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      Psychosocial and behavioral problems of children and adolescents in the early stage of reopening schools after the COVID-19 pandemic: a national cross-sectional study in China

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          Abstract

          This study aims to explore the psychosocial and behavioral problems of children and adolescents in the early stage of reopening schools. In this national cross-sectional study, a total of 11072 students from China were naturally divided into two groups based on their schooling status: reopened schools (RS) and home schooling (HS) group. The psychosocial and behavioral functioning were measured by Achenbach Child Behaviour Checklist (CBCL) and compared in these two groups. Multivariable logistic regression analyses were conducted to explore the independent predictors associated with the psychosocial and behavioral problems. Our results showed that the students in the RS group had more adverse behaviors than that of HS group. The RS group had the higher rates of parent-offspring conflict, prolonged homework time, increased sedentary time and sleep problems (all p < 0.001). When separate analyses were conducted in boys and girls, the RS group had the higher scores for (1) overall behavioral problems ( p = 0.02 and p = 0.01), internalizing ( p = 0.02 and p = 0.02) and externalizing ( p = 0.02 and p = 0.004) behaviors in the 6–11 age group; (2) externalizing ( p = 0.049 and p = 0.006) behaviors in the 12–16 age group. Multivariable regression showed parent-offspring conflict and increased sedentary time were the most common risk factors, while physical activity and number of close friends were protective factors for behavior problems in RS students ( p < 0.01 or 0.05). The present study revealed that students’ psychosocial and behavioral problems increased in the early stage of schools reopened unexpectedly. These findings suggest that close attention must be paid and holistic strategies employed in the school reopening process of post-COVID-19 period.

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          Early Transmission Dynamics in Wuhan, China, of Novel Coronavirus–Infected Pneumonia

          Abstract Background The initial cases of novel coronavirus (2019-nCoV)–infected pneumonia (NCIP) occurred in Wuhan, Hubei Province, China, in December 2019 and January 2020. We analyzed data on the first 425 confirmed cases in Wuhan to determine the epidemiologic characteristics of NCIP. Methods We collected information on demographic characteristics, exposure history, and illness timelines of laboratory-confirmed cases of NCIP that had been reported by January 22, 2020. We described characteristics of the cases and estimated the key epidemiologic time-delay distributions. In the early period of exponential growth, we estimated the epidemic doubling time and the basic reproductive number. Results Among the first 425 patients with confirmed NCIP, the median age was 59 years and 56% were male. The majority of cases (55%) with onset before January 1, 2020, were linked to the Huanan Seafood Wholesale Market, as compared with 8.6% of the subsequent cases. The mean incubation period was 5.2 days (95% confidence interval [CI], 4.1 to 7.0), with the 95th percentile of the distribution at 12.5 days. In its early stages, the epidemic doubled in size every 7.4 days. With a mean serial interval of 7.5 days (95% CI, 5.3 to 19), the basic reproductive number was estimated to be 2.2 (95% CI, 1.4 to 3.9). Conclusions On the basis of this information, there is evidence that human-to-human transmission has occurred among close contacts since the middle of December 2019. Considerable efforts to reduce transmission will be required to control outbreaks if similar dynamics apply elsewhere. Measures to prevent or reduce transmission should be implemented in populations at risk. (Funded by the Ministry of Science and Technology of China and others.)
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            The psychological impact of quarantine and how to reduce it: rapid review of the evidence

            Summary The December, 2019 coronavirus disease outbreak has seen many countries ask people who have potentially come into contact with the infection to isolate themselves at home or in a dedicated quarantine facility. Decisions on how to apply quarantine should be based on the best available evidence. We did a Review of the psychological impact of quarantine using three electronic databases. Of 3166 papers found, 24 are included in this Review. Most reviewed studies reported negative psychological effects including post-traumatic stress symptoms, confusion, and anger. Stressors included longer quarantine duration, infection fears, frustration, boredom, inadequate supplies, inadequate information, financial loss, and stigma. Some researchers have suggested long-lasting effects. In situations where quarantine is deemed necessary, officials should quarantine individuals for no longer than required, provide clear rationale for quarantine and information about protocols, and ensure sufficient supplies are provided. Appeals to altruism by reminding the public about the benefits of quarantine to wider society can be favourable.
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              A novel coronavirus outbreak of global health concern

