[Paper] Physical and Mental Health Impacts of COVID-19 on Healthcare Workers: A Scoping Review

Abstract

Background

The 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 healthcare workers (medical professionals) are at significantly high risk of infection and death due to excessive COVID-19 exposure. This review aims to summarize the evidence on the physical and mental health impacts of the COVID-19 pandemic on healthcare workers (medical professionals).

Methods

A scoping review was conducted using the Arksey and O'Malley framework. Systematic literature searches were performed using two databases: PubMed and Google Scholar. A total of 154 studies were identified, of which 10 met our criteria. Information on publication date, lead author's country, paper title, study design, study population, interventions and outcomes, and main findings was collected, and all research papers were categorized into two areas: physical and mental health impacts.

Results

A review of a total of 154 papers from PubMed (126) and Google Scholar (28) revealed that 58 of these were duplicates and were excluded. Of the remaining 96 papers, 82 were excluded after eligibility screening, and 4 papers could not be obtained in full text. A total of 10 full-text articles were reviewed and included in this study.

The authors identified the following risk factors associated with COVID-19 health impacts: working in high-risk settings, diagnosed family members, inadequate hand hygiene, improper hand hygiene before and after patient contact, improper use of PPE, close contact with patients (≥12 times/day), long daily contact time (≥15 hours), and unprotected exposure. The most common symptoms reported among healthcare workers were fever (85%), cough (70%), and fatigue (70%). Prolonged use of PPE resulted in skin symptoms and skin damage (97%), with the nose bridge (83%) being the most commonly affected area. Healthcare workers experienced high levels of depression, anxiety, insomnia, and distress. Female healthcare workers and nurses were disproportionately affected.

Conclusion

Frontline healthcare workers are directly exposed to risks of physical and mental health consequences as a result of providing care for COVID-19 patients. Although there are few intervention studies, early data suggest that implementation strategies to reduce infection risk, shorter commuting times, and mechanisms for mental health support may reduce morbidity and mortality among healthcare workers.

Keywords:

COVID-19, healthcare workers, health impacts, 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, including the United States, Italy, Spain, Germany, France, and Iran by February 2020 [3-5]. As of April 18, COVID-19 has spread to 198 countries, with 2.4 million cases and 150,000 deaths worldwide, and is considered a global pandemic [6-8].

Healthcare workers (HCWs) are one of the groups at high risk of contracting this infection [9-11]. In China, infections were reported among 3,387 healthcare workers, with 22 (0.6%) dying from the disease [9,12]. Similarly, Italy (20%), Spain (14%), and France (more than 50 HCWs) reported high infection rates among HCWs [10,13,14]. Given the significant burden, there is an increasing need to protect healthcare workers globally through the provision of personal protective equipment (PPE), training, fatigue management, and addressing psychosocial impacts [15-21].

The literature on the health impacts of providing care to COVID-19 patients is growing, but there is no review to guide physicians and leaders on the effectiveness of various interventions. This scoping review aims to summarize the evidence on the physical and mental health impacts of the COVID-19 pandemic on healthcare workers.

Methods

Study Design

Using the methodological framework by Arksey and O'Malley, a scoping review was conducted [22]. The following five steps were involved: identifying a clear research question and objectives, identifying relevant literature, selecting literature, extracting data, charting data, organizing data, summarizing, analyzing, and reporting [22]. The main research question guiding this review is: "What are the physical and mental health impacts of managing COVID-19 patients on frontline healthcare workers?"

Literature Search Strategy

Relevant papers from January to March 2020 were searched using PubMed or Medical Literature Analysis and Retrieval System Online (MEDLINE) and Google Scholar. Boolean operators "OR/AND" were used to search Medical Subject Headings (MeSH). The search terms were: ("2019-nCoV" OR "coronavirus" OR "COVID-19" OR "nCoV") AND ("healthcare workers") AND ("health impacts" OR "physical health" OR "mental health").

