Receive updates to your inbox!
Since December 2019, an epidemic of coronavirus disease 2019 (COVID-19) has spread rapidly from Wuhan, Hubei Province, China.1 As of March 7, there were 1272 confirmed coronavirus cases in Henan Province (the third-highest in China), which adjoins Hubei Province. Due to the high contagiousness of COVID-19 and the current lack of any effective vaccine or drug, scientists and physicians are conducting a series of clinical studies involving affected patients. In 2016, the World Health Organization (WHO) published “Guidance for Managing Ethical Issues in Infectious Disease”2 to ensure the scientific validity of and participants’ rights and safety in studies conducted during outbreaks. The guidance stated that there is a moral obligation to conduct timely scientific research. The Ethics Committee of the Henan Provincial People’s Hospital reviewed the COVID-19 studies from the hospital based on those guidelines.
Henan Provincial People's Hospital is a designated hospital for COVID-19. The ethics committee designed a review system for research proposals at the beginning of the epidemic, including the use of emergency video conference to review batches of project applications. Electronic documents were formally reviewed by the secretary and sent to members of the committee to review in advance of the meetings. Applications were voted on by quorum and members proposed clear reasons for the decisions and provided suggestions for revision after full discussion.
We examined all new applications for COVID-19–related studies and meeting minutes from February 2 through March 7, 2020, categorized the study type, determined the approval rate and review time, and summarized the issues in research proposals and informed consent forms consistent with the WHO document. Follow-up reviews of ongoing non–COVID-19 studies are not included in this study.
Ethics review conferences, held once every month in nonepidemic periods, were held 4 times in 35 days. The mean time was 2.13 days from application submissions until an initial review decision was made. For applications that required modifications, the mean time was 1.81 days for the resubmission to be reviewed again.
Forty-one applications were reviewed, including interventional studies (n = 21); diagnostic studies (n = 7); observational studies (n = 10); and other types (n = 3). Six (14.6%) were approved; 4 (9.8%), rejected; and 31 (75.6%), referred for modification.
Of the 4 rejected applications, 2 were denied because 1 involved a new, unapproved interferon-alfa treatment and another involved traditional Chinese medicine with many potential adverse reactions, so the potential risks outweighed benefits. The other 2 studies were denied because the laboratory biosafety level was inadequate, which may have led to virus leakage.
Of the 31 applications that required modifications, the issues with the research proposals and informed consent forms are indicated in Table 1 and Table 2. The most frequent issues with proposals were lack of statistical basis for the sample size calculation and deficiencies in inclusion and exclusion criteria. The most frequent issues with informed consent forms were that patients were not informed of the risks and that compensation was unreasonable.
During the outbreak, ethics committee review of COVID-19 studies at 1 hospital were conducted within a few days, more quickly than the 27 ethical reviews organized by the Médecins Sans Frontières ethics review board during the Ebola crisis, with a mean time of 12.4 days to provide a review after the initial request.3 However, the first-time study approval rate of 14.6 % was lower than 33.4% during the nonepidemic period in 2019 in the Henan Provincial People's Hospital, possibly reflecting researchers’ inexperience and the hasty preparation of documents. Review standards were not lowered during the outbreak.
The high frequency of issues with the research proposals and informed consent forms reflect that during an outbreak, researchers may use experimental drugs on affected patients, relax inclusion and exclusion criteria, and fail to offer reasonable compensation or to inform vulnerable patients of trial risks. Because the climate of fear may induce patients to agree to participate in research, the ethics committee paid special attention to such issues.
This study was limited to a small number of studies considered by 1 ethics committee. Future studies of other ethics committees should be conducted.
The 1918 influenza pandemic affected one-third of the world’s population and resulted in 50 million deaths. One hundred years ago, medical therapies and countermeasures were significantly limited, and information exchange that could facilitate any public health intervention primarily occurred by telephone, mail, or person-to-person interaction.
Now, more than a century later, a novel coronavirus is the cause of a new global pandemic threatening millions of lives.1 Today, many methods of sharing information have been subsumed by giant social media platforms that have incredible speed, reach, and penetration. More than 2.9 billion individuals use social media regularly, and many for long stretches of time.2
Current understanding of how these platforms can be harnessed to optimally support emergency response, resilience, and preparedness is not well understood. In this Viewpoint, we outline a framework for integrating social media as a critical tool in managing the current evolving pandemic as well as transforming aspects of preparedness and response for the future.
