Note: This is the tenth of a series of clinical briefs on the coronavirus outbreak. The information on this subject is continually evolving. The content within this activity serves as a historical reference to the information that was available at the time of this publication. We continue to add to the collection of activities on this subject as new information becomes available.

Clinical Context

What started out as a small outbreak in Wuhan, China quickly snowballed into a worldwide pandemic, sending fear and panic across the globe and prompting world leaders to institute broader border bans, lock down whole countries, and restrict outdoor activities and person-to-person contact as extreme measures to control the spread of the virus, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), which causes COVID-19. The larger the scale of the outbreak, the bigger the impact and greater the fear and infliction is on the psyche, as has been shown in previous epidemics. Epidemics and pandemics such as Ebola virus disease (EVD) and avian influenza (flu) were known to excite such erratic behavior.

The common association between virus outbreaks and mental health problems are shown by research. The EVD and avian flu pandemics caused worldwide panic and hysteria. Interestingly, people tend to underreact with more familiar threats such as the flu, even though there is a significant death rate associated with influenza, including a high disease burden albeit lower mortality compared with COVID-19. Nevertheless, people get more anxious and fearful with unfamiliar threats such as COVID-19. On March 3, the World Health Organization (WHO) Director-General gave opening remarks at the media briefing on COVID-19^[1] in which he cited one of the major differences between COVID-19 and the flu. He remarked that COVID-19 is now known to cause more severe disease than seasonal influenza.

The risk for mental illness associated with anxiety and grief over outbreaks may be less emphasized; however, it may affect far more people than the infectious illness itself. Mohamed F. Jalloh, MPH, and colleagues assessed the connection between closeness to the EVD outbreak in Sierra Leone in 2015 and the prevalence of mental health symptoms. Their findings, which were published in the March 2018 issue of BMJ Global Health,^[2] showed the perception that EVD infection was a threat and was significantly associated with higher risks for anxiety and depression and posttraumatic stress disorder (PTSD).

During his speech on March 3, the WHO Director-General gave some positive news that there had been no reports of EVD in the 2 weeks prior.^[1] He expressed gratitude for the "thousands of health workers who have sacrificed so much in the fight against [EVD] and for making sure we’re where we are."

He further stated the obvious that "... as one epidemic looks like [it is] ending, one front of the fight closing, another is becoming increasingly complex."

The world is justifiably anxious regarding the danger of COVID-19; however, patients and the public are not the only ones facing mental stress. WHO Director-General offered some comfort in his statement, acknowledging that it is understandable that people are "... afraid and uncertain. Fear is a natural human response to any threat, especially when it is a threat we don’t completely understand."

One encouraging difference he pointed out in comparing COVID-19 with the flu virus is that the seasonal flu cannot be contained; however, it is possible to contain COVID-19.

"We don’t do contact tracing for seasonal flu -- but countries should do it for COVID-19, because it will prevent infections and save lives. Containment is possible... which is why we must do everything we can to contain it," he stated.

Still, his positive outlook was laced with concern over "...countries’ abilities to respond [because they] are being compromised by the severe and increasing disruption to the global supply of personal protective equipment -- caused by rising demand, hoarding and misuse."

He acknowledged how the intensity of the current pandemic could place a lot of strain on healthcare workers as it already has in many countries.

He further stated, "Shortages are leaving doctors, nurses and other frontline healthcare workers dangerously ill-equipped to care for COVID-19 patients, due to limited access to supplies such as gloves, medical masks, respirators, goggles, face shields, gowns, and aprons.

"We can’t stop COVID-19 without protecting our health workers," he emphasized.

Can we sustain the global health workforce in this time of need?

Synopsis and Perspective

Healthcare workers often prioritize the needs of others above their own; however, they are also faced with some of the untoward effects of a pandemic, which includes increased burden of illness, increased risk for infections, and adverse effects on mental health.

In the study by Jalloh et al,^[2] 3564 individuals participated in interviews regarding their experience with EVD and also completed mental health rating scales. Researchers found that 6% of participants met criteria for anxiety and depression disorders, and 16% had a probable diagnosis of PTSD. Knowing someone who was quarantined for EVD infection was associated with approximately a 2-fold increase in the risk for anxiety/depression and PTSD. The perception that EVD infection was a threat was also significantly associated with higher risks for anxiety/depression and PTSD.

The effects of outbreaks of any significant magnitude can be multiple, but its effect on the psyche can be profound. These include a potential to exacerbate existing illnesses or precipitate new onset mental illness.

PANDAS = pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections; SSPE = subacute sclerosing panencephalitis.
Moukaddam N.^[3]

Everyone should be taking precautions to protect themselves from infection; however, strategies exist to also reduce the stress and fear associated with the risk for COVID-19, which is especially important for healthcare workers.

