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      Factors Associated With Mental Health Outcomes Among Health Care Workers Exposed to Coronavirus Disease 2019

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          Key Points

          Question

          What factors are associated with mental health outcomes among health care workers in China who are treating patients with coronavirus disease 2019 (COVID-19)?

          Findings

          In this cross-sectional study of 1257 health care workers in 34 hospitals equipped with fever clinics or wards for patients with COVID-19 in multiple regions of China, a considerable proportion of health care workers reported experiencing symptoms of depression, anxiety, insomnia, and distress, especially women, nurses, those in Wuhan, and front-line health care workers directly engaged in diagnosing, treating, or providing nursing care to patients with suspected or confirmed COVID-19.

          Meaning

          These findings suggest that, among Chinese health care workers exposed to COVID-19, women, nurses, those in Wuhan, and front-line health care workers have a high risk of developing unfavorable mental health outcomes and may need psychological support or interventions.

          Abstract

          This cross-sectional study assesses the magnitude of mental health consequences and associated factors among health care workers treating patients exposed to coronavirus disease 2019 (COVID-19) in China.

          Abstract

          Importance

          Health care workers exposed to coronavirus disease 2019 (COVID-19) could be psychologically stressed.

          Objective

          To assess the magnitude of mental health outcomes and associated factors among health care workers treating patients exposed to COVID-19 in China.

          Design, Settings, and Participants

          This cross-sectional, survey-based, region-stratified study collected demographic data and mental health measurements from 1257 health care workers in 34 hospitals from January 29, 2020, to February 3, 2020, in China. Health care workers in hospitals equipped with fever clinics or wards for patients with COVID-19 were eligible.

          Main Outcomes and Measures

          The degree of symptoms of depression, anxiety, insomnia, and distress was assessed by the Chinese versions of the 9-item Patient Health Questionnaire, the 7-item Generalized Anxiety Disorder scale, the 7-item Insomnia Severity Index, and the 22-item Impact of Event Scale–Revised, respectively. Multivariable logistic regression analysis was performed to identify factors associated with mental health outcomes.

          Results

          A total of 1257 of 1830 contacted individuals completed the survey, with a participation rate of 68.7%. A total of 813 (64.7%) were aged 26 to 40 years, and 964 (76.7%) were women. Of all participants, 764 (60.8%) were nurses, and 493 (39.2%) were physicians; 760 (60.5%) worked in hospitals in Wuhan, and 522 (41.5%) were frontline health care workers. A considerable proportion of participants reported symptoms of depression (634 [50.4%]), anxiety (560 [44.6%]), insomnia (427 [34.0%]), and distress (899 [71.5%]). Nurses, women, frontline health care workers, and those working in Wuhan, China, reported more severe degrees of all measurements of mental health symptoms than other health care workers (eg, median [IQR] Patient Health Questionnaire scores among physicians vs nurses: 4.0 [1.0-7.0] vs 5.0 [2.0-8.0]; P = .007; median [interquartile range {IQR}] Generalized Anxiety Disorder scale scores among men vs women: 2.0 [0-6.0] vs 4.0 [1.0-7.0]; P < .001; median [IQR] Insomnia Severity Index scores among frontline vs second-line workers: 6.0 [2.0-11.0] vs 4.0 [1.0-8.0]; P < .001; median [IQR] Impact of Event Scale–Revised scores among those in Wuhan vs those in Hubei outside Wuhan and those outside Hubei: 21.0 [8.5-34.5] vs 18.0 [6.0-28.0] in Hubei outside Wuhan and 15.0 [4.0-26.0] outside Hubei; P < .001). Multivariable logistic regression analysis showed participants from outside Hubei province were associated with lower risk of experiencing symptoms of distress compared with those in Wuhan (odds ratio [OR], 0.62; 95% CI, 0.43-0.88; P = .008). Frontline health care workers engaged in direct diagnosis, treatment, and care of patients with COVID-19 were associated with a higher risk of symptoms of depression (OR, 1.52; 95% CI, 1.11-2.09; P = .01), anxiety (OR, 1.57; 95% CI, 1.22-2.02; P < .001), insomnia (OR, 2.97; 95% CI, 1.92-4.60; P < .001), and distress (OR, 1.60; 95% CI, 1.25-2.04; P < .001).