              In December, 2019, Wuhan, Hubei province, China, became the centre of an outbreak of pneumonia of unknown cause, which raised intense attention not only within China but internationally. Chinese health authorities did an immediate investigation to characterise and control the disease, including isolation of people suspected to have the disease, close monitoring of contacts, epidemiological and clinical data collection from patients, and development of diagnostic and treatment procedures. By Jan 7, 2020, Chinese scientists had isolated a novel coronavirus (CoV) from patients in Wuhan. The genetic sequence of the 2019 novel coronavirus (2019-nCoV) enabled the rapid development of point-of-care real-time RT-PCR diagnostic tests specific for 2019-nCoV (based on full genome sequence data on the Global Initiative on Sharing All Influenza Data [GISAID] platform). Cases of 2019-nCoV are no longer limited to Wuhan. Nine exported cases of 2019-nCoV infection have been reported in Thailand, Japan, Korea, the USA, Vietnam, and Singapore to date, and further dissemination through air travel is likely.1, 2, 3, 4, 5 As of Jan 23, 2020, confirmed cases were consecutively reported in 32 provinces, municipalities, and special administrative regions in China, including Hong Kong, Macau, and Taiwan. 3 These cases detected outside Wuhan, together with the detection of infection in at least one household cluster—reported by Jasper Fuk-Woo Chan and colleagues 6 in The Lancet—and the recently documented infections in health-care workers caring for patients with 2019-nCoV indicate human-to-human transmission and thus the risk of much wider spread of the disease. As of Jan 23, 2020, a total of 835 cases with laboratory-confirmed 2019-nCoV infection have been detected in China, of whom 25 have died and 93% remain in hospital (figure ). 3 Figure Timeline of early stages of 2019-nCoV outbreak 2019-nCoV=2019 novel coronavirus. In The Lancet, Chaolin Huang and colleagues 7 report clinical features of the first 41 patients admitted to the designated hospital in Wuhan who were confirmed to be infected with 2019-nCoV by Jan 2, 2020. The study findings provide first-hand data about severity of the emerging 2019-nCoV infection. Symptoms resulting from 2019-nCoV infection at the prodromal phase, including fever, dry cough, and malaise, are non-specific. Unlike human coronavirus infections, upper respiratory symptoms are notably infrequent. Intestinal presentations observed with SARS also appear to be uncommon, although two of six cases reported by Chan and colleagues had diarrhoea. 6 Common laboratory findings on admission to hospital include lymphopenia and bilateral ground-glass opacity or consolidation in chest CT scans. These clinical presentations confounded early detection of infected cases, especially against a background of ongoing influenza and circulation of other respiratory viruses. Exposure history to the Huanan Seafood Wholesale market served as an important clue at the early stage, yet its value has decreased as more secondary and tertiary cases have appeared. Of the 41 patients in this cohort, 22 (55%) developed severe dyspnoea and 13 (32%) required admission to an intensive care unit, and six died. 7 Hence, the case-fatality proportion in this cohort is approximately 14·6%, and the overall case fatality proportion appears to be closer to 3% (table ). However, both of these estimates should be treated with great caution because not all patients have concluded their illness (ie, recovered or died) and the true number of infections and full disease spectrum are unknown. Importantly, in emerging viral infection outbreaks the case-fatality ratio is often overestimated in the early stages because case detection is highly biased