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[Article] Physical and mental health effects of COVID-19 on health care workers: a scoping review.

[Article] Physical and mental health effects of COVID-19 on health care workers: a scoping review.

Summary

Background

The coronavirus disease (COVID-19) pandemic has spread to 198 countries, with approximately 2.4 million confirmed cases and 150,000 deaths worldwide as of April 18. Frontline health care workers (healthcare workers) are at considerable risk of infection and death from excessive COVID-19 exposure. This review aimed to summarize the evidence of the physical and mental health effects of the COVID-19 pandemic on health care workers (healthcare workers).

Method

A scoping review was conducted using the Arksey O'Malley framework. A systematic literature search was conducted using two databases, PubMed and Google Scholar. We found 154 studies, 10 of which met our criteria. We collected information on publication date, country of first author, article title, study design, study population, interventions and outcomes, and primary findings, and divided all research articles into two areas: physical and mental health effects.

Result

A total of 154 articles from PubMed (126) and Google Scholar (28) were reviewed, of which 58 were found to be duplicates and were excluded. Of the remaining 96 articles, 82 were excluded after screening for eligibility and 4 articles were not available in full text. Ten full-text articles were reviewed and included in this study.

The authors' findings identified the following risk factors for COVID-19-related health effects: working in high-risk sectors, diagnosed family members, inadequate hand hygiene, improper hand hygiene before and after patient contact, improper PPE use, close patient contact (≥12 times/day), long daily contact time (≥15 hours ), and unprotected exposure. The most common symptoms identified among health care workers were fever (85%), cough (70%), and weakness (70%). Prolonged use of PPE resulted in skin symptoms and skin damage (97%), with nasal bridge (83%) being the most commonly affected site. Health care workers experienced high levels of depression, anxiety, insomnia, and distress. Female health care workers and nurses were disproportionately affected.

Conclusion.

Front-line health care workers are directly at risk for physical and mental outcomes as a result of providing care to patients with COVID-19. Although few intervention studies are available, early data suggest that implementation strategies to reduce the likelihood of infection, shorter travel lengths, and mental health support mechanisms can reduce morbidity and mortality among health care workers.

Keywords:

COVID-19, health care workers, health effects, risk factors, occupational health

Background

Coronavirus Disease 2019 (COVID-19) was first identified in Wuhan City in December 2019 and subsequently spread to Hubei Province and other parts of China [1,2]. After causing significant morbidity and mortality in China, COVID-19 spread to many other countries by February 2020, including the United States, Italy, Spain, Germany, France, and Iran [3-5]. As of April 18, COVID-19 has spread to 198 countries, infecting 2.4 million people and killing 150,000 worldwide, and is considered a global pandemic [6-8].

Healthcare workers (medical personnel) are among the groups at high risk of contracting this infection [9-11]. In China, 3387 healthcare workers were reported to be infected, and 22 healthcare workers (0.6%) died from this disease [9, 12]. Similarly, Italy (20%), Spain (14%), and France (>50 healthcare workers) reported high rates of HCW infection [10, 13, 14]. Given the large burden, there is an increasing need to protect healthcare workers worldwide through the provision of personal protective equipment (PPE), training, coping with fatigue, and addressing psychosocial effects [15-21].

COVID-19 There is a growing body of literature on the health impact of health care workers providing care to patients, but no review to guide physicians and supervisors on the effectiveness of various interventions. This scoping review aims to summarize the evidence of the physical and mental health effects of the COVID-19 pandemic on health care workers.

Method

Test Design

Using the methodological framework by Arksey and O'Malley, we conducted a scoping review [22]. The following five steps included identifying a clear research question and purpose, identifying relevant articles, selecting articles, extracting data, charting data, organizing data, summarizing, analyzing, and reporting [22]. The primary research question guiding this review was "What are the physical and mental health consequences of managing COVID-19 patients for front-line health care workers?" The results of the study are as follows.

Literature Search Strategy

PubMed or Medical Literature Analysis and Retrieval System Online (MEDLINE) and Google Scholar were searched for relevant articles from January to March 2020. The Boolean operator "OR/AND" was used to search for Medical subject headings (MeSH). Search terms were ("2019-nCoV" or "coronavirus" or "COVID-19" or "nCoV") and ("health professionals") and ("health effects" or "physical health" or "mental health").

Eligibility Criteria

The study, which included an assessment of the impact of COVID-19 on the health of healthcare workers, was published in English and was published between January and March 2020. Health care workers included all clinical staff, including physicians, nurses, paramedics, and technicians. Editorial, commentary, and non-English language articles were excluded.

Test identification and selection

Two researchers (NS and DMA) independently searched through the literature. The two sets of literature were then compared and duplicate references were removed. Figure 1 shows the preferred reporting items for the systematic review and meta-analysis (PRISMA), illustrating the process of searching and selecting research articles.