Directing People to Trusted Sources
To date, social media platforms have been important for disseminating information during the outbreak of coronavirus 2019 (COVID-19). The Centers for Disease Control and Prevention, the World Health Organization (WHO), numerous journals, and other health care organizations are regularly posting guidance across a host of platforms. Teams employed by larger social media platforms have also been involved in the response as searches for information about coronavirus are escalating and, at times, dominating conversations online.3,4 Facebook is using the news feed function to direct users to the WHO website and websites of local health authorities.3 Google Scholar has highlighted leading medical journals and other sites. Twitter and other social media sites are similarly pointing individuals who search (accounting for misspellings) for coronavirus-related content to reliable resources.4 Health care organizations, clinicians, and social media influencers should also actively direct online traffic to trusted sources.
It may also be time for social media platforms to take on an active public health role and in parallel use banners, pop-ups, and other tools to directly message users about hand washing and social distancing. This approach increases the likelihood of millions of people seeing the same messages whenever they access the platform, even if they forgo accessing the WHO website or other trusted sites.
Social media has also become a conduit for spreading both rumors and deliberate misinformation, and many perpetrators are deploying sites such as Facebook, Twitter, YouTube, and WhatsApp to create a sense of panic and confusion. Unlike any prior event, WHO has identified that the “the 2019-nCoV outbreak and response has been accompanied by a massive ‘infodemic’—an over-abundance of information—some accurate and some not—that makes it hard for people to find trustworthy sources and reliable guidance.”5 Research is needed to better understand the origins and spread of misinformation as well as coordinated efforts to disrupt its sources and identify, remove, and reduce its dissemination.
Social Media as a Diagnostic Tool and Referral System
Social media should be used to disseminate reliable information about when to get tested, what to do with the results, and where to receive care. If a vaccine becomes available, the same platforms could be used to encourage uptake and address challenges associated with vaccine hesitancy. These targeted efforts can occur in response to what people search for or in a more personalized approach based on an individual’s online profile, posts, and underlying risk. Health systems may become overwhelmed as testing becomes more available and as more mildly ill yet concerned individuals seek care; yet, social media platforms are well poised to enable users to remotely assess symptoms and determine their most appropriate course of action.6 The Facebook Preventive Health tool provides individuals with vetted guidelines about preventive health recommendations (eg, heart disease, cancer screening) and then directs users to geotargeted locations (eg, federally qualified health centers, retail clinics) where these services are available. Users also have the option to share the tool and their scheduled testing with their network.7 This could be modified to direct individuals (when relevant) to resources for COVID-19 testing. For those whose test results are positive for COVID-19, the platform could enable users to inform their contacts about the potential exposure and how to follow up for testing.
Enabling Connectivity and Psychological First Aid
As individuals start to self-quarantine and telecommute, new forms of social isolation are occurring. In some places in the US, funerals, weddings, religious services, in-restaurant dining, and other places of traditional socialization have already been severely limited or completely restricted. The long-term effects of social distancing and isolation will likely affect populations differently, necessitating comprehensive strategies for addressing the downstream sequelae. Navigating social isolation will be particularly challenging for already disadvantaged populations, such as older individuals, individuals with low socioeconomic status or housing insecurity, individuals managing chronic illnesses or disabilities, and individuals who are undocumented. Social media should be used to raise awareness about the needs of these groups in disasters and for development of new methods for communities to mobilize resources and support in the absence of physical contact. The “crisis response,” “safety check,” and related functions available on some social media platforms could enable more frequent status updates and sharing.8 Psychological first aid could be delivered through chatbots that use artificial intelligence to learn from the millions of interactions that are occurring in response to the pandemic and better understand critical needs. While social media cannot replace in-person contact, there may be ways to better use it to support recovery and resilience.
