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      The mental health of medical workers in Wuhan, China dealing with the 2019 novel coronavirus

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          Abstract

          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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          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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            Emerging understandings of 2019-nCoV

            The Lancet (2020)
            “There is an emergency in China, but it has not yet become a global health emergency...WHO is following this outbreak every minute of every day”, said Dr Tedros Ghebreyesus, Director-General of WHO, on Jan 23. A novel coronavirus (2019-nCoV) outbreak is emerging, but it is not yet a Public Health Emergency of International Concern (PHEIC). As we went to press, more than 500 cases have been confirmed in China, as well as in Japan, South Korea, Thailand, and the US. The virus can cause a severe respiratory illness, like SARS and MERS, and human-to-human transmission has been confirmed. These characteristics are driving China's urgent public health actions, as well as international concern. But much remains unknown. The pieces of the puzzle that is 2019-nCoV are only now beginning to come together. Today, we publish the first clinical data from individuals confirmed to be infected with 2019-nCoV from Wuhan, China. Chaolin Huang and colleagues provide comprehensive findings for the first 41 laboratory-confirmed cases. 27 of these 41 cases had direct exposure to the Wuhan seafood market that is thought to be the initial site of infection from an animal source. All had viral pneumonia. The severity of illness is concerning: almost a third of patients developed acute respiratory distress syndrome requiring intensive care; six patients died; five had acute cardiac injury; and four required ventilation. Separately, Jasper Fuk-Woo Chan and colleagues report clinical and microbiological data from a family of six people who had travelled to Wuhan and later presented with pneumonia to Shenzhen Hospital in Guangdong province. Five were identified as infected with 2019-nCoV. Notably, none had been to the Wuhan market, but two had visited a Wuhan hospital. The authors suggest these findings confirm human-to-human transmission. Together, these Articles provide an important initial picture of the clinical spectrum and transmission of this new disease. In an accompanying Comment, Chen Wang, George Gao, and colleagues describe the early sharing of clinical data from the outbreak and emphasise the urgent need for more information about pathogenesis and viral transmission, as well as the pressing need to develop best supportive care and a vaccine. They also caution against overstating the mortality risk, as early reported case-fatality rates may be high due to bias towards detecting severe cases. As David Heymann reflects in another accompanying Comment, publication of these Articles provides peer-reviewed information urgently needed to refine the risk assessment and response, which are happening in real time. China has quickly isolated and sequenced the virus and shared these data internationally. The lessons from the SARS epidemic—where China was insufficiently prepared to implement infection control practices—have been successfully learned. By most accounts, Chinese authorities are meeting international standards and isolating suspected cases and contacts, developing diagnostic and treatment procedures, and implementing public education campaigns. Dr Tedros has praised China for its transparency, data sharing, and quick response. Likewise, WHO has reacted fast and diligently. Despite massive attention and conjecture about the level of threat posed by 2019-nCoV, and whether WHO should declare a PHEIC, the agency's emergency committee has not bowed to pressure to take such a decision until necessary. We commend WHO for its resilience. There are still many gaps in our understanding. The early experiences of these patients and the response to their symptoms before cases were reported remain undocumented. The exposure and possible infection of health workers remain extremely worrying. We will not know for some time the consequences of the quarantine imposed in Wuhan on Jan 23, 2020. Chinese public health authorities are under enormous pressure to make difficult decisions with an incomplete, and rapidly changing, understanding of the epidemic. The shutdowns may seem a drastic step—whether they represent an effective control measure deserves careful investigation and much will likely depend on maintaining trust between authorities and the local population. News media that worsen fears by reporting a “killer virus“ only harm efforts to implement a succesful and safe infection control strategy. Openness and sharing of data are paramount. There are enormous demands for rapid access to information about this new virus, the patients and communities affected, and the response. But equally crucial is the need to ensure that those data are reliable, accurate, and independently scrutinised. As for all public health emergencies, we will be making all related Lancet content fully and freely available. © 2020 Reuters/Aly Song 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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              Mental health after the Boston marathon bombing.

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                Author and article information

                Contributors
                Journal
                Lancet Psychiatry
                Lancet Psychiatry
                The Lancet. Psychiatry
                Elsevier Ltd.
                2215-0366
                2215-0374
                5 February 2020
                March 2020
                5 February 2020
                : 7
                : 3
                : e14
                Affiliations
                [a ]Department of Psychiatry, RenMin Hospital of Wuhan University, Wuhan 430060, China
                [b ]Wuhan Mental Health Center, Wuhan, China
                [c ]Department of Psychiatry, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
                [d ]The School of Computer Science and Technology, Huazhong University of Science and Technology, Wuhan, China
                [e ]School of Health Sciences, Wuhan University, Wuhan, China
                [f ]Department of Psychiatry, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
                [g ]Shanghai Mental Health Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
                [h ]Peking University Sixth Hospital, Peking University Institute of Mental Health, NHC Key Laboratory of Mental Health (Peking University), National Clinical Research Center for Mental Disorders (Peking University Sixth Hospital), Beijing, China
                Article
                S2215-0366(20)30047-X
                10.1016/S2215-0366(20)30047-X
                7129673
                32035030
                edf28cee-140d-4654-bffb-b637c15ff975
                © 2020 Elsevier Ltd. All rights reserved.

                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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