Data extraction from selected studies

After papers were selected, data were extracted using the data extraction form and recorded in an Excel spreadsheet. The domains of the data extraction form were publication date, article title, journal title, study design, study setting and population, intervention, reported outcomes, and primary findings.

Summary of findings

The authors summarized their findings into the following research areas: mental health effects and physical health effects.

Result

Test Characteristics

A total of 154 articles were retrieved from PubMed (126 articles) and Google Scholar (28 articles). Fifty-eight duplicate articles were excluded. Of the remaining 96 articles, 82 articles were excluded because they were either not relevant to the impact of COVID-19 on health care professionals or were editorials or written in a language other than English, and English translations were not available. Of the remaining 14 articles, full text was not available for 4 articles. Ten full-text articles were reviewed and included in this study. Of the 10 studies included, two were written in Chinese, but English translations were available.

Research Area

Of the 10 studies included in this review, five studies assessed the impact of COVID-19 on mental health and five studies assessed the impact of COVID-19 on physical health for healthcare professionals. Methodological characteristics of these studies are summarized in Table 1. Six were cross-sectional, two were intervention, one was a retrospective cohort, and one was a case series. The study population consisted of both men and women, including front-line physicians, nurses, and professional staff. The majority (90%) of the studies were from scholars in the People's Republic of China (PRC) and one was from a Singapore-based scholar. Findings on the mental health and physical health effects of COVID-19 on health care providers from the included articles are summarized in Table 2.

Figure 1 : PRISMA flowchart for research database search

研究のデータベース検索のための PRISMA フローチャート

Table 1: Methodological Characteristics of COVID-19 Research Articles

Research AreaTest Design
N (%)
Test Design
N (%)
Test Design
N (%)
Cross-cutting study 3 (30%)
Intervention Studies 2 (20%)
4143 health care workers (nurses and medical
clerks)
Physical health effectsCross-cutting study 3 (30%)
Retrospective cohort study
1(10%)
Case Series 1(10%)
Healthcare professionals (nurses and doctors)
4143 Health care workers (nurses and doctors) 4143

Table 2: Summary findings of included COVID-19 research articles

Author, Year, CountryTest-NameStudy design and populationIntervention/outcomeMain findings
Impact on mental health Xiao H et al. 2020,ChinaImpact of Social Support on Sleep Quality of Medical Staff Treating Patients with Coronavirus Disease 2019 (COVID-19) in China in January and February 2020Cross-sectional study N=180Anxiety, self-efficacy, stress, sleep quality, social supportHigh levels of anxiety, stress, and self-efficacy were associated with sleep quality and social support
Huang JZ et al. 2020,ChinaMental health study of 230 medical staff of a tertiary care hospital with COVID-19Cross-sectional study N =246Mental health conditions (anxiety and post-traumatic stress disorder)Overall anxiety (23.04%)Severe anxiety (2.17%)Moderate anxiety (4.78%)Mild anxiety (16.09%)Women more anxious than men (25.67% vs 11.63%)Nurses more anxious than doctors (26.88% vs 14.29%)Stress disorder (27.39%)
Chen Q et al. 2020,ChinaChen Q et al. 2020,ChinaN=1230Interventions: staff rest areas, meals and daily supplies, video recording of staff daily routines, pre-employment training to address patient psychological issues, personal protective equipment, leisure activities and training to relax, psychological counselor Outcomes: irritability, poor motivation to rest, psychological distress before and after intervention
Kang L et al. 2020,Wuhan,ChinaMental Health of Healthcare Workers in Wuhan, China Treating New Coronaviruses in 2019Communication N=1230Intervention: psychological intervention medical team, hotline, building various group activities for stress reduction Outcome: changes in stress, anxiety, depressive symptoms, insomnia refusal, anger, and fear before and after interventionThis approach provides psychological protection for multiple aspects of the mental health of health care professionals.
Jianbo Lai et al. 2020,ChinaJianbo Lai et al. 2020,ChinaCross-sectional study N=1257,34 hospitalsDepression, anxiety, insomniaDistress (50.4%) Anxiety (44.6%) Insomnia (34.0%) Distress (71.5%) Increased psychological burden among nurses, women, Wuhan, and front-line healthcare workers
Physical health effects Ran L et al. 2020,Wuhan,Risk Factors for Healthcare Workers with Coronavirus Disease 2019: A Retrospective Cohort Study in Designated Hospitals in Wuhan, ChinaRetrospective cohort study N=83Sociodemographic characteristics, time to symptom progression, contact history, medical practice, hand hygiene, personal protective equipment28 healthcare workers diagnosed with COVID-19 Inappropriate PPE (p < 0.05) was associated with increased risk of infection associated with increased risk of infection
Liu M et al.2020, ChinaClinical characteristics of 30 healthcare workers infected with novel coronavirus pneumoniaCross-sectional study N=30Clinical Characteristics of Medical Staff in New Coronavirus PneumoniaTotal 30 cases, 26 mild, 4 severe cough (83.33%) most common symptom was fever (76.67%)
Lan J et al.2020,Hubei,Chinacoronavirus disease2019 Skin Injuries in Healthcare Professionals ManagingCross-sectional study N=700COVID-19 Skin complications associated with precautions among health care workers treating patientsPrevalence of skin damage: 97%Nose bridge most common site: 83.1%Dryness/tightness 70.3
Kangqi Ng et al. 2020,SingaporeCOVID-19 and risk to health care workers: case reportCase Report N=41Infection rates among 41 health care workers exposed to COVID-19 patients during the aerosol generation procedure No health care workers were infected with COVID-19.Surgical masks, hand hygiene, and other standard procedures were sufficient to prevent infection
VincentC.C. Cheng et al. 2020,HongkongIncreased infection control response to the rapidly evolving epidemiology of coronavirus disease 2019 (COVID19) caused by SARS-CoV-2 Hong KongCross-Sectional Study N=413Contact follow-up of healthcare workers with unprotected exposures2.7% (11/413) of healthcare workers had unprotected exposure, but no healthcare workers were infected