towards the more severe cases. As further data on the spectrum of mild or asymptomatic infection becomes available, one case of which was documented by Chan and colleagues, 6 the case-fatality ratio is likely to decrease. Nevertheless, the 1918 influenza pandemic is estimated to have had a case-fatality ratio of less than 5% 13 but had an enormous impact due to widespread transmission, so there is no room for complacency. Table Characteristics of patients who have been infected with 2019-nCoV, MERS-CoV, and SARS-CoV7, 8, 10, 11, 12 2019-nCoV * MERS-CoV SARS-CoV Demographic Date December, 2019 June, 2012 November, 2002 Location of first detection Wuhan, China Jeddah, Saudi Arabia Guangdong, China Age, years (range) 49 (21–76) 56 (14–94) 39·9 (1–91) Male:female sex ratio 2·7:1 3·3:1 1:1·25 Confirmed cases 835† 2494 8096 Mortality 25† (2·9%) 858 (37%) 744 (10%) Health-care workers 16‡ 9·8% 23·1% Symptoms Fever 40 (98%) 98% 99–100% Dry cough 31 (76%) 47% 29–75% Dyspnoea 22 (55%) 72% 40–42% Diarrhoea 1 (3%) 26% 20–25% Sore throat 0 21% 13–25% Ventilatory support 9·8% 80% 14–20% Data are n, age (range), or n (%) unless otherwise stated. 2019-nCoV=2019 novel coronavirus. MERS-CoV=Middle East respiratory syndrome coronavirus. SARS-CoV=severe acute respiratory syndrome coronavirus. * Demographics and symptoms for 2019-nCoV infection are based on data from the first 41 patients reported by Chaolin Huang and colleagues (admitted before Jan 2, 2020). 8 Case numbers and mortalities are updated up to Jan 21, 2020) as disclosed by the Chinese Health Commission. † Data as of Jan 23, 2020. ‡ Data as of Jan 21, 2020. 9 As an RNA virus, 2019-nCoV still has the inherent feature of a high mutation rate, although like other coronaviruses the mutation rate might be somewhat lower than other RNA viruses because of its genome-encoded exonuclease. This aspect provides the possibility for this newly introduced zoonotic viral pathogen to adapt to become more efficiently transmitted from person to person and possibly become more virulent. Two previous coronavirus outbreaks had been reported in the 21st century. The clinical features of 2019-nCoV, in comparison with SARS-CoV and Middle East respiratory syndrome (MERS)-CoV, are summarised in the table. The ongoing 2019-nCoV outbreak has undoubtedly caused the memories of the SARS-CoV outbreak starting 17 years ago to resurface in many people. In November, 2002, clusters of pneumonia of unknown cause were reported in Guangdong province, China, now known as the SARS-CoV outbreak. The number of cases of SARS increased substantially in the next year in China and later spread globally, 14 infecting at least 8096 people and causing 774 deaths. 12 The international spread of SARS-CoV in 2003 was attributed to its strong transmission ability under specific circumstances and the insufficient preparedness and implementation of infection control practices. Chinese public health and scientific capabilities have been greatly transformed since 2003. An efficient system is ready for monitoring and responding to infectious disease outbreaks and the 2019-nCoV pneumonia has been quickly added to the Notifiable Communicable Disease List and given the highest priority by Chinese health authorities. The increasing number of cases and widening geographical spread of the disease raise grave concerns about the future trajectory of the outbreak, especially with the Chinese Lunar New Year quickly approaching. Under normal circumstances, an estimated 3 billion trips would be made in the Spring Festival travel rush this year, with 15 million trips happening in Wuhan. The virus might further spread to other places during this festival period and cause epidemics, especially if it has acquired the ability to efficiently transmit from person to person. Consequently, the 2019-nCoV outbreak has led to implementation of extraordinary public health measures to reduce further spread of the virus within China and elsewhere. Although WHO has not recommended any international travelling restrictions so far, 15 the local government in Wuhan announced on Jan 23, 2020, the suspension of public transportation, with closure of airports, railway stations, and highways in the city, to prevent further disease transmission. 