Eligibility Criteria

Studies evaluating the impact of COVID-19 on healthcare workers' health, published in English from January to March 2020, were included. Healthcare workers encompassed all clinical staff, including doctors, nurses, emergency responders, and technicians. Editorials, commentaries, and non-English papers were excluded.

Identification and Selection of Studies

Two researchers (NS and DMA) conducted independent searches through the literature. They then compared the two sets of literature and removed duplicate articles. Figure 1 shows the process of searching and selecting research papers, following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.

Data Extraction from Selected Studies

After selecting the papers, data was extracted using a data extraction form and recorded in an Excel spreadsheet. The domains of the data extraction form included publication date, paper title, journal name, study design, research setting and population, intervention, reported outcomes, and key findings.

Summary of Findings

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

Results

Characteristics of the Studies

A total of 154 papers were searched from PubMed (126 papers) and Google Scholar (28 papers). Out of these, 58 duplicates were excluded. Among the remaining 96 papers, 82 were either not related to the impact of COVID-19 on healthcare workers, were opinion pieces, or were written in a language other than English, with no available English translation, and were thus excluded. Of the remaining 14 papers, 4 could not have their full texts obtained. Ten full-text articles were reviewed and included in the study. Of the 10 included studies, 2 were written in Chinese but had available English translations.

Research Areas

Of the 10 studies included in this review, 5 assessed the impact on mental health, and 5 evaluated the impact of COVID-19 on the physical health of healthcare workers. The methodological characteristics of these studies are summarized in Table 1. Among them, 6 studies were cross-sectional, 2 were intervention studies, 1 was a retrospective cohort study, and 1 was a case series. The study populations consisted of both male and female frontline physicians, nurses, and specialist staff. The majority of studies (90%) were from researchers in the People's Republic of China, with 1 study from researchers based in Singapore. The findings related to the mental and physical health impacts of COVID-19 on healthcare workers from the included papers are summarized in Table 2.

Figure 1: PRISMA Flowchart for Database Search of Studies

Table 1: Methodological Characteristics of COVID-19 Research Papers

Table 2: Summary Findings of Included COVID-19 Research Papers

Impact on Mental Health

Five papers discussed the mental health impacts on healthcare providers. In one study, among 230 healthcare workers who responded to mental health assessment scales, 53 (23.04%) had psychosocial issues. Of these 53 healthcare workers, a higher number of females (48, 90.57%) than males (5, 9.43%), and more nurses (43, 81.13%) than physicians (10, 18.9%) were affected by mental health problems due to the infectious outbreak [23]. The psychological impact on healthcare workers included overall anxiety (23–44%), severe anxiety (2.17%), moderate anxiety (4.78%), mild anxiety (16.09%), stress disorders (27.4–71%), depression (50.4%), and insomnia (34.0%) [23, 24]. Female anxiety was higher than male anxiety (25.67% vs 11.63%), and nurses experienced higher anxiety than physicians (26.88% vs 14.29%) [23].

Frontline healthcare workers engaged in COVID-19 patient care were at higher risk for depression (OR 1.52; 95% CI 1.11–2.09), anxiety (OR 1.57; 95% CI 1.22–2.02), insomnia (OR 2.97; 95% CI 1.92–4.60), and distress (OR 1.60; 95% CI 1.25–2.04) [24].

The tools used in these studies included self-reported anxiety scales [23, 25], Generalized Anxiety Disorder Scale [24], General Self-Efficacy Scale [25], Stanford Acute Stress Reaction Questionnaire [25], Pittsburgh Sleep Quality Index [25], Insomnia Severity Index [24], Social Support Rating Scale [25], Post-Traumatic Stress Disorder Self-Report Scale [23], and Impact of Event Scale [24].