Mental Health Impact

Five articles discussed the impact of mental health on health care providers. In one study, 53 (23.04%) of 230 health care providers who responded to a mental health rating scale had psychosocial problems. Of these 53 health care staff, 48 (90.57%) women (90.57%) and 43 (81.13%) nurses had more mental health problems due to the infectious outbreak than 5 (9.43%) men and 10 (18.9%) doctors, respectively [23]. The psychological impact on healthcare professionals was overall anxiety (23-44%), severe anxiety (2.17%), moderate anxiety (4.78%), mild anxiety (16.09%), stress disorder (27.4-71%), depression (50.4%) and insomnia (34.0%) [23,24]. Women had higher anxiety than men (25.67% vs. 11.63%) and nurses had higher than doctors (26.88% vs. 14.29%)[23].
Contact COVID-19 Front-line health care workers engaged in patient care had higher rates of depression (OR 1.52; 95% CI 1.11 to 2.09), anxiety (OR 1.57; 95% CI 1.22 to 2.02), insomnia (OR 2.97; 95% CI 1.92 to 4.60), and distress (OR 1.60; 95% CI 1. 25 to 2.04) [24].

Tools used in these studies included the Self-Rated Anxiety Scale [23, 25], the Generalized Anxiety Disorder Scale [24], the General Self-Efficacy Scale [25], the Stanford Acute Stress Response Questionnaire [25], the Pittsburgh Sleep Questionnaire [25], the Insomnia Severity Index [24], the Social Support Speed Scale [25], the Psychological Posttraumatic Stress Disorder Self-Rating Scale [23], and the Event Impact Scale [24] were included.

Physical health effects

COVID-19 infections and deaths among health care providers

An early study in the People's Republic of China (PRC) showed that healthcare workers were more susceptible to COVID-19. In a study of healthcare workers in the PRC, the risk of COVID-19 was associated with infectious and pulmonary diseases (RR = 2.13, 95% CI 1.45-3.95), diagnosed family members (RR = 2.76, 95% CI 2.02-3.77), poor hand hygiene (RR = 2.64, 95% CI 1.04-6. 71), suboptimal hand hygiene before and after patient contact (RR = 2.43, 95% CI 1.34-4.39), inappropriate PPE (RR = 2.82, 95% CI 1.11-7.18), close patient contact (12 times/day), long daily contact time (≥15 hours), and unprotected exposure. The disease has been shown to be associated with working in high-risk sectors. Common symptoms included fever (85%), cough (80%), weakness (70%), chest discomfort (7%), hemoptysis (7%), headache (7%), and diarrhea (7%) [17,26,27]. Similarly, another study showed that COVID-19 infected 30 medical staff members, including 20 hospital doctors and 8 nurses. Of these, 26 had mild and 4 had severe infections, and all were exposed to the virus [27]. In one case-control study in Singapore, the outcomes of 41 healthcare workers exposed to patients with COVID-19 pneumonia prior to the diagnosis of COVID were documented. None of the 41 healthcare workers developed COVID-19. All healthcare workers wore surgical masks and N 95 masks at the time of exposure [28].

Skin Condition

Prophylaxis against viral illnesses meant that health care workers had to wear personal protective equipment (PPE) for extended periods of time. In one cross-sectional study, skin damage was demonstrated in 97% of medical staff, with the nasal bridge (83.1%) being the most common affected site. The most common primary symptoms were dryness, tension, and desquamation (70.3%), which were associated with sustained PPE use of more than 6 hours and hand hygiene of more than 10 times/day [29].