16 Further efforts in travel restriction might follow. Active surveillance for new cases and close monitoring of their contacts are being implemented. To improve detection efficiency, front-line clinics, apart from local centres for disease control and prevention, should be armed with validated point-of-care diagnostic kits. Rapid information disclosure is a top priority for disease control and prevention. A daily press release system has been established in China to ensure effective and efficient disclosure of epidemic information. Education campaigns should be launched to promote precautions for travellers, including frequent hand-washing, cough etiquette, and use of personal protection equipment (eg, masks) when visiting public places. Also, the general public should be motivated to report fever and other risk factors for coronavirus infection, including travel history to affected area and close contacts with confirmed or suspected cases. Considering that substantial numbers of patients with SARS and MERS were infected in health-care settings, precautions need to be taken to prevent nosocomial spread of the virus. Unfortunately, 16 health-care workers, some of whom were working in the same ward, have been confirmed to be infected with 2019-nCoV to date, although the routes of transmission and the possible role of so-called super-spreaders remain to be clarified. 9 Epidemiological studies need to be done to assess risk factors for infection in health-care personnel and quantify potential subclinical or asymptomatic infections. Notably, the transmission of SARS-CoV was eventually halted by public health measures including elimination of nosocomial infections. We need to be wary of the current outbreak turning into a sustained epidemic or even a pandemic. The availability of the virus' genetic sequence and initial data on the epidemiology and clinical consequences of the 2019-nCoV infections are only the first steps to understanding the threat posed by this pathogen. Many important questions remain unanswered, including its origin, extent, and duration of transmission in humans, ability to infect other animal hosts, and the spectrum and pathogenesis of human infections. Characterising viral isolates from successive generations of human infections will be key to updating diagnostics and assessing viral evolution. Beyond supportive care, 17 no specific coronavirus antivirals or vaccines of proven efficacy in humans exist, although clinical trials of both are ongoing for MERS-CoV and one controlled trial of ritonavir-boosted lopinavir monotherapy has been launched for 2019-nCoV (ChiCTR2000029308). Future animal model and clinical studies should focus on assessing the effectiveness and safety of promising antiviral drugs, monoclonal and polyclonal neutralising antibody products, and therapeutics directed against immunopathologic host responses. We have to be aware of the challenge and concerns brought by 2019-nCoV to our community. Every effort should be given to understand and control the disease, and the time to act is now. This online publication has been corrected. The corrected version first appeared at thelancet.com on January 29, 2020
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                Author and article information