          Conclusions and Relevance

          In this survey of heath care workers in hospitals equipped with fever clinics or wards for patients with COVID-19 in Wuhan and other regions in China, participants reported experiencing psychological burden, especially nurses, women, those in Wuhan, and frontline health care workers directly engaged in the diagnosis, treatment, and care for patients with COVID-19.

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          Most cited references13

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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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            Transmission of 2019-nCoV Infection from an Asymptomatic Contact in Germany

            To the Editor: The novel coronavirus (2019-nCoV) from Wuhan is currently causing concern in the medical community as the virus is spreading around the world. 1 Since identification of the virus in late December 2019, the number of cases from China that have been imported into other countries is on the rise, and the epidemiologic picture is changing on a daily basis. We are reporting a case of 2019-nCoV infection acquired outside Asia in which transmission appears to have occurred during the incubation period in the index patient. A 33-year-old otherwise healthy German businessman (Patient 1) became ill with a sore throat, chills, and myalgias on January 24, 2020. The following day, a fever of 39.1°C (102.4°F) developed, along with a productive cough. By the evening of the next day, he started feeling better and went back to work on January 27. Before the onset of symptoms, he had attended meetings with a Chinese business partner at his company near Munich on January 20 and 21. The business partner, a Shanghai resident, had visited Germany between January 19 and 22. During her stay, she had been well with no signs or symptoms of infection but had become ill on her flight back to China, where she tested positive for 2019-nCoV on January 26 (index patient in Figure 1) (see Supplementary Appendix, available at NEJM.org, for details on the timeline of symptom development leading to hospitalization). On January 27, she informed the company about her illness. Contact tracing was started, and the above-mentioned colleague was sent to the Division of Infectious Diseases and Tropical Medicine in Munich for further assessment. At presentation, he was afebrile and well. He reported no previous or chronic illnesses and had no history of foreign travel within 14 days before the onset of symptoms. Two nasopharyngeal swabs and one sputum sample were obtained and were found to be positive for 2019-nCoV on quantitative reverse-transcriptase–polymerase-chain-reaction (qRT-PCR) assay. 2 Follow-up qRT-PCR assay revealed a high viral load of 108 copies per milliliter in his sputum during the following days, with the last available result on January 29. On January 28, three additional employees at the company tested positive for 2019-nCoV (Patients 2 through 4 in Figure 1). Of these patients, only Patient 2 had contact with the index patient; the other two patients had contact only with Patient 1. In accordance with the health authorities, all the patients with confirmed 2019-nCoV infection were admitted to a Munich infectious diseases unit for clinical monitoring and isolation. So far, none of the four confirmed patients show signs of severe clinical illness. This case of 2019-nCoV infection was diagnosed in Germany and transmitted outside Asia. However, it is notable that the infection appears to have been transmitted during the incubation period of the index patient, in whom the illness was brief and nonspecific. 3 The fact that asymptomatic persons are potential sources of 2019-nCoV infection may warrant a reassessment of transmission dynamics of the current outbreak. In this context, the detection of 2019-nCoV and a high sputum viral load in a convalescent patient (Patient 1) arouse concern about prolonged shedding of 2019-nCoV after recovery. Yet, the viability of 2019-nCoV detected on qRT-PCR in this patient remains to be proved by means of viral culture. Despite these concerns, all four patients who were seen in Munich have had mild cases and were hospitalized primarily for public health purposes. Since hospital capacities are limited — in particular, given the concurrent peak of the influenza season in the northern hemisphere — research is needed to determine whether such patients can be treated with appropriate guidance and oversight outside the hospital.
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              Updated understanding of the outbreak of 2019 novel coronavirus (2019‐nCoV) in Wuhan, China