Advancing Remote Learning
New approaches to enhance the education of health care professionals is needed. Social distancing will affect clinical training (eg, emergency department rotation) and didactic education (eg, anatomy laboratory). Stand-alone video conferencing services may be overwhelmed as many institutions move entirely online. Social media can be a useful tool for facilitating contact among students and supporting active learning. Front-line health care clinicians and other health care workers who provide care for critically ill patients with COVID-19 would also benefit from being able to share their experiences broadly in a deidentified way to advance education and teaching in an evolving crisis.
Social media data about symptoms, interactions, photos at events, travel routes, and other digital footprints about human behavior should be analyzed in real time to understand and model the transmission and trajectory of COVID-19. At present, Facebook is providing aggregated and anonymized data to researchers about how people move from location to location and associated population density maps to better inform how the virus is spreading. Merged social media data and electronic medical record data from consenting patients could also provide insights about individual-level risk.9 Basic and translational science can also be advanced through social media channels. Foundations have funded researchers to sequence the complete genome of COVID-19 in a short period of time. The output of these efforts included a research tool to further analyze the genome and a cell atlas that can be used to study how COVID-19 affects different organ functions. This infrastructure can be strengthened to facilitate communication among scientists working to address critical priorities related to animal and environmental research and candidate therapeutics and vaccines.
Enabling a Culture of Preparedness
More than 100 years ago, a global pandemic affected more than 500 million people worldwide. Today, in the midst of another public health emergency, some lessons from history demonstrate the importance of understanding how information spreads and individuals interact. Integrating social media as an essential tool in preparedness, response, and recovery can influence the response to COVID-19 and future public health threats.
Facing this critical situation, health care workers on the front line who are directly involved in the diagnosis, treatment, and care of patients with COVID-19 are at risk of developing psychological distress and other mental health symptoms. The ever-increasing number of confirmed and suspected cases, overwhelming workload, depletion of personal protection equipment, widespread media coverage, lack of specific drugs, and feelings of being inadequately supported may all contribute to the mental burden of these health care workers. Previous studies have reported adverse psychological reactions to the 2003 SARS outbreak among health care workers.5-8 Studies showed that those health care workers feared contagion and infection of their family, friends, and colleagues,5 felt uncertainty and stigmatization,5,6 reported reluctance to work or contemplating resignation,6 and reported experiencing high levels of stress, anxiety, and depression symptoms,7 which could have long-term psychological implications.7 Similar concerns about the mental health, psychological adjustment, and recovery of health care workers treating and caring for patients with COVID-19 are now arising.
Psychological assistance services, including telephone-, internet-, and application-based counseling or intervention, have been widely deployed by local and national mental health institutions in response to the COVID-19 outbreak. On February 2, 2020, the State Council of China announced that it was setting up nationwide psychological assistance hotlines to help during the epidemic situation.9 However, evidence-based evaluations and mental health interventions targeting front-line health care workers are relatively scarce.
To address this gap, the aim of current study was to evaluate mental health outcomes among health care workers treating patients with COVID-19 by quantifying the magnitude of symptoms of depression, anxiety, insomnia, and distress and by analyzing potential risk factors associated with these symptoms. Participants from Wuhan city (the capital of Hubei province) and other areas inside and outside Hubei province in China were enrolled in this survey to compare interregional differences. This study aimed to provide an assessment of the mental health burden of Chinese health care workers, which can serve as important evidence to direct the promotion of mental well-being among health care workers.
This study followed the American Association for Public Opinion Research (AAPOR) reporting guideline. Approval from the clinical research ethics committee of Renmin Hospital of Wuhan University was received before the initiation of this study. Verbal informed consent was provided by all survey participants prior to their enrollment. Participants were allowed to terminate the survey at any time they desired. The survey was anonymous, and confidentiality of information was assured.
The study is a cross-sectional, hospital-based survey conducted via a region-stratified, 2-stage cluster sampling from January 29, 2020, to February 3, 2020. During this period, the total confirmed cases of COVID-19 exceeded 10 000 in China. To compare the interregional differences of mental health outcomes among health care workers in China, samples were stratified by their geographic location (ie, Wuhan, other regions inside Hubei province, and regions outside Hubei province). Because Wuhan was most severely affected, more hospitals in Wuhan were sampled. Hospitals equipped with fever clinics or wards for COVID-19 were eligible to participate in this survey. A total of 20 hospitals in Wuhan (10 designated by the local government to treat COVID-19 and 10 nondesignated), 7 hospitals in other regions of Hubei province, and 7 hospitals from 7 other provinces with a high incidence of COVID-19 (1 hospital from each province) were included. In total, 34 hospitals were involved. Milestone events during the outbreak of COVID-19 and the duration of this study are presented in the eFigure in the Supplement.
