government of Wuhan has implemented policies to address these mental health problems. Medical staff infected with 2019-nCoV while at work will be identified as having work-related injuries. 3 As of Jan 25, 2020, 1230 medical workers have been sent from other provinces to Wuhan to care for patients who are infected and those with suspected infection, strengthen logistics support, and help reduce the pressure on health-care personnel. 4 Most general hospitals in Wuhan have established a shift system to allow front-line medical workers to rest and to take turns in high-pressured roles. Online platforms with medical advice have been provided to share information on how to decrease the risk of transmission between the patients in medical settings, which aims to eventually reduce the pressure on medical workers. Psychological intervention teams have been set up by the RenMin Hospital of Wuhan University and Mental Health Center of Wuhan, which comprise four groups of health-care staff. Firstly, the psychosocial response team (composed of managers and press officers in the hospitals) coordinates the management team's work and publicity tasks. Secondly, the psychological intervention technical support team (composed of senior psychological intervention experts) is responsible for formulating psychological intervention materials and rules, and providing technical guidance and supervision. Thirdly, the psychological intervention medical team, who are mainly psychiatrists, participates in clinical psychological intervention for health-care workers and patients. Lastly, the psychological assistance hotline teams (composed of volunteers who have received psychological assistance training in dealing with the 2019-nCoV epidemic) provide telephone guidance to help deal with mental health problems. Hundreds of medical workers are receiving these interventions, with good response, and their provision is expanding to more people and hospitals. Understanding the mental health response after a public health emergency might help medical workers and communities prepare for a population's response to a disaster. 5 On Jan 27, 2020, the National Health Commission of China published a national guideline of psychological crisis intervention for 2019-nCoV. 4 This publication marks the first time that guidance to provide multifaceted psychological protection of the mental health of medical workers has been initiated in China. The experiences from this public health emergency should inform the efficiency and quality of future crisis intervention of the Chinese Government and authorities around the world.
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              Epidemiologic and Clinical Characteristics of Novel Coronavirus Infections Involving 13 Patients Outside Wuhan, China

              This case series uses patient hospital data to summarize the clinical presentation and laboratory and imaging findings of 13 patients with confirmed 2019-nCoV infection admitted to hospitals in Beijing in January 2020.

                Author and article information

                Neurosci Bull
                Neurosci Bull
                Neuroscience Bulletin
                Springer Singapore (Singapore )
                25 February 2020
                March 2020
                : 36
                : 3
                : 299-302
                [1 ]GRID grid.16821.3c, ISNI 0000 0004 0368 8293, Shanghai Mental Health Center, , Shanghai Jiao Tong University School of Medicine, ; Shanghai, 200030 China
                [2 ]GRID grid.410642.5, Shanghai Changning Mental Health Center (Affiliated to East China Normal University), ; Shanghai, 200335 China
                [3 ]GRID grid.49470.3e, ISNI 0000 0001 2331 6153, Institute of Burns, , Tongren Hospital of Wuhan University (Wuhan Third Hospital), ; Wuhan, 430000 China
                [4 ]GRID grid.33199.31, ISNI 0000 0004 0368 7223, Affiliated Wuhan Mental Health Center, , Tongji Medical College of Huazhong University of Science and Technology, ; Wuhan, 430012 China
                [5 ]CAS Center for Excellence in Brain Science and Intelligence Technology, Shanghai, 200031 China
                [6 ]GRID grid.415630.5, ISNI 0000 0004 1782 6212, Shanghai Key Laboratory of Psychotic Disorders, ; Shanghai, 201108 China
                © Shanghai Institutes for Biological Sciences, CAS 2020
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                © Shanghai Institutes for Biological Sciences, CAS 2020


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