Impact on Healthcare Workers

In a recent article by James G. Adams, MD, and Ron M. Walls, MD, published in JAMA on March 20,^[4] authors stressed the need for support for healthcare workers. They indicated that an estimated number of 3000 healthcare workers in China have been infected, with at least 22 dead. There are also worries of transmission to family members. They outlined concerns healthcare workers can have regarding family transmission, such as priority testing, vaccination, and treatment, especially for persons who are immunocompromised and/or have chronic medical conditions. This, however, is yet to be determined, along with all the other uncertainties concerning the COVID-19.

Healthcare professionals should take extra caution. Following Centers for Disease Control and Prevention (CDC) guidance on what healthcare personnel should know about COVID-19^[5] is essential. The virus is believed to spread from person to person via respiratory droplets among close contacts, according to the CDC. The CDC defines "close contact" to mean at least 6 ft (2 m) for a prolonged period of time.

Another key source of transmission is having direct contact with infectious secretions from a person with COVID-19 (ie, sputum, serum, blood, and respiratory droplets). The CDC stresses the importance of wearing all recommended personal protective equipment (PPE) to reduce the risk for infection. The virus is known to live on surfaces for hours and maybe days in some cases, and so proper environmental cleaning is advised more frequently as a form of active contamination. This can be a source of assurance to the public and more so to frontline workers. Healthcare workers should be conscientious about their coworkers and practice proper hand hygiene and infection prevention practices to prevent transmission to coworkers. Efforts should not be diminished in disinfecting workplaces, healthcare tools such as stethoscopes, computers, keyboards, phones etc...

The National Center for PTSD at the US Dept of Veteran Affairs outlines 4 key areas of stress that healthcare workers often experience in disaster situation.^[6]

• Need to employ strict biosecurity measures
• Risk for disease transmission
• Multiple medical and personal demands
• Stigma

Healthcare workers are held to strict guidelines in ensuring infection control procedures are followed. The constant vigilance can be exhausting and stressful because of the nature of the disease with its quick spread and high disease burden. The symptoms of COVID-19 bear similarities to the flu. More information on the characterization of the virus is still ongoing. In the meantime, healthcare workers need to exercise vigilance in appropriate testing and diagnosis.

Lack of spontaneity was also cited as a source of stress during biosecurity measures. In certain areas, physical distancing or isolation can create a sense of loneliness. Another stress could be physical strain of wearing PPE (eg, dehydration, heat, exhaustion), depending on the location. Healthcare workers can be affected by conflicting personal and professional demands. Fear of infecting loved ones or being isolated from them has been cited as a concern, as well as demanding patient loads, workloads, and resource challenges in some areas. All these can add to the complexity of the already complex disease.

Also realizing their own fear and biases can be a struggle for healthcare providers who may fear being in contact with patients with COVID-19, particularly for individuals who may struggle with the confidence of voicing their needs and fears.

They encourage a self-care strategy that will enable them to carry on their duties, yet putting their own safety first without feelings of guilt because of unrealistic responsibility for the lives of others.

Below are recommendations from the US Department of Veteran Affairs for healthcare providers to follow during their daily work shifts:

US Department of Veterans Affairs: National Center for PTSD website.^[6]

How Can Institutions Help?

Protecting healthcare employees should be top on the list for organizations. First of all, leaders need to assess and recognize the risk for infection for their healthcare workers. Recognizing any underlying health risks they have is important. Currently it is known that older adults and persons with serious chronic medical conditions, such as diabetes and cardiovascular disease, are at increased risk of getting infected with severe COVID-19 disease. If possible, provisions should be made for healthcare workers with such conditions.

Currently, recognizing the risk for healthcare worker shortages, organizations are banning travel to medical meetings, canceling conferences, limiting nonessential travel, and recommending that personal travel be curtailed. To keep caregivers close and available, the travel restrictions should be to affected regions and to domestic and international sites. Avoiding travel and crowds may also decrease risk for infection.

Maintaining transparency goes a long way. According to authors Adams and Walls' recent article in JAMA,^[4] having frank conversations with frontline workers can help assuage anxiety. Such conversations can include adequate rest, tending to critical family needs, reassigning work tasks to focus on the immediate need, providing adequate help for needed breaks, and frequent communication to help staff remain focused. In addition, staff should be encouraged to ask for support and not fear retaliation.

Interim Guidance for First Responders, Including Emergency Medical Services

Responding to a viral pandemic can take an emotional toll on first responders. They are frontline workers who are often the first to respond to emergent medical needs, requests for assistance, and transport of ill patients. In an outbreak situation, emotions run high and first responders can be exposed to a range of personalities, experiences, and emotions that range from cynicism and annoyance to extreme panic and fear. The constant bombardment of fear and panic from persons they serve can have a mental and emotional negative effect on first responders.