              Abstract To help health workers and the public recognize and deal with the 2019 novel coronavirus (2019‐nCoV) quickly, effectively, and calmly with an updated understanding. A comprehensive search from Chinese and worldwide official websites and announcements was performed between 1 December 2019 and 9:30 am 26 January 2020 (Beijing time). A latest summary of 2019‐nCoV and the current outbreak was drawn. Up to 24 pm, 25 January 2020, a total of 1975 cases of 2019‐nCoV infection were confirmed in mainland China with a total of 56 deaths having occurred. The latest mortality was approximately 2.84% with a total of 2684 cases still suspected. The China National Health Commission reported the details of the first 17 deaths up to 24 pm, 22 January 2020. The deaths included 13 males and 4 females. The median age of the people who died was 75 (range 48‐89) years. Fever (64.7%) and cough (52.9%) were the most common first symptoms among those who died. The median number of days from the occurence of the first symptom to death was 14.0 (range 6‐41) days, and it tended to be shorter among people aged 70 years or more (11.5 [range 6‐19] days) than those aged less than 70 years (20 [range 10‐41] days; P = .033). The 2019‐nCoV infection is spreading and its incidence is increasing nationwide. The first deaths occurred mostly in elderly people, among whom the disease might progress faster. The public should still be cautious in dealing with the virus and pay more attention to protecting the elderly people from the virus.
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                Author and article information

                Journal
                JAMA Netw Open
                JAMA Netw Open
                JAMA Netw Open
                JAMA Network Open
                American Medical Association
                2574-3805
                23 March 2020
                March 2020
                23 March 2020
                : 3
                : 3
                : e203976
                Affiliations
                [1 ]Department of Psychiatry, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
                [2 ]Department of Psychiatry, Renmin Hospital of Wuhan University, Wuhan, China
                [3 ]Department of Psychiatry, Wuhan Youfu Hospital, Wuhan, China
                [4 ]Department of Psychiatry, Jingmen No. 2 People’s Hospital, Jingmen, China
                [5 ]Department of Psychiatry, Wuhan Wudong Hospital, Wuhan, China
                [6 ]Department of Nursing, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
                Author notes
                Article Information
                Accepted for Publication: March 2, 2020.
                Published: March 23, 2020. doi:10.1001/jamanetworkopen.2020.3976
                Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2020 Lai J et al. JAMA Network Open.
                Corresponding Authors: Zhongchun Liu, MD, Department of Psychiatry, Renmin Hospital of Wuhan University, 238 Jiefang Rd, Wuhan 430060, China ( zcliu6@ 123456whu.edu.cn ); Shaohua Hu, MD, Department of Psychiatry, First Affiliated Hospital, Zhejiang University School of Medicine, 79 Qingchun Rd, Hangzhou 310003, China ( dorhushaohua@ 123456zju.edu.cn ).
                Author Contributions: Drs Liu and S. Hu had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Drs Lai, Ma, and Y. Wang contributed equally and share first authorship. Drs Liu and S. Hu contributed equally as senior authors.
                Concept and design: Liu, S. Hu.
                Acquisition, analysis, or interpretation of data: Lai, Ma, Y. Wang, Cai, J. Hu, Wei, Wu, Du, Chen, Li, Tan, Kang, Yao, Huang, H. Wang, G. Wang.
                Drafting of the manuscript: Lai, Ma, Y. Wang, Liu, S. Hu.
                Critical revision of the manuscript for important intellectual content: Lai, Cai, J. Hu, Wei, Wu, Du, Chen, Li, Tan, Kang, Yao, Huang, H. Wang, G. Wang, Liu, S. Hu.
                Statistical analysis: Ma, Y. Wang, Liu, S. Hu.
                Obtained funding: Liu, S. Hu.
                Administrative, technical, or material support: Lai, Cai, J. Hu, Wei, Wu, Du, Chen, Li, Tan, Kang, Yao, Huang, H. Wang, G. Wang.
                Supervision: G. Wang, Liu, S. Hu.
                Conflict of Interest Disclosures: None reported.
                Funding/Support: This study was supported by grants 2018YFC1314600 and 2016YFC1307100 from the National Key Research and Development Program of China.
                Role of the Funder/Sponsor: The funder had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.
                Additional Contributions: We thank all the participants who contributed to our work.
                Article
                zoi200192
                10.1001/jamanetworkopen.2020.3976
                7090843
                32202646
                eee5e4bc-20d5-45d3-9571-88beb4a0e690
                Copyright 2020 Lai J et al. JAMA Network Open.

                This is an open access article distributed under the terms of the CC-BY License.

                History
                : 21 February 2020
                : 2 March 2020
                Funding
                Funded by: National Key Research and Development Program of China
                Categories
                Research
                Original Investigation
                Online Only
                Psychiatry

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