We focused on symptoms of depression, anxiety, insomnia, and distress for all participants, using Chinese versions of validated measurement tools.10-13 Accordingly, the 9-item Patient Health Questionnaire (PHQ-9; range, 0-27),10 the 7-item Generalized Anxiety Disorder (GAD-7) scale (range, 0-21),11 the 7-item Insomnia Severity Index (ISI; range, 0-28),12 and the 22-item Impact of Event Scale–Revised (IES-R; range, 0-88)13 were used to assess the severity of symptoms of depression, anxiety, insomnia, and distress, respectively. The total scores of these measurement tools were interpreted as follows: PHQ-9, normal (0-4), mild (5-9), moderate (10-14), and severe (15-21) depression; GAD-7, normal (0-4), mild (5-9), moderate (10-14), and severe (15-21) anxiety; ISI, normal (0-7), subthreshold (8-14), moderate (15-21), and severe (22-28) insomnia; and IES-R, normal (0-8), mild (9-25), moderate (26-43), and severe (44-88) distress. These categories were based on values established in the literature.10-13
The cutoff score for detecting symptoms of major depression, anxiety, insomnia, and distress were 10, 7,14 15, and 26, respectively. Participants who had scores greater than the cutoff threshold were characterized as having severe symptoms.
Demographic data were self-reported by the participants, including occupation (physician or nurse), sex (male or female), age (18-25, 26-30, 31-40, or >40 years), marital status, educational level (≤undergraduate or ≥postgraduate), technical title (junior, intermediate, or senior), geographic location (Wuhan, Hubei province outside Wuhan, or outside Hubei province), place of residence (urban or rural), and type of hospital (secondary or tertiary). The different technical titles of respondents refer to the professional titles certificated by the hospital. Participants were asked whether they were directly engaged in clinical activities of diagnosing, treating, or providing nursing care to patients with elevated temperature or patients with confirmed COVID-19. Those who responded yes were defined as frontline workers, and those who answered no were defined as second-line workers.
In the study, among the 1830 health care workers (702 [38.4%] physicians and 1128 [61.6%] nurses) asked to participate, 1257 respondents (68.7%) completed the survey. The occupational and geographic data of nonrespondents were similar to those of respondents (eTable 1 in the Supplement). Of the 1257 responding participants, 493 (39.2%) were physicians, and 764 (60.8%) were nurses. The response rates for physicians and nurses were 70.2% and 67.7%, respectively. Of the participants, 760 (60.5%) worked in Wuhan, 261 (20.8%) worked in Hubei province outside Wuhan, and 236 (18.8%) worked outside Hubei province. Most participants were women (964 [76.7%]), were aged 26 to 40 years (813 [64.7%]), were married, widowed, or divorced (839 [66.7%]), had an educational level of undergraduate or less (953 [75.8%]), had a junior technical title (699 [55.6%]), and worked in tertiary hospitals (933 [74.2%]). A total of 522 participants (41.5%) were frontline health care workers directly engaged in diagnosing, treating, or caring for patients with or suspected to have COVID-19. Nearly all participants (1220 [97.1%]) lived in urban areas (Table 1).
This cross-sectional survey enrolled 1257 respondents and revealed a high prevalence of mental health symptoms among health care workers treating patients with COVID-19 in China. Overall, 50.4%, 44.6%, 34.0%, and 71.5% of all participants reported symptoms of depression, anxiety, insomnia, and distress, respectively. Participants were divided in 3 groups (Wuhan, other regions in Hubei province, and regions outside Wuhan province) to compare interregional differences. Most participants were female, were nurses, were aged 26 to 40 years, were married, and worked in tertiary hospitals with a junior technical title. Nurses, women, those working in Wuhan, and frontline workers reported more severe symptoms on all measurements. Our study further indicated that being a woman and having an intermediate technical title were associated with experiencing severe depression, anxiety, and distress. Working in the front line was an independent risk factor for worse mental health outcomes in all dimensions of interest. Together, our findings present concerns about the psychological well-being of physicians and nurses involved in the acute COVID-19 outbreak.