Physical Health Impacts

COVID-19 Infections and Deaths among Healthcare Providers

Early studies from the People's Republic of China indicated that healthcare workers are highly susceptible to COVID-19. Research involving healthcare workers in the PRC showed that the risk of COVID-19 was associated with factors such as infections and lung diseases (RR = 2.13, 95% CI 1.45-3.95), diagnosed family members (RR = 2.76, 95% CI 2.02-3.77), inadequate hand hygiene (RR = 2.64, 95% CI 1.04-6.71), suboptimal hand hygiene before and after contact with patients (RR = 2.43, 95% CI 1.34-4.39), improper PPE use (RR = 2.82, 95% CI 1.11-7.18), close contact with patients (≥12 times/day), long daily contact hours (≥15 hours), and unprotected exposure. Common symptoms included fever (85%), cough (80%), fatigue (70%), chest discomfort (7%), hemoptysis (7%), headache (7%), and diarrhea (7%) [17, 26, 27]. Similarly, another study demonstrated that COVID-19 infected 30 healthcare workers, including 20 doctors and 8 nurses at a hospital. Of these, 26 cases were mild, and 4 were severe infections, with all cases having been exposed to the virus [27]. A case series study in Singapore recorded the outcomes of 41 healthcare workers exposed to COVID-19 pneumonia patients before diagnosis. None of the 41 healthcare workers developed COVID-19, as all were wearing surgical masks and N95 masks during exposure [28].

Dermatological Symptoms

Preventing viral diseases meant that healthcare workers had to wear personal protective equipment (PPE) for extended periods. A cross-sectional study showed that 97% of healthcare staff experienced skin damage, with the nasal bridge (83.1%) being the most common site affected. The most common symptoms were dryness, tension, and scaling (70.3%), which were associated with continuous PPE use for more than 6 hours and hand hygiene practices more than 10 times a day [29].

Discussion

This review collates evidence on the health impacts of COVID-19 on healthcare workers. The authors' findings suggest that healthcare workers are susceptible to various health effects due to the COVID-19 pandemic. The most commonly observed symptoms in COVID-19 patients were fever and cough, similar to those seen in the community. Several risk factors were identified: long working hours, working in high-risk departments, lack of personal protective equipment (PPE), diagnosed family members, inadequate hand hygiene, and improper infection management. Furthermore, prolonged use of PPE resulted in skin damage, with the nose bridge being the most commonly affected area. The fight against COVID-19 on the front lines renders healthcare workers vulnerable to psychological distress. This finding indicates high levels of depression, stress, anxiety, distress, anger, fear, insomnia, and post-traumatic stress disorder among healthcare workers. Women and nurses have disproportionately experienced mental health impacts. Frontline female nurses, working long hours under close contact with patients, may experience fatigue, stress, and anxiety. However, these findings require further research to prepare for the future.

Globally, COVID-19 has impacted numerous frontline healthcare workers. As of March 2020, COVID-19 had infected over 3,000 healthcare workers in China alone. Similar situations have been observed in past outbreaks of Ebola virus disease (EVD), Middle East respiratory syndrome (MERS), and severe acute respiratory syndrome (SARS). Figures from Sierra Leone, Liberia, and Guinea showed approximately 6-8% of Ebola cases among healthcare workers, while SARS infected about 1,000 healthcare workers with a 1.4% mortality rate occurring only in China. Early COVID-19 studies have highlighted concerning rates of morbidity and mortality. The fact that healthcare workers are at high risk of COVID-19 infection exacerbates the shortage of skilled workers, as many healthcare systems and emergency departments are operating at maximum capacity.

During outbreaks, healthcare workers experience significant stress. Studies from the Ebola outbreak in China reported extreme physical distress, depression, anxiety, and obsessive-compulsive symptoms among healthcare workers. During the MERS outbreak, a study in Saudi Arabia reported that nearly two-thirds of healthcare workers felt at risk of MERS-CoV infection and felt unsafe in their workplaces. These findings align with past SARS situations where healthcare workers reported high levels of fear related to transmission, family infection, emotional disorders, uncertainty, and stigma. Risk factors for mental health include overwhelming situations, social disruption in daily life, a sense of vulnerability, the risk of infection, and fear of infecting family or loved ones. Past outbreaks have shown that healthcare workers suffer from significant stress, and similar outcomes are expected for COVID-19.