                Contributors
                kexynj@hotmail.com
                tyli@vip.sina.com
                Journal
                Transl Psychiatry
                Transl Psychiatry
                Translational Psychiatry
                Nature Publishing Group UK (London )
                2158-3188
                3 June 2021
                3 June 2021
                2021
                : 11
                : 342
                Affiliations
                [1 ]GRID grid.418633.b, ISNI 0000 0004 1771 7032, Department of Child Health Care, Children’s Hospital, , Capital Institute of Pediatrics, ; Beijing, China
                [2 ]GRID grid.16821.3c, ISNI 0000 0004 0368 8293, Department of Developmental and Behavioral Pediatrics, , Shanghai Children’s Medical Center Affiliated to Medical School of Shanghai Jiaotong University, ; Shanghai, China
                [3 ]GRID grid.488412.3, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, , Children’s Hospital of Chongqing Medical University, ; Chongqing, China
                [4 ]GRID grid.430605.4, Department of Developmental-Behavioral Pediatrics, , the First Hospital of Jilin University, Changchun, ; Jilin, China
                [5 ]GRID grid.412987.1, ISNI 0000 0004 0630 1330, Department of Developmental-Behavioral Pediatrics, , Xinhua Hospital Affiliated to Medical School of Shanghai Jiaotong University, ; Shanghai, China
                [6 ]GRID grid.24827.3b, ISNI 0000 0001 2179 9593, Department of Pediatrics, , University of Cincinnati College of Medicine and Cincinnati Children’s Hospital Medical Center, ; Cincinnati, OH USA
                [7 ]GRID grid.11135.37, ISNI 0000 0001 2256 9319, Department of Biostatistics, , Peking University, ; Beijing, China
                [8 ]GRID grid.33199.31, ISNI 0000 0004 0368 7223, Department of Child Health Care,Tongji Hospital, Tongji Medical College, , Huazhong University of Science and Technology, ; Wuhan, Hubei China
                [9 ]GRID grid.412558.f, ISNI 0000 0004 1762 1794, Child Developmental & Behavioral Center, The Third Affiliated Hospital of Sun Yat-sen University, ; Guangzhou, China
                [10 ]GRID grid.452902.8, Department of Child Health Care, , Xi’an Children’s Hospital, ; Xi’an, Shaanxi China
                [11 ]GRID grid.256112.3, ISNI 0000 0004 1797 9307, Health Management Center, Fuzhou Children’s Hospital of Fujian Medical University, ; Fuzhou, China
                [12 ]GRID grid.459434.b, Children’s Hospital, Capital Institute of Pediatrics, ; Beijing, China
                [13 ]GRID grid.207374.5, ISNI 0000 0001 2189 3846, Department of Child Health Care, , Children’s Hospital Affiliated to Zhengzhou University, ; Zhengzhou, China
                [14 ]GRID grid.89957.3a, ISNI 0000 0000 9255 8984, Child Mental Health Research Center, Brain Hospital Affiliated to Nanjing Medical University, ; Nanjing, Jiangsu China
                [15 ]GRID grid.418633.b, ISNI 0000 0004 1771 7032, Department of Early Childhood Development, , Capital Institute of Pediatrics, ; Beijing, China
                [16 ]GRID grid.489271.1, Shanghai Pudong Institute of Education Development, ; Shanghai, China
                [17 ]Chongqing educational science research academy, Chongqing, China
                [18 ]GRID grid.459847.3, ISNI 0000 0004 1798 0615, Peking University Sixth Hospital, Peking University Institute of Mental Health, National Clinical Research Center for Mental Disorders, NHC Key Laboratory of Mental Health (Peking University), ; Beijing, China
                [19 ]GRID grid.418633.b, ISNI 0000 0004 1771 7032, Department of Epidemiology, , Capital Institute of Pediatrics, ; Beijing, China
                Author information
                http://orcid.org/0000-0001-5536-781X
                http://orcid.org/0000-0003-3293-7001
                http://orcid.org/0000-0002-1766-5418
                http://orcid.org/0000-0002-8309-1395
                http://orcid.org/0000-0002-2455-4986
                http://orcid.org/0000-0001-8830-8189
                http://orcid.org/0000-0002-3919-117X
                http://orcid.org/0000-0002-1511-652X
                http://orcid.org/0000-0002-2012-2617
                http://orcid.org/0000-0002-1220-6677
                http://orcid.org/0000-0001-5356-3956
                http://orcid.org/0000-0002-1940-7076
                Article
                1462
                10.1038/s41398-021-01462-z
                8172553
                34083509
                cef5851b-b55e-4f1a-a3f0-77daf41f97dc
                © The Author(s) 2021

                Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons license, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons license and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this license, visit http://creativecommons.org/licenses/by/4.0/.

                History
                : 17 August 2020
                : 22 April 2021
                : 4 May 2021
                Funding
                Funded by: the General Program of National Natural Science Foundation of China(NSFC No.81771223) the Key Research and Development Project of Social Livelihood of Science Innovation and Application Demonstration Project of Chongqing Municipal Science and Technology Commission (No.cstc2018jscx-mszdX0023)
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                © The Author(s) 2021

                Clinical Psychology & Psychiatry
                psychiatric disorders,scientific community,human behaviour

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