In this study, a significant proportion of participants experienced anxiety, depression, and insomnia symptoms, and more than 70% reported psychological distress. In a previous study during the acute SARS outbreak, 89% of health care workers who were in high-risk situations reported psychological symptoms.8 The psychological response of health care workers to an epidemic of infectious diseases is complicated. Sources of distress may include feelings of vulnerability or loss of control and concerns about health of self, spread of virus, health of family and others, changes in work, and being isolated.15 The fact that COVID-19 is human-to-human transmissible,1,3 associated with high morbidity, and potentially fatal16 may intensify the perception of personal danger. Additionally, predictable shortages of supplies and an increasing influx of suspected and actual cases of COVID-19 contribute to the pressures and concerns of health care workers.17
Of note, 76.7% of all participants were women, and 60.8% were nurses (90.8% of whom were female). Our findings further indicate that women reported more severe symptoms of depression, anxiety, and distress. Frontline nurses treating patients with COVID-19 are likely exposed to the highest risk of infection because of their close, frequent contact with patients and working longer hours than usual.18,19 Moreover, 71.5% of all nurses had junior titles, indicating that most had fewer years of work experience. During the SARS outbreak, a study conducted among health care workers in emergency departments also showed that nurses were more likely to develop distress and use behavioral disengagement than physicians.15 Frontline nurses treating patients with SARS were physically and psychologically challenged when committing themselves to providing high-quality nursing care for patients.19-22 Moreover, at the early stage of the SARS epidemic, nurses may have been less likely to be warned about exposure or provided with adequate protections.22 Particular attention is warranted regarding the mental health well-being of women and nurses treating patients with COVID-19.
Another finding in our study was that, compared with those in Hubei province outside Wuhan and those outside Hubei province, health care workers in Wuhan reported more severe symptoms of depression, anxiety, insomnia, and distress. Multivariable logistic regression analysis showed that working outside Hubei province was associated with lower risk of experiencing distress. These findings indicated more stress among health care workers in Wuhan, the origin and epicenter of the epidemic in China. In addition, working as a frontline health care worker with direct engagement of patients with COVID-19 was an independent risk factor for all symptoms. As frontline health care workers in Wuhan were at especially high risk for symptoms of depression, anxiety, insomnia, and distress, their mental health may require special attention.
This study has several limitations. First, it was limited in scope. Most participants (81.2%) were from Hubei province, limiting the generalization of our findings to less affected regions. Second, the study was carried out during 6 days and lacks longitudinal follow-up. Because of the increasingly arduous situation, the mental health symptoms of health care workers could become more severe. Thus, long-term psychological implications of this population are worth further investigation. Third, this study was unable to distinguish the association of symptoms with being a clinician in this region vs simply living in this region (because there was no comparator group) and was also unable to distinguish preexisting mental health symptoms vs new symptoms. Fourth, although the response rate of this study was 68.7%, response bias may still exist if the nonrespondents were either too stressed to respond or not at all stressed and therefore not interested in this survey.
In this survey study of physicians and nurses in hospitals with fever clinics or wards for patients with COVID-19 in China, health care workers responding to the spread of COVID-19 reported high rates of symptoms of depression, anxiety, insomnia, and distress. Protecting health care workers is an important component of public health measures for addressing the COVID-19 epidemic. Special interventions to promote mental well-being in health care workers exposed to COVID-19 need to be immediately implemented, with women, nurses, and frontline workers requiring particular attention.
Accepted for Publication: March 2, 2020.
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.