One of the major challenges in controlling this pandemic is the extreme shortage of PPE. The problem of high-infectivity pandemics has already jeopardized healthcare systems, leading to shortages in supplies and PPE. For instance, during the Ebola outbreak, many countries faced PPE shortages. Securing emergency medical supplies during a pandemic is related to the country's public health emergency response system. Therefore, it is appropriate to develop an emergency stockpile medical supply plan based on need, type, quality, and quantity of supplies.

Pandemics have significant psychological impacts on healthcare workers, highlighting the need for appropriate psychological support, intervention, and staff assistance. Specific psychological interventions for Chinese healthcare staff during COVID-19 included psychological support teams, counseling, availability of helplines, establishment of shift systems in hospitals, online platforms for medical support, incentives, provision of appropriate breaks and rest, spaces for rest and sleep, leisure activities such as yoga, reflection, and exercise, and motivational sessions. Protecting the welfare of healthcare workers through appropriate measures is an extremely important tool in the national emergency public health response to outbreaks. Without timely measures, while the disease may eventually subside, a new surge of patients suffering from psychological conditions may emerge.

Strengths and Limitations of the Studies

In the scoping review, a systematic and rigorous search strategy was applied according to the research objectives. This study presents a summary of recent scientific evidence and may enhance responses to current and future outbreaks. Considering the rapid progression of the pandemic, the studies presented here have relatively short follow-up periods. Additionally, this review includes only studies published in English, which means findings published in other languages may have been missed. The incidence of health impacts of COVID-19 on healthcare workers is not well-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 of physical and mental health outcomes due to their role in providing care for COVID-19 patients. The implementation of the following strategies may help reduce the burden of health impacts: appropriate provision and training on personal protective equipment, rigorous infection control measures, reduction in working hours, and provision of mental health and support services.

Abbreviations

COVID-19: Coronavirus Disease 2019

Healthcare Workers

Personal Protective Equipment (PPE)