The CDC has provided interim guidelines to address the unique challenges that emergency medical services (EMS) clinicians often face because of the nature of their work (eg, open setting, enclosed transport space, interventions with limited information, rapid medical decision making, a wide and varying range of patient acuity and healthcare resources that change with each jurisdiction).^[7] First responders should adhere to recommended PPE requirements to avoid or limit exposure to themselves and others. One critical element of personal safety is to avoid touching their hands to their face.

The CDC has also provided interim guidance to first responders, which include law enforcement, fire services, EMS clinicians, and emergency management officials who are likely to come into contact with persons with confirmed or possible COVID-19. The guidance advises EMS clinicians and first responders on their role in patient assessment, management, and transport procedures.

Impact on Specialized Services

The role of ID specialists have been magnified in recent pandemics during the last decades. Their responsibility in making timely and adequate clinical diagnoses and recommending appropriate antimicrobial agents in the spirit of stewardship and infection prevention strategies cannot be understated.

As the coronavirus outbreak continues to spread, ID specialists are in short supply and might be overwhelmed by the emergency, Thomas File Jr, MD, president of the Infectious Diseases Society of America.

"With fewer young doctors going into the specialty, there may not be enough ID specialists to handle the emergency," admitted Dr File.

"Depending on the burden on our healthcare systems, we're going to be at the center of caring for these patients," said Dr File, who is a practicing ID specialist at Summa Health in Akron, Ohio.

"Also, we have to spend time communicating with the community to dispel some of the myths [related to COVID-19]. So already, we're seeing an increased workload because of this. And if COVID-19 spreads significantly -- and I think we have to be prepared that it will -- we're going to need a larger workforce to deal with this." he said.

Dr File added that they are overtaxed because of "a very active influenza season" on top of helping the institution prepare for COVID-19 cases.

He emphasized that COVID-19 is not the only emerging pandemic that ID specialists have had to deal with or will have to deal with in the future. He cited the threats that Zika virus and severe acute respiratory syndrome (SARS) posed in past years.

"COVID-19 illustrates the need for more trained ID specialists, because we know we're going to be seeing more outbreaks in the future," Dr File explained.

Nevertheless, the number of physicians entering the ID field has steeply declined in recent years.

According to a 2019 Merritt Hawkins report,^[8] "Between the 2009-2010 and 2016-2017 fellowship matches, the number of adult ID programs filling all their positions dropped by 41% and the number of applicants decreased by 31%. In 2015, fewer than half of US ID fellowships filled their incoming classes."

In 2017, there were 9122 ID specialists in the United States, about 1% of the total number of American physicians, according to the American Association of Medical Colleges.^[9]

Impact on Children

Healthcare providers, along with the public, are encouraged to take care of their emotional health. According to the CDC,^[10] different and strong emotions often come with a natural disaster. The COVID-19 pandemic may be stressful for communities who equate this to a natural disaster. It is important to help children cope with emergencies. Unlike adults, some children may show early signs of distress whereas others may show signs much later. This range of reactions differs according to the child’s age, personality, and previous experiences. Encourage parents and caregivers to play an active role in reassuring children and portraying a calm and confident demeanor.

The CDC, on helping children cope with emergencies,^[11] recommends limiting exposure to media in the height of a disaster, as it can become more stressful for children (and adults) to see repeated images. In addition, reviewing safety plans is a good way to increase children’s confidence and provide some sense of control over the situation. Caregivers and parents are encouraged to continue or resume healthy lifestyle choices and maintain a certain amount of normalcy to decrease fear in children.

Impact on the Public

Rumors can fuel fear and anxiety. Knowing the facts can help. The CDC directs the public to call a healthcare provider if stress gets in the way of daily activities for several days in a row.^[12] Healthcare providers should be ready to provide the necessary information that is needed to calm fears and ease minds concerning the COVID-19 outbreak.

Some simple facts to stress to the public, as outlined by the CDC, include:

CDC website.^[13]

The Substance Abuse and Mental Health Services Administration offers additional practical tools to help healthcare practitioners deal with mental stress of the COVID-19 outbreak.^[14]

Clinical Implications

• In a previous study by Jalloh and colleagues, knowledge of someone in quarantine for EBD as well as the perception of EBD as a serious risk were associated with higher risks for anxiety/depression and PTSD in Sierra Leone.
• Means to reduce the effect of COVID-19 on mental health include persistent healthy behaviors and maintaining a strong support network. Individuals should pursue pleasurable activities and only check for factual updates on COVID-19 at limited intervals.
• Implications for the Healthcare Team: The healthcare team should inquire regarding the mental health of all patients as COVID-19 spreads and fears increase.

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