Consideration

This review collates the evidence on the health effects of COVID-19 on health care workers. The authors' findings suggest that health care workers are susceptible to a variety of health effects resulting from the COVID-19 pandemic. In COVID-19-infected individuals, the most common symptoms were fever and cough, similar to those seen in the community. Several risk factors were identified: long working hours, working in high-risk sectors, lack of personal protective equipment, diagnosed family members, unqualified hand washing, and improper infection control. In addition, prolonged PPE use resulted in skin damage, with the nasal bridge being the most common site. The struggle with COVID-19 on the front lines makes health care workers vulnerable to psychological distress. This finding is consistent with the high levels of depression, stress, anxiety, distress, and anxiety in health care workers.
depression, stress, anxiety, distress, anger, fear, insomnia, and post-traumatic stress disorder. Women and nurses were disproportionately affected by mental health. Frontline female nurses work long hours in close contact with patients, which can cause fatigue, stress, and anxiety. However, this finding requires further research to prepare for the future.

Worldwide, COVID-19 has impacted numerous frontline healthcare professionals. As of March 2020, COVID-19 has only infected over 3000 healthcare workers in China [30]. Similar situations have been identified in previous outbreaks of Ebola hemorrhagic fever (EVD), Middle East respiratory syndrome (MERS), and severe acute respiratory syndrome (SARS) [31-35]. Figures from Sierra Leone, Liberia, and Guinea show about 6~8% of Ebola among healthcare workers [35], SARS infected about 1000 healthcare workers, and 1.4% of deaths occurred only in China [36]. Early COVID-19 studies have shown worrisome morbidity and mortality [16, 20]. The fact that health care workers are at high risk of infection by COVID-19 is a major concern for many health care systems and emergency departments.
emergency departments to the best of their ability, which would exacerbate the shortage of skilled workers [18, 20, 30, 37].

During an outbreak, healthcare workers experience considerable stress. In a Chinese study during an Ebola epidemic, healthcare workers reported extreme somatization, depression, anxiety, and obsessive thoughts [38]. During the MERS epidemic, a Saudi Arabian study reported that almost two-thirds of healthcare workers felt at risk of contracting MERS CoV and felt unsafe at work [39]. These findings are consistent with previous SARS situations in which health care workers reported high levels of fear of transmission and infection to family members, emotional disturbance, uncertainty, and stigma [40, 41]. Mental health risk factors include overwhelming circumstances, social disruption of daily life, sense of vulnerability, risk of infection, and fear of infecting family members or loved ones [11]. In past
outbreaks, healthcare workers have suffered significant stress, and similar results are expected for COVID-19.

One of the main challenges faced in controlling this pandemic is the extreme shortage of PPE [18]. The problem of highly contagious pandemics has already compromised health systems, resulting in shortages of supplies and PPE. For example, during the Ebola epidemic, many countries faced PPE shortages [35, 42]. In a pandemic, the availability of emergency medical supplies is related to the country's public health emergency response system [18]. Therefore, it is appropriate to develop an emergency stockpile medical supplies plan to ensure supplies based on need, type, quality, and quantity.

Pandemics have a significant psychological impact on healthcare workers, underscoring the need for appropriate psychological support, intervention, and staff assistance. COVID-19 specific psychological interventions for Chinese medical staff include psychological intervention support teams, psychological counseling, availability of helplines, establishment of shift systems in hospitals, online platforms for medical support, incentives, provision of appropriate breaks and rest, places to rest and sleep provision, leisure activities like yoga, contemplation and exercise, and motivational sessions were included [15, 16]. Protecting the welfare of health care workers through appropriate measures is a crucial tool in a national emergency public health response to combat an outbreak. If timely measures are not taken, a new surge of patients suffering from psychological morbidity will emerge, although the disease will eventually subside.

Strengths and limitations of the test

The scoping review applied a systematic and vigorous search strategy according to the study objectives. This study presents a summary of recent scientific evidence and has the potential to enhance responses to current and future outbreaks. Given the rapid progression of the pandemic, the studies presented here have a relatively short follow-up period. In addition, this review includes only studies published in English and may have missed findings published in other languages. The incidence of health effects of COVID-19 on health care workers was not documented due to methodological limitations of the studies, particularly the difficulty in finding actual denominator data. Finally, there are relatively few intervention studies.

Conclusion.

Healthcare workers are at risk for physical and mental health consequences due to their role in providing care for COVID-19 patients. Implementation of the following strategies would help reduce the burden of health consequences: appropriate provision and training in the use of personal protective equipment, strict infection control practices, reduced work hours, and provision of mental health and support services.

Abbreviation

COVID-19: coronavirus disease; healthcare personnel; healthcare workers; personal protective equipment; PRISMA: recommended reporting items for systematic review and meta-analysis; EVD: Ebola virus disease; MERS: Middle East respiratory syndrome; SARS: severe acute respiratory syndrome

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