PRISMA: Preferred Reporting Items for Systematic Reviews and Meta-Analyses

EVD: Ebola Virus Disease

MERS: Middle East Respiratory Syndrome

SARS: Severe Acute Respiratory Syndrome

References

1. Information for Healthcare Professionals: COVID-19 | CDC. https://www.cdc. gov/coronavirus/2019-nCoV/hcp/index.html.Accessed 27 Mar 2020.
2. Technical guidance. https://www.who.int/emergencies/diseases/novelcoronavirus-2019/technical-guidance. Accessed 27 Mar
3. Holshue ML, DeBolt C, Lindquist S, Lofy KH, Wiesman J, Bruce H, et al. First case of 2019 novel coronavirus in the United States. N Engl J Med. 2020; 382(10):929–36. https://doi.org/10.1056/NEJMoa2001191.
4. Rothan HA, Byrareddy SN. The epidemiology and pathogenesis of coronavirus disease (COVID-19) outbreak. Journal of Autoimmun. Academic Press; 2020. p. 102433.
5. Bassetti M, Vena A, Giacobbe DR. The novel Chinese coronavirus (2019- nCoV) infections: Challenges for fighting the storm. Eur J Clin Invest. 2020; 50(3):e13209. https://doi.org/10.1111/eci.13209.
6. Situation reports. https://www.who.int/emergencies/diseases/novelcoronavirus-2019/situation-reports. Accessed 27 Mar
7. Dong E, Du H, Gardner L. An interactive web-based dashboard to track COVID-19 in real time. Lancet Infect Dis. 2020.https://doi.org/10.1016/ S1473-3099(20)30120-1.
8. Situation update worldwide, as of 28 March 2020. https://www.ecdc.europa. eu/en/geographical-distribution-2019-ncov cases. .
9. Lin M, Beliavsky A, Katz K, Powis JE, Ng W, Williams V, et al. What can early Canadian experience screening for COVID-19 teach us about how to prepare for a pandemic? Can Med Assoc J. 2020;192(12):E314–8.
   https://doi. org/10.1503/cmaj.200305.
10. Virus Knocks Thousands of Health Workers Out of Action in Europe.
    https://www.nytimes.com/2020/03/24/world/europe/coronavirus-europe-covid-19. html. Accessed 29 Mar 2020.
11. Koh D. Occupational risks for COVID-19 infection. Occup Med (Lond). 2020; 70(1):3–5.
12. Wang J, Zhou M, Liu F. Reasons for healthcare workers becoming infected with novel coronavirus disease 2019 (COVID-19) in China. J Hosp infect. 2020. https://doi.org/10.1016/j.jhin.2020.03.002.
13. ICN tells BBC World News viewers: Rising rate in COVID-19 infection amongst health workers requires urgent action | ICN - International Council of Nurses. https://www.icn.ch/news/icn-tells-bbc-world-news-viewers-risingrate-covid-19-infectionamongst-health-workers. Accessed 29 Mar 2020.
14. Lancet T. COVID-19: protecting health-care workers. Lancet. 2020;395(10228): 922. https://doi.org/10.1016/S0140-
    6736(20)30644-9. 15. Chen Q, Liang M, Li Y, Guo J, Fei D, Wang L, et al. Mental health care for medical staff in China during the COVID-19 outbreak. Lancet Psychiatry. 2020;7(4):e15–6.
15. Kang L, Li Y, Hu S, Chen M, Yang C, Yang BX, et al. The mental health of medical workers in Wuhan, China dealing with the 2019 novel coronavirus. Lancet Psychiatry. 2020;7(3):e14.
16. Ran L, Chen X, Wang Y, Wu W, Zhang L, Tan X. Risk factors of healthcare workers with corona virus disease 2019: A
    Retrospective Cohort Study in a Designated Hospital of Wuhan in China. Clin Infect Dis. 2020.
    https://doi.org/10.1093/cid/ciaa287.
17. Wang X, Zhang X, He J. Challenges to the system of reserve medical supplies for public health emergencies: reflections on the outbreak of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) epidemic in China. Biosci Trends. 2020;14(1):3–8.
18. Cascella M, Rajnik M, Cuomo A, Dulebohn SC, di Napoli R. Features, evaluation and treatment coronavirus (COVID-19). StatPearls Publishing. 2020;20.
19. Cavallo JJ, Donoho DA, Forman HP. Hospital capacity and operations in the coronavirus disease 2019 (COVID-19) pandemic—planning for the nth patient. JAMA Health Forum. 2020;1(3):–e200345.
20. Legido-Quigley H, Mateos-García JT, Campos VR, Gea-Sánchez M, Muntaner C, McKee M. The resilience of the Spanish health system against the COVID19 pandemic. The Lancet Public Health. 2020;2667(20):19–20.