The 2019 novel coronavirus disease (COVID-19) with an epidemic centered in Wuhan, China, was declared a public health emergency on January 20, 2020, by the World Health Organization and a public health emergency by the US on January 31, 2020. A total of 28 130 cases in mainland China and 22 cases in the Hong Kong Special Administrative Region (HKSAR) have been confirmed as of February 6, 2020, with a reported epidemic doubling time of 6.4 days.1 The early reported mortality rate of 4.3%2 appears to be lower than that of severe acute respiratory syndrome (SARS) and Middle East respiratory syndrome, but this initial figure is believed likely to be an underestimation, as most of the confirmed patients are still inpatients, and their condition is not yet resolved.
The first fatality of a physician documented globally was that of an otolaryngology physician in Wuhan on January 25, 2020, whose situation was similar to that of an otolaryngologist who died of SARS in the HKSAR in 2003. Thus, it is imperative that otolaryngologists and physicians globally stay abreast of this outbreak and appreciate essential precautionary practices that are potentially crucial in protecting themselves and patients during this epidemic. In many regions globally, including China and the HKSAR, it is a very common practice for patients with upper respiratory tract infections to seek family practitioners and otolaryngologists as a primary care physician. Such a practice inadvertently poses inherent risks for physicians examining patients potentially carrying the virus. The route of transmission has yet to be firmly established. However, based on current evidence, it is speculated that respiratory droplets and possibly fecal-oral routes are culprits, similar to the SARS epidemic in 2003.3,4
The association of COVID-19 with clinical services to the public has been severely disruptive, as redistribution of manpower and resources are required to critically meet the current and anticipated hospital service needs during the outbreak. There has been a reduction in elective clinics and operations to mobilize manpower to acute specialties combatting the outbreak and maximize hospital beds numbers available in anticipation of the outbreak. There is also understandably fear from the public in visiting hospitals. Both factors have resulted in a more than 50% reduction in daily patient visits to our specialist clinic. Although essential emergency and oncologic surgeries are still proceeding as usual, contingency plans are in place to reluctantly reduce such services if the outbreak becomes critical and significant. This rapid change in clinic provisions and rescheduling of patients causes substantial inconvenience to patients and potentially poses a risk with delayed assessments but is a necessity given the gravity of the current situation.
An area of particular concern in our field is aerosol-generating procedures that would include open systems for tracheostomies and possibly the performance of flexible laryngoscopy. With the current COVID-19 outbreak in our region and the previous experiences from SARS, all outpatient clinic patients are seen with otolaryngology physicians mandatorily wearing at a minimum an N95 respirator, gown, cap, eye protection, and gloves.5 This personal protective equipment (PPE) setting is inevitably cumbersome and uncomfortable. However, with substantial presymptomatic carriers of the virus having a mean incubation period of 5.2 days (with 95% of the distribution at 12.5 days),6 such PPE precautionary practices are an absolute necessity.
Our clinic layout has also been adjusted to facilitate a separate gown-up and gown-down area to prevent cross-contamination of practicing clinical areas. All patients attending the outpatient clinic department must have their body temperatures checked on arrival. Acknowledging the fact that many presymptomatic patients may not be febrile despite being COVID-19 carriers, we assess recent travel histories of all patients attending the clinic to facilitate them being seen in the accident and emergency departments as needed.
Our patient wards are open wards containing cubicles of 6 patients. Patients with a tracheostomy are all now covered with a closed system identical to when a patient is connected to a mechanical ventilator. This is to minimize the aerosol generated that could cross-contaminate the surrounding patients and health care workers given the suction requirements of these patients. All bedside procedures are performed in a separate treatment room away from patient cubicles with all health care workers wearing PPE as in our clinics.
Through all these changes in outpatient clinics and inpatient services, we are actively limiting the number of procedures performed and patients seen who are triaged as clinically nonurgent. Such practices help to eliminate unnecessary exposure and contamination at clinics, but this also results in delayed assessments for these patients, and ultimately it also adds a burden to the system because all of these patients must still be seen after the epidemic has settled.
The importance of our experience is that with the high risk of substantial exportation of asymptomatic patients globally, the risk of self-sustaining outbreaks globally appears inevitable, in particular in regions with close travel links with China. It is essential that these set measures and precautionary plans are readily available for use globally to fundamentally protect physicians during this epidemic in a timely manner. Otolaryngologists are at particularly high risk even when performing routine procedures and ought to be extra vigilant given the global footprint of the virus.