21. Arksey H, O’Malley L. Scoping studies: Towards a methodological framework. Int J Soc Res Methodol. 2005;8(1):19–32.
22. Huang JZ, Han MF, Luo TD, Ren AK, Zhou XP. Mental health survey of 230 medical staff in a tertiary infectious disease hospital for COVID-19. Chin J Ind Hyg Occup Dis. 2020;38(0):E001.
23. Lai J, Ma S, Wang Y, Cai Z, Hu J, Wei N, et al. Factors associated with mental health outcomes among health care workers exposed to coronavirus disease 2019. JAMA Netw Open. 2020;3(3):e203976.
24. Xiao H, Zhang Y, Kong D, Li S, Yang N. The effects of social support on sleep quality of medical staff treating patients with coronavirus disease 2019 (COVID-19) in January and February 2020 in China. Med Sci Monit. 2020;26:e923549.
25. Cheng VCC, Wong S-C, Chen JHK, Yip CCY, Chuang VWM, Tsang OTY, et al. Escalating infection control response to the rapidly evolving epidemiology of the Coronavirus disease 2019 (COVID-19) due to SARS-CoV-2 in Hong Kong. Infect Control Hosp Epidemiol. 2020;5:1–6.
26. Liu M, He P, Liu HG, Wang XJ, Li FJ, Chen S, et al. Clinical characteristics of 30 medical workers infected with new coronavirus pneumonia. Chin J Tuberc Respir Dis. 2020;43(3):209–14.
27. Ng K, Poon BH, Kiat Puar TH, Shan Quah JL, Loh WJ, Wong YJ, et al. COVID19 and the Risk to Health Care Workers: A Case Report. Ann intern Med. 2020 Mar 16. https://doi.org/10.7326/L20-0175.
28. Lan J, Song Z, Miao X, Li H, Li Y, Dong L, et al. Skin damage and the risk of infection among healthcare workers managing coronavirus disease-2019. J Am Acad Dermatol. 2020. https://doi.org/10.1016/j.jaad. 2020.03.014.
29. Remuzzi A, Remuzzi G. COVID-19 and Italy: what next? The Lancet. 2020. https://doi.org/10.1016/S0140-6736(20)30627-9.
30. Ebola Virus Disease in Health Care Workers — Guinea, 2014.
    https://www.cdc.gov/mmwr/preview/mmwrhtml/mm6438a6.htm. .
31. Senga M, Pringle K, Ramsay A, Brett-Major DM, Fowler RA, French I, et al. Factors underlying ebola virus infection among health workers, Kenema, Sierra Leone, 2014-2015. Clin Infect Dis. 2016;63(4):454–9.
32. Shalhoub S, Al-Hameed F, Mandourah Y, Balkhy HH, Al-Omari A, al Mekhlafi GA, et al. Critically ill healthcare workers with the middle east respiratory syndrome (MERS): A multicenter study. PLoS One. 2018 Nov 15;13(11): e0206831.
33. Chan-Yeung M. Severe acute respiratory syndrome (SARS) and healthcare workers. Vol. 10. Int J Occup Environ Health. 2004;10(4):421–7.
34. Health worker Ebola infections in Guinea, Liberia and Sierra Leone.
    https://www.who.int/hrh/documents/21may2015_web_final.pdf. Accessed 10 Apr 2020.
35. Zhou P, Huang Z, Xiao Y, Huang X, Fan X-G. Protecting Chinese healthcare workers while combating the 2019 novel
    coronavirus. Infect Control Hosp Epidemiol. 2020;5:1–4.
36. Evans DK, Goldstein M, Popova A. Health-care worker mortality and the legacy of the Ebola epidemic. Lancet Glob Health. 2015;3(8):e439–40.
37. Ji D, Ji Y-J, Duan X-Z, Li W-G, Sun Z-Q, Song X-A, et al. Prevalence of psychological symptoms among Ebola survivors and healthcare workers during the 2014-2015 Ebola outbreak in Sierra Leone: a cross-sectional study. Oncotarget. 2017;8(8):12784–
38. Abolfotouh MA, AlQarni AA, Al-Ghamdi SM, Salam M, Al-Assiri MH, Balkhy HH. An assessment of the level of concern among hospital-based healthcare workers regarding MERS outbreaks in Saudi Arabia. BMC infect Dis. 2017;17(1):4.
39. Maunder RG, Lancee WJ, Balderson KE, Bennett JP, Borgundvaag B, Evans S, et al. Long-term psychological and occupational effects of providing hospital healthcare during SARS outbreak. Emerg Infect Dis. 2006;12(12): 1924–32.
40. Maunder R, Hunter J, Vincent L, Bennett J, Peladeau N, Leszcz M, et al. The immediate psychological and occupational impact of the 2003 SARS outbreak in a teaching hospital. CMAJ. 2003;168(10):1245–51. 42. Selvaraj SA, Lee KE, Harrell M, Ivanov I, Allegranzi B. Infection rates and risk factors for infection among health workers during
    ebola and Marburg virus outbreaks: a systematic review. J Infect Dis. 2018;218(suppl_5):S679–89.